Maternal and Child Nursing
Ms. Melanie C. Tapnio
1. When teaching an adolescent about ovulation, you would include that ovulation is initiated by a
surge in which of the following?
a. Luteinizing hormone.
b. Progesterone.
c. Follicle-stimulating hormone.
d. Estrogen
2. A client with a history of toxic shock syndrome comes to the reproductive clinic seeking contraception.
Based on this information, which method should the nurse avoid recommending for this client?
a. Cervical cap
b. Female condom
c. Spermicide
d. Norplant
3. The nurse correctly teaches that intrauterine device (IUDs) are best suited for which of the following
women?
a. Nulliparas with more than one sexual partner
b. Women who have had sexually transmitted disease (STDs)
c. All sexually active women
d. Multipara with one sexual partner
4. Which statement by the patient indicates an understanding of the basal body temperature (BBT)
method?
a. I know my temperature must be taken before I go to work
b. I can expect a change in my temperature if ovulation occurs
c. My mucus discharge always changes at the beginning and end of my cycle
d. I must take my temperature at night and after getting up every day
5. Janet Jones is pregnant for the first time and has type 2 diabetes. She asks the nurse, “What hormone
increases throughout pregnancy and may interfere with my insulin dosage?” The nurse answers:
a. Progesterone
c. Human chorionic gonadotropin (HCG)
b. Estrogen
d. Human placental lactogen (HPL)
6. The structure in the fetus that caries oxygenated blood from the umbilical vein to the inferior vena
cava is the:
a. Ductus arteriosus
c. Foramen ovale
b. Ductus venosus
d. Pulmonary artery
7. While discussing the growth and development of the product of conception, a patient asks the nurse,
“During what time in my pregnancy is my baby most vulnerable to getting birth defects?” The nurse’s
response is:
a. “As your baby is forming in the first 2 months because organ development takes place at this
time.”
b. “Throughout your pregnancy.”
c. “Near the end of your pregnancy.”
d. “Halfway through your pregnancy: around 20 weeks or 5 months”
8. At a prenatal class, Ms. Gonzales states that she has just found out that she has a positive pregnancy
test. She asks the nurse. How long does it takes before I can feel my baby move?” The correct response
is:
a. “You should be feeling movement now”
b. “There is no specific time because every baby is different.”
c. “Around 20 weeks, or 5 months gestation”
d. “After the 35th week of pregnancy”
9. A patient at a prenatal class asks the nurse, “How do my baby’s lungs get air now that I’m pregnant?”
the nurse’s correct response is:
a. Your baby gets air from the placenta
b. No one knows how babies get air in the uterus. This is a good question”
c. Your lungs provide enough air for your baby to breath
d. Your baby’s lungs don’t need air at this time; the fetal lungs don’t function as lungs until birth
10. Joyce, an 18-year-old woman comes to the clinic because she thinks she is pregnant. Which of the
following is a probable sign of pregnancy that the nurse would expect this client to have?
a. Fetal heart tones
b. Nausea and vomiting
c. Amenorrhea
d. Hegar’s sign
11. A woman is having a contraction stress test (CST) in her last month of pregnancy. When assessing
the fetal monitor strip, the nurse notices that with most of the contractions, the fetal heart rate
uniformly slows at mid-contraction and then returns to baseline about 20 seconds after the
contraction is over. The nurse would interpret the test result to be
a. Negative: normal
b. Reactive negative
c. Positive: abnormal
d. Unsatisfactory
12. A woman, 36 weeks’ gestation, is having a CST with an oxytocin IV infusion pump. After two
contractions, the uterus stays contracted for more than 90 seconds. The best initial action of the
nurse is to
a. Help the client turn on her left side
b. Turn off the infusion pump
c. Wait 3 minutes for the uterus to relax
d. Administer prn terbutaline sulfate (Brethine)
13. A pregnant woman, in the first trimester, is to have a transabdominal ultrasound. The nurse would
include which of the following instructions?
a. Nothing by mouth (NPO) from 6:00 A.M. the morning of the test.
