Safe Maternity and Pediatric Nursing Care 2nd Edition Linnard Palmer TestBank
Table ofContents
Chapter 1. Introduction to Maternity and Pediatric
... [Show More] Nursing ............................... 2 Chapter 2. Culture................................ ................................ .. 15 Chapter 3. Women’s Health Promotion Across the Life Span ............................. 28 Chapter 4. Human Reproduction and Fetal Development................................ . 38 Chapter 5. Physical and Psychological Changes of Pregnancy ............................. 48 Chapter 6. Nursing Care During Pregnancy ................................ ............ 62 Chapter 7. Promoting a Healthy Pregnancy ................................ ............ 77 Chapter 8 Nursing Care of the Woman With Complications During Pregnancy .............. 82 Chapter 9. Nursing Care During Labor and Childbirth ................................ ... 82 Chapter 10. Nursing Care of the Woman With Complications During Labor and Birth....... 113 Chapter 11. Birth-Related Procedures ................................ ................ 136 Chapter 12. Postpartum Nursing Care ................................ ................ 158 Chapter 13. Postpartum Complications ................................ ............... 170 Chapter 14. Physiological and Behavioral Adaptations of the Newborn.................... 185 Chapter 15. Nursing Care of the Newborn ................................ ............ 195 Chapter 16. Newborn Nutrition ................................ ..................... 206 Chapter 17. Nursing Care of the Newborn at Risk................................ ...... 217 Chapter 19. Health Promotion of the Toddler ................................ ......... 243 Chapter 20. Health Promotion of the Preschooler ................................ ...... 255 Chapter 21. Health Promotion of the School-Aged Child ................................ 265 Chapter 22. Health Promotion of the Adolescent................................ ....... 274 Chapter 23. Nursing Care of the Hospitalized Child................................ ..... 284 Chapter 24. Acutely Ill Children and Their Needs ................................ ...... 297 Chapter 25. Adapting to Chronic Illness and Supporting the Family Unit .................. 313 Chapter 26. The Abused Child................................ ....................... 321 Chapter 27. Child With a Neurological Condition................................ ....... 333 Chapter 28. Child With a Sensory Impairment................................ ......... 344 Chapter 29. Child With a Mental Health Condition ................................ ..... 358 Chapter 30. Child With a Respiratory Condition ................................ ....... 371 Chapter 31. Child With a Cardiac Condition ................................ ........... 390 Chapter 32. Child With a Metabolic Condition ................................ ......... 405
1 | P a g eChapter 33. Child With a Musculoskeletal Condition................................ .... 414
Chapter 34. Child With a Gastrointestinal Condition................................ .... 427
Chapter 35. Child With a Genitourinary Condition ................................ ..... 444
Chapter 36. Child With a Skin Condition................................ .............. 458
Chapter 37. Child With a Communicable Disease ................................ ...... 474
Chapter 38. Child With an Oncological or Hematological Condition ....................... 484
Chapter 1. Introduction to Maternity and Pediatric Nursing
MULTIPLE CHOICE
1. A patient chooses to have the certified nurse midwife (CNM) provide care during
herpregnancy. What does the CNMs scope of practice include?
a. Practice independent from medical supervision
b. Comprehensive prenatal care
c. Attendance at all deliveries
d. Cesarean
sectionsANS: B
The CNM provides comprehensive prenatal and postnatal care, attends uncomplicated
deliveries,and ensures that a backup physician is available in case of unforeseen problems.
DIF: Cognitive Level: Comprehension REF: Page 6 OBJ: 12
TOP: Advance Practice Nursing Roles KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
2. Which medical pioneer discovered the relationship between the incidence of puerperal
feverand unwashed hands?
a. Karl Cred
b. Ignaz Semmelweis
c. Louis Pasteur
d. Joseph Lister
ANS: B
Ignaz Semmelweis deduced that puerperal fever was septic, contagious, and transmitted by
theunwashed hands of physicians and medical students.
DIF: Cognitive Level: Knowledge REF: Page 2 OBJ: 1TOP:
The Past KEY: Nursing Process Step: N/A
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
2 | P a g e3. A pregnant woman who has recently immigrated to the United States comments to the nurse,
I
am afraid of childbirth. It is so dangerous. I am afraid I will die. What is the best
nursingresponse reflecting cultural sensitivity?
a. Maternal mortality in the United States is extremely low.
b. Anesthesia is available to relieve pain during labor and childbirth.
c. Tell me why you are afraid of childbirth.
d. Your condition will be monitored during labor and
delivery.ANS: C
Asking the patient about her concerns helps promote understanding and individualizes
patientcare.
