Excelsior College NUR 209 Final Exam with Correct Answers, Exams of Nursing

Download Excelsior College NUR 209 Final Exam with Correct Answers and more Exams Nursing in PDF only on Docsity!

Excelsior College NUR 209 Final Exam with Correct

Answers

1.1M8E_N

2 points possible (graded, results hidden) Which assessment findings would indicate to the registered nurse that proper latch-on has occurred in a breastfeeding client? Select All That Apply. Dimpling of infant’s cheeks while suckling. A slurping sound as infant suckles. Tongue down with lips flanged. Audible swallowing. Rhythmic suckling.

2.1M8E_N

2 points possible (graded, results hidden) While caring for a laboring patient, the anesthesiologist asks the registered nurse to administer a dose of fenantyl via an epidural catheter. Which standard would guide the RN on their next step? AWHONN believes that registered nurses who are not licensed anesthesia care providers should monitor but not manage the delivery of analgesia and anesthesia by catheter techniques to pregnant women. AWHONN believes that registered nurses who are not licensed anesthesia care providers should both monitor and manage the delivery of analgesia and anesthesia by catheter techniques to pregnant women. AWHONN believes that registered nurses are responsible for increasing or decreasing the rate of a continuous infusion and program doses for

3.1M8E_N

2 points possible (graded, results hidden) While caring for a postpartum patient the RN notes that the patient’s perineal pad is saturated with bright red blood. Which question would the registered nurse ask the patient first? “Do you have to go to the bathroom?” “When was the last time you changed your peri pad?” “Are you having any cramping?”

4.1M8E_N

2 points possible (graded, results hidden) The breastfeeding patient calls the physician’s office and tells the registered nurse that she has been tired, has a temperature of 100°F and has a localized warm reddened area in the lower right quadrant of her right breast. What would be the most appropriate intervention? Apply an ice pack to the right breast and wear supportive bra. Pump the right breast and discard the milk for the next week. Wash the breasts with soap and water before each feeding.

5.1M8E_N

2 points possible (graded, results hidden) For each assessment finding, click to specify the stage of labor First: Contractions every 8 minutes

Second: Cervix effacement is at 30% Third: Separation of placenta, mother feels strong urge to push, contractions every 2-3 minutes lasting for over 1 minute

2 points possible (graded, results hidden) Which interventions would the registered nurse include in the plan of care for a patient with the nursing diagnosis of acute pain related to engorgement? Select all that apply. Inform the woman to place the infant at the same breast first with each breastfeeding episode. Instruct the woman to apply warm packs to both breasts for a few minutes before breastfeeding. Educate the woman to manually express breast milk after the newborn has nursed. Teach the woman to massage her breasts for a few minutes before breastfeeding. Advise the woman to expose her nipples to air after breastfeeding.

8.0M8E_N

2 points possible (graded, results hidden) The infant has an order to receive amoxicillin (Amoxil) orally every 6 hours. The safe medication dose is 50mg/kg/day in divided doses. The infant weighs 6 kg. How much medication will the RN administer to the infant per dose? Record your answer as a number using decimals if necessary (for example, write 0.5 instead of ½). Do not include words or abbreviations in your answer.

9.1M8E_N

75 mg 2 points possible (graded, results hidden) The RN places the infant with tracheoesophageal fistula under a radiant warmer with the infant’s head elevated at a 45-degree angle. Which statement by the mother indicates understanding of the most important reason for this position?

“This position helps my baby breathe better by opening up his lungs.” “This position keeps my baby more comfortable and closer to the warmer.” “This position prevents stomach juices from going upward into my baby’s lungs.”

10.1M8E_N

2 points possible (graded, results hidden) Which patient should the RN refer to the hospital ethics committee? The newborn who is anencephalic whose parents want everything done. The newborn whose mother is a known cocaine user and is HIV positive. The toddler who is admitted with multiple fractures.

11.1M8E_N

2 points possible (graded, results hidden) During the active phase of labor, a patient’s membranes spontaneously rupture. Which nursing action should the registered nurse do first after this occurs? Assess fetal heart rate. Perform a sterile vaginal exam. Instruct the patient to bear down with the next contraction.

12.1M8E_N

should the registered nurse anticipate to prevent postpartum hemorrhage during the third stage of labor? Administration of intravenous oxytocin. Clamping the umbilical cord before pulsations stop. Administration of subcutaneous terbutaline sulfate.

