Drill Exam 2: Maternity and Pediatric Nursing
138. Baby John was given a drug at birth to reverse the effects of a narcotic given to his mother in labor. What drug is commonly used for this: A. Naloxone (Narcan) B. Morphine Sulfate C. Sodium Chloride D. Penicillin G
A. Naloxone (Narcan)
70. Early decelerations: A. Require immediate physician notification B. Are a sign of fetal compromise C. Are an indication for a cesarean section D. Are a sign of fetal head compression
D. Are a sign of fetal head compression
68. True labor can be differentiated from false labor because in true labor, contractions will: A. Bring about progressive dilatation B. Occur immediately after membrane ruptures C. Stop when the client is encouraged to walk around D. Be less uncomfortable if client is in a side-lying position
A. Bring about progressive dilatation
44. A G1 patient is 20 weeks pregnant. She presents to the clinic today for her routine prenatal visit. The patient complaints of palpitations. What is the nurse's best response? A. "Palpitations are normal and are often related to the normal increase in your blood volume and pulse in pregnancy." B. "This issue needs further evaluation now." C. "Palpitations are normal and are related to the normal increase in your respiratory rate during pregnancy." D. "You need to keep a record when these episodes occur and bring it on your next visit
A. "Palpitations are normal and are often related to the normal increase in your blood volume and pulse in pregnancy."
Situation 6: One way to ensure optimal childbearing and childrearing is through provision of health education. 26. A nurse evaluates understanding of prenatal development in prenatal class. The nurse knows more teaching is required when one of the group members respond: A. "Smoking will help me have an easy labor because the baby will be small." B. "I should not smoke at all during pregnancy." C. "Infants born to mothers who smoke may suffer lung problems." D. "Chemicals from smoking pass through the placenta to the fetus."
A. "Smoking will help me have an easy labor because the baby will be small."
45. During a late-pregnancy visit, a patient is distraught about the dark red stretch marks that have just appeared on both sides of her lower abdomen. She wants to know what to do to ensure they will disappear after she delivers. What is the nurse's best response? weight A. "There is no treatment for stretch marks, but after birth they usually fade to a lighter pink." B. "Stretch marks seem to be familial, so you might want to see who had them in your family and what they used to make them fade." C. "Many women get these stretch marks, and yours seem less severe than many I've seen." D. "Stretch marks are from hormone-induced pigmentation changes during pregnancy, and they disappear after delivery."
A. "There is no treatment for stretch marks, but after birth they usually fade to a lighter pink." Rationale. A. Note: Stretch marks occur with the increasing weight by mother
122. Average adult dose is 500 mg. How much should be given to a 30-lb child? A. 100 mg B. 250 mg C. 300 mg D. 350 mg
A. 100 mg
123. Average adult dose is 250 mg. How much should be given to a 12-month-old infant? A. 20 mg B. 50 mg C. 75 mg D. 100 mg
A. 20 mg
92. Which of the following describes the rationale for preventing overdistention of the bladder in a postpartum client? A. A full bladder will displace the uterus and may cause postpartum hemorrhage B. A full bladder will prolapse, causing great deal of discomfort for the new mother C. A full bladder will cause diaphoresis and lead to complaints of discomfort and pain. D. A full bladder will rupture during palpation of the uterine fundus after delivery
A. A full bladder will displace the uterus and may cause postpartum hemorrhage
89. A 30-year-old patient is breastfeeding her 1-day-old infant which is not latching on correctly to the breast. What should the nurse do? A. After an attempt to help without success, make an appointment for a lactation consultation B. After an attempt to help, ask an experienced nurse to help C. After an attempt to help, ask another patient for some help D. Suggest the mother should use formula, as it is easier and just as nutritious as breast milk
A. After an attempt to help without success, make an appointment for a lactation consultation
145. In which circumstance would a nurse be concerned about language development of a 3-year-old child? A. Conversation with the child is 50% intelligible B. The child uses pronouns and prepositions when talking C. The child has a vocabulary of about 900 words D. The child is inquisitive and asks "why" a majority of the time
A. Conversation with the child is 50% intelligible
50. The fetal nervous system is formed by the germ layer known as which of the following? A. Ectoderm B. Mesoderm C. Endoderm D. Entoderm
A. Ectoderm Rationale. A Ectoderm- Nervous system Mesoderm- Heart Endoderm/Entoderm- GIT
100. A patient is 2 days post vaginal delivery and has done very little to provide hands-on care to her infant even though she reacts positively to the baby. What should the nurse do? A. Encourage the mother to change the diaper under supervision of the nurse B. Call for a social work consult C. Ask the family what is wrong with the patient D. Make a note in the chart
A. Encourage the mother to change the diaper under supervision of the nurse
7. Which of the following hormones stimulate the ovary to produce estrogen during the menstrual cycle? A. FSH B. GnRH C. LH D. HCG
A. FSH Rationale: A. " Follow MNEMONIC: FELP"= FSH: Estrogen and LH: Progesterone
143. Infants at 10 months discover object permanence. Which action would show an infant has developed object permanence? A. He looks for a cheese curl that falls off his high chair tray B. He cores when he is either hungry or lonely C. He prefers a large yellow ball to a small red one D. He smiles when the mobile on his crib jingles
A. He looks for a cheese curl that falls off his high chair tray
27. It is important to educate a pregnant client about the following: A. Headaches and blurred vision after 28 weeks of pregnancy B. Nausea and vomiting before 12 weeks of pregnancy C. Clear or white nipple discharge during pregnancy D. Frequent urination after the second trimester
A. Headaches and blurred vision after 28 weeks of pregnancy Rationale. A. In the first trimester, patient experiences nausea, headaches and blurred vision and frequent urination
58. The management of a client in the transition phase of labor is primarily directed toward: A. Helping the client maintain control B. Decreasing the intravenous fluid intake C. Reducing the client's discomfort with medications D. Having the client use simple breathing pattern during contractions
A. Helping the client maintain control
85. For patient who lost 1,500 mL of blood during the delivery and has hemoglobin level of 8, what discharge teaching is important? A. Increase her dietary iron and protein intake B. Walk at least 5,000 steps per day C. Increase the number of sitz bath to four per day D. Decrease contact with the baby
A. Increase her dietary iron and protein intake
120. Which nursing diagnosis should be the highest priority when caring for a preterm newborn? A. Ineffective thermoregulation B. Anticipatory grieving C. Altered body nutrition D. Risk for injury
A. Ineffective thermoregulation
127. The mother of a three-month-old infant asks the nurse when she can start feeding her baby solid food. Which of the following should the nurse include in teaching this mother about the nutritional needs of the infant? A. Infant cereal can be introduced by spoon when the extrusion reflex fades B. Solid food should be given as soon as the infant's first tooth erupts C. Pureed food can be offered when the infant has tripled birth weight D. Infant formula or breast milk provides adequate nutrients for the first year
A. Infant cereal can be introduced by spoon when the extrusion reflex fades Rationale: Note: Order of introducing food to infant includes: Cereal Vegetables Fruits Meat
