NR-327 Maternal-Child Nursing - Set 5 - Part 2

Correct Answer: Both face hypoglycemia, though for different reasons

The small infant runs low because glycogen and fat stores never accumulated, while the large infant runs low because fetal insulin stays high after the maternal sugar supply ends. Option b is incorrect because excess insulin explains the macrosomic infant alone. A growth restricted newborn drops its sugar from empty stores and a large brain drawing on a small body. Option c is incorrect because poor placental flow produced the undergrown infant, not the oversized one. Maternal diabetes delivers extra fuel across a healthy placenta and drives growth upward instead. Option d is incorrect because shoulder dystocia, clavicle fracture and nerve injury follow bulk at delivery. A newborn below the tenth percentile passes through the pelvis easily and faces asphyxia instead.

Correct Answer: The higher figure reflects missed and late pills

Typical use failure counts the way people actually take the pill, including doses missed or taken late, while perfect use assumes every dose on time, so the gap measures vulnerability to human error. Option a is incorrect because manufacturing defects are not what the two columns compare. Both rates describe the same product, differing only in how faithfully the person swallowing it follows the daily schedule. Option c is incorrect because the figures come from current formulations rather than from historical pills. Dose strength has fallen over the decades, yet the pill still fails mainly through inconsistent use rather than through chemistry. Option d is incorrect because age is not the variable being separated here. A woman of any age who takes every dose on schedule sits near the perfect use number, and a missed dose moves her toward the other.

Correct Answer: The tonic neck or fencing reflex

Turning the head of a relaxed supine newborn produces the fencing posture, with extension on the side the face turns toward and flexion opposite. It normally disappears by about four months. Option b is incorrect because the Moro follows a sudden drop of the head or a loud noise. Both arms abduct with the fingers fanning, then sweep back into an embrace as the infant cries. Option c is incorrect because Galant testing is done with the infant prone while the nurse strokes alongside the spine. The trunk and hips swing toward the stroked side, which is a different response entirely. Option d is incorrect because stroking the cheek makes a hungry newborn turn toward the touch and open the mouth. That pair of feeding reflexes involves the head and lips, not the limbs.

Correct Answer: Explain that both findings are normal and fade

Milia are plugged sebaceous glands on the nose and chin, and erythema toxicum is a benign blotchy rash that migrates during the first days. Both resolve without treatment or handling. Option a is incorrect because pressing on milia can inflame the skin and introduce bacteria. The plugged glands empty on their own within a few weeks, so lotions and squeezing serve no purpose. Option c is incorrect because infectious rashes in a newborn come with fever, lethargy, poor feeding, or pustules that spread and worsen. This blotchy eruption migrates from place to place and disappears in about a week. Option d is incorrect because separating mother and infant interrupts bonding and feeding for a harmless finding. Erythema toxicum is not contagious, and no precautions beyond ordinary care are needed for it.

Correct Answer: Explain that anniversary reactions are normal and expected

Grief after perinatal loss does not run on a schedule, and dates such as the due date bring the sorrow back for years, so the nurse names the reaction as expected and offers continued support. Option a is incorrect because weeping on a due date is an ordinary feature of bereavement, not a psychiatric emergency. Admission would be considered only for suicidal thinking or an inability to care for herself. Option b is incorrect because hiding every trace of the baby cuts her off from the mementos that help her mourn. Families are encouraged to keep what they treasure and to use it when they need it. Option c is incorrect because setting a deadline on mourning implies she is failing at it. Perinatal grief has no fixed end point, and a statement like this often stops a parent from asking for help again.

Correct Answer: Keep the offer open and store the mementos

Seeing and holding are offered but never forced, and many parents change their minds, so the nurse keeps the invitation open and files the photographs, prints and bands in case the family wants them later. Option a is incorrect because closing the subject removes a decision the parents may want to revisit within the hour. Documentation is necessary, yet on its own it leaves them no way back. Option b is incorrect because carrying the baby in after a clear refusal overrides the parents rather than supporting them. The offer is renewed with words, and the family sets the pace. Option d is incorrect because warning them about regret turns an invitation into pressure. Grief care follows the family's lead, and a parent pushed into holding a baby may carry that memory badly.

Correct Answer: Feed first on that side, chin toward the lump

A plugged duct clears when milk keeps moving. Starting on the affected breast when the infant sucks most strongly, aiming the chin at the lump, and massaging from behind it toward the nipple drains the blockage. Option a is incorrect because skipping feeds on that side is precisely how a plug becomes mastitis. Milk backs up behind the obstruction, pressure builds, and the surrounding tissue turns inflamed within a day or so. Option c is incorrect because antibiotics answer an infection, and nothing here points to one. There is no fever, no flu like aching and no red wedge, so the treatment aimed at mastitis does not apply. Option d is incorrect because the milk from this breast is perfectly good. Discarding it wastes the removal that would open the duct, and pumping alone empties less effectively than a well latched infant.

