NURS 3610 Quiz 2 Questions With
Complete Solutions
A nurse in a clinic is caring for a client who is 3 weeks
postpartum following the birth of a healthy newborn. The client
reports feeling "down" and sad, having no energy, and wanting
to cry. Which of the following is a priority action by the nurse?
A. Assist the family to identify prior use of positive coping skills
in family crises.
B. Ask the client if she has considered harming her newborn.
C. Anticipate a prescription by the provider for an
antidepressant.
D. Reinforce postpartum and newborn care discharge teaching.
Correct Answers B. Ask the client if she has considered
harming her newborn.
When using the nursing process in caring for a client, the first
action should focus on assessment of the client's mood, ability to
concentrate, thought processes, and if the client has had thoughts
of self-harm or of injuring her newborn.
A nurse in the labor and delivery unit is caring for a client who
is undergoing external fetal monitoring. The nurse observes that
the fetal heart rate begins to slow after the start of a contraction
and the lowest rate occurs after the peak of the contraction.
Which of the following actions should the nurse take first?
A. Place the client in the lateral position.
B. Increase the rate of maintenance IV infusion.
C. Elevate the client's legs.
,D. Administer oxygen using a nonrebreather mask. Correct
Answers A. Place the client in the lateral position.
This is a late deceleration and is associated with fetal hypoxemia
due to insufficient placental perfusion. Placing the client in the
lateral position is the first action the nurse should take.
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 Answers 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 admitting a term newborn following a cesarean birth.
The nurse observes that the newborn's skin is slightly yellow.
The finding indicates the newborn is experiencing a
complication related to which of the following?
A. Maternal/newborn blood group incompatibility
B. Absence of vitamin K
C. Physiologic jaundice
D. Maternal cocaine abuse Correct Answers A.
Maternal/newborn blood group incompatibility
, Maternal/newborn blood group incompatibility is the most
common form of pathologic jaundice and the jaundice appears
within the first 24 hr of life.
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 Answers C. 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 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 Answers B. Fundus
three fingerbreadths above the umbilicus
A full bladder can raise the level of uterine fundus and possibly
deviate it to the side.
Complete Solutions
A nurse in a clinic is caring for a client who is 3 weeks
postpartum following the birth of a healthy newborn. The client
reports feeling "down" and sad, having no energy, and wanting
to cry. Which of the following is a priority action by the nurse?
A. Assist the family to identify prior use of positive coping skills
in family crises.
B. Ask the client if she has considered harming her newborn.
C. Anticipate a prescription by the provider for an
antidepressant.
D. Reinforce postpartum and newborn care discharge teaching.
Correct Answers B. Ask the client if she has considered
harming her newborn.
When using the nursing process in caring for a client, the first
action should focus on assessment of the client's mood, ability to
concentrate, thought processes, and if the client has had thoughts
of self-harm or of injuring her newborn.
A nurse in the labor and delivery unit is caring for a client who
is undergoing external fetal monitoring. The nurse observes that
the fetal heart rate begins to slow after the start of a contraction
and the lowest rate occurs after the peak of the contraction.
Which of the following actions should the nurse take first?
A. Place the client in the lateral position.
B. Increase the rate of maintenance IV infusion.
C. Elevate the client's legs.
,D. Administer oxygen using a nonrebreather mask. Correct
Answers A. Place the client in the lateral position.
This is a late deceleration and is associated with fetal hypoxemia
due to insufficient placental perfusion. Placing the client in the
lateral position is the first action the nurse should take.
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 Answers 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 admitting a term newborn following a cesarean birth.
The nurse observes that the newborn's skin is slightly yellow.
The finding indicates the newborn is experiencing a
complication related to which of the following?
A. Maternal/newborn blood group incompatibility
B. Absence of vitamin K
C. Physiologic jaundice
D. Maternal cocaine abuse Correct Answers A.
Maternal/newborn blood group incompatibility
, Maternal/newborn blood group incompatibility is the most
common form of pathologic jaundice and the jaundice appears
within the first 24 hr of life.
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 Answers C. 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 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 Answers B. Fundus
three fingerbreadths above the umbilicus
A full bladder can raise the level of uterine fundus and possibly
deviate it to the side.
