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NURS 371 Exam 2 Questions And Correct Answers
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NURS 371 Exam 2 Questions And Correct Answers1st Degree Lacerations (laceration degrees) - ANSWER Involves only skin and
superficial structures above muscle
2nd Degree Lacerations (laceration degrees) - ANSWER Extends through perineal
muscles
3rd Degree Lacerations (laceration degrees) - ANSWER Extends through the anal
sphincter muscle
4th Degree Lacerations (laceration degrees) - ANSWER Continues through anterior
rectal wall
Stages of Adaptation - ANSWER -Taking in phase
-Taking hold phase
-Letting go phase
In-Taking Phase (stages of adaptation) - ANSWER -Time immediately after birth when
the client needs others to meet her needs & relives the birth process
-Mother demonstrates dependent behaviors & assumes a passive role in meeting own
basic needs
Taking Hold Phase (stages of adaptation) - ANSWER -Second phase characterized by
dependent and independent maternal behavior
-Mother becomes preoccupied with the present
Letting Go Phase (stages of adaptation) - ANSWER -Third phase in which woman
reestablishes relationships with others
, -Mother reestablishes relationships with others and demonstrates increased
responsibility & confidence in caring for the newborn
Episiotomy Care - ANSWER -Assess every 8 hours
-Apply ice to relieve discomfort & reduce edema (first measure)
-Sitz baths also can promote comfort and perineal healing (effective after first 24 hours)
-Use peri-bottle to clean site & blot dry instead of rubbing
BUBBLEEE (postpartum assessment) - ANSWER -Breasts (size, contour, engorgement)
-Uterus (height of fundus, firmness)
-Bladder (voiding, bladder emptying)
-Bowels (bowel sounds, distention)
-Lochia (amount, color, odor)
-Episiotomy/Perineum & Epidural site (lacerations, hematoma)
-Extremities
-Emotional status
Risk Factors for Postpartum Infection (postpartum assessment) - ANSWER -Operative
procedure (forceps, cesarean birth, vacuum extraction)
-History of diabetes, including gestational-onset diabetes
-Prolonged labor (more than 24 hours)
-Use of indwelling urinary catheter
Anemia hemoglobin less than 10.5 mg/dL Multiple vaginal exams during labor Prolonged
rupture of membranes greater than 24 hours Manual extraction of placenta
Compromised immune system positive HIV
Risk Factors for Postpartum Hemorrhage postpartum assessment ANSWER Precipitous
labor less than 3 hours Uterine atony Placenta previa or abruptio placenta Induction or
augmentation of labor Operative deliveries vacuum extraction, forceps, cesarean birth
Retained placental tissue greater than 30-minute third stage of labor Multiparity, more
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