practice exam 2

Question 1

An hour after admission to the nursery, Nurse Belle observes a newborn baby having spontaneous jerky movements of the limbs. The infant mother had a GDM gestational diabetes during pregnancy. Which of the following actions should the nurse take first?

Give dextrose water.
Call the physician immediately.
Determine the blood glucose level.
Observe closely for other symptoms.

Answer 1

Determine the blood glucose level.

Question 2

A 12 year old boy was riding his bike to school when he hit the curb. He fell an hurt his leg. The
school nurse was called and found him alert, conscious but in severe pain with a possible fracture on the right femur. What is the first action that the nurse should take?

Put him in a semi fowler’s position for comfort.
Check the pedal pulse and blanching sign in both legs.
Immobilize the affected limb with a splint and ask him not to move.
Make a thorough assessment of the circumstances surrounding the accidents.

Answer 2

Immobilize the affected limb with a splint and ask him not to move.

Question 3

A 4 year old child undergoes tonsillectomy for treatment of chronic tonsillitis unresponsive to
antibiotic therapy. After surgery, the child is brought to the recovery room. Which of the following actions should the nurse include in his plan of care?

Give ice cream as tolerated
Cough and deep breath every hour.
Institute measures to minimize crying.
Perform postural drainage every two hours.

Answer 3

Institute measures to minimize crying.

Question 4

The nurse in a newborn nursery has just receive report. Which of the following infants should the
nurse see first?

A 2 day old infant who is lying quietly with heart rate of 185.
A one day old infant is crying and the anterior fontanel is bulging.
A five hour old infant is sleeping and the hands and feet are blue bilaterally.
A 12 hour infant is being held, the respirations are 45 breaths per minute and irregular.

Answer 4

A 2 day old infant who is lying quietly with heart rate of 185.

Question 5

The nurse is caring for clients in a pediatric clinic. The mother of a 14 year old male privately tells
you that she is worried about her son because she unexpectedly walked into his room and
discovered his masturbating. Which of the following responses by the nurse is MOST appropriate?

“Tell you son he could go blind doing that”
“Why don’t you give him more privacy?”
“He’s really too young to be masturbating.”
“Masturbation is a normal part of sexual development.”

Answer 5

“Masturbation is a normal part of sexual development.”

Question 6

A 2 month old infant is brought to the pediatrician’s office for a well baby visit. During the
examination, congenital subluxation of the left his is suspected. The nurse knows that symptoms of
congenital hid dislocation include

A plantar flexion of the foot.
deformities of the foot and ankle.
asymmetry of the gluteal and thigh folds.
lengthening of the limb on the affected side.

Answer 6

asymmetry of the gluteal and thigh folds.

Question 7

A mother calls the well baby clinic to report that her 4 month old son has an upper respiratory
infection (URI) with a temperature of 104 F (40 C). The infant is scheduled to receive hid DPT and
TOPV immunization later that day. The mother ask the nurse if she should bring him in for scheduled
immunizations. Which of the following responses by the nurse would be MOST appropriate?

“Keep him at home. Will give him double dose next time.”
“Bring in him. His illness will not interfere with his immunization.”
“Keep him at home until his temperature and infection resolved.”
“Bring in him.

Answer 7

“Keep him at home until his temperature and infection resolved.”

Question 8

A mother brings her 4-year old daughter to the paediatrician for treatment of chronic otitis media. The
mother asks the nurse how she can prevent her child from getting ear infections so often. The
nurse’s response should be based on an understanding that the recurrence of otitis media can be
decreased by

covering the child’s ears while bathing.
treating respiratory infections quickly.
administering nose drops at bed time.
isolating her child from other children.

Answer 8

treating respiratory infections quickly.

Question 9

A 6-year old girl with chicken pox (varicella) is brought by her parents to the physician for evaluation.
The nurse knows the rash characteristic of chicken pox can be described as ___________________

petechiae.
maculopapular.
round or oval erythematous scaling patches.
small irregular red spots with minute bluish-white centers.

Answer 9

maculopapular

Question 10

A mother with four children calls the clinic for advice on how to care for her oldest child, who has
developed chicken pox. Which of the following statements, if made by the mother indicates a need
for further teaching?
Your Answer:
“ I can use calamine lotion if needed.”
“ I should remove the crusts so the skin can heal.”
“ I can use mittens if scratching becomes a problem.”
” I should keep my child home from school until the vesicles are crusted.”

Answer 10

” I should keep my child home from school until the vesicles are crusted.”

Question 11

A 3-week old boy is admitted with a diagnosis of pyloric stenosis. The mother tells the nurse that this
is her first child and asks if there is anything she can do to prevent this from happening to her next
child. Which of the following statements, if made by the nurse, BEST addresses her concern?

