MATERNAL AND CHILD HEALTH likely the result of which of the

NURSING PRACTICE QUESTIONS WITH following?

RATIONALE
a. Increased plasma HCG levels
1. When assessing the adequacy of b. Decreased intestinal motility
sperm for conception to occur, c. Decreased gastric acidity
which of the following is the most d. Elevated estrogen levels
useful criterion? 5. On which of the following areas
a. Sperm count would the nurse expect to observe
b. Sperm motility chloasma?
c. Sperm maturity
a. Breast, areola, and nipples
d. Semen volume
b. Chest, neck, arms, and legs
2. A couple who wants to conceive but
c. Abdomen, breast, and thighs
has been unsuccessful during the
d. Cheeks, forehead, and nose
last 2 years has undergone many
6. A pregnant client states that she
diagnostic procedures. When
“waddles” when she walks. The
discussing the situation with the
nurse’s explanation is based on
nurse, one partner states, “We know
which of the following as the cause?
several friends in our age group and
all of them have their own child
a. The large size of the
already, Why can’t we have one?”.
newborn
Which of the following would be the
b. Pressure on the pelvic
most pertinent nursing diagnosis for
muscles
this couple?
c. Relaxation of the pelvic
joints
a. Fear related to the unknown
d. Excessive weight gain
b. Pain related to numerous
7. Which of the following represents
procedures.
the average amount of weight
c. Ineffective family coping
gained during pregnancy?
related to infertility.
d. Self-esteem disturbance
a. 12 to 22 lb
related to infertility.
b. 15 to 25 lb
3. Which of the following urinary
c. 24 to 30 lb
symptoms does the pregnant
d. 25 to 40 lb
woman most frequently experience
8. When talking with a pregnant client
during the first trimester?
who is experiencing aching swollen,
leg veins, the nurse would explain
a. Dysuria
that this is most probably the result
b. Frequency
of which of the following?
c. Incontinence
d. Burning
a. Thrombophlebitis
4. Heartburn and flatulence, common
b. Pregnancy-induced
in the second trimester, are most
hypertension
 c. Pressure on blood vessels 13. Which of the following would be
from the enlarging uterus disadvantage of breast feeding?
d. The force of gravity pulling
down on the uterus a. Involution occurs more
9. Cervical softening and uterine rapidly
souffle are classified as which of the b. The incidence of allergies
following? increases due to maternal
antibodies
a. Diagnostic signs c. The father may resent the
b. Presumptive signs infant’s demands on the
c. Probable signs mother’s body
d. Positive signs d. There is a greater chance for
10. Which of the following would the error during preparation
nurse identify as a presumptive sign 14. Which of the following would cause
of pregnancy? a false-positive result on a
pregnancy test?
a. Hegar sign
b. Nausea and vomiting a. The test was performed less
c. Skin pigmentation changes than 10 days after an
d. Positive serum pregnancy abortion
test b. 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 c. The urine sample was stored
during the first trimester? too long at room
temperature
a. Introversion, egocentrism, d. A spontaneous abortion or a
narcissism missed abortion is impending
b. Awkwardness, clumsiness, 15. FHR can be auscultated with a
and unattractiveness fetoscope as early as which of the
c. Anxiety, passivity, following?
extroversion
d. Ambivalence, fear, fantasies a. 5 weeks gestation
12. During which of the following would b. 10 weeks gestation
the focus of classes be mainly on c. 15 weeks gestation
physiologic changes, fetal d. 20 weeks gestation
development, sexuality, during 16. A client LMP began July 5. Her EDD
pregnancy, and nutrition? should be which of the following?

a. Prepregnant period a. January 2

b. First trimester b. March 28
c. Second trimester c. April 12
d. Third trimester d. October 12
17. Which of the following fundal b. Second stage
heights indicates less than 12 weeks’ c. Third stage
gestation when the date of the LMP d. Fourth stage
is unknown? 22. Barbiturates are usually not given
for pain relief during active labor for
a. Uterus in the pelvis which of the following reasons?
b. Uterus at the xiphoid
c. Uterus in the abdomen a. The neonatal effects include
d. Uterus at the umbilicus hypotonia, hypothermia,
18. Which of the following danger signs generalized drowsiness, and
should be reported promptly during reluctance to feed for the
the antepartum period? first few days.
b. These drugs readily cross the
a. Constipation placental barrier, causing
b. Breast tenderness depressive effects in the
c. Nasal stuffiness newborn 2 to 3 hours after
d. Leaking amniotic fluid intramuscular injection.
19. Which of the following prenatal c. They rapidly transfer across
laboratory test values would the the placenta, and lack of an
nurse consider as significant? antagonist make them
generally inappropriate
a. Hematocrit 33.5% during labor.
b. Rubella titer less than 1:8 d. Adverse reactions may
c. White blood cells include maternal
8,000/mm3 hypotension, allergic or toxic
d. One hour glucose challenge reaction or partial or total
test 110 g/dL respiratory failure
20. Which of the following 23. Which of the following nursing
characteristics of contractions would interventions would the nurse
the nurse expect to find in a client perform during the third stage of
experiencing true labor? labor?

a. Occurring at irregular a. Obtain a urine specimen and

intervals other laboratory tests.
b. Starting mainly in the b. Assess uterine contractions
abdomen every 30 minutes.
c. Gradually increasing intervals c. Coach for effective client
d. Increasing intensity with pushing
walking d. Promote parent-newborn
21. During which of the following stages interaction.
of labor would the nurse assess 24. Which of the following actions
“crowning”? demonstrates the nurse’s
understanding about the newborn’s
a. First stage thermoregulatory ability?
 a. Placing the newborn under a a. The anterior is triangular
radiant warmer. shaped; the posterior is
b. Suctioning with a bulb diamond shaped.
syringe b. The posterior closes at 18
c. Obtaining an Apgar score months; the anterior closes
d. Inspecting the newborn’s at 8 to 12 weeks.
umbilical cord c. The anterior is large in size
25. Immediately before expulsion, when compared to the
which of the following cardinal posterior fontanel.
movements occur? d. The anterior is bulging; the
posterior appears sunken.
a. Descent 30. Which of the following groups of
b. Flexion newborn reflexes below are present
c. Extension at birth and remain unchanged
d. External rotation through adulthood?
26. Before birth, which of the following
structures connects the right and a. Blink, cough, rooting, and
left auricles of the heart? gag
b. Blink, cough, sneeze, gag
a. Umbilical vein c. Rooting, sneeze, swallowing,
b. Foramen ovale and cough
c. Ductus arteriosus d. Stepping, blink, cough, and
d. Ductus venosus sneeze
27. Which of the following when 31. Which of the following describes the
present in the urine may cause a Babinski reflex?
reddish stain on the diaper of a
newborn? a. The newborn’s toes will
hyperextend and fan apart
a. Mucus from dorsiflexion of the big
b. Uric acid crystals toe when one side of foot is
c. Bilirubin stroked upward from the
d. Excess iron ball of the heel and across
28. When assessing the newborn’s heart the ball of the foot.
rate, which of the following ranges b. The newborn abducts and
would be considered normal if the flexes all extremities and
newborn were sleeping? may begin to cry when
exposed to sudden
a. 80 beats per minute movement or loud noise.
b. 100 beats per minute c. The newborn turns the head
c. 120 beats per minute in the direction of stimulus,
d. 140 beats per minute opens the mouth, and begins
29. Which of the following is true to suck when cheek, lip, or
regarding the fontanels of the corner of mouth is touched.
newborn?
 d. The newborn will attempt to a. Threatened
crawl forward with both b. Imminent
arms and legs when he is c. Missed
placed on his abdomen on a d. Incomplete
flat surface 35. Which of the following factors
32. Which of the following statements would the nurse suspect as
best describes hyperemesis predisposing a client to placenta
gravidarum? previa?

