MATERNAL AND CHILD NURSING 2.

Decreased intestinal motility

1. When assessing the adequacy of sperm 3. Decreased gastric acidity
for conception to occur, which of the
following is the most useful criterion? 4. Elevated estrogen levels

1. Sperm count 5. On which of the following areas would

the nurse expect to observe chloasma?
2. Sperm motility
1. Breast, areola, and nipples
3. Sperm maturity
2. Chest, neck, arms, and legs
4. Semen volume
3. Abdomen, breast, and thighs
2. A couple who wants to conceive but has
been unsuccessful during the last 2 4. Cheeks, forehead, and nose
years has undergone many diagnostic 6. A pregnant client states that she
procedures. When discussing the “waddles” when she walks. The nurse’s
situation with the nurse, one partner explanation is based on which of the
states, “We know several friends in our following as the cause?
age group and all of them have their
own child already, Why can’t we have 1. The large size of the newborn
one?”. Which of the following would be 2. Pressure on the pelvic muscles
the most pertinent nursing diagnosis for
this couple? 3. Relaxation of the pelvic joints
1. Fear related to the unknown 4. Excessive weight gain
2. Pain related to numerous 7. Which of the following represents the
procedures. average amount of weight gained
during pregnancy?
3. Ineffective family coping related
to infertility. 1. 12 to 22 lb
4. Self-esteem disturbance related 2. 15 to 25 lb
to infertility.
3. 24 to 30 lb
3. Which of the following urinary
4. 25 to 40 lb
symptoms does the pregnant woman
most frequently experience during the 8. When talking with a pregnant client
first trimester? who is experiencing aching swollen, leg
veins, the nurse would explain that this
1. Dysuria
is most probably the result of which of
2. Frequency the following?
3. Incontinence 1. Thrombophlebitis
4. Burning 2. Pregnancy-
induced hypertension
4. Heartburn and flatulence, common in
the second trimester, are most likely 3. Pressure on blood vessels from
the result of which of the following? the enlarging uterus
1. Increased plasma HCG levels
 4. The force of gravity pulling 13. Which of the following would be
down on the uterus disadvantage of breast feeding?
9. Cervical softening and uterine souffle 1. Involution occurs more rapidly
are classified as which of the following?
2. The incidence of allergies
1. Diagnostic signs increases due to maternal
antibodies
2. Presumptive signs
3. The father may resent the
3. Probable signs infant’s demands on the
4. Positive signs mother’s body

10. Which of the following would the nurse 4. There is a greater chance for
identify as a presumptive sign of error during preparation
pregnancy? 14. Which of the following would cause a
1. Hegar sign false-positive result on a pregnancy
test?
2. Nausea and vomiting
1. The test was performed less
3. Skin pigmentation changes than 10 days after an abortion
4. Positive serum pregnancy test 2. The test was performed too
11. Which of the following common early or too late in the
emotional reactions to pregnancy pregnancy
would the nurse expect to occur during 3. The urine sample was stored
the first trimester? too long at room temperature
1. Introversion, egocentrism, 4. A spontaneous abortion or a
narcissism missed abortion is impending
2. Awkwardness, clumsiness, and 15. FHR can be auscultated with a
unattractiveness fetoscope as early as which of the
3. Anxiety, passivity, extroversion following?

4. Ambivalence, fear, fantasies 1. 5 weeks gestation

12. During which of the following would the 2. 10 weeks gestation

focus of classes be mainly on 3. 15 weeks gestation
physiologic changes, fetal development,
sexuality, during pregnancy, 4. 20 weeks gestation
and nutrition? 16. A client LMP began July 5. Her EDD
1. Prepregnant period should be which of the following?

2. First trimester 1. January 2

3. Second trimester 2. March 28

4. Third trimester 3. April 12

4. October 12
17. Which of the following fundal heights 3. Third stage
indicates less than 12 weeks’ gestation
when the date of the LMP is unknown? 4. Fourth stage

1. Uterus in the pelvis 22. Barbiturates are usually not given for
pain relief during active labor for which
2. Uterus at the xiphoid of the following reasons?
3. Uterus in the abdomen 1. The neonatal effects include
hypotonia, hypothermia,
4. Uterus at the umbilicus generalized drowsiness, and
18. Which of the following danger signs reluctance to feed for the first
should be reported promptly during the few days.
antepartum period? 2. These drugs readily cross the
1. Constipation placental barrier, causing
depressive effects in the
2. Breast tenderness newborn 2 to 3 hours after
3. Nasal stuffiness intramuscular injection.

4. Leaking amniotic fluid 3. They rapidly transfer across the

placenta, and lack of an
19. Which of the following prenatal antagonist make them generally
laboratory test values would the nurse inappropriate during labor.
consider as significant?
4. Adverse reactions may include
1. Hematocrit 33.5% maternal hypotension, allergic
or toxic reaction or partial or
2. Rubella titer less than 1:8
total respiratory failure
3. White blood cells 8,000/mm3
23. Which of the following nursing
4. One hour glucose challenge test interventions would the nurse perform
110 g/dL during the third stage of labor?