b. Drink one to two quarts of water and do not urinate before the test
c. Come to the clinic first for injection of the contrast dye
d. No special instructions are needed for this test
14. A 30-year-old primigravida tells the nurse that her hemorrhoids have become itchy and painful. After
instructing the patient about relief measures, the nurse determines that the patient needs further
instructions when she says:
a. I should sit in a warm sitz bath daily
b. I should apply an ice pack at night
c. I can use a topical ointment for relief
d. I should decrease my fluid intake
15. A primigravida at 16 weeks gestation tells the nurse that she’s having a hard time quitting smoking
while pregnant. The nurse should encourage the patient to quit smoking because smoking during
pregnancy is associated with:
a. Low-birth-weight infant’s
c. Placenta previa in the third trimester
b. Large-for-gestational-age infants d. Early decelerations during labor
SITUATION:
Mrs. Lopez is a 20-year-old patient who visits the clinic because she suspects she’s
pregnant. The patient’s last menstrual period was April 10-15
16. After the pregnancy is confirmed, the nurse calculates Ms. Lopez’s estimated date of confinement
(EDC) using Nagele’s rule. The nurse should instruct the patient that her EDC is:
a. January 17
c. February 17
b. January 22
d. February 22
17. Mrs. Lopez on her 30th – week pregnancy tells the clinic nurse that she has also been experiencing
shortness of breath. This patient had no history of heart or lung disease before the pregnancy. The
nurse should instruct the patient to:
a. March in place regularly and daily c. Use proper posture when standing
b. Apply a heating pad to her chest
d. Sleep on her back without a pillow
18. A woman in her seventh month of pregnancy has a hemoglobin of 10.5g. The nurse teaches the
woman about proper nutrition during pregnancy. Which statement made by the client indicates to
the nurse that teaching was effective?
a. “I eat liver once a week.”
b. “I have an orange for breakfast.”
c. “I eat six small meals a day.”
d. “I have a green leafy vegetable occasionally.”
19. A multigravid patient in active labor at term is diagnosed with polyhydramnios. The physician has
instructed the patient about possible neonatal complications related to the polyhydramnios. The
nurse determines that the patient has understood the instructions when the patient states that
polyhydramnios is associated with which of the following in the fetus or neonate?
a. Renal dysfunction
c. pulmonary hypoplasia
b. Intrauterine growth retardation
d. Gastrointestinal disorders
20. Nurse Anjie attends to another pregnant client who as two children. Her history reveals that her first
pregnancy ended in a stillbirth at 32 weeks of gestation, her second pregnancy with the birth of her
daughter at 35 weeks, and her third pregnancy with the birth of her son at 41 weeks. Using the GP
TPALM format. Nurse Anjie would record the woman’s current obstetrical history as:
G3P3 (T1 P1 A1 L3 M0)
G4P3 (T1 P2 L2 M0)
G4P4 (T2 P1 A0 L1 M0)
G3P3 (T1 P2 A0 L1 M0)
21. A 20-year-old primigravida at 8 weeks gestation visits the clinic with symptoms of slight reddish
vaginal bleeding and an occasional uterine cramp. The pregnancy test is positive. The patient states
that no tissue has been passed. The nurse should explain to the patient that these symptoms are
indicative of a type of abortion termed:
a. Missed
c. Incomplete
b. Inevitable
d. Threatened
22. The nurse is caring for a 34-year-old multipara during the immediate post operative period after
evacuation of a molar pregnancy. The nurse should instruct the patient to avoid pregnancy for at least
12 to 18 months to confirm the absence of:
a. Fibroid tumors
c. Chorioamnionitis
b. Amniotic fluid embolism
d. Choriocarcinoma
23. A Rh-negative, nonsensitized primigravida is scheduled to received RhO(D) immune globulin
(RhoGAM) at 28 weeks gestation. The nurse should instruct the patient that RhO(D) immune globulin:
a. Prevents sensitization for the next pregnancy
b. Needs to be given only during the pregnancy
c. Has severe adverse effects such as eczema
d. Should be given within 1 week after delivery
SITUATION:
Gina Santos is a 36-year-old multigravida who visits the clinic at 34 weeks gestation. Her
baseline blood pressure has routinely been 120 to 124/ 78 to 82. At this visit, she has gained 2 pounds in
1 week, her blood pressure is now 138/94, and she has a trace of proteinuria.
