maternal and child health nursing MCQ 5

1.   Which of the following would the nurse expect to assess as presumptive signs of pregnancy? 
A. Amenorrhea and quickening 
B. Uterine enlargement and Chadwick's sign 
C. A positive pregnancy test and a fetal outline 
D. Braxton Hicks contractions

ANS-A

Rationale: Presumptive signs, such as amenorrhea and quickening, are mostly subjective and may be indicative of other conditions or illnesses. Probable signs are objective but nonconclusive indicators — for example, uterine enlargement, Chadwick's sign, a positive pregnancy test, Braxton Hicks contractions, and Hegar's sign. Positive signs and objective indicators such as fetal outline on ultrasound confirm pregnancy.

.

2.   A pregnant client who is diabetic is at risk for having a large-for-gestational-age infant because of which of the following? 
A. Excess sugar causing reduced placental functioning 
B. Insulin acting as a growth hormone on the fetus 
C.excessive fluid accumilation in tissues

D. inactivity of insulin

ANS-B

 Rationale: Insulin acts as a growth hormone on the fetus. Therefore, pregnant diabetic clients must maintain good glucose control. Large babies are prone to complications and may have to be delivered by cesarean section. Neither excess sugar nor excess insulin reduces placental functioning. A high-calorie diet helps control the mother's disease and doesn't contribute to neonatal size.

3.   Twenty-four hours after birth, a neonate hasn't passed meconium. Noting this, the nurse suspects which condition? 
A. Hirschsprung's disease 
B. Celiac disease 
C. Intussusception 
D. An abdominal wall defect

ANS-A

 Rationale: Failure to pass meconium is an important diagnostic indicator for Hirschsprung's disease. Options B, C, and D aren't associated with failure to pass meconium.

4.   When caring for a client during the second stage of labor, which action would be least appropriate? 
A. Assisting the client with pushing 
B. Ensuring the client's legs are positioned appropriately 
C. Allowing the client clear liquids

D. Monitoring FHR

ANS-C

 Rationale: During this time, the client is usually offered ice chips rather than clear liquids. Nursing care for the client during the second stage of labor should include assisting the mother with pushing, helping position her legs for maximum pushing effectiveness, and monitoring the fetal heart rate.

5.   Which of the following functions would the nurse expect to be unrelated to the placenta? 
A. Production of estrogen and progesterone 
B. Detoxification of some drugs and chemicals 
C. Exchange site for food, gases, and waste 
D. The placenta is responsible for the production of maternal antibodies

ANS-D

 Rationale: Fetal immunities are transferred through the placenta, but the maternal immune system is actually suppressed during pregnancy to prevent maternal rejection of the fetus, which the mother's body considers a foreign protein. Thus,. The placenta produces estrogen and progesterone, detoxifies some drugs and chemicals, and exchanges nutrients and electrolytes.

6.   Which of the following would be least likely to affect the parent-child relationship? 
A. Readiness for the pregnancy 
B. Nature of the pregnancy 
C. Maturity of the parents 
D. Grandparent support

ANS-D

 Rationale: Extended family is important to the social development of the infant but doesn't affect the parent-child relationship. Readiness for pregnancy, a healthy and uncomplicated pregnancy, and parental maturity are factors that promote a positive parent-child relationship.

7.   A breast-feeding neonate will turn his head toward the mother's breast in a natural instinct to find food. What is the name of this reflex? 
A. Tonic neck reflex 
B. Moro's reflex 
C. Grasp reflex 
D. Rooting reflex

ANS-D

Rationale: The rooting reflex is a neonate's response to having his cheek stroked. The neonate will turn his head to the side of the stroked cheek and will open his mouth in anticipation of having a nipple placed in it. The tonic neck reflex is elicited by turning the neonate's head to the side when he's lying on his back. The extremities on the same side extend and those on the other side flex. Moro's reflex is the startle reflex. For example, when the neonate's crib is jolted, the neonate abducts his arms and extends them. The grasp reflex occurs when the neonate curls his fingers around another person's fingers.

8.   When determining maternal and fetal well-being, which assessment is least important? 
A. Signs of postural hypotension 
B. Fetal heart rate and activity 
C. The mother's acceptance of the growing fetus 
D. Signs of facial or digital abnormalities

ANS-A

 Rationale: Postural hypotension doesn't occur until late in the pregnancy and is easily correctable. Collection of other assessment data, such as fetal heart rate and activity, the mother's acceptance of the growing fetus, and signs of edema, should be started early in the pregnancy because abnormalities can put the mother or the fetus at risk for significant physiological and psychological problems.

