NURS 306 Quiz 9 V3 | NURS 306 OB |
Actual Q&A with Rationale (NURS306 Quiz
9) | West Coast University
1. A nurse is assessing a newborn 1 minute after birth and notes the following: heart rate
110/min, a weak cry, some flexion of the extremities, a grimace when the soles of the feet
are flicked, and a pink body with blue extremities. What APGAR score should the nurse
document?
A. 6
B. 5
C. 7
D. 8
Answer: A
Rationale: The newborn receives 2 points for heart rate over 100, 1 point for a weak cry, 1
point for some flexion, 1 point for grimace, and 1 point for acrocyanosis. Summing these
values results in a total APGAR score of 6. This score suggests that the infant may require
some assistance with resuscitation or closer monitoring during the transition period.
2. A postpartum client is diagnosed with a deep vein thrombosis (DVT). Which of the
following nursing interventions is the priority?
A. Applying ice packs to the affected calf
,B. Massaging the affected leg to improve circulation
C. Administering anticoagulant therapy as prescribed
D. Encouraging frequent ambulation
Answer: C
Rationale: Anticoagulant therapy is the mainstay of treatment for DVT to prevent further
clot formation and reduce the risk of pulmonary embolism. The nurse must never massage
the affected area as this can dislodge the thrombus. Strict bed rest is typically maintained
until the clot is stabilized and therapeutic levels of medication are reached.
3. A nurse is caring for a client who is 4 hours postpartum and reports heavy vaginal bleeding.
Upon palpation, the fundus is boggy and displaced to the right. Which action should the nurse
take first?
A. Perform a firm fundal massage
B. Assist the client to the bathroom to void
C. Administer oxytocin 10 units IM
D. Call the healthcare provider immediately
Answer: B
Rationale: A fundus that is displaced to the right usually indicates a distended bladder,
which prevents the uterus from contracting efficiently. Assisting the client to empty her
bladder is the first step to allow the uterus to return to the midline and contract. If the
, fundus remains boggy after voiding, then fundal massage and medications would be
appropriate next steps.
4. A newborn with hyperbilirubinemia is receiving phototherapy. Which nursing action is
essential for the safety of the newborn?
A. Applying lotion to the infant’s skin to prevent drying
B. Covering the newborn’s eyes with opaque shields
C. Limiting fluid intake to prevent overhydration
D. Keeping the newborn in a diaper and a shirt
Answer: B
Rationale: Phototherapy can cause retinal damage, making eye protection with opaque
shields a critical safety requirement. The infant should be unclothed except for a diaper to
maximize skin exposure to the light. It is also vital to increase fluid intake to help the infant
excrete bilirubin and prevent dehydration from the heat of the lights.
5. Which clinical finding should the nurse recognize as a sign of Magnesium Sulfate toxicity in
a client treated for preeclampsia?
A. Hyperactive deep tendon reflexes
B. Respiratory rate of 10 breaths per minute
C. Increased urinary output
D. Tachycardia
Actual Q&A with Rationale (NURS306 Quiz
9) | West Coast University
1. A nurse is assessing a newborn 1 minute after birth and notes the following: heart rate
110/min, a weak cry, some flexion of the extremities, a grimace when the soles of the feet
are flicked, and a pink body with blue extremities. What APGAR score should the nurse
document?
A. 6
B. 5
C. 7
D. 8
Answer: A
Rationale: The newborn receives 2 points for heart rate over 100, 1 point for a weak cry, 1
point for some flexion, 1 point for grimace, and 1 point for acrocyanosis. Summing these
values results in a total APGAR score of 6. This score suggests that the infant may require
some assistance with resuscitation or closer monitoring during the transition period.
2. A postpartum client is diagnosed with a deep vein thrombosis (DVT). Which of the
following nursing interventions is the priority?
A. Applying ice packs to the affected calf
,B. Massaging the affected leg to improve circulation
C. Administering anticoagulant therapy as prescribed
D. Encouraging frequent ambulation
Answer: C
Rationale: Anticoagulant therapy is the mainstay of treatment for DVT to prevent further
clot formation and reduce the risk of pulmonary embolism. The nurse must never massage
the affected area as this can dislodge the thrombus. Strict bed rest is typically maintained
until the clot is stabilized and therapeutic levels of medication are reached.
3. A nurse is caring for a client who is 4 hours postpartum and reports heavy vaginal bleeding.
Upon palpation, the fundus is boggy and displaced to the right. Which action should the nurse
take first?
A. Perform a firm fundal massage
B. Assist the client to the bathroom to void
C. Administer oxytocin 10 units IM
D. Call the healthcare provider immediately
Answer: B
Rationale: A fundus that is displaced to the right usually indicates a distended bladder,
which prevents the uterus from contracting efficiently. Assisting the client to empty her
bladder is the first step to allow the uterus to return to the midline and contract. If the
, fundus remains boggy after voiding, then fundal massage and medications would be
appropriate next steps.
4. A newborn with hyperbilirubinemia is receiving phototherapy. Which nursing action is
essential for the safety of the newborn?
A. Applying lotion to the infant’s skin to prevent drying
B. Covering the newborn’s eyes with opaque shields
C. Limiting fluid intake to prevent overhydration
D. Keeping the newborn in a diaper and a shirt
Answer: B
Rationale: Phototherapy can cause retinal damage, making eye protection with opaque
shields a critical safety requirement. The infant should be unclothed except for a diaper to
maximize skin exposure to the light. It is also vital to increase fluid intake to help the infant
excrete bilirubin and prevent dehydration from the heat of the lights.
5. Which clinical finding should the nurse recognize as a sign of Magnesium Sulfate toxicity in
a client treated for preeclampsia?
A. Hyperactive deep tendon reflexes
B. Respiratory rate of 10 breaths per minute
C. Increased urinary output
D. Tachycardia
