NURS 3610 Quiz 2 QUESTIONS WITH |\ |\ |\ |\ |\ |\
ANSWERS
A nurse is observing the electronic fetal heart rate monitor tracing for a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
client who is at 40 weeks of gestation and is in labor. The nurse should
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
suspect a problem with the umbilical cord when she observes which of the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
following patterns? |\
A. Early decelerations
|\ |\
B. Accelerations
|\
C. Late decelerations
|\ |\
D. Variable decelerations - CORRECT ANSWERS ✔✔D. Variable
|\ |\ |\ |\ |\ |\ |\ |\
decelerations
Variable decelerations occur when the umbilical cord becomes compressed
|\ |\ |\ |\ |\ |\ |\ |\ |\
and disrupts the flow of oxygen to the fetus.
|\ |\ |\ |\ |\ |\ |\ |\
* Think VEALCHOP
|\ |\
A nurse in the newborn nursery is caring for a group of newborns. Which of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the following newborns requires immediate intervention?
|\ |\ |\ |\ |\ |\
A. A newborn who is 24 hr post-delivery and has not voided.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
B. A newborn who is 18 hr post-delivery and has acrocyanosis
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
C. A newborn who is 24 hr post-delivery and has not passed meconium
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
,D. A newborn who is 12 hr post-delivery and has a temperature of 37.5C
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
(99.5F) - CORRECT ANSWERS ✔✔D. A newborn who is 12 hr post-delivery
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
and has a temperature of 37.5C (99.5F)
|\ |\ |\ |\ |\ |\ |\
Hyperthermia in the newborn requires immediately intervention. |\ |\ |\ |\ |\ |\ |\
Hyperthermia is typically caused by increased heat production related to
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
sepsis or decreased heat loss.
|\ |\ |\ |\
A nurse is assessing a client who is 12hr postpartum and received spinal
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
anesthesia for a cesarean birth. Which of the following findings requires
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
immediate intervention by the nurse? |\ |\ |\ |\
A. Blood pressure 100/70 mmHg
|\ |\ |\ |\
B. Headache pain rated 6 on a scale of 0 to 10
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
C. Respiratory rate 10/min
|\ |\ |\
D. Urinary output 30mL/hr - CORRECT ANSWERS ✔✔C. Respiratory rate
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
10/min
A client who has received spinal anesthesia is at risk for respiratory
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
depression and hypotension. A respiratory rate of 10/min indicates
|\ |\ |\ |\ |\ |\ |\ |\ |\
bradypnea and requires immediate intervention. |\ |\ |\ |\
A nurse is caring for a client who has just delivered her first newborn. The
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
nurse anticipates hyperbilirubinemmia due to Rh incompatibility. The nurse
|\ |\ |\ |\ |\ |\ |\ |\ |\
should understand that hyperbilirubinemia occurs with Rh incompatibility
|\ |\ |\ |\ |\ |\ |\ |\
for which of the following reasons?
|\ |\ |\ |\ |\
,A. The client's blood does not contain the Rh factor, she she produces anti-
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
Rh antibodies that cross the placental barrier and cause hemolysis of red
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
blood cells in newborns. |\ |\ |\
B. The client' blood contains the Rh factor and the newborn's does not and
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
antibodies that destroy red blood cells are formed in the fetus.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
C. The client has a history of receiving a transfusion with Rh-negative blood.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
D. The client's anti-A and anti-B antibodies cross the placenta and cause the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
destruction of the fetal red blood cells. - CORRECT ANSWERS ✔✔A. The
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
client's blood does not contain the Rh factor, she she produces anti-Rh
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
antibodies that cross the placental barrier and cause hemolysis of red blood
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
cells in newborns. |\ |\
If the Rh-negative client has been exposed to Rh-positive fetal blood, she will
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
produce antibodies against Rh factor. These antibodies can cross the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
placenta and destroy the red blood cells of the Rh-positive fetus. This
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
accelerated rate of red blood cell destruction results in the increased release
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
of bilirubin. The newborn's serum bilirubin level can rise quickly.
