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Maternity and Womens Health Care 11th Edition by Deitra Leonard Lowdermilk -Test Bank
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Chapter 02: Community Care: The Family and Culture
Lowdermilk: Maternity & Women’s Health Care, 11th Edition
MULTIPLE CHOICE
- A married couple lives in a single-family house with their newborn son and the husband’s daughter from a previous marriage. Based on this information, what family form best describes this family?
| a. | Married-blended family |
| b. | Extended family |
| c. | Nuclear family |
| d. | Same-sex family |
ANS: A
Married-blended families are formed as the result of divorce and remarriage. Unrelated family members join to create a new household. Members of an extended family are kin or family members related by blood, such as grandparents, aunts, and uncles. A nuclear family is a traditional family with male and female partners along with the children resulting from that union. A same-sex family is a family with homosexual partners who cohabit with or without children.
DIF: Cognitive Level: Remember REF: p. 19
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
- Which key factors play the most powerful role in the behaviors of individuals and families?
| a. | Rituals and customs |
| b. | Beliefs and values |
| c. | Boundaries and channels |
| d. | Socialization processes |
ANS: B
Beliefs and values are the most prevalent factors in the decision-making and problem-solving behaviors of individuals and families. This prevalence is particularly true during times of stress and illness. Although culture may play a part in the decision-making process of a family, ultimately, values and beliefs dictate the course of action taken by family members. Boundaries and channels affect the relationship between the family members and the health care team, not the decisions within the family. Socialization processes may help families with interactions within the community, but they are not the criteria used for decision making within the family.
DIF: Cognitive Level: Understand REF: pp. 21-22 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
- Using the family stress theory as an interventional approach for working with families experiencing parenting challenges, the nurse can assist the family in selecting and altering internal context factors. Which statement best describes the components of an internal context?
| a. | Biologic and genetic makeup |
| b. | Maturation of family members |
| c. | Family’s perception of the event |
| d. | Prevailing cultural beliefs of society |
ANS: C
The family stress theory is concerned with the family’s reaction to stressful events. Internal context factors include elements that a family can control such as psychologic defenses, family structure, and philosophic beliefs and values. The family stress theory focuses on ways that families react to stressful events. Maturation of family members is more relevant to the family life-cycle theory. The family stress theory focuses on internal elements that a family might be able to alter.
DIF: Cognitive Level: Understand REF: p. 21 TOP: Nursing Process: Diagnosis
MSC: Client Needs: Psychosocial Integrity
- The nurse is developing a plan of care for a Hispanic client who just delivered a newborn. Which cultural variation is most important to include in the care plan?
| a. | Breastfeeding is encouraged immediately after birth. |
| b. | Male infants are typically circumcised. |
| c. | Maternal grandmother participates in the care of the mother and her infant. |
| d. | Bathing is encouraged immediately after delivery. |
ANS: C
In the Hispanic family, the expectant mother is strongly influenced by her mother or mother-in-law. Breastfeeding is often delayed until the third postpartum day. Hispanic male infants are not usually circumcised. Bathing after delivery is most often delayed.
DIF: Cognitive Level: Apply REF: p. 26 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
- Which health care service represents a primary level of prevention?
| a. | Immunizations |
| b. | Breast self-examination (BSE) |
| c. | Home care for high-risk pregnancies |
| d. | Blood pressure screening |
ANS: A
Primary prevention involves health promotion and disease prevention activities to reduce the occurrence of illness and enhance the general health and quality of life. This level of care includes, for example, immunizations, using infant car seats, and providing health education to prevent tobacco use. BSE is an example of secondary prevention that involves early detection of health problems. Home care for a high-risk pregnancy is an example of tertiary prevention. This level of care follows the occurrence of a defect or disability. Blood pressure screening is an example of secondary prevention and is a screening tool for early detection of a health care problem.
DIF: Cognitive Level: Understand REF: p. 34
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
- What is the primary difference between hospital care and home health care?
| a. | Home care is routinely and continuously delivered by professional staff. |
| b. | Home care is delivered on an intermittent basis by professional staff. |
| c. | Home care is delivered for emergency conditions. |
| d. | Home care is not available 24 hours a day. |
ANS: B
Home care is generally delivered on an intermittent basis by professional staff members. The primary difference between health care in a hospital and home care is the absence of the continuous presence of professional health care providers in a client’s home. In a true emergency, the client should be directed to call 9-1-1 or to report to the nearest hospital’s emergency department. Generally, home health care entails intermittent care by a professional who visits the client’s home for a particular reason and provides on-site care for periods shorter than 4 hours at a time.
DIF: Cognitive Level: Understand REF: pp. 34-35
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
- To provide culturally competent care to an Asian-American family, which question should the nurse include during the assessment interview?
| a. | “Do you prefer hot or cold beverages?” |
| b. | “Do you want some milk to drink?” |
| c. | “Do you want music playing while you are in labor?” |
| d. | “Do you have a name selected for the baby?” |
ANS: A
Asian-Americans often prefer warm beverages. Milk is usually excluded from the diet of this population. Asian-American women typically labor in a quiet environment. Delaying naming the child is not uncommon for Asian-American families.
DIF: Cognitive Level: Apply REF: p. 27
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
- The woman’s family members are present when the nurse arrives for a postpartum and newborn visit. What should the nurse do?
| a. | Observe the family members’ interactions with the newborn and one another. |
| b. | Ask the woman to meet with her and the baby alone. |
| c. | Perform a brief assessment on all family members who are present. |
| d. | Reschedule the visit for another time so that the mother and infant can be privately assessed. |
ANS: A
The nurse should introduce her or himself to the client and to the other family members who are present. Family members in the home may be providing care and assistance to the mother and infant. However, this care may not be based on sound health practices. Nurses should take the opportunity to dispel myths while family members are present. The responsibility of the home care maternal-child nurse is to provide care to the new postpartum mother and to her infant, not to all family members. The nurse can politely ask about the other people in the home and their relationships with the mother. Unless an indication is given that the woman would prefer privacy, the visit may continue.
DIF: Cognitive Level: Analyze REF: p. 35
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
- What is a limitation of a home postpartum visit?
| a. | Distractions limit the nurse’s ability to teach. |
| b. | Identified problems cannot be resolved in the home setting. |
| c. | Necessary items for infant care are not available. |
| d. | Home visits to different families may require the nurse to travel a great distance. |
ANS: D
One limitation of home health visits is the distance the nurse must travel between clients. Driving directions should be obtained by telephone before the visit. The home care nurse is accustomed to distractions but may request that the television be turned off so that attention can be focused on the client and her family. Problems cannot always be resolved; however, appropriate referrals may be arranged by the nurse. The nurse is required to bring any necessary equipment, such as a thermometer, baby scale, or laptop computer, for documentation.
DIF: Cognitive Level: Understand REF: p. 35 TOP: Nursing Process: Planning
MSC: Client Needs: Safe and Effective Care Environment
- During the childbearing experience, which behavior might the nurse expect from an African-American client?
| a. | Seeking prenatal care early in her pregnancy |
| b. | Avoiding self-treatment of pregnancy-related discomfort |
| c. | Requesting liver in the postpartum period to prevent anemia |
| d. | Arriving at the hospital in advanced labor |
ANS: D
African-American women often arrive at the hospital in far-advanced labor and may view pregnancy as a state of wellness, which is often the reason for the delay in seeking prenatal care. African-American women practice many self-treatment options for various discomforts of pregnancy. African-American women may also request liver in the postpartum period, which is based on a belief that liver has a higher blood content.
DIF: Cognitive Level: Understand REF: p. 26
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
- Which resource best describes a health care service representing the tertiary level of prevention?
| a. | Stress management seminars |
| b. | Childbirth education classes for single parents |
| c. | BSE pamphlet and teaching |
| d. | Premenstrual syndrome (PMS) support group |
ANS: D
A PMS support group is an example of tertiary prevention, which follows the occurrence of a defect or disability (e.g., PMS). Stress management seminars are a primary prevention technique for preventing health care issues associated with stress. Childbirth education is a form of primary prevention. BSE information is a form of secondary prevention, which is aimed toward early detection of health problems.
DIF: Cognitive Level: Understand REF: p. 28
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
- When the services of an interpreter are needed, which is the most important factor for the nurse to consider?
| a. | Using a family member who is fluent in both languages |
| b. | Using an interpreter who is certified, and documenting the person’s name in the nursing notes |
| c. | Directing questions only to the interpreter |
| d. | Using an interpreter only in an emergency |
ANS: B
Using a certified interpreter ensures that the standards of care are met and that the information exchanged is reliable and unaltered. The name of the interpreter should be documented for legal purposes. Asking a family member to interpret may not be appropriate, although many health care personnel must adopt this approach in an emergency. Furthermore, most states require that certified interpreters be used when possible. When using an interpreter, the nurse should direct questions to the client. The interpreter is simply a means by which the nurse communicates with the client. Every attempt should be made to contact an interpreter whenever one is needed. During an emergency, health care workers often rely on information interpreted by family members. This information may be private and should be protected under the rules established by the Health Insurance Portability and Accountability Act (HIPAA). Furthermore, family members may skew information or may not be able to interpret the exact information the nurse is trying to obtain.
DIF: Cognitive Level: Apply REF: pp. 24, 25
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
- Which traditional family structure is decreasing in numbers and attributable to societal changes?
| a. | Extended family |
| b. | Binuclear family |
| c. | Nuclear family |
| d. | Blended family |
ANS: C
The nuclear family has long represented the traditional American family in which husband, wife, and children live as an independent unit. As a result of rapid changes in society, this number is steadily decreasing as other family configurations are socially recognized. Extended families involve additional blood relatives other than the parents. A binuclear family involves two households. A blended family is reconstructed after divorce and involves the merger of two families.
