365 Exam 3 questions
What information is important for the postpartum nurse to include when educating a patient receiving the Measles, Mumps, and Rubella (MMR) vaccine after childbirth? Select all that apply. 1."Avoid pregnancy for 4 weeks after receiving the vaccine." 2."Report a temperature over 99.0 to your physician or midwife." 3."You are receiving this vaccine because you are not immune to the rubella virus." 4."You may experience pain, redness, and swelling around the injection site." 5."You will only need this vaccine once in your lifetime."
1."Avoid pregnancy for 4 weeks after receiving the vaccine." 3."You are receiving this vaccine because you are not immune to the rubella virus." 4."You may experience pain, redness, and swelling around the injection site."
A nurse is caring for a patient who reports a spinal headache. What statements made by the patient indicate an understanding of a postdural puncture headache? Select all that apply. 1."I should drink a cola." 2."My headache will get better when I stand up." 3."My head hurts because the fluid around my spinal cord is decreased." 4."Dehydration caused my headache." 5."I should start to feel better in a few hours."
1."I should drink a cola." 3."My head hurts because the fluid around my spinal cord is decreased." Rationale: Option 1: Caffeine consumption has been shown to decrease symptoms of spinal headache. Option 2:Spinal headaches are worse when the patient is in an upright position and improved when the patient is laying down. Option 3: Spinal headaches are related to postdural puncture, and subsequent leakage of cerebrospinal fluid (CSF) leading to decreased levels of CSF. Option 4: Spinal headache is not caused by dehydration. Option 5: Spinal headache usually presents 24 to 48 hours and can take 7 to 10 days to resolve. Some patients may require intervention, such as a blood patch.
A nurse is caring for a patient 24 hours post-delivery. What information is important for the postpartum nurse to include in this patient's discharge teaching? Select all that apply. 1."Rise slowly to a standing position." 2."You can resume physical activity as soon as you feel up for it." 3."Drink plenty of water or Gatorade." 4."You might feel lightheaded when you stand because of the blood you lost during delivery." 5."Sit down if you feel dizzy or faint."
1."Rise slowly to a standing position." 3."Drink plenty of water or Gatorade." 5."Sit down if you feel dizzy or faint." Rationale: 2. Patients should be encouraged to rest for the first few weeks following childbirth. 4. Orthostatic hypotension is due to decreased vascular resistance, not blood loss.
When educating a non-breastfeeding primiparous patient, what information is important for the nurse to include? Select all that apply. 1."Wear a supportive bra or sports bra 24 hours a day." 2."If your breasts become engorged, you should pump to relieve the pressure." 3."Do not apply ice packs to the breasts because it will stimulation milk production." 4."You can take an analgesic for pain." 5."You may experience milk leakage for the first 1 to 2 weeks."
1."Wear a supportive bra or sports bra 24 hours a day." 4."You can take an analgesic for pain." Rationale: Non-breastfeeding women should be instructed to wear a supportive bra until her breasts become soft. Women experiencing engorgement may take an analgesic for pain. 2. Women should avoid expending milk or stimulating the breasts. 3.Women experiencing engorgement should apply ice to the breasts. 5.Non-breastfeeding women may experience milk leakage between 1-4 days post-delivery.
A new mother asks the nurse, "Why is my baby opening his mouth and turning his head?" What are the appropriate encouraging responses from the nurse? Select all that apply. 1."Your baby is hungry. Great job on noticing the signs that he needs you." 2."This is called 'rooting' and it is a normal infant response." 3."He's hungry, go ahead and feed him." 4."Why do you think? What could he be telling you?" 5."Sometimes babies do that. I will get you a pacifier."
1."Your baby is hungry. Great job on noticing the signs that he needs you." 2."This is called 'rooting' and it is a normal infant response." 4."Why do you think? What could he be telling you?"
