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NURS 3610 Quiz 2 With Verified Solutions
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NURS 3610 Quiz 2 With Verified Solutions 2024-2025A nurse is monitoring the electronic fetal heart rate monitor tracing for a client who is at
40 weeks of gestation and who is in labor. The nurse would suspect that the umbilical
cord is compromised when she observes which of the following patterns?
A. Early decelerations
B. Accelerations
C. Late decelerations
D. Variable decelerations - Answer D. Variable decelerations
Variable decelerations are those that occur when the umbilical cord has become
compressed and oxygen flow to the fetus is disrupted.
* Remember VEALCHOP
A newborn nursery nurse is caring for a group of newborns. Which of the following
newborns requires immediate intervention?
A. A newborn who is 24 hr post-delivery and has not voided.
B. A newborn who is 18 hr post-delivery and has acrocyanosis
C. A newborn who is 24 hr post-delivery and has not passed meconium
D. A newborn who is 12 hr post-delivery and has a temperature of 37.5C (99.5F) -
Answer D. A newborn who is 12 hr post-delivery and has a temperature of 37.5C (99.5F)
Hyperthermia in the newborn requires immediately intervention. Hyperthermia is usually
caused by increased heat production related to sepsis or decreased heat loss.
A nurse is providing care for a client who is 12hr postpartum and has had spinal
anesthesia for a cesarean birth. Which of the following findings would necessitate an
immediate nursing response?
A. Blood pressure 100/70 mmHg
,B. Headache pain of 6 on a scale of 0 to 10
C. Respiratory rate 10/min
D. Urinary output 30mL/hr - Answer C. Respiratory rate 10/min
A client who has undergone spinal anesthesia is susceptible to respiratory depression
and hypotension. The client is experiencing a respiratory rate of 10/min, which is
defined as bradypnea and should be treated immediately.
A nurse is providing care for a client who has just given birth to her first newborn. The
nurse suspects hyperbilirubinemia due to Rh incompatibility. The nurse should know
that hyperbilirubinemia occurs with Rh incompatibility for which of the following
reasons?
A. The Rh factor is not present in the client's blood; thus, she develops anti-Rh
antibodies, which cross the placental barrier and cause hemolysis of red blood cells in
the newborn.
B. The client's blood contains the Rh factor and that of the newborn does not; antibodies
that destroy red blood cells are formed in the fetus.
C. The client has a history of receiving a transfusion with Rh-negative blood.
D. The client's anti-A and anti-B antibodies cross the placenta and cause the destruction
of the fetus's red blood cells. -Answer A: The Rh factor in the blood is absent in this
client; hence, she develops anti-Rh antibodies which cross the placental barrier and
hemolyze red blood cells in the new borns.
If the Rh-negative customer has been sensitised or exposed to Rh-positive fetal blood,
she will develop antibodies against the Rh factor. These antibodies can cross the
placenta and lyse the red blood cells of the Rh-positive fetus. This increased rate of
destruction of red blood cells results in the increased release of bilirubin. The serum
bilirubin level of the newborn can increase rapidly.
A nurse is teaching a newborn's parent how to care for the cord stump. Which of the
following instructions should the nurse provide?
A. Wash the cord daily with mild soap and water.
B. Cover the cord with the diaper.
, C. Apply petroleum jelly to the cord stump.
D. Give a sponge bath until the cord stump falls off. -Answer D. Give a sponge bath until
the cord stump falls off.
Immersing the stump in water delays the drying, separation, and healing process.
Sponge baths are appropriate until the stump falls off.
A nurse is caring for a client who is postpartum. The client tells the nurse that the
newborn's maternal grandmother was born deaf and asks how she will know if her
newborn can hear well. The nurse should respond with which of the following
statements?
A. "There's nothing to be alarmed about in that regard. Most types of hearing loss are
not genetic."
B. "Look how she watches you when you talk to her. That's a very good indicator."
C. "We do routine audiological testing on newborns. You will know before you leave the
hospital."
D. "The best way to determine if your baby can hear is to clap your hands loudly and see
if she startles." - Response C. "We do routine hearing screenings on newborns. You'll
know the results before you leave the hospital."
Most states require hearing screening for all newborns. The two tests in use do not
diagnose hearing loss, but determine whether or not a newborn requires further
evaluation.
A nurse is providing care for a client who is initiating breastfeeding of her newborn after
birth of the baby. The new mother states, "I won't take anything for pain because I am
breast feeding." Which of the following statements is appropriate for the nurse to say?
A. You need to take pain medication so you can be comfortable.
B. "We can time your pain medication so you have an hour or two before the next
feeding."
C. "All medications are present in breast milk to some degree."
D. "You can refuse any pain medication if this concerns you." -Answer B. "We can time
your pain medication so you have an hour or two before the next feeding."
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