Maternity And Women’s Health Care,11th Edition by Deitra Leonard Lowdermilk -Test Bank

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Maternity And Women’s Health Care,11th Edition by Deitra Leonard Lowdermilk -Test Bank

Chapter 02: Community Care: The Family and Culture

Lowdermilk: Maternity & Women’s Health Care, 11th Edition

 

MULTIPLE CHOICE

 

  1. A married couple lives in a single-family house with their newborn son and the husband’s daughter from a previous marriage. Based on this information, what family form best describes this family?
a. Married-blended family
b. Extended family
c. Nuclear family
d. Same-sex family

 

 

ANS:  A

Married-blended families are formed as the result of divorce and remarriage. Unrelated family members join to create a new household. Members of an extended family are kin or family members related by blood, such as grandparents, aunts, and uncles. A nuclear family is a traditional family with male and female partners along with the children resulting from that union. A same-sex family is a family with homosexual partners who cohabit with or without children.

 

DIF:    Cognitive Level: Remember           REF:   p. 19

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. Which key factors play the most powerful role in the behaviors of individuals and families?
a. Rituals and customs
b. Beliefs and values
c. Boundaries and channels
d. Socialization processes

 

 

ANS:  B

Beliefs and values are the most prevalent factors in the decision-making and problem-solving behaviors of individuals and families. This prevalence is particularly true during times of stress and illness. Although culture may play a part in the decision-making process of a family, ultimately, values and beliefs dictate the course of action taken by family members. Boundaries and channels affect the relationship between the family members and the health care team, not the decisions within the family. Socialization processes may help families with interactions within the community, but they are not the criteria used for decision making within the family.

 

DIF:    Cognitive Level: Understand          REF:   pp. 21-22       TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. Using the family stress theory as an interventional approach for working with families experiencing parenting challenges, the nurse can assist the family in selecting and altering internal context factors. Which statement best describes the components of an internal context?
a. Biologic and genetic makeup
b. Maturation of family members
c. Family’s perception of the event
d. Prevailing cultural beliefs of society

 

 

ANS:  C

The family stress theory is concerned with the family’s reaction to stressful events. Internal context factors include elements that a family can control such as psychologic defenses, family structure, and philosophic beliefs and values. The family stress theory focuses on ways that families react to stressful events. Maturation of family members is more relevant to the family life-cycle theory. The family stress theory focuses on internal elements that a family might be able to alter.

 

DIF:    Cognitive Level: Understand          REF:   p. 21              TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Psychosocial Integrity

 

  1. The nurse is developing a plan of care for a Hispanic client who just delivered a newborn. Which cultural variation is most important to include in the care plan?
a. Breastfeeding is encouraged immediately after birth.
b. Male infants are typically circumcised.
c. Maternal grandmother participates in the care of the mother and her infant.
d. Bathing is encouraged immediately after delivery.

 

 

ANS:  C

In the Hispanic family, the expectant mother is strongly influenced by her mother or mother-in-law. Breastfeeding is often delayed until the third postpartum day. Hispanic male infants are not usually circumcised. Bathing after delivery is most often delayed.

 

DIF:    Cognitive Level: Apply                  REF:   p. 26              TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which health care service represents a primary level of prevention?
a. Immunizations
b. Breast self-examination (BSE)
c. Home care for high-risk pregnancies
d. Blood pressure screening

 

 

ANS:  A

Primary prevention involves health promotion and disease prevention activities to reduce the occurrence of illness and enhance the general health and quality of life. This level of care includes, for example, immunizations, using infant car seats, and providing health education to prevent tobacco use. BSE is an example of secondary prevention that involves early detection of health problems. Home care for a high-risk pregnancy is an example of tertiary prevention. This level of care follows the occurrence of a defect or disability. Blood pressure screening is an example of secondary prevention and is a screening tool for early detection of a health care problem.

 

DIF:    Cognitive Level: Understand          REF:   p. 34

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What is the primary difference between hospital care and home health care?
a. Home care is routinely and continuously delivered by professional staff.
b. Home care is delivered on an intermittent basis by professional staff.
c. Home care is delivered for emergency conditions.
d. Home care is not available 24 hours a day.

 

 

ANS:  B

Home care is generally delivered on an intermittent basis by professional staff members. The primary difference between health care in a hospital and home care is the absence of the continuous presence of professional health care providers in a client’s home. In a true emergency, the client should be directed to call 9-1-1 or to report to the nearest hospital’s emergency department. Generally, home health care entails intermittent care by a professional who visits the client’s home for a particular reason and provides on-site care for periods shorter than 4 hours at a time.

 

DIF:    Cognitive Level: Understand          REF:   pp. 34-35

TOP:   Nursing Process: Implementation

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. To provide culturally competent care to an Asian-American family, which question should the nurse include during the assessment interview?
a. “Do you prefer hot or cold beverages?”
b. “Do you want some milk to drink?”
c. “Do you want music playing while you are in labor?”
d. “Do you have a name selected for the baby?”

 

 

ANS:  A

Asian-Americans often prefer warm beverages. Milk is usually excluded from the diet of this population. Asian-American women typically labor in a quiet environment. Delaying naming the child is not uncommon for Asian-American families.

 

DIF:    Cognitive Level: Apply                  REF:   p. 27

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiologic Integrity

 

  1. The woman’s family members are present when the nurse arrives for a postpartum and newborn visit. What should the nurse do?
a. Observe the family members’ interactions with the newborn and one another.
b. Ask the woman to meet with her and the baby alone.
c. Perform a brief assessment on all family members who are present.
d. Reschedule the visit for another time so that the mother and infant can be privately assessed.

 

 

ANS:  A

The nurse should introduce her or himself to the client and to the other family members who are present. Family members in the home may be providing care and assistance to the mother and infant. However, this care may not be based on sound health practices. Nurses should take the opportunity to dispel myths while family members are present. The responsibility of the home care maternal-child nurse is to provide care to the new postpartum mother and to her infant, not to all family members. The nurse can politely ask about the other people in the home and their relationships with the mother. Unless an indication is given that the woman would prefer privacy, the visit may continue.

 

DIF:    Cognitive Level: Analyze               REF:   p. 35

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. What is a limitation of a home postpartum visit?
a. Distractions limit the nurse’s ability to teach.
b. Identified problems cannot be resolved in the home setting.
c. Necessary items for infant care are not available.
d. Home visits to different families may require the nurse to travel a great distance.

 

 

ANS:  D

One limitation of home health visits is the distance the nurse must travel between clients. Driving directions should be obtained by telephone before the visit. The home care nurse is accustomed to distractions but may request that the television be turned off so that attention can be focused on the client and her family. Problems cannot always be resolved; however, appropriate referrals may be arranged by the nurse. The nurse is required to bring any necessary equipment, such as a thermometer, baby scale, or laptop computer, for documentation.

