OVER 200 NCLEX RN EXAM QUESTIONS ANSWERED -NEW UPDATE

OVER 200 EXAM ANSWERED QUESTIONS FOR NCLEX RN: 4 NEW UPDATE EXAM The RN plans a diet teaching session to a CKD pt. The RN determines more teaching (wrong) is needed when the pt selects which option (SATA)? 1.) Grilled mozzarella sandwich, canned veggies, soup, diet cola 2.) Toast w/ PB, banana, & coffee 3.) Chicken sandwich w/ mustard, green salad, & lemonade 4.) Macaroni w/ salt sub., pudding w. raisins 5.) Spaghetti w/ meat balls, cabbage, & apple pie - CORRECT ANSWER 1,2,4 1 = grilled mozzarella sandwich is HIGH in Phosphorous; canned veggies is high in Sodium; soup is high in mag & salt; diet cola is high in phosphorous 2 = Banana is high in Potassium; coffee is high in phosphorous 4 = Macaroni w/ salt sub. is high in potassium Explanations: 3 = approp. lean protein 5 = approp. What is the diet needed for a pt w/ CKD? - CORRECT ANSWER HIGH CARB, Moderate FAT diet, RESTRICT sodium, potassium, & protein, & Low H2O intake (Chronic Kidney Disease diet) What are the following foods apart of what vitamin group? 1.) Fruits: Apples, cranberries, grapes, pineapples, & strawberries 2.) Veggies: Califlower, onion, pepper, radishes, summer squash, & lettuce 3.) Carbs: Pita, tortillas, white breads, & white rice 4.) Meat: Beef & chicken - CORRECT ANSWER LOW-Potassium foods (Chronic Kidney Disease diet) What foods are low PHOSPHOROUS foods? - CORRECT ANSWER 1.) Italian, french bread 2.) Corn or rice cereals & cream of wheat 3.) Unsalted popcorn 4.) Light-colored sodas & lemonades What is the Pt. teaching for Chronic Kidney Disease diet? - CORRECT ANSWER 1.) Another challenge is H2O intake 2.) Limit sodium to help cut down on thirst @ times may still feel thirsty 3.) To help w/ their thirst (Pt. teaching for CKD diet) Name the 4 things that helps pts w/ their thirst (them being thirsty) - CORRECT ANSWER 1.) Chew gum 2.) Rinse your mouth 3.) Such on a piece of ice, mints or hard candy 4.) Remember to change sugar-free candy if u have diabetes A RN caring for a 40-yr-old woman w/ a hx of UTI. Which strategies prevent UTIs (SATA)? 1.) Always wipe from front to back 2.) Voiding Q3-4 hrs 3.) Stay hydrated w/ @ least 6 glass of H2O 4.) Take antibiotics until symptoms subside 5.) Refrain from taking bubble baths - CORRECT ANSWER 1,2,3(?),5 2 = Decrease risk of infection 3 = need @ least 8 glass of water 5 = Increase irritation of urinary tract Explanation: 4 = Take ALL of the antibiotic A pt diagnosed w/ asthma is prescribed long-term corticosteroid med therapy. When the RN assesses the pts which manifestations of Cushing Syndrome is noticed (SATA)? 1.) Na2+ = 154 mmHg 2.) BP = 84/42 mmHg 3.) Hyperglycemia 4.) K+ = 3mmol/L 5.) Metabolic alkalosis - CORRECT ANSWER 1,3,4,5 1 = normal Na2+ is 135-145 4 = normal K+ is 3.5-5.1/.3 Explanations: 2 = Fluid retention, HTN Metabolic alkalosis is associated with what syndrome? - CORRECT ANSWER Cushing Syndrome The enhanced mineral corticoid effect in Cushing syndrome is caused by occupation of the a.) by the HIGH concentration of b.) - CORRECT ANSWER a.) MR b.) Cortisol These 2 things are more common in Cushing syndrome - CORRECT ANSWER 1.) HYPOkalemia 2.) Metabolic alkalosis Hypokalemia & Metabolic alkalosis are more common in in Cushing Syndrome caused by ectopic production (90%) than in other causes of Cushing Syndrome (10%) - CORRECT ANSWER Ectopic ACTH production The hypersecretion of adrenal cortex, over-secretion of cortisol - CORRECT ANSWER Cushing Syndrome (Cushing Syndrome) On the kidney the inside is called the a.) , the next layer is b.) , and the outside are the c.) called ontop of the kidneys - CORRECT ANSWER a.) Medulla b.) Cortex c.) Adrenal glands The following S&S are for what Syndrome? 1.) Personality changes 2.) Moon face 3.) INCREASED susceptibility to infection = HIGH amount of protein to eat 4.) Males: Gynecomastia 5.) Fat deposits on face & back of shoulders 6.) Hyperglycemia 7.) CNS irritability 8.) NA2+ & fluid retention = Edema 9.) Thin extremities 10.) GI distress = INCREASED Acid 11.) Buffalo hump 12.) Females: amenorrhea (no flow), Hissurism (extra hair) 13.) Thin skin = easily cut 14.) Purple striae 15.) Bruises & Petechiae 16.) Osteoporosis & bone fractures - CORRECT ANSWER Cushing Syndrome This is hyposecretion of adrenal cortex, under secretion of cortisol - CORRECT ANSWER Addison's Disease Name the 8 S&S of Addison's Disease - CORRECT ANSWER 1.) N/V/D 2.) Abd. pain 3.) Extreme fatigue 4.) Wt. loss & DECREASED appetite = double carbs & increased total calorie intake 5.) Darkening of your skin = hyperpigmentation 6.) Hypotension (even fainting) 7.) Salt cravings = hyponatremia 8.) Hypoglycemia (Addison's Disease) These following signs causes what? 1.) Severe V+ & D+ leading to dehydration 2.) DECREASED BP 3.) DECREASED Glucose 4.) DECREASED Na2+ 5.) INCREASED K+ - CORRECT ANSWER Adrenal crisis/shock What is the treatments for Addison's Disease? - CORRECT ANSWER 1.) Corticosteroids = a.) Prednisone = b.) Dexamethasone The RN is giving dietary education to a pt diagnosed w/ Cushing Syndrome. Which statements by the pt cause the RN to take action (SATA) (wrong)? 