Lippincott Questions Exam 2

25. The nurse explains to a newly admitted client inactively over that according to the gate control theory of pain a closed gate means that the client should experience what type of pain ? 1. no pain 2. sharp pain 3. light pain 4. moderate pain

1. no pain

13. A 24 year old Primigravid client who gives birth to a viable term neonate is prescribed oxytocin intravenously after delivery of the placenta. Which side would indicate to the nurse at the placenta is about to be delivered? 1. the cord lengthens outside the vagina 2. there is decreased vagina bleeding 3. the uterus cannot be palpated 4. the uterus changed discoid shape

1. the most reliable sign of disconnection from the uterine wall is cord lengthening

A breastfeeding client is seen at home by the visiting nurse 10 days after vaginal birth. The client has a warm red painful breast a temperature of 100 F in flu like symptoms. What should the nurse do? 1. Encourage the client to breast feed her infant using the unaffected breast 2. refer the woman to her HCP 3. inform the client that she needs to discontinue breastfeeding 4. instruct the woman to apply warm compresses to the affected breast

2. refer the woman to her HCP because she has mastitis

6. The nurse is discussing pain relief methods for a pregnant first time mom. The discussion should include which labor support methods? select all that apply 1. effleurage 2. positive reinforcement 3. guided imagery 4. pattern paced breathing 5. self containment theory 6. progressive relaxation

1,3,4,6

44. A one day old breastfed infant has a bilirubin level that is at an intermediate risk for jaundice .which statement by the infant's mother indicates an understanding of the teaching regarding jaundice ? 1. i should breastfeed my baby as often as possible 2. i should supplement with formula after every feeding 3. i should discontinue breastfeeding and change to formula feeding 4. i should place my baby in direct sunlight several times a day

1. Jaundice in a breastfeeding mother is common and not pathological.

1. A primigravid client at 38 weeks gestation comes to the Labor room because her water broke. The health care provider asked the nurse to verify spontaneous rupture of membranes using nitrazine paper. The nurse observes that the nitrazine paper turns bright blue period what action should the nurse take next 1. notify the HCP that the membranes are ruptured 2. perform a sterile vaginal examination to assess the cervix 3. document the findings of the nitrazine test 4. offer the client a sterile sanitary pad after performing perineal care

1. Nitrazine paper response to alkaline fluid by changing blue amniotic fluid is alkaline so the color verifies that the membranes are ruptured

33. Before placing the fetal monitoring device on a client's fundus the nurse reforms leopold's maneuvers. The nurse explains that the third maneuver is done for which reason? 1. To determine whether the fetal presenting part is engaged 2. to locate the fetal cephalic prominence 3. to distinguish between a breach in a cephalic presentation 4. to locate the position the fetal arms and legs

1. leopold's maneuvers are performed to determine the presentation and position of the fetus. the third maneuver determines whether the fetal presennting part is engaged in the maternal pelvis.

41. The nurse is caring for several mother baby couplets. In planning the care fore ach of the couplets, which mother would the nurse expect to have the most seevere afterbirth pains? 1. G4 P1 breasfeeding her infant 2. G3 P3 client who is breastfeeding her infant 3. G2 P2 c section who is bottle feeding 4. G2 P2 who is bottle feeding her infant

2. The major reasoons for afterbirth pains are breastfeeding, high parity, overdistended uterus during pregnancy, and a uterus filled with blood clots

5. A client gave birth vagina like 2 hours ago and has a third degree laceration. There is ice in place on her perineum. However her perineum is slightly edematous and the client is having pain rated 6 on a scale of 1 to 10 . Which nursing intervention would be the most appropriate at this time? 1. Begin sitz bath 2. administer pain medication per prescription 3. place ice packs to the perineum 4. administer prescription analgesics sprays to the perineum

2. Pain medication the first strategy to initiate at this pain level.

50. After the nurse councils of primiparous breast feeding client about diet and nutritional needs during lactation. Which client statement indicates a need for additional teaching ? 1. I need to increase my intake of vitamin D 2. I should drink at least 5 glasses of fluid daily 3. I need to get an extra 500 calories per day 4. I need to make sure I have enough calcium in my diet

