Maternal And Child Health Nursing NCLEX Quiz 5

1. A client who is 36 weeks pregnant comes to the clinic for a prenatal checkup. To assess the client's preparation for parenting. the nurse might ask which question?

“Are you planning to have epidural anesthesia?”

“Have you begun prenatal classes?”

“What changes have you made at home to get ready for the baby?”

“Can you tell me about the meals you typically eat each day?”

During the third trimester. the pregnant client typically perceives the fetus as a separate being. To verify that this has occurred. the nurse should ask whether she has made appropriate changes at home such as obtaining infant supplies and equipment.Option A: The type of anesthesia planned doesn’t reflect the client’s preparation for parenting.Option B: The client should have begun prenatal classes earlier in the pregnancy.Option D: The nurse should have obtained dietary information during the first trimester to give the client time to make any necessary changes.

Explanation

During the third trimester. the pregnant client typically perceives the fetus as a separate being. To verify that this has occurred. the nurse should ask whether she has made appropriate changes at home such as obtaining infant supplies and equipment.Option A: The type of anesthesia planned doesn’t reflect the client’s preparation for parenting.Option B: The client should have begun prenatal classes earlier in the pregnancy.Option D: The nurse should have obtained dietary information during the first trimester to give the client time to make any necessary changes.

2. After completing a second vaginal examination of a client in labor. the nurse-midwife determines that the fetus is in the right occiput anterior position and at (–1) station. Based on these findings. the nurse-midwife knows that the fetal presenting part is:

1 cm below the ischial spines.

Directly in line with the ischial spines.

1 cm above the ischial spines.

In no relationship to the ischial spines.

Fetal station — the relationship of the fetal presenting part to the maternal ischial spines — is described in the number of centimeters above or below the spines. A presenting part above the ischial spines is designated as –1. –2. or –3. A presenting part below the ischial spines. as +1. +2. or +3.

Explanation

Fetal station — the relationship of the fetal presenting part to the maternal ischial spines — is described in the number of centimeters above or below the spines. A presenting part above the ischial spines is designated as –1. –2. or –3. A presenting part below the ischial spines. as +1. +2. or +3.

3. A client. 30 weeks pregnant. is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is 8. What does this score indicate?

The fetus should be delivered within 24 hours.

The client should repeat the test in 24 hours.

The fetus isn’t in distress at this time.

The client should repeat the test in 1 week.

The BPP evaluates fetal health by assessing five variables: fetal breathing movements. gross body movements. fetal tone. reactive fetal heart rate. and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal. indicating that the fetus has a low risk of oxygen deprivation and isn’t in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may or may not be repeated if the score isn’t within normal limits.

Explanation

The BPP evaluates fetal health by assessing five variables: fetal breathing movements. gross body movements. fetal tone. reactive fetal heart rate. and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal. indicating that the fetus has a low risk of oxygen deprivation and isn’t in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may or may not be repeated if the score isn’t within normal limits.

4. The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first?

Change the client’s position.

Prepare for emergency cesarean section.

Check for placenta previa.

Administer oxygen.

Variable decelerations in fetal heart rate are an ominous sign. indicating compression of the umbilical cord. Changing the client’s position from supine to side-lying may immediately correct the problem.Option B: An emergency cesarean section is necessary only if other measures. such as changing position and amnioinfusion with sterile saline. prove unsuccessful.Option D: Administering oxygen may be helpful. but the priority is to change the woman’s position and relieve cord compression.

Explanation

Variable decelerations in fetal heart rate are an ominous sign. indicating compression of the umbilical cord. Changing the client’s position from supine to side-lying may immediately correct the problem.Option B: An emergency cesarean section is necessary only if other measures. such as changing position and amnioinfusion with sterile saline. prove unsuccessful.Option D: Administering oxygen may be helpful. but the priority is to change the woman’s position and relieve cord compression.

5. A client who's admitted to labor and delivery has the following assessment findings: gravida 2 para 1. estimated 40 weeks gestation. contractions 2 minutes apart. lasting 45 seconds. vertex +4 station. Which of the following would be the priority at this time?