1.) I should follow a low-protein diet 2.) I will double carb intake 3.) I will include bananas & broccoli w/ Q meal 4.) I will use a salt substitute w/ meals 5.) I should INCREASE total daily calories - CORRECT ANSWER 1,2,5 1 = Should be a HIGH protein diet 2 = LOW-carb diet 5 = Obese Explanations: 3 = Hypokalemia w/ increased K+ in diet 4 = Increased K+ Before a site survey the RN manager tells the charge RN to deny any knowledge of any sentenial events (causes unexpected deaths: ex: homicide, medical error) is asked by surveyor. What decision will the charge RN make? 1.) Inform supervisor 2.) Inform chief of medical director 3.) Confront RN manager & tell her, I'm uncomfortable lying to the surveyor 4.) Inform, surveyor, the charge RN was given instruction to not speak to them - CORRECT ANSWER 1 = always follow direct chain of command. RNs have a legal, professional & ethical obligation to tell the truth under any circumstances Explanations: 2 = Chief of medical director is responsible for the whole hospital; RNs would go to the RN Chief director 4 = UAP - LPN - RN - charge RN - RN manager - RN supervisor - CWO (chief RN officer) How do you deal w/ conflicts w/ staff members? What are the 3 different types of Staff management? - CORRECT ANSWER 1.) Notify supervisor 2.) Confrontation 3.) Deal w/ it later (Staff Management) Is the situation that is happening illegal? If so, what type of staff management is used? - CORRECT ANSWER If illegal, follow chain of command & inform 1 up (Staff Management) Is the situation that is happening NOT illegal? If so, what type of staff management is used? - CORRECT ANSWER Ask self is this action causing HARM? (Staff Management) Is the situation that is happening NOT illegal and is the action causing HARM? If so, what type of staff management is used? Ex: Pt says don't touch me, CNA giving a bed bath to pt CNA slapped pt or something. What should the RN do? - CORRECT ANSWER Confront pt & CNA & ask = What happened here? (Staff Management) This is inapprop. behavior that interferes w/ workflow on the unit & hinders staff to caring out their responsibilities - CORRECT ANSWER Disruptive behavior (Staff Management) Give an example of Disruptive behavior - CORRECT ANSWER CNA arguing w/ another RN while trying to get report (Staff Management) What would the RN do if they are trying to get report & a pt/another healthcare worker is causing disruptive behavior? 1.) Do I go 1 up? 2.) Confrontation 3.) Carry on w/ shift report & take CNA aside & talk about their disruptive behavior - CORRECT ANSWER 3 Pt on periordopril (ACE inhibitor). The RN determines that furthering teaching (wrong) is needed when the pt makes which statements (SATA)? 1.) I will include more broccoli & bananas in diet 2.) I will monitor BP @ least 1 wk 3.) I will take med QD in am 4.) I will use salt substitute w/ meals 5.) I will move slowly from a sitting position to a standing position - CORRECT ANSWER 1,4 1 = More broccoli & bananas blocks release of aldosterone which promotes K+ retention -AVOID foods high in K+ 4 = Increases K+ Explanations: 2 = Sufficient 3 = Consistent w/ time 5 = orthostatic hypotension The pt is scheduled for surgery the next am. The order states NPO w/o over-timing med. Which med causes the RN to question its admin before surgery (SATA)? 1.) Atenolol 25 mg for HTN 2.) Midazolam 5 mg to prevent seizures 3.) Aldosterone 25 mg for HTN 4.) Dexamethasone 4 mg for COPD 5.) Clopidogrel (Plavix) 75 mg QD for A-fib 6.) Alprazolam 25 mg given @ bedtime for insomnia - CORRECT ANSWER 3,5 3 = Hold, K+ sparing 5 = Stopped 3-7 days ac surgery *Give only anti-HTN, unless ometric Explanations: 1,2,4,6 = give all of these Roles & responsibilities of the RN manager position include (SATA). 1.) Monitoring the professional practice model on the unit 2.) Coordinating the pt's d/c care 3.) Empower the RN staff @ the admin's meetings 4.) F/U on pt's & farm complaints 5.) F/U on root cause analysis of incident reports - CORRECT ANSWER 1,3,4 Explanations: 2 = Charge RN or assigned RN for pt 5 = Risk management department - start an investigation A pt is being transfused 1 unit of PRBCs. The pt complains of burning @ IV site. The RN assesses the site & edema is present. Which action does the RN take 1st? (redness, edema, burning = infiltration) 1.) Stop the transfusion 2.) Flush the IV cannula w/ prefilled normal saline 3.) Remove the IV cannula & apply pressure to site 4.) Raise the extremity above heart level - CORRECT ANSWER 1 = & aspirate some blood, 10 mL -remove IV cannula, tape it, & raise the extremities above the heart level Explanations: 2 = never b/c would make worse 3 = Do NOT put pressure b/c make edema worse This is the diffusion or accumulation of fluids under the skin = intracellular or interstitial - CORRECT ANSWER Infiltration The following S&S are apart of what dealing w/ needles & fluid? 