1.

Parents bring their 8-month-old son to the emergency department because “He’s
breathing so fast that he can’t even eat, and he’s so hot.” Physical examination reveals nasal
flaring, intercostal retracting, and moderate expiratory wheezing. The nurse suspects that
the infant has:
a. acute spasmodic croup.
b. bronchiolitis.
c. epiglottitis.
d. aspirated a foreign body.

2. The nurse is preparing a child for a bronchoscopy. The child most likely has:
a. apnea.
b. bronchiolitis.
c. aspirated a foreign body.
d. pneumonia.

3. Which drug is a respiratory stimulant?

a. Isoniazid
b. Albuterol
c. Caffeine
d. Ribavirin

4. Active bleeding in a child following a tonsillectomy is indicated by:

a. refusal to drink fluids.
b. frequent swallowing.
c. “coffee grounds” emesis.
d. all of the above.

5. A child experiences bronchoconstriction 5 hours after an acute asthma attack. This is an

example of which kind of inflammatory response?
a. Immediate
b. Intermediate
c. Delayed
6. A nurse teaching a family about the use of pancreatic enzymes for the treatment of CF
should include:
a. “Administer the preparation thrice a day and before bedtime.”
b. “Dissolve the enzymes in warm whole milk.”
c. “Increase the dosage if the child has loose, fatty stools.”
d. “Chewing the enzymes will increase their efficacy.”

7. A test used in the diagnosis of CF is:

a. radioallergosorbent test (RAST).
b. sweat chloride.
c. culture for Pseudomonas.
d. Mantoux.

8. Which therapy is least likely to be used for a child with CF who is hospitalized with a
respiratory infection?
a. Chest physiotherapy every 3 hours
b. Intravenous antibiotics
c. Cough-suppressant medications
d. Postural drainage

9. An infant is hospitalized following an apparent life-threatening event. The apnea monitor

suddenly alarms. The nurse should first:
a. assess the infant.
b. question witnesses about the triggering event.
c. initiate cardiopulmonary resuscitation (CPR).
d. reset the monitor.

10. In a physical assessment of an infant with a ventricular septal defect (VSD), the nurse
notices dyspnea, hepatosplenomegaly, and periorbital edema and understands that these
are clinical manifestations of:
a. heart failure.
b. endocarditis.
c. fluid overload.
d. decreased central venous pressure.

11. Percentiles for average blood pressure are based on a child’s:

a. weight and gender.
b. age and gender.
c. gender and race.
d. age and weight.

12. Which nursing intervention is not appropriate when caring for an infant with
cardiovascular alterations?
a. Discouraging breastfeeding
b. Limiting bottle feedings to no longer than 30 minutes
c. Maintaining a neutral thermal environment
d. Providing periods of uninterrupted rest

13. Children with hypertension who are receiving loop diuretics are at risk for imbalances of:
a. calcium.
b. chloride.
c. potassium.
d. sodium.

14. A toddler is hospitalized with CHF and is receiving digoxin and furosemide. She has
vomited twice in the past 4 hours. The nurse’s best action is to:
a. increase the child’s fluid intake.
b. omit the next dose of furosemide.
c. check the child’s blood pressure before the next dose of digoxin.
d. get an order to draw a digoxin level.
15. An infant with a left-to-right shunt is admitted to the hospital in CHF. Yesterday, she
weighed 3.6 kg. A finding that indicates a worsening of her condition today is:
a. weight of 3.67 kg.
b. urine output of 40 mL in the past 8 hours.
c. rales in the lower lobes.
d. all of the above.

16. While the nurse is performing a newborn assessment, he finds that the infant’s blood
pressure in her arms is much higher than in her legs. The nurse suspects that the infant has:
a. aortic stenosis.
b. atrioventricular canal.
c. coarctation of the aorta.
d. truncus arteriosus.

17. Parents of a toddler with tetralogy of Fallot explain that they do not want him to
overexert himself, so they always keep him in his playpen or crib to limit his mobility. Based
on this information, the most appropriate nursing diagnosis is:
a. activity intolerance.
b. risk for impaired parenting.
c. caregiver role strain.
d. risk for delayed growth and development.

