Maternal and Child

Health Nursing 6

Situation 1.
Three- month- old Terry Pane, who has history
of diarrhea of 36 hours duration, is admitted to
the pediatric unit. He is diagnosed as having
gastroenteritis and dehydration. Terry is placed
on enteric precautions.

1.

a.
b.
c.
d.

In assessing the infant with diarrhea, the

nurse should expect to find:
Resilient skin turgor
A bulging fontanel
Marked restlessness
Decreased urinary output

2. When assessing Terry, the nurse would expect

to find a:
a.
Specific gravity of 1.014
b.
Urinary output of 50 ml/hour
c.
Depressed anterior fontanel
d.
History of allergies to various foods

3. The nurse understands that the magnitude of

Terrys fluid loss is best ascertained by:
a.
Comparing his pre-illness weight with
current weight.
b.
Noting the elevation of his hematocrit level.
c.
Evaluating his skin turgor carefully.
d.
Assessing the moistness of his mucous
membranes.

4. The physician orders ORS 150 ml per kg of

body weight per 24 hours for Terry , who
weighs 13 pounds. The nurse is aware that
Terrys intake of ORS should be:
a.
500 ml/24 hr
b.
750 ml/24 hr
c.
885 ml/24 hr
d.
965 ml/24 hr

5. Terry is receiving IV fluids via a scalp vein.

The nurse should:
a.
Check his pupils for reaction every hour.
b.
Observe behind his ear and inspect for
infiltration.
c.
Explain to the parents why they cannot hold
him now.
d.
Restrain Terrys arms & legs while not with
him.

6. Mr. and Mrs. Pane want to be involved with

Terrys care. The nurse realizes that they
understand the teaching about the
maintenance of enteric precautions when
they state, We should:
a.
wear a mask when we are holding Terry.
b.
close the door of his room most of the time.
c.
wear gloves each time we change his diaper.
d.
weigh his diaper each time we change him.

7. The best method of assessing Terrys reaponse

to treatment for dehydration is for the nurse
to:
a.
Measure his abdominal girth.
b.
Weigh him at the same time daily.
c.
Assess the color of his stools.
d.
Monitor his skin turgor frequently.

8. Once the severe effects of dehydration are

under control, the physician orders Lactinex
granules (lactobacilli) to:
a.
Recolonize the normal flora of the
gastrointestinal tract.
b.
Relieve the pain of gas in the gastrointestinal
tract.
c.
Relieve the pain caused by gastric
hyperactivity.
d.
Diminish inflammatory mucosal edema.

9. As 3-month-old Terry responds to therapy and

shows an interest in playing, the nurse
appropriately provides him with a:
a.
Push-pull toy
b.
Stuffed animals
c.
Large plastic ball
d.
Metallic mirror

10. Diarrheal disease is a major cause of

mortality in the Philippines. Among children
under the age of five, it is a major cause of
illness and death. In view of this, the DOH
launched a national program known as:
a.
ORS
b.
CDD
c.
VAD
d.
IDD

Situation 2.
Daniel James is admitted to the nursery from the
delivery room after a difficult delivery.

11. As the nurse examines Daniel, a positive

ortolanis sign is detected. This is indicated
by:
a.
A broadening of the perineum
b.
An apparent shortening of one leg
c.
An audible click on hip manipulation
d.
A unilateral droop of the hip

12. Daniel has congenital jip dysplasia. Daniel is

discharged the nurse should teach Mr. and
Mrs. James that hip dysplacia could be
avoided if Daniel is:
a.
Tightly swaddled in blankets.
b.
Carried straddling the hip.
c.
Periodically strapped to a cradleboard.
d.
Placed in an infant seat on a set schedule.

13. When Daniel is 6 months old, he is placed in a hip

spica cast for the treatment of the congenital hip
dysplasia. In planning home care with Mr. and Mrs.
James, the nurse should assess that:
a.
No special precautions will be necessary when
diapering him.
b.
The entire cast should be wrapped in plastic wrap to
prevent it from spoiling.
c.
The edges of the cast in the perineal area should be
covered with plastic wrap.
d.
Baby oil and powder should be used liberally
around the diaper rash.

