Maternal And Child Health Nursing NCLEX Quiz 8

1. The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct?

Two weeks before menstruation

Immediately after menstruation

Immediately before menstruation

Three weeks before menstruation

Ovulation occurs 14 days before the first day of the menstrual period (A). Although ovulation can occur in the middle of the cycle or 2 weeks after menstruation. this is only true for a woman who has a perfect 28-day cycle. For many women. the length of the menstrual cycle varies.

Explanation

Ovulation occurs 14 days before the first day of the menstrual period (A). Although ovulation can occur in the middle of the cycle or 2 weeks after menstruation. this is only true for a woman who has a perfect 28-day cycle. For many women. the length of the menstrual cycle varies.

2. The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks. "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate?

Herpes

Trichomonas

Gonorrhea

Syphilis

Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum. an infection caused by gonorrhea (C). and inclusion conjunctivitis. an infection caused by Chlamydia. The infant may be exposed to these bacteria when passing through the birth canal.Options A. B. and D: Ophthalmic ointment is not effective against Trichomonas. Gonorrhea. and Syphilis.

Explanation

Erythromycin ointment is instilled into the lower conjunctiva of each eye within 2 hours after birth to prevent ophthalmia neonatorum. an infection caused by gonorrhea (C). and inclusion conjunctivitis. an infection caused by Chlamydia. The infant may be exposed to these bacteria when passing through the birth canal.Options A. B. and D: Ophthalmic ointment is not effective against Trichomonas. Gonorrhea. and Syphilis.

3. Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn?

“Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period.”

“Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk.”

“I can start smoking cigarettes while breastfeeding because it will not affect my breast milk.”

“When I take a warm shower after I breastfeed. it relieves the pain from being engorged between breastfeedings.”

Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin. which will suppress ovulation and menses. but is not completely effective as a birth control method.Option B is incorrect because alcohol can immediately enter the breast milk.Option C: Nicotine is transferred to the infant in breast milk.Option D: Taking a warm shower will stimulate the production of milk. which will be more painful after breastfeedings.

Explanation

Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin. which will suppress ovulation and menses. but is not completely effective as a birth control method.Option B is incorrect because alcohol can immediately enter the breast milk.Option C: Nicotine is transferred to the infant in breast milk.Option D: Taking a warm shower will stimulate the production of milk. which will be more painful after breastfeedings.

4. When assessing a client at 12 weeks of gestation. the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?

At 16 weeks of gestation

At 20 weeks of gestation

At 24 weeks of gestation

At 30 weeks of gestation

Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy when they are beginning to anticipate the onset of labor and the birth of their child. At 30 weeks. is closest to the time when parents would be ready for such classes.Options A. B. and C are not the best times during pregnancy for the couple to attend childbirth education classes. At these times they will have other teaching needs. Early pregnancy classes often include topics such as nutrition. physiologic changes. coping with normal discomforts of pregnancy. fetal development. maternal and fetal risk factors. and evolving roles of the mother and her significant others.

Explanation

Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy when they are beginning to anticipate the onset of labor and the birth of their child. At 30 weeks. is closest to the time when parents would be ready for such classes.Options A. B. and C are not the best times during pregnancy for the couple to attend childbirth education classes. At these times they will have other teaching needs. Early pregnancy classes often include topics such as nutrition. physiologic changes. coping with normal discomforts of pregnancy. fetal development. maternal and fetal risk factors. and evolving roles of the mother and her significant others.

5. A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement?

Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking.

Hold the infant’s head firmly against the breast until he latches onto the nipple.

Encourage the mother to stop feeding for a few minutes and comfort the infant.

Provide a formula for the infant until he becomes calm. and then offer the breast again.

The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself. After such a time out. breastfeeding is often more successful.Options A and D would cause nipple confusion.Option B would only cause the infant to be more resistant. resulting in the mother and infant to become more frustrated.

Explanation

The infant is becoming frustrated and so is the mother; both need a time out. The mother should be encouraged to comfort the infant and to relax herself. After such a time out. breastfeeding is often more successful.Options A and D would cause nipple confusion.Option B would only cause the infant to be more resistant. resulting in the mother and infant to become more frustrated.

