Maternal And Child Health Nursing Test I - Set A
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This test contains 25 items Questions about Maternal and Child Health Nursing
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Maternal and Child Health Nursing Test I - Set A: Answers with Rationales
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- 1.
Which of the following common emotional reactions to pregnancy would the nurse expect to occur during the first trimester?
- A.
Introversion, egocentrism, narcissism
- B.
Awkwardness, clumsiness, and unattractiveness
- C.
Anxiety, passivity, extroversion
- D.
Ambivalence, fear, fantasies
Correct Answer
D. Ambivalence, fear, fantasiesExplanation
During the first trimester of pregnancy, it is common for women to experience ambivalence, fear, and fantasies. Ambivalence refers to having mixed feelings or uncertainty about the pregnancy, as it can bring both joy and anxiety. Fear is a natural emotional reaction due to the physical and emotional changes happening in the body, as well as concerns about the health and well-being of the baby. Fantasies can include daydreaming about the future, imagining what the baby will be like, or envisioning the role of being a parent. These emotional reactions are typical during the initial stage of pregnancy.Rate this question:
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- 2.
Which of the following nursing interventions would the nurse perform during the third stage of labor?
- A.
Obtain a urine specimen and other laboratory tests.
- B.
Assess uterine contractions every 30 minutes.
- C.
Coach for effective client pushing
- D.
Promote parent-newborn interaction.
Correct Answer
D. Promote parent-newborn interaction.Explanation
During the third stage of labor, which is the delivery of the placenta, the nurse's main focus is on promoting parent-newborn interaction. This stage involves the bonding and initial interaction between the parents and their newborn. The nurse may encourage the parents to hold and interact with the baby, facilitate skin-to-skin contact, and provide emotional support and guidance to promote a positive parent-infant relationship. This intervention is crucial for the emotional well-being of both the parents and the baby.Rate this question:
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- 3.
Which of the following describes the Babinski reflex?
- A.
The newborn’s toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward from the ball of the heel and across the ball of the foot.
- B.
The newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement or loud noise.
- C.
The newborn turns the head in the direction of stimulus, opens the mouth, and begins to suck when cheek, lip, or corner of mouth is touched.
- D.
The newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface
Correct Answer
A. The newborn’s toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward from the ball of the heel and across the ball of the foot.Explanation
The Babinski reflex is a normal reflex in newborns. It is characterized by the hyperextension and fanning apart of the toes when the sole of the foot is stroked. This reflex is a sign of a healthy nervous system in infants.Rate this question:
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- 4.
When talking with a pregnant client who is experiencing aching swollen, leg veins, the nurse would explain that this is most probably the result of which of the following?
- A.
Thrombophlebitis
- B.
Pregnancy-induced hypertension
- C.
Pressure on blood vessels from the enlarging uterus
- D.
The force of gravity pulling down on the uterus
Correct Answer
C. Pressure on blood vessels from the enlarging uterusExplanation
During pregnancy, the uterus expands in size and puts pressure on the blood vessels in the pelvic area, including the veins in the legs. This increased pressure can lead to aching and swollen leg veins. Thrombophlebitis refers to inflammation of a vein due to a blood clot, which is not the most probable cause in this case. Pregnancy-induced hypertension is a condition characterized by high blood pressure during pregnancy, which may cause various complications but is not directly related to aching swollen leg veins. The force of gravity pulling down on the uterus does not specifically explain the aching swollen leg veins.Rate this question:
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- 5.
FHR can be auscultated with a fetoscope as early as which of the following?
- A.
5 weeks gestation
- B.
10 weeks gestation
- C.
15 weeks gestation
- D.
20 weeks gestation
Correct Answer
D. 20 weeks gestationExplanation
FHR stands for fetal heart rate and refers to the heartbeat of the fetus. Auscultation is the process of listening to sounds within the body using a stethoscope or fetoscope. The question asks at what stage of gestation FHR can be auscultated with a fetoscope. The correct answer is 20 weeks gestation. This means that at around 20 weeks of pregnancy, the fetal heartbeat can be heard using a fetoscope.Rate this question:
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- 6.
