Question

A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with a Plastibell technique. Which of the following client statements indicates an understanding of circumcision care? (Select All that Apply.)

Answer 1

Correct Answers:

"I'll make sure his diaper is loose in the front"
"I'll call the doctor if I see any bleeding"
"I'll expect the plastic ring to fall off by itself within a week"

Rationale :

“I’ll make sure his diaper is loose in the front.”

🔷Keeping the diaper loose in the front minimizes pressure and friction on the glans and the Plastibell ring, which reduces pain and protects the healing tissue.

🔷Reduced friction lowers the risk of disruption of the ligature and bleeding, two common early complications.

🔷A loose front also helps maintain a clean, dry environment, limiting moisture‑associated skin damage and irritation from urine.

🔷This positioning prevents the diaper edge from catching or tugging on the plastic ring, which must never be pulled.

🔷Parents should check for rubbing during changes and re‑adjust the diaper to maintain gentle coverage without compression.

“I’ll call the doctor if I see any bleeding.”

🔷After a Plastibell circumcision, only minimal spotting is expected; active or persistent bleeding is not normal and warrants provider notification.

🔷Caregivers may apply gentle pressure with sterile gauze for 3–5 minutes; if bleeding does not stop, they should seek medical care promptly.

🔷Early recognition of bleeding is vital to prevent significant blood loss in a newborn, who has limited reserves.

🔷Additional red flags to report include foul discharge, spreading redness, fever, or the ring sliding proximally.

🔷Emphasizing when to call supports safe home monitoring and reduces risk of delayed treatment.

“I’ll expect the plastic ring to fall off by itself within a week.”

🔷With the Plastibell technique, the tied ligature causes the foreskin to necrose distally, and the ring separates naturally in ~5–8 days (occasionally up to 10).

🔷Parents should never pull on the ring; it may darken before detaching, which is expected.

🔷Until the ring falls, cleansing should be gentle with water, keeping the area clean and dry (avoid alcohol or harsh wipes).

🔷A small amount of yellow mucous film/eschar can appear during healing and is normal, not pus.

🔷Sponge bathing is preferred until the ring separates, maintaining hygiene without soaking the site.

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Answer 2

Correct Answers:

Amniotic fluid volume
Fetal breathing
Fetal motion

Rationale :

Amniotic fluid volume

🔶 The Biophysical Profile (BPP) includes amniotic fluid volume (AFV) because it reflects chronic placental perfusion and fetal renal function, both sensitive to long‑standing hypoxia.

🔶 AFV is scored by ultrasound using either maximum vertical pocket (MVP ≥ 2 cm) or AFI (generally 5–24 cm), with normal findings receiving 2 points.

🔶 Oligohydramnios (low fluid) suggests uteroplacental insufficiency and is strongly associated with adverse perinatal outcomes, prompting closer surveillance or delivery.

🔶 Because fluid volume changes slowly, it complements the acute variables (movement, tone, breathing), giving a balanced view of fetal well‑being.

🔶 Including AFV in the BPP helps clinicians differentiate transient fetal rest from true compromise, improving decision‑making about timing of delivery.

Fetal breathing

🔶 Fetal breathing movements (FBMs) are rhythmic diaphragmatic motions that indicate intact central nervous system (CNS) activity and adequate oxygenation.

🔶 On BPP, FBMs are present if there is a sustained episode ≥ 30 seconds within a 30‑minute observation; this earns 2 points.

🔶 FBMs are among the first acute behaviors to cease with hypoxemia/acidemia, so their presence is a reassuring sign.

🔶 Because FBMs are behavioral and oxygen‑dependent, they complement nonstress test results to reduce false positives.

🔶 Documenting FBMs helps the team gauge current fetal status, guiding whether to continue observation or expedite delivery.

Fetal motion (gross body movements)

🔶 Gross fetal movements (e.g., trunk/limb motions) demonstrate intact neuromuscular function and adequate oxygen delivery to the CNS and muscles.

