Module 1 Exam

Module 1 Exam
Questions
1. 1.ID: 383697173
A nurse is providing information to a group of pregnant clients and their partners about
the psychosocial development of an infant. Using Erikson's theory of psychosocial
development, the nurse tells the group that infants:
o
Rely on the fact that their needs will be met Correct
Need to tolerate a great deal of frustration and discomfort to develop a

healthy personality
Must have needs ignored for short periods to develop a healthy personality
Need to experience frustration, so it is best to allow an infant to cry for a

while before meeting his or her needs
Rationale: According to Eriksons theory of psychosocial development, infants struggle

to establish a sense of basic trust rather than a sense of basic mistrust in their world, their
caregivers, and themselves. If provided with consistent satisfying experiences that are
delivered in a timely manner, infants come to rely on the fact that their needs are met and
that, in turn, they will be able to tolerate some degree of frustration and discomfort until
those needs are met. This sense of confidence is an early form of trust and provides the
foundation for a healthy personality. Therefore the other options are incorrect.
Test-Taking Strategy: Use the process of elimination. Eliminate the option that contains
the closed-ended word "must." Eliminate the options that are comparable or alike and
indicate that experiencing frustration is necessary. Review Eriksons theory of
psychosocial development as it relates to the infant if you had difficulty with this
question.
Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child
nursing (3rd ed., pp. 56, 58). St. Louis: Elsevier.
Level of Cognitive Ability: Applying
Client Needs: Health Promotion and Maintenance

Integrated Process: Teaching and Learning
Content Area: Developmental Stages
Awarded 0.0 points out of 1.0 possible points.
2. 2.ID: 383697943
A nurse is weighing a breastfed 6-month-old infant who has been brought to the
pediatrician's office for a scheduled visit. The infant's weight at birth was 6 lb 8 oz. The
nurse notes that the infant now weighs 13 lb. The nurse should:
o
Tell the mother that the infant's weight is increasing as expected Correct
Tell the mother to decrease the daily number of feedings because the weight
gain is excessive
Tell the mother that semisolid foods should not be introduced until the infant's
weight stabilizes
o
Tell the mother that the infant should be switched from breast milk to formula
because the weight gain is inadequate
Rationale: Infants usually double their birth weight by 6 months and triple it by 1 year of
age. If the infant is 6 lb 8 oz, at birth, a weight of 13 lb at 6 months of age is to be
expected. Semisolid foods are usually introduced between 4 and 6 months of age.
Test-Taking Strategy: Use the process of elimination and focus on the data in the
question. Recalling that infants double their weight by 6 months of age will direct you to
the correct option. Review the growth rate of an infant if you had difficulty with this
question.
nursing (3rd ed., pp. 51-52). St. Louis: Elsevier.

Client Needs: Physiological Integrity
Integrated Process: Nursing Process/Implementation
3. 3.ID: 383697933
A nurse performing a physical assessment of a 12-month-old infant notes that the infant's
head circumference is the same as the chest circumference. On the basis of this finding,
the nurse should:
o
Suspect the presence of hydrocephalus
Suggest to the pediatrician that a skull x-ray be performed
Tell the mother that the infant is growing faster than expected
Document these measurements in the infant's health-care record Correct
Rationale: The head circumference growth rate during the first year is approximately 0.4
inch (1 cm) per month. By 10 to 12 months of age, the infants head and chest
circumferences are equal. Therefore, suspecting the presence of hydrocephalus, telling
the mother that the infant is growing faster than expected, and suggesting that a skull xray be performed are incorrect.
Test-Taking Strategy: Use the process of elimination. Eliminate the options that are
comparable or alike and indicate that the infant has a physiological problem. Review the
expected growth rate of an infant if you had difficulty with this question.
nursing (3rd ed., p. 52). St. Louis: Elsevier.

4. 4.ID: 383700007
A new mother asks the nurse, "I was told that my infant received my antibodies during
pregnancy. Does that mean that my infant is protected against infections?" Which
statement should the nurse make in response to the mother?
o
"Yes, your infant is protected from all infections."
"If you breastfeed, your infant is protected from infection."
"The transfer of your antibodies protects your infant until the infant is 12
months old."
o
"The immune system of an infant is immature, and the infant is at risk for
infection." Correct
Rationale: Transplacental transfer of maternal antibodies supplements the infants weak

response to infection until approximately 3 to 4 months of age. Although the infant
begins to produce immunoglobulin (Ig) soon after birth, by 1 year of age the infant has
only approximately 60% of the adult IgG level, 75% of the adult IgM level, and 20% of
the adult IgA level. Breast milk transmits additional IgA protection. The activity of Tlymphocytes also increases after birth. Even though the immune system matures during
infancy, maximal protection against infection is not achieved until early childhood. This
immaturity places the infant at risk for infection.
Test-Taking Strategy: Use the process of elimination. Eliminate the option containing the
closed-ended word "all." Recalling that breastfeeding alone does not protect the infant
from infection will assist you in eliminating the option that suggests breastfeeding
protects the infant. From the remaining options, use the strategy of selecting the umbrella
option to answer correctly. Review the physiological concepts related to the maturity of
body systems in an infant if you had difficulty with this question.
References: Lowdermilk, D., Perry, S., & Cashion. K. (2010). Maternity nursing (8th ed.,
pp. 446-447). St. Louis: Mosby.
McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child nursing (3rd
ed., p. 245). St. Louis: Elsevier.
Client Needs: Safe and Effective Care Environment
5. 5.ID: 383697962
A nurse is assessing the language development of a 9-month-old infant. Which
developmental milestone does the nurse expect to note in an infant of this age?
o
The infant babbles.
The infant says "Mama." Correct
The infant smiles and coos.
The infant babbles single consonants.
Rationale: An 8- to 9-month-old infant can string vowels and consonants together. The
first words, such as "Mama," "Daddy," "bye-bye," and "baby," begin to have meaning. A
1- to 3-month-old infant produces cooing sounds. Babbling is common in a 3- to 4month-old. Single-consonant babbling occurs between 6 and 8 months of age.
Test-Taking Strategy: Use the process of elimination and focus on the age of the infant.
Recalling the language development that occurs during infancy will direct you to the
correct option. Remember that an 8- to 9-month-old infant can string vowels and
consonants together. Review the developmental milestones related to language
development in an infant if you had difficulty with this question.
Level of Cognitive Ability: Understanding
Integrated Process: Nursing Process/Assessment
6. 6.ID: 383697923
The mother of a 9-month-old infant calls the nurse at the pediatrician's office, tells the
nurse that her infant is teething, and asks what can be done to relieve the infant's
discomfort. The nurse instructs the mother to:
o
Schedule an appointment with a dentist for a dental evaluation
Rub the infant's gums with baby aspirin that has been dissolved in water
Obtain an over-the-counter (OTC) topical medication for gum-pain relief
Give the infant cool liquids or a Popsicle and hard foods such as dry toast
Correct
Rationale: Although sometimes asymptomatic, teething is often signaled by behavior

such as nighttime awakening, daytime restlessness, an increase in nonnutritive sucking,
excess drooling, and temporary loss of appetite. Some degree of discomfort is normal. It
is unnecessary to obtain a dental evaluation, but a health-care professional should further
investigate any incidence of increased temperature, irritability, ear-tugging, or diarrhea.
The nurse may suggest that the mother provide cool liquids and hard foods such as dry
toast, Popsicles, or a frozen bagel for chewing to relieve discomfort. Hard, cold teethers
and ice wrapped in cloth may also provide comfort for inflamed gums. OTC medications
for gum relief should only be used as directed by the healthcare provider. Home remedies
such as rubbing the gums with aspirin should be discouraged, but acetaminophen
(Tylenol), administered as directed for the childs age, can relieve discomfort.
Test-Taking Strategy: Focus on the subject: teething and relieving the infants discomfort.
First recall that it is unnecessary to consult with a dentist. Next, eliminate the options that
are comparable or alike and involve administering medication to the infant. Review the
measures that will relieve the discomfort of teething if you had difficulty with this
question.
7. 7.ID: 383697994
A nurse is teaching the mother of an 11-month-old infant how to clean the infant's teeth.
The nurse tells the mother to:
o
Use water and a cotton swab and rub the teeth Correct
Use diluted fluoride and rub the teeth with a soft washcloth
Use a small amount of toothpaste and a soft-bristle toothbrush
Dip the infant's pacifier in maple syrup so that the infant will suck
Rationale: Because the primary teeth are used for chewing until the permanent teeth
erupt and because decay of the primary teeth often results in decay of the permanent
teeth, dental care must be started in infancy. The mother can use cotton swabs or a soft
washcloth to clean the teeth. Appropriate amounts of fluoride are necessary for the
development of healthy teeth, but infants usually receive fluoride when formula and
cereal are mixed with fluoridated water or through fluoride supplementation. Toothpaste
is not recommended because infants tend to swallow it, possibly ingesting excessive
amounts of fluoride. Dipping the infants pacifier in maple syrup is unacceptable because
of the risk of tooth decay.
Test-Taking Strategy: Use the process of elimination and focus on the subject, cleaning
the teeth. Recalling the risk associated with tooth decay will help eliminate the option
that identifies the use of maple syrup. To select from the remaining options, noting that
the client in the question is an infant will direct you to the correct option. Review the
procedure for cleaning teeth in an infant if you had difficulty with this question.
8. 8.ID: 3870763931
A nurse provides information about feeding to the mother of a 6-month-old infant. Which
statement by the mother indicates an understanding of the information?
o
"I can mix the food in the my infant's bottle if he won't eat it."
"Fluoride supplementation is not necessary until permanent teeth come in."
"Egg white should not be given to my infant because of the risk for an
allergy." Correct
"Meats are really important for iron, and I should start feeding meats to my
infant right away."

Rationale: Egg white, even in small quantities, is not given to the infant until the end of
the first year of life because it is a common food allergen. Fluoride supplementation may
be needed beginning at of 6 months, depending on the infants intake of fluoridated tap
water. Foods are never mixed with formula in the bottle. It may be difficult for the infant
to consume the formula, and it will also be difficult to determine the infants intake of the
formula. Solid foods may be introduced into the diet when the infant is 5 to 6 months old.
Rice cereal may be introduced first because of its low allergenic potential; or, depending
on the pediatricians preference, fruits and vegetables may be introduced first.
Test-Taking Strategy: Use the process of elimination. Read each option carefully and
think about the principles associated with feeding and nutrition. Recalling that allergy is a
concern will direct you to the correct option. Review the principles related to nutrition an
infant if you had difficulty with this question.
Reference: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternalchild nursing care (4th ed., p. 975). St. Louis: Elsevier.
Level of Cognitive Ability: Evaluating
Integrated Process: Nursing Process/Evaluation
Content Area: Nutrition
9. 9.ID: 383699176
A nurse provides instructions to a mother of a newborn infant who weighs 7 lb 2 oz about
car safety. The nurse tells the mother:
o
To secure the infant in the middle of the back seat in a rear-facing infant
safety seat Correct
To place the infant in a booster seat in the front seat of the car with the
shoulder and lap belts secured around the infant
That it is acceptable to place the infant in the front seat in a rear-facing infant
safety seat as long as the car has passenger-side air bags

o
That because of the infant's weight it is acceptable to hold the infant as long
as the mother and infant are sitting in the middle of the back seat of the car
Rationale: Infants should not be restrained in the front seats of cars. If a passenger-side
air bag is deployed, the air bag may severely jolt an infant safety seat, harming the infant.
Infants weighing less than 20 lb and those younger than 1 year should always be in the
middle of the back seat in a rear-facing car safety seat. An infant must be placed in an
infant safety seat and is never to be held by another person when riding in a car.
comparable or alike and recommend placing the infant in the front seat. To select from
the remaining options, keep safety in mind and remember that the infant should never be
held and should be placed in an infant safety seat. Review car safety principles for an
infant if you had difficulty with this question.
References: McKinney, E., James, S., Murray, S., & Ashwill, J. (2009). Maternal-child
American Academy of Pediatrics for information on car safety.
Content Area: Safety
10. 10.ID: 383697197
A nurse provides instructions to a mother about crib safety for her infant. Which
statement by the mother indicates a need for further instructions?
o
"I need to keep large toys out of the crib."
"The drop side needs to be impossible for my infant to release."
"Wood surfaces on the crib need to be free of splinters and cracks."
"The distance between the slats needs to be no more than 4 inches wide to
prevent entrapment of my infant's head or body." Correct

Rationale: The distance between slats must be no more than 2 inches to prevent
entrapment of the infants head and body. The mesh in a mesh-sided crib should have
openings smaller than inch. The drop side must be impossible for the infant to release,
and wood surfaces should be free of splinters, cracks, and lead-based paint. The mother
should avoid placing large toys in the crib, because an older infant may use them as steps
to climb over the side, possibly resulting in serious injury.
Test-Taking Strategy: Use the process of elimination and note the strategic words "need
for further instructions" in the query of the question. These words indicate a negative
event query and the need to select the incorrect statement by the mother. Visualizing each
of these options and keeping safety in mind will direct you to the correct option. Review
crib safety instructions if you had difficulty with this question.
11. 11.ID: 383699529
The mother of a 2-year-old tells the nurse that she is very concerned about her child
because he has developed "a will of his own" and "acts as if he can control others." The
nurse provides information to the mother to alleviate her concern, recalling that,
according to Erikson, a toddler is confronting which developmental task?
Initiative versus guilt
Trust versus mistrust
Industry versus inferiority
Autonomy versus doubt and shame Correct
Rationale: According to Erikson, the toddler is struggling with the developmental task of
acquiring a sense of autonomy while overcoming a sense of shame and doubt. Toddlers
discover that they have wills of their own and that they can control others. Asserting their
wills and insisting on their own way, however, often lead to conflict with those they love,
whereas submissive behavior is rewarded with affection and approval. Toddlers
experience conflict because they want to assert their own wills but do not want to risk
losing the approval of loved ones. Trust versus mistrust is the developmental task of the
infant. Initiative versus guilt is the developmental task of the preschool-age child.
Industry versus inferiority is the developmental task of the school-age child.
Test-Taking Strategy: Focus on the data in the question. Note the relationship between the
words "a will of his own" and the word "autonomy" in the correct option. Review
Eriksons developmental stages if you had difficulty with this question.
12. 12.ID: 383699193
A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of
control and security and ease feelings of helplessness and fear, the nurse should:
o
Spend as much time as possible with the toddler
Keep hospital routines as similar as possible to those at home Correct
Allow the toddler to play with other children in the nursing unit playroom
Allow the toddler to select toys from the nursing unit playroom that can be
brought into the toddler's hospital room
Rationale: The nurse can decrease the stress of hospitalization for the toddler by
incorporating the toddlers usual rituals and routines from home into nursing care
activities. Keeping hospital routines as similar to those of home as possible and
recognizing ritualistic needs gives the toddler some sense of control and security and
eases feelings of helplessness and fear. Spending as much time as possible with the
toddler and allowing the toddler to play with other children and select the toys he would
like to play with may be appropriate interventions, but keeping the hospital routine as
similar as possible to the routine at home will best maintain the toddlers sense of control
and security and ease feelings of helplessness and fear.
Test-Taking Strategy: Note the strategic word "best" in the question. Use the process of
elimination and focus on the subject, how to best maintain the toddlers sense of control
and security and ease feelings of helplessness and fear. This will assist you in selecting
the correct option. Review the psychosocial needs of the toddler with regard to
hospitalization if you had difficulty with this question.
Integrated Process: Nursing Process/Planning

13. 13.ID: 383699558
A nurse in a daycare setting is planning play activities for 2- and 3-year-old children.
Which of the following toys are most appropriate for these activities?
o
Blocks and push-pull toys Correct
Finger paints and card games
Simple board games and puzzles
Videos and cutting-and-pasting toys
Rationale: Toys for the toddler should meet the childs needs for activity and
inquisitiveness. The toddler enjoys objects of different textures such as clay, sand, finger
paints, and bubbles; push-pull toys; large balls; sand and water play; blocks; painting;
coloring with large crayons; large puzzles; and trucks or dolls. Card games, simple board
games, videos, and cutting-and-pasting toys are more appropriate play activities for the
preschooler.
Test-Taking Strategy: Use the process of elimination. Remember that all parts of an
option need to be correct for the option to be correct. Focusing on the age of the child
will direct you to the correct option. Review age-appropriate toys for the toddler if you
had difficulty with this question.

