Definition

Bag technique -- a tool making use of public health bag through which the nurse, during
his/her home visit, can perform nursing procedures with ease and deftness, saving time
and effort with the end in view of rendering effective nursing care.
Public health bag - is an essential and indispensable equipment of the public health nurse
which he/she has to carry along when he/she goes out home visiting. It contains basic
medications and articles which are necessary for giving care.
Rationale
To render effective nursing care to clients and /or members of the family during home
visit.
Principles
The use of the bag technique should minimize if not totally prevent the spread of
infection from individuals to families, hence, to the community.
Bag technique should save time and effort on the part of the nurse in the performance of
nursing procedures.
Bag technique should not overshadow concern for the patient rather should show the
effectiveness of total care given to an individual or family.
Bag technique can be performed in a variety of ways depending upon agency policies,
actual home situation, etc., as long as principles of avoiding transfer of infection is
carried out.

Maternal and Child Nursing Comprehensive

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1. A client in the 28th week gestation comes to the emergency department because she thinks that she is in
labor. To confirm a diagnosis of preterm labor, the nurse would expect physical examination to reveal:
a. Irregular uterine contractions with no cervical dilatation
b. Painful contractions with no cervical dilatation
c. Regular uterine contractions with cervical dilatation
d. Regular uterine contractions with no cervical dilatation
Ans: C – regular uterine contractions (every 10 minutes or more) along with cervical dilation before 36
weeks’ gestation or rupture of fluids indicates preterm labor. Uterine contractions without cervical change
don’t indicate preterm labor.

2. A client in the active phase of labor has reactive fetal monitor strip and has been encouraged to walk.
When she returns to bed for a monitor check, she complains of an urge to push. When performing vaginal
examination, the nurse accidentally ruptures the amniotic membranes, the umbilical cord comes out. What
should be done next?
a. Put the client in a knee-chest position
b. Call the physician or midwife
c. Push down on the uterine fundus
d. Set up for a fetal blood sampling to assess for fetal acidosis
Ans: A – the knee–to–chest position gets the weight off the baby and umbilical cord, which would prevent
blood flow. Calling d physician or midwife and setting up for blood sampling is important, but they have a
lower priority than getting d baby off the cord. Pushing down on d fundus would increase d danger by
further compromising blood flow.

3. A client is attempting to deliver vaginally despite the fact that her previous delivery was by cesarean
section. Her contractions are 2 to 3 minutes apart, lasting from 75 to 100 seconds. Suddenly, the client
complaints of intense abdominal pain and the fetal monitor stops picking up contractions. The nurse
recognizes that which of the following has occurred?
a. Abruptio placentae
b. Prolapsed cord
c. Partial placenta previa
d. Complete uterine rupture
Ans: D – in complete uterine rupture, the client would feel a sharp pain in the lower abdomen and
contractions would cease. Fetal heart rate would also cease within a few minutes. Uterine irritability would
continue to be indicated by the fetal heart monitor tracing with abruption placentae. With a prolapsed cord,
contractions would continue and there would be no pain from d prolapse itself. There would be vaginal
bleeding with a partial placenta previa, but no pain outside of the expected pain of contractions.

4. A client with gravida 3 para 2 at 40 weeks gestation is admitted with spontaneous contractions. The
physician performs an amniotomy to augment her labor. The priority nursing action is to:
a. Explain the rationale for the amniotomy to the client
b. Assess fetal heart tones after the amniotomy
c. Ambulate the client to strengthen the contraction pattern
d. Position the client in a lithotomy position to administer perineal care
Ans: B - the nurse should assess fetal heart tones. After an amniotomy is performed, the umbilical cord
may be washed down below the presenting part and cause umbilical cord compression, which would be
indicated by variable deceleration on the fetal heart tracing. An explanation of the rationale for amniotomy
would be given before d procedure. After assessing the fetal response to the amniotomy, perineal care s
provided. The nurse would ambulate client only if the presenting part were engaged.

5. The nurse can consider the fetus’s head to be engaged when:

a. The presenting part moves through the pelvis
b. The fetal head rotates to pass through the ischial spines
c. The fetal head extends as it passes under the symphysis pubis
d. The biparietal diameter passes the pelvic inlet
Ans: D – d fetus’s head s considered engaged when the biparietal diameter passes d pelvic inlet. The
presenting part moving through d pelvis s called descent. The head flexing so that the chin moves closer to
d chest s called flexion. Rotation of the head to pass through the ischial spines is called internal rotation.
Extension of the head as it passes under d symphysis pubis s called extension.

