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PNLE : Maternal and Child Health Nursing Exam 3

CARE PLANS TOOLS & APPS BULLETS

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1. A pregnant woman who is at term is admitted to the

birthing unit in active labor. The client has only progressed
from 2cm to 3 cm in 8 hours. She is diagnosed with
hypotonic dystocia and the physician ordered Oxytocin
(Pitocin) to augment her contractions. Which of the following
is the most important aspect of nursing intervention at this
time?

A. Timing and recording length of contractions.

B. Monitoring.
C. Preparing for an emergency cesarean birth.
D. Checking the perineum for bulging.

2. A client who hallucinates is not in touch with reality. It is

important for the nurse to:

A. Isolate the client from other patients.

B. Maintain a safe environment.
C. Orient the client to time, place, and person.
D. Establish a trusting relationship.
3. The nurse is caring to a child client who has had a
tonsillectomy. The child complains of having dryness of the
throat. Which of the following would the nurse give to the
child?

A. Cola with ice

B. Yellow noncitrus Jello
C. Cool cherry Kool-Aid
D. A glass of milk

4. The physician ordered Phenylephrine (Neo-Synephrine)

nasal spray to a 13-year-old client. The nurse caring to the
client provides instructions that the nasal spray must be used
exactly as directed to prevent the development of:

A. Increased nasal congestion.

B. Nasal polyps.
C. Bleeding tendencies.
D. Tinnitus and diplopia.

5. A client with tuberculosis is to be admitted in the hospital.

The nurse who will be assigned to care for the client must
institute appropriate precautions. The nurse should:

A. Place the client in a private room.

B. Wear an N 95 respirator when caring for the client.
C. Put on a gown every time when entering the room.
D. Don a surgical mask with a face shield when entering the
room.

6. Which of the following is the most frequent cause of

noncompliance to the medical treatment of open-angle
glaucoma?

A. The frequent nausea and vomiting accompanying use of

miotic drug.
B. Loss of mobility due to severe driving restrictions.
C. Decreased light and near-vision accommodation due to
 miotic effects of pilocarpine.
D. The painful and insidious progression of this type of
glaucoma.

7. In the morning shift, the nurse is making rounds in the

nursing care units. The nurse enters in a client’s room and
notes that the client’s tube has become disconnected from
the Pleurovac. What would be the initial nursing action?

A. Apply pressure directly over the incision site.

B. Clamp the chest tube near the incision site.
C. Clamp the chest tube closer to the drainage system.
D. Reconnect the chest tube to the Pleurovac.

8. Which of the following complications during a breech birth

the nurse needs to be alarmed?

A. Abruption placenta.
B. Caput succedaneum.
C. Pathological hyperbilirubinemia.
D. Umbilical cord prolapse.

9. The nurse is caring to a client diagnosed with severe

depression. Which of the following nursing approach is
important in depression?

A. Protect the client against harm to others.

B. Provide the client with motor outlets for aggressive,
hostile feelings.
C. Reduce interpersonal contacts.
D. Deemphasizing preoccupation with elimination,
nourishment, and sleep.

10. A 3-month-old client is in the pediatric unit. During

assessment, the nurse is suspecting that the baby may have
hypothyroidism when mother states that her baby does not:

A. Sit up.
 B. Pick up and hold a rattle.
C. Roll over.
D. Hold the head up.

11. The physician calls the nursing unit to leave an order. The
senior nurse had conversation with the other staff. The newly
hired nurse answers the phone so that the senior nurses may
continue their conversation. The new nurse does not
knowthe physician or the client to whom the order pertains.
The nurse should:

A. Ask the physician to call back after the nurse has read
the hospital policy manual.
B. Take the telephone order.
C. Refuse to take the telephone order.
D. Ask the charge nurse or one of the other senior staff
nurses to take the telephone order.

12. The staff nurse on the labor and delivery unit is assigned
to care to a primigravida in transition complicated by
hypertension. A new pregnant woman in active labor is
admitted in the same unit. The nurse manager assigned the
same nurse to the second client. The nurse feels that the
client with hypertension requires one-to-one care. What
would be the initial actionof the nurse?

A. Accept the new assignment and complete an incident

report describing a shortage of nursing staff.
B. Report the incident to the nursing supervisor and request
to be ioated.
C. Report the nursing assessment of the client in
transitional labor to the nurse manager and discuss
misgivings about the new assignment.
D. Accept the new assignment and provide the best care.

13. A newborn infant with Down syndrome is to be

discharged today. The nurse is preparing to give the
discharge teaching regarding the proper care at home. The
nurse would anticipate that the mother is probably at the:

A. 40 years of age.
B. 20 years of age.
C. 35 years of age.
D. 20 years of age.

14. The emergency department has shortage of staff. The

nurse manager informs the staff nurse in the critical care unit
that she has to ioat to the emergency department. What
should the staff nurse expect under these conditions?

A. The ioat staff nurse will be informed of the situation

before the shift begins.
B. The staff nurse will be able to negotiate the assignments
in the emergency department.
C. Cross training will be available for the staff nurse.
D. Client assignments will be equally divided among the
nurses.

15. The nurse is assigned to care for a child client admitted in

the pediatrics unit. The client is receiving digoxin. Which of
the following questions will be asked by the nurse to the
parents of the child in order to assess the client’s risk for
digoxin toxicity?

A. “Has he been exposed to any childhood communicable

diseases in the past 2-3 weeks?”
B. “Has he been taking diuretics at home?”
C. “Do any of his brothers and sisters have history of
cardiac problems?”
D. “Has he been going to school regularly?”

16. The nurse noticed that the signed consent form has an
error. The form states, “Amputation of the right leg” instead of
the left leg that is to be amputated. The nurse has
administered already the preoperative medications. What
should the nurse do?
 A. Call the physician to reschedule the surgery.
B. Call the nearest relative to come in to sign a new form.
C. Cross out the error and initial the form.
D. Have the client sign another form.

17. The nurse in the nursing care unit checks the iuctuation
in the water-seal compartment of a closed chest drainage
system. The iuctuation has stopped, the nurse would:

A. Vigorously strip the tube to dislodge a clot.

B. Raise the apparatus above the chest to move iuid.
C. Increase wall suction above 20 cm H2O pressure.
D. Ask the client to cough and take a deep breath.

