Maternal And Child Nursing Care 5th Edition By London – Test Bank

Maternal And Child Nursing Care 5th Edition By London – Test Bank

Chapter 10 The Expectant Family: Needs and Care
1) The nurse is preparing a class for expectant fathers. Which information should the nurse include?
1. Siblings adjust readily to the new baby.
2. Sexual activity is safe for normal pregnancy.
3. The expectant mother decides the feeding method.
4. Fathers are expected to be involved in labor and birth.
Answer: 2
Explanation:
1. Siblings often have difficulty adapting to the arrival of a new baby. Regression is often seen in siblings’ behaviors.
2. During a normal pregnancy, sexual activity is safe for both mother and baby.
3. Often, the father wants input into the feeding method.
4. In some cultures, labor and birth are only for women, and it is inappropriate for fathers to be involved with the labor and birth.
Page Ref: 213
Cognitive Level: Understanding
Client Need/Sub: Health Promotion and Maintenance
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care │ AACN Essential Competencies: IX.7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care│ NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others │ Nursing/Integrated Concepts: Planning/Teaching/Learning
Learning Outcome: 10.9 Identify some of the concerns that an expectant couple may have about sexual activity.
MNL Learning Outcome: 2.3.3. Implement client teaching that promotes health maintenance during pregnancy.

2) The spouse accompanies a pregnant client to a prenatal visit. Which question should the nurse use to determine the amount of anticipatory guidance the spouse will need?
1. “What kind of work do you do?”
2. “How moody has your wife been lately?”
3. “What furniture have you gotten for the baby?”
4. “How are you feeling about becoming a father?”
Answer: 4
Explanation:
1. Asking about vocation does not help determine the amount of anticipatory guidance the spouse will need.
2. Asking about the client’s mood does not help determine the amount of anticipatory guidance the spouse will need.
3. Buying furniture does not help determine the amount of anticipatory guidance the spouse will need.
4. Anticipatory guidance of the expectant father is a necessary part of any plan of care. He may need information on a variety of topics about the pregnancy, and the best question to learn the spouse’s needs is to ask about his feelings about becoming a father.
Page Ref: 195
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care │ AACN Essential Competencies: IX.4. Communicate effectively with all members of the healthcare team, including the client and the client’s support network│ NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions│ Nursing/Integrated Concepts: Assessment
Learning Outcome: 10.2 Describe actions the nurse can take to help maintain the well-being of the expectant father and siblings during a family’s pregnancy.
MNL Learning Outcome: 2.1.4. Assess the childbearing family’s psychosocial adaptation to pregnancy.
3) The nurse is teaching an early pregnancy class for clients in the first trimester of pregnancy. Which statement requires immediate intervention by the nurse?
1. “When my nausea is bad, I will drink some ginger tea.”
2. “It is normal for my vaginal discharge to get green colored.”
3. “I will urinate less often during the middle of my pregnancy.”
4. “The fatigue I am experiencing will improve in the second trimester.”
Answer: 2
Explanation:
1. Ginger helps nausea, and is safe for use during pregnancy.
2. Leukorrhea is an increase in white vaginal discharge and is an expected finding during pregnancy. Green discharge is not a normal finding and could indicate an infection. Further assessment is required for a client with green vaginal discharge.
3. As the uterus rises in the pelvis during the second trimester, urinary frequency decreases. Urinary frequency increases again during the end of the third trimester as the fetal head descends into the pelvis.
4. First-trimester fatigue is common; fatigue usually improves during the second trimester.
Page Ref: 205
Cognitive Level: Analyzing
Client Need/Sub: Health Promotion and Maintenance
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care │ AACN Essential Competencies: IX.7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care │ NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others│ Nursing/Integrated Concepts: Evaluation/Teaching/Learning
Learning Outcome: 10.6 Identify the common discomforts of pregnancy and their cause.
MNL Learning Outcome: 2.3.2. Recognize common discomforts of pregnancy and measures that can provide relief.