Situation 7: Diagnostic tests provide data about the well being of the pregnant client and the fetus. 31. A patient is 18 weeks pregnant, and the nurse is assisting the provider during her prenatal visit. She overhears the provider tell the patient that the alpha-fetoprotein (AFP) level is a required prenatal test. The nurse knows that this test: A. Is not required, and the patient has a right to refuse it B. Is required, because the patient is high risk because of her age C. Is a simple blood test, and all women get it between 15 and 18 weeks gestation D. Is not required, but is often associated with false-negative results
A. Is not required, and the patient has a right to refuse it Rationale. A. Note: AFP level detects neural tube birth defects (e.g decreased AFP= Down Syndrome)
79. A postpartum client has a temperature of 101.4°F, with uterus that is tender when palpated, remains unusually large, ad is not descending as normally expected. Which of the following should the nurse assess next? A. Lochia B. Breast C. Incision D. Urine
A. Lochia
99. A 16-year-old patient delivers her first baby and is on the postpartum unit. She has done very little to care for the infant and does not maintain eye contact with the infant. What should the nurse do? A. Make a referral to the social worker B. Notify the provider C. Make a referral to the lactation consultant D. Notify the charge nurse
A. Make a referral to the social worker
42. . A pregnant patient who's fatigued is likely to be more comfortable in which position? A. Modified sim's B. Supine with legs elevated C. Supine with head elevated D. Sitting upright with legs elevated
A. Modified sim's
20. Which of the following methods would be avoided for a woman who is 38 year, has three children, and smokes one pack of cigarettes per day? A. Oral contraceptives B. Cervical cap C. Diaphragm D. Intrauterine device
A. Oral contraceptives
135. When observing a toddler playing with other children in the playroom, the nurse would expect the toddler to engage in: A. Parallel play B. Solitary play C. Competitive play D. Tumbling-type play
A. Parallel play Rationale: Note: Option B. Solitary play is common in infants Option C. Competitive play is common in school aged
9. Variations in the length of the menstrual cycle are due to variations in the number of days in which of the following phases? A. Proliferative phase B. Luteal phase C. Ischemic phase D. Secretory phase
A. Proliferative phase
Situation 10: Children are very prone to accidents. Nurses share the responsibility in counseling parents about accident prevention. 146. When a mother with a 4-month-old infant comes to the well-baby clinic, the nurse should include in the accident prevention teaching plan the need to: A. Remove all tiny objects from the floor B. Cover electric outlets with safety plugs C. Keep crib rails up to the highest position D. Remove poisonous substances from low areas
A. Remove all tiny objects from the floor C. Keep crib rails up to the highest position
128. Which food should parents be taught to avoid giving their 6-month-old child? A. Scrambled eggs B. milk C. Cereal D. Applesauce
A. Scrambled eggs Rationale: A. Eggs are known to be irritants
130. When ordering a regular diet for a young toddler, the nurse should choose foods such as: A. Spaghetti and cheese sticks B. Corn dog and French fries C. Hamburger and grapes D. Hot dog and potato chips
A. Spaghetti and cheese sticks
Situation 9: Symptoms of pregnancy tend to cause discomforts to a woman. Providing empathetic and sound advice about measures to relieve these discomforts help promote overall health and well-being. 41. A client at 8 weeks' gestation calls complaining of slight nausea in the morning hours. Which of the following client interventions should the nurse question? A. Taking 1 teaspoon of bicarbonate soda in an 8-ounce glass of water B. Eating few low-sodium crackers before getting out of bed C. Avoiding the intake of liquids in the morning hours D. Eating six small meals a day instead of three large meals
A. Taking 1 teaspoon of bicarbonate soda in an 8-ounce glass of water Rationale. A. Taking bicarbonate soda may cause complications
Situation 18: Breastmilk remains the ideal nutritional source for infants through the first year of life. Nurses are prime people to teach the women about the benefits of breastfeeding and provide anticipatory guidance for problems that may occur. 86. Which of the following should the nurse do when a breastfeeding primipara tells the nurse that she has sore nipples? A. Tell her to breastfeed more frequently B. Administer an opioid analgesics before breastfeeding C. Encourage her to wear a nursing bra D. Use soap and water to clean the nipples
A. Tell her to breastfeed more frequently
54. A client is concerned about gaining weight during pregnancy. The nurse explains that the largest part of weight gain during pregnancy is because of: A. The fetus B. Fluid retention C. Metabolic alterations D. Increased blood volume
A. The fetus Rationale: A. Fluid retention- 20-25 % weight Increased blood volume- 12-16 % weight
114. Which of the following describes Babinski reflex? A. The newborn's toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of the foot is stroked upward B. The newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement or loud noise C. The newborn turns his head in the direction of stimulus, opens his mouth, and begins to suck when cheek, lip, or corner of the mouth is touched D. The newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface
A. The newborn's toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of the foot is stroked upward
139. Why are small-for-gestational-age newborns at risks for difficulty maintaining body temperature? A. They do not have as many fat stores as other infants B. They are more active than usual so throw off covers C. Their skin is more susceptible to conduction of cold D. They are preterm so are born relatively small in size
A. They do not have as many fat stores as other infants
17. When teaching the client who is receiving medroxyprogesterone (Depo-Provera) contraceptive injections, at which of the following times would the nurse instruct the client to return to the clinic for follow-up? A. Twelve weeks for a subsequent injection B. Six months for Papanicolaou smear C. One year for an annual gynecologic examination following times D. Five years for reevaluation of family planning goals B. Six months for Papanicolaou smear
A. Twelve weeks for a subsequent injection Rationale: A. Depo Provera- needs 12 weeks subsequent injection
69. What is the cause of late decelerations A. Utero-placental insufficiency B. Umbilical cord compression C. Prolonged labor D. Head compression
A. Utero-placental insufficiency Rationale: A Note: "VEAL" "CHOP" V- ariable C- ord compression E- arly H- ead compression A-ccelaration O- kay L- ate P- lacental insufficiency
124. The nurse practitioner has ordered amoxicillin 145 mg PO TID for a 28-lb toddler. It is supplied as a suspension of 250 mg/5 mL. The safe dosage is 35 mg/kg/24 hours. Is this dose safe? A. Yes B. No C. Cannot be determined D. There is inadequate data
A. Yes
5. The physician documented gynecoid pelvis after a pelvic exam of a client. The nurse knows that this refers to which of the following? A.) A typical female pelvis with a rounded inlet B. A normal pelvis with a a heart-shaped inlet C. An apelike pelvis with an oval inlet D. A flat female pelvis with a transverse oval inlet
A.) A typical female pelvis with a rounded inlet Rationale: A. A. Gynecoid- typical female pelvis with a rounded inlet B. Android- A normal pelvis with a heart-shaped inlet C. Anthropoid- An apelike pelvis with an oval inlet D. Platypelloid- A flat female pelvis with a transverse oval inlet
149. Which statement made by the young mother indicates she understands child-proofing her home and preventing injuries for her 3-year-old son? A. "The only way I can get my child to take his medicine is to pretend that it is candy." B. "All medications have child-resistant caps and are stored in the medicine cabinet above the sink." C. "My child is allowed to play in the backyard with a friend while I watch from the window and care for my newborn" D. "The electrical outlets are covered with protective devices and our front odor is only locked and chained at night for our protection."
