Maternity 2
14.Which of the following would be considered a normal assessment finding in a 1-day postpartum patient? a. Pinkish to brown lochia b. Voiding frequently 50 mL to 75 mL of urine c. Complaining of after pains d. Fundus 1 cm above the umbilicus
ANS: C The common discomfort of after pains is a normal assessment finding at 1-day postpartum.
11.The postpartum mother with a third degree laceration tells the nurse she is afraid to have a bowel movement because of her painful episiotomy. What should the nurse do? a. Offer a suppository or enema b. Encourage ambulation c. Offer stool softeners as prescribed d. Offer pain medication before defecating
ANS: C Stool softeners are available to ease the pain of defecation caused by hemorrhoids and birth trauma
12.What is the cause of gestational hypertension? a. Too much salt b. A toxin c. Unknown d. Diabetes
ANS: C The cause of gestational hypertension is unknown
9.Within the first hour following a vaginal delivery, the nurse assesses the mother and finds the fundus is firm and there is a trickle of bright red blood. What should be the nurses reaction to the assessment? a. This is a normal occurrence. b. This is abnormal and should be reported. c. The patient should be administered a blood thinner. d. The patient should be restricted to bed rest.
ANS: A A bright red drainage is normal immediately after delivery.
14.The nurse is assessing a kick count for a patient with gestational hypertension. What result should be a cause for concern? a. Less than three kicks per hour b. Less than five kicks per hour c. Less than seven kicks per hour d. Less than nine kicks per hour
ANS: A A kick count of fewer than three per hour is considered serious and a cause for concern.
8.A patient in her second trimester of pregnancy arrives at the hospital complaining of bright red, painless vaginal bleeding. What condition should the nurse immediately suspect? a. Abruptio placentae b. Hemorrhage c. Placenta previa d. Placentitis
ANS: C Placenta previa is a serious condition that consists of bright red painless vaginal bleeding occurring after 20 weeks of pregnancy.
22.The newborn infant has oxygenation problems and a lack of subcutaneous fat. What should the nurse determine as the gestational age of this infant? a. 20 to 37 completed weeks of pregnancy b. 38 to 41 completed weeks of pregnancy c. 14 to 36 completed weeks of pregnancy d. 42 or more completed weeks of pregnancy
ANS: A The lungs of preterm infants have not fully developed; therefore, they have problems with oxygenation.
32.A new mother asks for advice on how to quiet her fussy newborn. Which responses would be appropriate to suggest to the mother? (Select all that apply.) a. Prewarm the crib sheets with a hot water bottle b. Swaddle the newborn tightly in a receiving blanket c. Place the baby in a larger crib or infant bed d. Offer a pacifier or allow the infant to suckle at the breast e. Take the infant for a ride in the car
ANS: A, B, D, E
1.The nurse is observing a new mother interact with her infant. Which observation would indicate that bonding is occurring? (Select all that apply.) a. The mother is making eye contact with the infant. b. The mother is sending the infant to the nursery for feedings. c. The mother is cuddling with the infant and napping. d. The mother is requesting that the mother-in-law change all diapers. e. The mother states that her favorite thing to do with her baby is to breastfeed.
ANS: A, C, E Eye contact, cuddling, and enjoying infant feeding are all signs of positive parent-infant attachment (bonding). Sending the infant to the nursery for feedings and having someone else change all diapers could indicate difficulty with bonding.
6.Which finding should the nurse suspect as abnormal in the newborn during the initial assessment? a. Eyes crossed at times b. Persistent high-pitched cry c. Arms and legs flexed d. Slight bluish tinge of the extremities
ANS: B A high-pitched cry may indicate neurologic problems. Occasional crossing of the eyes, flexing of the arms and legs, and a bluish tinge of the extremities are all considered normal assessment findings in the newborn.
