Exam 2 Review (Evolve)

The student nurse asks the clinical instructor about changes in normal elimination patterns of infants. Which response given by the clinical instructor is most appropriate?

"Breastfed infants should pass stools three times a day for the first few weeks."

The nurse is teaching a student about stool patterns of a breastfed infant. What statement made by the student nurse indicates the need for further teaching?

"Stool would have a water ring in normal conditions." Stools in a normal breastfed neonate will not have a water ring. Presence of water ring in stool indicates diarrhea.

The nurse is asking patient questions to elicit cultural expectations about childbearing. What is an appropriate question to be asked by the nurse?

"What foods do you believe will help make a healthy baby?" "What do you and your family believe is healthy during pregnancy?" "What can you do to improve your health and the health of your baby?" "How can your labor support person make you comfortable during labor?"

Tonic neck reflex

"fencing posture" a newborn assumes when supine and turns head to the side

The nurse assisting a laboring patient is aware that the birth of the fetus is imminent. What is the station of the presenting part?

+5 Birth is imminent when the presenting part is at +4 to +5cm

During the vaginal examination of a laboring patient, the nurse analyzes that the fetus is in the right occiput anterior (ROA) position at -1 station. What is the position of the lowermost portion of the fetal presenting part?

1 cm above the ischial spine

A Native American woman gave birth to a baby girl 12 hours ago. The nurse notes that the woman keeps her baby in the bassinet except for feeding and states that she will wait until she gets home to begin breastfeeding. The nurse recognizes that she will wait until she gets home to begin breastfeeding. The nurse recognizes that this behavior is most likely a reflection of what?

A belief that babies should not be fed colostrum

Fetal monitoring of a pregnant patient revealed a regular smooth, undulating wavelike pattern of the FHR. What should the nurse infer about the fetus from these results?

Anemia

The nurse is planning care for a patient with a different cultural background. What is an appropriate goal?

As necessary, adapt the patient's cultural practices to their health needs.

While assessing a pregnant patient using a fetoscope, the nurse also palpates the abdomen of the patient. What is the purpose of palpating the abdomen of the patient?

Assessment of changes in FHR during and after contraction

The nurse is teaching students about culture and its variations. The nurse says, "There is this process by which groups melt into the mainstream, thus accounting for the notion of a melting pot, a phenomenon that has been said to occur in the United States." Which phenomenon is the nurse describing?

Assimilation

The nurse is caring for a non-English-speaking pregnant patient. What nursing interventions would help explain the procedure of vaginal examination to the patient?

Call a service for an interpreter

What does the nurse teach the patient about the benefits of breathing techniques in the second stage of labor?

Causes increase in abdominal pressure

Which characteristic is associated with false labor contractions?

Decrease in intensity with ambulation Although false labor contractions decrease with activity, true labor contractions are enhanced or stimulated with activity such as ambulation.

The nurse is caring for a pregnant patient during labor. What should the nurse do immediately after the child's birth?

Dry the infant and place in warm blanket

What intervention must the nurse performs for the patient demonstrating increased anxiety at the onset of labor?

Encourage a support person to stay with the patient

After performing Leopold maneuvers, the nurse finds that the fetus of a pregnant patient is in occiput posterior position. Which suitable action should the nurse employ while caring for the patient?

Encourage the patient to sit in hands-and-knees position

After observing the fetal heart activity in the electronic fetal monitor, the nurse suspects that the patients umbilical cord is compressed. What did the nurse observe on the monitor?

FHR variable decelerations

The nurse is teaching students about the relationship between patients and their families. Which statements by the student indicates ineffective learning?

Families may hold beliefs that conflict health care.

The nurse examines a 6-day-old newborn and observes that the infant's skin color and sclera appear yellowish. What would the nurse expect to find in the laboratory reports of the infant?

Free bilirubin levels greater than 20mg/dL

What should the nurse keep in mind about cultural influences while providing postpartum care for a patient of Mexican origin who has just delivered a baby?

