Ca MCN Rationale

MCN
1. A nurse is assessing the lochia in a 24-hour-postpartum client, and expresses blood clots with fundal massage. The
client’s fundus is firm but elevated, and deviated to the right. What would be the most appropriate nursing action?
A. Assess the activity pattern.
B. Change the perineal pad.
C. Assess the voiding pattern.
D. Administer analgesics.
Answer: C. Monitor urine output to assess if the bladder is emptying regularly, as a distended bladder could prevent the uterus
from contracting, leading to a collection of blood and the formation of blood clots. Increasing activity too soon might cause
persistent lochia rubra, but not blood clots. Changing the pad would promote comfort, but is not the most immediate intervention
for increased vaginal flow, especially if bladder distention is indicated. Administering analgesics is an important intervention for
cramping.
Reference: OLDS Maternal-Newborn Nursing & Women’s Health across the Lifespan by: Davidson * London * Ladewig, 8 th
Edition, © 2008 Assessment 35, item no. 274
2. The nurse is receiving results from clients who are having antenatal testing. The assessment data from which client
warrants prompt notification of the provider and a further plan of care?
A. Primigravida who reports fetal movements 6 times in 2 hours
B. Multigravida who had a positive oxytocin challenge test
C. Primigravida whose infant has a biophysical profile of 9
D. Multigravida whose infant has a reactive nonstress test
Rationale: B. (pg. 35) Late decelerations during an oxytocin challenge test indicate that the infant is not receiving enough oxygen
during contractions and is exhibiting signs of uteroplacental insufficiency. This client would need further medical intervention.
Fetal movement 6 times in 2 hours is adequate in a healthy fetus and a biophysical profile of 9 indicates that the risk of fetal
asphyxia is rare. A reactive nonstress test informs the health care provider that the fetus has 2 fetal heart rate accelerations of 15
beats per minute above baseline and lasting for 15 seconds within a 20 minute period, which is reassuring result and an
indication of fetal well-being.
Reference: Lippincott’s Q & A for NCLEX RN Ninth Edition Dianne Billings © 2008 item no. 32 pg. 22
3. Following a positive pregnancy test, a client begins discussing the changes that will occur in the next several months with
the nurse. Identifying the psychosocial aspect of pregnancy the nurse will incorporate into the plan of care as she
educates this client about the changes that occur in the first trimester:
A. Differentiating the self from the fetus
B. Enjoying the role of nurturer
C. Preparing for the reality of parenthood
D. Experiencing ambivalence about pregnancy
Rationale: D. (pg. 36) Many women in their first trimester feel ambivalent about being pregnant because of the significant life
changes that occur for most women who have a child. Ambivalence can bee expressed as a list of positive and negative
consequences of having a child, consideration of financial and social implications, and possible career changes. During the
second trimester, the infant becomes a separate individual to the mother. The mother will begin to enjoy the role of nurturer
postpartum. During the third trimester, the mother begins to prepare for parenthood all of the tasks that parenthood includes.
4. Using Nagele’s rule for a client whose last normal menstrual period began on May 10, the nurse determines that the
client’s estimated date of delivery would be which of the following?
A. January 13 C. February 13
B. January 17 D. February 17
Rationale: D. (pg. 36) When using Nagele’s rule to determine the estimated date of delivery, the nurse would count back 3
calendar months form the first day of the last menstrual period and add 7 days. This means the client’s estimated date of delivery
is February 17.
5 A client about 8 weeks pregnant, asks the nurse when she will be able to hear the fetal heartbeat. The nurse should
respond by telling the client that the fetal heartbeat can be heard with a Doppler ultrasound device when the gestation is
as early as which of the following?
A. 4 weeks C. 15 weeks
B. 8 weeks D. 18 weeks
Rationale: B. (pg. 37) With a Doppler ultrasound device, the fetal heartbeat can be heard as early as 8 weeks’ gestation. With a
fetoscope, the fetal heartbeat can be heard between 17 and 20 weeks’ gestation.
6. Which of the following statements by the nurse would be appropriate when responding to a primigravid client who asks,
“What should I do about this brown discoloration across my nose and cheeks?
A. “This usually disappears after delivery.”
B. “It is a sign of skin melanoma.”
C. “The discoloration is due to dilated capillaries.”
D. “It will fade if you use a prescribed cream.”
Rationale: A. Discoloration of the face that commonly appears during pregnancy, called chloasma (mask of pregnancy), usually
fades postpartum and is of no clinical significance. The client who is bothered by her appearance may be able to decrease its
prominence with ordinary makeup. Chloasma is not a sign of skin melanoma. It is caused by dilated capillaries. Rather, it results
from increased secretion of melanocyte-stimulating hormones caused by estrogen and progesterone secretion. No treatment is
necessary for this condition.
7. A client asks the nurse why taking folic acid is so important before and during pregnancy. Which of the following would be
the nurse’s best response?
A. “Folic acid is important in preventing anemia in mothers.”
B. “Eating foods with moderate amounts of folic acid helps regulate blood glucose levels.”
C. “Folic acid consumption helps with the absorption of iron during pregnancy.”
D. “Folic acid is needed to promote blood clotting and collagen formation in the newborn.”
Rationale: A. (pg. 41) Folic acid supplemental is recommended to prevent neural tube defects and anemia in pregnancy.
Deficiencies increase the risk of hemorrhage during delivery as well as infection. The recommended dose prior. To pregnancy is
400 mcg/day; while breast-feeding and during pregnancy, the recommended dosage is 500 to 600 mcg/day. Blood glucose
levels are not regulated by the intake of folic acid. Vitamin C potentiates the absorption of iron and is also associated with blood
clotting or collagen formation.
8. When preparing a prenatal class about endocrine changes that normally occur during pregnancy, which of the following
subjects would be included?
A. Human placental lactogen maintains the corpus luteum
B. Progesterone is responsible for hyperpigmentation and vascular skin changes
C. Estrogen relaxes smooth muscles in the respiratory tract
D. The thyroid enlarges with an increase in basal metabolic rate
Rationale: D. (pg. 42) Thyroid enlargement and increased basal body metabolism are common occurrences during pregnancy.
Human placental lactogen enhances milk production. Estrogen is responsible for hyperpigmentation and vascular skin changes.
Progesterone relaxes smooth muscle in the respiratory tract.
9. When developing a series of parent classes on fetal development, which of the following would the nurse include as
being developed by the end of the third month (9 to 12 weeks)?
A. External genitalia C. Brown fat stores
B. Myelinization of nerves D. Air ducts and alveoli
Rationale: A. (pg. 42) Although sex is not easily discerned at 9 to 12 weeks, external genitalia are developed at this period of
fetal developmental. Myelinization of the nerves begins at about 20 weeks’ gestation. Brown fat stores develop at approximately
21 to 24 weeks. Air ducts and alveoli develop later in the gestational period, at approximately 25 to 28 weeks.
10. During a childbirth preparation class, a primigravid client at 36 weeks’ gestation tells the nurse, “My lower back has really
been bothering me lately. Which of the following exercises suggested by the nurse would be most helpful?
A. Pelvic rocking C. Tailor sitting
B. Deep breathing D. Squatting
Rationale: A. (pg. 42) Pelvic rocking helps to relieve backache during pregnancy and early labor by making the spine more
flexible. Deep breathing exercises assist with relaxation and pain relief during labor. Tailor sitting and squatting help stretch the
perineal muscles in preparation for labor.
11. After a preparation for parenting class session, a pregnant client tells the nurse that she has had some yellow-gray frothy
vaginal discharge and local itching. The nurse’s best action is to advise the client to do which of the following?
A. Use an over-the-counter cream for yeast infections
B. Schedule an appointment at the clinic for an examination
C. Administer a vinegar douche under low pressure
D. Prepare for preterm labor and delivery
Rationale: B. (pg. 43) Increased vaginal discharge is normal during pregnancy, but yellow-gray frothy discharge with local itching
is associated with infection (e.g., Trichomonas vaginalis). The client’s symptoms must be further assessed by a health
professional because the client needs treatment for this condition. T. vaginalis infection is commonly treated with Metronidazole
(Flagyl). However, this drug is not used in the first trimester. In the first trimester, the typical treatment is topical clotrimazole.
Although a yeast infection is associated with vaginal itching, the vaginal discharge is cheese-like. Furthermore, because the
client may have a serious vaginal infection, over-the-counter medications are not advised until the client has been evaluated.
Douching is not recommended during pregnancy because it would predispose the client to an ascending infection. The client is
not exhibiting signs and symptoms of preterm labor, such as contractions or leaking fluid. And although the client’s complaints
are suggestive of a T. vaginalis infection, which can lead to preterm labor and premature rupture of the membranes, further
evaluation is needed to confirm the cause of infection.
12. During childbirth preparation classes for a group of adolescent primigravid clients, one of the clients asks, “How does the
baby breathe inside of me?” The nurse responds by explaining fetal circulation, stating that circulation of oxygenated
blood from the placenta begins with which of the following?
A. Umbilical cord C. Ductus arteriousus
B. Foramen ovale D. Umbilical vein
Rationale: D. (pg. 43) The umbilical cord normally consist of two arteries and one vein. Oxygen and other nutrients are carried to
the fetal circulation by the umbilical vein. The umbilical arteries carry oxygen-poor blood back to the placenta. The foremen ovale
is a shunt that allows blood returning from the lungs to mix. The ductus arteriousus allow oxygenated blood via the umbilical vein
to carried to the inferior vena cava.
13. Which of the following instructions would the nurse expect to include in the teaching plan for a group of primigravid clients
attending a parenting class about the placenta and the umbilical cord?
A. The highest oxygen content is found in the umbilical artery
B. About 10% of umbilical cords have only two vessels
C. The cord normally inserts in the center of the placenta
D. A nuchal cord usually occurs when the cord is abnormally short
Rationale: C. (pg. 43) The umbilical cord normally inserts in the center of the placenta. A velamentous cord does not insert
central into the placenta, and cord vessels branch out, which can lead to fetal hemorrhage. The highest oxygen content is found
in the umbilical vein. Oxygenated blood flows through the umbilical vein to the fetus. Blood leaving the fetus to return to the
placenta flows through the two umbilical arteries. About 1% of umbilical cord have only one artery. A nuchal cord occurs when
the cord is wrapped around the fetus’ neck, commonly because the cord is longer than normal.
Labor (13 – 19)

