Maternal and Child Health Nursing NCLEX Quiz 3

1. Normal lochial findings in the first 24 hours post-delivery include:

Bright red blood

Large clots or tissue fragments

A foul odor

The complete absence of lochia

Lochia should never contain large clots. tissue fragments. or membranes. A foul odor may signal infection. as may absence of lochia.

Explanation

Lochia should never contain large clots. tissue fragments. or membranes. A foul odor may signal infection. as may absence of lochia.

2. The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse should tell the patient that she can expect to feel the fetus move at which time?

Between 10 and 12 weeks’ gestation

Between 16 and 20 weeks’ gestation

Between 21 and 23 weeks’ gestation

Between 24 and 26 weeks’ gestation

A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks’ gestation. Before 16 weeks. the fetus is not developed enough for the woman to detect movement. After 20 weeks. the fetus continues to gain weight steadily. the lungs start to produce surfactant. the brain is grossly formed. and myelination of the spinal cord begins.

Explanation

A pregnant woman usually can detect fetal movement (quickening) between 16 and 20 weeks’ gestation. Before 16 weeks. the fetus is not developed enough for the woman to detect movement. After 20 weeks. the fetus continues to gain weight steadily. the lungs start to produce surfactant. the brain is grossly formed. and myelination of the spinal cord begins.

3. A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms?

Proteinuria. headaches. vaginal bleeding

Headaches. double vision. vaginal bleeding

Proteinuria. headaches. double vision

Proteinuria. double vision. uterine contractions

A patient with pregnancy-induced hypertension complains of a headache. double vision. and sudden weight gain. A urine specimen reveals proteinuria.Options A. B. and D: Vaginal bleeding and uterine contractions are not associated with pregnancy-induced hypertension.

Explanation

A patient with pregnancy-induced hypertension complains of a headache. double vision. and sudden weight gain. A urine specimen reveals proteinuria.Options A. B. and D: Vaginal bleeding and uterine contractions are not associated with pregnancy-induced hypertension.

4. A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in the early part of the first stage of labor. Her pain is likely to be most intense:

Around the pelvic girdle

Around the pelvic girdle and in the upper arms

Around the pelvic girdle and at the perineum

At the perineum

During most of the first stage of labor. pain centers around the pelvic girdle. During the late part of this stage and the early part of the second stage. pain spreads to the upper legs and perineum. During the late part of the second stage and childbirth. intense pain occurs at the perineum. Upper arm pain is not common during any stage of labor.

Explanation

During most of the first stage of labor. pain centers around the pelvic girdle. During the late part of this stage and the early part of the second stage. pain spreads to the upper legs and perineum. During the late part of the second stage and childbirth. intense pain occurs at the perineum. Upper arm pain is not common during any stage of labor.

5. The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage?

Active phase

Complete phase

Latent phase

Transitional phase

The transitional phase. which lasts 1 to 3 hours. is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 ½ to 2 minutes and last 45 to 90 seconds.Option A: The active phase lasts 4 ½ to 6 hours; it is characterized by contractions that start out moderately intense. grow stronger. and last about 60 seconds.Option B: The complete phase occurs during the second. not first. stage of labor.Option C: The latent phase lasts 5 to 8 hours and is marked by mild. short. irregular contractions.

Explanation

The transitional phase. which lasts 1 to 3 hours. is the shortest but most difficult part of the first stage of labor. This phase is characterized by intense uterine contractions that occur every 1 ½ to 2 minutes and last 45 to 90 seconds.Option A: The active phase lasts 4 ½ to 6 hours; it is characterized by contractions that start out moderately intense. grow stronger. and last about 60 seconds.Option B: The complete phase occurs during the second. not first. stage of labor.Option C: The latent phase lasts 5 to 8 hours and is marked by mild. short. irregular contractions.

