NUR 418 Exam 3 | Verified with 100% Correct Answers

NUR 418 Exam 3 | Verified with 100% Correct Answers A newborn born at 32 weeks gestation is showing signs of respiratory distress, including nasal flaring, tachypnea, and use of accessory muscles. The healthcare provider suspects Respiratory Distress Syndrome (RDS). What is the most likely cause of the infant's respiratory distress? A) Inadequate surfactant production due to immature lung development B) Inadequate blood circulation to the lungs C) Excessive surfactant production leading to lung collapse D) An obstruction in the upper airway causing airway resistance Which of the following diagnostic findings would be expected in a newborn with Respiratory Distress Syndrome (RDS)? A) A reticulogranular pattern resembling "ground glass" on chest X-ray B) Elevated lecithin-to-sphingomyelin (L/S) ratio C) High levels of phosphatidylglycerol (PG) D) Clear lung fields on chest X-ray Which of the following is a primary risk factor for developing Respiratory Distress Syndrome (RDS) in a newborn? A) Full-term gestation B) Low birth weight C) Premature birth D) Maternal smoking during pregnancy Which of the following interventions would be most appropriate for a newborn diagnosed with Respiratory Distress Syndrome (RDS)? A) Administering supplemental oxygen and surfactant therapy B) Providing oral feedings to promote lung growth C) Initiating mechanical ventilation without oxygen support D) Delaying interventions until the infant is 36 weeks gestation A newborn presents with nasal flaring, tachypnea, retractions, and cyanosis. The healthcare provider suspects Respiratory Distress Syndrome (RDS). Which of the following lab findings is most likely to be present in this infant? A) High levels of phosphatidylglycerol (PG) B) Lecithin-to-sphingomyelin (L/S) ratio greater than 2:1 C) Elevated pH and normal oxygen levels D) Low lecithin-to-sphingomyelin (L/S) ratio and low phosphatidylglycerol (PG) levels A nurse is educating a group of pregnant women about preterm labor. Which of the following statements by the nurse is correct regarding the risk of Respiratory Distress Syndrome (RDS) in preterm infants? A) Preterm infants are less likely to develop RDS because they are born with mature lungs. B) The risk of RDS is higher the earlier the gestation, particularly before 36 weeks. C) RDS only occurs if the infant is less than 32 weeks gestation. D) If a preterm infant has a mature L/S ratio, they will not develop RDS. Which of the following physical signs would the nurse most likely observe in a newborn with Respiratory Distress Syndrome (RDS)? A) Decreased work of breathing B) Expiratory grunting and nasal flaring C) Increased oxygen saturation and normal breath sounds D) Strong, regular breathing without signs of distress What is the underlying pathophysiology of Respiratory Distress Syndrome (RDS) in preterm infants? A) Overproduction of lung surfactant leads to alveolar collapse B) Underdeveloped alveolar saccules and lack of surfactant impair lung expansion C) Excessive oxygen intake causes airway resistance and atelectasis D) Low blood flow to the lungs causes inadequate oxygenation A newborn is diagnosed as Small for Gestational Age (SGA). Which of the following best describes the characteristics of this condition? A) The newborn's weight falls below the 50th percentile for gestational age. B) The newborn's weight is below the 10th percentile for gestational age, indicating intrauterine growth restriction C) The newborn's head circumference is smaller than expected, but weight is within normal limits. D) The newborn's weight is above the 90th percentile for gestational age. Which of the following best describes the difference between symmetrical and asymmetrical Small for Gestational Age (SGA) infants? A) Symmetrical SGA infants have normal head size but small body weight, while asymmetrical infants have both small head and body size. B) Symmetrical SGA infants have both small head and body size, while asymmetrical infants have a large head with a small body. C) Symmetrical SGA infants have both small head and body size, while asymmetrical infants have normal head size and smaller body weight. D) Symmetrical SGA infants have smaller weight and larger head size than asymmetrical infants. A nurse is assessing a newborn with an asymmetrical Small for Gestational Age (SGA) condition. Which of the following would be most likely observed during the physical assessment? A) A sunken abdomen, large head, and well-developed body B) A large head in relation to the body, muscle wasting, and lack of brown fat C) Excessive body fat, with