NCLEX: Maternal And Child Nursing Exam Practice Test

The client's statement that "Nausea and vomiting can be decreased if I eat a few crackers before arising" demonstrates understanding of self-care measures for common discomforts of pregnancy. Eating crackers before getting out of bed in the morning can help alleviate morning sickness by providing a bland, dry substance in the stomach. This can help absorb stomach acids and prevent nausea. This self-care measure is commonly recommended for pregnant women experiencing morning sickness.

When the nurse accidentally bumps the bassinet, the neonate's reaction of throwing out its arms, hands opened and crying is indicative of the startle reflex. The startle reflex is a normal reflex that occurs in response to a sudden, unexpected stimulus. This reflex is characterized by the baby's sudden extension and abduction of the arms, followed by bringing them back to the body and crying. It is an involuntary response that helps protect the baby from potential harm or danger.

In the first 24 hours post-delivery, it is normal to experience bright red blood as part of the lochial discharge. This is because the uterus is shedding the lining that built up during pregnancy. The presence of bright red blood indicates that the healing process is underway and the body is expelling the excess blood. It is important to note that large clots or tissue fragments, a foul odor, or the complete absence of lochia are not normal and may indicate a complication that requires medical attention.

The correct answer is between 16 and 20 weeks' gestation. This is when the patient can expect to feel the fetus move, also known as quickening. At this stage of pregnancy, the fetus has developed enough to start making movements that can be felt by the mother. Before this time, the fetus is still too small and the movements are not strong enough to be noticeable. After 20 weeks, the movements become more pronounced and can be felt regularly.

Partial placenta previa is a condition in which the placenta partially covers the cervix. The usual treatment for partial placenta previa is activity limited to bed rest. This is because bed rest helps to reduce the risk of bleeding and complications. By limiting activity, the client can minimize the pressure on the placenta and reduce the chances of further displacement or detachment. It is important for the client to avoid any strenuous activity or heavy lifting to prevent any harm to the placenta and the baby.

Breast-feeding the neonate at frequent intervals helps to prevent breast engorgement. Frequent feeding stimulates milk production and helps to maintain a steady milk supply, reducing the risk of engorgement. This also helps to ensure that the baby is getting enough milk and promotes bonding between the mother and baby. Wearing a supportive brassiere with nipple shields may provide comfort, but it does not directly prevent engorgement. Feeding the neonate for only 5 minutes per side on the first day may not be sufficient to establish a good milk supply. Decreasing fluid intake for the first 24 to 48 hours is not recommended as it can lead to dehydration and does not prevent engorgement.

Protamine sulfate is the antidote for heparin therapy. Heparin is an anticoagulant medication used to prevent blood clots. However, in some cases, it can cause excessive bleeding or other complications. Protamine sulfate works by neutralizing the effects of heparin, helping to reverse its anticoagulant effects and prevent further bleeding or complications. Therefore, if the postpartum client develops complications related to heparin therapy, the nurse would expect to administer protamine sulfate to counteract the effects of heparin.

A patient with pregnancy-induced hypertension may exhibit proteinuria, which is the presence of excessive protein in the urine. This is because high blood pressure can damage the blood vessels in the kidneys, leading to the leakage of protein into the urine. Headaches are also a common symptom of pregnancy-induced hypertension, as the high blood pressure can cause increased pressure in the brain. Double vision may occur due to the effects of high blood pressure on the blood vessels in the eyes.

The nurse should respond "No, it can initiate premature uterine contractions." because castor oil is known to stimulate the bowels and can potentially cause uterine contractions, which may lead to premature labor. It is important for pregnant patients to avoid any substances or medications that can potentially harm the fetus or cause complications during pregnancy.

Before applying an internal electronic fetal monitoring (EFM) device, the membranes must rupture. This is because the internal EFM is inserted through the cervix and into the uterus, and it needs direct contact with the amniotic fluid to accurately monitor the fetal heart rate. If the membranes have not ruptured, there is a risk of infection or injury to the fetus if the EFM is inserted. Therefore, it is necessary for the membranes to rupture before using an internal EFM.

