maternal and child nursing answers and rationale

8/20/2019 Maternal and Child Nursing Answers and Rationale

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1. B. Although all of the factors listed are important, sperm motility is the most significant criterion when

assessing male infertility. Sperm count, sperm maturity, and semen volume are all significant, but they are

not as significant sperm motility.

2. D. Based on the partner’s statement, the couple is verbalizing feelings of inadeuacy and negative

feelings about themselves and their capabilities. !hus, the nursing diagnosis of self"esteem disturbance ismost appropriate. #ear, pain, and ineffective family coping also may be present but as secondary nursing

diagnoses.

$. B. %ressure and irritation of the bladder by the growing uterus during the first trimester is responsible

for causing urinary freuency. &ysuria, incontinence, and burning are symptoms associated with urinary

tract infections.

'. C. &uring the second trimester, the reduction in gastric acidity in con(unction with pressure from the

growing uterus and smooth muscle rela)ation, can cause heartburn and flatulence. *+ levels increase inthe first, not the second, trimester. &ecrease intestinal motility would most li-ely be the cause of

constipation and bloating. strogen levels decrease in the second trimester.

/. D. +hloasma, also called the mas- of pregnancy, is an irregular hyperpigmented area found on the

face. 0t is not seen on the breasts, areola, nipples, chest, nec-, arms, legs, abdomen, or thighs.

. C. &uring pregnancy, hormonal changes cause rela)ation of the pelvic (oints, resulting in the typical

waddling3 gait. +hanges in posture are related to the growing fetus. %ressure on the surrounding muscles

causing discomfort is due to the growing uterus. 4eight gain has no effect on gait.

5. C. !he average amount of weight gained during pregnancy is 2' to $6 lb. !his weight gain consists of

the following7 fetus 8 5./ lb9 placenta and membrane 8 1./ lb9 amniotic fluid 8 2 lb9 uterus 8 2./ lb9 breasts

8 $ lb9 and increased blood volume 8 2 to ' lb9 e)travascular fluid and fat 8 ' to : lb. A gain of 12 to 22 lb is

insufficient, whereas a weight gain of 1/ to 2/ lb is marginal. A weight gain of 2/ to '6 lb is considered

e)cessive.

;. C. %ressure of the growing uterus on blood vessels results in an increased ris- for venous stasis in the

lower e)tremities. Subseuently, edema and varicose vein formation may occur. !hrombophlebitis is aninflammation of the veins due to thrombus formation. %regnancy"induced hypertension is not associated

with these symptoms. ravity plays only a minor role with these symptoms.

:. C. +ervical softening are two probable signs of pregnancy. %robable

signs are ob(ective findings that strongly suggest pregnancy. ?ther probable signs include *egar sign,

which is softening of the lower uterine segment9 %is-ace- sign, which is enlargement and softening of the

uterus9 serum laboratory tests9 changes in s-in pigmentation9 and ultrasonic evidence of a gestational sac


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%resumptive signs are sub(ective signs and include amenorrhea9 nausea and vomiting9 urinary freuency9

breast tenderness and changes9 e)cessive fatigue9 uterine enlargement9 and uic-ening.

16. B. %resumptive signs of pregnancy are sub(ective signs. ?f the signs listed, only nausea and vomiting

are presumptive signs. *egar sign,s-in pigmentation changes, and a positive serum pregnancy test are

considered probably signs, which are strongly suggestive of pregnancy.

11. D. &uring the first trimester, common emotional reactions include ambivalence, fear, fantasies,

or an)iety. !he second trimester is a period of well"being accompanied by the increased need to learn

about fetal growth and development. +ommon emotional reactions during this trimester include narcissism

passivity, or introversion. At times the woman may seem egocentric and self"centered. &uring the third

trimester, the woman typically feels aw-ward, clumsy, and unattractive, often becoming more introverted o

reflective of her own childhood.

12. B. #irst"trimester classes commonly focus on such issues as early physiologic changes, fetal

development, se)uality during pregnancy, and nutrition. Some early classes may include pregnant couples

Second and third trimester classes may focus on preparation for birth, parenting, and newborn care.

1$. C. 4ith breast feeding, the father’s body is not capable of providing the mil- for the newborn, which

may interfere with feeding the newborn, providing fewer chances for bonding, or he may be (ealous of the

infant’s demands on his wife’s time and body. Breast feeding is advantageous because uterine involution

occurs more rapidly, thus minimizing blood loss. !he presence of maternal antibodies in breast mil- helps

decrease the incidence of allergies in the newborn. A greater chance for error is associated with bottle

feeding. @o preparation is reuired for breast feeding.

1'. A. A false"positive reaction can occur if the pregnancy test is performed less than 16 days after an

abortion. %erforming the tests too early or too late in the pregnancy, storing the urine sample too long at

room temperature, or having a spontaneous or missed abortion impending can all produce false"negative

results.

1/. D. !he #* can be auscultated with a fetoscope at about 26 wee-’s gestation. #* usually is

ausculatated at the midline suprapubic region with &oppler ultrasound transducer at 16 to 12 wee-’s

gestation. #*, cannot be heard any earlier than 16 wee-s’ gestation.

1. C. !o determine the && when the date of the client’s C% is -nown use @agele rule. !o the first day o

the C%, add 5 days, subtract $ months, and add 1 year


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the level of the umbilicus at appro)imately 26 wee-s’ gestation and reaches the )iphoid at term or '6

wee-s.

1;. D. &anger signs that reuire prompt reporting lea-ing of amniotic fluid, vaginal bleeding, blurred vision

rapid weight gain, and elevated blood pressure. +onstipation, breast tenderness, and nasal stuffiness are

common discomforts associated with pregnancy.

1:. B. A rubella titer should be 17; or greater. !hurs, a finding of a titer less than 17; is significant, indicating

that the client may not possess immunity to rubella. A hematocrit of $$./G a white blood cell count of

;,666Hmm$, and a 1 hour glucose challenge test of 116 gHdl are with normal parameters.

26. D. 4ith true labor, contractions increase in intensity with wal-ing. 0n addition, true labor contractions

occur at regular intervals, usually starting in the bac- and sweeping around to the abdomen. !he interval o

true labor contractions gradually shortens.

21. B. +rowing, which occurs when the newborn’s head or presenting part appears at the vaginal opening,occurs during the second stage of labor. &uring the first stage of labor, cervical dilation and effacement

occur. &uring the third stage of labor, the newborn and placenta are delivered. !he fourth stage of labor

lasts from 1 to ' 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 read(ustment to the nonpregnant state.

22. C. Barbiturates are rapidly transferred across the placental barrier, and lac- of an antagonist ma-es

them generally inappropriate during active labor. @eonatal side effects of barbiturates include central

nervous system depression, prolonged drowsiness, delayed establishment of feeding


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2/. D. 0mmediately before e)pulsion or birth of the rest of the body, the cardinal movement of e)ternal

rotation occurs. &escent fle)ion, internal rotation, e)tension, and restitution


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$'. C. 0n a missed abortion, there is early fetal intrauterine death, and products of conception are not

e)pelled. !he cervi) remains closed9 there may be a dar- brown vaginal discharge, negative pregnancy

test, and cessation of uterine growth and breast tenderness. A threatened abortion is evidenced with

cramping and vaginal bleeding in early pregnancy, with no cervical dilation. An incomplete abortion

presents with bleeding, cramping, and cervical dilation. An incomplete abortion involves only e)pulsion of

part of the products of conception and bleeding occurs with cervical dilation.

$/. A. Cultiple gestation is one of the predisposing factors that may cause placenta previa. Iterine

anomalies abdominal trauma, and renal or vascular disease may predispose a client to abruptio placentae

$. B. A client with abruptio placentae may e)hibit concealed or dar- red bleeding, possibly reporting

sudden intense localized uterine pain. !he uterus is typically firm to board"li-e, and the fetal presenting par

may be engaged. Bright red, painless vaginal bleeding, a palpable fetal outline and a soft non"tender

abdomen are manifestations of placenta previa.

$5. D. Abruptio placentae is described as premature separation of a normally implanted placenta during the

second half of pregnancy, usually with severe hemorrhage. %lacenta previa refers to implantation of the

placenta in the lower uterine segment, causing painless bleeding in the third trimester of pregnancy.

ctopic pregnancy refers to the implantation of the products of conception in a site other than the

endometrium. 0ncompetent cervi) is a conduction characterized by painful dilation of the cervical os withou

uterine contractions.

$;. B. *yperstimulation of the uterus such as with o)ytocin during the induction of labor may result in

tetanic contractions prolonged to more than :6seconds, which could lead to such complications as fetal

distress, abruptio placentae, amniotic fluid embolism, laceration of the cervi), and uterine rupture. 4ea-

contractions would not occur. %ain, bright red vaginal bleeding, and increased restlessness and an)iety are

not associated with hyperstimulation.