6. A client is experiencing true labor when her contraction pattern shows:

a. Occasional irregular contractions
b. Irregular contractions that increase in intensity
c. Regular contractions that remain the same
d. Regular contractions that increase in frequency and duration
Ans: D- regular contractions that increase in frequency and duration as well as intensity indicate true labor.
The other choices don’t describe d contraction pattern of true labor.

7. A client is admitted to the hospital with contractions that are about 1 to 2 minutes apart and reveal that
her cervix is dilated 8 cm. The client is in which stage of labor?
a. Latent phase
b. Active phase
c. Third stage
d. Transitional phase
Ans: D- d client is in d transitional phase of labor. This phase of labor is characterized by cervical dilation
of 8 to 10 cm and contractions that are about 1 to 2 minutes apart and last for 60 to 90 seconds with strong
intensity. In the latent phase, the cervix is dilated 0 to 3 cm and contractions are irregular. During the active
phase, the cervix is dilated to 4 to 7 cm and contractions are about 5 to 8 minutes apart and last 45 to 60
seconds with moderate to strong intensity. The 3rd stage of labor extends from delivery of the neonate to
expulsion of the placenta and lasts from 5 to 30 minutes.

8. A client in the second stage of labor experiences rupture of membranes. The most appropriate
intervention by the nurse is to:
a. Assess the client’s vital signs immediately
b. Observe for prolapsed cord and monitor fetal heart rate
c. Administer oxygen through a face mask at 6-10 L per min
d. Position the client on her side
Ans: B – the nurse should immediately check for prolapsed cord and monitor FHR. When the membranes
rupture, the cord may become compressed between the fetus and maternal cervix or pelvis, thus
compromising fetoplacental perfusion. It isn’t necessary to position the client on her left side, monitor
maternal vital signs, or administer oxygen when the client’s membrane rupture.

9. A client in labor is being monitored by an internal electronic device to evaluate fetal station. The nurse
measures the duration of her contractions by:
a. Measuring from the beginning of the increment to the end of the decrement
b. Measuring from the beginning of one contraction to the beginning of the next
c. Measuring from the beginning of the decrement to the end of the increment
d. Using an intrauterine catheter that measures increases in contraction
Ans: A- the duration of a contraction is measured from the beginning of the increment to the end of the
decrement. Measuring from the beginning of one contraction to the beginning of the next reveals
frequency. Measuring from the beginning of one contraction to the beginning of the next reveals frequency.
Measuring during the acme phase of a contraction reveals intensity (measured with an intrauterine catheter
or by palpation).

10. A client is receiving magnesium sulfate to help suppress preterm labor. The nurse should watch for
which sign of magnesium toxicity?
a. Headache
b. Loss of deep tendon reflexes
c. Palpitations
d. Dyspepsia
Ans: B – magnesium toxicity causes signs of central nervous system depression, such as loss of deep
tendon reflexes, paralysis, respiratory depression, drowsiness, lethargy, blurred vision, slurred speech, and
confusion. Headache may be an adverse effect of calcium channel blockers, which are sometimes used to
treat preterm labor. Palpitations are an adverse effect of terbutaline and ritodrine, which are also used to
treat preterm labor. Dyspepsin may occur as an adverse effect of indomethacin, a prostaglandin synthesize
inhibitor, used to suppress preterm labor.

11. When assessing a postpartum client for uterine bleeding, the nurse finds the fundus to be boggy. After
fundal massage, the physician prescribes 0.2 mg of methylergonovine (Methergine) by mouth. What should
the nurse tell the client?
a. “Methergine is commonly used to help the uterus contract so that the bleeding will decrease. You may
experience more cramping as your uterus becomes firmer.”
b. “You will probably take this medication until you are discharged from the hospital. Every patient usually
needs to take this medication.”
c. “If your blood pressure is low, you won’t be able to take this medication; I will establish a new IV line so
I can start Pitocin again.”
d. “Most people don’t experience additional pain or cramping from taking this medication.”
Ans: A – Methylergonovine, an ergot alkaloid, is commonly given to stimulate sustained uterine
contraction. It allows the uterus to remain contracted and firm, thus decreasing postpartum bleeding.
Abdominal cramping, which may become painful, is a common adverse effect. Methergine is discontinued
when the lochia flow has decreased or the client complains of severe cramping. Clients may need only a
few doses of Methergine to keep the uterus contracted. Taking Methergine is contraindicated in clients with
hypertension.

12. The nurse is providing care for a postpartum client. Which of the following conditions would place this
client at greater risk for postpartum hemorrhage?
a. Hypertension
b. Uterine infection
c. Placenta previa
d. Severe pain
Ans: C – d client with placenta previa is at greatest risk for postpartum hemorrhage. In placenta previa, the
lower uterine segment doesn’t contract as well as the fundal part of the uterus; therefore, more bleeding
occurs. Hypertension, severe pain, and uterine infection don’t place the client at increased risk for
postpartum hemorrhage.

