Maternal Child Final Exam Questions & Answers with Rationales 2024

What is the purpose of the White House Conference on Children and Youth? a. Set criteria for normal growth patterns. b. Examine the number of live births in minority populations. c. Raise money to support well-child clinics in rural areas. d. Promote comprehensive child welfare. ANS: D White House Conferences on Children and Youth are held every 10 years to promote comprehensive child welfare. How many hours of hospital stay does legislation currently allow for a postpartum patient who has delivered vaginally without complications? a. 24 b. 48 c. 36 d. 72 ANS: B Postpartum patients who deliver vaginally stay in the hospital for an average of 48 hours; patients who have had a caesarean delivery usually stay 4 days. How does the clinical pathway or critical pathway improve quality of care? a. Lists diagnosis-specific implementations b. Outlines expected progress with stated timelines c. Prioritizes effective nursing diagnoses d. Describes common complications ANS: B Critical pathways outline expected progress with stated timelines. Any deviation from those timelines is called a variance How does electronic charting ensure comprehensive charting more effectively than handwritten charting? a. Provides a uniform style of chart b. Requires certain responses before allowing the user to progress c. All documentation is reflective of the nursing care plan d. Requires a daily audit by the charge nurse ANS: B Comprehensive electronic documentation is ensured by requiring specific input in designated categories before the user can progress through the system. A mother is anxious about her ability to breastfeed after her child is born because of her small breast size. What would be an important point to teach this mother? a. Milk is produced in ducts and lobules regardless of breast size. b. Supplementing breastfeeding with formula allows the infant to receive adequate nutrition. c. Breast size can be increased with exercise. d. Drinking extra milk during pregnancy allows breasts to produce adequate amounts of milk. ANS: A Breast size does not influence the ability to secrete milk. The nurse is speaking with a couple trying to conceive a child. What will the nurse remind the couple is a factor that can decrease sperm production? a. Infrequent sexual intercourse b. The man not being circumcised c. The penis and testes being small d. The testes being too warm ANS: D The scrotum is suspended away from the perineum to lower the temperature of the testes for sperm production. The nurse is assisting with pelvic inlet measurements on a pregnant woman. What measurement will provide the nurse with information about whether the woman can deliver vaginally? a. Diagonal conjugate b. Obstetric conjugate c. Transverse diameter d. Anteroposterior diameter ANS: B This measurement determines if the fetus can pass through the birth canal. The nurse is aware that the diagonal conjugate is 12 centimeters. What is the measurement in centimeters of the obstetric conjugate? a. 10 to 10.5 b. 11 to 11.5 c. 12.5 to 13 d. 14 to 14.5 ANS: A The obstetric conjugate is approximately 1.5 to 2 centimeters shorter than the diagonal conjugate. How long does sperm remain viable in the female reproductive tract? a. 12 hours b. 1 day c. 2 days d. 4 days ANS: D Sperm can remain viable in the reproductive tract of the female for as long as 4 to 5 days. Which hormone initiates the maturation of the ovarian follicle? a. Estrogen b. Follicle-stimulating hormone c. Progesterone d. Luteinizing hormone ANS: B Follicle-stimulating hormone (FSH) stimulates the maturation of a follicle. The nurse is reviewing fetal circulation with a pregnant patient and explains that blood circulates through the placenta to the fetus. What vessel(s) carry blood to the fetus? a. One umbilical vein b. Two umbilical veins c. One umbilical artery d. Two umbilical arteries ANS: A The umbilical vein transports richly oxygenated blood from the placenta to the fetus. During an ultrasound, two amnions and two placentas are observed. What will be the most likely result of this pregnancy? a. Dizygotic twins b. Monozygotic twins c. Conjoined twins d. High birth-weight twins ANS: A Dizygotic twins always have two amnions and two chorions (placentas). The nurse explains that the birth weight of monozygotic twins is frequently below average. What is the most likely cause? a. Inadequate space in the uterus b. Inadequate blood supply c. Inadequate