NUR 313 Exam 2
Is Rh+ mom and Rh- baby a problem? a. Yes b. No
B
Is Rh- mom and Rh- baby a problem? a. Yes b. No
B
What interventions should the nurse perform after an amniocentesis?
1. Assess fetus before, during, and after using either the doppler at 16 weeks or EFM at 24 weeks. 2. Position the patient in a lateral tilt. 3. Give Rhogam AFTER the procedure if mom is Rh-. 4. Instruct mom to perform fetal kick counts if she is at least 24 weeks gestation
A couple is concerned that their 4 year old infant will have problems once their baby delivers in 6 weeks. What is the best recommendation for this couple? a. Encourage the parents to take their 4 year old to sibling classes. b. Encourage the parents to set aside time for both children c. Encourage the parents to purchase a big brother/sister t-shirt for the 4 year old for the hospital d. Suggest that the clients could send their 4 year old to spend time with another family who has a newborn.
A
The most likely reason for increased bleeding during the immediate postpartum period is: a. Uterine atrophy b. Retained placental fragments c. Delivery of macrocosmic infant d. Lacerations
A
Which of the following findings indicate respiratory distress in the newborn? a. Tachypnea b. Apnea for 10 seconds c. Acrocyanosis d. Course rhonchi noted in the upper lobes
A - Be concerned about apnea lasting 20 seconds, central cyanosis, and complete rhonchi.
A nurse is visiting a breastfeeding client at home 2 weeks post delivery of a 7 pound boy via C/S. The lochia is serosa with a midline fundus palpated as firm in the symphysis pubis area. Her nipples are cracked. The client is crying a reports her uterine cramping and nipple pain as a 6/10. The client yells at the baby for crying. What is the nursing priority in this scenario. a. Perform a head to toe assessment on the newborn b. Encourage the client to join a postpartum support group c. Educate the client to take Motrin around the clock d. Evaluate the client's latching on and off procedures
A - Due to signs of impaired bonding, ensure the baby is healthy and taken care of properly, then check latching.
Is it possible for a mother to experience mixing of maternal and fetus blood during a woman's first pregnancy? a. Yes b. No
A - It is possible but very unlikely.
The best way to prevent hypothermia in the newborn is to: a. Place the baby on the mother's chest and dry with warm blankets b. Bathe the infant while under the radiant warmer c. Wrap the baby in 2 warm blankets with a hat on the head d. Place the infant under the radiant warmer for 30 minutes.
A - Kangaroo care is the best way to regulate baby's temperature.
The baby's lip/mouth/tongue are blue. Are you concerned? a. Yes b. No
A - Patient is showing signs of central cyanosis indicating respiratory distress. Other signs that might accompany respiratory distress is nasal flaring and grunting.
A 2 day old infant's blood values are: Blood: O- direct coomb's titer Glucose: 45 Bilirubin: 8.5mg/dL The mother's blood type is A+. What is the nursing priority? a. Continue to monitor b. Start an IV line and contact the physician c. Observe the baby for kernicterus d. Administer Rhogam per physician's orders
A - Rhogam isn't needed because mom is Rh+, glucose isn't a concern until it's <40, and bilirubin is below 15 so no intervention is needed.
What is considered the number one safest injection site in the adult? a. Ventrogluteal b. Vastus lateralis c. Rectis femoris d. Dorsal gluteal
A - Vastus lateralis is safest in children.
What information should a nurse include when teaching post-circumcision care to parents of a neonate before discharge? Select all that apply. a. The neonate must void before being discharged home b. Petrolium jelly should be applied to the glans of the penis with each diaper change c. The neonate can take tub baths while the circumcision heals d. Small amounts of blood noted on the front of the diaper should be reported e. The circumcision will require care for 2 to 4 days after discharge
A, B, E - We want to make sure they won't have voiding issues, and petroleum jelly prevents the diaper from sticking to the skin.