The oncoming nurse is reviewing her assignment for the day, and would like to identify who see first based on acuity. Which woman is at greatest risk for primary postpartum hemorrhage? 1.A G5P4 patient with obesity and undergoing labor induction. 2.A G2P2 patient who delivered a baby vaginally after an 8-hour labor augmented by oxytocin. 3.A G1P1 woman who just delivered via emergency cesarean section for fetal distress. 4.A G2P2 woman delivering vaginally after a cesarean section with her first pregnancy
1.A G5P4 patient with obesity and undergoing labor induction. Rationale: This patient has three risk factors for PPH: high parity, obesity and induced labor.
A postpartum nurse caring for a patient who had a vaginal delivery 3 hours ago notices heavy lochia. What are the priority nursing interventions for this patient? 1.Assess the position, tone and location of the fundus 2.Massage a boggy uterus 3.Document the findings and reassess in 1 hour 4.Quantify blood loss 5.Instruct the client to void and reevaluate
1.Assess the position, tone and location of the fundus 2.Massage a boggy uterus 4.Quantify blood loss 5.Instruct the client to void and reevaluate
A postpartum nurse is caring for a G1P1 patient 24 hours post-vaginal delivery. What is the priority action for the nurse when preparing to assess for uterine involution? 1.Assist the woman to a supine. 2.Instruct the woman to void. 3.Reassure the woman that she will not feel pain during the procedure. 4.Notify the woman that you will be visualizing her perineum.
1.Assist the woman to a supine Rationale: Palpitating for uterine involution should be performed with the patient in supine position. Option 2: An over-distended bladder can result in uterine displacement. The woman should void prior to uterine assessment to allow for an accurate assessment. Option 3:Many women feel discomfort with uterine palpation. Option 4:Assessment for uterine involution involves palpation of the uterine fundus.
The nurse is caring for a preterm infant who has recently started enteral feedings. What assessment findings would the nurse associate with the possible development of necrotizing enterocolitis (NEC)? Select all that apply. 1.Blood in the stool 2.Vomiting 3.Distended abdomen 4.Decreased gastric residuals 5.Visible bowel loops
1.Blood in the stool 2.Vomiting 3.Distended abdomen 5.Visible bowel loops Rationale: Option 1: Inflammation and damage to the bowel can result in occult blood in the stool. Option 2: Obstruction and slow gastric motility can lead to vomiting of stomach contents. Option 3: Obstruction and slow gastric motility can lead to abdominal distention. Option 4: Gastric residuals are increased due to slow gastric emptying. Option 5: Distended loops of bowel may become visible through the abdomen.
Why is it important for nurses to understand cultural competence for parental phases? 1.Cultural beliefs can influence the woman's behaviors and the amount of time she spends in each phase. 2.Cultural beliefs influence the degree of the father\"s care for the infant. 3.Cultural beliefs can affect the role of extended family members. 4.Cultural beliefs can influence the infant\"s name. 5.Cultural beliefs can influence parental decisions when disciplining a young child.
1.Cultural beliefs can influence the woman's behaviors and the amount of time she spends in each phase. 2.Cultural beliefs influence the degree of the father\"s care for the infant. 3.Cultural beliefs can affect the role of extended family members. 4.Cultural beliefs can influence the infant\"s name.
The father of a 5-week-old newborn calls the labor and delivery department. He mentions his wife is constantly crying and won't sleep. What are appropriate nursing interventions based on this information? Select all that apply. 1.Explain signs and symptoms of postpartum depression 2.Provide resources 3.Let it go for another week or so 4.Ask what he has done at home so far 5.Ask to speak to her and refer to physician
1.Explain signs and symptoms of postpartum depression 2.Provide resources 4.Ask what he has done at home so far 5.Ask to speak to her and refer to physician Rationale: Option 1: This is important for the father to know to understand why she may be feeling this way. Option 2:This is important for the father to be able to contact the right people to help. Option 3: Letting it go can turn into psychosis and suicidal thoughts. Option 4: This can help gather what he has done to try to help and encourages him that calling is the best help he could do. Option 5: It's important to triage the patient over the phone to make sure she is safe.
