NS 1 QUIZ 4 OB 2

1. In planning for home care of a woman with preterm labor, which concern must the nurse address?

a. Nursing assessments will be different from those done in the hospital setting.
b. Restricted activity and medications will be necessary to prevent recurrence of preterm labor.
c. Prolonged bed rest may cause negative physiologic effects.
d. Home health care providers will be necessary.

ANSWER C

Prolonged bed rest may cause adverse effects such as weight loss, loss of appetite, muscle wasting, weakness, bone
demineralization, decreased cardiac output, risk for thrombophlebitis, alteration in bowel functions, sleep disturbance,
and prolonged postpartum recovery. Nursing assessments will differ somewhat from those performed in the acute care
setting, but this is not the concern that needs to be addressed. Restricted activity and medication may prevent preterm
labor, but not in all women. In addition, the plan of care is individualized to meet the needs of each woman. Many
women will receive home health nurse visits, but care is individualized for each woman.

2. In evaluating the effectiveness of magnesium sulfate for the treatment of preterm labor, what finding would alert the
nurse to possible side effects?

a. Urine output of 160 mL in 4 hours

b. Deep tendon reflexes 2+ and no clonus
c. Respiratory rate of 16 breaths/min
d. Serum magnesium level of 10 mg/Dl

ANSWER D

The therapeutic range for magnesium sulfate management is 5 to 8 mg/dL. A serum magnesium level of 10 mg/dL could
lead to signs and symptoms of magnesium toxicity, including oliguria and respiratory distress. Urine output of 160 mL in
4 hours, deep tendon reflexes 2+ with no clonus, and respiratory rate of 16 breaths/min are normal findings.

3. A 22-year old woman has been brought into the delivery room and was diagnosed to have tachysystole labor.

What would be the characteristic of tachysystole labor?

a. Infrequent and brief contractions

b. More than 5 contractions per 10 minute intervals in 2 consecutive intervals
c. Prolonged active phase
d. Uterus can be easily indented by the fingertip

ANSWER: B

RATIO: Uterine tachysystole is a condition of excessively frequent uterine contractions during pregnancy. Uterine
tachysystole is defined as more than 5 contractions in 10 minutes, averaged over a 30-minute window.

4. A woman in preterm labor at 30 weeks of gestation receives two 12-mg doses of betamethasone intramuscularly. The
purpose of this pharmacologic treatment is to:

a. Stimulate fetal surfactant production.

b. Reduce maternal and fetal tachycardia associated with ritodrine administration.
c. Suppress uterine contractions.
d. Maintain adequate maternal respiratory effort and ventilation during magnesium sulfate therapy.

ANSWER A

Antenatal glucocorticoids given as intramuscular injections to the mother accelerate fetal lung maturity. Inderal would
be given to reduce the effects of ritodrine administration. Betamethasone has no effect on uterine contractions. Calcium
gluconate would be given to reverse the respiratory depressive effects of magnesium sulfate therapy.

5. A woman at 26 weeks of gestation is being assessed to determine whether she is experiencing preterm labor. What
finding indicates that preterm labor is occurring?

a. Estriol is not found in maternal saliva.

b. Irregular, mild uterine contractions are occurring every 12 to 15 minutes.
c. Fetal fibronectin is present in vaginal secretions.
d. The cervix is effacing and dilated to 2 cm.

ANSWER D

Cervical changes such as shortened endocervical length, effacement, and dilation are predictors of imminent preterm
labor. Changes in the cervix accompanied by regular contractions indicate labor at any gestation. Estriol is a form of
estrogen produced by the fetus that is present in plasma at 9 weeks of gestation. Levels of salivary estriol have been
shown to increase before preterm birth. Irregular, mild contractions that do not cause cervical change are not
considered a threat. The presence of fetal fibronectin in vaginal secretions between 24 and 36 weeks of gestation could
predict preterm labor, but it has only a 20% to 40% positive predictive value. Of more importance are other physiologic
clues of preterm labor such as cervical changes.

6. In evaluating the effectiveness of oxytocin induction, the nurse would expect:

a. Contractions lasting 40 to 90 seconds, 2 to 3 minutes apart.

b. The intensity of contractions to be at least 110 to 130 mm Hg.
c. Labor to progress at least 2 cm/hr dilation.
d. At least 30 mU/min of oxytocin will be needed to achieve cervical dilation.

