NURS 215 - Exam 2 - Chapters 17, 18, 23 (study set 1 of 3)
Ch. 18 18. The nurse is assessing the Apgar score for a 1-minute-old newborn and notes the following: HR 105 bpm, a pink body with blue feet, a strong cry, sneezing and minimal flexion. Which Apgar score will the nurse document as appropriate for this infant?
ANS: 8
Ch. 17 1. During pregnancy a woman's cardiovascular system expands to care for the growing fetus. After birth, during the early postpartum period, the woman eliminates the additional fluid volume she has been carrying. What is one way she does this? A) Urinary elimination B) Elimination of solid wastes C) Being too tired to eat D) Breathing off fluid vapor
ANS: A
Ch. 17 11. A nurse is describing a technique developed in the 1940s by Dr. Arnold Kegel to assist postpartum women with a common issue. The nurse explains that the purpose of this technique is to: A) strengthen the pelvic floor muscles to reduce urinary incontinence. B) strengthen the uterine muscle fibers to return to their pre pregnancy condition. C) strengthen the joints and return them to their normal state. D) strengthen the abdominal muscles to lessen the size of stretch marks.
ANS: A
Ch. 17 9. A nurse is caring for a client who has had a vaginal birth. The nurse understands that pelvic relaxation can occur in any woman experiencing a vaginal birth. Which should the nurse recommend to the client to improve pelvic floor tone? A) Kegel exercises B) urinating immediately when the urge is felt C) abdominal crunches D) sitz baths
ANS: A
Ch. 18 8. A nurse is assessing a neonate born approximately 2 hours ago. The nurse anticipates that the newborn's transition to extrauterine life would be typically accomplished by which time frame? A) first 6 to 10 hours of life B) first 2 to 6 hours of life C) first 10 to 14 hours of life D) first 12 to 24 hours of life
ANS: A
Ch. 23 10. Two weeks after a vaginal birth, a client presents with low-grade fever. The client also reports a loss of appetite and low energy levels. The health care provider suspects an infection of the episiotomy. What sign or symptom is most indicative of an episiotomy infection? A) foul-smelling vaginal discharge B) sudden onset of shortness of breath C) pain in the lower leg D) apprehension and diaphoresis
ANS: A
Ch. 23 17. The nurse is providing care for a postpartum client who has been diagnosed with a perineal infection and who is being treated with antibiotics. What is the nurse's most appropriate intervention? A) Encourage fluid intake. B) Encourage the client to limit mobility. C) Provide several small meals daily rather than three larger meals. D) Administer antacids with each dose of antibiotics.
ANS: A
Ch. 23 18. A nurse is caring for a postpartum client whose most recent assessment reveals a large, purple area of edema on the left side of her perineum. What is the nurse's best action? A) Report the finding promptly to the primary care provider. B) Apply an ice pack and reassess in 30 minutes. C) Provide the client with a hot pack and analgesia as prescribed. D) Document this expected finding and reassess frequently.
ANS: A
Ch. 23 3. A nurse is caring for a client in the postpartum period. When observing the client's condition, the nurse notices that the client tends to speak incoherently. The client's thought process is disoriented, and she frequently indulges in obsessive concerns. The nurse notes that the client has difficulty in relaxing and sleeping. The nurse interprets these findings as suggesting which condition? A) postpartum psychosis B) postpartum blues C) postpartum depression D) postpartum panic disorder
ANS: A
Ch. 23 12. A laboring woman with a history of a previous cesarean birth suddenly begins to exhibit manifestations of hypovolemic shock. Suspecting either complete or partial uterine rupture, which priority interventions should the nurse implement first? Select all that apply. A) Increase IV fluids immediately. B) Prepare to administer IV oxytocin to assist with uterine contraction. C) Call respiratory therapy to obtain ABGs. D) Prepare to administer epinephrine directing into the uterine muscle. E) Weigh all the blood-saturated bandages to determine amount of blood loss.
ANS: A, B
Ch. 23 19. On postpartum day 4, a client has a temperature of 101.4 °F (38.6 °C). Which findings would be consistent with a diagnosis of endometritis? Select all that apply. A) foul-smelling lochia B) tender uterus C) strong afterpains D) fluctuant, perineal mass E) swollen, warm breast
ANS: A, B
Ch. 17 10. The nurse is assisting a young mother who has decided not to breastfeed her infant. The nurse should make which suggestions to the client to ease discomfort and prevent breast engorgement? Select all that apply. A) Wear tight supportive bra 24 hours each day. B) Apply ice to the breast for approximately 15 to 20 minutes every other hour. C) Avoid sexual stimulation D) Pump her breasts once a day only. E) Take a hot shower.
