NURS 3610 Quiz 2 | Questions, Answers and Rationales
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NURS 3610
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NURS 3610
NURS 3610 Quiz 2 | Questions, Answers and Rationales 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...
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
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)
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
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.
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.
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."
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."
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."
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.
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.
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.
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