Final exam - mat
A nurse must give vitamin K 0.5 mg IM to a newborn baby. Which of the following needles could the nurse safely choose for the injection
5/8 inch 25 gauge
A postpartum hemorrhage for a vaginal delivery is defined as a blood loss greater than?
500ml
The nurse notes that a newborn, who is 5 minutes old exhibits the following characteristics: heart rate cry, the baby is well flexed, has a grimace, and a pink body with bluish hands and feet. What does the score to be?
8
The nurse notes that a newborn, who is 5 minutes old, exhibitis the following characteristics: heart rate 108 bpm, respiratory rate of cry, body pink with bluish hands and feet, some flexion. What does the nurse determine the baby's Apgar score is?
8
The nurse monitors his or her postpartum clients carefully because which of the following physiological changes occurs
Decreased blood volume
On examination, it is noted that a full-term primipara in active labour is right occipitoanterior (ROA), 7 cm dilated, and +3 station. Which of the report to the physician?
Descent is progressing well
The nurse is developing a plan of care for the postpartum client during the "taking in" phase. Which of the following would the nurse include
Discuss the labor and birth with the mother
A 2-day-old breastfeeding baby born via normal spontaneous vaginal delivery has been weighed in the newborn nursery. The nurse detern has lost 3.5 % of the birth weight. Which of the following nursing actions is appropriate?
Do nothing because this is a normal weight loss
A pregnant women informs the nurse that her last normal menstral period was on Sept 20, 2022. Using Nagele's rule, the nurse calculates the client's estimated date of delivery to be
June 27, 2023
When palpating the uterus it should normally be
Midline
The first type of lochia that occurs after birth is
rubra
A full-term neonate, Apgar 9/9, has just been admitted to the nursery after a cesarean delivery, fetal position LMA, under epidural anesthesia. Which of the following physiological findings would the nurse expect to see?
soft pulmonary crackle
A baby is just delivered. Which of the following physiological changes is of highest priority?
spontaneous respirations
A full term newborn was just born. Which nursing intervention is important for the nurse to perform first?
remove wet blankets
A client in labour, G2 P1, was admitted 1 hour ago at 2 cm dilated and 50% effaced. She was talkative and excited at that time. During t become serious, closing her eyes and breathing rapidly with each contraction. Which of the following is an accurate nursing assessment
the client is exhibiting an expected behaviour for labour
The umbilical cord normally contains which vessels?
two arteries and one vein
The nurse is assessing an episiotomy on a postpartum client. Which of the following normal findings should the nurse expect to see?
well approximated edges
Lochia alba is a colour
yellow to white
A 16-year old woman is being seen for the first time in the obstetric office. Which of the following comments by the young woman is highest priority for the nurse to respond to?
"On weekends we go out and drink a few beers"
The nurse is teaching the parents of a female baby how to change the baby's diapers. Which of the following should be included in the teaching?
Always wipe the perineum from front to back
The nurse is caring for a postpartum client who experienced a second-degree perineal tear at delivery 2 hours ago. Which of the following interv the nurse perform at this time?
Apply an ice pack to the perineum
A mother questions why the ophthalmic medication is given to the baby. Which of the following responses by the nurse would be appropr time?
"the medicine helps prevent eye infections"
An Apgar score is normally conducted at:
1 and 5 min
normal heart rate for a newborn is:
110-160
Birth weight is usually regained within the first.
2 weeks
To prevent infection, the nurse teaches the postpartum client to perform which of the following tasks?
Change the peripad at each voiding
A normal weight for a full-term infant is:
2500-4000 g
Lochia serosa can last up to
2weeks
Which one of the following nursing interventions would be appropriate for the nurse to perform in order to achieve the client care goal: The clie develop postpartum thrombophlebitis?
Encourage early ambulation
A normal respiratory rate in a newborn is?
30-60
A 2-day-old, exclusively breastfed baby is to be discharged home. Under what conditions should the nurse teach the parents to call the paediatrician
4. If the baby has eyes and skin that are tinged yellow
The nurse auscultates a fetal heart rate of 152 on a client in early labour. Which of the following actions by the nurse is appropriate?
A.Inform the mother that the rate is normal
In a newborn, cyanosis in their extremities is known as:
Acrocyanosis
A 32-weeks' gestation client states that she "thinks" she is leaking amniotic fluid. Which of the following advice should be given to this woman?
B. Go to the hospital to be assessed.
The nursing diagnosis -risk for suffication- is included in a standard care plan in the neonatal nursery. Which of the following outcome goi in relation to this diagnosis?
Baby is placed supine for sleep
A 2-day-old neonate received a vitamin K injection at birth. Which of the following signs/symptoms in the baby would indicate that the treatment was effective?
Blood clots after heel sticks
A gravid client, G3 P2, was examined 5 minutes ago. Her cervix was 8 cm dilated and 90% effaced. She now states that she needs to mo following actions should the nurse perform?
Evaluate the progress of labour
breastfeeding client, G10 P6, delivered 10 minutes ago. Which of the following assessments is most important for the nurse to perform at this time?
Fundus
The nurse is evaluating the involution of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluAte
Fundus 3 cm below the umbilicus, lochia serosa
Which one of the following findings should be reported to the primary health care practitioner when assessing a first-trimester gravida susp trophoblastic disease (hydatiform mole)?
Grape-like clusters passed from the vagina
A client, who is 7 cm dilated and 100% effaced, is breathing at a rate of 30 breaths per minute during contractions. Immediately after a contraction, she complains of tingling in her fingers with some lightheadedness. Which of the following actions should the nurse take at this time?
Have the woman breathe into cupped hands
In the acronym BUBBLE HE, the H stands for?
Homan's sign
The nurse is assessing the fetal station during a vaginal examination. Which of the following structures should the nurse palpate
Ischial spines
The nurse is examining a 2 day postpartum client whose funds is 2 cm below the umbilicus and whose bright red lochia satu hour. What should the nurse document in the nursing record?
Normal involution, lochia rubra moderate
A primipara, 4 hours postpartum, requests that the nurse diaper her baby after a feeding because " I am so tired right now. I just want to have something to eat and take a nap." Based on this information, the nurse concludes that the woman is exhibiting signs of which of the following?
Normal postpartum behyviour
The nurse enters a laboring client's room. The client is complaining of intense back pain with each contraction. The nurse concludes that the fetus is likely in which of the following positions?
Occiput posterior
A nurse is assessing a 1 day postpartum woman who had her baby by cesarean section. Which of the following should the nurse report to the surgeon
Pad saturation every 30 minutes
Which finding should the nurse expect when assessing a client with placenta previa?
Painless vaginal bleeding
full-term newborn was just born. Which nursing intervention is important for the nurse to perform first?
Remove wet blankets
What is the purpose of giving vitamin K to a newborn?
Required for blood coagulation
When an infant's cheek is touched and they turn their head towards the stimulus, this is known as the _______ reflex
Rooting
A woman has been diagnosed with a ruptured ectopic pregnancy. which of the following signs/symptoms is characteristic of this diagnosis?
Sharp unilateral pain
A client has been admitted with a diagnosis of hyperemesis gravidarum. Which of the following orders written by the primary health care provider is highest priority for the nurse to complete?
Start intravenous with multivitamins
A woman, 40 weeks gestation, calls the labour unit to see whether or not she should go to hospital to be evaluated. Which of the following statements by the woman indicates that she is probably in labour and should proceed to the hospital?
The contractions are about a minute long and I am unable to talk through them"
While evaluating the fetal heart monitor tracing on a client in labour, the nurse notes that there are fetal heart decelerations present must the nurse make at this time?
The relationship between the decelerations and the labour contractions
A woman had a baby by normal delivery 10 minutes ago. The nurse notes that a gush of blood was just expelled from the vagina and the umbilical cord lengthened. What should the nurse conclude?
The woman is about to deliver the placenta
The nurse is assessing the midline episiotomy on a postpartum client. Which of the following findings should the nurse expect to see?
Well-approximated edges.
To prevent infections, the nurse teaches the postpartum client to perform which of the following tasks?
change the peripad at each voiding
The anterior fontanel is the shape of a
diamond
Which medication in administered in the eyes of all newborns as a prophylaxis
erythromycin
An obstetrician is performing an amniotomy on a gravid woman in transition. Which of the following assessments must the nurse make immediately following the proceedure?
fetal heart rate
The return of the uterus to the to a nonpregnant state after birth, is known as:
involution