4) A client who is at 10 weeks’ gestation is concerned about the amount of saliva that is in her mouth since she seems to be spitting when she talks. How should the nurse respond?
1. “You should avoid astringent mouthwashes and chewing gum.”
2. “That’s called ptyalism, and it’s usually caused by increased salt intake during the second trimester.”
3. “Excess salivation commonly occurs during the first trimester, although the cause is unknown.”
4. “Let’s schedule you for a doctor’s appointment, because excessive salivation can signal a complication of pregnancy.”
Answer: 3
Explanation:
1. Astringent mouthwashes, chewing gum, and sucking hard candy may help relieve the bitter taste that often accompanies ptyalism.
2. Ptyalism, which is excess production of saliva, usually occurs during the first trimester and the cause is unknown.
3. Ptyalism, which is excess production of saliva, commonly occurs during the first trimester and the cause is unknown.
4. Excess salivation, also called ptyalism, is a normal occurrence in women during the first trimester.
Page Ref: 205
Cognitive Level: Understanding
Client Need/Sub: Health Promotion and Maintenance
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care │ AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches│ NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions│ Nursing/Integrated Concepts: Implementation
Learning Outcome: 10.6 Identify the common discomforts of pregnancy and their causes.
MNL Learning Outcome: 2.3.2. Recognize common discomforts of pregnancy and measures that can provide relief.

5) Upon arriving at the prenatal clinic in the morning, the nurse receives messages from four clients. Which client complaint should be addressed first?
1. Primipara at 24 weeks’ gestation with ankle edema
2. Multipara at 35 weeks’ gestation with new onset of hemorrhoids
3. Primipara at 9 weeks’ gestation with increased fatigue and nocturia
4. Multipara at 30 weeks’ gestation with vaginal bleeding after performing yoga
Answer: 4
Explanation:
1. Particularly during the second and third trimesters, ankle edema is a common pregnancy-related discomfort.
2. Hemorrhoids are a common pregnancy-related discomfort, especially during the second and third trimesters.
3. Fatigue and increased urination at night is a common pregnancy-related discomfort during the first trimester.
4. Vaginal bleeding after yoga is a warning sign that should be immediately reported to the healthcare provider; this client is the highest priority for care.
Page Ref: 211
Cognitive Level: Analyzing
Client Need/Sub: Physiological Integrity/Reduction of Risk Potential
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care │ AACN Essential Competencies: IX.1. Conduct comprehensive and focused physical, behavioral, psychological, spiritual, socioeconomic, and environmental assessments of health and illness parameters in clients, using developmentally and culturally appropriate approaches│ NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions│ Nursing/Integrated Concepts: Assessment
Learning Outcome: 10.7 Summarize appropriate measures to alleviate the common discomforts of pregnancy.
MNL Learning Outcome: 2.3.2. Recognize common discomforts of pregnancy and measures that can provide relief.
6) A 32-year-old primipara who is at 8 weeks’ gestation asks if she should expect any breathing changes as the pregnancy progresses. How should the nurse respond?
1. “By the third trimester, you will no longer feel as though you’re short of breath.”
2. “You may experience shortness of breath due to stretching of the round ligament.”
3. “If you develop shortness of breath, it should improve in the last few weeks of your pregnancy, as lightening occurs.”
4. “Shortness of breath is an abnormal finding during any stage of pregnancy, and it is considered a serious complication.”
Answer: 3
Explanation:
1. Shortness of breath occurs as the uterus rises into the abdomen and causes pressure on the diaphragm. This problem worsens in the last trimester.
2. Round ligament stretching causes a “grabbing” sensation in the lower abdomen and inguinal area.
3. The primigravida experiences considerable relief from shortness of breath in the last few weeks of pregnancy, when lightening occurs and the fetus and uterus move down in the pelvis.
4. Because of decreased vital capacity from pressure of the enlarging uterus on the diaphragm, shortness of breath is a common problem of pregnancy.
Page Ref: 207
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care │ AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings│ NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions│ Nursing/Integrated Concepts: Implementation
Learning Outcome: 10.7 Summarize appropriate measures to alleviate the common discomforts of pregnancy.
MNL Learning Outcome: 2.3.2. Recognize common discomforts of pregnancy and measures that can provide relief.