 

DIF:    Cognitive Level: Understand          REF:   p. 35              TOP:   Nursing Process: Planning

MSC:  Client Needs: Safe and Effective Care Environment

 

  1. During the childbearing experience, which behavior might the nurse expect from an African-American client?
a. Seeking prenatal care early in her pregnancy
b. Avoiding self-treatment of pregnancy-related discomfort
c. Requesting liver in the postpartum period to prevent anemia
d. Arriving at the hospital in advanced labor

 

 

ANS:  D

African-American women often arrive at the hospital in far-advanced labor and may view pregnancy as a state of wellness, which is often the reason for the delay in seeking prenatal care. African-American women practice many self-treatment options for various discomforts of pregnancy. African-American women may also request liver in the postpartum period, which is based on a belief that liver has a higher blood content.

 

DIF:    Cognitive Level: Understand          REF:   p. 26

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which resource best describes a health care service representing the tertiary level of prevention?
a. Stress management seminars
b. Childbirth education classes for single parents
c. BSE pamphlet and teaching
d. Premenstrual syndrome (PMS) support group

 

 

ANS:  D

A PMS support group is an example of tertiary prevention, which follows the occurrence of a defect or disability (e.g., PMS). Stress management seminars are a primary prevention technique for preventing health care issues associated with stress. Childbirth education is a form of primary prevention. BSE information is a form of secondary prevention, which is aimed toward early detection of health problems.

 

DIF:    Cognitive Level: Understand          REF:   p. 28

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. When the services of an interpreter are needed, which is the most important factor for the nurse to consider?
a. Using a family member who is fluent in both languages
b. Using an interpreter who is certified, and documenting the person’s name in the nursing notes
c. Directing questions only to the interpreter
d. Using an interpreter only in an emergency

 

 

ANS:  B

Using a certified interpreter ensures that the standards of care are met and that the information exchanged is reliable and unaltered. The name of the interpreter should be documented for legal purposes. Asking a family member to interpret may not be appropriate, although many health care personnel must adopt this approach in an emergency. Furthermore, most states require that certified interpreters be used when possible. When using an interpreter, the nurse should direct questions to the client. The interpreter is simply a means by which the nurse communicates with the client. Every attempt should be made to contact an interpreter whenever one is needed. During an emergency, health care workers often rely on information interpreted by family members. This information may be private and should be protected under the rules established by the Health Insurance Portability and Accountability Act (HIPAA). Furthermore, family members may skew information or may not be able to interpret the exact information the nurse is trying to obtain.

 

DIF:    Cognitive Level: Apply                  REF:   pp. 24, 25

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. Which traditional family structure is decreasing in numbers and attributable to societal changes?
a. Extended family
b. Binuclear family
c. Nuclear family
d. Blended family

 

 

ANS:  C

The nuclear family has long represented the traditional American family in which husband, wife, and children live as an independent unit. As a result of rapid changes in society, this number is steadily decreasing as other family configurations are socially recognized. Extended families involve additional blood relatives other than the parents. A binuclear family involves two households. A blended family is reconstructed after divorce and involves the merger of two families.

 

DIF:    Cognitive Level: Understand          REF:   p. 18

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. Which statement regarding the Family Systems Theory is inaccurate?
a. Family system is part of a larger suprasystem.
b. Family, as a whole, is equal to the sum of the individual members.
c. Changes in one family member affect all family members.
d. Family is able to create a balance between change and stability.

 

 

ANS:  B

A family, as a whole, is greater than the sum of its individual members. The other statements are accurate and can be attributed to the Family Systems Theory.

 

DIF:    Cognitive Level: Understand          REF:   p. 21

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. Which pictorial tool can assist the nurse in assessing the aspects of family life related to health care?
a. Genogram
b. Ecomap
c. Life-cycle model
d. Human development wheel

 

 

ANS:  A

A genogram depicts the relationships of the family members over generations. An ecomap is a graphic portrayal of the social relationships of the woman and her family. The life-cycle model, in no way, illustrates a family genogram; rather, it focuses on the stages that a person reaches throughout life. The human development wheel describes various stages of growth and development rather than the family members’ relationships to each other.

 

DIF:    Cognitive Level: Remember           REF:   pp. 20-21

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. When attempting to communicate with a client who speaks a different language, which action is the most appropriate?
a. Promptly and positively respond to project authority.
b. Never use a family member as an interpreter.
c. Talk to the interpreter to avoid confusing the client.
d. Provide as much privacy as possible.

 

 

ANS:  D

Providing privacy creates an atmosphere of respect and puts the client at ease. The nurse should not rush to judgment and should ensure she or he clearly understands the client’s message. In crisis situations, the nurse may need to use a family member or neighbor as a translator. The nurse should speak directly to the client to create an atmosphere of respect.

 

DIF:    Cognitive Level: Apply                  REF:   p. 24

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. The secondary level of prevention is best illustrated by which example?
a. Approved infant car seats
b. BSE
c. Immunizations
d. Support groups for parents of children with Down syndrome

 

 

ANS:  B

Infant car seats are an example of primary prevention. BSE is an example of the secondary level of prevention, which includes health-screening measures for early detection of health problems. Immunizations are an example of the primary level of prevention. Support groups are an example of tertiary prevention, which follows the occurrence of a defect or disability (e.g., Down syndrome).

 

DIF:    Cognitive Level: Understand          REF:   p. 28              TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which key point is important for the nurse to understand regarding the perinatal continuum of care?
a. Begins with conception and ends with the birth
b. Begins with family planning and continues until the infant is 1 year old
c. Begins with prenatal care and continues until the newborn is 24 weeks old
d. Refers to home care only

 

 

ANS:  B

The perinatal continuum of care begins with family planning and continues until the infant is 1 year old. It takes place both at home and in health care facilities. The perinatal continuum does not end with the birth. The perinatal continuum begins before conception and continues after the birth. Home care is one delivery component; health care facilities are another.

 

DIF:    Cognitive Level: Remember           REF:   p. 17              TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What information should the nurse be aware of regarding telephonic nursing care such as warm lines?
a. Were developed as a reaction to impersonal telephonic nursing care
b. Were set up to take complaints concerning health maintenance organizations (HMOs)
c. Are the second option when 9-1-1 hotlines are busy
d. Refer to community service telephone lines designed to provide new parents with encouragement and basic information

 

 

ANS:  D

Warm lines are one aspect of telephonic nursing care specifically designed to provide new parents with encouragement and basic information. Warm lines and similar services sometimes are set up by HMOs to provide new parents with encouragement and basic information. The name, warm lines, may have been suggested by the term hotlines, but these are not emergency numbers but are designed to provide new parents with encouragement and basic information.

 

DIF:    Cognitive Level: Remember           REF:   p. 34

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. When weighing the advantages and disadvantages of planning home care for perinatal services, what information should the nurse use in making the decision?
a. Home care for perinatal services is more dangerous for vulnerable neonates at risk of acquiring an infection from the nurse.
b. Home care for perinatal services is more cost-effective for the nurse than office visits.
c. Home care for perinatal services allows the nurse to interact with and include family members in teaching.
d. Home care for perinatal services is made possible by the ready supply of nurses with expertise in maternity care.

 

 

ANS:  C

Treating the whole family is an advantage of home care. Forcing neonates out in inclement weather and in public is more risky. Office visits are more cost-effective for the providers such as nurses because less travel time is involved. Unfortunately, home care options are limited by the lack of nurses with expertise in maternity care.