1.) Localized edema 2.) Cool blanking skin 3.) Tightness - CORRECT ANSWER Infiltration What are the 4 treatments for Infiltration? - CORRECT ANSWER 1.) Stop transfusion IMMEDIATELY 2.) Aspirate if possible 3.) Remove IV cannula = Do NOT apply pressure -just tape & raise ABOVE heart level 4.) Apply cold or warm compress This is the leakage of IV meds that have/has the potential to cause some serious damage to the extravascular tissue - CORRECT ANSWER Extravasation The following S&S are d/t what that deal with leakage of IV meds? 1.) Localized edema 2.) Cool, blanching skin, & tightness 3.) Burning sensation 4.) Redness 5.) Blisters 6.) Ulceration 7.) Stinging pain 8.) Tissue necrosis - CORRECT ANSWER Extravasation What is the nursing care for Extravasation? - CORRECT ANSWER 1.) Stop transfusion 2.) Aspirate if possible 3.) Mark areas of redness (see if improving) 4.) Inject antidote in IV cannula & surrounding tissue 5.) Raise affected arm on pillow (above heart level) 6.) Remove IV cannula 7.) Apply cold or warm compress K+, Cl-, Vancomycin Pt calls RN & complains about pain ! IV insertion site. He has dobutamine infused peripheral IV cath. After stopping infusion, which action does RN take next? 1.) Apply cold compresses to IV site 2.) Call HCP 3.) Mark around affected skin 4.) Position & support extremity - CORRECT ANSWER 2 = Signs of extravastation should be reported right away to start tx in a timely manner ac losing any tissue -get an antidote order Dobutamine thru a central line causes extravasation Explanations: 1 = Only WARM compresses 3 = after tx & monitor redness 4 = after initiating tx What is the side effect of Ca-channel blockers? - CORRECT ANSWER Tachycardia What is the side effect of ACE inhibitor? - CORRECT ANSWER Skin rash & neutropenia The RN assesses a pt in labor. Which assessments indicate that the pt in is the active phase of the 1st stage of labor (SATA)? 1.) Her contractions are 2-3 mins apart 2.) Her contractions are irregular 3.) Her contractions are 30-40 secs long 4.) There is an extensive amount of blood gush 5.) The pt is doubtful of ability to control pain - CORRECT ANSWER 1,5 Explanations: 2 = Contractions are Regular 3 = 40-60 seconds apart 4 = this occurs during the transition phase How long is the pregnancy in months, wks, or days? - CORRECT ANSWER 9 months, 40 wks, or 280 days Pregnancy is divided into 3, -wk trimesters - CORRECT ANSWER 13-wk When does the 1st trimester start and end? - CORRECT ANSWER 1st day of LMP till 13 wks (Maternity) 14 wks till 26 weeks is what trimester? - CORRECT ANSWER 2nd When does the 3rd trimester start and end? - CORRECT ANSWER 27 wks till 40 wks Name the 8 maternal changes in the 1st trimester - CORRECT ANSWER 1.) Nausea persists up to 12 wks 2.) Hegar sign occurs 3.) Goodell sign occurs 4.) Leukorrhea increases 5.) Chadwick sign 6.) Uterus rises above pelvic brim @ 12 wks 7.) wt. gain 2-4 lbs 8.) Placenta is fully functioning & producing hormones by 12 weeks During the a.) trimester, the placenta is fully functioning & producing by b.) wks - CORRECT ANSWER a.) 1st trimester b.) 12 wks (Maternal changes in the 1st trimester) This is the softening of the isthmus of cervix - CORRECT ANSWER Hegar sign (Maternal changes in the 1st trimester) This is the softening of the cervix - CORRECT ANSWER Goodell sign (Maternal changes in the 1st trimester) This is the bluish of vagina, cervix, & labia. Results for INCREASED blood flow - CORRECT ANSWER CHadwick sign (Maternal changes in the 1st trimester) What is the sign of pregnancy? - CORRECT ANSWER 6-8 wks after conception During this trimester the pregnant woman feels the baby low down in the bell and butterfly flutters - CORRECT ANSWER Maternity changes in the 2nd trimester What Maternity changes occur in the 2nd trimester? - CORRECT ANSWER 1.) Quickening, fetal movement btwn 16-20 wks 2.) Colostrum, may appear @ 16 wks 3.) Insulin resistance begins as early as 14-16 wks 4.) Cholesterol level INCREASES from 16-32 wks 5.) Uterus RISES to level of umbilicus @ 24 wks 6.) Wt. gain 1 lb per wk beginning in the 2nd trimester & continuing until delivery 7.) Fundus reaches level of umbilicus @ 20 wks 8.) Leg cramps may begin, varicose veins & constipation may develop @ 20 wks (Maternity changes in the 2nd trimester) This is the pre-milk, that is creamy white to yellowish glue - CORRECT ANSWER Colostrum (Maternity changes in the a.) trimester) 1.) b.)Fundus is 1/2 way btwn what 2 things @ 28 weeks - CORRECT ANSWER a.) 3rd trimester b.) umbilicus & xiphoid process (Maternity changes in the 3rd trimester) What type of breathing replaces abd. breathing? - CORRECT ANSWER Thoracic breathing (Maternity changes in the 3rd trimester) What is palpable? - CORRECT ANSWER Fetal outline (Maternity changes in the 3rd trimester) Heartburn may begin & this may develop - CORRECT ANSWER Hemorrhoids (Maternity changes in the 3rd trimester) Fundus reaches ANSWER Xiphoid process @ 32 weeks - CORRECT (Maternity changes in the 3rd trimester) This returns now and it occurs during the 1st trimester as well - CORRECT ANSWER Urinary frequency (Maternity changes in the 3rd trimester) Swollen ankles may occur, a.) problems, and b.) may develop - CORRECT ANSWER a.) Sleeping problems b.) Dyspnea What maternity changes occur in the 3rd trimester? - CORRECT ANSWER 1.) Fundus is 1/2 way btwn umbilicus & xiphoid process @ 28 wks 2.) Thoracic breathing