Maternal and Child Health Nursing NCLEX Questions Part 2 Answers and Rationale

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1. Answer C. When obtaining the history of a patient who may be in labor, the nurse’s highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illness, allergies, and support persons.

2. Answer B. During the second stage of labor, the nurse should assess the strength, frequency, and duration of contraction every 15 minutes. If maternal or fetal problems are detected, more frequent monitoring is necessary. An interval of 30 to 60 minutes between assessments is too long because of variations in the length and duration of patient’s labor.

3. Answer A. Blurred vision of other visual disturbance, excessive weight gain, edema, and increased blood pressure may signal severe preeclampsia. This condition may lead to eclampsia, which has potentially serious consequences for both the patient and fetus. Although hemorrhoids may be a problem during pregnancy, they do not require immediate attention. Increased vaginal mucus and dyspnea on exertion are expected as pregnancy progresses.

4. Answer B. Cystic fibrosis is a recessive trait; each offspring has a one in four chance of having the trait or the disorder. Maternal age is not a risk factor until age 35, when the incidence of chromosomal defects increases. Maternal exposure to rubella during the first trimester may cause congenital defects. Although a history or preterm labor may place the patient at risk for preterm labor, it does not correlate with genetic defects.

5. Answer C. Ovulation (the period when pregnancy can occur) is accompanied by a basal body temperature increase of 0.7 degrees F to 0.8 degrees F and clear, thin cervical mucus. A return to the preovulatory body temperature indicates a safe period for sexual intercourse. A slight rise in basal temperature early in the cycle is not significant. Breast tenderness and mittelschmerz are not reliable indicators of ovulation.

6. Answer A. An NST assesses the FHR during fetal movement. In a healthy fetus, the FHR accelerates with each movement. By pushing the control button when a fetal movement starts, the client marks the strip to allow easy correlation of fetal movement with the FHR. The FHR is assessed during uterine contractions in the oxytocin contraction test, not the NST. Pushing the control button after every three fetal movements or at the end of fetal movement wouldn’t allow accurate comparison of fetal movement and FHR changes.

7. Answer B. Blurred or double vision may indicate hypertension or preeclampsia and should be reported immediately. Urinary frequency is a common problem during pregnancy caused by increased weight pressure on the bladder from the uterus. Clients generally experience fatigue and nausea during pregnancy.

8. Answer B. Recent breast reduction surgeries are done in a way to protect the milk sacs and ducts, so breast-feeding after surgery is possible. Still, it’s good to check with the surgeon to determine what breast reduction procedure was done. There is the possibility that reduction surgery may have decreased the mother’s ability to meet all of her baby’s nutritional needs, and some supplemental feeding may be required. Preparing the mother for this possibility is extremely important because the client’s psychological adaptation to mothering may be dependent on how successfully she breast-feeds.

9. Answer B. Using two or more peripads would do little to reduce the pain or promote perineal healing. Cold applications, sitz baths, and Kegel exercises are important measures when the client has a fourth-degree laceration.

10. Answer B. In a client with gestational trophoblastic disease, an ultrasound performed after the 3rd month shows grapelike clusters of transparent vesicles rather than a fetus. The vesicles contain a clear fluid and may involve all or part of the decidual lining of the uterus. Usually no embryo (and therefore no fetus) is present because it has been absorbed. Because there is no fetus, there can be no extrauterine pregnancy. An extrauterine pregnancy is seen with an ectopic pregnancy.

11. Answer C. Fetal station — the relationship of the fetal presenting part to the maternal ischial spines — is described in the number of centimeters above or below the spines. A presenting part above the ischial spines is designated as –1, –2, or –3. A presenting part below the ischial spines, as +1, +2, or +3.

12. Answer D. Assessing the attachment process for breast-feeding should include all of the answers except the smacking of lips. A baby who’s smacking his lips isn’t well attached and can injure the mother’s nipples.

13. Answer D. Ultrasound is used between 18 and 40 weeks’ gestation to identify normal fetal growth and detect fetal anomalies and other problems. Amniocentesis is done during the third trimester to determine fetal lung maturity. Chorionic villi sampling is performed at 8 to 12 weeks’ gestation to detect genetic disease. Fetoscopy is done at approximately 18 weeks’ gestation to observe the fetus directly and obtain a skin or blood sample.

14. Answer C. The BPP evaluates fetal health by assessing five variables: fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic fluid volume. A normal response for each variable receives 2 points; an abnormal response receives 0 points. A score between 8 and 10 is considered normal, indicating that the fetus has a low risk of oxygen deprivation and isn’t in distress. A fetus with a score of 6 or lower is at risk for asphyxia and premature birth; this score warrants detailed investigation. The BPP may or may not be repeated if the score isn’t within normal limits.

15. Answer C. During the third trimester, the pregnant client typically perceives the fetus as a separate being. To verify that this has occurred, the nurse should ask whether she has made appropriate changes at home such as obtaining infant supplies and equipment. The type of anesthesia planned doesn’t reflect the client’s preparation for parenting. The client should have begun prenatal classes earlier in the pregnancy. The nurse should have obtained dietary information during the first trimester to give the client time to make any necessary changes.

16. Answer B. This question requires an understanding of station as part of the intrapartal assessment process. Based on the client’s assessment findings, this client is ready for delivery, which is the nurse’s top priority. Placing the client in bed, checking for ruptured membranes, and providing comfort measures could be done, but the priority here is immediate delivery.

17. Answer A. Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the umbilical cord. Changing the client’s position from supine to side-lying may immediately correct the problem. An emergency cesarean section is necessary only if other measures, such as changing position and amnioinfusion with sterile saline, prove unsuccessful. Administering oxygen may be helpful, but the priority is to change the woman’s position and relieve cord compression.

18. Answer A. Hemorrhage jeopardizes the client’s oxygen supply — the first priority among human physiologic needs. Therefore, the nursing diagnosis of Risk for deficient fluid volume related to hemorrhage takes priority over diagnoses of Risk for infection, Pain, and Urinary retention.

19. Answer A. Lactation is an example of a progressive physiological change that occurs during the postpartum period.

20. Answer B. The major maternal adverse reactions from cocaine use in pregnancy include spontaneous abortion first, not third, trimester abortion and abruption placentae.

21. Answer D. For most clients with type 1 diabetes mellitus, nonstress testing is done weekly until 32 weeks’ gestation and twice a week to assess fetal well-being.

22. Answer A. The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyper stimulated neurologic system by interfering with signal transmission at the neuromascular junction.

23. Answer B. The blastocyst takes approximately 1 week to travel to the uterus for implantation.

24. Answer A. An episiotomy serves several purposes. It shortens the second stage of labor, substitutes a clean surgical incision for a tear, and decreases undue stretching of perineal muscles. An episiotomy helps prevent tearing of the rectum but it does not necessarily relieves pressure on the rectum. Tearing may still occur.

25. Answer D. The fetus of a cocaine-addicted mother is at risk for hypoxia, meconium aspiration, and intrauterine growth retardation (IUGR). Therefore, the nurse must notify the physician of the client’s cocaine use because this knowledge will influence the care of the client and neonate. The information is used only in relation to the client’s care.

26. Answer B. After administration of rubella vaccine, the client should be instructed to avoid pregnancy for at least 3 months to prevent the possibility of the vaccine’s toxic effects to the fetus.

27. Answer D. The priority for the pregnant client having a seizure is to maintain a patent airway to ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be administered by face mask to prevent fetal hypoxia.

28. Answer A. In some birth settings, intravenous therapy is not used with low-risk clients. Thus, clients in early labor are encouraged to eat healthy snacks and drink fluid to avoid dehydration. Yogurt, which is an excellent source of calcium and riboflavin, is soft and easily digested. During pregnancy, gastric emptying time is delayed. In most hospital settings, clients are allowed only ice chips or clear liquids.

29. Answer A. When the client says the baby is coming, the nurse should first inspect the perineum and observe for crowning to validate the client’s statement. If the client is not delivering precipitously, the nurse can calm her and use appropriate breathing techniques.

30. Answer A. Using both hands to assess the fundus is useful for the prevention of uterine inversion.

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