B. "All medications have child-resistant caps and are stored in the medicine cabinet above the sink."
109. When assessing the newborn's heart rate, which of the following ranges would be considered normal if the newborn were sleeping? A. 80 bpm B. 100 bpm C. 120 bpm D. 140 bpm
B. 100 bpm
Situation 6: The physiology of good nutrition is important for the growth and development of children from various age groups. 126. A newborn weighing 3,000 grams and feeding every 4 hours needs 120 calories/kg of body weight every 24 hours for proper growth and development. How many ounces of 20-calories/ounce formula should this newborn receive at each feeding to meet nutritional needs? A. 2 ounces B. 3 ounces C. 4 ounce D. 6 ounces
B. 3 ounces
121. The adult dose is Dilantin 150 mg. How much should be given to a 6-year-old child? A. 20 mg B. 50 mg C. 75 mg D. 100 mg
B. 50 mg
133. The average 5-year-old child is incapable of: A. Tying shoelaces B. Abstract thought C. Making decisions D. Hand-eye coordination
B. Abstract thought
33. Fetal lung maturity is confirmed by phosphatidylglycerol and lecithin/sphingomyelin ratio. Patient education regarding this test is: A. Take nothing by mouth after midnight in preparation for an early-morning blood draw B. An amniocentesis will be done to test the amniotic fluid C. Remember to eat a meal before testing, as a mother's low blood sugar can alter the test results D. An amniocentesis will be done to test the cord blood
B. An amniocentesis will be done to test the amniotic fluid Rationale: B. Phosphatidylglycerol and lecithin/sphingomyelin ration= amniocentesis
52. Nutritional planning for a newly pregnant woman of average height weighing 145 pounds should include: A. A decrease of 200 calories per day B. An increase of 300 calories per day C. An increase of 500 calories per day. D. A maintenance of her present cal intake
B. An increase of 300 calories per day Rationale: B. Note: An increase of 300 calories per day= pregnant An increase of 500 calories per day= lactating mother
53. A primigravida woman in her 10th week of gestation is concerned because she has read that nutrition during pregnancy is important for the growth and development of the fetus. She wants to know something about the food she should eat. The nurse should: A. Instruct her to continue eating a normal diet B. Assess what she eat by taking a diet history C. Give her a list of food to help her better plan her meals D. Emphasize the importance of limiting salt and highly seasoned food
B. Assess what she eat by taking a diet history
Situation 3: Aside from moving their extremities, attempting to control head movement, and exhibiting a strong cry, mature newborns demonstrate neuromuscular function by demonstrating newborn reflexes. 111. Which of the following groups of newborn reflexes, are present at birth and remain unchanged through adulthood? A. Blink, cough, rooting and gag B. Blink, cough, sneeze, and gag C. Rooting, sneeze, swallowing and cough D. Stepping, blink, cough, and sneeze
B. Blink, cough, sneeze, and gag
148. Keeping in mind the leading cause of accidents in infants, the nurse should advise parents to: A. Buy clothes for the infant with buttons rather than snaps B. Check all toys for small removable parts C. Provide round cylinder-type toys D. Avoid finger foods before the age of 15 months
B. Check all toys for small removable parts
32. A 40-year-old patient who is 8 weeks pregnant and desires fetal testing is able to have the following test at this time: A. Biophysical profile B. Chorionic villus sampling C. Amniocentesis D. Alpha-fetoprotein test
B. Chorionic villus sampling
63. The nurse understands that the fetal head is in which of the following positions with a face presentation? A. Completely flexed B. Completely extended C. Partially extended D. Partially flexed
B. Completely extended
49. Which of the following terms refer to the thickened endometrium, in which the fertilized embryo implants? A. Endoderm B. Decidua C. Amnion D. Chorion
B. Decidua
13. When preparing to listen to the fetal heart rate at 12 week's gestation, the nurse would use which of the following? A. Stethoscope placed midline at the suprapubic region B. Doppler placed midline at the suprapubic region C. Fetoscope placed midway between the umbilicus and the xiphoid process D. External electronic fetal monitor placed at the umbilicus
B. Doppler placed midline at the suprapubic region Rationale: B. Doppler= 3 months; Fetoscope= 4months; Stethoscope= 5 months and above
80. During assessment of the perineum, the nurse identifies three medium-blue, soft, painful hemorrhoids. Which of the following would be the nurse's best initial action? A. Instruct the client to ambulate 3 times a day B. Encourage the client to use the sitz bath C. Teach the client about foods high in fiber D. Administer a stool softener
B. Encourage the client to use the sitz bath Avoid high in fiber, may cause constipation
22. During which of the following would the focus of classes be mainly on physiologic changes, fetal development, sexuality during pregnancy and nutrition? A. Prepregnant period B. First trimester C. Second trimester D. Third trimester
B. First trimester
112. A newborn who has an asymmetrical Moro reflex response should be further assessed for which of the following? A. Talipes equinovarus B. Fractured clavicle C. Congenital hypothyroidism D. Increased intracranial pressure
B. Fractured clavicle
119. While nipple-feeding a preterm newborn (32 weeks' gestation, 4 lb), the nurse notes evidence of exhaustion, increased respirations and pulse, and a dusky color. The nurse should stop the feeding and do which of the following? A. Notify the physician B. Gavage-feed the remainder C. Position the infant on the left side D. Administer oxygen via nasal cannula
B. Gavage-feed the remainder
97. The home health nurse visits a client 3 weeks after delivery. The single mother cries and tells the nurse, "I just can't seem to be able to take care of myself and the baby, too. I'm not a good mother. The baby cries a lot and gets on my nerves! I'm always sad and imitable!" which of the following nursing diagnoses would be most appropriate? A. Hopelessness B. Ineffective individual coping C. Powerlessness D. Altered parenting
B. Ineffective individual coping
129. Which instructions should be given to a mother of a 6-month-old infant regarding the introduction of solid food? A. The order of introducing food begins with cereal and meats, followed by fruits and vegetables. B. Introduce one food at a time, at intervals of 4 to 7 days C. Chopped table food or commercially prepared junior food are appropriate D. The quantity of formula will say the same as the amount of solid foods increase
B. Introduce one food at a time, at intervals of 4 to 7 days
90. A mother desires to exclusively breastfeed her full term infant. On admission to the mother/baby unit, the nurse discusses the ideal situation to enhance early and exclusive breastfeeding, which includes all of the following EXCEPT: A. Keeping the baby in the mother's room 24 hours (day and night) B. Letting the baby spend the first night in the nursery so the mother can sleep C. Performing skin-to-skin contact when possible D. Feeding the infant with proper latch-on when hunger cues are present
B. Letting the baby spend the first night in the nursery so the mother can sleep
115. What is the best way to test Moro reflex? A. Observe the infant while she is on her abdomen to see whether she can turn her head B. Lift the infant's head while she is supine and allow it to fall back one inch C. Shake the infant's crib until the infant responds by flailing her arms D. Make a sharp noise, such as clapping your hands, to wake an infant
B. Lift the infant's head while she is supine and allow it to fall back one inch
Situation 2: Nursing assessment is not only the first step in the nursing process, but also the fundamental means by which a nurse establishes and maintains contact with a child and family. Nurses must have the skills in performing Newborn Assessment in order to detect any health deviations that may require interventions. 106. An important nursing consideration when performing physical assessment on a newborn is to: A. Prevent squirming B. Maintain body temperature C. Examine the ears and throat before the eyes and nose D. Avoid restraints.