DIF: Cognitive Level: Application REF: Page 7-8 OBJ: 8
TOP: Cross-Cultural Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Psychological Adaptation
4. An urban area has been reported to have a high perinatal mortality rate. What information
doesthis provide?
a. Maternal and infant deaths per 100,000 live births per year
b. Deaths of fetuses weighing more than 500 g per 10,000 births per year
c. Deaths of infants up to 1 year of age per 1000 live births per year
d. Fetal and neonatal deaths per 1000 live births per
yearANS: D
The perinatal mortality rate includes fetal and neonatal deaths per 1000 live births per year.
DIF: Cognitive Level: Comprehension REF: Page 12, Box 1-6
OBJ: 9 TOP: The Present-Child Care
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
5. What is the focus of current maternity practice?
a. Hospital births for the majority of women
b. The traditional family unit
c. Separation of labor rooms from delivery rooms
d. A quality family experience for each
patientANS: D
Current maternity practice focuses on a high-quality family experience for all families,
traditional or otherwise.
DIF: Cognitive Level: Comprehension REF: Page 6 OBJ: 7
3 | P a g eTOP: The Present-Maternity Care KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance
6. Who advocated the establishment of the Childrens Bureau?
a. Lillian Wald
b. Florence Nightingale
c. Florence Kelly
d. Clara Barton
ANS: A
Lillian Wald is credited with suggesting the establishment of a federal Childrens Bureau.
DIF: Cognitive Level: Knowledge REF: Page 4 OBJ: 1 | 2 TOP:
The Past KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
7. What was the result of research done in the 1930s by the Childrens Bureau?
a. Children with heart problems are now cared for by pediatric cardiologists.
b. The Child Abuse and Prevention Act was passed.
c. Hot lunch programs were established in many schools.
d. Childrens asylums were
founded.ANS: C
School hot lunch programs were developed as a result of research by the Childrens Bureau on
theeffects of economic depression on children.
DIF: Cognitive Level: Knowledge REF: Page 4 OBJ: 2 | 3
TOP: The Past KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care
8. What government program was implemented to increase the educational
exposure ofpreschool children?
a. WIC
b. Title XIX of Medicaid
c. The Childrens Charter
d. Head
StartANS: D
Head Start programs were established to increase educational exposure of preschool children.
DIF: Cognitive Level: Knowledge REF: Page 3 OBJ: 5
TOP: Government Influences in Maternity and Pediatric Care KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Growth and Development
4 | P a g e9. What guidelines define multidisciplinary patient care in terms of expected outcome
andtimeframe from different areas of care provision?
a. Clinical pathways
b. Nursing outcome criteria
c. Standards of care
d. Nursing care
planANS: A
Clinical pathways, also known as critical pathways or care maps, are collaborative
guidelinesthat define patient care across disciplines. Expected progress within a specified
timeline is identified.
DIF: Cognitive Level: Knowledge REF: Page 12 OBJ: 14
TOP: Health Care Delivery Systems KEY: Nursing Process Step: N/A
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
10. A nursing student has reviewed a hospitalized pediatric patient chart, interviewed her
mother,and collected admission data. What is the next step the student will take to develop a
nursing care plan for this child?
a. Identify measurable outcomes with a timeline.
b. Choose specific nursing interventions for the child.
c. Determine appropriate nursing diagnoses.
d. State nursing actions related to the childs medical
diagnosis.ANS: C
The nurse uses assessment data to select appropriate nursing diagnoses from the NANDA-I list.
Outcomes and interventions are then developed to address the relevant nursing diagnoses.
DIF: Cognitive Level: Application REF: Page 11 OBJ: 13
TOP: Nursing Process KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
11. A nursing student on an obstetric rotation questions the floor nurse about the definition
of theLVN/LPN scope of practice. What resource can the nurse suggest to the student?
a. American Nurses Association
b. States board of nursing
c. Joint Commission
d. Association of Womens Health, Obstetric and Neonatal
NursesANS: B
The scope of practice of the LVN/LPN is published by the states board of nursing.