Placing the client in bed to begin fetal monitoring.

Preparing for immediate delivery.

Checking for ruptured membranes.

Providing comfort measures.

This question requires an understanding of station as part of the intrapartum assessment process. Based on the client’s assessment findings. this client is ready for delivery. which is the nurse’s top priority.Options A. C. and D: Placing the client in bed. checking for ruptured membranes. and providing comfort measures could be done. but the priority here is immediate delivery.

Explanation

This question requires an understanding of station as part of the intrapartum assessment process. Based on the client’s assessment findings. this client is ready for delivery. which is the nurse’s top priority.Options A. C. and D: Placing the client in bed. checking for ruptured membranes. and providing comfort measures could be done. but the priority here is immediate delivery.

6. A 39-year-old at 37 weeks gestation is admitted to the hospital with complaints of vaginal bleeding following the use of cocaine 1 hour earlier. Which complication is most likely causing the client's complaint of vaginal bleeding?

Placenta previa

Abruptio placentae

Ectopic pregnancy

Spontaneous abortion

The major maternal adverse reactions from cocaine use in pregnancy include spontaneous abortion first. not third. trimester abortion and abruptio placentae.

Explanation

The major maternal adverse reactions from cocaine use in pregnancy include spontaneous abortion first. not third. trimester abortion and abruptio placentae.

7. Which of the following would be inappropriate to assess in a mother who's breastfeeding?

The attachment of the baby to the breast.

The mother’s comfort level with positioning the baby.

Audible swallowing.

The baby’s lips smacking

Assessing the attachment process for breast-feeding should include all of the answers except the smacking of lips. A baby who’s smacking his lips isn’t well attached and can injure the mother’s nipples.

Explanation

Assessing the attachment process for breast-feeding should include all of the answers except the smacking of lips. A baby who’s smacking his lips isn’t well attached and can injure the mother’s nipples.

8. During a prenatal visit at 4 months gestation. a pregnant client asks whether tests can be done to identify fetal abnormalities. Between 18 and 40 weeks gestation. which procedure is used to detect fetal anomalies?

Amniocentesis.

Chorionic villi sampling.

Fetoscopy.

Ultrasound

Ultrasound is used between 18 and 40 weeks’ gestation to identify normal fetal growth and detect fetal anomalies and other problems.Option A: Amniocentesis is done during the third trimester to determine fetal lung maturity.Option B: Chorionic villi sampling is performed at 8 to 12 weeks’ gestation to detect genetic disease.Option C: Fetoscopy is done at approximately 18 weeks’ gestation to observe the fetus directly and obtain a skin or blood sample.

Explanation

Ultrasound is used between 18 and 40 weeks’ gestation to identify normal fetal growth and detect fetal anomalies and other problems.Option A: Amniocentesis is done during the third trimester to determine fetal lung maturity.Option B: Chorionic villi sampling is performed at 8 to 12 weeks’ gestation to detect genetic disease.Option C: Fetoscopy is done at approximately 18 weeks’ gestation to observe the fetus directly and obtain a skin or blood sample.

9. Which change would the nurse identify as a progressive physiological change in the postpartum period?

Lactation

Lochia

Uterine involution

Diuresis

Lactation is an example of a progressive physiological change that occurs during the postpartum period.

Explanation

Lactation is an example of a progressive physiological change that occurs during the postpartum period.

10. The nurse in charge is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client?

Risk for deficient fluid volume related to hemorrhage

Risk for infection related to the type of delivery

Pain related to the type of incision

Urinary retention related to periurethral edema

Hemorrhage jeopardizes the client’s oxygen supply — the first priority among human physiologic needs. Therefore. the nursing diagnosis of Risk for deficient fluid volume related to hemorrhage takes priority over diagnoses of Risk for Infection. Pain. and Urinary retention.

Explanation

Hemorrhage jeopardizes the client’s oxygen supply — the first priority among human physiologic needs. Therefore. the nursing diagnosis of Risk for deficient fluid volume related to hemorrhage takes priority over diagnoses of Risk for Infection. Pain. and Urinary retention.