14. 14.ID: 383697921
A mother of twin toddlers tells the nurse that she is concerned because she found her
children involved in sex play and didn't know what to do. The nurse should tell the
mother:
o
To separate her children during playtime
That if the behavior continues, she will need to bring her children to a child
psychologist
That if she notes the behavior again she should casually tell her children to
dress and to direct them to another activity Correct

o
To tell her children that what they are doing is bad and that they will be
punished if they are caught doing it again
Rationale: Sex play and masturbation are common among toddlers. Parents should
respect the toddlers curiosity as normal without judging the toddler as bad. Parents who
discover children involved in sex play may casually tell them to dress and direct them to
another play activity, thereby limiting sex play without producing feelings of shame or
anxiety. Bringing the children to a child psychologist, separating them at play, and
punishing them are all inappropriate.
Test-Taking Strategy: Use the process of elimination and focus on the word toddlers.
Recalling that sex play and masturbation are common among toddlers will direct you to
the correct option. Review psychosexual development in the toddler if you had difficulty
with this question.

15. 15.ID: 383699155
A nurse is assessing the motor development of a 24-month-old child. Which of the
following activities would the nurse expect the mother to report that the child can
perform? Select all that apply.
o
Put on and tie his shoes
Align two or more blocks Correct
Dress himself appropriately
Go to the bathroom without help
Turn the pages of a book one at a time Correct
Rationale: By 24 months of age, the toddler can put on simple items of clothing but
cannot differentiate front and back. Some other activities that children at this age can
perform include zipping large zippers, putting on shoes, washing and drying their hands,
aligning two or more blocks, and turning the pages of a book one at a time. The fine
motor skill needed to tie shoes is not yet developed. By the age of 4 to 5 years, the child
is more independent and can dress, eat, and go to the bathroom without help.
Test-Taking Strategy: Use the process of elimination. Focusing on the age of the child and
thinking about developmental stages will help direct you to the correct options. Review
motor development in the 24-month-old if you had difficulty with this question.
Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal Child
Nursing Care (4th ed., p. 1025). St. Louis: Elsevier.
16. 16.ID: 383697949
A nurse is assessing language development in a toddler from a bilingual family. The nurse
expects that the childs language development:
o
Is slower than expected Correct
Is developing as expected
Is more advanced than expected
Will require assistance from a speech therapist
Rationale: Although the age at which children begin to talk varies widely, most can
communicate verbally by the second birthday. The rate of language development depends
on physical maturity and the amount of reinforcement the child has received. Children of
bilingual families, twins, and children other than firstborns may have slower language
development. A child from a bilingual family does not require assistance from a speech
therapist to ensure language development.
Test-Taking Strategy: Use the process of elimination. Note that there are no data in the
question to indicate that the child needs assistance from a speech therapist. When
selecting from the remaining options, noting the word "bilingual" in the question and
recalling the factors that affect language development will direct you to the correct
option. Review the factors that affect language development if you had difficulty with
this question.
Content Area: Cultural Diversity
17. 17.ID: 3870763928
A mother asks the nurse when her child should have his first dentist visit. The nurse tells
the mother:
o
At age 3
Just before beginning kindergarten
Twelve months after the first primary tooth erupts
Soon after the first primary tooth erupts, usually around 1 year of age Correct
Rationale: The child should see the dentist soon after the first primary tooth erupts at
around 1 year of age. Therefore the remaining options are incorrect. Parents should be
aware of the dental guidelines for children and should not delay necessary dental care.
Test-Taking Strategy: Use the process of elimination and recall the importance of dental
care. Answer correctly by selecting the option that provides dental care at the earliest age.
Review dental care guidelines if you had difficulty with this question.

18. 18.ID: 383700017
The mother of a toddler asks the nurse when she will know that her child is ready to start
toilet training. The nurse tells the mother that which of the following observations is a
sign of physical readiness?
o
The child has been walking for 2 years.
The child can eat using a fork and knife.
The child no longer has temper tantrums.
The child can remove his or her own clothing. Correct
Rationale: Signs of physical readiness for toilet training include the following: The child
can remove her own clothing; is willing to let go of a toy when asked; is able to sit, squat,
and walk well; and has been walking for 1 year. Using a fork and knife, walking for 2
years, and an absence of temper tantrums are not signs of physical readiness.
Test-Taking Strategy: Use the process of elimination. Noting the strategic words "physical
readiness" in the question will assist you in eliminating the option that addresses temper
tantrums. To select from the remaining options, visualize each to help direct you to the
correct option. Review the signs of physical readiness for toilet training if you had
difficulty with this question.

19. 19.ID: 383699525
The mother of a child who weighs 45 lb asks a nurse about car safety seats. The nurse
tells the mother to place the child in a:
o
Booster seat in a rear-facing position in the front seat
Booster seat with one of the cars seat belts placed over the child Correct
Car safety seat in the back seat in a face-forward position
Car safety seat in a face-forward position in the front seat
Rationale: A child needs to remain in a car safety seat until he or she weighs 40 lb. Once
the child has outgrown the car safety seat, a booster seat is used. Booster seats are
designed to raise the child high enough so that the restraining straps are correctly
positioned over the childs chest and pelvis. The child should not be placed in the front
seat. A car safety seat is used for the child who weighs less than 40 lb. These seats are
placed in the middle of the back seat in a rear-facing position.
Test-Taking Strategy: Use the process of elimination and note that the child weighs 45 lb.
Keeping the subject of safety in mind and visualizing each of the options will direct you
to the correct option. Review car safety measures if you had difficulty with this question.
American Academy of Pediatrics for information on car safety.

20. 20.ID: 383699533
The mother of a 5-year-old asks the nurse how often her child should undergo a dental
examination. The nurse tells the mother that the child should have a dental examination:
o
Once a year
Every 3 months
Every 6 months Correct
Whenever a new primary tooth erupts
Rationale: Dental examinations for a 4- to 5-year-old child should be conducted every 6

months. Every 3 months, once a year, and whenever a new primary tooth erupts are all
incorrect.
Test-Taking Strategy: Knowledge regarding the schedule for dental examinations for a 5year-old child is needed to answer this question. Recalling the general principles related
to dental care and thinking about dental health care of an adult will help direct you to the
correct option. Review dental-care principles for a child if you had difficulty with this
question.

21. 21.ID: 383700001
A nurse, planning play activities for a hospitalized school-age child, uses Erikson's theory
of psychosocial development to select an appropriate activity. The nurse selects an
activity that will assist the child in developing:
o
Initiative
Autonomy
A sense of trust
A sense of industry Correct
Rationale: According to Erikson, the central task of the school-age years is the
development of a sense of industry. The school-age child replaces fantasy play with
"work" at school, crafts, chores, hobbies, and athletics. Development of trust is the task of
infancy. Development of autonomy is the task of toddlerhood. Development of initiative
is the task of the preschooler.
Test-Taking Strategy: Use knowledge regarding Eriksons stages of psychosocial
development to answer the question. Focusing on the words "school-age child" will help
direct you to the correct option. Review Eriksons stages of psychosocial development if
you had difficulty with this question.

22. 22.ID: 383699585
A nurse, assigned to care for a hospitalized child who is 8 years old, plans care, taking
into account Erik Eriksons theory of psychosocial development. According to Eriksons
theory, which of the following tasks represents the primary developmental task of this
child?
o
Mastering useful skills and tools Correct
Gaining independence from parents
Developing a sense of trust in the world
Developing a sense of control over self and body functions
Rationale: According to Eriksons theory of psychosocial development, the school-age

childs task is to master useful skills and tools of the culture (industry versus inferiority).
Gaining independence from parents is the psychosocial task of the adolescent.
Developing a sense of trust in the world is the psychosocial task of an infant. Developing
a sense of control over self and body functions is the psychosocial task of the toddler.
Test-Taking Strategy: Focus on the strategic words 8 years old in the question and think
about the developmental level of the child. Use knowledge of Eriksons theory of
psychosocial developmental to answer this question. Review Eriksons theory of
psychosocial development if you had difficulty with this question.

23. 23.ID: 383699535
A school nurse provides information to the parents of school-age children regarding
appropriate dental care. The nurse tells the parents that their children should:
o
Brush their teeth every morning and at bedtime
Brush and floss their teeth after meals and at bedtime Correct
Brush and floss their teeth every morning and at bedtime
Brush their teeth every morning and at bedtime and floss the teeth once a day,
preferably at bedtime
Rationale: School-age children are able to assume responsibility for their own dental
hygiene. Good oral health habits tend to be carried into the adult years, helping prevent
cavity formation for a lifetime. Thorough brushing with fluoride toothpaste followed by
flossing between the teeth should be done after meals and before bedtime. It is important
that parents set up a routine schedule for the child that promotes good daily oral hygiene
and gives them responsibility for their own dental care.
Test-Taking Strategy: Use the process of elimination. Use general principles and
guidelines related to dental care and select the option that provides the most frequent and
thorough dental care. Review these guidelines if you had difficulty with this question.

24. 24.ID: 383697903
The parents of an adolescent tell the school nurse that they are frustrated because their
daughter has become self-centered, lazy, and irresponsible. The nurse should tell the
parents:
o
That this is normal behavior for an adolescent Correct
To restrict any social privileges until the behavior stops
That this type of behavior is usually the result of parents' spoiling a child
That their daughter will need to see a child psychologist if the behavior
continues
Rationale: Identity formation is the major developmental task of adolescence. Energy is

focused within the self, and the adolescent is sometimes described as egocentric or selfabsorbed. Frustrated parents often describe teenagers during this phase as self-centered,
lazy, or irresponsible. In fact, the adolescent just needs time to think, concentrate on
himself or herself, and determine who he or she is going to be. Erikson describes the
conflict of this phase of psychosocial development as identity formation versus role
confusion. The assertions that a psychologist is needed and that the behavior is the result
of spoiling are incorrect. Restriction of social privileges will cause resentment and
rebellion in the adolescent.
Test-Taking Strategy: Focus on the adolescents behaviors described in the question.
Recalling the stages of psychosocial development according to Erikson will direct you to
the correct option. Remember that identity formation is a major developmental task of
adolescence. Review the psychosocial development of the adolescent if you had difficulty
with this question.
25. 25.ID: 383697937
A nurse is preparing to care for a hospitalized teenage girl who is in skeletal traction. The
nurse plans care knowing that the most likely primary concern of the teenager is:
o
Body image Correct
Obtaining adequate nutrition
Keeping up with schoolwork
Obtaining adequate rest and sleep
Rationale: Body image is of particular importance to an adolescent. Teenagers tend to be

concerned about their weight, complexion, sexual development, and acceptance by their
peers. They are not concerned about obtaining adequate nutrition and tend to eat fast
foods and junk foods and may experiment with weight-management techniques such as
fasting, diet pills and laxatives, self-induced vomiting, and fad diets. Keeping up with
schoolwork may be important to some teenagers, but it is not usually the primary
concern. Along with engaging in increasingly independent activities, teenagers tend to
stay up late and have difficulty waking in the morning. Obtaining adequate rest and sleep
is not teenagers primary concern.
Test-Taking Strategy: Note the strategic word "primary." Thinking about the psychosocial
development of the teenager (adolescent) will direct you to the correct option. Review
psychosocial development of the adolescent if you had difficulty with this question.
nursing (3rd ed., pp. 157, 160-161, 891). St. Louis: Elsevier.
26. 26.ID: 383697939
The mother of an adolescent calls the clinic nurse and reports that her daughter wants to
have her navel pierced. The mother asks the nurse about the dangers associated with body
piercing. The nurse tells the mother that:
o
Hepatitis B is a concern with body piercing
Infection always occurs when body piercing is done
Body piercing is generally harmless as long as it is performed under sterile
conditions Correct
o
It is important to discourage body piercing because of the risk of contracting

human immunodeficiency virus (HIV)
Rationale: Generally body piercing is harmless if the procedure is performed under

sterile conditions by a qualified person. Some of the complications that may occur are
bleeding, infection, keloid formation, and the development of allergies to metal. The area
needs to be cleaned at least twice a day (more often for a tongue piercing) to prevent
infection. HIV and hepatitis B infections are not associated with body piercing; however,
they are a possibility with tattooing.
closed-ended word "always." The fact that HIV and hepatitis B are not associated with
body piercing will help you eliminate these options. Review the complications associated
with body piercing if you had difficulty with this question.
27. 27.ID: 383697977
A sexually active adolescent asks the school nurse about the use of latex condoms and the
prevention of sexually transmitted infections (STIs). The nurse tells the adolescent that:
o
Use of a latex condom can prevent transmission of STIs Correct
The only way to prevent transmission of STIs is abstinence
Use of a latex condom is a good method for preventing pregnancy
A spermicide needs to be used along with a condom to prevent transmission

of STIs
Rationale: Use of a condom during intercourse can prevent transmission of STIs.

