MCN REVIEW GUIDE
QUESTIONS
1. A baby girl is born 8 weeks
premature. At birth, she has
no spontaneous respirations
but is successfully
resuscitated. Within several
hours she develops
respiratory grunting,
cyanosis, tachypnea, nasal
flaring, and retractions. She’s
diagnosed with respiratory
distress syndrome, intubated
and placed on a ventilator.
Which nursing action should
be included in the baby’s
plan of care to prevent
retinopathy of prematurity?
ANSWER: PARTIAL
PRESSURE OF OXYGEN
(Pao2) LEVELS
2. Andrea has no spontaneous
respiration at birth. Suppose
her amniotic fluid is heavily
stained with meconium.
Which would be your best
action?
ANSWER: KEEP HER
WARM UNTIL A
LARYNGOSCOPE CAN BE
PASSED
3. Which of the following
manifestations in a six month
old infant who was born
prematurely would lead a
nurse to suspect that the
infant has apnea?
ANSWER: A BASE OF
SPONTANEOUS
BREATHING FOR 20
SECONDS OR MORE
4. Heat regulation is the most
critical factor for a newborn’s
survival next to establishing
respiration. Which of the
following characteristics of
newborns predispose them to
poor heat regulation?
ANSWER: NEWBORNS
CANNOT SHIVER YET
5. Hypothermia is common in
newborn because of their
inability to control heat. The
following would be an
appropriate nursing
intervention to prevent heat
loss EXCEPT:
ANSWER: PLACE THE CRIB
BESIDE THE WALL
6. Which of the following is the
most important concept
associated with the high-risk
newborn?
ANSWER: SUPPORT THE
HIGH-RISK NEWBORN’S
CARDIOPULMONARY
ADAPTATION BY
MAINTAINING ADEQUATE
AIRWAY
7. Which of the following
nursing diagnoses would be
given priority in the care of a
newborn one hour of age?
ANSWER: ACTIVE
THERMOREGULATION
8. After therapeutic
interventions, a newborn
demonstrates adequate lung
expansion. The amount of
pressure that would enable
her to continue to re-inflate
the alveoli of her lungs would
be:
ANSWER: 15-20 CM H20
9. A nurse in the nursery is
caring for a neonate. On
assessment, the infant is
exhibiting grunting,
tachypnea, nasal flaring and
grunting. Respiratory distress
syndrome is diagnosed and
the physician prescribed
surfactant replacement
therapy by:
ANSWER: INSTILLATION
OF THE PREPARATION
INTO THE LUNGS
THROUGH AN
ENDOTREACHEAL TUBE
10. The reason nurse May
keeps the neonate in a
neutral thermal environment
is that when a newborn
becomes too cool, the
neonate requires:
ANSWER: MORE OXYGEN,
AND THE NEWBORN’S
METABOLIC RATE
INCREASES
11. The most common
adaptation of a child with
Tetralogy of Fallot
ANSWER: CLUBBING
FINGERS
12. Usually PDA closes as
the oxygen level increases
and the prostaglandin levels
fall. If it does not close, which
of the following drugs given?
ANSWER: INDOMETHACIN
13. During assessment of a
newborn diagnosed with a
cardiac anomaly, you
detected that the infant’s
femoral pulses are absent.
Which of the following
diseases is most likely
presented by the symptom?
ANSWER: COARACTATION
OF THE AORTA
14. The family is caring for
their youngest child Justin
who is suffering from
Tetralogy of Fallot. Which of
the following are defects
 associated with this
congenital heart condition?
ANSWER: VENTRICULAR
SEPTAL DEFECT,
OVERRIDING AORTA,
PULMONIC STENOSIS AND
RIGHT VENTRICULAR
HYPERTROPHY
15. A parent of an infant
who has a small atrial septal
defect makes all of the
following comments. Which
one indicates an accurate
understanding of the infant’s
condition?
