Maternal & Child Practice Exam 2

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1. For the client who is using oral contraceptives, the nurse informs the client about the need to take the pill at the same time each day to accomplish which of the following?

  1. Decrease the incidence of nausea
  2. Maintain hormonal levels
  3. Reduce side effects
  4. Prevent drug interactions

2. When teaching a client about contraception. Which of the following would the nurse include as the most effective method for preventing sexually transmitted infections?

  1. Spermicides
  2. Diaphragm
  3. Condoms
  4. Vasectomy

3. When preparing a woman who is 2 days postpartum for discharge, recommendations for which of the following contraceptive methods would be avoided?

  1. Diaphragm
  2. Female condom
  3. Oral contraceptives
  4. Rhythm method

4. For which of the following clients would the nurse expect that an intrauterine device would not be recommended?

  1. Woman over age 35
  2. Nulliparous woman
  3. Promiscuous young adult
  4. Postpartum client

5. A client in her third trimester tells the nurse, “I’m constipated all the time!” Which of the following should the nurse recommend?

  1. Daily enemas
  2. Laxatives
  3. Increased fiber intake
  4. Decreased fluid intake

6. Which of the following would the nurse use as the basis for the teaching plan when caring for a pregnant teenager concerned about gaining too much weight during pregnancy?

  1. 10 pounds per trimester
  2. 1 pound per week for 40 weeks
  3. ½ pound per week for 40 weeks
  4. A total gain of 25 to 30 pounds

7. The client tells the nurse that her last menstrual period started on January 14 and ended on January 20. Using Nagele’s rule, the nurse determines her EDD to be which of the following?

  1. September 27
  2. October 21
  3. November 7
  4. December 27

8. When taking an obstetrical history on a pregnant client who states, “I had a son born at 38 weeks gestation, a daughter born at 30 weeks gestation and I lost a baby at about 8 weeks,”the nurse should record her obstetrical history as which of the following?

  1. G2 T2 P0 A0 L2
  2. G3 T1 P1 A0 L2
  3. G3 T2 P0 A0 L2
  4. G4 T1 P1 A1 L2

9. When preparing to listen to the fetal heart rate at 12 weeks’ gestation, the nurse would use which of the following?

  1. Stethoscope placed midline at the umbilicus
  2. Doppler placed midline at the suprapubic region
  3. Fetoscope placed midway between the umbilicus and the xiphoid process
  4. External electronic fetal monitor placed at the umbilicus

10. When developing a plan of care for a client newly diagnosed with gestational diabetes, which of the following instructions would be the priority?

  1. Dietary intake
  2. Medication
  3. Exercise
  4. Glucose monitoring

11. A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of the following would be the priority when assessing the client?

  1. Glucosuria
  2. Depression
  3. Hand/face edema
  4. Dietary intake

12. A client 12 weeks’ pregnant come to the emergency department with abdominal cramping and moderate vaginal bleeding. Speculum examination reveals 2 to 3 cms cervical dilation.The nurse would document these findings as which of the following?

  1. Threatened abortion
  2. Imminent abortion
  3. Complete abortion
  4. Missed abortion

13. Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy?

  1. Risk for infection
  2. Pain
  3. Knowledge Deficit
  4. Anticipatory Grieving

14. Before assessing the postpartum client’s uterus for firmness and position in relation to the umbilicus and midline, which of the following shouldthe nurse do first?

  1. Assess the vital signs
  2. Administer analgesia
  3. Ambulate her in the hall
  4. Assist her to urinate

15. Which of the following should the nurse do when a primipara who is lactating tells the nurse that she has sore nipples?

  1. Tell her to breast feed more frequently
  2. Administer a narcotic before breast feeding
  3. Encourage her to wear a nursing brassiere
  4. Use soap and water to clean the nipples

16. The nurse assesses the vital signs of a client, 4 hours’ postpartum that are as follows: BP 90/60; temperature 100.4ºF; pulse 100 weak, thready; R 20 per minute. Which of the following shouldthe nurse do first?

  1. Report the temperature to the physician
  2. Recheck the blood pressure with another cuff
  3. Assess the uterus for firmness and position
  4. Determine the amount of lochia

17. The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which of the following assessments would warrant notification of the physician?