20. Which of the following characteristics of 1. Obtain a urine specimen and

contractions would the nurse expect to other laboratory tests.
find in a client experiencing true labor?
2. Assess uterine contractions
1. Occurring at irregular intervals every 30 minutes.

2. Starting mainly in the abdomen 3. Coach for effective client

pushing
3. Gradually increasing intervals
4. Promote parent-newborn
4. Increasing intensity with interaction.
walking
24. Which of the following actions
21. During which of the following stages of demonstrates the nurse’s
labor would the nurse assess understanding about the newborn’s
“crowning”? thermoregulatory ability?
1. First stage 1. Placing the newborn under a
2. Second stage radiant warmer.
 2. Suctioning with a bulb syringe 29. Which of the following is true regarding
the fontanels of the newborn?
3. Obtaining an Apgar score
1. The anterior is triangular
4. Inspecting the newborn’s shaped; the posterior is
umbilical cord diamond shaped.
25. Immediately before expulsion, which of 2. The posterior closes at 18
the following cardinal movements months; the anterior closes at 8
occur? to 12 weeks.
1. Descent 3. The anterior is large in size
2. Flexion when compared to the
posterior fontanel.
3. Extension
4. The anterior is bulging; the
4. External rotation posterior appears sunken.
26. Before birth, which of the following 30. Which of the following groups of
structures connects the right and left newborn reflexes below are present at
auricles of the heart? birth and remain unchanged through
1. Umbilical vein adulthood?

2. Foramen ovale 1. Blink, cough, rooting, and gag

3. Ductus arteriosus 2. Blink, cough, sneeze, gag

4. Ductus venosus 3. Rooting, sneeze, swallowing,

and cough
27. Which of the following when present in
the urine may cause a reddish stain on 4. Stepping, blink, cough, and
the diaper of a newborn? sneeze

1. Mucus 31. Which of the following describes the

Babinski reflex?
2. Uric acid crystals
1. The newborn’s toes will
3. Bilirubin hyperextend and fan apart from
dorsiflexion of the big toe when
4. Excess iron
one side of foot is stroked
28. When assessing the newborn’s heart upward from the ball of the
rate, which of the following ranges heel and across the ball of the
would be considered normal if the foot.
newborn were sleeping?
2. The newborn abducts and
1. 80 beats per minute flexes all extremities and may
begin to cry when exposed to
2. 100 beats per minute sudden movement or loud
3. 120 beats per minute noise.

4. 140 beats per minute 3. The newborn turns the head in

the direction of stimulus, opens
the mouth, and begins to suck
 when cheek, lip, or corner of 4. Incomplete
mouth is touched.
35. Which of the following factors would
4. The newborn will attempt to the nurse suspect as predisposing a
crawl forward with both arms client to placenta previa?
and legs when he is placed on
his abdomen on a flat surface 1. Multiple gestation

32. Which of the following statements best 2. Uterine anomalies

describes hyperemesis gravidarum? 3. Abdominal trauma
1. Severe anemia leading to 4. Renal or vascular disease
electrolyte, metabolic, and
nutritional imbalances in the 36. Which of the following would the nurse
absence of other medical assess in a client experiencing abruptio
problems. placenta?

