Maternal & Child Health Nursing NCLEX part 7
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PDF format, Answers and Rationales are available at the end of this questions.
1. During which of the following stages of labor would
the nurse assess “crowning”?
A. First stage
B. Second stage+
C. Third stage
D. Fourth stage
2. Barbiturates are usually not given for pain relief
during active labor for which of the following reasons?
A. The neonatal effects include hypotonia,
hypothermia, generalized drowsiness, and reluctance to feed for the first few
days.
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. Adverse reactions may include maternal hypotension,
allergic or toxic reaction or partial or total respiratory failure
3. Which of the following nursing interventions would
the nurse perform during the third stage of labor?
A. Obtain a urine specimen and other laboratory tests.
B. Assess uterine contractions every 30 minutes.
C. Coach for effective client pushing
D. Promote parent-newborn interaction.
4. Which of the following actions demonstrates the
nurse’s understanding of the newborn’s thermoregulatory ability?
A. Placing the newborn under a radiant warmer.
B. Suctioning with a bulb syringe
C. Obtaining an Apgar score
D. Inspecting the newborn’s umbilical cord
5. Immediately before expulsion, which of the
following cardinal movements occur?
A. Descent
B. Flexion
C. Extension
D. External rotation
6. Before birth, which of the following structures
connects the right and left auricles of the heart?
A. Umbilical vein
B. Foramen ovale
C. Ductus arteriosus
D. Ductus venosus
7. Which of the following when present in the urine
may cause a reddish stain on the diaper of a newborn?
A. Mucus
B. Uric acid crystals
C. Bilirubin
D. Excess iron
8. 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. 100 beats per minute
C. 120 beats per minute
D. 140 beats per minute
9. Which of the following is true regarding the
fontanels of the newborn?
A. The anterior is triangular shaped; the posterior is
diamond shaped.
B. The posterior closes at 18 months; the anterior
closes at 8 to 12 weeks.
C. The anterior is large in size when compared to the
posterior fontanel.
D. The anterior is bulging; the posterior appears
sunken.
10. Which of the following groups of newborn reflexes
below are present at birth and remain unchanged through adulthood?
A. Blink, cough, rooting, and gag
B. Blink, cough, sneeze, gag
C. Rooting, sneeze, swallowing, and cough
D. Stepping, blink, cough, and sneeze
11. 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
12. Which of the following statements best describes
hyperemesis gravidarum?
A. Severe anemia leading to an electrolyte, metabolic,
and nutritional imbalances in the absence of other medical problems.
B. Severe nausea and vomiting leading to an
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
13. Which of the following would the nurse identify as
a classic sign of PIH?
A. Edema of the feet and ankles
B. Edema of the hands and face
C. Weight gain of 1 lb/week
D. Early morning headache
14. In which of the following types of spontaneous
abortions would the nurse assess dark brown vaginal discharge and a negative
pregnancy test?
A. Threatened
B. Imminent
C. Missed
D. Incomplete
15. 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
16. 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
17. 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. Ectopic pregnancy
C. Incompetent cervix
D. Abruptio placentae
18. Which of the following may happen if the uterus
becomes overstimulated by oxytocin during the induction of labor?
A. Weak contraction prolonged to more than 70 seconds
B. Tetanic contractions prolonged to more than 90
seconds
C. Increased pain with bright red vaginal bleeding
D. Increased restlessness and anxiety
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
20. Which of the following best describes preterm
labor?
A. Labor that begins after 20 weeks gestation and
before 37 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 28 weeks gestation and before
40 weeks gestation
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. PROM removes the fetus most effective defense
against infection
C. Nursing care is based on fetal viability and
gestational age.
D. PROM is associated with malpresentation and
possibly incompetent cervix
22. Which of the following factors is the underlying
cause of dystocia?
A. Nutritional
B. Mechanical
C. Environmental
D. Medical
23. When uterine rupture occurs, which of the
following would be the priority?
A. Limiting hypovolemic shock
B. Obtaining blood specimens
C. Instituting complete bed rest
D. Inserting a urinary catheter
24. Which of the following is the nurse’s initial
action when umbilical cord prolapse occurs?
A. Begin monitoring maternal vital signs and FHR
B. Place the client in a knee-chest position in bed
C. Notify the physician and prepare the client for delivery
D. Apply a sterile warm saline dressing to the exposed
cord
25. Which of the following amounts of blood loss
following birth marks the criterion for describing postpartum hemorrhage?
A. More than 200 ml
B. More than 300 ml
C. More than 400 ml
D. More than 500 ml
26. 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. Endemic infection occurring randomly and localizing
in the peri glandular connective tissue
C. Temporary urinary retention due to decreased
perception of the urge to avoid
D. Breast injury caused by overdistention, stasis, and
cracking of the nipples
27. Which of the following best describes
thrombophlebitis?