ANSWER A

The goal of induction of labor would be to produce contractions that occur every 2 to 3 minutes and last 60 to 90
seconds. The intensity of the contractions should be 40 to 90 mm Hg by intrauterine pressure catheter. Cervical dilation
of 1 cm/hr in the active phase of labor would be the goal in an oxytocin induction. The dose is increased by 1 to 2
mU/min at intervals of 30 to 60 minutes until the desired contraction pattern is achieved. Doses are increased up to a
maximum of 20 to 40 mU/min.

7. A pregnant woman's amniotic membranes rupture. Prolapsed umbilical cord is suspected. What intervention would
be the top priority?

a. Placing the woman in the knee-chest position

b. Covering the cord in sterile gauze soaked in saline
c. Preparing the woman for a cesarean birth
d. Starting oxygen by face mask

ANSWER A

The woman is assisted into a position (e.g., modified Sims position, Trendelenburg position, or the knee-chest position)
in which gravity keeps the pressure of the presenting part off the cord. Although covering the cord in sterile gauze
soaked saline, preparing the woman for a cesarean, and starting oxygen by face mark are appropriate nursing
interventions in the event of a prolapsed cord, the intervention of top priority would be positioning the mother to
relieve cord compression.

8. Prepidil (prostaglandin gel) has been ordered for a pregnant woman at 43 weeks of gestation. The nurse recognizes
that this medication will be administered to:

a. Enhance uteroplacental perfusion in an aging placenta.

b. Increase amniotic fluid volume.
c. Ripen the cervix in preparation for labor induction.
d. Stimulate the amniotic membranes to rupture.

ANSWER C

It is accurate to state that Prepidil will be administered to ripen the cervix in preparation for labor induction. a hormone-
like substance, used in a pregnant woman to relax the muscles of the cervix (opening of the uterus) in preparation for
inducing labor at the end of a pregnancy. It is not administered to enhance uteroplacental perfusion in an aging
placenta, increase amniotic fluid volume, or stimulate the amniotic membranes to rupture.

9. The nurse is caring for a client whose labor is being augmented with oxytocin. He or she recognizes that the oxytocin
should be discontinued immediately if there is evidence of:

a. Uterine contractions occurring every 8 to 10 minutes.

b. A fetal heart rate (FHR) of 180 with absence of variability.
c. The client's needing to void.
d. Rupture of the client's amniotic membranes.

ANSWER B

This FHR is nonreassuring. The oxytocin should be discontinued immediately, and the physician should be notified. The
oxytocin should be discontinued if uterine hyperstimulation occurs. Stopping oxytocin after the active phase of labour
has started may reduce the number of women with contractions that become too long or too strong resulting in changes
to the baby's heart rate, and the risk of having a caesarean . Uterine contractions that are occurring every 8 to 10
minutes do not qualify as hyperstimulation. The client's needing to void is not an indication to discontinue the oxytocin
induction immediately or to call the physician. Unless a change occurs in the FHR pattern that is non reassuring or the
client experiences uterine hyperstimulation, the oxytocin does not need to be discontinued. The physician should be
notified that the client's membranes have ruptured.

10. With regard to the care management of preterm labor, nurses should be aware that:
 a. Because all women must be considered at risk for preterm labor and prediction is so hit-and-miss, teaching
pregnant women the symptoms probably causes more harm through false alarms.
b. Braxton Hicks contractions often signal the onset of preterm labor.
c. Because preterm labor is likely to be the start of an extended labor, a woman with symptoms can wait several
hours before contacting the primary caregiver.
d. The diagnosis of preterm labor is based on gestational age, uterine activity, and progressive cervical change.

ANSWER D

Gestational age of 20 to 37 weeks, uterine contractions, and a cervix that is 80% effaced or dilated 2 cm indicates
preterm labor. It is essential that nurses teach women how to detect the early symptoms of preterm labor. Braxton
Hicks contractions resemble preterm labor contractions, but they are not true labor. Waiting too long to see a health
care provider could result in not administering essential medications. Preterm labor is not necessarily long-term labor.