15.When discussing toxoplasmosis infection during pregnancy, what should the nurse caution the patient to avoid? a. Contact with an infected person b. Emptying cat litter boxes bare-handed c. Having unprotected sex d. Eating excessive amounts of shellfish
ANS: B A pregnant woman should wear gloves whenever having contact with cat feces as this is a possible source of toxoplasmosis infection.
6.Which statement would be a correct description of colostrum? a. Slightly yellow and low in protein b. Slightly yellow and provides antibodies c. Creamy and high in fat and protein d. Colorless and high in fat and carbohydrates
ANS: B Colostrum is slightly yellow in color and is rich in antibodies.
5.When is breast engorgement most likely to occur? a. When the infants mouth surrounds the areola when feeding b. When the breast tissue becomes congested c. When the breast is emptied completely at each feeding d. When the infants mouth grasps the nipple firmly
ANS: B Engorgement is the result of venous and lymphatic stasis (congestion).
.What should be included in a teaching plan regarding breast engorgement? a. It typically occurs on the first postpartum day b. It is usually first observed in the axillary region c. It occurs only in women who are not breastfeeding d. It occurs near the nipple on the third postpartum day
ANS: B Filling of the breast with milk (engorgement) usually begins in the axillary region on the third postpartum day when the milk comes in.
13.A mother delivered her baby at midnight and it is now 9 AM. She wants to sleep and asks the nurse to take care of the baby. What is this considered? a. Fatigue from labor b. Normal taking in response c. Abnormal taking in response d. Risk for altered maternal-infant bonding
ANS: B Her primary focus will be on her own needs such as sleep (taking in stage).
28.The nurse is assessing the newborn and discovers a yellowing of the skin. What is true for jaundice that appears at birth? a. Within normal limits b. Pathologic c. A result of iron deficiency d. Indicating possible hepatitis
ANS: B Jaundice observed at birth is considered an indicator of a pathologic condition, erythroblastosis fetalis. It is considered abnormal.
17.Following delivery of the newborn, which nursing intervention should be carried out immediately? a. Weigh the infant b. Warm the infant c. Bathe the infant d. Inoculate the infant
ANS: B Maintenance of body temperature is the primary concern when caring for the newborn.
1.A patient is admitted to the hospital with hyperemesis gravidarum. The patient is malnourished and severely dehydrated. The care plan should be altered to include which interventions? a. Hyperalimentation b. IV fluids and electrolyte replacement c. Hormone replacement therapy d. Vitamin supplements
ANS: B Medical treatment is aimed at meeting fluid and electrolyte replacement.
23.Why is vitamin K given by injection to the newborn? a. Most mothers have a vitamin K deficiency that develops during pregnancy. b. Bacteria that synthesize vitamin K are not present in newborns. c. Vitamin K prevents the synthesis of prothrombin. d. The newborn does not store vitamin K.
ANS: B Newborns are not able to synthesize vitamin K in the colon until they have adequate intestinal flora, therefore, the vitamin K injection is given as a prevention measure against hemorrhage.
30.A nursery nurse is implementing phototherapy for a jaundiced infant. What is the purpose of the phototherapy? a. It is initiated when the bilirubin level reaches 5 mg/dL. b. It converts bilirubin to a water-soluble form to be excreted in the urine. c. It changes bilirubin to a bile salt to be excreted through the bowel. d. It requires eye patches to remain in place 24 hours a day.
ANS: B Phototherapy converts the bilirubin into a water-soluble form to be excreted by the kidneys.
21.Which tests are performed to detect inborn errors of metabolism in the newborn? a. Blood glucose b. Phenylketonuria (PKU) c. Blood urea nitrogen (BUN) d. Prothrombin time (PT)
ANS: B State law requires certain diagnostic tests be performed on the newborn, including PKU, which detects an inborn error of metabolism.
34.What is the antidote for magnesium sulfate toxicity? a. Vitamin K b. Calcium gluconate c. Potassium sulfate d. Calcium carbonate
ANS: B The antidote for magnesium sulfate toxicity is calcium gluconate.
