NACE Care of the childbearing family
Total Questions : 95
Showing 25 questions, Sign in for moreA nurse is explaining physiological jaundice to a nursing student.Which of the following should the nurse include when discussing risk factors for neonatal physiological jaundice?
Explanation
The correct answer is choice D. Gestational age of 35-38 weeks.
This is because preterm babies are more likely to develop jaundice due to their immature liver and increased breakdown of red blood cells.Babies born between 35 and 38 weeks are considered late preterm and have a higher risk of jaundice than full-term babies.
Choice A is wrong because African American ethnicity is not a risk factor for jaundice.In fact, Asian, European, or native American ethnicity are more associated with jaundice.
Choice B is wrong because meconium-stained amniotic fluid is not a risk factor for jaundice.
Meconium is the first stool of the baby and it may indicate fetal distress, but it does not affect the bilirubin level.
Choice C is wrong because bottle feeding is not a risk factor for jaundice.In fact, breastfeeding is more associated with jaundice due to dehydration and poor caloric intake.
A baby boy is circumcised on the day of discharge.
Explanation
This is because circumcision is a surgical procedure that involves cutting off the foreskin of the penis, which may affect the urinary function of the baby.The nurse should make sure that the baby can urinate normally and without pain after the circumcision.
The amount of urine should be adequate for the baby’s weight and hydration status.
Choice B is wrong because the erectile ability of the penis is not affected by circumcision and is not a priority for discharge planning.
Choice C is wrong because the position of the urethral opening on the penis is not related to circumcision and should be assessed at birth, not at discharge.
Choice D is wrong because the presence of a small amount of white-yellow exudate around the glans tissue is normal and expected after circumcision.It is part of the healing process and does not indicate infection.The nurse should instruct the parents on how to care for the circumcised penis and when to seek medical attention if there are signs of complications.
A patient who is 38 weeks pregnant is admitted to the hospital in active labor.
On admission, the patient says, “For the past ten hours, I have been leaking small amounts of urine.” Which action should the nurse take initially?
Explanation
The correct answer is choice B. Test the patient’s vaginal secretions with nitrazine paper.
This is because the patient may be leaking amniotic fluid rather than urine, and nitrazine paper can help differentiate between the two by testing the pH level.Amniotic fluid is alkaline and will turn the paper blue, while urine is acidic and will turn the paper yellow.
Choice A is wrong because checking the patient’s bladder for distention will not help determine if the patient is leaking amniotic fluid or urine.
Choice C is wrong because checking the patient’s urine for glucose content will not help determine if the patient is leaking amniotic fluid or urine.
Glucose content may be elevated in patients with gestational diabetes, but this is not related to the patient’s complaint.
Choice D is wrong because obtaining a specimen of the patient’s vaginal secretions for culture will not help determine if the patient is leaking amniotic fluid or urine.
Culture may be done to check for infections, but this is not the initial action that the nurse should take.
A nurse is caring for a female client who suspects she is pregnant.
Which question, if asked by the nurse, is consistent with signs of early pregnancy?
Explanation
The correct answer is choice D. “Have you noticed any tenderness in your breasts?”
Breast tenderness is one of the early signs of pregnancy that may occur as early as one to two weeks after conception.It is caused by hormonal changes that prepare the breasts for lactation.
Choice A is wrong because shortness of breath is not a sign of early pregnancy.It may occur later in pregnancy due to the growing uterus pressing on the diaphragm.
Choice B is wrong because episodes of loss of consciousness are not a sign of early pregnancy.They may indicate a serious condition such as anemia, dehydration, or hypoglycemia that requires medical attention.
Choice C is wrong because spotting is not a sign of early pregnancy.
It may be a sign of implantation bleeding, which occurs when the fertilized egg attaches to the lining of the uterus.However, implantation bleeding is usually much lighter and shorter than a normal period.
A nurse is caring for a newborn with a gestational age of 42 weeks.
Which finding would the nurse expect during the assessment of this newborn?
Explanation
The correct answer is choice C. Dryness and flaking of the skin on the hands and feet.This is because a newborn with a gestational age of 42 weeks is considered post-mature and has lost the protective vernix caseosa that covers the skin of most newborns.The skin of a post-mature newborn is also more exposed to the amniotic fluid, which can cause it to peel and crack.
