Patient Rhea, already lying in the labor rooom, is having intense pain

all over her abdomen. Which comfort measure should nurse Dina use to
assist Rhea, a laboring woman to relax?
*
1/1
Recommend frequent position changes.
Palpate her filling bladder every 15 minutes.
Offer warm wet cloths to use on the client's face and neck.
Keep the room lights lit so the client and her coach can see everything.

Which of the following approaches by nurse Ted, assigned in the

Pediatric ward, is most reassuring to both the mother and her toddler
patient?
*
0/1
getting acquainted with the toddler before talking to the mother
having the mother hold the child while talking to the mother
. having the nurse aide hold the child while talking with the mother
holding the toddler while talking to the mother

Correct answer
having the mother hold the child while talking to the mother

On admission, nurse Helen is taking the child's weight for the following
purpose EXCEPT:
*
1/1
as basis for child's nutritional status
to determine child's approximate age
as basis for the dose for drug doctor will give
to determine if child's growth is within the normal

Jessa a 3 months pregnant woman is having her prenatal visit. She

tells nurse Tina that she doesn't know what is happening; one minute
she's happy that she is pregnant, and the next minute she cries for no
reason. Which response by nurse Tina is most appropriate?
*
1/1
"Don't worry about it; you'll feel better in a month or so."
"Have you talked to your husband about how you feel?"
"Perhaps you really don't want to be pregnant."
"Hormonal changes during pregnancy commonly result in mood swings."

Nurse Yeli is a nurse who is taking care of Jericho, a 16-year old male
patient. The best principle to consider when taking care of the
adolescent is:
*
1/1
consider them totally capable of their case
give them total assistance because anyone who is sick deserves it
consider the principle of doing activities with them rather than for them
give assistance only when requested to foster independence

Nurse Odette in the postpartum unit is assessing a newborn for signs

of breast-feeding problems. Which findings by Odette indicate a
problem? Select all that apply.
*
3/3
The infant exhibits fullness after being breastfed.
The infant exhibits dimpling of the cheeks.
The infant makes smacking or clicking sounds.
The infant who burps after breastfed.
The infant falls asleep after feeding less than 5 minutes.

Antonette is a pregnant woman at 18 weeks of gestation calls the

clinic to report that she has been experiencing occasional backaches
of mild-to-moderate intensity. Nurse Gina would recommend that she
Antonette:
*
1/1
Do Kegel exercises.
Do pelvic rock exercises.
Use a softer mattress.
Stay in bed for 24 hours.

Lilibeth is a woman who is 14 weeks pregnant tells nurse Jen that

she always had a glass of wine with dinner before she became
pregnant. Lilibeth has abstained during her first trimester and would
like to know if it is safe for her to have a drink with dinner now. Nurse
Jen would tell her:
*
1/1
"Since you're in your second trimester, there's no problem with having one drink with dinner."
"One drink every night is too much. One drink three times a week should be fine."
"Since you're in your second trimester, you can drink as much as you like."
"Because no one knows how much or how little alcohol it takes to cause fetal problems, the best course is
to abstain throughout your pregnancy."

Zenny is a woman who is gravida 3, para 2, enters the intrapartum

unit. She was attended and taken care by nurse Lucy. The most
important nursing assessments by Lucy to pateint Zenny are:
*
0/1
contraction pattern, amount of discomfort, and pregnancy history.
fetal heart rate, maternal vital signs, and the woman's nearness to birth.
last food intake, when labor began, and cultural practices the couple desires.
identification of ruptured membranes, the woman's gravida and para, and her support person.

Correct answer
fetal heart rate, maternal vital signs, and the woman's nearness to birth.
Feedback
All options describe relevant intrapartum nursing assessments, but the focus assessment has priority. If the
maternal and fetal conditions are normal and birth is not imminent, other assessments can be performed in an
unhurried manner. Contraction pattern, amount of discomfort, and pregnancy history are important nursing
assessments but do not take priority if the birth is imminent. Last food intake, when labor began, and cultural
practices the couple desires is an assessment that can occur later in the admission process, if time permits.
Identification of ruptured membranes, the woman's gravida and para, and her support person are assessments
that can occur later in the admission process if time permits.