2. Severe nausea and vomiting 1. Bright red, painless vaginal

leading to electrolyte, bleeding
metabolic, and nutritional 2. Concealed or external dark red
imbalances in the absence of bleeding
other medical problems.
3. Palpable fetal outline
3. Loss of appetite and continuous
vomiting that commonly results 4. Soft and nontender abdomen
in dehydration and ultimately
37. Which of the following is described as
decreasing maternal nutrients
premature separation of a normally
4. Severe nausea and diarrhea implanted placenta during the second
that can cause gastrointestinal half of pregnancy, usually with severe
irritation and possibly internal hemorrhage?
bleeding
1. Placenta previa
33. Which of the following would the nurse
2. Ectopic pregnancy
identify as a classic sign of PIH?
3. Incompetent cervix
1. Edema of the feet and ankles
4. Abruptio placentae
2. Edema of the hands and face
38. Which of the following may happen if
3. Weight gain of 1 lb/week
the uterus becomes overstimulated by
4. Early morning headache oxytocin during the induction of labor?
34. In which of the following types of 1. Weak contraction prolonged to
spontaneous abortions would the nurse more than 70 seconds
assess dark brown vaginal discharge
2. Tetanic contractions prolonged
and a negative pregnancy tests?
to more than 90 seconds
1. Threatened
3. Increased pain with bright red
2. Imminent vaginal bleeding
3. Missed
 4. Increased restlessness and 2. PROM removes the fetus most
anxiety effective defense against
infection
39. When preparing a client for cesarean
delivery, which of the following key 3. Nursing care is based on fetal
concepts should be considered when viability and gestational age.
implementing nursing care?
4. PROM is associated with
1. Instruct the mother’s support malpresentation and possibly
person to remain in the family incompetent cervix
lounge until after the delivery
42. Which of the following factors is the
2. Arrange for a staff member of underlying cause of dystocia?
the anesthesia department to
explain what to expect 1. Nurtional
postoperatively 2. Mechanical
3. Modify preoperative teaching 3. Environmental
to meet the needs of either a
planned or emergency cesarean 4. Medical
birth 43. When uterine rupture occurs, which of
4. Explain the surgery, expected the following would be the priority?
outcome, and kind of 1. Limiting hypovolemic shock
anesthetics
2. Obtaining blood specimens
40. Which of the following best describes
preterm labor? 3. Instituting complete bed rest
1. Labor that begins after 20 4. Inserting a urinary catheter
weeks gestation and before 37
44. Which of the following is the nurse’s
weeks gestation
initial action when umbilical cord
2. Labor that begins after 15 prolapse occurs?
weeks gestation and before 37
1. Begin monitoring maternal vital
weeks gestation
signs and FHR
3. Labor that begins after 24
2. Place the client in a knee-chest
weeks gestation and before 28
position in bed
weeks gestation
3. Notify the physician and
4. Labor that begins after 28
prepare the client for delivery
weeks gestation and before 40
weeks gestation 4. Apply a sterile warm saline
dressing to the exposed cord
41. When PROM occurs, which of the
following provides evidence of the 45. Which of the following amounts of
nurse’s understanding of the client’s blood loss following birth marks the
immediate needs? criterion for describing postpartum
hemorrhage?
1. The chorion and amnion
rupture 4 hours before the 1. More than 200 ml
onset of labor.
 2. More than 300 ml 2. Chills, fever, malaise, occurring
2 weeks after delivery
3. More than 400 ml
3. Muscle pain the presence of
4. More than 500 ml Homans sign, and swelling in
46. Which of the following is the primary the affected limb
predisposing factor related to mastitis? 4. Chills, fever, stiffness, and pain
1. Epidemic infection from occurring 10 to 14 days after
nosocomial sources localizing in delivery
the lactiferous glands and ducts 49. Which of the following are the most
2. Endemic infection occurring commonly assessed findings in cystitis?
randomly and localizing in the 1. Frequency, urgency,
periglandular connective tissue dehydration, nausea, chills, and
3. Temporary urinary retention flank pain
due to decreased perception of 2. Nocturia, frequency, urgency
the urge to avoid dysuria, hematuria, fever and
4. Breast injury caused by suprapubic pain
overdistention, stasis, and 3. Dehydration, hypertension,
cracking of the nipples dysuria, suprapubic pain, chills,
47. Which of the following best describes and fever
thrombophlebitis?
4. High fever, chills, flank pain
1. Inflammation and clot nausea, vomiting, dysuria, and
formation that result when frequency
blood components combine to 50. Which of the following best reflects the
form an aggregate body frequency of reported postpartum
2. Inflammation and blood clots “blues”?
that eventually become lodged 1. Between 10% and 40% of all
within the pulmonary blood new mothers report some form
vessels of postpartum blues
3. Inflammation and blood clots 2. Between 30% and 50% of all
that eventually become lodged new mothers report some form
within the femoral vein of postpartum blues
4. Inflammation of the vascular 3. Between 50% and 80% of all
endothelium with clot new mothers report some form
formation on the vessel wall of postpartum blues
48. Which of the following assessment 4. Between 25% and 70% of all
findings would the nurse expect if the new mothers report some form
client develops DVT? of postpartum blues
1. Midcalf pain, tenderness and 51. For the client who is using oral
redness along the vein contraceptives, the nurse informs the
client about the need to take the pill at
 the same time each day to accomplish 1. Daily enemas
which of the following?
2. Laxatives
1. Decrease the incidence of
nausea 3. Increased fiber intake

2. Maintain hormonal levels 4. Decreased fluid intake

3. Reduce side effects 56. Which of the following would the nurse
use as the basis for the teaching plan
4. Prevent drug interactions when caring for a pregnant teenager
concerned about gaining too much
52. When teaching a client about weight during pregnancy?
contraception. Which of the following
would the nurse include as the most 1. 10 pounds per trimester
effective method for preventing
sexually transmitted infections? 2. 1 pound per week for 40 weeks

1. Spermicides 3. ½ pound per week for 40 weeks

2. Diaphragm 4. A total gain of 25 to 30 pounds

3. Condoms 57. The client tells the nurse that her last
menstrual period started on January 14
4. Vasectomy and ended on January 20. Using
Nagele’s rule, the nurse determines her
53. When preparing a woman who is 2 days EDD to be which of the following?
postpartum for discharge,
recommendations for which of the 1. September 27
following contraceptive methods would
be avoided? 2. October 21