ANSWER: MY BABY NEEDS
TO HAVE A HEART
SURGERY IMMEDIATELY
16. A 4-year-old with
Tetralogy of Fallot is seen in a
squatting position near his
bed. The nurse should:
ANSWER: TAKE NO
ACTION IF HE LOOKS
COMFORTABLE BUT
CONTINUE TO OBSERVE
HIM
17. Meconium aspiration
syndrome (MAS) can be
prevented by:
ANSWER: SUNCTIONING
MOUTH, NOSE AND
POSTERIOR PHARYNX
JUST AFTER THE HEAD IS
DELIVERED
18. Myer, 2 months is
suspected of having
coarctation of the aorta. The
cardinal sign of this defect is:
ANSWER: UPPER
EXTREMITY
HYPERTENSION
19. A 10-year old boy who
is suspected of having
coarctation of the aorta is
hospitalized. It is essential
that the nurse performs
which of the following during
the initial physical
examination?
ANSWER: MONITORING BP
IN ALL FOUR EXTREMITIES
20. When assessing a
newly delivered neonate, the
nurse notes the following
findings: Arms and legs
slightly flexed; skin smooth
and transparent; abundant
lanugo on the back; slow
recoil of pinna; and few sole
creases. In light of these
findings, the care plan for
this neonate should include
nursing orders to monitor for:
ANSWER: RESPIRATORY
DISTRESS SYNDROME
21. Which independent
nursing intervention are
appropriate for a client who is
experiencing alteration in
oxygenation? SATA.
ANSWERS:
 Assisting with
positioning,
 Monitoring activity
intolerance,
 Encouraging deep
breathing exercises
 Provide suctioning
22. Five days after
admission, you have noted
on assessment the presence
of machinery like murmur
during heart auscultation,
wide pulse pressure and
decreased diastolic blood
pressure. Which congenital
cardiac anomaly is most
likely to be present?
ANSWER: PATENT DUCTUS
ARTERIUSUS
23. During assessment of a
newborn diagnosed with a
cardiac anomaly, you
detected that the infant’s
femoral pulses are absent.
Which of the following
diseases is most likely
presented by the symptom?
ANSWER: COARACTATION
OF THE AORTA
24. You are conducting a
preoperative teaching to the
parents of a child who is to
undergo a cardiac surgery for
correction of septal defect.
Which of the following should
you include in the health
teaching?
ANSWER: CONCEPT OF
PAIN MANAGEMENT
25. When developing the
initial plan of care for a
neonate who was born at 41
weeks’ gestation, was
diagnosed with Meconium
Aspiration Syndrome (MAS),
and requires mechanical
ventilation, which of the
following should the nurse
include
ANSWER: CARE OF AN
UMBILICAL ARTERIAL LINE
26. Which data supports
the Nurse’s assessment that
a newborn with acute
respiratory distress syndrome
is improving?
ANSWER: OXYGEN
SATURATION OF 92%
27. The Nurse admits in
the pediatric ward an infant
with respiratory distress.
Expected assessment would
be:
 ANSWER: NASAL FLARING
28. Baby Elmo has
surfactant administered at
birth. The purpose of
surfactant is to:
ANSWER: PREVENT
ALVEOLI FROM
32.
COLLAPSING ON
EXPIRATION
29. Baby Jenny who is
small-for-gestation is at
increased risk during the
transitional period for which
complication?
ANSWER: POLYCYTHEMIA
PROBABLY DUE TO
33.
CHRONIC FETAL HYPOXIA
30. Small for gestation age
newborns are at risk for
difficulty of maintaining body
temperature due to:
ANSWER: THE DO NOT
34.
HAVE AS MUCH FAT
STORES AS DO OTHER
INFANTS
31. A Nurse is assessing a
newborn who was born at 32
weeks gestation. Which of
the following would the Nurse
most likely find? SATA
ANSWERS:
 Ruddy skin,
 Copious vernix
caseosa,
 Scant lanugo
 High pitched cry
An insulin dependent
diabetic delivered a 10-pound
male. When the baby is
brought to the nursery, the
priority care is to
ANSWER: CHECK THE
BABY’S SERUM GLUCOSE
LEVEL AND ADMINISTER
GLUCOSE IF <40MG/DL
The physical finding
you would expect to be seen
in Jezie because of
prematurity is:
ANSWER: LACK OF SOLE
CREASES ON HER FEET
Which of the following
would the nurse need to
incorporate in the plan of
care for a newborn who is
large for gestational age
(LGA)? SATA
ANSWER:
 Observe closely for
signs of
hyperbilirubinemia
 Decrease stimulation
such as holding and
 talking to prevent
seizure
 Be alert for
respiratory problems
due to increased
intracranial pressure
 Assess for possible
impaired parenting
due to newborn’s
high-risk status
35. Baby girl Andrea born
vaginally was determined to
be large for gestational age.