18. The pediatric nurse in the neonatal unit was informed that
the baby that is brought to the mother in the hospital room is
wrong. The nurse determines that two babies were placed in
the wrong cribs. The most appropriate nursing action would
be to:

A. Determine who is responsible for the mistake and

terminate his or her employment.
B. Record the event in an incident/variance report and
notify the nursing supervisor.
C. Reassure both mothers, report to the charge nurse, and
do not record.
D. Record detailed notes of the event on the mother’s
medical record.

19. Before the administration of digoxin, the nurse completes

an assessment to a toddler client for signs and symptoms of
digoxin toxicity. Which of the following is the earliest and
most signiQcant sign of digoxin toxicity?

A. Tinnitus
B. Nausea and vomiting
C. Vision problem
D. Slowing in the heart rate
20. Which of the following treatment modality is appropriate
for a client with paranoid tendency?

A. Activity therapy.
B. Individual therapy.
C. Group therapy.
D. Family therapy.

21. The client with rheumatoid arthritis is for discharge. In

preparing the client for discharge on prednisone therapy, the
nurse should advise the client to:

A. Wear sunglasses if exposed to bright light for an

extended period of time.
B. Take oral preparations of prednisone before meals.
C. Have periodic complete blood counts while on the
medication.
D. Never stop or change the amount of the medication
without medical advice.

22. A pregnant client tells the nurse that she is worried about
having urinary frequency. What will be the most appropriate
nursing response?

A. “Try using Kegel (perineal) exercises and limiting iuids

before bedtime. If you have frequency associated with
fever, pain on voiding, or blood in the urine, call your
doctor/nurse-midwife.
B. “Placental progesterone causes irritability of the bladder
sphincter. Your symptoms will go away after the baby
comes.”
C. “Pregnant women urinate frequently to get rid of fetal
wastes. Limit iuids to 1L/daily.”
D. “Frequency is due to bladder irritation from concentrate
urine and is normal in pregnancy. Increase your daily
iuid intake to 3L.”

23. Which of the following will help the nurse determine that
the expression of hostility is useful?

A. Expression of anger dissipates the energy.

B. Energy from anger is used to accomplish what needs to
be done.
C. Expression intimidates others.
D. Degree of hostility is less than the provocation.

24. The nurse is providing an orientation regarding case

management to the nursing students. Which characteristics
should the nurse include in the discussion in understanding
case management?

A. Main objective is a written plan that combines discipline-

speciQc processes used to measure outcomes of care.
B. Main purpose is to identify expected client, family and
staff performance against the timeline for clients with
the same diagnosis.
C. Main focus is comprehensive coordination of client care,
avoid unnecessary duplication of services, improve
resource utilization and decrease cost.
D. Primary goal is to understand why predicted outcomes
have not been met and the correction of identiQed
problems.

25. The physician orders a dose of IV phenytoin to a child

client. In preparing in the administration of the drug, which
nursing action is not correct?

A. Infuse the phenytoin into a smaller vein to prevent purple

glove syndrome.
B. Check the phenytoin solution to be sure it is clear or light
yellow in color, never cloudy.
C. Plan to give phenytoin over 30-60 minutes, using an in-
line Qlter.
D. Flush the IV tubing with normal saline before starting
phenytoin.
26. The pregnant woman visits the clinic for check –up.
Which assessment Qndings will help the nurse determine that
the client is in 8-week gestation?

A. Leopold maneuvers.
B. Fundal height.
C. Positive radioimmunoassay test (RIA test).
D. Auscultation of fetal heart tones.

27. Which of the following nursing intervention is essential

for the client who had pneumonectomy?

A. Medicate for pain only when needed.

B. Connect the chest tube to water-seal drainage.
C. Notify the physician if the chest drainage exceeds
100mL/hr.
D. Encourage deep breathing and coughing.

28. The nurse is providing a health teaching to a group of

parents regarding Chlamydia trachomatis. The nurse is
correct in the statement, “Chlamydia trachomatis is not only
an intracellular bacterium that causes neonatal conjunctivitis,
but it also can cause:

A. Discoloration of baby and adult teeth.

B. Pneumonia in the newborn.
C. Snuoes and rhagades in the newborn.
D. Central hearing defects in infancy.

29. The nurse is assigned to care to a 17-year-old male client

with a history of substance abuse. The client asks the nurse,
“Have you ever tried or used drugs?” The most correct
response of the nurse would be:

A. “Yes, once I tried grass.”

B. “No, I don’t think so.”
C. “Why do you want to know that?”
D. “How will my answer help you?”
30. Which of the following describes a health care team with
the principles of participative leadership?

A. Each member of the team can independently make

decisions regarding the client’s care without necessarily
consulting the other members.
B. The physician makes most of the decisions regarding
the client’s care.
C. The team uses the expertise of its members to iniuence
the decisions regarding the client’s care.
D. Nurses decide nursing care; physicians decide medical
and other treatment for the client.

31. A nurse is giving a health teaching to a woman who

wants to breastfeed her newborn baby. Which hormone,
normally secreted during the postpartum period, iniuences
both the milk ejection reiex and uterine involution?

A. Oxytocin.
B. Estrogen.
C. Progesterone.
D. Relaxin.

32. One staff nurse is assigned to a group of 5 patients for

the 12-hour shift. The nurse is responsible for the overall
planning, giving and evaluating care during the entire shift.
After the shift, same responsibility will be endorsed to the
next nurse in charge. This describes nursing care delivered
via the:

A. Primary nursing method.

B. Case method.
C. Functional method.
D. Team method.

33. The ambulance team calls the emergency department

that they are going to bring a client who sustained burns in a
house Qre. While waiting for the ambulance, the nurse will
anticipate emergency care to include assessment for:

A. Gas exchange impairment.

B. Hypoglycemia.
C. Hyperthermia.
D. Fluid volume excess.

34. Most couples are using “natural” family planning

methods. Most accidental pregnancies in couples preferred
to use this method have been related to unprotected
intercourse before ovulation. Which of the following factor
explains why pregnancy may be achieved by unprotected
intercourse during the preovulatory period?

A. Ovum viability.
B. Tubal motility.
C. Spermatozoal viability.
D. Secretory endometrium.

35. An older adult client wakes up at 2 o’clock in the morning

and comes to the nurse’s station saying, “I am having
diqculty in sleeping.” What is the best nursing response to
the client?

A. “I’ll give you a sleeping pill to help you get more sleep
now.”
B. “Perhaps you’d like to sit here at the nurse’s station for a
while.”
C. “Would you like me to show you where the bathroom is?”
D. “What woke you up?”

