1. Which nursing diagnosis has the highest priority for a postpartum client who has developed disseminated intravascular coagulopathy (DIC)
A. Anticipating Grieving
B. High risk for infection
C. Risk for deficient f
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1. Which nursing diagnosis has the highest priority for a postpartum client who has developed disseminated intravascular coagulopathy (DIC)
A. Anticipating Grieving
B. High risk for infection
C. Risk for deficient fluid volume
D. Spiritual Distress
2. A newly delivered 9lb 4 ounce baby boy exhibits of respiratory distress. The nurse obtains a blood sample to assess the infant for which of the following?
A. Hypoglycemia
B. Pneumonia
C. Sepsis
D. Hyperbilirubinemia
3. The nurse explains to the client in premature that betamethesome is given to:
A. Stop uterine contractions
B. Prevent infection
C. Assist with fetal lung maturity
D. Prevent cervical dilation
4. The onset of late decelerations on the fetal monitor should lead the nurse to suspect which condition?
A. Head compression
B. Cord compression
C. Close uterine contractions
D. Decreased uteroplacental blood flow
5. The nurse receives a call for postpartum who delivered 7 days ago. The client report having increase bleeding. The nurse suspect late postpartum hemorrhage, which is most commonly caused by which of the following?
A. Uterine Atony
B. Disseminated intravascular coagulopathy C. Retained Placental fragments
D. Lacerations
6. Which of the following clients have the greatest risk for developing postpartum hemorrhage?
A. A client who gave birth to a boy weighing 5lb 2 ounces
B. A 17 year old client
C. A client who is diagnosed with endometritis D. A client experimenting uterine atony
7. A client is ordered heparin 2,500 units SQQD for treatment of thrombophlebitis. On hand is Heparin 5,000 units/ml. How many millimeters will the nurse administer?
A. 0.5 ml
B. 1ml
C. 2ml
D. 2.5 ml
8. Which nursing intervention is appropriate in the care of an infant with respiratory distress syndrome?
A. Perform a complete gestational age assessment
B. Perform chest physiotherapy
C. Suction mcconium from airway as needed
D. Maintain a neutral thermal environment this answer is also correct
9. A client who baby is jaundice ask, “How will those lights help my baby? Which statement by the nurse is accurate?
A. “The lights prevent more bilirubin from being released into your baby’s body”
B. “Exposing the skin to the air helps get rid ofjaundice”
C. “The lights help convert bilirubin to a form that the baby can get rid of”
D. “The lights release a substance that attacks the bilirubin in the body and destroys it”
10. While feeding an infant the nurse notes white patches over the germsand buccal cavity, the nurse’s next best intervention would be”
A. Document findings as normal
B. Further evaluate to no yeast infection
C. Prepare to give vitamin K
D. Assess maternal history for Herpes
11. The nurse is evaluating a client receiving magnesium sulfate. What clinical manifestations indicate that the medication is working?
A. Blood pressure 128/76
B. Serum magnesium level reaches 2.2 MEQ/L
C. Contractions are steady at a frequency of every four minutes D. There is an absence of seizure activity
NB. D is the correct answer but they gave credit for A too
12. A client in active labor is receiving an epidural, while it is being administered. Which of the following should the nurse consider as the highest priority?
A. Checking uterine contractions for an increase in strength
B. Positioning the mother flat in be, preventing spinal headache
C. Telling the mother that she will have an increase in urinary output D. Monitoring mother’s blood pressure for hypotension
13. The post cesarean section client has the following for breakfast
½ grapefruit
4 ounces prune juice 1 pint cottage cheese
½ pint of skim milk
1 ounce of apple juice
2 ounce container of jello
What is the total intake to be included on the intake and output sheet?
A. 350 ml B. 450 ml
C. 550 ml
D. 650 ml
14. What are the expected findings of a second day postpartum client?
A. Yellowish white lochia and fundus three fingerbreadths below the umbilicus
B. Red lochia with small clots and fundus midline and two fingerbreadths below the umbilicus
C. Pinkish brown lochia fundus midline and four fingerbreadths below the umbilicus
D. A large amount of bright red lochia with large clots and fundus midline at the umbilicus
15. The postpartum client is being treated for a UTI. Determine the flow rate for the following IV being administered by the infusion pump, Ampicilin 1.5g in 50 ml, 0.9% NS over 30 minutes
A. 75 ml/hr
B. 133.3 ml/hr
C. 150 ml/hr D. 100 ml/hr
16. A 15 year old female experiences a miscarriage at 12 weeks gestation. When she is informed about the miscarriage she begins to cry stating that she was upset about her pregnancy at first and now she is being punished for not her wanting her baby. Which of the following statements would be most therapeutic?
A. “You are still young, you probably were not ready for a baby right now” B. “This must be so hard for you. I am here if you want to talk”
C. “At least this happened early in your pregnancy before you felt your baby move”
D. “There is a good reason why this happened, God knows best.”
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