replaces abdominal breathing 3.) Fetal outline is palpable 4.) Heartburn may being, hemorrhoids may develop 5.) Fundus reaches xiphoid process @ 32 wks 6.) Urinary frequency returns (1st & 3rd) 7.) Swollen ankles may occur, sleeping problems, dyspnea may develop How does an RN obtain Obstetric hx? - CORRECT ANSWER GTPAL (Obtaining Obstetric hx: GTPAL) What does the G stand for? - CORRECT ANSWER Gravidity (Obtaining Obstetric hx: GTPAL) This is the # of pregnancies - CORRECT ANSWER Gravidity (Obtaining Obstetric hx: GTPAL) What does the T stand for? - CORRECT ANSWER Term = term births (Obtaining Obstetric hx: GTPAL) What does the P stand for? - CORRECT ANSWER Preterm (Obtaining Obstetric hx: GTPAL) What does Preterm mean? - CORRECT ANSWER Preterm births who are delivered BEFORE 37 wks (Obtaining Obstetric hx: GTPAL) What does the A stand for? - CORRECT ANSWER Abortions (Obtaining Obstetric hx: GTPAL) What does Abortions mean? - CORRECT ANSWER Pregnancies that did NOT reach 20 wks (Obtaining Obstetric hx: GTPAL) What does the L stand for? - CORRECT ANSWER Living (Obtaining Obstetric hx: GTPAL) What does living mean? - CORRECT ANSWER Infants that have survived birth How do you calculate the estimated DOB? - CORRECT ANSWER 1.) Count back 3 months from the 1st day of the LMP & add 7 days 2.) ex: last day of LMP was March 23, EDB would be December 30. What is the name of the rule used to calculate the estimated DOB? - CORRECT ANSWER Nagele rule (Nagele rule: estimated DOB) ex: LMP is Oct. 17, what is the EDB? - CORRECT ANSWER July 24 (Keep in mind!) How to determine wellbeing of fetus? - CORRECT ANSWER Check FHR When checking a fetuses FHR how is it checked @ 10-12 wks? - CORRECT ANSWER Detectable w/ Doppler When checking a fetuses FHR how is it checked @ 15-20 wks? - CORRECT ANSWER Detectable w/ fetoscope When checking a fetuses FHR what is their normal range for heartbeat? - CORRECT ANSWER 110-160 bpm How is the fundal height measured? - CORRECT ANSWER @ 18-32 wks, the ht of the fundus, measured in can w/ an empty bladded, is about the same as # of wks gestation (Fundal ht) Ex: 24 wks gestation, a. )what should a mom's fundal ht be? b.) And where is the fundal ht measured from? - CORRECT ANSWER a.) 24 cm b.) From symphysis pubis to top of fundus Name what is included in the Maternity diet - CORRECT ANSWER 1.) INCREASE intake by 300 calories above basal & activity needs 2.) INCREASE protein by 30g/day 3.) INCREASE intake of iron & folic acid thru diet & supplements as directed by HCP 4.) INCREASE intake of Vit A,C & calcium thru diet 5.) Drink a total of 8-10 glasses of fluid/day (Maternity diet) These are foods HIGH in what? 1.) Fish & red meat 2.) Cereals & yellow veggies 3.) Green leafy veggies & citrus fruits 4.) Egg yolks & dried fruits - CORRECT ANSWER Foods HIGH in IRON (FHR monitoring) This means that the fetus is moving, reactive, & healthy - CORRECT ANSWER Acceleration = normal (FHR monitoring) This is caused by head compression, FHR slowly, & smoothly decelerates @ the beginning of contraction & returns to baseline @ end of contraction - CORRECT ANSWER Early decelerations (FHR monitoring) This is the most common pattern caused by cord compression. - CORRECT ANSWER Variable decelerations = horrible (FHR monitoring) Variable decelerations is an abrupt in FHR that is variable in duration - CORRECT ANSWER abrupt DECREASE (FHR monitoring) If a fetus is having variable deceleration what are the 5 things for nursing care to help the fetus? - CORRECT ANSWER 1.) Change maternal position = knee-chest position 2.) Stop oxytocin = stimulates uterus to contract 3.) Admin O2 @ 10-L by face mask 4.) Vaginal exam to check for cod prolapse 5.) Inform HCP (FHR monitoring) This is a FHR 70 for 30-60 secs - CORRECT ANSWER Severe variable decelerations = horrible (FHR monitoring) Dealing w/ severe variable deceleration, late decelerations are indicative of - CORRECT ANSWER Uteroplacental insufficiency (FHR monitoring) What are the 6 parts of Nursing care for Severe variable decelerations? - CORRECT ANSWER 1.) Change maternal position to (L)-side = relieves pressure off vena cava & helps more blood & O2 get to the baby 2.) Stop oxytocin 3.) Admin O2 @ 10-L by face mask 4.) IV fluids, elevate legs to increase venous return (if hypotensive) 5.) Check FHR 6.) Inform HCP (Things to know) This is yellow-green & may indicate fetal distress - CORRECT ANSWER Meconium-stained amniotic fluid (Things to know) This has a shorter latent phase (14 hrs) - CORRECT ANSWER Multipara = 1 offspring (Things to know) If a women is Multipara, the mother should after amniotic membrane is ruptured & can NOT roam the room or hallway - CORRECT ANSWER Stay on bed rest (Things to know) These are no longer than 90 secs; time is from the beginning to the end of 1 single contraction - CORRECT ANSWER Contractions (Things to know) This should NOT be 2mins apart; from the beginning of 1 contraction to the beginning of the next 1 - CORRECT ANSWER Frequency This is the relationship of the fetal head to the mother's pelvis - CORRECT ANSWER Fetal station How does the Fetal station work? - CORRECT ANSWER (-) #'s is up