  1. A dark red discharge on a 2-day postpartum client
  2. A pink to brownish discharge on a client who is 5 days postpartum
  3. Almost colorless to creamy discharge on a client 2 weeks after delivery
  4. A bright red discharge 5 days after delivery

18. A postpartum client has a temperature of 101.4ºF, with a uterus that is tender when palpated, remains unusually large, and not descending as normally expected. Which of the following shouldthe nurse assess next?

  1. Lochia
  2. Breasts
  3. Incision
  4. Urine

19. Which of the following is the priority focus of nursing practice with the current early postpartum discharge?

  1. Promoting comfort and restoration of health
  2. Exploring the emotional status of the family
  3. Facilitating safe and effective self-and newborn care
  4. Teaching about the importance of family planning

20. Which of the following actions would be least effective in maintaining a neutral thermal environment for the newborn?

  1. Placing infant under radiant warmer after bathing
  2. Covering the scale with a warmed blanket prior to weighing
  3. Placing crib close to nursery window for family viewing
  4. Covering the infant’s head with a knit stockinette

21. A newborn who has an asymmetrical Moro reflex response should be further assessed for which of the following?

  1. Talipes equinovarus
  2. Fractured clavicle
  3. Congenital hypothyroidism
  4. Increased intracranial pressure

22. During the first 4 hours after a male circumcision, assessing for which of the following is the priority?

  1. Infection
  2. Hemorrhage
  3. Discomfort
  4. Dehydration

23. The mother asks the nurse. “What’s wrong with my son’s breasts? Why are they so enlarged?” Whish of the following would be the best response by the nurse?

  1. “The breast tissue is inflamed from the trauma experienced with birth”
  2. “A decrease in material hormones present before birth causes enlargement,”
  3. “You should discuss this with your doctor. It could be a malignancy”
  4. “The tissue has hypertrophied while the baby was in the uterus”

24. Immediately after birth the nurse notes the following on a male newborn: respirations 78; apical hearth rate 160 BPM, nostril flaring; mild intercostal retractions; and grunting at the end of expiration. Which of the following shouldthe nurse do?

  1. Call the assessment data to the physician’s attention
  2. Start oxygen per nasal cannula at 2 L/min.
  3. Suction the infant’s mouth and nares
  4. Recognize this as normal first period of reactivity

25. The nurse hears a mother telling a friend on the telephone about umbilical cord care. Which of the following statements by the mother indicates effective teaching?

  1. “Daily soap and water cleansing is best”
  2. ‘Alcohol helps it dry and kills germs”
  3. “An antibiotic ointment applied daily prevents infection”
  4. “He can have a tub bath each day”

26. A newborn weighing 3000 grams and feeding every 4 hours needs 120 calories/kg of body weight every 24 hours for proper growth and development. How many ounces of 20 cal/oz formula should this newborn receive at each feeding to meet nutritional needs?

  1. 2 ounces
  2. 3 ounces
  3. 4 ounces
  4. 6 ounces

27. The postterm neonate with meconium-stained amniotic fluid needs care designed to especially monitor for which of the following?

  1. Respiratory problems
  2. Gastrointestinal problems
  3. Integumentary problems
  4. Elimination problems

28. When measuring a client’s fundal height, which of the following techniques denotes the correct method of measurement used by the nurse?

  1. From the xiphoid process to the umbilicus
  2. From the symphysis pubis to the xiphoid process
  3. From the symphysis pubis to the fundus
  4. From the fundus to the umbilicus

29. A client with severe preeclampsia is admitted with of BP 160/110, proteinuria, and severe pitting edema. Which of the following would be most important to include in the client’s plan of care?

  1. Daily weights
  2. Seizure precautions
  3. Right lateral positioning
  4. Stress reduction

30. A postpartum primipara asks the nurse, “When can we have sexual intercourse again?” Which of the following would be the nurse’s best response?

  1. “Anytime you both want to.”
  2. “As soon as choose a contraceptive method.”
  3. “When the discharge has stopped and the incision is healed.”
  4. “After your 6 weeks examination.”

31. When preparing to administer the vitamin K injection to a neonate, the nurse would select which of the following sites as appropriate for the injection?

  1. Deltoid muscle
  2. Anterior femoris muscle
  3. Vastus lateralis muscle
  4. Gluteus maximus muscle

32. When performing a pelvic examination, the nurse observes a red swollen area on the right side of the vaginal orifice. The nurse would document this as enlargement of which of the following?