Choice A is wrong because sole creases that cover only the anterior one-third of the foot are characteristic of a preterm newborn, not a post-mature one.
Choice B is wrong because vernix caseosa is abundant in preterm newborns and decreases as gestational age increases.A post-mature newborn would have little or no vernix caseosa on the skin.
Choice D is wrong because a large amount of fine, downy hair (lanugo) on the back and shoulders is also typical of a preterm newborn, not a post-mature one.Lanugo usually disappears by 36 weeks of gestation.A post-mature newborn would have little or no lanugo on the body.
A patient who is 37 weeks pregnant and has gestational diabetes is admitted to the labor and delivery unit for induction.
The patient is placed on an external fetal monitor and receives an epidural anesthesia.Which action should the nurse take to identify a potential side effect of the epidural?
Explanation
This is because epidural anesthesia can cause hypotension (low blood pressure) which can affect the placental blood flow and fetal oxygenation.
The nurse should monitor the patient’s blood pressure frequently and intervene if it drops below the baseline.
Choice A is wrong because assessing the patient’s urine for acetone is not relevant to the side effects of epidural anesthesia.Acetone in urine can indicate diabetic ketoacidosis, a complication of diabetes that occurs when the body breaks down fat for energy due to lack of insulin.
However, this is not related to epidural anesthesia.
Choice B is wrong because monitoring the patient’s deep tendon reflexes is not relevant to the side effects of epidural anesthesia.Deep tendon reflexes can be affected by magnesium sulfate, a medication used to prevent seizures in patients with preeclampsia (a condition characterized by high blood pressure and proteinuria in pregnancy).
However, this is not related to epidural anesthesia.
Choice C is wrong because assessing the patient’s pupillary accommodation is not relevant to the side effects of epidural anesthesia.
Pupillary accommodation is the ability of the eye to adjust its focus from distant to near objects.It can be impaired by drugs that affect the nervous system, such as opioids or anticholinergics.
A patient is receiving magnesium sulfate.Which side effect should the nurse monitor for with this patient?
Explanation
The correct answer is choice D. Decreased respirations.Magnesium sulfate is a medication that can causerespiratory depression, which means it can slow down or stop breathing.
This is a serious side effect that needs to be monitored closely by the nurse.
Choice A is wrong because increased Babinski reflex is not a side effect of magnesium sulfate.
The Babinski reflex is a normal response in infants, but abnormal in adults.
It occurs when the big toe bends upward and the other toes fan out when the sole of the foot is stroked.Magnesium sulfate can causepoor reflexes, but not specifically the Babinski reflex.
Choice B is wrong because diarrhea is not a side effect of magnesium sulfate when given intravenously or intramuscularly.Diarrhea can occur when magnesium sulfate is taken orally as a laxative, but that is not the case in this question.
Choice C is wrong because tetany is not a side effect of magnesium sulfate.
Tetany is a condition that causes muscle spasms and cramps due to low levels of calcium in the blood.Magnesium sulfate can actually causehypocalcemia, which means low levels of calcium in the blood, but this does not usually result in tetany.Tetany is more likely to occur when there is low magnesium in the blood, which is calledhypomagnesemia.
A nurse is caring for a patient who is in labor and is placed on a monitor.How should the nurse determine the duration of contractions?
Explanation
The correct answer is choice C. Count the time from the beginning of one contraction to the end of the same contraction.
This is because the duration of a contraction is the length of time that the uterine muscle is tightening and relaxing.
The duration is measured from the start of one contraction until the end of that same contraction.
Choice A is wrong because it measures the frequency of contractions, not the duration.
The frequency is the time between the start of one contraction and the start of the next one.
Choice B is wrong because it measures only half of the duration of a contraction.
The middle of a contraction is when the uterine muscle reaches its peak intensity and then starts to relax.
Choice D is wrong because it measures both the duration and the interval of contractions.
The interval is the time between the end of one contraction and the start of the next one.
Normal ranges for contractions during labor are:
• Duration: 30 to 90 seconds
• Frequency: 2 to 5 minutes apart
• Interval: 30 to 120 seconds
A nurse is caring for a patient being evaluated for sexually transmitted infection (STI).A negative rapid plasma reagin (RPR) indicates that a patient is probably not infected with which STI?