Primavera is a premature infant who never seems to sleep longer than

an hour at a time. Each time a light is turned on, an incubator closes,
or people talk near her crib, she wakes up and inconsolably cries until
held. What is the correct nursing diagnosis beginning with "ineffective
coping, related to"?
*
1/1
Severe immaturity
Environmental stress
Physiologic distress
Behavioral responses

Beatrice is a nurse and a mother to a one year old daughter. The best
way Betrice can help her child complete the developmental task of the
first year is to:
*
0/1
ignore the child's cry to teach him tolerance
talk to him at scheduled times each day
introduce opportunities to hear music daily
keep the child's primary caregivers to as few as possible

Correct answer
keep the child's primary caregivers to as few as possible

Patient Carlos, a 9-year old child keeps on crying as he is in pain and

nervous on his upcoming surgical operation.Which of the following
nursing action by Nurse Jessica can encourage best the emotional
growth of a hospitalized child?
*
0/1
adhering strictly to hospital rules
allowing the child to mingle freely with other patients
allowing the child to have all his wants
accepting the child as he is

Correct answer
accepting the child as he is

Nurse Helen is caring for Irene, a postpartum client who delivers her
baby via cesarean section. Which finding should make nurse Helen
suspect endometritis in Irene?
*
1/1
dizzziness right after delivery
fever 2 days post partum
lethargy right after delivery

Nurse Cynthia is a senior nurse asigned in the maternity and labor

room unit. During labor a vaginal examination should be performed
only when necessary because of the risk of:
*
1/1
infection.
fetal injury.
discomfort.
perineal trauma.

Nurse Paul is caring for a low-risk client named Veronica who is in

active phase of labor. At which interval should nurse Paul assess the
fetal heart rate?
*
1/1
Every 15 minutes
Every 30 minutes
Every 45 minutes
Every 1 hour

Nurse Sunshine is attending an adolescent patient who came in due to

hyperventilation after a series of sports event. Which of the following
intervention would not be developmentally appropriate for a
hospitalized adolescent?
*
1/1
allow the adolescent to wear her own clothing
provide privacy when giving treatments
suggest that her parents bring in her favorite food
discourage visits from school friends

If Baby Oddie's response to treatment in an aggressive action, nurse

Queenie should:
*
0/1
not allow him to cry for a prolong period of time without providing him comfort.
consider crying a normal response and allow him to cry till he gets tired.
stop treatment as too much crying will tire his vocal cords
refer to the doctor as this may indicate treatment is not effective

Correct answer
not allow him to cry for a prolong period of time without providing him comfort.

Karla is a client at 40 weeks' gestation. Karla should be instructed to

go to a hospital or birth center for evaluation when she experiences:
*
0/1
fetal movement.
irregular contractions for 1 hour.
a trickle of fluid from the vagina.
thick pink or dark red vaginal mucus.

Correct answer
thick pink or dark red vaginal mucus.
Feedback
A trickle of fluid from the vagina may indicate rupture of the membranes, requiring evaluation for infection or
cord compression. The lack of fetal movement needs further assessment. Irregular contractions are a sign of
false labor and do not require further assessment. Bloody show may occur before the onset of true labor. It
does not require professional assessment unless the bleeding is pronounced.

Nurse Jasmin is a community health nurse advocating breast feeding

practice for the Mothers and their newly delivered babies in their
community. For what reason would breastfeeding be contraindicated?
*
1/1
Hepatitis B
Everted nipples
History of breast cancer 3 years ago
Human immunodeficiency virus (HIV) positive

Nurse Lina is auscultating the fetal heart rate of her pateint and
determines a rate of 152 bpm. Which nursing intervention is
appropriate for nurse Lina to her pateint?
*
1/1
Inform the mother that the rate is normal.
Reassess the fetal heart rate in 5 minutes because the rate is too high.
Report the fetal heart rate to the physician or nurse-midwife immediately.
Tell the mother that she is going to have a boy because the heart rate is fast.