the head in normal proportion to the body D) Well-rounded body and no visible signs of malnutrition Which of the following is a common risk for Small for Gestational Age (SGA) newborns? A) Hyperglycemia and excessive weight gain B) Cold stress and temperature instability C) Increased growth and development D) Decreased susceptibility to infection A nurse is caring for a Small for Gestational Age (SGA) infant. Which of the following interventions is most important to prevent complications? A) Encourage frequent feedings every 2 to 3 hours to prevent hypoglycemia. B) Allow the infant to sleep for long periods to conserve energy. C) Provide a high-calorie formula and reduce the number of feedings. D) Keep the infant on a fixed feeding schedule to ensure adequate nutrition. Which of the following conditions are Small for Gestational Age (SGA) infants more likely to experience due to poor oxygenation and poor growth in utero? A) Hypoglycemia, polycythemia, and infection B) Hyperglycemia and dehydration C) Hyperthermia and electrolyte imbalances D) Jaundice and electrolyte imbalance A nurse is assessing a full-term newborn who appears jaundiced at 48 hours of life. The jaundice is progressing from the head down to the thorax and abdomen. Based on the most likely cause, how should the nurse categorize this jaundice? A) Pathologic jaundice, due to excessive hemolysis B) Physiologic jaundice, due to ABO incompatibility C) Pathologic jaundice, resulting from an underlying infection D) Physiologic jaundice, due to immature liver function A nurse is teaching a new parent about the signs of jaundice in their newborn. Which of the following statements by the parent indicates the need for further teaching? A) "Jaundice typically starts in the head and progresses to the rest of the body." B) Jaundice that develops on the first day of life should be assessed by a healthcare provider." C) "It's normal for jaundice to appear within the first 24 hours in most babies. D) "Jaundice that appears after the first 24 hours is more likely to be physiologic." A newborn presents with jaundice on the first day of life, and lab results indicate a total serum bilirubin (TSB) level of 13 mg/dL. What is the most likely cause of this jaundice? A). Pathologic jaundice due to ABO incompatibility B). Physiologic jaundice due to immature liver function C) Physiologic jaundice due to a lack of breastfeeding D) Pathologic jaundice due to insufficient bilirubin conjugation A nurse is caring for a newborn receiving phototherapy for jaundice. Which of the following interventions should the nurse prioritize? A) Keep the infant under the phototherapy lights at all times, even during feedings. B) Ensure the infant is hydrated with breastmilk and monitor their temperature. C) Apply lotion to the infant's skin to prevent dryness and irritation. D) Remove the infant from phototherapy when they are crying to soothe them. Which of the following is the primary cause of physiologic jaundice in full-term neonates? A) Excessive hemolysis of red blood cells B) Immature liver that cannot adequately conjugate bilirubin C) ABO or Rh incompatibility D) Infections or metabolic disorders A newborn has been diagnosed with pathological jaundice, and the nurse is concerned about the potential for bilirubin toxicity. Which of the following complications could result from high bilirubin levels in a neonate? A) Hypoglycemia B) Respiratory distress C) Kernicterus and encephalopathy D) Hyperthermia A nurse is developing a care plan for a newborn in the NICU. Which of the following interventions would be most beneficial for promoting the infant's development and recovery? A) Limit exposure to noise and create a calm environment with appropriate ambient lighting. B) Encourage frequent handling of the infant to stimulate growth and promote bonding. C) Keep the infant in a bright environment to stimulate alertness and promote wakefulness. D) Schedule feedings and assessments every 4 hours to allow for uninterrupted sleep. A preterm newborn is diagnosed with bronchopulmonary dysplasia (BPD) following prolonged oxygen therapy. Which of the following interventions should the nurse prioritize to prevent further lung damage? A) Administer high levels of oxygen to maintain oxygen saturation levels above 98%. B) Gradually wean the newborn off oxygen as soon as possible to avoid prolonged oxygen exposure. C) Increase mechanical ventilation support to ensure adequate oxygenation. D) Provide respiratory support with high-frequency oscillation ventilation at all times. A newborn diagnosed with bronchopulmonary dysplasia (BPD) is being weaned off