🔶 The BPP awards 2 points when ≥ 3 discrete movements occur within a 30‑minute window, signaling healthy reactivity.

🔶 Decreased movement is an early sign of fetal hypoxia or acid–base imbalance, prompting escalation of care when absent.

🔶 Assessing motion alongside tone, breathing, and AFV yields a composite physiologic snapshot rather than relying on a single parameter.

🔶 Reliable scoring of movement improves risk stratification, helping determine the need for repeat testing, inpatient monitoring, or delivery.

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Answer 3

Correct Answers:

Maintain a calm, caring, professional demeanor
Ask the teen if she feels safe
Interview the client privately

Rationale :

Maintain a calm, caring, professional demeanor

🔷 A trauma‑informed approach lowers the client’s anxiety and hyperarousal, creating the psychological safety needed for disclosure.

🔷 A nonjudgmental, steady tone and open body language communicate respect and belief, which counters shame and self‑blame common after assault.

🔷 Calm professionalism helps the nurse build rapport quickly, enabling more accurate assessment of injury pattern, timeline, and risk.

🔷 It also supports autonomy, allowing the teen to make informed choices about resources (advocacy, SANE exam, safety planning).

🔷 This demeanor reduces the chance of retraumatization, aligning with best practices for trauma‑ and violence‑informed care.

Ask the teen if she feels safe

🔷 A direct, compassionate safety question assesses imminent danger and guides the urgency of interventions (e.g., secure environment, escalation).

🔷 It opens the door to a lethality screen (recent strangulation, threats, weapons, escalating violence), which predicts high‑risk harm.

🔷 Determining safety informs whether the nurse should initiate immediate safety measures and involve appropriate services per policy.

🔷 The response shapes individualized safety planning (safe contacts, code words, emergency numbers, options for emergency shelter).

🔷 Documenting the client’s own words about safety provides clear, defensible clinical evidence and supports continuity of care.

Interview the client privately

🔷 Private interviewing removes potential coercion or surveillance by the accompanying person, increasing the likelihood of truthful disclosure.

🔷 It protects confidentiality and reduces risk of retaliation, which can occur if controlling partners hear the teen’s account.

🔷 Privacy allows the nurse to use validated screening tools (e.g., HITS) and complete a HEADSSS psychosocial assessment safely.

🔷 In a private setting the nurse can review options and rights (medical care, evidence collection per policy, advocacy) without pressure.

🔷 It also enables meticulous injury documentation (location, size, photos per protocol) to support medical and future legal needs.

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Answer 4

Correct Answers:

Dysmenorrhea that is unresponsive to NSAIDs.

Rationale :

⭐Endometriosis commonly causes severe pelvic pain and dysmenorrhea that does not improve with NSAID therapy.

⭐The condition is due to ectopic endometrial tissue growth outside the uterus, which bleeds with the menstrual cycle.

⭐Associated symptoms include dyspareunia (painful intercourse) and infertility.

⭐Diagnosis often requires laparoscopy for direct visualization of lesions.

⭐ Early recognition helps guide treatment, such as hormonal suppression or surgical excision.

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Answer 5

Correct Answers:

“I preform range of motion exercises every 4 hours to help prevent contractures.“
"l play games with my child every day to keep them as independent as possible"
"l use utensils with large, padded handles to help my child feed themselves more easily."

Rationale :

“I perform range‑of‑motion exercises every 4 hours to help prevent contractures.”

🔷 Children with spastic CP have hypertonia that places them at high risk for muscle shortening and joint contractures; regular ROM maintains muscle length and joint mobility.

🔷 Slow, gentle, pain‑free stretching with a sustained hold reduces spasticity and helps preserve functional alignment.

🔷 Pairing ROM with proper positioning, night splints/AFOs, and PT guidance further prevents deformity and protects skin integrity.

🔷 Scheduling ROM throughout the day (e.g., every few hours while awake) counters the constant pull of spastic muscles and improves comfort and care efficiency.