“This is an inherited condition; it is not your fault.”
“This type of thing generally happens to first children.”
“When you have you second child at least you know what signs to look for.”
“This is a structural problem; it is not a reflection of your parenting skills.”

Answer 11

“This is a structural problem; it is not a reflection of your parenting skills.”

Question 12

The nurse in a well-child clinic assesses a 4-year old girl and observes multiple bruises on her back
and buttocks. The parents state they don’t know how the girl sustained the injury. The nurse should
____________ .

confront the parents about the suspected abuse.
refer the family to social services for counselling.
report the suspected child abuse to the appropriate authority.
document the suspicions about child abuse in the child’s medical record.

Answer 12

report the suspected child abuse to the appropriate authority.

Question 13

A 12-year old boy was riding his bike to school when he hit the curb. He fell and hurt his leg. The
school nurse was called and found him alert, conscious but in severe pain with a possible fracture on
the right femur. What is the first action that the nurse should take?

Put him in a semi-fowler’s position for comfort.
Check the pedal pulse and blanching sign in both legs
Immobilize the affected limb with a splint and ask him not to move.
Make a thorough assessment of the circumstances surrounding the accident

Answer 13

Immobilize the affected limb with a splint and ask him not to move.

Question 14

An 8-year old boy is seen in a clinic for treatment of Attention Deficit Disorder (ADD). Medication has
been prescribed for the child along with family counselling. The nurse teaches the parents about
medication and discusses parenting strategies. Which of the following statements, if made by the
parents, would indicate that further teaching is necessary?

“We will establish firm, but reasonable limits on his behaviour.”
“ We will give the medication at night so it doesn’t decrease his appetite.”
“ We will provide a regular routine for sleeping, eating, working, and playing.”
“ We will reduce distractions nd external stimuli to help him concentrate.”

Answer 14

“ We will give the medication at night so it doesn’t decrease his appetite.”

Question 15

An hour after admission to the nursery, the nurse observes a newborn baby having spontaneous
jerky movements of the limbs. The infant’s mother had gestational diabetes mellitus during
pregnancy. Which of the following actions should the nurse take first?

Give dextrose water
Call the physician immediately
Determine the blood glucose level
Observe closely for other symptoms

Answer 15

Determine the blood glucose level

Question 16

A mother brings her 4-year old daughter to the paediatrician for treatment of chronic otitis media. The
mother asks the nurse how she can prevent her child from getting ear infections so often. The
nurse’s response should be based on an understanding that the recurrence of otitis media can be
decreased by

Covering the child’s ears while bathing
Treating respiratory infections quickly.
Administering nose drops at bed time.
Isolating her child from other children.

Answer 16

Treating respiratory infections quickly.

Question 17

The nurse is addressing a group of high-risk teen mothers. Which risk factors that can lead to
attention-deficit/hyperactivity disorder (ADHD) in children would the nurse describe to the teen
mothers? Select all that apply.

Limited television exposure at ages 1 -3 years
Lack of proper parenting
Poor nutrition
Exposure to high levels of lead in childhood
Drinking alcohol during pregnancy

Answer 17

Lack of proper parenting
Poor nutrition
Exposure to high levels of lead in childhood
Drinking alcohol during pregnancy

Question 18

The nurse is caring for a child with a diagnosis of Kawasaki disease. The child’s parent asks the
nurse, “How does Kawasaki disease affect my child’s heart and blood vessels?” The nurse’s
response is based on the understanding that:

inflammation weakens blood vessels, leading to aneurysm.
increased lipid levels lead to the development of atherosclerosis.
untreated disease causes mitral valve stenosis.
altered blood flow increases cardiac workload with resulting heart failure.

Answer 18

inflammation weakens blood vessels, leading to aneurysm.

Question 19

A nurse is preparing for the admission of a child with a diagnosis of acute-stage Kawasaki disease.
On assessment of the child, the nurse expects to note which clinical manifestation of the acute stage
of the disease?

cracked lips
a normal appearance
conjunctival hyperemia
desquamation of the skin

Answer 19

conjunctival hyperemia

Question 20

A newborn is diagnosed with Hirschsprung disease. Which clinical manifestations found on
assessment supports this newborn’s diagnosis?

Altered electrolytes; projectile vomiting
Currant jelly stools; pain
Acute diarrhea; dehydration
Failure to pass meconium; abdominal distention

Answer 20

Failure to pass meconium; abdominal distention

Question 21

A nurse is caring for a child with patent ductus arteriosus.The nurse reviews the child assessment
data, knowing that which of the following is characteristic of this disorder?

