PN Comprehensive Review CD Questions 1-100 {COMP: No equations/formulas} 1.

A mother of a toddler tells the nurse that she has a difficult time getting the child to go to bed at night. The nurse suggests which of the following to the mother? 1. Inform the child of bedtime a few minutes before it is time for bed 2. Allow the child to have temper tantrums 3. Allow the child to set bedtime limits 4. Avoid a nap during the day Answer: 1 Rationale: Most toddlers take an afternoon nap, and until approximately age 2 some also require a morning nap. Toddlers often resist going to bed. Firm consistent limits are needed for temper tantrums or when toddlers try stalling tactics. Bedtime protests may be reduced by warning the child of bedtime a few minutes before the time. Test-Taking Strategy: Use the process of elimination. Options 3 and 4 can be eliminated using the concepts of growth and development. From the remaining options, select option 1 over option 2 because preparing the toddler for an event will minimize resistive behavior. Review the concepts of growth and development as they relate to a toddler if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Child Health References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 411-412. Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 172-173. 2. A nurse provides information to the mother of a toddler regarding toilet-training. The nurse avoids telling the mother which incorrect item? 1. Waiting until the child is 24 to 30 months old makes the task considerably easier 2. Bladder control is usually achieved before bowel control 3. The child should not be forced to sit on the potty for long periods 4. The ability of the child to remove clothing is a sign of physical readiness Answer: 2 Rationale: Waiting until the child is 24 to 30 months old makes the task considerably easier, because toddlers of this age are less negative and usually more willing to control their sphincters to please their parents. Bowel control is usually controlled before bladder control. The child should not be forced to sit for long periods. The ability to remove clothing is one of the physical signs of readiness. Test-Taking Strategy: Use the process of elimination. Note the key words avoids and incorrect in the question. These words indicate a false response question and that you need to select the incorrect item. Option 3 can be eliminated first. From the remaining options, recalling the physiological development of a toddler will assist in eliminating

PN~Comp~Review~CD~1-100~ 2 options 1 and 4 and direct you to the correct option. Review the task of toilet training if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 177. 3. A mother of a 3-year-old child is concerned because the child is still insisting on a bottle at nap time and at bedtime. The nurse suggests which of the following to the mother? 1. Do not allow the child to have the bottle 2. Allow the bottle during naps but not at bedtime 3. Allow the bottle if it contains juice 4. Allow the bottle if it contains water Answer: 4 Rationale: A toddler should not be allowed to fall asleep with a bottle because of the risk of dental caries. If the bottle is allowed in bed, it should contain only water. Test-Taking Strategy: Use the process of elimination. Eliminate options 1 and 2 because they are similar. From the remaining options, recalling that bottle dental caries is a risk in children will assist in directing you to option 4. Review instructions regarding preventing dental caries if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 380. Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 175. 4. A nurse checks the vital signs of an infant with a respiratory infection and notes that the respiratory rate is 50 breaths per minute. Which action is appropriate? 1. Notify the registered nurse 2. Administer oxygen 3. Recheck the respiratory rate in 15 minutes 4. Document the findings Answer: 4 Rationale: The normal respiratory rate in an infant is 30 to 60 breaths per minute. The normal apical heart rate is 120 to 160 beats per minute, and the average blood pressure is 46 to 92/38 to 71 mm Hg. The nurse would document the findings. Test-Taking Strategy: Knowledge regarding the normal vital signs of an infant is needed to answer this question. If you had difficulty with this question, review these normal parameters. Level of Cognitive Ability: Application

PN~Comp~Review~CD~1-100~ 3 Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 48. 5. A nurse prepares to take a blood pressure (BP) measurement on a school-age child. To obtain an accurate measurement, the nurse places the blood pressure cuff so that it covers: 1. One half of the distance between the antecubital fossa and the shoulder 2. One third of the distance between the antecubital fossa and the shoulder 3. Two thirds of the distance between the antecubital fossa and the shoulder 4. One fourth of the distance between the antecubital fossa and the shoulder Answer: 3 Rationale: The size of the BP cuff is important. Cuffs that are too small will cause falsely elevated values, and those that are too large will cause inaccurate low values. The cuff should cover two thirds of the distance between the antecubital fossa and the shoulder. Test-Taking Strategy: Use the process of elimination. Visualize the placement measurements described in each of the options. This will assist in directing you to option 3. If you had difficulty with this question, review BP measurement in children. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 30. 6. A nurse is evaluating the developmental level of a 2-year-old child. Which of the following does the nurse expect to observe in this child? 1. Uses a fork to eat 2. Holds a cup in one hand 3. Uses a knife for cutting food 4. Pours own milk into a cup Answer: 2 Rationale: By age 2 years, the child can hold a cup in one hand and uses a spoon well. By age 3 to 4 years, the child begins to use the fork. By the end of the preschool period, the child should begin to use a knife for cutting. Pouring liquids into a cup is a skill that requires fine-motor development. Test-Taking Strategy: Use the process of elimination and note the age of the child. Option 3 can be easily eliminated because of the word “knife.” Think about the finemotor skills that need to be developed in selecting the correct option from those remaining. With this in mind, eliminate options 1 and 4. If you had difficulty with this question, review the developmental skills of a 2-year-old child. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation

PN~Comp~Review~CD~1-100~ 4 Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 406-407. 7. A 4-year-old child diagnosed with leukemia is hospitalized for chemotherapy. The child is fearful of the hospitalization. Which nursing intervention does the nurse suggest to alleviate the child’s fears? 1. Advise the family to visit only during the scheduled visiting hours 2. Encourage play with other children of the same age 3. Provide a private room, allowing the child to bring their favorite toys from home 4. Encourage the child’s parents to stay with the child Answer: 4 Rationale: Although the preschooler may already be spending some time away from parents at a day care center or preschool, illness adds a stressor that makes separation more difficult. The child may repeatedly ask when parents will be coming for a visit or may constantly want to call the parents. Options 1 and 3 will increase stress related to separation anxiety. Option 2 is unrelated to the issue of the question and, additionally, may not be appropriate for a child at risk for immunocompromise. Test-Taking Strategy: Use the process of elimination. Note that the issue relates to the child’s fear. Options 1 and 3 will further increase anxiety and fear, and should be eliminated. Bearing the issue of the question in mind, and considering the child’s diagnosis, you should easily be directed to option 4 from the remaining options. Review the effects of hospitalization on a 4-year-old child if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 488. 8. A nurse prepares to administer digoxin (Lanoxin) to a 3-year-old child with a diagnosis of congestive heart failure and notes that the apical heart rate is 120 beats per minute. Which nursing action is appropriate? 1. Administer the digoxin 2. Recheck the apical heart rate in 15 minutes 3. Notify the registered nurse 4. Hold the medication Answer: 1 Rationale: The normal apical rate for a 3 year old is 80 to 125 beats per minute. Because the apical rate is within normal range, options 2, 3, and 4 are inappropriate. Test-Taking Strategy: Knowledge of the normal vital signs is needed to answer this question. Additionally, knowledge of the parameters related to the administration of digoxin will assist in directing you to option 1. If you had difficulty with this question, review these normal vital signs. Level of Cognitive Ability: Application Client Needs: Physiological Integrity

PN~Comp~Review~CD~1-100~ 5 Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 29. 9. A nurse provides instructions to a parent of a toddler experiencing physiological anorexia. The nurse determines the need for further instructions if the parent makes which statement? 1. “I should not force feed my child.” 2. “I should limit juice to 6 ounces per day.” 3. “I should feed my child if he or she will not eat.” 4. “I should limit snacks to 2 nutritious ones per day and give them only at my toddler’s request.” Answer: 3 Rationale: A toddler has the skills required to feed self. Children who can feed themselves should not be fed or forced fed. To increase nutritious intake, juice intake is limited to 6 ounces per day, and milk intake to 16 to 24 ounces per day. Additionally, the nurse instructs the mother to limit nutritious snacks to two per day and to give them only at the toddler’s request. Test-Taking Strategy: Note the key words need for further instructions in the stem of the question. These words indicate a false response question and that you need to select the incorrect client statement. Bearing in mind that the goal is to provide a nutritious intake will assist in directing you to option 3. Review physiological anorexia if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 175. 10. A nurse is caring for a 6-month-old infant. Which of the following would the nurse expect to note in this infant? 1. Uses simple words such as “mama” 2. Single-consonant babbling 3. Waves bye-bye 4. Uses gestures to communicate Answer: 2 Rationale: Using single-consonant babbling occurs between 6 and 8 months. Between 8 and 9 months, the infant begins to understand and obey simple commands such as “wave bye-bye.” Use of simple words such as “mama” and the use of gestures to communicate begin between 9 and 12 months. Test-Taking Strategy: Knowledge of language and communication developmental milestones is needed to answer the question. Noting the age of the infant identified in the question should assist in directing you to option 2. Review these developmental milestones if you had difficulty with this question.

PN~Comp~Review~CD~1-100~ 6 Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 119. 11. A nurse understands that an infant with a diagnosis of hydrocephalus has a head that is heavier than the average infant and that special safety precautions are needed when moving the infant. Which statement would the nurse include when providing instructions to the parents to reflect this safety need? 1. “When picking up your infant, support the infant’s neck and head with the open palm of your hand.” 2. “Feed your infant in a side-lying position.” 3. “Place a helmet on your infant when in bed.” 4. “Hyperextend your infant’s head with a rolled blanket under the neck area.” Answer: 1 Rationale: Hydrocephalus is a condition characterized by an enlargement of the cranium because of an abnormal accumulation of cerebrospinal fluid within the cerebral ventricular system. This characteristic causes the increase in the weight of the infant’s head. The infant’s head becomes top heavy. Supporting the infant’s head and neck when picking it up will prevent hyperextension of the neck area and the infant from falling backwards. The infant should be fed with the head elevated for proper motility of food processing. A helmet could suffocate an unattended infant during rest and sleep times, and hyperextension of the infant’s head can put pressure on the neck vertebrae causing injury. Test-Taking Strategy: Focus on the issue—prevention of injury when moving the infant with an enlarged head size. Options 2, 3, and 4 are unsafe practices and, additionally, do not specifically address the issue of the question—moving the infant. If you had difficulty with this question, review care to the infant with hydrocephalus. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 106-107. 12. A nurse is evaluating the parent’s understanding of discharge care regarding the functioning of the infant’s ventricular peritoneal shunt. Which statement by a parent indicates an understanding of the shunt complications? 1. “If my baby has a high-pitched cry, I should call the doctor.” 2. “I should position my baby on the side with the shunt when sleeping.” 3. “My baby will pass urine more often now that the shunt is in place.” 4. “I should call my doctor if my baby refuses purees.” Answer: 1 Rationale: If the shunt is broken or malfunctioning, the fluid from the ventricle part of

PN~Comp~Review~CD~1-100~ 7 the brain will not be diverted to the peritoneal cavity. The cerebrospinal fluid will build up in the cranial area. The result is intracranial pressure, which then causes a highpitched cry in the infant. The baby should not have pressure placed on the shunt side. Skin breakdown and possible compression to the apparatus could result. This type of shunt affects the gastrointestinal system, not the genitourinary system. Option 4 is only a concern if the baby becomes malnourished or dehydrated, which could then raise the body temperature. Otherwise, refusal to eat purees has no direct relationship to the shunt functioning. Test-Taking Strategy: Use the process of elimination. Remember that a high-pitched cry in an infant indicates a concern or problem. If you had difficulty with this question, review the findings that indicate a complication with a shunt. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 324. 13. A nurse is caring for a newborn with a diagnosis of spina bifida (meningomyelocele). The nurse monitors for a major symptom associated with this disorder when the nurse: 1. Checks the capillary refill on the nail beds of the upper extremities 2. Tests the urine for blood 3. Palpates the abdomen for masses 4. Checks for responses to painful stimuli from the torso downward Answer: 4 Rationale: Newborns with spina bifida (meningomyelocele type) demonstrate lack of nerve innervation from below the site of the gibbus (sac containing the meninges and spinal cord). They therefore show diminished or no responses to painful stimuli in the areas below the gibbus. Options 1, 2, and 3 are incorrect because the area above the gibbus is not affected. The capillary refill would be normal. The urine will not have blood present. If the kidneys are affected, proteinuria could be present, but this is not generally noted in the newborn period. No masses are present besides the gibbus on the back area, externally protruding from the vertebral deformity. Test-Taking Strategy: Note the key words major symptom. Recalling the anatomical location of spina bifida (meningomyelocele) will direct you to option 4. If you had difficulty with this question, review these complications. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 107. 14. A nurse is caring for a newborn with spina bifida (meningomyelocele type) who is scheduled for the removal of the gibbus (sac on the back filled with cerebrospinal fluid, meninges, and some of the spinal cord). In the preoperative period, the priority nursing

