Maternal And Child Health Nursing NCLEX Quiz 12

1. Which of the following statements best describes hyperemesis gravidarum?

Severe anemia leading to an electrolyte. metabolic. and nutritional imbalances in the absence of other medical problems.

Severe nausea and vomiting leading to an electrolyte. metabolic. and nutritional imbalances in the absence of other medical problems.

Loss of appetite and continuous vomiting that commonly results in dehydration and ultimately decreasing maternal nutrients

Severe nausea and diarrhea that can cause gastrointestinal irritation and possibly internal bleeding

The description of hyperemesis gravidarum includes severe nausea and vomiting. leading to the electrolyte. metabolic. and nutritional imbalances in the absence of other medical problems.Option A: Hyperemesis is not a form of anemia.Option C: Loss of appetite may occur secondary to nausea and vomiting of hyperemesis. which. if it continues. can deplete the nutrients transported to the fetus.Option D: Diarrhea does not occur with hyperemesis.

Explanation

The description of hyperemesis gravidarum includes severe nausea and vomiting. leading to the electrolyte. metabolic. and nutritional imbalances in the absence of other medical problems.Option A: Hyperemesis is not a form of anemia.Option C: Loss of appetite may occur secondary to nausea and vomiting of hyperemesis. which. if it continues. can deplete the nutrients transported to the fetus.Option D: Diarrhea does not occur with hyperemesis.

2. Which of the following describes the Babinski reflex?

The newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement or loud noise.

With the Babinski reflex. the newborn’s toes hyperextend and fan apart from dorsiflexion of the big toe when one side of the foot is stroked upward from the heel and across the ball of the foot.Option B: With the startle reflex. the newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement of loud noise.Option C: With the rooting and sucking reflex. the newborn turns his head in the direction of stimulus. opens the mouth. and begins to suck when the cheeks. lip. or corner of mouth is touched.Option D: With the crawl reflex. the newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface.

Explanation

With the Babinski reflex. the newborn’s toes hyperextend and fan apart from dorsiflexion of the big toe when one side of the foot is stroked upward from the heel and across the ball of the foot.Option B: With the startle reflex. the newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement of loud noise.Option C: With the rooting and sucking reflex. the newborn turns his head in the direction of stimulus. opens the mouth. and begins to suck when the cheeks. lip. or corner of mouth is touched.Option D: With the crawl reflex. the newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface.

3. Which of the following may happen if the uterus becomes overstimulated by oxytocin during the induction of labor?

Weak contraction prolonged to more than 70 seconds

Tetanic contractions prolonged to more than 90 seconds

Increased pain with bright red vaginal bleeding

Increased restlessness and anxiety

Hyperstimulation of the uterus such as with oxytocin during the induction of labor may result in tetanic contractions prolonged to more than 90seconds. which could lead to such complications as fetal distress. abruptio placentae. amniotic fluid embolism. laceration of the cervix. and uterine rupture.Option A: Weak contractions would not occur.Options C and D: Pain. bright red vaginal bleeding. and increased restlessness and anxiety are not associated with hyperstimulation.

Explanation

Hyperstimulation of the uterus such as with oxytocin during the induction of labor may result in tetanic contractions prolonged to more than 90seconds. which could lead to such complications as fetal distress. abruptio placentae. amniotic fluid embolism. laceration of the cervix. and uterine rupture.Option A: Weak contractions would not occur.Options C and D: Pain. bright red vaginal bleeding. and increased restlessness and anxiety are not associated with hyperstimulation.

4. Which of the following is described as premature separation of a normally implanted placenta during the second half of pregnancy. usually with severe hemorrhage?

Placenta previa

Ectopic pregnancy

Incompetent cervix

Abruptio placentae

Abruptio placentae is described as premature separation of a normally implanted placenta during the second half of pregnancy. usually with severe hemorrhage.Option A: Placenta previa refers to implantation of the placenta in the lower uterine segment. causing painless bleeding in the third trimester of pregnancy.Option B: Ectopic pregnancy refers to the implantation of the products of conception in a site other than the endometrium.Option C: Incompetent cervix is a conduction characterized by painful dilation of the cervical os without uterine contractions.

Explanation

Abruptio placentae is described as premature separation of a normally implanted placenta during the second half of pregnancy. usually with severe hemorrhage.Option A: Placenta previa refers to implantation of the placenta in the lower uterine segment. causing painless bleeding in the third trimester of pregnancy.Option B: Ectopic pregnancy refers to the implantation of the products of conception in a site other than the endometrium.Option C: Incompetent cervix is a conduction characterized by painful dilation of the cervical os without uterine contractions.

5. Which of the following best describes preterm labor?

Labor that begins after 20 weeks gestation and before 37 weeks gestation

Labor that begins after 15 weeks gestation and before 37 weeks gestation

Labor that begins after 24 weeks gestation and before 28 weeks gestation

Labor that begins after 28 weeks gestation and before 40 weeks gestation

Preterm labor is best described as labor that begins after 20 weeks’ gestation and before 37 weeks’ gestation. The other time periods are inaccurate.

