HESI Patient Review Susan Wilson (2) – Flashcards

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Based on Susan's assessment data and history, you identify which of the following as a priority nursing diagnosis for Susan at this time?
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Deficient fluid volume related to inadequate intake of fluids.
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With regard to rupture of membranes, which questions are important?
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A. "What time did your 'water break'?" C. "What was the color of the fluid?"
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Based on your assessment, you determine that the fetus is in a/an ____ presentation
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Cephalic/vertex/occiput
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Based on your assessment, you position the ultrasound transducer on Susan's abdomen at the:
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right lower quadrant
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Fetal heart rate increases can be associated with a variety of factors. These include:
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the mother receiving the drug Brethine (terbutaline) The mother receiving the drug Yutopar (ritodrine) Maternal fever or infection Fetal anemia Also, Maternal Dehydration Maternal Hyperthyroidism
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Susan has been monitored for 15 min. Which of the following actions on your part is indicated?
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Continue to monitor the fetal heart rate
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To measure the frequency contractions you examine a 10-minute strip and:
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determine the time from the beginning of one contraction to the beginning of the next
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You perform a vaginal exam to check for shortening and thinning of cervix. This is called
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effacement / effacing
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You also determine that the fetus is at zero station....Your response is based on the knowledge that zero station means that:
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the baby's presenting part is at the level of the mother's ischial spines
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zero station means that
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the baby's presenting part is at the level of the mother's ischial spines
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Based on your assessment of Susan (3 cm dilated, 80% effaced, fetus at zero station) and your interpretation of her data, you determine that she is now in which stage of labor?
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Stage one (until cervix is fully dilated)
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Susan decides to rest in bed. Which of the following positions are acceptable?
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right lateral left lateral
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You remind Susan that it is important for her to try to urinate every two hours. The rationale for this is that a distended bladder can:
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interfere with fetal descent cause difficulty in voiding after delivery increase the pain associated with uterine contractions
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In response to the order for Stradol (butorphanol tartrate), which of the following is indicated?
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Administer the Stradol as ordered
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You determine that Susan is now in which phase of stage one labor?
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Active phase
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A number of factors may affect the length of time a woman's labor will last. These include:
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maternal activity and position the parity of the mother fetal position and size
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What is the best nursing action to take at this time?
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Suggest that John take a short break and have another family member coach Susan temporarily
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You identify this as a/an________ deceleration
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Early
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Early deceleration is caused by
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compression of the head
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The anesthesiologist performs the epidural procedure and Susan begins to feel almost immediate relief from painful contractions. You know that a priority nursing intervention is to:
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frequently monitor Susan's blood pressure for hypotension
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Because Susan had an epidural she has not exhibited some of the signs/behaviors that otherwise characterize the transition phase. These include:
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amnesia between contractions diaphoresis reluctance to be touched physical shaking
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You examine a recent strip from the fetal monitor. The abnormal fetal heart rate pattern you observe is interpreted as a ___ deceleration
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late
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In response to the occurrence of a late deceleration, which of the following actions should be carried out FIRST?
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Turn on left side
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At this point, which of the following would be appropriate advice for Susan?
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Let me help you assume the knee-chest position if the urge to push is uncomfortable Don't push yet. Pant through contractions if you need to
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Based on your assessment of this male neonate, you determine that his 1-minute Apgar score is
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9
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As Susan and John admire their new son, you notice a sudden gush of blood from Susan's perineum and an apparent lengthening of the umbilical cord. You recognize that these signs indicate
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separation of the placenta
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After the placenta has been expelled, Dr. Cooper asks you to start a Pitocin (oxytocin) drip, at a concentration of 10 units in 1000 mL Lactated Ringer's. You know that Pitocin (oxytocin) is administered at this time to:
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stimulate uterine contractions
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Susan's pitocin drip is infusing with an infusion pump at a rate of 60 mL per hour ___ milliunit of drug is infusing per minute
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10
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The correct term for the cone shape of a vaginally-delivered infant's head is
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molded
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The newborn is prone to hypothermia because:
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Newborns have a large body surface to body weight ratio Blood vessels are close to the skin surface There is minimal subcutaneous fat
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John asks "Why does he need to have a shot already?" Your explanation to John is based on the knowledge that:
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Vitamin K is needed to prevent bleeding problems in the early neonatal period Newborns are unable to synthesize vitamin K due to absence of intestinal flora at birth
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apply erythromycin ophthalmic ointment to the newborn's eyes to:
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protect the infant from gonorrheal or chlamydial infection
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Which of the following assessments would be considered normal at this time?
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Fundus is firm, at the midline, and two fingerbreadths below the umbilicus
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At the next assessment, Susan's uterus is midline. The fundus feel boggy at one fingerbreadth below the umbilicus, what should you do first?
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Massage Susan's uterus
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the vaginal discharge that occurs during the postpartum period (puerperium), which and consists of blood, tissue, and mucous, is called
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lochia
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Which of the following is the expected progression of lochial changes during the puerperium?
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Rubra, serosa, alba
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The term that describes the expected gradual reduction in size of the uterus after delivery as it contracts to return to normal size is
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involution
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When John describes to you the advantages he sees in breastfeeding, you agree when he says:
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breastfed babies experience fewer respiratory illnesses than formula-fed babies breastfed babies are not likely to have allergies to their mother's breast milk breastfeeding is more economical
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Which of the following statements would indicate that Susan understands correct information on breastfeeding?
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To break suction, I will insert my finger into the corner of Jason's mouth before removing him from the breast When Jason has a growth spurt, he will want to nurse more often which will increase my milk supply
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After delivery, a declining level of estrogen allows for rising levels of the hormone responsible for milk production. You know that the hormone that stimulates milk production is
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prolactin
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The hormone responsible for milk ejection is
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oxytocin
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Susan expresses concern about engorged breasts. Some of her friends have told her that it's painful. You discuss engorgement with Susan and suggest:
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to help avoid engorgement, feed Jason at least every 2-3 hours around the clock to help avoid engorgement, make sure Jason is positioned for good milk transfer during feedings if engorgement occurs, express some milk prior to feedings to facilitate latching-on
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