1.

A client asks the nurse what a third degree laceration is. She was informed that she had one. The nurse
explains that this is:

A. That extended their anal sphincter

Explanation

Third degree laceration involves all in the second degree laceration and the external sphincter of the
rectum. Options B, C and D are under the second degree laceration.

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2.

Betina 30 weeks AOG discharged with a diagnosis of placenta previa. The nurse knows that the client
understands her care at home when she says:

C. I will have to remain in bed until my due date comes

Explanation

Placenta previa means that the placenta is the presenting part. On the first and second trimester there is
spotting. On the third trimester there is bleeding that is sudden, profuse and painless.

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3.

The uterus has already risen out of the pelvis and is experiencing farther into the abdominal area at
about the:

A.

8th week of pregnancy

B.
10th week of pregnancy

C.

12th week of pregnancy

D.

18th week of pregnancy

Correct Answer

D. 18th week of pregnancy

Explanation

On the 8th week of pregnancy, the uterus is still within the pelvic area. On the 10th week, the uterus is
still within the pelvic area. On the 12th week, the uterus and placenta have grown, expanding into the
abdominal cavity. On the 18th week, the uterus has already risen out of the pelvis and is expanding into
the abdominal area.

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4.

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

A.

Frequency

B.

Dysuria

C.
Incontinence

D.

Burning

Correct Answer

A. Frequency

Explanation

Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for
causing urinary frequency. Dysuria, incontinence and burning are symptoms associated with urinary
tract infection.

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5.

Mrs. Jimenez went to the health center for pre-natal check-up. the student nurse took her weight and
revealed 142 lbs. She asked the student nurse how much should she gain weight in her pregnancy.

A.

20-30 lbs

B.

25-35 lbs

C.

30- 40 lbs

D.

10-15 lbs
Correct Answer

B. 25-35 lbs

Explanation

A weight gain of 11. 2 to 15.9 kg (25 to 35 lbs) is currently recommended as an average weight gain in
pregnancy. This weight gain consists of the following: fetus- 7.5 lb; placenta- 1.5 lb; amniotic fluid- 2 lb;
uterus- 2.5 lb; breasts- 1.5 to 3 lb; blood volume- 4 lb; body fat- 7 lb; body fluid- 7 lb.

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6.

The nurse is preparing Mrs. Jordan for cesarean delivery. Which of the following key concept should the
nurse consider when implementing nursing care?

A.

Explain the surgery, expected outcome and kind of anesthetics.

B.

Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth.

C.

Arrange for a staff member of the anesthesia department to explain what to expect post-operatively.

D.

Instruct the mother’s support person to remain in the family lounge until after the delivery.

Correct Answer

B. Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth.

Explanation
A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative
teaching to meet the needs of either planned or emergency cesarean birth, the depth and breadth of
instruction will depend on circumstances and time available.

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7.

Bettine Gonzales is hospitalized for the treatment of severe preecplampsia. Which of the following
represents an unusual finding for this condition?

A.

Generalized edema

B.

Proteinuria 4+

C.

Blood pressure of 160/110

D.

Convulsions

Correct Answer

D. Convulsions

Explanation

Options A, B and C are findings of severe preeclampsia. Convulsions is a finding of eclampsia—an

obstetrical emergency.

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8.

Nurse Geli explains to the client who is 33 weeks pregnant and is experiencing vaginal bleeding that
coitus:

A.

Need to be modified in any way by either partner

B.

Is permitted if penile penetration is not deep.

C.

Should be restricted because it may stimulate uterine activity.

D.

Is safe as long as she is in side-lying position.

Correct Answer

C. Should be restricted because it may stimulate uterine activity.

Explanation

Coitus is restricted when there is watery discharge, uterine contraction and vaginal bleeding. Also those
women with a history of spontaneous miscarriage may be advised to avoid coitus during the time of
pregnancy when a previous miscarriage occurred.

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9.

Mrs. Precilla Abuel, a 32 year old mulripara is admitted to labor and delivery. Her last 3 pregnancies in
short stage one of labor. The nurses decide to observe her closely. The physician determines that Mrs.
Abuel’s cervix is dilated to 6 cm. Mrs. Abuel states that she is extremely uncomfortable. To lessen Mrs.
Abuel’s discomfort, the nurse can advise her to:
A.

Lie face down

B.

Not drink fluids

C.

Practice holding breaths between contractions

D.

Assume Sim’s position

Correct Answer

D. Assume Sim’s position

Explanation

When the woman is in Sim’s position, this puts the weight of the fetus on bed, not on the woman and
allows good circulation in the lower extremities.

