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The scope of this Nursing Test II is parallel to the NP2 NLE


Coverage:

Maternal and Child Health


Community Health Nursing
Communicable Diseases
Integrated Management of Childhood Illness

1. The student nurse is assigned to take the vital signs of the


clients in the pediatric ward. The student nurse reports to the
staff nurse that the parent of a toddler who is 2 days
postoperative after a cleft palate repair has given the toddler
a paciNer. What would be the best immediate action of the
nurse?

A. Notify the pediatrician of this Nnding


B. Reassure the student that this is an acceptable action on
the parent’s part
C. Discuss this action with the parents
D. Ask the student nurse to remove the paciNer from the
toddler’s mouth

2. The nurse is providing a health teaching to the mother of


an 8-year-old child with cystic Nbrosis. Which of the following
statement if made by the mother would indicate to the nurse
the need for further teaching about the medication regimen
of the child?

A. “My child might need an extra capsule if the meal is high


in fat”
B. “I’ll give the enzyme capsule before every snack”
C. “I’ll give the enzyme capsule before every meal”
D. “My child hates to take pills, so I’ll mix the capsule into a
cup of hot chocolate

3. The mother brought her child to the clinic for follow-up


check up. The mother tells the nurse that 14 days after
starting an oral iron supplement, her child’s stools are black.
Which of the following is the best nursing response to the
mother?

A. “I will notify the physician, who will probably decrease the


dosage slightly”
B. “This is a normal side effect and means the medication
is working”
C. “You sound quite concerned. Would you like to talk about
this further?”
D. “I will need a specimen to check the stool for possible
bleeding”

4. An 8-year-old boy with asthma is brought to the clinic for


check up. The mother asks the nurse if the treatment given to
her son is effective. What would be the appropriate response
of the nurse?

A. I will review Nrst the child’s height on a growth chart to


know if the treatment is working
B. I will review Nrst the child’s weight on a growth chart to
know if the treatment is working
C. I will review Nrst the number of prescriptions reNlls the
child has required over the last 6 months to give you an
accurate answer
D. I will review Nrst the number of times the child has seen
the pediatrician during the last 6 months to give you an
accurate answer

5. The nurse is caring to a child client who is receiving


tetracycline. The nurse is aware that in taking this
medication, it is very important to:

A. Administer the drug between meals


B. Monitor the child’s hearing
C. Give the drug through a straw
D. Keep the child out of the sunlight

6. A 14 day-old infant with a cyanotic heart defects and mild


congestive heart failure is brought to the emergency
department. During assessment, the nurse checks the apical
pulse rate of the infant. The apical pulse rate is 130 beats per
minute. Which of the following is the appropriate nursing
action?

A. Retake the apical pulse in 15 minutes


B. Retake the apical pulse in 30 minutes
C. Notify the pediatrician immediately
D. Administer the medication as scheduled

7. The physician prescribed gentamicin (Garamycin) to a


child who is also receiving chemotherapy. Before
administering the drug, the nurse should check the results of
the child’s:

A. CBC and platelet count


B. Auditory tests
C. Renal Function tests
D. Abdominal and chest x-rays

8. Which of the following is the suited size of the needle


would the nurse select to administer the IM injection to a
preschool child?

A. 18 G, 1-1/2 inch
B. 25 G, 5/8 inch
C. 21 G, 1 inch
D. 18 G, 1inch

9. A 9-year-old boy is admitted to the hospital. The boy is


being treated with salicylates for the migratory polyarthritis
accompanying the diagnosis of rheumatic fever. Which of the
following activities performed by the child would give a best
sign that the medication is effective?

A. Listening to story of his mother


B. Listening to the music in the radio
C. Playing mini piano
D. Watching movie in the dvd mini player

10. The physician decided to schedule the 4-year-old client


for repair of left undescended testicle. The Injection of a
hormone, HCG Nnds it less successful for treatment. To
administer a pentobarbital sodium (Nembutal) suppository
preoperatively to this client, in which position should the
nurse place him?

A. Supine with foot of bed elevated


B. Prone with legs abducted
C. Sitting with foot of bed elevated
D. Side-lying with upper leg jexed

11. The nurse is caring to a 24-month-old child diagnosed


with congenital heart defect. The physician prescribed
digoxin (Lanoxin) to the client. Before the administration of
the drug, the nurse checks the apical pulse rate to be 110
beats per minute and regular. What would be the next nursing
action?

