NursGuru

    Exam Review

    1. A patient delivered 2 hours ago without medication. She is alert and active in bed but has not been out of bed yet. She states she needs to go the bathroom. What is the nurse's most appropriate response?
      A)
      "I'll walk you to the bathroom and stay with you."
      B)
      ‘’I will get a bedpan for you."
      C)
      ‘’Leave your peri-pad in place after you use the restroom so I can check your bleeding when you get back."
      D)
      ‘’wait until I have had a chance to assess you first"
    2. The nurse is teaching a newborn care class to parents who are about to give birth to their first babies. Which statement indicates that teaching was effective?
      A)
      Keep umbilical cord dry and above the level of the diaper.
      B)
      Baby will need to breast feed every hour
      C)
      Be sure to always wrap baby in 2 blankets when going outside
      D)
      Limit the amount of time baby is skin to skin with parents
    3. The nurse has received shift report on the postpartum unit. Which patient should the nurse see first?
      A)
      First baby, day of delivery, fundus 2 cm above umbilicus deviated to left.
      B)
      Second baby, first postpartum day, hypoactive bowel sounds all quadrants.
      C)
      Third baby, first postpartum day, 3 cm diastasis recti abdominis
      D)
      Second baby, third day post-cesarean, moderate lochia serosa.
    4. A full term newborn was just born. Which nursing intervention is important for the nurse to perform first?
      A)
      Dry the infant throughly and place on mom skin to skin
      B)
      Determine Apgar Score.
      C)
      Encourage mother to begin breastfeeding.
      D)
      Administer medication for eye prophylaxis.

    Exam Review

    1. A mother asks whether or not she should be concerned that her baby never opens his mouth to breathe when his nose is so small. Which of the following is the nurse's best response?
      A)
      "Babies usually breathe in and out through their noses so they can feed without choking."
      B)
      "You are right. I will report the baby's small nasal openings to the pediatrician right away.*
      C)
      *Everything about babies is small. It truly is amazing how everything works so well."
      D)
      "The baby does rarely open his mouth but you can see that he isn't in any distress.
    2. Part of the health assessment of a newborn includes observation of the neonate's breathing pattern. A full-term newborn's breathing pattern is predominantly:
      A)
      Abdominal with synchronous chest movements.
      B)
      Chest breathing with nasal flaring.
      C)
      Diaphragmatic with chest retraction.
      D)
      Deep with a regular rhythm.
    3. At 1 minute after birth the nurse assesses the newborn and notes the following: Heart rate: 80 beats/minute Respiratory effort: slow, irregular Muscle tone: some flexion of extremities Reflex irritability: grimacing Color: blue and pale The nurse would calculate an Apgar score of:
      Correct Answer:4 Total Apgar Score
    4. The most important reason to protect the preterm infant from cold stress is that:
      A)
      It could make respiratory distress syndrome worse.
      B)
      Shivering to produce heat may use up too many calories.
      C)
      A low temperature may make the infant less able to digest nutrients.
      D)
      Cold decreases circulation to the extremities.

    Exam Review

    1. The nurse is assessing a newborn at 1 hour of age. Which finding requires the nurse's immediate action?
      A)
      Pauses in respiration lasting 30 seconds
      B)
      Respiratory rate 36, crackles present bilaterally
      C)
      Apical heart rate of 160 with mild systolic murmur heard
      D)
      Small white papules on nose and chin
    2. A new mother asks the nurse about the white substance" covering her infant. The nurse explains that the purpose of vernix caseosa is to:
      A)
      Protect the fetal skin from amniotic fluid.
      B)
      Promote normal peripheral nervous system development.
      C)
      Allow transport of oxygen and nutrients across the amnion.
      D)
      Regulate fetal temperature.
    3. Which of the following findings would be most concerning to the nurse caring for a newborn?
      A)
      Axillary temp of 96.9F (36.0 C) after 30 minutes of skin-to-skin contact with the mother
      B)
      Respiratory rate of 58 during assessment at beginning of shift
      C)
      Heart rate of 162 while crying vigorously after a diaper change.
      D)
      No void after 8-hours of life
    4. The nurse administers vitamin K to the newborn for what reason?
      A)
      Bacteria that synthesize vitamin K are not present in the newborn's intestinal tract, and it promotes normal clotting factors to develop sooner.
      B)
      Most mothers have a diet deficient in vitamin K, which results in the infant being deficient.
      C)
      Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection.
      D)
      The supply of vitamin K is inadequate for at least 3 to 4 months, and the newborn must be supplemented.