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10.

Which is true regarding the fontanels of the newborn?

A.

The anterior is large in shape when compared to the posterior fontanel.

B.

The anterior is triangular shaped; the posterior is diamond shaped.

C.

The anterior is bulging; the posterior appears sunken.

D.

The posterior closes at 18 months; the anterior closes at 8 to 12 months.

Correct Answer

A. The anterior is large in shape when compared to the posterior fontanel.

Explanation

The anterior fontanel is larger in size than the posterior fontanel. Additionally, the anterior fontanel,
which is diamond shaped closes at 18 month, whereas the posterior fontanel, which is triangular in
shape closes at 8 to 12 weeks. Neither fontanel should appear bulging, which may indicate increases ICP
or sunken, which may indicate hydration.

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11.

Mrs. Quijones gave birth by spontaneous delivery to a full term baby boy. After a minute after birth, he
is crying and moving actively. His birth weight is 6.8 lbs. What do you expect baby Quijones to weigh at 6
months?

A.

13 -14 lbs

B.

16 -17 lbs

C.
22 -23 lbs

D.

27 -28 lbs

Correct Answer

A. 13 -14 lbs

Explanation

The birth weight of an infant is doubled at 6 months and is tripled at 12 months.

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12.

During the first hours following delivery, the post partum client is given IVF with oxytocin added to
them. The nurse understands the primary reason for this is:

A.

To facilitate elimination

B.

To promote uterine contraction

C.

To promote analgesia

D.

To prevent infection
Correct Answer

B. To promote uterine contraction

Explanation

Oxytocin is a hormone produced by the pituitary gland that produces intermittent uterine contractions,
helping to promote uterine involution.

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13.

Nurse Luis is assessing the newborn’s heart rate. Which of the following would be considered normal if
the newborn is sleeping?

A.

80 beats per minute

B.

100 beats per minute

C.

120 beats per minute

D.

140 beats per minute

Correct Answer

B. 100 beats per minute

Explanation

The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute. If the
newborn was awake, the normal heart rate would range from 120 to 160 beats per minute.
Rate this question:

14.

The infant with Down Syndrome should go through which of the Erikson’s developmental stages first?

A.

Initiative vs. Self doubt

B.

Industry vs. Inferiority

C.

Autonomy vs. Shame and doubt

D.

Trust vs. Mistrust

Correct Answer

D. Trust vs. Mistrust

Explanation

The child with Down syndrome will go through the same first stage, trust vs. mistrust, only at a slow
rate. Therefore, the nurse should concentrate on developing on bond between the primary caregiver
and the child.

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15.

The child with phenylketonuria (PKU) must maintain a low phenylalanine diet to prevent which of the
following complications?
A.

Irreversible brain damage

B.

Kidney failure

C.

Blindness

D.

Neutropenia

Correct Answer

A. Irreversible brain damage

Explanation

The child with PKU must maintain a strict low phenylalanine diet to prevent central nervous system
damage, seizures and eventual death.

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16.

Which age group is with imaginative minds and creates imaginary friends?

A.

Toddler

B.

Preschool
C.

School

D.

Adolescence

Correct Answer

B. Preschool

Explanation

During preschool, this is the time when children do imitative play, imaginative play—the occurrence of
imaginative playmates, dramatic play where children like to act, dance and sing.

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17.

Which of the following situations would alert you to a potentially developmental problem with a child?

A.

Pointing to body parts at 15 months of age.

B.

Using gesture to communicate at 18 months.

C.

Cooing at 3 months.

D.
Saying “mama” or “dada” for the first time at 18 months of age.

Correct Answer

D. Saying “mama” or “dada” for the first time at 18 months of age.

Explanation

A child should say “mama” or “dada” during 10 to 12 months of age. Options A, B and C are all normal
assessments of language development of a child.

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18.

Isabelle, a 2 year old girl loves to move around and oftentimes manifests negativism and temper
tantrums. What is the best way to deal with her behavior?

A.

Tell her that she would not be loved by others is she behaves that way..

B.

Withholding giving her toys until she behaves properly.

C.

Ignore her behavior as long as she does not hurt herself and others.

D.

Ask her what she wants and give it to pacify her.

Correct Answer

C. Ignore her behavior as long as she does not hurt herself and others.
Explanation

If a child is trying to get attention or trying to get something through tantrums—ignore his/her behavior.

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19.

