NUR 325 Nursing Services Childbearing Family at CBU
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Free NUR 325 Nursing Services Childbearing Family at CBU Questions
The nurse is giving a lecture on violence against women. The nurse knows teaching needs to be reinforced when a woman states which of the following
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Domestic violence affects 1 in 4 women.
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Abuse often decreases during pregnancy.
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A woman's greatest risk for homicide is during separation or attempts to separate.
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Abused women often willingly go back to the abusers
Explanation
Correct Answer B: Abuse often decreases during pregnancy.
Explanation:
This statement is incorrect and indicates a misunderstanding that needs clarification. Abuse often begins or intensifies during pregnancy, putting both the woman and fetus at serious risk. Pregnancy is a known risk factor for increased domestic violence, not a protective time.
Why the Other Options Are Incorrect:
A. Domestic violence affects 1 in 4 women.
This is accurate. Research shows that approximately 1 in 4 women experience intimate partner violence during their lifetime.
C. A woman's greatest ri sk for homicide is during separation or attempts to separate.
This is true. The risk of lethal violence often spikes when a woman tries to leave or separate from an abusive partner.
D. Abused women often willingly go back to the abusers.
This reflects a complex reality, often tied to fear, economic dependency, emotional manipulation, or lack of support. It is not a knowledge error but rather a recognition of the psychological and social dynamics involved.
The nurse teaches her postpartum patient the rationale for urinating every two hours while awake. The nurse knows the patient understood when the patient states that overdistension of the bladder and urinary retention can often lead to:
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Postpartum hemorrhage and hematoma formation
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Fever and foul-smelling lochia
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Postpartum hemorrhage and urinary tract infection
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Urinary tract infection and uterine involution
Explanation
After delivery, bladder overdistension or urinary retention can displace the uterus upward and to the side, preventing proper uterine contraction. This uterine atony increases the risk of postpartum hemorrhage. Additionally, stagnant urine in a distended bladder provides an ideal environment for bacterial growth, leading to a urinary tract infection (UTI). Encouraging urination every two hours helps maintain uterine tone, promotes normal involution, and prevents these complications.
The doctor writes an order for Terbutaline to be given SQ. Which assessment finding will cause the nurse to question this order?
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BP 94/60
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P 132
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UCs are q 10 minutes
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FHR is Category 1
Explanation
A blood pressure of 94/60 is low but not critically so, contractions every 10 minutes are mild, and a Category 1 FHR is normal — none of these would prevent giving Terbutaline.
The nursery nurse is assessing a newborn that was just admitted to the nursery. The nursery nurse notices a cephalohematoma upon assessment of the head. The nursery knows that this infant is at risk for which condition
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Hypoxemia
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Hypoglycemia
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Hyperbilirubinemia
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Hyperglycemia
Explanation
Correct Answer C: Hyperbilirubinemia
Explanation
C. Hyperbilirubinemia
A cephalohematoma is a collection of blood between the skull and the periosteum caused by birth trauma, such as from forceps or vacuum delivery. As the hematoma resolves, the breakdown of red blood cells releases bilirubin, increasing the newborn’s risk for hyperbilirubinemia (jaundice).
Why the Other Options Are Incorrect:
A. Hypoxemia
Cephalohematoma is not associated with oxygen deprivation or respiratory compromise. Hypoxemia would be more related to pulmonary or cardiac issues.
B. Hypoglycemia
Though common in newborns under certain conditions (e.g., infants of diabetic mothers, preterm), hypoglycemia is not directly related to cephalohematoma.
D. Hyperglycemia
Newborns rarely experience hyperglycemia, and it is not related to birth trauma or cephalohematoma.
A multiparous woman has been in labor for 8 hours. Her membranes have just ruptured. The nurse's initial response should be:
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Prepare the patient for immediate birth
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Check the fluid with nitrazine paper
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Note the color and consistency of the fluid
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Assess the FHR
Explanation
When the membranes rupture, the priority nursing action is to assess the fetal heart rate (FHR). This ensures that the umbilical cord has not prolapsed or become compressed, which could compromise fetal oxygenation. Prompt evaluation of the FHR after membrane rupture helps identify any signs of fetal distress early so that immediate interventions can be initiated if necessary, ensuring both maternal and fetal safety.
When caring for a laboring mother, late decelerations are noted on the fetal heart rate monitor. What actions should the nurse take
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Turn the patient to her side
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Provide 2–3 liters of oxygen via mask
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Notify the health care provider
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Stop the oxytocin
Explanation
Correct Answers:
A. Turn the patient to her side
B. Provide 2–3 liters of oxygen via mask
C. Notify the health care provider
D. Stop the oxytocin
Explanation:
Late decelerations are a sign of uteroplacental insufficiency, meaning the fetus may not be receiving enough oxygen during contractions. These decelerations occur after the peak of a contraction and indicate compromised fetal oxygenation. Prompt nursing interventions are critical.
A. Turn the patient to her side
Correct. Repositioning the mother, especially to the left side, improves blood flow to the uterus and placenta by relieving pressure on the inferior vena cava.