Select all infants who are considered appropriate for gestational age: a. A preterm infant whose height and weight are at the 80% and the HC is at the 90%. b. A post-term infant whose HC and length are at the 85% and the weight is at the 90%. c. An infant whose height and weight are at the 95% and HC at the 90%. d. A term infant whose height, weight, and HC are all at the 5%. e. A term infant whose height, weight, and HC all fall between the 50% and 75%. f. A term infant whose weight and length are at the 60% and HC is at the 35%.
A, B, E, F - 2/3 of the criteria are between 10-90%.
What specific information should the nurse provide the client undergoing amniocentesis? Select all that apply. a. the test is done during ultrasound guidance b. numbing medicine is used if desired or necessary c. there are no significant risks to the mother of fetus that need to be discussed. d. you will need to be NPO prior to the test e. a tight abdominal bandage will need to remain in place for 12 hours f. you will need to empty your bladder prior to the procedure.
A, B, F - Only requires a regular bandage.
At the end of the 3rd stage of labor, there are many necessary nursing interventions. Select all that apply. a. Vigorously massage the fundus b. Prepare for the delivery of the placenta c. Assist the mother with breastfeeding d. Place the mother on her left side to optimize perfusion e. Administer IV Oxytocin/Pitocin per institution protocol
A, C, E - At the end of the 3rd stage of labor the placenta has been delivered. After delivery of the placenta, the goal is to contract the uterus to control bleeding. Massaging the fundus, administering oxytocin, and getting the mother to naturally produce oxytocin (through breastfeeding) helps contract the uterus. D is only necessary during pregnancy.
Which infants will need to have the circumcision delayed? Select all that apply. a. an infant delivered at 28 weeks b. an infant delivered at 39 weeks to a heroin addict mother c. a 38 week infant with descended testes and swelling due to breech presentation d. an infant whose parents have refused vitamin K injection e. an infant diagnosed with epispadis
A, D, E
What is the best and safest type of birth control for the breast feeding mother in the early postpartum period (first 6 weeks)? Select all that apply. a. Condoms b. Depo Provera c. Oral contraceptives d. Abstinence e. Copper IUD f. Rhythm method
A, D, E - Depo and other oral contraceptives can interrupt milk production, so it is best to wait until after 6 weeks (when a normal lactation pattern is established) to minimize this risk. Also, hyper coagulation is prevalent during this period, so avoid estrogen! It is recommended to wait 6 weeks to have sex.
A nurse notes that an infant has cyanotic hands and feet 8 hours after birth. Which of the following actions is the most appropriate? a. Administer oxygen b. Place the infant in the crib c. Assess oxygen saturation d. Notify the physician
B - Acrocyanosis is normal until 2 weeks old. Central cyanosis is when you would worry about respiratory distress.
A baby has acrocyanosis, or blue hands and feet. Are you concerned? a. Yes b. No
B - Acrocyanosis is normal, however central cyanosis is abnormal.
The nurse palpates a distended bladder on a woman who delivered vaginally 5 hours ago. The woman refuses to go to the bathroom, "I really don't need to go." Which of the following responses is the most appropriate? a. Okay I must be palpating your uterus. b. That feeling is most likely due to the effects of the anesthesia, but you will still need to try in order to empty your bladder. c. You still must be numb from the local anesthesia. d. That is a problem, I will need to catheterize you.
B - After an epidural, the woman may not feel like she has to urinate. However, it is important for her to empty her bladder every 1-2 hours to prevent the bladder from distending so that the uterus can properly contract.
To reduce the risk for complications associated with an infant with ABO incompatibilities, it is most important for the nurse to monitor: a. Serum WBC count b. Serum bilirubin level c. Blood type with Rh factor d. Temperature
B - Blood incompatibilities can result in hemolysis of the infant's blood cells. When too many RBC are broken down in a short amount of time, the liver can't keep up in excreting all of that material, so the baby's bilirubin levels will increase and they can become jaundice.