13. A client has delivered twins. What is the most important intervention for the nurse to perform?
a. Assess fundal tone and lochia flow
b. Apply a cold pack to the perineal area
c. Administer analgesics as ordered
d. Encourage voiding by offering the bedpan
Ans: A – women who experience a twin delivery are at a higher risk for postpartum hemorrhage due to
overdistention of d uterus, which causes uterine atony. Assessing fundal tone and lochia flow helps to
determine risks for hemorrhage. Applying cold packs to d perineum, administering analgesics as ordered,
and offering d bedpan r all significant nursing interventions, however, detecting and preventing postpartum
hemorrhage s most important.

14. Which of the following is a normal physiological response in the early postpartum period?
a. Urinary urgency and dysuria
b. Rapid diuresis
c. Decrease in blood pressure
d. Increased motility of the GI system
Ans: B – in d early postpartum period there s an increase in the glomerular filtration rate and a drop in
progesterone levels, which result in rapid diuresis. There should be no urinary urgency, although a woman
may be anxious about voiding. There is minimal change n blood pressure following childbirth and a
residual decrease in gastrointestinal motility.

15. During the 3rd postpartum day, which of the following would the nurse be most likely to find in the
client?
a. She’s interested in learning more about newborn care
b. She talks a lot about her birth experience
c. She sleeps whenever the baby isn’t present
d. She requests help in choosing a name for the baby
Ans: A – d 3rd to 10th days of postpartum care are the “taking–hold” phase, in which the new mother
strives for independence and s eager for her baby.
B, C & D – describe d phase n which d mother relives her birth experience.

16. Which of the following circumstances is most likely to cause uterine atony, leading to postpartum
hemorrhage?
a. Hypertension
b. Cervical and vaginal tears
c. Urine retention
d. Endometriosis
Ans: C – urine retention is most likely to cause uterine atony and subsequent postpartum hemorrhage.
Urine retention causes a distended bladder to displace the uterus above the umbilicus and to the side, which
prevents d uterus from contracting. The uterus needs to remain contacted if bleeding is to stay within
normal limits. Cervical and vaginal tears can cause postpartum hemorrhage, but in the postpartum period, a
full bladder is the most common cause of uterine bleeding. Endometritis, an infection of the inner lining of
the endometrium, and maternal hypertension don’t cause postpartum hemorrhage.
17. When assessing a client’s episiotomy, the nurse should be especially careful to observe:
a. Location
b. Discharge and odor
c. Edema and approximation
d. Subinvolution
Ans: C – an episiotomy should be assessed for edema and approximation of incision. An edematous
perineum causes more tension of d suture line and increased pain. Although d sutures may be difficult to
visualize, the suture line should be intact. Episiotomy location is important, but not as important as the
presence of edema. Discharge and odor refer to an assessment of lochia. Subinvolution refers to the
complete return of the uterus to its prepregnancy size and shape.

18. In performing a routine fundal assessment, the nurse finds that the client’s fundus is boggy. The nurse
should first:
a. Call the physician
b. Massage the fundus
c. Assess lochia flow
d. Obtain an order for methylergonovine
Ans: B – the nurse should begin to massage the uterus so that it will be stimulated to contract. Assessing
lochia flow can be done while the uterus is being massaged. The nurse shouldn’t leave the client to call the
physician. If the fundus remains boggy and the uterus continues to bleed, the nurse should use the call
button to ask another nurse to call d physician. Methylergonovine may be prescribed, if needed.

19. Which type of lochia should the nurse expect to find in a client who is 2 days postpartum?
a. Foul smelling
b. Serosa
c. Alba
d. Rubra
Ans: D – lochia rubra lasts about 4 days followed by lochia serosa, which extends through the 7th day, and
then lochia alba, which occurs during the 2nd and 3rd postpartum weeks. Foul–smelling lochia s a sign of
infection.

20. A client treated with magnesium sulfate during labor is now on the postpartum unit. The nurse should
be aware that the client is at risk for which of the following complications of magnesium sulfate therapy?
a. Hypotension
b. Uterine infection
c. Postpartum hemorrhage
d. Postpartum depression
Ans: C – because magnesium sulfate produces a smooth muscle depressive effect, the uterus should be
assessed for uterine atony. The uterus may be unable to maintain a firm tone, thus increasing the risk of
postpartum hemorrhage. Uterine infection and postpartum depression aren’t associated with magnesium
sulfate therapy. Magnesium sulfate does decrease blood pressure, but it’s considered more of
ananticonvulsant drug than an antihypertensive drug.