5 | P a g eDIF: Cognitive Level: Comprehension REF: Page 3, Legal and Ethical Considerations
OBJ: 18 TOP: Critical Thinking
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
12. What was recommended by Karl Cred in 1884?
a. All women should be delivered in a hospital setting.
b. Chemical means should be used to combat infection.
c. Podalic version should be done on all fetuses.
d. Silver nitrate should be placed in the eyes of
newborns.ANS: D
In 1884 Karl Cred recommended the use of 2% silver nitrate in the eyes of newborns to
reducethe incidence of blindness.
DIF: Cognitive Level: Knowledge REF: Page 2 OBJ: 1 TOP:
Use of Silver Nitrate KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
13. What is the purpose of the White House Conference on Children and Youth?
a. Set criteria for normal growth patterns.
b. Examine the number of live births in minority populations.
c. Raise money to support well-child clinics in rural areas.
d. Promote comprehensive child
welfare.ANS: D
White House Conferences on Children and Youth are held every 10 years to
promotecomprehensive child welfare.
DIF: Cognitive Level: Knowledge REF: Page 4 OBJ: 3
TOP: White House Conferences KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
14. How many hours of hospital stay does legislation currently allow for a postpartum patient
who has delivered vaginally without complications?
a. 24
b. 48
c. 36
d. 72
ANS: B
Postpartum patients who deliver vaginally stay in the hospital for an average of 48 hours;
patients who have had a cesarean delivery usually stay 4 days.
6 | P a g eDIF: Cognitive Level: Knowledge REF: Page 6 OBJ: 7TOP:
Hospital Terms for Postpartum Patients
KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
15. How does the clinical pathway or critical pathway improve quality of care?
a. Lists diagnosis-specific implementations
b. Outlines expected progress with stated timelines
c. Prioritizes effective nursing diagnoses
d. Describes common
complicationsANS: B
Critical pathways outline expected progress with stated timelines. Any deviation from those
timelines is called a variance.
DIF: Cognitive Level: Comprehension REF: Page 12 OBJ: 14
TOP: Critical Pathway KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
16. A patient asks the nurse to explain what is meant by gene therapy. What is the nurses
bestresponse?
a. Gene therapy can replace missing genes.
b. Gene therapy evaluates the parents genes.
c. Gene therapy can change the sex of the fetus.
d. Gene therapy supports the regeneration of defective
genes.ANS: A
Gene therapy can replace missing or defective genes.
DIF: Cognitive Level: Knowledge REF: Page 8 OBJ: 7
TOP: Gene Therapy KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
17. The nurse is clarifying information to a patient regarding diagnosis-related groups
(DRGs).What is the nurses best response when the patient asks how DRGs reduce medical
care costs?
a. By determining payment based on diagnosis
b. By requiring two medical opinions to confirm a diagnosis
c. By organizing HMOs
d. By defining a person who will require
7 | P a g ehospitalizationANS: A
DRGs determine the amount of payment and length of hospital stay based on the diagnosis.
DIF: Cognitive Level: Comprehension REF: Page 8 OBJ: 11
TOP: DRGs KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
18. What is the best example of a Nursing Interventions Classification (NIC) intervention?
a. Patient will ambulate in the hall independently for 10 minutes three times a day.
b. Nurse will report temperature elevations to the charge nurse.
c. Nurse will offer extra liquids at all meals.
d. Patient will express pain relief after
massage.ANS: C
NIC is a guide to nursing actions.
DIF: Cognitive Level: Comprehension REF: Page 12 | Page 14
OBJ: 15 TOP: NICs KEY: Nursing Process Step: N/A
MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care
19. How does electronic charting ensure comprehensive charting more effectively
thanhandwritten charting?
a. Provides a uniform style of chart
b. Requires certain responses before allowing the user to progress
c. All documentation is reflective of the nursing care plan
d. Requires a daily audit by the charge
nurseANS: B
Comprehensive electronic documentation is ensured by requiring specific input in
designatedcategories before the user can progress through the system.
DIF: Cognitive Level: Comprehension REF: Page 15-16 OBJ: 22 TOP:
Computer Charting KEY: Nursing Process Step: ImplementationMSC:
NCLEX: Safe, Effective Care Environment: Coordinated Care
20. The nurse reminds family members that the philosophy of family-centered care is to
providecontrol to the family over health care decisions. What is the appropriate term for this
type of control?
a. Empowerment
b. Insight
c. Regulation
d. Organization
8 | P a g eANS: A
The term empowerment refers to the control a family has over its own health care decisions.
