exam 2 nclex style questions

Which of the following would be considered a clinical sign of hemorrhage? 1. Increased blood pressure 2. Increasing pulse 3. Increased urinary output 4. Hunger

Answer: 2 Explanation: 2. Increasing pulse, widening pulse pressure would be considered a clinical sign of hemorrhage.

A baby is born precipitously in the ER. The nurses initial action should be to: Establish an airway for the baby Ascertain the condition of the fundus Quickly tie and cut the umbilical cord Move mother and baby to the birthing unit

Establish an airway for the baby The nurse should position the baby with head lower than chest and rub the infant's back to stimulate crying to promote oxygenation. There is no haste in cutting the cord.

A neonate is admitted to a hospital's central nursery. The neonate's vital signs are: temperature = 96.5 degrees F., heart rate = 120 bpm, and respirations = 40/minute. The infant is pink with slight acrocyanosis. The priority nursing diagnosis for the neonate is Ineffective thermoregulation related to fluctuating environmental temperatures. Potential for infection related to lack of immunity. Altered nutrition, less than body requirements related to diminished sucking reflex. \Altered elimination pattern related to lack of nourishment

Ineffective thermoregulation related to fluctuating environmental temperatures

A woman delivers a 3,250 g neonate at 42 weeks' gestation. Which physical finding is expected during an examination if this neonate? Abundant lanugo Absence of sole creases Breast bud of 1-2 mm in diameter Leathery, cracked, and wrinkled skin

Leathery, cracked, and wrinkled skin

The nurse understands that the classic symptom of endometritis in a postpartum client is which of the following? 1. Purulent, foul-smelling lochia 2. Decreased blood pressure 3. Flank pain 4. Breast is hot and swollen

1. Purulent, foul-smelling lochia

A postpartum woman is at increased risk for developing urinary tract problems because of which of the following? 1. Decreased bladder capacity 2. Inhibited neural control of the bladder following the use of anesthetic agents 3. Increased bladder sensitivity 4. Abnormal postpartum diuresis

2

The postpartum client is suspected of having acute cystitis. Which symptoms would the nurse expect to see in this client? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. High fever 2. Frequency 3. Suprapubic pain 4. Chills 5. Nausea and vomiting

2, 3

A client is experiencing excessive bleeding immediately after the birth of her newborn. After speeding up the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse should anticipate the physician requesting which medications? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Methergine 2. Coumadin 3. Misoprostol 4. Serotonin reuptake inhibitors (SSRIs) 5. Nonsteroidal anti-inflammatory drugs

Answer: 1, 3 Explanation: 1. Methergine is commonly used orally for postpartum hemorrhage. 3. Misoprostol is commonly used rectally for postpartum hemorrhage.

The nurse is caring for a postpartum client who is at risk for developing early postpartum hemorrhage. What interventions would be included in the plan of care to detect this complication? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Weigh perineal pads if the client has a slow, steady, free flow of blood from the vagina. 2. Massage the uterus every 2 hours. 3. Maintain vascular access. 4. Obtain blood specimens for hemoglobin and hematocrit. 5. Encourage the client to void if the fundus is displaced upward or to one side.

Answer: 1, 4 Explanation: 1. Weighing the perineal pads will indicate whether the client is bleeding more than anticipated. 4. The nurse reviews hemoglobin and hematocrit levels when available, and compares them to the admission baseline.`

The nurse is assisting a multiparous woman to the bathroom for the first time since her delivery 3 hours ago. When the client stands up, blood runs down her legs and pools on the floor. The client turns pale and feels weak. What would be the first action of the nurse? 1. Assist the client to empty her bladder 2. Help the client back to bed to check the fundus 3. Assess her blood pressure and pulse 4. Begin an IV of lactated Ringer's solution

Answer: 2 Explanation: 2. Massaging the fundus is the top priority because of the excessive blood loss. If the fundus is not firm, gentle fundal massage is performed until the uterus contracts.

Which relief measure would be most appropriate for a postpartum client with superficial thrombophlebitis? 1. Urge ambulation 2. Apply ice to the leg 3. Elevate the affected limb 4. Massage her calf \

Answer: 3 Explanation: 3. Treatment for superficial thrombophlebitis involves application of local heat, elevation of the affected limb, and analgesic agents.

A client had a cesarean birth 3 days ago. She has tenderness, localized heat, and redness of the left leg. She is afebrile. As a result of these symptoms, what would the nurse anticipate would be the next course of action? 1. That the client would be encouraged to ambulate freely 2. That the client would be given aspirin 650 mg by mouth 3. That the client would be given Methergine IM 4. That the client would be placed on bed rest

Answer: 4 Explanation: 4. These symptoms indicate the presence of superficial thrombophlebitis. The treatment involves bed rest, elevation of the affected limb, analgesics, and use of elastic support hose.`

The nurse suspects that a client has developed a perineal hematoma. What assessment findings would the nurse have detected to lead to this conclusion? 1. Facial petechiae 2. Large, soft hemorrhoids 3. Tense tissues with severe pain 4. Elevated temperature

3. Tense tissues with severe pain

he postpartum client has developed thrombophlebitis in her right leg. Which finding requires immediate intervention? 1. The client reports she had this condition after her last pregnancy. 2. The client develops pain and swelling in her left lower leg. 3. The client appears anxious, and describes pressure in her chest. 4. The client becomes upset that she cannot go home yet.