14. At 18 month sof age when Daniel visits the

clinic, it is discovered that he is anemic.
Considering his diagnosis, age, and dietary
needs, the nurse should suggest that Mrs.
James feed him:
a.
Bread pudding with raisins
b.
Fresh seedless grapes
c.
A slice of pumpkin pie
d.
An entire slice of apple

15. This refers to a diet that contains all the

nutrients and other substances found
naturally in food, in proper amounts and
proportion needed by the body to function
well.
a.
Regular diet.
b.
Bland diet.
c.
Diabetic diet.
d.
Balanced diet.

Situation 3. Ronald Taft, 1 month old, is admitted to the

hospital with diagnosis of hydrocephalus.
16. Because of the admission diagnosis, the abnormal
finding the nurse would expect to observe during
assessment of Ronald would be that:
a.
He is unable to support his head and shoulders
while prone.
b.
His anterior fontanel is tense on palpation.
c.
His head circumference is larger than his chest
circumference.
d.
He demonstrates poor eye-muscle coordination.

17. Ronald is scheduled for surgery and VP

shunt is to be inserted. A short-term
preoperative goal for Ronald would be to:
a.
Keep him as comfortable as possible to limit
crying.
b.
Establish and maintain a strict fixed feeding
schedule to ensure hydration.
c.
Use a thick head bandage to protect his head
from injury.
d.
Provide a wide variety of play objects to
maintain age-appropriate ion.stimulat

18. Preoperatively, after teaching Mr. and Mrs. Taft, the

nurse can evaluate their understanding of the
immediate postoperative positioning when they
state, We will avoid putting pressure on Ronalds
valve site by positioning him:
a.
In the position that provides him the most
comfort.
b.
On his back with a small support beneath his
neck.
c.
Flat with a small support against the right side of
his head and back.
d.
On his abdomen with a small support against the
left side of his head,

19. On the day after surgery, Ronalds

temperature rises to 103F. The nurse should
first notify the physician and then:
a.
Recheck the temperature 12 hours.
b.
Record the temperature on Ronalds chart.
c.
Remove any excess clothing from Ronald.
d.
Sponge Ronald with tepid alcohol.

Situation 4. John Lemel, 4 years old, is admitted

to pediatric unit with nephrotic syndrome.
His parents, Ida and Henry Lemel, are with
him.
20. On Johns admission, the nurse should assess
for:
a.
Flushed, ruddy complexion
b.
Dark frothy urine output
c.
Severe lethargy
d.
Chronic hypertension

21. When admitting John, the nurse assigns him

to a room with a:
a.
2-year-old boy with croup
b.
3-year-old boy with impetigo
c.
4-year-old boy with conjunctivitis
d.
5-year-old boy with fractured femur

22. When planning care for John, the nurse

includes:
a.
A diet low in carbohydrates and protein
b.
Restriction of fluids to 500 ml each shift
c.
Provision of meticulous skin care
d.
A lab test for blood type and cross match

23. The nurse realizes that Mr. and Mrs. Lemel

need further instruction for discharge when
they state:
a.
We know we need to test Johns eyelids
every morning.
b.
We will look at Johns eyelids every
morning.
c.
We will ignore any weight gain of Johns
since it is normal.
d.
We will give John his prednisone with
mea;s or milk.

24. The nurse has been teaching Mr. and Mrs.

Lemel about urine testing at home. The
statement by them that alerts the nurse to the
fact that the teaching has been effective is:
a.
We will discard the first urine before we test
for acetone.
b.
John is old enough to learn how to test his
own urine.
c.
We should notify the doctor if there is
protein in the urine.
d.
We realize his urine will show a false
positive if it is cloudy.

25. A few years later, John, who has chronic renal

failure, is admitted to the hospital critically ill. John
develops Cheyne-Stokes respirations and the nurse
suspects an increasing acid-base balance related to:
a.
Respiratory alkalosis from over breathing and
excess carbon dioxide output
b.
Metabolic alkalosis from an increase in base
bicarbonate due to his primary health problem
c.
Respiratory acidosis from impeded breathing and
the retention of the CO2.
d.
Metabolic acidosis from the concentration of
cations in body fluids, which displace bicarbonate.

