NURSING

1. A primigravida mother who is one day post delivery tells the nurse that she is not producing enough milk for her new baby, and she wants to begin breastfeeding at home when her milk comes in. What info should the nurse obtain before responding to the client? AͲwhen the lactation consultant is scheduled to visit the client in her home BͲthe womans understanding of how her body produces breast milk. CͲif the woman is feeling pressured by her family to breast feed her infant. DͲwhy the woman thinks her infant is not receiving enough milk CorrectͲD Sometimes new mothers do not understand that colostrums provided adequate nutrition the first three days following delivery. So the clients thinking regarding this issue should be assessed (D). Waiting for a visit from a lactation consultant (A) to address this issue is likely to inhibit lactation if the mother delays suckling the infant. Although assessing the mother’s understanding of milk production (B) may provide a teaching opportunity, it does not elicit information about the clients concern regarding the delay of breast feeding/ Assessing the mothers feelings about her family’s desire for her to breastfreed (C) doesn’t address the issue athand. 2. A client with endometritis is preparing for discharge on her third postpartum day, Which statement by he client indicates that the discharge teaching was effective? AͲI should limit my visitors until this infection clears BͲI will resume breastfeeding when the infection is gone CͲI should sit an upright position as much as possible DͲI will stop taking antibiotics when my fever disappears Correct Ͳ C A client with endo metris should sit in an upright position© to facilitate drainage of lochia and prevent infected fluids from enetering the peritoneal cavity. (A,B and D) indicate a needs for additional instruction. Endometritis is an infection of the endometrial lining and is not contagious, so visitors do not need to be restricted or limited(A). there is no indication to stop or withholding breastfeeding (b) if a client develops endometritis. All antibiotics should be completed regardless of fever abatement. 3. A multipara postpartum client complains about intenst cramping while breastfeeding. What instructions should the nurse provide to this client? AͲ TAKE A PRESCRIBED ANALGESIC AN HOUR PRIOR TO BREASTFEEDING BͲ change then infants position during the next feeding CͲ drink two glasses of Water 30 minutes prior to breastfeeding DͲ void and completely empty bladder before each feeding CorrectͲa The client is experiencing atterpains which typically affect multigravidas due to relaxation of the uterine muscles and release of oxytocin during breastfeeding. The client should take a prescribed analgesic one hour before breastfeeding (A) to relieve this discomfort. Infant positioning during B is effective in relieving sore nipples. C and D are not effectivemeasures for relieving uttering cramping. 4. A client at 28 weeks gestation is admitted to the obstetrical unit following her involvement in a motor vehicle collossion. After stabilizing the client, the nurse obtains a fetal monitor reading. What action should the nurse take if fetal tachycardia is assessed on the monitor? AͲ Suspect that the monitor is malfunctioning and recount the heart rate manually BͲExplain to the client that a rapid heart right is normal for a preterm fetus. CͲPerform a vaginal Examination to see if the accident initiated preterm labor DͲAdminister oxygen to the client and contact the healthcare provider immediately. CorrectͲ D Administering oxygen and contacting the healthcare provider (D) are the priority interventions for fetal oxygen deprivation secondary to placental abruption, which is known complication of trauma to the mother. AͲ wastes time and increased the chance of errors in the assessment. BͲprovides the client with dales information. CͲ increased the risk of hemorrhage, further compromising fetal oxygenation, and is not a recommended intervention at this time. Vaginal bleeding should be assessed without palpation. 5. The nurse is assessing a 24 hour postpartum client. Which finding would be most indicative of a postpartum infection. 6. in caring for a newborn infant who starts gagging and becomes cyanotic, what action should the nurse implement first? aͲgive three back blows to clear the airway bͲcall for assistance and start CPR cͲsuction mouth nose with bulb d. provide oxygen by resuscitation bag and mask correctͲc Suctioning with a bulb syringe may be the first and only action needed to clear the airway_C. Although – AͲ is appropriate for foreign body aspirations or choking, it is not indicated for this infant. BͲ us the next priority if the infant is not breathing or continues to be cyanotic. Newborns who are breathing usually become less cyanotic after the airway s cleared oxygen is administered(D). 7, the nurse is assessing a postpartum client who delivered an 11 pound infant veginally 2 hours ago. The client’s fundus is fingerbreadths above the umbilicus, deviated to the right side, and boogy. After the client voids 200 ml of urine using a bedpan, what action should the nurse implement? aͲ palpate the suprapubic region for distention t the client to the bathroom to void cͲreevaluate the clinet in 15 minutes dͲadminister a prn prescription for ocytocin correctͲa Neonatal maccrosoma increases the risk for iterine inertia, predisposing the client to uterine sinus bleeding, which cause the uterus to become boggy and displace, The client’s risk for postpartum bleeding is further increased by a full bladder, which should be assessed –AͲ after the client voids 200 ml using the bedpan. Before ambulating the client to the bathroomͲBͲ, thebladder should be assessed, Delaying assessment C doesn’t change the client’s uterine displacement, which is likely the result of a full bladder. Although oxytocin administrationͲDͲ may ultimately be indicated, further assessment, attempts to empty the bladder, and uterine massage should be implemented first. 