18. While the nurse is taking routine vital signs, she notices that the infant is having a hyper
cyanotic episode. What should the nurse do first?
a. Continue getting vital signs for a baseline comparison.
b. Place the infant in a knee–chest position.
c. Get a pulse oximetry reading.
d. Administer morphine sulfate.
19. Parents of children with congenital heart problems often experience a loss of control
when the child is hospitalized. The nurse who understands this will:
a. encourage parents to participate in their child’s care.
b. explain procedures before performing them.
c. answer questions honestly.
d. do all of the above.

20. The father of a child with a congenital heart defect asks the nurse why his daughter has
to take penicillin before she gets her teeth cleaned by the dentist. The nurse explains that
this is necessary to prevent:
a. infective endocarditis.
b. CHF.
c. rheumatic fever.
d. infected gums.

21. An indicator of infective endocarditis is:

a. positive blood cultures.
b. vegetation seen via Holter monitoring.
c. decreased erythrocyte sedimentation rate.
d. all of the above.

22. An example of an autoimmune disorder is:

a. hemolytic disease of the newborn.
b. DIC.
c. ITP.
d. VWD.

23. If a preschooler with mild hemophilia is experiencing joint pain, the nurse should:
a. administer children’s aspirin.
b. apply cold compresses.
c. do passive range-of-motion exercises.
d. give the child a warm bath in the tub.

24. Which statement about chelation therapy is true?

a. It is used to rid the body of excess sulfate.
b. It is used to treat one of the complications of factor VIII therapy.
c. It is used to manage hemosiderosis.
d. It often results in increased bleeding.

25. An example of a disorder inherited in an autosomal-inherited pattern is:

a. hemophilia A.
b. β-thalassemia.
c. VWD.
d. ABO-Rh incompatibility.

26. Which statement by an adolescent with iron deficiency anemia indicates that she needs
more teaching about her iron supplement?
a. “I’ll take my pill with orange juice.”
b. “I’ll keep the pills out of reach of my younger brother and sister.”
c. “I’ll double the dose during my periods.”
d. “It’s normal for my bowel movements to be black while I’m taking iron.”

27. A 4-year-old is admitted to the hospital with SCD. Her vital signs are a temperature of
37.2°C, heart rate of 124 beats/min (bpm), a respiratory rate of 38 breaths/min, and blood
pressure of 70/40 mm Hg. She is pale and listless and has splenomegaly. She is experiencing:
a. aplastic crisis.
b. acute chest syndrome.
c. a cerebrovascular accident (CVA).
d. acute sequestration crisis.
28. An infant receiving phototherapy for hyperbilirubinemia is at increased risk for:
a. hyperthermia.
b. hypothermia.
c. dehydration.
d. all of the above.

29. A toddler with hemophilia is at risk for:

a. altered growth related to poor appetite.
b. developmental delay related to activity restrictions.
c. infection related to decreased WBCs.
d. all of the above.

30. In taking the history of a child with ITP, the nurse is not surprised to discover that:
a. the child’s father has classic hemophilia.
b. the child had the flu 2 weeks ago.
c. the child fell off a bike last week.
d. the child suddenly had a red, raised rash appear today.

31. Infants receiving phototherapy should be fed every 2 to 3 hours to:

a. promote the excretion of bilirubin from the bowel.
b. prevent the development of hypothermia.
c. increase the life span of fetal erythrocytes in the blood.
d. increase renal and liver perfusions.

32. What is one reason that a small child is at a greater risk for airway problems than an
adult?
a. The child’s thicker, inflexible trachea can more easily obstruct the airway.
b. Children younger than 3 years are obligate nose breathers.
c. The child’s airway is narrower and more easily obstructed by small amounts of mucus.
d. The child’s smaller tongue creates more space for foreign body obstruction.
33. Baby Atkins has surfactant administered at birth. When Mrs. Atkins asks you why her
baby had to receive surfactant, what would be your best response?
a. “Surfactant helps him raise his lung secretions by relaxing his airway.”
b. “Surfactant keeps his tiny lung sacs open and this improves his breathing.”
c. “Surfactant relaxes his respiratory muscles to synchronize his breathing pattern.”
d. “Surfactant reduces the amount of lung secretions that he produces.”

