Test Bank 3 For Maternal & Child Health Nursing
Care of the Childbearing & Childrearing Family
9th Edition By JoAnne Silbert-Flagg.
|GRADED A+| (EXAM READY)
(Solved) SCORE A
A mother who is HIV-positive delivers a full-term newborn and asks the nurse if her baby will become
HIV-infected. Which explanation should the nurse provide?
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A.Most infants of HIV-positive women will continue to test positive for HIV antibodies.
B.Infants who have HIV-positive mothers carry the virus and will eventually develop the disease.
C.Medication taken during pregnancy to reduce the mother's viral load ensures that the infant is HIV-
negative.
D.HIV infection is determined at 18 months of age, when maternal HIV antibodies are no longer
present. –
Correct Answer :D.HIV infection is determined at 18 months of age, when maternal HIV antibodies are
no longer present.
Rationale:
All newborns of HIV-positive mothers receive passive HIV antibodies from the mother, so the
evaluation of an infant for the HIV virus is determined at 18 months of age, when all the maternal
antibodies are no longer in the infant's blood. Passive HIV antibodies disappear in the infant within 18
months of age. Option B is inaccurate. Although administration of HIV medication during pregnancy
can significantly reduce the risk of vertical transmission, treatment does not ensure that the virus will
not become manifest in the infant.
A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting
motions and will not grasp the nipple. Which intervention should the nurse implement?
A.Encourage frequent use of a pacifier so that the infant becomes accustomed to sucking.
B.Hold the infant's head firmly against the breast until he latches onto the nipple.
C.Encourage the mother to stop feeding for a few minutes and comfort the infant.
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D.Provide formula for the infant until he becomes calm, and then offer the breast again. –
Correct Answer :C.Encourage the mother to stop feeding for a few minutes and comfort the infant.
Rationale:
The infant is becoming frustrated and so is the mother; both need a time out. The mother should be
encouraged to comfort the infant and to relax herself. After such a time out, breastfeeding is often
more successful. Options A and D would cause nipple confusion. Option B would only cause the infant
to be more resistant, resulting in the mother and infant becoming more frustrated.
A client who delivered a healthy infant 5 days ago calls the clinic nurse and reports that her lochia is
getting lighter in color. Which action should the nurse take?
A.Instruct the client to go to the emergency room.
B.Recommend vaginal douching.
C.Explain this is a normal finding.
D.Determine if ovulation has occurred. –
Correct Answer :C.Explain this is a normal finding.
Rationale:The client is describing lochia serosa, a normal change in the lochial flow. Options A, B, and D
are not recommended for this normal finding.
A client at 30 weeks of gestation is on bed rest at home because of increased blood pressure. The
home health nurse has taught her how to take her own blood pressure and gave her parameters to
judge a significant increase in blood pressure. When the client calls the clinic complaining of
indigestion, which instruction should the nurse provide?
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A.Lie on your left side and call 911 for emergency assistance.
B.Take an antacid and call back if the pain has not subsided.
C.Take your blood pressure now, and if it is seriously elevated, go to the hospital.
D.See your health care provider to obtain a prescription for a histamine blocking agent. –
Correct Answer :C.Take your blood pressure now, and if it is seriously elevated, go to the hospital.
Rationale: Checking the blood pressure for an elevation is the best instruction to give at this time. A
blood pressure exceeding 140/90 mm Hg is indicative of preeclampsia. Epigastric pain can be a sign of
an impending seizure (eclampsia), a life-threatening complication of gestational hypertension.
Additional data are needed to confirm an emergency situation as described in option A. Options B and
D ignore the threat to client safety posed by a significant increase in blood pressure.
The nurse is counseling a couple who has sought information about conceiving. The couple asks the
nurse to explain when ovulation usually occurs. Which statement by the nurse is correct?
A.Two weeks before menstruation
B.Immediately after menstruation
C.Immediately before menstruation
D.Three weeks before menstruation –
Correct Answer :A.Two weeks before menstruation
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