Give the patient the baby's first diaper Allow bathing to be delayed for 2 weeks

The nurse gives a newborn an Apgar score of 4. What condition observed in the neonate would be consistent with the score?

HR of 70bpm not a normal finding and can be consistent with the condition

The primary hcp has administered terbutaline to a pregnant pt to postpone preterm labor. What changes would the nurse observe in the fetal heart monitor after this drug was administered?

Increase in FHR

After monitoring the fetal heart activity, the nurse concludes that there is impaired fetal oxygenation. What had the nurse observed in the fetal monitor to come to this conclusion?

Increase in the FHR to over 160bpm Late decelerations

The nurse is assessing the vital signs of a patient who is in the fourth stage of labor. The nurse finds that the patient's heart rate has decreased. What would be the most probable reason for the change in heart rate during labor?

Increased cardiac output

The nurse assisting a laboring patient recognizes the Ferguson reflex in the pt. What is the Ferguson reflex?

Maternal urge to bear down

What is the basic mechanism for heat generation in newborns?

Metabolism of brown fat

The nurse notes that, when placed on the scale the newborn immediately abducts and extends the arms and the fingers fan out with the thumb and forefinger forming a "C". What is this response known as?

Moro reflex

The nurse is teaching a group of students about contemporary American family organization. Which statement by the student indicates a need for additional teaching?

Most contemporary American families are nuclear families.

The student nurse finds that the patient who is in labor has sweat on the upper lip, is shivering in the extremities, and is vomiting. What would the student nurse interpret that the patient has symptoms of from these observations?

Onset of the second stage of labor

What are the common signs that are observed in the days preceding labor?

Persistent low backache Blood-tinged mucus Profuse vaginal mucus

What are the causes of somatic pain in a patient who is in the second phase of labor?

Pressure against the bladder Distention of the peritoneum Stretching of the perineal tissue

When placing a newborn under a radiant heat warmer to stabilize temp after birth, what should the nurse do?

Prewarm the radiant heart warmer and place the undressed newborn under it should be prewarmed so the infant does not not experience more cold stress

Which statements are appropriate for defining cultural competence?

Respecting cultural diversity Promoting healthy behaviors Acknowledging ethnic diversity Acknowledging linguistic diversity

What are the factors that speed up the dilation of the cervix?

Strong uterine contractions Pressure by amniotic fluid Force by fetal presenting part

The nurse is teaching the mother of a neonate about hunger cues in the baby. What hunger cues should the nurse teach the patient?

The baby will irritate easily The baby will cry incessantly The baby will not be able to sleep

When using intermittent auscultation (IA) to assess uterine activity, nurses should be aware of what?

The examiner's hand should be placed over the fundus before, during, and after contractions.

During the vaginal examination of a patient, the nurse notes that the fetus is in an oblique lie. What does this indicate?

The fetal lie will undergo change during labor

On completion of a vaginal examination on a laboring woman, the nurse records 50%, 6 cm, -1. What is the correct interpretation of the data?

The fetal presenting part is 1 cm above the ischial spines

A patient sustained a first-degree laceration during childbirth. What physical finding should the nurse infer from this?

The laceration extends through the skin and structures superficial to muscles

The nurse hears the FHT by placing a fetoscope ABOVE the umbilicus of a pregnant patient. What would the nurse infer from this assessment?

The lower extremities of the fetus will be observed initially during birth Breech position

The nurse assesses that a fetus is in a cephalic presentation. What does the nurse mean by the term fetal presentation?

The part of the fetus that enters the pelvic inlet first

Fetal well-being during labor is assessed by:

The response of the fetal heart rate (FHR) to uterine contractions (UCs).

What is the key disadvantage of multigenerational families?

They create stress for some member

The nurse performs nasal and oral suctioning of a newborn immediately after birth. What is the reason for this nursing intervention?

To stimulate respiration

While caring for a postpartum client, the nurse finds that she is unable to feed her newborn on time because the baby spends most of the time sleeping. What should the nurse suggest to the patient in this situation?

