2024-NUR 403 REVISION MATERIAL FOR
PEDIATRICS NURSING AND MOTHER-CHILD CARE.
100% COMPLETE WITH ANSWERS.
1. The nurse admits a client in active labor to the birthing
center. She is 100% effaced, dilated 3 cm, and at +1 station. What
stage of labor has this client reached?
First
Latent
Second
Transitional: First
Rationale
The first stage of labor lasts from the onset of contractions until the
cervix is fully dilated at 10 cm. The client is in the early phase of the first
stage of labor. There is no latent stage of labor. The second stage of labor
lasts from complete dilation to birth. There is no transitional stage of
labor; transition is the last phase of the first stage of labor.
2. When assessing a neonate immediately after birth, the
nurse observes an inability to close the eyes completely. The
nurse also observes drooping of the corner of the neonate's
mouth, and the absence of wrinkling of the forehead and
nasolabial fold. What does the nurse infer from these findings?
The neonate has bleeding in the subgaleal layer from labor.
The neonate's cranial nerve V was pressurized during labor.
The neonate's cranial nerve VII was pressurized during labor.
32
,The neonate was exposed to vaginal gonorrheal infection during
labor.: The neonate's cranial nerve VII was pressurized during
labor
Rationale
Inability to close the eyes completely, drooping of the corner of
mouth, and absence of wrinkling of the forehead and nasolabial fold
indicate facial paralysis. When the facial nerve, or cranial nerve VII,
is pressurized during labor, it can result in facial paralysis. Bleeding in
the subgaleal layer indicates subgaleal hemorrhage in a neonate.
Subgaleal hemorrhage is not characterized by inability to close the
1/
eyes, drooping of the corner of mouth, or absence of wrinkling of
the forehead and nasolabial fold. Cranial nerve V does not innervate
the face, so damage to cranial V does not result in facial paralysis. A
neonate who is exposed to vaginal gonorrheal infections during
labor may develop ophthalmia neonatorum, not facial paralysis. 3.
The nurse is assessing a 12-hour-old newborn. Which clinical finding
should be reported to the health care provider in a timely manner?
Jaundice
Cephalhematoma
Erythema toxicum
Edematous genitalia: Jaundice
Rationale
Jaundice occurring in the first 24 hours of life is pathological; it is
associated with Rh or another blood incompatibility. Cephalhematoma is
2/ 43
,a collection of blood between the skull and periosteum that does not
cross the suture line; it resolves within 6 weeks, and although it should
be documented it does not require treatment.
Erythema toxicum is newborn dermatitis, believed to be an
inflammatory response. The rash is harmless, and although it should be
documented it does not require treatment. Edematous genitalia, a
response to maternal hormones, are common in newborns.
4. The nurse is caring for four clients on the postpartum unit.
Which client will most likely state that she is having difficulty
sleeping due to afterbirth pains?
Multipara who has vaginally delivered three children
Primipara whose newborn weighed 7 1b
Multipara with effectively controlled diabetes
Multipara whose second child was small for gestational age: Multipara
who has vaginally delivered three children
Rationale
A multipara's uterus tends to contract and relax spasmodically, even if
uterine tone is effective, resulting in pain that may require an analgesic
for relief. A primipara's uterus usually remains in the contracted state
unless the newborn is large for gestational age. However, she is less
likely to have afterbirth pains requiring an analgesic than a multipara is.
If a client's diabetes is controlled during pregnancy, she is not likely to
give birth to a large infant. Although a multipara might have afterbirth
pains even with a small newborn, the pain probably will be mild because
the uterus was not fully stretched.
5. The nurse is assessing a new mother at a healthcare facility.
Which symptom does the nurse identify as a risk factor for
postpartum blues?
3/ 43
, Frantic energy
Mild irritability
Hallucinations
Unwillingness to sleep: Mild irritability
Rationale
Postpartum blues are transient symptoms that a client may experience
after childbirth. About 85% of women experience postpartum blues with
symptoms of mild irritability, tearfulness, rapid mood fluctuations, and
anxiety. About 0.1 % to 0.2% of postpartum women experience
postpartum psychosis. Frantic energy, hallucinations, and unwillingness
to sleep are clinical manifestations of postpartum psychosis. 6. When the
fetal head begins to crown during an emergency precipitous birth, how
should the nurse respond? Pressing firmly on the fundus
Applying gentle perinea' pressure
Encouraging the client to push forcefully
Telling the client to take prolonged deep breaths: Applying gentle
perineal pressure
Rationale
Applying gentle perineal pressure prevents too-rapid expulsion of the
head, which can lead to perineal laceration in the mother. Pressing firmly
on the fundus is contraindicated; a precipitate birth is caused by forceful
uterine contractions that expel uterine contents. Pushing may cause too-
rapid expulsion and perineal laceration. At this time the urge to push is
uncontrollable; the client will be unable to take prolonged deep breaths.