Which of the following is the nurse’s initial action when umbilical cord prolapse occurs?
- A.
Begin monitoring maternal vital signs and FHR
- B.
Place the client in a knee-chest position in bed
- C.
Notify the physician and prepare the client for delivery
- D.
Apply a sterile warm saline dressing to the exposed cord
Correct Answer
B. Place the client in a knee-chest position in bedExplanation
When umbilical cord prolapse occurs, the nurse's initial action is to place the client in a knee-chest position in bed. This position helps to relieve pressure on the cord and prevent further compression, which can lead to fetal distress or compromise. By placing the client in a knee-chest position, gravity helps to shift the weight of the fetus off the cord, allowing for better blood flow. This action should be taken immediately to ensure the safety of both the mother and the baby.Rate this question:
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- 7.
Which of the following danger signs should be reported promptly during the antepartum period?
- A.
Constipation
- B.
Breast tenderness
- C.
Nasal stuffiness
- D.
Leaking amniotic fluid
Correct Answer
D. Leaking amniotic fluidExplanation
During the antepartum period, it is important to promptly report any signs of leaking amniotic fluid. This is because it could indicate a rupture of the amniotic sac, which can lead to complications such as infection or preterm labor. Prompt reporting allows for timely medical intervention to ensure the health and safety of both the mother and the baby. Constipation, breast tenderness, and nasal stuffiness are common discomforts during pregnancy but do not pose the same level of risk as leaking amniotic fluid.Rate this question:
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- 8.
Which of the following groups of newborn reflexes below are present at birth and remain unchanged through adulthood?
- A.
Blink, cough, rooting, and gag
- B.
Blink, cough, sneeze, gag
- C.
Rooting, sneeze, swallowing, and cough
- D.
Stepping, blink, cough, and sneeze
Correct Answer
B. Blink, cough, sneeze, gagExplanation
The correct answer is Blink, cough, sneeze, gag. These reflexes are present at birth and remain unchanged through adulthood. The blink reflex is an automatic response to protect the eyes from potential harm. Coughing and sneezing reflexes help to clear the airways of irritants or foreign objects. The gag reflex is a protective mechanism that prevents choking by triggering the contraction of the throat muscles. These reflexes are essential for maintaining the safety and health of an individual.Rate this question:
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- 9.
A couple who wants to conceive but has been unsuccessful during the last 2 years has undergone many diagnostic procedures. When discussing the situation with the nurse, one partner states, “We know several friends in our age group and all of them have their own child already, Why can’t we have one?”. Which of the following would be the most pertinent nursing diagnosis for this couple?
- A.
Fear related to the unknown
- B.
Pain related to numerous procedures.
- C.
Ineffective family coping related to infertility.
- D.
Self-esteem disturbance related to infertility.
Correct Answer
D. Self-esteem disturbance related to infertility.Explanation
The most pertinent nursing diagnosis for this couple would be self-esteem disturbance related to infertility. This is because the couple's statement about their friends having children while they are unable to conceive suggests that they may be experiencing feelings of inadequacy, low self-worth, and a negative impact on their self-esteem due to their infertility.Rate this question:
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- 10.
Which of the following best describes thrombophlebitis?
- A.
Inflammation and clot formation that result when blood components combine to form an aggregate body
- B.
Inflammation and blood clots that eventually become lodged within the pulmonary blood vessels
- C.
Inflammation and blood clots that eventually become lodged within the femoral vein
- D.