a. Severe anemia leading to a. Multiple gestation

electrolyte, metabolic, and b. Uterine anomalies
nutritional imbalances in the c. Abdominal trauma
absence of other medical d. Renal or vascular disease
problems. 36. Which of the following would the
b. Severe nausea and vomiting nurse assess in a client experiencing
leading to electrolyte, abruptio placenta?
metabolic, and nutritional
imbalances in the absence a. Bright red, painless vaginal
of other medical problems. bleeding
c. Loss of appetite and b. Concealed or external dark
continuous vomiting that red bleeding
commonly results in c. Palpable fetal outline
dehydration and ultimately d. Soft and nontender
decreasing maternal abdomen
nutrients 37. Which of the following is described
d. Severe nausea and diarrhea as premature separation of a
that can cause normally implanted placenta during
gastrointestinal irritation and the second half of pregnancy,
possibly internal bleeding usually with severe hemorrhage?
33. Which of the following would the
nurse identify as a classic sign of a. Placenta previa
PIH? b. Ectopic pregnancy
c. Incompetent cervix
a. Edema of the feet and ankles d. Abruptio placentae
b. Edema of the hands and 38. Which of the following may happen
face if the uterus becomes
c. Weight gain of 1 lb/week overstimulated by oxytocin during
d. Early morning headache the induction of labor?
34. In which of the following types of
spontaneous abortions would the a. Weak contraction prolonged
nurse assess dark brown vaginal to more than 70 seconds
discharge and a negative pregnancy b. Tetanic contractions
tests? prolonged to more than 90
seconds
 c. Increased pain with bright a. The chorion and amnion
red vaginal bleeding rupture 4 hours before the
d. Increased restlessness and onset of labor.
anxiety b. PROM removes the fetus
39. When preparing a client for most effective defense
cesarean delivery, which of the against infection
following key concepts should be c. Nursing care is based on fetal
considered when implementing viability and gestational age.
nursing care? d. PROM is associated with
malpresentation and possibly
a. Instruct the mother’s incompetent cervix
support person to remain in 42. Which of the following factors is the
the family lounge until after underlying cause of dystocia?
the delivery
b. Arrange for a staff member a. Nurtional
of the anesthesia b. Mechanical
department to explain what c. Environmental
to expect postoperatively d. Medical
c. Modify preoperative 43. When uterine rupture occurs, which
teaching to meet the needs of the following would be the
of either a planned or priority?
emergency cesarean birth
d. Explain the surgery, expected a. Limiting hypovolemic shock
outcome, and kind of b. Obtaining blood specimens
anesthetics c. Instituting complete bed rest
40. Which of the following best d. Inserting a urinary catheter
describes preterm labor? 44. Which of the following is the nurse’s
initial action when umbilical cord
a. Labor that begins after 20 prolapse occurs?
weeks gestation and before
37 weeks gestation a. Begin monitoring maternal
b. Labor that begins after 15 vital signs and FHR
weeks gestation and before b. Place the client in a knee-
37 weeks gestation chest position in bed
c. Labor that begins after 24 c. Notify the physician and
weeks gestation and before prepare the client for
28 weeks gestation delivery
d. Labor that begins after 28 d. Apply a sterile warm saline
weeks gestation and before dressing to the exposed cord
40 weeks gestation 45. Which of the following amounts of
41. When PROM occurs, which of the blood loss following birth marks the
following provides evidence of the criterion for describing postpartum
nurse’s understanding of the client’s hemorrhage?
immediate needs?
 a. More than 200 ml a. Midcalf pain, tenderness and
b. More than 300 ml redness along the vein
c. More than 400 ml b. Chills, fever, malaise,
d. More than 500 ml occurring 2 weeks after
46. Which of the following is the delivery
primary predisposing factor related c. Muscle pain the presence of
to mastitis? Homans sign, and swelling in
the affected limb
a. Epidemic infection from d. Chills, fever, stiffness, and
nosocomial sources localizing pain occurring 10 to 14 days
in the lactiferous glands and after delivery
ducts 49. Which of the following are the most
b. Endemic infection occurring commonly assessed findings in
randomly and localizing in cystitis?
the periglandular connective
tissue a. Frequency, urgency,
c. Temporary urinary retention dehydration, nausea, chills,
due to decreased perception and flank pain
of the urge to avoid b. Nocturia, frequency,
d. Breast injury caused by urgency dysuria, hematuria,
overdistention, stasis, and fever and suprapubic pain
cracking of the nipples c. Dehydration, hypertension,
47. Which of the following best dysuria, suprapubic pain,
describes thrombophlebitis? chills, and fever
d. High fever, chills, flank pain
a. Inflammation and clot nausea, vomiting, dysuria,
formation that result when and frequency
blood components combine 50. Which of the following best reflects
to form an aggregate body the frequency of reported
b. Inflammation and blood clots postpartum “blues”?
that eventually become
lodged within the pulmonary a. Between 10% and 40% of all
blood vessels new mothers report some
c. Inflammation and blood clots form of postpartum blues
that eventually become b. Between 30% and 50% of all
lodged within the femoral new mothers report some
vein form of postpartum blues
d. Inflammation of the vascular c. Between 50% and 80% of all
endothelium with clot new mothers report some
formation on the vessel wall form of postpartum blues
48. Which of the following assessment d. Between 25% and 70% of all
findings would the nurse expect if new mothers report some
the client develops DVT? form of postpartum blues
51. For the client who is using oral time!” Which of the following
contraceptives, the nurse informs should the nurse recommend?
the client about the need to take the
pill at the same time each day to a. Daily enemas
accomplish which of the following? b. Laxatives
c. Increased fiber intake
a. Decrease the incidence of d. Decreased fluid intake
nausea 56. Which of the following would the
b. Maintain hormonal levels nurse use as the basis for the
c. Reduce side effects teaching plan when caring for a
d. Prevent drug interactions pregnant teenager concerned about
gaining too much weight during
52. When teaching a client about pregnancy?
contraception. Which of the
following would the nurse include as a. 10 pounds per trimester
the most effective method for b. 1 pound per week for 40
preventing sexually transmitted weeks
infections? c. ½ pound per week for 40
a. Spermicides weeks
b. Diaphragm d. A total gain of 25 to 30
c. Condoms pounds
d. Vasectomy 57. The client tells the nurse that her
53. When preparing a woman who is 2 last menstrual period started on
days postpartum for discharge, January 14 and ended on January
recommendations for which of the 20. Using Nagele’s rule, the nurse
following contraceptive methods determines her EDD to be which of
would be avoided? the following?

