Maternal And Child Health Nursing NCLEX Quiz 16

1. During the first 4 hours after a male circumcision, assessing for which of the following is the priority?

Infection

Hemorrhage

Discomfort

Dehydration

Hemorrhage is a potential risk following any surgical procedure. However, the infant has been given vitamin K to facilitate clotting, and the prophylactic dose is often not sufficient to prevent bleeding. Option A: Although infection is a possibility, the signs will not appear within 4 hours after the surgical procedure. Option C: The primary discomfort of circumcision occurs during the surgical procedure, not afterward. Option D: Although feedings are withheld prior to the circumcision, the chances of dehydration are minimal.

Explanation

Hemorrhage is a potential risk following any surgical procedure. However, the infant has been given vitamin K to facilitate clotting, and the prophylactic dose is often not sufficient to prevent bleeding. Option A: Although infection is a possibility, the signs will not appear within 4 hours after the surgical procedure. Option C: The primary discomfort of circumcision occurs during the surgical procedure, not afterward. Option D: Although feedings are withheld prior to the circumcision, the chances of dehydration are minimal.

2. The post-term neonate with meconium-stained amniotic fluid needs care designed to especially monitor for which of the following?

Respiratory problems

Gastrointestinal problems

Integumentary problems

Elimination problems

Intrauterine anoxia may cause relaxation of the anal sphincter and empty of meconium into the amniotic fluid. At birth, some of the meconium fluid may be aspirated, causing mechanical obstruction or chemical pneumonitis. Option B: The infant is not at increased risk for gastrointestinal problems. Option C: Even though the skin is stained with meconium, it is noninfectious (sterile) and nonirritating. Option D: The post-term meconium-stained infant is not at additional risk for bowel or urinary problems.

Explanation

Intrauterine anoxia may cause relaxation of the anal sphincter and empty of meconium into the amniotic fluid. At birth, some of the meconium fluid may be aspirated, causing mechanical obstruction or chemical pneumonitis. Option B: The infant is not at increased risk for gastrointestinal problems. Option C: Even though the skin is stained with meconium, it is noninfectious (sterile) and nonirritating. Option D: The post-term meconium-stained infant is not at additional risk for bowel or urinary problems.

3. A client with severe preeclampsia is admitted with BP 160/110, proteinuria, and severe pitting edema. Which of the following would be most important to include in the client’s plan of care?

Daily weights

Seizure precautions

Right lateral positioning

Stress reduction

Women hospitalized with severe preeclampsia need to be decreased CNS stimulation to prevent a seizure. Seizure precautions provide environmental safety should a seizure occur. Option A: Because of edema, daily weight is important but not the priority. Option C: Preeclampsia causes vasospasm and, therefore, can reduce uteroplacental perfusion. The client should be placed on her left side to maximize blood flow, and reduce blood pressure. and promote diuresis. Option D: Interventions to reduce stress and anxiety are very important to facilitate coping and a sense of control, but seizure precautions are the priority.

Explanation

Women hospitalized with severe preeclampsia need to be decreased CNS stimulation to prevent a seizure. Seizure precautions provide environmental safety should a seizure occur. Option A: Because of edema, daily weight is important but not the priority. Option C: Preeclampsia causes vasospasm and, therefore, can reduce uteroplacental perfusion. The client should be placed on her left side to maximize blood flow, and reduce blood pressure. and promote diuresis. Option D: Interventions to reduce stress and anxiety are very important to facilitate coping and a sense of control, but seizure precautions are the priority.

4. A newborn who has an asymmetrical Moro reflex response should be further assessed for which of the following?

Talipes equinovarus

Fractured clavicle

Congenital hypothyroidism

Increased intracranial pressure

A fractured clavicle would prevent the normal Moro response of symmetrical sequential extension and abduction of the arms, followed by flexion and adduction. Option A: In talipes equinovarus (clubfoot), the foot is turned medially and in plantar flexion, with the heel elevated. The feet are not involved with the Moro reflex. Option C: Hypothyroidism does not affect primitive reflexes. Option D: The absence of the Moro reflex is the most significant single indicator of central nervous system status, but it is not a sign of increased intracranial pressure.

Explanation

A fractured clavicle would prevent the normal Moro response of symmetrical sequential extension and abduction of the arms, followed by flexion and adduction. Option A: In talipes equinovarus (clubfoot), the foot is turned medially and in plantar flexion, with the heel elevated. The feet are not involved with the Moro reflex. Option C: Hypothyroidism does not affect primitive reflexes. Option D: The absence of the Moro reflex is the most significant single indicator of central nervous system status, but it is not a sign of increased intracranial pressure.

5. The mother asks the nurse, "What's wrong with my son's breasts? Why are they so enlarged?" Which of the following would be the best response by the nurse?

“The breast tissue is inflamed from the trauma experienced with birth.”

“A decrease in material hormones present before birth causes enlargement.”

“You should discuss this with your doctor. It could be a malignancy.”

“The tissue has hypertrophied while the baby was in the uterus.”

The presence of excessive estrogen and progesterone in the maternal-fetal blood, followed by prompt withdrawal at birth, precipitates breast engorgement, which will spontaneously resolve in 4 to 5 days after birth. Option A: The trauma of the birth process does not cause inflammation of the newborn’s breast tissue. Option C: Newborns do not have breast malignancy. This reply by the nurse would cause the mother to have undue anxiety. Option D: Breast tissue does not hypertrophy in the fetus or newborns.

