621 Exam

A newborn has a heart rate of 90 beats per minute, a regular respiratory rate of 40 breaths per minute, tight flexion of the extremities, a grimace when stimulated, and acrocyanosis. The nurse assigns an Apgar score of: 5. 6. 7. 8.

7

The nursing student is preparing a presentation illustrating the effects of hypoglycemia on an infant. Which signs or symptoms should the student be srue to include in the presentation? Select all that apply. A) Bradypnea B) Jitteriness C) Lethargy D) Seizures E) Hyperthermia

B, C, D

A fundal massage is sometimes performed on a postpartum woman. The nurse would perform this procedure to address which condition? A) uterine atony B) uterine prolapse C) uterine subinvolution D) uterine contraction

A

A nurse is conducting a review program for a group of neonatal nurses about pulmonary complications associated with preterm birth, explaining that the most common severe adverse pulmonary outcome of preterm birth is bronchopulmonary dysplasia. Which information would the nurse address as a preventive measure? A) antepartum administration of steroids to the mother B) administrating tocolytics to the mother before birth C) start resuscitation with 100% oxygen immediately after birth D) immediate intubation after birth

A

After a class for expectant parents on the various forms of birth control after the birth of their infant, the nurse realizes more training is needed when a participant makes which comment? A) "I'm going to be breastfeeding occasionally, so we won't need to use any other birth control for at least six months." B) "We will be discussing birth control with our primary care provider to find the best method for us." C) "We're going to use a barrier for the first few months and then decide what we want to do." D) "I'm going back on the pill as soon as the doctor okays it."

A

The nurse assesses a postpartum woman's perineum and notices that her lochial discharge is moderate in amount and red. The nurse would record this as what type of lochia? A) lochia rubra B) lochia serosa C) lochia normalia D) lochia alba

A

The nurse is concerned that the parents are having difficulties relating to their newborn. In an effort to assist with and encourage attachment, which activity should the nurse suggest? A) promoting skin-to-skin contact on the chest B) sleeping with the infant C) keeping the baby in the same room at all times D) playing a recording of their voices at all times

A

The nurse is examining the morning lab results of the newborns of mothers with diabetes. Which report finding should the nurse prioritize? A) Hypocalcemia B) Hypermagnesemia C) Hypobilirubinemia D) Hyperkalemia

A

A client in her seventh week of the postpartum period is experiencing bouts of sadness and insomnia. The nurse suspects that the client may have developed postpartum depression. What signs or symptoms are indicative of postpartum depression? Select all that apply. A) inability to concentrate B) loss of confidence C) manifestations of mania D) decreased interest in life E) bizarre behavior

A B D

A nurse is assessing a client with postpartal hemorrhage; the client is presently on IV oxytocin. Which interventions should the nurse perform to evaluate the efficacy of the drug treatment? Select all that apply. A) Assess the client's uterine tone. B) Monitor the client's vital signs. C) Assess the client's skin turgor. D) Get a pad count. E) Assess deep tendon reflexes.

A B D

A new mother is nervous about sudden infant death syndrome (SIDS) and asks the nurse how to prevent it when the newborn is ready to sleep. Which suggestions should the nurse include in the answer? Select all that apply. A) Place the infant on his or her back. B) Keep the infant dressed warmly at night. C) Not allow anyone to smoke around the infant. D) Let the newborn sleep in the same bed as the parents. E) Avoid using a pacifier when putting the infant to sleep.

A, C

A nurse is caring for a newborn with hypoglycemia. For which symptoms of hypoglycemia should the nurse monitor the newborn? Select all that apply. A) lethargy B) low-pitched cry C) cyanosis D) skin rashes E) jitteriness

A, C, E

A newborn is discharged from the hospital before undergoing metabolic screening. A community health nurse scheduling a follow-up home visit knows that the most appropriate time to perform the heel stick is: A) within 24 hours of birth. B) at least 24 hours after birth. C) at least 36 hours after birth. D) before the baby has received 8 feeds of breast milk or formula.

B

A nurse is developing a program to help reduce the risk of late postpartum hemorrhage in clients in the labor and birth unit. Which measure would the nurse emphasize as part of this program? A) administering broad-spectrum antibiotics B) inspecting the placenta after delivery for intactness C) manually removing the placenta at birth D) applying pressure to the umbilical cord to remove the placenta

B

A nurse is preparing a couple and their newborn for discharge. Which instructions would be most appropriate for the nurse to include in discharge teaching? A) introducing solid foods immediately to increase sleep cycle B) demonstrating comfort measures to quiet a crying infant C) encouraging daily outings to the shopping mall with the newborn D) allowing the infant to cry for at least an hour before picking him or her up

B

A postpartum client reports urinary frequency and burning. What cause would the nurse suspect? A) uterine atony B) urinary tract infection C) subinvolution D) stress incontinence

B

The nurse is assessing the breast of a woman who is 1 month postpartum. The woman reports a painful area on one breast with a red area. The nurse notes a local area on one breast to be red and warm to touch. What should the nurse consider as the potential diagnosis? A) breast yeast B) mastitis C) plugged milk duct D) engorgement

B

A nurse is caring for a client who has just given birth. What is the best method for the nurse to assess this client for postpartum hemorrhage? A) by assessing skin turgor B) by assessing blood pressure C) by frequently assessing uterine involution D) by monitoring hCG titers

C

A nurse is developing a plan of care for a woman who is at risk for thromboembolism. Which measure would the nurse include as the most cost-effective method for prevention? A) prophylactic heparin administration B) compression stockings C) early ambulation D) warm compresses

C

After the nurse teaches a local woman's group about postpartum affective disorders, which statement by the group indicates that the teaching was successful? A) "Postpartum blues usually resolves by the 4th or 5th postpartum day." B) "Postpartum psychosis usually appears soon after the woman comes home." C) "Postpartum depression develops gradually, appearing within the first 6 weeks." D) "Postpartum psychosis usually involves psychotropic drugs but not hospitalization."

C

Based on the nurse's knowledge about the postpartum period and an increase in blood coagulability during the first 48 hours, the nurse closely assesses the client for which condition? A) hyperglycemia B) varicose veins C) thromboembolism D) calcium depletion

C

The nurse is teaching discharge instructions to the young parents of a healthy newborn boy, whose vital signs are stable and whose circumcision appears clean and intact. The nurse should encourage the parents to call the health care provider if which situation is discovered? A) A yellowish crusty substance on the circumcision site B) Crying for 2 hours or more each day C) Redness at the base of the umbilical cord D) Straining when he is passing stools

C

What would the nurse expect to prioritize in the assessment of a newborn who has a positive Coombs test? A) tremor activity B) hyperglycemia C) jaundice development D) phenylketonuria

C

After teaching a group of new mothers about the physiologic jaundice in breastfed and bottle-fed newborns, the nurse determines that the teaching was successful when the mothers state which information? A) Peak bilirubin levels occur earlier for bottle-fed newborns than for breastfed newborns. B) The decline in bilirubin levels occurs more quickly in bottle-fed newborns. C) Jaundice associated with bottle feeding occurs in two distinct patterns. D) Breastfed newborns tend to have more frequent bowel movements.

D