7) A client in the first trimester of pregnancy is experiencing nausea. What should the nurse suggest the client do to relieve the nausea?
1. Eat spicy foods.
2. Eat small, frequent meals.
3. Avoid carbonated beverages.
4. Wait to eat for 2 hours in the morning.
Answer: 2
Explanation:
1. The nausea of pregnancy can be exacerbated by ketosis, fatigue, and certain foods, such as those containing caffeine or spices.
2. Avoiding severe hunger by eating small, frequent meals throughout the day can help to prevent or decrease the severity of the nausea.
3. Carbonated beverages might be helpful in decreasing nausea.
4. Eating dry carbohydrates prior to rising each day can help to prevent or decrease the severity of the nausea.
Page Ref: 208
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care │ AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings│ NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions│ Nursing/Integrated Concepts: Implementation
Learning Outcome: 10.7 Summarize appropriate measures to alleviate the common discomforts of pregnancy.
MNL Learning Outcome: 2.3.2. Recognize common discomforts of pregnancy and measures that can provide relief.
8) A client in the third trimester of pregnancy reports frequent leg cramps. What strategy would be most appropriate for the nurse to suggest?
1. Limit activity for several days.
2. Flex the foot to stretch the calf.
3. Point the toes of the affected leg.
4. Increase intake of protein-rich foods.
Answer: 2
Explanation:
1. Limiting activity is not appropriate.
2. Leg cramps are a common problem in pregnancy, resulting from an imbalance in the calcium–phosphorus ratio; pressure on nerves or decreased circulation in the legs from the enlarged uterus; or fatigue. Dorsiflexing the foot will stretch the calf muscles and will help relieve the cramps.
3. Pointing the toes will exacerbate leg cramps.
4. Protein intake does not affect leg cramps.
Page Ref: 209
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care │ AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings│ NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions│ Nursing/Integrated Concepts: Implementation
Learning Outcome: 10.7 Summarize appropriate measures to alleviate the common discomforts of pregnancy.
MNL Learning Outcome: 2.3.2. Recognize common discomforts of pregnancy and measures that can provide relief.

9) A client in the third trimester of pregnancy reports working 8 hours a day as a cashier and stands when at work. What response by the nurse is the most appropriate?
1. “No problem. Your baby will be fine.”
2. “Do you get regular breaks for eating?”
3. “Your risk of preterm labor is higher.”
4. “Standing might increase ankle swelling.”
Answer: 3
Explanation:
1. Standing more than 5 hours a day increases the risk of preterm labor. To be therapeutic in communication, avoid false reassurance.
2. Although breaks for eating, drinking, and toileting are important for pregnant employees, it is more important to tell the client about the increased risk of preterm labor.
3. Pregnant women who stand for more than 3 hours a day have an increased risk of preterm labor. Because preterm labor can put the infant’s life at risk, this statement would be the highest priority.
4. Although this is true, it is less important than teaching the client about the risks of preterm labor when standing more than 3 hours a day.
Page Ref: 210
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care │ AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings│ NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions│ Nursing/Integrated Concepts: Implementation
Learning Outcome: 10.8 Delineate self-care actions a pregnant woman and her family can take to maintain and promote well-being during each trimester of pregnancy.
MNL Learning Outcome: 2.3.3. Implement client teaching that promotes health maintenance during pregnancy.