24. The nurse anticipates that the doctor will instruct Mrs. Santos to:
a. Maintain bed rest on her left side
c. Maintain a high protein diet
b. Decrease fluid intake
d. Decrease calcium intake
25. Mrs. Santos tells the nurse she’s having sharp epigastric pain and immediately after that the patient
begins to have a seizure. The first nursing action by the nurse should be to:
a. Turn the patient to her left side
c. Call for assistance in the room
b. Pad the side rails of the bed
d. Increase the IV fluid rate
26. A woman, 40 weeks’ gestation, is admitted to the labor and delivery unit with possible placenta
previa. On the admission assessment, the nurse would expect to find
a. Signs of Couvelaire uterus
b. Severe lower abdominal pain
c. Painless vaginal bleeding
d. A board-like abdomen
27. A pregnant woman is admitted to the hospital with a diagnosis of placenta previa. Which of the
following would be the priority for this woman on admission?
a.
b.
c.
d.
28.
Performing a vaginal examination to assess the extent of bleeding.
Helping the woman remain ambulatory to reduce bleeding.
Assessing fetal heart tones by use of an external monitor.
Assessing uterine contractions by an internal pressure gauge.
Mrs. O’Neill returns to the hospital the next day with a complaint of vaginal bleeding. She states
that she snorted cocaine approximately 1 hour earlier. Which of the following complications is most
likely causing the patient’s complaint of vaginal bleeding?
a. Placenta previa
c. Ectopic pregnancy
b. Abruptio placentae
d. Spontaneous abortion
29. The nurse is caring for a patient receiving terbutaline. The nurse observes that the medication is
having a therapeutic effect when the patient:
a. No longer perceives pain in her perineal area
b. Dilates 1.5 cm every hour during labor
c. Has contractions that decrease in frequency and duration
d. Has a pulse rate that increases from 90 to 120 beats / min
30. Four different intrapartum patients present to the labor unit. Which of these patients would require
a cesarean delivery?
a. Primigravida with lowermost twin in a vertex presentation
b. Multipara with a transverse lie confirmed by the ultrasound
c. Multipara with the fetal station documented as “floating”
d. Primigravida with the fetus in an occiput posterior position
31. Which of the following patients would the nurse consider a priority for being placed at high risk for
fetal distress during labor?
a. A Patient with a 20-to 25-pound weight gain during pregnancy
b. An Rh-negative patient with a negative indirect Coombs’ test
c. A gestational diabetic whose glucose level was 90 mg/dl on admission
d. A patient at 43 weeks gestation admitted for induction of labor
32. Upon palpation of an intrapartum patient’s abdomen, the nurse assesses the fetus is in a breech
presentation. Where would the nurse auscultate for the fetal heart tones?
a. Above the umbilicus
c. Below the umbilicus
b. Left lower abdomen
d. Right lateral abdomen
33. Immediately after a spontaneous rupture of the membranes, the nurse observes a loop of umbilical
cord protruding from the vagina. The first nursing action would be to:
a. Administer oxygen
c. Document the deceleration
b. Notify the doctor
d. Elevate the hips on two pillows
34. The nurse reviews the contractile patterns seen during the latent phase of labor. Which of the
following statements made by the patient indicates that she understood the teaching?
a. My contractions should be every 2 to 3 minutes, lasting for 60 to 90 seconds, and will be
strong
b. I should expect not to be able to feel my contractions during the early latent phase of labor
c. My contractions will be mild, lasting for approximately 30 seconds, and occurring about every
10 minutes
d. I expect to be in the latent phase of labor for only a short time
35. The vaginal examination reveals that the fetus is in a vertex presentation and at a – 1 station. The
nurse would interpret these findings to indicate that the fetal:
A. head is engaged
C. head is above the ischial spines
B. buttocks are crowning
D. buttocks are below the ischial spines
SITUATION:
Maria Ramirez is a gravida 3 para 2 who presents to the hospital with a report that she
has noticed decreased fetal movement over the last 2 days.
36. The nurse performs Leopold’s maneuvers on Mrs. Ramirez and notes the following findings: a soft,
firm mass in the fundus; several knots and protrusions on the mother’s left side; and a hard, round,
movable object in the pubic area. The cephalic prominence is on the left side. Based on these findings,
the nurse determines that the fetal position is:
a. Left occipitoanterior (LOA)
c. Left sacroposterior (LSP)
b. Right occipitoanterior (ROA)
d. Right sacroposterior (RSP)
37. As Mrs. Ramirez enters the second stage of labor, the nurse observes what appear to be Mrs.
Ramirez’s membranes ruptures spontaneously. Which of the following would be the nurse’s priority
actions?
a. Have the patient turn on her left side
b. Coach the patient to bear down with the next contraction
c. Assess the fetal heart rate
d. Clean the perineal area with a warm washcloth
38. Which assessment would the nurse perform to validate that the membranes are ruptured?
a. Observe for a pink, mucous vaginal discharge
b. Test the leaking fluid with nitrazine paper
c. Assess the patient’s temperature, pulse, and blood pressure
d. Send a urine specimen from the patient to be cultured
39.