34. Baby Atkins is at risk for having apnea and bradycardia. What initial nursing intervention
should you initiate during these events to maintain his vital signs in a safe range?
a. Administer 2 drops (gtts) of oral theophylline by a small syringe into his mouth.
b. Gently flick the sole of his foot to stimulate the baby to breathe again.
c. Monitor rectal temperatures to prevent him from becoming cold or hot.
d. Vigorously suction him every 2 hours to keep airway clear of secretions.

34. You are concerned that Baby Atkins will develop hyperbilirubinemia because of his
immaturity. Because the prevention of jaundice is one of your NICU’s quality indicators,
what priority nursing intervention would you initiate to best prevent hyperbilirubinemia in
Baby Atkins?
a. Administer phenobarbital to all infants to help prevent jaundice.
b. Urge all mothers to breastfeed early to promote infants’ bowel motility.
c. Place all preterm and SGA infants in warm, dark, comforting environments.
d. Immediately place all infants under phototherapy following birth.

36. Mrs. Atkins asks you why the baby in the incubator next to her baby whose mother has
diabetes mellitus was fed so soon after birth. Why is it important for infants of diabetic
women to be fed early?
a. Their stomach is larger than usual due to overgrowth.
b. This helps prevent rebound hypoglycemia from occurring.
c. The mother probably didn’t eat much during her labor.
d. This helps clear thick mucus from the lower intestinal tract.
37. You are collaborating with your interprofessional team in the care of Becky, age 7 years.
The social worker believes that she is showing the first signs of separation anxiety. What
evidence would prompt the social worker to draw this conclusion?
a. Loud, demanding crying
b. Silent, sullen protesting
c. Quiet introspective thought
d. Inability to respond verbally

38. When near-drowning occurs, injury to organ systems is the result of:
a. hypoxia.
b. respiratory acidosis.
c. hypokalemia.
d. hypoglycemia.

39. What is one reason that a small child is at a greater risk for airway problems than an
adult?
a. The child’s thicker, inflexible trachea can more easily obstruct the airway.
b. Children younger than 3 years are obligate nose breathers.
c. The child’s airway is narrower and more easily obstructed by small amounts of mucus.
d. The child’s smaller tongue creates more space for foreign body obstruction.

40. Becky’s mother is worried Becky will have a traumatic hospital experience. Which of the
following would you advise her to do to help make Becky’s hospitalization less traumatic?
a. Suggest she keep her visits short so Becky can spend time with her nurse.
b. After visiting, don’t tell Becky she is leaving. Just try to slip quietly away.
c. Insist Becky have blood drawn by her bed because she fears the treatment room.
d. Take Becky to the playroom, a place where she can feel free from being hurt.

41. You are worried Becky’s 2-year-old roommate might aspirate a toy the family friend
brought in for her. Which of the following items is most likely to be aspirated, and therefore
poses the greatest risk to safety?
a. Puzzle pieces
b. Clothing for a baby doll
c. Crayons
d. Blocks that are 1-in. square

42. Becky’s mother and father ask you what type of therapeutic play would be best for
Becky. Which type of therapeutic play would best meet Becky’s needs if she will have a large
bandage on her foot after surgery?
a. Letting her hold and handle a syringe (with no needle attached)
b. Giving her a doll and a bandage to change
c. Supplying a video tape of a child having surgery for her to watch
d. Giving her a book to read about a child’s hospitalization experience

43. Which medication is used to treat severe acidosis associated with cardiac arrest?
a. Epinephrine
b. Calcium chloride
c. Sodium bicarbonate
d. Atropine sulfate

