TEST BANK FOR MATERNAL & CHILD HEALTH
NURSING CARE OF THE
CHILDBEARING & CHILDREARING FAMILY
1. The nurse explain to the student that which of the following factors increase a
woman's risk
for thrombosis? (Select all that apply.)
a. Use of stirrups for a prolonged period of time
b. Prolonged bedrest during or after labor and delivery
c. Adherence to a strict vegetarian diet
d. Excessive sweating during labor
e. Maternal age greater than 30 years of age - A, B, D, E
Use of stirrups for a prolonged period of time, bedrest, excessive sweating (leading to
dehydration) all increase the risk of thrombosis. Vegetarian diets are not related.
Maternal
age >35 increases the risk. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding
REF: p. 606 | Box 28.2 OBJ: Integrated Process: Teaching-Learning MSC:
Client Needs: Physiologic Integrity
2. A woman just received an injection of carboprost, 2500 mcg IM. What actions by the
nurse take priority? (Select all that apply.) a. Assess for nausea and vomiting
b. Assess fetal well-being.
c. Administer acetaminophen for headache.
d. Monitor urine output.
e. Notify the provider immediately. - B, E
The usual dose of carboprost is 250 mcg, so this excessive dose could lead to uterine
rupture. The nurse monitors the woman for signs of this and continually monitors the
fetus for well-being. The provider would be notified and agency policy followed for
variance reporting. Nausea, vomiting, and headache are side effects of the usual
dose of the drug.
This drug is excreted through urine, so monitoring urine output is important but not as
critical as checking fetal well-being and notifying the provider. PTS: 1 DIF: Cognitive
Level: Analysis/Analyzing
REF: p. 601 | Drug Guide Box OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
3. A home health care nurse is checking on a new mother with signs of obsessive-
compulsive
,disorder. What assessment findings correlate with this condition? (Select all that apply.)
a. Frequently checking on the baby
b. Fear of being alone with the baby
c. Woman states she feels worthless
d. Woman has bought $5,000 worth of toys
e. Mother states birth was very traumatic - A, B
Postpartum OCD often manifests with women performing obsessive behaviors and
voicing fear of being left alone with their baby. Feeling worthless is a sign of
depression. A spending spree might be a sign of the manic phase of bipolar disease.
Viewing the birth as
traumatic may lead to PTSD. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 615 OBJ: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
Chapter 29: The High-Risk Newborn: Problems Related to Gestational Age and
Development
McKinney: Evolve Resources for Maternal-Child Nursing, 5th Edition MULTIPLE
CHOICE
1. What is most helpful in preventing premature birth?
a. High socioeconomic status
b. Adequate prenatal care
c. Transitional Assistance to Needy Families
d. Women, Infants, and Children nutritional program - B
Prenatal care is vital in identifying possible problems. Women from higher economic
status are more likely to seek adequate prenatal care, but it is the care that is most
helpful. Government programs help with specific needs of the pregnant woman, but
adequate care is
more important. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 620 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
2. Compared to the term infant, the preterm infant has
a. few blood vessels visible though the skin.
b. more subcutaneous fat.
c. well-developed flexor muscles.
d. greater surface area in proportion to weight. - D
Preterm infants have greater surface area in proportion to their weight. They often have
visible blood vessels because their skin is thin and they have less fat. More fat and well-
developed flexor muscles are characteristic of a more mature infant. PTS: 1 DIF:
Cognitive Level: Knowledge/Remembering
REF: p. 623 OBJ: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
,3. Decreased surfactant production in the preterm lung is a problem because surfactant
a. causes increased permeability of the alveoli.
b. provides transportation for oxygen to enter the blood supply.
c. keeps the alveoli open during expiration.
d. dilates the bronchioles, decreasing airway resistance. - C
Surfactant prevents the alveoli from collapsing each time the infant exhales, thus
reducing
the work of breathing. It does not cause increased permeability, provide transportation
of oxygen or dilate the bronchioles. PTS: 1 DIF: Cognitive Level:
Knowledge/Remembering
REF: p. 635 OBJ: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
4. A preterm infant is on a respirator with intravenous lines and much equipment around
her when her parents come to visit for the first time. What action by the nurse is most
important?
a. Suggest that the parents visit for only a short time to reduce their anxieties.
b. Reassure the parents that the baby is progressing well.
c. Encourage the parents to touch her.
d. Discuss the care they will give her when she goes home. - C
Physical contact with the infant is important to establish early bonding. The nurse as the
support person and teacher is responsible for shaping the environment and making the
care giving responsive to the needs of both the parents and the infant. The nurse
should encourage the parents to touch their baby and show them how to do so safely.
