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1. What is the most common uterine site for implantation in the human?

a. Upper posterior wall

b. Lower posterior wall
c. Upper anterior wall
d. Lower anterior wall
2. Which of the following s derived from mesoderm?
a. Lining of the GI tract
b. Liver
c. Brain
d. Skeletal system
3. Which of the following could be considered as a positive sign of pregnancy?
a. Amenorrhea, nausea, vomiting
b. Frequency of urination
c. Braxton hicks contraction
d. Fetal outline by sonography
4. The Nurse checks the perineum of Helen. Which of the following characteristic of the
amniotic fluid would cause an alarm to the nurse?
a. Greenish
b. Scantly
c. Colorless
d. Blood tinged
5. To determine the clients EDC, which day f the menstrual period will you ask?
a. First
b. Last
c. Third
d. Second
6. In the mediate postpartum period the action of methylegonovine is to:
a. Causes sustained uterine contractions
b. Causes intermittent uterine contractions
c. Relaxes the uterus
d. Induces sleep so that the mother can rest after an exhausting labor
7. How many days and how much dosage will the IRON supplementation be taken?
a. 365 days / 300 mg
b. 210 days / 200 mg
c. 100 days / 100 mg
d. 50 days / 50 mg
8. A 40-year-old mother should avoid?
a. Traveling
b. Sex
c. Smoking
d. Exercising
9. She complained of leg cramps, which usually occurs at night. To provide relief, the nurse
tells Diane to:
a. Dorsiflex the foot while extending the knee when the cramps occur
b. Dorsiflex the foot while flexing the knee when the cramps occur
c. Plantar flex the foot while flexing the knee when the cramps occur
d. Plantar flex the foot while extending the knee when the cramps occur
10. Which of the following is characteristic of a false labor?
a. Bloody show
b. Contraction that are regular and increase in frequency and duration
c. Contraction are felt in the back and radiates towards the abdomen
d. None of the above
11. Which is a primary power of labor?
a. Uterine contractions
b. Pushing of the mother
c. Intrathoracic pressure
d. Abdominal contraction
12. A negative 1 [-1] station means that:
a. Fetus is crowning
b. Fetus is floating
c. Fetus is engaged
d. Fetus is at the ischial spine
13. In what presentation is the head in extreme flexion?
a. Sinciput
b. Brow
c. Vertex
d. Face
14. Ripening of the cervix occurs during the:
a. First stage
b. Second stage
c. Third stage
d. Fourth stage
15. Which of the following is not true regarding the third stage of labor?
a. Care should be taken in administration of bolus of oxytocin because it can cause
b. Signs of placental separation are lengthening of the cord, sudden gush of blood and
sudden change in shape of the uterus
c. It ranges from the time of expulsion of the fetus to the delivery of the placenta
d. The placenta is delivered approximately 5-15 minutes after delivery of the baby
16. The baby’ mother is RH (-). Which of the following laboratory tests will probably be
ordered for the newborn?
a. Direct Coomb’s
b. Indirect Coomb’s
c. Blood culture
d. Platelet count
17. On clients first postpartal day, the nurse assessment reveals the following: vital signs
within normal limits, a boggy uterus and perineal pad saturation with lochia rubra. What
should the nurse do?
a. Reassess the patient after an hour
b. Administer oxytocin
c. Massage the uterus
d. Notify the physician
18. Magnesium sulfate is ordered per IV. Which of the following should prompt the nurse to
refer to the obstetricians prior to administration of the drug?
a. BP = 180/100
b. Urine output is 40 ml/hour
c. RR = 12 bpm
d. (+) 2 deep tendon reflex
SITUATION: Danica is 24 y/o Filipin married to an American, she is pregnant for the second time
and now at 8 weeks AOG. She is RH (-) with blood type B.
19. Which of the following findings in Danica’s history would identify a need for her to
receive Rho (d) immune globulin?
a. Rh -, coombs +
b. Rh -, coombs –
c. Rh +, coombs –
d. Rh +, coombs +
20. A client who has missed two menstrual cycle period comes to the prenatal clinic
complaining of vaginal bleeding and one-sided lower-quadrant pain. The nurse suspects
that this client has.
a. Abruptio placenta
b. An ectopic pregnancy
c. An incomplete abortion
d. A rupture of a graffian follicle
21. A couple with one child had been trying, without success for several years to have
another child. Which of the following terms would describe the situation?
a. Primary infertility
b. Secondary infertility
c. Irreversible infertility
d. Sterility
22. When assessing the adequacy of sperm for conception to occur, which of the following is
the most helpful criterion?
a. Sperm count
b. Sperm motility
c. Sperm maturity
d. Sperm volume
23. During labor a client who is receiving epidural anesthesia has a sudden episode of severe
nausea, and her skin becomes pale and clammy the nurse immediate reaction is to:
a. Notify the physician
b. Check for vaginal bleeding
c. Elevate the client’s legs
d. Monitor the FHR every 3 minutes
24. At about 5 cm, a laboring client receives medication for pain. The nurse is aware that one
of the medications is given to women in labor that could cause respiratory depression of
the new born is:
a. Scopolamine
b. Meperidine (Demerol)
c. Promazine (Sparine)
d. Promethazine (Phenergan)
25. A client is on magnesium So4 therapy for severe pre-eclampsia. The nurse must be alert
for the first sign of an excessive blood magnesium level is:
a. Disturbance in sensorium
b. Increased in respiratory rate
c. Development of cardiac dysrhythmia
d. Disappearance of the knee-jerk reflex
26. Nurse would suspect an ectopic pregnancy if the client complained of:
a. An adherent painful ovarian mass
b. Lower abdominal cramping for a long period of time
c. Leukorrhea and dysuria a few days after the first missed period
d. Sharp lower right or left abdominal pain radiating to the shoulder
27. A client who has missed two menstrual cycle period comes to the prenatal clinic
complaining of vaginal bleeding and one-sided lower-quadrant pain. The nurse suspects
that this client has:
a. Abruptio placenta
b. An ectopic pregnancy
c. An incomplete abortion
d. A rupture of a Graafian follicle
SITUATION: Helen is arrived to the labor room and delivery area in labor. She complains of regular
uterine contractions with 8 to 10 minutes interval and states that her bag of water has been
ruptured. The fetus s in left occiput anterior position (LOA).
28. The nurse’s first action should be to:
a. Check the FHR
b. Start IV fluid as ordered
c. Call the physician
d. Place to a lying position
29. Which procedure would best determine if Helen’s BOW has ruptured?
a. A complete blood counts
b. Nitrazine paper test
c. Urinalysis
d. Vaginal examination
30. Initial assessment done and revealed following FH = 30cm, FHT = 145bpm, BP =
110/70mmHg. IE done by Dr. Zeus and revealed 4cm cervical dilatation. Helen asked for
Demerol. The nurse best response is:
a. “Try to wait until you really need it.”
b. “It is too early n your labor; medication will retard progress of uterine contraction.”
c. “I know you are in pain. I’ll just prepare your medication.”
d. “Perhaps a change in position will make you more comfortable.”