44. Michael’s history reveals he was born with choanal atresia. You know that screening
protocols on the birthing unit of your hospital specify assessments for this condition. What
assessment at birth may be performed to determine if newborns have this condition?
a. Observe if the infant can breathe well while lying in a prone position.
b. Close his mouth and observe if he can breathe through his nose.
c. Assess if the infant’s palatine tonsils are blocking the back of the throat.
d. Listen for the sound of either stridor or wheezing on inhalation

45. Michael has had two streptococcal pharyngitis infections in the past. You would want
your team members to know to
remind parents of children with streptococcal pharyngitis to give the full course of
prescribed antibiotic because, without this, a few children develop a complication such as:
a. Lymphedema or epiglottitis
b. Dental abscesses
c. Heart or kidney disease
d. Lung abscesses or emphysema

46. Michael’s 4-year-old roommate in the care unit is scheduled for a tonsillectomy later
today. In order to ensure that your nursing care is empathic and patient centered, what
food would be best to offer the roommate following his surgery?
a. Grilled cheese sandwich
b. Tomato juice and crackers
c. Potato chips and dip
d. A cold green ice pop

47. Michael has a barking cough, sore throat, and fever. You want to see if his throat looks
sore and swollen. What is the safest and most accurate way of performing this assessment?
a. Gag him with a tongue blade so you can inspect his tonsils.
b. Ask him to press down on his tongue with one of his fingers.
c. Elicit a gag reflex using only one of your gloved fingers.
d. Ask him to open his mouth and inspect his throat visually.

48. You want to teach Michael’s 3-year-old roommate about peak flow testing. During this
diagnostic test, what instruction should you provide?
a. “Hold your breath until I say, and then cough forcefully.”
b. “When I put the meter in your mouth, take a big, deep breath.”
c. “I need you to blow out through the meter as hard and fast as you can.”
d. “Breathe like you usually do when I put the meter against your mouth.”

49. Lana, who has thalassemia major, is scheduled for a bone marrow transplant, and her
mother is highly anxious about this upcoming procedure. Which of the following statements
is most accurate and best exemplifies patient-centered care?
a. “If you can hold her still during the procedure, the pain will pass more quickly for her.”
b. “We will go to great lengths to make sure Lana doesn’t develop an infection.”
c. “Lana will need to lie still while the new bone marrow infuses into her bones.”
d. “She will not need any further bone marrow aspirations after this.”

50. Lana has received iron chelation therapy by deferoxamine in the past. Which statement
by her mother would best assure you she understands the use and action of iron chelation
therapy?
a. “I know the drug acts to remove excess iron from my child.”
b. “I have to check Lana’s pulse before I turn on the pump.”
c. “The drug is used to increase the level of iron in bone cells.”
d. “The drug has minimal side effects, so I can’t really give it wrong.”

51. Which finding in a 1-year-old child with hypovolemic shock should be reported
immediately?
a. Flat anterior fontanel
b. Palpable peripheral pulses
c. Moist mucous membranes
d. Less responsive to painful stimuli

52. A neonate is admitted to the nursery. The nurse makes the following assessments:
weight 3845 grams, head circumference 35 cm, chest circumference 33 cm, positive
Ortolani sign, and presence of supernumerary nipples. Which of the assessments should be
reported to the health care practitioner?
a. Birth weight.
b. Head and chest circumferences.
c. Ortolani sign.
d. Supernumerary nipples.

53. The nurse is about to elicit the Moro reflex. Which of the following responses should the
nurse expect to see?
a. When the cheek of the baby is touched, the newborn turns toward the side that is
touched.
b. When the lateral aspect of the sole of the baby’s foot is stroked, the toes extend and fan
outward.
c. When the baby is suddenly lowered or startled, the neonate’s arms straighten outward
and the knees flex.
d. When the newborn is supine and the head is turned to one side, the arm on that same
side extends.

54. To check for the presence of Epstein’s pearls, the nurse should assess which part of the
neonate’s body?
a. Feet.
b. Hands.
c. Back.
d. Mouth.

55. The nurse is assessing a neonate in the newborn nursery. Which of the following findings
in a newborn should be reported to the neonatologist?
a. The eyes cross and uncross when they are open.
b. The ears are positioned in alignment with the inner and outer canthus of the eyes.
c. Axillae and femoral folds of the baby are covered with a white cheesy substance.
d. The nostrils flare whenever the baby inhales.

