Kaplan maternity - vsim clinical stimulation 2020 slkvnlsidvnlisknv fselijnaflknsklan slkdnslknalk PDF

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vsim clinical stimulation 2020 slkvnlsidvnlisknv fselijnaflknsklan slkdnslknalk sdlkcnlskcnlsak sklanfinfeowlk kalnfiofneiosckls...

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1. The pregnant client's first baby had jaundice ' at birth and required treatment. The client asks the nurse if there is a way to prevent jaundice from occurring in the new baby after it is born. The nurse plans which goal for the newborn? 1. Newborn will have yellow stools in the first 24 hours. 2. Newborn will maintain temperature of 98 degrees * F * (36.7 degrees * C) or higher. 3. Newborn will remain "nothing by mouth^ (NPO) for the first 12 hours. 4. Newborn will be treated with bilirubin lights if needed. (?) 2. The newborn is classified as small for gestational age at term. The nurse evaluates the infant for which most likely complication. 1. Hypertension 2. Birth trauma. 3. Hypoglycemia. 4. Hyperglycemia 3. The baby is born at 32 weeks’ gestation. The baby is having difficulty breathing. The nurse activates which nursing diagnosis for this baby? 1. Delayed Growth and Development related to immature lungs. 2. Ineffective Gas Exchange related to excessive fluid buildup in lungs. 3. Ineffective Breathing Pattern related to lack of adequate surfactant. 4. Excess Fluid Volume related to pulmonary edema because of surfactant levels. 4. A nurse teaches a new parent about formula feeding. The parent asks why holding the baby for feeding is necessary. Which is the nurse's best response 1. Shares feeding times between parents. 2. Prevents positional otitis media. 3. Provides parent with satisfaction 4. Allows for better infant sucking 5. A newborn receives an apgar score of five at 1 minute and six at 5 minutes. How does the nurse evaluate this newborn? 1. Requires suctioning and oxygen. 2. Normal, requiring

nothing. 3. Requires resuscitation and oxygen. 4. Requires stimulation and oxygen. 6. The client has a nonstress test at 32 weeks’ gestation. There are 3 accelerations of 20 beats per minute (BPM) in 15 minutes Which nursing diagnosis does the nurse enter into the client's plan of care? 1. Impaired Gas Exchange. 2. Readiness for Enhanced Childbearing Process 3. Activity Intolerance. 4. Risk for Disturbed Matemal-Fetal Dyad. 7. The infant is at 42.5 weeks gestation, weighs 8 2 oz (3640 ), and is 22 inches (55.88 cm) long. The birth was a routine cesarean birth because of cephalopelvic disproportion with Apgars of 8 and 9. Which action is most important for the nurse to take when giving care to this infant? 1. Routine newborn care and feeding. 2. Teaching parents about sick infant care. 3. Assessment for congenital anomalies. 4. Preparation for transfer to the neonatal intensive care unit 8. The gravida 3 para 2 client is in labor and progressing slowly. The nurse determines the client is cm dilated, at + 1 +1 station, with mild contractions every 3 minutes lasting 30 to 40 seconds, and membranes are intact. The client has been in labor 8 hours. The health care provider ruptures membranes Which action does the nurse take next to evaluate fetal well -being? 1. Performs Leopold maneuver. 2. Assesses fetal heart tones and color of. 3. Takes pregnant client's vital signs and fetal heart tones. 4. Evaluates intensity of contractions and dilation 9. The client gave birth vaginally 2 hours ago to a healthy baby. The nurse assesses the client at a routine postpartum check. The client goal is maintains postpartum assessments within expected parameters. Which finding indicates the goal is

being met? 1. Fundus firm at umbilicus, moderate lochia with no clots, and has voided a large amount 2. Fundus boggy at +1, small amount of lochia, and has not voided 3. Fundus firm at +2, moderate lochia with small clots, and no voiding 4. Fundus firm with massage, large amount of lochia, and has voided a small amount one time. 10. The client in labor has IV oxytocin augmentation. The contractions are now strong every 2 - 3 minutes, lasting 50 60 seconds. is time for the nurse to increase the oxytocin. Which action does the nurse take next? 1. Increases the oxytocin by the specified amount per protocol. 2. Decreases the oxytocin by half the specified increase amount 3. Does not increase the oxytocin and observes the contractions. 4. Increases the oxytocin by half the normal amount ordered. 11. The client is 36 weeks pregnant. There have been no problems, but the client now has some shortness of breath. The nurse enters which nursing diagnosis in the plan of care? 1. Ineffective Breathing Patter related to fetal pressure on the diaphragm. 2. Decreased Cardiac Output related to increase in maternal blood volume. 3. Risk for Activity Intolerance related to shortness of breath. 4. Excess Fluid Volume related to fetal circulating blood volume. 12. The nurse talks with a client who is 20 weeks pregnant and is asking about the baby's development. Which answer by the nurse is best? 1. There are fat deposits and lanugo begins to disappear. 2. The genitalia can now be seen on the ultrasound. 3. The body is covered in vernix and lanugo is present. 4. The eyes begin to reopen, and the body is plumper.