Abstinence is not the only way to prevent transmission of an STI. A spermicide used
along with a condom will help prevent pregnancy, not an STI. One disadvantage of
condoms is that they may fail to prevent pregnancy. Also, using a latex condom to
prevent pregnancy is unrelated to preventing the transmission of STIs.
Test-Taking Strategy: Use the process of elimination and focus on the subject, preventing
transmission of an STI. Eliminate the option using the closed-ended word "only."
Focusing on the subject will help you select the correct option from the remaining
options. Review the methods of preventing transmission of STIs if you had difficulty
with this question.
nursing (3rd ed., pp. 158, 166-167, 190). St. Louis: Elsevier.
Content Area: Infection Control
28. 28.ID: 383697915
A nurse helps a young adult conduct a personal lifestyle assessment. The nurse carefully
reviews the assessment with the young adult because such clients:
o
Are at risk for a serious illness
Are unable to afford health insurance
Are exposed to hazardous substances
Ignore physical symptoms and postpone seeking health care Correct
Rationale: Young adults are usually quite active, experience severe illnesses less
commonly than members of older age groups, tend to ignore physical symptoms, and
often postpone seeking health care. Clients in this developmental stage may benefit from
a personal lifestyle assessment. A personal lifestyle assessment can help the nurse and
client identify habits that increase the risk for cardiac, pulmonary, renal, malignant, and
other chronic diseases. Young adults are not at risk for serious illness. The young adult
may or may not be exposed to hazardous substances and may or may not be able to afford
health insurance.
Test-Taking Strategy: Use the process of elimination. Focusing on the subject, a
characteristic of young adults, will direct you to the correct option. Review the
characteristics associated with the young adult if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009) Fundamentals of nursing (7th ed., p. 182). St.
Louis: Mosby.
Content Area: Health Assessment/Physical Exam
29. 29.ID: 383699593
A nurse is conducting a psychosocial assessment of a young adult. Which of the
following observations would lead the nurse to determine that the client is demonstrating
a sign of emotional health? Select all that apply.
o
The young adult is sensitive to criticism.
The young adult verbalizes unrealistic fears.
The young adult verbalizes disappointment with life.
The young adult verbalizes satisfaction with friendships. Correct
The young adult has a sense of meaning and direction in life. Correct
Rationale: Most young adults have the physical and emotional resources and support
systems to meet the many challenges, tasks, and responsibilities they face. Signs of
emotional health in the young adult include a sense of meaning and direction in life,
successful negotiation of transitions, absence of feelings of being cheated or disappointed
by life, attainment of several long-term goals, satisfaction with personal growth and
development, reciprocated feelings of love for a partner, satisfaction with social
interactions and friendships, a generally cheerful attitude, no sensitivity to criticism, and
no unrealistic fears.
Test-Taking Strategy: Focus on the subject, a sign of emotional health. Select the options
that use positive words such as satisfaction and meaning and direction. Review the
signs of emotional health in the young adult if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009) Fundamentals of nursing (7th ed., pp. 178-179).
St. Louis: Mosby.
Level of Cognitive Ability: Analyzing
30. 30.ID: 383697191
According to Erik Eriksons developmental theory, which of the following choices are
developmental tasks of the middle adult?
o
Redefining self-perception and capacity for intimacy
Providing guidance during interactions with his children Correct
Verbalizing readiness to assume parental responsibilities
Making decisions concerning career, marriage, and parenthood
Rationale: According to Eriksons developmental theory, the primary developmental task

of the middle adult is to achieve generativity. Generativity is the willingness to care for
and guide others. Middle adults can achieve generativity with their own children or the
children of close friends or through guidance in social interactions with the next
generation. Making decisions concerning career, marriage, and parenthood; redefining
self-perception and capacity for intimacy; and verbalizing readiness to assume parental
responsibilities are all developmental tasks of the young adult.
Test-Taking Strategy: Use the process of elimination. Eliminate options that are
comparable or alike and relate to marriage and parenting. Also, focusing on the subject, a
middle adult, will direct you to the correct option. Review the developmental tasks of the
middle adult if you had difficulty with this question.
Reference: Potter, P., & Perry, A. (2009) Fundamentals of nursing (7th ed., pp. 140, 412).
St. Louis: Mosby.
31. 31.ID: 383700009
A nurse is planning dietary measures for an older client who is experiencing dysphagia.
Which of the following actions should the nurse include in the plan of care?
o
Encouraging the client to feed herself
Ensuring that most of the diet consists of liquids
Monitoring the client during meals to ensure that food is swallowed Correct
Consulting with the physician regarding feeding through an enteral tube
Rationale: Clients with dysphagia must be assisted during meals, and the nurse should
carefully observe the client to ensure that foods are successfully swallowed instead of
being trapped in the mouth. The diet should be nutritionally balanced and consist of both
solids and liquids. Aspiration of liquids or solids is possible and may lead to aspiration
pneumonia. Thickeners can be added to liquids, because thin liquids are most difficult to
swallow for clients with dysphagia. Clients with severe dysphagia may require enteral
tube feedings, but there is no information in the question to indicate that the dysphagia is
severe.
Test-Taking Strategy: Use the ABCs airway, breathing, and circulation. This will direct
you to the correct option. Remember that one risk that exists with dysphagia is aspiration.
Review nutritional measures for the older client with dysphagia and dysphagia
precautions if you had difficulty with this question.
Reference: Touhy, T., & Jett, K. (2010). Ebersole and Hess gerontological nursing
health aging (3rd ed., p. 115). St. Louis: Mosby.
32. 32.ID: 383699106
A nurse is obtaining assessment data from an older client about sleep patterns. The client
reports that she has been awakening during the night, awakens early in the morning and is
unable to fall back to sleep, and feels sleepy during the daytime. On the basis of these
reported data, the nurse should:
o
Report the findings to the physician
Document the findings in the medical record Correct
Ask the physician for a prescription for a nighttime sedative
Encourage the client to consume stimulants such as caffeinated coffee or tea

during the daytime hours
Rationale: Age-related changes in sleep include reduced sleep efficiency, increased

incidence of nocturnal awakening, increased incidence of early-morning awakening, and
increased daytime sleepiness. Because the reported data are normal age-related changes,
the nurse would document the findings. There is no reason to report the findings to the
physician. Sedatives should be avoided. The consumption of caffeinated beverages is
likely to increase disruption of sleep patterns.
question. Recalling the age-related changes related to sleep patterns and remembering
that those described in the question are normal will direct you to the correct option.
Review age-related sleep pattern changes if you had difficulty with this question.
health aging (3rd ed., pp. 149-150). St. Louis: Mosby.
33. 33.ID: 383697175
A nurse is developing a plan of care for an older client that will help maintain an
adequate sleep pattern. Which of the following actions should the nurse include in the
plan?
o
Encouraging at least one daytime nap
Discouraging the use of a night light at bedtime
Encouraging bedtime reading or listening to music Correct
Discouraging social interaction, particularly at bedtime
Rationale: Measures that will help maintain an adequate sleep pattern include balancing
daytime activities with rest, discouraging daytime naps, promoting social interactions,
and encouraging bedtime reading or listening to music. The use of a night light will foster
an environment that is both helpful and safe.
Test-Taking Strategy: Use the process of elimination. Thinking about the safety needs of
the older client will assist you in eliminating the option of discouraging the use of a
nightlight. To select from the remaining options, focusing on the subject, maintaining an
adequate sleep pattern, will direct you to the correct option. Review measures that will
maintain an adequate sleep pattern if you had difficulty with this question.
34. 34.ID: 383697195
A nurse is performing an admission assessment on an older client who will be seen by a
physician in a health care clinic. When the nurse asks the client about sexual and
reproductive function, he reports concern about sexual dysfunction. The nurse's next
action should be to:
o
Report the client's concern to the physician
Ask the client about medications he is taking Correct
Document the client's concern in the medical record
Tell the client that sexual dysfunction is a normal age-related change
Rationale: Sexual dysfunction is not a normal process of aging. The prevalence of

chronic illness and medication use is higher among older adults than in the younger
population. Illnesses and medications can interfere with the normal sexual function of
older men and women. Although the nurse may report the clients concern and document
the concern in his medical record, the next action is to ask the client about the
medications he is taking.
Test-Taking Strategy: Use the steps of the nursing process to answer the question. This
will direct you to the correct option, which is the only option related to assessment.
Review the causes of sexual dysfunction in the older client if you had difficulty with this
question.
35. 35.ID: 383697179
A community health nurse is providing information to a group of older clients about
measures to decrease the risk of contracting influenza during peak flu season. The nurse
tells the clients that:
o
It is best to do grocery shopping and other errands late in the day
They must stay in the house and ask a neighbor or family member to run their
errands
o
Drinking eight 8-oz glasses of fluid each day will reduce the risk of
contracting influenza
Wearing a scarf around the nose and mouth will help reduce the transmission
of airborne viruses Correct

Rationale: During peak influenza season, older clients should avoid crowds to decrease
the risk of contracting influenza. The nurse should encourage clients to do their shopping
and other errands early in the morning, when crowds are smaller, or to have someone else
shop for them. The use of a scarf across the nose and mouth can help reduce the
transmission of airborne viruses. Drinking eight 8-oz glasses of fluid a day will not
reduce the risk of contracting influenza; however, it will prevent dehydration if illness
occurs.
closed-ended word "must." Also eliminate the option that uses the words late in the
day. To select from the remaining options, focusing on the subject of the question, how
to decrease the risk of contracting influenza, will direct you to the correct option. Review
interventions used to decrease the risk of contracting influenza if you had difficulty with
this question.
References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patientcentered collaborative care (6th ed., pp. 658-659). St. Louis: Saunders.
Potter, P., & Perry, A. (2009). Fundamentals of nursing (7th ed., p. 927). St. Louis:
Mosby.
Content Area: Infection Control
36. 36.ID: 383697199

A nurse is caring for an older client who has a bronchopulmonary infection. The nurse
monitors the client's ability to maintain a patent airway because the normal aging process:
o
Increases the production of surfactant
Increases respiratory system compliance
Decreases an older client's ability to clear secretions Correct
Decreases the number of alveoli and increases the function of those remaining
Rationale: Respiratory changes related to the normal aging process decrease an older
adults ability to clear secretions and protect the airway. In healthy older adults, the
number of alveoli does not change or reduce significantly; their structure, however, is
altered. Respiratory system compliance decreases with advancing age because of a
progressive loss of elastic recoil of the lung parenchyma and conducting airways and
reduced elastic recoil of the lung and opposing forces of the chest wall. Production of
surfactant in the lung does not usually decrease with aging, nor does it increase.
However, the production of alveolar cells responsible for surfactant production is
diminished.
Test-Taking Strategy: Use the process of elimination and recall the normal age-related
changes in the older client. Note the relationship between the words "maintain a patent
airway" in the question and "ability to clear secretions" in the correct option. Review the
normal age-related changes of the respiratory system if you had difficulty with this
question.
Content Area: Adult Health/Respiratory

37. 37.ID: 383699108
An older female client asks a nurse why her hair has turned gray. Which of the following
responses is most appropriate for the nurse to make to the client?
o
"It is caused by hereditary factors."
"A loss of melanin occurs in the normal aging process." Correct
"The skin on the scalp becomes thin, causing moisture to escape."
"The number of sweat glands and blood vessels decreases in the normal aging
process."
Rationale: The number of melanocytes, which provide pigment and hair color, decreases
with age, giving older adults less protection from ultraviolet rays, paler skin color, and
graying hair. Although the skin becomes thinner with the aging process and the number
of sweat glands and blood vessels decreases, these changes are unrelated to graying hair.
Heredity factors influence when the process of graying begins but do not cause the
graying of hair.
Test-Taking Strategy: Use the process of elimination and recall the normal process of
aging. Note the relationship between the words "turned gray" in the question and "loss of
melanin" in the correct option. Review the age-related changes related to the hair if you
Reference: Ebersole, P., Hess, P., Touhy, T., Jett, K., & Luggen, A. (2008). Toward
healthy aging (7th ed., pp. 67-68). St. Louis: Mosby.

38. 38.ID: 383700013
A nurse provides instructions to an older adult about measures to prevent heatstroke.
Which statement by the client indicates a need for further instruction?
o
"I should drink extra fluids during the summer."
"I should wear cool, light clothing in warm weather."
"I need to wear a hat with a wide brim when I go outdoors."
"I need to wear additional antiperspirant and deodorant in warm weather."

Correct
Rationale: As an individual ages, the number of sweat glands decreases, resulting in

reduced body odor and reduced evaporative heat loss because of decreased sweating. The
need for antiperspirants and deodorants is decreased. However, older adults are at a
greater risk of heatstroke as a result of a compromised cooling mechanism; they should
therefore avoid heat exposure over long periods and in areas of high humidity. The older
adult should wear a hat with a wide brim and cool, lightweight, light-colored clothing
when outdoors. It is also important that the older adult maintain adequate hydration,
particularly during the summer and in hot climates.
Test-Taking Strategy: Focus on the subject, heatstroke, and note the strategic words "need
for further instruction." These words indicate a negative event query and the need to
select the incorrect option. Recall that with aging, bodily changes occur, including a
decrease in the number of sweat glands. This will help direct you to the correct option.
Review these age-related changes if you had difficulty with this question.
Reference: Ebersole, P., Hess, P., Touhy, T., Jett, K., & Luggen, A. (2008). Toward
healthy aging (7th ed., p. 417). St. Louis: Mosby.

39. 39.ID: 383697935
A nurse is performing an external and ophthalmoscopic examination of an older client.
Which age-related change would the nurse would expect to note?
Correct
Rationale: Age-related changes of the retina include narrowed and straightened blood
vessels, opaque gray arteries, and gray or yellow spots of hyaline degeneration, called
drusen, near the macula. Conjunctivitis is not an age-related change and is characterized
by the presence of a red sclera. Purulent material in the anterior chamber of the eye
occurs with iritis and is not an age-related change. It is characterized by the presence of
white material or drainage in the eye. Red blood vessels, a clear fundus, and a yelloworange optic disc are all normal, not age-related, findings.
Test-Taking Strategy: Focus on the subject, an age-related finding. Eliminate the options
that are comparable or alike and identify infections. To select from the remaining options,
recalling the normal color of the optic disc will direct you to the correct option. Review
age-related findings in the eye if you had difficulty with this question.