Situation 5. Eric Santos, 18 months old,

suddenly develops a left earache, slight nasal
congestion, and high fever. At the
pediatricians office his parents, Elisa and
Allen Santos, are informed that for the 2 nd time
their son has developed a middle ear infection.

26. The nurse knows that among infants and

children otitis media is considered the most
common:
a.
Bacterial infection
b.
Rickettsial infection
c.
Fungal infection
d.
Viral infection

27. Mr. and Mrs. Santos are anxious to know

why Eric has another episode of suppurative
otitis media. In replying the nurse should
explain the:
a.
Functional difference between an infants
eustachian tube and that of an older child.
b.
Difference between the size of the middle ear
cavity in infants and older children.
c.
Structural difference between the Eustachian
tube younger and older children.
d.
Immunologic difference between the young
child and the adult.

28. The most important nursing responsibility

during the myringotomy procedure is to:
a.
Have his mother stay and hold Eric in her
arms.
b.
Keep Eric restrained and completely
immobilized.
c.
Collect the aspirated drainage in a culture
tube.
d.
Maintain the continuous flow of local
anesthetic.

29. To help Mrs. Santos promote the

effectiveness of Erics myringotomy, the
nurse should suggest that Mrs. Santos:
a.
Position Eric with his affected ear down.
b.
Keep Eric flat on his back.
c.
Position Eric with his affected ear
uppermost.
d.
Observe Eric for bleeding from operative
site.

30. The nurse discusses the expected effects of

myringotomy and local manifestation of
complications with Mr. and Mrs. Santos. The
occurrences that should be reported at once
are:
a.
Mild or moderate hearing loss
b.
Lack of drainage and increased pain
c.
Bleeding and diminished pain.
d.
Low-grade temperature and headache.

Situation 6: Kent 2 years old, has a fractured

femur and is in Bryants traction.
31. After giving him morning care, the nurse
checks the traction to be sure that the hip
angle is maintained at:
a.
45 degrees
b.
60 degrees
c.
90 degrees
d.
180 degrees

32. Nursing care specific for a child in Bryants

traction should include:
a.
Checking the sites of pins for bleeding or
infection.
b.
Applying topical or antibiotic ointments as
ordered.
c.
Assessing that the elastic bandages daily to
the lubricate the skin.
d.
Removing the bandages daily to lubricate the
skin.

Situation 7. Regina Velasquez brings her 2-yearold son, Alvin to the pediatric clinic because
he has been irritable, lethargic, and pale. He
has had abdominal cramps and vomited this
morning. After a thorough physical
examination, Alvin is admitted to the pediatric
unit with lead poisoning (plumbism).

33. The nurse should be aware that a high level

of lead in the blood leads to:
a.
Marked anemia
b.
Increased urination
c.
Severe malnutrition
d.
Liver damage

34. developmentally, young children such as

Alvin are at risk for lead poisoning primarily:
a.
Their vascular system is very fragile.
b.
They have a high level of oral activity.
c.
Lead is easily available to them.
d.
Motor vehicle pollution has increased.

35. The nursing diagnosis that is used most

commonly with children with lead poisoning
is:
a.
Potential for injury
b.
Alteration in nutrition
c.
Alteration in comfort
d.
Unilateral neglect

Situation 8: Janet Lee is a nurse who works in

the teenage clinic of a large county hospital.
Ms. Lee is aware that during the adolescent
period there may be sexual experimentation.

36. One day, 16-year-old Martin Agustin comes

to the clinic with a complaint of a thick
urethral discharge. To confirm the suspected
diagnosis of gonorrhea the nurse should:
a.
Obtain a urine specimen.
b.
Draw blood for a VDRL.
c.
Get a sexual history.
d.
Take a urethral culture.