Explanation

The presence of excessive estrogen and progesterone in the maternal-fetal blood, followed by prompt withdrawal at birth, precipitates breast engorgement, which will spontaneously resolve in 4 to 5 days after birth. Option A: The trauma of the birth process does not cause inflammation of the newborn’s breast tissue. Option C: Newborns do not have breast malignancy. This reply by the nurse would cause the mother to have undue anxiety. Option D: Breast tissue does not hypertrophy in the fetus or newborns.

6. The nurse hears a mother telling a friend on the telephone about umbilical cord care. Which of the following statements by the mother indicates effective teaching?

“Daily soap and water cleansing are best.”

‘Alcohol helps it dry and kills germs.”

“An antibiotic ointment applied daily prevents infection.”

“He can have a tub bath each day.”

The application of 70% isopropyl alcohol to the cord minimizes microorganisms (germicidal) and promotes drying. The cord should be kept dry until it falls off and the stump has healed. Option C: Antibiotic ointment should only be used to treat an infection, not as a prophylaxis. Option D: Infants should not be submerged in a tub of water until the cord falls off and the stump has completely healed.

Explanation

The application of 70% isopropyl alcohol to the cord minimizes microorganisms (germicidal) and promotes drying. The cord should be kept dry until it falls off and the stump has healed. Option C: Antibiotic ointment should only be used to treat an infection, not as a prophylaxis. Option D: Infants should not be submerged in a tub of water until the cord falls off and the stump has completely healed.

7. When measuring a client’s fundal height, which of the following techniques denotes the correct method of measurement used by the nurse?

From the xiphoid process to the umbilicus

From the symphysis pubis to the xiphoid process

From the symphysis pubis to the fundus

From the fundus to the umbilicus

The nurse should use a nonelastic, flexible paper measuring tap, placing the zero point on the superior border of the symphysis pubis and stretching the tape across the abdomen at the midline to the top of the fundus. Options A. B. and D: The xiphoid and umbilicus are not appropriate landmarks to use when measuring the height of the fundus (McDonald’s measurement).

Explanation

The nurse should use a nonelastic, flexible paper measuring tap, placing the zero point on the superior border of the symphysis pubis and stretching the tape across the abdomen at the midline to the top of the fundus. Options A. B. and D: The xiphoid and umbilicus are not appropriate landmarks to use when measuring the height of the fundus (McDonald’s measurement).

8. A postpartum primipara asks the nurse. "When can we have sexual intercourse again?" Which of the following would be the nurse's best response?

“Anytime you both want to.”

“As soon as you choose a contraceptive method.”

“When the discharge has stopped, and the incision is healed.”

“After your 6 weeks examination.”

Cessation of the lochial discharge signifies healing of the endometrium. Risk of hemorrhage and infection is minimal 3 weeks after a normal vaginal delivery. Option A: Telling the client anytime is inappropriate because this response does not provide the client with the specific information she is requesting. Option B: The choice of a contraceptive method is important, but not the specific criteria for the safe resumption of sexual activity. Option D: Culturally, the 6-week examination has been used as the time frame for resuming sexual activity, but it may be resumed earlier.

Explanation

Cessation of the lochial discharge signifies healing of the endometrium. Risk of hemorrhage and infection is minimal 3 weeks after a normal vaginal delivery. Option A: Telling the client anytime is inappropriate because this response does not provide the client with the specific information she is requesting. Option B: The choice of a contraceptive method is important, but not the specific criteria for the safe resumption of sexual activity. Option D: Culturally, the 6-week examination has been used as the time frame for resuming sexual activity, but it may be resumed earlier.

9. A newborn weighing 3000 grams and feeding every 4 hours needs 120 calories/kg of body weight every 24 hours for proper growth and development. How many ounces of 20 cals/oz formula should this newborn receive at each feeding to meet nutritional needs?

2 ounces

3 ounces

4 ounces

6 ounces

To determine the amount of formula needed, do the following mathematical calculation. 3 kg x 120 cal/kg per day = 360 calories/day feeding q 4 hours = 6 feedings per day = 60 calories per feeding: 60 calories per feeding; 60 calories per feeding with formula 20 cal/oz = 3 ounces per feeding. Based on the calculation. 2. 4 or 6 ounces are incorrect.

Explanation

To determine the amount of formula needed, do the following mathematical calculation. 3 kg x 120 cal/kg per day = 360 calories/day feeding q 4 hours = 6 feedings per day = 60 calories per feeding: 60 calories per feeding; 60 calories per feeding with formula 20 cal/oz = 3 ounces per feeding. Based on the calculation. 2. 4 or 6 ounces are incorrect.

10. Immediately after birth, the nurse notes the following on a male newborn: respirations 78; apical heart rate 160 BPM, nostril-flaring; mild intercostal retractions, and grunting at the end of expiration. Which of the following should the nurse do?

Call the assessment data to the physician’s attention

Start oxygen per nasal cannula at 2 L/min.

Suction the infant’s mouth and nares

Recognize this as the normal first period of reactivity

The first 15 minutes to 1 hour after birth is the first period of reactivity involving respiratory and circulatory adaptation to extrauterine life. The data given reflect the normal changes during this time period. Options A and B: The infant’s assessment data reflect normal adaptation. Thus, the physician does not need to be notified, and oxygen is not needed. Option C: The data do not indicate the presence of choking, gagging, or coughing, which are signs of excessive secretions. Suctioning is not necessary.

Explanation

The first 15 minutes to 1 hour after birth is the first period of reactivity involving respiratory and circulatory adaptation to extrauterine life. The data given reflect the normal changes during this time period. Options A and B: The infant’s assessment data reflect normal adaptation. Thus, the physician does not need to be notified, and oxygen is not needed. Option C: The data do not indicate the presence of choking, gagging, or coughing, which are signs of excessive secretions. Suctioning is not necessary.