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NUR230 FINAL EXAM NEWEST ACTUAL
EXAM 2024-2025 QUESTIONS AND
CORRECT DETAILED ANSWERS| A+
GRADE
which infants are at greatest risk of developing physiological jaundice? (SATA) a. 3 hour infant born at term b. 2 day old infant born at 35 weeks c. an 18 hour old SGA baby who is having difficulty breastfeeding d. 2 day old baby diagnosed with a cephalhematoma e. 2 hour old infant who is O- and the mother is B+ positive Correct Answer b. 2 day old infant born at 35 weeks c. an 18 hour old SGA baby who is having difficulty breastfeeding d. 2 day old baby diagnosed with a cephalhematoma an infant admitted to the neonatal intensive care unit (NICU) in exhibiting signs of neonatal abstinence syndrome. Which of the following behaviors would support this diagnosis? a. high pitched shrill cry b. hyper-dynamic precordium c. depressed fontanels d. excessive regurgitation Correct Answer a. high pitched shrill cry You are caring for a couple who has a baby with cleft lip and palate. Which statement, by the mother, displays that she understands priority interventions while feedings? a. we need to monitor for jaundice b. we need to monitor for pain c. we need to monitor for respiratory distress and aspiration d. we need to monitor for hypoglycemia Correct Answer c. we need to monitor for respiratory distress and aspiration
which of the following is NOT a risk factor associated with mastitis? a. frequent feedings b. cracked nipples c. fatigue d. inadequate emptying of the breat Correct Answer a. frequent feedings rubin describes one of the phases of maternal postpartum adjustment as "Mothers focus attention on themselves and their recovery needs. Mothers are dependent on other to make decisions and to care for their newborns." Which phase is she describing? a. taking in b. letting in c. taking hold d. letting go Correct Answer a. taking in what is the purpose of giving newborns vitamin k/phytonadione? a. it helps newborns create intestinal bacteria b. given to prevent hemorrhage due to lack of vitamin k in gut c. aids in digestion of baby's first feedings d. given to enhance newborn immunity Correct Answer b. given to prevent hemorrhage due to lack of vitamin k in gut which of the following findings indicates respiratory distress in the newborn when all are present simultaneously? SATA a. RR - 70 b. apnea for 10 seconds c. intercostal retractions d. acrocyanosis e. grunting f. nasal flaring Correct Answer a. RR - 70 c. intercostal retractions
How is BP changed in the postpartum period? Correct Answer some elevations then returns to normal - really depends on the situation How is heart rate changed in the postpartum period? Correct Answer bradycardia occurs during the first 6-10 days What are some causes of high and low BP in postpartum? Correct Answer High BP: due to preeclampsia, chronic HTN, renal disease, anxiety Low BP: due uterine hemorrhage or hematoma What are some treatment options for high BP postpartum? Correct Answer - nifedipine, labetalol, methyldopa
- magnesium sulfate IV (if a BP problem typically continues at least 24 hours postpartum) What are some causes of tachycardia in postpartum? Correct Answer tachycardia: due to difficult labor and birth, hemorrhage, infection What are some causes of marked tachypnea in postpartum? Correct Answer marked tachypnea: respiratory disease or pulmonary edema What could cause a temp above 100.4 in postpartum? Correct Answer temp of 100.4 F or above: infection What are some cardio vascular changes postpartum? Correct Answer cardiac output declines by 30% in the first 2 weeks and reaches normal levels by 6-12 weeks
- diuresis assists to decrease extracellular fluid and weight loss
What will happen if a postpartum patient is unable to eliminate all the extra fluid? Correct Answer it can lead to pulmonary edema and cardiac problems Why might a postpartum patient have tachypnea? Correct Answer fever or pain Why might a postpartum patient have bradypnea? Correct Answer respiratory compromise (pulmonary edema or if they were on meds/anesthesia) Why should you watch for respiratory fluid overload in a postpartum patient? Correct Answer We are given a lot of things that can cause fluid overload:
- fluid bolus: typically given after epidural because it causes hypotension
- pitocin: can lead to water intoxication
- mag sulfate: can cause fluid to move into lungs What are some neurological problems that can occur in a postpartum patient? Correct Answer Headaches and visual changes (spots, blurring, bright lights) Why may a postpartum patient be experiencing a headache? Correct Answer - may result in fluid shifts in the first week after birth
- leakage of CSF due to epidural or spinal (tylenol, IV fluids, caffeine, blood patch)
- chronic or GHTN
- preeclampsia
- stress and fatigue (tylenol, motrin, rest!) If someone is experiencing a headache, what should you always ask about? Correct Answer Ask if they are having any visual changes
Postpartum weight changes? when do mom's typically return to pre-pregnant weight? Correct Answer - initial weight loss of 10- 12lb (baby, placenta, amniotic fluid)
