NUR 230 Exam 2 In Class QUESTIONS

NUR 230 Exam 2 In Class QUESTIONS the nurse is teaching a bottle-feeding mother how to manage engorgement when she gets home. which of the following statements indicates a lack of understanding by the mother on this topic - CORRECT ANSWER-running warm water over my breasts or expressing milk will help if my breasts get overly full reliable indicators of impending shock from early postpartum hemorrhage include all of the following EXCEPT - CORRECT ANSWER-blood pressure if a postpartum woman complains of extreme perineal pain, especially after having received pain medication, the FIRST action by the nurse should be - CORRECT ANSWER-assess the perineum upon examining a patient on day 2 after spontaneous vaginal delivery, a nurse finds the perineal pad to be completely saturated with bright red blood over the last 15 minutes. the priority in this scenario is - CORRECT ANSWER-massage the fundus blood loss of delivery is replenished by all of the following EXCEPT - CORRECT ANSWER-reduction of intravascular fluid through dehydration in labor which of the following information regarding postpartum women's bladder and bowel patterns is FALSE - CORRECT ANSWER-rectal suppositories and enemas may be safely used by all clients in the postpartum period which of the following types of birth control are contraindicated after hospital discharge for the breastfeeding mother in the early postpartum period - CORRECT ANSWER-oral contraceptives, mirena IUD the nurse recognizes all of the following PP changes are normal EXCEPT - CORRECT ANSWER-WBC of 40,000/mm^3 the nurse is teaching a postpartum mother about skin changes in the postpartum period. the nurse recognizes the mother needs additional teaching when the mother states - CORRECT ANSWER-i will have some hair loss for the first 12 months postpartum which postpartum clients require Rhogam - CORRECT ANSWER-mother who is Ainfant is A+, mother who is AB- infant is unknown and father is B-, mother who is Bstatus post miscarriage at 8 weeks a nurse receives report on four mother and baby couplets. which client should the nurse assess first - CORRECT ANSWER-a mother who calls out stating that an employee without the MBU ID badge is going to take her newborn for an X ray with the completion of the THIRD stage of labor and beginning of the FOURTH stage, there are many necessary nursing interventions. SATA - CORRECT ANSWERmassage the fundus, assist the mother with breastfeeding, administer IV oxytocin/pitocin rapidly per institution protocol related to uterine involution, the nurse recognizes all of the following statements are true EXCEPT - CORRECT ANSWER-the uterus should not be palpable abdominally after 2 days a nurse is caring for a postpartum client. she notices the mother saying to the father, "she has your beautiful eyes" this is a specific example of which of the following - CORRECT ANSWER-claiming a couple is concerned that their four year old infant will have problems once their new baby delivers in 6 weeks. what is the best recommendation for this couple - CORRECT ANSWER-encourage the parents to take their 4 year old to sibling classes a nursery nurse is caring for a newborn infant. she has just bathed a baby boy who is laying quietly under the warmer. the nurse uses an animated, high pitched voice and softly says, "what a big boy you are! you are so handsome! and so strong! arent you just a cutie pie!" as she says this, the baby's eyes widen, his head turns towards her voice, and his arms and legs begin actively moving. this is an example of - CORRECT ANSWER-entrainment a client is 6 hours postpartum. in an ideal world, what should nursing care focus on at this time - using reva rubin's theory as a guide - CORRECT ANSWER-providing pain medication, encouraging rest, and keeping the mother clean, dry, and comfortable which of the following is not a maternal or fetal indication for antepartal testing - CORRECT ANSWER-increased fetal activity a nurse is educating a pregnant client about kick counts. the client demonstrates a need for additional teaching when she states - CORRECT ANSWER-it is normal for babies to move less as they approach term a nurse is learning about the use of the ultrasonography in pregnancy. the nurse has a good understanding of the use of first trimester uses for ultrasonography when he identifies all of the following except - CORRECT ANSWER-visualization of the fetus and other structures during amniocentesis a nurse is learning about the use of ultrasonography in pregnancy. the nurse has a good understanding of the use of third trimester uses for ultrasonography when he identifies all of the following except - CORRECT ANSWER-visualization of the fetus other structures during chorionic villus sampling a client asks the nurse about nuchal translucency screening. the nurse is correct when she identifies this as - CORRECT ANSWER-an ultrasound measurement of the fluid at the nape of the fetal neck, identifies increased