Maternal Child Nursing Care 6th Edition Perry Test Bank

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Table of Contents
Table of Contents
Chapter 01: 21st Century Maternity Nursing
Chapter 02: Community Care: The Family and Culture
Chapter 03: Assessment and Health Promotion
Chapter 04: Reproductive System Concerns
Chapter 05: Infertility, Contraception, and Abortion
Chapter 06: Genetics, Conception, and Fetal Development
Chapter 07: Anatomy and Physiology of Pregnancy
Chapter 08: Nursing Care of the Family During Pregnancy
Chapter 09: Maternal and Fetal Nutrition
Chapter 10: Assessment of High Risk Pregnancy
Chapter 11: High Risk Perinatal Care: Preexisting Conditions
Chapter 12: High Risk Perinatal Care: Gestational Conditions
Chapter 13: Labor and Birth Processes
Chapter 14: Pain Management
Chapter 15: Fetal Assessment During Labor
Chapter 16: Nursing Care of the Family During Labor and Birth
Chapter 17: Labor and Birth Complications
Chapter 18: Maternal Physiologic Changes
Chapter 19: Nursing Care of the Family During the Postpartum Period
Chapter 20: Transition to Parenthood
Chapter 21: Postpartum Complications
Chapter 22: Physiologic and Behavioral Adaptations of the Newborn
Chapter 23: Nursing Care of the Newborn and Family
Chapter 24: Newborn Nutrition and Feeding
Chapter 25: The High Risk Newborn
Chapter 26: 21st Century Pediatric Nursing
Chapter 27: Family, Social, Cultural, and Religious Influences on Child Health Promotion
Chapter 28: Developmental and Genetic Influences on Child Health Promotion
Chapter 29: Communication, History, and Physical Assessment
Chapter 30: Pain Assessment and Management in Children
Chapter 31: The Infant and Family
Chapter 32: The Toddler and Family
Chapter 33: The Preschooler and Family
Chapter 34: The School-Age Child and Family
Chapter 35: The Adolescent and Family
Chapter 36: Impact of Chronic Illness, Disability, and End-of-Life Care for the Child and
Family
Chapter 37: Impact of Cognitive or Sensory Impairment on the Child and Family
Chapter 38: Family-Centered Care of the Child During Illness and Hospitalization
Chapter 39: Pediatric Variations of Nursing Interventions
Chapter 40: Respiratory Dysfunction
Chapter 41: Gastrointestinal Dysfunction
Chapter 42: Cardiovascular Dysfunction
Chapter 43: Hematologic and Immunologic Dysfunction
Chapter 44: Cancer
Chapter 45: Genitourinary Dysfunction
Chapter 46: Cerebral Dysfunction
Chapter 47: Endocrine Dysfunction
Chapter 48: Musculoskeletal or Articular Dysfunction
Test Bank - Maternal Child Nursing Care by Perry (6th Edition, 2017) 1
WWW.TESTBANKTANK.COM

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Chapter 49: Neuromuscular or Muscular Dysfunction

Chapter 01: 21st Century Maternity Nursing
MULTIPLE CHOICE
1. When providing care for a pregnant woman, the nurse should be aware that one of the most frequently
reported maternal medical risk factors is:
a. Diabetes mellitus. c. Chronic hypertension.
b. Mitral valve prolapse (MVP). d. Anemia.
ANS: A
The most frequently reported maternal medical risk factors are diabetes and hypertension associated with
pregnancy. Both of these conditions are associated with maternal obesity. There are no studies that indicate
MVP is among the most frequently reported maternal risk factors. Hypertension associated with pregnancy,
not chronic hypertension, is one of the most frequently reported maternal medical risk factors. Although
anemia is a concern in pregnancy, it is not one of the most frequently reported maternal medical risk factors in
pregnancy.
PTS: 1 DIF: Cognitive Level: Knowledge REF: 6
OBJ: Nursing Process: Assessment MSC: Client Needs: Physiologic Integrity
2. To ensure optimal outcomes for the patient, the contemporary maternity nurse must incorporate both
teamwork and communication with clinicians into her care delivery, The SBAR technique of communication is
an easy-to-remember mechanism for communication. Which of the following correctly defines this acronym?
a. Situation, baseline assessment, response
b. Situation, background, assessment, recommendation
c. Subjective background, assessment, recommendation
d. Situation, background, anticipated recommendation
ANS: B
The situation, background, assessment, recommendation (SBAR) technique provides a specific framework for
communication among health care providers. Failure to communicate is one of the major reasons for errors in
health care. The SBAR technique has the potential to serve as a means to reduce errors.
PTS: 1 DIF: Cognitive Level: Comprehension REF: 14
OBJ: Nursing Process: Assessment, Planning
MSC: Client Needs: Safe and Effective Care Environment
3. The role of the professional nurse caring for childbearing families has evolved to emphasize:
a. Providing care to patients directly at the bedside.

b. Primarily hospital care of maternity patients.
c. Practice using an evidence-based approach.
d. Planning patient care to cover longer hospital stays.
ANS: C
Professional nurses are part of the team of health care providers who collaboratively care for patients
throughout the childbearing cycle. Providing care to patients directly at the bedside is one of the nurses tasks;
however, it does not encompass the concept of the evolved professional nurse. Throughout the prenatal period,
nurses care for women in clinics and physicians offices and teach classes to help families prepare for
childbirth. Nurses also care for childbearing families in birthing centers and in the home. Nurses have been
critically important in developing strategies to improve the well-being of women and their infants and have led
the efforts to implement clinical practice guidelines using an evidence-based approach. Maternity patients have
experienced a decreased, rather than an increased, length of stay over the past 2 decades.
OBJ: Nursing Process: Implementation
4. A 23-year-old African-American woman is pregnant with her first child. Based on the statistics for infant
mortality, which plan is most important for the nurse to implement?
a. Perform a nutrition assessment.
b. Refer the woman to a social worker.
c. Advise the woman to see an obstetrician, not a midwife.
d. Explain to the woman the importance of keeping her prenatal care appointments.
ANS: D
Consistent prenatal care is the best method of preventing or controlling risk factors associated with infant
mortality. Nutritional status is an important modifiable risk factor, but a nutrition assessment is not the most
important action a nurse should take in this situation. The patient may need assistance from a social worker at
some time during her pregnancy, but a referral to a social worker is not the most important aspect the nurse
should address at this time. If the woman has identifiable high-risk problems, her health care may need to be
provided by a physician. However, it cannot be assumed that all African-American women have high-risk
issues. In addition, advising the woman to see an obstetrician is not the most important aspect on which the
nurse should focus at this time, and it is not appropriate for a nurse to advise or manage the type of care a
patient is to receive.
OBJ: Nursing Process: Planning MSC: Client Needs: Health Promotion and Maintenance
5. During a prenatal intake interview, the nurse is in the process of obtaining an initial assessment of a 21-year-
old Hispanic patient with limited English proficiency. It is important for the nurse to:

a. Use maternity jargon in order for the patient to become familiar with these terms.
b. Speak quickly and efficiently to expedite the visit.
c. Provide the patient with handouts.
d. Assess whether the patient understands the discussion.
ANS: D
Nurses contribute to health literacy by using simple, common words; avoiding jargon; and evaluating whether
the patient understands the discussion. Speaking slowly and clearly and focusing on what is important increase
understanding. Most patient education materials are written at too high a level for the average adult and may
not be useful for a client with limited English proficiency.
PTS: 1 DIF: Cognitive Level: Application REF: 5
OBJ: Nursing Process: Evaluation MSC: Client Needs: Health Promotion and Maintenance
6. When managing health care for pregnant women at a prenatal clinic, the nurse should recognize that the
most significant barrier to access to care is the pregnant womans:
a. Age. c. Educational level.
b. Minority status. d. Inability to pay.
ANS: D
The most significant barrier to health care access is the inability to pay for services; this is compounded by the
fact that many physicians refuse to care for women who cannot pay. Although adolescent pregnant clients
statistically receive less prenatal care, age is not the most significant barrier. Significant disparities in
morbidity and mortality rates exist for minority women; however, minority status is not the most significant
barrier to access of care. Disparities in educational level are associated with morbidity and mortality rates;
however, educational level is not the most significant barrier to access of care.
OBJ: Nursing Process: Assessment
7. What is the primary role of practicing nurses in the research process?
a. Designing research studies
b. Collecting data for other researchers
c. Identifying researchable problems
d. Seeking funding to support research studies

ANS: C
When problems are identified, research can be conducted properly. Research of health care issues leads to
evidence-based practice guidelines. Designing research studies is only one factor of the research process. Data
collection is one factor of research. Financial support is necessary to conduct research, but it is not the primary
role of the nurse in the research process.
OBJ: Nursing Process: Diagnosis, Evaluation
8. When the nurse is unsure about how to perform a patient care procedure, the best action would be to:
a. Ask another nurse.
b. Discuss the procedure with the patients physician.
c. Look up the procedure in a nursing textbook.
d. Consult the agency procedure manual and follow the guidelines for the procedure.
ANS: D
It is always best to follow the agencys policies and procedures manual when seeking information on correct
patient procedures. These policies should reflect the current standards of care and state guidelines. Each nurse
is responsible for her own practice. Relying on another nurse may not always be safe practice. Each nurse is
obligated to follow the standards of care for safe client care delivery. Physicians are responsible for their own
client care activity. Nurses may follow safe orders from physicians, but they are also responsible for the
activities that they as nurses are to carry out. Information provided in a nursing textbook is basic information
for general knowledge. Furthermore, the information in a textbook may not reflect the current standard of care
or individual state or hospital policies.
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
9. From the nurses perspective, what measure should be the focus of the health care system to reduce the rate
of infant mortality further?
a. Implementing programs to ensure womens early participation in ongoing prenatal care
b. Increasing the length of stay in a hospital after vaginal birth from 2 to 3 days
c. Expanding the number of neonatal intensive care units (NICUs)
d. Mandating that all pregnant women receive care from an obstetrician
ANS: A
Early prenatal care allows for early diagnosis and appropriate interventions to reduce the rate of infant

mortality. An increased length of stay has been shown to foster improved self-care and parental education.
However, it does not prevent the incidence of leading causes of infant mortality rates, such as low birth weight.
Early prevention and diagnosis reduce the rate of infant mortality. NICUs offer care to high-risk infants after
they are born. Expanding the number of NICUs would offer better access for high-risk care, but this factor is
not the primary focus for further reduction of infant mortality rates. A mandate that all pregnant women
receive obstetric care would be nearly impossible to enforce. Furthermore, certified nurse-midwives (CNMs)
have demonstrated reliable, safe care for pregnant women.
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
10. Alternative and complementary therapies:
a. Replace conventional Western modalities of treatment.
b. Are used by only a small number of American adults.
c. Recognize the value of clients input into their health care.
d. Focus primarily on the disease an individual is experiencing.
ANS: C
Many popular alternative healing modalities offer human-centered care based on philosophies that recognize
the value of the patients input and honor the individuals beliefs, values, and desires. Alternative and
complementary therapies are part of an integrative approach to health care. An increasing number of American
adults are seeking alternative and complementary health care options. Alternative healing modalities offer an
holistic approach to health, focusing on the whole person, not just the disease.
OBJ: Nursing Process: Planning MSC: Client Needs: Physiologic Integrity
11. A 38-year-old Hispanic woman delivered a 9-pound, 6-ounce girl vaginally after being in labor for 43
hours. The baby died 3 days later from sepsis. On what grounds would the woman potentially have a legitimate
legal case for negligence?
a. She is Hispanic. c. The standards of care were not met.
b. She delivered a girl. d. She refused fetal monitoring.
ANS: C
Not meeting the standards of care is a legitimate factor for a case of negligence. The clients race is not a factor
for a case of negligence. The infants gender is not a factor for a case of negligence. Although fetal monitoring
is the standard of care, the client has the right to refuse treatment. This refusal is not a case for negligence;
however, informed consent should be properly obtained, and the client should sign an against medical advice
form for refusal of any treatment that is within the standard of care.

12. A newly graduated nurse is attempting to understand the reason for increasing health care spending in the
United States. Her research finds that these costs are much higher compared with other developed countries as
a result of:
a. A higher rate of obesity among pregnant women.
b. Limited access to technology.
c. Increased usage of health care services along with lower prices.
d. Homogeneity of the population.
ANS: A
Health care is one of the fastest growing sectors of the U.S. economy. Currently, 17.4% of the gross domestic
product is spent on health care. Higher spending in the United States compared with 12 other industrialized
countries is related to higher prices and readily accessible technology along with greater obesity rates among
women. More than one third of women in the United States are obese. Of the U.S. population, 16% is
uninsured and has limited access to health care. Maternal morbidity and mortality are directly related to racial
disparities.
PTS: 1 DIF: Cognitive Level: Analysis REF: 5
OBJ: Nursing Process: Planning
13. The term used to describe legal and professional responsibility for practice for maternity nurses is:
a. Collegiality. c. Evaluation.
b. Ethics. d. Accountability.
ANS: D
Accountability refers to legal and professional responsibility for practice. Collegiality refers to a working
relationship with ones colleagues. Ethics refers to a code to guide practice. Evaluation refers to examination of
the effectiveness of interventions in relation to expected outcomes.
PTS: 1 DIF: Cognitive Level: Evaluation REF: 12
14. Through the use of social media technology, nurses can link with other nurses who may share similar
interests, insights about practice, and advocate for patients. The most concerning pitfall for nurses using this
technology is:
a. Violation of patient privacy and confidentiality.
b. Institutions and colleagues may be cast in an unfavorable light.

c. Unintended negative consequences for using social media.
d. Lack of institutional policy governing online contact.
ANS: A
The most significant pitfall for nurses using this technology is the violation of patient privacy and
confidentiality. Furthermore, institutions and colleagues can be cast in unfavorable lights with negative
consequences for those posting information. Nursing students have been expelled from school and nurses have
been fired or reprimanded by their Board of Nursing for injudicious posts. The American Nurses Association
has published six principles for social networking and nurses. All institutions should have policies guiding the
use of social media, and nurses should be familiar with these guidelines.
15. An important development that affects maternity nursing is integrative health care, which:
a. Seeks to provide the same health care for all racial and ethnic groups.
b. Blends complementary and alternative therapies with conventional Western treatment.
c. Focuses on the disease or condition rather than the background of the client.
d. Has been mandated by Congress.
ANS: B
Integrative health care tries to mix the old with the new at the discretion of the client and health care providers.
Integrative health care is a blending of new and traditional practices. Integrative health care focuses on the
whole person, not just the disease or condition. U.S. law supports complementary and alternative therapies but
does not mandate them.
OBJ: Nursing Process: Implementation MSC: Client Needs: Health Promotion and Maintenance
16. Recent trends in childbirth practices in the United States indicate that:
a. More than 15% of mothers had late or no prenatal care.
b. The percentage of Hispanics, non-Hispanic African Americans, and Caucasians who received
prenatal care was essentially the same.
c. Births occurring in the hospital accounted for 99% of births.
d. Cesarean births have been declining as a percentage of live births.

