Care of the Patient with Pediatric Problems

1. A nurse is taking a history from the parents of a 11-year-old girl admitted with Reye’s syndrome. Which illness should the nurse
expect the
parents to report their child having the previous week?
a. Chickenpox
b. Bacterial meningitis
c. Strep throat
d. Lyme disease
RATIONALE: Reye’s syndrome commonly occurs about 1 week after a child has had a viral infection, such as chickenpox (varicella) or
influenza. Children with flulike symptoms or chickenpox who receive aspirin are at increased risk for Reye’s syndrome. Bacterial
meningitis and strep throat are caused by bacteria and don’t lead to Reye’s syndrome. Lyme disease ¡s caused by a spirochete and
isn’t implicated in Reye’s syndrome.

2. A 3-month-oki infant with meningococcal meningitis has just been admitted to the pediatric unit. Which nursing intervention has
the highest priority?
a. Instituting droplet precautions
b. Administering acetaminophen (Tylenol)
c. Obtaining history information from the parents
d. Orienting the parents to the pediatric unit

3. A nurse is caring for a young child with tetralogy of Fallot (TOE). The child is upset and crying. The nurse observes that he’s
dyspneic and
cyanotic. Which position would help relieve the child’s dyspnea and cyanosis?
a. Sitting in bed with the head of the bed at a 45-degree angle
b. Squatting
c. Lying flat in bed
d. Lying on his right side

4. A nurse is assessing an infant for signs of increased intracranial pressure (ICP). What is the earliest sign of increased ICP in an
infant?
a. Vomiting
b. Papilledema
c. Vital sign changes
d. Irritability
RATIONALE: An infant with increased ICP is commonly fussy, irritable, and restless at first as a result of a headache cause by the ICP.
Vomiting occurs later. Papilledema is a late sign of increased ICP that may not be evident. Changes in vital signs occur later; pressure
on the brainstem slows pulse and respiration.

5. An infant is having his 2-month checkup at the pediatrician’s office. The physician tells the parents that she’s assessing for
Ortolani’s sign.
The nurse explains that the presence of Ortolani’s sign indicates dislocation of what joint?
a. Shoulder
b. Elbow
c. Knee
d. Hip
RATIONALE: To assess for Ortolani’s sign, the nurse abducts the infant’s hips while flexing the legs at the knees. This is performed on
all
infants to assess for congenital hip dislocation. The examiner listens and feels for a “click” as the femoral head enters the
acetabulum during the examination. This finding indicates a congenitally dislocated hip.

6. Parents of a 5-year-old call the clinic to tell the nurse that they think their child has been abused by her day-care provider. What
should the
nurse advise them to do?
a. Make an appointment to speak with the day-care provider.
b. Schedule an immediate appointment with the heath care provider.
c. Call the child protective services to file a complaint
d. Talk to the attorney to file discharges against the accused.
RATIONALE: Because more information needs to be obtained from the child and family, an immediate appointment is most
appropriate. It’s unclear what type of abuse the parents are concerned about. Calling child protective services is appropriate but
isn’t the first action to take; neither is talking to an attorney or the day-care provider.

7. A nurse is evaluating a child with acute poststreptococcal glomerulonephrtis (APSGN) for signs of improvement. Which finding
typically is the earliest sign of improvement?
a. Decreased hematuria
b. Increased appetite
c. Increased energy level
d. Decreased diarrhea
8. A 3-month-old infant just had a cleft lip and palette repair. To prevent trauma to the operative site, the nurse should:
a. Give the infant a pacifier to soothe him
b. lie the infant in the prone position.
c. place the infant’s arms in soft elbow restraint.
d. avoid touching the suture line, even to clean.
RATIONALE: Soft restraints from the upper arm to the wrist are appropriate because they prevent the infant from touching his lip
but allow him to hold a favorite item such as a blanket. Because they could damage the operative site, such objects as pacifiers,
suction catheters, and small spoons shouldn’t be placed in an infant’s mouth after cleft palette repair. An infant in a prone position
may rub his face on the sheets and traumatize the operative site. The suture line should be cleaned gently to prevent infection,
which could interfere with healing and damage the cosmetic appearance of the repair. Dried blood collecting on the suture line can
widen the scar.

9. Before administering a tube feeding to a toddler, which method should the nurse use to check the placement of a nasogastric
(NG) tube?
a. Abdominal X-rays
b. Injection of a small amount of air while listening with a stethoscope over the abdominal area
c. A check of the pH of fluid aspirated from the tube
d. Visualization of the measurement mark on the tube made at the time of insertion
RATIONALE: Intestinal, gastric, and respiratory fluids have different pH values. Therefore, checking the pH of fluid aspirated from the
tube ¡s the most reliable technique for checking proper NG tube placement without taking X-rays before each feeding. X-rays can’t
be performed multiple times a day on a daily basis. Because auscultation of air can be heard when the tube is in the esophagus as
well as in the stomach, this isn’t the best test for checking placement. Observing the insertion measurement mark isn’t a good check
either because the mark may remain the same even though the tube has migrated up or down into the esophagus, lungs, or
intestines.