40. 40.ID: 383699523
A nurse is reviewing the medical record of an older client with presbycusis. Which of the
following findings would the nurse expect to note in the client's record?
o
Unilateral conductive hearing loss
Difficulty hearing low-pitched tones
Difficulty hearing whispered words in the voice test Correct
Improved hearing ability during conversational speech
Rationale: Presbycusis, a sensorineural hearing loss, is the most common form of hearing
loss in older adults. Typically the loss is bilateral, resulting in difficulty hearing highpitched tones. The condition is revealed when the client has difficulty hearing whispered
words in the voice test and difficulty hearing consonants during conversational speech.
words "increased hearing." Recalling that the hearing loss in presbycusis is bilateral will
assist you in eliminating the option containing the word unilateral. For you to select
from the remaining options, it is necessary to know that the client has difficulty hearing
high-pitched tones (not low-pitched tones). Review age-related changes in hearing if you
References: Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patientcentered collaborative care. (6th ed., p. 1130 ). St. Louis: Saunders.
Touhy, T., & Jett, K. (2010). Ebersole and Hess gerontological nursing health aging (3rd
ed., pp. 79-80). St. Louis: Mosby.

41. 41.ID: 383697957
A nurse is performing a skin and peripheral vascular assessment on a client in later
adulthood. Which of the following observations would the nurse expect to note as an agerelated finding?
o
Thin, ridged toenails
Thick skin on the lower legs
Bounding dorsalis pedis pulse
Loss of hair on the lower legs Correct
Rationale: In later adulthood, the dorsalis pedis and posterior tibial pulses may become
more difficult to find. They would not be bounding. Trophic changes associated with
arterial insufficiency (thin, shiny skin; thick, ridged nails; loss of hair on the lower legs)
also occur normally with aging.
Test-Taking Strategy: Use the process of elimination. Recalling the age-related changes in
the skin and cardiovascular system and noting the words "loss of hair" will direct you to
the correct option. Review age-related changes in these body systems if you had

42. 42.ID: 383697185
A nurse performing a neurological assessment of a client in later adulthood notes that the
client has tremors of the hands. On the basis of this finding, the nurse should:
o
Document the findings Correct
Notify the physician immediately
Obtain a prescription for a muscle relaxant
Ask the physician about referring the client to a neurological specialist
Rationale: Senile tremors are occasionally noted in clients in later adulthood. These
benign tremors include intentional tremor of the hands, head-nodding (as if saying yes),
and tongue protrusion. Because this finding is an age-related occurrence, obtaining a
prescription for a muscle relaxant, notifying the physician immediately, and asking about
referring the client to a neurological specialist are unnecessary and incorrect.
comparable or alike and indicate contact with the physician. Review age-related changes
of the neurological system if you had difficulty with this question.
References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical
management for positive outcomes (8th ed., p. 1782). St. Louis: Saunders.
Jarvis, C. (2008). Physical examination and health assessment (5th ed., pp. 693, 704). St.
Louis: Saunders.

43. 43.ID: 383697181
A nurse observes a nursing assistant communicating with a hearing-impaired client in
later adulthood. The nurse should intervene if the nursing assistant:
o
Uses short sentences
Overarticulates words Correct
Uses facial expressions or gestures
Speaks at a normal rate and volume
Rationale: Hearing-impaired clients must supplement hearing with lip-reading. The client
needs to be able to see the speakers face and lips. The nurse would watch to see that the
nursing assistant avoided situations in which there is a glare or shadows on the clients
field of vision. The nurse would also remind the assistant to reduce or eliminate
background noise, speak at a normal rate and volume, and refrain from overarticulating
or shouting. The assistant should use short sentences and pause at the end of each
sentence and should use facial expressions or gestures to give useful clues.
Test-Taking Strategy: Note the strategic word "intervene" in the query of the question.
This word indicates that you need to select the option that indicates an incorrect action by
the nursing assistant. Visualize each of the options to help direct you to the correct one.
Review strategies to improve communication when a client has hearing loss if you had
References: Black, J., & Hawks, J. (2009). Medical-surgical nursing: Clinical

management for positive outcomes. (8th ed., p. 1727). St. Louis: Saunders.
Touhy, T. & Jett, K. (2010). Ebersole and Hess Gerontological nursing health aging (3rd
ed., p. 32). St. Louis: Mosby.
Content Area: Leadership and Management
44. 44.ID: 383699521
A nurse gathering subjective data from a client during a health assessment plans to ask
the client about the medical history of the client's extended family. About which family
members would the nurse ask the client?
o
Wife and wife's parents
Foster children and their parents
Wife's children from a previous marriage
Aunts, uncles, grandparents, and cousins Correct
Rationale: The extended family includes relatives, (aunts, uncles, grandparents, and
cousins) in addition to the nuclear family. The nuclear family consists of husband and
wife and perhaps one or more children. A blended family is formed when parents bring
unrelated children from prior or foster-parenting relationships into a new joint living
situation.
Test-Taking Strategy: Use the process of elimination. Focusing on the strategic words
"extended family" in the question will direct you to the correct option. Review family
structures if you had difficulty with this question.

Reference: Potter, P., & Perry, A. (2009) Fundamentals of nursing (7th ed., p. 241). St.
Louis: Mosby.
45. 45.ID: 383700019
A home health care nurse is visiting a male African-American client who was recently
discharged from the hospital. Which family member does the the nurse ensure is present
when teaching the client about his prescribed medications?
o
The client's son
The client's father
The client's mother Correct
The client's grandson
Rationale: African-American families are oriented around women. Within the AfricanAmerican family structure, the wife/mother is often charged with the responsibility of
protecting the health of family members. The African-American woman is expected to
assist each family member in maintaining good health and in determining the course of
treatment if a family member becomes ill. The nurse must recognize the importance of
the African-American woman in disseminating information and in assisting the client in
making decisions. Although the African-American man may be included in the decisionmaking process, the African-American family is often matrifocal, so the nurse ensures
that the woman is present. Therefore the other options are incorrect.
Test-Taking Strategy: Use the process of elimination. Eliminate the options that all
comparable or alike and identify male members of the family. Review the characteristics
of the African-American family system if you had difficulty with this question.
References: Giger, J., & Davidhizar, R. (2008) Transcultural nursing assessment &
intervention (5th ed., p. 200). St. Louis: Mosby.
Potter, P., & Perry, A. (2009) Fundamentals of nursing (7th ed., p. 118). St. Louis:
Mosby.
46. 46.ID: 383697193
A female client asks a nurse about the advantages of using a female condom. The nurse
tells the client that one advantage is:
o
It can be used along with a male condom
That it is 100% safe in preventing pregnancy
That it offers protection against sexually transmitted infections (STIs) Correct
That it does not have to be discarded after use and can be used several times
before a new one must be obtained
Rationale: A female condom is a loose-fitting tubular polyurethane pouch that is

anchored over the labia and cervix. The condom, which is prelubricated, is available
without a prescription. It cannot be combined with a male condom and should be used
just once, then discarded. Like the male condom, the female condom provides protection
against STIs. The pregnancy failure rate with typical use is approximately 21%.
Test-Taking Strategy: Use the process of elimination. Noting the word "condom" in the
question and recalling that one advantage of using a male condom is the prevention of
STIs will direct you to the correct option. Review the advantages and disadvantages of
this type of barrier device if you had difficulty with this question.
Reference: Lehne, R. (2010). Pharmacology for nursing care (7th ed., p. 746). St. Louis:
Saunders.
Content Area: Reproductive
47. 47.ID: 383699112
A nurse provides information to a client about the use of a diaphragm. Which of the
following statements indicates to the nurse that the client needs further information on
how to use the diaphragm?
o
"I need to reapply spermicidal cream with repeated intercourse."
"The diaphragm needs to be filled with spermicidal cream before insertion."
"The diaphragm can be inserted as long as 6 hours before intercourse."
"I can leave the diaphragm in place as long as I want after intercourse."
Correct
Rationale: The diaphragm may be inserted as long as 6 hours before intercourse and must
remain in place for at least 6 hours after. Because of the risk of toxic shock syndrome, the
diaphragm must not remain in place for more than 24 hours. The diaphragm must be
filled with spermicidal cream or jelly before insertion, and the spermicide must be
reapplied before intercourse is repeated.
Test-Taking Strategy: Use the process of elimination and note the strategic words "needs
further information." These words indicate a negative event query and the need to select
the incorrect client statement. Recalling that the risk of toxic shock syndrome exists with
the use of a diaphragm and noting the words "as long as I want" will direct you to the
correct option. Review client instructions for use of a diaphragm if you had difficulty
with this question.
Saunders.
48. 48.ID: 383700022
A nurse is discussing birth control methods with a client who is trying to decide which
method to use. On which major factor that will provide the motivation needed for
consistent implementation of a birth control method should the nurse focus?
o
Personal preference Correct
Family planning goals
Work and home schedules
Desire to have children in the future
Rationale: Personal preference is a major factor in providing the motivation needed for
consistent implementation of a birth control method. The nurse should educate the client
about the various contraceptive methods available so that expressions of preference may
be based on understanding. The desire to have children in the future, work and home
schedules, and family planning goals may affect the choice of birth control method but
are not motivating factors.
Test-Taking Strategy: Focus on the subject, the major factor that will provide motivation.
This will direct you to the correct option. Review factors to consider when helping a
client choose a birth control method if you had difficulty with this question.
Saunders.
49. 49.ID: 383699580
A sexually active married couple, discussing birth control methods with the nurse,
express the need for a method that is convenient. Because the couple has told the nurse
that family-planning goals have been met, which method of birth control does the nurse
suggest?
o
Diaphragm
Spermicide
Sterilization Correct
Male condom
Rationale: If family planning goals have already been met, sterilization of the male or
female partner may be desirable. When sexual activity is limited, use of a spermicide,
condom, or diaphragm may be most appropriate.
Test-Taking Strategy: Focus on the data in the question and note that the couple is
sexually active and is seeking a method of birth control that is convenient. Eliminate the
options that are comparable or alike and involve the application of a contraceptive
method. Review family planning and methods of birth control if you had difficulty with
this question.
50. 50.ID: 383697187
A nurse is gathering subjective data from a client who is seeking a prescription for an oral
contraceptive. To identify risk factors associated with the use of an oral contraceptive,
which question does the nurse ask?
o
"Are you dieting?"
"Do you smoke cigarettes?" Correct
"Do you engage in strenuous exercise such as jogging?"
"Do you normally have menstrual cramps with your periods?"
Rationale: Oral contraceptives have been associated with venous and arterial
thromboembolism, pulmonary embolism, myocardial infarction, and thrombotic stroke.
The risk of thromboembolitic phenomena is increased in the presence of other risk
factors, especially heavy smoking and a history of thrombosis. Additional risk factors
include hypertension, cerebrovascular disease, coronary artery disease, and surgery in
which postoperative thrombosis might be expected. Dieting, menstrual cramping, and
strenuous exercise are not risk factors associated with the use of oral contraceptives.
Test-Taking Strategy: Use the process of elimination and note that the question addresses
the use of an oral contraceptive. Focusing on the subject, identification of risk factors,
will direct you to the correct option. Review the risks associated with oral contraceptives
if you had difficulty with this question.
References: Lehne, R. (2010). Pharmacology for nursing care (7th ed., p. 741). St. Louis:
Saunders.
Content Area: Pharmacology
51. 51.ID: 383697171
A nurse reviews the health history of a client who will be seeing the physician to obtain a
prescription for a combination oral contraceptive (estrogen and progestin). Which of the
following findings in the health history would cause the nurse to determine that use of a
combination oral contraceptive is contraindicated?
o
The client has hyperlipidemia.
The client has type 2 diabetes mellitus.
The client is being treated for hypertension.
The client has been treated for breast cancer. Correct
Rationale: Combination oral contraceptives contain both estrogen and progestin and are
contraindicated during pregnancy and for women who have (or have a history of) the
following disorders: thrombophlebitis, thromboembolic disorders, cerebrovascular
disease, coronary-artery disease, myocardial infarction, known or suspected breast
cancer, known or suspected estrogen-dependent neoplasm, benign or malignant liver
tumors, and undiagnosed abnormal genital bleeding. They are used with caution in
women with diabetes mellitus, women who smoke heavily, women with risk factors for
cardiovascular disease (hypertension, obesity, hyperlipidemia), and women anticipating
elective surgery in which thrombosis might be expected.
Test-Taking Strategy: Focus on the subject, a contraindication of a combination oral
contraceptive. Recalling that a combination oral contraceptive contains estrogen will
direct you to the correct option, breast cancer. Review the contraindications of a
combination oral contraceptive if you had difficulty with this question.
References: Lehne, R. (2010). Pharmacology for nursing care (7th ed., p. 741). St. Louis:
Saunders.
Content Area: Pharmacology
52. 52.ID: 383699595
Clomiphene (Clomid, Serophene) is prescribed for a female client to treat infertility. The
nurse is providing information to the client and her spouse about the medication and tells
the couple that:
The couple should engage in coitus once a week during treatment
The physician should be notified immediately if breast engorgement occurs
If the oral tablets are not successful, the medication will be administered
intravenously
o
Multiple births occur in a small percentage of clomiphene-facilitated

pregnancies Correct
Rationale: Multiple births (usually twins) occur in a small percentage (8% to 10%) of
clomiphene-facilitated pregnancies, and the couple should be informed of this. The
medication is available in 50-mg tablets for oral use. There is no available intravenous
form. Breast engorgement is a common side effect of the medication that reverses after
medication withdrawal. When ovulation does occur as a result of use of clomiphene, it is
usually within 5 to 10 days after the last dose. The couple is instructed to engage in coitus
at least every other day during this time.
Test-Taking Strategy: Use the process of elimination. Note the relationship between the
words "treat infertility" in the question and "multiple births" in the correct option. Review
this medication if you had difficulty with this question.
Reference: Lehne, R. (2010). Pharmacology for nursing care (7th ed., pp. 754, 758). St.
Louis: Saunders.
53. 53.ID: 383699128
A nurse is reviewing the medical notes of a client seen by the physician to determine
whether the client is pregnant. The nurse determines that pregnancy was confirmed if
which of the following findings is documented?
o
Amenorrhea
Palpable fetal movement Correct
Thinning of the cervix
Positive result on home urine test for pregnancy
Rationale: The positive indicators of pregnancy include auscultation of fetal heart

sounds, fetal movement felt by the examiner, and visualization of the fetus with
sonography. Amenorrhea is a presumptive sign of pregnancy because it is experienced
and reported by the woman. Presumptive signs are not reliable indicators of pregnancy,
because any may be caused by conditions other than pregnancy. Thinning of the cervix
(the Hegar sign) and a positive pregnancy test result are probable indicators of pregnancy.
A false-positive pregnancy test result may occur as a result of an error in reading, the
presence of protein or blood in the urine, a recent pregnancy, a recent first-trimester
abortion, or medications the client is taking.
Test-Taking Strategy: Use the process of elimination. Noting the strategic word
"confirmed" will assist you in selecting the correct option. Recalling the presumptive,
probable, and positive signs of pregnancy will also assist you in answering correctly.
Review the positive signs of pregnancy if you had difficulty with this question.
Content Area: Maternity/Antepartum

54. 54.ID: 383697905
A nurse is preparing to assess the fetal heart rate (FHR) of a client who is 14 weeks
pregnant. Which piece of equipment does the nurse use to assess the FHR?
o
Fetoscope
Stethoscope
Doppler transducer Correct
Pulse oximetry on the client and a fetoscope
Rationale: Fetal heart sounds can be heard with a fetoscope by 20 weeks of gestation.
The Doppler transducer amplifies fetal heart sounds so that they are audible by 10 to 12
weeks of gestation. Fetal heart sounds cannot be heard with a stethoscope. Pulse oximetry
is not used to auscultate fetal heart sounds.
comparable or alike and involve a fetoscope. To select from the remaining options, note
the week of gestation of the client, which will direct you to the correct option. Review the
equipment used for auscultating fetal heart sounds if you had difficulty with this question.
References: Lowdermilk, D., Perry, S., & Cashion, K. (2010). Maternity nursing (8th ed.,
Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal-child
nursing care (4th ed., p. 244). St. Louis: Elsevier.

