Question

A nurse is planning care a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

Answer 1

Correct Answers:

Cluster the newborn’s care activities

Rationale :

🟢 Clustered care helps reduce stress and promotes physiologic stability in preterm newborns by minimizing frequent handling.

🟢 Preterm infants have immature neurologic and sensory systems, making them more prone to overstimulation; clustering care allows longer periods of uninterrupted rest.

🟢 Providing quiet and low-stimulation periods supports optimal brain development and helps regulate sleep-wake cycles, which are crucial for growth.

🟢 This intervention also decreases energy expenditure, allowing the newborn to use more calories for growth and organ maturation instead of constant stress responses.

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Answer 2

Correct Answers:

Dry, cracked skin

Rationale :

🟡 Post-term newborns (born after 42 weeks) often present with dry, cracked, or peeling skin due to prolonged exposure to amniotic fluid, which causes loss of the protective vernix caseosa.

🟡 Decreased vernix and less lanugo are typical because these protective layers diminish the longer the fetus remains in utero.

🟡 Scant subcutaneous fat is also common in post-term infants, as the placenta may begin to function less effectively, reducing nutrient and oxygen delivery.

🟡 The skin appears leathery and may have deep creases, indicating advanced gestational maturity.

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Answer 3

Correct Answers:

Give a sponge bath until cord stomp falls off.

Rationale :

🔷 Keeping the umbilical cord dry is essential to promote natural drying and separation, which usually occurs within 1–2 weeks after birth.

🔷 Sponge baths help prevent moisture accumulation and reduce the risk of infection by avoiding submersion of the stump in water.

🔷 Covering the cord with a diaper or applying substances like petroleum jelly can trap moisture and delay healing, increasing the risk of bacterial colonization.

🔷 Parents should be taught to fold the diaper below the cord and observe for signs of infection such as redness, foul odor, or discharge.

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Answer 4

Correct Answers:

“We do routine hearing screening on newborns. You'll know the results before you leave the hospital.”

Rationale :

🟣 Universal newborn hearing screening is a standard practice performed in hospitals before discharge to detect congenital hearing loss early.

🟣 Early identification of hearing impairment allows for timely interventions, which are crucial for speech and language development.

🟣 Relying on behavioral cues such as startling to sound or eye contact is not reliable for accurate assessment, especially in newborns.

🟣 Reassuring the parent about objective testing provides evidence-based information and supports parental confidence in the newborn’s care.

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Answer 5

Correct Answers:

Uteroplacental insufficiency

Rationale :

🔶 Late decelerations are a sign of uteroplacental insufficiency, where there is inadequate oxygen exchange between the placenta and the fetus.

🔶 They occur after the peak of the uterine contraction and return to baseline after the contraction ends, indicating fetal hypoxia.

🔶 Common causes include maternal hypotension, placental abruption, or post-maturity, all of which compromise placental perfusion.

🔶 Immediate nursing interventions include repositioning the mother (left lateral position), providing oxygen, and increasing IV fluids to improve placental blood flow.

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Answer 6

Correct Answers:

Position the client on her Side.

Rationale :

🌟 Repositioning the client to her side (preferably the left lateral position) is the priority intervention for late decelerations because it improves uteroplacental perfusion by relieving pressure on the inferior vena cava, enhancing blood flow to the placenta.

🌟 This action directly addresses uteroplacental insufficiency, the underlying cause of late decelerations, thereby improving fetal oxygenation.

🌟 Once repositioned, other supportive measures like administering oxygen and increasing IV fluids can be done, but they are secondary to improving placental blood flow.

🌟 Immediate corrective positioning helps prevent fetal hypoxia and possible complications such as fetal acidosis.

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Answer 7

Correct Answers:

“I’ll feed my baby every 2 hours."

Rationale :

🟩 Frequent breastfeeding, approximately every 2 hours, is the most effective way to relieve breast engorgement because it promotes regular milk removal, preventing milk stasis.

🟩 Early and consistent emptying of the breasts helps maintain milk flow and reduces pain and swelling associated with engorgement.