10. A nurse is giving instructions to parents of a school-age child diagnosed with sickle cell anemia. The instructions should include:
a. applying cold to affected areas to reduce the child’s discomfort.
b. restricting the child’s fluids during crisis situations.
c. avoiding areas of low oxygen concentration such as high altitudes.
d. encouraging the child to exercise to reduce the likelihood of crisis.

11. A nurse is performing a respiratory assessment on a 5-year-old child diagnosed with pneumonia. Which assessment finding
should be reported to the physician immediately?
a. Mouth breathing
b. Foul odor from the mouth
c. Moderate intercostal retractions
d. Irregular respirations while awake
RATIONALE: Normally, children and men use the abdominal muscles to breathe, whereas women use the thoracic muscles. Use of
the accessory or intercostal muscles would indicate a respiratory problem and should be immediately reported to the physician.
Mouth breathing and a foul odor from the mouth aren’t cause for concern. Irregular respirations while awake aren’t an unusual
finding in a young
child.

12. A nurse is conducting an examination of a 6 month old baby. During the examination, the nurse should be able to elicit which
reflex?
a. Babinski’s
b. Startle
c. Moro’s
d. Dance
RATIONALE: The nurse should be able to elicit the Babinski’s reflex because it may be present the entire first year of life. The startle
reflex actually disappears around 4 months of age; the Moro’s reflex, by 3 or 4 months of age; and the dance reflex, after the third or
fourth week. .

13. A toddler is hospitalized for evaluation and management of congenital heart disease (CH D). During discharge preparation, the
nurse should discuss which topic with the parents?
a. The need to withhold childhood immunizations
b. The importance of restricting the child’s fat intake
c. How to perform postural drainage
d. When to administer prophylactic antibiotics
RATIONALE: In CHD, areas of turbulent blood flow provide an optimal environment for bacterial growth. Therefore, a child with CHD
is at
increased risk for bacterial endocarditis, an infection of the heart valves and lining, and requires prophylactic antibiotics before
dental work and invasive procedures. These children should receive all childhood immunizations. They don’t require postural
drainage or dietary fat
restriction.

14. A preschool-age child underwent a tonsillectomy 4 hours ago. Which assessment finding should make the nurse suspect
postoperative
hemorrhage?
a. Vomiting of dark brown emesis
b. Refusal to drink clear fluids
c. Decreased heart rate
d. Frequent swallowing

15. A child, age 4, is admitted with a tentative diagnosis of congenital heart disease. When assessment reveals a bounding radial
pulse coupled
with a weak femoral pulse, the nurse suspects that the child has:
a. patent ductus arteriosus.
b. coarctation of the aorta.
c. a ventricular septal defect.
d. truncus arteriosus.

16. A pediatric nurse preceptor working on an oncology floor observes a new graduate crying in the nurses’ lounge. The nurse’s best
action
would be to:
a. let the graduate cry and get it out of her system.
b. ask the graduate what’s bothering her.
c. ask the graduate if she thinks she can handle being a pediatric nurse.
d. let the nurse-manager know that the new graduate isn’t ready for the emotions that working on this unit evokes.

17. A 2-year-old child is brought to the emergency department with a history of upper airway infection that has worsened over the
last 2 days. The nurse suspects the child has croup. Signs of croup include a hoarse voice, inspiratory stridor, and:
a. a barking cough.
b. a high fever.
c. sudden onset.
d. dysphagia.
RATIONALE: Croup is an acute viral respiratory illness characterized by a barking cough. Fever is usual[y low grade. Croup has a
gradual onset, and dysphagia isn’t a symptom.

18. To decrease the likelihood of bradyarrhythmias in children during endotracheal intubation, succinylcholine (Anectine) is used
with which agent?
a. Epinephrine (Adrenalin)
b. Isoproterenol (Isuprel)
c. Atropine
d. Lidocaine (Xylocaine)

19. Twenty-four hours after birth, a neonate hasn’t passed meconium. The nurse suspects which condition?
a. Hirschsprung’s disease
b. Celiac disease
c. Intussusception
d. Abdominal wall defect

20. A physician diagnoses leukemia in a child, age 4, who complains of being tired and sleeps most of the day. Which nursing
diagnosis reflects
the nurse’s understanding of the physiologic effects of leukemia?
a. Ineffective airway clearance related to fatigue
b. Activity intolerance related to anemia
c. Imbalanced nutrition: More than body requirements related to lack of activity
d. Ineffective cerebral tissue perfusion related to central nervous system i7fifration by leukemic cells

21. Which action should the nurse take first when admitting an 11-year-old child in sickle cell crisis?
a. Administer oral pain medication while obtaining the child’s history.
b. Begin I.V. fluids after obtaining the child’s history.
c. Instruct the parents about what to expect during this hospitalization.
d. Start oxygen therapy as soon as the child’s vital signs are taken.