A. Check the other vital signs and level of consciousness


B. Withhold the digoxin and notify the physician
C. Give the digoxin as prescribed
D. Check the apical and radial simultaneously, and if they
are the same, give the digoxin.

12. An 8-year-old client with cystic Nbrosis is admitted to the


hospital and will undergo a chest physiotherapy treatment.
The therapy should be properly coordinated by the nurse with
the respiratory therapy department so that treatments occur
during:

A. After meals
B. Between meals
C. After medication
D. Around the child’s play schedule

13. The nurse is providing health teaching about the


breastfeeding and family planning to the client who gave
birth to a healthy baby girl. Which of the following statement
would alert the nurse that the client needs further teaching?

A. “I understand that the hormones for breastfeeding may


affect when my periods come”
B. “Breastfeeding causes my womb to tighten and bleed
less after birth”
C. “I may not have periods while I am breastfeeding, so I
don’t need family planning”
D. “I can get pregnant as early as one month after my baby
was born”

14. A toddler is brought to the hospital because of severe


diarrhea and vomiting. The nurse assigned to the client
enters the client’s room and Nnds out that the client is using a
soiled blanket brought in from home. The nurse attempts to
remove the blanket and replace it with a new and clean
blanket. The toddler refuses to give the soiled blanket. The
nurse realizes that the best explanation for the toddler’s
behavior is:

A. The toddler did not bond well with the maternal Ngure
B. The blanket is an important transitional object
C. The toddler is anxious about the hospital experience
D. The toddler is resistive to nursing interventions

15. The nurse has knowledge about the developmental task


of the child. In caring a 3-year-old-client, the nurse knows that
the suited developmental task of this child is to:

A. Learn to play with other children


B. Able to trust others
C. Express all needs through speaking
D. Explore and manipulate the environment

16. A mother who gave birth to her second daughter is so


concerned about her 2-year old daughter. She tells the nurse,
“I am afraid that my 2-year-old daughter may not accept her
newly born sister”. It is appropriate to the nurse to response
that:

A. The older daughter be given more responsibility and


assure her “that she is a big girl now, and doesn’t need
Mommy as much”
B. The older daughter not have interaction with the baby at
the hospital, because she may harm her new sibling
C. The older daughter stay with her grandmother for a few
days until the parents and new baby are settled at home
D. The mother spend time alone with her older daughter
when the baby is sleeping

17. A 2-year-old client with cystic Nbrosis is conNned to bed


and is not allowed to go to the playroom. Which of the
following is an appropriate toy would the nurse select for the
child:

A. Puzzle
B. Musical automobile
C. Arranging stickers in the album
D. Pounding board and hammer
18. Which of the following clients is at high risk for
developmental problem?

A. A toddler with acute Glomerulonephritis on


antihypertensive and antibiotics
B. A 5-year-old with asthma on cromolyn sodium
C. A preschooler with tonsillitis
D. A 2 1/2 –year old boy with cystic Nbrosis

19. Which of the following would be the best divesionary


activity for the nurse to select for a 2 weeks hospitalized 3-
year-old girl?

A. Crayons and coloring books


B. doll
C. xylophone toy
D. puzzles

20. A nurse is providing safety instructions to the parents of


the 11-month-old child. Which of the following will the nurse
includes in the instructions?

A. Plugging all electrical outlets in the house


B. Installing a gate at the top and bottom of any stairs in the
home
C. Purchasing an infant car seat as soon as possible
D. Begin to teach the child not to place small objects in the
mouth

21. An 8-year-old girl is in second grade and the parents


decided to enroll her to a new school. While the child is
focusing on adjusting to new environment and peers, her
grades suffer. The child’s father severely punishes the child
and forces her daughter to study after school. The father
does not allow also her daughter to play with other children.
These data indicate to the nurse that this child is deprived of
forming which normal phase of development?
A. Heterosexual relationships
B. A love relationship with the father
C. A dependency relationship with the father
D. Close relationship with peers

22. A 5-year-old boy client is scheduled for hernia surgery.


The nurse is preparing to do preoperative teaching with the
child. The nurse should knows that the 5-year-old would:

A. Expect a simple yet logical explanation regarding the


surgery
B. Asks many questions regarding the condition and the
procedure
C. Worry over the impending surgery
D. Be uninterested in the upcoming surgery

23. The nine-year-old client is admitted in the hospital for


almost 1 week and is on bed rest. The child complains of
being bored and it seems tiresome to stay on bed and doing
nothing. What activity selected by the nurse would the child
most likely Nnd stimulating?