DIF: Cognitive Level: Understand REF: p. 18
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
- Which statement regarding the Family Systems Theory is inaccurate?
| a. | Family system is part of a larger suprasystem. |
| b. | Family, as a whole, is equal to the sum of the individual members. |
| c. | Changes in one family member affect all family members. |
| d. | Family is able to create a balance between change and stability. |
ANS: B
A family, as a whole, is greater than the sum of its individual members. The other statements are accurate and can be attributed to the Family Systems Theory.
DIF: Cognitive Level: Understand REF: p. 21
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
- Which pictorial tool can assist the nurse in assessing the aspects of family life related to health care?
| a. | Genogram |
| b. | Ecomap |
| c. | Life-cycle model |
| d. | Human development wheel |
ANS: A
A genogram depicts the relationships of the family members over generations. An ecomap is a graphic portrayal of the social relationships of the woman and her family. The life-cycle model, in no way, illustrates a family genogram; rather, it focuses on the stages that a person reaches throughout life. The human development wheel describes various stages of growth and development rather than the family members’ relationships to each other.
DIF: Cognitive Level: Remember REF: pp. 20-21
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
- When attempting to communicate with a client who speaks a different language, which action is the most appropriate?
| a. | Promptly and positively respond to project authority. |
| b. | Never use a family member as an interpreter. |
| c. | Talk to the interpreter to avoid confusing the client. |
| d. | Provide as much privacy as possible. |
ANS: D
Providing privacy creates an atmosphere of respect and puts the client at ease. The nurse should not rush to judgment and should ensure she or he clearly understands the client’s message. In crisis situations, the nurse may need to use a family member or neighbor as a translator. The nurse should speak directly to the client to create an atmosphere of respect.
DIF: Cognitive Level: Apply REF: p. 24
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
- The secondary level of prevention is best illustrated by which example?
| a. | Approved infant car seats |
| b. | BSE |
| c. | Immunizations |
| d. | Support groups for parents of children with Down syndrome |
ANS: B
Infant car seats are an example of primary prevention. BSE is an example of the secondary level of prevention, which includes health-screening measures for early detection of health problems. Immunizations are an example of the primary level of prevention. Support groups are an example of tertiary prevention, which follows the occurrence of a defect or disability (e.g., Down syndrome).
DIF: Cognitive Level: Understand REF: p. 28 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
- Which key point is important for the nurse to understand regarding the perinatal continuum of care?
| a. | Begins with conception and ends with the birth |
| b. | Begins with family planning and continues until the infant is 1 year old |
| c. | Begins with prenatal care and continues until the newborn is 24 weeks old |
| d. | Refers to home care only |
ANS: B
The perinatal continuum of care begins with family planning and continues until the infant is 1 year old. It takes place both at home and in health care facilities. The perinatal continuum does not end with the birth. The perinatal continuum begins before conception and continues after the birth. Home care is one delivery component; health care facilities are another.
DIF: Cognitive Level: Remember REF: p. 17 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
- What information should the nurse be aware of regarding telephonic nursing care such as warm lines?
| a. | Were developed as a reaction to impersonal telephonic nursing care |
| b. | Were set up to take complaints concerning health maintenance organizations (HMOs) |
| c. | Are the second option when 9-1-1 hotlines are busy |
| d. | Refer to community service telephone lines designed to provide new parents with encouragement and basic information |
ANS: D
Warm lines are one aspect of telephonic nursing care specifically designed to provide new parents with encouragement and basic information. Warm lines and similar services sometimes are set up by HMOs to provide new parents with encouragement and basic information. The name, warm lines, may have been suggested by the term hotlines, but these are not emergency numbers but are designed to provide new parents with encouragement and basic information.
DIF: Cognitive Level: Remember REF: p. 34
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
- When weighing the advantages and disadvantages of planning home care for perinatal services, what information should the nurse use in making the decision?
| a. | Home care for perinatal services is more dangerous for vulnerable neonates at risk of acquiring an infection from the nurse. |
| b. | Home care for perinatal services is more cost-effective for the nurse than office visits. |
| c. | Home care for perinatal services allows the nurse to interact with and include family members in teaching. |
| d. | Home care for perinatal services is made possible by the ready supply of nurses with expertise in maternity care. |
ANS: C
Treating the whole family is an advantage of home care. Forcing neonates out in inclement weather and in public is more risky. Office visits are more cost-effective for the providers such as nurses because less travel time is involved. Unfortunately, home care options are limited by the lack of nurses with expertise in maternity care.
DIF: Cognitive Level: Apply REF: p. 35
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
- In what form do families tend to be the most socially vulnerable?
| a. | Married-blended family |
| b. | Extended family |
| c. | Nuclear family |
| d. | Single-parent family |
ANS: D
The single-parent family tends to be economically and socially vulnerable, creating an unstable and deprived environment for the growth potential of children. The married-blended family, the extended family, and the nuclear family are not the most socially vulnerable.
DIF: Cognitive Level: Understand REF: p. 19 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
- While working in the prenatal clinic, nurses care for a very diverse group of clients. Which cultural factor related to health is most likely to drive acceptance of planned interventions?
| a. | Educational achievement |
| b. | Income level |
| c. | Subcultural group |
| d. | Individual beliefs |
ANS: D
The client’s beliefs are ultimately the key to the acceptance of health care interventions. However, these beliefs may be influenced by factors such as educational level, income level, and ethnic background. Educational achievement, income level, and being part of a subcultural group all are important factors. However, the nurse must understand that a woman’s concerns from her own point of view will have the most influence on her compliance and acceptance of health care interventions.
DIF: Cognitive Level: Apply REF: pp. 21-22 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
- A client’s household consists of her husband, his mother, and another child. To which family configuration does this client belong?
| a. | Multigenerational family |
| b. | Single-parent family |
| c. | Married-blended family |
| d. | Nuclear family |
ANS: A
A multigenerational family includes three or more generations living together. Both parents and a grandparent are living in this extended family. Single-parent families comprise an unmarried biologic or adoptive parent who may or may not be living with other adults. Married-blended families refer to those who are reconstructed after divorce. A nuclear family comprises male and female partners and their children living together as an independent unit.
DIF: Cognitive Level: Apply REF: p. 19
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
- Which term is an accurate description of the process by which people retain some of their own culture while adopting the practices of the dominant society?
| a. | Acculturation |
| b. | Assimilation |
| c. | Ethnocentrism |
| d. | Cultural relativism |
ANS: A
Acculturation is the process by which people retain some of their own culture while adopting the practices of the dominant society. This process takes place over the course of generations. Assimilation is a loss of cultural identity. Ethnocentrism is the belief in the superiority of one’s own culture over the cultures of others. Cultural relativism recognizes the roles of different cultures.
DIF: Cognitive Level: Understand REF: pp. 22-23 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
- In which culture is the father more likely to be expected to participate in the labor and delivery?
| a. | Asian-American |
| b. | African-American |
| c. | European-American |
| d. | Hispanic |
ANS: C
European-Americans expect the father to take a more active role in the labor and delivery of a newborn than the other cultures.
DIF: Cognitive Level: Understand REF: p. 27
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
- Which statement about the development of cultural competence is inaccurate?
| a. | Local health care workers and community advocates can help extend health care to underserved populations. |
| b. | Nursing care is delivered in the context of the client’s culture but not in the context of the nurse’s culture. |
| c. | Nurses must develop an awareness of and a sensitivity to various cultures. |
| d. | Culture’s economic, religious, and political structures influence practices that affect childbearing. |
ANS: B
Although the cultural context of the nurse affects the delivery of nursing care and is very important, the work of local health care workers and community advocates, developing sensitivity to various cultures, and the impact of economic, religious, and political structures are all parts of cultural competence.
DIF: Cognitive Level: Understand REF: pp. 27-28 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
- Which statement accurately describes the walking survey as a data collection tool?
| a. | The walking survey determines how much exercise an expectant mother has been getting, to help her make health care decisions. |
| b. | The walking survey usually takes place on the maternity ward but can be expanded to other areas of the hospital. |
| c. | The walking survey is a method of observing the resources and health-related environment of the community. |
| d. | The walking survey is performed by government census takers as part of their canvas. |
ANS: C
The walking survey is a valuable tool for the nurses in the community and has nothing to do with exercise. It is an observational method used to assess the health environment of the community. A walking survey takes place in the community, not the maternity ward, and is not part of the census; it is conducted by nurses in the community.
DIF: Cognitive Level: Remember REF: p. 30
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
- A Native-American woman gave birth to a baby girl 12 hours ago. The nurse notes that the woman keeps her baby in the bassinet except for bottle feeding and states that she will wait until she gets home to begin breastfeeding. The nurse recognizes that this behavior is most likely a reflection of what?
| a. | Delayed attachment |
| b. | Embarrassment |
| c. | Disappointment in the sex of the baby |
| d. | Belief that babies should not be fed colostrum |
ANS: D
Native Americans often use cradle boards and often avoid handling their newborn. They also believe that the infant should not be fed colostrum. Delayed attachment is a developmental concern, not a cultural belief. Embarrassment is not likely the cause for a delay in the initiation of breastfeeding and should be explored further by the nurse. The mother may voice her disappointment that the infant is a girl; however, this would rarely cause her to delay breastfeeding and would exhibit itself in other ways.
