OB HESI Study Questions (taken from HESI

NCLEX-RN book) 2022/2023 Exam Solution

Objective signs that signify ovulation - ANS-Abundant, thin, clear cervical mucus (egg-
white stretchiness), open cervical os, slight drop in basal body temp & then 0.5 to 1°F
rise, ferning

Ovulation occurs how many days before the next menstrual period? - ANS-14 days

3 ways to identify gestation of pregnancy - ANS-10 lunar months, 9 calendar months, 3

trimesters of 3 months each, 40 wk, 280 days

What maternal position provides optimum fetal and placental perfusion during
pregnancy? - ANS-Knee-chest but side-lying is most comfortable and removes pressure
from abdominal vessels

Major discomforts of first trimester and suggestions for relief for each - ANS-N/V:
crackers before rising.
Fatigue: 7-8hr sleep at night

Naegele's Rule - ANS-First day of LMP: Oct 24

Subtract 3 months: July 24
Add 7 days: July 31=Estimated Date of Delivery
(Adjust year accordingly)

Fundal height at 20 wk gestation - ANS-At the umbilicus

Approximate wt of fetus @ 20 wk gestation - ANS-300-400g

Characteristics of fetus @ 20 wk gestation - ANS-Looks like baby with hair, lanugo,

vernix. No subcutaneous fat.

Normal psychosocial responses to pregnancy in 2nd trimester - ANS-Acceptance of

pregnancy (ambivalence wanes)
Signs of maternal-fetal bonding

Peak of hemodilution in pregnancy - ANS-28-32 wk (decreases Hct)

3 principles relative to wt gain in pregnancy - ANS-Total gain average 24-30 lb

Gain should be consistent throughout pregnancy
Average of 0.9 lb/wk in 2nd & 3rd trimesters

How many calories should be added daily to the pregnant woman's diet? - ANS-300
calories
How much milk should a pregnant woman consume daily during pregnancy? - ANS-1
quart

At how many wks can fetal heart tones be auscultated by Doppler? - ANS-10-12 wks

Schedule of prenatal visits for low-risk pregnant woman - ANS-Once a month until 28
wks
Every 2 wks from 28-36 wks
Once a wk until delivery

Five maternal variables associated with diagnosis of high-risk pregnancy - ANS-1. Age
(<17, >34)
2. Parity (>5)
3. Dx of preeclampsia
4. Dx of Diabetes Mellitus
5. Dx of cardiac disease

Is one ultrasound exam useful in determining presence of IUGR? - ANS-No, serial

measurements are needed

What does the biophysical profile determine (BPP)? - ANS-Fetal well-being

List 3 nursing actions prior to ultrasound exam for woman in 1st trimester of pregnancy -
ANS-1. Have client fill bladder
2. Don't allow client to void
3. Position client supine w/uterine wedge

Advantage of CVS over amniocentesis - ANS--Can be done during 8-12 wks gestation
-Results returned in 1 wk
-Allows for decision about termination in 1st trimester

Why are serum or amniotic AFP levels done prenatally? - ANS-Elevated AFP levels
may indicate presence of neural tube defects.
Low AFP levels may indicate trisomy 21

Most important determinant of fetal maturity for extrauterine survival - ANS-L:S ratio
(lung maturity, lung surfactant development)

3 most common complications of amniocentesis - ANS-1. Spontaneous abortion

2. Fetal injury
3. Infection

4 changes of FHR - ANS-1. Accelerations

2. Early decelerations
3. Variable decelerations
4. Late decelerations
Cause of FHR accelerations and nursing treatment - ANS--Caused by burst of
sympathetic activity
-Reassuring and require no treatment

Cause of FHR early decelerations and nursing treatment - ANS--Caused by head

compression
-Benign and alert nurse to monitor for labor progress and fetal descent

Cause of FHR variable decelerations and nursing treatment - ANS--Caused by cord

compression
-Change of position should be tried first

Cause of FHR late decelerations and nursing treatment - ANS--Caused by

uteroplacental insufficiency (UPI)
-Place client on side and administer O2

VEAL CHOP (acronym for FHR interpretation) - ANS-Variables=Cord compression

Early decel=Head compression
Accelerations=OK
Late decel=Placental insufficiency

Most important indicator of fetal autonomic nervous system integrity and health - ANS-
FHR variability