Baby boy Villanueva, 4 months old, was seen at the pediatric clinic for his scheduled check-up. By this
period, baby Villanueva has already increased his height by how many inches?

A.

3 inches

B.

4 inches

C.

5 inches

D.

6 inches

Correct Answer

B. 4 inches

Explanation

From birth to 6 months, the infant grows 1 inch (2.5 cm) per month. From 6 to 12 months, the infant
grows ½ inch (1.25 cm) per month.

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20.

Alice, 10 years old was brought to the ER because of Asthma. She was immediately put under aerosol
administration of Terbutaline. After sometime, you observe that the child does not show any relief from
the treatment given. Upon assessment, you noticed that both the heart and respiratory rate are still
elevated and the child shows difficulty of exhaling. You suspect:

A.

Bronchiectasis

B.

Atelectasis

C.

Epiglotitis

D.

Status Asthmaticus

Correct Answer

D. Status Asthmaticus

Explanation

Status asthmaticus leads to respiratory distress and bronchospasm despite of treatment and
interventions. Mechanical ventilation maybe needed due to respiratory failure.

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21.

Nurse Jonas assesses a 2 year old boy with a tentative diagnosis of nephroblastoma. Symptoms the
nurse observes that suggest this problem include:
A.

Lymphedema and nerve palsy

B.

Hearing loss and ataxia

C.

Headaches and vomiting

D.

Abdominal mass and weakness

Correct Answer

D. Abdominal mass and weakness

Explanation

Nephroblastoma or Wilm’s tumor is caused by chromosomal abnormalities, most common kidney

cancer among children characterized by abdominal mass, hematuria, hypertension and fever.

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22.

Which of the following danger sings should be reported immediately during the antepartum period?

A.

Blurred vision

B.

Nasal stuffiness
C.

Breast tenderness

D.

Constipation

Correct Answer

A. Blurred vision

Explanation

Danger signs that require prompt reporting are leaking of amniotic fluid, blurred vision, vaginal bleeding,
rapid weight gain and elevated blood pressure. Nasal stuffiness, breast tenderness, and constipation are
common discomforts associated with pregnancy.

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23.

Nurse Jacob is assessing a 15 month old child with acute otitis media. Which of the following symptoms
would the nurse anticipate finding?

A.

Periorbital edema, absent light reflex and translucent tympanic membrane

B.

Irritability, purulent drainage in middle ear, nasal congestion and cough

C.

Diarrhea, retracted tympanic membrane and enlarged parotid gland

D.

Vomiting, pulling at ears and pearly white tympanic membrane

Correct Answer

B. Irritability, purulent drainage in middle ear, nasal congestion and cough

Explanation

Irritability, purulent drainage in middle ear, nasal congestion and cough, fever, loss of appetite, vomiting
and diarrhea are clinical manifestations of otitis media. Acute otitis media is common in children 6
months to 3 years old and 8 years old and above. Breast fed infants have higher resistance due to
protection of Eustachian tubes and middle ear from breast milk.

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24.

Which of the following is the most appropriate intervention to reduce stress in a preterm infant at 33
weeks gestation?

A.

Sensory stimulation including several senses at a time

B.

Tactile stimulation until signs of over stimulation develop

C.

An attitude of extension when prone or side lying

D.

Kangaroo care
Correct Answer

D. Kangaroo care

Explanation

Kangaroo care is the use of skin-to-skin contact to maintain body heat. This method of care not only
supplies heat but also encourages parent-child interaction.

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25.

The parent of a client with albinism would need to be taught which preventive healthcare measure by
the nurse:

A.

Ulcerative colitis diet

B.

Use of a high-SPF sunblock

C.

Hair loss monitoring

D.

Monitor for growth retardation

Correct Answer

B. Use of a high-SPF sunblock

Explanation
Without melanin production, the child with albinism is at risk for severe sunburns. Maximum sun
protection should be taken, including use of hats, long sleeves, minimal time in the sun and high-SPF
sunblock, to prevent any problems.

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Nursing Board Review Maternal And Child Health Nursing Part 2- Www. Rnpedia.Com

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Questions and Answers

1.

Nurse Bella explains to a 28 year old pregnant woman undergoing a non-stress test that the test is a way
of evaluating the condition of the fetus by comparing the fetal heart rate with:

A.

Fetal lie

B.

Fetal movement

C.

Maternal blood pressure

D.

Maternal uterine contractions

Correct Answer

B. Fetal movement

Explanation

Non-stress test measures response of the FHR to the fetal movement. With fetal movement, FHR
increase by 15 beats and remain for 15 seconds then decrease to average rate. No increase means poor
oxygenation perfusion to fetus.