Inflammation of the vascular endothelium with clot formation on the vessel wall
Correct Answer
D. Inflammation of the vascular endothelium with clot formation on the vessel wallExplanation
Thrombophlebitis is the inflammation of the vascular endothelium, which is the inner lining of the blood vessels, combined with the formation of a blood clot on the vessel wall. This condition occurs when the blood components combine and form an aggregate body, leading to inflammation and clot formation. It is not specific to any particular blood vessel, such as the pulmonary blood vessels or the femoral vein.Rate this question:
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- 11.
Which of the following best reflects the frequency of reported postpartum “blues”?
- A.
Between 10% and 40% of all new mothers report some form of postpartum blues
- B.
Between 30% and 50% of all new mothers report some form of postpartum blues
- C.
Between 50% and 80% of all new mothers report some form of postpartum blues
- D.
Between 25% and 70% of all new mothers report some form of postpartum blues
Correct Answer
C. Between 50% and 80% of all new mothers report some form of postpartum bluesExplanation
Between 50% and 80% of all new mothers report some form of postpartum blues. This answer reflects the frequency of reported postpartum "blues" as it suggests that a significant majority of new mothers experience this condition. The answer range of 50% to 80% indicates that a substantial portion of new mothers are affected by postpartum blues, highlighting the prevalence of this phenomenon.Rate this question:
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- 12.
When uterine rupture occurs, which of the following would be the priority?
- A.
Limiting hypovolemic shock
- B.
Obtaining blood specimens
- C.
Instituting complete bed rest
- D.
Inserting a urinary catheter
Correct Answer
A. Limiting hypovolemic shockExplanation
When uterine rupture occurs, the priority would be to limit hypovolemic shock. Uterine rupture can lead to severe bleeding, which can cause hypovolemia, a condition where there is a significant decrease in blood volume. This can result in inadequate perfusion to vital organs and can be life-threatening. Therefore, the immediate focus should be on controlling the bleeding and preventing further blood loss to stabilize the patient's condition and minimize the risk of hypovolemic shock.Rate this question:
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- 13.
When preparing a client for cesarean delivery, which of the following key concepts should be considered when implementing nursing care?
- A.
Instruct the mother’s support person to remain in the family lounge until after the delivery
- B.
Arrange for a staff member of the anesthesia department to explain what to expect postoperatively
- C.
Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth
- D.
Explain the surgery, expected outcome, and kind of anesthetics
Correct Answer
C. Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birthExplanation
When preparing a client for cesarean delivery, it is important to modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth. This is because the client may have different concerns and questions depending on whether the cesarean is planned or unexpected. By tailoring the teaching to the specific situation, the nurse can address any fears or uncertainties the client may have and provide appropriate information and support. This ensures that the client is well-prepared and informed for the procedure, leading to better outcomes and satisfaction.Rate this question:
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- 14.
Which of the following is the primary predisposing factor related to mastitis?
- A.
Epidemic infection from nosocomial sources localizing in the lactiferous glands and ducts
- B.
Endemic infection occurring randomly and localizing in the periglandular connective tissue
- C.
Temporary urinary retention due to decreased perception of the urge to avoid
- D.
Breast injury caused by overdistention, stasis, and cracking of the nipples
Correct Answer
D. Breast injury caused by overdistention, stasis, and cracking of the nipplesExplanation
Breast injury caused by overdistention, stasis, and cracking of the nipples is the primary predisposing factor related to mastitis. This is because when the nipples are cracked or injured, it creates a pathway for bacteria to enter the breast tissue. Overdistention and stasis can also lead to milk buildup, creating an environment that is conducive to bacterial growth. These factors increase the risk of infection and inflammation in the breast, leading to mastitis.Rate this question:
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- 15.
Which of the following would cause a false-positive result on a pregnancy test?
- A.
The test was performed less than 10 days after an abortion
- B.
The test was performed too early or too late in the pregnancy
- C.
The urine sample was stored too long at room temperature
- D.
