MATERNAL AND CHILD HEALTH NURSING 1
To prevent infection
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
B. through the skin and into the muscles
C. that involves anterior rectal wall
D. that extends through the perineal muscle.
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:
A. I am happy to note that we can have sex occasionally
when I have no bleeding.
B. I am afraid I might have an operation when my due
comes
C. I will have to remain in bed until my due date comes
D. I may go back to work since I stay only at the office.
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
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
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
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 D.
the family lounge until after the delivery. 13. Nurse Luis is assessing the newborn’s heart rate. Which
7. Bettine Gonzales is hospitalized for the treatment of of the following would be considered normal if the
severe preecplampsia. Which of the following represents newborn is sleeping?
an unusual finding for this condition? A. 80 beats per minute
A. generalized edema B. 100 beats per minute
B. proteinuria 4+ C. 120 beats per minute
C. blood pressure of 160/110 D. 140 beats per minute
D. convulsions 14. The infant with Down Syndrome should go through
8. Nurse Geli explains to the client who is 33 weeks which of the Erikson’s developmental stages first?
pregnant and is experiencing vaginal bleeding that coitus: A. Initiative vs. Self doubt
A. Need to be modified in any way by either partner B. Industry vs. Inferiority
B. Is permitted if penile penetration is not deep. C. Autonomy vs. Shame and doubt
C. Should be restricted because it may stimulate D. Trust vs. Mistrust
uterine activity. 15. The child with phenylketonuria (PKU) must maintain a
D. Is safe as long as she is in side-lying position. low phenylalanine diet to prevent which of the following
9. Mrs. Precilla Abuel, a 32 year old mulripara is admitted to complications?
labor and delivery. Her last 3 pregnancies in short stage one A. Irreversible brain damage
of labor. The nurses decide to observe her closely. The B. Kidney failure
physician determines that Mrs. Abuel’s cervix is dilated to 6 C. Blindness
cm. Mrs. Abuel states that she is extremely uncomfortable. D. Neutropenia
To lessen Mrs. Abuel’s discomfort, the nurse can advise her 16. Which age group is with imaginative minds and creates
to: imaginary friends?
A. lie face down A. Toddler
B. not drink fluids B. Preschool
C. practice holding breaths between contractions C. School
D. assume Sim’s position D. Adolescence
10. Which is true regarding the fontanels of the newborn? 17. Which of the following situations would alert you to a
A. The anterior is large in shape when compared to the potentially developmental problem with a child?
posterior fontanel. A. Pointing to body parts at 15 months of age.
B. The anterior is triangular shaped; the posterior is B. Using gesture to communicate at 18 months.
diamond shaped. C. Cooing at 3 months.
C. The anterior is bulging; the posterior appears sunken. D. Saying “mama” or “dada” for the first time at 18
D. The posterior closes at 18 months; the anterior closes months of age.
at 8 to 12 months. 18. Isabelle, a 2 year old girl loves to move around and
11. Mrs. Quijones gave birth by spontaneous delivery to a oftentimes manifests negativism and temper tantrums.
full term baby boy. After a minute after birth, he is crying What is the best way to deal with her behavior?
and moving actively. His birth weight is 6.8 lbs. What do A. Tell her that she would not be loved by others is
you expect baby Quijones to weigh at 6 months? she behaves that way..
A. 13 -14 lbs B. Withholding giving her toys until she behaves
B. 16 -17 lbs properly.
C. 22 -23 lbs C. Ignore her behavior as long as she does not hurt
D. 27 -28 lbs herself and others.
12. During the first hours following delivery, the post D. Ask her what she wants and give it to pacify her.
partum client is given IVF with oxytocin added to them. The 19. Baby boy Villanueva, 4 months old, was seen at the
nurse understands the primary reason for this is: pediatric clinic for his scheduled check-up. By this period,
A. To facilitate elimination baby Villanueva has already increased his height by how
B. To promote uterine contraction many inches?
C. To promote analgesia A. 3 inches
 B. 4 inches
C. 5 inches
D. 6 inches
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
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
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
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
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
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 B. Class II
C. Hair loss monitoring C. Class III
D. Monitor for growth retardation D. class IV
7. The client asks the nurse, “When will this soft spot at the
MATERNAL AND CHILD NURSING EXAM 2 top of the head of my baby will close?” The nurse should
1. Nurse Bella explains to a 28 year old pregnant woman instruct the mother that the neonate’s anterior fontanel
undergoing a non-stress test that the test is a way of will normally close by age:
evaluating the condition of the fetus by comparing the fetal A. 2-3 months
heart rate with: B. 6-8 months
A. Fetal lie C. 10-12 months
B. Fetal movement D. 12-18 months
C. Maternal blood pressure 8. When a mother bleeds and the uterus is relaxed, soft and
D. Maternal uterine contractions non-tender, you can account the cause to:
2. During a 2 hour childbirth focusing on labor and delivery A. Atony of the uterus
process for primigravida. The nurse describes the second B. Presence of uterine scar
maneuver that the fetus goes through during labor C. Laceration of the birth canal
progress when the head is the presenting part as which of D. Presence of retained placenta fragments
the following: 9. Mrs. Pichie Gonzales’s LMP began April 4, 2010. Her EDD
A. Flexion should be which of the following:
B. Internal rotation A. February 11, 2011
C. Descent B. January 11, 20111
D. External rotation C. December 12, 2010
3. Mrs. Jovel Diaz went to the hospital to have her serum D. Nowember 14, 2010
blood test for alpha-fetoprotein. The nurse informed her 10. Which of the following prenatal laboratory test values
about the result of the elevation of serum AFP. The patient would the nurse consider as significant?
asked her what was the test for: A. Hematocrit 33.5%
A. Congenital Adrenal Hyperplasia B. WBC 8,000/mm3
B. PKU C. Rubella titer less than 1:8
C. Down Syndrome D. One hour glucose challenge test 110 g/dL
D. Neural tube defects 11. Aling Patricia is a patient with preeclampsia. You advise
4. Fetal heart rate can be auscultated with a fetoscope as her about her condition, which would tell you that she has
early as: not really understood your instructions?
A. 5 weeks of gestation A. “I will restrict my fat in my diet.”
B. 10 weeks of gestation B. “I will limit my activities and rest more
C. 15 weeks of gestation frequently throughout the day.”
D. 20 weeks of gestation C. “I will avoid salty foods in my diet.”
5. Mrs. Bendivin states that she is experiencing aching D. “I will come more regularly for check-up.”
swollen, leg veins. The nurse would explain that this is most 12. Mrs. Grace Evangelista is admitted with severe
probably the result of which of the following: preeclampsia. What type of room should the nurse select
A. Thrombophlebitis this patient?
B. PIH A. A room next to the elevator.
C. Pressure on blood vessels from the enlarging uterus B. The room farthest from the nursing station.
D. The force of gravity pulling down on the uterus C. The quietest room on the floor.
6. Mrs. Ella Santoros is a 25 year old primigravida who has D. The labor suite.
Rheumatic heart disease lesion. Her pregnancy has just 13. During a prenatal check-up, the nurse explains to a
been diagnosed. Her heart disease has not caused her to client who is Rh negative that RhoGAM will be given:
limit physical activity in the past. Her cardiac disease and A. Weekly during the 8th month because this
functional capacity classification is: is her third pregnancy.
A. Class I
 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.
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. 5
B. 6
C. 7
D. 8
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
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
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
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
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.
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
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
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
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
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.
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
MATERNAL AND CHILD HEALTH NURSING 3
1. A pregnant woman who is at term is admitted to the
birthing unit in active labor. The client has only progressed
from 2cm to 3 cm in 8 hours. She is diagnosed with
hypotonic dystocia and the physician ordered Oxytocin
(Pitocin) to augment her contractions. Which of the
following is the most important aspect of nursing
intervention at this time?
A. Timing and recording length of
contractions.
B. Monitoring.
C. Preparing for an emergency cesarean birth.
D. Checking the perineum for bulging.
2. A client who hallucinates is not in touch with reality. It is
important for the nurse to:
A. Isolate the client from other patients.
B. Maintain a safe environment.
C. Orient the client to time, place, and person.
D. Establish a trusting relationship.
3. The nurse is caring to a child client who has had a
tonsillectomy. The child complains of having dryness of the
throat. Which of the following would the nurse give to the
child?
A. Cola with ice
B. Yellow noncitrus Jello
C. Cool cherry Kool-Aid
D. A glass of milk
4. The physician ordered Phenylephrine (Neo-Synephrine)
nasal spray to a 13-year-old client. The nurse caring to the
client provides instructions that the nasal spray must be
used exactly as directed to prevent the development of:
A. Increased nasal congestion.
B. Nasal polyps.
C. Bleeding tendencies.
D. Tinnitus and diplopia.
5. A client with tuberculosis is to be admitted in the
hospital. The nurse who will be assigned to care for the
client must institute appropriate precautions. The nurse
should:
A. Place the client in a private room.
B. Wear an N 95 respirator when caring for the client.
C. Put on a gown every time when entering the room.
 D. Don a surgical mask with a face shield when
entering the room.
6. Which of the following is the most frequent cause of
noncompliance to the medical treatment of open-angle
glaucoma?
A. The frequent nausea and vomiting accompanying
use of miotic drug.
B. Loss of mobility due to severe driving restrictions.
C. Decreased light and near-vision accommodation
due to miotic effects of pilocarpine.
D. The painful and insidious progression of this type of
glaucoma.
7. In the morning shift, the nurse is making rounds in the
nursing care units. The nurse enters in a client’s room and
notes that the client’s tube has become disconnected from
the Pleurovac. What would be the initial nursing action?
A. Apply pressure directly over the incision site.
B. Clamp the chest tube near the incision site.
C. Clamp the chest tube closer to the drainage system.
D. Reconnect the chest tube to the Pleurovac.
8. Which of the following complications during a breech
birth the nurse needs to be alarmed?
A. Abruption placenta.
B. Caput succedaneum.
C. Pathological hyperbilirubinemia.
D. Umbilical cord prolapse.
9. The nurse is caring to a client diagnosed with severe
depression. Which of the following nursing approach is
important in depression?
A. Protect the client against harm to others.
B. Provide the client with motor outlets for
aggressive, hostile feelings.
C. Reduce interpersonal contacts.
D. Deemphasizing preoccupation with
elimination, nourishment, and sleep.
10. A 3-month-old client is in the pediatric unit. During
assessment, the nurse is suspecting that the baby may have
hypothyroidism when mother states that her baby does
not:
A. Sit up.
B. Pick up and hold a rattle.
C. Roll over.
D. Hold the head up.
11. The physician calls the nursing unit to leave an order.
The senior nurse had conversation with the other staff. The
newly hired nurse answers the phone so that the senior
nurses may continue their conversation. The new nurse
does not knowthe physician or the client to whom the
order pertains. The nurse should:
A. Ask the physician to call back after the
nurse has read the hospital policy manual.
B. Take the telephone order.
C. Refuse to take the telephone order.
D. Ask the charge nurse or one of the other
senior staff nurses to take the telephone
order.
12. The staff nurse on the labor and delivery unit is
assigned to care to a primigravida in transition complicated
by hypertension. A new pregnant woman in active labor is
admitted in the same unit. The nurse manager assigned the
same nurse to the second client. The nurse feels that the
client with hypertension requires one-to-one care. What
would be the initial actionof the nurse?
A. Accept the new assignment and complete an incident
report describing a shortage of nursing staff.
B. Report the incident to the nursing supervisor and
request to be floated.
C. Report the nursing assessment of the client in
transitional labor to the nurse manager and discuss
misgivings about the new assignment.
D. Accept the new assignment and provide the best
care.
13. A newborn infant with Down syndrome is to be
discharged today. The nurse is preparing to give the
discharge teaching regarding the proper care at home. The
nurse would anticipate that the mother is probably at the:
A. 40 years of age.
B. 20 years of age.
C. 35 years of age.
D. 20 years of age.
14. The emergency department has shortage of staff. The
nurse manager informs the staff nurse in the critical care
unit that she has to float to the emergency department.
What should the staff nurse expect under these conditions?
A. The float staff nurse will be informed of the situation
before the shift begins.
B. The staff nurse will be able to negotiate the
assignments in the emergency department.
C. Cross training will be available for the staff nurse.
D. Client assignments will be equally divided among the
nurses.
15. The nurse is assigned to care for a child client admitted
in the pediatrics unit. The client is receiving digoxin. Which
of the following questions will be asked by the nurse to the
parents of the child in order to assess the client’s risk for
digoxin toxicity?
A. “Has he been exposed to any childhood
communicable diseases in the past 2-3 weeks?”
B. “Has he been taking diuretics at home?”
C. “Do any of his brothers and sisters have history of
cardiac problems?”
D. “Has he been going to school regularly?”
16. The nurse noticed that the signed consent form has an
error. The form states, “Amputation of the right leg”
instead of the left leg that is to be amputated. The nurse
has administered already the preoperative medications.
What should the nurse do?
A. Call the physician to reschedule the surgery.
B. Call the nearest relative to come in to sign a new
form.
C. Cross out the error and initial the form.
D. Have the client sign another form.
17. The nurse in the nursing care unit checks the fluctuation
in the water-seal compartment of a closed chest drainage
system. The fluctuation has stopped, the nurse would:
A. Vigorously strip the tube to dislodge a clot.
B. Raise the apparatus above the chest to move fluid.
C. Increase wall suction above 20 cm H2O pressure.
D. Ask the client to cough and take a deep breath.
18. The pediatric nurse in the neonatal unit was informed
that the baby that is brought to the mother in the hospital
room is wrong. The nurse determines that two babies were
placed in the wrong cribs. The most appropriate nursing
action would be to:
A. Determine who is responsible for the mistake and
terminate his or her employment.
B. Record the event in an incident/variance report and
notify the nursing supervisor.
C. Reassure both mothers, report to the charge nurse, and
do not record.
D. Record detailed notes of the event on the mother’s
medical record.
19. Before the administration of digoxin, the nurse
completes an assessment to a toddler client for signs and
symptoms of digoxin toxicity. Which of the following is the
earliest and most significant sign of digoxin toxicity?
A. Tinnitus
B. Nausea and vomiting
C. Vision problem
D. Slowing in the heart rate
20. Which of the following treatment modality is
appropriate for a client with paranoid tendency?
A. Activity therapy.
B. Individual therapy.
C. Group therapy.
D. Family therapy.
 21. The client with rheumatoid arthritis is for discharge. In
preparing the client for discharge on prednisone therapy,
the nurse should advise the client to:
A. Wear sunglasses if exposed to bright light
for an extended period of time.
B. Take oral preparations of prednisone
before meals.
C. Have periodic complete blood counts while
on the medication.
D. Never stop or change the amount of the
medication without medical advice.
22. A pregnant client tells the nurse that she is worried
about having urinary frequency. What will be the most
appropriate nursing response?
A. “Try using Kegel (perineal) exercises and limiting fluids
before bedtime. If you have frequency associated with
fever, pain on voiding, or blood in the urine, call your
doctor/nurse-midwife.
B. “Placental progesterone causes irritability of the
bladder sphincter. Your symptoms will go away after
the baby comes.”
C. “Pregnant women urinate frequently to get rid of fetal
wastes. Limit fluids to 1L/daily.”
D. “Frequency is due to bladder irritation from
concentrate urine and is normal in pregnancy. Increase
your daily fluid intake to 3L.”
23. Which of the following will help the nurse determine
that the expression of hostility is useful?
A. Expression of anger dissipates the energy.
B. Energy from anger is used to accomplish what needs
to be done.
C. Expression intimidates others.
D. Degree of hostility is less than the provocation.
24. The nurse is providing an orientation regarding case
management to the nursing students. Which characteristics
should the nurse include in the discussion in understanding
case management?
A. Main objective is a written plan that combines
discipline-specific processes used to measure outcomes
of care.
B. Main purpose is to identify expected client, family and
staff performance against the timeline for clients with
the same diagnosis.
C. Main focus is comprehensive coordination of client
care, avoid unnecessary duplication of services,
improve resource utilization and decrease cost.
D. Primary goal is to understand why predicted outcomes
have not been met and the correction of identified
problems.
25. The physician orders a dose of IV phenytoin to a child
client. In preparing in the administration of the drug, which
nursing action is not correct?
A. Infuse the phenytoin into a smaller vein to prevent
purple glove syndrome.
B. Check the phenytoin solution to be sure it is clear or
light yellow in color, never cloudy.
C. Plan to give phenytoin over 30-60 minutes, using an in-
line filter.
D. Flush the IV tubing with normal saline before starting
phenytoin.
26. The pregnant woman visits the clinic for check –up.
Which assessment findings will help the nurse determine
that the client is in 8-week gestation?
A. Leopold maneuvers.
B. Fundal height.
C. Positive radioimmunoassay test (RIA test).
D. Auscultation of fetal heart tones.
27. Which of the following nursing intervention is essential
for the client who had pneumonectomy?
A. Medicate for pain only when needed.
B. Connect the chest tube to water-seal drainage.
C. Notify the physician if the chest drainage exceeds
100mL/hr.
D. Encourage deep breathing and coughing.
28. The nurse is providing a health teaching to a group of
parents regarding Chlamydia trachomatis. The nurse is
correct in the statement, “Chlamydia trachomatis is not
only an intracellular bacterium that causes neonatal
conjunctivitis, but it also can cause:
A. Discoloration of baby and adult teeth.
B. Pneumonia in the newborn.
C. Snuffles and rhagades in the newborn.
D. Central hearing defects in infancy.
29. The nurse is assigned to care to a 17-year-old male
client with a history of substance abuse. The client asks the
nurse, “Have you ever tried or used drugs?” The most
correct response of the nurse would be:
A. “Yes, once I tried grass.”
B. “No, I don’t think so.”
C. “Why do you want to know that?”
D. “How will my answer help you?”
30. Which of the following describes a health care team
with the principles of participative leadership?
A. Each member of the team can independently make
decisions regarding the client’s care without
necessarily consulting the other members.
B. The physician makes most of the decisions regarding
the client’s care.
C. The team uses the expertise of its members to
influence the decisions regarding the client’s care.
D. Nurses decide nursing care; physicians decide medical
and other treatment for the client.
31. A nurse is giving a health teaching to a woman who
wants to breastfeed her newborn baby. Which hormone,
normally secreted during the postpartum period, influences
both the milk ejection reflex and uterine involution?
A. Oxytocin.
B. Estrogen.
C. Progesterone.
D. Relaxin.
32. One staff nurse is assigned to a group of 5 patients for
the 12-hour shift. The nurse is responsible for the overall
planning, giving and evaluating care during the entire shift.
After the shift, same responsibility will be endorsed to the
next nurse in charge. This describes nursing care delivered
via the:
A. Primary nursing method.
B. Case method.
C. Functional method.
D. Team method.
33. The ambulance team calls the emergency department
that they are going to bring a client who sustained burns in
a house fire. While waiting for the ambulance, the nurse
will anticipate emergency care to include assessment for:
A. Gas exchange impairment.
B. Hypoglycemia.
C. Hyperthermia.
D. Fluid volume excess.
34. Most couples are using “natural” family planning
methods. Most accidental pregnancies in couples preferred
to use this method have been related to unprotected
intercourse before ovulation. Which of the following factor
explains why pregnancy may be achieved by unprotected
intercourse during the preovulatory period?
A. Ovum viability.
B. Tubal motility.
C. Spermatozoal viability.
D. Secretory endometrium.
35. An older adult client wakes up at 2 o’clock in the
morning and comes to the nurse’s station saying, “I am
having difficulty in sleeping.” What is the best nursing
response to the client?
A. “I’ll give you a sleeping pill to help you get more
sleep now.”
B. “Perhaps you’d like to sit here at the nurse’s station
for a while.”
 C. “Would you like me to show you where the
bathroom is?”
D. “What woke you up?”
36. The nurse is taking care of a multipara who is at 42
weeks of gestation and in active labor, her membranes
ruptured spontaneously 2 hours ago. While auscultating for
the point of maximum intensity of fetal heart tones before
applying an external fetal monitor, the nurse counts 100
beats per minute. The immediate nursing action is to:
A. Start oxygen by mask to reduce fetal distress.
B. Examine the woman for signs of a prolapsed cord.
C. Turn the woman on her left side to increase placental
perfusion.
D. Take the woman’s radial pulse while still auscultating
the FHR.
37. The nurse must instruct a client with glaucoma to avoid
taking over-the-counter medications like:
A. Antihistamines.
B. NSAIDs.
C. Antacids.
D. Salicylates.
38. A male client is brought to the emergency department
due to motor vehicle accident. While monitoring the client,
the nurse suspects increasing intracranial pressure when:
A. Client is oriented when aroused from sleep, and
goes back to sleep immediately.
B. Blood pressure is decreased from 160/90 to 110/70.
C. Client refuses dinner because of anorexia.
D. Pulse is increased from 88-96 with occasional
skipped beat.
39. The nurse is conducting a lecture to a class of nursing
students about advance directives to preoperative clients.
Which of the following statement by the nurse js correct?
A. “The spouse, but not the rest of the family, may
override the advance directive.”
B. “An advance directive is required for a “do not
resuscitate” order.”
C. “A durable power of attorney, a form of advance
directive, may only be held by a blood relative.”
D. “The advance directive may be enforced even in the
face of opposition by the spouse.”
40. A client diagnosed with schizophrenia is shouting and
banging on the door leading to the outside, saying, “I need
to go to an appointment.” What is the appropriate nursing
intervention?
A. Tell the client that he cannot bang on the door.
B. Ignore this behavior.
C. Escort the client going back into the room.
D. Ask the client to move away from the door.
41. Which of the following action is an accurate tracheal
suctioning technique?
A. 25 seconds of continuous suction during catheter
insertion.
B. 20 seconds of continuous suction during catheter
insertion.
C. 10 seconds of intermittent suction during catheter
withdrawal.
D. 15 seconds of intermittent suction during catheter
withdrawal.
42. The client’s jaw and cheekbone is sutured and wired.
The nurse anticipates that the most important thing that
must be ready at the bedside is:
A. Suture set.
B. Tracheostomy set.
C. Suction equipment.
D. Wire cutters.
43. A mother is in the third stage of labor. Which of the
following signs will help the nurse determine the signs of
placental separation?
A. The uterus becomes globular.
B. The umbilical cord is shortened.
C. The fundus appears at the introitus.
D. Mucoid discharge is increased.
44. After therapy with the thrombolytic alteplase (t-PA),
what observation will the nurse report to the physician?
A. 3+ peripheral pulses.
B. Change in level of consciousness and headache.
C. Occasional dysrhythmias.
D. Heart rate of 100/bpm.
45. A client who undergone left nephrectomy has a large
flank incision. Which of the following nursing action will
facilitate deep breathing and coughing?
A. Push fluid administration to loosen
respiratory secretions.
B. Have the client lie on the unaffected side.
C. Maintain the client in high Fowler’s
position.
D. Coordinate breathing and coughing
exercise with administration of analgesics.
46. The community nurse is teaching the group of mothers
about the cervical mucus method of natural family
planning. Which characteristics are typical of the cervical
mucus during the “fertile” period of the menstrual cycle?
A. Absence of ferning.
B. Thin, clear, good spinnbarkeit.
C. Thick, cloudy.
D. Yellow and sticky.
47. A client with ruptured appendix had surgery an hour
ago and is transferred to the nursing care unit. The nurse
placed the client in a semi-Fowler’s position primarily to:
A. Facilitate movement and reduce complications
from immobility.
B. Fully aerate the lungs.
C. Splint the wound.
D. Promote drainage and prevent
subdiaphragmatic abscesses.
48. Which of the following will best describe a management
function?
A. Writing a letter to the editor of a nursing journal.
B. Negotiating labor contracts.
C. Directing and evaluating nursing staff members.
D. Explaining medication side effects to a client.
49. The parents of an infant client ask the nurse to teach
them how to administer Cortisporin eye drops. The nurse is
correct in advising the parents to place the drops:
A. In the middle of the lower conjunctival sac
of the infant’s eye.
B. Directly onto the infant’s sclera.
C. In the outer canthus of the infant’s eye.
D. In the inner canthus of the infant’s eye.
50. The nurse is assessing on the client who is admitted due
to vehicle accident. Which of the following findings will
help the nurse that there is internal bleeding?
A. Frank blood on the clothing.
B. Thirst and restlessness.
C. Abdominal pain.
D. Confusion and altered of consciousness.
51. The nurse is completing an assessment to a newborn
baby boy. The nurse observes that the skin of the newborn
is dry and flaking and there are several areas of an apparent
macular rash. The nurse charts this as:
A. Icterus neonatorum
B. Multiple hemangiomas
C. Erythema toxicum
D. Milia
52. The client is brought to the emergency department
because of serious vehicle accident. After an hour, the
client has been declared brain dead. The nurse who has
been with the client must now talk to the family about
organ donation. Which of the following consideration is
necessary?
A. Include as many family members as possible.
B. Take the family to the chapel.
C. Discuss life support systems.
D. Clarify the family’s understanding of brain death.
53. The nurse is teaching exercises that are good for
pregnant women increasing tone and fitness and
decreasing lower backache. Which of the following should
the nurse exclude in the exercise program?
A. Stand with legs apart and touch hands to floor
three times per day.
B. Ten minutes of walking per day with an emphasis
on good posture.
C. Ten minutes of swimming or leg kicking in pool per
day.
D. Pelvic rock exercise and squats three times a day.
54. A client with obsessive-compulsive behavior is admitted
in the psychiatric unit. The nurse taking care of the client
knows that the primary treatment goal is to:
A. Provide distraction.
B. Support but limit the behavior.
C. Prohibit the behavior.
D. Point out the behavior.
55. After ileostomy, the nurse expects that the drainage
appliance will be applied to the stoma:
A. When the client is able to begin self-care
procedures.
B. 24 hours later, when the swelling subsided.
C. In the operating room after the ileostomy
procedure.
D. After the ileostomy begins to function.
56. A female client who has a 28-day menstrual cycle asks
the community health nurse when she get pregnant during
her cycle. What will be the best nursing response?
A. It is impossible to determine the fertile period
reliably. So it is best to assume that a woman is
always fertile.
B. In a 28-day cycle, ovulation occurs at or about day 14.
The egg lives for about 24 hours and the sperm live
for about 72 hours. The fertile period would be
approximately between day 11 and day 15.
C. In a 28- day cycle, ovulation occurs at or about day
14. The egg lives for about 72 hours and the sperm
live for about 24 hours. The fertile period would be
approximately between day 13 and 17.
D. In a 28-day cycle, ovulation occurs 8 days before the
next period or at about day 20. The fertile period is
between day 20 and the beginning of the next period.
57. Which of the following statement describes the role of
a nurse as a client advocate?
A. A nurse may override clients’ wishes for their own
good.
B. A nurse has the moral obligation to prevent harm and
do well for clients.
C. A nurse helps clients gain greater independence and
self-determination.
D. A nurse measures the risk and benefits of various
health situations while factoring in cost.
58. A community health nurse is providing a health
teaching to a woman infected with herpes simplex 2. Which
of the following health teaching must the nurse include to
reduce the chances of transmission of herpes simplex 2?
A. “Abstain from intercourse until lesions heal.”
B. “Therapy is curative.”
C. “Penicillin is the drug of choice for treatment.”
D. “The organism is associated with later development of
hydatidiform mole.
59. The nurse in the psychiatric ward informed the male client that
he will be attending the 9:00 AM group therapy sessions. The client
tells the nurse that he must wash his hands from 9:00 to 9:30 AM
each day and therefore he cannot attend. Which concept does the
nursing staff need to keep in mind in planning nursing intervention
for this client?
A. Depression underlines ritualistic behavior.
B. Fear and tensions are often expressed in disguised form
through symbolic processes.
C. Ritualistic behavior makes others uncomfortable.
D. Unmet needs are discharged through ritualistic behavior.
60. The nurse assesses the health condition of the female client.
The client tells the nurse that she discovered a lump in the breast
last year and hesitated to seek medical advice. The nurse
understands that, women who tend to delay seeking medical
advice after discovering the disease are displaying what common
defense mechanism?
A. Intellectualization.
B. Suppression.
C. Repression.
D. Denial.
61. Which of the following situations cannot be delegated by the
registered nurse to the nursing assistant?
A. A postoperative client who is stable needs to ambulate.
B. Client in soft restraint who is very agitated and crying.
C. A confused elderly woman who needs assistance with
eating.
D. Routine temperature check that must be done for a client
at end of shift.
62. In the admission care unit, which of the following client would
the nurse give immediate attention?
A. A client who is 3 days postoperative with left calf pain.
B. A client who is postoperative hip pinning who is complaining
of pain.
C. New admitted client with chest pain.
D. A client with diabetes who has a glucoscan reading of 180.
63. A couple seeks medical advice in the community health care
unit. A couple has been unable to conceive; the man is being
evaluated for possible problems. The physician ordered semen
analysis. Which of the following instructions is correct regarding
collection of a sperm specimen?
A. Collect a specimen at the clinic, place in iced container, and
give to laboratory personnel immediately.
B. Collect specimen after 48-72 hours of abstinence and bring to
clinic within 2 hours.
C. Collect specimen in the morning after 24 hours of abstinence
and bring to clinic immediately.
D. Collect specimen at night, refrigerate, and bring to clinic the
next morning.
64. The physician ordered Betamethasone to a pregnant woman at
34 weeks of gestation with sign of preterm labor. The nurse
expects that the drug will:
A. Treat infection.
B. Suppress labor contraction.
C. Stimulate the production of surfactant.
D. Reduce the risk of hypertension.
65. A tracheostomy cuff is to be deflated, which of the following
nursing intervention should be implemented before starting the
procedures?
A. Suction the trachea and mouth.
B. Have the obdurator available.
C. Encourage deep breathing and coughing.
D. Do a pulse oximetry reading.
66. A client is diagnosed with Tuberculosis and respiratory isolation
is initiated. This means that:
A. Gloves are worn when handling the client’s tissue, excretions,
and linen.
B. Both client and attending nurse must wear masks at all times.
C. Nurse and visitors must wear masks until chemotherapy is
begun. Client is instructed in cough and tissue techniques.
D. Full isolation; that is, caps and gowns are required during the
period of contagion.
67. A client with lung cancer is admitted in the nursing care unit.
The husband wants to know the condition of his wife. How should
the nurse respond to the husband?
A. Find out what information he already has.
B. Suggest that he discuss it with his wife.
C. Refer him to the doctor.
D. Refer him to the nurse in charge.
68. A hospitalized client cannot find his handkerchief and accuses
other cient in the room and the nurse of stealing them. Which is
the most therapeutic approach to this client?
A. Divert the client’s attention.
B. Listen without reinforcing the client’s belief.
C. Inject humor to defuse the intensity.
D. Logically point out that the client is jumping to
conclusions.
69. After a cystectomy and formation of an ileal conduit, the nurse
provides instruction regarding prevention of leakage of the pouch
and backflow of the urine. The nurse is correct to include in the
instruction to empty the urine pouch:
A. Every 3-4 hours.
B. Every hour.
C. Twice a day.
D. Once before bedtime.
70. Which telephone call from a student’s mother should the
school nurse take care of at once?
A. A telephone call notifying the school nurse that the child’
pediatrician has informed the mother that the child will
need cardiac repair surgery within the next few weeks.
B. A telephone call notifying the school nurse that the child’s
pediatrician has informed the mother that the child has
head lice.
C. A telephone call notifying the school nurse that a child has a
temperature of 102ºF and a rash covering the trunk and
upper extremities of the body.
D. A telephone call notifying the school nurse that a child
underwent an emergency appendectomy during the
previous night.
71. Which of the following signs and symptoms that require
immediate attention and may indicate most serious complications
during pregnancy?
A. Severe abdominal pain or fluid discharge from the
vagina.
B. Excessive saliva, “bumps around the areolae, and
increased vaginal mucus.
C. Fatigue, nausea, and urinary frequency at any time
during pregnancy.
D. Ankle edema, enlarging varicosities, and heartburn.
72. The nurse is assessing the newborn boy. Apgar scores are 7 and
9. The newborn becomes slightly cyanotic. What is the initial
nursing action?
A. Elevate his head to promote gravity drainage of
secretions.
B. Wrap him in another blanket, to reduce heat loss.
C. Stimulate him to cry,, to increase oxygenation.
D. Aspirate his mouth and nose with bulb syringe.
73. The nurse is formulating a plan of care to a client with a
somatoform disorder. The nurse needs to have knowledge of
which psychodynamic principle?
A. The symptoms of a somatoform disorder are an attempt
to adjust to painful life situations or to cope with
conflicting sexual, aggressive, or dependent feelings.
B. The major fundamental mechanism is regression.
C. The client’s symptoms are imaginary and the suffering is
faked.
D. An extensive, prolonged study of the symptoms will be
reassuring to the client, who seeks sympathy, attention and
love.
74. An infant is brought to the health care clinic for three
immunizations at the same time. The nurse knows that hepatitis B,
DPT, and Haemophilus influenzae type B immunizations should:
A. Be drawn in the same syringe and given in one
injection.
B. Be mixed and inject in the same sites.
C. Not be mixed and the nurse must give three
injections in three sites.
D. Be mixed and the nurse must give the injection
in three sites.
75. A female client with cancer has radium implants. The nurse
wants to maintain the implants in the correct position. The nurse
should position the client:
A. Flat in bed.
B. On the side only.
C. With the foot of the bed elevated.
D. With the head elevated 45-degrees (semi-Fowler’s).
76. The nurse wants to know if the mother of a toddler
understands the instructions regarding the administration of syrup
of ipecac. Which of the following statement will help the nurse to
know that the mother needs additional teaching?
A. “I’ll give the medicine if my child gets into some toilet bowl
cleaner.”
B. “I’ll give the medicine if my child gets into some aspirin.”
C. “I’ll give the medicine if my child gets into some plant
bulbs.”
D. “I’ll give the medicine if my child gets into some vitamin
pills.”
77. To assess if the cranial nerve VII of the client was damaged,
which changes would not be expected?
A. Drooling and drooping of the mouth.
B. Inability to open eyelids on operative side.
C. Sagging of the face on the operative side.
D. Inability to close eyelid on operative side.
78. The community health nurse makes a home visit to a family.
During the visit, the nurse observes that the mother is beating her
child. What is the priority nursing intervention in this situation?
A. Assess the child’s injuries.
B. Report the incident to protective agencies.
C. Refer the family to appropriate support group.
D. Assist the family to identify stressors and use of other coping
mechanisms to prevent further incidents.
79. The nurse in the neonatal care unit is supervising the actions of
a certified nursing assistant in giving care to the newborns. The
nursing assistant mistakenly gives a formula feeding to a newborn
that is on water feeding only. The nurse is responsible for the
mistake of the nursing assistant:
A. Always, as a representative of the institution.
B. Always, because nurses who supervise less-trained
individuals are responsible for their mistakes.
C. If the nurse failed to determine whether the nursing
assistant was competent to take care of the client.
D. Only if the nurse agreed that the newborn could be fed
formula.
80. The nurse is assigned to care for a client with urinary calculi.
Fluid intake of 2L/day is encouraged to the client. the primary
reason for this is to:
A. Reduce the size of existing stones.
B. Prevent crystalline irritation to the ureter.
C. Reduce the size of existing stones
D. Increase the hydrostatic pressure in the urinary tract.
81. The nurse is counseling a couple in their mid 30’s who have
been unable to conceive for about 6 months. They are concerned
that one or both of them may be infertile. What is the best advice
the nurse could give to the couple?
A. “it is no unusual to take 6-12 months to get pregnant,
especially when the partners are in their mid-30s. Eat well,
exercise, and avoid stress.”
B. “Start planning adoption. Many couples get pregnant
when they are trying to adopt.”
C. “Consult a fertility specialist and start testing before you
get any older.”
D. “Have sex as often as you can, especially around the time
of ovulation, to increase your chances of pregnancy.”
82. The nurse is caring for a cient who Is a retired nurse. A 24-hour
urine collection for Creatinine clearance is to be done. The client
tells the nurse, “I can’t remember what this test is for.” The best
response by the nurse is:
A. “It provides a way to see if you are passing any protein in
your urine.”
B. “It tells how well the kidneys filter wastes from the
blood.”
C. “It tells if your renal insufficiency has affected your heart.”
D. “The test measures the number of particles the kidney
filters.”
83. The nurse observes the female client in the psychiatric ward
that she is having a hard time sleeping at night. The nurse asks the
client about it and the client says, “I can’t sleep at night because of
fear of dying.” What is the best initial nursing response?
A. “It must be frightening for you to feel that way. Tell me
more about it.”
B. “Don’t worry, you won’t die. You are just here for some
test.”
C. “Why are you afraid of dying?”
D. “Try to sleep. You need the rest before tomorrow’s test.”
84. In the hospital lobby, the registered nurse overhears a two staff
members discussing about the health condition of her client. What
would be the appropriate action for the registered nurse to take?
A. Join in the conversation, giving her input about
the case.
B. Ignore them, because they have the right to
discuss anything they want to.
C. Tell them it is not appropriate to discuss such
things.
D. Report this incident to the nursing supervisor.
85. The client has had a right-sided cerebrovascular accident. In
transferring the client from the wheelchair to bed, in what position
should a client be placed to facilitate safe transfer?
A. Weakened (L) side of the cient next to bed.
B. Weakened (R) side of the client next to bed.
C. Weakened (L) side of the client away from bed.
D. Weakened (R) side of the cient away from bed.
86. The child client has undergone hip surgery and is in a spica cast.
Which of the following toy should be avoided to be in the child’s
bed?
A. A toy gun.
B. A stuffed animal.
C. A ball.
D. Legos.
 87. The LPN/LVN asks the registered nurse why oxytocin (Pitocin),
10 units (IV or IM) must be given to a client after birth fo the fetus.
The nurse is correct to explain that oxytocin:
A. Minimizes discomfort from “afterpains.”
B. Suppresses lactation.
C. Promotes lactation.
D. Maintains uterine tone.
88. The nurse in the nursing care unit is aware that one of the
medical staff displays unlikely behaviors like confusion, agitation,
lethargy and unkempt appearance. This behavior has been
reported to the nurse manager several times, but no changes
observed. The nurse should:
A. Continue to report observations of unusual behavior until the
problem is resolved.
B. Consider that the obligation to protect the patient from harm
has been met by the prior reports and do nothing further.
C. Discuss the situation with friends who are also nurses to get
ideas .
D. Approach the partner of this medical staff member with these
concerns.
89. The physician ordered tetracycline PO qid to a child client who
weights 20kg. The recommended PO tetracycline dose is 25-50
mg/kg/day. What is the maximum single dose that can be safely
administered to this child?
A. 1 g
B. 500 mg
C. 250 mg
D. 125 mg
90. The nurse is completing an obstetric history of a woman in
labor. Which event in the obstetric history will help the nurse
suspects dysfunctional labor in the current pregnancy?
A. Total time of ruptured membranes was 24 hours with the
second birth.
B. First labor lasting 24 hours.
C. Uterine fibroid noted at time of cesarean delivery.
D. Second birth by cesarean for face presentation.
91. The nurse is planning to talk to the client with an antisocial
personality disorder. What would be the most therapeutic
approach?
A. Provide external controls.
B. Reinforce the client’s self-concept.
C. Give the client opportunities to test reality.
D. Gratify the client’s inner needs.
92. The nurse is teaching a group of women about fertility
awareness, the nurse should emphasize that basal body
temperature:
A. Can be done with a mercury thermometer but no a digital
one.
B. The average temperature taken each morning.
C. Should be recorded each morning before any activity.
D. Has a lower degree of accuracy in predicting ovulation
than the cervical mucus test.
93. The nursing applicant has given the chance to ask questions
during a job interview at a local hospital. What should be the most
important question to ask that can increase chances of securing a D. Notify the physician.
job offer? 100. A client who undergone appendectomy 3 days ago is
A. Begin with questions about client care assignments, scheduled for discharge today. The nurse notes that the client is
advancement opportunities, and continuing education. restless, picking at bedclothes and saying, “I am late on my
B. Decline to ask questions, because that is the responsibility appointment,” and calling the nurse by the wrong name. The nurse
of the interviewer. suspects:
C. Ask as many questions about the facility as possible. A. Panic reaction.
D. Clarify information regarding salary, benefits, and working B. Medication overdose.
hours first, because this will help in deciding whether or C. Toxic reaction to an antibiotic.
not to take the job. D. Delirium tremens.
94. The nurse advised the pregnant woman that smoking and
alcohol should be avoided during pregnancy. The nurse takes into
account that the developing fetus is most vulnerable to
environment teratogens that cause malformation during:
A. The entire pregnancy.
B. The third trimester.
C. The first trimester.
D. The second trimester.
95. A male client tells the nurse that there is a big bug in his bed.
The most therapeutic nursing response would be:
A. Silence.
B. “Where’s the bug? I’ll kill it for you.”
C. “I don’t see a bug in your bed, but you seem afraid.”
D. “You must be seeing things.”
96. A pregnant client in late pregnancy is complaining of groin pain
that seems worse on the right side. Which of the following is the
most likely cause of it?
A. Beginning of labor.
B. Bladder infection.
C. Constipation.
D. Tension on the round ligament.
97. The nurse is conducting a lecture to a group of volunteer
nurses. The nurse is correct in imparting the idea that the Good
Samaritan law protects the nurse from a suit for malpractice when:
A. The nurse stops to render emergency aid and leaves before
the ambulance arrives.
B. The nurse acts in an emergency at his or her place of
employment.
C. The nurse refuses to stop for an emergency outside of the
scope of employment.
D. The nurse is grossly negligent at the scene of an emergency.
98. A woman is hospitalized with mild preeclampsia. The nurse is
formulating a plan of care for this client, which nursing care is least
likely to be done?
A. Deep-tendon reflexes once per shift.
B. Vital signs and FHR and rhythm q4h while awake.
C. Absolute bed rest.
D. Daily weight.
99. While feeding a newborn with an unrepaired cardiac defect,
the nurse keeps on assessing the condition of the client. The nurse
notes that the newborn’s respiration is 72 breaths per minute.
What would be the initial nursing action?
A. Burp the newborn.
B. Stop the feeding.
C. Continue the feeding.

MATERNAL AND CHILD HEALTH NURSING 1
1. (A) that extended their anal sphincter. 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.
2. (C) I will have to remain in bed until my due date
comes. 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.
3. (D) 18th week of pregnancy. 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.
4. (A) frequency. 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.
5. (B) 25-35 lbs. 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.
6. (B) Modify preoperative teaching to meet the needs
of either a planned or emergency cesarean birth. 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.
7. (D) convulsions. Options A, B and C are findings of
severe preeclampsia. Convulsions is a finding of
eclampsia—an obstetrical emergency.
8. (C) Should be restricted because it may stimulate
uterine activity.. 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.
9. (D) assume Sim’s position. 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.
10. (A) The anterior is large in shape when compared to
the posterior fontanel.. 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.
11. (A) 13 -14 lbs. The birth weight of an infant is
doubled at 6 months and is tripled at 12 months.
12. (B) To promote uterine contraction. Oxytocin is a
hormone produced by the pituitary gland that
produces intermittent uterine contractions, helping
to promote uterine involution.
13. (B) 100 beats per minute. 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.
14. (D) Trust vs. Mistrust. 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.
15. (A) Irreversible brain damage. The child with PKU
must maintain a strict low phenylalanine diet to
prevent central nervous system damage, seizures
and eventual death.
16. (B) Preschool. 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.
17. (D) Saying “mama” or “dada” for the first time at 18
months of age.. 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.
18. (C) Ignore her behavior as long as she does not hurt
herself and others.. If a child is trying to get
attention or trying to get something through
tantrums—ignore his/her behavior.
19. (B) 4 inches. 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.
20. (D) Status Asthmaticus. Status asthmaticus leads to
respiratory distress and bronchospasm despite of
treatment and interventions. Mechanical
ventilation maybe needed due to respiratory
failure.
21. (D) Abdominal mass and
weakness. Nephroblastoma or Wilm’s tumor is
caused by chromosomal abnormalities, most
common kidney cancer among children
characterized by abdominal mass, hematuria,
hypertension and fever.
22. (A) blurred vision. 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.
23. (B) irritability, purulent drainage in middle ear,
nasal congestion and cough. 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.
24. (D) Kangaroo care. 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.
25. (B) Use of a high-SPF sunblock. 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 significant, indicating that the client may not possess should ask the mother focused questions; however,
prevent any problems. immunity to rubella. A hematocrit of 33.5%, WBC of based on initial information, the analysis of separation
8,000/mm3, and a 1 hour glucose challenge test of 110 anxiety would be most valid. Separation anxiety is a
MATERNAL AND CHILD NURSING EXAM 2 g/dL are within normal parameters. normal toddler response. When the child senses he is
11. (B) “I will limit my activities and rest more frequently being sent away from those who most provide him with
throughout the day.”Pregnant woman with love and security. Crying is one way a child expresses a
1. (B) Fetal movement. Non-stress test measures response
preeclampsia should be in a complete bed rest. When physical need; however, the nurse would be hasty in
of the FHR to the fetal movement. With fetal
body is in recumbent position, sodium tends to be drawing this as first conclusion based on what the
movement, FHR increase by 15 beats and remain for 15
excreted at a faster rate. It is the best method of aiding mother has said. Nurturing overdependence or not
seconds then decrease to average rate. No increase
increased excretion of sodium and encouraging providing structure for the toddler are inaccurate
means poor oxygenation perfusion to fetus.
diuresis. Rest should always be in a lateral recumbent conclusions based on the information provided.
2. (A) Flexion. The 6 cardinal movements of labor are
position to avoid uterine pressure on the vena cava and 20. (B) Body image disturbance. Mylene is experiencing
descent, flexion, internal rotation, extension, external
prevent supine hypotension. uneasiness about the curvative of her spine, which will
rotation and expulsion.
12. (C) The quietest room on the floor.A loud noise such as be more evident when she wears a bathing suit. This
3. (D) Neural tube defects. Alpha-fetoprotein is a
a crying baby, or a dropped tray of equipment may be data suggests a body image disturbance. There is no
substance produces by the fetal liver that is present in
sufficient to trigger a seizure initiating eclampsia, a evidence of anxiety or ineffective coping. The fact that
amniotic fluid and maternal serum. The level is
woman with severe preeclampsia should be admiotted Mylene is planning to attend a pool party dispels a
abnormally high in the maternal serum if the fetus has
to a private room so she can rest as undisturbed as diagnosis of social isolation.
an open spinal or abdominal defect because the open
possible. Darken the room if possible because bright 21. (B) undigested fat. The client with cystic fibrosis
defect allows more AFP to appear.
light can trigger seizures. absorbs fat poorly because of the think secretions
4. (D) 20 weeks of gestation. The FHR can be auscultated
13. (D) Within 72 hours after delivery if infant is found to blocking the pancreatic duct. The lack of natural
with a fetoscope at about 20 weeks of gestation. FHR is
be Rh positive. RhoGAM is given to Rh-negative pancreatic enzyme leads to poor absorption of
usually auscultated at the midline suprapubic region
mothers within 72 hours after birth of Rh-positive baby predominantly fats in the duodenum. Foul-smelling,
with Doppler ultrasound at 10 to 12 weeks of gestation.
to prevent development of antibodies in the maternal frothy stool is termed steatorrhea.
FHR cannot be heard any earlier than 10 weeks of
blood stream, which will be fata to succeeding Rh- 22. (C) the father may resent the infant’s demands on the
gestation.
positive offspring. mother’s body. With breast feeding, the father’s body is
5. (C) Pressure on blood vessels from the enlarging
14. (B) 6. Heart rate of 99 bpm-1; weak cry-1; irregular not capable of providing the milk for the newborn,
uterus. Pressure of the growing fetus on blood vessels
respiration-1; moving all extremities-2; extremities are which may interfere with feeding the newborn,
results in an increase risk for venous stasis in the lower
slightly blue-1; with a total score of 6. providing fewer chances for bonding, or he may be
extremities. Subsequently, edema and varicose vein
15. (D) genius. IQ= mental age/chronological age x 100. jealous of the infant’s demands on his wife time and
formation may occur.
Mental age refers to the typical intelligence level found body. Breast feeding is advantageous because uterine
6. (A) Class I. Clients under class I has no physical activity
for people at a give chronological age. OQ of 140 and involution occurs more rapidly, thus minimizing blood
limitation. There is a slight limitation of physical activity
above is considered genius. loss. The presence of maternal antibodies in breast milk
in class II, ordinary activity causes fatigue, palpitation,
16. (D) Fetal alcohol syndrome. The newborn with fetal helps decrease the incidence of allergies in the
dyspnea or angina. Class III is moderate limitation of
alcohol syndrome has a number of possible problems at newborn. A greater chance for error is associated with
physical activity; less than ordinary activity causes
birth. Characteristics that mark the syndrome include bottle feeding. No preparation required for breast
fatigue. Unable to carry on any activity without
pre and postnatal growth retardation; CNS involvement feeding.
experiencing discomfort is under class IV.
such as cognitive challenge, microcephally and cerebral 23. (A) Turner’s syndrome. Lymphedema, webbed neck and
7. (D) 12-18 months. Anterior fontanel closes at 12-18
palsy; and a distinctive facial feature of a short low posterior hairline, these are the 3 key assessment
months while posterior fontanel closes at birth until 2
palpebral fissure and thin upper lip. features in Turner’s syndrome. If the child is diagnosed
months.
17. (A) Monitoring for adequate nutritional intake. The early in age, proper treatment can be offered to the
8. (A) Atony of the uterus. Uterine atony, or relaxation of
infant with cleft lip is unable to create an adequate seal family. All newborns should be screened for possible
the uterus is the most frequent cause of postpartal
for sucking. The child is at risk for inadequate congenital defects.
hemorrhage. It is the inability to maintain the uterus in
nutritional intake as well as aspiration. 24. (D) Temporary separation from the loved one. The
contracted state.
18. (C) a deficiency of clotting factor VIII. Hemophillia A predominant perception of death by preschool age
9. (B) January 11, 20111. Using the Nagel’s rule, he use
(classic hemophilia) is a deficiency in factor VIII (an children is that death is temporary separation. Because
this formula ( -3 calendar months + 7 days).
alpha globulin that stabilizes fibrin clots). that child is losing someone significant and will not see
10. (C) Rubella titer less than 1:8. A rubella titer should be
19. (D) The mother is describing her child’s separation that person again, it’s inaccurate to infer death is
1:8 or greater. Thus, a finding of a titer less than 1:8 is
anxiety. Before coming to any conclusion, the nurse insignificant, regardless of the child’s response.
25. (D) sodium retention, water retention and potassium
loss. 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.
MATERNAL AND CHILD HEALTH NURSING 3
1. A. The oxytocic effect of Pitocin increases the intensity
and durations of contractions; prolonged contractions
will jeopardize the safetyof the fetus and necessitate
discontinuing the drug.
2. B. It is of paramount importance to prevent the client
from hurting himself or herself or others.
3. B. After tonsillectomy, clear, cool liquids should be
given. Citrus, carbonated, and hot or cold liquids should
be avoided because they may irritate the throat. Red
liquids should be avoided because they give the
appearance of blood if the child vomits. Milk and milk
products including pudding are avoided because they
coat the throat, cause the child to clear the throat, and
increase the risk of bleeding.
4. A. Phenylephrine, with frequent and continued use, can
cause rebound congestion of mucous membranes.
5. B. The N 95 respirator is a high-particulate filtration
mask that meets the CDC performance criteria for a
tuberculosis respirator.
6. C. The most frequent cause of noncompliance to the
treatment of chronic, or open-angle glaucoma is the
miotic effects of pilocarpine. Pupillary constriction
impedes normal accommodation, making night driving
difficult and hazardous, reducing the client’s ability to
read for extended periods and making participation in
games with fast-moving objects impossible.
7. B. This stops the sucking of air through the tube and
prevents the entry of contaminants. In addition,
clamping near the chest wall provides for some stability
and may prevent the clamp from pulling on the chest
tube.
8. D. Because umbilical cord’s insertion site is born before
the fetal head, the cord may be compressed by the
after-coming head in a breech birth.
9. B. It is important to externalize the anger away from
self.
10. D. Development normally proceeds cephalocaudally; so
the first major developmental milestone that the infant
achieves is the ability to hold the head up within the
first 8-12 weeks of life. In hypothyroidism, the infant’s
muscle tone would be poor and the infant would not be
able to achieve this milestone.
11. D. Get a senior nurse who know s the policies, the
client, and the doctor. Generally speaking, a nurse
should not accept telephone orders. However, if it is
necessary to take one, follow the hospital’s policy
regarding telephone orders. Failure to followhospital
policy could be considered negligence. In this case, the
nurse was new and did not know the hospital’s policy
concerning telephone orders. The nurse was also
unfamiliar with the doctor and the client. Therefore the
nurse should not take the order unless a) no one else is
available and b) it is an emergency situation.
12. C. The nurse is obligated to inform the nurse manager
about changes in the condition of the client, which may
change the decision made by the nurse manager.
13. A. Perinatal risk factors for the development of Down
syndrome include advanced maternal age, especially
with the first pregnancy.
14. B. Assignments should be based on scope of practice
and expertise.
15. B. The child who is concurrently taking digoxin and
diuretics is at increased risk for digoxin toxicity due to
the loss of potassium. The child and parents should be
taught what foods are high in potassium, and the child
should be encouraged to eat a high-potassium diet. In
addition, the child’s serum potassium level should be
carefully monitored.
16. A. The responsible for an accurate informed consent is
the physician. An exception to this answer would be a
life-threatening emergency, but there are no data to
support another response.
17. D. Asking the client to cough and take a deep breath
will help determine if the chest tube is kinked or if the
lungs has reexpanded.
18. B. Every event that exposes a client to harm should be
recorded in an incident report, as well as reported to
the appropriate supervisors in order to resolve the
current problems and permit the institution to prevent
the problem from happening again.
19. D. One of the earliest signs of digoxin toxicity is
Bradycardia. For a toddler, any heart rate that falls
below the norm of about 100-120 bpm would indicate
Bradycardia and would necessitate holding the
medication and notifying the physician.
20. B. This option is least threatening.
21. D. In preparing the client for discharge that is receiving
prednisone, the nurse should caution the client to (a)
take oral preparations after meals; (b) remember that
routine checks of vital signs, weight, and lab studies are
critical; (c) NEVER STOP OR CHANGE THE AMOUNT OF
MEDICATION WITHOUT MEDICAL ADVICE; (d) store the
medication in a light-resistant container.
22. A. Progesterone also reduces smooth muscle motility in
the urinary tract and predisposes the pregnant woman
to urinary tract infections. Women should contact their
doctors if they exhibit signs of infection. Kegel exercise
will help strengthen the perineal muscles; limiting fluids
at bedtime reduces the possibility of being awakened
by the necessity of voiding.
23. B. This is the proper use of anger.
24. C. There are several models of case management, but
the commonality is comprehensive coordination of care
to better predict needs of high-risk clients, decrease
exacerbations and continually monitor progress
overtime.
25. A. Phenytoin should be infused or injected into larger
veins to avoid the discoloration know as purple glove
syndrome; infusing into a smaller vein is not
appropriate.
26. C. Serum radioimmunoassay (RIA) is accurate within
7days of conception. This test is specific for HCG, and
accuracy is not compromised by confusion with LH.
27. D. Surgery and anesthesia can increase mucus
production. Deep breathing and coughing are essential
to prevent atelectasis and pneumonia in the client’s
only remaining lung.
28. B. Newborns can get pneumonia (tachypnea, mild
hypoxia, cough, eosinophilia) and conjunctivitis from
Chlamydia.
29. D. The client may perceive this as avoidance, but it is
more important to redirect back to the client, especially
in light of the manipulative behavior of drug abusers
and adolescents.
30. C. It describes a democratic process in which all
members have input in the client’s care.
31. A. Contraction of the milk ducts and let-down reflex
occur under the stimulation of oxytocin released by the
posterior pituitary gland.
32. B. In case management, the nurse assumes total
responsibility for meeting the needs of the client during
the entire time on duty.
33. A. Smoke inhalation affects gas exchange.
34. C. Sperm deposited during intercourse may remain
viable for about 3 days. If ovulation occurs during this
period, conception may result.
35. B. This option shows acceptance (key concept) of this
age-typical sleep pattern (that of waking in the early
morning).
36. D. Taking the mother’s pulse while listening to the FHR
will differentiate between the maternal and fetal heart
rates and rule out fetal Bradycardia.
37. A. Antihistamines cause pupil dilation and should be
avoided with glaucoma.
38. A. This suggests that the level of consciousness is
decreasing.
39. D. An advance directive is a form of informed consent,
and only a competent adult or the holder of a durable
power of attorney has the right to consent or refuse
treatment. If the spouse does not hold the power of
attorney, the decisions of the holder, even if opposed
by the spouse, are enforced.
40. C. Gentle but firm guidance and nonverbal direction is
needed to intervene when a client with schizophrenic
symptoms is being disruptive.
41. C. Suctioning is only done for 10 seconds,
intermittently, as the catheter is being withdrawn.
42. D. The priority for this client is being able to establish
an airway.
43. A. Signs of placental separation include a change in the
shape of the uterus from ovoid to globular.
44. B. This could indicate intracranial bleeding. Alteplase is
a thrombolytic enzyme that lyses thrombi and emboli.
Bleeding is an adverse effect. Monitor clotting times
and signs of any gastrointestinal or internal bleeding.
45. D. Because flank incision in nephrectomy is directly
below the diaphragm, deep breathing is painful.
Additionally, there is a greater incisional pull each time
the person moves than there is with abdominal surgery.
