NURS 215 - Exam 3 - Chapters 20, 24, and 25

Ch. 20 1. A young mother gives birth to twin boys who shared the same placenta. What serious complication are they at risk for? A) Twin-to-twin transfusion syndrome (TTTS) B) HELLP syndrome C) TORCH syndrome D) ABO incompatibility

ANS: A

Ch. 20 14. A nurse is caring for a client who just experienced a miscarriage in her first trimester. When asked by the client why this happened, which is the best response from the nurse? A) abnormal fetal development B) rejection of the embryo through an immune response C) implantation abnormality D) lack of sufficient progesterone produced by the corpus luteum

ANS: A

Ch. 20 18. A pregnant client at 20 weeks' gestation arrives at the health care facility reporting excessive vaginal bleeding and no fetal movements. Which assessment finding would the nurse anticipate in this situation? A) cervical incompetence B) ectopic pregnancy C) congenital malformations D) placenta previa

ANS: A

Ch. 20 3. A woman with severe preeclampsia is receiving magnesium sulfate. The woman's serum magnesium level is 9.0 mEq/L. Which finding would the nurse most likely note? A) diminished reflexes B) elevated liver enzymes C) seizures D) serum magnesium level of 6.5 mEq/L

ANS: A

Ch. 20 8. A nurse is caring for a client undergoing treatment for ectopic pregnancy. Which symptom is observed in a client if rupture or hemorrhaging occurs before the ectopic pregnancy is successfully treated? A) phrenic nerve irritation B) painless bright red vaginal bleeding C) fetal distress D) tetanic contractions

ANS: A

Ch. 24 1. A newborn with severe meconium aspiration syndrome (MAS) is not responding to conventional treatment. Which measure would the nurse anticipate as possibly necessary for this newborn? A) extracorporeal membrane oxygenation (ECMO) B) respiratory support with a ventilator C) insertion of a laryngoscope for deep suctioning D) replacement of an endotracheal tube via X-ray

ANS: A

Ch. 24 12. The nurse is caring for a small-for-gestational-age infant at 1 hour old, after a difficult birth, with a glucose level of 40 mg/dL (2.5 mmol/L). Which nursing action would be the priority? A) Initiate early oral feedings. B) Ensure feedings are on demand. C) Initiate daily newborn weights. D) Monitor the infant at feedings.

ANS: A

Ch. 24 15. An infant has a grade 3 intraventricular hemorrhage (IVH). The nurse monitors the infant for which complication? A) hydrocephalus B) encephalitis C) meningitis D) intraparenchymal hemorrhage

ANS: A

Ch. 24 3. Which type of nutrition would the nurse expect to administer to a preterm infant who was born at 34 weeks' gestation and has developed necrotizing enterocolitis (NEC)? A) Total parenteral nutrition (TPN) B) Gavage feeding method C) Trophic feeding technique D) Oral breastfeeding

ANS: A

Ch. 25 10. A 6-week gestation client asks the nurse what foods she should eat to help prevent neural tube disorders in her growing baby. The nurse would recommend which foods? A) Spinach, oranges, and beans B) Milk, yogurt, and cheese C) Bananas, avocados, and coconut D) Pork, beans, and poultry

ANS: A

Ch. 25 11. For which potential neonatal infection does the nurse anticipate using ophthalmic erythromycin? A) Chlamydia trachomatis B) Group B streptococcus C) Human immunodeficiency virus D) Herpes simplex virus Type 1

ANS: A

Ch. 25 13. The nurse is working with a group of parents of children who have congenital heart disorders. Which statement made by the parents should the nurse prioritize for further assessment? A) "She gets so tired when she is eating." B) "They say he has a heart murmur but it may go away." C) "His chest measurement is the same as his head." D) "When I move her legs up toward her chest I hear a click."