6. With regard to small-for-gestational-age (SGA) infants and intrauterine growth restriction (IUGR). nurses should be aware that:

In the first trimester. diseases or abnormalities result in asymmetric IUGR.

Infants with asymmetric IUGR have the potential for normal growth and development.

In asymmetric IUGR. weight is slightly more than SGA. whereas length and head circumference are somewhat less than SGA.

Symmetric IUGR occurs in the later stages of pregnancy.

The infant with asymmetric IUGR has the potential for normal growth and development.SGA infants have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy.Option A: IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester. as a result of disease or abnormalities.Option C: Weight is less than the 10th percentile. but the head circumference is greater than the 10th percentile (within normal limits).Option D: IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester. as a result of disease or abnormalities;

Explanation

The infant with asymmetric IUGR has the potential for normal growth and development.SGA infants have reduced brain capacity. The asymmetric form occurs in the later stages of pregnancy.Option A: IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester. as a result of disease or abnormalities.Option C: Weight is less than the 10th percentile. but the head circumference is greater than the 10th percentile (within normal limits).Option D: IUGR is either symmetric or asymmetric. The symmetric form occurs in the first trimester. as a result of disease or abnormalities;

7. A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating. and states that because she had nothing to eat. she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority?

Altered nutrition. less than body requirements for lactation

Alteration in comfort related to nausea and abdominal distention

Impaired bowel motility related to pain medication and immobility

Fatigue related to cesarean delivery and physical care demands of infant

Impaired bowel motility caused by surgical anesthesia. pain medication. and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus.Options A and B are both caused by impaired bowel motility.Option D is not as important as impaired motility.

Explanation

Impaired bowel motility caused by surgical anesthesia. pain medication. and immobility is the priority nursing diagnosis and addresses the potential problem of a paralytic ileus.Options A and B are both caused by impaired bowel motility.Option D is not as important as impaired motility.

8. One hour following a normal vaginal delivery. a newborn infant boy's axillary temperature is 96° F. his lower lip is shaking and. when the nurse assesses for a Moro reflex. the boy's hands shake. Which intervention should the nurse implement first?

Stimulate the infant to cry.

Wrap the infant in warm blankets.

Feed the infant formula.

Obtain a serum glucose level.

This infant is demonstrating signs of hypoglycemia. possibly secondary to a low body temperature. The nurse should first. determine the serum glucose level.Option A is an intervention for a lethargic infant.Option B should be done based on the temperature. but first the glucose level should be obtained.Option C helps raise the blood sugar. but first. the nurse should determine the glucose level.

Explanation

This infant is demonstrating signs of hypoglycemia. possibly secondary to a low body temperature. The nurse should first. determine the serum glucose level.Option A is an intervention for a lethargic infant.Option B should be done based on the temperature. but first the glucose level should be obtained.Option C helps raise the blood sugar. but first. the nurse should determine the glucose level.

9. The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take?

Administer oxygen by face mask.

Notify the health care provider of the client’s symptoms.

Have the client breathe into her cupped hands.

Check the client’s blood pressure and fetal heart rate.

Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands. (A) (B and D).Option A is inappropriate because the carbon dioxide level is low. not the oxygen level.Options B and D are not specific for this situation.

Explanation

Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands. (A) (B and D).Option A is inappropriate because the carbon dioxide level is low. not the oxygen level.Options B and D are not specific for this situation.

10. A patient has undergone an amniocentesis for evaluation of fetal well-being. Which intervention would be included in the nurse's plan of care after the procedure? Select all that apply.

Perform ultrasound to determine fetal positioning.

Observe the patient for possible uterine contractions.

Administer RhoGAM to the patient if she is Rh negative.

Perform a mini catheterization to obtain a urine specimen to assess for bleeding.

Ultrasound is used prior to the procedure as a visualization aid to assist with insertion of the transabdominal needle. There is no need to assess the urine for bleeding as this is not considered to be a typical presentation or complication.

Explanation

Ultrasound is used prior to the procedure as a visualization aid to assist with insertion of the transabdominal needle. There is no need to assess the urine for bleeding as this is not considered to be a typical presentation or complication.

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