The nurse would assess this
newborn carefully for:
ANSWER: INCREASED
INTRACRANIAL PRESSURE
36. Which of the following
newborn characteristics
would suggest that there was
nutritional deprivation during
fetal growth?
ANSWER: WIDELY
SEPARATED SUTURES
37. Therese has just given
birth at 42 weeks’ gestation.
When the nurse assesses the
neonate, which physical
finding is expected?
ANSWER: DESQUAMATION
OF EPIDERMIS
38. Baby Jeorge develops
hyperbilirubinemia. What is a
method used to treat
hyperbilirubinemia in a
newborn?
ANSWER: EARLY FEEDING
TO SPEED PASSAGE OF
MECONIUM
39. The following are signs
and symptoms of
Intussusception. SATA
ANSWERS:
 Abdominal pain
 Currant Jelly Stool
 Sausage Shaped
Mass
 Draw legs towards
the chest
40. All of the following are
included in the Assessment in
Metabolic Alkalosis. SATA
ANSWERS:
 The child will breath
slowly and hallowly
 pH will be elevated
(near or above 7.45)
 Hc03 level will be
near or above 28
mEq/L
41. Metabolic acidosis may
result from diarrhea. When
diarrhea occurs, a great deal
of sodium is lost with stool.
This excessive loss of Na, in
turn, causes the body to
conserve Ions in an attempt
to keep the total number of
positive and negative ions in
serum balanced. As a result,
all of the following will occur
except:
ANSWER: ARTERIAL
BLOOD GAS ANALYSIS
WILL REVEAL AN
INCREASED pH
42. A Nurse is preparing to
care for a child with a
diagnosis of
Intussusceptions. The Nurse
reviews the child’s record
and expects to note which
symptom of this disorder
documented?
ANSWER: BRIGHT RED
AND MUCUS STOOL
43. For a child with
diagnosis of Hirschsprung’s
disease, you expect the
child’s stool to be
ANSWER: RIBBON LIKE
STOOL
44. In Hypertonic
Dehydration water is lost in a
greater proportion than
electrolytes and it occurs
when fluid intake decreases
in conjunction with a fluid
loss increase. It occurs in a
child with: SATA
ANSWERS:
 Nausea
 Fever
 Profuse diarrhea
 Renal disease
45. Signs and symptoms of
hypnotic dehydration
includes all the following
except:
ANSWER: INCREASED
URINE OUTPUT
46. Hypotonic dehydration
occurs when there is a
disproportionately high loss
of electrolytes relative to
fluid lost. The plasma
concentration of sodium and
chloride will be low. This
could result from all of the
following except:
ANSWER: EXCESSIVE
INTAKE OF SALT
ASSOCIATED WITH GREAT
GAIN THROUGH INTAKE
47. The child has cleft lift.
Chieloplasty was done. What
is the post operativce nursing
care to be observe? SATA
 ANSWERS:
 Place the infant in
supine position
 Maintain patent
airway
 Clean the suture line
using water
48. The most common
diagnostic procedure used for
Hirschsprung’s disease and
Intussusception is Barium
Enema:
ANSWER: TRUE
49. What is the most
common complication if the
child has cleft palate?
ANSWER: OTITIS MEDIA
50. The following are signs
and symptoms of
Intussusception: SATA
ANSWER:
 Distended abdomen
 Dance’s sign
 Hematochezia
51. When diarrhea occurs,
or when a child becomes
diaphoretic because of fever,
the fluid output can be
markedly decreased.
ANSWER: FALSE
52. Infants do not
concentrate urine as well as
adults because their kidneys
are immature.
ANSWER: TRUE
53. Isotonic dehydration is
when a child’s body loses
more water than it absorbs
(as with diarrhea) or absorbs
less fluid than it excretes (as
with nausea and vomiting).
As a result, all of the
following will occur. SATA
ANSWERS:
 There will be a
decrease in the
volume of blood
plasma
 The body
compensates for this
rapidly by shifting
interstitial fluid in
the volume of blood
plasma
54. Overhydration is
serious as dehydration
because the ECF overload
can lead to cardiovascular
overload and cardiac failure.