- postpartum diuresis: 5lbs
- may return to pre-pregnant weight by 6th-8th week but DEPENDS on diet, exercise, and the patient BUBBLEHE Correct Answer Breasts Uterus Bladder Bowels Lochia Episiotomy Homan's Sign Emotional Status What should be assessed during a breast assessment? Correct Answer - size and shape
- abnormalities, reddened areas, or engorgement
- presence of breast fullness due to milk presence
- assess nipples for cracks, fissures, soreness, or inversion What are some recommendations given to mother's who do not want to breastfeed? Correct Answer - well-fitting bra or ace wrap binder
- cold compress/cabbage leaves (comfort)
- anti-inflammatory medication
- no warm shower on breast (back to shower)
- no stimulation!! how often should mother's breastfeed? Correct Answer feeding pattern every 1.5-3hrs (8-12 times per 24hr period)
True or false: you should twitch which breast you start with each feed because the baby is more aggressive with the first breast Correct Answer true True or false: breast may feel heavy, but not hardened, sore, or reddened Correct Answer true Can breastfeeding mothers consume alcohol? Correct Answer Yes; but should not consume alcohol for at least 2 hours before nursing, and alcohol consumption should be limited to occasional use different position of breastfeeding Correct Answer - cradle
- modified cradle
- football hold
- side-lying what position is good for women who have bigger breast? Correct Answer football hold What is a good latch? Correct Answer - as much of the areola in mouth as possible
- baby is swallowing
- no smaking noise nipple shields Correct Answer used for flat or inverted nipples Should you allow nipples to air dry or should you pat them dry? why? Correct Answer air dry to prevent breakdown What are some concerns about breastfeeding? Correct Answer - pain due to nipple tenderness
- embarrassment about breastfeeding
- feeling ties down to the demands of breastfeeding
- unequal feeding responsibilities/fathers left out
What can plugged ducts lead too? Correct Answer mastitis What is mastitis? Correct Answer infection of the breast tissue What sort of bacterias cause mastitis? Correct Answer staph aureus, e. coli, candida albicans (yeast) What are the symptoms of mastitis? Correct Answer sudden onset: chills, fever (≥101F), malaise
- reddened, painful, swollen areas on breast
- possible discharge from nipples What are some treatment options for mastitis? Correct Answer - warm compresses
- analgesics
- 7 - 10 of antibiotics!!! What are some prevention measures for mastitis? Correct Answer
- supportive bras to prevent milk stasis
- good hand washing
- prompt attention to blocked milk ducts
- regular, complete emptying of breast
- good positioning and latch
- report flu-like symptoms What are some factors that associate with development of mastitis? Correct Answer - milk stasis!
- actions that promote/multiply bacteria
- breast/nipple trauma
- obstruction of ducts
- change in number of feedings/failure to empty breast
- lowered maternal defenses (stress/fatigue)
What is the main difference between mastitis and engorgement? Correct Answer mastitis usually only effects one breast where as engorgement effects both breast What are the symptoms of breast engorgement? Correct Answer breast are hard and painful due to fullness with a gradual onset
- not associated with high fever What are some recommendations for breast engorgement? Correct Answer - don't miss feedings
- hand express or pump to soften breast/nipples before feedings
- warm compresses before feedings to help with "let down"
- cold applications between feedings to slow milk production
- well fitted bra 24 hours
- cabbage leaves to reduce edema
- breastfeed more often Weaning off of breastfeeding Correct Answer substitute one feed for one cup or bottle over a few days to a week
- gradually increase bottle/cup feed as time goes on Why is slow method of weaning important? Correct Answer - prevents breast engorgement
- allows infants to alter their own eating methods at their own rates
- provides time for psychological adjustment What are some common things seen in an abdominal assessment for a postpartum patient? Correct Answer - abd is loose and flabby but will respond to exercise
- uterine ligaments will gradually return to their pre-pregnant state
- diastasis recti abdominis
- stretch marks
How long does it take for the uterus to contracts 1 finger-breadth? Correct Answer 1 fingerbreadth (1cm) per day When will the fundus descend to the pelvis? Correct Answer fundus will descend 1cm per day until it is at the pelvis on the 10th day What does a firm fundus mean? Correct Answer well contracted with limited bleeding What does a spongy/soft uterus mean? Correct Answer - fundus is higher in the abd or off to the side (bladder full)
- uterine atony = increased bleeding possible causes of uterine atony/bleeding Correct Answer - high levels of oxytocin
- multipara
- multiples
- LGA
- Red haired women postpartum bowel changes Correct Answer - bowels are sluggish!
