ABSN Hybrid Summer -NURS428 Reassessment 1 EBR Roseman University of Health Sciences School of Nursing.

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Ace Your Test with ABSN Hybrid Summer -NURS428 Reassessment 1 EBR Roseman University of Health Sciences School of Nursing. Actual Questions and Solutions - Full Set

Free ABSN Hybrid Summer -NURS428 Reassessment 1 EBR Roseman University of Health Sciences School of Nursing. Questions

1.

The nursery nurse begins caring for the infant in the delivery room as soon as the infant is delivered. When is the appropriate time for the nurse to perform the APGAR assessment?

  • When the infant has signs of distress, such as difficulty breathing.
  • The health care provider will perform the first Apgar assessment.
  • At least twice; 1 minute and 5 minutes after birth.
  • Every 15 minutes during the first hour after birth.

Explanation

Explanation

Correct Answer: C) At least twice; 1 minute and 5 minutes after birth

The APGAR assessment is a standardized newborn evaluation performed at 1 minute and 5 minutes after birth for all newborns, regardless of whether distress is apparent. The 1-minute score reflects the newborn's transition from intrauterine to extrauterine life, while the 5-minute score evaluates response to any resuscitative efforts. If the score remains low at 5 minutes, additional assessments are performed at 10-minute intervals.

It is not performed only when distress is present — it is a routine assessment for all newborns (A is incorrect). The APGAR is performed by the nurse, not reserved for the provider (B is incorrect). Every 15 minutes is the frequency for routine vital sign monitoring, not APGAR scoring (D is incorrect).

2.

A nurse is assessing a 38-year-old pregnant client (R.B.) with complaints that may suggest a hypertensive disorder of pregnancy. Which assessments and tests should the nurse prioritize? (Select all that apply)

  • Glucose tolerance test
  • Deep tendon reflexes
  • Non-stress test (NST)
  • Complete blood count (CBC)
  • Vaginal exam
  • Urine dipstick

Explanation

Explanation

Correct Answer: B) Deep tendon reflexes, C) Non-stress test (NST), D) Complete blood count (CBC), F) Urine dipstick

In a client suspected of having a hypertensive disorder such as preeclampsia, the nurse prioritizes assessments that evaluate maternal and fetal status. Deep tendon reflexes help identify neurologic irritability and risk for seizures. A urine dipstick assesses for proteinuria, a key diagnostic finding. A CBC evaluates for hemoconcentration and platelet levels, which are important in severe disease. A non-stress test assesses fetal well-being and oxygenation.

A glucose tolerance test is used to screen for gestational diabetes, not hypertensive disorders. A vaginal exam is not a priority unless there are labor-related concerns.

3.

The nurse is caring for a client in the active phase of the first stage of labor. The client reports a new onset of severe abdominal pain. What is the priority nursing action?

  • Offer client pain medications
  • Assess for vaginal bleeding
  • Apply a pulse oximeter
  • Prepare for a cesarean section

Explanation

Explanation

Correct Answer: B) Assess for vaginal bleeding

A sudden onset of severe abdominal pain during labor may indicate a complication such as placental abruption or uterine rupture. Immediate assessment for vaginal bleeding helps identify life-threatening conditions.

Administering pain medication or preparing for surgery occurs after assessment, and pulse oximetry does not address the immediate concern.

4.

The nurse administers a Rhogam injection to a client with a negative blood type at 28 weeks gestation. The client asks the nurse if future injections of this medication are needed. What is the best response by the nurse?

  • Yes, Rhogam only works for 12 weeks so you will need another injection after you deliver.
  • No, this one injection will prevent your body from creating antibodies against the Rh factor.
  • It depends. Your healthcare provider will do an amniocentesis to determine your baby's blood type before you give birth.
  • It depends. You will need another injection within 72 hours after you deliver if your baby's blood type is Rh+.

Explanation

Explanation

Correct Answer: D) It depends. You will need another injection within 72 hours after you deliver if your baby's blood type is Rh+.

Rh-negative clients receive Rhogam (Rho(D) immune globulin) at 28 weeks gestation prophylactically. A second dose is required within 72 hours after delivery if the newborn is confirmed to be Rh-positive, to prevent maternal sensitization — the development of anti-Rh antibodies that could harm future Rh-positive pregnancies. If the baby is Rh-negative, no further injection is needed.

Stating Rhogam only works for 12 weeks (A) is inaccurate. Claiming one injection is sufficient regardless of delivery outcome (B) is incorrect. Amniocentesis to determine fetal blood type (C) is not standard practice for this purpose — the baby's blood type is determined after birth from cord blood.

5.

The nurse is caring for a client of 22 weeks gestation who presents to the clinic for a follow-up prenatal visit. Which of the following assessments will the nurse perform?

  • Fundal height
  • Vaginal Exam
  • Leopold's maneuver
  • Pregnancy history

Explanation

Explanation

Correct Answers: A) Fundal height and D) Pregnancy history

At 22 weeks gestation, fundal height measurement is a standard assessment performed at each prenatal visit to monitor fetal growth — the fundal height in centimeters should approximately equal the gestational age in weeks. Pregnancy history (obstetric and medical history review) is an ongoing assessment component of every prenatal visit.

Vaginal exams are not routinely performed at 22 weeks unless there is a specific clinical indication such as signs of preterm labor or cervical incompetence. Leopold's maneuver is typically performed in the third trimester (after 28–36 weeks) to assess fetal position and presentation — it is not a standard assessment at 22 weeks.

6.

The nurse at an OB/GYN clinic evaluates a client over the phone who recently started taking oral contraceptives. The client reports shortness of breath, chest pain, and a mild elevation in blood pressure. What advice will the nurse give to the client?

  • "The symptoms you are describing are expected side effects."
  • "This is life threatening. Go to the emergency room immediately."
  • "Stop taking the contraceptives and come into the office tomorrow."
  • "Continue taking the pills and the symptoms should subside soon."

Explanation

Explanation

Correct Answer: B) "This is life threatening. Go to the emergency room immediately."

Shortness of breath and chest pain in a client taking oral contraceptives are warning signs of thromboembolism, such as pulmonary embolism, which is a medical emergency. Immediate evaluation in an emergency setting is required to prevent life-threatening complications.

These symptoms are not expected side effects, delaying care is unsafe, and continuing the medication could worsen the condition.

7.

The labor and delivery nurse is preparing for the delivery of their client's newborn infant. The nurse brings a stack of warm blankets into the room and places them at the bedside. Which statement by the nurse best educates the parents on why warm blankets are needed?

  • "We will use the warm blankets to dry the baby which will help to prevent cold stress"
  • "We will wrap the baby in warm blankets after delivery so that they will not shiver."
  • "We will use the blankets to warm the baby's hands and feet to prevent acrocyanosis."
  • "We will use the warm blankets only if the baby has a low temperature."

Explanation

Explanation

Correct Answer: A) "We will use the warm blankets to dry the baby which will help to prevent cold stress"

Newborns are at high risk for cold stress (hypothermia) immediately after birth because they are wet with amniotic fluid and transition from a warm intrauterine environment to a cooler external environment. Drying the newborn promptly with warm blankets is the primary intervention to prevent evaporative heat loss — the most significant mechanism of heat loss at birth — thereby preventing cold stress and its metabolic consequences such as hypoglycemia and acidosis.

Newborns do not shiver effectively as a thermoregulatory mechanism — they rely on non-shivering thermogenesis through brown fat metabolism (B is inaccurate). Acrocyanosis (bluish hands and feet) is a normal finding in newborns and is not caused by temperature loss requiring blankets (C). Warm blankets are used routinely for all newborns at delivery, not only for those with documented low temperature (D).

8.

The nurse is caring for a couple at a fertility clinic. After determining the client has a low sperm count, they have opted for artificial insemination. What should the nurse include in the teaching to prepare them for this procedure?

  • You will be fully numbed before the abdominal needle insertion.
  • There will be a speculum inserted in the vagina to get the sperm closer to the uterus.
  • We will use the embryo that was fertilized in the laboratory.
  • This procedure is highly successful and will only need to be performed one time.

Explanation

Explanation

Correct Answer: B) There will be a speculum inserted in the vagina to get the sperm closer to the uterus.

Artificial insemination (intrauterine insemination) involves placing prepared sperm directly into the uterus using a catheter, typically after inserting a speculum. This is a minimally invasive procedure and does not involve abdominal needles or anesthesia.

Option A describes procedures like amniocentesis. Option C refers to in vitro fertilization. Option D is incorrect because multiple attempts are often needed, and success rates vary.

9.

The nurse is caring for a client who asks why their newborn needs a Vitamin K injection. What is the nurse's best response?

  • "Most mothers have a diet deficient in vitamin K, which results in the infant being deficient."
  • "Vitamin K prevents the synthesis of prothrombin in the liver and must be given by injection."
  • "Newborns cannot synthesize their own vitamin K which increases their risk of bleeding."
  • "The supply of vitamin K is inadequate for at least the first year and must be supplemented."

Explanation

Explanation

Correct Answer: C) "Newborns cannot synthesize their own vitamin K which increases their risk of bleeding."

Newborns are born with very low levels of vitamin K because it does not cross the placenta well, and their gut has not yet been colonized by the bacteria that produce vitamin K. Since vitamin K is essential for the synthesis of clotting factors (II, VII, IX, X), deficiency places newborns at risk for Vitamin K Deficiency Bleeding (VKDB), a potentially life-threatening condition. The intramuscular injection at birth prevents this.

Maternal dietary deficiency is not the primary reason — the issue is the newborn's own inability to produce sufficient vitamin K. Vitamin K actually promotes (not prevents) prothrombin synthesis, making option B factually incorrect. The supplementation is not required for the entire first year — a single injection at birth is sufficient for most newborns.

10.

The nurse is educating a laboring client who is about to receive epidural anesthesia. Which statement by the nurse best describes the side effects the client may experience?

  • "It is possible to experience a drop in blood pressure afterward."
  • "You may experience some drowsiness as the medication gets in your bloodstream."
  • "You may feel a frequent need to urinate after the effects set in."
  • "It is possible to feel more numbness on one side, so you should lie flat on your back."

Explanation

Explanation

Correct Answer: A) "It is possible to experience a drop in blood pressure afterward."

Hypotension is the most common and well-documented side effect of epidural anesthesia. The epidural blocks sympathetic nerve fibers, causing vasodilation and a subsequent drop in blood pressure. This is why IV fluid preloading is performed before epidural placement and blood pressure is monitored frequently afterward.

Epidurals are regional anesthetics affecting the lower body — significant drowsiness or systemic sedation (B) is not a typical effect, as the medication remains largely localized. Epidurals typically cause urinary retention, not frequency (C is incorrect). If unilateral numbness occurs, the client should be repositioned to their side — not placed flat on their back — as supine positioning causes aortocaval compression in pregnancy (D is incorrect and potentially harmful).

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