MCN Drill Answers No Answer

1 MATERNAL AND CHILD NURSING
Prepared by: Archie D. Alviz, R.N., R.M., N.C. II | manofsteel_archie@yahoo.com| facebook fan page: Sir Archie D. Alviz
MATERNAL AND CHILD NURSING A. douching after sexual intercourse.

B. sex during menstruation.
1. Which drug category may be safely administered C. performing Kegsl exercises.
during pregnancy? D. safe and responsible sex.
A. Category A
B. Category B 8. Using Naegle’s Rule, calculate the estimate date of
C. Category C delivery if the woman’s LMP was October 1.
D. Category D A. June 23
B. July 8
2. Which of the following is a positive indication of C. December 23
pregnancy? D. January 8
A. Quickening
B. Chadwick’s sign 9. Which of the following would be appropriate to teach
C. Auscultation of fetal heart sounds the pregnant woman regarding exercise?
D. Ballottement A. Avoid any physical activity during the second
trimester
3. During the last months of pregnancy, the nurse B. Contact sports are allowed during the first trimester
should instruct the client to: C. Extremely active women should reduce the level of
A. rest on her left side for at least 1 hour in the morning exertion
and afternoon D. Relaxation and stretching exercises should be
B. sleep on her back during the night and during naps discontinued.
C. start nipple exercises and stimulation twice a day
D. start to cut back on water intake, especially at night 10. One of the functions of the amniotic fluid is to:
A. exchange nutrients from mother to fetus
4. When teaching a pregnant woman about traveling B. immobilize the fetus
during the pregnancy, it is important to focus on which of C. protect the woman’s uterus
the following? D. regulate temperature
A. If traveling by car, stop every 2 hours for 10 minutes
B. Get plenty of rest before long trips made in 11. A feeling of ambivalence about the pregnancy is:
automobiles A. a sign of unwanted pregnancy
C. Travel in any type of aircraft is acceptable B. normal in early pregnancy
D. Travel can be completed anytime throughout the C. rare at any stage of pregnancy
pregnancy D. typical in late pregnancy
5. Which of the following is recommended for all 12. Which assessment relates most directly to rupture
women during the childbearing age? membranes and release of amniotic fluid?
A. Additional B vitamins A. Bloody show
B. Additional vitamin A B. Fluid with a pH of 7.0 to 7.5 with nitrazine test
C. Folic acid supplement C. Fluid with a pH of 5.0 with nitrazine test
D. Vitamin C supplement D. Woman complains of urge to push
6. An 18-year old girl visits to obtain a contraceptive. 13. When the placenta is delivered with the dull side out
She elected to use the intrauterine device (IUD) as a (Duncan presentation), the woman is at risk for:
method of birth control. The major concern with the use A. excessive bleeding
of the IUD is: B. hemorrhoids
A. thrombophlebitis. C. increased lacerations of the perineum
B. pain on intercourse. D. sterility
C. infection.
D. abnormal bleeding and hemorrhage. 14. To assess the uterine contraction during labor, the
nurse:
7. The client begins to question the nurse about A. asks the woman if she is having a contraction.
sexuality and becoming sexually active. During sexual B. palpates above the symphysis pubis.
counseling, the nurse should place a major point of C. palpates just below the xyphoid process of the
emphasis on: sternum.
D. performs a sterile vaginal examination. D. Take an OTC diuretic if you have swelling during the
pregnancy
15. The nurse knows that a postpartum client’s
susceptibility to hemorrhage is most likely related to a: 21. When providing postpartum teaching about self-care,
A. boggy uterus one of the danger signs that a lactating woman should
B. firm fundus know to report to the birth attendant is:
C. long labor A. breast engorgement to a degree that the baby can’t
D. negative Homan’s sign latch on.
B. breast fullness just before feeding .
16. Between 24 and 28 weeks, all pregnant women C. nipple soreness after feedings.
should be screened for: D. nipple dryness before feedings.
A. Anemia
B. Bladder infections 22. “Show” is usually present in:
C. Diabetes A. Braxton Hicks contraction.
D. Neural tube defects B. false labor.
C. true labor.
17. Which of these measures would be helpful for the D. Second stage of labor only.
pregnant client complaining of sleeplessness?
A. Eat evening meal close to bedtime 23. APGAR score assessments are completed at:
B. Sit in a sitz bath before bedtime A. birth and 10 minutes.
C. Try to remain in one position when sleeping B. 1 and 5 minutes.
D. Use pillows to help find a comfortable position C. 5 minutes and upon arrival to the nursery.
D. the time of birth.
18. Why is the first 8 weeks of pregnancy known as the
critical period of human development? 24. A newborn of 4 hours displays grunting respirations
A. By the time this period ends, the embryo is and a respiratory rate of 70 breaths/minute. The priority
completely safe from any damage nursing intervention would be to:
B. Many embryos die during this period A. begin resuscitative measures and call for help.
C. The infant’s sex is determined at the end of the eight B. continue to monitor respiratory status variations are
week normal.
D. The major structures of the embryo are forming, and C. obtain vital signs every 15 minutes.
damage can result in major birth defects D. transfer the newborn to the mother’s room for
feeding.
19. Which of these statements is most accurate about
the placenta? 25. Which measure would be used to prevent loss of heat
A. The blood of the baby mixes with the mother’s blood in the newborn?
to permit exchange of nutrients and oxygen. A. Immediately give the baby a bath
B. The blood of the baby and the mother do not mix; B. Place the baby on the mother’s bare stomach
exchange occurs across blood vessels and the walls of the C. Offer the baby warm glucose water
villi. D. Wrap the baby in room-temperature blankets
C. The placenta lets the blood from the fetus cross to
the mother, but the mother’s blood does not cross to the 26. Which of the following indicates that the new mother
fetus. understands how to handle breast milk safely?
D. The placenta serves as a complete barrier between A. “I can store fresh milk in the refrigerator for only 24
the baby and mother so that any drugs the mother takes hours.”
do not cross the baby. B. “I can store frozen breast milk for up to 1 month.”
C. “I need to express my breast milk into a clear glass.”
20. Which of the following is the best recommendation D. “I should never store my breast milk in a frozen-food
about taking medicines during pregnancy? locker.”
A. All over-the-counter (OTC) drugs are safe during
pregnancy 27. To prevent infection of the perineal area after
B. All herbal preparations are safe during pregnancy delivery, the nurse should instruct the client to:
C. Don’t take anything during pregnancy without asking A. Begin sitz bath at the first sign of infection
your health care provider B. Pull panties straight down
C. Use hot water to cleanse the area after bowel C. synchronized movement of the baby’s chest and
movement abdomen.
D. Wipe with sweeping motion, from front to back D. the baby’s chest expanding as a whole.
28. Analgesics given too late in labor can result in which 35. The most efficient way for a baby to regulate
of the following? temperature is to:
A. Contractions that increase in intensity A. burn body fat.
B. Early deceleration B. move arms and legs.
C. FHR dropping to 100 beat per minute C. shiver.
D. Pain during contractions D. use brown fat.
29. In evaluating the effects if oxytocin after delivery, the 36. Which measure would be most effective in
nurse should monitor for: preventing the transfer of gonorrhea or Chlamydia to the
A. effective breastfeeding. infant’s eyes from the mother?
B. engorged breasts. A. Administering Vitamin K
C. relief of pain. B. Bathing the newborn
D. the uterus remaining firm. C. Cleaning the infant’s eyes with warm saline
D. Applying erythromycin ointment
30. During active labor, the mother usually exhibits which
of the following behaviors? 37. A newborn will respond to sudden noises or jarring
A. Difficulty following directions movement by throwing out the arms and drawing up the
B. Excitedness and talkativeness legs. This is called a:
C. Frustration and irritability A. Moro reflex
D. Serious expression and apprehension B. Babinski reflex
C. Rooting reflex
31. When evaluating the effectiveness of instruction D. Tonic neck reflex
regarding breastfeeding, which of the following responses
by the mother indicate that she understands the 38. The nurse is caring for a newborn at 12 hours of life.
teaching? The newborn has just voided. The most appropriate
A. “I need to rub my nipples to toughen them up.” response by the nurse would be:
B. “I should apply lotion to my nipples to prevent A. immediately check vital signs.
