Show
Home Subjects Expert solutions Create Log in Sign up Upgrade to remove ads Only ₩37,125/year
Terms in this set (48)A 37 week pregnant woman presents to triage with reports of a headache and begins to have a seizure. What actions should the nurse take? 1, 2. & 3. Correct: This client in triage experiencing a seizure should be gently lowered to the floor, with her head protected. Oxygen is needed to ensure supply of oxygen to mom and fetus. Seizure activity should be monitored for tonic and clonic phases of seizure, timing, and body part affected. The nurse is assessing a newborn to determine gestational age. What findings
by the nurse would indicate the infant is premature? 1, 3. & 4. Correct: The nurse is assessing a neonate for indications of premature gestational age. In a full term infant, the ear pinna would spring back firmly and quickly, so a slow response indicates probable prematurity. Lanugo is also an indicator of gestational age. Lanugo that covers all the shoulders and chest indicate prematurity. Vernix is the waxy, cheesy coating that is noted on the neonate after birth. A large amount of vernix, in this case covering axilla, back and the buttocks, denotes prematurity. ... 2. Correct: If the neonate's toes curl downward when the soles of the feet are stroked, it may be evidence that neurologic damage from asphyxia has occurred. A normal response would be for the toes to curl fan out when the soles of the feet are stroked. ... 1. Incorrect: Naloxone is not indicated here. Naloxone reverses the effects of morphine. There is nothing in the stem indicating that the client received a narcotic. The nurse is educating a group of sexually active teenagers about Chlamydia. What should the nurse teach these clients to prevent them from acquiring or transmitting this disease ? 1. Use a latex condom when having sex to protect
against Chlamydia. ... ... 3. Correct: Spermicidal agents have an approximately 25% failure rate in preventing pregnancy. These agents kill sperm by destroying the protective surface of sperm and preventing metabolic activities necessary for survival he nurse is caring for a client with hyperemesis gravidarum. What electrolyte imbalance is most likely? 4. Correct: Hyperemesis gravidarum is characterized by persistent severe pregnancy related nausea and vomiting. There is a large amount of potassium in the upper GI tract. A client with prolonged vomiting will lose potassium in the emesis. Additionally, the client is unable to replace the lost potassium due to the persistent nausea and vomiting. Post epidural anesthesia, a laboring client's blood pressure drops to 92/42. Which intervention by the
nurse takes priority? 3. Correct: When you turn them on their side, this relieves pressure on the vena cava and the BP will go UP. All of the beds in a 10 bed Labor, Delivery, Recovery, Postpartum Unit (LDRP) are full when one of the nurses assigned that day calls in sick.
A nurse from the Med surg unit is transferred to the LDRP unit. Which client should the charge nurse assign to this nurse? 1. Correct: This client is at lowest risk for complications. She is having infrequent contractions and is not at high risk for preterm delivery. She is also receiving an oral tocolytic, terbutaline. Tocolytic agents are used to inhibit uterine contractions and suppress preterm labor. The medical surgical nurse should be able to safely provide care for this client. A client has just found out that she is pregnant and asks the nurse, "When is my baby due?" The client's last menstrual period began March 3. What date will the nurse calculate as the expected date of confinement? 1. December 3 3. Correct: The most common method of determining the expected date of confinement is by Nagele's rule. To use this method begin with the first day of the last menstrual period, add seven days, subtract 3 months and add one year. So the expected date of confinement for this client would be December 10. A mother of a newborn is crying and tells the nurse, "I am worried about my baby. His Apgar score was 6 and the nurses had to help him breath for a while." What response should the nurse make to this mother? 2. "Stop crying. Your baby is fine now and will continue to get stronger as the day progresses." 3. "Your baby's Apgar score was normal. The score was 6 at 1 minute which is typical." 4. "It is normal for you to feel this way. Let me explain what the Apgar score is used for." 4. Correct: This statement recognizes the mother's feelings and seeks to educate. Providing relevant information may decrease her anxiety and encourage further communication. The women's health charge nurse is making assignments for the next shift. The unit is short one staff member and will receive a nurse from the medical surgical unit. Which clients should be assigned to the medical surgical nurse? 1. Total abdominal hysterectomy (TAH). 1., 3. and 6. Correct: When a nurse is pulled to another unit, always assign them like a brand new nurse. A client with a TAH, Breast reduction or bladder suspension require basic post-operative care. These are within the scope of knowledge of a brand new nurse with medical-surgical knowledge. A postpartum client who is 2 hours post vaginal delivery remains on a oxytocin infusion for bleeding. Upon examination, the nurse determines that the client's fundus is boggy and soft.
