Nurse Moose
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    Exam Review

    1. A nurse is assisting in the care of a newborn immediately after birth. Which of the following is the first action the nurse should take to assist in thermoregulation?
      A)Check the newborn's temperature.
      B)Put a hat on the newborn's head.
      C)Wrap the newborn in a blanket.
      D)Dry the newborn thoroughly.
    2. A nurse is educating student nurses about Vitamin K administration in newborns. Which fact is correct?
      A)Vitamin K aids in digestion and nutrient absorption.
      B)Vitamin K prevents potentially life-threatening intracranial hemorrhage.
      C)Vitamin K is required per state mandate for all preterm infants.
      D)Vitamin K is only beneficial for male infants undergoing a circumcision.
    3. The daily fluid requirement for infants less than 10 Kg is 100 mL/Kg. Calculate how many milliliters an hour an infant weighing 2.5 pounds should receive. Enter the numeric value only. Round to the nearest tenth place.
    4. A postpartum client who plans on formula-feeding her newborn asks, "When should my period return?" Which response by the nurse would be most appropriate?
      A)"It's difficult to say but it will probably return in about 2 to 3 weeks.”.
      B)"You won't have to worry about it returning for at least 6 months.”.
      C)"It varies, but you can estimate it returning in about 7 to 9 weeks.”.
      D)"You don't have to worry about that now.It'll be quite a while.”. — . . .
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    Exam Review

    1. A postpartum woman who delivered 24 hours ago denies excessive bleeding, pain, or burning. She states she has not had a bowel movement since before delivery and that she has been "urinating so much over the past several hours.”. Which response by the nurse would be most appropriate?
      A)"It's likely you have an infection. Let me get an order for a complete blood count and urine specimen.”.
      B)"The anesthesia that you received is wearing off and your bladder is working again.”.
      C)"Diuresis is a sign of postpartum hemorrhage. Let me assess your bleeding right now.”.
      D)"It's a result of hormonal changes that cause the body to eliminate excess fluids accumulated during pregnancy.”. —
    2. A nurse is caring for a client who delivered a healthy newborn 2 hours ago. The client's blood type is O negative, and the newborn's blood type is A positive. Which nursing action is most appropriate?
      A)Withhold Rho(D) immune globulin (Rhogam) because the mother has already delivered.
      B)Administer Rhogam within 72 hours postpartum.
      C)Withhold Rhogam because there is no indication for a second dose with the newborn's blood type.
      D)Administer Rhogam only if the mother plans future pregnancies.
    3. A postpartum patient has been receiving a magnesium sulfate infusion for treatment of severe preeclampsia. It has been about 8 hours since her vaginal delivery and upon assessment the nurse finds the following: temperature 98.3°F, pulse rate 88 beats/min, respiratory rate 16 breaths/min, blood pressure (BP) 148/78 mm Hg, 2+ deep tendon reflexes, 100 cc of clear yellow urine over the past hour, heavy rubra lochia, and a boggy fundus. What is the most appropriate action for the nurse to take?
      A)Administering a uterotonic medication to control bleeding.
      B)Call for a stat magnesium sulfate level.
      C)Administer additional magnesium sulfate to maintain therapeutic levels.
      D)Monitoring the patient's blood pressure and reflexes.
    4. During a postpartum follow-up, a woman with a history of deep vein thrombosis (DVT) asks about starting birth control pills. What is the nurse's best response?
      A)Estrogen-containing contraceptives are contraindicated due to your history of blood clots.
      B)Birth control pills will actually lower your risk of another blood clot.
      C)The barrier method such as condoms is the only safe option with your history.
      D)You can safely use any oral contraceptive.
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    Exam Review

    1. A postpartum mother presents to the healthcare clinic for her 6 week postnatal check-up. During the assessment, she expresses feelings of overwhelming sadness, hopelessness, and guilt. She also mentions a loss of interest in activities she once enjoyed and difficulty bonding with her newborn. Which nursing action is most appropriate for the nurse to take in this situation?
      A)Provide education on the normal and expected emotional changes experienced during the postpartum period.
      B)Ensure she is not left alone in the room with the baby while you prepare to transfer her to inpatient psychiatric care.
      C)Conduct a comprehensive assessment of the mother's mental health and refer her for further evaluation and support.
      D)Reassure the mother that these feelings will resolve on their own as she adjusts to motherhood.
    2. A newborn has an APGAR Score of 6 at 5 minutes. Which of the following is the priority?
      A)Obtaining umbilical blood gases.
      B)Beginning resuscitative measures.
      C)Promoting kangaroo care.
      D)Initiating IV fluid therapy.
    3. Assessment of a newborn reveals uneven gluteal (buttocks) skin creases and a 'click' when Ortolani's maneuver is performed. Which of the following would the nurse suspect?
      A)Slipping of the periosteal joint.
      B)Overriding of the pelvic bone.
      C)Normal newborn variation.
      D)Developmental (congenital) hip dysplasia.
    4. The doctor has ordered Gentamicin IM 1.3 mg/kg q 12 hours. Infant weighs 3.7 pounds. How many mg of Gentamicin would this infant receive? Enter the numeric value only. Round to the nearest 100th place example: 1.23 type your answer.
    Page 3 of 5