A. Inflammation and clot formation that result when
blood components combine to form an aggregate body
B. Inflammation and blood clots that eventually become
lodged within the pulmonary blood vessels
C. Inflammation and blood clots that eventually become
lodged within the femoral vein
D. Inflammation of the vascular endothelium with clot
formation on the vessel wall
28. Which of the following assessment findings would
the nurse expect if the client develops DVT?
A. Midcalf pain, tenderness and redness along the vein
B. Chills, fever, malaise, occurring 2 weeks after
delivery
C. Muscle pain the presence of Homans sign, and
swelling in the affected limb
D. Chills, fever, stiffness, and pain occurring 10 to
14 days after delivery
29. Which of the following are the most commonly
assessed findings in cystitis?
A. Frequency, urgency, dehydration, nausea, chills,
and flank pain
B. Nocturia, frequency, urgency dysuria, hematuria,
fever and suprapubic pain
C. Dehydration, Hypertension, dysuria, suprapubic
pain, chills, and fever
D. High fever, chills, flank pain nausea, vomiting,
dysuria, and frequency
30. Which of the following best reflects the frequency
of reported postpartum “blues”?
A. Between 10% and 40% of all new mothers report some
form of postpartum blues
B. Between 30% and 50% of all new mothers report some
form of postpartum blues
C. Between 50% and 80% of all new mothers report some
form of postpartum blues
D. Between 25% and 70% of all new mothers report some
form of postpartum blues
Answers and Rationale
1. Answer: B. Second stage
Crowing, which occurs when the newborn’s head or
presenting part appears at the vaginal opening, occurs during the second stage
of labor.
Option A: During the first stage of labor, cervical
dilation and effacement occur.
Option C: During the third stage of labor, the newborn
and placenta are delivered.
Option D: 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.
2. Answer: C. They rapidly transfer across the
placenta, and lack of an antagonist make them generally inappropriate during
labor.
Barbiturates are rapidly transferred across the placental
barrier, and lack of an antagonist makes them generally inappropriate during
active labor.
Option A: 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.
Option B:
Narcotic analgesic readily crosses the placental barrier, causing
depressive effects in the newborn 2 to 3 hours after intramuscular injection.
Option D:
Regional anesthesia is associated with adverse reactions such as
maternal hypotension, allergic or toxic reaction, or partial or total
respiratory failure.
3. Answer: D. Promote parent-newborn interaction.
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.
Option A: Collecting a urine specimen and other
laboratory tests is done on admission during the first stage of labor.
Option B: Assessing uterine contractions every 30
minutes is performed during the latent phase of the first stage of labor.
Option D: Coaching the client to push effectively is
appropriate during the second stage of labor.
4. Answer: A. Placing the newborn under a radiant
warmer.
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.
Option B: Suctioning with a bulb syringe helps
maintain a patent airway.
Option C: Obtaining an Apgar score measures the
newborn’s immediate adjustment to extrauterine life.
Option D: Inspecting the umbilical cord aids in
detecting cord anomalies.
5. Answer: D. External rotation
Immediately before expulsion or birth of the rest of
the body, the cardinal movement of external rotation occurs.
Options A, B, and C: Descent flexion, internal
rotation, extension, and restitution (in this order) occur before external
rotation.
6. Answer: B. Foramen ovale
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.
Options A, C, and D: The umbilical vein, ductus
arteriosus, and ductus venosus are obliterated at birth.
7. Answer: B. Uric acid crystals
Uric acid crystals in the urine may produce the
reddish “brick dust” stain on the diaper.
Option A: Mucus would not produce a stain.
Options C and D: Bilirubin and iron are from hepatic adaptation.
8. Answer: B. 100 beats per minute
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.
9. Answer: C. The anterior is large in size when
compared to the posterior fontanel.
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.
10. Answer: B. Blink, cough, sneeze, gag
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.
11. Answer: 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.
With the Babinski reflex, the newborn’s toes
hyperextend and fan apart from dorsiflexion of the big toe when one side of the
foot is stroked upward from the heel and across the ball of the foot.
Option B: With the startle reflex, the newborn abducts
and flexes all extremities and may begin to cry when exposed to sudden movement
of loud noise.
Option C: 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.
Option D: 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.
12. Answer: B. Severe nausea and vomiting leading to
the electrolyte, metabolic, and nutritional imbalances in the absence of other
medical problems.
The description of hyperemesis gravidarum includes
severe nausea and vomiting, leading to the electrolyte, metabolic, and
nutritional imbalances in the absence of other medical problems.
Option A: Hyperemesis is not a form of anemia.
Option C: Loss of appetite may occur secondary to
nausea and vomiting of hyperemesis, which, if it continues, can deplete the
nutrients transported to the fetus.
Option D:
Diarrhea does not occur with hyperemesis.
13. Answer: B. Edema of the hands and face
Edema of the hands and face is a classic sign of PIH.
Option A: Many healthy pregnant woman experience foot
and ankle edema.
