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50 Cards in this Set

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A nurse is assessing a client 2 hours postpartum. Her blood pressure is 98/60, pulse is 90, and she has saturated two pads in the last hour. What should be the initial nursing action?

a. Massage fundus until firm
b. Notify the physician
c. Increase IV infusion
d. Administer pitocin
A. Massage fundus until firm

The initial management of excessive postpartum bleeding is firm massage of the uterine fundus.
A nurse is performing an assessment on a postpartum patient for signs of potential postpartum hemorrhage. Which of the following are risk factors that the nurse should watch for? [select all that apply]

a. First pregnancy
b. Prolonged labor
c. Magnesium sulfate administration during labor
d. Gestational diabetes
e. Uterine hypertonia
f. Oxytocin-induced labor
B. Prolonged labor

C. Magnesium sulfate administration during labor

F. Oxytocin-induced labor

Risk factors and causes of postpartum hemorrhage include prolonged labor, high parity, and magnesium sulfate and oxytocin administration during labor.
Which of the following is the leading cause of postpartum hemorrhage?

a. Pitocin administration during labor
b. Uterine atony
c. Uterine inversion
d. Placenta previa
B. Uterine atony

Uterine atony is the leading cause of PPH and is associated w/ high parity, hydramnios, and multifetal gestation.
A nurse is ordered to administer ergonovine (Ergotrate) for a postpartum patient in the unit. Which of the following assessment findings would indicate that the patient should not receive the medication?

a. Patient’s labor lasted for 24 hours
b. Patient’s temperature = 101F
c. Patient’s history of cardiac disease
d. Patient’s diagnosis of gestational diabetes
C. Patient’s history of cardiac disease

Ergonovine (Ergotrate) is used to increase uterine contraction. The drug is contraindicated in patients with a cardiovascular disease.
A nurse is ordered to give Methergine for a postpartum patient in the unit. Which of the following should the nurse assess prior to administering the medication?

a. Amount of bleeding
b. Respiration rate
c. Blood pressure
d. Blood glucose level
C. Blood pressure

The nurse should check the BP before administering Methergine. Drug shouldn’t be given if BP is over 140/90 mmHg.
A nurse is caring for a 48-hour-postpartum client who complains of urinary frequency and dysuria. Her temperature is 100F, pulse 72, respirations 18, and blood pressure 108/72. The nurse should anticipate an order to:

a. Administer antibiotics
b. Insert an indwelling catheter
c. Administer oral anti-inflammatory
d. Obtain urine culture
D. Obtain urine culture

Frequency and dysuria warrant further investigation, and clean-catch urine specimen could identify the causative organism if an infection were present. It is inappropriate to administer antibiotics before confirming presence and causative agent of infection.
A postpartum patient is experiencing severe hypotension, bradycardia, and bleeding. A large, red, rounded mass protruding outside the vagina is also noted upon further assessment. Which of the following conditions is the patient experiencing?

a. Placenta previa
b. Uterine inversion
c. Disseminated intravascular coagulation
d. Endometritis
B. Uterine inversion

Inversion of the uterus after birth is a potentially life-threatening complication. The primary presenting signs of uterine inversion are hemorrhage, shock, and pain in the absence of palpable fundus.
A nurse is caring for a patient experiencing uterine inversion. Which of the following medications should the nurse anticipate to administer to the patient prior to uterine replacement?

a. Oxytocin
b. Broad-spectrum antibiotic
c. Magnesium sulfate
d. Misoprostol
C. Magnesium sulfate

Tocolytics such as magnesium sulfate may be given to relax the uterus before attempting replacement.
A nursing diagnosis of: Deficient fluid volume is developed for a patient experiencing postpartum hemorrhage. Which of the following interventions isn’t appropriate for the patient?

a. Administer ordered oxytocin
b. Start infusion w/ 18-gauge IV catheter
c. Insert indwelling catheter
d. Monitor lochia for foul smell and profusion
D. Monitor lochia for foul smell and profusion