9.   A neonate receives an Apgar score at 1 and 5 minutes after birth. The 5-minute Apgar score is more predictive for which of the following? 
A. Residual neurologic damage 
B. Residual respiratory depression 
C. Congenital heart defects

D. gestational age of neonate

ANS-A

 Rationale: Apgar scores at 1 and 5 minutes after delivery estimate the severity of respiratory and neurologic depression. Studies have shown a high correlation between a low 5-minute Apgar score and the incidence of residual neurological damage. Apgar scores aren't used to determine the presence of congenital heart defects or the gestational age of the neonate.

and nausea during pregnancy.

10.   Which of the following is the most serious adverse effect associated with oxytocin (Pitocin) administration during labor? 
A. Tetanic contractions 
B. Elevated blood pressure 
C. Early decelerations of fetal heart rate 
D.Dehydration

ANS-A

Rationale: Tetanic contractions are the most serious adverse effect associated with administering oxytocin. When tetanic contractions occur, the fetus is at high risk for hypoxia and the mother is at risk for uterine rupture. The client may be at risk for pulmonary edema if large amounts of oxytocin have been administered, and this drug can also increase blood pressure. However, pulmonary edema and increased blood pressure aren't the most serious adverse effects. Early decelerations of fetal heart rate aren't associated with oxytocin administration.

11.    While caring for pregnant adolescents, the nurse should develop a plan of care that incorporates which health concern? 
A. Age of menarche 
B. Family and home life 
C. Healthy eating habits 
D. Level of emotional maturity

ANS-D

 Rationale: When assessing an adolescent initially, the nurse should try to determine the client's level of emotional maturity. This forms the basis for the nursing plan of care. Age of menarche, family and home life, and healthy eating habits, though important, aren't as significant as determining the emotional maturity of the client.

12.   Which of the following is the most important aspect of nursing care in the postpartum period? 
A. Supporting the mother's ability to successfully feed and care for her neonate 
B. Involving the family in the teaching 
C. Providing group discussions on infant care

D. Lochia monitoring

ANS-A

Rationale: Most of the nursing interventions during the postpartum period are directed toward helping the mother successfully adapt to the parenting role. Although family involvement in teaching, group discussions on infant care, and lochia monitoring are important aspects of care, the mother's ability to feed and care for her infant takes priority.

13.  The uterus returns to the pelvic cavity in which time frame? 
A. 7th to 9th day postpartum 
B. 2 weeks postpartum 
C. End of the 6th week postpartum 
D. When the lochia changes to alba

ANS-A

 Rationale: The normal involutional process returns the uterus to the pelvic cavity in 7 to 9 days. A significant involutional complication is the failure of the uterus to return to the pelvic cavity within the prescribed time period. This is known as subinvolution.

14. A client is admitted to the labor and delivery department in preterm labor. To help manage preterm labor the nurse would expect to administer: 
A. ritodrine (Yutopar). 
B. bromocriptine (Parlodel). 
C. magnesium sulfate. 
D. betamethasone

ANS-A

Rationale: Ritodrine reduces frequency and intensity of uterine contractions by stimulating vitamin B12 receptors in the uterine smooth muscle. It's the drug of choice when trying to inhibit labor. Bromocriptine, a dopamine receptor agonist and an ovulation stimulant, is used to inhibit lactation in the postpartum period. Magnesium sulfate, an anticonvulsant, is used to treat preeclampsia and eclampsia — a life-threatening form of pregnancy-induced hypertension. Betamethasone, a synthetic corticosteroid, is used to stimulate fetal pulmonary surfactant (administered to the mother).

15. A primigravida at 34 weeks' gestation is diagnosed with hydramnios. After delivery of the neonate, a priority for the nurse is to assess the neonate for: 
A. diabetes mellitus. 
B. esophageal atresia. 
C. kidney disorders. 
D. cardiac defects

ANS-B

Rationale: Esophageal fistula and anencephaly are associated with hydramnios, which is an excess of amniotic fluid. Oligohydramnios, or a decreased amount of amniotic fluid, is associated with renal defects. Diabetes mellitus and cardiac defects aren't associated with either oligohydramnios or hydramnios.