 

DIF:    Cognitive Level: Apply                  REF:   p. 35

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. In what form do families tend to be the most socially vulnerable?
a. Married-blended family
b. Extended family
c. Nuclear family
d. Single-parent family

 

 

ANS:  D

The single-parent family tends to be economically and socially vulnerable, creating an unstable and deprived environment for the growth potential of children. The married-blended family, the extended family, and the nuclear family are not the most socially vulnerable.

 

DIF:    Cognitive Level: Understand          REF:   p. 19              TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. While working in the prenatal clinic, nurses care for a very diverse group of clients. Which cultural factor related to health is most likely to drive acceptance of planned interventions?
a. Educational achievement
b. Income level
c. Subcultural group
d. Individual beliefs

 

 

ANS:  D

The client’s beliefs are ultimately the key to the acceptance of health care interventions. However, these beliefs may be influenced by factors such as educational level, income level, and ethnic background. Educational achievement, income level, and being part of a subcultural group all are important factors. However, the nurse must understand that a woman’s concerns from her own point of view will have the most influence on her compliance and acceptance of health care interventions.

 

DIF:    Cognitive Level: Apply                  REF:   pp. 21-22       TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. A client’s household consists of her husband, his mother, and another child. To which family configuration does this client belong?
a. Multigenerational family
b. Single-parent family
c. Married-blended family
d. Nuclear family

 

 

ANS:  A

A multigenerational family includes three or more generations living together. Both parents and a grandparent are living in this extended family. Single-parent families comprise an unmarried biologic or adoptive parent who may or may not be living with other adults. Married-blended families refer to those who are reconstructed after divorce. A nuclear family comprises male and female partners and their children living together as an independent unit.

 

DIF:    Cognitive Level: Apply                  REF:   p. 19

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

  1. Which term is an accurate description of the process by which people retain some of their own culture while adopting the practices of the dominant society?
a. Acculturation
b. Assimilation
c. Ethnocentrism
d. Cultural relativism

 

 

ANS:  A

Acculturation is the process by which people retain some of their own culture while adopting the practices of the dominant society. This process takes place over the course of generations. Assimilation is a loss of cultural identity. Ethnocentrism is the belief in the superiority of one’s own culture over the cultures of others. Cultural relativism recognizes the roles of different cultures.

 

DIF:    Cognitive Level: Understand          REF:   pp. 22-23       TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. In which culture is the father more likely to be expected to participate in the labor and delivery?
a. Asian-American
b. African-American
c. European-American
d. Hispanic

 

 

ANS:  C

European-Americans expect the father to take a more active role in the labor and delivery of a newborn than the other cultures.

 

DIF:    Cognitive Level: Understand          REF:   p. 27

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Psychosocial Integrity

 

  1. Which statement about the development of cultural competence is inaccurate?
a. Local health care workers and community advocates can help extend health care to underserved populations.
b. Nursing care is delivered in the context of the client’s culture but not in the context of the nurse’s culture.
c. Nurses must develop an awareness of and a sensitivity to various cultures.
d. Culture’s economic, religious, and political structures influence practices that affect childbearing.

 

 

ANS:  B

Although the cultural context of the nurse affects the delivery of nursing care and is very important, the work of local health care workers and community advocates, developing sensitivity to various cultures, and the impact of economic, religious, and political structures are all parts of cultural competence.

 

DIF:    Cognitive Level: Understand          REF:   pp. 27-28       TOP:   Nursing Process: Planning

MSC:  Client Needs: Psychosocial Integrity

 

  1. Which statement accurately describes the walking survey as a data collection tool?
a. The walking survey determines how much exercise an expectant mother has been getting, to help her make health care decisions.
b. The walking survey usually takes place on the maternity ward but can be expanded to other areas of the hospital.
c. The walking survey is a method of observing the resources and health-related environment of the community.
d. The walking survey is performed by government census takers as part of their canvas.

 

 

ANS:  C

The walking survey is a valuable tool for the nurses in the community and has nothing to do with exercise. It is an observational method used to assess the health environment of the community. A walking survey takes place in the community, not the maternity ward, and is not part of the census; it is conducted by nurses in the community.

 

DIF:    Cognitive Level: Remember           REF:   p. 30

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A Native-American woman gave birth to a baby girl 12 hours ago. The nurse notes that the woman keeps her baby in the bassinet except for bottle feeding and states that she will wait until she gets home to begin breastfeeding. The nurse recognizes that this behavior is most likely a reflection of what?
a. Delayed attachment
b. Embarrassment
c. Disappointment in the sex of the baby
d. Belief that babies should not be fed colostrum

 

 

ANS:  D

Native Americans often use cradle boards and often avoid handling their newborn. They also believe that the infant should not be fed colostrum. Delayed attachment is a developmental concern, not a cultural belief. Embarrassment is not likely the cause for a delay in the initiation of breastfeeding and should be explored further by the nurse. The mother may voice her disappointment that the infant is a girl; however, this would rarely cause her to delay breastfeeding and would exhibit itself in other ways.

 

DIF:    Cognitive Level: Understand          REF:   p. 27

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. While completing an assessment of a homeless woman, the nurse should be aware of which of the following ailments this client is at a higher risk to develop? (Select all that apply.)
a. Infectious diseases
b. Chronic illness
c. Anemia
d. Hyperthermia
e. Substance abuse

 

 

ANS:  A, B, C, E

Poor living conditions contribute to higher rates of infectious disease. Many homeless individuals engage in sexual favors, which may expose them to sexually transmitted infections (STIs). Poor nutrition can lead to anemia. Lifestyle factors also contribute to chronic illness. Exposure to cold temperatures and harsh environmental surroundings may lead to hypothermia. Many homeless people turn to alcohol and other substances as coping mechanisms.

 

DIF:    Cognitive Level: Analyze               REF:   pp. 32-33

TOP:   Nursing Process: Assessment

MSC:  Client Needs: Safe and Effective Care Environment

 

Chapter 16: Labor and Birth Processes

Lowdermilk: Maternity & Women’s Health Care, 11th Edition

 

MULTIPLE CHOICE

 

  1. A new mother asks the nurse when the “soft spot” on her son’s head will go away. What is the nurse’s best response, based upon her understanding of when the anterior frontal closes?
a. 2 months
b. 8 months
c. 12 months
d. 18 months

 

 

ANS:  D

The larger of the two fontanels, the anterior fontanel, closes by 18 months after birth. The posterior fontanel closes at 6 to 8 weeks. The remaining three options are too early for the anterior fontanel to close.

 

DIF:    Cognitive Level: Understand          REF:   p. 367

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is performing an initial assessment of a client in labor. What is the appropriate terminology for the relationship of the fetal body parts to one another?
a. Lie
b. Presentation
c. Attitude
d. Position

 

 

ANS:  C

Attitude is the relationship of the fetal body parts to one another. Lie is the relationship of the long axis (spine) of the fetus to the long axis (spine) of the mother. Presentation refers to the part of the fetus that enters the pelvic inlet first and leads through the birth canal during labor at term. Position is the relationship of the presenting part of the fetus to the four quadrants of the mother’s pelvis.

