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Maternal & Child Practice Exam 1 (PM)
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Question 1
Which of the following describes the Babinski reflex?
A
The newborn’s toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward from the ball of the heel and across the ball of the foot.
B
The newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement or loud noise.
C
The newborn turns the head in the direction of stimulus, opens the mouth, and begins to suck when cheek, lip, or corner of mouth is touched.
D
The newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface
Question 1 Explanation:
With the babinski reflex, the newborn’s toes hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward form the heel and across the ball of the foot. With the startle reflex, the newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement of loud noise. With the rooting and sucking reflex, the newborn turns his head in the direction of stimulus, opens the mouth, and begins to suck when the cheeks, lip, or corner of mouth is touched. With the crawl reflex, the newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface.
Question 2
During which of the following would the focus of classes be mainly on physiologic changes, fetal development, sexuality, during pregnancy, and nutrition?
A
Prepregnant period
B
Third trimester
C
Second trimester
D
First trimester
Question 2 Explanation:
First-trimester classes commonly focus on such issues as early physiologic changes, fetal development, sexuality during pregnancy, and nutrition. Some early classes may include pregnant couples. Second and third trimester classes may focus on preparation for birth, parenting, and newborn care.
Question 3
Which of the following when present in the urine may cause a reddish stain on the diaper of a newborn?
A
Excess iron
B
Mucus
C
Uric acid crystals
D
Bilirubin
Question 3 Explanation:
Uric acid crystals in the urine may produce the reddish “brick dust” stain on the diaper. Mucus would not produce a stain. Bilirubin and iron are from hepatic adaptation.
Question 4
Which of the following actions demonstrates the nurse’s understanding about the newborn’s thermoregulatory ability?
A
Placing the newborn under a radiant warmer.
B
Inspecting the newborn’s umbilical cord
C
Obtaining an Apgar score
D
Suctioning with a bulb syringe
Question 4 Explanation:
The newborn’s ability to regulate body temperature is poor. Therefore, placing the newborn under a radiant warmer aids in maintaining his or her body temperature. Suctioning with a bulb syringe helps maintain a patent airway. Obtaining an Apgar score measures the newborn’s immediate adjustment to extrauterine life. Inspecting the umbilical cord aids in detecting cord anomalies.
Question 5
Which of the following would the nurse assess in a client experiencing abruptio placenta?
A
Bright red, painless vaginal bleeding
B
Concealed or external dark red bleeding
C
Palpable fetal outline
D
Soft and nontender abdomen
Question 5 Explanation:
A client with abruptio placentae may exhibit concealed or dark red bleeding, possibly reporting sudden intense localized uterine pain. The uterus is typically firm to boardlike, and the fetal presenting part may be engaged. Bright red, painless vaginal bleeding, a palpable fetal outline and a soft nontender abdomen are manifestations of placenta previa.
Question 6
A client LMP began July 5. Her EDD should be which of the following?
A
April 12
B
March 28
C
January 2
D
October 12
Question 6 Explanation:
To determine the EDD when the date of the client’s LMP is known use Nagele rule. To the first day of the LMP, add 7 days, subtract 3 months, and add 1 year (if applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July) minus 3 = 4 (April). Therefore, the client’s EDD is April 12.
Question 7
Which of the following is the primary predisposing factor related to mastitis?
A
Epidemic infection from nosocomial sources localizing in the lactiferous glands and ducts
B
Temporary urinary retention due to decreased perception of the urge to avoid
C
Breast injury caused by overdistention, stasis, and cracking of the nipples
D
Endemic infection occurring randomly and localizing in the periglandular connective tissue
Question 7 Explanation:
With mastitis, injury to the breast, such as overdistention, stasis, and cracking of the nipples, is the primary predisposing factor. Epidemic and endemic infections are probable sources of infection for mastitis. Temporary urinary retention due to decreased perception of the urge to void is a contributory factor to the development of urinary tract infection, not mastitis.
Question 8
Which of the following common emotional reactions to pregnancy would the nurse expect to occur during the first trimester?
A
Ambivalence, fear, fantasies
B
Introversion, egocentrism, narcissism
C
Anxiety, passivity, extroversion
D
Awkwardness, clumsiness, and unattractiveness
Question 8 Explanation:
During the first trimester, common emotional reactions include ambivalence, fear, fantasies, or anxiety. The second trimester is a period of well-being accompanied by the increased need to learn about fetal growth and development. Common emotional reactions during this trimester include narcissism, passivity, or introversion. At times the woman may seem egocentric and self-centered. During the third trimester, the woman typically feels awkward, clumsy, and unattractive, often becoming more introverted or reflective of her own childhood.
Question 9
Which of the following amounts of blood loss following birth marks the criterion for describing postpartum hemorrhage?
A
More than 400 ml
B
More than 500 ml
C
More than 200 ml
D
More than 300 ml
Question 9 Explanation:
Postpartum hemorrhage is defined as blood loss of more than 500 ml following birth. Any amount less than this not considered postpartum hemorrhage.
Question 10
Which of the following best describes thrombophlebitis?
A
Inflammation and blood clots that eventually become lodged within the femoral vein
B
Inflammation and clot formation that result when blood components combine to form an aggregate body
C
Inflammation of the vascular endothelium with clot formation on the vessel wall
D
Inflammation and blood clots that eventually become lodged within the pulmonary blood vessels
Question 10 Explanation:
Thrombophlebitis refers to an inflammation of the vascular endothelium with clot formation on the wall of the vessel. Blood components combining to form an aggregate body describe a thrombus or thrombosis. Clots lodging in the pulmonary vasculature refers to pulmonary embolism; in the femoral vein, femoral thrombophlebitis.
Question 11
A couple who wants to conceive but has been unsuccessful during the last 2 years has undergone many diagnostic procedures. When discussing the situation with the nurse, one partner states, “We know several friends in our age group and all of them have their own child already, Why can’t we have one?”. Which of the following would be the most pertinent nursing diagnosis for this couple?
A
Pain related to numerous procedures.
B
Ineffective family coping related to infertility.
C
Fear related to the unknown
D
Self-esteem disturbance related to infertility.
Question 11 Explanation:
Based on the partner’s statement, the couple is verbalizing feelings of inadequacy and negative feelings about themselves and their capabilities. Thus, the nursing diagnosis of self-esteem disturbance is most appropriate. Fear, pain, and ineffective family coping also may be present but as secondary nursing diagnoses.
Question 12
Which of the following fundal heights indicates less than 12 weeks’ gestation when the date of the LMP is unknown?
A
Uterus at the xiphoid
B
Uterus in the abdomen
C
Uterus in the pelvis
D
Uterus at the umbilicus
Question 12 Explanation:
When the LMP is unknown, the gestational age of the fetus is estimated by uterine size or position (fundal height). The presence of the uterus in the pelvis indicates less than 12 weeks’ gestation. At approximately 12 to 14 weeks, the fundus is out of the pelvis above the symphysis pubis. The fundus is at the level of the umbilicus at approximately 20 weeks’ gestation and reaches the xiphoid at term or 40 weeks.
Question 13
Which of the following statements best describes hyperemesis gravidarum?
A
Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems.
B
Severe anemia leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems.
C
Loss of appetite and continuous vomiting that commonly results in dehydration and ultimately decreasing maternal nutrients
D
Severe nausea and diarrhea that can cause gastrointestinal irritation and possibly internal bleeding
Question 13 Explanation:
The description of hyperemesis gravidarum includes severe nausea and vomiting, leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems. Hyperemesis is not a form of anemia. Loss of appetite may occur secondary to the nausea and vomiting of hyperemesis, which, if it continues, can deplete the nutrients transported to the fetus. Diarrhea does not occur with hyperemesis.
Question 14
When uterine rupture occurs, which of the following would be the priority?
A
Limiting hypovolemic shock
B
Inserting a urinary catheter
C
Obtaining blood specimens
D
Instituting complete bed rest
Question 14 Explanation:
With uterine rupture, the client is at risk for hypovolemic shock. Therefore, the priority is to prevent and limit hypovolemic shock. Immediate steps should include giving oxygen, replacing lost fluids, providing drug therapy as needed, evaluating fetal responses and preparing for surgery. Obtaining blood specimens, instituting complete bed rest, and inserting a urinary catheter are necessary in preparation for surgery to remedy the rupture.
Question 15
A pregnant client states that she “waddles” when she walks. The nurse’s explanation is based on which of the following as the cause?
A
The large size of the newborn
B
Pressure on the pelvic muscles
C
Relaxation of the pelvic joints
D
Excessive weight gain
Question 15 Explanation:
During pregnancy, hormonal changes cause relaxation of the pelvic joints, resulting in the typical “waddling” gait. Changes in posture are related to the growing fetus. Pressure on the surrounding muscles causing discomfort is due to the growing uterus. Weight gain has no effect on gait.
Question 16
Immediately before expulsion, which of the following cardinal movements occur?
A
Extension
B
Flexion
C
Descent
D
External rotation
Question 16 Explanation:
Immediately before expulsion or birth of the rest of the body, the cardinal movement of external rotation occurs. Descent flexion, internal rotation, extension, and restitution (in this order) occur before external rotation.
Question 17
In which of the following types of spontaneous abortions would the nurse assess dark brown vaginal discharge and a negative pregnancy tests?
A
Missed
B
Imminent
C
Threatened
D
Incomplete
Question 17 Explanation:
In a missed abortion, there is early fetal intrauterine death, and products of conception are not expelled. The cervix remains closed; there may be a dark brown vaginal discharge, negative pregnancy test, and cessation of uterine growth and breast tenderness. A threatened abortion is evidenced with cramping and vaginal bleeding in early pregnancy, with no cervical dilation. An incomplete abortion presents with bleeding, cramping, and cervical dilation. An incomplete abortion involves only expulsion of part of the products of conception and bleeding occurs with cervical dilation.
Question 18
When assessing the newborn’s heart rate, which of the following ranges would be considered normal if the newborn were sleeping?
A
80 beats per minute
B
120 beats per minute
C
100 beats per minute
D
140 beats per minute
Question 18 Explanation:
The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute. If the newborn was awake, the normal heart rate would range from 120 to 160 beats per minute.
Question 19
When preparing a client for cesarean delivery, which of the following key concepts should be considered when implementing nursing care?