Correct Answer: The newborn is in significant respiratory distress

Grunting is the infant forcing air against a partly closed glottis to hold the alveoli open, and paired with flaring and rapid breathing it marks distress that needs prompt evaluation. Option b is incorrect because periodic breathing means short pauses followed by rapid breaths without color change or effort. Nothing about flaring nostrils and grunting belongs to that benign pattern. Option c is incorrect because hunger produces rooting, hand to mouth movements and fussing, not labored expiration. Treating these signs as feeding cues would delay oxygen assessment in a struggling infant. Option d is incorrect because a chilled newborn shows mottling, cool skin and falling temperature. Cold stress can certainly worsen breathing, yet the grunt itself signals alveoli collapsing rather than simple heat loss.

Correct Answer: Falling glucose and worsening metabolic acidosis

Burning brown fat consumes oxygen and glucose quickly, so the infant becomes hypoglycemic and shifts to anaerobic metabolism. Lactic acid then accumulates, producing metabolic acidosis that further impairs breathing and perfusion. Option a is incorrect because rapid shallow breathing in a chilled newborn signals rising demand, not better gas exchange. Oxygen consumption climbs faster than intake, so saturation tends to drop rather than improve. Option b is incorrect because cold drives the metabolic rate up, not down. Norepinephrine release pushes the infant to burn limited reserves for heat, which is exactly why growth and weight gain suffer. Option d is incorrect because acidosis interferes with surfactant rather than helping it. Alveoli become harder to keep open, adding grunting and retractions to an infant already struggling with the cold.

Correct Answer: Rouse the newborn and help the mother latch him

Newborns should not go beyond three to four hours between feeds in the first weeks. Undressing him, changing the diaper, skin to skin contact and drops of colostrum on the lips will rouse him to feed. Option a is incorrect because a sleepy newborn in the first days often will not signal hunger at all. Waiting on him means missed feeds, falling glucose, slow bilirubin clearance and a supply that never gets established. Option b is incorrect because plain water gives a newborn no calories and carries real danger. Free water dilutes serum sodium and can trigger seizures, and human milk already supplies complete hydration. Option c is incorrect because charting the observation postpones the intervention this newborn needs now. Another three hours would stretch the interval to eight, well past what a newborn this age tolerates.

Correct Answer: Sharp chest pain with shortness of breath

Chest pain with shortness of breath is one of the ACHES danger signs and may signal a pulmonary embolism or a myocardial infarction, so the client stops the pill and seeks care immediately. Option a is incorrect because nausea is the most common early side effect of the estrogen component and usually settles within two or three months. Taking the pill with food or at bedtime relieves it. Option b is incorrect because breakthrough spotting appears in most users during the first three cycles and is expected rather than dangerous. Stopping the pill over spotting is what actually leads to pregnancy. Option d is incorrect because tender breasts reflect the hormonal adjustment of the first cycles, not a vascular event. A supportive bra and reassurance are enough while the body adapts to the new hormones.

Correct Answer: The findings need feeding assessment and provider notification

Birth weight should be regained by ten to fourteen days, and output below six wet diapers daily after the first week signals poor transfer. This combination calls for a full feeding evaluation and a provider call. Option b is incorrect because losing weight is expected only in the first days. The loss should halt by about the fifth day, so a newborn still under his birth weight at two weeks falls outside every normal curve. Option c is incorrect because longer sessions do not fix ineffective transfer. Feeds that already run past an hour signal a shallow latch, and stretching them further tires the infant without moving more milk. Option d is incorrect because waiting another two weeks risks dehydration and further weight loss in a newborn who is already behind. Delay is the danger here, and reassurance without evaluation is the error to avoid.

Correct Answer: Loose greenish brown stools passed frequently

Loose green brown stools mean the light treated bilirubin is leaving the body through the gut. Frequent stooling is the goal, so the nurse changes diapers promptly and watches the perianal skin. Option a is incorrect because firm infrequent stools would keep bilirubin inside the intestine, where it is deconjugated and reabsorbed. Slow stooling raises the level rather than lowering it. Option c is incorrect because black tarry stool suggests digested blood in the gastrointestinal tract. That finding belongs to bleeding or swallowed maternal blood, not to bilirubin being excreted under blue light. Option d is incorrect because pale putty colored stool points to bile that never reaches the bowel. Such a stool signals obstruction of the biliary tree and calls for urgent evaluation.