1. Diaphragm 3. November 7

2. Female condom 4. December 27

3. Oral contraceptives 58. When taking an obstetrical history on a

pregnant client who states, “I had a son
4. Rhythm method born at 38 weeks gestation, a daughter
born at 30 weeks gestation and I lost a
54. For which of the following clients would
baby at about 8 weeks,” the nurse
the nurse expect that an intrauterine should record her obstetrical history as
device would not be recommended? which of the following?
1. Woman over age 35 1. G2 T2 P0 A0 L2
2. Nulliparous woman 2. G3 T1 P1 A0 L2
3. Promiscuous young adult 3. G3 T2 P0 A0 L2
4. Postpartum client 4. G4 T2 P1 A1 L2
55. A client in her third trimester tells the 59. When preparing to listen to the fetal
nurse, “I’m constipated all the time!” heart rate at 12 weeks’ gestation, the
Which of the following should the nurse
recommend?
 nurse would use which of the 4. Missed abortion
following?
63. Which of the following would be the
1. Stethoscope placed midline at priority nursing diagnosis for a client
the umbilicus with an ectopic pregnancy?
2. Doppler placed midline at the 1. Risk for infection
suprapubic region
2. Pain
3. Fetoscope placed midway
between the umbilicus and the 3. Knowledge Deficit
xiphoid process 4. Anticipatory Grieving
4. External electronic fetal 64. Before assessing the postpartum
monitor placed at the umbilicus client’s uterus for firmness and position
60. When developing a plan of care for a in relation to the umbilicus and midline,
client newly diagnosed with gestational which of the following should the nurse
diabetes, which of the following do first?
instructions would be the priority? 1. Assess the vital signs
1. Dietary intake 2. Administer analgesia
2. Medication 3. Ambulate her in the hall
3. Exercise 4. Assist her to urinate
4. Glucose monitoring 65. Which of the following should the nurse
do when a primipara who is lactating
61. A client at 24 weeks gestation has
gained 6 pounds in 4 weeks. Which of tells the nurse that she has sore
the following would be the priority nipples?
when assessing the client? 1. Tell her to breast feed more
1. Glucosuria frequently
2. Administer a narcotic before
2. Depression
breast feeding
3. Hand/face edema
3. Encourage her to wear a
4. Dietary intake nursing brassiere
62. A client 12 weeks’ pregnant come to 4. Use soap and water to clean the
the emergency department with nipples
abdominal cramping and moderate
vaginal bleeding. Speculum examination 66. The nurse assesses the vital signs of a
reveals 2 to 3 cms cervical dilation. The client, 4 hours’ postpartum that are as
nurse would document these findings follows: BP 90/60; temperature
100.4ºF; pulse 100 weak, thready; R 20
as which of the following?
per minute. Which of the following
1. Threatened abortion should the nurse do first?
2. Imminent abortion 1. Report the temperature to the
physician
3. Complete abortion
 2. Recheck the blood pressure 3. Facilitating safe and effective
with another cuff self-and newborn care
3. Assess the uterus for firmness 4. Teaching about the importance
and position of family planning
4. Determine the amount of lochia 70. Which of the following actions would be
least effective in maintaining a neutral
67. The nurse assesses the postpartum thermal environment for the newborn?
vaginal discharge (lochia) on four
clients. Which of the following 1. Placing infant under radiant
assessments would warrant notification warmer after bathing
of the physician?
2. Covering the scale with a
1. A dark red discharge on a 2-day warmed blanket prior to
postpartum client weighing
2. A pink to brownish discharge on 3. Placing crib close to nursery
a client who is 5 days window for family viewing
postpartum
4. Covering the infant’s head with
3. Almost colorless to creamy a knit stockinette
discharge on a client 2 weeks
after delivery 71. A newborn who has an asymmetrical
Moro reflex response should be further
4. A bright red discharge 5 days assessed for which of the following?
after delivery
1. Talipes equinovarus
68. A postpartum client has a temperature
of 101.4ºF, with a uterus that is tender 2. Fractured clavicle
when palpated, remains unusually 3. Congenital hypothyroidism
large, and not descending as normally
expected. Which of the following should 4. Increased intracranial pressure
the nurse assess next? 72. During the first 4 hours after a male
1. Lochia circumcision, assessing for which of the
following is the priority?
2. Breasts
1. Infection
3. Incision
2. Hemorrhage
4. Urine
3. Discomfort
69. Which of the following is the priority
focus of nursing practice with the 4. Dehydration
current early postpartum discharge? 73. The mother asks the nurse. “What’s
1. Promoting comfort and wrong with my son’s breasts? Why are
restoration of health they so enlarged?” Whish of the
following would be the best response
2. Exploring the emotional status by the nurse?
of the family
 1. “The breast tissue is inflamed 76. A newborn weighing 3000 grams and
from the trauma experienced feeding every 4 hours needs 120
with birth” calories/kg of body weight every 24
hours for proper growth and
2. “A decrease in material development. How many ounces of 20
hormones present before birth cal/oz formula should this newborn
causes enlargement,” receive at each feeding to meet
3. “You should discuss this with nutritional needs?
your doctor. It could be a 1. 2 ounces
malignancy”
2. 3 ounces
4. “The tissue has hypertrophied
while the baby was in the 3. 4 ounces
uterus”
4. 6 ounces
74. Immediately after birth the nurse notes
the following on a male newborn: 77. The postterm neonate with meconium-
respirations 78; apical hearth rate 160 stained amniotic fluid needs care
BPM, nostril flaring; mild intercostal designed to especially monitor for
retractions; and grunting at the end of which of the following?
expiration. Which of the following 1. Respiratory problems
should the nurse do?
2. Gastrointestinal problems
1. Call the assessment data to the
physician’s attention 3. Integumentary problems

