NURS 132 Exam 1 Questions With Complete Solutions
A client is seen at the clinic at 14 weeks of gestation for a
follow-up appointment. At which level does the nurse expect to
palpate the fundus?
a. Nonpalpable above the symphysis at 14 weeks of gestation
b. Slightly above the symphysis pubis
c. At the level of the umbilicus
d. Slightly above the umbilicus Correct Answers B
In normal pregnancies, the uterus grows at a predictable rate. It
may be palpated above the symphysis pubis sometime between
the 12th and 14th weeks of pregnancy. As the uterus grows, it
may be palpated above the symphysis pubis sometime between
the 12th and 14th weeks of pregnancy. At 14 weeks, the uterus
is not yet at the level of the umbilicus. The fundus is not
palpable above the umbilicus until 22 to 24 weeks of gestation.
A client is warm and asks for a fan in her room for her comfort.
The nurse enters the room to assess the mother and her infant
and finds the infant unwrapped in his crib with the fan blowing
over him on high. The nurse instructs the mother that the fan
should not be directed toward the newborn and that the newborn
should be wrapped in a blanket. The mother asks why. How
would the nurse respond?
a. "Your baby may lose heat by convection, which means that he
will lose heat from his body to the cooler ambient air. You
should keep him wrapped, and should prevent cool air from
blowing on him."
,b. "Your baby may lose heat by conduction, which means that
he will lose heat from his body to the cooler ambient air. You
should keep him wrapped, and should prevent cool air from
blowing on him."
c. "Your baby may lose heat by evaporation, which means that
he will lose heat from his body to the cooler ambient air. You
should keep Correct Answers A
Convection is the flow of heat from the body surface to cooler
ambient air. Because of heat loss by convection, all newborns in
open bassinets should be wrapped to protect them from the cold.
Conduction is the loss of heat from the body surface to cooler
surfaces, not air, in direct contact with the newborn. Evaporation
is a loss of heat that occurs when a liquid is converted into a
vapor. In the newborn, heat loss by evaporation occurs as a
result of vaporization of moisture from the skin. Cold stress may
occur from excessive heat loss; however, this does not imply
that the infant will become stressed if not bundled at all times.
Furthermore, excessive bundling may result in a rise in the
infant's temperature.
A new client and her partner arrive on the labor, delivery,
recovery, and postpartum (LDRP) unit for the birth of their first
child. The nurse applies the electronic fetal monitor (EFM) to
the woman. Her partner asks you to explain what is printing on
the graph, referring to the EFM strip. He wants to know what the
baby's heart rate should be. What is the nurse's best response?
a. "Don't worry about that machine; that's my job."
b. "The baby's heart rate will fluctuate in response to what is
happening during labor."
,c. "The top line graphs the baby's heart rate, and the bottom line
lets me know how strong the contractions are."
d. "Your physician will explain all of that later." Correct
Answers B
Explaining what indicates a normal FHR teaches the partner
about fetal monitoring and provides support and information to
alleviate his fears. Telling the partner not to worry discredits his
feelings and does not provide the teaching he is requesting.
Telling the partner that the graph indicates how strong the
contractions are provides inaccurate information and does not
address the partner's concerns about the FHR. The EFM graphs
the frequency and duration of the contractions, not their
intensity. Nurses should take every opportunity to provide
teaching to the client and her family, especially when
information is requested.
A new mother states that her infant must be cold because the
baby's hands and feet are blue. This common and temporary
condition is called what?
a. Acrocyanosis
b. Erythema toxicum neonatorum
c. Harlequin sign
d. Vernix caseosa Correct Answers A
Acrocyanosis, or the appearance of slightly cyanotic hands and
feet, is caused by vasomotor instability, capillary stasis, and a
high hemoglobin level. Acrocyanosis is normal and
intermittently appears over the first 7 to 10 days after childbirth.
Erythema toxicum neonatorum (also called erythema
, neonatorum) is a transient newborn rash that resembles flea
bites. The harlequin sign is a benign, transient color change in
newborns. One half of the body is pale, and the other one half is
ruddy or bluish-red with a line of demarcation. Vernix caseosa is
a cheeselike, whitish substance that serves as a protective
covering for the newborn.
A newborn is placed under a radiant heat warmer. The nurse
understands that thermoregulation presents a problem for the
newborn. What is the rationale for this difficulty?
a. The renal function of a newborn is not fully developed, and
heat is lost in the urine.
b. The small body surface area of a newborn favors more rapid
heat loss than does an adult's body surface area.
c. Newborns have a relatively thin layer of subcutaneous fat that
provides poor insulation.
d. Their normal flexed posture favors heat loss through
perspiration. Correct Answers C
The newborn has little thermal insulation. Furthermore, the
blood vessels are closer to the surface of the skin. Changes in
environmental temperature alter the temperature of the blood,
thereby influencing temperature regulation centers in the
hypothalamus. Heat loss does not occur through urination.
Newborns have a higher body surface-to-weight ratio than
adults. The flexed position of the newborn helps guard against
heat loss, because it diminishes the amount of body surface
exposed to the environment.