PN~Comp~Review~CD~1-100~ 8 action is to monitor: 1. Blood pressure 2. Moisture of the normal saline dressing on the gibbus area 3. Specific gravity of the urine 4. Anterior fontanel for depression Answer: 2 Rationale: The newborn is at risk for infection before closure of the gibbus. A sterile normal saline dressing is placed over the gibbus to maintain moisture of the gibbus and its contents. This prevents tearing or breakdown of the skin integrity at the site. Blood pressure is difficult to determine during the newborn period and is not the best indicator of infection. Urine concentration is not well developed in the newborn stage of development. Depression of the anterior fontanel is a sign of dehydration. With spina bifida, an increase in intracranial pressure is more of a priority. A complication of spina bifida would demonstrate a bulging or taut anterior fontanel. Test-Taking Strategy: Focus on the issue—a preoperative priority nursing action. Blood pressure and specific gravity are common preoperative assessments but are not as reliable an indicator of changes in newborn status as they would be for an older child. From the remaining options, note the relation between the issue and option 2. Review preoperative care and newborn development of organs and body functioning if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 108. 15. A nursing student is conducting a clinical conference regarding the hormones that are related to pregnancy. The instructor asks the student about the function of thyroxine. Which statement by the student indicates an understanding of this hormone? 1. “It softens the muscles and joints of the pelvis.” 2. “It is the primary hormone of milk production.” 3. “It increases during pregnancy to stimulate basal metabolic rate.” 4. “It maintains the uterine lining for implantation.” Answer: 3 Rationale: Thyroxine increases during pregnancy to stimulate basal metabolic rates. Relaxin is the hormone that softens the muscles and joints of the pelvis. Prolactin is the primary hormone of milk production. Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle including the uterus. Test-Taking Strategy: Knowledge regarding the function of the various hormones related to pregnancy is needed to answer this question. Focusing on the name of the hormone “thyroxine” will assist in directing you to option 3. If you are unfamiliar with these hormones, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning

PN~Comp~Review~CD~1-100~ 9 Content Area: Fundamental Skills Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 366. 16. A nurse is caring for a hospitalized child with a history of seizures who is receiving phenytoin sodium (Dilantin). Which of the following would be included in the plan of care for this child? 1. Monitoring intake and output 2. Checking the blood pressure before administering the phenytoin 3. Providing oral hygiene, especially care of the gums 4. Administering medications 1 hour before food intake Answer: 3 Rationale: Phenytoin sodium causes gum bleeding and hypertrophy, and therefore oral hygiene is important. Soft toothbrushes and gum massage should be instituted to reduce the risk of complications and prevent further trauma. Options 1 and 2 are incorrect because the intake and output as well as blood pressure are not affected by this medication. Option 4 is incorrect because directions for administration of this medication include dispensing with food to minimize gastrointestinal upset. Test-Taking Strategy: Knowledge of the side effects and method of administering oral phenytoin sodium is required to answer this question. Remember, phenytoin causes gum bleeding and hypertrophy, and therefore oral hygiene is important. If you had difficulty with this question, review the side effects of this medication. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 858. 17. A nurse is caring for a child receiving carbamazepine (Tegretol) who has a carbamazepine level drawn. Which of the following results indicates a therapeutic level? 1. 1 mcg/mL 2. 3 mcg/mL 3. 6 mcg/mL 4. 15 mcg/mL Answer: 3 Rationale: When carbamazepine is administered, blood levels need to be drawn periodically to check for the child’s absorption of the medication. The amount of the medication prescribed is based on the blood level achieved. The therapeutic serum level for this medication is 4 to 12 mcg/mL. Test-Taking Strategy: Knowledge of the therapeutic serum level for this medication will assist in selecting the correct option. Remember, the therapeutic serum level for this medication is 4 to 12 mcg/mL. If you had difficulty with this question, review this therapeutic level.

PN~Comp~Review~CD~1-100~ 10 Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 166. 18. A nurse is developing a plan of care for a child with autism. The nurse identifies which of the following as the priority problem for this child? 1. Impaired social interaction 2. Risk for injury 3. Disturbed thought processes 4. Impaired verbal communication Answer: 2 Rationale: Risk for injury related to an inability to anticipate danger, a tendency for selfmutilation, and sensory perceptual deficits is the priority concern. Impaired social interaction, disturbed thought processes, and impaired verbal communication are also appropriate problems for the child with autism, but the priority is the risk for injury. Test-Taking Strategy: Use Maslow’s Hierarchy of Needs theory to answer this question. Physiological needs take priority. When a physiological need does not exist, safety needs are the priority. None of the options address a physiological need. Option 2 addresses the safety need. Review care to the child with autism if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Planning Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 763. 19. A nurse assisting is collecting data on a child and suspects physical abuse. The nurse understands that which of the following is a primary and legal nursing responsibility? 1. Document the child’s physical assessment findings accurately and thoroughly 2. Report the case in which the abuse is suspected 3. Refer the family to the appropriate support groups 4. Assist the family in identifying resources and support systems Answer: 2 Rationale: The primary legal nursing responsibility when child abuse is suspected is to report the case. All 50 states require health care professionals to report all cases of suspected abuse. Although documenting findings, assisting the family, and referring the family to appropriate resources and support groups are important, the primary legal responsibility is to report the case. Test-Taking Strategy: Use the process of elimination, noting the key words primary and legal. In addition to the many implications associated with child abuse, abuse is a crime. With this in mind, option 2, reporting the case of abuse, is the primary responsibility. If you had difficulty with this question, review the responsibilities of the nurse when child

PN~Comp~Review~CD~1-100~ 11 abuse is suspected. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 586-587. 20. A nurse assists in monitoring for early signs of meningitis in a child and assists with attempting to elicit Kernig’s sign. The appropriate procedure to elicit Kernig’s sign is to: 1. Bend the head towards the knees and hips and check for pain 2. Tap the facial nerve and check for spasm 3. Compress the upper arm and check for tetany 4. Extend the leg and knee and check for pain Answer: 4 Rationale: Kernig’s sign is pain that occurs with extension of the leg and knee. Brudzinski’s sign occurs when flexion of the head causes flexion of the hips and knees. Chvostek’s sign, seen in tetany, is a spasm of the facial muscles elicited by tapping the facial nerve in the region of the parotid gland. Trousseau’s sign is a sign for tetany in which carpal spasm can be elicited by compressing the upper arm and causing ischemia to the nerves distally. Test-Taking Strategy: Knowledge regarding the appropriate procedure to elicit Kernig’s sign is needed to answer the question. Remember, Kernig’s sign is pain that occurs with extension of the leg and knee. If you had difficulty with this question, review these signs, their significance, and the procedure to elicit these signs. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1524. 21. Several children have contracted measles (rubeola) in a local school, and the nurse provides information to the mothers of the school children about this communicable disease. Which statement by a mother indicates a need for further information? 1. “Respiratory symptoms such as a profuse runny nose, cough, and fever occur before the development of a rash.” 2. “Small blue-white spots with a red base may appear in the mouth.” 3. “The rash usually begins behind the ears at the hairline.” 4. “The infectious period ranges from 10 days before symptoms start to 15 days after the rash appears.” Answer: 4 Rationale: The infectious period for rubeola ranges from 1 to 2 days before the onset of symptoms to 4 days after the rash appears. Options 1, 2, and 3 are accurate descriptions of rubeola. Option 4 describes the infectious period for rubella (German measles). Test-Taking Strategy: Note the key words need for further information. These words

PN~Comp~Review~CD~1-100~ 12 indicate a false response question and that you need to select the incorrect client statement. Recalling that the infectious period ranges from 1 to 2 days before the onset of symptoms to 4 days after the rash appears will direct you to option 4. If you are unfamiliar with the clinical manifestations associated with rubeola, review this content. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Child Health Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 743. 22. A nurse is caring for a hospitalized child with a diagnosis of rubella (German measles). The nurse reviews the physician’s progress notes and reads that the child has developed Forschheimer’s sign. Based on this documentation, which of the following would the nurse expect to note in the child? 1. Petechial spots located on the palate 2. Small blue-white spots noted on the buccal mucosa 3. A fiery red edematous rash on the cheeks 4. Swelling of the parotid gland Answer: 1 Rationale: Forschheimer’s sign refers to petechial spots, which are reddish and pinpoint and are located on the soft palate. Small blue-white spots noted on the buccal mucosa are known as Koplik’s spots, seen in rubeola. A fiery red edematous rash on the cheeks, also called “slapped cheek,” is seen in erythema infectiosum. Swelling of the parotid gland is seen in mumps. Test-Taking Strategy: Knowledge regarding the clinical manifestations in rubella is needed to answer this question. If you were familiar with the clinical manifestations of other communicable diseases, you would be able to eliminate options 2, 3, and 4. Remember, Forschheimer’s sign refers to petechial spots. If you are unfamiliar with Forschheimer’s sign, review this information. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 1023. 23. A nurse assigned to care for a child with mumps is monitoring the child for the signs and symptoms associated with the most common complication of mumps. The nurse monitors for which of the following that is indicative of the most common complication? 1. A red, swollen testicle 2. Nuchal rigidity 3. Pain 4. Deafness Answer: 2 Rationale: The most common complication of mumps is aseptic meningitis with the

PN~Comp~Review~CD~1-100~ 13 virus being identified in the cerebrospinal fluid. Common signs include nuchal rigidity, lethargy, and vomiting. A red, swollen testicle may be indicative of orchitis. Although this complication appears to cause most concern among parents, it is not the most common complication. Although mumps is one of the leading causes of unilateral nerve deafness, is does not occur frequently. Muscular pain, parotid pain, or testicular pain may occur, but pain does not indicate a sign of a common complication. Test-Taking Strategy: Knowledge that aseptic meningitis is the most common complication of mumps will direct you to option 2. If you had difficulty with this question, review the complications associated with mumps. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 225. 24. A mother brings her 6-year-old child to the clinic because the child has developed a rash on the trunk and on the scalp. The mother reports that the child has had a low-grade temperature, has not felt like eating, and has been generally tired. The child is diagnosed with varicella (chickenpox). The mother inquires about the infectious period associated with chickenpox, and the nurse tells the mother that the infectious period: 1. Is unknown 2. Is 1 to 2 days before the onset of the rash to 5 days after the onset of lesions and the crusting of lesions 3. Is 10 days before the onset of symptoms to 15 days after the rash appears 4. Ranges from 2 weeks or less up to several months Answer: 2 Rationale: The infectious period for varicella is 1 to 2 days before the onset of the rash to 5 days after the onset of lesions and the crusting of lesions. In roseola, the infectious period is unknown. Option 3 describes rubella. Option 4 describes diphtheria. Test-Taking Strategy: Use the process of elimination. Option 1 can be easily eliminated first. Eliminate options 3 and 4 next because the time frames in these two options seem rather lengthy. If you had difficulty with this question, review the infectious period associated with varicella. Level of Cognitive Ability: Application Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 251. 25. A 6-month-old infant receives a diphtheria and tetanus toxoid and pertussis vaccine (DTP) immunization at the well-baby clinic. The mother returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. The appropriate suggestion to the mother would be to: 1. Apply a warm pack to the injection site

PN~Comp~Review~CD~1-100~ 14 2. Bring the infant back to the clinic 3. Apply an ice pack to the injection site 4. Monitor the infant for a fever Answer: 3 Rationale: Occasionally, tenderness, redness, or swelling may occur at the site of the injection. This can be relieved with ice packs for the first 24 hours followed by warm compresses if the inflammation persists. It is not necessary to bring the infant back to the clinic. Option 4 may be an appropriate intervention but is not specific to the issue of the question. Test-Taking Strategy: Use the process of elimination. Option 4 can be eliminated first because it does not relate specifically to the issue of the question. Eliminate option 2 next as an unnecessary intervention. From the remaining options, general principles related to the effects of heat and cold will direct you to option 3. Review the complications and associated interventions for immunizations if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Child Health Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 71. 26. A 5-year-old child is hospitalized with Rocky Mountain spotted fever (RMSF). The health record reveals documentation that the child was bitten by a tick 2 weeks ago. The child presents with complaints of headache, fever, and anorexia, and the nurse notes a rash on the palms of the hands and soles of the feet. The nurse reviews the physician’s orders and anticipates that which of the following will be prescribed? 1. Tetracycline (Achromycin) 2. Amphotericin B (Ketoconazole) 3. Ganciclovir (Foscarnet) 4. Amantadine (symmetrel) Answer: 1 Rationale: The nursing care of a child with RMSF will include the administration of tetracycline. An alternative medication is chloramphenicol (Chloromycetin), a fluoroquinolone. Amphotericin B is used for fungal infections. Ganciclovir is used to treat cytomegalovirus. Amantadine is used to treat influenza A virus, Parkinson's disease, and drug-induced extrapyramidal reactions. Test-Taking Strategy: Knowledge regarding the treatment plan associated with RMSF is required to answer this question. If you are unfamiliar with this treatment plan or with the medications identified in the options, review this content. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 256.

