NUR 221 Final Exam UPDATED ACTUAL
Exam Questions and CORRECT 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 ANSWER - 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
ANSWER - 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 ANSWER - Monitor
skin temperature closely.
Reposition the newborn every 2 hours.
Cover the newborn's eyes with eye shields or patches.
Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before
administration of methylergonovine, what is the priority assessment? - CORRECT
ANSWER - 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 ANSWER - 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 ANSWER - 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.
What is uterine atony? - CORRECT ANSWER - Failure of the uterus to "cramp down"
and tighten after delivery
Hemorrahge medication for postpartum mom - CORRECT ANSWER - Hemabate
methylergine
oxtocin
cytotec
Hemabate (Carboprost) - CORRECT ANSWER - do not give if you have asthma!
o Uterine Contraction / prevention of bleeding - smooth muscle contraction
use with caution on woman who have a history of:liver heart lungs disease. asthma hypertension
diabetes or uterine scarring
Methylergonovine (Methergine) - CORRECT ANSWER - Acts directly on the uterine
muscle to stimulate forceful contractions. Used for postpartum hemorrhage.
Precautions/interactions: use with extreme caution in clients with hypertension, preeclampsia,
heart disease, venoatrial shunts, mitral valve stenosis, sepsis, or hepatic or renal impairment.
Side effects: potential vasoconstriction, hypertension, headache. Interventions: continuously
monitor BP, assess uterine bleeding, and uterine tone.
Exam Questions and CORRECT 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 ANSWER - 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
ANSWER - 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 ANSWER - Monitor
skin temperature closely.
Reposition the newborn every 2 hours.
Cover the newborn's eyes with eye shields or patches.
Methylergonovine is prescribed for a woman to treat postpartum hemorrhage. Before
administration of methylergonovine, what is the priority assessment? - CORRECT
ANSWER - 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 ANSWER - 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 ANSWER - 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.
What is uterine atony? - CORRECT ANSWER - Failure of the uterus to "cramp down"
and tighten after delivery
Hemorrahge medication for postpartum mom - CORRECT ANSWER - Hemabate
methylergine
oxtocin
cytotec
Hemabate (Carboprost) - CORRECT ANSWER - do not give if you have asthma!
o Uterine Contraction / prevention of bleeding - smooth muscle contraction
use with caution on woman who have a history of:liver heart lungs disease. asthma hypertension
diabetes or uterine scarring
Methylergonovine (Methergine) - CORRECT ANSWER - Acts directly on the uterine
muscle to stimulate forceful contractions. Used for postpartum hemorrhage.
Precautions/interactions: use with extreme caution in clients with hypertension, preeclampsia,
heart disease, venoatrial shunts, mitral valve stenosis, sepsis, or hepatic or renal impairment.
Side effects: potential vasoconstriction, hypertension, headache. Interventions: continuously
monitor BP, assess uterine bleeding, and uterine tone.
