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MATERNAL AND CHILD HEALTH likely the result of which of the

NURSING PRACTICE QUESTIONS WITH following?


RATIONALE
a. Increased plasma HCG levels
1. When assessing the adequacy of b. Decreased intestinal motility
sperm for conception to occur, c. Decreased gastric acidity
which of the following is the most d. Elevated estrogen levels
useful criterion? 5. On which of the following areas
a. Sperm count would the nurse expect to observe
b. Sperm motility chloasma?
c. Sperm maturity
a. Breast, areola, and nipples
d. Semen volume
b. Chest, neck, arms, and legs
2. A couple who wants to conceive but
c. Abdomen, breast, and thighs
has been unsuccessful during the
d. Cheeks, forehead, and nose
last 2 years has undergone many
6. A pregnant client states that she
diagnostic procedures. When
“waddles” when she walks. The
discussing the situation with the
nurse’s explanation is based on
nurse, one partner states, “We know
which of the following as the cause?
several friends in our age group and
all of them have their own child
a. The large size of the
already, Why can’t we have one?”.
newborn
Which of the following would be the
b. Pressure on the pelvic
most pertinent nursing diagnosis for
muscles
this couple?
c. Relaxation of the pelvic
joints
a. Fear related to the unknown
d. Excessive weight gain
b. Pain related to numerous
7. Which of the following represents
procedures.
the average amount of weight
c. Ineffective family coping
gained during pregnancy?
related to infertility.
d. Self-esteem disturbance
a. 12 to 22 lb
related to infertility.
b. 15 to 25 lb
3. Which of the following urinary
c. 24 to 30 lb
symptoms does the pregnant
d. 25 to 40 lb
woman most frequently experience
8. When talking with a pregnant client
during the first trimester?
who is experiencing aching swollen,
leg veins, the nurse would explain
a. Dysuria
that this is most probably the result
b. Frequency
of which of the following?
c. Incontinence
d. Burning
a. Thrombophlebitis
4. Heartburn and flatulence, common
b. Pregnancy-induced
in the second trimester, are most
hypertension
c. Pressure on blood vessels 13. Which of the following would be
from the enlarging uterus disadvantage of breast feeding?
d. The force of gravity pulling
down on the uterus a. Involution occurs more
9. Cervical softening and uterine rapidly
souffle are classified as which of the b. The incidence of allergies
following? increases due to maternal
antibodies
a. Diagnostic signs c. The father may resent the
b. Presumptive signs infant’s demands on the
c. Probable signs mother’s body
d. Positive signs d. There is a greater chance for
10. Which of the following would the error during preparation
nurse identify as a presumptive sign 14. Which of the following would cause
of pregnancy? a false-positive result on a
pregnancy test?
a. Hegar sign
b. Nausea and vomiting a. The test was performed less
c. Skin pigmentation changes than 10 days after an
d. Positive serum pregnancy abortion
test b. The test was performed too
11. Which of the following common early or too late in the
emotional reactions to pregnancy pregnancy
would the nurse expect to occur c. The urine sample was stored
during the first trimester? too long at room
temperature
a. Introversion, egocentrism, d. A spontaneous abortion or a
narcissism missed abortion is impending
b. Awkwardness, clumsiness, 15. FHR can be auscultated with a
and unattractiveness fetoscope as early as which of the
c. Anxiety, passivity, following?
extroversion
d. Ambivalence, fear, fantasies a. 5 weeks gestation
12. During which of the following would b. 10 weeks gestation
the focus of classes be mainly on c. 15 weeks gestation
physiologic changes, fetal d. 20 weeks gestation
development, sexuality, during 16. A client LMP began July 5. Her EDD
pregnancy, and nutrition? should be which of the following?

a. Prepregnant period a. January 2


b. First trimester b. March 28
c. Second trimester c. April 12
d. Third trimester d. October 12
17. Which of the following fundal b. Second stage
heights indicates less than 12 weeks’ c. Third stage
gestation when the date of the LMP d. Fourth stage
is unknown? 22. Barbiturates are usually not given
for pain relief during active labor for
a. Uterus in the pelvis which of the following reasons?
b. Uterus at the xiphoid
c. Uterus in the abdomen a. The neonatal effects include
d. Uterus at the umbilicus hypotonia, hypothermia,
18. Which of the following danger signs generalized drowsiness, and
should be reported promptly during reluctance to feed for the
the antepartum period? first few days.
b. These drugs readily cross the
a. Constipation placental barrier, causing
b. Breast tenderness depressive effects in the
c. Nasal stuffiness newborn 2 to 3 hours after
d. Leaking amniotic fluid intramuscular injection.
19. Which of the following prenatal c. They rapidly transfer across
laboratory test values would the the placenta, and lack of an
nurse consider as significant? antagonist make them
generally inappropriate
a. Hematocrit 33.5% during labor.
b. Rubella titer less than 1:8 d. Adverse reactions may
c. White blood cells include maternal
8,000/mm3 hypotension, allergic or toxic
d. One hour glucose challenge reaction or partial or total
test 110 g/dL respiratory failure
20. Which of the following 23. Which of the following nursing
characteristics of contractions would interventions would the nurse
the nurse expect to find in a client perform during the third stage of
experiencing true labor? labor?

a. Occurring at irregular a. Obtain a urine specimen and


intervals other laboratory tests.
b. Starting mainly in the b. Assess uterine contractions
abdomen every 30 minutes.
c. Gradually increasing intervals c. Coach for effective client
d. Increasing intensity with pushing
walking d. Promote parent-newborn
21. During which of the following stages interaction.
of labor would the nurse assess 24. Which of the following actions
“crowning”? demonstrates the nurse’s
understanding about the newborn’s
a. First stage thermoregulatory ability?
a. Placing the newborn under a a. The anterior is triangular
radiant warmer. shaped; the posterior is
b. Suctioning with a bulb diamond shaped.
syringe b. The posterior closes at 18
c. Obtaining an Apgar score months; the anterior closes
d. Inspecting the newborn’s at 8 to 12 weeks.
umbilical cord c. The anterior is large in size
25. Immediately before expulsion, when compared to the
which of the following cardinal posterior fontanel.
movements occur? d. The anterior is bulging; the
posterior appears sunken.
a. Descent 30. Which of the following groups of
b. Flexion newborn reflexes below are present
c. Extension at birth and remain unchanged
d. External rotation through adulthood?
26. Before birth, which of the following
structures connects the right and a. Blink, cough, rooting, and
left auricles of the heart? gag
b. Blink, cough, sneeze, gag
a. Umbilical vein c. Rooting, sneeze, swallowing,
b. Foramen ovale and cough
c. Ductus arteriosus d. Stepping, blink, cough, and
d. Ductus venosus sneeze
27. Which of the following when 31. Which of the following describes the
present in the urine may cause a Babinski reflex?
reddish stain on the diaper of a
newborn? a. The newborn’s toes will
hyperextend and fan apart
a. Mucus from dorsiflexion of the big
b. Uric acid crystals toe when one side of foot is
c. Bilirubin stroked upward from the
d. Excess iron ball of the heel and across
28. When assessing the newborn’s heart the ball of the foot.
rate, which of the following ranges b. The newborn abducts and
would be considered normal if the flexes all extremities and
newborn were sleeping? may begin to cry when
exposed to sudden
a. 80 beats per minute movement or loud noise.
b. 100 beats per minute c. The newborn turns the head
c. 120 beats per minute in the direction of stimulus,
d. 140 beats per minute opens the mouth, and begins
29. Which of the following is true to suck when cheek, lip, or
regarding the fontanels of the corner of mouth is touched.
newborn?
d. The newborn will attempt to a. Threatened
crawl forward with both b. Imminent
arms and legs when he is c. Missed
placed on his abdomen on a d. Incomplete
flat surface 35. Which of the following factors
32. Which of the following statements would the nurse suspect as
best describes hyperemesis predisposing a client to placenta
gravidarum? previa?

a. Severe anemia leading to a. Multiple gestation


electrolyte, metabolic, and b. Uterine anomalies
nutritional imbalances in the c. Abdominal trauma
absence of other medical d. Renal or vascular disease
problems. 36. Which of the following would the
b. Severe nausea and vomiting nurse assess in a client experiencing
leading to electrolyte, abruptio placenta?
metabolic, and nutritional
imbalances in the absence a. Bright red, painless vaginal
of other medical problems. bleeding
c. Loss of appetite and b. Concealed or external dark
continuous vomiting that red bleeding
commonly results in c. Palpable fetal outline
dehydration and ultimately d. Soft and nontender
decreasing maternal abdomen
nutrients 37. Which of the following is described
d. Severe nausea and diarrhea as premature separation of a
that can cause normally implanted placenta during
gastrointestinal irritation and the second half of pregnancy,
possibly internal bleeding usually with severe hemorrhage?
33. Which of the following would the
nurse identify as a classic sign of a. Placenta previa
PIH? b. Ectopic pregnancy
c. Incompetent cervix
a. Edema of the feet and ankles d. Abruptio placentae
b. Edema of the hands and 38. Which of the following may happen
face if the uterus becomes
c. Weight gain of 1 lb/week overstimulated by oxytocin during
d. Early morning headache the induction of labor?
34. In which of the following types of
spontaneous abortions would the a. Weak contraction prolonged
nurse assess dark brown vaginal to more than 70 seconds
discharge and a negative pregnancy b. Tetanic contractions
tests? prolonged to more than 90
seconds
c. Increased pain with bright a. The chorion and amnion
red vaginal bleeding rupture 4 hours before the
d. Increased restlessness and onset of labor.
anxiety b. PROM removes the fetus
39. When preparing a client for most effective defense
cesarean delivery, which of the against infection
following key concepts should be c. Nursing care is based on fetal
considered when implementing viability and gestational age.
nursing care? d. PROM is associated with
malpresentation and possibly
a. Instruct the mother’s incompetent cervix
support person to remain in 42. Which of the following factors is the
the family lounge until after underlying cause of dystocia?
the delivery
b. Arrange for a staff member a. Nurtional
of the anesthesia b. Mechanical
department to explain what c. Environmental
to expect postoperatively d. Medical
c. Modify preoperative 43. When uterine rupture occurs, which
teaching to meet the needs of the following would be the
of either a planned or priority?
emergency cesarean birth
d. Explain the surgery, expected a. Limiting hypovolemic shock
outcome, and kind of b. Obtaining blood specimens
anesthetics c. Instituting complete bed rest
40. Which of the following best d. Inserting a urinary catheter
describes preterm labor? 44. Which of the following is the nurse’s
initial action when umbilical cord
a. Labor that begins after 20 prolapse occurs?
weeks gestation and before
37 weeks gestation a. Begin monitoring maternal
b. Labor that begins after 15 vital signs and FHR
weeks gestation and before b. Place the client in a knee-
37 weeks gestation chest position in bed
c. Labor that begins after 24 c. Notify the physician and
weeks gestation and before prepare the client for
28 weeks gestation delivery
d. Labor that begins after 28 d. Apply a sterile warm saline
weeks gestation and before dressing to the exposed cord
40 weeks gestation 45. Which of the following amounts of
41. When PROM occurs, which of the blood loss following birth marks the
following provides evidence of the criterion for describing postpartum
nurse’s understanding of the client’s hemorrhage?
immediate needs?
a. More than 200 ml a. Midcalf pain, tenderness and
b. More than 300 ml redness along the vein
c. More than 400 ml b. Chills, fever, malaise,
d. More than 500 ml occurring 2 weeks after
46. Which of the following is the delivery
primary predisposing factor related c. Muscle pain the presence of
to mastitis? Homans sign, and swelling in
the affected limb
a. Epidemic infection from d. Chills, fever, stiffness, and
nosocomial sources localizing pain occurring 10 to 14 days
in the lactiferous glands and after delivery
ducts 49. Which of the following are the most
b. Endemic infection occurring commonly assessed findings in
randomly and localizing in cystitis?
the periglandular connective
tissue a. Frequency, urgency,
c. Temporary urinary retention dehydration, nausea, chills,
due to decreased perception and flank pain
of the urge to avoid b. Nocturia, frequency,
d. Breast injury caused by urgency dysuria, hematuria,
overdistention, stasis, and fever and suprapubic pain
cracking of the nipples c. Dehydration, hypertension,
47. Which of the following best dysuria, suprapubic pain,
describes thrombophlebitis? chills, and fever
d. High fever, chills, flank pain
a. Inflammation and clot nausea, vomiting, dysuria,
formation that result when and frequency
blood components combine 50. Which of the following best reflects
to form an aggregate body the frequency of reported
b. Inflammation and blood clots postpartum “blues”?
that eventually become
lodged within the pulmonary a. Between 10% and 40% of all
blood vessels new mothers report some
c. Inflammation and blood clots form of postpartum blues
that eventually become b. Between 30% and 50% of all
lodged within the femoral new mothers report some
vein form of postpartum blues
d. Inflammation of the vascular c. Between 50% and 80% of all
endothelium with clot new mothers report some
formation on the vessel wall form of postpartum blues
48. Which of the following assessment d. Between 25% and 70% of all
findings would the nurse expect if new mothers report some
the client develops DVT? form of postpartum blues
51. For the client who is using oral time!” Which of the following
contraceptives, the nurse informs should the nurse recommend?
the client about the need to take the
pill at the same time each day to a. Daily enemas
accomplish which of the following? b. Laxatives
c. Increased fiber intake
a. Decrease the incidence of d. Decreased fluid intake
nausea 56. Which of the following would the
b. Maintain hormonal levels nurse use as the basis for the
c. Reduce side effects teaching plan when caring for a
d. Prevent drug interactions pregnant teenager concerned about
gaining too much weight during
52. When teaching a client about pregnancy?
contraception. Which of the
following would the nurse include as a. 10 pounds per trimester
the most effective method for b. 1 pound per week for 40
preventing sexually transmitted weeks
infections? c. ½ pound per week for 40
a. Spermicides weeks
b. Diaphragm d. A total gain of 25 to 30
c. Condoms pounds
d. Vasectomy 57. The client tells the nurse that her
53. When preparing a woman who is 2 last menstrual period started on
days postpartum for discharge, January 14 and ended on January
recommendations for which of the 20. Using Nagele’s rule, the nurse
following contraceptive methods determines her EDD to be which of
would be avoided? the following?

a. Diaphragm a. September 27
b. Female condom b. October 21
c. Oral contraceptives c. November 7
d. Rhythm method d. December 27
54. For which of the following clients 58. When taking an obstetrical history
would the nurse expect that an on a pregnant client who states, “I
intrauterine device would not be had a son born at 38 weeks
recommended? gestation, a daughter born at 30
weeks gestation and I lost a baby at
a. Woman over age 35 about 8 weeks,” the nurse should
b. Nulliparous woman record her obstetrical history as
c. Promiscuous young adult which of the following?
d. Postpartum client
55. A client in her third trimester tells a. G2 T2 P0 A0 L2
the nurse, “I’m constipated all the b. G3 T1 P1 A0 L2
c. G3 T2 P0 A0 L2
d. G4 T2 P1 A1 L2 a. Threatened abortion
59. When preparing to listen to the fetal b. Imminent abortion
heart rate at 12 weeks’ gestation, c. Complete abortion
the nurse would use which of the d. Missed abortion
following? 63. Which of the following would be the
priority nursing diagnosis for a client
a. Stethoscope placed midline with an ectopic pregnancy?
at the umbilicus
b. Doppler placed midline at a. Risk for infection
the suprapubic region b. Pain
c. Fetoscope placed midway c. Knowledge Deficit
between the umbilicus and d. Anticipatory Grieving
the xiphoid process 64. Before assessing the postpartum
d. External electronic fetal client’s uterus for firmness and
monitor placed at the position in relation to the umbilicus
umbilicus and midline, which of the following
60. When developing a plan of care for a should the nurse do first?
client newly diagnosed with
gestational diabetes, which of the a. Assess the vital signs
following instructions would be the b. Administer analgesia
priority? c. Ambulate her in the hall
d. Assist her to urinate
a. Dietary intake 65. Which of the following should the
b. Medication nurse do when a primipara who is
c. Exercise lactating tells the nurse that she has
d. Glucose monitoring sore nipples?
61. A client at 24 weeks gestation has
gained 6 pounds in 4 weeks. Which a. Tell her to breast feed more
of the following would be the frequently
priority when assessing the client? b. Administer a narcotic before
breast feeding
a. Glucosuria c. Encourage her to wear a
b. Depression nursing brassiere
c. Hand/face edema d. Use soap and water to clean
d. Dietary intake the nipples
62. A client 12 weeks’ pregnant come to 66. The nurse assesses the vital signs of
the emergency department with a client, 4 hours’ postpartum that
abdominal cramping and moderate are as follows: BP 90/60;
vaginal bleeding. Speculum temperature 100.4ºF; pulse 100
examination reveals 2 to 3 cms weak, thready; R 20 per minute.
cervical dilation. The nurse would Which of the following should the
document these findings as which of nurse do first?
the following?
a. Report the temperature to c. Facilitating safe and effective
the physician self-and newborn care
b. Recheck the blood pressure d. Teaching about the
with another cuff importance of family
c. Assess the uterus for planning
firmness and position 70. Which of the following actions
d. Determine the amount of would be least effective in
lochia maintaining a neutral thermal
67. The nurse assesses the postpartum environment for the newborn?
vaginal discharge (lochia) on four
clients. Which of the following a. Placing infant under radiant
assessments would warrant warmer after bathing
notification of the physician? b. Covering the scale with a
warmed blanket prior to
a. A dark red discharge on a 2- weighing
day postpartum client c. Placing crib close to nursery
b. A pink to brownish discharge window for family viewing
on a client who is 5 days d. Covering the infant’s head
postpartum with a knit stockinette
c. Almost colorless to creamy 71. A newborn who has an
discharge on a client 2 weeks asymmetrical Moro reflex response
after delivery should be further assessed for which
d. A bright red discharge 5 days of the following?
after delivery
68. A postpartum client has a a. Talipes equinovarus
temperature of 101.4ºF, with a b. Fractured clavicle
uterus that is tender when palpated, c. Congenital hypothyroidism
remains unusually large, and not d. Increased intracranial
descending as normally expected. pressure
Which of the following should the 72. During the first 4 hours after a male
nurse assess next? circumcision, assessing for which of
the following is the priority?
a. Lochia
b. Breasts a. Infection
c. Incision b. Hemorrhage
d. Urine c. Discomfort
69. Which of the following is the priority d. Dehydration
focus of nursing practice with the 73. The mother asks the nurse. “What’s
current early postpartum discharge? wrong with my son’s breasts? Why
are they so enlarged?” Whish of the
a. Promoting comfort and following would be the best
restoration of health response by the nurse?
b. Exploring the emotional
status of the family
a. “The breast tissue is inflamed 76. A newborn weighing 3000 grams
from the trauma experienced and feeding every 4 hours needs 120
with birth” calories/kg of body weight every 24
b. “A decrease in material hours for proper growth and
hormones present before development. How many ounces of
birth causes enlargement,” 20 cal/oz formula should this
c. “You should discuss this with newborn receive at each feeding to
your doctor. It could be a meet nutritional needs?
malignancy”
d. “The tissue has a. 2 ounces
hypertrophied while the b. 3 ounces
baby was in the uterus” c. 4 ounces
74. Immediately after birth the nurse d. 6 ounces
notes the following on a male 77. The postterm neonate with
newborn: respirations 78; apical meconium-stained amniotic fluid
hearth rate 160 BPM, nostril flaring; needs care designed to especially
mild intercostal retractions; and monitor for which of the following?
grunting at the end of expiration.
Which of the following should the a. Respiratory problems
nurse do? b. Gastrointestinal problems
c. Integumentary problems
a. Call the assessment data to d. Elimination problems
the physician’s attention 78. When measuring a client’s fundal
b. Start oxygen per nasal height, which of the following
cannula at 2 L/min. techniques denotes the correct
c. Suction the infant’s mouth method of measurement used by
and nares the nurse?
d. Recognize this as normal first
period of reactivity a. From the xiphoid process to
75. The nurse hears a mother telling a the umbilicus
friend on the telephone about b. From the symphysis pubis to
umbilical cord care. Which of the the xiphoid process
following statements by the mother c. From the symphysis pubis to
indicates effective teaching? the fundus
d. From the fundus to the
a. “Daily soap and water umbilicus
cleansing is best” 79. A client with severe preeclampsia is
b. ‘Alcohol helps it dry and kills admitted with of BP 160/110,
germs” proteinuria, and severe pitting
c. “An antibiotic ointment edema. Which of the following
applied daily prevents would be most important to include
infection” in the client’s plan of care?
d. “He can have a tub bath each
day” a. Daily weights
b. Seizure precautions a. Increase in maternal
c. Right lateral positioning estrogen secretion
d. Stress reduction b. Decrease in maternal
80. A postpartum primipara asks the androgen secretion
nurse, “When can we have sexual c. Secretion of androgen by the
intercourse again?” Which of the fetal gonad
following would be the nurse’s best d. Secretion of estrogen by the
response? fetal gonad
84. A client at 8 weeks’ gestation calls
a. “Anytime you both want to.” complaining of slight nausea in the
b. “As soon as choose a morning hours. Which of the
contraceptive method.” following client interventions should
c. “When the discharge has the nurse question?
stopped and the incision is
healed.” a. Taking 1 teaspoon of
d. “After your 6 weeks bicarbonate of soda in an 8-
examination.” ounce glass of water
81. When preparing to administer the b. Eating a few low-sodium
vitamin K injection to a neonate, the crackers before getting out
nurse would select which of the of bed
following sites as appropriate for the c. Avoiding the intake of liquids
injection? in the morning hours
d. Eating six small meals a day
a. Deltoid muscle instead of thee large meals
b. Anterior femoris muscle 85. The nurse documents positive
c. Vastus lateralis muscle ballottement in the client’s prenatal
d. Gluteus maximus muscle record. The nurse understands that
82. When performing a pelvic this indicates which of the
examination, the nurse observes a following?
red swollen area on the right side of
the vaginal orifice. The nurse would a. Palpable contractions on the
document this as enlargement of abdomen
which of the following? b. Passive movement of the
unengaged fetus
a. Clitoris c. Fetal kicking felt by the client
b. Parotid gland d. Enlargement and softening
c. Skene’s gland of the uterus
d. Bartholin’s gland 86. During a pelvic exam the nurse
83. To differentiate as a female, the notes a purple-blue tinge of the
hormonal stimulation of the embryo cervix. The nurse documents this as
that must occur involves which of which of the following?
the following?
a. Braxton-Hicks sign
b. Chadwick’s sign
c. Goodell’s sign Which of the following assessments
d. McDonald’s sign should be avoided?
87. During a prenatal class, the nurse
explains the rationale for breathing a. Maternal vital sign
techniques during preparation for b. Fetal heart rate
labor based on the understanding c. Contraction monitoring
that breathing techniques are most d. Cervical dilation
important in achieving which of the 90. Which of the following would be the
following? nurse’s most appropriate response
to a client who asks why she must
a. Eliminate pain and give the have a cesarean delivery if she has a
expectant parents something complete placenta previa?
to do
b. Reduce the risk of fetal a. “You will have to ask your
distress by increasing physician when he returns.”
uteroplacental perfusion b. “You need a cesarean to
c. Facilitate relaxation, possibly prevent hemorrhage.”
reducing the perception of c. “The placenta is covering
pain most of your cervix.”
d. Eliminate pain so that less d. “The placenta is covering the
analgesia and anesthesia are opening of the uterus and
needed blocking your baby.”
88. After 4 hours of active labor, the 91. The nurse understands that the fetal
nurse notes that the contractions of head is in which of the following
a primigravida client are not strong positions with a face presentation?
enough to dilate the cervix. Which
of the following would the nurse a. Completely flexed
anticipate doing? b. Completely extended
c. Partially extended
a. Obtaining an order to begin d. Partially flexed
IV oxytocin infusion 92. With a fetus in the left-anterior
b. Administering a light breech presentation, the nurse
sedative to allow the patient would expect the fetal heart rate
to rest for several hour would be most audible in which of
c. Preparing for a cesarean the following areas?
section for failure to progress
d. Increasing the a. Above the maternal
encouragement to the umbilicus and to the right of
patient when pushing begins midline
89. A multigravida at 38 weeks’ b. In the lower-left maternal
gestation is admitted with painless, abdominal quadrant
bright red bleeding and mild c. In the lower-right maternal
contractions every 7 to 10 minutes. abdominal quadrant
d. Above the maternal challenging the routine use of
umbilicus and to the left of analgesics and anesthetics during
midline childbirth. Which of the following
93. The amniotic fluid of a client has a was an outgrowth of this concept?
greenish tint. The nurse interprets
this to be the result of which of the a. Labor, delivery, recovery,
following? postpartum (LDRP)
b. Nurse-midwifery
a. Lanugo c. Clinical nurse specialist
b. Hydramnio d. Prepared childbirth
c. Meconium 98. A client has a midpelvic contracture
d. Vernix from a previous pelvic injury due to
94. A patient is in labor and has just a motor vehicle accident as a
been told she has a breech teenager. The nurse is aware that
presentation. The nurse should be this could prevent a fetus from
particularly alert for which of the passing through or around which
following? structure during childbirth?

