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Monday, August 5, 2013

ANSWERS AND RATIONALE – PRACTICE TEST II MATERNAL AND CHILD HEALTH

ANSWERS AND RATIONALE – PRACTICE TEST II MATERNAL AND
CHILD HEALTH

1. B. Regular 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 FSH and LH.
Therefore, follicles do not mature, ovulation is
inhibited, and pregnancy is prevented. The
estrogen content of the oral site contraceptive
may cause the nausea, regardless of when the
pill is taken. Side effects and drug interactions
may occur with oral contraceptives regardless of
the time the pill is taken.

2. C. Condoms, when used correctly and
consistently, are the most effective
contraceptive method or barrier against
bacterial and viral sexually transmitted
infections. Although spermicides kill sperm, they
do not provide reliable protection against the
spread of sexually transmitted infections,
especially intracellular organisms such as HIV.
Insertion and removal of the diaphragm along
with the use of the spermicides may cause
vaginal irritations, which could place the client at
risk for infection transmission. Male sterilization
eliminates spermatozoa from the ejaculate, but
it does not eliminate bacterial and/or viral
microorganisms that can cause sexually
transmitted infections.

3. A. The 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 6 weeks’ examination
following childbirth or after a weight loss of 15
lbs or more. In addition, for maximum
effectiveness, spermicidal jelly should be placed
in the dome and around the rim. However,
spermicidal jelly should not be inserted into the
vagina until involution is completed at
approximately 6 weeks. Use of a female condom
protects the reproductive system from the
introduction of semen or spermicides into the
vagina and may be used after childbirth. Oral
contraceptives may be started within the first
postpartum week to ensure suppression of
ovulation. For the couple who has determined
the female’s fertile period, using the rhythm
method, avoidance of intercourse during this
period, is safe and effective.

4. C. An IUD may increase the risk of pelvic
inflammatory disease, especially in women with
more than one sexual partner, because of the
increased risk of sexually transmitted infections.
An UID 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 risks associated with IUD use.
Most IUD users are over the age of 30. Although
there is a slightly higher risk for infertility in
women who have never been pregnant, the IUD
is an acceptable option as long as the riskbenefit
ratio is discussed. IUDs may be inserted
immediately after delivery, but this is not
recommended because of the increased risk and
rate of expulsion at this time.

5. C. During the third trimester, the enlarging
uterus places pressure on the intestines. This
coupled with the effect of hormones on smooth
muscle relaxation causes decreased intestinal
motility (peristalsis). Increasing fiber in the diet
will help fecal matter pass more quickly through
the intestinal tract, thus decreasing the amount
of water that is absorbed. As a result, stool is
softer and easier to pass. Enemas could
precipitate preterm labor and/or electrolyte loss
and should be avoided. Laxatives may cause
preterm labor by stimulating peristalsis and may
interfere with the absorption of nutrients. Use
for more than 1 week can also lead to laxative
dependency. Liquid in the diet helps provide a
semisolid, soft consistency to the stool. Eight to
ten glasses of fluid per day are essential to
maintain hydration and promote stool
evacuation.

6. D. To ensure adequate fetal growth and
development during the 40 weeks of a
pregnancy, a total weight gain 25 to 30 pounds is
recommended: 1.5 pounds in the first 10 weeks;
9 pounds by 30 weeks; and 27.5 pounds by 40
weeks. The pregnant woman should gain less
weight in the first and second trimester than in
the third. During the first trimester, the client
should only gain 1.5 pounds in the first 10
weeks, not 1 pound per week. A weight gain of ½
pound per week would be 20 pounds for the
total pregnancy, less than the recommended
amount.

7. B. To calculate the EDD by Nagele’s rule, add 7
days to the first day of the last menstrual period
and count back 3 months, changing the year
appropriately. To obtain a date of September 27,
7 days have been added to the last day of the
LMP (rather than the first day of the LMP), plus 4
months (instead of 3 months) were counted
back. To obtain the date of November 7, 7 days
have been subtracted (instead of added) from
the first day of LMP plus November indicates
counting back 2 months (instead of 3 months)
from January. To obtain the date of December
27, 7 days were added to the last day of the LMP
(rather than the first day of the LMP) and
December indicates counting back only 1 month
(instead of 3 months) from January.

8. D. The client has been pregnant four times,
including current pregnancy (G). Birth at 38
weeks’ gestation is considered full term (T),
while birth form 20 weeks to 38 weeks is
considered preterm (P). A spontaneous abortion
occurred at 8 weeks (A). She has two living
children (L).

9. B. At 12 weeks gestation, the uterus rises out of
the pelvis and is palpable above the symphysis
pubis. The Doppler intensifies the sound of the
fetal pulse rate so it is audible. The uterus has
merely risen out of the pelvis into the abdominal
cavity and is not at the level of the umbilicus.
The fetal heart rate at this age is not audible
with a stethoscope. The uterus at 12 weeks is
just above the symphysis pubis in the abdominal
cavity, not midway between the umbilicus and
the xiphoid process. At 12 weeks the FHR would
be difficult to auscultate with a fetoscope.
Although the external electronic fetal monitor
would project the FHR, the uterus has not risen
to the umbilicus at 12 weeks.

10. A. Although all of the choices are important in
the management of diabetes, diet therapy is the
mainstay of the treatment plan and should
always be the priority. Women diagnosed with
gestational diabetes generally need only diet
therapy without medication to control their
blood sugar levels. Exercise, is important for all
pregnant women and especially for diabetic
women, because it burns up glucose, thus
decreasing blood sugar. However, dietary intake,
not exercise, is the priority. All pregnant women
with diabetes should have periodic monitoring
of serum glucose. However, those with
gestational diabetes generally do not need daily
glucose monitoring. The standard of care
recommends a fasting and 2- hour postprandial
blood sugar level every 2 weeks.

11. C. After 20 weeks’ 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. The three classic signs of
preeclampsia are hypertension, edema, and
proteinuria. Although urine is checked for
glucose at each clinic visit, this is not the priority.
Depression may cause either anorexia or
excessive food intake, leading to excessive
weight gain or loss. This is not, however, the
priority consideration at this time. Weight gain
thought to be caused by excessive food intake
would require a 24-hour diet recall. However,
excessive intake would not be the primary
consideration for this client at this time.

12. B. Cramping and vaginal bleeding coupled with
cervical dilation signifies that termination of the
pregnancy is inevitable and cannot be
prevented. Thus, the nurse would document an
imminent abortion. In a threatened abortion,
cramping and vaginal bleeding are present, but
there is no cervical dilation. The symptoms may
subside or progress to abortion. In a complete
abortion all the products of conception are
expelled. A missed abortion is early fetal
intrauterine death without expulsion of the
products of conception.

13. B. For the client with an ectopic pregnancy,
lower abdominal pain, usually unilateral, is the
primary symptom. Thus, pain is the priority.
Although the potential for infection is always
present, the risk is low in ectopic pregnancy
because pathogenic microorganisms have not
been introduced from external sources. The
client may have a limited knowledge of the
pathology and treatment of the condition and
will most likely experience grieving, but this is
not the priority at this time.

14. 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. Vital sign
assessment is not necessary unless an
abnormality in uterine assessment is identified.
Uterine assessment should not cause acute pain
that requires administration of analgesia.
Ambulating the client is an essential component
of postpartum care, but is not necessary prior to
assessment of the uterus.

15. A. Feeding more frequently, about every 2
hours, will decrease the infant’s frantic, vigorous
sucking from hunger and will decrease breast
engorgement, soften the breast, and promote
ease of correct latching-on for feeding. Narcotics
administered prior to breast feeding are passed
through the breast milk to the infant, causing
excessive sleepiness. Nipple soreness is not
severe enough to warrant narcotic analgesia. All
postpartum clients, especially lactating mothers,
should wear a supportive brassiere with wide
cotton straps. This does not, however, prevent
or reduce nipple soreness. Soaps are drying to
the skin of the nipples and should not be used
on the breasts of lactating mothers. Dry nipple
skin predisposes to cracks and fissures, which
can become sore and painful.

16. D. A weak, thready pulse elevated to 100 BPM
may indicate impending hemorrhagic shock. An
increased pulse is a compensatory mechanism of
the body in response to decreased fluid volume.
Thus, the nurse should check the amount of
lochia present. Temperatures up to 100.48F in
the first 24 hours after birth are related to the
dehydrating effects of labor and are considered
normal. Although rechecking 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. The 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
check the extent of vaginal bleeding first. Then it
would be appropriate to check the uterus, which
may be a possible cause of the hemorrhage.

17. D. Any bright red vaginal discharge would be
considered abnormal, but especially 5 days after
delivery, when the lochia is typically pink to
brownish. Lochia rubra, a dark red discharge, is
present for 2 to 3 days after delivery. Bright red
vaginal bleeding at this time suggests late
postpartum hemorrhage, which occurs after the
first 24 hours following delivery and is generally
caused by retained placental fragments or
bleeding disorders. Lochia rubra is the normal
dark red discharge occurring in the first 2 to 3
days after delivery, containing epithelial cells,
erythrocyes, leukocytes and decidua. Lochia
serosa is a pink to brownish serosanguineous
discharge occurring from 3 to 10 days after
delivery that contains decidua, erythrocytes,
leukocytes, cervical mucus, and microorganisms.
Lochia alba is an almost colorless to yellowish
discharge occurring from 10 days to 3 weeks
after delivery and containing leukocytes,
decidua, epithelial cells, fat, cervical mucus,
cholesterol crystals, and bacteria.

18. A. The data suggests an infection of the
endometrial lining of the uterus. The lochia may
be decreased or copious, dark 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. Typically, transient fever, usually
101ºF, may be present with breast
engorgement. Symptoms of mastitis include
influenza-like manifestations. Localized infection
of an episiotomy or C-section incision rarely
causes systemic symptoms, and uterine
involution would not be affected. The client data
do not include dysuria, frequency, or urgency,
symptoms of urinary tract infections, which
would necessitate assessing the client’s urine.

19. 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, exploring the
family’s emotional status, and teaching about
family planning are important in
postpartum/newborn nursing care, they are not
the priority focus in the limited time presented
by early post-partum discharge.

20. C. Heat loss by radiation occurs when the
infant’s crib is placed too near cold walls or
windows. Thus placing the newborn’s crib close
to the viewing window would be least effective.
Body heat is lost through evaporation during
bathing. Placing the infant under the radiant
warmer after bathing will assist the infant to be
rewarmed. Covering the scale with a warmed
blanket prior to weighing prevents heat loss
through conduction. A knit cap prevents heat
loss from the head a large head, a large body
surface area of the newborn’s body.

21. B. A fractured clavicle would prevent the normal
Moro response of symmetrical sequential
extension and abduction of the arms followed by
flexion and adduction. In talipes equinovarus
(clubfoot) the foot is turned medially, and in
plantar flexion, with the heel elevated. The feet
are not involved with the Moro reflex.
Hypothyroiddism has no effect on the primitive
reflexes. Absence of the Moror reflex is the most
significant single indicator of central nervous
system status, but it is not a sign of increased
intracranial pressure.

22. B. Hemorrhage is a potential risk following any
surgical procedure. Although the infant has been
given vitamin K to facilitate clotting, the
prophylactic dose is often not sufficient to
prevent bleeding. Although infection is a
possibility, signs will not appear within 4 hours
after the surgical procedure. The primary
discomfort of circumcision occurs during the
surgical procedure, not afterward. Although
feedings are withheld prior to the circumcision,
the chances of dehydration are minimal.

23. B. The presence of excessive estrogen and
progesterone in the maternal- fetal blood
followed by prompt withdrawal at birth
precipitates breast engorgement, which will
spontaneously resolve in 4 to 5 days after birth.
The trauma of the birth process does not cause
inflammation of the newborn’s breast tissue.
Newborns do not have breast malignancy. This
reply by the nurse would cause the mother to
have undue anxiety. Breast tissue does not
hypertrophy in the fetus or newborns.

24. D. The first 15 minutes to 1 hour after birth is
the first period of reactivity involving respiratory
and circulatory adaptation to extrauterine life.
The data given reflect the normal changes during
this time period. The infant’s assessment data
reflect normal adaptation. Thus, the physician
does not need to be notified and oxygen is not
needed. The data do not indicate the presence
of choking, gagging or coughing, which are signs
of excessive secretions. Suctioning is not
necessary.

25. B. Application of 70% isopropyl alcohol to the
cord minimizes microorganisms (germicidal) and
promotes drying. The cord should be kept dry
until it falls off and the stump has healed.
Antibiotic ointment should only be used to treat
an infection, not as a prophylaxis. Infants should
not be submerged in a tub of water until the
cord falls off and the stump has completely
healed.

26. B. To determine the amount of formula needed,
do the following mathematical calculation. 3 kg x
120 cal/kg per day = 360 calories/day feeding q 4
hours = 6 feedings per day = 60 calories per
feeding: 60 calories per feeding; 60 calories per
feeding with formula 20 cal/oz = 3 ounces per
feeding. Based on the calculation. 2, 4 or 6
ounces are incorrect.

27. A. Intrauterine anoxia may cause relaxation 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. The infant is not at increased risk
for gastrointestinal problems. Even though the
skin is stained with meconium, it is noninfectious
(sterile) and nonirritating. The postterm
meconium- stained infant is not at additional risk
for bowel or urinary problems.

28. C. The nurse should use a nonelastic, flexible,
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. The xiphoid and
umbilicus are not appropriate landmarks to use
when measuring the height of the fundus
(McDonald’s measurement).

29. B. Women hospitalized with severe
preeclampsia need decreased CNS stimulation to
prevent a seizure. Seizure precautions provide
environmental safety should a seizure occur.
Because of edema, daily weight is important but
not the priority. Preclampsia causes vasospasm
and therefore can reduce utero-placental
perfusion. The client should be placed on her left
side to maximize blood flow, reduce blood
pressure, and promote diuresis. Interventions to
reduce stress and anxiety are very important to
facilitate coping and a sense of control, but
seizure precautions are the priority.

30. C. Cessation of the lochial discharge signifies
healing of the endometrium. Risk of hemorrhage
and infection are minimal 3 weeks after a
normal vaginal delivery. Telling the client
anytime is inappropriate because this response
does not provide the client with the specific
information she is requesting. Choice of a
contraceptive method is important, but not the
specific criteria for safe resumption of sexual
activity. Culturally, the 6- weeks’ examination
has been used as the time frame for resuming
sexual activity, but it may be resumed earlier.

31. C. The middle third of the vastus lateralis is the
preferred injection site for vitamin K
administration because it is free of blood vessels
and nerves and is large enough to absorb the
medication. The deltoid muscle of a newborn is
not large enough for a newborn IM injection.
Injections into this muscle in a small child might
cause damage to the radial nerve. The anterior
femoris muscle is the next safest muscle to use
in a newborn but is not the safest. Because of
the proximity of the sciatic nerve, the gluteus
maximus muscle should not be until the child
has been walking 2 years.

32. D. Bartholin’s glands are the glands on either
side of the vaginal orifice. The clitoris is female
erectile tissue found in the perineal area above
the urethra. The parotid glands are open into the
mouth. Skene’s glands open into the posterior
wall of the female urinary meatus.

33. D. The fetal gonad must secrete estrogen for the
embryo to differentiate as a female. An increase
in maternal estrogen secretion does not affect
differentiation of the embryo, and maternal
estrogen secretion occurs in every pregnancy.
Maternal androgen secretion remains the same
as before pregnancy and does not affect
differentiation. Secretion of androgen by the
fetal gonad would produce a male fetus.

34. A. Using bicarbonate would increase the amount
of sodium ingested, which can cause
complications. Eating low-sodium crackers
would be appropriate. Since liquids can increase
nausea avoiding them in the morning hours
when nausea is usually the strongest is
appropriate. Eating six small meals a day would
keep the stomach full, which often decrease
nausea.

35. B. Ballottement indicates passive movement of
the unengaged fetus. Ballottement is not a
contraction. Fetal kicking felt by the client
represents quickening. Enlargement and
softening of the uterus is known as Piskacek’s
sign.

36. B. Chadwick’s sign refers to the purple-blue tinge
of the cervix. Braxton Hicks contractions are
painless contractions beginning around the 4th
month. Goodell’s sign indicates softening of the
cervix. Flexibility of the uterus against the cervix
is known as McDonald’s sign.

37. C. Breathing techniques can raise the pain
threshold and reduce the perception of pain.
They also promote relaxation. Breathing
techniques do not eliminate pain, but they can
reduce it. Positioning, not breathing, increases
uteroplacental perfusion.

38. A. The client’s labor is hypotonic. The nurse
should call the physical and obtain an order for
an infusion of oxytocin, which will assist the
uterus to contact more forcefully in an attempt
to dilate the cervix. Administering light sedative
would be done for hypertonic uterine
contractions. Preparing for cesarean section is
unnecessary at this time. Oxytocin would
increase the uterine contractions and hopefully
progress labor before a cesarean would be
necessary. It is too early to anticipate client
pushing with contractions.

39. D. The signs indicate placenta previa and vaginal
exam to determine cervical dilation would not
be done because it could cause hemorrhage.
Assessing maternal vital signs can help
determine maternal physiologic status. Fetal
heart rate is important to assess fetal well-being
and should be done. Monitoring the contractions
will help evaluate the progress of labor.

40. D. A complete placenta previa occurs when the
placenta covers the opening of the uterus, thus
blocking the passageway for the baby. This
response explains what a complete previa is and
the reason the baby cannot come out except by
cesarean delivery. Telling the client to ask the
physician is a poor response and would increase
the patient’s anxiety. Although a cesarean would
help to prevent hemorrhage, the statement does
not explain why the hemorrhage could occur.
With a complete previa, the placenta is covering
the entire cervix, not just most of it.

41. B. With a face presentation, the head is
completely extended. With a vertex
presentation, the head is completely or partially
flexed. With a brow (forehead) presentation, the
head would be partially extended.

42. D. With this presentation, the fetal upper torso
and back face the left upper maternal abdominal
wall. The fetal heart rate would be most audible
above the maternal umbilicus and to the left of
the middle. The other positions would be
incorrect.

43. C. The greenish tint is due to the presence of
meconium. Lanugo is the soft, downy hair on the
shoulders and back of the fetus. Hydramnios
represents excessive amniotic fluid. Vernix is the
white, cheesy substance covering the fetus.

44. D. In a breech position, because of the space
between the presenting part and the cervix,
prolapse of the umbilical cord is common.
Quickening is the woman’s first perception of
fetal movement. Ophthalmia neonatorum
usually results from maternal gonorrhea and is
conjunctivitis. Pica refers to the oral intake of
nonfood substances.

45. A. Dizygotic (fraternal) twins involve two ova
fertilized by separate sperm. Monozygotic
(identical) twins involve a common placenta,
same genotype, and common chorion.

46. C. The zygote is the single cell that reproduces
itself after conception. The chromosome is the
material that makes up the cell and is gained
from each parent. Blastocyst and trophoblast are
later terms for the embryo after zygote.

47. D. Prepared childbirth was the direct result of
the 1950’s challenging of the routine use of
analgesic and anesthetics during childbirth. The
LDRP was a much later concept and was not a
direct result of the challenging of routine use of
analgesics and anesthetics during childbirth.
Roles for nurse midwives and clinical nurse
specialists did not develop from this challenge.

48. C. The ischial spines are located in the mid-pelvic
region and could be narrowed due to the
previous pelvic injury. The symphysis pubis,
sacral promontory, and pubic arch are not part
of the mid-pelvis.

49. B. Variations in the length of the menstrual cycle
are due to variations in the proliferative phase.
The menstrual, secretory and ischemic phases
do not contribute to this variation.

50. B. Testosterone is produced by the Leyding cells
in the seminiferous tubules. Follicle-stimulating
hormone and leuteinzing hormone are released
by the anterior pituitary gland. The
hypothalamus is responsible for releasing

gonadotropin-releasing hormone.

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