22. A toddler is admitted to the facility with nephrotic syndrome. The nurse carefully monitors the toddler’s fluid intake and output
and checks
urine specimens regularly with a reagent strip (Labstix). Which finding is the nurse most likely to see?
a. Proteinuria
b. Glycosuria
c. Ketonuria
d. Polyuria

23. A 6-month-oki infant is brought to the clinic. The mother reports the infant has been lethargic. The infant’s anterior fontanel is
sunken. What other assessment data are a priority for the nurse to collect?
a. Temperature, pulse, and respiratory rate
b. Pulse, respiratory rate and skin turgor
c. Respiratory rate, skin and turgor
d. Pulse, skin turgor, and number of wet diapers the infant had in the last 24 hours

24. A mother and infant are admitted to the emergency department following a motor vehicle crash. The infant is unresponsive to
verbal and tactile stimuli, his pupils are dilated, and a nurse observes lacerations on his head, neck, and upper torso. The infant’s
mother is experiencing
respiratory distress and is being treated in another room in the emergency department. The nurse learns that the parents are
divorced and
have joint custody of the infant. The father arrives in the emergency department. The nurse should:
a. contact social services to establish contact with the next of kin and obtain consent to treat the mother and infant.
b. ask the infant’s father to sign consents for emergency treatment of the mother and infant.
c. ask the infant’s father to sign consent for emergency treatment of the infant.
d. contact social services to establish contact with the court to obtain consent to treat the infant.
RATIONALE: The father may give consent for treatment of the infant, but he may not give consent to treat the mother (his former
wife). The mother’s next of kin should be contacted for consent. Because the father may give consent for the infant to be treated, it
isn’t necessary to contact the court at this time.

25. A mother, who is visibly upset, carries her 2-month-old infant into the crowded emergency department. The child appears limp
and lifeless. The mother screams to the nurse for help. The nurse’s first action should be:
a. take the infant from the mother and offer to help.
b. take the infant and mother back to a treatment room.
c. call the resuscitation team and the supervisor.
d. call security and the hospital administration.

26. A 4-year-old child arrives in the emergency department with a history of transient consciousness and unconsciousness. The
nurse should
suspect:
a. subdural hematoma.
b. epidural hematoma.
c. subarachnoid hemorrhage.
d. concussion.

27. An adolescent with well-controlled type 1 diabetes has assumed complete management of his disease and wants to participate
in gymnastics after school. To ensure safe participation, the nurse should instruct him to adjust his therapeutic regimen by:
a. eating a snack before each gymnastics practice.
b. measuring his urine glucose level before each gymnastics practice.
c. measuring his blood glucose level after each gymnastics practice.
d. increasing his morning dosage of intermediate-acting insulin.

28. A mother tells the nurse that she wants to begin toilet training her 22-month-old child. The most important factor regarding
toilet training that
the nurse should stress to her is:
a. developmental readiness of the child.
b. consistency in approach.
c. the mother’s positive attitude.
d. developmental level of the child’s peers.
RATIONALE: The most important factor is developmental readiness because if the child isn’t developmentally ready, both the child
and parent will become frustrated. Consistency is important when toilet training is started; the mother’s positive attitude is
important when the child is determined to be ready. Developmental levels of children are individualized and comparison to peers
isn’t useful.

29. A preschooler goes into cardiac arrest. When performing cardiopulmonary resuscitation (CPR) on a child, how should the nurse
deliver chest compressions?
a. With the fingers of one hand
b. With two fingertips
c. With the palm of one hand
d. With the heel of one hand

30. A toddler with a ventricular septal defect is receiving digoxin (Lanoxin) to treat heart failure. Which assessment finding should be
the nurse’s priority concern?
a. Bradycardia
b. Tachycardia
c. Hypertension
d. Hyperactivity
Care of Patients with Communicable Diseases

31. Ms. Bartolome, a newly registered nurse is working on a clinical medical area with a census of 20. Each patient has different
illnesses. Which of the following is the most important method for Ms. Bartolome to use to protect each patient from
microorganisms?
a. Wearing a gown
b. Placing each patient in a private room
c. Hand washing
d. Wearing gloves

32. Identification of the chain of infection allows health care providers to:
a. Test patients for resistance to communicable disease
b. Request more money for building isolation hospital
c. Work with the physician to identify the most appropriate antibiotic.
d. Determine points at which the infection can be stopped or prevented

33. A teen age girl who was admitted to the hospital because of fever and abdominal cramps is now manifesting rose spots on her
abdomen which is specific to enteric fever. You are aware that if the patient is experiencing specific signs and symptoms, he is now
on what stage of infection?
a. Incubation Period c. Acute Illness
b. Prodromal Stage d. Convalescence Stage

34. Wearing personal protective equipment when handling a communicable client is necessary to protect the nurse and prevent the
transmission of infection to others. Which of the following, if made by the nurse is correct when taking into consideration of removal
of PPE after handling a communicable client?
A. Removing of goggles first before gloves
B. Hand washing is not required right after gloves was removed
D. Mask is the PPE to be removed last