DIF: Cognitive Level: Understand REF: p. 27
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
MULTIPLE RESPONSE
- While completing an assessment of a homeless woman, the nurse should be aware of which of the following ailments this client is at a higher risk to develop? (Select all that apply.)
| a. | Infectious diseases |
| b. | Chronic illness |
| c. | Anemia |
| d. | Hyperthermia |
| e. | Substance abuse |
ANS: A, B, C, E
Poor living conditions contribute to higher rates of infectious disease. Many homeless individuals engage in sexual favors, which may expose them to sexually transmitted infections (STIs). Poor nutrition can lead to anemia. Lifestyle factors also contribute to chronic illness. Exposure to cold temperatures and harsh environmental surroundings may lead to hypothermia. Many homeless people turn to alcohol and other substances as coping mechanisms.
DIF: Cognitive Level: Analyze REF: pp. 32-33
TOP: Nursing Process: Assessment
MSC: Client Needs: Safe and Effective Care Environment
Chapter 04: Assessment and Health Promotion
Lowdermilk: Maternity & Women’s Health Care, 11th Edition
MULTIPLE CHOICE
- Due to the effects of cyclic ovarian changes in the breast, when is the best time for breast self-examination (BSE)?
| a. | Between 5 and 7 days after menses ceases |
| b. | Day 1 of the endometrial cycle |
| c. | Midmenstrual cycle |
| d. | Any time during a shower or bath |
ANS: A
The physiologic alterations in breast size and activity reach their minimal level approximately 5 to 7 days after menstruation ceases. Therefore, BSE is best performed during this phase of the menstrual cycle. Day 1 of the endometrial cycle is too early to perform an accurate BSE. After the midmenstrual cycle, breasts are likely to become tender and increase in size, which is not the ideal time to perform BSE. Lying down after a shower or bath with a small towel under the shoulder of the side being examined is appropriate teaching for BSE. A secondary BSE may be performed while in the shower.
DIF: Cognitive Level: Understand REF: p. 63 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
- Individual irregularities in the ovarian (menstrual) cycle are most often caused by what?
| a. | Variations in the follicular (preovulatory) phase |
| b. | Intact hypothalamic-pituitary feedback mechanism |
| c. | Functioning corpus luteum |
| d. | Prolonged ischemic phase |
ANS: A
Almost all variations in the length of the ovarian cycle are the result of variations in the length of the follicular phase. An intact hypothalamic-pituitary feedback mechanism would be regular, not irregular. The luteal phase begins after ovulation. The corpus luteum is dependent on the ovulatory phase and fertilization. During the ischemic phase, the blood supply to the functional endometrium is blocked, and necrosis develops. The functional layer separates from the basal layer, and menstrual bleeding begins.
DIF: Cognitive Level: Understand REF: pp. 66-67
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
- How would the physiologic process of the sexual response best be characterized?
| a. | Coitus, masturbation, and fantasy |
| b. | Myotonia and vasocongestion |
| c. | Erection and orgasm |
| d. | Excitement, plateau, and orgasm |
ANS: B
Physiologically, according to Masters (1992), sexual response can be analyzed in terms of two processes: vasocongestion and myotonia. Coitus, masturbation, and fantasy are forms of stimulation for the physical manifestation of the sexual response. Erection and orgasm occur in two of the four phases of the sexual response cycle. Excitement, plateau, and orgasm are three of the four phases of the sexual response cycle.
DIF: Cognitive Level: Knowledge REF: p. 68
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
- Which action would be inappropriate for the nurse to perform before beginning the health history interview?
| a. | Smile and ask the client whether she has any special concerns. |
| b. | Speak in a relaxed manner with an even, nonjudgmental tone. |
| c. | Make the client comfortable. |
| d. | Tell the client her questions are irrelevant. |
ANS: D
The woman should be assured that all of her questions are relevant and important. Beginning any client interaction with a smile is important and assists in putting the client at ease. If the nurse speaks in a relaxed manner, then the client will likely be more relaxed during the interview. The client’s comfort should always be ensured before beginning the interview.
DIF: Cognitive Level: Understand REF: pp. 78-79
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
- The nurse guides a woman to the examination room and asks her to remove her clothes and put on an examination gown with the front open. The woman replies, “I have special undergarments that I do not remove for religious reasons.” Which is the most appropriate response from the nurse?
| a. | “You can’t have an examination without removing all your clothes.” |
| b. | “I’ll ask the physician to modify the examination.” |
| c. | “Tell me about your undergarments. I’ll explain the examination procedure, and then we can discuss how you can comfortably have your examination.” |
| d. | “I have no idea how we can accommodate your beliefs.” |
ANS: C
Explaining the examination procedure reflects cultural competence by the nurse and shows respect for the woman’s religious practices. The nurse must respect the rich and unique qualities that cultural diversity brings to individuals. The examination can be modified to ensure that modesty is maintained. In recognizing the value of cultural differences, the nurse can modify the plan of care to meet the needs of each woman. Telling the client that her religious practices are different or strange is inappropriate and disrespectful to the client.
DIF: Cognitive Level: Apply REF: pp. 79-80 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
- A woman arrives at the clinic for her annual examination. She tells the nurse that she thinks she has a vaginal infection, and she has been using an over-the-counter cream for the past 2 days to treat it. How should the nurse initially respond?
| a. | Inform the woman that vaginal creams may interfere with the Papanicolaou (Pap) test for which she is scheduled. |
| b. | Reassure the woman that using vaginal cream is not a problem for the examination. |
| c. | Ask the woman to describe the symptoms that indicate to her that she has a vaginal infection. |
| d. | Ask the woman to reschedule the appointment for the examination. |
ANS: C
An important element of the health history and physical examination is the client’s description of any symptoms she may be experiencing. The best response is for the nurse to inquire about the symptoms the woman is experiencing. Women should not douche, use vaginal medications, or have sexual intercourse for 24 to 48 hours before obtaining a Pap test. Although the woman may need to reschedule a visit for her Pap test, her current symptoms should still be addressed.
DIF: Cognitive Level: Apply REF: p. 79
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
- Preconception and prenatal care have become important components of women’s health. What is the guiding principal of preconception care?
| a. | Ensure that pregnancy complications do not occur. |
| b. | Identify the woman who should not become pregnant. |
| c. | Encourage healthy lifestyles for families desiring pregnancy. |
| d. | Ensure that women know about prenatal care. |
ANS: C
Preconception counseling guides couples in how to avoid unintended pregnancies, how to identify and manage risk factors in their lives and in their environment, and how to identify healthy behaviors that promote the well-being of the woman and her potential fetus. Preconception care does not ensure that pregnancy complications will not occur. In many cases, problems can be identified and treated and may not recur in subsequent pregnancies. For many women, counseling can allow behavior modification before any damage is done, or a woman can make an informed decision about her willingness to accept potential hazards. If a woman is seeking preconception care, then she is likely aware of prenatal care.
DIF: Cognitive Level: Understand REF: p. 69 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
- Ovarian function and hormone production decline during which transitional phase?
| a. | Climacteric |
| b. | Menarche |
| c. | Menopause |
| d. | Puberty |
ANS: A
The climacteric phase is a transitional period during which ovarian function and hormone production decline. Menarche is the term that denotes the first menstruation. Menopause refers only to the last menstrual period. Puberty is a broad term that denotes the entire transitional period between childhood and sexual maturity.
DIF: Cognitive Level: Remember REF: p. 67
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
- Which statement indicates that a client requires additional instruction regarding BSE?
| a. | “Yellow discharge from my nipple is normal if I’m having my period.” |
| b. | “I should check my breasts at the same time each month, after my period.” |
| c. | “I should also feel in my armpit area while performing my breast examination.” |
| d. | “I should check each breast in a set way, such as in a circular motion.” |
ANS: A
Discharge from the nipples requires further examination from a health care provider. The breasts should be checked at the same time each month. The armpit should also be examined. A circular motion is the best method during which to ascertain any changes in the breast tissue.
DIF: Cognitive Level: Analyze REF: p. 63
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
- A blind woman has arrived for an examination. Her guide dog assists her to the examination room. She appears nervous and says, “I’ve never had a pelvic examination.” What response from the nurse would be most appropriate?
| a. | “Don’t worry. It will be over before you know it.” |
| b. | “Try to relax. I’ll be very gentle, and I won’t hurt you.” |
| c. | “Your anxiety is common. I was anxious when I first had a pelvic examination.” |
| d. | “I’ll let you touch each instrument that I’ll use during the examination as I tell you how it will be used.” |
ANS: D
The client who is visually impaired needs to be oriented to the examination room and needs a full explanation of what the examination entails before the nurse proceeds. Telling the client that the examination will be over quickly diminishes the client’s concerns. The nurse should openly and directly communicate with sensitivity. Women who have physical disabilities should be respected and involved in the assessment and physical examination to the full extent of their abilities. Telling the client that she will not be hurt does not reflect respect or sensitivity. Although anxiety may be common, the nurse should not discuss her own issues nor compare them to the client’s concerns.
DIF: Cognitive Level: Apply REF: p. 80 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
- Which female reproductive organ(s) is(are) responsible for cyclic menstruation?
| a. | Uterus |
| b. | Ovaries |
| c. | Vaginal vestibule |
| d. | Urethra |
ANS: A
The uterus is responsible for cyclic menstruation and also houses and nourishes the fertilized ovum and the fetus. The ovaries are responsible for ovulation and the production of estrogen. The vaginal vestibule is an external organ that has openings to the urethra and vagina. The urethra is not a reproductive organ, although it is found in the area.
DIF: Cognitive Level: Remember REF: p. 60
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
- Which body part both protects the pelvic structures and accommodates the growing fetus during pregnancy?
| a. | Perineum |
| b. | Bony pelvis |
| c. | Vaginal vestibule |
| d. | Fourchette |
ANS: B
The bony pelvis protects and accommodates the growing fetus. The perineum covers the pelvic structures. The vaginal vestibule contains openings to the urethra and vagina. The fourchette is formed by the labia minor.
