Maternal Health/Pediatrics

When measuring a client’s fundal height, which of the following techniques denotes the correct method of measurement used by the nurse?

• From the fundus to the umbilicus

• From the symphysis pubis to the xiphoid process

• From the symphysis pubis to the fundus

• From the xiphoid process to the umbilicus

Answer explanation

The nurse should use a nonelastic, flexible, paper measuring tape, placing the zero point on the superior border of the symphysis pubis and stretching the tape across the abdomen at the midline to the top of the fundus. The xiphoid and umbilicus are not appropriate landmarks to use when measuring the height of the fundus (McDonald’s measurement).

The nurse understands that the fetal head is in which of the following positions with a face presentation? 

• Completely flexed

• Partially flexed

• Partially extended

• Completely extended

Answer explanation

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

The nurse hears a mother telling a friend on the telephone about umbilical cord care. Which of the following statements by the mother indicates effective teaching?

• "Alcohol helps it dry and kills germs"

• "He can have a tub bath each day"

• "An antibiotic ointment applied daily prevents infection"

• "Daily soap and water cleansing is best"

Answer explanation

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

A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of the following would be the priority when assessing the client?

• Depression

• Hand or face edema

• Dietary intake

• Glucosuria

A postpartum primipara asks the nurse, "When can we have sexual intercourse again?" Which of the following would be the nurse's best response?

• “As soon as choose a contraceptive method.”

• “Anytime you both want to.”

• "As soon as you choose a contraceptive method"

• "When the discharge has stopped and the incision has healed"

Answer explanation

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

When taking an obstetrical history on a pregnant client who states, “I had a son born at 38 weeks gestation, a daughter born at 30 weeks gestation and I lost a baby at about 8 weeks,” the nurse should record her obstetrical history as which of the following?

• G3 T1 P1 A0 L2

• G4 T1 P1 A1 L2

• G3 T2 P0 A0 L2

• G2 T2 P0 A0 L2

Answer explanation

Sue Freidman is pregnant for the four time. One child was born at 39 weeks gestation; one child at36 weeks gestation. Her last pregnancy ended in abortion at 10weeks. She has two children, age 4 and 2.

Which of the following is the priority focus of nursing practice with the current early postpartum discharge?

• Teaching about the importance of family planning

• Facilitating safe and effective self-and newborn care

• Exploring the emotional status of the family

• Promoting comfort and restoration of health

Which term refers to the single cell that reproduces itself after conception?

Answer explanation

The zygote is the single cell that reproduces itself after conception.

The mother asks the nurse. “What’s wrong with my son’s breasts? Why are they so enlarged?” Whish of the following would be the best response by the nurse?

• “A decrease in material hormones present before birth causes enlargement,”

• “The breast tissue is inflamed from the trauma experienced with birth”

• “The tissue has hypertrophied while the baby was in the uterus

• “You should discuss this with your doctor. It could be a malignancy”

Answer explanation

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

Lymph node biopsy is diagnostic in Kawasaki disease.

• True

• False

Answer explanation

Diagnoses for Kawasaki disease consists of coronary angiogram or echocardiogram to detect swelling of in the walls of the arteries of the child (primarily affects children).

The children who are older than 6 months are given long term low dose of aspirin. It is also recommended that the child must be given a yearly dose of flu vaccine. They must also be monitored for the effects of the disease on the heart.