a. Quickening a. Symphysis pubis


b. Ophthalmia neonatorum b. Sacral promontory
c. Pica c. Ischial spines
d. Prolapsed umbilical cord d. Pubic arch
95. When describing dizygotic twins to a 99. When teaching a group of
couple, on which of the following adolescents about variations in the
would the nurse base the length of the menstrual cycle, the
explanation? nurse understands that the
underlying mechanism is due to
a. Two ova fertilized by variations in which of the following
separate sperm phases?
b. Sharing of a common
placenta a. Menstrual phase
c. Each ova with the same b. Proliferative phase
genotype c. Secretory phase
d. Sharing of a common chorion d. Ischemic phase
96. Which of the following refers to the 100. When teaching a group of
single cell that reproduces itself adolescents about male hormone
after conception? production, which of the following
would the nurse include as being
a. Chromosome produced by the Leydig cells?
b. Blastocyst
c. Zygote a. Follicle-stimulating hormone
d. Trophoblast b. Testosterone
97. In the late 1950s, consumers and c. Leuteinizing hormone
health care professionals began
Gonadotropin releasing hormone d. A colorful busy box
105. The mother of a 2-month-old
101. While performing physical is concerned that she may be
assessment of a 12 month-old, the spoiling her baby by picking her up
nurse notes that the infant’s when she cries. Which of the
anterior fontanelle is still slightly following would be the nurse’s best
open. Which of the following is the response?
nurse’s most appropriate action?
a. Notify the physician a. “ Let her cry for a while
immediately because there is before picking her up, so you
a problem. don’t spoil her”
b. Perform an intensive b. “Babies need to be held and
neurologic examination. cuddled; you won’t spoil her
c. Perform an intensive this way”
developmental examination. c. “Crying at this age means the
d. Do nothing because this is a baby is hungry; give her a
normal finding for the age. bottle”
102. When teaching a mother d. “If you leave her alone she
about introducing solid foods to her will learn how to cry herself
child, which of the following to sleep”
indicates the earliest age at which 106. When assessing an 18-
this should be done? month-old, the nurse notes a
characteristic protruding abdomen.
a. 1 month Which of the following would
b. 2 months explain the rationale for this finding?
c. 3 months
d. 4 months a. Increased food intake owing
103. The infant of a substance- to age
abusing mother is at risk for b. Underdeveloped abdominal
developing a sense of which of the muscles
following? c. Bowlegged posture
d. Linear growth curve
a. Mistrust 107. If parents keep a toddler
b. Shame dependent in areas where he is
c. Guilt capable of using skills, the toddle
d. Inferiority will develop a sense of which of the
104. Which of the following toys following?
should the nurse recommend for a
5-month-old? a. Mistrust
b. Shame
a. A big red balloon c. Guilt
b. A teddy bear with button d. Inferiority
eyes
c. A push-pull wooden truck
108. Which of the following is an c. “Encourage active play at
appropriate toy for an 18-month- bedtime to tire him out so he
old? will fall asleep faster.”
d. “Read him a story and allow
a. Multiple-piece puzzle him to play quietly in his bed
b. Miniature cars until he falls asleep.”
c. Finger paints 112. When providing therapeutic
d. Comic book play, which of the following toys
109. When teaching parents would best promote imaginative
about the child’s readiness for toilet play in a 4-year-old?
training, which of the following signs
should the nurse instruct them to a. Large blocks
watch for in the toddler? b. Dress-up clothes
c. Wooden puzzle
a. Demonstrates dryness for 4 d. Big wheels
hours 113. Which of the following
b. Demonstrates ability to sit activities, when voiced by the
and walk parents following a teaching session
c. Has a new sibling for about the characteristics of school-
stimulation age cognitive development would
d. Verbalizes desire to go to the indicate the need for additional
bathroom teaching?
110. When teaching parents
about typical toddler eating a. Collecting baseball cards and
patterns, which of the following marbles
should be included? b. Ordering dolls according to
size
a. Food “jags” c. Considering simple problem-
b. Preference to eat alone solving options
c. Consistent table manners d. Developing plans for the
d. Increase in appetite future
111. Which of the following 114. A hospitalized schoolager
suggestions should the nurse offer states: “I’m not afraid of this place,
the parents of a 4-year-old boy who I’m not afraid of anything.” This
resists going to bed at night? statement is most likely an example
of which of the following?
a. “Allow him to fall asleep in
your room, then move him a. Regression
to his own bed.” b. Repression
b. “Tell him that you will lock c. Reaction formation
him in his room if he gets out d. Rationalization
of bed one more time.” 115. After teaching a group of
parents about accident prevention
for schoolagers, which of the
following statements by the group 119. Which of the following would
would indicate the need for more be most appropriate for a nurse to
teaching? use when describing menarche to a
13-year-old?
a. “Schoolagers are more active
and adventurous than are a. A female’s first menstruation
younger children.” or menstrual “periods”
b. “Schoolagers are more b. The first year of
susceptible to home hazards menstruation or “period”
than are younger children.” c. The entire menstrual cycle or
c. “Schoolagers are unable to from one “period” to
understand potential another
dangers around them.” d. The onset of uterine
d. “Schoolargers are less maturation or peak growth
subject to parental control 120. A 14-year-old boy has acne
than are younger children.” and according to his parents,
116. Which of the following skills dominates the bathroom by using
is the most significant one learned the mirror all the time. Which of the
during the schoolage period? following remarks by the nurse
would be least helpful in talking to
a. Collecting the boy and his parents?
b. Ordering
c. Reading a. “This is probably the only
d. Sorting concern he has about his
117. A child age 7 was unable to body. So don’t worry about it
receive the measles, mumps, and or the time he spends on it.”
rubella (MMR) vaccine at the b. “Teenagers are anxious
recommended scheduled time. about how their peers
When would the nurse expect to perceive them. So they
administer MMR vaccine? spend a lot of time
grooming.”
a. In a month from now c. “A teen may develop a poor
b. In a year from now self-image when
c. At age 10 experiencing acne. Do you
d. At age 13 feel this way sometimes?”
118. The adolescent’s inability to d. “You appear to be keeping
develop a sense of who he is and your face well washed.
what he can become results in a Would you feel comfortable
sense of which of the following? discussing your cleansing
method?”
a. Shame 121. Which of the following
b. Guilt should the nurse suspect when
c. Inferiority noting that a 3-year-old is engaging
d. Role diffusion
in explicit sexual behavior during a. Lowered resistance from
doll play? malnutrition
b. Ineffective functioning of the
a. The child is exhibiting normal Eustachian tubes
pre-school curiosity c. Plugging of the Eustachian
b. The child is acting out tubes with food particles
personal experiences d. Associated congenital
c. The child does not know how defects of the middle ear.
to play with dolls 125. While performing a
d. The child is probably neurodevelopmental assessment on
developmentally delayed. a 3-month-old infant, which of the
122. Which of the following following characteristics would be
statements by the parents of a child expected?
with school phobia would indicate
the need for further teaching? a. A strong Moro reflex
b. A strong parachute reflex
a. “We’ll keep him at home c. Rolling from front to back
until phobia subsides.” d. Lifting of head and chest
b. “We’ll work with his teachers when prone
and counselors at school.” 126. By the end of which of the
c. “We’ll try to encourage him following would the nurse most
to talk about his problem.” commonly expect a child’s birth
d. “We’ll discuss possible weight to triple?
solutions with him and his
counselor.” a. 4 months
123. When developing a teaching b. 7 months
plan for a group of high school c. 9 months
students about teenage pregnancy, d. 12 months
the nurse would keep in mind which 127. Which of the following best
of the following? describes parallel play between two
toddlers?
a. The incidence of teenage
pregnancies is increasing. a. Sharing crayons to color
b. Most teenage pregnancies separate pictures
are planned. b. Playing a board game with a
c. Denial of the pregnancy is nurse
common early on. c. Sitting near each other while
d. The risk for complications playing with separate dolls
during pregnancy is rare. d. Sharing their dolls with two
124. When assessing a child with different nurses
a cleft palate, the nurse is aware 128. Which of the following would
that the child is at risk for more the nurse identify as the initial
frequent episodes of otitis media priority for a child with acute
due to which of the following? lymphocytic leukemia?
a. Instituting infection control a. Displacement
precautions b. Projection
b. Encouraging adequate intake c. Repression
of iron-rich foods d. Psychosis
c. Assisting with coping with 132. Which of the following
chronic illness should the nurse expect to note as a
d. Administering medications frequent complication for a child
via IM injections with congenital heart disease?
129. Which of the following
information, when voiced by the a. Susceptibility to respiratory
mother, would indicate to the nurse infection
that she understands home care b. Bleeding tendencies
instructions following the c. Frequent vomiting and
administration of a diphtheria, diarrhea
tetanus, and pertussis injection? d. Seizure disorder
133. Which of the following would
a. Measures to reduce fever the nurse do first for a 3-year-old
b. Need for dietary restrictions boy who arrives in the emergency
c. Reasons for subsequent rash room with a temperature of 105
d. Measures to control degrees, inspiratory stridor, and
subsequent diarrhea restlessness, who is learning forward
130. Which of the following and drooling?
actions by a community health nurse
is most appropriate when noting a. Auscultate his lungs and
multiple bruises and burns on the place him in a mist tent.
posterior trunk of an 18-month-old b. Have him lie down and rest
child during a home visit? after encouraging fluids.
c. Examine his throat and
a. Report the child’s condition perform a throat culture
to Protective Services d. Notify the physician
immediately. immediately and prepare for
b. Schedule a follow-up visit to intubation.
check for more bruises. 134. Which of the following would
c. Notify the child’s physician the nurse need to keep in mind as a
immediately. predisposing factor when
d. Don nothing because this is a formulating a teaching plan for child
normal finding in a toddler. with a urinary tract infection?
131. Which of the following is
being used when the mother of a a. A shorter urethra in females
hospitalized child calls the student b. Frequent emptying of the
nurse and states, “You idiot, you bladder
have no idea how to care for my sick c. Increased fluid intake
child”? d. Ingestion of acidic juices
135. Which of the following c. The child engages in
should the nurse do first for a 15- competitive types of play
year-old boy with a full leg cast who d. Immediate gratification is
is screaming in unrelenting pain and necessary to develop
exhibiting right foot pallor signifying initiative.
compartment syndrome? 139. Which of the following is
characteristic of a preschooler with
a. Medicate him with mid mental retardation?
acetaminophen.
b. Notify the physician a. Slow to feed self
immediately b. Lack of speech
c. Release the traction c. Marked motor delays
d. Monitor him every 5 minutes d. Gait disability
136. At which of the following 140. Which of the following
ages would the nurse expect to assessment findings would lead the
administer the varicella zoster nurse to suspect Down syndrome in
vaccine to child? an infant?

a. At birth a. Small tongue


b. 2 months b. Transverse palmar crease
c. 6 months c. Large nose
d. 12 months d. Restricted joint movement
137. When discussing normal 141. While assessing a newborn
infant growth and development with with cleft lip, the nurse would be
parents, which of the following toys alert that which of the following will
would the nurse suggest as most most likely be compromised?
appropriate for an 8-month-old?
a. Sucking ability
a. Push-pull toys b. Respiratory status
b. Rattle c. Locomotion
c. Large blocks d. GI function
d. Mobile 142. When providing
138. Which of the following postoperative care for the child with
aspects of psychosocial a cleft palate, the nurse should
development is necessary for the position the child in which of the
nurse to keep in mind when following positions?
providing care for the preschool
child? a. Supine
b. Prone
a. The child can use complex c. In an infant seat
reasoning to think out d. On the side
situations. 143. While assessing a child with
b. Fear of body mutilation is a pyloric stenosis, the nurse is likely to
common preschool fear note which of the following?
a. Regurgitation d. Weight gain
b. Steatorrhea 148. Which of the following
c. Projectile vomiting should the nurse do first after noting
d. “Currant jelly” stools that a child with Hirschsprung
144. Which of the following disease has a fever and watery
nursing diagnoses would be explosive diarrhea?
inappropriate for the infant with
gastroesophageal reflux (GER)? a. Notify the physician
immediately
a. Fluid volume deficit b. Administer antidiarrheal
b. Risk for aspiration medications
c. Altered nutrition: less than c. Monitor child ever 30
body requirements minutes
d. Altered oral mucous d. Nothing, this is characteristic
membranes of Hirschsprung disease
145. Which of the following 149. A newborn’s failure to pass
parameters would the nurse meconium within the first 24 hours
monitor to evaluate the after birth may indicate which of the
effectiveness of thickened feedings following?
for an infant with gastroesophageal
reflux (GER)? a. Hirschsprung disease
b. Celiac disease
a. Vomiting c. Intussusception
b. Stools d. Abdominal wall defect
c. Uterine 150. When assessing a child for
d. Weight possible intussusception, which of
146. Discharge teaching for a child the following would be least likely to
with celiac disease would include provide valuable information?
instructions about avoiding which of
the following? a. Stool inspection
b. Pain pattern
a. Rice c. Family history
b. Milk d. Abdominal palpation
c. Wheat
d. Chicken
147. Which of the following would
the nurse expect to assess in a child
with celiac disease having a celiac
crisis secondary to an upper
respiratory infection?

