Maternal-Child Nursing Exam 2: Questions and Answers, Exams of Nursing

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NUR2513 Maternal-Child Exam 2: Questions/Answers

Providing care to the postpartum client, the nurse recognizes that women are hypercoagulable during the third trimester of pregnancy. Assessment of this client should include evaluation for the development of venous thromboembolism. Which of the follow should be included in this eval? SATA A. Observe distal upper extremities for swelling/edema B. Observe lower extremities for symmetry C. Asses for uterine cramping D. Observe respiratory rate and effort E. Auscultate lung sounds Right Ans - B. Observe lower extremities for symmetry D. Observe respiratory rate and effort E. Auscultate lung sounds A newborn is prescribed to receive Vitamin K 0.5 mg intramuscularly. How should the nurse administer the medication to the newborn? A. Provide medication immediately before breastfeeding B. Administer medication into the vastus lateralis C. Notify physician for swelling and irritation at the injection site D. Administer the medication in the deltoid muscle Right Ans - B. Administer medication into the vastus lateralis Which technique is used to palpate the fundal heigh on postpartum client? A. Placing one hand on the fundus, one on the perineum B. Resting both hands on the fundus C. Palpating the fundus with only fingertip pressure D. Placing one hand at the base of the uterus , one on the fundus Right Ans - D. Placing one hand at the base of the uterus , one on the fundus A nurse is caring for a 4 yr old female. Which of the following is expected of a preschool-aged child A. Describing manifestations of illness B. Understanding cause of illness C. Relating fears to magical thinking D. Awareness of body function Right Ans - A new mother asks the nurse how soon she can try to breastfeed after deliery. Which of the following would be the nurses best response?

A. Once the infant has his first feeding of formula B. Immediately after birth C. In 24 hours after her infant is given water D. After the infant is allowed to rest Right Ans - B. Immediately after birth Which assessment finding indicated to the nurse that a newborn has hip sublaxtion? A. Crying on straightening of the right leg B. Inward rotation of the right foot C. Inability of the right hip to abduct D. Drawing of the legs underneath while prone Right Ans - C. Inability of the right hip to abduct A nurse is helping her postpartum client up to the bathroom for the first time after delivery. Which finding indicates her lochia is within normal imites? A. the color of the flow is red B. Lochia contains large clots C. The flow is over 500 mL D. Her uterus is boggy and soft Right Ans - A. the color of the flow is red A nurse is caring for an infant with myelomeningocele. Which of the following actions should the nurse include in the preoperative plan of care. A. Place the infant in a supine position B. Assess the infants temp rectally C. Apply a sterile, moist dressing on the sac D. Assist the caregiver with cuddling the infant Right Ans - C. Apply a sterile, moist dressing on the sac The nurse is inspecting a males newborns genitalia. Which action should the nurse avoid when conducting this assessment? A. Palpating if testes are descended into the scrotal sac B. Retracting the foreskin over the glans to assess for secretions C. Inspecting if the urethral opening appears circular D. Inspecting the genital area for irritated skin Right Ans - B. Retracting the foreskin over the glans to assess for secretions During a home visit, the nurse determines that a toddler has a difficult temperament. What did the nurse observe in this toddler? SATA A. Rhythmic

D. Stroke the outer edge of the sole of the infants foot up toward the toes Right Ans - C. Hold the infant upright with his feet touching a flat survive Hypoglycemia in a mature infant is defined as blood glucose level below which amount? A. 100mg/100mL whole blood B. 80mg/100mL whole blood C. 30 mg/100 mL whole blood D. 40mg/100mL whole blood Right Ans - D. 40mg/100mL whole blood A nurse is assessing a newborn. Which would be considered a normal finding A. Asymmetry B. Acrocyanosis C. Apnea D. Atonia Right Ans - B. Acrocyanosis The nurse is assessing a term newborn. Which findings should the nurse expect when assessing the patterns of sole creases? A. Creased covering 1/4of the foot B. Creases on 2/3 of the foot c. Longitudinal but no horizontal creases D. Heel creases but no anterior creases Right Ans - B. Creases on 2/3 of the foot A postpartum woman is prescribed an antibiotic because of endometritis. her breastfed infant should be observed particularly for which of the following? A. irritability and loss of appetite B. Signs of thrush and easy bruising C. Decreased sleep levels and increased appetite D. Jaundice that does not respond to phototherapy Right Ans - B. Signs of thrush and easy bruising The nurse assesses a postpartum clients discharge as being moderate in amount and red in color. How should the nurse document the appearance of the lochia? A. Lochia rubra B. Lochia normalia C. Lochia serosa D. Lochia alba Right Ans - A. Lochia rubra

Nurse is assisting a new mother to begin breastfeeding for her newborn son. Which action is most appropriate for the nurse to take? A. Cautioning her not to allow the infant to grasp the areola of her breast to prevent soreness B. Positioning the infant near her breast and stroking his cheek to encourage him to suck C. Stressing that breastfeeding is a normal process and minimal help is needed to learn it D. Encouraging her to lie on her side and help the baby become wide awake by talking to him Right Ans - B. Positioning the infant near her breast and stroking his cheek to encourage him to suck Nurse instructed a mother on the importance of providing a toddler with a balanced diet. Which observation during a home visit indicates that instruction has been effective? A. child take candy from a dish that is placed on the coffee table in the living room B. Mother prepares a scrambled egg for the toddlers breakfast C. mother places a serving of fried finger foods on a plate for the child D. The child is eating a piece of cake and ice cream for lunch Right Ans - B. Mother prepares a scrambled egg for the toddlers breakfast Why are postpartum women prone to urinary retention? A. decreased bladder sensation results from edema because of pressure of birth B. Catheterization at the time of delivery reduces bladder tonicity C. Frequent partial voiding never relieves the bladder pressure D. Mild dehydration causes concentrated urin volume in the bladder Right Ans - A. decreased bladder sensation results from edema because of pressure of birth women who delivered a term neonate 3 days ago is complaining of fever, fatigue and heavy vaginal discharge. On assessment, the nurse notes that her fundus is tender on palpation and heavy with foul smelling lochia. What is most likely the cause of these symtoms? A. UTI B. Postpartum hemorrhage C. Mastitis

A. seperate the child from the caregiver during the exam? B. allow the child to role play C. Use the medical terminology to describe what will happen D. Keep medical equipment visible to the child Right Ans - B. allow the child to role play A newborn who was delivered 2 hrs ago is being assessed in the nursery. Upon exam, nurse notes a flattened nasal brduge, wide set eyes, low set ears and overall decrease in tone. Given these exam findings, what diagnostic rst would the nurse anticipate that the physician will order A. Hemoglobin electrophoresis B. CT of the brain C. Meconium toxicology testing D. Chromosomal blood testing Right Ans - D. Chromosomal blood testing During a home visit, a new motheris concerned that after 3 meconium stools her newborn now has yellow seedy stools. What should the nurse explain to the mother? A. Baby may be developing an allergy to breast milk B. this is a normal finding C. Child will need to be isolated until the stool can be cultured D. This is most likely a symptom of diarrhea Right Ans - B. this is a normal finding Nurse observes a mother telling a toddlers that pasta and potatoes will make the child fat. What should the nurse instruct the mother about these food items? A. The child should be instructed to restict carbs after the age of 5 B. No more than 30% of all food should be from carbs C. It is more important to restrict protein than carbs D. Toddlers needs carbs for brain function Right Ans - D. Toddlers needs carbs for brain function A preterm infant is placed in a radiant heat warmer immediately after birth. Which of the following nursing diagnosis is the intervention addressing? A. ineffective thermoregulation B. Impaired gas exchange related to immature pulmonary functioning C. Risk for deficient fluid volume related to insensible water loss

D. Risk for imbalanced nutrition, less than body requirements Right Ans - A. ineffective thermoregulation Nurse is called to the room of a client who had a term delivery of a 9lb 8oz newborn 24 hours ago. Client is noted to have lost consciousness on her to the bathroom. What is the priority nursing assessment for the client? A. call the provider B. assess the fundus C. assess blood pressure and HR D. Assess ability to void Right Ans - C. assess blood pressure and HR A new born infant has loose yellow stool. The infant appears healthy, but his mother is concerned that this means he is allergic to breast milk. Which of the following is the nurses best response? A. Breast-fed infants stools are normally loose B. Consider changing to a soybean formula C. Try burping the infant more frequently D. You may need to have the infant investigated for bile duct disease Right Ans - A. Breast-fed infants stools are normally loose A nurse is caring for a 9mon old influenza. Which of the following might be a toy that could be used to interact, play or distract them from the discomfort. A. teddy bear with buttons B. Legos C. Cloth doll D. Large plastic stacking blocks Right Ans - D. Large plastic stacking blocks A newborn with esophageal atresia has just returned from surgery to place a gastrostomy tube. Which nursing diagnosis will the nurse use to plan the care for this client? A. Risk for imbalanced nutrition B. Risk for deficient fluid volume C.Risk for ineffective gas exchange D. Risk for impaired thermoregulation Right Ans - A. Risk for imbalanced nutrition Nurse is caring for a postpartum woman 18 hrs after primary c-section for preeclampsia. The client is noted to have a boggy uterus and a moderate to

A. Follows a light to midline B. Follows the finger full 180 degrees C. Produces tears when he cries D. Has a white rather than a red reflex Right Ans - A. Follows a light to midline The nurse is preparing a seminar on breastfeeding for a group of pregnant clients. Which information should the nurse include during the seminar? A. Uterine involution is slowed by breastfeeding B. Breastfeeding might increase the risk of breast cancer C Breastfeeding enhances bonding with the infant D. Breastfeeding mothers have decreased risk of developing thrombophlebitis Right Ans - C Breastfeeding enhances bonding with the infant When assessing a newborn, the APGAR assess the ability of the newborn to transition to extrauterine life. What does the APGAR assess. SATA A. Gender B. Respirations C. Birth time D. Heart Rate E. Color Right Ans - B. Respirations D. Heart Rate E. Color At birth, the infant has dry, cracked skin, absence of vernix, lack of subcutaneous fat, fingernails extending beyond fingertips and poor turgor. Based on these findings, how would the nurse classify this neonate? A. Small gestational age B. Preterm C. Large for gestational age D. Post term Right Ans - D. Post term A parent is describing to the nurse activities that her 4yr old preschool child is achieving. The nurse knows that this child is experiencing which task of ericksons psychosocial stage of development? A. Industry vs. inferiority B. Trust vs. Mistrust C. Autonomy vs. Shame/doubt D. Initiative vs. Guilt Right Ans - D. Initiative vs. Guilt

A newborn is jaundiced and receiving phototherapy via ultraviolet bank lights. Which of the following is an appropriate intervention when caring for an infant with hyperbilirubinemia and receiving phototherapy? A. Apply an oil based lotion to the newborms skin to prevent drying and cracking B. Change the newborns position every 4 hours C. Limit the newborns intake of milk to prevent nausea, vomiting and diarrhea D. Place eyeshields over the newborns closed eyes Right Ans - D. Place eyeshields over the newborns closed eyes The nurse is called to the room of a client who delivered a macrosomic infant 20 hours ago. Upon assessment the fundus is noted to be boggy and displaced to the left and moderate amount of vaginal bleeding is noted. What is priority action? A. Empty the bladder B. Initiate IV access C. Provide pain medication D. Administer uterotonic medication Right Ans - A. Empty the bladder Which of the following is an advantage of breastfeeding for the infant? A. Breast milk contains antibodies and thus decreases the possibility of GI illnesses B. Breast milk is more difficult to digest, so it makes the infant feel fuller longer C. Breast milk leads to firmer stools, increasing bowel tone D. It takes less effort for an infant to suck at a breast than a bottle Right Ans

• A. Breast milk contains antibodies and thus decreases the possibility of GI illnesses During a home visit, a postpartum is complaining of a sore area on one breast. The nurse notes a local area on the left breast is lumpy, red and warm to touch and palpates a small lump. For which health problem should the nurse plan care for this client? A. Engorgement B. Plugged milk duct C. Breast Cancer D. Mastitis Right Ans - D. Mastitis

E. An infant whose bilateral leg length is symmetric Right Ans - A. An infant who has one leg that appears longer than the other B. An infant who has a click in the hip joint when one hip is maneuvered C. An infant who has extra skin folds on the inner thigh of one leg When caring for a newborn several hours after birth, what would the nurse assess as normal newborns respiratory rate? A. 20 to 30 breaths/min B. 16 to 20 breaths/min C. 12 to 16 breaths/min D. 30 to 60 breaths/min Right Ans - D. 30 to 60 breaths/min An infant develops hydrocephalus at 2 weeks of age. Which finding would the nurse expect to assess? A. Hypothermia in the late afternoon B. Excessive thirst C. A soft, fretful cry D. Bulging fontanels Right Ans - D. Bulging fontanels The nurse is evaluating a new mothers ability to effectively breastfeed in her infant. Which criteria indicates that the mother should be able to breastfeed independently? SATA A. Nurse places pillow under the baby for support B. Infant swallows spontaneously and frequently C. Breasts are soft and non-tender D. Nipples are everted E. The mothers hold the infant close to her breast in a football hold Right Ans - B. Infant swallows spontaneously and frequently C. Breasts are soft and non-tender D. Nipples are everted E. The mothers hold the infant close to her breast in a football hold While inspecting a newborns head, the nurse identifies a swelling of the scalp on the right posterior side of the head that doe snot cross the suture line. What term describes this finding? A. enlarged fontanelle B. Molding C. Cephalohematoma D. Caput Succedaneum Right Ans - C. Cephalohematoma

A nurse is assessing a newborn that was admitted to the newborn nursery 28 hours ago. Mothers history includes addition to recreational drugs. Which finding would the nurse expect to note during the assessment of this newborn? A. Sleepiness B. Flaccid Extremities C. Quiets with swaddling D. incessant crying Right Ans - D. incessant crying When planning care for a postpartum client the nurse is aware that which site is the most common for postpartum infection? A. Milk ducts B. Bloodstream C. Urinary bladder D. Reproductive tract Right Ans - D. Reproductive tract The nurse on the postpartum unit is reviewing uterotonic (oxytocic medications) with a group of nursing students. Which of the following would be included in this discussion? A. Terbutaline B. Mag Sulfate C. Misoprostil D. Phytonadione Right Ans - C. Misoprostil The nurse is assessing the breast of a woman who is 1 mon postpartum. The women reports painful, inflamed area on one breast. Upon assessment, the nurse notes a wedged shaped area on one breast to be red and warm to touch. Clients temp 101.8. what should the nurse consider as the potential diagnosis. A. Engorgement B. Breast yeast infection C. Plugged milk duct D. Mastitis Right Ans - Which action by the mother relates to the nurse that she is accepting her child? A. Her husband spends time holding the baby B. She turns her face to meet the infants eyes when she holds her C. she has many visitors in the room

The nurse is providing discharge teaching to the postpartum client regarding mood changes to report. In differentiating between the "baby blues" and postpartum depression, which of the following statements should be included in the instruction? A. Postpartum depression may occur on the 5th day but will resolve spontaneously by the end of the 6th week B. Baby blues are the result of hormonal shifts and should resolve by the end of the 6th postpartum week. C. Baby blues may present in the first few days after birth resolve prior to the second postpartum week D. Postpartum depression is the result of hormonal changes related to the end of pregnancy and will not require intervention or med management. 11` Right Ans - The nurse is assessing the fundus of a client on postpartum on day 2. What should the nurse expect when palpating the fundus? A. Fundus two fingerbreadths above symphysis pubis and firm B. Fundus two fingerbreadths below the umbilicus and firm C. Fundus 4cm below tjhe umbilic and midline D. Fundus 4cm above the symphysis pubis and firm Right Ans - B. Fundus two fingerbreadths below the umbilicus and firm A new mother asks the nurse how to determine if the baby is receiving enough breast milk. How should the nurse respond to the mother? A. You need to weight the infant before and after each feeding B. The infant should not become constipated C. The infant should gain weight and have 6 wet diapers daily D. The infant should sleep atleast 3 hours between feedings Right Ans - C. The infant should gain weight and have 6 wet diapers daily The nurse is teaching new parents how to calculate the amount of formula to feed their newborn each day. The baby weighs 8lb. how much formula should the nurse teach the parents to provide each day. A. 30-36oz B. 42-54oz C. 20-24 oz D. 60-72oz Right Ans - C. 20-24 oz