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27. A nurse prepares to administer a measles, mumps, and rubella (MMR) vaccine to a 5year-old child. The nurse plans to administer this vaccine: 1. Intramuscularly in the anterolateral aspect of the thigh 2. Intramuscularly in the deltoid muscle 3. Subcutaneously in the outer aspect of the upper arm 4. Subcutaneously in the gluteal muscle Answer: 3 Rationale: MMR is administered subcutaneously in the outer aspect of the upper arm. Each child should receive two vaccinations, the first between 12 and 15 months of age and the second between 4 and 6 years or 11 and 12 years. Test-Taking Strategy: Knowledge that MMR is administered subcutaneously will assist in eliminating options 1 and 2. From the remaining options, recalling that the gluteal muscle is most often used for intramuscular injections will assist in directing you to option 3. Review the procedures related to the administration of MMR if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 123. 28. A client has been seen in the clinic and has been diagnosed with endometriosis. The client asks the nurse to describe this condition. The nurse tells the client that endometriosis is: 1. The presence of tissue outside the uterus that resembles the endometrium 2. Pain that occurs during ovulation 3. Also known as primary dysmenorrhea 4. The cause of cessation of menstruation Answer: 1 Rationale: Endometriosis is defined as the presence of tissue outside the uterus that resembles the endometrium in both structure and function. The response of this tissue to the stimulation of estrogen and progesterone during the menstrual cycle is identical to that of the endometrium. Primary dysmenorrhea refers to menstrual pain without identified pathology. Mittelschmerz refers to pelvic pain the occurs midway between menstrual periods, and amenorrhea is the cessation of menstruation for a period of at least 3 cycles or 6 months in a woman who has established a pattern of menstruation, and can be due to a variety of causes. Test-Taking Strategy: Focus on the issue—endometriosis. Note the relation between this issue and the key words resembles the endometrium in option 1. If you had difficulty with this question and are unfamiliar with this disorder, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Fundamental Skills

PN~Comp~Review~CD~1-100~ 16 Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 292. 29. A nurse obtains a health history from a mother of a 15-month-old child before administering a measles, mumps, and rubella (MMR) vaccine. Which of the following information would be the priority before the administration of this vaccine? 1. Allergy to eggs 2. A recent cold 3. The presence of diarrhea 4. Any recent ear infections Answer: 1 Rationale: Before the administration of MMR vaccine, a thorough health history needs to be obtained. MMR is used with caution in a child with a history of an allergy to gelatin, or eggs, because the live measles vaccine is produced by chick embryo cell culture. MMR also contains a small amount of the antibiotic neomycin. Options 2, 3, and 4 are not contraindications to administering immunizations. Test-Taking Strategy: Use the process of elimination. Knowledge that options 2, 3, and 4 are not contraindications to administering immunizations will assist in answering this question. Additionally, the key word priority should assist in directing you to option 1. If you had difficulty with this question, review the nursing implications related to the administration of MMR. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 123. 30. A nursing student is asked to discuss human immunodeficiency virus (HIV) during a clinical conference. The nursing student includes which correct item in the discussion? 1. Most newborns of HIV positive women test positive for the HIV virus 2. HIV primarily attacks the hematological system 3. In HIV the B cells are depleted and cannot signal T4 cells to form protective antibodies 4. The HIV virus attacks the immune system by destroying T lymphocytes Answer: 4 Rationale: Children born to HIV positive women test positive for HIV antibody, not HIV virus. This is actually a measure of maternal antibody and not indicative of true infection. T4 cells are depleted in number and cannot signal B cells to form protective antibodies to fight off the invading virus. The virus attacks the immune system by destroying T lymphocytes. Test-Taking Strategy: Use the process of elimination. Eliminate option 2 first knowing that HIV attacks the immune system. Eliminate option 1 next with the knowledge that newborns test positive for HIV antibody, but not the virus. Recalling that T4 cells (not B cells) are depleted will assist in eliminating option 3. Review the physiological occurrences in HIV if you had difficulty with this question.

PN~Comp~Review~CD~1-100~ 17 Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 80. 31. A nurse is reading the physician’s documentation regarding a pregnant client and notes that the physician has documented that the client has an android pelvic shape. The nurse understands that this pelvic shape is: 1. Rounded and most favorable for a vaginal birth 2. Narrow and oval and not the most favorable for a vaginal birth 3. Wedge-shaped and narrow and nonfavorable for a vaginal birth 4. Flat and nonfavorable for a vaginal birth Answer: 3 Rationale: The android pelvic shape is wedge-shaped and narrow and is a nonfavorable shape for a vaginal birth. A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable pelvic shape for a vaginal birth. An anthropoid pelvic shape is long, narrow, and oval. It is not as favorable of a shape for a vaginal birth as the gynecoid pelvic shape; however, it is a more favorable pelvic shape than the platypelloid or android. The platypelloid pelvic shape is flattened with a wide, short oval shape and is also a nonfavorable shape for a vaginal birth. Test-Taking Strategy: Focus on the issue—an android pelvic shape. Recalling that an android pelvic shape is wedge-shaped and narrow will direct you to option 3. If you had difficulty with this question, review the characteristics of the various pelvic shapes. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 14. 32. The physician prescribes laboratory studies on an infant of a human immunodeficiency virus (HIV) positive woman to determine the presence of HIV infection. Which laboratory study would the nurse expect to be prescribed? 1. Western blot 2. Chest x-ray 3. CD4 count 4. p24 antigen assay Answer: 4 Rationale: True HIV infection in the infant is confirmed by a p24 antigen assay, a culture of HIV, or a polymerase chain reaction (PCR). A Western blot confirms the presence of HIV antibodies. The CD4 count indicates how well the immune system is working. A chest x-ray evaluates the presence of other manifestations of HIV infection. Test-Taking Strategy: Focus on the issue—the presence of HIV infection in an infant. Remember, true HIV infection in the infant is confirmed by a p24 antigen assay, a culture

PN~Comp~Review~CD~1-100~ 18 of HIV, or a polymerase chain reaction (PCR). If you are unfamiliar with these laboratory studies, review this content. Specific laboratory tests to review include the enzyme-linked immunosorbent assay (ELISA), Western blot, CD4 counts, and p24 antigen assay. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Child Health Reference: Price, D., & Gwin, J. (2005). Thompson’s pediatric nursing (9th ed.). Philadelphia: W.B. Saunders, p. 80. 33. A nurse is measuring the fundal height of a client who is 30-weeks gestation. In preparing to perform the procedure the nurse would: 1. Turn the client onto her left side 2. Instruct the client to lie in a prone position 3. Place the client in a prone position with the head of the bed elevated 4. Have the client stand for the procedure Answer: 1 Rationale: When measuring fundal height, the client lies in a supine position and the nurse instructs the woman to turn onto her left side. The nurse then elevates the left buttock by placing a pillow under the area. This position will assist in preventing supine hypotension. Options 2, 3, and 4 are incorrect client positions for measuring fundal height. Test-Taking Strategy: Focus on the issue of the question and think about the physiological effects of an enlarged uterus at 30 weeks of gestation. Eliminate options 2 and 3 first because they are similar. From the remaining options, recalling the potential for supine hypotension or by knowing that the standing position is inappropriate for measuring fundal height will assist in directing you to option 1. Review the procedure for measuring fundal height if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 416. 34. A nurse is assisting in conducting a childbirth class and is instructing pregnant women about the method of effleurage. The nurse instructs the woman to perform the procedure by: 1. Contracting and then consciously relaxing different muscle groups 2. Contracting an area of the body such as an arm or leg and then concentrating or letting tension go from the rest of the body 3. Massaging the abdomen during contractions using both hands in a circular motion 4. Instructing the significant other to stroke or massage a tightened muscle by the use of touch Answer: 3

PN~Comp~Review~CD~1-100~ 19 Rationale: Effleurage is massage of the abdomen during contractions. Women learn to do effleurage using both hands in a circular motion. Progressive relaxation involves contracting and then consciously releasing different muscle groups. Neuromuscular disassociation helps the woman relax her body even when one group of muscles is strongly contracted. In this procedure the woman contracts an area such as an arm or leg and then concentrates on letting tension go from the rest of the body. Touch relaxation helps the woman learn to loosen taut muscles when they are touched by her partner. Test-Taking Strategy: Use the process of elimination, focusing on the issue—effleurage. Remember, effleurage is massage of the abdomen during contractions. If you had difficulty with this question or are unfamiliar with this cutaneous stimulation technique, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 65. 35. A clinic nurse is planning care to meet the emotional needs of a pregnant woman. Which nursing intervention would least likely assist in meeting emotional needs? 1. Providing an opportunity for the pregnant woman to discuss the aspects of pregnancy 2. Using a caring and supportive approach when dealing with the pregnant woman 3. Offering praise and reinforcement for compliance with treatment therapies 4. Providing the mother with pamphlets and booklets to read about the pregnancy Answer: 4 Rationale: The woman’s emotional needs can be met by providing regular opportunities for discussing aspects of her pregnancy and prenatal care, by using a caring and supportive approach, and by offering praise and reinforcement. The nurse should also discuss the emotional changes of pregnancy, family alterations, and changes in marital relationships that may occur. Option 4 will least likely assist in meeting the emotional needs of the woman. Test-Taking Strategy: Note the key words least likely in the stem of the question. Note that options 1, 2, and 3 are similar in that they identify interventions that are both positive and deal directly with the client. Option 4 promotes the use of materials for the client to read on her own. Review the methods that will assist in meeting the emotional needs of a pregnant woman if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 51, 229. 36. A pregnant client asks a nurse about the types of exercises that are allowable during the pregnancy. The nurse would instruct the client that the safest exercise to engage in is which of the following?

PN~Comp~Review~CD~1-100~ 20 1. Bicycling with the legs in the air 2. Swimming 3. Scuba diving 4. Low-weight gymnastics Answer: 2 Rationale: Non–weight-bearing exercises are preferable to weight-bearing exercises. Exercises to avoid are shoulder standing and bicycling with the legs in the air because the use of the knee-chest position should be avoided. Competitive or high-risk sports such as scuba diving, water skiing, downhill skiing, horseback riding, basketball, volleyball, and gymnastics should be avoided. Non–weight-bearing exercises such as swimming are allowable. Test-Taking Strategy: Use the process of elimination. Identify those activities or exercises that could cause or produce an injury to the fetus. This should direct you to option 2. If you had difficulty with this question, review teaching points related to exercises that are safe for a client who is pregnant. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 55. 37. A nurse is teaching a pregnant client about the warning signs in pregnancy that require the need to notify the physician. The nurse determines that further teaching is needed if the client states that it is necessary to call the physician if which of the following occurs? 1. Visual disturbances 2. Rapid weight gain 3. Facial edema 4. Irregular painless contractions Answer: 4 Rationale: Visual disturbances, rapid weight gain, and generalized or facial edema are warning signs in pregnancy. Braxton Hicks contractions are the normal, irregular, painless contractions of the uterus that may occur throughout the pregnancy. Additional warning signs in pregnancy include vaginal bleeding, premature rupture of the membranes, preterm uterine contractions that are normal and regular, change in or absence of fetal activity, severe headache, epigastric pain, persistent vomiting, abdominal pain, and signs of infection. Test-Taking Strategy: Note the key words further teaching is needed and use the process of elimination. These words indicate a false response question and that you need to select the incorrect client statement. Recalling the manifestations associated with Braxton Hicks contractions will assist in directing you to option 4. If you had difficulty with this question, review the warning signs in pregnancy and the characteristics associated with Braxton Hicks contractions. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity

PN~Comp~Review~CD~1-100~ 21 Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 58, 83. 38. A pregnant woman who visits a health care clinic for the first prenatal visit hears the physician discuss the preembryonic period of development with the nurse. The woman asks the nurse what this means. The nurse tells the woman that the preembryonic period is the: 1. Period of time before conception 2. First 2 weeks of fetal development following conception 3. Fetal development period from the beginning of the third week through the eighth week after conception 4. Longest period of fetal development Answer: 2 Rationale: The preembryonic period is the first 2 weeks after conception. Around the fourth day after conception, the fertilized ovum, now called a zygote, enters the uterus. The embryonic period of development extends from the beginning of the third week through the eighth week after conception. Basic structures of all major body organs are completed during the embryonic period. The fetal period is the longest part of prenatal development. It begins 9 weeks after conception and ends with birth. All major systems are present in their basic form. Test-Taking Strategy: Use the process of elimination and knowledge regarding the process of fetal development. Focusing on the key words preembryonic period of development will assist in directing you to option 2. If you are unfamiliar with fetal development, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 234-235. 39. A nurse is teaching a pregnant woman about the physiological effects and hormonal changes that occur in pregnancy, and the woman asks the nurse about the purpose of progesterone. The nurse tells the woman that the purpose of progesterone is to: 1. Maintain the uterine lining for implantation 2. Stimulate metabolism of glucose and convert the glucose to fat 3. Prevent the involution of the corpus luteum and maintain the production of progesterone until the placenta is formed 4. Stimulate uterine development to provide an environment for the fetus, and stimulate the breasts to prepare for lactation Answer: 1 Rationale: Progesterone maintains the uterine lining for implantation and relaxes all smooth muscle. Human placental lactogen stimulates the metabolism of glucose and converts the glucose to fat and is antagonistic to insulin. Human chorionic gonadotropin