 

DIF:    Cognitive Level: Remember           REF:   p. 369

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. When assessing the fetus using Leopold’s maneuvers, the nurse feels a round, firm, and movable fetal part in the fundal portion of the uterus and a long, smooth surface in the mother’s right side close to midline. What is the position of the fetus?
a. ROA
b. LSP
c. RSA
d. LOA

 

 

ANS:  C

Fetal position is denoted with a three-letter abbreviation. The first letter indicates the presenting part in either the right or the left side of the maternal pelvis. The second letter indicates the anatomic presenting part of the fetus. The third letter stands for the location of the presenting part in relationship to the anterior, posterior, or transverse portion of the maternal pelvis. Palpation of a round, firm fetal part in the fundal portion of the uterus would be the fetal head, indicating that the fetus is in a breech position with the sacrum as the presenting part in the maternal pelvis. Palpation of the fetal spine along the mother’s right side denotes the location of the presenting part in the mother’s pelvis. The ability to palpate the fetal spine indicates that the fetus is anteriorly positioned in the maternal pelvis. This fetus is anteriorly positioned in the right side of the maternal pelvis with the sacrum as the presenting part. RSA is the correct three-letter abbreviation to indicate this fetal position. ROA denotes a fetus that is anteriorly positioned in the right side of the maternal pelvis with the occiput as the presenting part. LSP describes a fetus that is posteriorly positioned in the left side of the pelvis with the sacrum as the presenting part. A fetus that is LOA would be anteriorly positioned in the left side of the pelvis with the occiput as the presenting part.

 

DIF:    Cognitive Level: Apply                  REF:   p. 370

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which statement by the client would lead the nurse to believe that labor has been established?
a. “I passed some thick, pink mucus when I urinated this morning.”
b. “My bag of waters just broke.”
c. “The contractions in my uterus are getting stronger and closer together.”
d. “My baby dropped, and I have to urinate more frequently now.”

 

 

ANS:  C

Regular, strong contractions with the presence of cervical change indicate that the woman is experiencing true labor. Although the loss of the mucous plug (operculum) often occurs during the first stage of labor or before the onset of labor, it is not the indicator of true labor. Spontaneous rupture of membranes often occurs during the first stage of labor; however, it is not an indicator of true labor. The presenting part of the fetus typically becomes engaged in the pelvis at the onset of labor but is not the indicator of true labor.

 

DIF:    Cognitive Level: Understand          REF:   p. 376

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse has received a report regarding a client in labor. The woman’s last vaginal examination was recorded as 3 cm, 30%, and –2. What is the nurse’s interpretation of this assessment?
a. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm above the ischial spines.
b. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm above the ischial spines.
c. Cervix is effaced 3 cm and dilated 30%; the presenting part is 2 cm below the ischial spines.
d. Cervix is dilated 3 cm and effaced 30%; the presenting part is 2 cm below the ischial spines.

 

 

ANS:  B

The sterile vaginal examination is recorded as centimeters of cervical dilation, percentage of cervical dilation, and the relationship of the presenting part to the ischial spines (either above or below). For this woman, the cervix is dilated 3 cm and effaced 30%, and the presenting part is 2 cm above the ischial spines. The first interpretation of this vaginal examination is incorrect; the cervix is dilated 3 cm and is 30% effaced. However, the presenting part is correct at 2 cm above the ischial spines. The remaining two interpretations of this vaginal examination are incorrect. Although the dilation and effacement are correct at 3 cm and 30%, the presenting part is actually 2 cm above the ischial spines.

 

DIF:    Cognitive Level: Comprehend        REF:   p. 370 | pp. 373-374

TOP:   Nursing Process: Assessment | Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A pregnant woman is at 38 weeks of gestation. She wants to know whether there are any signs that “labor is getting close to starting.” Which finding is an indication that labor may begin soon?
a. Weight gain of 1.5 to 2 kg (3 to 4 lb)
b. Increase in fundal height
c. Urinary retention
d. Surge of energy

 

 

ANS:  D

Women speak of having a burst of energy before labor. The woman may lose 0.5 to 1.5 kg, as a result of water loss caused by electrolyte shifts that, in turn, are caused by changes in the estrogen and progesterone levels. When the fetus descends into the true pelvis (called lightening), the fundal height may decrease. Urinary frequency may return before labor.

 

DIF:    Cognitive Level: Understand          REF:   p. 376            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which stage of labor varies the most in length?
a. First
b. Second
c. Third
d. Fourth

 

 

ANS:  A

The first stage of labor is considered to last from the onset of regular uterine contractions to the full dilation of the cervix. The first stage is significantly longer than the second and third stages combined. In a first-time pregnancy, the first stage of labor can take up to 20 hours. The second stage of labor lasts from the time the cervix is fully dilated to the birth of the fetus. The average length is 20 minutes for a multiparous woman and 50 minutes for a nulliparous woman. The third stage of labor lasts from the birth of the fetus until the placenta is delivered. This stage may be as short as 3 minutes or as long as 1 hour. The fourth stage of labor, recovery, lasts approximately 2 hours after the delivery of the placenta.

 

DIF:    Cognitive Level: Remember           REF:   p. 376            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse expects which maternal cardiovascular finding during labor?
a. Increased cardiac output
b. Decreased pulse rate
c. Decreased white blood cell (WBC) count
d. Decreased blood pressure

 

 

ANS:  A

During each contraction, 400 ml of blood is emptied from the uterus into the maternal vascular system, which increases cardiac output by approximately 10% to 15% during the first stage of labor and by approximately 30% to 50% in the second stage of labor. The heart rate increases slightly during labor. The WBC count can increase during labor. During the first stage of labor, uterine contractions cause systolic readings to increase by approximately 10 mm Hg. During the second stage, contractions may cause systolic pressures to increase by 30 mm Hg and diastolic readings to increase by 25 mm Hg.

 

DIF:    Cognitive Level: Understand          REF:   p. 379            TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What is the correct term describing the slight overlapping of cranial bones or shaping of the fetal head during labor?
a. Lightening
b. Molding
c. Ferguson reflex
d. Valsalva maneuver

 

 

ANS:  B

Molding also permits adaptation to various diameters of the maternal pelvis. Lightening is the mother’s sensation of decreased abdominal distention, which usually occurs the week before labor. The Ferguson reflex is the contraction urge of the uterus after the stimulation of the cervix. The Valsalva maneuver describes conscious pushing during the second stage of labor.

 

DIF:    Cognitive Level: Remember           REF:   p. 367

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which presentation is accurately described in terms of both the resenting part and the frequency of occurrence?
a. Cephalic: occiput, at least 96%
b. Breech: sacrum, 10% to 15%
c. Shoulder: scapula, 10% to 15%
d. Cephalic: cranial, 80% to 85%

 

 

ANS:  A

In cephalic presentations (head first), the presenting part is the occiput; this presentation occurs in 96% of births. In a breech birth, the sacrum emerges first; this presentation occurs in approximately 3% of births. In shoulder presentations, the scapula emerges first; this presentation occurs in only 1% of births. In a cephalic presentation, the part of the head or cranium that emerges first is the occiput; cephalic presentations occur in 96% of births.

