NUR 335 Exam 3
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."
Which of the following is the treatment of choice for primary postpartum hemorrhage? A. Terbutaline B. Oxytocin C. Misoprostol D. Low-weight heparin
b) oxytocin Oxytocin is the treatment of choice for primary postpartum hemorrhage.
A nurse is assessing a newborn one day after a circumcision with a plastibell. The nurse observes the mother placing lubricant on the circumcision during the diaper change. How should the nurse respond? 1. "Lubricant can cause displacement of the plastibell." 2. "Do not use lubricant during the diaper change." 3. "Lubrication is an excellent technique in caring for the circumcision." 4. "It is always important to lubricate to prevent the diaper from sticking."
1. "Lubricant can cause displacement of the plastibell."
The nurse observes a client breastfeeding a newborn and completes a LATCH assessment of the feeding. The nurse notes the infant needs stimulation to latch, and has some audible swallowing with stimulation and minimal assistance from the nurse for positioning. The client's nipples are everted, and the client denies any pain or discomfort. What score will the nurse document? 1. 7 2. 6 3. 8 4. 9
1. 7
A client states that breastfeeding is very painful. The nurse observes redness and cracking on both nipples. What actions by the nurse would be appropriate? Select all that apply. 1. Assess the infant's latch position. 2. Instruct the client to apply ice to her breasts before feeding. 3. Notify the health care provider to monitor for infection. 4. Instruct the client to express colostrum and rub it on her nipple. 5. Teach the client to wash breasts with water only.
1. Assess the infant's latch position. 3. Notify the health care provider to monitor for infection. 4. Instruct the client to express colostrum and rub it on her nipple. 5. Teach the client to wash breasts with water only.
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.
Which statement should the nurse include in an education program for parents regarding Sudden Infant Death Syndrome (SIDS)? 1. Babies need to be placed in the supine position for sleeping. 2. Babies should be swaddled from birth until one year old. 3. Babies should be placed in the prone position for naps to prevent abnormal head shape. 4. Pacifiers should not be offered to babies who established effective breastfeeding.
1. Babies need to be placed in the supine position for sleeping.
A postpartum nurse is caring for a patient who gave birth 1 hour ago following a 24-hour long induction. The patient had an epidural for pain control during labor. What assessment finding should immediately be reported to the healthcare provider? 1. Boggy uterus 2. Bilateral lower extremity numbness 3. Uncontrollable shaking 4. Moderate vaginal bleeding
1. Boggy uterus
A nurse is working in the emergency department when a family member brings in a 4-month-old infant. Upon assessment, the nurse suspects the infant has pediatric abusive head trauma (PAHT). Which assessment findings are consistent with a PAHT diagnosis? Select all that apply. 1. Breathing Problems 2. Convulsions 3. Crying for 30 minutes 4. Lethargy 5. Vomiting
1. Breathing Problems 2. Convulsions 3. Crying for 30 minutes 4. Lethargy 5. Vomiting
During a routine assessment, the nurse notes diastasis recti abdominis on a postpartum patient. What is the priority nursing intervention for this patient? 1. Continue with the assessment, as this is a normal finding. 2. Notify the physician or midwife STAT. 3. Assist the woman in applying an abdominal binder. 4. Instruct the woman to avoid using her abdominal muscles.
1. Continue with the assessment, as this is a normal finding.
A nurse is caring for a postpartum patient who had an uncomplicated delivery 12 hours ago. Vital signs are: BP 125/88, HR 90, O2 saturation 98%, temperature 100.0 F. What is the priority nursing intervention? 1. Document as within normal limits. 2. Administer Acetaminophen 650 mg PO PRN. 3. Notify the physician or midwife. 4. Remove extra blankets and recheck in 1 hour.
1. Document as within normal limits.
Immediately after birth, the nurse notes the patient's fundus is palpated midway between the umbilicus and symphysis pubis. What is the priority nursing action? 1. Document the findings as within normal limits 2. Perform fundal massage 3. Instruct the woman to empty her bladder 4. Reassess every 5 minutes
1. Document the findings as within normal limits
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 nurse is evaluating the reflexes in an LGA infant born vaginally with a shoulder dystocia. The nurse notes that with a loud noise, the infant abducts and extends his left arm, and his fingers fan out and form a "C" with the thumb and index finger. What is the priority action by the nurse? 1. Notify the provider. 2. Reassess using a different technique. 3. Document the findings. 4. Reassess after the infant is 24 hours old.