3. The client appears anxious, and describes pressure in her chest.

the postpartum client who delivered 2 days ago has developed endometritis. Which entry would the nurse expect to find in this client's chart? 1. "Cesarean birth after extended labor with ruptured membranes." 2. "Unassisted childbirth and afterbirth." 3. "External fetal monitoring used throughout labor." 4. "The client has history of pregnancy-induced hypertension."

1. "Cesarean birth after extended labor with ruptured membranes." Explanation: 1. Cesarean birth is the single most significant risk of postpartum endometritis as well as prolonged premature rupture of the amniotic membranes (PPROM).

Which findings would indicate the presence of a perineal wound infection? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Redness 2. Tender at the margins 3. Vaginal bleeding 4. Hardened tissue 5. Purulent drainage

Answer: 1, 2, 4, 5 Explanation: 1. Redness is a classic sign of a perineal wound infection. 2. The wound is typically red, indurated, tender at the margins, and draining purulent exudate. 4. The wound is typically red, indurated, tender at the margins, and draining purulent exudate. 5. Purulent drainage is a classic signs of a perineal wound infectio

The client delivered vaginally 2 hours ago after receiving an epidural analgesia. She has a slight tingling sensation in both lower extremities, but normal movement. She sustained a second-degree perineal laceration. Her perineum is edematous and ecchymotic. What should the nurse include in the plan of care for this client? 1. Assist the client to the bathroom in 2 hours to void. 2. Place a Foley catheter now. 3. Apply warm packs to the perineum three times a day. 4. Allow the client to rest for the next 8 hours.

Answer: 1 Explanation: 1. This client is at risk for urinary retention and bladder overdistention. Overdistention occurs postpartum when the woman is unable to empty her bladder, usually because of trauma or the effects of anesthesia. After the effects of anesthesia have worn off, if the woman cannot void, postpartum urinary retention is highly indicative of a urinary tract infection (UTI). Assisting the client to the bathroom is the most likely intervention that will prevent urinary retention.

he client has experienced a postpartum hemorrhage at 6 hours postpartum. After controlling the hemorrhage, the client's partner asks what would cause a hemorrhage. How should the nurse respond? 1. "Sometimes the uterus relaxes and excessive bleeding occurs." 2. "The blood collected in the vagina and poured out when your partner stood up." 3. "Bottle-feeding prevents the uterus from getting enough stimulation to contract." 4. "The placenta had embedded in the uterine tissue abnormally."

Answer: 1 Explanation: 1. Uterine atony (relaxation of the uterus) is the leading cause of early postpartum hemorrhage, accounting for over 50% of postpartum hemorrhage cases.`

Risk factors associated with increased risk of thromboembolic disease include which of the following? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply. 1. Diabetes mellitus 2. Varicose veins 3. Hypertension 4. Adolescent pregnancy 5. Malignancy

Answer: 1, 2, 5 Explanation: 1. Diabetes mellitus is a risk factor for thromboembolic disease. 2. Varicose veins are a risk factor for thromboembolic disease. 5. Malignancy is a risk factor for thromboembolic disease.

A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse's highest priority should be to: Connect the resuscitation bag to the oxygen outlet Turn on the apnea and cardiorespiratory monitors Set up the intravenous line with 5% dextrose in water Set the radiant warmer control temperature at 36.5* C (97.6*F)

Connect the resuscitation bag to the oxygen outlet The highest priority on admission to the nursery for a newborn with low Apgar scores is airway, which would involve preparing respiratory resuscitation equipment. The other options are also important, although they are of lower priority.

he postpartum client states that she doesn't understand why she can't enjoy being with her baby. What would the nurse be concerned about? 1. Postpartum psychosis 2. Postpartum infection 3. Postpartum depression 4. Postpartum blues

DEPRESSION

While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the following nursing actions should be performed initially? Activate the code blue or emergency system Do nothing because acrocyanosis is normal in the neonate Immediately take the newborn's temperature according to hospital policy Notify the physician of the need for a cardiac consult

Do nothing because acrocyanosis is normal in the neonate

To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include: Monitoring for the passage of meconium each shift Instituting phototherapy for 30 minutes every 6 hours Substituting breastfeeding for formula during the 2nd day after birth Supplementing breastfeeding with glucose water during the first 24 hours

Monitoring for the passage of meconium each shift Question 36 Explanation: Bilirubin is excreted via the GI tract; if meconium is retained, the bilirubin is reabsorbed.

When performing a newborn assessment, the nurse should measure the vital signs in the following sequence: Pulse, respirations, temperature Temperature, pulse, respirations Respirations, temperature, pulse Respirations, pulse, temperature

Respirations, pulse, temperature this sequence is least disturbing. Touching with the stethoscope and inserting the thermometer increase anxiety and elevate vital signs.