A
Instruct the mother’s support person to remain in the family lounge until after the delivery
B
Arrange for a staff member of the anesthesia department to explain what to expect postoperatively
C
Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth
D
Explain the surgery, expected outcome, and kind of anesthetics
Question 19 Explanation:
A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching to meet the needs of either a planned or emergency cesarean birth, the depth and breadth of instruction will depend on circumstances and time available. Allowing the mother’s support person to remain with her as much as possible is an important concept, although doing so depends on many variables. Arranging for necessary explanations by various staff members to be involved with the client’s care is a nursing responsibility. The nurse is responsible for reinforcing the explanations about the surgery, expected outcome, and type of anesthetic to be used. The obstetrician is responsible for explaining about the surgery and outcome and the anesthesiology staff is responsible for explanations about the type of anesthesia to be used.
Question 20
Which of the following factors would the nurse suspect as predisposing a client to placenta previa?
A
Multiple gestation
B
Uterine anomalies
C
Abdominal trauma
D
Renal or vascular disease
Question 20 Explanation:
Multiple gestation is one of the predisposing factors that may cause placenta previa. Uterine anomalies abdominal trauma, and renal or vascular disease may predispose a client to abruptio placentae.
Question 21
When PROM occurs, which of the following provides evidence of the nurse’s understanding of the client’s immediate needs?
A
The chorion and amnion rupture 4 hours before the onset of labor.
B
Nursing care is based on fetal viability and gestational age.
C
PROM is associated with malpresentation and possibly incompetent cervix
D
PROM removes the fetus most effective defense against infection
Question 21 Explanation:
PROM can precipitate many potential and actual problems; one of the most serious is the fetus loss of an effective defense against infection. This is the client’s most immediate need at this time. Typically, PROM occurs about 1 hour, not 4 hours, before labor begins. Fetal viability and gestational age are less immediate considerations that affect the plan of care. Malpresentation and an incompetent cervix may be causes of PROM.
Question 22
Which of the following assessment findings would the nurse expect if the client develops DVT?
A
Chills, fever, stiffness, and pain occurring 10 to 14 days after delivery
B
Muscle pain the presence of Homans sign, and swelling in the affected limb
C
Chills, fever, malaise, occurring 2 weeks after delivery
D
Midcalf pain, tenderness and redness along the vein
Question 22 Explanation:
Classic symptoms of DVT include muscle pain, the presence of Homans sign, and swelling of the affected limb. Midcalf pain, tenderness, and redness, along the vein reflect superficial thrombophlebitis. Chills, fever and malaise occurring 2 weeks after delivery reflect pelvic thrombophlebitis. Chills, fever, stiffness and pain occurring 10 to 14 days after delivery suggest femoral thrombophlebitis.
Question 23
Which of the following is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage?
A
Incompetent cervix
B
Abruptio placentae
C
Placenta previa
D
Ectopic pregnancy
Question 23 Explanation:
Abruptio placentae is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage. Placenta previa refers to implantation of the placenta in the lower uterine segment, causing painless bleeding in the third trimester of pregnancy. Ectopic pregnancy refers to the implantation of the products of conception in a site other than the endometrium. Incompetent cervix is a conduction characterized by painful dilation of the cervical os without uterine contractions.
Question 24
Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester?
A
Frequency
B
Dysuria
C
Incontinence
D
Burning
Question 24 Explanation:
Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary frequency. Dysuria, incontinence, and burning are symptoms associated with urinary tract infections.
Question 25
FHR can be auscultated with a fetoscope as early as which of the following?
A
15 weeks gestation
B
5 weeks gestation
C
20 weeks gestation
D
10 weeks gestation
Question 25 Explanation:
The FHR can be auscultated with a fetoscope at about 20 week’s gestation. FHR usually is ausculatated at the midline suprapubic region with Doppler ultrasound transducer at 10 to 12 week’s gestation. FHR, cannot be heard any earlier than 10 weeks’ gestation.
Question 26
Which of the following factors is the underlying cause of dystocia?
A
Nurtional
B
Environmental
C
Mechanical
D
Medical
Question 26 Explanation:
Dystocia is difficult, painful, prolonged labor due to mechanical factors involving the fetus (passenger), uterus (powers), pelvis (passage), or psyche. Nutritional, environment, and medical factors may contribute to the mechanical factors that cause dystocia.
Question 27
Barbiturates are usually not given for pain relief during active labor for which of the following reasons?
A
They rapidly transfer across the placenta, and lack of an antagonist make them generally inappropriate during labor.
B
The neonatal effects include hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the first few days.
C
Adverse reactions may include maternal hypotension, allergic or toxic reaction or partial or total respiratory failure
D
These drugs readily cross the placental barrier, causing depressive effects in the newborn 2 to 3 hours after intramuscular injection.
Question 27 Explanation:
Barbiturates are rapidly transferred across the placental barrier, and lack of an antagonist makes them generally inappropriate during active labor. Neonatal side effects of barbiturates include central nervous system depression, prolonged drowsiness, delayed establishment of feeding (e.g. due to poor sucking reflex or poor sucking pressure). Tranquilizers are associated with neonatal effects such as hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the first few days. Narcotic analgesic readily cross the placental barrier, causing depressive effects in the newborn 2 to 3 hours after intramuscular injection. Regional anesthesia is associated with adverse reactions such as maternal hypotension, allergic or toxic reaction, or partial or total respiratory failure.
Question 28
Which of the following would the nurse identify as a presumptive sign of pregnancy?
A
Hegar sign
B
Nausea and vomiting
C
Positive serum pregnancy test
D
Skin pigmentation changes
Question 28 Explanation:
Presumptive signs of pregnancy are subjective signs. Of the signs listed, only nausea and vomiting are presumptive signs. Hegar sign,skin pigmentation changes, and a positive serum pregnancy test are considered probably signs, which are strongly suggestive of pregnancy.
Question 29
Which of the following prenatal laboratory test values would the nurse consider as significant?
A
One hour glucose challenge test 110 g/dL
B
Rubella titer less than 1:8
C
White blood cells 8,000/mm3
D
Hematocrit 33.5%
Question 29 Explanation:
A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less than 1:8 is significant, indicating that the client may not possess immunity to rubella. A hematocrit of 33.5% a white blood cell count of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dl are with normal parameters.
Question 30
Which of the following is the nurse’s initial action when umbilical cord prolapse occurs?
A
Begin monitoring maternal vital signs and FHR
B
Notify the physician and prepare the client for delivery
C
Place the client in a knee-chest position in bed
D
Apply a sterile warm saline dressing to the exposed cord
Question 30 Explanation:
The immediate priority is to minimize pressure on the cord. Thus the nurse’s initial action involves placing the client on bed rest and then placing the client in a knee-chest position or lowering the head of the bed, and elevating the maternal hips on a pillow to minimize the pressure on the cord. Monitoring maternal vital signs and FHR, notifying the physician and preparing the client for delivery, and wrapping the cord with sterile saline soaked warm gauze are important. But these actions have no effect on minimizing the pressure on the cord.
Question 31
Which of the following best reflects the frequency of reported postpartum “blues”?
A
Between 30% and 50% of all new mothers report some form of postpartum blues
B
Between 25% and 70% of all new mothers report some form of postpartum blues
C
Between 10% and 40% of all new mothers report some form of postpartum blues
D
Between 50% and 80% of all new mothers report some form of postpartum blues
Question 31 Explanation:
According to statistical reports, between 50% and 80% of all new mothers report some form of postpartum blues. The ranges of 10% to 40%, 30% to 50%, and 25% to 70% are incorrect.
Question 32
Which of the following is true regarding the fontanels of the newborn?
A
The posterior closes at 18 months; the anterior closes at 8 to 12 weeks.
B
The anterior is bulging; the posterior appears sunken.
C
The anterior is large in size when compared to the posterior fontanel.
D
The anterior is triangular shaped; the posterior is diamond shaped.
Question 32 Explanation:
The anterior fontanel is larger in size than the posterior fontanel. Additionally, the anterior fontanel, which is diamond shaped, closes at 18 months, whereas the posterior fontanel, which is triangular shaped, closes at 8 to 12 weeks. Neither fontanel should appear bulging, which may indicate increased intracranial pressure, or sunken, which may indicate dehydration.
Question 33
During which of the following stages of labor would the nurse assess “crowning”?
A
Second stage
B
Fourth stage
C
First stage
D
Third stage
Question 33 Explanation:
Crowing, which occurs when the newborn’s head or presenting part appears at the vaginal opening, occurs during the second stage of labor. During the first stage of labor, cervical dilation and effacement occur. During the third stage of labor, the newborn and placenta are delivered. The fourth stage of labor lasts from 1 to 4 hours after birth, during which time the mother and newborn recover from the physical process of birth and the mother’s organs undergo the initial readjustment to the nonpregnant state.
Question 34
Which of the following danger signs should be reported promptly during the antepartum period?
A
Leaking amniotic fluid
B
Breast tenderness
C
Constipation
D
Nasal stuffiness
Question 34 Explanation:
Danger signs that require prompt reporting leaking of amniotic fluid, vaginal bleeding, blurred vision, rapid weight gain, and elevated blood pressure. Constipation, breast tenderness, and nasal stuffiness are common discomforts associated with pregnancy.
Question 35
Which of the following nursing interventions would the nurse perform during the third stage of labor?
A
Promote parent-newborn interaction.
B
Obtain a urine specimen and other laboratory tests.
C
Coach for effective client pushing
D
Assess uterine contractions every 30 minutes.
Question 35 Explanation:
During the third stage of labor, which begins with the delivery of the newborn, the nurse would promote parent-newborn interaction by placing the newborn on the mother’s abdomen and encouraging the parents to touch the newborn. Collecting a urine specimen and other laboratory tests is done on admission during the first stage of labor. Assessing uterine contractions every 30 minutes is performed during the latent phase of the first stage of labor. Coaching the client to push effectively is appropriate during the second stage of labor.
Question 36
On which of the following areas would the nurse expect to observe chloasma?
A
Abdomen, breast, and thighs
B
Cheeks, forehead, and nose
C
Chest, neck, arms, and legs
D
Breast, areola, and nipples
Question 36 Explanation:
Chloasma, also called the mask of pregnancy, is an irregular hyperpigmented area found on the face. It is not seen on the breasts, areola, nipples, chest, neck, arms, legs, abdomen, or thighs.
Question 37
Which of the following would cause a false-positive result on a pregnancy test?
