Maternal And Child Health Nursing Test II - Set A
This contains 25 items Questions about Maternal and Child Health Nursing
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Maternal and Child Health Nursing Test II - Set A: Answer with Rationale
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Questions and Answers
- 1.
When assessing the adequacy of sperm for conception to occur, which of the following is the most useful criterion?
- A.
Sperm count
- B.
Sperm motility
- C.
Sperm maturity
- D.
Semen volume
Correct Answer
B. Sperm motilityExplanation
Sperm motility is the most useful criterion when assessing the adequacy of sperm for conception to occur. Motility refers to the ability of sperm to move and swim effectively. It is crucial for sperm to be able to navigate through the female reproductive tract and reach the egg for fertilization to take place. Even if a man has a high sperm count, if the sperm are not motile, they may not be able to fertilize the egg. Therefore, sperm motility is a key factor in determining the likelihood of successful conception.Rate this question:
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- 2.
Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester?
- A.
Dysuria
- B.
Frequency
- C.
Incontinence
- D.
Burning
Correct Answer
B. FrequencyExplanation
During the first trimester of pregnancy, the pregnant woman most frequently experiences the symptom of frequency. This refers to the need to urinate more often than usual. This symptom is caused by hormonal changes and increased blood flow to the pelvic area, which puts pressure on the bladder. It is a common and normal symptom experienced by many pregnant women in the early stages of pregnancy.Rate this question:
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- 3.
Heartburn and flatulence, common in the second trimester, are most likely the result of which of the following?
- A.
Increased plasma HCG levels
- B.
Decreased intestinal motility
- C.
Decreased gastric acidity
- D.
Elevated estrogen levels
Correct Answer
C. Decreased gastric acidityExplanation
Heartburn and flatulence in the second trimester are most likely the result of decreased gastric acidity. During pregnancy, the hormone progesterone relaxes the muscles in the body, including the muscles that control the opening between the esophagus and the stomach. This relaxation can cause stomach acid to flow back into the esophagus, leading to heartburn. Additionally, decreased gastric acidity can also contribute to the development of gas in the digestive system, resulting in flatulence.Rate this question:
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- 4.
On which of the following areas would the nurse expect to observe chloasma?
- A.
Breast, areola, and nipples
- B.
Chest, neck, arms, and legs
- C.
Abdomen, breast, and thighs
- D.
Cheeks, forehead, and nose
Correct Answer
D. Cheeks, forehead, and noseExplanation
Chloasma, also known as melasma, is a skin condition characterized by dark patches on the face. These patches typically appear on the cheeks, forehead, and nose, which are areas that are commonly exposed to sunlight. Therefore, it is expected that a nurse would observe chloasma on these specific areas of the face.Rate this question:
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- 5.
A pregnant client states that she “waddles” when she walks. The nurse’s explanation is based on which of the following as the cause?
- A.
The large size of the newborn
- B.
Pressure on the pelvic muscles
- C.
Relaxation of the pelvic joints
- D.
Excessive weight gain
Correct Answer
C. Relaxation of the pelvic jointsExplanation
During pregnancy, the hormone relaxin is released which causes the ligaments and joints in the pelvic area to become more relaxed and flexible. This allows for the baby to pass through the birth canal during delivery. As a result of this relaxation, the pelvic joints may become looser and unstable, leading to a change in the woman's gait and causing her to "waddle" when she walks. The other options, such as the large size of the newborn, pressure on the pelvic muscles, and excessive weight gain, may contribute to discomfort during pregnancy but are not specifically related to the waddling gait.Rate this question:
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- 6.
Which of the following represents the average amount of weight gained during pregnancy?
- A.
12 to 22 lb
- B.
15 to 25 lb
- C.
24 to 30 lb
- D.
25 to 40 lb
Correct Answer
C. 24 to 30 lbExplanation
During pregnancy, it is normal for women to gain weight due to the growth of the baby, placenta, amniotic fluid, and increased blood volume. The average amount of weight gained during pregnancy is typically between 24 to 30 lb. This range takes into account the various factors that contribute to weight gain during pregnancy and is considered a healthy and normal range for most women.Rate this question:
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- 7.
Which of the following would the nurse identify as a presumptive sign of pregnancy?
- A.
Hegar sign
- B.
Nausea and vomiting
- C.
Skin pigmentation changes
- D.
