G and D

Question 1

Which age group has the greatest potential to demonstrate regression when they are sick?

A. Infant
B. Toddler
C. Adolescent
D. Young Adult

Answer 1

Correct Answer: B. Toddler

Regression is most seen among toddlers and it can be caused by stressful situations such as hospitalization, the arrival of a new sibling, or starting a new school.

Question 2

One of the participants attending a parenting class asks the teacher “What is the leading cause of death during the first month of life?

A. Bacterial sepsis
B. Respiratory distress of newborn
C. SIDS (Sudden Infant Death Syndrome)
D. Neonatal hemorrhage

Answer 2

Correct Answer: C. SIDS

According to the CDC, sudden infant death syndrome (SIDS) remains to be one of the leading causes of infant death. Around 1,300 infants died in 2018 due to this condition. SIDS is defined as the sudden and unexplained death of a baby younger than 1-year-old.

Question 3

Which stage of development is most unstable and challenging regarding the development of personal identity?

A. Adolescence
B. Toddlerhood
C. Middle Childhood
D. Young adulthood

Answer 3

Correct Answer: A. Adolescence

Although it occurs throughout one’s lifetime, identity development is considered to be the primary psychosocial task of adolescence or as described by Erickson on identity versus identity confusion. Individuals in this stage start to integrate their values, abilities, inner drives, and past experiences into who they are as persons.

Question 4

Which age group would have the most tendency towards eating disorders?

A. Adolescence
B. Toddlerhood
C. Preschool
D. Infancy

Answer 4

Correct Answer: A. Adolescence

The adolescent stage is the time where the body starts to change and with factors including exposure from media and peer pressure that provide them the perception of an ideal body image which would then affect their dietary behaviors leading to eating disorders.

Question 5

When assessing an older adult., the nurse may expect an increase in:
A. Nail growth
B. Skin turgor
C. Urine residual
D. Nerve conduction velocity

Answer 5

Correct Answer: C. Urine residual

Older adults with other health conditions such as diabetes, enlarged prostate (men), or pelvic organ prolapse (women) may cause incomplete bladder emptying resulting in increased urine residual.

Question 6

A maternity nurse is providing instruction to a new mother regarding the psychosocial development of the newborn infant. Using Erikson’s psychosocial development theory, the nurse would instruct the mother to

A. Allow the newborn infant to signal a need
B. Anticipate all of the needs of the newborn infant
C. Avoid the newborn infant during the first 10 minutes of crying
D. Allow the infant to cry, once lessen, then attend to the infant

Answer 6

Correct Answer: A. Allow the newborn infant to signal a need.

If a newborn is not allowed to signal a need, the newborn will not learn how to control the environment. The primary way the caregiver can build trust with the baby is to respond when they try to communicate. Because babies can’t use words to express themselves, they use nonverbal strategies to communicate what they’re thinking and feeling at all times.

Question 7

A mother of a three (3)-year-old tells a clinic nurse that the child is constantly rebelling and having temper tantrums. The nurse most appropriately tells the mother to:

A. Punish the child every time the child says “no”, to change the behavior
B. Allow the behavior because this is normal at this age period
C. Set limits on the child’s behavior
D. Ignore the child when this behavior occurs

Answer 7

Correct Answer: D. Ignore the child when this behaviour occurs.

Question 8

The parents of a two (2)-year-old boy arrive at a hospital for a visit. The child is in the playroom when the parents arrive. When the parents enter the playroom, the child does not readily approach the parents. The nurse interprets this behavior as indicating that:

A. The child is withdrawn
B. The child is self-centered
C. The child has adjusted to the hospitalized setting
D. This is a normal pattern

Answer 8

Correct Answer: D. This is a normal pattern.

The phases through which young children progress when separated from their parents include protest, despair, and denial or detachment. In the stage of despair, the child may not approach them readily or may cling to a parent.

Question 9

The mother of a three (3)-year-old is concerned because her child still is insisting on a bottle at nap time and bedtime. Which of the following is the most appropriate suggestion to the mother?