A
A spontaneous abortion or a missed abortion is impending
B
The test was performed too early or too late in the pregnancy
C
The test was performed less than 10 days after an abortion
D
The urine sample was stored too long at room temperature
Question 37 Explanation:
A false-positive reaction can occur if the pregnancy test is performed less than 10 days after an abortion. Performing the tests too early or too late in the pregnancy, storing the urine sample too long at room temperature, or having a spontaneous or missed abortion impending can all produce false-negative results.
Question 38
Which of the following would be disadvantage of breast feeding?
A
The incidence of allergies increases due to maternal antibodies
B
The father may resent the infant’s demands on the mother’s body
C
There is a greater chance for error during preparation
D
Involution occurs more rapidly
Question 38 Explanation:
With breast feeding, the father’s body is not capable of providing the milk for the newborn, which may interfere with feeding the newborn, providing fewer chances for bonding, or he may be jealous of the infant’s demands on his wife’s time and body. Breast feeding is advantageous because uterine involution occurs more rapidly, thus minimizing blood loss. The presence of maternal antibodies in breast milk helps decrease the incidence of allergies in the newborn. A greater chance for error is associated with bottle feeding. No preparation is required for breast feeding.
Question 39
Which of the following are the most commonly assessed findings in cystitis?
A
Dehydration, hypertension, dysuria, suprapubic pain, chills, and fever
B
Nocturia, frequency, urgency dysuria, hematuria, fever and suprapubic pain
C
High fever, chills, flank pain nausea, vomiting, dysuria, and frequency
D
Frequency, urgency, dehydration, nausea, chills, and flank pain
Question 39 Explanation:
Manifestations of cystitis include, frequency, urgency, dysuria, hematuria nocturia, fever, and suprapubic pain. Dehydration, hypertension, and chills are not typically associated with cystitis. High fever chills, flank pain, nausea, vomiting, dysuria, and frequency are associated with pvelonephritis.
Question 40
When assessing the adequacy of sperm for conception to occur, which of the following is the most useful criterion?
A
Sperm count
B
Semen volume
C
Sperm maturity
D
Sperm motility
Question 40 Explanation:
Although all of the factors listed are important, sperm motility is the most significant criterion when assessing male infertility. Sperm count, sperm maturity, and semen volume are all significant, but they are not as significant sperm motility.
Question 41
Heartburn and flatulence, common in the second trimester, are most likely the result of which of the following?
A
Increased plasma HCG levels
B
Elevated estrogen levels
C
Decreased intestinal motility
D
Decreased gastric acidity
Question 41 Explanation:
During the second trimester, the reduction in gastric acidity in conjunction with pressure from the growing uterus and smooth muscle relaxation, can cause heartburn and flatulence. HCG levels increase in the first, not the second, trimester. Decrease intestinal motility would most likely be the cause of constipation and bloating. Estrogen levels decrease in the second trimester.
Question 42
Which of the following characteristics of contractions would the nurse expect to find in a client experiencing true labor?
A
Starting mainly in the abdomen
B
Occurring at irregular intervals
C
Gradually increasing intervals
D
Increasing intensity with walking
Question 42 Explanation:
With true labor, contractions increase in intensity with walking. In addition, true labor contractions occur at regular intervals, usually starting in the back and sweeping around to the abdomen. The interval of true labor contractions gradually shortens.
Question 43
Cervical softening and uterine souffle are classified as which of the following?
A
Diagnostic signs
B
Presumptive signs
C
Positive signs
D
Probable signs
Question 43 Explanation:
Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy. Probable signs are objective findings that strongly suggest pregnancy. Other probable signs include Hegar sign, which is softening of the lower uterine segment; Piskacek sign, which is enlargement and softening of the uterus; serum laboratory tests; changes in skin pigmentation; and ultrasonic evidence of a gestational sac. Presumptive signs are subjective signs and include amenorrhea; nausea and vomiting; urinary frequency; breast tenderness and changes; excessive fatigue; uterine enlargement; and quickening.
Question 44
Which of the following best describes preterm labor?
A
Labor that begins after 28 weeks gestation and before 40 weeks gestation
B
Labor that begins after 15 weeks gestation and before 37 weeks gestation
C
Labor that begins after 24 weeks gestation and before 28 weeks gestation
D
Labor that begins after 20 weeks gestation and before 37 weeks gestation
Question 44 Explanation:
Preterm labor is best described as labor that begins after 20 weeks’ gestation and before 37 weeks’ gestation. The other time periods are inaccurate.
Question 45
Which of the following represents the average amount of weight gained during pregnancy?
A
24 to 30 lb
B
15 to 25 lb
C
25 to 40 lb
D
12 to 22 lb
Question 45 Explanation:
The average amount of weight gained during pregnancy is 24 to 30 lb. This weight gain consists of the following: fetus – 7.5 lb; placenta and membrane – 1.5 lb; amniotic fluid – 2 lb; uterus – 2.5 lb; breasts – 3 lb; and increased blood volume – 2 to 4 lb; extravascular fluid and fat – 4 to 9 lb. A gain of 12 to 22 lb is insufficient, whereas a weight gain of 15 to 25 lb is marginal. A weight gain of 25 to 40 lb is considered excessive.
Question 46
When talking with a pregnant client who is experiencing aching swollen, leg veins, the nurse would explain that this is most probably the result of which of the following?
A
Pregnancy-induced hypertension
B
The force of gravity pulling down on the uterus
C
Thrombophlebitis
D
Pressure on blood vessels from the enlarging uterus
Question 46 Explanation:
Pressure of the growing uterus on blood vessels results in an increased risk for venous stasis in the lower extremities. Subsequently, edema and varicose vein formation may occur. Thrombophlebitis is an inflammation of the veins due to thrombus formation. Pregnancy-induced hypertension is not associated with these symptoms. Gravity plays only a minor role with these symptoms.
Question 47
Which of the following may happen if the uterus becomes overstimulated by oxytocin during the induction of labor?
A
Tetanic contractions prolonged to more than 90 seconds
B
Weak contraction prolonged to more than 70 seconds
C
Increased restlessness and anxiety
D
Increased pain with bright red vaginal bleeding
Question 47 Explanation:
Hyperstimulation of the uterus such as with oxytocin during the induction of labor may result in tetanic contractions prolonged to more than 90seconds, which could lead to such complications as fetal distress, abruptio placentae, amniotic fluid embolism, laceration of the cervix, and uterine rupture. Weak contractions would not occur. Pain, bright red vaginal bleeding, and increased restlessness and anxiety are not associated with hyperstimulation.
Question 48
Before birth, which of the following structures connects the right and left auricles of the heart?
A
Foramen ovale
B
Umbilical vein
C
Ductus arteriosus
D
Ductus venosus
Question 48 Explanation:
The foramen ovale is an opening between the right and left auricles (atria) that should close shortly after birth so the newborn will not have a murmur or mixed blood traveling through the vascular system. The umbilical vein, ductus arteriosus, and ductus venosus are obliterated at birth.
Question 49
Which of the following groups of newborn reflexes below are present at birth and remain unchanged through adulthood?
A
Stepping, blink, cough, and sneeze
B
Blink, cough, rooting, and gag
C
Blink, cough, sneeze, gag
D
Rooting, sneeze, swallowing, and cough
Question 49 Explanation:
Blink, cough, sneeze, swallowing and gag reflexes are all present at birth and remain unchanged through adulthood. Reflexes such as rooting and stepping subside within the first year.
Question 50
Which of the following would the nurse identify as a classic sign of PIH?
A
Weight gain of 1 lb/week
B
Edema of the feet and ankles
C
Edema of the hands and face
D
Early morning headache
Question 50 Explanation:
Edema of the hands and face is a classic sign of PIH. Many healthy pregnant woman experience foot and ankle edema. A weight gain of 2 lb or more per week indicates a problem. Early morning headache is not a classic sign of PIH.
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Maternal & Child Practice Exam 1 (EM)
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Question 1
Which of the following characteristics of contractions would the nurse expect to find in a client experiencing true labor?
A
Increasing intensity with walking
B
Gradually increasing intervals
C
Starting mainly in the abdomen
D
Occurring at irregular intervals
Question 1 Explanation:
With true labor, contractions increase in intensity with walking. In addition, true labor contractions occur at regular intervals, usually starting in the back and sweeping around to the abdomen. The interval of true labor contractions gradually shortens.
Question 2
Which of the following common emotional reactions to pregnancy would the nurse expect to occur during the first trimester?
A
Awkwardness, clumsiness, and unattractiveness
B
Anxiety, passivity, extroversion
C
Introversion, egocentrism, narcissism
D
Ambivalence, fear, fantasies
Question 2 Explanation:
During the first trimester, common emotional reactions include ambivalence, fear, fantasies, or anxiety. The second trimester is a period of well-being accompanied by the increased need to learn about fetal growth and development. Common emotional reactions during this trimester include narcissism, passivity, or introversion. At times the woman may seem egocentric and self-centered. During the third trimester, the woman typically feels awkward, clumsy, and unattractive, often becoming more introverted or reflective of her own childhood.
Question 3
Which of the following when present in the urine may cause a reddish stain on the diaper of a newborn?
A
Uric acid crystals
B
Excess iron
C
Bilirubin
D
Mucus
Question 3 Explanation:
Uric acid crystals in the urine may produce the reddish “brick dust” stain on the diaper. Mucus would not produce a stain. Bilirubin and iron are from hepatic adaptation.
Question 4
A couple who wants to conceive but has been unsuccessful during the last 2 years has undergone many diagnostic procedures. When discussing the situation with the nurse, one partner states, “We know several friends in our age group and all of them have their own child already, Why can’t we have one?”. Which of the following would be the most pertinent nursing diagnosis for this couple?
A
Pain related to numerous procedures.
B
Ineffective family coping related to infertility.
C
Fear related to the unknown
D
Self-esteem disturbance related to infertility.
Question 4 Explanation:
Based on the partner’s statement, the couple is verbalizing feelings of inadequacy and negative feelings about themselves and their capabilities. Thus, the nursing diagnosis of self-esteem disturbance is most appropriate. Fear, pain, and ineffective family coping also may be present but as secondary nursing diagnoses.
Question 5
A client LMP began July 5. Her EDD should be which of the following?
A
October 12
B
March 28
C
January 2
D
April 12
Question 5 Explanation:
To determine the EDD when the date of the client’s LMP is known use Nagele rule. To the first day of the LMP, add 7 days, subtract 3 months, and add 1 year (if applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July) minus 3 = 4 (April). Therefore, the client’s EDD is April 12.
