NACE Care Of Childbearing Family 2024/2025
Questions With 100% Correct Answers
After a client received an epidural anesthesia, a nurse should make which of these
assessments first?
· Determine whether the client has bladder distention
· Determine whether the client has sensory impairment in the legs
· Determine the frequency of the client's contractions
Determine the clients blood pressure - ANSWERThe nurse should determine the
client's blood pressure first. Since epidural anesthesia may cause the blood pressure
to drop, it is important to ensure there is adequate blood flow to the baby. The other
options may be subsequent assessments the nurse would make, but should not be
the first assessment.
The client who is 16 weeks pregnant attends the antepartal clinic. She makes all of
these comments to a nurse. Which of these comments by this client requires
FURTHER discussion by the nurse?
· I drink about 2.5 quarts of fluids every day
· I've gained about 7 pounds so far. I'll probably gain another 20 pounds by the time I
deliver
· I had a problem with hemorrhoids with my other pregnancy, so now I eat a large
serving of bran every evening
· I'm being careful to eat mostly salt-free and to use no salt in my cooking -
ANSWERThe fourth statement requires further discussion. Sodium requirements
increase during pregnancy. However, the sodium provided by the average diet is
likely to be adequate for expectant mothers. Use of additional salt is rarely
warranted.
A nurse teaches pregnancy exercises to a group of pregnant women. The nurse
should include an explanation that pelvic rock will be helpful at any time in their lives
should the women develop which of these conditions?
· Hemorrhoids
· Intestinal flatus
· Lower back pain
· Leg cramps - ANSWERPelvic rock helps to relieve lower back pains. Pelvic rocking
helps to relieve a sore back by stretching the lower back muscles. Pelvic rocking also
helps stimulate the digestive system, realigns the uterus, and keeps the stomach
muscles toned.
A client who is in active labor has a vaginal examination which reveals she is 5cm
dilated and 100% effaced at a -1 station. At the peak of a contraction, the amniotic
fluid ruptures. Which of these actions should a nurse take first?
· Records the findings and notify the provider
· Change the linen and make the client comfortable
· Check the perineal area and assess for crowning
, · Assess the fetal heart rate and check for regularity - ANSWERAfter rupture of the
membranes, there is a danger of cord prolapse; therefore, the nurse should assess
the fetal heart rate for regularity. Variable decelerations can occur as a result of cord
compression secondary to cord prolapse. There is also a risk for infection after
membrane rupture.
After teaching a class about relieving leg cramps during pregnancy, a nurse evaluates
the effectiveness of the instructions. Which of these comments, if made by the
participants, would require FURTHER instruction?
· When I get a leg cramps in the middle of the night, my husband presses on my knee
and pushes my foot toward my leg
· Sometimes when I'm sitting at my typewriter, I get a horrible leg cramp. First, I
stand and bear weight on my leg in the middle of the night
· I take a heating pad to bed with me so that I can use it if I get a leg cramp in the
middle of the night
· When I get a leg cramp while sitting at my desk, I flex my knee and extend my foot -
ANSWERThe fourth comment would require further education. With leg cramps, the
leg should be straightened and toes should be flexed toward the shin.
A client who is scheduled for a cesarean delivery has the following written
preoperative orders. Which should the nurse question?
· Nothing by mouth after midnight
· Atropine sulfate 0.4mg IM on call
· Indwelling urinary catheter to be inserted in the morning
· Cleansing enema this evening - ANSWERThe order for a cleansing enema in the
evening should be discussed with the physician. A cleansing enema is not usually
done prior to a cesarean section.
A client who is G1P0 is receiving IV oxytocin injection for labor augmentation.
Because of the effects of Pitocin, a nurse should assess the client for which of these
adverse effects of Pitocin?
· Bradypnea and diarrhea
· Insomnia and tachycardia
· Hypotension and diuresis
· Headache and water intoxication - ANSWERWith doses of 20mU/min on above,
oxytocin exerts an antidiuretic effect decreases free water exchange in the kidney,
and markedly decreases urine output. Blood pressure initially may decrease, but
after prolonged administration, the blood pressure increases above the baseline.
Oxytocin does not cause bradycardia, diarrhea, insomnia, or tachycardia.
With doses of 20mU/min on above, oxytocin exerts an antidiuretic effect decreases
free water exchange in the kidney, and markedly decreases urine output. Blood
pressure initially may decrease, but after prolonged administration, the blood
pressure increases above the baseline. Oxytocin does not cause bradycardia,
diarrhea, insomnia, or tachycardia. - ANSWERBreastfeeding accounts for up to 20-
40% of mother-to-child HIV transmissions. Thus, HIV infected women are
encouraged to formula feed their infants.