37. Because Martin is allergic to penicillin, the

physician orders tetracycline (Sumycin) to
treat the infection. The nurse would know
that the teaching about the administration of
tetracycline was effective when Martin says
he should take the drug:
a.
With meals or milk.
b.
At least 1 hour before meals.
c.
Approximately 30 minutes after meals.
d.
Just before meals.

38. The nurse would determine that the teaching

about the side effects of tetracycline was
understood when Martin says that the
medication could cause:
a.
Constipation
b.
Diarrhea
c.
Vertigo
d.
Tinnitus

39. Another client, Abe Gold, 16 years old,

comes to the clinic. He is sexually active and
is worried about having syphilis. The nurse is
aware that an early diagnosis of syphilis is
important and its presence is often
detremined by:
a.
A discharge from the penis
b.
Evidence of a rash
c.
Multiple gummatous lesions
d.
A lesion on the penis

40. The Dr. diagnoses that Abe does in fact have

syphilis and orders penicillin G (Pentids) and
probenicid (Benemid). The nurse explains to Abe
the rationale for both drugs being used is:
a.
Each drug attacks the organism during different
stages of cell multiplication.
b.
Probenecid decreases the potential for an allergic
reaction developing to the penicillin, which treats
the syphilis.
c.
The penicillin treats his syphilis while the
probenecid relieves his severe urethritis.
d.
Probenecid delays excretion of penecillin by the
kidneys to maintain effective blood levels for
longer periods.

Situation 9: Gerald Chu, 6 months old, has

eczema. He is admitted to the hospital
because of secondary infection of his face
and head from constant scratching.
41. The nurse is aware that eczema is a
nonspecific ailment that is:
a.
Associated with chronic respiratory
infections
b.
Predominantly found in infants
c.
Easily treated
d.
Highly contagious

42. The most important nursing care for infants

with eczema is:
a.
Prevention of secondary infections
b.
Identification of causative factors
c.
Provision of sufficient hydration
d.
Promotion of physical growth

43. Allergic reactions in eczematous clients are

most often caused by:
a.
wools, house dust, and dog hairs
b.
fruits., eggs, and wheat
c.
Milk, eggs, and peanuts
d.
Wools, meat, and milk

44. An assessment of Gerald's growth and

developmental level should reveal that he
could:
a.
Hold his bottle by himself
b.
Crawl forward
c.
Say mama
d.
Turn pages in a book

45. The nurse evaluates that Geralds mother

needs more teaching regarding Geralds care
when she states:
a.
I will be careful not to cuts Geralds nails
short.
b.
I am going to buy him a whole new set of
cotton clothing.
c.
I will make sure not to give him any whole
milk products.
d.
I have given all his woolen blankets to my
nephew.

Situation 10: Daniel and Florence Smiths new

infant daughter Lara, is born with a cleft lip.
46. Immediate nursing care for Lara should be
directed primarily toward:
a.
Preventing the occurrence of infection.
b.
Modifying feeding methods.
c.
Keeping the baby from crying.
d.
Minimizing handling by parents.

47. Mrs. Smith bottle-feeds Lara with a special

nipple. To minimize regurgitation of the
feedings, the nurse instructs Mrs. Smith to:
a.
Feed Lara while sitting her up in an infant
seat.
b.
Hold and burp Lara frequently while feeding.
c.
Give Lara the thickened formula as ordered.
d.
Lay Lara on her side with the bottle firmly
propped.

48. Mr. and Mrs. Smith ask when Laras cleft lip
will be repaired. The nurse responds:
a.
When the baby is 8 to 12 weeks old.
b.
Usually at about 18 months of age.
c.
Not until she has teeth in her mouth.
d.
As soon as she starts to lose weight.

49. Laras lip is repaired surgically.

Postoperatively, the nurse will provide
nutrition for the baby via:
a.
A plastic teaspoon
b.
Intravenous feeding
c.
A rubber-tipped syringe
d.
Nasogastric tube feedings

50. Following each feeding, the first action by

the nurse should be to:
a.
Cuddle Lara for a few minutes.
b.
Place Lara on her abdomen.
c.
Burp Lara several times.
d.
Clean and rinse Laras suture line.