🔷 Caregivers should document tolerance, avoid forceful stretching, and coordinate with PT/OT to individualize frequency and technique.

“I play games with my child every day to keep them as independent as possible.”

🔷 Daily play‑based, task‑specific practice promotes motor learning and neuroplasticity, directly supporting self‑care independence.

🔷 Purposeful play (stacking, dressing dolls, simple chores) targets fine‑ and gross‑motor skills, bilateral coordination, and problem‑solving in a motivating context.

🔷 Consistent engagement reduces learned dependence, enhances confidence, and supports psychosocial development and participation.

🔷 Integrating strategies from PT/OT/SLP (cueing, graded assistance, assistive tech) makes activities accessible and safe.

🔷 Emphasis on function over perfection (small wins, energy conservation, rest breaks) sustains participation and long‑term independence.

“I use utensils with large, padded handles to help my child feed themselves more easily.”

🔷 Adaptive utensils increase grip size and friction, compensating for spasticity, poor dexterity, and ataxic movements to enable self‑feeding.

🔷 Improved utensil control shortens mealtime, reduces fatigue and frustration, and strengthens the child’s autonomy in ADLs.

🔷 When combined with optimal seating/positioning (upright 90‑90‑90, trunk support, feet supported) and slower pacing, feeding becomes safer and more efficient.

🔷 Collaboration with OT refines utensil selection (angled spoons, weighted handles, scoop dishes) to match the child’s motor profile.

🔷 Enhancing self‑feeding also supports oromotor practice, better nutritional intake, and quality of life for the child and family.

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Answer 6

Correct Answers:

Gradual weaning of breastfeeding

Rationale :

♦️Mastitis is usually caused by milk stasis, engorgement, and cracked nipples, which allow bacteria to enter.

♦️Gradual weaning does not cause mastitis because it allows breast milk production to slowly decrease.

♦️Risk factors include infrequent feedings, poor latch, and breast engorgement.

♦️Early signs include localized breast pain, redness, warmth, and systemic fever.

♦️Proper breastfeeding techniques and frequent emptying of the breasts prevent mastitis.

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Answer 7

Correct Answers:

Uteroplacental insufficiency

Rationale :

🔴Late decelerations on fetal monitoring indicate uteroplacental insufficiency, where the placenta is not delivering adequate oxygen to the fetus.

🔴They typically occur after the peak of contractions and resolve after contraction ends.

🔴Interventions include maternal repositioning, oxygen administration, and stopping oxytocin if infusing.

🔴Persistent late decelerations may signal the need for emergency delivery.

🔴Nurses must act promptly to prevent fetal hypoxia and acidosis.

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Answer 8

Correct Answers:

The elevated AFP means my baby may have spina bifida

Rationale :

⚫Elevated alpha-fetoprotein (AFP) in maternal serum is associated with neural tube defects such as spina bifida or anencephaly.

⚫Down syndrome is usually associated with low AFP levels, not elevated.

⚫AFP is produced by the fetal liver and enters maternal circulation.

⚫Abnormal levels warrant further testing such as ultrasound or amniocentesis.

⚫Screening allows for early detection and intervention planning.

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Answer 9

Correct Answers:

Pancreatic enzymes will not be necessary if our child has a good appetite and regular bowel movements.

Rationale :

🟠Children with cystic fibrosis have pancreatic insufficiency, requiring enzyme replacement regardless of appetite.

🟠Pancreatic enzymes aid in digesting fat, protein, and carbohydrates to prevent malnutrition.

🟠Even with good appetite, without enzymes the child will suffer malabsorption, steatorrhea, and poor growth.

🟠Nutrition is managed with high-calorie, high-protein diets plus supplements.

🟠Parents need to understand that enzymes are a lifelong therapy for effective digestion.

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Answer 10

Correct Answers:

6

Rationale :

💠Heart rate 120/min = 2 points (normal >100).

💠Respiratory effort: slow, weak cry = 1 point.

💠Muscle tone: some flexion of extremities = 1 point.

💠Reflex irritability: grimace = 1 point.