B. Maintain body temperature Rationale: B. Ensure effective thermoregulation at this stage= may use radiant warmer
37. Which of the following would the nurse identify as a presumptive sign of pregnancy? A. Hegar sign B. Nausea and vomiting C. Skin pigmentation changes D. Positive serum pregnancy test
B. Nausea and vomiting
Situation 3: Trixie, a 35-year-old pregnant client is at the well baby clinic for her prenatal visit. She is on her 12th week of pregnancy. 11. . Trixie tells the nurse that her last menstrual period started January 14 and ended January 20. Using Nagele's rule, the nurse determines her estimated date of delivery to be which of the following? A. September 27 B. October 21 C. November 7 D. December 27
B. October 21 Rationale: B. Using the Naegele's Rule; (-3 months, + 7days)= October 21
38. The nurse documents positive ballottement in the client's prenatal record. The nurse understands that this indicates which of the following? A. Contractions palpable on the abdomen B. Passive movement of the unengaged fetus C. Fetal kicking felt by the client D. Enlargement and softening of the uterus
B. Passive movement of the unengaged fetus
118. When implementing supportive measures for airway clearance for the preterm newborn, the nurse would plan to do which of the following? A. Assess for hypoglycemia and other complications, such as fractures and Bell's palsy B. Perform suctioning as needed, positioning the newborn to facilitate chest expansion C. Observe for hypercalcemia, respiratory distress, polycythemia, and altered parenting D. Provide chest physiotherapy before feedings, assessing for potential respiratory distress
B. Perform suctioning as needed, positioning the newborn to facilitate chest expansion Note: Suctioning do not need Doctor's Order
75. Which of the following is the nurse's initial action when umbilical cord prolapse occurs? A. Begin monitoring maternal and fetal vital signs B. Place the client in a knee-chest position C. Notify the physician immediately and prepare the client for delivery D. Apply a sterile water saline dressing to the exposed cord
B. Place the client in a knee-chest position
87. Lactation is stimulated by: A. Estrogen B. Prolactin C. Progesterone D. FSH
B. Prolactin
8. Days 6 through 14 of the menstrual cycle institute which of the following? A. Estrogen B. Proliferative C. Luteal D. Secretory
B. Proliferative Rationale: B. Phases of Menstruation ("PSIM") Proliferative= 6-14 days Secretory= 15-21 days Ischemic= 21-28 days Menstruation: 1-5 days
147. When teaching a mother how to prevent accidents while caring for her 6-month-old infant, the nurse should emphasize that at this age, a child can: A. Sit up B. Roll over C. Crawl lengthy distances D. Stand while holding on to furniture
B. Roll over Note: Option A: Sit-up is 7-8months Option C. Crawl lengthy distances (9 months) Option D. Stand while holding (8-10 months)
Situation 10: Assessing the fetal growth all throughout pregnancy is important because the predictable stages of fetal development provide guides for determining the well-being of individual fetuses. 46. The corpus luteum acts as the placenta for the implanted ovum until the end of which of the following gestational months? A. First B. Second C. Third D. Fourth
B. Second Rationale. B. In the 3rd trimester- placenta occurs
82. A postpartum client has not been immunized against rubella. The nurse understands that the patient needs rubella immunization prior to her discharge. What instruction will the nurse give the patient regarding this injection? A. She can get the injection at her postpartum visit B. She should not become pregnant in the next 3 months C. She should not take her prenatal vitamins once she receives the injection D. She cannot take birth control pills after receiving the injection Rationale: B. Rubella is live attenuated- teratogenic
B. She should not become pregnant in the next 3 months
62. When describing fetal position, the first letter in the series denotes which of the following? A. Presenting part of the fetus B. Side of the maternal pelvis C. Size of the maternal pelvis D. Type of fetal delivery
B. Side of the maternal pelvis
117. Which of the following assessment finding would the nurse expect in the preterm newborn? A. Tachypnea, decreased or absent parental visits, constant return to fetal position, hyperpnea B. Tachypnea, abnormal ABG values, decreased sucking reflex, temperature instability C. Cyanosis, abnormal ABG values, unstable core body temperature, increased gag and sucking reflexes D. Hyperpnea, unstable core body temperature, bradycardia, cyanosis, arching behaviors and hyperextension
B. Tachypnea, abnormal ABG values, decreased sucking reflex, temperature instability This indicates for small for gestational age (SGA)
3. When teaching a group of adolescents about male hormone production, which of the following would the nurse include as being produced by the Leydigg cells? A Follicle-stimulating hormone B. Testosterone C. Luteinizing hormone D. Gonadotropin-releasing hormone
B. Testosterone Rationale: B. Leydigg cells produce the male hormone; testosterone only male hormone in the choice
72. Katrina's last vaginal exam was recorded as 6cm, 80% and -3. How does the nurse interpret this assessment? A. The cervix is effaced 6 cm and dilated 80%; the presenting part is 3 cm below the ischial spine. B. The cervix is dilated 6 cm and effaced 80%; the presenting part is 3 cm above the ischial spine. C. The cervix is effaced 6 cm and dilated 80%; the presenting part is 3 cm above the ischial spine. D. The cervix is dilated 6 cm and effaced 80%; the presenting part is 3 cm below the ischial spine.
B. The cervix is dilated 6 cm and effaced 80%; the presenting part is 3 cm above the ischial spine. Rationale: D. Note: (-)- floating; above ischial spine (0)- engaged (+)- below ischial spine; crowning
110. Which of the following when present in the urine may cause a reddish stain on the diaper of a newborn? A. Mucus B. Uric acid crystals C. Bilirubin D. Excess iron
B. Uric acid crystals
144. A 15-month old is playing in the playpen. The nurse evaluates that the child's ability to perform physical tasks is at the age-related norm when the child is able to: A. Build a tower of 6 blocks B. Walk across the playpen with ease C. Throw all the toys out of the playpen D. Stand in the playpen holding onto the sides
B. Walk across the playpen with ease
39. The client has completed an at-home pregnancy test with positive results. Which of the following indicates the client understands the meaning of the test results? A. "I understand that this means I have ovulated in the past 24 hours." B. "I understand that this means I am not pregnant." C. "I understand that this means I might be pregnant." D. "I understand that this means I am pregnant."