Bonding needs to occur, and this can be fostered by encouraging the parents to spend
time with the infant. It is important to keep the parents informed about the infant's
progression, but the nurse needs to be honest with the explanations. Discussing home
care needs to wait until the
parents are ready and discharge is closer with known needs. PTS: 1 DIF: Cognitive
Level: Application/Applying
REF: p. 631 OBJ: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
5. A nurse is caring for a late preterm infant. What action by the nurse is inconsistent
with best practice to prevent cold stress?
a. Wean the infant directly to an open crib.
b. Check temperature every 3 to 4 hours.
c. Encourage kangaroo care.
d. Place infant on a radiant warmer. - A
Weaning to an open crib takes many steps and is not done directly because of the risk
of cold stress. The other actions help prevent cold stress. PTS: 1 DIF: Cognitive Level:
Application/Applying
, REF: pp. 622-623 OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
6. Which preterm infant should receive gavage feedings instead of a bottle?
a. Sometimes gags when a feeding tube is inserted
b. Is unable to coordinate sucking and swallowing
c. Sucks on a pacifier during gavage feedings
d. Has an axillary temperature of 98.4° F, an apical pulse of 149 beats/min, and
respirations of 54 breaths/min - B
An infant who cannot coordinate sucking, swallowing, and breathing should receive
gavage feedings. The other infants are ready for bottle feedings. PTS: 1 DIF:
Cognitive Level: Comprehension/Understanding
REF: p. 627 OBJ: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
7. Overstimulation may cause increased oxygen use in a preterm infant. Which nursing
intervention helps to avoid this problem?
a. Group all care activities together to provide long periods of rest.
b. While giving your report to the next nurse, stand in front of the incubator and talk
softly about how the infant responds to stimulation.
c. Teach the parents signs of overstimulation, such as turning the face away or
stiffening and extending the extremities and fingers.
d. Keep charts on top of the incubator so the nurses can write on them there. - C
Parents should be taught these signs of overstimulation so they will learn to adapt
their care to the needs of their infant. This may understimulate the infant during
those long periods and overtire the infant during the procedures. Talking in front of
the incubator could overstimulate the baby. Placing objects on top of the incubator or
using it as a writing surface increases the noise inside. PTS: 1 DIF: Cognitive Level:
Application/Applying
REF: p. 629 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
8. A premature infant never seems to sleep longer than an hour at a time. Each time a
light is
turned on, an incubator closes, or people talk near her crib, she wakes up and cries
inconsolably until held. The correct nursing diagnosis is ineffective coping related to a.
severe immaturity.
b. environmental stress.
c. physiologic distress.
d. behavioral responses. - B
This nursing diagnosis is the most appropriate for this infant. Light and sound are known
adverse stimuli that add to an already stressed premature infant. The nurse must monitor
the
NURSING CARE OF THE
CHILDBEARING & CHILDREARING FAMILY
1. The nurse explain to the student that which of the following factors increase a
woman's risk
for thrombosis? (Select all that apply.)
a. Use of stirrups for a prolonged period of time
b. Prolonged bedrest during or after labor and delivery
c. Adherence to a strict vegetarian diet
d. Excessive sweating during labor
e. Maternal age greater than 30 years of age - A, B, D, E
Use of stirrups for a prolonged period of time, bedrest, excessive sweating (leading to
dehydration) all increase the risk of thrombosis. Vegetarian diets are not related.
Maternal
age >35 increases the risk. PTS: 1 DIF: Cognitive Level: Comprehension/Understanding
REF: p. 606 | Box 28.2 OBJ: Integrated Process: Teaching-Learning MSC:
Client Needs: Physiologic Integrity
2. A woman just received an injection of carboprost, 2500 mcg IM. What actions by the
nurse take priority? (Select all that apply.) a. Assess for nausea and vomiting
b. Assess fetal well-being.
c. Administer acetaminophen for headache.
d. Monitor urine output.
e. Notify the provider immediately. - B, E
The usual dose of carboprost is 250 mcg, so this excessive dose could lead to uterine
rupture. The nurse monitors the woman for signs of this and continually monitors the
fetus for well-being. The provider would be notified and agency policy followed for
variance reporting. Nausea, vomiting, and headache are side effects of the usual
dose of the drug.
This drug is excreted through urine, so monitoring urine output is important but not as
critical as checking fetal well-being and notifying the provider. PTS: 1 DIF: Cognitive
Level: Analysis/Analyzing
REF: p. 601 | Drug Guide Box OBJ: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
3. A home health care nurse is checking on a new mother with signs of obsessive-
compulsive
,disorder. What assessment findings correlate with this condition? (Select all that apply.)
a. Frequently checking on the baby
b. Fear of being alone with the baby
c. Woman states she feels worthless
d. Woman has bought $5,000 worth of toys
e. Mother states birth was very traumatic - A, B
Postpartum OCD often manifests with women performing obsessive behaviors and
voicing fear of being left alone with their baby. Feeling worthless is a sign of
depression. A spending spree might be a sign of the manic phase of bipolar disease.