ANS: C
Almost all births occur within the hospital setting. Only 5.2% of Caucasians mothers had either late care or no
care. There are disparities in the receipt of prenatal care by ethnicity: 12.2% of Hispanic women and 11.8% of
non-Hispanic black women received either late or no prenatal care. The percentage of cesarean births is
increasing.
17. Recent trends in childbirth practice indicate that:
a. Delayed pushing is now discouraged in the second stage of labor.
b. Episiotomy rates are increasing.
c. Midwives perform more episiotomies than physicians.
d. Newborn infants remain with the mother and are encouraged to breastfeed.
ANS: D
Breastfeeding is encouraged for newborns immediately after birth. Delayed pushing is encouraged for several
reasons. Episiotomy rates are declining. Midwives perform fewer episiotomies than physicians.
18. The nurse caring for a pregnant client should be aware that the U.S. birth rate shows which trend?
a. Births to unmarried women are more likely to have less favorable outcomes.
b. Birth rates for women 40 to 44 years old are beginning to decline.
c. Cigarette smoking among pregnant women continues to increase.
d. The rates of maternal death owing to racial disparity are elevated in the United States.
ANS: A
Low-birth-weight infants and preterm birth are more likely because of the large number of teenagers in the
unmarried group. Birth rates for women in their early 40s continue to increase. Fewer pregnant women smoke.
In the United States, there is significant racial disparity in the rates of maternal death.
OBJ: Nursing Process: Assessment

19. Maternity nursing care that is based on knowledge gained through research and clinical trials is:
a. Derived from the Nursing Intervention Classification.
b. Known as evidence-based practice.
c. At odds with the Cochrane School of traditional nursing.
d. An outgrowth of telemedicine.
ANS: B
Evidence-based practice is based on knowledge gained from research and clinical trials. The Nursing
Intervention Classification is a method of standardizing language and categorizing care. Dr. Cochrane
systematically reviewed research trials and is part of the evidence-based practice movement. Telemedicine uses
communication technologies to support health care.
OBJ: Nursing Process: Assessment MSC: Client Needs: Psychosocial Integrity
20. The level of practice a reasonably prudent nurse provides is called:
a. The standard of care. c. A sentinel event.
b. Risk management. d. Failure to rescue.
ANS: A
Guidelines for standards of care are published by various professional nursing organizations. Risk management
identifies risks and establishes preventive practices, but it does not define the standard of care. Sentinel events
are unexpected negative occurrences. They do not establish the standard of care. Failure to rescue is an
evaluative process for nursing, but it does not define the standard of care.
OBJ: Nursing Process: Diagnosis
21. During a prenatal intake interview, the client informs the nurse that she would prefer a midwife to provide
her care during pregnancy and deliver her infant. What information would be most appropriate for the nurse to
share with this patient?
a. Midwifery care is available only to clients who are uninsured because their services are less
expensive than an obstetrician. Costs are often lower than an obstetric provider.
b. The client will receive fewer interventions during the birth process.
c. The client should be aware that midwives are not certified.

d. Delivery can take place only at the clients home or in a birth center.
ANS: B
This patient will be able to participate actively in all decisions related to the birth process and is likely to
receive fewer interventions during the birth process. Midwifery services are available to all low-risk pregnant
women, regardless of the type of insurance they have. Midwifery care in all developed countries is strictly
regulated by a governing body, which ensures that core competencies are met. In the United States, this body is
the American College of Nurse-Midwives. Midwives can provide care and delivery at home, in freestanding
birth centers, and in community and teaching hospitals.
22. While obtaining a detailed history from a woman who has recently emigrated from Somalia, the nurse
realizes that the client has undergone female genital mutilation (FGM). The nurses best response to this patient
is:
a. This is a very abnormal practice and rarely seen in the United States.
b. Do you know who performed this so that it can be reported to the authorities?
c. We will be able to restore your circumcision fully after delivery.
d. The extent of your circumcision will affect the potential for complications.
ANS: D
The extent of your circumcision will affect the potential for complications is the most appropriate response.
The patient may experience pain, bleeding, scarring, or infection and may require surgery before childbirth.
With the growing number of immigrants from countries where FGM is practiced, nurses will increasingly
encounter women who have undergone the procedure. Although this practice is not prevalent in the United
States, it is very common in many African and Middle Eastern countries for religious reasons. Responding
with, This is a very abnormal practice and rarely seen in the United States is culturally insensitive. The
infibulation may have occurred during infancy or childhood. The client will have little to no recollection of the
event. She would have considered this to be a normal milestone during her growth and development. The
International Council of Nurses has spoken out against this procedure as harmful to a womans health.
23. To ensure patient safety, the practicing nurse must have knowledge of the current Joint Commissions Do
Not Use list of abbreviations. Which of the following is acceptable for use?
a. q.o.d. or Q.O.D. c. International Unit
b. MSO4 or MgSO4 d. Lack of a leading zero

ANS: C
The abbreviations i.u. and I.U. are no longer acceptable because they could be misread as I.V. or the number
10. The abbreviation q.o.d. or Q.O.D. should be written out as every other day. The period after the Q could be
mistaken for an I; the o could also be mistaken for an i. With MSO4 or MgSO4, it is too easy to confuse one
medication for another. These medications are used for very different purposes and could put a client at risk for
an adverse outcome. They should be written as morphine sulfate and magnesium sulfate. The decimal point
should never be missed before a number to avoid confusion (i.e., 0.4 rather than .4).
24. Healthy People 2020 has established national health priorities that focus on a number of maternal-child
health indicators. Nurses are assuming greater roles in assessing family health and providing care across the
perinatal continuum. Therefore it is important for the nurse to be aware that significant progress has been made
in:
a. The reduction of fetal deaths and use of prenatal care.
b. Low birth weight and preterm birth.
c. Elimination of health disparities based on race.
d. Infant mortality and the prevention of birth defects.
ANS: A
Trends in maternal child health indicate that progress has been made in relation to reduced infant and fetal
deaths and increased prenatal care. Notable gaps remain in the rates of low birth weight and preterm births.
According to the March of Dimes, persistent disparities still exist between African Americans and non-
Hispanic Caucasians. Many of these negative outcomes are preventable through access to prenatal care and the
use of preventive health practices. This demonstrates the need for comprehensive community-based care for all
mothers, infants, and families.
MULTIPLE RESPONSE
25. Which interventions would help alleviate the problems associated with access to health care for maternity
patients (Select all that apply)?
a. Provide transportation to prenatal visits.
b. Provide childcare so that a pregnant woman may keep prenatal visits.
c. Mandate that physicians make house calls.

