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NUR 230 EXAM 2 | Latest Actual Exam | All 50 Questions and Correct Answers, Exams of Nursing

Walden UniversityNursing

1.) The nurse is providing instructions to a client who is breastfeeding her newborn. Which ofthe following statements by the client indicates the need for further instructions? “I should. Use water and antibacterial soap to clean my nipples” “I should breastfeed 8-12 time per day” “I should use pillows to help support my baby while at the breast” “I should make sure the baby latches on well in the beginning” 2.) The nurse is teaching a post-partum client who has been prescribed Pho(D) immune globulin (RhoGAM) about the purpose of this medication. The nurse determines that teaching is effective if the client states that RhoGAM will protect her next baby from A. Developing Rh antigens B. Being affected by Rh incompatibility C. Developing physiological jaundice D. Having Rh positive blood 3.) The nurse is caring for a client in the 4th stage of labor following a spontaneous vaginal delivery. The medical record indicates an estimated blood loss of 600mL.

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NUR 230 EXAM 2 | Latest Actual Exam |
All 50 Questions and Correct Answers |
Verified Answers!
1.) The nurse is providing instructions to a client who is breastfeeding her newborn. Which of the
following statements by the client indicates the need for further instructions?
“I should. Use water and antibacterial soap to clean my nipples”
“I should breastfeed 8-12 time per day”
“I should use pillows to help support my baby while at the breast”
“I should make sure the baby latches on well in the beginning”
2.) The nurse is teaching a post-partum client who has been prescribed Pho(D) immune globulin
(RhoGAM) about the purpose of this medication. The nurse determines that teaching is effective
if the client states that RhoGAM will protect her next baby from
A. Developing Rh antigens
B. Being affected by Rh incompatibility
C. Developing physiological jaundice
D. Having Rh positive blood
3.) The nurse is caring for a client in the 4th stage of labor following a spontaneous vaginal
delivery. The medical record indicates an estimated blood loss of 600mL. The client has a hx of
HTN. Which medication should the nurse recognize as being contraindicated for this client.
A. Methyl prostaglandin
B. Oxytocin
C. Methylergonovine
D. Misoprostol
4.) The nurse is caring for assigned postpartum clients. The nurse recognized that client at
highest risk for a post-partum infection is the client who
A. Had eclampsia
B. Delivered a preterm infant
C. Delivered via cesarean birth
D. Had a second-degree laceration
5.) The nurse is caring for a client and notes the following laboratory results on the first day
after delivery: WBC count 22,000mm, hemoglobin 13.0 g/dL, and platelets 90,000mm3. Which
of the following is a correct interpretation of the client’s laboratory values?
A. Client is developing a postpartum infection
B. Platelets are abnormal and would place the client at risk for postpartum hemorrhage
C. Hemoglobin is low but normal for the postpartum client
Blood bank needs to be notified to send immune globulin human for the client
6.) The nurse is caring for a client who gave birth 18 hours ago. The client reports that her
nipples are getting tender and the baby is not breastfeeding well. Which of the following
responses is appropriate by the nurse?
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Download NUR 230 EXAM 2 | Latest Actual Exam | All 50 Questions and Correct Answers and more Exams Nursing in PDF only on Docsity!

NUR 230 EXAM 2 | Latest Actual Exam |

All 50 Questions and Correct Answers |

Verified Answers!

1.) The nurse is providing instructions to a client who is breastfeeding her newborn. Which ofthe following statements by the client indicates the need for further instructions? “I should. Use water and antibacterial soap to clean my nipples” “I should breastfeed 8 - 12 time per day” “I should use pillows to help support my baby while at the breast” “I should make sure the baby latches on well in the beginning” 2.) The nurse is teaching a post-partum client who has been prescribed Pho(D) immune globulin (RhoGAM) about the purpose of this medication. The nurse determines that teaching is effective if the client states that RhoGAM will protect her next baby from A. Developing Rh antigens B. Being affected by Rh incompatibility C. Developing physiological jaundice D. Having Rh positive blood 3.) The nurse is caring for a client in the 4th^ stage of labor following a spontaneous vaginal delivery. The medical record indicates an estimated blood loss of 600mL. The client has a hx of HTN. Which medication should the nurse recognize as being contraindicated for this client. A. Methyl prostaglandin B. Oxytocin C. Methylergonovine D. Misoprostol 4.) The nurse is caring for assigned postpartum clients. The nurse recognized that client at highest risk for a post-partum infection is the client who A. Had eclampsia B. Delivered a preterm infant C. Delivered via cesarean birth D. Had a second-degree laceration 5.) The nurse is caring for a client and notes the following laboratory results on the first day after delivery: WBC count 22,000mm, hemoglobin 13.0 g/dL, and platelets 90,000mm3. Which of the following is a correct interpretation of the client’s laboratory values? A. Client is developing a postpartum infection B. Platelets are abnormal and would place the client at risk for postpartum hemorrhage C. Hemoglobin is low but normal for the postpartum client Blood bank needs to be notified to send immune globulin human for the client 6.) The nurse is caring for a client who gave birth 18 hours ago. The client reports that her nipples are getting tender and the baby is not breastfeeding well. Which of the following responses is appropriate by the nurse?