💠Color: pink body, blue extremities (acrocyanosis) = 1 point.

💠Total = 6, indicating moderate depression, requiring supportive care and monitoring.

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Custom: NUR209 Final Assessment Su2. 2025

No.

1 :
A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with a Plastibell technique. Which of the following client statements indicates an understanding of circumcision care? (Select All that Apply.)

2 :
A nurse is caring for a client having a biophysical profile. The client asks what the test is for. What should the nurse include in the response? (Select All that Apply.)

3 :
A 16-year-old is brought to the emergency room by her boyfriend with bruising around her eyes and neck. When asked what happened she states, "l walked into a door." What are the most appropriate interventions by the nurse? (Select All that Apply.)

4 :
A clinic nurse is assessing a client with a suspected diagnosis of endometriosis. Which of the following findings in the client's medical history should the nurse identify as consistent with a diagnosis of endometriosis?

5 :
Which statements made by the parent indicate that appropriate care is being provided to a a-year-old who has spastic type cerebral palsy? (Select All that Apply.)

6 :
The nurse knows that which of the following is not a cause of mastitis?

7 :
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

8 :
Which statement made by a pregnant patient indicates teaching was effective related to an elevated alpha fetoprotein (AFP) level?

9 :
The nurse is preparing a 2-year-old child with cystic fibrosis for discharge home. Which statement made by the parents suggests that additional education is necessary?

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Custom: NUR209 Final Assessment Su2. 2025

No.

1 : A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with a Plastibell technique. Which of the following client statements indicates an understanding of circumcision care? (Select All that Apply.)

2 : A nurse is caring for a client having a biophysical profile. The client asks what the test is for. What should the nurse include in the response? (Select All that Apply.)

3 : A 16-year-old is brought to the emergency room by her boyfriend with bruising around her eyes and neck. When asked what happened she states, "l walked into a door." What are the most appropriate interventions by the nurse? (Select All that Apply.)

4 : A clinic nurse is assessing a client with a suspected diagnosis of endometriosis. Which of the following findings in the client's medical history should the nurse identify as consistent with a diagnosis of endometriosis?

5 : Which statements made by the parent indicate that appropriate care is being provided to a a-year-old who has spastic type cerebral palsy? (Select All that Apply.)

6 : The nurse knows that which of the following is not a cause of mastitis?

7 : A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

8 : Which statement made by a pregnant patient indicates teaching was effective related to an elevated alpha fetoprotein (AFP) level?

9 : The nurse is preparing a 2-year-old child with cystic fibrosis for discharge home. Which statement made by the parents suggests that additional education is necessary?

1 :
A nurse on a postpartum unit is giving discharge instructions to a client whose newborn had a circumcision with a Plastibell technique. Which of the following client statements indicates an understanding of circumcision care? (Select All that Apply.)

2 :
A nurse is caring for a client having a biophysical profile. The client asks what the test is for. What should the nurse include in the response? (Select All that Apply.)

3 :
A 16-year-old is brought to the emergency room by her boyfriend with bruising around her eyes and neck. When asked what happened she states, "l walked into a door." What are the most appropriate interventions by the nurse? (Select All that Apply.)

4 :
A clinic nurse is assessing a client with a suspected diagnosis of endometriosis. Which of the following findings in the client's medical history should the nurse identify as consistent with a diagnosis of endometriosis?

5 :
Which statements made by the parent indicate that appropriate care is being provided to a a-year-old who has spastic type cerebral palsy? (Select All that Apply.)

6 :
The nurse knows that which of the following is not a cause of mastitis?

7 :
A nurse is caring for a client who is in labor and has an external fetal monitor. The nurse observes late decelerations on the monitor strip and interprets them as indicating which of the following?

8 :
Which statement made by a pregnant patient indicates teaching was effective related to an elevated alpha fetoprotein (AFP) level?

9 :
The nurse is preparing a 2-year-old child with cystic fibrosis for discharge home. Which statement made by the parents suggests that additional education is necessary?