DIF: Cognitive Level: Knowledge REF: Page 2 OBJ: 7
TOP: Empowerment KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
21. A patient in the prenatal clinic is concerned about losing her job because of her
pregnancy.The nurse instructs her that the Family Medical Leave Act (FMLA) allows an
employee to be absent from work without pay. How many weeks does the FMLA allow a
woman to recover from childbirth or care for a sick family member without loss of benefits
or pay status?
a. 4
b. 6
c. 10
d. 12
ANS: D
The FMLA allows for employees to leave work for up to 12 weeks to recover from childbirth
orto care for an ill family member without losing benefits or pay status.
DIF: Cognitive Level: Knowledge REF: Page 3 OBJ: 5 TOP:
FMLA KEY: Nursing Process Step: Implementation
MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation
22. What term appropriately describes the nurse who is able to adapt health care
practices tomeet the needs of various cultures?
a. Culturally aware
b. Culturally sensitive
c. Culturally competent
d. Culturally
adaptiveANS: C
The nurse who is able to adapt health care to meet the needs of various cultures is said
to beculturally competent.
DIF: Cognitive Level: Knowledge REF: Page 7 OBJ: 8
TOP: Cultural Competency KEY: Nursing Process Step: N/A
MSC: NCLEX: N/A
23. What is one major advantage to the application of critical thinking?
a. Problem-free care
9 | P a g eb. Limitation of approaches to care
c. Decreased need for assessment
d. Problem
preventionANS: D
Critical thinking results in problem prevention in designing nursing care.
DIF: Cognitive Level: Comprehension REF: Page 14 OBJ: 19
TOP: Critical Thinking KEY: Nursing Process Step: N/A MSC:
NCLEX: N/A
24. Student practical nurses are discussing the North American Nursing Diagnosis
AssociationInternational (NANDA-I) taxonomy in post conference on the acute care clinical
setting. The students are aware that the role of the LPN with nursing diagnosis formulation
is what?
a. To initiate and identify nursing diagnosis specific to patient
b. To update changes in nursing diagnosis as needed
c. To have an understanding of nursing diagnosis terminology
d. To accurately document nursing diagnosis on patient plan of
careANS: C
The registered nurse is responsible to initiate, identify, update, and document nursing
diagnoses.The licensed practical nurse is responsible to have an understanding of nursing
diagnosis terminology.
DIF: Cognitive Level: Comprehension REF: Page 14 OBJ: 17
TOP: NANDA-I taxonomy KEY: Nursing Process Step: Nursing Diagnosis
MSC: NCLEX: Health Promotion and Maintenance: Data Collection Techniques
MULTIPLE RESPONSE
25. What services are birthing centers able to provide? (Select all that apply.)
a. Prenatal care
b. Labor and delivery services
c. Classes for new mothers
d. Adoption referrals
e. Family planning
ANS: A, B, C, E
Birthing centers are capable of providing full-service obstetric care, classes for new mothers,
andfamily planning. Birthing centers do not offer adoption services.
10 | P a g eDIF: Cognitive Level: Comprehension REF: Page 6 OBJ: 7
TOP: Birthing Centers KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Coordinated Care
26. What developments in the early 20th century encouraged women to seek hospitalization
forchildbirth? (Select all that apply.)
a. Use of specialized obstetric instruments
b. Use of anesthesia
c. Physicians closer relationships with hospitals
d. Focus on family-centered care
e. Insurance
coverageANS: A, B, C
In the early 1900s, the development of specialized obstetric instruments, better modes of
anesthesia, and the physicians reliance on hospital services were instrumental in encouraging
women to seek hospitalization for childbirth.
DIF: Cognitive Level: Comprehension REF: Page 3 OBJ: 7
TOP: Hospitalization for Childbirth KEY: Nursing Process Step: ImplementationMSC:
NCLEX: Safe, Effective Care Environment: Safety and Infection Control
27. What nonfamily-centered policies were prevalent in the 1960s? (Select all that apply.)
a. Waiting room for fathers
b. Sedation of mother during labor
c. Delay of reunion of mother and infant
d. Lenient visiting hours
e. Restrictions of visitations by minor
childrenANS: A, B, C, E
Hospital policies in the 1960s provided a separate waiting room for fathers while the mother
went through labor in a sedated state. The reunion of mother and infant was delayed for
severalhours because of the sedation. Visiting hours were rigid and disallowed the visitation
of minor children.
