Final Exam-NUR 221; Questions and Answers
The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor.
The nurse notes the presence of the umbilical cord protruding from the vagina. What is the
firstnursing action with this finding? Correct-Place the client in Trendelenburg's position.
The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage.
Which sign, if noted, would be an early sign of excessive blood loss? Correct-An increase in
the pulse rate from 88 to 102 beats per minute.
During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should
be checked every 15 minutes during the first hour. An increasing pulse is an early sign of
excessive blood loss because the heart pumps faster to compensate for reduced blood
volume.
The nurse is preparing to care for a newborn receiving phototherapy. Which interventions
should be included in the plan of care? Select all that apply. Correct-Monitor skin
temperature closely.
Reposition the newborn every 2 hours.
Cover the newborn's eyes with eye shields or patches.
, Final Exam-NUR 221; Questions and Answers
Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before
administration of methylergonovine, what is the priority assessment? Correct-
Methylergonovine, an ergot alkaloid, is used to prevent or control postpartum hemorrhage by
contracting the uterus. Methylergonovine causes continuous uterine contractions and may
elevate the blood pressure. A priority assessment before the administration of the medication
is to check the blood pressure. The obstetrician needs to be notified if hypertension is
present.
Methylergonovine Correct-contraindicated in clients with significant cardiovascular
disease, peripheral vascular disease, hypertension, preeclampsia, or eclampsia.
A postpartum client is attempting to breast-feed for the first time. The nurse notes that the
client has inverted nipples. What nursing action should the nurse take to assist the client in
breast-feeding the newborn infant? Correct-Provide breast shells and assist the mother
with using a breast pump before each feeding to make the nipples easier for the newborn
infant to grasp.
The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor.
The nurse notes the presence of the umbilical cord protruding from the vagina. What is the
firstnursing action with this finding? Correct-Place the client in Trendelenburg's position.
The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage.
Which sign, if noted, would be an early sign of excessive blood loss? Correct-An increase in
the pulse rate from 88 to 102 beats per minute.
During the fourth stage of labor, the maternal blood pressure, pulse, and respiration should
be checked every 15 minutes during the first hour. An increasing pulse is an early sign of
excessive blood loss because the heart pumps faster to compensate for reduced blood
volume.
The nurse is preparing to care for a newborn receiving phototherapy. Which interventions
should be included in the plan of care? Select all that apply. Correct-Monitor skin
temperature closely.
Reposition the newborn every 2 hours.
Cover the newborn's eyes with eye shields or patches.
, Final Exam-NUR 221; Questions and Answers
Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before
administration of methylergonovine, what is the priority assessment? Correct-
Methylergonovine, an ergot alkaloid, is used to prevent or control postpartum hemorrhage by
contracting the uterus. Methylergonovine causes continuous uterine contractions and may
elevate the blood pressure. A priority assessment before the administration of the medication
is to check the blood pressure. The obstetrician needs to be notified if hypertension is
present.
Methylergonovine Correct-contraindicated in clients with significant cardiovascular
disease, peripheral vascular disease, hypertension, preeclampsia, or eclampsia.
A postpartum client is attempting to breast-feed for the first time. The nurse notes that the
client has inverted nipples. What nursing action should the nurse take to assist the client in
breast-feeding the newborn infant? Correct-Provide breast shells and assist the mother
with using a breast pump before each feeding to make the nipples easier for the newborn
infant to grasp.