4 causes of decreased FHR variability - ANS-1. Hypoxia

2. Acidosis
3. Drugs
4. Fetal sleep

Most important action when cord prolapse is determined - ANS-Position mother to

relieve pressure on cord or push presenting part off cord with fingers until emergency
delivery is accomplished

Reactive non-stress test - ANS-FHR acceleration of 15 bpm for 15 sec in response to

fetal movement

Dangers of nipple-stimulation stress test - ANS--Inability to control oxytocin "dosage"

-Tetany/hyperstimulation

Normal fetal scalp pH in labor - ANS-7.25-7.35

Fetal scalp pH in labor of 7.2 indicates what? - ANS-True acidosis

6 prodromal signs of labor - ANS-Lightening, Braxton Hicks contractions, increased

bloody show, loss of mucous plug, burst of energy, & nesting behaviors
True labor vs. False labor - ANS-True: regular, rhythmic contractions that intensify with
ambulation, pain in abdomen sweeping around from back, cervical changes.
False: Irregular rhythm, abdominal pain (not in back) that decreases with ambulation

2 ways to determine whether membranes have truly ruptured - ANS-Nitrazine testing

paper turns dark blue or black, & Demonstration of fluid ferning under microscope

Are psychoprophylactic breathing techniques prescribed for use according to the stage
and phase of labor? - ANS-No. Clients should use these techniques according to their
discomfort level and should change techniques when one is no longer working for
relaxation.

2 reasons to withhold anesthesia and analgesia until the midactive phase of stage I
labor - ANS-If given too early it can retard labor, if given too late it can cause fetal
distress.

Results of hyperventilation in the laboring client and nursing actions to relieve condition
- ANS-Respiratory alkalosis occurs. Relieved by breathing into a paper bag or cupped
hands.

Maternal changes that characterize the transition phase of labor - ANS-Irritability and
unwillingness to be touched. Does not want to be left alone. N/V, hiccups

When should a laboring client have a vaginal exam? - ANS-Vaginal exam should be
done prior to analgesia and anesthesia to R/O cord prolapse, to determine labor
progress, and to determine when pushing can begin.

Cervical effacement - ANS-The taking up of the lower cervical segment into the upper
segment; the shortening of the cervix expressed in percentages from 0-100% or
complete effacement

Where is FHR best heard? - ANS-Fetal back in vertex, OA positions

Normal FHR during labor - ANS-110-160 bpm

Normal maternal BP during labor - ANS-<140/90

Normal maternal HR during labor - ANS-<100

Normal maternal temperature during labor - ANS-<100.4F

4 nursing actions for 2nd stage of labor - ANS-1. Make sure cervix is completely dilated
before pushing is allowed.
2. Assess FHR with each contraction.
3. Teach woman to hold breath for no longer than 10 seconds.
4. Teach pushing technique.

3 signs of placental separation - ANS-1. Gush of blood

2. Lengthening of cord
3. Globular shape of fetus

Why and when should postpartum Pitocin be administered? - ANS-Administered to

prevent postpartum hemorrhage and atony. Give immediately after delivery of placenta.

Contraindication of ergot drugs (Methergine) - ANS-HTN

5 S/S respiratory distress in newborn - ANS-1. Tachypnea

2. Dusky color
3. Flaring nares
4. Retractions
5. Grunting

If meconium is passed in utero, what action must the nurse take in the delivery room? -
ANS-Arrange for immediate ET tube insertion to determine the presence of meconium
below the vocal cords (prevent pneumonitis and meconium aspiration syndrome)

What is considered a good Apgar score? - ANS-7-10

Purpose of eye prophylaxis in newborn - ANS-Prevent opthalmia neonatorum (results

from exposure to gonorrhea in vagina)

Danger associated with regional blocks - ANS-Hypotension resulting from vasodilation

below block, pools blood in periphery, reducing venous return

Major cause of maternal death when general anesthesia is administered? - ANS-

Aspiration of gastric contents

Why are PO meds avoided in labor? - ANS-Gastric activity slows or stops in labor,
decreasing absorption from PO route; may cause vomiting