Nurse Gail teaches a postpartum client named Maritess about

observation of lochia. Nurse Gail determines the Maritess's
understanding when the she says that on the second day postpartum,
the lochia should be which color?
*
1/1
red
pale
yellow
black

Bruce is about to become a father. Her wife, Mina is now on her 2nd
trimester of pregnancy. Nurse Roxanne should be aware that the
partner's/husband's main role in pregnancy is to:
*
0/1
Provide financial support.
Protect the pregnant woman from "old wives' tales."
Support and nurture the pregnant woman.
Make sure the pregnant woman keeps prenatal appointments.

Correct answer
Support and nurture the pregnant woman.
Feedback
(The partner's main role in pregnancy is to nurture the pregnant woman and respond to her feelings of
vulnerability. In older societies, the man enacted the ritual couvade. Changing cultural and professional
attitudes have encouraged fathers' participation in the birth experience over the past 30 years.)

Beatrice is a pregnant woman at 10 weeks of gestation. She jogs three

or four times per week. Beatrice is concerned about the effect of
exercise on the fetus. Nurse Gemma should inform her:
*
1/1
"You don't need to modify your exercising any time during your pregnancy."
"Stop exercising because it will harm the fetus."
"You may find that you need to modify your exercise to walking later in your pregnancy, around the
seventh month."
"Jogging is too hard on your joints; switch to walking now."

Maria is a woman who is 32 weeks' pregnant. Maria is informed by

nurse Christy that a danger sign of pregnancy could be:
*
0/1
Constipation.
Alteration in the pattern of fetal movement.
Heart palpitations.
Edema in the ankles and feet at the end of the day.

Correct answer
Alteration in the pattern of fetal movement.
Feedback
(An alteration in the pattern or amount of fetal movement may indicate fetal jeopardy. Constipation, heart
palpitations, and ankle and foot edema are normal discomforts of pregnancy that occur in the second and
third trimesters.)

Nurse Tina is assigned to a daycare center. She was asked by a parent

with a 2-year old child. The best way for parents to aid a toddler, in
achieving her developmental task would be to:
*
1/1
urge her to dress herself completely alone
give her small hospital chores she can do
help her learn to count
allow her to make simple decisions

Nurse Alicia provides instructions to Cindy, a new mother who is about

to breast-feed her newborn infant. Nurse Alicia observes the Cindy as
she breast-feeds for the first time and determines Cindy needs further
teaching if the new mother applies which technique?
*
0/1
Tilts up the nipple or squeezes the areola, pushing it into the newborn's mouth.
Let her baby feel her arreola as she let her breast near her babys mouth
Clean her breast with a clean cloth before breastfeeding her baby
looking for a comfortable position for her and her baby while breastfeeding.

Correct answer
Tilts up the nipple or squeezes the areola, pushing it into the newborn's mouth.

An infant named Mercy is to receive gastrostomy feedings. Which

intervention should nurse Anne institute to prevent bloating,
gastrointestinal reflux into the esophagus, vomiting, and respiratory
compromise?
*
0/1
a.Rapid bolusing of the entire amount in 15 minutes
b.Warm cloths to the abdomen for the first 10 minutes
c.Slow, small, warm bolus feedings over 30 minutes
d.Cold, medium bolus feedings over 20 minutes

Correct answer
c.Slow, small, warm bolus feedings over 30 minutes

Nurse Faye is preparing to perform Leopold's maneuvers to her

pregnant clients for prenatal check up. Why are Leopold's maneuvers
used by nurses and health practicioners?
*
0/1
To determine the status of the membranes
To determine cervical dilation and effacement
To determine the best location to assess the fetal heart rate
To determine whether the fetus is in the posterior position

Correct answer
To determine the best location to assess the fetal heart rate
Feedback
Leopold's maneuvers are often performed before assessing the fetal heart rate (FHR). These maneuvers help
identify the best location to obtain the FHR. A Nitrazine or ferning test can be performed to determine the
status of the fetal membranes. Dilation and effacement are best determined by vaginal examination.
Assessment of fetal position is more accurate with vaginal examination.