Viewing the birth as
traumatic may lead to PTSD. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 615 OBJ: Nursing Process: Assessment
MSC: Client Needs: Psychosocial Integrity
Chapter 29: The High-Risk Newborn: Problems Related to Gestational Age and
Development
McKinney: Evolve Resources for Maternal-Child Nursing, 5th Edition MULTIPLE
CHOICE
1. What is most helpful in preventing premature birth?
a. High socioeconomic status
b. Adequate prenatal care
c. Transitional Assistance to Needy Families
d. Women, Infants, and Children nutritional program - B
Prenatal care is vital in identifying possible problems. Women from higher economic
status are more likely to seek adequate prenatal care, but it is the care that is most
helpful. Government programs help with specific needs of the pregnant woman, but
adequate care is
more important. PTS: 1 DIF: Cognitive Level: Knowledge/Remembering
REF: p. 620 OBJ: Nursing Process: Assessment
MSC: Client Needs: Health Promotion and Maintenance
2. Compared to the term infant, the preterm infant has
a. few blood vessels visible though the skin.
b. more subcutaneous fat.
c. well-developed flexor muscles.
d. greater surface area in proportion to weight. - D
Preterm infants have greater surface area in proportion to their weight. They often have
visible blood vessels because their skin is thin and they have less fat. More fat and well-
developed flexor muscles are characteristic of a more mature infant. PTS: 1 DIF:
Cognitive Level: Knowledge/Remembering
REF: p. 623 OBJ: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
,3. Decreased surfactant production in the preterm lung is a problem because surfactant
a. causes increased permeability of the alveoli.
b. provides transportation for oxygen to enter the blood supply.
c. keeps the alveoli open during expiration.
d. dilates the bronchioles, decreasing airway resistance. - C
Surfactant prevents the alveoli from collapsing each time the infant exhales, thus
reducing
the work of breathing. It does not cause increased permeability, provide transportation
of oxygen or dilate the bronchioles. PTS: 1 DIF: Cognitive Level:
Knowledge/Remembering
REF: p. 635 OBJ: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
4. A preterm infant is on a respirator with intravenous lines and much equipment around
her when her parents come to visit for the first time. What action by the nurse is most
important?
a. Suggest that the parents visit for only a short time to reduce their anxieties.
b. Reassure the parents that the baby is progressing well.
c. Encourage the parents to touch her.
d. Discuss the care they will give her when she goes home. - C
Physical contact with the infant is important to establish early bonding. The nurse as the
support person and teacher is responsible for shaping the environment and making the
care giving responsive to the needs of both the parents and the infant. The nurse
should encourage the parents to touch their baby and show them how to do so safely.
Bonding needs to occur, and this can be fostered by encouraging the parents to spend
time with the infant. It is important to keep the parents informed about the infant's
progression, but the nurse needs to be honest with the explanations. Discussing home
care needs to wait until the
parents are ready and discharge is closer with known needs. PTS: 1 DIF: Cognitive
Level: Application/Applying
REF: p. 631 OBJ: Nursing Process: Implementation
MSC: Client Needs: Psychosocial Integrity
5. A nurse is caring for a late preterm infant. What action by the nurse is inconsistent
with best practice to prevent cold stress?
a. Wean the infant directly to an open crib.
b. Check temperature every 3 to 4 hours.
c. Encourage kangaroo care.
d. Place infant on a radiant warmer. - A
Weaning to an open crib takes many steps and is not done directly because of the risk
of cold stress. The other actions help prevent cold stress. PTS: 1 DIF: Cognitive Level:
Application/Applying
, REF: pp. 622-623 OBJ: Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
6. Which preterm infant should receive gavage feedings instead of a bottle?
a. Sometimes gags when a feeding tube is inserted
b. Is unable to coordinate sucking and swallowing
c. Sucks on a pacifier during gavage feedings
d. Has an axillary temperature of 98.4° F, an apical pulse of 149 beats/min, and
respirations of 54 breaths/min - B
An infant who cannot coordinate sucking, swallowing, and breathing should receive
gavage feedings. The other infants are ready for bottle feedings. PTS: 1 DIF:
Cognitive Level: Comprehension/Understanding
REF: p. 627 OBJ: Nursing Process: Assessment
MSC: Client Needs: Physiologic Integrity
7. Overstimulation may cause increased oxygen use in a preterm infant. Which nursing
intervention helps to avoid this problem?
a. Group all care activities together to provide long periods of rest.
b. While giving your report to the next nurse, stand in front of the incubator and talk
softly about how the infant responds to stimulation.
c. Teach the parents signs of overstimulation, such as turning the face away or
stiffening and extending the extremities and fingers.
d. Keep charts on top of the incubator so the nurses can write on them there. - C
Parents should be taught these signs of overstimulation so they will learn to adapt
their care to the needs of their infant. This may understimulate the infant during
those long periods and overtire the infant during the procedures. Talking in front of
the incubator could overstimulate the baby. Placing objects on top of the incubator or
using it as a writing surface increases the noise inside. PTS: 1 DIF: Cognitive Level:
Application/Applying
REF: p. 629 OBJ: Nursing Process: Implementation
MSC: Client Needs: Health Promotion and Maintenance
8. A premature infant never seems to sleep longer than an hour at a time. Each time a
light is
turned on, an incubator closes, or people talk near her crib, she wakes up and cries
inconsolably until held. The correct nursing diagnosis is ineffective coping related to a.
severe immaturity.
b. environmental stress.
c. physiologic distress.
d. behavioral responses. - B
This nursing diagnosis is the most appropriate for this infant. Light and sound are known
adverse stimuli that add to an already stressed premature infant. The nurse must monitor
the
