Maternal child health nursing MCQ 1

1.   A client in labor received an epidural anesthetic when her dilation reached 5 cm. Which of the following nursing diagnoses would have the highest priority for her at this time? 

    A. Impaired urinary elimination related to the effects of the epidural anesthesia.

B. monitoring blood pressure and preventing hypotension

C. Impaired skin integrity

D. watch for hypertension.

ANS;B

Rationale: The highest priority of care for the client receiving an epidural anesthetic is monitoring blood pressure and preventing hypotension, which is a frequent complication of regional anesthesia. I.V. fluids are given before the epidural agent to increase blood volume and cardiac output and to minimize hypotension. Although impaired urinary elimination is a potential problem, it isn't the highest priority. Deficient knowledge doesn’t take priority over the risk for injury. Impaired skin integrity is unlikely because the labor client is typically healthy and the amount of time the client remains in bed doesn't cause skin breakdown.

2.   A neonate born 18 hours ago with meningomyelocele over the lumbosacral region is scheduled for corrective surgery. Preoperatively, what is the most important nursing goal? 
A. Preventing infection 
B. Ensuring adequate hydration 
C. Provide antibiotics

 D. immunization to be given

ANS; A

A Rationale: Preventing infection is the nurse's primary preoperative goal for a neonate with meningomyelocele. Although the other options are relevant for this neonate, they're secondary to preventing infection.

3.   Which of the following correctly defines puerperium? 
A. The 1st hour after birth 
B. The 6 weeks following birth 
C. The days spent in the hospital 
D. The duration of breast-feeding

ANS;B

 Rationale: Puerperium is defined as the 6 weeks postpartum. The other options are incorrect.

4.   The nurse should tell new mothers who are breast-feeding that breast milk is produced when: 
A. the placenta is delivered, causing the secretion of prolactin. 
B. the neonate begins to suckle and stimulates the anterior pituitary to produce         prolactin that secrete milk

 c.  the action of Folicle stimulating hormone

 d.  the action of Lutinising hormone

ANS; A

a Rationale: Delivery of the placenta causes the secretion of prolactin, which in turn produces breast milk. Thus, retained placental fragments can interfere with the production of milk. When the neonate sucks at the breast, the hypothalamus stimulates the production of prolactin-releasing factor, which further stimulates active production of prolactin to maintain milk production; sucking, however, doesn't initiate prolactin secretion. Oxytocin acts to constrict milk glands and push milk forward in the ducts that lead to the nipple. The role of relaxin is unknown.

5.   When performing a nursing assessment of a client's episiotomy, the nurse would especially assess for: 
A. location. 
B. discharge and odor. 
C. edema and approximation. 
D. subinvolution.

ANS c

Rationale: Episiotomies should be assessed for edema and approximation of the incision. An edematous perineum causes more tension of the suture line and increases pain. Although the sutures may be difficult to visualize, the suture line should be intact. Episiotomy location is important but not as important as the presence of edema. Discharge and odor refer to an assessment of the lochia. Subinvolution refers to the complete return of the uterus to its prepregnancy size and shape.

6.   When caring for a client who has had a cesarean birth, which action is inappropriate? 
A. Removing the initial dressing for incision inspection 
B. Monitoring pain status and providing necessary relief 
C. Supporting self-esteem concern body image disturbance

 D. monitoring vitals sings.

ANS-A

 Rationale: Nursing care should never include removing the initial dressing put on in the operating room. Appropriate nursing care for the incision would include circling any drainage, reporting findings to the physician, and reinforcing the dressing as needed. The other options are appropriate.

7.   When caring for a client who is a primigravida, the nurse would expect that the second stage would normally last how long? 
A. Approximately 2 hours 
B. Less than 1 hour 
C. 4 hours 
D. 3 hours

ANS-A

 Rationale: The average length of time a primigravida needs to push is approximately 2 hours. Longer than that might mean the client is experiencing an arrest in descent. Few primigravidas have a second stage of labor shorter than 1 hour.

