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 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).

2.

The nurse continues to care for the client in the antepartum unit and has received several provider orders. Review the electronic health record (EHR) below and for each provider’s order, specify whether the order is essential, nonessential, or contraindicated for this client.

  • Administer magnesium sulfate 4 g bolus IV over 15–30 minutes

  • Monitor blood pressure every 15 minutes

  • Have client lie in supine position

  • Administer betamethasone 12.5 mg IM now; repeat in 24 hours

  • Collect urine sample for culture and sensitivity

Explanation

Explanation

Correct Answer: A) Essential ,B) Essential, C) Contraindicated, D) Essential, E) Nonessential

Magnesium sulfate is essential in suspected preeclampsia to prevent seizures. Frequent blood pressure monitoring is critical to assess severity and progression. The supine position is contraindicated in pregnancy because it can compress the inferior vena cava, reducing placental perfusion and worsening maternal and fetal status.

Betamethasone is essential to promote fetal lung maturity if preterm delivery is a risk. A urine culture is not a priority in this situation, making it nonessential compared to immediate maternal and fetal stabilization needs.

3.

The neonatal nurse is providing discharge education to first-time parents about their newborn. They ask about the benefits of breastfeeding versus bottle feeding their infant. Which statement by the parent would indicate that they understand the benefits of breastfeeding?

  • "I won't have to use contraception while I am breastfeeding since I have not yet resumed my periods."

  • "The commercial grade formula I can buy at the store has the same composition as my breastmilk."

  • "As my baby grows, I will need to supplement, since the volume of breastmilk I produce stays the same."

  • "The amount and composition of my breastmilk will change to meet my baby's needs as they grow."

Explanation

Explanation

Correct Answer: D) "The amount and composition of my breastmilk will change to meet my baby's needs as they grow."

One of the most remarkable and unique benefits of breastfeeding is that breast milk dynamically changes in both volume and composition as the baby grows and develops. It transitions from colostrum (rich in antibodies and protein) in the first days, to transitional milk, and then to mature milk — continually adapting its nutritional content, immunological factors, and caloric density to meet the infant's evolving needs.

Breastfeeding reduces but does not eliminate the risk of pregnancy — contraception is still recommended (A is a dangerous misconception). Commercial formula cannot replicate the full immunological and bioactive properties of breastmilk (B is incorrect). Breast milk production increases with demand as the baby grows — supplementation is not routinely needed if breastfeeding is well established (C is incorrect).

4.

The assessment findings are as follows. These results indicate that the client is most likely experiencing ___ due to ___.

  • Preeclampsia due to headache

  • Gestational diabetes due to fundal height

  • Preterm labor due to back pain

  • Preeclampsia due to back pain

Explanation

Explanation

Correct Answer: A) Preeclampsia due to headache

A persistent headache in a pregnant client is a concerning sign of preeclampsia, a hypertensive disorder characterized by increased blood pressure and possible organ involvement. Headache reflects cerebral irritation and is a key warning sign that requires immediate evaluation.

Gestational diabetes is associated with abnormal glucose levels, not headache. Fundal height relates to fetal growth, and back pain is a common discomfort in pregnancy or may suggest labor, but it is not a primary indicator of preeclampsia.

5.

The nurse is caring for a client with A+ blood who has been prescribed a blood transfusion. The nurse places a 20-gauge peripheral intravenous (IV) line, flushes it with normal saline, and verifies the client has signed consent. What is the next step in the transfusion process?

  • Pick up blood from the blood bank

  • Double check the blood with another registered nurse (RN)

  • Prime Y tubing with blood and saline

  • Initiate the blood transfusion within one hour of obtaining blood

Explanation

Explanation

Correct Answer: A) Pick up blood from the blood bank

After ensuring IV access and consent, the next step is to obtain the blood from the blood bank. Verification with another nurse and initiation occur after the blood is obtained.

Priming tubing and starting transfusion are done after proper verification procedures.

6.

The nurse is caring for a client during a prolonged second stage of labor. The nurse observes that the fetal head retracts against the client’s perineum immediately following delivery of the head (turtle sign). Which of the following action(s) will the nurse anticipate in this situation? (Select all that apply)

  • Administer fundal pressure

  • Apply suprapubic pressure

  • Assist client in flexing thighs out and towards ears

  • Call for additional assistance

  • Prepare for emergency interventions

Explanation

Explanation

Correct Answer: B) Apply suprapubic pressure, C) Assist client in flexing thighs out and towards ears, D) Call for additional assistance, E) Prepare for emergency interventions

The turtle sign indicates shoulder dystocia, an obstetric emergency where the fetal shoulders are impacted. Immediate interventions include the McRoberts maneuver (flexing thighs), applying suprapubic pressure to dislodge the shoulder, calling for help, and preparing for further emergency measures if initial maneuvers fail.

Fundal pressure is contraindicated because it can worsen impaction and increase the risk of fetal injury or uterine rupture.

7.

The nurse is assessing a client who gave birth 72 hours ago to a healthy infant and is formula-feeding only. The nurse notices that both of the client's breasts are swollen, warm, and tender on palpation. What is the most appropriate nursing intervention for this client?

  • Run warm water on the breasts during a shower.

  • Apply ice compresses and or cabbage leaves to the breasts.

  • Express small amounts of milk from the breasts to relieve pressure.

  • Instruct client to wear a loose-fitting bra to prevent nipple irritation.

Explanation

Explanation

Correct Answer: B) Apply ice compresses and/or cabbage leaves to the breasts

This client is experiencing breast engorgement secondary to milk coming in while not breastfeeding. For non-breastfeeding clients, the goal is to suppress lactation — not stimulate further milk production. Ice compresses reduce swelling, pain, and inflammation, while cabbage leaves (a well-supported evidence-based remedy) contain compounds that help reduce engorgement and suppress milk production when applied to the breasts.

Warm water or heat on the breasts (A) stimulates milk letdown and would worsen engorgement — contraindicated for a non-breastfeeding client. Expressing milk (C) signals the body to produce more milk, perpetuating the problem. A well-fitting, supportive bra — not a loose one (D) — provides compression that helps suppress lactation and reduce discomfort.

8.

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.

9.

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).

10.

The nurse is assessing a client who reports they have missed three menstrual periods and is now visiting the prenatal clinic. The client reports having enlarged breasts, urinary frequency, and nausea and is concerned that they may be pregnant. What is the best response by the nurse?

  • "It sounds like you are definitely pregnant. Congratulations!"

  • "You might be pregnant, but we will have to do a pregnancy test and measure your fundus to be sure."

  • "These signs could be caused by other things, so we will need to hear the fetal heartbeat to be certain."

  • "You should come back in 4 weeks to do further testing."

Explanation

Explanation

Correct Answer: B) "You might be pregnant, but we will have to do a pregnancy test and measure your fundus to be sure."

The client is reporting presumptive signs of pregnancy, which are not definitive. Confirmation requires diagnostic testing such as a pregnancy test and further assessment.

Option A assumes pregnancy without confirmation, C delays appropriate testing, and D postpones necessary evaluation.

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