31. The pregnant women ask, “When does the heart and the brain of the baby form?” The
best response made by the nurse is:
a. First month
b. Second month
c. Third month
d. Fourth month
32. Fetal heart tone variability indicates:
a. Cord compression
b. Placental insufficiency
c. Fetal head compression
d. Hypoxia
33. Late deceleration indicates:
a. Cord compression
b. Placental insufficiency
c. Fetal head compression
d. Hypoxia
34. Early deceleration indicates:
a. Cord compression
b. Placental insufficiency
c. Fetal head compression
d. Hypoxia
35. Blood therapeutic level of magnesium So4?
a. 0.5 – 1.5 meq/l
b. 0.5 – 1 meq
c. 0.5 – 5 meq
d. 0.5 – 2 meq
36. When the client is only 15 years-old, the nurse caring for such client during labor process
should assess the client for signs of:
a. Uterine atony
b. Cephalo-pelvic disproportion
c. Rapid second stage labor
d. Early deceleration pattern
37. Due to hyperventilation, the nurse should assess the client for sign and symptoms of:
a. Metabolic alkalosis
b. Metabolic acidosis
c. Respiratory acidosis
d. Respiratory alkalosis
38. The client experiences severe back pain the nurse should instruct that her severe back
pain is cause by what fetal position?
a. Oblique
b. Transverse
c. Posterior
d. Anterior
39. The client calls out the nurse. “the baby is coming” the nurse first action is:
a. Inspect the perineum
b. Open the emergency delivery box
c. Auscultate the heart sounds
d. Contact the birth attendant
40. To help the client remain calm and cooperative during imminent delivery, the nurse
should tell the client:
a. “you are right the baby is coming”
b. “do you want to help me get you through this”
c. “your doctor will see you soon”
d. “I’ll explain what’s happening”
41. The nurse is caring to woman in active labor. Which information is most important to
assess in order to prevent the complication during labor and delivery?
a. Family history of lung illness
b. Food allergies
c. Number of cigarettes smoked per month
d. Last food intake
42. When the bag of water rupture’s the nurse should expect to see:
a. A large amount of bloody fluid
b. A moderate amount of clear to straw-colored
c. A small segment of umbilical cord
d. Greenish fluid
43. When bag of water rupture, the nurse first action is:
a. Notify the physician
b. Measure the amount of fluid
c. Monitor fetal heart tone
d. Perform vaginal examination
44. The client has midline episiotomy. The purpose of the episiotomy is:
a. Allow forcep to be applied
b. Enlarge the vaginal opening
c. Eliminate possibility of laceration
d. Eliminate the need for CS
45. Baby boy Anthony is under photo therapy, the nurse should;
a. Limit fluid intake
b. Cover infants’ eyes
c. Keep the baby covered with cloth
d. The light s 2 inches away from the baby
46. The neonate is post mature, the nurse should assess for symptom of:
a. Infection
b. Hypoglycemia
c. Delayed meconium
d. Elevated bilirubin
47. When assessing post-term neonate, the nurse anticipates that the neonate will have:
a. Flat nose
b. Small hands and feet
c. A red rash n the abdomen
d. Wrinkled and peeling skin
48. A primiparous client who is bottle feeding her baby. Ask, “when should I start giving the
baby solid foods?” the reply would be:
a. 2 months of age
b. 6 months of age
c. 8 months of age
d. 10 months of age
49. In collecting abreast milk, how many months should a milk stored in freezer?
a. 2 months
b. 3 months
c. 4 months
d. 6 months
50. What type of container should be use in storing the expressed breast milk?
a. Stainless
b. Rubber
c. Latex
d. Plastic
51. To determine the date of confinement, the nurse should assess:
a. Fundic height
b. Date of last intercourse
c. Last menstrual period
d. Age of menarche
52. When discovering prolapse cord, the nurse anticipates that the client’s delivery is:
a. CS
b. Induced with oxytocin
c. Vaginal birth with forcep
d. Postponed as possible
53. The nurse prepares a client with a rupture’s tubal pregnancy for immediate surgery. The
nurse understands that the informed consent will have to include permission for?
a. Myomectomy
b. Hysterectomy
c. Salphingectomy
d. D/C
54. A client with a history of rheumatic heart disease as admitted in early labor. The nurse
should encourage this client to assume:
a. Supine
b. Semi-fowlers
c. Trendelenburg
d. Left lateral
55. A client who has just began breastfeeding for newborn complains that her nipples feel
very sore. The mother should be encouraged to;
a. Apply continuous ice packs to her breast
b. Take the analgesic medication as ordered
c. Remove the baby from the breast for few days to rest the nipples
d. Apply warm compress
56. The nurse assess the newborn using the Apgar score. At one minute after birth the baby
has a heart rate of 120, slow and irregular respiration, weak cry, some flexion of
extremities and pink body with blue extremities. The one-minute Apgar score should be
recorded as:
a. 5
b. 6
c. 7
d. 8
57. A 16-year-old primipara, at 32 weeks gestation, is admitted to the hospital. Her blood
pressure is 170/110mmHg and she has +4 proteinuria. She has gained 50 pounds during
pregnancy and her face and extremities are edematous. The nurse assess that client
probably has:
a. Eclampsia
b. Mild pre-eclampsia
c. Severe pre-eclampsia
d. Chronic hypertensive disease
58. A client arrives n the birthing room with the fetal head crowning. The nurse recognizes
that birth is imminent and tells the client to:
a. Push with all her power
b. Use pant blowing
c. Assume Trendelenburg position
d. Hold her breath and turn to left side
59. A new mother is inspecting her baby girl for the first time. The baby breast re swollen and
there is a red vaginal discharge. When the mother asks what is wrong the nurse should
a. Your baby appears to have problem
b. I do not see any unusual, what exactly do you see on the baby
c. It is nothing to worry about. The swelling and discharge will go away
d. The swelling and discharge are expected and normal
60. A 17-year-old client tells the nurse that her sister had an ectopic pregnancy about three
months ago and had to have her tube removed. The nurse knows that this young woman
needs further explanation when she states:
a. I guess I’ll have to wait awhile to become aunt
b. This kind of thing can happen to my sister again
c. This kind of thing can happen after pelvic infection
d. My sister is lucky because she’ll never have a period again
61. Epidural anesthesia is administered to a client. A primary responsibility of the nurse is to
assess for:
a. Tachycardia
b. Hypotension
c. Decreases urinary output
d. Precipitous second stage of labor
62. Large for gestational age infant of a diabetic mother should be assesses for:
a. The presence of Mongolian spot
b. A blood sugar level less than 40
c. A body temperature less than 184f
d. Elevated bilirubin level in the first 24 hours
63. While a client is receiving IV magnesium so4 for pre-eclampsia, a primary nursing
intervention would be:
a. Limiting her fluid intake to 1000ml per 24 hours
b. Preparing for the possibility of precipitate labor