 

DIF:    Cognitive Level: Understand          REF:   p. 368            TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A labor and delivery nurse should be cognizant of which information regarding how the fetus moves through the birth canal?
a. Fetal attitude describes the angle at which the fetus exits the uterus.
b. Of the two primary fetal lies, the horizontal lie is that in which the long axis of the fetus is parallel to the long axis of the mother.
c. Normal attitude of the fetus is called general flexion.
d. Transverse lie is preferred for vaginal birth.

 

 

ANS:  C

The normal attitude of the fetus is called general flexion. The fetal attitude is the relationship of the fetal body parts to each one another. The horizontal lie is perpendicular to the mother; in the longitudinal (or vertical) lie, the long axes of the fetus and the mother are parallel. Vaginal birth cannot occur if the fetus stays in a transverse lie.

 

DIF:    Cognitive Level: Understand          REF:   p. 369            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. A woman’s position is an important component of the labor progress. Which guidance is important for the nurse to provide to the laboring client?
a. The supine position, which is commonly used in the United States, increases blood flow.
b. The laboring client positioned on her hands and knees (“all fours” position) is hard on the woman’s back.
c. Frequent changes in position help relieve fatigue and increase the comfort of the laboring client.
d. In a sitting or squatting position, abdominal muscles of the laboring client will have to work harder.

 

 

ANS:  C

Frequent position changes relieve fatigue, increase comfort, and improve circulation. Blood flow can be compromised in the supine position; any upright position benefits cardiac output. The “all fours” position is used to relieve backache in certain situations. In a sitting or squatting position, the abdominal muscles work in greater harmony with uterine contractions.

 

DIF:    Cognitive Level: Apply                  REF:   p. 375

TOP:   Nursing Process: Planning | Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Certain changes stimulate chemoreceptors in the aorta and carotid bodies to prepare the fetus for initiating respirations immediately after birth. Which change in fetal physiologic activity is not part of this process?
a. Fetal lung fluid is cleared from the air passages during labor and vaginal birth.
b. Fetal partial pressure of oxygen (PO2) decreases.
c. Fetal partial pressure of carbon dioxide in arterial blood (PaCO2) increases.
d. Fetal respiratory movements increase during labor.

 

 

ANS:  D

Fetal respiratory movements actually decrease during labor. Fetal lung fluid is cleared from the air passages during labor and vaginal birth. Fetal PO2 decreases, and fetal PaCO2 increases.

 

DIF:    Cognitive Level: Understand          REF:   p. 379

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which description of the four stages of labor is correct for both the definition and the duration?
a. First stage: onset of regular uterine contractions to full dilation; less than 1 hour to 20 hours
b. Second stage: full effacement to 4 to 5 cm; visible presenting part; 1 to 2 hours
c. Third stage: active pushing to birth; 20 minutes (multiparous woman), 50 minutes (nulliparous woman)
d. Fourth stage: delivery of the placenta to recovery; 30 minutes to 1 hour

 

 

ANS:  A

Full dilation may occur in less than 1 hour, but in first-time pregnancies full dilation can take up to 20 hours. The second stage of labor extends from full dilation to birth and takes an average of 20 to 50 minutes, although 2 hours is still considered normal. The third stage of labor extends from birth to the expulsion of the placenta and usually takes a few minutes. The fourth stage begins after the expulsion of the placenta and lasts until homeostasis is reestablished (approximately 2 hours).

 

DIF:    Cognitive Level: Understand          REF:   pp. 376-377   TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Nurses should be cognizant of what regarding the mechanism of labor?
a. Seven critical movements must progress in a more or less orderly sequence.
b. Asynclitism is sometimes achieved by means of the Leopold’s maneuver.
c. Effects of the forces determining descent are modified by the shape of the woman’s pelvis and the size of the fetal head.
d. At birth, the baby is said to achieve “restitution”; that is, a return to the C-shape of the womb.

 

 

ANS:  C

The size of the maternal pelvis and the ability of the fetal head to mold also affect the process. The seven identifiable movements of the mechanism of labor simultaneously occur in combinations, not in precise sequences. Asynclitism is the deflection of the baby’s head; the Leopold’s maneuver is a means of judging descent by palpating the mother’s abdomen. Restitution is the rotation of the baby’s head after the infant is born.

 

DIF:    Cognitive Level: Understand          REF:   p. 377

TOP:   Nursing Process: Planning | Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which statement related to fetal positioning during labor is correct and important for the nurse to understand?
a. Position is a measure of the degree of descent of the presenting part of the fetus through the birth canal.
b. Birth is imminent when the presenting part is at +4 to +5 cm below the spine.
c. The largest transverse diameter of the presenting part is the suboccipitobregmatic diameter.
d. Engagement is the term used to describe the beginning of labor.

 

 

ANS:  B

The station of the presenting part should be noted at the beginning of labor to determine the rate of descent. Position is the relationship of the presenting part of the fetus to the four quadrants of the mother’s pelvis; station is the measure of degree of descent. The largest diameter is usually the biparietal diameter. The suboccipitobregmatic diameter is the smallest, although one of the most critical. Engagement often occurs in the weeks just before labor in nulliparous women and before or during labor in multiparous women.

 

DIF:    Cognitive Level: Understand          REF:   p. 370

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which basic type of pelvis includes the correct description and percentage of occurrence in women?
a. Gynecoid: classic female pelvis; heart shaped; 75%
b. Android: resembling the male pelvis; wide oval; 15%
c. Anthropoid: resembling the pelvis of the ape; narrow; 10%
d. Platypelloid: flattened, wide, and shallow pelvis; 3%

 

 

ANS:  D

A platypelloid pelvis is flattened, wide, and shallow; approximately 3% of women have this shape. The gynecoid pelvis is the classic female shape, slightly ovoid and rounded; approximately 50% of women have this shape. An android or malelike pelvis is heart shaped; approximately 23% of women have this shape. An anthropoid or apelike pelvis is oval and wide; approximately 24% of women have this shape.

 

DIF:    Cognitive Level: Remember           REF:   p. 374

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What is the nurse’s understanding of the appropriate role of primary and secondary powers?
a. Primary powers are responsible for the effacement and dilation of the cervix.
b. Effacement is generally well ahead of dilation in women giving birth for the first time; they are closer together in subsequent pregnancies.
c. Scarring of the cervix caused by a previous infection or surgery may make the delivery a bit more painful, but it should not slow or inhibit dilation.
d. Pushing in the second stage of labor is more effective if the woman can breathe deeply and control some of her involuntary needs to push, as the nurse directs.

 

 

ANS:  A

The primary powers are responsible for dilation and effacement; secondary powers are concerned with expulsion of the fetus. Effacement is generally well ahead of dilation in first-time pregnancies; they are closer together in subsequent pregnancies. Scarring of the cervix may slow dilation. Pushing is more effective and less fatiguing when the woman begins to push only after she has the urge to do so.

