Question 1.
A nurse on the postpartum unit is caring for a client following a
cesarean birth. Which of the following assessments is the
... [Show More] nurse’s
priority?
Amount of lochia
- When using the airway, breathing, circulation approach to
client care, the nurse should place the priority in the
immediate postpartum period on assessing the amount of
postpartum lochia. The greatest risk to the client is bleeding
and postpartum hemorrhage.
Question 2.
A nurse is caring for a client who is in labor and whose fetus is in
the right occiput posterior position. The client is dilated to 8 cm
and reports back pain. Which of the following actions should the
nurse take?
Apply sacral counter pressure
- Sacral counter pressure assists in relieving back labor pain
related to fetal posterior position.
Question 3.
A nurse is demonstrating to a client how to bathe her newborn. In
which order should the nurse perform the following actions?
Wipe the newborn’s eyes from the inner canthus outward. Wash the
newborn’s neck by lifting the newborn’s chin. Cleanse the skin
around the newborn’s umbilical cord stump. Wash the newborn’s
legs and feet. Clean the newborn’s diaper area.
- Use a head to toe, clean to dirty approach when washing a
newborn.
Question 4.
A nurse is caring for a client and her partner who have
experienced a fetal death. Which of the following actions should
the nurse take?
Take photos of the newborn to give to the parents.
- The nurse should create a memory box that includes
mementos of the newborn (ex: photos, the newborn’s ID
bands, the newborn’s hat, & the newborn’s blanket).
Question 5.
A nurse is caring for a client who is at 36 weeks of gestation
and has a positive contraction stress test. The nurse should
plan to prepare the client for which of the following
diagnostic tests?
Biophysical profile
- A positive contraction stress test indicates that further
evaluation of the fetus is necessary (baby’s heart slowed or
showed abnormality during contraction). A biophysical
profile will provide further evaluation with real-time
ultrasound.
Question 6.
A nurse is reviewing the medical record of a client who is
postpartum and has preeclampsia. Which of the following
laboratory results should the nurse report to the provider?
Platelets 50,000/mm3
- A platelet count of 50,000/mm3 is below the expected
reference range, which can indicate disseminated
intravascular coagulation. The nurse should report this result
to the provider.
Question 7.
A nurse is assessing a newborn who was born at 26 weeks of
gestation using the New Ballard Score. Which of the following
findings should the nurse expect?
Minimal arm recoil
- The nurse should expect a newborn who was born at 26
weeks gestation to have decreased muscular tone, or
minimal arm recoil.
Question 8.
A nurse is assessing a newborn following circumcision. Which of
the following findings should the nurse identify as an indication
that the newborn is experiencing pain?
Chin quivering
- Behavioral responses to a newborn’s pain include facial
expressions (ex: chin quivering, grimacing, & furrowing of
the brow).
Question 10.
A nurse is assessing the newborn of a client who took a selective
serotonin reuptake inhibitor (SSRI) during pregnancy. Which of the
following manifestations should the nurse identify as an indication
of withdrawal from an SSRI?
Vomiting
- Expected clinical manifestations associated with fetal exposure
to SSRIs include irritability, agitation, tremors, diarrhea, & vomiting.
These usually last 2 days. [Show Less]