Mrs. Cortez calls out, “My baby’s coming! To ensure the patient’s safety, the nurse’s initial action
would be to:
a. Observe the perineum
c. Encourage the patient to deep breathe
b. Notify the obstetrician on call
d. Initiate I.V. fluids
40.
Immediately after delivery the nurse would expect to assess Mrs. Sanchez’s fundus to be:
a. Deviated to the right
b. One fingerbreadth above the level of the umbilicus
c. Firm and contracted at the umbilicus
d. Four fingerbreadths above the umbilicus and slightly deviated to the left
41.
Jocelyn Lim, a gravida 1 para 1001, has vaginally delivered a full-term infant without complications.
After the first postpartum day, she tells the postpartum nurse that she’s afraid that something is
wrong because she’s perspiring and urinating more than normal. Her temperature is 100.0OF
(37.8OC). The nurse should appropriately reply:
a. You’re probably responding to an infection in your body; I’ll call the doctor and report your
symptoms
b. Your temperature is slightly elevated. You could have an infection. I’ll call the doctor to report
your temperature
c. It’s common to perspire and urinate a lot after childbirth; your body is getting rid of the excess
fluid that was used in pregnancy
d. I’m surprised you’re urinating a lot because you don’t have other signs of diabetes
SITUATION:
Lourdes Cruz, a 28-year-old multipara, vaginally delivered a term infant. Her amniotic
membranes were ruptured for 12 hours before her admission. She experienced a prolonged first stage of
labor and received lumbar epidural anesthetic and a midline episiotomy.
42.
The nurse prepares the nursing plan of care and recognizes that Mrs. Cruz is at high risk for infection
related to:
a. Leukocytosis 20, 000/ µl
c. Pulse rate 76 beats / minute
b. 99. 6OF (37. 5OC) temperature
d. Midline episiotomy
43.
During the nursing assessment, which of the following findings in Mrs. Cruz would be indicative of
dehydration related to prolonged labor?
a. Temperature 100.1OF (37.8OC)
c. Leukocytosis 20, 000/ µ l
b. Pulse rate 80 beats/ minute
d. Blood pressure 140/ 90
SITUATION:
Chanda Reyes is a 35-year-old multipara who delivered a full term infant via cesarean
section because of a breech presentation.
44.
The nurse recognizes that which of the following events would be the most important contribution
to the prevention of thromboembolism?
a. Increasing oral fluid intake
b. Administering pain medication as needed
c. Providing O2 therapy
d. Encouraging frequent ambulation
45.
Mrs. Reyes is in a hypercoagulable state immediately after birth. To determine Mrs. Reyes risk of
developing thrombophlebitis in the postpartum period, the nurse should assess:
a. The condition of the IV site
c. The lungs for adventitious sounds
b. For Homan’s sign
d. Deep tendon reflexes
SITUATION:
Brenda Lacson is a 32-year-old primigravida who vaginally delivered a full-term infant
without complications. She states that she would like to take a nap but allows the nurse to take vital signs
and perform an assessment.
46.
The nurse recognizes that Mrs. Lacson is experiencing what phase?
a. Postpartum phase
c. Taking-hold phase
b. Taking-in phase
d. Letting-go phase
47.
The best time to teach a postpartum patient about maternal and infant care is during which of the
following phases?
a. Postpartum phase
c. Taking-hold phase
b. Taking-in phase
d. Letting-go phase
SITUATION: Nurse Lisa manages her own Reproductive and Children’s clinic in Sorsogon and attends
to health conditions of mothers and children. The following conditions pertain to the growing fetus.
48. Obstetrical client Marichu asks how much longer nurse Lisa will refer to the baby inside her as an
embryo. What would be the best explanation?
a. Her baby will be a fetus as soon as the placenta forms
b. From the time of implantation until 5 to 8 weeks, the baby is an embryo
c. After 20th week of pregnancy, the baby is called zygote
d. This term is used during the time of fertilization
49. Marichu is worried that her baby will be born with congenital heart disease. What assessment of a
fetus at birth is important to help detect congenital heart defect?
a. Determining the color of the umbilical cord is not green
b. Assessing whether the umbilical cord has two arteries and one vein
c. Assessing the wharto’s jelly of the cord has a ph higher than 7.2
d. Measuring the length of the cord to certain that it is not longer than 3 feet.