10) A pregnant client asks what kinds of medications cause birth defects. Which statement would best answer this question?
1. “Almost all medications will cause birth defects in the first trimester.”
2. “To be safe, do not take any medication without talking to your doctor.”
3. “Too much vitamin C is one of the most common issues but is avoidable.”
4. “Birth defects are very rare. Do not worry; your healthcare provider will watch for problems.”
Answer: 2
Explanation:
1. Not all medications are teratogenic.
2. Pregnant women need to avoid all medications—prescribed, homeopathic, or over-the-counter—if possible.
3. Vitamin C can cause rebound scurvy but is not teratogenic.
4. The nurse should avoid a “do not worry” answer to ensure therapeutic communication, but it is appropriate to instruct the client to talk to the doctor about medications.
Page Ref: 215
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care │ AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings│ NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions│ Nursing/Integrated Concepts: Implementation
Learning Outcome: 10.8 Delineate self-care actions a pregnant woman and her family can take to maintain and promote well-being during each trimester of pregnancy.
MNL Learning Outcome: 2.3.3. Implement client teaching that promotes health maintenance during pregnancy.

11) A pregnant client who swims 3 to 5 times per week asks the nurse if she should stop this activity. What is the appropriate nursing response?
1. “You should discontinue your exercise program immediately.”
2. “You should increase the number of times you swim per week.”
3. “You should decrease the number of times you swim per week.”
4. “You should continue your exercise program because it would be beneficial.”
Answer: 4
Explanation:
1. Thirty minutes of moderate-intensity exercise daily is recommended for pregnant women, but even mild exercise is helpful. There is no reason for the exercise to be discontinued.
2. Thirty minutes of moderate-intensity exercise daily is recommended for pregnant women. There is no reason for the exercise to be increased.
3. Thirty minutes of moderate-intensity exercise daily is recommended for pregnant women. There is no reason for the exercise to be decreased.
4. Thirty minutes of moderate-intensity exercise daily is recommended for pregnant women, but even mild exercise is helpful. Women who exercise regularly have better muscle tone, self-image, bowel function, energy levels, sleep, and postpartum recovery than do those who are sedentary.
Page Ref: 211
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care │ AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings│ NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions│ Nursing/Integrated Concepts: Implementation
Learning Outcome: 10.8 Delineate self-care actions a pregnant woman and her family can take to maintain and promote well-being during each trimester of pregnancy.
MNL Learning Outcome: 2.3.3. Implement client teaching that promotes health maintenance during pregnancy.

12) A pregnant client in the 21st week of pregnancy is planning a vacation with family and asks which method of travel she should use. How should the nurse respond?
1. “Travel by bus.”
2. “Fly on an airplane.”
3. “Take an automobile.”
4. “Do not travel this late in the pregnancy.”
Answer: 2
Explanation:
1. Traveling by bus is similar to traveling by automobile, which does not allow for frequent enough ambulation.
2. As pregnancy progresses, long-distance trips are best taken by plane.
3. Automobile travel does not allow for frequent enough ambulation.
4. It is not necessary to cease travel altogether.
Page Ref: 210
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care │ AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings│ NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions│ Nursing/Integrated Concepts: Implementation
Learning Outcome: 10.8 Delineate self-care actions a pregnant woman and her family can take to maintain and promote well-being during each trimester of pregnancy.
MNL Learning Outcome: 2.3.3. Implement client teaching that promotes health maintenance during pregnancy.
13) The nurse is explaining the importance of fetal activity assessment to a pregnant client. What should the nurse do to best reinforce the significance of fetal kick monitoring?
1. Perform daily phone calls to the client at work or home.
2. Ask the client to remember to count the fetal movements.
3. Explain the reason for counting fetal movement to the client.
4. Review the client’s written record of fetal movement at each visit.
Answer: 3
Explanation:
1. Daily phone calls would take emphasis away from the importance of the client’s counting of fetal movement.
2. Writing down the count is more accurate than the client’s simply remembering. When the nurse examines the written record the client has kept, it reinforces the importance of the record and improves the likelihood of continued record keeping.
3. Many healthcare providers encourage pregnant women to monitor their unborn child’s well-being by regularly assessing fetal activity beginning at 28 weeks’ gestation. Vigorous activity generally provides reassurance of fetal well-being, but a marked decrease in activity or cessation of movement may indicate a problem that needs immediate evaluation.
4. Knowing the reasons for the counting will increase understanding of the process but will not reinforce the significance of the task.
Page Ref: 207
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care │ AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings│ NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions│ Nursing/Integrated Concepts: Implementation
Learning Outcome: 10.8 Delineate self-care actions a pregnant woman and her family can take to maintain and promote well-being during each trimester of pregnancy.
MNL Learning Outcome: 2.3.3. Implement client teaching that promotes health maintenance during pregnancy.