$:. C. A -ey 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. 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. Arranging for necessary e)planations by various staff members to be involved with the

client’s care is a nursing responsibility. !he nurse is responsible for reinforcing the e)planations about the

surgery, e)pected outcome, and type of anesthetic to be used. !he obstetrician is responsible for

e)plaining about the surgery and outcome and the anesthesiology staff is responsible for e)planations

about the type of anesthesia to be used.

'6. A. %reterm labor is best described as labor that begins after 26 wee-s’ gestation and before $5 wee-s’

gestation. !he other time periods are inaccurate.


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'1. B. %?C can precipitate many potential and actual problems9 one of the most serious is the fetus loss

of an effective defense against infection. !his is the client’s most immediate need at this time. !ypically,

%?C occurs about 1 hour, not ' hours, before labor begins. #etal viability and gestational age are less

immediate considerations that affect the plan of care. Calpresentation and an incompetent cervi) may be

causes of %?C.

'2. B. &ystocia is difficult, painful, prolonged labor due to mechanical factors involving the fetus


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':. B. Canifestations of cystitis include, freuency, urgency, dysuria, hematuria nocturia, fever, and

suprapubic pain. &ehydration, hypertension, and chills are not typically associated with cystitis. *igh fever

chills, flan- pain, nausea, vomiting, dysuria, and freuency are associated with pvelonephritis.

/6. C. According to statistical reports, between /6G and ;6G of all new mothers report some form of

postpartum blues. !he ranges of 16G to '6G, $6G to /6G, and 2/G to 56G are incorrect.

A@S4 A@& A!0?@A

1. B. Although all of the factors listed are important, sperm motility is the most significant criterion when

assessing male infertility. Sperm count, sperm maturity, and semen volume are all significant, but they are

not as significant sperm motility.

2. D. Based on the partner’s statement, the couple is verbalizing feelings of inadeuacy and negative

feelings about themselves and their capabilities. !hus, the nursing diagnosis of self"esteem disturbance is

most appropriate. #ear, pain, and ineffective family coping also may be present but as secondary nursing

diagnoses.

$. B. %ressure and irritation of the bladder by the growing uterus during the first trimester is

responsible for causing urinary freuency. &ysuria, incontinence, and burning are symptoms associated

with urinary tract infections.

'. C. &uring the second trimester, the reduction in gastric acidity in con(unction with pressure from the

growing uterus and smooth muscle rela)ation, can cause heartburn and flatulence. *+ levels increase in

the first, not the second, trimester. &ecrease intestinal motility would most li-ely be the cause of

constipation and bloating. strogen levels decrease in the second trimester.

/. D. +hloasma, also called the mas- of pregnancy, is an irregular hyperpigmented area found on the

face. 0t is not seen on the breasts, areola, nipples, chest, nec-, arms, legs, abdomen, or thighs.

. C. &uring pregnancy, hormonal changes cause rela)ation of the pelvic (oints, resulting in the typical

waddling3 gait. +hanges in posture are related to the growing fetus. %ressure on the surrounding muscles

causing discomfort is due to the growing uterus. 4eight gain has no effect on gait.

5. C. !he average amount of weight gained during pregnancy is 2' to $6 lb. !his weight gain consists

of the following7 fetus 8 5./ lb9 placenta and membrane 8 1./ lb9 amniotic fluid 8 2 lb9 uterus 8 2./ lb9 breasts

8 $ lb9 and increased blood volume 8 2 to ' lb9 e)travascular fluid and fat 8 ' to : lb. A gain of 12 to 22 lb is

insufficient, whereas a weight gain of 1/ to 2/ lb is marginal. A weight gain of 2/ to '6 lb is considered

e)cessive.

;. C. %ressure of the growing uterus on blood vessels results in an increased ris- for venous stasis in

the lower e)tremities. Subseuently, edema and varicose vein formation may occur. !hrombophlebitis is an

inflammation of the veins due to thrombus formation. %regnancy"induced hypertension is not associated

with these symptoms. ravity plays only a minor role with these symptoms.

:. C. +ervical softening are two probable signs of pregnancy.

%robable signs are ob(ective findings that strongly suggest pregnancy. ?ther probable signs include *egarsign, which is softening of the lower uterine segment9 %is-ace- sign, which is enlargement and softening of

the uterus9 serum laboratory tests9 changes in s-in pigmentation9 and ultrasonic evidence of a gestational

sac. %resumptive signs are sub(ective signs and include amenorrhea9 nausea and vomiting9 urinary

freuency9 breast tenderness and changes9 e)cessive fatigue9 uterine enlargement9 and uic-ening.

16. B. %resumptive signs of pregnancy are sub(ective signs. ?f the signs listed, only nausea and

vomiting are presumptive signs. *egar sign, s-in pigmentation changes, and a positive serum pregnancy

test are considered probably signs, which are strongly suggestive of pregnancy.

https://www.blogger.com/nullhttps://www.blogger.com/null


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11. D. &uring the first trimester, common emotional reactions include ambivalence, fear, fantasies, or

an)iety. !he second trimester is a period of well"being accompanied by the increased need to learn about

fetal growth and development. +ommon emotional reactions during this trimester include narcissism,

passivity, or introversion. At times the woman may seem egocentric and self"centered. &uring the third

trimester, the woman typically feels aw-ward, clumsy, and unattractive, often becoming more introverted or

reflective of her own childhood.

12. B. #irst"trimester classes commonly focus on such issues as early physiologic changes, fetal

development, se)uality during pregnancy, and nutrition. Some early classes may include pregnant couples.Second and third trimester classes may focus on preparation for birth, parenting, and newborn care.

1$. C. 4ith breast feeding, the father’s body is not capable of providing the mil- for the newborn, which

may interfere with feeding the newborn, providing fewer chances for bonding, or he may be (ealous of the

infant’s demands on his wife’s time and body. Breast feeding is advantageous because uterine involution

occurs more rapidly, thus minimizing blood loss. !he presence of maternal antibodies in breast mil- helps

decrease the incidence of allergies in the newborn. A greater chance for error is associated with bottle

feeding. @o preparation is reuired for breast feeding.

1'. A. A false"positive reaction can occur if the pregnancy test is performed less than 16 days after an

abortion. %erforming the tests too early or too late in the pregnancy, storing the urine sample too long at

room temperature, or having a spontaneous or missed abortion impending can all produce false"negativeresults.

1/. D. !he #* can be auscultated with a fetoscope at about 26 wee-’s gestation. #* usually is

ausculatated at the midline suprapubic region with &oppler ultrasound transducer at 16 to 12 wee-’s

gestation. #*, cannot be heard any earlier than 16 wee-s’ gestation.

1. C. !o determine the && when the date of the client’s C% is -nown use @agele rule. !o the first

day of the C%, add 5 days, subtract $ months, and add 1 year


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suc-ing refle) or poor suc-ing pressure=. !ranuilizers are associated with neonatal effects such as

hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the first few days. @arcotic

analgesic readily cross the placental barrier, causing depressive effects in the newborn 2 to $ hours after

intramuscular in(ection. egional anesthesia is associated with adverse reactions such as maternal

hypotension, allergic or to)ic reaction, or partial or total respiratory failure.

2$. D. &uring 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. +ollecting a urine specimen and other laboratory tests is done on admissionduring the first stage of labor. Assessing uterine contractions every $6 minutes is performed during the

latent phase of the first stage of labor. +oaching the client to push effectively is appropriate during the

second stage of labor.

2'. A. !he newborn’s ability to regulate body temperature is poor. !herefore, placing the newborn under

a radiant warmer aids in maintaining his or her body temperature. Suctioning with a bulb syringe helps

maintain a patent airway. ?btaining an Apgar score measures the newborn’s immediate ad(ustment to

e)trauterine life. 0nspecting the umbilical cord aids in detecting cord anomalies.

2/. D. 0mmediately before e)pulsion or birth of the rest of the body, the cardinal movement of e)ternal

rotation occurs. &escent fle)ion, internal rotation, e)tension, and restitution


10/94

$'. C. 0n a missed abortion, there is early fetal intrauterine death, and products of conception are not

e)pelled. !he cervi) remains closed9 there may be a dar- brown vaginal discharge, negative pregnancy

test, and cessation of uterine growth and breast tenderness. A threatened abortion is evidenced with

cramping and vaginal bleeding in early pregnancy, with no cervical dilation. An incomplete abortion presents

with bleeding, cramping, and cervical dilation. An incomplete abortion involves only e)pulsion of part of the

products of conception and bleeding occurs with cervical dilation.

$/. A. Cultiple gestation is one of the predisposing factors that may cause placenta previa. Iterine

anomalies abdominal trauma, and renal or vascular disease may predispose a client to abruptio placentae.$. B. A client with abruptio placentae may e)hibit concealed or dar- red bleeding, possibly reporting

sudden intense localized uterine pain. !he uterus is typically firm to boardli-e, and the fetal presenting part

may be engaged. Bright red, painless vaginal bleeding, a palpable fetal outline and a soft nontender

abdomen are manifestations of placenta previa.