ANS: A, B, C
Ch. 18 4. A new mother is alarmed because her newborn has lost 10 ounces in weight since being born 2 days ago. She believes that she has been breastfeeding properly. Which information would the nurse include as a likely cause of this phenomenon? Select all that apply. A) Absence of salt- and fluid-retaining maternal hormones B) The infant's voiding and passing stool C) Low calorie content of colostrum D) A congenital digestive disorder E) An increase in fetal metabolism F) Failure of mother to bond with newborn
ANS: A, B, C
Ch. 23 6. When caring for a client with postpartum depression (PPD), which assessment findings would confirm the diagnosis? Select all that apply. A) Sense of isolation B) Decreased energy C) Hostility toward others D) Extreme anxiety E) Hot or cold flashes
ANS: A, B, C
Ch. 23 7. A nurse discovers a perineal hematoma in a woman who has recently given birth. Which interventions should the nurse make in this case? Select all that apply. A) Estimate the size of the hematoma and report it B) Administer a mild analgesic as prescribed C) Apply an ice pack to the site D) Administer an antibiotic E) Perform fundal massage F) Administer methotrexate
ANS: A, B, C
Ch. 18 3. What are common risk factors for developing newborn jaundice? Select all that apply. A) fetal-maternal blood group incompatibility B) prematurity C) breastfeeding D) certain drugs E) maternal gestational diabetes F) too frequent feedings
ANS: A, B, C, D, E
Ch. 23 20. Which postpartum clients would require the nurse to intervene? Select all that apply. A) Primipara with vital signs including temperature 100.2, blood pressure 140/ 86, pulse 124, respiratory rate 12. B) Multipara with vital signs including temperature 99, blood pressure 136/84, pulse 96, respiratory rate 32. C) Postpartum client with urine output of 30 ml/hour for 2 hours. D) First day postpartum client with blood pressure 84/48, pulse 128, respiratory rate 16. E) Postpartum client requesting newborn stay in nursery so that she can nap. F) Primipara with vital signs including temperature 100.2, respiratory rate 28, oxygen saturation 94%.
ANS: A, B, C, D, F
Ch. 17 13. A nurse visiting a postpartum client at home is reviewing the need for the woman to meet her own nutritional needs. The woman is breastfeeding her newborn. The nurse determines that the client understands her nutritional needs based on which statements? Select all that apply. A) "I need to drink about 2 to 3 quarts of fluid each day." B) "I should have about 4 servings of fruits each day." C) "I need to eat about 7 servings of vegetables daily." D) "I will have at least 4 to 5 servings of milk each day." E) "I need to cut way back on any fats and oils daily."
ANS: A, B, D
Ch. 18 19. A nurse is explaining the Apgar scoring to new mother and her partner. What should the nurse point out about this scoring method? Select all that apply. A) It is done at 1 and 5 minutes after birth. B) The baby is considered vigorous if the5-minute score is above 7. C) Each factor receives a score of 0 or 2. D) The Apgar score is used to guide newborn resuscitation. E) The Apgar score is an immediate assessment of newborn cardiopulmonary adaptation
ANS: A, B, E
Ch. 17 14. When assessing the episiotomy site of a postpartum client that delivered 3-hours ago, the nurse would document which findings as expected? Select all that apply. A) Edema B) Redness C) Slight bruising D) Discharge E) Bleeding
ANS: A, C
Ch. 17 17. During the early postpartum period, a new mother is displaying dependent behaviors. What behaviors would the nurse recognize as normal for this period? Select all that apply. A) Needing assistance with changing her peripad B) Desiring to hold her infant C) Telling the nurse about her delivery experience. D) Asking the nurse to take the newborn away so she can rest. E) Changing her newborn's diaper with guidance from the nurse.
ANS: A, C, D
Ch. 18 14. Upon examination of the skin, which assessment findings would the nurse recognize as normal findings for a full-term newborn at 3 hours of age? Select all that apply. A) Lanugo on the back B) Vernix caseosa over the abdomen and lower extremities C) Milia D) Acrocyanosis E) Jaundice
ANS: A, C, D
Ch. 23 14. What is a risk factor for developing a postpartum infection? Select all that apply. A) diabetes type 1 B) thin build C) prolonged labor D) cesarean birth E) rupture of membranes at time of birth
ANS: A, C, D
Ch. 23 13. A mother is experiencing postpartum hemorrhage shortly after delivery of her infant. Which nursing interventions would be appropriate for this client? Select all that apply. A) Encourage the mother to breast-feed her infant if she is breast-feeding. B) Begin uterine massage with both hands on the fundus of the uterus. C) Turn the mother on her side and inspect the area under her buttocks for blood. D) Encourage increased fluid intake. E) Monitor vital signs every 15 minutes.
