Maternal and Child Health Nursing Practice
Which behaviors would be exhibited during the letting-go phase of maternal role adaptation.
Select all that apply. - ANS Emergence of family unit
Sexual intimacy relationship continuing
Defining one's individual roles
While making a visit to the home of a postpartum woman 1 week after birth, the nurse should
recognize that the woman would characteristically: - ANS Vacillate between the desire to have
her own nurturing needs met and the need to take charge of her own care and that of her
newborn.
Which of the following is the most common kind of placental adherence seen in pregnant
women? - ANS Accreta
A 40-year-old woman with a high body mass index (BMI) is 10 weeks pregnant. Which
diagnostic tool is appropriate to suggest to her at this time? - ANS Transvaginal ultrasound
A nurse providing care for the antepartum woman should understand that the contraction stress
test (CST): - ANS Is considered to have a negative result if no late decelerations are observed
with the contractions.
In the past, factors to determine whether a woman was likely to have a high-risk pregnancy
were evaluated primarily from a medical point of view. A broader, more comprehensive
approach to high-risk pregnancy has been adopted. There are now four categories based on
threats to the health of the woman and the outcome of pregnancy. Which of the options listed
here is not included as a category? - ANS Geographic
A woman who is at 36 weeks of gestation is having a nonstress test. Which statement indicates
her correct understanding of the test? - ANS "This test observes for fetal activity and an
acceleration of the fetal heart rate to determine the well-being of the baby."
What is an appropriate indicator for performing a contraction stress test? - ANS Maternal
diabetes mellitus and postmaturity
The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has
smoked throughout the pregnancy, and fundal height measurements now are suggestive of
growth restriction in the fetus. In addition to ultrasound to measure fetal size, what would be
another tool useful in confirming the diagnosis? - ANS Doppler blood flow analysis
A nurse is providing instruction for an obstetrical patient to perform a daily fetal movement count
(DFMC). Which instructions could be included in the plan of care? Select all that apply. - ANS
-The patient can monitor fetal activity once daily for a 60-minute period and note activity.
-Monitor fetal activity two times a day either after meals or before bed for a period of 2 hours or
until 10 fetal movements are noted.
-Count all fetal movements in a 12-hour period daily until 10 fetal movements are noted.
A patient has undergone an amniocentesis for evaluation of fetal well-being. Which intervention
would be included in the nurse's plan of care after the procedure? Select all that apply. - ANS
Observe the patient for possible uterine contractions.
Administer RhoGAM to the patient if she is Rh negative.
With regard to small-for-gestational-age (SGA) infants and intrauterine growth restriction
(IUGR), nurses should be aware that: - ANS Infants with asymmetric IUGR have the potential
for normal growth and development.
, A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia
(PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now
complaining of nausea and bloating, and states that because she had nothing to eat, she is too
weak to breastfeed her infant. Which nursing diagnosis has the highest priority? - ANS
Impaired bowel motility related to pain medication and immobility
The nurse is teaching care of the newborn to a childbirth preparation class and describes the
need for administering antibiotic ointment into the eyes of the newborn. An expectant father
asks, "What type of disease causes infections in babies that can be prevented by using this
ointment?" Which response by the nurse is accurate? - ANS Gonorrhea
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? - ANS
Encourage the mother to stop feeding for a few minutes and comfort the infant.
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? - ANS Two weeks before menstruation
The nurse instructs a laboring client to use accelerated blow breathing. The client begins to
complain of tingling fingers and dizziness. Which action should the nurse take? - ANS Have the
client breathe into her cupped hands.
When assessing a client at 12 weeks of gestation, the nurse recommends that she and her
husband consider attending childbirth preparation classes. When is the best time for the couple
to attend these classes? - ANS At 30 weeks of gestation
One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96°
F, his lower lip is shaking and, when the nurse assesses for a Moro reflex, the boy's hands
shake. Which intervention should the nurse implement first? - ANS Obtain a serum glucose
level
Which statement made by the client indicates that the mother understands the limitations of
breastfeeding her newborn? - ANS "Breastfeeding my infant consistently every 3 to 4 hours
stops ovulation and my period.
A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For
which of the following would the nurse be alert? - ANS Endometritis
A client at 36 weeks gestation is schedule for a routine ultrasound prior to an amniocentesis.
After teaching the client about the purpose for the ultrasound, which of the following client
statements would indicate to the nurse in charge that the client needs further instruction? - ANS
The ultrasound identifies blood flow through the umbilical cord
While the postpartum client is receiving heparin for thrombophlebitis, which of the following
drugs would the nurse expect to administer if the client develops complications related to
heparin therapy? - ANS Protamine sulfate
When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse
in charge would expect to do which of the following? - ANS Check the vital signs every 2 to 4
hours
A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal
block anesthesia before delivery. After the nurse explains this type of anesthesia to the client,
which of the following locations identified by the client as the area of relief would indicate to the
nurse that the teaching was effective? - ANS Perineum
Which behaviors would be exhibited during the letting-go phase of maternal role adaptation.