A. Do not allow the child to have the bottle
B. Allow the bottle during naps but not at bedtime
C. Allow the bottle if it contains juice
D. Allow the bottle if it contains water

Answer 9

Correct Answer: D. Allow the bottle if it contains water

It is recommended that parents should wean their children off the bottle at 15-18 months of age. But If a bottle is still attached to the child at 3 years of age during naptime or bedtime, it should contain only water to prevent the risk of dental caries.

Question 10

A nurse is evaluating the developmental level of a two (2)-year-old. Which of the following does the nurse expect to observe in this child?

A. Uses a fork to eat
B. Uses a cup to drink
C. Uses a knife for cutting food
D. Pours own milk into a cup

Answer 10

Correct Answer: B. Uses a cup to drink

By age 2 years, the child can use a cup and can use a spoon correctly but with some spilling. Children can start learning how to use a cup without a lid when they are 9 months old. Most experts recommend introducing utensils between 10 and 12 months, as an almost-toddler starts to show signs that she’s interested. A spoon should be first on the child’s tray since it’s easier to use.

Question 11

A clinic nurse assesses the communication patterns of a five (5)-month-old infant. The nurse determines that the infant is demonstrating the highest level of developmental achievement expected if the infant:

A. Uses simple words such as “mama”
B. Uses monosyllabic babbling
C. Links syllables together
D. Coos when comforted

Answer 11

Correct Answer: B. Uses monosyllabic babbling.

Monosyllabic babbling occurs between 3 and 6 months of age. The infant starts to produce vowels and combines them with consonants, producing syllables (e.g., ba, da, la, ga). An infant should be babbling away by now, and those babbles might even be starting to sound like real words. Five-month-olds can begin to put consonant and vowel sounds together.

Question 12

A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For which of the following would the nurse be alert?

A. Endometritis
B. Endometriosis
C. Salpingitis
D. Pelvic thrombophlebitis

Answer 12

Correct Answer: A. Endometritis

Endometritis is an infection of the uterine lining and can occur after prolonged rupture of membranes. Symptoms include swelling of the abdomen, abnormal vaginal bleeding or discharge, fever, discomfort with bowel movement, and pain in the lower abdomen or pelvic region.

Question 13

A client at 36 weeks gestation is scheduled for a routine ultrasound prior to amniocentesis. After teaching the client about the purpose of the ultrasound, which of the following client statements would indicate to the nurse in charge that the client needs further instruction?

A. The ultrasound will help to locate the placenta.
B. The ultrasound identifies blood flow through the umbilical cord.
C. The test will determine where to insert the needle.
D. The ultrasound locates a pool of amniotic fluid.

Answer 13

Correct Answer: B. The ultrasound identifies blood flow through the umbilical cord.

Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not accomplish this.

Question 14

While the postpartum client is receiving heparin for thrombophlebitis, which of the following drugs would the nurse expect to administer if the client develops complications related to heparin therapy?

A. Calcium gluconate
B. Protamine sulfate
C. Methylergonovine (Methergine)
D. Nitrofurantoin (Macrodantin)

Answer 14

Correct Answer: B. Protamine sulfate

Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding complications caused by heparin overdose.

Question 15

When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in charge would expect to do which of the following?

A. Turn the neonate every 6 hours
B. Encourage the mother to discontinue breastfeeding.
C. Notify the physician if the skin becomes bronze in color.
D. Check the vital signs every 2 to 4 hours.

Answer 15

Correct Answer: D. Check the vital signs every 2 to 4 hours

While caring for an infant receiving phototherapy for treatment of jaundice, vital signs are checked every 2 to 4 hours because hyperthermia can occur due to the phototherapy lights.

Question 16

A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal block anesthesia before delivery. After the nurse explains this type of anesthesia to the client, which of the following locations identified by the client as the area of relief would indicate to the nurse that the teaching was effective?

A. Back
B. Abdomen
C. Fundus
D. Perineum

Answer 16

Correct Answer: D. Perineum

A bilateral pudendal block is used for vaginal deliveries to relieve pain primarily in the perineum and vagina. Pudendal block anesthesia is adequate for episiotomy and its repair.

Question 17

The nurse is caring for a primigravida at about 2 months and 1-week gestation. After explaining self-care measures for common discomforts of pregnancy, the nurse determines that the client understands the instructions when she says:

A. “Nausea and vomiting can be decreased if I eat a few crackers before rising.”
B. “If I start to leak colostrum, I should cleanse my nipples with soap and water.”
C. “If I have a vaginal discharge, I should wear nylon underwear.”
D. “Leg cramps can be alleviated if I put an ice pack on the area.”

