RNSG 1300 Exam Chapter 27 Questions & Answers

RNSG 1300 Exam Chapter 27 Questions & Answers Ch 27 1. A nurse is caring for a newborn shortly after birth and places the newborn under a radiant warmer. Which of the following potential complications does this action help to prevent? Cold stress 2. A nurse is assisting with the care of a client who is in labor. Immediately after delivery of a newborn, which of the following actions should the nurse take first? Dry the newborn 3. A nurse is caring for a client who is postpartum and is breastfeeding her infant. Which of the following findings indicates mastitis? Red and painful area in one breast 4. A nurse is preparing to examine a post-term newborn immediately following delivery. Which of the following findings should she expect to observe? (Select all that apply) Cracked, peeking skin, and Moro reflex 5. A nurse is preparing to administer vitamin K IM to a newborn. Into which of the following muscles should the nurse inject the medication? Vastus lateralis 6. A nurse is caring for a newborn whose mother is positive for the hepatitis B surface antigen. Which of the following treatments should the nurse receive? Hepatitis B immune globulin and the hepatitis B vaccine within 12 hr of birth 7. A nurse is assisting with the care of a client who is receiving oxytocin via IV infusion following a vaginal delivery. Which of the following findings should the nurse monitor to evaluate effectiveness of this medication? Fundal consistency 8. A nurse is caring for a client 2 hr following a spontaneous vaginal delivery and notes that the client has saturated two perineal pads with blood in a 30 min period. Which of the following actions should the nurse take first? Check the consistency of the client’s uterine fundus 9. A nurse is reinforcing discharge teaching with a client who is 2 days postpartum and has a history of postpartum depression. Which of the following instructions should the nurse include? Sleep as much as possible 10. A nurse is assisting in the care of a newborn immediately following birth. The nurse notes mucus bubbling out of the newborn’s mouth and nose. Which of the following actions should the nurse take first? Suction the newborn’s mouth with a bulb syringe 11. A nurse is caring for a client who is postpartum. The nurse should recognize which of the following statements by the client as a possible indication of inhibition of parental attachment? I just wish he had more hair. I’m going to have to keep a hat on his head till he grows some. 12. A nurse on the postpartum unit is planning to delegate client care to an assistive personnel (AP). Which of the following tasks should the nurse plan to delegate to the AP? Provide a sitz bath to a client who has a fourth-degree laceration and is 2 days postpartum 13. A nurse is preparing to administer vitamin k 1mg IM to a newborn. Available is vitamin k injection 1mg/0.5mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) 0.5 14. A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the baby’s mouth, which of the following responses by the nurse is appropriate? You should place your nipple and some of the areola into her mouth. 15. A nurse is reinforcing discharging teaching with a client who is 2 days postpartum. Which of the following statements should the nurse include in the teaching? If you breastfeed your newborn, expect two to three stools per day. 16. A home health care nurse is reinforcing teaching about breast engorgement with a client who is postpartum and is breastfeeding her newborn. Which of the following client statements indicates an understanding of the teaching? I’ll feed my baby every 2 hours 17. A nurse is reinforcing teaching with a group of clients about nutritional requirements during lactation. Which of the following nutrients should the nurse instruct the clients to increase? Zinc 18. A nurse is reinforcing teaching about crib safety with the parent of a newborn. Which of the following statements by the parent indicates an understanding of the teaching? I will warm the crib sheets before putting my baby to bed 19. A nurse is caring for a newborn immediately following delivery. After assuring a patient airway, which of the following actions should be the nurse’s priority? Dry the newborn 20. A nurse is assisting in the care of a newborn shortly after birth. Which of the following actions should the nurse take to assist in the prevention of hyperbilirubinemia? Initiate early feeding 21. A nurse is collecting data from a client who is 1 day postpartum. Which of the following findings requires intervention by the nurse? Displaced fundus from the midline 22. A nurse is assisting a client with breastfeeding her newborn. The nurse