What is the priority nursing intervention? 4. Correct: If the fundus is boggy and soft, massaging the fundus until firm will increase uterine tone and decrease bleeding. This is the only option that will fix the problem. A client's membranes spontaneously rupture at 10 cm dilation and
+2 station. The nurse notes that the fluid is colored green. What client preparation is the priority nursing action? 3. Correct: Green stained fluid indicates fetal passage of meconium. The fetus must be suctioned by the healthcare provider when the head is still on the perineum and before the baby takes its first breath. This will remove any particulate matter from the meconium that may cause aspiration. How should the nurse respond to a pregnant client who asks, "How will I know when it is time to go to the hospital?" 1. Correct: Yes! This is the appropriate teaching. A gush or trickle of fluid from the vagina should be evaluated regardless of whether contractions are occurring. Infection and compression of the umbilical cord are possible complications. Which finding in fetal heart rate during a non-stress test would indicate to the
nurse that a potential problem for the fetus may exist? 2. Correct. A non-reactive test is when the FHR accelerates less than 15 beats per minute above baseline. This may indicate fetal compromise. A primipara at 36 weeks gestation is seen in the OB/GYN clinic. Which sign/symptom should the nurse immediately report to the primary healthcare provider? 1. Correct: Facial and upper extremity edema can be a sign of pre-eclampsia, which can endanger both the mother and fetus. Preeclampsia is a pregnancy complication characterized by high blood pressure and signs of damage to another organ system, often the kidneys. Preeclampsia usually begins after 20 weeks of pregnancy in a woman whose blood pressure had been normal. Even a slight rise in blood pressure may be a sign of preeclampsia. Left untreated, preeclampsia can lead to serious, even fatal, complications. Signs and symptoms of preeclampsia include hypertension and may include: Proteinuria; Severe headaches; Changes in vision; Upper abdominal pain; Nausea or vomiting; Decreased urine output; Thrombocytopenia; Impaired liver function; Shortness of breath; Sudden weight gain, and edema, particularly in face and hands. A client at 34 weeks gestation with pregnancy induced hypertension (PIH) reports "heartburn." Which action by the nurse has priority? 3. Correct: Epigastric discomfort is commonly described as "heartburn" by pregnant clients, but epigastric discomfort is a symptom of impending rupture of the liver capsule and seizures associated with worsening PIH and eclampsia. As a new nurse we need to assume the worst. Call the primary healthcare provider. The nurse is
having an education class for pregnant women. A question is raised about exercise. What is the nurse's best response? 1. Correct: Best advice for pregnant women. The healthcare provider can individualize according to the physical condition of the woman and the stage of pregnancy. ... 2. Correct: This client is entering the third trimester when the risk of preterm labor and delivery are highest. Women who are aware of the consequences of preterm birth may be more likely to take action to prevent it. Signs and symptoms of preterm labor should be recognized and reported immediately to the primary healthcare provider. ... 4. Correct: Labor can progress rapidly even in a primipara. As the fetal presenting part descends, pressure is placed on the rectum and many women report that it feels as though they need to have a bowel movement. The symptoms described indicate that the client has fully dilated and is at +1 or better station, and delivery may be imminent. A full term infant is being assessed 12 hours after birth. The infant's respiratory rate is 50 and shallow, with periods of apnea. What action by the nurse takes priority? 3. Correct: Normal respirations in the healthy neonate are generally shallow and expected to be between 30 and 50 times per minute with short periods of apnea up to 5 seconds. This infant is displaying a normal respiratory status for the newborn. The nurse should continue to monitor the infant. When assessing a newborn following a breech delivery, what physical findings should the nurse report to the primary healthcare provider as positive indications of congenital hip dysplasia