Best way to administer IV drugs in labor - ANS-At beginning of contraction, push a little
medication in while uterine blood vessels are constricted=reduces dose to fetus

When is it dangerous to administer butorphanol (Stadol), an agonist/antagonist

narcotic? - ANS-When client is an undiagnosed drug abuser of narcotics, it can cause
immediate withdrawal S/S

One of the first S/S of hypotension after receiving regional block - ANS-Nausea

3 nursing actions when hypotension occurs in laboring client - ANS-1. Turn client to left
side
2. Administer O2 via mask @ 10L/min
3. Increase rate of IV infusion (if it doesn't contain med)

4th stage of labor - ANS-1st 4 hr after delivery of placenta

Nursing actions to assist in preventing postpartum hemorrhage - ANS-Massage fundus

and keep bladder emptied

Nursing actions to promote comfort in 3rd degree episiotomy extending to the anal
sphincter - ANS-Ice pack, witch hazel compress, no rectal manipulation

Nursing interventions to enhance maternal-infant bonding during 4th stage of labor -

ANS-1. Withhold eye prophylaxis for up to 2hr
2. Perform newborn admission & routine procedures in room w/parents
3. Encourage early initiation of breastfeeding
4. Darken room to encourage newborn to open eyes
5. Skin-to-skin

3 nursing interventions to ease discomfort of afterpains - ANS-1. Keep bladder empty

2. Provide warm blanket for abdomen
3. Administer analgesics prescribed by HCP

S/S full bladder that might occur in 4th stage of labor - ANS-Fundus above umbilicus,
uterus not at midline, increased bleeding (uterine atony)

1st action by nurse when soft, boggy uterus is palpated - ANS-Fundal massage

S/S hypovolemic shock - ANS-Pallor, clammy skin, tachycardia, lightheadedness,

hypotension

How often should nurse check fundus during 4th stage of labor? - ANS-Q15 min for 1hr;
Q30 for 2hr if normal

A nurse discovers a postpartum client w/a boggy uterus that is displaced above and to
the right of the umbilicus. Immediate nursing action? - ANS-Perform immediate fundal
massage. Ambulate to bathroom or use bedpan to empty bladder (bladder distention)

Which women experience afterpains more than others? - ANS-Breastfeeding women,

multiparas, women who experience overdistention of uterus

3hr after delivery client has temp of 99.5. What nursing actions are indicated? - ANS-
Elevated temp probably due to dehydration and work of labor. Force fluids and reassess
temp in 1hr. Notify HCP if temp >100.4F

Client feels faint on way to bathroom. What nursing assessments should be made? -
ANS-Assess BP sitting and lying. Assess Hgb & Hct for anemia
Factor that places postpartum client at risk for thromboembolism? - ANS-Increased
clotting factors

Breastfeeding mother complains of very tender nipples. What nursing actions should be
taken? - ANS-1. Have client demonstrate infant position on breast.
2. Leave bra open to air-dry nipples for 15 min, 3x daily.
3. Express colostrum and rub on nipples.

3 days postpartum lactating mother has full, warm, taut, tender breasts. What nursing
action should be taken? - ANS-She is engorged. Have newborn suckle frequently, take
measures to increase milk flow: warm water, massage breast, & supportive bra

Resuming sexual intercourse after delivery - ANS-Avoid until postpartum exam. Use
water-soluble lubricant. Expect slight discomfort due to vaginal changes.