PN~Comp~Review~CD~1-100~ 22 prevents involution of the corpus luteum and maintains the production of progesterone until the placenta is formed. Estrogen stimulates uterine development to provide an environment for the fetus, and stimulates the breasts to prepare for lactation. Test-Taking Strategy: Use the process of elimination. Focusing on the issue of the question—the purpose of progesterone—and recalling the physiology related to the reproductive system will direct you to option 1. Review the function and purpose of progesterone if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 12. 40. A nurse is reviewing the record of a pregnant client and notes that the physician has documented the presence of Chadwick’s sign. The nurse understands that the hormone responsible for the development of this sign is which of the following? 1. Human chorionic gonadotropin (hCG) 2. Estrogen 3. Progesterone 4. Prolactin Answer: 2 Rationale: The cervix undergoes significant changes following conception. The most obvious changes occur in color and consistency. In response to the increasing levels of estrogen, the cervix becomes congested with blood, resulting in the characteristic bluish color that extends to include the vagina and labia. This discoloration, referred to as Chadwick’s sign, is one of the earliest signs of pregnancy. Test-Taking Strategy: Knowledge regarding Chadwick’s sign and the physiological changes and hormones responsible for this sign is needed to answer this question. If you are unfamiliar with Chadwick’s sign, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 83. 41. The nurse is assisting in performing an assessment on a pregnant client and is preparing to take the client’s blood pressure. The nurse positions the client: 1. Lying down 2. In a sitting position 3. On the right side 4. On the left side Answer: 2 Rationale: Because position affects blood pressure in the pregnant woman, the method for obtaining a blood pressure reading should be standardized as much as possible. The

PN~Comp~Review~CD~1-100~ 23 blood pressure reading should be obtained in the sitting position with the arm supported in a horizontal position at heart level. Options 1, 3, and 4 are incorrect, and these positions may cause physiological stress that will affect the blood pressure reading. Test-Taking Strategy: Use the process of elimination. Note that options 1, 3, and 4 are similar are should be eliminated. If you are unfamiliar with the procedure of performing a blood pressure reading on a pregnant client, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 254. 42. A nurse is assisting in performing an assessment on a pregnant client with a history of cardiac disease and is checking the client for venous congestion. The nurse inspects which body area knowing that venous congestion is most commonly noted in this area? 1. Vulva 2. Fingers 3. Around the eyes 4. Around the abdomen Answer: 1 Rationale: Assessment of the cardiovascular system includes observation for venous congestion that can develop into varicosities. Venous congestion is most commonly noted in the legs, vulva, or rectum. It would be difficult to assess for edema in the abdominal area of a client that is pregnant. Although edema may be noted in the fingers and around the eyes, edema in these areas would not be directly associated with venous congestion. Test-Taking Strategy: Use the process of elimination. Focus on the key word venous. From the options presented, the vulva is the area that would present the most venous pressure. Review data collection techniques of the cardiovascular system in a pregnant client if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 224. 43. A pregnant client is seen in the health care clinic for a regular prenatal visit. The client tells the nurse that she is experiencing irregular contractions, and the nurse determines that the client is experiencing Braxton Hicks contractions. Which of the following nursing actions would be appropriate? 1. Instruct the client to maintain bed rest for the remainder of the pregnancy 2. Instruct the client that these contractions are common and may occur throughout the pregnancy 3. Contact the physician

PN~Comp~Review~CD~1-100~ 24 4. Call the maternity unit and inform them that the client will be admitted in a prelabor condition Answer: 2 Rationale: Braxton Hicks contractions are irregular, painless contractions that occur throughout pregnancy, although many expectant mothers do not notice them until the third trimester. Because Braxton Hicks contractions may occur and are normal in some pregnant women during pregnancy, options 1, 3, and 4 are unnecessary and inaccurate. Test-Taking Strategy: Use the process of elimination. Options 3 and 4 are similar and can be eliminated first. From the remaining options, recalling that Braxton Hicks contractions can occur throughout pregnancy will assist in directing you to option 2. If you had difficulty with this question, review the physiology associated with Braxton Hicks contractions. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 83. 44. A nursing instructor has given a lecture on the reproductive cycle of the female and asks a nursing student to identify the anatomical structure that supports and protects the internal reproductive organs. The student correctly responds by identifying which structure? 1. Ovaries 2. Pelvis 3. Vagina 4. Fallopian tube Answer: 2 Rationale: The pelvis is a bony structure that supports and protects the lower abdominal and internal reproductive organs. The functions of the ovaries include sex hormone production and maturation of an ovum during each reproductive cycle. The vagina allows discharge of the menstrual flow, is the female organ of coitus, and permits the passage of the fetus from the uterus to outside the mother’s body during childbirth. The fallopian tubes are lined with folded epithelium containing cilia that beat rhythmically toward the uterine cavity to propel the ovum through the tube. Test-Taking Strategy: Use knowledge regarding the function of the anatomical structures of the female reproductive system. Focusing on the key words supports and protects the internal reproductive organs will direct you to option 2. If you had difficulty with this question, review the function and structure of the pelvis. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 12-13.

PN~Comp~Review~CD~1-100~ 25 45. A nurse is assisting in performing an assessment on a pregnant client during the first prenatal visit. The client is anxious to know the sex of the fetus and asks the nurse when this information will be available. The nurse responds by telling the client that the sex of the fetus can be determined by: 1. Weeks 6 to 8 2. Weeks 8 to 10 3. Weeks 12 to 16 4. Weeks 20 to 22 Answer: 3 Rationale: By the end of the twelfth week, the fetal sex can be determined by the appearance of the external genitalia on ultrasound. Test-Taking Strategy: Knowledge regarding fetal development is needed to answer this question. If you had difficulty with this question, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 30. 46. A nurse is assisting in conducting a teaching session with a group of female adolescents. The nurse tells the adolescents that the primary hormone that induces the growth of pubic and axillary hair at puberty is: 1. Testosterone 2. Oxytocin 3. Prolactin 4. Progesterone Answer: 1 Rationale: Testosterone is produced by the adrenal glands in the female and induces the growth of pubic and axillary hair at puberty. Oxytocin stimulates contractions during birth and stimulates postpartum contractions to compress uterine vessels and control bleeding. Prolactin stimulates the secretion of milk. Progesterone stimulates the secretions of the endometrial glands, causing endometrial vessels to become highly dilated and tortuous in preparation for possible embryo implantation. Test-Taking Strategy: Knowledge regarding the functions of the various hormones in the female reproductive system is needed to answer this question. Focusing on the key words induces the growth of pubic and axillary hair at puberty will assist in directing you to option 1. If you had difficulty with this question, review the functions of the various hormones of the female reproductive system. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 21-23.

PN~Comp~Review~CD~1-100~ 26 47. A nursing student is reviewing the anatomy and physiology of the female reproductive system. The student reads oxytocin is produced by the: 1. Ovaries 2. Anterior pituitary gland 3. Posterior pituitary gland 4. Pancreas Answer: 3 Rationale: Oxytocin is produced by the posterior pituitary gland and stimulates the uterus to produce contractions during birth. Follicle-stimulating hormone and luteinizing hormone are produced by the anterior pituitary gland. The ovaries are the endocrine glands that produce estrogen and progesterone. The pancreas produces insulin and other enzymes that aid in digestion. Test-Taking Strategy: Knowledge regarding the various hormones and the productions and secretion of the hormones is needed to answer this question. Focus on the issue “oxytocin” to direct you to option 3. If you had difficulty with this question or are unfamiliar with these hormones, review this content. Level of Cognitive Ability: Knowledge Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 225. 48. A nurse is reading the physician’s documentation regarding a pregnant client and notes that the physician has documented that the client has a platypelloid pelvic shape. The nurse understands that this pelvic shape is: 1. Rounded and most favorable for a vaginal birth 2. Narrow and oval and not the most favorable for a vaginal birth 3. Wedge-shaped and narrow and nonfavorable for a vaginal birth 4. Flat and nonfavorable for a vaginal birth Answer: 4 Rationale: The platypelloid pelvic shape is flattened with a wide, short oval shape and is a nonfavorable shape for a vaginal birth. A gynecoid pelvic shape is rounded with a wide pubic arch and is the most favorable pelvic shape for a vaginal birth. An anthropoid pelvic shape is long, narrow, and oval. It is not as favorable of a shape for a vaginal birth as the gynecoid pelvic shape; however, it is a more favorable pelvic shape than the platypelloid or android. The android pelvic shape is wedge-shaped and narrow and is a nonfavorable shape for a vaginal birth. Test-Taking Strategy: Use knowledge regarding the characteristics of the various pelvic shapes to answer the question. Recalling the characteristics of a platypelloid pelvic shape will direct you to option 4. If you had difficulty with this question, review the characteristics of the various pelvic shapes. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum

PN~Comp~Review~CD~1-100~ 27 Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 14. 49. A nurse is collecting data from a female client who is suspected of having mittelschmerz. Which of the following would the nurse expect to note? 1. Pain at the beginning of menstruation 2. Profuse vaginal bleeding 3. Sharp pain located on the right side of the pelvis 4. Pain that occurs during intercourse Answer: 3 Rationale: Mittelschmerz (middle pain) refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain is due to growth of the dominant follicle within the ovary, or rupture of the follicle and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain is fairly sharp and is felt on the right or left side of the pelvis. It generally lasts a few hours to two days, and slight vaginal bleeding may accompany the discomfort. Test-Taking Strategy: Knowledge that mittelschmerz is “middle pain” will assist in eliminating option 1. Knowing that this occurs because of growth of the follicle or rupture of the follicle will assist in eliminating options 2 and 4. If you are unfamiliar with this disorder, review this content. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Fundamental Skills References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 254. Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 384. 50. A nurse is teaching a pregnant client how to perform Kegel exercises. The nurse tells the client that the purpose of these exercises is to: 1. Strengthen the pelvic floor in preparation for delivery 2. Prevent urinary tract infections 3. Reduce backache 4. Prevent ankle edema Answer: 1 Rationale: Kegel exercises will assist in strengthening the pelvic floor. Pelvic tilt exercises will help reduce backaches. Instructing a client to drink 8 oz of fluids six times a day will help prevent urinary tract infections. Leg elevation will assist in preventing ankle edema. Test-Taking Strategy: Focus on the issue of the question and use the process of elimination. Recalling that Kegel exercises will help strengthen the perineal floor muscles will assist in directing you to the correct option. If you had difficulty with this question, review the purpose of Kegel exercises. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning

PN~Comp~Review~CD~1-100~ 28 Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 49, 55. 51. A nurse is instructing a pregnant client regarding dietary measures to promote a healthy pregnancy. The nurse instructs the client to consume an adequate intake of fluid on a daily basis. Which statement by the mother indicates an understanding of the daily fluid requirement? 1. “I should drink 8 to 12 glasses of liquid in addition to my daily milk requirement.” 2. “I should drink 8 to 12 glasses of liquid a day and I can count the tea, fruit juices, or milk that I drink.” 3. “I should drink 8 to 12 glasses of liquid a day and I can count the carbonated soft drinks that I consume.” 4. “I should drink 8 to 12 glasses of liquid a day and can count the coffee that I drink.” Answer: 1 Rationale: The nurse should instruct the client to drink an adequate fluid intake on a daily basis to assist in digestion and in the management of constipation. Eight to twelve glasses of liquids (1500 to 2000 mL) in addition to the daily milk requirement are recommended every day. This fluid should be water or fruit and vegetable juices rather than carbonated soft drinks or caffeinated beverages. Test-Taking Strategy: Use the process of elimination. Recalling that carbonated soft drinks and caffeine-containing products should be avoided will assist in eliminating options 2, 3, and 4. Remember that milk requirements are not included in the total fluid intake of 1500 to 2000 mL. This will direct you to option 1. If you had difficulty with this question, review client instructions regarding water and fluid intake during pregnancy. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Antepartum References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 8-10. Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 63. 52. A nurse is instructing a pregnant client how to increase dietary sources of iron. The nurse tells the client that which food is the highest source of dietary iron? 1. Milk 2. Dark-green leafy vegetables 3. Potatoes 4. Cantaloupe Answer: 2 Rationale: Dietary sources of iron include lean meats, liver, shellfish, dark-green leafy vegetables, legumes, whole grains and enriched grains, cereals, and molasses. Milk is high in calcium and also contains phosphorus. Cantaloupe and potatoes are high in vitamin C. Test-Taking Strategy: Use the process of elimination and knowledge of the dietary

