Unit 2 TopHat Questions Flashcards
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Q: While performing a complete assessment of a term neonate, which of the following findings would alert the nurse to notify the pediatrician?
a. red reflect in the eyes
b. expiratory grunt
c. respiratory rate of 45 breaths per minute
d. prominent xiphoid process
b. expiratory grunt
a. an absent reflex may indicate congenital cataracts, the presence of a red reflect in the eyes in normal
c. respiratory rate of 45 breaths/minute is normal in a term neonate
d. xiphoid process./and a prominent are normal findings in a term neonate
an expiratory grunt is significant and should be reported promptly, because it may indicate respiratory distress and the need for further intervention such as oxygen or resuscitation efforts
Q: A 27 yr old female 30 weeks pregnant presents to her MD for routine follow-up : Bp 150/105 Hg. She was previously normotensive. Urinalysis reveals 1+ proteinuria. Serum uric acid level is 5.0mg/dl. Platelet count and liver function tests are normal. 24hr. Urine collection shows 1.1g. of protein
Which of the followong does this patient most likely have? A. Chronic hypertension B. Gestational Hypertension C. Normal Blood pressure for pregnancy D. Pre-eclampsia
D. Pre-eclampsia
Q: 38 year old woman who is 36 weeks pg presents with HTN since age 34 with requires antihypertensive drugs. Prior to PG her BP was 130/70. During her first trimester BP 120/60 and has risen in recent weeks to 150/95. She is complaining of worsening lower extremity edema. 24 hour urine shows 1500 mg of protein. Lab values for lytes, liver function tests platelet count are normal.
What is the patients diagnosis? A. Chronic essential hypertension B. Eclampsia C. HELLP syndrome D. Preeclampsia
D. Preeclampsia
Q: 36 week PG woman presents complaining of mid-epigastric tenderness, nausea and vomiting. She looks unwell. Her BP is 146/100, lab test show normal renal function, low platelet count, AST level of 80 IU/L ( elevated liver enzymes, and hemolysis with a microangiopathic blood smear. She is diagnosed with HELLP . Which of the following is the most\ important initial therapeutic intervention for this patient?
A. Bedrest until fetal reaches 40 weeks
B. Immediate delivery
C. Platelet infusion to prevent bleeding
D. Right upper quadrant ultrasound
B. Immediate delivery
Q: A prim parous client who is bottle feeding her neonate at 12 hours after birth asks the nurse, “When will my menstrual cycle return? Which of the following responses by the nurse would be most appropriate?
A. “Your menstrual cycle will return in 3 to 4 weeks.”
B. “It will probably be 6 to 10 weeks before it starts again.”
C. “You can expect your menses to start in 12 to 14 weeks.”
D. “Your menses will return in 16 to 18 weeks.”
B. “It will probably be 6 to 10 weeks before it starts again.”
Q: A client is in the first hour of her recovery after a vaginal deliver. During an assessment, the lochia is moderate, bright red and is trickling from the vagina. The nurse locates the fundus at the umbilicus: it is firm and midline with no palpable bladder. The client vital signs remain at their baseline. Based on this information, the nurse would implement which of the following actions?
A. Increase the I.V. rate
B. Recheck the admission hematocrit and hemoglobin levels
C. Report the finding to the health care provider.
D. Document the findings as normal
C. Report the finding to the health care provider.
BRIGHT red is not normal = fresh blood, DARK red is normal
Q: When developing the plan of care for a prim parous client during the first 12 hours after vaginal delivery, which of the following concerns of the client should be the nurse’s primary focus of care/
A. The neonate
B. The family
C. The client’s own comfort
D. The client’s significant other
C. The client’s own comfort
Q: Two hours after vaginally delivering a viable male neonate under epidural anesthesia, the client with a midline episiotomy ambulates to the bathroom to void. After voiding, the nurse assesses the clients bladder, finding it distended. The nurse interprets this finding based on the understanding that the clients bladder distention is most likely caused by which of the following?
A. Prolonged first stage of labor
B. Urinary tract infection
C. Pressure of the uterus on the bladder
D. Edema in the lower urinary tract area
D. Edema in the lower urinary tract area
Q: At which of the following locations would the nurse expect to palpate the fundus of a prim parous client two hours after delivery of a neonate?
A. Halfway between the umbilicus and the symphysis pubis
B. At the level of the umbilicus
C. Just below the level of the umbilicus
D. Above the level of the umbilicus
B. At the level of the umbilicus
Q: A client delivered vaginally two hours ago and has a third-degree laceration . There is ice in place on her perineum. However, her perineum is slightly edematous and the client is complaining of pain rated 6 on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time?
A. Begin sitz baths
B. Administer pain medication per order
C. Replace ice packs to the perineum
D. Initiate anesthetic sprays to the perineum
B. Administer pain medication per order
Q: While the nurse is preparing to assist the primparous client to the bathroom to void 6 hours after a vaginal delivery under epidural anesthesia, the client says that she feels dizzy when sitting up on the side of the bed. The nurse explains that this is most likely caused by which of the following.
A. Effects of the anesthetic during labor.
B. Hemorrhage during the delivery process
C. Effects of analgesics used during labor
D. Decreased blood volume in the vascular system
D. Decreased blood volume in the vascular system
Q: The nurse is assessing a cesarean section client who delivered 12 hours ago. Finding include a distended abdomen with faint bowel sounds x 1 quadrant, fundus firm at umbilicus, lochia scant , rubra, and pain rated 4 on a scale of 1 to 10. The I.V. and Foley
catheter have been discontinued and the client was medicated 3 hours ago for pain. When planning care for this client, what should the nurse identify as the highest priority interventions.
A. Medicate the client
B. Incentive spirometry
C. Ambulate the client
D. Encourage caring for infant
C. Ambulate the client
Q: While making a home visit to a postpartum client on day 11, the nurse would anticipate that the client’s lochia would be which of the following colors?
A. Dark red
B. Pink
C. Brown
D. White
D. White
Q: A primiparous client who underwent a caesarean delivery 30 minutes ago is a candidate for Rho(D) immune globulin (RhoGAM). The nurse anticipates administering this ordered medication within which of the following time frames after delivery?
A. 8 hours
B. 24 hours
C. 72 hours
D. 96 hours
C. 72 hours