2. Start oxygen per nasal cannula 4. Elimination problems

at 2 L/min. 78. When measuring a client’s fundal
3. Suction the infant’s mouth and height, which of the following
nares techniques denotes the correct method
of measurement used by the nurse?
4. Recognize this as normal first
period of reactivity 1. From the xiphoid process to the
umbilicus
75. The nurse hears a mother telling a
friend on the telephone about umbilical 2. From the symphysis pubis to
cord care. Which of the following the xiphoid process
statements by the mother indicates 3. From the symphysis pubis to
effective teaching? the fundus
1. “Daily soap and water cleansing 4. From the fundus to the
is best” umbilicus
2. ‘Alcohol helps it dry and kills 79. A client with severe preeclampsia is
germs” admitted with of BP 160/110,
3. “An antibiotic ointment applied proteinuria, and severe pitting edema.
daily prevents infection” Which of the following would be most
important to include in the client’s plan
4. “He can have a tub bath each of care?
day”
 1. Daily weights that must occur involves which of the
following?
2. Seizure precautions
1. Increase in maternal estrogen
3. Right lateral positioning secretion
4. Stress reduction 2. Decrease in maternal androgen
80. A postpartum primipara asks the nurse, secretion
“When can we have sexual intercourse 3. Secretion of androgen by the
again?” Which of the following would fetal gonad
be the nurse’s best response?
4. Secretion of estrogen by the
1. “Anytime you both want to.” fetal gonad
2. “As soon as choose a 84. A client at 8 weeks’ gestation calls
contraceptive method.” complaining of slight nausea in the
3. “When the discharge has morning hours. Which of the following
stopped and the incision is client interventions should the nurse
healed.” question?

4. “After your 6 weeks 1. Taking 1 teaspoon of

examination.” bicarbonate of soda in an 8-
ounce glass of water
81. When preparing to administer the
vitamin K injection to a neonate, the 2. Eating a few low-sodium
nurse would select which of the crackers before getting out of
following sites as appropriate for the bed
injection? 3. Avoiding the intake of liquids in
1. Deltoid muscle the morning hours

2. Anterior femoris muscle 4. Eating six small meals a day

instead of thee large meals
3. Vastus lateralis muscle
85. The nurse documents positive
4. Gluteus maximus muscle ballottement in the client’s prenatal
82. When performing a pelvic examination, record. The nurse understands that this
the nurse observes a red swollen area indicates which of the following?
on the right side of the vaginal orifice. 1. Palpable contractions on the
The nurse would document this as abdomen
enlargement of which of the following?
2. Passive movement of the
1. Clitoris unengaged fetus
2. Parotid gland 3. Fetal kicking felt by the client
3. Skene’s gland 4. Enlargement and softening of
4. Bartholin’s gland the uterus

83. To differentiate as a female, the 86. During a pelvic exam the nurse notes a
hormonal stimulation of the embryo purple-blue tinge of the cervix. The
 nurse documents this as which of the 4. Increasing the encouragement
following? to the patient when pushing
begins
1. Braxton-Hicks sign
89. A multigravida at 38 weeks’ gestation is
2. Chadwick’s sign admitted with painless, bright red
3. Goodell’s sign bleeding and mild contractions every 7
to 10 minutes. Which of the following
4. McDonald’s sign assessments should be avoided?
87. During a prenatal class, the nurse 1. Maternal vital sign
explains the rationale for breathing
techniques during preparation for labor 2. Fetal heart rate
based on the understanding that 3. Contraction monitoring
breathing techniques are most
important in achieving which of the 4. Cervical dilation
following?
90. Which of the following would be the
1. Eliminate pain and give the nurse’s most appropriate response to a
expectant parents something to client who asks why she must have a
do cesarean delivery if she has a complete
placenta previa?
2. Reduce the risk of fetal distress
by increasing uteroplacental 1. “You will have to ask your
perfusion physician when he returns.”
3. Facilitate relaxation, possibly 2. “You need a cesarean to
reducing the perception of pain prevent hemorrhage.”
4. Eliminate pain so that less 3. “The placenta is covering most
analgesia and anesthesia are of your cervix.”
needed
4. “The placenta is covering the
88. After 4 hours of active labor, the nurse opening of the uterus and
notes that the contractions of a blocking your baby.”
primigravida client are not strong
enough to dilate the cervix. Which of 91. The nurse understands that the fetal
the following would the nurse head is in which of the following
anticipate doing? positions with a face presentation?