Incisional pain following nephrectomy generally
requires analgesics administration every 3-4 hours for
24-48 hours after surgery. Therefore, turning, coughing
and deep-breathing exercises should be planned to
maximize the analgesic effects.
46. B. Under high estrogen levels, during the period
surrounding ovulation, the cervical mucus becomes
thin, clear, and elastic (spinnbarkeit), facilitating sperm
passage.
47. D. After surgery for a ruptured appendix, the client
should be placed in a semi-Fowler’s position to
promote drainage and to prevent possible
complications.
48. C. Directing and evaluation of staff is a major
responsibility of a nursing manager.
49. A. The recommended procedure for administering
eyedrops to any client calls for the drops to be placed in
the middle of the lower conjunctival sac.
50. B. Thirst and restlessness indicate hypovolemia and
hypoxemia. Internal bleeding is difficult to recognized
and evaluate because it is not apparent.
51. C. Erythema toxicum is the normal, nonpathological
macular newborn rash.
52. D. The family needs to understand what brain death is
before talking about organ donation. They need time to
accept the death of their family member. An
environment conducive to discussing an emotional
issue is needed.
53. A. Bending from the waist in pregnancy tends to make
backache worse.
54. B. Support and limit setting decrease anxiety and
provide external control.
55. C. The stoma drainage bag is applied in the operating
room. Drainage from the ileostomy contains secretions
that are rich in digestive enzymes and highly irritating
to the skin. Protection of the skin from the effects of
these enzymes is begun at once. Skin exposed to these
enzymes even for a short time becomes reddened,
painful and excoriated.
56. B. It is the most accurate statement of physiological
facts for a 28-day menstrual cycle: ovulation at day 14,
egg life span 24 hours, sperm life span of 72 hours.
Fertilization could occur from sperm deposited before
ovulation.
57. C. An advocate role encourage freedom of choice,
includes speaking out for the client, and supports the
client’s best interests.
58. A. Abstinence will eliminate any unnecessary pain
during intercourse and will reduce the possibility of
transmitting infection to one’s sexual partner.
59. B. Anxiety is generated by group therapy at 9:00 AM.
The ritualistic behavioral defense of hand washing
decreases anxiety by avoiding group therapy.
60. D. Denial is a very strong defense mechanism used to
allay the emotional effects of discovering a potential
threat. Although denial has been found to be an
effective mechanism for survival in some instances,
such as during natural disasters, it may in greater
pathology in a woman with potential breast carcinoma.
61. B. The registered nurse cannot delegate the
responsibility for assessment and evaluation of clients.
The status of the client in restraint requires further
assessment to determine if there are additional causes
for the behavior.
62. C. The client with chest pain may be having a
myocardial infarction, and immediate assessment and
intervention is a priority.
63. B. Is correct because semen analysis requires that a
freshly masturbated specimen be obtained after a rest
(abstinence) period of 48-72 hours.
64. C. Betamethasone, a form of cortisone, acts on the fetal
lungs to produce surfactant.
65. A. Secretions may have pooled above the tracheostomy
cuff. If these are not suctioned before deflation, the
secretions may be aspirated.
66. C. Proper handling of sputum is essential to allay
droplet transference of bacilli in the air. Clients need to
be taught to cover their nose and mouth with tissues
when sneezing or coughing. Chemotherapy generally
renders the client noninfectious within days to a few
weeks, usually before cultures for tubercle bacilli are
negative. Until chemical isolation is established, many
institutions require the client to wear a mask when
visitors are in the room or when the nurse is in
attendance. Client should be in a well-ventilated room,
without air recirculation, to prevent air contamination.
67. A. It is best to establish baseline information first.
68. B. Listening is probably the most effective response of
the four choices.
69. A. Urine flow is continuous. The pouch has an outlet
valve for easy drainage every 3-4 hours. (the pouch
should be changed every 3-5 days, or sooner if the
adhesive is loose).
70. C. A high fever accompanied by a body rash could
indicate that the child has a communicable disease and
would have exposed other students to the infection.
The school nurse would want to investigate this
telephone call immediately so that plans could be
instituted to control the spread of such infection.
71. A. Severe abdominal pain may indicate complications of
pregnancy such as abortion, ectopic pregnancy, or
abruption placenta; fluid discharge from the vagina may
indicate premature rupture of the membrane.
72. D. Gentle aspiration of mucus helps maintain a patent
airway, required for effective gas exchange.
73. A. Somatoform disorders provide a way of coping with
conflicts.
74. C. Immunization should never be mixed together in a
syringe, thus necessitating three separate injections in
three sites. Note: some manufacturers make a
premixed combination of immunization that is safe and
effective.
75. A. Clients with radioactive implants should be
positioned flat in bed to prevent dislodgement of the
vaginal packing. The client may roll to the side for meals
but the upper body should not be raised more than 20
degrees.
76. A. Syrup of ipecac is not administered when the
ingested substances is corrosive in nature. Toilet bowl
cleaners, as a collective whole, are highly corrosive
substances. If the ingested substance “burned” the
esophagus going down, it will “burn” the esophagus
coming back up when the child begins to vomit after
administration of syrup of ipecac.
77. B. Inability to open eyelids on operative side is seen
with cranial nerve III damage.
78. A. Assessment of physical injuries (like bruises,
lacerations, bleeding and fractures) is the first priority.
79. C. The nurse who is supervising others has a legal
obligation to determine that they are competent to
perform the assignment, as well as legal obligation to
provide adequate supervision.
80. D. Increasing hydrostatic pressure in the urinary tract
will facilitate passage of the calculi.
81. A. Infertility is not diagnosed until atleast 12months of
unprotected intercourse has failed to produce a
pregnancy. Older couples will experience a longer time
to get pregnant.
82. B. Determining how well the kidneys filter wastes states
the purpose of a Creatinine clearance test.
83. A. Acknowledging a feeling tone is the most therapeutic
response and provides a broad opening for the client to
elaborate feelings.
84. C. The behavior should be stopped. The first is to
remind the staff that confidentiality maybe violated.
85. C. With a right-sided cerebrovascular accident the client
would have left-sided hemiplegia or weakness. The
client’s good side should be closest to the bed to
facilitate the transfer.
86. D. Legos are small plastic building blocks that could
easily slip under the child’s cast and lead to a break in
skin integrity and even infection. Pencils,
backscratchers, and marbles are some other narrow or
small items that could easily slip under the child’s cast
and lead to a break in skin integrity and infection.
87. D. Oxytocin (Pitocin) is used to maintain uterine tone.
88. B. The submission of reports about incidents that
expose clients to harm does not remove the obligation
to report ongoing behavior as long as the risk to the
client continues.
89. C. The recommended dosage of tetracycline is 25-
50mg/kg/day. If the child weighs 20kg and the
maximum dose is 50mg/kg, this would indicate a total
daily dose of 1000mg of tetracycline. In this case, the
child is being given this medication four times a day.
Therefore the maximum single dose that can be given is
250mg (1000 mg of tetracycline divided by four doses.)
90. C. An abnormality in the uterine muscle could reduce
the effectiveness of uterine contractions and lengthen
the duration of subsequent labors.
91. A. Personality disorders stem from a weak superego,
implying a lack of adequate controls.
92. C. The basal body temperature is the lowest body
temperature of a healthy person that is taken
immediately after waking and before getting out of bed.
The BBT usually varies from 36.2 ºC to 36.3ºC during
menses and for about 5-7 days afterward. About the
time of ovulation, a slight drop in temperature may be
seen, after ovulation in concert with the increasing
progesterone levels of the early luteal phase, the BBT
rises 0.2-0.4 ºC. This elevation remains until 2-3 days
before menstruation, or if pregnancy has occurred.
93. A. This choice implies concern for client care and self-
improvement.
94. C. The first trimester is the period of organogenesis,
that is, cell differentiation into the various organs,
tissues, and structures.
95. C. This response does not contradict the client’s
perception, is honest, and shows empathy.
96. D. Tension on round ligament occurs because of the
erect human posture and pressure exerted by the
growing fetus.
97. D. The Good Samaritan Law does not impose a duty to
stop at the scene of an emergency outside of the scope
of employment, therefore nurses who do not stop are
not liable for suit.
98. C. Although reducing environment stimuli and activity is
necessary for a woman with mild preeclampsia, she will
most probably have bathroom privileges.
99. B. A normal respiratory rate for a newborn is 30-40
breaths per minute.
100. D. The behavior described is likely to be symptoms of
delirium tremens, or alcohol withdrawal (often
unsuspected on a surgical unit.)