Question Which assessment findings would indicate to the registered nurse thatproper latch-on has occurred in a breastfeeding client? Select All That Apply. A. Tongue down with lips flanged.B.  A slurping sound as infant suckles.C.  Dimpling of infant’s cheeks while suckling. D. Rhythmic suckling. E. Audible swallowing. While caring for a laboring patient, the anesthesiologist asks the registered nurse to administer a dose of fenantyl via an epidural catheter. Which standard would guide the RN on their next step?A. AWHONN believes that registered nurses who are not licensed anesthesia care providers should monitor but not manage the delivery of analgesia and anesthesia by catheter techniques to pregnant women.B.  AWHONN believes that registered nurses who are not licensed anesthesia care providers should both monitor and manage the delivery of analgesia and anesthesia by catheter techniques to pregnant womenC.  AWHONN believes that registered nurses are responsible for increasing or decreasing the rate of a continuous infusion and program doses for epidural analgesia and anesthesia to pregnant women.   While caring for a postpartum patient the RN notes that the patient’s perineal pad is saturated with bright red blood. Which question would the registered nurse ask the patient first?A.  “Do you have to go to the bathroom?” B. “When was the last time you changed your peri pad?” C. “Are you having any cramping?”  The breastfeeding patient calls the physician’s office and tells the registered nurse that she has been tired, has a temperature of 100°F and has a localized warm reddened area in the lower right quadrant of her right breast. What would be the most appropriate intervention? A. Apply an ice pack to the right breast and wear supportive bra. B. Pump the right breast and discard the milk for the next week.  C. Wash the breasts with soap and water before each feeding.   While caring for a postpartum patient who delivered a healthy baby 12 hours ago, the registered nurse observes that the patient is passive and hesitant about making decisions concerning her own care and the care of her newborn. In response to this observation, which intervention would be implemented by the registered nurse?A.  Encourage participation in any unit learning activities pertaining to infant care.B.  Ask her to share her birth experience.  C. Suggest that she begin to write her birth announcements.  What teaching should the registered nurse provide to the parents of a child recovering from repair of a cleft palate?A.  The child may have increased episodes of chronic otitis media. B. The child may have difficulty sensing the temperature of food. C. The child may have a poor appetite from decreased sense of taste.  Which interventions would the registered nurse include in the plan of care for a patient with the nursing diagnosis of acute pain related to engorgement? Select all that apply.A. Instruct the woman to apply warm packs to both breasts for a few minutes before breastfeeding. B.Inform the woman to place the infant at the same breast first with each breastfeeding episode. C.Educate the woman to manually express breast milk after the newborn has nursed.D. Advise the woman to expose her nipples to air after breastfeeding.E. Teach the woman to massage her breasts for a few minutes before breastfeeding.  The infant has an order to receive amoxicillin (Amoxil) orally every 6 hours. The safe medication dose is 50mg/kg/day in divided doses. The infant weighs 6 kg.   How much medication will the RN administer to the infant per dose? Record your answer as a number using decimals if necessary (for example, write 0.5 instead of ½). Do not include words or abbreviations in your answer.   ______ mg.   The RN places the infant with tracheoesophageal fistula under a radiant warmer with the infant’s head elevated at a 45-degree angle. Which statement by the mother indicates understanding of the most important reason for this position?A. “This position helps my baby breathe better by opening up his lungs.” B. “This position keeps my baby more comfortable and closer to the warmer.” C. “This position prevents stomach juices from going upward into my baby’s lungs.”  Which patient should the RN refer to the hospital ethics committee?A. The newborn who is anencephalic whose parents want everything done. B. The newborn whose mother is a known cocaine user and is HIV positive. C. The toddler who is admitted with multiple fractures.   During the active phase of labor, a patient’s membranes spontaneously rupture. Which nursing action should the registered nurse do first after this occurs?A.  Assess fetal heart rate.B.  Perform a sterile vaginal exam. C. Instruct the patient to bear down with the next contraction.   