21. The nurse is assessing an infant with tracheoesophageal fistula. Which finding would the nurse expect
to encounter?
a. Increase in saliva
b. Gastric tube easily passed
c. Feeding without difficulty
d. Normal chest x-ray
Ans: A – d infant’s inability to swallow saliva leads to an increase in saliva. The other options aren’t likely
findings in tracheoesophageal fistula. The infant is unable to pass a gastric tube. During feedings, the infant
is at risk for choking and cyanosis. Pulmonary infiltrates, labor collapse, and atelectasis frequently appear
on the chest x – ray.

22. A client is scheduled for amniocentesis. When preparing her for the procedure, the nurse should:
a. Ask her to void
b. Instruct her to drink 1 liter of fluid
c. Prepare her for IV anesthesia
d. Place her on her side
Ans: A – to prepare a client for amnioceptesis, the nurse should ask d client to empty her bladder to reduce
the risk of bladder perforation. The nurse may instruct the client to drink 1 L of fluid to fill d bladder before
transabdominal ultrasound (unless ultrasound is done before amniocentesis to locate the placenta). I.V.
anesthesia isn’t given for amniocentesis. The client should be supine during the procedure; after ward, she
should be placed on her left side to avoid supine hypotension, promote venous return, and ensure adequate
cardiac output.

23. Six hours after birth, a neonate is transferred to the nursery. The nurse is planning interventions to
prevent hypothermia. What is a common source of radiant heat loss?
a. Low room humidity
b. Cold weight scale
c. Cool incubator walls
d. Cool room temperature
Ans: C – common sources of radiant heat loss include cool incubator walls and windows. Low room
humidity promotes evaporative heat loss. When the skin directly contacts a cooler object, such as a cold
weight scale, conductive heat loss may occur. A cool room temperature may lead to convective heat loss.

24. A client is in the 25th week of pregnancy. Which procedure is used to detect anomalies?
a. Amniocentesis
b. Chorionic villi sampling
c. Fetoscopy
d. Ultrasound
Ans: D – ultrasound is used between 18 and 40 weeks’ gestation to identify normal fetal growth and detect
fetal anomalies and other problems. Amniocentesis is done during the 3rd trimester to determine fetal lung
maturity. Chorionic villi sampling is performed at 8 to 12 week’s gestation to detect genetic disease.
Fetoscopy is done at about 18 weeks’ gestation to observe the fetus directly and obtain a skin specimen or
blood sample.

25. Which nursing intervention has priority when feeding an infant with a cleft lip or palate?
a. Directing the flow of milk in the center of the mouth
b. Providing frequent, small feedings
c. Avoiding breastfeeding
d. Infrequent burping
Ans: B – frequent small feedings help to prevent fatigue and frustration in the infant. The flow of milk
should be directed to side of the mouth. Breastfeeding may be possible. These infant’s need frequent
burping because of d large amount of air swallowed while feeding.

26. During physical examination, a client in her 32nd week of pregnancy becomes pale, dizzy and light-
headed while supine. Which intervention takes priority?
a. Turning the client onto her left side
b. Asking the client to breathe deeply
c. Listening to fetal heart tones
d. Measuring the client’s blood pressure
Ans: A - as the uterus enlarges, pressure on the inferior vena cava increased, compromising venous return
and causing blood pressure to drop. This may lead to syncope and other symptoms when the client is
supine. Turning the client onto her left side relieves pressure on the vena cava, restoring normal venous
return and blood pressure. Deep breathing wouldn’t relieve this client’s symptoms. Listening to fetal heart
tones and measuring the client’s blood pressure don’t provide relevant information.

27. A client has meconium-stained amniotic fluid. The fetal monitor strip shows fetal bradycardia. Fetal
blood sampling indicates a pH of 7.12. Based on this finding, which nursing intervention is called for?
a. Administer oxygen, as prescribed
b. Prepare for cesarean delivery
c. Reposition the client
d. Start IV oxytocin infusion, as prescribed
Ans: B – fetal blood pH of 7.19 or lower signals severe fetal acidosis; meconium–stained amniotic fluid
and bradycardia are additional signs of fetal distress that warrant cesarean delivery. Oxygen administration
and client repositioning may improve uteroplacental perfusion but are only temporary measures. Oxytoxin
administration increased contractions, exacerbating fetal stress.

28. Which of the following phases of uterine contractions is described as the letting-down phase?
a. Increment
b. Decrement
c. Acme
d. Variability
Ans: B – decrement is the letting–down phase of uterine contractions. Increment refers to the building–up
phase, and acme is the peak of the contraction. Variability refers to the normal variation in the heart rate,
caused by continuous interplay other parasympathetic and sympathetic nervous systems.