55. 55.ID: 383697925
A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of
pregnancy notes that the FHR is 160 beats per minute. The nurse should:
o
Document the findings Correct
Notify the physician of the finding
Wait 15 minutes and then recheck the FHR
Tell the client that the FHR is faster than normal but that it is nothing to be
concerned about at this time
Rationale: The normal fetal heart depends on gestational age (usually higher in the first
trimester) and is generally in the range of 120 to 160 beats per minute. A FHR of 160
beats per minute is within the normal range, so documentation is the only action
indicated.
Test-Taking Strategy: Recalling that the normal FHR is in the range of 120 to 160 beats
per minute will direct you to the correct option, documenting the findings. Also note that
the incorrect options are comparable or alike in that they indicate concern over the FHR
finding. Review the normal FHR if you had difficulty with this question.

56. 56.ID: 383699144
A nurse is preparing to auscultate a fetal heart rate (FHR). The nurse performs the
Leopold maneuvers to determine the position of the fetus and then places the fetoscope
over the:
o
Chest of the fetus
Back of the fetus Correct
Carotid artery in the neck of the fetus
Brachial area of one extremity of the fetus
Rationale: The nurse would use the Leopold maneuvers to identify the position of the
fetus and to determine the location of the fetal back. The fetal heart rate is most easily
heard through the fetal back because it usually lies closest to the surface of the maternal
abdomen. Because of the position of the fetus in the maternal abdomen (fetal position),
auscultation of the FHR over the chest, carotid artery, or brachial area is not possible.
Test-Taking Strategy: Use the process of elimination and visualize each of the options.
Recalling the position of the fetus in the maternal abdomen will direct you to the correct
option. Review the procedure for auscultating the FHR and the Leopold maneuvers if you
Reference: Lowdermilk, D., Perry, S., & Cashion, K. (2010). Maternity nursing (8th ed.,
pp. 319, 347). St. Louis: Mosby.

57. 57.ID: 383699110
A nurse is assessing a fetal heart rate (FHR) and places the fetoscope on the mother's
abdomen to count the FHR. The nurse simultaneously palpates the mother's radial pulse
and notes that it is synchronized with the sounds heard through the fetoscope. Which
action should the nurse take?
o
Asks the mother to lie still while both the FHR and the radial pulse rate are
counted.
o
Move the fetoscope to another area on the mother's abdomen to locate the
fetal heart. Correct
Count the FHR for 30 seconds and then count the radial pulse rate of the
mother for 30 seconds.

o
Count the FHR for 60 seconds, ensuring that it is synchronized consistently

with the mother's radial pulse.
Rationale: When auscultating the fetal heart rate, the nurse would place the fetoscope on
the maternal abdomen, over the fetal back. The nurse would then palpate the mothers
radial pulse. If her pulse is synchronized with the sounds from the fetoscope, the nurse
would move the fetoscope to another area on the mothers abdomen to locate the FHR.
The nurse needs to be sure that the FHR is what is actually being heard. Other sounds that
may be heard are the funic souffle (blood flowing through the umbilical cord) and the
uterine souffle (blood flowing through the uterine vessels). The funic souffle is
synchronized with the FHR; the uterine souffle is synchronized with the mothers pulse.
Test-Taking Strategy: Focus on the data in the question. Noting that the sounds heard
through the fetoscope are synchronized with the mothers radial pulse will help direct you
to the correct option. Also note that the incorrect options are comparable or alike in that
they indicate continuing with the counting of the heart rate. Review the procedure for
auscultating the FHR if you had difficulty with this question.
p. 319). St. Louis: Mosby.
58. 58.ID: 383699583
A nurse is assessing a fetal heart rate (FHR) and notes accelerations from the baseline
rate when the fetus is moving. The nurse interprets this finding as:
o
A reassuring sign Correct
A nonreassuring sign
An indication of fetal distress
An indication of the need to contact the physician
Rationale: When assessing the FHR, the nurse determines that the findings are reassuring
or whether further steps should be taken to clarify data or correct problems. Reassuring
signs include an average rate between 120 and 160 beats per minute at term; a regular
rhythm or a rhythm with slight fluctuations; accelerations from the baseline rate, often
occurring with fetal movement; and the absence of decreases from the baseline rate. A
nonreassuring sign suggests fetal distress, warranting immediate intervention and
indicating the need to contact the physician.
Test-Taking Strategy: Use the process of elimination. Note that the incorrect options are
comparable or alike, indicating a problem and the need for immediate intervention.
Review reassuring signs during monitoring of the FHR if you had difficulty with this
question.
Integrated Process: Nursing Process/Analysis
Content Area: Maternity/Intrapartum
59. 59.ID: 383697189
A nurse-midwife, performing a vaginal examination of a client who suspects that she is
pregnant, documents the presence of the Chadwick sign. The nurse reads the client's
record and interprets this sign as indicating:
o
A thinning of the cervix
A positive sign of pregnancy
That cervical softening is present
That the cervix was seen to be violet Correct
Rationale: One probable sign of pregnancy is the Chadwick sign violet coloration of
the cervix, which is normally pink. The color change, which also extends into the vagina
and labia, occurs because of increased vascularity of the pelvic organs. Thinning of the
cervix is termed the Hegar sign, and softening of the cervix is called the Goodell sign.
These are both probable signs of pregnancy.
Test-Taking Strategy: Focus on the subject, the Chadwick sign. Recalling that the
Chadwick sign is the name given to violet coloration of the cervix, which is normally
pink, and that this is a probable sign of pregnancy will direct you to the correct option.
Review the presumptive, probable, and positive signs of pregnancy if you had difficulty
with this question.
60. 60.ID: 383699531
A client is pregnant for the sixth time. She tells the nurse that she has had three elective
first-trimester abortions and that she has a son who was born at 40 weeks' gestation and a
daughter who was born at 36 weeks' gestation. In calculating the gravidity and para
(parity), the nurse determines that the client is:
o
Gravida 6, para 2 Correct
Gravida 2, para 6
Gravida 2, para 2
Gravida 3, para 6
Rationale: The term gravida refers to the number of pregnancies, of any duration, that a
woman has had. Parity (para) refers to the number of pregnancies that have progressed
past 20 weeks at delivery. Therefore this client is gravida 6 (pregnant for the sixth time),
para 2 (has a son and a daughter). Pregnancy outcomes may also be described with the
GTPAL acronym: gravida (G), term births (T), preterm births (P), abortions (A), and live
births (L). The GTPAL for this client would be G = 6, T = 1, P = 1, A = 3, L = 2.
Test-Taking Strategy: Knowledge regarding the calculation of gravida and para is needed
to answer this question. Recalling that gravida refers to the number of pregnancies and
para refers to the number of pregnancies that have progressed past 20 weeks at delivery
will direct you to the correct option. Review gravida and para as a component of the
obstetric history if you had difficulty with this question.
61. 61.ID: 383697969
A nurse is determining the estimated date of delivery for a pregnant client, using Nagele's
rule, and notes documentation that the date of the client's last menstrual period was
August 30, 2013. The nurse determines the estimated date of delivery to be:
o
July 6, 2014
May 6, 2014
June 6, 2014 Correct
May 30, 2014
Rationale: Nageles rule is often used to establish the estimated date of delivery. This
method involves subtracting 3 months and adding 7 days to the date of the first day of the
last normal menstrual period, then correcting the year. Subtracting 3 months from August
30, 2013, brings the date to May 30, 2013; adding 7 days brings it to June 6, 2013.
Finally, the year is corrected, bringing the estimated date of delivery to June 6, 2014.
Test-Taking Strategy: Recalling Nageles rule will assist you in answering this question.
(Remember when you calculate the date for this client that there are 31 days in May.)
Review Nageles rule if you had difficulty with this question.
62. 62.ID: 383697169
A rubella titer is performed on a pregnant client, and the results indicate a titer of less
than 1:8. The nurse tells the client that:
o
The test results are normal
She has developed immunity to the rubella virus
The test will need to be repeated during the pregnancy Correct
She must have been exposed to the rubella virus at some point in her life
Rationale: A client is not immune to rubella if the titer is 1:8 or less. If the client is not
immune, retesting will be performed during the pregnancy. Additionally, rubella
immunization is required after delivery if the client is not immune. Therefore telling the
client that she has developed immunity to the rubella virus, telling her that she may have
been exposed to rubella, and telling her that the test results are normal are all incorrect.
comparable or alike and indicate that the results are normal or that the woman has
developed immunity. Review this laboratory test and the result that indicates immunity to
rubella if you had difficulty with this question.
nursing care (4th ed., pp. 241, 546). St. Louis: Elsevier.
Content Area: Laboratory Values
63. 63.ID: 383699104
A hepatitis B screen is performed on a pregnant client, and the results indicate the
presence of antigens in the client's blood. On the basis of this finding, the nurse
determines that:
o
The results are negative
The client needs to receive the hepatitis B series of vaccines
The results indicate that the mother does not have hepatitis B
Hepatitis immune globulin and vaccine will be administered to the newborn

infant soon after birth Correct
Rationale: A hepatitis B screen is performed to determine the presence of antigens in

maternal blood. If they are present, the newborn will need to receive hepatitis immune
globulin and vaccine soon after birth. Therefore, noting that the results are negative,
noting that the client needs to receive the hepatitis B series of vaccines, and noting that
the results indicate that the mother does not have hepatitis B are all incorrect
interpretations.
comparable or alike and indicate that the results are negative and that the mother does not
have hepatitis B. To select from the remaining options, recall the significance of antigens
in maternal blood, which will direct you to the correct option. Review the significance of
the hepatitis B screen during pregnancy if you had difficulty with this question.
Content Area: Laboratory Values
64. 64.ID: 3870763920
A multigravida pregnant woman asks the nurse when she will start to feel fetal
movements. Around which week of gestation does the nurse tell the mother that fetal
movements are first noticed?
o
6 weeks
8 weeks
12 weeks
16 weeks Correct
Rationale: Fetal movements (quickening) are first noticed by the multigravida pregnant
woman at 16 to 20 weeks of gestation and gradually increase in frequency and strength.
The other options are incorrect.
Test-Taking Strategy: Knowledge regarding quickening is required to answer this
question. In this situation it is best to select the option that identifies the longest duration
of gestation. Review the process of quickening if you had difficulty with this question.
65. 65.ID: 383699587
The nurse provides information to a pregnant client who is experiencing nausea and
vomiting about measures to relieve the discomfort. Which statement by the mother
indicates the need for further information?
o
"I need to avoid eating fried or greasy foods."
"I need to be sure to drink adequate fluids with my meals." Correct
"I should eat five or six small meals a day rather than three full meals."
"I should keep dry crackers at my bedside and eat them before I get out of bed
in the morning."
Rationale: To alleviate nausea and vomiting, the client should avoid drinking fluids with
meals. The client should keep dry crackers at her bedside, avoid fried foods, and eat
smaller meals. Additionally, the client should eat dry crackers every 2 hours to prevent an
empty stomach and avoid spicy foods and foods with strong odors, such as onion and
cabbage.
Test-Taking Strategy: Use the process of elimination, noting the strategic words "need for
further information." These words indicate a negative event query and the need to select
the incorrect statement. Use knowledge of general principles related to nutrition and the
measures to alleviate nausea and vomiting to direct you to the correct option. Review the
measures that will alleviate nausea and vomiting if you had difficulty with this question.
66. 66.ID: 383699130
A nurse provides information to a pregnant client with hemorrhoids about measures that
will alleviate her discomfort. Which of the following actions does the nurse tell the client
to take? Select all that apply.
o
Sleep lying on her back
Shower daily but avoid sitting in a bathtub
Apply cool compresses to the hemorrhoids Correct
Contact the nurse-midwife if any bleeding occurs
Elevate her hips on a pillow when resting or during sleep Correct
Rationale: To relieve the discomfort of hemorrhoids, the client should take frequent tepid
baths. The client is also instructed to apply cool witch hazel compresses or anesthetic
ointment to the hemorrhoids and to assume a side-lying position with the hips elevated on
a pillow. The client may experience some bleeding, which is normal. However, if the
bleeding persists, the physician or nurse-midwife should be contacted.
Test-Taking Strategy: Focus on the subject, alleviating the discomfort of hemorrhoids.
Read each option carefully and think about the pathophysiology and the anatomical
location of hemorrhoids to answer correctly. Review the measures to relieve the
discomfort of hemorrhoids if you had difficulty with this question.
nursing (3rd ed., pp 271-272). St. Louis: Elsevier.
67. 67.ID: 383697927
A pregnant client asks a nurse about the use of noninvasive acupressure as a
complementary alternative therapy to relieve nausea. The nurse tells the client that:
o
Complementary alternative therapies should not be used during pregnancy
Devices that apply pressure alone are available over the counter Correct
The physician or nurse-midwife needs to provide a prescription for