maternal health d. Inadequate placental nutrition ANS: D The single placenta may not be able to provide adequate nutrition to two fetuses. Of what is the normal umbilical cord comprised? a.1 artery carrying blood to the fetus and 1 vein carrying blood away from the fetus b.1 artery carrying blood to the fetus and 2 veins carrying blood away from the fetus c. 2 arteries carrying blood away from the fetus and 1 vein carrying blood to the fetus d. 2 arteries carrying blood to the fetus and 2 veins carrying blood away from the fetus ANS: C The umbilical cord is comprised of 2 arteries carrying blood away from the fetus and 1 vein carrying blood to the fetus. A woman reports that her last normal menstrual period began on August 5, 2013. What is this woman's expected delivery date using Nägele's rule? a. April 30, 2014 b. May 5, 2014 c. May 12, 2014 d. May 26, 2014 ANS: C To determine the expected date of delivery, count backward 3 months from the first day of the last menstrual period, then add 7 days and change the year if necessary. In a routine prenatal visit, the nurse examining a patient who is 37 weeks pregnant notices that the fetal heart rate (FHR) has dropped to 120 beats/min from a rate of 160 beats/min earlier in the pregnancy. What is the nurse's first action? a. Ask if the patient has taken a sedative. b. Notify the physician. c. Turn the patient to her right side. d. Record the rate as a normal finding. ANS: D The FHR at term ranges from a low of 110 to 120 beats/min to a high of 150 to 160 beats/min. This should be recorded as normal. The FHR drops in the late stages of pregnancy. A woman who is 7 weeks pregnant tells the nurse that this is not her first pregnancy. She has a 2-year-old son and had one previous spontaneous abortion. How would the nurse document the patient's obstetric history using the TPALM system? a. Gravida 2, para 20120 b. Gravida 3, para 10011 c. Gravida 3, para 10110 d. Gravida 2, para 11110 term-18 ANS: C Refer to Box 4-1 in the textbook for the TPALM system of identifying gravida and para. A woman tells the nurse that she is quite sure she is pregnant. The nurse recognizes which as a positive sign of pregnancy? a. Amenorrhea b. Uterine enlargement c. HCG detected in the urine d. Fetal heartbeat ANS: D Positive indications are caused only by the developing fetus and include fetal heart activity, visualization by ultrasound, and fetal movements felt by the examiner. What symptom presented by a pregnant women is indicative of abruptio placentae? a. Painless vaginal bleeding b. Uterine irritability with contractions c. Vaginal bleeding and back pain d. Premature rupture of membranes ANS: C Bleeding accompanied by abdominal or lower back pain is a typical manifestation of abruptio placentae. The nurse is preparing a pregnant patient for an abdominal ultrasound at 8 weeks' gestation. What intervention will the nurse implement before this diagnostic test? a. Instruct the patient to take nothing by mouth after midnight the night before the test. b. Initiate an IV. c. Encourage the patient to drink 1 to 2 quarts of water before the test. d. Instruct the patient to remove all jewelry. ANS: C Ultrasound uses high-frequency sound waves to visualize structures within the body; the examination may use a transvaginal probe or an abdominal transducer; abdominal ultrasound during early pregnancy requires a full bladder for proper visualization (have the woman drink 1 to 2 quarts of water before the examination). The young prenatal patient with gestational diabetes mellitus (GDM) says, "I am frightened that I will have to deal with insulin injections for the rest of my life." What is the best response by the nurse? a. "After delivery your doctor will prescribe oral hypoglycemic medication to control your disease. Pills are so much simpler than insulin injections." b. "Have you considered an insulin pump?" c. "After a while those insulin injections won't seem so bad." d. "It will most likely resolve 6 weeks or so after the baby is born." ANS: D GDM usually resolves by 6 weeks after delivery. The nurse is caring for a prenatal patient diagnosed with a placenta previa. What is the best position for this patient? a. Flat on her back with knees flexed to help prevent haemorrhage b. On her side to prevent supine hypotension c. In the semi-Fowler's position to prevent supine hypotension d. In the knee-chest position to reduce pressure on the placenta ANS: B The prenatal patient with placenta previa is