304 Exam 3 Quizzes

Which three risk factors have been cited as having a possible effect on prenatal development? a. Nutrition, stress, and mother's age b. Prematurity, stress, and mother's age c. Nutrition, mother's age, and fetal infections d. Fetal infections, prematurity, and placenta previa

a

While auscultating for fetal heart tones in a pregnant client, the nurse observes persistent fetal tachycardia. Which condition would be an anticipated finding? a. If the client's body temperature has increased b. If the tachycardia is caused by late decelerations c. If the tachycardia is related to minimal variability d. If the client's uterine contractions are elevated

a

In newborn babies which parameters measured through the Apgar score? SATA. a. Heart rate b. Respiratory rate c. Muscle tone d. Pupillary reflex e. Hearing acuity

a, b, c

What are the characteristics of a uterine contraction? SATA. a. Frequency (how often contractions occur) b. Intensity (the strength of the contraction at its peak) c. Resting time (the tension in the uterine muscle between contraction) d. Appearance (shape and height) e. Attitude (the way the uterus presents itself)

a, b, c

The nurse is assessing an older adult who is grieving after the loss of a spouse. What are normal signs of grief that the nurse would expect to find? (Select all that apply) a. Loss of interest in attending outside activities b. Feeling fatigued c. Difficulty making decisions d. Problems with remembering things e. Change in appetite and eating patterns

a, b, c, d, e

After removal of the retained placental fragment, the client is recovering on the mother-baby unit. Which intervention would the nurse identify as the priority of care? a. Monitoring the infant's ability to breastfeed b. Checking the perineum frequently c. Assessing VS frequently d. Encouraging the client to ambulate

b

At which age is an impact expected to turn from the abdomen to the back? a. 2 to 4 months b. 4 to 6 months c. 6 to 8 months d. 8 to 10 months

b

During a newborn assessment, the nurse notes that the heart rate is 110 beats per minute, respiratory rates vary from 35 to 40 breaths per minute, and the neonate has a pink complexion. Which conclusion would the nurse make based on these findings? a. The neonate has hyperthermia b. The neonate exhibits normal findings c. The neonate has acrocyanosis d. The neonate has an infected umbilicus

b

How would the nurse identify an increase volume of breast milk? a. By observing the infant's skin color b. By observing the infant's urine color c. By observing the infant's sleeping pattern d. By observing the infant's meconium stool color

b

The nurse explains to a student nurse that the most prevalent clinical manifestation of abruptio placentae (as opposed to placenta previa) is which client condition? a. Bleeding b. Intense abdominal pain c. Uterine activity d. Cramping

b

The nurse is caring for a patient who is near death. What assessment finding cues the nurse that death is approaching? a. Skin irritation b. Mottling c. Increased urine output d. Weakness

b

The nurse is monitoring the client's FHR and notices late decelerations associated with uterine contractions, including a gradual decrease in and return to baseline. To which condition the nurse attribute this pattern? a. Fundal pressure b. Uteroplacental insufficiency c. Vaginal exam d. Fetal scalp stimulation

b

When performing a pulse oximetry to assess a newborn for congenital heart defects, which would the nurse bear in mind? a. the screening test is performed after 48 hours of age b. The test is performed in newborns right hand and on one foot c. the infant has passed if oxygen saturation is greater than 80% d. the infant is evaluated in case of a 10% difference in the extremities

b

Which action by the parent of an 8-month-old infant might cause an allergic response in the infant? a. Breastfeeding the infant b. Feeding the infant whole cow's milk c. Feeding the infant breast milk from a bottle d. Feeding the infant iron-fortified formulas

b

Which area of concern is appropriate to focus on when providing care to pregnant adolescents? a. Feelings of isolation b. Late entry into prenatal care c. Increased risk for c-section d. Risk for chromosomal abnormalities

b

Which clinical finding with the nurse expect to find while assessing a neonate during the first 30 minutes after birth? a. Heart rate increases from 100 to 120 beats per minute b. Fine crackles may be present on auscultation c. Peristaltic waves may be noted over the abdomen d. Respirations are shallow and may reach up to 60 breaths per minute

b

Which fetal heart tracing characteristics are considered reassuring or normal (category 1)? a. Bradycardia not accompanied by baseline variability b. Early decelerations, either present or absent c. Sinusoidal pattern, either present or absent d. Tachycardia not accompanied by baseline variability

b

Which intervention would the nurse perform while using a fiberoptic blanket and phototherapy light for a newborn with jaundice? a. Provide intermittent feedings of glucose water b. cover the newborns eyes with an opaque mask c. place the fully unclothed newborn under the light d. wrap the neck in newborn in a fiberoptic linked