Situation 11. Ellaine Mariano, 4 years old, is

brought to the pediatricians office with
complains of earache, sore throat, low grade
fever, a cough, and general malaise. The nurse
prepares the nescessary equipment to perform
an otoscopic examination, a throat
examination, and throat culture.

51. To properly visualize the canal during the

otoscopic examination, the pinna of the ear
must be pulled:
a.
Down and forward
b.
Up and back
c.
Up and forward
d.
Down and back

52. When examining Elaines throat, the nurse

should position a tongue blade to the side of
the childs tongue primarily to avoid:
a.
Interfering with the visual examination.
b.
Eliciting the gag reflex.
c.
Hurting any of the teeth.
d.
Obstructing the airway.

53. Dorcol cough syrup is ordered for Elaine.

Each teaspoonful contains dextromethorphan
hydrobromide 7.5 mg. When administering
the cough syrup, the nurse should administer:
a.
5 ml
b.
3.75 ml
c.
2.5 ml
d.
7.5 ml
2.5/5 x 7.5= 3.7 ml

54. In assessing 4-year-old Elaine, the nurse

would expect her to:
a.
Have a vocabulary of 1,500 words.
b.
Use just three-or four-word sentences.
c.
Ask the definitions of new words.
d.
Name two or three different colors.

55. When Elaine is 8 years old she has a tonsillectomy

under general anesthesia without any untoward
sequelae. During the immediate postoperative period,
a nursing intervention for Elaine would be to
maintain:
a. hydration by providing cool liquids frequently
b. consciousness by encouraging interaction with her
mother
c. airway patency by positioning her on the side
d. aeration by assisting with coughing and deep
breathing

56. When taking the history and assessing Karl,

the nurse would expect to find:
a.
Constipation, abdominal pain, flatulence,
rickets
b.
Constipation, abdominal distention,
peripheral edema, increased clotting time
c.
Diarrhea, muscle wasting, anemia,
osteomalacia, steatorrhea
d.
Diarrhea, malnutrition, rickets, anemia,
steatorrhea, and increased stools.

57. The effectiveness of gluten-restricted diet in

a child with celiac disease can be assessed on
the 2nd day by having the nurse and mother
evaluate the child for:
a.
Decreased irritability
b.
Maintenance of weight
c.
Normal bowel movements
d.
Disappearance of steatorrhea

58. Karl is anemic. The nurse suspects that the

anemia is caused by:
a.
An inadequate amount of the intrinsic factor
b.
The small amount of iron included in his diet
c.
The poor absorption of iron and folic acid
d.
His minimal appetite and low food intake

59. The delivery room nurse explains to Mrs.

Lustig and her husband, Ira, that an Apgar
score recorded 5 minutes after birth helps to
evaluate the:
a.
Effectiveness of the labor and delivery
b.
Adequacy of transition to extrauterine life
c.
Possibility of respiratory distress syndrome
d.
Gestational age of the infant

60. The nurse is aware that the nursing action

would best promote parent-infant attachment
behaviors would be:
a.
Encouraging rooming-in, with parental infant
care.
b.
Keeping the new family together
immediately postpartum.
c.
Restricting visitation on the postpartum unit.
d.
Supporting the parents choice of
breastfeeding.

61. Mrs. Lustig is breastfeeding her infant on the

delivery table. The nurse assists her by:
a.
Touching the infants cheek adjacent to the
nipple to elicit the rooting reflex.
b.
Leaving them alone and allowing the infant
to nurse as long as desired.
c.
Positioning the infant to grasp the nipple so
as to express milk.
d.
Giving the infant a bottle first to evaluate the
babys ability to suck.

62. Mr. and Mrs. Lustig note petechiae on the

newborns face and neck. The nurse informs
them that this is a result of:
a.
Increased intravascular pressure during
delivery.
b.
Decreased vitamin K level in the newborn
infant.
c.
A rash called erythema toxicum.
d.
Excessive superficial capillaries.