c. Restricting visitors and keeping the room darkened and quiet
d. Obtaining magnesium gluconate for use as an antagonist of necessary
64. A few weeks after discharge, a postpartum client develops mastitis and telephones for
advice concerning breastfeeding. The nurse should tell the client to:
a. Start to wean the baby from the breast to reduce the pain
b. Get an antibiotic from the physician and start formula feedings
c. Pump her breast and wear tight feeding bra to suppress milk production
d. Breastfeed often because this will keep the breast empty and reduce the pain
65. A client had a blood pressure of 90/50 during her first visit to the pre-natal clinic. At 34
weeks gestation her blood pressure is now 120/76, the nurse recognizes that this can
occur because of:
a. The possible development of pre-eclampsia
b. The development of essential hypertension
c. An increase stroke volume during pregnancy
d. An expected rise in blood pressure as pregnancy progresses
66. At a pre-natal visit at weeks gestation, a client complains or discomfort with irregular
contraction. The nurse instructs the client to:
a. Lie down until they stop
b. Walk around
c. Time the contraction
d. Take aspirin
67. During the vaginal examination, the doctor palpates the fetal head a large diamond
shaped fontanel, based on this assessment, the nurse knows that the fetal presentation
would be:
a. Face
b. Transverse
c. Vertex
d. Brow
68. During augmentation of labor with intravenous oxytocin, a multiparous client becomes
pale and diaphoretic and complains of severe lower abdominal pain with a tearing
sensation. Fetal distress s noted on the monitor. The nurse should suspect:
a. Precipitate labor
b. Amniotic fluid embolus
c. Rupture of uterus
d. Uterine prolapsed
69. Transmission of HIV from an infected person to another is:
a. Most frequently in nurses with needle stick injury
b. Only if there is a large viral load in the blood
c. Most commonly as a result of sexual contact
d. In all infants born to woman with HIV infection
70. After vaginal examination, the nurse determines that the client fetus is in occiput
posterior position. The nurse would anticipate that the client will have:
a. A precipitous birth
b. Intense back pain
c. Frequent leg cramps
d. Nausea and vomiting
71. Placenta is combination of what structure?
a. Decidua capsularis and blastocyst
b. Decidua vera and tropoblast
c. Decidua basalis and tropoblast
d. Decidua capsularis and tropoblast
72. Madel is instructing another pregnant client regarding measure to increases the source
of iron from the diet. She tells the client to consume which food that contains the highest
source of daily iron?
a. Milk
b. Dark green leafy vegetables
c. Potatoes
d. Ampalaya
73. The client experiences urinary retention with overflow, the nurse should instruct the
client to perform what exercise.
a. Swimming
b. Pelvic raking
c. Kegel’s exercise
d. Walking
74. The nurse is checking a laboring client, her assessment reveals the head at +3 station.
What will the nurse do?
a. Prepare for delivery of the baby
b. Administer oxygen
c. Determine if contraction is increasing
d. Determine FHT
75. The nurse would identify which situation as an indication for the administration Rhogam?
a. A woman who is Rh+
b. Woman on prolonged labor
c. Woman with endometritis
d. Abortion
76. Julie, a pregnant adolescent client asks the nurse about the menstrual cycle. The nurse
describes the cycle and tells the adolescent that its normal durations is:
a. 14 days
b. 28 days
c. 30 days
d. 45 days
77. Liza, a multi gravida woman ask the nurse in the clinic when she will be able to start the
fetus moving, the nurse correct response would be:
a. 6-8 weeks
b. 10-12 weeks
c. 14-16 weeks
d. 24-30 weeks
78. Nurse Leda is providing instruction to a pregnant woman regarding measure that will
assist in alleviating heartburn, which statement of the client indicates understanding of
these measures?
a. “I would le down for an hour after eating”
b. “I should avoid between meal snack”
c. “I should eat more spicy food”
d. “I should avoid eating gas-forming food”
79. A primigravida client is experiencing Braxton-hick’s contraction. Which statement is true
concerning this type of contraction?
a. Intensified by walking
b. Confined to low back
c. Do not increase in intensity and frequency
d. Cervical effacement and dilation occur
80. Which statement would the nurse make to the client about strae gravidarum?
a. Occur in all pregnancy
b. Are silvery streaks that appears especially at late period of pregnancy
c. Can be decrease by application of cocoa
d. Will fade from reddish to silvery color streaks
81. Lecithin-salphingomyelin exam is done to determine maturity of what organ?
a. Liver
b. Lungs
c. Testes
d. Spleen
82. The nurse is aware that the nausea and vomiting commonly experienced by many
women during the first trimester of pregnancy is an adaptation to the increase level of:
a. Estrogen
b. Progesterone
c. Human chorionic gonadotropin
d. Human placental lactogen
83. A client who is 10 weeks pregnant calls the clinic and complains of morning sickness. To
promote relief, the nurse should suggest:
a. Eating dry toast cracker
b. Increase fat intake
c. Have 2 small meals everyday
d. Give spicy food
84. A pregnant client asks the nurse about the effect of smoking on pregnancy
a. The placenta is impermeable to nicotine
b. Smoking relieves tension
c. Vasoconstriction will impair circulation
d. It has no effect to pregnancy
85. The nurse is caring to a client with placenta previa. The nurse reviews the physician order
and would question which order?
a. Prepare client for ultrasound
b. Obtain equipment for internal examination
c. Prepare to draw blood sample
d. Monitor FHT
86. Couples who visit infertility clinic have the following need, which is the priority?
a. Education about reproduction
b. Determine who between them is infertile
c. Counseling to help them maximize their potential
d. Knowledge about the procedure necessary to diagnose infertile
87. What could be the primary nursing diagnosis for easy fatigability
a. Pain
b. Disturbance in role performance
c. Activity intolerance
d. Self-care deficit
88. Which of the following food will you advise to relieve leg cramps?
a. Mongo, cheese, dilis, sardines
b. Petchay
c. Nut, legumes
d. Rise and bread
89. The lochia during the first 3 days post-partum
a. Rubra
b. Serosa
c. Alba
d. Alca
90. What is the important nursing action when assisting the doctor with pelvic examination?
a. Instruct the client to douche before exam
b. Explain to the client that she will not pain
c. Have the client empty the bladder
d. Position on dorsal recumbent
91. A client n labor has been pushing effectively for 2 hours. A nurse determines that the
client’s primary physiologic need at this time is to:
a. Ambulate
b. Rest between contraction
c. Change position frequently
d. Consume oral food or fluid
92. The nurse determines that the client is beginning the second stage of labor when which
of the following assessment is noted?