1. Obtaining an order to begin IV 1. Completely flexed

oxytocin infusion 2. Completely extended
2. Administering a light sedative 3. Partially extended
to allow the patient to rest for
several hour 4. Partially flexed

3. Preparing for a cesarean section 92. With a fetus in the left-anterior breech
for failure to progress presentation, the nurse would expect
the fetal heart rate would be most
audible in which of the following areas?
 1. Above the maternal umbilicus 1. Chromosome
and to the right of midline
2. Blastocyst
2. In the lower-left maternal
abdominal quadrant 3. Zygote

3. In the lower-right maternal 4. Trophoblast

abdominal quadrant 97. In the late 1950s, consumers and health
4. Above the maternal umbilicus care professionals began challenging
and to the left of midline the routine use of analgesics and
anesthetics during childbirth. Which of
93. The amniotic fluid of a client has a the following was an outgrowth of this
greenish tint. The nurse interprets this concept?
to be the result of which of the
1. Labor, delivery, recovery,
following?
postpartum (LDRP)
1. Lanugo
2. Nurse-midwifery
2. Hydramnio
3. Clinical nurse specialist
3. Meconium
4. Prepared childbirth
4. Vernix
98. A client has a midpelvic contracture
94. A patient is in labor and has just been from a previous pelvic injury due to a
told she has a breech presentation. The motor vehicle accident as a teenager.
nurse should be particularly alert for The nurse is aware that this could
which of the following? prevent a fetus from passing through or
around which structure during
1. Quickening childbirth?
2. Ophthalmia neonatorum 1. Symphysis pubis
3. Pica 2. Sacral promontory
4. Prolapsed umbilical cord
3. Ischial spines
95. When describing dizygotic twins to a 4. Pubic arch
couple, on which of the following would
the nurse base the explanation? 99. When teaching a group of adolescents
about variations in the length of the
1. Two ova fertilized by separate menstrual cycle, the nurse understands
sperm that the underlying mechanism is due
2. Sharing of a common placenta to variations in which of the following
phases?
3. Each ova with the same
genotype 1. Menstrual phase

4. Sharing of a common chorion 2. Proliferative phase

96. Which of the following refers to the 3. Secretory phase

single cell that reproduces itself after 4. Ischemic phase
conception?
 100. When teaching a group of 3. Guilt
adolescents about male hormone
production, which of the following 4. Inferiority
would the nurse include as being 104. Which of the following toys
produced by the Leydig cells? should the nurse recommend for a 5-
1. Follicle-stimulating hormone month-old?

2. Testosterone 1. A big red balloon

3. Leuteinizing hormone 2. A teddy bear with button eyes

Gonadotropin releasing hormone 3. A push-pull wooden truck

101. While performing physical 4. A colorful busy box

assessment of a 12 month-old, the 105. The mother of a 2-month-old is
nurse notes that the infant’s anterior concerned that she may be spoiling her
fontanelle is still slightly open. Which of baby by picking her up when she cries.
the following is the nurse’s most Which of the following would be the
appropriate action? nurse’s best response?
1. Notify the physician 1. “ Let her cry for a while before
immediately because there is a picking her up, so you don’t
problem. spoil her”
2. Perform an intensive neurologic 2. “Babies need to be held and
examination. cuddled; you won’t spoil her
3. Perform an intensive this way”
developmental examination. 3. “Crying at this age means the
4. Do nothing because this is a baby is hungry; give her a
normal finding for the age. bottle”

102. When teaching a mother about 4. “If you leave her alone she will
introducing solid foods to her child, learn how to cry herself to
which of the following indicates the sleep”
earliest age at which this should be 106. When assessing an 18-month-
done? old, the nurse notes a characteristic
1. 1 month protruding abdomen. Which of the
following would explain the rationale
2. 2 months for this finding?
3. 3 months 1. Increased food intake owing to
age
4. 4 months
2. Underdeveloped abdominal
103. The infant of a substance- muscles
abusing mother is at risk for developing
a sense of which of the following? 3. Bowlegged posture
1. Mistrust 4. Linear growth curve
2. Shame
107. If parents keep a toddler parents of a 4-year-old boy who resists
dependent in areas where he is capable going to bed at night?
of using skills, the toddle will develop a
sense of which of the following? 1. “Allow him to fall asleep in your
room, then move him to his
1. Mistrust own bed.”
2. Shame 2. “Tell him that you will lock him
in his room if he gets out of bed
3. Guilt one more time.”
4. Inferiority 3. “Encourage active play at
108. Which of the following is an bedtime to tire him out so he
appropriate toy for an 18-month-old? will fall asleep faster.”