11. A 25-year old woman in the delivery room has been diagnosed to have hypotonic labor. The nurse would confirm the
diagnosis with the presence of which of the following characteristics?

a. Contractions has more than 90 seconds duration

b. Frequency of contractions are less than 2 minutes
c. The number of contractions is usually infrequent which is not more than 2 or 3 occurring in a 10-mute period
d. Strong and frequent contractions

ANSWER: C

RATIO: A mother who has hypotonic labor has the following signs and symptoms: the number of uterine contractions in
hypotonic contractions is unusually slow or infrequent; there are only two or three contractions occurring within a 10-
minute period; the strength of contractions does not rise above 10 mmHg, and they occur mostly during the active
phase of labor.

12, Which of the following cases would strongly contribute to the hypotonic labor of the mother?

a. Nulliparity
b. Polyhydramnios
c. Small for gestational age fetus
d. Grand multiparity

ANSWER: D

RATIO: The uterus of a mother who has given birth four or more times (grand multiparity) becomes lax leading to the
occurrence of hypotonic labor. Other predisposing factors of hypotonic labor would be multiple gestations, macrosomia,
and hydramnios.

13, During hypotonic labor the fetus may be in distress. When the obstetrician has performed amniotomy, which of the
following is the nurse going to do?

a. Observe for the odor of the amniotic fluid

b. Determine the amount of amniotic fluid present
c. Observe for the color of the amniotic fluid
d. Check for the presence of blood in the amniotic fluid

ANSWER: C

RATIO: The first thing that the nurse should do once amniotomy is done during a hypotonic labor is to assess for the
color of the amniotic fluid and check for the presence of meconium. If the amniotic fluid is green, this must be reported
immediately since the fetus is already in distress.

14. When assessing the mother who is undergoing hypotonic labor the nurse must assess signs of infection if the is
already prolonged. Which of the following would indicate that the mother has an infection?

a. Fetal bradycardia
b. Presence of meconium in the amniotic fluid
c. Fever and chills
d. Distended bladder

ANSWER: C

RATIO: The presence of fever alone would indicate that the mother is currently experiencing an infection. Fever is a
defense mechanism of the body in order to decrease the proliferation of microorganisms in the body.
15. During an ultrasonography the physician has noticed that the baby’s hips and knees are flexed so that the baby is

sitting cross-legged, with feet beside the bottom. What is being presented in this situation?

a. Frank breech
b. Incomplete breech
c. Complete breech
d. Footling breech

ANSWER: C

RATIO: Complete breech is when both of the baby's knees are bent and his feet and bottom are closest to the birth
canal. Incomplete breech is when one of the baby's knees is bent and his foot and bottom are closest to the birth canal.
Frank breech is when the baby's legs are folded flat up against his head and his bottom is closest to the birth canal.
There is also footling breech where one or both feet are presenting.

16. Which of the following conditions must the nurse alert to the obstetrician when performing a delivery?

a. Cord prolapse
b. Rupture of membranes
c. Crowning of head
d. External rotation of the head

ANSWER: A

RATIO: Cord prolapse must be placed in priority since this will cause fetal distress due to the cord compression due to
the prolapse. This can lead to oxygen flow obstruction to the fetus. 4 of 6

17. When the fetus is in a breech presentation, the nurse must perform which of the following procedures early in

labor?

a. Ritgen’s maneuver
b. Episiotomy
c. External cephalic version
d. Fundal push

ANSWER: A

RATIO: In order to facilitate easy delivery in a breech presentation, the nurse must perform Ritgen’s Maneuver in order
to protect the perineum during delivery. Since it is difficult for the mother to deliver the malpresented fetus during
delivery, the perineum is prone to develop tears or worse the tears can extend to the anus causing large lacerations.

18. This type of presentation is caused by hyper-extension of the fetal head so that neither the occiput nor the

sinciput is palpable on vaginal examination

a. Sinciput
b. Occiput
c. Transverse
d. Face

ANSWER: D

RATIO: Face presentation occurs when baby's spine extended until the head is shifted back so baby's face comes

through the pelvis first. Baby may settle in a face presentation before labor. A baby who is in a face-first position often

started as an extended (chin up) occiput posterior or occiput transverse position.