The nurse is assessing the head of a newborn. Which assessment data does the nurse document as a normal finding? Select all that apply. 1.Fontanels soft and flat 2.Anterior fontanel triangle shaped at 3 cm 3.Posterior fontanel diamond shaped at less than 1 cm 4.Molding present with overriding sutures 5.Fontanels bulge when crying
1.Fontanels soft and flat 4.Molding present with overriding sutures 5.Fontanels bulge when crying
The nurse is providing discharge instructions for a postpartum patient who is breastfeeding. The nurse teaches her about risk factors for mastitis. What risk factors will the nurse include? Select all that apply. 1.If the baby weans suddenly 2.If the mother returns to work and cannot pump her breasts regularly 3.If plugged milk ducts do not get emptied 4.If the mother has a cold 5.If the baby has a poor latch
1.If the baby weans suddenly 2.If the mother returns to work and cannot pump her breasts regularly 3.If plugged milk ducts do not get emptied 5.If the baby has a poor latch
The nurse is preparing for a delivery and reviewing the prenatal record. Which risk factor may place the neonate at risk for complications? Select all that apply. 1.Meconium-stained amniotic fluid 2.Labor and birth after 40 weeks gestation 3.Maternal hypertension 4.Maternal age of 18 5.Prolonged labor over 24 hours
1.Meconium-stained amniotic fluid 3.Maternal hypertension 5.Prolonged labor over 24 hours
A postpartum patient who has just delivered has uterine atony, heavy vaginal bleeding, and is pale with clammy skin. Which nursing actions are appropriate at this time? Select all that apply. 1.Notify the provider and request immediate bedside evaluation 2.Ensure IV access with a large bore catheter 3.Assist the patient to walk to the bathroom to void 4.Raise the head of the patient's bed 5.Massage the uterine fundus
1.Notify the provider and request immediate bedside evaluation 2.Ensure IV access with a large bore catheter 5.Massage the uterine fundus rationale: Option 1: Prompt provider notification will expedite implementation of treatment for postpartum hemorrhage. Option 2: This is to replace fluids and administer blood. Option 3: The patient is symptomatic for hypovolemic shock and should not ambulate. Option 4: Raising the head of the bed would divert blood flow from the head. The bed should be flat or in Trendelenburg position for shock. Option 5: This is necessary to correct uterine atony.
The telehealth care nurse is checking in with postpartum patients. Which patient should be instructed to come in for evaluation? 1.Patient who is 14 days post-vaginal birth with return of bright red lochia 2.Patient who is 3 days post-cesarean birth with scant pink lochia 3.Patient who is 12 days post-vaginal birth with scant yellow lochia 4.Patient who is 21 days post-vaginal birth with scant yellow lochia
1.Patient who is 14 days post-vaginal birth with return of bright red lochia Rationale: Return to the lochia rubra state is concerning for late postpartum hemorrhage from subinvolution.
new nurse is assigned to care for a lesbian couple on the mother-baby unit. The nurse is heterosexual has never cared for a homosexual patient before. What is important for the nurse to do prior to meeting the couple? 1.Perform self-reflection of personal beliefs on homosexuality. 2.Review the laws for same-sex parents. 3.Ask the previous nurse if both parents are called mom. 4.Discuss the care with the charge nurse for the shift.
1.Perform self-reflection of personal beliefs on homosexuality. Rationale: When caring for patients who may be different from oneself, it is imperative to reflect on one's personal beliefs and consider the impact that beliefs have on behavior.
The nursing instructor is explaining to a group of students how the neonate transitions to extrauterine life. Which changes regarding the respiratory and cardiovascular systems are correct? Select all that apply. 1.Pulmonary vascular resistance decreases as lung function begins. 2.The foramen ovale closes but may reopen from significant hypoxia. 3.Hypoxemia and acidosis leads to vasodilation of the pulmonary arteries. 4.Amniotic fluid remaining in the lungs after birth may inhibit lung expansion. 5.Cardiac murmurs auscultated at birth will resolve by 72 hours of age.