A. Watching a video
B. Putting together a puzzle
C. Assembling handouts with the nurse for an upcoming
staff development meeting
D. Listening to a compact disc

24. The parent of a 16-year-old boy tells the nurse that his
son is driving a motorbike very fast and with one hand. “It is
making me crazy!” What would be the best explanation of the
nurse to the behavior of the boy?

A. The adolescent might have an unconscious death wish


B. The adolescent feels indestructible
C. The adolescent lacks life experience to realize how
dangerous the behavior is
D. The adolescent has found a way to act out hostility
toward the parent

25. An 8-month-old infant is admitted to the hospital due to


diarrhea. The nurse caring for the client tells the mother to
stay beside the infant while making assessment. Which of
the following developmental milestones the infant has
reached?

A. Has a three-word vocabulary


B. Interacts with other infants
C. Stands alone
D. Recognizes but is fearful of strangers

26. The community nurse is conducting a health teaching in


the group of married women. When teaching a woman about
fertility awareness, the nurse should emphasize that the
basal body temperature:

A. Should be recorded each morning before any activity


B. Is the average temperature taken each morning
C. Can be done with a mercury thermometer but not a
digital one
D. Has a lower degree of accuracy in predicting ovulation
than the cervical mucus test

27. The community nurse is providing an instruction to the


clients in the health center about the use of diaphragm for
family planning. To evaluate the understanding of the
woman, the nurse asks her to demonstrate the use of the
diaphragm. Which of following statement indicates a need
for further health teaching?

A. “I should check the diaphragm carefully for holes every


time I use it.”
B. “The diaphragm must be left in place for at least 6 hours
after intercourse.”
C. “I really need to use the diaphragm and jelly most during
the middle of my menstrual cycle
D. “I may need a different size diaphragm if I gain or lose
more than 20 pounds”

28. The client visits the clinic for prenatal check-up. While
waiting for the physician, the nurse decided to conduct health
teaching to the client. The nurse informed the client that
primigravida mother should go to the hospital when which
patter is evident?

A. Contractions are 2-3 minutes apart, lasting 90 seconds,


and membranes have ruptured
B. Contractions are 5-10 minutes apart, lasting 30 seconds,
and are felt as strong menstrual cramps
C. Contractions are 3-5 minutes apart, accompanied by
rectal pressure and bloody show
D. Contractions are 5 minutes apart, lasting 60 seconds,
and increasing in intensity

29. A nurse is planning a home visit program to a new mother


who is 2 weeks postpartum and breastfeeding, the nurse
includes in her health teaching about the resumption of
fertility, contraception and sexual activity. Which of the
following statement indicates that the mother has
understood the teaching?

A. “Because breastfeeding speeds the healing process after


birth, I can have sex right away and not worry about
infection”
B. “Because I am breastfeeding and my hormones are
decreased, I may need to use a vaginal lubricant when I
have sex”
C. “After birth, you have to have a period before you can get
pregnant again’
D. “Breastfeeding protects me from pregnancy because it
keeps my hormones down, so I don’t need any
contraception until I stop breastfeeding”

30. A community nurse enters the home of the client for


follow-up visit. Which of the following is the most appropriate
area to place the nursing bag of the nurse when conducting a
home visit?

A. cushioned footstool
B. bedside wood table
C. kitchen countertop
D. living room sofa

31. The nurse in the health center is making an assessment


to the infant client. The nurse notes some rashes and small
juid-Nlled bumps in the skin. The nurse suspects that the
infant has eczema. Which of the following is the most
important nursing goal:

A. Preventing infection
B. Providing for adequate nutrition
C. Decreasing the itching
D. Maintaining the comfort level

32. The nurse in the health center is providing immunization


to the children. The nurse is carefully assessing the condition
of the children before giving the vaccines. Which of the
following would the nurse note to withhold the infant’s
scheduled immunizations?