14. The physician orders intermittent fetal heart rate monitoring for a 20-year-old obese primigravid client at 40 weeks’
gestation who is admitted to the birthing center in the first stage of labor. The nurse would monitor the client’s fetal heart
rate pattern at which of the following intervals?
A. every 15 minutes during the latent phase
B. every 30 minutes during the active phase
C. every 60 minutes during the initial phase
D. every 2 hours during the transitional phase
Rationale: B. (pg. 81) Labor is categorized into three phases: latent, active and transition. During the active stage of labor,
intermittent fetal monitoring is performed every 30 minutes to detect changes in fetal heart rate such as bradycardia, tachycardia,
or decelerations. If complications develop, more frequent or continuous electronic fetal monitoring may be needed. During the
latent phase, intermittent monitoring is usually performed every 2 hours because contractions during this time are usually less
frequent. During the transition phase, intermittent monitoring is performed every 5 to 15 minutes because the client is getting
closer to delivery of the baby. There is no initial phase of labor.
Reference: Lippincott’s Q & A for NCLEX RN Ninth Edition Dianne Billings © 2008 Test 3 item no. 1 pg. 69
15. Assessment of primigravid client in active labor who has had no analgesia reveals complete cervical effacement, dilation
of 8 cm, and the fetus at 0 station. Which of the following behaviors would the nurse anticipate that the client will exhibit
during this phase of labor?
A. excitement C. numbness of the legs
B. loss of control D. feeling of relief
Rationale: B. (pg. 81) Assessment findings indicate that the client is in the transition phase of labor. During this phase, it is not
unusual for clients to exhibit a loss of control or irritability. Leg tremors, nausea, vomiting and an urge to bear down also are
common. Excitement is associated with the latent phase of labor. Numbness of the legs may occur when epidural anesthesia
has been given; however it is rare when no anesthesia is given. Feelings of relief generally occur during the second stage, when
the client begins bearing-down effort.
16. A primigravid client is admitted as an outpatient for an external cephalic version. For which of the following would the
nurse assess the client as a possible contraindication for the procedure?
A. multiple gestation C. maternal Rh-negative blood type
B. breech presentation D. history of gestational diabetes
Rationale: A. (pg. 82) External cephalic version is the turning of the fetus from a breech position to the vertex position to prevent
the need for a cesarean delivery. Gentle pressure is used to rotate the fetus in a forward direction to a cephalic lie.
Contraindications to the procedure include multiple gestation because the potential for fetal injury or uterine injury, severe
oligohydramnios (decreased amniotic fluid), contraindications to a vaginal birth (e.g., cephalopelvic disproportion), and
unexplained third trimester bleeding. If the mother has Rh-negative blood type, the procedure can be performed and Rh
immunoglobulin should be administered in case minimal bleeding occurs. A history of gestational diabetes is not contraindication
unless the fetus is large for gestational age and the client has cephalopelvic disproportion.
17. A multigravida in active labors is 7 cm dilated. The fetal heart rate baseline is 130 bpm with moderate variability. The
client begins to have variable decelerations to 100 to 110 bpm. What should the nurse do next?
A. perform a vaginal examination
B. notify the physician of the decelerations
C. reposition the client and continue to evaluate the tracing
D. administer oxygen via mask at 2 L/minute
Rationale: C. (pg. 85) The cause of variable decelerations is cord compression, which may be relieved by moving the client to
one side or another. If the client is already on the left side, changing the client to the right side is appropriate. Performing a
vaginal examination will let the nurse know how far dilated the client is but will not relieve the cord compression. If the
decelerations are not relieved by position changes, oxygen should be initiated but the rate should be 8 to 10 L/minute. Notifying
the physician should occur if turning the client and administering oxygen do not relieve the decelerations.
18. The nurse while shopping in the local department store, hears a multiparous woman say loudly, “I think the baby’s
coming.” After asking someone to call the nearest hospital, the nurse assists the client to deliver a term neonate. While
waiting for the ambulance, the nurse suggests that the mother initiate breast-feeding, primarily for which of the following
reasons?
A. to begin the parenteral-infant bonding process
B. to prevent neonatal hypothermia
C. to provide glucose to the neonate
D. to contract the mother’s uterus
Rationale: D. (pg. 86) After an emergency delivery, the nurse suggests that the mother begin breast-feeding to contract the
uterus. Breast-feeding stimulates the natural production of oxytocin. In a multiparous client, uterine atony is a potential
complication because of the stretching of the uterine fibers following each subsequent pregnancy. Although breast-feeding does
help to begin the parental-infant bonding process, this is not the primary reason for the nurse to suggest breast-feeding.
Prevention of neonatal hypothermia is accomplished by placing blankets on both the neonate and the mother. Although
colostrums in breast milk provides the neonate with nutrient and immunoglobulins, the primary reason for breast-feeding is to
stimulate the natural production of oxytocin to contract the uterus.
19. While the nurse is caring for the multiparous client in active labor at 36 weeks’ gestation, the client tells the nurse, “I think
my bag of water just broke.” Which of the following would the nurse do first?
A. turn the client to the right side
B. assess the color, amount, and odor of the fluid
C. assess the fetal heart rate pattern
D. assess the client’s cervical dilation
Rationale: C. (pg. 87) After spontaneous rupture of the amniotic fluid, the gushing fluid may carry the umbilical cord out of the
birth canal. Sudden deceleration of the fetal heart commonly signifies cord compression and/or prolapse of the cord, which would
require immediate delivery. This client is particularly at risk because the fetus is preterm and the fetal head may not be engaged.
Turning the client to the right side is not a priority action. However, changing the client’s position would be appropriate if variable
decelerations are present. The nurse should assess the color, amount, and odor of fluid, but this can be done once the fetal
heart rate is assessed and no problems are detected. Cervical dilation should be checked but only after the fetal heart rate is
assessed.
20. Following an epidural and placement of internal monitors, a client’s labor is augmented. Contractions are lasting greater
than 90 seconds and occurring every 1½ minutes. The uterine resting is greater than 20 mm mercury with a