1. Notify the provider.
The nurse is assessing a 4-hour-old neonate. What behaviors would the nurse expect the newborn to exhibit? Select all that apply. 1. Passage of meconium 2. Responsive to external stimuli 3. Sleepy and uninterested in breastfeeding 4. Grunting and irregular respirations 5. Spontaneous Moro reflexes
1. Passage of meconium 2. Responsive to external stimuli
The nurse is teaching a discharge class for parents with preterm infants. Which characteristic would the nurse use to describe the preterm neonate? 1. Preterm infants have less brown fat stores at birth to use for thermoregulation. 2. Preterm infants have well-developed flexor muscles to be able to shiver when cold stressed. 3. The term infant is more prone to dehydration than the preterm infant. 4. Preterm infants have abundant lanugo to use for thermoregulation.
1. Preterm infants have less brown fat stores at birth to use for thermoregulation.
The nurse encourages the mother to hold her newborn skin-to-skin shortly after birth. What is the most appropriate reason for this action? 1. To encourage breastfeeding 2. To promote parent-infant attachment 3. For infant security until identification bands are applied 4. To provide the newborn protective antibodies
2. To promote parent-infant attachment
The nurse is teaching a new mother about how the immune system protects the newborn. Which statement made by the nurse is correct? Select all that apply. 1. "The maternal transfer of IgM through delivery protects the newborn." 2. "The mother passes IgA through breastmilk and this provides additional protection to the newborn." 3. "The newborn receives IgG antibodies which provide immunity from infections which the mother has previously developed antibodies." 4. "The fragile newborn skin and mucous membranes cause exposure to bacteria." 5. "Active immunity is only acquired through vaccination."
2. "The mother passes IgA through breastmilk and this provides additional protection to the newborn." 3. "The newborn receives IgG antibodies which provide immunity from infections which the mother has previously developed antibodies."
A client is concerned because her 2-hour-old newborn is sleeping skin-to-skin and will not breastfeed. Which response by the nurse is correct to explain this behavior? 1. "The medication you received in labor is affecting the baby's ability to stay awake." 2. "This is a normal response after birth and may last an hour or two." 3. "The baby could be sleepy because of a low glucose level. Try to wake the baby up and breastfeed." 4. "We can give the baby a bath to wake the baby up."
2. "This is a normal response after birth and may last an hour or two."
A nulliparous client expresses a desire to breastfeed. She asks the nurse how she can be successful. How should the nurse respond? 1. "No preparation is required. It's natural and will come easily." 2. "You can start prenatally by attending classes and gathering a support system." 3. "Begin by pumping prenatally and storing your breast milk." 4. "You should seek the advice of friends and family who have breastfed."
2. "You can start prenatally by attending classes and gathering a support system."
The nurse is caring for a male infant who was circumcised 30 minutes ago. What are the responsibilities of the nurse after the procedure? Select all that apply. 1. Clean the penis every diaper change and wrap with petroleum-impregnated gauze. 2. Assess the penis every 15 minutes for the first hour for signs of bleeding, then every 2 to 3 hours per hospital policy. 3. Assess for urination and document findings. 4. Administer pain medication if ordered. 5. Fasten the diaper firmly over the penis to prevent friction and promote hemostasis.
2. Assess the penis every 15 minutes for the first hour for signs of bleeding, then every 2 to 3 hours per hospital policy. 3. Assess for urination and document findings. 4. Administer pain medication if ordered.