63. Mrs. Lustig asks the nurse what she can do to

ease the discomfort caused by a cracked left
nipple. She should be instructed to:
a.
Use a breast shield to keep the baby from
direct contact with the nipple.
b.
Nurse the baby on the right side first until the
left side heals.
c.
Stop nursing for 2 day to allow the nipple to
heal.
d.
Manually express milk and feed it to the
baby from a bottle.

64. When changing her infant, Mrs. Lustig

notices a reddened area on the infants
buttocks. The nurse should:

Have staff nurses, instead of Mrs. Lustig,

change the infant.

Use both lotion and powder to protect the

involved area.

Encourage Mrs. Lustig to cleanse and change

the infant more often.

Notify the Dr. and request an order for a

topical ointment.

65. The nurse is aware that during the taking-in

phase of the postpartum period, the area of
health teaching that Mrs. Lustig will be most
responsive to is:
a.
Family planning
b.
Infant feeding
c.
Infant hygiene
d.
Perineal care

66. Mrs. Evans eventually decides to use oral

contraceptives. When obtaining the health
history, the nurse should consider that oral
contraceptives are contraindicated in the
client who:
a.
Has a family history of CVA
b.
Is over 30 years of age
c.
Smokes a pack of cigarettes per day
d.
Has a history of a multiple pregnancy

67. The physician orders progesterone oral

contraceptives (minipills). The nurse
instructs Mrs. Evans to take one pill daily:
a.
During the first 5 days of the menstrual
cycle.
b.
During the 5 days surrounding ovulation.
c.
Throughout the menstrual cycle.
d.
Throughout the first 21 days of the menstrual
cycle.

68. The nurse would know that Mrs. Evans

understood the teaching about the side
effects of excessive estrogen when she
indicates it would cause:
a.
Nausea and vomiting
b.
Amenorrhea
c.
Depression and lethargy
d.
Hypomenorrhea

69. The nurse recognizes that Mrs. Evans

understands the teaching about minipills
when she states that she will discontinue the
oral contraceptive at once if she experiences:
a.
Increased leukorrhea
b.
Chest pain
c.
Mittelschrmerz
d.
Menorrhagia

70. The nurse uses nitrazine paper to test the pH

of the leaking fluid. If amniotic fluid is
present, the nitrazine paper will become:
a.
Red
b.
Orange
c.
Blue
d.
Purple

71. Ms. Clancys labor does not progress, and a

cesarean delivery is performed. Afterward,
she tells the nurse that she is a natural
childbirth flunkie. The postpartal phase of
adjustment that this statement most closely
typifies is:
a.
Taking hold
b.
Working through
c.
Taking in
d.
Letting go

72. Baby boy Clancy weighed 2450 gm (5.5 lb)

at delivery. He would be classified as being:
a.
Average for gestational age
b.
Small for gestational age
c.
Average for gestational age but preterm
d.
Preterm and immature

73. After baby Clancy is admitted to the

newborn nursery, the nurse observes that he
has a weak high-pitched cry, seems jittery,
and has irregular respirations. The nurse
should associate these symptoms with:
a.
Hypoglycemia
b.
Hypercalcemia
c.
Hypovolemia
d.
Hypothyroidism

74. Ms. Clancy chooses to bottle feed her

newborn because this will cause the least
interference with full resumption of her law
practice. Before discharge the nurse should
teach Ms. Clancy that if breast engorgement
occurs, she should:
a.
Take 2 aspirins every 4 hours.
b.
Apply hot compresses to the breasts.
c.
Wear a tightly fitted brassiere.
d.
Cease drinking milk for 2 weeks.

Mrs. Tan is admitted for severe bleeding.

75. After placing Mrs. Tan in the bed, the nurse
should:
a.
Perform a vaginal examination.
b.
Check fetal heart tones.
c.
Administer a fleets enema.
d.
Obtain an amniotomy set up.