nonreassuring fetal heart rate and pattern. Which of the following actions should the nurse take first?
A. notify the health care provider
B. turn off oxytocin (Pitocin) infusion
C. turn the client to her left side
D. increase the maintenance I.V fluids
Rationale: B. (pg. 88) The client is experiencing uterine hyperstimulation from the oxytocin (Pitocin). The first intervention should
be to stop the oxytocin infusion, which may be the cause of the long, frequent contractions, elevated resting tone, and
nonreassuring fetal heart patters. Only after turning off the oxytocin, should the nurse turn the client to her left side to better
perfuse the mother and fetus. Then she should increase the maintenance I.V. fluids to allow available oxygen to be carried to the
mother and fetus. When all other interventions are initiated, she should notify the health care provider.
21. A client has admitted use of cocaine prior to beginning labor. After the infant is born, that nurse should anticipate the
need to include which of the following actions in the infant’s plan of care?
A. urine toxicology screening
B. notify hospital security
C. limiting contact with visitors
D. contacting local law enforcement
Rationale: A. (pg. 107) A urine toxicology will be collected to document that the infant has been exposed to illegal drug use. This
documentation will be the basis for legal action for the protection of this infant. If the infant tests positive for cocaine, the legal
system will be activated to provide and ensure protection custody for this child. Hospital security would not become involved
unless the mother is obtaining or using drugs on hospital premises. The mother and infant have the same privileges as any
hospitalized client unless the safety of the infant is jeopardized, thus limiting contact with visitors would not be appropriate. Local
law enforcement agencies would be contacted only if the mother initiates use of the drugs on hospital premises and such contact
would be made through the hospital security system.
22. The physician orders an intramuscular injection of phytonadione (AquaMEPHYTON) for a term neonate. The nurse
explains to the mother that this medication is used to prevent which of the following?
A. hypoglycemia C. hemorrhage
B. hyperbilirubinemia D. polycythemia
Rationale: C. (pg. 108) Phytonadione (vitamin K or AquaMEPHYTON) acts as preventive measure against neonatal hemorrhagic
disease. At birth, the neonate does not have the intestinal flora to produce vitamin K, which is necessary for coagulation.
Hypoglycemia is prevented and treated by feeding the infant. Hyperbilirubinemia severity can be decreased by early feeding and
passage of meconium to excrete the bilirubin. Hyperbilirubinemia is treated with phototherapy. Polycythemia may occur in
neonates who are large for gestation age or post-term. Clamping of the umbilical cord before pulsations cease reduces the
incidence of polycythemia. Generally, polycythemia is not treated unless it is extremely severe.
23. When developing the plan of care for primiparous client during the first 12 hours after vaginal delivery, which of the
following concerns of the client should be the nurse’s primary focus of care?
A. the neonate C. the client’s own comfort
B. the family D. the client significant other
Rationale: C. (pg. 108) The first 12 hours after delivery are part of the taking-in-phase of maternal postpartum adjustment, which
typically lasts from 1 to 3 days. During the taking-in phase, the client is primarily concerned with her own needs. After the first 1
to 3 days postpartum, the client is in the taking-hold phase and can focus more on the needs of the neonate. Although the family
is an important for the mother’s emotional support, during the taking-in phase the mother is focused on her self.
24. The nurse assesses a swollen ecchymosed area to the right of an episiotomy on a primiparous client 6 hours after a
vaginal delivery. Which of the following actions should the nurse do next?
A. apply an ice pack to the perineal area
B. assess the client’s temperature
C. have the client take a warm sitz bath
D. contact the physician for orders for an antibiotic
Rationale: A. (pg. 108) The client has a hematoma. During the first 24 hours postpartum, ice packs can be applied to the perineal
area to reduce swelling and discomfort. Ice packs usually are not effective after the first 24 hours. Although vital signs, including
temperature, are important assignments, taking the client’s temperature is unrelated to the hematoma and would provide no
additional information about swelling. After 24 hours, the client may obtain more relief by taking a warm sitz bath. This moist heat
is an effective way to increase circulation to the perineum and provide comfort. Usually, hematomas resolve without further
treatment within 6 weeks. Additionally, the nurse should measure the hematoma to provide baseline for subsequent
measurements and should notify the physician of its presence. An antibiotic is not warranted at this point because the client is
not exhibiting any signs of symptoms of infection.
25. Which of the following drugs can be given to the mother before a preterm birth to help reduce the severity of respiratory
distress syndrome?
A. Betamethasone
B. Diazepam
C. Phenobarbital
D. RhoGAM
26. Which of the following is a positive indication of pregnancy?
A. Quickening C. Auscultation of fetal heart sounds
B. Chadwick’s sign D. Ballottement
27. During the last months of pregnancy, the nurse should instruct the client to:
A. rest on her left side for at least 1 hour in the morning and afternoon
B. sleep on her back during the night and during naps
C. start nipple exercises and stimulation twice a day
D. start to cut back on water intake, especially at night
28. When teaching a pregnant woman about traveling during the pregnancy, it is important to focus on which of the following?
A. If traveling by car, stop every 2 hours for 10 minutes
B. Get plenty of rest before long trips made in automobiles
C. Travel in any type of aircraft is acceptable
D. Travel can be completed anytime throughout the pregnancy
29. Which of the following is recommended for all women during the childbearing age?
A. Additional B vitamins C. Folic acid supplement
B. Additional vitamin A D. Vitamin C supplement
30. Between 24 and 28 weeks, all pregnant women should be screened for:
A. Anemia C. Diabetes
B. Bladder infections D. Neural tube defects
31. Which of these measures would be helpful for the pregnant client complaining of sleeplessness?
A. Eat evening meal close to bedtime
B. Sit in a sitz bath before bedtime
C. Try to remain in one position when sleeping
D. Use pillows to help find a comfortable position
32. Why is the first 8 weeks of pregnancy known as the critical period of human development?
A. By the time this period ends, the embryo is completely safe from any damage
B. Many embryos die during this period
C. The infant’s sex is determined at the end of the eight week
D. The major structures of the embryo are forming, and damage can result in major birth defects
33. Which of these statements is most accurate about the placenta?