The type of molding in a neonate's head is determined by fetal body flexion or extension. This means that the positioning of the baby's body during delivery, whether it is flexed or extended, can affect the shape of the head. Molding occurs as the baby's skull bones shift and overlap to fit through the birth canal. The amount of molding can vary depending on how the baby is positioned during delivery.

After observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision, the nurse in charge would first apply gentle pressure to the site with a sterile gauze pad. This is the most appropriate action to control the bleeding and promote clot formation. It is important to address the bleeding promptly to prevent further complications. Notifying the pediatrician immediately may be necessary depending on the severity of the bleeding, but applying pressure should be the first step taken. Checking the diaper and circumcision again in 30 minutes or securing the diaper tightly to apply pressure on the site are not the most appropriate initial actions.

Checking the vital signs every 2 to 4 hours is important when caring for a neonate receiving phototherapy for jaundice. Phototherapy can cause dehydration and electrolyte imbalances, so monitoring vital signs regularly helps to assess the neonate's hydration status and overall well-being. Turning the neonate every 6 hours is not specific to phototherapy and is more related to preventing pressure ulcers. Encouraging the mother to discontinue breastfeeding is not necessary as breastfeeding is important for the neonate's nutrition and hydration. Notifying the physician if the skin becomes bronze in color may indicate a potential adverse reaction to phototherapy, but it is not the most immediate and essential action to take.

The nurse would be alert for endometritis in this postpartum patient who was in labor for 30 hours and had ruptured membranes for 24 hours. Prolonged labor and prolonged rupture of membranes increase the risk of infection, specifically in the endometrium (lining of the uterus). Endometritis is an inflammation or infection of the endometrium, which can occur after childbirth. Therefore, the nurse would be vigilant for signs and symptoms of endometritis in this patient.

Tailor sitting is a sitting position that involves sitting on the floor with the knees bent and the soles of the feet together. This position helps to open up the pelvis and relieve pressure on the lower back. It can also help to improve posture and strengthen the pelvic floor muscles. By suggesting tailor sitting, the nurse is recommending a position that can help alleviate the client's lower back pain and provide some relief after a long day at work.

During the early part of the first stage of labor, the pain is likely to be most intense around the pelvic girdle. This is because the cervix is dilating and the baby's head is descending into the pelvis, causing pressure and stretching of the pelvic ligaments and muscles. The pain may radiate to the lower back and thighs as well. However, as the labor progresses, the pain may also be felt at the perineum, which is the area between the vagina and the anus, as the baby's head puts pressure on this area during the pushing stage.

The transitional phase is the shortest but most difficult part of the first stage of labor. This phase occurs when the cervix is dilated from 8 to 10 centimeters and the contractions become stronger and closer together. The woman may experience intense pain and discomfort during this phase, as well as feelings of exhaustion and uncertainty. The transitional phase is often described as the most challenging part of labor because it marks the transition from early labor to active labor, and the woman may feel overwhelmed by the intensity of the contractions and the physical and emotional changes she is experiencing.

The client's statement that the ultrasound identifies blood flow through the umbilical cord indicates a need for further instruction. Ultrasound does not typically assess blood flow through the umbilical cord. It is used to locate the placenta, determine the insertion site for amniocentesis, and locate a pool of amniotic fluid.

The perineum is the correct location for relief after a bilateral pudendal block anesthesia. This type of anesthesia involves injecting a local anesthetic into the area around the pudendal nerve, which provides pain relief to the perineum during delivery. Therefore, if the client identifies the perineum as the area of relief, it indicates that the teaching was effective and the client understands the intended location of the anesthesia.