best placed on her side with a pillow for support. This position not only reduces stress on the placenta but also reduces the possibility of supine hypotension. A woman who is 35 weeks pregnant has a total placenta previa. She asks the nurse, "Will I be able to deliver vaginally?" What explanation by the nurse is the most appropriate? a. "Yes, you can deliver vaginally until 36 weeks." b. "A vaginal delivery can be attempted, but if bleeding occurs, a cesarean section will be done." c. "A cesarean section is performed when the mother has a total placenta previa." d. "There is no reason why you cannot have a vaginal delivery." ANS: C A cesarean delivery is done for a partial or total placenta previa. What drug will the nurse plan to have available for immediate IV administration whenever magnesium sulfate is administered to a maternity patient? a. Ergonovine maleate (Ergotrate) b. Oxytocin c. Calcium gluconate d. Hydralazine (Apresoline) ANS: C Calcium gluconate reverses the effects of magnesium sulfate and should be available for immediate use when a woman receives magnesium sulfate. A woman seeking prenatal care relates a history of macrosomic infants, two stillbirths, and polyhydramnios with each pregnancy. What does the nurse recognize these factors highly suggest? a. Toxoplasmosis b. Abruptio placentae c. Hydatidiform mole d. Diabetes mellitus ANS: D Large (macrosomic) infants over 9 pounds are linked to gestational diabetes. The nurse is caring for a pregnant woman diagnosed with preeclampsia. What will the nurse explain is the objective of magnesium sulfate therapy for this patient? a. To prevent convulsions b. To promote diaphoresis c. To increase reflex irritability d. To act as a saline cathartic ANS: A Magnesium sulfate is a central nervous system depressant given to prevent seizures. The nurse is caring for a pregnant woman receiving an intravenous infusion with magnesium sulfate. What is the most appropriate nursing intervention? a. Count respirations and report a rate of less than 12 breaths/min. b. Count respirations and report a rate of more than 20 breaths/min. c. Check blood pressure and report a rate of less than 100/60 mm Hg. d. Monitor urinary output and report a rate of less than 100 mL/hr. ANS: A Excessive magnesium sulfate may cause respiratory depression A patient who is 28 weeks pregnant presents with consistent hypertension. What need would the home health nurse make the first priority? a. Activity restriction b. Balanced nutrition c. Increased fluid intake to ensure adequate hydration d. Instruction about the effect of diuretics ANS: A Bed rest reduces the flow of blood to skeletal muscles, making more blood available to the placenta and enhancing fetal oxygenation. While caring for a laboring woman, the nurse notices a pattern of variable decelerations in fetal heart rate with uterine contractions. What is the nurse's initial action? a. Stop the oxytocin infusion. b. Increase the intravenous flow rate. c. Reposition the woman on her side. d. Start oxygen via nasal cannula. ANS: C Repositioning the woman is the first response to a pattern of variable decelerations. If the decelerations continue, then oxygen should be administered and/or the flow rate of oxygen should be increased. What is the best nursing action to implement when late decelerations occur? a. Reposition the patient to supine b. Decrease flow of intravenous (IV) fluids c. Increase oxygen to 10 L/minute d. Prepare to increase oxytocin drip ANS: C The major objective of care for late decelerations is to increase maternal oxygen. IV fluids are increased to increase placental perfusion, oxytocin drips are stopped, and the patient is positioned to prevent supine hypotension. At 1 and 5 minutes of life, a newborn's Apgar score is 9. What does the nurse understand that a score of 9 indicates? a. The newborn will require resuscitation. b. The newborn may have physical disabilities. c. The newborn will have above average intelligence. d. The newborn is in stable condition. ANS: D Apgar scoring is a system for evaluating the infant's need for resuscitation at birth. Five categories are evaluated on a scale from 0 to 2, with the highest score being 10. A score of 9 indicates that the newborn is stable. The physician performs an amniotomy on a laboring woman. What will be the nurse's priority assessment immediately following this procedure? a. Fetal heart rate b. Fluid amount c. Maternal blood pressure d. Deep tendon reflexes ANS: A The