NUR 2513 Maternal Child Nursing Exam 2 (Questions With 100% Correct & Verified Answers)

Maternal Exam 2 1. In providing care to the postpartum client, the nurse recognizes that women are hypercoagulable during the third trimester of pregnancy and that assessment of this client should include evaluation for the development of venous thromboembolism. Which of the following should be included in this evaluation? (SATA) A. Observe the distal upper extremities for swelling/edema B. Observe the lower extremities for symmetry C. Assessment of uterine cramping D. Observation of respiratory rate and effort E. Auscultation of lung sounds 2. A newborn is prescribed to receive vitamin K 0.5 mg intramuscularly. How should the nurse administer this medication to the newborn? A. Provide the medication immediately before breastfeeding. B. Administer the medication into the vastus lateralis. C. Notify the physician for swelling and irritation at the injection site. D. Administer the medication in the deltoid muscle. 3. Which technique is used to palpate the fundal height on a postpartum client? A. Placing one hand on the fundus, one on the perineum B. Resting both hands on the fundus C. Palpating the fundus with only fingertip pressure D. Placing one hand at the base of the uterus, one on the fundus. 4. A nurse is caring for a 4-year-old female. Which of the following is expected of a preschool-aged child? A. Describing manifestations of illnessB. Understanding cause of illness C. Relating fears to magical thinking D. Awareness of body function 5. A new mother asks the nurse how soon she can try to breastfeed after delivery. Which of the following would be the nurse’s best response? A. “Once the infant has a first feeding of formula.” B. “Immediately after birth.” C. “In 24 hours after her infant is given water.” D. “After the infant is allowed to rest.” 6. Which assessment finding indicates to the nurse that a newborn has hip subluxation? A. Crying on straightening of the right leg B. Inward rotation of the right foot C. Inability of the right hip to abduct D. Drawing of the legs underneath while prone 7. A nurse is helping her postpartum client up to the bathroom for the first time after delivery. Which finding indicates her lochia is within normal limits? A. The color of the flow is red. B. Lochia contains large clots. C. The flow is over 500 mL. D. Her uterus is boggy and soft. 8. A nurse is caring for an infant with myelomeningocele. Which of the following actions should the nurse include in the preoperative plan of care? A. Place the infant in a supine position.B. Assess the infant’s temperature rectally. C. Apply a sterile, moist dressing on the sac. D. Assist the caregiver with cuddling the infant. 9. The nurse is inspecting a male newborn’s genitalia. Which action should the nurse avoid when conducting this assessment? A. Palpating if testes are descended into the scrotal sac. B. Retracting the foreskin over the glans to assess for secretions. C. Inspecting if the urethral opening appears circular. D. Inspecting the genital area for irritated skin. 10. During a home visit, the nurse determines that a toddler has a difficult temperament. What did the nurse observe in this toddler? (SATA) A. Rhythmic B. Minimal adaptability C. Withdrawing D. Intense mood 11. The nurse instructs the parents of a newborn on actions to prevent sudden infant death syndrome (SIDS). Which observation indicates that teaching has been effective? A. The baby is on an every-2-hour formula feeding schedule. B. Newborn is placed on the back to sleep. C. Parents signed a waiver refusing routing immunizations after birth. D. Mother removes a pacifier from the baby’s mouth. 12. A neonatal nurse is assessing a 2-hour-old male newborn. She notes that the urethra meatus is not midline, but is displaced on the dorsal surface (top side) of the penis. What is the medical term for this?A. Undescended testicle B. Varicocele C. Hypospadias D. Epispadias 13. The newborn’s birthweight is 8lb 8oz. What is the weight in kg? 3.9 14. The nurse is assessing a client at her 8-week postpartum appointment. The client states that she feels tired all the time, has trouble falling and staying asleep, feels very overwhelmed and forgetful, and “just doesn’t feel connected” to her baby. She denies thoughts of harming herself or her baby. These symptoms may indicate which of the following to the nurse? A. Baby blues B. Normal postpartum feelings C. Postpartum psychosis D. Postpartum depression 15. When collecting data from an infant, which of the following techniques should the nurse use to elicit the stepping reflex? A. Place an object in the infant’s palm. B. Strike a flat surface on which the infant is lying. C. Hold the infant upright with his feet touching a flat surface. D. Stroke the outer edge of the sole of the infant’s foot up toward the toes. 16. Hypoglycemia in a mature infant is defined as blood glucose level below which arnount? A. 100 mg/100 mL whole blood B. 80 mg/100 mL whole blood C. 30 mg/100 mL whole bloodD. 