Interventions for deficient fluid volume include administration of oxytocin to increase uterine contractility, IV infusion using an 18-gauge catheter to provide fluid or blood replacement, and indwelling catheter to provide accurate output assessment. Foul smelling lochia is an indicator of infection.
Which of the following should be closely monitored in a postpartum patient receiving IV albumin after a postpartum hemorrhage?

a. Intake and output
b. Febrile reactions
c. Air embolism
d. Level of consciousness
A. Intake and output

Fluid resuscitation must be closely monitored because fluid overload may occur. Intravascular fluid overload occurs more frequently with colloid (such as albumin) therapy than w/ other fluids.
Which of the following would be the drug of choice for treatment of idiopathic thrombocytopenic purpura (ITP)?

a. Desmopressin
b. Factor VIII
c. Prednisone
d. Plasma transfusion
C. Prednisone

Idiopathic thrombocytopenic purpura (ITP) is an autoimmune disorder in which antiplatelet antibodies decrease the lifespan of platelets. If ITP is diagnosed during pregnancy, the woman is likely to be treated w/ corticosteroids or IV immunoglobulin.
A nurse is assessing a patient for risk of developing a DVT. Which of the following statements is true regarding DVT in pregnancy?

a. It is characterized by bilateral leg pain and swelling
b. Physical examination indicates redness and cool, clammy skin
c. More common during pregnancy than in postpartum
d. Signs and symptoms include chest pain, friction rub, and diaphoresis
C. More common during pregnancy than in postpartum

DVT is characterized by unilateral leg pain, swelling, and is more common during pregnancy than after birth.
A nurse is ordered to administer PO Coumadin for a patient while receiving continuous IV heparin after being diagnosed w/ a DVT. What should be the most appropriate action by the nurse?

a. Contact physician and question the order
b. Stop IV infusion for 30 minutes prior to administering PO Coumadin
c. Stop IV infusion for 1 hour prior to administering PO Coumadin
d. Give medication as ordered
D. Give medication as ordered

Initial treatment for DVT is an anticoagulant, usually IV heparin. Therapy continues for 3-5 days or until symptoms resolve. Oral anticoagulant is started during this time and will be continued for approximately 3 months.
Which of the following statements is true regarding postpartum infections?

a. Occurs w/in 28 days after miscarriage, abortion, or childbirth
b. Manifested by fever higher than 40C and lasting 5 consecutive days
c. The leading cause of maternal morbidity and mortality
d. The most common cause is hemorrhage
A. Occurs w/in 28 days after miscarriage, abortion or childbirth

Postpartum infection is an infection of the reproductive tract that occurs w/in 28 days postpartum. Endometritis is the common cause and is manifested by a presence of fever higher than 38C or more for 2 consecutive days.
Which of the following would be an early sign or symptom of mastitis in a postpartum patient?

a. Pain
b. Redness
c. Swelling
d. Chills
D. Chills

In mastitis, symptoms rarely appear before the end of the first postpartum week and are more common in the second to fourth weeks. Chills, fever, malaise, and local breast tenderness are noted first.
A postpartum patient diagnosed w/ mastitis asks the nurse about the condition. Which of the following is an appropriate response by the nurse?

a. It usually involved both breasts
b. It is more common in first-time mothers
c. E. Coli is the most common cause of the condition
d. Breastfeeding is contraindicated if the condition is present
B. It is more common in first-time mothers

Mastitis mostly affects first-time mothers who are breastfeeding and is always unilateral. It develops well after flow of milk has been established. The infecting organism generally is the hemolytic staphylococcus aureus.
A nurse is caring for a patient recovering from a cesarean delivery. To prevent thrombophlebitis, the nurse plans to encourage the patient to:

a. Remain on bed rest
b. Ambulate frequently
c. Apply warm packs on the legs
d. Elevate her legs
B. Ambulate frequently

The major causes of thrombophlebitis are venous stasis and hypercoagulation; both of w/c are present during pregnancy and continue into postpartum. The patient should be encouraged to ambulate frequently to promote circulation and prevent stasis.
Which of the following interventions would be most appropriate for a postpartum patient receiving IV heparin therapy following a diagnosis of thrombophlebitis?