a. Diaphragm a. September 27
b. Female condom b. October 21
c. Oral contraceptives c. November 7
d. Rhythm method d. December 27
54. For which of the following clients 58. When taking an obstetrical history
would the nurse expect that an on a pregnant client who states, “I
intrauterine device would not be had a son born at 38 weeks
recommended? gestation, a daughter born at 30
weeks gestation and I lost a baby at
a. Woman over age 35 about 8 weeks,” the nurse should
b. Nulliparous woman record her obstetrical history as
c. Promiscuous young adult which of the following?
d. Postpartum client
55. A client in her third trimester tells a. G2 T2 P0 A0 L2
the nurse, “I’m constipated all the b. G3 T1 P1 A0 L2
c. G3 T2 P0 A0 L2
 d. G4 T2 P1 A1 L2 a. Threatened abortion
59. When preparing to listen to the fetal b. Imminent abortion
heart rate at 12 weeks’ gestation, c. Complete abortion
the nurse would use which of the d. Missed abortion
following? 63. Which of the following would be the
priority nursing diagnosis for a client
a. Stethoscope placed midline with an ectopic pregnancy?
at the umbilicus
b. Doppler placed midline at a. Risk for infection
the suprapubic region b. Pain
c. Fetoscope placed midway c. Knowledge Deficit
between the umbilicus and d. Anticipatory Grieving
the xiphoid process 64. Before assessing the postpartum
d. External electronic fetal client’s uterus for firmness and
monitor placed at the position in relation to the umbilicus
umbilicus and midline, which of the following
60. When developing a plan of care for a should the nurse do first?
client newly diagnosed with
gestational diabetes, which of the a. Assess the vital signs
following instructions would be the b. Administer analgesia
priority? c. Ambulate her in the hall
d. Assist her to urinate
a. Dietary intake 65. Which of the following should the
b. Medication nurse do when a primipara who is
c. Exercise lactating tells the nurse that she has
d. Glucose monitoring sore nipples?
61. A client at 24 weeks gestation has
gained 6 pounds in 4 weeks. Which a. Tell her to breast feed more
of the following would be the frequently
priority when assessing the client? b. Administer a narcotic before
breast feeding
a. Glucosuria c. Encourage her to wear a
b. Depression nursing brassiere
c. Hand/face edema d. Use soap and water to clean
d. Dietary intake the nipples
62. A client 12 weeks’ pregnant come to 66. The nurse assesses the vital signs of
the emergency department with a client, 4 hours’ postpartum that
abdominal cramping and moderate are as follows: BP 90/60;
vaginal bleeding. Speculum temperature 100.4ºF; pulse 100
examination reveals 2 to 3 cms weak, thready; R 20 per minute.
cervical dilation. The nurse would Which of the following should the
document these findings as which of nurse do first?
the following?
 a. Report the temperature to c. Facilitating safe and effective
the physician self-and newborn care
b. Recheck the blood pressure d. Teaching about the
with another cuff importance of family
c. Assess the uterus for planning
firmness and position 70. Which of the following actions
d. Determine the amount of would be least effective in
lochia maintaining a neutral thermal
67. The nurse assesses the postpartum environment for the newborn?
vaginal discharge (lochia) on four
clients. Which of the following a. Placing infant under radiant
assessments would warrant warmer after bathing
notification of the physician? b. Covering the scale with a
warmed blanket prior to
a. A dark red discharge on a 2- weighing
day postpartum client c. Placing crib close to nursery
b. A pink to brownish discharge window for family viewing
on a client who is 5 days d. Covering the infant’s head
postpartum with a knit stockinette
c. Almost colorless to creamy 71. A newborn who has an
discharge on a client 2 weeks asymmetrical Moro reflex response
after delivery should be further assessed for which
d. A bright red discharge 5 days of the following?
after delivery
68. A postpartum client has a a. Talipes equinovarus
temperature of 101.4ºF, with a b. Fractured clavicle
uterus that is tender when palpated, c. Congenital hypothyroidism
remains unusually large, and not d. Increased intracranial
descending as normally expected. pressure
Which of the following should the 72. During the first 4 hours after a male
nurse assess next? circumcision, assessing for which of
the following is the priority?
a. Lochia
b. Breasts a. Infection
c. Incision b. Hemorrhage
d. Urine c. Discomfort
69. Which of the following is the priority d. Dehydration
focus of nursing practice with the 73. The mother asks the nurse. “What’s
current early postpartum discharge? wrong with my son’s breasts? Why
are they so enlarged?” Whish of the
a. Promoting comfort and following would be the best
restoration of health response by the nurse?
b. Exploring the emotional
status of the family
 a. “The breast tissue is inflamed 76. A newborn weighing 3000 grams
from the trauma experienced and feeding every 4 hours needs 120
with birth” calories/kg of body weight every 24
b. “A decrease in material hours for proper growth and
hormones present before development. How many ounces of
birth causes enlargement,” 20 cal/oz formula should this
c. “You should discuss this with newborn receive at each feeding to
your doctor. It could be a meet nutritional needs?
malignancy”
d. “The tissue has a. 2 ounces
hypertrophied while the b. 3 ounces
baby was in the uterus” c. 4 ounces
74. Immediately after birth the nurse d. 6 ounces
notes the following on a male 77. The postterm neonate with
newborn: respirations 78; apical meconium-stained amniotic fluid
hearth rate 160 BPM, nostril flaring; needs care designed to especially
mild intercostal retractions; and monitor for which of the following?
grunting at the end of expiration.
Which of the following should the a. Respiratory problems
nurse do? b. Gastrointestinal problems
c. Integumentary problems
a. Call the assessment data to d. Elimination problems
the physician’s attention 78. When measuring a client’s fundal
b. Start oxygen per nasal height, which of the following