$5. D. Abruptio placentae is described as premature separation of a normally implanted placenta during

the second half of pregnancy, usually with severe hemorrhage. %lacenta previa refers to implantation of the

placenta in the lower uterine segment, causing painless bleeding in the third trimester of pregnancy. ctopic

pregnancy refers to the implantation of the products of conception in a site other than the endometrium.

0ncompetent cervi) is a conduction characterized by painful dilation of the cervical os without uterine

contractions.$;. B. *yperstimulation of the uterus such as with o)ytocin during the induction of labor may result in

tetanic contractions prolonged to more than :6seconds, which could lead to such complications as fetal

distress, abruptio placentae, amniotic fluid embolism, laceration of the cervi), and uterine rupture. 4ea-

contractions would not occur. %ain, bright red vaginal bleeding, and increased restlessness and an)iety are

not associated with hyperstimulation.

$:. C. A -ey 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. 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. Arranging for necessary e)planations by various staff members to be involved with the

client’s care is a nursing responsibility. !he nurse is responsible for reinforcing the e)planations about the

surgery, e)pected outcome, and type of anesthetic to be used. !he obstetrician is responsible for e)plaining

about the surgery and outcome and the anesthesiology staff is responsible for e)planations about the type

of anesthesia to be used.

'6. A. %reterm labor is best described as labor that begins after 26 wee-s’ gestation and before $5

wee-s’ gestation. !he other time periods are inaccurate.

'1. B. %?C can precipitate many potential and actual problems9 one of the most serious is the fetus

loss of an effective defense against infection. !his is the client’s most immediate need at this time. !ypically,

%?C occurs about 1 hour, not ' hours, before labor begins. #etal viability and gestational age are less

immediate considerations that affect the plan of care. Calpresentation and an incompetent cervi) may be

causes of %?C.

'2. B. &ystocia is difficult, painful, prolonged labor due to mechanical factors involving the fetus


11/94

''. B. !he immediate priority is to minimize pressure on the cord. !hus the nurse’s initial action involves

placing the client on bed rest and then placing the client in a -nee"chest position or lowering the head of the

bed, and elevating the maternal hips on a pillow to minimize the pressure on the cord. Conitoring maternal

vital signs and #*, notifying the physician and preparing the client for delivery, and wrapping the cord with

sterile saline soa-ed warm gauze are important. But these actions have no effect on minimizing the

pressure on the cord.

'/. D. %ostpartum hemorrhage is defined as blood loss of more than /66 ml following birth. Any amount

less than this not considered postpartum hemorrhage.'. D. 4ith mastitis, in(ury to the breast, such as overdistention, stasis, and crac-ing of the nipples, is

the primary predisposing factor. pidemic and endemic infections are probable sources of infection for

mastitis. !emporary urinary retention due to decreased perception of the urge to void is a contributory factor

to the development of urinary tract infection, not mastitis.

'5. D. !hrombophlebitis refers to an inflammation of the vascular endothelium with clot formation on the

wall of the vessel. Blood components combining to form an aggregate body describe a thrombus or

thrombosis. +lots lodging in the pulmonary vasculature refers to pulmonary embolism9 in the femoral vein,

femoral thrombophlebitis.

';. C. +lassic symptoms of &J! include muscle pain, the presence of *omans sign, and swelling of the

affected limb. Cidcalf pain, tenderness, and redness, along the vein reflect superficial thrombophlebitis.+hills, fever and malaise occurring 2 wee-s after delivery reflect pelvic thrombophlebitis. +hills, fever,

stiffness and pain occurring 16 to 1' days after delivery suggest femoral thrombophlebitis.

':. B. Canifestations of cystitis include, freuency, urgency, dysuria, hematuria nocturia, fever, and

suprapubic pain. &ehydration, hypertension, and chills are not typically associated with cystitis. *igh fever

chills, flan- pain, nausea, vomiting, dysuria, and freuency are associated with pvelonephritis.

/6. C. According to statistical reports, between /6G and ;6G of all new mothers report some form of

postpartum blues. !he ranges of 16G to '6G, $6G to /6G, and 2/G to 56G are incorrect.

/1. B. egular timely ingestion of oral contraceptives is necessary to maintain hormonal levels of the

drugs to suppress the action of the hypothalamus and anterior pituitary leading to inappropriate secretion of

#S* and *. !herefore, follicles do not mature, ovulation is inhibited, and pregnancy is prevented. !he

estrogen content of the oral site contraceptive may cause the nausea, regardless of when the pill is ta-en.

Side effects and drug interactions may occur with oral contraceptives regardless of the time the pill is ta-en.

/2. C. +ondoms, when used correctly and consistently, are the most effective contraceptive method or

barrier against bacterial and viral se)ually transmitted infections. Although spermicides -ill sperm, they do

not provide reliable protection against the spread of se)ually transmitted infections, especially intracellular

organisms such as *0J. 0nsertion and removal of the diaphragm along with the use of the spermicides may

cause vaginal irritations, which could place the client at ris- for infection transmission. Cale sterilization

eliminates spermatozoa from the e(aculate, but it does not eliminate bacterial andHor viral microorganisms

that can cause se)ually transmitted infections.

/$. A. !he diaphragm must be fitted individually to ensure effectiveness. Because of the changes to the

reproductive structures during pregnancy and following delivery, the diaphragm must be refitted, usually at

the wee-s’ e)amination following childbirth or after a weight loss of 1/ lbs or more. 0n addition, for

ma)imum effectiveness, spermicidal (elly should be placed in the dome and around the rim. *owever,

spermicidal (elly should not be inserted into the vagina until involution is completed at appro)imately

wee-s. Ise of a female condom protects the reproductive system from the introduction of semen or

spermicides into the vagina and may be used after childbirth. ?ral contraceptives may be started within the

first postpartum wee- to ensure suppression of ovulation. #or the couple who has determined the female’s

fertile period, using the rhythm method, avoidance of intercourse during this period, is safe and effective.


12/94

/'. C. An 0I& may increase the ris- of pelvic inflammatory disease, especially in women with more than

one se)ual partner, because of the increased ris- of se)ually transmitted infections. An I0& should not be

used if the woman has an active or chronic pelvic infection, postpartum infection, endometrial hyperplasia or

carcinoma, or uterine abnormalities. Age is not a factor in determining the ris-s associated with 0I& use.

Cost 0I& users are over the age of $6. Although there is a slightly higher ris- for infertility in women who

have never been pregnant, the 0I& is an acceptable option as long as the ris-"benefit ratio is discussed.

0I&s may be inserted immediately after delivery, but this is not recommended because of the increased ris-

and rate of e)pulsion at this time.//. C. &uring the third trimester, the enlarging uterus places pressure on the intestines. !his coupled

with the effect of hormones on smooth muscle rela)ation causes decreased intestinal motility


13/94

generally do not need daily glucose monitoring. !he standard of care recommends a fasting and 2"hour

postprandial blood sugar level every 2 wee-s.

1. C. After 26 wee-s’ gestation, when there is a rapid weight gain, preeclampsia should be suspected,

which may be caused by fluid retention manifested by edema, especially of the hands and face. !he three

classic signs of preeclampsia are hypertension, edema, and proteinuria. Although urine is chec-ed for

glucose at each clinic visit, this is not the priority. &epression may cause either anore)ia or e)cessive food

inta-e, leading to e)cessive weight gain or loss. !his is not, however, the priority consideration at this time.

4eight gain thought to be caused by e)cessive food inta-e would reuire a 2'"hour diet recall. *owever,e)cessive inta-e would not be the primary consideration for this client at this time.

2. B. +ramping and vaginal bleeding coupled with cervical dilation signifies that termination of the

pregnancy is inevitable and cannot be prevented. !hus, the nurse would document an imminent abortion. 0n

a threatened abortion, cramping and vaginal bleeding are present, but there is no cervical dilation. !he

symptoms may subside or progress to abortion. 0n a complete abortion all the products of conception are

e)pelled. A missed abortion is early fetal intrauterine death without e)pulsion of the products of conception.

$. B. #or the client with an ectopic pregnancy, lower abdominal pain, usually unilateral, is the primary

symptom. !hus, pain is the priority. Although the potential for infection is always present, the ris- is low in

ectopic pregnancy because pathogenic microorganisms have not been introduced from e)ternal sources.

!he client may have a limited -nowledge of the pathology and treatment of the condition and will most li-elye)perience grieving, but this is not the priority at this time.

'. D. Before uterine assessment is performed, it is essential that the woman empty her bladder. A full

bladder will interfere with the accuracy of the assessment by elevating the uterus and displacing to the side

of the midline. Jital sign assessment is not necessary unless an abnormality in uterine assessment is

identified. Iterine assessment should not cause acute pain that reuires administration of analgesia.

