MATERNAL CHILD
NURSING
ASSESSMENT
QNS & ANS
2 VERSIONS
2023/2024
,1. Describe Epiglottis o Patho: Inflammation of the epiglottis (flap that covers the larynx). This is an
emergency because the epiglottis cannot open to allow in air. It occurs often from the age of 2 to 8
years old. It can be bacterial or viral (H. influenzae B is a common cause that has been reduced by
hib vaccine). o Assessment: It resembles a mild upper respiratory tract infection, but spreads to the
epiglottis in 1 to 2 days. The child then experiences a high fever, sore throat, inspiratory stridor,
hoarseness, tongue protrudes, and excessive saliva. ▪ Stimulating the gag reflex can cause a
complete obstruction, so never attempt to stimulate it, visualize it, or get a direct culture. o
Management: Oxygen is used for respiratory distress, IV fluids, antibiotics, and an endotracheal
airway may be required to manage
2. A nurse is caring for a client undergoing an oxytocin-stimulated contraction test. The nurse notes
three contractions in 10 min with late decelerations occurring with two of the contractions. Which of
the following findings should the nurse report to the provider Positive- Indicates an adverse
reaction by the fetus and should be reported to the provider
3. A nurse is caring for a client who is at 32 wks gestation and is experiencing preterm labor. What
meds should the nurse plan to administer? . betamethasone
4. Newborn is receiving phototherapy for an elevated bilirubin. What actions should nurse take? 1)
Monitor lamp's energy throughout the therapy to ensure newborn is receiving the appropriate
amount to be effective 2) Provide breast milk or infant formula to maintain hydration and promote
excretion of bilirubin in stool. (Glucose water or plain water can increase circulation to the liver and
impede bilirubin excretion.) 3) Apply eye patches so light does not damage newborn's eyes 4)
Avoid applying any topical substance because it can absorb heat and cause burns. 5) Cover perianal
region
5. Which factor significantly contributed to the shift from home births to hospital births in the early
20th century? Technologic developments became available to physicians
, 6. Nurse is performing a newborn assessment, which of the following should the nurse identify as a
sign of spina bifida occulta? Tuft of hair
7. A nurse is evaluating the degree of bonding between a mother and her infant who has been
hospitalized for a high bilirubin. To collect this data the nurse should observe the mother feeding the
infant
8. Does the placenta provide nutrition no it provides for gas exchange, baby gets oxygen
9. Mrs. Smith is a G1P0 at 38 weeks and 4 days. She calls the nurse triage line with complaints of a
headache and spotty vision. What should the triage nurse encourage Mrs. Smith to do? On
evaluation Mrs. Smith’ vitals are: BP: 148/92 P: 68 R: 16 T: 37.1 Pain: 4/10 for headache Reflexes:
3+ SVE: fingertip/thick/-3
a. Mrs. Smith states baby has been active, and her contractions have been every 5-8 minutes apart
lasting two minutes or so. Monitors are applied to Mrs. Smith. Fetal heartrate is 125 bpm with
accelerations and no decelerations. Irritability is noted with occasional contractions that palpate
mild for intensity. What are some other questions the triage nurse should ask Mrs. Smith? When
did the contractions start? Are you currently experiencing headaches, blurred vision, any
lightheadedness? Are you feeling the baby move/kick counts completed? Have you taken any
medication for the headaches and other symptoms? Do you have a history of HTN? Are you on
any medications to control your HTN? When was the last time you ate/drank anything? How
often are you eating/drinking and how much? How is your pain? Has your water broken?
b. Mrs. Smith states that her bag of water is still intact. Her headache started two days ago and is
not getting better with Tylenol, oral hydration, or rest. She states she only notices seeing stars or
flashes with her vision that are constant for the last few hours. She has not been dizzy. Mrs.