All of the following are true
about overhydration except:
ANSWER: THE EXCESS
FLUID IN THESE
INSTANCES IS USUALLY
 INTRAVASCULAR AND  Echocardiography
INTERSTITIAL Colored doppler
 MRI
 ECG
55. Postoperative nursing
care to an infant with cleft 60. It is a type of
palate includes positioning congenital heart disease
into: which is an abnormal
communication between the
ANSWER: PRONE two atria, allowing blood to
TRENDELENBURG shift from left to the right
POSITION atrium Causing an increase in
the volume in the right side
of the heart and generally
56. Postoperative nursing results in ventricular
hypertrophy and increased
care to an infant with cleft lift
pulmonary artery blood flow
includes positioning into:
ANSWER: ATRIAL SEPTAL
ANSWER: SUPINE DEFECT
POSITION
61. It is a type of Atrial
Septal Defect wherein the
57. It is the most common opening is at the lower end of
type of congenital heart the septum
disease wherein the pressure ANSWER: OSTIUM
in the left ventricle is greater PREMIUM (ASD1)
than in the right ventricles
ANSWER: VENTRAL 62. It is a type of Atrial
SEPTAL DEFECT Septal Defect wherein the
opening is near the center of
58. It Indicates the the septum
presence of a defect that ANSWER: OSTIUM
permits the passage of blood SECUNDUM (ASD2)
from the higher pressure, left
sided cardiac chamber to a 63. What are the
lower pressure, right sided manifestations of a patient
cardiac chamber. with Atrial Septal Defect?
ANSWER: ACYANOTIC SATA
HEART DISEASE/ ANSWER:
INCREASED PULMONARY  Harsh systolic
BLOOD FLOW murmur over the 2nd
or 3rd interspace
59. How Ventral septal (pulmonic area)
defect diagnose. SATA  Enlarged right side
ANSWERS: of the heart
  Increased pulmonary 68. It occurs when blood is
circulation shunted from the venous to
 Separation in the the arterial system as a
atrial septum result of abnormal
 Increased oxygen communication between the
saturation in the two system (deoxygenated
right atrium blood to oxygenated blood)
or RIGHT-LEFT shunts.
64. What are the most ANSWER: CYANOTIC
common diagnostic HEART DISEASE/
procedure for Atrial Septal DECREASED PULMONARY
defect? BLOOD FLOW
ANSWER:
 Echocardiography 69. What will happen when
 Cardiac there is a decreased
catheterization pulmonary blood flow that
 Doppler involves obstruction in the
pulmonary artery? SATA
65. What to observe in ANSWER:
postoperative client with  Increases pressure
Atrial Septal defect? in the right side of
ANSWER: OBSERVE FOR the heart
ARRHYTHMIAS  Deoxygenated blood
shunts from right to
66. A Nurse is assessing a left RESULTING in
newborn who was diagnose deoxygenated blood
with PDA. Which of the invading the
following would the Nurse systemic circulation
most likely find? SATA
ANSWERS: 70. It is an extremely
 Wide pulse pressure serious disorder because the
 Low diastolic tricuspid valve is completely
pressure closed allowing no blood to
 Machinery murmur flow from the right atrium to
 ECG is normal – but the right ventricle.
may show ventricle ANSWER: TRICUSPID
enlargement if the ATRESIA
shunt is large
71. Tricuspid Atresia causes
67. The most common blood to cross through the
diagnostic procedure used for patent foramen ovale into
PDA is: the left atrium, bypassing the
ANSWER: lungs. What will be develop
ECHOCARDIOGRAPHY into an infant if the shunts
are close? SATA
ANSWER:
  Extreme Cyanosis presented by these
 Tachycardia symptoms?
 Dyspnea ANSWER: TETRALOGY OF
FALLOT
72. Which nursing
management should be 75. It is a procedure in
included in the baby’s plan of treating Tetralogy of Fallot
care in treating Tricuspid wherein it relieves pulmonary
Atresia? stenosis, VSD and overriding
ANSWER: aorta.
