Maternal & Child Practice Exam 2

Maternal & Child Practice Exam 2 The postterm neonate with meconium-stained amniotic fluid needs care designed to especially monitor for which of the following? A Elimination problems B Respiratory problems C Integumentary problems D Gastrointestinal problems Intrauterine anoxia may cause relaxation of the anal sphincter and emptying of meconium into the amniotic fluid. At birth some of the meconium fluid may be aspirated, causing mechanical obstruction or chemical pneumonitis. The infant is not at increased risk for gastrointestinal problems. Even though the skin is stained with meconium, it is noninfectious (sterile) and nonirritating. The postterm meconium-stained infant is not at additional risk for bowel or urinary problems. A newborn who has an asymmetrical Moro reflex response should be further assessed for which of the following? A Fractured clavicle B Increased intracranial pressure C Talipes equinovarus D Congenital hypothyroidism A fractured clavicle would prevent the normal Moro response of symmetrical sequential extension and abduction of the arms followed by flexion and adduction. In talipes equinovarus (clubfoot) the foot is turned medially, and in plantar flexion, with the heel elevated. The feet are not involved with the Moro reflex. Hypothyroiddism has no effect on the primitive reflexes. Absence of the Moror reflex is the most significant single indicator of central nervous system status, but it is not a sign of increased intracranial pressure. The amniotic fluid of a client has a greenish tint. The nurse interprets this to be the result of which of the following? A Lanugo B Vernix C Hydramnio D Meconium The greenish tint is due to the presence of meconium. Lanugo is the soft, downy hair on the shoulders and back of the fetus. Hydramnios represents excessive amniotic fluid. Vernix is the white, cheesy substance covering the fetus. A multigravida at 38 weeks' gestation is admitted with painless, bright red bleeding and mild contractions every 7 to 10 minutes. Which of the following assessments should be avoided? A Maternal vital sign B Fetal heart rate C Cervical dilation D Contraction monitoring The signs indicate placenta previa and vaginal exam to determine cervical dilation would not be done because it could cause hemorrhage. Assessing maternal vital signs can help determine maternal physiologic status. Fetal heart rate is important to assess fetal well-being and should be done. Monitoring the contractions will help evaluate the progress of labor. When preparing to listen to the fetal heart rate at 12 weeks' gestation, the nurse would use which of the following? A Stethoscope placed midline at the umbilicus B Doppler placed midline at the suprapubic region C Fetoscope placed midway between the umbilicus and the xiphoid process D External electronic fetal monitor placed at the umbilicus At 12 weeks gestation, the uterus rises out of the pelvis and is palpable above the symphysis pubis. The Doppler intensifies the sound of the fetal pulse rate so it is audible. The uterus has merely risen out of the pelvis into the abdominal cavity and is not at the level of the umbilicus. The fetal heart rate at this age is not audible with a stethoscope. The uterus at 12 weeks is just above the symphysis pubis in the abdominal cavity, not midway between the umbilicus and the xiphoid process. At 12 weeks the FHR would be difficult to auscultate with a fetoscope. Although the external electronic fetal monitor would project the FHR, the uterus has not risen to the umbilicus at 12 weeks. The nurse assesses the vital signs of a client, 4 hours' postpartum that are as follows: BP 90/60; temperature 100.4ºF; pulse 100 weak, thready; R 20 per minute. Which of the following shouldthe nurse do first? A Recheck the blood pressure with another cuff B Report the temperature to the physician C Assess the uterus for firmness and position D Determine the amount of lochia A weak, thready pulse elevated to 100 BPM may indicate impending hemorrhagic shock. An increased pulse is a compensatory mechanism of the body in response to decreased fluid volume. Thus, the nurse should check the amount of lochia present. Temperatures up to 100.48F in the first 24 hours after birth are related to the dehydrating effects of labor and are considered normal. Although rechecking the blood pressure may be a correct choice of action, it is not the first action that should be implemented in light of the other data. The data indicate a potential impending hemorrhage. Assessing the uterus for firmness and position in relation to the umbilicus and midline is important, but the nurse should check the extent of vaginal bleeding first. Then it would be appropriate to check the uterus, which may be a possible cause of the hemorrhage. For the client who is using oral contraceptives, the nurse informs the client about the need to take the pill at the same time each day to accomplish which of the following? A Prevent drug interactions B Decrease the incidence of nausea C Maintain hormonal levels D Reduce side effects Regular timely ingestion of oral contraceptives is necessary to maintain hormonal levels of the drugs to suppress the action of the hypothalamus and anterior pituitary leading to inappropriate secretion of FSH and LH. Therefore, follicles do not mature, ovulation is inhibited, and pregnancy is prevented. The estrogen content of the oral site contraceptive may cause the nausea, regardless of when the pill is taken. Side effects and drug interactions may occur withoral contraceptives regardless of the time the pill is taken. .............