Maternal and Child Nursing Flashcards

The nurse is assessing a postpartum patient on day 2 and notes significant engorgement. What is the most effective comfort measure?

Answer: Feed the infant frequently or pump regularly to empty the breasts

Frequent emptying of the breasts through nursing or pumping is the most effective treatment for engorgement. Warm compresses before feeding aid let-down; cold compresses after feeding reduce inflammation. Restricting feeds worsens engorgement and can lead to mastitis.

A nurse is assessing a child with suspected meningitis. Which finding is a positive Kernig's sign?

Answer: Inability to extend the knee when the hip is flexed to 90 degrees

Kernig's sign is positive when the patient cannot fully extend the knee when the hip is flexed at 90 degrees, due to meningeal irritation and hamstring spasm. Brudzinski's sign is when neck flexion causes involuntary hip/knee flexion.

A G3P2 patient presents at 39 weeks in active labor. Suddenly the nurse notes a loop of umbilical cord protruding from the vagina. The priority nursing action is:

Answer: Manually hold the presenting part off the cord and call for emergency assistance

Umbilical cord prolapse is an obstetric emergency causing fetal hypoxia from cord compression. The nurse must manually elevate the presenting part off the cord (not push the cord back), position the patient in Trendelenburg or knee-chest, apply moist warm saline gauze to the cord, and call for emergency cesarean section.

When performing the Ballard assessment on a preterm infant, which neuromuscular criterion would suggest the youngest gestational age?

Answer: Scarf sign: elbow crosses midline without resistance

In the Ballard Maturational Assessment, neuromuscular tone increases with gestational age. The most premature infants have the least tone. A scarf sign where the elbow crosses the midline freely (no resistance) indicates very low gestational age and hypotonia.

The nurse is caring for a neonate with suspected hypoglycemia. Which clinical sign should the nurse monitor for?

Answer: Jitteriness, high-pitched cry, and poor feeding

Neonatal hypoglycemia presents with jitteriness/tremors, irritability, high-pitched cry, poor feeding, apnea, cyanosis, and seizures in severe cases. Blood glucose <2.6 mmol/L (<47 mg/dL) in neonates requires prompt treatment.

A nurse is teaching a new mother about the 'danger signs' of postpartum depression versus 'baby blues.' Which symptom indicates postpartum depression requiring referral?

Answer: Persistent sadness and inability to care for self or baby lasting more than 2 weeks

Baby blues (tearfulness, mood swings) typically resolve within 2 weeks and require support only. Postpartum depression is characterized by persistent low mood, inability to care for the infant or self, feelings of hopelessness, and symptoms lasting more than 2 weeks — requiring professional evaluation and treatment.