Tiêu đề RECALLS 8 (NP2) - STUDENT COPY ✅

11. Staku, the new nurse in the OB ward, is evaluating a client who claims to be in labor. Which findings would help Staku confirm the client’s belief? A. She is contracting q 5min x 60 sec. B. Her cervix has dilated from 2 to 4 cm. C. Her membranes have ruptured D. The fetal head is engaged. 12. A client who is in labor (G2 P1001) was admitted one hour ago at 2cm dilated and 50% effaced. At the time of admission, she was talkative and excited. However, in the past 10 minutes, she has become more severe, closing her eyes and breathing rapidly with each contraction. What is the accurate nursing assessment of the situation? A. The client had poor childbirth education prior to labor. B. The client is exhibiting an expected behavior for labor. C. The client is becoming hypoxic and hypercapnic. D. The client needs her alpha-fetoprotein levels checked. 13. During the latent phase of labor, when should the nurse assess the fetal heart pattern of a low-risk woman, G1 P0000? SATA 1 After vaginal exams. 2 Before administration of analgesics. 3 Periodically at the end of a contraction. 4 Every ten minutes. 5 Before ambulating A. 1,2,5 B. 2,3,4,5 C. 2,4,5 D. 1,2,3,5 14. The newly admitted client is shouting and complaining due to severe back labor. Which of the following nursing interventions would be most helpful to the condition of the client? A. Assist the client with childbirth breathing/deep breathing. B. Encourage mother to have an epidural anesthesia. C. Provide direct sacral pressure. D. Use a hydrotherapy tub. 15. As the nurses were busy evaluating a client in labor, Jhoanna left the nurse station. At 8:00 p.m., a pregnant client at full term called the nurse station to ask whether she was in labor. The nurse determined that the client was likely in labor after the client mentioned: A. “At 6:00 p.m., the contractions were about 5 mins apart. Now, they’re about 7 minutes apart.” B. “I took a walk at 6:00 p.m., and now I talk through my contractions easier than I could then.” C. “ I took a shower about a half hour ago. The contractions seem to hurt more since I finished.” D. “ I had some tightening in my belly late this afternoon, and I still feel it after waking up from my 2-hour nap” Situation: A patient, 32 weeks pregnant experiencing severe headache, is admitted to the hospital with pre-eclampsia. 16. Nurse Colet would anticipate that the primary health care provider would request tests to evaluate the fetus for which of the following? A. Severely low red blood cells B. Hypoprothrombinemia C. Craniosynostosis D. Intrauterine growth restriction 17. Nurse Colet is assessing for clonus. Which of the following actions should nurse Colet perform? A. Strike the woman’s patellar tendon B. Palpate the woman’s ankle C. Dorsiflex the woman’s foot. D. Position the woman’s feet flat on the floor. 18. Nurse Colet assessed the client and found a blood pressure of 170/112, 4+ proteinuria, and a weight gain of 10 pounds over the last two days. Nurse Colet also expected these signs and symptoms to be present. A. Fundal height of 32 cm. B. Papilledema C. Patellar reflexes of +2 D. Nystagmus 19. Nurse Colet is grading a woman’s reflexes. Which of the following grades would indicate reflexes that are slightly hyperreflexic? A. +1 B. +2 C. +3 D. +4 20. A woman who was diagnosed with severe pre-eclampsia also developed HELLP syndrome. Nurse Colet will assess for which of the following signs and symptoms? A. Decreased Level of serum creatinine B. Increased level of serum creatinine C. Hematochezia D. Epigastric Pain Situation: Childhood trauma is the primary factor contributing to mortality in children over the age of 1, as well as a significant contributor to impairment throughout childhood and adolescence. 21. Dr. Robles ask Nurse Colet if which of the following is a physiological effect og immobilization on children? A. Metabolic rate increases B. Increased joint mobility can lead to contractures in a short time. C. Venous stasis can lead to thrombi or emboli formation. D. Bone calcium increases, releasing excess calcium into the body. 22. A young female has recently sustained an injury to her ankle while attending school. Aside from contacting the child's parents, what is the most suitable intervention that needs to be done by Nurse Maloi? A. Apply Ice B. Observe for edema and discoloration. C. Encourage child to assume a position of comfort. D. Obtain consent for parenteral administration of acetaminophen or aspirin. 