36. The nurse is taking care of a multipara who is at 42

weeks of gestation and in active labor, her membranes
ruptured spontaneously 2 hours ago. While auscultating for
the point of maximum intensity of fetal heart tones before
applying an external fetal monitor, the nurse counts 100
beats per minute. The immediate nursing action is to:
 A. Start oxygen by mask to reduce fetal distress.
B. Examine the woman for signs of a prolapsed cord.
C. Turn the woman on her left side to increase placental
perfusion.
D. Take the woman’s radial pulse while still auscultating the
FHR.

37. The nurse must instruct a client with glaucoma to avoid

taking over-the-counter medications like:

A. Antihistamines.
B. NSAIDs.
C. Antacids.
D. Salicylates.

38. A male client is brought to the emergency department

due to motor vehicle accident. While monitoring the client,
the nurse suspects increasing intracranial pressure when:

A. Client is oriented when aroused from sleep, and goes

back to sleep immediately.
B. Blood pressure is decreased from 160/90 to 110/70.
C. Client refuses dinner because of anorexia.
D. Pulse is increased from 88-96 with occasional skipped
beat.

39. The nurse is conducting a lecture to a class of nursing

students about advance directives to preoperative clients.
Which of the following statement by the nurse js correct?

A. “The spouse, but not the rest of the family, may override
the advance directive.”
B. “An advance directive is required for a “do not
resuscitate” order.”
C. “A durable power of attorney, a form of advance directive,
may only be held by a blood relative.”
D. “The advance directive may be enforced even in the face
of opposition by the spouse.”
40. A client diagnosed with schizophrenia is shouting and
banging on the door leading to the outside, saying, “I need to
go to an appointment.” What is the appropriate nursing
intervention?

A. Tell the client that he cannot bang on the door.

B. Ignore this behavior.
C. Escort the client going back into the room.
D. Ask the client to move away from the door.

41. Which of the following action is an accurate tracheal

suctioning technique?

A. 25 seconds of continuous suction during catheter

insertion.
B. 20 seconds of continuous suction during catheter
insertion.
C. 10 seconds of intermittent suction during catheter
withdrawal.
D. 15 seconds of intermittent suction during catheter
withdrawal.

42. The client’s jaw and cheekbone is sutured and wired. The
nurse anticipates that the most important thing that must be
ready at the bedside is:

A. Suture set.
B. Tracheostomy set.
C. Suction equipment.
D. Wire cutters.

43. A mother is in the third stage of labor. Which of the

following signs will help the nurse determine the signs of
placental separation?

A. The uterus becomes globular.

B. The umbilical cord is shortened.
C. The fundus appears at the introitus.
 D. Mucoid discharge is increased.

44. After therapy with the thrombolytic alteplase (t-PA), what

observation will the nurse report to the physician?

A. 3+ peripheral pulses.
B. Change in level of consciousness and headache.
C. Occasional dysrhythmias.
D. Heart rate of 100/bpm.

45. A client who undergone left nephrectomy has a large

iank incision. Which of the following nursing action will
facilitate deep breathing and coughing?

A. Push iuid administration to loosen respiratory

secretions.
B. Have the client lie on the unaffected side.
C. Maintain the client in high Fowler’s position.
D. Coordinate breathing and coughing exercise with
administration of analgesics.

46. The community nurse is teaching the group of mothers

about the cervical mucus method of natural family planning.
Which characteristics are typical of the cervical mucus during
the “fertile” period of the menstrual cycle?

A. Absence of ferning.
B. Thin, clear, good spinnbarkeit.
C. Thick, cloudy.
D. Yellow and sticky.

47. A client with ruptured appendix had surgery an hour ago

and is transferred to the nursing care unit. The nurse placed
the client in a semi-Fowler’s position primarily to:

A. Facilitate movement and reduce complications from

immobility.
B. Fully aerate the lungs.
 C. Splint the wound.
D. Promote drainage and prevent subdiaphragmatic
abscesses.

48. Which of the following will best describe a management

function?

A. Writing a letter to the editor of a nursing journal.

B. Negotiating labor contracts.
C. Directing and evaluating nursing staff members.
D. Explaining medication side effects to a client.

49. The parents of an infant client ask the nurse to teach

them how to administer Cortisporin eye drops. The nurse is
correct in advising the parents to place the drops:

A. In the middle of the lower conjunctival sac of the infant’s

eye.
B. Directly onto the infant’s sclera.
C. In the outer canthus of the infant’s eye.
D. In the inner canthus of the infant’s eye.

50. The nurse is assessing on the client who is admitted due

to vehicle accident. Which of the following Qndings will help
the nurse that there is internal bleeding?

A. Frank blood on the clothing.

B. Thirst and restlessness.
C. Abdominal pain.
D. Confusion and altered of consciousness.

51. The nurse is completing an assessment to a newborn

baby boy. The nurse observes that the skin of the newborn is
dry and iaking and there are several areas of an apparent
macular rash. The nurse charts this as:

A. Icterus neonatorum
B. Multiple hemangiomas
 C. Erythema toxicum
D. Milia

52. The client is brought to the emergency department

because of serious vehicle accident. After an hour, the client
has been declared brain dead. The nurse who has been with
the client must now talk to the family about organ donation.
Which of the following consideration is necessary?

A. Include as many family members as possible.

B. Take the family to the chapel.
C. Discuss life support systems.
D. Clarify the family’s understanding of brain death.

53. The nurse is teaching exercises that are good for

pregnant women increasing tone and Qtness and decreasing
lower backache. Which of the following should the nurse
exclude in the exercise program?

A. Stand with legs apart and touch hands to ioor three

times per day.
B. Ten minutes of walking per day with an emphasis on
good posture.
C. Ten minutes of swimming or leg kicking in pool per day.
D. Pelvic rock exercise and squats three times a day.

54. A client with obsessive-compulsive behavior is admitted

in the psychiatric unit. The nurse taking care of the client
knows that the primary treatment goal is to:

A. Provide distraction.
B. Support but limit the behavior.
C. Prohibit the behavior.
D. Point out the behavior.

55. After ileostomy, the nurse expects that the drainage

appliance will be applied to the stoma:
 A. When the client is able to begin self-care procedures.
B. 24 hours later, when the swelling subsided.
C. In the operating room after the ileostomy procedure.
D. After the ileostomy begins to function.

56. A female client who has a 28-day menstrual cycle asks

the community health nurse when she get pregnant during
her cycle. What will be the best nursing response?