A. The blood of the baby mixes with the mother’s blood to permit exchange of nutrients and oxygen.
B. The blood of the baby and the mother do not mix; exchange occurs across blood vessels and the walls of the villi.
C. The placenta lets the blood from the fetus cross to the mother, but the mother’s blood does not cross to the fetus.
D. The placenta serves as a complete barrier between the baby and mother so that any drugs the mother takes do not
cross the baby.
34. Which of the following is the best recommendation about taking medicines during pregnancy?
A. All over-the-counter (OTC) drugs are safe during pregnancy
B. All herbal preparations are safe during pregnancy
C. Don’t take anything during pregnancy without asking your health care provider
D. Take an OTC diuretic if you have swelling during the pregnancy
35. A feeling of ambivalence about the pregnancy is:

A. a sign of unwanted pregnancy C. rare at any stage of pregnancy
B. normal in early pregnancy D. typical in late pregnancy
36. Which assessment relates most directly to rupture membranes and release of amniotic fluid?
A. Bloody show
B. Fluid with a pH of 7.0 to 7.5 with nitrazine test
C. Fluid with a pH of 5.0 with nitrazine test
D. Woman complains of urge to push
37. When the placenta is delivered with the dull side out (Duncan presentation), the woman is at risk for:
A. excessive bleeding
B. hemorrhoids
C. increased lacerations of the perineum
D. sterility
38. To assess the uterine contraction during labor, the nurse:
A. asks the woman if she is having a contraction.
B. palpates above the symphysis pubis.
C. palpates just below the xyphoid process of the sternum.
D. performs a sterile vaginal examination.
39. The nurse knows that a postpartum client’s susceptibility to hemorrhage is most likely related to a:
A. boggy uterus C. long labor
B. firm fundus D. negative Homan’s sign
40. Which of the following indicates that the new mother understands how to handle breast milk safely?
A. “I can store fresh milk in the refrigerator for only 24 hours.”
B. “I can store frozen breast milk for up to 1 month.”
C. “I need to express my breast milk into a clear glass.”
D. “I should never store my breast milk in a frozen-food locker.”
41. To prevent infection of the perineal area after delivery, the nurse should instruct the client to:
A. Begin sitz bath at the first sign of infection
B. Pull panties straight down
C. Use hot water to cleanse the area after bowel movement
D. Wipe with sweeping motion, from front to back
42. Analgesics given too late in labor can result in which of the following?
A. Contractions that increase in intensity
B. Early deceleration
C. FHR dropping to 100 beat per minute
D. Pain during contractions
43. In evaluating the effects if oxytocin after delivery, the nurse should monitor for:
A. effective breastfeeding. C. relief of pain.
B. engorged breasts. D. the uterus remaining firm.
44. During active labor, the mother usually exhibits which of the following behaviors?
A. Difficulty following directions
B. Excitedness and talkativeness
C. Frustration and irritability
D. Serious expression and apprehension
45. When providing postpartum teaching about self-care, one of the danger signs that a lactating woman should know to
report to the birth attendant is:
A. breast engorgement to a degree that the baby can’t latch on.
B. breast fullness just before feeding .
C. nipple soreness after feedings.
D. nipple dryness before feedings.
46. “Show” is usually present in:

A. Braxton Hicks contraction. C. true labor.
B. false labor. D. Second stage of labor only.
47. Which assessment most closely relates to a diagnosis of ectopic pregnancy?