3.What is the first secretion produced by the breast? a. Prolactin b. Colostrum c. False milk d. Whey
ANS: B The first secretion to be produced by the breast is colostrum.
29.The nurse is giving a bath demonstration for a group of new mothers. What should be included in the demonstration? a. Apply baby powder generously to keep baby dry. b. Cleanse perineum from front to back. c. Use scented soap to make baby smell good. d. Partially submerge head in water when shampooing.
ANS: B The perineum should be cleansed by wiping from the anterior to the posterior. Excessive use of powders and scented soaps can irritate the skin. The head should not be submerged in water.
2.What is the name of the vaginal discharge that occurs immediately following delivery? a. Lochia serosa b. Lochia rubra c. Lochia palatine d. Lochia alba
ANS: B The vaginal discharge that occurs immediately following discharge is known as lochia rubra and is made up mostly of blood
20.A 14-year-old pregnant adolescent arrives at the hospital in early labor. The nurse should recognize that the adolescent is at a greater risk for which problem? a. Calcium deficit b. Cephalopelvic disproportion c. Bleeding tendency d. Low hemoglobin levels
ANS: B There are several physiological concerns for pregnant adolescents, including cephalopelvic disproportion.
24.What should be included when discussing the care of a circumcised infant after discharge from the hospital? a. Gently remove the yellow exudate from the foreskin. b. Apply sterile petroleum gauze after each diaper change. c. Wipe the circumcision with alcohol each day. d. Avoid the use of cloth diapers until the foreskin has healed.
ANS: B Wash the penis at diaper change and apply sterile petroleum gauze. The yellow exudate should not be removed as it is part of the normal healing process. The circumcised area should be cleansed gently, not with alcohol. Cloth diapers are sometimes recommended to promote healing.
1.When assessing a mother 12 hours following the delivery of a baby, where should the nurse expect to palpate the fundus? a. 2 cm below the umbilicus b. At the umbilicus c. 1 cm below the umbilicus d. Halfway between the umbilicus and the symphysis pubis
ANS: B Within 12 hours, the fundus rises to the level of the umbilicus. The fundus should be firm. Immediately following delivery, the fundus will be felt halfway between the umbilicus and the symphysis.
24.A neonate is born with weak muscle tone, froglike extremities, and ears that fold easily. From these observations, what gestational age should the nurse give this infant? a. Full term b. Small for gestational age c. Preterm d. Post-term
ANS: C Preterm infant posture is froglike, the muscle tone is weak, and the ears are easily folded.
27.The nurse assures a patient who has become sensitized to the Rh antigen that she can be protected for future pregnancies by receiving what injection? a. Iron b. Vitamin B12 c. RhoGAM d. Type O blood
ANS: C RhoGAM prevents the development of naturally occurring maternal antibodies.
30.Which of the following measures could help prevent infant abduction? (Select all that apply.) a. Only transport infants by carrying them b. Require staff members to wear appropriate identification badges c. Respond immediately when an alarm sounds d. Never leave infants unattended at any time e. Take all the infants to their mothers at the same time
ANS: B, C, D Staff members should always wear appropriate ID badges and should respond immediately when an alarm sounds. Infants should never be left unattended. Infants should always be transported in their cribs, never by carrying them. The nurse should transport only one infant at a time.
16.What is a major complication of gestational diabetes that affects the infant? a. Lack of nutrition b. Dehydration c. Hypoglycemia d. Hyperglycemia
ANS: C A result of gestational diabetes is neonatal hypoglycemia.
31.Why do alcohol and illegal drugs endanger the fetus? a. Both are absorbed into the bloodstream. b. Both affect the mother. c. Both cross the placental barrier. d. Both increase the heart rate of the fetus.
ANS: C Alcohol and illicit drugs cross the placental barrier and affect the fetus.