oxygen. Which of the following is a key intervention in managing this infant's condition? A) Administer high doses of systemic steroids to reduce inflammation. B) Maintain stable oxygen levels to avoid lung damage and ensure adequate oxygen saturation. C) Encourage the infant to take deep breaths to increase lung compliance. D) Wean the infant off oxygen as quickly as possible, regardless of oxygen saturation levels. A preterm newborn with bronchopulmonary dysplasia (BPD) is receiving treatment. Which of the following medications is most commonly used to improve lung compliance in this condition? A) Antibiotics to prevent infection B) Bronchodilators and inhaled steroids C) Antipyretics for fever reduction D) Diuretics to reduce fluid retention A preterm infant with bronchopulmonary dysplasia (BPD) is receiving oxygen therapy. Which of the following strategies should the nurse implement to minimize further damage to the infant's lungs? A) Use the lowest amount of oxygen necessary to maintain acceptable oxygen saturation levels. B) Administer high-flow oxygen to ensure the infant's oxygen levels are consistently high. C) Monitor oxygen saturation levels every 4 hours and adjust oxygen as needed. D) Avoid using any oxygen therapy once the infant is stable to promote lung healing. A nurse is assessing an infant with bronchopulmonary dysplasia (BPD) who is being treated with theophylline. What is the purpose of administering this medication? A) To promote hydration and prevent dehydration B) To reduce inflammation in the lungs and improve oxygenation C) To stimulate the central nervous system and improve respiratory effort D) To increase heart rate and improve blood flow to the lungs At which age does an infant's birth weight typically double? A) 3 months B) 6 months C) 9 months D) 12 months At what age does the posterior fontanelle typically close? A) 4-6 weeks B) 6-8 weeks C) 12-18 months D) 3-4 months Which of the following is characteristic of an infant in Erikson's psychosocial stage of trust vs. mistrust? A) Enjoys solitary play and begins to develop trust in caregivers. B) Is developing a sense of autonomy and beginning to explore. C) Begins to exhibit independence from caregivers. D) Displays the ability to share and cooperate with others. Which of the following pain assessment tools is most appropriate for an infant with neurological impairment or a child up to 7 years of age? A) Numeric scale B) FLACC scale C) FACES scale D) Oucher scale A nurse is assessing an infant's pain using the FLACC scale. Which of the following would be considered a moderate pain response for facial expression in this scale? A) Relaxed face B) Grimacing or frowning C) Smile or neutral expression D) No expression of pain Which of the following clinical presentations would indicate that an infant is experiencing pain? A) Decreased heart rate, normal respiratory rate, and calm demeanor B) Increased heart rate, decreased oxygen saturation, and a furrowed brow C) Stable vital signs, smiling face, and relaxed posture D) Normal respiratory rate, low blood pressure, and drowsiness A postpartum patient reports feelings of worthlessness, irritability, lack of appetite, and excessive fears about her baby's safety. What should be the nurse's initial action? A) Suggest that the patient take time for herself and relax. B) Ask the patient about her thoughts on infant care and assess her mood and interactions with the baby. C) Advise the patient to visit her family doctor for medication. D) Recommend that the patient talk to her partner about her concerns. Which of the following statements by a postpartum patient would be a red flag for possible postpartum depression (PPD)? A) "I'm feeling overwhelmed "B) "I have trouble sleeping C) "I feel like I'm not good enough as a mom, and I don't think I can take care of my baby." D) "I'm exhausted." A postpartum mother has been diagnosed with moderate postpartum depression. Which of the following pharmacologic treatments is most commonly prescribed for this condition? A) Benzodiazepines B) Antidepressants (SSRIs or SNRIs) C) Antipsychotics D) Mood stabilizers When screening for postpartum depression, which of the following is a key assessment question for the nurse to ask during the postpartum assessment? A) "How are you feeling about being a mother?" B) "Have you experienced any significant stressors in your life recently?" C) "Do you feel that your baby is safe in your care?" D) "Have you had a history of depression or anxiety?" A nurse is performing a postpartum assessment using the BUBBLE-HE method. Which of the following findings related to the uterus would