Maternal and Child Nursing Flashcards

A primipara asks the nurse when to expect the onset of true labor. Which characteristic distinguishes true labor from false (Braxton Hicks) contractions?

Answer: Contractions become regular, stronger, longer, and closer together

True labor contractions progressively increase in frequency, duration, and intensity, cause cervical change, and are not relieved by rest, hydration, or position change. Braxton Hicks contractions are irregular, do not intensify progressively, and may be relieved by activity change.

A postpartum patient develops symptoms of mastitis. Which nursing intervention is most important?

Answer: Encourage continued breastfeeding and complete the antibiotic course

Mastitis treatment includes continued breastfeeding (or pumping) to prevent milk stasis, antibiotics (usually dicloxacillin or cephalexin), rest, analgesia, and warm compresses. Stopping breastfeeding worsens milk stasis and can lead to abscess formation.

A nurse is assessing a newborn's gestational age using the Ballard scale. Which finding suggests a term (38–40 weeks) newborn?

Answer: Full creases over entire plantar surface, firm ear cartilage, descended testes

Term newborns (38–40 weeks) have full plantar creases, firm ear cartilage that springs back immediately, descended testes in males, and minimal lanugo. Premature infants have fewer plantar creases, softer cartilage, and more lanugo.

Which medication is routinely administered to newborns within 1 hour of birth to prevent hemorrhagic disease?

Answer: Vitamin K (phytonadione)

Newborns are born with a deficiency of vitamin K-dependent clotting factors (II, VII, IX, X) because vitamin K does not cross the placenta effectively and the gut flora that produce it are absent. Intramuscular vitamin K prevents hemorrhagic disease of the newborn.

A 4-year-old child is brought to the emergency department with burns on both buttocks and the perineal area in a clear geometric pattern. The nurse should:

Answer: Document findings and report suspected child abuse immediately

Geometric, bilateral, and symmetrical burns on the buttocks and perineum — especially with clear margins — are classic indicators of immersion burns from deliberate abuse. The nurse is a mandatory reporter and must report to child protective services immediately.

The nurse is assessing a child for signs of increased intracranial pressure (ICP). Which finding is most specific to increased ICP in a 9-month-old infant?

Answer: Bulging anterior fontanelle

In infants with open fontanelles, bulging or tenseness of the anterior fontanelle is the most specific sign of increased ICP. In older children and adults where fontanelles are closed, papilledema and Cushing's triad are used.