1.Pulmonary vascular resistance decreases as lung function begins. 2.The foramen ovale closes but may reopen from significant hypoxia. 4.Amniotic fluid remaining in the lungs after birth may inhibit lung expansion. Rationale: Option 1: Pulmonary vascular resistance decreases to allow increased blood flow through the pulmonary vessels. Option 2: This opening closes between the right and left atriums when left atrial pressure is higher than right. It may reopen from significant hypoxia. Option 3: Persistent hypoxemia and acidosis leads to constriction of the pulmonary arteries. Option 4: Compression of the thorax at delivery forces amniotic fluid from the lungs. Excess fluid from cesarean delivery or precipitous birth may impair lung expansion ability. Option 5: There are several different causes of cardiac murmurs. Some do not resolve within the first few hours of life or days after birth.
A newborn is experiencing cold stress. Which assessment data by the nurse will require further evaluation? 1.Tachypnea 2.Shivering 3.Hypoglycemia 4.Hypertonia 5.Lethargy
1.Tachypnea 3.Hypoglycemia 5.Lethargy Rationale: Option 1: Increased respiratory rate occurs to increase metabolism. Option 2: Neonates cannot shiver. They may be jittery from hypoglycemia. Option 3: Glucose level will drop as energy is used to increase metabolic rate. Option 4: Hypotonia, not hypertonia, is seen with cold stress. Option 5: neonates will be difficult to arouse and feed.
. The nurse is assuming care for a postpartum patient who delivered vaginally two hours ago. What information in the shift-change report should alert the nurse to assess for uterine atony? Select all that apply. 1.The patient is not breastfeeding. 2.The patient voided 10 minutes ago. 3.The patient's labor was augmented with oxytocin. 4.This is the patient's sixth baby. 5.The patient had systemic analgesics in labor.
1.The patient is not breastfeeding. 3.The patient's labor was augmented with oxytocin. 4.This is the patient's sixth baby.
The nurse is assuming care for a postpartum patient who delivered vaginally two hours ago. What information in the shift-change report should alert the nurse to assess for uterine atony? Select all that apply. 1.The patient is not breastfeeding. 2.The patient voided 10 minutes ago. 3.The patient's labor was augmented with oxytocin. 4.This is the patient's sixth baby. 5.The patient had systemic analgesics in labor.
1.The patient is not breastfeeding. 3.The patient's labor was augmented with oxytocin. 4.This is the patient's sixth baby.
A neonate born at 28 weeks is 9 days old. During the nurse's assessment, symptoms of necrotizing enterocolitis (NEC) are noted. What is the highest priority symptom to address? 1.Unstable temperature 2.Bloody stools 3.Increased gastric residual 4.Abdominal distension
1.Unstable temperature rationale: can be symptom of shock
A patient on the postpartum unit reports passing an egg-sized clot. What are the priority nursing interventions for this patient? Select all that apply. 1.Weigh the clot. 2.Report the findings to the physician or midwife. 3.Assist the patient to the bathroom. 4.Administer Oxytocin 10U IM. 5.Call for rapid response.
1.Weigh the clot. 2.Report the findings to the physician or midwife. Rationale: Option 1 &2: Clots the size of an egg or larger should be weighed and the findings should be reported to the physician or midwife. Option 3: Assisting the patient to the bathroom is not priority at this time. Option 4: Passing a medium-sized clot does not require Oxytocin administration unless it is accompanied by heavy bleeding or uterine atony. Option 5: Passing an egg-sized clot does not necessitate a rapid response.
A postpartum patient has just been started on intravenous (IV) antibiotics for endometritis. When does the nurse anticipate discontinuing the antibiotics? 1.24 hours after the starting dose 2.24 hours after the patient becomes afebrile 3.10-14 days after starting dose 4.When the uterine tenderness is gone
2. 24 hours after the patient becomes afebrile Rationale: When the patient is afebrile for 24 hours, IV antibiotics are discontinued.