It involves an opening between two atria.
It produces abnormalities in the atrial septum.
It involves an opening between the two ventricles.
It involves an artery that connects the aorta and pulmonary artery during fetal life.

Answer 21

It involves an artery that connects the aorta and pulmonary artery during fetal life.

Question 22

During a nonstress test (NST), the electronic tracing displays a relatively flat line for fetal movement,
making it difficult to evaluate the fetal heart rate (FHR). To mark the strip, the nurse in charge should
instruct the client to push the control button at which time?

At the end of fetal movement
After every three fetal movements
At the beginning of each contraction
A At the beginning of each fetal movement

Answer 22

At the beginning of each fetal movement

Question 23

In the later part of the 3rd trimester, the mother may experience shortness of breath. This complaint maybe explained as

the woman maybe experiencing complication of pregnancy.
the fundus of the uterus is high pushing the diaphragm upwards.
a normal occurrence in pregnancy because the fetus is using more oxygen .
the woman is having allergic reaction to the pregnancy and its hormones .

Answer 23

the fundus of the uterus is high pushing the diaphragm upwards.

Question 24

Which of the following findings in a woman would be consistent with a pregnancy of two months duration?

Fullness of the breast and urinary frequency
Braxton Hicks contractions and quickening
Increased respiratory rate and ballottement
Weight gain of 6-10 lbs. and presence of striae gravidarum

Answer 24

Fullness of the breast and urinary frequency

Question 25

When a pregnant woman experiences leg cramps, the correct nursing intervention to relieve the muscle cramps is ___________ Your Answer: allow the woman to exercise let the woman walk for a while. ask the woman to raise her legs. let the woman lie down and dorsiflex the foot towards the knees .

Answer 25

ask the woman to raise her legs.

Question 26

A postpartum nurse is preparing to care for a woman who has just delivered a healthy newborn infant. In the immediate postpartum period the nurse plans to take the woman’s vital signs every hour for the first 2 hours and then every 4 hours. every 30 minutes during the first hour and then every hour for the next two hours. every 5 minutes for the first 30 minutes and then every hour for the next 4 hours. every 15 minutes during the first hour and then every 30 minutes for the next two hours.

Answer 26

every 15 minutes during the first hour and then every 30 minutes for the next two hours.

Question 27

Which of the following factors might result in a decreased supply of breast milk in a PP mother? An alcoholic drink Frequent feedings Maternal diet high in vitamin C Supplemental feedings with formula

Answer 27

Supplemental feedings with formula

Question 28

To monitor the frequency of the uterine contraction during labor, the right technique is to time the contraction _______________. from the end of one contraction to the beginning of the next contraction . from the beginning of one contraction to the end of the same contraction . from the deceleration of one contraction to the acme of the next contraction. from the beginning of one contraction to the beginning of the next contraction .

Answer 28

from the beginning of one contraction to the end of the same contraction .

Question 29

A patient is in the second stage of labor. During this stage, how frequently should the nurse in charge assess her uterine contractions? Every 5 minutes Every 15 minutes Every 30 minutes Every 60 minutes

Answer 29

Every 15 minutes

Question 30

To monitor the frequency of the uterine contraction during labor, the right technique is to time the contraction From the beginning of one contraction to the end of the same contraction From the beginning of one contraction to the beginning of the next contraction From the end of one contraction to the beginning of the next contraction From the deceleration of one contraction to the acme of the next contraction

Answer 30

From the beginning of one contraction to the end of the same contraction

Question 31

When determining the duration of a uterine contraction the right technique is to time it from The beginning of one contraction to the end of the same contraction The end of one contraction to the beginning of another contraction The acme point of one contraction to the acme point of another contraction The beginning of one contraction to the end of another contraction

Answer 31

The beginning of one contraction to the end of the same contraction

Question 32

What are the important considerations that the nurse must remember after the placenta is delivered? SATA Check if the placenta is complete including the membranes Check if the cord is long enough for the baby Check if the umbilical cord has 3 blood vessels Check if the cord has a meaty portion and a shiny portion

Answer 32

Check if the placenta is complete including the membranes Check if the umbilical cord has 3 blood vessels

Question 33

The following are correct statements about false labor EXCEPT The pain is irregular in intensity and frequency. The duration of contraction progressively lengthens over time There is no vaginal bloody discharge. The cervix is still closed.

Answer 33

The duration of contraction progressively lengthens over time

Question 34

After completing a second vaginal examination of a client in labor, the nurse midwife determines that the fetus is in the right occiput anterior position and at (–1) station. Based on these findings, the nurse-midwife knows that the fetal presenting part is: Your Answer: 1 cm below the ischial spines. directly in line with the ischial spines. 1 cm above the ischial spines. in no relationship to the ischial spines.