1. Multiple-piece puzzle 4. “Read him a story and allow

him to play quietly in his bed
2. Miniature cars until he falls asleep.”
3. Finger paints 112. When providing therapeutic
4. Comic book play, which of the following toys would
best promote imaginative play in a 4-
109. When teaching parents about year-old?
the child’s readiness for toilet training,
which of the following signs should the 1. Large blocks
nurse instruct them to watch for in the 2. Dress-up clothes
toddler?
3. Wooden puzzle
1. Demonstrates dryness for 4
hours 4. Big wheels

2. Demonstrates ability to sit and 113. Which of the following

walk activities, when voiced by the parents
following a teaching session about the
3. Has a new sibling for characteristics of school-age cognitive
stimulation development would indicate the need
4. Verbalizes desire to go to the for additional teaching?
bathroom 1. Collecting baseball cards and
110. When teaching parents about marbles
typical toddler eating patterns, which of 2. Ordering dolls according to size
the following should be included?
3. Considering simple problem-
1. Food “jags” solving options
2. Preference to eat alone 4. Developing plans for the future
3. Consistent table manners 114. A hospitalized schoolager
4. Increase in appetite states: “I’m not afraid of this place, I’m
not afraid of anything.” This statement
111. Which of the following is most likely an example of which of
suggestions should the nurse offer the the following?
 1. Regression 4. At age 13
2. Repression 118. The adolescent’s inability to
develop a sense of who he is and what
3. Reaction formation he can become results in a sense of
4. Rationalization which of the following?

115. After teaching a group of 1. Shame

parents about accident prevention for 2. Guilt
schoolagers, which of the following
statements by the group would indicate 3. Inferiority
the need for more teaching?
4. Role diffusion
1. “Schoolagers are more active
and adventurous than are 119. Which of the following would
younger children.” be most appropriate for a nurse to use
when describing menarche to a 13-
2. “Schoolagers are more year-old?
susceptible to home hazards
than are younger children.” 1. A female’s first menstruation or
menstrual “periods”
3. “Schoolagers are unable to
understand potential dangers 2. The first year of menstruation
around them.” or “period”

4. “Schoolargers are less subject 3. The entire menstrual cycle or

to parental control than are from one “period” to another
younger children.” 4. The onset of uterine maturation
116. Which of the following skills is or peak growth
the most significant one learned during 120. A 14-year-old boy has acne and
the schoolage period? according to his parents, dominates the
1. Collecting bathroom by using the mirror all the
time. Which of the following remarks by
2. Ordering the nurse would be least helpful in
talking to the boy and his parents?
3. Reading
1. “This is probably the only
4. Sorting concern he has about his body.
117. A child age 7 was unable to So don’t worry about it or the
receive the measles, mumps, and time he spends on it.”
rubella (MMR) vaccine at the 2. “Teenagers are anxious about
recommended scheduled time. When how their peers perceive them.
would the nurse expect to administer So they spend a lot of time
MMR vaccine? grooming.”
1. In a month from now 3. “A teen may develop a poor
2. In a year from now self-image when experiencing
acne. Do you feel this way
3. At age 10 sometimes?”
 4. “You appear to be keeping your 4. The risk for complications
face well washed. Would you during pregnancy is rare.
feel comfortable discussing
your cleansing method?” 124. When assessing a child with a
cleft palate, the nurse is aware that the
121. Which of the following should child is at risk for more frequent
the nurse suspect when noting that a 3- episodes of otitis media due to which of
year-old is engaging in explicit sexual the following?
behavior during doll play?
1. Lowered resistance from
1. The child is exhibiting normal malnutrition
pre-school curiosity
2. Ineffective functioning of the
2. The child is acting out personal Eustachian tubes
experiences
3. Plugging of the Eustachian
3. The child does not know how to tubes with food particles
play with dolls
4. Associated congenital defects of
4. The child is probably the middle ear.
developmentally delayed.
125. While performing a
122. Which of the following neurodevelopmental assessment on a
statements by the parents of a child 3-month-old infant, which of the
with school phobia would indicate the following characteristics would be
need for further teaching? expected?
1. “We’ll keep him at home until 1. A strong Moro reflex
phobia subsides.”
2. A strong parachute reflex
2. “We’ll work with his teachers
and counselors at school.” 3. Rolling from front to back

3. “We’ll try to encourage him to 4. Lifting of head and chest when

talk about his problem.” prone

4. “We’ll discuss possible solutions 126. By the end of which of the

with him and his counselor.” following would the nurse most
commonly expect a child’s birth weight
123. When developing a teaching to triple?
plan for a group of high school students
about teenage pregnancy, the nurse 1. 4 months
would keep in mind which of the 2. 7 months
following?
3. 9 months
1. The incidence of teenage
pregnancies is increasing. 4. 12 months

2. Most teenage pregnancies are 127. Which of the following best

planned. describes parallel play between two
toddlers?
3. Denial of the pregnancy is
common early on. 1. Sharing crayons to color
separate pictures
 2. Playing a board game with a 2. Schedule a follow-up visit to
nurse check for more bruises.
3. Sitting near each other while 3. Notify the child’s physician
playing with separate dolls immediately.
4. Sharing their dolls with two 4. Don nothing because this is a
different nurses normal finding in a toddler.
128. Which of the following would 131. Which of the following is being
the nurse identify as the initial priority used when the mother of a hospitalized
for a child with acute lymphocytic child calls the student nurse and states,
leukemia? “You idiot, you have no idea how to
care for my sick child”?
1. Instituting infection control
precautions 1. Displacement
2. Encouraging adequate intake of 2. Projection
iron-rich foods
3. Repression
3. Assisting with coping with
chronic illness 4. Psychosis

