NURS 3610, QUESTIONS WITH 100% VERIFIED ANSWERS
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she observes which of the following patterns?
...
A nurse is observing the electronic fetal heart rate monitor tracing for a client who is at 40 weeks of
gestation and is in labor. The nurse should suspect a problem with the umbilical cord when she
observes which of the following patterns?
A. Early decelerations
B. Accelerations
C. Late decelerations
D. Variable decelerations - Correct answerD. Variable decelerations
Variable decelerations occur when the umbilical cord becomes compressed and disrupts the flow of
oxygen to the fetus.
* Think VEALCHOP
A nurse in the newborn nursery is caring for a group of newborns. Which of the following newborns
requires immediate intervention?
A. A newborn who is 24 hr post-delivery and has not voided.
B. A newborn who is 18 hr post-delivery and has acrocyanosis
C. A newborn who is 24 hr post-delivery and has not passed meconium
D. A newborn who is 12 hr post-delivery and has a temperature of 37.5C (99.5F) - Correct answerD. A
newborn who is 12 hr post-delivery and has a temperature of 37.5C (99.5F)
Hyperthermia in the newborn requires immediately intervention. Hyperthermia is typically caused by
increased heat production related to sepsis or decreased heat loss.
A nurse is assessing a client who is 12hr postpartum and received spinal anesthesia for a cesarean
birth. Which of the following findings requires immediate intervention by the nurse?
A. Blood pressure 100/70 mmHg
B. Headache pain rated 6 on a scale of 0 to 10
C. Respiratory rate 10/min
D. Urinary output 30mL/hr - Correct answerC. Respiratory rate 10/min
A client who has received spinal anesthesia is at risk for respiratory depression and hypotension. A
respiratory rate of 10/min indicates bradypnea and requires immediate intervention.
A nurse is caring for a client who has just delivered her first newborn. The nurse anticipates
hyperbilirubinemmia due to Rh incompatibility. The nurse should understand that hyperbilirubinemia
occurs with Rh incompatibility for which of the following reasons?
A. The client's blood does not contain the Rh factor, she she produces anti-Rh antibodies that cross
the placental barrier and cause hemolysis of red blood cells in newborns.
B. The client' blood contains the Rh factor and the newborn's does not and antibodies that destroy red
blood cells are formed in the fetus.
C. The client has a history of receiving a transfusion with Rh-negative blood.
,D. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction of the fetal
red blood cells. - Correct answerA. The client's blood does not contain the Rh factor, she she produces
anti-Rh antibodies that cross the placental barrier and cause hemolysis of red blood cells in newborns.
If the Rh-negative client has been exposed to Rh-positive fetal blood, she will produce antibodies
against Rh factor. These antibodies can cross the placenta and destroy the red blood cells of the Rh-
positive fetus. This accelerated rate of red blood cell destruction results in the increased release of
bilirubin. The newborn's serum bilirubin level can rise quickly.
A nurse is teaching a newborn's parent to care for the umbilical cord stump. Which of the following
instructions should the nurse include?
A. Wash the cord daily with mild soap and water.
B. Cover the cord with the diaper.
C. Apply petroleum jelly to the cord stump.
D. Give a sponge bath until the cord stump falls off. - Correct answerD. Give a sponge bath until the
cord stump falls off.
Immersing the umbilical cord stump in water can delay the process of drying, separation, and healing.
Sponge baths are appropriate until the stump falls off.
A nurse is caring for a client who is postpartum. The client tells the nurse that the newborn's maternal
grandmother was born deaf and asks how to tell if her newborn hears well. Which of the following
statements should the nurse make?
A. "There is no need to worry about that. Most forms of hearing loss are not inherited."
B. "Look at how she looks at you when you speak. That's a good sign."
C. "We do routine hearing screenings on newborns. You'll know the results before you leave the
hospital."
D. "The best way to determine if your baby can hear is to clap your hands loudly and see if she
startles." - Correct answerC. "We do routine hearing screenings on newborns. You'll know the results
before you leave the hospital."
Most states mandate hearing screening for all newborns. The two tests in use do not diagnose hearing
loss, but determine whether or not a newborn requires further evaluation.
A nurse is caring for a client who is beginning to breastfeed her newborn after delivery. The new
mother states, "I don't want to take anything for pain because I am breastfeeding." Which of the
following statements should the nurse make?
A. "You need to take pain medications so you are more comfortable."
B. "We can time your pain medication so that you have an hour or two before the next feeding."
C. "All medications are found in breast milk to some extent."
D. "You have the option of not taking pain medication if you are concerned." - Correct answerB. "We
can time your pain medication so that you have an hour or two before the next feeding."
This answer provides the client an option that allows for administration of pain medication but
minimizes the effect it will have on the newborn while breastfeeding.
A nurse is completing discharge instructions for a new mother and her 2-day-old newborn. The mother
asks, "How will I know if my baby gets enough breast milk?" Which of the following responses should
the nurse make?
A. "Your baby should have a wake cycle of 30 to 60 minutes after each feeding."
B. "Your baby should wet 6 to 8 diapers per day."
, C. "Your baby should burp after each feeding."
D. "Your baby should sleep at least 6 hours between feedings." - Correct answerB. "Your baby should
wet 6 to 8 diapers per day."
Newborns should wet 6 to 8 diapers per day. This is an indication that the newborn is getting enough
fluids.
A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following actions should
the nurse anticipate in the care of this client? (SATA)
A. Document fundal height.
B. Massage a firm fundus.
C. Observe the lochia during palpation of fundus.
D. Determine whether the fundus is midline.
E. Administer methylgonovine maleate if uterus is boggy. - Correct answerA C D E
A nurse is caring for a client who is 2 hr postpartum. The nurse notes that the client soaked a perineal
pad in 10 min, the client's skin color is ashen, and states she feels weak and light headed. After
applying oxygen via nonrebreather face mask at 10 L/min which of the following actions should the
nurse take next?
A. Insert an indwelling urinary catheter.
B. Administer oxytocin by continuous IV infusion.
C. Tilt the client onto her right side with her legs elevated to at least 30.
D. Massage the client's fundus to promote contractions. - Correct answerD. Massage the client's
fundus to promote contractions.
A soaked perineal pad in less than 15 min, ashen skin color, and report of weakness and light
headedness can indicate that the client is at greatest risk for hypovolemic shock. Therefore, the next
action the nurse should take is to massage the client's fundus to expel blood clots and promote uterine
contraction to stop the bleeding.
A nurse is assessing a client who is 8 hr postpartum and multiparous. Which of the following findings
should alert the nurse to the client's need to urinate?
A. Moderate lochia rubra
B. Fundus three fingerbreadths above the umbilicus
C. Moderate swelling of the labia
D. Blood pressure 130/84 mmHg - Correct answerB. Fundus three fingerbreadths above the umbilicus
A full bladder can raise the level of uterine fundus and possibly deviate it to the side.
A nurse is caring for a client who is 5 hr postpartum following a vaginal birth of a newborn weighing 9
lb 6 oz (4252g). The nurse should recognize that this client is at risk for which of the following
postpartum complications?
A. Puerperal infections
B. Retained placental fragments
C. Thrombophlebitis
D. Uterine atony - Correct answerD. Uterine atony
A uterus that is over distended, such as from a macrosomic fetus, has an increased risk of uterine
atony.
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