Answer 17

Correct Answer: A. “Nausea and vomiting can be decreased if I eat a few crackers before arising”

Eating dry crackers before arising can assist in decreasing the common discomfort of nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime can also help.

Question 18

Forty-eight hours after delivery, the nurse in charge plans discharge teaching for the client about infant care. By this time, the nurse expects that the phase of postpartum psychological adaptation that the client would be in would be termed which of the following?

A. Taking in
B. Letting go
C. Taking hold
D. Resolution

Answer 18

Correct Answer: C. Taking hold

Beginning after completion of the taking-in phase, the taking-hold phase lasts about 10 days. During this phase, the client is concerned with her need to resume control of all facets of her life in a competent manner. At this time, she is ready to learn self-care and infant care skills.

Question 19

A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse tells the client that the usual treatment for partial placenta previa is which of the following?

A. Activity limited to bed rest.
B. Platelet infusion.
C. Immediate cesarean delivery.
D. Labor induction with oxytocin.

Answer 19

Correct Answer: A. Activity limited to bed rest

Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring of the client’s bleeding.

Question 20

The nurse plans to instruct the postpartum client about methods to prevent breast engorgement. Which of the following measures would the nurse include in the teaching plan?

A. Feeding the neonate a maximum of 5 minutes per side on the first day.
B. Wearing a supportive brassiere with nipple shields.
C. Breastfeeding the neonate at frequent intervals.
D. Decreasing fluid intake for the first 24 to 48 hours.

Answer 20

Correct Answer: C. Breastfeeding the neonate at frequent intervals

Prevention of breast engorgement is key. The best technique is to empty the breast regularly while feeding. Engorgement is less likely when the mother and neonate are together, as in single-room maternity care continuous rooming-in, because nursing can be done conveniently to meet the neonate’s and mother’s needs.

Question 21

When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands open, and begins to cry. The nurse interprets this reaction as indicative of which of the following reflexes?

A. Startle reflex
B. Babinski reflex
C. Grasping reflex
D. Tonic neck reflex

Answer 21

Correct Answer: A. Startle reflex

The Moro, or startle, reflex occurs when the neonate responds to stimuli by extending the arms, hands open, and then moving the arms in an embracing motion. The Moro reflex, present at birth, disappears at about age 3 months.

Question 22

A primigravida client at 25 weeks gestation visits the clinic and tells the nurse that her lower back aches when she arrives home from work. The nurse should suggest that the client perform:

A. Tailor sitting
B. Leg lifting
C. Shoulder circling
D. Squatting exercises

Answer 22

Correct Answer: A. Tailor sitting

Tailor sitting is an excellent exercise that helps to strengthen the client’s back muscles and also prepares the client for the process of labor. The client should be encouraged to rest periodically during the day and avoid standing or sitting in one position for a long time.

Question 23

Which of the following would the nurse in charge do first after observing a 2-cm circle of bright red bleeding on the diaper of a neonate who just had a circumcision?

A. Notify the neonate’s pediatrician immediately.
B. Check the diaper and circumcision again in 30 minutes.
C. Secure the diaper tightly to apply pressure on the site.
D. Apply gentle pressure to the site with a sterile gauze pad.

Answer 23

Correct Answer: D. Apply gentle pressure to the site with a sterile gauze pad

If bleeding occurs after circumcision, the nurse should first apply gentle pressure on the area with sterile gauze. Bleeding is not common but requires attention when it occurs.

Question 24

Which of the following would the nurse most likely expect to find when assessing a pregnant client with abruption placenta?

A. Excessive vaginal bleeding
B. Rigid, board-like abdomen
C. Tetanic uterine contractions
D. Premature rupture of membranes

Answer 24

Correct Answer: B. Rigid, board-like abdomen

The most common assessment finding in a client with abruption placenta is a rigid or boardlike abdomen. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus with the initial separation, also is common.

Question 25

While the client is in active labor with twins and the cervix is 5 cm dilated, the nurse observes contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the following would be the nurse’s most appropriate action?