Answer 34

1 cm above the ischial spines.

Question 35

The cervical dilatation taken at 8:00 AM in a G1P0 patient was 6 centimeters. A repeat I.E. done at 10 A. M. showed that cervical dilation was 7 cm. The correct interpretation of this result is: Labor is progressing as expected The latent phase of Stage 1 is prolonged The active phase of Stage 1 is protracted The duration of labor is normal

Answer 35

The active phase of Stage 1 is protracted

Question 36

A primiparous woman is in the taking-in stage of psychosocial recovery and adjustment following birth. The nurse, recognizing the needs of women during this stage, should: Foster an active role in the baby's care. Provide time for the mother to reflect on the events of and her behavior during childbirth. Recognize the woman's limited attention span by giving her written materials to read when she gets home rather than doing a teaching session now. Promote maternal independence by encouraging her to meet her own hygiene and comfort needs.

Answer 36

Provide time for the mother to reflect on the events of and her behavior during childbirth.

Question 37

Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should: Tell the woman she can rest after she feeds her baby Recognize this as a behavior of the taking-hold stage Record the behavior as ineffective maternal-newborn attachment Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time

Answer 37

Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time

Question 38

When making a visit to the home of a postpartum woman one week after birth, the nurse should recognize that the woman would characteristically: Express a strong need to review events and her behavior during the process of labor and birth Exhibit a reduced attention span, limiting readiness to learn Vacillate between the desire to have her own nurturing needs met and the need to take charge of her own care and that of her newborn Have reestablished her role as a spouse/partner

Answer 38

Vacillate between the desire to have her own nurturing needs met and the need to take charge of her

Question 39

As part of the postpartum assessment, the nurse examines the breasts of a primiparous breastfeeding woman who is one day postpartum. An expected finding would be: Soft, non-tender; colostrum is present Leakage of milk at let down Swollen, warm, and tender upon palpation A few blisters and a bruise on each areola

Answer 39

Soft, non-tender; colostrum is present

Question 40

Following the birth of her baby, a woman expresses concern about the weight she gained during pregnancy & how quickly she can lose it now that the baby is born. The nurse, in describing the expected pattern of weight loss, shld begin by telling her that: Return to prepregnant weight is usually achieved by the end of the postpartum period Fluid loss from diuresis, diaphoresis, and bleeding accounts for about a 3 pound weight loss The expected weight loss immediately after birth averages about 11 to 13 pounds Lactation will inhibit weight loss since caloric intake must increase to support milk production

Answer 40

The expected weight loss immediately after birth averages about 11 to 13 pounds

Question 41

Which of the following responses is most appropriate for a mother with diabetes who wants to breastfeed her infant but is concerned about the effects of breastfeeding on her health? Mothers with diabetes who breast-feed have a hard time controlling their insulin needs. Mothers with diabetes shouldn't breastfeed because of potential complications. Mothers with diabetes shouldn't breastfeed; insulin requirements are doubled. Mothers with diabetes may breastfeed; insulin requirements may decrease from breastfeeding.

Answer 41

Mothers with diabetes may breastfeed; insulin requirements may decrease from breastfeeding.

Question 42

Before giving a PP client the rubella vaccine, which of the following facts should the nurse include in client teaching? The vaccine is safe in clients with egg allergies Breast-feeding isn't compatible with the vaccine Transient arthralgia and rash are common adverse effects The client should avoid getting pregnant for 3 months after the vaccine because the vaccine has teratogenic effects

Answer 42

The client should avoid getting pregnant for 3 months after the vaccine because the vaccine has teratogenic effects

Question 43

Which of the following complications may be indicated by continuous seepage of blood from the vagina of a PP client, when palpation of the uterus reveals a firm uterus 1 cm below the umbilicus? Retained placental fragments Urinary tract infection Cervical laceration Uterine atony

Answer 43

Cervical laceration

Question 44

A nurse is preparing a list of self-care instructions for a PP client who was diagnosed with mastitis. Select all instructions that would be included on the list. Take the prescribed antibiotics until the soreness subsides. Wear supportive bra Avoid decompression of the breasts by breastfeeding or breast pump Rest during the acute phase Continue to breastfeed if the breasts are not too sore.

Answer 44

Wear supportive bra Rest during the acute phase Continue to breastfeed if the breasts are not too sore.