A. a dry cough
B. a skin rash
C. a low-grade fever
D. a runny nose

33. A mother brought her child in the health center for


hepatitis B vaccination in a series. The mother informs the
nurse that the child missed an appointment last month to
have the third hepatitis B vaccination. Which of the following
statements is the appropriate nursing response to the
mother?
A. “I will examine the child for symptoms of hepatitis B”
B. “Your child will start the series again”
C. “Your child will get the next dose as soon as possible”
D. “Your child will have a hepatitis titer done to determine if
immunization has taken place.”

34. The community health nurse implemented a new


program about effective breast cancer screening technique
for the female personnel of the health department of
Valenzuela. Which of the following technique should the
nurse consider to be of the lowest priority?

A. Yearly breast exam by a trained professional


B. Detailed health history to identify women at risk
C. Screening mammogram every year for women over age
50
D. Screening mammogram every 1-2 years for women over
age of 40.

35. Which of the following technique is considered an aseptic


practice during the home visit of the community health
nurse?

A. Wrapping used dressing in a plastic bag before placing


them in the nursing bag
B. Washing hands before removing equipment from the
nursing bag
C. Using the client’s soap and cloth towel for hand washing
D. Placing the contaminated needles and syringes in a
labeled container inside the nursing bag

36. The nurse is planning to conduct a home visit in a small


community. Which of the following is the most important
factor when planning the best time for a home care visit?

A. Purpose of the home visit


B. Preference of the patient’s family
C. Location of the patient’s home
D. Length of time of the visit will take

37. The nurse assigned in the health center is counseling a


30-year-old client requesting oral contraceptives. The client
tells the nurse that she has an active yeast infection that has
recurred several times in the past year. Which statement by
the nurse is inaccurate concerning health promotion actions
to prevent recurring yeast infection?

A. “During treatment for yeast, avoid vaginal intercourse for


one week”
B. “Wear loose-Ntting cotton underwear”
C. “Avoid eating large amounts of sugar or sugar-bingeing”
D. “Douche once a day with a mild vinegar and water
solution”

38. During immunization week in the health center, the parent


of a 6-month-old infant asks the health nurse, “Why is our
baby going to receive so many immunizations over a long
time period?” The best nursing response would be:

A. “The number of immunizations your baby will receive


shows how many pediatric communicable and infectious
diseases can now be prevented.”
B. “You need to ask the physician”
C. “The number of immunizations your baby will receive is
determined by your baby’s health history and age”
D. “It is easier on your baby to receive several
immunizations rather than one at a time”

39. The community health nurse is conducting a health


teaching about nutrition to a group of pregnant women who
are anemic and are lactose intolerant. Which of the following
foods should the nurse especially encourage during the third
trimester?

A. Cheese, yogurt, and Nsh for protein and calcium needs


plus prenatal vitamins and iron supplements
B. Prenatal iron and calcium supplements plus a regular
adult diet
C. Red beans, green leafy vegetables, and Nsh for iron and
calcium needs plus prenatal vitamins and iron
supplements
D. Red meat, milk and eggs for iron and calcium needs plus
prenatal vitamins and iron supplements

40. A woman with active tuberculosis (TB) and has visited the
health center for regular therapy for Nve months wants to
become pregnant. The nurse knows that further information
is necessary when the woman states:

A. “Spontaneous abortion may occur in one out of Nve


women who are infected”
B. “Pulmonary TB may jeopardize my pregnancy”
C. “I know that I may not be able to have close contact with
my baby until contagious is no longer a problem
D. “I can get pregnant after I have been free of TB for 6
months”

41. The Department of Health is alarmed that almost 33


million people suffer from food poisoning every year.
Salmonella enteritis is responsible for almost 4 million cases
of food poisoning. One of the major goals is to promote
proper food preparation. The community health nurse is
tasks to conduct health teaching about the prevention of
food poisoning to a group of mother everyday. The nurse can
help identify signs and symptoms of speciNc organisms to
help patients get appropriate treatment. Typical symptoms of
salmonella include:

A. Nausea, vomiting and paralysis


B. Bloody diarrhea
C. Diarrhea and abdominal cramps
D. Nausea, vomiting and headache

42. A community health nurse makes a home visit to an


elderly person living alone in a small house. Which of the
following observation would be a great concern?