6. After 3 days of breastfeeding. a postpartal patient reports nipple soreness. To relieve her discomfort. the nurse should suggest that she:

Apply warm compresses to her nipples just before feedings

Lubricate her nipples with expressed milk before feeding

Dry her nipples with a soft towel after feedings

Apply soap directly to her nipples. and then rinse

Measures that help relieve nipple soreness in a breastfeeding patient include lubrication the nipples with a few drops of expressed milk before feedings. applying ice compresses just before feeding. letting the nipples air dry after feedings. and avoiding the use of soap on the nipples.

Explanation

Measures that help relieve nipple soreness in a breastfeeding patient include lubrication the nipples with a few drops of expressed milk before feedings. applying ice compresses just before feeding. letting the nipples air dry after feedings. and avoiding the use of soap on the nipples.

7. A female adult patient is taking a progestin-only oral contraceptive or mini pill. Progestin use may increase the patient's risk for:

Endometriosis

Female hypogonadism

Premenstrual syndrome

Tubal or ectopic pregnancy

Women taking the mini pill have a higher incidence of tubal and ectopic pregnancies. possibly because progestin slows ovum transport through the fallopian tubes.Options A. B. and C: Endometriosis. female hypogonadism. and premenstrual syndrome are not associated with progestin-only oral contraceptives.

Explanation

Women taking the mini pill have a higher incidence of tubal and ectopic pregnancies. possibly because progestin slows ovum transport through the fallopian tubes.Options A. B. and C: Endometriosis. female hypogonadism. and premenstrual syndrome are not associated with progestin-only oral contraceptives.

8. Because cervical effacement and dilation are not progressing in a patient in labor. the doctor orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patient's fluid intake and output closely during oxytocin administration?

Oxytocin causes water intoxication

Oxytocin causes excessive thirst

Oxytocin is toxic to the kidneys

Oxytocin has a diuretic effect

The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water intoxication. leading to seizures. coma. and death.Option B: Excessive thirst results from the work of labor and limited oral fluid intake—not oxytocin.Options C and D: Oxytocin has no nephrotoxic or diuretic effects. In fact. it produces an antidiuretic effect.

Explanation

The nurse should monitor fluid intake and output because prolonged oxytocin infusion may cause severe water intoxication. leading to seizures. coma. and death.Option B: Excessive thirst results from the work of labor and limited oral fluid intake—not oxytocin.Options C and D: Oxytocin has no nephrotoxic or diuretic effects. In fact. it produces an antidiuretic effect.

9. Five hours after birth. a neonate is transferred to the nursery. where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss?

Low room humidity

Cold weight scale

Cool incubator walls

Cool room temperature

A common source of radiant heat loss includes cool incubator walls and windows.Option A: Low room humidity promotes evaporative heat loss.Option B: When the skin directly contacts a cooler object. such as a cold weight scale. conductive heat loss may occur.Option D: A cool room temperature may lead to convective heat loss.

Explanation

A common source of radiant heat loss includes cool incubator walls and windows.Option A: Low room humidity promotes evaporative heat loss.Option B: When the skin directly contacts a cooler object. such as a cold weight scale. conductive heat loss may occur.Option D: A cool room temperature may lead to convective heat loss.

10. After administering bethanechol to a patient with urine retention. the nurse in charge monitors the patient for adverse effects. Which is most likely to occur?

Decreased peristalsis

Increase heart rate

Dry mucous membranes

Nausea and Vomiting

Bethanechol will increase GI motility. which may cause nausea. belching. vomiting. intestinal cramps. and diarrhea.Option A: Peristalsis is increased rather than decreased.Option B: With high doses of bethanechol. cardiovascular responses may include vasodilation. decreased cardiac rate. and decreased the force of cardiac contraction. which may cause hypotension.Option C: Salivation or sweating may gently increase.

Explanation

Bethanechol will increase GI motility. which may cause nausea. belching. vomiting. intestinal cramps. and diarrhea.Option A: Peristalsis is increased rather than decreased.Option B: With high doses of bethanechol. cardiovascular responses may include vasodilation. decreased cardiac rate. and decreased the force of cardiac contraction. which may cause hypotension.Option C: Salivation or sweating may gently increase.

Maternal And Child Health Nursing NCLEX Quiz 3