Test Bank
Maternity and Pediatric Nursing 5th Edition by SUSAN RICCI,
TERRI KYLE and SUSAN CARMAN
1
,MULTIPLE CHOICES
An expectant father tells the nurse he fears that his wife is "losing her mind." He states that
she is constantly rubbing her abdomen and talking to the baby and that she actually
reprimands the baby when it moves too much. Which recommendation should the nurse
make to this expectant father?
A. Suggest that his wife seek professional counseling to deal with her symptoms.
B. Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D. Reassure him that normal maternal-fetal bonding is occurring. - ✓✓ Correct Ans - D)
Reassure him that normal maternal-fetal bonding is occurring.
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not reflect
ambivalence. No intervention is needed. Quickening, the first perception of fetal
movement, occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal
bonding during the second trimester. Options A and C are not necessary because the
behaviors displayed are normal.
The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure
is completed, it is most important for the nurse to obtain which information?
2
,A. Maternal blood pressure
B. Maternal temperature
C. Fetal heart rate (FHR)
D. White blood cell count (WBC) - ✓✓ Correct Ans - C. Fetal heart rate (FHR)
Rationale:
The FHR should be assessed before and after the procedure to detect changes that may
indicate the presence of cord compression or prolapse. An amniotomy (artificial rupture of
membranes [AROM]) is used to stimulate labor when the condition of the cervix is
favorable. The fluid should be assessed for color, odor, and consistency. Option A should
be assessed every 15 to 20 minutes during labor but is not specific for AROM. Option B is
monitored hourly after the membranes are ruptured to detect the development of
amnionitis. Option D should be determined for all clients in labor.
A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery.
In developing a plan of care, the nurse should give the highest priority to which finding?
A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced
C.Tiny white papules on the nose or chin
3
, D.Red patches on the cheeks and trunk - ✓✓ Correct Ans - B. Skin color that is slightly
jaundiced
Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin,
which should be further evaluated in a newborn <24 hours old. Acrocyanosis (blue color of
the hands and feet) is a common finding in newborns; it occurs because the capillary
system is immature. Milia are small white papules present on the nose and chin that are
caused by sebaceous gland blockage and disappear in a few weeks. Small red patches on
the cheeks and trunk are called erythema toxicum neonatorum, a common finding in
newborns.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is
prescribed. Which instruction should the nurse provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected
breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the
infant. - ✓✓ Correct Ans - A.Breastfeed the infant, ensuring that both breasts are
completely emptied.
4
Maternity and Pediatric Nursing 5th Edition by SUSAN RICCI,
TERRI KYLE and SUSAN CARMAN
1
,MULTIPLE CHOICES
An expectant father tells the nurse he fears that his wife is "losing her mind." He states that
she is constantly rubbing her abdomen and talking to the baby and that she actually
reprimands the baby when it moves too much. Which recommendation should the nurse
make to this expectant father?
A. Suggest that his wife seek professional counseling to deal with her symptoms.
B. Explain that his wife is exhibiting ambivalence about the pregnancy.
C. Ask him to report similar abnormal behaviors at the next prenatal visit.
D. Reassure him that normal maternal-fetal bonding is occurring. - ✓✓ Correct Ans - D)
Reassure him that normal maternal-fetal bonding is occurring.
Rationale:
These behaviors are positive signs of maternal-fetal bonding and do not reflect
ambivalence. No intervention is needed. Quickening, the first perception of fetal
movement, occurs at 17 to 20 weeks of gestation and begins a new phase of prenatal
bonding during the second trimester. Options A and C are not necessary because the
behaviors displayed are normal.
The nurse is preparing a laboring client for an amniotomy. Immediately after the procedure
is completed, it is most important for the nurse to obtain which information?
2
,A. Maternal blood pressure
B. Maternal temperature
C. Fetal heart rate (FHR)
D. White blood cell count (WBC) - ✓✓ Correct Ans - C. Fetal heart rate (FHR)
Rationale:
The FHR should be assessed before and after the procedure to detect changes that may
indicate the presence of cord compression or prolapse. An amniotomy (artificial rupture of
membranes [AROM]) is used to stimulate labor when the condition of the cervix is
favorable. The fluid should be assessed for color, odor, and consistency. Option A should
be assessed every 15 to 20 minutes during labor but is not specific for AROM. Option B is
monitored hourly after the membranes are ruptured to detect the development of
amnionitis. Option D should be determined for all clients in labor.
A nurse receives a shift change report for a newborn who is 12 hours post-vaginal delivery.
In developing a plan of care, the nurse should give the highest priority to which finding?
A.Cyanosis of the hands and feet
B.Skin color that is slightly jaundiced
C.Tiny white papules on the nose or chin
3
, D.Red patches on the cheeks and trunk - ✓✓ Correct Ans - B. Skin color that is slightly
jaundiced
Rationale: Jaundice, a yellow skin coloration, is caused by elevated levels of bilirubin,
which should be further evaluated in a newborn <24 hours old. Acrocyanosis (blue color of
the hands and feet) is a common finding in newborns; it occurs because the capillary
system is immature. Milia are small white papules present on the nose and chin that are
caused by sebaceous gland blockage and disappear in a few weeks. Small red patches on
the cheeks and trunk are called erythema toxicum neonatorum, a common finding in
newborns.
A breastfeeding postpartum client is diagnosed with mastitis, and antibiotic therapy is
prescribed. Which instruction should the nurse provide to this client?
A.Breastfeed the infant, ensuring that both breasts are completely emptied.
B.Feed expressed breast milk to avoid the pain of the infant latching onto the infected
breast.
C.Breastfeed on the unaffected breast only until the mastitis subsides.
D.Dilute expressed breast milk with sterile water to reduce the antibiotic effect on the
infant. - ✓✓ Correct Ans - A.Breastfeed the infant, ensuring that both breasts are
completely emptied.
4
