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