ANSWERS AND RATIONALE – PRACTICE II MATERNAL AND CHILD HEALTH

ANSWERS AND RATIONALE – PRACTICE 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.