C. "I understand that this means I might be pregnant." Rationale C. +HCG means probable sign
150. Which statement made by a mother of a 7-year-old child indicates she understands strategies to prevent accidents? A. "A helmet is not necessary now that my child has learned how to ride a bicycle." B. "My child has taken swimming lessons and swims unsupervised in our pool." C. "My child wears a helmet, wrist guards, and knee and elbow pads when skateboarding." D. "My child wears a helmet while going the sole operator of an all-terrain vehicle."
C. "My child wears a helmet, wrist guards, and knee and elbow pads when skateboarding."
Situation 2: The Menstrual Cycle refers to the changes in the uterus and ovaries, which recur cyclically from the time of the menarche to the menopause. 6. A client asks, "How much blood do I lose during menstruation?" Which of the following would be the nurse's best response? A. "Normal blood loss can be a little or a lot. B. "Normal blood loss is about 1 cup." C. "Normal blood loss is about 1/4 cup." D. "Normal blood loss is about 1/8 cup."
C. "Normal blood loss is about 1/4 cup." Rationale: C. Normal blood loss is about ¼ cup or 50 ml
113. During assessment of a newborn, the nurse is evaluating the rooting reflex. Which assessment techniques and findings would indicate the presence of this reflex? (1) The cheek is stroked (2) The tongue is depressed (3) The outer sole of the foot is stroked (4) The infant flexes the hand and toes (5) The infant coughs (6) The infant begins to suck A. 3 and 4 B. 5 and 6 C. 1 and 6 D. 1 and 2
C. 1 and 6
125. An infant is hospitalized for dehydration. The child has just urinated and the practitioner has changed the IV order to 5% dextrose in 1/2 normal saline and 20 mEq/L of potassium chloride. A 500 mL bag of 5% dextrose in /1⁄2 normal saline is available. The potassium chloride label reads 2 mEq/mL. How many millimeters of potassium chloride should the nurse add to the 500 mL bag? A. 2.5 mL B. 5 mL C. 10 mL D. 15 mL
C. 10 mL
Situation 8: You are working as a Pediatric Nurse in your own Child Health Nursing Clinic. The following cases pertain to Assessment and Care of the Newborn at Risk conditions. 136. A mother of a 2-year-old daughter asks, "At what age can I be able to take the blood pressure of my daughter as a routine procedure since hypertension is common in the family?" The most appropriate response would be: A. 2 years old B. 4 years old C. 3 years old D. 6 years old
C. 3 years old
23. Which of the following approaches to childbirth education advocates slow breathing, deep relaxation, and a person to act as coach? A. Dick-Read method B. New Childbirth method C. Bradley method D. Lamaze method
C. Bradley method Rationale: It teaches couples to manage labor through deep breathing and the support of a partner or labor coach.
35. What lab work is ordered on a pregnant patient suspected of having HELLP syndrome? A. Glucose screen and CBC B. Liver biopsy and liver enzymes C. CBC, platelet count, and liver enzymes D. Nonstress test and a biophysical profile
C. CBC, platelet count, and liver enzymes Rationale. C. Note: HELLP= Hemolysis, Elevated liver enzymes, Low Platelets
43. Heartburn and flatulence, common in the second trimester, are most likely the result of which of the following? A. Increased plasma HCG levels B. Decreased intestinal motility option C. Decreased gastric acidity D. Elevated estrogen levels
C. Decreased gastric acidity
95. Which of the following is the priority focus of nursing practice considering the current trend of early postpartum discharge? A. Promoting comfort and restoration health B. Exploring the emotional status of the family C. Facilitating safe and effective self-care and newborn care D. Teaching about the importance of family planning
C. Facilitating safe and effective self-care and newborn care
15. When measuring the fundal height of any pregnant client, which of the following techniques denotes the correct method of measurement by the nurse? A. From the xiphoid process to the umbilicus B. From the symphysis pubis to the xiphoid process C. From the symphysis pubs to the fundus D. From the fundus to the umbilicus
C. From the symphysis pubs to the fundus
Situation 17: Nurses play a role in anticipating and planning client needs after discharge. 81. Which of the following would be most important to include in the discharge teaching plan for a client who had a suction curettage evacuation of the uterus for hydatidiform molar pregnancy? A. Continuation of prenatal vitamins for 6 weeks B. Psychological support for grief counseling C. Importance of follow-up care D. Hormonal contraceptives to prevent pregnancy
C. Importance of follow-up care Rationale: C. Note: In H-mole pregnancy- not allowed to be pregnant for 2 years
67. Which of the following physiologic findings is expected during labor? A. Decreased white blood cell count B. Decreased blood pressure C. Increased cardiac output D. Increased blood glucose level
C. Increased cardiac output
2. A client has a midpelvic contracture from a previous pelvic injury due to a motor vehicle accident as a teenager. The nurse is aware that this could prevent a fetus from passing through or around which structure during childbirth? A. Symphysis pubis B. Sacral promontory C. Ischial spines D. Pubic arch
C. Ischial spines
84. The nurse counsels a postpartum client on the frequency and timing of breast self-exams. When should the exams be conducted in this patient? A. Weekly and mid-cycle B. Monthly mid-cycle C. Monthly during the menstrual cycle D. Every day during the menstrual cycle
C. Monthly during the menstrual cycle Rationale: C. Breast self exam is usually done monthly, after or before 7 days of menstrual cycle
14. Which of the following findings during a prenatal exam should the nurse report to the physician for further evaluation? A. Breast tenderness B. Increased areolar pigmentation C. Nodularity in the upper-let outer quadrant D. Prominent superficial veins
C. Nodularity in the upper-let outer quadrant Rationale: C. Left upper quadrant- common modules/tumor are found in the breast
93. During the postpartum period, while considering nursing measures to help parent-child relationships, the nurse should be aware that the most important factor at this time is the: A. Anesthesia during labor B. Duration and difficulty of labor C. Physical condition of the infant D. Health status during pregnancy
C. Physical condition of the infant
102. Which of the following actions would be least effective in maintaining a neutral environment for the newborn? A. Placing an infant under a radiant warmer after bathing B. Covering the scale with a warmed blanket prior to weighing C. Placing crib close to the nursery window for family viewing D. Covering the infant's head with a stockinette
C. Placing crib close to the nursery window for family viewing
94. When caring for a family on postpartum unit, the nurse must be aware that all the tasks, responsibilities, and attitudes that makeup child care can be called parenting and that either parent can exhibit these qualities. Which factor would most importantly influence parenting ability? A. Marriage with flexible roles B. Inborn ability based on instinct C. Positive childhood roles and concepts D. Good education in growth and development
C. Positive childhood roles and concepts
Situation 8: All maternal body systems are altered by pregnancy. The following questions pertain to the signs and symptoms of pregnancy. 36. Cervical softening and uterine souffle are classified as which of the following? A. Diagnostic signs B. Presumptive signs C. Probable signs D. Positive signs
C. Probable signs
18. For which of the following clients would the nurse expect that an intrauterine device would not be recommended? A. Woman over age 35 B. Nulliparous woman C. Promiscuous young adult D. Postpartum client
C. Promiscuous young adult Rationale: C. Promiscuous clients are those with many sexual partners