A. Brownish red, tapioca-like vesicles
B. Elevated temperature
C. Spotting or bleeding 2 to 3 weeks after a missed menstrual period
D. Sudden absence of fetal movement
48. The drug of choice to treat pregnancy-induced hypertension is:
A. iron and vitamins C. furosemide (Lasix)
B. diazepam (valium) D. magnesium sulfate
49. Which nursing intervention would be appropriate for a client who has a diastolic blood pressure of more than 20 mmHg
on the “roll-over” test?
A. Increase intake of oral fluids
B. Rest on left side as much as possible
C. Schedule follow-up care every 2 weeks
D. Use the stairs to increase activity level
50. A mother receiving medications for pregnancy-induced hypertension should have her diastolic blood pressure maintained
in the range of 90 to 100 mmHg to:
A. avoid causing fetal anoxia. C. prevent premature contractions.
B. ensure progression of labor. D. present sudden elevations in pulse.
51. A nurse caring for an infant with congenital heart failure (CHF) is monitoring the infant closely for
signs of congestive heart failure. The nurse assesses the infant for which early signs of CHF?
A. Pallor
B. Cough
C. Tachycardia
D. Slow and shallow breathing
Answer: C (page 464)
Rationale: Congestive heart failure is the inability of the heart to pump a sufficient amount of oxygen to
meet the metabolic needs of the body. The early signs of CHF include tachycardia, tachypnea, profuse
scalp sweating, fatigue and irritability.
Reference: Saunders Comprehensive Review for the NCLEX-RN Examination 5 th Edition by: Linda Anne
Silvestre © 2011 Chapter 39 item no.397 pg. 463
52. A nurse is caring for a child with a suspected diagnosis of rheumatic fever. The nurse reviews the
laboratory results, knowing that which laboratory study would assist in confirming the diagnosis?
A. Immunoglobulin
B. Red blood count
C. White blood cell count
D. Antistreptolysin O titer
Answer: D (page 465)
Rationale: Rheumatic heart fever is an inflammatory autoimmune disease that effects the connective
tissues of the heart, joints, subcutaneous tissues and blood vessels of the cns.
Silvestre © 2011 Chapter 39 item no. 398 pg. 463
53. A nurse is preparing for the admission of a child with a diagnosis of acute-stage Kawasaki disease.
On assessment of the child, the nurse expects to note which clinical manifestation of the acute stage
of the disease?
A. Cracked lips
B. Normal appearance
C. Conjunctival hyperemia
D. Desquamation of the skin
Rationale: Kawasaki disease is also known as mucocutaneous lymph node syndrome and is an acute
systemic inflammatory illness.In acute stage stage the child has fever, conjuctival hyperemia, red throat,
swollen hands, rash and enlargement of the cervical lymph nodes
54. A nurse provides home care instructions to the parents of a child with congestive heart failure
regarding the procedure for administration of digoxin. Which statement made by the parent indicates
the need for further instructions?
A. “I will not mix the medication with food”
B. If more than one dose is missed, I will call the physician”
C. “I will take the child’s pulse before administering the medication”
D. “If the child vomits after medication administration, I will repeat the dose”
Rationale: Digoxin is a cardiac glycoside. The parents need to be instructed that if the child vomits after
digoxin is administered they are not to repeat the dose
55. A physician has prescribed oxygen as needed for an infant with congestive heart failure. In which
situation should the nurse administer the oxygen to the infant?
A. During sleep
B. When changing the infant’s diapers
C. When the mother is holding the infant
D. When drawing blood for electrolyte level testing
Rationale: CHF is the inability of the heart to pump a sufficient amount of oxygen to meet the metabolic
needs of the body.
56. A clinic nurse reviews the record of a child just seen by a physician and diagnosed with suspected
aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically
found in this disorder?
A. Pallor
B. Hyperactivity
C. Exercise intolerance
D. Gastrointestinal disturbances
Rationale: Aortic stenosis is a narrowing or stricture of the aortic valve causing resistance to blood in the
left ventricle decreased cardiac output left ventricular hypertrophy and pulmonary vascular congestion. A
child with aortic stenosis shows signs of exercise intolerance, chest pain and dizziness.
Reference: Saunders Comprehensive Review for the NCLEX-RN Examination 5th Edition by: Linda Anne
57. The nurse is caring for an adolescent who is receiving frequent visits from peer group members. The
nurse understands that groups are important in the emotional development of an individual because
they:
A. Always protect their members
B. Are easily identified by their members
C. Go through the same developmental phase
D. Identify acceptable behavior for their members
Rationale: D. (pg.66) Learning from others occur in a group setting and is reinforced by group acceptance
of the norms.
Reference: Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination 19 th Edition, Item
no. 3 Page 50. © 2010
58. To help parents cope with the behavior of young school-age children, the nurse suggests that it
would help if they:
A. Avoid asking specific questions C. Be consistent about established rules
B. Give children a list of expectations D. Allow the children to set up their own routines
Rationale: C. (pg.66) Because of a short attention span and distractibility, consistent limit setting is crucial
toward providing an environment that promotes concentration, prevents confusion, and minimizes conflicts.
no. 10 Page 50. © 2010
59. A 2-year-old child is admitted with a diagnosis of pneumonia and is given antibiotics, fluids and
oxygen. The child’s temperature rises until it reaches 103°F. The nurse calls the physician at the
mother’s request, but the physician sees no need to change treatment, even though the child has a
history of febrile seizures. Although concerned, the nurse takes no further action. Later, the child has
a seizure that results in neurologic impairment. Legally,
A. The physician’s decision takes precedence over the nurse’s concern
B. The nurse’s failure to further question the physician placed the child at risk
C. High fevers are common in children; therefore presents little cause for concern
D. The physician is totally responsible for the client’s health history and treatment regimen
Rationale: B. (pg.67) It is the nurse’s responsibility to foresee potential harm and prevent risks by acting as
an advocate.
no. 14 Page 51. © 2010
60. A 3-year-old boy with eczema of the face and arms has disregarded the nurse’s warnings to “stop
scratching—or else!” The nurse finds the toddler scratching so intensely that his arms are bleeding.
With great flurry, the nurse ties the toddler’s arms to the crib sides, saying “I’m going to teach you
one way or another.” In this situation, the nurse:
A. Has used actions that can be interpreted as assault and battery
B. Has responded to the problem with considerable accountability
C. Had to protect the toddler’s skin and acted the same as any reasonably prudent nurse
D. Had tried to explain to the toddler and expected the toddler to understand and cooperate
Rationale: A. (pg.67) Assault is a threat or an attempt to do violence to another, and battery means