16.  When administering magnesium sulfate to a client with preeclampsia, the nurse understands that this drug is given to do which of the following? 
A. Prevent seizures 
B. Reduce blood pressure 
C. Slow the process of labor 
D. increasing diuresis

ANS-A

 Rationale: The chemical makeup of magnesium is similar to that of calcium and, therefore, magnesium will act like calcium in the body. As a result, magnesium will block seizure activity in a hyperstimulated neurologic system by interfering with signal transmission at the neural musculature junction. Reducing blood pressure, slowing labor, and increasing diuresis are secondary effects of magnesium.

17. When assessing a neonate, the nurse observes a vaguely outlined area of scalp edema. Which term should the nurse use when documenting this observation? 
A. Cephalhematoma 
B. Petechiae 
C. Subdural hematoma 
D. Caput succedaneum

ANS-D

 Rationale: Caput succedaneum refers to a vaguely outlined area of scalp edema that crosses the suture lines and typically clears within a few days after birth. Cephalhematoma is a swelling of the head that results from subcutaneous bleeding caused by pressure exerted on the soft tissues during delivery; it's characterized by sharply demarcated boundaries that don't cross the suture lines. Petechiae are minute, circumscribed, hemorrhagic areas of the skin. A subdural hematoma is an accumulation of blood between the dura and the brain tissue.

18.               The nurse is caring for a client in the first 4 weeks of pregnancy. The nurse should expect to collect which assessment findings? 
A. Presence of menses 
B. Uterine enlargement 
C. Breast sensitivity 
D. Fetal heart tones

ANS-C

 Rationale: Breast sensitivity is the only sign assessed within the first 4 weeks of pregnancy. Amenorrhea is expected during this time. The other assessment findings don't occur until after the first 4 weeks of pregnancy.

19.  Which of the following describes the term fetal position? 
A. Relationship of the fetus's presenting part to the mother's pelvis 
B. Fetal posture 
C. Fetal head or breech at cervical os 
D. Relationship of the fetal long axis to

ANS-A

 Rationale: Fetal position refers to the relationship of the fetus's presenting part to the mother's pelvis. Fetal posture refers to "attitude." Presentation refers to the part of the fetus at the cervical os. Lie refers to the relationship of the fetal long axis to that of the mother's long axis.

20.   Which of the following should be the nurse's initial action immediately following the birth of the neonate? 
A. Aspirating mucus from the neonate's nose and mouth 
B. Drying the infant to stabilize the neonate's temperature 
C. Promoting parental bonding

D. identifying the neonate

ANS-B

 Rationale: The nurse's first action is to dry the neonate and stabilize the neonate's temperature. Aspiration of the infant's nose and mouth occurs at the time of delivery. Promoting parental bonding and identifying the neonate are appropriate after the neonate has been dried.

.

21.  Which of the following is not a contributory factor to thermoregulation in the preterm neonate? 
A. Immature central nervous system (CNS) 
B. Large skin surface area 
C. Lack of subcutaneous (S.C.) and brown fat 
D. Tendency toward capillary fragility

ANS-D

Rationale: Tendency toward capillary fragility has nothing to do with thermoregulation. The hypothalamus is the site of temperature regulation. In preterm neonates, the CNS is poorly developed, so these neonates may be more prone to temperature instability. The large skin surface area provides the perfect medium for heat loss through evaporation and convection. Lack of S.C. and brown fat are also contributors to temperature instability. Without S.C. fat, there is nothing to insulate the infant from heat loss. Brown fat provides calories that help with heat production.

.

22.               While receiving phototherapy, a neonate begins to have frequent, loose, watery, green stools and is very irritable. The nurse's interpretation is: 
A. this is a normal adverse effect of phototherapy. 
B. the neonate is developing lactose intolerance

C. malabsorption

D. the neonate's bilirubin is rising to dangerous levels.

ANS-A

 Rationale: Phototherapy increases gastric motility, causing the neonate to have many green, watery stools. The increased gastric motility also causes the neonate to be irritable. There is no evidence that the neonate has a lactose intolerance or malabsorption problem, nor is there evidence that the neonate's bilirubin is rising to dangerous levels.

23.  A 19-year-old primagravida tells the nurse that the physician told her that she needed to increase her intake of thiamine (vitamin B1) in her diet. The nurse should instruct the client to consume more: 
A. milk. 
B. rice. 
C. asparagus.