Miss 2 consecutive days of birth control pills - ANS-Take 2 pills for 2 days and use
alternative form of birth control

Reason for increased urination in postpartum period - ANS-Up to 3000 ml/day can be
voided because of reduction in the 40% plasma increase during pregnancy

Most common cause of uterine atony in 1st 24hr postpartum - ANS-Full bladder

Postpartum woman: WBC 17,000, afebrile, no S/S infection. Nursing actions? - ANS-
Continue routine assessments. Normal leukocytosis occurs during postpartal period
because of placental site healing

Purpose of giving docusate sodium (Colace) to postpartum client? - ANS-To soften

stool in mothers w/3rd or 4th degree episiotomies, hemorrhoids, or C-section delivery

What should the fundal height be at 3 days postpartum for a woman who has had a
vaginal delivery? - ANS-3 fingerbreadths/cm below umbilicus

3 signs of positive bonding between parents and infant - ANS-1. Call infant by name
2. Exploring newborn head to toe
3. Using en face position

Newborn transitional period - ANS-6-8hr

3 factors that predispose to respiratory depression in newborn - ANS-1. C-section

delivery
2. Magnesium sulfate given to mother in labor
3. Asphyxia or fetal distress during labor
Danger of heat loss to newborn in 1st few hours of life - ANS-Leads to depletion of
glucose, body begins to use brown fat for energy, producing ketones (causing
ketoacidosis and shock)

Normal newborn temperature - ANS-97.7-99.4F

Normal newborn HR - ANS-110-160 bpm

Normal newborn respiratory rate - ANS-30-60 breaths per minute

Normal newborn BP - ANS-80/50

Newborn temp <97F, what nursing actions should be taken? - ANS-1. Place newborn in
isolette or under radiant warmer & attach skin probe to regulate temp in warmer.
2. Wrap newborn double if isolette/warmer not available
3. Put cap on head
4. WATCH FOR S/S HYPOTHERMIA & HYPOGLYCEMIA

Size of newborn head in relation to chest - ANS-Head is usually 2 cm larger unless

severe molding occurred

Possible causes of shrill, high-pitched, weak cry of newborn - ANS-CNS anomalies,

brain damage, hypoglycemia, drug withdrawal

Caput - ANS-Edema on newborn's head. Caput crosses suture lines. NORMAL finding

Cephalohematoma - ANS-Cephalohematoma. Bleeding between skull and periosteum

(could cause hyperbilirubinemia). Does not cross suture lines. ABNORMAL finding.

Common symptoms of newborns w/Downs Syndrome - ANS-Low-set ears, simian

crease on palm, protruding tongue, Brushfield spots in iris, epicanthal folds

3 ways to determine congenital hip dislocation in newborn - ANS-1. Hip click

2. Asymmetric gluteal folds
3. Unequal limb lengths

Babinski reflex present for how long? - ANS-Present until 12-18 months of age

Small for gestational age (SGA) - ANS-Weight below 10th percentile for estimated
weeks of gestation

Large for gestational age (LGA) - ANS-Weight above 90th percentile for estimated
weeks of gestation

Average for gestational age (AGA) - ANS-Weight between 10th and 90th percentiles for
estimated weeks of gestation
Suctioning baby's nose and mouth with bulb syringe, which should be suctioned first? -
ANS-Mouth suctioned first. Stimulating the nares can initiate inspiration, which could
cause aspiration of the mucus in oral pharynx

Normal blood glucose in term neonate - ANS-40-80 mg/dl

Why does newborn need Vitamin K in the 1st hr after birth? - ANS-Sterile gut at delivery
lacks intestinal bacteria necessary for synthesis of Vitamin K. Vitamin K is needed in the
clotting cascade to prevent hemorrhagic disorders.

Physiologic jaundice caused by what in newborn? - ANS-Occurs at 2-3 days of life.

Caused by immature liver's inability to metabolize amino acid phenylalanine

When is screening test for phenylketonuria done? - ANS-At 2-3 days of life, or after
enough milk is ingested to allow for determination of body's ability to metabolize amino
acid phenylalanine

A term newborn should take in how many calories each day? - ANS-110 kcal/day

After initial weight loss, how much weight should the newborn gain each day? - ANS-1
oz or 30 g/day

5 S/S parents should report immediately to HCP - ANS-1. Lethargy

2. Temp >100F
3. Vomiting
4. Green stools
5. Refusal of 2 feeds in a row

Instructions to give woman w/threatened abortion - ANS-Maintain strict bedrest for 24-
48hr. Avoid sexual intercourse for 2 wks.

Nursing interventions for woman hospitalized w/hyperemesis gravidarum - ANS-1.