|\ |\ |\ |\ |\ |\ |\ |\ |\
A nurse is teaching a newborn's parent to care for the umbilical cord stump.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
Which of the following instructions should the nurse include?
|\ |\ |\ |\ |\ |\ |\ |\
A. Wash the cord daily with mild soap and water.
|\ |\ |\ |\ |\ |\ |\ |\ |\
B. Cover the cord with the diaper.
|\ |\ |\ |\ |\ |\
C. Apply petroleum jelly to the cord stump.
|\ |\ |\ |\ |\ |\ |\
D. Give a sponge bath until the cord stump falls off. - CORRECT ANSWERS
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
✔✔D. Give a sponge bath until the cord stump falls off.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
, Immersing the umbilical cord stump in water can delay the process of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
drying, separation, and healing. Sponge baths are appropriate until the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
stump falls off. |\ |\
A nurse is caring for a client who is postpartum. The client tells the nurse
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
that the newborn's maternal grandmother was born deaf and asks how to tell
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
if her newborn hears well. Which of the following statements should the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
nurse make? |\
A. "There is no need to worry about that. Most forms of hearing loss are not
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
inherited."
B. "Look at how she looks at you when you speak. That's a good sign."
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
C. "We do routine hearing screenings on newborns. You'll know the results
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
before you leave the hospital." |\ |\ |\ |\
D. "The best way to determine if your baby can hear is to clap your hands
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
loudly and see if she startles." - CORRECT ANSWERS ✔✔C. "We do routine
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
hearing screenings on newborns. You'll know the results before you leave the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
hospital."
|\
Most states mandate hearing screening for all newborns. The two tests in use
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
do not diagnose hearing loss, but determine whether or not a newborn
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
requires further evaluation. |\ |\
A nurse is caring for a client who is beginning to breastfeed her newborn
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
after delivery. The new mother states, "I don't want to take anything for pain
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
because I am breastfeeding." Which of the following statements should the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
nurse make? |\
A. "You need to take pain medications so you are more comfortable."
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
ANSWERS
A nurse is observing the electronic fetal heart rate monitor tracing for a
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
client who is at 40 weeks of gestation and is in labor. The nurse should
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
suspect a problem with the umbilical cord when she observes which of the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
following patterns? |\
A. Early decelerations
|\ |\
B. Accelerations
|\
C. Late decelerations
|\ |\
D. Variable decelerations - CORRECT ANSWERS ✔✔D. Variable
|\ |\ |\ |\ |\ |\ |\ |\
decelerations
Variable decelerations occur when the umbilical cord becomes compressed
|\ |\ |\ |\ |\ |\ |\ |\ |\
and disrupts the flow of oxygen to the fetus.
|\ |\ |\ |\ |\ |\ |\ |\
* Think VEALCHOP
|\ |\
A nurse in the newborn nursery is caring for a group of newborns. Which of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
the following newborns requires immediate intervention?
|\ |\ |\ |\ |\ |\
A. A newborn who is 24 hr post-delivery and has not voided.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
B. A newborn who is 18 hr post-delivery and has acrocyanosis
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
C. A newborn who is 24 hr post-delivery and has not passed meconium
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
,D. A newborn who is 12 hr post-delivery and has a temperature of 37.5C
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
(99.5F) - CORRECT ANSWERS ✔✔D. A newborn who is 12 hr post-delivery
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
and has a temperature of 37.5C (99.5F)
|\ |\ |\ |\ |\ |\ |\
Hyperthermia in the newborn requires immediately intervention. |\ |\ |\ |\ |\ |\ |\
Hyperthermia is typically caused by increased heat production related to
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
sepsis or decreased heat loss.