Question 6
Which of the following statements best describes hyperemesis gravidarum?
A
Severe anemia leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems.
B
Severe nausea and diarrhea that can cause gastrointestinal irritation and possibly internal bleeding
C
Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems.
D
Loss of appetite and continuous vomiting that commonly results in dehydration and ultimately decreasing maternal nutrients
Question 6 Explanation:
The description of hyperemesis gravidarum includes severe nausea and vomiting, leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems. Hyperemesis is not a form of anemia. Loss of appetite may occur secondary to the nausea and vomiting of hyperemesis, which, if it continues, can deplete the nutrients transported to the fetus. Diarrhea does not occur with hyperemesis.
Question 7
Which of the following is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage?
A
Placenta previa
B
Incompetent cervix
C
Ectopic pregnancy
D
Abruptio placentae
Question 7 Explanation:
Abruptio placentae is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage. Placenta previa refers to implantation of the placenta in the lower uterine segment, causing painless bleeding in the third trimester of pregnancy. Ectopic pregnancy refers to the implantation of the products of conception in a site other than the endometrium. Incompetent cervix is a conduction characterized by painful dilation of the cervical os without uterine contractions.
Question 8
Which of the following best reflects the frequency of reported postpartum “blues”?
A
Between 50% and 80% of all new mothers report some form of postpartum blues
B
Between 25% and 70% of all new mothers report some form of postpartum blues
C
Between 30% and 50% of all new mothers report some form of postpartum blues
D
Between 10% and 40% of all new mothers report some form of postpartum blues
Question 8 Explanation:
According to statistical reports, between 50% and 80% of all new mothers report some form of postpartum blues. The ranges of 10% to 40%, 30% to 50%, and 25% to 70% are incorrect.
Question 9
Which of the following is the primary predisposing factor related to mastitis?
A
Temporary urinary retention due to decreased perception of the urge to avoid
B
Breast injury caused by overdistention, stasis, and cracking of the nipples
C
Endemic infection occurring randomly and localizing in the periglandular connective tissue
D
Epidemic infection from nosocomial sources localizing in the lactiferous glands and ducts
Question 9 Explanation:
With mastitis, injury to the breast, such as overdistention, stasis, and cracking of the nipples, is the primary predisposing factor. Epidemic and endemic infections are probable sources of infection for mastitis. Temporary urinary retention due to decreased perception of the urge to void is a contributory factor to the development of urinary tract infection, not mastitis.
Question 10
Which of the following would cause a false-positive result on a pregnancy test?
A
A spontaneous abortion or a missed abortion is impending
B
The test was performed less than 10 days after an abortion
C
The test was performed too early or too late in the pregnancy
D
The urine sample was stored too long at room temperature
Question 10 Explanation:
A false-positive reaction can occur if the pregnancy test is performed less than 10 days after an abortion. Performing the tests too early or too late in the pregnancy, storing the urine sample too long at room temperature, or having a spontaneous or missed abortion impending can all produce false-negative results.
Question 11
In which of the following types of spontaneous abortions would the nurse assess dark brown vaginal discharge and a negative pregnancy tests?
A
Incomplete
B
Threatened
C
Missed
D
Imminent
Question 11 Explanation:
In a missed abortion, there is early fetal intrauterine death, and products of conception are not expelled. The cervix remains closed; there may be a dark brown vaginal discharge, negative pregnancy test, and cessation of uterine growth and breast tenderness. A threatened abortion is evidenced with cramping and vaginal bleeding in early pregnancy, with no cervical dilation. An incomplete abortion presents with bleeding, cramping, and cervical dilation. An incomplete abortion involves only expulsion of part of the products of conception and bleeding occurs with cervical dilation.
Question 12
Which of the following may happen if the uterus becomes overstimulated by oxytocin during the induction of labor?
A
Increased restlessness and anxiety
B
Tetanic contractions prolonged to more than 90 seconds
C
Weak contraction prolonged to more than 70 seconds
D
Increased pain with bright red vaginal bleeding
Question 12 Explanation:
Hyperstimulation of the uterus such as with oxytocin during the induction of labor may result in tetanic contractions prolonged to more than 90seconds, which could lead to such complications as fetal distress, abruptio placentae, amniotic fluid embolism, laceration of the cervix, and uterine rupture. Weak contractions would not occur. Pain, bright red vaginal bleeding, and increased restlessness and anxiety are not associated with hyperstimulation.
Question 13
Immediately before expulsion, which of the following cardinal movements occur?
A
Flexion
B
Descent
C
Extension
D
External rotation
Question 13 Explanation:
Immediately before expulsion or birth of the rest of the body, the cardinal movement of external rotation occurs. Descent flexion, internal rotation, extension, and restitution (in this order) occur before external rotation.
Question 14
Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester?
A
Incontinence
B
Dysuria
C
Burning
D
Frequency
Question 14 Explanation:
Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary frequency. Dysuria, incontinence, and burning are symptoms associated with urinary tract infections.
Question 15
Which of the following prenatal laboratory test values would the nurse consider as significant?
A
One hour glucose challenge test 110 g/dL
B
Rubella titer less than 1:8
C
Hematocrit 33.5%
D
White blood cells 8,000/mm3
Question 15 Explanation:
A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less than 1:8 is significant, indicating that the client may not possess immunity to rubella. A hematocrit of 33.5% a white blood cell count of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dl are with normal parameters.
Question 16
Before birth, which of the following structures connects the right and left auricles of the heart?
A
Foramen ovale
B
Umbilical vein
C
Ductus venosus
D
Ductus arteriosus
Question 16 Explanation:
The foramen ovale is an opening between the right and left auricles (atria) that should close shortly after birth so the newborn will not have a murmur or mixed blood traveling through the vascular system. The umbilical vein, ductus arteriosus, and ductus venosus are obliterated at birth.
Question 17
When assessing the newborn’s heart rate, which of the following ranges would be considered normal if the newborn were sleeping?
A
140 beats per minute
B
120 beats per minute
C
80 beats per minute
D
100 beats per minute
Question 17 Explanation:
The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute. If the newborn was awake, the normal heart rate would range from 120 to 160 beats per minute.
Question 18
Which of the following nursing interventions would the nurse perform during the third stage of labor?
A
Promote parent-newborn interaction.
B
Assess uterine contractions every 30 minutes.
C
Coach for effective client pushing
D
Obtain a urine specimen and other laboratory tests.
Question 18 Explanation:
During the third stage of labor, which begins with the delivery of the newborn, the nurse would promote parent-newborn interaction by placing the newborn on the mother’s abdomen and encouraging the parents to touch the newborn. Collecting a urine specimen and other laboratory tests is done on admission during the first stage of labor. Assessing uterine contractions every 30 minutes is performed during the latent phase of the first stage of labor. Coaching the client to push effectively is appropriate during the second stage of labor.
Question 19
FHR can be auscultated with a fetoscope as early as which of the following?
A
5 weeks gestation
B
15 weeks gestation
C
10 weeks gestation
D
20 weeks gestation
Question 19 Explanation:
The FHR can be auscultated with a fetoscope at about 20 week’s gestation. FHR usually is ausculatated at the midline suprapubic region with Doppler ultrasound transducer at 10 to 12 week’s gestation. FHR, cannot be heard any earlier than 10 weeks’ gestation.
Question 20
When assessing the adequacy of sperm for conception to occur, which of the following is the most useful criterion?
A
Sperm count
B
Sperm motility
C
Semen volume
D
Sperm maturity
Question 20 Explanation:
Although all of the factors listed are important, sperm motility is the most significant criterion when assessing male infertility. Sperm count, sperm maturity, and semen volume are all significant, but they are not as significant sperm motility.
Question 21
Cervical softening and uterine souffle are classified as which of the following?
A
Positive signs
B
Presumptive signs
C
Diagnostic signs
D
Probable signs
Question 21 Explanation:
Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy. Probable signs are objective findings that strongly suggest pregnancy. Other probable signs include Hegar sign, which is softening of the lower uterine segment; Piskacek sign, which is enlargement and softening of the uterus; serum laboratory tests; changes in skin pigmentation; and ultrasonic evidence of a gestational sac. Presumptive signs are subjective signs and include amenorrhea; nausea and vomiting; urinary frequency; breast tenderness and changes; excessive fatigue; uterine enlargement; and quickening.
Question 22
Which of the following danger signs should be reported promptly during the antepartum period?
A
Constipation
B
Nasal stuffiness
C
Leaking amniotic fluid
D
Breast tenderness
Question 22 Explanation:
Danger signs that require prompt reporting leaking of amniotic fluid, vaginal bleeding, blurred vision, rapid weight gain, and elevated blood pressure. Constipation, breast tenderness, and nasal stuffiness are common discomforts associated with pregnancy.
Question 23
When preparing a client for cesarean delivery, which of the following key concepts should be considered when implementing nursing care?
A
Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth
B
Instruct the mother’s support person to remain in the family lounge until after the delivery
C
Explain the surgery, expected outcome, and kind of anesthetics
D
Arrange for a staff member of the anesthesia department to explain what to expect postoperatively
Question 23 Explanation:
A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching to meet the needs of either a planned or emergency cesarean birth, the depth and breadth of instruction will depend on circumstances and time available. Allowing the mother’s support person to remain with her as much as possible is an important concept, although doing so depends on many variables. Arranging for necessary explanations by various staff members to be involved with the client’s care is a nursing responsibility. The nurse is responsible for reinforcing the explanations about the surgery, expected outcome, and type of anesthetic to be used. The obstetrician is responsible for explaining about the surgery and outcome and the anesthesiology staff is responsible for explanations about the type of anesthesia to be used.
Question 24
Which of the following is true regarding the fontanels of the newborn?
A
The anterior is large in size when compared to the posterior fontanel.
B
The anterior is bulging; the posterior appears sunken.
C
The anterior is triangular shaped; the posterior is diamond shaped.
D
The posterior closes at 18 months; the anterior closes at 8 to 12 weeks.
Question 24 Explanation:
The anterior fontanel is larger in size than the posterior fontanel. Additionally, the anterior fontanel, which is diamond shaped, closes at 18 months, whereas the posterior fontanel, which is triangular shaped, closes at 8 to 12 weeks. Neither fontanel should appear bulging, which may indicate increased intracranial pressure, or sunken, which may indicate dehydration.