a. Respiratory distress
b. Lethargy
c. Watery diarrhea
ANSWER AND RATIONALE areola, nipples, chest, neck, arms,
legs, abdomen, or thighs.
1. B. Although all of the factors listed 6. C. During pregnancy, hormonal
are important, sperm motility is the changes cause relaxation of the
most significant criterion when pelvic joints, resulting in the typical
assessing male infertility. Sperm “waddling” gait. Changes in posture
count, sperm maturity, and semen are related to the growing fetus.
volume are all significant, but they Pressure on the surrounding
are not as significant sperm motility. muscles causing discomfort is due to
2. D. Based on the partner’s the growing uterus. Weight gain has
statement, the couple is verbalizing no effect on gait.
feelings of inadequacy and negative 7. C. The average amount of weight
feelings about themselves and their gained during pregnancy is 24 to 30
capabilities. Thus, the nursing lb. This weight gain consists of the
diagnosis of self-esteem disturbance following: fetus – 7.5 lb; placenta
is most appropriate. Fear, pain, and and membrane – 1.5 lb; amniotic
ineffective family coping also may fluid – 2 lb; uterus – 2.5 lb; breasts –
be present but as secondary nursing 3 lb; and increased blood volume – 2
diagnoses. to 4 lb; extravascular fluid and fat –
3. B. Pressure and irritation of the 4 to 9 lb. A gain of 12 to 22 lb is
bladder by the growing uterus insufficient, whereas a weight gain
during the first trimester is of 15 to 25 lb is marginal. A weight
responsible for causing urinary gain of 25 to 40 lb is considered
frequency. Dysuria, incontinence, excessive.
and burning are symptoms 8. C. Pressure of the growing uterus on
associated with urinary tract blood vessels results in an increased
infections. risk for venous stasis in the lower
4. C. During the second trimester, the extremities. Subsequently, edema
reduction in gastric acidity in and varicose vein formation may
conjunction with pressure from the occur. Thrombophlebitis is an
growing uterus and smooth muscle inflammation of the veins due to
relaxation, can cause heartburn and thrombus formation. Pregnancy-
flatulence. HCG levels increase in induced hypertension is not
the first, not the second, trimester. associated with these symptoms.
Decrease intestinal motility would Gravity plays only a minor role with
most likely be the cause of these symptoms.
constipation and bloating. Estrogen 9. C. Cervical softening (Goodell sign)
levels decrease in the second and uterine soufflé are two probable
trimester. signs of pregnancy. Probable signs
5. D. Chloasma, also called the mask of are objective findings that strongly
pregnancy, is an irregular suggest pregnancy. Other probable
hyperpigmented area found on the signs include Hegar sign, which is
face. It is not seen on the breasts, softening of the lower uterine
segment; Piskacek sign, which is
enlargement and softening of the classes may focus on preparation for
uterus; serum laboratory tests; birth, parenting, and newborn care.
changes in skin pigmentation; and 13. C. With breast feeding, the father’s
ultrasonic evidence of a gestational body is not capable of providing the
sac. Presumptive signs are milk for the newborn, which may
subjective signs and include interfere with feeding the newborn,
amenorrhea; nausea and vomiting; providing fewer chances for
urinary frequency; breast bonding, or he may be jealous of the
tenderness and changes; excessive infant’s demands on his wife’s time
fatigue; uterine enlargement; and and body. Breast feeding is
quickening. advantageous because uterine
10. B. Presumptive signs of pregnancy involution occurs more rapidly, thus
are subjective signs. Of the signs minimizing blood loss. The presence
listed, only nausea and vomiting are of maternal antibodies in breast milk
presumptive signs. Hegar sign, skin helps decrease the incidence of
pigmentation changes, and a allergies in the newborn. A greater
positive serum pregnancy test are chance for error is associated with
considered probably signs, which bottle feeding. No preparation is
are strongly suggestive of required for breast feeding.
pregnancy. 14. A. A false-positive reaction can
11. D. During the first trimester, occur if the pregnancy test is
common emotional reactions performed less than 10 days after an
include ambivalence, fear, fantasies, abortion. Performing the tests too
or anxiety. The second trimester is a early or too late in the pregnancy,
period of well-being accompanied storing the urine sample too long at
by the increased need to learn about room temperature, or having a
fetal growth and development. spontaneous or missed abortion
Common emotional reactions during impending can all produce false-
this trimester include narcissism, negative results.
passivity, or introversion. At times 15. D. The FHR can be auscultated with
the woman may seem egocentric a fetoscope at about 20 week’s
and self-centered. During the third gestation. FHR usually is
trimester, the woman typically feels ausculatated at the midline
awkward, clumsy, and unattractive, suprapubic region with Doppler
often becoming more introverted or ultrasound transducer at 10 to 12
reflective of her own childhood. week’s gestation. FHR, cannot be
12. B. First-trimester classes commonly heard any earlier than 10 weeks’
focus on such issues as early gestation.
physiologic changes, fetal 16. C. To determine the EDD when the
development, sexuality during date of the client’s LMP is known
pregnancy, and nutrition. Some use Nagele rule. To the first day of
early classes may include pregnant the LMP, add 7 days, subtract 3
couples. Second and third trimester months, and add 1 year (if
applicable) to arrive at the EDD as
follows: 5 + 7 = 12 (July) minus 3 = 4 occurs during the second stage of
(April). Therefore, the client’s EDD is labor. During the first stage of labor,
April 12. cervical dilation and effacement
17. A. When the LMP is unknown, the occur. During the third stage of
gestational age of the fetus is labor, the newborn and placenta are
estimated by uterine size or position delivered. The fourth stage of labor
(fundal height). The presence of the lasts from 1 to 4 hours after birth,
uterus in the pelvis indicates less during which time the mother and
than 12 weeks’ gestation. At newborn recover from the physical
approximately 12 to 14 weeks, the process of birth and the mother’s
fundus is out of the pelvis above the organs undergo the initial
symphysis pubis. The fundus is at readjustment to the nonpregnant
the level of the umbilicus at state.
approximately 20 weeks’ gestation 22. C. Barbiturates are rapidly
and reaches the xiphoid at term or transferred across the placental
40 weeks. barrier, and lack of an antagonist
18. D. Danger signs that require prompt makes them generally inappropriate
reporting leaking of amniotic fluid, during active labor. Neonatal side
vaginal bleeding, blurred vision, effects of barbiturates include
rapid weight gain, and elevated central nervous system depression,
blood pressure. Constipation, breast prolonged drowsiness, delayed
tenderness, and nasal stuffiness are establishment of feeding (e.g. due to
common discomforts associated poor sucking reflex or poor sucking
with pregnancy. pressure). Tranquilizers are
19. B. A rubella titer should be 1:8 or associated with neonatal effects
greater. Thurs, a finding of a titer such as hypotonia, hypothermia,
less than 1:8 is significant, indicating generalized drowsiness, and
that the client may not possess reluctance to feed for the first few
immunity to rubella. A hematocrit of days. Narcotic analgesic readily cross
33.5% a white blood cell count of the placental barrier, causing
8,000/mm3, and a 1 hour glucose depressive effects in the newborn 2
challenge test of 110 g/dl are with to 3 hours after intramuscular
normal parameters. injection. Regional anesthesia is
20. D. With true labor, contractions associated with adverse reactions
increase in intensity with walking. In such as maternal hypotension,
addition, true labor contractions allergic or toxic reaction, or partial
occur at regular intervals, usually or total respiratory failure.
starting in the back and sweeping 23. D. During the third stage of labor,
around to the abdomen. The which begins with the delivery of the
interval of true labor contractions newborn, the nurse would promote
gradually shortens. parent-newborn interaction by
21. B. Crowing, which occurs when the placing the newborn on the
newborn’s head or presenting part mother’s abdomen and encouraging
appears at the vaginal opening, the parents to touch the newborn.
Collecting a urine specimen and approximately 100 beats per
other laboratory tests is done on minute. If the newborn was awake,
admission during the first stage of the normal heart rate would range
labor. Assessing uterine contractions from 120 to 160 beats per minute.
every 30 minutes is performed 29. C. The anterior fontanel is larger in
during the latent phase of the first size than the posterior fontanel.
stage of labor. Coaching the client to Additionally, the anterior fontanel,
push effectively is appropriate which is diamond shaped, closes at
during the second stage of labor. 18 months, whereas the posterior
24. A. The newborn’s ability to regulate fontanel, which is triangular shaped,
body temperature is poor. closes at 8 to 12 weeks. Neither
Therefore, placing the newborn fontanel should appear bulging,
under a radiant warmer aids in which may indicate increased
maintaining his or her body intracranial pressure, or sunken,
temperature. Suctioning with a bulb which may indicate dehydration.
syringe helps maintain a patent 30. B. Blink, cough, sneeze, swallowing
airway. Obtaining an Apgar score and gag reflexes are all present at
measures the newborn’s immediate birth and remain unchanged
adjustment to extrauterine life. through adulthood. Reflexes such as
Inspecting the umbilical cord aids in rooting and stepping subside within
detecting cord anomalies. the first year.
25. D. Immediately before expulsion or 31. A. With the babinski reflex, the
birth of the rest of the body, the newborn’s toes hyperextend and fan
cardinal movement of external apart from dorsiflexion of the big
rotation occurs. Descent flexion, toe when one side of foot is stroked
internal rotation, extension, and upward form the heel and across
restitution (in this order) occur the ball of the foot. With the startle
before external rotation. reflex, the newborn abducts and
26. B. The foramen ovale is an opening flexes all extremities and may begin
between the right and left auricles to cry when exposed to sudden
(atria) that should close shortly after movement of loud noise. With the
birth so the newborn will not have a rooting and sucking reflex, the
murmur or mixed blood traveling newborn turns his head in the
through the vascular system. The direction of stimulus, opens the
umbilical vein, ductus arteriosus, mouth, and begins to suck when the
and ductus venosus are obliterated cheeks, lip, or corner of mouth is
at birth. touched. With the crawl reflex, the
27. B. Uric acid crystals in the urine may newborn will attempt to crawl
produce the reddish “brick dust” forward with both arms and legs
stain on the diaper. Mucus would when he is placed on his abdomen
not produce a stain. Bilirubin and on a flat surface.
iron are from hepatic adaptation. 32. B. The description of hyperemesis
28. B. The normal heart rate for a gravidarum includes severe nausea
newborn that is sleeping is and vomiting, leading to electrolyte,
metabolic, and nutritional intense localized uterine pain. The
imbalances in the absence of other uterus is typically firm to boardlike,
medical problems. Hyperemesis is and the fetal presenting part may be
not a form of anemia. Loss of engaged. Bright red, painless vaginal
appetite may occur secondary to the bleeding, a palpable fetal outline
nausea and vomiting of and a soft nontender abdomen are
hyperemesis, which, if it continues, manifestations of placenta previa.
can deplete the nutrients 37. D. Abruptio placentae is described
transported to the fetus. Diarrhea as premature separation of a
does not occur with hyperemesis. normally implanted placenta during
33. B. Edema of the hands and face is a the second half of pregnancy,
classic sign of PIH. Many healthy usually with severe hemorrhage.
pregnant woman experience foot Placenta previa refers to
and ankle edema. A weight gain of 2 implantation of the placenta in the
lb or more per week indicates a lower uterine segment, causing
problem. Early morning headache is painless bleeding in the third
not a classic sign of PIH. trimester of pregnancy. Ectopic
34. C. In a missed abortion, there is pregnancy refers to the implantation
early fetal intrauterine death, and of the products of conception in a
products of conception are not site other than the endometrium.
expelled. The cervix remains closed; Incompetent cervix is a conduction
there may be a dark brown vaginal characterized by painful dilation of
discharge, negative pregnancy test, the cervical os without uterine
and cessation of uterine growth and contractions.
breast tenderness. A threatened 38. B. Hyperstimulation of the uterus
abortion is evidenced with cramping such as with oxytocin during the
and vaginal bleeding in early induction of labor may result in
pregnancy, with no cervical dilation. tetanic contractions prolonged to
An incomplete abortion presents more than 90seconds, which could
with bleeding, cramping, and lead to such complications as fetal
cervical dilation. An incomplete distress, abruptio placentae,
abortion involves only expulsion of amniotic fluid embolism, laceration
part of the products of conception of the cervix, and uterine rupture.
and bleeding occurs with cervical Weak contractions would not occur.
dilation. Pain, bright red vaginal bleeding,
35. A. Multiple gestation is one of the and increased restlessness and
predisposing factors that may cause anxiety are not associated with
placenta previa. Uterine anomalies hyperstimulation.
abdominal trauma, and renal or 39. C. A key point to consider when
vascular disease may predispose a preparing the client for a cesarean
client to abruptio placentae. delivery is to modify the
36. B. A client with abruptio placentae preoperative teaching to meet the
may exhibit concealed or dark red needs of either a planned or
bleeding, possibly reporting sudden emergency cesarean birth, the
depth and breadth of instruction will (passage), or psyche. Nutritional,
depend on circumstances and time environment, and medical factors
available. Allowing the mother’s may contribute to the mechanical
support person to remain with her factors that cause dystocia.
as much as possible is an important 43. A. With uterine rupture, the client is
concept, although doing so depends at risk for hypovolemic shock.
on many variables. Arranging for Therefore, the priority is to prevent
necessary explanations by various and limit hypovolemic shock.
staff members to be involved with Immediate steps should include
the client’s care is a nursing giving oxygen, replacing lost fluids,
responsibility. The nurse is providing drug therapy as needed,
responsible for reinforcing the evaluating fetal responses and
explanations about the surgery, preparing for surgery. Obtaining
expected outcome, and type of blood specimens, instituting
anesthetic to be used. The complete bed rest, and inserting a
obstetrician is responsible for urinary catheter are necessary in
explaining about the surgery and preparation for surgery to remedy
outcome and the anesthesiology the rupture.
staff is responsible for explanations 44. B. The immediate priority is to
about the type of anesthesia to be minimize pressure on the cord. Thus
used. the nurse’s initial action involves
40. A. Preterm labor is best described as placing the client on bed rest and
labor that begins after 20 weeks’ then placing the client in a knee-
gestation and before 37 weeks’ chest position or lowering the head
gestation. The other time periods of the bed, and elevating the
are inaccurate. maternal hips on a pillow to
41. B. PROM can precipitate many minimize the pressure on the cord.
potential and actual problems; one Monitoring maternal vital signs and
of the most serious is the fetus loss FHR, notifying the physician and
of an effective defense against preparing the client for delivery, and
infection. This is the client’s most wrapping the cord with sterile saline
immediate need at this time. soaked warm gauze are important.
Typically, PROM occurs about 1 But these actions have no effect on
hour, not 4 hours, before labor minimizing the pressure on the cord.
begins. Fetal viability and gestational 45. D. Postpartum hemorrhage is
age are less immediate defined as blood loss of more than
considerations that affect the plan 500 ml following birth. Any amount
of care. Malpresentation and an less than this not considered
incompetent cervix may be causes postpartum hemorrhage.
of PROM. 46. D. With mastitis, injury to the
42. B. Dystocia is difficult, painful, breast, such as overdistention,
prolonged labor due to mechanical stasis, and cracking of the nipples, is
factors involving the fetus the primary predisposing factor.
(passenger), uterus (powers), pelvis Epidemic and endemic infections are
probable sources of infection for 10% to 40%, 30% to 50%, and 25%
mastitis. Temporary urinary to 70% are incorrect.
retention due to decreased 51. B. Regular timely ingestion of oral
perception of the urge to void is a contraceptives is necessary to
contributory factor to the maintain hormonal levels of the
development of urinary tract drugs to suppress the action of the
infection, not mastitis. hypothalamus and anterior pituitary
47. D. Thrombophlebitis refers to an leading to inappropriate secretion of
inflammation of the vascular FSH and LH. Therefore, follicles do
endothelium with clot formation on not mature, ovulation is inhibited,
the wall of the vessel. Blood and pregnancy is prevented. The
components combining to form an estrogen content of the oral site
aggregate body describe a thrombus contraceptive may cause the
or thrombosis. Clots lodging in the nausea, regardless of when the pill is
pulmonary vasculature refers to taken. Side effects and drug
pulmonary embolism; in the femoral interactions may occur with oral
vein, femoral thrombophlebitis. contraceptives regardless of the
48. C. Classic symptoms of DVT include time the pill is taken.
muscle pain, the presence of 52. C. Condoms, when used correctly
Homans sign, and swelling of the and consistently, are the most
affected limb. Midcalf pain, effective contraceptive method or
tenderness, and redness, along the barrier against bacterial and viral
vein reflect superficial sexually transmitted infections.
thrombophlebitis. Chills, fever and Although spermicides kill sperm,
malaise occurring 2 weeks after they do not provide reliable
delivery reflect pelvic protection against the spread of
thrombophlebitis. Chills, fever, sexually transmitted infections,
stiffness and pain occurring 10 to 14 especially intracellular organisms
days after delivery suggest femoral such as HIV. Insertion and removal
thrombophlebitis. of the diaphragm along with the use
49. B. Manifestations of cystitis include, of the spermicides may cause
frequency, urgency, dysuria, vaginal irritations, which could place
hematuria nocturia, fever, and the client at risk for infection
suprapubic pain. Dehydration, transmission. Male sterilization
hypertension, and chills are not eliminates spermatozoa from the
typically associated with cystitis. ejaculate, but it does not eliminate
High fever chills, flank pain, nausea, bacterial and/or viral
vomiting, dysuria, and frequency are microorganisms that can cause
associated with pvelonephritis. sexually transmitted infections.
50. C. According to statistical reports, 53. A. The diaphragm must be fitted
between 50% and 80% of all new individually to ensure effectiveness.
mothers report some form of Because of the changes to the
postpartum blues. The ranges of reproductive structures during
pregnancy and following delivery,
the diaphragm must be refitted, but this is not recommended
usually at the 6 weeks’ examination because of the increased risk and
following childbirth or after a weight rate of expulsion at this time.
loss of 15 lbs or more. In addition, 55. C. During the third trimester, the
for maximum effectiveness, enlarging uterus places pressure on
spermicidal jelly should be placed in the intestines. This coupled with the
the dome and around the rim. effect of hormones on smooth
However, spermicidal jelly should muscle relaxation causes decreased
not be inserted into the vagina until intestinal motility (peristalsis).
involution is completed at Increasing fiber in the diet will help
approximately 6 weeks. Use of a fecal matter pass more quickly
female condom protects the through the intestinal tract, thus
reproductive system from the decreasing the amount of water that
introduction of semen or is absorbed. As a result, stool is
spermicides into the vagina and may softer and easier to pass. Enemas
be used after childbirth. Oral could precipitate preterm labor
contraceptives may be started and/or electrolyte loss and should
within the first postpartum week to be avoided. Laxatives may cause
ensure suppression of ovulation. For preterm labor by stimulating
the couple who has determined the peristalsis and may interfere with
female’s fertile period, using the the absorption of nutrients. Use for
rhythm method, avoidance of more than 1 week can also lead to
intercourse during this period, is laxative dependency. Liquid in the
safe and effective. diet helps provide a semisolid, soft
54. C. An IUD may increase the risk of consistency to the stool. Eight to ten
pelvic inflammatory disease, glasses of fluid per day are essential
especially in women with more than to maintain hydration and promote
one sexual partner, because of the stool evacuation.
increased risk of sexually 56. D. To ensure adequate fetal growth
transmitted infections. An UID and development during the 40
should not be used if the woman has weeks of a pregnancy, a total weight
an active or chronic pelvic infection, gain 25 to 30 pounds is
postpartum infection, endometrial recommended: 1.5 pounds in the
hyperplasia or carcinoma, or uterine first 10 weeks; 9 pounds by 30
abnormalities. Age is not a factor in weeks; and 27.5 pounds by 40
determining the risks associated weeks. The pregnant woman should
with IUD use. Most IUD users are gain less weight in the first and
over the age of 30. Although there is second trimester than in the third.
a slightly higher risk for infertility in During the first trimester, the client
women who have never been should only gain 1.5 pounds in the
pregnant, the IUD is an acceptable first 10 weeks, not 1 pound per
option as long as the risk-benefit week. A weight gain of ½ pound per
ratio is discussed. IUDs may be week would be 20 pounds for the
inserted immediately after delivery,
total pregnancy, less than the symphysis pubis in the abdominal
recommended amount. cavity, not midway between the
57. B. To calculate the EDD by Nagele’s umbilicus and the xiphoid process.
rule, add 7 days to the first day of At 12 weeks the FHR would be
the last menstrual period and count difficult to auscultate with a
back 3 months, changing the year fetoscope. Although the external
appropriately. To obtain a date of electronic fetal monitor would
September 27, 7 days have been project the FHR, the uterus has not
added to the last day of the LMP risen to the umbilicus at 12 weeks.
(rather than the first day of the 60. A. Although all of the choices are
LMP), plus 4 months (instead of 3 important in the management of
months) were counted back. To diabetes, diet therapy is the
obtain the date of November 7, 7 mainstay of the treatment plan and
days have been subtracted (instead should always be the priority.
of added) from the first day of LMP Women diagnosed with gestational
plus November indicates counting diabetes generally need only diet
back 2 months (instead of 3 months) therapy without medication to
from January. To obtain the date of control their blood sugar levels.
December 27, 7 days were added to Exercise, is important for all
the last day of the LMP (rather than pregnant women and especially for
the first day of the LMP) and diabetic women, because it burns up
December indicates counting back glucose, thus decreasing blood
only 1 month (instead of 3 months) sugar. However, dietary intake, not
from January. exercise, is the priority. All pregnant
58. D. The client has been pregnant four women with diabetes should have
times, including current pregnancy periodic monitoring of serum
(G). Birth at 38 weeks’ gestation is glucose. However, those with
considered full term (T), while birth gestational diabetes generally do
form 20 weeks to 38 weeks is not need daily glucose monitoring.
considered preterm (P). A The standard of care recommends a
spontaneous abortion occurred at 8 fasting and 2-hour postprandial
weeks (A). She has two living blood sugar level every 2 weeks.
children (L). 61. C. After 20 weeks’ gestation, when
59. B. At 12 weeks gestation, the uterus there is a rapid weight gain,
rises out of the pelvis and is palpable preeclampsia should be suspected,
above the symphysis pubis. The which may be caused by fluid
Doppler intensifies the sound of the retention manifested by edema,
fetal pulse rate so it is audible. The especially of the hands and face. The
uterus has merely risen out of the three classic signs of preeclampsia
pelvis into the abdominal cavity and are hypertension, edema, and
is not at the level of the umbilicus. proteinuria. Although urine is
The fetal heart rate at this age is not checked for glucose at each clinic
audible with a stethoscope. The visit, this is not the priority.
uterus at 12 weeks is just above the Depression may cause either
anorexia or excessive food intake, bladder will interfere with the
leading to excessive weight gain or accuracy of the assessment by
loss. This is not, however, the elevating the uterus and displacing
priority consideration at this time. to the side of the midline. Vital sign
Weight gain thought to be caused by assessment is not necessary unless
excessive food intake would require an abnormality in uterine
a 24-hour diet recall. However, assessment is identified. Uterine
excessive intake would not be the assessment should not cause acute
primary consideration for this client pain that requires administration of
at this time. analgesia. Ambulating the client is
62. B. Cramping and vaginal bleeding an essential component of
coupled with cervical dilation postpartum care, but is not
signifies that termination of the necessary prior to assessment of the
pregnancy is inevitable and cannot uterus.
be prevented. Thus, the nurse would 65. A. Feeding more frequently, about
document an imminent abortion. In every 2 hours, will decrease the
a threatened abortion, cramping infant’s frantic, vigorous sucking
and vaginal bleeding are present, from hunger and will decrease
but there is no cervical dilation. The breast engorgement, soften the
symptoms may subside or progress breast, and promote ease of correct
to abortion. In a complete abortion latching-on for feeding. Narcotics
all the products of conception are administered prior to breast feeding
expelled. A missed abortion is early are passed through the breast milk
fetal intrauterine death without to the infant, causing excessive
expulsion of the products of sleepiness. Nipple soreness is not
conception. severe enough to warrant narcotic
63. B. For the client with an ectopic analgesia. All postpartum clients,
pregnancy, lower abdominal pain, especially lactating mothers, should
usually unilateral, is the primary wear a supportive brassiere with
symptom. Thus, pain is the priority. wide cotton straps. This does not,
Although the potential for infection however, prevent or reduce nipple
is always present, the risk is low in soreness. Soaps are drying to the
ectopic pregnancy because skin of the nipples and should not be
pathogenic microorganisms have used on the breasts of lactating
not been introduced from external mothers. Dry nipple skin predisposes
sources. The client may have a to cracks and fissures, which can
limited knowledge of the pathology become sore and painful.
and treatment of the condition and 66. D. A weak, thready pulse elevated to
will most likely experience grieving, 100 BPM may indicate impending
but this is not the priority at this hemorrhagic shock. An increased
time. pulse is a compensatory mechanism
64. D. Before uterine assessment is of the body in response to
performed, it is essential that the decreased fluid volume. Thus, the
woman empty her bladder. A full nurse should check the amount of
lochia present. Temperatures up to 10 days to 3 weeks after delivery
100.48F in the first 24 hours after and containing leukocytes, decidua,
birth are related to the dehydrating epithelial cells, fat, cervical mucus,
effects of labor and are considered cholesterol crystals, and bacteria.
normal. Although rechecking the 68. A. The data suggests an infection of
blood pressure may be a correct the endometrial lining of the uterus.
choice of action, it is not the first The lochia may be decreased or
action that should be implemented copious, dark brown in appearance,
in light of the other data. The data and foul smelling, providing further
indicate a potential impending evidence of a possible infection. All
hemorrhage. Assessing the uterus the client’s data indicate a uterine
for firmness and position in relation problem, not a breast problem.
to the umbilicus and midline is Typically, transient fever, usually
important, but the nurse should 101ºF, may be present with breast
check the extent of vaginal bleeding engorgement. Symptoms of mastitis
first. Then it would be appropriate include influenza-like
to check the uterus, which may be a manifestations. Localized infection
possible cause of the hemorrhage. of an episiotomy or C-section
67. D. Any bright red vaginal discharge incision rarely causes systemic
would be considered abnormal, but symptoms, and uterine involution
especially 5 days after delivery, would not be affected. The client
when the lochia is typically pink to data do not include dysuria,
brownish. Lochia rubra, a dark red frequency, or urgency, symptoms of
discharge, is present for 2 to 3 days urinary tract infections, which would
after delivery. Bright red vaginal necessitate assessing the client’s
bleeding at this time suggests late urine.
postpartum hemorrhage, which 69. C. Because of early postpartum
occurs after the first 24 hours discharge and limited time for
following delivery and is generally teaching, the nurse’s priority is to
caused by retained placental facilitate the safe and effective care
fragments or bleeding disorders. of the client and newborn. Although
Lochia rubra is the normal dark red promoting comfort and restoration
discharge occurring in the first 2 to 3 of health, exploring the family’s
days after delivery, containing emotional status, and teaching
epithelial cells, erythrocyes, about family planning are important
leukocytes and decidua. Lochia in postpartum/newborn nursing
serosa is a pink to brownish care, they are not the priority focus
serosanguineous discharge in the limited time presented by
occurring from 3 to 10 days after early post-partum discharge.
delivery that contains decidua, 70. C. Heat loss by radiation occurs
erythrocytes, leukocytes, cervical when the infant’s crib is placed too
mucus, and microorganisms. Lochia near cold walls or windows. Thus
alba is an almost colorless to placing the newborn’s crib close to
yellowish discharge occurring from the viewing window would be least
effective. Body heat is lost through maternal-fetal blood followed by
evaporation during bathing. Placing prompt withdrawal at birth
the infant under the radiant warmer precipitates breast engorgement,
after bathing will assist the infant to which will spontaneously resolve in
be rewarmed. Covering the scale 4 to 5 days after birth. The trauma
with a warmed blanket prior to of the birth process does not cause
weighing prevents heat loss through inflammation of the newborn’s
conduction. A knit cap prevents heat breast tissue. Newborns do not have
