NUR 313 Exam 2 questions with correct answers
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 Correct
Answer-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.
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 Correct Answer-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.
A baby has acrocyanosis, or blue hands and feet. Are you concerned?
a. Yes
b. No Correct Answer-B
- Acrocyanosis is normal, however central cyanosis is abnormal.
The baby's lip/mouth/tongue are blue. Are you concerned?
a. Yes
b. No Correct Answer-A
- Patient is showing signs of central cyanosis indicating respiratory
distress. Other signs that might accompany respiratory distress is nasal
flaring and grunting.
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 Correct Answer-A
- Be concerned about apnea lasting 20 seconds, central cyanosis, and
complete rhonchi.
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 Correct Answer-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.
The nurse palpates a distended bladder on a woman who delivered
vaginally 5 hours ago. The woman refuses to go to the bathroom, "I
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 Correct
Answer-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.
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 Correct Answer-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.
A baby has acrocyanosis, or blue hands and feet. Are you concerned?
a. Yes
b. No Correct Answer-B
- Acrocyanosis is normal, however central cyanosis is abnormal.
The baby's lip/mouth/tongue are blue. Are you concerned?
a. Yes
b. No Correct Answer-A
- Patient is showing signs of central cyanosis indicating respiratory
distress. Other signs that might accompany respiratory distress is nasal
flaring and grunting.
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 Correct Answer-A
- Be concerned about apnea lasting 20 seconds, central cyanosis, and
complete rhonchi.
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 Correct Answer-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.
The nurse palpates a distended bladder on a woman who delivered
vaginally 5 hours ago. The woman refuses to go to the bathroom, "I