Situation 19: Postpartum nursing care extends from the termination of labor to 6 weeks thereafter, in which the nurse bears responsibilities. 91. When caring for a client in the postpartum "taking-in" psychosocial adaptation phase, the nurse should plan to do which of the following? A. Promote self-care activities B. Expect control of elimination functions C. Provide nourishment and rest D. Teach newborn care skills
C. Provide nourishment and rest Rationale: C Note: Taking In- self-centered mother Taking hold- baby centered Let go- create new journey with baby
55. A patient who is 20 weeks pregnant tells the nurse that her prenatal vitamin makes her sick. Which is the best suggestion? A. Take the vitamin with breakfast B. Stop taking the vitamin for a few days and then resume C. Take the vitamin at bedtime D. Take the vitamin with milk between meals
C. Take the vitamin at bedtime Rationale: C. Taking the vitamin at bedtime help mother to sleep
108. Which of the following is true regarding the fontanels of the newborn? A. The anterior is triangle-shaped; the posterior is diamond-shaped B. The posterior closes at 18 months; the anterior closes at 2 to 3 months C. The anterior is larger in size when compared to the posterior fontanel D. The anterior is bulging; the posterior appears sunken
C. The anterior is larger in size when compared to the posterior fontanel Rationale: C. Note: Anterior: Diamond shape; closes 18 months; while Posterior: Triangle shape: closes 2 months
105. A nurse providing care to a newborn would use knowledge of which of the following concepts underlying adaptation of the newborn's immune system? A. Iron stores from the mother are sufficient to carry the newborn through the 5th month of extrauterine life B. Unconjugated bilirubin can leave the vascular system and permeate the other extravascular tissues C. The newborn is unable to limit invading organisms at their point of entry D. Most newborns void in the first 24 hours after birth and 5 to 20 times thereafter
C. The newborn is unable to limit invading organisms at their point of entry
73. While in active labor at 6cm, Katrina requests for an epidural. The nurse knows: A. The patient is too far dilated to receive an epidural B. An epidural is not an intervention indicated for this stage in labor C. The patient will need to have labs drawn before an epidural can be given D. An epidural can be given to manage the client's pain
C. The patient will need to have labs drawn before an epidural can be given Rationale: C. Before administering epidural, platelet count needs to be checked
Situation 13: A nurse is aware that the delivery process can be affected by factors including the maternal pelvis, fetal position, and fetal presentation. 61. Which of the following factors affecting labor is associated with the passageway A. Size of the fetal head and its ability to mold to the maternal pelvis B. The presentation of the fetus in relation to maternal pelvis C. The structure of the maternal pelvis D. The frequency, duration and strength of uterine contractions
C. The structure of the maternal pelvis
Situation 7: The different theories on growth and development serve as guide in rendering nursing care to clients. Thus, it is essential that nurses be aware of these theories. 131. According to Erikson's theory of emotional development, infants will develop a sense of trust when: A. They can identify their mother and father B. They feel a sense of belonging, accepted as part of the family C. They can predict what is coming, and their needs are consistently met D. Their nutritional and hygiene needs are provided on a daily basis
C. They can predict what is coming, and their needs are consistently met
57. Barbiturates are usually not given for pain relief during active labor for which of the following reasons? A. The neonatal effects include hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the first few days B. These drugs readily cross the placental barrier, causing depressive effects in the newborn 2 to 3 hours after intramuscular injection C. They rapidly transfer across the placenta, and lack of an antagonist make them generally inappropriate during active labor D. Adverse reactions may include maternal hypotension, allergic or toxic reaction, or partial or total respiratory failure
C. They rapidly transfer across the placenta, and lack of an antagonist make them generally inappropriate during active labor Rationale: C. Option A: Neonatal side effects Option B: Narcotic analgesic effect Option D. Regional anesthesia effect
PEDIATRIC NURSING Situation 1: The first hours after birth represent a critical adjustment period for the newborn. The nurse must provide direct care to the newborn immediately after birth. 101. Which of the following would the nurse identify as goal of newborn care in the initial postpartum period? A. To facilitate development of a close parent-newborn relationship B. To assist parents in developing healthy attitudes about childbearing practices. C. To identify actual or potential problems requiring immediate or emergency D. To provide the parents of the newborn with information about well-baby programs
C. To identify actual or potential problems requiring immediate or emergency
103. When preparing to administer the vitamin K to a neonate, the nurse would select which of the following sites as appropriate for the injection? A. Deltoid muscle B. Anterior femoris muscle C. Vastus lateralis muscle D. Gluteus maximus muscle
C. Vastus lateralis muscle
137. You typically gag children to inspect the back of their throat. When is it important NOT to elicit a gag reflex? A. When a girl has a geographic tongue B. When a boy has a possible inguinal hernia C. When a child has symptoms of epiglottitis D. When children are under 5 years of age
C. When a child has symptoms of epiglottitis
Situation 1: The Anatomy and Physiology of the Reproductive System is a basic knowledge that nurses must know. 1. Which of the following refers to the single cell that reproduces itself after conception? A. Chromosome B. Blastocyst C. Zygote D. Trophoblast
C. Zygote
28. A 26-week, G1PO patient confides to the nurse that her husband refuses to have intercourse because he is afraid he will hurt the baby by introducing germs. What information would be helpful to this couple? A. A mucous substance called leukorrhea will clear the vagina of any unfriendly bacteria B Douching with warm saline solution after intercourse will protect the baby from bacteria C.The mucous plug that seals the cervix acts as a barrier against bacterial invasion during pregnancy D. Couples having sexual problems during pregnancy should consider making an appointment with a marriage counselor
C.The mucous plug that seals the cervix acts as a barrier against bacterial invasion during pregnancy Note: In the 2nd trimester- highest libido of mother
34. What is the primary reason an ultrasound is done in the first trimester? A. Evaluate fetal structure B. Measure amniotic fluid C. Determine sex D Determine gestational age
D Determine gestational age
Situation 5: Research demonstrates that childbirth preparation courses can increase satisfaction, reduce the amount of reported pain, and increase feelings of control for the pregnant woman and her partner. Thus, childbirth education is now recommended for all expectant parents by most care providers. 21. Which of the following best defines childbirth education? A. The minimal level of teaching requirements for prenatal care in this country, as advocated by health care professionals B. Approach to childbirth involving the use of a coach and advocation of natural childbirth without analgesia C. Achievement of a positive, safe and rewarding labor and birth experience for parents and family members D Information, exercises and techniques to deal with the discomforts of pregnancy, labor and birth
D Information, exercises and techniques to deal with the discomforts of pregnancy, labor and birth Rationale: D. When we say childbirth education it refers to information
83. A postpartum patient's husband asks, "When can my wife and I resume intercourse?" What is the nurse's best response? A. "Anytime your wife feels like she wants to." B. "You can resume intercourse in 6 months." C. "When her birth control method starts to work." D. "It is advised to wait until after her 6-week checkup."
