Maternal And Child Health Nursing NCLEX Quiz 2

1. Immediately after delivery. the nurse-midwife assesses the neonate's head for signs of molding. Which factors determine the type of molding?

Fetal body flexion or extension

Maternal age. body frame. and weight

Maternal and paternal ethnic backgrounds

Maternal parity and gravidity

Fetal attitude—the overall degree of body flexion or extension—determines the type of molding in the head a neonate.Options B. C. and D: Molding. is not influenced by maternal age. body frame. weight. parity. and gravidity or by maternal and paternal ethnic backgrounds.

Explanation

Fetal attitude—the overall degree of body flexion or extension—determines the type of molding in the head a neonate.Options B. C. and D: Molding. is not influenced by maternal age. body frame. weight. parity. and gravidity or by maternal and paternal ethnic backgrounds.

2. Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision?

Notify the neonate’s pediatrician immediately

Check the diaper and circumcision again in 30 minutes

Secure the diaper tightly to apply pressure on the site

Apply gentle pressure to the site with a sterile gauze pad

If bleeding occurs after circumcision. the nurse should first apply gently pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs.

Explanation

If bleeding occurs after circumcision. the nurse should first apply gently pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs.

3. A pregnant patient asks the nurse if she can take castor oil for her constipation. How should the nurse respond?

“Yes. it produces no adverse effect.”

“No. it can initiate premature uterine contractions.”

“No. it can promote sodium retention.”

“No. it can lead to increased absorption of fat-soluble vitamins.”

Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects. but it does not promote sodium retention. Castor oil is not known to increase absorption of fat-soluble vitamins. although laxatives. in general. may decrease absorption if intestinal motility is increased.

Explanation

Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects. but it does not promote sodium retention. Castor oil is not known to increase absorption of fat-soluble vitamins. although laxatives. in general. may decrease absorption if intestinal motility is increased.

4. A primigravida client at 25 weeks gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform:

Tailor sitting

Leg lifting

Shoulder circling

Squatting exercises

Tailor sitting is an excellent exercise that helps to strengthen the client’s back muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time.

Explanation

Tailor sitting is an excellent exercise that helps to strengthen the client’s back muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time.

5. A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several clots. What is the primary nursing diagnosis for this patient?

Knowledge deficit

Fluid volume deficit

Anticipatory grieving

Pain

If bleeding and clots are excessive. this patient may become hypovolemic. Pad count should be instituted.Options A. C. and D: Although the other diagnoses apply to this patient. they are not the primary diagnosis.

Explanation

If bleeding and clots are excessive. this patient may become hypovolemic. Pad count should be instituted.Options A. C. and D: Although the other diagnoses apply to this patient. they are not the primary diagnosis.

6. Which of the following would the nurse most likely expect to find when assessing a pregnant client with abruption placenta?

Excessive vaginal bleeding

Rigid. board-like abdomen

Titanic uterine contractions

Premature rupture of membranes

The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. Pain. usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation. also is common.

Explanation

The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. Pain. usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation. also is common.

7. For a patient in active labor. the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied?

The membranes must rupture

The fetus must be at 0 station

The cervix must be dilated fully

The patient must receive anesthesia

Internal EFM can be applied only after the patient’s membranes have ruptured when the fetus is at least at the -1 station. and when the cervix is dilated at least 2 cm. Although the patient may receive anesthesia. it is not required before application of an internal EFM device.

Explanation

Internal EFM can be applied only after the patient’s membranes have ruptured when the fetus is at least at the -1 station. and when the cervix is dilated at least 2 cm. Although the patient may receive anesthesia. it is not required before application of an internal EFM device.

8. A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm. completely effaced (100 %). and at 0 station. What phase of labor is she in?

Active phase

Latent phase

Expulsive phase

Transitional phase

The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most difficult and intense for the patient.Option A: The active phase extends from 4 to 7 cm; it is moderate for the patient.Option B: The latent phase extends from 0 to 3 cm; it is mild in nature.Option C: The expulsive phase begins immediately after the birth and ends with separation and expulsion of the placenta.

Explanation

The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most difficult and intense for the patient.Option A: The active phase extends from 4 to 7 cm; it is moderate for the patient.Option B: The latent phase extends from 0 to 3 cm; it is mild in nature.Option C: The expulsive phase begins immediately after the birth and ends with separation and expulsion of the placenta.

9. A client tells the nurse. "I think my baby likes to hear me talk to him." When discussing neonates and stimulation with sound. which of the following would the nurse include as a means to elicit the best response?

High-pitched speech with tonal variations

Low-pitched speech with a sameness of tone

Cooing sounds rather than words

Repeated stimulation with loud sounds

Providing stimulation and speaking to neonates is important. Some authorities believe that speech is the most important type of sensory stimulation for a neonate. Neonates respond best to speech with tonal variations and a high-pitched voice. A neonate can hear all sound louder than about 55 decibels.

Explanation

Providing stimulation and speaking to neonates is important. Some authorities believe that speech is the most important type of sensory stimulation for a neonate. Neonates respond best to speech with tonal variations and a high-pitched voice. A neonate can hear all sound louder than about 55 decibels.

10. While the client is in active labor with twins and the cervix is 5 cm dilates. the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse's most appropriate action?

Note the fetal heart rate patterns

Notify the physician immediately

Administer oxygen at 6 liters by mask

Have the client pant-blow during the contractions

The nurse should contact the physician immediately because the client is most likely experiencing hypotonic uterine contractions. These contractions tend to be painful but ineffective. The usual treatment is oxytocin augmentation unless cephalopelvic disproportion exists.

Explanation

The nurse should contact the physician immediately because the client is most likely experiencing hypotonic uterine contractions. These contractions tend to be painful but ineffective. The usual treatment is oxytocin augmentation unless cephalopelvic disproportion exists.