19. Anna Carla the mother who is already prolonged in labor says to the nurse, “This is hopeless; I really can’t do it

anymore. I’m so much frustrated.” Which of the following nursing responses is most therapeutic?

a. “The doctor is doing everything she can in order to help you get past this labor.”
b. “Would you opt to be placed in a caesarean section instead?”
c. “It must be hard for you to be experiencing this. But let’s think positive and be patient, you can still do
this.”
d. “We’ll see other options that we can do in order to augment this labor that you are experiencing.”

ANSWER: C

RATIO: The nurse acknowledges the difficulties of the mother during labor and encourages the mother to push through
with it. The rest of the other options are non-therapeutic.

20. The nurse providing care to a woman in labor should understand that cesarean birth:
 a. Is declining in frequency in the twenty-first century in the United States.
b. Is more likely to be performed for poor women in public hospitals who do not receive the nurse counseling as do
wealthier clients.
c. Is performed primarily for the benefit of the fetus.
d. Can be either elected or refused by women as their absolute legal right.

ANSWER C

The most common indications for cesarean birth are danger to the fetus related to labor and birth complications.
Cesarean births are increasing in the United States in this century. Wealthier women who have health insurance and
who give birth in a private hospital are more likely to experience cesarean birth. A woman's right to elect cesarean
surgery is in dispute, as is her right to refuse it if in doing so she endangers the fetus. Legal issues are not absolutely
clear.

21. Which drug is used for treating a client with severe postpartum bleeding?

a. Nifedipine (Adalat)
b. Oxytocin (Pitocin)
c. Propranolol (Inderal)
d. Metronidazole (Flagyl)

ANSWER B

(Oxytocin (Pitocin) is a synthetic hormone used to induce labor and to control severe postpartum bleeding by making
the uterus contract. Nifedipine (Adalat) is a calcium channel blocker that is used intocolytic therapy for preterm labor.
Propranolol (Inderal) is used to reverse intolerable cardiovascular effects of terbutaline (Brethine). Metronidazole
(Flagyl) is a broad-spectrum antibiotic that is used to treat chorioamnionitis after cesarean birth.)

22. The nurse assisted with the delivery of a newborn. Which nursing action is most effective in preventing heat loss by
evaporation?

a. Warming the crib pad

b. Closing the doors to the room
c. Drying the infant with a warm blanket
d. Turning on the overhead radiant warmer

ANSWER C

Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the newborn dry by drying
the wet newborn at birth prevents hypothermia via evaporation. Hypothermia caused by conduction occurs when the
newborn is on a cold surface, such as a cold pad or mattress, and heat from the newborn's body is transferred to the
colder object (direct contact). Warming the crib pad assists in preventing hypothermia by conduction. Convection occurs
as air moves across the newborn's skin from an open door and heat is transferred to the air. Radiation occurs when heat
from the newborn radiates to a colder surface (indirect contact).

23. The mother of a newborn calls the clinic and reports that when cleaning the umbilical cord, she noticed that the cord
was moist and that discharge was present. What is the most appropriate nursing instruction for this mother?

a. Bring the infant to the clinic.

b. This is a normal occurrence.
c. Increase the number of times that the cord is cleaned per day.
d. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge continues.

ANSWER A

Symptoms of umbilical cord infection are moistness, oozing, discharge, and a reddened base around the cord. If
symptoms of infection occur, the client should be instructed to notify a health care provider (HCP). If these symptoms
occur, antibiotics may be necessary. Options 2, 3, and 4 are inappropriate nursing interventions for the description given
in the question.

24. The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress syndrome. Which
assessment findings would alert the nurse to the possibility of this syndrome?

a. Tachypnea and retractions

b. Acrocyanosis and grunting
c. Hypotension and bradycardia
d. Presence of a barrel chest and acrocyanosis

ANSWER A

A newborn infant with respiratory distress syndrome may present with clinical signs of cyanosis, tachypnea or apnea,
nasal flaring, chest wall retractions, or audible grunts. Acrocyanosis, a bluish discoloration of the hands and feet, is
associated with immature peripheral circulation, and is common in the first few hours of life. Options 2, 3, and 4 do not
indicate clinical signs of respiratory distress syndrome

25. Ms Melissa a mother of a term newborn has curiously asked about the thick, white, cheesy coating on her son’s skin.
The nurse must correctly describe this as

a. lanugo
b. milia
c. café-au-lait spots
d. vernix caseosa

ANSWER: D

RATIO: Lanugo is a type of fine hair that grows on the bodies of human fetuses while they are developing in the womb.