Ambulating the client is an essential component of postpartum care, but is not necessary prior to

assessment of the uterus.

/. A. #eeding more freuently, about every 2 hours, will decrease the infant’s frantic, vigorous suc-ing

from hunger and will decrease breast engorgement, soften the breast, and promote ease of correct

latching"on for feeding. @arcotics administered prior to breast feeding are passed through the breast mil- to

the infant, causing e)cessive sleepiness. @ipple soreness is not severe enough to warrant narcotic

analgesia. All postpartum clients, especially lactating mothers, should wear a supportive brassiere with wide

cotton straps. !his does not, however, prevent or reduce nipple soreness. Soaps are drying to the s-in of

the nipples and should not be used on the breasts of lactating mothers. &ry nipple s-in predisposes to

crac-s and fissures, which can become sore and painful.

. D. A wea-, thready pulse elevated to 166 B%C may indicate impending hemorrhagic shoc-. An

increased pulse is a compensatory mechanism of the body in response to decreased fluid volume. !hus,

the nurse should chec- the amount of lochia present. !emperatures up to 166.';# in the first 2' hours after

birth are related to the dehydrating effects of labor and are considered normal. Although rechec-ing the

blood pressure may be a correct choice of action, it is not the first action that should be implemented in light

of the other data. !he data indicate a potential impending hemorrhage. Assessing the uterus for firmness

and position in relation to the umbilicus and midline is important, but the nurse should chec- the e)tent of

vaginal bleeding first. !hen it would be appropriate to chec- the uterus, which may be a possible cause of

the hemorrhage.

5. D. Any bright red vaginal discharge would be considered abnormal, but especially / days after

delivery, when the lochia is typically pin- to brownish. ochia rubra, a dar- red discharge, is present for 2 to

$ days after delivery. Bright red vaginal bleeding at this time suggests late postpartum hemorrhage, which

occurs after the first 2' hours following delivery and is generally caused by retained placental fragments or

bleeding disorders. ochia rubra is the normal dar- red discharge occurring in the first 2 to $ days after

https://www.blogger.com/nullhttps://www.blogger.com/null


14/94

delivery, containing epithelial cells, erythrocyes, leu-ocytes and decidua. ochia serosa is a pin- to

brownish serosanguineous discharge occurring from $ to 16 days after delivery that contains decidua,

erythrocytes, leu-ocytes, cervical mucus, and microorganisms. ochia alba is an almost colorless to

yellowish discharge occurring from 16 days to $ wee-s after delivery and containing leu-ocytes, decidua,

epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria.

;. A. !he data suggests an infection of the endometrial lining of the uterus. !he lochia may be

decreased or copious, dar- brown in appearance, and foul smelling, providing further evidence of a possible

infection. All the client’s data indicate a uterine problem, not a breast problem. !ypically, transient fever,usually 161L#, may be present with breast engorgement. Symptoms of mastitis include influenza"li-e

manifestations. ocalized infection of an episiotomy or +"section incision rarely causes systemic symptoms,

and uterine involution would not be affected. !he client data do not include dysuria, freuency, or urgency,

symptoms of urinary tract infections, which would necessitate assessing the client’s urine.

:. C. Because of early postpartum discharge and limited time for teaching, the nurse’s priority is to

facilitate the safe and effective care of the client and newborn. Although promoting comfort and restoration

of health, e)ploring the family’s emotional status, and teaching about family planning are important in

postpartumHnewborn nursing care, they are not the priority focus in the limited time presented by early post"

partum discharge.

56. C. *eat loss by radiation occurs when the infant’s crib is placed too near cold walls or windows.!hus placing the newborn’s crib close to the viewing window would be least effective. Body heat is lost

through evaporation during bathing. %lacing the infant under the radiant warmer after bathing will assist the

infant to be rewarmed. +overing the scale with a warmed blan-et prior to weighing prevents heat loss

through conduction. A -nit cap prevents heat loss from the head a large head, a large body surface area of

the newborn’s body.

51. B. A fractured clavicle would prevent the normal Coro response of symmetrical seuential e)tension

and abduction of the arms followed by fle)ion and adduction. 0n talipes euinovarus


15/94

5. B. !o determine the amount of formula needed, do the following mathematical calculation. $ -g )

126 calH-g per day E $6 caloriesHday feeding ' hours E feedings per day E 6 calories per feeding7 6

calories per feeding9 6 calories per feeding with formula 26 calHoz E $ ounces per feeding. Based on the

calculation. 2, ' or ounces are incorrect.

55. A. 0ntrauterine ano)ia may cause rela)ation of the anal sphincter and emptying of meconium into

the amniotic fluid. At birth some of the meconium fluid may be aspirated, causing mechanical obstruction or

chemical pneumonitis. !he infant is not at increased ris- for gastrointestinal problems. ven though the s-in

is stained with meconium, it is noninfectious


16/94

;. B. +hadwic-’s sign refers to the purple"blue tinge of the cervi). Bra)ton *ic-s contractions are

painless contractions beginning around the 'th month. oodell’s sign indicates softening of the cervi).

#le)ibility of the uterus against the cervi) is -nown as Cc&onald’s sign.

;5. C. Breathing techniues can raise the pain threshold and reduce the perception of pain. !hey also

promote rela)ation. Breathing techniues do not eliminate pain, but they can reduce it. %ositioning, not

breathing, increases uteroplacental perfusion.

;;. A. !he client’s labor is hypotonic. !he nurse should call the physical and obtain an order for an

infusion of o)ytocin, which will assist the uterus to contact more forcefully in an attempt to dilate the cervi). Administering light sedative would be done for hypertonic uterine contractions. %reparing for cesarean

section is unnecessary at this time. ?)ytocin would increase the uterine contractions and hopefully progress

labor before a cesarean would be necessary. 0t is too early to anticipate client pushing with contractions.

;:. D. !he signs indicate placenta previa and vaginal e)am to determine cervical dilation would not be

done because it could cause hemorrhage. Assessing maternal vital signs can help determine maternal

physiologic status. #etal heart rate is important to assess fetal well"being and should be done. Conitoring

the contractions will help evaluate the progress of labor.

:6. D. A complete placenta previa occurs when the placenta covers the opening of the uterus, thus

bloc-ing the passageway for the baby. !his response e)plains what a complete previa is and the reason the

baby cannot come out e)cept by cesarean delivery. !elling the client to as- the physician is a poor responseand would increase the patient’s an)iety. Although a cesarean would help to prevent hemorrhage, the

statement does not e)plain why the hemorrhage could occur. 4ith a complete previa, the placenta is

covering all the cervi), not (ust most of it.

:1. B. 4ith a face presentation, the head is completely e)tended. 4ith a verte) presentation, the head

is completely or partially fle)ed. 4ith a brow


17/94

166. B. !estosterone is produced by the eyding cells in the seminiferous tubules. #ollicle"stimulating

hormone and leuteinzing hormone are released by the anterior pituitary gland. !he hypothalamus is

responsible for releasing gonadotropin"releasing hormone.

161. D. !he anterior fontanelle typically closes anywhere between 12 to 1; months of age. !hus,

assessing the anterior fontanelle as still being slightly open is a normal finding reuiring no further action.

Because it is normal finding for this age, notifying he physician or performing additional e)aminations are

inappropriate.

162. D. Solid foods are not recommended before age ' to months because of the suc-ing refle) andthe immaturity of the gastrointestinal tract and immune system. !herefore, the earliest age at which to

introduce foods is ' months. Any time earlier would be inappropriate.

16$. A. According to ri-son, infants need to have their needs met consistently and effectively to develop

a sense of trust. An infant whose needs are consistently unmet or who e)periences significant delays in

having them met, such as in the case of the infant of a substance"abusing mother, will develop a sense of

uncertainty, leading to mistrust of caregivers and the environment. !oddlers develop a sense of shame

when their autonomy needs are not met consistently. %reschoolers develop a sense of guilt when their

sense of initiative is thwarted. Schoolagers develop a sense of inferiority when they do not develop a sense

of industry.

16'. D. A busy bo) facilitates the fine motor development that occurs between ' and months. Balloonsare contraindicated because small children may aspirate balloons. Because the button eyes of a teddy bear

may detach and be aspirated, this toy is unsafe for children younger than $ years. A /"month"old is too

young to use a push"pull toy.

16/. B. 0nfants need to have their security needs met by being held and cuddled. At 2 months of age,

they are unable to ma-e the connection between crying and attention. !his association does not occur until

late infancy or early toddlerhood. etting the infant cry for a time before pic-ing up the infant or leaving the

infant alone to cry herself to sleep interferes with meeting the infant’s need for security at this very young

age. 0nfants cry for many reasons. Assuming that the child s hungry may cause overfeeding problems such

as obesity.