PN~Comp~Review~CD~1-100~ 29 sources of iron to assist in answering the question. Remember, dark-green leafy vegetables are high in iron. If you had difficulty with this question, review the food items high in iron. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 60. 53. A nurse has instructed a postpartum client who is hepatitis B positive how to safely bottle-feed her newborn to prevent the transmission of the infection. Which action by the client indicates an understanding of this procedure? 1. Tests the temperature of the formula before initiating feeding 2. Holds the infant properly during feeding and burping 3. Washes and dries her hands before feeding 4. Requests that the window be closed before feeding Answer: 3 Rationale: Hepatitis B virus (HBV) is highly contagious by direct contact with blood and body fluids of infected persons. Strict hand washing before contact with the newborn will assist in preventing the transmission of infection. Options 1 and 2 are appropriate feeding techniques for bottle-feeding, but do not minimize disease transmission for hepatitis B. Option 4 will not affect disease transmission. Test-Taking Strategy: Focus on the issue of the question—disease transmission to the newborn. This focus and the process of elimination will direct you to option 3. Review measures to prevent disease transmission of hepatitis if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 160. 54. The pregnant client who is anemic tells the nurse that she is concerned about her baby’s condition following delivery. The nurse makes which statement that will best address the client’s concern? 1. “You will not have any problems if you follow all the advice the doctor has given you.” 2. “Your baby will need to spend a few days in the neonatal intensive care unit following delivery.” 3. “Don’t worry about your baby; complications are rare.” 4. “The effects of anemia on your baby are difficult to predict, but let’s review your plan of care to assure you are providing the best nutrition and growth potential.” Answer: 4 Rationale: The effects of maternal iron-deficiency anemia on the developing fetus and neonate are unclear. In general, it is believed that the fetus will receive adequate maternal stores of iron, even if a deficiency is present. Neonates of severely anemic mothers have

PN~Comp~Review~CD~1-100~ 30 been reported to experience reduced red cell volume, hemoglobin levels, and iron stores. Options 1 and 3 provide a false reassurance to the client. Option 2 will cause further concern in the client. Option 4 provides the most realistic support for the client and allows the nurse an opportunity to review the client’s plan of care to clarify information and reassure the mother. Test-Taking Strategy: Use the process of elimination and therapeutic communication techniques to answer the question. Eliminate options 1 and 3 because these statements provide a false reassurance to the client. Eliminate option 2 next because this statement will cause further concern in the client. If you had difficulty with this question, review therapeutic communication techniques and the effects of maternal anemia on the fetus. Level of Cognitive Ability: Application Client Needs: Psychosocial Integrity Integrated Process: Communication and Documentation Content Area: Maternity/Postpartum References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 107. Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 225. McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, pp. 30-31. 55. A nurse assists a pregnant client with cardiac disease to identify resources to help her care for her 18-month-old child during the last trimester of pregnancy. The nurse encourages the pregnant client to use these resources primarily to: 1. Help the mother prepare for labor and delivery 2. Reduce excessive maternal stress and fatigue 3. Prepare the 18-month-old child for maternal separation during hospitalization 4. Avoid exposure to potential pathogens and resulting infections Answer: 2 Rationale: A variety of factors can cause increased emotional stress during pregnancy resulting in further cardiac complications. The client with known cardiac disease is at greater risk for such complications. Use of appropriate resources will assist the client to avoid emotional stress, thus reducing additional cardiac compromise during the last trimester. Options 1, 3, and 4 are not primary purposes for use of resources with the pregnant cardiac client. Test-Taking Strategy: Focus on the issue of the question noting the client’s diagnosis. Also noting the key word primarily in the stem of the question will assist in directing you to option 2. Review considerations in caring for the pregnant client with cardiac disease if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 225. 56. A nurse is caring for a client who had a cesarean section to deliver a nonviable fetus

PN~Comp~Review~CD~1-100~ 31 due to abruptio placentae. The client develops signs of disseminated intravascular coagulopathy (DIC). The spouse asks the nurse what is happening, and the nurse explains the condition. The spouse becomes upset and says to the nurse, “I lost my baby and now my wife? What am I going to do?” Which problem most appropriately addresses the situation? 1. Grieving related to loss of the baby 2. Deficient knowledge related to the disease process 3. Anxiety related to the reason the baby died 4. Hopelessness related to the loss of baby and illness of the spouse Answer: 4 Rationale: A person who lacks hope experiences hopelessness and sees no way out of the situation except for death. There are no data in the question that support the diagnosis of grieving, deficient knowledge, or anxiety. Test-Taking Strategy: Identify the client of the question, which is the spouse. Next, focus on the statement of the spouse to assist in directing you to the correct option. Options 2 and 3 can be eliminated first because they are unrelated to the spouse’s statement. From the remaining options, although the spouse is experiencing grief, note that the spouse’s statement most appropriately supports hopelessness. Review the defining characteristics for hopelessness if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 287, 290. 57. A nurse is caring for a client with sickle cell disease who is in labor. The nurse assures that the client receives appropriate intravenous (IV) fluid intake and oxygen consumption to primarily: 1. Stimulate the labor process 2. Avoid the necessity of a cesarean delivery 3. Prevent dehydration and hypoxemia 4. Eliminate the need for analgesic administration Answer: 3 Rationale: A variety of conditions, including dehydration, hypoxemia, infection, and exertion, can stimulate the sickling process during labor. Maintaining adequate IV fluid intake and the administration of oxygen via facemask will help to assure a safe environment for maternal/fetal health during labor. These measures will not stimulate the labor process, avoid the need for a cesarean delivery, or eliminate the need for analgesic administration. Test-Taking Strategy: Note the relation between “appropriate IV fluid intake and oxygen consumption” in the question and “prevent dehydration and hypoxemia” in the correct option. This relation and knowledge regarding the care measures for sickle cell anemia will direct you to option 3. Review care to a client with sickle cell disease who is in labor if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity

PN~Comp~Review~CD~1-100~ 32 Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 226. 58. A nurse is instructing a maternity client how to keep a fetal activity diary. The nurse tells the client to: 1. Schedule the counting periods in the morning when the fetal movement is highest 2. Lie on the stomach when preparing to count the fetal movement 3. Expect the baby to move at least 35 times in 3 hours 4. Contact the physician if the baby’s movements are fewer than 10 times in 2 hours Answer: 4 Rationale: Most healthy fetuses move at least 10 times in 2 hours. Slowing or stopping of fetal movement may be an indication that the fetus needs some attention and evaluation. In general, women are advised to count fetal movements for 30 minutes 3 times a day. The client should lie on the left side during the procedure because it provides optimal circulation to the uterus-placenta-fetus unit. The time of day may affect fetal movement: fetal movement is lower in the morning and higher in the evening. Test-Taking Strategy: Use the process of elimination. Read each option carefully and use knowledge regarding fetal movement to direct you to option 4. If you had difficulty with this question, review client instructions regarding normal fetal activity. Level of Cognitive Ability: Application Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Implementation Content Area: Maternity/Antepartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 997. 59. A nurse is providing health care information to a pregnant client who is human immunodeficiency virus (HIV) positive. The nurse instructs the client that it is important to avoid alcohol and cigarettes during pregnancy and to get adequate rest primarily to: 1. Avoid further stress on the maternal immune system 2. Reduce the risk of anemia during pregnancy 3. Minimize the possibility of preterm labor 4. Minimize the risk of premature rupture of membranes Answer: 1 Rationale: The use of alcohol and cigarettes during the pregnancy of an HIV-infected client, as well as not getting appropriate rest, can compromise the maternal immune system and interfere with medical treatments that may be in place. Collectively, such factors may place both the mother and fetus at additional risk during the pregnancy. Option 1 identifies the primary nursing management issue for the HIV-infected client. Test-Taking Strategy: Use the process of elimination and focus on the diagnosis of the client. Note the key words primarily in the question and immune in the correct option. Although all of the options are important, the option that specifically relates to the client with HIV is option 1. Review care measures for the pregnant client with HIV if you had difficulty with this question.

PN~Comp~Review~CD~1-100~ 33 Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Antepartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 666. 60. A pregnant client with mitral valve prolapse is receiving anticoagulant therapy during pregnancy. The nurse collects data on the client and expects that the client will indicate that which of the following medications is prescribed? 1. Oral intake of 15 mg of warfarin (Coumadin) daily 2. Intravenous infusion of heparin sodium 5000 U daily 3. Subcutaneous administration of heparin sodium 5000 U daily 4. Subcutaneous administration of terbutaline (Brethine) Answer: 3 Rationale: Pregnant women with mitral valve prolapse are frequently given anticoagulant therapy during pregnancy because they are at greater risk for thromboembolic disease during the antenatal, intrapartal, and postpartum periods. Warfarin (Coumadin) is contraindicated during pregnancy because it passes through the placental barrier, causing potential fetal malformations and hemorrhagic disorders. Heparin sodium, which does not pass through the placental barrier, is safe to use during pregnancy and would be administered by the subcutaneous route. Terbutaline is indicated for preterm labor management only. Test-Taking Strategy: Use the process of elimination and knowledge regarding the medications that are safe during pregnancy. Eliminate options 1 and 4 first because warfarin is contraindicated and terbutaline is indicated for preterm labor management only. From the remaining options, select option 3 because of the word “subcutaneous.” Review the treatment measures for the pregnant client with mitral valve prolapse if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum References: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 907. McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 655. 61. A clinic nurse is reviewing the records of the pregnant clients that will be seen in the clinic. Which client profile presents the greatest risk for human immunodeficiency virus (HIV) infection? 1. A 33-year-old gravida III client 2. An adolescent with multiple heterosexual contacts 3. A 25-year-old client with a history of spontaneous abortions 4. A multigravida client with a history of repeat cesarean deliveries Answer: 2

PN~Comp~Review~CD~1-100~ 34 Rationale: Though all women are at risk for developing HIV during their reproductive years, it is believed that adolescents are particularly at risk because they engage in high-risk behaviors. The client profiles in options 1, 3, and 4 identify potential at-risk situations for a variety of obstetrical risk factors, but not necessarily HIV infection. Test-Taking Strategy: Use the process of elimination and knowledge regarding the transmission of HIV to assist in answering the question. This focus will direct you to option 2. Review the etiology related to HIV if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Antepartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 110. 62. Methylergonovine maleate (Methergine) is prescribed for a client in the immediate postpartum period. The nurse tells the client that the medication has been prescribed to: 1. Relax the muscles of the uterus 2. Relieve nausea 3. Promote lactation 4. Stimulate contraction of the uterus Answer: 4 Rationale: Methylergonovine maleate (Methergine) is an ergot alkaloid that stimulates smooth muscles. Because the smooth muscle of the uterus is especially sensitive to the medication, it is used in the postpartum period to stimulate the uterus to contract and prevent or control postpartum hemorrhage. Options 1, 2, and 3 are incorrect actions of the medication. Test-Taking Strategy: Use the process of elimination. Recalling that the medication is used to control hemorrhage will direct you to option 4. Review the action and purpose of this medication if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 241, 247. 63. Oxytocin (Pitocin) is administered to a client following the delivery of the placenta. The nurse assisting in caring for the client observes for an effective response from the medication by monitoring for: 1. Urinary output 2. Milk production 3. Decreased afterbirth pains 4. Uterine contractions Answer: 4 Rationale: Oxytocin stimulates uterine contractions and may be administered to reduce the incidence of hemorrhage after expulsion of the placenta. It does not directly affect

PN~Comp~Review~CD~1-100~ 35 urinary output or milk production. The subsequent contraction of the uterus may cause an increase in the afterbirth pains. Test-Taking Strategy: Use the process of elimination. Recalling that the medication causes uterine contractions and is used to control hemorrhage will direct you to option 4. Review the action and purpose of this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Postpartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 206. 64. A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is positioned on the delivery room table, and the nurse places the client in the: 1. Trendelenburg’s position with the legs in stirrups 2. Semi-Fowler’s position with a pillow under the knees 3. Prone position with the legs separated and elevated 4. Supine position with a wedge under the right hip Answer: 4 Rationale: Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This occurrence leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and subsequently the fetus. The best position to prevent this would be side-lying with the uterus displaced off the abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides displacement of the uterus. Trendelenburg positioning places pressure from the pregnant uterus on the diaphragm and lungs, decreasing respiratory capacity and oxygenation. A semi-Fowler’s, prone, or Trendelenburg’s position with the legs in stirrups is not practical for this type of abdominal surgery. Test-Taking Strategy: Use the process of elimination, noting that the client is having a cesarean delivery. Also, recall the appropriate position to prevent vena cava syndrome. Visualizing each of the positions identified in the options will direct you to option 4. If you had difficulty with this question, review care to the client having a cesarean delivery. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Intrapartum Reference: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005). Maternal-child nursing (2nd ed.). St. Louis: Elsevier, p. 456. 65. A nurse is providing emergency measures to a pregnant client with a prolapsed cord. The mother becomes anxious and frightened and says to the nurse, “Why are all of these people in here? Is my baby going to be alright?” Which problem is the client most likely experiencing at this time? 1. Fear