the hip bone 0 = Ischial spine (+) #'s is close to and when the fetus is ready to come out (Fetal station) a.) I'm @ 0, which means what? from here it's all b.) . I'm on my way out! - CORRECT ANSWER a.) 0 = head fully engage b.) (+) This presentation (lie) of the baby is butt first; the spine of the baby is parallel to spine of mom - CORRECT ANSWER Longitudinal or vertical line & Breech presentation This presentation (lie) of the baby is if the head is the presenting part - CORRECT ANSWER Longitudinal lie & Vertex presentation This presentation (lie) of the baby is when the baby is laying side to side (hip to hip) w/ back first & in a ball The shoulder is 1st & spine is perpendicular to mom's spine - CORRECT ANSWER Transverse lie & shoulder (Acromion) presentation Name the 4 stages of Labor - CORRECT ANSWER 1.) Stage 1 has 3 phases = a.) Latent = b.) Active = c.) Transition 2.) Stage 2 = Delivery of the baby 3.) Stage 3 = Delivery of the placenta 4.) Stage 4 = Recovery = lasts about 2 hrs AFTER delivery of placenta (Stages of Labor: Stage 1, 3 phases) In this phase, a woman's cervix is 1-3 cm; contractions are Q30-40secs & are 5-20 mins apart - CORRECT ANSWER Phase 1 = latent (Stages of Labor: Stage 1, 3 phases) In this phase, a woman's cervix is 4-7 cm; contractions are Q40-60secs & are 2-3 mins apart - CORRECT ANSWER Phase 2 = Active (Stages of Labor: Stage 1, 3 phases) In this phase, a woman's cervix is 8-10 cm; contractions are Q60-90 secs & are 2 mins apart - CORRECT ANSWER Phase 3 = transition (Stages of Labor: Stage 1, 3 phases) This is the thinning of the cervix, which goes from thick to 100% in transition phase - CORRECT ANSWER Effacement (Stages of Labor: Stage 1, 3 phases) If a woman's effacement is 2mins or 90secs what should the RN do? - CORRECT ANSWER Its an emergency & notify HCP immediately (Stages of Labor: Stage 2) These types of contractions are stronger, longer, & shorter apart - CORRECT ANSWER True contractions (Stages of Labor) In this stage of labor, the delivery of the baby occurs & starts w/ a complete dilation & end w/ birth of a baby - CORRECT ANSWER Stage 2 of Labor (Stages of Labor: Stage 2) During stage 2 the RN would do a vaginal exam to check if head is a.) & also check if b.) - CORRECT ANSWER a.) Engaged b.) Cord is around baby's neck (Stages of Labor: Stage 2) How is a baby delivered by an OB? - CORRECT ANSWER 1.) Deliver baby 2.) then, deliver the shoulders 3.) Suckin mouth & nose 4.) Put matching ID bracelets on baby & parents BEFORE leaving delivery room (Stages of Labor) 1.) During this stage the placenta separates from uterine wall/delivery of the placenta - CORRECT ANSWER Stage 3 of Labor (Stages of Labor: Stage 3) 2.) Give _ a.) after the placenta is delivered b/c it will cause the uterus to contract & help to get back to b.) . - CORRECT ANSWER a.) Oxytocin b.) Normal (Stages of Labor: Stage 3) 2.) Check to make sure the placenta is fully intacked b/c if NOT it can cause . - CORRECT ANSWER Hemorrhage or uterine atrophy (Stages of Labor: Stage 3) 2.) Later signs of reframed placental fragments is a.) and this occurs b.) hrs later - CORRECT ANSWER a.) Infection b.) 48-72 hrs later (Stages of Labor: Stage 3) 3.) As soon as the infant is born, the RN will do what 3 things? - CORRECT ANSWER 1.) Dry & suction the infant 2.) Perform Apgar assessment 3.) Allow skin-to-skin contact w/ mother after delivery IMMEDIATELY (Stages of Labor: Stage 3) 4.) During this stage, cover the newborn's head w/ what 2 things to prevent heat loss? - CORRECT ANSWER 1.) Cap, & 2.) a Blanket (Stages of Labor) This stage includes the 1st 2 hrs post-labor - CORRECT ANSWER Stage 4 of Labor (Stages of Labor: Stage 4) Assess vital signs Q a.) mins for 1 hr, then Q b.) mins until stable - CORRECT ANSWER a.) Q15 mins b.) Q30 mins (Stages of Labor: Stage 4) During this stage, the RN assesses what 4 things? - CORRECT ANSWER 1.) Assess fundal firmness & ht 2.) Bladded 3.) Lochia (Rubra, serosa, & alba) 4.) Perineum Q15mins for 1 hr, then Q30mins for 2 hrs (Stages of Labor: Stage 4) This is firm, midline @ or below the umbilicus - CORRECT ANSWER Fundus (Stages of Labor: Stage 4) If the fundus is soft or boggy what should the RN do? - CORRECT ANSWER Massage (Stages of Labor: Stage 4) If the fundus is above the umbilicus & to the (R) of the abdomen what should the RN suspect? - CORRECT ANSWER A full bladder (Stages of Labor: Stage 4) This type of Lochia appears 1st and lasts for 1-3 days - CORRECT ANSWER Rubra (red) (Stages of Labor: Stage 4) This type of Lochia appears 2nd and lasts for 4-10 days - CORRECT ANSWER Serosa (pink) (Stages of Labor: Stage 4) This type of Lochia appears 1st and lasts for 11 days to 6 wks - CORRECT ANSWER Alba (white) (Stages of Labor: Stage 4) This is moderate d/c w/ clots 2cm to 3cm - CORRECT ANSWER Lochia: rubra (red) (Stages of Labor: Stage 4: Lochia) Always check perineal pads. There should be 1 saturated pad Q a.) , if saturates in 5mins, b.) . This means a woman could have c.) - CORRECT ANSWER a.) Qhr b.) Inform HCP c.) Retained placenta This is usually done @ 1 & 5 mins after birth - CORRECT ANSWER Apgar score (Apgar score) An