16. B. Inderdeveloped abdominal musculature gives the toddler a characteristically protruding

abdomen. &uring toddlerhood, food inta-e decreases, not increases. !oddlers are characteristically

bowlegged because the leg muscles must bear the weight of the relatively large trun-. !oddler growth

patterns occur in a stepli-e, not linear pattern.

165. B. According to ri-son, toddlers e)perience a sense of shame when they are not allowed to

develop appropriate independence and autonomy. 0nfants develop mistrust when their needs are not

consistently gratified. %reschoolers develop guilt when their initiative needs are not met while schoolagers

develop a sense of inferiority when their industry needs are not met.

16;. C. Ooung toddlers are still sensorimotor learners and they en(oy the e)perience of feeling different

te)tures. !hus, finger paints would be an appropriate toy choice. Cultiple"piece toys, such as puzzle, are

too difficult to manipulate and may be hazardous if the pieces are small enough to be aspirated. Ciniature

cars also have a high potential for aspiration. +omic boo-s are on too high a level for toddlers. Although

they may en(oy loo-ing at some of the pictures, toddlers are more li-ely to rip a comic boo- apart.

16:. D. !he child must be able to sate the need to go to the bathroom to initiate toilet training. Isually, a

child needs to be dry for only 2 hours, not ' hours. !he child also must be able to sit, wal-, and suat. A

new sibling would most li-ely hinder toilet training.

116. A. !oddlers become pic-y eaters, e)periencing food (ags and eating large amounts one day and

very little the ne)t. A toddler’s food gags e)press a preference for the ritualism of eating one type of food for

several days at a time. !oddlers typically en(oy socialization and limiting others at meal time. !oddlers prefer


18/94

to feed themselves and thus are too young to have table manners. A toddler’s appetite and need for

calories, protein, and fluid decrease due to the dramatic slowing of growth rate.

111. D. %reschoolers commonly have fears of the dar-, being left alone especially at bedtime, and

ghosts, which may affect the child’s going to bed at night. Nuiet play and time with parents is a positive

bedtime routine that provides security and also readies the child for sleep. !he child should sleep in his own

bed. !elling the child about loc-ing him in his room will viewed by the child as a threat. Additionally, a loc-ed

door is frightening and potentially hazardous. Jigorous activity at bedtime stirs up the child and ma-es more

difficult to fall asleep.112. B. &ress"up clothes enhance imaginative play and imagination, allowing preschoolers to engage in

rich fantasy play. Building bloc-s and wooden puzzles are appropriate for encouraging fine motor

development. Big wheels and tricycles encourage gross motor development.

11$. D. !he school"aged child is in the stage of concrete operations, mar-ed by inductive reasoning,

logical operations, and reversible concrete thought. !he ability to consider the future reuires formal thought

operations, which are not developed until adolescence. +ollecting baseball cards and marbles, ordering

dolls by size, and simple problem"solving options are e)amples of the concrete operational thin-ing of the

schoolager.

11'. C. eaction formation is the schoolager’s typical defensive response when hospitalized. 0n reaction

formation, e)pression of unacceptable thoughts or behaviors is prevented


19/94

for the development of self image provides information about the adolescent’s needs to the parents and

may help to gain trust with the adolescent. As-ing the adolescent how he feels about the acne will

encourage the adolescent to share his feelings. &iscussing the cleansing method shows interest and

concern for the adolescent and also can help to identify any patient"teaching needs for the adolescent

regarding cleansing.

121. B. %reschoolers should be developmentally incapable of demonstrating e)plicit se)ual behavior. 0f a

child does so, the child has been e)posed to such behavior, and se)ual abuse should be suspected. )plicit

se)ual behavior during doll play is not a characteristic of preschool development nor symptomatic ofdevelopmental delay. 4hether or nor the child -nows how to play with dolls is irrelevant.

122. A. !he parents need more teaching if they state that they will -eep the child home until the phobia

subsides. &oing so reinforces the child’s feelings of worthlessness and dependency. !he child should

attend school even during resolution of the problem. Allowing the child to verbalize helps the child to

ventilate feelings and may help to uncover causes and solutions. +ollaboration with the teachers and

counselors at school may lead to uncovering the cause of the phobia and to the development of solutions.

!he child should participate and play an active role in developing possible solutions.

12$. C. !he adolescent who becomes pregnant typically denies the pregnancy early on. arly recognition

by a parent or health care provider may be crucial to timely initiation of prenatal care. !he incidence of

adolescent pregnancy has declined since 1::1, yet morbidity remains high. Cost teenage pregnancies areunplanned and occur out of wedloc-. !he pregnant adolescent is at high ris- for physical complications

including premature labor and low"birth"weight infants, high neonatal mortality, iron deficiency anemia,

prolonged labor, and fetopelvic disproportion as well as numerous psychological crises.

12'. B. Because of the structural defect, children with cleft palate may have ineffective functioning of their

ustachian tubes creating freuent bouts of otitis media. Cost children with cleft palate remain well"

nourished and maintain adeuate nutrition through the use of proper feeding techniues. #ood particles do

not pass through the cleft and into the ustachian tubes. !here is no association between cleft palate and

congenial ear deformities.

12/. D. A $"month"old infant should be able to lift the head and chest when prone. !he Coro refle)

typically diminishes or subsides by $ months. !he parachute refle) appears at : months. olling from front

to bac- usually is accomplished at about / months.

12. D. A child’s birth weight usually triples by 12 months and doubles by ' months. @o specific birth

weight parameters are established for 5 or : months.

125. C. !oddlers engaging in parallel play will play near each other, but not with each other. !hus, when

two toddlers sit near each other but play with separate dolls, they are e)hibiting parallel play. Sharing

crayons, playing a board game with a nurse, or sharing dolls with two different nurses are all e)amples of

cooperative play.

12;. A. Acute lymphocytic leu-emia


20/94

1$6. A. Cultiple bruises and burns on a toddler are signs child abuse. !herefore, the nurse is responsible

for reporting the case to %rotective Services immediately to protect the child from further harm. Scheduling

a follow"up visit is inappropriate because additional harm may come to the child if the nurse waits for further

assessment data. Although the nurse should notify the physician, the goal is to initiate measures to protect

the child’s safety. @otifying the physician immediately does not initiate the removal of the child from harm

nor does it absolve the nurse from responsibility. Cultiple bruises and burns are not normal toddler in(uries.

1$1. B. !he mother is using pro(ection, the defense mechanism used when a person attributes his or her

own undesirable traits to another. &isplacement is the transfer of emotion onto an unrelated ob(ect, such aswhen the mother would -ic- a chair or bang the door shut. epression is the submerging of painful ideas

into the unconscious. %sychosis is a state of being out of touch with reality.

1$2. A. +hildren with congenital heart disease are more prone to respiratory infections. Bleeding

tendencies, freuent vomiting, and diarrhea and seizure disorders are not associated with congenital heart

disease.

1$$. D. !he child is e)hibiting classic signs of epiglottitis, always a pediatric emergency. !he physician

must be notified immediately and the nurse must be prepared for an emergency intubation or tracheostomy.

#urther assessment with auscultating lungs and placing the child in a mist tent wastes valuable time. !he

situation is a possible life"threatening emergency. *aving the child lie down would cause additional distress

and may result in respiratory arrest. !hroat e)amination may result in laryngospasm that could be fatal.1$'. A. 0n females, the urethra is shorter than in males. !his decreases the distance for organisms to

travel, thereby increasing the chance of the child developing a urinary tract infection. #reuent emptying of

the bladder would help to decrease urinary tract infections by avoiding sphincter stress. 0ncreased fluid

inta-e enables the bladder to be cleared more freuently, thus helping to prevent urinary tract infections.

!he inta-e of acidic (uices helps to -eep the urine p* acidic and thus decrease the chance of flora

development.

1$/. B. +ompartment syndrome is an emergent situation and the physician needs to be notified

immediately so that interventions can be initiated to relieve the increasing pressure and restore circulation.

Acetaminophen

ischemia. !he cast, not traction, is being used in this situation for immobilization, so releasing the traction

would be inappropriate. 0n this situation, specific action not continued monitoring is indicated.

1$. D. !he varicella zoster vaccine


21/94

1'6. B. &own syndrome is characterized by the following a transverse palmar crease


22/94

Answers and Rationale

1. B. egular timely ingestion of oral contraceptives is necessary to maintain hormonal levels of the drugs

to suppress the action of the hypothalamus and anterior pituitary leading to inappropriate secretion of #S*

and *. !herefore, follicles do not mature, ovulation is inhibited, and pregnancy is prevented. !he estrogen

content of the oral site contraceptive may cause the nausea, regardless of when the pill is ta-en. Side

effects and drug interactions may occur withoral contraceptives regardless of the time the pill is ta-en.