- episiotomy, lacerations, or hemorrhoids may delay elimination Why are bowels sluggish after delivery? Correct Answer increased levels of progesterone, decreased muscle tone, birth process, anesthesia if C/S Why may an episiotomy, lacerations, or hemorrhoids may delay elimination? treatment? Correct Answer fear of tearing! tx: stool softners (docusate sodium) and tucks pads for hemorrhoids itching and coolness
What are some postpartum bladder change? Correct Answer - increased bladder capacity during pregnancy
- swelling and bruising of tissues around the urethra
- decreased sensitivity to fluid pressure
- decreased sensation of bladder filling (especially with epidurals)
- urinary output is greater due to puerperal diuresis
- increased chance of infection due to dilated ureters and renal pelvis
- monitor adequacy of urinary elimination/distention How much extracellular fluid should the kidneys rid after pregnancy? Correct Answer 2000 - 3000mL of extracellular fluid What are some symptoms of UTI? Correct Answer - frequency and urgency
- dysuria
- nocturia
- hematuria
- suprapubic pain
- slightly elevated temp What are interventions for UTI? Correct Answer - good perineal hygiene
- maintain adequate fluid intake
- empty bladder with the urge to void, or at least every 2-4 hours while awake
- void before and after intercourse
- wear cotton underwear
- increase acidity of the urine What is lochia? Correct Answer after delivery, vaginal discharge of blood, mucus, atrophied uterine cells lochia rubra, lochia serosa, lochia alba: color and day Correct Answer lochia rubra: red (first 2-4 days)
What are some medications to prevent postpartum hemorrhage? Correct Answer - oxytocin (must give 10u IM if no IV)
- methylergonovine maleate (methergine): DONT use for women with high BP
- carboprost (hemabate): side effect, DIARRHEA
- misoprostol (cytotec): flat tampon thing, may follow with oral doses Cervical changes in a postpartum patient Correct Answer - cervix is spongy, flabby, and may appeared bruised
- external os may have lacerations and is irregular and closes slowly
- shape of the external os changes to a lateral slit (diaphragm needs to be refitted if using this form of BC) Vaginal changes in a postpartum patient Correct Answer - may be edematous, bruised, with small superficial lacerations When does the vagina decrease in size and rugae start to reappear PP? Correct Answer 3 - 4 weeks When does the vagina return to prepregnant size? Correct Answer 6 weeks when does an episiotomy initially start to heal pp? completely heal? Correct Answer - initially: 2-3 weeks
- completely: 6 months 1st Degree laceration of perineum Correct Answer only vaginal mucosa involved
- sometimes repair 2nd Degree laceration of perineum Correct Answer Vaginal mucosa and into perineal muscle
- must repair 3rd Degree laceration of perineum Correct Answer Mucosa, through perineal muscles, into anal sphincter 4th Degree laceration of perineum Correct Answer Mucosa, through perineal muscles, all the way through anal sphincter What should you assess when you assess the perineum? (REEDA) Correct Answer Redness Edema or swelling Ecchymosis or bruising Discharge Approximation (how well edges of incision repair together) What are some perineal care interventions done on a postpartum patient? Correct Answer - ice packs (after 1st 6 hours)
- topical anesthetics
- waffle cushions
- surgigator
- sitz bath Hemorrhoid care in a postpartum patient Correct Answer - comfort/healing: sitz bath, topical anesthetics, ointments, rectal suppositories, or which hazel pads
- assume side-lying position when possible and avoid prolonged sitting
- adequate fluid intake and stool softners Care after C/S birth Correct Answer - minimize respiratory complications (IS, deep breathing, ambulating）
- Rest: between care of self and infant
- pain management: Percocet, lortab, Motrin, Tylenol
- minimize gas pains: ambulation, simethicone
Maternal Role Attainment (becoming a mother) stages Correct Answer The process by which a woman learns mothering behaviors
- anticipatory
- formal
- informal
- personal Maternal role attainment: anticipatory stage Correct Answer begins during pregnancy looks for role models fantasizes about being a mother role play begins expectations Maternal role attainment: formal stage Correct Answer - Begins with birth of the infant
- Role is guided by expectations of other in her social system Maternal role attainment: Informal stage Correct Answer new mother begins to develop her new role as it fits her lifestyle and makes future parenting goals Maternal role attainment: Personal stage Correct Answer - woman internalizes her role and experiences harmony of self, confidence, and competence in her role as a mother What is the postpartum blues? Correct Answer transient period of depression; usually during the first 3-5 days PP up to 6 weeks When does postpartum blues typically resolve? Correct Answer usually resolves naturally within 10-14 days Do you typically see postpartum blues in first time moms or mother's with multiple children? Correct Answer first time mom's
What are symptoms of postpartum blues? Correct Answer - mood swings: mild depression --> happy feelings
- self-limiting
- irritable/overly sensitive
- episodic tearfulness without cause
- difficulty sleeping
- feeling of being let down
- anxiety risk factors of postpartum blues Correct Answer - rapid hormone changes (estrogen, progesterone, and prolactin)
- fatigue, discomfort, overstimulation, insecurity, anxiety
- emotional letdown after birth
- if C/S, grief in response of fantasizing vaginal birth nursing care management of postpartum blues Correct Answer - anticipatory guidance
- validating feelings and reassurance
- rest (quiet time) and good nutrition
- parenting reference materials
- support networks and the inclusion of the family
- open visiting hours and rooming in Postpartum depression: occurrence? what does not occur? what else can occur? Correct Answer - greatest occurrence is around 4th week
- depression: no characterized by mood swings!
- can contemplate suicide as a way of escape and to protect the baby- dying seems more favorable than living risk factors for postpartum depression Correct Answer - primigravida
- ambivalence towards pregnancy (mixed feelings)
- history of previous PP depression or depression