FHR should be assessed for at least 1 full minute after the membranes rupture and must be recorded and reported. Marked slowing of the rate or variable decelerations suggests that the fetal umbilical cord may have descended with the fluid gush and is being compressed. Fluid amount should be assessed and recorded but is not the top priority. Maternal blood pressure and deep tendon reflexes are not appropriate assessments following rupture of membranes. What is the most important nursing intervention during the fourth stage of labor? a. Monitor the frequency and intensity of contractions. b. Provide comfort measures. c. Assess for hemorrhage. d. Promote bonding. ANS: C Immediately after giving birth, every woman is assessed for signs of hemorrhage. The nurse formulates a nursing diagnosis for a woman in the fourth stage of labor. What is the most appropriate nursing diagnosis? a. Pain related to increasing frequency and intensity of contractions. b. Fear related to the probable need for cesarean delivery. c. Dysuria related to prolonged labor and decreased intake. d. Risk for injury related to hemorrhage. ANS: D In the fourth stage of labor, a priority nursing action is identifying and preventing hemorrhage. A woman who is 6 cm dilated has the urge to push. What will the nurse instruct the woman to do during the contraction? a. Use slow-paced breathing. b. Hold her breath and push. c. Blow in short breaths. d. Use rapid-paced breathing. ANS: C If a laboring woman feels the urge to push before the cervix is fully dilated, then she is taught to blow in short breaths to avoid bearing down. The nurse is preparing a teaching plan for a woman receiving a subarachnoid block before delivery. What nursing action will be included in this plan to prevent the associated side effect of this type of anesthesia? a. Restrict oral fluids. b. Keep legs flexed. c. Walk with assistance as soon as possible. d. Lie flat for several hours. ANS: D The woman would be advised to remain flat for several hours after the block to decrease the chance of postspinal headache. When a pregnant woman arrives at the labor suite, she tells the nurse that she wants to have an epidural for delivery. What is a contraindication to an epidural block? a. Abnormal clotting b. Previous cesarean delivery c. History of migraine headaches d. History of diabetes mellitus ANS: A An epidural block is not used if a woman has abnormal blood clotting. A woman who is 33 weeks pregnant is admitted to the obstetric unit because her membranes ruptured spontaneously. What complication should the nurse closely assess for with this patient? a. Chorioamnionitis b. Hemorrhage c. Hypotension d. Amniotic fluid embolism ANS: A Infection of the amniotic sac, called chorioamnionitis, may cause prematurely ruptured membranes, or it may be a consequence of rupture because the barrier to the uterine cavity is broken. The initial vaginal examination of a woman admitted to the labor unit reveals that the cervix is dilated 9 cm. The panicked woman begs the nurse, "Please give me something." What is the most appropriate pain relief intervention for a woman in precipitate labor? a. Get an order for an intravenous narcotic. b. Notify the anesthesiologist for an epidural block. c. Stay and breathe with her during contractions. d. Tell her to bear with it because she is close to delivery. ANS: C The nurse would stay with the woman experiencing precipitate labor and breathe with her during contractions to help the woman focus and cope with each contraction. A student nurse questions the instructor regarding what alteration should be made for the assessment of the fundus of a new postoperative cesarean section patient. What is the best response? a. The fundus is not assessed until the second postoperative day. b. The fundus is assessed by "walking" fingers from the side of the uterus to the midline. c. The fundus is assessed only if large clots appear in lochia. d. The fundus is assessed only once every shift. ANS: B Assessment of the fundus following a cesarean section is done as usual, but using especially gentle fundal massage. A woman required a cesarean section for safe delivery of her newborn. She is planning to breastfeed and verbalized concern about pain. What is the best suggestion by the nurse? a. "Consider formula feeding for the first few days." b. "Pumping breast milk would be best for now." c. "Take pain medication 30 to 40 minutes prior to nursing." d. "Use the football hold when