4/ 43
PEDIATRICS NURSING AND MOTHER-CHILD CARE.
100% COMPLETE WITH ANSWERS.
1. The nurse admits a client in active labor to the birthing
center. She is 100% effaced, dilated 3 cm, and at +1 station. What
stage of labor has this client reached?
First
Latent
Second
Transitional: First
Rationale
The first stage of labor lasts from the onset of contractions until the
cervix is fully dilated at 10 cm. The client is in the early phase of the first
stage of labor. There is no latent stage of labor. The second stage of labor
lasts from complete dilation to birth. There is no transitional stage of
labor; transition is the last phase of the first stage of labor.
2. When assessing a neonate immediately after birth, the
nurse observes an inability to close the eyes completely. The
nurse also observes drooping of the corner of the neonate's
mouth, and the absence of wrinkling of the forehead and
nasolabial fold. What does the nurse infer from these findings?
The neonate has bleeding in the subgaleal layer from labor.
The neonate's cranial nerve V was pressurized during labor.
The neonate's cranial nerve VII was pressurized during labor.
32
,The neonate was exposed to vaginal gonorrheal infection during
labor.: The neonate's cranial nerve VII was pressurized during
labor
Rationale
Inability to close the eyes completely, drooping of the corner of
mouth, and absence of wrinkling of the forehead and nasolabial fold
indicate facial paralysis. When the facial nerve, or cranial nerve VII,
is pressurized during labor, it can result in facial paralysis. Bleeding in
the subgaleal layer indicates subgaleal hemorrhage in a neonate.
Subgaleal hemorrhage is not characterized by inability to close the
1/
eyes, drooping of the corner of mouth, or absence of wrinkling of
the forehead and nasolabial fold. Cranial nerve V does not innervate
the face, so damage to cranial V does not result in facial paralysis. A
neonate who is exposed to vaginal gonorrheal infections during
labor may develop ophthalmia neonatorum, not facial paralysis. 3.
The nurse is assessing a 12-hour-old newborn. Which clinical finding
should be reported to the health care provider in a timely manner?
Jaundice
Cephalhematoma
Erythema toxicum
Edematous genitalia: Jaundice
Rationale
Jaundice occurring in the first 24 hours of life is pathological; it is
associated with Rh or another blood incompatibility. Cephalhematoma is
2/ 43
,a collection of blood between the skull and periosteum that does not
cross the suture line; it resolves within 6 weeks, and although it should
be documented it does not require treatment.
Erythema toxicum is newborn dermatitis, believed to be an
inflammatory response. The rash is harmless, and although it should be
documented it does not require treatment. Edematous genitalia, a
response to maternal hormones, are common in newborns.
4. The nurse is caring for four clients on the postpartum unit.
Which client will most likely state that she is having difficulty
sleeping due to afterbirth pains?
Multipara who has vaginally delivered three children
Primipara whose newborn weighed 7 1b
Multipara with effectively controlled diabetes
Multipara whose second child was small for gestational age: Multipara
who has vaginally delivered three children
Rationale
A multipara's uterus tends to contract and relax spasmodically, even if
uterine tone is effective, resulting in pain that may require an analgesic
for relief. A primipara's uterus usually remains in the contracted state
unless the newborn is large for gestational age. However, she is less
likely to have afterbirth pains requiring an analgesic than a multipara is.
If a client's diabetes is controlled during pregnancy, she is not likely to
give birth to a large infant. Although a multipara might have afterbirth
pains even with a small newborn, the pain probably will be mild because
the uterus was not fully stretched.
5. The nurse is assessing a new mother at a healthcare facility.
Which symptom does the nurse identify as a risk factor for
postpartum blues?
3/ 43
, Frantic energy
Mild irritability
Hallucinations
Unwillingness to sleep: Mild irritability
Rationale
Postpartum blues are transient symptoms that a client may experience
after childbirth. About 85% of women experience postpartum blues with
symptoms of mild irritability, tearfulness, rapid mood fluctuations, and
anxiety. About 0.1 % to 0.2% of postpartum women experience
postpartum psychosis. Frantic energy, hallucinations, and unwillingness
to sleep are clinical manifestations of postpartum psychosis. 6. When the
fetal head begins to crown during an emergency precipitous birth, how
should the nurse respond? Pressing firmly on the fundus
Applying gentle perinea' pressure
Encouraging the client to push forcefully
Telling the client to take prolonged deep breaths: Applying gentle
perineal pressure
Rationale
Applying gentle perineal pressure prevents too-rapid expulsion of the
head, which can lead to perineal laceration in the mother. Pressing firmly
on the fundus is contraindicated; a precipitate birth is caused by forceful
uterine contractions that expel uterine contents. Pushing may cause too-
rapid expulsion and perineal laceration. At this time the urge to push is
uncontrollable; the client will be unable to take prolonged deep breaths.
4/ 43