(CHD)? 2 & 4. Correct: When assessing a newborn, the nurse must determine which findings are normally expected at birth versus abnormal findings that should be reported to the primary healthcare provider. Two expected findings suggestive of congenital hip dysplasia (CHD) include limited abduction of one leg and the presence of an Ortolani click when the affected hip is placed into the "frog-leg" position. Which lab value on a client who is one day postpartum should the nurse report to the primary healthcare provider immediately? 3. Correct: A hematocrit in postpartum women can drop as low as 20% (0.2) and not require transfusion in the absence of symptoms of hypovolemia. A hematocrit of 18% and lower should be reported even in the absence of dizziness, lightheadedness, shortness of breath with exertion, and syncope. ... 2. Correct: Circurmoral cyanosis is bluish discoloration of and around the lips. It is an indicator of cyanotic heart defect. A nurse is teaching a group of women about human papillomavirus (HPV). What should the nurse tell the women that human papillomavirus puts women at risk for? ... Which postpartum client should the nurse assign to a private
room? 1. Correct: This client should be in a private room for her protection and the protection of other postpartum women. The presence of antibodies for Hepatitis C indicates HCV infection and possibly impaired immune function due to liver damage. In addition, Hepatitis C is transmitted by contact with body fluids and it is likely that lochia will be found on toilet surfaces. It is also common for postpartum women to have some kind of wound (perineal laceration or episiotomy) and they will be at increased risk of HCV contaminated lochia coming into contact with their wound. ... 4. Correct: The fetal heart rate is assessed for at least 1 minute after amniotomy. The umbilical cord could be displaced in a large fluid gush, resulting in compression and interruption of blood flow through it. ... 3. Correct: Cold stress is the biggest danger to a newborn. A newborn is wet, and evaporation will rapidly cool the baby, which can cause hypoglycemia and respiratory distress. The stimulus of drying the skin also promotes vigorous crying and lung expansion in most healthy infants. Which client should the
nurse assign to a room closest to the nurse's station? 2. Correct: A client with a diagnosis of placenta previa is at high risk for bleeding and must be monitored closely. Placenta previa is a complication of pregnancy in which the placenta is either partially or wholly inserted in the lower uterine wall and blocks the cervix. It is the leading cause of antepartum hemorrhage. Clients with this complication will have to have a C-section to prevent harm to the mother and fetus from bleeding. A client in labor is placed on an external fetal monitor. Which interventions should the nurse perform if a late fetal heart rate deceleration
occurs? 1., 2. & 5. Correct: Late fetal heart rate decelerations are associated with fetal hypoxia and acidosis. Positioning the mother on her left side prevents compression of the vena cava. Oxygen administration increases maternal, then fetal blood level, thus treating current and preventing further development of hypoxia and acidosis. Failure to recognize fetal monitoring strip abnormalities and failure to report abnormalities to the primary healthcare provider are deviations from the standard of care. A primigravida client at 35 weeks gestation has been diagnosed with human papillomavirus (HPV). The nurse knows that the most important information to discuss with this client is
what? 2. Correct: HPV is a sexually transmitted viral infection that can cause genital warts or even precancerous lesions. This virus is spread by direct contact with infected mucous membranes and is transmitted through sexual contact. Although HPV generally clears itself through the human immune system, clients diagnosed with this infection are recommended to have a follow-up Pap smear every six months for the first year, particularly if infected with HPV 16 or HPV 18. Which manifestations, if noted in a pregnant client, would the nurse need to report to the primary healthcare provider? 1., 2., 4., & 6. Correct: These are danger signs/symptoms of pregnancy and need further investigation by the primary HCP. These signs could indicate preeclampsia, fluid and electrolyte disturbances, and other high risk complications during pregnancy A client comes to an obstetric clinic for a routine prenatal
