Maternal And Child Health Nursing (Intrapartum And Postpartum)

What is the condition called whereby the placenta is implanted in the lower uterine segment. It can be classified as partially, totally, or marginal.?

A nurse is administering a shot of Vitamin K to a 30 day-old infant. Which of the following tar- get areas is the most appropriate? 

• Gluteus maximus

• Gluteus minimus

• Vastus lateralis

• Vastus medialis

A woman is seen in the prenatal clinic and complains of morning sickness. Which self care measures will the nurse suggest to the client?

• To eat eggs for breakfast

• To eat three well balanced meals every day

• To eat fatty or spicy foods only at the noontime meal

• To eat a dry crackers before getting out of bed in the morning

A walk-in client enters into the clinic with a chief complaint of abdominal pain and diarrhea. The nurse takes the client’s vital sign hereafter. What phrase of nursing process is being implemented here by the nurse? 

• Assessment

• Diagnosis

• Planning

• Implementation

Mrs. Lim begins to cry as the nurse discusses hair loss. The best response would be: 

• “Don’t worry. It’s only temporary”

• “Why are you crying? I didn’t get to the bad news yet”

• “Your hair is really pretty”

• “I know this will be difficult for you, but your hair will grow back after the completion of chemotheraphy”

In the later part of the 3rd trimester, the mother may experience shortness of breath. This complaint maybe explained as: 

• A normal occurrence in pregnancy because the fetus is using more oxygen

• The fundus of the uterus is high pushing the diaphragm upwards

• The woman is having allergic reaction to the pregnancy and its hormones

• The woman maybe experiencing complication of pregnancy

If there is a decrease of alpha-fetoprotein in the amniotic fluid, it would signify what disease is the fetus risk for?

Basing on the normal Conduction System of the heart, numer 2 is called the:

A patient asks a nurse, “My doctor recom- mended I increase my intake of folic acid. What type of foods contain the highest concentration of folic acids?” 

• Green vegetables and liver

• Yellow vegetables and red meat

• Carrots

• Milk

When taking an obstetrical history on a pregnant client who states, “I had a son born at 38 weeks gestation, a daughter born at 30 weeks gestation and I lost a baby at about 8 weeks,”the nurse should record her obstetrical history as which of the following? 

• G2 T2 P0 A0 L2

• G3 T1 P1 A0 L2

• G3 T2 P0 A0 L2

• G4 T1 P1 A1 L2

The hormone responsible for a positive pregnancy test is: 

• Estrogen

• Progesterone

• Human chorionic gonadotrophin

• Follicle stimulating hormone

Sterile technique is used whenever: 

• Strict isolation is required

• Terminal disinfection is performed

• Invasive procedures are performed

• Protective isolation is necessary

The client tells the nurse that her last menstrual period started on January 14 and ended on January 20. Using Nagele’s rule, the nurse determines her EDD to be which of the following? 

• September 27

• October 21

• November 7

• December 27

It is best describe as a systematic, rational method of planning and providing nursing care for individual, families, group and community 

• Critical thinking

• Scientific method

• Nursing process

• Nursing diagnosis

Incident of prostate cancer is found to have been reduced on a population exposed in tolerable amount of sunlight. Which vitamin is associated with this phenomenon?

• Vitamin A

• Vitamin B

• Vitamin C

• Vitamin D

The nurse is preparing to take vital sign in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client’s temperature? 

• Oral

• Axillary

• Radial

• Heat sensitive tape

Which of the following is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage?

• Placenta previa

• Ectopic pregnancy

• Incompetent cervix

• Abruptio placentae

How would you correctly document this ECG strip on the client's chart using the correct medical terminology?

Which of the following best describes preterm labor?    

• Labor that begins after 20 weeks gestation and before 37 weeks gestation

• Labor that begins after 15 weeks gestation and before 37 weeks gestation

• Labor that begins after 24 weeks gestation and before 28 weeks gestation

• Labor that begins after 28 weeks gestation and before 40 weeks gestation

The nurse prepare IM injection that is irritating to the subcutaneous tissue. Which of the following is the best action in order to prevent tracking of the medication 

• Use a small gauge needle

• Apply ice on the injection site

• Administer at a 45 degree angle

• Use the Z track technique

What is the procedure called whereby the physician removes a small piece of villi between 8 to 12 weeks' gestation under ultrasound guidance?

Which of the following patients is at greatest risk for developing pressure ulcers? 

• An alert, chronic arthritic patient treated with steroids and aspirin

• An 88-year old incontinent patient with gastric cancer who is confined to his bed at home

• An apathetic 63-year old COPD patient receiving nasal oxygen via cannula

• A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed.

After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping and muscle weakness. These symptoms probably indicate that the patient is experiencing: 

• Hypokalemia

• Hyperkalemia

• Anorexia

• Dysphagia

The main reason for an expected increased need for iron in pregnancy is: 

• The mother may have physiologic anemia due to the increased need for red blood cell mass as well as the fetal requires about 350-400 mg of iron to grow

• The mother may suffer anemia because of poor appetite

• The fetus has an increased need for RBC which the mother must supply

• The mother may have a problem of digestion because of pica

If there is an INCREASE in alpha-fetoprotein 

Calculate the heart rate of the patient using the ECG strip provided above.