The nurse is assessing a neonate 1 hour after birth. Which assessment data by the nurse will require further evaluation? 1. Apical pulse of 105 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
The nurse is performing a physical assessment on a 40-week neonate. Which assessment data does the nurse document as normal? Select all that apply. 1. Head circumference 33cm, chest circumference 35 cm 2. Equal gluteal folds 3. Clear-milky fluid leaking from nipples 4. Acrocyanosis of hands and feet 5. Overriding sutures
2. Equal gluteal folds 3. Clear-milky fluid leaking from nipples 4. Acrocyanosis of hands and feet 5. Overriding sutures
When performing a gestational age assessment using a Ballard Maturational Score on a 39-week-old neonate, what physical and neuromuscular maturity findings will be observed? Select all that apply. 1. Mongolian spots 2. Instant ear recoil 3. Testis in the scrotum 4. Acrocyanosis 5. 00 square window
2. Instant ear recoil 3. Testis in the scrotum 5. 00 square window
A nurse is caring for a patient 6 hours post-vaginal delivery of a term neonate. She notes a white blood cell count of 20,000/mm. What is the priority nursing intervention for this patient? 1. Notify the physician or midwife 2. Interpret as a normal finding 3. Administer Tylenol 1,000mg PO 4. Order a repeat CBC for the next morning
2. Interpret as a normal finding
The nursery nurse is caring for a neonate diagnosed by prenatal ultrasound with polycystic kidney disease. Which assessment would be a priority for this neonate? 1. Limit medication administration due to the risk of side effects and toxicity. 2. Monitor urine output. 3. Monitor sodium levels. 4. Prevent dehydration with supplementation.
2. Monitor urine output.
A nurse initiates measures to maintain thermoregulation in a newborn. Which statement best describes why neonates are at a higher risk for thermoregulatory problems? 1. Neonates have a smaller body surface area. 2. Neonates have decreased subcutaneous fat. 3. Neonates are able to shiver and increase heat production. 4. Neonates have a lower metabolic rate.
2. Neonates have decreased subcutaneous fat.
The nurse is teaching a new mother about newborn screening tests. What should the mother be taught regarding the screening tests performed prior to the newborn's discharge? Select all that apply. 1. All states screen for 30 disorders and require newborn screening. 2. Newborn screenings consist of blood and hearing tests. 3. A neonate with PKU cannot be fed breastmilk or formula, due to the inability to metabolize phenylalanine. 4. The newborn screening of blood should be obtained after 24 to 48 hours of life. 5. All states require that newborns are screened for hearing loss.
2. Newborn screenings consist of blood and hearing tests. 3. A neonate with PKU cannot be fed breastmilk or formula, due to the inability to metabolize phenylalanine. 5. All states require that newborns are screened for hearing loss.
The nurse understands that which is a primary reason that women stop breastfeeding before the eighth week? 1. Engorgement 2. Painful nipples 3. Mastitis 4. Thrush
2. Painful nipples
The nurse is preparing discharge instructions for the parents of a newborn. When developing the teaching plan, the nurse must include which rights for teaching? Select all that apply. 1. Right day 2. Right context 3. Right content 4. Right goal 5. Right method
2. Right context 3. Right content 4. Right goal 5. Right method
A nurse is assessing a male infant several hours after a circumcision. Which finding would the nurse document as a sign of pain requiring intervention? 1. Sucking on pacifier 2. Sudden high-pitched cry 3. Crying with diaper change 4. Decreased muscle tone
2. Sudden high-pitched cry
A nurse is educating a patient on the mother-baby unit about breastfeeding. Which statements made by the patient indicate need for further teaching? Select all that apply. 1. "During the first 24 hours postpartum, my breasts should be soft and non-tender." 2. "Colostrum gives my baby protection from viruses and bacteria." 3. "Colostrum is thick and whitish in color." 4. "Colostrum has more carbohydrates than breast milk." 5. "I might feel throbbing pain in my breasts for the first 1 to 2 days."
3. "Colostrum is thick and whitish in color." 4. "Colostrum has more carbohydrates than breast milk."
A new mother calls the provider's office, concerned about her toddler's behavior toward the family's newborn. Which statement by the mother would require further assessment by the nurse? 1. "Even though my toddler is fully potty-trained, they have begun wetting their pants again." 2. "My toddler has insisted on using a bottle at mealtimes." 3. "I caught my toddler hitting the baby when I was not in the room." 4. "My toddler said they 'hated' the baby and has started to throw tantrums."
3. "I caught my toddler hitting the baby when I was not in the room."