 

DIF:    Cognitive Level: Understand          REF:   p. 372            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which statement regarding the care of a client in labor is correct and important to the nurse as he or she formulates the plan of care?
a. The woman’s blood pressure will increase during contractions and fall back to prelabor normal levels between contractions.
b. The use of the Valsalva maneuver is encouraged during the second stage of labor to relieve fetal hypoxia.
c. Having the woman point her toes will reduce leg cramps.
d. Endogenous endorphins released during labor will raise the woman’s pain threshold and produce sedation.

 

 

ANS:  D

The endogenous endorphins released during labor will raise the woman’s pain threshold and produce sedation. In addition, physiologic anesthesia of the perineal tissues, caused by the pressure of the presenting part, decreases the mother’s perception of pain. Blood pressure levels increase during contractions but remain somewhat elevated between them. The use of the Valsalva maneuver is discouraged during the second stage labor because of a number of unhealthy outcomes, including fetal hypoxia. Pointing the toes can cause leg cramps, as can the process of labor itself.

 

DIF:    Cognitive Level: Understand          REF:   p. 380            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which adaptation of the maternal-fetal exchange of oxygen occurs in response to uterine contraction?
a. The maternal-fetal exchange of oxygen and waste products continues except when placental functions are reduced.
b. This maternal-fetal exchange increases as the blood pressure decreases.
c. It diminishes as the spiral arteries are compressed.
d. This exchange of oxygen and waste products is not significantly affected by contractions.

 

 

ANS:  C

Uterine contractions during labor tend to decrease circulation through the spiral electrodes and subsequent perfusion through the intervillous space. The maternal blood supply to the placenta gradually stops with contractions. The exchange of oxygen and waste products decreases. The exchange of oxygen and waste products is affected by contractions.

 

DIF:    Cognitive Level: Understand          REF:   p. 379

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiologic Integrity

 

  1. Which statement is the best rationale for assessing the maternal vital signs between uterine contractions?
a. During a contraction, assessing the fetal heart rate is the priority.
b. Maternal circulating blood volume temporarily increases during contractions.
c. Maternal blood flow to the heart is reduced during contractions.
d. Vital signs taken during contractions are not accurate.

 

 

ANS:  B

During uterine contractions, blood flow to the placenta temporarily stops, causing a relative increase in the mother’s blood volume, which, in turn, temporarily increases blood pressure and slows the pulse. Monitoring fetal responses to the contractions is important; however, this question concerns the maternal vital signs. Maternal blood flow is increased during a contraction. Vital signs are altered by contractions but are considered accurate for that period.

 

DIF:    Cognitive Level: Apply                  REF:   p. 379

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What is the primary difference between the labor of a nullipara and that of a multipara?
a. Amount of cervical dilation
b. Total duration of labor
c. Level of pain experienced
d. Sequence of labor mechanisms

 

 

ANS:  B

In a first-time pregnancy, the descent is usually slow but steady; in subsequent pregnancies, the descent is more rapid, resulting in a shorter duration of labor. Cervical dilation is the same for all labors. The level of pain is individual to the woman, not to the number of labors she has experienced. The sequence of labor mechanisms is the same with all labors.

 

DIF:    Cognitive Level: Understand          REF:   p. 378

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which nursing assessment indicates that a woman who is in second-stage labor is almost ready to give birth?
a. Fetal head is felt at 0 station during the vaginal examination.
b. Bloody mucous discharge increases.
c. Vulva bulges and encircles the fetal head.
d. Membranes rupture during a contraction.

 

 

ANS:  C

During the active pushing (descent) phase, the woman has strong urges to bear down as the presenting part of the fetus descends and presses on the stretch receptors of the pelvic floor. The vulva stretches and begins to bulge, encircling the fetal head. Birth of the head occurs when the station is +4. A 0 station indicates engagement. Bloody show occurs throughout the labor process and is not an indication of an imminent birth. Rupture of membranes can occur at any time during the labor process and does not indicate an imminent birth.

 

DIF:    Cognitive Level: Analyze               REF:   pp. 376-377

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Nurses can help their clients by keeping them informed about the distinctive stages of labor. Which description of the phases of the first stage of labor is accurate?
a. Latent: Mild, regular contractions; no dilation; bloody show; duration of 2 to 4 hours
b. Active: Moderate, regular contractions; 4- to 7-cm dilation; duration of 3 to 6 hours
c. Lull: No contractions; dilation stable; duration of 20 to 60 minutes
d. Transition: Very strong but irregular contractions; 8- to 10-cm dilation; duration of 1 to 2 hours

 

 

ANS:  B

The active phase is characterized by moderate, regular contractions; 4- to 7-cm dilation; and a duration of 3 to 6 hours. The latent phase is characterized by mild-to-moderate and irregular contractions; dilation up to 3 cm; brownish-to-pale pink mucus, and a duration of 6 to 8 hours. No official “lull” phase exists in the first stage. The transition phase is characterized by strong- to-very strong and regular contractions; 8- to 10-cm dilation; and a duration of 20 to 40 minutes.

 

DIF:    Cognitive Level: Understand          REF:   p. 376            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. Which changes take place in the woman’s reproductive system, days or even weeks before the commencement of labor? (Select all that apply.)
a. Lightening
b. Exhaustion
c. Bloody show
d. Rupture of membranes
e. Decreased fetal movement

 

 

ANS:  A, C, D

Signs that precede labor may include lightening, urinary frequency, backache, weight loss, surge of energy, bloody show, and rupture of membranes. Many women experience a burst of energy before labor. A decrease in fetal movement is an ominous sign that does not always correlate with labor.

 

DIF:    Cognitive Level: Understand          REF:   p. 376

TOP:   Nursing Process: Planning | Nursing Process: Implementation

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Which factors influence cervical dilation? (Select all that apply.)
a. Strong uterine contractions
b. Force of the presenting fetal part against the cervix
c. Size of the woman
d. Pressure applied by the amniotic sac
e. Scarring of the cervix

 

 

ANS:  A, B, D, E

Dilation of the cervix occurs by the drawing upward of the musculofibrous components of the

cervix, which is caused by strong uterine contractions. Pressure exerted by the amniotic fluid while the membranes are intact or by the force applied by the presenting part can also promote cervical dilation. Scarring of the cervix as a result of a previous infection or surgery may slow cervical dilation. Pelvic size or the size of the woman does not affect cervical dilation.

 

DIF:    Cognitive Level: Understand          REF:   p. 374            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. At least five factors affect the process of labor and birth. These are easily remembered as the five Ps. Which factors are included in this process? (Select all that apply.)
a. Passenger
b. Passageway
c. Powers
d. Pressure
e. Psychologic response

 

 

ANS:  A, B, C, E

The five Ps are passenger (fetus and placenta), passageway (birth canal), powers (contractions), position of the mother, and psychologic response. Pressure is not one of the five Ps.

 

DIF:    Cognitive Level: Understand          REF:   p. 367

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Because of its size and rigidity, the fetal head has a major effect on the birth process. Which bones comprise the structure of the fetal skull? (Select all that apply.)
a. Parietal
b. Temporal
c. Fontanel
d. Occipital
e. Femoral

 

 

ANS:  A, B, D

The fetal skull has two parietal bones, two temporal bones, an occipital bone, and a frontal bone. The fontanels are membrane-filled spaces.