Positive serum pregnancy test
Correct Answer
B. Nausea and vomitingExplanation
Nausea and vomiting are commonly experienced during the early stages of pregnancy and are considered presumptive signs. These symptoms are often referred to as morning sickness and can occur due to hormonal changes in the body. While they are not definitive proof of pregnancy, they are often one of the first signs that women notice and can indicate the possibility of being pregnant. The other options, such as Hegar sign (softening of the cervix), skin pigmentation changes, and a positive serum pregnancy test, are considered probable or positive signs of pregnancy, rather than presumptive signs.Rate this question:
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- 8.
During which of the following would the focus of classes be mainly on physiologic changes, fetal development, sexuality, during pregnancy, and nutrition?
- A.
Prepregnant period
- B.
First trimester
- C.
Second trimester
- D.
Third trimester
Correct Answer
B. First trimesterExplanation
During the first trimester of pregnancy, the focus of classes would mainly be on physiologic changes, fetal development, sexuality, and nutrition. This is because the first trimester is a crucial period when the body undergoes significant changes to accommodate the growing fetus. It is important for expectant mothers to understand these changes and how they can affect their health and the development of the baby. Additionally, nutrition plays a vital role during this period as it directly impacts the growth and development of the fetus. Therefore, classes during the first trimester would primarily focus on these topics.Rate this question:
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- 9.
Which of the following would be disadvantage of breast feeding?
- A.
Involution occurs more rapidly
- B.
The incidence of allergies increases due to maternal antibodies
- C.
The father may resent the infant’s demands on the mother’s body
- D.
There is a greater chance for error during preparation
Correct Answer
C. The father may resent the infant’s demands on the mother’s bodyExplanation
Breastfeeding is a natural and beneficial way to nourish a baby, but it may lead to the father feeling left out or resentful. This is because breastfeeding requires the mother to spend a significant amount of time and energy on feeding the baby, which can make the father feel excluded or less involved in the caregiving process. This disadvantage can strain the relationship between the parents and create feelings of resentment or frustration.Rate this question:
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- 10.
A client LMP began July 5. Her EDD should be which of the following?
- A.
January 2
- B.
March 28
- C.
April 12
- D.
October 12
Correct Answer
C. April 12Explanation
The EDD (Estimated Due Date) is calculated by adding 280 days (40 weeks) to the first day of the last menstrual period (LMP). In this case, if the client's LMP began on July 5, adding 280 days would give us April 12 as the estimated due date.Rate this question:
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- 11.
Which of the following fundal heights indicates less than 12 weeks’ gestation when the date of the LMP is unknown?
- A.
Uterus in the pelvis
- B.
Uterus at the xiphoid
- C.
Uterus in the abdomen
- D.
Uterus at the umbilicus
Correct Answer
A. Uterus in the pelvisExplanation
The fundal height is a measurement of the distance from the top of the uterus to the pubic bone. In early pregnancy, the uterus is still located in the pelvis. As the pregnancy progresses, the uterus gradually moves up and out of the pelvis. Therefore, if the fundal height is at the level of the pelvis, it indicates less than 12 weeks of gestation when the date of the last menstrual period (LMP) is unknown.Rate this question:
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- 12.
Which of the following prenatal laboratory test values would the nurse consider as significant?
- A.
Hematocrit 33.5%
- B.
Rubella titer less than 1:8
- C.
White blood cells 8,000/mm3
- D.
One hour glucose challenge test 110 g/dL
Correct Answer
B. Rubella titer less than 1:8Explanation
A rubella titer less than 1:8 is considered significant because it indicates that the pregnant woman is not immune to rubella. Rubella is a viral infection that can cause serious birth defects if contracted during pregnancy. Therefore, it is important for pregnant women to be immune to rubella. A titer of 1:8 or higher indicates immunity, while a titer less than 1:8 indicates a lack of immunity.Rate this question:
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- 13.
Which of the following characteristics of contractions would the nurse expect to find in a client experiencing true labor?
- A.
Occurring at irregular intervals
- B.
Starting mainly in the abdomen
- C.
Gradually increasing intervals
- D.
Increasing intensity with walking
Correct Answer
D. Increasing intensity with walkingExplanation
During true labor, contractions become more intense and frequent as the labor progresses. This is because walking and movement can help the baby move down the birth canal, causing increased pressure on the cervix and intensifying the contractions. Therefore, the nurse would expect to find increasing intensity with walking in a client experiencing true labor.Rate this question:
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- 14.
