TRANSITION EXAM WITH DETAILED
ANSWERS AND RATIONLE NEWEST
VERSION.
A nurse is providing information to a group of pregnant clients and their
partners about the psychosocial development of an infant. Using Erikson's
theory of psychosocial development, the nurse tells the group that infants:
A. Need to experience frustration, so it is best to allow an infant to cry for a
while before meeting his or her needs
B. Must have needs ignored for short periods to develop a healthy
personality
C. Rely on the fact that their needs will be met
D. Need to tolerate a great deal of frustration and discomfort to develop a
healthy personality - CorreCt Answers -C. Rely on the fact that their needs
will be met
Rationale: According to Erikson's theory of psychosocial development,
infants struggle to establish a sense of basic trust rather than a sense of
basic mistrust in their world, their caregivers, and themselves. If provided
with consistent satisfying experiences that are delivered in a timely
manner, infants come to rely on the fact that their needs are met and that,
in turn, they will be able to tolerate some degree of frustration and
discomfort until those needs are met. This sense of confidence is an early
,form of trust and provides the foundation for a healthy personality.
Therefore the other options are incorrect.
A nurse monitoring a client in labor notes this fetal heart rate pattern (see
figure) on the electronic fetal monitoring strip. The most appropriate
nursing action would be to:
A. Stop the oxytocin (Pitocin) infusion
B. Administer oxygen with a face mask at 8 to 10 L/min
C. Continue to monitor the client and fetal heart rate patterns
D. Notify the registered nurse of the findings - CorreCt Answers -C.
Continue to monitor the client and fetal heart rate patterns
Rationale: Early decelerations are not associated with fetal compromise
and require no intervention. They occur during contractions as the fetal
head presses against the woman's pelvis or soft tissues, such as the cervix.
Early decelerations have a gradual rather than an abrupt decrease from
baseline. They have a consistent appearance in that one early deceleration
looks similar to others. Early decelerations mirror the contraction,
beginning near its onset and returning to the baseline by the end of the
contraction, with the low point of the deceleration occurring near the
contraction's peak. The rate at the lowest point of the deceleration usually
remains greater than 100 beats per minute.
,A nurse notes the presence of variable decelerations on the fetal heart rate
monitor strip and suspects cord compression. The nurse should
immediately:
A. Notify the registered nurse
B. Insert a gloved finger into the mother's vagina to feel for cord
compression
C. Perform a vaginal examination on the mother
D. Position the mother so that her hips are elevated - CorreCt Answers -D.
Position the mother so that her hips are elevated
Rationale: Conditions that restrict blood flow through the umbilical cord
may result in variable decelerations. If cord compression is suspected, the
mother is immediately repositioned. She may be turned to her side, or her
hips may be elevated to shift the fetal presenting part toward her
diaphragm. A hands-and-knees position may also reduce compression of a
cord that is trapped behind the fetus. Several position changes may be
required before the pattern improves or resolves. The nurse may need to
contact the registered nurse, but this would not be the immediate action.
Although the nurse may check the woman's vaginal area for the presence of
the umbilical cord, a vaginal exam is not performed because of the
possibility of further compromise of blood flow through the umbilical cord.
Because of this risk, the nurse would not insert a gloved finger into the
vagina to feel for the cord.
A woman in labor whose cervix is not completely dilated is pushing
strenuously during contractions. Which method of breathing should the
, nurse encourage the woman to perform to help her overcome the urge to
push?
A. Cleansing breaths
B. Blowing repeatedly in short puffs
C. Deep inspiration and expiration at the beginning and end, respectively,
of each contraction
D. Holding her breath and using the Valsalva maneuver - CorreCt Answers
-B. Blowing repeatedly in short puffs
Rationale: If a woman pushes strenuously before the cervix is completely
dilated, she risks injury to the cervix and the fetal head. Blowing prevents
closure of the glottis and breath-holding, helping overcome the urge to
push strenuously. The woman would be encouraged to blow repeatedly,
using short puffs, when the urge to push is strong. Cleansing breaths (deep
inspiration and expiration at the beginning and end of each contraction)
are encouraged during the first stage of labor to provide oxygenation and
reduce myometrial hypoxia and to promote relaxation. The woman would
not be encouraged to hold her breath or perform the Valsalva maneuver,
which is a bearing-down maneuver.
A woman receives a subarachnoid (spinal) block for a cesarean delivery. For
which adverse effect of the block does the postpartum nurse monitor the
woman?
A. Hypertension