35. As an epidemiologist, the nurse is responsible for reporting cases of notifiable diseases. What law mandates reporting of cases of
notifiable diseases?
A. R.A. 3573 C. R.A. 1054
B. R.A. 3753 D. R.A. 1082
36. You are taking care of a patient who was diagnosed with communicable disease and you are about to leave the clients room.
Place the following nursing procedures in correct sequence in removing personal protective equipment:
1. Remove gloves
2. Perform hand hygiene
3. Remove the mask
4. Remove protective eyewear and dispose of properly
5. Remove gown when preparing to leave the room
6. Proper hand hygiene
A. 1, 2, 3, 4, 5, 6 C. 1, 2, 4, 5, 3, 6
B. 1, 2, 5, 3, 4, 6 D. 1, 4, 2, 5, 3, 6
37. A 35-year old male client was admitted to the hospital with a diagnosis of Buerger’s disease complains of fever and cough. After
3 days of hospitalization, he developed pneumonia. This type of infection is classified as:
A. Hospital Acquired Pneumonia
B. Community Acquired Pneumonia
C. Pneumocysti Carinii Pneumonia
D. Atypical Pneumonia

38. Mr. Santos who has a chief complain of dry cough for more than 2 weeks is now confirmed of having tuberculosis. After placing
him on respiratory isolation, he asked the nurse why it is necessary. The nurse should explain that:
A. Tuberculosis is spread through close contact only
B. Tuberculosis can be acquired via inhalation of droplets containing diseased nuclei
C. Close contact is necessary for TB transmission
D. Isolation is necessary for TB clients for this will promote faster healing

39. A neonate male client who was rushed to the emergency room because fever, swelling of the palate and was transferred to a
private room after establishing his airway. After series of laboratory tests, diagnosis of diphtheria was confirmed. The mother asked
you about the disease. You explain that this disease is an acute, highly contagious, toxin-mediated infection caused by
Corynebacterium diphtheriae that is primarily transmitted through:
A. Intimate contact with asymptomatic carrier
B. Respiratory droplet from convalescing patients
C. Option B is correct
D. Options A and B are correct

40. . You are assigned to handle a client who is diagnosed with inhalation anthrax. Which among the following will you expect the
doctor to order for the management of this infection?
A. Ciprofloxacin for 60 days C. Penicillin for 10 days
B. Doxycycline for 14 days D. Doxycycline for 21 days
41. You are assessing a preschool child who was reported to you with manifestations of continuous excessive coughing that result to
bluish discoloration of the face of the child. Upon further investigation, you suspect that the client is having pertussis. Which of the
following manifestations will you note to conclude that the child is still in paroxysmal stage of pertussis?
1. Successive, excessive coughing
2. Vomiting
3. Whooping followed by paroxysms of cough
4. Mucoid rhinoria and morning bronchial cough
A. 1, 2 and 3 C. 2 & 4
B. 1 & 3 D. 4 only

42. Client X who is experiencing numbness and paresthesia on his lower extremities for the past few months associated with a non
healing wound at the big toe seeks consultation in a public health center in their barangay. The attending physician ordered for skin
scraping on the site of the wound and confirmed presence of Mycobacterium leprae. When the nurse assess the body of Client X,
she notes presence of multiple, symmetrical and erythematous lesions and deterioration of fingertips and toes. The nurse would
most likely classify this type of leprosy as:
A. Borderline C. Lepromatous
B. Tuberculoid D. Indeterminate
43. Mr. Adolf was seen in a dermatologic clinic because of his lesions on his lower thoracic area. He also complains that these lesions
are very painful. Upon inspection, the area is found to be erythematous and edematous clustered vesicles. You suspect that Mr.
Adolf has:
A. Herpes Zoster C. Varicella
B. Herpes Simplex D. Impetigo

44. A clinical instructor in San Lazaro Hospital is discussing the difference and similarities of Measles and rubella infection to a group
of senior student nurses. Which of the following information is the least accurate about the two infection?
A. They are both enveloped RNA viruses
B. They induce lifelong immunity
C. They are both transmitted by respiratory aerosol with skin rashes
D. They both causes significant congenital anomalies

45. A 3-year-old child with chickenpox was admitted to the hospital and confined in a private room. Upon visiting the room of the
client, the parent voice out to you that they are concern about their son scratching the lesions. Which among the following
instructions will be most helpful in addressing the concern of the parents?
A. “Applying cortisone cream is necessary to prevent itching.”
B. “ Mitten can be placed on the hands of the child.”
C. “You need to keep your child in a warm room at night so that covers will not cause your child to scratch.”
D. “Warm milk at bedtime will help him sleep and will prevent scratching of the lesions.”