A client is seen at the clinic at 14 weeks of gestation for a
follow-up appointment. At which level does the nurse expect to
palpate the fundus?
a. Nonpalpable above the symphysis at 14 weeks of gestation
b. Slightly above the symphysis pubis
c. At the level of the umbilicus
d. Slightly above the umbilicus Correct Answers B
In normal pregnancies, the uterus grows at a predictable rate. It
may be palpated above the symphysis pubis sometime between
the 12th and 14th weeks of pregnancy. As the uterus grows, it
may be palpated above the symphysis pubis sometime between
the 12th and 14th weeks of pregnancy. At 14 weeks, the uterus
is not yet at the level of the umbilicus. The fundus is not
palpable above the umbilicus until 22 to 24 weeks of gestation.
A client is warm and asks for a fan in her room for her comfort.
The nurse enters the room to assess the mother and her infant
and finds the infant unwrapped in his crib with the fan blowing
over him on high. The nurse instructs the mother that the fan
should not be directed toward the newborn and that the newborn
should be wrapped in a blanket. The mother asks why. How
would the nurse respond?
a. "Your baby may lose heat by convection, which means that he
will lose heat from his body to the cooler ambient air. You
should keep him wrapped, and should prevent cool air from
blowing on him."
,b. "Your baby may lose heat by conduction, which means that
he will lose heat from his body to the cooler ambient air. You
should keep him wrapped, and should prevent cool air from
blowing on him."
c. "Your baby may lose heat by evaporation, which means that
he will lose heat from his body to the cooler ambient air. You
should keep Correct Answers A
Convection is the flow of heat from the body surface to cooler
ambient air. Because of heat loss by convection, all newborns in
open bassinets should be wrapped to protect them from the cold.
Conduction is the loss of heat from the body surface to cooler
surfaces, not air, in direct contact with the newborn. Evaporation
is a loss of heat that occurs when a liquid is converted into a
vapor. In the newborn, heat loss by evaporation occurs as a
result of vaporization of moisture from the skin. Cold stress may
occur from excessive heat loss; however, this does not imply
that the infant will become stressed if not bundled at all times.
Furthermore, excessive bundling may result in a rise in the
infant's temperature.
A new client and her partner arrive on the labor, delivery,
recovery, and postpartum (LDRP) unit for the birth of their first
child. The nurse applies the electronic fetal monitor (EFM) to
the woman. Her partner asks you to explain what is printing on
the graph, referring to the EFM strip. He wants to know what the
baby's heart rate should be. What is the nurse's best response?
a. "Don't worry about that machine; that's my job."
b. "The baby's heart rate will fluctuate in response to what is
happening during labor."
,c. "The top line graphs the baby's heart rate, and the bottom line
lets me know how strong the contractions are."
d. "Your physician will explain all of that later." Correct
Answers B
Explaining what indicates a normal FHR teaches the partner
about fetal monitoring and provides support and information to
alleviate his fears. Telling the partner not to worry discredits his
feelings and does not provide the teaching he is requesting.
Telling the partner that the graph indicates how strong the
contractions are provides inaccurate information and does not
address the partner's concerns about the FHR. The EFM graphs
the frequency and duration of the contractions, not their
intensity. Nurses should take every opportunity to provide
teaching to the client and her family, especially when
information is requested.
A new mother states that her infant must be cold because the
baby's hands and feet are blue. This common and temporary
condition is called what?
a. Acrocyanosis
b. Erythema toxicum neonatorum
c. Harlequin sign
d. Vernix caseosa Correct Answers A
Acrocyanosis, or the appearance of slightly cyanotic hands and
feet, is caused by vasomotor instability, capillary stasis, and a
high hemoglobin level. Acrocyanosis is normal and
intermittently appears over the first 7 to 10 days after childbirth.
Erythema toxicum neonatorum (also called erythema
, neonatorum) is a transient newborn rash that resembles flea
bites. The harlequin sign is a benign, transient color change in
newborns. One half of the body is pale, and the other one half is
ruddy or bluish-red with a line of demarcation. Vernix caseosa is
a cheeselike, whitish substance that serves as a protective
covering for the newborn.
A newborn is placed under a radiant heat warmer. The nurse
understands that thermoregulation presents a problem for the
newborn. What is the rationale for this difficulty?
a. The renal function of a newborn is not fully developed, and
heat is lost in the urine.
b. The small body surface area of a newborn favors more rapid
heat loss than does an adult's body surface area.
c. Newborns have a relatively thin layer of subcutaneous fat that
provides poor insulation.
d. Their normal flexed posture favors heat loss through
perspiration. Correct Answers C
The newborn has little thermal insulation. Furthermore, the
blood vessels are closer to the surface of the skin. Changes in
environmental temperature alter the temperature of the blood,
thereby influencing temperature regulation centers in the
hypothalamus. Heat loss does not occur through urination.
Newborns have a higher body surface-to-weight ratio than
adults. The flexed position of the newborn helps guard against
heat loss, because it diminishes the amount of body surface
exposed to the environment.