A. It is impossible to determine the fertile period reliably. So

it is best to assume that a woman is always fertile.
B. In a 28-day cycle, ovulation occurs at or about day 14.
The egg lives for about 24 hours and the sperm live for
about 72 hours. The fertile period would be
approximately between day 11 and day 15.
C. In a 28- day cycle, ovulation occurs at or about day 14.
The egg lives for about 72 hours and the sperm live for
about 24 hours. The fertile period would be
approximately between day 13 and 17.
D. In a 28-day cycle, ovulation occurs 8 days before the next
period or at about day 20. The fertile period is between
day 20 and the beginning of the next period.

57. Which of the following statement describes the role of a

nurse as a client advocate?

A. A nurse may override clients’ wishes for their own good.

B. A nurse has the moral obligation to prevent harm and do
well for clients.
C. A nurse helps clients gain greater independence and self-
determination.
D. A nurse measures the risk and beneQts of various health
situations while factoring in cost.

58. A community health nurse is providing a health teaching

to a woman infected with herpes simplex 2. Which of the
following health teaching must the nurse include to reduce
the chances of transmission of herpes simplex 2?
 A. “Abstain from intercourse until lesions heal.”
B. “Therapy is curative.”
C. “Penicillin is the drug of choice for treatment.”
D. “The organism is associated with later development of
hydatidiform mole.

59. The nurse in the psychiatric ward informed the male

client that he will be attending the 9:00 AM group therapy
sessions. The client tells the nurse that he must wash his
hands from 9:00 to 9:30 AM each day and therefore he
cannot attend. Which concept does the nursing staff need to
keep in mind in planning nursing intervention for this client?

A. Depression underlines ritualistic behavior.

B. Fear and tensions are often expressed in disguised form
through symbolic processes.
C. Ritualistic behavior makes others uncomfortable.
D. Unmet needs are discharged through ritualistic behavior.

60. The nurse assesses the health condition of the female

client. The client tells the nurse that she discovered a lump in
the breast last year and hesitated to seek medical advice.
The nurse understands that, women who tend to delay
seeking medical advice after discovering the disease are
displaying what common defense mechanism?

A. Intellectualization.
B. Suppression.
C. Repression.
D. Denial.

61. Which of the following situations cannot be delegated by

the registered nurse to the nursing assistant?

A. A postoperative client who is stable needs to ambulate.

B. Client in soft restraint who is very agitated and crying.
C. A confused elderly woman who needs assistance with
eating.
 D. Routine temperature check that must be done for a client
at end of shift.

62. In the admission care unit, which of the following client

would the nurse give immediate attention?

A. A client who is 3 days postoperative with left calf pain.

B. A client who is postoperative hip pinning who is
complaining of pain.
C. New admitted client with chest pain.
D. A client with diabetes who has a glucoscan reading of
180.

63. A couple seeks medical advice in the community health

care unit. A couple has been unable to conceive; the man is
being evaluated for possible problems. The physician ordered
semen analysis. Which of the following instructions is correct
regarding collection of a sperm specimen?

A. Collect a specimen at the clinic, place in iced container,

and give to laboratory personnel immediately.
B. Collect specimen after 48-72 hours of abstinence and
bring to clinic within 2 hours.
C. Collect specimen in the morning after 24 hours of
abstinence and bring to clinic immediately.
D. Collect specimen at night, refrigerate, and bring to clinic
the next morning.

64. The physician ordered Betamethasone to a pregnant

woman at 34 weeks of gestation with sign of preterm labor.
The nurse expects that the drug will:

A. Treat infection.
B. Suppress labor contraction.
C. Stimulate the production of surfactant.
D. Reduce the risk of hypertension.

65. A tracheostomy cuff is to be deiated, which of the

following nursing intervention should be implemented before
starting the procedures?

A. Suction the trachea and mouth.

B. Have the obdurator available.
C. Encourage deep breathing and coughing.
D. Do a pulse oximetry reading.

66. A client is diagnosed with Tuberculosis and respiratory

isolation is initiated. This means that:

A. Gloves are worn when handling the client’s tissue,

excretions, and linen.
B. Both client and attending nurse must wear masks at all
times.
C. Nurse and visitors must wear masks until chemotherapy
is begun. Client is instructed in cough and tissue
techniques.
D. Full isolation; that is, caps and gowns are required during
the period of contagion.

67. A client with lung cancer is admitted in the nursing care

unit. The husband wants to know the condition of his wife.
How should the nurse respond to the husband?

A. Find out what information he already has.

B. Suggest that he discuss it with his wife.
C. Refer him to the doctor.
D. Refer him to the nurse in charge.

68. A hospitalized client cannot Qnd his handkerchief and

accuses other cient in the room and the nurse of stealing
them. Which is the most therapeutic approach to this client?

A. Divert the client’s attention.

B. Listen without reinforcing the client’s belief.
C. Inject humor to defuse the intensity.
D. Logically point out that the client is jumping to
 conclusions.

69. After a cystectomy and formation of an ileal conduit, the

nurse provides instruction regarding prevention of leakage of
the pouch and backiow of the urine. The nurse is correct to
include in the instruction to empty the urine pouch:

A. Every 3-4 hours.

B. Every hour.
C. Twice a day.
D. Once before bedtime.

70. Which telephone call from a student’s mother should the

school nurse take care of at once?

A. A telephone call notifying the school nurse that the child’

pediatrician has informed the mother that the child will
need cardiac repair surgery within the next few weeks.
B. A telephone call notifying the school nurse that the
child’s pediatrician has informed the mother that the
child has head lice.
C. A telephone call notifying the school nurse that a child
has a temperature of 102ºF and a rash covering the
trunk and upper extremities of the body.
D. A telephone call notifying the school nurse that a child
underwent an emergency appendectomy during the
previous night.

71. Which of the following signs and symptoms that require

immediate attention and may indicate most serious
complications during pregnancy?

A. Severe abdominal pain or iuid discharge from the

vagina.
B. Excessive saliva, “bumps around the areolae, and
increased vaginal mucus.
C. Fatigue, nausea, and urinary frequency at any time
during pregnancy.
 D. Ankle edema, enlarging varicosities, and heartburn.

72. The nurse is assessing the newborn boy. Apgar scores

are 7 and 9. The newborn becomes slightly cyanotic. What is
the initial nursing action?

A. Elevate his head to promote gravity drainage of

secretions.
B. Wrap him in another blanket, to reduce heat loss.
C. Stimulate him to cry,, to increase oxygenation.
D. Aspirate his mouth and nose with bulb syringe.

73. The nurse is formulating a plan of care to a client with a

somatoform disorder. The nurse needs to have knowledge of
which psychodynamic principle?