50. Additionally, Nurse Lisa would gather more information about Marichu’s worry about what may
threaten the health of her baby. What would nurse Lisa find?
a. Has Marichu been overly anxious about something
b. Has Marichu suffered from any communicable/contagious disease at the time of her early
stage of pregnancy
c. Has Marichu engaged in sexual activity during the fetal development
d. Has Marichu engaged in any detrimental activities during fetal development stage, e.g.
smoking, drinking, taking drugs, a bad fall, or attempt to terminate pregnancy
51. A woman has delivered her baby 2 hours ago. She asked the nurse, “My baby looks dirty with this
entire slimy thing on her. Can I bather my baby now?” The nurse’s best response is:
a. “Sure, you can do what you wish since she is your baby. Let me help you”
b. “The slimy thing actually protects her from infection. We will bathe the baby after 4 hours”
c. “The slimy thing is part of the baby. So it’s not really dirty”
d. “It sure looks dirty but unfortunately, we cannot remove it yet until tomorrow”
52. The nurse knows the studies have shown that waiting for the pulsations to stop before clamping the
cord prevents that fetus from having which of the following?
a. Anemia
C. Rh incompatibility
b. Congenital heart defects
D. Hyperbilirubinemia
53. A 3-month-old still has a Moro reflex. Which statement is most true of this reflex?
a. A Moro reflex normally lasts until 9 months.
b. It is not important how long the reflex persists, only that it is present at birth.
c. A Moro reflex present at 3 months of age requires referral for a neurologic exam.
d. Most 3-month-olds still have a Moro reflex.
54. An infant is breastfed. When assessing her stools, which of the following data would be typical?
a. Stools of breastfed infants are usually harder than those of bottle-fed infants.
b. Breastfed infants usually have fewer stools than bottle-fed infants.
c. Breastfed infants are less likely to be constipated than bottle-fed infants.
d. Stools of breastfed infants tend to have a strong odor.
55. A mother asks the pediatric nurse about what she should begin to feed her 6-month-old infant. The
correct response is:
a. Egg whites are the least allergenic food to be introduced into the baby’s diet.
b. Rice cereal is the first solid introduces that is least allergenic of the cereals.
c. Formula is the only source of nutrition given for the first year.
d. Fruits and vegetables are good sources of iron.
56. The best activity that a preschooler’s parents could use to help her achieve the developmental task
of the preschool period is to
a. Provide her with clothes that snap rather than button.
b. Teach her street-crossing safety.
c. Allow her to experiment with PlayDoh.
d. Help her learn how to follow rules.
57. A 9-year-old is hospitalized for a long-term illness. The best project to give her to help her achieve her
developmental task would be
a. A scrapbook that will take 3 weeks to complete.
b. A puppet show that will take 2 weeks to plan.
c. Watching her favorite program on television.
d. Sewing a purse that will take one afternoon,
58. A school nurse prepares a lecture on puberty for 5th and 6th grade girls. She asks the group, “What is
the first sign of puberty?” A student correctly replies:
a. “The appearance of breast buds”
b. “The occurrence of the first menarche.”
c. “An increase in energy and appetite”
d. “Appearance of body odor.”
59. A teenager refuses to wear the clothes his mother bought for him. He states he wants to look like the
other kids at school and wear clothes like they wear. The nurse explains this behaviour is an example
of teenage rebellion related to internal conflicts of:
a. Autonomy vs. shame and doubt
c. Identity vs. role confusion.
b. Trust vs. mistrust
d. Initiative vs. inferiority..
60. When assessing a child who complains of abdominal pain, what is the most appropriate nursing
action?
a. Palpate the most painful area first.
b. Palpate for rebound tenderness.
c. Avoid painful areas until the end of the assessment.
d. Use deep palpation for abdominal tenderness.
61. What should the nurse do first when preparing to do a physical assessment on a sleeping 8-monthold baby?
a. Measure the occipital-frontal head circumference.
b. Auscultate the heart and lungs.
c. Check the eyes for red reflex.
d. Wake the baby.