ANS: A, C, D, E
Ch. 17 19. The nurse is inspecting a new mother's perineum. What actions would the nurse take for this client? Select all that apply. A) Inspect the episiotomy for sutures and to ensure that the edges are approximated. B) Palpate the episiotomy for pain. C) Note any hemorrhoids. D) Place the patient in Trendelenburg position for inspection. E) Gently palpate for any hematomas.
ANS: A, C, E
Ch. 18 7. A mother who is 4 days postpartum and is breastfeeding expresses to the nurse that her breast seems to be tender and engorged. Which suggestions should the nurse give to the mother to relieve breast engorgement? Select all that apply. A) Take warm-to-hot showers to encourage milk release. B) Feed the newborn in the sitting position only. C) Express some milk manually before breastfeeding. D) Massage the breasts from the nipple toward the axillary area. E) Apply warm compresses to the breasts prior to nursing.
ANS: A, C, E
Ch. 17 18. The nurse is conducting a breast exam on a postpartum mother on the second day following delivery. What findings would the nurse determine to be normal? Select all that apply. A) Breasts feel slightly firm. B) Nipples have several cracks on both breasts. C) One reddened area on the left breast 3 cm in size. D) Flattened nipple on the right breast E) Breasts are non-painful
ANS: A, D, E
Ch. 18 20. A nurse is conducting an in-service education program for a group of nurses working in the newborn nursery. The nurse has explained the events that occur as fetal circulation transitions to newborn circulation. The nurse determines the session is successful after the participants put the chain of events in which order? All options must be used. A. Birth occurs. B. The foramen ovale closes. C. The ductus arteriosus closes. D. An increase in systemic blood pressure occurs with continued increase in blood flow to the lungs. E. Pulmonary blood flow increases, and pulmonary venous return to the left side of the heart increases.
ANS: A, E, B, D, C
Ch. 17 20. After the abdominal dressing is removed 24 hours following a cesarean delivery, the nurse inspects the incision and observes drainage from the incision, redness along the suture line and moderate edema. Staples are intact. What action would the nurse take? A) Record the findings in the client's chart. B) Let the RN know of your findings. C) Since everything appears normal, continue to monitor the incision every 4 hours. D) Re-apply a dressing over the incision line.
ANS: B
Ch. 17 6. Which finding would the nurse describe as "light" or "small" lochia? A) 1- to 2-inch lochia stain on the perineal pad or a 10 ml loss B) 4-inch stain or a 10 to 25 ml loss C) 4- to 6-inch stain with an estimated loss of 25 to 50 ml D) pad is saturated within 1 hour after changing it
ANS: B
Ch. 17 7. When giving a postpartum client self-care instructions in preparation for discharge, the nurse instructs her to report heavy or excessive bleeding. How should the nurse describe "heavy bleeding?" A) saturating 1 pad in 3 hours B) saturating 1 pad in 1 hour C) saturating 1 pad in 6 hours D) saturating 1 pad in 8 hours
ANS: B
Ch. 18 11. The nurse is inspecting the mouth of a newborn and finds small, white cysts on the gums and hard palate. The nurse documents this finding as: A) thrush. B) Epstein's pearls. C) milia. D) vernix caseosa.
ANS: B
Ch. 18 2. While teaching a newborn nutrition class to a group of pregnant women, the nurse encourages breastfeeding because it is a major source of which immunoglobulin? A) IgG B) IgA C) IgM D) IgE
ANS: B
Ch. 18 5. The nurse is helping her client to recognize signs of hunger in her newborn. The nurse knows that her client needs additional teaching when she states that which sign is one of the early signs of hunger? A) restlessness B) crying C) tense body D) tongue thrusting
ANS: B
Ch. 23 9. A nurse is caring for a client with idiopathic thrombocytopenic purpura (ITP). Which intervention should the nurse perform first? A) administration of prescribed nonsteroidal anti-inflammatory drugs (NSAIDs) B) administration of platelet transfusions as prescribed C) avoiding administration of oxytocics D) continual firm massage of the uterus
ANS: B
Ch. 18 15. What treatments would the nurse perform in caring for a newly circumcised newborn? Select all that apply. A) Apply talc powder to the diaper area with each diaper change. B) Wash the penis with warm water at each diaper change. C) Fasten the diaper loosely to prevent unnecessary friction as irritation. D) Report if there is a bleeding spot the size of a dime on the diaper. E) Notify the doctor if the newborn does not void after 4 hours.
