- ACTUAL EXAM 200 QUESTIONS AND

NUR 242 Exam #2 Review LATEST UPDATE

- ACTUAL EXAM 200 QUESTIONS AND

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-Ascertain whether the woman is in true of false labor -Check the fundus to ensure that it is firm ( size and consistency of a grapefruit), located in the midline and below the umbilicus -Position the woman and cleanse the vulva and perineal areas -Check for crowning, low grunting sounds from the woman, and increase in blood-tinged show -Check for lengthening of the umbilical cord protruding from the vagina - CORRECT ANSWER: Nursing Interventions during the various stages of labor and birth, in order

-Complete expulsion of amniotic membranes and placenta at birth -Complication-free labor and birth process -Breastfeeding

-Ambulation - CORRECT ANSWER: Factors that facilitate uterine involution

-Eating a wide variety of food with high nutrient density -Using foods and recipes that required little or no preparation -Avoiding high-fat, fast foods, and fad weight reduction diets -Avoiding harmful substances like alcohol, tobacco, and drugs -Avoiding excessive intake of fat, salt, sugar, and caffeine

-Eating the recommended daily servings from each food group - CORRECT ANSWER:

What nutritional recommendations can the nurse give to the new mother post partum?

-Fever more than 100.4 after the first 24 hours following birth -Foul-smelling lochia or an unexpected change in color or amount -Visual changes, such as blurred vision or spots, or headaches -Calf pain experienced with dorsiflexion of the foot -Swelling, redness, or discharge at the episiotomy site -Dysuria, burning, or incomplete emptying of the bladder -Shortness of breath or difficulty breathing

-Depression or extreme mood swings - CORRECT ANSWER: Postpartum Danger

Signs

-Increase in apprehension or irritability -Spontaneous rupture of membranes -Sudden appearance of sweat on upper lip -Increase in blood tinged show -Low grunting sounds from the woman -Complaints of rectal and perineal pressure 1 / 3

-Beginning of bearing down efforts - CORRECT ANSWER: Typical signs of the second stage of labor

-Lithotomy with feet up in stirrups; most convenient position for caregivers -Semisitting with pillows underneath the knees, arms, and back -Lateral/side-lying with curved back and upper leg supported by partner -Sitting on birthing stool: opens pelvis, enhances the pull of gravity, and helps with pushing

-Squatting/supported squatting: Gives the woman a sense of control

-Kneeling with hands on bed and knees comfortably apart - CORRECT ANSWER:

Positions used for the second stage of labor

-Prolonged labor and difficult birth -Incomplete expulsion of amniotic membranes and placenta -Uterine infection

-Overdistension of uterine muscles - CORRECT ANSWER: Factors that inhibit

involution

"Be sure to change your pajamas to prevent you from chilling." - CORRECT ANSWER: A client who gave birth 5 days ago reports profuse sweating during the night. What should the nurse recommend to the client in this regard?

"The discharge consists of mucus, tissue debris, and blood; this gives it the deep red color." - CORRECT ANSWER: A nurse examining a client who underwent a vaginal birth 24 hours ago. The client asks the nurse why her discharge is such a deep red color. What explanation is most accurate for the nurse to give?

"Within 1 to 3 weeks, your diaphragm should return to normal and your breathing will feel like it did before pregnancy." - CORRECT ANSWER: A client who had a vaginal delivery 2 days ago asks the nurse when she will be able to breathe normally again.Which response by the nurse is most accurate?

"You should be seen by your health care provider if you have blurred vision." -

CORRECT ANSWER: A client has been discharged after a cesarean birth. Which

should the nurse include in the discharge teaching?

"Your body usually retains extra fluids during pregnancy, so this is one way it rids itself of the excess fluid." - CORRECT ANSWER: A client who delivered a baby 36 hours ago informs the nurse that she has been passing unusually large volumes of urine very often. How should the nurse explain this to the client?

• - CORRECT ANSWER: ___ station is designated when the presenting part is at the

level of the maternal ischial spines.

A moderate amount of lochia rubra - CORRECT ANSWER: When assessing the uterus

of a 2-day postpartum client, which finding would the nurse evaluate as normal? 2 / 3

accelerations - CORRECT ANSWER: Fetal ___ are transitory increases in the FHR

above the baseline that are associated with sympathetic nervous stimulation.

Active bowel sounds; Passing gas; Nondistended abdomen - CORRECT ANSWER: A

nurse is assessing a client during the postpartum period. Which findings indicate normal postpartum adjustment?

Administration of oxygen by mask - CORRECT ANSWER: The nurse caring for a client in preterm labor observes abnormal fetal heart rate patterns. Which nursing intervention should the nurse perform next?

Advantage: Electronic fetal monitoring produces a continuous record of the FHR, unlike the intermittent auscultation, when gaps are likely.Disadvantage: Continuous monitoring can limit the maternal movement and encourages her to like in the supine position, which reduces placental perfusion. - CORRECT ANSWER: What are the advantages and disadvantages to continuous fetal monitoring?

Afterpains - CORRECT ANSWER: ___ are the painful uterine contractions some

women experience during the early postpartum period.

Afterpains are more acute in multiparous women secondary to repeated stretching of the uterine muscles, which reduces muscle tone, allowing for altering uterine contraction

and relaxation. - CORRECT ANSWER: Why are after pains more acute in multiparous

women?

Artifact - CORRECT ANSWER: ___ describes the irregular variations or absence of

fetal heart rate due to erroneous causes on the fetal monitor record.

Assess amount of cervical dilation - CORRECT ANSWER: During admission

assessment of a cline in labor, the nurse observes that there is no vaginal bleeding yet.What nursing intervention is appropriate in the absence of vaginal bleeding when the client is in the early stage of labor?

Atony - CORRECT ANSWER: This state of the uterus allows for excessive

Boggy or relaxed uterus - CORRECT ANSWER: During assessment of the mother

during the postpartum period, what sign should alert the nurse that the client is likely experiencing uterine atony?

Bonding - CORRECT ANSWER: Development of a close emotional attachment to a

newborn by the parents during the first 30 to 60 minutes after birth

Breasts are hard; Breasts are tender - CORRECT ANSWER: A nurse is to care for a

client during the postpartum period. The client reports pain and discomfort in her

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