d. Provide low-cost or no-cost health care insurance.
e. Provide job training.
ANS: A, B, D
Lack of transportation to visits, lack of childcare, and lack of affordable health insurance are prohibitive factors
associated with lack of prenatal care. House calls are not a cost-effective approach to health care. Although job
training may result in employment and income, the likelihood of significant changes during the time frame of
the pregnancy is remote.
PTS: 1 DIF: Cognitive Level: Implementation REF: 5
26. Which of the following statements indicate that the nurse is practicing appropriate family-centered care
techniques (Select all that apply)?
a. The nurse commands the mother to do as she is told.
b. The nurse allows time for the partner to ask questions.
c. The nurse allows the mother and father to make choices when possible.
d. The nurse informs the family about what is going to happen.
e. The nurse tells the patients sister, who is a nurse, that she cannot be in the room during the
delivery.
ANS: B, C
Including the partner in the care process and allowing the couple to make choices are important elements of
family-centered care. The nurse should never tell the mother what to do. Family-centered care involves
collaboration between the health care team and the client. Unless an institutional policy limits the number of
attendants at a delivery, the client should be allowed to have whomever she wants present (except when the
situation is an emergency and guests are asked to leave).
OBJ: Nursing Process: Implementation MSC: Client Needs: Psychosocial Integrity
MATCHING
Medical errors are a leading cause of death in the United States. The National Quality Forum has
recommended numerous safe practices that nursing can promote to reduce errors. Match each safe practice
with the correct statement.
a. Ask the patient to teach back.
b. Comply with CDC guidelines.

c. Ensure that information is documented in a timely manner.
d. Promote interventions that will reduce patient risk.
e. Reduce exposure to radiation.
27. Hand hygiene
28. Informed consent
29. Culture measurement, feedback, and intervention
30. Pediatric imaging
31. Patient care information
27. ANS: B PTS: 1 DIF: Cognitive Level: Application
REF: 5 OBJ: Nursing Process: Implementation
NOT: The National Quality Forum updated its publication Safe Practices for Better Healthcare in 2010,
outlining 24 safe practices that should be used in all health care settings to reduce the risk of harm from the
environment of care, processes, and systems. These are only a few of the recommended practices; however,
nurses should be familiar with these guidelines.
28. ANS: A PTS: 1 DIF: Cognitive Level: Application
29. ANS: D PTS: 1 DIF: Cognitive Level: Application
30. ANS: E PTS: 1 DIF: Cognitive Level: Application

31. ANS: C PTS: 1 DIF: Cognitive Level: Application

Chapter 02: Community Care: The Family and Culture
MULTIPLE CHOICE
1. A married couple lives in a single-family house with their newborn son and the husbands daughter from a
previous marriage. On the basis of the information given, what family form best describes this family?
a. Married-blended family c. Nuclear family
b. Extended family d. Same-sex family
ANS: A
Married-blended families are formed as the result of divorce and remarriage. Unrelated family members join
together 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 and the children resulting from that union. A same-sex family is a family with homosexual partners
who cohabit with or without children.
2. In what form do families tend to be most socially vulnerable?
a. Married-blended family c. Nuclear family
b. Extended family d. Single-parent family
ANS: D
The single-parent family tends to be vulnerable economically and socially, 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.
OBJ: Nursing Process: Planning MSC: Client Needs: Psychosocial Integrity
3. Health care functions carried out by families to meet their members needs include:
a. Developing family budgets.
b. Socializing children.
c. Meeting nutritional requirements.
d. Teaching family members about birth control.
ANS: C

Meeting nutritional requirements is a fundamental health promotion behavior. Although creating a family
budget may be helpful, it does not indicate that funds will be allotted to meet health needs if money is scarce.
Often families cannot afford preventive care and rely on emergency departments for their health care needs.
Socialization of children may be important, but it is not directly related to the health care of individuals in a
family unit. Birth control may be important, but it is not a basic survival health care function.
4. The nurse should be aware that the criteria used to make decisions and solve problems within families are
based primarily on family:
a. Rituals and customs. c. Boundaries and channels.
b. Values and beliefs. d. Socialization processes.
ANS: B
Values and beliefs are the most prevalent factors in the decision-making and problem-solving techniques of
families. 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 with the community, but they are not the criteria used for
decision making within the family.
5. Using the family stress theory as an intervention approach for working with families experiencing parenting,
the nurse can help the family change internal context factors. These include:
a. Biologic and genetic makeup.
b. Maturation of family members.
c. The familys perception of the event.
d. The prevailing cultural beliefs of society.
ANS: C
The family stress theory is concerned with the familys reaction to stressful events; internal context factors
include elements that a family can control such as psychologic defenses. It is not concerned with biologic and
genetic makeup, maturation of family members, or the prevailing cultural beliefs of society.
OBJ: Nursing Process: Diagnosis MSC: Client Needs: Psychosocial Integrity
6. While working in the prenatal clinic, you care for a very diverse group of patients. When planning
interventions for these families, you realize that acceptance of the interventions will be most influenced by:

a. Educational achievement. c. Subcultural group.
b. Income level. d. Individual beliefs.
ANS: D
The patients beliefs are ultimately the key to 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 subcultural group all are important factors. However, the nurse must
understand that a womans concerns from her own point of view will have the most influence on her
compliance.
7. The nurses care of a Hispanic family includes teaching about infant care. When developing a plan of care,
the nurse bases interventions on the knowledge that in traditional Hispanic families:
a. Breastfeeding is encouraged immediately after birth.
b. Male infants typically are circumcised.
c. The maternal grandmother participates in the care of the mother and her infant.
d. Special herbs mixed in water are used to stimulate the passage of meconium.
ANS: C
In Hispanic families, the expectant mother is influenced strongly by her mother or mother-in-law.
Breastfeeding often is delayed until the third postpartum day. Hispanic male infants usually are not
circumcised. Olive or castor oil may be given to stimulate the passage of meconium.
8. The womans family members are present when the home care maternal-child 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. Do a brief assessment on all family members present.
d. Reschedule the visit for another time so that the mother and infant can be assessed privately.
ANS: A

The nurse should introduce herself to the patient and the other family members 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
her infant, not to all family members. The nurse can politely ask about the other people in the home and their
relationships with the woman. Unless an indication is given that the woman would prefer privacy, the visit may
continue.
9. The nurse should be aware that during the childbearing experience an African-American woman is most
likely to:
a. Seek prenatal care early in her pregnancy.
b. Avoid self-treatment of pregnancy-related discomfort.
c. Request liver in the postpartum period to prevent anemia.
d. Arrive at the hospital in advanced labor.
ANS: D
African-American women often arrive at the hospital in far-advanced labor. These women may view
pregnancy as a state of wellness, which is often the reason for delay in seeking prenatal care. African-
American women practice many self-treatment options for various discomforts of pregnancy, and they may
request liver in the postpartum period, but this is based on a belief that the liver has a high blood content.
OBJ: Nursing Process: Assessment MSC: Client Needs: Health Promotion and Maintenance
10. To provide competent care to an Asian-American family, the nurse should include which of the following
questions during the assessment interview?
a. Do you prefer hot or cold beverages?
b. Do you want 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 usually is excluded from the diet of this population.
Asian-American women typically labor in a quiet atmosphere. Delaying naming the child is common for
Asian-American families.