a. Contractions are regular
b. Membranes are ruptured
c. Cervix is dilated completely
d. The client begins to expel clear vaginal fluid
93. A nurse performing assessment of the client who is scheduled for cesarean section.
Which assessment finding would indicate a need to contact a doctor immediately?
a. Hemoglobin 11g/l
b. FHT of 180 bpm
c. Maternal pulse of 85 bpm
d. WBC of 12,000/mm3
94. A nurse is caring a mother who is receiving oxytocin by intravenously. Which assessment
finding indicated that infusion must be stop?
a. Contraction every 2 minutes
b. Duration of 90 seconds
c. FHT of 90 bpm
d. All of the above
95. A nurse is caring for a client in labor and is monitoring the fetal heart tone. The nurse
notes that presence of episodic deceleration during uterine contraction
a. Notify the physician
b. Reposition the mother
c. Document the findings
d. Administer oxygen
96. When primigravida is in the active labor the patient may be taken to delivery room when:
a. Cervix is fully dilated
b. Bag of water ruptures
c. Cervical effacement occurs
d. Transition phase occurs
97. The nurse should Mona who suffers from vaginal bleeding to:
a. Take laxative so that she does not strain at stool
b. Save all perineal pads
c. Call the clinic when the bleeding stops
d. Record fluid intake and urinary output
98. The nurse assesses the labor contraction by describing all of the following except:
a. Duration
b. Intensity
c. Frequency
d. Location
99. The post-partum mother asks the nurse about when should coitus can be resumed.
a. 48 hours
b. 2 weeks
c. 1 week
d. 6 weeks
100. Folic acid supplement is required during pregnancy to prevent:
a. Anemia
b. Neural tube defect
c. Cranio facial deformity
d. Down syndrome

SITUATION: Because pregnancy I a physiologic process, the health sector aims to make pregnancy
for the women and gestation for the fetus as safe and medically uneventful as far as possible.
101. The 2000 Philippine Health Statistics revealed that the main cause of reported maternal
deaths is due to:
a. Postpartum hemorrhage
b. Pregnancy with abortive outcomes
c. Hypertension
d. None of the above
102. Every woman has the right to visit the nearest health care facility for antenatal
registration and to avail prenatal care services. How often should the expectant mother
visit the health center when she is on her 8th month of pregnancy?
a. Every other day after the 8th month of pregnancy till delivery
b. Every other week at 8th month of pregnancy till delivery
c. Every two weeks after the 8th month of pregnancy till delivery
d. None of the above
103. Tetanus toxoid vaccination is important for pregnant women and child bearing women
to prevent them and their baby from acquiring tetanus. How many doses of Tetanus
Toxoid vaccine should be given to the mother in order to protect the baby from acquiring
neonatal tetanus?
a. One dose
b. Two doses
c. Three doses
d. Four doses
104. How many doses of tetanus toxoid vaccine are needed to protect a mother and her
baby against the disease, during her pregnancy and for lifetime immunity?
a. Three doses
b. Four doses
c. Five doses
d. Six doses
105. A pregnant woman with hypertension is suffering from postpartum hemorrhage. The
following are the first aid measures to be done by the community health nurse, except:
a. Massage uterus and expel clots
b. Give Ergometrine 0.2 mg IM and another dose after 15 minutes
c. Placed cupped palmed hands on the uterine fundus and feel for the state of
d. Apply bimanual uterine compression if postpartum bleeding still persists
106. The community health nurse should give supportive care to the pregnant mother during
labor. The nurse should do the following, except:
a. Encourage the mother to take a bath during the onset of labor
b. Encourage the mother to drink and eat when she feels hungry
c. Remind the mother to empty the bladder every 2 hours
d. Encourage the mother to do breathing exercises for her to have energy in pushing
the baby out of her birth canal
107. The nurse should assess the progress of labor. She knows that the pregnant woman is in
false labor if:
a. The cervix is dilated 4 cm
b. There is an increase in contraction
c. The membranes are not ruptured
d. All of the above
108. The community nurse should counsel the mother of the recommended schedule of her
first postpartum visit, which is:
a. 3-5 days after delivery
b. 6 weeks after delivery
c. A day after delivery
d. 3 weeks after delivery
109. During family planning counseling sessions, the nurse should include which topic in the
a. Birth control methods
b. Birth spacing
c. Ideal number of children
d. All of the above
110. It is the nurse’s responsibility to give the couple enough information about the different
methods of contraception. What are the factors that should be considered in method
a. The age of the woman
b. The woman’s reproductive stage
c. The effectiveness of a method
d. All of the above
111. A population pyramid is a graphical illustration that shows the distribution of various age
groups in a human population which normally forms the shape of a pyramid. A
population pyramid with a broad base indicates:
a. Higher proportion of children and a low proportion of older people
b. Higher proportion of older people and a low proportion of children
c. Higher female populations
d. Higher male populations
112. A mother who wishes to use Lactation Amenorrhea method as a form of family planning
method should be instructed:
a. To use other forms of FP methods for 3 months
b. About the potential side effects
c. To wait for at least 1 moth to be more effective as a FP method
d. Alternate breastfeeding with formula feeling to be more effective
113. In providing guidance for a couple wishing to avoid pregnancy, the nurse reviews the
record of a client who has a normal 29-day cycle. On which of the following days would
the nurse expect the client to ovulate?
a. Day 5 or 6
b. Day 13 or 14
c. Day 15 or 16
d. Day 28 or 29
114. A client who is taking oral contraceptives should immediately report which symptoms
associated with the adverse effect of OC’s?
a. Blurred vision
b. Nausea
c. Breakthrough bleeding
d. Breast tenderness
115. A mother asks Nurse Basyang about subcutaneous implants and how long will the
implants be effective. Her best response is:
a. “It is effective for one month.”
b. “It is effective for 12 months.”
c. “It is effective up to 5 years.”
d. “It is effective for 10 years.”
116. A client who gave birth to a healthy 8-pound infant 3 hours ago is admitted to the
postpartum unit. Which nursing plan is best in assisting this mother to bond with her
newborn infant?
a. Encourage the mother to provide total care for her infant.
b. Provide privacy so the mother can develop a relationship with the infant.
c. Encourage the father to provide most of the infant’s care during hospitalization.
d. Meet the mother’s physical needs demonstrate warmth towards the infant.
117. Which maternal behavior is the nurse most likely to see when a new mother receives
her infant for the first time?
a. She eagerly reaches for the infant, undresses the infant, and examines the infant
b. Her arms and hands receive the infant and she then trace the infant’s profile with her
c. Her arms and hands receive the infant and she then cuddle the infant to her own
d. She eagerly reaches for the infant and then holds the infant close to her own body.