62. In a term newborn, you would expect to find which of the following patterns of sole creases?
a. Creases covering one fourth of the foot
b. Longitudinal but no horizontal creases
c. Creases on three-fourths of the foot
d. Heel but no anterior crease
63. After teaching the parents of an 18-month-old who treated for a for a foreign body obstruction about
three cardinal signs indicative of choking, the nurse determines that the teaching has been successful
when the parents state that a child is choking when he/she cannot speak, turns blue, and does which
of the following?
A.
Vomits
B. Gasps
C. Gags
D. Collapses
64. The father of a 2-year-old phones the emergency room on Sunday evening and informs the nurse his
son put a bead in his nose. What is the most appropriate recommendation made by the nurse?
A. “Try to remove the bead at home as soon as possible; you might try using a pair of tweezers.”
B. “Be sure to take your child to the paediatrician in the morning so the paediatrician can remove
the bead in the office.”
C. “You should bring your child to the emergency room tonight so the bead can be removed as soon
as possible.”
D. “Ask your child to blow his nose several times; this should dislodge the bead.”
65. A 3-year-old is brought into the emergency department in her mother’s arms. The child’s mouth is
open and she is drooling and lethargic. Her mother states that she became ill suddenly within the
past 2 hours. What should the nurse do first?
A. Draw blood cultures for complete blood count
B. Start an intravenous line
C. Inspect the child’s throat with a tongue blade
D. Maintain the child in an undisturbed, upright position
66. Which of the following, if described by the parents of a child with cystic fibrosis, indicates that the
parents understand the underlying problem of the disease?
A. An abnormality in the body’s mucus-secreting glands.
B. Formation of fibrous cysts in various body organs.
C. Failure of the pancreatic ducts to develop properly.
D. Reaction to the formation of antibodies against streptococcus.
67. A 9-month-old with cystic fibrosis does not like taking pancreatic enzyme supplement with meals and
snacks. The mother does not like to force the child to take the supplement. The most important
reason for the child to take the pancreatic enzyme supplement with meals and snacks is:
A. The child will become dehydrated if the supplement is not taken with meals and snacks.
B. The child needs these pancreatic enzymes to help the digestive system absorb fats,
carbohydrates, and proteins.
C. The child needs the pancreatic enzymes to aid in liquefying mucus to keep the lungs clear.
D. The child will experience severe diarrhea if the supplement is not taken as prescribed.
68. The triage nurse in the emergency room must prioritize the children waiting to be seen. Which of the
following children is in the greatest need of emergency medical treatment?
A. A 6 year-old with a fever of 40˚C (104˚F), a muffled voice, no spontaneous cough and drooling.
B. A 3-year-old with a fever of 37.8˚C (100˚F), barky cough, and mild intercostal retractions.
C. A 4-year-old with a fever of 38.3˚C (101˚F), a hoarse cough, stridor, and restlessness.
D. A 13-year-old with a fever of 40˚C (104˚F), chills and a cough with thick yellow secretions.
69. A child diagnosed with tetralogy of Fallot becomes upset, crying, and trashing around when a blood
specimen is obtained. The child’s color becomes blue and respiratory rate increases to 44 bpm. Which
of the following actions should the nurse do first?
A. Obtain prescription for sedation for the child
B. Assess for an irregular heart rate and rhythm
C. Explain to the child that it will only hurt for a short time
D. Place the child in a knee-chest position
70. When assessing a child after heart surgery to correct tetralogy of Fallot, which of the following should
alert the nurse to suspect a low cardiac output?
A. Bounding pulses and mottled skin
B. Altered level of consciousness and thready pulse
C. Capillary refill of 2 seconds and blood pressure of 96/67 mmHg
D. Extremities warm to touch and pale skin
71. A child with Kawasaki disease is receiving low dose of aspirin. The mother calls the clinic and states
that the child has been exposed to influenza. Which recommendations should the nurse make?
A. Increase fluid intake
B. Stop taking aspirin
C. Keep the child home from school
D. Weigh the child daily
72. When developing the plan of care for a newly admitted 2-year-old child with the diagnosis of Kawasaki
disease, which of the following should be the priority?
A. Taking vital signs every 6 hours
B. Monitoring intake and output
C. Minimizing skin discomfort
D. Providing range-of-motion exercise
73. The nurse is teaching the parents of a child with sickle cell disease. To instruct them how to prevent
sickle cell crisis, she should include which instructions?
A. Restrict the child’s fluid intake to less than 1 quart per day
B. Drink at least 2 quarts of fluids per day
C. Stay away from other teenagers
D. Avoid physical activity
74. The nurse explains to the parents of a 1-year-old child admitted to the hospital in sickle cell crisis that
the local tissue damage the child has on admission is caused by which of the following?