Milia are small, bump-like cysts found under the skin. They are usually 1 to 2 millimeters (mm) in size. Café-au-lait

spots or macules (CALS or CALM) are flat, pigmented spots on the skin. They are commonly referred to as “birthmarks”,

but are often not present at birth.

26. When Nurse Lovely is assessing the newborn, she has noted that the newborn has caput succedaneum. Which of the
following statements about this condition is correct?

a. It usually resolves within 3 to 6 weeks

b. It involves swelling of tissue over the presenting part of the presenting head
c. It doesn’t cross the cranial suture lines
d. It’s a collection of blood between the skull and the periosteum

ANSWER: B

RATIO: Caput succedaneum is the swelling of tissue over the presenting part of the fetal scalp due to sustained pressure;
it resolves within the next 4 days.

27. Nurse Sierra is attending a newborn. To help her limit the development of hyperbilirubinemia in the newborn, her
plan of care for her patient should include

a. Monitoring for the passage of meconium each shift

b. Instituting phototherapy for 30 minutes every 6 hours
c. Substituting breastfeeding for formula during the 2nd day after birth
d. Supplementing breastfeeding with glucose water during the first 24 hours

ANSWER: A

RATIO: Bilirubin is excreted via the digestive tract through bile; if meconium is retained, that means that the newborn’s

bilirubin was reabsorbed.

28. Nurse V is preparing to administer a vitamin K shot to a newborn. Aling Julia is asking the nurse why her newborn
infant needs the injection. The best nursing response would be

a. “Your infant needs vitamin K to develop immunity passive artificial immunity.”

b. “Vitamin K will protect your infant from having jaundice.”
c. “Newborn infants are deficient in vitamin K, and this shot will prevent your infant from any abnormal bleeding.”
d. “Newborns have sterile bowels, and vitamin K will help promote the growth of good bacteria in the digestive
tract.”

ANSWER: C

RATIO: Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn
infant to prevent abnormal bleeding. Newborn infants are vitamin K deficient because the bowel does not have the
bacteria necessary for synthesizing fat-soluble vitamin K. The infant’s bowel does not have support the production of
vitamin K until bacteria adequately colonizes it by food ingestion.

29. The nurse is assessing a newborn who was born to a mother who is addicted to drugs. Which assessment finding
would the nurse expect to note during the assessment of this newborn?

a. Lethargy
b. Sleepiness
c. Constant crying
d. Cuddles when being held

ANSWE C
A newborn of a woman using drugs is irritable. The infant is overloaded easily by sensory stimulation. The infant may cry
incessantly and be difficult to console. The infant would hyperextend and posture rather than cuddle when being held.

30. A full-term newborn was just born. Nurse Sasha must know that the most important nursing intervention to perform
first would be

a. Assessing the APGAR score

b. Remove the wet blankets
c. Apply eye prophylaxis
d. Elicit the Moro reflex

ANSWER: B

RATIO: When newborns are wet, they can become hypothermic from heat loss resulting from evaporation. They may
then develop cold stress syndrome. The first Apgar score is not done until 60 seconds after delivery. The wet blankets
should have been removed from the baby well before that time. Eye prophylaxis can be delayed until after the parents
have begun bonding with their baby. Although the baby’s central nervous system must be carefully assessed, reflex
assessment should be postponed until after the baby is dried and is breathing on his or her own.

31. Nurse Angel notes that a 6-hour-old newborn has cyanotic hands and feet. Which of the following nursing
interventions would be appropriate?

a. Assess oxygen saturation with the pulse oximeter

b. Swaddle the newborn in a blanket
c. Place the child under the UV light
d. Administer oxygen

ANSWER: B

RATIO: The baby’s extremities are cyanotic as a result of the baby’s immature circulatory system. Swaddling helps to
warm the baby’s hands and feet.