11. The patients family is important to the maternity nurse because:
a. They pay the bills.
b. The nurse will know which family member to avoid.
c. The nurse will know which mothers will really care for their children.
d. The family culture and structure will influence nursing care decisions.
ANS: D
Family structure and culture influence the health decisions of mothers.
12. A mothers household consists of her husband, his mother, and another child. She is living in a(n):
a. Extended family. c. Married-blended family.
b. Single-parent family. d. Nuclear family.
ANS: A
An extended family includes blood relatives living with the nuclear family. 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 refers to families reconstructed after divorce. A
nuclear family is where male and female partners and their children live as an independent unit.
13. A traditional family structure in which male and female partners and their children live as an independent
unit is known as a(n):
a. Extended family. c. Nuclear family.
b. Binuclear family. d. Blended family.
ANS: C
About two thirds of U.S. households meet the definition of a nuclear family. Extended families include
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.

14. Which statement about family systems theory is inaccurate?
a. A family system is part of a larger suprasystem.
b. A family as a whole is equal to the sum of the individual members.
c. A change in one family member affects all family members.
d. The 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 parts. The other statements are characteristics of a system
that states that a family is greater than the sum of its parts.
15. A pictorial tool that can assist the nurse in assessing aspects of family life related to health care is the:
a. Genogram. c. Life cycle model.
b. Family values construct. d. Human development wheel.
ANS: A
A genogram depicts the relationships of family members over generations.
16. The process by which people retain some of their own culture while adopting the practices of the dominant
society is known as:
a. Acculturation. c. Ethnocentrism.
b. Assimilation. 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. Acculturation describes the process by which people retain some of their own culture while adopting
the practices of the dominant society. Ethnocentrism is the belief in the superiority of ones own culture over
the cultures of others. Acculturation describes the process by which people retain some of their own culture
while adopting the practices of the dominant society. Cultural relativism recognizes the roles of different
cultures. Acculturation describes the process by which people retain some of their own culture while adopting

the practices of the dominant society.
17. When attempting to communicate with a patient who speaks a different language, the nurse should:
a. Respond promptly and positively to project authority.
b. Never use a family member as an interpreter.
c. Talk to the interpreter to avoid confusing the patient.
d. Provide as much privacy as possible.
ANS: D
Providing privacy creates an atmosphere of respect and puts the patient at ease. The nurse should not rush to
judgment and should make sure that he or she understands the patients message clearly. In crisis situations, the
nurse may need to use a family member or neighbor as a translator. The nurse should talk directly to the patient
to create an atmosphere of respect.
18. In which culture is the father more likely to be expected to participate in the labor and delivery?
a. Asian-American c. European-American
b. African-American d. Hispanic
ANS: C
European-Americans expect the father to take a more active role in the labor and delivery than the other
cultures.
19. Which statement about cultural competence is not accurate?
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 clients culture but not in the context of the nurses
culture.
c. Nurses must develop an awareness of and sensitivity to various cultures.

d. A cultures economic, religious, and political structures influence practices that affect childbearing.
ANS: B
The cultural context of the nurse also affects nursing care. The work of local health care workers and
community advocates is part of cultural competence; the nurses cultural context is also important. Developing
sensitivity to various cultures is part of cultural competence, but the nurses cultural context is also important.
The impact of economic, religious, and political structures is part of cultural competence; the nurses cultural
context is also important.
MULTIPLE RESPONSE
20. The nurse is preparing for a home visit to complete a newborn wellness checkup. The neighborhood has a
reputation for being dangerous. Identify which precautions the nurse should take to ensure her safety (Select all
that apply).
a. Having access to a cell phone at all times.
b. Visiting alone due to the agencys staffing model.
c. Carrying an extra set of car keys.
d. Avoiding groups of strangers hanging out in doorways.
e. Wearing her usual amount of jewelry.
ANS: A, C, D
Nurse safety is an important component of home care. The nurse should be fully aware of the home
environment and the neighborhood in which the home care is being provided. In this situation, nurses should
visit in pairs, have access to a cell phone at all times, and wear a limited amount of jewelry. The car should be
parked in a well-lit area and locked at all times. An extra set of keys kept in the nursing home care bag avoids
time and frustration if the nurse should become locked out of her automobile. Car keys spread between the
fingers can also be used of the weapon if necessary. Groups of strangers, dark alleys, and unrestrained dogs
should be avoided at all times.
MATCHING
You are getting ready to participate in discharge teaching with a nonEnglish-speaking new mother. The
interpreter has arrived on the patient care unit to assist you in providing culturally competent care. In the
correct order, from 1 through 6, number the steps that you would take to work with the interpreter.
a. Introduce yourself to the interpreter and converse informally.

b. Outline your statements and questions, listing the key pieces of information you need to know.
c. Make sure the interpreter is comfortable with technical terms.
d. Learn something about the culture of the patient.
e. Make notes on what you learned for future reference.
f. Stop every now and then and ask the interpreter How is it going?
21. Step One
22. Step Two
23. Step Three
24. Step Four
25. Step Five
26. Step Six
MSC: Client Needs: Health Promotion and Maintenance
NOT: To work successfully with an interpreter, the nurse must organize her teaching into four categories.
These include actions that are necessary before the interview, meeting with the interpreter, during the
interview, and after the interview. The nurse must be sensitive to cultural and situational differences (e.g., a
woman from the Middle East may not wish to have a male interpreter present).

25. ANS: F PTS: 1 DIF: Cognitive Level: Application
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Chapter 03: Assessment and Health Promotion
MULTIPLE CHOICE
1. The two primary functions of the ovary are:
a. Normal female development and sex hormone release.
b. Ovulation and internal pelvic support.
c. Sexual response and ovulation.
d. Ovulation and hormone production.
ANS: 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; the ovaries are not responsible for internal pelvic support.
Sexual response is a feedback mechanism involving the hypothalamus, anterior pituitary gland, and the
ovaries. Ovulation does occur in the ovaries.
2. The uterus is a muscular, pear-shaped organ that is responsible for:
a. Cyclic menstruation. c. Fertilization.
b. Sex hormone production. d. Sexual arousal.
ANS: A
The uterus is an organ for reception, implantation, retention, and nutrition of the fertilized ovum; it also is
responsible for cyclic menstruation. Hormone production and fertilization occur in the ovaries. Sexual arousal
is a feedback mechanism involving the hypothalamus, the pituitary gland, and the ovaries.
3. Unique muscle fibers make the uterine myometrium ideally suited for:
a. Menstruation. c. Ovulation.
b. The birth process. 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.
4. The hormone responsible for maturation of mammary gland tissue is:
a. Estrogen. c. Prolactin.
b. Testosterone. 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 emptying of the breasts.
5. Because of the effect of cyclic ovarian changes on the breast, the best time for breast self-examination (BSE)
is:
a. 5 to 7 days after menses ceases. c. Midmenstrual cycle.
b. Day 1 of the endometrial cycle. d. Any time during a shower or bath.
ANS: A
The physiologic alterations in breast size and activity reach their minimal level about 5 to 7 days after
menstruation stops. All women should perform BSE during this phase of the menstrual cycle.
6. Menstruation is periodic uterine bleeding:
a. That occurs every 28 days.
b. In which the entire uterine lining is shed.
c. That is regulated by ovarian hormones.
d. That leads to fertilization.
ANS: C