loss from the head a large head, a breast malignancy. This reply by the
large body surface area of the nurse would cause the mother to
newborn’s body. have undue anxiety. Breast tissue
71. B. A fractured clavicle would prevent does not hypertrophy in the fetus or
the normal Moro response of newborns.
symmetrical sequential extension 74. D. The first 15 minutes to 1 hour
and abduction of the arms followed after birth is the first period of
by flexion and adduction. In talipes reactivity involving respiratory and
equinovarus (clubfoot) the foot is circulatory adaptation to
turned medially, and in plantar extrauterine life. The data given
flexion, with the heel elevated. The reflect the normal changes during
feet are not involved with the Moro this time period. The infant’s
reflex. Hypothyroiddism has no assessment data reflect normal
effect on the primitive reflexes. adaptation. Thus, the physician does
Absence of the Moror reflex is the not need to be notified and oxygen
most significant single indicator of is not needed. The data do not
central nervous system status, but it indicate the presence of choking,
is not a sign of increased intracranial gagging or coughing, which are signs
pressure. of excessive secretions. Suctioning is
72. B. Hemorrhage is a potential risk not necessary.
following any surgical procedure. 75. B. Application of 70% isopropyl
Although the infant has been given alcohol to the cord minimizes
vitamin K to facilitate clotting, the microorganisms (germicidal) and
prophylactic dose is often not promotes drying. The cord should be
sufficient to prevent bleeding. kept dry until it falls off and the
Although infection is a possibility, stump has healed. Antibiotic
signs will not appear within 4 hours ointment should only be used to
after the surgical procedure. The treat an infection, not as a
primary discomfort of circumcision prophylaxis. Infants should not be
occurs during the surgical submerged in a tub of water until
procedure, not afterward. Although the cord falls off and the stump has
feedings are withheld prior to the completely healed.
circumcision, the chances of 76. B. To determine the amount of
dehydration are minimal. formula needed, do the following
73. B. The presence of excessive mathematical calculation. 3 kg x 120
estrogen and progesterone in the cal/kg per day = 360 calories/day
feeding q 4 hours = 6 feedings per maximize blood flow, reduce blood
day = 60 calories per feeding: 60 pressure, and promote diuresis.
calories per feeding; 60 calories per Interventions to reduce stress and
feeding with formula 20 cal/oz = 3 anxiety are very important to
ounces per feeding. Based on the facilitate coping and a sense of
calculation. 2, 4 or 6 ounces are control, but seizure precautions are
incorrect. the priority.
77. A. Intrauterine anoxia may cause 80. C. Cessation of the lochial discharge
relaxation of the anal sphincter and signifies healing of the
emptying of meconium into the endometrium. Risk of hemorrhage
amniotic fluid. At birth some of the and infection are minimal 3 weeks
meconium fluid may be aspirated, after a normal vaginal delivery.
causing mechanical obstruction or Telling the client anytime is
chemical pneumonitis. The infant is inappropriate because this response
not at increased risk for does not provide the client with the
gastrointestinal problems. Even specific information she is
though the skin is stained with requesting. Choice of a
meconium, it is noninfectious contraceptive method is important,
(sterile) and nonirritating. The but not the specific criteria for safe
postterm meconium-stained infant resumption of sexual activity.
is not at additional risk for bowel or Culturally, the 6-weeks’ examination
urinary problems. has been used as the time frame for
78. C. The nurse should use a resuming sexual activity, but it may
nonelastic, flexible, paper measuring be resumed earlier.
tape, placing the zero point on the 81. C. The middle third of the vastus
superior border of the symphysis lateralis is the preferred injection
pubis and stretching the tape across site for vitamin K administration
the abdomen at the midline to the because it is free of blood vessels
top of the fundus. The xiphoid and and nerves and is large enough to
umbilicus are not appropriate absorb the medication. The deltoid
landmarks to use when measuring muscle of a newborn is not large
the height of the fundus enough for a newborn IM injection.
(McDonald’s measurement). Injections into this muscle in a small
79. B. Women hospitalized with severe child might cause damage to the
preeclampsia need decreased CNS radial nerve. The anterior femoris
stimulation to prevent a seizure. muscle is the next safest muscle to
Seizure precautions provide use in a newborn but is not the
environmental safety should a safest. Because of the proximity of
seizure occur. Because of edema, the sciatic nerve, the gluteus
daily weight is important but not the maximus muscle should not be until
priority. Preclampsia causes the child has been walking 2 years.
vasospasm and therefore can reduce 82. D. Bartholin’s glands are the glands
utero-placental perfusion. The client on either side of the vaginal orifice.
should be placed on her left side to The clitoris is female erectile tissue
found in the perineal area above the 87. C. Breathing techniques can raise
urethra. The parotid glands are open the pain threshold and reduce the
into the mouth. Skene’s glands open perception of pain. They also
into the posterior wall of the female promote relaxation. Breathing
urinary meatus. techniques do not eliminate pain,
83. D. The fetal gonad must secrete but they can reduce it. Positioning,
estrogen for the embryo to not breathing, increases
differentiate as a female. An uteroplacental perfusion.
increase in maternal estrogen 88. A. The client’s labor is hypotonic.
secretion does not effect The nurse should call the physical
differentiation of the embryo, and and obtain an order for an infusion
maternal estrogen secretion occurs of oxytocin, which will assist the
in every pregnancy. Maternal uterus to contact more forcefully in
androgen secretion remains the an attempt to dilate the cervix.
same as before pregnancy and does Administering light sedative would
not effect differentiation. Secretion be done for hypertonic uterine
of androgen by the fetal gonad contractions. Preparing for cesarean
would produce a male fetus. section is unnecessary at this time.
84. A. Using bicarbonate would increase Oxytocin would increase the uterine
the amount of sodium ingested, contractions and hopefully progress
which can cause complications. labor before a cesarean would be
Eating low-sodium crackers would necessary. It is too early to
be appropriate. Since liquids can anticipate client pushing with
increase nausea avoiding them in contractions.
the morning hours when nausea is 89. D. The signs indicate placenta previa
usually the strongest is appropriate. and vaginal exam to determine
Eating six small meals a day would cervical dilation would not be done
keep the stomach full, which often because it could cause hemorrhage.
decrease nausea. Assessing maternal vital signs can
85. B. Ballottement indicates passive help determine maternal physiologic
movement of the unengaged fetus. status. Fetal heart rate is important
Ballottement is not a contraction. to assess fetal well-being and should
Fetal kicking felt by the client be done. Monitoring the
represents quickening. Enlargement contractions will help evaluate the
and softening of the uterus is known progress of labor.
as Piskacek’s sign. 90. D. A complete placenta previa
86. B. Chadwick’s sign refers to the occurs when the placenta covers the
purple-blue tinge of the cervix. opening of the uterus, thus blocking
Braxton Hicks contractions are the passageway for the baby. This
painless contractions beginning response explains what a complete
around the 4th month. Goodell’s sign previa is and the reason the baby
indicates softening of the cervix. cannot come out except by cesarean
Flexibility of the uterus against the delivery. Telling the client to ask the
cervix is known as McDonald’s sign. physician is a poor response and
would increase the patient’s anxiety. same genotype, and common
Although a cesarean would help to chorion.
prevent hemorrhage, the statement 96. C. The zygote is the single cell that
does not explain why the reproduces itself after conception.
hemorrhage could occur. With a The chromosome is the material
complete previa, the placenta is that makes up the cell and is gained
covering all the cervix, not just most from each parent. Blastocyst and
of it. trophoblast are later terms for the
91. B. With a face presentation, the embryo after zygote.
head is completely extended. With a 97. D. Prepared childbirth was the direct
vertex presentation, the head is result of the 1950’s challenging of
completely or partially flexed. With the routine use of analgesic and
a brow (forehead) presentation, the anesthetics during childbirth. The
head would be partially extended. LDRP was a much later concept and
92. D. With this presentation, the fetal was not a direct result of the
upper torso and back face the left challenging of routine use of
upper maternal abdominal wall. The analgesics and anesthetics during
fetal heart rate would be most childbirth. Roles for nurse midwives
audible above the maternal and clinical nurse specialists did not
umbilicus and to the left of the develop from this challenge.
middle. The other positions would 98. C. The ischial spines are located in
be incorrect. the mid-pelvic region and could be
93. C. The greenish tint is due to the narrowed due to the previous pelvic
presence of meconium. Lanugo is injury. The symphysis pubis, sacral
the soft, downy hair on the promontory, and pubic arch are not
shoulders and back of the fetus. part of the mid-pelvis.
Hydramnios represents excessive 99. B. Variations in the length of the
amniotic fluid. Vernix is the white, menstrual cycle are due to
cheesy substance covering the fetus. variations in the proliferative phase.
94. D. In a breech position, because of The menstrual, secretory and
the space between the presenting ischemic phases do not contribute
part and the cervix, prolapse of the to this variation.
umbilical cord is common. 100. B. Testosterone is produced
Quickening is the woman’s first by the Leyding cells in the
perception of fetal movement. seminiferous tubules. Follicle-
Ophthalmia neonatorum usually stimulating hormone and leuteinzing
results from maternal gonorrhea hormone are released by the
and is conjunctivitis. Pica refers to anterior pituitary gland. The
the oral intake of nonfood hypothalamus is responsible for
substances. releasing gonadotropin-releasing
95. A. Dizygotic (fraternal) twins involve hormone.
two ova fertilized by separate 101. D. The anterior fontanelle
sperm. Monozygotic (identical) typically closes anywhere between
twins involve a common placenta, 12 to 18 months of age. Thus,
assessing the anterior fontanelle as younger than 3 years. A 5-month-old
still being slightly open is a normal is too young to use a push-pull toy.
finding requiring no further action. 105. B. Infants need to have their
Because it is normal finding for this security needs met by being held
age, notifying he physician or and cuddled. At 2 months of age,
performing additional examinations they are unable to make the
are inappropriate. connection between crying and
102. D. Solid foods are not attention. This association does not
recommended before age 4 to 6 occur until late infancy or early
months because of the sucking toddlerhood. Letting the infant cry
reflex and the immaturity of the for a time before picking up the
gastrointestinal tract and immune infant or leaving the infant alone to
system. Therefore, the earliest age cry herself to sleep interferes with
at which to introduce foods is 4 meeting the infant’s need for
months. Any time earlier would be security at this very young age.
inappropriate. Infants cry for many reasons.
103. A. According to Erikson, Assuming that the child s hungry
infants need to have their needs may cause overfeeding problems
met consistently and effectively to such as obesity.
develop a sense of trust. An infant 106. B. Underdeveloped
whose needs are consistently unmet abdominal musculature gives the
or who experiences significant toddler a characteristically
delays in having them met, such as protruding abdomen. During
in the case of the infant of a toddlerhood, food intake decreases,
substance-abusing mother, will not increases. Toddlers are
develop a sense of uncertainty, characteristically bowlegged
leading to mistrust of caregivers and because the leg muscles must bear
the environment. Toddlers develop the weight of the relatively large
a sense of shame when their trunk. Toddler growth patterns
autonomy needs are not met occur in a steplike, not linear
consistently. Preschoolers develop a pattern.
sense of guilt when their sense of 107. B. According to Erikson,
initiative is thwarted. Schoolagers toddlers experience a sense of
develop a sense of inferiority when shame when they are not allowed to
they do not develop a sense of develop appropriate independence
industry. and autonomy. Infants develop
104. D. A busy box facilitates the mistrust when their needs are not
fine motor development that occurs consistently gratified. Preschoolers
between 4 and 6 months. Balloons develop guilt when their initiative
are contraindicated because small needs are not met while schoolagers
children may aspirate balloons. develop a sense of inferiority when
Because the button eyes of a teddy their industry needs are not met.
bear may detach and be aspirated, 108. C. Young toddlers are still
this toy is unsafe for children sensorimotor learners and they
enjoy the experience of feeling security and also readies the child
different textures. Thus, finger for sleep. The child should sleep in
paints would be an appropriate toy his own bed. Telling the child about
choice. Multiple-piece toys, such as locking him in his room will viewed
puzzle, are too difficult to by the child as a threat. Additionally,
manipulate and may be hazardous if a locked door is frightening and
the pieces are small enough to be potentially hazardous. Vigorous
aspirated. Miniature cars also have a activity at bedtime stirs up the child
high potential for aspiration. Comic and makes more difficult to fall
books are on too high a level for asleep.
toddlers. Although they may enjoy 112. B. Dress-up clothes enhance
looking at some of the pictures, imaginative play and imagination,
toddlers are more likely to rip a allowing preschoolers to engage in
comic book apart. rich fantasy play. Building blocks and
109. D. The child must be able to wooden puzzles are appropriate for
sate the need to go to the bathroom encouraging fine motor
to initiate toilet training. Usually, a development. Big wheels and
child needs to be dry for only 2 tricycles encourage gross motor
hours, not 4 hours. The child also development.
must be able to sit, walk, and squat. 113. D. The school-aged child is in
A new sibling would most likely the stage of concrete operations,
hinder toilet training. marked by inductive reasoning,
110. A. Toddlers become picky logical operations, and reversible
eaters, experiencing food jags and concrete thought. The ability to
eating large amounts one day and consider the future requires formal
very little the next. A toddler’s food thought operations, which are not
gags express a preference for the developed until adolescence.
ritualism of eating one type of food Collecting baseball cards and
for several days at a time. Toddlers marbles, ordering dolls by size, and
typically enjoy socialization and simple problem-solving options are
limiting others at meal time. examples of the concrete
Toddlers prefer to feed themselves operational thinking of the
and thus are too young to have table schoolager.
manners. A toddler’s appetite and 114. C. Reaction formation is the
need for calories, protein, and fluid schoolager’s typical defensive
decrease due to the dramatic response when hospitalized. In
slowing of growth rate. reaction formation, expression of
111. D. Preschoolers commonly unacceptable thoughts or behaviors
have fears of the dark, being left is prevented (or overridden) by the
alone especially at bedtime, and exaggerated expression of opposite
ghosts, which may affect the child’s thoughts or types of behaviors.
going to bed at night. Quiet play and Regression is seen in toddlers and
time with parents is a positive preshcoolers when they retreat or
bedtime routine that provides return to an earlier level of
development. Repression refers to 117. C. Based on the
the involuntary blocking of recommendations of the American
unpleasant feelings and experiences Academy of Family Physicians and
from one’s awareness. the American Academy of Pediatrics,
Rationalization is the attempt to the MMR vaccine should be given at
make excuses to justify the age of 10 if the child did not
unacceptable feelings or behaviors. receive it between the ages of 4 to 6
115. C. The schoolager’s cognitive years as recommended.
level is sufficiently developed to Immunization for diphtheria and
enable good understanding of and tetanus is required at age 13.
adherence to rules. Thus, 118. D. According to Erikson, role
schoolagers should be able to diffusion develops when the
understand the potential dangers adolescent does not develop a sense
around them. With growth comes of identity and a sense or where he
greater freedom and children fits in. Toddlers develop a sense of
become more adventurous and shame when they do not achieve
daring. The school-aged child is also autonomy. Preschoolers develop a
still prone to accidents and home sense of guilt when they do not
hazards, especially because of develop a sense of initiative. School-
increased motor abilities and age children develop a sense of
independence. Plus the home inferiority when they do not develop
hazards differ from other age a sense of industry.
groups. These hazards, which are 119. A. Menarche refers to the
potentially lethal but tempting, may onset of the first menstruation or
include firearms, alcohol, and menstrual period and refers only to
medications. School-age children the first cycle. Uterine growth and
begin to internalize their own broadening of the pelvic girdle
controls and need less outside occurs before menarche.
direction. Plus the child is away from 120. A. Stating that this is
home more often. Some parental or probably the only concern the
caregiver assistance is still needed to adolescent has and telling the
answer questions and provide parents not to worry about it or the
guidance for decisions and time her spends on it shuts off
responsibilities. further investigation and is likely to
116. C. The most significant skill make the adolescent and his parents
learned during the school-age feel defensive. The statement about
period is reading. During this time peer acceptance and time spent in
the child develops formal adult front of the mirror for the
articulation patterns and learns that development of self image provides
words can be arranged in structure. information about the adolescent’s
Collective, ordering, and sorting, needs to the parents and may help
although important, are not most to gain trust with the adolescent.
significant skills learned. Asking the adolescent how he feels
about the acne will encourage the
adolescent to share his feelings. pregnancy has declined since 1991,
Discussing the cleansing method yet morbidity remains high. Most
shows interest and concern for the teenage pregnancies are unplanned
adolescent and also can help to and occur out of wedlock. The
identify any patient-teaching needs pregnant adolescent is at high risk
for the adolescent regarding for physical complications including
cleansing. premature labor and low-birth-
121. B. Preschoolers should be weight infants, high neonatal
developmentally incapable of mortality, iron deficiency anemia,
demonstrating explicit sexual prolonged labor, and fetopelvic
behavior. If a child does so, the child disproportion as well as numerous
has been exposed to such behavior, psychological crises.
and sexual abuse should be 124. B. Because of the structural
suspected. Explicit sexual behavior defect, children with cleft palate
during doll play is not a may have ineffective functioning of
characteristic of preschool their Eustachian tubes creating
development nor symptomatic of frequent bouts of otitis media. Most
developmental delay. Whether or children with cleft palate remain
nor the child knows how to play well-nourished and maintain
with dolls is irrelevant. adequate nutrition through the use
122. A. The parents need more of proper feeding techniques. Food
teaching if they state that they will particles do not pass through the
keep the child home until the phobia cleft and into the Eustachian tubes.
subsides. Doing so reinforces the There is no association between
child’s feelings of worthlessness and cleft palate and congenial ear
dependency. The child should deformities.
attend school even during resolution 125. D. A 3-month-old infant
of the problem. Allowing the child to should be able to lift the head and
verbalize helps the child to ventilate chest when prone. The Moro reflex
feelings and may help to uncover typically diminishes or subsides by 3
causes and solutions. Collaboration months. The parachute reflex
with the teachers and counselors at appears at 9 months. Rolling from
school may lead to uncovering the front to back usually is accomplished
cause of the phobia and to the at about 5 months.
development of solutions. The child 126. D. A child’s birth weight
should participate and play an active usually triples by 12 months and
role in developing possible solutions. doubles by 4 months. No specific
123. C. The adolescent who birth weight parameters are
becomes pregnant typically denies established for 7 or 9 months.
the pregnancy early on. Early 127. C. Toddlers engaging in
recognition by a parent or health parallel play will play near each
care provider may be crucial to other, but not with each other.
timely initiation of prenatal care. Thus, when two toddlers sit near
The incidence of adolescent each other but play with separate
dolls, they are exhibiting parallel child from further harm. Scheduling
play. Sharing crayons, playing a a follow-up visit is inappropriate
board game with a nurse, or sharing because additional harm may come
dolls with two different nurses are to the child if the nurse waits for
all examples of cooperative play. further assessment data. Although
128. A. Acute lymphocytic the nurse should notify the
leukemia (ALL) causes leukopenia, physician, the goal is to initiate
resulting in immunosuppression and measures to protect the child’s
increasing the risk of infection, a safety. Notifying the physician
leading cause of death in children immediately does not initiate the
with ALL. Therefore, the initial removal of the child from harm nor
priority nursing intervention would does it absolve the nurse from
be to institute infection control responsibility. Multiple bruises and
precautions to decrease the risk of burns are not normal toddler
infection. Iron-rich foods help with injuries.
anemia, but dietary iron is not an 131. B. The mother is using
initial intervention. The prognosis of projection, the defense mechanism
ALL usually is good. However, later used when a person attributes his or
on, the nurse may need to assist the her own undesirable traits to
child and family with coping since another. Displacement is the
death and dying may still be an issue transfer of emotion onto an
in need of discussion. Injections unrelated object, such as when the
should be discouraged, owing to mother would kick a chair or bang
increased risk from bleeding due to the door shut. Repression is the
thrombocytopenia. submerging of painful ideas into the
129. A. The pertusis component unconscious. Psychosis is a state of
may result in fever and the tetanus being out of touch with reality.
component may result in injection 132. A. Children with congenital
soreness. Therefore, the mother’s heart disease are more prone to
verbalization of information about respiratory infections. Bleeding
measures to reduce fever indicates tendencies, frequent vomiting, and
understanding. No dietary diarrhea and seizure disorders are
restrictions are necessary after this not associated with congenital heart
injection is given. A subsequent rash disease.
is more likely to be seen 5 to 10 days 133. D. The child is exhibiting
after receiving the MMR vaccine, classic signs of epiglottitis, always a
not the diphtheria, pertussis, and pediatric emergency. The physician
tetanus vaccine. Diarrhea is not must be notified immediately and
associated with this vaccine. the nurse must be prepared for an
130. A. Multiple bruises and burns emergency intubation or
on a toddler are signs child abuse. tracheostomy. Further assessment
Therefore, the nurse is responsible with auscultating lungs and placing
for reporting the case to Protective the child in a mist tent wastes
Services immediately to protect the valuable time. The situation is a
possible life-threatening emergency. months. DtaP is routinely given at 2,
Having the child lie down would 4, 6, and 15 to 18 months and a
cause additional distress and may booster at 4 to 6 years.
result in respiratory arrest. Throat 137. C. Because the 8-month-old
examination may result in is refining his gross motor skills,
laryngospasm that could be fatal. being able to sit unsupported and
134. A. In females, the urethra is also improving his fine motor skills,
shorter than in males. This probably capable of making hand-to-
decreases the distance for hand transfers, large blocks would
organisms to travel, thereby be the most appropriate toy
increasing the chance of the child selection. Push-pull toys would be
developing a urinary tract infection. more appropriate for the 10 to 12-
Frequent emptying of the bladder month-old as he or she begins to
would help to decrease urinary tract cruise the environment. Rattles and
infections by avoiding sphincter mobiles are more appropriate for
stress. Increased fluid intake enables infants in the 1 to 3 month age
the bladder to be cleared more range. Mobiles pose a danger to
frequently, thus helping to prevent older infants because of possible
urinary tract infections. The intake strangulation.
of acidic juices helps to keep the 138. B. During the preschool
urine pH acidic and thus decrease period, the child has mastered a
the chance of flora development. sense of autonomy and goes on to
135. B. Compartment syndrome is master a sense of initiative. During
an emergent situation and the this period, the child commonly
physician needs to be notified experiences more fears than at any
immediately so that interventions other time. One common fear is fear
can be initiated to relieve the of the body mutilation, especially
increasing pressure and restore associated with painful experiences.
circulation. Acetaminophen The preschool child uses simple, not
(Tylenol) will be ineffective since the complex, reasoning, engages in
pain is related to the increasing associative, not competitive, play
pressure and tissue ischemia. The (interactive and cooperative play
cast, not traction, is being used in with sharing), and is able to tolerate
this situation for immobilization, so longer periods of delayed
releasing the traction would be gratification.
inappropriate. In this situation, 139. A. Mild mental retardation
specific action not continued refers to development disability
monitoring is indicated. involving an IQ 50 to 70. Typically,
136. D. The varicella zoster the child is not noted as being
vaccine (VZV) is a live vaccine given retarded, but exhibits slowness in
after age 12 months. The first dose performing tasks, such as self-
of hepatitis B vaccine is given at feeding, walking, and taking. Little or
birth to 2 months, then at 1 to 4 no speech, marked motor delays,
months, and then again at 6 to 18 and gait disabilities would be seen in
more severe forms mental 144. D. GER is the backflow of
retardation. gastric contents into the esophagus
140. B. Down syndrome is resulting from relaxation or
characterized by the following a incompetence of the lower
transverse palmar crease (simian esophageal (cardiac) sphincter. No
crease), separated sagittal suture, alteration in the oral mucous
oblique palpebral fissures, small membranes occurs with this
nose, depressed nasal bridge, high- disorder. Fluid volume deficit, risk
arched palate, excess and lax skin, for aspiration, and altered nutrition
wide spacing and plantar crease are appropriate nursing diagnoses.
between the second and big toes, 145. A. Thickened feedings are
hyperextensible and lax joints, large used with GER to stop the vomiting.
protruding tongue, and muscle Therefore, the nurse would monitor
weakness. the child’s vomiting to evaluate the
141. A. Because of the defect, the effectiveness of using the thickened
child will be unable to from the feedings. No relationship exists
mouth adequately around nipple, between feedings and
thereby requiring special devices to characteristics of stools and uterine.
allow for feeding and sucking If feedings are ineffective, this
gratification. Respiratory status may should be noted before there is any
be compromised if the child is fed change in the child’s weight.
improperly or during postoperative 146. C. Children with celiac
period, Locomotion would be a disease cannot tolerate or digest
problem for the older infant because gluten. Therefore, because of its
of the use of restraints. GI gluten content, wheat and wheat-
functioning is not compromised in containing products must be
the child with a cleft lip. avoided. Rice, milk, and chicken do
142. B. Postoperatively children not contain gluten and need not be
with cleft palate should be placed on avoided.
their abdomens to facilitate 147. C. Episodes of celiac crises
drainage. If the child is placed in the are precipitated by infections,
supine position, he or she may ingestion of gluten, prolonged
aspirate. Using an infant seat does fasting, or exposure to
not facilitate drainage. Side-lying anticholinergic drugs. Celiac crisis is
does not facilitate drainage as well typically characterized by severe
as the prone position. watery diarrhea. Respiratory distress
143. C. Projectile vomiting is a key is unlikely in a routine upper
symptom of pyloric stenosis. respiratory infection. Irritability,
Regurgitation is seen more rather than lethargy, is more likely.
commonly with GER. Steatorrhea Because of the fluid loss associated
occurs in malabsorption disorders with the severe watery diarrhea, the
such as celiac disease. “Currant jelly” child’s weight is more likely to be
stools are characteristic of decreased.
intussusception.
148. A. For the child with
Hirschsprung disease, fever and
explosive diarrhea indicate
enterocolitis, a life-threatening
situation. Therefore, the physician
should be notified immediately.
Generally, because of the intestinal
obstruction and inadequate ANSWER AND RATIONALE
propulsive intestinal movement,
antidiarrheals are not used to treat 1. B. Although all of the factors listed
Hirschsprung disease. The child is are important, sperm motility is the
acutely ill and requires intervention, most significant criterion when
with monitoring more frequently assessing male infertility. Sperm
than every 30 minutes. Hirschsprung count, sperm maturity, and semen
disease typically presents with volume are all significant, but they
chronic constipation. are not as significant sperm motility.
149. A. Failure to pass meconium 2. D. Based on the partner’s
within the first 24 hours after birth statement, the couple is verbalizing
may be an indication of feelings of inadequacy and negative
Hirschsprung disease, a congenital feelings about themselves and their
anomaly resulting in mechanical capabilities. Thus, the nursing
obstruction due to inadequate diagnosis of self-esteem disturbance
motility in an intestinal segment. is most appropriate. Fear, pain, and
Failure to pass meconium is not ineffective family coping also may
associated with celiac disease, be present but as secondary nursing
intussusception, or abdominal wall diagnoses.