You can wake the baby up by gently massaging his back

Under which circumstances should a vaginal examination be performed by the nurse

an admission to the hospital at the start of labor on maternal perception of perineal pressure or the urge to bear down when membranes rupture

Which is the nurse's priority action when observing late decelerations?

change maternal position

The nurse must administer erythromycin opthalmic ointment to a newborn after birth. What should the nurse do?

cleanse eyes from inner to outer canthus before administration instillation of the ointment can be delayed for up to 1 hour to facilitate eye-to-eye contact between the newborn and parents should be applied in conjunctival sac to avoid accidental injury to eye

Normal findings that would suggest and Apgar score of 7 to 10

clear eyes acrocyanosis flexed posture in the neonate

Third-degree laceration

continues through the anal sphincter muscle

After reviewing the laboratory reports of a pregnant patient at term, the primary health care provider advised the nurse to administer IV fluids to the patient. What is the reason for giving such advice?

dehydration

Green-colored stool indicated

diarrhea

While performing a vaginal exam of the patient in active labor, the nurse notes decelerations in the fetal heart during uterine contractions. What should the nurse do in this situation?

document it as a normal finding

The nurse helps a breastfeeding mother change the diaper of her 16-hour-old newborn after the first bowel movement. The mother expresses concern because the large amount of thick, sticky stool is very dark green, almost black in color. She asks the nurse if something is wrong. How should the nurse respond to this mother's concern?

explaining to the mother that the stool is called meconium and is expected of all newborns for the first few bowel movements

Second degree laceration

extends through muscles of the perineal body

What test is performed to determine if membranes are ruptured?

fern test

Babinski reflex

flaring of toes when sole is stroked

The patient reports severe lower back pain during labor. Which position does the nurse plan for the patient during childbirth?

hands-and-knees position reduces stress on the back

The nurse is discussing the importance of breastfeeding and the risks associated with cow's milk with a new mother. What condition is associated with feeding cow's milk to the infant?

hypocalcemia human milk contains calcium and phosphorus at a ratio of 2:1. This is an optimal proportion for bone mineralization. In cow's milk the calcium level is very high and the phosphorus level is very low. This results in decreased calcium absorption. Calcium levels are high, but the overall absorption and availability are very low.

The nurse is assessing a newborn undergoing phototherapy. What changes would the nurse likely notice in the newborn during the process?

increased stool frequency bilirubin is eliminated through stools

The nurse is teaching a group of pregnant patients about early identification of preterm labor. What signs and symptoms of preterm labor should the nurse include in the teaching?

increased vaginal discharge presence of vaginal bleeding painful uterine contractions (UCs)

The nurse is teaching a patient, who is pregnant for the first time, about the signals that indicate the beginning of labor. Which sign will the nurse mention as a signal for the beginning of labor?

involuntary contractions

Fourth-degree laceration

involves the anterior rectal wall

The nurse is briefing a patient who is pregnant for the first time about lightening. Which statement should the nurse mention to describe lightening to the patient?

it allows the patient to breathe more easily

During a prenatal assessment a patient asks the nurse about the disadvantages of spinal anesthesia. What does the nurse teach the patient about potential effect of spinal anesthesia?

it increases probability of operative birth

The nurse observes late decelerations of the fetal heart rate (FHR) in the second phase of labor of a pregnant patient. The nurse assesses the pregnant patient and elevates the lower extremities of the patient. Which assessment finding would be the reason for this nursing intervention?

maternal hypotension

A mother of a newborn reports to the nurse that the child developed bluish pigmentation on the back. What could be the reason for this condition?

mongolian spots

When assisting a patient who has completed the first stage of labor, the nurse observes the patient for supine hypotension. What are the factors of supine hypotension that the nurse notes?

obesity anxiety and pain multifetal pregnancy

Signs of true labor contractions

painful a regular pattern of frequency progression of intensity and duration

What finding would the nurse expect in a neonate in the period of decreased responsiveness, which occurs around 60 to 100 minutes after the first period of reactivity?