Menstruation is periodic uterine bleeding that is controlled by a feedback system involving three cycles:
endometrial, hypothalamic-pituitary, and ovarian. The average length of a menstrual cycle is 28 days, but
variations are normal. During the endometrial cycle, the functional two thirds of the endometrium is shed. Lack
of fertilization leads to menstruation.
7. Individual irregularities in the ovarian (menstrual) cycle are most often caused by:
a. Variations in the follicular (preovulatory) phase.
b. An intact hypothalamic-pituitary feedback mechanism.
c. A functioning corpus luteum.
d. A 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 is regular, not irregular. The luteal phase begins
after ovulation. The corpus luteum depends 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.
8. Prostaglandins are produced in most organs of the body, including the uterus. Other source(s) of
prostaglandins is/are:
a. Ovaries. c. Menstrual blood.
b. Breast milk. d. The vagina.
ANS: C
Menstrual blood is a potent source of prostaglandins. Prostaglandins are produced in most organs of the body
and in menstrual blood. The ovaries, breast milk, and vagina are neither organs nor a source of prostaglandins.
9. Physiologically, sexual response can be characterized by:
a. Coitus, masturbation, and fantasy. c. Erection and orgasm.
b. Myotonia and vasocongestion. 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.
10. The long-term treatment plan for an adolescent with an eating disorder focuses on:
a. Managing the effects of malnutrition.
b. Establishing sufficient caloric intake.
c. Improving family dynamics.
d. Restructuring 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 individuals
body image.
11. 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 states, I have special undergarments that I do not remove
for religious reasons. The most appropriate response from the nurse would be:
a. You cant have an examination without removing all your clothes.
b. Ill ask the doctor to modify the examination.
c. Tell me about your undergarments. Ill explain the examination procedure, and then we can discuss
how you can have your examination comfortably.
d. What? Ive never heard of such a thing! That sounds different and strange.
ANS: C
This statement reflects cultural competence by the nurse and shows respect for the womans religious practices.
The nurse must respect the rich and unique qualities that cultural diversity brings to individuals. In recognizing

the value of these differences, the nurse can modify the plan of care to meet the needs of each woman.
12. 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 doctor has retired, and she is going to
see the womens health nurse practitioner for her visit. To facilitate a positive health care experience, the nurse
should:
a. Remind the woman that she is long overdue for her examination and that she should come in
annually.
b. Listen carefully and allow extra time for this womans health history interview.
c. Reassure the woman that a nurse practitioner is just as good as her old doctor.
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 and to ensure 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 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 with women in this age group.
13. 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 would be to:
a. Reassure the woman that the examination will not reveal any problems.
b. Explain the process of vulvar self-examination to the woman and reassure her 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.

14. 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. The nurses
initial response should be to:
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 history and physical examination is the clients description of any symptoms she
may be experiencing. Although vaginal creams may interfere with the Pap test, the best response is for the
nurse to inquire about the symptoms the patient 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.
15. The transition phase during which ovarian function and hormone production decline is called:
a. The climacteric. c. Menopause.
b. Menarche. d. Puberty.
ANS: A
The climacteric is a transitional phase 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 stage between childhood and sexual maturity.
16. Which statement would indicate that the client requires additional instruction about breast self-
examination?
a. Yellow discharge from my nipple is normal if Im having my period.
b. I should check my breasts at the same time each month, like 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. I should check my breasts
at the same time each month, like after my period, I should also feel in my armpit area while performing my
breast examination, and I should check each breast in a set way, such as in a circular motion all indicate
successful learning.
17. A woman who is 6 months pregnant has sought medical attention, saying she fell down the stairs. What
scenario would cause an emergency department nurse to suspect that the woman has been a victim of intimate
partner violence (IPV)?
a. The woman and her partner are having an argument that is loud and hostile.
b. The woman has injuries on various parts of her body that are in different stages of healing.
c. Examination reveals a fractured arm and fresh bruises.
d. She avoids making eye contact and is hesitant to answer questions.
ANS: B
The patient may have multiple injuries in various stages of healing that indicates a pattern of violence. An
argument is not always an indication of battering. A fractured arm and fresh bruises could be caused by the
reported fall and doesnt necessarily indicate IPV. . It is normal for the woman to have a flat affect.
18. A 20-year-old patient calls the clinic to report that she has found a lump in her breast. The nurses best
response is:
a. Dont worry about it. Im sure its nothing.
b. Wear a tight bra, and it should shrink.
c. Many women have benign lumps and bumps in their breasts. However, to make sure that its
benign, you should come in for an examination by your physician.
d. Check it again in 1 month and call me back if its still there.
ANS: C

The nurse should try to ease the clients fear, but provide a time for a thorough evaluation of the lump because
it may indicate abnormal changes in the breast. Discrediting the patients findings may discourage her from
continuing with breast self-examination. Wearing a tight bra may irritate the skin and would not cause the
lump to shrink. Delaying treatment may allow proliferation of abnormal cells.
19. The female reproductive organ(s) responsible for cyclic menstruation is/are the:
a. Uterus. c. Vaginal vestibule.
b. Ovaries. d. Urethra.
ANS: A
The uterus is responsible for cyclic menstruation. It also houses and nourishes the fertilized ovum and the
fetus. The ovaries are responsible for ovulation and production of estrogen; the uterus is responsible for cyclic
menstruation. The vaginal vestibule is an external organ that has openings to the urethra and vagina; the uterus
is responsible for cyclic menstruation. The urethra is not a reproductive organ, although it is found in the area.
20. The body part that both protects the pelvic structures and accommodates the growing fetus during
pregnancy is the:
a. Perineum. c. Vaginal vestibule.
b. Bony pelvis. 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.
21. A fully matured endometrium that has reached the thickness of heavy, soft velvet describes the _____
phase of the endometrial cycle.
a. Menstrual c. Secretory
b. Proliferative d. Ischemic
ANS: C
The secretory phase extends from the day of ovulation to approximately 3 days before the next menstrual
cycle. During this phase, the endometrium becomes fully mature. During the menstrual phase, the

endometrium is being shed; the endometrium is fully mature again during the secretory phase. The
proliferative phase is a period of rapid growth, but the endometrium becomes fully mature again during the
secretory phase. During the ischemic phase, the blood supply is blocked, and necrosis develops. The
endometrium is fully mature during the secretory phase.
22. The stimulated release of gonadotropin-releasing hormone and follicle-stimulating hormone is part of the:
a. Menstrual cycle. c. Ovarian cycle.
b. Endometrial cycle. d. Hypothalamic-pituitary cycle.
ANS: D
The menstrual, endometrial, and ovarian cycles are interconnected. However, the cyclic release of hormones is
the function of the hypothalamus and pituitary glands.
23. Certain fatty acids classified as hormones that are found in many body tissues and that have roles in many
reproductive functions are known as:
a. Gonadotropin-releasing hormone (GnRH).
b. Prostaglandins (PGs).
c. Follicle-stimulating hormone (FSH).
d. Luteinizing hormone (LH).
ANS: B
PGs affect smooth muscle contraction and changes in the cervix. GnRH, FSH, and LH are part of the
hypothalamic-pituitary cycle, which responds to the rise and fall of estrogen and progesterone.
24. 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. The orgasmic phase is the final state of the sexual response cycle.