DIF: Cognitive Level: Comprehension REF: Page 3 OBJ: 7
TOP: Nonfamily-centered Practices KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
28. The nurse is aware that there is a legal responsibility to report certain diseases and
conditionsto county or state health authorities. Which would be included? (Select all that
apply.)
11 | P a g ea. Tuberculosis
b. Child abuse
c. Industrial accidents
d. Sexually transmitted diseases
e. Food-borne
infectionsANS: A, B, D,
E
The nurse has a legal responsibility to report communicable diseases (such as tuberculosis
andsexually transmitted diseases), food-borne infections, child abuse, and threats of suicide.
DIF: Cognitive Level: Comprehension REF: Page 6, Legal and Ethical Considerations box
OBJ: 6 TOP: Reportable Diseases
KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
29. An inservice program at a long-term care facility is reviewing the Nursing Outcomes
Classification (NOC) with nursing staff. After the presentation the nurses review resident
careplans. Which of the following are found to be appropriately written outcomes? (Select
all that apply.)
a. Suction patient orally every 4 hours and as needed.
b. Auscultate lung sounds every 2 hours.
c. Provide Tylenol as ordered by health care provider.
d. Patient states Pain has decreased after medication administration.
e. Patient blood pressure recorded as 120/72 after dressing change.
ANS: D, E
NOC was developed to identify outcomes of nursing care that are directly influenced by
nursingactions. Outcomes are defined as the behaviors and feelings of the patient in response
to the nursing care given. Suctioning patient, auscultating lung sounds, and providing Tylenol
are nursing actions.
DIF: Cognitive Level: Application REF: Page 12-14 OBJ: 16
TOP: Nursing Outcomes Classification (NOC)
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
30. Practical nursing students are using critical thinking skills to study for an upcoming
test.What will these students include when studying? (Select all that apply.)
a. Memorization of facts first
b. Prioritizing information
12 | P a g ec. Relating facts to other facts
d. Making assumptions
e. Reviewing before the
testANS: B, C, E
Using critical thinking when studying involves understanding facts before memorizing,
prioritizing information to be memorized, relating facts to other facts, using all five senses,
reviewing before tests, and reading critically. Critical thinking does not involve assumption
asdoes general thinking.
DIF: Cognitive Level: Comprehension REF: Page 15 OBJ: 20 TOP:
Critical Thinking KEY: Nursing Process Step: EvaluationMSC:
NCLEX: Safe, Effective Care Environment
31. What factors have played a role in meeting the goals of Healthy People 2020 as it relates
thegoals for outcomes of pregnancy? (Select all that apply.)
a. Early prenatal care
b. Increased number of surgical births
c. NICU care
d. Use of prenatal glucocorticoids
e. Fetal surgery
ANS: A, C, D, E
Early prenatal care, fetal surgery, use of prenatal glucocorticoids, technology, and NICU care
have played a role in increasing the positive outcome of pregnancy, and the goals of
Healthy People 2020 may well be met. Increase in surgical births and multiple gestations
do not work toward meeting the goals of Healthy People 2020.
DIF: Cognitive Level: Comprehension REF: Page 16-17 OBJ: 21
TOP: Healthy People 2020 KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection
32. A community health nurse is providing specialized care to patients in the home setting.
Whatkind of specialized care may this nurse be providing? (Select all that apply.)
a. Glucose monitoring
b. Heparin therapy
c. Family education
d. Total parenteral nutrition
e. Provision of referral
servicesANS: A, B, D
Glucose monitoring, heparin therapy, and total parenteral nutrition are categorized as
13 | P a g especializedcare that may be provided by the community health nurse. Family education and
provision of referral are categorized as therapeutic care.
DIF: Cognitive Level: Application REF: Page 16-17 OBJ: 23
TOP: Community Health KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
COMPLETION
33. The nurse who is very conscientious about hand hygiene is following the concepts set out
by
and
.
ANS:
Lister, Pasteur OR Pasteur, Lister
Both Lister and Pasteur set out that handwashing could reduce incidence of infection by cross-
contamination.
DIF: Cognitive Level: Knowledge REF: Page 2 OBJ: 1
TOP: Handwashing KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Safety and Infection Control
34. The first White House Conference on Children and Youth was called by President
.
ANS:
Theodore Roosevelt
Theodore Roosevelt called the first White House Conference in
1909.DIF: Cognitive Level: Knowledge REF: Page 4 OBJ: 1
TOP: White House Conferences KEY: Nursing Process Step: N/A
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
35. The nurse reviewing the specific recovery goals set out on a clinical pathway observed
thattwo goals were not met by their designated timeline. The nurse records a negative
for these two goals.