14) A 23-year-old client who is at 10 weeks’ gestation with a first pregnancy expresses worry over feeling no sexual desire for her spouse and asks if this is normal. How should the nurse respond?
1. “That’s unusual. Throughout a healthy pregnancy, sexual desire usually increases with each trimester.”
2. “That’s unusual. Usually, there are minimal changes in sexual desire throughout a healthy pregnancy.”
3. “That sounds normal. In many cases, sexual desire decreases in the first trimester, but it increases again during the second trimester.”
4. “That sounds normal. During the first trimester, sexual desire often decreases; however, by the third trimester, sexual desire is usually greater than before pregnancy.”
Answer: 3
Explanation:
1. While each woman may be different, sexual desire often decreases during the first trimester, increases during the second trimester, and then decreases again during the third trimester.
2. While each woman may be different, sexual desire often decreases during the first trimester, increases during the second trimester, and then decreases again during the third trimester.
3. During the first trimester, factors such as fatigue, nausea, vomiting, and breast tenderness may decrease desire for sexual activity. During the second trimester, as these discomforts lessen and pelvic vascular congestion increases, the woman may experience greater sexual satisfaction than before pregnancy.
4. While each woman may be different, sexual desire often decreases during the first trimester, increases during the second trimester, and then decreases again during the third trimester.
Page Ref: 214
Cognitive Level: Applying
Client Need/Sub: Health Promotion and Maintenance
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care │ AACN Essential Competencies: IX.3. Implement holistic, client-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings│ NLN Competencies: Context and Environment; Practice; conduct population-based transcultural health assessments and interventions│ Nursing/Integrated Concepts: Implementation
Learning Outcome: 10.9 Identify some of the concerns that an expectant couple may have about sexual activity.
MNL Learning Outcome: 2.3.4. Implement nursing interventions that address pregnant women with special concerns.

15) The nurse is assisting an expectant couple in developing a birth plan. Which instructions should the nurse include when teaching about this plan?
1. It is a communication tool between the client and the healthcare provider.
2. It is a legally binding contract between the client and the healthcare provider.
3. It allows the client to make choices about the birth process; however, these choices cannot be altered.
4. It includes only client choices and does not take into account standard choices of the healthcare provider.
Answer: 1
Explanation:
1. The birth plan is used as a tool for communication among the expectant parents, the
healthcare provider, and the healthcare professionals at the birth setting.
2. It is not a legal document.
3. The written plan identifies options that are available; thus, it can be altered.
4. The birth plan is used as a tool for communication among the expectant parents, the
healthcare provider, and the healthcare professionals at the birth setting.

Page Ref: 197
Cognitive Level: Applying
Client Need/ Sub: Health Promotion and Maintenance
Standards: QSEN Competencies: I.A.1. Integrate understanding of multiple dimensions of client centered care │ AACN Essential Competencies: IX.7. Provide appropriate client teaching that reflects developmental stage, age, culture, spirituality, client preferences, and health literacy considerations to foster client engagement in their care│ NLN Competencies: Relationship Centered Care; Practice; learn cooperatively, facilitate the learning of others│ Nursing/Integrated Concepts: Implementation/Teaching/Learning
Learning Outcome: 10.4 Identify information that expectant parents may need to assist them in making the best decisions possible about issues related to pregnancy, labor, and birth.
MNL Learning Outcome: 2.3.3. Implement client teaching that promotes health maintenance during pregnancy.