COMPREHENSIVE QUESTIONS AND
ANSWERS
◉A breastfeeding infant, screened for congenital hypothyroidism, is
found to have low levels of thyroxine (t4) and high levels of thyroid
stimulating hormone (TSH)/ What is the best explanation for this
finding?
A. The thyroxine level is low because the TSH level is high.
B. High thyroxine levels normally occur in breastfeeding infants.
C. The thyroid gland does not produce normal levels of thyroxine for
several weeks after birth
D. The TSH is high because of the low production of T4 by the
thyroid.. Answer: D. The TSH is high because of the low production
of T4 by the thyroid.
◉The nurse is assessing a 2-hour-old infant born by cesarean
delivery at 39-weeks gestation. Which assessment finding should
receive the highest priority when planning this infants care?
A. Blood pressure 76/42 mm/Hg
B. Faint heart murmur
,C. Respiratory rate 76 breaths/min
D. Blood glucose 45 mg/dl. Answer: C. Respiratory rate 76
breaths/min
◉At 20-weeks gestation, a client who has gained 20 pounds during
this pregnancy tells the nurse that she is feeling fetal movement.
Fundal height measurement is 20 cm, and the clients only complaint
is that her breasts are leaking clear fluid. Which assessment finding
warrants further evaluation?
A. Presence of fetal movements.
B. Gestational weight gain
C. Fundal height measurement
D. Leakage from breasts. Answer: B. Gestational weight gain
◉The nurse is planning discharge teaching for a client who had an
evacuation of gestational
trophoblastic disease (GTD) two days ago. Which information is
most important for the nurse to
include in this client's teaching plan?. Answer: Oral contraceptive
use for at least one year.
◉A pregnant woman in the first trimester of pregnancy has a
hemoglobin of 8.6 mg/dl and a hematocrit of 25.1%. What food
should the nurse encourage this client to include in her diet?
,A. Carrots
B. Chicken
C. Yogurt
D. Cheese. Answer: B. Chicken
◉The newborn nursery admission protocol includes a prescption
for phytonadione (Vitamin K1, AquaMEPHYTON) 0.5 mg IM to
newborns upon admission. The ampoule provides 2 mg/ml. How
many ml should the nurse administer?. Answer: 0.3
◉The nurse places one hand above the symphysis while massaging
the fundus of a multiparous client
whose uterine tone is boggy 15 minutes after delivering a 7 pound
10 ounce infant. Which information
should the nurse provide the client about this finding?. Answer: Both
the lower uterine segment and the fundus must be massaged.
◉The nurse is preparing to administer methylergonovine maleate
(Methergine)
to a postpartum client. Based on what assessment finding should the
nurse
withhold the drug?
A. Respiratory rate of 22 breaths/min
B. A large amount of lochia rubra
, C. Blood pressure 149/90
D. Positive Homan's sign. Answer: C. Blood pressure 149/90
◉At 6-weeks gestation, the rubella titer of a client indicates she is
non-immune. When is the best time
to administer a rubella vaccine to this client?. Answer: Early
postpartum, within 72 hours of delivery.
◉A client receiving oxytocin (Pitocin) to augment early labor. Which
assessment is most important for the nurse to obtain each time the
infusion rate
is increased?
A. Pain level
B. Blood pressure
C. Infusion site
D. Contraction pattern. Answer: D. Contraction pattern.
◉A client delivers a viable infant , but begins to have excessive
uncontrolled vaginal .. notifying the healthcare provider of the
clients condition ,What information is most important
A. Maternal blood pressure
B. Maternal apical pulse
C. Time pitocin infusion completed