Maternal and Child Nursing Flashcards

The nurse is administering oxytocin to augment labor. Which finding requires the nurse to stop the infusion and notify the physician?

Answer: Uterine contractions lasting more than 90 seconds occurring every 1 minute (tachysystole)

Uterine tachysystole (contractions >5 in 10 minutes) or prolonged contractions (>90 seconds) with oxytocin can cause fetal hypoxia. The infusion must be stopped and the patient repositioned, given oxygen, and the physician notified.

A nurse is teaching a woman in her third trimester about kick counts. Which finding should prompt immediate evaluation?

Answer: Fewer than 10 movements in 2 hours

Most protocols recommend counting until 10 movements are felt; if fewer than 10 movements occur in 2 hours (or per the specific protocol used), the patient should be evaluated promptly with a non-stress test. Decreased fetal movement can signal fetal compromise.

A nurse is caring for a child with croup (laryngotracheobronchitis). Which intervention is most effective for mild croup?

Answer: Cool mist or sitting in cool night air, maintaining calm environment

Mild croup is treated with cool humidified air (cool mist humidifier or cool night air), which reduces subglottic edema. Keeping the child calm prevents agitation which worsens stridor. Oral or IM dexamethasone reduces inflammation. Severe cases may need nebulized racemic epinephrine.

A nurse is assessing a child with suspected appendicitis. Which assessment finding is most specific for appendicitis?

Answer: Rebound tenderness at McBurney's point

Rebound tenderness (pain worsening upon sudden release of pressure) at McBurney's point (one-third of the way from the right anterior superior iliac spine to the umbilicus) is the classic sign of appendiceal inflammation and peritoneal irritation.

A nurse is reviewing lab results for a pregnant woman at 28 weeks. Her serum ferritin is 8 ng/mL and hemoglobin is 9.5 g/dL. What should the nurse anticipate ordering?

Answer: Oral iron supplementation and dietary iron counseling

Low ferritin (depleted iron stores) and low hemoglobin indicate iron deficiency anemia in pregnancy. First-line treatment is oral iron supplementation (elemental iron 150–200 mg/day in divided doses) with dietary counseling. IV iron is reserved for cases of intolerance or non-response to oral therapy.

A 10-month-old infant presents with high fever and a generalized macular rash that appears as the fever breaks. What condition does the nurse suspect?

Answer: Roseola infantum (Sixth disease)

Roseola (HHV-6) classically presents in infants 6–24 months old with 3–5 days of high fever (up to 40°C), followed by the appearance of a generalized rose-pink macular rash as the fever breaks. This sequence — fever first, rash after — is the hallmark.