8.   At 32 weeks' gestation, a client is admitted to the hospital with a diagnosis of pregnancy-induced hypertension. Based on this diagnosis, the nurse expects assessment to reveal which sign? 
A. Edema 
B. Fever 
C. Glycosuria 
D. Vomiting

ANS-A

 Rationale: Classic signs of pregnancy-induced hypertension include edema (especially of the face), elevated blood pressure, and proteinuria. Fever is a sign of infection. Glycosuria indicates hyperglycemia. Vomiting may be associated with any number of disorders.

9.   For a client who is fully dilated, which of the following actions would be inappropriate during the second stage of labor? 
A. Positioning the mother for effective pushing 
B. Preparing for delivery of the baby 
C. Assessing vital signs

 D.Artificial rupture of membrance

ANS-D

Rationale: In most cases, the membranes have ruptured (spontaneously or artificially) by this stage of labor. Positioning for effective pushing, preparing for delivery, and assessing vital signs every 15 minutes are appropriate actions at this time.

10.             Which of the following would not be an indication of placental detachment? 
A. An abrupt lengthening of the cord 
B. An increase in the number of contractions 
C. Relaxation of the uterus 
D. Increased vaginal bleeding

ANS-C

 Rationale: Relaxation isn't an indication for detachment of the placenta. An abrupt lengthening of the cord, an increase in the number of contractions, and an increase in vaginal bleeding are all indications that the placenta has detached from the wall of the uterus.

11.             Which of the following situations is more likely to predispose a client to postpartum hemorrhage?
A. Birth of a 3,175-g (7 lb) infant 
B. Birth of twins 
C. Prolonged first stage of labor 
D. Pregnancy-induced hypertension (PIH)

ANS.B Rationale: Multiple gestation causes overdistention of the abdomen, which can lead to uterine atony and, thus, uterine hemorrhage. A weight of 3,175 g (7 lb) is classified as normal for an infant. A macrocosmic infant (4,000 g [8 lb, 13½ oz]) could cause uterine atony. Neither long labor nor PIH causes postpartum hemorrhage.

12.             Which of the following describes how the nurse interprets a neonate's Apgar score of 8 at 5 minutes? 
A. A neonate who is in good condition 
B. A neonate who is mildly depressed 
C. A neonate who is moderately depressed 
D. A neonate who is very depressed.

ANS-A

 Rationale: An Apgar score of 8 indicates that the neonate has made a good transition to extrauterine life. A score of 4 to 6 would indicate moderate distress; a score of 0 to 3 would indicate severe distress.

13.             The nurse is caring for a client with a midline episiotomy and a third-degree laceration. The nurse understands that this type of laceration: 
A. extends into the anterior wall of the rectum. 
B. extends to the perineal skin and other superficial muscle

C. extends to anal spicter mucle

D. superficial skin only

ANS-C

 Rationale: Lacerations are tears that occur during childbirth. A third-degree laceration extends into the anal sphincter muscle. A first-degree laceration is limited to the perineal skin and other superficial structures such as the labia. A second-degree laceration reaches the perineal muscles, and a fourth-degree laceration involves the anterior rectal wall.

14.             Which of the following would be inappropriate to assess in a mother who is breast-feeding? 
A. The attachment of the neonate to the breast 
B. The mother's comfort level with positioning the neonate 
C. Audible swallowing 
D. The smacking of lips

ANS-D

 Rationale: Assessing the att.achment process for breast-feeding should include all of the answers except the smacking of lips. A neonate who is smacking his lips isn't well attached and can injure the mother's nipples.