46. A group of adult people who are working in a factory was rushed to the hospital because of diarrhea, fever, weakness and
fatigue. Laboratory test was made and a diagnosis of amoebiasis was established. As a competent nurse, you will do all of the
following nursing interventions except:
A. Enforce and practice standard precaution
B. Antidiarrheal drugs should not be circumvent
C. After treatment, stools should be rechecked to make sure the infection has been cleared
D. Instruct the patient to shun drinking alcohol

47. An outbreak of cholera was declared in one of the barangay in Bulacan. You are aware that clients with this infection produces
copious diarrhea in which 1 L of fluid per hour are lost and rehydration efforts should be vigorous and sustained. Being the public
health nurse, you know that the following are management that can be given to cholera patients, except:
A. Rapid infusion of large amount of I.V isotonic solution
B. Administration of isotonic sodium bicarbonate or sodium lactate
C. Potassium replacement
D. Rapid infusion of large amount of I.V hypertonic solution

49. Manolo and his family, who lives in a dumped area was rushed to the health center in due to headache, weakness and vomiting
several hours after ingestion of clams and oysters. They are suspected of having paralytic shellfish poisoning. In this case, which of
the following materials that is available in public health center is utilized to weaken the effect of the toxin?
A. Activated charcoal C. Fresh milk
B. Coconut milk D. Weak vinegar solution

50. Assessment was done to a female client who was rushed to the emergency department with a chief complain of high fever
associated with abdominal cramps. The nurse on duty noted presence of red rashes on the trunk area. Enteric fever was suspected
case of the client. The attending physician asked the nurse to watch out for pain in the right lower abdomen for possible perforation
of which of the following organ?
A. Small intestine C. Gallbladder
B. Colon D. Spleen

51. The Provincial Health Office of province of Samar send a group of nurses in one of the barangay where schistosomiasis is
endemic. Further studies and investigations reveal that 70% of the residents are affected with the infection. Which of the following
drugs would be most helpful in treating schistosomiasis?
A. Metronidazole C. Hetrazan
B. Praziquantel D. Chloroquine

52. Gina, who recently travelled to Palawan seeks medical advice because of flu-like symptoms, including chills, fever, fatigue,
headache, and myalgia. Blood smear was made and diagnosis of malaria was established. Gina asked the nurse what other
manifestations might she experience if she will be left untreated. You are most correct if you state that typical pattern of
manifestations of malarial infection are:
A. Cold stage, warm stage, wet stage
B. Cold stage, wet stage, warm stage
C. Warm stage, cold stage, wet stage
D. Wet stage, cold stage , warm stage

53. The community physician ordered CBC to Mariel who are suspected of having H-fever because she is manifesting high grade
fever with episodes of gastric pain. As the nurse taking care of the client, your expected CBC finding in clients with dengue
hemorrhagic fever is:
A. Increased WBC & decreased RBC
B. Decreased hematocrit & increased platelet
C. Decreased platelet & increased hematocrit
D. Increased hematocrit & decreased hemoglobin

54. Filariasis is a debilitating infection caused by nematode parasites that usually lives and migrate in the lymphatic vessels and
lymph nodes of the body. To immediately determine the presence of antigen in the blood of a suspected client with this infection,
which of the following laboratory tests will you use?
A. Nocturnal blood examination
B. Immunochromatographic test
C. Blood smear
D. Complete blood count

55. During rainy season, cases of leptospirosis usually increases specially in flood-prone areas. To prevent contracting with this
disease, you will educate the people that the drug that is used as prophylaxis is:
A. Doxycycline C. Chloramphenicol
B. Rifampicin D. Ziduvodine
56. A 3-year-old male client who was admitted to the hospital because of high grade fever and convulsion. History reveals that the
client contracted pneumonia a week prior to the hospitalization. Further assessment was made and the nurse notes that there are
presence of nucchal rigidity and positive Brudzinski’s sign. Parents of the child were informed that the case of the client would most
probably meningitis. Base on the history of the client, which of the following would be the cause of the infection?
A. Haemopilus influenzae B
B. Neisseria meningitides
C. Streptococcus pnemoniae
D. Meningococcus
57. Emilie Lopamia, a 35-year-old female was bitten by a stray dog on the left hand. She sought an advice of the nurse in the health
center. The best response of the nurse is:
A. “You should observe the dog for changes in behavior so you will know if the dog is possibly rabid or not.”
B. “You should receive immunization for rabies immediately.”
C. “You don’t have to worry because it’s just a minor wound.”
D. “You should receive immunization for rabies & tetanus as soon as possible.”

58. You are teaching a cluster of student nurses about the stages of syphilis and its manifestations. Which of the following will you
include in your discussion as signs and symptoms associated with secondary syphilis?
A. Painless, papular lesions on the perineum, fingers, and eyelids
B. Absence of lesions
C. Deep asymmetrical granulomatous lesions
D. Well-defined generalized lesions on the palms, soles, and perineum

59. A client with HIV is taking zidovudine (AZT). AZT is a drug that acts to:
A. Destroy the virus
B. Enhance the body’s antibody production
C. Slow replication of the virus
D. Neutralize the toxins produced by the virus

60. You are conducting health teaching to a group of mothers in a barangay located in Manila. After the discussion, a lady came to
you and ask you about the manifestations of gonorrhoea in women. You should emphasize that for women, gonorrhoea:
A.Is often marked by symptoms of dysuria or vaginal bleeding
B. Does not lead to serious complication
C. Can be treated but not cured
D. May not cause symptoms until serious complication occurs

Obstetric Nursing

61. A client arrives at the clinic for the first prenatal assessment. The client tells a nurse that the first day of her last menstrual
period was October 19, 2012. Using Nagele’s rule, the nurse determines the estimated date of confinement is:
A. July 12, 2012
B. July 26, 2013
C. August 12, 2013
D. August 26, 2013