A. Big mirror in a wall


B. Scattered and unwashed dishes in the sink
C. Shiny joors with scattered rugs
D. Brightly lit rooms

43. The health nurse is conducting health teaching about


“safe” sex to a group of high school students. Which of the
following statement about the use of condoms should the
nurse avoid making?

A. “Condoms should be used because they can prevent


infection and because they may prevent pregnancy”
B. “Condoms should be used even if you have recently
tested negative for HIV”
C. “Condoms should be used every time you have sex
because condoms prevent all forms of sexually
transmitted diseases”
D. “Condoms should be used every time you have sex even
if you are taking the pill because condoms can prevent
the spread of HIV and gonorrhea”

44. The department of health is promoting the breastfeeding


program to all newly mothers. The nurse is formulating a plan
of care to a woman who gave birth to a baby girl. The nursing
care plan for a breast-feeding mother takes into account that
breast-feeding is contraindicated when the woman:

A. Is pregnant
B. Has genital herpes infection
C. Develops mastitis
D. Has inverted nipples

45. The City health department conducted a medical mission


in Barangay Marulas. Majority of the children in the Barangay
Marulas were diagnosed with pinworms. The community
health nurse should anticipate that the children’s chief
complaint would be:

A. Lack of appetite
B. Severe itching of the scalp
C. Perianal itching
D. Severe abdominal pain

46. The mother brought her daughter to the health center.


The child has head lice. The nurse anticipates that the
nursing diagnosis most closely correlated with this is:

A. Fluid volume deNcit related to vomiting


B. Altered body image related to alopecia
C. Altered comfort related to itching
D. Diversional activity deNcit related to hospitalization

47. The mother brings a child to the health care clinic


because of severe headache and vomiting. During the
assessment of the health care nurse, the temperature of the
child is 40 degree Celsius, and the nurse notes the presence
of nuchal rigidity. The nurse is suspecting that the child might
be suffering from bacterial meningitis. The nurse continues
to assess the child for the presence of Kernig’s sign. Which
Nnding would indicate the presence of this sign?

A. Flexion of the hips when the neck is jexed from a lying


position
B. Calf pain when the foot is dorsijexed
C. Inability of the child to extend the legs fully when lying
supine
D. Pain when the chin is pulled down to the chest

48. A community health nurse makes a home visit to a child


with an infectious and communicable disease. In planning
care for the child, the nurse must determine that the primary
goal is that the:
A. Child will experience mild discomfort
B. Child will experience only minor complications
C. Child will not spread the infection to others
D. Public health department will be notiNed

49. The mother brings her daughter to the health care clinic.
The child was diagnosed with conjunctivitis. The nurse
provides health teaching to the mother about the proper care
of her daughter while at home. Which statement by the
mother indicates a need for additional information?

A. “I do not need to be concerned about the spreading of


this infection to others in my family”
B. “I should apply warm compresses before instilling
antibiotic drops if purulent discharge is present in my
daughter’s eye”
C. “I can use an ophthalmic analgesic ointment at nighttime
if I have eye discomfort”
D. “I should perform a saline eye irrigation before instilling,
the antibiotic drops into my daughter’s eye if purulent
discharge is present”

50. A community health nurse is caring for a group of jood


victims in Marikina area. In planning for the potential needs of
this group, which is the most immediate concern?

A. Finding affordable housing for the group


B. Peer support through structured groups
C. Setting up a 24-hour crisis center and hotline
D. Meeting the basic needs to ensure that adequate food,
shelter and clothing are available