A. The symptoms of a somatoform disorder are an attempt

to adjust to painful life situations or to cope with
coniicting sexual, aggressive, or dependent feelings.
B. The major fundamental mechanism is regression.
C. The client’s symptoms are imaginary and the suffering is
faked.
D. An extensive, prolonged study of the symptoms will be
reassuring to the client, who seeks sympathy, attention
and love.

74. An infant is brought to the health care clinic for three

immunizations at the same time. The nurse knows that
hepatitis B, DPT, and Haemophilus iniuenzae type B
immunizations should:

A. Be drawn in the same syringe and given in one injection.

B. Be mixed and inject in the same sites.
C. Not be mixed and the nurse must give three injections in
three sites.
D. Be mixed and the nurse must give the injection in three
sites.
75. A female client with cancer has radium implants. The
nurse wants to maintain the implants in the correct position.
The nurse should position the client:

A. Flat in bed.
B. On the side only.
C. With the foot of the bed elevated.
D. With the head elevated 45-degrees (semi-Fowler’s).

76. The nurse wants to know if the mother of a toddler

understands the instructions regarding the administration of
syrup of ipecac. Which of the following statement will help
the nurse to know that the mother needs additional teaching?

A. “I’ll give the medicine if my child gets into some toilet

bowl cleaner.”
B. “I’ll give the medicine if my child gets into some aspirin.”
C. “I’ll give the medicine if my child gets into some plant
bulbs.”
D. “I’ll give the medicine if my child gets into some vitamin
pills.”

77. To assess if the cranial nerve VII of the client was

damaged, which changes would not be expected?

A. Drooling and drooping of the mouth.

B. Inability to open eyelids on operative side.
C. Sagging of the face on the operative side.
D. Inability to close eyelid on operative side.

78. The community health nurse makes a home visit to a

family. During the visit, the nurse observes that the mother is
beating her child. What is the priority nursing intervention in
this situation?

A. Assess the child’s injuries.

B. Report the incident to protective agencies.
C. Refer the family to appropriate support group.
 D. Assist the family to identify stressors and use of other
coping mechanisms to prevent further incidents.

79. The nurse in the neonatal care unit is supervising the

actions of a certiQed nursing assistant in giving care to the
newborns. The nursing assistant mistakenly gives a formula
feeding to a newborn that is on water feeding only. The nurse
is responsible for the mistake of the nursing assistant:

A. Always, as a representative of the institution.

B. Always, because nurses who supervise less-trained
individuals are responsible for their mistakes.
C. If the nurse failed to determine whether the nursing
assistant was competent to take care of the client.
D. Only if the nurse agreed that the newborn could be fed
formula.

80. The nurse is assigned to care for a client with urinary

calculi. Fluid intake of 2L/day is encouraged to the client. the
primary reason for this is to:

A. Reduce the size of existing stones.

B. Prevent crystalline irritation to the ureter.
C. Reduce the size of existing stones
D. Increase the hydrostatic pressure in the urinary tract.

81. The nurse is counseling a couple in their mid 30’s who

have been unable to conceive for about 6 months. They are
concerned that one or both of them may be infertile. What is
the best advice the nurse could give to the couple?

A. “it is no unusual to take 6-12 months to get pregnant,

especially when the partners are in their mid-30s. Eat
well, exercise, and avoid stress.”
B. “Start planning adoption. Many couples get pregnant
when they are trying to adopt.”
C. “Consult a fertility specialist and start testing before you
get any older.”
 D. “Have sex as often as you can, especially around the
time of ovulation, to increase your chances of
pregnancy.”

82. The nurse is caring for a cient who Is a retired nurse. A

24-hour urine collection for Creatinine clearance is to be
done. The client tells the nurse, “I can’t remember what this
test is for.” The best response by the nurse is:

A. “It provides a way to see if you are passing any protein in

your urine.”
B. “It tells how well the kidneys Qlter wastes from the blood.”
C. “It tells if your renal insuqciency has affected your heart.”
D. “The test measures the number of particles the kidney
Qlters.”

83. The nurse observes the female client in the psychiatric

ward that she is having a hard time sleeping at night. The
nurse asks the client about it and the client says, “I can’t sleep
at night because of fear of dying.” What is the best initial
nursing response?

A. “It must be frightening for you to feel that way. Tell me

more about it.”
B. “Don’t worry, you won’t die. You are just here for some
test.”
C. “Why are you afraid of dying?”
D. “Try to sleep. You need the rest before tomorrow’s test.”

84. In the hospital lobby, the registered nurse overhears a two

staff members discussing about the health condition of her
client. What would be the appropriate action for the
registered nurse to take?

A. Join in the conversation, giving her input about the case.

B. Ignore them, because they have the right to discuss
anything they want to.
C. Tell them it is not appropriate to discuss such things.
 D. Report this incident to the nursing supervisor.

85. The client has had a right-sided cerebrovascular accident.

In transferring the client from the wheelchair to bed, in what
position should a client be placed to facilitate safe transfer?

A. Weakened (L) side of the cient next to bed.

B. Weakened (R) side of the client next to bed.
C. Weakened (L) side of the client away from bed.
D. Weakened (R) side of the cient away from bed.

86. The child client has undergone hip surgery and is in a

spica cast. Which of the following toy should be avoided to
be in the child’s bed?

A. A toy gun.
B. A stuffed animal.
C. A ball.
D. Legos.

87. The LPN/LVN asks the registered nurse why oxytocin

(Pitocin), 10 units (IV or IM) must be given to a client after
birth fo the fetus. The nurse is correct to explain that
oxytocin:

A. Minimizes discomfort from “afterpains.”

B. Suppresses lactation.
C. Promotes lactation.
D. Maintains uterine tone.

88. The nurse in the nursing care unit is aware that one of the
medical staff displays unlikely behaviors like confusion,
agitation, lethargy and unkempt appearance. This behavior
has been reported to the nurse manager several times, but no
changes observed. The nurse should:

A. Continue to report observations of unusual behavior until

the problem is resolved.
 B. Consider that the obligation to protect the patient from
harm has been met by the prior reports and do nothing
further.
C. Discuss the situation with friends who are also nurses to
get ideas .
D. Approach the partner of this medical staff member with
these concerns.

89. The physician ordered tetracycline PO qid to a child client

who weights 20kg. The recommended PO tetracycline dose
is 25-50 mg/kg/day. What is the maximum single dose that
can be safely administered to this child?