apgar score of 7-10 means an infant is - CORRECT ANSWER Good (Apgar score) An apgar score of 4-6 means an infant is - CORRECT ANSWER Needs moderate resuscitation efforts (Apgar score) An apgar score of 0-3 means an infant is - CORRECT ANSWER Severe need for resuscitation (Apgar score) What are the 5 parts of the Apgar score? - CORRECT ANSWER 1.) HR 2.) Resp. effort 3.) Muscle tone 4.) Reflex irritability 5.) Color (Apgar score) For HR, what score will an infant get if its absent - CORRECT ANSWER 0 (Apgar score) For HR, what score will an infant get if its 100 - CORRECT ANSWER 1 (Apgar score) For HR, what score will an infant get if its 100 - CORRECT ANSWER 2 (Apgar score) For resp. effort, what score will an infant get if it has NO cry - CORRECT ANSWER 0 (Apgar score) For resp. effort, what score will an infant get if it has a weak cry - CORRECT ANSWER 1 (Apgar score) For resp. effort, what score will an infant get if it has a vigorous cry - CORRECT ANSWER 2 (Apgar score) For muscle tone, what score will an infant get if it has a flaccid tone - CORRECT ANSWER 0 (Apgar score) For muscle tone, what score will an infant get if it has some flexion - CORRECT ANSWER 1 (Apgar score) For muscle tone, what score will an infant get if it has a total flexion - CORRECT ANSWER 2 (Apgar score) For reflex irritability, what score will an infant get if it has no response to a foot tap - CORRECT ANSWER 0 (Apgar score) For reflex irritability, what score will an infant get if it has a slight response to a foot tap (grimace) - CORRECT ANSWER 1 (Apgar score) For reflex irritability, what score will an infant get if it has quick, foot removal - CORRECT ANSWER 2 (Apgar score) For color, what score will an infant get if it has a dusky, cyanotic color? - CORRECT ANSWER 0 (Apgar score) For color, what score will an infant get if it has a acrocyanotic? - CORRECT ANSWER 1 (Apgar score) For color, what score will an infant get if it is totally pink? - CORRECT ANSWER 2 This is given to Rh(-) women after a miscarriage, abortion, or any procedure or complication that INCREASES the risk for maternal-fetal blood exchange - CORRECT ANSWER RhoGAM When is RhoGAM given? - CORRECT ANSWER 1.) Amniocentesis 2.) PUBS* = Purcutaneous umbilicus blood sampling 3.) Abd. trauma RhoGAM is routinely given @ wks gestation to Rh(-) moms w/ (-) antibody titer - CORRECT ANSWER 28 wks RhoGAM is given to a.) moms after delivery or abortion when fetus is b.) - CORRECT ANSWER a.) Rh (-) b.) Rh(+) RhoGAM must be given w/in a.) hrs AFTER delivery, ALWAYS given _b.) - CORRECT ANSWER a.) 72 hrs b.) IM RhoGAM (immune globin) is a blood product, so it is must be checked by - CORRECT ANSWER 2 RNs Which is an indicator that the pt had an effective intervention to tx her mild pre-eclampsia? 1.) BP = 146/82 2.) Periorbital edema 3.) Deep tenderness reflexes +2 4.) Proteinuria - CORRECT ANSWER 3 = normal Explanations: 1 = BP is still high; improved when below 140/90 2 = not under control 4 = not under control; +1 or lower means it it under control This is caused by a BP /140/90 - CORRECT ANSWER Pre-eclampsia = Mild pre-eclampsia 1.) This usually develops last 10 wks of gestation or up to 48 hrs post-delivery 2.) Protein of / 0.3g in a 24-hr specimen 3.) Wt. gain 2lb/wk 4.) Proteinuria / +1 (dipstick check) 5.) Edema, especially around eyes, face, & fingers 6.) Reflexes may be normal or 2+ - CORRECT ANSWER Mild-pre-eclampsia What are the 2 CNS symptoms of Mild Pre-eclampsia? - CORRECT ANSWER Possible mild HA & slight irritability Deep tendon reflexes are known as what type of reflex? - CORRECT ANSWER Patellar (knee- jerk) reflex (Patellar (knee-jerk) reflex) Deep tendon reflexes are graded as follows: A pt has NO response; always abnormal - CORRECT ANSWER 0 (Patellar (knee-jerk) reflex) Deep tendon reflexes are graded as follows: A pt has a slight but definitely present response; may or may not be normal = knee moves 15-30 degrees - CORRECT ANSWER 1+ (Patellar (knee-jerk) reflex) Deep tendon reflexes are graded as follows: A pt has a brisk response; normal - CORRECT ANSWER 2+ 1.) This usually develops last 10 wks of gestation or up to 48 hrs post-delivery 2.) Protein of / 0.3g in a 24-hr specimen 3.) Wt. gain 2lb/wk 4.) Proteinuria / +1 (dipstick check) 5.) Edema, especially around eyes, face, & fingers 6.) Reflexes may be normal or 2+ 7.) CNS symptoms: possible mild HA, slight irritability 8.) BP/ 149/90 ALL the above w/ 2 of the below are what type of Pre-eclampsia? 