DIF: Cognitive Level: Knowledge REF: p. 62
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
- Which phase of the endometrial cycle best describes a heavy, velvety soft, fully matured endometrium?
| a. | Menstrual |
| b. | Proliferative |
| c. | Secretory |
| d. | Ischemic |
ANS: C
The secretory phase extends from the day of ovulation to approximately 3 days before the next menstrual cycle. During this secretory phase, the endometrium becomes fully mature again. During the menstrual phase, the endometrium is shed. The proliferative phase is a period of rapid growth. During the ischemic phase, the blood supply is blocked and necrosis develops.
DIF: Cognitive Level: Understand REF: p. 67
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
- Which part of the menstrual cycle includes the stimulated release of gonadotropin-releasing hormone (GnRH) and follicle-stimulating hormone (FSH)?
| a. | Menstrual phase |
| b. | Endometrial cycle |
| c. | Ovarian cycle |
| d. | Hypothalamic-pituitary cycle |
ANS: D
The cyclic release of hormones is the function of the hypothalamus and pituitary glands. The menstrual cycle is a complex interplay of events that simultaneously occur in the endometrium, hypothalamus, pituitary glands, and ovaries. The endometrial cycle consists of four phases: menstrual phase, proliferative phase, secretory phase, and ischemic phase. The ovarian cycle remains under the influence of FSH and estrogen.
DIF: Cognitive Level: Remember REF: pp. 65-66
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
- What fatty acids (classified as hormones) are found in many body tissues with complex roles in many reproductive functions?
| a. | GnRH |
| b. | Prostaglandins (PGs) |
| c. | FSH |
| d. | Luteinizing hormone (LH) |
ANS: B
PGs affect smooth muscle contraction and changes in the cervix. GnRH is part of the hypothalamic-pituitary cycle, which responds to the rise and fall of estrogen and progesterone. FSH is part of the hypothalamic-pituitary cycle, which responds to the rise and fall of estrogen and progesterone. LH is part of the hypothalamic-pituitary cycle, which responds to the rise and fall of estrogen and progesterone.
DIF: Cognitive Level: Remember REF: p. 67
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
- Which information regarding substance abuse is important for the nurse to understand?
| a. | Although cigarette smoking causes a number of health problems, it has little direct effect on maternity-related health. |
| b. | Women, ages 21 to 34 years, have the highest rates of specific alcohol-related problems. |
| c. | Coffee is a stimulant that can interrupt body functions and has been related to birth defects. |
| d. | Prescription psychotherapeutic drugs taken by the mother do not affect the fetus; otherwise, they would not have been prescribed. |
ANS: B
Although a very small percentage of childbearing women have alcohol-related problems, alcohol abuse during pregnancy has been associated with a number of negative outcomes. Cigarette smoking impairs fertility and is a cause of low-birth-weight infants. Caffeine consumption has not been related to birth defects. Psychotherapeutic drugs have some effect on the fetus, and that risk must be weighed against their benefit to the mother.
DIF: Cognitive Level: Understand REF: p. 74
TOP: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
- As part of their participation in the gynecologic portion of the physical examination, which approach should the nurse take?
| a. | Take a firm approach that encourages the client to facilitate the examination by following the physician’s instructions exactly. |
| b. | Explain the procedure as it unfolds, and continue to question the client to get information in a timely manner. |
| c. | Take the opportunity to explain that the trendy vulvar self-examination is only for women at risk for developing cancer. |
| d. | Help the woman relax through the proper placement of her hands and proper breathing during the examination. |
ANS: D
Breathing techniques are important relaxation techniques that can help the client during the examination. The nurse should encourage the client to participate in an active partnership with the health care provider. Explanations during the procedure are fine, but many women are uncomfortable answering questions in the exposed and awkward position of the examination. Vulvar self-examination on a regular basis should be encouraged and taught during the examination.
DIF: Cognitive Level: Apply REF: p. 83
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
- Which statement best describes Kegel exercises?
| a. | Kegel exercises were developed to control or reduce incontinent urine loss. |
| b. | Kegel exercises are the best exercises for a pregnant woman because they are so pleasurable. |
| c. | Kegel exercises help manage stress. |
| d. | Kegel exercises are ineffective without sufficient calcium in the diet. |
ANS: A
Kegel exercises help control the urge to urinate. Although these exercises may be fun for some, the most important factor is the control they provide over incontinence. Kegel exercises help manage urination, not stress. Calcium in the diet is important but not related to Kegel exercises.
DIF: Cognitive Level: Remember REF: p. 92 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
- The microscopic examination of scrapings from the cervix, endocervix, or other mucous membranes to detect premalignant or malignant cells is called what?
| a. | Bimanual palpation |
| b. | Rectovaginal palpation |
| c. | Papanicolaou (Pap) test |
| d. | Four As procedure |
ANS: C
The Pap test is a microscopic examination for cancer that should be regularly performed, depending on the client’s age. Bimanual palpation is a physical examination of the vagina. Rectovaginal palpation is a physical examination performed through the rectum. The four As procedure is an intervention to help a client stop smoking.
DIF: Cognitive Level: Remember REF: p. 86
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
- Which questionnaire would be best for the nurse to use when screening an adolescent client for an eating disorder?
| a. | Four Cs |
| b. | Dietary Guidelines for Americans |
| c. | SCOFF screening tool |
| d. | Dual-energy x-ray absorptiometry (DEXA) scan |
ANS: C
A screening tool specifically developed to identify eating disorders uses the acronym SCOFF. Each question scores 1 point. A score of 2 or more indicates that the client may have anorexia nervosa or bulimia. The letters represent the following questions:
- Do you make yourself Sick because you feel too full?
- Do you worry about loss of Control over the amount that you eat?
- Have you recently lost more than One stone (14 pounds) in a 3-month period?
- Do you think that you are too Fat, even if others think you are thin?
- Does Food dominate your life?
The 4 Cs are used to determine cultural competence. Dietary Guidelines for Americans provide nutritional guidance for all, not only for those with eating disorders. The DEXA scan is used to determine bone density.
DIF: Cognitive Level: Apply REF: p. 75 TOP: Nursing Process: Diagnosis
MSC: Client Needs: Health Promotion and Maintenance
- The unique muscle fibers that constitute the uterine myometrium make it ideally suited for what?
| a. | Menstruation |
| b. | Birth process |
| c. | Ovulation |
| d. | Fertilization |
ANS: B
The myometrium is made up of layers of smooth muscle that extend in three directions. These muscles assist in the birth process by expelling the fetus, ligating blood vessels after birth, and controlling the opening of the cervical os.
DIF: Cognitive Level: Apply REF: pp. 60-61
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
- Which hormone is responsible for the maturation of mammary gland tissue?
| a. | Estrogen |
| b. | Testosterone |
| c. | Prolactin |
| d. | Progesterone |
ANS: D
Progesterone causes maturation of the mammary gland tissue, specifically acinar structures of the lobules. Estrogen increases the vascularity of the breast tissue. Testosterone has no bearing on breast development. Prolactin is produced after birth and released from the pituitary gland; it is produced in response to infant suckling and an emptying of the breasts.
DIF: Cognitive Level: Remember REF: p. 62
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
- What is the goal of a long-term treatment plan for an adolescent with an eating disorder?
| a. | Managing the effects of malnutrition |
| b. | Establishing sufficient caloric intake |
| c. | Improving family dynamics |
| d. | Restructuring client perception of body image |
ANS: D
The treatment of eating disorders is initially focused on reestablishing physiologic homeostasis. Once body systems are stabilized, the next goal of treatment for eating disorders is maintaining adequate caloric intake. Although family therapy is indicated when dysfunctional family relationships exist, the primary focus of therapy for eating disorders is to help the adolescent cope with complex issues. The focus of treatment in individual therapy for an eating disorder involves restructuring cognitive perceptions about the individual’s body image.
DIF: Cognitive Level: Apply REF: p. 75
TOP: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
- A 62-year-old woman has not been to the clinic for an annual examination for 5 years. The recent death of her husband reminded her that she should come for a visit. Her family physician has retired, and she is going to see the women’s health nurse practitioner for her visit. What should the nurse do to facilitate a positive health care experience for this client?
| a. | Remind the woman that she is long overdue for her examination and that she should come in annually. |
| b. | Carefully listen, and allow extra time for this woman’s health history interview. |
| c. | Reassure the woman that a nurse practitioner is just as good as her old physician. |
| d. | Encourage the woman to talk about the death of her husband and her fears about her own death. |
ANS: B
The nurse has an opportunity to use reflection and empathy while listening, as well as ensure an open and caring communication. Scheduling a longer appointment time may be necessary because older women may have longer histories or may need to talk. A respectful and reassuring approach to caring for women older than age 50 years can help ensure that they continue to seek health care. Reminding the woman about her overdue examination, reassuring the woman that she has a good practitioner, and encouraging conversation about the death of her husband and her own death are not the best approaches.
DIF: Cognitive Level: Apply REF: pp. 78-79 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
- During a health history interview, a woman states that she thinks that she has “bumps” on her labia. She also states that she is not sure how to check herself. The correct response by the nurse would be what?
| a. | Reassure the woman that the examination will reveal any problems. |
| b. | Explain the process of vulvar self-examination, and reassure the woman that she should become familiar with normal and abnormal findings during the examination. |
| c. | Reassure the woman that “bumps” can be treated. |
| d. | Reassure her that most women have “bumps” on their labia. |
ANS: B
During the assessment and evaluation, the responsibility for self-care, health promotion, and enhancement of wellness is emphasized. The pelvic examination provides a good opportunity for the practitioner to emphasize the need for regular vulvar self-examination. Providing reassurance to the woman concerning the “bumps” would not be an accurate response.