Weigh daily
2. Check urine ketones TID
3. Give progressive diet
4. Check FHR Q8hr
5. Monitor for electrolyte imbalances

Discharge counseling for woman post hydatidiform mole evacuation by D&C - ANS-1.
Prevent pregnancy for 1 yr
2. Monthly HCG levels for 1 yr
Postop D&C:
1. Call if bright red vag bleeding or foul-smelling discharge occurs
2. Temp spikes >100.4F
Suspect which condition if woman of childbearing age presents w/bilateral or unilateral
abd pain, with or without bleeding? - ANS-Ectopic pregnancy

3 S/S abruptio placentae - ANS-1. Fetal distress

2. Rigid, board-like abd
3. Dark red or absent vag bleeding

4 S/S placenta previa - ANS-1. No pain

2. Bright red vag bleeding
3. Normal FHR
4. Soft uterus

HPV treatment - ANS-Need pap smear in prenatal period. Treatment with laser ablation.

HPV teaching - ANS-Teach about immunization with females age 9-30. Associated
w/cervical carcinoma in mother & respiratory papimatosis in neonate.

HPV - ANS-Detection of dry, wartlike growths on vulva or rectum

Teaching to pregnant adolescent - ANS-Establish trust and rapport before counseling

and teaching can begin. Will not respond to authoritarian approach. Consider
developmental tasks of identity and social and individual intimacy.

Pregnant adolescents prone to which complications? - ANS--Preeclampsia

-IUGR
-CPD
-STIs
-Anemia

Warning S/S preterm labor - ANS-1. >5 contractions/hour

2. Cramps
3. Low, dull backache
4. Pelvic pressure
5. Change in vaginal discharge

Factors predisposing woman to preterm labor - ANS-1. UTI

2. Diabetes
3. Overdistention of uterus
4. Cardiac disease
5. Placenta previa
6. Psychosocial factors (stress, etc.)

When is preterm labor able to be arrested? - ANS-Cervix is <4cm dilated, <50%

effaced, membranes intact & not bulging out of cervical os

Major S/E of beta-adrenergic tocolytic drugs (Terbutaline, Ritodrine) - ANS-Tachycardia

Special actions needed in intrapartum period if labor is unable to be arrested? - ANS-
Monitor FHR continuously & limit drugs that cross placental barrier to prevent further
compromise

Prolonged latent phase for multipara - ANS->14hr

Prolonged latent phase for nullipara - ANS->20hr

Multiparas' average cervical dilation per hour - ANS-1.5 cm

Nulliparas' average cervical dilation per hour - ANS-1.2 cm

Major nursing goals R/T pregnancy-induced HTN w/preeclampsia - ANS-1.

Maintenance of uteroplacental perfusion
2. Prevention of seizures
3. Prevention of complications (HELLP, DIC, abruption)

Purpose of administering magnesium sulfate - ANS-Prevent seizures by decreasing

CNS irritability

Main action of magnesium sulfate - ANS-Central nervous system depression (seizure

prevention)

Antidote for magnesium sulfate - ANS-Calcium gluconate

3 main assessment findings indicating toxic effects of magnesium sulfate - ANS-1.

Reduced urinary output
2. Reduced respiratory rate
3. Decreased reflexes

Major S/S preeclampsia - ANS-1. Increase of BP of 30 mmHg systolic and 15 mmHg

diastolic over previous baseline
2. Proteinuria (albuminuria)
3. CNS disturbances
4. Epigastric pain

Priority nursing action after spontaneous or artificial rupture of membranes - ANS-

Assess FHR

Most common complication of oxytocin augmentation or induction of labor - ANS-Tetany

3 nursing actions if complication from induction of labor occurs - ANS-1. Turn of pitocin
2. Turn client onto side
3. Administer O2 via mask
S/S water intoxication from effect of Pitocin on antidiuretic hormone - ANS-N/V, HA,
hypotension

3 nursing interventions during forceps delivery - ANS-1. Ensure empty bladder

2. Auscultate FHR before application, during process, & between traction periods
3. Observe for maternal lacerations and newborn cerebral or facial trauma

Cause of preeclampsia - ANS-Exact cause unknown. Appears to be R/T vasospasm

w/increased peripheral resistance and vascular damage. Decreased perfusion results in
damage to numerous organs.