Nurse Christy has been a Pediatric nurse for 20 years already.Which of

the following prime factors is most important in understanding the
significance of illness or hospitalization among children?
*
1/1
religious belief and affiliation
age of the child and stage of development
social class and economic standing
culture and ethnic group where family belongs

Adele, a premature infant with respiratory distress syndrome (RDS)

receives artificial surfactant. How does nurse Belle explain surfactant
therapy to the parents?
*
1/1
"Surfactant improves the ability of your baby's lungs to exchange oxygen and carbon dioxide."
"The drug keeps your baby from requiring too much sedation."
"Surfactant is used to reduce episodes of periodic apnea."
"Your baby needs this medication to fight a possible respiratory tract infection."
Which information regarding safer and more responsible behavior
should nurse Jasmin provide when counseling agroup of adolescent
nursing clients who have chosen to be sexually active?(Select all that
apply.)
*
0/2
"If your partner insists on having sex even though you don't want to, you should comply to show you
really love him."
"You can choose to say 'No' to sex, even if your long-term partner says that your relationship has matured
beyond the mutual masturbation stage."
"Latex condoms lubricated with petroleum jelly provide for comfort and additional barrier protection."
"Insist that your opposite sex partner use birth control to reduce the risk of HIV."
"Women should carry and use female condoms."

Correct answer
"You can choose to say 'No' to sex, even if your long-term partner says that your relationship has matured
beyond the mutual masturbation stage."
"Women should carry and use female condoms."
Feedback
"You can choose to say 'No' to sex, even if your long-term partner says that your relationship has matured
beyond the mutual masturbation stage."

"Women should carry and use female condoms."

Rationale
Only certain types of birth control allow for safer sex and reduce risk for sexually transmitted infections
(STIs). Male and female condoms offer barrier protection. Petroleum jelly does not provide additional barrier
protection. Partners should never pressure, threaten, or abuse to obtain sexual favors.

Nurse Mia is caring for a newly pregnant woman named Anabel. Mia
would advise Anabel that ideally prenatal care should begin:
*
1/1
Before the first missed menstrual period.
After the first missed menstrual period.
After the second missed menstrual period.
After the third missed menstrual period.

Dennis, a parent, wants to wait outside until a procedure is completed

on his child. Which is the nurse Lovely's best response?
*
1/1
"It is required that you will be by his side"
"That is fine, I will stay with your child during the procedure."
"Its a hospital policy for parents to step out of the room during procedures."
"This test will only take a few minutes, why don't you stay."

LAST NAME,FIRST NAME*

Dela Pena, Odynah C.

Nurse Liz is attending patient Marcus, a 13-year old adolescent who

came in due to severe pain. Which of the following is the most
important concern of an adolescent?
*
0/1
threatened by helplessness
body mutilation fear
interferes with achievement
alteration in body image

Correct answer
alteration in body image

Janice is a worried pregnant client who ask her OB-GYNE if there will
be chances her baby might also developed abnormalities just like her
first born child. Janice OB GYNE ordered for multiple marker test. This
test is used to assess the fetus for which condition?
*
1/1
Down syndrome
Congenital cardiac abnormality
Diaphragmatic hernia
Anencephaly

Baby Gino is a newborn admitted to the neonatal intensive care unit

(NICU) after being delivered at 29 weeks of gestation to a 28-year-old
multiparous, married, Caucasian woman whose pregnancy was
uncomplicated until the premature rupture of membranes and preterm
birth. Gino's parents arrive for their first visit after the birth. The
parents walk toward the bedside but remain approximately 5 feet
away from the bed. What is nurse Jean's most appropriate action?
*
0/1
Wait quietly at the newborn's bedside until the parents come closer.
Go to the parents, introduce him or herself, and gently encourage them to meet their infant. Explain the
equipment first, and then focus on the newborn.
Leave the parents at the bedside while they are visiting so that they have some privacy.
Tell the parents only about the newborn's physical condition and caution them to avoid touching their
baby.

Correct answer
Go to the parents, introduce him or herself, and gently encourage them to meet their infant. Explain the
equipment first, and then focus on the newborn.

After delivery, Shella the postpartum nurse instructs patient Denisse

with known cardiac disease to call for the ward nurse when she needs
to get out of bed or when she plans to care for her newborn infant.
Which rationale is the basis for these instructions?
*
1/1
pamper the mother who was tired during labor
return of services payed for admission
avoid maternal or infant injury caused by the potential for syncope or overexertion.
to let the mother start know that nurses in the ward can take care of her new born in times that she wants
to rest.

Ina, an expectant mother in labor is under the care of nure Patricia.