The postpartum nurse is educating a patient who is receiving the Measles, Mumps, and Rubella (MMR) vaccine. What statement made by the patient indicates the need for further teaching? 1. "My arm might be sore where I was given a shot." 2. "I will avoid pregnancy for 4 weeks." 3. "I will need to receive this vaccine again during my next pregnancy." 4. "I am being vaccinated against German measles."
3. "I will need to receive this vaccine again during my next pregnancy."
A breastfeeding mother changes her newborn's diaper and asks the nurse why the stool is black and difficult to clean. What is the best response by the nurse? 1. "This can be caused by blood in the stool and I will check it to make sure everything is okay." 2. "Let me call the physician and see if we need to supplement the baby with formula." 3. "The stool is normal and called meconium. The baby may pass this for the first day or two." 4. "The iron you took during the pregnancy caused the stool to be tarry and thick."
3. "The stool is normal and called meconium. The baby may pass this for the first day or two."
The postpartum nurse is caring for a patient with an anterior laceration following the vaginal delivery of a 9 lb infant. What information is a priority for the nurse to include in her teaching? 1. "You might have difficulty with bowel movement because of the tear." 2. "Make sure you take a stool softener and laxative at home." 3. "You may experience difficulty with urination because of swelling." 4. "You will probably experience mild pain for a few days."
3. "You may experience difficulty with urination because of swelling."
A postpartum nurse is caring for multiple patients on the mother-baby unit. Which task can the nurse delegate to the Licensed Practical Nurse (LPN)? 1. Re-admit a patient 2 weeks post-op cesarean section with an infection 2. A G1P1 needing discharge teaching 3. A G2P1 who gave birth yesterday and has moderate lochia rubra 4. A G6P6 2 days post-op cesarean section at 34 weeks gestation
3. A G2P1 who gave birth yesterday and has moderate lochia rubra
A nurse is checking several newborn reflexes on a 2-day-old neonate. Which reflex would require further investigation? 1. The neonate turning the head toward the nurse's finger after stroking the cheek 2. The neonate grasping the nurse's fingers tightly when one finger is placed in the palm of the hand 3. Asymmetrical abduction of the arms when the nurse jars the crib 4. The toes fanning out when the nurse strokes the lateral surface of the sole in an upward motion
3. Asymmetrical abduction of the arms when the nurse jars the crib
A G6P5 patient who is 24-hours post vaginal delivery reports severe cramp-like uterine pain. What is the priority nursing intervention for this patient? 1. Document the pain score in the electronic medical record. 2. Assess the perineum for a vaginal hematoma. 3. Encourage warm packs to the abdomen. 4. Notify the healthcare provider STAT.
3. Encourage warm packs to the abdomen.
The postpartum nurse is educating a new mother on ways to prevent contamination of expressed breastmilk. What action should be included in the plan of teaching? 1. Wash nipples with soap and water before pumping. 2. Pump into sterile containers only. 3. Wash hands before touching breasts. 4. Refreeze unused portions of breastmilk within 2 hours.
3. Wash hands before touching breasts.
A nurse is teaching a new mother about breastfeeding her newborn. Which statement by the mother would indicate the need for additional education? 1. "The baby's stomach can only hold 1 to 2 teaspoons per feeding for the first few days." 2. "Breastfed babies have more stools than formula-fed babies." 3. "The baby receives natural passive immunity through breastmilk." 4. "A breastfed baby has an increased risk of jaundice."
4. "A breastfed baby has an increased risk of jaundice."
The nurse overhears a client and spouse discussing the needs for the newborn to have daily baths to maintain cleanliness. What is the appropriate response from the nurse? 1. "Babies smell so good right after a bath." 2. "Nobody bathes infants daily anymore." 3. "Daily baths with soap are important for newborns." 4. "Tell me more about what you know about bathing newborns."
4. "Tell me more about what you know about bathing newborns."
Which nursing action is the most appropriate demonstration of cultural awareness? 1. Allow the parents to put honey in the newborn's bottle. 2. Speak slowly and show pictures to a client who speaks very little English. 3. Encourage the mother to rest at night and room-in during the day. 4. Assist family with taking-in as desired and delay interventions as necessary.