Answers and Rationales

1. C. Nothing must be placed in the mouth of a toddler who


just undergone a cleft palate repair until the suture line
has completely healed. It is the nurse’s responsibility to
inform the parent of the client. Spoon, forks, straws, and
tongue blades are other unacceptable items to place in
the mouth of a toddler who just undergone cleft palate
repair. The general principle of care is that nothing
should enter the mouth until the suture line has
completely healed.
2. D. The pancreatic capsules contain pancreatic enzyme
that should be administered in a cold, not a hot, medium
(example: chilled applesauce versus hot chocolate) to
maintain the medication’s integrity.
3. B. When oral iron preparations are given correctly, the
stools normally turn dark green or black. Parents of
children receiving this medication should be advised that
this side effect indicates the medication is being
absorbed and is working well.
4. C. Reviewing the number of prescription reNlls the child
has required over the last 6 months would be the best
indicator of how well controlled and thus how effective
the child’s asthma treatment is. Breakthrough wheezing,
shortness of breath, and upper respiratory infections
would require that the child take additional medication.
This would be rejected in the number of prescription
reNlls.
5. D. Tetracycline may cause a phototoxic reaction.
6. D. The normal heart rate of an infant is 120-160 beats
per minute.
7. C. Both gentamicin and chemotherapeutic agents can
cause renal impairment and acute renal failure; thus
baseline renal function must be evaluated before
initiating either medication.
8. C. In selecting the correct needle to administer an IM
injection to a preschooler, the nurse should always look
at the child and use judgment in evaluating muscle mass
and amount of subcutaneous fat. In this case, in the
absence of further data, the nurse would be most correct
in selecting a needle gauge and length appropriate for
the “average’ preschool child. A medium-gauge needle
(21G) that is 1 inch long would be most appropriate.
9. C. The purpose of the salicylate therapy is to relieve the
pain associated with the migratory polyarthritis
accompanying the rheumatic fever. Playing mini piano
would require movement of the child’s joints and would
provide the nurse with a means of evaluating the child’s
level of pain.
10. D. The recommended position to administer rectal
medications to children is side-lying with the upper leg
jexed. This position allows the nurse to safely and
effectively administer the medication while promoting
comfort for the child.
11. C. For a 12month-old child, 110 apical pulse rate is
normal and therefore it is safe to give the digoxin. A
toddler’s normal pulse rate is slightly lower than an
infant’s (120).
12. B. Chest physiotherapy treatments are scheduled
between meals to prevent aspiration of stomach
contents, because the child is placed in a variety of
positions during the treatment process.
13. C. It is common misconception that breastfeeding may
prevent pregnancy.
14. B. The “security blanket” is an important transitional
object for the toddler. It provides a feeling of comfort and
safety when the maternal Ngure is not present or when in
a new situation for which the toddler was not prepared.
Virtually any object (stuffed animal, doll, book etc) can
become a security blanket for the toddler.
15. D. Toddlers need to meet the developmental milestone of
autonomy versus shame and doubt. In order to
accomplish this, the toddler must be able to explore and
manipulate the environment.
16. D. The introduction of a baby into a family with one or
more children challenges parent to promote acceptance
of the baby by siblings. The parent’s attitudes toward the
arrival of the baby can set the stage for the other
children’s reaction. Spending time with the older siblings
alone will also reassure them of their place in the family,
even though the older children will have to eventually
assume new positions within the family hierarchy.
17. D. The autonomous toddler would be frustrated by being
conNned to be. The pounding board and hammer is
developmentally appropriate and an excellent way for the
toddler to release frustration.
18. D. It is the developmental task of an 18-month-old
toddler to explore and learn about the environment. The
respiratory complications associated with cystic Nbrosis
(which are present in almost all children with cystic
Nbrosis) could prevent this development task from
occurring.
19. C. The best diversion for a hospitalized child aged 2-3
years old would be anything that makes noise or makes
a mess; xylophone which certainly makes noise or music
would be the best choice.
20. B. An 11-month-old child stands alone and can walk
holding onto people or objects. Therefore the installation
of a gate at the top and bottom of any stairs in the house
is crucial for the child’s safety.
21. D. In second grade a child needs to form a close
relationships with peers.
22. B. A 5-year-old is highly concerned with body integrity.
The preschool-age child normally asks many questions
and in a situation such as this, could be expected to ask
even more.
23. C. A 9-year-old enjoys working and feeling a sense of
accomplishment. The school-age child also enjoys
“showing off,” and doing something with the nurse on the
pediatric unit would allow this. This activity also provides
the school-age child a needed opportunity to interact