118. A client who s attending antepartum classes asks the nurse why her health care provider
has prescribed iron tablets. The nurse’s response is based on what knowledge?
a. Supplementary iron is more efficiently utilized during pregnancy
b. It is difficult to consume 18 mg of additional iron by diet alone
c. Iron absorption is decreased in the GI tract during pregnancy
d. Iron is needed to prevent megaloblastic anemia n the last trimester
119. When educating a pregnant client about home safety, which of the following
information is least appropriate for the nurse to include in the teaching plan?
a. When taking a shower, place a non-skid mat on the floor of the tub or shower
b. Avoid climbing stairs
c. Avoid wearing high heels
d. Use non-slip rugs on the floor
120. A woman comes to the health clinic because she thinks she is pregnant. Tests are
performed and the pregnancy is confirmed. The client’s last menstrual period began on
September 8 and lasted for 6 days. The nurse calculates that her expected date of
confinement (EDC) is:
a. May 15
b. June 15
c. June 21
d. July 8
121. A woman comes to the clinic for routine pre-natal check up at 34 weeks gestation.
Abdominal palpitation reveals the fetal position as right occipital anterior (ROA). At which
of the following sites would the nurse expect to find the fetal heart tone?
a. Below the umbilicus, on the mother’s left side
b. Below the umbilicus, on the mother’s right side
c. Above the umbilicus, on the mother’s left side
d. Above the umbilicus, on the mother’s right side
122. Mrs. Dimaano complains about her morning sickness. The nurse provides health
teachings to the client. Which of the following statements made by the client indicates a
need for further instruction by the nurse?
a. “I will avoid spicy or fatty foods.”
b. “I will postpone eating until supper.”
c. “I will eat small frequent feeding.”
d. “I will eat crackers and dry toast before arising.”
123. Nurse Mian is preparing to assist in performing Leopold’s maneuver to a pregnant client.
Which of the following should the nurse include n preparing the client for this
a. Tell the client to drink a glass of water before the procedure
b. Locate the fetal heart tones
c. Tell the client to void before beginning examination
d. Advise the client not to eat anything 4 hours before the exam
124. Mrs. Makiss is scheduled for a non-stress test. After the test, the result documented on
the chart is no accelerations during the 40-minute observation. The nurse interprets
these findings as:
a. A reactive stress test
b. A nonreactive stress test
c. An unsatisfactory stress test
d. The result are inconclusive
125. Another client had a nonstress tests for the past few weeks and the result were reactive.
A few minutes ago, the results were nonreactive. The nurse anticipates that the client will
be prepared for:
a. A return appointment in 2 to 7 days to repeat the nonstress test
b. A contraction stress test
c. Hospital admission with continuous fetal monitoring
d. Immediate induction of labor
126. A pregnant woman s having contraction stress test (CST) performed. Which of the
following shows a negative test result?
a. 50% or more contractions cause a late deceleration
b. No FHR decelerations occur with contractions
c. Decrease in FHR that occurs towards the end of a contraction and continues after the
d. All of the options indicate a negative result
127. During her first trimester, a woman experiences many physiologic changes that lead her
to think she is pregnant. Which of the following changes will the nurse likely tell her are
normal changes for an 8-week pregnancy?
a. Dysuria
b. Colostrum secretion
c. Nosebleeds
d. Dependent edema
128. Following her baby’s birth, the women’s uterine fundus is soft, midline, 2 cm above the
umbilicus, and she has saturated two pads within 30 minutes. Which immediate need by
the client should be addressed?
a. Be cleaned and have another pad change
b. Empty her bladder.
c. Have an increase in her IV fluids of Ringer’s Lactate
d. Have her fundus massaged
129. Nurse Junifer is caring for a woman who is having labor induced with an oxytocin
(Pitocin) drip. Which assessment of the client indicates there is a problem?
a. The fetal heart rate is 160 bpm
b. The woman has three contractions in 5 minutes
c. Contraction duration is 60 seconds
d. Early fetal rate decelerations are occurring
130. Mrs. Fortalejo is in labor and taking three cleansing breaths followed by four, slow, deep
breaths with each contraction. She is experiencing much discomfort with her
contractions. What is most appropriate for the nurse to take?
a. Demonstrate to Mrs. Fortalejo a different breathing pattern during contraction
b. Ask the physician for an order of pain medication
c. Have the man take a break and instruct Mrs. Fortalejo in another breathing pattern
d. Leave the couple alone as they have their routine established
131. Nurse Kristine is teaching childbirth education classes. What topic should be included
during the second trimester?
a. Overview of the conception
b. Medication and breastfeeding
c. Infant care
d. Strategies to relieve the discomforts of pregnancy
132. Nurse Esther is caring for a woman in labor who suddenly complains of dizziness,
becomes pale, and has 30-point drop in her BP with an increase in pulse rate. What is the
most appropriate initial nursing action?
a. Turn her to her left side
b. Have her breath into a paper bag
c. Notify her physician
d. Increase her IV fluids
133. A woman is 25% over her ideal weight of 140 pounds. She would like to lose weight
before becoming pregnant. The woman is 2 months into her weight loss program. Which
indicates she is following proper weight management principles?
a. Carefully selects only carbohydrate and fat choices for meals
b. Has lost a total of 4 pounds
c. Is now 5% over her ideal weight
d. Goes to beginning aerobics for three times a week
134. A 38-week primigravida who works as a secretary and sits at a computer 8 hours each
day tells the nurse that her feet have began to swell. Which instruction would be most
effective in preventing pooling of blood in the lower extremities?
a. Wear support stockings
b. Reduce salt in her diet
c. Move about every hour
d. Avoid constrictive clothing
135. A client receiving epidural anesthesia begins to experience nausea and becomes pale
and clammy. What intervention should the nurse implement first?
a. Raise the foot of the bed
b. Assess for vaginal bleeding
c. Evaluate the fetal heart rate
d. Take the client’s blood pressure
136. A 34-week pregnant client calls the clinic complaining of severe headache, blurred
vision, and swollen feet. The nurse expects the physician to tell the client to:
a. Have it checked in the hospital
b. Come to the clinic tomorrow morning
c. Decrease salt intake and increase fluids
d. Rest for 4 hours a day for 3 days and come to the clinic if symptoms persist
137. Nurse Grasya went to give her morning care to a postpartum mother, she observed the
mother talking to the baby, checking diaper, and asking infant care questions. Nurse
Grasya determines that the client is in which post-partal phase of psychological
a. Taking in
b. Taking on
c. Taking hold
d. Letting go
138. During an initial pre-natal visit, a pregnant client states she has had 2 miscarriages at 12
weeks and 13 weeks, one child delivered at 38 weeks, and another child delivered at 40
weeks. The nurse document this as:
a. G4P2/T2A2
b. G3P3/T2A1
c. G3P2/T2A2
d. G4P3T3A0
139. A woman who is 24-hours post-partum and who has an episiotomy would be instructed
to report which of the following findings immediately?
a. Decrease in urine output
b. Absence of daily bowel movement
c. Presence of lochia rubra
d. Increase in perineal pain sensation
140. A client in active labor is admitted with pre-eclampsia. Which assessment finding is most
significant in planning this client’s care?
a. Patellar reflex 4+
b. Blood pressure 158/80
c. Four-hour urine output 240 ml
d. Respiration 12/minute
141. When explaining “post-partum blues” to a client who is 1-day post-partum, which
symptoms should the nurse include in the teaching plan?