8. a client asks the nurse about the harmful effects of taking prescribed drugs during pregnancy. When do drugs taken by a mother have the most significant effect on a fetus? a. 24 hours before delivery b. the first trimester c. first stage of labor d. six weeks prior to becoming pregnant correctͲb Drugs taken during the first trimester of pregnanacyͲBͲ cause the most concern for fetal development. Although(A,C,D) should be considered, teratogenic effects of drugs on embryological formation during the first trimester of pregnancy are most significant. 9. the nurse observes a newborn with swelling of the scalp and suspects that is the result of birth trauma. Which intervention should the nurse implement to differentiate between caput succedaneum and cephalhematoma? a. transilluminate the skull b. palpate the anterior fontanel c. examine the suture lines d. measure the head circumference CorrectͲc Cephalhematome is bound by suture lines while caput succedaneum crosses suture lines, so –CͲ aids in differentiating between the two conditions. AͲ is used to assess for the possibility of excess fluid or decreased brain tissue in the skill. B and D are not helpful in differentiaiting between the teo conditions 10.a woman who recently delivered a normal newborn calls the clinic crying and describes feeling overwhelmed and discouraged. Which information is most important for the nure to obtain? a. does she describe herself as described b. has she seen a mental health provider c. how long has she been feeling this way d. is there anyone with her at this time? CorrectͲc “baby blues” are expected, usually resolve with the first week after delivery and rarely need additional treatment, but the nurse should further assess for postpartum depression. The most important information to obtain is the onset and duration of the client’s feelingsͲCͲ to assess for postpartum depression (A). Additional information (A,B, and D) should also be obtained to determine the need for referrals and support persons. 11, a client is admitted to the hospital in active labor, and the nurse plans to assess her blood pressure q15 minutes between contractions. What is the main reason for determining the client’s blood pressure between contractions? 12. a client at 29 weeks gestation is receiving magnesium sulfate 3 grams pre term labor. After administering the loading dose, what asssessment finding should the nurse report to the healthcare provider immediately? a. a decrease in respirations from 20 to 17 breaths/min b. an increase in temperature from 98.9 to 99.9 cͲan increase in blod pressure from 110/65 to 120/85 d. a decrease in deep tendon reflexes from 3+ to 1+ correctͲD A decrease in the deep tendon reflexes occurs prior to respiratory depression which is a sign of magnesium sulfate toxicity –DͲ and needs to be reported to the health care provider immediately. A needs to be monitored closely, but does not need to be reported immedietly. (B and C) are not related to the administration of magnesium sulfate 13. at a routine prenatal visit, a client at 34 weeks gestation complains of nasal stuffiness and occasional nose bleeds aͲestrogen bͲprogesterone cͲrelaxin dͲhuman chorionic gonadotropion correctͲa Increased estrogen secretion during pregnancy induces edema and vascular congestion of the nasal mucosa, which can lead to nasal stuffiness and epistaxis (A). (B, C and D) have no effect on nasal mucosa. 14, a client whose blood type is o negative delivers an infant who is o positive. Six hours after delivery the client has a negative indirect coombs. Which intervention should the nurse implement? aͲadminister one standard dose of Rhogam within 72 hours of delivery bͲ teach the new mother about incompatibility of blood types and RhoGAM cͲͲassess the direct Coombs result of the infant to determine if RhoGAM is necessary d Ͳevaluate the father’s blood type and Rh to crossmatch the RhoHAM correct ͲA Indirect Coombs measures whether or not maternal blood has been sensitixed to the Rh factor. Then this blood test is negative, it means that no sensitization has occurred and can be further prevented if the administration of RhoGAM occurs within72 hours of delivery –A. BͲ is the impotant but not aas important as administering RhoGAM. CͲ doesn’t determine eligibility for RhoGAM. DͲ is not taken into consideration in the preparation of RhoGAM. 15. An RhͲnegative client sufferes a miscarraige at 12 weeks gestation. Which plan for Rho(d) immune globulin (RhoGAM) administartion should the nurse implement? aͲadminister Rho immune globulin (RhoGAM) within 2 weeks following the miscarriage b. Rho(D) immune globulin (Rhogam) is not needed since the was not a full term infant cͲadminister Rho(D) immune globulin (RhoGAM) within 72 hrs after the misscarriage dͲadminister Rho(d) immune globulin (RhoGAM) only if the fetus is determines to be RhͲpositive. Correct Ͳc RhoGAM should be administered within 72 hours after a miscarriage © to be effective in preventing isoimmune hemolytic disease with the next pregnancy. (A) is too late. (B and D) are false. RhoGAM should be administered to all RH negative women following a miscarriage 16. Following vaginal delivery in a birthing suite, the nurse assesses a newborn male and finds that his respiration are 58 breaths per minute and his hands and feet are cyanotic. What action should the nurse take? aͲRecord the findings and continue to observe the infant bͲadminister oxygen at 5l/minute cͲNotify the pediatrician immediately dͲtransfer the infant into the nursery to determine his oxygen saturation rate. CorrectͲa Based on the date provided (A) is the best intervention. A newborn infants respirations should rage between 40 Ͳ60 breaths/min. Acrocyanosis (bluing if the hands and feet) is a normal occurrence at birth and should not be confused with central cyanosis, which reflects impaired gas exchange and is exhibited by the neonate’s skin and mucous membrane turning blue. (B,C, AND D) should be implemented if central cyanosis is noted.