62. A client who has just been told that she is pregnant wants to know when the baby’s heart will be completely developed and
beating. The nurse reads in the client’s chart that the health care provider has determined the client to be at 6 weeks’ gestation.
The nurse’s best response to the client would be:
A. “Your baby’s heart right now consists of two parallel tubes, so we can’t hear it today.”
B. “Your baby’s heart right now is beginning to partition into four chambers and has begun to beat, so we should be able to
hear it with a Doppler.”
C. “Your baby’s heart right now is beginning to partition into four chambers and has begun to beat, so we should be able to
hear it with a fetoscope.”
D. “Your baby’s heart right now has double heart chambers and has begun to beat, so we should be able to see it beat using
an ultrasound machine.”

63. A pregnant client asks a nurse in the clinic when she will be able to begin to feel the fetus move. The nurse responds by telling
the mother that fetal movements will be noted between which of the following weeks of gestation
A. 6 and 8
B. 8 and 10
C. 10 and 12
D. 16 and 20

64. A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The physician
prescribes a contraction stress test, and the results are documented as negative. A nurse interprets the finding of the
contraction stress test as indicating:
A. A normal test result
B. An abnormal test result
C. A high risk for fetal demise
D. The need for cesarean delivery
65. A nurse is describing cardiovascular system changes that occur during pregnancy to a client and understands that which of the
finding would be:
normal for a client in the second trimester?
A. Increase in pulse rate
B. Increase in blood pressure
C. Frequent bowel elimination

66. The nurse is reviewing the record of a pregnant client and notes that the physician has documented the presence of Chadwick’s
sign. The nurse understands that the hormone responsible for the development of this sign is which of the following?
A. Human chorionic gonadotropin
B. Estrogen
C. Progesterone
D. Prolactin

67. A nurse is providing instructions to a client in the first trimester of pregnancy regarding measures to assist in reducing breast
tenderness. The nurse tells the client to:
A. Avoid wearing bra
B. Wash the breasts with warm water and keep them dry
C. Wear tight-fitting blouses or dresses to provide support
D. Wash the nipples and areolar area daily with soap and massage the breasts with lotion

68. A client in preterm labor (31 weeks) who is dilated to 4cm has been started on magnesium sulfate and contractions have
stopped. If the client’s labor can be inhibited for the next 48 hours, what medication does the nurse anticipate will be
prescribed?
A. Betametasone
B. Nalbuphine (Nubain)
C. Rho(D) immune globulin (Rhogam)
D. Dinoprostone (Cervidil vaginal insert)

69. After the spontaneous rupture of a laboring woman’s membranes, the fetal heart rate drops to 85 beats/min. which should be
the nurse’s priority action?
A. Notify the physician of the need for an amnioinfusion
B. Document the description of the fetal bradycardia in the nursing notes
C. Reposition the laboring woman to knee-chest
D. Assess the vagina and cervix with a gloved hand

70. A nurse is collecting data during an admission assessment of a client who is pregnant with twins. The client has a healthy 5-year-
old child who was delivered at 38 weeks and tells the nurse that she does not have a history of any type of fetal demise. The
nurse would document the GTPAL for this client as:
A. 3, 2, 0, 0, 1
B. 2, 1, 0, 0, 1
C. 1, 1, 1, 0, 1
D. 2, 0, 0, 0, 1

71. A nurse is caring for a client in labor. The nurse determines that the client is beginning the second stage of labor when which of
the following assessments is noted?
A. The contraction are regular
B. The membranes have ruptured
C. The cervix is dilated completely
D. The client begins to expel clear vaginal fluid

72. A nurse in the labor room is caring for a client in the active stage of labor. The nurse is assessing the fetal patterns and notes a
late deceleration on the monitor strip. The appropriate nursing action is to:
A. Administer oxygen via face mask
B. Place the mother in a supine position
C. Increase the rate of the oxytocin (Pitocin) intravenous infusion
D. Document the findings and continue to monitor the fetal patterns

73. A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the
external monitor tracing during a contraction?
A. Variability
B. Accelerations
C. Early decelerations
D. Variable decelerations
74. A client arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. The client tells the
nurse that a home pregnancy test was positive but that she began to have mild cramps and is now having moderate vaginal
bleeding. On physical examination of the client, it is noted that the client has a dilated cervix. The nurse determines that the
client is experiencing which type of abortion?
A. Inevitable
B. Incomplete
C. Threatened
D. Septic

75. A maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal
bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician’s prescriptions and would question
which prescription?
A. Prepare the client for an ultrasound
B. Obtain equipment for a manual pelvic examination
C. Prepare to draw a hemoglobin and hematocrit blood sample
D. Obtain equipment for external electronic fetal heart rate monitoring

76. A nurse is reviewing the physician’s prescriptions for a client admitted for premature rupture of the membranes. Gestational
age of the fetus is determined to be 37 weeks. Which physician’s prescription should the nurse question?
A. Perform a vaginal examination every shift
B. Monitor maternal vital signs frequently
C. Monitor fetal heart rate continuously
D. Administer ampicillin 1 g as an intravenous piggyback every 6 hours

77. A nurse implements a teaching plan for a pregnant client who is newly diagnosed with gestational diabetes mellitus. Which
statement made by the client indicates a need for further teaching?
A. “I should stay on the diabetic diet.”
B. “I should perform glucose monitoring at home.”
C. “I should avoid exercise because of the negative effects on insulin production.”
D. “I should be aware of any infections and report signs of infection immediately to my health care provider.”