Question 25
Which of the following best describes preterm labor?
A
Labor that begins after 24 weeks gestation and before 28 weeks gestation
B
Labor that begins after 15 weeks gestation and before 37 weeks gestation
C
Labor that begins after 20 weeks gestation and before 37 weeks gestation
D
Labor that begins after 28 weeks gestation and before 40 weeks gestation
Question 25 Explanation:
Preterm labor is best described as labor that begins after 20 weeks’ gestation and before 37 weeks’ gestation. The other time periods are inaccurate.
Question 26
On which of the following areas would the nurse expect to observe chloasma?
A
Abdomen, breast, and thighs
B
Breast, areola, and nipples
C
Chest, neck, arms, and legs
D
Cheeks, forehead, and nose
Question 26 Explanation:
Chloasma, also called the mask of pregnancy, is an irregular hyperpigmented area found on the face. It is not seen on the breasts, areola, nipples, chest, neck, arms, legs, abdomen, or thighs.
Question 27
During which of the following stages of labor would the nurse assess “crowning”?
A
Fourth stage
B
Second stage
C
Third stage
D
First stage
Question 27 Explanation:
Crowing, which occurs when the newborn’s head or presenting part appears at the vaginal opening, occurs during the second stage of labor. During the first stage of labor, cervical dilation and effacement occur. During the third stage of labor, the newborn and placenta are delivered. The fourth stage of labor lasts from 1 to 4 hours after birth, during which time the mother and newborn recover from the physical process of birth and the mother’s organs undergo the initial readjustment to the nonpregnant state.
Question 28
Which of the following amounts of blood loss following birth marks the criterion for describing postpartum hemorrhage?
A
More than 400 ml
B
More than 200 ml
C
More than 500 ml
D
More than 300 ml
Question 28 Explanation:
Postpartum hemorrhage is defined as blood loss of more than 500 ml following birth. Any amount less than this not considered postpartum hemorrhage.
Question 29
When uterine rupture occurs, which of the following would be the priority?
A
Instituting complete bed rest
B
Inserting a urinary catheter
C
Limiting hypovolemic shock
D
Obtaining blood specimens
Question 29 Explanation:
With uterine rupture, the client is at risk for hypovolemic shock. Therefore, the priority is to prevent and limit hypovolemic shock. Immediate steps should include giving oxygen, replacing lost fluids, providing drug therapy as needed, evaluating fetal responses and preparing for surgery. Obtaining blood specimens, instituting complete bed rest, and inserting a urinary catheter are necessary in preparation for surgery to remedy the rupture.
Question 30
Which of the following best describes thrombophlebitis?
A
Inflammation and blood clots that eventually become lodged within the pulmonary blood vessels
B
Inflammation and blood clots that eventually become lodged within the femoral vein
C
Inflammation and clot formation that result when blood components combine to form an aggregate body
D
Inflammation of the vascular endothelium with clot formation on the vessel wall
Question 30 Explanation:
Thrombophlebitis refers to an inflammation of the vascular endothelium with clot formation on the wall of the vessel. Blood components combining to form an aggregate body describe a thrombus or thrombosis. Clots lodging in the pulmonary vasculature refers to pulmonary embolism; in the femoral vein, femoral thrombophlebitis.
Question 31
Which of the following would be disadvantage of breast feeding?
A
Involution occurs more rapidly
B
The incidence of allergies increases due to maternal antibodies
C
The father may resent the infant’s demands on the mother’s body
D
There is a greater chance for error during preparation
Question 31 Explanation:
With breast feeding, the father’s body is not capable of providing the milk for the newborn, which may interfere with feeding the newborn, providing fewer chances for bonding, or he may be jealous of the infant’s demands on his wife’s time and body. Breast feeding is advantageous because uterine involution occurs more rapidly, thus minimizing blood loss. The presence of maternal antibodies in breast milk helps decrease the incidence of allergies in the newborn. A greater chance for error is associated with bottle feeding. No preparation is required for breast feeding.
Question 32
Which of the following represents the average amount of weight gained during pregnancy?
A
15 to 25 lb
B
24 to 30 lb
C
25 to 40 lb
D
12 to 22 lb
Question 32 Explanation:
The average amount of weight gained during pregnancy is 24 to 30 lb. This weight gain consists of the following: fetus – 7.5 lb; placenta and membrane – 1.5 lb; amniotic fluid – 2 lb; uterus – 2.5 lb; breasts – 3 lb; and increased blood volume – 2 to 4 lb; extravascular fluid and fat – 4 to 9 lb. A gain of 12 to 22 lb is insufficient, whereas a weight gain of 15 to 25 lb is marginal. A weight gain of 25 to 40 lb is considered excessive.
Question 33
Which of the following fundal heights indicates less than 12 weeks’ gestation when the date of the LMP is unknown?
A
Uterus in the abdomen
B
Uterus at the xiphoid
C
Uterus in the pelvis
D
Uterus at the umbilicus
Question 33 Explanation:
When the LMP is unknown, the gestational age of the fetus is estimated by uterine size or position (fundal height). The presence of the uterus in the pelvis indicates less than 12 weeks’ gestation. At approximately 12 to 14 weeks, the fundus is out of the pelvis above the symphysis pubis. The fundus is at the level of the umbilicus at approximately 20 weeks’ gestation and reaches the xiphoid at term or 40 weeks.
Question 34
A pregnant client states that she “waddles” when she walks. The nurse’s explanation is based on which of the following as the cause?
A
The large size of the newborn
B
Relaxation of the pelvic joints
C
Excessive weight gain
D
Pressure on the pelvic muscles
Question 34 Explanation:
During pregnancy, hormonal changes cause relaxation of the pelvic joints, resulting in the typical “waddling” gait. Changes in posture are related to the growing fetus. Pressure on the surrounding muscles causing discomfort is due to the growing uterus. Weight gain has no effect on gait.
Question 35
Which of the following describes the Babinski reflex?
A
The newborn turns the head in the direction of stimulus, opens the mouth, and begins to suck when cheek, lip, or corner of mouth is touched.
B
The newborn’s toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward from the ball of the heel and across the ball of the foot.
C
The newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement or loud noise.
D
The newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface
Question 35 Explanation:
With the babinski reflex, the newborn’s toes hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward form the heel and across the ball of the foot. With the startle reflex, the newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement of loud noise. With the rooting and sucking reflex, the newborn turns his head in the direction of stimulus, opens the mouth, and begins to suck when the cheeks, lip, or corner of mouth is touched. With the crawl reflex, the newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface.
Question 36
Which of the following factors would the nurse suspect as predisposing a client to placenta previa?
A
Multiple gestation
B
Renal or vascular disease
C
Uterine anomalies
D
Abdominal trauma
Question 36 Explanation:
Multiple gestation is one of the predisposing factors that may cause placenta previa. Uterine anomalies abdominal trauma, and renal or vascular disease may predispose a client to abruptio placentae.
Question 37
Which of the following would the nurse identify as a classic sign of PIH?
A
Edema of the hands and face
B
Edema of the feet and ankles
C
Early morning headache
D
Weight gain of 1 lb/week
Question 37 Explanation:
Edema of the hands and face is a classic sign of PIH. Many healthy pregnant woman experience foot and ankle edema. A weight gain of 2 lb or more per week indicates a problem. Early morning headache is not a classic sign of PIH.
Question 38
During which of the following would the focus of classes be mainly on physiologic changes, fetal development, sexuality, during pregnancy, and nutrition?
A
Third trimester
B
Prepregnant period
C
First trimester
D
Second trimester
Question 38 Explanation:
First-trimester classes commonly focus on such issues as early physiologic changes, fetal development, sexuality during pregnancy, and nutrition. Some early classes may include pregnant couples. Second and third trimester classes may focus on preparation for birth, parenting, and newborn care.
Question 39
Which of the following factors is the underlying cause of dystocia?
A
Nurtional
B
Medical
C
Environmental
D
Mechanical
Question 39 Explanation:
Dystocia is difficult, painful, prolonged labor due to mechanical factors involving the fetus (passenger), uterus (powers), pelvis (passage), or psyche. Nutritional, environment, and medical factors may contribute to the mechanical factors that cause dystocia.
Question 40
When PROM occurs, which of the following provides evidence of the nurse’s understanding of the client’s immediate needs?
A
Nursing care is based on fetal viability and gestational age.
B
PROM is associated with malpresentation and possibly incompetent cervix
C
PROM removes the fetus most effective defense against infection
D
The chorion and amnion rupture 4 hours before the onset of labor.
Question 40 Explanation:
PROM can precipitate many potential and actual problems; one of the most serious is the fetus loss of an effective defense against infection. This is the client’s most immediate need at this time. Typically, PROM occurs about 1 hour, not 4 hours, before labor begins. Fetal viability and gestational age are less immediate considerations that affect the plan of care. Malpresentation and an incompetent cervix may be causes of PROM.
Question 41
Heartburn and flatulence, common in the second trimester, are most likely the result of which of the following?
A
Decreased intestinal motility
B
Decreased gastric acidity
C
Elevated estrogen levels
D
Increased plasma HCG levels
Question 41 Explanation:
During the second trimester, the reduction in gastric acidity in conjunction with pressure from the growing uterus and smooth muscle relaxation, can cause heartburn and flatulence. HCG levels increase in the first, not the second, trimester. Decrease intestinal motility would most likely be the cause of constipation and bloating. Estrogen levels decrease in the second trimester.
Question 42
Which of the following actions demonstrates the nurse’s understanding about the newborn’s thermoregulatory ability?
A
Inspecting the newborn’s umbilical cord
B
Suctioning with a bulb syringe
C
Obtaining an Apgar score
D
Placing the newborn under a radiant warmer.
Question 42 Explanation:
The newborn’s ability to regulate body temperature is poor. Therefore, placing the newborn under a radiant warmer aids in maintaining his or her body temperature. Suctioning with a bulb syringe helps maintain a patent airway. Obtaining an Apgar score measures the newborn’s immediate adjustment to extrauterine life. Inspecting the umbilical cord aids in detecting cord anomalies.
Question 43
Which of the following would the nurse assess in a client experiencing abruptio placenta?