ANS: B, C
Ch. 18 16. A hepatitis B positive mother delivers a newborn. What precautions would the nurse take in caring for this infant? Select all that apply. A) Give the mother a one-time dose of hepatitis B immunoglobulin within 12 hours after delivery. B) Bathe the newborn thoroughly soon after birth to remove maternal blood. C) Give the newborn the HBV vaccination within 12 hours after birth. D) Tell the mother that she cannot breast-feed her newborn due to the infection. E) The newborn will need to stay in the hospital for several extra days for additional IV medications to treat the infection.
ANS: B, C
Ch. 18 9. A nurse is assessing a newborn who is about 4 /2 hours old. The nurse would expect this newborn to exhibit which behavior? Select all that apply. A) sleeping B) interest in environmental stimuli C) passage of meconium D) difficulty arousing the newborn E) spontaneous Moro reflexes
ANS: B, C
Ch. 23 16. A new mother is diagnosed with a venous thromboembolism in her left calf. Which risk factor is associated with this problem? Select all that apply. A) maternal age greater than 30 B) cesarean birth C) obesity D) precipitous birth E) hypotension
ANS: B, C
Ch. 17 8. A client who has given birth a week ago reports discomfort when defecating and ambulating. The birth involved an episiotomy. Which suggestions should the nurse provide to the client to provide local comfort? Select all that apply. A) Maintain correct posture. B) Use of warm sitz baths. C) Use of anesthetic sprays. D) Use of witch hazel pads. E) Use good body mechanics.
ANS: B, C, D
Ch. 23 15. What intervention would the nurse recommend for a new breastfeeding mother with mastitis? Select all that apply. A) Encourage the client to breastfeed the infant every 3 to 4 hours. B) Begin feedings on the unaffected breast. C) Take prescribed antibiotics for 10 days. D) Apply warm compresses as a comfort measure for her pain. E) Stop breastfeeding until the infection clears up.
ANS: B, C, D
Ch. 18 6. The nurse is teaching a couple about the pros and cons of circumcision for their infant son. The nurse knows teaching has been effective when the couple can identify which contraindications to circumcision? Select all that apply. A) Difficult intravenous access B) Preterm infant C) Bleeding disorder D) Congenital genitourinary disorder E) Active infection
ANS: B, C, D, E
Ch. 18 12. A nurse is reviewing the laboratory test results of a neonate. Which finding would be a cause of concern for the nurse? Select all that apply. A) hemoglobin 17.2 g/dL B) hematocrit 34% C) platelets 270,000/uL D) red blood cells 3.2 (1,000,000/uL) E) white blood cells 22,000/mm3
ANS: B, D
Ch. 17 16. A client who gave birth 18 hours ago is experiencing a change in lochia flow from scant to moderate. Prioritize the actions the nurse would take to assess the client's fundus. All options must be used. A. Assess blood pressure. B. Assist the clients to empty her bladder in the bathroom. C. Massage the fundus if boggy. D. Palpate the fundus. E. Increase IV oxytocin or breastfeed the newborn. F. Notify the primary care provider.
ANS: B, D, C, E, A, F
Ch. 17 2. A nurse is assessing a woman during the first 24 hours after birth. Which assessment finding would the nurse determine as acceptable during this time? Select all that apply. A) Inverted nipples following breastfeeding B) Fundus one fingerbreadth below the umbilicus C) Hypotonic bowel sounds D) Urination of 100 mL every 4 hours E) Moderate saturation of peripad every 3 hours
ANS: B, E
Ch. 17 12. Which client should the postpartum nurse assess first after receiving shift report? A) The 3-day postpartum client who has a pulse of 50 bpm. B) The 12-hour postpartum client who has a temperature of 100.4 ° F (38 ° C). C) The 2-day postpartum client who has a blood pressure of 138/90 mm Hg. D) The 1-day postpartum client who has a respiratory rate of 20 breaths/minute.
