MOTHER BABY EXAM 1 REVIEW W/RATIONALES P5
A nurse is providing education to a client during the first prenatal visit. Which of the
following statements by the client should indicate to the nurse a need for clarification? -
Answers - "I should increase my calcium intake to 1,500 milligrams per day"
Answer Rationale:
A woman's dietary reference intake (DRI) of calcium for pregnancy and lactation is
the same for a woman who is not pregnant. The DRI for a woman older than 19
years of age is 1,000 mg/day, which should supply enough calcium for fetal bone
and tooth development and to maintain maternal bone mass.
A nurse is providing teaching to a client who is planning on becoming pregnant about
the changes she should expect. Identify the sequence of maternal changes. (Move the
steps into the box on the right, placing them in the selected order of performance. Use
all the steps.) - Answers - 1)Amenorrhea
2) Goodell's sign
3) Quickening
4) Lightening
A nurse is reinforcing teaching about contraceptive methods with a client. Which of the
following should the nurse recognize as a contraindication for diaphragm use? -
Answers - The client has pelvic relaxation.
Answer Rationale:
Pelvic relaxation and large cystocele are contraindications for diaphragm use.
A nurse is caring for a client following an amniotomy who is now in the active phase of
the first stage of labor. Which of the following actions should the nurse implement with
this client? - Answers - Encourage the client to empty her bladder every 2 hr.
Answer Rationale:
A client in labor should be encouraged to empty her bladder every 2 hr. Bladder
distention can impede the descent of the fetus and slow the progression of labor. It
can also contribute to uterine atony after delivery, increasing the client's risk of
postpartum hemorrhage.
A nurse is reinforcing teaching about reducing perineal infection with a client following a
vaginal delivery. Which of the following should the nurse include in the teaching? (Select
all that apply.) - Answers - Blot the perineal area dry after cleansing.
Clean the perineal area from front to back.
Perform hand hygiene before and after voiding.
Wash the perineal area using a squeeze bottle of warm water after each
, voiding.
Answer Rationale:
Blot the perineal area dry is correct. Good perineal care is important to clean the
skin folds, which often contain secretions that act as a medium for micro-organism
growth. Therefore, the area should be thoroughly dried by blotting.
Clean the perineal area from front to back is correct. Good perianal care is
important to clean the skin folds, which often contain secretions that harbor
microorganisms. Wiping from front to back decreases the chances of transmitting fecal
organisms to other areas, such as the urinary meatus, episiotomy incision, or
lacerations resulting from childbirth.
Perform hand hygiene before and after voiding is correct. Hand hygiene is the
primary method of reducing micro-organisms on the hands and thereby reducing
the risk of transmission that can lead to infection.
Wash the perineal area using a squeeze bottle of warm water after each
voiding is correct. Rinsing with a solution of water is more effective at removing
micro-organisms than wiping.
A nurse is assisting with the care of a newborn immediately following birth. Which of the
following medications should the nurse anticipate administering? (Select all that apply.) -
Answers - Vitamin K injection
Hepatitis B immunization
Antibiotic ointment to both eyes
A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following
actions should the nurse anticipate in the care of this client? (Select all that apply.) -
Answers - Document fundal height.
Observe the lochia during palpation of fundus.
Determine whether the fundus is midline.
Administer methylergonovine maleate if uterus is boggy.
A nurse is reinforcing teaching about newborn care with a postpartum client. Which of
the following statements by the client indicates a need for further teaching? - Answers -
"Baby powder will help prevent a diaper rash."
Answer Rationale:
Lotions, creams, oils, or powders can alter a newborn's skin and provide a medium
for bacterial growth or cause an allergic response. Powders can be inhaled, leading
to respiratory distress. This statement requires the nurse to clarify instruction on
newborn care.
A nurse is providing teaching about expected gestational changes to a client who is at
12 weeks of gestation. Which of the following statements by the client indicates a need
for further teaching? - Answers - "I will use only nonprescription medications while
pregnant."
