1.
While breastfeeding, a new mother strokes the top of her baby's head and asks the nurse about the baby's
swollen scalp. The nurse responds that the swelling is caput succedaneum. Which additional information should
the nurse provide this new mother?
A) The infant should be positioned to reduce the swelling.
Feedback: INCORRECT
B) The swelling is a subperiosteal collection of blood.
Feedback: INCORRECT
C) The pediatrician will aspirate the blood if it gets larger.
Feedback: INCORRECT
D) The scalp edema will subside in a few days after birth.
Feedback: CORRECT
Feedback: Caput succedaneum is edema of the fetal scalp that crosses over the suture lines and is caused by
pressure on the fetal head against the cervix during labor; it subside in a few days after birth without treatment.
Cephalohematoma, a subperiosteal collection of blood that does not cross the suture lines and is a common
benign birth injury.
2.
A client at 30-weeks gestation, complaining of pressure over the pubic area, is admitted for observation. She is
contracting irregularly and demonstrates underlying uterine irritability. Vaginal examination reveals that her
cervix is closed, thick, and high. Based on these data, which intervention should the nurse implement first?
A) Provide oral hydration.
Feedback: INCORRECT
B) Have a complete blood count (CBC) drawn.
Feedback: INCORRECT
C) Obtain a specimen for urine analysis.
Feedback: CORRECT
D) Place the client on strict bedrest.
Feedback: INCORRECT
,Feedback: Obtaining a urine analysis (C) should be done first because preterm clients with uterine irritability
and contractions are often suffering from a urinary tract infection, and this should be ruled out first.
3.
A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the
most likely presenting symptom for a pediatric client with AIDS is:
A) Shortness of breath.
Feedback: INCORRECT
B) Joint pain.
Feedback: INCORRECT
C) A persistent cold.
Feedback: CORRECT
D) organomegaly.
Feedback: INCORRECT
Feedback: Respiratory tract infections commonly occur in the pediatric population. However, the child with
AIDS has a decreased ability to defend the body against these infections and often the presenting symptom of a
child with AIDS is a persistent cold (C).
4.
A client who has an autosomal dominant inherited disorder is exploring family planning options and the risk of
transmission of the disorder to an infant. The nurse's response should be based on what information?
A) Males inherit the disorder with a greater frequency than females.
Feedback: INCORRECT
B) Each pregnancy carries a 50% chance of inheriting the disorder.
Feedback: CORRECT
C) The disorder occurs in 25% of pregnancies.
Feedback: INCORRECT
D) All children will be carriers of the disorder.
Feedback: INCORRECT
,Feedback: According to the laws of inheritance, an autosomal dominant disorder has a 50% chance of being
transmitted with each pregnancy (B), and if transmitted, the disorder will appear in the child.
5.
Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first
time?
A) She eagerly reaches for the infant, undresses the infant, and examines the infant completely.
Feedback: INCORRECT
B) Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.
Feedback: CORRECT
C) Her arms and hands receive the infant and she then cuddles the infant to her own body.
Feedback: INCORRECT
D) She eagerly reaches for the infant and then holds the infant close to her own body.
Feedback: INCORRECT
Feedback: Attachment/bonding theory indicates that most mothers will demonstrate behaviors described in (B)
during the first visit with the newborn, which may be at delivery or later. After the first visit, the mother may
exhibit greater affection such as eagerly reaching, hugging, etc. (A, C, and D).
6.
A pregnant client tells the nurse that the first day of her last menstrual period was August 2, 2006. Based on
Nägele’s rule, what is the estimated date of delivery?
A) April 25, 2007.
Feedback: INCORRECT
B) May 9, 2007.
Feedback: CORRECT
C) May 29, 2007.
Feedback: INCORRECT
D) June 2, 2007.
Feedback: INCORRECT
, Feedback: INCORRECT
Since this woman's first day of her last normal menstrual period occurred on August 2, 2006, the estimated date
of delivery is May 9, 2007 (B). Nägele’s rule is used to calculate the expected date of delivery, and is obtained
by subtracting 3 months and adding 7 days beginning from the first day of the last normal menstrual period.
7.
A woman who gave birth 48 hours ago is bottle-feeding her infant. During assessment, the nurse determines that
both breasts are swollen, warm, and tender upon palpation. What action should the nurse take?
A) Apply cold compresses to both breasts for comfort.
Feedback: CORRECT
B) Instruct the client run warm water on her breasts.
Feedback: INCORRECT
C) Wear a loose-fitting bra to prevent nipple irritation.
Feedback: INCORRECT
D) Express small amounts of milk to relieve pressure.
Feedback: INCORRECT
Feedback:
The client is experiencing engorgement even though she is bottle-feeding her infant, and cold compresses (A)
may help reduce discomfort. Lactation begins about the third day after delivery, so the mother should avoid any
breast stimulation, such as (B or D), which further stimulates milk production.
8.
A woman who had a miscarriage 6 months ago becomes pregnant. Which instruction is most important for the
nurse to provide this client?
A) Elevate lower legs while resting.
Feedback: INCORRECT
B) Increase caloric intake by 200 to 300 calories per day.
Feedback: INCORRECT
C) Increase water intake to 8 full glasses per day.
Feedback: INCORRECT