cracking.” B. notify the physician.
C. “I should nurse at least 10 minutes on one breast C. continue to monitor voiding patterns.
before offering the next breast.” D. obtain an order for a straight catheter.
D. “I should use soap and water to gently cleanse my
breast gently.” 39. Which position should newborns be placed when
sleeping?
32. Which of the following should the nurse recommend A. Back
to the breastfeeding mother to limit in her diet? B. Head of bed elevated
A. Cheese C. Prone
B. Fruit D. Side lying with pillow
C. Strongly flavored foods
D. Vegetables 40. Most babies should be fed:
A. Every 1 to 2 hours
33. The fontanels are soft spots formed by the: B. Every 2 to 4 hours
A. blood accumulated between the bone and C. Every 4 to 6 hours
periosteum. D. On demand
B. edema of the scalp from birth pressure.
C. junction of individual skull bones. 41. Which of the following drugs can be given to the
D. pressure of a vacuum extractor. mother before a preterm birth to help reduce the severity
of respiratory distress syndrome?
34. Signs of respiratory distress in a neonate include: A. Betamethasone
A. grunting with expiration. B. Diazepam
B. respiratory rate of 50 breaths per minute. C. Phenobarbital
D. RhoGAM D. Use the stairs to increase activity level
42. Which intervention is the priority immediately after 49. A mother receiving medications for pregnancy-
the delivery of a newborn who does not breathe? induced hypertension should have her diastolic blood
A. Clear air passages of obstructive substances pressure maintained in the range of 90 to 100 mmHg to:
B. Keep the mother calm A. avoid causing fetal anoxia.
C. Place bulb suction at head of the bed B. ensure progression of labor.
D. Rub the baby’s back C. prevent premature contractions.
D. present sudden elevations in pulse.
43. In which position should the newborn with
intracranial hemorrhage be placed? 50. Which of the following would be a priority
A. Prone intervention for a client with the prolapsed cord?
B. Side-lying A. Cover the cord with a dry sterile tower
C. Slightly elevated head of bed B. Monitor the mother’s vital signs
D. Supine C. Place the woman in the Trendelenburg position
D. Start medication as ordered
44. Which of the following contraceptive methods also
offers protection against sexually transmitted infections? 51. Juday has been experiencing regular, coordinated
A. Abstinence contractions with cervical dilation moving from 4 cm to 6
B. Coitus interruptus cm in the last half, and her membranes are still intact.
C. Fertility awareness methods Juday is in which of the following stages of labor?
D. Oral contraceptives A. Latent phase of the second stage of labor
B. Active phase of the first stage of labor
45. In teaching the postoperative client who has just had C. Placental stage or the third stage of labor
a vasectomy, it is important to focus on: D. Predelivery stage or the prelabor stage of labor
A. asking how his partner feels about the surgery.
B. alternate methods of expressing sexual needs and 52. Lhia is admitted in active labor. The nurse locates
desires fetal heart sounds in the upper left quadrant of her
C. discussing that a vasectomy does not make client less abdomen. The nurse recognizes which of the following?
of a man A. Lhia will probably deliver very quickly and without
D. using birth control until sperm counts are zero for 6 problems.
weeks. B. This indicates Lhia will probably have a breech
delivery.
46. Which assessment most closely relates to a diagnosis C. The fetus is in the most common anterior fetal
of ectopic pregnancy? position.
A. Brownish red, tapioca-like vesicles D. This position is referred to as being left anteropelvic.
B. Elevated temperature
C. Spotting or bleeding 2 to 3 weeks after a missed 53. After the third stage of labor, the nurse may have
menstrual period which of the following responsibilities?
D. Sudden absence of fetal movement A. Administration of intramuscular oxytocin to facilitate
uterine contractility.
47. The drug of choice to treat pregnancy-induced B. Monitoring for blood loss greater than 60 cc, which
hypertension is: would indicate gross hemorrhage.
A. iron and vitamins C. Noting if the placenta makes a Schultze presentation,
B. diazepam (valium) which is a sign of gross complication.
C. furosemide (Lasix) D. Pushing down on the relaxed uterus to aid in the
D. magnesium sulfate removal of the placenta