PN~Comp~Review~CD~1-100~ 36 2. Powerlessness 3. Ineffective coping 4. Disturbed sensory perception Answer: 1 Rationale: The mother is anxious and frightened, and the appropriate nursing diagnosis for the client at this time is fear. There are no data in the question to support the nursing diagnoses of powerlessness, ineffective coping, or disturbed sensory perception, although these nursing diagnoses may be a consideration for this client at some point during the hospitalized experience. Test-Taking Strategy: When answering questions related to nursing diagnosis, focus specifically on the data provided in the question. Note the relation between the words “frightened” in the question and “fear” in the correct option. Review the defining characteristics for fear if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 198-199. Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 248. 66. A nurse is assisting to care for a pregnant client in labor who will be delivering twins. The nurse prepares to monitor the fetal heart rates by: 1. Placing the external fetal monitor over the fetus that is most anterior to the mother’s abdomen 2. Placing the external fetal monitor over the fetus that is most posterior to the mother’s abdomen 3. Placing external fetal monitors so that each fetal heart rate is monitored separately 4. Placing the fetal monitor so that one fetus is monitored for a 15-minute period followed by a 15-minute fetal monitoring period for the second fetus Answer: 3 Rationale: In a client with a multifetal pregnancy, each fetal heart rate is monitored separately. Options 1, 2, and 4 are incorrect because these actions would not provide information regarding the status of each fetus. Test-Taking Strategy: Use the process of elimination and knowledge regarding the monitoring of fetal status in a multifetal pregnancy. Note that options 1, 2, and 4 are similar in that they all relate to monitoring only one fetus at one time. Review care to the client with a multifetal pregnancy if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Intrapartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 194. 67. A nurse in the delivery room is assisting with the delivery of a newborn. Which

PN~Comp~Review~CD~1-100~ 37 observation would indicate that the placenta has separated from the uterine wall and is ready for delivery? 1. Shortening length and changing color in the umbilical cord 2. A soft and boggy uterus 3. Maternal complaints of severe uterine cramping 4. Changes in the shape of the uterus Answer: 4 Rationale: Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus, a firmly contracted uterus, and the uterus changing from a discoid to globular shape. The client may experience vaginal fullness, but not severe uterine cramping. Test-Taking Strategy: Use the process of elimination. Recalling that the placenta is attached to the uterine wall will assist in directing you to option 4. Review the findings associated with placental separation if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Intrapartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.) St. Louis: Mosby, p. 596. 68. A nurse is checking the lochia discharge on a 1-day postpartum woman. The nurse notes that the lochia is red in color and has a foul-smelling odor. The nurse determines that this finding indicates: 1. A normal finding 2. The presence of infection 3. The need for increased oral fluids 4. The need for increased ambulation Answer: 2 Rationale: Lochia, the discharge present after birth, is red in color the first 1 to 3 days and gradually decreases in amount. Normal lochia has a fleshy odor similar to the odor that is present during menstrual flow. Foul-smelling or purulent lochia usually indicates infection, and these findings are not normal. Encouraging the woman to drink fluids or ambulate are not accurate interpretations related to the assessment finding. Test-Taking Strategy: Use the process of elimination, noting the key words foul-smelling. These key words should direct you to option 2. If you had difficulty with this question, review normal assessment findings of lochia in the postpartum woman. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum References: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, pp. 206-207. Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 194. 69. A nurse in the postpartum unit is instructing a mother regarding lochia and the

PN~Comp~Review~CD~1-100~ 38 amount of expected lochia drainage. The nurse instructs the mother that the normal amount of lochia may vary but should never exceed: 1. 1 pad a day 2. 2 pads a day 3. 3 pads a day 4. 8 pads a day Answer: 4 Rationale: The normal amount of lochia may vary with the individual but should never exceed 4 to 8 pads a day. The average number of pads used daily is 6. Test-Taking Strategy: Use the process of elimination. Focusing on the key words should never exceed will assist in directing you to option 4. If you had difficulty with this question, review postpartum assessment. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Postpartum References: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 193-194. Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 630. 70. A nurse is collecting data on a client who is 6-hours postpartum following delivery of a full-term healthy newborn. The client tells the nurse that she feels faint and dizzy. Which nursing action would be appropriate? 1. Obtain a hemoglobin and hematocrit level 2. Instruct the mother to request help when getting out of bed 3. Elevate the head of the bed 4. Inform the nursery room nurse to avoid bringing the newborn to the mother until the feelings of light-headedness and dizziness have subsided Answer: 2 Rationale: Orthostatic hypotension may occur during the first 8 hours after birth. Feelings of faintness or dizziness are signs that caution the nurse to be aware of the client’s safety. The nurse should advise the mother to get help the first few times the mother gets out of bed. Option 1 requires a physician’s order. Option 3 is not a helpful action. Option 4 is unnecessary. Test-Taking Strategy: Use the process of elimination and focus on the issue of the question—client safety. Option 4 is inappropriate and should be eliminated first. Elevating the head of the bed is not a helpful nursing intervention to treat these symptoms. From the remaining options, recall that safety is a primary issue. This should assist in directing you to the correct option. If you had difficulty with this question, review postpartum nursing interventions. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders,

PN~Comp~Review~CD~1-100~ 39 p. 201. 71. The nurse in the postpartum unit notes that the result of a rubella titer drawn on a postpartum client during the antepartum period is 1:8. Which of the following would the nurse anticipate to be prescribed by the physician? 1. A repeat rubella titer in 2 weeks 2. Administration of a subcutaneous rubella virus vaccine 3. Administration of a subcutaneous rubella virus vaccine for the newborn 4. Counseling to the mother and informing the mother that this is a normal titer Answer: 2 Rationale: A blood sample for rubella titer is done on all women in the antepartum or postpartum period. A woman with a titer of 1:8 or less should receive a subcutaneous rubella virus vaccine (Meruvax II). This stimulates active immunity against the rubella virus. The woman should be counseled to avoid pregnancy for 3 months after receiving the vaccine. Test-Taking Strategy: Knowledge regarding the expected titer results for rubella is required to answer this question. Recalling that a titer of 1:8 or less requires the administration of a subcutaneous rubella virus vaccine to the mother will direct you to option 2. If you are unfamiliar with this titer, review this content. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Postpartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 211. 72. A postpartum client asks the nurse when she can resume sexual activity. The nurse tells the client that sexual activity can: 1. Be resumed at any time 2. Not be resumed until the 8-week physician checkup 3. Be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped 4. Be resumed after a normal menstrual period begins Answer: 3 Rationale: It is recommended that women refrain from sexual intercourse until the episiotomy has healed and the lochia has stopped. This process usually takes about 3 weeks. Options 1, 2, and 4 are inaccurate. Test-Taking Strategy: Knowledge regarding instructions to the mother regarding sexual activity following birth and delivery is needed to answer this question. Remember, sexual activity can be resumed in about 3 weeks when the episiotomy has healed and the lochia has stopped. If you had difficulty with this question, review this content. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Maternity/Postpartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.).

PN~Comp~Review~CD~1-100~ 40 Philadelphia: W.B. Saunders, p. 207. 73. A nurse is monitoring a client for signs of postpartum depression. Which of the following if noted in the new mother would indicate the need for further assessment related to this form of depression? 1. The mother is caring for the infant in a loving manner 2. The mother constantly complains of tiredness and fatigue 3. The mother demonstrates an interest in the surroundings 4. The mother looks forward to visits from the father of the newborn Answer: 2 Rationale: Postpartum depression is not the normal depression that many new mothers experience from time to time. The woman experiencing depression shows less interest in her surroundings and a loss of her usual emotional response toward the family. The woman is also unable to show pleasure or love, and may have intense feelings of unworthiness, guilt, and shame. The woman often expresses a sense of loss of self. Generalized fatigue, complaints of ill health, and difficulty in concentrating are also present. The mother would have little interest in food and experience sleep disturbances. Test-Taking Strategy: Note the key words need for further assessment. Use the process of elimination, noting that options 1, 3, and 4 identify positive maternal behaviors. If you had difficulty with this question, review the clinical manifestations of postpartum depression. Level of Cognitive Ability: Analysis Client Needs: Psychosocial Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, p. 199. 74. A nurse is caring for a client who delivered a healthy newborn via vaginal delivery. An episiotomy was performed, and the woman has developed a wound infection at the episiotomy site. The nurse provides instructions to the mother regarding care related to the infection. Which statement by the mother indicates a need for further instructions? 1. “I need to take the antibiotics as prescribed.” 2. “I need to apply warm compresses to provide comfort.” 3. “I need to take warm sitz baths to promote healing.” 4. “I need to isolate my infant for 48 hours after starting the antibiotics.” Answer: 4 Rationale: Broad-spectrum antibiotics will be prescribed for the mother, and the mother should be instructed to take the antibiotics as prescribed. Analgesics are often necessary, and warm compresses or sitz baths may be used to provide comfort in the area. The infant is not routinely isolated from the mother with a wound infection, but the mother must be taught how to protect the infant from contact with contaminated articles. Test-Taking Strategy: Use the process of elimination, noting the key words need for further instructions. Eliminate options 2 and 3 first because they are similar. From the remaining options, knowing that the infant does not need to be isolated from the mother will assist in directing you to the correct option. Review care to the client with a wound

PN~Comp~Review~CD~1-100~ 41 infection from an episiotomy site if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Maternity/Postpartum Reference: Leifer, G. (2005). Maternity nursing (9th ed.). Philadelphia: W.B. Saunders, pp. 292-293. 75. A nurse is assisting in developing a plan of care for a postpartum client who was diagnosed with superficial venous thrombosis. The nurse avoids including which incorrect intervention in the plan of care? 1. Elevating the affected extremity 2. Maintaining bed rest 3. Applying warm pads to the affected area 4. Administering the prescribed anticoagulants Answer: 4 Rationale: Thrombosis that is limited to the superficial veins of the saphenous system is treated with analgesics, rest, and elastic support stockings. Elevation of the lower extremity improves venous return and may also be recommended. Warm packs may be applied to the affected area to promote healing. There is no need for anticoagulants or antiinflammatory agents unless the condition persists. After 5 to 7 days of bed rest, and when symptoms disappear, the woman may gradually begin to ambulate. Test-Taking Strategy: Note the key words avoids and incorrect. These key words indicate a false response question and that you need to select the incorrect intervention. Also note the word “superficial” and focus on the diagnosis. Recalling that anticoagulants are not used to treat superficial venous thrombosis will assist in directing you to option 4. Review therapeutic management of superficial venous thrombosis if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Maternity/Postpartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 243. 76. A nurse is monitoring a preterm newborn for respiratory distress syndrome (RDS). Which findings in the newborn would alert the nurse to the possibility of this syndrome? 1. Hypotension and bradycardia 2. Tachypnea and retractions 3. Acrocyanosis and grunting 4. The presence of a barrel chest with acrocyanosis Answer: 2 Rationale: The newborn with respiratory distress syndrome may present with cyanosis, tachypnea or apnea, nasal flaring, chest wall retractions, or audible expiratory grunts. Acrocyanosis is the bluish discoloration of the hands and feet, is associated with immature peripheral circulation, and is not uncommon in the first few hours of life.