Question 45

A nurse is caring for a PP client with a diagnosis of DVT who is receiving a continuous intravenous infusion of heparin sodium. Which of the following laboratory results will the nurse specifically review to determine if an effective and appropriate dose of the heparin is being delivered? Prothrombin time Internationalized normalized ratio Activated partial thromboplastin time Platelet count

Answer 45

Activated partial thromboplastin time

Question 46

A nurse performs an assessment on a client who is 4 hours PP. The nurse notes that the client has cool, clammy skin and is restless and excessively thirsty. The nurse prepares immediately to: Assess for hypovolemia and notify the health care provider Begin hourly pad counts and reassure the client Begin fundal massage and start oxygen by mask Elevate the head of the bed and assess vital signs

Answer 46

Assess for hypovolemia and notify the health care provider

Question 47

When delivering the baby’s head the nurse supports the mother’s perineum to prevent tear. This technique is called Marmet’s technique Ritgen’s technique Duncan maneuver Schultze maneuver

Answer 47

Ritgen’s technique

Question 48

In a gravido-cardiac mother, the first 2 hours postpartum (4th stage of labor and delivery) particularly in a cesarean section is a critical period because at this stage There is a fluid shift from the placental circulation to the maternal circulation which can overload the compromised heart. The maternal heart is already weak and the mother can die The delivery process is strenuous to the mother The mother is tired and weak which can distress the heart

Answer 48

There is a fluid shift from the placental circulation to the maternal circulation which can overload the compromised heart.

Question 49

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? Symphysis pubis Sacral promontory Ischial spines Pubic arch

Answer 49

Ischial spines

Question 50

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? Menstrual phase Proliferative phase Secretory phase Ischemic phase

Answer 50

Proliferative phase

Question 51

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? Follicle-stimulating hormone Testosterone Luteinizing hormone Gonadotropin-releasing hormone

Answer 51

Testosterone

Question 52

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? Notify the physician immediately because there is a problem. Perform an intensive neurological examination. Perform an intensive developmental examination. Do nothing because this is a normal finding for the age.

Answer 52

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

Question 53

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? 1 month 2 months 3 months 4 months

Answer 53

4 months

Question 54

The infant of a substance-abusing mother is at risk for developing a sense of which of the following? Mistrust Shame Guilt Inferiority

Answer 54

Mistrust

Question 55

When giving narcotic analgesics to mother in labor, the special consideration to follow is - The progress of labor is well established reaching the transitional stage - Uterine contraction is progressing well and delivery of the baby is imminent - Cervical dilatation has already reached at least 8 cm. and the station is at least (+)2 - Uterine contractions are strong and the baby will not be delivered yet within the next 3 hours

Answer 55

Uterine contractions are strong and the baby will not be delivered yet within the next 3 hours

Question 56

Which of the following would the nurse assess in a client experiencing abruptio placenta? Palpable fetal outline Soft and nontender abdomen Bright red, painless vaginal bleeding Concealed or external dark red bleeding

Answer 56

Concealed or external dark red bleeding

Question 57

The fetal heart rate is checked following rupture of the bag of waters in order to ________ . Check if the fetus is suffering from head compression Determine if cord compression followed the rupture Determine if there is utero-placental insufficiency Check if fetal presenting part has adequately descended following the rupture

Answer 57

Determine if cord compression followed the rupture

Question 58

Upon assessment, the nurse got the following findings: 2 perineal pads highly saturated with blood within 2 hours post partum, PR= 80 bpm, fundus soft and boundaries not well defined. The appropriate nursing diagnosis is Normal blood loss Blood volume deficiency Hemorrhage secondary to uterine atony Inadequate tissue perfusion related to hemorrhage

Answer 58

Hemorrhage secondary to uterine atony

Question 59

To prevent preterm labor from progressing, drugs are usually prescribed to halt the labor. The drugs commonly given are Prostaglandin and Oxytocin. Progesterone and Estrogen. Dexamethasone and Prostaglandin. Magnesium sulfate and Terbutaline.

Answer 59

Magnesium sulfate and Terbutaline.

Question 60

When assessing an 18-month-old, the nurse notes a characteristic protruding abdomen. Which of the following would explain the rationale for this finding? Increased food intake owing to age. Underdeveloped abdominal muscles. Bow Legged posture. Linear growth curve.

Answer 60

Underdeveloped abdominal muscles.

Question 61

Nurse Flower Bloom observes that the Ellie's uterine contractions are irregular in frequency and short in duration. Ellie screams in pain during contractions. Which of the following actions is considered BEST for the nurse to perform? Try to divert attention from pain. Administer pain reliever as ordered. Stay with the patient and offer her a back rub. Document and report frequency and duration of contractions..

Answer 61

Stay with the patient and offer her a back rub.

Question 62

The physician is considering augmenting her labor with oxytocin. What would make Nurse Flower Bloom question the use of oxytocin for Patient Ellie? She had an amniocentesis performed during pregnancy. Her fetus is large for gestational age by a sonogram. Her membrane ruptured after only 1 hour of labor. Her blood pressure is slightly elevated above normal.