5.A patient is admitted to the hospital with signs of an ectopic pregnancy. What should the plan of care include for the patient? a. Long-term bed rest b. Episodes of extreme hypertension c. Surgery to remove the embryo/fetus d. Treatment for dehydration
ANS: C An ectopic implantation occurs somewhere outside the uterus and either resolves itself in a spontaneous abortion or requires surgical intervention.
7.What is characteristic of a normal breastfed infants stool? a. Green and loose b. Dark green and sticky c. Pale yellow and frequent d. Light brown and pasty
ANS: C Breastfed infants tend to pass stools frequently and they are pale yellow to golden in color and pasty in consistency.
15.A new Native American mother tells the nurse that when she goes home, her mother-in-law will be caring for the baby while she rests. The nurse has concerns. What should the nurse do? a. Explain the importance of ambulating to recover b. Explain the importance of maternal-infant bonding c. Explore ways to blend this with safe health teaching d. Encourage this cultural behavior
ANS: C Follow principles that facilitate nursing practice within transcultural situations.
19.The nurse identifies that the newborn is jaundiced within the first 24 hours of birth, with jaundice occurring over bony prominences of the face and the mucous membrane. What type of jaundice does this represent? a. Physiological b. Normal c. Pathologic d. Transitory
ANS: C Jaundice that appears within the first 48 hours of life is termed pathologic jaundice and is abnormal.
23.Compared to older infants of comparable weight, how much higher is the morbidity and mortality rate for preterm infants? a. 1 to 2 times b. 2 to 3 times c. 3 to 4 times d. 4 to 5 times
ANS: C The morbidity and mortality rate for preterm infants is higher by 3 to 4 times that of an older infant of similar weight.
7.What symptom, no matter what stage of pregnancy, should be reported immediately? a. Backache b. Urinary frequency c. Vaginal bleeding d. Uterine tightening
ANS: C Women should be instructed to contact their physician if any bleeding occurs during pregnancy.
10.A patient presents with symptoms of abruptio placentae. To facilitate uterine-placental perfusion, in what position would the nurse place the patient? a. Prone position b. Trendelenburg position c. Supine position d. Modified side-lying position
ANS: D A modified side-lying position facilitates uterine-placental perfusion.
22.Which newborn assessment finding can suggest a chromosomal disorder? a. Epstein pearls b. Gynecomastia c. Babinski reflex d. Simian crease
ANS: D A simian crease may indicate a chromosomal disorder.
20.What is the term for the cream cheeselike substance that protects the infants skin from amniotic fluid? a. Lanugo b. Meconium c. Desquamation d. Vernix caseosa
ANS: D At birth, the skin is covered with a yellowish-white cream cheeselike substance called vernix caseosa.
4.What complication of delivery should the nurse expect with the birth of multiple fetuses? a. An ectopic tendency b. Difficulty with breastfeeding c. A vaginal delivery d. Loss of uterine tone
ANS: D Delivery of multiple fetuses is often complicated by loss of uterine tone. Oftentimes multiple fetuses are delivered by cesarean.
11.A pregnant woman visits a clinic visit during her 21st week of pregnancy. The nurse identifies edema, hypertension, and proteinuria. What condition does the nurse suspect? a. Allergy b. Protein deficiency c. Circulatory problem d. Gestational hypertension
ANS: D Gestational hypertension (GH), formerly referred to as pregnancy-induced hypertension (PIH), is a disease encountered during pregnancy or early in the puerperium, characterized by increasing hypertension, proteinuria, and generalized edema. These signs generally appear after the 20th week of pregnancy.