cannula at 2 L/min. techniques denotes the correct
c. Suction the infant’s mouth method of measurement used by
and nares the nurse?
d. Recognize this as normal first
period of reactivity a. From the xiphoid process to
75. The nurse hears a mother telling a the umbilicus
friend on the telephone about b. From the symphysis pubis to
umbilical cord care. Which of the the xiphoid process
following statements by the mother c. From the symphysis pubis to
indicates effective teaching? the fundus
d. From the fundus to the
a. “Daily soap and water umbilicus
cleansing is best” 79. A client with severe preeclampsia is
b. ‘Alcohol helps it dry and kills admitted with of BP 160/110,
germs” proteinuria, and severe pitting
c. “An antibiotic ointment edema. Which of the following
applied daily prevents would be most important to include
infection” in the client’s plan of care?
d. “He can have a tub bath each
day” a. Daily weights
 b. Seizure precautions a. Increase in maternal
c. Right lateral positioning estrogen secretion
d. Stress reduction b. Decrease in maternal
80. A postpartum primipara asks the androgen secretion
nurse, “When can we have sexual c. Secretion of androgen by the
intercourse again?” Which of the fetal gonad
following would be the nurse’s best d. Secretion of estrogen by the
response? fetal gonad
84. A client at 8 weeks’ gestation calls
a. “Anytime you both want to.” complaining of slight nausea in the
b. “As soon as choose a morning hours. Which of the
contraceptive method.” following client interventions should
c. “When the discharge has the nurse question?
stopped and the incision is
healed.” a. Taking 1 teaspoon of
d. “After your 6 weeks bicarbonate of soda in an 8-
examination.” ounce glass of water
81. When preparing to administer the b. Eating a few low-sodium
vitamin K injection to a neonate, the crackers before getting out
nurse would select which of the of bed
following sites as appropriate for the c. Avoiding the intake of liquids
injection? in the morning hours
d. Eating six small meals a day
a. Deltoid muscle instead of thee large meals
b. Anterior femoris muscle 85. The nurse documents positive
c. Vastus lateralis muscle ballottement in the client’s prenatal
d. Gluteus maximus muscle record. The nurse understands that
82. When performing a pelvic this indicates which of the
examination, the nurse observes a following?
red swollen area on the right side of
the vaginal orifice. The nurse would a. Palpable contractions on the
document this as enlargement of abdomen
which of the following? b. Passive movement of the
unengaged fetus
a. Clitoris c. Fetal kicking felt by the client
b. Parotid gland d. Enlargement and softening
c. Skene’s gland of the uterus
d. Bartholin’s gland 86. During a pelvic exam the nurse
83. To differentiate as a female, the notes a purple-blue tinge of the
hormonal stimulation of the embryo cervix. The nurse documents this as
that must occur involves which of which of the following?
the following?
a. Braxton-Hicks sign
b. Chadwick’s sign
 c. Goodell’s sign Which of the following assessments
d. McDonald’s sign should be avoided?
87. During a prenatal class, the nurse
explains the rationale for breathing a. Maternal vital sign
techniques during preparation for b. Fetal heart rate
labor based on the understanding c. Contraction monitoring
that breathing techniques are most d. Cervical dilation
important in achieving which of the 90. Which of the following would be the
following? nurse’s most appropriate response
to a client who asks why she must
a. Eliminate pain and give the have a cesarean delivery if she has a
expectant parents something complete placenta previa?
to do
b. Reduce the risk of fetal a. “You will have to ask your
distress by increasing physician when he returns.”
uteroplacental perfusion b. “You need a cesarean to
c. Facilitate relaxation, possibly prevent hemorrhage.”
reducing the perception of c. “The placenta is covering
pain most of your cervix.”
d. Eliminate pain so that less d. “The placenta is covering the
analgesia and anesthesia are opening of the uterus and
needed blocking your baby.”
88. After 4 hours of active labor, the 91. The nurse understands that the fetal
nurse notes that the contractions of head is in which of the following
a primigravida client are not strong positions with a face presentation?
enough to dilate the cervix. Which
of the following would the nurse a. Completely flexed
anticipate doing? b. Completely extended
c. Partially extended
a. Obtaining an order to begin d. Partially flexed
IV oxytocin infusion 92. With a fetus in the left-anterior
b. Administering a light breech presentation, the nurse
sedative to allow the patient would expect the fetal heart rate
to rest for several hour would be most audible in which of
c. Preparing for a cesarean the following areas?
section for failure to progress
d. Increasing the a. Above the maternal
encouragement to the umbilicus and to the right of
patient when pushing begins midline
89. A multigravida at 38 weeks’ b. In the lower-left maternal
gestation is admitted with painless, abdominal quadrant
bright red bleeding and mild c. In the lower-right maternal
contractions every 7 to 10 minutes. abdominal quadrant
 d. Above the maternal challenging the routine use of
umbilicus and to the left of analgesics and anesthetics during
midline childbirth. Which of the following
93. The amniotic fluid of a client has a was an outgrowth of this concept?
greenish tint. The nurse interprets
this to be the result of which of the a. Labor, delivery, recovery,
following? postpartum (LDRP)
b. Nurse-midwifery
a. Lanugo c. Clinical nurse specialist
b. Hydramnio d. Prepared childbirth
c. Meconium 98. A client has a midpelvic contracture
d. Vernix from a previous pelvic injury due to
94. A patient is in labor and has just a motor vehicle accident as a
been told she has a breech teenager. The nurse is aware that
presentation. The nurse should be this could prevent a fetus from
particularly alert for which of the passing through or around which
following? structure during childbirth?

