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NUR 403 Exam 2 Prep Questions with Correct Answers
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NUR 403 Exam 2 Prep Questions with Correct Answers
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NUR 403 Exam 2 Prep Questions with CorrectAnswers
The nurse admits a client in active labor to the birthing center. She is
100% effaced, dilated 3 cm, and at +1 station. What stage of labor has
this client reached?
First
Latent
Second
Transitional Correct Answer-First
Rationale
The first stage of labor lasts from the onset of contractions until the
cervix is fully dilated at 10 cm. The client is in the early phase of the
first stage of labor. There is no latent stage of labor. The second stage of
labor lasts from complete dilation to birth. There is no transitional stage
of labor; transition is the last phase of the first stage of labor.
When assessing a neonate immediately after birth, the nurse observes an
inability to close the eyes completely. The nurse also observes drooping
of the corner of the neonate's mouth, and the absence of wrinkling of the
forehead and nasolabial fold. What does the nurse infer from these
findings?
,The neonate has bleeding in the subgaleal layer from labor.
The neonate's cranial nerve V was pressurized during labor.
The neonate's cranial nerve VII was pressurized during labor.
The neonate was exposed to vaginal gonorrheal infection during labor.
Correct Answer-The neonate's cranial nerve VII was pressurized during
labor
Rationale
Inability to close the eyes completely, drooping of the corner of mouth,
and absence of wrinkling of the forehead and nasolabial fold indicate
facial paralysis. When the facial nerve, or cranial nerve VII, is
pressurized during labor, it can result in facial paralysis. Bleeding in the
subgaleal layer indicates subgaleal hemorrhage in a neonate. Subgaleal
hemorrhage is not characterized by inability to close the eyes, drooping
of the corner of mouth, or absence of wrinkling of the forehead and
nasolabial fold. Cranial nerve V does not innervate the face, so damage
to cranial V does not result in facial paralysis. A neonate who is exposed
to vaginal gonorrheal infections during labor may develop ophthalmia
neonatorum, not facial paralysis.
The nurse is assessing a 12-hour-old newborn. Which clinical finding
should be reported to the health care provider in a timely manner?
,Jaundice
Cephalhematoma
Erythema toxicum
Edematous genitalia Correct Answer-Jaundice
Rationale
Jaundice occurring in the first 24 hours of life is pathological; it is
associated with Rh or another blood incompatibility. Cephalhematoma is
a collection of blood between the skull and periosteum that does not
cross the suture line; it resolves within 6 weeks, and although it should
be documented it does not require treatment. Erythema toxicum is
newborn dermatitis, believed to be an inflammatory response. The rash
is harmless, and although it should be documented it does not require
treatment. Edematous genitalia, a response to maternal hormones, are
common in newborns.
The nurse is caring for four clients on the postpartum unit. Which client
will most likely state that she is having difficulty sleeping due to
afterbirth pains?
Multipara who has vaginally delivered three children
, Primipara whose newborn weighed 7 lb
Multipara with effectively controlled diabetes
Multipara whose second child was small for gestational age Correct
Answer-Multipara who has vaginally delivered three children
Rationale
A multipara's uterus tends to contract and relax spasmodically, even if
uterine tone is effective, resulting in pain that may require an analgesic
for relief. A primipara's uterus usually remains in the contracted state
unless the newborn is large for gestational age. However, she is less
likely to have afterbirth pains requiring an analgesic than a multipara is.
If a client's diabetes is controlled during pregnancy, she is not likely to
give birth to a large infant. Although a multipara might have afterbirth
pains even with a small newborn, the pain probably will be mild because
the uterus was not fully stretched.
The nurse is assessing a new mother at a healthcare facility. Which
symptom does the nurse identify as a risk factor for postpartum blues?
Frantic energy
Mild irritability
Hallucinations
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