4. Assist family with taking-in as desired and delay interventions as necessary.
The nurse is performing an assessment on a neonate. What does the nurse document for the assessment data in the image below? 1. Molding 2. Cephalhematoma 3. Subdural hematoma 4. Caput succedaneum
4. Caput succedaneum
When preparing to administer an injection to a neonate, which priority nursing action prevents transmission of blood-borne pathogens to the neonate? 1. Checking maternal Hepatitis B and HIV status 2. Bathing the neonate prior to the injection 3. Wearing gloves to administer the injection 4. Cleaning the area with alcohol to remove all maternal blood and amniotic fluid
4. Cleaning the area with alcohol to remove all maternal blood and amniotic fluid
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
A day shift nurse gives a report to the night shift nurse on four newborns. Which newborn should be assessed first? 1. Newborn 15 hours old with acrocyanosis 2. Preterm newborn breastfeeding for the second time 3. Male newborn who failed the hearing test and was circumcised today 4. Newborn with clear breath sounds and grunting
4. Newborn with clear breath sounds and grunting
The nurse is completing a home visit on a family with a 1-month-old infant. During this visit, the nurse is completing a safety assessment. Which finding by the nurse would require further intervention? 1. The baby sleeps in a crib right next to the parent's bed. 2. The baby was found to be swaddled in a light blanket. 3. The baby was offered a pacifier at nap time. 4. The baby had a strong smell of cigarette smoke.
4. The baby had a strong smell of cigarette smoke.
Lactogenesis occurs in the breast following delivery of the infant. In which area does milk production occurs in the breast?
Alveolar glands
Endometrial changes are assessed by examining which of the following? A. Vital signs B. Lochia C. Fundal height D. All of the above
B) lochia The appearance and amount of lochia tells the nurse about the progress of endometrial shedding and regeneration.
The first follow-up visit should take place: A. 24 hours after discharge B. 48-72 hours after discharge C. One week after discharge D. It depends
B. 48-72 hours after discharge The first follow-up visit should take place 48-72 hours after discharge.
Meconium Aspiration Syndrome affects: A. Preterm infants B. Post-term infants C. Children over 1 month D. None of the above
B. Post term infants Large and post-term infants are likely to pass meconium in utero, leading to a dangerous respiratory situation.
Which of the following is a contraindication for breastfeeding? A. Obesity B. Tuberculosis C. Prematurity D. Autoimmune disease
B. Tuberculosis Active or latent tuberculosis in the mother is a contraindication for breastfeeding.
Which of the following is the condition that affects infants who have received mechanical ventilation? A. LS syndrome B. RDS C. BPD D. PDA
C. BPD BPD or bronchopulmonary dysplasia is a potentially fatal complication of use of mechanical ventilation and oxygenation in neonates.
The neonate is given which of the following to facilitate blood coagulation? A. Oxygen B. Erythromycin C. Vitamin K D. Hepatitis B vaccine
C. Vitamin K Vitamin K is administered I M after birth to compensate for the absence of vitamin K due to the lack of intestinal flora.
Acute hypertension is treated with what? A. IV labetolol and hydralazine B. Nifedipine C. Frequent monitoring of vital signs D. All of the above
D. All of the above Nursing actions for acute hypertension include medication with I V labetolol and hydralazine, nifedipine, and frequent monitoring of vital signs.
Gastrointestinal postpartum changes include which of the following? A. Constipation B. Hemorrhoids C. Increased appetite D. All of the above
D. all of the above After delivery the mother may experience constipation, hemorrhoids, and increased appetite.
When does a mother begin adjusting to her new role? A. Pregnancy B. Infancy C. First four months D. After four months
a) pregnancy The first stage of motherhood occurs during pregnancy.
Which of the following is protective tissue that assists in thermoregulation in the neonate? A. Brown fat B. Foramen ovale C. Bilirubin D. Vernix
a. Brown fat Brown fat is the protective adipose tissue that can be metabolized to generate warmth in the neonate.
Postpartum blues are caused by what? A. Hormones B. Stress C. Fatigue D. All of the above
d) all of the above Hormonal changes, stress, and fatigue all contribute to postpartum blues.