a. Quickening a. Symphysis pubis

b. Ophthalmia neonatorum b. Sacral promontory
c. Pica c. Ischial spines
d. Prolapsed umbilical cord d. Pubic arch
95. When describing dizygotic twins to a 99. When teaching a group of
couple, on which of the following adolescents about variations in the
would the nurse base the length of the menstrual cycle, the
explanation? nurse understands that the
underlying mechanism is due to
a. Two ova fertilized by variations in which of the following
separate sperm phases?
b. Sharing of a common
placenta a. Menstrual phase
c. Each ova with the same b. Proliferative phase
genotype c. Secretory phase
d. Sharing of a common chorion d. Ischemic phase
96. Which of the following refers to the 100. When teaching a group of
single cell that reproduces itself adolescents about male hormone
after conception? production, which of the following
would the nurse include as being
a. Chromosome produced by the Leydig cells?
b. Blastocyst
c. Zygote a. Follicle-stimulating hormone
d. Trophoblast b. Testosterone
97. In the late 1950s, consumers and c. Leuteinizing hormone
health care professionals began
Gonadotropin releasing hormone d. A colorful busy box
105. The mother of a 2-month-old
101. While performing physical is concerned that she may be
assessment of a 12 month-old, the spoiling her baby by picking her up
nurse notes that the infant’s when she cries. Which of the
anterior fontanelle is still slightly following would be the nurse’s best
open. Which of the following is the response?
nurse’s most appropriate action?
a. Notify the physician a. “ Let her cry for a while
immediately because there is before picking her up, so you
a problem. don’t spoil her”
b. Perform an intensive b. “Babies need to be held and
neurologic examination. cuddled; you won’t spoil her
c. Perform an intensive this way”
developmental examination. c. “Crying at this age means the
d. Do nothing because this is a baby is hungry; give her a
normal finding for the age. bottle”
102. When teaching a mother d. “If you leave her alone she
about introducing solid foods to her will learn how to cry herself
child, which of the following to sleep”
indicates the earliest age at which 106. When assessing an 18-
this should be done? month-old, the nurse notes a
characteristic protruding abdomen.
a. 1 month Which of the following would
b. 2 months explain the rationale for this finding?
c. 3 months
d. 4 months a. Increased food intake owing
103. The infant of a substance- to age
abusing mother is at risk for b. Underdeveloped abdominal
developing a sense of which of the muscles
following? c. Bowlegged posture
d. Linear growth curve
a. Mistrust 107. If parents keep a toddler
b. Shame dependent in areas where he is
c. Guilt capable of using skills, the toddle
d. Inferiority will develop a sense of which of the
104. Which of the following toys following?
should the nurse recommend for a
5-month-old? a. Mistrust
b. Shame
a. A big red balloon c. Guilt
b. A teddy bear with button d. Inferiority
eyes
c. A push-pull wooden truck
108. Which of the following is an c. “Encourage active play at
appropriate toy for an 18-month- bedtime to tire him out so he
old? will fall asleep faster.”
d. “Read him a story and allow
a. Multiple-piece puzzle him to play quietly in his bed
b. Miniature cars until he falls asleep.”
c. Finger paints 112. When providing therapeutic
d. Comic book play, which of the following toys
109. When teaching parents would best promote imaginative
about the child’s readiness for toilet play in a 4-year-old?
training, which of the following signs
should the nurse instruct them to a. Large blocks
watch for in the toddler? b. Dress-up clothes
c. Wooden puzzle
a. Demonstrates dryness for 4 d. Big wheels
hours 113. Which of the following
b. Demonstrates ability to sit activities, when voiced by the
and walk parents following a teaching session
c. Has a new sibling for about the characteristics of school-
stimulation age cognitive development would
d. Verbalizes desire to go to the indicate the need for additional
bathroom teaching?
110. When teaching parents
about typical toddler eating a. Collecting baseball cards and
patterns, which of the following marbles
should be included? b. Ordering dolls according to
size
a. Food “jags” c. Considering simple problem-
b. Preference to eat alone solving options
c. Consistent table manners d. Developing plans for the
d. Increase in appetite future
111. Which of the following 114. A hospitalized schoolager
suggestions should the nurse offer states: “I’m not afraid of this place,
the parents of a 4-year-old boy who I’m not afraid of anything.” This
resists going to bed at night? statement is most likely an example
of which of the following?
a. “Allow him to fall asleep in
your room, then move him a. Regression
to his own bed.” b. Repression
b. “Tell him that you will lock c. Reaction formation
him in his room if he gets out d. Rationalization
of bed one more time.” 115. After teaching a group of
parents about accident prevention
for schoolagers, which of the
 following statements by the group 119. Which of the following would
would indicate the need for more be most appropriate for a nurse to
teaching? use when describing menarche to a
13-year-old?
a. “Schoolagers are more active
and adventurous than are a. A female’s first menstruation
younger children.” or menstrual “periods”
b. “Schoolagers are more b. The first year of
susceptible to home hazards menstruation or “period”
than are younger children.” c. The entire menstrual cycle or
c. “Schoolagers are unable to from one “period” to
understand potential another
dangers around them.” d. The onset of uterine
d. “Schoolargers are less maturation or peak growth
subject to parental control 120. A 14-year-old boy has acne
than are younger children.” and according to his parents,
116. Which of the following skills dominates the bathroom by using
is the most significant one learned the mirror all the time. Which of the
during the schoolage period? following remarks by the nurse
would be least helpful in talking to
a. Collecting the boy and his parents?
b. Ordering
c. Reading a. “This is probably the only
d. Sorting concern he has about his
117. A child age 7 was unable to body. So don’t worry about it
receive the measles, mumps, and or the time he spends on it.”
rubella (MMR) vaccine at the b. “Teenagers are anxious
recommended scheduled time. about how their peers
When would the nurse expect to perceive them. So they
administer MMR vaccine? spend a lot of time
grooming.”
a. In a month from now c. “A teen may develop a poor
b. In a year from now self-image when
c. At age 10 experiencing acne. Do you
d. At age 13 feel this way sometimes?”
118. The adolescent’s inability to d. “You appear to be keeping
develop a sense of who he is and your face well washed.
what he can become results in a Would you feel comfortable
sense of which of the following? discussing your cleansing
method?”
a. Shame 121. Which of the following
b. Guilt should the nurse suspect when
c. Inferiority noting that a 3-year-old is engaging
d. Role diffusion
 in explicit sexual behavior during a. Lowered resistance from
doll play? malnutrition
b. Ineffective functioning of the
a. The child is exhibiting normal Eustachian tubes
pre-school curiosity c. Plugging of the Eustachian
b. The child is acting out tubes with food particles
personal experiences d. Associated congenital
c. The child does not know how defects of the middle ear.
to play with dolls 125. While performing a
d. The child is probably neurodevelopmental assessment on
developmentally delayed. a 3-month-old infant, which of the
122. Which of the following following characteristics would be
statements by the parents of a child expected?
with school phobia would indicate
the need for further teaching? a. A strong Moro reflex
b. A strong parachute reflex
a. “We’ll keep him at home c. Rolling from front to back
until phobia subsides.” d. Lifting of head and chest
b. “We’ll work with his teachers when prone
and counselors at school.” 126. By the end of which of the
c. “We’ll try to encourage him following would the nurse most
to talk about his problem.” commonly expect a child’s birth
d. “We’ll discuss possible weight to triple?
solutions with him and his
counselor.” a. 4 months
123. When developing a teaching b. 7 months
plan for a group of high school c. 9 months
students about teenage pregnancy, d. 12 months
the nurse would keep in mind which 127. Which of the following best
of the following? describes parallel play between two
toddlers?
a. The incidence of teenage
pregnancies is increasing. a. Sharing crayons to color
b. Most teenage pregnancies separate pictures
are planned. b. Playing a board game with a
c. Denial of the pregnancy is nurse
common early on. c. Sitting near each other while
d. The risk for complications playing with separate dolls
during pregnancy is rare. d. Sharing their dolls with two
124. When assessing a child with different nurses
a cleft palate, the nurse is aware 128. Which of the following would
that the child is at risk for more the nurse identify as the initial
frequent episodes of otitis media priority for a child with acute
due to which of the following? lymphocytic leukemia?
 a. Instituting infection control a. Displacement
precautions b. Projection
b. Encouraging adequate intake c. Repression
of iron-rich foods d. Psychosis
c. Assisting with coping with 132. Which of the following
chronic illness should the nurse expect to note as a
d. Administering medications frequent complication for a child
via IM injections with congenital heart disease?
129. Which of the following
information, when voiced by the a. Susceptibility to respiratory
mother, would indicate to the nurse infection
that she understands home care b. Bleeding tendencies
instructions following the c. Frequent vomiting and
administration of a diphtheria, diarrhea
tetanus, and pertussis injection? d. Seizure disorder
133. Which of the following would
a. Measures to reduce fever the nurse do first for a 3-year-old
b. Need for dietary restrictions boy who arrives in the emergency
c. Reasons for subsequent rash room with a temperature of 105
d. Measures to control degrees, inspiratory stridor, and
subsequent diarrhea restlessness, who is learning forward
130. Which of the following and drooling?
actions by a community health nurse
is most appropriate when noting a. Auscultate his lungs and
multiple bruises and burns on the place him in a mist tent.
posterior trunk of an 18-month-old b. Have him lie down and rest
child during a home visit? after encouraging fluids.
c. Examine his throat and
a. Report the child’s condition perform a throat culture
to Protective Services d. Notify the physician
immediately. immediately and prepare for
b. Schedule a follow-up visit to intubation.
check for more bruises. 134. Which of the following would
c. Notify the child’s physician the nurse need to keep in mind as a
immediately. predisposing factor when
d. Don nothing because this is a formulating a teaching plan for child
normal finding in a toddler. with a urinary tract infection?
131. Which of the following is
being used when the mother of a a. A shorter urethra in females
hospitalized child calls the student b. Frequent emptying of the
nurse and states, “You idiot, you bladder
have no idea how to care for my sick c. Increased fluid intake
child”? d. Ingestion of acidic juices
135. Which of the following c. The child engages in
should the nurse do first for a 15- competitive types of play
year-old boy with a full leg cast who d. Immediate gratification is
is screaming in unrelenting pain and necessary to develop
exhibiting right foot pallor signifying initiative.
compartment syndrome? 139. Which of the following is
characteristic of a preschooler with
a. Medicate him with mid mental retardation?
acetaminophen.
b. Notify the physician a. Slow to feed self
immediately b. Lack of speech
c. Release the traction c. Marked motor delays
d. Monitor him every 5 minutes d. Gait disability
136. At which of the following 140. Which of the following
ages would the nurse expect to assessment findings would lead the
administer the varicella zoster nurse to suspect Down syndrome in
vaccine to child? an infant?

a. At birth a. Small tongue

b. 2 months b. Transverse palmar crease
c. 6 months c. Large nose
d. 12 months d. Restricted joint movement
137. When discussing normal 141. While assessing a newborn
infant growth and development with with cleft lip, the nurse would be
parents, which of the following toys alert that which of the following will
would the nurse suggest as most most likely be compromised?
appropriate for an 8-month-old?
a. Sucking ability
a. Push-pull toys b. Respiratory status
b. Rattle c. Locomotion
c. Large blocks d. GI function
d. Mobile 142. When providing
138. Which of the following postoperative care for the child with
aspects of psychosocial a cleft palate, the nurse should
development is necessary for the position the child in which of the
nurse to keep in mind when following positions?
providing care for the preschool
child? a. Supine
b. Prone
a. The child can use complex c. In an infant seat
reasoning to think out d. On the side
situations. 143. While assessing a child with
b. Fear of body mutilation is a pyloric stenosis, the nurse is likely to
common preschool fear note which of the following?
 a. Regurgitation d. Weight gain
b. Steatorrhea 148. Which of the following
c. Projectile vomiting should the nurse do first after noting
d. “Currant jelly” stools that a child with Hirschsprung
144. Which of the following disease has a fever and watery
nursing diagnoses would be explosive diarrhea?
inappropriate for the infant with
gastroesophageal reflux (GER)? a. Notify the physician
immediately
a. Fluid volume deficit b. Administer antidiarrheal
b. Risk for aspiration medications
c. Altered nutrition: less than c. Monitor child ever 30
body requirements minutes
d. Altered oral mucous d. Nothing, this is characteristic
membranes of Hirschsprung disease
145. Which of the following 149. A newborn’s failure to pass
parameters would the nurse meconium within the first 24 hours
monitor to evaluate the after birth may indicate which of the
effectiveness of thickened feedings following?
for an infant with gastroesophageal
reflux (GER)? a. Hirschsprung disease
b. Celiac disease
a. Vomiting c. Intussusception
b. Stools d. Abdominal wall defect
c. Uterine 150. When assessing a child for
d. Weight possible intussusception, which of
146. Discharge teaching for a child the following would be least likely to
with celiac disease would include provide valuable information?
instructions about avoiding which of
the following? a. Stool inspection
b. Pain pattern
a. Rice c. Family history
b. Milk d. Abdominal palpation
c. Wheat
d. Chicken
147. Which of the following would
the nurse expect to assess in a child
with celiac disease having a celiac
crisis secondary to an upper
respiratory infection?

a. Respiratory distress
b. Lethargy
c. Watery diarrhea
Nursing Board Review: Maternal and
Child Health Nursing Practice Test Part
1

1. A client asks the nurse what a third 3. The uterus has already risen out of the
degree laceration is. She was informed that pelvis and is experiencing farther into the
she had one. The nurse explains that this is: abdominal area at about the:

a. 8th week of pregnancy

a. that extended their anal sphincter
b. 10th week of pregnancy
b. through the skin and into the muscles
c. 12th week of pregnancy
c. that involves anterior rectal wall
d. 18th week of pregnancy
d. that extends through the perineal
muscle.
4. Which of the following urinary symptoms
2. Betina 30 weeks AOG discharged with a does the pregnant woman most frequently
diagnosis of placenta previa. The nurse experience during the first trimester:
knows that the client understands her care
a. frequency
at home when she says:
b. dysuria
c. incontinence
a. I am happy to note that we can have sex d. burning
occasionally when I have no bleeding.
b. I am afraid I might have an operation
when my due comes 5. Mrs. Jimenez went to the health center
c. I will have to remain in bed until my due for pre-natal check-up. the student nurse
date comes took her weight and revealed 142 lbs. She
d. I may go back to work since I stay only at asked the student nurse how much should
the office. she gain weight in her pregnancy.

