Maternal/OB finals review

An 18-month-old infant has Pneumocystis carinii pneumonia. Results of enzyme-linked immunosorbent assay (ELISA) testing indicate that she is HIV positive. When planning care, the nurse should consider which of the following factors? A. The infant's mother is likely HIV positive. B. The infant's ELISA test result is probably a false positive for HIV. C. Antiretroviral medications are inappropriate for infants and children who have HIV. D. HIV-positive status is a contraindication for measles, mumps, and rubella immunizations.

Correct Answer: A. The infant's mother is likely HIV positive. Transmission of HIV from a woman to her infant can occur during pregnancy, in delivery, or through breastfeeding. Although it is possible for the infant to acquire HIV from sexual abuse, mother-to-child transmission accounts for the majority of HIV/AIDS cases in infants. B. The ELISA test is unreliable for HIV testing in infants under 18 months of age because of false-positive results due to maternal antibodies. The results are reliable, however, for clients 18 months of age and older. C. While antiretroviral medications cannot cure HIV, they do slow the progress of the infection for clients of all ages. D. Infants who are HIV positive should receive immunization against childhood illnesses, including measles, mumps, rubella, and influenza.

A nurse is facilitating a group discussion with preschool teachers about child abuse. Which of the following examples should the nurse use to illustrate a suggestive finding? A. Bruising of both knees with sutures on 1 B. Arm cast for a spiral fracture of the forearm C. Consistent bedwetting at nap time D. Frequent, vague reports of a stomachache or a headache

Correct Answer: B. Arm cast for a spiral fracture of the forearm Spiral fractures occur from the twisting of an extremity. In most instances, spiral fractures of the arm result from an abusive injury. A. Bruising of the knees and sutures are typical findings associated with accidental childhood injuries, such as falling off a bicycle. Lacerations or abrasions to the backs of the legs are suggestive of physical abuse. C. Bedwetting has many causes and affects many preschoolers. In the absence of other findings, it does not indicate abuse. Pain with urination or recurrent urinary tract infections suggest sexual abuse. D. In the absence of other findings, these reports do not indicate abuse. However, abdominal pain and swelling accompanied by indications of punching are suggestive of physical abuse.

A nurse is assessing a newborn. Which of the following findings should the nurse report to the provider? A. Pink-tinged urine B. Scant amount of nipple discharge C. Grunting with expiration D. Bluish discoloration of feet and hands

Correct Answer: C. Grunting with expiration Grunting, nasal flaring, and substernal or intercostal retractions are signs of respiratory distress in a newborn. The nurse should report this finding to the provider. A. Pink-tinged urine is an expected finding in a newborn and is caused by uric acid crystals. B. Nipple discharge is an expected finding in a newborn due to the effects of maternal estrogen during pregnancy. D. Bluish discoloration of the hands and feet is known as acrocyanosis. This is an expected finding in a newborn.

A nurse is assessing a client who missed 2 menstrual cycles and reports that she might be pregnant. Which of the following findings is a positive sign of pregnancy? A. Quickening B. Breast tenderness C. Uterine enlargement D. Auscultation of a fetal heart rate

Correct Answer: D. Auscultation of a fetal heart rate The auscultation of a fetal heart rate is a conclusive sign of pregnancy. A. Quickening is the mother's report of feeling fetal movement. This is a presumptive sign of pregnancy because it is client-reported and could have other causes. B. Breast tenderness is a presumptive sign of pregnancy because it is client-reported and could have other causes. C. Uterine enlargement is a probable sign of pregnancy when detected by an examiner. While strongly suggestive of pregnancy, probable signs are not conclusive.

A nurse in the emergency department is assessing a preschooler for indications of child maltreatment. The nurse should identify that which of the following findings is a manifestation of physical abuse? A. Multiple dental caries B. Malnutrition C. Frequent urinary tract infections D. Bruises at various stages of healing

Correct Answer: D. Bruises at various stages of healing The nurse should recognize that bruises at various stages of healing are a manifestation of physical abuse. A. Depriving a child of medical and dental care is a manifestation of physical neglect. B. Malnutrition is a manifestation of physical neglect. C. Frequent urinary tract infections are a manifestation of sexual abuse.

A nurse in the emergency department is caring for a child who has bruises that support a suspicion of child abuse. Which of the following actions should the nurse take? A. Ask the child if his parents are responsible for the abuse B. Notify the facility's risk manager C. Interview the child with his parents present D. Report the suspected abuse to local authorities

Correct Answer: D. Report the suspected abuse to local authorities The nurse should initiate the process of removing the child from the abusive environment by following the facility's protocol for reporting the situation to child protective services or local law enforcement. A. The nurse should avoid the use of the term "abuse" and should ask the child to describe what happened without making an accusation or placing blame on an individual. B. A risk manager evaluates situations that could create liability for the facility. In this situation, the child is not at risk from the facility or staff. C. The nurse should interview the child privately to provide a safe environment in which the child feels able to talk about what happened.

A charge nurse is providing education about child maltreatment to a group of newly licensed nurses. Which of the following pieces of information should the charge nurse include in the teaching? A. Preschoolers have the highest rates of maltreatment. B. In single-parent families, the parent's non-biological partner is typically the abuser of the child. C. Children who were born prematurely are more likely to be maltreated. D. Child maltreatment occurs equally across all socioeconomic groups.

Correct Answer: C. Children who were born prematurely are more likely to be maltreated. Children who were born prematurely often require prolonged hospitalization after birth, which can interrupt the parent-child bonding that typically occurs in early infancy. Additionally, this group of children often have increased care needs, which increases the risk of caregiver fatigue and can lead to an increased potential for maltreatment. A. While child maltreatment occurs in all age groups, infants from birth to 1 year of age have the highest rate of maltreatment. B. In single-parent families, the parent is more often the abuser than the nonbiological partner. D. While child maltreatment does occur across all socioeconomic groups, the most cases occur in families of lower income and education level. These families often have a greater number of additional stressors and restricted access to available support systems.

A nurse is teaching a client who is at 30 weeks gestation about warning signs of complications that she should report to her provider. Which of the following findings should the nurse include in the teaching? A. Mild constipation B. Nasal congestion C. Vaginal bleeding D. 10 fetal movements per hour

Correct Answer: C. Vaginal bleeding Vaginal bleeding can be an abnormal finding during pregnancy indicating a complication such as placental abruption, placenta previa, or preterm labor. A. Mild constipation is an expected finding in pregnancy due to the slowing of intestinal motility secondary to the increase in circulating progesterone and compression of the intestines by the enlarged uterus. B. Nasal congestion is an expected finding during pregnancy due to the swelling of mucous membranes secondary to increased circulating estrogen. D. The client should feel the fetus move at least 3 times per hour. Therefore, 10 movements in an hour is an expected finding.

A nurse is assessing a client who is at 36 weeks of gestation. Which of the following manifestations should the nurse recognize as a potential prenatal complication and report to the provider? A. Varicose veins B. Double vision C. Leukorrhea D. Flatulence

Double vision, blurred vision, or visual disturbances are signs of potential complications associated with preeclampsia. The nurse should report this finding to the provider. A. Varicose veins are a common manifestation associated with pregnancy. They are caused by the relaxation of the smooth muscle walls of the veins and pelvic vasocongestion. C. Leukorrhea is a hormonal production of an abundant amount of mucus. It is a common manifestation associated with pregnancy. D. Flatulence is a common manifestation associated with pregnancy. Progesterone causes reduced gastrointestinal motility.