15.             A multigravida at 36 weeks' gestation visits the emergency department because her boyfriend has beaten her severely. The first nursing intervention should be to: 
A. contact the authorities. 
B. ensure the client's safety. 
C. Identify the cause

D. inform to police in legal aspect

ANS-B

 Rationale: The first nursing intervention is to ensure the client's safety because these clients are terrified that the abuser will arrive and continue the cycle of violence. After this has been done, the nurse can contact the authorities, identify a support person, and ensure confidentiality. Photographing the client's injuries requires the client's consent.

16.             A client who is 7 months pregnant reports severe leg cramps at night. Which nursing action would be most effective in helping her cope with these cramps? 
A. Suggesting that she walk for 1 hour twice per day 
B. Advising her to elevate foot

C. Advice that it is Common during late pregnancy

D. Advice to take warm water

ANS-C

 Rationale: Common during late pregnancy, leg cramps cause shortening of the gastrocnemius muscle in the calf. Dorsiflexing or standing on the affected leg extends that muscle and relieves the cramp. Although moderate exercise promotes circulation, walking 2 hours per day during the third trimester is excessive. Excessive calcium intake may cause hypercalcemia, promoting leg cramps; the physician must evaluate the client's need for calcium supplements. If the client eats a balanced diet, calcium supplements or additional servings of high-calcium foods may be unnecessary.

17.  Which instructions should the nurse give to a client who is 26 weeks pregnant and complains of constipation? 
A. Encourage her to increase her intake of roughage and to drink at least six 8 oz glasses of water per day. 
B. advice to take laxatives

     C. Advice to avoid Non vegetarian

      D. Advice to avoid spicy food

ANS;A

 Rationale: The best instruction is to encourage the client to increase her intake of high-fibre foods (roughage) and to drink at least six glasses of water per day. Mild laxatives and stool softeners may be needed, but dietary changes should be tried first. Straining during defecation and diarrhea can stimulate uterine contractions, but telling the client to go to the evaluation unit doesn't address her concern.

18. Labor is divided into how many stages? 
A. Five 
B. Three 
C. Two 
D. Four

ANS-D

 Rationale: Labor is divided into four stages: first stage, onset of labor to full dilation; second stage, full dilation to birth of the baby; third stage, birth of the placenta; and fourth stage, 1-hour postpartum. The first stage is divided into three phases: early, active, and transition.

19.   A neonate has vesicular lesions on the soles and palms, red rash around the mouth and anus, and is small for gestational age. The neonate has contracted which sexually transmitted disease from the mother? 
A. Syphilis 
B. Gonorrhea 
C.AIDS

D.measles

ANS-A

Rationale: These symptoms, together with appropriate serologic tests, indicate congenital syphilis. Gonorrhea would be indicated by ophthalmia neonatorum. Rubella isn't a sexually transmitted disease. Neonates affected with Type 2 herpes manifest jaundice, seizures, increased temperature, and characteristic vesicular lesions.

20.   Prevention of preterm births is vital for which reason? 
A. It's costly to care for these neonates. 
B. Preterm birth causes more than half of the neonatal deaths in the United States. 
C. These neonates usually wind up with long-term h

b Rationale: Prematurity is the leading cause of neonatal deaths in the United States; other industrialized nations have fewer premature births and fewer neonatal deaths than the United States does. Although the other three answers are complications of prematurity, prevention is the outcome nurses must focus on while providing care to their clients.

21.   When teaching a group of pregnant teens about reproduction and conception, the nurse is correct when stating that fertilization occurs: 
A. in the uterus. 
B. when the ovum is released. 
C. near the fimbriated end. 
D Fertilization occurs in the first third of the fallopian tube

ANS-D

 Rationale: Fertilization occurs in the first third of the fallopian tube. After ovulation, an ovum is released by the ovary into the abdominopelvic cavity. It enters the fallopian tube at the fimbriated end and moves through the tube on the way to the uterus. Sperm cells "swim up" the tube and meet the ovum in the first third of the fallopian tube. The fertilized ovum then travels to the uterus and implants. Nurses must know where fertilization occurs because of the risk of an ectopic pregnancy.