56. A 40-week-gestation neonate is in the first period of reactivity. Which of the following
actions should the nurse take at this time?
a. Encourage the parents to bond with their baby.
b. Notify the neonatologist of the finding.
c. Perform the gestational age assessment.
d. Place the baby under the overhead warmer.

57. The nurse notes that a newborn, who is 5 minutes old, exhibits the following
characteristics: heart rate 108 bpm, respiratory rate 29 rpm with lusty cry, pink body with
bluish hands and feet, some flexion. What does the nurse determine the baby’s Apgar score
is?
a. 6
b. 7
c. 8
d. 9

58. A neonate, who is being admitted into the well-baby nursery, is exhibiting each of the
following assessment findings. Which of the findings must the nurse report to the primary
health care provider?
a. Harlequin sign.
b. Extension of the toes when the lateral aspect of the sole is stroked.
c. Elbow moves past the midline when the scarf sign is assessed.
d. Telangiectatic nevi.

59. The mother notes that her baby has a “bulge” on the back of one side of the head. She
calls the nurse into the room to ask what the bulge is. The nurse notes that the bulge covers
the right parietal bone but does not cross the suture lines. The nurse explains to the mother
that the bulge results from which of the following?
a. Molding of the baby’s skull so that the baby could fit through her pelvis.
b. Swelling of the tissues of the baby’s head from the pressure of her pushing.
c. The position that the baby took in her pelvis during the last trimester of her pregnancy.
d. Small blood vessels that broke under the baby’s scalp during birth.

60. A nurse is providing discharge teaching to the parents of a newborn. Which of the
following should be included when teaching the parents how to care for the baby’s umbilical
cord?
a. Cleanse it with hydrogen peroxide if it starts to smell.
b. Remove it with sterile tweezers at one week of age.
c. Call the doctor if greenish drainage appears.
d. Cover it with sterile dressings until it falls off.
61. A mother asks the nurse which powder she should purchase to use on the baby’s skin.
What should the nurse’s response be?
a. “Any powder made especially for babies should be fine.”
b. “It is recommended that powder not be put on babies.”
c. “There is no real difference except that many babies are allergic to cornstarch so it should
not be used.”
d. “As long as you only put it on the buttocks area, you can use any brand of baby powder
that you like.”

62. The nurse is teaching the parents of a 1-day-old baby how to give a sponge bath. Which
of the following actions should be included?
a. Clean the eyes from outer canthus to inner canthus.
b. Cleanse the ear canals with a cotton swab.
c. Assemble all supplies before beginning the bath.
d. Check temperature of the bath water with fingertips.

63. The nurse is teaching the parents of a female baby how to change the baby’s diapers.
Which of the following should be included in the teaching?
a. Always wipe the perineum from front to back.
b. Remove any vernix caseosa from the labial folds.
c. Put powder on the buttocks every time the baby stools.
d. Weigh every diaper in order to assess for hydration.

64. The nurse has provided anticipatory guidance to a couple that has just delivered a baby.
Which of the following is an appropriate short-term goal for the care of their new baby?
a. The baby will have a bath with soap every morning.
b. During a supervised play period, the baby will be placed on the tummy every day.
c. The baby will be given a pacifier after each feeding.
d. For the first month of life, the baby will sleep on its side in a crib next to the parents.

65. A nurse is advising a mother of a neonate being discharged from the hospital regarding
car seat safety. Which of the following should be included in the teaching plan?
a. Put the car seat facing forward only after the baby reaches twenty pounds.
b. The baby’s car seat should be placed facing the rear in the front seat of the car.
c. A fist should fit between the straps of the seat and the baby’s body.
d. Seat belt adjusters should always be used to support infant car seats.