DIF: Cognitive Level: Apply REF: p. 86
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
- Which statement regarding female sexual response is inaccurate?
| a. | Women and men are more alike than different in their physiologic response to sexual arousal and orgasm. |
| b. | Vasocongestion is the congestion of blood vessels. |
| c. | Orgasmic phase is the final state of the sexual response cycle. |
| d. | Facial grimaces and spasms of the hands and feet are often part of arousal. |
ANS: C
The final state of the sexual response cycle is the resolution phase after orgasm. Men and women are surprisingly alike. Vasocongestion causes vaginal lubrication and engorgement of the genitals. Arousal is characterized by increased muscular tension (myotonia).
DIF: Cognitive Level: Remember REF: p. 68
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
- A client at 24 weeks of gestation says she has a glass of wine with dinner every evening. Why should the nurse counsel her to eliminate all alcohol intake?
| a. | Daily consumption of alcohol indicates a risk for alcoholism. |
| b. | She is at risk for abusing other substances as well. |
| c. | Alcohol places the fetus at risk for altered brain growth. |
| d. | Alcohol places the fetus at risk for multiple organ anomalies. |
ANS: C
No period during pregnancy is safe to consume alcohol. The documented effects of alcohol consumption during pregnancy include fetal mental retardation, learning disabilities, high activity level, and short attention span. The fetal brain grows most rapidly in the third trimester and is vulnerable to alcohol exposure during this time. Abuse of other substances has not been linked to alcohol use.
DIF: Cognitive Level: Understand REF: p. 74
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
- Which statement by the client indicates that she understands BSE?
| a. | “I will examine both breasts in two different positions.” |
| b. | “I will examine my breasts 1 week after my menstrual period starts.” |
| c. | “I will examine only the outer upper area of the breast.” |
| d. | “I will use the palm of the hand to perform the examination.” |
ANS: B
The woman should examine her breasts when hormonal influences are at their lowest level. The client should be instructed to use four positions: standing with arms at her sides, standing with arms raised above her head, standing with hands pressed against hips, and lying down. The entire breast needs to be examined, including the outer upper area. The client should use the sensitive pads of the middle three fingers.
DIF: Cognitive Level: Analyze REF: p. 63 TOP: Nursing Process: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
- What is the primary reason why a woman who is older than 35 years may have difficulty achieving pregnancy?
| a. | Personal risk behaviors influence fertility. |
| b. | Mature women have often used contraceptives for an extended time. |
| c. | Her ovaries may be affected by the aging process. |
| d. | Prepregnancy medical attention is lacking. |
ANS: C
Once the mature woman decides to conceive, a delay in becoming pregnant may occur because of the normal aging of the ovaries. Older adults participate in fewer risk behaviors than younger adults. The past use of contraceptives is not the problem. Prepregnancy medical care is both available and encouraged.
DIF: Cognitive Level: Knowledge REF: p. 73
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
- What is the most dangerous effect on the fetus of a mother who smokes cigarettes while pregnant?
| a. | Genetic changes and anomalies |
| b. | Extensive central nervous system damage |
| c. | Fetal addiction to the substance inhaled |
| d. | Intrauterine growth restriction |
ANS: D
The major consequences of smoking tobacco during pregnancy are low-birth-weight infants, prematurity, and increased perinatal loss. Cigarettes will not normally cause genetic changes or extensive central nervous system damage. Addiction to tobacco is not usually a concern related to the neonate.
DIF: Cognitive Level: Comprehend REF: p. 74
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
MULTIPLE RESPONSE
- What are the two primary functions of the ovary? (Select all that apply.)
| a. | Normal female development |
| b. | Ovulation |
| c. | Sexual response |
| d. | Hormone production |
| e. | Sex hormone release |
ANS: B, D
The two functions of the ovaries are ovulation and hormone production. The presence of ovaries does not guarantee normal female development. The ovaries produce estrogen, progesterone, and androgen. Ovulation is the release of a mature ovum from the ovary. Sexual response is a feedback mechanism involving the hypothalamus, anterior pituitary gland, and ovaries.
DIF: Cognitive Level: Apply REF: p. 62
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
- Which statements regarding menstruation (periodic uterine bleeding) are accurate? (Select all that apply.)
| a. | Menstruation occurs every 28 days. |
| b. | During menstruation, the entire uterine lining is shed. |
| c. | Menstruation begins 7 to 10 days after ovulation. |
| d. | Menstruation leads to fertilization. |
| e. | Average blood loss during menstruation is 50 ml. |
ANS: A, B, E
Menstruation is the periodic uterine bleeding that is controlled by a feedback system involving three cycles: the endometrial cycle, the hypothalamic-pituitary cycle, and the ovarian cycle. The average length of a menstrual cycle is 28 days; however, variations are normal. During the endometrial cycle, the functional two thirds of the endometrium is shed. The average blood loss is 50 ml with a normal range of 20 to 80 ml. Menstruation occurs 14 days after ovulation. The lack of fertilization leads to menstruation.
DIF: Cognitive Level: Apply REF: p. 65
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
- Women of all ages will receive substantial and immediate benefits from smoking cessation. The process is not easy, and most people have attempted to quit numerous times before achieving success. Which organizations provide self-help and smoking cessation materials? (Select all that apply.)
| a. | Leukemia and Lymphoma Society |
| b. | March of Dimes |
| c. | American Cancer Society |
| d. | American Lung Association |
| e. | Easter Seals |
ANS: B, C, D
The March of Dimes, the American Lung Association, and the American Cancer Society have self-help materials available. The Leukemia and Lymphoma Society support research for these two types of cancer. Easter Seals is best known for its work with disabled children.
DIF: Cognitive Level: Apply REF: p. 93 TOP: Nursing Process: Planning
MSC: Client Needs: Psychosocial Integrity
- Many pregnant teenagers wait until the second or third trimester to seek prenatal care. What should the nurse recognize as reasons for this delay? (Select all that apply.)
| a. | Lack of realization that they are pregnant |
| b. | Uncertainty as to where to go for care |
| c. | Continuing to deny the pregnancy |
| d. | Desire to gain control over their situation |
| e. | Wanting to hide the pregnancy as long as possible |
ANS: A, B, C, E
These reasons are all valid explanations why teens delay seeking prenatal care. An adolescent often has little to no understanding of the increased physiologic needs that a pregnancy places on her body. Once care is sought, it is often sporadic, and many appointments are usually missed. The nurse should formulate a diagnosis that assists the pregnant teen to receive adequate prenatal care. Planning for her pregnancy and impending birth actually provides some sense of control for the teen and increases her feelings of competency. Receiving praise from the nurse when she attends her prenatal appointments will reinforce the teen’s positive self-image.
DIF: Cognitive Level: Analyze REF: pp. 72-73 TOP: Nursing Process: Diagnosis
MSC: Client Needs: Psychosocial Integrity
MATCHING
To promote wellness and prevent illness throughout the life span, it is important for the nurse to be cognizant of immunization recommendations for women older than 18 years. Match each immunization with the correct schedule.
| a. | Tetanus-diphtheria-pertussis (Tdap) |
| b. | Measles, mumps, rubella |
| c. | Herpes zoster |
| d. | Hepatitis B |
| e. | Influenza |
| f. | Human papillomavirus (HPV) |
- Three injections for girls between the ages 9 to 26 years
- Primary series of three injections
- Annually
- Once and then a booster every 10 years
- One dose after age 65 years
- Once if born after 1956
- ANS: F DIF: Cognitive Level: Apply REF: pp. 90-91
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
NOT: This guideline is applicable to most women; however, health care providers individualize the timing of tests and immunizations for each woman.
- ANS: D DIF: Cognitive Level: Apply REF: pp. 90-91
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
NOT: This guideline is applicable to most women; however, health care providers individualize the timing of tests and immunizations for each woman.
- ANS: E DIF: Cognitive Level: Apply REF: pp. 90-91
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
NOT: This guideline is applicable to most women; however, health care providers individualize the timing of tests and immunizations for each woman.
- ANS: A DIF: Cognitive Level: Apply REF: pp. 90-91
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
NOT: This guideline is applicable to most women; however, health care providers individualize the timing of tests and immunizations for each woman.
- ANS: C DIF: Cognitive Level: Apply REF: pp. 90-91
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
NOT: This guideline is applicable to most women; however, health care providers individualize the timing of tests and immunizations for each woman.
- ANS: B DIF: Cognitive Level: Apply REF: pp. 90-91
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
NOT: This guideline is applicable to most women; however, health care providers individualize the timing of tests and immunizations for each woman.
Chapter 25: Newborn Nutrition and Feeding
Lowdermilk: Maternity & Women’s Health Care, 11th Edition
MULTIPLE CHOICE
- A new mother recalls from prenatal class that she should try to feed her newborn daughter when she exhibits feeding readiness cues rather than waiting until the baby is frantically crying. Which feeding cue would indicate that the baby is ready to eat?
| a. | Waves her arms in the air |
| b. | Makes sucking motions |
| c. | Has the hiccups |
| d. | Stretches out her legs straight |
ANS: B
Sucking motions, rooting, mouthing, and hand-to-mouth motions are examples of feeding readiness cues. Waving her arms in the air, having the hiccups, and stretching out her extremities are not typical feeding readiness cues.