13.2M8E_N

2 points possible (graded, results hidden) Which fetal lie is most conductive to a spontaneous vaginal birth? Transverse Longitudin al Oblique

14.1M8E_N

2 points possible (graded, results hidden) After delivery of the newborn, the registered nurse instructs the postpartum mother to call for the nurse when getting out of bed for the first time to void. The registered nurse informs the client that the most important reason is to: observe the newborn while the mother is busy. minimize the potential for postpartum hemorrhage. avoid maternal injury caused by the potential for syncope.

15.1M8E_N

2 points possible (graded, results hidden) The RN is preparing to give carboprost tromethamine to a client with uterine atony. Which side effect would the RN assess for following administration of this medication? Seizure s Vomitin g Anxiety

16.1M8E_N

2 points possible (graded, results hidden) After ambulating in the hall and returning to bed, the patient states that her water broke. The fetal heart rate is 85 beats per minute and the vaginal exam reveals the cervix is 90% effaced, 2 cm dilated, vertex presentation -2 station. There is a pulsating cord felt in the anterior portion of the vagina. Which intervention would the registered nurse perform immediately? Adjust the fetal monitor so an accurate fetal heart rate pattern can be assessed. Position the patient on her left side to move the fetus off the vena cava. Apply pressure to the presenting part to prevent pressure on the umbilical cord.

17.2M8E_N

2 points possible (graded, results hidden) The Labor and Delivery Room Nurse is caring for a woman in a labor. Upon admission, the patient stated, “my water broke 2-hours ago.” What is a concern of prolonged rupture of membranes?

The mother developing bradycardia

18.1M8E_N

2 points possible (graded, results hidden) A registered nurse is assessing the fundus of a postpartum patient one day after delivery and notes that the fundus is soft and spongy. Which is the first nursing intervention to perform? Notify the health care provider. Massage the fundus gently until it firms. Document fundal height and consistency.

19.1M8E_N

2 points possible (graded, results hidden) An 11-month-old infant with spastic cerebral palsy was seen this week at the developmental pediatrician’s office because he is not rolling over or attempting to sit. Which is an expected outcome for the nursing diagnosis Impaired physical mobility? The client will roll from back to front by 16 months of age. The client will be given 3 ounces of formula every 3 hours by next office visit. The client will remain safe at all times.

20.1M8E_N

2 points possible (graded, results hidden)

Which statement made by the postpartum patient indicates to the RN that more discharge teaching is needed regarding the resumption of sexual activity after giving birth? “The Doctor told me to wait until my discharge turns white in color before resuming sexual activity.” “I know I can ovulate as soon as two weeks postpartum therefore I will need to use contraception.” “Because I’m breastfeeding I don’t need to consider any other form of contraception right now.”

21.2M8E_N

2 points possible (graded, results hidden) A Labor and Delivery RN is caring for a new mother who wants to breast feed her baby. Which of the following is considered the “gold standard” to initiate breast feeding? Consult with a Lactation Consultant to visit the patient prior to discharge Ensure the baby has skin-to-skin contact with the mother, the first hour following birth Apply cool compresses to decrease pain and swelling of the breasts

22.2M8E_N

2 points possible (graded, results hidden) Which of the following interventions would be the priority when caring for a woman in the 20th week of gestation with placenta abruption? Assess, control, and replace blood volume Educate the patient on having a cesarean birth Assess the frequency of contractions

promote venous pooling.

Hold the infant in the knee-chest position to decrease venous blood return.

26.1M8E_N

2 points possible (graded, results hidden) The registered nurse should collaborate with the lactation consultant if which event occurred in the first 48 hours after birth with the breastfeeding mother? Mother voices concern about amount of milk being taken. Mother is complaining of full, hard breasts. Mother is complaining of sore, bruised nipples.

27.1M8E_N

2 points possible (graded, results hidden) The post-partum client is receiving methylergonovine maleate. Which assessment finding should cause the RN to hold the medication? Blood pressure of 140/100 Heart rate of 90 Oxygen saturation of 93%

28.1M8E_N

2 points possible (graded, results hidden) The registered nurse is caring for the patient in labor and interprets the fetal monitor tracing to have moderate variability. Which action should

Provide labor support. Place the woman on her left side. Notify the health care provider.

29.1M8E_N

2 points possible (graded, results hidden) Which nursing intervention would be appropriate while caring for a newborn whose mother was addicted to heroin during her pregnancy? Swaddle the newborn tightly. Observe newborn in well-lit nursery. Feed the newborn half strength formula.

30.2M8E_N

2 points possible (graded, results hidden) What information would the registered nurse expect to gather when interviewing the parent of a newborn with suspected Hirschsprung’s disease? Stool pattern Urination frequency Sleep schedule

31.1M8E_N

2 points possible (graded, results hidden)