   D. beef

ANS-A

Rationale: Good sources of thiamin include pork, liver, milk, potatoes, enriched cereals, and enriched breads. Rice, asparagus, and beef aren't good sources of thiamine.

24. Bettine Gonzales is hospitalized for the treatment of severe preecplampsia. Which of the following represents an unusual finding for this condition? 

A.

Generalized edema

B.

Proteinuria 4+

C.

Blood pressure of 160/110

D.

Convulsions

ANS-D

Rationale

Options A, B and C are findings of severe preeclampsia. Convulsions is a finding of eclampsia—an obstetrical emergency

25. The child with phenylketonuria (PKU) must maintain a low phenylalanine diet to prevent which of the following complications? 

A.Irreversible brain damage

B.Kidney failure

C.Blindness

D.Neutropenia

ANS-A

Rationale

The child with PKU must maintain a strict low phenylalanine diet to prevent central nervous system damage, seizures and eventual death.

26. The uterus has already risen out of the pelvis and is experiencing farther into the abdominal area at about the: 

A.8th week of pregnancy

B.10th week of pregnancy

C.12th week of pregnancy

D.18th week of pregnancy

ANS-D

Rationale

On the 8th week of pregnancy, the uterus is still within the pelvic area. On the 10th week, the uterus is still within the pelvic area. On the 12th week, the uterus and placenta have grown, expanding into the abdominal cavity. On the 18th week, the uterus has already risen out of the pelvis and is expanding into the abdominal area.

27. The nurse is preparing Mrs. Jordan for cesarean delivery. Which of the following key concept should the nurse consider when implementing nursing care? 

A.Explain the surgery, expected outcome and kind of anesthetics.

B.Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth.

C.Arrange for a staff member of the anesthesia department to explain what to expect post-operatively.

D.Instruct the mother’s support person to remain in the family lounge until after the delivery.

ANS-B

Rationale

A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching to meet the needs of either planned or emergency cesarean birth, the depth and breadth of instruction will depend on circumstances and time available.

28. Which of the following danger sings should be reported immediately during the antepartum period? 

A.Blurred vision

B.Nasal stuffiness

C.Breast tenderness

D.Constipation

ANS-A

Rationale

Danger signs that require prompt reporting are leaking of amniotic fluid, blurred vision, vaginal bleeding, rapid weight gain and elevated blood pressure. Nasal stuffiness, breast tenderness, and constipation are common discomforts associated with pregnancy.

29. Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester: 

A.Frequency

B.Dysuria

C.Incontinence

D.Burning

ANS-A

Rationale

Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary frequency. Dysuria, incontinence and burning are symptoms associated with urinary tract infection.

30. The infant with Down Syndrome should go through which of the Erikson’s developmental stages first? 

A.Initiative vs. Self doubt

B.Industry vs. Inferiority

C.Autonomy vs. Shame and doubt

D.Trust vs. Mistrust

ANS-D

Rationale

The child with Down syndrome will go through the same first stage, trust vs. mistrust, only at a slow rate. Therefore, the nurse should concentrate on developing on bond between the primary caregiver and the child.

31. Which is true regarding the fontanels of the newborn? 

A.The anterior is large in shape when compared to the posterior fontanel.

B.The anterior is triangular shaped; the posterior is diamond shaped.

C.The anterior is bulging; the posterior appears sunken.

D.The posterior closes at 18 months; the anterior closes at 8 to 12 months.

ANS-A

Rationale

The anterior fontanel is larger in size than the posterior fontanel. Additionally, the anterior fontanel, which is diamond shaped closes at 18 month, whereas the posterior fontanel, which is triangular in shape closes at 8 to 12 weeks. Neither fontanel should appear bulging, which may indicate increases ICP or sunken, which may indicate hydration.

32. Alice, 10 years old was brought to the ER because of Asthma. She was immediately put under aerosol administration of Terbutaline. After sometime, you observe that the child does not show any relief from the treatment given. Upon assessment, you noticed that both the heart and respiratory rate are still elevated and the child shows difficulty of exhaling. You suspect: 

A.Bronchiectasis

B.Atelectasis

C.Epiglotitis

D.Status Asthmaticus

ANS-D

Rationale

Status asthmaticus leads to respiratory distress and bronchospasm despite of treatment and interventions. Mechanical ventilation maybe needed due to respiratory failure.

33. Which age group is with imaginative minds and creates imaginary friends? 

A.Toddler

B.Preschool

C.School

D.Adolescence

ANS-B

Rationale

During preschool, this is the time when children do imitative play, imaginative play—the occurrence of imaginative playmates, dramatic play where children like to act, dance and sing.