1. Mood swings
2. Panic attacks
3. Tearfulness
4. Decreased need for sleep
5. Disinterest in the infant
a. 1 and 3
b. 1, 3, 4
c. All except 2
d. All of the above
142. A primigravida client with severe pre-eclampsia is receiving magnesium sulfate via
continuous IV infusion. Which assessment data indicates to the nurse that the client is
experiencing magnesium sulfate toxicity?
a. Deep tendon reflexes 2+
b. Blood pressure 140/90
c. Respiratory rate 18/minute
d. Urine output 90ml/4 hours
143. A woman with severe PIH was delivered 2 hours ago. Which nursing action should be
included in the plan of are for her post-partum hospital stay?
a. Continuing to monitor blood pressure, respirations and reflexes
b. Encouraging frequent family visits
c. Keeping her NPO
d. Maintain an Iv access to the circulatory system
144. Discharge instructions are given to a woman who had been admitted with placenta
previa. Which statement by the client to her husband best demonstrates she
understands the teaching?
a. “We can’t have sex.”
b. “I have to return n a few days for a vaginal exam.”
c. “I will have to have a caesarian delivery for this and other pregnancies.”
d. “I can go back to part-time work beginning tomorrow.”
145. The nurse s caring for a woman who is 35 weeks pregnant. She comes to the emergency
room with painless, vaginal bleeding. This is her third pregnancy and she states that this
has never happened before. What would be avoided in caring for this client?
a. Allowing her husband to stay with her
b. Keeping her at rest
c. Shaving the perineum
d. Performing vaginal examination
146. Nurse Hannah is caring for a woman with placenta previa who has been hospitalized for
several weeks. She is now at 38-weeks gestation and her membranes have ruptured. The
amniotic fluid has a greenish color and the woman has started to bleed again. What
would the nurse first action?
a. Administer oxygen
b. Place her in Trendelenburg position
c. Call the doctor and prepare for a caesarian birth
d. Move her to the delivery room immediately
SITUATION: Nursing process always must be implemented with an awareness of the
interrelationship, during child bearing, of the maternal and fetal needs and their manifestations.
The nurse needs to keep in mind that interventions for the mother may have an impact on the
developing fetus and vice versa.
147. Knowledge of sexual functioning is defined as the extent of understanding conveyed
about sexual development and responsible sexual practices. The following are specific
indicators that suggest that this outcome has been achieved except:
a. Ability of the client to describe effective contraception
b. The client was able to describe the societal influences on sexual behavior
c. The client was able to describe the inner sense of his/her identity
d. The client was able to describe measures to prevent sexually transmitted diseases
148. To preserve the reproductive health of the woman and man, guidelines for safer sex
practices were established. Which of the following statements is not included?
a. The use of condom is the best protection against infection. Condoms are latex, use
oil-based lubricant rather than water-based lubricant because it can weaken the
b. Be selective in choosing sexual partners
c. For safer oral-vaginal sex, a condom split in two or a plastic dental dam covering the
mouth should be used to protect against the exchange of body fluids
d. Use condom every sexual intercourse
149. A 22-year old woman has missed two of her regular menstrual periods. Her doctor
confirms an early, intrauterine pregnancy. To determine her expected due date, which of
the following assessments is more important?
a. Date of her first menstrual period
b. Date of sexual intercourse
c. Date of last normal menstrual period
d. Age of menarche
150. A primigravida client asks Nurse Isabelle how the action of hormones during pregnancy
affects her body. Nurse Isabelle responds on the basis that hormones:
a. Raise resistance to insulin
b. Blocks the release f insulin form the pancreas
c. Prevents the liver form metabolizing glycogen
d. Enhances the conversion of food to glucose
151. Nurse Hannah s caring for a young diabetic woman who is in her first trimester of
pregnancy. As the pregnancy continues Nurse Hannah should anticipate which change in
her medication needs?
a. A decrease in the need for short-acting insulin
b. A steady increase in insulin requirements
c. Oral hypoglycemic drugs will be given several times daily
d. The variable pattern of insulin absorption throughout the pregnancy requires
constant adjustment
152. Maricar asks Nurse Sarah at what of gestation is the product of conception prone to
teratogenic insults to the cardiovascular system?
a. 4th week
b. 8th week
c. 12th week
d. 16th week
153. Nurse Mian discusses the fetal circulation to the students. To check whether the student
understands her teaching she asks, “What s the fetal structure that carries oxygenated
blood from the umbilical cord to the inferior vena cava.” The student correctly answers,
“It is the:
a. Ductus venosus
b. Ductus arteriosus
c. Pulmonary artery
d. Formane ovale
154. The day after the client has caesarian birth, the indwelling catheter is removed. The
nurse can best evaluate that the client’s urinary function has returned to normal when:
a. Client’s urinalysis indicates no bacteria present
b. Client has residual urine of 90 ml after voiding
c. Client’s daily urinary output is at least 1000 ml
d. Client voids at least 300 ml four hours after catheter removal
155. A nurse is working with a particular cultural group in which it is not uncommon for
grandparents to live with their married children and to assist with child rearing and
discipline issues. This is an example of which of the following?
a. Blended family
b. Traditional family
c. Two-career family
d. Intragenerational family
156. Nurse Isabel is conducting a family assessment to a pregnant client and asks the
following question: “How, as a family, do you deal with disappointments or stressful
changes that occur and affect the members of your family?” the nurse s trying to identify:
a. Health beliefs
b. Family communication patterns
c. Family coping mechanism
d. Potential family problems
157. Regardless of whether someone is planning on childbearing, everyone is wiser by being
familiar with reproductive anatomy and physiology and his or her own body’s
reproductive and sexual health. Which of the following is true about the reproductive
a. Male and female reproductive system arise form the same embryonic origin
b. The sex of an individual is determined 10 weeks after conception
c. If testosterone is not present at 5 weeks, the gonadal tissue differentiates not ovaries
d. Estrogen influences the enlargement of the labia majora and clitoris
158. During the secretory phase of menstrual cycle, the glands of the uterine endometrium
becomes corkscrew in appearance and dilated with quantities of glycogen and mucin.