32. The nurse administers erythromycin ointment (0.5%) to the eyes of a newborn and the mother asks the nurse why
this is performed. Which explanation is best for the nurse to provide about neonatal eye prophylaxis?

a. Protects the newborn's eyes from possible infections acquired while hospitalized.
b. Prevents cataracts in the newborn born to a woman who is susceptible to rubella.
c. Minimizes the spread of microorganisms to the newborn from invasive procedures during labor.
d. Prevents an infection called ophthalmia neonatorum from occurring after delivery in a newborn born to a
woman with an untreated gonococcal infection.

ANSWER D

Erythromycin ophthalmic ointment 0.5% is used as a prophylactic treatment for ophthalmia neonatorum, which is
caused by the bacterium Neisseria gonorrhoeae. Preventive treatment of gonorrhea is required by law. Options 1, 2, and
3 are not the purposes for administering this medication to a newborn infant.

33. The nurse prepares to administer a vitamin K injection to a newborn, and the mother asks the nurse why her infant
needs the injection. What best response should the nurse provide?

a. "Your newborn needs vitamin K to develop immunity."

b. "The vitamin K will protect your newborn from being jaundiced."
c. "Newborns have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel."
d. "Newborns are deficient in vitamin K, and this injection prevents your newborn from bleeding."

ANSWER D

Vitamin K is necessary for the body to synthesize coagulation factors. Vitamin K is administered to the newborn to
prevent bleeding disorders. Vitamin K promotes liver formation of the clotting factors II, VII, IX, and X. Newborns are
vitamin K-deficient because the bowel does not have the bacteria necessary for synthesizing fat-soluble vitamin K. The
normal flora in the intestinal tract produces vitamin K. The newborn's bowel does not support the normal production of
vitamin K until bacteria adequately colonize it. The bowel becomes colonized by bacteria as food is ingested. Vitamin K
does not promote the development of immunity or prevent the infant from becoming jaundiced

34. The nurse is performing an initial assessment on a newborn infant. When assessing the infant's head, the nurse
notes that the ears are low-set. Which nursing action is most appropriate?

a. Document the findings.

b. Arrange for hearing testing.
c. Notify the health care provider.
d. Cover the ears with gauze pads.

ANSWER C
Low or oddly placed ears are associated with various congenital defects and should be reported immediately. Although
the findings should be documented, the most appropriate action would be to notify the health care provider. Options 2
and 4 are inaccurate and inappropriate nursing actions.

35. The nurse is assessing the reflexes of a newborn infant. In eliciting the Moro reflex, the nurse should perform which
action?

a. Make a loud, abrupt noise to startle the newborn.

b. Stimulate the ball of the foot of the newborn by firm pressure.
c. Stimulate the perioral cavity of the newborn infant with a finger.
d. Stimulate the pads of the newborn infant's hands by firm pressure.

ANSWER A

The Moro reflex is elicited by placing the newborn on a flat surface and striking the surface or making a loud, abrupt
noise to startle the newborn. The newborn assumes sharp extension and abduction of the arms with the thumbs and
forefingers in a C position; this is followed by flexion and adduction to an "embrace" position (legs follow a similar
pattern). The Moro reflex is present at birth and is absent by 6 months of age if neurological maturation is not delayed. A
persistent response lasting more than 6 months may indicate a neurological abnormality. The rooting reflex is elicited by
stimulating the perioral area with the finger. The palmar grasp reflex is elicited by stimulating the palm of the hand by
firm pressure, and the plantar grasp reflex is elicited by stimulating the ball of the foot by firm pressure.

36. The nurse is performing Apgar scoring for a newborn immediately after birth. The nurse notes that the heart rate is
less than 100, respiratory effort is irregular, and muscle tone shows some extremity flexion. The newborn grimaces
when suctioned with a bulb syringe, and the skin color indicates some cyanosis of the extremities. The nurse should
most appropriately document which Apgar score for the newborn?

a. 3
b. 5
c. 7
d. 10

ANSWER B

One of the earliest indicators of successful adaptation of the newborn is the Apgar score. Scores range from 0 to 10. Five
criteria are used to measure the infant's adaptation. Heart rate: absent = 0; less than 100 = 1; greater than 100 = 2.
Respiratory effort: absent = 0; slow or irregular weak cry = 1; good, crying lustily = 2. Muscle tone: limp or hypotonic = 0;
some extremity flexion = 1; active, moving, and well flexed = 2. Irritability or reflexes (measured by bulb suctioning): no
response = 0; grimace = 1; cough, sneeze, or vigorous cry = 2. Color: cyanotic or pale = 0; acrocyanotic, cyanosis of
extremities = 1; pink = 2. Newborn infants with an Apgar score of 5 to 7 often require resuscitative interventions. Scores
of less than 5 indicate that the newborn infant is having difficulty adjusting to extrauterine life and requires more
vigorous resuscitation.