 IV infusion of PGE1 ANSWER: BROCK
 Surgery PROCEDURE

73. What are the four (4) 76. It is a procedure in

anomalies present in treating Tetralogy of Fallot
Tetralogy of Fallot? SATA wherein it creates a shunt
ANSWER: between the aorta and the
 VSD pulmonary artery (creating a
 Dextroposition ductus arteriosus to allow
(overriding) of the blood to leave the aorta and
aorta enter the pulmonary artery,
 Hypertrophy of the oxygenate the lungs and
right ventricle return to the left side of the
 Pulmonary stenosis heart, the aorta and the
body.
74. During assessment of a ANSWER: BLALOCK-
newborn diagnosed with a TAUSSIG PROCEDURE
cardiac anomaly, you
detected that the infant’s 77. What are the
Skin is cyanotic/bluish, there therapeutic management
is a presence of should be included in the
polycythemia, severe baby’s plan of care in
dyspnea, growth restriction, treating Tetralogy of Fallot?
clubbing of the fingers, ANSWER:
squatting/knee chest position  Surgery- to connect
when resting, Syncope the heart defects
(fainting), Hyper cyanotic  Place the baby in a
episodes (spells), Cognitive knee chest
challenge, Loud, harsh,  Administer oxygen
widely transmitted murmur  Administer morphine
or a soft, scratchy localized sulfate
systolic murmur in the left  Administer Oral
second, as well as third or Propanolol
fourth parasternal interspace
may be present. Which 78. It is the narrowing of
disease is most likely the pulmonary valve or the
 pulmonary artery jut distal to
the valve and Inability of the 82. What are the 2
right ventricle to evacuate locations of coarctation of the
blood by way of the aorta? SATA
pulmonary artery because of ANSWER:
the obstruction leads to right  Preductal
ventricular hypertrophy.  Postductal
ANSWER: PULMONARY
STENOSIS 83. During assessment of a
newborn diagnosed with a
79. A Nurse is assessing a cardiac anomaly, you
newborn who was diagnose detected that the infant’s
with Pulmonary Stenosis. brachial pulses are absent.
Which of the following would Which of the following
the Nurse most likely find?
diseases is most likely
SATA
presented by the symptom?
ANSWERS:
 Symptomatic, ANSWER: COARCTATION
Cyanosis, Thrill OF THE AORTA
 Systolic ejection
murmur 84. What are the signs and
 signs of mild (right- symptoms of lower BP in the
sided) heart failure lower extremities? SATA
 Widely split of the ANSWERS:
2nd heart sound  Leg pain on exertion
 Cold feet
80. It is the most common  Muscle spasms
therapeutic management of  Pulse is weak,
Pulmonary Stenosis wherein delayed or even
a catheter with an uninflated absent
balloon at its tip is inserted
and passed through the heart 85. What are the signs and
into the stenosed valve. symptoms of higher BP in
ANSWER: BALLOON upper extremities? SATA
ANGIOPLASTY ANSWERS:
 Headache
81. It is the leading cause  Epistaxis
of congestive heart failure in  Pulse in the upper
the first few months of life extremities will be
wherein there is narrowing of rapid and bounding
the lumen of the aorta due to
constricting band and occurs 86. It is a surgery
most frequently in boys than procedure done to a patient
in girls with Coarctation of the Aorta
ANSWER: COARCTATION where in the narrowed
OF THE AORTA portion of the aorta is
 removed and the new ends of maintain the entire heart
aorta are anastomosed. Also, action.
a graft of transplanted ANSWER: HYPOPLASTIC
subclavian artery may be LEFT HEART SYNDROME
necessary if the narrowed
section is so extensive than 90. What are the
an anastomosis cannot be therapeutic management
accomplished readily. should be included in the
ANSWER: baby’s plan of care in
INTERVENTIONAL treating Hypoplastic Left
ANGIOGRAPHY (BALLOON Heart syndrome?
CATHETER) ANSWER:
 Ultrasound –
87. A Nurse is assessing a prenatally
newborn who was diagnose  Echocardiography
with Transposition of the  Prostaglandin
Great Arteries. Which of the therapy- to maintain
following would the Nurse a PDA---to increase
most likely find? SATA blood supply to the
ANSWERS: aorta
 Cyanotic from birth  Heart
 Enlarged heart transplantation- to
 Heart changes prolonged the child’s
 Low oxygen life
saturation
91. A system that plays a
88. A Nurse is assessing a major role in maintaining
newborn who was diagnose fluid, electrolyte, acid–base
with Total Anomalous balance and serves as the
Pulmonary Venous Return. main route by which
Which of the following would substances are taken into the
the Nurse most likely find? body and can be a major
SATA source of loss if vomiting or
ANSWERS: diarrhea occurs.