touching an individual in an offensive manner or actually injuring another person.
no. 20 Page 52. © 2010
61. A toddler screams and cries noisily after parental visits, disturbing all the other children. When the
crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the
door. The toddler is left there until the crying ceases, a matter of 30 to 45 minutes. Legally,
A. The child needed to have limits set to control the crying
B. The child had a right to remain in the room with the other children
C. The segregation of the child for more than 30 minutes was too long
D. The other children had to be considered, so the child needed to be removed
Rationale: B. (pg.68) Legally, a client cannot be locked in room (isolated) unless there is a threat
of danger involved either to the client or to other clients.
no. 23 Page 52. © 2010
62. A client is admitted with the diagnosis of possible placenta previa. The nurse begins IV fluids,
administer oxygen, and draws blood for laboratory tests as ordered. The client’s apprehension is
increasing, and she asks the nurse what is happening. The nurse tells her not to worry, that she is
going to be alright, and that everything is under control. What is the best description of the nurse’s
statement?
A. Adequate, because the preparations are routine and need no explanation
B. Incorrect, because only the physician should explain why treatments are being done
C. Proper, because the client’s anxieties would be increased if she knew the dangers
D. Questionable, because the client has the right to know what treatment is being given and why
Rationale: D. (pg.68) The client’s right are violated. All clients have the right to a complete and accurate
explanation of the treatment.
no. 24 Page 52. © 2010
63. A client has been told she needs a hysterectomy for cervical cancer is upset being unable to have
more children. What should the nurse should do?
A. Evaluate her willingness to pursue adoption
B. Encourage her to focus on her own recovery
C. Emphasize that she does have two children already
D. Ensure that all treatment options have been explored
Rationale: D. (pg.68) Although a hysterectomy may be performed, conservative management may include
cervical conization and laser treatment that do not preclude future pregnancies; clients have a right to be
informed by their physician of all treatment options.
no. 26 Page 52. © 2010
64. Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of the
hospital because of difficulty at home with her 2-year-old son. Staff members are unable to contact
her physician. The client arrives at the nursery dressed and ready to leave and asks that her infant
be given to her dress and take home. What is the most appropriate nursing action?
A. Explain to the client that her infant must remain in the hospital until signed out by the physician
B. Give the infant to the client to take home, making sure that she receives information regarding
care of a 2-day-old infant
C. Allow the child time with the baby before she leaves, but emphasize that the baby is a minor and
legally must remain until orders are received.
D. Tell the client that under the circumstances, hospital policies prevents the staff from releasing the
infant into her care, but she will be informed when the infant is discharged.
Rationale: B. (pg.69) When the client signs herself and the baby out of the hospital, she is legally
responsible for her infant and must be given the baby.
no. 35 Page 53. © 2010
65. The nurse is instructing a group of volunteer nurses on the technique of administering the smallpox
vaccine. What method should the nurse teach the group to administer the vaccine correctly?
A. Z-track injection
B. Intravenous injection
C. Subcutaneous injection
D. Intradermal scratch injection
Rationale: D. (pg.71) The vaccination is scratched into the skin using bifurcated needle.
no. 57 Page 55. © 2010
66. A pregnant client is now in the third trimester. The client tells the nurse she wants to have general
anesthesia for the birth. What is the nurse’s best response?
A. “You are worried about too much pain?”
B. “I will tell your doctor about this request.”
C. “You don’t want to be awake during the birth?”
D. “I can understand that because labor is uncomfortable.”
Rationale: C. (pg.71) Paraphrasing encourages the client to express the rationale for this request.
no. 60 Page 55. © 2010
67. A nurse prepares to administer digoxin (lanoxin) to a 3 year old child with a diagnosis of congestive
heart failure and notes that the apical heart rate is 110 beats/min. Based on this finding which nursing
action is appropriate?
A. Hold the medication
B. Notify the physician
C. Administer the digoxin
D. Recheck the apical rate in 15 minutes
Answer. C (p. 389) The normal apical heart rate for a 3 year old is 80 to 120 beats/min.
Reference: Saunders Comprehensive Review of Nursing for the NCLEX-RN Examination 5 th Edition by
Linda Anne Silvestre © 2011 Chapter 33 Item no. 335 Page 387.
68. A mother of a 3 year old asks a clinic nurse about appropriate and safe toys for the child. The nurse
tells the mother that the appropriate toy for a 3 year old child is which of the following?
A. A wagon C. A farm set
B. A golf set D. a jack set with marbles
Answer: A (p. 390) Toys for the toddler must be strong, safe and too large to swallow or place in the ear or
nose.
69. The mother of a 3 year old is concerned because her child still is insisting on a bottle at nap time and
at bed time. Which of the following is the appropriate suggestion to the mother?
A. Allow the bottle if it contains juice
B. Allow the bottle if it contains water
C. Do not allow the child to have the bottle
D. Allow the bottle during naps but not at bedtime
Answer. B (p. 390) A toddler should never be allowed to fall asleep with a bottle containing milk, juice,
soda pop, sweetened water or any other sweet liquid
70. A nurse is preparing a plan of care for a newborn with fetal alcohol syndrome. The nurse should
include which priority intervention in the plan of care?
A. Allow the newborn to establish own sleep-rest pattern
B. Maintain the newborn in a brightly lighted area of the nursery
C. Encourage frequent handling of the newborn by staff and parents
D. Monitor the newborn’s response to feedings and weight gain pattern
Answer. D (p. 356). Fetal alcohol syndrome is caused by maternal alcohol use during pregnancy
71. A new mother expresses concern to a nurse regarding sudden infant death syndrome (SIDS) she
asks the nurse how to position her new infant for sleep. The nurse appropriately tells the mother that
the infant should be placed in the:
A. Side or prone
B. Back or prone
C. Stomach with the face turned
D. Back rather than on the stomach
Answer. D (p. 452) Sudden infant death syndrome is the unexpected death of apparently healthy infant
younger than 1 year for whom an investigation of the death and a through autopsy fails to show an
adequate cause of death. Several theories are proposed regarding the cause, but the exact cause is
unknown. Nurses should encourage parents to place the infant on the back (supine for sleep). Infants in the
prone position (on the stomach) may be able to move their heads to the side, increasing the risk of
suffocation. The infant may have the ability to turn to a prone position from the side-lying position.