a. Ambulate patient w/ assist
b. Administer PO aspirin Q12H
c. Encourage bed rest
d. Teach patient to use oral contraceptive
C. Encourage bed rest

Initial therapy for thrombophlebitis usually includes bed rest to help prevent embolus formation, and IV anticoagulant therapy. Oral contraceptives are contraindicated because of the increased risk for thrombosis.
A nurse is teaching a couple about fertility awareness methods (FAM) of contraception. When teaching about the advantages and disadvantages of the method of contraception, which of the following statements would be most appropriate?

a. Lower risk of pregnancy during the fertile phase
b. It may require training sessions
c. Daily monitoring isn’t necessary
d. Increased effectiveness in women who have irregular menses
B. It may require training sessions

Advantages of FAM include low to no cost, absence of chemicals and hormones, and lack of alteration of menstrual pattern. Disadvantages include adherence to strict record-keeping, decreased effectiveness in women w/ irregular menses, and it may require time-consuming training sessions.
A catholic couple just received teaching about fertility awareness methods (FAM) of contraception. Which of the following patient statements would indicate a need for further teaching?

a. We can have sexual relations during fertile days
b. An emergency contraceptive pill should be available as backup
c. The contraception method is acceptable by our church
d. It doesn’t protect against HIV or STIs
A. We can have sexual relations during fertile days

Fertility awareness methods (FAM) provide contraception by relying on avoidance of sexual relations during fertile periods. An emergency contraceptive pill should be readily available during the initial learning phase to help prevent unintentional conception.
A nurse is teaching a group of male high-school students about proper condom use. Which of the following should be included in the teaching?

a. It is safest to withdraw the penis after it has become flaccid after ejaculation
b. Water-based lubricants should be avoided to prevent breaking the condom
c. Polyurethane condoms aren’t widely used due to a potential for severe allergic reaction
d. Remove any air remaining on the tip after condom placement
D. Remove any air remaining on the tip after condom placement

It is safest to withdraw the penis while it is still erect, not flaccid, to be most effective in spillage prevention. Petroleum-based lubricants should be avoided because they can cause the condom to break. After putting on the condom, any remaining air should be removed on the tip.
A patient in the local health clinic just received proper use and care of a diaphragm. Which of the following patient statements indicate a need for further teaching?

a. I will wash the diaphragm with mild soap and water
b. I have to dust the diaphragm with cornstarch after washing
c. Spermicide should be always used with the diaphragm
d. It should be removed within 3 hours of sexual activity
D. It should be removed within 3 hours of sexual activity

The diaphragm must be left in place for at least 6 hours after the last intercourse. There is a greater chance of becoming pregnant if the diaphragm is removed before the 6-hour period.
A nurse is explaining to a female client about the advantages and disadvantages of using an intrauterine device. Which of the following is a disadvantage of intrauterine devices?

a. Infection
b. Device has to be in place for at least 6 hours after intercourse
c. Increased cost of the device
d. Loss of sexual stimulation
A. Infection

Disadvantages of intrauterine devices include increased risk for pelvic inflammatory disease shortly after placement, infection, unintentional expulsion of the device, and possible uterine perforation.
A nurse is counseling a group of sexually active college-age women about the use of birth control pills. The pill would be contraindicated for a woman with:

a. Hypotension
b. Irregular menstrual periods
c. Gall bladder disease
d. Lactation more than 6 weeks postpartum
C. Gall bladder disease

Use of oral contraceptives is contraindicated in women who have history of CAD, breast cancer, gall bladder disease, hypertension, impaired liver function, headaches w/ focal symptoms, and lactation less than 6 weeks postpartum.
A nurse is teaching a group of female high-school students about emergency contraception. Which of the following statements isn’t appropriate for the teaching?

a. It can be taken within 120 hours of unprotected intercourse or birth control mishap
b. Taking an antiemetic 1 hour after taking the drug helps prevent nausea
c. A pregnancy test is needed if menstruation doesn’t occur within 21 days of taking the pills
d. Emergency contraception doesn’t protect against pregnancy in the days or weeks following treatment
B. Taking an antiemetic 1 hour after taking the drug helps prevent nausea