checkup at 32 weeks gestation. The nurse palpates the client's abdomen to determine fetal position so that fetal heart sounds can be assessed. It is determined that the fetal position is left occipital anterior (LOA). Where should the nurse place the Doppler to hear fetal heart sounds? 1. Correct: The point of maximal intensity of the fetus is on the mom's abdomen where the fetal heart tones (FHT) is the loudest, usually over the fetal back. Divide the mom's pelvis into 4 quadrants (right and left anterior and right and left posterior). The occiput of the head is the most common presenting part and is abbreviated O. The occiput and back are pressing against left side of mom's abdomen; FHT would be heard below umbilicus on left side. The nurse is teaching comfort measures to a postpartum client with an episiotomy and external hemorrhoids. Which teaching points should the nurse include? 1., 3., 4., 5., & 6. Correct: Ice causes vasoconstriction and is most effective if applied soon after the birth to prevent edema and to numb the area. Chemical ice packs or clean gloves filled with ice may be used during the first 12 hours after a vaginal birth. Witch hazel contains chemicals called tannins. When applied directly to the skin, witch hazel might help reduce swelling and help repair broken skin. Analgesics such as acetaminophen and nonsteroidal anti inflammatory drugs (NSAIDs) such as ibuprofen frequently are prescribed to provide relief for mild to moderate discomfort. Topical anesthetic may be used as needed to decrease surface discomfort and allow more comfortable ambulation. Sexual intercourse prior to healing of the episiotomy may contribute to further perineal damage. A nurse has provided postpartum discharge
instructions to a client who had a cesarean section. What statement by the client would indicate to the nurse that further teaching is necessary? 2. Correct: This is an incorrect statement. C-sections require a much longer recovery. The client will not have the abdominal muscles to press down on the brake pedal in an emergency. Therefore, new moms who had C-sections should wait until after the three week postpartum appointment to drive. The nurse is instructing expectant first-time mothers about the process of rooming-in while at the hospital. After discussing security protocols, one client asks the nurse what to do if no staff is available when
toileting or showering assistance is needed. The nurse knows teaching was successful when another client responds with what statement? 4. CORRECT. There are many safety and security measures implemented to diminish the potential for newborn abductions. At no time should a newborn ever be left alone, even in the mother's room. In the unlikely event no authorized staff can assist the client in the bathroom, the newborn should be wheeled by the mother into the bathroom and kept in view at all times. A nurse is caring for a multipara client in active labor who received morphine 4 mg IVP for pain. Thirty minutes later,
the client had a precipitous delivery. What should the nurse prepare to administer to the newborn? 2. Correct: The primary side effect of opioids is respiratory depression, which is more likely to affect the newborn. Naloxone reverses opioid-induced respiratory depression. This newborn will need naloxone to reverse the effects of the narcotic that was given to mom 30 minutes earlier. A client in active labor has an epidural catheter inserted for management of pain. Which finding should the nurse report to the primary health care provider? 3. Correct: Hypotension is an adverse effect of epidural analgesia due to vasodilation. Maternal hypotension reduces blood supply to the placenta, decreasing fetal oxygen supply. Immediate intervention is required. ... 1., 3., 4. & 5. Correct: Are all indicators of adequate fluid intake in a newborn. Gaining weight, a heart rate between 70 to 190 beats per minute (BMP), six to eight wet diapers a day and periods of contentment after feedings alternate with periods of wakefulness indicate adequate breast feeding. ... 2., & 5. Correct: False labor or Braxton Hicks contractions are mild, irregular frequency, and intermittent; decrease in frequency, duration, and intensity with walking or position changes; often stop with sleep or comfort measures such as oral hydration or emptying of the bladder. False labor contractions are typically felt as a tightening or pulling sensation of the top of the uterus. In contrast, true labor contractions are more commonly felt in the lower back and gradually sweep around to the lower abdomen. A pregnant client's initial blood work shows a negative rubella titer. The nurse is aware this result indicates what important course of action? 