72. A clinic nurse reads the results of a Mantoux test on a 3 year old child. The results indicate an area of
induration measuring 10mm. The nurse would interpret these results as:
A. Positive
B. Negative
C. Inconclusive
D. Definitive and requiring a repeat test
Answer. A (p. 453) Induration measuring 10 mm or more is considered to be a positive result in children
younger than 4 years of age ad in children with chronic illness or at high risk for exposure to tuberculosis.
Reference: Mosby’s Comprehensive Review of Nursing for the NCLEX-RN Examination 5 th Edition by
73. A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of
transmission of this infection which of the following should be included in the plan of care?
A. Maintain enteric precautions
B. Maintain neutropenic precautions
C. No precautions are required as long as antibiotics have been started
D. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics
Answer: D (page 432) Meningitis is an infectious process of the central venous system caused by bacteria
and viruses it may be acquired as primary disease or complications of neurosurgery, trauma or infection
74. After a tonsillectomy, a child begins to vomit bright red blood. The initial nursing action is to:
A. Notify the physician
B. Maintain NPO status
C. Turn the child to the side
D. Administer the prescribed antiemetic
Answer: C (page 437) After tonsillectomy, if bleeding occurs, the nurse immediately turns the child to the
side to prevent aspiration and then notifies the physician
75. A day care nurse is observing a 2 year old child and suspects that the child may have strabismus.
Which observation made by the nurse might indicate this condition?
A. The child has difficulty hearing
B. The child consistently tilts the head to see
C. The child consistently turns the head to see
D. The child does not respond when spoken to
Answer: B (page 437) Strabismus is a condition in which the eyes are not aligned because of lack of
coordination of the extraocular muscles
76. A nurse is reviewing the laboratory results for a child scheduled for tonsillectomy. The nurse
determines that which laboratory value is most significant to review
A. Creatinine level
B. Prothrombin time
C. Sedimentation rate
D. Blood urea nitrogen level
Answer: B (page 437) A tonsillectomy is the surgical removal of the tonsils. Because the tonsillar area is so
vascular, postoperative bleeding is a concern
77. A nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of
care to place the child in which appropriate position?
A. Supine
B. Side-lying
C. High Fowler’s
D. Tredelenburg’s
Answer: B (page 437) The child should be placed in a prone or side lying position after the surgical
procedure to facilitate drainage
78 . After tonsillectomy, a nurse reviews the physician’s postoperative prescriptions. Which of the
following physician’s prescriptions does the nurse question?
A. Monitor for bleeding
B. Suction every 2 hours
C. Give no milk or milk products
D. Give clear, cool liquids when awake and alert
Answer: B (p. 438). After tonsillectomy suction equipment should be available but suctioning is not
performed when there is obstruction.
79. A nurse is providing home care instructions to the mother of a 10 year old child with hemophilia.
Which of the following activities should the nurse suggest that the child could participate in safety
with peers?
A. Soccer
B. Basketball
C. Swimming
D. Field hockery
Answer: C (p. 524) Children should avoid contact sports and to take precautions such as wearing elbow
and knee pads and helmets with other sports.
80. A 10-year-old child with Hemophilia A has slipped on the ice and bumped his knees. The nurse
should prepare to administer an:
A. Injection of factor X
B. Intravenous infusion of iron
C. Intravenous infusion of factor VII
D. Intramuscular injection of iron using the Z-tract method
Answer: C (p. 525). The primary treatment is a replacement of the missing clotting factor, additional
medications such as agents to relieve pain depending on the source of bleeding from the disorder.
81. An infant with congestive heart failure is receiving diuretic therapy and a nurse is closely monitoring
the intake and output. The nurse uses which most appropriate method to assess the urine output?
A. Weighing the diapers
B. Inserting a Foley Catheter
C. Comparing intake with output
D. Measuring the amount of water added to formula
Answer: A (page 465) CHF is the inability of the heart to pump a sufficient amount of oxygen to meet the
metabolic needs of the body
82. A nurse has provided home care instructions to the mother of a child who is being discharged after
cardiac surgery. Which statement made by the mother indicates a need for further instructions?
A. ” A balance of rest and exercise is important”
B. “I can apply lotion or powder to the incision if it is itchy”
C. “Activities in which my child could fall need to be avoided for 2 to 4 weeks”
D. “Large crowds of people need to be avoided for at least 2 weeks after surgery
Answer: B (page 466). The mother should be instructed that lotions and powders should not be applied to
the incision site after cardiac surgery
83. A nurse receives a telephone call from the admitting office and is told that a child with rheumatic
fever will be arriving in the nursing unit for admission. On admission, the nurse prepares to ask the
mother which question to elicit assessment information specific to the development of rheumatic
fever?
A. “Has the child complained of back pain?”
B. “Has the child complained of headaches?”
C. “Has the child had any nausea or vomiting?”
D. “Did the child have a sore throat or fever within the last 2 months?”
Answer: D (page 466) Rheumatic fever is an inflammatory autoimmune disease that affects the connective
tissues of the heart, joints, subcutaneous tissues and blood vessels of the central nervous system
84. A nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the
child’s record and expects to note which symptom of this disorder documented?
A. Watery diarrhea
B. Ribbon like stools
C. Profuse projectile vomiting
D. Bright red blood and mucus in the stools
Answer: D (page 482) Intussusception is a telescoping of one portion of the bowel into another
85. A clinic nurse reviews the record of an infant and notes that the physician has documented a
diagnosis of suspected Hirschsprung’s disease. The nurse reviews the assessment findings
documented in the record, knowing that which symptom most likely led the mother to seek health
care for the infant?
A. Diarrhea
B. Projectile vomiting
C. Regurgitation of feedings
D. Foul smelling ribbon like stools
Answer: D (page 482) Hirschsprung’s disease is a congenital anomaly also known as congenital
aganglionosis or anganglionic megacolon
86. An infant has just returned to the nursing unit after a surgical repair of a cleft lip on the right side. The
nurse places the infant in which best position at this time?
A. Prone position
B. On the stomach
C. Left lateral position
D. Right lateral position
Answer: C (page 483) A cleft lip is a congenital anomaly that occurs as a result of failure of soft tissue or
bony structure to fuse during embryonic development
87. A nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with
tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this
condition documented in the record?
A. Incessant crying
