1600 Exam 1 EAQ
A mother asks the neonatal nurse why her infant must be monitored so closely for hypoglycemia when her type 1 diabetes was in excellent control during the entire pregnancy. How would the nurse best respond?
a) 'A healthy newborn's glucose level drops after birth, so we're being especially cautious with your baby because of your diabetes' b) 'A newborn's pancreas produces an increased amount of insulin during the first day of birth, so we are checking to see whether hypoglycemia has occurred' c) 'Babies of mothers with diabetes do not have large stores of glucose at birth, so it's difficult for them to maintain the blood glucose level within an acceptable range' d) 'Babies of mothers with diabetes have a higher-than-average insulin level because of the excess glucose received from the mother during pregnancy, so the glucose level may drop'
Which is an appropriate response to a 24-year old client with type 1 diabetes who asks how her pregnancy will affect her diet and insulin needs?
a) 'Insulin needs will decrease; the excess glucose will be used for fetal growth' b) 'Diet and insulin needs won't change, and maternal and fetal needs will be met' c) 'Protein needs will increase, and adjustments to insulin dosage will be necessary' d) 'Insulin and dietary needs will be adjusted in accordance with the results of blood glucose monitoring'
Betamethasone, 12mg is prescribed for a client at 32 weeks gestation in active labor. Which response would the nurse give the client when asked why the medication is being given?
a) 'It increases cervical dilation' b) 'Fetal lung maturity is accelerated' c) 'The risk of a precipitous birth is reduced' d) 'The potential for maternal hypertension is minimized'
Which is the desired outcome for the intrapartum client during the third stage of labor?
a) Absence of discomfort b) Firmly contracted uterine fundus c) Efficient fetal heart beat viability d) Maternal respiratory rate within the expected range Rationale: Stage III of labor involves delivery of the placenta
Which collaborative nursing actions would help prevent venous thrombosis in a client during the perioperative period?
a) Administer subq heparin injections b) Give IV thrombolytic medications c) Assist the client to don antiembolism stockings d) Apply pneumatic compression devices to the legs e) Remind the client about the importance of bed rest Correct answers are highlighted (a, c, d)
A 37 y/o G3P2001 client with hypertension and type 1 diabetes with good glycemic control is seen in the antepartum testing unit for an NST at 36 weeks. Her OB hx includes an intrauterine fetal death at 38 weeks. What risk factors in the client's hx indicate the need for an NST?
a) Age 35+ b) Risk for placenta previa c) Risk for placental insufficency d) Hx of stillbirth e) Hypertension f) Type 1 diabetes Correct answers are highlighted (a, c, d, e, f)
Which nonpharmalogical nursing intervention is effective in helping relieve postoperative pain?
a) Ambulation b) Repositioning c) Purse-lipped breathing d) Deep breathing and coughing
Which are the medical concerns in adolescent pregnancies?
a) Anemia b) Macrosomia c) Gestational diabetes d) Poor maternal weight gain e) Pregnancy induced hypertension Correct answers are highlighted (a, d, e)
A client in early active labor at 40 weeks gestation reports that her membranes ruptured 26 hours ago. Initial assessments of the fetal heart rate range between 168-174 bpm. Which is the priority nursing action?
a) Assessing maternal VS b) Planning for emergency birth c) Administering O2 by nasal cannula d) Preparing for fetal scalp blood sampling
When getting a postoperative client out of bed, which action will the nurse take to avoid postural hypotension?
a) Avoid giving the prescribed morphine sulfate before getting the client up b) Have the client sit on the edge of the bed for a few minutes before standing up c) Withhold the prescribed calcium channel blocker until the client is already up d) Educate the client about the reasons to avoid getting up soon after surgery
Which factor(s) place an infant at risk for SIDS?
a) Breast feeding b) Cigarette smoking c) Prone sleep position d) Advanced maternal age e) Lower socioeconomic status Correct answers are highlighted (b, c, e)
The nurse applies fetal and uterine monitors to the abdomen of a client in active labor. When the client has contractions, the nurse notes a 15 bpm deceleration of the fetal heart rate below the baseline lasting 15 seconds. Which is the next nursing action?
a) Calling primary health care provider b) Changing the maternal position c) Obtaining maternal BP d) Preparing the environment for an immediate birth
Which safety consideration is the nurse following when obtaining the client's family hx and checking for a medical alert bracelet?
a) Client identification b) Injury prevention for staff c) Injury prevention for clients d) Risk for errors and adverse events
Which effect does the nurse expect after an amniotomy is performed on a client in active labor?
a) Diminished vaginal bleeding b) Less discomfort with contractions c) Progressive dilation and effacement d) Increased maternal and fetal heart rates
A newborn is admitted to the nursery weighing 10 lbs 2 oz. Which intervention would the nurse implement in relation to this baby's birth weight?
a) Document the findings b) Delay starting oral feedings c) Perform serial glucose readings d) Place the newborn in a heated crib
Which task is classified as low priority when planning client care for the day?