Questions With 100% Correct Answers
After a client received an epidural anesthesia, a nurse should make which of these
assessments first?
· Determine whether the client has bladder distention
· Determine whether the client has sensory impairment in the legs
· Determine the frequency of the client's contractions
Determine the clients blood pressure - ANSWERThe nurse should determine the
client's blood pressure first. Since epidural anesthesia may cause the blood pressure
to drop, it is important to ensure there is adequate blood flow to the baby. The other
options may be subsequent assessments the nurse would make, but should not be
the first assessment.
The client who is 16 weeks pregnant attends the antepartal clinic. She makes all of
these comments to a nurse. Which of these comments by this client requires
FURTHER discussion by the nurse?
· I drink about 2.5 quarts of fluids every day
· I've gained about 7 pounds so far. I'll probably gain another 20 pounds by the time I
deliver
· I had a problem with hemorrhoids with my other pregnancy, so now I eat a large
serving of bran every evening
· I'm being careful to eat mostly salt-free and to use no salt in my cooking -
ANSWERThe fourth statement requires further discussion. Sodium requirements
increase during pregnancy. However, the sodium provided by the average diet is
likely to be adequate for expectant mothers. Use of additional salt is rarely
warranted.
A nurse teaches pregnancy exercises to a group of pregnant women. The nurse
should include an explanation that pelvic rock will be helpful at any time in their lives
should the women develop which of these conditions?
· Hemorrhoids
· Intestinal flatus
· Lower back pain
· Leg cramps - ANSWERPelvic rock helps to relieve lower back pains. Pelvic rocking
helps to relieve a sore back by stretching the lower back muscles. Pelvic rocking also
helps stimulate the digestive system, realigns the uterus, and keeps the stomach
muscles toned.
A client who is in active labor has a vaginal examination which reveals she is 5cm
dilated and 100% effaced at a -1 station. At the peak of a contraction, the amniotic
fluid ruptures. Which of these actions should a nurse take first?
· Records the findings and notify the provider
· Change the linen and make the client comfortable
· Check the perineal area and assess for crowning
, · Assess the fetal heart rate and check for regularity - ANSWERAfter rupture of the
membranes, there is a danger of cord prolapse; therefore, the nurse should assess
the fetal heart rate for regularity. Variable decelerations can occur as a result of cord
compression secondary to cord prolapse. There is also a risk for infection after
membrane rupture.
After teaching a class about relieving leg cramps during pregnancy, a nurse evaluates
the effectiveness of the instructions. Which of these comments, if made by the
participants, would require FURTHER instruction?
· When I get a leg cramps in the middle of the night, my husband presses on my knee
and pushes my foot toward my leg
· Sometimes when I'm sitting at my typewriter, I get a horrible leg cramp. First, I
stand and bear weight on my leg in the middle of the night
· I take a heating pad to bed with me so that I can use it if I get a leg cramp in the
middle of the night
· When I get a leg cramp while sitting at my desk, I flex my knee and extend my foot -
ANSWERThe fourth comment would require further education. With leg cramps, the
leg should be straightened and toes should be flexed toward the shin.
A client who is scheduled for a cesarean delivery has the following written
preoperative orders. Which should the nurse question?
· Nothing by mouth after midnight
· Atropine sulfate 0.4mg IM on call
· Indwelling urinary catheter to be inserted in the morning
· Cleansing enema this evening - ANSWERThe order for a cleansing enema in the
evening should be discussed with the physician. A cleansing enema is not usually
done prior to a cesarean section.
A client who is G1P0 is receiving IV oxytocin injection for labor augmentation.
Because of the effects of Pitocin, a nurse should assess the client for which of these
adverse effects of Pitocin?
· Bradypnea and diarrhea
· Insomnia and tachycardia
· Hypotension and diuresis
· Headache and water intoxication - ANSWERWith doses of 20mU/min on above,
oxytocin exerts an antidiuretic effect decreases free water exchange in the kidney,
and markedly decreases urine output. Blood pressure initially may decrease, but
after prolonged administration, the blood pressure increases above the baseline.
Oxytocin does not cause bradycardia, diarrhea, insomnia, or tachycardia.
With doses of 20mU/min on above, oxytocin exerts an antidiuretic effect decreases
free water exchange in the kidney, and markedly decreases urine output. Blood
pressure initially may decrease, but after prolonged administration, the blood
pressure increases above the baseline. Oxytocin does not cause bradycardia,
diarrhea, insomnia, or tachycardia. - ANSWERBreastfeeding accounts for up to 20-
40% of mother-to-child HIV transmissions. Thus, HIV infected women are
encouraged to formula feed their infants.
