Maternity Exam 2

52問 • 2年前

問題一覧

1. The nurse is caring for a cl ient who gave birth 18hrs ago.The client reports that her nipples are getting tender & the baby is not breastfeeding well. Which response is appropriate by the nurse?

“Make sure to compress the breast so the baby can get an adequate amount of breast tissue into the mouth.” Try removing the infant’s clothing and putting the baby skin to skin on your chest.”

2. The nurse is caring for a client who is 1hr postpartum & observes a moderate amount of lochia rubra & several small clots on the client’s perineal pad. The fundus is midline & firm at the umbilicus. Which of the following actions should the nurse implement?

Document the findings & continue to monitor the client

3. The nurse is teaching a client with DM1 who just delivered a healthy baby.What information should the nurse include in the client’s teaching?

Due to hormonal changes after delivery, the need for insulin may decrease

4. The nurse is caring for clients in the postpartum unit.Which client should the nurse see first?

Primipara mother requesting help with repositioning her baby to decrease incisional pain from a cesarean delivery Multipara mother who has saturated 2 perineal pads in one hour

5. The nurse is assigned clients who delivered within the last 24hrs & just received the change-of-shift report. Which client should the nurse assess first?

The client who has changes in pulse from 76 to 102

6. The nurse is caring for a formula-feeding postpartum client who reports painful swollen breasts on her 3rd postpartum day. The nurse should encourage the mother to

Place cabbage leaves on the breasts Refrain from expelling milk

7. The nurse is assessing a client who is 24hrs postpartum.Which finding is most important for the nurse to follow up?

Fundus is slightly firm

8. The nurse is caring for a client who delivered vaginally 4hrs ago.Her fundus is right of midline, & firm only with massage. What is the priority action by the nurse?

Perform a straight catheterization & massage the fundus until its firm

9. The nurse is preparing to assess a postpartum client’s fundus.The nurse should put the HOB down to 30 degrees, ensure the client’s bladder has been emptied recently and

Place hand above symphysis pubis for support

10. The nurse is caring for a client who delivered a healthy infant 4 hrs ago. The nurse notes the mother’s temp is 98.7. Which action is priority for the nurse?

Continue to monitor the client

11.The nurse is providing instructions to a client who is breastfeeding her newborn. Which statement by the client indicates the need for further instructions?

“I should see the baby’s cheeks dimple when sucking”

12. The nurse is teaching a postpartum client who has been prescribed Rho (D) immune globulin (RhoGAM) about the purpose of this med. The nurse determines that teaching is effective if the client states that RhoGAM will protect her next baby from

Being affected by Rh incompatibility

13.The nurse is caring for a client in the 4th stage of labor following a spontaneous vaginal delivery. The medical record indicates an estimated blood loss of 600 mL. The client has a medical history of HTN. which med should the nurse recognize as being contraindicated for this client?

Methylergonovine

14. The nurse is caring for assigned postpartum clients. The nurse recognizes the client at highest risk for a postpartum infection is the client who

Had prolonged rupture of membranes Delivered via cesarean birth

15.The nurse is caring for a client & notes the following lab results on the 1st day after delivery: WBC count 8.0 mm, hemoglobin 10.0 g/dL, and platelets 200 mm. Which is a correct interpretation of the client’s lab values?

Hemoglobin is low, but normal for the postpartum client

16. The nurse is caring for a breastfeeding 4-day postpartum client. The client reports her breasts feel heavy & painful. The nurse should instruct the client to do what before nursing the baby?

Express a small amount of breast milk

17.The nurse is caring for a postpartum client & observes heavy lochia rubra. The client is alert & oriented. The nurse should perform which action first?

Assess maternal BP and pulse for signs of hypovolemic shock

18. The nurse is caring for a client who delivered a newborn by normal spontaneous vaginal delivery 24 hrs ago. The client has a temp of 101.0F. The nurse should

Determine if the client’s lochia has a foul smell

19. The nurse is caring for a 15 yr old client & her newborn. The client is upset because the newborn cries every few hrs & occupies a lot of her time. Which statement is best to help facilitate mother-infant attachment for this client?

Educate the mother about normal newborn growth & development Demonstrate different positions for holding her infant while feeding

20. The nurse is caring for a postpartum client & her newborn. The nurse observes the newborn crying & the mother rushing quickly to attend to the newborn. Once picked up, the newborn begins rooting. This reflects the client is experiencing

Synchrony

21. The nurse is caring for a postpartum client of Vietnamese descent. The client’s husband brings a large container of seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup for the client. Which is an appropriate response by the nurse?

“I’ll warm the soup in the microwave for you”

22. The nurse is providing discharge instructions to a new mother about formula feeding. Which statement by the client indicates a need for further teaching?

“I should use any bottles that I have prepared from a concentrate within 24 hrs”

23.The nurse is teaching a client who has mastitis about self-care. Which statement by the client indicates the need for further teaching?

“I need to leave some milk in each breast so this doesn’t happen again”

24. A nurse is providing postpartum care to a mother with diabetes & her newborn. One & one-half hrs post-delivery, the nurse observed tremors of the newborn’s extremities. The BG level is obtained from a heel stick & the results are 50 mg/dL. Which action should the nurse take next?

