SEKOLAH TINGGI INDONESIA MAJU

FINAL TEST TERM

ACADEMIC YEAR 2018-2019
Subject : N-CLEX Name :
Lecturer : Fitriani Pratiwi, M.Pd Semester : VII
Day/Date: Time :11.00-12.30

I. MULTIPLE CHOICE QUESTION.

Choose the correct answers!
1. The mother of a 14-month-old child reports to the nurse that her child will not fall asleep at night without a bottle of
milk in the crib and often wakes during the night asking for another. Which of the following instructions by the nurse
is correct?
A. Allow the child to have the bottle at bedtime, but withhold the one later in the night.
B. Put juice in the bottle instead of milk.
C. Give only a bottle of water at bedtime.
D. o not allow bottles in the crib.
2. Which of the following actions is NOT appropriate in the care of a 2-month-old infant?
A. Place the infant on her back for naps and bedtime.
B. Allow the infant to cry for 5 minutes before responding if she wakes during the night as she may fall back asleep.
C. Talk to the infant frequently and make eye contact to encourage language development.
D. Wait until at least 4 months to add infant cereals and strained fruits to the diet.
3. An older patient asks a nurse to recommend strategies to prevent constipation. Which of the following suggestions
would be helpful? Note: More than one answer may be correct.
A. Get moderate exercise for at least 30 minutes each day. A.
B. Drink 6-8 glasses of water each day.
C. Eat a diet high in fiber.
D. Take a mild laxative if you don't have a bowel movement every day.
4. A child is admitted to the hospital with suspected rheumatic fever. Which of the following observations is NOT
confirming of the diagnosis?
A. A reddened rash visible over the trunk and extremities.
B. A history of sore throat that was self-limited in the past month.
C. A negative antistreptolysin O titer.
D. An unexplained fever.
5. An infant with congestive heart failure is receiving diuretic therapy at home. Which of the following symptoms
would indicate that the dosage may need to be increased?
A. Sudden weight gain.
B. Decreased blood pressure.
C. Slow, shallow breathing.
D. Bradycardia.
6. A nurse is providing discharge information to a patient with peripheral vascular disease (penyakit pembuluh darah
perifer). Which of the following information should be included in instructions?
A. Walk barefoot whenever possible.
B. Use a heating pad to keep feet warm.
C. Avoid crossing the legs.
D. Use antibacterial ointment to treat skin lesions at risk of infection.
7. A 23 year old patient in the 27th week of pregnancy has been hospitalized on complete bed rest for 6 days. She
experiences sudden shortness of breath, accompanied by chest pain. Which of the following conditions is the most
likely cause of her symptoms?
A. Myocardial infarction due to a history of atherosclerosis.
B. Pulmonary embolism due to deep vein thrombosis (DVT).
C. Anxiety attack due to worries about her baby's health.
D. Congestive heart failure due to fluid overload.
8. A toddler has recently been diagnosed with cerebral palsy. Which of the following information should the nurse
provide to the parents? Note: More than one answer may be correct.
A. Regular developmental screening is important to avoid secondary developmental delays.
B. Cerebral palsy is caused by injury to the upper motor neurons and results in motor dysfunction, as well as
possible ocular and speech difficulties.
C. Developmental milestones may be slightly delayed but usually will require no additional intervention.
D. Parent support groups are helpful for sharing strategies and managing health care issues.

II. MATCHING QUESTION

Match the statements with correct answer!

1. A nurse is planning care for a newborn of a (…..) Risk for injury related to
diabetic mother. A priority nursing diagnosis for low blood glucose levels.
this infant is:
1. Hyperthermia related to excess fat and
glycogen
2. Risk for injury related to low blood glucose
levels
3. Risk for delayed development related to
excessive size
4. Risk for aspiration related to impaired suck and
swallow reflexes
2. A nurse is caring for four 1-day postpartum (.....) Connect the resuscitation
clients. Which client has an abnormal finding that bag to the oxygen outlet.
would require further intervention?
1. The client with mild after pains.
2. The client with a pulse rate of 60 beats per
minutes
3. The client with colostrum discharge from both
breasts.
4. The client with lochia that is read and has a
foul-smelling odor.

3. A nurse is assessing a client who is 6 hours post- (……) Newborns are deficient
partum after delivering a full-term healthy infant. in Vitamin K, and this injection
The client complains to the nurse of feelings of prevents your newborn from
faintness and dizziness. Which nursing action bleeding.
would be most appropriate?
1. Elevate the client's legs.
2. Determine the hemoglobin and hematocrit
levels.
3. Instruct the client to request help when getting
out of bed.
4. Inform the nursery room nurse to avoid
bringing the newborn infant to the client until the
feelings of faintness and dizziness have subsided.
4. A nurse in a newborn nursery receives a (…..) Drying the infant with a
telephone call the prepare for the admission of a warm blanket.
43-week gestation newborn with Apgar scores of
1 & 4. In planning for admission of this newborn,
the nurse's highest priority should be to:
1. Turn on the apnea and cardiorespiratory
monitors.
2. Connect the resuscitation bag to the oxygen
outlet.
3. Set up the I.V. line with 5% dextrose in water.
4. Set the radiant warmer control temperature at
 97.6 degrees F.
5. A nurse prepares to administer a Vitamin K (…..) Instruct the client to
injection to a newborn, and the mother asks the request help when getting out
nurse why her infant needs the injection. The of bed.
best response by the nurse would be:
1. Your newborn needs Vitamin K to develop
immunity.
2. The Vitamin K will protect your newborn from
being jaundiced.
3. Newborns have sterile bowels, and Vitamin K
promotes the growth of bacteria in the bowel.
4. Newborns are deficient in Vitamin K, and this
injection prevents your newborn from bleeding.
6. A nurse in a delivery room is assisting with the (…..) Document the findings.
delivery of a newborn. After delivery, the nurse
prepares to prevent heat loss in the newborn
resulting from evaporation by:
1. Warming the crib pad.
2. Closing the doors to the room.
3. Drying the infant with a warm blanket.
4. Turning on the overhead radiant warmer.

7. A nurse is assessing a newborn infant after (…..) The client with lochia that
circumcision and notes that the circumcised area is read and has a foul-smelling
is red with a small amount of bloody drainage. odor.
Which of the following nursing actions is
appropriate?
1. Contact the physician.
2. Apply gentle pressure.
3. Reinforce the dressing.
4. Document the findings.

III. TRUE OR FALSE

No Statements T/F
1. Patients in a coma do not feel pain because they are unconscious.
2. A blood pressure of 140/90 mm Hg is obtained during a severe
episode of pain; it drops to 120/70 mm Hg. This does not
necessarily indicate pain relief
3. The nurse is monitoring a client in active stage of labor. The client
has been experiencing contractions that are short, irregular, and
weak. The nurse documents that the client is experiencing which
type of labor dystocia?
1. Hypotonic
2. Precipitous
3. Hypertonic
4. Preterm labor → 1. Acute pain
4. A pain-treatment plan should address both the physical and
emotional aspects of the client's pain.
5. Toxoplasmosis is transmitted to the infant by Transplacental
passage in the protozoa