While assisting with the delivery of a full-term newborn, which standard of care should the registered nurse anticipate to prevent postpartum hemorrhage during the third stage of labor? A. Administration of intravenous oxytocin. B. Clamping the umbilical cord before pulsations stop. C. Administration of subcutaneous terbutaline sulfate.  Which fetal lie is most conductive to a spontaneous vaginal birth? A. TransverseB.  LongitudinalC.  Oblique   After delivery of the newborn, the registered nurse instructs the postpartum mother to call for the nurse when getting out of bed for the first time to void. The registered nurse informs the client that the most important reason is to: A. observe the newborn while the mother is busy.B.  minimize the potential for postpartum hemorrhage. C. avoid maternal injury caused by the potential for syncope.   The RN is preparing to give carboprost tromethamine to a client with uterine atony. Which side effect would the RN assess for following administration of this medication?A.  SeizuresB.  Vomiting C. Anxiety   After ambulating in the hall and returning to bed, the patient states that her water broke. The fetal heart rate is 85 beats per minute and the vaginal exam reveals the cervix is 90% effaced, 2 cm dilated, vertex presentation -2 station. There is a pulsating cord felt in the anterior portion of the vagina. Which intervention would the registered nurse perform immediately? A. Adjust the fetal monitor so an accurate fetal heart rate pattern can be assessed.B.  Position the patient on her left side to move the fetus off the vena cava.C.  Apply pressure to the presenting part to prevent pressure on the umbilical cord. submitted Submit   In addition to breathing with contractions, which comfort measure should the RN suggest to a woman with ruptured membranes in the first stage of labor?A. Take a warm bath.B.  Lying in the lithotomy position. C. Practicing Kegel exercises.  A registered nurse is assessing the fundus of a postpartum patient one day after delivery and notes that the fundus is soft and spongy. Which is the first nursing intervention to perform?A.  Notify the health care provider. B. Massage the fundus gently until it firms.C.  Document fundal height and consistency.  An 11-month-old infant with spastic cerebral palsy was seen this week at the developmental pediatrician’s office because he is not rolling over or attempting to sit. Which is an expected outcome for the nursing diagnosis Impaired physical mobility?A.  The client will roll from back to front by 16 months of age. B. The client will be given 3 ounces of formula every 3 hours by next office visit. C. The client will remain safe at all times.  Which statement made by the postpartum patient indicates to the RN that more discharge teaching is needed regarding the resumption of sexual activity after giving birth? A. “The Doctor told me to wait until my discharge turns white in color before resuming sexual activity.” B. “I know I can ovulate as soon as two weeks postpartum therefore I will need to use contraception.”C.  “Because I’m breastfeeding I don’t need to consider any other form of contraception right now.”   The RN is assisting a new mother with breastfeeding one day after birth. Which assessment would cause the RN to notify the Lactation Consultant?A.  Baby is feeding for 30 minutes every 1 ½ hoursB.  The mother has thin, yellow discharge from the nipple C. The mother has inverted nipples bilaterally  A baby is born with a diaphragmatic hernia. Which nursing action is the priority in providing immediate care for this newborn?A.  Establish intravenous accessB.  Insert nasogastric tube C. Assist with intubation  A pregnant patient asks the RN how to tell whether contractions are true contractions or Braxton Hicks contractions. Which is characteristic of Braxton Hicks contractions?A.  Begin irregularly but become regular and predictable. B. Ambulation increases the frequency of contractionsC.  A warm shower decreases the intensity of contractions.  The RN is caring for a woman in the second stage of labor. Which direction should the nurse provide to the client?A.  Push with contractions and rest between them. B. Begin pushing as soon as the cervix has dilated to 10 cm. C. Hold her breath while pushing during contractions.   A 4-month-old with Tetralogy of Fallot becomes acutely cyanotic with rapid shallow respirations while having blood drawn. Which is the appropriate nursing intervention?A.  Lay the infant flat with the legs elevated to reduce work on the heart. B. Sit the infant upright with the legs dangling to promote venous pooling.C.  Hold the infant in the knee-chest position to decrease venous blood return.  Health Science Science Nursing NURSING RN nur 209 Share QuestionEmailCopy link Comments (0)