Option C: A weight gain of 2 lb or more per week
indicates a problem.
Option D: Early morning headache is not a classic sign
of PIH.
14. Answer: C. Missed
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.
Option A: A threatened abortion is evidenced with
cramping and vaginal bleeding in early pregnancy, with no cervical dilation.
Option B: An imminent-abortion indicated by bleeding
and pain along with an effaced cervix.
Option D: An incomplete abortion involves only
expulsion of part of the products of conception and bleeding occurs with
cervical dilation.
15. Answer: A. Multiple gestation
Multiple gestation is one of the predisposing factors
that may cause placenta previa.
Options B, C, and D: Uterine anomalies abdominal
trauma and renal or vascular disease may predispose a client to abruptio
placentae.
16. Answer: B. Concealed or external dark red bleeding
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 board-like, and the fetal presenting part may
be engaged.
Options A, C, and D: Bright red, painless vaginal
bleeding, a palpable fetal outline, and a soft non-tender abdomen are
manifestations of placenta previa.
17. Answer: D. Abruptio placentae
Abruptio placentae is described as premature
separation of a normally implanted placenta during the second half of
pregnancy, usually with severe hemorrhage.
Option A: Placenta previa refers to implantation of
the placenta in the lower uterine segment, causing painless bleeding in the
third trimester of pregnancy.
Option B: Ectopic pregnancy refers to the implantation
of the products of conception in a site other than the endometrium.
Option C: Incompetent cervix is a conduction characterized
by painful dilation of the cervical os without uterine contractions.
18. Answer: B. Tetanic contractions prolonged to more
than 90 seconds
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.
Option A: Weak contractions would not occur.
Options C and D: Pain, bright red vaginal bleeding,
and increased restlessness and anxiety are not associated with
hyperstimulation.
19. Answer: C. Modify preoperative teaching to meet
the needs of either a planned or emergency cesarean birth
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.
Option A: 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.
Option B: Arranging for necessary explanations by
various staff members to be involved with the client’s care is a nursing
responsibility.
Option D: 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.
20. Answer: A. Labor that begins after 20 weeks
gestation and before 37 weeks gestation
Preterm labor is best described as labor that begins
after 20 weeks’ gestation and before 37 weeks’ gestation. The other time
periods are inaccurate.
21. Answer: B. PROM removes the fetus most effective
defense against infection
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.
Option A: Typically, PROM occurs about 1 hour, not 4
hours, before labor begins.
Option C: Fetal viability and gestational age are less
immediate considerations that affect the plan of care.
Option D: Malpresentation and an incompetent cervix
may be causes of PROM.
22. Answer: B. Mechanical
Dystocia is difficult, painful, prolonged labor due to
mechanical factors involving the fetus (passenger), uterus (powers), pelvis
(passage), or psyche.
Options A, C, and D: Nutritional, environment, and
medical factors may contribute to the mechanical factors that cause dystocia.
23. Answer: A. Limiting hypovolemic shock
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.
Options B, C, and D: Obtaining blood specimens,
instituting complete bed rest and inserting a urinary catheter are necessary
for preparation for surgery to remedy the rupture.
24. Answer: B. Place the client in a knee-chest
position in bed
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.
Options A, C, and D: 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.
25. Answer: D. More than 500 ml
Postpartum hemorrhage is defined as blood loss of more
than 500 ml following birth. Any amount less than this not considered
postpartum hemorrhage.
26. Answer: D. Breast injury caused by overdistention,
stasis, and cracking of the nipples
With mastitis, injury to the breast, such as
overdistention, stasis, and cracking of the nipples, is the primary
predisposing factor.
Options A and B: Epidemic and endemic infections are
probable sources of infection for mastitis.
Option D: 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.
27. Answer: D. Inflammation of the vascular endothelium
with clot formation on the vessel wall
Thrombophlebitis refers to an inflammation of the
vascular endothelium with clot formation on the wall of the vessel.
Option A: Blood components combining to form an
aggregate body describe a thrombus or thrombosis
Options B and C: Clots lodging in the pulmonary
vasculature refers to pulmonary embolism; in the femoral vein, femoral
thrombophlebitis.
28. Answer: C. Muscle pain the presence of Homans
sign, and swelling in the affected limb
Classic symptoms of DVT include muscle pain, the
presence of Homans sign, and swelling of the affected limb.
Option A: Midcalf pain, tenderness, and redness, along
the vein reflect superficial thrombophlebitis.
Option B: Chills, fever and malaise occurring 2 weeks
after delivery reflect pelvic thrombophlebitis.
Option D: Chills, fever, stiffness and pain occurring 10 to 14 days
after delivery suggest femoral thrombophlebitis.
29. Answer: B. Nocturia, frequency, urgency dysuria,
hematuria, fever and suprapubic pain
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 pyelonephritis.
30. Answer: C. Between 50% and 80% of all new mothers
report some form of postpartum blues
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.
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