Which should nurse Patricia recognize as being associated with fetal
compromise?
*
0/1
Active fetal movements
Fetal heart rate in the 140s
Contractions lasting 90 seconds
Meconium-stained amniotic fluid

Correct answer
Meconium-stained amniotic fluid
Feedback
When fetal oxygen is compromised, relaxation of the rectal sphincter allows passage of meconium into the
amniotic fluid. Active fetal movement is an expected occurrence. The expected FHR range is 120 to 160 bpm.
The fetus should be able to tolerate contractions lasting 90 seconds if the resting phase is sufficient to allow
for a return of adequate blood flow.

On day 3 of life, Baby Joy, a newborn, continues to require 100%

oxygen by nasal cannula. her parents ask if they may hold baby Joy
during his next gavage feeding. Considering that baby Joy is
physiologically stable, what response should nurse Maria provide?
*
1/1
"Parents are not allowed to hold their infants who are dependent on oxygen."
"You may only hold your baby's hand during the feeding."
."Feedings cause more physiologic stress; therefore, the baby must be closely monitored. I don't think you
should hold the baby."
"You may hold your baby during the feeding."

Leanne is a 2-year old toddler who has been admitted to the pediatric
unit for a nutritional assessment. Which of the following toys would be
best for her development?
*
1/1
bouncing ball
barbie doll
push-pull toy
doctor-nurse kit

YEAR & SECTION (eg 2A)*

2-E

Nurse Erika is assigned in the labor room. Which is an essential part of

nursing care for a laboring client?
*
1/1
Helping the woman manage the pain
Eliminating the pain associated with labor
Feeling comfortable with the predictable nature of intrapartal care
Sharing personal experiences regarding labor and birth to decrease her anxiety

Liza is a pregnant client for series of blood tests ordered by her OB-
GYNE. Liza's bood tests includes HIV testing. Prenatal testing for
human immunodeficiency virus (HIV) is recommended for:
*
0/1
All women, regardless of risk factors.
A woman who has had more than one sexual partner.
A woman who has had a sexually transmitted infection.
A woman who is monogamous with her partner.

Correct answer
All women, regardless of risk factors.
Feedback
(Testing for the antibody to HIV is strongly recommended for all pregnant women. A HIV test is recommended
for all women, regardless of risk factors. Women who test positive for HIV can be treated, reducing the risk of
transmission to the fetus.)

Angelica is a school nurse assigned in elementary education. She

rushed her student named Mia,a 7-year old child, due to a lacerated
wound while actively playing at school. Reaction manifested by
children who are hospitalized because of something wrong they have
done is
*
0/1
denial
covering up
guilt
anger

Correct answer
guilt

Which clinical findings would alert nurse Lester that Justine, a

neonate, is expressing pain?
*
0/1
Low-pitched crying; tachycardia; eyelids open wide
Cry face; flaccid limbs; closed mouth
High-pitched, shrill cry; withdrawal; change in heart rate
Cry face; eyes squeezed; increase in blood pressure

Correct answer
Cry face; eyes squeezed; increase in blood pressure

Which nursing assessment by nurse Florabel indicates that her patient

who is in the second stage of labor is almost ready to give birth?
*
1/1
Bloody mucous discharge increases.
The vulva bulges and encircles the fetal head.
The membranes rupture during a contraction.
The fetal head is felt at 0 station during the vaginal examination.

Nurse Zennia is assigned in the Pediatric ward attending several ill

and difficult pedia patients. To gain the cooperation of a negativistic
child in the hospital, nurse Zennia should:
*
0/1
ignore the child's refusal
give in to his wishes
allow him to do whatever he wants
present possible choices

Correct answer
present possible choices

Nurse Lester is teaching a group of adolescents in a Nursing School

about safer and more responsible sex practices. In addition to
discussing abstinence, which information is the most appropriate for
nurse Lester to include in the session?
*
1/1
"Having sex with someone you love shows the partner that you are committed to staying with him or her
for the long term."
"Safer sex includes applying spermicides on female genitalia to reduce transmission of infections before
intercourse."
"Engaging in sex is a personal choice that you should prepare for without ever feeling pressured by
another."
"Responsible sex involves knowing who your partner had sex with in the immediate past.close double
quote