Maternal And Child Health Nursing NCLEX Quiz 34

1. After a Rh(-) mother has delivered her Rh (+) baby. the mother is given RhoGam. This is done in order to:

Prevent the recurrence of Rh(+) baby in future pregnancies

Ensure those future pregnancies will not lead to maternal illness

To prevent the newborn from having problems of incompatibility when it breastfeeds

In Rh incompatibility. a Rh(-) mother will produce antibodies against the fetal Rh (+) antigen which she may have gotten because of the mixing of maternal and fetal blood during labor and delivery. Giving her RhoGam right after birth will prevent her immune system from being permanently sensitized to Rh antigen.

Explanation

In Rh incompatibility. a Rh(-) mother will produce antibodies against the fetal Rh (+) antigen which she may have gotten because of the mixing of maternal and fetal blood during labor and delivery. Giving her RhoGam right after birth will prevent her immune system from being permanently sensitized to Rh antigen.

2. The lochia on the first few days after delivery is characterized as

Pinkish with some blood clots

Whitish with some mucus

Reddish with some mucus

Serous with some brown tinged mucus

Right after delivery. the vaginal discharge called lochia will be reddish because there is some blood. endometrial tissue. and mucus. Since it is not pure blood it is non-clotting.

Explanation

Right after delivery. the vaginal discharge called lochia will be reddish because there is some blood. endometrial tissue. and mucus. Since it is not pure blood it is non-clotting.

3. Postpartum Period: The fundus of the uterus is expected to go down normally postpartally about __ cm per day.

1.0 cm

2.0 cm

2.5 cm

3.0 cm

The uterus will begin involution right after delivery. It is expected to regress/go down by 1 cm. per day and becomes no longer palpable about 1 week after delivery.

Explanation

The uterus will begin involution right after delivery. It is expected to regress/go down by 1 cm. per day and becomes no longer palpable about 1 week after delivery.

4. The nursing intervention to relieve pain in breast engorgement while the mother continues to breastfeed is

Apply cold compress on the engorged breast

Apply warm compress on the engorged breast

Massage the breast

Apply analgesic ointment

Warm compress is applied if the purpose is to relieve pain but ensure lactation to continue. If the purpose is to relieve pain as well as suppress lactation. the compress applied is cold.

Explanation

Warm compress is applied if the purpose is to relieve pain but ensure lactation to continue. If the purpose is to relieve pain as well as suppress lactation. the compress applied is cold.

5. To enhance milk production. a lactating mother must do the following interventions EXCEPT:

Increase fluid intake including milk

Eat foods that increase lactation which is called galactagogues

Exercise adequately like aerobics

Have adequate nutrition and rest

All the above nursing measures are needed to ensure that the mother is in a healthy state. However. aerobics does not necessarily enhance lactation.

Explanation

All the above nursing measures are needed to ensure that the mother is in a healthy state. However. aerobics does not necessarily enhance lactation.

6. Lochia normally disappears after how many days postpartum?

5 days

7-10 days

18-21 days

28-30 days

Normally. lochia disappears after 10 days postpartum. What’s important to remember is that the color of lochia gets to be lighter (from reddish to whitish) and scantier every day.

Explanation

Normally. lochia disappears after 10 days postpartum. What’s important to remember is that the color of lochia gets to be lighter (from reddish to whitish) and scantier every day.

7. To ensure adequate lactation the nurse should teach the mother to:

Breastfeed the baby on self-demand day and night

Feed primarily during the day and allow the baby to sleep through the night

Feed the baby every 3-4 hours following a strict schedule

Breastfeed when the breast are engorged to ensure adequate supply

Feeding on self-demand means the mother feeds the baby according to baby’s need. Therefore. this means there will be regular emptying of the breasts. which is essential to maintain adequate lactation.

Explanation

Feeding on self-demand means the mother feeds the baby according to baby’s need. Therefore. this means there will be regular emptying of the breasts. which is essential to maintain adequate lactation.

8. An appropriate nursing intervention when caring for a postpartum mother with thrombophlebitis is:

Encourage the mother to ambulate to relieve the pain in the leg

Instruct the mother to apply elastic bondage from the foot going towards the knee to improve venous return flow

Apply warm compress on the affected leg to relieve the pain

Elevate the affected leg and keep the patient on bedrest

If the mother already has thrombophlebitis. the nursing intervention is bedrest to prevent the possible dislodging of the thrombus and keeping the affected leg elevated to help reduce the inflammation.

Explanation

If the mother already has thrombophlebitis. the nursing intervention is bedrest to prevent the possible dislodging of the thrombus and keeping the affected leg elevated to help reduce the inflammation.

9. A woman who delivered normally per vagina is expected to void within ___ hours after delivery.

3 hrs

4 hrs.

6-8 hrs

12-24 hours

A woman who has had normal delivery is expected to void within 6-8 hrs. If she is unable to do so after 8 hours. the nurse should stimulate the woman to void. If nursing interventions to stimulate spontaneous voiding don’t work. the nurse may decide to catheterize the woman.

Explanation

A woman who has had normal delivery is expected to void within 6-8 hrs. If she is unable to do so after 8 hours. the nurse should stimulate the woman to void. If nursing interventions to stimulate spontaneous voiding don’t work. the nurse may decide to catheterize the woman.

10. The nurse should anticipate that hemorrhage related to uterine atony may occur postnatally if this condition was present during the delivery:

Excessive analgesia was given to the mother

Placental delivery occurred within thirty minutes after the baby was born

An episiotomy had to be done to facilitate delivery of the head

The labor and delivery lasted for 12 hours

Excessive analgesia can lead to uterine relaxation thus lead to hemorrhage postpartally. Both B and D are normal and C is at the vaginal introitus thus will not affect the uterus.

Explanation

Excessive analgesia can lead to uterine relaxation thus lead to hemorrhage postpartally. Both B and D are normal and C is at the vaginal introitus thus will not affect the uterus.