Explanation
The correct answer is choice B. Syphilis.A negative rapid plasma reagin (RPR) test indicates that a patient is probably not infected with syphilis, a sexually transmitted infection (STI) caused by the bacterium Treponema pallidum.The RPR test works by detecting the nonspecific antibodies that your body produces while fighting the infection.
Choice A is wrong because herpes simplex II is a viral infection that causes genital herpes, and it is not detected by the RPR test.
Choice C is wrong because gonorrhea is a bacterial infection caused by Neisseria gonorrhoeae, and it is also not detected by the RPR test.
Choice D is wrong because condylomata are genital warts caused by human papillomavirus (HPV), and they are not detected by the RPR test either.
The RPR test is a screening test, and it can give false-positive results due to other conditions or infections.Therefore, a positive RPR test should always be confirmed by a more specific treponemal test, such as TPPA or FTA-ABS.The RPR test can also be used to monitor the treatment response of syphilis, as the antibody levels should decrease after effective antibiotic therapy.
Question 10.
Explanation
he correct answer is choice C. The reason for the patient’s visit at this time.
This information will help the nurse assess the patient’s motivation, readiness, and urgency for contraception.
It will also help the nurse tailor the education and counseling to the patient’s specific needs and preferences.
Choice A is wrong because the amount of sexual experience that the patient has had is not relevant to determine the patient’s knowledge base.
It may also make the patient feel uncomfortable or judged.
Choice B is wrong because the type of contraceptive that the patient’s friends are using is not a reliable source of information.
Different methods may have different advantages and disadvantages for different people.
The nurse should provide evidence-based information and guidance on various options.
Choice D is wrong because the method of contraception that the patient believes will provide protection from sexually transmitted diseases may not be accurate or effective.
A nurse is caring for a newborn of a diabetic mother (IDM).
What should the nurse monitor for during care of the newborn?
Explanation
Answer and explanation..
The correct answer is choice C. Jitteriness.Jitteriness is a sign of low blood sugar (hypoglycemia) which is common in infants of diabetic mothers (IDM) because they have high levels of insulin in their blood that lower their glucose levels after birth.Hypoglycemia can also cause other symptoms such as seizures, lethargy, poor feeding, sweating, trembling, and pale complexion.
Choice A is wrong because abdominal distention is not a typical symptom of IDM.
It can be caused by other conditions such as intestinal obstruction or infection.
Choice B is wrong because high-pitched cry is not a specific symptom of IDM.
It can be caused by many factors such as pain, hunger, or neurological problems.
Choice D is wrong because excessive drooling is not a common symptom of IDM.
It can be a sign of oral problems such as teething or infection.
Normal ranges for blood glucose in newborns are 40 to 150 mg/dL (2.2 to 8.3 mmol/L).
IDM should be monitored closely for hypoglycemia and treated promptly with glucose if needed.
A nurse is assessing a newborn.
Which finding may indicate a problem?
Explanation
The correct answer is choice A. The newborn’s nostrils flare slightly during respiration.This is a sign of respiratory distress in a newborn.
Flaring nostrils indicate that the newborn is working hard to breathe and may not be getting enough oxygen.
Choice B is wrong because the newborn’s hands and feet are blue and feel cool.This is a normal finding called acrocyanosis, which occurs due to immature peripheral circulation.
It usually resolves within 24 to 48 hours after birth.
Choice C is wrong because the newborn’s eyes move randomly when his head is turned to the side.This is a normal finding called nystagmus, which occurs due to immature eye muscles and coordination.
It usually disappears by 6 months of age.
Choice D is wrong because the newborn’s tongue thrusts forward when it is lightly touched.This is a normal finding called the extrusion reflex, which helps the newborn to suck and swallow.
It usually fades by 4 months of age.
The nurse suspects drug abuse in a patient admitted with no prenatal care and a diagnosis of abruptio placentae.Which question would elicit the most information from the patient concerning the suspected drug use?
Explanation
The correct answer is choice C. “What drugs have you used during your pregnancy?”.
This question is open-ended and nonjudgmental, which encourages the patient to disclose more information about her drug use.