66. A nurse is providing anticipatory guidance to a couple regarding the baby’s

immunization schedule. Which of the following statements by the parents shows that
further teaching by the nurse is needed?
a. The first hepatitis B injection is given by 1 month of age.
b. The first polio injection will be given at 2 months of age.
c. The MMR (measles, mumps, and rubella) immunization should be administered before
the first birthday.
d. Three DTaP (diphtheria, tetanus, and acellular pertussis) shots will be given during the
first year of life.

67. A nurse is advising a couple of a newborn regarding when they should call their
pediatrician. Which of the following responses show that the teaching was effective? Select
all that apply.
a. If the baby repeatedly refuses to feed.
b. If the baby’s breathing is irregular.
c. If the baby has no tears when he cries.
d. If the baby is repeatedly difficult to awaken.
5. If the baby’s temperature is above 100.4ºF.
68. A nurse is providing anticipatory guidance to a couple before they take home their
newborn. Which of the following should be included?
a. If their baby is sleeping soundly, they should not awaken the baby for a feeding.
b. If they take their baby outside, they should put sunscreen on the baby.
c. They should purchase liquid acetaminophen to be used when ordered by the
pediatrician.
d. They should notify their pediatrician when the umbilical cord falls off.
69. A mucousy baby is being left with the parents for the first time after delivery. Which of
the following should the nurse teach the parents regarding use of the bulb syringe?
a. Suction the nostrils before suctioning the mouth.
b. Make sure to suction the back of the throat.
c. Insert the syringe before compressing the bulb.
d. Dispose of the drainage in a tissue or a cloth.

70. A nurse must give vitamin K 0.5 mg IM to a newly born baby. Which of the following
needles could the nurse safely choose for the injection?
a. 5⁄8 inch, 18 gauge.
b. 5⁄8 inch, 25 gauge.
c. 1 inch, 18 gauge.
d. 1 inch, 25 gauge.

71. A nurse is practicing the procedures for conducting cardiopulmonary resuscitation (CPR)
in the neonate. Which site should the nurse use to assess the pulse of a baby?
a. Carotid.
b. Radial.
c. Brachial.
d. Pedal.
72. A baby has just been admitted into the neonatal nursery. Before taking the newborn’s
vital signs, the nurse should warm his or her hands and the stethoscope in order to prevent
heat loss resulting from which of the following?
a. Evaporation.
b. Conduction.
c. Radiation.
d. Convection.

73. The nurse is developing a teaching plan for parents who are taking home their 2-day-old
breastfed baby. Which of the following should the nurse include in the plan?
a. Wash hands well before picking up the baby.
b. Refrain from having visitors for the first month.
c. Wear a mask to prevent transmission of a cold.
d. Sterilize the breast pump supplies for the first month.

74. It is time for a baby, who is in the drowsy behavioral state, to breastfeed. Which of the
following techniques could the mother use to arouse the baby? Select all that apply.
a. Swaddle or tightly bundle the baby.
b. Hand express milk onto the baby’s lips.
c. Talk with the baby while making eye contact.
d. Remove the baby’s shirt and change the diaper.
e. Play pat-a-cake with the baby.

75. A bottle-feeding mother is providing a return demonstration of how to burp the baby.
Which of the following would indicate that further teaching is needed?
a. The woman gently strokes and pats her baby’s back.
b. The woman positions the baby face down on her lap.
c. The woman waits to burp the baby until the baby’s feeding is complete.
d. The woman states that a small amount of regurgitated formula is acceptable.
76. A breastfeeding baby is born with a tight frenulum. Which of the following is an
important assessment for the nurse to make?
a. Integrity of the baby’s uvula.
b. Presence of maternal nipple damage.
c. Presence of neonatal tongue injury.
d. The baby’s breathing pattern.

77. A mother is told that she should bottle-feed her child for medical reasons. Which of the
following maternal disease states are consistent with the recommendation? Select all that
apply.
a. Untreated, active tuberculosis.
b. Hepatitis B surface antigen positive.
c. Human immunodeficiency virus positive.
d. Chorioamnionitis.
e. Mastitis.