2. C. +ondoms, when used correctly and consistently, are the most effective contraceptive method or

barrier against bacterial and viral se)ually transmitted infections. Although spermicides -ill sperm, they do

not provide reliable protection against the spread of se)ually transmitted infections, especially intracellular

organisms such as *0J. 0nsertion and removal of the diaphragm along with the use of the spermicides may

cause vaginal irritations, which could place the client at ris- for infection transmission. Cale sterilization

eliminates spermatozoa from the e(aculate, but it does not eliminate bacterial andHor viral microorganisms

that can cause se)ually transmitted infections.

$. A. !he diaphragm must be fitted individually to ensure effectiveness. Because of the changes to

the reproductive structures during pregnancy and following delivery, the diaphragm must be refitted,

usually at the wee-s’ e)amination following childbirth or after a weight loss of 1/ lbs or more. 0n addition,

for ma)imum effectiveness, spermicidal (elly should be placed in the dome and around the rim. *owever,

spermicidal (elly should not be inserted into the vagina until involution is completed at appro)imately

wee-s. Ise of a female condom protects thereproductive system from the introduction of semen or

spermicides into the vagina and may be used after childbirth. ?ral contraceptives may be started within the

first postpartum wee- to ensure suppression of ovulation . #or the couple who has determined the female’sfertile period, using the rhythm method, avoidance of intercourse during this period, is safe and effective.

'. C. An 0I& may increase the ris- of pelvic inflammatory disease, especially in women with more than

one se)ual partner, because of the increased ris- of se)ually transmitted infections. An I0& should not be

used if the woman has an active or chronic pelvic infection, postpartum infection, endometrial hyperplasia

or carcinoma, or uterine abnormalities. Age is not a factor in determining the ris-s associated with 0I& use

Cost 0I& users are over the age of $6. Although there is a slightly higher ris- for infertility in women who

have never been pregnant, the 0I& is an acceptable option as long as the ris-"benefit ratio is discussed.

0I&s may be inserted immediately after delivery, but this is not recommended because of the increased

ris- and rate of e)pulsion at this time.

/. C. &uring the third trimester, the enlarging uterus places pressure on the intestines. !his coupled with

the effect of hormones on smooth muscle rela)ation causes decreased intestinal motility


23/94

preterm labor by stimulating peristalsis and may interfere with the absorption of nutrients. Ise for more

than 1 wee- can also lead to la)ative dependency. iuid in the diet helps provide a semisolid, soft

consistency to the stool. ight to ten glasses of fluid per day are essential to maintain hydration and

promote stool evacuation.

. D. !o ensure adeuate fetal growth and development during the '6 wee-s of a pregnancy, a total

weight gain 2/ to $6 pounds is recommended7 1./ pounds in the first 16 wee-s9 : pounds by $6 wee-s9and 25./ pounds by '6 wee-s. !he pregnant woman should gain less weight in the first and second

trimester than in the third. &uring the first trimester, the client should only gain 1./ pounds in the first 16

wee-s, not 1 pound per wee-. A weight gain of K pound per wee- would be 26 pounds for the total

pregnancy, less than the recommended amount.

5. B. !o calculate the && by @agele’s rule, add 5 days to the first day of the last menstrual period and

count bac- $ months, changing the year appropriately. !o obtain a date of September 25, 5 days have

been added to the last day of the C%


24/94

generally do not need daily glucose monitoring. !he standard of care recommends a fasting and 2"hour

postprandial blood sugar level every 2 wee-s.

11. C. After 26 wee-s’ gestation, when there is a rapid weight gain, preeclampsia should be suspected,

which may be caused by fluid retention manifested by edema, especially of the hands and face. !he three

classic signs of preeclampsia are hypertension, edema, and proteinuria. Although urine is chec-ed for

glucose at each clinic visit, this is not the priority. &epression may cause either anore)ia or e)cessive foodinta-e, leading to e)cessive weight gain or loss. !his is not, however, the priority consideration at this time

4eight gain thought to be caused by e)cessive food inta-e would reuire a 2'"hour diet recall. *owever,

e)cessive inta-e would not be the primary consideration for this client at this time.

12. B. +ramping and vaginal bleeding coupled with cervical dilation signifies that termination of the

pregnancy is inevitable and cannot be prevented. !hus, the nurse would document an imminent abortion.

0n a threatened abortion, cramping and vaginal bleeding are present, but there is no cervical dilation. !he

symptoms may subside or progress to abortion. 0n a complete abortion all the products of conception are

e)pelled. A missed abortion is early fetal intrauterine death without e)pulsion of the products of conception

1$. B. #or the client with an ectopic pregnancy, lower abdominal pain, usually unilateral, is the primary

symptom. !hus, pain is the priority. Although the potential for infection is always present, the ris- is low in

ectopic pregnancy because pathogenic microorganisms have not been introduced from e)ternal sources.

!he client may have a limited -nowledge of the pathology and treatment of the condition and will most

li-ely e)perience grieving, but this is not the priority at this time.

1'. D. Before uterine assessment is performed, it is essential that the woman empty her bladder. A full

bladder will interfere with the accuracy of the assessment by elevating the uterus and displacing to the side

of the midline. Jital sign assessment is not necessary unless an abnormality in uterine assessment is

identified. Iterine assessment should not cause acute pain that reuires administration of analgesia.

Ambulating the client is an essential component of postpartum care, but is not necessary prior to

assessment of the uterus.

1/. A. #eeding more freuently, about every 2 hours, will decrease the infant’s frantic, vigorous suc-ing

from hunger and will decrease breast engorgement, soften the breast, and promote ease of correct

latching"on for feeding. @arcotics administered prior to breast feeding are passed through the breast mil-

to the infant, causing e)cessive sleepiness. @ipple soreness is not severe enough to warrant narcotic

analgesia. All postpartum clients, especially lactating mothers, should wear a supportive brassiere with

wide cotton straps. !his does not, however, prevent or reduce nipple soreness. Soaps are drying to the

s-in of the nipples and should not be used on the breasts of lactating mothers. &ry nipple s-in predisposes

to crac-s and fissures, which can become sore and painful.

1. D. A wea-, thready pulse elevated to 166 B%C may indicate impending hemorrhagic shoc-. An

increased pulse is a compensatory mechanism of the body in response to decreased fluid volume. !hus,


25/94

the nurse should chec- the amount of lochia present. !emperatures up to 166.';# in the first 2' hours afte

birth are related to the dehydrating effects of labor and are considered normal. Although rechec-ing the

blood pressure may be a correct choice of action, it is not the first action that should be implemented in

light of the other data. !he data indicate a potential impending hemorrhage. Assessing the uterus for

firmness and position in relation to the umbilicus and midline is important, but the nurse should chec- the

e)tent of vaginal bleeding first. !hen it would be appropriate to chec- the uterus, which may be a possible

cause of the hemorrhage.

15. D. Any bright red vaginal discharge would be considered abnormal, but especially / days after delivery

when the lochia is typically pin- to brownish. ochia rubra, a dar- red discharge, is present for 2 to $ days

after delivery. Bright red vaginal bleeding at this time suggests late postpartum hemorrhage, which occurs

after the first 2' hours following delivery and is generally caused by retained placental fragments or

bleeding disorders. ochia rubra is the normal dar- red discharge occurring in the first 2 to $ days after

delivery, containing epithelial cells, erythrocyes, leu-ocytes and decidua. ochia serosa is a pin- to

brownish serosanguineous discharge occurring from $ to 16 days after delivery that contains decidua,

erythrocytes, leu-ocytes, cervical mucus, and microorganisms. ochia alba is an almost colorless to

yellowish discharge occurring from 16 days to $ wee-s after delivery and containing leu-ocytes, decidua,

epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria.

1;. A. !he data suggests an infection of the endometrial lining of the uterus. !he lochia may be decreased

or copious, dar- brown in appearance, and foul smelling, providing further evidence of a possible infection.

All the client’s data indicate a uterine problem, not a breast problem. !ypically, transient fever, usually

161L#, may be present with breast engorgement. Symptoms of mastitis include influenza"li-e

manifestations. ocalized infection of an episiotomy or +"section incision rarely causes systemicsymptoms, and uterine involution would not be affected. !he client data do not include dysuria, freuency,

or urgency, symptoms of urinary tract infections, which would necessitate assessing the client’s urine.

1:. C. Because of early postpartum discharge and limited time for teaching, the nurse’s priority is to

facilitate the safe and effective care of the client and newborn. Although promoting comfort and restoration

of health, e)ploring the family’s emotional status, and teaching about family planning are important in

postpartumHnewborn nursing care, they are not the priority focus in the limited time presented by early

post"partum discharge.

