Answers
A nurse is administering a rubella immunization to a client who is 2 days
postpartum. What statement indicates to the nurse the client needs further
instruction?
a. I cannot receive rubella immunization during pregnancy
b. I can conceive anytime i want after 10 days
c. I can continue to breastfeed
d. I wills till need to have my provider perform a rubella titer with my next
pregnancy correct answer b. I can conceive anytime i want after 10 days
A nurse is assessing a 12 hr old newborn and notes a resp rate of 44 with shallow
respirations and periods of apnea lasting up to 10 seconds. What action should
the nurse take?
a. continue routine monitoring
b. place newborn prone
c. request a script for supplemental o2
d. perform chest percussion correct answer a. continue routine monitoring
A nurse is assessing a 2 day old newborn and notes an egg-shaped, edematous,
bluish discoloration that does not cross the suture line. What pieces of info should
the nurse provide to the mother when she inquires about the finding?
a. this will resolve within 3-6 wks without treatment
b. this will resolve on its own within 3-4 days
c. this is expected at birth so you don't need to worry about it
d. the provider might drain this area with a syringe correct answer a. this will
resolve within 3-6 wks without treatment
A nurse is assessing a 4 hr old newborn who is to breastfeed and notes hands and
feet that are cool and slightly blue What action should the nurse take?
a. check the newborns temp using temporal thermometer
b. place the naked newborn on the mothers bare chest and cover both with a
blanket
c. apply an o2 hood over the newborns head and neck
d. give the newborn glucose water between feedings correct answer b. place the
naked newborn on the mothers bare chest and cover both with a blanket
, A nurse is assessing a client who is 14 hr postpartum and has a 3rd degree
perineal laceration. The client's temp is 37.8 C (100F), her fundus is firm and
slightly deviated to the right. The client reports a gush of blood when she
ambulates and no bm since delivery. What action should the nurse take?
a. notify the provider about the elevated temp
b. massage the client's fundus
c. administer bisacodyl supp
d. assist the client to empty her bladder correct answer d. assist the client to
empty her bladder
A nurse is assessing a client who is postpartum following a vacuum-assisted birth.
For what finding should the nurse monitor to identify a cervical laceration?
a. a gush of rubra lochia when the nurse massages the uterus
b. continuous lochia flow and flaccid uterus
c. slow trickle of bright vaginal bleeding and a firm fundus
d. report of increasing pain and pressure in the perineal area correct answer c.
slow trickle of bright vaginal bleeding and a firm fundus
A nurse is assessing a newborn 1 hr after birth. What assessment findings should
the nurse report to the provider?
a. acrocyanosis
b. jaundice of the sclera
c. resp rate 50
d. cbg 60 correct answer b. jaundice of the sclera
A nurse is assessing a newborn 1 min after birth andnotes a hr of 136/min, resp
36, well flexed extremities, responding to stimuli with a cry, blue hands and feet.
What Apgar score should the nurse assign to the newborn?
a. 10
b. 9
c. 8
d. 7 correct answer b. 9
A nurse is assessing a newborn for congenital hip dysplasia. What finding should
the nurse expect?
a. temp of one leg differing from that of the other