D. "It is advised to wait until after her 6-week checkup." Rationale: D. The best answer when asked when to resume intercourse is until the incision heals or in the mnemonic "666"- 6 weeks after delivery
10. During the menstrual cycle, ovulation generally occurs at which of the following times? A. 7 days after the last day of menstruation B. 14 days after the last day of the menstrual cycle C. 7 days before the end of menstruation D. 14 days before the end of the menstrual cycle
D. 14 days before the end of the menstrual cycle
78. The nurse assesses the postpartum vaginal discharge on four clients. Which of the following assessments would warrant notification of the physician? A. A dark red discharge on a 2-day postpartum client B. A pink to brownish discharge on a client who is 5 days postpartum C. Almost colorless to creamy discharge on a client 2 weeks after delivery D. A bright red discharge 5 days after delivery
D. A bright red discharge 5 days after delivery Rationale: D Note: Lochia rubra- 2-3 days Lochia serosa- 3-10 days Lochia alba- 10-13 days
64. With a fetus in the left anterior breech presentation, the nurse would expect the fetal heart rate would be most audible in which of the following areas? A. Above the maternal umbilicus and to the right of midline B. In the lower left maternal abdominal quadrant C. In the lower left right maternal abdominal quadrant D. Above the maternal umbilicus and to the left of midline
D. Above the maternal umbilicus and to the left of midline
Situation 20: The postpartum period represents a time of emotional stress for the new mother. The nurse, therefore, should provide emotional and psychological support in order promote maternal-infant and family- infant attachment. 96. Which of 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
D. Ambivalence, fear, fantasies Rationale: D Note: Psychological Tasks During Pregnancy 1st trimester: accept the pregnancy; ambivalence (2 opposing feelings) 2nd trimester: accept the fetus. Feels quickening, narcissism and introversion 3rd trimester: preparing for childbirth and parenthood, nesting (walay gawas2x)
Situation 16: Doing Physical Assessment during the postpartum period is essential because it provides baselines data of the client's health status for earlier detection of any deviation from the normal. 76. Before assessing the postpartum client's uterus for firmness and position in relation to the umbilicus and midline, which of the following should the nurse do first? A. Assess the vital signs B. Administer analgesia C. Ambulate the client in the hall D. Assist the client to urinate
D. Assist the client to urinate
48. An expectant mother asks the nurse in the prenatal clinic, "When can I expect to feel my baby move?" Which of the following would be the nurse's best response? A. At about 2 months B. At about 3 months C. At about 4 months D. At about 5 months
D. At about 5 months Rationale. D. Note. At about 5 months, the fetus is 19 cm and 300 grams
Situation 4: A Preterm Newborn will need care from a skilled professional health team. 116. When describing a preterm newborn, the nurse would describe the newborn as being born at which of the following? A. Before 25 weeks' gestation B. After 25 weeks' gestation C. After 37 weeks' gestation D. Before 37 weeks' gestation
D. Before 37 weeks' gestation
104. The first period of reactivity in the newborn begins at birth. The following are characteristics of this period EXCEPT: A. This lasts for 30 minutes B. Respirations are increased to 80/minute C. Flaring of nares and grunting are common D. Bowel sounds are present
D. Bowel sounds are present Rationale: D. Bowel sounds are usually absent
77. Which of the following would the nurse expect to find when assessing a client who delivered a newborn 12 hours ago? A. Lochia alba B. Soft, boggy fundus C. Transient tachycardia D. Complaints of hunger
D. Complaints of hunger Rationale: D Option A: lochia alba- not considered, since newborn was delivered 12 hours ago Option B: soft, boggy fundus- may indicate bleeding, uterine atony Option C: transient tachycardia- not considered may initially be bradycardia
Situation 4: Family Planning involves the conscious decision making by which a couple decides on the number and spacing of children and the timing of births. The nurse assists the couple in choosing a family planning method by describing the methods available for reproductive planning along with its advantages and disadvantages. 16. In counseling the couple about the various Family Planning Methods, the nurse identifies that the most important factor in choosing a contraceptive method is: A. Financial expense B. Compliance with cultural expectations C. Non-contraceptive benefits D. Correct and consistent use
D. Correct and consistent use
Situation 11: Nutrition is an important aspect during pregnancy. It has a direct bearing on her health and on the fetal growth and development. Nurses can help guide pregnant women in planning a good diet. 51. The nurse in the prenatal clinic should provide nutritional counseling to all newly pregnant women because: A. Most weight gain during pregnancy is fluid retention X B. Dietary allowances should not increase during pregnancy C. Pregnant women must adhere to a specific pregnancy diet D. Different sources of essential nutrients are favored by different cultural groups
D. Different sources of essential nutrients are favored by different cultural groups
140. Baby John develops hyperbilirubinemia. What is a method used to treat hyperbilirubinemia in a newborn? A. Keeping infants in a warm and dark environment B. Administration of cardiovascular stimulant C. Gentle exercise to stop muscle breakdown D. Early feeding to speed passage of meconium
D. Early feeding to speed passage of meconium
12. When taking an obstetric history of Trixie, who states, "I had a son born at 38 weeks' gestation, a daughter born at 30 weeks gestation, and I lost a baby at about 8 weeks," the nurse should record her obstetric history as which of the following? A. G3 T2 PO AO L2 B. G4 T1 P1 A0 L2 C. G3 T2 PO A1 L2 D. G4 T1 P1 A1 L2
D. G4 T1 P1 A1 L2 Rationale: D. Since patient is being taken with an obstetric history- automatically patient is pregnant= Gravida: 4 Terms: Gravida- # of pregnancies Parity- Age of viability (20 weeks) Term- 37 weeks Preterm- <37 weeks Abortion- <20 weeks Living- # of children alive
19. When discussing contraceptive choices with a client who has a history of thrombophlebitis, the nurse would keep in mind that which of the following would be contraindicated? A. Intrauterine device B. Subdermal implants C. Intramuscular injections D. Hormonal contraceptives
D. Hormonal contraceptives
132. The nurse explains to the mother of a 2-year-old girl that the child's negativism is normal for her age and that it is helping her meet her need for: A. Trust B. Attention C. Discipline D. Independence
D. Independence
88. The nurse is recommending how to prevent iron-deficiency anemia in a healthy, full-term, exclusively breastfed infant. What should the nurse suggest? A. Iron drops after 1 month of age B. Iron-fortified commercial formula by 4-6 months of age C. Iron-fortified infant cereal by 2 months of age D. Iron-fortified infant cereal by 4-6 months of age
D. Iron-fortified infant cereal by 4-6 months of age