Explanation

Preterm labor is best described as labor that begins after 20 weeks’ gestation and before 37 weeks’ gestation. The other time periods are inaccurate.

6. In which of the following types of spontaneous abortions would the nurse assess dark brown vaginal discharge and a negative pregnancy test?

Threatened

Imminent

Missed

Incomplete

In a missed abortion. there is early fetal intrauterine death. and products of conception are not expelled. The cervix remains closed; there may be a dark brown vaginal discharge. negative pregnancy test. and cessation of uterine growth and breast tenderness.Option A: A threatened abortion is evidenced with cramping and vaginal bleeding in early pregnancy. with no cervical dilation.Option B: An imminent-abortion indicated by bleeding and pain along with an effaced cervix.Option D: An incomplete abortion involves only expulsion of part of the products of conception and bleeding occurs with cervical dilation.

Explanation

In a missed abortion. there is early fetal intrauterine death. and products of conception are not expelled. The cervix remains closed; there may be a dark brown vaginal discharge. negative pregnancy test. and cessation of uterine growth and breast tenderness.Option A: A threatened abortion is evidenced with cramping and vaginal bleeding in early pregnancy. with no cervical dilation.Option B: An imminent-abortion indicated by bleeding and pain along with an effaced cervix.Option D: An incomplete abortion involves only expulsion of part of the products of conception and bleeding occurs with cervical dilation.

7. Which of the following would the nurse assess in a client experiencing abruptio placenta?

Bright red. painless vaginal bleeding

Concealed or external dark red bleeding

Palpable fetal outline

Soft and nontender abdomen

A client with abruptio placentae may exhibit concealed or dark red bleeding. possibly reporting sudden intense localized uterine pain. The uterus is typically firm to board-like. and the fetal presenting part may be engaged.Options A. C. and D: Bright red. painless vaginal bleeding. a palpable fetal outline. and a soft non-tender abdomen are manifestations of placenta previa.

Explanation

A client with abruptio placentae may exhibit concealed or dark red bleeding. possibly reporting sudden intense localized uterine pain. The uterus is typically firm to board-like. and the fetal presenting part may be engaged.Options A. C. and D: Bright red. painless vaginal bleeding. a palpable fetal outline. and a soft non-tender abdomen are manifestations of placenta previa.

8. Which of the following factors would the nurse suspect as predisposing a client to placenta previa?

Multiple gestation

Uterine anomalies

Abdominal trauma

Renal or vascular disease

Multiple gestation is one of the predisposing factors that may cause placenta previa.Options B. C. and D: Uterine anomalies abdominal trauma and renal or vascular disease may predispose a client to abruptio placentae.

Explanation

Multiple gestation is one of the predisposing factors that may cause placenta previa.Options B. C. and D: Uterine anomalies abdominal trauma and renal or vascular disease may predispose a client to abruptio placentae.

9. Which of the following would the nurse identify as a classic sign of PIH?

Edema of the feet and ankles

Edema of the hands and face

Weight gain of 1 lb/week

Early morning headache

Edema of the hands and face is a classic sign of PIH.Option A: Many healthy pregnant woman experience foot and ankle edema.Option C: A weight gain of 2 lb or more per week indicates a problem.Option D: Early morning headache is not a classic sign of PIH.

Explanation

Edema of the hands and face is a classic sign of PIH.Option A: Many healthy pregnant woman experience foot and ankle edema.Option C: A weight gain of 2 lb or more per week indicates a problem.Option D: Early morning headache is not a classic sign of PIH.

10. When preparing a client for cesarean delivery. which of the following key concepts should be considered when implementing nursing care?

Instruct the mother’s support person to remain in the family lounge until after the delivery

Arrange for a staff member of the anesthesia department to explain what to expect postoperatively

Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth

Explain the surgery. expected outcome. and kind of anesthetics

A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching to meet the needs of either a planned or emergency cesarean birth. the depth and breadth of instruction will depend on circumstances and time available.Option A: Allowing the mother’s support person to remain with her as much as possible is an important concept. although doing so depends on many variables.Option B: Arranging for necessary explanations by various staff members to be involved with the client’s care is a nursing responsibility.Option D: The nurse is responsible for reinforcing the explanations about the surgery expected outcome. and type of anesthetic to be used. The obstetrician is responsible for explaining about the surgery and outcome. and the anesthesiology staff is responsible for explanations about the type of anesthesia to be used.

Explanation

A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching to meet the needs of either a planned or emergency cesarean birth. the depth and breadth of instruction will depend on circumstances and time available.Option A: Allowing the mother’s support person to remain with her as much as possible is an important concept. although doing so depends on many variables.Option B: Arranging for necessary explanations by various staff members to be involved with the client’s care is a nursing responsibility.Option D: The nurse is responsible for reinforcing the explanations about the surgery expected outcome. and type of anesthetic to be used. The obstetrician is responsible for explaining about the surgery and outcome. and the anesthesiology staff is responsible for explanations about the type of anesthesia to be used.