48. Which nursing intervention would be appropriate for 54. Which action of the following instructions to a child
a client who has a diastolic blood pressure of more than would be most appropriate before a painful procedure?
20 mmHg on the “roll-over” test? A. “Do not tell the child anything, just proceed with the
A. Increase intake of oral fluids procedure.
B. Rest on left side as much as possible B. “This won’t hurt at all.”
C. Schedule follow-up care every 2 weeks C. “This is going to hurt.”
D. “Would you like t help me?” D. hyperglycemia
55. Which method would be helpful when administering 61. Which of the following should the examiner do to
liquid medication to a preschool-aged child? assess for scoliosis?
A. Ask the child if he/she would like to take the A. Assist the child to look in a mirror for characteristic
medication from a cup or spoon. curing.
B. Give the child a drop or two of liquid over an hour top B. Have the child place the chin on the chest, place
help prevent spitting it out. hands together, bend over, and let the hands hang freely.
C. Tell the child the medicine is sweet candy syrup that C. Have the child turn sideways, and look for bulging in
he/she will like. the thoracic region.
D. Tell the child firmly to take the medicine. D. Palpate the spine for indentation in the lower back.
56. After a tubal ligation, it is not uncommon for the 62. During an episode of somnambulism, it would be
woman to complain of: appropriate for the nurse to:
A. shoulder pain. A. ask the child what he/she is doing
B. hemorrhoids. B. immediately wake the child.
C. leg pain. C. pull the child back to bed.
D. breast tenderness. D. observe for safety measures to avoid injury.
57. When examining a postpartal woman, the nurse 63. Which instruction should the nurse provide the
should immediately report: adolescent who is experiencing acne?
A. a fundus that is palpated 2 cm below the umbilicus on A. Avoid chocolate in the diet.
the second postpartal day. B. Inspect skin for adverse reactions to treatment.
B. a fundus that cannot be located by palpation on the C. Pop pimples only when they are white with pus.
ninth postpartal day. D. Scrub skin twice a day with prescribed medication.
C. a soft, spongy uterine fundus noted during the first
four hour postpartum. 64. Which of the following is an inappropriate technique
D. red, bloody vaginal discharge on the perineal pad on to use when giving a back rub?
the first day postpartum. A. Long, even upward strokes
B. Tapping lightly with the edge of the hand
58. Which of the following clinical practices is C. Firm scratching motion
appropriate to solicit initial respiration of the high-risk D. Application of lotion
newborn?
A. Rubbing the back 65. You are giving a parenting class. You will discuss
B. Spanking the buttocks which of the following with the parents of Dora, a 2-year
C. Slapping the face old child?
D. Squeezing the thorax A. Dora can be expected to be cooperative and easily
cooperative and easily controlled at this stage of
59. On the third hospital day in the nursery, Mr. and Mrs. development.
Smith’s newborn baby girl Rhian is diagnosed with Rh B. Dora may prefer finger foods and clothing she can put
incompatibility. Mrs. Smith is a gravida 2, para 1, abortion on without assistance at this age.
1. This disease causes blood cell hemolysis that is C. Expect Dora to want to be held and cuddled a great
probably directly due to deal at this stage of her development.
A. the exchange of fetal and maternal blood in the utero D. At this age, Dora will take the initiative in activities
B. Rh positive fetus and Rh positive father and will question everything.
C. Rh negative mother, Rh positive father
D. the sin of the abortion of the first child 66. When obtaining vital signs, which of the following is
appropriate?
60. Baby girl Luisa was born large for gestational age. A. Oral temperature in children younger that 6 years
After being delivered vaginally, this infant should be B. Radial pulse in children older than 2 years
carefully assessed for: C. Rectal temperature in child with hematology disorder
A. increased intracranial pressure D. Tympanic temperature in child with ventilating tubes
B. hypothermia
C. decreased red blood levels (anemia)
67. When discharging a child from the hospital, it is most C. Vegetables