indicate an abnormality requiring further evaluation? A) The uterus is firm and midline, 2 finger breaths below the umbilicus. B) The uterus is boggy and deviated to the left, 1 finger breath above the umbilicus. C) The uterus is firm with mild cramping, located at the level of the umbilicus. D) The uterus is firm and midline, 3 finger breaths below the umbilicus. Rationale: A boggy uterus (lack of tone) and deviation to the left suggest uterine atony or bladder distention, both of which require intervention. A postpartum nurse is performing an assessment of a patient's breasts using the BUBBLE-HE method. Which finding should be reported immediately to the healthcare provider? A) The breasts are soft, and the nipples are intact. B) The breasts are firm, and the nipples are cracked and painful. C) The breasts are filling, and the nipples are everted. D) The breasts are soft, and the nipples are inverted. Rationale: Cracked, painful nipples can indicate improper latch or breastfeeding technique and may lead to infection or further tissue damage. Immediate intervention is necessary. During an assessment 48hrs after birth, a nurse notes that the patient's lochia is dark red with small clots and has a moderate amount. Which of the following is the correct interpretation of this finding? A) Lochia rubra is normal during the first 1-3 days postpartum. B) Lochia alba is normal and should be observed in the first 24 hours postpartum. C) Lochia serosa is expected during the first 3-7 days postpartum. D) Lochia rubra with large clots should be expected after 7 days postpartum. Rationale: Lochia rubra (dark red, with small clots) is normal in the early postpartum period (1-3 days). It indicates the shedding of the uterine lining. Large clots or heavy flow should be reported. A postpartum patient who had a cesarean section 20hrs ago, is reporting abdominal discomfort. The nurse is performing an assessment of the bowels using the BUBBLE-HE method. Which finding would be expected in this patient? A) No bowel sounds and no passage of flatus. B) Bowel sounds are present, but no bowel movement has occurred yet. C) Decreased bowel sounds with nausea and vomiting. D) Absent bowel sounds with increased abdominal distention. Rationale: It is common for patients after a cesarean section to experience delayed bowel function, which may result in no bowel movement for a few days, though bowel sounds should still be present. Which of the following findings would be normal during a postpartum bladder assessment at the hospital using the BUBBLE-HE method? A) The bladder is palpable above the symphysis pubis, and the patient has not voided for 12 hours. B) The bladder is nonpalpable, and the patient has voided 200 mL of light yellow urine. C) The bladder is tender to palpation, and the patient has not voided for 8 hours. D) The bladder is distended, and the patient has voided 100 mL of dark amber urine. Rationale: A nonpalpable bladder and normal urine output (200 mL) of light yellow urine are expected findings. Difficulty voiding or a distended bladder would be abnormal and require intervention. During the postpartum assessment, a nurse observes that a patient's legs have swelling and tenderness in the calf area. What is the most important assessment for the nurse to perform next? A) Check for pedal pulses. B) Assess for redness and warmth. C) Perform Homan's sign test. D) Ask the patient about their recent activity level. Rationale: Swelling and tenderness in the calf may indicate a deep vein thrombosis (DVT), and Homan's sign (pain on dorsiflexion of the foot) can help assess for this condition. Further intervention may be needed if the test is positive. A postpartum patient is displaying signs of baby blues, including crying, irritability, and mild mood swings. The nurse understands that these symptoms: A) Are a normal part of postpartum adaptation, resolving within 2 weeks. B) Indicate the development of postpartum depression and require immediate treatment. C) Are a sign of an underlying psychiatric disorder requiring psychiatric consultation. D) Should be addressed with medication to prevent the development of severe depression. Rationale: "Baby blues" are common in the first few days to weeks postpartum. These mild mood changes resolve on their own. Postpartum depression (PPD) requires more persistent and severe symptoms and intervention. A nurse is assessing a postpartum patient's episiotomy site using the REEDA scale. Which of the following would indicate normal healing? A) Redness, edema, and discharge at the site. B) Redness and mild edema without discharge. C) Redness, edema, and