A. “Apply a small amount of topical breast cream to help with the discomfort” B. “Make sure to compress the breast so the baby can get an adequate mount of breast tissue into the mouth.” C. Wait until the baby is crying to show hunger, then breastfeed to help improve latching.” D. “Try removing the infant’s clothing and putting the baby skin to skin on your chest.” 7 .) The nurse is caring for a client who is 1 hour postpartum and observes a moderate amount of lochia rubra and several small clots on the client’s perineal pad. The fundus is midline and firm at the umbilicus. Which of the following actions should the nurse implement? A. Notify the PCP B. Document findings and continue to monitor the client C. Encourage the client to empty bladder D. Increase the frequency of the fundal massage 8 .) The nurse is teaching a client with Diabetes Mellitus (Type 1) who just delivered a healthy baby. Which of the following information should the nurse include in the client’steaching? A. Change to oral hypoglycemia medications that will control sugar levels better than insulin B. Urine should be checked for ketones every time the client voids C. Due to hormonal changes after delivery, the need for insulin may decrease D. Feed the baby formula since insulin received though breastfeeding may cause low sugar. 9 .) The nurse is caring for the following clients in the postpartum unit. Which client should the nurse see first? A. Multipara mother who has saturated 2 perineal pads in one hour B. Primipara mother who delivered 3 hours ago and is having difficulty getting the baby to latch on to the breast C. Primipara mother requesting help with repositioning her baby to decrease incisional pain from a cesarean delivery D. Multipara mother who delivered 16 hours and is experiencing abdominal cramping and sweating. 10 .) The nurse is assigned clients who delivered withing the last 24 hours and just receivedthe change of shift report. Which of the following clients should the nurse assess first? A. The client who reports discomfort in the perineal area from an episiotomy B. The client who has a temp of 100.3F orally C. The client who reports passing a dime sized clot with the last void D. The client who has changes in pulse from 76 to 102 11 .) The nurse is caring for a formula-feeding postpartum client who reports painful swollen breasts on her third post-partum day. The nurse should encourage the mother to A. Gently massage the breasts B. Refrain from expelling milk C. Place lettuce leaves on the breasts D. Stimulate the nipple manually 12 .) The nurse is assessing a client who is 24 hours postpartum. Which of the followingfindings is most important for the nurse to follow up?

D. Instruct the client to drink 2- 3 glasses of water within the next 24 hours 19.) The nurse is caring for a 15 year old client and her newborn. The client is texting on her phone and ignores her newborn. Which strategy should help facilitate mother-infant attachment for this client? A. Suggest the mother put the phone on vibrate and interact with her newborn B. Arrange for the mother to watch a video on parent-infant interaction C. Demonstrate different positions for holding her infant while feeding D. Show the mother how the infant initiates interaction and pays attention to her 20.) The nurse is caring for a postpartum client and her newborn. The nurse observes the newborn crying and the mother picking the newborn up to calm them down. This reflects the client is experiencing A. Mutuality B. Synchrony C. Reciprocity D. Claiming 21.) The nurse is caring for a postpartum client of Vietnamese descent. The client’s husband brings a large container of seaweed soup to the hospital. When the nurse enters the room, the husband asks for help with warming the soup for the client. Which of the following is an appropriate response by the nurse? A. “I’ll warm the soup in the microwave for you” B. “What ingredients are in the soup?” C. “Didn’t you like your lunch today?” D. “is the doctor okay with you eating this soup?” 22.) The nurse is providing discharge instructions to a new mother about formula feeding. Which of the following statements by the client indicates a need for a further teaching? A. “I should hold my baby in a semi-upright position during the feeding” B. “My baby needs about 6 - 8 feedings per day” C. “I should burp my baby after a few ounces” D. “I should use prepared bottles within 24 hours” 23.) The nurse is caring for a client who has mastitis about self-care. Which of the following statements by the client indicates the need for further teaching? A. “I will wear a comfortable bra for support between feedings” B. “I need to get plenty of rest” C. “I will take my antibiotics as prescribed until finished” D. “I need to leave some milk in each breast so this doesn’t happen again” 24.) A nurse is providing postpartum care to a mother with diabetes and her newborn. One- and one-half hours post-delivery, the nurse observed tremors of the newborn’s extremities. Which action should the nurse take? A. Obtain a CBC with differential B. Feed the newborn concentrated formula