 

DIF:    Cognitive Level: Remember           REF:   p. 367

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

Chapter 36: Hemolytic Disorders and Congenital Anomalies

Lowdermilk: Maternity & Women’s Health Care, 11th Edition

 

MULTIPLE CHOICE

 

  1. To explain hemolytic disorders in the newborn to new parents, the nurse who cares for the newborn population must be aware of the physiologic characteristics related to these conditions. What is the most common cause of pathologic hyperbilirubinemia?
a. Hepatic disease
b. Hemolytic disorders
c. Postmaturity
d. Congenital heart defect

 

 

ANS:  B

Hemolytic disorders in the newborn are the most common cause of pathologic hyperbilirubinemia (jaundice). Although hepatic damage, prematurity, and congenital heart defects may cause pathologic hyperbilirubinemia, they are not the most common causes.

 

DIF:    Cognitive Level: Apply                  REF:   p. 882            TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Physiologic Integrity

 

  1. Which infant is most likely to express Rh incompatibility?
a. Infant of an Rh-negative mother and a father who is Rh positive and homozygous for the Rh factor
b. Infant who is Rh negative and a mother who is Rh negative
c. Infant of an Rh-negative mother and a father who is Rh positive and heterozygous for the Rh factor
d. Infant who is Rh positive and a mother who is Rh positive

 

 

ANS:  A

If the mother is Rh negative and the father is Rh positive and homozygous for the Rh factor, then all the offspring of this union will be Rh positive. Only Rh-positive offspring of an Rh-negative mother are at risk for Rh incompatibility. Only the Rh-positive offspring of an Rh-negative mother are at risk. If the mother is Rh negative and the father is Rh positive and heterozygous for the factor, a 50% chance exists that each infant born of this union will be Rh positive, and a 50% chance exists that each will be born Rh negative. No risk for incompatibility exists if both the mother and the infant are Rh positive.

 

DIF:    Cognitive Level: Understand          REF:   p. 883            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. What is the highest priority nursing intervention for an infant born with myelomeningocele?
a. Protect the sac from injury.
b. Prepare the parents for the child’s paralysis from the waist down.
c. Prepare the parents for closure of the sac when the child is approximately 2 years of age.
d. Assess for cyanosis.

 

 

ANS:  A

A major preoperative nursing intervention for a neonate with a myelomeningocele is the protection of the protruding sac from injury to prevent its rupture and the resultant risk of central nervous system (CNS) infection. The long-term prognosis in an affected infant can be determined to a large extent at birth, with the degree of neurologic dysfunction related to the level of the lesion, which determines the nerves involved. A myelomeningocele should be surgically closed within 24 hours. Although the nurse should assess for multiple potential problems in this infant, the major nursing intervention is to protect the sac from injury.

 

DIF:    Cognitive Level: Understand          REF:   p. 892

TOP:   Nursing Process: Planning | Nursing Process: Implementation

MSC:  Client Needs: Physiologic Integrity

 

  1. Which nursing diagnosis is most appropriate for a newborn diagnosed with a diaphragmatic hernia?
a. Risk for impaired parent-infant attachment
b. Imbalanced nutrition, related to less than body requirements
c. Risk for infection
d. Impaired gas exchange

 

 

ANS:  D

Herniation of the abdominal viscera into the thoracic cavity may cause severe respiratory distress and represent a neonatal emergency. Oxygen therapy, mechanical ventilation, and the correction of acidosis are necessary in infants with large defects. Although imbalanced nutrition, related to less than body requirements, may be a factor in providing care to a newborn with a diaphragmatic hernia, the priority nursing diagnosis relates to the oxygenation issues arising from the lung hypoplasia that occurs with diaphragmatic hernia. The nutritional needs of this infant may be a clearly identified need; however, at this time the nurse should be most concerned about impaired gas exchange. This infant is at risk for infection, especially once the surgical repair has been performed. The extent of the herniation may have hindered normal development of the lungs in utero, resulting in respiratory distress.

 

DIF:    Cognitive Level: Apply                  REF:   p. 894            TOP:   Nursing Process: Diagnosis

MSC:  Client Needs: Physiologic Integrity

 

  1. What is the clinical finding most likely to be exhibited in an infant diagnosed with erythroblastosis fetalis?
a. Edema
b. Immature red blood cells
c. Enlargement of the heart
d. Ascites

 

 

ANS:  B

Erythroblastosis fetalis occurs when the fetus compensates for the anemia associated with Rh incompatibility by producing large numbers of immature erythrocytes to replace those hemolyzed. Edema occurs with hydrops fetalis, a more severe form of erythroblastosis fetalis. The fetus with hydrops fetalis may exhibit effusions into the peritoneal, pericardial, and pleural spaces, as well as demonstrate signs of ascites.

 

DIF:    Cognitive Level: Understand          REF:   p. 883

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiologic Integrity

 

  1. Which statement regarding congenital anomalies of the cardiovascular and respiratory systems is correct?
a. Cardiac disease may demonstrate signs and symptoms of respiratory illness.
b. Screening for congenital anomalies of the respiratory system need only be performed for infants experiencing respiratory distress.
c. Choanal atresia can be corrected with the use of a suction catheter to remove the blockage.
d. Congenital diaphragmatic hernias are diagnosed and treated after birth.

 

 

ANS:  A

The cardiac and respiratory systems function together; therefore, initial findings will be related to respiratory illness. Screening for congenital respiratory system anomalies is necessary, even for infants who appear normal at birth. All newborns should have critical congenital heart disease (CCHD) screening performed before discharge. Choanal atresia requires emergency surgery. Congenital diaphragmatic hernias are prenatally discovered on ultrasound.

 

DIF:    Cognitive Level: Understand          REF:   p. 889

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Physiologic Integrity

 

  1. When attempting to screen and educate parents regarding the treatment of developmental dysplasia of the hip (DDH), which intervention should the nurse perform?
a. Be able to perform the Ortolani and Barlow tests.
b. Teach double or triple diapering for added support.
c. Explain to the parents the need for serial casting.
d. Carefully monitor infants for DDH at follow-up visits.

 

 

ANS:  D

Because DDH often is not detected at birth, infants should be carefully monitored at follow-up visits. The Ortolani and Barlow tests must be performed by experienced clinicians to prevent fracture or other damage to the hip. Double or triple diapering is not recommended because it promotes hip extension, thus worsening the problem. Serial casting is recommended for clubfoot, not DDH.

 

DIF:    Cognitive Level: Apply                  REF:   p. 899            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is assigned a home care visit of a 5-day-old infant for the treatment of jaundice. A thorough assessment is completed, and a health history is obtained. Which sign or symptom indicates that the infant may be displaying the initial phase of encephalopathy?
a. High-pitched cry
b. Severe muscle spasms (opisthotonos)
c. Fever and seizures
d. Hypotonia, lethargy, and poor suck

 

 

ANS:  D

The early and most subtle symptoms of bilirubin encephalopathy include hypotonia, lethargy, poor suck, and a depressed or absent Moro reflex. Should the infant display symptoms such as a high-pitched cry, severe muscle spasms, hyperreflexia, or an arching of the back, the nurse should be aware that the baby has progressed beyond the more subtle signs of the first phase of encephalopathy. Medical attention is immediately necessary. Symptoms may progress from the subtle indications of the first phase to fever and seizures in as few as 24 hours. Only approximately one half of these infants survive, and those that do will have permanent sequelae, including auditory deficiencies, intellectual deficits, and movement abnormalities.