Thirty hours after delivery, the nurse expects that the client would be in the phase of postpartum psychological adaptation known as "Taking hold." This phase occurs after the initial "Taking in" phase, where the client is focused on her own needs and is dependent on others for care. In the "Taking hold" phase, the client starts to take more initiative and becomes more interested in learning about and caring for her infant. This is an important time for the nurse to provide teaching on infant care. "Letting go" and "Resolution" are not the correct answers as they do not accurately describe this specific phase of postpartum adaptation.

The primary nursing diagnosis for this patient is fluid volume deficit. The patient is experiencing vaginal bleeding and has passed several clots, indicating a potential loss of blood. This can lead to a decrease in circulating blood volume, resulting in fluid volume deficit. The abdominal cramping may also be a symptom of this deficit. The other options, knowledge deficit, anticipatory grieving, and pain, do not directly address the patient's physical condition and symptoms.

The transitional phase of labor is the phase between the active phase and the second stage of labor. During this phase, the cervix dilates from 8 to 10 cm and the baby moves further down the birth canal. The woman may experience strong contractions and intense pain. In this case, the woman's cervix is already at 8 cm and completely effaced, indicating that she is in the transitional phase of labor.

A pregnant client with abruption placenta is likely to have a rigid, boardlike abdomen. This is because abruption placenta is a condition where the placenta separates from the uterine wall prematurely, leading to internal bleeding. The accumulation of blood behind the placenta causes the uterus to become tense and rigid, resulting in a boardlike feeling when palpated by the nurse. This symptom is an important indicator of abruption placenta and requires immediate medical attention.

Progestin-only oral contraceptives, also known as minipills, are a type of birth control pill that contains only progestin hormone. These pills work by thickening the cervical mucus, which makes it difficult for sperm to reach the egg. However, they do not always prevent ovulation. In rare cases, if ovulation occurs while taking the minipill, there is a risk of fertilization happening outside the uterus, leading to a tubal or ectopic pregnancy. This is because the minipill does not provide the same level of protection against pregnancy as combined oral contraceptives, which contain both estrogen and progestin hormones.

High-pitched speech with tonal variations is the best means to elicit the best response from neonates. Neonates are more responsive to high-pitched sounds and tonal variations because their auditory system is still developing. High-pitched speech with tonal variations can capture their attention and engage them in a more meaningful way. This type of speech can also help in promoting language development and bonding between the caregiver and the baby.

Lubricating the nipples with expressed milk before feeding can help to relieve nipple soreness. Breast milk has natural moisturizing properties and can help to soothe and protect the nipples during breastfeeding. Additionally, lubricating the nipples with breast milk can also help to prevent friction and irritation during feeding.

During oxytocin administration, the nurse must monitor the patient's fluid intake and output closely because oxytocin can cause water intoxication. Oxytocin has antidiuretic effects, which means it can cause the body to retain water. This can lead to an imbalance in fluid levels and electrolytes, potentially causing water intoxication. Monitoring the patient's fluid intake and output is important to ensure that they are not retaining too much fluid and to detect any signs of water intoxication, such as fluid overload or hyponatremia.

Cools incubator walls can be a common source of radiant heat loss for a neonate. Incubators are designed to maintain a warm and controlled environment for newborns, but if the walls of the incubator are cool, they can absorb and dissipate heat, leading to hypothermia in the neonate. It is important for the nurse to ensure that the incubator is functioning properly and that the walls are adequately insulated to prevent heat loss.

Bethanechol is a cholinergic agonist that stimulates the parasympathetic nervous system. One of its common side effects is nausea and vomiting. This occurs because the drug increases gastrointestinal motility, leading to increased gastric emptying and potential irritation of the stomach lining. Therefore, it is expected for the nurse to monitor the patient for these adverse effects after administering bethanechol.

The nurse should notify the physician immediately because the client is in active labor with twins and the cervix is 5 cm dilated. Contractions occurring every 7 to 8 minutes in a 30-minute period may indicate a potential problem or complication that requires medical attention. It is important to involve the physician in order to ensure the safety and well-being of both the mother and the babies.