A.
B.
C.
D.
Autoimmune reaction complicated by hypoxia
Lack of oxygen in the red blood cells
Obstruction to circulation
Elevated serum blirubin concentration
75. The mother asks the nurse why her child’s haemoglobin was normal at birth by now the child has S
haemoglobin. Which of the following responses is appropriate?”
A. “The placenta bars passage of the haemoglobin S from the mother to the fetus.”
B. “The red bone marrow does not begin to produce haemoglobin S until several months after birth.”
C. “Antibodies transmitted from you to the fetus provide the newborn with temporary immunity.”
D. “The newborn has a high concentration of fetal haemoglobin in the blood for some time after
birth.”
76. What is the most appropriate method to use when drawing blood from a child with haemophilia?
A. Use finger puncture for lab draws.
B. Prepare to administer platelets
C. Apply heat to the extremity before venipunctures
D. Schedule all labs to be drawn at one time
77. A diagnosis of haemophilia A is confirmed in an infant. Which of the following instructions should the
nurse provide the parents as the infant becomes more mobile and starts to crawl?
A. Administer one-half of a children’s aspirin for a temperature higher than 101˚F (38.3˚C)
B. Sew a thick padding into the elbows and knees of the child’s clothing
C. Check the color of the child’s urine everyday
D. Expect the eruption of the primary teeth to produce moderate to severe bleeding.
78. A child with haemophilia presents with burning sensation in the knee and reluctance to move the
body part. The nurse collaborates with the care team to provide factor replacement and:
A. Administer an aspirin-containing compound
B. Institute rest, ice, compression and elevation
C. Begin physical therapy with active range of motion
D. Initiate skin traction
79. The nurse is preparing to administer furosimide to a3-year-old with a heart defect. The nurse verifies
the child’s identity by checking the arm band and:
A. Asking the child to state her name
B. Checking the room number
C. Asking the child to tell her birth date
D. Asking the parent the child’s name
80. Which of the following measures would be most effective in helping the infant with a cleft lip and
palate to retain oral feeding?
A. Burp the infant at frequent intervals
B. Feed the infant small amounts at one time
C. Place the end of the nipple far to the back of the infant’s tongue
D. Maintain the infant in a lying position while feeding
81. The parent of an infant with cleft lip and palate asks the nurse when the infant’s cleft palate will be
repaired. The nurse responds by stating that the first repair of a cleft palate is usually done at which
of the following times?
A. Before the eruption of teeth
B. When the child weighs 10 kg
C. Before the development of speech
D. After the child learns to drink from a cup
82. After teaching the parents of a neonate diagnosed with tracheoesophageal fistula about this anomaly,
the nurse determines that the teaching was successful when the father describes the condition as
which of the following?
A. “The muscle below the stomach is too tight, causing the baby to vomit forcefully.”
B. “There is a blind upper pouch and an opening from the esophagus into the airway.”
C. “The lower bowel is lacking certain nerves to allow normal function.”
D. “A part of the bowel is on the outside without anything covering it. “
83. Which of the following would indicate that an infant with tracheoesophageal fistula needs suctioning?
A. Brassy cough
B. Substernal retractions
C. Decreased activity
D. Increased respiratory rate
84. A 4-week-old infant admitted with a diagnosis of hypertrophic pyloric stenosis presents with history
of vomiting. The nurse should anticipate that the infant’s vomitus would contain which of the
following?
A. Bile and streaks of blood
B. Mucus and bile
C. Mucus and streaks of blood
D. Stool and bile
85. When an infant with pyloric stenosis is admitted to the hospital, which of the following should the
nurse do first?
A. Weigh the infant
B. Begin an intravenous infusion
C. Switch the infant to an oral electrolyte solution
D. Orient the mother to the hospital unit
86. When assessing a 4-month-old infant diagnosed with possible intussusceptions, the nurse should
expect the mother to relate which of the following about the infant’s crying and episodes of pain?
A. Constant accompanied by leg extension
B. Intermittent with knees drawn to the chest
C. Shrill during ingestion of solids
D. Intermittent while being held in mother’s arm
87. A nasogastric tube was inserted during surgery to correct an infant’s intussusception, is no longer
freely removing gastric secretions. Which of the following should the nurse do next?