should explain that which of the following reflexed will initiate sucking? Rooting 23. A nurse is collecting data from a newborn who is 12 hr old. His representation rate is 44/min, shallow, with periods of apnea lasting up to 5 seconds. Which of the following actions should the nurse take? Continue routine monitoring 24. A nurse is collecting data from a client who gave birth one week ago. Which of the following findings should the nurse identify as a manifestation of endometritis? Pelvic pain 25. A nurse is reinforcing discharge teaching about circumcision care with the parent of a newborn who had a circumcision using the plastibell device. Which of the following client statements indicates an understanding of the teaching? (Select all that apply). I’ll expect the plastic ring to fall off by itself within a week, I’ll call the doctor if I see any bleeding, and I’ll make sure his diaper is loose in the front. 26. A nurse is caring for a client who has unrelieved episiotomy pain 8 hr following delivery. Which of the following actions should the nurse take? Apply an ice pack to the perineum 27. A nurse is reinforcing teaching about umbilical cord care with a client who is postpartum. Which of the following instructions should the nurse include? The stump should fall off in 10 to 14 days 28. A nurse is assisting with the care of a newborn immediately following birth. Which of the following medications should the nurse expect to administer? (select all that apply) Phytonadione injection, Hepatitis B, antibiotic ophthalmic ointment 29. A nurse is collecting data from a client who is postpartum 2 hr following delivery of a healthy newborn. Which of the following findings indicates the client’s bladder is distended? Elevated fundus level 30. A nurse is collecting data from a client who is 12 hr postpartum. Which of the following findings should the nurse expect? Fundus firm at the level of the umbilicus 31. A nurse who is caring for a newborn observes signs of respiratory distress, jitteriness, and lethargy. Which of the following actions should the nurse take? Obtain blood glucose by heel stick 32. A nurse is collecting data from a newborn and notes a swollen area on the head that does not cross the suture line. The nurse should document this finding as which of the following? Cephalhematoma 33. A nurse is reinforcing teaching with a client who has genital herpes. Which of the following client statements should the nurse identify as understanding of the teaching? The lesions can spread to other areas of my body 34. A nurse is collecting data from a postpartum client and notes the client’s fundus is boggy and displaced to the right. Which of the following actions should the nurse take? Assist the client to the bathroom to void 35. A nurse is reinforcing teaching with a parent about using an iron fortified formula to feed her newborn. Which of the following information should the nurse include in the teaching? The newborn’s iron source will start to deplete 36. A nurse is caring for a client who is postpartum. The client states, “ I am concerned about my baby’s hearing because my mother was born deaf” Which of the following statements should the nurse make? We do routine hearing screenings on newborns. You’ll know the results before you leave the hospital. 37. A nurse is caring for a client who is 1 day postpartum following a cesarean birth. To prevent thrombophlebitis, the nurse should contribute which of the following interventions to the client’s plan of care? Have the client ambulate frequently in the hallway. 38. A nurse is assessing a client who is 8hr postpartum and multiparous. Which of the following findings should alert the nurse to the client’s need to urinate? Fundus three fingerbreadths above the umbilicus 39. A nurse is caring for a postpartum client following a vaginal birth of a newborn weighing 4252 (9 lb 6 oz). The nurse should identify that this client is at risk for which of the following postpartum complications? Uterine atony 40. A nurse is collecting data form a client who is postpartum. Which of the following findings should alert the nurse to the possibility of a postpartum complication? HR 110/min 41. A nurse is collecting data from a client who is 14 hr postpartum. The nurse notes: breasts soft; fundus firm, slightly deviated to the right; moderate lochia rubra; temperature 37.7 C (100 F), pulse rate 88/min, rr 18/min. Which of the following actions should the nurse perform? Ask the client to empty her bladder 42. A nurse is assisting in the care of a client who is experiencing sore nipples from breastfeeding. Which of the following actions should the nurse take? Encourage the client to change the newborn’s position with each feeding