4. Administering medications via 132. Which of the following should

IM injections the nurse expect to note as a frequent
complication for a child with congenital
129. Which of the following heart disease?
information, when voiced by the
mother, would indicate to the nurse 1. Susceptibility to respiratory
that she understands home care infection
instructions following the 2. Bleeding tendencies
administration of a diphtheria, tetanus,
and pertussis injection? 3. Frequent vomiting and diarrhea

1. Measures to reduce fever 4. Seizure disorder

2. Need for dietary restrictions 133. Which of the following would

the nurse do first for a 3-year-old boy
3. Reasons for subsequent rash who arrives in the emergency room
4. Measures to control with a temperature of 105 degrees,
subsequent diarrhea inspiratory stridor, and restlessness,
who is learning forward and drooling?
130. Which of the following actions
by a community health nurse is most 1. Auscultate his lungs and place
appropriate when noting multiple him in a mist tent.
bruises and burns on the posterior 2. Have him lie down and rest
trunk of an 18-month-old child during a after encouraging fluids.
home visit?
3. Examine his throat and perform
1. Report the child’s condition to a throat culture
Protective Services
immediately.
 4. Notify the physician 2. Rattle
immediately and prepare for
intubation. 3. Large blocks

134. Which of the following would 4. Mobile

the nurse need to keep in mind as a 138. Which of the following aspects
predisposing factor when formulating a of psychosocial development is
teaching plan for child with a urinary necessary for the nurse to keep in mind
tract infection? when providing care for the preschool
child?
1. A shorter urethra in females
2. Frequent emptying of the 1. The child can use complex
bladder reasoning to think out
situations.
3. Increased fluid intake
2. Fear of body mutilation is a
4. Ingestion of acidic juices common preschool fear
135. Which of the following should 3. The child engages in
the nurse do first for a 15-year-old boy competitive types of play
with a full leg cast who is screaming in
unrelenting pain and exhibiting right 4. Immediate gratification is
foot pallor signifying compartment necessary to develop initiative.
syndrome? 139. Which of the following is
characteristic of a preschooler with mid
1. Medicate him with
acetaminophen. mental retardation?

2. Notify the physician 1. Slow to feed self

immediately 2. Lack of speech
3. Release the traction 3. Marked motor delays
4. Monitor him every 5 minutes 4. Gait disability
136. At which of the following ages 140. Which of the following
would the nurse expect to administer assessment findings would lead the
the varicella zoster vaccine to child? nurse to suspect Down syndrome in an
1. At birth infant?

2. 2 months 1. Small tongue

3. 6 months 2. Transverse palmar crease

4. 12 months 3. Large nose

137. When discussing normal infant 4. Restricted joint movement

growth and development with parents, 141. While assessing a newborn with
which of the following toys would the cleft lip, the nurse would be alert that
nurse suggest as most appropriate for which of the following will most likely
an 8-month-old? be compromised?
1. Push-pull toys
 1. Sucking ability 2. Stools
2. Respiratory status 3. Uterine
3. Locomotion 4. Weight
4. GI function 146. Discharge teaching for a child
with celiac disease would include
142. When providing postoperative instructions about avoiding which of the
care for the child with a cleft palate, the following?
nurse should position the child in which
of the following positions? 1. Rice
1. Supine 2. Milk
2. Prone 3. Wheat
3. In an infant seat 4. Chicken
4. On the side 147. Which of the following would
the nurse expect to assess in a child
143. While assessing a child with with celiac disease having a celiac crisis
pyloric stenosis, the nurse is likely to secondary to an upper respiratory
note which of the following? infection?
1. Regurgitation 1. Respiratory distress
2. Steatorrhea 2. Lethargy
3. Projectile vomiting 3. Watery diarrhea
4. “Currant jelly” stools 4. Weight gain
144. Which of the following nursing 148. Which of the following should
diagnoses would be inappropriate for the nurse do first after noting that a
the infant with gastroesophageal reflux child with Hirschsprung disease has a
(GER)? fever and watery explosive diarrhea?
1. Fluid volume deficit 1. Notify the physician
2. Risk for aspiration immediately

3. Altered nutrition: less than 2. Administer antidiarrheal

body requirements medications

4. Altered oral mucous 3. Monitor child ever 30 minutes

membranes 4. Nothing, this is characteristic of
145. Which of the following Hirschsprung disease
parameters would the nurse monitor to 149. A newborn’s failure to pass
evaluate the effectiveness of thickened meconium within the first 24 hours
feedings for an infant with after birth may indicate which of the
gastroesophageal reflux (GER)? following?
1. Vomiting 1. Hirschsprung disease
 2. Celiac disease
3. Intussusception
4. Abdominal wall defect
150. When assessing a child for
possible intussusception, which of the
following would be least likely to
provide valuable information?
1. Stool inspection
2. Pain pattern
3. Family history
4. Abdominal palpation