acupressure
It is all right to try any type of complementary alternative therapy to relieve
the nausea
Rationale: As a complementary alternative therapy, acupressure over the Neiguan
acupuncture point (approximately three fingers width above the wrist crease on the inner
arm) is performed with the use of electrical impulses or with a device that applies
pressure alone. Devices that apply an electrical impulse over this point require a
prescription from a physician or nurse-midwife. Devices that apply pressure alone are
available over the counter. Certain types (those that are noninvasive and are not harmful)
may be acceptable for use during pregnancy. Not all types of complementary alternative
therapies can be used during pregnancy, because some may be harmful to the mother,
fetus, or both.
Test-Taking Strategy: Use the process of elimination. Noting the strategic word
noninvasive acupressure will help direct you to the correct option. Review
complementary alternative therapies to relieve nausea and those that are safe during
pregnancy if you had difficulty with this question.
68. 68.ID: 383699134
A nurse is telling a pregnant client about the signs that must be reported to the physician
or nurse-midwife. The nurse tells the client that the physician or nurse-midwife should be
contacted if which of the following occurs?
o
Morning sickness
Breast tenderness
Urinary frequency
Puffiness of the face Correct
Rationale: Danger signs in pregnancy include swelling of the fingers (rings become
tight), puffiness of the face or around the eyes; vaginal bleeding, with or without
discomfort; rupture of the membranes; a continuous pounding headache; visual
disturbances; persistent or severe abdominal pain; chills or fever; painful urination;
persistent vomiting; and a change in the frequency or strength of fetal movements.
Morning sickness, breast tenderness, and frequent urination are common occurrences
during pregnancy and do not warrant contacting the physician or nurse-midwife.
Test-Taking Strategy: Use the process of elimination and focus on the subject, a sign that
should be reported. Eliminate the options that are comparable or alike and indicate
common occurrences during pregnancy. Review the danger signs in pregnancy if you had
69. 69.ID: 383699597
A pregnant client tells the nurse that she has a 2-year-old child at home and expresses
concern about how the toddler will adapt to a newborn infants being brought into the
home. Which of the following statements is the most appropriate response for the nurse to
make to the client?
o
"Dont be concerned; any 2-year-old would welcome a newborn."
"If your 2-year-old becomes angry or jealous, you should have the child seen
by a child psychologist."
o
"A 2-year-old toddler will be more concerned about exploring the

environment, so theres no reason to be concerned."
"Even though a 2-year-old may have little perception of time, if any changes
in sleeping arrangements need to be made for the newborn they should be carried
out several weeks before birth." Correct
Rationale: Sibling adaptation to the birth of an infant depends largely on age and
developmental level. Very young children (2 years or younger) are unaware of the
maternal changes occurring during pregnancy and are unable to understand that a new
brother or sister is going to be born. Even though toddlers have little perception of time,
if any changes in sleeping arrangements need to be made they should be carried out
several weeks before the birth of the new baby. Until a child feels secure in the affection
of his or her parents, expecting a 2-year-old to welcome a new "stranger" is unrealistic.
The parents can be taught to accept strong feelings such as anger, jealousy, and frustration
without judgment and to continue to reinforce the childs feelings of being loved.
nontherapeutic and avoid addressing the clients concern. To select from the remaining
options, recall that anger and jealousy are expected feelings in a toddler, which will assist
you in eliminating this option. Review the concepts related to sibling adaptation if you
Integrated Process: Communication and Documentation
70. 70.ID: 383700015
A Muslim woman and her husband are seen in the health care clinic because the woman
suspects that she is pregnant. When planning for the physical assessment of the woman,
the nurse ensures that:
o
A female physician examines the woman Correct
The woman's husband remains in the examining room at all times
The woman is examined without any other people in the examining room
Written permission is obtained from the woman to obtain subjective health

data
Rationale: Fear, modesty, and a desire to avoid examination by men may keep some
women from seeking health care during pregnancy. In many cultures (e.g., Muslim,
Hindu, Latino), exposure of a womans genitals to men is considered demeaning. Nurses
must remember that the reputations of women from these cultures depend on their
demonstrated modesty. It is best for a female physician or practitioner to perform the
examination. If this is not possible, the woman should be carefully draped, with her legs
completely covered. A female nurse should remain with the woman at all times.
Obtaining permission from the husband may be necessary before an examination or
treatment can be performed.
Test-Taking Strategy: Focus on the subject, a Muslim client. Recalling that modesty is a
cultural characteristic of a Muslim woman will direct you to the correct option. Review
these cultural characteristics if you had difficulty with this question.
Lowdermilk, D., Perry, S., & Cashion, K., (2010). Maternity nursing (8th ed., p. 45). St.
Louis: Mosby.

71. 71.ID: 383700003
A nurse is teaching a pregnant client about nutrition and food sources that are high in
folic acid. Which of the following food items does the nurse tell the client contains the
highest amount of folic acid?
o
Lettuce
Oranges
Broccoli
Pinto beans Correct
Rationale: Foods high in folic acid include beans (black, kidney, pinto, refried), peanuts,
orange juice and oranges, asparagus, peas, broccoli, lettuce, and spinach. Pinto beans
contain 294 mcg per 1-cup serving. An orange contains 44 mcg per 1-cup serving, lettuce
contains 60 mcg per 1-cup serving, and broccoli contains 78 mcg per 1-cup serving.
Test-Taking Strategy: Note the strategic words "highest amount" in the query of the
question. These words indicate that all of the items in the options contain folic acid but
also that you need to select the item that contains the greatest amount. You need to recall
that beans are high in folic acid to answer correctly. Review foods high in folic acid if
Content Area: Nutrition

72. 72.ID: 383697909
A pregnant client is scheduled to undergo a transabdominal ultrasound, and the nurse
provides information to the client about the procedure. The nurse tells the client that:
o
The procedure takes about 2 hours
She will be positioned on her back for the procedure
A probe coated with gel will be inserted into the vagina
That she may need to drink fluids before the test and may not void until the
test has been completed Correct
Rationale: For a transabdominal ultrasound, the woman is positioned on her back, with
her head elevated, but is turned slightly to one side to prevent supine hypotension. A
wedge or rolled blanket is placed under one hip to help her maintain this position
comfortably. If a full bladder is necessary, the woman is instructed to drink several
glasses of clear fluid 1 hour before the test and told that she should not void until the test
has been completed. Warm mineral oil or transmission gel is spread over her abdomen,
and the sonographer slowly moves a transducer over the abdomen to obtain a picture. The
procedure takes 10 to 30 minutes. For transvaginal ultrasonography, a transvaginal probe
is inserted into the vagina.
Test-Taking Strategy: Use the process of elimination. Note the word transabdominal in
the question and eliminate the option that contains the words inserted into the vagina.
Recalling that the pregnant client is at risk for supine hypotension will help you eliminate
the option that involves positioning the client on her back. To select from the remaining
options, visualize this procedure and eliminate the option stating that the test will take 2
hours, because this is a lengthy period. Review the procedure for transabdominal
ultrasound if you had difficulty with this question.

73. 73.ID: 383697911
An amniocentesis is scheduled for a pregnant client who is in the third trimester of
pregnancy. The nurse tells the client that the most common indication for amniocentesis
during the third trimester is:
o
Determination of fetal lung maturity Correct
Checking the amniotic fluid for intrauterine infection
Checking the fetal cells for chromosomal abnormalities
Determination of whether alpha-fetoprotein (AFP) is present in the amniotic

fluid
Rationale: The most common indications for amniocentesis in the third trimester are
determination of fetal lung maturity and evaluation of the fetus condition when the
woman has Rh isoimmunization. The most common purpose for midtrimester
amniocentesis is to examine fetal cells in the amniotic fluid to identify chromosomal
abnormalities. Midtrimester amniocentesis is also performed to evaluate the fetus
condition when the woman is sensitized to Rh-positive blood, to diagnose intrauterine
infection, and to investigate amniotic-fluid AFP and acetylcholinesterase when the
maternal serum AFP concentration is increased.
Test-Taking Strategy: Use the process of elimination. Noting the words "third trimester"
in the question will help direct you to the option that addresses fetal lung maturity. Use of
the ABCs airway, breathing, and circulation will also direct you to the correct
option. Review the indications for performing an amniocentesis in the third trimester if
74. 74.ID: 383699527
A nurse performs a nonstress test on a pregnant client. The nurse determines that the
results are nonreactive if which of the following findings is noted on the electronic
monitoring recording strip?
o
Absence of accelerations after fetal movement Correct
Accelerations without fetal movement with fetal heart rate (FHR) increases of
15 beats per minute for 15 seconds
Acceleration of the FHR by 25 to 30 beats per minute for at least 15 seconds
in response to fetal movement

o
Two fetal heart accelerations within a 20-minute period, peaking at 15 beats

per minute above baseline and lasting 15 seconds from baseline to baseline
Rationale: In a nonreactive (nonreassuring) stress test, the monitor recording would not
demonstrate the required characteristics of a reactive (reassuring) recording within a 40minute period. In a reactive (reassuring) recording, at least two fetal heart accelerations,
with or without fetal movement detected by the woman, occur within a 20-minute period,
peak at least 15 beats per minute above the baseline, and last 15 seconds from baseline to
baseline.
Test-Taking Strategy: Use the process of elimination. Note the relationship between the
word "nonreactive" in the question and absence in the correct option. Review
interpretation of the results of a nonstress test if you had difficulty with this question.
Reference: Lowdermilk, D., Perry, S., & Cashion, K., (2010). Maternity nursing (8th ed.,
75. 75.ID: 383699514
A nurse is assisting a nurse-midwife in performing an amniotomy. After the procedure,
the nurse should perform the following actions. Assign the correct order of priority to the
items on the list, using 1 to indicate the first action and 5 the last.
Incorrect
o Assist the woman in cleaning the perineal area
o Assess the color, odor, and other characteristics of the amniotic fluid
o Check the woman's heart rate and blood pressure
o Assess the fetal heart rate
o Ask the woman about the need to void
The correct order is:
o Assess the fetal heart rate
o Assess the color, odor, and other characteristics of the amniotic fluid
o Check the woman's heart rate and blood pressure
o Assist the woman in cleaning the perineal area

o Ask the woman about the need to void
Rationale: The FHR is assessed immediately after amniotomy. The umbilical cord could
be displaced in a large fluid gush, resulting in compression and interruption of blood flow
through it. Next the nurse checks the amniotic fluid for abnormalities, which could
indicate a problem with the fetus. The nurse should then assess the mothers vital signs to
ensure that they have not been affected by the procedure. The nurse then assists the
woman in cleaning the perineal area and finally asks the woman about the need to void.
Test-Taking Strategy: Note the strategic word "priority." Use the ABCs airway,
breathing, and circulation and recall that the FHR is the priority (remember that cord
compression is the primary concern after amniotomy). Because the amniotic fluid
provides information about fetal status, this is checked next. After assessing the fetus,
focus on the mother. Again, remember the ABCs to help determine that vital signs are
taken next. To select from the remaining options, recall that to decrease the risk of
infection it is best to clean the perineal area next. Review the priority interventions after
amniotomy if you had difficulty with this question.
Content Area: Delegating/Prioritizing
2. 76.ID: 383700034
A nurse is taking the vital signs of a pregnant client who has been admitted to the labor
unit. The nurse notes that the client's temperature is 100.6 F, the pulse rate is 100 beats
per minute, and respirations are 24 breaths per minute. On the basis of these findings,
what is the most appropriate nursing action?
o
Recheck the vital signs in 1 hour
Notify the nurse-midwife of the findings Correct
Continue collecting subjective and objective data
Document the findings in the client's medical record
Rationale: The womans temperature should range from 98 F to 99.6 F. The pulse rate
should be 60 to 90 beats per minute, and respirations should be 12 to 20 breaths per
minute. A temperature of 100.4 F or higher, especially in the presence of an increased
pulse rate and faster respirations, suggests infection, and the nurse-midwife or physician
should be notified. Although the findings would be documented, the nurse would most
appropriately contact the nurse-midwife or physician. Once the nurse has contacted the
nurse-midwife or physician, the nurse would continue the assessment. Vital signs would
be rechecked as prescribed or in accordance with agency protocol.
question. Noting that the vital signs are elevated above normal range will help direct you
to the correct option. Review normal maternal vital signs in the intrapartum period if you
Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal Child
Nursing Care (4th ed., pp. 449-451, 467). St. Louis: Elsevier.
o 77.ID: 383697931
A nurse is caring for a pregnant client in the labor unit who suddenly experiences
spontaneous rupture of the membranes. On inspecting the amniotic fluid, the nurse notes
that it is clear, with creamy white flecks. What is the most appropriate action for the nurse
to take on the basis of this finding?
o
Document the findings. Correct
Check the client's temperature.
Report the findings to the nurse-midwife.
Obtain a sample of the amniotic fluid for laboratory analysis.
Rationale: Amniotic fluid should be clear and may include bits of vernix, the creamy
white fetal skin lubricant. Therefore the nurse would most appropriately document the
findings. Checking the clients temperature, reporting the findings to the nurse-midwife,
and obtaining a sample of the amniotic fluid for laboratory analysis are not necessary.
Cloudy, yellow, or foul-smelling amniotic fluid suggests infection. Green fluid indicates
that the fetus passed meconium before birth. If abnormalities are noted, the nurse should
notify the nurse-midwife.
Test-Taking Strategy: Use the process of elimination. Noting the word "clear" in the
question will help direct you to the correct option. Review the expected findings of
amniotic fluid if you had difficulty with this question.
Reference: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternal
Child Nursing Care (4th ed., p. 455). St. Louis: Elsevier.
o 78.ID: 383697901
A client in labor complains of back discomfort. Which position that will best aid in
relieving the discomfort does the nurse encourage the mother to assume?
o
Prone
Supine
Standing
Hands and knees Correct
Rationale: "Back labor," in which the back of the fetal head puts pressure on the womans
sacral promontory (occiput posterior position), is common. The discomfort of back labor
is difficult to relieve with medication alone. Positions that encourage the fetus to move
away from the sacral promontory are the hands-and-knees position and leaning forward
over a birthing ball (a sturdy ball similar to a beach ball). These positions reduce back
pain and enhance the internal-rotation mechanism of labor. It would be difficult for the
woman to assume a prone position. The supine position places the client at risk for supine
hypotension. A standing position might increase pressure, worsening the womans
backache.
Test-Taking Strategy: Focus on the subject of the question, relieving back discomfort, and
note the strategic word "best" in the query of the question. Visualizing each of the
positions in the options will direct you to the correct option. Review the measures for
relieving back discomfort if you had difficulty with this question.
o 79.ID: 383697913
A nurse monitoring a client in labor notes this fetal heart rate pattern (see figure) on the
electronic fetal monitoring strip. The most appropriate nursing action would be to:
Stop the oxytocin (Pitocin) infusion
Notify the nurse-midwife or physician
Administer oxygen with a face mask at 8 to 10 L/min
Continue to monitor the client and fetal heart rate patterns Correct
Rationale: Early decelerations are not associated with fetal compromise and require no
intervention. They occur during contractions as the fetal head presses against the
womans pelvis or soft tissues, such as the cervix. Early decelerations have a gradual
rather than an abrupt decrease from baseline. They have a consistent appearance in that
one early deceleration looks similar to others. Early decelerations mirror the contraction,
beginning near its onset and returning to the baseline by the end of the contraction, with
the low point of the deceleration occurring near the contractions peak. The rate at the
lowest point of the deceleration usually remains greater than 100 beats per minute.
Test-Taking Strategy: Knowledge regarding the appearance and significance of early
decelerations is needed to answer this question. Recalling that early decelerations are not
associated with fetal compromise will help you answer correctly. Review the appearance
and significance of early decelerations if you had difficulty with this question.
Child Nursing Care (4th ed., pp. 430-431). St. Louis: Elsevier.
o 80.ID: 383699116
A nurse notes the presence of variable decelerations on the fetal heart rate monitor strip
and suspects cord compression. The nurse should immediately:
o
Notify the nurse-midwife or physician
Perform a vaginal examination on the mother
Position the mother so that her hips are elevated Correct
Insert a gloved finger into the mother's vagina to feel for cord compression
Rationale: Conditions that restrict blood flow through the umbilical cord may result in
variable decelerations. If cord compression is suspected, the mother is immediately
repositioned. She may be turned to her side, or her hips may be elevated to shift the fetal
presenting part toward her diaphragm. A hands-and-knees position may also reduce
compression of a cord that is trapped behind the fetus. Several position changes may be
required before the pattern improves or resolves. The nurse may need to contact the
nurse-midwife or physician, but this would not be the immediate action. Although the
nurse may check the womans vaginal area for the presence of the umbilical cord, a
vaginal exam is not performed because of the possibility of further compromise of blood
flow through the umbilical cord. Because of this risk, the nurse would not insert a gloved
finger into the vagina to feel for the cord.
Test-Taking Strategy: Note the strategic word "immediately" in the query of the question
and use the ABCs airway, breathing, and circulation to answer the question. The
only action that would provide circulation is positioning the mother so that her hips are
elevated, which would relieve cord compression. Review the immediate nursing
measures when cord compression is suspected if you had difficulty with this question.
nursing care (4th ed., p. 432). St. Louis: Elsevier.
Content Area: Critical Care
o 81.ID: 383697919
A woman in labor whose cervix is not completely dilated is pushing strenuously during
contractions. Which method of breathing should the nurse encourage the woman to
perform to help her overcome the urge to push?
o
Cleansing breaths
Blowing repeatedly in short puffs Correct
Holding her breath and using the Valsalva maneuver
Deep inspiration and expiration at the beginning and end, respectively, of