risk of trisomy 13/18/21, >3mm is considered abnormal all of the following are included in a biophysical profile except - CORRECT ANSWERdoppler blood flow analysis of the umbilical artery a nurse is educating a client about amniocentesis. which of the following statements indicates a need for additional education of the client about this procedure - CORRECT ANSWER-in amniocentesis, a needle is passed through the cervix under ultrasonic visualization so a small amount of amniotic fluid can be withdrawn, it is possible to perform amniocentesis after 10 weeks gestation (after 14 weeks when uterus is pelvic organ) a nurse is educating a client about chorionic villus sampling. which of the following statements indicates a need for additional education of the client about this procedure - CORRECT ANSWER-the pregnancy loss rate is 2 times higher with CVS compared to amniocentesis a nurse is educating a client about percutaneous umbilical blood sampling. which of the following statements indicates a need for additional education of the client about this procedure - CORRECT ANSWER-PUBS may be conducted in all trimesters (only 2nd and 3rd) which of the following statements regarding maternal serum alpha fetoprotein tests is false - CORRECT ANSWER-MSAFP is used as a screening tool for chromosomal abnormalities in pregnancy which of the following statements regarding the coombs test are true - CORRECT ANSWER-the coombs test is a test for Rh incompatibility, the indirect coombs test is a test of the mothers blood and the direct coombs test is a test of the newborn baby's or fetal blood, if the maternal coombs test is positive it will give a titer for Rh antibodies in the maternal blood (>1:8 indicates need for fetal evaluation), fetal middle cerebral artery doppler flow studies are used to determine the severity of fetal hemolytic anemia the nurse is teaching a prenatal client about cell-free DNA screening of maternal blood. which of the following statements indicates a need for additional education of the client about this test - CORRECT ANSWER-this test is now offered to all pregnant women which of the following statements about the contraction stress test is false - CORRECT ANSWER-CST results are reactive, nonreactive, suspicious, or equivocal a pregnant mother's blood type is A-. the father of the baby's blood type is B+. what is the likelihood that her infant will be Rh factor +? Rh- factor is autosomal recessive (dd) and Rh+ is homozygous autosomal dominant (DD) - CORRECT ANSWER-100% chance the infant will be Rh+ all cases of full monosomy are lethal except - CORRECT ANSWER-turner syndrome which statement most accurately describes dominant genetic disorders - CORRECT ANSWER-the risk factor remains the same no matter how many affected children are already in the family a client asks the nurse "did my baby inherit his cleft palate and cleft lip from me? no one in my family has ever had this" the best response by the nurse is - CORRECT ANSWER-most of the common malformations that babies are born with - like cleft palate and cleft lip - result from a combination of genetic and environmental factors after completing all of the BUBBLEHER assessments and noting that all are WDL, the nurse reviews the laboratory findings on the postpartum mother. (H&H are low) what is the priority in this scenario? - CORRECT ANSWER-assess the client's orthostatic vital signs after completing all of the assessments on a postpartum client and noting that all were WDL, the nurse reviews the laboratory findings on a client. orthostatic BP and P are performed and no changes are noted. (H&H still low) what is the priority in this scenario - CORRECT ANSWER-push fluids by mouth and notify the HCP a nurse assesses a formula feeding client's breast on day 4 post cesarean section. the breasts are firm and warm to touch. what is the priority in this scenario - CORRECT ANSWER-apply cold compresses to the breast and axillae areas after completing the BUBBLEHER assessments and noting that all are WDL, the nurse reviews the laboratory findings on the postpartum cesarean section mother. (H&H still low) the nurse then assesses orthostatic vital signs and notes a 20% increase in pulse and 20% decrease in BP. the client becomes dizzy and nauseated. the client is placed back in the bed. the HCP is notified. what is the priority in this scenario - CORRECT ANSWER-recommend the client be cross-matched for 2 units of RBCs, bolus the client with 500 mL of normal saline, administer an IV antiemetic with the completion of the third stage of labor/beginning of the fourth stage, there are many necessary nursing interventions. SATA - CORRECT ANSWER-massage the fundus, assist the mother with breastfeeding, administer IV oxytocin/pitocin rapidly per institution protocol a nurse is estimating blood loss on a postpartum client. the scale reads 1.8 kg with a saturated pad and chux. the dry weight of the pad and chux is 300 g. what is the blood loss in mL - CORRECT ANSWER-