A nurse is caring for a patient in the immediate postpartum period. Upon assessment, the nurse notes heavy bleeding and a boggy uterus that does not respond to fundal massage. What are the priority nursing actions? Place in the correct order. 1. Increase frequency of vital signs 2. Perform fundal massage 3. Notify the physician or midwife of excessive blood loss 4. Achieve free-flowing venous access
2. Perform fundal massage 3. Notify the physician or midwife of excessive blood loss 4. Achieve free-flowing venous access 1. Increase frequency of vital signs
The triage nurse receives a phone call from the parent of a 3-week old male infant. The parent states that the infant has had a pink tinge in their diaper for the last two days. How should the nurse respond? 1."A pink tinge can be a normal finding in the diaper." 2."A pink color may indicate dehydration." 3."You may need to change the diaper more frequently." 4."No worries. Keep your scheduled appointment next month."
2."A pink color may indicate dehydration."
A nurse is educating a patient about deep vein thrombosis (DVT). What information should be included in the discharge plan? Select all that apply. 1."Hit your call light when you are ready to get out of bed for the first time." 2."Avoid crossing your legs while sitting." 3."Your doctor wants you to wear compression stockings." 4."Make sure not to walk around too much." 5."Massage your calves daily to prevent a blood clot."
2."Avoid crossing your legs while sitting." 3."Your doctor wants you to wear compression stockings."
A nurse is preparing to administer the Measles, Mumps, and Rubella (MMR) vaccine to a patient before discharge from the hospital. What question is most important for the nurse to ask prior to administering the vaccine? 1."Do you plan on becoming pregnant again in the next 6 months?" 2."Did you recently receive the RhoGAM?" 3."Which arm do you prefer I give this in?" 4."Have you ever had this vaccine before?"
2."Did you recently receive the RhoGAM?" Rationale: Rh immune globulin may interfere with the immune response to live vaccinations. Option 1: Women who receive the MMR vaccine should avoid pregnancy for 4 weeks. Option 2: Asking which arm the patient prefers is not the priority. Option 3: Some women will require multiple doses.
he postpartum nurse is educating a patient on bowel function post-childbirth. What information is important for the nurse to include? Select all that apply. 1."Drink at least 2 liters of fluids a day." 2."Eat a lot of fruits and vegetables." 3."Avoid whole grains and legumes." 4."Your bowels should be back to normal within 2-3 days." 5."Try not to ambulate too much."
2."Eat a lot of fruits and vegetables." 4."Your bowels should be back to normal within 2-3 days." Rationale: Option 1: Women should be instructed to increase fluid intake to at least 3,000mL a day. Option 2: A diet that includes fiber-rich foods promotes intestinal peristalsis. Option 3: A diet that includes fiber-rich foods promotes intestinal peristalsis. Option 4: Normal bowel function usually returns in 2-3 days after delivery. Option 5: Ambulation promotes intestinal peristalsis and reduces the risk for constipation.
The nurse is caring for a client with diabetes mellitus. She asks the nurse why strict blood glucose control is important. What is the correct response by the nurse? Select all that apply. 1."High maternal blood glucose can cause hyperglycemia in the infant, as well." 2."High maternal blood glucose can cause hypoglycemia in the infant." 3."Congenital anomalies are more likely with uncontrolled diabetes." 4."Precipitous births are more likely when blood glucose is uncontrolled." 5."Your infant is more at risk for birth injuries, such as a broken collar bone, if your blood glucose is too high."
2."High maternal blood glucose can cause hypoglycemia in the infant." 3."Congenital anomalies are more likely with uncontrolled diabetes." 5."Your infant is more at risk for birth injuries, such as a broken collar bone, if your blood glucose is too high." Rationale: Option 1: Hyperglycemia in the mother causes hyperinsulinemia in the infant. This leads to lower neonatal blood glucose levels, not higher. Option 2: Hyperglycemia in the mother causes hyperinsulinemia in the infant. This leads to lower neonatal blood glucose levels. Option 3: Uncontrolled diabetes can cause cardiac and other congenital defects in the developing infant. It can also lead to miscarriage and stillbirth. Option 4: Infants of mothers with diabetes are more likely to be large for gestational age, which makes labor longer and more difficult. Option 5: Infants of mothers with diabetes are more likely to be large for gestational age, which can lead to shoulder dystocia and birth injuries.