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2.
During a 2 hour childbirth focusing on labor and delivery process for primigravida. The nurse describes
the second maneuver that the fetus goes through during labor progress when the head is the presenting
part as which of the following:

A.

Flexion

B.

Internal rotation

C.

Descent

D.

External rotation

Correct Answer

A. Flexion

Explanation

The 6 cardinal movements of labor are descent, flexion, internal rotation, extension, external rotation
and expulsion.

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3.

Mrs. Jovel Diaz went to the hospital to have her serum blood test for alpha-fetoprotein. The nurse
informed her about the result of the elevation of serum AFP. The patient asked her what was the test
for:

A.
Congenital Adrenal Hyperplasia

B.

PKU

C.

Down Syndrome

D.

Neural tube defects

Correct Answer

D. Neural tube defects

Explanation

Alpha-fetoprotein is a substance produces by the fetal liver that is present in amniotic fluid and
maternal serum. The level is abnormally high in the maternal serum if the fetus has an open spinal or
abdominal defect because the open defect allows more AFP to appear.

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4.

Fetal heart rate can be auscultated with a fetoscope as early as:

A.

5 weeks of gestation

B.

10 weeks of gestation
C.

15 weeks of gestation

D.

20 weeks of gestation

Correct Answer

D. 20 weeks of gestation

Explanation

The FHR can be auscultated with a fetoscope at about 20 weeks of gestation. FHR is usually auscultated
at the midline suprapubic region with Doppler ultrasound at 10 to 12 weeks of gestation. FHR cannot be
heard any earlier than 10 weeks of gestation.

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5.

Mrs. Bendivin states that she is experiencing aching swollen, leg veins. The nurse would explain that this
is most probably the result of which of the following:

A.

Thrombophlebitis

B.

PIH

C.

Pressure on blood vessels from the enlarging uterus

D.

The force of gravity pulling down on the uterus

Correct Answer

C. Pressure on blood vessels from the enlarging uterus

Explanation

Pressure of the growing fetus on blood vessels results in an increase risk for venous stasis in the lower
extremities. Subsequently, edema and varicose vein formation may occur.

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6.

Mrs. Ella Santoros is a 25 year old primigravida who has Rheumatic heart disease lesion. Her pregnancy
has just been diagnosed. Her heart disease has not caused her to limit physical activity in the past. Her
cardiac disease and functional capacity classification is:

A.

Class I

B.

Class II

C.

Class III

D.

Class IV

Correct Answer
A. Class I

Explanation

Clients under class I has no physical activity limitation. There is a slight limitation of physical activity in
class II, ordinary activity causes fatigue, palpitation, dyspnea or angina. Class III is moderate limitation of
physical activity; less than ordinary activity causes fatigue. Unable to carry on any activity without
experiencing discomfort is under class IV.

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7.

The client asks the nurse, “When will this soft spot at the top of the head of my baby will close?” The
nurse should instruct the mother that the neonate’s anterior fontanel will normally close by age:

A.

2-3 months

B.

6-8 months

C.

10-12 months

D.

12-18 months

Correct Answer

D. 12-18 months

Explanation

Anterior fontanel closes at 12-18 months while posterior fontanel closes at birth until 2 months.
Rate this question:

8.

When a mother bleeds and the uterus is relaxed, soft and non-tender, you can account the cause to:

A.

Atony of the uterus

B.

Presence of uterine scar

C.

Laceration of the birth canal

D.

Presence of retained placenta fragments

Correct Answer

A. Atony of the uterus

Explanation

Uterine atony, or relaxation of the uterus is the most frequent cause of postpartal hemorrhage. It is the
inability to maintain the uterus in contracted state.

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9.

Mrs. Pichie Gonzales’s LMP began April 4, 2010. Her EDD should be which of the following:

A.
February 11, 2011

B.

January 11, 20111

C.

December 12, 2010

D.

November 14, 2010

Correct Answer

B. January 11, 20111

Explanation

Using the Nagel’s rule, he use this formula ( -3 calendar months + 7 days).

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10.

Which of the following prenatal laboratory test values would the nurse consider as significant?

A.

Hematocrit 33.5%

B.

WBC 8,000/mm3
C.

Rubella titer less than 1:8

D.

One hour glucose challenge test 110 g/dL

Correct Answer

C. Rubella titer less than 1:8

Explanation

A rubella titer should be 1:8 or greater. Thus, a finding of a titer less than 1:8 is significant, indicating
that the client may not possess immunity to rubella. A hematocrit of 33.5%, WBC of 8,000/mm3, and a 1
hour glucose challenge test of 110 g/dL are within normal parameters.