A. 1 g
B. 500 mg
C. 250 mg
D. 125 mg

90. The nurse is completing an obstetric history of a woman

in labor. Which event in the obstetric history will help the
nurse suspects dysfunctional labor in the current pregnancy?

A. Total time of ruptured membranes was 24 hours with the

second birth.
B. First labor lasting 24 hours.
C. Uterine Qbroid noted at time of cesarean delivery.
D. Second birth by cesarean for face presentation.

91. The nurse is planning to talk to the client with an

antisocial personality disorder. What would be the most
therapeutic approach?

A. Provide external controls.

B. Reinforce the client’s self-concept.
C. Give the client opportunities to test reality.
D. Gratify the client’s inner needs.

92. The nurse is teaching a group of women about fertility

awareness, the nurse should emphasize that basal body
temperature:

A. Can be done with a mercury thermometer but no a digital

one.
B. The average temperature taken each morning.
C. Should be recorded each morning before any activity.
D. Has a lower degree of accuracy in predicting ovulation
than the cervical mucus test.

93. The nursing applicant has given the chance to ask

questions during a job interview at a local hospital. What
should be the most important question to ask that can
increase chances of securing a job offer?

A. Begin with questions about client care assignments,

advancement opportunities, and continuing education.
B. Decline to ask questions, because that is the
responsibility of the interviewer.
C. Ask as many questions about the facility as possible.
D. Clarify information regarding salary, beneQts, and
working hours Qrst, because this will help in deciding
whether or not to take the job.

94. The nurse advised the pregnant woman that smoking and
alcohol should be avoided during pregnancy. The nurse takes
into account that the developing fetus is most vulnerable to
environment teratogens that cause malformation during:

A. The entire pregnancy.

B. The third trimester.
C. The Qrst trimester.
D. The second trimester.

95. A male client tells the nurse that there is a big bug in his
bed. The most therapeutic nursing response would be:

A. Silence.
 B. “Where’s the bug? I’ll kill it for you.”
C. “I don’t see a bug in your bed, but you seem afraid.”
D. “You must be seeing things.”

96. A pregnant client in late pregnancy is complaining of

groin pain that seems worse on the right side. Which of the
following is the most likely cause of it?

A. Beginning of labor.
B. Bladder infection.
C. Constipation.
D. Tension on the round ligament.

97. The nurse is conducting a lecture to a group of volunteer

nurses. The nurse is correct in imparting the idea that the
Good Samaritan law protects the nurse from a suit for
malpractice when:

A. The nurse stops to render emergency aid and leaves

before the ambulance arrives.
B. The nurse acts in an emergency at his or her place of
employment.
C. The nurse refuses to stop for an emergency outside of
the scope of employment.
D. The nurse is grossly negligent at the scene of an
emergency.

98. A woman is hospitalized with mild preeclampsia. The

nurse is formulating a plan of care for this client, which
nursing care is least likely to be done?

A. Deep-tendon reiexes once per shift.

B. Vital signs and FHR and rhythm q4h while awake.
C. Absolute bed rest.
D. Daily weight.

99. While feeding a newborn with an unrepaired cardiac

defect, the nurse keeps on assessing the condition of the
client. The nurse notes that the newborn’s respiration is 72
breaths per minute. What would be the initial nursing action?

A. Burp the newborn.

B. Stop the feeding.
C. Continue the feeding.
D. Notify the physician.

100. A client who undergone appendectomy 3 days ago is

scheduled for discharge today. The nurse notes that the
client is restless, picking at bedclothes and saying, “I am late
on my appointment,” and calling the nurse by the wrong
name. The nurse suspects:

A. Panic reaction.
B. Medication overdose.
C. Toxic reaction to an antibiotic.
D. Delirium tremens.

Answers and Rationales

1. A. The oxytocic effect of Pitocin increases the intensity

and durations of contractions; prolonged contractions
will jeopardize the safetyof the fetus and necessitate
discontinuing the drug.
2. B. It is of paramount importance to prevent the client
from hurting himself or herself or others.
3. B. After tonsillectomy, clear, cool liquids should be given.
Citrus, carbonated, and hot or cold liquids should be
avoided because they may irritate the throat. Red liquids
should be avoided because they give the appearance of
blood if the child vomits. Milk and milk products
including pudding are avoided because they coat the
throat, cause the child to clear the throat, and increase
the risk of bleeding.
4. A. Phenylephrine, with frequent and continued use, can
cause rebound congestion of mucous membranes.
5. B. The N 95 respirator is a high-particulate Qltration mask
 that meets the CDC performance criteria for a
tuberculosis respirator.
6. C. The most frequent cause of noncompliance to the
treatment of chronic, or open-angle glaucoma is the
miotic effects of pilocarpine. Pupillary constriction
impedes normal accommodation, making night driving
diqcult and hazardous, reducing the client’s ability to
read for extended periods and making participation in
games with fast-moving objects impossible.
7. B. This stops the sucking of air through the tube and
prevents the entry of contaminants. In addition, clamping
near the chest wall provides for some stability and may
prevent the clamp from pulling on the chest tube.
8. D. Because umbilical cord’s insertion site is born before
the fetal head, the cord may be compressed by the after-
coming head in a breech birth.
9. B. It is important to externalize the anger away from self.
10. D. Development normally proceeds cephalocaudally; so
the Qrst major developmental milestone that the infant
achieves is the ability to hold the head up within the Qrst
8-12 weeks of life. In hypothyroidism, the infant’s muscle
tone would be poor and the infant would not be able to
achieve this milestone.
11. D. Get a senior nurse who know s the policies, the client,
and the doctor. Generally speaking, a nurse should not
accept telephone orders. However, if it is necessary to
take one, follow the hospital’s policy regarding telephone
orders. Failure to followhospital policy could be
considered negligence. In this case, the nurse was new
and did not know the hospital’s policy concerning
telephone orders. The nurse was also unfamiliar with the
doctor and the client. Therefore the nurse should not
take the order unless a) no one else is available and b) it
is an emergency situation.
12. C. The nurse is obligated to inform the nurse manager
about changes in the condition of the client, which may
change the decision made by the nurse manager.
13. A. Perinatal risk factors for the development of Down
syndrome include advanced maternal age, especially
 with the Qrst pregnancy.
14. B. Assignments should be based on scope of practice
and expertise.
15. B. The child who is concurrently taking digoxin and
diuretics is at increased risk for digoxin toxicity due to
the loss of potassium. The child and parents should be
taught what foods are high in potassium, and the child
should be encouraged to eat a high-potassium diet. In
addition, the child’s serum potassium level should be
carefully monitored.
16. A. The responsible for an accurate informed consent is
the physician. An exception to this answer would be a
life-threatening emergency, but there are no data to
support another response.
17. D. Asking the client to cough and take a deep breath will
help determine if the chest tube is kinked or if the lungs
has reexpanded.
18. B. Every event that exposes a client to harm should be
recorded in an incident report, as well as reported to the
appropriate supervisors in order to resolve the current
problems and permit the institution to prevent the
problem from happening again.
19. D. One of the earliest signs of digoxin toxicity is
Bradycardia. For a toddler, any heart rate that falls below
the norm of about 100-120 bpm would indicate
Bradycardia and would necessitate holding the
medication and notifying the physician.
20. B. This option is least threatening.
21. D. In preparing the client for discharge that is receiving
prednisone, the nurse should caution the client to (a)
take oral preparations after meals; (b) remember that
routine checks of vital signs, weight, and lab studies are
critical; (c) NEVER STOP OR CHANGE THE AMOUNT OF
MEDICATION WITHOUT MEDICAL ADVICE; (d) store the
medication in a light-resistant container.
22. A. Progesterone also reduces smooth muscle motility in
the urinary tract and predisposes the pregnant woman to
urinary tract infections. Women should contact their
doctors if they exhibit signs of infection. Kegel exercise
 will help strengthen the perineal muscles; limiting iuids
at bedtime reduces the possibility of being awakened by
the necessity of voiding.
23. B. This is the proper use of anger.
24. C. There are several models of case management, but
the commonality is comprehensive coordination of care
to better predict needs of high-risk clients, decrease
exacerbations and continually monitor progress
overtime.
25. A. Phenytoin should be infused or injected into larger
veins to avoid the discoloration know as purple glove
syndrome; infusing into a smaller vein is not appropriate.
26. C. Serum radioimmunoassay (RIA) is accurate within
7days of conception. This test is speciQc for HCG, and
accuracy is not compromised by confusion with LH.
27. D. Surgery and anesthesia can increase mucus
production. Deep breathing and coughing are essential to
prevent atelectasis and pneumonia in the client’s only
remaining lung.
28. B. Newborns can get pneumonia (tachypnea, mild
hypoxia, cough, eosinophilia) and conjunctivitis from
Chlamydia.
29. D. The client may perceive this as avoidance, but it is
more important to redirect back to the client, especially
in light of the manipulative behavior of drug abusers and
adolescents.
30. C. It describes a democratic process in which all
members have input in the client’s care.
31. A. Contraction of the milk ducts and let-down reiex
occur under the stimulation of oxytocin released by the
posterior pituitary gland.
32. B. In case management, the nurse assumes total
responsibility for meeting the needs of the client during
the entire time on duty.
33. A. Smoke inhalation affects gas exchange.
34. C. Sperm deposited during intercourse may remain
viable for about 3 days. If ovulation occurs during this
period, conception may result.
35. B. This option shows acceptance (key concept) of this
 age-typical sleep pattern (that of waking in the early
morning).
36. D. Taking the mother’s pulse while listening to the FHR
will differentiate between the maternal and fetal heart
rates and rule out fetal Bradycardia.
37. A. Antihistamines cause pupil dilation and should be
avoided with glaucoma.
38. A. This suggests that the level of consciousness is
decreasing.
39. D. An advance directive is a form of informed consent,
and only a competent adult or the holder of a durable
power of attorney has the right to consent or refuse
treatment. If the spouse does not hold the power of
attorney, the decisions of the holder, even if opposed by
the spouse, are enforced.
40. C. Gentle but Qrm guidance and nonverbal direction is
needed to intervene when a client with schizophrenic
symptoms is being disruptive.
41. C. Suctioning is only done for 10 seconds, intermittently,
as the catheter is being withdrawn.
42. D. The priority for this client is being able to establish an
airway.
43. A. Signs of placental separation include a change in the
shape of the uterus from ovoid to globular.
44. B. This could indicate intracranial bleeding. Alteplase is a
thrombolytic enzyme that lyses thrombi and emboli.
Bleeding is an adverse effect. Monitor clotting times and
signs of any gastrointestinal or internal bleeding.
45. D. Because iank incision in nephrectomy is directly
below the diaphragm, deep breathing is painful.
Additionally, there is a greater incisional pull each time
the person moves than there is with abdominal surgery.
Incisional pain following nephrectomy generally requires
analgesics administration every 3-4 hours for 24-48
hours after surgery. Therefore, turning, coughing and
deep-breathing exercises should be planned to maximize
the analgesic effects.
46. B. Under high estrogen levels, during the period
surrounding ovulation, the cervical mucus becomes thin,
 clear, and elastic (spinnbarkeit), facilitating sperm
passage.
47. D. After surgery for a ruptured appendix, the client should
be placed in a semi-Fowler’s position to promote
drainage and to prevent possible complications.
48. C. Directing and evaluation of staff is a major
responsibility of a nursing manager.
49. A. The recommended procedure for administering
eyedrops to any client calls for the drops to be placed in
