NUR 313 EXAM 2 QUESTIONS & ANSWERS
At the end of the 3rd stage of labor, there are many necessary nursing interventions.
Select all that apply.
a. Vigorously massage the fundus
b. Prepare for the delivery of the placenta
c. Assist the mother with breastfeeding
d. Place the mother on her left side to optimize perfusion
e. Administer IV Oxytocin/Pitocin per institution protocol - Answer -A, C, E
- At the end of the 3rd stage of labor the placenta has been delivered. After delivery of
the placenta, the goal is to contract the uterus to control bleeding. Massaging the
fundus, administering oxytocin, and getting the mother to naturally produce oxytocin
(through breastfeeding) helps contract the uterus. D is only necessary during
pregnancy.
A G2P1 at 40 weeks gestation presents to trial and reports, "I think I'm in labor. My
contractions are 4-5 minutes apart, I had a gust of clear vaginal fluid about 15 minutes
ago. In prioritizing care for this client, the nurse should FIRST:
a. Assess a sterile cervical exam
b. Assist the HCP in the collection of the AmniSure test
c. Assess the client's vital signs
d. Place the client on the external fetal monitor - Answer -D
- When the client first comes to the floor in active labor, place her on the monitor so we
can get a look at the baby's status.
A baby has acrocyanosis, or blue hands and feet. Are you concerned?
a. Yes
b. No - Answer -B
- Acrocyanosis is normal, however central cyanosis is abnormal.
- The most likely cause of active bleeding is a boggy uterus, so applying pressure to
force it to constrict with slow/stop the bleeding.
After completing all the BUBBLE LE assessments and noting all are WDL, the nurse
reviews the lab findings on the postpartum mother. See the findings below, what is the
priority in this scenario?
Hgb: Pre-delivery (10), Now (7.2)
Hct: Pre-elivery (36%), Now 23%)
, RBC: Pre-delivery (5.2), Now (4.2)
WBC: Pre-delivery (18,000), Now (20,000)
a. Massage the fundus and administer oxytocin
b. Notify the HCP and recommend a blood transfusion
c. Assess the client's temperature and recommend blood cultures to be drawn
d. Assess the client's orthostatic vital signs - Answer -D
A nurse receives report on 4 mother and baby couplets. Which client should the nurse
assess first?
a. A mother post C/S 8 hours ago requesting pain medication. The baby is in NBN.
b. A mother who slept uninterrupted for 8 hours who reports a saturated perineal pad.
Infant is at the breast.
c. A mother who calls out to report that her baby's hands and feet are cyanotic.
d. A mother who calls out stating that an employee without the MBU ID badge is going
to take her newborn for an X-ray. - Answer -D
- The nurse should be cautious of anyone trying to abduct the child. A is expected and
fine, B is normal since it was over 8 hours, and C is normal.
A nurse is visiting a breastfeeding client at home 2 weeks post delivery of a 7 pound
boy via C/S. The lochia is serosa with a midline fundus palpated as firm in the
symphysis pubis area. Her nipples are cracked. The client is crying a reports her uterine
cramping and nipple pain as a 6/10. The client yells at the baby for crying. What is the
nursing priority in this scenario.
a. Perform a head to toe assessment on the newborn
b. Encourage the client to join a postpartum support group
c. Educate the client to take Motrin around the clock
d. Evaluate the client's latching on and off procedures - Answer -A
- Due to signs of impaired bonding, ensure the baby is healthy and taken care of
properly, then check latching.
Which intervention would help prevent development of postpartum thrombophlebitis?
a. Promote adequate oral fluid intake
b. Promote early ambulation
c. Place SCDs on all patients
d. Administer SQ low molecular weight Heparin - Answer -B
- Early ambulation is the best way to prevent DVTs. Use SCDs for women on bed rest.
Also, always start with the least invasive intervention (D is very invasive).
Is Rh- mom and Rh- baby a problem?
At the end of the 3rd stage of labor, there are many necessary nursing interventions.
Select all that apply.
a. Vigorously massage the fundus
b. Prepare for the delivery of the placenta
c. Assist the mother with breastfeeding
d. Place the mother on her left side to optimize perfusion
e. Administer IV Oxytocin/Pitocin per institution protocol - Answer -A, C, E
- At the end of the 3rd stage of labor the placenta has been delivered. After delivery of
the placenta, the goal is to contract the uterus to control bleeding. Massaging the
fundus, administering oxytocin, and getting the mother to naturally produce oxytocin
(through breastfeeding) helps contract the uterus. D is only necessary during
pregnancy.
A G2P1 at 40 weeks gestation presents to trial and reports, "I think I'm in labor. My
contractions are 4-5 minutes apart, I had a gust of clear vaginal fluid about 15 minutes
ago. In prioritizing care for this client, the nurse should FIRST:
a. Assess a sterile cervical exam
b. Assist the HCP in the collection of the AmniSure test
c. Assess the client's vital signs
d. Place the client on the external fetal monitor - Answer -D
- When the client first comes to the floor in active labor, place her on the monitor so we
can get a look at the baby's status.
A baby has acrocyanosis, or blue hands and feet. Are you concerned?
a. Yes
b. No - Answer -B
- Acrocyanosis is normal, however central cyanosis is abnormal.
- The most likely cause of active bleeding is a boggy uterus, so applying pressure to
force it to constrict with slow/stop the bleeding.
After completing all the BUBBLE LE assessments and noting all are WDL, the nurse
reviews the lab findings on the postpartum mother. See the findings below, what is the
priority in this scenario?
Hgb: Pre-delivery (10), Now (7.2)
Hct: Pre-elivery (36%), Now 23%)
, RBC: Pre-delivery (5.2), Now (4.2)
WBC: Pre-delivery (18,000), Now (20,000)
a. Massage the fundus and administer oxytocin
b. Notify the HCP and recommend a blood transfusion
c. Assess the client's temperature and recommend blood cultures to be drawn
d. Assess the client's orthostatic vital signs - Answer -D
A nurse receives report on 4 mother and baby couplets. Which client should the nurse
assess first?
a. A mother post C/S 8 hours ago requesting pain medication. The baby is in NBN.
b. A mother who slept uninterrupted for 8 hours who reports a saturated perineal pad.
Infant is at the breast.
c. A mother who calls out to report that her baby's hands and feet are cyanotic.
d. A mother who calls out stating that an employee without the MBU ID badge is going
to take her newborn for an X-ray. - Answer -D
- The nurse should be cautious of anyone trying to abduct the child. A is expected and
fine, B is normal since it was over 8 hours, and C is normal.
A nurse is visiting a breastfeeding client at home 2 weeks post delivery of a 7 pound
boy via C/S. The lochia is serosa with a midline fundus palpated as firm in the
symphysis pubis area. Her nipples are cracked. The client is crying a reports her uterine
cramping and nipple pain as a 6/10. The client yells at the baby for crying. What is the
nursing priority in this scenario.
a. Perform a head to toe assessment on the newborn
b. Encourage the client to join a postpartum support group
c. Educate the client to take Motrin around the clock
d. Evaluate the client's latching on and off procedures - Answer -A
- Due to signs of impaired bonding, ensure the baby is healthy and taken care of
properly, then check latching.
Which intervention would help prevent development of postpartum thrombophlebitis?
a. Promote adequate oral fluid intake
b. Promote early ambulation
c. Place SCDs on all patients
d. Administer SQ low molecular weight Heparin - Answer -B
- Early ambulation is the best way to prevent DVTs. Use SCDs for women on bed rest.
Also, always start with the least invasive intervention (D is very invasive).
Is Rh- mom and Rh- baby a problem?