ANS:
variance
Using a clinical pathway model with goals and associated timelines, the nurse must record
anegative variance when a timeline is not met and consider a new approach or an
14 | P a g eextended timeline.
DIF: Cognitive Level: Comprehension REF: Page 12 OBJ: 14
TOP: Variances KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Management of Care
36.
.
is purposeful, goal-directed thinking based
onscientific evidence rather than assumption or memorization.
ANS:
Critical thinking
Critical thinking is purposeful and goal-directed thinking as oppo
Chapter 2. Culture
MULTIPLE CHOICE
1. The nurse is assessing a newborn. What sign of hypoglycemia does the nurse record?
a. Increased nasal mucus
b. Increased temperature
c. Active muscle movements
d. High-pitched cry
ANS: D
There are many signs of hypoglycemia in the newborn. One is a high-pitched cry.
DIF: Cognitive Level: Comprehension REF: Page 219 OBJ: 9
TOP: Signs of Hypoglycemia KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Reduction of Risk
2. What would the nurse expect to find when assessing the fundus of the uterus immediately
afterdelivery?
a. Well-contracted with its upper border at or just below the umbilicus
b. Well-contracted with its upper border three or four fingerbreadths above the umbilicus
c. Relaxed with its upper border level with the umbilicus
d. Relaxed with its upper border two or three fingerbreadths below the
umbilicusANS: A
Immediately after the placenta is expelled, the uterine fundus can be felt as a firm mass,
aboutthe size of a grapefruit, at the level of the umbilicus.
15 | P a g eDIF: Cognitive Level: Comprehension REF: Page 200 OBJ: 2
TOP: Fundus Assessment KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. What statement made by a new mother indicates she needs additional information
aboutbreastfeeding?
a. I let the baby nurse 10 to 15 minutes on the first breast and then switch to the other breast.
b. The baby needs to nurse at least 5 minutes on the breast to get the hindmilk.
c. The baby has been nursing every 2 to 3 hours.
d. If the baby gets fussy between feedings, I give her a bottle of
water.ANS: D
Supplemental feedings of formula or water should not be offered to a healthy newborn who is
breastfeeding.
DIF: Cognitive Level: Comprehension REF: Page 223-227
OBJ: 14 TOP: BreastfeedingSupplemental Feedings
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. After delivery, the nurses assessment reveals a soft, boggy uterus located above the
level ofthe umbilicus. What is the most appropriate nursing intervention?
a. Notify the physician.
b. Massage the fundus.
c. Initiate measures that encourage voiding.
d. Position the patient
flat.ANS: B
A poorly contracted uterus should be massaged until firm to prevent hemorrhage.
DIF: Cognitive Level: Application REF: Page 202 OBJ: 9
TOP: Boggy Uterus KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. What type of lochia will the nurse assess initially after delivery?
a. Serosa
b. Rubra
c. Alba
d. Vaginalis
ANS: B
The initial vaginal discharge after delivery is called lochia rubra. It is red and moderately
heavy.Lochia rubra lasts for up to 3 days postpartum.
16 | P a g eDIF: Cognitive Level: Knowledge REF: Page 202 OBJ: 4
TOP: Lochia Rubra KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
6. A woman will be discharged 48 hours after a vaginal delivery. When planning
dischargeteaching, the nurse would include what information about lochia?
a. Lochia should disappear 2 to 4 weeks postpartum.
b. It is normal for the lochia to have a slightly foul odor.
c. A change in lochia from pink to bright red should be reported.
d. A decrease in flow will be noticed with ambulation and activity.
ANS: C
A return to bright red lochia rubra may indicate a late postpartum hemorrhage and must be
reported.
DIF: Cognitive Level: Application REF: Page 203 OBJ: 18TOP:
Hemorrhage KEY: Nursing Process Step: Planning
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
7. What instruction should the nurse teach the postpartum woman about perineal self-care?
a. Perform perineal self-care at least twice a day.
b. Cleanse with warm water in a squeeze bottle from front to back.
c. Remove perineal pads from the rectal area toward the vagina.
d. Use cool water to decrease edema of the
perineum.ANS: B
Cleansing from front to back prevents contamination from the rectal area.