    Exam Review

    1. A postpartum woman telephones about her 6-day-old infant. She is not scheduled for, weight check until the infant is 10 days old, and she is worried about whether breastfeeding going well. Effective breastfeeding is best indicated by the newborn who:
      A)
      Has at least six to eight wet diapers per day
      B)
      Sleeps for 6 hours at a time between feedings
      C)
      Gains 1 to 2 ounces per week
      D)
      Has at least one breast milk stool every 24 hours
    2. Four newborns were admitted into the neonatal nursery 1 hour ago. They are all sleeping in overhead warmers. Which of the babies should the nurse ask the neonatologist to evaluate?
      A)
      The neonate with respirations of 78 and a heart rate of 176
      B)
      The neonate with a temperature of 99.1 F and a weight of 3000 grams
      C)
      The neonate with raised white specks on the gums
      D)
      The neonate with white spots on the bridge of the nose
    3. A nurse is assessing a newborn at 2 hours of life. Which of the following findings should the nurse report to the neonatologist?
      A)
      Intracostal retractions
      B)
      Caput succedaneum
      C)
      Positive Babinski sign
      D)
      Pink-tinged urine in the diaper
    4. A postpartum client is to receive the Rubella vaccine prior to discharge from the hospital. Why is she instructed to not become pregnant for 4 weeks after receiving this vaccine?
      A)
      The vaccine is a live virus and may cause birth defects in the fetus.
      B)
      Tests to determine if the client developed immunity are not accurate for a month.
      C)
      She may have the virus and feel too sick to tolerate a pregnancy.
      D)
      Her body is not ready to nurture another pregnancy so quickly.

    Exam Review

    1. Your patient just had her first baby two days ago. The infant is healthy and breastfeeding well. What are important things to teach her about the safety of her baby: (select all that apply)
      A)
      Keep the baby on his to back to sleep
      B)
      Keep the cord as dry as possible until it falls off
      C)
      Always keep the baby dressed and wrapped in 2 blankets when you go outside
      D)
      After your milk comes in your baby should have 3-4 wet or dirty diapers a day
      E)
      Have the bulb syringe near the baby at all times
    2. The nurse is assessing a one hour old newborn delivered vaginally after a 15 hour labor. Upon palpation of the head, the nurse notices swelling of the tissue over the presenting part of the infant's head, crossing the suture lines. How would the nurse document this finding?
      A)
      Caput succedaneum present.
      B)
      Severe molding present.
      C)
      Cephalhematoma present.
      D)
      Fontanels soft and flat.
    3. A woman gave birth to a 7-pound, 3-ounce infant boy 2 hours ago. The nurse determines that the woman's bladder is distended because her fundus is now 3 cm above the umbilicus and to the right of the midline. In the immediate postpartum period, the most serious consequence likely to occur from bladder distention is:
      A)
      Excessive uterine bleeding
      B)
      A bladder rupture
      C)
      Bladder wall atony
      D)
      Urinary tract infection
    4. The laboratory results for a postpartum woman are as follows: blood type: A + rubella: non-immune hematocrit: 30% GBS: negative How would the nurse best interpret these data?
      A)
      A rubella injection is advised
      B)
      A blood transfusion is advised
      C)
      The nurse should contact the provider for an antibiotic order an
      D)
      RhoGAM injection should be administered within 72 hours

    Exam Review

    1. The nurse is caring for a postpartum patient who experienced a second-degree laceration at delivery 2 hours ago. Which of the following interventions should the nurse perform at this time?
      A)
      Apply an ice pack to the perineum
      B)
      Teach the woman to insert nothing into her rectum
      C)
      Advise the woman to sit on a pillow
      D)
      Advise the woman to use sitz bath after each void
    2. Rho immune globulin (Rhogam) will be ordered postpartum if which situation occurs?
      A)
      Mother Rh-, baby Rh+
      B)
      Mother Rh-, baby Rh-
      C)
      Mother Rh+, baby Rh+
      D)
      Mother Rh+, baby Rh-
    3. While assessing a patient who gave birth 5 hours ago, the nurse finds that the woman has completely saturated: pad within 15 minutes. What is the nurse's first action?
      A)
      Assess the woman's fundus and massage it if boggy
      B)
      Assess the woman's pulse and BP for signs of hypovolemic shock
      C)
      Call the woman's primary healthcare provider
      D)
      Begin an IV infusion of Ringer's lactate solution and administer oxytocin
    4. The nurse is going to administer a dose of Vitamin K (Aquamephyton) 0.5mg IM to a newborn. Available: Vitamin K 1 mg/1ml. How many mLs would the nurse administer? (Please answer numerically only)