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NURS368 Exam 1 Questions With Answers
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Which is the priority nursing action during the immediate postpartum period? A: Palpate fundus B: Check pain level C: Perform pericare D: Assess breasts - ANSWER A: Palpate fundus What is your next assessment after assessing the breasts during postpartum care? A: Palpate uterus B: Palpate bladder C: Listen to bowel sounds D: Listen to lung sounds - ANSWER C: Listen to bowel sounds What is a normal assessment 4 days postpartum? A: Fundus 1 cm above, lochia rosa B: Fundus 4 cm above, lochia alba C: Fundus 2 cm below, lochia rubra D: Fundus 4 cm below, lochia serosa - ANSWER D: Fundus 4 cm below, lochia serosa Which of the following full-term newborns requires immediate intervention? A: Baby with seesaw breathing B: Baby with irregular breathing with 10-second pauses C: Baby with coordinated thoracic and abdominal breathing D: Baby with a respiratory rate of 52 - ANSWER A: Baby with seesaw breathing Which set of vitals are normal for this quiet, awake, term newborn? A: RR-45, HR- B: RR-58, HR-
C: RR-20, HR-
D: RR-40, HR-148 - ANSWER D: RR-40, HR-
A baby just delivered. Which of the following physiological changes is of highest priority? A: Thermoregulation B: Spontaneous respirations C: Extrauterine circulatory shift D: Successful feeding - ANSWER B: Spontaneous respirations A mother and her 2-day old baby are preparing for discharge. Which of the following situations would be reason for the baby's discharge to be cancelled? A: The baby's temperature is 97.8 F B: The baby's TSB is 19 mg/dL C: The baby's blood glucose is 59 mg/dL D: The baby's respirations are irregular - ANSWER B: The baby's TSB is 19 mg/dL Which breast assessment finding is most effective for breastfeeding? A: Inverted nipples B: Everted nipples C: Flat nipples D: Large nipples - ANSWER B: Everted nipples True or false: Breastfed infants are more likely to become constipated than formula-fed infants. A: True B: False - ANSWER B: False What is the most common allergy seen in infants? A: Formula B: Breastmilk C: Cow's milk D: Honey - ANSWER C: Cow's milk
What hormone stimulates breast milk production?
A: Estrogen B: Progesterone C: Prolactin D: Oxytocin - ANSWER C: Prolactin
How much weight loss is considered normal for a baby to lose within the first couple days after birth?
A: Up to 2% of birth weight B: Up to 7% of birth weight C: Up to 10% of birth weight D: Up to 15% of birth weight - ANSWER C: Up to 10% of birth weight
A woman has a 5 y/o son, a 3 y/o daughter, and is pregnant again. What is her G/P? - ANSWER 3/
A patient has twin boys who are 4 y/o. She is pregnant again. What is her G/P? - ANSWER 2/
A pregnant woman reports having had a SAB at 13 weeks, a delivery of a preterm infant and then two deliveries of full-term healthy infants. What is her G/P? - ANSWER 5/
A woman is pregnant for the second time. She has a 2 y/o son at home. What is her G/P?
A woman is in her 7th month of her first pregnancy. What is her G/P? - ANSWER 1/
A woman has just given birth to her first baby at term. What is her G/P? - ANSWER 1/
Mary is pregnant. She previously had a miscarriage at 11 weeks gestation. Then, she had twins at 32 weeks gestation, both of whom die 2 days after birth. What is her GTPAL and G/P? - ANSWER GTPAL: 3/0/2/1/ G/P: 3/
Sally had a baby at 38 weeks gestation. Then, she had twins at 36 weeks gestation who both did well. She had an elective abortion at 8 weeks gestation many years ago. Sally is currently pregnant again, with twins. What is her GTPAL and G/P? - ANSWER GTPAL: 4/1/2/1/ G/P: 4/
Nancy gave birth to twins at 38 weeks gestation, both of whom did fine. Two years later she had a singleton birth at 41 weeks gestation. Two years after that she had another baby born on its due date. What is her GTPAL and G/P? - ANSWER GTPAL: 3/4/0/0/ G/P: 3/
Which is NOT a result of decreased body temperature and cold stress in the newborn?
A: Increased metabolic rate B: Decreased metabolic rate C: Metabolism of brown fat D: Vasoconstriction - ANSWER B: Decreased metabolic rate
Your patient delivered a full-term baby 12 hours ago. The woman and her husband, who are in their early 20s, have just been informed by their pediatrician that their baby has trisomy 21 (Down syndrome). This is their first child and they did not have prenatal genetic testing. You nursing care will include (Select all that apply):
B: The 3rd week of gestation C: The 4th week of gestation D: The 5th week of gestation - ANSWER C: The 4th week of gestation
Which placental hormone is responsible for regulating glucose availability to the fetus?