76. Mrs. Tans bleeding increases, and an

emergency cesarean delivery is performed.
Baby Tan is suctioned, dried, and transported
to the NICU. The admitting nurse assesses
baby Tans Silverman-Anderson index to be
3. This value reflects the babys need for:
a.
Increase caloric intake and fluids
b.
Respiratory support and observation
c.
Continuous cardiac monitoring
d.
Assessment of neurologic reflexes

77. A finding of the physical assessment that

may indicate that baby Tan is preterm is:
a.
Many superficial veins
b.
A positive babinski reflex
c.
Absent femoral pulses
d.
Flexion of extremities

78. Eight hours after birth, Baby Tan is observed

to have a respiratory rate of 68 per minute
with nasal flaring and cyanosis. He is
diagnosed as having respiratory distress
syndrome. A finding consistent with this
diagnosis is:
a.
Pulse rate 100
b.
Arterial blood pH 7.50
c.
Diminished breath sounds
d.
Inspiratory stridor

79. Supplemental O2 is ordered as part of Baby

Tans treatment. To prevent retrolental
fibroplasias the nurse plans to:
a.
Analyze O2 concentration frequently.
b.
Warm and humidify all O2 flow.
c.
Apply eye patches to both eyes.
d.
Administer O2 by blood.

80. The primary nurse in the NICU is caring for

baby Tan suspects that he has necrotizing
enterocolitis (NEC) when:
a.
Several severe bouts of projectile vomiting
are observed.
b.
Large amounts of residual formula are
withdrawn before gavage.
c.
An increased number of explosive stools are
noted.
d.
Circumoral pallor develops during gastric
feeding.

81. When admitting Mrs. Murray, one of the first

question the nurse should ask is:
a.
How frequent are your contractions and
how long do they last?
b.
What time was your last meal and what did
you eat?
c.
Are you planning to breastfeed or to bottle
feed?
d.
What is your expected date of delivery?

82. Mrs. Murrays Dr. arrives and examines her. The Dr.
states that her cervix is completely effaced, dilation
is 4 cm and station is 0. On the basis of this
information, the nurse should:
a.
Check the FHR every 5 minutes and record it on her
chart.
b.
Continue to tell Mr. Murray to coach her in the use
of breathing techniques.
c.
Call anesthesia department and alert them to an
imminent delivery.
d.
Ask Mrs. Murray how bad her pain is and whether
she wants medication.

83. The teaching plan for Mr. Murray should

include the information that it would be best
for him:
a.
Leave Mrs. Murray alone periodically so that
she can rest between contractions.
b.
See that Mrs. Murray remains supine so that
the monitoring equipment is not disturbed.
c.
Keep the conversation in the labor room to a
minimum so that Mrs. Murray can
concentrate.
d.
Let Mrs. Murray know the progress she is
making and that she is doing a good job.

84. During the labor, Mrs. Murray says, Were

so worried about our baby because Im a
whole month early. The nurses best
response would be:
a.
Dont worry, the care of preterm babies has
greatly improved.
b.
I can understand why you and your husband
are worried.
c.
Your Dr. is very good, try not to worry
about it now.
d.
I dont blame you for worrying; there is
some danger.

85. Later in labor an internal cardiac monitor is

attached to the fetal scalp. The nurse should
be concerned about a fetal heart rate that:
a.
Varied from 130 to 140 beats per minute
b.
Dropped to 110 beats during Mrs. Murrays
contractions
c.
Occasionally dropped to 90 beats unrelated
to contractions
d.
Did not drop during Mrs. Murrays
contractions

Situation 12: Colleen Reyes, age 32, delivers a

baby girl who is admitted to the newborn
nursey.

86. later, while inspecting her baby, Mrs. Reyes

asked the nurse if her newborn has flat feet.
The nurse recalls that:
a.
Flat feet are common in children and infants.
b.
This is difficult to assess because the feet are
too small.
c.
The arch of the newborns foot is covered
with fat pad, giving the appearance of being
flat.
d.
Flat feet are associated with major
deformities of the bones of the feet such as
clubfoot.

87. The nurse palpates the femoral pulses of

baby Reyes. This procedure is done to detect
the presence of:
a.
Ventricular septal defect
b.
Coarctation of the aorta
c.
Patent ductus arteriosus
d.
Atrial septal defect

88. The nurse also assesses baby Reyes for

central cyanosis as indicative congenital
heart defects that affect cardiac circulation
by:
a.
Shunting of blood right to left
b.
Shunting of blood left to right
c.
Obstructing the floe of blood between the left
and right sides of the heart.
d.
Preventing shunting of blood between the
left and right sides of the heart.

