MATERNAL AND CHILD HEALTH NURSING TEST
QUESTIONS AND VERIFIED ANSWERS WITH
RATIONALES. A GRADE EXAM.
A postpartum patient was in labor for 30 hours
... [Show More] and had ruptured membranes for 24
hours. For which of the following would the nurse be alert?
A. Endometritis
B. Endometriosis
C. Salpingitis
D. Pelvic thrombophlebitis
ANS: A. Endometritis
Rationale: Endometritis is an infection of the uterine lining and can occur after
prolonged rupture of membranes.
A client at 36 weeks gestation is schedule for a routine ultrasound prior to an
amniocentesis. After teaching the client about the purpose for the ultrasound,
which of the following client statements would indicate to the nurse in charge that
the client needs further instruction?
A. The ultrasound will help to locate the placenta
B. The ultrasound identifies blood flow through the umbilical cord
C. The test will determine where to insert the needle
D. The ultrasound locates a pool of amniotic fluid
ANS: B. The ultrasound identifies blood flow through the umbilical cord.
Rationale: Before amniocentesis, a routine ultrasound is valuable in locating the
placenta, locating a pool of amniotic fluid, and showing the physician where to
insert the needle. Color Doppler imaging ultrasonography identifies blood flow
through the umbilical cord. A routine ultrasound does not accomplish this.
While the postpartum client is receiving heparin for thrombophlebitis, which of the
following drugs would the nurse expect to administer if the client develops
complications related to heparin therapy? ANS: Protamine Sulfate
Rationale: Protamine sulfate is a heparin antagonist given intravenously to
counteract bleeding complications caused by heparin overdose.
When caring for a 3-day-old neonate who is receiving phototherapy to treat
jaundice, the nurse in charge would expect to do which of the following?
ANS: Check the vital signs every 2 to 4 hours.
Rationale: While caring for an infant receiving phototherapy for Tx. of jaundice,
vital signs are checked every 2 to 4 hours because hyperthermia can occur due to
the phototherapy lights.
A primigravida in active labor is about 9 days post-term. The client desires a
bilateral pudendal block anesthesia before delivery. After the nurse explains this
type of anesthesia to the client, which of the following locations identified by the
client as the area of relief would indicate to the nurse that the teaching was
effective? ANS: Perineum
Rationale: A bilateral pudendal block is used for vaginal deliveries to relieve pain
primarily in the perineum and vagina. Pudendal block anesthesia is adequate for
episiotomy and its repair.
The nurse is caring for a primigravida at about 2 months and 1 week gestation.
After explaining self-care measures for common discomforts of pregnancy, the
nurse determines that the client understands the instructions when she says:
ANS: "Nausea and vomiting can be decreased if I eat a few crackers before
arising"
Rationale: Eating dry crackers before arising can assist in decreasing the common
discomfort of nausea and vomiting. Avoiding strong food odors and eating a highprotein snack before bedtime can also help.
Forty-eight hours after delivery, the nurse in charge plans discharge teaching for
the client about infant care. By this time, the nurse expects that the phase of
postpartum psychological adaptation that the client would be in would be termed
which of the following? ANS: Taking hold
Rationale: Beginning after completion of the taking-in phase, the taking hold phase
lasts about 10 days. During this phase, the client is concerned with her need to
resume control of all facets of her life in a competent manner. At this time, she is
ready to learn self-care and infant care skills.
A pregnant client is diagnosed with partial placenta previa. In explaining the
diagnosis, the nurse tells the client that the usual treatment for partial placenta
previa is which of the following? ANS: Activity limited to bed rest
Rationale: Treatment of partial placenta previa includes bed rest, hydration, and
careful monitoring of the client's bleeding.
The nurse plans to instruct the postpartum client about methods to prevent breast
engorgement. Which of the following measures would the nurse include in the
teaching plan? ANS: Breast-feeding the neonate at frequent intervals.
Rationale: Prevention of breast engorgement is key. The best technique is to empty
the breast regularly with feeding. Engorgement is less likely when the mother and
neonate are together, as in single room maternity care continuous rooming in,
because nursing can be done conveniently to meet the neonate's and mother's
needs.
When the nurse on duty accidentally bumps the bassinet, the neonate throws out its
arms, hands opened, and begins to cry. The nurse interprets this reaction as
indicative of which of the following reflexes? ANS: Startle reflex
Rationale: The Moro, or startle, reflex occurs when the neonate responds to stimuli
by extending the arms, hands open, and then moving the arms in an embracing
motion. The Moro reflex, present at birth, disappears at about age 3 months.