A: Progesterone B: Estrogen C: hCG D: hPL - ANSWER D: hPL
The appropriate recommended weight gain during pregnancy for a woman with a normal BMI is:
A: 10-15 lbs B: 6-20 lbs C: 21-25 lbs D: 25-35 lbs - ANSWER D: 25-35 lbs
Presumptive signs of pregnancy are:
A: All the objective signs of pregnancy B: Those perceived by the healthcare provider C: Physiological changes perceived by the woman herself D: Those attributed to the fetus - ANSWER C: Physiological changes perceived by the woman herself (?)
Physiological changes in pregnancy:
A: Involve primarily reproductive organs B: Are protective of the woman and/or fetus C: Are most profound in the first trimester D: Primarily impact the musculoskeletal system - ANSWER B: Are protective of the woman and/or fetus
RhoGAM would be administered during pregnancy at 28 weeks gestation to women with the following blood type:
A: O+ B: O- C: A+ D: AB - ANSWER B: O-
Blood volume increases during pregnancy by:
A: 20-30% B: 30-40% C: 40-50% D: 50-60% - ANSWER C: 40-50%
Which of the following lab results indicates anemia?
A: Hgb 11. B: Hgb 10 C: HCT 34% D: HCT 38% - ANSWER B: Hgb 10
C: Baseline rate of 150 bpm, decreased variability, no fetal heart rate decelerations D: Baseline rate of 130 bpm, average variability, decreases after uterine contractions - ANSWER B: Baseline rate of 150 ppm, moderate variability, accelerations to 170 bpm for 20 seconds
Potential causes of late decelerations include:
A: Maternal fever B: Umbilical cord compression C: Uteroplacental insufficiency D: Fetal activity - ANSWER C: Uteroplacental insufficiency
The goal of maternal position changes for a prolonged deceleration is:
A: Maximizing uterine blood flow B: Increasing uterine contractions C: Maximizing maternal oxygenation D: Increasing maternal movement - ANSWER A: Maximizing uterine blood flow
Increased information provided by assessment of uterine contractions with an intrauterine pressure catheter includes:
A: Frequency, duration, intensity, and resting tone B: Frequency, duration, and intensity C: Intensity only D: Labor progress - ANSWER A: Frequency, duration, intensity, and resting tone
Fetal heart rate should be assess in a low-risk woman in active labor:
A: Every 5 mins B: Every 10 mins C: Every 15 mins D: Every 30 mins - ANSWER D: Every 30 mins
Variable decelerations are typically related to:
A: Cord compression B: Head compression C: Uteroplacental insufficiency D: Uterine hyperstimulation due to hypovolemia - ANSWER A: Cord compression
Nursing interventions related to late decelerations include all of the following EXCEPT:
A: Initiate pitocin induction B: Initiate IV bolus C: Change maternal position D: Initiate oxygen therapy - ANSWER A: Initiate pitocin induction
Teaching regarding the care of the newborn begins:
A: During pregnancy B: Within a few hours after delivery C: 12 hrs after delivery D: The day of discharge - ANSWER A: During pregnancy
the nipple full of formula and decrease the amount of air your baby swallows"
Contraindications for breastfeeding include which of the following? (Select all that apply):
A: Woman is using cocaine B: Woman is being treated for mastitis C: Woman is receiving chemotherapy for lymphoma D: Infant has thrush - ANSWER C: Woman is receiving chemotherapy for lymphoma
Which of the following are true statements regarding the let-down reflex? (Select all that apply):
A: Contractions of the myoepithelial cells forces milk into the duct system B: Oxytocin is released in response to infant suckling and woman's emotions C: It can occur during sexual arousal D: It occurs multiple times during feeding session - ANSWER A: Contractions of the myoepithelial cells forces milk into the duct system B: Oxytocin is released in response to infant suckling and woman's emotions C: It can occur during sexual arousal D: It occurs multiple times during feeding session
You observe that a 2-day postpartum woman is having difficulty breastfeeding. Her baby is crying and moving his head from side to side. Your first nursing action is to:
A: Assist the woman into a comfortable position B: Assist the woman in calming her baby C: Show the woman how to properly position the baby D: Tell the woman that her baby is not hungry and to wait a few hours - ANSWER B:
Assist the woman in calming her baby
Labor pain in active labor is primarily caused by:
A: Cervical dilation B: Uterine contractions C: Fetal descent D: Perineal tearing - ANSWER B: Uterine contractions
Passenger, as one of the 4 P's of labor, refers to:
A: The position of the mother B: The passage of the vagina C: The fetal descent in the pelvis D: The fetus - ANSWER D: The fetus
An involuntary urge to push is most likely a sign of:
A: Malposition of the fetus B: Transition to active labor C: Low fetal station D: Imminent delivery - ANSWER C: Low fetal station
False labor is characterized by:
A: Irregular uterine contractions and cervical change B: Back pain that radiates to the lower abdomen
B: Placenta previa C: Woman's desire to have a CS vs. vaginal birth D: Obstetrician preference for a CS delivery - ANSWER C: Woman's desire to have a CS vs. vaginal birth
The experiences of a CS birth parents differ from those of vaginal birth parents in which of the following?
