NUR 113 Unit 3 Practice Questions
The nurse is teaching participants in a prenatal class regarding breast-feeding versus formula feeding. A client asks, "What is the primary advantage of breast-feeding?" Which response is most appropriate? 1 "Breast-fed infants have fewer infections." 2 "Breast-feeding inhibits ovulation in the mother." 3 "Breast-fed infants adhere more easily to a feeding schedule." 4 "Breast-feeding provides more protein than cow's milk formula does."
1 breast-fed infants have fewer infections Maternal antibodies are transferred from the mother in breast milk, providing protection for a longer time than do antibodies transferred to the fetus by way of the placenta. The neonate is protected by the antibodies and thus has fewer infections. The fetus' own antibody system is immature at birth. Women who breast-feed completely (day and night with no supplementary feedings) may avoid ovulation and resumption of the menstrual cycle. Use of formula or solid foods decreases breast-feeding frequency and can lead to ovulation. Ovulation generally occurs before menses, making it difficult to know when the menstrual cycle is resuming. Therefore, breast-feeding is considered one of the least reliable methods of contraception for the new mother. Because of the higher carbohydrate content of breast milk, which is digested rapidly, breast-fed infants wake more frequently than formula-fed infants. Their feeding demands take more time to regulate than do the formula-fed infants'. Breast milk has 1.1 g protein/100 mL; cow's milk has 3.5 g/100 mL. Whole cow's milk is unsuitable for infants.
Thiamine (vitamin B1) and niacin (vitamin B3) are prescribed for a client with alcoholism. Which body function maintained by these vitamins will the nurse monitor? 1 Neuronal activity 2 Bowel elimination 3 Efficient circulation 4 Prothrombin development
1 Neuronal activity Thiamine and niacin help convert glucose for energy and influence nerve activity. These vitamins do not affect elimination. These vitamins are not related to circulatory activity. Vitamin K, not thiamine and niacin, is essential for the manufacture of prothrombin.
The nursing assessment of a client with severe preeclampsia who is receiving magnesium sulfate reveals a pulse rate of 55 beats/min, a respiratory rate of 10 breaths/min, and a flushed face. Which is the next nursing action? 1 Stopping the infusion and starting an infusion of dextrose and water 2 Continuing the infusion and notifying the primary health care provider 3 Continuing the infusion and documenting the findings in the clinical record 4 Decreasing the rate of the infusion and obtaining blood for a magnesium level
1 Stopping the infusion and starting an infusion of dextrose and water The client's slow pulse, respirations, and flushed face are signs of magnesium sulfate toxicity. The infusion should be stopped and the intravenous site maintained with an infusion of dextrose 5% in water because an antagonist (calcium gluconate) may be prescribed. Continuing the infusion and notifying the primary health care provider is unsafe because continuing the infusion will make the central nervous system (CNS) depression more severe. The primary health care provider should be notified after the infusion has been stopped. Continuing the infusion and documenting the findings in the clinical record are unsafe; the client's clinical manifestations indicate a life-threatening condition. It is unsafe to decrease the rate of the infusion because the CNS depression will worsen. Blood for determination of the magnesium level should be obtained, but not before the infusion is stopped.
A newborn has an Apgar score of 3 at 1 minute after birth. Which is the immediate nursing action in response to this Apgar score? 1 Start resuscitation. 2 Administer oxygen. 3 Place in a heated crib. 4 Stimulate by tapping the toes.
1 start resuscitation An Apgar score of 3 indicates a severely depressed newborn with apnea, slow heart rate, and an absence of reflexes; resuscitation should be ongoing and should have been started before 1 minute elapsed. A patent airway must be established before oxygen is administered. Although thermoregulation is important, establishing a patent airway and initiating respiration are of greater importance. Stimulation efforts are ineffective for a neonate who requires resuscitative measures.
Which is an appropriate nursing intervention for a neonate with respiratory distress syndrome (RDS)? 1 Avoid handling the infant to conserve energy. 2 Position the infant to promote respiratory efforts. 3 Assess the infant for congenital birth defects to enable early treatment. 4 Set the incubator thermostat 10°F (12°C) below body temperature to prevent shivering
2 Position the infant to promote respiratory efforts. Positioning the infant with the head slightly hyperextended and changing the position every 1 to 2 hours help respiratory secretions drain; this will increase oxygenation by enhancing respiratory efforts. Extensive handling is not desired, but infants do need to be touched. All newborns, not just those with RDS, are assessed for congenital birth defects. Setting the incubator thermostat 10°F (12°C) below body temperature is too low; it may exacerbate the respiratory distress.
Which would the nurse recommend to a new mother when teaching her about the care of the newborn's umbilical cord area? 1 Remove the cord clamp only after the cord stump has separated. 2 Smooth ointment or baby lotion around the cord after the sponge bath. 3 Leave the area untouched or clean with soap and water; then pat it dry. 4 Wrap an elastic bandage snugly around the waist area over the cord site.
3 Leave the area untouched or clean with soap and water; then pat it dry. Healing is optimal when the area is left alone or, if needed, is washed with mild soap and water and then gently dried. The cord clamp is removed when the cord stump is dry, usually at 24 hours. Ointment and other emollients will keep the cord moist; rapid drying of the cord is preferred. Wrapping an elastic bandage snugly around the waist area over the cord site prevents the cord from drying and provides a dark, warm, moist medium for the growth of organisms.
In an effort to foster a healthy grief response to the birth of a stillborn child, which response would the nurse make to the mother's questions about the cause? 1 "This often happens when something is wrong with the baby." 2 "It's God's will; we have to have faith that it was for the best." 3 "You're young, and you'll have other children—wait and see." 4 "You may be wondering whether something you did caused this."
4 "You may be wondering whether something you did caused this." The nurse would say, "You may be wondering whether something you did caused this." The mother must be helped to identify her feelings to foster a healthy grief response. Many stillborn children are apparently free of any defects. Telling the woman that it was God's will and that we have to have faith that it was for the best is based on the nurse's religious beliefs; there is no indication that the client has the same beliefs, so this closes off communication. Telling her that she is young and will have other children is false reassurance; it does not encourage the client to explore her feelings.
Which assessment finding indicates that disseminated intravascular coagulation (DIC) is occurring in a postpartum client who has experienced an abruptio placentae? 1 Boggy uterus 2 Hypovolemic shock 3 Multiple vaginal clots 4 Bleeding at the venipuncture site
4 Bleeding at the venipuncture site Bleeding at the venipuncture site indicates afibrinogenemia; massive clotting in the area of the separation has resulted in a decrease in the circulating fibrinogen level. A boggy uterus indicates uterine atony. Although hypovolemic shock may occur with DIC, there are other causes of hypovolemic shock, not just DIC. Blood clots indicate an adequate fibrinogen level; however, vaginal clots may indicate a failure of the uterus to contract and should be explored further.
Which is the focus of nursing care for a newborn with respiratory distress syndrome? 1 Tapping the toes to stimulate respirations 2 Turning the infant frequently to prevent apnea 3 Maintaining oxygen concentration at 40% to support respiration 4 Keeping the infant warm to maintain body temperature at 98°F (37°C)
4 Keeping the infant warm to maintain body temperature at 98°F (37°C) A warm environment is most important, because if the neonate has to maintain body temperature it will further compromise physical status by increasing metabolic activity and oxygen demand. Frequent turning and stimulation such as tapping the toes are both contraindicated, because increased activity increases oxygen demands. The oxygen percentage will vary with the neonate's Po2 values; the concentration of oxygen should never be set at a fixed amount.
Which interventions would be included in the nursing care for a client receiving magnesium sulfate for severe preeclampsia? Select all that apply. One, some, or all responses may be correct. 1 Monitoring deep tendon reflexes 2 Assessing urine output every 8 hours 3 Maintaining a dark, quiet environment 4 Using a pump to regulate the medication 5 Having calcium gluconate available at the bedside 6 Notifying the health care provider if the respiratory rate is slower than 20 breaths/min
Monitoring deep tendon reflexes Maintaining a dark, quiet environment Using a pump to regulate the medication Having calcium gluconate available at the bedside Magnesium sulfate level is monitored closely because toxicity may occur with levels over 8 mg/dL. It works by relaxing skeletal muscle; therefore deep tendon reflexes should be assessed hourly. Maintaining a dark, quiet environment decreases stimulation and reduces the risk of seizures. Magnesium sulfate must be administered with the use of an infusion pump because it can be toxic and cause respiratory distress. Calcium gluconate is the antidote to magnesium sulfate and should be immediately available for the treatment of overdose. Assessing urine output every 8 hours is not sufficient. Urine output of less than 30 mL/h must be reported to the primary health care provider. A respiratory rate slower than 12 breaths/min, not 20, must be reported to the primary health care provider.