A nurse is providing education to a client during the first prenatal visit. Which of the
following statements by the client should indicate to the nurse a need for clarification? -
Answers - "I should increase my calcium intake to 1,500 milligrams per day"
Answer Rationale:
A woman's dietary reference intake (DRI) of calcium for pregnancy and lactation is
the same for a woman who is not pregnant. The DRI for a woman older than 19
years of age is 1,000 mg/day, which should supply enough calcium for fetal bone
and tooth development and to maintain maternal bone mass.
A nurse is providing teaching to a client who is planning on becoming pregnant about
the changes she should expect. Identify the sequence of maternal changes. (Move the
steps into the box on the right, placing them in the selected order of performance. Use
all the steps.) - Answers - 1)Amenorrhea
2) Goodell's sign
3) Quickening
4) Lightening
A nurse is reinforcing teaching about contraceptive methods with a client. Which of the
following should the nurse recognize as a contraindication for diaphragm use? -
Answers - The client has pelvic relaxation.
Answer Rationale:
Pelvic relaxation and large cystocele are contraindications for diaphragm use.
A nurse is caring for a client following an amniotomy who is now in the active phase of
the first stage of labor. Which of the following actions should the nurse implement with
this client? - Answers - Encourage the client to empty her bladder every 2 hr.
Answer Rationale:
A client in labor should be encouraged to empty her bladder every 2 hr. Bladder
distention can impede the descent of the fetus and slow the progression of labor. It
can also contribute to uterine atony after delivery, increasing the client's risk of
postpartum hemorrhage.
A nurse is reinforcing teaching about reducing perineal infection with a client following a
vaginal delivery. Which of the following should the nurse include in the teaching? (Select
all that apply.) - Answers - Blot the perineal area dry after cleansing.
Clean the perineal area from front to back.
Perform hand hygiene before and after voiding.
Wash the perineal area using a squeeze bottle of warm water after each
, voiding.
Answer Rationale:
Blot the perineal area dry is correct. Good perineal care is important to clean the
skin folds, which often contain secretions that act as a medium for micro-organism
growth. Therefore, the area should be thoroughly dried by blotting.
Clean the perineal area from front to back is correct. Good perianal care is
important to clean the skin folds, which often contain secretions that harbor
microorganisms. Wiping from front to back decreases the chances of transmitting fecal
organisms to other areas, such as the urinary meatus, episiotomy incision, or
lacerations resulting from childbirth.
Perform hand hygiene before and after voiding is correct. Hand hygiene is the
primary method of reducing micro-organisms on the hands and thereby reducing
the risk of transmission that can lead to infection.
Wash the perineal area using a squeeze bottle of warm water after each
voiding is correct. Rinsing with a solution of water is more effective at removing
micro-organisms than wiping.
A nurse is assisting with the care of a newborn immediately following birth. Which of the
following medications should the nurse anticipate administering? (Select all that apply.) -
Answers - Vitamin K injection
Hepatitis B immunization
Antibiotic ointment to both eyes
A nurse is caring for a client who had a vaginal delivery 2 hr ago. Which of the following
actions should the nurse anticipate in the care of this client? (Select all that apply.) -
Answers - Document fundal height.
Observe the lochia during palpation of fundus.
Determine whether the fundus is midline.
Administer methylergonovine maleate if uterus is boggy.
A nurse is reinforcing teaching about newborn care with a postpartum client. Which of
the following statements by the client indicates a need for further teaching? - Answers -
"Baby powder will help prevent a diaper rash."
Answer Rationale:
Lotions, creams, oils, or powders can alter a newborn's skin and provide a medium
for bacterial growth or cause an allergic response. Powders can be inhaled, leading
to respiratory distress. This statement requires the nurse to clarify instruction on
newborn care.
A nurse is providing teaching about expected gestational changes to a client who is at
12 weeks of gestation. Which of the following statements by the client indicates a need
for further teaching? - Answers - "I will use only nonprescription medications while
pregnant."