24. Which of the following best describes the effectiveness of childbirth education? A. It provides expectant parents with knowledge and skills necessary to cope with pregnancy B. It prepares expectant parents to be informed consumers of birthing attendants and facilities C. It provides a long time for expectant parents to express their concerns and fears D. It improves newborn health, parent-newborn bonding, and ability to cope with labor
D. It improves newborn health, parent-newborn bonding, and ability to cope with labor
Situation 9: Knowledge of the Growth and Developmental milestones of children allows the parents and health care providers alike to identify delays in the growth and development of the child. 141. While performing a neurodevelopmental assessment on a 3-month-old infant, which of the following characteristics would be expected? A. A strong Moro reflex B. A strong parachute reflex C. Roiling from front to back D. Lifting of head and chest when prone
D. Lifting of head and chest when prone
30. The nurse is planning an educational program for a client who is in her third trimester of pregnancy. Which of the following a childbirth education topics would be most appropriate? A. Childbirth health care provider selection B. Morning sickness management C. Nutritional needs during pregnancy D. Pain relief during labor and delivery
D. Pain relief during labor and delivery Rationale: D. Options B and C are focused in the 1st trimester
40. The client has come to the clinic because she suspects that she is pregnant. Which of the following would be the most definitive way to confirm the diagnosis? A. Client's report of amenorrhea for 3 months B. Positive Hegar's sign C. Pigmentation changes of the breast D. Palpation of fetal movement by the care provider
D. Palpation of fetal movement by the care provider Rationale. D. Positive sign- palpation of fetal movement
65. A patient is in labor and has just been told she has a breech presentation. The nurse should be particularly alert for which of the following? A. Quickening B. Ophthalmia neonatorum C. Pica D. Prolapsed umbilical cord
D. Prolapsed umbilical cord
60. Which of the following nursing interventions would the nurse perform during the third stage of labor? A. Obtain a urine specimen and other laboratory tests B. Assess uterine contraction every 30 minutes C. Coach for effective client pushing D. Promote parent-newborn interaction
D. Promote parent-newborn interaction Rationale: D. Third stage of labor or placental delivery: promoting parent-newborn interaction
142. What should the nurse emphasize when guiding parents about teething of their 6-month-old infant? A. Drooling is not normal and indicates that something is wrong B. Most infants will have a high fever and will be irritable and refuse to eat C. The use of teething powders and hard candy is encouraged D. Providing a frozen teething ring helps relieve the inflammation
D. Providing a frozen teething ring helps relieve the inflammation
107. A newborn's head circumference is 34 cm, and chest circumference is 32 cm. Which nursing action would be appropriate? A. Refer the newborn for evaluation for psychomotor retardation B. Prepare the mother for the probability that the physician will want to transilluminate the cranial vault C. Measure the occipitofrontal circumference daily D. Record the findings and take no further action
D. Record the findings and take no further action Rationale: D. Note: Normally, Head> Chest after born; After 24 hours: head should descend
134. If the preschooler is hospitalized, which of the following is likely to describe his or her feelings? A. Frustrated by the need to alter his or her rituals B. Depressed and angry C. Fearful of losing his or her self-esteem D. Restricted and restrained for mobilization
D. Restricted and restrained for mobilization
29. Second-trimester teaching includes all EXCEPT: A. Safe use of seat belts B. Pelvic rock exercises C. Signs of potential problems D. Restriction of tub bathing
D. Restriction of tub bathing
25. The following topics should be included in childbirth education for pregnant adolescents EXCEPT? A. Interpersonal relationships B. Sexuality issues C. Weight gain D. Sibling preparation classes
D. Sibling preparation classes Rationale: D. Rarely done
59. A client arrives at the hospital with the fetus' head already crowning. The client is bearing down, and birth appears imminent. The nurse should: A. Transfer her immediately by stretcher to the birthing unit B. Tell her to breathe through her mouth and not to bear down C. Instruct the client to pant during contractions and to breathe through her mouth D. Support the perineum with the hand to prevent tearing and tell the client to pant
D. Support the perineum with the hand to prevent tearing and tell the client to pant
74. Katina's latest vaginal exam is recorded as 8 cm, 90% and -2, when her water breaks. Immediately thereafter, the fetal heart rate decelerates into 60s. The nurse knows: A. This is a normal response when membranes rupture B. This is a normal fetal heart rate patter C. This could be a sign of uterine rupture D. This could be a sign of cord prolapse
D. This could be a sign of cord prolapse
98. Which of the following observable behaviors indicates that the client outcome of "will demonstrate positive bonding behaviors" has been met? A. Placing the infant across the knees or on the bed B. Handling the infant for feeding and diaper changes C. Asking few questions about newborn care D. Touching the unwrapped infant with palms of hands
D. Touching the unwrapped infant with palms of hands
Situation 15: Katrina, 27 years old, is newly admitted at Holy Child's Hospital in active labor. 71. When a client is positioned for birth, both legs should be positioned simultaneously to prevent: A. Venous stasis on the legs B. Pressure on the perineum C. Excessive pull of the fascia D. Trauma to the uterine ligaments
D. Trauma to the uterine ligaments
Situation 14: Nursing care during labor and delivery focuses on the physiologic safety of both the mother and the newborn. A competent nurse must know the basic concepts in labor and delivery. 66. Which of the following correctly identifies the theory explaining the onset of labor caused by a release of a complex cascade of bioactive chemical agents into the amniotic fluid? A. Oxytocin theory B. Prostaglandin theory C. Progesterone deprivation theory D. Uterine decidua activation theory
D. Uterine decidua activation theory Rationale: D Option A: Oxytocin theory: Uterus becomes more sensitive to oxytocin as pregnancy advances Option B: Prostaglandin theory: Lipids trigger steroids, releases precursors that increases prostaglandins Option C: Progesterone deprivation theory: Decrease progesterone in placenta
4. When performing a pelvic examination, the nurse observes a red, swollen area on the right side of the client's vaginal orifice. The nurse would document this as enlargement of which of the following: A. Clitoris B. Parotid gland C. Skene's gland D. bartholin's gland
D. bartholin's gland
47. Which of the following would the nurse estimate as the approximate gestational age for 19-cm fetus expelled by a client? A. 2 months B. 3 months C. 4 months D.5 months
D.5 months Rationale. D 2 months= 2-5 cm 3 months= 6-9 cm 4 months= 12-17 cm 5 months= 19 cm
Situation 12: Medical and nursing care given to a pregnant woman during labor and delivery varies for each stage of labor and delivery. Nurses must have basic knowledge on these stapes, to carve as gulus in rendering appropriate nursing interventions. 56. During which of the following stages of labor would the nurse assess "crowning"? A. First b. Second c. Third d. Fourth
b. Second