b

Which method would the nurse use to assess the temperature of a neonate 12 hours after birth? a. Rectal route b. Axillary route c. Temporal artery d. Tympanic route

b

Which observation by the nurse indicates that a 7-month0old infant many have delayed motor development? a. The infant is unable to crawl b. The infant is unable to sit without support c. The infant cannot pull themselves up to stand d. The infant cannot walk even when holding the furniture

b

Which statement is accurate regarding caring for a client in the third stage of Labor? a. The placenta eventually detaches itself from a flaccid uterus b. The duration of the third stage may be short and last from the birth of the fetus until the placenta is delivered c. It is important that the dark, roughened maternal surface of those placenta appear before the shiny fetal surface d. The major risk for women during the third stage of Labor is rapid heart rate

b

Which would be the postpartum nurse's priority assessment based on the report at 0900 from L&D to transfer a client to the postpartum unit? a. Pain b. Fundus c. Perineum d. Vital signs

b

Which interventions does a nurse implement to help a patient at the end of life maintain autonomy while in a hospital? (Select all that apply.) a. Use therapeutic techniques when communicating with the patient. b. Allow the patient to determine timing and scheduling of interventions. c. Allow patients to have visitors at any time. d. Provide the patient with a private room close to the nurses' station. e. Encourage the patient to eat when hungry.

b, c, e

Which early feeding-readiness cues are exhibited for a breastfed newborn? SATA. a. Crying b. Rooting reflex c. Sucking motions d. Withdrawing into sleep e. Hand-to-mouth movements

b, c, e,

The nurse is assessing a term infant one minute after birth. The infant has a heart rate of 120 beats per minute, a good cry, well flexed extremities, and acrocyanosis. The infant cried while suctioning the nares. Which Apgar score would the nurse document for this infant?

9

Which infant action is considered a developmental milestone at 11 to 12 months of age? a. The infant turns from side to back b. The infant sits alone without support c. The infant pulls self to standing or sitting position d. The infant walked holding onto furniture

d

At which age would a child be able to properly hold an object? a. 1 to 2 years b. 3 to 4 years c. 5 to 6 years d. 7 to 8 years

a

The nurse is administering an amnioinfusion to a client with oligohydramnios. Which risk would the nurse primarily monitor for during administration? a. Overdistension of the uterus b. High risk of placental abruption c. FHR accelerations d. Increased uterine contractions

a

Which assessment would the nurse make after assessing an electronic fetal heart tracing that indicates umbilical cord compression? a. Variable decelerations b. Increase FHR c. Decrease FHR d. Early decelerations

a

Which condition in a newborn requires immediate intervention? a. Absence of reflexes b. Presence of molding c. Cyanosis of hands and feet d. Salt and protuberant abdomen

a

Which documentation reflects on the neurologic activity of the neonate? a. The ability to suck b. Head circumference c. Abdominal movements d. Head-to-toe measurements

a

Which gross-motor skill would the nurse expect from a 5-month-old infant? a. Roll from abdomen to back b. Scoot or crawl hands and knees c. Sit upright without support d. Walk while holding onto furniture

a

Which language skill would the nurse expect to find a 1-year-old infant? a. Ability to say three to five words b. A vocabulary of up to 300 words c. Ability to follow some grammatical rules d. Ability to say six new words each day

a

Which statement is accurate regarding episodic accelerations in FHR with fetal movement when caring for a laboring client? a. They are reassuring of fetal well-being b. They are caused by umbilical cord compression c. They warrant close observation of the fetus d. They result from uteroplacental insufficiency

a

Which actions implemented by the nurse help grieving families? (Select all that apply.) a. Encourage involvement in nonthreatening group social activities. b. Follow up with the family to make sure all their questions are answered. c. Remind them that feelings of sadness or pain can return around anniversaries. d. Encourage survivors to ask for help. e. Look for overuse of alcohol, sleeping aids, or street drugs

a, b, c, d, e

Which physiologic changes are expected in neonates during the two to 8 hours after birth? SATA. a. Production of mucus b. increase muscle tone c. Retractions of the chest d. Brief periods of Bradypnea e. Brief periods of tachycardia

a, b, e

Which circumstances would warrant the nurse to perform a vaginal examination? SATA. a. On admission to the hospital at the start of labor b. When accelerations in FHR are noted c. On maternal perception of perineal pressure or the urge to bear down d. When rupture of membrane (ROM) occurs e. When bright red bleeding is observed

a, c, d

Which assessment findings with the nurse recognizes normal reflexes in the newborn? SATA. a. The newborn turns the head toward a stimulus with the mouth open when eliciting the rooting reflex b. The newborns fingers fan out when the Palmer reflex is checked c. The newborn forces the tongue outward when the tongue is touched d. The newborn exhibits symmetric abduction and extension of the arms, and fingers from a "C" when the Moro reflex is elicited e. The newborns toes hyperextend with dorsiflexion of the big toe when the sole of the foot is stroked upward along the lateral aspect

a, c, d, e

The nurse is caring for a client in labor who presents with variable decelerations in FHR. What are the nursing interventions in the order in which they would be performed for this client?