a) Drawing arterial blood gases on a client in respiratory distress b) Turning and positioning a client after hip replacement surgery c) Teaching self-administration of insulin injections before discharge d) Obtaining and recording VS q 2 hrs on postoperative client
Which is a nonreassuring fetal heart rate pattern?
a) Early decelerations with average variability b) Changes in baseline variability from 5-10bpm c) Increases in fetal heart rate from 135 to 150 bpm with fetal activity d) Variable decelerations that last 60 seconds, then return to baseline tachycardaia Rationale: variable decelerations indicate cord compression
The practice of separating parents from their newborn immediately after birth and limiting their time with the infant during the first few days after delivery contradicts studies related to which?
a) Early rooming-in b) Taking-in behaviors c) Taking-hold behaviors d) Parent-child attachment
Which topics would the nurse include in the teaching session for a pregnant client regarding maternal discomforts caused by fetal growth and hormonal changes?
a) Emesis b) Nausea c) Diarrhea d) Backache e) Dyspepsia Correct answers are highlighted (a, b, d, e)
What are the purposes of applying the four elements of safety, critical thinking, stability, and time in delegation?
a) Encouraging effective delegation decisions b) Ensuring effectiveness in performing elements of care c) Determining level of readiness d) Developing the expectations of individuals to achieve safety goals e) Assessing the ability of UAP to perform the task Correct answers are highlighted (a, b, e)
While changing her newborn daughter's diaper, a client expresses concern about a small spot of red vaginal discharge on the diaper. How would the nurse respond to this concern?
a) Explain that this is an expected finding b) Obtain a prescription for vaginal cultures c) Assess the infant for other signs of bleeding d) Apply a urine specimen bag to the perineum Rationale: discharge on the diaper is related to the influence of maternal hormones; it is temporary and unrelated to problems with infection or bleeding
The RN delegates the care of a client in the immediate postoperative period to the PCA. Which tasks are within the scope of practice for the PCA?
a) Feeding the client b) Ambulating the client for the first time c) Monitoring VS d) Assisting the client with bathing e) Teaching exercises to the client Correct answers are highlighted (a, d)
Which complications are associated with excessive weight gain during pregnancy in adolescents?
a) Fetal anemia b) Preterm labor c) Cesarean delivery d) Maternal mortality e) Postpartum obesity Correct answers are highlighted (b, c, e)
The nurse explains to the pregnant client that the NST she is scheduled to have will assess the response of the fetal heart rate to which item?
a) Fetal gestational age b) Fetal physical activity c) Maternal blood pressure d) Maternal uterine contractions
Which is a potential cause of fetal tachycardia when a client is in active labor?
a) Fetal head compression b) Umbilical cord compression c) Increased maternal metabolism d) Pudendal anesthesia administration
Which changes would the nurse include in the childbirth class focusing on the maternal psychologic and physiologic alterations that occur near the end of pregnancy?
a) Food cravings increase b) Nesting needs increase c) Dependency needs decrease d) Anxiety about childbirth increases e) Gastrointestinal motility decreases Correct answers are highlighted (b, d, e)
Which nursing interventions require the nurse to wear gloves?
a) Giving a back rub b) Cleaning newborn after delivery c) Emptying a portable wound drainage system d) Interviewing a client in the emergency department e) Obtaining the BP of a client who is positive for HIV Correct answers are highlighted (b, c)
Fetal heart rate tracing abnormalities are observed on the fetal monitor when a client in active labor turns to the supine position. Which nursing action is most beneficial at this time?
a) Helping the client change her position b) Informing the client of the problem with the fetus c) Administering O2 by mask to the client at 2L/min d) Readjusting placement of the fetal monitor on the client's abdomen
Which maternal complication is associated with precipitous labor and birth?
a) Hypertension b) Hypoglycemia c) Chilling and shivering d) Bleeding and infection
After checking the fetal heart rate of a client after an amniotomy procedure, which intervention by the nurse would be appropriate?
a) Inspecting the perineum b) Preparing for immediate birth c) Measuring the maternal BP d) Increasing the IV fluid rate Rationale: inspecting for fetal cord prolapse
The nurse is explaining insulin needs to a client with gestational diabetes who is in her second trimester of pregnancy. Which information would the nurse give to this client?
a) Insulin needs will increase during the second trimester b) Insulin needs will decrease during the second trimester c) Insulin needs will not change during the second trimester e) Insulin will be switched to an oral antidiabetic medication during the second trimester
A newborn is Rh+ and the mother is Rh-. When the parents ask why their baby will receive an Rh-negative exchange transfusion, which explanation will the nurse provide?
a) It is neutral and will not react with the baby's blood b) The possibility of a transfusion reaction is eliminated c) The RBCs will not be destroyed by maternal anti-Rh antibodies d) The choice of Rh+ or Rh- blood is determined by blood availability
A pregnant client asks how smoking will affect her baby. Which information about cigarette smoking will influence the nurse's response?