a. 20-30 lbs
b. 25-35 lbs
c. 30- 40 lbs
d. 10-15 lbs

6. The nurse is preparing Mrs. Jordan for

cesarean delivery. Which of the following
key concept should the nurse consider
when implementing nursing care?
a. Explain the surgery, expected outcome states that she is extremely uncomfortable.
and kind of anesthetics. To lessen Mrs. Abuel’s discomfort, the
b. Modify preoperative teaching to meet nurse can advise her to:
the needs of either a planned or emergency
cesarean birth. a. lie face down
c. Arrange for a staff member of the b. not drink fluids
anesthesia department to explain what to c. practice holding breaths between
expect post-operatively. contractions
d. Instruct the mother’s support person to d. assume Sim’s position
remain in the family lounge until after the
delivery.
10. Which is true regarding the fontanels of
the newborn?
7. Bettine Gonzales is hospitalized for the
treatment of severe preecplampsia. Which a. The anterior is large in shape when
of the following represents an unusual compared to the posterior fontanel.
finding for this condition? b. The anterior is triangular shaped; the
posterior is diamond shaped.
a. generalized edema c. The anterior is bulging; the posterior
b. proteinuria 4+ appears sunken.
c. blood pressure of 160/110 d. The posterior closes at 18 months; the
d. convulsions anterior closes at 8 to 12 months.

8. Nurse Geli explains to the client who is 33 11. Mrs. Quijones gave birth by
weeks pregnant and is experiencing vaginal spontaneous delivery to a full term baby
bleeding that coitus: boy. After a minute after birth, he is crying
and moving actively. His birth weight is 6.8
a. Need to be modified in any way by either lbs. What do you expect baby Quijones to
partner weigh at 6 months?
b. Is permitted if penile penetration is not
deep. a. 13 -14 lbs
c. Should be restricted because it may b. 16 -17 lbs
stimulate uterine activity. c. 22 -23 lbs
d. Is safe as long as she is in side-lying d. 27 -28 lbs
position.

12. During the first hours following delivery,

9. Mrs. Precilla Abuel, a 32 year old the post partum client is given IVF with
mulripara is admitted to labor and delivery. oxytocin added to them. The nurse
Her last 3 pregnancies in short stage one of understands the primary reason for this is:
labor. The nurses decide to observe her
closely. The physician determines that Mrs. a. To facilitate elimination
Abuel’s cervix is dilated to 6 cm. Mrs. Abuel b. To promote uterine contraction
c. To promote analgesia
d. To prevent infection 17. Which of the following situations would
alert you to a potentially developmental
problem with a child?
13. Nurse Luis is assessing the newborn’s
heart rate. Which of the following would be a. Pointing to body parts at 15 months of
considered normal if the newborn is age.
sleeping? b. Using gesture to communicate at 18
months.
a. 80 beats per minute c. Cooing at 3 months.
b. 100 beats per minute d. Saying “mama” or “dada” for the first
c. 120 beats per minute time at 18 months of age.
d. 140 beats per minute

18. Isabelle, a 2 year old girl loves to move

14. The infant with Down Syndrome should around and oftentimes manifests
go through which of the Erikson’s negativism and temper tantrums. What is
developmental stages first? the best way to deal with her behavior?

a. Initiative vs. Self doubt a. Tell her that she would not be loved by
b. Industry vs. Inferiority others is she behaves that way..
c. Autonomy vs. Shame and doubt b. Withholding giving her toys until she
d. Trust vs. Mistrust behaves properly.
c. Ignore her behavior as long as she does
not hurt herself and others.
15. The child with phenylketonuria (PKU) d. Ask her what she wants and give it to
must maintain a low phenylalanine diet to pacify her.
prevent which of the following
complications?
19. Baby boy Villanueva, 4 months old, was
a. Irreversible brain damage seen at the pediatric clinic for his scheduled
b. Kidney failure check-up. By this period, baby Villanueva
c. Blindness has already increased his height by how
d. Neutropenia many inches?

a. 3 inches
16. Which age group is with imaginative b. 4 inches
minds and creates imaginary friends? c. 5 inches
d. 6 inches
a. Toddler
b. Preschool
c. School 20. Alice, 10 years old was brought to the
d. Adolescence ER because of Asthma. She was
immediately put under aerosol
administration of Terbutaline. After c. diarrhea, retracted tympanic membrane
sometime, you observe that the child does and enlarged parotid gland
not show any relief from the treatment d. Vomiting, pulling at ears and pearly white
given. Upon assessment, you noticed that tympanic membrane
both the heart and respiratory rate are still
elevated and the child shows difficulty of
exhaling. You suspect: 24. Which of the following is the most
appropriate intervention to reduce stress in
a. Bronchiectasis a preterm infant at 33 weeks gestation?
b. Atelectasis
c. Epiglotitis a. Sensory stimulation including several
d. Status Asthmaticus senses at a time
b. tactile stimulation until signs of over
stimulation develop
21. Nurse Jonas assesses a 2 year old boy c. An attitude of extension when prone or
with a tentative diagnosis of side lying
nephroblastoma. Symptoms the nurse d. Kangaroo care
observes that suggest this problem include:

a. Lymphedema and nerve palsy 25. The parent of a client with albinism
b. Hearing loss and ataxia would need to be taught which preventive
c. Headaches and vomiting healthcare measure by the nurse:
d. Abdominal mass and weakness
a. Ulcerative colitis diet
b. Use of a high-SPF sunblock
22. Which of the following danger sings c. Hair loss monitoring
should be reported immediately during the d. Monitor for growth retardation
antepartum period?

a. blurred vision
b. nasal stuffiness
c. breast tenderness
d. constipation

23. Nurse Jacob is assessing a 15 month old

child with acute otitis media. Which of the
following symptoms would the nurse
anticipate finding?

a. periorbital edema, absent light reflex and

translucent tympanic membrane
b. irritability, purulent drainage in middle
ear, nasal congestion and cough
 Nursing Board Review : Maternal and
Child Health Nursing Part 2