|\ |\ |\ |\
A nurse is assessing a client who is 12hr postpartum and received spinal
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
anesthesia for a cesarean birth. Which of the following findings requires
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
immediate intervention by the nurse? |\ |\ |\ |\
A. Blood pressure 100/70 mmHg
|\ |\ |\ |\
B. Headache pain rated 6 on a scale of 0 to 10
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
C. Respiratory rate 10/min
|\ |\ |\
D. Urinary output 30mL/hr - CORRECT ANSWERS ✔✔C. Respiratory rate
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
10/min
A client who has received spinal anesthesia is at risk for respiratory
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
depression and hypotension. A respiratory rate of 10/min indicates
|\ |\ |\ |\ |\ |\ |\ |\ |\
bradypnea and requires immediate intervention. |\ |\ |\ |\
A nurse is caring for a client who has just delivered her first newborn. The
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
nurse anticipates hyperbilirubinemmia due to Rh incompatibility. The nurse
|\ |\ |\ |\ |\ |\ |\ |\ |\
should understand that hyperbilirubinemia occurs with Rh incompatibility
|\ |\ |\ |\ |\ |\ |\ |\
for which of the following reasons?
|\ |\ |\ |\ |\
,A. The client's blood does not contain the Rh factor, she she produces anti-
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
Rh antibodies that cross the placental barrier and cause hemolysis of red
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
blood cells in newborns. |\ |\ |\
B. The client' blood contains the Rh factor and the newborn's does not and
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
antibodies that destroy red blood cells are formed in the fetus.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
C. The client has a history of receiving a transfusion with Rh-negative blood.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
D. The client's anti-A and anti-B antibodies cross the placenta and cause the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
destruction of the fetal red blood cells. - CORRECT ANSWERS ✔✔A. The
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
client's blood does not contain the Rh factor, she she produces anti-Rh
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
antibodies that cross the placental barrier and cause hemolysis of red blood
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
cells in newborns. |\ |\
If the Rh-negative client has been exposed to Rh-positive fetal blood, she will
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
produce antibodies against Rh factor. These antibodies can cross the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
placenta and destroy the red blood cells of the Rh-positive fetus. This
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
accelerated rate of red blood cell destruction results in the increased release
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
of bilirubin. The newborn's serum bilirubin level can rise quickly.
|\ |\ |\ |\ |\ |\ |\ |\ |\
A nurse is teaching a newborn's parent to care for the umbilical cord stump.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
Which of the following instructions should the nurse include?
|\ |\ |\ |\ |\ |\ |\ |\
A. Wash the cord daily with mild soap and water.
|\ |\ |\ |\ |\ |\ |\ |\ |\
B. Cover the cord with the diaper.
|\ |\ |\ |\ |\ |\
C. Apply petroleum jelly to the cord stump.
|\ |\ |\ |\ |\ |\ |\
D. Give a sponge bath until the cord stump falls off. - CORRECT ANSWERS
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
✔✔D. Give a sponge bath until the cord stump falls off.
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
, Immersing the umbilical cord stump in water can delay the process of
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
drying, separation, and healing. Sponge baths are appropriate until the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\
stump falls off. |\ |\
A nurse is caring for a client who is postpartum. The client tells the nurse
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
that the newborn's maternal grandmother was born deaf and asks how to tell
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
if her newborn hears well. Which of the following statements should the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
nurse make? |\
A. "There is no need to worry about that. Most forms of hearing loss are not
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
inherited."
B. "Look at how she looks at you when you speak. That's a good sign."
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
C. "We do routine hearing screenings on newborns. You'll know the results
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
before you leave the hospital." |\ |\ |\ |\
D. "The best way to determine if your baby can hear is to clap your hands
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
loudly and see if she startles." - CORRECT ANSWERS ✔✔C. "We do routine
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
hearing screenings on newborns. You'll know the results before you leave the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
hospital."
|\
Most states mandate hearing screening for all newborns. The two tests in use
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
do not diagnose hearing loss, but determine whether or not a newborn
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
requires further evaluation. |\ |\
A nurse is caring for a client who is beginning to breastfeed her newborn
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
after delivery. The new mother states, "I don't want to take anything for pain
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
because I am breastfeeding." Which of the following statements should the
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
nurse make? |\
A. "You need to take pain medications so you are more comfortable."
|\ |\ |\ |\ |\ |\ |\ |\ |\ |\ |\