a) It relieves maternal tension, and the fetus responds accordingly to the reduction in stress b) The resulting vasoconstriction affects both fetal and maternal blood vessels c) Substances contained in smoke permeate through the placenta and compromise the fetus's well-being d) Effects are limited because fetal circulation and maternal circulation are separated by the placental barrier
The nurse is assessing a 12-hour-old newborn. Which clinical finding would be reported to the health care provider in a timely manner?
a) Jaundice b) Cephalhematoma c) Erthyema toxicum d) Edematous genitalia
Which exercises would the nurse teach the client that she may perform on the first postoperative day following a cesarean section?
a) Leg bends b) Foot circles c) Pelvic rocking d) Shoulder circles e) Deep breathing f) Kegels Correct answers are highlighted (a, b, d, e, f)
Which is a consequence on the neonate of maternal smoking during pregnancy?
a) Low birth weight b) Facial abnormalities c) Chronic lung problems d) Hyperglycemic reactions
As a client enters the second stage of labor, fetal monitoring shows early decelerations of the fetal heart rate with a return to baseline at the end of each contraction. Which is the common cause of this fetal heart rate pattern?
a) Maternal diabetes b) Fetal cord prolapse c) Maternal hypotension d) Fetal head compression
In her 36th week of gestation, a client with type 1 diabetes delivers a 9 lb 10 oz infant via cesarean birth. Which condition is this infant at high risk for developing?
a) Meconium ileus b) Physiological jaundice c) Respiratory distress syndrome d) Increased intracranial pressure Rationale: 36 week gestation indicates possibility of immature lung tissue
Which are the major complications noticed in adolescent girls during pregnancy?
a) Obesity b) Bleeding c) Ectopic pregnancy d) Gestational diabetes e) Spontaneous abortion Correct answers are highlighted (c, e)
Nursing actions after a client has had general anesthesia are directed at preventing which postoperative respiratory complication?
a) Pleural effusion b) Empyema c) Pnemothorax d) Atelectasis
Why is a multiple gestation pregnancy considered to be high risk?
a) Postpartum hemorrhage is an expected complication b) Perinatal mortality is two to three times more likely in multiple than single births c) Optimal psychological adjustment after a multiple birth requires 6 months to a year d) Maternal mortality is higher during the prenatal period in the setting of multiple gestation
Which are risk factors for diabetes in pregnancy?
a) Preterm birth b) Hypertension c) Cesarean birth d) Placenta previa e) Placental abruption Correct answers are highlighted (a, b, c)
Late decelerations are present on the monitor strip of a client with an intravenous infusion who received an epidural 20 minutes ago. Which action would the nurse take immediately?
a) Reposition the client from supine to left lateral b) Increase the intravenous flow rate from 125 to 150 mL/hr c) Administer oxygen at a rate of 8-10 L/min by facemask d) Assess the maternal blood pressure for systolic pressure below 100 mm Hg
Which assessment finding in a pregnant client would prompt the nurse to notify the primary health care provider?
a) Slight dependent edema at 38 weeks gestation b) Fundal height at the umbilicus at 16 weeks gestation c) Fetal heart rate of 150 bpm at 24 weeks gestation d) Maternal heart rate of 92 bpm at 28 weeks gestation Rationale: fundal height should be at the umbilicus at 20 weeks gestation, anything prior should be below umbilicus in healthy single pregnancy
The nurse teaching a prenatal class is asked why infants of diabetic mothers are larger than those born to women who do not have diabetes. On which information about pregnancy and diabetes would the nurse base their response?
a) Taking exogenous insulin stimulates fetal growth b) Consuming more calories covers the insulin secreted by the fetus c) Extra circulating glucose causes the fetus to acquire fatty deposits d) Fetal weight gain increases as a result of the common response of maternal overeating
Which assessment finding is most significant in an infant of a diabetic mother who is large for gestational age?
a) Temp of less than 98 F b) Heart rate of 110 bpm c) Blood glucose level of less than 40 mg/dL d) Increasing bilirubin during the first 24 hrs
Which statement describes the primary reason why the nurse raises three of the four side rails on the bed of an 83-year-old client who is postanesthesia for a fractured hip?
a) The action is a safety measure because of the client's age b) Clients older than 60 years of age should use side rails c) The side rails serve as handholds to facilitate the client's ability to move in bed d) All older adults are disoriented for several days after anesthesia
A client is at 38 weeks gestation and is in labor with ruptured membranes and the fetus in a breech position. Which would the nurse conclude from observing the amniotic fluid as green?
a) The fetus has a neural tube defect b) Fetal well being is compromised c) Intrauterine infection as developed d) Meconium is being expelled with contractions
When the nurse brings a newborn to the new mother, the mother comments about the milia on her infant's face. Which information would the nurse include when responding?
a) They are common and will disappear within 2-3 days b) Avoid squeezing them and don't try to wash them off c) They are birthmarks and will disappear in 3-4 months d) Proper hand-washing technique is important because milia are infectious
Which is the priority nursing care for a client at 38 weeks gestation, admitted with the diagnosis of placenta previa?
a) Withholding oral intake b) Assessing for hemorrhage c) Avoiding extraneous stimuli d) Encouraging supervised ambulation