40 mg/100 mL whole blood 17. The nurse is assessing a newborn. Which would be considered a normal finding? A. Asymmetry B. Acrocyanosis C. Apnea D. Atonia 18. The nurse is assessing a term newborn. Which finding should the nurse expect when assessing the patterns of sole creases? A. Creases covering one-fourth of the foot. B. Creases on two-thirds of the foot. C. Longitudinal but no horizontal creases. D. Heel creases but no anterior creases. 19. A postpartum woman is prescribed an antibiotic because of endometritis. Her breastfed infant should be observed particularly for which of the following? A. Irritability and loss of appetite. B. Signs of thrush and easy bruising. C. Decreased sleep levels and increased appetite. D. Jaundice that does not respond to phototherapy. 20. The nurse assesses a postpartum client’s discharge as being moderate in amount and red in color. How should the nurse document the appearance of the lochia? A. Lochia rubra B. Lochia normalia C. Lochia serosaD. Lochia alba 21. The nurse is assisting a new mother to begin breastfeeding her newborn son. Which action is the most appropriate for the nurse to take? A. Cautioning her not to allow the infant to grasp the areola of her breast to prevent soreness. B. Positioning the infant near her breast and stroking his cheek to encourage him to suck. C. Stressing that breastfeeding is a normal process and minimal help is needed to learn it. D. Encouraging her to lie on her side and help the baby become wide-awake by talking to him. 22. The nurse had instructed a mother on the importance of providing a toddler with a balanced diet. Which observation during a home visit indicates that instruction has been effective? A. The child takes candy from a dish that is placed on the coffee table in the living room. B. The mother prepares a scrambled egg for the toddler's breakfast. C. The mother places a serving of fried finger foods on a plate for the child. D. The child is eating a piece of cake and ice cream for lunch. 23. Why are postpartum women prone to urinary retention? A. Decreased bladder sensation results from edema because of pressure of birth. B. Catheterization at the time of delivery reduces bladder tonicity. C. Frequent partial voiding never relieves the bladder pressure. D. Mild dehydration causes a concentrated urine volume in the bladder. 24. A woman who delivered a term neonate 3 days ago is complaining of fever, fatigue, and heavy vaginal discharge. On assessment, the nurse notes that her fundus is tender on palpation and heavy, with foul smelling lochia. What is the most likely cause of these symptoms?A. Urinary tract infection B. Postpartum hemorrhage C. Mastitis D. Endometritis 25. After delivery, a client is diagnosed with postpartum preeclampsia. What care will the nurse provide to this client? (SATA) A. Maintain on bed rest B. Monitor urine output and daily weight C. Administer antihypertensive medication as prescribed D. Instruct on the need for a fluid bolus E. Administer magnesium sulfate as prescribed 26. A postpartum woman has a fourth-degree perineal laceration. Which of the following physician orders would the nurse question? A. An order for PRN Docusate Sodium B. Administration of a sitz bath C. Administration of acetaminophen/oxycodone for pain D. Administration of an enema 27. The nurse is preparing formula for a preterm infant. Which type of formula will most likely be prescribed for this client? A. 24 calories per ounce B. 20 calories per ounce C. Glucose water D. Iron supplemented28. The physician ordered promethazine 25 mg at bedtime for the client. PRomethazine is supplied as 6.25mg/5mL. How many mL will the nurse administer? 20 29. The nurse in the pediatric clinic is recording anthropometric data in the 12-month-old child’s chart. The father asks,”Is my son growing the way that he should?” Which of the following nurse’s responses is based on the knowledge of expected growth of a 12-month-old? A. The child’s weight at 12 months should be equal to birth weight x 2 (double). B. The child’s weight will be equal to birth weight x 3 at 12 months (triple). C. Increases in height/length are most rapid from 9-12 months. D. The child’s height should increase by 2 inches per month. 30. Which of the following actions should the nurse take to prepare the preschool-aged child for a physical examination? A. Separate the child from the caregiver during the exam. B. Allow the child to role play. C. Use medical terminology to describe what will happen. D. Keep medical equipment visible to the child. 31. A newborn who was delivered 2 hours ago is being assessed in the nursery. Upon exam, the nurse notes a flattened nasal bridge, wide-set eyes, low set ears, and overall decrease in tone. Given these exam findings, what diagnostic tests would the nurse anticipate that the physician will order? A. Hemoglobin electrophoresis B. Computed tomography (CT) of the brain C. Meconium toxicology testing D. Chromosomal blood testing32. During a home visit, a new mother is concerned that, after three meconium stools, her newborn now has yellow seedy stools. What should the nurse explain to the mother? A. The baby may be developing an allergy to breast milk. B. This is a normal finding. C. The child will need to be isolated until the stool can be cultured. D. This is most likely a symptom of diarrhea. 