DIF: Cognitive Level: Application REF: Page 204 OBJ: 2
TOP: Perineal Care KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
8. A postpartum woman is not immune to rubella. What will the nurse expect?
a. The rubella virus vaccine should be administered before discharge.
b. The woman should receive the rubella virus vaccine at her 6-week postpartum checkup.
c. The woman should be instructed not to get pregnant until she receives the rubella vaccine.
d. No intervention is indicated at this time because the woman is not at risk for
rubella.ANS: A
The woman who is not immune to rubella is immunized in the immediate postpartum
periodbecause there is no danger of her being pregnant.
DIF: Cognitive Level: Comprehension REF: Page 209 OBJ: 2
17 | P a g eTOP: Rubella KEY: Nursing Process Step: Planning
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
9. Which statement indicates the new mother is breastfeeding correctly?
a. I will alternate breasts when feeding the baby.
b. I keep the baby on a 4-hour feeding schedule.
c. I let the baby stay on the first breast only 5 minutes.
d. I put only the nipple in the babys mouth when I am breastfeeding.
ANS: A
Alternating breasts for feeding increases milk production, particularly hindmilk, which has
ahigher protein and fat content.
DIF: Cognitive Level: Comprehension REF: Page 224, Table 9-4
OBJ: 14 TOP: Breastfeeding
KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
10. The nurse is counseling a lactating mother about diet. What would the nurse include with
thisinformation?
a. Consume 500 more calories than her usual prepregnancy diet.
b. Eat less meat and more fruits and vegetables.
c. Drink 3 to 4 tall glasses of fluid daily.
d. Eat 1000 more calories than her usual prepregnancy
diet.ANS: A
To maintain nutrient stores while breastfeeding, the mother needs 500 additional calories
eachday over her prepregnancy diet.
DIF: Cognitive Level: Comprehension REF: Page 230 OBJ: 15
TOP: BreastfeedingMaternal Nutrition
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
11. A woman asks about resumption of her menstrual cycle after childbirth. What should
thenurse respond?
a. A woman will not ovulate in the absence of menstrual flow.
b. Most nonlactating women resume menstruation about 2 months postpartum.
c. Generally, a woman does not ovulate in the first few cycles after childbirth.
d. The return of menstruation is delayed when a woman does not
breastfeed.ANS: B
18 | P a g eMenstrual periods resume in about 6 to 8 weeks if the woman is not breastfeeding.
DIF: Cognitive Level: Comprehension REF: Page 205 OBJ: 4
TOP: Return of Menses KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
12. In what situation will the physician order RhoGAM?
a. An unsensitized Rh-negative mother has an Rh-positive infant.
b. An Rh-negative mother becomes sensitized.
c. A sensitized infant has a rising bilirubin level.
d. An unsensitized infant exhibits no outward
signs.ANS: A
The Rh-negative woman should receive RhoGAM within 72 hours after the birth of an Rh-
positive infant.
DIF: Cognitive Level: Analysis REF: Page 209 OBJ: 4
TOP: RhoGAM KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
13. After birth, the nurse quickly dries and wraps the newborn in a blanket. How does this
actionprevent heat loss?
a. Conduction
b. Radiation
c. Evaporation
d. Convection
ANS: C
Newborns lose heat quickly after birth as fluid evaporates from their bodies.
DIF: Cognitive Level: Comprehension REF: Page 216, Table 9-3
OBJ: 2 TOP: Thermoregulation
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
14. What will the nurses instructions for a new mother to care for the infants umbilical
cordinclude?
a. Keeping the area covered with a sterile dressing
b. Dressing the stump with antibiotic ointment at every diaper change
c. Fastening the diaper low to allow for air circulation
d. Giving the newborn a daily tub bath until the cord falls
offANS: C
19 | P a g eDiaper placement below the umbilical stump allows for drying by air circulation.
DIF: Cognitive Level: Application REF: Page 218-219, Skill 9-6
OBJ: 2 TOP: Umbilical Cord Care
KEY: Nursing Process Step: Implementation
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease
15. A new mother states her preference to formula feed her newborn. What will the
nurseplanning discharge instructions tell her to help suppress lactation and promote
comfort?
a. Wear a well-fitting bra continuously for several days.
b. Stand in a warm shower, letting the water spray over the breasts.
c. Express small amounts of milk from the breasts several times a day.
d. Massage the breasts when they
ache.ANS: A
When a mother does not wish to breastfeed, a snug bra worn around the clock can help [Show Less]