23. Kristin, who is 10 years old, experienced a fracture in the epiphyseal plate of her right fibula as a result of falling out of a tree. When engaging in a conversation about this injury with her parents, the nurse should consider which of the following factors? A. Healing is usually delayed in this type of fracture. B. Bone growth can be affected by this type of fracture. C. This is an unusual fracture site in young children. D. This type of fracture is inconsistent with a fall. 24. The mother Kristin asked you, what is the advantage of using fiberglass cast instead of plaster of paris cast? A. Cheaper B. Dries easily C. Molds closely to body parts D. Smooth exterior 25. Which of the following would be the most appropriate play activity for a 3 year old child in a spica cast? A. Marbles B. Game of checkers C. Coloring with crayons D. Playing with toy telephone Situation: Baby Alden, a newborn weighing 2.5 kg, was born prematurely at 35 weeks. Within 24 hours of birth, he developed visible jaundice, characterized by a yellowing of his skin and the whites of his eyes. 26. The mother of the baby asked Nurse Colet Which of the following laboratory findings would the nurse expect to see in a baby diagnosed with erythroblastosis fetalis? A. Hematocrit 24%. B. Leukocyte count 45,000 cells/mm3 C. Sodium 125 mEq/L. D. Potassium 5.5 mEq/L. Rationale. 27. A jaundice neonate must have a heel stick to assess bilirubin levels. Which of the following actions should the nurse make during the procedure? A. Cover the foot with an iced wrap for one minute prior to the procedure. B. Avoid puncturing the lateral heel to prevent damaging sensitive structures. C. Blot the site with a dry gauze after rubbing it with an alcohol swab. D. Grasp the calf of the baby during the procedure to prevent injury. 2 | Page
28. A newborn nursery nurse notes that a baby’s body is jaundiced at 36 hours of life. Which of the following nursing interventions will be most therapeutic? A. Maintain a warm ambient environment. B. Have the mother feed the baby frequently. C. Have the mother hold the baby skin to skin. D. Place the baby naked by a closed sunlit window. 29. Nurse Colet noticed that the neonate that is under phototherapy because of elevated bilirubin levels, has loose and green stools. Which of the following is the appropriate action should the nurse take at this time? A. Discontinue the phototherapy B. Notify the MD. C. Obtain the baby’s temperature D. Assess the skin integrity of the baby. 30. A 5-day-old baby receiving phototherapy has the following nursing diagnosis: Risk for fluid volume deficit. Which of the following client outcomes calls for the nurse to keep an eye on the infant? A. 6 saturated diapers in 24 hours. B. Breastfeeds 6 times in 24 hours. C. 12% weight loss since birth. D. Apical heart rate of 176 bpm. 31. Which of the following must Nurse Maloi include in her discharge teaching regarding the vaccine? A. The woman should not become pregnant for at least 4 weeks. B. The woman should pump and dump her breast milk for 1 week. C. The mother must wear a surgical mask when she cares for the baby. D. Passive antibodies transported across the placenta will protect the baby 32. A client who is three days postpartum is asking why she needs to receive the rubella vaccine before being discharged from the hospital. Which of the following explanations should the nurse provide? A. The client’s current obstetric condition is ideal for administering the vaccine. B. The client’s immune system is particularly receptive during the postpartum period. C. The client’s baby will be at a high risk of contracting rubella if the mother does not get vaccinated. D. The client’s insurance will cover the cost of the vaccine if it is administered during the immediate postpartum period. 33. To help prevent infection, Nurse Mikha teaches the postpartum client to do which of the following? A. Use antibiotic ointment on the perineum daily. B. Replace the peripad after each time she urinates. C. Urinate at least every two hours. D. Spray the perineum with povidone-iodine solution after each bathroom visit. 