Answer 62

Her membrane ruptured after only 1 hour of labor.

Question 63

Nurse Goldy Locks notices patient's uterine contractions are 70 seconds long and occur every 90 seconds when assessing the frequency of her contractions after she receives oxytocin. What would be the nurse's FIRST action? Give an emergency bolus of oxytocin to relaxed the uterus. Discontinue the administration of the oxytocin infusion. Increase the rate of client's IV infusion. Ask client to turn to her left side and breathe deeply.

Answer 63

Discontinue the administration of the oxytocin infusion.

Question 64

Nurse Goldy Locks monitors the patient, knowing that which finding indicates an adequate contraction pattern? Three to 5 contractions in a 10-minute period, with resultant cervical dilatation. Four contractions every 5 minutes, without resultant cervical dilatation. One contraction every 10 minutes, without resultant cervical dilatation. One contraction per minute, with resultant cervical dilatation.

Answer 64

Three to 5 contractions in a 10-minute period, with resultant cervical dilatation.

Question 65

Which of the following nursing measures would the nurse LEAST CONSIDERS to Patient Ellie with oxytocin drip? Know how to recognize potential adverse reactions.. Administer oxytocin drug with caution. Monitor patient closely when infusing oxytocin. Inform patient about potential complications.

Answer 65

Inform patient about potential complications.

Question 66

Maldie Maldita, a multiparous patient is admitted due to labor pains which started an hour ago. During the vaginal examination, the nurse noted the complete dilatation of the cervix and effacement is 100 percent. The patient is in true labor pains. Which of the following problems with labor and delivery is completed in less than 3 hours? Precipitous Preterm Induced Prolonged

Answer 66

Precipitous

Question 67

Patient Maldie Maldita was referred to the physician, routine blood examinations were taken. After reviewing the serum electrolyte levels an order of isotonic intravenous (IV) infusion was prescribed. Which IV solution should the nurse prepare? 5 percent dextrose in water 0.45 percent sodium chloride solution 10 percent dextrose in water 3 percent sodium chloride solution

Answer 67

0.45 percent sodium chloride solution

Question 68

The patient during labor would anticipate some emotional support. Which of the following nursing interventions should Nurse Sarah provide to keep the patient calm? Giving praise for her the sense of satisfaction regarding quick labor. Support in maintaining a sense of control. Explanation of the effect of labor on the newborn. Allowing the patient to express pain and anxiety.

Answer 68

Support in maintaining a sense of control.

Question 69

Patient Maldie Maldita asks why her labor is much shorter compared to previous deliveries. Which of the following is the BEST RESPONSE? Onset of contraction was gradual. Multigravida patient has shorter labor. Cervical lengthening was longer. Induction of labor was done.

Answer 69

Onset of contraction was gradual.

Question 70

Nurse Sarah reads the physician's prescription to administer methylergonovine maleate (Methergin) intramuscularly after delivery. The rationale for giving this medication is which of the following? Reduces the amount of lochia drainage. Prevents postpartum hemorrhage. Decreases uterine contractions. Maintains normal blood pressure.

Answer 70

Prevents postpartum hemorrhage.

Question 71

Lady Dee a postpartum patient, who has delivered a stillborn wants to leave the hospital without a physician's order. The patient still hooked to an intravenous fluid (IVF) and is on closed postpartum monitoring. To avoid liability, which of the following is an APPROPRIATE action by nurse Love Valentine? Notify nursing supervisor of the patient's plans to leave. Arrange medication prescriptions at the patient's preferred pharmacy. Notify directly the attending obstetrician. Ask the patient about transportation plans from the hospital.

Answer 71

Notify nursing supervisor of the patient's plans to leave.

Question 72

Nurse Love Valentine informs patient Ashley on the need for early ambulation. Which of the nurse's instructions on ambulation is INCORRECT? Assist the patient from sitting to standing position. Raise the head of the bed slowly to achieve sitting position of the patient. Allow the patient to rise from the bed to a standing position unassisted. Assist patient to rise from lying to sitting position.

Answer 72

Allow the patient to rise from the bed to a standing position unassisted.

Question 73

Nurse Winter Cool explains to the mothers that early indication for hypovolemia caused by postpartum hemorrhage is _________. increasing pulse and decreasing blood pressure. altered mental status and level of consciousness. dizziness and increasing respiratory rate. cool, clammy skin, and pale mucous membranes.

Answer 73

increasing pulse and decreasing blood pressure.

Question 74

The nurse educator Cherry Blossom reviewed the risk factors for postpartum hemorrhage for the mothers. Which of the following factors IS NOT included ________? ruptured uterus uterine atony overdistended uterus retroversion of the uterus

Answer 74

retroversion of the uterus

Question 75

During the normal postpartum course, when would the nurse expect to note the fundal assessment that will be in line with the umbilicus? Immediately after the delivery 4 days after the delivery When the client's bladder is full The day after the delivery

Answer 75

Immediately after the delivery

Question 76

A postpartum patient asks nurse Blue Lagoon when she may safely resume sexual activity. Which of the following information should the nurse tell the patient on resumption of sexual activity? In 2 to 4 weeks At any time after the 6-week physician check-up When her normal menstrual period has resumed

Answer 76

In 2 to 4 weeks

Question 77

Maldie Maldita a multigravida, in her 20th weeks of gestation visited the community clinic with complaints of dizziness, vertigo, and heartburns. After the physical assessment, Nurse Harper finds the patient as malnourished. Iron supplementation was prescribed because of her low hemoglobin level. Which statement, if made by Maldie, would indicate an understanding of health instructions? "My body has all the iron it needs and I don't need to take supplements." "Meat does not provide iron and should be avoided." "The iron is best absorbed if taken on an empty stomach." "Iron supplements will give green color to my stool."

Answer 77

"The iron is best absorbed if taken on an empty stomach."

Question 78

Maldie was given iron as supplemental vitamin to prevent maternal anemia. She asks if it will not be affected because she is regularly taking Vitamin C. Which of the following would be the BEST response of the nurse? "Take two other vitamins separately." "Take the iron after a full meal." "Absorption of iron is enhanced with Vitamin C." "Drink milk when taking the iron supplement."

Answer 78

"Absorption of iron is enhanced with Vitamin C."

Question 79

Maldie was also advised to take calcium supplements on the 2nd and 3rd trimester of pregnancy. Which of the following would ENHANCE her intestinal absorption of calcium? Fat-soluble vitamins Proteins Minerals Water soluble vitamins

Answer 79

Fat-soluble vitamins

Question 80

Nurse Harper observes Evelyn has a knowledge deficit regarding fetal nutrition. Nurse Harper has to explain that the MAIN SOURCE of nutrition for the baby is which of the following? Amniotic fluid Uterus Placenta Chorionic Villi

Answer 80

Placenta

Question 81

Nurse Harper provides health instruction to the patient experiencing heartburn. Which statement by the patient indicates a NEED for further instructions? I have to ______. drink milk between meals eat small, frequent meals avoid fatty or spicy foods lie down after eating

Answer 81

lie down after eating

Question 82

The giving of medication to a pediatric patient is a serious responsibility of a nurse. Nurse Imelda has just been assigned to the Pediatric Wards. When giving medicine to pediatric patients, dosage varies. Which of the following should Nurse Imelda consider? Height and surface area Size, surface area & age Size, surface area, age & height Size & surface area

Answer 82

Size, surface area, age & height

Question 83

The Headnurse checks Nurse Imelda's knowledge on administering oral medications to pediatric patients. Which of the following statements below should she choose as CORRECT? - A child's reaction to a dose ordered by a physician is not less predictable than adult's reaction. - When giving oral medication, the child as young as two years of age cannot be taught to a swallow drugs. - The child should be told to place the tablet in the middle of his tongue and drink water to wash down the tablet. - The possibility of error is greater in the giving of medication to children than to adults.

Answer 83

The possibility of error is greater in the giving of medication to children than to adults.

Question 84

In infants and toddlers, which part should Nurse Imelda often use for intramuscular injection to reduce the risk of vascular and peripheral nerve injuries? Gluteus maximus Dorso-gluteal Deltoid muscle Vastus laterals

Answer 84

Vastus laterals

Question 85

Administering medication intramuscularly can produce a variety of serious adverse effects has been revealed in comprehensive surveys of research reports. When asked by the Headnurse what is the MOST common complication that may arise, Nurse Imelda should mention ______. abscess nerve palsies and paralysis hematoma muscle contracture

Answer 85

hematoma

Question 86

Prior to administering the drugs ordered by the Pediatrician, Nurse Imelda needs to know if she is giving the ordered medication to the right patient. The FIRST step is _______. Check the patient's hospital bracelet. Ask the parent/significant other to state name of patient and birth date of patient. Verify patient's allergies with chart and with patient. Compare medication order to identification bracelet.

Answer 86

Ask the parent/significant other to state name of patient and birth date of patient.

Question 87

Minimie on one year of age, is admitted due to pneumonia. She IV antibiotics, antipyretic, decongestant and vitamins as medications. She also is under oxygen therapy. Nurse Messy See has been worried about Minimie's refusal to take her oral drugs. How will she handle the situation? Leave the child alone Seek the help of the mother in giving the oral drug. Mix the drug with milk to cover up the unfavorable taste. Get angry with the mother and the child.