A
Bright red, painless vaginal bleeding
B
Palpable fetal outline
C
Concealed or external dark red bleeding
D
Soft and nontender abdomen
Question 43 Explanation:
A client with abruptio placentae may exhibit concealed or dark red bleeding, possibly reporting sudden intense localized uterine pain. The uterus is typically firm to boardlike, and the fetal presenting part may be engaged. Bright red, painless vaginal bleeding, a palpable fetal outline and a soft nontender abdomen are manifestations of placenta previa.
Question 44
Which of the following would the nurse identify as a presumptive sign of pregnancy?
A
Positive serum pregnancy test
B
Nausea and vomiting
C
Hegar sign
D
Skin pigmentation changes
Question 44 Explanation:
Presumptive signs of pregnancy are subjective signs. Of the signs listed, only nausea and vomiting are presumptive signs. Hegar sign,skin pigmentation changes, and a positive serum pregnancy test are considered probably signs, which are strongly suggestive of pregnancy.
Question 45
Which of the following assessment findings would the nurse expect if the client develops DVT?
A
Chills, fever, malaise, occurring 2 weeks after delivery
B
Muscle pain the presence of Homans sign, and swelling in the affected limb
C
Midcalf pain, tenderness and redness along the vein
D
Chills, fever, stiffness, and pain occurring 10 to 14 days after delivery
Question 45 Explanation:
Classic symptoms of DVT include muscle pain, the presence of Homans sign, and swelling of the affected limb. Midcalf pain, tenderness, and redness, along the vein reflect superficial thrombophlebitis. Chills, fever and malaise occurring 2 weeks after delivery reflect pelvic thrombophlebitis. Chills, fever, stiffness and pain occurring 10 to 14 days after delivery suggest femoral thrombophlebitis.
Question 46
Barbiturates are usually not given for pain relief during active labor for which of the following reasons?
A
Adverse reactions may include maternal hypotension, allergic or toxic reaction or partial or total respiratory failure
B
These drugs readily cross the placental barrier, causing depressive effects in the newborn 2 to 3 hours after intramuscular injection.
C
They rapidly transfer across the placenta, and lack of an antagonist make them generally inappropriate during labor.
D
The neonatal effects include hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the first few days.
Question 46 Explanation:
Barbiturates are rapidly transferred across the placental barrier, and lack of an antagonist makes them generally inappropriate during active labor. Neonatal side effects of barbiturates include central nervous system depression, prolonged drowsiness, delayed establishment of feeding (e.g. due to poor sucking reflex or poor sucking pressure). Tranquilizers are associated with neonatal effects such as hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the first few days. Narcotic analgesic readily cross the placental barrier, causing depressive effects in the newborn 2 to 3 hours after intramuscular injection. Regional anesthesia is associated with adverse reactions such as maternal hypotension, allergic or toxic reaction, or partial or total respiratory failure.
Question 47
Which of the following groups of newborn reflexes below are present at birth and remain unchanged through adulthood?
A
Blink, cough, sneeze, gag
B
Blink, cough, rooting, and gag
C
Rooting, sneeze, swallowing, and cough
D
Stepping, blink, cough, and sneeze
Question 47 Explanation:
Blink, cough, sneeze, swallowing and gag reflexes are all present at birth and remain unchanged through adulthood. Reflexes such as rooting and stepping subside within the first year.
Question 48
Which of the following are the most commonly assessed findings in cystitis?
A
High fever, chills, flank pain nausea, vomiting, dysuria, and frequency
B
Nocturia, frequency, urgency dysuria, hematuria, fever and suprapubic pain
C
Frequency, urgency, dehydration, nausea, chills, and flank pain
D
Dehydration, hypertension, dysuria, suprapubic pain, chills, and fever
Question 48 Explanation:
Manifestations of cystitis include, frequency, urgency, dysuria, hematuria nocturia, fever, and suprapubic pain. Dehydration, hypertension, and chills are not typically associated with cystitis. High fever chills, flank pain, nausea, vomiting, dysuria, and frequency are associated with pvelonephritis.
Question 49
Which of the following is the nurse’s initial action when umbilical cord prolapse occurs?
A
Notify the physician and prepare the client for delivery
B
Begin monitoring maternal vital signs and FHR
C
Place the client in a knee-chest position in bed
D
Apply a sterile warm saline dressing to the exposed cord
Question 49 Explanation:
The immediate priority is to minimize pressure on the cord. Thus the nurse’s initial action involves placing the client on bed rest and then placing the client in a knee-chest position or lowering the head of the bed, and elevating the maternal hips on a pillow to minimize the pressure on the cord. Monitoring maternal vital signs and FHR, notifying the physician and preparing the client for delivery, and wrapping the cord with sterile saline soaked warm gauze are important. But these actions have no effect on minimizing the pressure on the cord.
Question 50
When talking with a pregnant client who is experiencing aching swollen, leg veins, the nurse would explain that this is most probably the result of which of the following?
A
The force of gravity pulling down on the uterus
B
Thrombophlebitis
C
Pressure on blood vessels from the enlarging uterus
D
Pregnancy-induced hypertension
Question 50 Explanation:
Pressure of the growing uterus on blood vessels results in an increased risk for venous stasis in the lower extremities. Subsequently, edema and varicose vein formation may occur. Thrombophlebitis is an inflammation of the veins due to thrombus formation. Pregnancy-induced hypertension is not associated with these symptoms. Gravity plays only a minor role with these symptoms.
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1. When assessing the adequacy of sperm for conception to occur, which of the following is the most useful criterion?
Sperm count
Sperm motility
Sperm maturity
Semen volume
2. A couple who wants to conceive but has been unsuccessful during the last 2 years has undergone many diagnostic procedures. When discussing the situation with the nurse, one partner states, “We know several friends in our age group and all of them have their own child already, Why can’t we have one?”. Which of the following would be the most pertinent nursing diagnosis for this couple?
Fear related to the unknown
Pain related to numerous procedures.
Ineffective family coping related to infertility.
Self-esteem disturbance related to infertility.
3. Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester?
Dysuria
Frequency
Incontinence
Burning
4. Heartburn and flatulence, common in the second trimester, are most likely the result of which of the following?
Increased plasma HCG levels
Decreased intestinal motility
Decreased gastric acidity
Elevated estrogen levels
5. On which of the following areas would the nurse expect to observe chloasma?
Breast, areola, and nipples
Chest, neck, arms, and legs
Abdomen, breast, and thighs
Cheeks, forehead, and nose
6. A pregnant client states that she “waddles” when she walks. The nurse’s explanation is based on which of the following as the cause?
The large size of the newborn
Pressure on the pelvic muscles
Relaxation of the pelvic joints
Excessive weight gain
7. Which of the following represents the average amount of weight gained during pregnancy?
12 to 22 lb
15 to 25 lb
24 to 30 lb
25 to 40 lb
8. When talking with a pregnant client who is experiencing aching swollen, leg veins, the nurse would explain that this is most probably the result of which of the following?
Thrombophlebitis
Pregnancy-induced hypertension
Pressure on blood vessels from the enlarging uterus
The force of gravity pulling down on the uterus
9. Cervical softening and uterine souffle are classified as which of the following?
Diagnostic signs
Presumptive signs
Probable signs
Positive signs
10. Which of the following would the nurse identify as a presumptive sign of pregnancy?
Hegar sign
Nausea and vomiting
Skin pigmentation changes
Positive serum pregnancy test
11. Which of the following common emotional reactions to pregnancy would the nurse expect to occur during the first trimester?
Introversion, egocentrism, narcissism
Awkwardness, clumsiness, and unattractiveness
Anxiety, passivity, extroversion
Ambivalence, fear, fantasies
12. During which of the following would the focus of classes be mainly on physiologic changes, fetal development, sexuality, during pregnancy, and nutrition?
Prepregnant period
First trimester
Second trimester
Third trimester
13. Which of the following would be disadvantage of breast feeding?
Involution occurs more rapidly
The incidence of allergies increases due to maternal antibodies
The father may resent the infant’s demands on the mother’s body
There is a greater chance for error during preparation
14. Which of the following would cause a false-positive result on a pregnancy test?
The test was performed less than 10 days after an abortion
The test was performed too early or too late in the pregnancy
The urine sample was stored too long at room temperature
A spontaneous abortion or a missed abortion is impending
15. FHR can be auscultated with a fetoscope as early as which of the following?
5 weeks gestation
10 weeks gestation
15 weeks gestation
20 weeks gestation
16. A client LMP began July 5. Her EDD should be which of the following?
January 2
March 28
April 12
October 12
17. Which of the following fundal heights indicates less than 12 weeks’ gestation when the date of the LMP is unknown?
Uterus in the pelvis
Uterus at the xiphoid
Uterus in the abdomen
Uterus at the umbilicus
18. Which of the following danger signs should be reported promptly during the antepartum period?
Constipation
Breast tenderness
Nasal stuffiness
Leaking amniotic fluid
19. Which of the following prenatal laboratory test values would the nurse consider as significant?
Hematocrit 33.5%
Rubella titer less than 1:8
White blood cells 8,000/mm3
One hour glucose challenge test 110 g/dL
20. Which of the following characteristics of contractions would the nurse expect to find in a client experiencing true labor?
Occurring at irregular intervals
Starting mainly in the abdomen
Gradually increasing intervals
Increasing intensity with walking
21. During which of the following stages of labor would the nurse assess “crowning”?
First stage
Second stage
Third stage
Fourth stage
22. Barbiturates are usually not given for pain relief during active labor for which of the following reasons?
The neonatal effects include hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the first few days.
These drugs readily cross the placental barrier, causing depressive effects in the newborn 2 to 3 hours after intramuscular injection.
They rapidly transfer across the placenta, and lack of an antagonist make them generally inappropriate during labor.
Adverse reactions may include maternal hypotension, allergic or toxic reaction or partial or total respiratory failure
23. Which of the following nursing interventions would the nurse perform during the third stage of labor?
Obtain a urine specimen and other laboratory tests.
Assess uterine contractions every 30 minutes.
Coach for effective client pushing
Promote parent-newborn interaction.
24. Which of the following actions demonstrates the nurse’s understanding about the newborn’s thermoregulatory ability?
Placing the newborn under a radiant warmer.
Suctioning with a bulb syringe
Obtaining an Apgar score
Inspecting the newborn’s umbilical cord
25. Immediately before expulsion, which of the following cardinal movements occur?
Descent
Flexion
Extension
External rotation
26. Before birth, which of the following structures connects the right and left auricles of the heart?
Umbilical vein
Foramen ovale
Ductus arteriosus
Ductus venosus
27. Which of the following when present in the urine may cause a reddish stain on the diaper of a newborn?
Mucus
Uric acid crystals
Bilirubin
Excess iron
28. When assessing the newborn’s heart rate, which of the following ranges would be considered normal if the newborn were sleeping?
