Providing care to the postpartum client, the nurse recognizes that women are hypercoagulable
during the third trimester of pregnancy. Assessment of this client should include evaluation for
the development of venous thromboembolism. Which of the follow should be included in this
eval? SATA
A. Observe distal upper extremities for swelling/edema
B. Observe lower extremities for symmetry
C. Asses for uterine cramping
D. Observe respiratory rate and effort
E. Auscultate lung sounds - ANS B. Observe lower extremities for symmetry
D. Observe respiratory rate and effort
E. Auscultate lung sounds
A newborn is prescribed to receive Vitamin K 0.5 mg intramuscularly. How should the nurse
administer the medication to the newborn?
A. Provide medication immediately before breastfeeding
B. Administer medication into the vastus lateralis
C. Notify physician for swelling and irritation at the injection site
D. Administer the medication in the deltoid muscle - ANS B. Administer medication into the
vastus lateralis
Which technique is used to palpate the fundal heigh on postpartum client?
A. Placing one hand on the fundus, one on the perineum
B. Resting both hands on the fundus
C. Palpating the fundus with only fingertip pressure
D. Placing one hand at the base of the uterus , one on the fundus - ANS D. Placing one hand at
the base of the uterus , one on the fundus
A nurse is caring for a 4 yr old female. Which of the following is expected of a preschool-aged
child
A. Describing manifestations of illness
B. Understanding cause of illness
C. Relating fears to magical thinking
D. Awareness of body function - ANS
A new mother asks the nurse how soon she can try to breastfeed after deliery. Which of the
following would be the nurses best response?
A. Once the infant has his first feeding of formula
B. Immediately after birth
C. In 24 hours after her infant is given water
D. After the infant is allowed to rest - ANS B. Immediately after birth
, Which assessment finding indicated to the nurse that a newborn has hip sublaxtion?
A. Crying on straightening of the right leg
B. Inward rotation of the right foot
C. Inability of the right hip to abduct
D. Drawing of the legs underneath while prone - ANS C. Inability of the right hip to abduct
A nurse is helping her postpartum client up to the bathroom for the first time after delivery.
Which finding indicates her lochia is within normal imites?
A. the color of the flow is red
B. Lochia contains large clots
C. The flow is over 500 mL
D. Her uterus is boggy and soft - ANS A. the color of the flow is red
A nurse is caring for an infant with myelomeningocele. Which of the following actions should the
nurse include in the preoperative plan of care.
A. Place the infant in a supine position
B. Assess the infants temp rectally
C. Apply a sterile, moist dressing on the sac
D. Assist the caregiver with cuddling the infant - ANS C. Apply a sterile, moist dressing on the
sac
The nurse is inspecting a males newborns genitalia. Which action should the nurse avoid when
conducting this assessment?
A. Palpating if testes are descended into the scrotal sac
B. Retracting the foreskin over the glans to assess for secretions
C. Inspecting if the urethral opening appears circular
D. Inspecting the genital area for irritated skin - ANS B. Retracting the foreskin over the glans to
assess for secretions
During a home visit, the nurse determines that a toddler has a difficult temperament. What did
the nurse observe in this toddler? SATA
A. Rhythmic
B. Minimal adaptability
C. Withdrawing
D. Intense mood - ANS B. Minimal adaptability
C. Withdrawing
D. Intense mood
The nurse instructs the parents of a newborn on actions of a newborn on actions to prevent
sudden infant death syndrome. Which observation indicates the teaching has been effective?
A. The baby is an every 2-hr formula feeding schedule
B. Newborn is placed on the back to sleep
C. Parents signed a waiver refusing routing immunizations after birth
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