a. Assist client the client in changing position b. Discontinue oxytocin administration c. Administer oxygen at 8 to 10 L/min d. Notify the primary HCP e. Assist with a vaginal or speculum exam f. Assist with amnioinfusion if prescribed g. Assist with c-section or assisted vaginal delivery

1. The nurse is caring for a neonate who has a provider prescription to apply erythromycin 0.5% ophthalmic ointment to the neonate's eyes in the first hour after birth. In which order would the nurse perform these interventions?

a. Don gloves and cleanse the eyes if necessary b. Place a thumb and finger at the corner of each lid c. Press gently on the periorbital bridges to open the eyes d. Squeeze the tube to apply ointment to the lower conjunctival sac e. Spread the ointment from the inner canthus to the outer canthus f. Observe the eyes for irritation

A 28-year-old multipara delivered a 9 lb. 3 oz baby girl 1 hour ago after a 22-hour labor with a forceps-assisted birth. As the client is holding her daughter, she keeps shifting position and is becoming increasingly irritable and annoyed with everyone in the room. Which action would the nurse initially take? a. Massage the fundus b. Check the perineum c. Assess VS d. Check the tone of the fundus

b

A nurse is making rounds on a client who had a vaginal delivery, and suspects that the client is having excessive postpartum bleeding. Which would be the priority intervention at this time? a. Call the primary HCP b. Massage the uterine fundus c. Increase the rate of IV fluids d. Monitor pad count, and perform catheterization

b

A pregnant client experienced preterm labor at 30 weeks of gestation. On assessing the client, the nurse finds that the newborn is at risk for having cerebral palsy. Which medication administration would the nurse performed to prevent cerebral palsy in the newborn? a. Calcium gluconate b. Magnesium sulfate c. Glucocorticoid drugs d. Antibiotic medications

b

A patient is receiving palliative care for symptom management related to anxiety and pain. A family member asks whether the patient is dying and now in "hospice." What does the nurse tell the family member about palliative care? (Select all that apply.) a. Palliative care and hospice are the same thing. b. Palliative care is for any patient, at any time, with any disease, in any setting. c. Palliative care strategies are primarily designed to treat the patient's illness. d. Palliative care relieves the symptoms of illness and treatment. e. Palliative care is started at the end of life.

b, d

A parent tells the nurse, "My 2-year-old child doesn't do what I tell him." Which suggestion would the nurse make to the parent? a. Encourage the toddler's independence b. Ask the toddler to follow your instructions c. Limit the opportunities for a 'no' answer d. Wait until the toddler looks for instructions

c

At which age does the anterior fontanelle close? a. Between 1 and 6 months b. Between 6 and 12 months c. Between 12 and 18 months d. Between 18 and 24 months

c

At which age should a child perform fine motor skills such as transferring objects from hand to hand? a. 2 to 4 months b. 4 to 6 months c. 6 to 8 months d. 8 to 10 months

c

When assessing a 1-week-old infant, the nurse observes that the newborn has apnea, lethargy, jitteriness, and feeding problems. Which condition would the nurse suspect as the cause of the infant's symptoms? a. HR of 120 bpm b. Body temperature of 99.5f c. Blood glucose level of 38 mg/dL d. BP of 80/40 mmHg

c

When monitoring the client in labor, the nurse knows that the likely cause of variable fetal heart rate (FHR) decelerations is which factor? a. Uterine tachysystole b. Maternal hypertension c. Umbilical cord compression d. Epidural or spinal anesthesia

c

Which clinical finding would the nurse expect when examining a 36-week-old newborn male infant immediately after birth? a. Rugae covering the scrotal sac b. Desquamation of the epidermis c. Vernix caseosa covering the body d. Erythema toxicum

c

Which condition in an infant is considered a sentinel event and associates neonatal phototherapy? a. Malaria b. Urinary problems c. Severe hyperbilirubinemia d. Birth weight less than 2500g