each contraction
Rationale: If a woman pushes strenuously before the cervix is completely dilated, she
risks injury to the cervix and the fetal head. Blowing prevents closure of the glottis and
breath-holding, helping overcome the urge to push strenuously. The woman would be
encouraged to blow repeatedly, using short puffs, when the urge to push is strong.
Cleansing breaths (deep inspiration and expiration at the beginning and end of each
contraction) are encouraged during the first stage of labor to provide oxygenation and
reduce myometrial hypoxia and to promote relaxation. The woman would not be
encouraged to hold her breath or perform the Valsalva maneuver, which is a bearingdown maneuver.
Test-Taking Strategy: Use the process of elimination. Eliminate options that are
comparable or alike; cleansing breaths include deep inspiration and expiration at the
beginning and end of each contraction. Recalling that the Valsalva maneuver is a bearingdown maneuver will help you eliminate this option. Review breathing techniques during
labor if you had difficulty with this question.
Reference: Lowdermilk, D., Perry, S., & Cashion, K., (2010). Maternity nursing (8th ed.,
o 82.ID: 383697929
A woman receives a subarachnoid (spinal) block for a cesarean delivery. For which
adverse effect of the block does the postpartum nurse monitor the woman?
o
Pruritus
Vomiting
Headache Correct
Hypertension
Rationale: The adverse effects associated with a subarachnoid block include maternal
hypotension, bladder distention, and postdural headache. Postdural headache occurs as a
result of cerebrospinal fluid leakage at the site of dural puncture. A spinal headache is
postural, worsening when the woman is upright and possibly disappearing when she is
lying flat. Bed rest with oral or intravenous hydration helps relieve the headache. Nausea,
vomiting, and pruritus are adverse effects associated with the use of intrathecal opioids.
Test-Taking Strategy: Use the process of elimination. Noting the word "spinal" in the
question and focusing on the subject, an adverse effect, will help direct you to the correct
option. Review the adverse effects of a subarachnoid block if you had difficulty with this
question.
Content Area: Maternity/Postpartum
o 83.ID: 383697951
A nurse is monitoring a woman who is receiving oxytocin (Pitocin) to induce labor.
Which action should the nurse, on suddenly noting the presence of late decelerations on
the fetal heart rate (FHR) monitor, take first?
o
Stopping the oxytocin infusion Correct
Notifying the nurse-midwife or physician
Checking the woman's blood pressure and pulse
Increasing the intravenous (IV) rate of the nonadditive solution
Rationale: Oxytocin stimulates uterine smooth muscle, resulting in increased strength,

duration, and frequency of uterine contractions. The nurse monitors the client who is
receiving oxytocin closely and, if uterine hypertonicity or a nonreassuring FHR pattern,
such as late decelerations occurs, intervenes to reduce uterine activity and increase fetal
oxygenation. The nurse would first stop the oxytocin infusion. The nurse would next
increase the IV rate of the nonadditive solution, place the woman in a side-lying position,
and administer oxygen through a snug face mask at a rate of 8 to 10 L/min. The nurse
would then notify the nurse-midwife or physician of the adverse reaction, the nursing
interventions taken, and the response to interventions. The nurse would monitor the
womans vital signs while she is receiving oxytocin, but this would not be the first action
in this situation.
Test-Taking Strategy: Use the process of elimination and note the strategic word "first."
Noting that the question indicates that the client is receiving oxytocin and recalling the
adverse effects of oxytocin will direct you to the correct option. Review the adverse
effects of oxytocin and the associated nursing interventions if you had difficulty with this
question.
o 84.ID: 383697959
Immediately after delivery, the nurse assesses the woman's uterine fundus. At what
location does the nurse expect to be able to palpate the fundus?
o
In the pelvic cavity
2 cm above the umbilicus
At the level of the umbilicus
Midway between the symphysis pubis and umbilicus Correct
Rationale: Immediately after delivery, the uterus is about the size of a large grapefruit or
softball. The fundus may be palpated midway between the symphysis pubis and the
umbilicus but then rises to a level just above the umbilicus and then sinks to the level of
the umbilicus, where it remains for about 24 hours. After 24 hours, the fundus begins to
descend by approximately 1 cm, or one fingers breadth, per day. By the 10th to 14th day,
the fundus is in the pelvic cavity and cannot be palpated abdominally.
Test-Taking Strategy: Knowledge regarding the descent of the uterine fundus is required
to answer this question. Noting the strategic words "immediately after delivery" will help
direct you to the correct option. Review the expected findings in the immediate
postpartum period related to involution if you had difficulty with this question.
o 85.ID: 383697907
A nurse is taking the vital signs of a woman who delivered a healthy newborn 1 hour ago.
The nurse notes that the woman's radial pulse rate is 55 beats per minute. On the basis of
this finding, which action by the nurse is most appropriate?
o
Documenting the finding Correct
Helping the woman get out of bed and walk
Performing active and passive range-of-motion exercises
Reporting the finding to the nurse-midwife or physician immediately
Rationale: After delivery, bradycardia (pulse rate 50 to 70 beats per minute) may occur.
The lower pulse rate reflects the large amount of blood returning to the central circulation
after delivery of the placenta. The increase in central circulation results in increased
stroke volume and permits a slower heart rate to provide adequate maternal circulation. It
is not necessary to notify the nurse-midwife or physician immediately, because a pulse
rate of 55 beats per minute is a normal finding. The client should remain on bed rest in
the immediate postpartum period. Although range-of-motion exercises are important for
the client on bed rest, this action is unrelated to the data in the question. Therefore, the
most appropriate nursing action is to document the finding.
Test-Taking Strategy: Use the process of elimination. Recalling the physiological
alterations that occur in the woman after delivery will direct you to the correct option.
Remember that after delivery bradycardia may occur and that it is a normal finding.
Review the expected vital sign measurements in the immediate postpartum period if you
o 86.ID: 383699511
A nurse is monitoring the amount of lochia drainage on a perineal pad in a woman who is
1 hour postpartum and notes a 5-inch bloodstain (see figure). How does the nurse report
the amount of lochial flow?
Scant
Light
Moderate Correct
Heavy
Rationale: Lochia is the discharge from the uterus, consisting of blood from the vessels
of the placental site and debris from the deciduas, that occurs during the postpartum
period. Use the following guide to determine the amount of flow: scant = less than 2.5 cm
(1 inch) on menstrual pad in 1 hour; light = less than 10 cm (4 inches) on menstrual pad
in 1 hour; moderate = less than 15 cm (6 inches) on menstrual pad in 1 hour; heavy =
saturated menstrual pad in 1 hour; and excessive = menstrual pad saturated in 15 minutes.
Test-Taking Strategy: Focus on the data in the question and the figure. Noting the words
5-inch bloodstain and the use of guidelines to determine the amount of lochial flow will
direct you to the correct option. If you had difficulty with this question, review
postpartum assessment of the amount of lochial flow.
nursing (3rd ed., p. 457, 700). St. Louis: Elsevier.
nursing care (4th ed., pp. 526-527). St. Louis: Elsevier.
Integrated Process: Nursing Process - assessment

o 87.ID: 383699114
A woman who delivered a healthy newborn 6 hours earlier complains of discomfort at the
episiotomy site. Which action by the nurse is the most appropriate?
o
Applying an ice pack to the perineum Correct
Contacting the nurse-midwife or physician
Administering an intravenous (IV) opioid analgesic
Assisting the woman in taking a warm sitz bath
Rationale: Ice causes vasoconstriction and is most effective if applied to the perineal area
soon after birth to prevent edema and numb the area. Ice is used for the first 12 to 24
hours after a vaginal birth. Sitz baths, which provide continuous circulation of water,
cleanse and comfort the traumatized perineum. Warm water is most effective after 24
hours have elapsed since delivery. An IV opioid analgesic is not necessary. Rather, an
anesthetic spray that will decrease surface discomfort may be used. It is not necessary to
notify the nurse-midwife or physician.
Test-Taking Strategy: Use the process of elimination and focus on the womans
complaint. Recalling that episiotomy pain is to be expected will assist in eliminating the
option that involves contacting the nurse-midwife or physician. An IV medication is not
required to relieve the discomfort, so eliminate this option. To select from the remaining
options, recall the effects of heat and cold and note that the client gave birth 6 hours ago.
Review measures to relieve perineal discomfort in the postpartum period if you had

o 88.ID: 383697955
A postpartum nurse provides information to a new mother who is being discharged from
the maternity unit about signs and symptoms that should be reported to her health care
provider. Which statement by the mother indicates a need for further information?
o
"My temperature needs to remain within a normal range."
"Frequent urination and burning when I urinate are expected." Correct
"Feelings of pelvic fullness or pelvic pressure are a sign of a problem."
"I will call my nurse-midwife if I get any redness, swelling, or tenderness in

my legs."
Rationale: The new mother is instructed to notify the nurse-midwife or physician if any
of the following occurs: fever; localized areas of redness, swelling, or pain in either
breast that is not relieved by support or analgesics; persistent abdominal tenderness;
feelings of pelvic fullness or pressure; persistent perineal pain; frequency, urgency, or
burning on urination; a change in the character of lochia (increased amount, resumption
of bright-red color, passage of clots, foul odor); localized tenderness, redness, swelling,
or warmth of the legs; and swelling, redness, drainage from, or separation of an
abdominal incision.
Test-Taking Strategy: Use the process of elimination and note the strategic words "need
for further information." These words indicate a negative event query and the need to
select the incorrect statement. Recalling the signs of a urinary tract infection will direct
you to the correct option. Review the postpartum signs and symptoms that should be
reported if you had difficulty with this question.
o 89.ID: 383699125
A nurse, monitoring a client in the fourth stage of labor, checks the client's vital signs
every 15 minutes. The nurse notes that the client's pulse rate has increased from 70 to 100
beats per minute. On the basis of this finding, which priority action should the nurse
take?
o
Checking the client's uterine fundus Correct
Notifying the nurse-midwife immediately
Documenting the vital signs in the client's medical record
Continuing to check the client's vital signs every 15 minutes
Rationale: During the fourth stage of labor, the womans vital signs should be assessed
every 15 minutes during the first hour. An increasing pulse rate is an early sign of
excessive blood loss, because the heart pumps faster to compensate for reduced blood
volume. The blood pressure decreases as the blood volume diminishes, but this is a later
sign of hypovolemia. The most common reason for excessive postpartum bleeding is that
the uterus is not firmly contracting and compressing open vessels at the placental site.
Therefore the nurse should check the clients uterine fundus for firmness, height, and
positioning. Notifying the nurse-midwife immediately is not necessary unless the nurse is
unable to determine the cause of bleeding and is unable to correct it. Continuing to check
the clients vital signs every 15 minutes will delay necessary intervention. Although the
findings will need to be documented, the priority action is to assess the client for
bleeding.
Test-Taking Strategy: Use the process of elimination. Noting that the pulse rate has
increased and recalling the signs of bleeding and shock will help direct you to the correct
option. Also note that the correct option addresses assessment of the cause for bleeding.
Review the signs of bleeding and the causes in the postpartum client if you had difficulty
with this question.
o 90.ID: 383697177
A nurse calculates a newborn infant's Apgar score 1 minute after birth and determines that
the score is 6. The nurse should take which most appropriate action?
o
Recheck the score in 5 minutes
Initiate cardiopulmonary resuscitation
Provide no action except to support the infant's spontaneous efforts
Gently stimulate the infant by rubbing his back while administering oxygen
Correct
Rationale: The Apgar score is a method of rapid evaluation of an infants