 

DIF:    Cognitive Level: Analyze               REF:   p. 884

TOP:   Nursing Process: Assessment          MSC:  Client Needs: Health Promotion and Maintenance

 

  1. Most congenital anomalies of the CNS result from defects in the closure of the neural tube during fetal development. Which factor has the greatest impact on this process?
a. Maternal diabetes
b. Maternal folic acid deficiency
c. Socioeconomic status
d. Maternal use of anticonvulsant

 

 

ANS:  B

All of these environmental influences may affect the development of the CNS. Maternal folic acid deficiency has a direct bearing on the failure of neural tube closure. As a preventative measure, folic acid supplementation (0.4 mg/day) is recommended for all women of childbearing age.

 

DIF:    Cognitive Level: Analyze               REF:   p. 891            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiologic Integrity

 

  1. The condition, hypospadias, encompasses a wide range of penile abnormalities. Which information should the nurse provide to the anxious parents of an affected newborn?
a. Mild cases involve a single surgical procedure.
b. Infant should be circumcised.
c. Repair is performed as soon as possible after birth.
d. No correlation exists between hypospadia and testicular cancer.

 

 

ANS:  A

Mild cases of hypospadias are often repaired for cosmetic reasons, and repair involves a single surgical procedure, enabling the male child to urinate in a standing position and to have an adequate sexual organ. These infants are not circumcised; the foreskin will be needed during the surgical repair. Repair is usually performed between 1 and 2 years of age. A correlation between hypospadias and testicular cancer exists; therefore, these children will require long-term follow-up observation.

 

DIF:    Cognitive Level: Apply                  REF:   p. 902

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiologic Integrity

 

  1. The nurse is instructing a family how to care for their infant in a Pavlik harness to treat DDH. What information should be included in the teaching?
a. Apply lotion or powder to minimize skin irritation.
b. Remove the harness several times a day to prevent contractures.
c. Return to the clinic every 1 to 2 weeks.
d. Place a diaper over the harness, preferably using an absorbent disposable diaper.

 

 

ANS:  C

Infants have a rapid growth pattern. Therefore, the child needs to be assessed by the practitioner every 1 to 2 weeks for possible adjustments. Lotions and powders should not be used with the harness, and the harness should not be removed, except as directed by the practitioner. A thin disposable diaper can be placed under the harness.

 

DIF:    Cognitive Level: Understand          REF:   p. 900

TOP:   Nursing Process: Implementation   MSC:  Client Needs: Physiologic Integrity

 

  1. A neonate is born with mild clubfeet. When the parents ask the nurse how this will be corrected, how should the nurse respond?
a. Traction is tried first.
b. Surgical intervention is needed.
c. Frequent, serial casting is tried first.
d. Children outgrow this condition when they learn to walk.

 

 

ANS:  C

Serial casting, the preferred treatment, is begun shortly after birth and before discharge from the nursery. Successive casts allows for gradual stretching of skin and tight structures on the medial side of the foot. Manipulation and casting of the leg are frequently repeated (every week) to accommodate the rapid growth of early infancy. Surgical intervention is performed only if serial casting is not successful. Children do not improve without intervention.

 

DIF:    Cognitive Level: Understand          REF:   p. 901            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiologic Integrity

 

  1. Which statement regarding hemolytic diseases of the newborn is most accurate?
a. Rh incompatibility matters only when an Rh-negative child is born to an Rh-positive mother.
b. ABO incompatibility is more likely than Rh incompatibility to precipitate significant anemia.
c. Exchange transfusions are frequently required in the treatment of hemolytic disorders.
d. The indirect Coombs’ test is performed on the mother before birth; the direct Coombs’ test is performed on the cord blood after birth.

 

 

ANS:  D

An indirect Coombs’ test may be performed on the mother a few times during pregnancy. Only the Rh-positive child of an Rh-negative mother is at risk. ABO incompatibility is more common than Rh incompatibility but causes less severe problems; significant anemia, for instance, is rare with ABO. Exchange transfers infrequently are needed because of the decrease in the incidence of severe hemolytic disease in newborns from Rh incompatibility.

 

DIF:    Cognitive Level: Understand          REF:   pp. 884, 885  TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. Cleft lip or palate is a common congenital midline fissure, or opening, in the lip or palate resulting from the failure of the primary palate to fuse. Multiple genetic and, to a lesser extent, environmental factors may lead to the development of a cleft lip or palate. Which factors are included? (Select all that apply.)
a. Alcohol consumption
b. Female gender
c. Use of some anticonvulsant medications
d. Maternal cigarette smoking
e. Antibiotic use in pregnancy

 

 

ANS:  A, C, D

Factors associated with the potential development of cleft lip or palate are maternal infections, alcohol consumption, radiation exposure, corticosteroid use, use of some anticonvulsant medications, male gender, Native-American or Asian descent, and maternal smoking during pregnancy. Cleft lip is more common in male infants. Antibiotic use in pregnancy is not associated with the development of cleft lip or palate.

 

DIF:    Cognitive Level: Understand          REF:   p. 895            TOP:   Nursing Process: Planning

MSC:  Client Needs: Physiologic Integrity

 

  1. The most widespread use of postnatal testing for genetic disease is the routine screening of newborns for inborn errors of metabolism (IEM). Which conditions are considered metabolic disorders? (Select all that apply.)
a. Phenylketonuria (PKU)
b. Galactosemia
c. Hemoglobinopathy
d. Cytomegalovirus (CMV)
e. Rubella

 

 

ANS:  A, B, C

PKU is an IEM that can be diagnosed with newborn screening. Galactosemia is a metabolic defect that falls under the category of an IEM. Sickle cell disease and thalassemia are hemoglobinopathies that can be detected by newborn screening. CMV and rubella cannot be detected by newborn screening and are not metabolic disorders; rather, they are viruses contracted by the fetus.

 

DIF:    Cognitive Level: Understand          REF:   p. 904            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

 

  1. The nurse is caring for an infant with DDH. Which clinical manifestations should the nurse expect to observe? (Select all that apply.)
a. Positive Ortolani click
b. Unequal gluteal folds
c. Negative Babinski sign
d. Trendelenburg sign
e. Telescoping of the affected limb

 

 

ANS:  A, B

A positive Ortolani test and unequal gluteal folds are clinical manifestations of DDH observed from birth to 2 to 3 months of age. A negative Babinski sign, Trendelenburg sign, and telescoping of the affected limb are not clinical manifestations of DDH.

 

DIF:    Cognitive Level: Apply                  REF:   p. 900            TOP:   Nursing Process: Planning

MSC:  Client Needs: Health Promotion and Maintenance

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