breastfeeding." ANS: D The best answer is to encourage use of the football hold to decrease pressure on the operative site. There is no indication for the woman to formula feed or pump. Some pain medications should not be taken when breastfeeding. A woman has given birth to an unresponsive newborn that NICU staff are attempting to revive. The patient and her husband are grief stricken and request the child be baptized immediately. What is the nurse's most appropriate action? a. Contact the hospital chaplain. b. Request the couple's clergy. c. Baptize the newborn. d. Ask the physician to baptize the newborn. ANS: C If the condition of a newborn is poor, the parents may wish to have a baptism performed. The minister or priest is notified. However this is an emergency, so the nurse may perform the baptism by pouring water on the infant's forehead while saying, "I baptize you in the name of the Father, and of the Son, and of the Holy Spirit." If there is any doubt as to whether the infant is alive, the baptism is given conditionally: "If you are capable of receiving baptism, I baptize you in the name of the Father, and of the Son, and of the Holy Spirit." The physician is attending to the patient's immediate health needs. In the recovery room, the nurse checks the newly delivered woman's fundus following a cesarean section. How would the nurse proceed with this assessment? a. Palpate from the midline to the side of the body. b. Palpate from the symphysis to the umbilicus. c. Palpate from the side of the uterus to the midline. d. Massage the abdomen in a circular motion. ANS: C The fundus is checked gently by walking the fingers from the side of the uterus to the midline. A primipara tells the nurse, "My afterpains get worse when I am breastfeeding." What is the most appropriate nursing response? a. "I'll get you some aspirin to relieve the cramping that you feel." b. "Afterpains are more intense with your first baby." c. "Breastfeeding releases a hormone that causes your uterus to contract." d. "A change of position when you're breastfeeding might help." ANS: C Breastfeeding mothers may have more afterpains because infant suckling causes the posterior pituitary to release oxytocin, which is a hormone that contracts the uterus. A woman will be discharged 48 hours after a vaginal delivery. When planning discharge teaching, the nurse would include what information about lochia? a. Lochia should disappear 2 to 4 weeks postpartum. b. It is normal for the lochia to have a slightly foul odor. c. A change in lochia from pink to bright red should be reported. d. A decrease in flow will be noticed with ambulation and activity. ANS: C A return to bright red lochia rubra may indicate a late postpartum hemorrhage and must be reported. Although the child with type 1 diabetes had her prescribed insulin at 7:30 AM, the child is complaining of hunger and thirst and is drowsy at 10:30 AM. What should the nurse do first? a. Walk the patient in the hall for 10 minutes. b. Allow the patient a short nap. c. Give her a cup of orange juice. d. Test her blood with a glucometer and give insulin according to the sliding scale. c. A child with diabetes mellitus is observed to have cold symptoms. What signs and symptoms will alert parents of the possibility of ketoacidosis? (Select all that apply.) a. Chest congestion b. Ear pain c. Fruity breath d. Hyperactivity e. Nausea C & E What does the nurse instruct a 12-year-old to do when teaching how to administer insulin? a. Make sure injection sites are 6 inches apart. b. Select an injection site that was recently exercised. c. Inject the needle at a 90-degree angle. d. Give the injection deep into the muscle c. Inject the needle at a 90-degree angle. The nurse discussed treatment of hypoglycemia with an adolescent. Which statement by the adolescent leads the nurse to determine the patient understood the instructions? a. When my blood glucose is low or if I begin to feel hungry and weak, I will eat six LifeSavers. b. When my blood glucose is low or if I begin to feel hungry and weak, I will give myself Lispro insulin. c. When my blood glucose is low or if I begin to feel hungry and weak, I will have a slice of cheese. d. When my blood glucose is low or if I begin to feel hungry and weak, I will drink a diet soda a. When my blood glucose is low or if I begin to feel hungry and weak, I will eat six LifeSavers. The nurse asks, "Do your parents drink every day?" The adolescent suddenly shouts, "I'm not going to