The nurse can then assess the type, frequency, and amount of drugs used and plan appropriate interventions.
Choice A is wrong because it is a closed-ended question that can be answered with a yes or no, and it implies criticism of the patient’s behavior, which may make her defensive and less willing to cooperate.
Choice B is wrong because it is also a closed-ended question that can be answered with a yes or no, and it may frighten or anger the patient, who may not be aware of the legal implications of her drug use.
Choice D is wrong because it is too vague and may not cover all the possible drugs that the patient may have used, such as prescription medications, alcohol, or tobacco.
It also labels the patient as a drug user, which may offend her or make her feel ashamed.
A patient with no prenatal care is admitted to the labor and delivery unit.She is placed on an external fetal monitor, and an intravenous infusion is begun.
A tentative diagnosis of abruptio placentae is made.Which finding would support this diagnosis?
Explanation
This means that the uterus is constantly contracted and does not relax between contractions.This can cause the placenta to separate from the uterine wall, which is called placental abruption or abruptio placentae.Placental abruption can deprive the baby of oxygen and nutrients and cause heavy bleeding in the mother.
Choice B is wrong because strong uterine contractions every 3-4 minutes are normal during labor and do not indicate placental abruption.
Choice C is wrong because bile-colored vomitus is not a sign of placental abruption, but rather a sign of hyperemesis gravidarum, a severe form of nausea and vomiting during pregnancy.
Choice D is wrong because fetal heart rate acceleration with fetal activity is a normal finding and indicates a healthy baby.Placental abruption can cause fetal distress and a decrease in fetal heart rate.
A nurse caring for a patient in labor is evaluating the fetal heart monitor.Which finding would indicate fetal distress?
Explanation
The correct answer is choice A and it indicates fetal distress because it is a sign oflate deceleration.Late decelerations are due touteroplacental insufficiencyas the result of decreased blood flow and oxygen to the fetus during the uterine contractions.This causeshypoxemiaand can lead to fetal acidosis and neurological damage.
Choice B is wrong because it indicates anormal variabilityin the fetal heart rate, which reflects a healthy autonomic nervous system.A normal fetal heart rate is 120-160 beats per minute.
Choice C is wrong because it indicates anearly accelerationin the fetal heart rate, which is a benign finding that may occur with fetal movement or stimulation.
Choice D is wrong because it indicates anearly decelerationin the fetal heart rate, which is a normal response to fetal head compression during contractions.
It does not indicate fetal distress.
Normal ranges for fetal heart rate patterns are:
• Baseline: 120-160 beats per minute
• Variability: 6-25 beats per minute
• Accelerations: at least 15 beats per minute above baseline for at least 15 seconds
• Decelerations: none or early (mirror contractions)
A client is at the antepartal clinic for a pregnancy test.Which finding, if present, would be considered a positive sign of pregnancy?
Explanation
The correct answer is choice D. Presence of human chorionic gonadotropin (hCG) in blood.This is apositive sign of pregnancythat can only be attributed to a fetus.hCG is a hormone produced by the placenta that can be detected in blood or urine tests.
Choice A. Quickening.This is apresumptive sign of pregnancythat is based on the woman’s report of feeling fetal movements in her lower abdomen.This can occur at 16 weeks for second time moms and around 20 weeks for first time moms.However, this sign is not conclusive as other conditions can cause similar sensations.
Choice B. Uterine enlargement.This is aprobable sign of pregnancythat can be observed by the nurse or doctor through palpation.However, this sign does not mean 100% that a baby is growing in the uterus as it can be due to other causes such as fibroids or tumors.
Choice C. Urinary frequency.This is apresumptive sign of pregnancythat is based on the woman’s report of needing to urinate more often than usual.This can be caused by hormonal changes and increased blood volume during pregnancy.However, this sign is not definitive as other conditions such as urinary tract infections or diabetes can also cause frequent urination.
A nurse is caring for a patient who is receiving oxytocin injection intravenously for labor induction.The nurse should monitor this patient for which adverse effect of oxytocin?
Explanation
The correct answer is choice D. Insufficient relaxation of the uterus between contractions.This is also known astachysystoleorhyperstimulation, which can cause fetal distress and uterine rupture.Oxytocin is a hormone that stimulates uterine contractions, but it can also cause them to be too strong or too frequent if given in high doses or for too long.