After completing all the assessment (BUBBLE LE) on a postpartum client, the nurse reviews the lab findings on a client. See the findings below. Orthostatic BP and P are performed and no changes are noted. What is the priority in the scenario? Hgb: Pre-delivery (10), Now (7.2) Hct: Pre-delivery (36), Now (23) RBC: Pre-delivery (5.2), Now (4.2) WBC: Pre-delivery (18,000), Now (20,000) a. Massage the fundus and administer oxytocin b. Push fluids by mouth and notify the HCP c. Assess the client temperature and recommend blood cultures be drawn d. Reassess the client's orthostatic vital signs in 30 minutes
B - Client is losing blood, go ahead and get fluids in. You already massaged the fundus when assessing using BUBBLE LE.
Which infant best fits the criteria for having a Dubowitz/Gestational Age Assessment/Ballard exam? a. A 39 week old baby at one hour of birth who's mother received consistent prenatal care. b. A 38 week two hour old baby who's mother received inconsistent prenatal care. c. A 32 week 2 day old infant who's mother received no prenatal care. d. A 37 week 6 hour old infant born to a heroin addicted mother who's prenatal care started 4 weeks ago.
B - Dubowitz is only performed 1-2 hours after birth. - Gestational Age Assessment only done on those with little or no prenatal care.
Which intervention would help prevent development of postpartum thrombophlebitis? a. Promote adequate oral fluid intake b. Promote early ambulation c. Place SCDs on all patients d. Administer SQ low molecular weight Heparin
B - Early ambulation is the best way to prevent DVTs. Use SCDs for women on bed rest. Also, always start with the least invasive intervention (D is very invasive).
Erythromycin ointment is administered to newborns to: a. Prevent staph infections in the eye b. Prevent neonatal blindness c. Prevent hemorrhagic disorders d. Prophylactically treat group B strep
B - Erythromycin is given to prevent neonatal blindness that can result when mom has an STD (gonorrhea) infection.
At birth, an infant is placed under a radiant warmer, dried off, and stimulated. The infant exhibits central cyanosis and is breathing 14 breaths/minute with no crying, tone is flaccid, HR is 90 and decreasing. What is the priority? a. Begin bag and mask chest compressions b. Position the infant's head in the sniff position c. Chart the APGAR score as a 2 d. Administer blow by oxygen
B - The sniff position allows for opening of the airways and may be enough to get the child adequately breathing. - Start bagging when HR <100, start chest compressions when HR <80.
Which postpartum client requires Rhogam? Select all that apply. a. Mother O+, infant AB+ b. Mother A-, infant A+ c. Mother B-, infant B- d. Mother AB-, infant is unknown, father is B- e. Mother B-, status post miscarriage at 8 weeks f. Mother O+, infant O-
B, D, E - Administer Rhogam only for Rh- women with infants that are either Rh+ or unknown blood type. Administer within 72 hours.
An hour old infant has the following vital signs: Temp.: 97.9 Pulse: 142 RR: 44 Over the last 15 minutes the infant has been jittery. What is the nursing priority? a. Assess the infant for sneezing and high pitched shrill cry b. Turn the radiant warmer up by 1 degree celsius and reassess the temperature in 15 minutes. c. Assess the infant's glucose level via heel stick. d. Send the umbilical cord segment for drugs or alcohol abuse.
C - Hypoglycemia (<40) can be seen with cold stress. Check glucose first even when you suspect drugs.
What is the most important information to impart to a postpartum client who is scheduled to receive a Rubella injection? a. We will need to retest your blood at your postpartum visit in 6 weeks b. This vaccination will help you not to spread Rubella to your infant c. Use some sort of birth control or abstinence for a month d. If you plan to breastfeed, then we will need to delay the vaccination for 6 weeks.
C - Rubella vaccine is a teratogen. This will help with future pregnancies.