An OTC antiemetic should be taken 1 hour before each dose. Emergency contraception will not protect the woman against pregnancy if she engages in unprotected intercourse in the days or weeks that follow treatment.
The nurse reminded the patient who is taking oral contraceptives to call and report to the primary healthcare provider immediately if she experiences which of the following signs and symptoms?

a. Numbness and tingling of extremities
b. Headache or chest pain
c. Fatigue, and decreased appetite
d. Fever, nausea and vomiting
B. Headache or chest pain

The patient should stop taking the pill and report to the primary healthcare provider immediately of experiencing abdominal pain, chest pain or SOB, sudden or persistent headaches, eye problems, or severe leg pain.
A female patient who is about to undergo a sterilization procedure asks the nurse what she should expect after tubal ligation. Which of the following is the most appropriate response by the nurse?

a. You will not have any menstrual period after the procedure
b. There is still a chance that you can become pregnant after the procedure
c. You will feel no pain during ovulation
d. You will enjoy sexual relations more
D. You will enjoy sexual relations more

The patient’s menstrual period will be about the same as before sterilization. The patient may also feel pain during ovulation. There shouldn’t have any change in sexual functioning and it is highly unlikely that pregnancy will occur after sterilization.
The patient comes to the local clinic for a medical abortion. The nurse administered methotrexate for the patient. The nurse would know that the drug does which of the following?

a. Soften and dilate the cervix
b. Blocks blood vessels in the placenta
c. Blocks absorption of folic acid
d. Stimulates contractions
C. Blocks absorption of folic acid

Methotrexate, usually given IM or orally, is a cytotoxic drug that causes early abortion by blocking folic acid in the fetal cells so that they cannot divide.
Upon assessment of the newborn, the nurse notes limited movement of the left arm w/ crepitus at the shoulder, and absence of moro reflex on the left side. The nurse would suspect which condition?

a. Klumpke palsy
b. Phrenic nerve injury
c. Fracture of the clavicle
d. Erb’s palsy
C. Fracture of the clavicle

The clavicle is the bone most fractured during birth. Diagnostic findings for a clavicle fracture include limited movement of the arm, crepitus over the bone, and the absence of Moro reflex on the affected side.
Infants born to mothers w/ diabetes are at risk for which of the following complications?

a. Low birth weight
b. Hyperglycemia
c. Post-term birth
d. Hypocalcemia
D. Hypocalcemia

Compared to nondiabetic pregnancies, infants born to mothers / diabetes are at risk for macrosomia, hypoglycemia, preterm birth, and hypocalcemia.
Plan of care for a newborn with a phrenic nerve injury includes:

a. Ventilation support
b. Immobilization of the arm
c. Application of artificial tears
d. Gentle manipulation of the arm
A. Ventilation support

The phrenic nerve arises from the neck (C3-C5) and innervates the diaphragm. Infants with diaphragmatic paralysis usually require mechanical ventilation support, at least for the first few days after birth.
A nurse is performing newborn assessment on an infant following a breech birth. The nurse note flaccid extremities, diaphragmatic breathing, and distended bladder. The infant is experiencing which condition?

a. Phrenic nerve injury
b. Spinal shock
c. Erb’s palsy
d. Intraspinal hemorrhage
B. Spinal shock

Common signs of spinal shock include flaccid extremities, diaphragmatic breathing, paralized abdominal movements, atonic anal sphincter, and distended bladder.
Plan of care for a newborn that developed an infection include all of the following except:

a. Encourage breastfeeding the infant
b. Administer IV fluids
c. Follow isolation procedures
d. Routine suctioning of secretions
D. Routine suctioning of secretions

Routine suctioning is not recommended and can further compromise the infant’s immune status, as well as cause hypoxia and increased ICP.
Clinical feature for a newborn infected with toxoplasmosis infection would include:

a. Lesions on upper extremities
b. Periorbital edema
c. Hydrocephalus
d. Limb atrophy
C. Hydrocephalus