PN~Comp~Review~CD~1-100~ 42 Options 1, 3, and 4 do not indicate clinical signs of respiratory distress syndrome. Test-Taking Strategy: Use the process of elimination. Recalling that acrocyanosis is a normal sign in a newborn will assist in eliminating options 3 and 4. From the remaining options, focusing on the issue of the question, RDS, will direct you to option 2. If you had difficulty with this question, review these clinical manifestations of RDS. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 152. 77. A nurse is caring for a neonate born to a mother who is addicted to drugs. The nurse expects to observe which of the following while caring for the neonate? 1. Sleeps quietly 2. Is easy to console when crying 3. Is lethargic 4. Cries incessantly Answer: 4 Rationale: A neonate born to a woman who is addicted to drugs is irritable, may cry incessantly, and may be difficult to console. The neonate would hyperextend and posture rather that cuddle when being held. Test-Taking Strategy: Use the process of elimination. Eliminate options 1, 2, and 3 because they are similar and indicate a lack of hyperactivity. Review the assessment findings in the neonate born to a drug-addicted mother if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Maternity/Postpartum Reference: Lowdermilk, D., & Perry, A. (2004). Maternity & women’s health care (8th ed.). St. Louis: Mosby, p. 1075. 78. A nurse is reviewing the criteria for early discharge of a newborn infant with her mother. Which of the following if noted in the infant would indicate that the criteria for early discharge have not been met? 1. Infant’s vital signs are documented as normal and stable 2. Infant has urinated and passed at least one stool 3. Infant has completed at least two successful feedings 4. Infant has evidence of significant jaundice Answer: 4 Rationale: Criteria for early discharge in the newborn include no evidence of significant jaundice within the first 24 hours after birth. The infant should have urinated and passed at least one stool, completed at least two successful feedings, and have normal vital signs for at least 12 hours. Test-Taking Strategy: Use the process of elimination, noting the key words have not

PN~Comp~Review~CD~1-100~ 43 been met. Note that the only abnormal finding is option 4, which indicates the presence of jaundice. Review early discharge criteria for a newborn if you are unfamiliar with this area. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Postpartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 235. 79. A nurse has provided instructions to the mother of a male newborn who is not circumcised about measures to clean the penis. Which statement by the mother indicates an understanding of this procedure? 1. “I need to retract the foreskin and clean the penis every time I give my newborn a bath.” 2. “I should gently retract the foreskin as far as it will go on the penis, and then pull the skin back over the penis after cleaning.” 3. “I should retract the foreskin and clean the penis every time I change the diaper.” 4. “I need to avoid pulling back the foreskin to clean the penis because this may cause adhesions.” Answer: 4 Rationale: In newborn males, prepuce is continuous with the epidermis of the glans and is not retractable. If retraction is forced, adhesions can develop. It is best to allow separation of the foreskin to occur naturally, which usually occurs between 3 years and puberty. Most foreskins are retractable by 3 years of age and should be pushed back gently at this time for cleaning once a week. Test-Taking Strategy: Use the process of elimination. Note that options 1, 2, and 3 are similar in that they all recommend retracting the foreskin. Option 4 is the option that is different. If you had difficulty with this question, review teaching points related to cleaning the penis in a newborn who is uncircumcised. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Maternity/Postpartum Reference: Leifer, G. (2003). Introduction to maternity & pediatric nursing (4th ed.). Philadelphia: W.B. Saunders, p. 291. 80. A client with a history of spinal cord injury is receiving baclofen (Lioresal) for muscle spasms. The nurse determines that the client is experiencing a side effect of this medication if the client experiences: 1. Photosensitivity 2. Drowsiness 3. Hypertension 4. Muscle pain Answer: 2 Rationale: Baclofen is a centrally acting skeletal muscle relaxant. Side effects of

PN~Comp~Review~CD~1-100~ 44 baclofen (Lioresal) include drowsiness, dizziness, weakness, and nausea. Occasional side effects include headache, paresthesia of the hands and feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion. Options 1, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Recalling that baclofen is a centrally acting skeletal muscle relaxant will assist in directing you to option 2. If you had difficulty with this question, review the side effects related to baclofen. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 108. 81. A client is receiving diazepam (Valium) for its skeletal muscle relaxant effects. The nurse would monitor this client for which side effect of this medication? 1. Urinary retention 2. Headache 3. Incoordination 4. Increased salivation Answer: 3 Rationale: Diazepam is a centrally acting skeletal muscle relaxant. Incoordination and drowsiness are common side effects resulting from this medication. The other options are incorrect. Test-Taking Strategy: Use the process of elimination. Recalling that diazepam is a centrally acting skeletal muscle relaxant will assist in directing you to option 3. If you had difficulty with this question, review the side effects related to diazepam. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W. B. Saunders, p. 316. 82. A client with multiple sclerosis is receiving dantrolene (Dantrium) for relief of muscle spasticity. The nurse checks the results of which laboratory value periodically ordered while the client is taking this medication? 1. Liver function studies 2. Creatinine level 3. Sedimentation rate 4. White blood cell count Answer: 1 Rationale: Dantrolene can cause liver damage, and the nurse should monitor the results of liver function studies. Baseline liver function studies are done before therapy starts, and regular liver function studies are performed throughout therapy. Dantrolene is discontinued if no relief of spasticity is achieved in 6 weeks. The other options are incorrect.

PN~Comp~Review~CD~1-100~ 45 Test-Taking Strategy: Use the process of elimination. Recalling that this medication is hepatotoxic will direct you to the correct option. If you had difficulty with this question, review the adverse effects of dantrolene. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W.B. Saunders, p. 286. 83. A nurse has provided instructions to a client regarding the method for instilling eye drops into the left eye. The nurse determines that the client needs further instructions if the client does which of the following during a return demonstration? 1. Lies with the head to one side, puts the drop in the inner canthus, and slowly turns to the other side while blinking 2. Lies supine, pulls down on the lower lid, and puts the drop in the lower lid 3. Lies supine, pulls up on the upper lid, and puts the drop in the upper lid 4. Tilts the head back, pulls down on the lower lid and puts the drop in the lower lid Answer: 3 Rationale: It is correct procedure for the client to either lie down or sit with the head tilted back. The thumb or finger is used to pull down on the lower lid. The client holds the bottle like a pencil (tip facing downward), and squeezes the bottle so that the drop falls into the sac. The client then gently closes the eye. An alternative method for clients who blink very easily is to place the client in the supine position with the head turned to one side. The eye to be used is uppermost. The client squeezes the drop onto the inner canthus. The client turns from this side to the other while blinking. Surface tension and gravity then cause the drop to move into the conjunctival sac. Test-Taking Strategy: Use the process of elimination, noting the key words needs further instructions. These words indicate a false response question and that you need to select the incorrect action. Visualizing each procedure described in the options will direct you to option 3. Review the procedure for the administration of eye medications if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W. B. Saunders, p. 1185. 84. A client asks the nurse to describe the preferred provider organization model of care because the client is unsure of the procedure involved in this form of health care. Which statement by the nurse indicates an inaccurate description of this form of organization? 1. “It represents an arrangement between employers and insurance companies.” 2. “It provides member services from a selected group of providers.” 3. “Members can commonly elect to see any participating physician without prior authorization.”

PN~Comp~Review~CD~1-100~ 46 4. “Beneficiaries are limited to those providers that are participating physicians for any required health care services.” Answer: 4 Rationale: Options 1, 2, and 3 are accurate descriptions of the preferred provider organization. In the exclusive provider organization, beneficiaries are limited to those providers that are participating physicians for any required health care services. If members elect to see physicians outside the exclusive provider organization, services may not be covered. Test-Taking Strategy: Note the key word inaccurate in the stem of the question. These words indicate a false response question and that you need to select the incorrect description. Use the process of elimination and knowledge regarding preferred provider organizations to assist in answering the question. If you had difficulty with this question, review the characteristics of the various health maintenance organizations. Level of Cognitive Ability: Comprehension Client Needs: Safe, Effective Care Environment Integrated Process: Teaching/Learning Content Area: Fundamental Skills Reference: Potter, P., & Perry, A. (2005). Fundamentals of nursing (6th ed.). St. Louis: Mosby, p. 29. 85. An adult client had a cerebrospinal fluid (CSF) analysis after lumbar puncture. The nurse interprets that a negative value of which of the following is consistent with normal findings? 1. White blood cells 2. Red blood cells 3. Protein 4. Glucose Answer: 2 Rationale: The adult with normal cerebrospinal fluid has no red blood cells in the CSF. The client may have small levels of white blood cells (0 to 3 per mm3). Protein (15 to 45 mg/dl) and glucose (40 to 80 mg/dl) are normally present in CSF. Test-Taking Strategy: To answer this question accurately, it is necessary to be familiar with the normal components of CSF. Review this procedure and the expected findings if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Neurological References: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 351. Pagana, K., & Pagana, T. (2003). Mosby’s diagnostic and laboratory test reference (6th ed.). St. Louis: Mosby, pp. 574-577. 86. A client who has fallen from a roof and fractured his ribs has the following arterial blood gas results: pH 7.42, PaCO2 32 mm Hg, PaO2 89 mm Hg, HCO3− level 22 mEq/L. The nurse interprets that the client’s blood gases indicate which of the following?

PN~Comp~Review~CD~1-100~ 47 1. Normal results 2. Metabolic alkalosis 3. Metabolic acidosis 4. Respiratory alkalosis Answer: 4 Rationale: The client has respiratory alkalosis. Normal ranges are pH 7.35 to 7.45, PaCO2 35 to 45, and bicarbonate level 22 to 26 mEq/L. With acidosis, the pH would be less than 7.35; with alkalosis, the pH would be greater than 7.45. Carbon dioxide levels would be elevated in respiratory acidosis. Bicarbonate levels would be low if metabolic acidosis was present. Test-Taking Strategy: Specific knowledge related to arterial blood gas (ABG) analysis is needed to answer this question correctly. Recalling that with alkalosis the pH would be greater than 7.45 will direct you to option 4. Review the procedure for analyzing ABGs if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Respiratory Reference: Chernecky, C., & Berger, B. (2004). Laboratory tests and diagnostic procedures (4th ed.). Philadelphia: W.B. Saunders, p. 245. 87. A transcutaneous electrical nerve stimulation (TENS) unit is prescribed for a client with pain, and the nurse provides information to the client about the TENS unit. Which statement by the client indicates the need for further information? 1. “Electrodes are attached to the skin.” 2. “The unit relieves pain.” 3. “The unit will reduce the need for analgesics.” 4. “Needles are inserted in the subcutaneous tissue to stimulate the nerve.” Answer: 4 Rationale: The TENS unit is a portable unit, and the client controls the system for relieving pain and reducing the need for analgesics. It is attached to the skin of the body by electrodes. Needles are not used. Test-Taking Strategy: Note the key words need for further information. These words indicate a false response question and that you need to select the incorrect client statement. Noting the word “needles” in option 4 will direct you to this option. Review the concepts related to the TENS unit if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Teaching/Learning Content Area: Pharmacology Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 589-590. 88. A nurse is employed in a long-term care facility. Diclofenac (Voltaren) is prescribed for the client with osteoarthritis. Which of the following medications, if noted on the client’s record, would alert the nurse to consult with the physician?

PN~Comp~Review~CD~1-100~ 48 1. Warfarin sodium (Coumadin) 2. Mesoridazine besylate (Serentil) 3. Primidone (Mysoline) 4. Trifluoperazine hydrochloride (Stelazine) Answer: 1 Rationale: Diclofenac is a nonsteroidal antiinflammatory (NSAID) drug. Interactions may occur with anticoagulants. The nurse should consult with the physician regarding a potential medication interaction. Mesoridazine besylate is an antipsychotic medication. Primidone is an anticonvulsant, and trifluoperazine hydrochloride is an antipsychotic. These medications are not contraindicated when administering diclofenac. Test-Taking Strategy: Knowledge regarding the contraindications associated with the administration of this medication is required to answer this question. Remember, diclofenac is contraindicated with warfarin sodium. Review this medication if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Safe, Effective Care Environment Integrated Process: Nursing Process/Data Collection Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W. B. Saunders, p. 317. 89. A client is receiving a maintenance dose of oral dantrolene sodium (Dantrium) for the treatment of spasticity. The nurse reviews the medication record expecting that which of the following doses would be prescribed? 1. 50 mg daily 2. 100 mg daily 3. 100 mg twice daily 4. 200 mg four times daily Answer: 3 Rationale: For treatment of spasticity, dantrolene is administered orally. The initial dose in adults is 25 mg once daily. The usual maintenance dosage is 100 mg 2 to 4 times daily. If beneficial effects do not develop within 45 days, dantrolene therapy should be discontinued. Test-Taking Strategy: Knowledge of the adult oral dose of this medication is required to answer this question. If you are unfamiliar with this maintenance dosage, review this medication. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology Reference: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W. B. Saunders, p. 285. 90. A physician is planning to administer a skeletal muscle relaxant to a client with a spinal cord injury. The medication is going to be administered intrathecally (within the spinal column). Which of the following medications would the nurse expect to be