29. Which diagnostic procedure will best determine whether a client in labor has spontaneous rupture of
amniotic membranes?
a. Complete blood count
b. Fern test
c. Urinalysis
d. Vaginal examination
Ans: B – a fern test indicates spontaneous rapture of amniotic membranes. The name of this test refers to
the microscopic fernlike pattern produced by sodium chloride crystallization in dried amniotic fluid, which
indicates the presence of ruptured amniotic membranes. A complete blood count might indicate infection
(if white blood cells are increased), but it won’t indicate whether the amniotic sac had ruptured. Urinalysis
doesn’t test for d presence of amniotic fluid. A vaginal examination may determine whether the membranes
have ruptured but isn’t conclusive.

30. A client is admitted to the hospital in preterm labor. To halt her uterine contractions, the nurse expects
to administer:
a. Magnesium sulfate
b. Dinoprostone
c. Ergonovine maleate
d. Terbutaline
Ans: D – terbutaline, a beta 2–receptor agonist, is used to inhibit preterm uterine contractions. Magnesium
sulfate is used to treat pregnancy–induced hypertension. Dinoprostone is used to induce fetal expulsion and
promote cervical dilation and softening. Ergonovine maleate is used to stop uterine blood flow, for
example, in hemorrhage.

31. A 2-year-old child is admitted to the hospital with Hirschprung’s disease. During the nursing history,
the mother describes the child’s stools to the nurse as foul-smelling and:
a. Small, hard pebbles
b. Large and frothy
c. Cordlike
d. Ribbonlike
Ans: D – choices A and C are not characteristic of Hirschprung’s disease. Choice B is characteristic of
cystic fibrosis. Ribbonlike stool pattern is characteristic of agangionic colon.

32. The nurse explains to a toddler’s parents that the treatment of choice for congenital aganglionic
megacolon would be:
a. Surgical removal of affected colon
b. Modified diet high in fiber
c. Medication to stimulate the colon
d. Permanent colostomy
Ans: A – the aganglionic section of the colon is removed so the remaining intestines can function. Diet
changes will not make a difference owing to the lack of peristalsis. There is no medication that will make
an aganglionic colon function. A permanent colostomy is not necessary. A temporary colostomy is
performed using a two or three stage procedure to correct the problem.

33. A 7-year-old child is admitted to the hospital with nephritic syndrome. In the assessment phase, the
nurse is aware that a classic symptom is:
a. Increased urine output
b. Hematuria
c. Elevated blood pressure
d. Proteinuria
Ans: D – there is decreased urine output. Hematuria is positive in glomerulonephritis. The blood pressure is
normal or slightly below normal. There is a massive proteinuria.

34. During the edematous phase of nephritic syndrome, an important nursing intervention is to:
a. Provide meticulous skin care
b. Encourage fluid intake
c. Encourage moderate activity
d. Weigh the client every other day
Ans: A – edema increases the potential for skin breakdown, so skin care is extremely important. Fluid
intake is limited to decrease the workload on the circulatory system with the excess fluid. The child should
e weighed at least daily and often twice a day.

35. In evaluating the effectiveness of the prednisone therapy, the nurse realizes that a child with nephritic
syndrome will continue to take the drug until after:
a. Edema has disappeared
b. Urine no longer contains protein
c. Hematuria has resolved
d. His “moon” face has disappeared
Ans: B – some edema may continue even after the drug has been stopped. Prednisone is continued as long
as there is protein in the urine. Hematuria is a symptom of glomerulonephritis and not nephrosis. His
“moon” face is a side effect of the drug and will continue as long as prednisone is taken.

36. A mother brings her 3-year-old son to the emergency room. He is crying with apparent acute abdominal
pain. After initial assessment, intussusception is suspected. What type of characteristic stool would the
mother most likely report?
a. Black tarlike
b. Ribbonlike
c. Red currant-jellylike
d. Frothy and foul-smelling
Ans: C – choice A would indicate old blood in the stool. Choice B is characteristic of Hirschprung’s
disease. Choice C is characteristic of intussusception and indicates fresh blood. Choice D is characteristic
of cystic fibrosis.

37. A one-moth-old infant is at the physician’s office for a follow-up visit after surgery for pyloric stenosis.
Which of the following is the best indicator that the infant is recovering well from his surgery?
a. Mother reports infants feeding well every 4 hours
b. The infant has demonstrated a satisfactory weight gain
c. The infant is in the 90% in length on the growth chart
d. Mother reports infant has a normal stool pattern
Ans: B – choice A is subjective information and therefore not the best answer. Choice B is objective
information that indicates the infant is maintaining and absorbing his feedings. Choice C is not directly
related to food absorption. Choice D is subjective information and not the best indicator of food intake and
absorption.