13. The nurse evaluates the fontanels of a newborn immediately after birth. Two days later, the nurse determines that the fontanels are larger than they were after birth. Which does the nurse know about this change? 1. Molding of the head has decreased 2. Fontanels are growing as the head grows. 3. Caused by a deformity of the head. 4. Indicates increased intracranial pressure. 14. A nurse teaches clients who are in the first trimester of pregnancy. The nurse knows it is most important to teach which topics at this time? Select all that apply. 1. Use of tobacco, alcohol, and drugs. 2. Preparations for the baby 3. Infant feeding decisions. 4. Anticipated feelings about pregnancy. 5. Amounts of exercise and rest. 6. Fetal growth and development 15. The client has the first prenatal visit at the clinic. The client asks the nurse when to expect the baby. The nurse determines the last menstrual period was on March 26. Which date does the nurse tell the client to expect the baby? Type the month and day of the month in the blank using only numbers. Separate the month and day with a period (e.g.,4.22) . Month day 1.02 16. The client comes to the emergency department at 38 weeks’ gestation. The client reports bright red vaginal bleeding with clots, no pain, and the baby is moving in utero. The client says there has been some previous bleeding that looked the same but was not reported. Which is the priority ng action for this client? 1. Prepare a double delivery set up to evaluate the bleeding. 2. Type and crossmatch the client for 2 units of blood. 3. Examine the cervix for signs of labor.

4. Evaluate the fetal heartbeat and the pregnant client's vital signs. 17. The client comes to the clinic for the first prenatal visit. The client thinks the pregnancy is 8 weeks along. The client has numerous health issues and their concern for the health of the fetus. The health care provider orders an ultrasound. Which ultrasound report causes the nurse the greatest concern? 1. Absent fetal cardiac activity. 2. Crown -rump length 1.5 cm. 3. Presence of gestational sac. 4. Presence of 2 embryos. 18. The nurse times contractions for laboring clients by palpation. Which contraction pattern requires the nurse to intervene? 1. Mild contractions every 5 minutes lasting 45-60 seconds. 2. Strong contractions every 3 minutes lasting 45 to 60 seconds. 3. Moderate contractions every 3 minutes lasting 60 seconds. 4. Strong contractions every 2 minutes lasting 90 seconds. 19. The primipara at 35 weeks’ gestation experiences mild contractions about every 5 minutes. The client calls the triage nurse at the hospital. which question does the nurse use to determine if the client is in true labor? Select all that apply 1. "Is your cervix dilating and effacing?" 2. there is any change in the contractions if you walk around?" 3. Are the contractions getting any harder?" 4. Where do you feel most of the pain? 5. Are the contractions getting shorter? 6. "Are the contractions getting closer together than when you first felt them?" 20. The client is diagnosed with severe preeclampsia. The client is hospitalized in the 35th week of pregnancy. The nurse places which priority goal in the client's care plan? 1.

Will maintain bed rest in the right lateral position 2. Will not experience severe hypertension with epigastric pain. 3. Will not experience weight gain of more than 4 pounds in a week. 4. Will ingest a diet high in carbohydrates and low in protein. 21. A nurse in the clinic performs a pregnancy test and tells the couple they are pregnant. They are both excited and appear happy. At the next clinic visit, the client tells the nurse the partner is quiet and withdrawn although seeming Initially happy at the news. Which is the best response by the nurse 1. The partner should seek psychiatric help for depression 2. When the pregnancy is more obvious, the partner will feel better. 3. The client should be less enthusiastic around the partner. 4. The changes in their life may be causing the partner anxiety 22. The client in labor has a pregnancy history that includes a 6-year-old, a 4-year-old, a miscarriage at 10 weeks, and a stillbirth at 28 weeks. Which number does the nurse record for the gravida? Type the correct answer in the blank. 5 gravida 23. A client has a child with spina bifida. The client is in early pregnancy and asks the nurse about the possibility of the second child having spina bifida Which is the best response by the nurse? 1. You shouldn't worry about it now since you can't change things. 2. You will know after an alpha fetoprotein test completed at about 16 weeks." 3. There is no risk if you took your folic acid before you got pregnant." 4. "There is a 25 % chance that this baby will have spina bifida."