Choice A is wrong because oxytocin does not decrease body temperature.
Choice B is wrong because oxytocin does not cause maternal cardiac arrhythmias.
Choice C is wrong because oxytocin does not cause urinary retention.
A nurse is caring for a patient who is receiving oxytocin injection intravenously for labor induction.The nurse should monitor this patient for which adverse effect of oxytocin?
Explanation
The correct answer is choice D. Insufficient relaxation of the uterus between contractions.This is also known astachysystoleorhyperstimulation, which can cause fetal distress and uterine rupture.Oxytocin is a hormone that stimulates uterine contractions, but it can also cause them to be too strong or too frequent if given in high doses or for too long.
Choice A is wrong because oxytocin does not decrease body temperature.
Choice B is wrong because oxytocin does not cause maternal cardiac arrhythmias.
Choice C is wrong because oxytocin does not cause urinary retention.
When assessing a newborn, which is the best method for the nurse to use to elicit the Moro reflex?
Explanation
The correct answer is choice A.Making a loud sound within close range of the newborn will elicit the Moro reflex, which is an involuntary protective motor response against abrupt disruption of body balance or extremely sudden stimulation.The Moro reflex involves three distinct components: spreading out the arms (abduction), pulling the arms in (adduction), and crying (usually).
Choice B is wrong because firmly stroking the soles of the newborn’s feet with a thumb nail will elicit the Babinski reflex, which is a normal response in infants that involves fanning out and curling of the toes.
Choice C is wrong because using the newborn’s hands to raise the baby from a supine position without supporting the head will elicit the traction response, which is a normal response in infants that involves flexion of the elbows and shoulders.
Choice D is wrong because holding the newborn in an upright position so that the infant’s feet touch a cool, flat surface will elicit the stepping reflex, which is a normal response in infants that involves alternating steps with each foot.
The mother visits her infant in the nursery.
The nurse shows the mother how to place her finger in the palm of the baby’s hand so that the baby will squeeze her finger.This behavior on the nurse’s part reflects an understanding of which principle?
Explanation
The correct answer is choice C. When the neonate responds to the mother by some signal, attachment behavior is stimulated in the mother.This is based on therooting reflex, which helps the baby find the breast or bottle to start feeding and also promotes bonding between the mother and the baby.
Choice A is wrong because acrocyanosis is a normal condition in newborns that causes bluish discoloration of the hands and feet due to poor circulation.It is not related to muscle tone or reflexes.
Choice B is wrong because myelinization of nerves is a process that occurs gradually during development and is not influenced by tactile stimulation.Myelin is a fatty substance that covers nerve fibers and helps them transmit signals faster and more efficiently.
Choice D is wrong because reflexes are involuntary movements or actions that do not depend on conscious thought or learning.They are not directly related to growth patterns, although they may indicate the health and development of the brain and nervous system.
A client in preterm labor tells the nurse, “It’s okay that I am in labor.I’m not worried.
My sister’s baby was born this early, and he is doing great.” How should the nurse interpret this statement by the client? The client is:.
Explanation
The correct answer is choice A. The client is trying to reassure herself concerning the present situation.This is a common coping strategy for women who face the risk of preterm labor and delivery.The client may be experiencing fear, anxiety, or denial about the possible outcomes of her pregnancy.
Choice B is wrong because coping as expected in this situation implies that there is a normal or standard way of coping with preterm labor, which is not true.Different women may cope differently depending on their personal, social, and emotional factors.
Choice C is wrong because anxious to see the new baby does not reflect the client’s statement.
The client is not expressing excitement or eagerness about the birth, but rather a rationalization that everything will be okay despite the risks.
Choice D is wrong because able to use previously learned knowledge in a new situation does not apply to the client’s statement.
The client is not using her sister’s experience as a source of information or guidance, but rather as a way of minimizing or dismissing her own situation.
The mother of a 4-hour-old newborn reports to a nurse, “My son is producing breast milk.” The nurse’s response should be based on which understanding about newborn physiology? This is:.
Explanation
The correct answer is choice C: Related to the influence of maternal hormones.This is because breast milk contains many hormones that pass into it from the mother’s body, such as prolactin, thyroid hormones, and estrogen.