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11.

Aling Patricia is a patient with preeclampsia. You advise her about her condition, which would tell you
that she has not really understood your instructions?

A.

“I will restrict my fat in my diet.”

B.

“I will limit my activities and rest more frequently throughout the day.”

C.

“I will avoid salty foods in my diet.”

D.
“I will come more regularly for check-up.”

Correct Answer

B. “I will limit my activities and rest more frequently throughout the day.”

Explanation

Pregnant woman with preeclampsia should be in a complete bed rest. When body is in recumbent
position, sodium tends to be excreted at a faster rate. It is the best method of aiding increased excretion
of sodium and encouraging diuresis. Rest should always be in a lateral recumbent position to avoid
uterine pressure on the vena cava and prevent supine hypotension.

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12.

Mrs. Grace Evangelista is admitted with severe preeclampsia. What type of room should the nurse select
this patient?

A.

A room next to the elevator.

B.

The room farthest from the nursing station.

C.

The quietest room on the floor.

D.

The labor suite.

Correct Answer
C. The quietest room on the floor.

Explanation

A loud noise such as a crying baby, or a dropped tray of equipment may be sufficient to trigger a seizure
initiating eclampsia, a woman with severe preeclampsia should be admiotted to a private room so she
can rest as undisturbed as possible. Darken the room if possible because bright light can trigger seizures.

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13.

During a prenatal check-up, the nurse explains to a client who is Rh negative that RhoGAM will be given:

A.

Weekly during the 8th month because this is her third pregnancy.

B.

During the second trimester, if amniocentesis indicates a problem.

C.

To her infant immediately after delivery if the Coomb’s test is positive.

D.

Within 72 hours after delivery if infant is found to be Rh positive.

Correct Answer

D. Within 72 hours after delivery if infant is found to be Rh positive.

Explanation

RhoGAM is given to Rh-negative mothers within 72 hours after birth of Rh-positive baby to prevent
development of antibodies in the maternal blood stream, which will be fata to succeeding Rh-positive
offspring.
Rate this question:

14.

A baby boy was born at 8:50pm. At 8:55pm, the heart rate was 99 bpm. She has a weak cry, irregular
respiration. She was moving all extremities and only her hands and feet were still slightly blue. The nurse
should enter the APGAR score as:

A.

B.

C.

D.

Correct Answer

B. 6

Explanation

Heart rate of 99 bpm-1; weak cry-1; irregular respiration-1; moving all extremities-2; extremities are
slightly blue-1; with a total score of 6.

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15.

Billy is a 4 year old boy who has an IQ of 140 which means:

A.

Average normal

B.

Very superior

C.

Above average

D.

Genius

Correct Answer

D. Genius

Explanation

IQ= mental age/chronological age x 100. Mental age refers to the typical intelligence level found for
people at a give chronological age. OQ of 140 and above is considered genius.

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16.

A newborn is brought to the nursery. Upon assessment, the nurse finds that the child has short
palpebral fissures, thinned upper lip. Based on this data, the nurse suspects that the newborn is MOST
likely showing the effects of:

A.

Chronic toxoplasmosis

B.
Lead poisoning

C.

Congenital anomalies

D.

Fetal alcohol syndrome

Correct Answer

D. Fetal alcohol syndrome

Explanation

The newborn with fetal alcohol syndrome has a number of possible problems at birth. Characteristics
that mark the syndrome include pre and postnatal growth retardation; CNS involvement such as
cognitive challenge, microcephally and cerebral palsy; and a distinctive facial feature of a short palpebral
fissure and thin upper lip.

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17.

A priority nursing intervention for the infant with cleft lip is which of the following:

A.

Monitoring for adequate nutritional intake

B.

Teaching high-risk newborn care

C.

Assessing for respiratory distress

D.

Preventing injury

Correct Answer

A. Monitoring for adequate nutritional intake

Explanation

The infant with cleft lip is unable to create an adequate seal for sucking. The child is at risk for
inadequate nutritional intake as well as aspiration.

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18.

Nurse Jacob is assessing a 12 year old who has hemophilia A. Which of the following assessment findings
would the nurse anticipate?

A.

An excess of RBC

B.

An excess of WBC

C.

A deficiency of clotting factor VIII

D.