DIF: Cognitive Level: Understand REF: p. 609 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
- A pregnant woman wants to breastfeed her infant; however, her husband is not convinced that there are any scientific reasons to do so. The nurse can give the couple printed information comparing breastfeeding and bottle feeding. Which statement regarding bottle feeding using commercially prepared infant formulas might influence their choice?
| a. | Bottle feeding using a commercially prepared formula increases the risk that the infant will develop allergies. |
| b. | Bottle feeding helps the infant sleep through the night. |
| c. | Commercially prepared formula ensures that the infant is getting iron in a form that is easily absorbed. |
| d. | Bottle feeding requires that multivitamin supplements be given to the infant. |
ANS: A
Exposure to cow’s milk poses a risk of developing allergies, eczema, and asthma. Newborns should be fed during the night, regardless of the feeding method. Iron is better absorbed from breast milk than from formula. Commercial formulas are designed to meet the nutritional needs of the infant and to resemble breast milk. No supplements are necessary.
DIF: Cognitive Level: Apply REF: p. 602 TOP: Nursing Process: Diagnosis
MSC: Client Needs: Physiologic Integrity, Basic Care and Comfort
- A postpartum woman telephones the provider regarding her 5-day-old infant. The client is not scheduled for another weight check until the infant is 14 days old. The new mother is worried about whether breastfeeding is going well. Which statement indicates that breastfeeding is effective for meeting the infant’s nutritional needs?
| a. | Sleeps for 6 hours at a time between feedings |
| b. | Has at least one breast milk stool every 24 hours |
| c. | Gains 1 to 2 ounces per week |
| d. | Has at least six to eight wet diapers per day |
ANS: D
After day 4, when the mother’s milk comes in, the infant should have six to eight wet diapers every 24 hours. Typically, infants sleep 2 to 4 hours between feedings, depending on whether they are being fed on a 2- to 3-hour schedule or cluster-fed. The infant’s sleep pattern is not an indication whether the infant is breastfeeding well. The infant should have a minimum of three bowel movements in a 24-hour period. Breastfed infants typically gain 15 to 30 g/day.
DIF: Cognitive Level: Understand REF: pp. 613-614 TOP: Nursing Process: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
- A primiparous woman is delighted with her newborn son and wants to begin breastfeeding as soon as possible. How should the client be instructed to position the infant to facilitate correct latch-on?
| a. | The infant should be positioned with his or her arms folded together over the chest. |
| b. | The infant should be curled up in a fetal position. |
| c. | The woman should cup the infant’s head in her hand. |
| d. | The infant’s head and body should be in alignment with the mother. |
ANS: D
The infant’s head and body should be in correct alignment with the mother and the breast during latch-on and feeding. The infant should be facing the mother with his arms hugging the breast. The baby’s body should be held in correct alignment (i.e., ears, shoulder, and hips in a straight line) during feedings. The mother should support the baby’s neck and shoulders with her hand and not push on the occiput.
DIF: Cognitive Level: Apply REF: p. 610
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
- A breastfeeding woman develops engorged breasts at 3 days postpartum. What action will help this client achieve her goal of reducing the engorgement?
| a. | Skip feedings to enable her sore breasts to rest. |
| b. | Avoid using a breast pump. |
| c. | Breastfeed her infant every 2 hours. |
| d. | Reduce her fluid intake for 24 hours. |
ANS: C
The mother should be instructed to attempt feeding her infant every 2 hours while massaging the breasts as the infant is feeding. Skipping feedings may cause further swelling and discomfort. If the infant does not adequately feed and empty the breast, then the mother may pump to extract the milk and relieve some of the discomfort. Dehydration further irritates swollen breast tissue.
DIF: Cognitive Level: Understand REF: p. 623
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
- At a 2-month well-baby examination, it was discovered that an exclusively breastfed infant had only gained 10 ounces in the past 4 weeks. The mother and the nurse develop a feeding plan for the infant to increase his weight gain. Which change in dietary management will assist the client in meeting this goal?
| a. | Begin solid foods. |
| b. | Have a bottle of formula after every feeding. |
| c. | Have one extra breastfeeding session every 24 hours. |
| d. | Start iron supplements. |
ANS: C
Usually the solution to slow weight gain is to improve the feeding technique. Position and the latch-on technique are evaluated, and adjustments are made. Adding a feeding or two within a 24-hour period might help. Solid foods should not be introduced to an infant for at least 4 to 6 months. Bottle feeding may cause nipple confusion and may limit the supply of milk. Iron supplements have no bearing on weight gain.
DIF: Cognitive Level: Apply REF: p. 615
TOP: Nursing Process: Planning | Nursing Process: Implementation
MSC: Client Needs: Physiologic Integrity
- Parents have been asked by the neonatologist to provide breast milk for their newborn son, who was born prematurely at 32 weeks of gestation. The nurse who instructs them regarding pumping, storing, and transporting the milk needs to assess their knowledge of lactation. Which statement is valid?
| a. | Premature infants more easily digest breast milk than formula. |
| b. | A glass of wine just before pumping will help reduce stress and anxiety. |
| c. | The mother should only pump as much milk as the infant can drink. |
| d. | The mother should pump every 2 to 3 hours, including during the night. |
ANS: A
Human milk is the ideal food for preterm infants, with benefits that are unique, in addition to those benefits received by full-term, healthy infants. Greater physiologic stability occurs with breastfeeding, compared with formula feeding. Consumption of alcohol during lactation is approached with caution. Excessive amounts can have serious effects on the infant and can adversely affect the mother’s milk ejection reflex. To establish an optimal milk supply, the most appropriate instruction for the mother should be to pump 8 to 10 times a day for 10 to 15 minutes on each breast.
DIF: Cognitive Level: Analyze REF: p. 616 TOP: Nursing Process: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
- A new mother wants to be sure that she is meeting her daughter’s needs while feeding the baby commercially prepared infant formula. The nurse should evaluate the mother’s knowledge about appropriate infant feeding techniques. Which statement by the client reassures the nurse that correct learning has taken place?
| a. | “Since reaching 2 weeks of age, I add rice cereal to my daughter’s formula to ensure adequate nutrition.” |
| b. | “I warm the bottle in my microwave oven.” |
| c. | “I burp my daughter during and after the feeding as needed.” |
| d. | “I refrigerate any leftover formula for the next feeding.” |
ANS: C
Most infants swallow air when fed from a bottle and should be given a chance to burp several times during and after the feeding. Solid food should not be introduced to the infant for at least 4 to 6 months after birth. A microwave should never be used to warm any food to be given to an infant. The heat is not distributed evenly, which may pose a risk of burning the infant. Any formula left in the bottle after the feeding should be discarded because the infant’s saliva has mixed with it.
DIF: Cognitive Level: Understand REF: p. 626 TOP: Nursing Process: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
- A nurse is discussing the storage of breast milk with a mother whose infant is preterm and in the special care nursery. Which statement indicates that the mother requires additional teaching?
| a. | “I can store my breast milk in the refrigerator for 3 months.” |
| b. | “I can store my breast milk in the freezer for 3 months.” |
| c. | “I can store my breast milk at room temperature for 4 hours.” |
| d. | “I can store my breast milk in the refrigerator for 3 to 5 days.” |
ANS: A
Breast milk for the hospitalized infant can be stored in the refrigerator for only 8 days, not for 3 months. Breast milk can be stored in the freezer for 3 months, in a deep freezer for 6 months, or at room temperature for 4 hours. Human milk for the healthy or preterm hospitalized infant can be kept in the refrigerator for up to 8 days or in the freezer for up to 3 months, but only for 4 hours or less at room temperature.
DIF: Cognitive Level: Analyze REF: p. 618 TOP: Nursing Process: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
- A new mother asks the nurse what the “experts say” about the best way to feed her infant. Which recommendation of the American Academy of Pediatrics (AAP) regarding infant nutrition should be shared with this client?
| a. | Infants should be given only human milk for the first 6 months of life. |
| b. | Infants fed on formula should be started on solid food sooner than breastfed infants. |
| c. | If infants are weaned from breast milk before 12 months, then they should receive cow’s milk, not formula. |
| d. | After 6 months, mothers should shift from breast milk to cow’s milk. |
ANS: A
Breastfeeding and human milk should also be the sole source of milk for the first 12 months, not for only the first 6 months. Infants should be started on solids when they are ready, usually at 6 months, whether they start on formula or breast milk. If infants are weaned from breast milk before 12 months, then they should receive iron-fortified formula, not cow’s milk.
DIF: Cognitive Level: Apply REF: p. 601 TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
- Which statement is the best rationale for recommending formula over breastfeeding?
| a. | Mother has a medical condition or is taking drugs that could be passed along to the infant via breast milk. |
| b. | Mother lacks confidence in her ability to breastfeed. |
| c. | Other family members or care providers also need to feed the baby. |
| d. | Mother sees bottle feeding as more convenient. |
ANS: A
Breastfeeding is contraindicated when mothers have certain viruses, tuberculosis, are undergoing chemotherapy, or are using or abusing drugs. Some women lack confidence in their ability to produce breast milk of adequate quantity or quality. The key to encouraging these mothers to breastfeed is anticipatory guidance beginning as early as possible during the pregnancy. A major barrier for many women is the influence of family and friends. She may view formula feeding as a way to ensure that the father and other family members can participate. Each encounter with the family is an opportunity for the nurse to educate, dispel myths, and clarify information regarding the benefits of breastfeeding. Many women see bottle feeding as more convenient and less embarrassing than breastfeeding. They may also see breastfeeding as incompatible with an active social life. Although modesty issues related to feeding the infant in public may exist, these concerns are not legitimate reasons to formula-feed an infant. Often, the decision to formula feed rather than breastfeed is made without complete information regarding the benefits of breastfeeding.