A. Aspirate the tube with a syringe
B. Irrigate the tube with distilled water
C. Increase the level of suction
D. Rotate the tube
88. During physical assessment of a 4-month-old infant with Hirschsprung’s disease, the nurse should
most likely note which of the following?
A. Scaphoid-shaped abdomen
B. Weight less than expected for height and weight
C. Cyanosis of fingers and toes
D. Hyperactive deep tendon reflexes
89. An infant diagnosed with Hirschsprung’s disease undergoes surgery with the creation of a temporary
colostomy. Which of the following statements by the parent regarding indicates the need for further
teaching?
A. “The colostomy is only temporary.”
B. “The colostomy may include two separate openings.”
C. “The colostomy will give time for the nerves to return to normal.”
D. “Right after the procedure the stoma may appear purple.”
90. Eight hours ago, an infant with Hirschsprung’s disease had surgery to create a colostomy. Which of
the following findings should alert the nurse to notify the primary care provider immediately?
A. A 3-cm increase in abdominal circumference
B. Periods of occasional fussiness
C. Absence of bowel sounds
D. Evidence of infant’s returning appetite
91. Which of the following statements by the mother of an 18-month-old child should indicate to the
nurse that the child needs laboratory testing for lead levels?
A. “My child does not always wash after playing outside.”
B. “My child drinks two cups of milk every day.”
C. “My child has more temper tantrums than other kids.”
D. “My child is smaller than other kids of the same age.”
92. When teaching the mother of a toddler diagnosed with lead poisoning, which of the following should
the nurse include as the most serious complication if the condition goes untreated?
A. Cirrhosis of the liver
B. Stunted growth rate
C. Neurologic deficits
D. Heart failure
93. During assessment of a child with celiac disease, the nurse should most likely note which of the
following physical findings?
A. Enlarged liver
B. Protruberant abdomen
C. Tender inguinal lymphnodes
D. Periorbital edema
94. Which of the following would be appropriate for a 12-month-old child with celiac disease?
A. Oatmeal
B. Pancake
C. Corn tortilla
D. Waffles
95. When explaining to the parents of a child with a hydrocele about the possible cause of the condition,
the nurse bases explanation on the interpretation that a hydrocele is most likely the result of which
condition?
A. Blockage in the inguinal canal that allows fluid to accumulate in epididymis and ductus deferens
B. Failure of the upper part of the processus vaginalis to atrophy, allowing accumulation of fluid in
the testicle and peritoneal cavity
C. A patent processus vaginalis that result in the collection of fluid along the spermatic cord or
tunical vaginalis of the testicle
D. An obliterated processus vaginalis that allows fluid to accumulate in the scrotal sac.
96. During a clinic visit, the mother of an infant with hydrocele states that the infant’s scrotum is smaller
now than when he was born. After teaching the mother about the infant’s condition, which of the
following statements by the mother indicates that the teaching has been effective?
A. “I guess keeping his bottom up has helped.”
B. “Massaging his groin area is working.”
C. “It seems like the fluid is being reabsorbed.”
D. “Keeping him quiet and infant seat has helped.”
97. A 16-month-old child is seen in the clinic for a check-up for the first time. The nurse notices that the
toddler limps when walking. Which of the following would be appropriate to use when assessing this
toddler for developmental dysplasia of the hip?
A. Ortalani’s manuever
B. Barlow’s manuever
C. Adam’s position
D. Trendelenburg’s sign
98. When teaching the family of an older infant who has had a spica cast applied for developmental
dysplasia of the hip, which information should the nurse include when describing the abduction
stabilizer bar?
A. It can be adjusted to a position of comfort
B. It is used to lift the child
C. It adds strength to the cast
D. It is necessary to turn the child
99. After teaching the parents of an infant with clubfoot requiring application of a plaster cast how to
care for the cast, which of the following statements would indicate that the parents have understood
the teaching?
A. “If the cast becomes soiled, we’ll clean it with soap and water.”
B. “We’ll elevate the leg with the cast on pillows, so the leg is above heat level.”
C. “We will check the color and temperature of the toes of the casted leg frequently.”
D. “The petals on the edge of the cast can be removed after the first 24 hours.”
100.
A preschooler with a fractured femur of the left leg in traction tells the nurse his leg hurts. It is
too early for pain medication. The nurse should:
A. Place a pillow under the child’s buttocks to provide support
B. Remove the weight from the left leg
C. Assess the feet for signs of neurovascular impairment
D. Reposition the pulleys so the traction is looser