the middle of the lower conjunctival sac.
50. B. Thirst and restlessness indicate hypovolemia and
hypoxemia. Internal bleeding is diqcult to recognized
and evaluate because it is not apparent.
51. C. Erythema toxicum is the normal, nonpathological
macular newborn rash.
52. D. The family needs to understand what brain death is
before talking about organ donation. They need time to
accept the death of their family member. An environment
conducive to discussing an emotional issue is needed.
53. A. Bending from the waist in pregnancy tends to make
backache worse.
54. B. Support and limit setting decrease anxiety and provide
external control.
55. C. The stoma drainage bag is applied in the operating
room. Drainage from the ileostomy contains secretions
that are rich in digestive enzymes and highly irritating to
the skin. Protection of the skin from the effects of these
enzymes is begun at once. Skin exposed to these
enzymes even for a short time becomes reddened,
painful and excoriated.
56. B. It is the most accurate statement of physiological
facts for a 28-day menstrual cycle: ovulation at day 14,
egg life span 24 hours, sperm life span of 72 hours.
Fertilization could occur from sperm deposited before
ovulation.
57. C. An advocate role encourage freedom of choice,
includes speaking out for the client, and supports the
client’s best interests.
58. A. Abstinence will eliminate any unnecessary pain during
 intercourse and will reduce the possibility of transmitting
infection to one’s sexual partner.
59. B. Anxiety is generated by group therapy at 9:00 AM. The
ritualistic behavioral defense of hand washing decreases
anxiety by avoiding group therapy.
60. D. Denial is a very strong defense mechanism used to
allay the emotional effects of discovering a potential
threat. Although denial has been found to be an effective
mechanism for survival in some instances, such as
during natural disasters, it may in greater pathology in a
woman with potential breast carcinoma.
61. B. The registered nurse cannot delegate the
responsibility for assessment and evaluation of clients.
The status of the client in restraint requires further
assessment to determine if there are additional causes
for the behavior.
62. C. The client with chest pain may be having a myocardial
infarction, and immediate assessment and intervention
is a priority.
63. B. Is correct because semen analysis requires that a
freshly masturbated specimen be obtained after a rest
(abstinence) period of 48-72 hours.
64. C. Betamethasone, a form of cortisone, acts on the fetal
lungs to produce surfactant.
65. A. Secretions may have pooled above the tracheostomy
cuff. If these are not suctioned before deiation, the
secretions may be aspirated.
66. C. Proper handling of sputum is essential to allay droplet
transference of bacilli in the air. Clients need to be taught
to cover their nose and mouth with tissues when
sneezing or coughing. Chemotherapy generally renders
the client noninfectious within days to a few weeks,
usually before cultures for tubercle bacilli are negative.
Until chemical isolation is established, many institutions
require the client to wear a mask when visitors are in the
room or when the nurse is in attendance. Client should
be in a well-ventilated room, without air recirculation, to
prevent air contamination.
67. A. It is best to establish baseline information Qrst.
68. B. Listening is probably the most effective response of
the four choices.
69. A. Urine iow is continuous. The pouch has an outlet
valve for easy drainage every 3-4 hours. (the pouch
should be changed every 3-5 days, or sooner if the
adhesive is loose).
70. C. A high fever accompanied by a body rash could
indicate that the child has a communicable disease and
would have exposed other students to the infection. The
school nurse would want to investigate this telephone
call immediately so that plans could be instituted to
control the spread of such infection.
71. A. Severe abdominal pain may indicate complications of
pregnancy such as abortion, ectopic pregnancy, or
abruption placenta; iuid discharge from the vagina may
indicate premature rupture of the membrane.
72. D. Gentle aspiration of mucus helps maintain a patent
airway, required for effective gas exchange.
73. A. Somatoform disorders provide a way of coping with
coniicts.
74. C. Immunization should never be mixed together in a
syringe, thus necessitating three separate injections in
three sites. Note: some manufacturers make a premixed
combination of immunization that is safe and effective.
75. A. Clients with radioactive implants should be positioned
iat in bed to prevent dislodgement of the vaginal
packing. The client may roll to the side for meals but the
upper body should not be raised more than 20 degrees.
76. A. Syrup of ipecac is not administered when the ingested
substances is corrosive in nature. Toilet bowl cleaners,
as a collective whole, are highly corrosive substances. If
the ingested substance “burned” the esophagus going
down, it will “burn” the esophagus coming back up when
the child begins to vomit after administration of syrup of
ipecac.
77. B. Inability to open eyelids on operative side is seen with
cranial nerve III damage.
78. A. Assessment of physical injuries (like bruises,
lacerations, bleeding and fractures) is the Qrst priority.
79. C. The nurse who is supervising others has a legal
obligation to determine that they are competent to
perform the assignment, as well as legal obligation to
provide adequate supervision.
80. D. Increasing hydrostatic pressure in the urinary tract will
facilitate passage of the calculi.
81. A. Infertility is not diagnosed until atleast 12months of
unprotected intercourse has failed to produce a
pregnancy. Older couples will experience a longer time to
get pregnant.
82. B. Determining how well the kidneys Qlter wastes states
the purpose of a Creatinine clearance test.
83. A. Acknowledging a feeling tone is the most therapeutic
response and provides a broad opening for the client to
elaborate feelings.
84. C. The behavior should be stopped. The Qrst is to remind
the staff that conQdentiality maybe violated.
85. C. With a right-sided cerebrovascular accident the client
would have left-sided hemiplegia or weakness. The
client’s good side should be closest to the bed to
facilitate the transfer.
86. D. Legos are small plastic building blocks that could
easily slip under the child’s cast and lead to a break in
skin integrity and even infection. Pencils, backscratchers,
and marbles are some other narrow or small items that
could easily slip under the child’s cast and lead to a break
in skin integrity and infection.
87. D. Oxytocin (Pitocin) is used to maintain uterine tone.
88. B. The submission of reports about incidents that
expose clients to harm does not remove the obligation to
report ongoing behavior as long as the risk to the client
continues.
89. C. The recommended dosage of tetracycline is 25-
50mg/kg/day. If the child weighs 20kg and the maximum
dose is 50mg/kg, this would indicate a total daily dose of
1000mg of tetracycline. In this case, the child is being
given this medication four times a day. Therefore the
maximum single dose that can be given is 250mg (1000
mg of tetracycline divided by four doses.)
 90. C. An abnormality in the uterine muscle could reduce the
effectiveness of uterine contractions and lengthen the
duration of subsequent labors.
91. A. Personality disorders stem from a weak superego,
implying a lack of adequate controls.
92. C. The basal body temperature is the lowest body
temperature of a healthy person that is taken
immediately after waking and before getting out of bed.
The BBT usually varies from 36.2 ºC to 36.3ºC during
menses and for about 5-7 days afterward. About the
time of ovulation, a slight drop in temperature may be
seen, after ovulation in concert with the increasing
progesterone levels of the early luteal phase, the BBT
rises 0.2-0.4 ºC. This elevation remains until 2-3 days
before menstruation, or if pregnancy has occurred.
93. A. This choice implies concern for client care and self-
improvement.
94. C. The Qrst trimester is the period of organogenesis, that
is, cell differentiation into the various organs, tissues, and
structures.
95. C. This response does not contradict the client’s
perception, is honest, and shows empathy.
96. D. Tension on round ligament occurs because of the
erect human posture and pressure exerted by the
growing fetus.
97. D. The Good Samaritan Law does not impose a duty to
stop at the scene of an emergency outside of the scope
of employment, therefore nurses who do not stop are not
liable for suit.
98. C. Although reducing environment stimuli and activity is
necessary for a woman with mild preeclampsia, she will
most probably have bathroom privileges.
99. B. A normal respiratory rate for a newborn is 30-40
breaths per minute.
100. D. The behavior described is likely to be symptoms of
delirium tremens, or alcohol withdrawal (often
unsuspected on a surgical unit.)
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