A. Note the fetal heart rate patterns.
B. Notify the physician immediately.
C. Administer oxygen at 6 liters by mask.
D. Have the client pant-blow during the contractions.

Answer 25

Correct Answer: B. Notify the physician immediately.

The nurse should contact the physician immediately because the client is most likely experiencing hypotonic uterine contractions. These contractions tend to be painful but ineffective. The usual treatment is oxytocin augmentation unless cephalopelvic disproportion exists.

Question 26

A 31-year-old multipara is admitted to the birthing room after initial examination reveals her cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in?

A. Active phase
B. Latent phase
C. Expulsive phase
D. Transitional phase

Answer 26

Correct Answer: D. Transitional phase

The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most difficult and intense for the patient.

Question 27

A pregnant patient asks the nurse if she can take castor oil for her constipation. How should the nurse respond?

A. “Yes, it produces no adverse effect.”
B. “No, it can initiate premature uterine contractions.”
C. “No, it can promote sodium retention.”
D. “No, it can lead to increased absorption of fat-soluble vitamins.”

Answer 27

Correct Answer: B. “No, it can initiate premature uterine contractions.”

Castor oil can initiate premature uterine contractions in pregnant women. It also can produce other adverse effects, but it does not promote sodium retention.

Question 28

A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal bleeding for the past 8 hours. She has passed several clots. What is the primary nursing diagnosis for this patient?

A. Knowledge deficit
B. Fluid volume deficit
C. Anticipatory grieving
D. Pain

Answer 28

Correct Answer: B. Fluid volume deficit

If bleeding and clots are excessive, this patient may become hypovolemic. Pad count should be instituted. Blood volume expands during pregnancy, and a considerable portion of the weight of a pregnant woman is retained water.

Question 29

A woman who is at 36 weeks of gestation is having a nonstress test. Which statement indicates her correct understanding of the test?

A. “I will need to have a full bladder for the test to be done accurately.”
B. “I should have my husband drive me home after the test because I may be nauseated.”
C. “This test will help to determine whether the baby has Down syndrome or a neural tube defect.”
D. “This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby.”

Answer 29

Correct Answer: D. “This test observes for fetal activity and an acceleration of the fetal heart rate to determine the well-being of the baby.”

The nonstress test is one of the most widely used techniques to determine fetal well-being and is accomplished by monitoring fetal heart rate in conjunction with fetal activity and movements.

Question 30

The nurse is counseling a couple who has sought information about conceiving. The couple asks the nurse to explain when ovulation usually occurs. Which statement by the nurse is correct?

A. Two weeks before menstruation.
B. Immediately after menstruation.
C. Immediately before menstruation.
D. Three weeks before menstruation.

Answer 30

Correct Answer: A. Two weeks before menstruation

Ovulation occurs 14 days before the first day of the menstrual period (A). Although ovulation can occur in the middle of the cycle or 2 weeks after menstruation, this is only true for a woman who has a perfect 28-day cycle. For many women, the length of the menstrual cycle varies.

Question 31

The nurse instructs a laboring client to use accelerated blow breathing. The client begins to complain of tingling fingers and dizziness. Which action should the nurse take?

A. Administer oxygen by face mask.
B. Notify the health care provider of the client’s symptoms.
C. Have the client breathe into her cupped hands.
D. Check the client’s blood pressure and fetal heart rate.

Answer 31

Correct Answer: C. Have the client breathe into her cupped hands.

Tingling fingers and dizziness are signs of hyperventilation (blowing off too much carbon dioxide). Hyperventilation is treated by retaining carbon dioxide. This can be facilitated by breathing into a paper bag or cupped hands.

Question 32

When assessing a client at 12 weeks of gestation, the nurse recommends that she and her husband consider attending childbirth preparation classes. When is the best time for the couple to attend these classes?

A. At 16 weeks of gestation.
B. At 20 weeks of gestation.
C. At 24 weeks of gestation.
D. At 30 weeks of gestation.

Answer 32

Correct Answer: D. At 30 weeks of gestation.

Learning is facilitated by an interested pupil. The couple is most interested in childbirth toward the end of the pregnancy when they are beginning to anticipate the onset of labor and the birth of their child. At 30 weeks, is closest to the time when parents would be ready for such classes.