d. Facial grimaces and spasms of 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).
25. As part of their participation in the gynecologic portion of the physical examination, nurses should:
a. Take a firm approach that encourages the client to facilitate the examination by following the
physicians 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 cancer.
d. Help the woman relax through 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 patient to participate in an active partnership with the 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.
26. During which phase of the cycle of violence does the batterer become contrite and remorseful?
a. Battering phase c. Tension-building phase
b. Honeymoon phase d. Increased drug-taking phase
ANS: B
During the tension-building phase, the batterer becomes increasingly hostile, swears, threatens, and throws
things. This is followed by the battering phase where violence actually occurs, and the victim feels powerless.
During the honeymoon phase, the victim of IPV wants to believe that the battering will never happen again,

and the batterer will promise anything to get back into the home. Often the batterer increases the use of drugs
during the tension-building phase.
27. A patient at 24 weeks of gestation says she has a glass of wine with dinner every evening. The nurse will
counsel her to eliminate all alcohol intake because:
a. A daily consumption of alcohol indicates a risk for alcoholism.
b. She will be at risk for abusing other substances as well.
c. The fetus is placed at risk for altered brain growth.
d. The fetus is at risk for multiple organ anomalies.
ANS: C
There is no period during pregnancy when it is safe to consume alcohol. The documented effects of alcohol
consumption during pregnancy include mental retardation, learning disabilities, high activity level, and short
attention span. The 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.
28. As a powerful central nervous system stimulant, which of these substances can lead to miscarriage, preterm
labor, placental separation (abruption), and stillbirth?
a. Heroin c. PCP
b. Alcohol d. Cocaine
ANS: D
Cocaine is a powerful CNS stimulant. Effects on pregnancy associated with cocaine use include abruptio
placentae, preterm labor, precipitous birth, and stillbirth. Heroin is an opiate. Its use in pregnancy is associated
with preeclampsia, intrauterine growth restriction, miscarriage, premature rupture of membranes, infections,
breech presentation, and preterm labor. The most serious effect of alcohol use in pregnancy is fetal alcohol
syndrome. The major concerns regarding PCP use in pregnant women are its association with polydrug abuse
and the neurobehavioral effects on the neonate.
29. The microscopic examination of scrapings from the cervix, endocervix, or other mucous membranes to
detect premalignant or malignant cells is called:
a. Bimanual palpation. c. A Papanicolaou (Pap) test.

b. Rectovaginal palpation. d. A four As procedure.
ANS: C
The Pap test is a microscopic examination for cancer that should be performed regularly, depending on the
clients age. Bimanual palpation is a physical examination of the vagina. Rectovaginal palpation is a physical
examination performed through the rectum. The four As is an intervention procedure to help a patient stop
smoking.
OBJ: Nursing Process: Implementation MSC: Client Needs: Physiologic Integrity
30. As a girl progresses through development, she may be at risk for a number of age-related conditions. While
preparing a 21-year-old client for her first adult physical examination and Papanicolaou (Pap) test, the nurse is
aware of excessiveness shyness. The young woman states that she will not remove her bra because, There is
something wrong with my breasts; one is way bigger. What is the best response by the nurse in this situation?
a. Please reschedule your appointment until you are more prepared.
b. It is okay; the provider will not do a breast examination.
c. I will explain normal growth and breast development to you.
d. That is unfortunate; this must be very stressful for you.
ANS: C
During adolescence, one breast may grow faster than the other. Discussion regarding this aspect of growth and
development with the patient will reassure her that there may be nothing wrong with her breasts. Young
women usually enter the health system for screening (Pap tests begin at age 21 or 3 years after first sexual
activity). Situations such as these can produce great stress for the young woman, and the nurse and health care
provider should treat her carefully. Asking her to reschedule would likely result in the clients not returning for
her appointment at all. A breast examination at her age is part of the complete physical examination. Young
women should be taught about normal breast development and begin doing breast self-examinations. Although
the last response shows empathy on the part of the nurse and acknowledges the patients stress, it does not
correct the patients deficient knowledge related to normal growth and development.
OBJ: Nursing Process: Diagnosis MSC: Client Needs: Health Promotion and Maintenance
31. Which statement by the patient indicates that she understands breast self-examination?
a. I will examine both breasts in two different positions.
b. I will perform breast self-examination 1 week after my menstrual period starts.
c. I will examine the outer upper area of the breast only.
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 patient 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 patient should use the sensitive pads of the middle three fingers.
32. A pregnant woman who abuses cocaine admits to exchanging sex for her drug habit. This behavior places
her at a greater risk for:
a. Depression of the central nervous system
b. Hypotension and vasodilation
c. Sexually transmitted diseases
d. Postmature birth
ANS: C
Sex acts exchanged for drugs places the woman at increased risk for sexually transmitted diseases because of
multiple partners and lack of protection. Cocaine is a central nervous system stimulant that causes
hypertension and vasoconstriction. Premature delivery of the infant is one of the most common problems
associated with cocaine use during pregnancy.
33. A woman who is older than 35 years may have difficulty achieving pregnancy primarily because:
a. Personal risk behaviors influence fertility
b. She has 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.

34. The most dangerous effect on the fetus of a mother who smokes cigarettes while pregnant is:
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 normally will not cause genetic changes or extensive central nervous
system damage. Addiction to tobacco is not a usual concern related to the neonate.
35. Despite warnings, prenatal exposure to alcohol continues to exceed by far exposure to illicit drugs. A
diagnosis of fetal alcohol syndrome (FAS) is made when there are visible markers in each of three categories.
Which is category is not associated with a diagnosis of FAS?
a. Respiratory conditions c. CNS abnormality
b. Impaired growth d. Craniofacial dysmorphologies
ANS: A
Respiratory difficulties are not a category of conditions that are related to FAS. Abnormalities related to FAS
include organ deformities, genital malformations, and kidney and urinary defects. Impaired growth is a visible
marker for FAS. CNS abnormalities with neurologic and intellectual impairments are categories used to assist
in the diagnosis of FAS. An infant with FAS manifests at least two craniofacial abnormalities, such as
microcephaly, short palpebral fissures, poorly developed philtrum, thin upper lip, or flattening of the maxilla.
36. When the nurse is alone with a battered patient, the patient seems extremely anxious and says, It was all my
fault. The house was so messy when he got home and I know he hates that. The best response by the nurse is:
a. No one deserves to be hurt. Its not your fault. How can I help you?
b. What else do you do that makes him angry enough to hurt you?
c. He will never find out what we talk about. Dont worry. Were here to help you.