ANS: A

Ch. 25 15. A baby with developmental dysplasia of the hip is placed in a Pavlik harness. The harness positions the hip in which position? A) a flexed, abducted position to press the femur head against the acetabulum B) an extended, abducted position to stabilize the femur head and the acetabulum C) a flexed, adducted position to point the femur towards the acetabulum D) an extended, adducted position to relieve pressure from the femur against the acetabulum

ANS: A

Ch. 25 16. Congenital myelomeningocele is commonly associated with which condition? A) hydrocephalus C) cranial suture overlap B) microcephaly D) absence of the cranial vault

ANS: A

Ch. 25 6. Assessment reveals that a young mother has several risk factors for giving birth to an infant with a neural tube defect. Which laboratory test would the nurse expect to be used to monitor the fetus for this birth defect? A) alpha-fetoprotein levels B) genetic studies C) folic acid levels D) cultures for infections

ANS: A

Ch. 24 16. A neonate receiving oxygen at concentrations greater than 70% is at risk for developing which complication? Select all that apply. A) retinopathy of prematurity B) pulmonary edema C) intraventricular hemorrhage D) pulmonary hypoplasia E) cerebral palsy

ANS: A, B

Ch. 24 4. A preterm infant is born at risk for normochromic, normocytic anemia. Which nursing action reduces the risk of the infant developing this condition? (Select all that apply.) A) Coordinate blood draws so that they are as few as possible B) Delay cord clamping at birth C) Perform phototherapy D) Use caution when administering IV therapy E) Administer indomethacin F) Perform a cranial ultrasound

ANS: A, B

Ch. 25 3. Which of the following is a cause of retinopathy of prematurity (ROP)? Select all that apply. A) Oxygen saturation maintained above 95% B) Presence of immature retinal blood vessels C) Acid-base imbalances D) Intraventricular hemorrhage leading to retinal detachment E) Birth injury

ANS: A, B

Ch. 24 7. The nurse needs to conduct a procedure on a preterm newborn. Which measures would be most effective in reducing pain? Select all that apply. A) swaddling the newborn closely B) offering a pacifier prior to a procedure C) encouraging kangaroo care during procedures D) removing tape quickly from the skin E) increasing the volume on device alarms

ANS: A, B, C

Ch. 25 18. Which actions should nurses advocate to help the nation achieve the 2020 National Health Goals? Select all that apply. A) teaching about folic acid supplementation prior to conception B) obtaining early prenatal care C) providing support after the diagnosis of a fetal disorder D) encouraging sonograms at every prenatal visit E) initiating oral iron supplementation at the time of conception

ANS: A, B, C

Ch. 24 17. Which nursing interventions promote healthy development of the preterm neonate? Select all that apply. A) nesting B) nonnutritive sucking C) quiet hours D) covering the incubator E) supine sleep position

ANS: A, B, C, D

Ch. 24 18. At birth, an infant is below average in weight, length, and head circumference and has a high hematocrit level. Which problem would the nurse assess for in this infant? Select all that apply. A) low glucose level B) high bilirubin level C) prolonged acrocyanosis D) cold stress E) caput succedaneum

ANS: A, B, C, D

Ch. 24 19. The administration of caffeine has become common in NICU infants with apnea of prematurity. The NICU nurse explains the advantages of this medication to the parents and knows the parents understood when they make which statements? Select all that apply. A) Caffeine stimulates the breathing center of the preterm infant's brain. B) Caffeine has a superior safety profile with fewer side effects than theophylline. C) Caffeine improves the rate of recovery when used in conjunction with CPAP therapy. D) The neonate can be discharged home while taking caffeine, as it can be given orally. E) Caffeine can be given to neonates as either caffeine citrate or caffeine sodium benzoate.

ANS: A, B, C, D

Ch. 25 17. An infant with a tracheoesophageal fistula is carefully examined to identify other teratogenic effects at the same week in gestation. Which systems need to be examined? Select all that apply. A) vertebral B) cardiac C) anal D) legs E) respiratory

ANS: A, B, C, D

Ch. 25 9. The nurse reviews the antenatal history and notes of a term newborn. The mother admits to continual daily use of alcohol throughout her pregnancy. For which should the nurse assess the infant? Select all that apply. A) abnormal smallness of the head B) a flatter groove between the nose and upper lip C) weight below the 10th percentile for gestational age D) inadequate sucking E) respiratory complications F) positive rooting reflex G) abundant sole creases

ANS: A, B, C, D

Ch. 25 20. A community health nurse is teaching a group of clients about the zika virus. Which statements by the clients indicate to the nurse that the teaching was effective? Select all that apply. A) Zika can be transmitted by mosquitoes, sexual activity, and blood exposure. B) A pregnant woman with zika may have a baby with microcephaly and other congenital anomalies. C) It is best for men who have been exposed to zika to wait six months before attempting conception. D) Women who have been exposed to zika should wait six months before attempting conception. E) There is no treatment for newborns with zika, but they will have supportive care based on the defects.

ANS: A, B, C, E

Ch. 25 4. An infant is experiencing transient tachypnea of the newborn (TTN). Symptoms that may be seen in this infant include which of the following? Select all that apply. A) Nasal flaring B) Respirations of 60 per minute C) Retractions D) Increased appetite E) Expiratory grunting

ANS: A, B, C, E

Ch. 20 7. Which assessment findings, experienced by the client at 36 weeks' gestation, would the nurse document as diagnostic signs of severe preeclampsia? Select all that apply. A) blood pressure of 164/110 mm Hg B) elevated liver enzymes C) edema D) +1 proteinuria E) Elevated serum creatinine

ANS: A, B, D, E

Ch. 24 11. A preterm infant with enteral tube feedings is being monitored for weight gain. What would be priorities for the nurse to include in the infant's plan of care? Select all that apply. A) Weigh daily. B) Measure daily intake and output. C) Monitor weight weekly. D) Assess serum electrolytes. E) Monitor Coombs results. F) Assess for dehydration. G) Measure abdominal girth AC.

ANS: A, B, D, F, G

Ch. 24 8. A nurse is assessing a preterm newborn for possible sepsis. The nurse suspects an early onset infection based on which risk factors? Select all that apply. A) preterm labor B) prolonged rupture of membranes C) immaturity of the immune system D) decreased gastric acid E) maternal fever

ANS: A, B, E

Ch. 20 13. The nurse is preparing the plan of care for a woman hospitalized for hyperemesis gravidarum. Which interventions should the nurse prioritize? Select all that apply. A) maintaining NPO status for the first day B) preparing the woman for insertion of a feeding tube C) administering antiemetic agents D) obtaining baseline blood electrolyte levels E) monitoring intake and output

ANS: A, C, D, E

Ch. 25 8. During the birth of a postterm infant, the nurse suspects that meconium aspiration may have occurred in utero. What findings would correlate with this suspicion? Select all that apply. A) The newborn has green staining of the fingernails. B) The umbilical cord is stained bright red. C) The newborn has labored abdominal respirations. D) The newborn makes bearing down movements. E) The anterior fontanels are sunken at birth. F) Green amniotic fluid is present at birth.

ANS: A, C, D, F

Ch. 20 20. A client visits a health care facility reporting amenorrhea for 10 weeks, fatigue, and breast tenderness. Which assessment findings should the nurse prioritize for immediate intervention? Select all that apply. A) elevated hCG levels B) whitish discharge from the vagina C) absence of fetal heart sound D) dyspareunia E) hyperemesis gravidarum

ANS: A, C, E

Ch. 25 14. Which situation is likely to result in the presence of developmental dysplasia of the hip (DDH) at birth? Select all that apply. A) breech birth B) transverse lie C) female gender D) male gender E) oligohydramnios

ANS: A, C, E

Ch. 20 12. A patient in labor and delivery has just been diagnosed with pre-eclampsia. Which signs and symptom should the nurse prioritize when assessing this client? Select all that apply. A) BP 140/90 mm Hg B) slow reflexes C) glucose in urine D) edema of face E) headache

ANS: A, D, E

Ch. 20 11. The nurse is caring for a client with an ectopic pregnancy. Which symptom is a sign that the tube has ruptured? A) Foul-smelling discharge B) Hypovolemic shock C) Pelvic pain D) V aginal spotting

ANS: B

Ch. 20 16. A pregnant woman with preeclampsia is to receive magnesium sulfate IV. Which assessment should the nurse prioritize before administering a new dose? the nurse anticipate in this situation? A) blood pressure B) patellar reflex C) heart rate D) anxiety level prioritize?

ANS: B

Ch. 20 4. A woman pregnant with twins comes to the clinic for an evaluation. The nurse closely assesses the client for which potential problem? A) oligohydramnios B) preeclampsia C) post-term labor D) chorioamnionitis

ANS: B

Ch. 20 5. A student nurse asks the instructor what percentage of clinically recognized pregnancies end in miscarriages during the first trimester. Which response from the nurse is the most accurate? A) 5% to 10% B) 15% to 20% C) 21% to 30% D) 31% to 40%

ANS: B

Ch. 24 10. A perinatal nurse is providing care for a large for gestational age neonate admitted to the observational unit after a complicated vaginal birth resulting in shoulder dystocia. Which assessment would be a priority for the nurse to perform? A) Ballard assessment B) Moro assessment C) Dubowitz assessment D) suck assessment

ANS: B

Ch. 24 5. The nurse is visiting the parents of a newborn diagnosed with periventricular leukomalacia. Which statement indicates that the parents understand the newborn's health problem? A) "Once the infection clears up, the baby will be fine." B) "We will need to plan for special care to help with learning disabilities." C) "In a few months, more brain tissue will grow to fill in the hollow areas in the brain." D) "In a few months, the baby will need to have physical therapy to train muscles to work."

ANS: B

Ch. 25 12. Which postoperative goal is most important following surgical repair of a cleft lip and palate? A) Obtaining adequate nutrition B) Relieving surgical pain C) Monitoring fluid volume D) Encouraging family bonding

ANS: B

Ch. 25 19. A premature infant in the neonatal intensive care unit exhibits worsening respiratory distress and is noted to have abdominal distention, absent bowel sounds, and frequent diarrhea stools that are positive for hemoccult. What diagnosis would be most likely to correlate with the symptoms? A) Garamycin resistant bacteria B) Necrotizing enterocolitis C) Rotavirus infection D) Respiratory distress syndrome

ANS: B

Ch. 25 2. When caring for a term newborn, the nurse observes yellow discoloration of the newborn's skin. Which of the following would indicate to the nurse that the jaundice is physiologic in nature? A) Yellow discoloration of skin within 24 hours of birth B) Cord blood bilirubin concentration of 2.5 mg/dl C) Serum bilirubin rising at 0.75 mg/dl every 4 hours D) Visible jaundice lasting two weeks

ANS: B

Ch. 25 5. A newborn is suspected of having gastroschisis at birth. How would the nurse differentiate this problem from other congenital defects? A) The abdominal contents are contained within a thin, transparent sac. B) The intestines appear reddened and swollen and have no sac around them. C) The umbilical cord comes out of middle of the defect. D) The skin over the abdomen is wrinkled and looks like a prune.

ANS: B

Ch. 20 19. A pregnant client is admitted to a health care facility after her laboratory results reveal elevated liver enzymes, thrombocytopenia, and low hemoglobin and hematocrit. Which assessment findings should the nurse prioritize for this client? Select all that apply. A) Watery diarrhea B) Nausea and vomiting C) Generalized edema D) Epigastric pain and tenderness E) Excessive weight loss

ANS: B, C, D

Ch. 20 10. The nurse is required to assess a client for HELLP syndrome. Which are the signs and symptoms of this condition? Select all that apply. A) blood pressure higher than 160/110 mm Hg B) epigastric pain C) oliguria D) upper right quadrant pain E) hyperbilirubinemia

ANS: B, D, E

Ch. 24 20. The NICU nurse is caring for a preterm neonate with respiratory distress syndrome on mechanical ventilation. Which assessment data would alert the nurse that a pneumothorax might have developed? Select all that apply. A) Neonate's blood pressure is 80/50. B) The neonate's respiratory rate is 68. C) Oxygen saturation is 92% and heart rate is 130. D) Neonate is exhibiting nasal flaring and grunting. E) Chest radiography reveals low lung volume and a ground glass appearance. F) The neonate's chest is asymmetrical with decreased breath sounds on one side.

ANS: B, D, F

Ch. 20 9. A nurse is caring for a pregnant client with eclamptic seizure. Which is a characteristic of eclampsia? A) Muscle rigidity is followed by facial twitching. B) Respirations are rapid during the seizure. C) Coma occurs after seizure. D) Respiration fails after the seizure

ANS: C

Ch. 24 6. Which intervention should a nurse implement to promote thermal regulation in a preterm newborn? A) Assess the newborn's temperature every 8 hours until stable. B) Set the temperature of the radiant warmer at a fixed level. C) Observe for clinical signs of cold stress such as weak cry. D) Check the blood pressure of the infant every 2 hours.

ANS: C

Ch. 24 9. A jaundiced neonate must have heel sticks to assess bilirubin levels. Which assessment findings would indicate that the neonate is in pain? Select all that apply. A) There is flaccid muscle tone of the affected limb. B) Respiration rate is 52 breaths per minute. C) Heart rate is 180 beats per minutes. D) Oxygen saturation level is 88%. E) The infant has facial grimacing and quivering chin.

ANS: C, D, E

Ch. 20 15. A pregnant client is being admitted for severe preeclampsia. When assigning room placement, which area would be most appropriate? A) Beside the supply room B) Near the staff elevator C) Across from the nurse's station D) At the end of the hallway

ANS: D

Ch. 20 17. The nurse is assessing a client at 12 weeks' gestation at a routine prenatal visit who reports something doesn't feel right. Which assessment findings should the nurse prioritize? A) elevated hCG levels, enlarged abdomen, quickening B) vaginal bleeding, absence of FHR, increased hPL levels C) visible fetal skeleton on ultrasound, absence of quickening, enlarged abdomen D) gestational hypertension, hyperemesis gravidarum, absence of FHR

ANS: D

Ch. 20 2. Why is a woman with a molar pregnancy at risk for disseminated intravascular coagulation (DIC)? A) Molar tissue releases substances that increase clotting factors B) Molar tissue releases substances that break down clotting factors C) Molar tissue inhibits the production of vitamin K D) Molar tissue causes emboli to form within the uterus

ANS: D

Ch. 20 6. A patient who is 16 weeks pregnant is passing pieces of body tissue along with blood clots and dark red blood from the vagina. What should the nurse direct the patient to do at this time? A) Begin immediate bed rest. B) Count the number of perineal pads that are saturated with blood. C) Continue with normal daily activity and monitor pulse rate every hour. D) Seek immediate medical attention and bring the expressed vaginal material.

ANS: D

Ch. 24 13. The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement? A) "Late preterm infant complications are considered minor compared to the preterm newborn." B) "The late preterm infant is more mature and able to cope as well as a full-term infant." C) "Late preterm newborns have fewer clinical problems leading to shorter hospital stays." D) "A late preterm newborn may have more clinical problems compared with full-term newborns."

ANS: D

Ch. 24 14. Which factors in a maternal birth record are risks for fetal growth restriction? A) premature rupture of membranes, gestational diabetes, or multiparity B) twin pregnancy, gestational diabetes, or essential hypertension C) renal disease, maternal age over 35, or congenital malformations D) congenital malformations, infections, or placental insufficiency

ANS: D

Ch. 24 2. When assessing an infant born at 32 weeks' gestation, which finding would lead the nurse to suspect to suspect that the newborn has a patent ductus arteriosus (PDA)? A) Weak, thready pulse B) Decreased pulse rate C) High diastolic arterial pressure D) Continuous murmur on auscultation

ANS: D

Ch. 25 1. A newborn has been diagnosed with a group B streptococcal infection shortly after birth. The nurse understands that the newborn most likely acquired this infection from which cause? A) improper hand washing B) contaminated formula C) nonsterile catheter insertion D) mother's birth canal

ANS: D

Ch. 25 7. A neonate born addicted to cocaine is now being treated with medication for acute neonatal abstinence syndrome. Which medication will be prescribed to relieve withdrawal symptoms? A) meperidine B) adrenalin C) naloxone D) morphine sulphate

ANS: D