Question Which assessment findings would indicate to the registered nurse thatproper latch-on has occurred in a breastfeeding client? Select All That Apply. A. Tongue down with lips flanged.B.  A slurping sound as infant suckles.C.  Dimpling of infant’s cheeks while suckling. D. Rhythmic suckling. E. Audible swallowing. While caring for a laboring patient, the anesthesiologist asks the registered nurse to administer a dose of fenantyl via an epidural catheter. Which standard would guide the RN on their next step?A. AWHONN believes that registered nurses who are not licensed anesthesia care providers should monitor but not manage the delivery of analgesia and anesthesia by catheter techniques to pregnant women.B.  AWHONN believes that registered nurses who are not licensed anesthesia care providers should both monitor and manage the delivery of analgesia and anesthesia by catheter techniques to pregnant womenC.  AWHONN believes that registered nurses are responsible for increasing or decreasing the rate of a continuous infusion and program doses for epidural analgesia and anesthesia to pregnant women.   While caring for a postpartum patient the RN notes that the patient’s perineal pad is saturated with bright red blood. Which question would the registered nurse ask the patient first?A.  “Do you have to go to the bathroom?” B. “When was the last time you changed your peri pad?” C. “Are you having any cramping?”  The breastfeeding patient calls the physician’s office and tells the registered nurse that she has been tired, has a temperature of 100°F and has a localized warm reddened area in the lower right quadrant of her right breast. What would be the most appropriate intervention? A. Apply an ice pack to the right breast and wear supportive bra. B. Pump the right breast and discard the milk for the next week.  C. Wash the breasts with soap and water before each feeding.   While caring for a postpartum patient who delivered a healthy baby 12 hours ago, the registered nurse observes that the patient is passive and hesitant about making decisions concerning her own care and the care of her newborn. In response to this observation, which intervention would be implemented by the registered nurse?A.  Encourage participation in any unit learning activities pertaining to infant care.B.  Ask her to share her birth experience.  C. Suggest that she begin to write her birth announcements.  What teaching should the registered nurse provide to the parents of a child recovering from repair of a cleft palate?A.  The child may have increased episodes of chronic otitis media. B. The child may have difficulty sensing the temperature of food. C. The child may have a poor appetite from decreased sense of taste.  Which interventions would the registered nurse include in the plan of care for a patient with the nursing diagnosis of acute pain related to engorgement? Select all that apply.A. Instruct the woman to apply warm packs to both breasts for a few minutes before breastfeeding. B.Inform the woman to place the infant at the same breast first with each breastfeeding episode. C.Educate the woman to manually express breast milk after the newborn has nursed.D. Advise the woman to expose her nipples to air after breastfeeding.E. Teach the woman to massage her breasts for a few minutes before breastfeeding.  The infant has an order to receive amoxicillin (Amoxil) orally every 6 hours. The safe medication dose is 50mg/kg/day in divided doses. The infant weighs 6 kg.   How much medication will the RN administer to the infant per dose? Record your answer as a number using decimals if necessary (for example, write 0.5 instead of ½). Do not include words or abbreviations in your answer.   ______ mg.   The RN places the infant with tracheoesophageal fistula under a radiant warmer with the infant’s head elevated at a 45-degree angle. Which statement by the mother indicates understanding of the most important reason for this position?A. “This position helps my baby breathe better by opening up his lungs.” B. “This position keeps my baby more comfortable and closer to the warmer.” C. “This position prevents stomach juices from going upward into my baby’s lungs.”  Which patient should the RN refer to the hospital ethics committee?A. The newborn who is anencephalic whose parents want everything done. B. The newborn whose mother is a known cocaine user and is HIV positive. C. The toddler who is admitted with multiple fractures.   During the active phase of labor, a patient’s membranes spontaneously rupture. Which nursing action should the registered nurse do first after this occurs?A.  Assess fetal heart rate.B.  Perform a sterile vaginal exam. C. Instruct the patient to bear down with the next contraction.   While assisting with the delivery of a full-term newborn, which standard of care should the registered nurse anticipate to prevent postpartum hemorrhage during the third stage of labor? A. Administration of intravenous oxytocin. B. Clamping the umbilical cord before pulsations stop. C. Administration of subcutaneous terbutaline sulfate.  Which fetal lie is most conductive to a spontaneous vaginal birth? A. TransverseB.  LongitudinalC.  Oblique   After delivery of the newborn, the registered nurse instructs the postpartum mother to call for the nurse when getting out of bed for the first time to void. The registered nurse informs the client that the most important reason is to: A. observe the newborn while the mother is busy.B.  minimize the potential for postpartum hemorrhage. C. avoid maternal injury caused by the potential for syncope.   The RN is preparing to give carboprost tromethamine to a client with uterine atony. Which side effect would the RN assess for following administration of this medication?A.  SeizuresB.  Vomiting C. Anxiety   After ambulating in the hall and returning to bed, the patient states that her water broke. The fetal heart rate is 85 beats per minute and the vaginal exam reveals the cervix is 90% effaced, 2 cm dilated, vertex presentation -2 station. There is a pulsating cord felt in the anterior portion of the vagina. Which intervention would the registered nurse perform immediately? A. Adjust the fetal monitor so an accurate fetal heart rate pattern can be assessed.B.  Position the patient on her left side to move the fetus off the vena cava.C.  Apply pressure to the presenting part to prevent pressure on the umbilical cord. submitted Submit   In addition to breathing with contractions, which comfort measure should the RN suggest to a woman with ruptured membranes in the first stage of labor?A. Take a warm bath.B.  Lying in the lithotomy position. C. Practicing Kegel exercises.  A registered nurse is assessing the fundus of a postpartum patient one day after delivery and notes that the fundus is soft and spongy. Which is the first nursing intervention to perform?A.  Notify the health care provider. B. Massage the fundus gently until it firms.C.  Document fundal height and consistency.  An 11-month-old infant with spastic cerebral palsy was seen this week at the developmental pediatrician’s office because he is not rolling over or attempting to sit. Which is an expected outcome for the nursing diagnosis Impaired physical mobility?A.  The client will roll from back to front by 16 months of age. B. The client will be given 3 ounces of formula every 3 hours by next office visit. C. The client will remain safe at all times.  Which statement made by the postpartum patient indicates to the RN that more discharge teaching is needed regarding the resumption of sexual activity after giving birth? A. “The Doctor told me to wait until my discharge turns white in color before resuming sexual activity.” B. “I know I can ovulate as soon as two weeks postpartum therefore I will need to use contraception.”C.  “Because I’m breastfeeding I don’t need to consider any other form of contraception right now.”   The RN is assisting a new mother with breastfeeding one day after birth. Which assessment would cause the RN to notify the Lactation Consultant?A.  Baby is feeding for 30 minutes every 1 ½ hoursB.  The mother has thin, yellow discharge from the nipple C. The mother has inverted nipples bilaterally  A baby is born with a diaphragmatic hernia. Which nursing action is the priority in providing immediate care for this newborn?A.  Establish intravenous accessB.  Insert nasogastric tube C. Assist with intubation  A pregnant patient asks the RN how to tell whether contractions are true contractions or Braxton Hicks contractions. Which is characteristic of Braxton Hicks contractions?A.  Begin irregularly but become regular and predictable. B. Ambulation increases the frequency of contractionsC.  A warm shower decreases the intensity of contractions.  The RN is caring for a woman in the second stage of labor. Which direction should the nurse provide to the client?A.  Push with contractions and rest between them. B. Begin pushing as soon as the cervix has dilated to 10 cm. C. Hold her breath while pushing during contractions.   A 4-month-old with Tetralogy of Fallot becomes acutely cyanotic with rapid shallow respirations while having blood drawn. Which is the appropriate nursing intervention?A.  Lay the infant flat with the legs elevated to reduce work on the heart. B. Sit the infant upright with the legs dangling to promote venous pooling.C.  Hold the infant in the knee-chest position to decrease venous blood return.  Health Science Science Nursing NURSING RN nur 209 Share QuestionEmailCopy link Comments (0)