34. A client asks the nurse what a third degree laceration is. She was informed that she had one. The nurse explains that this is: 

A.That extended their anal sphincter

B.Through the skin and into the muscles

C.That involves anterior rectal wall

D.That extends through the perineal muscle.

ANS-A

Rationale

Third degree laceration involves all in the second degree laceration and the external sphincter of the rectum. Options B, C and D are under the second degree laceration.

35. Nurse Luis is assessing the newborn’s heart rate. Which of the following would be considered normal if the newborn is sleeping? 

A.80 beats per minute

B.100 beats per minute

C.120 beats per minute

D.140 beats per minute

ANS-B

Rationale

The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute. If the newborn was awake, the normal heart rate would range from 120 to 160 beats per minute.

36. Nurse Jonas assesses a 2 year old boy with a tentative diagnosis of nephroblastoma. Symptoms the nurse observes that suggest this problem include: 

A.Lymphedema and nerve palsy

B.Hearing loss and ataxia

C.Headaches and vomiting

D.Abdominal mass and weakness

ANS-D

Rationale

Nephroblastoma or Wilm’s tumor is caused by chromosomal abnormalities, most common kidney cancer among children characterized by abdominal mass, hematuria, hypertension and fever.

37. Which of the following is the most appropriate intervention to reduce stress in a preterm infant at 33 weeks gestation? 

A.Sensory stimulation including several senses at a time

B.Tactile stimulation until signs of over stimulation develop

C.An attitude of extension when prone or side lying

D.Kangaroo care

ANS-D

Rationale

Kangaroo care is the use of skin-to-skin contact to maintain body heat. This method of care not only supplies heat but also encourages parent-child interaction.

38. Betina 30 weeks AOG discharged with a diagnosis of placenta previa. The nurse knows that the client understands her care at home when she says: 

A.I am happy to note that we can have sex occasionally when I have no bleeding.

B.I am afraid I might have an operation when my due comes

C.I will have to remain in bed until my due date comes

D.I may go back to work since I stay only at the office.

ANS-C

Rationale

Placenta previa means that the placenta is the presenting part. On the first and second trimester there is spotting. On the third trimester there is bleeding that is sudden, profuse and painless.

39. Baby boy Villanueva, 4 months old, was seen at the pediatric clinic for his scheduled check-up. By this period, baby Villanueva has already increased his height by how many inches? 

 

A.3 inches

B.4 inches

C.5 inches

D.6 inches

ANS-B

Rationale

From birth to 6 months, the infant grows 1 inch (2.5 cm) per month. From 6 to 12 months, the infant grows ½ inch (1.25 cm) per month.

40. Which of the following situations would alert you to a potentially developmental problem with a child? 

A.Pointing to body parts at 15 months of age.

B.Using gesture to communicate at 18 months.

C.Cooing at 3 months.

D.Saying “mama” or “dada” for the first time at 18 months of age.

ANS-D

Rationale

A child should say “mama” or “dada” during 10 to 12 months of age. Options A, B and C are all normal assessments of language development of a child.

41. Nurse Geli explains to the client who is 33 weeks pregnant and is experiencing vaginal bleeding that coitus: 

A.Need to be modified in any way by either partner

B.Is permitted if penile penetration is not deep.

C.Should be restricted because it may stimulate uterine activity.

D.Is safe as long as she is in side-lying position.

ANS-C

Rationale

Coitus is restricted when there is watery discharge, uterine contraction and vaginal bleeding. Also those women with a history of spontaneous miscarriage may be advised to avoid coitus during the time of pregnancy when a previous miscarriage occurred.

42. Isabelle, a 2 year old girl loves to move around and oftentimes manifests negativism and temper tantrums. What is the best way to deal with her behavior? 

A.Tell her that she would not be loved by others is she behaves that way..

B.Withholding giving her toys until she behaves properly.

C.Ignore her behavior as long as she does not hurt herself and others.

D.Ask her what she wants and give it to pacify her.

ANS-C

Rationale

If a child is trying to get attention or trying to get something through tantrums—ignore his/her behavior.

43. Nurse Jacob is assessing a 15 month old child with acute otitis media. Which of the following symptoms would the nurse anticipate finding? 