22.  about using drugs safely during pregnancy in her teaching? 
A. "During the first 3 months, avoid all medications except ones prescribed by y

d Rationale: Because all medications can be potentially harmful to the growing fetus, telling the client to consult with her health care provider before taking any medications is the best teaching. The client needs to understand that any medication taken at any time during pregnancy can be teratogenic.

23.  Lochia normally progresses in which pattern? 
A. Rubra, serosa, alba 
B. Serosa, rubra, alba 
C. Serosa, alba, rubra 
D. Rubra, alba, serosa

ANS-A

Rationale: As the uterus involutes and the placental attachment area heals, lochia changes from bright red (rubra), to pinkish (serosa), to clear white (alba). The other options are incorrect.

24.    Which of the following describes the rationale for administering vitamin K to every neonate? 
A. Neonates don't receive the clotting factor in utero. 
B. The neonate lacks intestinal flora to make the vitamin. 
C. Stop the bleeding from umblicus

D. it prevent phenylketonuria

ANS-B

 Rationale: Neonates are at risk for bleeding disorders during the 1st week of life because their GI tracts are sterile at birth and lack the intestinal flora needed to produce vitamin K, which is necessary for blood coagulation. Vitamin K stimulates the liver to produce clotting factors. Vitamin K doesn't prevent PKU, which is an inherited metabolic disease.

25.   Which of the following would be inappropriate to include in the plan of care for a client during the fourth stage of labor? 
A. Vital signs and fundal checks every 15 minutes 
B. Time with the neonate to initiate breast-feeding 
C. Catheterization isn't routinely done to protect the bladder from trauma

D.Monitor  FHR

ANS-C

Rationale: Catheterization isn't routinely done to protect the bladder from trauma. It's done, however, for a postpartum complication of urinary retention. The other options are appropriate measures to include in the plan of care during the fourth stage of labor.

26.  Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client? 
A. Applying cold to limit edema during the first 12 to 24 hours

B. Using two or more peripads

C. sitz baths

D. Kegel exercises

ANS-B Rationale: Using two or more peripads would do little to reduce the pain or promote perineal healing. Cold applications, sitz baths, and Kegel exercises are important measures when the client has a fourth-degree laceration.

27.  A healthy term white neonate male should weigh approximately: 
A. 7 lb (3.2 kg). 
B. 8 lb (3.6 kg). 
C. 7½ lb (3.4 kg). 
D. an amount that varies with length of pregnancy

C Rationale: The normal weight for a term neonate white male should be about 7½ lb. White females should weigh about 7 lb. Neonates of Asian or Black mothers often weigh less.

28.  The nurse is caring for a client with mild active bleeding from placenta previa. Which assessment factor indicates that an emergency cesarean section may be necessary? 
A. Increased maternal blood pressure of 150/90 mm Hg 
B. Decreased amount maternal pulse rate

C. Decresed FHR

D. Decreased urine output

ANS-C

 Rationale: A drop in fetal heart rate signals fetal distress and may indicate the need for a cesarean delivery to prevent neonatal death. Maternal blood pressure, pulse rate, respiratory rate, intake and output, and description of vaginal bleeding are all important assessment factors; however, changes in these factors don't always necessitate the delivery of the neonate.

29.  A nurse in a prenatal clinic is assessing a 28-year-old woman who is 24 weeks pregnant. Which findings would lead this nurse to suspect that the client has mild preeclampsia? 
A. Glycosuria, hypertension, seizures 
B. Hematuria, blurry vision,Hypotension

C. Abdominal pain,blurred vision, reduced urine output

D. hypertension, edema, and proteinuria

ANS-D

 Rationale: The typical findings of mild preeclampsia are hypertension, edema, and proteinuria. Seizures are a sign of eclampsia. Abdominal pain, blurry vision, and reduced urine output are signs of severe preeclampsia. The other findings aren't typically found in women with preeclampsia.