26. C. *eat loss by radiation occurs when the infant’s crib is placed too near cold walls or windows. !hus

placing the newborn’s crib close to the viewing window would be least effective. Body heat is lost through

evaporation during bathing. %lacing the infant under the radiant warmer after bathing will assist the infant to

be rewarmed. +overing the scale with a warmed blan-et prior to weighing prevents heat loss through

conduction. A -nit cap prevents heat loss from the head a large head, a large body surface area of the

newborn’s body.


26/94

21. B. A fractured clavicle would prevent the normal Coro response of symmetrical seuential e)tension

and abduction of the arms followed by fle)ion and adduction. 0n talipes euinovarus


27/94

2;. C. !he nurse should use a nonelastic, fle)ible, paper measuring tape, placing the zero point on the

superior border of the symphysis pubis and stretching the tape across the abdomen at the midline to the

top of the fundus. !he )iphoid and umbilicus are not appropriate landmar-s to use when measuring the

height of the fundus


28/94

$/. B. Ballottement indicates passive movement of the unengaged fetus. Ballottement is not a contraction.

#etal -ic-ing felt by the client represents uic-ening. nlargement and softening of the uterus is -nown as

%is-ace-’s sign.

$. B. +hadwic-’s sign refers to the purple"blue tinge of the cervi). Bra)ton *ic-s contractions are painless

contractions beginning around the 'th month. oodell’s sign indicates softening of the cervi). #le)ibility of

the uterus against the cervi) is -nown as Cc&onald’s sign.

$5. C. Breathing techniues can raise the pain threshold and reduce the perception of pain. !hey also

promote rela)ation. Breathing techniues do not eliminate pain, but they can reduce it. %ositioning, not

breathing, increases uteroplacental perfusion.

$;. A. !he client’s labor is hypotonic. !he nurse should call the physical and obtain an order for an infusion

of o)ytocin, which will assist the uterus to contact more forcefully in an attempt to dilate the cervi).

Administering light sedative would be done for hypertonic uterine contractions. %reparing for cesarean

section is unnecessary at this time. ?)ytocin would increase the uterine contractions and hopefully

progress labor before a cesarean would be necessary. 0t is too early to anticipate client pushing with

contractions.

$:. D. !he signs indicate placenta previa and vaginal e)am to determine cervical dilation would not be

done because it could cause hemorrhage. Assessing maternal vital signs can help determine maternal

physiologic status. #etal heart rate is important to assess fetal well"being and should be done. Conitoring

the contractions will help evaluate the progress of labor.

'6. D. A complete placenta previa occurs when the placenta covers the opening of the uterus, thus bloc-in

the passageway for the baby. !his response e)plains what a complete previa is and the reason the baby

cannot come out e)cept by cesarean delivery. !elling the client to as- the physician is a poor response and

would increase the patient’s an)iety. Although a cesarean would help to prevent hemorrhage, the

statement does not e)plain why the hemorrhage could occur. 4ith a complete previa, the placenta is

covering all the cervi), not (ust most of it.

'1. B. 4ith a face presentation, the head is completely e)tended. 4ith a verte) presentation, the head is

completely or partially fle)ed. 4ith a brow


29/94

''. D. 0n a breech position, because of the space between the presenting part and the cervi), prolapse of

the umbilical cord is common. Nuic-ening is the woman’s first perception of fetal movement. ?phthalmia

neonatorum usually results from maternal gonorrhea and is con(unctivitis. %ica refers to the oral inta-e of

nonfood substances.

'/. A. &izygotic


30/94

leading to mistrust of caregivers and the environment. !oddlers develop a sense of shame when their

autonomy needs are not met consistently. %reschoolers develop a sense of guilt when their sense of initiative

is thwarted. Schoolagers develop a sense of inferiority when they do not develop a sense of industry.

'. D. A busy bo) facilitates the fine motor development that occurs between ' and months. Balloons are

contraindicated because small children may aspirate balloons. Because the button eyes of a teddy bear may

detach and be aspirated, this toy is unsafe for children younger than $ years. A /"month"old is too young to use

a push"pull toy.

/. B. 0nfants need to have their security needs met by being held and cuddled. At 2 months of age, they are

unable to ma-e the connection between crying and attention. !his association does not occur until late infancy

or early toddlerhood. etting the infant cry for a time before pic-ing up the infant or leaving the infant alone to

cry herself to sleep interferes with meeting the infant’s need for security at this very young age. 0nfants cry for

many reasons. Assuming that the child s hungry may cause overfeeding problems such as obesity.

. B. Inderdeveloped abdominal musculature gives the toddler a characteristically protruding abdomen.

&uring toddlerhood, food inta-e decreases, not increases. !oddlers are characteristically bowlegged because

the leg muscles must bear the weight of the relatively large trun-. !oddler growth patterns occur in a stepli-e,

not linear pattern.

5. B. According to ri-son, toddlers e)perience a sense of shame when they are not allowed to develop

appropriate independence and autonomy. 0nfants develop mistrust when their needs are not consistently

gratified. %reschoolers develop guilt when their initiative needs are not met while schoolagers develop a sense

of inferiority when their industry needs are not met.

;. C. Ooung toddlers are still sensorimotor learners and they en(oy the e)perience of feeling different te)tures.

!hus, finger paints would be an appropriate toy choice. Cultiple"piece toys, such as puzzle, are too difficult to

manipulate and may be hazardous if the pieces are small enough to be aspirated. Ciniature cars also have a

high potential for aspiration. +omic boo-s are on too high a level for toddlers. Although they may en(oy loo-ing

at some of the pictures, toddlers are more li-ely to rip a comic boo- apart.

:. D. !he child must be able to sate the need to go to the bathroom to initiate toilet training. Isually, a child

needs to be dry for only 2 hours, not ' hours. !he child also must be able to sit, wal-, and suat. A new sibling

would most li-ely hinder toilet training.

16. A. !oddlers become pic-y eaters, e)periencing food (ags and eating large amounts one day and very little

the ne)t. A toddler’s food gags e)press a preference for the ritualism of eating one type of food for several


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days at a time. !oddlers typically en(oy socialization and limiting others at meal time. !oddlers prefer to feed

themselves and thus are too young to have table manners. A toddler’s appetite and need for calories, protein,

and fluid decrease due to the dramatic slowing of growth rate.

11. D. %reschoolers commonly have fears of the dar-, being left alone especially at bedtime, and ghosts, whic

may affect the child’s going to bed at night. Nuiet play and time with parents is a positive bedtime routine that

provides security and also readies the child for sleep. !he child should sleep in his own bed. !elling the child

about loc-ing him in his room will viewed by the child as a threat. Additionally, a loc-ed door is frightening and

potentially hazardous. Jigorous activity at bedtime stirs up the child and ma-es more difficult to fall asleep.

12. B. &ress"up clothes enhance imaginative play and imagination, allowing preschoolers to engage in rich

fantasy play. Building bloc-s and wooden puzzles are appropriate for encouraging fine motordevelopment. Big

wheels and tricycles encourage gross motor development.

1$. D. !he school"aged child is in the stage of concrete operations, mar-ed by inductive reasoning, logical

operations, and reversible concrete thought. !he ability to consider the future reuires formal thought

operations, which are not developed until adolescence. +ollecting baseball cards and marbles, ordering dolls

by size, and simple problem"solving options are e)amples of the concrete operational thin-ing of the

schoolager.

1'. C. eaction formation is the schoolager’s typical defensive response when hospitalized. 0n reaction

formation, e)pression of unacceptable thoughts or behaviors is prevented


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1. C. !he most significant s-ill learned during the school"age period is reading. &uring this time the child

develops formal adult articulation patterns and learns that words can be arranged in structure. +ollective,

ordering, and sorting, although important, are not most significant s-ills learned.

15. C. Based on the recommendations of the American Academy of #amily %hysicians and the American

Academy of %ediatrics, the CC vaccine should be given at the age of 16 if the child did not receive it

between the ages of ' to years as recommended. 0mmunization for diphtheria and tetanus is reuired at age

1$.

1;. D. According to ri-son, role diffusion develops when the adolescent does not develop a sense of identity

and a sense or where he fits in. !oddlers develop a sense of shame when they do not achieve autonomy.

%reschoolers develop a sense of guilt when they do not develop a sense of initiative. School"agechildren

develop a sense of inferiority when they do not develop a sense of industry.

1:. A. Cenarche refers to the onset of the first menstruation or menstrual period and refers only to the first

cycle. Iterine growth and broadening of the pelvic girdle occurs before menarche.

26. A. Stating that this is probably the only concern the adolescent has and telling the parents not to worry

about it or the time her spends on it shuts off further investigation and is li-ely to ma-e the adolescent and his

parents feel defensive. !he statement about peer acceptance and time spent in front of the mirror for the

development of self image provides information about the adolescent’s needs to the parents and may help to

gain trust with the adolescent. As-ing the adolescent how he feels about the acne will encourage the

adolescent to share his feelings. &iscussing the cleansing method shows interest and concern for the

adolescent and also can help to identify any patient"teaching needs for the adolescent regarding cleansing.