cardiorespiratory adaptation after birth. The nurse scores the infant at 1 minute and 5
minutes in five areas: heart rate, respiratory effort, muscle tone, reflex response, and
color. The infant is assigned a score of 0 to 2 in each of the five areas, and the scores are
totaled. If the score ranges from 8 to 10, no action is needed other than support of the
infants spontaneous efforts and continued observation. If the score falls between 4 and 7,
the nurse gently stimulates the infant by rubbing his back while administering oxygen.
The nurse also determines whether the mother received opioids, which may have
depressed the infants respirations. If the score is between 1 and 3, the infant needs
resuscitation.
Test-Taking Strategy: Focus on the Apgar score identified in the question. Recalling that
the score ranges from 0 to 10 will help direct you to the correct option. Review the
significance of the Apgar score if you had difficulty with this question.
o 91.ID: 383697917
A nurse monitoring a newborn infant notes that the infant's respirations are 40 breaths per
minute. On the basis of this finding, what is the most appropriate action for the nurse to
take?
o
Documenting the findings Correct
Contacting the pediatrician
Placing the infant in an oxygen tent
Wrapping an extra blanket around the infant
Rationale: The normal respiratory rate of a newborn infant is 30 to 60 breaths per minute
(average 40). The nurse would document the findings. Contacting the pediatrician,
placing the infant in an oxygen tent, and wrapping an extra blanket around the infant are
all unnecessary actions.
Test-Taking Strategy: Knowledge regarding the normal respiratory rate in a newborn
infant is needed to answer this question. Focus on the data in the question and recall that
40 breaths per minute is normal. Review normal newborn vital signs if you had difficulty
with this question.
Content Area: Newborn
o 92.ID: 383699123
A nurse in the newborn nursery, performing an assessment of a newborn, prepares to
measure the chest circumference. The nurse places the tape measure around the infant:
o
In the axillary area
At the level of the nipples Correct
2 inches below the nipples
At the level of the umbilicus
Rationale: The chest circumference of the infant is measured at the level of the nipples. It
is usually 2 to 3 cm smaller than the heads circumference. The average circumference of
the chest is 30.5 to 33 cm (12 to 13 inches). (If molding of the head is present, the head
and chest measurements may be equal at birth.) The other options are incorrect
anatomical areas for measuring chest circumference.
Test-Taking Strategy: Focus on the subject, measuring chest circumference. Visualizing
each of the options will help direct you to the correct one. Review the procedure for
measuring chest circumference in a newborn infant if you had difficulty with this
question.
o 93.ID: 383700005
A nurse in the pediatrician's office is checking the Babinski reflex in a 3-month-old
infant. The nurse determines that the infant's response is normal if which of the following
findings is noted?
o
The infant turns to the side that is touched.
The fingers curl tightly and the toes curl forward.
The toes flare and the big toe is dorsiflexed. Correct
There is extension of the extremities on the side to which the head is turned,
with flexion on the opposite side.

Rationale: To elicit the Babinski reflex, the nurse strokes the lateral sole of the foot from
the heel to across the base of the toes. In the expected response, the toes flare and the big
toe dorsiflexes. The Babinski reflex disappears at 12 months of age. Turning to the side
that is touched is the expected response when the rooting reflex is elicited. Tight curling
of the fingers and forward curling of the toes is the expected response when the grasp
reflex (palmar and plantar) is elicited. Extension of the extremities on the side to which
the head is turned with flexion on the opposite side is the expected response when the
tonic neck reflex is elicited.
Test-Taking Strategy: Knowledge regarding the method of testing and the expected
response of the Babinski reflex is needed to answer this question. Recalling that to elicit
Babinski reflex the nurse would stroke the lateral sole of the foot will direct you to the
correct option. Review the procedure for testing this reflex in an infant and the expected
response if you had difficulty with this question.
o 94.ID: 383699546
Intramuscular phytonadione (vitamin K) 0.5 mg is prescribed for a newborn. After the
medication is prepared, in which anatomical site does the nurse administer it?
o
Gluteal muscle
Deltoid muscle
Rectus femoris muscle
Vastus lateralis muscle Correct
Rationale: Vitamin K is administered to the newborn infant in the hour after birth to help
prevent hemorrhagic disease. The best site for intramuscular injection is the infants
vastus lateralis muscle, although, if necessary, the rectus femoris muscle may be used.
The large vastus lateralis muscle is located away from the sciatic nerve, as well as the
femoral artery and vein. The rectus femoris muscle is nearer these structures, and an
injection there is more hazardous. The deltoid muscle is not used to administer
intramuscular injections in the newborn infant. The gluteal muscles are never used until a
child has been walking for at least a year. These muscles are poorly developed and
dangerously near the sciatic nerve.
Test-Taking Strategy: Use the process of elimination. Visualizing the anatomical location
of each of the muscles identified in the options will direct you to the correct option.
Review the procedure for administering vitamin K to a newborn if you had difficulty with
this question.
o 95.ID: 383699589
A newborn infant's blood glucose level is analyzed by the laboratory. The laboratory staff
calls the nurse and reports that the blood glucose level is 40 mg/dL. On the basis of this
result, which action should the nurse take first?
o
Hold the next scheduled feeding
Contact the nurse-midwife or physician Correct
Document the results in the newborn's medical record
Ask the laboratory to draw another blood sample in 2 hours and repeat the
test
Rationale: The blood glucose level for a newborn infant should remain above 40 mg/dL.
If glucose is not constantly available to the brain, permanent damage may occur. The
nurse would most appropriately contact the nurse-midwife or physician to obtain
prescriptions regarding feeding the infant with a low blood glucose. The nurse would also
follow agency policy regarding feeding infants with a low blood glucose level if such a
policy exists. A common practice is to feed the infant if the glucose level is 40 mg/dL or
less. Holding the next scheduled feeding is harmful. Although the nurse would document
the laboratory result, this is not the most appropriate initial action. Another blood sample
may need to be drawn if it is prescribed, but asking the laboratory to repeat the test in 2
hours is not the appropriate action.
Test-Taking Strategy: Note the strategic word "first" in the query of the question.
Recalling the normal blood glucose level for a newborn and recalling the danger
associated with a low blood glucose level will direct you to the correct option. Review
nursing interventions for maintaining a safe blood glucose level in the newborn if you
o 96.ID: 383700011
A nurse demonstrates the procedure for bathing a newborn to a new mother. The next day,
the nurse watches as the mother bathes the infant. The nurse determines that the mother is
performing the procedure correctly if she:
o
Washes the diaper area first
Washes the infant's chest first
Uncovers only the body part being washed Correct
Uses a cotton-tipped swab to carefully clean inside the infant's nose
Rationale: Bathing should start with the eyes and face, usually the cleanest areas. Next,
the external ear and the areas behind the ears are cleansed. The infants neck should be
washed because formula, lint, or breast milk often accumulates in the folds of the neck.
The hands and arms are then washed. Next, the infants legs are washed, and the diaper
area is washed last. The person administering the bath should keep the infant warm by
uncovering only the area being washed. Cotton-tipped swabs are not used to clean the
infants ears or nose because injury could occur if the infant were to move suddenly.
Test-Taking Strategy: Use the process of elimination. Remembering the basic techniques
of bathing a client will assist you in answering this question. Always start with the
cleanest area of the body first and proceed to the dirtiest area. Also, recalling that cottontipped swabs can cause injury will assist you in eliminating this option. Review the
procedure for bathing an infant if you had difficulty with this question.
Integrated Process: Nursing Process/Evaluation
o 97.ID: 383697947
The mother of a newborn who was circumcised before discharge from the hospital calls
the nurse at the pediatrician's office and tells the nurse that she is concerned because she
has noticed a yellow crust over the circumcision site. The nurse tells the mother:
o
To bring the infant to the pediatrician's office to be checked
That the crust is to be expected as a normal part of healing Correct
To remove the crust, using a warm, wet face cloth and a mild soap
That it could indicate a sign of an infection and that the infant's temperature
should be checked every 2 hours
Rationale: After circumcision, a yellow crust may form over the circumcision site. This
crust is a normal part of healing and should not be removed. The mother should be told to
expect this occurrence. Yellow crusting or discharge is not a sign of infection, and the
pediatrician does not need to be notified, because the finding is to be expected.
comparable or alike and indicate that a complication exists. To select from the remaining
options, recall the normal process of healing. This will help you answer correctly. Review
the expected findings after circumcision if you had difficulty with this question.
o 98.ID: 383699132
A new mother who is breastfeeding her newborn calls the nurse at the pediatrician's office
and reports that her infant is passing seedy, mustard-yellow stools. The nurse tells the
mother:
o
That this is normal for breastfed infants Correct
To decrease the number of feedings by two per day
That the stools should be solid and pale yellow to light brown
To monitor the infant for infection and, if a fever develops, to contact the
pediatrician
Rationale: Breastfed infants pass very soft, seedy, mustard-yellow stools. Formula-fed
infants excrete stools that are more solid and pale yellow to light brown. Decreasing the
number of feedings might be harmful to the newborn. Because this finding is an expected
occurrence in a breastfed infant, infection is not a concern.
comparable or alike and indicate that the infants stools are abnormal. Remember,
breastfed infants pass very soft, seedy, mustard-yellow stools. Review the expected
elimination patterns in a breastfed infant if you had difficulty with this question.
Reference: Perry, S., Hockenberry, M., Lowdermilk, D., & Wilson, D. (2010). Maternalchild nursing care (4th ed., p. 614). St. Louis: Elsevier.
o 99.ID: 383697183
A nurse is assessing a newborn infant for jaundice. Which of the following actions should
the nurse take to assess the infant for its presence?
o
Squeeze the infant's nail beds
Squeeze the infant's brachial area
Apply pressure with a finger over the umbilical area
Apply pressure with a finger on the infant's forehead Correct
Rationale: To assess an infant for jaundice, pressure is applied with a finger over a bony
area such as the nose, forehead, or sternum for several seconds to empty all capillaries in
that spot. If jaundice is present, the blanched area will appear yellow before the
capillaries refill. Jaundice is first noticeable in the head and then progresses gradually
toward the abdomen and extremities because of the newborn infants circulatory pattern.
Squeezing the infants nail beds and brachial area and applying pressure with a finger
over the umbilical area are all incorrect methods of assessing for jaundice. Assessing for
jaundice in natural light is recommended because artificial lighting and reflection from
nursery walls may distort the actual skin color. Visual assessment of jaundice does not,
however, provide an accurate assessment of the level of serum bilirubin.
Test-Taking Strategy: Use the process of elimination. Eliminate options that contain the
word "squeeze." To select from the remaining options, recall that jaundice is first
noticeable in the head; this will direct you to the correct option. Review the procedure for
assessing for jaundice in a newborn if you had difficulty with this question.

o 100.ID: 383697945
A prescription is written to administer hepatitis B vaccine (Recombivax HB) to a
newborn infant. Before administering the vaccine, the nurse should:
o
Check the infant for jaundice
Check the infant's temperature
Obtain parental consent to administer the vaccine Correct
Request that a hepatitis blood screen be performed on the infant
Rationale: Hepatitis B vaccine is for immunization against infection caused by all known
subtypes of hepatitis B virus. The usual recommended schedule is to administer the
vaccine at birth, at 1 month of age, and again at 6 months of age. Parental consent must
be obtained before the vaccine is administered. Checking the infants temperature,
checking for jaundice, and requesting that a hepatitis blood screen be performed on the
infant are all unnecessary.
Test-Taking Strategy: Knowledge regarding the administration of the hepatitis B vaccine
to a newborn is required to answer this question. Remember, parental consent is required
before the vaccine is administered. Review the procedure for administering this vaccine
to a newborn if you had difficulty with this question.


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Module 1 Exam

Rely on the fact that their needs will be met Correct

Need to tolerate a great deal of frustration and discomfort to develop a

Need to experience frustration, so it is best to allow an infant to cry for a

Rationale: According to Eriksons theory of psychosocial development, infants struggle

Client Needs: Health Promotion and Maintenance

Level of Cognitive Ability: Applying

Suspect the presence of hydrocephalus

Suggest to the pediatrician that a skull x-ray be performed

Document these measurements in the infant's health-care record Correct

Client Needs: Health Promotion and Maintenance

"Yes, your infant is protected from all infections."

"If you breastfeed, your infant is protected from infection."

Rationale: Transplacental transfer of maternal antibodies supplements the infants weak

The infant babbles.

The infant says "Mama." Correct

The infant smiles and coos.

The infant babbles single consonants.

Schedule an appointment with a dentist for a dental evaluation

Obtain an over-the-counter (OTC) topical medication for gum-pain relief

Rationale: Although sometimes asymptomatic, teething is often signaled by behavior

Use a small amount of toothpaste and a soft-bristle toothbrush

"Fluoride supplementation is not necessary until permanent teeth come in."

infant right away."

shoulder and lap belts secured around the infant

safety seat as long as the car has passenger-side air bags

"I need to keep large toys out of the crib."

"The drop side needs to be impossible for my infant to release."

"Wood surfaces on the crib need to be free of splinters and cracks."

prevent entrapment of my infant's head or body." Correct

Initiative versus guilt

Trust versus mistrust

Industry versus inferiority

Autonomy versus doubt and shame Correct

Spend as much time as possible with the toddler

Keep hospital routines as similar as possible to those at home Correct

Awarded 0.0 points out of 1.0 possible points.

Blocks and push-pull toys Correct

Finger paints and card games

Simple board games and puzzles

Videos and cutting-and-pasting toys

Awarded 0.0 points out of 1.0 possible points.

To separate her children during playtime

dress and to direct them to another activity Correct

Integrated Process: Nursing Process/Implementation

Put on and tie his shoes

Align two or more blocks Correct

Dress himself appropriately

Go to the bathroom without help

Turn the pages of a book one at a time Correct

Is slower than expected Correct

Is more advanced than expected

Will require assistance from a speech therapist

Just before beginning kindergarten

Twelve months after the first primary tooth erupts

Level of Cognitive Ability: Applying

The child has been walking for 2 years.

The child can eat using a fork and knife.

The child no longer has temper tantrums.

The child can remove his or her own clothing. Correct

Level of Cognitive Ability: Applying

Booster seat in a rear-facing position in the front seat

Car safety seat in the back seat in a face-forward position

Car safety seat in a face-forward position in the front seat