Select all that apply. - ANS Emergence of family unit
Sexual intimacy relationship continuing
Defining one's individual roles
While making a visit to the home of a postpartum woman 1 week after birth, the nurse should
recognize that the woman would characteristically: - ANS Vacillate between the desire to have
her own nurturing needs met and the need to take charge of her own care and that of her
newborn.
Which of the following is the most common kind of placental adherence seen in pregnant
women? - ANS Accreta
A 40-year-old woman with a high body mass index (BMI) is 10 weeks pregnant. Which
diagnostic tool is appropriate to suggest to her at this time? - ANS Transvaginal ultrasound
A nurse providing care for the antepartum woman should understand that the contraction stress
test (CST): - ANS Is considered to have a negative result if no late decelerations are observed
with the contractions.
In the past, factors to determine whether a woman was likely to have a high-risk pregnancy
were evaluated primarily from a medical point of view. A broader, more comprehensive
approach to high-risk pregnancy has been adopted. There are now four categories based on
threats to the health of the woman and the outcome of pregnancy. Which of the options listed
here is not included as a category? - ANS Geographic
A woman who is at 36 weeks of gestation is having a nonstress test. Which statement indicates
her correct understanding of the test? - ANS "This test observes for fetal activity and an
acceleration of the fetal heart rate to determine the well-being of the baby."
What is an appropriate indicator for performing a contraction stress test? - ANS Maternal
diabetes mellitus and postmaturity
The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has
smoked throughout the pregnancy, and fundal height measurements now are suggestive of
growth restriction in the fetus. In addition to ultrasound to measure fetal size, what would be
another tool useful in confirming the diagnosis? - ANS Doppler blood flow analysis
A nurse is providing instruction for an obstetrical patient to perform a daily fetal movement count
(DFMC). Which instructions could be included in the plan of care? Select all that apply. - ANS
-The patient can monitor fetal activity once daily for a 60-minute period and note activity.
-Monitor fetal activity two times a day either after meals or before bed for a period of 2 hours or
until 10 fetal movements are noted.
-Count all fetal movements in a 12-hour period daily until 10 fetal movements are noted.
A patient has undergone an amniocentesis for evaluation of fetal well-being. Which intervention
would be included in the nurse's plan of care after the procedure? Select all that apply. - ANS
Observe the patient for possible uterine contractions.
Administer RhoGAM to the patient if she is Rh negative.
With regard to small-for-gestational-age (SGA) infants and intrauterine growth restriction
(IUGR), nurses should be aware that: - ANS Infants with asymmetric IUGR have the potential
for normal growth and development.
, A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia
(PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now
complaining of nausea and bloating, and states that because she had nothing to eat, she is too
weak to breastfeed her infant. Which nursing diagnosis has the highest priority? - ANS
Impaired bowel motility related to pain medication and immobility
The nurse is teaching care of the newborn to a childbirth preparation class and describes the
need for administering antibiotic ointment into the eyes of the newborn. An expectant father
asks, "What type of disease causes infections in babies that can be prevented by using this
ointment?" Which response by the nurse is accurate? - ANS Gonorrhea
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? - ANS
Encourage the mother to stop feeding for a few minutes and comfort the infant.
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? - ANS Two weeks before menstruation
The nurse instructs a laboring client to use accelerated blow breathing. The client begins to
complain of tingling fingers and dizziness. Which action should the nurse take? - ANS Have the
client breathe into her cupped hands.
When assessing a client at 12 weeks of gestation, the nurse recommends that she and her
husband consider attending childbirth preparation classes. When is the best time for the couple
to attend these classes? - ANS At 30 weeks of gestation
One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96°
F, his lower lip is shaking and, when the nurse assesses for a Moro reflex, the boy's hands
shake. Which intervention should the nurse implement first? - ANS Obtain a serum glucose
level
Which statement made by the client indicates that the mother understands the limitations of
breastfeeding her newborn? - ANS "Breastfeeding my infant consistently every 3 to 4 hours
stops ovulation and my period.
A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For
which of the following would the nurse be alert? - ANS Endometritis
A client at 36 weeks gestation is schedule for a routine ultrasound prior to an amniocentesis.
After teaching the client about the purpose for the ultrasound, which of the following client
statements would indicate to the nurse in charge that the client needs further instruction? - ANS
The ultrasound identifies blood flow through the umbilical cord
While the postpartum client is receiving heparin for thrombophlebitis, which of the following
drugs would the nurse expect to administer if the client develops complications related to
heparin therapy? - ANS Protamine sulfate
When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse
in charge would expect to do which of the following? - ANS Check the vital signs every 2 to 4
hours
A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal
block anesthesia before delivery. After the nurse explains this type of anesthesia to the client,
which of the following locations identified by the client as the area of relief would indicate to the
nurse that the teaching was effective? - ANS Perineum