talk about that! It's none of your business, anyway! Leave me alone!" How does the nurse interpret the adolescent's behavior? a. The adolescent is acting out and needs to be brought under control so the conference can continue. b. The adolescent is trying to shift the focus of the conference away from himself, and the nurse needs to refocus. c. The adolescent is demonstrating that this problem requires the assistance of a psychiatrist. d. The adolescent is responding to the discrediting of his parents, which causes anxiety. d. The adolescent is responding to the discrediting of his parents, which causes anxiety. A 15-year-old boy was previously active in a band and saved money to buy a special guitar. What would a nurse assess as an early sign of depression in this boy? a. He gives up the band to spend time with his girlfriend. b. He spends all of his time at the library studying to qualify for the honor society. c. He gives his guitar away and spends his time listening to music in his room. d. He withdraws all of his money out of the bank to buy an expensive leather jacket. He gives his guitar away and spends his time listening to music in his room. A mother is concerned because her adolescent son is always in trouble for fighting at school and always seems to be angry. She mentions that her husband drinks a bit. Which understanding will guide the nurse's response? a. The boy is displaying antisocial behavior and should be evaluated for mental illness. b. The boy is displaying one of the typical defense patterns of children of alcoholics and should receive immediate treatment. c. The mother is displaying her own anger with her husband's drinking, and she needs immediate intervention. d. The boy is only one member of the family affected by alcoholism, and all members should receive immediate intervention. The boy is only one member of the family affected by alcoholism, and all members should receive immediate intervention. An adolescent is brought to the emergency department after an automobile accident. When the nurse approaches the adolescent, he becomes combative. The nurse notes his speech is slurred and his gait is ataxic. What does the nurse suspect the adolescent has used? a. Alcohol b. Cocaine c. Amphetamines d. PCP Alcohol A 9-year-old child hospitalized for neutropenia is placed in protective isolation. What is the most appropriate response for the nurse to make when the child asks, "Why do you have to wear a gown and mask when you are in my room?" a. "Nurses and doctors wear gowns and masks because you have a condition that could be spread to others." b. "The gown and mask are to protect you because you could get an infection very easily." c. "I'm wearing this because there are a lot of bacteria in the hospital." d. "I might look scary but you won't need this after you have had medication for 24 hours." "The gown and mask are to protect you because you could get an infection very easily." The home health nurse discovers a family infected with pediculosis. What information can the nurse provide to the mother to start eradication of the lice? a. Cover the hair with Vaseline. b. Apply a soda-vinegar solution to the hair. c. Comb through the hair with a vinegar-water solution. d. Shampoo the hair with dish detergent c. Comb through the hair with a vinegar-water solution. The nurse caring for a patient with severe frostbite observes a purple flush on the hands and feet. What is the most appropriate nursing action? a. Report this sign immediately. b. Place a warm towel over the extremities. c. Gently sponge with cool water. d. Medicate for pain. Medicate for pain A 5-year-old boy is brought to the emergency department with a second-degree burn of his entire right arm and hand, anterior trunk and genital area, and front of right thigh. The nurse assesses the body surface area (BSA) percentage burn as %. ANS: 26 A child is brought to the emergency department with severe frostbite. Which body parts should be warmed first? a. Hands and arms b. Feet and legs c. Fingers and toes d. Head and torso ANS: D In extreme cases of exposure to freezing temperatures, the head and torso should be warmed before the extremities. The nurse is assisting with an admission assessment of a child with scarlet fever. Which actions will the nurse expect to implement? (Select all that apply.) a. Obtain a throat culture. b. Encourage ambulation. c. Assess for desquamation. d. Initiate droplet precautions. e. Administer isoniazid. ANS: A, C