Maternal and Child Health Nursing NCLEX Questions Part 1

Posted in Maternal Newborn Nursing by admin On February 13, 2010. 2 Comments

1. A postpartum patient was in labor for 30 hours and had ruptured membranes for 24 hours. For
which of the following would the nurse be alert?
a. Endometritis
b. Endometriosis
c. Salpingitis
d. Pelvic thrombophlebitis
2. A client at 36 weeks’ gestation is schedule for a routine ultrasound prior to an amniocentesis. After
teaching the client about the purpose for the ultrasound, which of the following client statements
would indicate to the nurse in charge that the client needs further instruction?
a. The ultrasound will help to locate the placenta
b. The ultrasound identifies blood flow through the umbilical cord
c. The test will determine where to insert the needle
d. The ultrasound locates a pool of amniotic fluid
3. While the postpartum client is receiving herapin for thrombophlebitis, which of the following drugs
would the nurse Mica expect to administer if the client develops complications related to heparin
therapy?
a. Calcium gluconate
b. Protamine sulfate
c. Methylegonovine (Methergine)
d. Nitrofurantoin (macrodantin)
4. When caring for a 3-day-old neonate who is receiving phototherapy to treat jaundice, the nurse in
charge would expect to do which of the following?
a. Turn the neonate every 6 hours
b. Encourage the mother to discontinue breast-feeding
c. Notify the physician if the skin becomes bronze in color
d. Check the vital signs every 2 to 4 hours
5. A primigravida in active labor is about 9 days post-term. The client desires a bilateral pudendal
block anesthesia before delivery. After the nurse explains this type of anesthesia to the client,
which of the following locations identified by the client as the area of relief would indicate to the
nurse that the teaching was effective?
a. Back
b. Abdomen
c. Fundus
d. Perineum
6. The nurse is caring for a primigravida at about 2 months and 1 week gestation. After explaining
self-care measures for common discomforts of pregnancy, the nurse determines that the client
understands the instructions when she says:
a. “Nausea and vomiting can be decreased if I eat a few crackers before arising”
b. “If I start to leak colostrum, I should cleanse my nipples with soap and water”
c. “If I have a vaginal discharge, I should wear nylon underwear”
d. “Leg cramps can be alleviated if I put an ice pack on the area”
7. Thirty hours after delivery, the nurse in charge plans discharge teaching for the client about infant
care. By this time, the nurse expects that the phase of postpartal psychological adaptation that
the client would be in would be termed which of the following?
a. Taking in
b. Letting go
c. Taking hold
d. Resolution
8. A pregnant client is diagnosed with partial placenta previa. In explaining the diagnosis, the nurse
tells the client that the usual treatment for partial placenta previa is which of the following?
a. Activity limited to bed rest
b. Platelet infusion
c. Immediate cesarean delivery
d. Labor induction with oxytocin
9. Nurse Julia plans to instruct the postpartum client about methods to prevent breast engorgement.
Which of the following measures would the nurse include in the teaching plan?
a. Feeding the neonate a maximum of 5 minutes per side on the first day
b. Wearing a supportive brassiere with nipple shields
c. Breast-feeding the neonate at frequent intervals
d. Decreasing fluid intake for the first 24 to 48 hours
10. When the nurse on duty accidentally bumps the bassinet, the neonate throws out its arms, hands
opened, and begins to cry. The nurse interprets this reaction as indicative of which of the
following reflexes?
a. Startle reflex
b. Babinski reflex
c. Grasping reflex
d. Tonic neck reflex
11. A primigravida client at 25 weeks’ gestation visits the clinic and tells the nurse that her lower
back aches when she arrives home from work. The nurse should suggest that the client perform:
a. Tailor sitting
b. Leg lifting
c. Shoulder circling
d. Squatting exercises
12. Which of the following would the nurse in charge do first after observing a 2-cm circle of bright
red bleeding on the diaper of a neonate who just had a circumcision?
a. Notify the neonate’s pediatrician immediately
b. Check the diaper and circumcision again in 30 minutes
c. Secure the diaper tightly to apply pressure on the site
d. Apply gently pressure to the site with a sterile gauze pad
13. Which of the following would the nurse Sandra most likely expect to find when assessing a
pregnant client with abruption placenta?
a. Excessive vaginal bleeding
b. Rigid, boardlike abdomen
c. Titanic uterine contractions
d. Premature rupture of membranes
14. While the client is in active labor with twins and the cervix is 5 cm dilates, the nurse observes
contractions occurring at a rate of every 7 to 8 minutes in a 30-minute period. Which of the
following would be the nurse’s most appropriate action?
a. Note the fetal heart rate patterns
b. Notify the physician immediately
c. Administer oxygen at 6 liters by mask
d. Have the client pant-blow during the contractions
15. A client tells the nurse, “I think my baby likes to hear me talk to him.” When discussing neonates
and stimulation with sound, which of the following would the nurse include as a means to elicit
the best response?
a. High-pitched speech with tonal variations
b. Low-pitched speech with a sameness of tone
c. Cooing sounds rather than words
d. Repeated stimulation with loud sounds
16. A 31-year-old multipara is admitted to the birthing room after initial examination reveals her
cervix to be at 8 cm, completely effaced (100 %), and at 0 station. What phase of labor is she in?
a. Active phase
b. Latent phase
c. Expulsive phase
d. Transitional phase
17. A pregnant patient asks the nurse Kate if she can take castor oil for her constipation. How should
the nurse respond?
a. “Yes, it produces no adverse effect.”
b. “No, it can initiate premature uterine contractions.”
c. “No, it can promote sodium retention.”
d. “No, it can lead to increased absorption of fat-soluble vitamins.”
18. A patient in her 14th week of pregnancy has presented with abdominal cramping and vaginal
bleeding for the past 8 hours. She has passed several cloth. What is the primary nursing
diagnosis for this patient?
a. Knowledge deficit
b. Fluid volume deficit
c. Anticipatory grieving
d. Pain
19. Immediately after a delivery, the nurse-midwife assesses the neonate’s head for signs of
molding. Which factors determine the type of molding?
a. Fetal body flexion or extension
b. Maternal age, body frame, and weight
c. Maternal and paternal ethnic backgrounds
d. Maternal parity and gravidity
20. For a patient in active labor, the nurse-midwife plans to use an internal electronic fetal monitoring
(EFM) device. What must occur before the internal EFM can be applied?
a. The membranes must rupture
b. The fetus must be at 0 station
c. The cervix must be dilated fully
d. The patient must receive anesthesia
21. A primigravida patient is admitted to the labor delivery area. Assessment reveals that she is in
early part of the first stage of labor. Her pain is likely to be most intense:
a. Around the pelvic girdle
b. Around the pelvic girdle and in the upper arms
c. Around the pelvic girdle and at the perineum
d. At the perineum
22. A female adult patient is taking a progestin-only oral contraceptive, or minipill. Progestin use may
increase the patient’s risk for:
a. Endometriosis
b. Female hypogonadism
c. Premenstrual syndrome
d. Tubal or ectopic pregnancy
23. A patient with pregnancy-induced hypertension probably exhibits which of the following
symptoms?
a. Proteinuria, headaches, vaginal bleeding
b. Headaches, double vision, vaginal bleeding
c. Proteinuria, headaches, double vision
d. Proteinuria, double vision, uterine contractions
24. Because cervical effacement and dilation are not progressing in a patient in labor, Dr. Smith
orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patient’s fluid
intake and output closely during oxytocin administration?
a. Oxytoxin causes water intoxication
b. Oxytocin causes excessive thirst
c. Oxytoxin is toxic to the kidneys
d. Oxytoxin has a diuretic effect
25. Five hours after birth, a neonate is transferred to the nursery, where the nurse intervenes to
prevent hypothermia. What is a common source of radiant heat loss?
a. Low room humidity
b. Cold weight scale
c. Cools incubator walls
d. Cool room temperature
26. After administering bethanechol to a patient with urine retention, the nurse in charge monitors
the patient for adverse effects. Which is most likely to occur?
a. Decreased peristalsis
b. Increase heart rate
c. Dry mucous membranes
d. Nausea and Vomiting
27. The nurse in charge is caring for a patient who is in the first stage of labor. What is the shortest
but most difficult part of this stage?
a. Active phase
b. Complete phase
c. Latent phase
d. Transitional phase
28. After 3 days of breast-feeding, a postpartal patient reports nipple soreness. To relieve her
discomfort, the nurse should suggest that she:
a. Apply warm compresses to her nipples just before feedings
b. Lubricate her nipples with expressed milk before feeding
c. Dry her nipples with a soft towel after feedings
d. Apply soap directly to her nipples, and then rinse
29. The nurse is developing a teaching plan for a patient who is 8 weeks pregnant. The nurse should
tell the patient that she can expect to feel the fetus move at which time?
a. Between 10 and 12 weeks’ gestation
b. Between 16 and 20 weeks’ gestation
c. Between 21 and 23 weeks’ gestation
d. Between 24 and 26 weeks’ gestation
30. Normal lochial findings in the first 24 hours post-delivery include:
a. Bright red blood
 b. Large clots or tissue fragments
c. A foul odor
d. The complete absence of lochia
1. Nurse Julia is aware that Labor is divided into how many stages?
a. Five
b. Three
c. Two
d. Four

2. Pen, a nurse-midwife determines that a client is in the second stage of labor and may start
pushing. What marks the beginning of the second stage, and what marks the end?
a. Cervical dilation of 7 to 8 cm; complete cervical dilation
b. Complete cervical dilation; delivery of the neonate
c. Cervical dilation of 7 to 8 cm; delivery of the placenta
d. Complete cervical dilation; delivery of the placenta

3. Jannah, who is in labor receives epidural anesthesia. The nurse should assess carefully for
which adverse reaction to the anesthetic agent?
a. Hypotensive crisis
b. Fetal tachycardia
c. Renal toxicity
d. Increased beat-to-beat variability in the fetal heart rate (FHR)

4. Nurse Venice is aware that one of the following is the most serious adverse effect associated
with oxytocin (Pitocin) administration during labor?
a. Tetanic contractions
b. Elevated blood pressure
c. Early decelerations of fetal heart rate
d. Water intoxication

5. Nurse Olive asseses a client for evidence of postpartum hemorrhage during the third stage of
labor. Early signs of this postpartum complication include:
a. an increased pulse rate, decreased respiratory rate, and increased blood pressure.
b. a decreased pulse rate, increased respiratory rate, and increased blood pressure.
c. a decreased pulse rate, decreased respiratory rate, and increased blood pressure.
d. an increased pulse rate, increased respiratory rate, and decreased blood pressure.

6. To promote comfort during labor, Nurse Michelle advises a client to assume certain positions
and avoid others. Which position may cause maternal hypotension and fetal hypoxia?
a. Lateral position
b. Squatting position
c. Supine position
d. Standing position

7. After delivering a neonate, a client delivers the placenta. At this time, where does nurse Adam
expect to palpate the uterine fundus?
a. At the midline, 0.4″ to 0.8″ (1 to 2 cm) above the umbilicus
b. At the midline, 0.4″ to 0.8″ (1 to 2 cm) below the umbilicus
c. Left of the midline, 0.8″ to 1″ (2 to 3 cm) above the umbilicus
d. Left of the midline, 0.8″ to 1″ (2 to 3 cm) below the umbilicus
8. During the active phase of the first stage of labor, Maricris undergoes an amniotomy. After this
procedure, which nursing diagnosis takes the highest priority?
a. Deficient knowledge related to amniotomy
b. Ineffective fetal cerebral tissue perfusion related to cord compression
c. Pain related to increasing strength of contractions
d. Risk for infection related to rupture of membranes

9. A client with active genital herpes is admitted to the labor and delivery area during the first stage
of labor. Which type of birth should nurse Roy anticipate for this client?
a. Mid forceps
b. Low forceps
c. Induction
d. Cesarean

10. After a client enters the second stage of labor, nurse Blessy notes that her amniotic fluid is
port-wine colored. What does this finding suggest?
a. Increased bloody show
b. Normal amniotic fluid
c. Abruptio placentae
d. Meconium

11. Clariz arrives at the health care facility, stating that her bed linens were wet when she woke up
this morning. She says no fluid is leaking but complains of mild abdominal cramps and lower back
discomfort. Vaginal examination reveals cervical dilation of 3 cm, 100% effacement, and positive
ferning. Based on these findings, the nurse concludes that the client is in which phase of the first
stage of labor?
a. Active phase
b. Latent phase
c. Expulsive phase
d. Transitional phase

12. A client in labor tells April that she feels a strong urge to push. Physical examination reveals
that her cervix is not completely dilated. The nurse-midwife tells her not to push yet. What is the
rationale for this instruction?
a. Early pushing may cause edema and impede fetal descent.
b. The nurse-midwife isn’t ready to assist her.
c. The fetus hasn’t rotated into the proper position.
d. Pushing at this time may cause rupture of the membranes.

13. An assisted birth using forceps or a vacuum extractor may be performed for ineffective
pushing, for large infants, to shorten the second stage of labor, or for a malpresentation. Nurse Sally
is caring for the mother following an assisted birth should keep which of the following in mind?
a. A vacuum extractor is safer than forceps because it causes less trauma to the baby and the
mother’s perineum.
b. The baby will develop a cephalohematoma as a result of the instrumentation.
c. The use of instruments during the birth process is a fairly rare occurrence.
d. Additional nursing interventions are needed to ensure an uncomplicated postpartum.

14. Nurse Divina is aware that the following would be an inappropriate indication of placental
detachment?
a. An abrupt lengthening of the cord
b. An increase in the number of contractions
c. Relaxation of the uterus
d. Increased vaginal bleeding

15. When reviewing a fetal monitor strip, nurse Roy looks for reassuring and nonreassuring fetal
heart rate (FHR) patterns. Which pattern is nonreassuring?
a. FHR that accelerates to baseline tachycardia
b. Baseline FHR that doesn’t increase
c. Variable FHR pattern that begins and ends abruptly
d. Short-term variability that doesn’t decrease

16. Nurse Adrian is aware that an expected fetal adverse reaction to meperidine (Demerol) during
labor is:
a. decreased beat-to-beat variability.
b. bradycardia.
c. late decelerations.
d. none known

17. During labor, Amy greatly relies on her husband for support. They previously attended
childbirth education classes, and now he’s working with her on comfort measures. Which nursing
diagnosis would be appropriate for this couple?
a. Ineffective family coping: Compromised related to labor
b. Readiness for enhanced family coping related to participation in pregnancy and delivery
c. Powerlessness related to pain
d. Ineffective role performance related to involvement with the pregnancy

18. Late in the first stage of labor, Olivia receives a spinal block to relieve discomfort. A short time
later, her husband tells the nurse that his wife feels dizzy and is complaining of numbness around
her lips. What do the client’s symptoms suggest?
a. Anesthesia overdose
b. Transition to the second stage of labor
c. Anxiety
d. Dehydration

19. Denice with intrauterine growth retardation is admitted to the labor and delivery unit and started
on an I.V. infusion of oxytocin (Pitocin). Which of the following is least likely to be included in her
plan of care?
a. Carefully titrating the oxytocin based on her pattern of labor
b. Monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes
c. Allowing the client to ambulate as tolerated
d. Helping the client use breathing exercises to manage her contractions

20. Lou is in the first stage of labor enters the labor and delivery area. She seems anxious and
tells the nurse that she hasn’t attended childbirth education classes. Her husband, who accompanies
her, is also unprepared for childbirth. Which nursing intervention would be most effective for the
couple at this time?
a. Teach the client progressive muscle relaxation.
b. Instruct the husband on touch, massage, and breathing patterns.
c. Use hypnosis on the client and her husband.
d. Teach the client and her husband about pain transmission.
21. Which of the following physiologic changes during labor makes it necessary for nurse Hazel to
assess blood pressure frequently?
a. Blood pressure decreases as a sign of maternal pain.
b. Alterations in cardiovascular function affect the fetus
c. Blood pressure decreases at the peak of each contraction.
d. Decreased blood pressure is the first sign of preeclampsia.

22. During the fourth stage of labor, Jessica should be assessed carefully for:
a. uterine atony
b. complete cervical dilation
c. placental expulsion
d. umbilical cord prolapse

23. Several minutes after a vaginal delivery, nursing assessment reveals blood gushing from the
client’s vagina, umbilical cord lengthening, and a globular-shaped uterus. Nurse Luz should suspect
which condition?
a. Cervical or vaginal laceration
b. Placental separation
c. Postpartum hemorrhage
d. Uterine involution

24. Nurse Mariane is caring for a client who’s in labor. The physician still isn’t present. After the
baby’s head is delivered, which nursing intervention would be most appropriate?
a. Checking for the umbilical cord around the baby’s neck\
b. Placing antibiotic ointment in the baby’s eyes
c. Turning the baby’s head to the side to drain secretions
d. Assessing the baby for respirations

25. Vicky, who is in labor shouts to the nurse, “My baby is coming right now! I feel like I have to
push!” An immediate nursing assessment reveals that the head of the fetus is crowning. After asking
another staff member to notify the physician and setting up for delivery, which nursing intervention is
most appropriate?
a. Gently pulling at the baby’s head as it’s delivered
b. Holding the baby’s head back until the physician arrives
c. Applying gentle pressure to the baby’s head as it’s delivered
d. Placing the mother in the Trendelenburg position until the physician arrives

Situation: During an Anatomy and Physiology class, the lecturer discussed about the female
reproductive system.

1. Estrogen, one of the hormones regulating cyclic activities in female reproductive system is
responsible for which effect?
a. Increases the quantity and pH of cervical mucus, causing it to become thin and watery and can
be stretched to a distance of 10-13 cm.
b. Inhibits the production of LH
c. Increases endometrial tortuosity
d. All of the above

2. Jessa, 17 years old, is bleeding between periods of less than two weeks. This condition is an
abnormality in the menstrual cycle known as:
a. Metrorrhagia
b. Menorrhagia
c. Amenorrhea
d. Dysmenorrheal

3. One factor of having a normal delivery is the size of the pelvis. Pelvis serves as the passageway
for the passenger (fetus) during childbirth. The most ideal pelvis for childbirth is:
a. Android
b. Anthropoid
c. Platypelloid
d. Gynecoid

4. An important landmark of the pelvis that determines the distance of the descent of the head is
known as:
a. Linea terminalis
b. Sacrum
c. Ischial spines
d. Ischial tuberosities

5. The permanent cessation of menstruation is:

a. Amenorrhea
b. Menopause
c. Oligomenorrhea
d. Hypomenorrhea

Situation: Mrs. Donna, pregnant for 16 weeks age of gestation (AOG), visits the health care facility
for her prenatal check-up with her only son, Mark. During assessment the client told the nurse that
previously she got pregnant twice. The first was with her only child, Mark, who was delivered at 35
weeks AOG and the other pregnancy was terminated at about 20 weeks AOG.

6. Based on the data obtained, Mrs. Donna’s GTPAL score is:

a. 20111
b. 21111
c. 30111
d. 31111

7. Discomforts during pregnancy are discussed by the nurse to the Mrs. Donna. Which of the
following, when complained by the client would alert the nurse?
a. Easy fatigability
b. Nausea and vomiting
c. Edema of the lower extremities
d. Heartburn

8. Psychological and emotional responses of pregnant women differ. However, general emotional
response has been noted during pregnancy based on their gestational age. Mrs. Donna will most
likely have which emotional response towards her pregnancy?
a. Presents denial disbelief and sometimes repression.
b. Has personal identification of the baby and realistic plans for future of the child.
c. Fantasizes the appearance of the baby.
d. Verbalizes fear of death during childbirth.
9. The nurse assisted Mrs. Donna to a dorsal recumbent position and is about to assess the fetal
heart rate (FHR). Which of the following apparatus should the nurse use in auscultating for the FHR?
a. Doppler apparatus
b. Fetoscope
c. Ultrasound
d. Stethoscope

10. Mrs. Donna asked the nurse, when a fetal heart starts beating. The nurse correctly responded
by stating:
a. 3 weeks AOG
b. 8 weeks AOG
c. 12 weeks AOG
d. 20 weeks AOG

Situation: Mrs. Dela Cruz is in labor and is brought to the emergency room with a ruptured bag of
water.

11. The nurse’s initial action once the bag of water has ruptured is:
a. Take the fetal heart tones
b. Put the client to the bed immediately
c. Perform an IE
d. Take the woman’s temperature

12. Mrs. Dela Cruz’s has contractions growing stronger which lasts for 40-60 seconds and occur
approximately every 3-5 minutes. The doctor is about to perform an IE, the nurse expects that the
client’s cervical dilatation will be:
a. 0-3 cm
b. 4-7 cm
c. 8-10 cm
d. 11-13 cm

13. The doctor informed the woman that she is on station -1. Mrs. Dela Cruz asked the nurse, what
does a station -1 means, the most appropriate response of the nurse is:
a. “It means that engagement has already occurred.”
b. “The presenting part of your baby is at the entrance of the true pelvis or the largest diameter of
the presenting part into the true pelvis.”
c. “Your baby is still floating or “ballotable”
d. “The presenting part of your baby is at the vulvar ring of your reproductive organ.”

14. The history of Mrs. Dela Cruz revealed that she is a multipara. When should the nurse
transport the client from the labor room to the delivery room?
a. When the cervical dilatation is 8 cm.
b. When the cervical dilatation is 10 cm.
c. When the cervical dilatation is 9 cm.
d. When the client feels the urge to push.

15. Monitoring contractions is very important during labor. To monitor uterine contractions, what
should the nurse do?
a. Observe for the client’s facial expression to know that the contraction has started or stopped.
b. Instruct the client take note of the duration of her contractions.
c. Offer ice chips to the woman.
d. Spread the fingers lightly over the fundus to monitor the contraction.

16. Uterine contractions can occur because of the interplay of the contractile enzyme adenosine
triphosphate and the influence some hormones. Which of the following least likely contributes to the
occurrence of uterine contractions?
a. Oxytocin
b. Estrogen
c. Prolactin
d. All of the above

17. Dysfunctional labor may be caused by which of the following?

a. Excessive or too early analgesia administration
b. Exhausted mother
c. Overdistention of the uterus
d. All of the above

18. The client’s uterine contractions are hypotonic. The nurses top priority with hypotonic
contractions during the intrapartal period is:
a. Pain relief
b. Psychological support
c. Monitoring the lochia for possible bleeding
d. Infection control

19. For a woman experiencing hypotonic contractions, what should be done initially?
a. Obtain an ultrasonic result
b. Infusion of oxytocin
c. Administration of analgesia
d. Amniotomy

20. The most important nursing consideration in a postpartal woman with a hypotonic contraction
is:
a. Assessment for infection
b. Assessment for bleeding
c. Assessment for FHR
d. Assessment for woman’s coping mechanism

Situation: Bleeding during pregnancy is a serious case and should be managed immediately.

21. Mrs. Diane is diagnosed with Placenta Previa. The main difference with the bleeding in
placenta previa and abruption placenta is that placenta previa has:
a. Painful bleeding
b. Rigid abdomen
c. Bright-red blood
d. Blood filled with clots

22. In caring for a client diagnosed with placenta previa, the nurse should avoid which of the
following?
a. Inspecting the perineum
b. Performing a Kleihauer-Betke test
c. Performing a pelvic examination
d. All of the above

23. For the nurse to distinguish that the bleeding of the patient is placenta previa or abruption
placenta what should she ask the woman?
a. Whether there was accompanying pain
b. What she has done for bleeding
c. Estimation of blood loss
d. All of the above

24. Continued bleeding may result to fetal distress. The nurse knows that the fetus is being
compromised when she observed or note which of the following:
a. Fetal tachycardia
b. Fetal bradycardia
c. Fetal thrashing
d. All of the above

25. A woman in labor is diagnosed with abruption placenta. The nurse would expect which findings
in the client’s history that may contribute to the occurrence of the complication?
a. Age of 24 years old
b. Cigarette smoking
c. Sleeping 8 hours per night
d. Sitting for long period

1. Andrea with suspected rheumatic fever is admitted to the pediatric unit. When obtaining the
child’s history, the nurse considers which information to be most important?
a. A fever that started 3 days ago
b. Lack of interest in food
c. A recent episode of pharyngitis
d. Vomiting for 2 days

2. Nurse Liza is administering a medication via the intraosseous route to a child. Intraosseous drug
administration is typically used when a child is:
a. Under age 3
b. Over age 3
c. Critically ill and under age 3
d. Critically ill and over age 3

3. When assessing a child’s cultural background, the nurse in charge should keep in mind that:
a. Cultural background usually has little bearing on a family’s health practices
b. Physical characteristics mark the child as part of a particular culture
c. Heritage dictates a group’s shared values
d. Behavioral patterns are passed from one generation to the next

4. While examining a 2-year-old child, the nurse in charge sees that the anterior fontanel is open.
The nurse should:
a. Notify the doctor
b. Look for other signs of abuse
c. Recognize this as a normal finding
d. Ask about a family history of Tay-Sachs disease
5. The nurse is aware that the most common assessment finding in a child with ulcerative colitis
is:
a. Intense abdominal cramps
b. Profuse diarrhea
c. Anal fissures
d. Abdominal distention

6. When administering an I.M. injection to an infant, the nurse in charge should use which site?
a. Deltoid
b. Dorsogluteal
c. Ventrogluteal
d. Vastus lateralis

7. A child with a poor nutritional status and weight loss is at risk for a negative nitrogen balance. To
help diagnose this problem, the nurse in charge anticipates that the doctor will order which
laboratory test?
a. Total iron-binding capacity
b. Hemoglobin
c. Total protein
d. Serum transferring

8. When developing a plan of care for a male adolescent, the nurse considers the child’s
psychosocial needs. During adolescence, psychosocial development focuses on:
a. Becoming industrious
b. Establishing an identity
c. Achieving intimacy
d. Developing initiative

9. When developing a plan care for a hospitalized child, nurse Mica knows that children in which
age group are most likely to view illness as a punishment for misdeeds?
a. Infancy
b. Preschool age
c. Scholl age
d. Adolescence

10. Nurse Taylor suspects that a child, age 4, is being neglected physically. To best assess the
child’s nutritional status, the nurse should ask the parents which question?
a. “Has your child always been so thin?”
b. “Is your child a picky eater?”
c. “What did your child eat for breakfast?”
d. “Do you think your child eats enough?”

11. A female child, age 2, is brought to the emergency department after ingesting an unknown
number of aspirin tablets about 30 minutes earlier. On entering the examination room, the child is
crying and clinging to the mother. Which data should the nurse obtain first?
a. Heart rate, respiratory rate, and blood pressure
b. Recent exposure to communicable diseases
c. Number of immunizations received
d. Height and weight
12. A mother asks the nurse how to handle her 5-year-old child, who recently started wetting the
pants after being completely toilet trained. The child just started attending nursery school 2 days a
week. Which principle should guide the nurse’s response?
a. The child forgets previously learned skills
b. The child experiences growth while regressing, regrouping, and then progressing
c. The parents may refer less mature behaviors
d. The child returns to a level of behavior that increases the sense of security.

13. A female child, age 6, is brought to the health clinic for a routine checkup. To assess the child’s
vision, the nurse should ask:
a. “Do you have any problems seeing different colors?”
b. “Do you have trouble seeing at night?”
c. “Do you have problems with glare?”
d. “How are you doing in school?”

14. During a well-baby visit, Jenny asks the nurse when she should start giving her infant solid
foods. The nurse should instruct her to introduce which solid food first?
a. Applesauce
b. Egg whites
c. Rice cereal
d. Yogurt

15. To decrease the likelihood of bradyarrhythmias in children during endotracheal intubation,

succinylcholine (Anectine) is used with which of the following agents?
a. Epinephrine (Adrenalin)
b. Isoproterenol (Isuprel)
c. Atropine sulfate
d. Lidocaine hydrochloride (Xylocaine)

16. A 1 year and 2-month-old child weighing 26 lb (11.8 kg) is admitted for traction to treat
congenital hip dislocation. When preparing the patient’s room, the nurse anticipates using which
traction system?
a. Bryant’s traction
b. Buck’s extension traction
c. Overhead suspension traction
d. 90-90 traction

17. Mandy, age 12, is 7 months pregnant. When teaching parenting skills to an adolescent, the
nurse knows that which teaching strategy is least effective?
a. Providing a one-on-one demonstration and requesting a return demonstration, using a live infant
model
b. Initiating a teenage parent support group with first – and – second-time mothers
c. Using audiovisual aids that show discussions of feelings and skills
d. Providing age-appropriate reading materials

18. When performing a physical examination on an infant, the nurse in charge notes abnormally
low-set ears. This findings is associated with:
a. Otogenous tetanus
b. Tracheoesophageal fistula
c. Congenital heart defects
d. Renal anomalies
19. Nurse Raven should expect a 3-year-old child to be able to perform which action?
a. Ride a tricycle
b. Tie the shoelaces
c. Roller-skates
d. Jump rope

20. Nurse Betina is teaching a group of parents about otitis media. When discussing why children
are predisposed to this disorder, the nurse should mention the significance of which anatomical
feature?
a. Eustachian tubes
b. Nasopharynx
c. Tympanic membrane
d. External ear canal

21. The nurse is evaluating a female child with acute poststreptoccocal glomerulonephritis for
signs of improvement. Which finding typically is the earliest sign of improvement?
a. Increased urine output
b. Increased appetite
c. Increased energy level
d. Decreased diarrhea

22. Dr. Smith prescribes corticosteroids for a child with nephritic syndrome. What is the primary
purpose of administering corticosteroids to this child?
a. To increase blood pressure
b. To reduce inflammation
c. To decrease proteinuria
d. To prevent infection

23. Parents bring their infant to the clinic, seeking treatment for vomiting and diarrhea that has
lasted for 2 days. On assessment, the nurse in charge detects dry mucous membranes and lethargy.
What other findings suggests a fluid volume deficit?
a. A sunken fontanel
b. Decreased pulse rate
c. Increased blood pressure
d. Low urine specific gravity

24. How should the nurse May prepare a suspension before administration?
a. By diluting it with normal saline solution
b. By diluting it with 5% dextrose solution
c. By shaking it so that all the drug particles are dispersed uniformly
d. By crushing remaining particles with a mortar and pestle

25. What should be the initial bolus of crystalloid fluid replacement for a pediatric patient in shock?
a. 20 ml/kg
b. 10 ml/kg
c. 30 ml/kg
d. 15 ml/kg

26. Becky, age 5, with intelligence quotient of 65 is admitted to the hospital for evaluation. When
planning care, the nurse should keep in mind that this child is:
a. Within the lower range of normal intelligence
b. Mildly retarded but educable
c. Moderately retarded but trainable
d. Completely dependent on others for care

27. Maureen, age 12, is brought to the clinic for evaluation for a suspected eating disorder. To best
assess the effects of role and relationship patterns on the child’s nutritional intake, the nurse should
ask:
a. “What activities do you engage in during the day?”
b. “Do you have any allergies to foods?”
c. “Do you like yourself physically?”
d. “What kinds of food do you like to eat?”

28. Sudden infant death syndrome (SIDS) is one of the most common causes of death in infants.
At what age is the diagnosis of SIDS most likely?
a. At 1 to 2 years of age
b. At I week to 1 year of age, peaking at 2 to 4 months
c. At 6 months to 1 year of age, peaking at 10 months
d. At 6 to 8 weeks of age

29. When evaluating a severely depressed adolescent, the nurse knows that one indicator of a
high risk for suicide is:
a. Depression
b. Excessive sleepiness
c. A history of cocaine use
d. A preoccupation with death

30. A child is diagnosed with Wilms’ tumor. During assessment, the nurse in charge expects to
detect:
a. Gross hematuria
b. Dysuria
c. Nausea and vomiting
d. An abdominal mass