78. The nurse is caring for a client, 37 weeks’ gestation, who was just told that she is group B
strep (positive). The client states, “How could that happen? I only have sex with my
husband. Will my baby be OK?” Based on this information, which of the following should the
nurse communicate to the client?
a. The client’s partner must have acquired the bacteria during a sexual encounter.
b. The bacteria do not injure babies, but they could cause the client to have a bad sore
throat. c. The client is high risk for developing pelvic inflammatory disease from the
bacteria.
d. Antibiotics will be administered during labor to prevent vertical transmission of the
bacteria.

79. The nurse is caring for a client in labor and delivery with the following history: G2P1000,
39 weeks’ gestation in transition phase, FH 135 with early decelerations. The client states,
“I’m so scared. Please make sure the baby is ok!” Which of the following responses by the
nurse is appropriate?
a. “There is absolutely nothing to worry about.”
b. “The fetal heart rate is within normal limits.”
c. “How did your first baby die?”
d. “Was your first baby preterm?”

80. A certified nursing assistant (CNA) is working with a registered nurse (RN) in the
neonatal nursery. It would be appropriate for the nurse to delegate which of the following
actions to the assistant?
a. Admission assessment on a newly delivered baby.
b. Patient teaching of a neonatal sponge bath.
c. Placement of a bag on a baby for urine collection.
d. Hourly neonatal blood glucose assessments.

81. A fetus is in the LOA position in utero. Which of the following findings would the nurse
observe when doing Leopold’s maneuvers?
a. Hard round object in the fundal region.
b. Flat object above the symphysis pubis.
c. Soft round object on the left side of the uterus.
d. Small objects on the right side of the uterus.

82. A woman is being interviewed by a triage nurse at a medical doctor’s office. Which of
the following signs/symptoms by the client would warrant the nurse to suggest that a
pregnancy test be done? Select all that apply.
a. Amenorrhea.
b. Fever.
c. Fatigue.
d. Nausea.
e. Dysuria.

83. A woman is seeking counseling regarding tubal ligation. Which of the following should
the nurse include in her discussion?
a. The woman will no longer menstruate.
b. The surgery should be done when the woman is ovulating.
c. The surgery is easily reversible.
d. The woman will be under anesthesia during the procedure.

84. A woman is admitted to the labor and delivery unit with active tuberculosis. She has not
been under a physician’s care and is not on medication. Which of the following actions
should the nursery nurse perform when the neonate is delivered?
a. Isolate the baby from the other babies in a special care nursery.
b. Keep the baby in the regular care nursery but separated from the mother.
c. Isolate the baby with the mother in the mother’s room.
d. Obtain an order from the doctor for antituberculosis medications for the baby.

85. A client has just received synthetic prostaglandins for the induction of labor. The nurse
plans to monitor the client for which of the following side effects?
a. Nausea and uterine tetany.
b. Hypertension and vaginal bleeding.
c. Urinary retention and severe headache.
d. Bradycardia and hypothermia.

86. The triage nurse in an obstetric clinic received the following four messages during the
lunch hour. Which of the women should the nurse telephone first?
a. “My section incision from last week is leaking a whitish yellow discharge and I have a
fever. What should I do?”
b. “I am 39 weeks pregnant with my first baby. I am having contractions about every ten
minutes.”
c. “My boyfriend and I had intercourse this morning and our condom broke. What should
we do?”
d. “I started my period yesterday. I need some medicine for these terrible menstrual
cramps.”

87. A patient is placed on bed rest at home for mild preeclampsia at 38 weeks’ gestation.
Which of the following must the nurse teach the patient regarding her condition?
a. Eat a sodium-restricted diet.
b. Check her temperature 4 times daily.
c. Report swollen hands and face.
d. Limit fluids to 1 liter per day.

88. The health care practitioner caring for a pregnant client diagnosed with gonorrhea
writes the following order: ceftriaxone 250 mg IM one dose. The medication is available in
1-gram vials. The nurse adds 8 mL of normal saline to the vial. How many mL of the
medication should the nurse administer? __________ mL.

89. A 42-week-gestation neonate is being assessed. Which of the following findings would
the nurse expect to see?
a. Folded and flat pinnae.
b. Smooth plantar surfaces.
c. Loose and peeling skin.
d. Short pliable fingernails.