1.) BP of 160/110 on 2 or more occasions 2.) Proteinuria 2+ or 3+ (2g in 24-hr specimen) 3.) Generalized edema (very puffy face & hands) 4.) Deep tendon reflexes (DTR) 3+ or greater, plus clonus 5.) Oliguria (100 mL/4hrs; 25mL/hr) = normal is 30 mL/hr 6.) Severe HA, visual disturbances = blurred vision, photophobia, blind spots 7.) ELEVATED serum creatinine (in blood), thrombocytopenia, & marked liver enzyme elevation (AST) w/ epigastric pain r/t liver spasms - CORRECT ANSWER Severe Pre-eclampsia (Severe Pre-eclampsia) This is involuntary muscle contractions & relaxations; spastic muscles - CORRECT ANSWER Clonus (Severe Pre-eclampsia) What are the normal levels for serum creatinine? - CORRECT ANSWER 0.6-1.2 Pt. teaching for Pre-eclampsia & eclampsia - CORRECT ANSWER 1.) CNS symptoms: visual disturbances, HA, N/V, hyperreflexia, & convulsions 2.) Hepatic sign: epigastric pain 3.) Renal sign: oliguria, proteinuria 4.) Fluid d/c or bleeding from vagina 5.) Change in fetal movement or INCREASE FHR 6.) Signs of infection: chills, temps over 100.4, dysuria, & abd. pain (Pt. teaching for Pre-eclampsia & eclampsia) What are the CNS symptoms - CORRECT ANSWER Visual disturbances, HA, N/V, hyperreflexia, & convulsions (Pt. teaching for Pre-eclampsia & eclampsia) What are the Hepatic sign - CORRECT ANSWER Epigastric pain (Pt. teaching for Pre-eclampsia & eclampsia) What are the Renal signs? - CORRECT ANSWER Oliguria, proteinuria (Pt. teaching for Pre-eclampsia & eclampsia) What are the 4 signs of infection? - CORRECT ANSWER 1.) Chills 2.) Temp over 100.4 3.) Dysuria (painful or difficulty urinating; burning sensation) 4.) Abd. pain The pt came from her 16 wks gestation visit & asked the RN of how does her baby look like. Which is an accurate response by the RN? 1.) Extremities are just starting to show & you can hear a heartbeat now 2.) Lung & ears are functional now 3.) He would be sucking his thumb right now 4.) We can tell the sex of your baby today - CORRECT ANSWER 4 Explanations: 1= @ 8 wks 2 = lungs = develop @ 12 wks, when baby is born; ears are 38 wks 3 = 20 wks, 11 oz RN report was given to the night shift RN about 4-pregnant pts in active labor. Which pt does the RN assess 1st? (Nullipara never has given birth before) 1.) A Nullipara pt @ 10 cm dilation & 100% effacement 2.) A nullipara pt w/ fetus in transverse lie & FHR of 155 bpm 3.) A nullipara pt @ 8 cm dilation w/ presenting fetal part @ +2 station 4.) A nullipara pt @ 0 station w/ fetus in breech presentation/position - CORRECT ANSWER 3 = must go thru transverse very quickly Explanations: 1 = 1st time mom take forever 2 = pt has time; 1st time take a long time 4 = fetus just engaged in pelvis; bottom first; still has time The RN creates a dietary teaching plan for a pregnant pt. Which info will the RN include? 1.) Preterm requirements will double 2.) Increase calories by 800kcal/day 3.) Need to INCREASE IRON 4.) Decrease sea salt intake - CORRECT ANSWER 3 = & increase folic acid; 30g/day, 27- 30g/day; given iron supplements in 2nd trimester Explanations: 1 = increase protein by 30g/day; about 60g/day 2 = 1st trimester don't have to ass any calories to diet; 2nd = 300kcal/day, 3rd = 450calories/day 4 = fluid volume increase, need a little bit more salt; drink 8-10 oz glasses of H2O QD Which pt would the antepartum RN assess 1st? 1.) A pt w/ epistaxis 10 wks gestation 2.) A pt who just noticed rectal varicosities @ 14 wks 3.) A pt complaining of epigastric pain @ 20 weeks 4.) A pt complaining of cramps @ 34 wks - CORRECT ANSWER 3 = continuous or intense abd. pain can be an indication for ectopic pregnancy, preeclampsia, or abruptio placentae = raise red flags = ectopic pregnancy, pre-eclampsia, abruption placentae Explanations: 1 = normal; d/t high estrogen levels 2 = normal; large uterus & pressure in rectum and legs 4 = normal; elevate legs, straighten knee; someone seek it A pt is taking 2 tabs of K+ of (20 mEq) BID. The pt's creative level is 1.7 mg/dL. What action is the priority for the RN? (normal 0.6-1.2) 1.) Ask for nephrologist consult 2.) Give K+ as scheduled 3.) Assess pt's fluid balance 4.) Inform HCP - CORRECT ANSWER 4 = HIGH creatinine level could be a result of impaired kidney function, thus results in hyperkalemia - Priority is to notify the HCP ac giving dose --AVOID med & notify HCP Explanations: 2 = NOT; hold med drive pt into hyperkalemia 3 = won't give any info. A pt is admitted w/ having cutaneous nodular melanoma lesions. A small clear drainage from the lesions. Which PPE does the RN use when bathing & changing the linens for this pt? 1.) Gloves 2.) Gown & gloves 3.) Gown, gloves, mask 4.) Gown & gloves to change linen; gloves when taking bath - CORRECT ANSWER 2 = Contact precautions Explanation: 4 = this doesn''t make sense A pt @ his end-stage of dying. The pt's spouse asks the RN how she can provide comfort to the pt in his final hrs/ Which intervention will the RN advise the spouse to implement (SATA)? 1.) Getting the pt's favorite book & read it to him 2.) Helping encourage fluid intake 3.) Massaging pt's feet & ankles 4.) Holding hands 5.) Having a conversation w/ the pt - CORRECT ANSWER 1,3,4,5 1 = is something he would enjoy Interventions to provide comfort A pt w/ severe hypothermia 14 hrs post-mitral valve replacement. Which assessment will the RN perform 1st? 1.) Check if the pt is shivering 2.) Determine if pt is cyanotic 3.) Check telemetry monitor for arrhythmia 4.) Determine if calcium is low - CORRECT ANSWER 3 = Hypothermia put pt @ risk for ventricular dysrhythmia -very severe & critical *Post-mitral valve replacement 24 hrs post-surgery it is critical = 5 H's & 5T's cause cardiac arrest Explanations: 2 = cyanosis & malting of the sign 4 = not related Name the 5 H's dealing w/ the Causes of Cardiac Arrest - CORRECT ANSWER 1.) Hypovolemia 2.) Hypoxia 3.) Hydrogen ions = pH 7, acidosis 4.) Hyper/hypokalemia 5.) Hypothermia Name the 5 T's dealing w/ the Causes of Cardiac Arrest - CORRECT ANSWER 1.) Toxins = drug intoxification 2.) Tamponade = hypotension muttled or absent; blood in pericarium 3.) Tension pneumothorax 4.) Thrombosis (PE) 5.) Trauma (chest trauma) = blunt trauma to the chest A 4-month old infant is scheduled for a wellness check visit. The mother is stating that she tried to introduce blend food to the baby & she stuck her tongue out & spit the food. Which response by RN is approp.? 1.) That is a normal reflex 2.) Switch food ingredients, the baby might have disliked the 1st choice 3.) Add H2O to good to change texture 4.) Try pre-packed food from pharmacy - CORRECT ANSWER 1 = extrusion reflex, baby may not be ready to try new solid food = subside maybe 5-6 months; your baby is not developmentally ready to take foods * Introduce new foods @ 4-6 months The following reflexes are apart of what type of assessment for Infant 1.) Rooting 2.) Moro 3.) Tonic neck 4.) Babinski 5.) Palmer grasp 6.) Plantar 7.) Stepping - CORRECT ANSWER Neuromuscular assessment for Infants (Neuromuscular assessment for Infants: Reflexes, Normal responses) Baby turns towards stimulus when check or corner of tip is touched - CORRECT ANSWER Rooting reflex (Neuromuscular assessment for Infants: Reflexes, Normal responses) When does the rooting reflex disappears? - CORRECT ANSWER 3-4 months (Neuromuscular assessment for Infants: Reflexes, Normal responses) When startled, baby symmetrically extends & abducts ALL extremities - CORRECT ANSWER Moro reflex (Neuromuscular assessment for Infants: Reflexes, Normal responses) When does the Moro reflex disappears? - CORRECT ANSWER 3-4 months (Neuromuscular assessment for Infants: Reflexes, Normal responses) When neck is turned to side, baby assumes fencing posture - CORRECT ANSWER Tonic neck (Neuromuscular assessment for Infants: Reflexes, Normal responses) When does the tonic neck reflex disappears? - CORRECT ANSWER 3-4 months (Neuromuscular assessment for Infants: Reflexes, Normal responses) When sole of foot is stroked from heel to toe, toes fan apart from big toe - CORRECT ANSWER Babinski reflex (Neuromuscular assessment for Infants: Reflexes, Normal responses) When does the Babinski reflex disappears? - CORRECT ANSWER 1yr-18 months (Neuromuscular assessment for Infants: Reflexes, Normal responses) If an infant still has the Babinski reflex after 18 months what does this mean? - CORRECT ANSWER The infant has something wrong in their brain = the infant has a neuromuscular disorder -2 yrs old (Neuromuscular assessment for Infants: Reflexes, Normal responses) When examiner's finger is placed in the infant's palm, the infant will grasp it - CORRECT ANSWER Palmer grasp (Neuromuscular assessment for Infants: Reflexes, Normal responses) When does the Palmer grasp disappears? - CORRECT ANSWER 3-4 months (Neuromuscular assessment for Infants: Reflexes, Normal responses) A finger @ base of toes cause them to curl downward - CORRECT ANSWER Plantar reflex (Neuromuscular assessment for Infants: Reflexes, Normal responses) When does the plantar reflex disappears? - CORRECT ANSWER 8 months (Neuromuscular assessment for Infants: Reflexes, Normal responses) When infant is held in upright position w/ feet touching a hard surface, walking motion are made - CORRECT ANSWER Stepping reflex (Neuromuscular assessment for Infants: Reflexes, Normal responses) When does the stepping reflex disappears? - CORRECT ANSWER 3-4 months The RN assesses a 7-month old baby during a wellness visit. Which finding would the RN expect on this assessment? 1.) Has a princer grasp 2.) Sit up w/o support 3.) x3 the baby's birth wt. 4.) Palpable posterior fontanelle - CORRECT ANSWER 2 = @ this age; 6 months Explanations: 1 = 9 months 3 = @ 7 months doubled wt.; triples @ 1 yr 4 = close @ 2-3 months The RN observe a student assess neonates in the newborn nursey. Which action by the student RN requires immediate intervention (wrong) by RN? 1.) Documenting a (-) red light reflex in a 2-day old neonate 2.) Testing the tonic neck reflex by lying neonate supine & turning the head to the L-side 3.) Testing the rooting reflex by stroking the corner of the neonates mouth 4.) Documenting a (+) Babinski reflex in a 1-day neonate - CORRECT ANSWER 1 = should be (+), (-) neuro deficit INCREASED ICP -Inform HCP --Evaluated IMMEDIATELY Explanations: 2,3&4 are all correct (Reflex) This is a normal response for this type of reflex Both eyes are RED - CORRECT ANSWER Red reflex (Red reflex) What should the RN is an pt has a normal red reflex? - CORRECT ANSWER No action required (Red reflex) What does it mean when a pt has 1 eye that is red & the other eye has NO color - CORRECT ANSWER Red reflex absent = unilateral (Red reflex) What will the RN if a pt has an absent red reflex? - CORRECT ANSWER See HCP urgently (Red reflex) What does it mean when 1 eye is red & 1 eye is white? - CORRECT ANSWER Red reflex Abnormal = white eyes (Red reflex) What will the RN do if a pt has an abnormal red reflex? - CORRECT ANSWER See HCP urgently