Nursing interventions to prevent further CNS irritability in preeclampsia client - ANS-

Darken room, limit visitors, maintain close 1:1 nurse:client ratio, place in private room,
cluster interventions to disturb client as little as possible

Oral hypoglycemic effect on pregnancy - ANS-Oral hypoglycemic meds are teratogenic.

Insulin should be used.

3 maternal complications of gestational diabetes - ANS-Hypoglycemia, hyperglycemia,

ketoacidosis

3 fetal complications of gestational diabetes - ANS-Macrosomia, hypoglycemia @ birth,

fetal anomalies

When should nurse hold dose of magnesium sulfate & call HCP? - ANS--Client's
respirations <12/min
-Absent DTRs
-Urinary output <100 ml/4 hr

3 priority nursing actions in postdelivery period for client with preeclampsia - ANS-1.
Monitor for S/S blood loss
2. Continue to assess BP & DTRs Q4hr
3. Monitor for uterine atony

Why is regular insulin used in labor? - ANS-Short-acting, predictable, can be infused IV,
can be D/C'd quickly

What are the 2 most difficult times for control in pregnant diabetic? - ANS-Late in 3rd
trimester and in postpartum period. Insulin needs drop sharply

3 conditions more likely to develop in clients w/diabetes mellitus - ANS-Preeclampsia,

hydramnios, infection

When is cardiac disease in pregnancy most dangerous? - ANS-At peak plasma volume
increase, between 28 & 32 weeks gestation, & during stage II of labor
Does insulin cross the placenta-breast barrier? - ANS-No. Insulin-dependent women
may breastfeed

Euglycemia - ANS-60-100 mg/dl

Contraceptive technique recommended for diabetic women - ANS-Diaphragm

w/spermicide. Client should avoid birth control pills, which contain estrogen, and IUDs,
which are an infection risk,

Nursing interventions to maintain cardiac perfsion in laboring cardiac client - ANS-1.

Position client in semi- or high Fowler position
2. Prevent Valsava maneuvers
3. Position client in side-lying position for regional anesthesia
4. Avoid stirrups because of possible popliteal vein compression and decreased venous
return.

S/S cardiac decompensation in laboring client w/cardiac disease - ANS-1. Tachycardia

2. Tachypnea
3. Dry cough
4. Rales in lung bases
5. Dyspnea
6. Orthopnea

Gentle counterpressure against perineum during emergency delivery prevents what? -

ANS-Maternal lacerations & fetal cerebral trauma

When may VBAC be considered? - ANS-Low transverse incision was performed and
can be documented; if original complication does not occur

Reason for antacid or gastric antisecretory drugs prior to anesthesia for C-section -
ANS-Antacid buffers alkalize stomach secretions-if aspiration occurs, less lung damage.
Antisecretory reduces gastric acid, reducing risk for gastric aspiration

C-section clients prone to what postoperative complications? - ANS-Paralytic ileus,

infection, thromboembolism, respiratory complications, impaired fetal-maternal bonding

HIV positive antibody test breast feed? - ANS-No. HIV has been found in breast milk

Common S/E ABX to treat puerperal infection - ANS--GI adverse reactions: N/V/D,
cramping
-Hypersensitivity reactions: rashes, urticaria, hives

S/S endometriosis - ANS-1. Subinvolution (boggy, high uterus)

2. Lochia returning to rubra with foul smell
3. Temp at or >100.4F
4. Unusual fundal tenderness
Nursing actions for endometriosis and parametritis - ANS-1. Promote lochial drainage
2. Antipyretic measures (acetaminophen, cool baths)
3. Administration of analgesics and ABX as rx'd
4. Increase of fluids
5. Attention to high protein & high Vit C diet

4 predisposing factors to postpartum infection - ANS-1. Operative delivery

2. Intrauterine manipulation
3. Anemia or poor physical health
4. Traumatic delivery
5. Hemorrhage

4 predisposing factors to postpartum hemorrhage - ANS-1. Dystocia or prolonged labor

2. Overdistension of uterus
3. Abruptio placentae
4. Infection

Immediate nursing actions to be taken when postpartum hemorrhage detected - ANS-1.