33. The nurse observes a mother telling a toddler that pasta and potatoes will make the child fat. What should the nurse instruct the mother about these food items? A. The child should be instructed to restrict carbohydrates after the age of 5 years. B. No more than 30% of all food should be from carbohydrate sources. C. It is more important to restrict protein than carbohydrates. D. Toddlers need carbohydrates for brain function. 34. A preterm infant is placed in a radiant heat warmer immediately after birth. Which of the following nursing diagnosis is this intervention addressing? A. Ineffective thermoregulation related to immaturity. B. Impaired gas exchange related to immature pulmonary functioning. C. Risk for deficient fluid volume related to insensible water loss. D. Risk for imbalanced nutrition, less than body requirements. 35. The nurse is called to the room of a client who had a term delivery of a 9 lb. 8 oz. newborn 24 hours ago. The client is noted to have lost consciousness on her way to the bathroom. What is the priority nursing assessment for the client? A. Call the provider B. Assess the fundus C. Assess blood pressure and heart rate.D. Assess ability to void 36. A newborn infant has loose, yellow stools. The infant appears healthy, but his mother is concerned that this means he is allergic to breast milk. Which of the following is the nurse’s best response? A. “Breast-feed infants’ stools are normally loose.” B. “Consider changing to a soybean formula.” C. “Try burping the infant more frequently.” D. “You may need to have the infant investigated for bile duct disease.” 37. A nurse is caring for a 9-month-old influenza. Which of the following might be a toy that could be used to interact, play, or distract them from the discomfort? A. Teddy bear with button eyes B. Legos C. Cloth doll D. Large plastic stacking blocks 38. A newborn with esophageal atresia has just returned from surgery to place a gastrostomy tube. Which nursing diagnosis will the nurse use to plan the care for this client? A. Risk for imbalanced nutrition B. Risk for deficient fluid volume C. Risk for ineffective gas exchange D. Risk for impaired thermoregulation 39. The nurse is caring for a postpartum woman 18 hours after primary cesarean section for preeclampsia. The client is noted to have a boggy uterus and a moderate to large amount of vaginal bleeding. The nurse notifies the physician of these findings and expects an order for which of the following medications?A. Terbutaline B. Hydrocodone/acetaminophen C. Magnesium sulfate D. Carboprost 40. A nurse is caring for a client who has just delivered her first newborn. The infant has been diagnosed with hyperbilirubinemia. While providing education to the client on this condition, the nurse should include which of the following as potential causes of this condition? (SATA) A. ABO incompatibility B. Rh isoimmunization C. Allergy to breast milk D. Biliary atresia E. Prenatal alcohol consumption 41. According to Erickson, which stage of development has the developmental task “Trust vs. Mistrust”? A. Early childhood B. Infancy C. Adolescence D. Toddler 42. A father is concerned that his 3-day old infant’s face appears yellow. Which response should the nurse provide to the father? A. “This is a very serious condition. Your infant will be transferred to the neonatal intensive care unit (NICU) immediately.”B. “This is a mild jaundice due to the immaturity of the baby’s liver. We will continue to monitor bilirubin levels.” C. “It would be best to switch from breastfeeding to formula feeding to help the baby excrete the bilirubin.” D. “This buildup of bilirubin in the baby occurred because your wife and baby are both negative blood types.” 43. The parents of a newborn are concerned that something is wrong with their newborn’s eyesight. What should the nurse instruct the parents as being an expected finding in the newborn? A. Follows a light to the midline B. Follows the finger a full 180 degrees C. Produces tears when he cries D. Has a white rather than a red reflex 44. The nurse is preparing a seminar on breastfeeding for a group of pregnant clients. Which information should the nurse include during this seminar? A. Uterine involution is slowed by breastfeeding. B. Breastfeeding might increase the risk of breast cancer. C. Breast-feeding enhances bonding with the infant. D. Breastfeeding mothers have a decreased risk of developing thrombophlebitis. 45. When assessing a newborn, the Apgar score assesses the ability of the newborn to transition to extrauterine life. Which of the following does the Apgar score assess? (SATA) A. Gender B. Respirations C. Birth timeD. Heart rate E. Color 46. At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernails extending beyond the fingertips, and poor turgor. Based on these findings, how would the nurse classify this neonate? A. Small for gestational age (SGA) B. Preterm C. Large for gestational age (SGA) D. Post term 47. A parent is describing to the nurse activities that her 4-year-old preschool child is achieving. The nurse knows that this child is experiencing which task of Erickson’s psychosocial stage of development? A. Industry vs. Inferioruty B. Trust vs. Mistrust C. Autonomy vs. Shame/Doubt D. Initiative vs. Guilt 48. A medication order states, administer ketorolac 7.5 mg IV now. Available is ketorolac 15 mg/mL. How many mL should the nurse administer? 0.5 49. A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. Which of the following is an appropriate intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy. A. Apply an oil-based lotion to the newborn’s skin to prevent drying and cracking. B. Change the newborn’s position every 4 hours.C. Limit the newborn’s intake of milk to prevent nausea, vomiting, and diarrhea. D. Placed eye shields over the newborn’s closed eyes. 50. The nurse is called to the room of a client who delivered a macrosomic infant 20 hours ago. Upon assessment the fundus is noted to be boggy and displaced to the left, and a moderate amount of vaginal bleeding is noted. What is the priority nursing actions? A. Empty the bladder B. Initiate IV access C. Provide pain medication D. Administer uterotonic medication 51. Which of the following is an advantage of breastfeeding for the infant? A. Breast milk contains antibodies and thus decreases the possibility of gastrointestinal illnesses. B. Breast milk is more diffiult to digest, so it makes the infant feel fuller longer. C. Breast milk leads to firmer stools, increasing bowel tone. D. It takes less effort for an infant to suck at a breast than a bottle. 52. During a home visit, a postpartum client is complaining of a sore throat area on one breast. The nurse notes a local area on the left breast to be lumpy, red, and warm to the touch and palpates a small lump. For which health problem should the nurse plan care for this client? A. Engorgement B. Plugged milk duct C. Breast cancer D. Mastitis53. According to Piaget, which basic concept will the child learn due the first year of life? A. His parents are not perfect. B. He is not an extension of their parents. C. He cannot be fooled by changing shapes. D. Most procedures can be reversed. 54. A nurse at a well-baby clinic is collecting data about a nine-month-old infant. The nurse understands which of the following occurs at this stage of development? A. Scribble with crayons B. Fears strangers C. Use of one to three-word sentences D. Walking with one handheld 55. A postpartum woman (gravida 1, para 1) asks the nurse immediately after delivery if she should request rooming-in with her infant. Which of the following response by the nurse would be correct? A. “Rooming-in allows increased maternal-newborn contact.” B. “This puts too much responsibility on a first-time mother.” C. “Resting for the first 3 days postpartum will be better for you.” D. “It depends on whether you will breastfeed or not.” 56. The nurse provides discharge instructions to a postpartum client. Which client statement indicates that teaching has been effective? A. “I can begin having intercourse when I get home.” B. “I should notify the physician if my discharge decreases in amount.” C. “I should limit climbing stairs to four times a day.”D. “I can return to my full-time job after 6 weeks.” 57. A nurse is assessing a newborn infant for congenital hip dysplasia.Which signs or symptoms should be brought to the attention of the health care provider for further evaluation? (SATA) A. An infant who has one leg that appears longer than the other. B. An infant who has a click in the hip joint when one hip is maneuvered. C. An infant who has extra skin folds on the inner thigh of one leg. D. An infant who is actively moving all extremities. E. An infant whose bilateral leg length is symmetric. 58. When caring for a newborn several hours after birth, what would the nurse assess as a normal newborn’s respiratory rate? A. 20 to 30 breaths/min B. 16 to 20 breaths/min C. 12 to 16 breaths/min D. 30 to 60 breaths/min 59. An infant develops hydrocephalus at 2 weeks of age. Which finding would the nurse expect to assess? A. Hypothermia in the late afternoon B. Excessive thirst C. A soft, fretful cry D. Bulging fontanels 60. The nurse is evaluating a new mother’s ability to effectively breastfeed her infant. Which criteria indicates that the mother should be able to breastfeed independently? (SATA) A. Nurse places pillows under the baby for support.B. Infant swallows spontaneously and frequently. C. Breasts are soft and non-tender. D. Nipples are everted. E. The mothers hold the infant close to her breast in a football hold. 61. While inspecting a newborn’s head, the nurse identifies a swelling of the scalp on the right posterior side of the head that does not cross the suture line. What term describes this finding? A. Enlarged fontanelle B. Molding C. Cephalohematoma D. Caput succedaneum 62. A nurse is assessing a newborn that was admitted to the newborn nursery 28 hours ago. Mother’s history includes addition to recreational drugs. Which finding would the nurse expect to note during the assessment of this newborn? A. Sleepiness B. Flaccid extremities C. Quiets with swaddling D. Incessant crying 63. When planning care for a postpartum client, the nurse is aware that which site is the most common for postpartum infection? A. Milk ducts B. Bloodstream C. Urinary bladder D. Reproductive tract64. The nurse on the postpartum unit is reviewing uterotonic (oxytocic medications with a group of nursing students. Which of the following would be included in this discussion? A. Terbutaline B. Magnesium sulfate C. Misoprostil D. Phytonadione 65. The nurse is assessing the breast of a woman who is 1 month postpartum . The woman reports a painful, inflamed area on one breast. Upon assessment, the nurse notes a wedged-shaped area on one breast to be red and warm to touch. Client’s temperature is 101.8 F. What should the nurse consider as the potential diagnosis? A. Engorgement B. Breast yeast infection C. Plugged milk duct D. Mastitis 66. Which action by the mother relates to the nurse that she is accepting her child? A. Her husband spends time holding the baby. B. She turns her face to meet the infant’s eyes when she holds her. C. She has many visitors in the room. D. She fills out the birth certificate while in the hospital. 67. In caring for the postpartum client, the nurse will include assessment and observation for signs of postpartum hemorrhage. Which of the following would increase the risk for postpartum hemorrhage? (SATA) A. History of iron deficiency anemia B. Maternal blood type AC. Dysfunctional or prolonged labor D. Multiparity E. Macrosomic infant 68. While assessing the newborn’s 5-minute Apgar score, the nurse notes the infant’s hands and feet are blue, heart rate is 154 beats per minute, crying vigorously, withdraws foot in response to slapping the sole, and actively moving arms and legs. What score would the nurse assign to this infant? A. 7 B. 6 C. 9 D. 10 69. The nurse is concerned that a new mother is not showing interest in the newborn and does not participate in newborn care. What action should the nurse take to help the mother and newborn at this time? A. Consult a case manager to complete a postpartum assessment. B. Contact a family member to care for the infant upon discharge. C. Notify Social Services department due to neglect to remove the newborn from the home. D. Ask the client if it would be better for the baby to put up for adoption. 70. By the time children reach their tenth birthday, they should have learned to trust others and should have developed a sense of what? A. Intimacy B. Industry C. Integrity D. Identity71. The nurse is providing discharge teaching to the postpartum client regarding mood changes to report. In differentiating between the “baby blues” and postpartum depression, which of the following statements should be included in the instruction? A. “Postpartum depression may occur on the 5th postpartum day but will resolve spontaneously by the end of the 6th week.” B. “Baby blues are the result of hormonal shifts and should resolve by the end of the sixth postpartum week.” C. “Baby blues may present in the first few days after birth resolve prior to the second postpartum week.” D. “Postpartum depression is the result of hormonal changes related to the end of pregnancy and will not require intervention or medication management.” 72. Calculate a client’s total intake in milliliters (mL) from 0700 to 1500. Continuous IV infusion of Lactated Ringer’s (LR) @ 125 mL/hr. Oral intake ½ cup of green tea, 8 oz. glass of apple juice, 1/2 bowel cream of wheat, and 4 oz of jello. 1850 73. The nurse is assessing the fundus of a client on postpartum on day 2. What should the nurse expect when palpating the fundus? A. Fundus two fingerbreadths above symphysis pubis and firm. B. Fundus two fingerbreadths below the umbilicus and firm. C. Fundus 4 cm below the umbilicus and midline. D. Fundus 4 cm above the symphysis pubis and firm. 74. A new mother asks the nurse how to determine if the baby is receiving enough breast milk. How should the nurse respond to the mother?A. “You need to weigh the infant before and after each feeding.” B. “The infant should not become constipated.” C. “The infant should gain weight and have six wet diapers daily.” D. “The infant should sleep at least 3 hours between feedings.” 75. The nurse is teaching new parents how to calculate the amount of formula to feed their newborn each day. The baby weighs 8 lbs. How much formula should the nurse teach the parents to provide each day? A. 30 to 36 oz B. 42 to 54 oz C. 20 to 24 oz D. 60 to 72 oz