B. Provide 2–3 liters of oxygen via mask
Correct. Administering oxygen helps increase the amount of oxygen available to the fetus through the placenta.
C. Notify the health care provider
Correct. The provider must be informed, especially if late decelerations persist, as further medical or surgical intervention may be required.
D. Stop the oxytocin
Correct. Oxytocin stimulates contractions, which can exacerbate fetal distress. Stopping it reduces uterine activity and improves fetal oxygenation.
A nurse is working for a high-risk perinatologist that specializes in seeing cardiac patients who are pregnant. The nurse has four messages that must be returned.
Which client will you schedule for an appointment as soon as possible
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The patient who is 35 weeks pregnant and complaining of swelling in her feet.
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The patient who is 34 weeks pregnant complaining of a persistent cough.
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The client who is 33 weeks pregnant who said she gets tired and now requires a nap in the afternoon.
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A client who is 39 weeks pregnant and complains of a sudden weight loss of 1.5 lbs.
Explanation
Correct Answer B: The patient who is 34 weeks pregnant complaining of a persistent cough.
Explanation:
B. The patient who is 34 weeks pregnant complaining of a persistent cough.
In a pregnant client with known or suspected cardiac disease, a persistent cough may indicate pulmonary congestion or left-sided heart failure, especially in the third trimester when cardiac demands are higher. This symptom could signal decompensation and requires prompt cardiac evaluation.
Why the Other Options Are Incorrect:
A. The patient who is 35 weeks pregnant and complaining of swelling in her feet.
Mild lower extremity swelling is common in late pregnancy due to increased venous pressure and is not necessarily a sign of cardiac decompensation unless associated with other symptoms such as dyspnea, orthopnea, or rapid weight gain.
C. The client who is 33 weeks pregnant who said she gets tired and now requires a nap in the afternoon.
Fatigue is a common symptom in pregnancy and does not specifically suggest acute cardiac decline without other concerning features such as shortness of breath, chest pain, or palpitations.
D. A client who is 39 weeks pregnant and complains of a sudden weight loss of 1.5 lbs.
A small drop in weight may occur near term due to changes in fluid retention or appetite before labor and is less concerning than signs of cardiac or respiratory compromise.
A client tells the nurse she is to have a cerclage and wants to know why the doctor is going to do this. The nurse provides education about a cerclage. Which statement indicates teaching needs to be reinforced
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A cerclage is a suture placed on the cervix.
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A cerclage will prevent preterm labor.
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A cerclage is done to help prevent the cervix from dilating too early.
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A cerclage is done because I have had spontaneous abortions in the past because my cervix opened too early
Explanation
Correct Answer B: A cerclage will prevent preterm labor.
Explanatiom:
B. A cerclage will prevent preterm labor.
This statement indicates a misunderstanding. A cerclage is used to prevent cervical insufficiency, which can lead to painless cervical dilation and second-trimester losses. However, it does not prevent preterm labor, which involves uterine contractions and other physiological processes beyond just cervical weakness.
Why the Other Options Are Correct:
A. A cerclage is a suture placed on the cervix.
This is accurate. A cerclage involves placing a stitch around the cervix to reinforce it and prevent premature opening.
C. A cerclage is done to help prevent the cervix from dilating too early.
Correct. The goal of cerclage is to mechanically support the cervix and delay or prevent early dilation.
D. A cerclage is done because I have had spontaneous abortions in the past because my cervix opened too early.
Correct. A history of painless cervical dilation leading to mid-trimester pregnancy losses is a key indication for a cerclage.
The nursery nurse is assessing a newborn that was just admitted to the nursery. The nursery nurse notices a cephalohematoma upon assessment of the head. The nurse knows that this infant is at risk for which condition?
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Hypoxemia
-
Hypoglycemia
-
Hyperbilirubinemia
-
Hyperglycemia
Explanation
A cephalohematoma is a collection of blood between the skull bone and its periosteum, typically caused by birth trauma. As the trapped red blood cells in the hematoma break down, bilirubin levels rise, increasing the newborn’s risk for hyperbilirubinemia (jaundice). Close monitoring of bilirubin levels is essential to prevent complications such as kernicterus. Hypoxemia, hypoglycemia, and hyperglycemia are not directly associated with cephalohematoma.
A patient with pregnancy-induced hypertension is admitted complaining of a pounding headache and epigastric pain. Nursing care is based on the knowledge that these signs indicate:
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Anxiety due to hospitalization
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Impending seizures
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Effects of magnesium sulfate
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Panic attack
Explanation
In a patient with pregnancy-induced hypertension (PIH) or preeclampsia, symptoms such as a severe headache, epigastric pain, and visual disturbances indicate worsening preeclampsia and possible progression to eclampsia (seizures). Epigastric pain results from hepatic involvement and potential subcapsular liver swelling. The nurse should immediately report these findings, maintain a calm environment, initiate seizure precautions, and prepare for possible administration of magnesium sulfate to prevent seizures.
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