21. B. %reschoolers should be developmentally incapable of demonstrating e)plicit se)ual behavior. 0f a child

does so, the child has been e)posed to such behavior, and se)ual abuse should be suspected. )plicit se)ual

behavior during doll play is not a characteristic of preschool development nor symptomatic of developmental

delay. 4hether or nor the child -nows how to play with dolls is irrelevant.

22. A. !he parents need more teaching if they state that they will -eep the child home until the phobia

subsides. &oing so reinforces the child’s feelings of worthlessness and dependency. !he child should attend

school even during resolution of the problem. Allowing the child to verbalize helps the child to ventilate feelings

and may help to uncover causes and solutions. +ollaboration with the teachers and counselors at school may

lead to uncovering the cause of the phobia and to the development of solutions. !he child should participate

and play an active role in developing possible solutions.


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2$. C. !he adolescent who becomes pregnant typically denies the pregnancy early on. arly recognition by a

parent or health care provider may be crucial to timely initiation of prenatal care. !he incidence of adolescent

pregnancy has declined since 1::1, yet morbidity remains high. Cost teenage pregnancies are unplanned and

occur out of wedloc-. !he pregnant adolescent is at high ris- for physical complications including premature

labor and low"birth"weight infants, high neonatal mortality, iron deficiency anemia, prolonged labor, and

fetopelvic disproportion as well as numerous psychological crises.

2'. B. Because of the structural defect, children with cleft palate may have ineffective functioning of their

ustachian tubes creating freuent bouts of otitis media. Cost children with cleft palate remain well"nourished

and maintain adeuate nutrition through the use of proper feeding techniues. #ood particles do not pass

through the cleft and into the ustachian tubes. !here is no association between cleft palate and congenial ea

deformities.

2/. D. A $"month"old infant should be able to lift the head and chest when prone. !he Coro refle) typicallydiminishes or subsides by $ months. !he parachute refle) appears at : months. olling from front to bac-

usually is accomplished at about / months.

2. D. A child’s birth weight usually triples by 12 months and doubles by ' months. @o specific birth weight

parameters are established for 5 or : months.

25. C. !oddlers engaging in parallel play will play near each other, but not with each other. !hus, when two

toddlers sit near each other but play with separate dolls, they are e)hibiting parallel play. Sharing crayons,

playing a board game with a nurse, or sharing dolls with two different nurses are all e)amples of cooperative

play.

2;. A. Acute lymphocytic leu-emia


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to 16 days after receiving the CC vaccine, not the diphtheria, pertussis, and tetanus vaccine. &iarrhea is not

associated with this vaccine.

$6. A. Cultiple bruises and burns on a toddler are signs child abuse. !herefore, the nurse is responsible for

reporting the case to %rotective Services immediately to protect the child from further harm. Scheduling a

follow"up visit is inappropriate because additional harm may come to the child if the nurse waits for further

assessment data. Although the nurse should notify the physician, the goal is to initiate measures to protect the

child’s safety. @otifying the physician immediately does not initiate the removal of the child from harm nor does

it absolve the nurse from responsibility. Cultiple bruises and burns are not normal toddler in(uries.

$1. B. !he mother is using pro(ection, the defense mechanism used when a person attributes his or her own

undesirable traits to another. &isplacement is the transfer of emotion onto an unrelated ob(ect, such as when

the mother would -ic- a chair or bang the door shut. epression is the submerging of painful ideas into the

unconscious. %sychosis is a state of being out of touch with reality.

$2. A. +hildren with congenital heart disease are more prone to respiratory infections. Bleeding tendencies,

freuent vomiting, and diarrhea and seizure disorders are not associated with congenital heart disease.

$$. D. !he child is e)hibiting classic signs of epiglottitis, always a pediatric emergency. !he physician must be

notified immediately and the nurse must be prepared for an emergency intubation or tracheostomy. #urther

assessment with auscultating lungs and placing the child in a mist tent wastes valuable time. !he situation is a

possible life"threatening emergency. *aving the child lie down would cause additional distress and may result

in respiratory arrest. !hroat e)amination may result in laryngospasm that could be fatal.

$'. A. 0n females, the urethra is shorter than in males. !his decreases the distance for organisms to travel,

thereby increasing the chance of the child developing a urinary tract infection. #reuent emptying of the

bladder would help to decrease urinary tract infections by avoiding sphincter stress. 0ncreased fluid inta-e

enables the bladder to be cleared more freuently, thus helping to prevent urinary tract infections. !he inta-e o

acidic (uices helps to -eep the urine p* acidic and thus decrease the chance of flora development.

$/. B. +ompartment syndrome is an emergent situation and the physician needs to be notified immediately so

that interventions can be initiated to relieve the increasing pressure and restore circulation. Acetaminophen

not traction, is being used in this situation for immobilization, so releasing the traction would be inappropriate.

0n this situation, specific action not continued monitoring is indicated.


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$. D. !he varicella zoster vaccine


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'$. C. %ro(ectile vomiting is a -ey symptom of pyloric stenosis. egurgitation is seen more commonly with

. Steatorrhea occurs in malabsorption disorders such as celiac disease. +urrant (elly3 stools are

characteristic of intussusception.

''. D. is the bac-flow of gastric contents into the esophagus resulting from rela)ation or incompetence o

the lower esophageal


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intussusception. Acute, episodic abdominal pain is characteristics of intussusception. A sausage"shaped mass

may be palpated in the right upper uadrant.

Answers and ationale

1. Answer: (B) Maternal cardiac condition

0n general, when the heart is compromised such as in maternal cardiac condition, the condition can lead to les

blood supply to the uterus conseuently to the placenta which provides the fetus with the essential nutrients

and o)ygen. !hus if the blood supply is less, the baby will suffer from chronic hypo)ia leading to a small"for"

gestational age condition.

2. Answer: (A) 21-24 weeks

Jiability means the capability of the fetus to liveHsurvive outside of the uterine environment. 4ith the present

technological and medical advances, 21 wee-s A? is considered as the minimum fetal age for viability.

$. Answer: (A) Article II section 12

!he %hilippine +onstitution of 1:;5 guarantees the right of the unborn child from conception eual to the

mother as stated in Article 00 State %olicies, Section 12.

'. Answer: (B) Abortion is both ioral and ille!al in o"r co"ntr#

0nduced Abortion is illegal in the country as stated in our %enal +ode and any person who performs the act for

a fee commits a grave offense punishable by 16"12 years of imprisonment.

/. Answer: (C) $o ake the deli%er# e&&ort &ree and the other does not need to '"sh with contractions

#orceps delivery under epidural anesthesia will ma-e the delivery process less painful and reuire less effort to

push for the mother. %ushing reuires more effort which a compromised heart may not be able to endure.

. Answer: (D) terine contractions are stron! and the bab# will not be deli%ered #et within the net *

ho"rs.

@arcotic analgesics must be given when uterine contractions are already well established so that it will not

cause stoppage of the contraction thus protracting labor. Also, it should be given when delivery of fetus is

imminent or too close because the fetus may suffer respiratory depression as an effect of the drug that can

pass through placental barrier.

5. Answer: (C) $he acti%e 'hase o& +ta!e 1 is 'rotracted

!he active phase of Stage 0 starts from 'cm cervical dilatation and is e)pected that the uterus will dilate by 1cm

every hour. Since the time lapsed is already 2 hours, the dilatation is e)pected to be already ; cm. *ence, the

active phase is protracted.


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;. Answer: (B) +tron!l# t"!!in! on the "bilical cord to deli%er the 'lacenta and hasten 'lacental

se'aration

4hen the placenta is still attached to the uterine wall, tugging on the cord while the uterus is rela)ed can lead

to inversion of the uterus. ight tugging on the cord when placenta has detached is alright in order to help

deliver the placenta that is already detached.

:. Answer: (B) Deterine i& cord co'ression &ollowed the r"'t"re

After the rupture of the bag of waters, the cord may also go with the water because of the pressure of the

rupture and flow. 0f the cord goes out of the cervical opening, before the head is delivered


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0n monitoring the intensity of the contraction the best place is to place the fingertips at the fundal area. !he

fundus is the contractile part of the uterus and the fingertips are more sensitive than the palm of the hand.

1/. Answer: (B) ro the be!innin! o& one contraction to the be!innin! o& the net contraction

#reuency of the uterine contraction is defined as from the beginning of one contraction to the beginning of

another contraction.

1. Answer: (B) Ace

Acme is the technical term for the highest point of intensity of a uterine contraction.

15. Answer: (A) $he be!innin! o& one contraction to the end o& the sae contraction

&uration of a uterine contraction refers to one contraction. !hus it is correctly measure from the beginning of

one contraction to the end of the same contraction and

maternal and child nursing answers and rationale

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