Which response by a postpartum patient indicates to the nurse that learning of uterine involution has taken place? Select all that apply. 1."My uterus will stay this big until I get my period again." 2."It will take between 6-8 weeks for my uterus to return to normal size." 3."Contractions will cause my uterus to shrink." 4."My uterus will not be as small as it was before I had a baby." 5."My uterus will return to the size of a volleyball."
2."It will take between 6-8 weeks for my uterus to return to normal size." 3."Contractions will cause my uterus to shrink." Rationale: Option 1: Menses does not affect uterine involution. Option 2: Involution of the uterus takes between 6-8 weeks post-delivery. Option 3: Uterine involution occurs through contractions, atrophy of the uterine muscles, and a decrease in the size of uterine cells" Option 4: The uterus will revert to pre-pregnancy size through the process of involution. Option 5: The typical size of a uterus is comparable to a pear.
The nurse is caring for a patient who was diagnosed with gestational diabetes mellitus (GDM) at 28 weeks of pregnancy. The patient had an uncomplicated vaginal birth 12 hours ago. Which statement made by the patient would require further education? 1."Breastfeeding my baby will help reduce my risk for developing Type II diabetes." 2."My diabetes will resolve in the next few weeks, so there is no need for follow up." 3."I have a much higher risk of developing Type II diabetes now that I have had gestational diabetes." 4."I need to see a provider for preconception glucose control prior to my next pregnancy."
2."My diabetes will resolve in the next few weeks, so there is no need for follow up." Rationale: Follow up with a provider is essential for those with GDM as up to 1/3 of women will continue to have abnormal glucose metabolism at the postpartum appointment.
What statement made by a primiparous patient 4 hours post-delivery requires further assessment by the nurse? 1."Is it normal for it to burn when I go pee?" 2."My uterus is cramping really bad." 3."I think I want to try breastfeeding." 4."Will you take the baby to the nursery so I can nap?"
2."My uterus is cramping really bad." Rationale: Primiparous women usually do not experience discomfort related to uterine contractions during the postpartum period. Option 1: Dysuria can be caused by trauma to the urethra during delivery.
A postpartum client asks the nurse why her temperature is slightly elevated. What is the correct response from the nurse? Select all that apply. 1."You had a fever during labor and the antibiotics have not started working yet." 2."The hard work of labor can cause your temperature to increase." 3."It is common for women to experience mild temperature elevation after giving birth." 4."Your body is going through a lot of hormonal changes right now, which can increase your temperature." 5."Do you feel hot? I will get you some Tylenol."
2."The hard work of labor can cause your temperature to increase." 3."It is common for women to experience mild temperature elevation after giving birth." 4."Your body is going through a lot of hormonal changes right now, which can increase your temperature." Rationale: Option 1: Slight temperature elevation in the postpartal period does not indicate infection. Option 2: Slight temperature elevation postpartum is often related to muscle exertion and dehydration. Option 3: Postpartum women commonly experience temperature elevation due to muscular exertion, exhaustion, dehydration, or hormonal changes. Option 4: Postpartum women commonly experience temperature elevation due to muscular exertion, exhaustion, dehydration, or hormonal changes. Option 5: Slight temperature elevation in the postpartal period does not warrant medication.
The postpartum nurse is educating a patient about what to expect when she goes home. What information about diaphoresis is important to include in the teaching? Select all that apply. 1."Sweating occurs in the weeks after childbirth because of increased estrogen levels." 2."You might experience periods of profuse sweating." 3."This is your body's way of getting rid of extra fluid." 4."Wearing a cotton nightgown will help with comfort." 5."If you experience profuse sweating you should take your temperature."
2."You might experience periods of profuse sweating." 3."This is your body's way of getting rid of extra fluid." 4."Wearing a cotton nightgown will help with comfort." 5."If you experience profuse sweating you should take your temperature."