Question 33

One hour following a normal vaginal delivery, a newborn infant boy’s axillary temperature is 96° F, his lower lip is shaking and, when the nurse assesses for a Moro reflex, the boy’s hands shake. Which intervention should the nurse implement first?

A. Stimulate the infant to cry.
B. Wrap the infant in warm blankets.
C. Feed the infant formula.
D. Obtain a serum glucose level.

Answer 33

Correct Answer: D. Obtain a serum glucose level.

This infant is demonstrating signs of hypoglycemia, possibly secondary to a low body temperature. The nurse should first determine the serum glucose level.

Question 34

Which statement made by the client indicates that the mother understands the limitations of breastfeeding her newborn?

A. “Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period.”
B. “Breastfeeding my baby immediately after drinking alcohol is safer than waiting for the alcohol to clear my breast milk.”
C. “I can start smoking cigarettes while breastfeeding because it will not affect my breast milk.”
D. “When I take a warm shower after I breastfeed, it relieves the pain from being engorged between breastfeedings.”

Answer 34

Correct Answer: A. “Breastfeeding my infant consistently every 3 to 4 hours stops ovulation and my period.”

Continuous breastfeeding on a 3- to 4-hour schedule during the day will cause a release of prolactin, which will suppress ovulation and menses, but is not completely effective as a birth control method.

Question 35

When assessing the adequacy of sperm for conception to occur, which of the following is the most useful criterion?

A. Sperm count
B. Sperm motility
C. Sperm maturity
D. Semen volume

Answer 35

Correct Answer: B. Sperm motility

Although all of the factors listed are important, sperm motility is the most significant criterion when assessing male infertility. To reach and fertilize an egg, sperm must move — wriggling and swimming through a woman’s cervix, uterus, and fallopian tubes. This is known as motility. Males are most likely to be fertile if at least 40% of their sperm are moving.

Question 36

Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester?

A. Dysuria
B. Frequency
C. Incontinence
D. Burning

Answer 36

Correct Answer: B. Frequency

Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary frequency.

Question 37

In which of the following areas would the nurse expect to observe chloasma?

A. Breast, areola, and nipples
B. Chest, neck, arms, and legs
C. Abdomen, breast, and thighs
D. Cheeks, forehead, and nose

Answer 37

Correct Answer: D. Cheeks, forehead, and nose

Chloasma, also called the mask of pregnancy, is an irregular hyperpigmented area found on the face. It is not seen on the breasts, areola, nipples, chest, neck, arms, legs, abdomen, or thighs.

Question 38

Cervical softening and uterine souffle are classified as which of the following?

A. Diagnostic signs
B. Presumptive signs
C. Probable signs
D. Positive signs

Answer 38

Correct Answer: C. Probable signs

Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy. Probable signs are objective findings that strongly suggest pregnancy.

Question 39

Which of the following would the nurse identify as a presumptive sign of pregnancy?

A. Hegar sign
B. Nausea and vomiting
C. Skin pigmentation changes
D. Positive serum pregnancy test

Answer 39

Correct Answer: B. Nausea and vomiting

Presumptive signs of pregnancy are subjective signs. Of the signs listed, only nausea and vomiting are presumptive signs.

Question 40

During which of the following would the focus of classes be mainly on physiologic changes, fetal development, sexuality, during pregnancy, and nutrition?

A. Prepregnant period
B. First trimester
C. Second trimester
D. Third trimester

Answer 40

Correct Answer: B. First trimester

First-trimester classes commonly focus on such issues as early physiologic changes, fetal development, sexuality during pregnancy, and nutrition. Some early classes may include pregnant couples.

Question 41

Which of the following would be a disadvantage of breastfeeding?

A. Involution occurs more rapidly.
B. The incidence of allergies increases due to maternal antibodies.
C. The father may resent the infant’s demands on the mother’s body.
D. There is a greater chance for error during preparation.

Answer 41

Correct Answer: C. The father may resent the infant’s demands on the mother’s body

With breastfeeding, the father’s body is not capable of providing the milk for the newborn, which may interfere with feeding the newborn, providing fewer chances for bonding, or he may be jealous of the infant’s demands on his wife’s time and body.