A nurse assesses a breastfeeding client's breasts on day 4 post C/S. The breasts are firm and warm to touch. What is the priority in this scenario? a. Notify the HCP and recommend a lactation suppressant. b. Educate the client to express milk from her breasts every 3 hours. c. Intermittently apply cool/lukewarm compresses to the breast axillae areas d. Apply lanolin/lansinoh to her nipples every 2-3 hours.
C - The breasts are overproducing milk and we need to naturally suppress lactation/nipple stimulation. A cool compress prevents milk/breast engorgement. - Lanolin is for chapped/cracked nipples, not engorged breasts.
Upon examining a patient on day 2 after spontaneous vaginal delivery, a nurse finds the perineal pad to be completely saturated with bright red blood over the last 15 minutes. The priority in this scenario is: a. Start a second IV line of NS b. Notify the HCP c. Massage the fundus d. Assess vital signs
C - The most likely cause of active bleeding is a boggy uterus, so applying pressure to force it to constrict with slow/stop the bleeding.
What is the safest injection site for newborn infants? a. Deltoid b. Ventrogluteal c. Vastus lateralis d. Rectis femoris
C - This is the area with the most muscle in newborns, because they've been kicking in the womb.
After completing the ballard assessment, the nurse determines that the infant's weight is at the 95%; height at the 85%; and head circumference at the 50%. Based on this the nurse would classify the infant as: a. SGA b. LGA c. AGA d. Not enough info
C - Two criteria are between the 10-90 percentile, so they are categorized as AGA.
Many side effects are likely to occur due to epidurals during the postpartum period. Select all that apply. a. difficulty breathing b. retained placental fragments c. urinary retention d. return of sensation is gradual and varies but usually returns in 4-6 hours e. the infant may experience difficulty latching on
C, D, E
After completing all the BUBBLE LE assessments and noting all are WDL, the nurse reviews the lab findings on the postpartum mother. See the findings below, what is the priority in this scenario? Hgb: Pre-delivery (10), Now (7.2) Hct: Pre-elivery (36%), Now 23%) RBC: Pre-delivery (5.2), Now (4.2) WBC: Pre-delivery (18,000), Now (20,000) a. Massage the fundus and administer oxytocin b. Notify the HCP and recommend a blood transfusion c. Assess the client's temperature and recommend blood cultures to be drawn d. Assess the client's orthostatic vital signs
D
Before administering Rhogam to the postpartum woman, the most important lab value to assess is: a. The results of the Percutaneous Umbilical Blood Sample b. The father's blood type c. A Coombs titer on the infant d. The infant's blood type
D - PUBS test is done during pregnancy, so it wouldn't affect the postpartum mom. - Once the baby is born you have 72 hours to give Rhogam. So go ahead and get baby's blood type before giving the medicine to mom.
A nurse receives report on 4 mother and baby couplets. Which client should the nurse assess first? a. A mother post C/S 8 hours ago requesting pain medication. The baby is in NBN. b. A mother who slept uninterrupted for 8 hours who reports a saturated perineal pad. Infant is at the breast. c. A mother who calls out to report that her baby's hands and feet are cyanotic. d. A mother who calls out stating that an employee without the MBU ID badge is going to take her newborn for an X-ray.
D - The nurse should be cautious of anyone trying to abduct the child. A is expected and fine, B is normal since it was over 8 hours, and C is normal.
A G2P1 at 40 weeks gestation presents to trial and reports, "I think I'm in labor. My contractions are 4-5 minutes apart, I had a gust of clear vaginal fluid about 15 minutes ago. In prioritizing care for this client, the nurse should FIRST: a. Assess a sterile cervical exam b. Assist the HCP in the collection of the AmniSure test c. Assess the client's vital signs d. Place the client on the external fetal monitor
D - When the client first comes to the floor in active labor, place her on the monitor so we can get a look at the baby's status.