A postpartum patient is in the emergency department 17 days after a vaginal birth for heavy vaginal bleeding due to subinvolution of the uterus. Which is the best explanation by the nurse? 1."Your uterus is collapsing into the vagina." 2."Your uterus is not returning to its prepregnant size as it should be." 3."Your uterus is infected." 4."Your uterus has turned inside out."
2."Your uterus is not returning to its prepregnant size as it should be."
The nurse is assessing a neonate 1 hour after birth. Which assessment data by the nurse will require further evaluation? 1.Apical pulse of105 beats per minute 2.Axillary temperature at 97 oF 3.Respiratory rate of 32 breaths per minutes 4.Hands and feet cyanotic
2.Axillary temperature at 97 oF Option 1: Normal pulse is 110 to 160 bpm, and may decline during sleep or a period of inactivity. Option 2:The temperature is below normal (97.7-99) and requires intervention. Option 3: Normal RR is 30 to 60 bpm. Option 4: Acrocyanosis is a normal finding and may be seen in the first 24 hours of life.
The nurse is performing a neonatal assessment. Which statement describes the normal breathing pattern of a full-term neonate? 1.Respirations less than 30 during sleep 2.Diaphragmatic and abdominal breathing 3.Deep, synchronous abdominal breathing 4.Nasal flaring with irregular breathing
2.Diaphragmatic and abdominal breathing normal in a full-term neonate
A postpartum patient who had an emergency cesarean delivery due to abruptio placentae is oozing blood from her incision and IV site and is becoming increasingly anxious. Which complication does the nurse suspect based on these assessment findings? 1.Hemolysis elevated liver low platelet (HELLP) syndrome 2.Disseminated intravascular coagulation (DIC) 3.Pulmonary edema 4.Wound dehiscence
2.Disseminated intravascular coagulation (DIC) Rationale: Option 1: HELLP syndrome can lead to DIC, but the signs and symptoms describe DIC. Option 2: The signs and symptoms of DIC include bleeding from gums, IV site, and incision site; uncontrolled uterine bleeding, increased anxiety, and shock. Option 3: Pulmonary edema causes shortness of breath and audible rales. Option 4: Wound dehiscence would not cause bleeding from the IV site.
The nurse is caring for a patient who has an order for misoprostol (Cytotec) for postpartum hemorrhage. Which part of the order should the nurse question? 1.Route is rectal 2.Dose is 50 mcg 3.Route is oral 4.Dose is 800 mcg
2.Dose is 50 mcg Rationale: This is the dose for cervical ripening. The dose for controlling postpartum hemorrhage is 200-1000 mcg. The route is rectal or oral.
The nurse performs a newborn assessment and finds a heart rate of 180 beats per minute. What data by the nurse is necessary to determine if the heart rate is a sign of distress? 1.Skin color 2.Time of birth 3.Maternal temperature 4.Apgar score
2.Time of birth rationale: this is normal in the initial period of reactivity
To prevent damage to the premature infant's skin, what interventions should the nurse perform? Select all that apply. 1.Bathe the infant with a mild, alkaline solution. 2.Use the minimum amount of tape needed to secure tubes or IV lines. 3.Avoid changing position and skin sheering. 4.Use water, air, or gel mattresses. 5.Assess skin at least once a shift for breakdown or infection.
2.Use the minimum amount of tape needed to secure tubes or IV lines. 4.Use water, air, or gel mattresses. 5.Assess skin at least once a shift for breakdown or infection. Rationale: Option 1: A pH neutral soap should be used when bathing the infant. Option 2: Adhesives should be used sparingly on the infant's skin. Option 3: The infant's position should be changed frequently to prevent pressure ulcers and skin breakdown. Option 4: Water, air, or gel mattresses can be used for gentle positioning and comfort. Option 5: Skin should be assessed frequently because the fragile skin of a preterm neonate is predisposed to injury.
A mother asks the nurse when her infant's nasogastric tube may be removed. What is the correct response by the nurse? 1."Once he is eating at least 60 mL per feeding." 2."When he reaches an adjusted gestational age of 34 weeks." 3."When he demonstrates a coordinated suck, swallow, breathe pattern." 4."Once he can maintain a blood glucose level above 50 mg/dL."