38. A baby has died from sudden infant death syndrome (SIDS). SIDS is often initially mistaken for:
a. Failure to thrive
b. Viral infection
c. Meningitis
d. Child abuse
Ans: D – choice A, B and C and conditions that have no symptoms that could be mistaken for SIDS.
Bruising occurs due to the pooling and settling of blood once the infant has died. This gives the appearance
that the child has been beaten.

39. During the initial assessment of a child with Reye’s syndrome, the mother reports that about a week
ago, the child had:
a. Mumps
b. Meningitis
c. Influenza
d. Cellulites
Ans: C – choices A, B and D are conditions not associated with Reye’s syndrome. Influenza usually
precedes Reye’s syndrome.

40. The most important nursing intervention in caring for a child with Reye’s syndrome is to:
a. Prevent skin breakdown
b. Monitor intake and output
c. Do range-of-motion exercises
d. Turn every 2 hours
Ans: B – this is not a life-threatening problem. Careful monitoring of intake and output aids in preventing
cerebral edema or dehydration. Choice c is not associated with a life-threatening problem. This intervention
is not as important as preventing cerebral edema or dehydration.

41. Because of liver involvement associated with Reye’s syndrome, the nurse should use which special
caution when caring for children with this condition:
a. Administering IM injections
b. Monitoring output from the catheter
c. Assessing the level of consciousness
d. Turning the child
Ans: A – prolonged bleeding may occur owing to impaired coagulation. Pressure should be applied to the
injection site for a longer period of time. Choices B, C and D are not related to liver function.

42. A one-year-old infant is admitted to the hospital to rule out cystic fibrosis. During the admission
process the infant passes a stool. The nurse realizing that his stool is symptomatic of cystic fibrosis, charts
it as:
a. Small and constipated
b. Green and odorous
c. Large and bulky
d. Yellow and loose
Ans: C – choice A and D type of stool are not symptomatic of CF. Stools are not green but are foul
smelling. Nondigested food, owing to malabsorption, is excreted, causing an increase in amount and bulk
of stools.

43. A child is diagnosed with cystic fibrosis. He is receiving pancreatic enzymes. Once the pancreatic
enzymes the child is taking are effective, he will:
a. Have normal bowel movements
b. Increase 2 lb in weight per week
c. Have decreased NaCl in his sweat
d. Have fewer respiratory infections per year
Ans: A – pancreatic enzymes aid in absorption of nutrients from the intestines so the stools become normal.
Choice B is not a realistic weight gain. Pancreatic enzymes are not related to the respiratory system.
Pancreatic enzymes are not related to the respiratory system. Pancreatic enzymes are not related to the
NaCl level in the sweat.

44. A 6-year-old is hospitalized with acute lymphocytic leukemia. She is placed on protective isolation,
which concerns her parents. The nurse should explain that this will:
a. Protect her from too many visitors
b. Protect her from infectious organisms
c. Provide a quiet, private environment for her
d. Keep other children away from the child
Ans: B – the purpose of protective isolation is to protect the child from exposure to organisms from other
people. With leukemia, changes in the blood cell number and composition make the child susceptible to
infection. The purpose of protective isolation is to protect the child from exposure to organisms from other
people. Choice D is not the purpose of protective isolation. Preventing infection through direct contact with
anyone is the purpose.

45. The nurse discusses mouth care with a 6-year-old girl who has acute lymphocytic leukemia and her
mother. The nurse explains that when tooth-brushing is contraindicated, the most effective way to clean
teeth is:
a. Rinsing with water
b. Chewing gum after eating
c. Rinsing with hydrogen peroxide
d. Use a Water Pik
Ans: D – choice A is not very effective and does not stimulate the gums. Choice B is not very effective and
does not stimulate the gums. Choice C does not stimulate the gums and prevent gingivitis. Choice D will
effectively rinse the mouth and stimulate the gums.

46. A 12-year-old girl hospitalized with a diagnosis of rheumatic fever. To minimize her joint pain during
acute episodes, the nurse should teach the parents to:
a. Immobilize the joints in a functional position
b. Do full range of motion on all joints daily
c. Apply heat to the involved joints
d. Massage joints briskly with lotion after her bath
Ans: A – immobilization allows rest and healing. The pain can be so intense that even the weight of a
blanket can hurt. Movement of joints (choices B and D) causes pain. The pressure of the healing pad or hot
water bottle can cause pain.