A spontaneous abortion or a missed abortion is impending
Correct Answer
A. The test was performed less than 10 days after an abortionExplanation
Performing a pregnancy test less than 10 days after an abortion can cause a false-positive result. After an abortion, the hormone hCG (human chorionic gonadotropin) may still be present in the body, which is the hormone detected by pregnancy tests. It takes time for hCG levels to decrease after an abortion, so if a test is done too soon, it may detect the remaining hCG and give a false-positive result. Therefore, performing a test within 10 days of an abortion can lead to a false-positive result.Rate this question:
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- 16.
Barbiturates are usually not given for pain relief during active labor for which of the following reasons?
- A.
The neonatal effects include hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the first few days.
- B.
These drugs readily cross the placental barrier, causing depressive effects in the newborn 2 to 3 hours after intramuscular injection.
- C.
They rapidly transfer across the placenta, and lack of an antagonist make them generally inappropriate during labor.
- D.
Adverse reactions may include maternal hypotension, allergic or toxic reaction or partial or total respiratory failure
Correct Answer
C. They rapidly transfer across the placenta, and lack of an antagonist make them generally inappropriate during labor.Explanation
Barbiturates are not given for pain relief during active labor because they rapidly transfer across the placenta and lack an antagonist, making them generally unsuitable. This means that the drugs can easily reach the fetus, causing depressive effects in the newborn shortly after injection. Additionally, the lack of an antagonist means that there is no medication available to counteract any adverse effects that may occur. Therefore, barbiturates can pose risks to both the mother and the baby during labor.Rate this question:
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- 17.
Which of the following would the nurse identify as a classic sign of PIH?
- A.
Edema of the feet and ankles
- B.
Edema of the hands and face
- C.
Weight gain of 1 lb/week
- D.
Early morning headache
Correct Answer
B. Edema of the hands and faceExplanation
Edema of the hands and face is a classic sign of PIH (pregnancy-induced hypertension) because it is caused by the retention of fluid in the body. PIH is a condition that occurs during pregnancy and is characterized by high blood pressure and damage to organs such as the liver and kidneys. Edema, or swelling, is a common symptom of PIH and is often seen in the hands and face due to the increased pressure in the blood vessels. This can be a result of the body's inability to eliminate excess fluid properly.Rate this question:
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- 18.
Which of the following best describes preterm labor?
- A.
Labor that begins after 20 weeks gestation and before 37 weeks gestation
- B.
Labor that begins after 15 weeks gestation and before 37 weeks gestation
- C.
Labor that begins after 24 weeks gestation and before 28 weeks gestation
- D.
Labor that begins after 28 weeks gestation and before 40 weeks gestation
Correct Answer
A. Labor that begins after 20 weeks gestation and before 37 weeks gestationExplanation
Preterm labor refers to labor that starts after 20 weeks gestation but before 37 weeks gestation. This means that the woman goes into labor earlier than expected, which can have potential risks for the baby's health and development. It is important to monitor and manage preterm labor to ensure the best possible outcome for both the mother and the baby.Rate this question:
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- 19.
Which of the following factors is the underlying cause of dystocia?
- A.
Nurtional
- B.
Mechanical
- C.
Environmental
- D.
Medical
Correct Answer
B. MechanicalExplanation
Mechanical factors refer to physical obstructions or difficulties during childbirth that can lead to dystocia. This can include issues such as a large fetus, abnormal fetal position, or problems with the birth canal. These mechanical factors can prevent the normal progression of labor and delivery, causing complications and potentially endangering both the mother and the baby.Rate this question:
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- 20.
Which of the following are the most commonly assessed findings in cystitis?
- A.
Frequency, urgency, dehydration, nausea, chills, and flank pain
- B.
Nocturia, frequency, urgency dysuria, hematuria, fever and suprapubic pain
- C.
Dehydration, hypertension, dysuria, suprapubic pain, chills, and fever
- D.