90. A 39-week-gestation client is admitted to the labor and delivery unit for a scheduled
cesarean delivery. The nurse should inform the surgeon regarding which of the following
admission laboratory findings?
a. Potassium 4.9 mEq/L.
b. Sodium 136 mEq/L.
c. Platelet count 75,000 cells/mm3.
d. White blood cell count 15,000 cells/mm3.

91. A mother questions the nurse about when the newborn screening tests for inborn
diseases will be performed. Which of the following is an appropriate response by the nurse?
a. The doctor took blood from the baby’s umbilical cord at birth.
b. A sample of the baby’s first urine and first stool were sent for testing.
c. A vial of blood was drawn and sent when the baby was admitted to the nursery.
d. Blood from the baby’s heel was sent after the baby had been fed a few times.

92. The nurse would be concerned that a 26-week-gravid client is carrying an unwanted
pregnancy when the client makes which of the following statements?
a. “The baby hasn’t started to move yet.”
b. “My back aches every night when I get home from work.”
c. “I am finding it very hard always to eat the right things.”
d. “I am no longer able to wear my old clothes.”

93. A young man is planning to use the condom as a contraceptive device. The nurse should
teach him that which of the following actions is needed to maximize the condom’s
effectiveness?
a. Use only water-soluble lubricants.
b. Use only natural lambskin condoms.
c. Apply the condom to a flaccid penis.
d. Apply it tightly to the tip of the penis.

94. In 2000, the perinatal mortality rate in one county was 16. The nurse interprets that
information as which of the following?
a. 16 babies died between 28 and 40 weeks’ gestation per 1,000 full-term pregnancies.
b. 16 babies died between 28 weeks’ gestation and 28 days of age per 1,000 live births.
c. 16 babies died between birth and 1 month of life per 1,000 full-term pregnancies.
d. 16 babies died between 1 month of life and 1 year of life per 1,000 live births.
95. A client has been admitted with a diagnosis of threatened abortion. She is wearing a pad
which weighed 15 grams when it was clean. It now weighs 30 grams. How many mL of blood
can the nurse estimate that the client has lost? __________ mL.
96. A school nurse is discussing the male reproductive system with the students in a high
school health class. Which of the following information about the hormone testosterone
should be included in the discussion?
a. “Testosterone is what makes boys more muscular than girls.”
b. “The level of testosterone in boys changes every month like female hormones do.”
c. “Testosterone is produced by the male prostate gland.”
d. “The production of testosterone usually stops by the time a man is fifty years old.”

97. A woman is in the “taking-hold phase” of the postpartum period. Which of the following
behaviors would the nurse expect to see?
a. The woman is on the telephone relating her experiences to family and friends.
b. The woman asks for a meal tray and eats a variety of foods brought from home.
c. The woman is interested in learning baby care skills from the nurse.
d. The woman takes a nap after each breastfeeding and each meal.

98. A client’s amniocentesis results are reported as 45, X. How should the nurse interpret
these findings?
a. The fetus is nonviable.
b. The fetus is a normal female.
c. The baby will be a hermaphrodite.
d. The girl will be short and sterile.
99. The nurse is teaching a new mother about the physical characteristics of her baby.
Which of the following statements should the nurse include in her discussion?
a. “The anterior fontanel will close by the time the baby is 18 months of age.”
b. “The grasp reflex will last until the baby is about 10 months old.”
c. “Your baby can see shapes but will not be able to see colors clearly for about 6 months.”
d. “Your baby will likely be started on solid foods when he is between 2 and 3 months of
age.”

100. A laboring woman, G4P3003, who was 6 cm dilated 1 hour ago cries, “Hurry. I have to
go to the bathroom to have a bowel movement.” The nurse notes that there is an increase
in bloody show. Which of the following actions by the nurse is appropriate?
a. Assess cervical dilation.
b. Help the woman to the bathroom.
c. Ask the woman if she needs pain medicine.
d. Check the fetal heart rate.