37. The nurse in the delivery room is performing an initial assessment on a newborn infant. When examining the
umbilical cord, the nurse should expect to observe which finding?

a. One artery
b. Two veins
c. Two arteries
d. One artery and one vein

ANSWER C

The umbilical cord is made up of two arteries to carry blood from the embryo to the chorionic villi and one vein that
returns blood to the embryo. There should be no odor noted from the umbilical cord. Options 1, 2, and 4 are incorrect

38. The nursing history for a newborn suspected of having pyloric stenosis would most likely reveal which of the

following?

a. Frequent vomiting of bile-stained fluid

b. Cyanosis and vomiting immediately after feedings
c. Mild emesis progressing to projectile vomiting
d. Absence of gastrointestinal peristalsis

ANSWER: C

RATIO: Mild regurgitation or emesis that progresses to projectile vomiting is a pattern of vomiting associated with
pyloric stenosis.

39. Nurse Madeline is assessing the reflexes of a newborn. The nurse assesses which of the following reflexes by placing
a finger in the newborn’s mouth?
 a. Sucking reflex
b. Landau reflex
c. Babinski reflex
d. Moro reflex

ANSWER: A The sucking reflex is tested by placing something, such as a finger, in the infant’s mouth and seeing if the
infant begins to suck on the object.

40. Nurse Hope is assessing a newborn on admission to the NICU. Which of the following findings should the nurse
report to the attending physician?

a. Intercostal retractions
b. Caput succedaneum
c. Epstein’s pearls
d. Harlequin sign

ANSWER: A Intercostal retractions are a sign of respiratory distress. Caput succedaneum is a normal finding in a
neonate. Epstein’s pearls are often seen in the mouths of neonates. Harlequin sign, although odd-appearing, is a normal
finding in a neonate

41. 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. Attend to the newborn infant immediately when crying

ANSWER A

Allow the newborn infant to signal a need. Trust vs Mistrust stage-This will allow the infant opportunity to gain trust.

42. A mother of a 3-year-old tells a clinic nurse that the child is rebelling constantly 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 C

Set limits on the child's behavior-According to Erikson, the child focuses on independence between ages 1 and 3 years.
Gaining independence often means that the child has to rebel against the parents' wishes. Saying things like "no" or
"mine" and having temper tantrums are common during this period of development. Being consistent and setting limits
on the child's behavior are the necessary elements.

43. A nurse is evaluating the developmental level of a 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 B. By age 2 years, the child can use a cup and can use a spoon correctly but with some spilling. By ages 3 to 4,
the child begins to use a fork. By the end of the preschool period, the child should be able to pour milk into a cup and
begin to use a knife for cutting.

44. A clinic nurse assesses the communication patterns of a 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 B. Using monosyllabic babbling occurs between 3 and 6 months of age. Using simple words such as "mama"
occurs between 9 and 12 months. Linking syllables together when communicating occurs between 6 and 9 months.
Cooing begins at birth and continues until 2 months.

45. A nurse is preparing to care for a 5-year-old who has been placed in traction following a fracture of the femur. The
nurse plans care, knowing that which of the following is the most appropriate activity for this child?
 a. Large picture books
b. A radio
c. Crayons and coloring book
d. A sports video

ANSWER C. In the preschooler, play is simple and imaginative and includes activities such as crayons and coloring
books, puppets, felt and magnetic boards, and Play-Doh. Large picture books are most appropriate for the infant. A radio
and a sports video are most appropriate for the adolescent.