d. You have to remember that he is frustrated and angry so he takes it out on you.
ANS: A
The nurse should stress that the patient is not at fault. Asking what the patient did to make her husband angry
is placing the blame on the woman and would be an inappropriate statement. The nurse should not provide
false reassurance. To assist the woman, the nurse should be honest. Often the batterer will find out about the
conversation.
37. A common effect of both smoking and cocaine use in the pregnant woman is:
a. Vasoconstriction c. Changes in insulin metabolism
b. Increased appetite d. Increased metabolism
ANS: A
Both smoking and cocaine use cause vasoconstriction, which results in impaired placental blood flow to the
fetus. Smoking and cocaine use decrease the appetite. Smoking and cocaine use do not change insulin
metabolism. Smoking can increase metabolism.
MULTIPLE RESPONSE
38. Many pregnant teens wait until the second or third trimester to seek prenatal care. The nurse should
understand that the reasons behind this delay include:
a. Lack of realization that they are pregnant.
b. Uncertainty as to where to go for care.
c. Continuing to deny the pregnancy.
d. A desire to gain control over their situation.
e. Wanting to hide the pregnancy as long as possible.
ANS: A, B, C, E
These are all valid reasons for the teen to 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 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 feelings of competency. Receiving praise from the
nurse when she attends her prenatal appointments will reinforce the teens positive self-image.

OBJ: 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) d. Hepatitis B
b. Measles, mumps, rubella e. Influenza
c. Herpes Zoster f. Human papillomavirus (HPV)
39. Three injections for girls between the ages 9 to 26.
40. Primary series of three injections.
41. Annually.
42. Once and then a booster every 10 years.
43. One dose after age 65.
44. Once if born after 1956.
39. ANS: F PTS: 1 DIF: Cognitive Level: Application
NOT: These guidelines are applicable to most women; however, health care providers individualize the timing
of tests and immunizations for each woman.

Chapter 04: Reproductive System Concerns
MULTIPLE CHOICE
1. When assessing a patient for amenorrhea, the nurse should be aware that this is unlikely to be caused by:
a. Anatomic abnormalities. c. Lack of exercise.
b. Type 1 diabetes mellitus. d. Hysterectomy.
ANS: C
Lack of exercise is not a cause of amenorrhea. Strenuous exercise may cause amenorrhea. Anatomic
abnormalities, type 1 diabetes mellitus, and hysterectomy all are possible causes of amenorrhea.
2. When a nurse is counseling a woman for primary dysmenorrhea, which nonpharmacologic intervention
might be recommended?
a. Increasing the intake of red meat and simple carbohydrates
b. Reducing the intake of diuretic foods such as peaches and asparagus
c. Temporarily substituting physical activity for a sedentary lifestyle
d. Using a heating pad on the abdomen to relieve cramping
ANS: D
Heat minimizes cramping by increasing vasodilation and muscle relaxation and minimizing uterine ischemia.
Dietary changes such as eating less red meat may be recommended for women experiencing dysmenorrhea.
Increasing the intake of diuretics, including natural diuretics such as asparagus, cranberry juice, peaches,
parsley, and watermelon, may help ease the symptoms associated with dysmenorrhea. Exercise has been found
to help relieve menstrual discomfort through increased vasodilation and subsequent decreased ischemia.
3. Which symptom described by a patient is characteristic of premenstrual syndrome (PMS)?
a. I feel irritable and moody a week before my period is supposed to start.
b. I have lower abdominal pain beginning the third day of my menstrual period.
c. I have nausea and headaches after my period starts, and they last 2 to 3 days.

d. I have abdominal bloating and breast pain after a couple days of my period.
ANS: A
PMS is a cluster of physical, psychologic, and behavioral symptoms that begin in the luteal phase of the
menstrual cycle and resolve within a couple of days of the onset of menses. Complaints of lower abdominal
pain, nausea and headaches, and abdominal bloating all are associated with PMS. However, the timing
reflected is inaccurate.
4. A woman complains of severe abdominal and pelvic pain around the time of menstruation that has gotten
worse over the last 5 years. She also complains of pain during intercourse and has tried unsuccessfully to get
pregnant for the past 18 months. These symptoms are most likely related to:
a. Endometriosis. c. Primary dysmenorrhea.
b. PMS. d. Secondary dysmenorrhea.
ANS: A
Symptoms of endometriosis can change over time and may not reflect the extent of the disease. Major
symptoms include dysmenorrhea and deep pelvic dyspareunia (painful intercourse). Impaired fertility may
result from adhesions caused by endometriosis. Although endometriosis may be associated with secondary
dysmenorrhea, it is not a cause of primary dysmenorrhea or PMS. In addition, this woman is complaining of
dyspareunia and infertility, which are associated with endometriosis, not with PMS or primary or secondary
dysmenorrhea.
5. Nafarelin is currently used as a treatment for mild-to-severe endometriosis. The nurse should tell a woman
taking this medication that the drug:
a. Stimulates the secretion of gonadotropin-releasing hormone (GnRH), thereby stimulating ovarian
activity.
b. Should be sprayed into one nostril every other day.
c. Should be injected into subcutaneous tissue BID.
d. Can cause her to experience some hot flashes and vaginal dryness.
ANS: D
Nafarelin is a GnRH agonist, and its side effects are similar to effects of menopause. The hypoestrogenism
effect results in hot flashes and vaginal dryness. Nafarelin is a GnRH agonist that suppresses the secretion of
GnRH and is administered twice daily by nasal spray.

6. While interviewing a 31-year-old woman before her routine gynecologic examination, the nurse collects
data about the clients recent menstrual cycles. The nurse should collect additional information with which
statement?
a. The woman says her menstrual flow lasts 5 to 6 days.
b. She describes her flow as very heavy.
c. She reports that she has had a small amount of spotting midway between her periods for the past 2
months.
d. She says the length of her menstrual cycle varies from 26 to 29 days.
ANS: B
Menorrhagia is defined as excessive menstrual bleeding, in either duration or amount. Heavy bleeding can
have many causes. The amount of bleeding and its effect on daily activities should be evaluated. A menstrual
flow lasting 5 to 6 days is a normal finding. Mittlestaining, a small amount of bleeding or spotting that occurs
at the time of ovulation (14 days before onset of the next menses), is considered normal. During her
reproductive years, a woman may have physiologic variations in her menstrual cycle. Variations in the length
of a menstrual cycle are considered normal.
7. When evaluating a patient whose primary complaint is amenorrhea, the nurse must be aware that lack of
menstruation is most often the result of:
a. Stress. c. Pregnancy.
b. Excessive exercise. d. Eating disorders.
ANS: C
Amenorrhea, or the absence of menstrual flow, is most often a result of pregnancy. Although stress, excessive
exercise, and eating disorders all may be contributing factors, none is the most common factor associated with
amenorrhea.
OBJ: Nursing Process: Assessment, Diagnosis
8. A 36-year-old woman has been given a diagnosis of uterine fibroids. When planning care for this patient, the
nurse should know that:
a. Fibroids are malignant tumors of the uterus that require radiation or chemotherapy.

Maternal Child Nursing Care 6th Edition Perry Test Bank

Maternal Child Nursing Care 6th Edition Perry Test Bank

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