A primigravida client at 25 weeks gestation visits the clinic and tells the nurse that
her lower back aches when she arrives home from work. The nurse should suggest
that the client perform: ANS: Tailor sitting
Rationale: Tailor sitting is an excellent exercise that helps to strengthen the client's
back muscles and also prepares the client for the process of labor. The client
should be encouraged to rest periodically during the day and avoid standing or
sitting in one position for a long time.
Which of the following would the nurse in charge do first after observing a 2-cm
circle of bright red bleeding on the diaper of a neonate who just had a
circumcision? ANS: Apply gentle pressure to the site with a sterile gauze pad.
Rationale: If bleeding occurs after circumcision, the nurse should first apply gentle
pressure on the area with sterile gauze.
Which of the following would the nurse most likely expect to find when assessing
a pregnant client with abruption placenta? ANS: Rigid, board like abdomen
Rationale: The most common assessment finding in a client with abruption
placenta is a rigid or board-like abdomen. Pain, usually reported as a sharp
stabbing sensation high in the uterine fundus with the initial separation, also is
common.
While the client is in active labor with twins and the cervix is 5 cm dilates, the
nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-
minute period. Which of the following would be the nurse's most appropriate
action? ANS: Notify the physician immediately.
Rationale: The nurse should contact the physician immediately because the client
is most likely experiencing hypotonic uterine contractions. These contractions tend
to be painful but ineffective. The usual treatment is oxytocin augmentation, unless
cephalopelvic disproportion exists.
A client tells the nurse, "I think my baby likes to hear me talk to him." When
discussing neonates and stimulation with sound, which of the following would the
nurse include as a means to elicit the best response? ANS: High-pitched speech
with tonal variations
Rationale: Providing stimulation and speaking to neonates is important. Some
authorities believe that speech is the most important type of sensory stimulation for
a neonate. Neonates respond best to speech with tonal variations and a highpitched voice. A neonate can hear all sound louder than about 55 decibels.
A 31-year-old multipara is admitted to the birthing room after initial examination
reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What
phase of labor is she in? ANS: Transitional phase
Rationale: The transitional phase of labor extends from 8 to 10 cm; it is the shortest
but most difficult and intense for the patient. The latent phase extends from 0 to 3
cm; it is mild in nature. The active phase extends from 4 to 7 cm; it is moderate for
the patient. The expulsive phase begins immediately after the birth and ends with
separation and expulsion of the placenta.
A pregnant patient asks the nurse if she can take castor oil for her constipation.
How should the nurse respond? ANS: "No, it can initiate premature uterine
contractions."
Castor oil can initiate premature uterine contractions in pregnant women. It also
can produce other adverse effects, but it does not promote sodium retention. Castor
oils is not known to increase absorption of fat-soluble vitamins, although laxatives
in general may decrease absorption if intestinal motility is increased.
A patient in her 14th week of pregnancy has presented with abdominal cramping
and vaginal bleeding for the past 8 hours. She has passed several cloth. What is the
primary nursing diagnosis for this patient? ANS: Fluid volume deficit
Rationale: If bleeding and clots are excessive, this patient may become
hypovolemic. Pad count should be instituted. Although the other diagnoses are
applicable to this patient, they are not the primary diagnosis.
Immediately after a delivery, the nurse-midwife assesses the neonate's head for
signs of molding. Which factors determine the type of molding? ANS: Fetal body
flexion or extension
Rationale:
Fetal attitude—the overall degree of body flexion or extension—determines the
type of molding in the head a neonate.
For a patient in active labor, the nurse-midwife plans to use an internal electronic
fetal monitoring (EFM) device. What must occur before the internal EFM can be
applied? ANS: The membranes must rupture
Rationale:
Internal EFM can be applied only after the patient's membranes have ruptured,
when the fetus is at least at the -1 station, and when the cervix is dilated at least 2
cm.
A primigravida patient is admitted to the labor delivery area. Assessment reveals
that she is in early part of the first stage of labor. Her pain is likely to be most
intense: ANS: Around the pelvic girdle
Rationale: During most of the first stage of labor, pain centers around the pelvic
girdle.
A female adult patient is taking a progestin-only oral contraceptive, or mini pill.
Progestin use may increase the patient's risk for: ANS: Tubal or ectopic pregnancy
Rationale:
Women taking the minipill have a higher incidence of tubal and ectopic
pregnancies, possibly because progestin slows ovum transport through the
Fallopian tubes.
A patient with pregnancy-induced hypertension probably exhibits which of the [Show Less]