Maternal And Child Health Nursing NCLEX Quiz 11

1. Which of the following actions demonstrates the nurse's understanding of the newborn's thermoregulatory ability?

Placing the newborn under a radiant warmer.

Suctioning with a bulb syringe

Obtaining an Apgar score

Inspecting the newborn’s umbilical cord

The newborn’s ability to regulate body temperature is poor. Therefore. placing the newborn under a radiant warmer aids in maintaining his or her body temperature.Option B: Suctioning with a bulb syringe helps maintain a patent airway.Option C: Obtaining an Apgar score measures the newborn’s immediate adjustment to extrauterine life.Option D: Inspecting the umbilical cord aids in detecting cord anomalies.

Explanation

The newborn’s ability to regulate body temperature is poor. Therefore. placing the newborn under a radiant warmer aids in maintaining his or her body temperature.Option B: Suctioning with a bulb syringe helps maintain a patent airway.Option C: Obtaining an Apgar score measures the newborn’s immediate adjustment to extrauterine life.Option D: Inspecting the umbilical cord aids in detecting cord anomalies.

2. During which of the following stages of labor would the nurse assess "crowning"?

First stage

Second stage

Third stage

Fourth stage

Crowing. which occurs when the newborn’s head or presenting part appears at the vaginal opening. occurs during the second stage of labor.Option A: During the first stage of labor. cervical dilation and effacement occur.Option C: During the third stage of labor. the newborn and placenta are delivered.Option D: The fourth stage of labor lasts from 1 to 4 hours after birth. during which time the mother and newborn recover from the physical process of birth and the mother’s organs undergo the initial readjustment to the nonpregnant state.

Explanation

Crowing. which occurs when the newborn’s head or presenting part appears at the vaginal opening. occurs during the second stage of labor.Option A: During the first stage of labor. cervical dilation and effacement occur.Option C: During the third stage of labor. the newborn and placenta are delivered.Option D: The fourth stage of labor lasts from 1 to 4 hours after birth. during which time the mother and newborn recover from the physical process of birth and the mother’s organs undergo the initial readjustment to the nonpregnant state.

3. Immediately before expulsion. which of the following cardinal movements occur?

Descent

Flexion

Extension

External rotation

Immediately before expulsion or birth of the rest of the body. the cardinal movement of external rotation occurs.Options A. B. and C: Descent flexion. internal rotation. extension. and restitution (in this order) occur before external rotation.

Explanation

Immediately before expulsion or birth of the rest of the body. the cardinal movement of external rotation occurs.Options A. B. and C: Descent flexion. internal rotation. extension. and restitution (in this order) occur before external rotation.

4. Before birth. which of the following structures connects the right and left auricles of the heart?

Umbilical vein

Foramen ovale

Ductus arteriosus

Ductus venosus

The foramen ovale is an opening between the right and left auricles (atria) that should close shortly after birth so the newborn will not have a murmur or mixed blood traveling through the vascular system.Options A. C. and D: The umbilical vein. ductus arteriosus. and ductus venosus are obliterated at birth.

Explanation

The foramen ovale is an opening between the right and left auricles (atria) that should close shortly after birth so the newborn will not have a murmur or mixed blood traveling through the vascular system.Options A. C. and D: The umbilical vein. ductus arteriosus. and ductus venosus are obliterated at birth.

5. Which of the following groups of newborn reflexes below are present at birth and remain unchanged through adulthood?

Blink. cough. rooting. and gag

Blink. cough. sneeze. gag

Rooting. sneeze. swallowing. and cough

Stepping. blink. cough. and sneeze

Blink. cough. sneeze. swallowing and gag reflexes are all present at birth and remain unchanged through adulthood. Reflexes such as rooting and stepping subside within the first year.

Explanation

Blink. cough. sneeze. swallowing and gag reflexes are all present at birth and remain unchanged through adulthood. Reflexes such as rooting and stepping subside within the first year.

6. Which of the following nursing interventions would the nurse perform during the third stage of labor?

Obtain a urine specimen and other laboratory tests.

Assess uterine contractions every 30 minutes.

Coach for effective client pushing

Promote parent-newborn interaction.

During the third stage of labor. which begins with the delivery of the newborn. the nurse would promote parent-newborn interaction by placing the newborn on the mother’s abdomen and encouraging the parents to touch the newborn.Option A: Collecting a urine specimen and other laboratory tests is done on admission during the first stage of labor.Option B: Assessing uterine contractions every 30 minutes is performed during the latent phase of the first stage of labor.Option D: Coaching the client to push effectively is appropriate during the second stage of labor.