    Exam Review

    1. A newborn with respiratory distress syndrome (RDS) is prescribed artificial surfactant therapy. The parents express concern and ask the nurse about the purpose of this treatment. How should the nurse best explain the use of artificial surfactant in the management of RDS to the parents?
      A)Surfactant is used to reduce episodes of periodic apnea.
      B)Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide.
      C)Your baby needs this medication to reduce fever and inflammation in the lungs.
      D)It prevents your baby from experiencing discomfort during breathing.
    2. Which finding in a postpartum patient most strongly suggests subinvolution?
      A)Uterus nonpalpable by week 2.
      B)Lochia serosa on day 5.
      C)Fundus firm and midline, 2 cm below the umbilicus on day 3.
      D)Uterus palpable above the umbilicus on day 7. — . . .
    3. At 3 hours postpartum, a gravida 2, para 2 complains of rectal pressure and increasing perineal pain. She is unable to void. This woman had a low forceps delivery with a midline episiotomy and a third-degree laceration. The fundus is firm and one fingerbreadth below the umbilicus. Lochia is moderate, bright red and without clots. The nurse is correct to assess further for
      A)a hemorrhoid.
      B)a bladder infection.
      C)uterine atony.
      D)a vaginal laceration or hematoma.
    4. A nurse is caring for a newborn in the postpartum unit. The parents express concern about their baby's weight loss of 5
      A)Weight loss can be normal but 5
      B)Weight loss occurs as a result of normal physiological processes such as fluid loss and adjusting to a new feeding pattern.
      C)It's primarily due to the baby's inability to digest breast milk or formula initially.
      D)Newborns lose weight because they have a higher metabolism than adults.
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    Exam Review

    1. A 28 year old G1 delivered 16 hours ago via forceps assisted vaginal delivery of a 9lb 2 oz male infant with a 4th degree repair. Estimated blood loss (EBL) was 378 mL. She was in the second stage of labor for 3.5 hours and is very sore and swollen. Vital signs are within normal limits and she reports her pain at 6/10. She is ambulating and last voided 300 cc of clear yellow urine 4 hours ago. Bowel sounds are active and she is passing gas but has had no bowel movement since delivery. The nurse understands that a 4th degree laceration tore through the rectal wall and anal sphincter and that the patient will need to:
      A)See a pelvic floor specialist before discharge.
      B)Apply pressure to the perineum during voiding.
      C)Schedule a follow up for reconstructive surgery.
      D)Take a stool softener to help ease her first bowel movement.
    2. A 28 year old G1 delivered 16 hours ago via forceps assisted vaginal delivery of a 9lb 2 oz male infant with a 4th degree repair. Estimated blood loss (EBL) was 378 mL. She was in the second stage of labor for 3.5 hours and is very sore and swollen. Vital signs are within normal limits and she reports her pain at 6/10. She is ambulating and last voided 300 cc of clear yellow urine 4 hours ago. Bowel sounds are active and she is passing gas but has had no bowel movement since delivery. The patient asks you what are some of the risk factors that made her have such a bad laceration and what are the best practices for perineal care in the postpartum period?
      A)Risk factors include Macrosomic infant, Primigravida, Operative vaginal delivery, and Prolonged pressure of fetal head on vaginal mucosa. Perineal care includes Intermittent ice pack use, Assess/treat pain, Fundal massage, and REEDA assessment.
      B)Risk factors include Great grand multiparity, Polyhydramnios, IUGR, and Assessing for clonus. Perineal care includes Sitz Bath, Heat packs, No Answers Chosen, and Assessing for clonus.
      C)Risk factors include Prolonged pressure of fetal head on vaginal mucosa, Great grand multiparity, Assessing for clonus, and Polyhydramnios. Perineal care includes REEDA assessment, Fundal massage, IUGR, and Heat packs.
      D)Risk factors include Macrosomic infant, Primigravida, Operative vaginal delivery, and Assessing for clonus. Perineal care includes Intermittent ice pack use, Assess/treat pain, Sitz Bath, and REEDA assessment.
    3. A 28 year old G1 delivered 16 hours ago via forceps assisted vaginal delivery of a 9lb 2 oz male infant with a 4th degree repair. Estimated blood loss (EBL) was 378 mL. She was in the second stage of labor for 3.5 hours and is very sore and swollen. Vital signs are within normal limits and she reports her pain at 6/10. She is ambulating and last voided 300 cc of clear yellow urine 4 hours ago. Bowel sounds are active and she is passing gas but has had no bowel movement since delivery. The nurse enters the room to complete her afternoon assessment of the patient. Her fundus is boggy, 2 cm above the umbilicus, and displaced to the right. Her bleeding is heavy with large clots expelled. The nurse recognizes this bleeding is likely because of:
      A)Uterine atony.
      B)An undiagnosed bleeding disorder.
      C)The 4th degree laceration.
      D)A hematoma.
    4. A 28-year-old G1 delivered 16 hours ago via forceps-assisted vaginal delivery of a 9lb 2 oz male infant with a 4th-degree repair. Quantitative blood loss (QBL) is 378mL. She was in the second stage of labor for 3.5 hours and is very sore and swollen. Vital signs are within normal limits and she reports her pain at 6/10. She is ambulating and last voided 300cc of clear yellow urine 4 hours ago. Bowel sounds are active, and she is passing gas but has not had a bowel movement since delivery. The patient is straight cathed and stabilized, and a few hours later, the nurse enters the room to discuss discharge teaching about lochia. Match each phase of lochia to the correct description: Rubra (pick 3), Serosa (pick 3), Alba (pick 3).
      Consists of mucus and leukocytes.Yellowish/white color.Serosanguineous consistency.Fleshy odor.Pinkish/brown color.Lasts from day 4-10 postpartum.Lasts from day 1-3 postpartum.Lasts from day 10-8 weeks postpartum.Dark red color.
      Rubra✓✓✓
      Serosa✓✓✓
      Alba✓✓✓
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