24. A nurse provides care for the newborn in the delivery area. The baby is breathing and crying well with good color. The nurse knows which priority is next. 1. Record apgar scores. 2. Begin bonding with parents. 3. Initiate physical assessment. 4. Prevent cold stress 25. The client in labor is monitored internally. The fetal heart rate drops from 162 to 135. The decrease starts when the contraction is strongest and lasts until the contraction is completely relaxed. Which does the nurse do next? 1. Nothing this is a normal pattern. 2. Applies oxygen to client at 4L / minutes. 3. Has client turn to left side -lying position. 4. Reattaches the internal electrode 26. The newborn is admitted to the nursery. Mottled skin, circumoral cyanosis, and respirations of 72 with occasional periods of apnea are observed. Which assessment does the nurse make first? 1. Temperature. 2. Heart sounds. 3. Blood pressure. 4. Respirations. 27. A new parent asks the nurse why the baby needs an injection so soon after birth. The baby was born vaginally with no trauma or problems. the apgar scores were 9 and 9. Which information does the nurse give to the parent? 1. This injection will help the baby eat better and sooner. 2. This injection will help prevent infections in the baby 3. This injection will help prevent bleeding in the baby 4. This injection will help the baby gain weight better. 28. The nurse provides care for a client who is positive for group B Streptococcus, not treated before the birth of newborn client. The newborn is 39 weeks’ gestation and weighs 7 lb 9 oz (3388 ). Which goals does the nurse plan for this newborn(Select all that apply) 1. Will have

temperature of 100.8 degrees * F * (33.22 degrees * C) within 24 hours. 2. Will receive first antibiotic prior to obtaining blood cultures. 3. Will have no symptoms of infection in first week. 4. Will not develop conjunctivitis within 4 days. 5. Will have normal blood cultures within 3 days. 6. Will have no grunting or cyanosis in 24 hours 29. The client in labor monitored with an internal electronic fetal monitor. The pattern begins to show severe variable decelerations below 65 beats per minute (BPM) lasting 40 seconds. The nurse quickly has the client turn to left side Which is the most appropriate goal for this client? 1. Will be prepared for immediate cesarean birth 2. Will from side to side every 15 minutes. 3. Will prepare for immediate birth with forceps. 4. Will have no decelerations after repositioning. 30. The client is in labor with leaking membranes. The fetus is at -1 station. Contractions are mild every 5 mjns lasting 40 secs. The client is instructed to walk. The nurse applies which form of the fetal and contraction monitoring. 1. Tocodynamometer and ultrasound transducer which is least invasive 2. Transducer tipped intrauterine pressure catheter (IUPC) and ultrasound transducer which is faster to apply. 3. Tocodynamometer and scalp electrode which is easiest to monitor. 4. Transducer tipped intrauterine pressure catheter and scalp electrode which is the most accurate monitoring 31. A nurse cares for 4 clients in labor. Which client needs to be seen first? 1. Gravida 4 para 3, contractions q 2 minutes and lasting 90 seconds, 8 cm and 100 % 2. Gravida 2 para contractions 3 minutes and lasting 60 seconds, 5 cm

and 90 % 3. Gravida 3 para 2, contractions q 3 minutes and lasting 60 seconds , 6 cm and 80 % . 4. Gravida 1 para contractions q 5 minutes and lasting 30 seconds, 3 cm and 75 %. 32. A client in labor has an epidural anesthesia placed. The nurse must make which important assessment while the anesthetic is in place? 1. Temperature for decrease. 2. Feet and legs for edema. 3. Respirations for increase. 4. Bladder for distention. 33. The pregnant client is Rh negative. This is the first pregnancy It is determined the father is Rh positive. An indirect Coombs ' test at 28 weeks is negative. Which evaluation does the nurse make for this situation? 1. The fetus has erythroblastosis fetalis and cannot receive Rh 0 (D) immune globulin. 2. The client has not been sensitized and Rh 0 (D) immune globulin is given. 3. The client has become Rh sensitized and Rh 0 (D) immune globulin is given. 4. The fetus has not been sensitized and will receive Rh (D) globulin at birth. 34. The infant is born to the client who drank alcohol heavily during pregnancy. The infant is diagnosed with fetal alcohol syndrome. A nursing diagnosis of Ineffective Family Coping related to fetal alcohol syndrome written the nurse discontinues the diagnosis when which observation is made? 1. Parents ask the social worker for institutions child placement. 2. Infant begins to gain weight appropriately. 3. Infant sleeps quietly through the night. 4. Parents ask the social worker for community resource assistance 35. The nurse tells the client in labor that delivery will occur soon. Which information most likely causes the nurse to