47. Discharge planning of a child with rheumatic fever should include teaching the child and parents to
recognize which of the following toxic symptoms of sodium salicylate?
a. Blurred vision and itching
b. Chills and fever
c. Acetone breath odor
d. Tinnitus and nausea
Ans: D – Choice A, B and C are not toxic symptoms. Choice D are common toxic symptoms of salicylates.

48. A neonate in the newborn nursery is suspected of having a tracheoesophageal fistula. A major symptom
the nurse observed was:
a. Hypersensitive gag reflex
b. Dry mouth with no drooling
c. Cyanosis
d. Lethargy
Ans: C – Choice A and D are not symptoms of this condition. TEF symptoms are excessive salivation and
drooling. Cyanosis is due to the fistula from the trachea and the esophagus.

49. A 3-year-old child is diagnosed with Kawasaki’s disease. The nurse observes which of the following
symptoms?
a. Below-normal temperature
b. Strawberry tongue
c. Edema of the face
d. Swelling in the groin
Ans: B – with this disease, there is fever for more than 5 days. Strawberry tongue is a symptom of the
disease. There is also reddening of the rest of the oropharynx. There is edema of the hands and feet as well
as redness. Swelling occurs in the cervical lymph nodes with this disease.

50. The therapeutic management for a child who has been diagnosed with Kawasaki’s disease will include
administering which of the following medications?
a. Acetaminophen (Tylenol)
b. Globulin
c. Antibiotics
d. Steroids
Ans: B – aspirin is usually given to reduce inflammation. Globulin is given to minimize possible cardiac
complications. Antibiotics and steroids are not usually given for this condition.

51. A mother is being instructed on the best method of administering syrup of ipecac in the initial home
management of an accidental ingestion. The nurse should inform her that syrup of ipecac should be
administered with:
a. Milk
b. Activated charcoal
c. One to two glasses of tepid water
d. Large amounts of cold water
Ans: C – milk or carbonated drinks should be avoided with administration of syrup of ipecac because they
may delay emesis. The purpose of administering activated charcoal is to bind with the poison so that body
absorption of the poison will be decreased. Because the purpose of syrup of ipecac is to induce vomiting,
these drugs would decrease effectiveness of each other. The therapeutic action of S of I is facilitated by
following the dose with 100 to 200 ml of tepid water or other clear liquids in children (200 – 300 ml in
adults). There could be a problem with water intoxication and decreased effectiveness of S of I with the
administration of large amounts of cold water.

52. A 7-year-old child has been taking phenytoin and Phenobarbital for control of chronic recurrent
seizures. In the physical exam, the nurse notes that the child has hyperplasia of the gums. The nurse should
recognize that hyperplasia of the gums is:
a. A common occurrence with chronic recurrent seizures
b. A common side effect of phenytoin
c. Not related to the drugs or the disease
d. An unusual side effects of phenobarbital
Ans: B – many children who have seizures do have this side effect. However, it has nothing specifically to
do with the seizure. Hyperplasia of the gums is a side effect of phenytoin. Phenytoin administration is seen
most commonly in children and adolescents. It never occurs in edentulous clients. Hyperplasia of the gums
is a side effect of phonation. Phenytoin administration is seen most commonly in children and adolescents.
It never occurs in edentulous client. Hyperplasia of the gums is not a side effect of Phenobarbital.

53. A 7-month-old infant has been on antibiotic therapy. The nurse notes that the child has white patches in
his mouth that will not rub off. The physician orders nystatin (Mycostatin) 1 ml, PO, QID. The nurse
should realize that the appropriate technique in administering this medication is to:
a. Give 0.5 ml in each side of the mouth
b. Give with milk or food
c. Give through a nipple
d. Follow with water
Ans: A – nystatin is a local antibiotic and must come into contact with the infected area to be effective.
Giving half of the dose on each side of the mouth will increase the area of contact and consequently
increase the effectiveness of the drug. Giving with milk or food, through a nipple, or following medication
with water (choices B, C and D) would decrease effectiveness by decreasing direct contact of the
medication with the infected area.

54. A primary objective for planning nursing care of an edematous child with nephritic syndrome would be
to:
a. Ambulation
b. A low-carbohydrate diet
c. A high-protein diet
d. A low-protein diet
Ans: C – the child with nephrosis should be on bed rest in the edematous state. High-carbohydrate diet is
needed for energy and the caloric intake. Protein replacement is critical because of the massive proteinuria
and hypoalbuminemia with nephrosis. High=protein diet is needed for protein replacement.