important for the nurse to document: D. Fruit
A. that child’s belongings were sent with caregivers.
B. reaction of child to staff. 74. Which of the following interventions might be most
C. teaching follow-up care to family caregivers. effective in preventing glomerulonephritis?
D. weight of the child on discharge. A. Daily administration of children’s multivitamins and
iron.
68. Which assessment findings most closely correlate B. Increasing all children’s fluid intake to 3 liters daily.
with the diagnosis of Tetralogy of Fallot? C. Prompt evaluation of childhood complaints of sore
A. Cyanosis throat.
B. Elevated blood pressure D. Teaching children to avoid promptly when the urge is
C. Normal weight felt.
D. Weak pulse in lower extremities
75. Which of the following would most likely be noted in
69. Which action would be most appropriate when caring a child with acute glomerulonephritis?
for a child with idiopathic thrombocytopenic purpura? A. Blood pressure of 90/40 mmHg
A. Administer enemas to promote bowel movements. B. Hypovolemia and signs of dehydration
B. Do not give intramuscular injections. C. Hematuria and pulmonary edema
C. Place child with head of bed elevated. D. Severe, foul-smelling diarrhea
D. Weigh daily at the same time.
76. A key developmental task of parenting is learning to
70. The most common chronic childhood illness is: determine if their child is crying from hunger, discomfort,
A. common cold. or some other reason.
B. diabetes mellitus. A. Preschooler
C. mumps. B. Infant
D. asthma.
C. Toddler
71. Which of the following considerations is appropriate D. School-age child
regarding children undergoing diagnostic procedures?
A. Parents should be asked to restrain infants when 77. Alice is 4 months of age. Her mother is singing to her.
indicated. What type of response should be expected of Alice?
B. Toddlers should be given procedures quickly and A. Imitating the sounds
without warning to decrease resistance. B. Smiling, cooing, and gurgling
C. Adolescents should be expected to tolerate C. Saying “da-da”
procedures maturely and without fear. D. Watching her mother’s face without making a sound
D. School-age children should be given thorough
explanations for procedures. 78. At what age should an infant begin to locate an object
hidden under a blanket?
72. After an endoscopy study, which of the following A. 6 months
interventions would be most important? B. 8 months
A. Pushing oral fluids immediately to promote C. 10 months
elimination of dye. D. 12 months
B. Monitoring airway and respiratory function for the
first 4 hours. 79. Which of the following would be most effective in
C. Applying a warm compress to the neck to reduce reducing the workload of the heart of a child with heart
spasm. failure?
D. Administering atropine to reduce pulmonary A. Bed rest in a semi-Fowler’s position
secretions. B. Digoxin administration daily, IV or orally
C. Oxygen therapy by mask, cannula or tent
73. The nurse is aware that of the following food D. Intravenous infusion of 2 to 3 liters daily
supplies, the better source of iron for the infant is which
of the following? 80. Crying is to avoided in a child who has had a cleft lip
A. Human breast milk repair because it
B. Iron-fortified cereals A. sustains a traumatic experience.
B. places tension on the suture line. 87. Mara, aged 6, is admitted to your unit after an
C. threatens maternal-infant bonding. automobile accident. You would suspect increased
D. predisposes to respiratory difficulties. intracranial pressure if your assessment revealed which of
the following?
81. To visualize the inner surface of a child’s lower eyelid A. Bradycardia rhythm
and most of the bottom globe, the nurse would B. Decreased pulse pressure
A. press on the lower lid with a finger tip. C. Hypotensive blood pressure
B. pull the top eyelid outward and up. D. Tachypnea
C. invert the top eyelid with a special apparatus.
D. use a cotton tip to flip the lower lid. 88. Which of the following are signs of autonomic
dysreflexia?
82. When teaching Carlo, 14 years old, to walk with A. Bradycardia and flushed face
crutches, the nurse should instruct his to B. Headache and hypertension
A. move one crutch forward at a time when using a C. Hypertension and pallor
three-point swing through gait. D. Pale skin and dizziness
B. carry books and other items in a backpack to keep his
hands free. 89. Bimby, 2 years old, has been diagnosed with cerebral
C. Rest the crutch pad on the upper arm to bear his palsy. The nurse should explain which of the following to
weight on the axilla crutch pad. Bimby’s parents?
D. use a two-point gait when no weight is allowed. A. Cerebral palsy involves a progressive nerve
generation.
83. Which of the following would be a serious danger B. Contractures are unavoidable since ambulation is
sign if noted in a child after head trauma? impossible.
A. Memory deficit with inability to recall time or date. C. The brain damage that occurred at birth can be
B. Complaint of headache along the area of trauma. repaired with surgery when the child is older.
C. Blood pressure moving from 120/80 mmHg to 130/50 D. Two children with cerebral palsy may exhibit totally
mmHg. different symptoms and abilities.
D. Pupils are equally and briskly reactive to light.
90. The nurse should expect which of the following
84. Jan, aged 13, is admitted with third degree burns over findings when assessing a child with acute otitis media?
25% of her body. Which of the following is an immediate A. Excessive cerumen in the outer ear
concern in Jan’s plan of care? B. Recent respiratory infection
A. Liberal medication to control Jan’s severe pain C. Increase mobility on the pneumatic examination
B. Arranging age-appropriate diversional activities D. Copious amount of tenacious fluid
C. Preventing hypovolemia and circulatory collapse
D. Increasing oral intake of proteins to build tissue 91. Because abuse involves and affects all the members
of a family, the nurse should have which of the following
85. Care of the child in coma would include as part of the care plan goals?
A. Encouraging parents to be positive since coma is A. Disrupting the dysfunctional family
often short term in children. B. Improving overall family functioning
B. Performing passive range of motion exercises to C. Punishing the abusive family member
maintain muscle tone. D. Removing the abuse victim from the family
C. Feeding the child with a spoon and fork to stimulate
memories of normal activities. 92. Surgery is stressful for all children, and emotional
D. Maintaining the child, in a flat, supine position to support should be included in the nurse’s plan of care.
simulate normal sleeping position. Which of the following is a useful intervention to prepare
the child before eye surgery?
86. Hypoglycemia in children may be caused by A. Showing the child a doll with patched over both eyes.
A. missing an insulin injection. B. Restraining the child at the wrist bilaterally for 24
B. missing a meal or a snack. hours
C. too small an insulin dose. C. Avoiding discussion of the impending surgery
D. too large a meal or snack. D. Introducing the child to other children on the unit