80 beats per minute
100 beats per minute
120 beats per minute
140 beats per minute
29. Which of the following is true regarding the fontanels of the newborn?
The anterior is triangular shaped; the posterior is diamond shaped.
The posterior closes at 18 months; the anterior closes at 8 to 12 weeks.
The anterior is large in size when compared to the posterior fontanel.
The anterior is bulging; the posterior appears sunken.
30. Which of the following groups of newborn reflexes below are present at birth and remain unchanged through adulthood?
Blink, cough, rooting, and gag
Blink, cough, sneeze, gag
Rooting, sneeze, swallowing, and cough
Stepping, blink, cough, and sneeze
31. Which of the following describes the Babinski reflex?
The newborn’s toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward from the ball of the heel and across the ball of the foot.
The newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement or loud noise.
The newborn turns the head in the direction of stimulus, opens the mouth, and begins to suck when cheek, lip, or corner of mouth is touched.
The newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface
32. Which of the following statements best describes hyperemesis gravidarum?
Severe anemia leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems.
Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems.
Loss of appetite and continuous vomiting that commonly results in dehydration and ultimately decreasing maternal nutrients
Severe nausea and diarrhea that can cause gastrointestinal irritation and possibly internal bleeding
33. Which of the following would the nurse identify as a classic sign of PIH?
Edema of the feet and ankles
Edema of the hands and face
Weight gain of 1 lb/week
Early morning headache
34. In which of the following types of spontaneous abortions would the nurse assess dark brown vaginal discharge and a negative pregnancy tests?
Threatened
Imminent
Missed
Incomplete
35. Which of the following factors would the nurse suspect as predisposing a client to placenta previa?
Multiple gestation
Uterine anomalies
Abdominal trauma
Renal or vascular disease
36. Which of the following would the nurse assess in a client experiencing abruptio placenta?
Bright red, painless vaginal bleeding
Concealed or external dark red bleeding
Palpable fetal outline
Soft and nontender abdomen
37. Which of the following is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage?
Placenta previa
Ectopic pregnancy
Incompetent cervix
Abruptio placentae
38. Which of the following may happen if the uterus becomes overstimulated by oxytocin during the induction of labor?
Weak contraction prolonged to more than 70 seconds
Tetanic contractions prolonged to more than 90 seconds
Increased pain with bright red vaginal bleeding
Increased restlessness and anxiety
39. When preparing a client for cesarean delivery, which of the following key concepts should be considered when implementing nursing care?
Instruct the mother’s support person to remain in the family lounge until after the delivery
Arrange for a staff member of the anesthesia department to explain what to expect postoperatively
Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth
Explain the surgery, expected outcome, and kind of anesthetics
40. Which of the following best describes preterm labor?
Labor that begins after 20 weeks gestation and before 37 weeks gestation
Labor that begins after 15 weeks gestation and before 37 weeks gestation
Labor that begins after 24 weeks gestation and before 28 weeks gestation
Labor that begins after 28 weeks gestation and before 40 weeks gestation
41. When PROM occurs, which of the following provides evidence of the nurse’s understanding of the client’s immediate needs?
The chorion and amnion rupture 4 hours before the onset of labor.
PROM removes the fetus most effective defense against infection
Nursing care is based on fetal viability and gestational age.
PROM is associated with malpresentation and possibly incompetent cervix
42. Which of the following factors is the underlying cause of dystocia?
Nurtional
Mechanical
Environmental
Medical
43. When uterine rupture occurs, which of the following would be the priority?
Limiting hypovolemic shock
Obtaining blood specimens
Instituting complete bed rest
Inserting a urinary catheter
44. Which of the following is the nurse’s initial action when umbilical cord prolapse occurs?
Begin monitoring maternal vital signs and FHR
Place the client in a knee-chest position in bed
Notify the physician and prepare the client for delivery
Apply a sterile warm saline dressing to the exposed cord
45. Which of the following amounts of blood loss following birth marks the criterion for describing postpartum hemorrhage?
More than 200 ml
More than 300 ml
More than 400 ml
More than 500 ml
46. Which of the following is the primary predisposing factor related to mastitis?
Epidemic infection from nosocomial sources localizing in the lactiferous glands and ducts
Endemic infection occurring randomly and localizing in the periglandular connective tissue
Temporary urinary retention due to decreased perception of the urge to avoid
Breast injury caused by overdistention, stasis, and cracking of the nipples
47. Which of the following best describes thrombophlebitis?
Inflammation and clot formation that result when blood components combine to form an aggregate body
Inflammation and blood clots that eventually become lodged within the pulmonary blood vessels
Inflammation and blood clots that eventually become lodged within the femoral vein
Inflammation of the vascular endothelium with clot formation on the vessel wall
48. Which of the following assessment findings would the nurse expect if the client develops DVT?
Midcalf pain, tenderness and redness along the vein
Chills, fever, malaise, occurring 2 weeks after delivery
Muscle pain the presence of Homans sign, and swelling in the affected limb
Chills, fever, stiffness, and pain occurring 10 to 14 days after delivery
49. Which of the following are the most commonly assessed findings in cystitis?
Frequency, urgency, dehydration, nausea, chills, and flank pain
Nocturia, frequency, urgency dysuria, hematuria, fever and suprapubic pain
Dehydration, hypertension, dysuria, suprapubic pain, chills, and fever
High fever, chills, flank pain nausea, vomiting, dysuria, and frequency
50. Which of the following best reflects the frequency of reported postpartum “blues”?
Between 10% and 40% of all new mothers report some form of postpartum blues
Between 30% and 50% of all new mothers report some form of postpartum blues
Between 50% and 80% of all new mothers report some form of postpartum blues
Between 25% and 70% of all new mothers report some form of postpartum blues
Answers and Rationales
B. Although all of the factors listed are important, sperm motility is the most significant criterion when assessing male infertility. Sperm count, sperm maturity, and semen volume are all significant, but they are not as significant sperm motility.
D. Based on the partner’s statement, the couple is verbalizing feelings of inadequacy and negative feelings about themselves and their capabilities. Thus, the nursing diagnosis of self-esteem disturbance is most appropriate. Fear, pain, and ineffective family coping also may be present but as secondary nursing diagnoses.
B. Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary frequency. Dysuria, incontinence, and burning are symptoms associated with urinary tract infections.
C. During the second trimester, the reduction in gastric acidity in conjunction with pressure from the growing uterus and smooth muscle relaxation, can cause heartburn and flatulence. HCG levels increase in the first, not the second, trimester. Decrease intestinal motility would most likely be the cause of constipation and bloating. Estrogen levels decrease in the second trimester.
D. Chloasma, also called the mask of pregnancy, is an irregular hyperpigmented area found on the face. It is not seen on the breasts, areola, nipples, chest, neck, arms, legs, abdomen, or thighs.
C. During pregnancy, hormonal changes cause relaxation of the pelvic joints, resulting in the typical “waddling” gait. Changes in posture are related to the growing fetus. Pressure on the surrounding muscles causing discomfort is due to the growing uterus. Weight gain has no effect on gait.
C. The average amount of weight gained during pregnancy is 24 to 30 lb. This weight gain consists of the following: fetus – 7.5 lb; placenta and membrane – 1.5 lb; amniotic fluid – 2 lb; uterus – 2.5 lb; breasts – 3 lb; and increased blood volume – 2 to 4 lb; extravascular fluid and fat – 4 to 9 lb. A gain of 12 to 22 lb is insufficient, whereas a weight gain of 15 to 25 lb is marginal. A weight gain of 25 to 40 lb is considered excessive.
C. Pressure of the growing uterus on blood vessels results in an increased risk for venous stasis in the lower extremities. Subsequently, edema and varicose vein formation may occur. Thrombophlebitis is an inflammation of the veins due to thrombus formation. Pregnancy-induced hypertension is not associated with these symptoms. Gravity plays only a minor role with these symptoms.
C. Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy. Probable signs are objective findings that strongly suggest pregnancy. Other probable signs include Hegar sign, which is softening of the lower uterine segment; Piskacek sign, which is enlargement and softening of the uterus; serum laboratory tests; changes in skin pigmentation; and ultrasonic evidence of a gestational sac. Presumptive signs are subjective signs and include amenorrhea; nausea and vomiting; urinary frequency; breast tenderness and changes; excessive fatigue; uterine enlargement; and quickening.
B. Presumptive signs of pregnancy are subjective signs. Of the signs listed, only nausea and vomiting are presumptive signs. Hegar sign,skin pigmentation changes, and a positive serum pregnancy test are considered probably signs, which are strongly suggestive of pregnancy.
D. During the first trimester, common emotional reactions include ambivalence, fear, fantasies, or anxiety. The second trimester is a period of well-being accompanied by the increased need to learn about fetal growth and development. Common emotional reactions during this trimester include narcissism, passivity, or introversion. At times the woman may seem egocentric and self-centered. During the third trimester, the woman typically feels awkward, clumsy, and unattractive, often becoming more introverted or reflective of her own childhood.
B. First-trimester classes commonly focus on such issues as early physiologic changes, fetal development, sexuality during pregnancy, and nutrition. Some early classes may include pregnant couples. Second and third trimester classes may focus on preparation for birth, parenting, and newborn care.
C. With breast feeding, the father’s body is not capable of providing the milk for the newborn, which may interfere with feeding the newborn, providing fewer chances for bonding, or he may be jealous of the infant’s demands on his wife’s time and body. Breast feeding is advantageous because uterine involution occurs more rapidly, thus minimizing blood loss. The presence of maternal antibodies in breast milk helps decrease the incidence of allergies in the newborn. A greater chance for error is associated with bottle feeding. No preparation is required for breast feeding.
A. A false-positive reaction can occur if the pregnancy test is performed less than 10 days after an abortion. Performing the tests too early or too late in the pregnancy, storing the urine sample too long at room temperature, or having a spontaneous or missed abortion impending can all produce false-negative results.
D. The FHR can be auscultated with a fetoscope at about 20 week’s gestation. FHR usually is ausculatated at the midline suprapubic region with Doppler ultrasound transducer at 10 to 12 week’s gestation. FHR, cannot be heard any earlier than 10 weeks’ gestation.