Fundal massage
2. Notify HCP if fundus doesn't firm
3. Count pads to estimate blood loss
4. Assess VS
5. Increase IV fluids & administer oxytocin infusion as rx'd

Still continue breastfeeding w/mastitis? - ANS-Yes. Stopping breastfeeding abruptly

may make situation worse by increasing congestion, engorgement and encouraging
bacterial growth.
May need to stop if pus is present or if ABX contraindicated for neonate.

Major CNS danger signals in neonate - ANS-Lethargy, high-pitched cry, jitteriness,

seizures, bulging fontanels

What does Silverman-Anderson index measure? - ANS-Respiratory difficulty

2 major complications of O2 toxicity - ANS-Retrolental fibroplasias and

bronchopulmonary dysplasia

Necrotizing entercolitis caused by: - ANS-Ischemic hypoxia, abd distention, sepsis, lack
of absorption from intestines

Necrotizing entercolitis manifested by: - ANS-Injury to intestinal mucosa

Intraventricular hemorrhage is more common in __? - ANS-Premature neonates &

VLBW babies
Intraventricular hemorrhage results in S/S of - ANS-Increased ICP

Oxygenation is more difficult for neonate with what issues? - ANS-Respiratory distress
syndrome, alveolar prematurity and lack of surfactant, anemia, polycythemia

Cardinal S/S sepsis in newborn - ANS-1. Lethargy

2. Temp instability
3. Difficulty feeding
4. Subtle color changes
5. Subtle behavior changes
6. Hyperbilirubinemia

Nursing interventions to treat newborn hypothermia - ANS-1. Place under radiant

warmer or incubator w/skin probe over liver
2. Warm all items touching newborn

1 gram of urine or blood in diaper/pad = how many ml? - ANS-1gm=1ml

Factors to look for in assessing newborn's ability to take nourishment by nipple & mouth
- ANS-1. Infant has good suck
2. Coordinated suck-swallow
3. <20 min to feed
4. Gain 20-30 g/day

Complications associated w/total parenteral nutrition - ANS-1. Hyperglycemia

2. Electrolyte imbalance
3. Dehydration
4. Infection

Supplements given to newborn to prevent rickets - ANS-Calcium & Vit D

4 nursing interventions to enhance family and parent adjustment to high-risk newborn -

ANS-1. Initiate early visitation to NICU
2. Provide daily info to family
3. Encourage participation in support group for parents
4. Encourage all attempts at care-giving

Risk factors for hyperbilirubinemia - ANS-1. Rh incompatibility

2. ABO incompatibility
3. Prematurity
4. Sepsis
5. Perinatal asphyxia

S/S hyperbilirubinemia in neonate - ANS-1. Bilirubin levels rising 5 mg/day

2. Jaundice
3. Dark urine
4. Anemia
5. High RBC
6. Dark stools

Nursing diagnosis R/T hyperbilirubinemia - ANS-Risk for injury R/T predisposition of

bilirubin for fat cells in brain

3 nursing interventions for neonate undergoing phototherapy - ANS-1. Apply opaque

mask over eyes
2. Leave diaper loose so stools and urine can be monitored
3. Turn Q2hr
4. Watch for dehydration

S/S neonatal narcotic withdrawal - ANS-1. Irritability

2. Hyperactivity
3. High-pitched cry
4. Frantic sucking
5. Coarse flapping tremors
6. Poor feeding

Neonate's response to over-stimulation - ANS-Failure to thrive, absence of crying

How to determine length of tube needed for gavage feeding of newborn - ANS-Measure
from bridge of nose to earlobe, then to halfway point between xiphoid and umbilicus

2 best ways to determine correct placement of gavage tube in infant's stomach - ANS-1.
Aspiration of stomach contents & pH testing
2. Auscultation of air bubble injected into stomach

Characteristics of neonate w/fetal alcohol syndrome - ANS-1. Microcephaly

2. Growth retardation
3. Short palpebral fissures
4. Maxillary hypoplasia