93. While observing a two-year old girl recently admitted A. assign chores appropriate to the child’s age.
to the hospital, the nurse becomes concerned by which of B. be flexible and lenient regarding limits.
the following characteristics? C. give instructions to this child in the group setting with
A. The child is not yet potty trained. the other siblings.
B. The child replies “no” to every position. D. delay punishing the child to allow the child to think
C. The child cannot share toys. about mistakes.
D. The child recognizes 4-6 words.
100.Which of the following is commonly seen in children
94. Nurse Olive who works in an adolescent clinic knows with anorexia nervosa?
that obesity A. Morbid obesity
A. in teenagers, is commonly due to hypothyroidism, B. Ingesting copious amounts of water
hypopituitarism, or other endocrine problem. C. Body mass index above 85% of expected
B. is no more likely to be associated with emotional D. Binge eating and purging
conflicts in teenagers who are not obese, than in
teenagers who are obsess.
C. during adolescence, is highly correlated with
significant psychopathology.
D. is often associated with poor recognition of either
hunger of satiation.
95. An 18-month old is being admitted with a diagnosis of

Wilm’s tumor. Which nursing intervention takes priority?
A. Checking vital signs every 8 hours for incidence of
hypertension.
B. Placing a sign over the bed which says, “Do not
palpate the abdomen”.
C. Raising the head of the bed to ease breathing.
D. Monitoring the urinary output every 2 hours.
96. Children who have brain tumor will have which of the
following symptoms?
A. Abdominal pain
B. Vomiting
C. Hypotension
D. Diarrhea
97. Clara is 15 years old ad is admitted to the hospital

with anorexia nervosa. She is a model and often spoken as
an overachiever. As the nurse interviews Clara and her
family, she may discover other characteristics such as
A. early development of secondary sex characteristics.
B. amenorrhea.
C. permissive parenting.
D. hyperglycemia.
98. Mateo, a child with an IQ of 44, would be categorized

as having which type of mental retardation?
A. Mild
B. Moderate
C. Severe
D. Profound
99. When providing anticipatory guidance to parents of a

hyperactive child, the nurse would encourage them to

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1 MATERNAL AND CHILD NURSING

MATERNAL AND CHILD NURSING A. douching after sexual intercourse.

D. RhoGAM D. Use the stairs to increase activity level

D. “Would you like t help me?” D. hyperglycemia

67. When discharging a child from the hospital, it is most C. Vegetables

95. An 18-month old is being admitted with a diagnosis of

97. Clara is 15 years old ad is admitted to the hospital

98. Mateo, a child with an IQ of 44, would be categorized

99. When providing anticipatory guidance to parents of a

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