make this determination? 1. Client is a gravida 2, para 1 with a 9-month - old baby 2. Client is 6 cm dilated, 100 % effaced , with urge to push . 3. Client is 10 cm dilated, 100 % effaced with urge to push 4. Client is a gravida 3 para 2 with an urge to push 36. A client is 39 weeks pregnant. The delivery will be by cesarean birth due to a breech presentation Which information does the nurse give the client regarding the delivery? (Select all that apply.) 1. Will have an indwelling urinary catheter inserted 2. Will plan for epidural anesthesia. 3. Will be given medication to relax prior to surgery, 4. Will have an IV started in the preoperative area 5. Will have a full bowel prep. 6. Will be admitted the night before surgery. 37. The client is 24 -hours postpartum after a difficult vaginal birth that included a manual removal of the placenta. The client's temperature is 101 2F(38.4C ) with chills . Which nursing diagnosis does the nurse place in the client's plan of care? 1. Ineffective Thermoregulation related to entrance of breast milk. 2. Acute Pain related to wound infection. 3. Ineffective Self -health Management related to poor prenatal care. 4. Risk for Injury related to proliferation of infection. 38. A client with gestational diabetes mellitus is 36 weeks pregnant. A contraction stress test (CST) is completed. The results show no late decelerations in the 10 - minute window. Which does the nurse plan for this client? 1. Plans for immediate cesarean delivery. 2. Prepares for labor stimulation. 3. Repeat contraction stress test in 7 days. 4. Repeat contraction stress test in 24 hours.

39. The new parent asks the nurse why breastfeeding is encouraged immediately after birth. Which is the nurse's best response? 1. Immediate suckling helps establish good breastfeeding and bonding." 2. The placenta will come out easier and you will bleed less." 3. The baby needs nutrients after the work of being born." 4. Babies are hungry immediately after birth and will sleep better." 40. The nurse presents childbirth preparation classes to a group of parents-to-be. One participant asks, "Why should we attend these classes? After all, childbirth is a natural process." Which is the nurse's best response? 1. Why wouldn't you want to attend the classes? They are especially for you." 2. Maybe you could help teach these classes if you already know what is happening." 3. This is voluntary and you do not need to be here if you do not want to be. 4. It is helpful to have an understanding of what is happening and what will happen." 41. The client is 7 months pregnant. The client calls the clinic reporting pain and burning on urination and a temperature of 101.2 degrees * F * (38.4 degrees * C) . The nurse knows this is a danger sign of pregnancy. The nurse enters which priority nursing diagnosis in the plan of care? 1. Deficient Fluid Volume. 2. Ineffective Coping. 3. Impaired Urinary Elimination. 4. Acute Pain. 42. A gravida 1 para 0 client is 36 weeks’ gestation. The client says, " The baby seems to be lower in my pelvis now and there is less shortness of breath but there is more swelling in my feet and legs. The nurse plans which goal for the client? 1. Client will comply with bed rest for the remainder of the pregnancy. 2. Client will plan for labor

and birth in several weeks. 3. Client will decrease salt in the diet because of edema. 4. Client will increase fluids to 3000 mL daily. 43. The pregnant client comes to the clinic for the first prenatal visit the client has had type 1 diabetes since age 8. The client is fearful and ambivalent about the pregnancy. The nurse enters a nursing diagnosis in the care plan for which most important problem. 1. Inadequate food intake related to current insulin levels 2. Possible diabetic complications such as hypo or hyperglycemia. 3. Fear and ambivalence about the pregnancy causing bonding problems. 4. Discomforts of early pregnancy and disease process causing sleeping problems. 44. The nurse presents childbirth preparation classes to a group of parents- to-be One participant asks, ' Why should we attend these classes After all childbirth is a natural process. Which is the nurse's best response? 1. " Why wouldn't you want to attend the classes? They are especially for you." 2. "Maybe you could help teach these classes if you already know what is happening. " 3. This is voluntary and you do not need to be here if you do not want to be." 4. It is helpful to have an understanding of what is happening and what will happen." 45. The nurse observes the new parent holding the preterm baby. The baby is in an enface position. The parent talks to the baby quietly and looks the baby in the eyes. Which observation does the nurse make about the parent and child? 1. Parent is not making attachment behaviors. 2. Baby is not making attachment behaviors. 3. Weak bonding behaviors. 4. Strong bonding behaviors....