Feed the newborn breastmilk or formula

25.The nurse is caring for a Rh-positive infant who was born to a Rh-negative mother. The pediatrician orders a direct Coombs test on the cord blood sample to determine damaging antibodies. The nurse should suspect maternal isoimmunization if the infant appears

Jaundiced

26. The nurse is caring for a newborn 4 hrs after birth. Which action should the nurse include in the plan of care to prevent jaundice?

Initiate early feeding

27.The nurse is observing a new mother caring for her newborn for the 1st time. Which observation requires the nurse to intervene?

Mother heating a bottle of formula in the microwave

28. The nurse is caring for a full-term newborn in the nursery. Which finding is expected during the physical assessment?

Responds to sounds Dry, cracked or excessive peeling skin

29.The nurse is caring for a 2-day-old male newborn of Jewish parents. When reviewing the provider’s orders, which requires follow up by the nurse? A prescription for

Scheduled circumcision ( because they don’t usually have one?)

30.The nurse is caring for the following newborn clients. Which client should the nurse assess first?

The newborn who is 4 hrs old & has a low temp The newborn who is 4 hours old and has elevated bilirubin level

31.The nurse is assessing a male newborn with a gestational age of 40 wks. Which assessment should the nurse determine is consistent with the newborn’s gestational age?

Absent vernix Wasted physical appearance

32.The nurse is caring for a newborn who was born 30 mins ago. The nurse recognizes which as a probable sign of respiratory distress?

Nasal flaring at rest

33.The nurse is assessing a newborn who has just been delivered. Which is the priority physiological change?

Spontaneous respirations Thermoregulation

34. The nurse is caring for a newborn immediately following birth. After ensuring a patent airway, which is the priority nursing action?

Dry the skin

35.The nurse is assessing a newborn who has just been admitted to the nursery. Which finding requires further intervention by the nurse?

Head circumference is 11.5 in & chest circumference is 14 in

36. The nurse is caring for a newborn in the nursery. The grandmother of the newborn asks if she can take the newborn to the mother’s room. Which is an appropriate response by the nurse?

“Have the mother call & I will bring the baby to the room”

37.The nurse is working in the nursery caring for newborns. Which newborn requires immediate intervention?

Newborn who is 48 hrs post-delivery & has not passed meconium

38.The nurse is preparing a newborn who is 24 hrs old for discharge. The nurse should notify the PHCP if the newborn has

Apneic episodes lasting 30 secs

39.The nurse is assessing a newborn. Which finding is a priority for the nurse to follow up?

Irregular respirations at a rate of 72

40. A nurse is caring for a client who delivered a baby 24 hrs ago. The client has a blood type of AB negative. Which intervention should the nurse include in the client’s plan of care?

Assess the newborn for jaundice

41. The nurse is assigning a one-minute Apgar score to a newborn. The assessment includes a pulse of 98, respirations 36, acrocyanosis, strong cry, & some flexion. Which is the correct Apgar score?

42.The nurse is caring for an infant who has died from SIDS. the parents request some time alone with their infant. Which action should the nurse take?

Ask the parents if they would like to bathe & dress the infant

The nurse is providing instructions to a client who is breastfeeding her newborn. Which of the following statements by the client indicates the need for further instructions?

“I should. Use water and antibacterial soap to clean my nipples”

The nurse is caring for a client and notes the following laboratory results on the first day after delivery: WBC count 22,000mm, hemoglobin 13.0 g/dL, and platelets 90,000mm3. Which of the following is a correct interpretation of the client’s laboratory values?

Client is developing a postpartum infection

A nurse is providing postpartum care to a mother with diabetes and her newborn. One- and one-half hours post-delivery, the nurse observed tremors of the newborn’s extremities. Which action should the nurse take?

Obtain a blood glucose level

The nurse is caring for a newborn who was circumcised 30 minutes ago. Assessment reveals a moderate amount of bright red blood on the dressing. Which of the following should the nurse preform first?

Apply slight pressure and a gauze dressing

The nurse prepares to administer a Vitamin K injection to a newborn. The mother asks the nurse why her infant needs the injection. Which of the following is the best response by the nurse?

“Newborns are deficient in Vitamin K, and this injection prevents your newborn from bleeding

The nurse is developing a plan of care for an 18-hour old baby who is receiving phototherapy. Which of the following interventions should the nurse include in the plan?

Cover the eyes with an opaque mask

The nurse is assessing a neonate for signs of ICP. Which of the following findings indicate increased ICP in the neonate?

Tight anterior fontanel

The nurse has received report on an agpar score of 6 on the second test. The nurse interprets this result as an

Indicator of moderate difficulty adjusting to extrauterine life

The nurse is caring for a preterm infant who has yellow skin color and a rising bilirubin level. The nurse is aware that this infant is at risk for

Brain damage

The nurse is teaching a postpartum client about the tonic neck newborn reflex. The nurse determines teaching has been effective when the client reports that the newborn will

Turn the head to the left, extend left extremity, and flex right extremity

NUR 170 exam 4

V Farris · 50問 · 2年前

NUR 170 exam 4