Which of the following is a positive sign of pregnancy? 

• Fetal movement felt by mother

• Enlargement of the uterus

• (+) pregnancy test

• (+) ultrasound

What is the normal ratio of bicarbonate to carbonic acid to maintain the HOMEOSTASIS of the body?

A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client’s body temperature? 

• Oral

• Axillary

• Arterial line

• Rectal

Which of the following is an example of nursing malpractice?

• The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia.

• The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping.

• The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus

• The nurse administers the wrong medication to a patient and the patient vomits. This information is documented and reported to the physician and the nursing supervisor.

A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. An appropriate nursing diagnosis would be: 

• Ineffective airway clearance related to thick, tenacious secretions.

• Ineffective airway clearance related to dry, hacking cough.

• Ineffective individual coping to COPD.

• Pain related to immobilization of affected leg.

A client with gravida 3 para 2 at 40 weeks' gestation is admitted with spontaneous contractions. The physician performs an amniotomy to augment her labor. The PRIORITY nursing action is to: Client's needs category: Physiological Integrity Cognitive level: Knowledge

• Explain the rationale for the amniotomy to the patient

• Monitor fetal heart tones after the amniotomy

• Ambulate the client to strengthen the contraction pattern

• Position the client in a lithotomy position to administer perineal care

Which of the following would the nurse assess in a client experiencing abruptio placenta?

• Bright red, painless vaginal bleeding

• Concealed or external dark red bleeding

• Palpable fetal outline

• Soft and nontender abdomen

Calculate the heart rate of the patient using the ECG strip above.

Which of the following principles of primary nursing has proven the most satisfying to the patient and nurse? 

• Continuity of patient care promotes efficient, cost-effective nursing care

• Autonomy and authority for planning are best delegated to a nurse who knows the patient well

• Accountability is clearest when one nurse is responsible for the overall plan and its implementation.

• The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care.

The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml? 

• 5 gtt/minute

• 13 gtt/minute

• 25 gtt/minute

• 50 gtt/minute

A registered nurse reaches to answer the telephone on a busy pediatric unit, momentarily turning away from a 3 month-old infant she has been weighing. The infant falls off the scale, suffering a skull fracture. The nurse could be charged with: 

• Defamation

• Assault

• Battery

• Malpractice

A client in the active phase of labor has a reactive fetal monitor strip and has been encouraged to walk. When she returns to bed for a monitor check, she complains for an urge to push. The nurse notes that the amniotic membranes have ruptured and she can visualize the umbilical cord. What should the nurse do next? Client's needs category: Physiological Integrity Client's needs subcategory: Reduction of risk potential Cognitive level: Analysis

• Put the client in a knee-to-chest position

• Call the physician or midwife because it is emergent

• Push down on the uterine fundus

• Arrange for fetal blood sampling to assess for fetal acidosis

It is th partial or complete premature detachment of the placenta from its site of implantation in the uterus. It is usually occuring in the late third trimester or in labor.

When preparing the mother who is on her 4th month of pregnancy for abdominal ultrasound, the nurse should instruct her to: 

• Observe NPO from midnight to avoid vomiting

• Do perineal flushing properly before the procedure

• Drink at least 2 liters of fluid 2 hours before the procedure and not void until the procedure is done

• Void immediately before the procedure for better visualization

An LPN assists a registered nurse in developing a teaching plan for a pregnant client newly diagnosed with diabetes mellitus. Which of the following is inappropriate to include in the plan?

• Effects of diabetes on the pregnancy and fetus

• Nutritional requirements for pregnancy and diabetic control

• Avoidance of exercise because of the negative effects on insulin production

• Awareness of any infections and reporting these immediately to the health care provider

An iron supplement is prescribed for a pregnant client. The nurse tells the client that it is best to take the iron supplemet with:

• Milk

• Water

• Tea

• Orange juice

Deficiency of this mineral results in tetany, osteomalacia, osteoporosis and rickets.

• Vitamin D

• Iron

• Calcium

• Sodium

During which of the following stages of labor would the nurse assess “crowning”?

• First stage

• Second stage

• Third stage

• Fourth stage

Which of the following nursing interventions would the nurse perform during the third stage of labor?

• Obtain a urine specimen and other laboratory tests.

• Assess uterine contractions every 30 minutes.

• Coach for effective client pushing

• Promote parent-newborn interaction.

If patient asks the nurse her opinion about a particular physicians and the nurse replies that the physician is incompetent, the nurse could be held liable for: 

• Slander

• Libel

• Assault

• Respondent superior

Which of the following assessment findings would the nurse expect if the client develops DVT? 

• Midcalf pain, tenderness and redness along the vein

• Chills, fever, malaise, occurring 2 weeks after delivery

• Muscle pain the presence of Homans sign, and swelling in the affected limb

• Chills, fever, stiffness, and pain occurring 10 to 14 days after delivery

A second year nursing student has just suf- fered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most important action that nursing student should take? 

• Immediately see a social worker

• Start prophylactic AZT treatment

• Start prophylactic Pentamide treatment

• Seek counseling