30.  A client who has received a new prescription for oral contraceptives asks the nurse how to take them. Which of the following would the nurse instruct the client to report to her primary caregiver? 
A. Breast tenderness 
B. Breakthrough bleeding

C. decreased menstrual flow

D. blurred vision and headaches

ANS-D

 Rationale: Some adverse effects of birth control pills, such as blurred vision and headaches, require a report to the health care provider. Because these two effects in particular may be precursors to cardiovascular compromise and embolus, the client may need to use another form of birth control. Breast tenderness, breakthrough bleeding, and decreased menstrual flow may occur as a normal response to the use of birth control pills.

31.  Which of the following is not a contributing factor to unstable blood sugars in the neonate? 
A. Prematurity 
B. Respiratory distress 
C. Postdated infant 
D. Cesarean delivery

ANS-D

Rationale: Neonates delivered by cesarean birth without any other contributing factors should have adequate stores of brown fat to control blood glucose levels. Stores of brown fat aren't deposited until 36 weeks, so infants born at less than 36 weeks won't have the necessary stores to maintain a normal blood glucose level. Neonates who have respiratory distress or are postdated will use up their stores of brown fat as a result of these complications.

32. At what gestational age would a primigravida expect to feel "quickening"? 
A. 12 weeks 
B. 16 to 18 weeks 
C. 20 to 22 weeks 
D. By the end of the 26th week

ANS-C

Rationale: It's important for the nurse to distinguish between a client who is having her first baby and one who has already had a baby. For the client who is pregnant for the first time, quickening occurs around 20 to 22 weeks. Women who have had children will feel quickening earlier, usually around 18 to 20 weeks, because they recognize the sensations.

33. When does the third stage of labor end? 
A. When the neonate is born 
B. When the client is fully dilated 
C. After the birth of the placenta 
D. When the client is transferred to her postpartum bed

ANS-C

Rationale: The third stage of labor ends with the birth of the placenta. The first stage of labor ends with complete cervical dilation and effacement. The second stage of labor ends with the birth of the neonate. The fourth stage of labor comprises the first 4 hours after birth.

34.  When caring for a client with preeclampsia, which action is a priority? 
A. Monitoring the client's labor carefully and preparing for a fast delivery 
B. Continually assessing the fetal tracing for signs of fetal distress 
C. Checking vital signs

  D. seizure activity

ANS-D

Rationale: A client with preeclampsia is at risk for seizure activity because her neurologic system is overstimulated. Therefore, in addition to administering pharmacologic interventions to reduce the possibility of seizures, the nurse should lessen auditory and visual stimulation. Although the other actions are important, they're of a lesser priority.

35.  An appropriate-for-gestational-age neonate should weigh: 
A. between the 10th and the 90th percentiles for age. 
B. at least 2,500 g (5 lb, 8 oz). 
C. between 2,000 and 4,000 g (4 lb, 6 oz and 8 lb, 12 oz). 
D. in the 50th percent

ANS-A

Rationale: Appropriate-for-gestational-age neonate weights fall between the 10th and the 90th percentiles for age. Large-for-gestational-age weight is above the 90th percentile, and small-for-gestational-age is below the 10th percentile for age.

36. Which of the following clients would have the highest priority for being monitored with internal fetal monitoring? 
A. Client with ruptured membranes 
B. Client at complete dilation and +2 station 
C. Client in latent phase with intact Membrance

D. fetus in a vertex position and meconium-stained fluid

ANS-D

Rationale: The client with the fetus in a vertex position and meconium-stained fluid would have the highest priority for being monitored with internal fetal monitoring. The client with meconium-stained amniotic fluid is at highest risk for fetal distress. Internal fetal monitoring requires that the client have ruptured membranes and be dilated at least 1 cm and that the fetal presenting part is reachable. In many institutions, fetal monitoring is used routinely on all clients and is most useful in situations in which a high probability exists of maternal contractile problems or fetal distress. Fetal monitoring provides an almost continuous recording of the labor events. The client who is completely dilated and at +2 station is ready to deliver and wouldn't need fetal monitoring. Internal monitoring can't be done with intact membranes.