c

Which condition would the nurse recognize in a newborn with pale blue lips, feet, and palms 48 hours after birth? a. Acrocyanosis b. Polycythemia c. Central cyanosis d. Transient tachypnea

c

Which intervention would the nurse recommend to a postpartum client who reports firm, hot, and shiny breast? a. Cold compression b. Breast massage c. Placing cabbage leaves over the breast d. Anti-inflammatory drugs

c

Why is vitamin K administered to newborns? a. It reduces bilirubin levels b. It increases the production of red blood cells c. It enhances the ability of blood to clot d. It stimulates the formation of surfactant

c

A client at 39 weeks of gestation with a history of preeclampsia is admitted to the L&D unit. She suddenly experiences increase contraction frequency every one to two minutes; dark red vaginal bleeding; and a tense painful abdomen. the nurse would suspect the onset of which client condition? a. Eclamptic seizure b. Uterine rupture c. Placenta previa d. Abruptio placentae

d

Approximately how many centimeters does toddler grow each year? a. 1.7 cm b. 3.5 cm c. 6.2 cm d. 7.5 cm

d

At which age can an infant normally place objects into containers? a. 4 to 6 months b. 6 to 8 months c. 8 to 10 months d. 10 to 12 months

d

At which age would a baby be expected to crawl on the floor using arms and legs? a. 2 to 4 months b. 4 to 6 months c. 6 to 8 months d. 8 to 10 months

d

At which age would the nurse expect a baby to have no head lag? a. 1 month b. 2 months c. 3 months d. 4 months

d

The nurse is caring for a client who is undergoing treatment for a DVT. Which s/s would the nurse monitor in the client to evaluate the response to treatment? a. Dysuria, petechiae, and vertigo b. Petechiae, hematuria, and dysuria c. Hematuria, increased lochia, and vertigo d. Hematuria, petechiae, and increased lochia

d

Which action does the nurse expect a 4-month-old infant to perform? a. Using a pincer grasp b. Banging objects together c. Placing object in a container d. Placing objects from hand to mouth

d

Which developmental milestone would an infant begin to demonstrate at the age of 7 to 9 months? a. Smiling responsively b. Differentiating a stranger from a familiar person c. Linking visual to auditory stimuli d. Realizing things exist even when unseen

d

Which factor relates to the type of injury common for a specific age group? a. Provision of adult supervision b. Educational level of the parent c. Physical health d. Developmental level

d

Which factor would contribute to weight loss in a 7-month-old? a. Change from breast milk to infant formula b. Inclusion of soy-based formula in the diet c. Dehydration from adaption to new foods d. Inclusion of fruit juices and flavored drinks

d

Which interpretation would the nurse have for an Apgar score of 10 at one minute after birth? a. an infant having no difficulty adjusting to extrauterine life and needing no further testing b. an infant in severe distress who needs or substation c. A prediction of a future free of neurologic problems d. An infant having no difficulty adjusting to extrauterine life but who should be assessed again at 5 minutes after birth

d

Which is a newborn benefit when placed on the client's bare chest in the prone position? a. To improve the newborn's appetite b. To prevent the newborn's aspiration c. To prevent "baby blues" in the newborn d. To improve the newborn's thermoregulation

d

Which nursing intervention would suppress lactation in a client who had a stillbirth? a. Run warm water over the client's breast b. Administers strong analgesics c. Administer oral and IV fluids d. Advised the client to wear a breast binder for the first 72 hours after giving birth

d

Which stool assessment finding would prompt the nurse to evaluate a newborn breastfeeding effectiveness? a. greenish yellow, loose stools on the third day b. yellow soft and seedy stools on the 7th day c. Greener, thinner, and less sticky stools on the second day d. Greenish, black, thick, and sticky meconium stools on the third day

d

When monitoring a client in labor who has just received spinal analgesia, which assessment findings would the nurse report to the HCP? SATA. a. Maternal BP of 108/79 b. Maternal HR of 98 c. Respiratory rate of 14 breaths/min d. FHR of 100 bpm e. Minimal variability on a FHR monitor

d, e

A nurse has the responsibility of managing a patient's postmortem care. What is the proper order for completing postmortem care when there is no autopsy ordered? a. Bathe the body of the deceased. b. Collect any needed specimens. c. Remove all tubes and indwelling lines. d. Position the body for family viewing. e. Speak to the family members about their possible participation. f. Ensure that the request for organ/tissue donation and/or autopsy was completed. g. Notify support person (e.g., spiritual care provider, bereavement specialist) for the family. h. Accurately tag the body, including the identity of the deceased and safety issues regarding infection control. i. Elevate the head of the bed.

f, i, b, e, g, c, a, d, h