C. Obtain a blood glucose level D. Place the newborn skin to skin with mother 25.) The nurse is caring for a Rh-positive infant who was born to a Rh-negative mother. The pediatrician orders a direct Coombs test on the cord blood sample to determine damaging antibodies. The nurses should suspect maternal isoimmunization if the infant appears. A. Lethargic B. Irritable C. Jaundiced D. Cyanosis 26.) The nurse is caring for a newborn 4 hours after birth. Which of the following actions should the nurse include in the plan of care to prevent jaundice? A. Suction excess mucus with bulb syringe B. Initiate early feeding C. Begin phototherapy D. Prepare for an exchange blood transfusion 27.) The nurse is observing a new mother caring for her newborn for the first time. Which of the following observations requires the nurse to intervene? A. Mother supporting the head when holding the newborn B. Mother using a cotton-tipped swab to clean the newborn’s ears C. Mother cleaning the newborns eyes from inner to outer canthus D. Mother keeping the diaper below the umbilical cord 28.) The nurse is caring for a full-term in the nursery. Which of the following findings is expected during the physical assessment? A. Dry, cracked or excessive peeling skin B. Fist often clenched with thumb under fingers C. Thin, transparent skin D. Excessive lanugo 29.) The nurse is caring for a 2-day old male newborn of Jewish parents. When reviewing the PCP’s ordered, which of the following requires follow up by the nurse? A prescription for A. Vaccinations B. Hearing screening C. Formula if not enough breast milk intake D. Scheduled circumcision 30.) The nurse is caring for the following newborn clients. Which client should the nurse assess first? A. The newborn who is 18 hours old and has not passed a meconium stool B. The newborn who is 8 hours old and has periods of apnea lasting 10 seconds C. The newborn who is 12 hours old and has blue hands and feet D. The newborn who is 4 hours old and has elevated bilirubin level

A. Newborn who is 18 hours post-delivery and has acrocyanosis B. Newborn who is 12 hours post-delivery and has a soft heart murmur C. Newborn who is 8 hours post-delivery and has not voided D. Newborn who is 10 hours post-delivery and has not passed meconium 38.) The nurse is preparing a newborn who is 24 hours old for discharge. The nurse should notify the PCP if the newborn has A. A blood glucose level of 30 mg/dL B. Caput succedaneum C. A bilirubin of 4mg/dL D. Respirations of 32 39.) The nurse is assessing a newborn. Which is the following findings is a priority for the nurse to follow up? A. Chin quivering and negative gag reflex B. Erythema toxicum and milia C. Blood pressure of 78/56 mmHg and pulse of 116 D. Irregular shallow respirations at a rate of 44 40.) A nurse caring for a client who delivered a baby 24 hours ago. The client has a blood type of AB negative. Which intervention should the nurse include in the client’s plan of care? A. Check the infant’s hemoglobin (Hgb) and hematocrit (Hct) level B. Assess the newborn for jaundice C. Assess the infant for hypoglycemia D. Determine the blood type of the father 41.) 42.) 43.) The nurse is caring for a newborn who was circumcised 30 minutes ago. Assessment reveals a moderate amount of bright red blood on the dressing. Which of the following should the nurse preform first? A. Notify the PCP B. Reassess the penis in 30 minutes C. Apply slight pressure and a gauze dressing D. Assess the infant’s vital signs 44.) The nurse prepares to administer a Vitamin K injection to a newborn. The mother asks the nurse why her infant needs the injection. Which of the following is the best response by the nurse? A. “The vitamin K will protect your newborn from being jaundiced” B. “Your newborn needs vitamin K to begin digesting milk” C. “Newborns are deficient in Vitamin K, and this injection prevents your newborn from bleeding”

D. “Newborns have sterile bowels, and Vitamin K promotes growth of bacteria in the bowel” 45.) The nurse is developing a plan of care for an 18-hour old baby who is receiving phototherapy. Which of the following interventions should the nurse include in the plan? A. Tightly swaddle the baby to maintain normal temperature. B. Administer prescribed IV fluids C. Cover the eyes with an opaque mask D. Give the baby rehydration therapy after all feedings. 46.) The nurse is assessing a neonate for signs of ICP. Which of the following findings indicate increased ICP in the neonate? A. Fluid behind tympanic membrane B. Hypotension C. Jugular vein distension D. Tight anterior fontanel 47.) The nurse has received report on an agpar score of 6 on the second test. The nurse interprets this result as an A. Infant who appears to be having severe distress B. Infant having difficulty adjusting to extrauterine life C. Indicator of moderate difficulty adjusting to extrauterine life D. Indicator of possible neurologic problems 48.) The nurse is caring for a preterm infant who has yellow skin color and a rising bilirubin level. The nurse is aware that this infant is at risk for A. Renal failure B. Neutropenia C. Brain damage D. Respiratory infection 49.) The nurse is teaching a postpartum client about the tonic neck newborn reflex. The nurse determines teaching has been effective when the client reports that the newborn will A. Turn the head to the left, extend left extremity, and flex right extremity B. Extend and abduct the arms and legs with the toes fanning out C. Extend both arms out and abduct them in an embracing motion D. Move legs up and down when held on a firm surface 50.) The nurse is preforming an assessment of a newborn suspected of having unilateral developmental dysplasia of the hip (DDH). Which of the following assessment findings should the nurse expect to note in this condition? A. Asymmetry of the gluteal skin folds when the legs are extended B. An apparent short femur on the unaffected side C. Full range of motion in the affected hip D. Asymmetrical adduction of the affected hip when placed in supine with the knees and hips flexed.