Maternal and Child Nursing Flashcards

During the first stage of labor, a nurse monitors fetal heart rate (FHR) and notes early decelerations. What is the most appropriate nursing action?

Answer: Continue to monitor — early decelerations are normal and benign

Early decelerations mirror contractions and are caused by head compression during uterine contractions. They are a benign, normal finding and do not require intervention, only continued monitoring. They are distinguished from late and variable decelerations which require action.

A primigravida at 38 weeks gestation presents with BP 158/104, severe headache, and 3+ proteinuria. What condition should the nurse suspect?

Answer: Severe preeclampsia

Severe preeclampsia is characterized by BP ≥160/110, severe headache, visual changes, epigastric pain, and significant proteinuria. This patient's BP of 158/104 with symptoms crosses into severe range. HELLP involves hemolysis, elevated liver enzymes, and low platelets.

A nurse is teaching a new mother about breastfeeding. Which finding indicates the newborn is latching correctly?

Answer: The infant's mouth covers most of the areola, not just the nipple

A good latch requires the infant to have the nipple and most of the areola in their mouth, with lips flanged outward. Shallow latch (nipple only) is the most common cause of nipple pain, poor milk transfer, and early breastfeeding failure.

A neonate is born with Apgar scores of 4 at 1 minute and 6 at 5 minutes. What do these scores indicate?

Answer: Moderate depression requiring continued assessment and intervention

Apgar scores of 7–10 are normal; 4–6 indicate moderate depression requiring stimulation and possible supplemental oxygen; 0–3 indicate severe depression requiring immediate resuscitation. Scores are reassessed at 5 and 10 minutes.

A child is admitted with suspected epiglottitis. Which nursing action is the highest priority?

Answer: Do not attempt to visualize the throat or obtain a throat swab

In suspected epiglottitis, examining the throat or causing distress can precipitate complete airway obstruction. The priority is airway management in a controlled setting. Diagnosis is made cautiously; immediate airway protection takes precedence.

The nurse is assessing a 2-year-old child's developmental milestones. Which finding is a concern?

Answer: No two-word phrases by 24 months

By 24 months, children should use at least two-word phrases. Failure to achieve this is a developmental red flag for speech/language delay or autism spectrum disorder and warrants referral. The other findings are normal for a 2-year-old.