  1. Clitoris
  2. Parotid gland
  3. Skene’s gland
  4. Bartholin’s gland

33. To differentiate as a female, the hormonal stimulation of the embryo that must occur involves which of the following?

  1. Increase in maternal estrogen secretion
  2. Decrease in maternal androgen secretion
  3. Secretion of androgen by the fetal gonad
  4. Secretion of estrogen by the fetal gonad

34. A client at 8 weeks’ gestation calls complaining of slight nausea in the morning hours. Which of the following client interventions should the nurse question?

  1. Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water
  2. Eating a few low-sodium crackers before getting out of bed
  3. Avoiding the intake of liquids in the morning hours
  4. Eating six small meals a day instead of thee large meals

35. The nurse documents positive ballottement in the client’s prenatal record. The nurse understands that this indicates which of the following?

  1. Palpable contractions on the abdomen
  2. Passive movement of the unengaged fetus
  3. Fetal kicking felt by the client
  4. Enlargement and softening of the uterus

36. During a pelvic exam the nurse notes a purple-blue tinge of the cervix. The nurse documents this as which of the following?

  1. Braxton-Hicks sign
  2. Chadwick’s sign
  3. Goodell’s sign
  4. McDonald’s sign

37. During a prenatal class, the nurse explains the rationale for breathing techniques during preparation for labor based on the understanding that breathing techniques are most important in achieving which of the following?

  1. Eliminate pain and give the expectant parents something to do
  2. Reduce the risk of fetal distress by increasing uteroplacental perfusion
  3. Facilitate relaxation, possibly reducing the perception of pain
  4. Eliminate pain so that less analgesia and anesthesia are needed

38. After 4 hours of active labor, the nurse notes that the contractions of a primigravida client are not strong enough to dilate the cervix. Which of the following would the nurse anticipate doing?

  1. Obtaining an order to begin IV oxytocin infusion
  2. Administering a light sedative to allow the patient to rest for several hour
  3. Preparing for a cesarean section for failure to progress
  4. Increasing the encouragement to the patient when pushing begins

39. A multigravida at 38 weeks’ gestation is admitted with painless, bright red bleeding and mild contractions every 7 to 10 minutes. Which of the following assessments should be avoided?

  1. Maternal vital sign
  2. Fetal heart rate
  3. Contraction monitoring
  4. Cervical dilation

40. Which of the following would be the nurse’s most appropriate response to a client who asks why she must have a cesarean delivery if she has a complete placenta previa?

  1. “You will have to ask your physician when he returns.”
  2. “You need a cesarean to prevent hemorrhage.”
  3. “The placenta is covering most of your cervix.”
  4. “The placenta is covering the opening of the uterus and blocking your baby.”

41. The nurse understands that the fetal head is in which of the following positions with a face presentation?

  1. Completely flexed
  2. Completely extended
  3. Partially extended
  4. Partially flexed

42. With a fetus in the left-anterior breech presentation, the nurse would expect the fetal heart rate would be most audible in which of the following areas?

  1. Above the maternal umbilicus and to the right of midline
  2. In the lower-left maternal abdominal quadrant
  3. In the lower-right maternal abdominal quadrant
  4. Above the maternal umbilicus and to the left of midline

43. The amniotic fluid of a client has a greenish tint. The nurse interprets this to be the result of which of the following?

  1. Lanugo
  2. Hydramnio
  3. Meconium
  4. Vernix

44. A patient is in labor and has just been told she has a breech presentation. The nurse should be particularly alert for which of the following?

  1. Quickening
  2. Ophthalmia neonatorum
  3. Pica
  4. Prolapsed umbilical cord

45. When describing dizygotic twins to a couple, on which of the following would the nurse base the explanation?

  1. Two ova fertilized by separate sperm
  2. Sharing of a common placenta
  3. Each ova with the same genotype
  4. Sharing of a common chorion

46. Which of the following refers to the single cell that reproduces itself after conception?

  1. Chromosome
  2. Blastocyst
  3. Zygote
  4. Trophoblast

47. In the late 1950s, consumers and health care professionals began challenging the routine use of analgesics and anesthetics during childbirth. Which of the following was an outgrowth of this concept?

