Maternal and Child Nursing Reviewer 2023/24

Maternal and Child Nursing Reviewer 2023/24 1. 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? A. Endometritis B.2 Endometriosis C. Salpingitis D. Pelvic thrombophlebitis RATIONALE: Endometritis is an infection of the uterine lining and can occur after prolonged rupture of membranes. Symptoms include swelling of the abdomen, abnormal vaginal bleeding or discharge, fever, discomfort with bowel movement, and pain in the lower abdomen or pelvic region. 2. A client at 36 weeks gestation is scheduled for a routine ultrasound prior to amniocentesis. After teaching the client about the purpose of the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction? A. The ultrasound will help to locate the placenta. B. The ultrasound identifies blood flow through the umbilical cord. C. The test will determine where to insert the needle. D. The ultrasound locates a pool of amniotic fluid. RATIONALE: Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this. 3. 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? A. Calcium gluconate B. Protamine sulfate C. Methylergonovine (Methergine) D. Nitrofurantoin (Macrodantin) Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding complications caused by heparin overdose. 4. 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? A. Turn the neonate every 6 hours B. Encourage the mother to discontinue breastfeeding. C. Notify the physician if the skin becomes bronze in color. D. Check the vital signs every 2 to 4 hours. RATIONALE: While caring for an infant receiving phototherapy for treatment of jaundice, vital signs are checked every 2 to 4 hours because hyperthermia can occur due to the phototherapy lights. 5. 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? A. Back B. Abdomen C. Fundus D. Perineum RATIONALE: A bilateral pudendal block is used for vaginal deliveries to relieve pain primarily in the perineum and vagina. Pudendal block anesthesia is adequate for episiotomy and its repair. 6. The nurse is caring for a primigravida at about 2 months and 1-week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says: A. “Nausea and vomiting can be decreased if I eat a few crackers before rising.” B. “If I start to leak colostrum, I should cleanse my nipples with soap and water.” C. “If I have a vaginal discharge, I should wear nylon underwear.” D. “Leg cramps can be alleviated if I put an ice pack on the area.” RATIONALE: Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help. 7. Forty-eight hours after delivery, the nurse in charge plans discharge teaching for the client about infant care. By this time, the nurse expects that the phase of postpartum psychological adaptation that the client would be in would be termed which of the following? A. Taking in B. Letting go C. Taking hold D. Resolution RATIONALE: Beginning after completion of the taking-in phase, the taking-hold phase lasts about 10 days. During this phase, the client is concerned with her need to resume control of all facets of her life in a competent manner. At this time, she is ready to learn self-care and infant care skills. 8. A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following? A. Activity limited to bed rest. B. Platelet infusion. C. Immediate cesarean delivery. D. Labor induction with oxytocin. RATIONALE: Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client’s bleeding. 9. The nurse plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan? A. Feeding the neonate a maximum of 5 minutes per side on the first day. B. Wearing a supportive brassiere with nipple shields. C. Breastfeeding the neonate at frequent intervals. D. Decreasing fluid intake for the first 24 to 48 hours. RATIONALE: Prevention of breast engorgement is key. The best technique is to empty the breast regularly while feeding. Engorgement is less likely when the mother and neonate are together, as in single-room maternity care continuous rooming-in, because nursing can be done conveniently to meet the neonate’s and mother’s needs. 10. When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands open, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes? A. Startle reflex B. Babinski reflex C. Grasping reflex D. Tonic neck reflex RATIONALE: The Moro, or startle, reflex occurs when the neonate responds to stimuli by extending the arms, hands open, and then moving the arms in an embracing motion. The Moro reflex, present at birth, disappears at about age 3 months . . . . . . . . . .