B. Coughing at nighttime
C. Choking with feedings
D. Severe projectile vomiting
Answer: C (page 483) In esophageal atresia and tracheoesophageal fistula, the esophagus terminates
before it reaches the stomach ending in a blind pouch
88. A child is hospitalized because of persistent vomiting. The nurse monitors the child closely for:
A. Diarrhea
B. Metabolic acidosis
C. Metabolic alkalosis
D. Hyperactive bowel sounds
Answer: C (page 483) Vomiting causes the loss of hydrochloric acid and subsequent metabolic alkalosis
89. A nurse is caring for a newborn infant with a suspected diagnosis of imperforate anus. The nurse
monitors the infant, knowing that which of the following is a clinical manifestation associated with this
disorder?
A. Bile stained fecal emesis
B. The passage of currant jelly-like stools
C. Failure to pass meconium stool in the first 24 hours after birth
D. Sausage-shaped mass palpated in the upper right abdominal quadrant
Answer: C (page 483) Imperforate anus is the incomplete development or absence of the anus in its
normal position in the perineum
90. A nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On admission assessment,
which data would the nurse expect to obtain when asking the mother about the child’s symptoms?
A. Watery diarrhea
B. Projectile vomiting
C. Increased urine output
D. Vomiting large amounts of bile
Answer: B (page 484) In pyloric stenosis, hypertrophy of the circular muscles of the of the pylorus causes
narrowing of the pyloric canal bet the stomach and the duodenum
91. An infant of a mother infected with HIV is seen in the clinic each month and is being monitored for
symptoms indicative of human immunodeficiency virus infection. The nurse assesses the infant,
knowing that the most common opportunistic infection of children infected with HIV is:
A. Meningitis
B. Gastroenteritis
C. Cytomegalovirus infection
D. Pneumocystis jiroveci pneumonia
Answer: D (page 542) Aids is a disorder caused by HIV and characterized by generalized dysfunction of
the immune system
92. A clinic nurse is instructions the mother of a child with human immunodeficiency virus infection
regarding immunizations. The nurse tells the mother that
A. Then hepatitis B vaccine will not be given to the child
B. The inactivated influenza vaccine will be given yearly
C. The varicella vaccine will be given before 6 months of age
D. A western blot test needs to be performed and the results evaluated before immunizations
Answer: B (page 543) Immunization against common childhood illnesses are recommended for all children
exposed to or infected with HIV
93. A physician prescribes laboratory studies for an infant of a woman positive for human deficiency virus
to determine the presence of HIV antigen in the infant. The nurse anticipates that which laboratory
study will be prescribed for the infant?
A. Chest x-ray
B. Western blot
C. CD4 cell count
D. p24 antigen assay
Answer: D (page 543) The detection of HIV in infants is confirmed by a p24 antigen assay, virus culture of
HIV or polymerase chain reaction
94. A nurse is caring for a 4 year old child virus with human immunodeficiency virus infection. In planning
care to address the child’s psychosocial needs, the nurse expects that this child?
A. Will express fear, withdrawal and denial
B. Begins to understand that something is wrong
C. Is unable to grasp the concept of illness and death
D. Begins to conceptualize the death process as involving physical harm
Answer: D (page 544). A preschool child begins to conceptualize the death process as involving physical
harm.
95. A nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to
the surgical unit. The nurse plans to monitor which of the following parameters most carefully during
the next hour?
A. Urinary output of 20ml/hr
B. Temperature of 37.6°C
C. Blood pressure of 100/70 mm Hg
D. Serous drainage on the surgical dressing
Answer: A (page 222) Urine output should be maintained at a minimum of 30ml/hr for an adult. A output of
less than 30 ml for each 2 consecutive hours should be reported to the physician.
96. A postoperative child asks the nurse why it is so important to deep breathe and cough after surgery.
When formulating a response, the nurse incorporates the understanding that retained pulmonary
secretions in a postoperative client can lead to:
A. Pneumonia
B. Fluid imbalance
C. Pulmonary embolism
D. Carbon Dioxide retention
Answer: A (page 222) Postoperative respiratory problems are atelectasis, pneumonia and pulmonary
emboli.
97. A nurse is developing a plan of care for a child scheduled for surgery. The nurse should include
which activity in the nursing care plan for the child on the day of surgery?
A. Have the client void immediately before going into surgery
B. Avoid oral hygiene and rinsing with mouthwash
C. Verify that the client has not eaten for the last 24 hours
D. Report immediately any slight increase in blood pressure or pulse
Answer: A (page 222). The nurse would assist the client to void immediately before surgery so that the
bladder will be empty
98. A 17 – year – old cliet with a perforated gastric ulcer is scheduled for surgery. The client cannot sign
the operative consent form because of sedation from opioid analgesics that have been administered.
The nurse should take which appropriate action in the care of this client?
A. Obtain a court order for the surgery
B. Send the client to surgery without the consent form being signed
C. Have the hospital chaplain sign the informed consent immediately
D. Obtain telephone consent from a family member, following agency policy
Answer: D (page 222) Every effort should be made obtain permission from a responsible family member to
perform surgery if the client is unable to sign the consent.
99. A preoperative 17 – year – old expresses anxiety to a nurse about upcoming surgery. Which
response by the nurse is most likely to stimulate further discussion between the client and the nurse?
A. ” If it’s any help, everyone is nervous before surgery”
B. “I will be happy to explain the entire surgical produce to you”
C. “Can you share with me what you’ve been told about your surgery”
D. “Let me tell you about the care you’ll receive after surgery and the amount of pain you can
anticipate”
Answer: C (page 223) Explanations should begin with the information that the client knows.
100. A nurse is conducting pre-operative teaching with a 15 – year – old client about the use of an
incentive spirometer. The nurse should include which piece of information in discussion with the
client?
A. Inhale as rapidly as possible
B. Keep a loose seal between the lips and the mouthpiece
C. After maximum inspiration, hold the breath for 15 seconds and exhale
D. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90
degrees
Answer: D (page 223) For optimal lung expansion with the incentive spirometer, the client should assume
the semi-Fowler’s or High Fowler’s position

Ca MCN Rationale

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ca MCN Rationale

Uploaded by

Copyright:

Available Formats

MCN

Labor (13 – 19)

33. Which of these statements is most accurate about the placenta?

35. A feeling of ambivalence about the pregnancy is:

46. “Show” is usually present in:

47. Which assessment most closely relates to a diagnosis of ectopic pregnancy?

You might also like