  1. Labor, delivery, recovery, postpartum (LDRP)
  2. Nurse-midwifery
  3. Clinical nurse specialist
  4. Prepared childbirth

48. A client has a midpelvic contracture from a previous pelvic injury due to a motor vehicle accident as a teenager. The nurse is aware that this could prevent a fetus from passing through or around which structure during childbirth?

  1. Symphysis pubis
  2. Sacral promontory
  3. Ischial spines
  4. Pubic arch

49. When teaching a group of adolescents about variations in the length of the menstrual cycle, the nurse understands that the underlying mechanism is due to variations in which of the following phases?

  1. Menstrual phase
  2. Proliferative phase
  3. Secretory phase
  4. Ischemic phase

50. When teaching a group of adolescents about male hormone production, which of the following would the nurse include as being produced by the Leydig cells?

  1. Follicle-stimulating hormone
  2. Testosterone
  3. Leuteinizing hormone
  4. Gonadotropin releasing hormone
Answers and Rationales
  1. B. Regular timely ingestion of oral contraceptives is necessary to maintain hormonal levels of the drugs to suppress the action of the hypothalamus and anterior pituitary leading to inappropriate secretion of FSH and LH. Therefore, follicles do not mature, ovulation is inhibited, and pregnancy is prevented. The estrogen content of the oral site contraceptive may cause the nausea, regardless of when the pill is taken. Side effects and drug interactions may occur withoral contraceptives regardless of the time the pill is taken.
  2. C. Condoms, when used correctly and consistently, are the most effective contraceptive method or barrier against bacterial and viral sexually transmitted infections. Although spermicides kill sperm, they do not provide reliable protection against the spread of sexually transmitted infections, especially intracellular organisms such as HIV. Insertion and removal of the diaphragm along with the use of the spermicides may cause vaginal irritations, which could place the client at risk for infection transmission. Male sterilization eliminates spermatozoa from the ejaculate, but it does not eliminate bacterial and/or viral microorganisms that can cause sexually transmitted infections.
  3. A. The diaphragm must be fitted individually to ensure effectiveness. Because of the changes to the reproductive structures during pregnancy and following delivery, the diaphragm must be refitted, usually at the 6 weeks’ examination following childbirth or after a weight loss of 15 lbs or more. In addition, for maximum effectiveness, spermicidal jelly should be placed in the dome and around the rim. However, spermicidal jelly should not be inserted into the vagina until involution is completed at approximately 6 weeks. Use of a female condom protects thereproductive system from the introduction of semen or spermicides into the vagina and may be used after childbirth. Oral contraceptives may be started within the first postpartum week to ensure suppression of ovulation . For the couple who has determined the female’s fertile period, using the rhythm method, avoidance of intercourse during this period, is safe and effective.
  4. C. An IUD may increase the risk of pelvic inflammatory disease, especially in women with more than one sexual partner, because of the increased risk of sexually transmitted infections. An UID should not be used if the woman has an active or chronic pelvic infection, postpartum infection, endometrial hyperplasia or carcinoma, or uterine abnormalities. Age is not a factor in determining the risks associated with IUD use. Most IUD users are over the age of 30. Although there is a slightly higher risk for infertility in women who have never been pregnant, the IUD is an acceptable option as long as the risk-benefit ratio is discussed. IUDs may be inserted immediately after delivery, but this is not recommended because of the increased risk and rate of expulsion at this time.
  5. C. During the third trimester, the enlarging uterus places pressure on the intestines. This coupled with the effect of hormones on smooth muscle relaxation causes decreased intestinal motility (peristalsis). Increasing fiber in the diet will help fecal matter pass more quickly through the intestinal tract, thus decreasing the amount of water that is absorbed. As a result, stool is softer and easier to pass. Enemas could precipitate preterm laborand/or electrolyte loss and should be avoided. Laxatives may cause preterm labor by stimulating peristalsis and may interfere with the absorption of nutrients. Use for more than 1 week can also lead to laxative dependency. Liquid in the diet helps provide a semisolid, soft consistency to the stool. Eight to ten glasses of fluid per day are essential to maintain hydration and promote stool evacuation.
  6. D. To ensure adequate fetal growth and development during the 40 weeks of a pregnancy, a total weight gain 25 to 30 pounds is recommended: 1.5 pounds in the first 10 weeks; 9 pounds by 30 weeks; and 27.5 pounds by 40 weeks. The pregnant woman should gain less weight in the first and second trimester than in the third. During the first trimester, the client should only gain 1.5 pounds in the first 10 weeks, not 1 pound per week. A weight gain of ½ pound per week would be 20 pounds for the total pregnancy, less than the recommended amount.
  7. B. To calculate the EDD by Nagele’s rule, add 7 days to the first day of the last menstrual period and count back 3 months, changing the year appropriately. To obtain a date of September 27, 7 days have been added to the last day of the LMP (rather than the first day of the LMP), plus 4 months (instead of 3 months) were counted back. To obtain the date of November 7, 7 days have been subtracted (instead of added) from the first day of LMP plus November indicates counting back 2 months (instead of 3 months) from January. To obtain the date of December 27, 7 days were added to the last day of the LMP (rather than the first day of the LMP) and December indicates counting back only 1 month (instead of 3 months) from January.
  8. D. The client has been pregnant four times, including current pregnancy (G). Birth at 38 weeks’ gestation is considered full term (T), while birth form 20 weeks to 38 weeks is considered preterm (P). A spontaneous abortion occurred at 8 weeks (A). She has two living children (L).
  9. B. At 12 weeks gestation, the uterus rises out of the pelvis and is palpable above the symphysis pubis. The Doppler intensifies the sound of the fetal pulse rate so it is audible. The uterus has merely risen out of the pelvis into the abdominal cavity and is not at the level of the umbilicus. The fetal heart rate at this age is not audible with a stethoscope. The uterus at 12 weeks is just above the symphysis pubis in the abdominal cavity, not midway between the umbilicus and the xiphoid process. At 12 weeks the FHR would be difficult to auscultate with a fetoscope. Although the external electronic fetal monitor would project the FHR, the uterus has not risen to the umbilicus at 12 weeks.
  10. A. Although all of the choices are important in the management of diabetes, diet therapy is the mainstay of the treatment plan and should always be the priority. Women diagnosed with gestational diabetes generally need only diet therapy without medication to control their blood sugar levels. Exercise, is important for all pregnant women and especially for diabetic women, because it burns up glucose, thus decreasing blood sugar. However, dietary intake, not exercise, is the priority. All pregnant women with diabetes should have periodic monitoring of serum glucose. However, those with gestational diabetes generally do not need daily glucose monitoring. The standard of care recommends a fasting and 2-hour postprandial blood sugar level every 2 weeks.
  11. C. After 20 weeks’ gestation, when there is a rapid weight gain, preeclampsia should be suspected, which may be caused by fluid retention manifested by edema, especially of the hands and face. The three classic signs of preeclampsia are hypertension, edema, and proteinuria. Although urine is checked for glucose at each clinic visit, this is not the priority. Depression may cause either anorexia or excessive food intake, leading to excessive weight gain or loss. This is not, however, the priority consideration at this time. Weight gain thought to be caused by excessive food intake would require a 24-hour diet recall. However, excessive intake would not be the primary consideration for this client at this time.
  12. B. Cramping and vaginal bleeding coupled with cervical dilation signifies that termination of the pregnancy is inevitable and cannot be prevented. Thus, the nurse would document an imminent abortion. In a threatened abortion, cramping and vaginal bleeding are present, but there is no cervical dilation. The symptoms may subside or progress to abortion. In a complete abortion all the products of conception are expelled. A missed abortion is early fetal intrauterine death without expulsion of the products of conception.
  13. B. For the client with an ectopic pregnancy, lower abdominal pain, usually unilateral, is the primary symptom. Thus, pain is the priority. Although the potential for infection is always present, the risk is low in ectopic pregnancy because pathogenic microorganisms have not been introduced from external sources. The client may have a limited knowledge of the pathology and treatment of the condition and will most likely experience grieving, but this is not the priority at this time.
  14. D. Before uterine assessment is performed, it is essential that the woman empty her bladder. A full bladder will interfere with the accuracy of the assessment by elevating the uterus and displacing to the side of the midline. Vital sign assessment is not necessary unless an abnormality in uterine assessment is identified. Uterine assessment should not cause acute pain that requires administration of analgesia. Ambulating the client is an essential component of postpartum care, but is not necessary prior to assessment of the uterus.