with others in the absence of school and personal
friends.
24. B. Adolescents do feel indestructible, and this is rejected
in many risk-taking behaviors.
25. D. An 8-month-old infant both recognizes and is fearful
of strangers. This developmental milestone is known as
“stranger anxiety”.
26. A. The basal body temperature (BBT) is the lowest body
temperature of a healthy person that is taken
immediately after waking and before getting out of bed.
The BBT usually varies from 36.2 – 36.3 degree Celsius
during menses and for about 5-7 days afterward. About
the time of ovulation, a slight drop approximately 0.05
degree Celsius in temperature may be seen; after
ovulation, in concert with the increasing progesterone
levels of the early luteal phase, the BBT rises 0.2-0.4
degree Celsius. This elevation remains until 2-3 days
before menstruation, or if pregnancy has occurred.
27. C. The woman must understand that, although the
“fertile” period is approximately midcycle, hormonal
variations do occur and can result in early or late
ovulations. To be effective, the diaphragm should be
inserted before every intercourse.
28. D. Although instructions vary among birth centers,
primigravidas should seek care when regular
contractions are felt about 5 minutes apart, becoming
longer and stronger.
29. B. Prolactin suppresses estrogen, which is needed to
stimulate vaginal lubrication during arousal.
30. B. A wood surface provides the least chance for
organisms to be present.
31. A. Preventing infection in the infant with eczema is the
nurse’s most important goal. The infant with eczema is
at high risk for infection due to numerous breaks in the
skin’s integrity. Intact skin is always the infant’s Nrst line
of defense against infection.
32. B. A skin rash could indicate a concurrent infectious
disease process in the infant. The scheduled
immunizations should be withheld until the status of the
infant’s health can be determined. Fevers above 38.5
degrees Celsius, alteration in skin integrity, and
infectious-appearing secretions are indications to
withhold immunizations.
33. C. Continuity is essential to promote active immunity and
give hepatitis B lifelong prophylaxis. Optimally, the third
vaccination is given 6 months after the Nrst.
34. B. Because of the high incidence of breast cancer, all
women are considered to be at risk regardless of health
history.
35. B. Handwashing is the best way to prevent the spread of
infection.
36. A. The purpose of the visit takes priority.
37. D. Frequent douching interferes with the natural
protective barriers in the vagina that resist yeast
infection and should be avoided.
38. A. Completion for the recommended schedule of infant
immunizations does not require a large number of
immunizations, but it also provides protection against
multiple pediatric communicable and infectious
diseases.
39. C. This is appropriate foods that are high in iron and
calcium but would not affect lactose intolerance.
40. D. Intervention is needed when the woman thinks that
she needs to wait only 6 months after being free of TB
before she can get pregnant. She needs to wait 1.5-
2years after she is declared to be free of TB before she
should attempt pregnancy.
41. C. Salmonella organisms cause lower GI symptoms
42. C. It is a safety hazard to have shiny joors and scattered
rugs because they can cause falls and rugs should be
removed.
43. C. Condoms do not prevent ALL forms of sexually
transmitted diseases.
44. A. Pregnancy is one contraindication to breast-feeding.
Milk secretion is inhibited and the baby’s sucking may
stimulate uterine contractions.
45. C. Perianal itching is the child’s chief complaint
associated with the diagnosis of pinworms. The itching,
in this instance, is often described as being “intense” in
nature. Pinworms infestation usually occurs because the
child is in the anus-to-mouth stage of development (child
uses the toilet, does not wash hands, places hands and
pinworm eggs in mouth). Teaching the child hand
washing before eating and after using the toilet can
assist in breaking the cycle.
46. C. Severe itching of the scalp is the classic sign and
symptom of head lice in a child. In turn, this would lead
to the nursing diagnosis of “altered comfort”.
47. C. Kernig’s sign is the inability of the child to extend the
legs fully when lying supine. This sign is frequently
present in bacterial meningitis. Nuchal rigidity is also
present in bacterial meningitis and occurs when pain
prevents the child from touching the chin to the chest.
48. C. The primary goal is to prevent the spread of the
disease to others. The child should experience no
complication. Although the health department may need
to be notiNed at some point, it is no the primary goal. It is
also important to prevent discomfort as much as
possible.
49. A. Conjunctivitis is highly contagious. Antibiotic drops
are usually administered four times a day. When purulent
discharge is present, saline eye irrigations or eye
applications of warm compresses may be necessary
before instilling the medication. Ophthalmic analgesic
ointment or drops may be instilled, especially at bedtime,
because discomfort becomes more noticeable when the
eyelids are closed.
50. D. The question asks about the immediate concern. The
ABCs of community health care are always attending to
people’s basic needs of food, shelter, and clothing

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