46. A 16-year-old is admitted to the hospital for acute appendicitis, and an appendectomy is performed. Which of the
following nursing interventions is most appropriate to facilitate normal growth and development?

a. Allow the family to bring in the child's favorite computer games

b. Encourage the parents to room-in with the child
c. Encourage the child to rest and read
d. Allow the child to participate in activities with other individuals in the same age group when the condition
permits

ANSWER D. Adolescents often are not sure whether they want their parents with them when they are hospitalized.
Because of the importance of the peer group, separation from friends is a source of anxiety. Ideally, the members of the
peer group will support their ill friend. Options a, b, and c isolate the child from the peer group

47. The nurse teaches parents how to help their children learn impulse control and cooperative behaviors. This would
occur during which of the stages of development defined by Erikson?

a. A.Trust versus mistrust

b. B.Initiative versus guilt
c. C.Industry versus inferiority
d. D.Autonomy vs. Shame and doubt

ANSWER B Initiative vs Guilt. The stage of initiative versus guilt occurs from ages 3 to 6 years, during which children
develop direction and purpose. Teaching impulse control and cooperative behaviors during this stage help the child to
avoid risks of altered growth and development. In the autonomy versus sense of shame and doubt stage, toddlers learn
to achieve self-control and willpower. Trust versus mistrust is the first stage, during which children develop faith and
optimism. During the industry versus inferiority stage, children develop a sense of competency.

48. The abnormal finding in an evaluation of growth and development for a 6-month-old infant would be:

a. weight gain of 4 to 7 ounces per week.

b. length increase of 1 inch in 2 months.
c. head lag present.
d. can sit alone for a few seconds.

ANSWER: C The infant should be holding the head up well by 5 months of age. If head lag is present at 6 months, the
child should undergo further evaluation. development is cephalocaudal lifting the head and shoulders is the one that the
infant learns to do first at 4 months. The infant can usually sit with support at about 5 months of age and can sit alone at
about 8 months.

49. A mother of a child tells the nurse, “I constantly see my five-year-old son fondling with his genitals.” She appears
tensed because according to him this may seem deviant for a preschooler. The nurse should tell the father that

a. “This behavior is abnormal. You should scold your child when you see him next time.”
b. “Just ignore the behavior of the child.”
c. “This act is to deviant. He probably will develop sexual disorders later on.”
d. “Tell the child to do it privately in his room. And make no issue out of it.”

ANSWER: D According to Freud’s Psychosexual Theory the child’s sexual energy at this stage is located at the genitals.
One of the common behavior of children at this stage is fondling of the genitals which is normal. The parent should
advise the child to do it privately instead.

50. A mother tells the nurse, “My 4-year-old daughter tells me that she hates me. What should I do?” As a nurse you are
going to tell her

a. “You may be mistreating your daughter. That’s why she hates you.”
b. “You should take your daughter out for a play sometimes for her to like you.”
c. “You should tell your daughter that you love her very much.”
d. “You should be patient about your daughter. She is undergoing a stage which is normal for her. Just be
supportive.”
ANSWER: D The daughter, according to Freud, is undergoing a phase during her age known as Elektra Complex, where
the girl will be more attached to the father than the mother. Oedipal Complex is the opposite for the male child.

51. How many hours after fertilization will the laboratory-grown zygotes be inserted into the woman’s uterus?

A. 12 hours
B. 24 hours
C. 48 hours
D. 40 hours
ANSWER: D By 40 hours after fertilization, the fertilized ovum will have undergone their first cell division. This is the
perfect time to insert the zygotes into the mother’s uterus.

52. Based from the information above, how many fertilized eggs will be inserted in the woman’s uterus?

A. 1 only
B. 1-2 fertilized ova
C. 3-4 fertilized ova
D. Up to 5 fertilized ova may be transferred
ANSWER B. For women who is under 35 years of age, only one or two fertilized ova are chosen and transferred back to
her uterine cavity through the cervix by means of a thin catheter. If the woman is more than 40 years of age up to five
embryos may be transferred.

53. Why is progesterone or luteinizing hormone prescribed to a woman after undergoing IVF?
A. Due to the blockage of the fallopian tubes
B. Hormonal imbalances brought about by the procedure
C. The corpus luteum can be injured by the aspiration of the follicle
D. Due to cysts growing on the mother’s ovaries
ANSWER: C One of the common occurrences in aspirating ova from the female’s ovaries is that the needle tends to
rupture the corpus luteum which is responsible for producing progesterone.