DIF: Cognitive Level: Understand REF: p. 603 TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
- Which statement regarding the nutrient needs of breastfed infants is correct?
| a. | Breastfed infants need extra water in hot climates. |
| b. | During the first 3 months, breastfed infants consume more energy than formula-fed infants. |
| c. | Breastfeeding infants should receive oral vitamin D drops daily during at least the first 2 months. |
| d. | Vitamin K injections at birth are not necessary for breastfed infants. |
ANS: C
Human milk contains only small amounts of vitamin D. All infants who are breastfed should receive 400 International Units of vitamin D each day. Neither breastfed nor formula-fed infants need to be fed water, not even in very hot climates. During the first 3 months, formula-fed infants consume more energy than breastfed infants and therefore tend to grow more rapidly. Vitamin K shots are required for all infants because the bacteria that produce it are absent from the baby’s stomach at birth.
DIF: Cognitive Level: Understand REF: p. 605 TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
- The nurse should be cognizant of which statement regarding the unique qualities of human breast milk?
| a. | Frequent feedings during predictable growth spurts stimulate increased milk production. |
| b. | Milk of preterm mothers is the same as the milk of mothers who gave birth at term. |
| c. | Milk at the beginning of the feeding is the same as the milk at the end of the feeding. |
| d. | Colostrum is an early, less concentrated, less rich version of mature milk. |
ANS: A
Growth spurts (at 10 days, 3 weeks, 6 weeks, and 3 months) usually last 24 to 48 hours, after which the infants resume normal feeding. The milk of mothers of preterm infants is different from that of mothers of full-term infants to meet the needs of these newborns. Milk changes composition during feeding. The fat content of the milk increases as the infant feeds. Colostrum precedes mature milk and is more concentrated and richer in proteins and minerals (but not fat).
DIF: Cognitive Level: Understand REF: p. 607 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
- A nurse providing couplet care should understand the issue of nipple confusion. In which situation might this condition occur?
| a. | Breastfeeding babies receive supplementary bottle feedings. |
| b. | Baby is too abruptly weaned. |
| c. | Pacifiers are used before breastfeeding is established. |
| d. | Twins are breastfed together. |
ANS: A
Nipple confusion can result when babies go back and forth between bottles and breasts, especially before breastfeeding is established in 3 to 4 weeks; bottle feeding and breastfeeding require different skills. Abrupt weaning can be distressing to the mother and/or baby but should not lead to nipple confusion. Pacifiers used before breastfeeding is established can be disruptive but do not lead to nipple confusion. Breastfeeding twins require some logistical adaptations but should not lead to nipple confusion.
DIF: Cognitive Level: Understand REF: p. 614 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
- Which information should the nurse provide to a breastfeeding mother regarding optimal self-care?
| a. | She will need an extra 1000 calories a day to maintain energy and produce milk. |
| b. | She can return to prepregnancy consumption patterns of any drinks as long as she gets enough calcium. |
| c. | She should avoid trying to lose large amounts of weight. |
| d. | She must avoid exercising because it is too fatiguing. |
ANS: C
Large weight loss releases fat-stored contaminants into her breast milk, and it also involves eating too little and/or exercising too much. A breastfeeding mother needs to add only 200 to 500 extra calories to her diet to provide the extra nutrients for her infant. However, this is true only if she does not drink alcohol, limits coffee to no more than two cups (including caffeine in chocolate, tea, and some sodas, too), and carefully reads the herbal tea ingredients. Although she needs her rest, moderate exercise is healthy.
DIF: Cognitive Level: Understand REF: p. 620 TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
- A newly delivered mother who intends to breastfeed tells her nurse, “I am so relieved that this pregnancy is over so that I can start smoking again.” The nurse encourages the client to refrain from smoking. However, this new mother is insistent that she will resume smoking. How will the nurse adapt her health teaching with this new information?
| a. | Smoking has little-to-no effect on milk production. |
| b. | No relationship exists between smoking and the time of feedings. |
| c. | The effects of secondhand smoke on infants are less significant than for adults. |
| d. | The mother should always smoke in another room. |
ANS: D
The new mother should be encouraged not to smoke. If she continues to smoke, she should be encouraged to always smoke in another room, removed from the baby. Smoking may impair milk production. When the products of tobacco are broken down, they cross over into the breast milk. Tobacco also results in a reduction of the antiinfective properties of breast milk. Research supports the conclusion that mothers should not smoke within 2 hours before a feeding (AAP Committee on Drugs, 2001). The effects of secondhand smoke on infants include excessive crying, colic, upper respiratory infections, and an increased risk of sudden infant death syndrome (SIDS).
DIF: Cognitive Level: Apply REF: p. 622 TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
- A new father is ready to take his wife and newborn son home. He proudly tells the nurse who is discharging them that within the next week he plans to start feeding the infant cereal between breastfeeding sessions. Which information should the nurse provide regarding this feeding plan?
| a. | “Feeding solid foods before your son is 4 to 6 months old may decrease your son’s intake of sufficient calories.” |
| b. | “Feeding solid foods between breastfeeding sessions before your son is 4 to 6 months old will lead to an early cessation of breastfeeding.” |
| c. | “Your feeding plan will help your son sleep through the night.” |
| d. | “Feeding solid foods before your son is 4 to 6 months old will limit his growth.” |
ANS: B
The introduction of solid foods before the infant is 4 to 6 months of age may result in overfeeding and decreased intake of breast milk. The belief that feeding solid foods helps infants sleep through the night is untrue. The proper balance of carbohydrate, protein, and fat for an infant to grow properly is in the breast milk or formula.
DIF: Cognitive Level: Apply REF: p. 629 TOP: Nursing Process: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
- According to demographic research, which woman is least likely to breastfeed and therefore most likely to need education regarding the benefits and proper techniques of breastfeeding?
| a. | Between 30 and 35 years of age, Caucasian, and employed part time outside the home |
| b. | Younger than 25 years of age, Hispanic, and unemployed |
| c. | Younger than 25 years of age, African-American, and employed full time outside the home |
| d. | 35 years of age or older, Caucasian, and employed full time at home |
ANS: C
Women least likely to breastfeed are typically younger than 25 years of age, have a lower income, are less educated, are employed full time outside the home, and are African-American.
DIF: Cognitive Level: Understand REF: p. 603
TOP: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
- The nurse is explaining the benefits associated with breastfeeding to a new mother. Which statement by the nurse would provide conflicting information to the client?
| a. | Women who breastfeed have a decreased risk of breast cancer. |
| b. | Breastfeeding is an effective method of birth control. |
| c. | Breastfeeding increases bone density. |
| d. | Breastfeeding may enhance postpartum weight loss. |
ANS: B
Although breastfeeding delays the return of fertility, it is not an effective birth control method. Women who breastfeed have a decreased risk of breast cancer, an increase in bone density, and a possibility of faster postpartum weight loss.
DIF: Cognitive Level: Understand REF: p. 621 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
- While discussing the societal impacts of breastfeeding, the nurse should be cognizant of the benefits and educate the client accordingly. Which statement as part of this discussion would be incorrect?
| a. | Breastfeeding requires fewer supplies and less cumbersome equipment. |
| b. | Breastfeeding saves families money. |
| c. | Breastfeeding costs employers in terms of time lost from work. |
| d. | Breastfeeding benefits the environment. |
ANS: C
Actually, less time is lost to work by breastfeeding mothers, in part because infants are healthier. Breastfeeding is convenient because it does not require cleaning or transporting bottles and other equipment. It saves families money because the cost of formula far exceeds the cost of extra food for the lactating mother. Breastfeeding uses a renewable resource; it does not need fossil fuels, advertising, shipping, or disposal.
DIF: Cognitive Level: Understand REF: p. 602 TOP: Nursing Process: Evaluation
MSC: Client Needs: Health Promotion and Maintenance
- In assisting the breastfeeding mother to position the baby, which information regarding positioning is important for the nurse to keep in mind?
| a. | The cradle position is usually preferred by mothers who had a cesarean birth. |
| b. | Women with perineal pain and swelling prefer the modified cradle position. |
| c. | Whatever the position used, the infant is “belly to belly” with the mother. |
| d. | While supporting the head, the mother should push gently on the occiput. |
ANS: C
The infant naturally faces the mother, belly to belly. The football position is usually preferred after a cesarean birth. Women with perineal pain and swelling prefer the side-lying position because they can rest while breastfeeding. The mother should never push on the back of the head. It may cause the baby to bite, hyperextend the neck, or develop an aversion to being brought near the breast.
DIF: Cognitive Level: Apply REF: p. 610
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
- Nurses should be able to teach breastfeeding mothers the signs that the infant has correctly latched on. Which client statement indicates a poor latch?
| a. | “I feel a firm tugging sensation on my nipples but not pinching or pain.” |
| b. | “My baby sucks with cheeks rounded, not dimpled.” |
| c. | “My baby’s jaw glides smoothly with sucking.” |
| d. | “I hear a clicking or smacking sound.” |
ANS: D
The clicking or smacking sound may indicate that the baby is having difficulty keeping the tongue out over the lower gum ridge. The mother should hope to hear the sound of swallowing. The tugging sensation without pinching is a good sign. Rounded cheeks are a positive indicator of a good latch. A smoothly gliding jaw also is a good sign.
DIF: Cognitive Level: Understand REF: p. 611 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
- The breastfeeding mother should be taught a safe method to remove the breast from the baby’s mouth. Which suggestion by the nurse is most appropriate?
| a. | Slowly remove the breast from the baby’s mouth when the infant has fallen asleep and the jaws are relaxed. |
| b. | Break the suction by inserting your finger into the corner of the infant’s mouth. |
| c. | A popping sound occurs when the breast is correctly removed from the infant’s mouth. |
| d. | Elicit the Moro reflex to wake the baby and remove the breast when the baby cries. |
ANS: B
Inserting a finger into the corner of the baby’s mouth between the gums to break the suction avoids trauma to the breast. The infant who is sleeping may lose grasp on the nipple and areola, resulting in chewing on the nipple that makes it sore. A popping sound indicates improper removal of the breast from the baby’s mouth and may cause cracks or fissures in the breast. Most mothers prefer the infant to continue to sleep after the feeding. Gentle wake-up techniques are recommended.