High fever, chills, flank pain nausea, vomiting, dysuria, and frequency
Correct Answer
B. Nocturia, frequency, urgency dysuria, hematuria, fever and suprapubic painExplanation
The most commonly assessed findings in cystitis are nocturia (frequent urination at night), frequency (frequent urination), urgency (sudden and strong need to urinate), dysuria (painful urination), hematuria (blood in the urine), fever, and suprapubic pain (pain in the lower abdomen). These symptoms are typically seen in individuals with cystitis and are used to diagnose the condition.Rate this question:
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- 21.
Which of the following may happen if the uterus becomes overstimulated by oxytocin during the induction of labor?
- A.
Weak contraction prolonged to more than 70 seconds
- B.
Tetanic contractions prolonged to more than 90 seconds
- C.
Increased pain with bright red vaginal bleeding
- D.
Increased restlessness and anxiety
Correct Answer
B. Tetanic contractions prolonged to more than 90 secondsExplanation
If the uterus becomes overstimulated by oxytocin during the induction of labor, tetanic contractions prolonged to more than 90 seconds may occur. This means that the contractions become very strong and last longer than normal, which can be dangerous for both the mother and the baby. It can lead to decreased blood flow to the placenta, causing fetal distress and potentially leading to complications such as fetal hypoxia or uterine rupture. Therefore, it is important to closely monitor the contractions and adjust the oxytocin dosage to prevent this from happening.Rate this question:
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- 22.
Which of the following factors would the nurse suspect as predisposing a client to placenta previa?
- A.
Multiple gestation
- B.
Uterine anomalies
- C.
Abdominal trauma
- D.
Renal or vascular disease
Correct Answer
A. Multiple gestationExplanation
Multiple gestation, or carrying more than one fetus, is a known risk factor for placenta previa. This condition occurs when the placenta partially or completely covers the cervix, which can lead to bleeding during pregnancy. With multiple gestation, there is a higher likelihood of the placenta implanting lower in the uterus, increasing the risk of placenta previa. Uterine anomalies, abdominal trauma, and renal or vascular disease may also have an impact on placenta previa, but multiple gestation is a more direct and specific risk factor.Rate this question:
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- 23.
When assessing the newborn’s heart rate, which of the following ranges would be considered normal if the newborn were sleeping?
- A.
80 beats per minute
- B.
100 beats per minute
- C.
120 beats per minute
- D.
140 beats per minute
Correct Answer
B. 100 beats per minuteExplanation
A newborn's heart rate can vary depending on their activity level. When a newborn is sleeping, a heart rate of 100 beats per minute would be considered normal. This is because during sleep, the body is in a relaxed state and the heart rate tends to decrease slightly. Heart rates below 100 beats per minute may indicate bradycardia, while heart rates above 100 beats per minute may indicate tachycardia.Rate this question:
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- 24.
Before birth, which of the following structures connects the right and left auricles of the heart?
- A.
Umbilical vein
- B.
Foramen ovale
- C.
Ductus arteriosus
- D.
Ductus venosus
Correct Answer
B. Foramen ovaleExplanation
Before birth, the foramen ovale connects the right and left auricles of the heart. This is a small opening in the septum between the two atria. It allows blood to bypass the lungs, as the fetus receives oxygen from the placenta instead of breathing air. After birth, when the baby takes its first breath, the foramen ovale typically closes and becomes the fossa ovalis.Rate this question:
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- 25.
Cervical softening and uterine souffle are classified as which of the following?
- A.
Diagnostic signs
- B.
Presumptive signs
- C.
Probable signs
- D.
Positive signs
Correct Answer
C. Probable signsExplanation
Cervical softening and uterine souffle are classified as probable signs. These signs are not definitive proof of pregnancy, but they strongly suggest its presence. Cervical softening refers to the softening of the cervix, which occurs due to increased blood flow and hormonal changes. Uterine souffle is a soft blowing sound heard over the pregnant uterus, caused by increased blood flow through the uterine arteries. These signs are considered probable because they are commonly associated with pregnancy, but they can also occur in other conditions.Rate this question:
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