Smith denies epigastric pain, nausea or vomiting. She states her ankles and feet are a little more
swollen than normal, but she has not been getting daily weights. She states that she has been
drinking more water to see if her headaches are from dehydration, but she hasn’t noticed an
increase in urine output. The triage nurse calls the on-call obstetrician, Dr. White, and fills him
in on the patient. Dr. White would like the preeclampsia lab work up done. What labs are
consistent with the preeclampsia lab work up? Why are these labs consistent with the
preeclampsia lab work up? The doctor may order a CBC to check platelets and other blood
counts, a liver function tests, kidney function test to check the body’s clotting ability and a
urinalysis to check for protein. An ultrasound may be done to check the baby’s growth and a
fetal stress test may be done to monitor the baby’s heart rate during the mother’s contractions
NURSING
ASSESSMENT
QNS & ANS
2 VERSIONS
2023/2024
,1. Describe Epiglottis o Patho: Inflammation of the epiglottis (flap that covers the larynx). This is an
emergency because the epiglottis cannot open to allow in air. It occurs often from the age of 2 to 8
years old. It can be bacterial or viral (H. influenzae B is a common cause that has been reduced by
hib vaccine). o Assessment: It resembles a mild upper respiratory tract infection, but spreads to the
epiglottis in 1 to 2 days. The child then experiences a high fever, sore throat, inspiratory stridor,
hoarseness, tongue protrudes, and excessive saliva. ▪ Stimulating the gag reflex can cause a
complete obstruction, so never attempt to stimulate it, visualize it, or get a direct culture. o
Management: Oxygen is used for respiratory distress, IV fluids, antibiotics, and an endotracheal
airway may be required to manage
2. A nurse is caring for a client undergoing an oxytocin-stimulated contraction test. The nurse notes
three contractions in 10 min with late decelerations occurring with two of the contractions. Which of
the following findings should the nurse report to the provider Positive- Indicates an adverse
reaction by the fetus and should be reported to the provider
3. A nurse is caring for a client who is at 32 wks gestation and is experiencing preterm labor. What
meds should the nurse plan to administer? . betamethasone
4. Newborn is receiving phototherapy for an elevated bilirubin. What actions should nurse take? 1)
Monitor lamp's energy throughout the therapy to ensure newborn is receiving the appropriate
amount to be effective 2) Provide breast milk or infant formula to maintain hydration and promote
excretion of bilirubin in stool. (Glucose water or plain water can increase circulation to the liver and
impede bilirubin excretion.) 3) Apply eye patches so light does not damage newborn's eyes 4)
Avoid applying any topical substance because it can absorb heat and cause burns. 5) Cover perianal
region
5. Which factor significantly contributed to the shift from home births to hospital births in the early
20th century? Technologic developments became available to physicians
, 6. Nurse is performing a newborn assessment, which of the following should the nurse identify as a
sign of spina bifida occulta? Tuft of hair
7. A nurse is evaluating the degree of bonding between a mother and her infant who has been
hospitalized for a high bilirubin. To collect this data the nurse should observe the mother feeding the
infant
8. Does the placenta provide nutrition no it provides for gas exchange, baby gets oxygen
9. Mrs. Smith is a G1P0 at 38 weeks and 4 days. She calls the nurse triage line with complaints of a
headache and spotty vision. What should the triage nurse encourage Mrs. Smith to do? On
evaluation Mrs. Smith’ vitals are: BP: 148/92 P: 68 R: 16 T: 37.1 Pain: 4/10 for headache Reflexes:
3+ SVE: fingertip/thick/-3
a. Mrs. Smith states baby has been active, and her contractions have been every 5-8 minutes apart
lasting two minutes or so. Monitors are applied to Mrs. Smith. Fetal heartrate is 125 bpm with
accelerations and no decelerations. Irritability is noted with occasional contractions that palpate
mild for intensity. What are some other questions the triage nurse should ask Mrs. Smith? When
did the contractions start? Are you currently experiencing headaches, blurred vision, any
lightheadedness? Are you feeling the baby move/kick counts completed? Have you taken any
medication for the headaches and other symptoms? Do you have a history of HTN? Are you on
any medications to control your HTN? When was the last time you ate/drank anything? How
often are you eating/drinking and how much? How is your pain? Has your water broken?
b. Mrs. Smith states that her bag of water is still intact. Her headache started two days ago and is
not getting better with Tylenol, oral hydration, or rest. She states she only notices seeing stars or
flashes with her vision that are constant for the last few hours. She has not been dizzy. Mrs.
Smith denies epigastric pain, nausea or vomiting. She states her ankles and feet are a little more
swollen than normal, but she has not been getting daily weights. She states that she has been
drinking more water to see if her headaches are from dehydration, but she hasn’t noticed an
increase in urine output. The triage nurse calls the on-call obstetrician, Dr. White, and fills him
in on the patient. Dr. White would like the preeclampsia lab work up done. What labs are
consistent with the preeclampsia lab work up? Why are these labs consistent with the
preeclampsia lab work up? The doctor may order a CBC to check platelets and other blood
counts, a liver function tests, kidney function test to check the body’s clotting ability and a
urinalysis to check for protein. An ultrasound may be done to check the baby’s growth and a
fetal stress test may be done to monitor the baby’s heart rate during the mother’s contractions