defect. 3. B. Pressure and irritation of the
150. C. Because intussusception is bladder by the growing uterus
not believed to have a familial during the first trimester is
tendency, obtaining a family history responsible for causing urinary
would provide the least amount of frequency. Dysuria, incontinence,
information. Stool inspection, pain and burning are symptoms
pattern, and abdominal palpation associated with urinary tract
would reveal possible indicators of infections.
intussusception. Current, jelly-like 4. C. During the second trimester, the
stools containing blood and mucus reduction in gastric acidity in
are an indication of intussusception. conjunction with pressure from the
Acute, episodic abdominal pain is growing uterus and smooth muscle
characteristics of intussusception. A relaxation, can cause heartburn and
sausage-shaped mass may be flatulence. HCG levels increase in
palpated in the right upper the first, not the second, trimester.
quadrant. Decrease intestinal motility would
most likely be the cause of
constipation and bloating. Estrogen
levels decrease in the second signs of pregnancy. Probable signs
trimester. are objective findings that strongly
5. D. Chloasma, also called the mask of suggest pregnancy. Other probable
pregnancy, is an irregular signs include Hegar sign, which is
hyperpigmented area found on the softening of the lower uterine
face. It is not seen on the breasts, segment; Piskacek sign, which is
areola, nipples, chest, neck, arms, enlargement and softening of the
legs, abdomen, or thighs. uterus; serum laboratory tests;
6. C. During pregnancy, hormonal changes in skin pigmentation; and
changes cause relaxation of the ultrasonic evidence of a gestational
pelvic joints, resulting in the typical sac. Presumptive signs are
“waddling” gait. Changes in posture subjective signs and include
are related to the growing fetus. amenorrhea; nausea and vomiting;
Pressure on the surrounding urinary frequency; breast
muscles causing discomfort is due to tenderness and changes; excessive
the growing uterus. Weight gain has fatigue; uterine enlargement; and
no effect on gait. quickening.
7. C. The average amount of weight 10. B. Presumptive signs of pregnancy
gained during pregnancy is 24 to 30 are subjective signs. Of the signs
lb. This weight gain consists of the listed, only nausea and vomiting are
following: fetus – 7.5 lb; placenta presumptive signs. Hegar sign, skin
and membrane – 1.5 lb; amniotic pigmentation changes, and a
fluid – 2 lb; uterus – 2.5 lb; breasts – positive serum pregnancy test are
3 lb; and increased blood volume – 2 considered probably signs, which
to 4 lb; extravascular fluid and fat – are strongly suggestive of
4 to 9 lb. A gain of 12 to 22 lb is pregnancy.
insufficient, whereas a weight gain 11. D. During the first trimester,
of 15 to 25 lb is marginal. A weight common emotional reactions
gain of 25 to 40 lb is considered include ambivalence, fear, fantasies,
excessive. or anxiety. The second trimester is a
8. C. Pressure of the growing uterus on period of well-being accompanied
blood vessels results in an increased by the increased need to learn about
risk for venous stasis in the lower fetal growth and development.
extremities. Subsequently, edema Common emotional reactions during
and varicose vein formation may this trimester include narcissism,
occur. Thrombophlebitis is an passivity, or introversion. At times
inflammation of the veins due to the woman may seem egocentric
thrombus formation. Pregnancy- and self-centered. During the third
induced hypertension is not trimester, the woman typically feels
associated with these symptoms. awkward, clumsy, and unattractive,
Gravity plays only a minor role with often becoming more introverted or
these symptoms. reflective of her own childhood.
9. C. Cervical softening (Goodell sign) 12. B. First-trimester classes commonly
and uterine soufflé are two probable focus on such issues as early
physiologic changes, fetal 16. C. To determine the EDD when the
development, sexuality during date of the client’s LMP is known
pregnancy, and nutrition. Some use Nagele rule. To the first day of
early classes may include pregnant the LMP, add 7 days, subtract 3
couples. Second and third trimester months, and add 1 year (if
classes may focus on preparation for applicable) to arrive at the EDD as
birth, parenting, and newborn care. follows: 5 + 7 = 12 (July) minus 3 = 4
13. C. With breast feeding, the father’s (April). Therefore, the client’s EDD is
body is not capable of providing the April 12.
milk for the newborn, which may 17. A. When the LMP is unknown, the
interfere with feeding the newborn, gestational age of the fetus is
providing fewer chances for estimated by uterine size or position
bonding, or he may be jealous of the (fundal height). The presence of the
infant’s demands on his wife’s time uterus in the pelvis indicates less
and body. Breast feeding is than 12 weeks’ gestation. At
advantageous because uterine approximately 12 to 14 weeks, the
involution occurs more rapidly, thus fundus is out of the pelvis above the
minimizing blood loss. The presence symphysis pubis. The fundus is at
of maternal antibodies in breast milk the level of the umbilicus at
helps decrease the incidence of approximately 20 weeks’ gestation
allergies in the newborn. A greater and reaches the xiphoid at term or
chance for error is associated with 40 weeks.
bottle feeding. No preparation is 18. D. Danger signs that require prompt
required for breast feeding. reporting leaking of amniotic fluid,
14. A. A false-positive reaction can vaginal bleeding, blurred vision,
occur if the pregnancy test is rapid weight gain, and elevated
performed less than 10 days after an blood pressure. Constipation, breast
abortion. Performing the tests too tenderness, and nasal stuffiness are
early or too late in the pregnancy, common discomforts associated
storing the urine sample too long at with pregnancy.
room temperature, or having a 19. B. A rubella titer should be 1:8 or
spontaneous or missed abortion greater. Thurs, a finding of a titer
impending can all produce false- less than 1:8 is significant, indicating
negative results. that the client may not possess
15. D. The FHR can be auscultated with immunity to rubella. A hematocrit of
a fetoscope at about 20 week’s 33.5% a white blood cell count of
gestation. FHR usually is 8,000/mm3, and a 1 hour glucose
ausculatated at the midline challenge test of 110 g/dl are with
suprapubic region with Doppler normal parameters.
ultrasound transducer at 10 to 12 20. D. With true labor, contractions
week’s gestation. FHR, cannot be increase in intensity with walking. In
heard any earlier than 10 weeks’ addition, true labor contractions
gestation. occur at regular intervals, usually
starting in the back and sweeping
around to the abdomen. The 23. D. During the third stage of labor,
interval of true labor contractions which begins with the delivery of the
gradually shortens. newborn, the nurse would promote
21. B. Crowing, which occurs when the parent-newborn interaction by
newborn’s head or presenting part placing the newborn on the
appears at the vaginal opening, mother’s abdomen and encouraging
occurs during the second stage of the parents to touch the newborn.
labor. During the first stage of labor, Collecting a urine specimen and
cervical dilation and effacement other laboratory tests is done on
occur. During the third stage of admission during the first stage of
labor, the newborn and placenta are labor. Assessing uterine contractions
delivered. The fourth stage of labor every 30 minutes is performed
lasts from 1 to 4 hours after birth, during the latent phase of the first
during which time the mother and stage of labor. Coaching the client to
newborn recover from the physical push effectively is appropriate
process of birth and the mother’s during the second stage of labor.
organs undergo the initial 24. A. The newborn’s ability to regulate
readjustment to the nonpregnant body temperature is poor.
state. Therefore, placing the newborn
22. C. Barbiturates are rapidly under a radiant warmer aids in
transferred across the placental maintaining his or her body
barrier, and lack of an antagonist temperature. Suctioning with a bulb
makes them generally inappropriate syringe helps maintain a patent
during active labor. Neonatal side airway. Obtaining an Apgar score
effects of barbiturates include measures the newborn’s immediate
central nervous system depression, adjustment to extrauterine life.
prolonged drowsiness, delayed Inspecting the umbilical cord aids in
establishment of feeding (e.g. due to detecting cord anomalies.
poor sucking reflex or poor sucking 25. D. Immediately before expulsion or
pressure). Tranquilizers are birth of the rest of the body, the
associated with neonatal effects cardinal movement of external
such as hypotonia, hypothermia, rotation occurs. Descent flexion,
generalized drowsiness, and internal rotation, extension, and
reluctance to feed for the first few restitution (in this order) occur
days. Narcotic analgesic readily cross before external rotation.
the placental barrier, causing 26. B. The foramen ovale is an opening
depressive effects in the newborn 2 between the right and left auricles
to 3 hours after intramuscular (atria) that should close shortly after
injection. Regional anesthesia is birth so the newborn will not have a
associated with adverse reactions murmur or mixed blood traveling
such as maternal hypotension, through the vascular system. The
allergic or toxic reaction, or partial umbilical vein, ductus arteriosus,
or total respiratory failure. and ductus venosus are obliterated
at birth.
27. B. Uric acid crystals in the urine may newborn will attempt to crawl
produce the reddish “brick dust” forward with both arms and legs
stain on the diaper. Mucus would when he is placed on his abdomen
not produce a stain. Bilirubin and on a flat surface.
iron are from hepatic adaptation. 32. B. The description of hyperemesis
28. B. The normal heart rate for a gravidarum includes severe nausea
newborn that is sleeping is and vomiting, leading to electrolyte,
approximately 100 beats per metabolic, and nutritional
minute. If the newborn was awake, imbalances in the absence of other
the normal heart rate would range medical problems. Hyperemesis is
from 120 to 160 beats per minute. not a form of anemia. Loss of
29. C. The anterior fontanel is larger in appetite may occur secondary to the
size than the posterior fontanel. nausea and vomiting of
Additionally, the anterior fontanel, hyperemesis, which, if it continues,
which is diamond shaped, closes at can deplete the nutrients
18 months, whereas the posterior transported to the fetus. Diarrhea
fontanel, which is triangular shaped, does not occur with hyperemesis.
closes at 8 to 12 weeks. Neither 33. B. Edema of the hands and face is a
fontanel should appear bulging, classic sign of PIH. Many healthy
which may indicate increased pregnant woman experience foot
intracranial pressure, or sunken, and ankle edema. A weight gain of 2
which may indicate dehydration. lb or more per week indicates a
30. B. Blink, cough, sneeze, swallowing problem. Early morning headache is
and gag reflexes are all present at not a classic sign of PIH.
birth and remain unchanged 34. C. In a missed abortion, there is
through adulthood. Reflexes such as early fetal intrauterine death, and
rooting and stepping subside within products of conception are not
the first year. expelled. The cervix remains closed;
31. A. With the babinski reflex, the there may be a dark brown vaginal
newborn’s toes hyperextend and fan discharge, negative pregnancy test,
apart from dorsiflexion of the big and cessation of uterine growth and
toe when one side of foot is stroked breast tenderness. A threatened
upward form the heel and across abortion is evidenced with cramping
the ball of the foot. With the startle and vaginal bleeding in early
reflex, the newborn abducts and pregnancy, with no cervical dilation.
flexes all extremities and may begin An incomplete abortion presents
to cry when exposed to sudden with bleeding, cramping, and
movement of loud noise. With the cervical dilation. An incomplete
rooting and sucking reflex, the abortion involves only expulsion of
newborn turns his head in the part of the products of conception
direction of stimulus, opens the and bleeding occurs with cervical
mouth, and begins to suck when the dilation.
cheeks, lip, or corner of mouth is 35. A. Multiple gestation is one of the
touched. With the crawl reflex, the predisposing factors that may cause
placenta previa. Uterine anomalies anxiety are not associated with
abdominal trauma, and renal or hyperstimulation.
vascular disease may predispose a 39. C. A key point to consider when
client to abruptio placentae. preparing the client for a cesarean
36. B. A client with abruptio placentae delivery is to modify the
may exhibit concealed or dark red preoperative teaching to meet the
bleeding, possibly reporting sudden needs of either a planned or
intense localized uterine pain. The emergency cesarean birth, the
uterus is typically firm to boardlike, depth and breadth of instruction will
and the fetal presenting part may be depend on circumstances and time
engaged. Bright red, painless vaginal available. Allowing the mother’s
bleeding, a palpable fetal outline support person to remain with her
and a soft nontender abdomen are as much as possible is an important
manifestations of placenta previa. concept, although doing so depends
37. D. Abruptio placentae is described on many variables. Arranging for
as premature separation of a necessary explanations by various
normally implanted placenta during staff members to be involved with
the second half of pregnancy, the client’s care is a nursing
usually with severe hemorrhage. responsibility. The nurse is
Placenta previa refers to responsible for reinforcing the
implantation of the placenta in the explanations about the surgery,
lower uterine segment, causing expected outcome, and type of
painless bleeding in the third anesthetic to be used. The
trimester of pregnancy. Ectopic obstetrician is responsible for
pregnancy refers to the implantation explaining about the surgery and
of the products of conception in a outcome and the anesthesiology
site other than the endometrium. staff is responsible for explanations
Incompetent cervix is a conduction about the type of anesthesia to be
characterized by painful dilation of used.
the cervical os without uterine 40. A. Preterm labor is best described as
contractions. labor that begins after 20 weeks’
38. B. Hyperstimulation of the uterus gestation and before 37 weeks’
such as with oxytocin during the gestation. The other time periods
induction of labor may result in are inaccurate.
tetanic contractions prolonged to 41. B. PROM can precipitate many
more than 90seconds, which could potential and actual problems; one
lead to such complications as fetal of the most serious is the fetus loss
distress, abruptio placentae, of an effective defense against
amniotic fluid embolism, laceration infection. This is the client’s most
of the cervix, and uterine rupture. immediate need at this time.
Weak contractions would not occur. Typically, PROM occurs about 1
Pain, bright red vaginal bleeding, hour, not 4 hours, before labor
and increased restlessness and begins. Fetal viability and gestational
age are less immediate
considerations that affect the plan 500 ml following birth. Any amount
of care. Malpresentation and an less than this not considered
incompetent cervix may be causes postpartum hemorrhage.
of PROM. 46. D. With mastitis, injury to the
42. B. Dystocia is difficult, painful, breast, such as overdistention,
prolonged labor due to mechanical stasis, and cracking of the nipples, is
factors involving the fetus the primary predisposing factor.
(passenger), uterus (powers), pelvis Epidemic and endemic infections are
(passage), or psyche. Nutritional, probable sources of infection for
environment, and medical factors mastitis. Temporary urinary
may contribute to the mechanical retention due to decreased
factors that cause dystocia. perception of the urge to void is a
43. A. With uterine rupture, the client is contributory factor to the
at risk for hypovolemic shock. development of urinary tract
Therefore, the priority is to prevent infection, not mastitis.
and limit hypovolemic shock. 47. D. Thrombophlebitis refers to an
Immediate steps should include inflammation of the vascular
giving oxygen, replacing lost fluids, endothelium with clot formation on
providing drug therapy as needed, the wall of the vessel. Blood
evaluating fetal responses and components combining to form an
preparing for surgery. Obtaining aggregate body describe a thrombus
blood specimens, instituting or thrombosis. Clots lodging in the
complete bed rest, and inserting a pulmonary vasculature refers to
urinary catheter are necessary in pulmonary embolism; in the femoral
preparation for surgery to remedy vein, femoral thrombophlebitis.
the rupture. 48. C. Classic symptoms of DVT include
44. B. The immediate priority is to muscle pain, the presence of
minimize pressure on the cord. Thus Homans sign, and swelling of the
the nurse’s initial action involves affected limb. Midcalf pain,
placing the client on bed rest and tenderness, and redness, along the
then placing the client in a knee- vein reflect superficial
chest position or lowering the head thrombophlebitis. Chills, fever and
of the bed, and elevating the malaise occurring 2 weeks after
maternal hips on a pillow to delivery reflect pelvic
minimize the pressure on the cord. thrombophlebitis. Chills, fever,
Monitoring maternal vital signs and stiffness and pain occurring 10 to 14
FHR, notifying the physician and days after delivery suggest femoral
preparing the client for delivery, and thrombophlebitis.
wrapping the cord with sterile saline 49. B. Manifestations of cystitis include,
soaked warm gauze are important. frequency, urgency, dysuria,
But these actions have no effect on hematuria nocturia, fever, and
minimizing the pressure on the cord. suprapubic pain. Dehydration,
45. D. Postpartum hemorrhage is hypertension, and chills are not
defined as blood loss of more than typically associated with cystitis.
High fever chills, flank pain, nausea, microorganisms that can cause
vomiting, dysuria, and frequency are sexually transmitted infections.
associated with pvelonephritis. 53. A. The diaphragm must be fitted
50. C. According to statistical reports, individually to ensure effectiveness.
between 50% and 80% of all new Because of the changes to the
mothers report some form of reproductive structures during
postpartum blues. The ranges of pregnancy and following delivery,
10% to 40%, 30% to 50%, and 25% the diaphragm must be refitted,
to 70% are incorrect. usually at the 6 weeks’ examination
51. B. Regular timely ingestion of oral following childbirth or after a weight
contraceptives is necessary to loss of 15 lbs or more. In addition,
maintain hormonal levels of the for maximum effectiveness,
drugs to suppress the action of the spermicidal jelly should be placed in
hypothalamus and anterior pituitary the dome and around the rim.
leading to inappropriate secretion of However, spermicidal jelly should
FSH and LH. Therefore, follicles do not be inserted into the vagina until
not mature, ovulation is inhibited, involution is completed at
and pregnancy is prevented. The approximately 6 weeks. Use of a
estrogen content of the oral site female condom protects the
contraceptive may cause the reproductive system from the
nausea, regardless of when the pill is introduction of semen or
taken. Side effects and drug spermicides into the vagina and may
interactions may occur with oral be used after childbirth. Oral
contraceptives regardless of the contraceptives may be started
time the pill is taken. within the first postpartum week to
52. C. Condoms, when used correctly ensure suppression of ovulation. For
and consistently, are the most the couple who has determined the
effective contraceptive method or female’s fertile period, using the
barrier against bacterial and viral rhythm method, avoidance of
sexually transmitted infections. intercourse during this period, is
Although spermicides kill sperm, safe and effective.
they do not provide reliable 54. C. An IUD may increase the risk of
protection against the spread of pelvic inflammatory disease,
sexually transmitted infections, especially in women with more than
especially intracellular organisms one sexual partner, because of the
such as HIV. Insertion and removal increased risk of sexually
of the diaphragm along with the use transmitted infections. An UID
of the spermicides may cause should not be used if the woman has
vaginal irritations, which could place an active or chronic pelvic infection,
the client at risk for infection postpartum infection, endometrial
transmission. Male sterilization hyperplasia or carcinoma, or uterine
eliminates spermatozoa from the abnormalities. Age is not a factor in
ejaculate, but it does not eliminate determining the risks associated
bacterial and/or viral with IUD use. Most IUD users are
over the age of 30. Although there is second trimester than in the third.
a slightly higher risk for infertility in During the first trimester, the client
women who have never been should only gain 1.5 pounds in the
pregnant, the IUD is an acceptable first 10 weeks, not 1 pound per
option as long as the risk-benefit week. A weight gain of ½ pound per
ratio is discussed. IUDs may be week would be 20 pounds for the
inserted immediately after delivery, total pregnancy, less than the
but this is not recommended recommended amount.
because of the increased risk and 57. B. To calculate the EDD by Nagele’s
rate of expulsion at this time. rule, add 7 days to the first day of
55. C. During the third trimester, the the last menstrual period and count
enlarging uterus places pressure on back 3 months, changing the year
the intestines. This coupled with the appropriately. To obtain a date of
effect of hormones on smooth September 27, 7 days have been
muscle relaxation causes decreased added to the last day of the LMP
intestinal motility (peristalsis). (rather than the first day of the
Increasing fiber in the diet will help LMP), plus 4 months (instead of 3
fecal matter pass more quickly months) were counted back. To
through the intestinal tract, thus obtain the date of November 7, 7
decreasing the amount of water that days have been subtracted (instead
is absorbed. As a result, stool is of added) from the first day of LMP
softer and easier to pass. Enemas plus November indicates counting
could precipitate preterm labor back 2 months (instead of 3 months)
and/or electrolyte loss and should from January. To obtain the date of
be avoided. Laxatives may cause December 27, 7 days were added to
preterm labor by stimulating the last day of the LMP (rather than
peristalsis and may interfere with the first day of the LMP) and
the absorption of nutrients. Use for December indicates counting back
more than 1 week can also lead to only 1 month (instead of 3 months)
laxative dependency. Liquid in the from January.
diet helps provide a semisolid, soft 58. D. The client has been pregnant four
consistency to the stool. Eight to ten times, including current pregnancy
glasses of fluid per day are essential (G). Birth at 38 weeks’ gestation is
to maintain hydration and promote considered full term (T), while birth
stool evacuation. form 20 weeks to 38 weeks is
56. D. To ensure adequate fetal growth considered preterm (P). A
and development during the 40 spontaneous abortion occurred at 8
weeks of a pregnancy, a total weight weeks (A). She has two living
gain 25 to 30 pounds is children (L).
recommended: 1.5 pounds in the 59. B. At 12 weeks gestation, the uterus
first 10 weeks; 9 pounds by 30 rises out of the pelvis and is palpable
weeks; and 27.5 pounds by 40 above the symphysis pubis. The
weeks. The pregnant woman should Doppler intensifies the sound of the
gain less weight in the first and fetal pulse rate so it is audible. The
uterus has merely risen out of the three classic signs of preeclampsia
pelvis into the abdominal cavity and are hypertension, edema, and
is not at the level of the umbilicus. proteinuria. Although urine is
The fetal heart rate at this age is not checked for glucose at each clinic
audible with a stethoscope. The visit, this is not the priority.
uterus at 12 weeks is just above the Depression may cause either
symphysis pubis in the abdominal anorexia or excessive food intake,
cavity, not midway between the leading to excessive weight gain or
umbilicus and the xiphoid process. loss. This is not, however, the
At 12 weeks the FHR would be priority consideration at this time.
difficult to auscultate with a Weight gain thought to be caused by
fetoscope. Although the external excessive food intake would require
electronic fetal monitor would a 24-hour diet recall. However,
project the FHR, the uterus has not excessive intake would not be the
risen to the umbilicus at 12 weeks. primary consideration for this client
60. A. Although all of the choices are at this time.
important in the management of 62. B. Cramping and vaginal bleeding
diabetes, diet therapy is the coupled with cervical dilation
mainstay of the treatment plan and signifies that termination of the
should always be the priority. pregnancy is inevitable and cannot
Women diagnosed with gestational be prevented. Thus, the nurse would
diabetes generally need only diet document an imminent abortion. In
therapy without medication to a threatened abortion, cramping
control their blood sugar levels. and vaginal bleeding are present,
Exercise, is important for all but there is no cervical dilation. The
pregnant women and especially for symptoms may subside or progress
diabetic women, because it burns up to abortion. In a complete abortion
glucose, thus decreasing blood all the products of conception are
sugar. However, dietary intake, not expelled. A missed abortion is early
exercise, is the priority. All pregnant fetal intrauterine death without
women with diabetes should have expulsion of the products of
periodic monitoring of serum conception.
glucose. However, those with 63. B. For the client with an ectopic
gestational diabetes generally do pregnancy, lower abdominal pain,
not need daily glucose monitoring. usually unilateral, is the primary
The standard of care recommends a symptom. Thus, pain is the priority.
fasting and 2-hour postprandial Although the potential for infection
blood sugar level every 2 weeks. is always present, the risk is low in
61. C. After 20 weeks’ gestation, when ectopic pregnancy because
there is a rapid weight gain, pathogenic microorganisms have
preeclampsia should be suspected, not been introduced from external
which may be caused by fluid sources. The client may have a
retention manifested by edema, limited knowledge of the pathology
especially of the hands and face. The and treatment of the condition and
will most likely experience grieving, 66. D. A weak, thready pulse elevated to
but this is not the priority at this 100 BPM may indicate impending
time. hemorrhagic shock. An increased
64. D. Before uterine assessment is pulse is a compensatory mechanism
performed, it is essential that the of the body in response to
woman empty her bladder. A full decreased fluid volume. Thus, the
bladder will interfere with the nurse should check the amount of
accuracy of the assessment by lochia present. Temperatures up to
elevating the uterus and displacing 100.48F in the first 24 hours after
to the side of the midline. Vital sign birth are related to the dehydrating
assessment is not necessary unless effects of labor and are considered
an abnormality in uterine normal. Although rechecking the
assessment is identified. Uterine blood pressure may be a correct
assessment should not cause acute choice of action, it is not the first
pain that requires administration of action that should be implemented
analgesia. Ambulating the client is in light of the other data. The data
an essential component of indicate a potential impending
postpartum care, but is not hemorrhage. Assessing the uterus
necessary prior to assessment of the for firmness and position in relation
uterus. to the umbilicus and midline is
65. A. Feeding more frequently, about important, but the nurse should
every 2 hours, will decrease the check the extent of vaginal bleeding
infant’s frantic, vigorous sucking first. Then it would be appropriate
from hunger and will decrease to check the uterus, which may be a
breast engorgement, soften the possible cause of the hemorrhage.
breast, and promote ease of correct 67. D. Any bright red vaginal discharge
latching-on for feeding. Narcotics would be considered abnormal, but
administered prior to breast feeding especially 5 days after delivery,
are passed through the breast milk when the lochia is typically pink to
to the infant, causing excessive brownish. Lochia rubra, a dark red
sleepiness. Nipple soreness is not discharge, is present for 2 to 3 days
severe enough to warrant narcotic after delivery. Bright red vaginal
analgesia. All postpartum clients, bleeding at this time suggests late
especially lactating mothers, should postpartum hemorrhage, which
wear a supportive brassiere with occurs after the first 24 hours
wide cotton straps. This does not, following delivery and is generally
however, prevent or reduce nipple caused by retained placental
soreness. Soaps are drying to the fragments or bleeding disorders.
skin of the nipples and should not be Lochia rubra is the normal dark red
used on the breasts of lactating discharge occurring in the first 2 to 3
mothers. Dry nipple skin predisposes days after delivery, containing
to cracks and fissures, which can epithelial cells, erythrocyes,
become sore and painful. leukocytes and decidua. Lochia
serosa is a pink to brownish
serosanguineous discharge in the limited time presented by
occurring from 3 to 10 days after early post-partum discharge.
delivery that contains decidua, 70. C. Heat loss by radiation occurs
erythrocytes, leukocytes, cervical when the infant’s crib is placed too
mucus, and microorganisms. Lochia near cold walls or windows. Thus
alba is an almost colorless to placing the newborn’s crib close to
yellowish discharge occurring from the viewing window would be least
10 days to 3 weeks after delivery effective. Body heat is lost through
and containing leukocytes, decidua, evaporation during bathing. Placing
epithelial cells, fat, cervical mucus, the infant under the radiant warmer
cholesterol crystals, and bacteria. after bathing will assist the infant to
68. A. The data suggests an infection of be rewarmed. Covering the scale
the endometrial lining of the uterus. with a warmed blanket prior to
The lochia may be decreased or weighing prevents heat loss through
copious, dark brown in appearance, conduction. A knit cap prevents heat
and foul smelling, providing further loss from the head a large head, a
evidence of a possible infection. All large body surface area of the
the client’s data indicate a uterine newborn’s body.
problem, not a breast problem. 71. B. A fractured clavicle would prevent
Typically, transient fever, usually the normal Moro response of
101ºF, may be present with breast symmetrical sequential extension
engorgement. Symptoms of mastitis and abduction of the arms followed
include influenza-like by flexion and adduction. In talipes
manifestations. Localized infection equinovarus (clubfoot) the foot is
of an episiotomy or C-section turned medially, and in plantar
incision rarely causes systemic flexion, with the heel elevated. The
symptoms, and uterine involution feet are not involved with the Moro
would not be affected. The client reflex. Hypothyroiddism has no
data do not include dysuria, effect on the primitive reflexes.
frequency, or urgency, symptoms of Absence of the Moror reflex is the
urinary tract infections, which would most significant single indicator of
necessitate assessing the client’s central nervous system status, but it
urine. is not a sign of increased intracranial
69. C. Because of early postpartum pressure.
discharge and limited time for 72. B. Hemorrhage is a potential risk
teaching, the nurse’s priority is to following any surgical procedure.