A deficiency of clotting factor IX

Correct Answer

C. A deficiency of clotting factor VIII

Explanation

Hemophillia A (classic hemophilia) is a deficiency in factor VIII (an alpha globulin that stabilizes fibrin
clots).

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19.

Celine, a mother of a 2 year old tells the nurse that her child “cries and has a fit when I have to leave him
with a sitter or someone else.” Which of the following statements would be the nurse’s most accurate
analysis of the mother’s comment?

A.

The child has not experienced limit-setting or structure.

B.

The child is expressing a physical need, such as hunger.

C.

The mother has nurtured overdependence in the child.

D.

The mother is describing her child’s separation anxiety.

Correct Answer

D. The mother is describing her child’s separation anxiety.

Explanation
Before coming to any conclusion, the nurse should ask the mother focused questions; however, based
on initial information, the analysis of separation anxiety would be most valid. Separation anxiety is a
normal toddler response. When the child senses he is being sent away from those who most provide
him with love and security. Crying is one way a child expresses a physical need; however, the nurse
would be hasty in drawing this as first conclusion based on what the mother has said. Nurturing
overdependence or not providing structure for the toddler are inaccurate conclusions based on the
information provided.

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20.

Mylene Lopez, a 16 year old girl with scoliosis has recently received an invitation to a pool party. She
asks the nurse how she can disguise her impairment when dressed in a bathing suit. Which nursing
diagnosis can be justified by Mylene’s statement?

A.

Anxiety

B.

Body image disturbance

C.

Ineffective individual coping

D.

Social isolation

Correct Answer

B. Body image disturbance

Explanation
Mylene is experiencing uneasiness about the curvative of her spine, which will be more evident when
she wears a bathing suit. This data suggests a body image disturbance. There is no evidence of anxiety or
ineffective coping. The fact that Mylene is planning to attend a pool party dispels a diagnosis of social
isolation.

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21.

The foul-smelling, frothy characteristic of the stool in cystic fibrosis results from the presence of large
amounts of which of the following:

A.

Sodium and chloride

B.

Undigested fat

C.

Semi-digested carbohydrates

D.

Lipase, trypsin and amylase

Correct Answer

B. Undigested fat

Explanation

The client with cystic fibrosis absorbs fat poorly because of the think secretions blocking the pancreatic
duct. The lack of natural pancreatic enzyme leads to poor absorption of predominantly fats in the
duodenum. Foul-smelling, frothy stool is termed steatorrhea.

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22.

Which of the following would be a disadvantage of breast feeding?

A.

Involution occurs 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 of error during preparation

Correct Answer

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

Explanation

With breast feeding, 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 time and body. Breast feeding is advantageous because uterine involution
occurs more rapidly, thus minimizing blood loss. The presence of maternal antibodies in breast milk
helps decrease the incidence of allergies in the newborn. A greater chance for error is associated with
bottle feeding. No preparation required for breast feeding.

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23.
A client is noted to have lymphedema, webbed neck and low posterior hairline. Which of the following
diagnoses is most appropriate?

A.

Turner’s syndrome

B.

Down’s syndrome

C.

Marfan’s syndrome

D.

Klinefelter’s syndrome

Correct Answer

A. Turner’s syndrome

Explanation

Lymphedema, webbed neck and low posterior hairline, these are the 3 key assessment features in
Turner’s syndrome. If the child is diagnosed early in age, proper treatment can be offered to the family.
All newborns should be screened for possible congenital defects.

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24.

A 4 year old boy most likely perceives death in which way:

A.

An insignificant event unless taught otherwise

B.

Punishment for something the individual did

C.

Something that just happens to older people

D.

Temporary separation from the loved one.

Correct Answer

D. Temporary separation from the loved one.

Explanation

The predominant perception of death by preschool age children is that death is temporary separation.
Because that child is losing someone significant and will not see that person again, it’s inaccurate to
infer death is insignificant, regardless of the child’s response.

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25.

Catherine Diaz is a 14 year old patient on a hematology unit who is being treated for sickle cell crisis.
During a crisis such as that seen in sickle cell anemia, aldosterone release is stimulated. In what way
might this influence Catherine’s fluid and electrolyte balance?

A.

Sodium loss, water loss and potassium retention

B.

Sodium loss, water los and potassium loss

C.

Sodium retention, water loss and potassium retention

D.

Sodium retention, water retention and potassium loss

Correct Answer

D. Sodium retention, water retention and potassium loss

Explanation

Stress stimulates the adrenal cortex to increase the release of aldosterone. Aldosterone promotes the
resorption of sodium, the retention of water and the loss of potassium.

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