Answer 87

Seek the help of the mother in giving the oral drug.

Question 88

As a one-year-old child, Nurse Messy understands the reason(s) why Minimie continuously refuse to take her drugs. It is because it is nor for her age to ________. have separation anxiety. internalize the attitudes of others. utilize magical thinking. be negativistic in all matters.

Answer 88

be negativistic in all matters.

Question 89

The BEST way to administer oxygen on Minimie is by _______. hood face mask Incentive Spirometer nasal catherer

Answer 89

nasal catherer

Question 90

What IMPORTANT evaluation parameter should Nurse Messy observe would show improvement in Minimie's condition? Absence of fever. Absence of chest indrawing. Respiratory rate of 45 beats per minute. Respiratory rate of 55 beats/ minute.

Answer 90

Absence of chest indrawing.

Question 91

Nurse Ocean Wave conducts her INITIAL assessment on Sandie. The patient keeps on crying and constantly pulls her right ear. What is her MOST APPROPRIATE action? Request parent to carry the child. Take Sandie's vital sign Refer to the attending physician. Assess the description and frequency of pain.

Answer 91

Assess the description and frequency of pain.

Question 92

Based on her knowledge on otitis media, Nurse Ocean Wave recalls that children are predisposed to AOM due to the following risk factors, EXCEPT _______. absence of breastfeeding swimming exposure to cigarette smoke poor hygiene

Answer 92

absence of breastfeeding

Question 93

To promote drainage and reduce pressure from fluid, Nurse Ocean Wave's nursing intervention is to have the child assume any of the following positions, EXCEPT ______. tilt head to side if sitting up lie on the affected area put the pillows behind the head lie on the non-affected ear

Answer 93

lie on the affected area

Question 94

Nurse Ester is rotated to the Pediatrics Ward. As such, she needs to review the principles and concepts of human growth and development to better appreciate her role. Being assigned to care for pediatric patients, Nurse Ester should remember which of the following statements? Toddler period ranges from 12 to 36 months. An infant's tongue is smaller than the adult. Early childhood period ranges from 3 to 7 years. Breast milk provides complete infant nutrition

Answer 94

Toddler period ranges from 12 to 36 months.

Question 95

While Nurse Ester was taking the temperature of Baby Chooka, the mother asked Nurse Ester when growth and development become more rapid. Her answer should be, during at _______ months of life. 10 9 12 11

Answer 95

12

Question 96

Alaia, a patient with severe preeclampsia, is admitted to the hospital. She is a student and she insists on continuing her studies while in the hospital despite being instructed to rest. Nurse Isabelle is concerned about the patient's welfare and her ability to comply with the doctor's instructions. What should be the APPROPRIATE action? Include a significant other in helping the patient understand the need for rest. Instruct the patient that the baby's health is more important than hef studies at this time. Develop a routine with the patient to balance her studies and her rest needs. Ask her why she is not complying with the prescription for bed rest.

Answer 96

Develop a routine with the patient to balance her studies and her rest needs.

Question 97

Patient Alaia, who seems to be irritated with the nurse, said, "I don't want to talk to you because you're only a nurse. I will wait for my doctor." Which of the following is an APPROPRIATE response by the nurse? "I'm angry with the way you dismiss me." "So then you would prefer to speak with the doctor?" "I understand. I should call your doctor." "Your doctor prescribed this for us to do nursing care."

Answer 97

"Your doctor prescribed this for us to do nursing care."

Question 98

A group was given a scenario of a pregnant woman in the OB ward. The scenario states that the nurse is discussing the nursing process with a newly hired nurse. Which of the following describes the planning phase of the nursing process? Identify the nursing diagnoses. Gather information if the patient's problem has been resolved in the evaluation phase. Review the patient's history during the assessment. Prioritize patient problems.

Answer 98

Prioritize patient problems.

Question 99

Nurse Cherry Blossom one of the group leaders reviewed the steps of the nursing process with the group. Which of the following data should the nurse identify as objective data? (Select all that apply) Respiratory rate is 22/min. Feels pain after a 10-minute walk. Pain is rated as 3 on a scale of 10 Skin is pinkish in color, warm and dry.

Answer 99

Respiratory rate is 22/min. Skin is pinkish in color, warm and dry.

Question 100

According to the nursing process, which of the following actions the nurse takes if the pain does not satisfactorily relieve? Wait for more time for the pain reliever to take effect. Collect additional data as to why the patient has not been relieve of pain. Teach the patient relaxation breathing techniques. Refer to attending physician

Answer 100

Collect additional data as to why the patient has not been relieve of pain.