1. Nurse Bella explains to a 28 year old

pregnant woman undergoing a non-stress
test that the test is a way of evaluating the
condition of the fetus by comparing the
fetal heart rate with:

a. Fetal lie 3. Mrs. Jovel Diaz went to the hospital to

b. Fetal movement have her serum blood test for alpha-
c. Maternal blood pressure fetoprotein. The nurse informed her about
d. Maternal uterine the result of the elevation of serum AFP.
contractions The patient asked her what was the test for:

a. Congenital Adrenal Hyperplasia

2. During a 2 hour childbirth focusing on b. PKU
labor and delivery process for primigravida. c. Down Syndrome
The nurse describes the second maneuver d. Neural tube defects
that the fetus goes through during labor
progress when the head is the presenting
part as which of the following: 4. Fetal heart rate can be auscultated with a
fetoscope as early as:
a. Flexion
b. Internal rotation a. 5 weeks of gestation
c. Descent b. 10 weeks of gestation
d. External rotation c. 15 weeks of gestation
d. 20 weeks of gestation

5. Mrs. Bendivin states that she is

experiencing aching swollen, leg veins. The
nurse would explain that this is most
probably the result of which of the
following:

a. Thrombophlebitis
b. PIH
c. Pressure on blood vessels from the
enlarging uterus
d. The force of gravity pulling down on the
uterus
 d. Nowember 14, 2010

6. Mrs. Ella Santoros is a 25 year old

primigravida who has Rheumatic heart 10. Which of the following prenatal
disease lesion. Her pregnancy has just been laboratory test values would the nurse
diagnosed. Her heart disease has not consider as significant?
caused her to limit physical activity in the
past. Her cardiac disease and functional a. Hematocrit 33.5%
capacity classification is: b. WBC 8,000/mm3
c. Rubella titer less than 1:8
a. Class I d. One hour glucose challenge test 110 g/dL
b. Class II
c. Class III
d. class IV 11. Aling Patricia is a patient with
preeclampsia. You advise her about her
condition, which would tell you that she has
7. The client asks the nurse, “When will this not really understood your instructions?
soft spot at the top of the head of my baby
will close?” The nurse should instruct the a. “I will restrict my fat in my diet.”
mother that the neonate’s anterior fontanel b. “I will limit my activities and rest more
will normally close by age: frequently throughout the day.”
a. 2-3 months c. “I will avoid salty foods in my diet.”
b. 6-8 months d. “I will come more regularly for check-up.”
c. 10-12 months
d. 12-18 months
12. Mrs. Grace Evangelista is admitted with
severe preeclampsia. What type of room
8. When a mother bleeds and the uterus is should the nurse select this patient?
relaxed, soft and non-tender, you can
account the cause to: a. A room next to the elevator.
b. The room farthest from the nursing
a. Atony of the uterus station.
b. Presence of uterine scar c. The quietest room on the floor.
c. Laceration of the birth canal d. The labor suite.
d. Presence of retained placenta fragments

13. During a prenatal check-up, the nurse

9. Mrs. Pichie Gonzales’s LMP began April 4, explains to a client who is Rh negative that
2010. Her EDD should be which of the RhoGAM will be given:
following:
a. Weekly during the 8th month because
a. February 11, 2011 this is her third pregnancy.
b. January 11, 20111 b. During the second trimester, if
c. December 12, 2010 amniocentesis indicates a problem.
c. To her infant immediately after delivery if following:
the Coomb’s test is positive.
d. Within 72 hours after delivery if infant is a. Monitoring for adequate nutritional
found to be Rh positive. intake
b. Teaching high-risk newborn care
c. Assessing for respiratory distress
14. A baby boy was born at 8:50pm. At d. Preventing injury
8:55pm, the heart rate was 99 bpm. She has
a weak cry, irregular respiration. She was
moving all extremities and only her hands 18. Nurse Jacob is assessing a 12 year old
and feet were still slightly blue. The nurse who has hemophilia A. Which of the
should enter the APGAR score as: following assessment findings would the
nurse anticipate?
a. 5
b. 6 a. an excess of RBC
c. 7 b. an excess of WBC
d. 8 c. a deficiency of clotting factor VIII
d. a deficiency of clotting factor IX

15. Billy is a 4 year old boy who has an IQ of

140 which means: 19. Celine, a mother of a 2 year old tells the
nurse that her child “cries and has a fit
a. average normal when I have to leave him with a sitter or
b. very superior someone else.” Which of the following
c. above average statements would be the nurse’s most
d. genius accurate analysis of the mother’s
comment?

16. A newborn is brought to the nursery. a. The child has not experienced limit-
Upon assessment, the nurse finds that the setting or structure.
child has short palpebral fissures, thinned b. The child is expressing a physical need,
upper lip. Based on this data, the nurse such as hunger.
suspects that the newborn is MOST likely c. The mother has nurtured
showing the effects of: overdependence in the child.
d. The mother is describing her child’s
a. Chronic toxoplasmosis separation anxiety.
b. Lead poisoning
c. Congenital anomalies
d. Fetal alcohol syndrome 20. Mylene Lopez, a 16 year old girl with
scoliosis has recently received an invitation
to a pool party. She asks the nurse how she
17. A priority nursing intervention for the can disguise her impairment when dressed
infant with cleft lip is which of the in a bathing suit. Which nursing diagnosis
can be justified by Mylene’s statement? a. An insignificant event unless taught
otherwise
a. Anxiety b. Punishment for something the individual
b. Body image disturbance did
c. Ineffective individual coping c. Something that just happens to older
d. Social isolation people
d. Temporary separation from the loved
one.
21. The foul-smelling, frothy characteristic
of the stool in cystic fibrosis results from
the presence of large amounts of which of 25. Catherine Diaz is a 14 year old patient
the following: on a hematology unit who is being treated
for sickle cell crisis. During a crisis such as
a. sodium and chloride that seen in sickle cell anemia, aldosterone
b. undigested fat release is stimulated. In what way might
c. semi-digested carbohydrates this influence Catherine’s fluid and
d. lipase, trypsin and amylase electrolyte balance?

a. sodium loss, water loss and potassium

22. Which of the following would be a retention
disadvantage of breast feeding? b. sodium loss, water los and potassium loss
c. sodium retention, water loss and
a. involution occurs rapidly potassium retention
b. the incidence of allergies increases due to d. sodium retention, water retention and
maternal antibodies potassium loss
c. the father may resent the infant’s
demands on the mother’s body
d. there is a greater chance of error during
preparation

23. A client is noted to have lymphedema,

webbed neck and low posterior hairline.
Which of the following diagnoses is most
appropriate?

a. Turner’s syndrome
b. Down’s syndrome
c. Marfan’s syndrome
d. Klinefelter’s syndrome

24. A 4 year old boy most likely perceives

death in which way: