Maternal & Child Health Nursing NCLEX part 2

 Maternal & Child Health Nursing NCLEX part 2

 

 

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1. For the client who is using oral contraceptives, the nurse informs the client about the need to take the pill at the same time each day to accomplish which of the following?

 

A. Decrease the incidence of nausea

B. Maintain hormonal levels

C. Reduce side effects

D. Prevent drug interactions

 

2. When teaching a client about contraception. Which of the following would the nurse include as the most effective method for preventing sexually transmitted infections?

 

A. Spermicides

B. Diaphragm

C. Condoms

D. Vasectomy

 

3. When preparing a woman who is 2 days postpartum for discharge, recommendations for which of the following contraceptive methods would be avoided?

 

A. Diaphragm

B. Female condom

C. Oral contraceptives

D. Rhythm method

 

4. For which of the following clients would the nurse expect that an intrauterine device would not be recommended?

 

A. Woman over age 35

B. Nulliparous woman

C. Promiscuous young adult

D. Postpartum client

 

5. A client in her third trimester tells the nurse, “I’m constipated all the time!” Which of the following should the nurse recommend?

 

A. Daily enemas

B. Laxatives

C. Increased fiber intake

D. Decreased fluid intake

 

6. Which of the following would the nurse use as the basis for the teaching plan when caring for a pregnant teenager concerned about gaining too much weight during pregnancy?

 

A. 10 pounds per trimester

B. 1 pound per week for 40 weeks

C. ½ pound per week for 40 weeks

D. A total gain of 25 to 30 pounds

 

7. The client tells the nurse that her last menstrual period started on January 14 and ended on January 20. Using Nagele’s rule, the nurse determines her EDD to be which of the following?

 

A. September 27

B. October 21

C. November 7

D. December 27

 

8. When taking an obstetrical history on a pregnant client who states, “I had a son born at 38 weeks gestation, a daughter born at 30 weeks gestation and I lost a baby at about 8 weeks,” the nurse should record her obstetrical history as which of the following?

 

A. G2 T2 P0 A0 L2

B. G3 T1 P1 A0 L2

C. G3 T2 P0 A0 L2

D. G4 T1 P1 A1 L2

 

9. When preparing to listen to the fetal heart rate at 12 weeks’ gestation, the nurse would use which of the following?

 

A. Stethoscope placed midline at the umbilicus

B. Doppler placed midline at the suprapubic region

C. Fetoscope placed midway between the umbilicus and the xiphoid process

D. External electronic fetal monitor placed at the umbilicus

 

10. When developing a plan of care for a client newly diagnosed with gestational diabetes, which of the following instructions would be the priority?

 

A. Dietary intake

B. Medication

C. Exercise

D. Glucose monitoring

 

11. A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of the following would be the priority when assessing the client?

 

A. Glucosuria

B. Depression

C. Hand/face edema

D. Dietary intake

 

12. A client 12 weeks’ pregnant come to the emergency department with abdominal cramping and moderate vaginal bleeding. Speculum examination reveals 2 to 3 cm cervical dilation.The nurse would document these findings as which of the following?

 

A. Threatened abortion

B. Imminent abortion

C. Complete abortion

D. Missed abortion

 

13. Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy?

 

A. Risk for infection

B. Pain

C. Knowledge Deficit

D. Anticipatory Grieving

 

14. Before assessing the postpartum client’s uterus for firmness and position in relation to the umbilicus and midline, which of the following should the nurse do first?

 

A. Assess the vital signs

B. Administer analgesia

C. Ambulate her in the hall

D. Assist her to urinate

 

15. Which of the following should the nurse do when a primipara who is lactating tells the nurse that she has sore nipples?

 

A. Tell her to breastfeed more frequently

B. Administer a narcotic before breastfeeding

C. Encourage her to wear a nursing brassiere

D. Use soap and water to clean the nipples

 

16. The nurse assesses the vital signs of a client, 4 hours’ postpartum that are as follows: BP 90/60; temperature 100.4ºF; pulse 100 weak, thready; R 20 per minute. Which of the following should the nurse do first?

 

A. Report the temperature to the physician

B. Recheck the blood pressure with another cuff

C. Assess the uterus for firmness and position

D. Determine the amount of lochia

 

17. The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which of the following assessments would warrant notification of the physician?

 

A. A dark red discharge on a 2-day postpartum client

B. A pink to brownish discharge on a client who is 5 days postpartum

C. Almost colorless to creamy discharge on a client 2 weeks after delivery

D. A bright red discharge 5 days after delivery

 

18. A postpartum client has a temperature of 101.4ºF, with a uterus that is tender when palpated, remains unusually large, and not descending as normally expected. Which of the following should the nurse assess next?

 

A. Lochia

B. Breasts

C. Incision

D. Urine

 

19. Which of the following is the priority focus of nursing practice with the current early postpartum discharge?

 

A. Promoting comfort and restoration of health

B. Exploring the emotional status of the family

C. Facilitating safe and effective self and newborn care

D. Teaching about the importance of family planning

 

20. Which of the following actions would be least effective in maintaining a neutral thermal environment for the newborn?

 

A. Placing infant under radiant warmer after bathing

B. Covering the scale with a warmed blanket prior to weighing

C. Placing crib close to nursery window for family viewing

D. Covering the infant’s head with a knit stockinette

 

21. A newborn who has an asymmetrical Moro reflex response should be further assessed for which of the following?

 

A. Talipes equinovarus

B. Fractured clavicle

C. Congenital hypothyroidism

D. Increased intracranial pressure

 

22. During the first 4 hours after a male circumcision, assessing for which of the following is the priority?

 

A. Infection

B. Hemorrhage

C. Discomfort

D. Dehydration

 

23. The mother asks the nurse. “What’s wrong with my son’s breasts? Why are they so enlarged?” Whish of the following would be the best response by the nurse?

 

A. “The breast tissue is inflamed from the trauma experienced with birth.”

B. “A decrease in material hormones present before birth causes enlargement,”

C. “You should discuss this with your doctor. It could be a malignancy.”

D. “The tissue has hypertrophied while the baby was in the uterus.”

 

24. Immediately after birth the nurse notes the following on a male newborn: respirations 78; apical heart rate 160 BPM, nostril flaring; mild intercostal retractions; and grunting at the end of expiration. Which of the following should the nurse do?

 

A. Call the assessment data to the physician’s attention

B. Start oxygen per nasal cannula at 2 L/min.

C. Suction the infant’s mouth and nares

D. Recognize this as normal first period of reactivity

 

25. The nurse hears a mother telling a friend on the telephone about umbilical cord care. Which of the following statements by the mother indicates effective teaching?

 

A. “Daily soap and water cleansing is best.”

B. ‘Alcohol helps it dry and kills germs.”

C. “An antibiotic ointment applied daily prevents infection.”

D. “He can have a tub bath each day.”

 

26. A newborn weighing 3000 grams and feeding every 4 hours needs 120 calories/kg of body weight every 24 hours for proper growth and development. How many ounces of 20 cals/oz formula should this newborn receive at each feeding to meet nutritional needs?

 

A. 2 ounces

B. 3 ounces

C. 4 ounces

D. 6 ounces

 

27. The post-term neonate with meconium-stained amniotic fluid needs care designed to especially monitor for which of the following?

 

A. Respiratory problems

B. Gastrointestinal problems

C. Integumentary problems

D. Elimination problems

 

28. When measuring a client’s fundal height, which of the following techniques denotes the correct method of measurement used by the nurse?

 

A. From the xiphoid process to the umbilicus

B. From the symphysis pubis to the xiphoid process

C. From the symphysis pubis to the fundus

D. From the fundus to the umbilicus

 

29. A client with severe preeclampsia is admitted with of BP 160/110, proteinuria, and severe pitting edema. Which of the following would be most important to include in the client’s plan of care?

 

A. Daily weights

B. Seizure precautions

C. Right lateral positioning

D. Stress reduction

 

30. A postpartum primipara asks the nurse, “When can we have sexual intercourse again?” Which of the following would be the nurse’s best response?

 

A. “Anytime you both want to.”

B. “As soon as choose a contraceptive method.”

C. “When the discharge has stopped, and the incision is healed.”

D. “After your 6 weeks examination.”

 

31. When preparing to administer the vitamin K injection to a neonate, the nurse would select which of the following sites as appropriate for the injection?

 

A. Deltoid muscle

B. Anterior femoris muscle

C. Vastus lateralis muscle

D. Gluteus maximus muscle

 

32. When performing a pelvic examination, the nurse observes a red swollen area on the right side of the vaginal orifice. The nurse would document this as enlargement of which of the following?

 

A. Clitoris

B. Parotid gland

C. Skene’s gland

D. Bartholin’s gland

 

33. To differentiate as a female, the hormonal stimulation of the embryo that must occur involves which of the following?

 

A. Increase in maternal estrogen secretion

B. Decrease in maternal androgen secretion

C. Secretion of androgen by the fetal gonad

D. Secretion of estrogen by the fetal gonad

 

34. A client at 8 weeks’ gestation calls complaining of slight nausea in the morning hours. Which of the following client interventions should the nurse question?

 

A. Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water

B. Eating a few low-sodium crackers before getting out of bed

C. Avoiding the intake of liquids in the morning hours

D. Eating six small meals a day instead of three large meals

 

35. The nurse documents positive ballottement in the client’s prenatal record. The nurse understands that this indicates which of the following?

 

A. Palpable contractions on the abdomen

B. Passive movement of the unengaged fetus

C. Fetal kicking felt by the client

D. Enlargement and softening of the uterus

 

36. During a pelvic exam, the nurse notes a purple-blue tinge of the cervix. The nurse documents this as which of the following?

 

A. Braxton-Hicks sign

B. Chadwick’s sign

C. Goodell’s sign

D. McDonald’s sign

 

37. During a prenatal class, the nurse explains the rationale for breathing techniques during preparation for labor based on the understanding that breathing techniques are most important in achieving which of the following?

 

A. Eliminate pain and give the expectant parents something to do

B. Reduce the risk of fetal distress by increasing uteroplacental perfusion

C. Facilitate relaxation, possibly reducing the perception of pain

D. Eliminate pain so that less analgesia and anesthesia are needed

 

38. After 4 hours of active labor, the nurse notes that the contractions of a primigravida client are not strong enough to dilate the cervix. Which of the following would the nurse anticipate doing?

 

A. Obtaining an order to begin IV oxytocin infusion

B. Administering a light sedative to allow the patient to rest for several hours

C. Preparing for a cesarean section for failure to progress

D. Increasing the encouragement to the patient when pushing begins

 

39. A multigravida at 38 weeks’ gestation is admitted with painless, bright red bleeding and mild contractions every 7 to 10 minutes. Which of the following assessments should be avoided?

 

A. Maternal vital sign

B. Fetal heart rate

C. Contraction monitoring

D. Cervical dilation

 

40. Which of the following would be the nurse’s most appropriate response to a client who asks why she must have a cesarean delivery if she has a complete placenta previa?

 

A. “You will have to ask your physician when he returns.”

B. “You need a cesarean to prevent hemorrhage.”

C. “The placenta is covering most of your cervix.”

D. “The placenta is covering the opening of the uterus and blocking your baby.”

 

41. The nurse understands that the fetal head is in which of the following positions with a face presentation?

 

A. Completely flexed

B. Completely extended

C. Partially extended

D. Partially flexed

 

42. With a fetus in the left anterior breech presentation, the nurse would expect the fetal heart rate would be most audible in which of the following areas?

 

A. Above the maternal umbilicus and to the right of midline

B. In the lower-left maternal abdominal quadrant

C. In the lower-right maternal abdominal quadrant

D. Above the maternal umbilicus and to the left of midline

 

43. The amniotic fluid of a client has a greenish tint. The nurse interprets this to be the result of which of the following?

 

A. Lanugo

B. Hydramnios

C. Meconium

D. Vernix

 

44. A patient is in labor and has just been told she has a breech presentation. The nurse should be particularly alert for which of the following?

 

A. Quickening

B. Ophthalmia neonatorum

C. Pica

D. Prolapsed umbilical cord

 

45. When describing dizygotic twins to a couple, on which of the following would the nurse base the explanation?

 

A. Two ova fertilized by separate sperm

B. Sharing of a common placenta

C. Each ova with the same genotype

D. Sharing of a common chorion

 

46. Which of the following refers to the single cell that reproduces itself after conception?

 

A. Chromosome

B. Blastocyst

C. Zygote

D. Trophoblast

 

47. In the late 1950s, consumers and health care professionals began challenging the routine use of analgesics and anesthetics during childbirth. Which of the following was an outgrowth of this concept?

 

A. Labor, delivery, recovery, postpartum (LDRP)

B. Nurse-midwifery

C. Clinical nurse specialist

D. Prepared childbirth

 

48. A client has a mid pelvic contracture from a previous pelvic injury due to a motor vehicle accident as a teenager. The nurse is aware that this could prevent a fetus from passing through or around which structure during childbirth?

 

A. Symphysis pubis

B. Sacral promontory

C. Ischial spines

D. Pubic arch

 

49. When teaching a group of adolescents about variations in the length of the menstrual cycle, the nurse understands that the underlying mechanism is due to variations in which of the following phases?

 

A. Menstrual phase

B. Proliferative phase

C. Secretory phase

D. Ischemic phase

 

50. When teaching a group of adolescents about male hormone production, which of the following would the nurse include as being produced by the Leydig cells?

 

A. Follicle-stimulating hormone

B. Testosterone

C. Luteinizing hormone

D. Gonadotropin-releasing hormone

 

51. While performing a physical assessment of a 12 month-old, the nurse notes that the infant’s anterior fontanel is still slightly open. Which of the following is the nurse’s most appropriate action?

A. Notify the physician immediately because there is a problem.

B. Perform an intensive neurological examination.

C. Perform an intensive developmental examination.

D. Do nothing because this is a normal finding for the age.

 

52. When teaching a mother about introducing solid foods to her child, which of the following indicates the earliest age at which this should be done?

 

A. 1 month

B. 2 months

C. 3 months

D. 4 months

 

53. The infant of a substance-abusing mother is at risk for developing a sense of which of the following?

 

A. Mistrust

B. Shame

C. Guilt

D. Inferiority

 

54. Which of the following toys should the nurse recommend for a 5-month-old?

 

A. A big red balloon

B. A teddy bear with button eyes

C. A push-pull wooden truck

D. A colorful busy box

 

55. The mother of a 2-month-old is concerned that she may be spoiling her baby by picking her up when she cries. Which of the following would be the nurse’s best response?

 

A. “ Let her cry for a while before picking her up, so you don’t spoil her.”

B. “Babies need to be held and cuddled; you won’t spoil her this way.”

C. “Crying at this age means the baby is hungry; give her a bottle.”

D. “If you leave her alone she will learn how to cry herself to sleep.”

 

56. When assessing an 18-month-old, the nurse notes a characteristic protruding abdomen. Which of the following would explain the rationale for this finding?

 

A. Increased food intake owing to age

B. Underdeveloped abdominal muscles

C. Bowlegged posture

D. Linear growth curve

 

57. If parents keep a toddler dependent in areas where he is capable of using skills, the toddler will develop a sense of which of the following?

 

A. Mistrust

B. Shame

C. Guilt

D. Inferiority

 

58. Which of the following is an appropriate toy for an 18-month-old?

 

A. Multiple-piece puzzle

B. Miniature cars

C. Finger paints

D. Comic book

 

59. When teaching parents about the child’s readiness for toilet training, which of the following signs should the nurse instruct them to watch for in the toddler?

 

A. Demonstrates dryness for 4 hours

B. Demonstrates ability to sit and walk

C. Has a new sibling for stimulation

D. Verbalizes desire to go to the bathroom

 

60. When teaching parents about typical toddler eating patterns, which of the following should be included?

 

A .Food “jags.”

B. Preference to eat alone

C. Consistent table manners

D. Increase in appetite

 

61. Which of the following suggestions should the nurse offer the parents of a 4-year-old boy who resists going to bed at night?

 

A. “Allow him to fall asleep in your room, then move him to his own bed.”

B. “Tell him that you will lock him in his room if he gets out of bed one more time.”

C. “Encourage active play at bedtime to tire him out so he will fall asleep faster.”

D. “Read him a story and allow him to play quietly in his bed until he falls asleep.”

 

62. When providing therapeutic play, which of the following toys would best promote imaginative play in a 4-year-old?

 

A. Large blocks

B. Dress-up clothes

C. Wooden puzzle

D. Big wheels

 

63. Which of the following activities, when voiced by the parents following a teaching session about the characteristics of school-age cognitive development would indicate the need for additional teaching?

 

A. Collecting baseball cards and marbles

B. Ordering dolls according to size

C. Considering simple problem-solving options

D. Developing plans for the future

 

64. A hospitalized school ager states: “I’m not afraid of this place, I’m not afraid of anything.” This statement is most likely an example of which of the following?

 

A. Regression

B. Repression

C. Reaction formation

D. Rationalization

 

65. After teaching a group of parents about accident prevention for school agers, which of the following statements by the group would indicate the need for more teaching?

 

A. “Schoolagers are more active and adventurous than are younger children.”

B. “Schoolagers are more susceptible to home hazards than are younger children.”

C. “Schoolagers are unable to understand potential dangers around them.”

D. “Schoolargers are less subject to parental control than are younger children.”

 

66. Which of the following skills is the most significant one learned during the school age period?

 

A. Collecting

B. Ordering

C. Reading

D. Sorting

 

67. A child age 7 was unable to receive the measles, mumps, and rubella (MMR) vaccine at the recommended scheduled time. When would the nurse expect to administer MMR vaccine?

 

A. In a month from now

B. In a year from now

C. At age 10

D. At age 13

 

68. The adolescent’s inability to develop a sense of who he is and what he can become results in the sense of which of the following?

 

A. Shame

B. Guilt

C. Inferiority

D. Role diffusion

 

69. Which of the following would be most appropriate for a nurse to use when describing menarche to a 13-year-old?

 

A. A female’s first menstruation or menstrual “periods.”

B. The first year of menstruation or “period.”

C. The entire menstrual cycle or from one “period” to another

D. The onset of uterine maturation or peak growth

 

70. A 14-year-old boy has acne and according to his parents, dominates the bathroom by using the mirror all the time.

Which of the following remarks by the nurse would be least helpful in talking to the boy and his parents?

 

A. “This is probably the only concern he has about his body. So don’t worry about it or the time he spends on it.”

B. “Teenagers are anxious about how their peers perceive them. So they spend a lot of time grooming.”

C. “A teen may develop a poor self-image when experiencing acne. Do you feel this way sometimes?”

D. “You appear to be keeping your face well washed. Would you feel comfortable discussing your cleansing method?”

 

71. Which of the following should the nurse suspect when noting that a 3-year-old is engaging in explicit sexual behavior during doll play?

 

A. The child is exhibiting normal pre-school curiosity

B. The child is acting out personal experiences

C. The child does not know how to play with dolls

D. The child is probably developmentally delayed.

 

72. Which of the following statements by the parents of a child with school phobia would indicate the need for further teaching?

 

A. “We’ll keep him at home until phobia subsides.”

B. “We’ll work with his teachers and counselors at school.”

C. “We’ll try to encourage him to talk about his problem.”

D. “We’ll discuss possible solutions with him and his counselor.”

 

73. When developing a teaching plan for a group of high school students about teenage pregnancy, the nurse would keep in mind which of the following?

 

A. The incidence of teenage pregnancies is increasing.

B. Most teenage pregnancies are planned.

C. Denial of the pregnancy is common early on.

D. The risk for complications during pregnancy is rare.

 

74. When assessing a child with a cleft palate, the nurse is aware that the child is at risk for more frequent episodes of otitis media due to which of the following?

 

A. Lowered resistance from malnutrition

B. Ineffective functioning of the Eustachian tubes

C. Plugging of the Eustachian tubes with food particles

D. Associated congenital defects of the middle ear.

 

75. While performing a neurodevelopmental assessment on a 3-month-old infant, which of the following characteristics would be expected?

 

A. A strong Moro reflex

B. A strong parachute reflex

C. Rolling from front to back

D. Lifting of head and chest when prone

 

76. By the end of which of the following would the nurse most commonly expect a child’s birth weight to triple?

 

A. 4 months

B. 7 months

C. 9 months

D. 12 months

 

77. Which of the following best describes parallel play between two toddlers?

 

A. Sharing crayons to color separate pictures

B. Playing a board game with a nurse

C. Sitting near each other while playing with separate dolls

D. Sharing their dolls with two different nurses

 

78. Which of the following would the nurse identify as the initial priority for a child with acute lymphocytic leukemia?

 

A. Instituting infection control precautions

B. Encouraging adequate intake of iron-rich foods

C. Assisting with coping with chronic illness

D. Administering medications via IM injections

 

79. Which of the following information, when voiced by the mother, would indicate to the nurse that she understands home care instructions following the administration of diphtheria, tetanus, and pertussis injection?

 

A. Measures to reduce fever

B. Need for dietary restrictions

C. Reasons for subsequent rash

D. Measures to control subsequent diarrhea

 

80. Which of the following actions by a community health nurse is most appropriate when noting multiple bruises and burns on the posterior trunk of an 18-month-old child during a home visit?

 

A. Report the child’s condition to Protective Services immediately.

B. Schedule a follow-up visit to check for more bruises.

C. Notify the child’s physician immediately.

D. Don nothing because this is a normal finding in a toddler.

 

81. Which of the following is being used when the mother of a hospitalized child calls the student nurse and states, “You idiot, you have no idea how to care for my sick child”?

 

A. Displacement

B. Projection

C. Repression

D. Psychosis

 

82. Which of the following should the nurse expect to note as a frequent complication for a child with congenital heart disease?

 

A. Susceptibility to respiratory infection

B. Bleeding tendencies

C. Frequent vomiting and diarrhea

D. Seizure disorder

 

83. Which of the following would the nurse do first for a 3-year-old boy who arrives in the emergency room with a temperature of 105 degrees, inspiratory stridor, and restlessness, who is leaning forward and drooling?

 

A. Auscultate his lungs and place him in a mist tent.

B. Have him lie down and rest after encouraging fluids.

C. Examine his throat and perform a throat culture

D. Notify the physician immediately and prepare for intubation.

 

84. Which of the following would the nurse need to keep in mind as a predisposing factor when formulating a teaching plan for a child with a urinary tract infection?

 

A. A shorter urethra in females

B. Frequent emptying of the bladder

C. Increased fluid intake

D. Ingestion of acidic juices

 

85. Which of the following should the nurse do first for a 15-year-old boy with a full leg cast who is screaming in unrelenting pain and exhibiting right foot pallor signifying compartment syndrome?

 

A. Medicate him with acetaminophen.

B. Notify the physician immediately

C. Release the traction

D. Monitor him every 5 minutes

 

86. At which of the following ages would the nurse expect to administer the varicella zoster vaccine to a child?

 

A. At birth

B. 2 months

C. 6 months

D. 12 months

 

87. When discussing normal infant growth and development with parents, which of the following toys would the nurse suggest as most appropriate for an 8-month-old?

 

A. Push-pull toys

B. Rattle

C. Large blocks

D. Mobile

 

88. Which of the following aspects of psychosocial development is necessary for the nurse to keep in mind when providing care for the preschool child?

 

A. The child can use complex reasoning to think out situations.

B. Fear of body mutilation is a common preschool fear

C. The child engages in competitive types of play

D. Immediate gratification is necessary to develop initiative.

 

89. Which of the following is characteristic of a preschooler with mid-mental retardation?

 

A. Slow to feed self

B. Lack of speech

C. Marked motor delays

D. Gait disability

 

90. Which of the following assessment findings would lead the nurse to suspect Down syndrome in an infant?

 

A. Small tongue

B. Transverse palmar crease

C. Large nose

D. Restricted joint movement

 

91. While assessing a newborn with cleft lip, the nurse would be alert that which of the following will most likely be compromised?

 

A. Sucking ability

B. Respiratory status

C. Locomotion

D. GI function

 

92. When providing postoperative care for the child with a cleft palate, the nurse should position the child in which of the following positions?

 

A. Supine

B. Prone

C. In an infant seat

D. On the side

 

93. While assessing a child with pyloric stenosis, the nurse is likely to note which of the following?

 

A. Regurgitation

B. Steatorrhea

C. Projectile vomiting

D. “Currant jelly” stools

 

94. Which of the following nursing diagnoses would be inappropriate for the infant with gastroesophageal reflux (GER)?

 

A. Fluid volume deficit

B. Risk for aspiration

C. Altered nutrition: less than body requirements

D. Altered oral mucous membranes

 

95. Which of the following parameters would the nurse monitor to evaluate the effectiveness of thickened feedings for an infant with gastroesophageal reflux disease (GERD)?

 

A. Vomiting

B. Stools

C. Uterine

D. Weight

 

96. Discharge teaching for a child with celiac disease would include instructions about avoiding which of the following?

 

A. Rice

B. Milk

C. Wheat

D. Chicken

 

97. Which of the following would the nurse expect to assess in a child with celiac disease having a celiac crisis secondary to an upper respiratory infection?

 

A. Respiratory distress

B. Lethargy

C. Watery diarrhea

D. Weight gain

 

98. Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea?

 

A. Notify the physician immediately

B. Administer antidiarrheal medications

C. Monitor child ever 30 minutes

D. Nothing, this is characteristic of Hirschsprung disease

 

99. A newborn’s failure to pass meconium within the first 24 hours after birth may indicate which of the following?

 

A. Hirschsprung disease

B. Celiac disease

C. Intussusception

D. Abdominal wall defect

 

100. When assessing a child for possible intussusception, which of the following would be least likely to provide valuable information?

 

A. Stool inspection

B. Pain pattern

C. Family history

D. Abdominal palpation

 

Answers and Rationale

1. Answer: B. Maintain hormonal levels

 

Regular timely ingestion of oral contraceptives is necessary to maintain hormonal levels of the drugs to suppress the action of the hypothalamus and anterior pituitary leading to inappropriate secretion of FSH and LH. Therefore, follicles do not mature, ovulation is inhibited, and pregnancy is prevented.

 

Option A: The estrogen content of the oral site contraceptive may cause nausea, regardless of when the pill is taken.

Options C and D: Side effects and drug interactions may occur with oral contraceptives regardless of the time the pill is taken.

 

2. Answer: C. Condoms

 

Condoms, when used correctly and consistently, are the most effective contraceptive method or barrier against bacterial and viral sexually transmitted infections.

 

Option A: Although spermicides kill sperm, they do not provide reliable protection against the spread of sexually transmitted infections, especially intracellular organisms such as HIV.

Option B: Insertion and removal of the diaphragm along with the use of the spermicides may cause vaginal irritations, which could place the client at risk for infection transmission.

Option D: Male sterilization eliminates spermatozoa from the ejaculate, but it does not eliminate bacterial and/or viral microorganisms that can cause sexually transmitted infections.

 

3 Answer: A. Diaphragm

 

The diaphragm must be fitted individually to ensure effectiveness. Because of the changes to the reproductive structures during pregnancy and following delivery, the diaphragm must be refitted, usually at the 6 weeks’ examination following childbirth or after a weight loss of 15 lbs or more. In addition, for maximum effectiveness, the spermicidal jelly should be placed in the dome and around the rim. However, the spermicidal jelly should not be inserted into the vagina until involution is completed at approximately 6 weeks.

 

Option B: Use of a female condom protects the reproductive system from the introduction of semen or spermicides into the vagina and may be used after childbirth.

Option C: Oral contraceptives may be started within the first postpartum week to ensure suppression of ovulation.

Option D: For the couple who has determined the female’s fertile period, using the rhythm method, avoidance of intercourse during this period, is safe and effective.

 

4. Answer: C. Promiscuous young adult

 

An IUD may increase the risk of pelvic inflammatory disease, especially in women with more than one sexual partner, because of the increased risk of sexually transmitted infections. An IUD should not be used if the woman has an active or chronic pelvic infection, postpartum infection, endometrial hyperplasia or carcinoma, or uterine abnormalities.

 

Option A: Age is not a factor in determining the risks associated with IUD use. Most IUD users are over the age of 30.

Option B: Although there is a slightly higher risk for infertility in women who have never been pregnant, the IUD is an acceptable option as long as the risk-benefit ratio is discussed.

Option D: IUDs may be inserted immediately after delivery, but this is not recommended because of the increased risk and rate of expulsion at this time.

 

5. Answer: C. Increased fiber intake

 

During the third trimester, the enlarging uterus places pressure on the intestines. This coupled with the effect of hormones on smooth muscle relaxation causes decreased intestinal motility (peristalsis). Increasing fiber in the diet will help fecal matter pass more quickly through the intestinal tract, thus decreasing the amount of water that is absorbed. As a result, the stool is softer and easier to pass.

 

Option A: Enemas could precipitate preterm labor and electrolyte loss and should be avoided.

Option B: Laxatives may cause preterm labor by stimulating peristalsis and may interfere with the absorption of nutrients. Use for more than 1 week can also lead to laxative dependency.

Option D: Liquid in the diet helps provide a semisolid, soft consistency to the stool. Eight to ten glasses of fluid per day are essential to maintain hydration and promote stool evacuation.

 

6. Answer: D. A total gain of 25 to 30 pounds

 

To ensure adequate fetal growth and development during the 40 weeks of a pregnancy, a total weight gain 25 to 30 pounds is recommended:

 

Option A: 1.5 pounds in the first 10 weeks; 9 pounds by 30 weeks; and 27.5 pounds by 40 weeks. The pregnant woman should gain less weight in the first and second trimester than in the third.

Option B: During the first trimester, the client should only gain 1.5 pounds in the first 10 weeks, not 1 pound per week.

Option C: A weight gain of ½ pound per week would be 20 pounds for the total pregnancy, less than the recommended amount.

 

7. Answer: B. October 21

 

To calculate the EDD by Nagele’s rule, add 7 days to the first day of the last menstrual period and count back 3 months, changing the year appropriately.

 

Option A: To obtain a date of September 27, 7 days have been added to the last day of the LMP (rather than the first day of the LMP), plus 4 months (instead of 3 months) were counted back.

Option C: To obtain the date of November 7, 7 days have been subtracted (instead of added) from the first day of LMP plus November indicates counting back 2 months (instead of 3 months) from January.

Option D: To obtain the date of December 27, 7 days were added to the last day of the LMP (rather than the first day of the LMP) and December indicates counting back only 1 month (instead of 3 months) from January.

8. Answer: D. G4 T1 P1 A1 L2

 

The client has been pregnant four times, including current pregnancy (G). Birth at 38 weeks’ gestation is considered full term (T), while birth form 20 weeks to 38 weeks is considered preterm (P). A spontaneous abortion occurred at 8 weeks (A). She has two living children (L).

 

9. Answer: B. Doppler placed midline at the suprapubic region

 

At 12 weeks gestation, the uterus rises out of the pelvis and is palpable above the symphysis pubis. The Doppler intensifies the sound of the fetal pulse rate so it is audible. The uterus has merely risen out of the pelvis into the abdominal cavity and is not at the level of the umbilicus.

 

Option A: The fetal heart rate at this age is not audible with a stethoscope.

Option C: The uterus at 12 weeks is just above the symphysis pubis in the abdominal cavity, not midway between the umbilicus and the xiphoid process. At 12 weeks the FHR would be difficult to auscultate with a fetoscope.

Option D: Although the external electronic fetal monitor would project the FHR, the uterus has not risen to the umbilicus at 12 weeks.

 

10. Answer: A. Dietary intake

 

Although all of the choices are important in the management of diabetes, diet therapy is the mainstay of the treatment plan and should always be the priority.

 

Option B: Women diagnosed with gestational diabetes generally need only diet therapy without medication to control their blood sugar levels.

Option C:  Exercise, is important for all pregnant women and especially for diabetic women, because it burns up glucose, thus decreasing blood sugar. However, dietary intake, not exercise, is the priority.

Option D: All pregnant women with diabetes should have periodic monitoring of serum glucose. However, those with gestational diabetes generally do not need daily glucose monitoring. The standard of care recommends a fasting and 2-hour postprandial blood sugar level every 2 weeks.

 

11. Answer: C. Hand/face edema

 

After 20 weeks’ gestation, when there is a rapid weight gain, preeclampsia should be suspected, which may be caused by fluid retention manifested by edema, especially of the hands and face. The three classic signs of preeclampsia are hypertension, edema, and proteinuria.

 

Option A: Although urine is checked for glucose at each clinic visit, this is not the priority.

Option B: Depression may cause either anorexia or excessive food intake, leading to excessive weight gain or loss. This is not, however, the priority consideration at this time.

Option D: Weight gain thought to be caused by excessive food intake would require a 24-hour diet recall. However, excessive intake would not be the primary consideration for this client at this time.

 

12. Answer: B. Imminent abortion

 

Cramping and vaginal bleeding coupled with cervical dilation signifies that termination of the pregnancy is inevitable and cannot be prevented. Thus, the nurse would document an imminent abortion.

 

Option A: In a threatened abortion, cramping and vaginal bleeding are present, but there is no cervical dilation. The symptoms may subside or progress to abortion.

Option C: In a complete abortion all the products of conception are expelled.

Option D: A missed abortion is early fetal intrauterine death without expulsion of the products of conception.

 

13. Answer: B. Pain

 

For the client with an ectopic pregnancy, lower abdominal pain, usually unilateral, is the primary symptom. Thus, pain is the priority.

 

Option A: Although the potential for infection is always present, the risk is low in ectopic pregnancy because pathogenic microorganisms have not been introduced from external sources.

Options C and D: The client may have a limited knowledge of the pathology and treatment of the condition and will most likely experience grieving, but this is not the priority at this time.

14. Answer: D. Assist her to urinate

 

Before the uterine assessment is performed, it is essential that the woman empties her bladder. A full bladder will interfere with the accuracy of the assessment by elevating the uterus and displacing to the side of the midline.

 

Option A: Vital sign assessment is not necessary unless an abnormality in uterine assessment is identified.

Option B: Uterine assessment should not cause acute pain that requires administration of analgesia.

Option C: Ambulating the client is an essential component of postpartum care, but is not necessary prior to assessment of the uterus.

 

15. Answer: A. Tell her to breastfeed more frequently

 

Feeding more frequently, about every 2 hours, will decrease the infant’s frantic, vigorous sucking from hunger and will decrease breast engorgement, soften the breast, and promote ease of correct latching on for feeding.

 

Option B: Narcotics administered prior to breastfeeding are passed through the breast milk to the infant, causing excessive sleepiness. Nipple soreness is not severe enough to warrant narcotic analgesia.

Option C: All postpartum clients, especially lactating mothers, should wear a supportive brassiere with wide cotton straps. This does not, however, prevent or reduce nipple soreness.

Option D: Soaps are drying to the skin of the nipples and should not be used on the breasts of lactating mothers. Dry nipple skin predisposes to cracks and fissures, which can become sore and painful.

 

16. Answer: D. Determine the amount of lochia

 

A weak, thready pulse elevated to 100 BPM may indicate impending hemorrhagic shock. An increased pulse is a compensatory mechanism of the body in response to decreased fluid volume. Thus, the nurse should check the amount of lochia present.

 

Option A: Temperatures up to 100.48F in the first 24 hours after birth are related to the dehydrating effects of labor and are considered normal.

Option B: Although rechecking the blood pressure may be a correct choice of action; it is not the first action that should be implemented in light of the other data. The data indicate a potential impending hemorrhage.

Option C: Assessing the uterus for firmness and position in relation to the umbilicus and midline is important, but the nurse should check the extent of vaginal bleeding first. Then it would be appropriate to check the uterus, which may be a possible cause of the hemorrhage.

 

17. Answer: D. A bright red discharge 5 days after delivery

 

Any bright red vaginal discharge would be considered abnormal, but especially 5 days after delivery, when the lochia is typically pink to brownish. Lochia rubra, a dark red discharge, is present for 2 to 3 days after delivery. Bright red vaginal bleeding at this time suggests late postpartum hemorrhage, which occurs after the first 24 hours following delivery and is generally caused by retained placental fragments or bleeding disorders.

 

Option A: Lochia rubra is the normal dark red discharge occurring in the first 2 to 3 days after delivery, containing epithelial cells, erythrocyTes, leukocytes, and decidua.

Option B: Lochia serosa is a pink to brownish serosanguineous discharge occurring from 3 to 10 days after delivery that contains decidua, erythrocytes, leukocytes, cervical mucus, and microorganisms.

Option C: Lochia alba is an almost colorless to yellowish discharge occurring from 10 days to 3 weeks after delivery and containing leukocytes, decidua, epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria.

 

18. Answer: A. Lochia

 

The data suggests an infection of the endometrial lining of the uterus. The lochia may be decreased or copious, dark brown in appearance, and foul smelling, providing further evidence of a possible infection.

 

Option B: All the client’s data indicate a uterine problem, not a breast problem. Typically, transient fever, usually 101ºF, may be present with breast engorgement. Symptoms of mastitis include influenza-like manifestations.

Option C: Localized infection of an episiotomy or C-section incision rarely causes systemic symptoms, and uterine involution would not be affected.

Option D: The client data do not include dysuria, frequency, or urgency, symptoms of urinary tract infections, which would necessitate assessing the client’s urine.

 

19. Answer: C. Facilitating safe and effective self and newborn care

 

Because of early postpartum discharge and limited time for teaching, the nurse’s priority is to facilitate the safe and effective care of the client and newborn.

 

Options A, B, and D: Although promoting comfort and restoration of health, exploring the family’s emotional status, and teaching about family planning are important in postpartum/newborn nursing care, they are not the priority focus in the limited time presented by early postpartum discharge.

 

20. Answer: C. Placing crib close to nursery window for family viewing

 

Heat loss by radiation occurs when the infant’s crib is placed too near cold walls or windows. Thus placing the newborn’s crib close to the viewing window would be least effective. Body heat is lost through evaporation during bathing.

 

Option A: Placing the infant under the radiant warmer after bathing will assist the infant to be rewarmed.

Option B: Covering the scale with a warmed blanket prior to weighing prevents heat loss through conduction.

Option D: A knit cap prevents heat loss from the head a large head, a large body surface area of the newborn’s body.

 

21. Answer: B. Fractured clavicle

 

A fractured clavicle would prevent the normal Moro response of symmetrical sequential extension and abduction of the arms followed by flexion and adduction.

 

Option A: In talipes equinovarus (clubfoot) the foot is turned medially, and in plantar flexion, with the heel elevated. The feet are not involved with the Moro reflex.

Option C: Hypothyroidism has no effect on the primitive reflexes.

Option D: Absence of the Moro reflex is the most significant single indicator of central nervous system status, but it is not a sign of increased intracranial pressure.

 

22. Answer: B. Hemorrhage

 

Hemorrhage is a potential risk following any surgical procedure. Although the infant has been given vitamin K to facilitate clotting, the prophylactic dose is often not sufficient to prevent bleeding.

 

Option A: Although infection is a possibility, signs will not appear within 4 hours after the surgical procedure.

Option C: The primary discomfort of circumcision occurs during the surgical procedure, not afterward.

Option D: Although feedings are withheld prior to the circumcision, the chances of dehydration are minimal.

 

23. Answer: B. “A decrease in material hormones present before birth causes enlargement,”

 

The presence of excessive estrogen and progesterone in the maternal-fetal blood followed by prompt withdrawal at birth precipitates breast engorgement, which will spontaneously resolve in 4 to 5 days after birth.

 

Option A: The trauma of the birth process does not cause inflammation of the newborn’s breast tissue.

Option C: Newborns do not have breast malignancy. This reply by the nurse would cause the mother to have undue anxiety.

Option D: Breast tissue does not hypertrophy in the fetus or newborns.

 

24. Answer: D. Recognize this as normal first period of reactivity

 

The first 15 minutes to 1 hour after birth is the first period of reactivity involving respiratory and circulatory adaptation to extrauterine life. The data given reflect the normal changes during this time period.

 

Options A and B: The infant’s assessment data reflect normal adaptation. Thus, the physician does not need to be notified and oxygen is not needed.

Option C: The data do not indicate the presence of choking, gagging or coughing, which are signs of excessive secretions. Suctioning is not necessary.

 

25. Answer: B. ‘Alcohol helps it dry and kills germs”

 

Application of 70% isopropyl alcohol to the cord minimizes microorganisms (germicidal) and promotes drying. The cord should be kept dry until it falls off and the stump has healed.

 

Option C: Antibiotic ointment should only be used to treat an infection, not as a prophylaxis.

Option D: Infants should not be submerged in a tub of water until the cord falls off and the stump has completely healed.

 

26. Answer: B. 3 ounces

 

To determine the amount of formula needed, do the following mathematical calculation. 3 kg x 120 cal/kg per day = 360 calories/day feeding q 4 hours = 6 feedings per day = 60 calories per feeding: 60 calories per feeding; 60 calories per feeding with formula 20 cal/oz  = 3 ounces per feeding. Based on the calculation. 2, 4 or 6 ounces are incorrect.

 

27. Answer: A. Respiratory problems

 

Intrauterine anoxia may cause relaxation of the anal sphincter and emptying of meconium into the amniotic fluid. At birth some of the meconium fluid may be aspirated, causing mechanical obstruction or chemical pneumonitis.

 

Option B: The infant is not at increased risk for gastrointestinal problems.

Option C: Even though the skin is stained with meconium, it is noninfectious (sterile) and nonirritating.

Option D: The post-term meconium-stained infant is not at additional risk for bowel or urinary problems.

 

28. Answer: C. From the symphysis pubis to the fundus

 

The nurse should use a non elastic, flexible, paper measuring tape, placing the zero point on the superior border of the symphysis pubis and stretching the tape across the abdomen at the midline to the top of the fundus.

 

Options A, B, and D: The xiphoid and umbilicus are not appropriate landmarks to use when measuring the height of the fundus (McDonald’s measurement).

 

29. Answer: B. Seizure precautions

 

Women hospitalized with severe preeclampsia need decreased CNS stimulation to prevent a seizure. Seizure precautions provide environmental safety should a seizure occur.

 

Option A: Because of edema, daily weight is important but not the priority.

Option C: Preclampsia causes vasospasm and therefore can reduce utero-placental perfusion. The client should be placed on her left side to maximize blood flow, reduce blood pressure, and promote diuresis.

Option D: Interventions to reduce stress and anxiety are very important to facilitate coping and a sense of control, but seizure precautions are the priority.

 

30. Answer: C. “When the discharge has stopped and the incision is healed.”

 

Cessation of the lochial discharge signifies healing of the endometrium. Risk of hemorrhage and infection are minimal 3 weeks after a normal vaginal delivery.

 

Option A: Telling the client anytime is inappropriate because this response does not provide the client with the specific information she is requesting.

Option B: Choice of a contraceptive method is important, but not the specific criteria for safe resumption of sexual activity.

Option D: Culturally, the 6-weeks’ examination has been used as the time frame for resuming sexual activity, but it may be resumed earlier.

 

31. Answer: C. Vastus lateralis muscle

 

The middle third of the vastus lateralis is the preferred injection site for vitamin K administration because it is free of blood vessels and nerves and is large enough to absorb the medication.

 

Option A: The deltoid muscle of a newborn is not large enough for a newborn IM injection. Injections into this muscle in a small child might cause damage to the radial nerve.

Option B: The anterior femoris muscle is the next safest muscle to use in a newborn but is not the safest.

Option D: Because of the proximity of the sciatic nerve, the gluteus maximus muscle should not be until the child has been walking 2 years.

 

32. Answer: D. Bartholin’s gland

 

Bartholin’s glands are the glands on either side of the vaginal orifice.

 

Option A: The clitoris is female erectile tissue found in the perineal area above the urethra.

Option B: The parotid glands are open into the mouth.

Option C: Skene’s glands open into the posterior wall of the female urinary meatus.

 

33. Answer: D. Secretion of estrogen by the fetal gonad

 

The fetal gonad must secrete estrogen for the embryo to differentiate as a female.

 

Option A: An increase in maternal estrogen secretion does not effect differentiation of the embryo, and maternal estrogen secretion occurs in every pregnancy.

Option B: Maternal androgen secretion remains the same as before pregnancy and does not affect differentiation.

Option C: Secretion of androgen by the fetal gonad would produce a male fetus.

 

34. Answer: A. Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water.

 

Using bicarbonate would increase the amount of sodium ingested, which can cause complications.

 

Option B: Eating low-sodium crackers would be appropriate.

Option C: Since liquids can increase nausea avoiding them in the morning hours when nausea is usually the strongest is appropriate.

Option D: Eating six small meals a day would keep the stomach full, which often decrease nausea.

 

35. Answer: B. Passive movement of the unengaged fetus

 

Ballottement indicates passive movement of the unengaged fetus.

 

Option A: Ballottement is not a contraction.

Option C: Fetal kicking felt by the client represents quickening.

Option D: Enlargement and softening of the uterus is known as Piskacek’s sign.

 

36. Answer: B. Chadwick’s sign

 

Chadwick’s sign refers to the purple-blue tinge of the cervix.

 

Option A: Braxton Hicks contractions are painless contractions beginning around the 4th month.

Option C: Goodell’s sign indicates softening of the cervix.

Option D: Flexibility of the uterus against the cervix is known as McDonald’s sign.

 

37. Answer: C. Facilitate relaxation, possibly reducing the perception of pain

 

Breathing techniques can raise the pain threshold and reduce the perception of pain. They also promote relaxation.

 

Options A, B, and D: Breathing techniques do not eliminate pain, but they can reduce it. Positioning, not breathing, increases uteroplacental perfusion.

 

38. Answer: A. Obtaining an order to begin IV oxytocin infusion

 

The client’s labor is hypotonic. The nurse should call the physical and obtain an order for an infusion of oxytocin, which will assist the uterus to contract more forcefully in an attempt to dilate the cervix.

 

Option B: Administering light sedative would be done for hypertonic uterine contractions.

Option C: Preparing for cesarean section is unnecessary at this time.

Option D: Oxytocin would increase the uterine contractions and hopefully progress labor before a cesarean would be necessary. It is too early to anticipate client pushing with contractions.

 

39. Answer: D. Cervical dilation

 

The signs indicate placenta previa and vaginal exam to determine cervical dilation would not be done because it could cause hemorrhage.

 

Option A: Assessing maternal vital signs can help determine maternal physiologic status.

Option B: Fetal heart rate is important to assess fetal well-being and should be done.

Option C: Monitoring the contractions will help evaluate the progress of labor.

 

40. Answer: D. “The placenta is covering the opening of the uterus and blocking your baby.”

 

A complete placenta previa occurs when the placenta covers the opening of the uterus, thus blocking the passageway for the baby. This response explains what a complete previa is and the reason the baby cannot come out except by cesarean delivery.

 

Option A: Telling the client to ask the physician is a poor response and would increase the patient’s anxiety.

Option B: Although a cesarean would help to prevent hemorrhage, the statement does not explain why the hemorrhage could occur.

Option C: With a complete previa, the placenta is covering all the cervix, not just most of it.

 

41. Answer: B. Completely extended

 

With a face presentation, the head is completely extended.

 

Options A and D: With a vertex presentation, the head is completely or partially flexed.

Option C: With a brow (forehead) presentation, the head would be partially extended.

 

42. Answer: D. Above the maternal umbilicus and to the left of midline

 

With this presentation, the fetal upper torso and back face the left upper maternal abdominal wall. The fetal heart rate would be most audible above the maternal umbilicus and to the left of the middle. The other positions would be incorrect.

 

43. Answer: C. Meconium

The greenish tint is due to the presence of meconium.

 

Option A: Lanugo is the soft, downy hair on the shoulders and back of the fetus.

Option B: Hydramnios represents excessive amniotic fluid.

Option D: Vernix is the white, cheesy substance covering the fetus.

 

44. Answer: D. Prolapsed umbilical cord

 

In a breech position, because of the space between the presenting part and the cervix, prolapse of the umbilical cord is common.

 

Option A: Quickening is the woman’s first perception of fetal movement.

Option B: Ophthalmia neonatorum usually results from maternal gonorrhea and is conjunctivitis.

Option C: Pica refers to the oral intake of nonfood substances.

 

45. Answer: A. Two ova fertilized by separate sperm

 

Dizygotic (fraternal) twins involve two ova fertilized by separate sperm. Monozygotic (identical) twins involve a common placenta, same genotype, and common chorion.

 

46. Answer: C. Zygote

 

The zygote is the single cell that reproduces itself after conception.

 

Option A: The chromosome is the material that makes up the cell and is gained from each parent.

Options B and D: Blastocyst and trophoblast are later terms for the embryo after zygote.

 

47. Answer: D. Prepared childbirth

 

Prepared childbirth was the direct result of the 1950’s challenging of the routine use of analgesic and anesthetics during childbirth.

 

Option A: The LDRP was a much later concept and was not a direct result of the challenging of routine use of analgesics and anesthetics during childbirth.

Options B and C: Roles for the nurse midwives and clinical nurse specialists did not develop from this challenge.

 

48. Answer: C. Ischial spines

 

The ischial spines are located in the mid-pelvic region and could be narrowed due to the previous pelvic injury.

 

Options A, B, and D: The symphysis pubis, sacral promontory, and pubic arch are not part of the mid-pelvis.

 

49. Answer: B. Proliferative phase

 

Variations in the length of the menstrual cycle are due to variations in the proliferative phase.

 

Options A, C, and D: The menstrual, secretory, and ischemic phases do not contribute to this variation.

 

50. Answer: B. Testosterone

 

Testosterone is produced by the Leydig cells in the seminiferous tubules.

 

Options A and C: Follicle-stimulating hormone and luteinizing hormone are released by the anterior pituitary gland.

Option D: The hypothalamus is responsible for releasing gonadotropin-releasing hormone.

 

 

51. Answer: D. Do nothing because this is a normal finding for the age.

 

The anterior fontanelle typically closes anywhere between 12 to 18 months of age. Thus, assessing the anterior fontanelle as still being slightly open is a normal finding requiring no further action. Because it is normal finding for this age, notifying the physician or performing additional examinations are inappropriate.

 

52. Answer: D. 4 months

 

Solid foods are not recommended before age 4 to 6 months because of the sucking reflex and the immaturity of the gastrointestinal tract and immune system. Therefore, the earliest age at which to introduce foods is 4 months. Any time earlier would be inappropriate.

 

53. Answer: A. Mistrust

 

According to Erikson, infants need to have their needs met consistently and effectively to develop a sense of trust. An infant whose needs are consistently unmet or who experiences significant delays in having them met, such as in the case of the infant of a substance-abusing mother, will develop a sense of uncertainty, leading to mistrust of caregivers and the environment.

 

Option B: Toddlers develop a sense of shame when their autonomy needs are not met consistently.

Option C: Preschoolers develop a sense of guilt when their sense of initiative is thwarted.

Option D: Schoolagers develop a sense of inferiority when they do not develop a sense of industry.

 

54. Answer: D. A colorful busy box

 

A busy box facilitates the fine motor development that occurs between 4 and 6 months.

 

Option A: Balloons are contraindicated because small children may aspirate balloons.

Option B: Because the button eyes of a teddy bear may detach and be aspirated, this toy is unsafe for children younger than 3 years.

Option C:  A 5-month-old is too young to use a push-pull toy.

 

55. Answer: B. “Babies need to be held and cuddled; you won’t spoil her this way.”

 

Infants need to have their security needs met by being held and cuddled. At 2 months of age, they are unable to make the connection between crying and attention. This association does not occur until late infancy or early toddlerhood.

 

Option A: Letting the infant cry for a time before picking up the infant or leaving the infant alone to cry herself to sleep interferes with meeting the infant’s need for security at this very young age.

Option C: Infants cry for many reasons. Assuming that the child Is hungry may cause overfeeding problems such as obesity.

 

56. Answer: B. Underdeveloped abdominal muscles

 

Underdeveloped abdominal musculature gives the toddler a characteristically protruding abdomen.

 

Option A: During toddlerhood, food intake decreases, not increases.

Option C: Toddlers are characteristically bowlegged because the leg muscles must bear the weight of the relatively large trunk.

Option D: Toddler growth patterns occur in a steplike, not linear pattern.

 

57. Answer: B. Shame

 

According to Erikson, toddlers experience a sense of shame when they are not allowed to develop appropriate independence and autonomy.

 

Option A: Infants develop mistrust when their needs are not consistently gratified.

Option C: Preschoolers develop guilt when their initiative needs are not met.

Option D: While schoolagers develop a sense of inferiority when their industry needs are not met.

 

58. Answer: C. Finger paints

 

Young trent textures. Thus, finger paints would be an appropriate toy choice.

 

Option A: Multiple-piece toddlers are still sensorimotor learners and they enjoy the experience of feeling dizzy, such as puzzle, are too difficult to manipulate and may be hazardous if the pieces are small enough to be aspirated.

Option B: Miniature cars also have a high potential for aspiration.

Option D: Comic books are on too high a level for toddlers. Although they may enjoy looking at some of the pictures, toddlers are more likely to rip a comic book apart.

 

59. Answer: D. Verbalizes desire to go to the bathroom

 

The child must be able to sate the need to go to the bathroom to initiate toilet training.

 

Option A: Usually, a child needs to be dry for only 2 hours, not 4 hours.

Option B: The child also must be able to sit, walk, and squat.

Option C: A new sibling would most likely hinder toilet training.

 

60. Answer: A. Food “jags.”

 

Toddlers become picky eaters, experiencing food jags and eating large amounts one day and very little the next. A toddler’s food gags express a preference for the ritualism of eating one type of food for several days at a time.

 

Option B: Toddlers typically enjoy socialization and limiting others at meal time.

Option C: Toddlers prefer to feed themselves and thus are too young to have table manners.

Option D: A toddler’s appetite and the need for calories, protein, and fluid decrease due to the dramatic slowing of growth rate.

61. Answer: D. “Read him a story and allow him to play quietly in his bed until he falls asleep.”

 

Preschoolers commonly have fears of the dark, being left alone especially at bedtime, and ghosts, which may affect the child’s going to bed at night. Quiet play and time with parents is a positive bedtime routine that provides security and also readies the child for sleep.

 

Option A: The child should sleep in his own bed.

Option B: Telling the child about locking him in his room will viewed by the child as a threat. Additionally, a locked door is frightening and potentially hazardous.

Option C: Vigorous activity at bedtime stirs up the child and makes more difficult to fall asleep.

 

62. Answer: B. Dress-up clothes

 

Dress-up clothes enhance imaginative play and imagination, allowing preschoolers to engage in rich fantasy play.

 

Options A and C: Building blocks and wooden puzzles are appropriate for encouraging fine motor development.

Option D: Big wheels and tricycles encourage gross motor development.

 

63. Answer: D. Developing plans for the future

 

The school-aged child is in the stage of concrete operations, marked by inductive reasoning, logical operations, and reversible concrete thought. The ability to consider the future requires formal thought operations, which are not developed until adolescence.

 

Options A, B, and C: Collecting baseball cards and marbles, ordering dolls by size, and simple problem-solving options are examples of the concrete operational thinking of the schoolager.

 

64. Answer: C. Reaction formation

 

Reaction formation is the school ager’s typical defensive response when hospitalized. In reaction formation, expression of unacceptable thoughts or behaviors is prevented (or overridden) by the exaggerated expression of opposite thoughts or types of behaviors.

 

Option A: Regression is seen in toddlers and preschoolers when they retreat or return to an earlier level of development.

Option B: Repression refers to the involuntary blocking of unpleasant feelings and experiences from one’s awareness.

Option D: Rationalization is the attempt to make excuses to justify unacceptable feelings or behaviors.

 

65. Answer: C. “Schoolagers are unable to understand potential dangers around them.”

 

The school ager’s cognitive level is sufficiently developed to enable good understanding of and adherence to rules. Thus, school agers should be able to understand the potential dangers around them.

 

Option A: With growth comes greater freedom and children become more adventurous and daring.

Option B: The school-aged child is also still prone to accidents and home hazards, especially because of increased motor abilities and independence. Plus the home hazards differ from other age groups. These hazards, which are potentially lethal but tempting, may include firearms, alcohol, and medications.

Option D: School-age children begin to internalize their own controls and need less outside direction. Plus the child is away from home more often. Some parental or caregiver assistance is still needed to answer questions and provide guidance for decisions and responsibilities.

 

66. Answer: C. Reading

 

The most significant skill learned during the school-age period is reading. During this time the child develops formal adult articulation patterns and learns that words can be arranged in structure.

Options A, B, and D: Collective, ordering, and sorting, although important, are not most significant skills learned.

 

67. Answer: C. At age 10

 

Based on the recommendations of the American Academy of Family Physicians and the American Academy of Pediatrics, the MMR vaccine should be given at the age of 10 if the child did not receive it between the ages of 4 to 6 years as recommended. Immunization for diphtheria and tetanus is required at age 13.

 

68. Answer: D. Role diffusion

 

According to Erikson, role diffusion develops when the adolescent does not develop a sense of identity and a sense or where he fits in.

 

Option A: Toddlers develop a sense of shame when they do not achieve autonomy.

Option B: Preschoolers develop a sense of guilt when they do not develop a sense of initiative.

Option C: School-age children develop a sense of inferiority when they do not develop a sense of industry.

 

69. Answer: A. A female’s first menstruation or menstrual “periods”

 

Menarche refers to the onset of the first menstruation or menstrual period and refers only to the first cycle. Uterine growth and broadening of the pelvic girdle occur before menarche.

 

70. Answer: A. “This is probably the only concern he has about his body. So don’t worry about it or the time he spends on it.”

 

Stating that this is probably the only concern the adolescent has and telling the parents not to worry about it or the time he spends on it shuts off further investigation and is likely to make the adolescent and his parents feel defensive.

 

Option B: The statement about peer acceptance and time spent in front of the mirror for the development of self-image provides information about the adolescent’s needs to the parents and may help to gain trust with the adolescent.

Option C: Asking the adolescent how he feels about the acne will encourage the adolescent to share his feelings.

Option D: Discussing the cleansing method shows interest and concern for the adolescent and also can help to identify any patient-teaching needs for the adolescent regarding cleansing.

 

71. Answer: B. The child is acting out personal experiences

 

Preschoolers should be developmentally incapable of demonstrating explicit sexual behavior. If a child does so, the child has been exposed to such behavior, and sexual abuse should be suspected.

 

Options C and D: Explicit sexual behavior during doll play is not a characteristic of preschool development nor symptomatic of developmental delay. Whether or nor the child knows how to play with dolls is irrelevant.

 

72. Answer: A. “We’ll keep him at home until phobia subsides.”

 

The parents need more teaching if they state that they will keep the child home until the phobia subsides. Doing so reinforces the child’s feelings of worthlessness and dependency.

 

Option B: The child should attend school even during resolution of the problem.

Option C: Allowing the child to verbalize helps the child to ventilate feelings and may help to uncover causes and solutions.

Option D: Collaboration with the teachers and counselors at school may lead to uncovering the cause of the phobia and to the development of solutions. The child should participate and play an active role in developing possible solutions.

 

73. Answer: C. Denial of the pregnancy is common early on.

 

The adolescent who becomes pregnant typically denies the pregnancy early on. Early recognition by a parent or health care provider may be crucial to timely initiation of prenatal care.

 

Option A: The incidence of adolescent pregnancy has declined since 1991, yet morbidity remains high.

Option B: Most teenage pregnancies are unplanned and occur out of wedlock.

Option D: The pregnant adolescent is at high risk for physical complications including premature labor and low-birth-weight infants, high neonatal mortality, iron deficiency anemia, prolonged labor, and fetopelvic disproportion as well as numerous psychological crises.

 

74. Answer: B. Ineffective functioning of the Eustachian tubes

 

Because of the structural defect, children with cleft palate may have ineffective functioning of their Eustachian tubes creating frequent bouts of otitis media.

 

Option A: Most children with cleft palate remain well-nourished and maintain adequate nutrition through the use of proper feeding techniques.

Option C: Food particles do not pass through the cleft and into the Eustachian tubes.

Option D: There is no association between cleft palate and congenital ear deformities.

 

75. Answer: D. Lifting of head and chest when prone

 

A 3-month-old infant should be able to lift the head and chest when prone.

 

Option A: The Moro reflex typically diminishes or subsides by 3 months.

Option B: The parachute reflex appears at 9 months.

Option C: Rolling from front to back usually is accomplished at about 5 months.

 

76. Answer: D. 12 months

 

A child’s birth weight usually triples by 12 months and doubles by 4 months. No specific birth weight parameters are established for 7 or 9 months.

 

77. Answer: C. Sitting near each other while playing with separate dolls

 

Toddlers engaging in parallel play will play near each other, but not with each other. Thus, when two toddlers sit near each other but play with separate dolls, they are exhibiting parallel play.

 

Options A, B, and D: Sharing crayons, playing a board game with a nurse, or sharing dolls with two different nurses are all examples of cooperative play.

 

78. Answer: A. Instituting infection control precautions

 

Acute lymphocytic leukemia (ALL) causes leukopenia, resulting in immunosuppression and increasing the risk of infection, a leading cause of death in children with ALL. Therefore, the initial priority nursing intervention would be to institute infection control precautions to decrease the risk of infection.

 

Option B:  Iron-rich foods help with anemia, but dietary iron is not an initial intervention.

Option C: The prognosis of ALL usually is good. However, later on, the nurse may need to assist the child and family with coping since death and dying may still be an issue in need of discussion.

Option D: Injections should be discouraged, owing to increased risk of bleeding due to thrombocytopenia.

 

79. Answer: A. Measures to reduce fever

 

The pertussis component may result in fever and the tetanus component may result in injection soreness. Therefore, the mother’s verbalization of information about measures to reduce fever indicates understanding.

 

Option B: No dietary restrictions are necessary after this injection is given.

Option C: Subsequent rash is more likely to be seen 5 to 10 days after receiving the MMR vaccine, not diphtheria, pertussis, and tetanus vaccine.

Option D: A Diarrhea is not associated with this vaccine.

 

80. Answer: A. Report the child’s condition to Protective Services immediately.

 

Multiple bruises and burns on a toddler are signs child abuse. Therefore, the nurse is responsible for reporting the case to Protective Services immediately to protect the child from further harm.

 

Option B: Scheduling a follow-up visit is inappropriate because additional harm may come to the child if the nurse waits for further assessment data.

Option C: Although the nurse should notify the physician, the goal is to initiate measures to protect the child’s safety. Notifying the physician immediately does not initiate the removal of the child from harm nor does it absolve the nurse from responsibility.

Option D: Multiple bruises and burns are not normal toddler injuries.

 

81. Answer: B. Projection

 

The mother is using projection, the defense mechanism used when a person attributes his or her own undesirable traits to another.

 

Option A: Displacement is the transfer of emotion onto an unrelated object, such as when the mother would kick a chair or bang the door shut.

Option C: Repression is the submerging of painful ideas into the unconscious.

Option D: Psychosis is a state of being out of touch with reality.

 

82. Answer: A. Susceptibility to respiratory infection

 

Children with congenital heart disease are more prone to respiratory infections.

 

Options B, C, and D: Bleeding tendencies, frequent vomiting, and diarrhea and seizure disorders are not associated with congenital heart disease.

 

83. Answer: D. Notify the physician immediately and prepare for intubation.

 

The child is exhibiting classic signs of epiglottitis, always a pediatric emergency. The physician must be notified immediately and the nurse must be prepared for an emergency intubation or tracheostomy.

 

Option A: Further assessment with auscultating lungs and placing the child in a mist tent wastes valuable time. The situation is a possible life-threatening emergency.

Option B: Having the child lie down would cause additional distress and may result in respiratory arrest.

Option C: Throat examination may result in laryngospasm that could be fatal.

 

84. Answer: A. A shorter urethra in females

 

In females, the urethra is shorter than in males. This decreases the distance for organisms to travel, thereby increasing the chance of the child developing a urinary tract infection.

 

Option B: Frequent emptying of the bladder would help to decrease urinary tract infections by avoiding sphincter stress.

Option C: Increased fluid intake enables the bladder to be cleared more frequently, thus helping to prevent urinary tract infections.

Option D: The intake of acidic juices helps to keep the urine pH acidic and thus decrease the chance of flora development.

 

85. Answer: B. Notify the physician immediately

 

Compartment syndrome is an emergent situation and the physician needs to be notified immediately so that interventions can be initiated to relieve the increasing pressure and restore circulation.

 

Option A: Acetaminophen (Tylenol) will be ineffective since the pain is related to the increasing pressure and tissue ischemia.

Option C: The cast, not traction, is being used in this situation for immobilization, so releasing the traction would be inappropriate.

Option D:  In this situation, specific action not continued monitoring is indicated.

 

86. Answer: D. 12 months

 

The varicella zoster vaccine (VZV) is a live vaccine given after age 12 months. The first dose of hepatitis B vaccine is given at birth to 2 months, then at 1 to 4 months, and then again at 6 to 18 months. DTaP is routinely given at 2, 4, 6, and 15 to 18 months and a booster at 4 to 6 years.

 

87. Answer: C. Large blocks

 

Because the 8-month-old is refining his gross motor skills, being able to sit unsupported and also improving his fine motor skills, probably capable of making hand-to-hand transfers, large blocks would be the most appropriate toy selection.

 

Option A: Push-pull toys would be more appropriate for the 10 to 12-month-old as he or she begins to cruise the environment.

Options B and D: Rattles and mobiles are more appropriate for infants in the 1 to 3 month age range. Mobiles pose a danger to older infants because of possible strangulation.

 

88. Answer: B. Fear of body mutilation is a common preschool fear

 

During the preschool period, the child has mastered a sense of autonomy and goes on to master a sense of initiative. During this period, the child commonly experiences more fears than at any other time. One common fear is fear of the body mutilation, especially associated with painful experiences.

 

Options A, C, and D: The preschool child uses simple, not complex, reasoning, engages in associative, not competitive, play (interactive and cooperative play with sharing), and is able to tolerate longer periods of delayed gratification.

 

89. Answer: A. Slow to feed self

 

Mild mental retardation refers to development disability involving an IQ 50 to 70. Typically, the child is not noted as being retarded, but exhibits slowness in performing tasks, such as self-feeding, walking, and taking.

 

Options B, C, and D: Little or no speech, marked motor delays, and gait disabilities would be seen in more severe forms mental retardation.

 

90. Answer: B. Transverse palmar crease

 

Down syndrome is characterized by the following a transverse palmar crease (simian crease), separated sagittal suture, oblique palpebral fissures, small nose, depressed nasal bridge, high arched palate, excess and lax skin, wide spacing and plantar crease between the second and big toes, hyperextensible and lax joints, large protruding tongue, and muscle weakness.

 

91. Answer: A. Sucking ability

 

Because of the defect, the child will be unable to from the mouth adequately around the nipple, thereby requiring special devices to allow for feeding and sucking gratification.

 

Option B: Respiratory status may be compromised if the child is fed improperly or during postoperative period

Option C: Locomotion would be a problem for the older infant because of the use of restraints.

Option D: GI functioning is not compromised in the child with a cleft lip.

 

92. Answer: B. Prone

 

Postoperatively children with cleft palate should be placed on their abdomens to facilitate drainage.

 

Option A: If the child is placed in the supine position, he or she may aspirate.

Option C: Using an infant seat does not facilitate drainage.

Option D: Side-lying does not facilitate drainage as well as the prone position.

 

93. Answer: C. Projectile vomiting

 

Projectile vomiting is a key symptom of pyloric stenosis.

 

Option A: Regurgitation is seen more commonly with GERD.

Option B: Steatorrhea occurs in malabsorption disorders such as celiac disease.

Option D: “Currant jelly” stools are characteristic of intussusception.

 

94. Answer: D. Altered oral mucous membranes

 

GERD is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac) sphincter. No alteration in the oral mucous membranes occurs with this disorder.

 

Options A, B, and C: Fluid volume deficit, risk for aspiration, and altered nutrition are appropriate nursing diagnoses.

 

95. Answer: A. Vomiting

Thickened feedings are used with GER to stop the vomiting. Therefore, the nurse would monitor the child’s vomiting to evaluate the effectiveness of using the thickened feedings.

Options B and C: No relationship exists between feedings and characteristics of stools and uterine.

Option D:  If feedings are ineffective, this should be noted before there is any change in the child’s weight.

96. Answer: C. Wheat

 

Children with celiac disease cannot tolerate or digest gluten. Therefore, because of its gluten content, wheat and wheat-containing products must be avoided.

 

Options A, B, and D: Rice, milk, and chicken do not contain gluten and need not be avoided.

 

97. Answer: C. Watery diarrhea

 

Episodes of celiac crises are precipitated by infections, ingestion of gluten, prolonged fasting, or exposure to anticholinergic drugs. Celiac crisis is typically characterized by severe watery diarrhea.

 

Option A: Respiratory distress is unlikely in a routine upper respiratory infection.

Option B: Irritability, rather than lethargy, is more likely.

Option D: Because of the fluid loss associated with the severe watery diarrhea, the child’s weight is more likely to be decreased.

 

98. Answer: A. Hirschsprung disease

 

For the child with Hirschsprung disease, fever and explosive diarrhea indicate enterocolitis, a life-threatening situation. Therefore, the physician should be notified immediately.

 

Option B:  Generally, because of the intestinal obstruction and inadequate propulsive intestinal movement, antidiarrheals are not used to treat Hirschsprung disease.

Option C: The child is acutely ill and requires intervention, with monitoring more frequently than every 30 minutes.

Option D: Hirschsprung disease typically presents with chronic constipation.

 

99. Answer: A. Hirschsprung disease

 

Failure to pass meconium within the first 24 hours after birth may be an indication of Hirschsprung disease, a congenital anomaly resulting in mechanical obstruction due to inadequate motility in an intestinal segment.

Options B, C, and D: Failure to pass meconium is not associated with celiac disease, intussusception, or abdominal wall defect.

 

100. Answer: C. Family history

 

Because intussusception is not believed to have a familial tendency, obtaining a family history would provide the least amount of information.

Options A, B, and D: Stool inspection, pain pattern, and abdominal palpation would reveal possible indicators of intussusception. Current, jelly-like stools containing blood and mucus are an indication of intussusception. Acute, episodic abdominal pain is characteristics of intussusception. A sausage-shaped mass may be palpated in the right upper quadrant.

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