During which of the following stages of labor would the nurse assess “crowning”?
- A.
First stage
- B.
Second stage
- C.
Third stage
- D.
Fourth stage
Correct Answer
B. Second stageExplanation
During the second stage of labor, the nurse would assess "crowning." This is because the second stage of labor is the stage when the baby's head begins to appear at the vaginal opening. Crowning refers to the moment when the widest part of the baby's head is visible and stretching the vaginal opening. It is an important milestone indicating that the baby is about to be born. Therefore, it is during the second stage of labor that the nurse would assess crowning.Rate this question:
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- 15.
Which of the following actions demonstrates the nurse’s understanding about the newborn’s thermoregulatory ability?
- A.
Placing the newborn under a radiant warmer.
- B.
Suctioning with a bulb syringe
- C.
Obtaining an Apgar score
- D.
Inspecting the newborn’s umbilical cord
Correct Answer
A. Placing the newborn under a radiant warmer.Explanation
Placing the newborn under a radiant warmer demonstrates the nurse's understanding about the newborn's thermoregulatory ability. This action helps to maintain the newborn's body temperature by providing external heat, which is important for a newborn as they are unable to regulate their own body temperature effectively.Rate this question:
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- 16.
Immediately before expulsion, which of the following cardinal movements occur?
- A.
Descent
- B.
Flexion
- C.
Extension
- D.
External rotation
Correct Answer
D. External rotationExplanation
Immediately before expulsion, the fetus undergoes external rotation. This movement refers to the rotation of the baby's head as it aligns with the mother's pelvis during the birthing process. It allows for the baby's shoulders to pass through the birth canal more easily. Descent, flexion, and extension are cardinal movements that occur earlier in the birthing process, while external rotation happens just before expulsion.Rate this question:
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- 17.
Which of the following when present in the urine may cause a reddish stain on the diaper of a newborn?
- A.
Mucus
- B.
Uric acid crystals
- C.
Bilirubin
- D.
Excess iron
Correct Answer
B. Uric acid crystalsExplanation
Uric acid crystals, when present in the urine of a newborn, can cause a reddish stain on their diaper. Uric acid is a waste product that is normally excreted in urine. In newborns, the concentration of uric acid in the urine is often high, leading to the formation of crystals. These crystals can cause discoloration of the diaper, resulting in a reddish stain. This is a common occurrence in newborns and is not typically a cause for concern.Rate this question:
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- 18.
Which of the following is true regarding the fontanels of the newborn?
- A.
The anterior is triangular shaped; the posterior is diamond shaped.
- B.
The posterior closes at 18 months; the anterior closes at 8 to 12 weeks.
- C.
The anterior is large in size when compared to the posterior fontanel.
- D.
The anterior is bulging; the posterior appears sunken.
Correct Answer
C. The anterior is large in size when compared to the posterior fontanel.Explanation
The anterior fontanel is larger in size when compared to the posterior fontanel of a newborn. Fontanels are soft spots on a baby's skull that allow for the growth and expansion of the brain. The anterior fontanel is located at the top of the baby's head and is shaped like a diamond, while the posterior fontanel is located at the back of the head and is triangular in shape. The anterior fontanel typically closes between 8 to 12 weeks of age, while the posterior fontanel closes at around 18 months.Rate this question:
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- 19.
Which of the following statements best describes hyperemesis gravidarum?
- A.
Severe anemia leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems.
- B.
Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems.
- C.
Loss of appetite and continuous vomiting that commonly results in dehydration and ultimately decreasing maternal nutrients
- D.
Severe nausea and diarrhea that can cause gastrointestinal irritation and possibly internal bleeding
Correct Answer
B. Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems.Explanation
Hyperemesis gravidarum is a condition characterized by severe nausea and vomiting during pregnancy. It is different from normal morning sickness as it leads to electrolyte, metabolic, and nutritional imbalances. This means that the excessive vomiting can cause imbalances in important substances in the body, such as electrolytes and nutrients. This condition occurs in the absence of other medical problems, distinguishing it from other causes of vomiting like gastrointestinal irritation or internal bleeding.Rate this question:
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- 20.
In which of the following types of spontaneous abortions would the nurse assess dark brown vaginal discharge and a negative pregnancy tests?
- A.
Threatened
- B.
Imminent
- C.
Missed
- D.
Incomplete
Correct Answer
C. MissedExplanation
In a missed spontaneous abortion, the fetus has died but is not expelled from the uterus. This can result in the presence of dark brown vaginal discharge, which is a sign of old blood. Additionally, a negative pregnancy test indicates that the hormone levels associated with pregnancy have decreased, further supporting the diagnosis of a missed abortion.Rate this question:
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- 21.
Which of the following would the nurse assess in a client experiencing abruptio placenta?
- A.
Bright red, painless vaginal bleeding
- B.
Concealed or external dark red bleeding
- C.
Palpable fetal outline
- D.
Soft and nontender abdomen
Correct Answer
B. Concealed or external dark red bleedingExplanation
In a client experiencing abruptio placenta, the nurse would assess for concealed or external dark red bleeding. This is because abruptio placenta is a condition where the placenta separates prematurely from the uterine wall, leading to bleeding. The bleeding may be concealed, meaning it is trapped behind the placenta, or it may be external and visible. The dark red color of the bleeding indicates that it is old blood, which is a characteristic of abruptio placenta. This assessment finding is important to identify and manage the condition promptly to prevent further complications.Rate this question:
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- 22.
Which of the following is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage?
- A.
Placenta previa
- B.
Ectopic pregnancy
- C.
Incompetent cervix
- D.
Abruptio placentae
Correct Answer
D. Abruptio placentaeExplanation
Abruptio placentae is described as the premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage. This condition can lead to complications such as fetal distress, preterm birth, and maternal hemorrhage. It is important to diagnose and manage abruptio placentae promptly to ensure the well-being of both the mother and the baby. Placenta previa refers to the abnormal implantation of the placenta in the lower part of the uterus, ectopic pregnancy is when the fertilized egg implants outside of the uterus, and incompetent cervix is the inability of the cervix to retain a pregnancy.Rate this question:
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- 23.
When PROM occurs, which of the following provides evidence of the nurse’s understanding of the client’s immediate needs?
- A.
The chorion and amnion rupture 4 hours before the onset of labor.
- B.
PROM removes the fetus most effective defense against infection
- C.
Nursing care is based on fetal viability and gestational age.
- D.
PROM is associated with malpresentation and possibly incompetent cervix
Correct Answer
B. PROM removes the fetus most effective defense against infectionExplanation
PROM (premature rupture of membranes) refers to the rupture of the amniotic sac before the onset of labor. This rupture removes the fetus's most effective defense against infection, which is the intact amniotic sac acting as a barrier against pathogens. When the amniotic sac is ruptured, it increases the risk of infection for both the mother and the fetus. Therefore, understanding that PROM removes the fetus's most effective defense against infection demonstrates the nurse's understanding of the client's immediate needs, which include preventing infection and ensuring the safety and well-being of both the mother and the fetus.Rate this question:
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- 24.
Which of the following amounts of blood loss following birth marks the criterion for describing postpartum hemorrhage?
- A.
More than 200 ml
- B.
More than 300 ml
- C.
More than 400 ml
- D.
More than 500 ml
Correct Answer
D. More than 500 mlExplanation
Postpartum hemorrhage is defined as excessive bleeding following childbirth. The criterion for describing postpartum hemorrhage is when the amount of blood loss exceeds 500 ml. This amount is considered significant and requires medical attention to prevent complications. Blood loss between 200-500 ml is considered normal after childbirth, but anything above 500 ml is considered abnormal and requires intervention.Rate this question:
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- 25.
Which of the following assessment findings would the nurse expect if the client develops DVT?
- A.
Midcalf pain, tenderness and redness along the vein
- B.
Chills, fever, malaise, occurring 2 weeks after delivery
- C.
Muscle pain the presence of Homans sign, and swelling in the affected limb
- D.
Chills, fever, stiffness, and pain occurring 10 to 14 days after delivery
Correct Answer
C. Muscle pain the presence of Homans sign, and swelling in the affected limbExplanation
The correct answer suggests that if the client develops DVT, they would experience muscle pain, the presence of Homans sign, and swelling in the affected limb. This is a common presentation of DVT, where the affected limb may be swollen, painful, and show signs of Homans sign, which is pain in the calf upon dorsiflexion of the foot.Rate this question:
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