Week 3 EAQ/HESIs Flashcards
Diminished movement in an extremity may indicate _______ damage.
nerve
The nurse performs a newborn assessment and evaluates the infant’s reflexes. How does the nurse perform the Moro reflex?
Hold the infant upright with his feet touching a solid surface.
Place a finger in the infant’s palm and assess whether the infant’s hand closes in a fist.
Slightly raise the infant’s head and trunk and allow the infant to drop back 30 degrees.
Stroke the lateral side of the sole of the infant’s foot from the heel to the ball of the foot.
Slightly raise the infant’s head and trunk and allow the infant to drop back 30 degrees.
This would elicit the infant’s arms and legs to extend and abduct, with fingers fanning open.
While administering the vitamin K to the infant, which action should the nurse take?
Select the middle third of the vastus lateralis for use.
Place the infant on the abdomen for better visualization.
Use the V technique after cleaning the ventral gluteal area.
Administer the medication using a 22 gauge, ½ inch needle.
Select the middle third of the vastus lateralis for use.
The nurse next prepares to administer the erythromycin ointment. Which approach should the nurse use to administer the ointment?
Apply ointment across the closed eyelids and rub the eye gently.
Open the eye using two fingers and apply ointment to the upper lid.
Apply gentle pressure to the inner canthus after applying ointment to eyes.
Cover entire lower conjunctiva with ointment after gently retracting the lid.
Cover entire lower conjunctiva with ointment after gently retracting the lid.
The infant rash, erythema toxicum, is very common and usually disappears by the _____ day of life.
third
The loose _______ stools are a typical response to phototherapy
green
The client asks how she will know the phototherapy is working. How should the nurse respond?
Stools are loose and bright green.
Formula feedings increase.
Serum bilirubin level decreases.
Skin is resilient with no indications of jaundice.
Serum bilirubin level decreases.
Which intervention would the nurse recommend for post-cesarean gas pain?
Lying on the right side
Walking around the room
Using a straw when drinking water
Supporting the incision when moving
Walking around the room
A client at 36 weeks’ gestation has a blood pressure of 140/90. Which additional sign of preeclampsia would the nurse assess for?
Urine dipstick positive for protein
Mild ankle edema
Episodes of dizziness on arising
Weight gain of 2 lb (907 g) in 2 weeks
Urine dipstick positive for protein
Which test is used to confirm breech presentation?
Ultrasound
Fetal scalp pH
Amniocentesis
Digital pelvimetry
Ultrasound
Which is a neonatal effect of maternal smoking during pregnancy?
Low birth weight
Facial abnormalities
Chronic lung problems
Hyperglycemic reactions
Low birth weight
Why is a multiple-gestation pregnancy considered a high risk?
Postpartum hemorrhage is an expected complication.
Perinatal mortality is two to three times more likely in multiple than in single births.
Optimal psychological adjustment after a multiple birth requires 6 months to 1 year.
Maternal mortality is higher during the prenatal period in the setting of multiple gestation.
Perinatal mortality is two to three times more likely in multiple than in single births.
Which position increases cardiac output in the obstetrical client with cardiac disease?
Trendelenburg
Low semi-Fowler
Lateral positioning
Supine with legs elevated
Lateral positioning
A pregnant client is admitted with abdominal pain and heavy vaginal bleeding. Which is the immediate nursing action?
Establish intravenous access
Elevate the head of the bed
Position the client laterally to the left
Administer an intramuscular analgesic
Establish intravenous access
Which factor contraindicates sexual intercourse during pregnancy?
Fetal tachycardia
Presence of leukorrhea
Premature rupture of membranes
Imminence of the estimated date of birth
Premature rupture of membranes
For which complication would a client who has had a spontaneous abortion be assessed?
Hemorrhage
Dehydration
Hypertension
Subinvolution
Hemorrhage
Which is the priorityinitial nursing intervention during the admission of a primigravida in labor?
Monitoring the fetal heart rate
Asking the client when she ate last
Obtaining the client’s health history
Determining whether the membranes have ruptured
Monitoring the fetal heart rate
When a fetus is in a footling breech presentation, the nurse plans and implements care with which consideration in mind?
Severe back discomfort will occur.
Length of labor usually is shortened.
Cesarean birth probably will be necessary.
Meconium in the amniotic fluid is a sign of fetal hypoxia.
Cesarean birth probably will be necessary.
A breast-feeding mother experiences redness and pain in the left breast, a temperature of 100.8°F (38.2°C), chills, and malaise. Which condition would the nurse suspect?
Mastitis
Engorgement
Blocked milk duct
Inadequate milk production
Mastitis
Which condition is most commonly associated with late decelerations of the fetal heart rate?
Head compression
Maternal hypothyroidism
Uteroplacental insufficiency
Umbilical cord compression
Uteroplacental insufficiency
Which preexisting condition is an indication for a cesarean birth?
Gonorrhea
Chlamydia
Chronic hepatitis
Active genital herpes
Active genital herpes
Which is the most appropriate nursing intervention for a client admitted to the high-risk prenatal unit at 35 weeks’ gestation with a diagnosis of complete placenta previa?
Applying a pad to the perineal area
Having oxygen available at the bedside
Allowing bathroom privileges with assistance
Educating the client regarding the intensive care nursery
Having oxygen available at the bedside
If hemorrhage should occur, oxygen is necessary to prevent maternal and fetal compromise. A perineal pad is not necessary; close monitoring is required. The client admitted with a complete placenta previa is usually on complete bed rest. It is too soon to discuss the neonatal intensive care unit, because this may ultimately be unnecessary.
A client comes to the emergency room reporting severe abdominal cramping and heavy bleeding at 10 weeks’ gestation. Cervical examination reveals heavy bleeding; the cervical os is open and tissue is present. Which type of abortion is the client experiencing?
Missed
Complete
Inevitable
Threatened
Inevitable
A client has had surgery for a ruptured fallopian tube from an ectopic pregnancy. Which information would be included in the postoperative teaching plan?
Effect on future pregnancies
How to prevent another tubal pregnancy
Need for Rho (D) immune globulin to prevent isoimmunization
Importance of not douching after intercourse, because this may dislodge a fertilized egg
Effect on future pregnancies
Removing a fallopian tube does not impair the ovaries’ ability to release an egg, which may be fertilized in the remaining tube if it is undamaged. There is no known way to prevent future tubal pregnancies. There is no information to indicate that the client is Rh negative, requiring the administration of Rho (D) immune globulin. Liquid from a douche does not reach the fallopian tube or dislodge a fertilized egg; in addition, douching is no longer recommended at any time.