DIF: Cognitive Level: Apply REF: p. 611
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
- Which type of formula is not diluted with water, before being administered to an infant?
| a. | Powdered |
| b. | Concentrated |
| c. | Ready-to-use |
| d. | Modified cow’s milk |
ANS: C
Ready-to-use formula can be poured directly from the can into the baby’s bottle and is good (but expensive) when a proper water supply is not available. Formula should be well mixed to dissolve the powder and make it uniform in consistency. Improper dilution of concentrated formula may cause malnutrition or sodium imbalances. Cow’s milk is more difficult for the infant to digest and is not recommended, even if it is diluted.
DIF: Cognitive Level: Understand REF: p. 629
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
- How many kilocalories per kilogram (kcal/kg) of body weight does a breastfed term infant require each day?
| a. | 50 to 65 |
| b. | 75 to 90 |
| c. | 95 to 110 |
| d. | 150 to 200 |
ANS: C
For the first 3 months, the infant needs 110 kcal/kg/day. At ages 3 to 6 months, the requirement is 100 kcal/kg/day. This level decreases slightly to 95 kcal/kg/day from 6 to 9 months and increases again to 100 kcal/kg/day until the baby reaches 12 months.
DIF: Cognitive Level: Remember REF: p. 604
TOP: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
- Which action by the mother will initiate the milk ejection reflex (MER)?
| a. | Wearing a firm-fitting bra |
| b. | Drinking plenty of fluids |
| c. | Placing the infant to the breast |
| d. | Applying cool packs to her breast |
ANS: C
Oxytocin, which causes the MER reflex, increases in response to nipple stimulation. A firm bra is important to support the breast; however, it will not initiate the MER reflex. Drinking plenty of fluids is necessary for adequate milk production, but adequate intake of water alone will not initiate the MER reflex. Cool packs to the breast will decrease the MER reflex.
DIF: Cognitive Level: Understand REF: p. 607
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
- As the nurse assists a new mother with breastfeeding, the client asks, “If formula is prepared to meet the nutritional needs of the newborn, what is in breast milk that makes it better?” What is the nurse’s best response?
| a. | More calories |
| b. | Essential amino acids |
| c. | Important immunoglobulins |
| d. | More calcium |
ANS: C
Breast milk contains immunoglobulins that protect the newborn against infection. The calorie count of formula and breast milk is approximately the same. All the essential amino acids are in both formula and breast milk; however, the concentrations may differ. Calcium levels are higher in formula than in breast milk, which can cause an excessively high renal solute load if the formula is not properly diluted.
DIF: Cognitive Level: Apply REF: p. 607
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
- Which instruction should the nurse provide to reduce the risk of nipple trauma?
| a. | Limit the feeding time to less than 5 minutes. |
| b. | Position the infant so the nipple is far back in the mouth. |
| c. | Assess the nipples before each feeding. |
| d. | Wash the nipples daily with mild soap and water. |
ANS: B
If the infant’s mouth does not cover as much of the areola as possible, the pressure during sucking will be applied to the nipple, thus causing trauma to the area. Stimulating the breast for less than 5 minutes will not produce the extra milk the infant may need and will also limit access to the higher-fat hindmilk. Assessing the nipples for trauma is important; however, this action alone will not prevent sore nipples. Soap can be drying to the nipples and should be avoided during breastfeeding.
DIF: Cognitive Level: Apply REF: p. 624
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
- A new mother asks whether she should feed her newborn colostrum, because it is not “real milk.” What is the nurse’s most appropriate answer?
| a. | Colostrum is high in antibodies, protein, vitamins, and minerals. |
| b. | Colostrum is lower in calories than milk and should be supplemented by formula. |
| c. | Giving colostrum is important in helping the mother learn how to breastfeed before she goes home. |
| d. | Colostrum is unnecessary for newborns. |
ANS: A
Colostrum is important because it has high levels of the nutrients needed by the neonate and helps protect against infection. Supplementation is not necessary and will decrease stimulation to the breast and decrease the production of milk. It is important for the mother to feel comfortable in this role before discharge; however, the importance of the colostrum to the infant is the top priority. Colostrum provides immunities and enzymes necessary to cleanse the gastrointestinal system, among other things.
DIF: Cognitive Level: Remember REF: p. 607
TOP: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
MULTIPLE RESPONSE
- Which actions are examples of appropriate techniques to wake a sleepy infant for breastfeeding? (Select all that apply.)
| a. | Unwrapping the infant |
| b. | Changing the diaper |
| c. | Talking to the infant |
| d. | Slapping the infant’s hands and feet |
| e. | Applying a cold towel to the infant’s abdomen |
ANS: A, B, C
Unwrapping the infant, changing the diaper, and talking to the infant are appropriate techniques to use when trying to wake a sleepy infant. The parent can rub, never slap, the infant’s hands or feet to wake the infant. Applying a cold towel to the infant’s abdomen may lead to cold stress in the infant. The parent may want to apply a cool cloth to the infant’s face to wake the infant.
DIF: Cognitive Level: Apply REF: p. 615
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
- A nurse is discussing the signs and symptoms of mastitis with a mother who is breastfeeding. Which findings should the nurse include in the discussion? (Select all that apply.)
| a. | Breast tenderness |
| b. | Warmth in the breast |
| c. | Area of redness on the breast often resembling the shape of a pie wedge |
| d. | Small white blister on the tip of the nipple |
| e. | Fever and flulike symptoms |
ANS: A, B, C, E
Breast tenderness, warmth in the breast, redness on the breast, and fever and flulike symptoms are commonly associated with mastitis and should be included in the nurse’s discussion of mastitis. A small white blister on the tip of the nipple generally is not associated with mastitis but is commonly seen in women who have a plugged milk duct.
DIF: Cognitive Level: Analyze REF: p. 625 TOP: Nursing Process: Planning
MSC: Client Needs: Physiologic Integrity
- The Baby Friendly Hospital Initiative endorsed by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) was founded to encourage institutions to offer optimal levels of care for lactating mothers. Which actions are included in the “Ten Steps to Successful Breastfeeding for Hospitals”? (Select all that apply.)
| a. | Give newborns no food or drink other than breast milk. |
| b. | Have a written breastfeeding policy that is communicated to all staff members. |
| c. | Help mothers initiate breastfeeding within hour of childbirth. |
| d. | Give artificial teats or pacifiers as necessary. |
| e. | Return infants to the nursery at night. |
ANS: A, B, C
No artificial teats or pacifiers (also called dummies or soothers) should be given to breastfeeding infants. Although pacifiers have been linked to a reduction in SIDs, they should not be introduced until the infant is 3 to 4 weeks old and breastfeeding is well established. No other food or drink should be given to the newborn unless medically indicated. The breastfeeding policy should be routinely communicated to all health care staff members. All staff should be trained in the skills necessary to maintain this policy. Breastfeeding should be initiated within hour of childbirth, and all mothers need to be shown how to maintain lactation even if separated from their babies. The facility should practice rooming in and keep mothers and babies together 24 hours a day.
DIF: Cognitive Level: Apply REF: p. 608
TOP: Nursing Process: Implementation
MSC: Client Needs: Safe and Effective Care Environment
- Which statements concerning the benefits or limitations of breastfeeding are accurate? (Select all that apply.)
| a. | Breast milk changes over time to meet the changing needs as infants grow. |
| b. | Breastfeeding increases the risk of childhood obesity. |
| c. | Breast milk and breastfeeding may enhance cognitive development. |
| d. | Long-term studies have shown that the benefits of breast milk continue after the infant is weaned. |
| e. | Benefits to the infant include a reduced incidence of SIDS. |
ANS: A, C, D, E
Breastfeeding actually decreases the risk of childhood obesity. Human milk is the perfect food for human infants. Breast milk changes over time to meet the demands of the growing infant. Scientific evidence is clear that human milk provides the best nutrients for infants with continued benefits long after weaning. Fatty acids in breast milk promote brain growth and development and may lead to enhanced cognition. Infants who are breastfed experience a reduced incidence of SIDS.
DIF: Cognitive Level: Understand REF: p. 602 TOP: Nursing Process: Planning
MSC: Client Needs: Health Promotion and Maintenance
- The AAP recommends pasteurized donor milk for preterm infants if the mother’s own milk in not available. Which statements regarding donor milk and milk banking are important for the nurse to understand and communicate to her client? (Select all that apply.)
| a. | All milk bank donors are screened for communicable diseases. |
| b. | Internet milk sharing is an acceptable source for donor milk. |
| c. | Donor milk may be given to transplant clients. |
| d. | Donor milk is used in neonatal intensive care units (NICUs) for severely low-birth-weight infants only. |
| e. | Donor milk may be used for children with immunoglobulin A (IgA) deficiencies. |
ANS: A, C, E
Because of the antiinfective and growth promotion properties for donor milk, donor milk is highly recommended for preterm and sick infants, as well as for term newborns. Human donor milk has also been used for older children with short gut syndrome, immunodeficiencies, metabolic disorders, or congenital anomalies. Human donor milk has also been used in the adult population—posttransplant clients and for those with colitis, ulcers, or cirrhosis of the liver. Some mothers acquire milk through Internet-based or community-based milk sharing. The U.S. Food and Drug Administration (FDA) has issued a warning regarding this practice. Samples of milk from these sources are higher in contaminants and infectious disease. A milk bank that belongs to the Human Milk Banking Association of North America should always be used for donor milk. All donors are scrupulously screened, and the milk is tested to determine its safety for use.
DIF: Cognitive Level: Analyze REF: pp. 619-620
TOP: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
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