Correct Answer: Jitteriness with poor feeding and lethargy

Tremors, feeble sucking and sleepiness are the classic low glucose picture, often joined by an unstable temperature and a weak cry, so the nurse checks a bedside glucose right away. Option a is incorrect because a lusty cry and eager rooting describe a well fed, neurologically intact newborn. Those behaviors reassure the nurse rather than pointing toward a falling sugar. Option b is incorrect because ruddy skin with a strong pulse fits polycythemia or fluid overload. Hypoglycemic newborns more often look pale and sweaty, with dusky lips and shallow breathing. Option c is incorrect because solid tone and lively reflexes are exactly what a stable newborn shows. Low sugar tends to produce floppiness instead, along with tremor and difficulty staying awake.

Correct Answer: "We will fold the diaper below the cord and sponge bathe him"

Keeping the stump clean, dry, and open to air speeds separation, and folding the diaper below it prevents soaking. Sponge baths continue until the cord falls off, usually within one to two weeks. Option b is incorrect because covering the stump traps moisture and delays drying. Dressings also hide the redness, odor, or drainage that would warn the parents of an infection developing around the base. Option c is incorrect because side lying with props is unsafe sleep. Infants belong flat on the back on a firm surface with nothing else in the crib, in the parents' room for the early months. Option d is incorrect because submerging a newborn keeps the cord wet and invites bacteria. Daily tub baths also dry the skin, and two or three baths each week meet a healthy infant's needs.

Correct Answer: Morning temperature and changes in cervical mucus

Fertility awareness rests on a temperature taken every morning before rising and on the daily pattern of cervical mucus, which turns clear, slippery and stretchy as ovulation approaches, with both markers recorded together. Option a is incorrect because body weight and meal times say nothing about when an ovum is released. Neither measurement shifts with the hormonal changes that open and close the fertile window each cycle. Option c is incorrect because tenderness and mood swings cluster in the luteal phase, after ovulation has already passed. Using them as a signal would place intercourse squarely inside the days the couple wants to avoid. Option d is incorrect because pulse and sleep length are not reproductive markers at all. Poor sleep can actually distort the basal temperature reading, which is one reason the method demands a steady daily routine.

Correct Answer: Evaluation is appropriate now given her age

Infertility is defined as a year of regular unprotected intercourse without conception, but the threshold drops to six months once the female partner reaches thirty five, so evaluation is appropriate for her now. Option a is incorrect because two years is longer than any current guideline recommends. Delaying that far wastes reproductive time that matters most in a client already past thirty five. Option b is incorrect because age forty is the point at which immediate evaluation is advised, not the point at which it becomes available. Access is not withheld from younger clients who meet the time criterion. Option d is incorrect because the twelve month rule applies to women under thirty five. Applying it here would postpone testing for another half year while ovarian reserve continues its steady decline.

Correct Answer: Stronger uterine contractions with less vaginal bleeding

Suckling releases oxytocin from the posterior pituitary, which contracts the uterus. The mother feels afterpains, but involution proceeds faster and blood loss is lower than in a woman who does not nurse. Option a is incorrect because engorgement is common in the breastfeeding mother around the third to fifth day. Nursing frequently limits how severe it becomes, yet no one can promise it will not happen. Option b is incorrect because feeding method does not shield a woman from postpartum depression. Overclaiming a benefit like this sets her up for guilt if her mood dips, and it is not what the evidence supports. Option c is incorrect because milk production has no bearing on how a laceration or episiotomy knits together. Perineal healing depends on hygiene, ice then warmth, nutrition and rest rather than on the chosen feeding method.

Correct Answer: The newborn is placed on a cold scale

Conduction moves heat from the newborn into a cooler object touching the body, so an unpadded cold scale draws warmth directly through the skin. Pre-warming and covering the scale prevents this loss. Option a is incorrect because a cold window pulls heat across the space between it and the infant without contact, which defines radiation. Moving the bassinet away from outside walls is the fix here. Option b is incorrect because moisture turning to vapor from skin or linen carries heat away by evaporation. Drying the infant and swapping out the wet blanket addresses that route instead. Option d is incorrect because moving air sweeping over exposed skin describes convection. Closing isolette portholes, shutting doors, and steering the crib clear of vents corrects that problem, not warming a surface.

Correct Answer: The newborn jaundiced at eight hours of age

Yellowing that appears before the newborn completes one full day of life signals hemolysis until proven otherwise, so this infant needs a bilirubin level and provider notification without delay. Option b is incorrect because day three sits squarely inside the physiologic peak. Normal red cell breakdown and an immature liver enzyme raise bilirubin gradually, and this pattern resolves without any intervention. Option c is incorrect because jaundice on the fourth day still falls within the expected window for a term infant. Physiologic yellowing fades over one to two weeks and needs no urgent call. Option d is incorrect because yellowing that begins late on the second day arrives after the twenty four hour mark. Timing alone makes it physiologic, and this newborn is stable and feeding.