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1. There are 4 newborns in the NICU, which patient do you assess first? – Newborn that has a temperature of 96.7 and is 17 inches long.
2. Nursing interventions after birth with pain in perineum area. SATA – cold sitz bath, have patient lay on her side, administer Ibuprofen, as ordered.
3. New grad nurse, assessing the fundus, which is the proper way? – Support the lower uterine portion while the other hand is palpating the fundus.
4. Patient who gave birth 48 hours ago, which level is the fundus? – 2 Finger breadth below the umbilicus.
5. Upon assessment of fundus, nurse noted that it is shifted to the right side, what is the next nursing action? – Have the patient void.
6. Patient experiencing engorgement of breasts but has decided that she wants her baby bottle fed, which nursing action should be done? – Apply an ice pack to breast
7. Patient just gave birth and complaining of being cold and shaking – Provide a warm blanket
8. Postpartum patient with fever of 99.8 – Increase fluids and continue to monitor.
9. Patient is not immune to Rubella, when can she get the Rubella vaccine? – After delivery.
10. Patient is breastfeeding, went to the bathroom 3x with 800 mL of urine output but feeling dizzy upon getting up, which nursing diagnosis should the nurse include in the plan of care? – Risk for injury.
11. Patient is concerned about diuresis after giving birth, which hormone is decreased and is responsible for the diuresis? – Estrogen
12. Patient’s pad was saturated after 15 minutes of assessment, what is the next step - Assess the patient’s fundus.
13. Patient delivered today and has physicians’ orders of the following – stool softener, cold sitz bath, and ice pack on perineum area, what does the patient have? – Episiotomy.
14. Nurse is teaching the patient about lochia, which is incorrect? – You should have bright red bleeding for the next week.
15. Nurse overheard a patient who is breastfeeding, talking on the phone, which statement by the patient should the nurse intervene? – I need to get back in shape and should change my plate/diet
16. Chinese patient who just gave birth, what is an incorrect approach by the nurse? – Tells the patient that she must take care of the baby instead of a female relative
17. Doctor ordered Methergine for the patient, what is this used for? Postpartum hemorrhage.
18. After the baby is delivered what is the first nursing action? Suction respiratory tract
19. Baby is scheduled to be given an injection of Vitamin K on their own yet, so they are at risk for bleeding and delayed clotting.
20. Apgar Score of baby that has pink body, blue extremities, HR of 132, RR of 38, flexed, with weak cry – 7 or 8 (not sure)
21. What substance is in the baby’s lung that prevents alveolar collapse – Surfactant
22. Husband called the clinic and is concerned that her wife who gave birth a week ago has episodes of crying and being sad, what should the nurse tell him – These are signs of postpartum blues, which is normal and due to the hormonal changes after giving birth.
23. Neonate who has blood sugar of 55 mg/dL, what to do next – Provide routine feedings.
24. Patient is asking about her baby that was delivered with the vacuum assistance and has swelling in her head that did not cross the suture lines – Cephalohematoma
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