Maternal and Child Health Nclex RN Answer And Rational

1. Answer a.
Rational: The nurse offers the client the opportunity to empty her bladder prior to the pelvic exam. An empty bladder will decrease pelvic pressure and discomfort experienced during the exam. Determining the client’s feelings about the pregnancy and teaching the client about relaxation breathing techniques are not interventions that will facilitate the pelvic exam.The female client needs to be in the lithotomy position for the exam.
2. Answer d.
Rational: In older children, a regular diet can generally be offered after rehydration is achieved. Early reintroduction of nutrients is desirable. Continued feeding or early reintroduction of a normal diet has no adverse effects and actually lessens the severity and duration of the illness. A diet of easily digestible foods such as cereals, cooked vegetables, and meats is adequate for the older child. A BRAT diet is contraindicated because the diet has little nutritional value (low in energy and protein), is high in carbohydrates, and is low in electrolytes.
3. Answer d.
Rational: The major efforts in the postoperative period are directed toward protecting the operative site. Elbow restraints are used to prevent the infant from rubbing or disturbing
the suture line and are applied immediately after surgery. It is important to remove the elbow restraints one at a time periodically to exercise the arms and to provide relief from the restrictions and to observe the skin integrity
4.Answer a.
Rational: The client is in shock and the primary goal is to reduce the threat of hypoxia; therefore, the nurse administers oxygen. Lowering the head of the bed increases blood flow to the head and may increase abdominal pressure. Measuring abdominal girth and assessing pain are relevant, but does not assist in meeting the client’s immediate needs.
5.Answer c.
Rational: No action is needed as ear wax rarely leads to hearing impairment. Excess removal can interfere with its function of removing dirt from the ear canal. It is not necessary to clean the ear with a Q-tip or apply ear drops.
6. Answer a.
Rational: In the active phase of labor the cervical dilation ranges from 3 to 7 cm. During the latent phase of labor, cervical dilation ranges from 0 to 3 cm, and during the transition phase from 7 to 10 cm. Effacement and descent occur as the fetus descends into the maternal pelvis. Complete effacement (cervical thinning) is 100%. Zero station is engagement, plus 1,2,3,4 stations indicate where the presenting part is located in relation to the maternal ischial spines.
7. Answer b.
Rational: Normal conversation is conducted at about 50 dB, and thus the child will not be able to hear normal conversation or whispering.The child has a hearing loss that will need to be treated. The nurse follows up with the audiologist to be sure the child is receiving care. The child will be able to hear fire alarms, loud noises, and shrill sounds, but will require follow-up care for his hearing loss
8.Answer c.
Rational: Nasal antihistamine sprays reduce inflammation at first; after 3 days they actually cause inflammation, and are therefore used on a short-term basis. The sprays do not cause reflux of gastric contents into the esophagus
9. Answer c.
Rational: Immediately after surgery the nurse offers the child ice chips. Milk clings to the back of the pharynx so it is difficult to swallow.Juice can sting the surgical site. Ginger alebubbles can be irritating. Ice chips are soothing
10. Answer d.
Rational: The left lateral side-lying position causes the heavy uterus to tip forward, away from the vena cavae, allowing free blood return from the lower extremities and adequate placental filling and circulation.Assuming this position decreases maternal BP. Positioning the client is a comfort measure;
decreasing fetal heart rate and increasing contraction frequency are not goals of positioning.
11. Answer d.
Rational: Infants and children with acute diarrhea and dehydrations are first treated with oral rehydration therapy; this is more effective, safer, less painful, and less costly than IV rehydration. Fruit juices and gelatin have high carbohydrate content,very low electrolyte content, and high osmolarity. Chicken broth is not given because it contains excessive sodium and inadequate carbohydrates
12. Answer c.
Rational: Standing for prolonged periods of time causes pooling of blood and distention of blood vessels. Women are also cautioned to not sit with legs crossed or wear knee high hose or garters. Vitamin C may be helpful in reducing the size of varicosities because it is necessary for the formation
of blood vessel collagen and endothelium.Exercising stimulates venous blood return and is effective in alleviating varicosities.Elastic support stockings such as TED hose are recommended for relief of varicosities
13.Answer a.
Rational: Following surgery, the infant will have to alter an established pattern of breathing and adjust to breathing through the nose. The nurse instructs the parents to position
the infant in a semiupright position while feeding to provide the infant with the most comfort. The nurse advises the parents not to place the infant on the abdomen as this will put pressure on the suture line. The parents are instructed to burp the infant frequently, and to not remove the metal appliance for feeding.
14.Answer b.
Rational: Live virus vaccines such as the MMR are contraindicated during pregnancy because they may transmit the viral infection to a fetus. The abdominal ultrasound and prenatal vitamins are considered normal orders for a pregnant client. Amniocentesis,if required, may be performed at 14 weeks’gestation when an adequate amount of amniotic fluid is available