pinkish skin color shallow respirations

What would a breastfeeding mother who is concerned that her baby is not getting enough to eat find most helpful and most cost-effective on the day after discharge?

placing a call to the hospital nursery warm line

The nurse clamps the umbilical cord of a preterm infant after 3 minutes of birth. What would be the possible effect in the newborn associated with this action?

polycythemia

While the infant is sleeping, the nurse finds that the infant's heart rate is 60beats/minute. What should the nurse do in this situation?

reassess the heart rate after 30 minutes

The nurse is caring for a pregnant patient who is administered mag sulfate to prevent preterm labor. Which parameters should the nurse assess in the patient to determine drug toxicity?

respiratory status LOC DTR

Cremasteric reflex

retraction of testes when chilled

The nurse restricts the visitors of a pregnant patient and gives a specific time for the patient to rest and sleep after the labor. What maternal patient experience could be the probable reason for this nursing action?

severe fatigue during labor

The nurse is assessing the nuerologic activity of a neonate. What observation should the nurse report?

the ability to suck the neurologic assessment of neonates is performed by determining reflex behaviors, such as sucking, rooting, and grasping.

The nurse is educating first-time mothers on breastfeeding. What are the common reasons for breastfeeding cessation?

the mother may have insufficient supply of milk the mother may have painful nipples while feeding the mother may not get enough sleep during breastfeeding the mother may have insufficient knowledge about lactation

The nurse observes that a pregnant patient has a high temperature and a foul smell of amniotic fluid during labor. Which possible complications would the nurse find in the patient and in the neonate after delivery?

the neonate may have pneumonia the patient may have a pelvic abscess the neonate may have bacteremia and sepsis

Upon reviewing the laboratory reports, the nurse finds that the patient has meconium in the amniotic fluid. What would the nurse infer from this finding?

the patient has prolonged pregnancy

With regard to umbilical cord care, what should the nurses be aware of?

the stump can easily become infected the cord clamp is removed after 24 hrs when it is dry the average cord separation time is 10 to 14 days

The nurse knows that the second stage of labor, the descent phase, has begun when what happens?

the woman experiences a strong urge to bear down

What does the nurse teach the patient about the benefits of combining relaxation with walking, slow dancing, or rocking?

this method may help the baby rotate through the pelvis

A breastfed neonate has a stool frequency of more than

three times per day

When the nurse observes early decelerations, what is the most important nursing action?

to document the finding

Why is Vitamin k given to the newborn?

to enhance ability of blood to clot

The nurse observes that a patient tickles her babys lips with her nipple while breastfeeding. Why does the patient do this?

to help stimulate mouth opening by her baby

After administering phenylephrine as prescribed to a pregnant patient, the nurse places three pillows under the patient's lower extremities. What is the rationale for this intervention?

to increase the patient's blood pressure

A patient has been laboring for several hours and after checking the patient's cervix, the nurse finds the patient's cervix is dilated 9 cm and the patient is having strong uterine contractions (UCs) each lasting for 45 to 90 seconds. Based on these observations, the nurse determines that the patient is in which stage of labor?

transition phase of the first stage of labor

What findings would the nurse expect in a neonate within 30 minutes of birth?

tremors nasal flaring audible grunting

Watery stools are normal findings of breastfed infants

true

What distance is used to define personal space?

varies Cultural traditions define the appropriate personal space for various social interactions. Although the need for personal space varies from person to person and with the situation, the actual physical dimensions of comfort zones differ from culture to culture.

When weighing a newborn, what should the nurse do?

weigh the newborn at the same time each day for accuracy

The nurse is caring for a Hispanic patient who has given birth to a baby. When does the nurse expect the patient to start breastfeeding?

when the milk comes

The nurse is assessing a neonate who is administered vitamin k IM. What changes in the neonate would the nurse primarily monitor to ensure safety?

yellow discoloration of sclera After vitamin k is administered, neonates develop jaundice-like side effects.