37. Immediately after a spontaneous rupture of the membranes, the nurse observes a loop of umbilical cord protruding from the vagina. The first nursing action would be to: 
A. administer oxygen. 
B. notify the physician. 
C. document the deceleration

 D.  elevate the hips on two pillows.

ANS-D

Rationale: The first nursing action would be to elevate the hips on two pillows. The primary goal with prolapse of the umbilical cord is to remove the pressure from the cord. Changing the maternal position is the first intervention. Acceptable positions include knee-chest, side-lying, and elevation of the hips. The nurse may also perform a vaginal examination and attempt to push the presenting part of the cord while being careful not to add any pressure to the cord. Administering oxygen benefits the fetus only if circulation through the cord has been reestablished. The nurse does notify the physician and document the deceleration, care provided, and outcome but only after providing the initial emergency care to the client

38. Which of the following hormones is responsible for the let-down reflex? 
A. Oxytocin 
B. Prolactin 
C. Estrogen 
D. Progesterone

ANS-A

 Rationale: Oxytocin is responsible for milk let-down, the process that brings milk to the nipple. The other hormones mentioned contribute indirectly to the lactation process. Prolactin stimulates lactation. Estrogen stimulates development of the duct in the breast. Progesterone acts to increase the lobes, lobules, and alveoli of the breasts

39  During the first 3 months, which hormone is responsible for maintaining pregnancy? 
A. Human chorionic gonadotropin (HCG) 
B. Progesterone 
C. Estrogen 
D. Relaxin

a Rationale: HCG is the hormone responsible for maintaining the pregnancy until the placenta is in place and functioning. Serial HCG levels are used to determine the status of the pregnancy in clients with complications. Progesterone and estrogen are important hormones responsible for many of the body's changes during pregnancy. Relaxin is an ovarian hormone that causes the mother to feel tired, thus promoting her to seek rest.

40.  Which condition could a mother have and still be allowed to breast-feed her child? 
A. Positive for human immunodeficiency virus (HIV) 
B. Active tuberculosis (TB) 
C. Endometritis 
D. Cardiac disease

ANS-C

 Rationale: Of the listed conditions, endometritis is the only one in which a mother can continue to breast-feed provided that the antibiotics she's taking aren't contraindicated. A mother who has HIV or active TB is strongly discouraged from breast-feeding because of concerns about transmitting the infection to the neonate. Clients with cardiac disease are also discouraged from breast-feeding because of the strain on the mother's defective heart.

41.  The physician decides to artificially rupture the membranes. Following this procedure, the nurse checks the fetal heart tones for which reason? 
A. To determine fetal well-being 
B. To assess for prolapsed cord 
C. To assess fetal position

D. To check the fetal heart rate

ANS-B

 Rationale: After a client has an amniotomy, the nurse should ensure that the cord isn't prolapsed and that the baby tolerated the procedure well. The most effective way to do this is to check the fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal examination. Artificial rupture of membranes doesn't indicate an imminent delivery.

42. Which of the following is the approximate time that the blastocyst spends traveling to the uterus for implantation? 
A. 2 days 
B. 7 days 
C. 10 days 
D. 14 weeks

b Rationale: The blastocyst takes approximately 1 week to travel to the uterus for implantation. The other options are incorrect.

43. The nurse is caring for a neonate 12 hours after birth. Which clinical manifestation would be the earliest indication that the neonate may have cystic fibrosis? 
A. Steatorrhea 
B. Meconium ileus 
C. Decreased sodium levels 
D. Rhinorrhea

ANS-B

Rationale: In cystic fibrosis, the small intestine becomes blocked with thick meconium; therefore, meconium ileus is the earliest indication that a neonate has the disorder. Steatorrhea may be present later and may be used as a guideline for administration of pancreatic enzymes. Infants and children with this disorder have increased sodium levels, and rhinorrhea isn't usually present.