3. CORRECT: A negative titer indicates the client has no rubella antibodies present currently. But because the rubella vaccine contains a live virus, the client cannot be safely vaccinated until after delivery. ... 1, 4, & 5. Correct: The LPN scope of practice varies from state to state, although basic tasks are consistent. Taking vital signs, even initially, is among the tasks that can be delegated to the LPN. Other appropriate duties include collecting urine for ordered tests and even obtaining a vaginal swab. These can definitely be delegated to a licensed practical nurse. A client has delivered a set of premature twins. The neonatal intensive care unit (NICU) notifies the charge nurse on the postpartum floor the death of one infant is expected within the hour. What is the priority action by the charge nurse? 2. Correct: The priority action is to allow the mother to be with the infant and perhaps to hold the infant prior to demise to help in the grieving process. Escorting the mother immediately to the NICU can be accomplished by the UAP while the charge nurse initiates other actions needed by this client. What term should the nurse use to document that a woman is pregnant for the first time? 1. Correct: A woman pregnant for the first time. The prefix "primi" means first. "Gravida" refers to a woman who is or has been pregnant, regardless of the duration or outcome of the pregnancy. The nurse is working in the term nursery. Which task should be performed first on a newborn? 2. Correct: The APGAR is done to determine whether a newborn needs help breathing or is having heart trouble. It looks at the newborn's breathing effort, HR, muscle tone, reflexes, and skin color and is the most important initial assessment for a newborn ... 4. Correct: Check the FHR immediately following the rupture of membranes. Changes in FHR pattern such as bradycardia or variable decelerations may indicate prolapsed umbilical cord. ... 1. Correct: Quickening is the term used to refer to fetal movement when first sensed by the expectant mother. It is challenging for first time mothers to differentiate between actual fetal movement and other sensations, but usually between weeks 16 and 20, actual kicks or changes in fetal body position are noted by the mother. Sets found in the same folder*HURST REVIEW Qbank/Customize Quiz - Leadership50 terms Baiileytaylor NCLEX Studying56 terms holly_elizabeth47 Quiz customizer93 terms eric_thomas26 Reduction of Risk86 terms wagnej6420 Other sets by this creatorNIH Stroke Scale Group A Patient 1-66 terms Jessalyn_Blythe1 NCLEX-Leadership36 terms Jessalyn_Blythe1 NCLEX-Psych50 terms Jessalyn_Blythe1 NCLEX-Adult Health66 terms Jessalyn_Blythe1 Other Quizlet setsThe 1920s- Module and Reading Quiz20 terms Mteczon545 38-4811 terms Fjellape_ CPSC 4440 Final155 terms treich032894 Study Guide 5 bio13 terms minoguekl Related questionsQUESTION what are the types of narcotics 15 answers QUESTION What are the nursing interventions for nifedipine? 7 answers QUESTION What are some signs of cardiac decompensation? 9 answers QUESTION What is the other name for genital warts? 15 answers Which lab value on a client who is one day postpartum should the nurse report to the primary health care provider immediately?Which lab value on a client who is one day postpartum should the nurse report to the primary healthcare provider immediately? 3. Correct: A hematocrit in postpartum women can drop as low as 20% (0.2) and not require transfusion in the absence of symptoms of hypovolemia.
When making a visit to the home of a postpartum woman one week after birth the nurse should recognize that the woman would characteristically?One week after birth the woman should exhibit behaviors characteristic of the taking-hold stage. This stage lasts for as long as 4 to 5 weeks after birth.
When assessing a mother 12 hours following the delivery of a baby where should the nurse expect to palpate the fundus?Immediately after delivery, the upper portion of the uterus, known as the fundus, is midline and palpable halfway between the symphysis pubis and the umbilicus. By approximately one hour post delivery, the fundus is firm and at the level of the umbilicus.
Which finding would indicate a baby who may be considered preterm?Key points about prematurity
Babies born before 37 weeks of pregnancy are considered premature or born too early. Many premature babies also weigh less than 5 pounds, 8 ounces (2,500 grams).
|
Which lab value on a client who is one day postpartum should the nurse report to the primary healthcare provider immediately?
Urheberrechte © © 2024 ketiadaan Inc.