Toxoplasmosis is a multisystem disease caused by a parasite commonly found in cats. For some infected neonates, hydrocephalus is the only clinical sign of the disease.
The preterm newborn of a mother who used cocaine during pregnancy is experiencing vomiting, diarrhea, weight loss, tremors, and tachypnea. What is the best explanation for these symptoms?

a. Sepsis
b. Maternal substance abuse
c. Gestational diabetes
d. Traumatic birth
B. Maternal substance abuse

The severity of withdrawal that an infant experiences can be assessed by using a scoring system such as the Finnegan scale. It evaluates the infant on potentially life-threatening signs such as vomiting, diarrhea, weight loss, irritability, tremors, and tachypnea.
The primary goal for the drug-dependent newborn is to reduce withdrawal symptoms and promote adequate respiration, temperature, and nutrition. What intervention best reflects that goal?

a. Positioning of infant in side-lying position
b. Administer medications such as narcan
c. Maintaining NPO status
d. Monitor for hyperthermia
A. Positioning of infant in side-lying position

Proper positioning in the right side-lying or semi-Fowler's position prevents possible aspiration of secretions. The nurse would monitor for hypothermia and use of narcan is contraindicated in infants born to narcotic addicts because it may cause severe s/s of narcotic abstinence syndrome and seizures.
A nurse is caring for an infant who was born to a patient with a history of long-term substance abuse. Which assessment finding would the nurse note for the infant?

a. Decreased tendon reflexes
b. Lethargy
c. Irritability
d. Absent moro reflex
C. Irritability

Withdrawal symptoms in the neonate are described as neonatal abstinence syndrome. It is characterized by CNS irritability, respiratory distress, and autonomic dysfunction.
Which of the following, if used long-term during pregnancy would place a higher risk to develop SIDS in the newborn?

a. Alcohol
b. Cocaine
c. Ampethamines
d. Tobacco
D. Tobacco

Infants born to women who smoke are about 30% more likely to be preterm, and have a higher risk of SIDS as compared w/ infants born to non-smokers.
Which of the following would the nurse administer for the newborn of a mother w/ untreated gonorrhea?

a. Methadone
b. Nystatin
c. Clyndamycin
d. 0.5% erythromycin
D. 0.5% erythromycin

Erythromycin eye ointment is administered w/in the first hour after birth to prevent opthalmia neonatorum, which is caused by gonorrhea infection.
Which of the following would the nurse note for an infant born to a mother w/ a history of alcohol abuse?

a. Abnormal feeding pattern
b. Thin lower lip
c. Hypersensitivity to external stimuli
d. Hyperactivity
D. Hyperactivity

Neonatal effects of alcohol abuse include hyperactivity, thin upper lip, short eyelid opening, flat midface, microcephaly, and attention deficits.
An infant born weighing 8 lbs 3 oz. would be at risk for which of the following? [select all that apply]

a. Fractured clavicle
b. Congenital heart defect
c. Retinopathy
d. Hyperbilirubinemia
e. Hypoglycemia
f. Neonatal abstinence syndrome
A. Fractured clavicle

B. Congenital heart defect

E. Hypoglycemia


Large-for-gestational age infants are at higher risk for birth injuries (fractured clavicle), congenital anomalies, and hypoglycemia. Neonatal abstinence syndrome is characterized by signs and symptoms commonly associated w/ maternal substance abuse.
Which of the following newborn patients needs further assessment for pathologic jaundice?

a. A term infant who showed jaundice 24 hours after birth
b. A preterm infant who showed jaundice 2 days after birth
c. Jaundice appearing in a term infant 12 hours after birth
d. Preterm formula-fed infant w/ serum bilirubin level of 10 mg/dL at 5th day of life
C. Jaundice appearing in a term infant 12 hours after birth

Jaundice is usually considered pathologic if it appears w/in 24 hours of birth, if total serum bilirubin levels increase by more than 5 mg/dL in 24 hours, and if serum bilirubin levels exceeds 15 mg/dL at any time.
A nurse is teaching the mother of an infant w/ hyperbilirubinemia about proper feeding instructions. Which of the following statements should be included in the teaching?