purulent drainage. D) Ecchymosis, tenderness, and minimal edema. Rationale: Ecchymosis (bruising), mild tenderness, and minimal edema are expected as the episiotomy site heals. Significant redness, discharge, or purulent drainage could indicate infection. A nurse is assessing the paternal adaptation to pregnancy. The expectant father expresses feelings of jealousy toward the mother for receiving all the attention during the pregnancy. Which of the following is the best nursing intervention? A) Encourage the father to withdraw from the pregnancy and give the mother space. B) Reassure the father that as the pregnancy progresses, he will become more involved. C) Suggest that the father take over all of the mother's responsibilities at home. D) Advise the father to ignore his feelings and focus on the baby after birth. Rationale: As the pregnancy becomes more visible and the father becomes involved in prenatal visits, his sense of connection to the pregnancy will increase. The nurse should offer reassurance and validate the father's feelings of uncertainty. During the first trimester of pregnancy, a father expresses ambivalence about the pregnancy and seems uncertain about his role. The nurse recognizes that this is typical of which phase of paternal adaptation? A) Announcement Phase B) Moratorium Phase C) Focusing Phase D) Acceptance Phase Rationale: During the first trimester, fathers often experience ambivalence, uncertainty, and need time to accept the pregnancy as "real." This is known as the Announcement Phase of paternal adaptation. A pregnant woman is in her second trimester and is feeling more connected to her baby after hearing the heartbeat and feeling fetal movements. The nurse recognizes that this is characteristic of which phase of maternal adaptation? A) Acceptance of the Pregnancy B) Second Trimester Adaptation Phase C) Reordering Relationships D) Focusing Phase Rationale: The second trimester, also known as the "moratorium phase," is when the mother begins to feel more connected to the fetus, especially through experiences like hearing the heartbeat and feeling fetal movements. A pregnant woman in her third trimester expresses concerns about her body image, noting that she feels uncomfortable with the physical changes of pregnancy. Which of the following would best support the nurse's assessment of the patient's psychosocial and emotional changes? A) Counsel the patient that physical changes are temporary and will resolve after childbirth. B) Provide detailed information on how to cope with labor pain management techniques. C) Provide education on expected pregnancy changes, body image, and proper nutrition. D) Reassure the patient that body image concerns are rare during pregnancy. Rationale: Body image concerns are common in pregnancy, especially during the third trimester. Offering education on expected changes and supporting healthy nutrition can help the patient feel more in control and less anxious about her appearance. A nurse is discussing the developmental tasks of pregnancy with a pregnant adolescent. The nurse recognizes that which of the following developmental tasks may be challenging for the adolescent due to her ongoing developmental needs? A) "Binding in" (integrating the pregnancy into self-concept) B) "Seeking safe passage" through pregnancy, labor, and birth C) "Reordering relationships" with friends, family, and peers D) "Accepting the child" and preparing for parenting responsibilities Rationale: Adolescents may struggle with "reordering relationships," as they are still in the process of establishing their own identity and independence. Pregnancy may disrupt these developmental tasks, adding additional stress. Which of the following cultural factors can influence the role transition to parenthood, particularly for fathers? A) Only Western cultures value paternal involvement in childrearing. B) In some cultures, extended family, such as the grandmother, may assume the primary caregiver role for both the mother and baby postpartum. C) All cultures expect fathers to be highly involved in every aspect of pregnancy and childrearing. D) Cultural differences do not affect the role transition to parenthood. Rationale: In some cultures, the extended family plays a significant role in supporting the new mother and baby, with roles differing for fathers. Understanding cultural differences is important in supporting role transitions. A nurse is caring for a postpartum patient who is experiencing uterine atony and heavy bleeding. The nurse assesses the uterus and notes that it is soft and boggy. Which of the following is the first nursing action?