7.The new mother has decided not to breastfeed the baby. How should the nurse correctly instruct the mother to suppress her milk supply? a. Pump the breasts to remove milk b. Apply warm, moist compresses c. Restrict oral fluids d. Apply a firm bra and ice packs
ANS: D If a patient is not breastfeeding, compress the breasts with a firm bra and wrapped ice packs to suppress the milk supply
26.A primigravida is Rh negative and her husband is Rh positive. She is concerned about the health of the fetus. The nurse explains that there is little danger to the fetus if it is Rh positive; however, the mother would become sensitized during delivery. If this were the case, the mother would produce what in subsequent pregnancies? a. Rh-negative blood cells b. Rh-positive blood cells c. Rh-negative antibodies d. Rh-positive antibodies
ANS: D If the mother is exposed to the Rh antigen, Rh-positive antibodies will be produced after delivery of an Rh-positive baby
2.A patient with hyperemesis gravidarum asks the nurse what would have happened if she had not come to the hospital. What result is the best response by the nurse? a. A large for gestational age infant b. Anorexia nervosa c. Preterm delivery d. Maternal or fetal death
ANS: D If untreated, hyperemesis gravidarum can result in maternal or fetal death.
3.How should twins who share a placenta and come from one fertilized ovum be identified? a. Dizygotic b. Trizygotic c. Genetically different d. Monozygotic
ANS: D Monozygotic twins, also known as identical twins, originate from one fertilized ovum and share a placenta
9.A pregnant woman comes to the hospital 3 weeks before her estimated date of birth (EDB) complaining of severe pain and a rigid abdomen. What should the nurse immediately suspect as the cause of the pain? a. Placenta previa b. Appendicitis c. Ectopic pregnancy d. Abruptio placentae
ANS: D The major symptoms of abruptio placentae are severe pain and a rigid abdomen.
25.The nurse is caring for a newborn who was circumcised earlier in the day. What should be included in the plan of care? a. Administration of a topical anesthetic to the site b. Application of ice to stop bleeding c. Retraction of any remaining foreskin d. Observation for bleeding for the first 12 hours
ANS: D The nurse should assess for bleeding for the first 12 hours following the circumcision. Gentle pressure should be applied to control bleeding.
12.A new mother had spinal anesthesia during a cesarean delivery. She now has a desire to void and can wiggle her toes. What should be the nurses response when the mother asks to go the bathroom? a. Assess her blood pressure b. Obtain a wheelchair c. Palpate her bladder d. Put slippers on her feet
ANS: D The nurse should check that the mother is wearing slippers to ensure better footing.
16.Before initially feeding an infant, what reflex should the nurse assess? a. Moro reflex b. Rooting reflex c. Babinski reflex d. Swallow reflex
ANS: D The nurse should verify that the infant is able to swallow normally before feeding.
10.What is the appropriate way to assess the fundus of the postpartum patient? a. Using the side of one hand moving down from the umbilicus b. Using one hand over the lower segment of the uterus c. Using one hand pushing upward from the lower uterus d. Using one hand on the lower uterine segment while the other hand locates the fundus of the uterus
ANS: D The proper way to assess the fundus of a mother who has just given birth is by placing one hand on the lower uterine segment while the other hand locates the fundus of the uterus.
8.During the immediate postpartum period, the mother has a temperature of 100.2 F, pulse 52, respirations 18, BP 138/84. What should the nurse do? a. Report the temperature as abnormal b. Continue to monitor every 15 minutes c. Report the pulse as abnormal d. Nothing as the vital signs are normal
ANS: D The vital signs are normal for a new postpartum patient.
32.Cognitive impairment, facial abnormalities, and growth retardation are characteristics of which abnormality in a fetus? a. Fetal dependency b. Fetal immaturity c. Malnutrition dependency d. Fetal alcohol syndrome
ANS: D Use of alcohol may result in multiple anomalies called fetal alcohol syndrome. The fetus may also be born with alcohol dependency and immaturity,
35.What is a prominent feature of postpartum depression? a. Failure to thrive b. Rejection of the infant c. Inability to care for the baby d. Problems with the babys father
NS: B A prominent feature of PPD is rejection of the infant.
36.What is the usual treatment for severe postpartum depression? a. Improved nutrition b. Vitamin therapy c. Pharmacologic interventions d. Support group therapy
NS: C Support therapy is not enough for major PPD. Pharmacologic interventions are needed in most instances.