a. The infant should be taking formula until jaundice is treated
b. Infant should be fed every 8-10 hours
c. Breastfeeding is contraindicated in infants w/ jaundice
d. Initiate feeding early and feed the infant every 2-4 hours
D. Initiate feeding early and feed the infant every 2-4 hours

Initiating early and frequent feedings enhance secretion of bilirubin in the stools. Breastfeeding should be initiated w/in 2 hours after birth and every 2-4 hours thereafter.
Which of the following signs and symptoms would be noted in a newborn diagnosed w/ hyperbilirubinemia?

a. Hypoxia
b. Hyperthermia
c. Hyperglycemia
d. Metabolic alkalosis
A. Hypoxia

The nurse should observe for signs of hypoxia, hypothermia, hypoglycemia, and metabolic acidosis, which occur as a result of hyperbilirubinemia and increase the risk of brain damage.
A nurse is caring for a newborn w/ hyperbilirubinemia. Which of the following interventions is not appropriate for the newborn during phototherapy?

a. Reposition frequently
b. Cleanse skin frequently
c. Avoid stimulation
d. Cover infant’s eyes w/ patches
C. Avoid stimulation

During phototherapy, the skin is cleansed frequently to prevent irritation. Frequent repositioning maximizes body surface exposure and eye patches or eye shields are used to prevent eye damage. Stimulation is provided when performing necessary interventions.
An Rh-negative woman just gave birth to an Rh-positive boy. The indirect and direct Coomb’s tests are both negative. Which of the following would be the most appropriate action?

a. Administer Rhogam to the newborn within 24 hours of birth
b. Observe newborn for signs of pathologic jaundice
c. Administer Rhogam to the woman within 72 hours of the newborn’s birth
d. Prepare infant for emergency exchange transfusion
C. Administer Rhogam to the woman within 72 hours of the newborn’s birth

The unsensitized Rh-negative mother whose baby is Rh-positive should receive Rh(D) immunoglobulin within 72 hours of birth to prevent her from producing antibodies to the fetal blood cells that entered her bloodstream during birth.
A nurse is developing the plan of care for an Rh-positive newborn of an Rh-negative mother. The primary goal of care for the infant is to prevent:

a. Hyperbilirubinemia
b. Congenital abnormalities
c. Respiratory distress syndrome
d. Sepsis
A. Hyperbilirubinemia

A primary cause of pathologic hyperbilirubinemia is hemolytic disease of the newborn such as Rh-incompatibility. Hemolytic disorders occur when maternal antibodies form in response to an antigen from fetal blood crossing the placenta and entering maternal circulation. Maternal IgG antibodies then cross the placenta, causing hemolysis of fetal RBCs resulting in hyperbilirubinemia and jaundice.
The mother of a newborn with a cleft lip asks the nurse about cleft lip repair for the child. Which of the following statements is the most appropriate response by the nurse?

a. Cleft lip cannot be repaired and life-long management is needed
b. Cleft lip repair can only be done on full term infants
c. Cleft lip repair is usually performed between 6 months and 2 years
d. Cleft lip repair is usually done during the first weeks of life
D. Cleft lip repair is usually done during the first weeks of life

The treatment for a cleft lip is surgical repair, which usually is done between ages 6 and 12 weeks, if the infant is healthy and free of infection.
Which of the following interventions should not be included in the plan of care for a newborn w/ myelomeningocele?

a. Measure head circumference
b. Place newborn in supine position
c. Cover sac on the back w/ sterile dressing
d. Keep hips flexed and legs abducted
B. Place newborn in supine position

The infant should be placed in prone position w/ hips slightly flexed and legs abducted to minimize tension on the sac.
A nurse is performing an assessment on a newborn suspected of having a congenital heart defect. Which of the following patient findings would alert the nurse of a possible cardiac problem?

a. Bluish discoloration of hands and feet
b. Heart rate = 160 beats/min
c. Respirations = 70 breaths/min
d. Temperature = 98.7
C. Respirations = 70 breaths/min

Because the cardiac and respiratory systems function together, cardiac disease can be manifested by respiratory signs and symptoms. Tachypnea, a respiratory rate greater than 60 breaths/min without dyspnea is typically a subtle clue of a presence of cardiac malformation.