34. A client who is three days postpartum asks the nurse, "When can my husband and I resume sexual activity?" The nurse should advise the couple to wait until which of the following conditions is met? A. The client has completed her six-week postpartum check-up. B. The episiotomy has healed and the lochia has stopped. C. The lochia has turned pink and the vaginal tenderness has subsided. D. The client has had her first menstrual period after childbirth. 35. A woman, 24 hours postpartum, complains of excessive sweating but has no other symptoms. Which of the following actions should the nurse take? A. Measure the woman's temperature. B. Suggest the woman reduce her fluid intake. C. Reassure the woman that this is a normal occurrence. D. Notify the neonate's pediatrician. Situation: Lara, a 30-year-old woman, gave birth to her first child, a healthy baby boy, two days ago. She is experiencing lochia discharges, which are normal vaginal discharges following childbirth. Sarah notices that the color and amount of discharge vary throughout the day, and she has questions about what is considered normal in terms of color, consistency, and duration of lochia. 36. The nurse is assessing the involution progress of a woman who is 3 days postpartum. Which of the following findings would the nurse evaluate as normal? A. Fundus 1 cm above the umbilicus, with lochia that is pink (rosa). B. Fundus 2 cm above the umbilicus, with lochia that is white (alba). C. Fundus 2 cm below the umbilicus, with lochia that is red (rubra). D. Fundus 3 cm below the umbilicus, with lochia that is pink tinged with blood (serosa). 37. During a home visit, the nurse evaluates a client who is 2 weeks postpartum. Which of the following signs or symptoms should the nurse anticipate? A. Profuse sweating (diaphoresis). B. Whitish vaginal discharge (lochia alba). C. Cracked nipples. D. High blood pressure (hypertension). 38. The day after giving birth, a woman's uterus is firm and located 1 cm below the umbilicus. She reports moderate lochia and expresses concern, saying, "All I do is go to the bathroom." What is an appropriate nursing response? A. Catheterize the client as per doctor's orders. B. Monitor the client's next urination. C. Explain to the client that polyuria is normal. D. Assess the specific gravity of the next urination. 39. A breastfeeding client, G10P6408, delivered 10 minutes ago. What is the most critical assessment for the nurse to conduct at this time? A. Pulse. B. Fundus. C. Bladder. D. Breast. 40. The nurse is attending to a Seventh Day Adventist woman who had a cesarean section delivery of a baby boy. Which of the following inquiries should the nurse make regarding the woman’s care? A. “Would you prefer a vegetarian clear liquid diet to be ordered for you?” B. “Do you require any special accommodations for your Sabbath on Sunday?” C. “Would you like assistance in arranging for the baptism with your clergy?” D. “Will a clergy member be performing the circumcision on your baby?” Situation: Emily is currently at 28 weeks of gestation and has been closely monitored due to the higher risks associated with monochorionic pregnancies, she attends regular prenatal appointments to ensure both babies are developing adequately and to address any potential complications promptly. Emily is preparing for the unique challenges and joys of welcoming two babies into her life simultaneously, knowing that careful monitoring and medical management are essential for the health and well-being of her monochorionic twins. 41. A pregnant woman is expecting monochorionic twins. For which of the following complications should this pregnancy be monitored? A. Low amniotic fluid levels B. Placenta covering the cervix C. Disproportion between the fetal head and the mother's pelvis D. Abnormal blood flow between the twins 42. During ultrasound examination, it is observed that a hospitalized woman with monochorionic twins is experiencing twin-to-twin transfusion syndrome. Which of the following should the nurse closely monitor in this client? A. Rapid fundal growth. B. Vaginal bleeding. C. Projectile vomiting. D. Congestive heart failure. 43. A nurse is assessing four clients who are 22 weeks pregnant. The nurse notifies the obstetrician which client may potentially be pregnant with twins. A. The client who states that she feels huge. B. The client with a weight gain of 13 pounds. C. The client whose fundal height measurement is 26 cm. 3 | Page