Explanation

During the third stage of labor. which begins with the delivery of the newborn. the nurse would promote parent-newborn interaction by placing the newborn on the mother’s abdomen and encouraging the parents to touch the newborn.Option A: Collecting a urine specimen and other laboratory tests is done on admission during the first stage of labor.Option B: Assessing uterine contractions every 30 minutes is performed during the latent phase of the first stage of labor.Option D: Coaching the client to push effectively is appropriate during the second stage of labor.

7. Which of the following when present in the urine may cause a reddish stain on the diaper of a newborn?

Mucus

Uric acid crystals

Bilirubin

Excess iron

Uric acid crystals in the urine may produce the reddish “brick dust” stain on the diaper.Option A: Mucus would not produce a stain.Options C and D: Bilirubin and iron are from hepatic adaptation.

Explanation

Uric acid crystals in the urine may produce the reddish “brick dust” stain on the diaper.Option A: Mucus would not produce a stain.Options C and D: Bilirubin and iron are from hepatic adaptation.

8. When assessing the newborn's heart rate. which of the following ranges would be considered normal if the newborn were sleeping?

80 beats per minute

100 beats per minute

120 beats per minute

140 beats per minute

The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute. If the newborn was awake. the normal heart rate would range from 120 to 160 beats per minute.

Explanation

The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute. If the newborn was awake. the normal heart rate would range from 120 to 160 beats per minute.

9. Which of the following is true regarding the fontanels of the newborn?

The anterior is triangular shaped; the posterior is diamond shaped.

The posterior closes at 18 months; the anterior closes at 8 to 12 weeks.

The anterior is large in size when compared to the posterior fontanel.

The anterior is bulging; the posterior appears sunken.

The anterior fontanel is larger in size than the posterior fontanel. Additionally. the anterior fontanel. which is diamond shaped. closes at 18 months. whereas the posterior fontanel. which is triangular shaped. closes at 8 to 12 weeks. Neither fontanel should appear bulging. which may indicate increased intracranial pressure. or sunken. which may indicate dehydration.

Explanation

The anterior fontanel is larger in size than the posterior fontanel. Additionally. the anterior fontanel. which is diamond shaped. closes at 18 months. whereas the posterior fontanel. which is triangular shaped. closes at 8 to 12 weeks. Neither fontanel should appear bulging. which may indicate increased intracranial pressure. or sunken. which may indicate dehydration.

10. Barbiturates are usually not given for pain relief during active labor for which of the following reasons?

The neonatal effects include hypotonia. hypothermia. generalized drowsiness. and reluctance to feed for the first few days.

These drugs readily cross the placental barrier. causing depressive effects in the newborn 2 to 3 hours after intramuscular injection.

They rapidly transfer across the placenta. and lack of an antagonist make them generally inappropriate during labor.

Adverse reactions may include maternal hypotension. allergic or toxic reaction or partial or total respiratory failure

Barbiturates are rapidly transferred across the placental barrier. and lack of an antagonist makes them generally inappropriate during active labor.Option A: Neonatal side effects of barbiturates include central nervous system depression. prolonged drowsiness. delayed establishment of feeding (e.g. due to poor sucking reflex or poor sucking pressure). Tranquilizers are associated with neonatal effects such as hypotonia. hypothermia. generalized drowsiness. and reluctance to feed for the first few days.Option B: Narcotic analgesic readily crosses the placental barrier. causing depressive effects in the newborn 2 to 3 hours after intramuscular injection.Option D: Regional anesthesia is associated with adverse reactions such as maternal hypotension. allergic or toxic reaction. or partial or total respiratory failure.

Explanation

Barbiturates are rapidly transferred across the placental barrier. and lack of an antagonist makes them generally inappropriate during active labor.Option A: Neonatal side effects of barbiturates include central nervous system depression. prolonged drowsiness. delayed establishment of feeding (e.g. due to poor sucking reflex or poor sucking pressure). Tranquilizers are associated with neonatal effects such as hypotonia. hypothermia. generalized drowsiness. and reluctance to feed for the first few days.Option B: Narcotic analgesic readily crosses the placental barrier. causing depressive effects in the newborn 2 to 3 hours after intramuscular injection.Option D: Regional anesthesia is associated with adverse reactions such as maternal hypotension. allergic or toxic reaction. or partial or total respiratory failure.