PN~Comp~Review~CD~1-100~ 49 prescribed and administered by this route? 1. Cyclobenzaprine hydrochloride (Flexeril) 2. Chlorzoxazone (Paraflex) 3. Dantrolene sodium (Dantrium) 4. Baclofen (Lioresal) Answer: 4 Rationale: Baclofen is the only skeletal muscle relaxant that can be administered intrathecally within the spinal column. Test-Taking Strategy: Knowledge regarding intrathecal administration of muscle relaxants is required to answer this question. If you are unfamiliar with this form of therapy, review this content. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Pharmacology References: Hodgson, B., & Kizior, R. (2005). Saunders nursing drug handbook 2005. Philadelphia: W. B. Saunders, p. 107. Lehne, R. (2004). Pharmacology for nursing care (5th ed.). Philadelphia: W.B. Saunders, p. 210. 91. A nurse is caring for a client being treated for a fat embolus after multiple fractures. Which of the following data would the nurse determine as the most favorable indication of resolution of the fat embolus? 1. Arterial oxygen level of 78 mm Hg 2. Minimal dyspnea 3. Clear chest x-ray 4. Oxygen saturation of 85% Answer: 3 Rationale: A clear chest x-ray is a favorable indicator that a fat embolus is resolving. When fat embolism occurs, there is a “snowstorm” appearance to the chest x-ray. Eupnea, not minimal dyspnea, is a normal sign. Arterial oxygen levels should be 80 to 100 mm Hg. Oxygen saturation should be greater than 95%. Test-Taking Strategy: Note the key words most favorable. Knowledge of normal baseline respiratory values will assist in answering this question. Knowing that the arterial oxygen and oxygen saturation levels are below normal helps you to eliminate options 1 and 4. Dyspnea, even at a minimal level, is not normal and can be eliminated also. A clear chest x-ray is a normal finding, and is the answer to the question as stated. Review this complication of a fracture if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Musculoskeletal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes. (7th ed.). Philadelphia: W.B. Saunders, p. 629. 92. A client has undergone a fasciotomy to treat compartment syndrome of the leg. The

PN~Comp~Review~CD~1-100~ 50 nurse would expect that which type of wound care will be prescribed for the fasciotomy site? 1. Dry sterile dressings 2. Moist sterile saline dressings 3. Hydrocolloid dressings 4. One-half strength Betadine dressings Answer: 2 Rationale: The fasciotomy site is not sutured, but is left open to relieve pressure and edema. The site is covered with moist sterile saline dressings. After 3 to 5 days, when perfusion is adequate and edema subsides, the wound is debrided and closed. Options 1, 3, and 4 are incorrect. Test-Taking Strategy: This question can be answered by knowing what a fasciotomy involves and knowing the basics of wound care. With fasciotomy, the skin is not sutured closed, but left open for pressure relief. Moist tissue needs to remain moist, which eliminates option 1. A hydrocolloid dressing is not indicated for use with clean, open incisions, which eliminates option 3. The incision is clean, not dirty, so there should be no reason to require Betadine. Knowing that Betadine can be irritating to normal tissues is an additional reason to choose option 2 over option 4. Review postprocedure care following a fasciotomy if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Musculoskeletal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, pp. 143-144. 93. A nurse has provided instructions to a client in an arm cast about the signs and symptoms of compartment syndrome. The nurse determines that the client understands the information if the client reports which early symptom of compartment syndrome? 1. Pain that is relieved only by a narcotic analgesic 2. Pain that increases when the arm is dependent 3. Cold, bluish colored fingers 4. Numbness and tingling in the fingers Answer: 4 Rationale: The earliest symptom of compartment syndrome is paresthesia (numbness and tingling in the fingers). Other symptoms include pain unrelieved by narcotics, pain that increases with limb elevation, and pallor and coolness to the distal limb. Cyanosis is a late sign. Test-Taking Strategy: Note the key word early. Because cyanosis is a late sign, option 3 is eliminated first. Knowing that compartment syndrome is characterized by insufficient circulation and ischemia secondary to pressure, you would look for symptoms that are consistent with pressure. Pain would be increased with elevation rather than dependency, so option 2 can be eliminated also. Because the pain of ischemia is generally not relieved with analgesics, this cannot be an early symptom either. This leaves numbness and tingling as the answer. Review the early signs of compartment syndrome if you had difficulty with this question.

PN~Comp~Review~CD~1-100~ 51 Level of Cognitive Ability: Analysis Client Needs: Health Promotion and Maintenance Integrated Process: Nursing Process/Evaluation Content Area: Adult Health/Musculoskeletal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 824. 94. An older client is brought to the emergency room via ambulance after sustaining a fall. An x-ray indicates that the client sustained a femoral neck fracture. The nurse would expect to note which of the following on inspection of the client’s leg? 1. Lengthening, adduction, and external rotation 2. Shortening, abduction, and internal rotation 3. Shortening, adduction, and external rotation 4. Lengthening, abduction, and internal rotation Answer: 3 Rationale: Typical signs and symptoms following femoral neck fracture include shortening of the affected leg, adduction, and external rotation. The client may report slight groin pain, or pain on the medial side of the knee. Moving the fractured extremity significantly increases the pain. Test-Taking Strategy: Knowledge of basic signs and symptoms of hip fracture is necessary to answer this question. Remember, shortening of the affected leg, adduction, and external rotation would occur. Review the signs of a femoral neck fracture if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Musculoskeletal References: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1678. Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 831. 95. A client has been taught to use a walker to aid in mobility following internal fixation of a hip fracture. The nurse determines that the client is using the walker incorrectly if the client: 1. Holds the walker using the handgrips 2. Leans forward slightly when advancing the walker 3. Advances the walker with reciprocal motion 4. Supports body weight on the hands while advancing the weaker leg Answer: 3 Rationale: The client should use the walker by placing the hands on the handgrips for stability. The client lifts the walker to advance it, and leans forward slightly while moving it. The client walks into the walker, supporting the body weight on the hands while moving the weaker leg. A disadvantage of the walker is that it does not allow for reciprocal walking motion. If the client were to try to use reciprocal motion with a walker, the walker would advance forward one side at a time as the client walks; thus, the

PN~Comp~Review~CD~1-100~ 52 client would not be supporting the weaker leg with the walker during ambulation. Test-Taking Strategy: Note the key word incorrectly. These words indicate a false response question and that you need to select the incorrect client action. Holding the walker using the handgrips is an obvious correct action, and is eliminated first. The client must lean forward slightly in order to move the walker forward, so this option is eliminated as well. Reciprocal motion is moving one leg and the opposite arm at the same time. If the client were trying to do this with a walker, the client would be twisting the walker from side to side as it advances. This would be incorrect, and is therefore the answer to the question. Review the principles related to the use of a walker if you had difficulty with this question. Level of Cognitive Ability: Comprehension Client Needs: Health Promotion and Maintenance Integrated Process: Teaching/Learning Content Area: Adult Health/Musculoskeletal Reference: deWit, S. (2005). Fundamental concepts and skills for nursing. Philadelphia: W.B. Saunders, pp. 793, 805. 96. A client who has had a total knee replacement tells the nurse that there is pain with extension of the knee. The nurse should: 1. Put the client’s knee through full passive range of motion 2. Immobilize the knee temporarily 3. Administer an analgesic 4. Notify the physician immediately Answer: 3 Rationale: Pain with knee extension is a common complaint of clients after knee replacement surgery. This is because preoperatively the client placed the knee in flexion to reduce pain, and flexion contracture has resulted. The nurse should encourage the client to keep the knee extended, and administer analgesics as needed. Test-Taking Strategy: Use the process of elimination. The question states that there is pain with extension only. Immobilizing the knee will not help, so this option may be eliminated first. Putting the joint through full range of motion may be more than the client can tolerate. From the remaining options, you need to know that flexion contracture can occur, which would lead you to choose medicating the client rather than notifying the physician. Review the expected findings following a total knee replacement if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Reference: Christensen, B., & Kockrow, E. (2003). Adult health nursing (4th ed.). St. Louis: Mosby, p. 126. 97. A nurse is caring for a client who had an above the knee amputation 2 days ago. The residual limb was wrapped with an elastic compression bandage and has fallen off. The nurse immediately: 1. Calls the physician

PN~Comp~Review~CD~1-100~ 53 2. Rewraps the stump with an elastic compression bandage 3. Applies ice to the site 4. Applies a dry sterile dressing and elevates it on one pillow Answer: 2 Rationale: If the client with amputation has a cast or elastic compression bandage that falls off, the nurse must immediately wrap the stump with another elastic compression bandage. Otherwise, excessive edema will rapidly form, which could cause a significant delay in rehabilitation. Test-Taking Strategy: Use the process of elimination. Eliminate option 4 first. Elevation on one pillow is not going to greatly impede the development of edema once compression is released. For the same reason, option 3 is eliminated. Ice would be of limited value in controlling edema from this cause. From the remaining options, the better option is to reapply the compression bandage. If the physician were called, the order would likely be to reapply the compression dressing anyway. Review care to the client following an amputation if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Implementation Content Area: Adult Health/Musculoskeletal Reference: Linton, A., & Maebius, N. (2003). Introduction to medical-surgical nursing (3rd ed.). Philadelphia: W.B. Saunders, p. 845. 98. A client with a herniated intervertebral lumbar disk complains of a knifelike, stabbing pain in the lower back, as well as pain radiating into the right buttock. The nurse interprets that the sharp, stabbing pain is probably a result of: 1. Muscle spasm in the area of the herniated disk 2. Pressure on the spinal cord 3. Pressure on the spinal nerve root 4. Excess cerebrospinal fluid production in the area Answer: 1 Rationale: Compression of a nerve results in inflammation, which then irritates adjacent muscles, putting them into spasm. The pain of muscle spasm is continuous, knifelike, and localized in the affected area. Options 2, 3, and 4 are incorrect. Test-Taking Strategy: Use the process of elimination. Eliminate option 4 first because this is unlikely to occur. Pressure on a spinal nerve root causes the symptoms of sciatica, so option 3 can be eliminated next. Pressure on the spinal cord itself could result in a variety of manifestations, depending on the area involved. The pain of muscle spasm has the characteristics described in the question, which helps you choose option 1 over option 2. Additionally, the words “herniated disk” are stated in the question and again in option 1. Review the characteristics of a muscle spasm if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Musculoskeletal Reference: Lewis, S., Heitkemper, M., & Dirksen, S. (2004). Medical-surgical nursing: Assessment and management of clinical problems (6th ed.). St. Louis: Mosby, p. 1656.

PN~Comp~Review~CD~1-100~ 54

99. A nurse has an order to place a client with a herniated lumbar intervertebral disk on bed rest to minimize the pain. The nurse plans to put the bed: 1. In high-Fowler’s position with the foot of the bed flat 2. In semi-Fowler’s position with the knee gatch slightly raised 3. In semi-Fowler’s position with the foot of the bed flat 4. Flat with the knee gatch raised Answer: 2 Rationale: Clients with low back pain are often more comfortable when placed in semiFowler’s position with the knee gatch slightly raised or with pillows under the knees. The bed is placed in semi-Fowler’s position with the knee gatch raised sufficiently to flex the knees. This relaxes the muscles of the lower back and relieves pressure on the spinal nerve root. Test-Taking Strategy: Knowledge of this specific position helps you to answer this question. If you are not familiar with it, however, look at the information in the question. The client has back pain with a ruptured intervertebral disk. Positions that relieve this discomfort include those that provide slight flexion of lower back muscles, which relieves pressure and avoids extension of the spine. Keeping the foot of the bed flat will enhance extension of the spine, so options 1 and 3 should be eliminated first. Option 4 would excessively stretch the lower back and would also put the client at risk for thrombophlebitis. By the process of elimination, the correct answer is option 2. Review care to a client with a herniated lumbar intervertebral disk if you had difficulty with this question. Level of Cognitive Ability: Application Client Needs: Physiological Integrity Integrated Process: Nursing Process/Planning Content Area: Adult Health/Musculoskeletal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes. (7th ed.). Philadelphia: W.B. Saunders, p. 2143. 100. A nurse is caring for a client who has had spinal fusion with insertion of hardware. The nurse would be especially concerned with which of the following findings? 1. Complaints of discomfort during repositioning 2. An oral temperature of 101° F 3. Old, bloody drainage outlined on the surgical dressing 4. Discomfort during coughing and deep breathing exercises Answer: 2 Rationale: For this specific type of surgery, the nurse monitors the neurovascular status of the lower extremities, watches for signs and symptoms of infection, and inspects the surgical site for evidence of cerebrospinal fluid leakage (drainage is clear, tests positive for glucose). A mild fever is expected after insertion of hardware, but a temperature over 101° F should be reported, because it might possibly require that the hardware be removed. Test-Taking Strategy: Each of the options contains at least a slight deviation from normal, but the question asks which option would cause the nurse to be “especially concerned.” Thus you are looking for the option that has the greatest deviation from

PN~Comp~Review~CD~1-100~ 55 normal. Options 1 and 4 are expected after surgery, and although the nurse tries to minimize discomfort, the client is likely to have some discomfort even with proper analgesic use. The words “old” and “outlined” in option 3 indicate that this is not a new occurrence. This leaves the temperature of 101° F, which is excessive, and should be reported. Review the complications associated with this surgical procedure if you had difficulty with this question. Level of Cognitive Ability: Analysis Client Needs: Physiological Integrity Integrated Process: Nursing Process/Data Collection Content Area: Adult Health/Musculoskeletal Reference: Black, J., & Hawks, J. (2005). Medical-surgical nursing: Clinical management for positive outcomes. (7th ed.). Philadelphia: W.B. Saunders, p. 2144.

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