These hormones can affect the baby’s growth and development, and sometimes cause temporary breast enlargement and milk secretion in newborns of both sexes.This is called neonatal galactorrhea or “witch’s milk” and it is harmless and usually resolves within a few weeks
Choice A is wrong because neonatal galactorrhea is not a symptom of an endocrine disorder.It is a normal physiological response to maternal hormones that cross the placenta during pregnancy and are present in breast milk
Choice B is wrong because neonatal galactorrhea is not related to the need for chromosomal determination of gender identity.Gender identity is determined by a complex interaction of genetic, hormonal, and environmental factors, and it is not influenced by breast milk production in newborns
Choice D is wrong because neonatal galactorrhea is not a symptom of an abnormal proliferation of mammary alveoli.
Mammary alveoli are the milk-producing cells in the breast, and they are stimulated by prolactin to secrete milk.Neonatal galactorrhea does not indicate any abnormality in the structure or function of the mammary glands
A nurse is observing the internal fetal monitor readings of a laboring client.The fetal heart rate is between 130 and 138 beats per minute, with moderate beat-to-beat variability.
How should the nurse interpret this finding?
Explanation
he correct answer is choice B. Sufficient perfusion and circulation of the fetus.This is because the fetal heart rate is within the normal range of 110 to 160 beats per minute, and there is moderate beat-to-beat variability, which indicates a healthy nervous system.
Choice A is wrong because insufficient perfusion of the placenta would cause fetal distress and abnormal fetal heart rate patterns, such as late decelerations or minimal variability.
Choice C is wrong because maternal hypoxia would not directly affect the fetal heart rate, unless it leads to placental insufficiency or uterine hyperstimulation.
Choice D is wrong because fetal hypoxia would cause signs of fetal distress, such as tachycardia, bradycardia, or absent variability.
A nurse is caring for a newborn who is placed in a neutral thermal environment.What is the desired outcome of this measure?
Explanation
The correct answer is choice A: To minimize the patient’s oxygen needs.
A neutral thermal environment is an environment in which a neonate maintains a normal body temperature while minimizing energy expenditure and oxygen consumption.This is important for the wellbeing of neonates, especially those who are preterm or have respiratory insufficiency.
Choice B is wrong because the conversion of glucose to lactic acid is not a desired outcome of a neutral thermal environment.This conversion occurs when there is inadequate oxygen supply to the tissues, resulting in anaerobic metabolism and metabolic acidosis.
Choice C is wrong because the absorption of surfactant from the alveoli is not affected by a neutral thermal environment.
Surfactant is a substance that reduces surface tension and prevents alveolar collapse.It is produced by type II alveolar cells and secreted into the alveoli.
Choice D is wrong because the metabolism of brown fat stores is not a desired outcome of a neutral thermal environment.
Brown fat is a specialized tissue that generates heat by nonshivering thermogenesis in response to cold stress.
It is located in the nape of the neck, between the scapulae, and around the kidneys and adrenals.It increases the metabolic rate and oxygen consumption of neonates.
On her first visit, a patient had a baseline hemoglobin of 13.0 gm and a hematocrit of 42.9%.She has been taking ferrous sulfate tablets and eating an iron-rich diet.She returned to the clinic at 30 weeks gestation and has a hemoglobin of 11.0 gm and a hematocrit of 36.3%.She is concerned and confused about why these lab values have gone down.
In responding, which physiological change during pregnancy should the nurse describe to the patient?
Explanation
The correct answer is choice D. The increase in maternal blood volume is greater than the increase in maternal red blood cells.
This means that the concentration of hemoglobin and hematocrit in the blood is diluted by the extra fluid.
This is a normal physiological adaptation to pregnancy and does not indicate iron deficiency anemia.
Choice A is wrong because placental hormones do not chelate maternal iron.
Chelation is a process of binding metal ions to organic molecules, which is not relevant to this question.
Choice B is wrong because fetal demand for iron is not greater than maternal intake.
The mother can meet the iron needs of the fetus by increasing her dietary intake and taking iron supplements.
Choice C is wrong because maternal intestinal absorption of iron is not decreased during pregnancy.
In fact, it may be increased due to higher levels of estrogen and progesterone.
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