facilitate the safe and effective care Although the infant has been given
of the client and newborn. Although vitamin K to facilitate clotting, the
promoting comfort and restoration prophylactic dose is often not
of health, exploring the family’s sufficient to prevent bleeding.
emotional status, and teaching Although infection is a possibility,
about family planning are important signs will not appear within 4 hours
in postpartum/newborn nursing after the surgical procedure. The
care, they are not the priority focus primary discomfort of circumcision
occurs during the surgical submerged in a tub of water until
procedure, not afterward. Although the cord falls off and the stump has
feedings are withheld prior to the completely healed.
circumcision, the chances of 76. B. To determine the amount of
dehydration are minimal. formula needed, do the following
73. B. The presence of excessive mathematical calculation. 3 kg x 120
estrogen and progesterone in the cal/kg per day = 360 calories/day
maternal-fetal blood followed by feeding q 4 hours = 6 feedings per
prompt withdrawal at birth day = 60 calories per feeding: 60
precipitates breast engorgement, calories per feeding; 60 calories per
which will spontaneously resolve in feeding with formula 20 cal/oz = 3
4 to 5 days after birth. The trauma ounces per feeding. Based on the
of the birth process does not cause calculation. 2, 4 or 6 ounces are
inflammation of the newborn’s incorrect.
breast tissue. Newborns do not have 77. A. Intrauterine anoxia may cause
breast malignancy. This reply by the relaxation of the anal sphincter and
nurse would cause the mother to emptying of meconium into the
have undue anxiety. Breast tissue amniotic fluid. At birth some of the
does not hypertrophy in the fetus or meconium fluid may be aspirated,
newborns. causing mechanical obstruction or
74. D. The first 15 minutes to 1 hour chemical pneumonitis. The infant is
after birth is the first period of not at increased risk for
reactivity involving respiratory and gastrointestinal problems. Even
circulatory adaptation to though the skin is stained with
extrauterine life. The data given meconium, it is noninfectious
reflect the normal changes during (sterile) and nonirritating. The
this time period. The infant’s postterm meconium-stained infant
assessment data reflect normal is not at additional risk for bowel or
adaptation. Thus, the physician does urinary problems.
not need to be notified and oxygen 78. C. The nurse should use a
is not needed. The data do not nonelastic, flexible, paper measuring
indicate the presence of choking, tape, placing the zero point on the
gagging or coughing, which are signs superior border of the symphysis
of excessive secretions. Suctioning is pubis and stretching the tape across
not necessary. the abdomen at the midline to the
75. B. Application of 70% isopropyl top of the fundus. The xiphoid and
alcohol to the cord minimizes umbilicus are not appropriate
microorganisms (germicidal) and landmarks to use when measuring
promotes drying. The cord should be the height of the fundus
kept dry until it falls off and the (McDonald’s measurement).
stump has healed. Antibiotic 79. B. Women hospitalized with severe
ointment should only be used to preeclampsia need decreased CNS
treat an infection, not as a stimulation to prevent a seizure.
prophylaxis. Infants should not be Seizure precautions provide
environmental safety should a safest. Because of the proximity of
seizure occur. Because of edema, the sciatic nerve, the gluteus
daily weight is important but not the maximus muscle should not be until
priority. Preclampsia causes the child has been walking 2 years.
vasospasm and therefore can reduce 82. D. Bartholin’s glands are the glands
utero-placental perfusion. The client on either side of the vaginal orifice.
should be placed on her left side to The clitoris is female erectile tissue
maximize blood flow, reduce blood found in the perineal area above the
pressure, and promote diuresis. urethra. The parotid glands are open
Interventions to reduce stress and into the mouth. Skene’s glands open
anxiety are very important to into the posterior wall of the female
facilitate coping and a sense of urinary meatus.
control, but seizure precautions are 83. D. The fetal gonad must secrete
the priority. estrogen for the embryo to
80. C. Cessation of the lochial discharge differentiate as a female. An
signifies healing of the increase in maternal estrogen
endometrium. Risk of hemorrhage secretion does not effect
and infection are minimal 3 weeks differentiation of the embryo, and
after a normal vaginal delivery. maternal estrogen secretion occurs
Telling the client anytime is in every pregnancy. Maternal
inappropriate because this response androgen secretion remains the
does not provide the client with the same as before pregnancy and does
specific information she is not effect differentiation. Secretion
requesting. Choice of a of androgen by the fetal gonad
contraceptive method is important, would produce a male fetus.
but not the specific criteria for safe 84. A. Using bicarbonate would increase
resumption of sexual activity. the amount of sodium ingested,
Culturally, the 6-weeks’ examination which can cause complications.
has been used as the time frame for Eating low-sodium crackers would
resuming sexual activity, but it may be appropriate. Since liquids can
be resumed earlier. increase nausea avoiding them in
81. C. The middle third of the vastus the morning hours when nausea is
lateralis is the preferred injection usually the strongest is appropriate.
site for vitamin K administration Eating six small meals a day would
because it is free of blood vessels keep the stomach full, which often
and nerves and is large enough to decrease nausea.
absorb the medication. The deltoid 85. B. Ballottement indicates passive
muscle of a newborn is not large movement of the unengaged fetus.
enough for a newborn IM injection. Ballottement is not a contraction.
Injections into this muscle in a small Fetal kicking felt by the client
child might cause damage to the represents quickening. Enlargement
radial nerve. The anterior femoris and softening of the uterus is known
muscle is the next safest muscle to as Piskacek’s sign.
use in a newborn but is not the
86. B. Chadwick’s sign refers to the 90. D. A complete placenta previa
purple-blue tinge of the cervix. occurs when the placenta covers the
Braxton Hicks contractions are opening of the uterus, thus blocking
painless contractions beginning the passageway for the baby. This
around the 4th month. Goodell’s sign response explains what a complete
indicates softening of the cervix. previa is and the reason the baby
Flexibility of the uterus against the cannot come out except by cesarean
cervix is known as McDonald’s sign. delivery. Telling the client to ask the
87. C. Breathing techniques can raise physician is a poor response and
the pain threshold and reduce the would increase the patient’s anxiety.
perception of pain. They also Although a cesarean would help to
promote relaxation. Breathing prevent hemorrhage, the statement
techniques do not eliminate pain, does not explain why the
but they can reduce it. Positioning, hemorrhage could occur. With a
not breathing, increases complete previa, the placenta is
uteroplacental perfusion. covering all the cervix, not just most
88. A. The client’s labor is hypotonic. of it.
The nurse should call the physical 91. B. With a face presentation, the
and obtain an order for an infusion head is completely extended. With a
of oxytocin, which will assist the vertex presentation, the head is
uterus to contact more forcefully in completely or partially flexed. With
an attempt to dilate the cervix. a brow (forehead) presentation, the
Administering light sedative would head would be partially extended.
be done for hypertonic uterine 92. D. With this presentation, the fetal
contractions. Preparing for cesarean upper torso and back face the left
section is unnecessary at this time. upper maternal abdominal wall. The
Oxytocin would increase the uterine fetal heart rate would be most
contractions and hopefully progress audible above the maternal
labor before a cesarean would be umbilicus and to the left of the
necessary. It is too early to middle. The other positions would
anticipate client pushing with be incorrect.
contractions. 93. C. The greenish tint is due to the
89. D. The signs indicate placenta previa presence of meconium. Lanugo is
and vaginal exam to determine the soft, downy hair on the
cervical dilation would not be done shoulders and back of the fetus.
because it could cause hemorrhage. Hydramnios represents excessive
Assessing maternal vital signs can amniotic fluid. Vernix is the white,
help determine maternal physiologic cheesy substance covering the fetus.
status. Fetal heart rate is important 94. D. In a breech position, because of
to assess fetal well-being and should the space between the presenting
be done. Monitoring the part and the cervix, prolapse of the
contractions will help evaluate the umbilical cord is common.
progress of labor. Quickening is the woman’s first
perception of fetal movement.
Ophthalmia neonatorum usually stimulating hormone and leuteinzing
results from maternal gonorrhea hormone are released by the
and is conjunctivitis. Pica refers to anterior pituitary gland. The
the oral intake of nonfood hypothalamus is responsible for
substances. releasing gonadotropin-releasing
95. A. Dizygotic (fraternal) twins involve hormone.
two ova fertilized by separate 101. D. The anterior fontanelle
sperm. Monozygotic (identical) typically closes anywhere between
twins involve a common placenta, 12 to 18 months of age. Thus,
same genotype, and common assessing the anterior fontanelle as
chorion. still being slightly open is a normal
96. C. The zygote is the single cell that finding requiring no further action.
reproduces itself after conception. Because it is normal finding for this
The chromosome is the material age, notifying he physician or
that makes up the cell and is gained performing additional examinations
from each parent. Blastocyst and are inappropriate.
trophoblast are later terms for the 102. D. Solid foods are not
embryo after zygote. recommended before age 4 to 6
97. D. Prepared childbirth was the direct months because of the sucking
result of the 1950’s challenging of reflex and the immaturity of the
the routine use of analgesic and gastrointestinal tract and immune
anesthetics during childbirth. The system. Therefore, the earliest age
LDRP was a much later concept and at which to introduce foods is 4
was not a direct result of the months. Any time earlier would be
challenging of routine use of inappropriate.
analgesics and anesthetics during 103. A. According to Erikson,
childbirth. Roles for nurse midwives infants need to have their needs
and clinical nurse specialists did not met consistently and effectively to
develop from this challenge. develop a sense of trust. An infant
98. C. The ischial spines are located in whose needs are consistently unmet
the mid-pelvic region and could be or who experiences significant
narrowed due to the previous pelvic delays in having them met, such as
injury. The symphysis pubis, sacral in the case of the infant of a
promontory, and pubic arch are not substance-abusing mother, will
part of the mid-pelvis. develop a sense of uncertainty,
99. B. Variations in the length of the leading to mistrust of caregivers and
menstrual cycle are due to the environment. Toddlers develop
variations in the proliferative phase. a sense of shame when their
The menstrual, secretory and autonomy needs are not met
ischemic phases do not contribute consistently. Preschoolers develop a
to this variation. sense of guilt when their sense of
100. B. Testosterone is produced initiative is thwarted. Schoolagers
by the Leyding cells in the develop a sense of inferiority when
seminiferous tubules. Follicle-
they do not develop a sense of develop appropriate independence
industry. and autonomy. Infants develop
104. D. A busy box facilitates the mistrust when their needs are not
fine motor development that occurs consistently gratified. Preschoolers
between 4 and 6 months. Balloons develop guilt when their initiative
are contraindicated because small needs are not met while schoolagers
children may aspirate balloons. develop a sense of inferiority when
Because the button eyes of a teddy their industry needs are not met.
bear may detach and be aspirated, 108. C. Young toddlers are still
this toy is unsafe for children sensorimotor learners and they
younger than 3 years. A 5-month-old enjoy the experience of feeling
is too young to use a push-pull toy. different textures. Thus, finger
105. B. Infants need to have their paints would be an appropriate toy
security needs met by being held choice. Multiple-piece toys, such as
and cuddled. At 2 months of age, puzzle, are too difficult to
they are unable to make the manipulate and may be hazardous if
connection between crying and the pieces are small enough to be
attention. This association does not aspirated. Miniature cars also have a
occur until late infancy or early high potential for aspiration. Comic
toddlerhood. Letting the infant cry books are on too high a level for
for a time before picking up the toddlers. Although they may enjoy
infant or leaving the infant alone to looking at some of the pictures,
cry herself to sleep interferes with toddlers are more likely to rip a
meeting the infant’s need for comic book apart.
security at this very young age. 109. D. The child must be able to
Infants cry for many reasons. sate the need to go to the bathroom
Assuming that the child s hungry to initiate toilet training. Usually, a
may cause overfeeding problems child needs to be dry for only 2
such as obesity. hours, not 4 hours. The child also
106. B. Underdeveloped must be able to sit, walk, and squat.
abdominal musculature gives the A new sibling would most likely
toddler a characteristically hinder toilet training.
protruding abdomen. During 110. A. Toddlers become picky
toddlerhood, food intake decreases, eaters, experiencing food jags and
not increases. Toddlers are eating large amounts one day and
characteristically bowlegged very little the next. A toddler’s food
because the leg muscles must bear gags express a preference for the
the weight of the relatively large ritualism of eating one type of food
trunk. Toddler growth patterns for several days at a time. Toddlers
occur in a steplike, not linear typically enjoy socialization and
pattern. limiting others at meal time.
107. B. According to Erikson, Toddlers prefer to feed themselves
toddlers experience a sense of and thus are too young to have table
shame when they are not allowed to manners. A toddler’s appetite and
need for calories, protein, and fluid 114. C. Reaction formation is the
decrease due to the dramatic schoolager’s typical defensive
slowing of growth rate. response when hospitalized. In
111. D. Preschoolers commonly reaction formation, expression of
have fears of the dark, being left unacceptable thoughts or behaviors
alone especially at bedtime, and is prevented (or overridden) by the
ghosts, which may affect the child’s exaggerated expression of opposite
going to bed at night. Quiet play and thoughts or types of behaviors.
time with parents is a positive Regression is seen in toddlers and
bedtime routine that provides preshcoolers when they retreat or
security and also readies the child return to an earlier level of
for sleep. The child should sleep in development. Repression refers to
his own bed. Telling the child about the involuntary blocking of
locking him in his room will viewed unpleasant feelings and experiences
by the child as a threat. Additionally, from one’s awareness.
a locked door is frightening and Rationalization is the attempt to
potentially hazardous. Vigorous make excuses to justify
activity at bedtime stirs up the child unacceptable feelings or behaviors.
and makes more difficult to fall 115. C. The schoolager’s cognitive
asleep. level is sufficiently developed to
112. B. Dress-up clothes enhance enable good understanding of and
imaginative play and imagination, adherence to rules. Thus,
allowing preschoolers to engage in schoolagers should be able to
rich fantasy play. Building blocks and understand the potential dangers
wooden puzzles are appropriate for around them. With growth comes
encouraging fine motor greater freedom and children
development. Big wheels and become more adventurous and
tricycles encourage gross motor daring. The school-aged child is also
development. still prone to accidents and home
113. D. The school-aged child is in hazards, especially because of
the stage of concrete operations, increased motor abilities and
marked by inductive reasoning, independence. Plus the home
logical operations, and reversible hazards differ from other age
concrete thought. The ability to groups. These hazards, which are
consider the future requires formal potentially lethal but tempting, may
thought operations, which are not include firearms, alcohol, and
developed until adolescence. medications. School-age children
Collecting baseball cards and begin to internalize their own
marbles, ordering dolls by size, and controls and need less outside
simple problem-solving options are direction. Plus the child is away from
examples of the concrete home more often. Some parental or
operational thinking of the caregiver assistance is still needed to
schoolager. answer questions and provide
guidance for decisions and further investigation and is likely to
responsibilities. make the adolescent and his parents
116. C. The most significant skill feel defensive. The statement about
learned during the school-age peer acceptance and time spent in
period is reading. During this time front of the mirror for the
the child develops formal adult development of self image provides
articulation patterns and learns that information about the adolescent’s
words can be arranged in structure. needs to the parents and may help
Collective, ordering, and sorting, to gain trust with the adolescent.
although important, are not most Asking the adolescent how he feels
significant skills learned. about the acne will encourage the
117. C. Based on the adolescent to share his feelings.
recommendations of the American Discussing the cleansing method
Academy of Family Physicians and shows interest and concern for the
the American Academy of Pediatrics, adolescent and also can help to
the MMR vaccine should be given at identify any patient-teaching needs
the age of 10 if the child did not for the adolescent regarding
receive it between the ages of 4 to 6 cleansing.
years as recommended. 121. B. Preschoolers should be
Immunization for diphtheria and developmentally incapable of
tetanus is required at age 13. demonstrating explicit sexual
118. D. According to Erikson, role behavior. If a child does so, the child
diffusion develops when the has been exposed to such behavior,
adolescent does not develop a sense and sexual abuse should be
of identity and a sense or where he suspected. Explicit sexual behavior
fits in. Toddlers develop a sense of during doll play is not a
shame when they do not achieve characteristic of preschool
autonomy. Preschoolers develop a development nor symptomatic of
sense of guilt when they do not developmental delay. Whether or
develop a sense of initiative. School- nor the child knows how to play
age children develop a sense of with dolls is irrelevant.
inferiority when they do not develop 122. A. The parents need more
a sense of industry. teaching if they state that they will
119. A. Menarche refers to the keep the child home until the phobia
onset of the first menstruation or subsides. Doing so reinforces the
menstrual period and refers only to child’s feelings of worthlessness and
the first cycle. Uterine growth and dependency. The child should
broadening of the pelvic girdle attend school even during resolution
occurs before menarche. of the problem. Allowing the child to
120. A. Stating that this is verbalize helps the child to ventilate
probably the only concern the feelings and may help to uncover
adolescent has and telling the causes and solutions. Collaboration
parents not to worry about it or the with the teachers and counselors at
time her spends on it shuts off school may lead to uncovering the
cause of the phobia and to the front to back usually is accomplished
development of solutions. The child at about 5 months.
should participate and play an active 126. D. A child’s birth weight
role in developing possible solutions. usually triples by 12 months and
123. C. The adolescent who doubles by 4 months. No specific
becomes pregnant typically denies birth weight parameters are
the pregnancy early on. Early established for 7 or 9 months.
recognition by a parent or health 127. C. Toddlers engaging in
care provider may be crucial to parallel play will play near each
timely initiation of prenatal care. other, but not with each other.
The incidence of adolescent Thus, when two toddlers sit near
pregnancy has declined since 1991, each other but play with separate
yet morbidity remains high. Most dolls, they are exhibiting parallel
teenage pregnancies are unplanned play. Sharing crayons, playing a
and occur out of wedlock. The board game with a nurse, or sharing
pregnant adolescent is at high risk dolls with two different nurses are
for physical complications including all examples of cooperative play.
premature labor and low-birth- 128. A. Acute lymphocytic
weight infants, high neonatal leukemia (ALL) causes leukopenia,
mortality, iron deficiency anemia, resulting in immunosuppression and
prolonged labor, and fetopelvic increasing the risk of infection, a
disproportion as well as numerous leading cause of death in children
psychological crises. with ALL. Therefore, the initial
124. B. Because of the structural priority nursing intervention would
defect, children with cleft palate be to institute infection control
may have ineffective functioning of precautions to decrease the risk of
their Eustachian tubes creating infection. Iron-rich foods help with
frequent bouts of otitis media. Most anemia, but dietary iron is not an
children with cleft palate remain initial intervention. The prognosis of
well-nourished and maintain ALL usually is good. However, later
adequate nutrition through the use on, the nurse may need to assist the
of proper feeding techniques. Food child and family with coping since
particles do not pass through the death and dying may still be an issue
cleft and into the Eustachian tubes. in need of discussion. Injections
There is no association between should be discouraged, owing to
cleft palate and congenial ear increased risk from bleeding due to
deformities. thrombocytopenia.
125. D. A 3-month-old infant 129. A. The pertusis component
should be able to lift the head and may result in fever and the tetanus
chest when prone. The Moro reflex component may result in injection
typically diminishes or subsides by 3 soreness. Therefore, the mother’s
months. The parachute reflex verbalization of information about
appears at 9 months. Rolling from measures to reduce fever indicates
understanding. No dietary
restrictions are necessary after this not associated with congenital heart
injection is given. A subsequent rash disease.
is more likely to be seen 5 to 10 days 133. D. The child is exhibiting
after receiving the MMR vaccine, classic signs of epiglottitis, always a
not the diphtheria, pertussis, and pediatric emergency. The physician
tetanus vaccine. Diarrhea is not must be notified immediately and
associated with this vaccine. the nurse must be prepared for an
130. A. Multiple bruises and burns emergency intubation or
on a toddler are signs child abuse. tracheostomy. Further assessment
Therefore, the nurse is responsible with auscultating lungs and placing
for reporting the case to Protective the child in a mist tent wastes
Services immediately to protect the valuable time. The situation is a
child from further harm. Scheduling possible life-threatening emergency.
a follow-up visit is inappropriate Having the child lie down would
because additional harm may come cause additional distress and may
to the child if the nurse waits for result in respiratory arrest. Throat
further assessment data. Although examination may result in
the nurse should notify the laryngospasm that could be fatal.
physician, the goal is to initiate 134. A. In females, the urethra is
measures to protect the child’s shorter than in males. This
safety. Notifying the physician decreases the distance for
immediately does not initiate the organisms to travel, thereby
removal of the child from harm nor increasing the chance of the child
does it absolve the nurse from developing a urinary tract infection.
responsibility. Multiple bruises and Frequent emptying of the bladder
burns are not normal toddler would help to decrease urinary tract
injuries. infections by avoiding sphincter
131. B. The mother is using stress. Increased fluid intake enables
projection, the defense mechanism the bladder to be cleared more
used when a person attributes his or frequently, thus helping to prevent
her own undesirable traits to urinary tract infections. The intake
another. Displacement is the of acidic juices helps to keep the
transfer of emotion onto an urine pH acidic and thus decrease
unrelated object, such as when the the chance of flora development.
mother would kick a chair or bang 135. B. Compartment syndrome is
the door shut. Repression is the an emergent situation and the
submerging of painful ideas into the physician needs to be notified
unconscious. Psychosis is a state of immediately so that interventions
being out of touch with reality. can be initiated to relieve the
132. A. Children with congenital increasing pressure and restore
heart disease are more prone to circulation. Acetaminophen
respiratory infections. Bleeding (Tylenol) will be ineffective since the
tendencies, frequent vomiting, and pain is related to the increasing
diarrhea and seizure disorders are pressure and tissue ischemia. The
cast, not traction, is being used in with sharing), and is able to tolerate
this situation for immobilization, so longer periods of delayed
releasing the traction would be gratification.
inappropriate. In this situation, 139. A. Mild mental retardation
specific action not continued refers to development disability
monitoring is indicated. involving an IQ 50 to 70. Typically,
136. D. The varicella zoster the child is not noted as being
vaccine (VZV) is a live vaccine given retarded, but exhibits slowness in
after age 12 months. The first dose performing tasks, such as self-
of hepatitis B vaccine is given at feeding, walking, and taking. Little or
birth to 2 months, then at 1 to 4 no speech, marked motor delays,
months, and then again at 6 to 18 and gait disabilities would be seen in
months. DtaP is routinely given at 2, more severe forms mental
4, 6, and 15 to 18 months and a retardation.
booster at 4 to 6 years. 140. B. Down syndrome is
137. C. Because the 8-month-old characterized by the following a
is refining his gross motor skills, transverse palmar crease (simian
being able to sit unsupported and crease), separated sagittal suture,
also improving his fine motor skills, oblique palpebral fissures, small
probably capable of making hand-to- nose, depressed nasal bridge, high-
hand transfers, large blocks would arched palate, excess and lax skin,
be the most appropriate toy wide spacing and plantar crease
selection. Push-pull toys would be between the second and big toes,
more appropriate for the 10 to 12- hyperextensible and lax joints, large
month-old as he or she begins to protruding tongue, and muscle
cruise the environment. Rattles and weakness.
mobiles are more appropriate for 141. A. Because of the defect, the
infants in the 1 to 3 month age child will be unable to from the
range. Mobiles pose a danger to mouth adequately around nipple,
older infants because of possible thereby requiring special devices to
strangulation. allow for feeding and sucking
138. B. During the preschool gratification. Respiratory status may
period, the child has mastered a be compromised if the child is fed
sense of autonomy and goes on to improperly or during postoperative
master a sense of initiative. During period, Locomotion would be a
this period, the child commonly problem for the older infant because
experiences more fears than at any of the use of restraints. GI
other time. One common fear is fear functioning is not compromised in
of the body mutilation, especially the child with a cleft lip.
associated with painful experiences. 142. B. Postoperatively children
The preschool child uses simple, not with cleft palate should be placed on
complex, reasoning, engages in their abdomens to facilitate
associative, not competitive, play drainage. If the child is placed in the
(interactive and cooperative play supine position, he or she may
aspirate. Using an infant seat does fasting, or exposure to
not facilitate drainage. Side-lying anticholinergic drugs. Celiac crisis is
does not facilitate drainage as well typically characterized by severe
as the prone position. watery diarrhea. Respiratory distress
143. C. Projectile vomiting is a key is unlikely in a routine upper
symptom of pyloric stenosis. respiratory infection. Irritability,
Regurgitation is seen more rather than lethargy, is more likely.
commonly with GER. Steatorrhea Because of the fluid loss associated
occurs in malabsorption disorders with the severe watery diarrhea, the
such as celiac disease. “Currant jelly” child’s weight is more likely to be
stools are characteristic of decreased.
intussusception. 148. A. For the child with
144. D. GER is the backflow of Hirschsprung disease, fever and
gastric contents into the esophagus explosive diarrhea indicate
resulting from relaxation or enterocolitis, a life-threatening
incompetence of the lower situation. Therefore, the physician
esophageal (cardiac) sphincter. No should be notified immediately.
alteration in the oral mucous Generally, because of the intestinal
membranes occurs with this obstruction and inadequate
disorder. Fluid volume deficit, risk propulsive intestinal movement,
for aspiration, and altered nutrition antidiarrheals are not used to treat
are appropriate nursing diagnoses. Hirschsprung disease. The child is
145. A. Thickened feedings are acutely ill and requires intervention,
used with GER to stop the vomiting. with monitoring more frequently
Therefore, the nurse would monitor than every 30 minutes. Hirschsprung
the child’s vomiting to evaluate the disease typically presents with
effectiveness of using the thickened chronic constipation.
feedings. No relationship exists 149. A. Failure to pass meconium
between feedings and within the first 24 hours after birth
characteristics of stools and uterine. may be an indication of
If feedings are ineffective, this Hirschsprung disease, a congenital
should be noted before there is any anomaly resulting in mechanical
change in the child’s weight. obstruction due to inadequate
146. C. Children with celiac motility in an intestinal segment.
disease cannot tolerate or digest Failure to pass meconium is not
gluten. Therefore, because of its associated with celiac disease,
gluten content, wheat and wheat- intussusception, or abdominal wall
containing products must be defect.
avoided. Rice, milk, and chicken do 150. C. Because intussusception is
not contain gluten and need not be not believed to have a familial
avoided. tendency, obtaining a family history
147. C. Episodes of celiac crises would provide the least amount of
are precipitated by infections, information. Stool inspection, pain
ingestion of gluten, prolonged pattern, and abdominal palpation
would reveal possible indicators of when my due comes
intussusception. Current, jelly-like c. I will have to remain in bed until my due
stools containing blood and mucus date comes
are an indication of intussusception. d. I may go back to work since I stay only at
Acute, episodic abdominal pain is the office.
characteristics of intussusception. A
sausage-shaped mass may be
palpated in the right upper 3. The uterus has already risen out of the
quadrant. pelvis and is experiencing farther into the
abdominal area at about the:

a. 8th week of pregnancy


b. 10th week of pregnancy
c. 12th week of pregnancy
d. 18th week of pregnancy

4. Which of the following urinary symptoms


Nursing Board Review: Maternal and does the pregnant woman most frequently
experience during the first trimester:
Child Health Nursing Practice Test Part
1 a. frequency
b. dysuria
c. incontinence
d. burning
1. A client asks the nurse what a third
degree laceration is. She was informed that
she had one. The nurse explains that this is: 5. Mrs. Jimenez went to the health center
for pre-natal check-up. the student nurse
a. that extended their anal sphincter took her weight and revealed 142 lbs. She
b. through the skin and into the muscles asked the student nurse how much should
c. that involves anterior rectal wall she gain weight in her pregnancy.
d. that extends through the perineal
muscle. a. 20-30 lbs
b. 25-35 lbs
c. 30- 40 lbs
2. Betina 30 weeks AOG discharged with a d. 10-15 lbs
diagnosis of placenta previa. The nurse
knows that the client understands her care
at home when she says: 6. The nurse is preparing Mrs. Jordan for
cesarean delivery. Which of the following
a. I am happy to note that we can have sex key concept should the nurse consider
occasionally when I have no bleeding. when implementing nursing care?
b. I am afraid I might have an operation
a. Explain the surgery, expected outcome states that she is extremely uncomfortable.
and kind of anesthetics. To lessen Mrs. Abuel’s discomfort, the
b. Modify preoperative teaching to meet nurse can advise her to:
the needs of either a planned or emergency
cesarean birth. a. lie face down
c. Arrange for a staff member of the b. not drink fluids
anesthesia department to explain what to c. practice holding breaths between
expect post-operatively. contractions
d. Instruct the mother’s support person to d. assume Sim’s position
remain in the family lounge until after the
delivery.
10. Which is true regarding the fontanels of
the newborn?
7. Bettine Gonzales is hospitalized for the
treatment of severe preecplampsia. Which a. The anterior is large in shape when
of the following represents an unusual compared to the posterior fontanel.
finding for this condition? b. The anterior is triangular shaped; the
posterior is diamond shaped.
a. generalized edema c. The anterior is bulging; the posterior
b. proteinuria 4+ appears sunken.
c. blood pressure of 160/110 d. The posterior closes at 18 months; the
d. convulsions anterior closes at 8 to 12 months.

8. Nurse Geli explains to the client who is 33 11. Mrs. Quijones gave birth by
weeks pregnant and is experiencing vaginal spontaneous delivery to a full term baby
bleeding that coitus: boy. After a minute after birth, he is crying
and moving actively. His birth weight is 6.8
a. Need to be modified in any way by either lbs. What do you expect baby Quijones to
partner weigh at 6 months?
b. Is permitted if penile penetration is not
deep. a. 13 -14 lbs
c. Should be restricted because it may b. 16 -17 lbs
stimulate uterine activity. c. 22 -23 lbs
d. Is safe as long as she is in side-lying d. 27 -28 lbs
position.