A.Periorbital edema, absent light reflex and translucent tympanic membrane

B.Irritability, purulent drainage in middle ear, nasal congestion and cough

C.Diarrhea, retracted tympanic membrane and enlarged parotid gland

D.Vomiting, pulling at ears and pearly white tympanic membrane

ANS-B

Rationale

Irritability, purulent drainage in middle ear, nasal congestion and cough, fever, loss of appetite, vomiting and diarrhea are clinical manifestations of otitis media. Acute otitis media is common in children 6 months to 3 years old and 8 years old and above. Breast fed infants have higher resistance due to protection of Eustachian tubes and middle ear from breast milk.

44. The parent of a client with albinism would need to be taught which preventive healthcare measure by the nurse: 

A.Ulcerative colitis diet

B.Use of a high-SPF sunblock

C.Hair loss monitoring

D.Monitor for growth retardation

ANS-B

Rationale

Without melanin production, the child with albinism is at risk for severe sunburns. Maximum sun protection should be taken, including use of hats, long sleeves, minimal time in the sun and high-SPF sunblock, to prevent any problems.

45. Mrs. Precilla Abuel, a 32 year old mulripara is admitted to labor and delivery. Her last 3 pregnancies in short stage one of labor. The nurses decide to observe her closely. The physician determines that Mrs. Abuel’s cervix is dilated to 6 cm. Mrs. Abuel states that she is extremely uncomfortable. To lessen Mrs. Abuel’s discomfort, the nurse can advise her to: 

A.Lie face down

B.Not drink fluids

C.Practice holding breaths between contractions

D.Assume Sim’s position

ANS-D

Rationale

When the woman is in Sim’s position, this puts the weight of the fetus on bed, not on the woman and allows good circulation in the lower extremities.

46. During the first hours following delivery, the post partum client is given IVF with oxytocin added to them. The nurse understands the primary reason for this is: 

A.To facilitate elimination

B.To promote uterine contraction

C.To promote analgesia

D.To prevent infection

ANS-B

Rationale

Oxytocin is a hormone produced by the pituitary gland that produces intermittent uterine contractions, helping to promote uterine involution.

47. Which of the following would most likely lead the nurse to suspect that a woman is experiencing postpartum psychosis?

A) Delirium
B) Feelings of guilt
C) Sadness
D) Insomnia

ANS;A
Rationale;

Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. It is manifested by depression that escalates to delirium, hallucinations, anger toward self and infant, bizarre behavior, mania, and thoughts of hurting herself and the infant. Feelings of guilt, sadness, and insomnia are associated with postpartum depression.

48. After teaching a woman with a postpartum infection about care after discharge, which client statement indicates the need for additional teaching?

A) "I need to call my doctor if my temperature goes above 100.4 degrees F."
B) "When I put on a new pad, I'll start at the back and go forward."
C) "If I have chills or my discharge has a strange odor, I'll call my doctor."
D) "I'll point the spray of the peri-bottle so it the water flows front to back."

ANS; B
Rationale;

The woman needs additional teaching when she states that she should apply the perineal pad starting at the back and going forward. The pad should be applied using a front-to-back motion. Notifying the health care provider of a temperature above 100.4 degrees F, aiming the peri-bottle spray so that the flow goes from front to back, and reporting danger signs such as chills or lochia with a strange odor indicate effective teaching.

49. Which of the following would be most appropriate when massaging a woman's fundus?

A) Place the hands on the sides of the abdomen to grasp the uterus.
B) Use an up-and-down motion to massage the uterus.
C) Wait until the uterus is firm to express clots.
D) Continue massaging the uterus for at least 5 minutes.

ANS;C
Rationale;The uterus must be firm before attempts to express clots are made because application of firm pressure on an uncontracted uterus could lead to uterine inversion. One hand is placed on the fundus and the other hand is placed on the area above the symphysis pubis. Circular motions are used for massage. There is no specified amount of time for fundal massage. Uterine tissue responds quickly to touch, so it is important not to overmassage the fundus.

50. While providing care to a woman who is experiencing postpartum hemorrhage, the nurse weighs her perineal pads to estimate blood loss. The pad weighs 20 g. The nurse documents this as which amount?

A) 5 mL
B) 10 mL
C) 15 mL
D) 20 mL

ANS; D
Rationale;

When weighing perineal pads to determine blood loss, 1 gram of pad weight is equivalent to 1 mL of blood loss. A pad that weighs 20 g would indicate a 20-mL blood loss