Maternal And Child Health Nursing NCLEX Quiz 35

1. The following are nursing measures to stimulate lactation EXCEPT

Frequent regular breastfeeding

Breast pumping

Breast massage

Application of cold compress on the breast

To stimulate lactation. a warm compress is applied to the breast. A cold application will cause vasoconstriction thus reducing the blood supply consequently the production of milk.

Explanation

To stimulate lactation. a warm compress is applied to the breast. A cold application will cause vasoconstriction thus reducing the blood supply consequently the production of milk.

2. In a woman who is not breastfeeding. menstruation usually occurs after how many weeks?

2-4 weeks

6-8 weeks

6 months

12 months

When the mother does not breastfeed. the normal menstruation resumes about 6-8 weeks after delivery. This is due to the fact that after delivery. the hormones estrogen and progesterone gradually decrease thus triggering negative feedback to the anterior pituitary to release the Follicle-Stimulating Hormone (FSH) which in turn stimulates the ovary to again mature a Graafian follicle and the menstrual cycle post pregnancy resumes.

Explanation

When the mother does not breastfeed. the normal menstruation resumes about 6-8 weeks after delivery. This is due to the fact that after delivery. the hormones estrogen and progesterone gradually decrease thus triggering negative feedback to the anterior pituitary to release the Follicle-Stimulating Hormone (FSH) which in turn stimulates the ovary to again mature a Graafian follicle and the menstrual cycle post pregnancy resumes.

3. According to Rubin's theory of maternal role adaptation. the mother will go through 3 stages during the postpartum perioD. These stages are:

Going through. adjustment period. adaptation period

Taking-in. taking hold and letting-go

Attachment phase. adjustment phase. adaptation phase

Taking-hold. letting-go. attachment phase

Rubin’s theory states that the 3 stages that a mother goes through for maternal adaptation are: taking-in. taking-hold and letting-go. In the taking-in stage. the mother is more passive and dependent on others for care. In taking-hold. the mother begins to assume a more active role in the care of the child and in letting-go. the mother has become adapted to her maternal role.

Explanation

Rubin’s theory states that the 3 stages that a mother goes through for maternal adaptation are: taking-in. taking-hold and letting-go. In the taking-in stage. the mother is more passive and dependent on others for care. In taking-hold. the mother begins to assume a more active role in the care of the child and in letting-go. the mother has become adapted to her maternal role.

4. When the uterus is firm and contracted after delivery but there is vaginal bleeding. the nurse should suspect

Laceration of soft tissues of the cervix and vagina

Uterine atony

Uterine inversion

Uterine hypercontractility

When the uterus is firm and contracted it means that the bleeding is not in the uterus but other parts of the passageway such as the cervix or the vagina.

Explanation

When the uterus is firm and contracted it means that the bleeding is not in the uterus but other parts of the passageway such as the cervix or the vagina.

5. The neonate of a mother with diabetes mellitus is prone to developing hypoglycemia because:

The pancreas is immature and unable to secrete the needed insulin

There is rapid diminution of glucose level in the baby’s circulating blood and his pancreas is normally secreting insulin

The baby is reacting to the insulin given to the mother

His kidneys are immature leading to a high tolerance for glucose

If the mother is diabetic. the fetus while in utero has a high supply of glucose. When the baby is born and is now separate from the mother. it no longer receives a high dose of glucose from the mother. In the first few hours after delivery. the neonate usually does not feed yet thus this can lead to hypoglycemia.

Explanation

If the mother is diabetic. the fetus while in utero has a high supply of glucose. When the baby is born and is now separate from the mother. it no longer receives a high dose of glucose from the mother. In the first few hours after delivery. the neonate usually does not feed yet thus this can lead to hypoglycemia.

6. A nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has a saturated a perineal pad in 1 hour. The nurse reports the amount of lochial flow as:

Excessive

Heavy

Light

Scanty

Heavy lochial discharge is a saturated menstrual pad in 1 hour.Option A: Excessive = menstrual pad saturated in 15 minutes.Option C: Light = less than 10 cm on a menstrual pad in 1 hour.Option D: Scanty = less than 2.5 cm on a menstrual pad in 1 hour.16.

Explanation

Heavy lochial discharge is a saturated menstrual pad in 1 hour.Option A: Excessive = menstrual pad saturated in 15 minutes.Option C: Light = less than 10 cm on a menstrual pad in 1 hour.Option D: Scanty = less than 2.5 cm on a menstrual pad in 1 hour.16.

7. The uterine fundus right after delivery of placenta is palpable at

Level of Xyphoid process

Level of umbilicus

Level of symphysis pubis

Midway between umbilicus and symphysis pubis

Immediately after the delivery of the placenta. the fundus of the uterus is expected to be at the level of the umbilicus because the contents of the pregnancy have already been expelled. The fundus is expected to recede by 1 fingerbreadths (1cm) every day until it becomes no longer palpable above the symphysis pubis.

Explanation

Immediately after the delivery of the placenta. the fundus of the uterus is expected to be at the level of the umbilicus because the contents of the pregnancy have already been expelled. The fundus is expected to recede by 1 fingerbreadths (1cm) every day until it becomes no longer palpable above the symphysis pubis.

8. Which of the following is an abnormal vital sign in postpartum?

Pulse rate between 50-60/min

BP diastolic increase from 80 to 95mm Hg

BP systolic between 100-120mm Hg

Respiratory rate of 16-20/min

All the vital signs given in the choices are within normal range except an increase of 15mm Hg in the diastolic which is a possible sign of hypertension in pregnancy.

Explanation

All the vital signs given in the choices are within normal range except an increase of 15mm Hg in the diastolic which is a possible sign of hypertension in pregnancy.

9. The following are interventions to make the fundus contract postpartally EXCEPT

Make the baby suck the breast regularly

Apply ice cap on fundus

Massage the fundus vigorously for 15 minutes until contracted

Give oxytocin as ordered

Massaging the fundus of the uterus should not be vigorous and should only be done until the uterus feels firm and contracted. If the massage is vigorous and prolonged. the uterus will relax due to over stimulation.

Explanation

Massaging the fundus of the uterus should not be vigorous and should only be done until the uterus feels firm and contracted. If the massage is vigorous and prolonged. the uterus will relax due to over stimulation.

10. The following are nursing interventions to relieve episiotomy wound pain EXCEPT

Giving analgesic as ordered

Sitz bath

Perineal heat

Perineal care

Perineal care is primarily done for personal hygiene regardless of whether there is pain or not; episiotomy wound or not.

Explanation

Perineal care is primarily done for personal hygiene regardless of whether there is pain or not; episiotomy wound or not.