This activity is stimulated by which hormone?
a. Progesterone
b. Estrogen
c. Glycogen
d. Prolactin
159. A client expresses concern about his son who is a homosexual. He states, “Nag-aalala
ako sa kanya, alam ko sa impyerno and tuloy niya.” In responding to this client, the nurse
should consider which of the following important information?
a. Sexual development is genetically determined and not affected by environment
b. What constitutes normal sexual expression varies among cultures and religions
c. Normal sexuality is described as whatever behaviors give pleasure and satisfaction to
those adults involved
d. Since alternative lifestyles are now so well accepted in society, this parent should not
feel so much concern
160. The nurse working in a family planning clinic is aware that oral contraceptives are not
contraindicated for which of the following patients?
a. A 30-year old woman who smoke more that 15 cigarettes a day
b. A 30-year old diabetic woman
c. A 10-week postpartum client who is not breastfeeding
d. A client who experiences migraine with aura
161. An intrauterine device is being fitted to a client. The nurse understands that IUD
prevents pregnancy by:
a. Creating a sterile inflammatory process that prevents implantation
b. Suppressing secretion of FSH and LH
c. Blocking fallopian tube to prevent entry of the ovum
d. Killing the spermatozoa before they can enter the cervix
162. The nurse will advise a pregnant client, who is scheduled for amniocentesis, to perform
which of the following?
a. Increase the fluid intake to help aspirate more amniotic fluid during the procedure
b. Lie in side lying-position to avoid supine hypotension during the procedure
c. Ask the client to take a deep breath and hold it during insertion of needle
d. Ret for 30 minutes after the procedure
163. A high-risk pregnant client will go through a non-tress test. The result indicates a
reactive non-stress test. The client asks the nurse what it means. The nurse aptly replies
by saying:
a. “The fetus is receiving adequate oxygen.”
b. “The fetal heart rate is decreasing, instead of increasing, with every contraction.”
c. “There is no fetal movement during stimulation.”
d. “You are at risk for premature labor; the doctor may prescribe tocolytic drug.”
164. Which f the following common emotional reactions to pregnancy would the nurse
expect to occur during the first trimester?
a. Introversion, egocentrism, narcissism
b. Awkwardness, clumsiness, and unattractiveness
c. Anxiety, passivity, extroversion
d. Ambivalence, fear, fantasies
165. Which of the following statements, if made by a woman who is 12 weeks pregnant,
would be essential for a nurse to further evaluate?
a. “I thought I wanted to be pregnant, but now I don’t know.”
b. “My husband is angry because got pregnant.”
c. “Being pregnant makes me feel very tired.”
d. “I don’t want t get too fat while I’m pregnant.”
SITUATION: Today’s pediatric nurse faces an array of challenges in providing care for their
children and families. A nurse requires competent skills form wide spectrum of both
technological and psychosocial disciplines.
166. Nurse Hannah is assessing a healthy neonate upon admission to the nursery. Which
characteristic would the admitting nurse record as normal?
a. Hypertonia
b. Irregular respiratory rate of 50 bpm
c. Head circumference measuring 31 cm
d. High-pitched or shrill cry
167. The nurse is caring for a child with hemophilia who is actively bleeding. Which nursing
action is most important in the prevention of the crippling effects of bleeding?
a. Active range of motion
b. Avoidance of all dental care
c. Encourage genetic counseling
d. Elevate and immobilize the affected extremity
168. An infant is being treated for talipes equinovarus. Which statement by the child’s
mother indicates the best understanding of the casting process?
a. “My child will have successive casts until the desired result are achieved.”
b. “Wearing cast is very painful, so I’ll need to medicate her every 4 hours.”
c. “Once the cast is on, it will remain on until the deformity is corrected.”
d. “My child will be immobilized and confined to an infant seat.”
169. A young child is admitted with acute epiglottitis. Which is of the highest priority as the
nurse plans care?
a. Assessing the airway frequently
b. Turning, coughing, and deep breathing
c. Administering cough medicine as ordered
d. Encouraging the child to eat
170. A young child with high bronchial asthma is admitted for the second time in 1 month.
Cystic fibrosis is suspected. Which physiological assessment is most likely to be seen in
the child with cystic fibrosis?
a. Expectoration of large amount of thin, frothy mucus with coughing, and bubbling
rhonchi for lung sounds
b. High serum NaCl levels and low NaCl levels in the sweat
c. Large, loose, foul-smelling stools with normal frequency of a chronic diarrhea of
unformed stools
d. Obesity from malabsorption of fats and polycythemia form poor oxygenation of
171. Which finding would alert the nurse to potential problems in a newly delivered term
infant of a mother whose blood type is O negative?
a. Jaundice
b. Negative direct Coombs
c. Infant’s blood type is O negative
d. Resting heart rate is 155 bpm
172. A 10-year old child is admitted to the hospital with sickle cell crisis. Which client goal is
most appropriate for this child?
a. The client will participate in daily aerobic exercises
b. The client will take an antibiotic until the temperature is within normal limits
c. The client will increase fluid intake
d. The client will utilize cold compress to control pain
173. The nurse has been instructing the parents of a toddler about nutrition. Which of the
following statements best indicates the parents’ understanding of an appropriate diet for
a toddler?
a. “It’s unusual to be a picky eater.”
b. “A multivitamin each day will meet my child’s nutritional needs.”
c. “Toddler needs serving s from each food group daily.”
d. “Toddlers should still be eating prepared junior foods.”
174. A child has cerebral palsy and is hospitalized for corrective surgery for muscle
contractures. What is the most important immediate post-operative goal?
a. Ambulate using adaptive devices
b. Demonstrate optimal oxygenation
c. Verbalize pain control
d. Complete daily self-care needs
175. The nurse is teaching the parents of a child who is being treated in clinic for otitis media.
Which of the following statements is essential to include in the teaching?
a. “Do not take acetaminophen as this is contraindicated.”
b. “Take the medication until the pain and fever are gone.”
c. “Do not apply heat to the ear.”
d. “take all of the medications as ordered.”