3."When he demonstrates a coordinated suck, swallow, breathe pattern." Infants must be able to suck, swallow, and breathe appropriately to tolerate oral feedings and have the NG tube removed.
The nurse is caring for a postpartum patient diagnosed with endometritis. Which factors in the patient's history puts her at highest risk for endometritis? 1.Painful menstruation 2.Active labor six hours 3.Cesarean birth for second stage arrest disorder 4.Vacuum assisted vaginal delivery for fetal distress
3.Cesarean birth for second stage arrest disorder Rationale: Unscheduled Cesarean birth is the primary risk factor for endometritis.
The nurse is assessing a postpartum patient with a suspected vaginal hematoma. Which assessment finding would alert the nurse to a vaginal hematoma? 1.Firm midline fundus with heavy bleeding 2.Bilateral labial edema 3.Report of severe pain in the vaginal area. 4.Purple bulging mass protruding from anus
3.Report of severe pain in the vaginal area Rationale: Hematomas cause severe pain. 1. This is a sign of a bleeding laceration. 2. A hematoma would not cause bilateral edema. This is common after vaginal births. 4. hemorrhoid
A postpartum patient with gestational diabetes is being discharged. What should the nurse include in her discharge instructions? 1.The patient will need to continue insulin injections for six weeks. 2.The patient should continue monitoring blood glucose levels four times daily for six weeks. 3.The patient should be screened for impaired glucose tolerance at 6-12 weeks postpartum. 4.The baby should be screened for juvenile diabetes.
3.The patient should be screened for impaired glucose tolerance at 6-12 weeks postpartum. Rationale: Gestational diabetes increased the chance of impaired glucose tolerance and type II diabetes and it is recommended that screening is done 6-12 weeks postpartum.
After the birth of a newborn, what is the priority nursing action to prevent cold stress? 1.Swaddle in warm blankets 2.Place under a radiant warmer 3.Place a stocking cap on the neonate's head 4.Dry the neonate thoroughly
4. Dry the neonate thoroughly Rationale: Dry, skin to skin (optional), and then swaddle immediately after birth
A postpartum woman calls the clinic about her 4-day-old infant. The baby is not scheduled for a well-baby visit for another 10 days. The mother states, "I am worried that my baby is not getting enough to eat at the breast." Which response by the nurse about effective breastfeeding would be appropriate? 1."As long as your baby gains its birth weight back by one month, breastfeeding is effective." 2."It is normal for your nipples to be sore after breastfeeding." 3."It is important that you take the baby off the breast after 15 minutes of breastfeeding." 4."You should anticipate your baby to void 8 times per day."
4."You should anticipate your baby to void 8 times per day." The newborn should have at least eight wet diapers and several stools per day once breastfeeding is established.
The nurse is assessing a new mother who brought her 6-month-old infant for a well check. The mother is 16-years-old and her mother came with her to the visit. The infant's grandmother is holding the new baby and answering all of the questions. What part of the becoming a mother process does the nurse note to be lacking? 1.Commitment, attachment and preparation 2.Acquaintance and learning to care 3.Learning a new normal 4.Achieving maternal identity
4.Achieving maternal identity Rationale: Achievement of a maternal identity begins around 4 months.
The nurse is caring for patient newly diagnosed with endometritis. What assessment findings are consistent with endometritis? 1.Abdominal cramping and cloudy urine 2.Dizziness and hypotension 3.Edema and hypertension 4.Uterine tenderness and foul-smelling lochia
4.Uterine tenderness and foul-smelling lochia
A client is preparing to formula-feed her one-day-old newborn with a bottle. The client states, "I cannot remember how much to feed my baby, and this bottle is in milliliters. What is the most I should be feeding my baby with this bottle?" Enter the nurse's answer in numerical value.
Newborns should take no more than 0.5 to 1 ounce with each feeding, which equates to 15 to 30 milliliters.