89. The nurse understands that CHF is the usual

sequela to congenital congenital defects that
result from left to right shunting of blood in
the heart. With this knowledge, the nurse
would be aware that a sign that would be
most indicative of early onset of CHF in the
infant would be:
a.
Decreased heart rate
b.
Increased respiratory rate
c.
Liver 2 cm below the costal margin
d.
Cyanosis of skin

Situation 13: Accompanied by her husband, Joan

Carey, gravida ii para i is admitted in early
labor.
90. As the nurse inspects her perineum, Mrs.
Carey suddenly turns pale and says that she
feels as if she is going to faint, although she
is lying float on her back. The nurse should:
a.
Elevate her head.
b.
Elevate her feet.
c.
Start O2 IV fluids.
d.
Turn her on her left side.

91. During labor Mrs. Carey begins to

experience dizziness and tingling of her
hands. The nurse tells Mr. Carey to instruct
his wife to:
a.
Hold her breath with the next contraction.
b.
Breath into her cupped hands or a paper bag.
c.
Use a fast deep-breathing pattern.
d.
Pant during the next three contractions.

92. Mrs. Carey has been in labor for 4 hours and

her cervix is 5 cm dilated. She had been
having good contractions until the past 30
minutes, when her contractions until the past
30 minutes, when her contractions gradually
became irregular and of fair quality. In caring
for her, the nurse should first check her for:
a.
Uterine dysfunction
b.
False labor
c.
A full bladder
d.
A breech presentation

93. In assessing Mrs. Carey for signs that the

transitional phase is beginning , the nurse
would expect her to have:
a.
Bulging of the perineum
b.
Crowning of the fetal head
c.
Pinkish vaginal discharge
d.
Rectal pressure during contraction

Situation 14: Arlene Dannon is 17 years old and

is 36 weeks pregnant. When she comes to
prenatal clinic she found to have a mild
pregnancy-induced hypertension. The
physician plans to treat her on an out patient
basis.

94. Although the exact cause of PIH is unknown,

the nurse knows that it is often associated
with:
a.
A limited amount of calories
b.
A vitamin deficiency
c.
An inadequate intake of protein
d.
An inability to absorb minerals

95. When providing health teaching concerning

PIH, a therapeutic instruction that the nurse
should give Mrs. Dannon is:
a.
Rest frequently in the side lying position.
b.
Eat sodium-free diet.
c.
Limit fluid intake to 1000 ml a day.
d.
Walk at least a mile a day.

96. Mrs. Dannons physical status gets

progressively worse and she is admitted to
the high-risk prenatal unit at the local
community hospital. During the admitting
history and physical assessment the nurse
should expect to find:
a.
Difficulty in breathing
b.
Vaginal spotting
c.
BP of 130/80
d.
Proteinuria of 3+

97. The physician orders a large dose of

magnesium sulfate. To evaluate the
therapeutic effectiveness of this therapy, the
nurse should assess for:
a.
Excessive urinary output
b.
Absent deep tendon reflexes
c.
A decreased respiratory rate
d.
An increased in BP

Situation n15: Kimberly Abrams, 32 years old, develops

severe pain in her left leg during her 29th week of
pregnancy. Thrombophlebitis is diagnosed, and she
is admitted to the hospital, prescribed bed rest, and
started on anticoagulant.
98. The nurse should be aware that the only
anticoagulant that Mrs. Abrams can safely receive:
a.
Heparin sodium
b.
Warfarin sodium
c.
Dicumarol
d.
Embolex

99. Mrs. Abrams has blood drawn for activated

partial thromboplastin time (APTT). One day
her APTT is reported to be 98 seconds. The
nurse notifies the Dr. because the anti
coagulant should be:
a.
Increased for better clotting results.
b.
Omitted for today and the APTT rechecked
tomorrow.
c.
Changed to one of the other effected anticoagulants
d.
Discontinued because the APTT is normal.

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