176. The nurse is assessing a newborn 5 minutes after birth. He has full extension of the
extremities, is acrocyanotic, has a heart rate of 124, a full, lust cry, and resist the suction
catheter. The nurse should record the Apgar score as:
a. 6
b. 7
c. 8
d. 9
177. The mother of a newborn learns that her infant son hast lost 8 oz since birth 2 days ago.
The nurse explains that this weight loss is normal. What explanation will the nurse
provide for the weight loss result?
a. Feeding infants every 4 hours instead of every 3 hours
b. Loss of fluid from the cord stump
c. Limited food intake since birth
d. Regurgitation of feedings
178. A 4-week old premature infant has been receiving epoetin alfa (Epogen) for the last 3
weeks. Which assessment findings indicates to the nurse that the drug is effective?
a. Slowly increasing urinary output over the last week
b. Respiratory rate changes form the 40s to the 60s
c. Changes in apical heart rate from the 180s to the 140s
d. Changes in indirect bilirubin from 12 mg/dl to 8 mg/dl
179. Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant
warmer. The infant has spontaneous respirations and the nurse assesses an apical heart
rate of 80 beats/minute and respiration of 20 breaths/minute. What action should the
nurse perform next?
a. Initiate positive pressure ventilation
b. Intervene after the one-minute Apgar is assessed
c. Initiate CPR on the infant
d. Assess the infant’s blood glucose level
180. A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The
nurse knows that the most likely presenting symptoms for a pediatric client with AIDS is:
a. Shortness of breath
b. Joint pain
c. A persistent cold
d. Organomegaly
181. The nurse in a well-baby clinic is assessing a 12-month old child. He is 30 inches tall and
weighs 30 lbs. his birth weight is 8 lbs. how does the nurse interpret this data?
a. Normal height, increased weight
b. Normal height, decreased weight
c. Small for age, normal weight
d. Tall for age, but weight appropriate for height
182. The mother of an infant who has had a cleft lip repair has been taught he post-operative
care needed. What does the nurse hope to see when evaluating this mother’s
understanding of this care?
a. Positioning the child on his abdomen to facilitate drainage of oral secretions
b. Comforting the child as soon as he starts to fuss, to prevent his crying
c. Using a regular bottle nipple to feed the infant in a semi-reclining position
d. Cleaning the suture line with warm water and washcloth once a day
183. A 37- week gestation neonate has been born to a woman with insulin-dependent
diabetes mellitus and is admitted to the nursery. Which of the following is most essential
when planning immediate care for the infant?
a. Glucose monitoring
b. Daily weights
c. Supplemental formula feeding
d. An apnea monitor
184. A newborn who is being cared for in an open warming unit has an axillary temperature
of 96.2 deg F (35.7 deg C). it is essential that the nurse take which of the following
a. Wrap the newborn in a blanket
b. Notify the parents for the findings
c. Increase the heat control setting on the warming unit
d. Perform a heel-stick to check the capillary blood glucose
185. Which nursing action should be included in the care of the infant with caput
a. Aspiration of the trapped blood under the periosteum
b. Explanation to the parents about the cause/prognosis
c. Gentle rubbing in a circular motion to decrease size
d. Application of cold to reduce size
186. The nursery nurse carries a newborn baby into his mother’s room. The mother states, “I
think my baby is afraid of me, every time I make a loud noise, he jumps.” What should be
the nurse initial action?
a. Encourage her not to be so nervous with her baby
b. Reassure her that this is normal reflexive reaction for her baby
c. Take the baby back to the nursery for neurologic examination
d. Wrap the baby more lightly in warm blankets
187. The nurse should refer the parents of an 8-month-old child to a health care provider if the
child is unable to do which of the following?
a. Stand momentarily without holding onto furniture
b. Stand along well for long period of time
c. Stoop to recover an object
d. Sit without support for long periods of time
188. A mother comes to the clinic complaining about her 7moth-old son having colic. Nurse
Hannah should not include which teaching?
a. “I should avoid over feeding my child.”
b. “This discomfort is more common in infants who are formula fed.”
c. “I should let my infant burp after every feeding.”
d. “I should try to place hot water bottle on my infant’s abdomen for comfort.”
189. A baby undergoes surgery to correct an esophageal atresia and tracheoesophageal fistula.
Which nursing diagnosis has the highest priority during the first 24-hours post-operatively?
a. Ineffective airway clearance
b. Imbalanced nutrition: Less than body requirements
c. Interrupted breastfeeding
d. Hypothermia
190. It is now recommended that children with asthma who are taking long-term inhaled
steroids should be assessed frequently because which of the following may develop?
a. Cough
b. Osteoporosis
c. Slowed growth
d. Cushing syndrome
191. Which of the following explains why iron-deficiency anemia is common during
a. Milk is poor source of iron
b. Iron cannot be stored during fetal development
c. Fetal iron stress are depleted by age 1 month
d. Dietary iron cannot be started until age 12 months
192. A 6-month-old infant is receiving Digoxin (Lanoxin). The nurse should notify the
practitioner and withhold the medication if the apical pulse is less than which of the
a. 60
b. 70
c. 80
d. 110-120
193. The nurse is discharging from the hospital a 7-month-old who weighs 15 lbs. the parents
have put the child in the back seat of the car with the car seat facing the front seat. Upon
seeing the parent’s action, what should the nurse prioritize to do?
a. Ask the parents to wait while the nurse obtains the correct car seat
b. Complete the discharge with the child sitting facing the front seat
c. Give the parents a manual on proper car seat placements
d. Show the parents proper placement of the seat facing the back seat
194. Which nursing intervention is appropriate when caring for this child’s surgical incision one
day after the cleft lip repair?
a. Clean the incision only when serous exudates forms
b. Rub the incision gently with a sterile cotton-tipped swab
c. Rinse the incision with sterile water after feeding
d. Replace the Logan Bar carefully after cleaning the incision
195. When taking a diet history from the mother of a 7-year-old child with phenylketonuria, a
report of an intake of which of the following foods should cause the nurse to become
a. Coke zero
b. Carrots
c. Orange juice
d. Banana
196. A toddler who has been treated for a foreign body aspiration begins to fuss and cry when
the parents attempt to leave the hospital for an hour. The nurse interprets this behavior
as indicating separation anxiety involving which of the following?
a. Protest
b. Despair
c. Regression
d. Detachment
197. Which of the following foods should the nurse encourage the mother to offer to her child
with iron-deficiency anemia?
a. Rice cereal, whole milk, and yell vegetables
b. Potato, peas and chicken
c. Macaroni, cheese and ham
d. Pudding, green vegetables, and rice
198. The mother asks the nurse why her child’s hemoglobin was normal at birth but now the
child has S hemoglobin. Which of the following responses by the nurse would be most
a. “The placenta bars passage f the hemoglobin S from the mother to the fetus.”
b. “The red bone marrow does not begin to procedure hemoglobin S until several months
after birth.”
c. “Antibodies transmitted from you to the fetus provide the newborn with temporary
d. “The newborn has high concentration of fetal hemoglobin in the blood for some time
after birth.”
199. The child was confirmed to have UTI and was confined to the hospital. The father tells
Nurse Joey, “My wife and I are concerned because our child refuses to obey us concerning
the prevention of UTI. Our child refuses to take her medication unless we buy her present.
We don’t want to use discipline because of the illness, but we’re worried about the
behavior.” Which response by the nurse is best?
a. “I sympathize with your difficulties, but just ignore the behavior for now.”
b. “I understand it’s hard to discipline a child who is ill, but things need to be kept as
normal as possible.”
c. “I understand that things are difficult for you right not, but your child is ill and deserves
a special treatment.”
d. “I understand your concern, but this type pf behavior happens all the time, your child
will get over it when feeling better.”