ANS: C
Ch. 17 15. The nurse is performing an assessment for a client in the immediate postpartum period. Which assessment finding should the nurse prioritize? A) Infection B) Dehydration C) Hemorrhage D) Bladder distention
ANS: C
Ch. 17 4. Based on the nurse's knowledge about the postpartum period and an increase in blood coagulability during the first 48 hours, the nurse closely assesses the client for which condition? A) hyperglycemia B) varicose veins C) thromboembolism D) calcium depletion
ANS: C
Ch. 17 5. A woman who had a cesarean birth of twins 6 hours ago reports shortness of breath and pain in her right calf. What complication should the nurse expect? A) infection B) hemorrhage C) pulmonary emboli D) fluid volume overload
ANS: C
Ch. 18 1. Why are newborns born to diabetic mothers prone to hypoglycemia? A) Excess subcutaneous fat reduces blood flow to the tissues B) Increased metabolic stress due to the stress on mother's body C) Elevated insulin production metabolized glucose faster D) Liver is immature and cannot convert glycogen to glucose
ANS: C
Ch. 18 13. The parents are concerned their newborn appears to be cold all the time. The nurse should point out the infant is best helped by which primary method in the first few days? A) External with blankets by the nursing staff B) Skin to skin contact with mother C) Brown fat store usage D) Shivering and increased metabolic rate
ANS: C
Ch. 18 17. A nurse receives the shift report on four infants. Baby A is 16 hours old, HR 117, RR 32, axillary temperature 98oF (36.6oC), BP 72/43 mm Hg, bilirubin 3.5 mg/dL rooming in with mother Baby B is 8 hours old, HR 152, RR 48, axillary temperature 97.7oF (36.5oC), BP 60/40 mm Hg, bilirubin 3 mg/dL, returning to nursery for night Baby C is 19 hours old, HR 140, RR 45, axillary temperature 98.6oF (37oC), BP 68/45 mm Hg, bilirubin 4 mg/dL, rooming in with mother Baby D is 4 hours old, HR 160, RR 60, axillary temperature 98.6oF (37oC), BP 80/45 mm Hg, bilirubin 2 mg/dL, returning to nursery for night. Which baby would the nurse assess first? A) baby A B) baby B C) baby C D) baby D
ANS: C
Ch. 23 8. A nurse is caring for a postpartum client who has a history of thrombosis during pregnancy and is at high risk of developing a pulmonary embolism. For which sign or symptom should the nurse monitor the client to prevent the occurrence of pulmonary embolism? A) sudden change in mental status B) difficulty in breathing C) calf swelling D) sudden chest pain
ANS: C
Ch. 23 5. A female client who has very recently given birth arrives at a health care center complaining of painful urination. Assessment also reveals that the client has a temperature of 102 °F (38.9 °C) The physician suspects the client has pyelonephritis. Which of the following would the nurse expect to assess? Select all that apply. A) Fatigue B) Constipation C) Flank pain D) Chills E) Anorexia
ANS: C, D, E
Ch. 17 3. A G1 P0101 woman delivered by cesarean is now in the recovery room. She received Duramorph via intrathecal catheter. On review of orders before transfer to the postpartum unit, the nurse notes one entry that needs clarification by the physician. Which order is the source of the nurse's concern? A) Maintain IV with 1 L LR with 20 units Pitocin over 8 hours. B) Maintain compression stockings until ambulatory. C) Monitor I & O. D) Monitor respirations every 4 hours for 24 hours.
ANS: D
Ch. 23 1. The nurse is conducting a class for postpartum women about mood disorders. The nurse describes a transient, self-limiting mood disorder that affects mothers after birth. The nurse determines that the women understood the description when they identify the condition as postpartum: A) depression. B) psychosis. C) bipolar disorder. D) blues.
ANS: D
Ch. 23 11. A nurse finds that a client is bleeding excessively after a vaginal birth. Which assessment finding would indicate retained placental fragments as a cause of bleeding? A) soft and boggy uterus that deviates from the midline B) firm uterus with trickle of bright red blood in perineum C) firm uterus with a steady stream of bright red blood D) Large uterus with painless dark red blood mixed with clots
ANS: D
Ch. 23 2. A nurse is assessing a postpartum client. Which finding would the cause the nurse the greatest concern? A) leg pain on ambulation with mild ankle edema B) calf pain with dorsiflexion of the foot C) perineal pain with swelling along the episiotomy D) sharp stabbing chest pain with shortness of breath
ANS: D
Ch. 23 4. A nurse is assigned to care for a client experiencing early postpartum hemorrhage. The nurse is required to administer the prescribed methylergonovine maleate intramuscularly to the client. Which condition would the nurse identify as necessitating the cautious administration of this drug? A) mild fever B) respiratory problems C) low blood pressure D) cardiovascular disease
ANS: D
Ch. 18 10. A nurse is assessing a newborn's gestational age, when determining neuromuscular maturity, which parameters would the nurse assess? Select all that apply. A) lanugo B) genitals C) posture D) arm recoil E) scarf sign
ANS: D, E