NUR 313 Exam 2 Review Questions and Complete Solutions
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Course
NUR 313
Institution
NUR 313
At the end of the 3rd stage of labor, there are many necessary nursing interventions. Select all that apply.
a. Vigorously massage the fundus b. Prepare for the delivery of the placenta c. Assist the mother with breastfeeding d. Place the mother on her left side to optimize perfusion e. Administer...
NUR 313 Exam 2 Review Questions and
Complete Solutions
At the end of the 3rd stage of labor, there are many necessary nursing interventions.
Select all that apply.
a. Vigorously massage the fundus
b. Prepare for the delivery of the placenta
c. Assist the mother with breastfeeding
d. Place the mother on her left side to optimize perfusion
e. Administer IV Oxytocin/Pitocin per institution protocol ✅A, C, E
- At the end of the 3rd stage of labor the placenta has been delivered. After delivery of
the placenta, the goal is to contract the uterus to control bleeding. Massaging the
fundus, administering oxytocin, and getting the mother to naturally produce oxytocin
(through breastfeeding) helps contract the uterus. D is only necessary during
pregnancy.
A G2P1 at 40 weeks gestation presents to trial and reports, "I think I'm in labor. My
contractions are 4-5 minutes apart, I had a gust of clear vaginal fluid about 15 minutes
ago. In prioritizing care for this client, the nurse should FIRST:
a. Assess a sterile cervical exam
b. Assist the HCP in the collection of the AmniSure test
c. Assess the client's vital signs
d. Place the client on the external fetal monitor ✅D
- When the client first comes to the floor in active labor, place her on the monitor so we
can get a look at the baby's status.
A baby has acrocyanosis, or blue hands and feet. Are you concerned?
a. Yes
b. No ✅B
- Acrocyanosis is normal, however central cyanosis is abnormal.
The baby's lip/mouth/tongue are blue. Are you concerned?
a. Yes
b. No ✅A
- Patient is showing signs of central cyanosis indicating respiratory distress. Other signs
that might accompany respiratory distress is nasal flaring and grunting.
, Which of the following findings indicate respiratory distress in the newborn?
a. Tachypnea
b. Apnea for 10 seconds
c. Acrocyanosis
d. Course rhonchi noted in the upper lobes ✅A
- Be concerned about apnea lasting 20 seconds, central cyanosis, and complete
rhonchi.
A 2 day old infant's blood values are:
Blood: O- direct coomb's titer
Glucose: 45
Bilirubin: 8.5mg/dL
The mother's blood type is A+. What is the nursing priority?
a. Continue to monitor
b. Start an IV line and contact the physician
c. Observe the baby for kernicterus
d. Administer Rhogam per physician's orders ✅A
- Rhogam isn't needed because mom is Rh+, glucose isn't a concern until it's <40, and
bilirubin is below 15 so no intervention is needed.
The nurse palpates a distended bladder on a woman who delivered vaginally 5 hours
ago. The woman refuses to go to the bathroom, "I really don't need to go." Which of the
following responses is the most appropriate?
a. Okay I must be palpating your uterus.
b. That feeling is most likely due to the effects of the anesthesia, but you will still need to
try in order to empty your bladder.
c. You still must be numb from the local anesthesia.
d. That is a problem, I will need to catheterize you. ✅B
- After an epidural, the woman may not feel like she has to urinate. However, it is
important for her to empty her bladder every 1-2 hours to prevent the bladder from
distending so that the uterus can properly contract.
Upon examining a patient on day 2 after spontaneous vaginal delivery, a nurse finds the
perineal pad to be completely saturated with bright red blood over the last 15 minutes.
The priority in this scenario is:
a. Start a second IV line of NS
b. Notify the HCP
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