  15. A. Feeding more frequently, about every 2 hours, will decrease the infant’s frantic, vigorous sucking from hunger and will decrease breast engorgement, soften the breast, and promote ease of correct latching-on for feeding. Narcotics administered prior to breast feeding are passed through the breast milk to the infant, causing excessive sleepiness. Nipple soreness is not severe enough to warrant narcotic analgesia. All postpartum clients, especially lactating mothers, should wear a supportive brassiere with wide cotton straps. This does not, however, prevent or reduce nipple soreness. Soaps are drying to the skin of the nipples and should not be used on the breasts of lactating mothers. Dry nipple skin predisposes to cracks and fissures, which can become sore and painful.
  16. D. A weak, thready pulse elevated to 100 BPM may indicate impending hemorrhagic shock. An increased pulse is a compensatory mechanism of the body in response to decreased fluid volume. Thus, the nurse should check the amount of lochia present. Temperatures up to 100.48F in the first 24 hours after birth are related to the dehydrating effects of labor and are considered normal. Although rechecking the blood pressure may be a correct choice of action, it is not the first action that should be implemented in light of the other data. The data indicate a potential impending hemorrhage. Assessing the uterus for firmness and position in relation to the umbilicus and midline is important, but the nurse should check the extent of vaginal bleeding first. Then it would be appropriate to check the uterus, which may be a possible cause of the hemorrhage.
  17. D. Any bright red vaginal discharge would be considered abnormal, but especially 5 days after delivery, when the lochia is typically pink to brownish. Lochia rubra, a dark red discharge, is present for 2 to 3 days after delivery. Bright red vaginal bleeding at this time suggests late postpartum hemorrhage, which occurs after the first 24 hours following delivery and is generally caused by retained placental fragments or bleeding disorders. Lochia rubra is the normal dark red discharge occurring in the first 2 to 3 days after delivery, containing epithelial cells, erythrocyes, leukocytes and decidua. Lochia serosa is a pink to brownish serosanguineous discharge occurring from 3 to 10 days after delivery that contains decidua, erythrocytes, leukocytes, cervical mucus, and microorganisms. Lochia alba is an almost colorless to yellowish discharge occurring from 10 days to 3 weeks after delivery and containing leukocytes, decidua, epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria.
  18. A. The data suggests an infection of the endometrial lining of the uterus. The lochia may be decreased or copious, dark brown in appearance, and foul smelling, providing further evidence of a possible infection. All the client’s data indicate a uterine problem, not a breast problem. Typically, transient fever, usually 101ºF, may be present with breast engorgement. Symptoms of mastitis include influenza-like manifestations. Localized infection of an episiotomy or C-section incision rarely causes systemic symptoms, and uterine involution would not be affected. The client data do not include dysuria, frequency, or urgency, symptoms of urinary tract infections, which would necessitate assessing the client’s urine.
  19. C. Because of early postpartum discharge and limited time for teaching, the nurse’s priority is to facilitate the safe and effective care of the client and newborn. Although promoting comfort and restoration of health, exploring the family’s emotional status, and teaching about family planning are important in postpartum/newborn nursing care, they are not the priority focus in the limited time presented by early post-partum discharge.
  20. C. Heat loss by radiation occurs when the infant’s crib is placed too near cold walls or windows. Thus placing the newborn’s crib close to the viewing window would be least effective. Body heat is lost through evaporation during bathing. Placing the infant under the radiant warmer after bathing will assist the infant to be rewarmed. Covering the scale with a warmed blanket prior to weighing prevents heat loss through conduction. A knit cap prevents heat loss from the head a large head, a large body surface area of the newborn’s body.
  21. B. A fractured clavicle would prevent the normal Moro response of symmetrical sequential extension and abduction of the arms followed by flexion and adduction. In talipes equinovarus (clubfoot) the foot is turned medially, and in plantar flexion, with the heel elevated. The feet are not involved with the Moro reflex. Hypothyroiddism has no effect on the primitive reflexes. Absence of the Moror reflex is the most significant single indicator of central nervous system status, but it is not a sign of increased intracranial pressure.
  22. B. Hemorrhage is a potential risk following any surgical procedure. Although the infant has been given vitamin K to facilitate clotting, the prophylactic dose is often not sufficient to prevent bleeding. Although infection is a possibility, signs will not appear within 4 hours after the surgical procedure. The primary discomfort of circumcision occurs during the surgical procedure, not afterward. Although feedings are withheld prior to the circumcision, the chances of dehydration are minimal.
  23. B. The presence of excessive estrogen and progesterone in the maternal-fetal blood followed by prompt withdrawal at birth precipitates breast engorgement, which will spontaneously resolve in 4 to 5 days after birth. The trauma of the birth process does not cause inflammation of the newborn’s breast tissue. Newborns do not have breast malignancy. This reply by the nurse would cause the mother to have undue anxiety. Breast tissue does not hypertrophy in the fetus or newborns.
  24. D. The first 15 minutes to 1 hour after birth is the first period of reactivity involving respiratory and circulatory adaptation to extrauterine life. The data given reflect the normal changes during this time period. The infant’s assessment data reflect normal adaptation. Thus, the physician does not need to be notified and oxygen is not needed. The data do not indicate the presence of choking, gagging or coughing, which are signs of excessive secretions. Suctioning is not necessary.
  25. B. Application of 70% isopropyl alcohol to the cord minimizes microorganisms (germicidal) and promotes drying. The cord should be kept dry until it falls off and the stump has healed. Antibiotic ointment should only be used to treat an infection, not as a prophylaxis. Infants should not be submerged in a tub of water until the cord falls off and the stump has completely healed.
  26. B. To determine the amount of formula needed, do the following mathematical calculation. 3 kg x 120 cal/kg per day = 360 calories/day feeding q 4 hours = 6 feedings per day = 60 calories per feeding: 60 calories per feeding; 60 calories per feeding with formula 20 cal/oz  = 3 ounces per feeding. Based on the calculation. 2, 4 or 6 ounces are incorrect.
  27. A.  Intrauterine anoxia may cause relaxation of the anal sphincter and emptying of meconium into the amniotic fluid. At birth some of the meconium fluid may be aspirated, causing mechanical obstruction or chemical pneumonitis. The infant is not at increased risk for gastrointestinal problems. Even though the skin is stained with meconium, it is noninfectious (sterile) and nonirritating. The postterm meconium-stained infant is not at additional risk for bowel or urinary problems.
  28. C.  The nurse should use a nonelastic, flexible, paper measuring tape, placing the zero point on the superior border of the symphysis pubis and stretching the tape across the abdomen at the midline to the top of the fundus. The xiphoid and umbilicus are not appropriate landmarks to use when measuring the height of the fundus (McDonald’s measurement).
  29. B. Women hospitalized with severe preeclampsia need decreased CNS stimulation to prevent a seizure. Seizure precautions provide environmental safety should a seizure occur. Because of edema, daily weight is important but not the priority. Preclampsia causes vasospasm and therefore can reduce utero-placental perfusion. The client should be placed on her left side to maximize blood flow, reduce blood pressure, and promote diuresis. Interventions to reduce stress and anxiety are very important to facilitate coping and a sense of control, but seizure precautions are the priority.
  30. C. Cessation of the lochial discharge signifies healing of the endometrium. Risk of hemorrhage and infection are minimal 3 weeks after a normal vaginal delivery. Telling the client anytime is inappropriate because this response does not provide the client with the specific information she is requesting. Choice of a contraceptive method is important, but not the specific criteria for safe resumption of sexual activity. Culturally, the 6-weeks’ examination has been used as the time frame for resuming sexual activity, but it may be resumed earlier.
  31. C. The middle third of the vastus lateralis is the preferred injection site for vitamin K administration because it is free of blood vessels and nerves and is large enough to absorb the medication. The deltoid muscle of a newborn is not large enough for a newborn IM injection. Injections into this muscle in a small child might cause damage to the radial nerve. The anterior femoris muscle is the next safest muscle to use in a newborn but is not the safest. Because of the proximity of the sciatic nerve, the gluteus maximus muscle should not be until the child has been walking 2 years.
  32. D. Bartholin’s glands are the glands on either side of the vaginal orifice. The clitoris is female erectile tissue found in the perineal area above the urethra. The parotid glands are open into the mouth. Skene’s glands open into the posterior wall of the female urinary meatus.
  33. D. The fetal gonad must secrete estrogen for the embryo to differentiate as a female. An increase in maternal estrogen secretion does not effect differentiation of the embryo, and maternal estrogen secretion occurs in every pregnancy. Maternal androgen secretion remains the same as before pregnancy and does not effect differentiation. Secretion of androgen by the fetal gonad would produce a male fetus.
  34. A. Using bicarbonate would increase the amount of sodium ingested, which can cause complications. Eating low-sodium crackers would be appropriate. Since liquids can increase nausea avoiding them in the morning hours when nausea is usually the strongest is appropriate. Eating six small meals a day would keep the stomach full, which often decrease nausea.
  35. B. Ballottement indicates passive movement of the unengaged fetus. Ballottement is not a contraction. Fetal kicking felt by the client represents quickening. Enlargement and softening of the uterus is known as Piskacek’s sign.
  36. B. Chadwick’s sign refers to the purple-blue tinge of the cervix. Braxton Hicks contractions are painless contractions beginning around the 4th month. Goodell’s sign indicates softening of the cervix. Flexibility of the uterus against the cervix is known as McDonald’s sign.
  37. C. Breathing techniques can raise the pain threshold and reduce the perception of pain. They also promote relaxation. Breathing techniques do not eliminate pain, but they can reduce it. Positioning, not breathing, increases uteroplacental perfusion.
  38. A. The client’s labor is hypotonic. The nurse should call the physical and obtain an order for an infusion of oxytocin, which will assist the uterus to contact more forcefully in an attempt to dilate the cervix. Administering light sedative would be done for hypertonic uterine contractions. Preparing for cesarean section is unnecessary at this time. Oxytocin would increase the uterine contractions and hopefully progress labor before a cesarean would be necessary. It is too early to anticipate client pushing with contractions.
  39. D. The signs indicate placenta previa and vaginal exam to determine cervical dilation would not be done because it could cause hemorrhage. Assessing maternal vital signs can help determine maternal physiologic status. Fetal heart rate is important to assess fetal well-being and should be done. Monitoring the contractions will help evaluate the progress of labor.
  40. D. A complete placenta previa occurs when the placenta covers the opening of the uterus, thus blocking the passageway for the baby. This response explains what a complete previa is and the reason the baby cannot come out except by cesarean delivery. Telling the client to ask the physician is a poor response and would increase the patient’s anxiety. Although a cesarean would help to prevent hemorrhage, the statement does not explain why the hemorrhage could occur. With a complete previa, the placenta is covering all the cervix, not just most of it.
  41. B. With a face presentation, the head is completely extended. With a vertex presentation, the head is completely or partially flexed. With a brow (forehead) presentation, the head would be partially extended.
  42. D. With this presentation, the fetal upper torso and back face the left upper maternal abdominal wall. The fetal heart rate would be most audible above the maternal umbilicus and to the left of the middle. The other positions would be incorrect.
  43. C. The greenish tint is due to the presence of meconium. Lanugo is the soft, downy hair on the shoulders and back of the fetus. Hydramnios represents excessive amniotic fluid. Vernix is the white, cheesy substance covering the fetus.
  44. D. In a breech position, because of the space between the presenting part and the cervix, prolapse of the umbilical cord is common. Quickening is the woman’s first perception of fetal movement. Ophthalmia neonatorum usually results from maternal gonorrhea and is conjunctivitis. Pica refers to the oral intake of nonfood substances.
  45. A. Dizygotic (fraternal) twins involve two ova fertilized by separate sperm. Monozygotic (identical) twins involve a common placenta, same genotype, and common chorion.
  46. C. The zygote is the single cell that reproduces itself after conception. The chromosome is the material that makes up the cell and is gained from each parent. Blastocyst and trophoblast are later terms for the embryo after zygote.
  47. D. Prepared childbirth was the direct result of the 1950’s challenging of the routine use of analgesic and anesthetics during childbirth. The LDRP was a much later concept and was not a direct result of the challenging of routine use of analgesics and anesthetics during childbirth. Roles for  nurse midwives and clinical nurse specialists did not develop from this challenge.
  48. C. The ischial spines are located in the mid-pelvic region and could be narrowed due to the previous pelvic injury. The symphysis pubis, sacral promontory, and pubic arch are not part of the mid-pelvis.
  49. B. Variations in the length of the menstrual cycle are due to variations in the proliferative phase. The menstrual, secretory and ischemic phases do not contribute to this variation.
  50. B. Testosterone is produced by the Leyding cells in the seminiferous tubules. Follicle-stimulating hormone and leuteinzing hormone are released by the anterior pituitary gland. The hypothalamus is responsible for releasing gonadotropin-releasing hormone.