Maternal Child NCLEX Review Questions and Answers | 100% Correct!!

Maternal Child NCLEX Review Questions and Answers | 100% Correct!! A nurse is assessing a premature infant. What would initially alert the nurse that the infant is having respiratory distress? A. Flaring nostrils B. Sporadic crying C. Ineffective cough D. Decreased pulse rate -Answer-Answer: A Rationale: In attempt to increase intake of oxygen, the respiratory rate increases with flaring of nostrils as a cardinal sign. It is significant to note that when a neonate is in respiratory distress, the rate of respirations will increase. Sporadic crying, ineffective cough, and decreased pulse rate may be indicative of infant distress but are not classic signs of respiratory distress. A newborn infant is diagnosed with a patent ductus arteriosus (PDA). The nurse is aware that this is indicative of a defect that: A. typically results in cyanosis B. may result in congestive heart failure C. also causes pulmonary stenosis D. normally does not close after birth -Answer-Answer: B Rationale: Defects that result in increased pulmonary blood flow such as patent ductus arteriosus (PDA) and other atrial and ventricular septal defects may cause congestive heart failure. PDA is a vascular connection that during fetal life bypasses the pulmonary vascular bed and directs blood from the pulmonary artery to the aorta. Defects that involve decreased pulmonary blood (such as tetralogy of Fallot) or obstruction to blood flow out of the heart (such as pulmonary stenosis) typically result in cyanosis. PDA does not cause pulmonary stenosis. A PDA normally closes soon after birth. If the ductus does remain open after birth, the direction of blood flow in the ductus is reversed by the higher pressure in the aorta, so there may not be any signs of the disorder. Which of the following signs would alert a nurse to withdrawal in the infant of a mother addicted to heroin? A. lethargy and a lack of appetite B. restlessness, irritability, and tremors C. no crying and hypoactive reflexes D. hyperactive reflexes and diaphoresis -Answer-Answer: B Rationale: Heroin does cross the placental barrier; therefore the infant is born addicted to heroin and will display signs of withdrawal such as restlessness, irritability, and tremors. The items listed in answer options A, C, and D are not associated with heroin withdrawal. A neonate weights 8 lb, 1 oz at birth. At age 3 days, the weight has decreased to 7 lb, 12 oz. The nurse should instruct the mother to: A. increase the amount of formula to prevent further dehydration and weight loss B. continue feeding on demand because the noted weight loss is within normal limits C. give additional feedings because the weight loss indicates inadequate caloric intake D. switch to a different formula because the current one is inadequate to maintain weight -Answer-Answer: B Rationale: Neonates tend to lose 5% -- 10% of their birth weight during the first few days after birth, mostly because of decreased, but acceptable, nutrition and extracellular fluid loss. Increasing formula volumes and feedings or changing the formula is not necessary in this situation. A nurse explains to a new mother reasons for her newborn's cranial molding and determines that the mother needs further instruction when she makes which of the following statements? A. "The molding should disappear within a few days." B. "The molding is caused by an overriding of the cranial bones." C. "The brain may be damaged if the molding doesn't resolve quickly." D. "The amount of molding is related to the amount and length of pressure on the head." -Answer-Answer: C Rationale: Brain damage is not directly associated with cranial molding. During vaginal delivery, the cranial bones tend to override when the head accommodates the size of the mother's birth canal. The amount and length of pressure influence the degree of molding, which usually disappears in a few days without any other interventions or long- lasting effects. An infant is born with Down syndrome should be assessed for which condition? A. Clubfoot B. Cleft palate C. Cardiac defect D. Choanal atresia -Answer-Answer: C Rationale: Approximately 30% -- 40% of infants born with Down Syndrome have congenital heart defects, typically endocardial cushion defects. Clubfoot, cleft palate, and choanal atresia are all congenital defects. Clubfoot is a deformity in which portions of the foot and ankle are twisted out of normal position. A cleft palate is incomplete closure of the palate resulting in failure of the primary palate to fuse. Choanal atresia is an obstruction of the posterior nares by tissue or bone. A nursery nurse performs an initial newborn assessment and checks the umbilical cord to identify which normal finding? A. One artery and two veins B. One artery and one vein C. Two arteries and two veins D. Two arteries and one vein -Answer-Answer: D