🟩 Other supportive measures may include warm compresses before feeding to stimulate let-down and cold compresses after feeding to reduce swelling, but frequent nursing is the primary intervention.

🟩 Allowing the baby to feed on demand also helps regulate the mother’s milk production and alleviates discomfort faster.

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Answer 8

Correct Answers:

a surge of energy

Rationale :

🟦 A surge of energy, also called "nesting", is a common sign that precedes labor as hormonal changes stimulate the mother to prepare for the baby’s arrival.

🟦 This burst of energy often occurs in the days or hours before true labor begins and is considered a normal pre-labor symptom.

🟦 Other signs that may accompany this include lightening (baby dropping), increased vaginal discharge, and mild backache, which indicate the body is preparing for labor.

🟦 The surge of energy should not be confused with the active phase of labor; however, it signals that labor is approaching soon.

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Answer 9

Correct Answers:

Right lower

Rationale :

🟨 Leopold maneuvers help determine fetal position by palpation. A round, firm, moveable part in the fundus indicates the fetal head, meaning the breech (buttocks) is down near the pelvis.

🟨 The long, smooth surface on the right side corresponds to the fetal back, which is the optimal site for auscultating fetal heart tones (FHTs).

🟨 Since the back is on the right side and the presenting part (buttocks) is down, FHTs are best heard below the umbilicus in the right lower quadrant.

🟨 FHTs are typically auscultated over the fetal back or chest, as this area provides the clearest sound conduction.

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Answer 10

Correct Answers:

Red and painful area in one breast

Rationale :

🟥 Mastitis is a localized breast infection that typically presents with a red, warm, and painful area on one breast, often accompanied by fever and malaise.

🟥 It usually occurs due to milk stasis or a blocked milk duct, allowing bacterial entry, commonly Staphylococcus aureus, through a nipple fissure.

🟥 Unlike engorgement, which affects both breasts symmetrically, mastitis is unilateral and localized to one specific area.

🟥 Early identification and continued breastfeeding (or milk expression) are important to resolve milk stasis and prevent abscess formation.

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Custom Exam 3 N205 (Spring~2025)

No.

1 :
A nurse is planning care a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

2 :
A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect?

3 :
A nurse is teaching a newborn’s parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?

4 :
A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?

5 :
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

6 :
A nurse caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?

7 :
A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?

8 :
A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?

9 :
A nurse a is Caring for a client, Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right Side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

10 :
A nurse is caring for a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?

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Custom Exam 3 N205 (Spring~2025)

No.

1 : A nurse is planning care a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

2 : A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect?

3 : A nurse is teaching a newborn’s parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?

4 : A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?

5 : A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

6 : A nurse caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?

7 : A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?

8 : A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?

9 : A nurse a is Caring for a client, Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right Side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

10 : A nurse is caring for a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?

1 :
A nurse is planning care a preterm newborn. Which of the following nursing interventions to promote development should be included in the plan of care?

2 :
A nurse is assessing a newborn who was born at 42.5 weeks of gestation. Which of the following findings should the nurse expect?

3 :
A nurse is teaching a newborn’s parent to care for the umbilical cord stump. Which of the following instructions should the nurse include?

4 :
A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following statements should the nurse make?

5 :
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

6 :
A nurse caring for a client who is in active labor and notes late decelerations on the fetal monitor. Which of the following is the priority nursing action?

7 :
A home health nurse is teaching a client who is breastfeeding about managing breast engorgement. Which of the following client statements indicates understanding of the teaching?

8 :
A nurse in a prenatal clinic is caring for a client who is at 39 weeks of gestation who asks about the signs that precede the onset of labor. Which of the following should the nurse identify as a sign that precedes labor?

9 :
A nurse a is Caring for a client, Using Leopold maneuvers, the nurse palpates a round, firm, moveable part in the fundus of the uterus and a long, smooth surface on the client's right Side. In which abdominal quadrant should the nurse expect to auscultate fetal heart tones?

10 :
A nurse is caring for a client who is 3 days postpartum and is attempting to breastfeed. Which of the following findings indicate mastitis?