 Absent spleen ANSWER:
 Mildly cyanotic GASTROINTESTINAL
 Easily gets tired TRACT

89. It is a type of cardiac 92. Fluid is normally

anomaly wherein the left obtained by the body through
ventricle is nonfunctional. oral ingestion of fluid and by
There is a Lack of adequate
the water formed in the
strength to pump blood into
the systemic circulation metabolic breakdown of food.
causes the right ventricle to
ANSWER: TRUE
hypertrophy as it tries to
93. In infants, the relatively  the osmotic
greater surface area to body pressure in
mass also causes a greater extracellular spaces
insensible loss. decreases.
 The kidneys begin
ANSWER: TRUE to excrete more
94. Fluid intake is altered fluid to decrease
when a child is nauseated ECF volume and
and unable to ingest fluid or bring the proportion
is vomiting and losing fluid of electrolytes and
ingested. fluid back into line.
ANSWER: TRUE  This may lead to a
secondary
extracellular
95. It occurs when water dehydration
and salt are lost in proportion
to each other 100. It is as serious as
ANSWER: ISOTONIC
dehydration because the ECF
DEHYDRATION
overload can lead to
96. It occurs when water is cardiovascular overload and
lost out of proportion to salt cardiac failure.
or water depletion. ANSWER:
ANSWER: HYPERTONIC OVERHYDRATION
DEHYDRATION
101. What are the
97. Fluid shifts from the
interstitial and intracellular manifestations that body
spaces into the bloodstream serum is becoming acidotic?
(from areas of less osmotic SATA
pressure to areas of greater ANSWERS:
pressure).  The pH of blood is
ANSWER: TRUE normally slightly
10alkaline, ranging
98. Dehydration occurs in
the interstitial and from 7.35 to 7.45.
intracellular compartments.  PCO2 (the amount of
ANSWER: TRUE dissolved carbon
dioxide in arterial
99. What will happen when blood) is normally 35
low levels of electrolytes to 45 mm Hg.
occur? SATA
 The level of
ANSWERS:
bicarbonate (HCO3)
 in arterial blood is alkalosis results from
normally 22 to 26 vomiting?
mEq/L.
ANSWER: HYPOKALEMIA

102. What will happen when

105. DOES THE WHOLE
there is an excessive loss of
SECTION OF LYDIA HALL WILL
Sodium?
BE ABLE TO PASS THE FINAL
ANSWER:
EXAMINATION?
 A child becomes
ANSWER: ABSOLUTELY
acidotic as the YES!
number of Ions in
the blood increases
106. A nurse in the nursery
proportionately over
is monitoring a preterm infant
the number of oh for respiratory distress
ions present. syndrome. Which assessment
 Arterial blood gas signs if noted in the newborn
analysis will reveal a would alert the nurse to the
decreased pH (under possibility of this syndrome?
7.35) ANSWER: TACHYPNEA AND
 low hco3 value (near RETRACTIONS
or below 22 mEq/L).
107. For Hirschsprung’s disease, there is
103. In assessing Metabolic no stool in the rectum.
Alkalosis. Which of the
ANSWER: TRUE
following would the Nurse
most likely find?
ANSWERS: 108. A child diagnosed with
intussusceptions. The nurse performs
 The child will
an assessment on a child knowing
breathe slowly and that which of the following is a
shallowly characteristic of this disorder?
 pH will be elevated ANSWER: INVAGINATION OF A
(near or above 7.45) SECTION OF THE INTESTINE
 HCO3 level will be INTO THE DISTAL BOWEL
near or above 28
mEq/L 109. The GI system play a major
role in maintaining fluid, electrolyte,
and acid-base balance. The GI
104. Barry has frequent system often is involved with two
bouts of vomiting. What severe acid-base imbalances which is
secondary electrolyte problem ANSWER: METABOLIC ACIDOSIS
often occurs when metabolic AND METABOLIC ALKALOSIS
110. The following are signs and
symptoms of intussusceptions
except

ANSWER: SLOW PR