C. To determine the EDD when the date of the client’s LMP is known use Nagele rule. To the first day of the LMP, add 7 days, subtract 3 months, and add 1 year (if applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July) minus 3 = 4 (April). Therefore, the client’s EDD is April 12.
A. When the LMP is unknown, the gestational age of the fetus is estimated by uterine size or position (fundal height). The presence of the uterus in the pelvis indicates less than 12 weeks’ gestation. At approximately 12 to 14 weeks, the fundus is out of the pelvis above the symphysis pubis. The fundus is at the level of the umbilicus at approximately 20 weeks’ gestation and reaches the xiphoid at term or 40 weeks.
D. Danger signs that require prompt reporting leaking of amniotic fluid, vaginal bleeding, blurred vision, rapid weight gain, and elevated blood pressure. Constipation, breast tenderness, and nasal stuffiness are common discomforts associated with pregnancy.
B. A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less than 1:8 is significant, indicating that the client may not possess immunity to rubella. A hematocrit of 33.5% a white blood cell count of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dl are with normal parameters.
D. With true labor, contractions increase in intensity with walking. In addition, true labor contractions occur at regular intervals, usually starting in the back and sweeping around to the abdomen. The interval of true labor contractions gradually shortens.
B. Crowing, which occurs when the newborn’s head or presenting part appears at the vaginal opening, occurs during the second stage of labor. During the first stage of labor, cervical dilation and effacement occur. During the third stage of labor, the newborn and placenta are delivered. The fourth stage of labor lasts from 1 to 4 hours after birth, during which time the mother and newborn recover from the physical process of birth and the mother’s organs undergo the initial readjustment to the nonpregnant state.
C. Barbiturates are rapidly transferred across the placental barrier, and lack of an antagonist makes them generally inappropriate during active labor. Neonatal side effects of barbiturates include central nervous system depression, prolonged drowsiness, delayed establishment of feeding (e.g. due to poor sucking reflex or poor sucking pressure). Tranquilizers are associated with neonatal effects such as hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the first few days. Narcotic analgesic readily cross the placental barrier, causing depressive effects in the newborn 2 to 3 hours after intramuscular injection. Regional anesthesia is associated with adverse reactions such as maternal hypotension, allergic or toxic reaction, or partial or total respiratory failure.
D. During the third stage of labor, which begins with the delivery of the newborn, the nurse would promote parent-newborn interaction by placing the newborn on the mother’s abdomen and encouraging the parents to touch the newborn. Collecting a urine specimen and other laboratory tests is done on admission during the first stage of labor. Assessing uterine contractions every 30 minutes is performed during the latent phase of the first stage of labor. Coaching the client to push effectively is appropriate during the second stage of labor.
A. The newborn’s ability to regulate body temperature is poor. Therefore, placing the newborn under a radiant warmer aids in maintaining his or her body temperature. Suctioning with a bulb syringe helps maintain a patent airway. Obtaining an Apgar score measures the newborn’s immediate adjustment to extrauterine life. Inspecting the umbilical cord aids in detecting cord anomalies.
D. Immediately before expulsion or birth of the rest of the body, the cardinal movement of external rotation occurs. Descent flexion, internal rotation, extension, and restitution (in this order) occur before external rotation.
B. The foramen ovale is an opening between the right and left auricles (atria) that should close shortly after birth so the newborn will not have a murmur or mixed blood traveling through the vascular system. The umbilical vein, ductus arteriosus, and ductus venosus are obliterated at birth.
B. Uric acid crystals in the urine may produce the reddish “brick dust” stain on the diaper. Mucus would not produce a stain. Bilirubin and iron are from hepatic adaptation.
B. The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute. If the newborn was awake, the normal heart rate would range from 120 to 160 beats per minute.
C. The anterior fontanel is larger in size than the posterior fontanel. Additionally, the anterior fontanel, which is diamond shaped, closes at 18 months, whereas the posterior fontanel, which is triangular shaped, closes at 8 to 12 weeks. Neither fontanel should appear bulging, which may indicate increased intracranial pressure, or sunken, which may indicate dehydration.
B. Blink, cough, sneeze, swallowing and gag reflexes are all present at birth and remain unchanged through adulthood. Reflexes such as rooting and stepping subside within the first year.
A. With the babinski reflex, the newborn’s toes hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward form the heel and across the ball of the foot. With the startle reflex, the newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement of loud noise. With the rooting and sucking reflex, the newborn turns his head in the direction of stimulus, opens the mouth, and begins to suck when the cheeks, lip, or corner of mouth is touched. With the crawl reflex, the newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface.
B. The description of hyperemesis gravidarum includes severe nausea and vomiting, leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems. Hyperemesis is not a form of anemia. Loss of appetite may occur secondary to the nausea and vomiting of hyperemesis, which, if it continues, can deplete the nutrients transported to the fetus. Diarrhea does not occur with hyperemesis.
B. Edema of the hands and face is a classic sign of PIH. Many healthy pregnant woman experience foot and ankle edema. A weight gain of 2 lb or more per week indicates a problem. Early morning headache is not a classic sign of PIH.
C. In a missed abortion, there is early fetal intrauterine death, and products of conception are not expelled. The cervix remains closed; there may be a dark brown vaginal discharge, negative pregnancy test, and cessation of uterine growth and breast tenderness. A threatened abortion is evidenced with cramping and vaginal bleeding in early pregnancy, with no cervical dilation. An incomplete abortion presents with bleeding, cramping, and cervical dilation. An incomplete abortion involves only expulsion of part of the products of conception and bleeding occurs with cervical dilation.
A. Multiple gestation is one of the predisposing factors that may cause placenta previa. Uterine anomalies abdominal trauma, and renal or vascular disease may predispose a client to abruptio placentae.
B. A client with abruptio placentae may exhibit concealed or dark red bleeding, possibly reporting sudden intense localized uterine pain. The uterus is typically firm to boardlike, and the fetal presenting part may be engaged. Bright red, painless vaginal bleeding, a palpable fetal outline and a soft nontender abdomen are manifestations of placenta previa.
D. Abruptio placentae is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage. Placenta previa refers to implantation of the placenta in the lower uterine segment, causing painless bleeding in the third trimester of pregnancy. Ectopic pregnancy refers to the implantation of the products of conception in a site other than the endometrium. Incompetent cervix is a conduction characterized by painful dilation of the cervical os without uterine contractions.
B. Hyperstimulation of the uterus such as with oxytocin during the induction of labor may result in tetanic contractions prolonged to more than 90seconds, which could lead to such complications as fetal distress, abruptio placentae, amniotic fluid embolism, laceration of the cervix, and uterine rupture. Weak contractions would not occur. Pain, bright red vaginal bleeding, and increased restlessness and anxiety are not associated with hyperstimulation.
C. A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching to meet the needs of either a planned or emergency cesarean birth, the depth and breadth of instruction will depend on circumstances and time available. Allowing the mother’s support person to remain with her as much as possible is an important concept, although doing so depends on many variables. Arranging for necessary explanations by various staff members to be involved with the client’s care is a nursing responsibility. The nurse is responsible for reinforcing the explanations about the surgery, expected outcome, and type of anesthetic to be used. The obstetrician is responsible for explaining about the surgery and outcome and the anesthesiology staff is responsible for explanations about the type of anesthesia to be used.
A. Preterm labor is best described as labor that begins after 20 weeks’ gestation and before 37 weeks’ gestation. The other time periods are inaccurate.
B. PROM can precipitate many potential and actual problems; one of the most serious is the fetus loss of an effective defense against infection. This is the client’s most immediate need at this time. Typically, PROM occurs about 1 hour, not 4 hours, before labor begins. Fetal viability and gestational age are less immediate considerations that affect the plan of care. Malpresentation and an incompetent cervix may be causes of PROM.
B. Dystocia is difficult, painful, prolonged labor due to mechanical factors involving the fetus (passenger), uterus (powers), pelvis (passage), or psyche. Nutritional, environment, and medical factors may contribute to the mechanical factors that cause dystocia.
A. With uterine rupture, the client is at risk for hypovolemic shock. Therefore, the priority is to prevent and limit hypovolemic shock. Immediate steps should include giving oxygen, replacing lost fluids, providing drug therapy as needed, evaluating fetal responses and preparing for surgery. Obtaining blood specimens, instituting complete bed rest, and inserting a urinary catheter are necessary in preparation for surgery to remedy the rupture.
B. The immediate priority is to minimize pressure on the cord. Thus the nurse’s initial action involves placing the client on bed rest and then placing the client in a knee-chest position or lowering the head of the bed, and elevating the maternal hips on a pillow to minimize the pressure on the cord. Monitoring maternal vital signs and FHR, notifying the physician and preparing the client for delivery, and wrapping the cord with sterile saline soaked warm gauze are important. But these actions have no effect on minimizing the pressure on the cord.
D. Postpartum hemorrhage is defined as blood loss of more than 500 ml following birth. Any amount less than this not considered postpartum hemorrhage.
D. With mastitis, injury to the breast, such as overdistention, stasis, and cracking of the nipples, is the primary predisposing factor. Epidemic and endemic infections are probable sources of infection for mastitis. Temporary urinary retention due to decreased perception of the urge to void is a contributory factor to the development of urinary tract infection, not mastitis.
D. Thrombophlebitis refers to an inflammation of the vascular endothelium with clot formation on the wall of the vessel. Blood components combining to form an aggregate body describe a thrombus or thrombosis. Clots lodging in the pulmonary vasculature refers to pulmonary embolism; in the femoral vein, femoral thrombophlebitis.
C. Classic symptoms of DVT include muscle pain, the presence of Homans sign, and swelling of the affected limb. Midcalf pain, tenderness, and redness, along the vein reflect superficial thrombophlebitis. Chills, fever and malaise occurring 2 weeks after delivery reflect pelvic thrombophlebitis. Chills, fever, stiffness and pain occurring 10 to 14 days after delivery suggest femoral thrombophlebitis.
B. Manifestations of cystitis include, frequency, urgency, dysuria, hematuria nocturia, fever, and suprapubic pain. Dehydration, hypertension, and chills are not typically associated with cystitis. High fever chills, flank pain, nausea, vomiting, dysuria, and frequency are associated with pvelonephritis.
C. According to statistical reports, between 50% and 80% of all new mothers report some form of postpartum blues. The ranges of 10% to 40%, 30% to 50%, and 25% to 70% are incorrect.