78. A nurse is performing an assessment of a primigravida who is being evaluated in a clinic during her second trimester of
pregnancy. Which of the following indicates an abnormal physical finding that necessitates further testing?
A. Quickening
B. Braxton Hicks contraction
C. Fetal heart rate of 180 beats/min
D. Consistent increase in fundal height

79. A nurse is performing a measurement of fundal height in a client whose pregnancy has reached 36 weeks of gestation. During
the measurement the client begins to feel lightheaded. On the basis of knowledge of the physiological changes of pregnancy,
the nurse determines that this symptom is most likely a result of:
A. Emotional instability
B. Compression of the vena cava
C. A full bladder
D. Insufficient iron intake

80. A nurse in a maternity unit is reviewing the records of the clients on the unit. Which client would the nurse identify as being at
the greatest risk of developing disseminated intravascular coagulation?
A. A primigravida with mild preeclampsia
B. A primigravida who delivered a 10-lb infant 3 hours ago
C. A gravida II who has just been diagnosed with dead fetus syndrome
D. A gravida IV who delivered 8 hours ago and has lost 500 ml of blood

81. A nurse is caring for a client with severe toxemia of pregnancy. The client is receiving an intravenous (IV) infusion of magnesium
sulfate. Of the following items, which item is considered to be of highest priority to have available?
A. Percussion hammer
B. Tongue blade
C. Potassium chloride injection
D. Calcium gluconate injection

82. Rho(D) immune globulin (RhoGAM) is prescribed for a client after delivery and the nurse provides information to the client
about the purpose of the medication. The nurse determines that the woman understands the purpose of the medication if the
woman states that it will protect her next baby from which of the following?
A. Having Rh-positive blood
 B. Developing a rubella infection
C. Developing physiological jaundice
D. Being affected by Rh incompatibility

83. Methylergonovine (Methergine) is prescribed for a client with postpartum hemorrhage. Before administering the medication, a
nurse contacts the health care provider who prescribed the medication if which condition is documented in the client’s medical
history?
A. Hypotension
B. Hypothyroidism
C. Diabetes mellitus
D. Peripheral vascular disease

84. A nurse is administering an intravenous analgesic to a laboring woman. The woman inquires as to why the nurse is waiting for a
contraction to begin before she infuses the medication into the intravenous line. Which of the following is the nurse’s most
appropriate response?
A. “The medication will provide the most optimal relief when it is given while your pain level is highest.”
B. “Because the uterine blood vessels constrict during a contraction, the fetus will be less affected by the medication.”
C. “The medication will only affect you and your pain level when given during a contraction.”
D. “You will experience a lower incidence of adverse effects from the medication when administered during a
contraction.”

85. A postpartum nurse is taking the vital signs of a client who delivered a healthy infant 4 hours ago. The nurse notes that the
client’s temperature is 100.2 F. Which of the following actions would be appropriate?
A. Notify the physician
B. Document the findings
C. Retake the temperature in 15 minutes
D. Increase hydration by encouraging fluids

86. A clinic nurse is performing an assessment on a client who is 6 days postpartum. When assessing involution, the nurse expects
the uterine fundus to be located at which area?
A. At the level of the umibilicus
B. Halfway between the umbilicus and symphysis pubis
C. Halfway between the xiphoid process and umbilicus
D. Just below the xiphoid process

87. A postpartum nurse is providing instructions to a client after delivery of a healthy infant. The nurse instructs the client that she
should expect normal bowel elimination to return:
A. 3 days postpartum
B. 7 days postpartum
C. On the day of the delivery
D. Within 2 weeks postpartum

88. A nurse is developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. Which of
the following interventions is a component of the plan of care?
A. Ambulation four to six times daily
B. Administration of anticoagulants
C. Elevation of the affected extremity
D. Application of ice packs to the affected area
89. The mother of a newborn calls a clinic and reports to a nurse that when cleaning the umbilical cord, the mother
noticed that the cord was moist and that discharge was present. The appropriate nursing instruction to the mother is
which of the following?
A. Bring the infant to the clinic
B. This is a normal occurrence
C. Increase the number of times that the cord is cleaned per day
D. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues

90. A discharge nurse is discussing mastitis with a postpartum client. Which of the following statements by the client
would indicate a need for further instruction?
A. “If I develop a hot, reddened, triangle-shaped area on my breast, I should contact my health care provider.”
B. “I may develop mastitis if I wear underwire bras, experience excessive fatigue, or suddenly decrease the number
of feedings.”
C. “If I develop a fever, chills, or body aches at any time after discharge, I should stop breast feeding
immediately.”
D. “Antibiotics, rest, warm compresses, and adequate fluid intake are all important for the treatment of mastitis.”