A: Emotional responses to the childbirth experience B: Ability to breastfeed C: Nutritional needs D: Maternal hormonal changes - ANSWER A: Emotional responses to the childbirth experience
A common indication for an urgent surgical birth includes:
A: Fetal intolerance of labor B: Posterior vertex position C: Failed assisted vaginal birth without fetal stress D: Maternal request for the procedure - ANSWER A: Fetal intolerance of labor
Your patient, who gave birth to a 7-lb baby boy two hours ago, is complaining of uterine cramping (after-pains). This is her second baby and she is breastfeeding. Your assessment reveals a firm fundus at midline at 1 cm below the umbilicus. Select all of your initial nursing actions:
A: Instruct the pt. to bottle-feed for 36 hrs or until the cramping has stopped B: Place a warm blanket on her abdomen C: Explain that these are normal for second-time mothers to experience
D: Offer the pt. acetaminophen with codeine so she can continue to breastfeed - ANSWER B: Place a warm blanket on her abdomen C: Explain that these are normal for second-time mothers to experience
Your patient gave birth to a 6-lb baby girl 6 hrs ago. It was a spontaneous delivery. You note on your assessment of her perineum that there is some edema and slight bruising. She stated that her pain was at 1 on the pain scale. Your nursing action would be to:
A: Continue applying ice to the perineum B: Assist her with a sitz bath C: Encourage her to keep her bladder empty D: Administer ibuprofen 800 mg - ANSWER A: Continue applying ice to the perineum
To decrease the risk of orthostatic hypotension during the first few hours after the birth, the nurse should:
A: Assist the pt. to the bathroom by using a wheelchair B: Break open and ammonia ampule and have the pt. take a deep breath before getting up C: Have the pt. sit on the side of the bed for a few mins before standing D: Check the pt. BP before assisting her to the bathroom - ANSWER C: Have the pt. sit on the side of the bed for a few mins before standing
Select the statements that are true regarding primary engorgement:
A: Only women who are lactating will experience primary engorgement B: It is caused by an increase in the vascular and lymphatic system of the breast C: The breasts become large, firm, and warm to touch D: It subsides within 24-36 hrs - ANSWER B: It is caused by an increase in the vascular and lymphatic system of the breast
C: Insert an indwelling Foley catheter D: Palpate for bladder distension - ANSWER D: Palpate for bladder distension
A pt. who delivered vaginally and has a 3rd-degree laceration is being prepared for discharge. Which of the following instructions should the nurse include in her discharge teaching? (Select all that apply):
A: Drink at least 2 liters of fluid a day B: Ambulate several times a day C: Eat plenty of whole grain foods, and fruits and vegetables D: Use suppositories to help promote regular, soft bowel movements - ANSWER A: Drink at least 2 liters of fluid a day B: Ambulate several times a day C: Eat plenty of whole grain foods, and fruits and vegetables
Your postpartum pt. is 10 hrs post-birth. She experienced an uncomplicated labor and birth and her newborn is full term with Apgar scores of 9 at 1 min and 9 at 5 mins. During your assessment, you note that she was hungry and very interested in telling you about her birth experience. You had to remind her to change her baby's diaper and to feed her baby. Based on this assessment you determine that she is:
A: Having difficulty bonding with her baby B: Not concerned about her baby's needs C: In the taking-in phase D: In the taking-hold phase - ANSWER C: In the taking-in phase
Which 2 day postpartum woman has an abnormal finding that requires intervention?
A: A 23 year old Arabic woman who plans to breastfeed but wants to bottle feed until her milk comes in
B: A 28 year old Chinese woman who refuses to take a shower. C: A 20 year old Japanese woman who has her mother care for her baby. D: A 19 year old Caucasian woman who requests that her baby stay in the nursery so she can sleep. - ANSWER D: A 19 year old Caucasian woman who requests that her baby stay in the nursery so she can sleep.
Your pt. is a 25-yr-old gravida 1 woman who is 2 hrs postpartum. You note on assessment that her fundus is firm and midline. She is experiencing a steady stream of blood. The bed linen under her is soaked in blood. Based on these findings and observations, you suspect that she is exhibiting early S/Sx of a PPH related to:
A: Uterine atony B: Laceration of the cervical or vaginal area C: Retained placental tissue D: Fibroids - ANSWER B: Laceration of the cervical or vaginal area
Mrs. Fischer is 4 days post birth. She calls the clinic and tells the triage nurse that she has a temperature and does not feel well. What additional assessment findings does the triage nurse need to obtain to assist in her nursing assessment? (Select all that apply):
A: When did she notice an increase in temperature and what is her temperature? B: Is she experiencing pain, and if so, where is it located? C: What is the amount of her fluid intake within the past 24 hrs? D: What is the color and amount of her bleeding? - ANSWER A: When did she notice an increase in temperature and what is her temperature? B: Is she experiencing pain, and if so, where is it located? C: What is the amount of her fluid intake within the past 24 hrs? D: What is the color and amount of her bleeding?
Foul-smelling lochia occurs:
