NUR 2513 Maternal-Child Nursing Exam-with 100% verified solutions 2024-2025, Exams of Nursing

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NUR 2513 Maternal-Child Nursing Exam-with 100%

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Which behaviors would be exhibited during the letting-go phase of maternal role adaptation. Select all that apply. Emergence of family unit Sexual intimacy relationship continuing Defining one's individual roles While making a visit to the home of a postpartum woman 1 week after birth, the nurse should recognize that the woman would characteristically: Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn. Which of the following is the most common kind of placental adherence seen in pregnant women? Accreta A 40-year-old woman with a high body mass index (BMI) is 10 weeks pregnant. Which diagnostic tool is appropriate to suggest to her at this time? Transvaginal ultrasound A nurse providing care for the antepartum woman should understand that the contraction stress test (CST): Is considered to have a negative result if no late decelerations are observed with the contractions. In the past, factors to determine whether a woman was likely to have a high-risk pregnancy were evaluated primarily from a medical point of view. A broader, more comprehensive approach to high-risk pregnancy has been adopted. There are now four categories based on threats to the

health of the woman and the outcome of pregnancy. Which of the options listed here is not included as a category? Geographic A woman who is at 36 weeks of gestation is having a nonstress test. Which statement indicates her correct understanding of the test? "This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby." What is an appropriate indicator for performing a contraction stress test? Maternal diabetes mellitus and postmaturity The nurse sees a woman for the first time when she is 30 weeks pregnant. The woman has smoked throughout the pregnancy, and fundal height measurements now are suggestive of growth restriction in the fetus. In addition to ultrasound to measure fetal size, what would be another tool useful in confirming the diagnosis? Doppler blood flow analysis A nurse is providing instruction for an obstetrical patient to perform a daily fetal movement count (DFMC). Which instructions could be included in the plan of care? Select all that apply. -The patient can monitor fetal activity once daily for a 60-minute period and note activity. -Monitor fetal activity two times a day either after meals or before bed for a period of 2 hours or until 10 fetal movements are noted. -Count all fetal movements in a 12-hour period daily until 10 fetal movements are noted. A patient has undergone an amniocentesis for evaluation of fetal well- being. Which intervention would be included in the nurse's plan of care after the procedure? Select all that apply. Observe the patient for possible uterine contractions. Administer RhoGAM to the patient if she is Rh negative.

With regard to small-for-gestational-age (SGA) infants and intrauterine growth restriction (IUGR), nurses should be aware that: Infants with asymmetric IUGR have the potential for normal growth and development. A client who delivered by cesarean section 24 hours ago is using a patient-controlled analgesia (PCA) pump for pain control. Her oral intake has been ice chips only since surgery. She is now complaining of nausea and bloating, and states that because she had nothing to eat, she is too weak to breastfeed her infant. Which nursing diagnosis has the highest priority? Impaired bowel motility related to pain medication and immobility The nurse is teaching care of the newborn to a childbirth preparation class and describes the need for administering antibiotic ointment into the eyes of the newborn. An expectant father asks, "What type of disease causes infections in babies that can be prevented by using this ointment?" Which response by the nurse is accurate? Gonorrhea A new mother is having trouble breastfeeding her newborn. The child is making frantic rooting motions and will not grasp the nipple. Which intervention should the nurse implement? Encourage the mother to stop feeding for a few minutes and comfort the infant. The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct? Two weeks before menstruation

The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take? Have the client breathe into her cupped hands. When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes? At 30 weeks of gestation One hour following a normal vaginal delivery, a newborn infant boy's axillary temperature is 96° F, his lower lip is shaking and, when the nurse assesses for a Moro reflex, the boy's hands shake. Which intervention should the nurse implement first? Obtain a serum glucose level Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn? "Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period. A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert? Endometritis

A client at 36 weeks gestation is schedule for a routine ultrasound prior to an amniocentesis. After teaching the client about the purpose for the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction? The ultrasound identifies blood flow through the umbilical cord While the postpartum client is receiving heparin for thrombophlebitis, which of the following drugs would the nurse expect to administer if the client develops complications related to heparin therapy? Protamine sulfate When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following? Check the vital signs every 2 to 4 hours A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective? Perineum The nurse is caring for a primigravida at about 2 months and 1 week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says: "Nausea and vomiting can be decreased if I eat a few crackers before arising"

Forty eight hours after delivery, the nurse in charge plans discharge teaching for the client about infant care. By this time, the nurse expects that the phase of postpartum psychological adaptation that the client would be in would be termed which of the following? Taking hold A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following? Activity limited to bed rest The nurse plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan? Breast-feeding the neonate at frequent intervals When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands opened, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes? Startle reflex A primigravida client at 25 weeks gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform: Tailor sitting

Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision? Apply gentle pressure to the site with a sterile gauze pad Which of the following would the nurse most likely expect to find when assessing a pregnant client with abruption placenta? Rigid, board-like abdomen While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse's most appropriate action? Notify the physician immediately A client tells the nurse, "I think my baby likes to hear me talk to him." When discussing neonates and stimulation with sound, which of the following would the nurse include as a means to elicit the best response? High-pitched speech with tonal variations A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in? Transitional phase A pregnant patient asks the nurse if she can take castor oil for her constipation. How should the nurse respond? "No, it can initiate premature uterine contractions."

A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several cloth. What is the primary nursing diagnosis for this patient? Fluid volume deficit Immediately after a delivery, the nurse-midwife assesses the neonate's head for signs of molding. Which factors determine the type of molding? Fetal body flexion or extension For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring (EFM) device. What must occur before the internal EFM can be applied? The membranes must rupture A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in early part of the first stage of labor. Her pain is likely to be most intense: Around the pelvic girdle A female adult patient is taking a progestin-only oral contraceptive, or mini pill. Progestin use may increase the patient's risk for: Tubal or ectopic pregnancy

A patient with pregnancy-induced hypertension probably exhibits which of the following symptoms? Proteinuria, headaches, double vision Because cervical effacement and dilation are not progressing in a patient in labor,the doctor orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patient's fluid intake and output closely during oxytocin administration? Oxytocin causes water intoxication Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to prevent hypothermia. What is a common source of radiant heat loss? Cools incubator wall After administering bethanechol to a patient with urine retention, the nurse in charge monitors the patient for adverse effects. Which is most likely to occur? Nausea and Vomiting The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest but most difficult part of this stage? Transitional phase After 3 days of breast-feeding, a postpartal patient reports nipple soreness. To relieve her discomfort, the nurse should suggest that she: Lubricate her nipples with expressed milk before feeding

The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse should tell the patient that she can expect to feel the fetus move at which time? Between 16 and 20 weeks' gestation Normal lochial findings in the first 24 hours post-delivery include: Bright red blood Accompanied by her husband, a patient seeks admission to the labor and delivery area. The client states that she is in labor and says she attended the hospital clinic for prenatal care. Which question should the nurse ask her first? "What is your expected due date? A patient is in the second stage of labor. During this stage, how frequently should the nurse in charge assess her uterine contractions? Every 15 minutes A patient is in her last trimester of pregnancy. Nurse Vickie should instruct her to notify her primary health care provider immediately if she notices: Blurred vision

The nurse in-charge is reviewing a patient's prenatal history. Which finding indicates a genetic risk factor? The patient has a child with cystic fibrosis A adult female patient is using the rhythm (calendar-basal body temperature) method of family planning. In this method, the unsafe period for sexual intercourse is indicated by: 3 full days of elevated basal body temperature and clear, thin cervical mucus During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal movement, making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, the nurse in charge should instruct the client to push the control button at which time? At the beginning of each fetal movement When evaluating a client's knowledge of symptoms to report during her pregnancy, which statement would indicate to the nurse in charge that the client understands the information given to her? "If I have blurred or double vision, I should call the clinic immediately." When assessing a client during her first prenatal visit, the nurse discovers that the client had a reduction mammoplasty. The mother indicates she wants to breast-feed. What information should the nurse give to this mother regarding breastfeeding success?

"I support your commitment; however, you may have to supplement each feeding with formula." Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of the following would be contraindicated when caring for this client? Instructing the client to use two or more peri pads to cushion the area A client makes a routine visit to the prenatal clinic. Although she is 14 weeks pregnant, the size of her uterus approximates that in an 18- to 20- week pregnancy. Dr. Charles diagnoses gestational trophoblastic disease and orders ultrasonography. The nurse expects ultrasonography to reveal: grapelike clusters. After completing a second vaginal examination of a client in labor, the nurse-midwife determines that the fetus is in the right occiput anterior position and at (-1) station. Based on these findings, the nurse-midwife knows that the fetal presenting part is: 1 cm above the ischial spines. Which of the following would be inappropriate to assess in a mother who's breastfeeding? The baby's lips smacking

During a prenatal visit at 4 months gestation, a pregnant client asks whether tests can be done to identify fetal abnormalities. Between 18 and 40 weeks gestation, which procedure is used to detect fetal anomalies? Ultrasound A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to evaluate the health of her fetus. Her BPP score is 8. What does this score indicate? The fetus isn't in distress at this time. A client who is 36 weeks pregnant comes to the clinic for a prenatal checkup. To assess the client's preparation for parenting, the nurse might ask which question? "What changes have you made at home to get ready for the baby?" A client who's admitted to labor and delivery has the following assessment findings: gravida 2 para 1, estimated 40 weeks gestation, contractions 2 minutes apart, lasting 45 seconds, vertex +4 station. Which of the following would be the priority at this time? Preparing for immediate delivery The nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in fetal heart rate. What should the nurse do first? Change the client's position.

The nurse in charge is caring for a postpartum client who had a vaginal delivery with a midline episiotomy. Which nursing diagnosis takes priority for this client? Risk for deficient fluid volume related to hemorrhage Which change would the nurse identify as a progressive physiological change in postpartum period? Lactation A 39-year-old at 37 weeks gestation is admitted to the hospital with complaints of vaginal bleeding following the use of cocaine 1 hour earlier. Which complication is most likely causing the client's complaint of vaginal bleeding? Abruptio placentae A client with type 1 diabetes mellitus who is a multigravida visits the clinic at 27 weeks gestation. The nurse should instruct the client that for most pregnant women with type 1 diabetes mellitus: Nonstress testing is performed weekly until 32 weeks' gestation. When administering magnesium sulfate to a client with preeclampsia, the nurse understands that this drug is given to: Prevent seizures What is the approximate time that the blastocyst spends traveling to the uterus for implantation?

7 days After teaching a pregnant woman who is in labor about the purpose of the episiotomy, which of the following purposes stated by the client would indicate to the nurse that the teaching was effective? Shortens the second stage of labor A primigravida client at about 35 weeks gestation in active labor has had no prenatal care and admits to cocaine use during the pregnancy. Which of the following persons must the nurse notify? Physician who will attend the delivery of the infant When preparing a teaching plan for a client who is to receive a rubella vaccine during the postpartum period, the nurse in charge should include which of the following? Pregnancy should be avoided for 3 months after the immunization A client with eclampsia begins to experience a seizure. Which of the following would the nurse in charge do first? Maintain a patent airway While caring for a multigravida client in early labor in a birthing center, which of the following foods would be best if the client requests a snack? Yogurt

The multigravida mother with a history of rapid labor who us in active labor calls out to the nurse, "The baby is coming!" which of the following would be the nurse's first action? Inspect the perineum While assessing a primipara during the immediate postpartum period, the nurse in charge plans to use both hands to assess the client's fundus to: Prevent uterine inversion When assessing the adequacy of sperm for conception to occur, which of the following is the most useful criterion? Sperm motility A couple who wants to conceive but has been unsuccessful during the last 2 years has undergone many diagnostic procedures. When discussing the situation with the nurse, one partner states, "We know several friends in our age group and all of them have their own child already, Why can't we have one?". Which of the following would be the most pertinent nursing diagnosis for this couple? Self-esteem disturbance related to infertility. Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester? Frequency Heartburn and flatulence, common in the second trimester, are most likely the result of which of the following? Decreased gastric acidity

On which of the following areas would the nurse expect to observe chloasma? Cheeks, forehead, and nose A pregnant client states that she "waddles" when she walks. The nurse's explanation is based on which of the following as the cause? Relaxation of the pelvic joints Which of the following represents the average amount of weight gained during pregnancy? 24 to 30 lb When talking with a pregnant client who is experiencing aching swollen, leg veins, the nurse would explain that this is most probably the result of which of the following? Pressure on blood vessels from the enlarging uterus Cervical softening and uterine souffle are classified as which of the following? Probable signs Which of the following would the nurse identify as a presumptive sign of pregnancy?

Nausea and vomiting Which of the following common emotional reactions to pregnancy would the nurse expect to occur during the first trimester? Ambivalence, fear, fantasies During which of the following would the focus of classes be mainly on physiologic changes, fetal development, sexuality, during pregnancy, and nutrition? First trimester Which of the following would be disadvantage of breast feeding? The father may resent the infant's demands on the mother's body Which of the following would cause a false-positive result on a pregnancy test? The test was performed less than 10 days after an abortion FHR can be auscultated with a fetoscope as early as which of the following? 20 weeks gestation A client LMP began July 5. Her EDD should be which of the following? April 12

Which of the following fundal heights indicates less than 12 weeks' gestation when the date of the LMP is unknown? Uterus in the pelvis Which of the following danger signs should be reported promptly during the antepartum period? Leaking amniotic fluid Which of the following prenatal laboratory test values would the nurse consider as significant? Rubella titer less than 1: Which of the following characteristics of contractions would the nurse expect to find in a client experiencing true labor? Increasing intensity with walking During which of the following stages of labor would the nurse assess "crowning"? Second stage Barbiturates are usually not given for pain relief during active labor for which of the following reasons? They rapidly transfer across the placenta, and lack of an antagonist make them generally inappropriate during labor.

Which of the following nursing interventions would the nurse perform during the third stage of labor? Promote parent-newborn interaction. Which of the following actions demonstrates the nurse's understanding about the newborn's thermoregulatory ability? Placing the newborn under a radiant warmer Immediately before expulsion, which of the following cardinal movements occur? External rotation Before birth, which of the following structures connects the right and left auricles of the heart? Foramen ovale Which of the following when present in the urine may cause a reddish stain on the diaper of a newborn? Uric acid crystals When assessing the newborn's heart rate, which of the following ranges would be considered normal if the newborn were sleeping? 100 beats per minute Which of the following is true regarding the fontanels of the newborn?

The anterior is large in size when compared to the posterior fontanel. Which of the following groups of newborn reflexes below are present at birth and remain unchanged through adulthood? Blink, cough, sneeze, ga Which of the following describes the Babinski reflex? 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. Which of the following statements best describes hyperemesis gravidarum? Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional imbalances in the absence of other medical problems Which of the following would the nurse identify as a classic sign of PIH? Edema of the hands and face In which of the following types of spontaneous abortions would the nurse assess dark brown vaginal discharge and a negative pregnancy tests? Missed Which of the following factors would the nurse suspect as predisposing a client to placenta previa?

Multiple gestation Which of the following would the nurse assess in a client experiencing abruptio placenta? Concealed or external dark red bleeding Which of the following is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage? Abruptio placentae Which of the following may happen if the uterus becomes overstimulated by oxytocin during the induction of labor? Tetanic contractions prolonged to more than 90 seconds When preparing a client for cesarean delivery, which of the following key concepts should be considered when implementing nursing care? Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth Which of the following best describes preterm labor? Labor that begins after 20 weeks gestation and before 37 weeks gestation When PROM occurs, which of the following provides evidence of the nurse's understanding of the client's immediate needs?

PROM removes the fetus most effective defense against infection Which of the following factors is the underlying cause of dystocia? Mechanical When uterine rupture occurs, which of the following would be the priority? Limiting hypovolemic shock Which of the following is the nurse's initial action when umbilical cord prolapse occurs? Place the client in a knee-chest position in bed Which of the following amounts of blood loss following birth marks the criterion for describing postpartum hemorrhage? More than 500 ml Which of the following is the primary predisposing factor related to mastitis? Breast injury caused by overdistention, stasis, and cracking of the nipples Which of the following best describes thrombophlebitis? Inflammation of the vascular endothelium with clot formation on the vessel wall

Which of the following assessment findings would the nurse expect if the client develops DVT? Muscle pain the presence of Homans sign, and swelling in the affected limb Which of the following are the most commonly assessed findings in cystitis? Nocturia, frequency, urgency dysuria, hematuria, fever and suprapubic pain Which of the following best reflects the frequency of reported postpartum "blues"? Between 50% and 80% of all new mothers report some form of postpartum blues 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? Maintain hormonal levels When teaching a client about contraception. Which of the following would the nurse include as the most effective method for preventing sexually transmitted infections? Condoms

When preparing a woman who is 2 days postpartum for discharge, recommendations for which of the following contraceptive methods would be avoided? Diaphragm For which of the following clients would the nurse expect that an intrauterine device would not be recommended? Promiscuous young adult A client in her third trimester tells the nurse, "I'm constipated all the time!" Which of the following should the nurse recommend? Increased fiber intake Which of the following would the nurse use as the basis for the teaching plan when caring for a pregnant teenager concerned about gaining too much weight during pregnancy? A total gain of 25 to 30 pounds The client tells the nurse that her last menstrual period started on January 14 and ended on January 20. Using Nagele's rule, the nurse determines her EDD to be which of the following? October 21 When taking an obstetrical history on a pregnant client who states, "I had a son born at 38 weeks gestation, a daughter born at 30 weeks gestation and I lost a baby at about 8 weeks,"the nurse should record her obstetrical history as which of the following? G4 T1 P1 A1 L2