12. During the first hours following delivery,


9. Mrs. Precilla Abuel, a 32 year old the post partum client is given IVF with
mulripara is admitted to labor and delivery. oxytocin added to them. The nurse
Her last 3 pregnancies in short stage one of understands the primary reason for this is:
labor. The nurses decide to observe her
closely. The physician determines that Mrs. a. To facilitate elimination
Abuel’s cervix is dilated to 6 cm. Mrs. Abuel b. To promote uterine contraction
c. To promote analgesia
d. To prevent infection 17. Which of the following situations would
alert you to a potentially developmental
problem with a child?
13. Nurse Luis is assessing the newborn’s
heart rate. Which of the following would be a. Pointing to body parts at 15 months of
considered normal if the newborn is age.
sleeping? b. Using gesture to communicate at 18
months.
a. 80 beats per minute c. Cooing at 3 months.
b. 100 beats per minute d. Saying “mama” or “dada” for the first
c. 120 beats per minute time at 18 months of age.
d. 140 beats per minute

18. Isabelle, a 2 year old girl loves to move


14. The infant with Down Syndrome should around and oftentimes manifests
go through which of the Erikson’s negativism and temper tantrums. What is
developmental stages first? the best way to deal with her behavior?

a. Initiative vs. Self doubt a. Tell her that she would not be loved by
b. Industry vs. Inferiority others is she behaves that way..
c. Autonomy vs. Shame and doubt b. Withholding giving her toys until she
d. Trust vs. Mistrust behaves properly.
c. Ignore her behavior as long as she does
not hurt herself and others.
15. The child with phenylketonuria (PKU) d. Ask her what she wants and give it to
must maintain a low phenylalanine diet to pacify her.
prevent which of the following
complications?
19. Baby boy Villanueva, 4 months old, was
a. Irreversible brain damage seen at the pediatric clinic for his scheduled
b. Kidney failure check-up. By this period, baby Villanueva
c. Blindness has already increased his height by how
d. Neutropenia many inches?

a. 3 inches
16. Which age group is with imaginative b. 4 inches
minds and creates imaginary friends? c. 5 inches
d. 6 inches
a. Toddler
b. Preschool
c. School 20. Alice, 10 years old was brought to the
d. Adolescence ER because of Asthma. She was
immediately put under aerosol
administration of Terbutaline. After c. diarrhea, retracted tympanic membrane
sometime, you observe that the child does and enlarged parotid gland
not show any relief from the treatment d. Vomiting, pulling at ears and pearly white
given. Upon assessment, you noticed that tympanic membrane
both the heart and respiratory rate are still
elevated and the child shows difficulty of
exhaling. You suspect: 24. Which of the following is the most
appropriate intervention to reduce stress in
a. Bronchiectasis a preterm infant at 33 weeks gestation?
b. Atelectasis
c. Epiglotitis a. Sensory stimulation including several
d. Status Asthmaticus senses at a time
b. tactile stimulation until signs of over
stimulation develop
21. Nurse Jonas assesses a 2 year old boy c. An attitude of extension when prone or
with a tentative diagnosis of side lying
nephroblastoma. Symptoms the nurse d. Kangaroo care
observes that suggest this problem include:

a. Lymphedema and nerve palsy 25. The parent of a client with albinism
b. Hearing loss and ataxia would need to be taught which preventive
c. Headaches and vomiting healthcare measure by the nurse:
d. Abdominal mass and weakness
a. Ulcerative colitis diet
b. Use of a high-SPF sunblock
22. Which of the following danger sings c. Hair loss monitoring
should be reported immediately during the d. Monitor for growth retardation
antepartum period?

a. blurred vision
b. nasal stuffiness 1. (A) that extended their anal sphincter
c. breast tenderness Third degree laceration involves all in the
d. constipation second degree laceration and the external
sphincter of the rectum. Options B, C and D
are under the second degree laceration.
23. Nurse Jacob is assessing a 15 month old
child with acute otitis media. Which of the 2. (C) I will have to remain in bed until my
following symptoms would the nurse due date comes
anticipate finding? Placenta previa means that the placenta is
the presenting part. On the first and second
a. periorbital edema, absent light reflex and trimester there is spotting. On the third
translucent tympanic membrane trimester there is bleeding that is sudden,
b. irritability, purulent drainage in middle profuse and painless.
ear, nasal congestion and cough
3. (D) 18th week of pregnancy 8. (C) Should be restricted because it may
On the 8th week of pregnancy, the uterus is stimulate uterine activity.
still within the pelvic area. On the 10th Coitus is restricted when there is watery
week, the uterus is still within the pelvic discharge, uterine contraction and vaginal
area. On the 12th week, the uterus and bleeding. Also those women with a history
placenta have grown, expanding into the of spontaneous miscarriage may be advised
abdominal cavity. On the 18th week, the to avoid coitus during the time of
uterus has already risen out of the pelvis pregnancy when a previous miscarriage
and is expanding into the abdominal area. occurred.

4. (A) frequency 9. (D) assume Sim’s position


Pressure and irritation of the bladder by the When the woman is in Sim’s position, this
growing uterus during the first trimester is puts the weight of the fetus on bed, not on
responsible for causing urinary frequency. the woman and allows good circulation in
Dysuria, incontinence and burning are the lower extremities.
symptoms associated with urinary tract
infection. 10. (A) The anterior is large in shape when
compared to the posterior fontanel.
5. (B) 25-35 lbs The anterior fontanel is larger in size than
A weight gain of 11. 2 to 15.9 kg (25 to 35 the posterior fontanel. Additionally, the
lbs) is currently recommended as an anterior fontanel, which is diamond shaped
average weight gain in pregnancy. This closes at 18 month, whereas the posterior
weight gain consists of the following: fetus- fontanel, which is triangular in shape closes
7.5 lb; placenta- 1.5 lb; amniotic fluid- 2 lb; at 8 to 12 weeks. Neither fontanel should
uterus- 2.5 lb; breasts- 1.5 to 3 lb; blood appear bulging, which may indicate
volume- 4 lb; body fat- 7 lb; body fluid- 7 lb. increases ICP or sunken, which may indicate
hydration.
6. (B) Modify preoperative teaching to
meet the needs of either a planned or 11. (A) 13 -14 lbs
emergency cesarean birth. The birth weight of an infant is doubled at 6
A key point to consider when preparing the months and is tripled at 12 months.
client for a cesarean delivery is to modify
the preoperative teaching to meet the 12. (B) To promote uterine contraction
needs of either planned or emergency Oxytocin is a hormone produced by the
cesarean birth, the depth and breadth of pituitary gland that produces intermittent
instruction will depend on circumstances uterine contractions, helping to promote
and time available. uterine involution.

7. (D) convulsions 13. (B) 100 beats per minute


Options A, B and C are findings of severe The normal heart rate for a newborn that is
preeclampsia. Convulsions is a finding of sleeping is approximately 100 beats per
eclampsia—an obstetrical emergency. minute. If the newborn was awake, the
normal heart rate would range from 120 to Status asthmaticus leads to respiratory
160 beats per minute. distress and bronchospasm despite of
treatment and interventions. Mechanical
14. (D) Trust vs. Mistrust ventilation maybe needed due to
The child with Down syndrome will go respiratory failure.
through the same first stage, trust vs.
mistrust, only at a slow rate. Therefore, the 21. (D) Abdominal mass and weakness
nurse should concentrate on developing on Nephroblastoma or Wilm’s tumor is caused
bond between the primary caregiver and by chromosomal abnormalities, most
the child. common kidney cancer among children
characterized by abdominal mass,
15. (A) Irreversible brain damage hematuria, hypertension and fever.
The child with PKU must maintain a strict
low phenylalanine diet to prevent central 22. (A) blurred vision
nervous system damage, seizures and Danger signs that require prompt reporting
eventual death. are leaking of amniotic fluid, blurred vision,
vaginal bleeding, rapid weight gain and
16. (B) Preschool elevated blood pressure. Nasal stuffiness,
During preschool, this is the time when breast tenderness, and constipation are
children do imitative play, imaginative common discomforts associated with
play—the occurrence of imaginative pregnancy.
playmates, dramatic play where children
like to act, dance and sing. 23. (B) irritability, purulent drainage in
middle ear, nasal congestion and cough
17. (D) Saying “mama” or “dada” for the Irritability, purulent drainage in middle ear,
first time at 18 months of age. nasal congestion and cough, fever, loss of
A child should say “mama” or “dada” during appetite, vomiting and diarrhea are clinical
10 to 12 months of age. Options A, B and C manifestations of otitis media. Acute otitis
are all normal assessments of language media is common in children 6 months to 3
development of a child. years old and 8 years old and above. Breast
fed infants have higher resistance due to
18. (C) Ignore her behavior as long as she protection of Eustachian tubes and middle
does not hurt herself and others. ear from breast milk.
If a child is trying to get attention or trying
to get something through tantrums—ignore 24. (D) Kangaroo care
his/her behavior. Kangaroo care is the use of skin-to-skin
contact to maintain body heat. This method
19. (B) 4 inches of care not only supplies heat but also
From birth to 6 months, the infant grows 1 encourages parent-child interaction.
inch (2.5 cm) per month. From 6 to 12
months, the infant grows ½ inch (1.25 cm) 25. (B) Use of a high-SPF sunblock
per month. Without melanin production, the child with
albinism is at risk for severe sunburns.
20. (D) Status Asthmaticus Maximum sun protection should be taken,
including use of hats, long sleeves, minimal The nurse describes the second maneuver
time in the sun and high-SPF sunblock, to that the fetus goes through during labor
prevent any problems. progress when the head is the presenting
part as which of the following:

a. Flexion
b. Internal rotation
c. Descent
d. External rotation

3. Mrs. Jovel Diaz went to the hospital to


have her serum blood test for alpha-
fetoprotein. The nurse informed her about
the result of the elevation of serum AFP.
The patient asked her what was the test for:

a. Congenital Adrenal Hyperplasia


b. PKU
c. Down Syndrome
d. Neural tube defects

4. Fetal heart rate can be auscultated with a


fetoscope as early as:
Nursing Board Review : Maternal and
a. 5 weeks of gestation
Child Health Nursing Part 2 b. 10 weeks of gestation
c. 15 weeks of gestation
d. 20 weeks of gestation

1. Nurse Bella explains to a 28 year old


pregnant woman undergoing a non-stress 5. Mrs. Bendivin states that she is
test that the test is a way of evaluating the experiencing aching swollen, leg veins. The
condition of the fetus by comparing the nurse would explain that this is most
fetal heart rate with: probably the result of which of the
following:
a. Fetal lie
b. Fetal movement a. Thrombophlebitis
c. Maternal blood pressure b. PIH
d. Maternal uterine contractions c. Pressure on blood vessels from the
enlarging uterus
d. The force of gravity pulling down on the
2. During a 2 hour childbirth focusing on uterus
labor and delivery process for primigravida.
d. Nowember 14, 2010

6. Mrs. Ella Santoros is a 25 year old


primigravida who has Rheumatic heart 10. Which of the following prenatal
disease lesion. Her pregnancy has just been laboratory test values would the nurse
diagnosed. Her heart disease has not consider as significant?
caused her to limit physical activity in the
past. Her cardiac disease and functional a. Hematocrit 33.5%
capacity classification is: b. WBC 8,000/mm3
c. Rubella titer less than 1:8
a. Class I d. One hour glucose challenge test 110 g/dL
b. Class II
c. Class III
d. class IV 11. Aling Patricia is a patient with
preeclampsia. You advise her about her
condition, which would tell you that she has
7. The client asks the nurse, “When will this not really understood your instructions?
soft spot at the top of the head of my baby
will close?” The nurse should instruct the a. “I will restrict my fat in my diet.”
mother that the neonate’s anterior fontanel b. “I will limit my activities and rest more
will normally close by age: frequently throughout the day.”
a. 2-3 months c. “I will avoid salty foods in my diet.”
b. 6-8 months d. “I will come more regularly for check-up.”
c. 10-12 months
d. 12-18 months
12. Mrs. Grace Evangelista is admitted with
severe preeclampsia. What type of room
8. When a mother bleeds and the uterus is should the nurse select this patient?
relaxed, soft and non-tender, you can
account the cause to: a. A room next to the elevator.
b. The room farthest from the nursing
a. Atony of the uterus station.
b. Presence of uterine scar c. The quietest room on the floor.
c. Laceration of the birth canal d. The labor suite.
d. Presence of retained placenta fragments

13. During a prenatal check-up, the nurse


9. Mrs. Pichie Gonzales’s LMP began April 4, explains to a client who is Rh negative that
2010. Her EDD should be which of the RhoGAM will be given:
following:
a. Weekly during the 8th month because
a. February 11, 2011 this is her third pregnancy.
b. January 11, 20111 b. During the second trimester, if
c. December 12, 2010 amniocentesis indicates a problem.
c. To her infant immediately after delivery if following:
the Coomb’s test is positive.
d. Within 72 hours after delivery if infant is a. Monitoring for adequate nutritional
found to be Rh positive. intake
b. Teaching high-risk newborn care
c. Assessing for respiratory distress
14. A baby boy was born at 8:50pm. At d. Preventing injury
8:55pm, the heart rate was 99 bpm. She has
a weak cry, irregular respiration. She was
moving all extremities and only her hands 18. Nurse Jacob is assessing a 12 year old
and feet were still slightly blue. The nurse who has hemophilia A. Which of the
should enter the APGAR score as: following assessment findings would the
nurse anticipate?
a. 5
b. 6 a. an excess of RBC
c. 7 b. an excess of WBC
d. 8 c. a deficiency of clotting factor VIII
d. a deficiency of clotting factor IX

15. Billy is a 4 year old boy who has an IQ of


140 which means: 19. Celine, a mother of a 2 year old tells the
nurse that her child “cries and has a fit
a. average normal when I have to leave him with a sitter or
b. very superior someone else.” Which of the following
c. above average statements would be the nurse’s most
d. genius accurate analysis of the mother’s
comment?

16. A newborn is brought to the nursery. a. The child has not experienced limit-
Upon assessment, the nurse finds that the setting or structure.
child has short palpebral fissures, thinned b. The child is expressing a physical need,
upper lip. Based on this data, the nurse such as hunger.
suspects that the newborn is MOST likely c. The mother has nurtured
showing the effects of: overdependence in the child.
d. The mother is describing her child’s
a. Chronic toxoplasmosis separation anxiety.
b. Lead poisoning
c. Congenital anomalies
d. Fetal alcohol syndrome 20. Mylene Lopez, a 16 year old girl with
scoliosis has recently received an invitation
to a pool party. She asks the nurse how she
17. A priority nursing intervention for the can disguise her impairment when dressed
infant with cleft lip is which of the in a bathing suit. Which nursing diagnosis
can be justified by Mylene’s statement? a. An insignificant event unless taught
otherwise
a. Anxiety b. Punishment for something the individual
b. Body image disturbance did
c. Ineffective individual coping c. Something that just happens to older
d. Social isolation people
d. Temporary separation from the loved
one.
21. The foul-smelling, frothy characteristic
of the stool in cystic fibrosis results from
the presence of large amounts of which of 25. Catherine Diaz is a 14 year old patient
the following: on a hematology unit who is being treated
for sickle cell crisis. During a crisis such as
a. sodium and chloride that seen in sickle cell anemia, aldosterone
b. undigested fat release is stimulated. In what way might
c. semi-digested carbohydrates this influence Catherine’s fluid and
d. lipase, trypsin and amylase electrolyte balance?

a. sodium loss, water loss and potassium


22. Which of the following would be a retention
disadvantage of breast feeding? b. sodium loss, water los and potassium loss
c. sodium retention, water loss and
a. involution occurs rapidly potassium retention
b. the incidence of allergies increases due to d. sodium retention, water retention and
maternal antibodies potassium loss
c. the father may resent the infant’s
demands on the mother’s body
d. there is a greater chance of error during
preparation

23. A client is noted to have lymphedema,


webbed neck and low posterior hairline. 1. (B) Fetal movement
Which of the following diagnoses is most Non-stress test measures response of the
appropriate? FHR to the fetal movement. With fetal
movement, FHR increase by 15 beats and
a. Turner’s syndrome remain for 15 seconds then decrease to
b. Down’s syndrome average rate. No increase means poor
c. Marfan’s syndrome oxygenation perfusion to fetus.
d. Klinefelter’s syndrome
2. (A) Flexion
The 6 cardinal movements of labor are
24. A 4 year old boy most likely perceives descent, flexion, internal rotation,
death in which way: extension, external rotation and expulsion.
Uterine atony, or relaxation of the uterus is
3. (D) Neural tube defects the most frequent cause of postpartal
Alpha-fetoprotein is a substance produces hemorrhage. It is the inability to maintain
by the fetal liver that is present in amniotic the uterus in contracted state.
fluid and maternal serum. The level is
abnormally high in the maternal serum if 9. (B) January 11, 20111
the fetus has an open spinal or abdominal Using the Nagel’s rule, he use this formula (
defect because the open defect allows -3 calendar months + 7 days).
more AFP to appear.
10. (C) Rubella titer less than 1:8
4. (D) 20 weeks of gestation A rubella titer should be 1:8 or greater.
The FHR can be auscultated with a Thus, a finding of a titer less than 1:8 is
fetoscope at about 20 weeks of gestation. significant, indicating that the client may
FHR is usually auscultated at the midline not possess immunity to rubella. A
suprapubic region with Doppler ultrasound hematocrit of 33.5%, WBC of 8,000/mm3,
at 10 to 12 weeks of gestation. FHR cannot and a 1 hour glucose challenge test of 110
be heard any earlier than 10 weeks of g/dL are within normal parameters.
gestation.
11. (B) “I will limit my activities and rest
5. (C) Pressure on blood vessels from the more frequently throughout the day.”
enlarging uterus Pregnant woman with preeclampsia should
Pressure of the growing fetus on blood be in a complete bed rest. When body is in
vessels results in an increase risk for venous recumbent position, sodium tends to be
stasis in the lower extremities. excreted at a faster rate. It is the best
Subsequently, edema and varicose vein method of aiding increased excretion of
formation may occur. sodium and encouraging diuresis. Rest
should always be in a lateral recumbent
6. (A) Class I position to avoid uterine pressure on the
Clients under class I has no physical activity vena cava and prevent supine hypotension.
limitation. There is a slight limitation of
physical activity in class II, ordinary activity 12. (C) The quietest room on the floor.
causes fatigue, palpitation, dyspnea or A loud noise such as a crying baby, or a
angina. Class III is moderate limitation of dropped tray of equipment may be
physical activity; less than ordinary activity sufficient to trigger a seizure initiating
causes fatigue. Unable to carry on any eclampsia, a woman with severe
activity without experiencing discomfort is preeclampsia should be admiotted to a
under class IV. private room so she can rest as undisturbed
as possible. Darken the room if possible
7. (D) 12-18 months because bright light can trigger seizures.
Anterior fontanel closes at 12-18 months
while posterior fontanel closes at birth until 13. (D) Within 72 hours after delivery if
2 months. infant is found to be Rh positive.
RhoGAM is given to Rh-negative mothers
8. (A) Atony of the uterus within 72 hours after birth of Rh-positive
baby to prevent development of antibodies however, based on initial information, the
in the maternal blood stream, which will be analysis of separation anxiety would be
fata to succeeding Rh-positive offspring. most valid. Separation anxiety is a normal
toddler response. When the child senses he
14. (B) 6 is being sent away from those who most
Heart rate of 99 bpm-1; weak cry-1; provide him with love and security. Crying is
irregular respiration-1; moving all one way a child expresses a physical need;
extremities-2; extremities are slightly blue- however, the nurse would be hasty in
1; with a total score of 6. drawing this as first conclusion based on
what the mother has said. Nurturing
15. (D) genius overdependence or not providing structure
IQ= mental age/chronological age x 100. for the toddler are inaccurate conclusions
Mental age refers to the typical intelligence based on the information provided.
level found for people at a give
chronological age. OQ of 140 and above is 20. (B) Body image disturbance
considered genius. Mylene is experiencing uneasiness about
the curvative of her spine, which will be
16. (D) Fetal alcohol syndrome more evident when she wears a bathing
The newborn with fetal alcohol syndrome suit. This data suggests a body image
has a number of possible problems at birth. disturbance. There is no evidence of anxiety
Characteristics that mark the syndrome or ineffective coping. The fact that Mylene
include pre and postnatal growth is planning to attend a pool party dispels a
retardation; CNS involvement such as diagnosis of social isolation.
cognitive challenge, microcephally and
cerebral palsy; and a distinctive facial 21. (B) undigested fat
feature of a short palpebral fissure and thin The client with cystic fibrosis absorbs fat
upper lip. poorly because of the think secretions
blocking the pancreatic duct. The lack of
17. (A) Monitoring for adequate nutritional natural pancreatic enzyme leads to poor
intake absorption of predominantly fats in the
The infant with cleft lip is unable to create duodenum. Foul-smelling, frothy stool is
an adequate seal for sucking. The child is at termed steatorrhea.
risk for inadequate nutritional intake as well
as aspiration. 22. (C) the father may resent the infant’s
demands on the mother’s body
18. (C) a deficiency of clotting factor VIII With breast feeding, the father’s body is not
Hemophillia A (classic hemophilia) is a capable of providing the milk for the
deficiency in factor VIII (an alpha globulin newborn, which may interfere with feeding
that stabilizes fibrin clots). the newborn, providing fewer chances for
bonding, or he may be jealous of the
19. (D) The mother is describing her child’s infant’s demands on his wife time and body.
separation anxiety. Breast feeding is advantageous because
Before coming to any conclusion, the nurse uterine involution occurs more rapidly, thus
should ask the mother focused questions; minimizing blood loss. The presence of
maternal antibodies in breast milk helps
decrease the incidence of allergies in the
newborn. A greater chance for error is
associated with bottle feeding. No
preparation required for breast feeding.

23. (A) Turner’s syndrome


Lymphedema, webbed neck and low
posterior hairline, these are the 3 key
assessment features in Turner’s syndrome.
If the child is diagnosed early in age, proper
treatment can be offered to the family. All
newborns should be screened for possible
congenital defects.

24. (D) Temporary separation from the


loved one.
The predominant perception of death by
preschool age children is that death is
temporary separation. Because that child is
losing someone significant and will not see
that person again, it’s inaccurate to infer
death is insignificant, regardless of the
child’s response.

25. (D) sodium retention, water retention


and potassium loss
Stress stimulates the adrenal cortex to
increase the release of aldosterone.
Aldosterone promotes the resorption of
sodium, the retention of water and the loss
of potassium.