91. A nurse is assessing a pregnant woman. Which signs or symptoms indicate a hydatidiform mole?
a. Rapid fetal heart tones
b. Abnormally high human chorionic gonadotropin (hCG) levels
c. Slow uterine growth
d. Lack of symptoms of pregnancy
RATIONALE: In a pregnant woman with a hydatidiform mole, the trophoblast villi proliferate and then degenerate.
Proliferating trophoblast cells produce abnormally high hCG levels. No fetal heart tones are heard because there is no
viable fetus. Because there is rapid proliferation of the trop hoblast cells, the uterus grows fast and is larger than expected
for a given gestational date. Because of the greatly elevated hCG levels, a woman with hydatidiform mole often has
marked nausea and vomiting.

92. A client is experiencing an early postpartum hemorrhage. With item in the client’s care plan requires revision?
a. Inserting an indwelling urinary catheter
b. Fundal massage
c. Administration of oxytocics
d. Pad court
RATIONALE: By the time the client is hemorrhaging, a pad count is no longer appropriate. Inserting an indwelling urinary
catheter eliminates the possibility that a full bladder may be contributing to the hemorrhage. Fundal massage is
appropriate to ensure that the uterus is well contracted, and oxytocics may be ordered to promote sustained uterine
contraction.

93. A client is admitted to the facility with a suspected ectopic pregnancy. When reviewing the client’s heath history for
risk factors for this abnormal condition, the nurse expects to find:
a. a history of pelvic inflammatory disease.
b. grand multiparity (five or more births).
c. use of an intrauterine device for 1 year.
d. use of a hormonal contraceptive for 5 years.
RATIONALE: Pelvic inflammatory disease with accompanying salpingitis is commonly implicated in cases of tubal
obstruction, the primary cause of ectopic pregnancy. Ectopic pregnancy isn’t associated with grand multiparity or
hormonal contraceptive use. Ectopic pregnancy is associated with use of an intrauterine device for 2 years or more.

94. Initial client assessment information includes: blood pressure 160/110 mm Hg, pulse 88 beats/minute, respiratory rate
22 breaths/minute, reflexes +3/+4 with 2 beat clonus. Urine specimen reveals +3 protein, negative sugar and ketones.
Based on these findings, a nurse should expect the client to have which complaints?
a. Headache, blurred vision, and facial and extremity swelling
b. Abdominal pain, urinary frequency, and pedal edema
c. Diaphoresis, nystagmus, and dizziness
d. Lethargy, chest pain, and shortness of breath

95. On the second postpartum day, a client tells the nurse she feels anxious and tearful. Which assessment finding is most
consistent with the client’s statement?
a. Poor coping skills

b. Postpartum “blues”
c. Postpartum depression
d. Postpartum psychosis
RATIONALE: Postpartum “blues” are a normal, expected finding 2 days postpartum. About 50% to 70% of postpartum
clients experience transient depression during the first 7 to 10 days after giving birth. Postpartum depression and
postpartum psychosis aren’t seen until later than the second day postpartum. A statement by the client about not being
able to care for her neonate or herself would indicate poor coping skills.

96. Which finding indicates placental detachment?

a. An abrupt lengthening of the cord
b. A decrease in the number of contractions
c. Relaxation of the uterus
d. Decreased vaginal bleeding

97. In the maternal attachment process, which statement best describes the anticipated actions in the taking-hoki phase?
a. Mother’s needs being met first
b. Looking at the baby
c. Kissing, embracing, and caring for the neonate
d. Talking about the neonate
RATIONALE: Taking-hold behaviors, the third step in parent-neonate attachment, are best described by activities that
involve tactile contact. These behaviors indicate that the parents have made significant strides toward taking care of their
neonate. Meeting the mother’s needs first, looking at the neonate, and talking about the neonate are typically associated
with the taking-in period.

98. A nurse is providing dietary teaching to a pregnant client. To help meet the client’s iron needs, the nurse should advise
her to eat:
a. grains and milk
b. tomatoes and fish.
c. eggs and citrus fruit.
d. spinach and beef.

99. A woman in her 34th week of pregnancy presents with sudden onset of bright red vaginal bleeding. Her uterus is soft,
and she’s experiencing no pain. Fetal heart rate is 120 beats/minute. Based on this history, the nurse should suspect:
a. abruptio placentae.
b. preterm labor.
c. placenta previa.
d. threatened abortion.
RATIONALE: Placenta previa is associated with painless vaginal bleeding that occurs when the placenta or a portion of the
placenta covers the cervical os. In abruptio placentae, the placenta tears away from the wall of the uterus before birth;
the client usually has pain and a boardlike uterus. Preterm labor is associated with contractions and shouldn’t involve
bright red bleeding. By definition, threatened abortion occurs during the first 20 weeks’ gestation.

100. In the fourth stage of labor, a full bladder increases the risk of what postpartum complication?
a. Shock
b. Disseminated intravascular coagulation (DIC)
c. Hemorrhage
d. Infection