55. The predominant purpose of the first APGAR score of a newborn is to:
a. Determine gross abnormal motor function
b. Obtain a baseline for comparison with the infant’s future adaptation to the environment
c. Evaluate the infant’s vital function
d. Determine the extent of congenital malformation
Ans: A- Apgar scores are not related to the infant’s care, but to the infant’s physical condition. (B) Apgar
scores assess the current physical condition of the infant and are not related to future environmental
adaptation. (C) the purpose of the Apgar system is to evaluate the physical condition of the newborn at
birth and to determine if there is an immediate need for resusciation. (D) congenital malformations are not
one of the areas assessed with Apgar scores.
56. Provide the one-minute APGAR score for an infant born with the following findings: respiratory effort,
slow and irregular; muscle tone, some flexion of extremities; reflex irritability, vigorous cry and; color,
body pink, blue extremities.
a. 7
b. 10
c. 8
d. 9
Ans: A- seven out of possible perfect score of 10 is correct. Two points are given for heart rate above 100;
1 point is given for slow, irregular respiratory effort; 1 point is given for some flexion of extremities in
assessing muscle tone; 2 points are given for vigorous cry in assessing reflex irritability; 1 point is assessed
for color when the body is pink with blue extremities (acrocyanosis). (B) for a perfect Apgar score of 10,
the infant would have a heart rate over 100 but would also have a good cry , active motion, and be
completely pink. (C) for an Apgar score of 8 the respiratory rate, muscle tone, or color wouldneed to fall
into the 2 point rather than the 1point category. (D) for this infant to receive an Apgar score of 9, four of t
he areas evaluated would need ratings of 2 points and one area a rating of 1 point

57. An 8-year-old child comes to the physician’s clinic complaining of swelling and pain in the knees. His
mother says, “The swelling occurred for no reason, and it keeps getting worse.” The initial diagnosis is
Lyme disease. When talking to the mother and child, questions related to which of the following would be
important to include in the initial history?
a. A decreased urinary output and flank pain
b. A fever over 103oF occurring over the last 2 – 3 weeks
c. Rashes covering the palms of the hands and the soles of the feet
d. Headaches, malaise or sore throat
Ans: A- urinary tract symptoms are not commonly associated with Lyme disease. (B) a fever of 103.oF is
not characteristic of lYme disease. (C) the rash that is associated with Lyme disease does not appear on the
palms of the hands and the soles of the feet. (D) classic symptoms of Lyme disease include headache,
malaise, fatigue, anorexia, stiff neck, generalized lymphadenopathy, splenomegaly., conjunctivitis, sore
throat, a abdominal pain, and cough

58. The most commonly known vectors of Lyme disease are:

a. Mites
b. Fleas
c. Ticks
d. Mosquitoes
Ans: A- mites are not common vector of Lyme disease. (B) fleas are not the common vector of Lyme
disease (C) ticks are the common vector of lyme disease. (D) mosquitos are not the common vector of
Lyme disease

59. A specific laboratory technique specific for diagnosing Lyme disease is:
a. Polymerase chain reaction
b. Heterophil antibody test
c. Decreased serum calcium level
d. Increased serum potassium level
Ans: A-nursing process phase; analysis; client need; physiological integrity area: pediatrics polymerase
chain reaction is the laboratory technique specific for lyme disease (B) heterophil antibody test is used to
diagnose mononucleosis. (C) lyme disease does not decrease the serum calcium level. (D) lyme disease
does not increase the serum potassium level

60. The nurse would expect to include which of the following when planning the management of the client
with Lyme disease?
a. Complete bed rest for 6-8 weeks
b. Tetracycline treatment
c. IV amphotericin B
d. High-protein with limited fluids
Ans: A- the client is not placed on complete bed rest for 6 weeks. (B) tetracycline is the treatment of choice
for children with Lyme disease who are over the age of 9. (C) IV amphotericin B is the treatment for
histoplasmosis. (D) the client is not restricted to a high-protein diet with limited fluids

61. A six-month-old infant has been admitted to the emergency room with febrile seizures. In the teaching
of the parents, the nurse states that:
a. Sustained temperature elevation over 103oF is generally related to febrile seizures
b. Febrile seizures do not usually recur
c. There is little risk of neurological deficit and mental retardation as sequele to febrile seizures
d. Febrile seizures are associated with disease of the central nervous system
Ans: A-the temperature elevation related to febrile seizures generally exceeds 101oF, and seizures occur
during the temperature rise rather than after a prolonged elevation. (B) febrile seizures may recur and are
more likely to do so when the first seizure occurs in the 1st year of life. (C) There is little risk of
neurological deficit mental retardation, or altered behavior secondary to febrile seizures. (D) Febrile
seizures are associated with disease of the central nervous system