44.   When magnesium sulfate is administered to a client in labor, its action occurs at which of the following sites? 
A. Neural-muscular junctions 
B. Distal renal tubules 
C. Central nervous system (CNS) 
D. Myocardial fibers

ANS-A

Rationale: Because magnesium has chemical properties similar to those of calcium, it will assume the role of calcium at the neural muscular junction. It doesn't act on the distal renal tubules, CNS, or myocardial fibers.

45.  Which of the following describes a preterm neonate? 
A. A neonate weighing less than 2,500 g (5 lb, 8 oz) 
B. A low-birth-weight neonate 
C. A neonate born at less than 37 weeks' gestation regardless of weight 
D. A neonate diagnosed with intrauterine growth retardation.

ANS-C

Rationale: A preterm infant is a neonate born at less than 37 weeks' gestation regardless of what the neonate weighs. Infants weighing less than 2,500 g are described as low-birth-weight neonate. A full-term neonate can be diagnosed with intrauterine growth retardation.

46.  client is experiencing an early postpartum hemorrhage. Which action is inappropriate? 
A. Inserting an indwelling urinary catheter 
B. Fundal massage 
C. Administration of oxytoxics 
D. Pad count

ANS-D

Rationale: By the time the client is hemorrhaging, a pad count is no longer appropriate. Inserting an indwelling urinary catheter eliminates the possibility that a full bladder may be contributing to the hemorrhage. Fundal massage is appropriate to ensure that the uterus is well contracted, and oxytoxics may be ordered to promote sustained uterine contraction.

47.  Which of the following is normal neonate calorie intake? 
A. 110 to 130 calories per kg 
B. 30 to 40 calories per lb of body weight 
C. At least 2 ml per feeding 
D. 90 to 100 calories per kg

ANS-A

A Rationale: Calories per kg is the accepted way of determining appropriate nutritional intake for a neonate. The recommended calorie requirement is 110 to 130 calories per kg of neonate body weight. This level will maintain a consistent blood glucose level and provide enough calories for continued growth and development

48. Which assessment finding would the nurse interpret as abnormal for a term male neonate who is 1 hour old? 
A. Enlargement of the mammary glands 
B. Slightly yellowish hue to the skin 
C. Blue hands and feet 
D. Black and blue spot

ANS-B

Rationale: A slightly yellowish hue to the skin would be abnormal because it's too early for the neonate to be showing signs of jaundice. The finding should be reported immediately to the neonate's health care provider. All of the remaining responses are normal findings for a 1-hour-old neonate male

49. Which assessment finding would lead the nurse to suspect dehydration in a preterm neonate? 
A. Bulging fontanels 
B. Excessive weight gain 
C. Urine specific gravity below 1.012 
D. Urine output below 1 ml/hour

ANS-D

Rationale: A urine output below 1 ml/hour is a sign of dehydration. Other signs of dehydration include depressed fontanels, excessive weight loss, decreased skin turgor, dry mucous membranes, and urine specific gravity above 1.012.

50  In performing a routine fundal assessment, the nurse finds a client's fundus to be "boggy." The nurse should first: 
A. call the physician. 
B. massage the fundus. 
C. assess lochia flow. 
D. start methylergonovine

ANS-B

Rationale: The nurse should begin to massage the uterus so that the uterus will be stimulated to contract. Lochia flow can be assessed while the uterus is being massaged. The client shouldn't be left while the nurse calls the physician. If the fundus remains boggy and the uterus continues to bleed, the nurse should use the call light to ask another nurse to call the physician. An order for methylergonovine may be obtained at this time if needed, or the nurse may administer methylergonovine as written.