2. the breastfeeding mom she should be drinking 8 to 10 glasses of fluid a day

2. A client is in the first hour of her recovery after vaginal birth . During an assessment the lochia is moderate is bright red and is trickling from the vagina. The nurse locates the fundus at the umbilicus it is firm in midline with no palpable bladder. The clients vital signs remain at their baseline. Based on this information the nurse would implement which action? 1. increase the IV rate 2. recheck the admission hemocrit and hemoglobin levels 3. report the findings to the HCP 4. document the finding as normal

3. At any point in the postpartum period the lochia should be dark in color rather than bright red the volume should not be great enough to trickle or run from the vagina.

30. Assessment of a client reveals cervical dilation at 8 centimeters in complete effacement. The client has severe back pain during the phase of Labor. The nurse explains that the client severe black pain is most likely caused by the fetal occiput being in which position? 1. Breech 2. Transverse 3. Posterior 4. anterior

3. Posterior- the fetal head is pushing on the mom's sacrum causing pain

36. A multi gravita in active labor is 7 centimeters dilated. The FHR baseline is 130 BPM with moderate variability. The client begins to have variable to celebrations to 100 to 110 BP M. What should the nurse do next? 1. Perform a vaginal examination 2. notify the HCP of the decelerations 3. reposition the client and continue to evaluate fetal heart rate 4. administer oxygen via mask 2L per minute

3. The cause of variable decelerations is cord compression which may be relieved by moving the client to one side or another

55. The nurse teaches the primiparous client planning to return to work in six weeks about storing breastmilk. which client statement indicates a need for further teaching? 1. I can safely store freshly expressed milk at room temperature for eight hours 2. I will be sure to label the breast milk with the date time and amount 3. i must discard any breast milk stored for more than three days in the refrigerator 4. I can keep the breast milk in a deep freeze clean glass bottle for up to a year

3. breast milk can be stored from 5 to 7 days in the refrigerator

7.In response to the nurses questions about how she's feeling a postpartum client states that she is fine. She then begins talking to the baby checking their diaper in asking infant care questions period the nurse determines that the client is in which postpartum phase of psychological adaptation ? 1. taking in 2. taking on 3. taking hold 4. letting go

3. taking hold- fulfilling the infants needs

46. A primiparous client who's beginning to breast feed her neo Nate asked the nurse "is it important for my baby to get colostrum?" when instructing the client the nurse would explain that colostrum provides the neo Nate with which factors: 1.more fat than breast milk 2.Vitamin K which is in the unit lacks 3.delayed meconium passage 4. passive immunity from maternal antibodies

4. Colostrum is a thin watery yellow fluid composed of protein sugar fat water minerals vitamins and maternal antibodies

43. A diabetic postpartum client plans to breastfeed the nurse determines that the client's understanding of breast feeding instructions is sufficient when the client makes which statement? 1. Insulin will be transferred to the baby through breast milk. 2. breastfeeding is not recommended for diabetic mothers 3. breast milk from diabetic mothers contains few antibodies 4. breast feeding will assist lowering maternal blood glucose

4. breast feeding consumes maternal calories in requires energy that increases the maternal basal metabolic rate and assist in lowering the maternal blood glucose levels

3. The nurse is caring for a multi gravid a woman who was one day postpartum following a vagina birth which findings indicates a need for further assessment ? 1. hemoglobin 12 .1 G/dl 2. WBC count of 15,000 MCL 3. Pulse of 60 beats per minute 4. temperature of 100.8 F

4.A temperature of 100. 8 F. within the first 24 hours postpartum maternal temperature may increase 100.4 F

10. 2 hours after original birth under epidural anesthesia the client with the midline episiotomy ambulates the bathroom to avoid. After voiding the nurse assesses the clients bladder finding it distended. The nurse interprets this finding based on the understanding that the clients bladder distention is most likely caused by which factor? 1. Prologue for stage of Labor 2. urinary tract infection 3. pressure of the uterus on the bladder 4. edema in the lower urinary tract area

Urinary tension soon after birth is usually caused by edema and trauma of the lower urinary tract this commonly results in difficulty with initiating voiding