1. You are performing abdominal exam on a 9th month pregnant woman. A.

Hypoactivity
While lying supine, she felt breathless, had pallor, tachycardia, and cold B. High birth weight
clammy skin. The correct assessment of the woman’s condition is that she C. Poor wake and sleep patterns
is: D. High threshold of stimulation
A. Experiencing the beginning of labor
B. Having supine hypotension
C. Having sudden elevation of BP 11. Hyaline membrane disease is a severe form of?
D. Going into shock A. Respiratory distress syndrome
B. Neonatal jaundice
2. Smoking is contraindicated in pregnancy because C. Celiac disease
A. Nicotine causes vasodilation of the mother’s blood vessels D. Lead poisoning
B. Carbon monoxide binds with the hemoglobin of the mother reducing
available hemoglobin for the fetus 12. A child can sit without support at the age of?
C. The smoke will make the fetus and the mother feel dizzy A. 5 months
D. Nicotine will cause vasoconstriction of the fetal blood vessels B. 8 months
C. 12 months
3. Vitamin K is prescribed for a neonate. A nurse prepares to administer the D. 15 months
medication in which muscle site?
A. Deltoid 13. Signs of cold stress that the nurse must be alert when caring for a Newborn
B. Triceps is:
C. Vastus lateralis A. Hypothermia
D. Biceps B. Decreased activity level
C. Shaking
4. When newborns have been on formula for 36-48 hours, they should have a: D. Increased RR
A. Screening for PKU
B. Vitamin K injection 14. Which of the following is the best method for performing a physical
C. Test for necrotizing enterocolitis examination on a toddler
D. Heel stick for blood glucose level A. From head to toe
B. Distally to proximally
C. From abdomen to toes, the to head
5. When assessing the term newborn, the following are observed: newborn is D. From least to most intrusive
alert, heart and respiratory rates have stabilized, and meconium has been
passed. The nurse determines that the newborn is exhibiting behaviors 15. Nurse Veronica is teaching a group of parents about otitis media. When
indicating discussing why children are predisposed to this disorder, the nurse should
A. Initial period of reactivity mention the significance of which anatomical feature?
B. Second period of reactivity A. Nasopharynx
C. Decreased responsiveness period B. Eustachian tubes
D. Period of sleep C. External ear canal
D. Tympanic membrane
6. Which condition would be missed if newborns are screened before they
have tolerated protein feedings for at least 48 hours? 16. Dustin who was diagnosed with Hirschsprung’s disease has a fever and
A. Hypothyroidism watery explosive diarrhea. Which of the following would Nurse Joyce do
B. Cystic fibrosis first?
C. Phenylketonuria A. Administer an antidiarrheal.
D. Sickle cell disease B. Notify the physician immediately.
C. Monitor the child every 30 minutes.
7. A client makes a routine visit to the prenatal clinic. Although she is 14 D. Nothing. (These findings are common in Hirschsprung’s disease.)
weeks pregnant, the size of her uterus approximates that in an 18- to 20-
week pregnancy. Dr. Charles diagnoses gestational trophoblastic disease 17. Nurse Nancy is assessing a child with pyloric stenosis; she is likely to note
and orders ultrasonography. The nurse expects ultrasonography to reveal: which of the following?
A. An empty gestational sac. A. “Currant jelly” stools
B. Grapelike clusters. B. Regurgitation
C. A severely malformed fetus. C. Steatorrhea
D. An extra uterine pregnancy D. Projectile vomiting

8. While assessing a primipara during the immediate postpartum period, the 18. An 11-year-old girl with celiac disease was discharged from the hospital. An
nurse in charge plans to use both hands to assess the client’s fundus to: appropriate teaching was carried out by the nurse if the parents are aware
A. Prevent uterine inversion of avoiding which of the following?
B. Promote uterine involution A. Chicken
C. Hasten the puerperium period B. Wheat
D. Determine the size of the fundus C. Milk
D. Rice
9. A neonate has been diagnosed with caput succedaneum. Which statement
is correct about this condition? 19. Which of the following applies to the defect emerging from residual
A. It usually resolves in 3-6 weeks peritoneal fluid confined within the lower segment of the
B. It doesn’t cross the cranial suture line processusvaginalis?
C. It’s a collection of blood between the skull and the A. Inguinal hernia
periosteum B. Incarcerated hernia
D. It involves swelling of tissue over the presenting part of the C. Communicating hydrocele
presenting head D. Noncommunicating hydrocele

10. Which neonatal behavior is most commonly associated with fetal alcohol 20. Baby Jonathan was born with cleft lip (CL); Nurse Barbara would be alert
syndrome (FAS)? that which of the following will most likely be compromised?
A. GI function
B. Locomotion
C. Sucking ability
D. Respiratory status
21. A preschooler with a history of cleft palate repair comes to the clinic for a
routine well-child check-up. To determine if this child is experiencing a long-
term effect of cleft palate, a nurse should ask which of the following
questions?
a. “Was the child recently treated for pneumonia?”
b. “Does the child play with an imaginary friend?”
c. “Is the child unresponsive when given directions?”
d. “Has the child had any difficulty swallowing food?”
22. During an initial prenatal visit a hemoglobin level is obtained on a client in
her first trimester of pregnancy. The nurse reviews the results and
determines the findings to be abnormal and indicative of iron deficiency
anemia. The nurse performs an assessment on the client expecting to note
which of the following in this type of anemia?
a. Pink, mucous membranes
b. Increased vaginal secretions
c. Complaints of headaches and fatigue
d. Complains of increased frequency of voiding
23. A primigravida is receiving magnesium sulfate for the treatment of
gestational hypertension. The nurse who is caring for the client is
performing assessments every 30 minutes. Which funding would be of most
concern to the nurse?
a. Urinary output of 20 mL
b. Deep tendon reflexes of 2+
c. Fetal heart rate of 120 beats/min
d. Respiratory rate of 10 breaths per minute
24. A nurse is planning to teach a pregnant client about assessment of preterm
contractions. The nurse plans to use which strategy as the effective
teaching method?
a. Describe the process verbally in great detail
b. Place a monitor on the client's abdomen, and have her palpate simultaneously
c. Palpate for uterine contractions at the same time as the client
d. Provide a pamphlet with multiple pictures and drawings
25. A woman at 32weeks' gestation is brought into the emergency department
after an automobile accident. The Client is bleeding vaginally and fetal
assessment indicates moderate fetal distress. Which of the following should
the nurse do first in an attempt to reduce the stress on the fetus?
a. Start intravenous (IV) fluids at a keep open rate
B. Set up for an immediate cesarean section delivery
c. Elevate the head of the bed to a semi-Fowler's position
d. Administer oxygen via a face mask at 7 to 10 liters per minute
26. A nurse is reviewing the record of a pregnant client seen in the health care
clinic for the first prenatal visit. Which of the following data if noted on the
client's record would alert the nurse that the client is at risk for developing
gestational diabetes during this pregnancy?
a. The client's last baby weighed 10 pounds at birth.
b. The client's previous deliveries were by cesarean birth.
c. The client has a family history of cardiovascular disease.
d. The client is 5 feet 3 inches in height and weighs 165 pounds.
27. A rubella titer is performed on a woman who has just been told that she is
pregnant, and the results of the titer indicate that the mother is not
immune to rubella. Which of the following would the nurse anticipate to be
prescribed for this mother?
a. Immunization with rubella
b. Retesting the rubella titer during pregnancy
c. Counseling the mother regarding therapeutic abortion
d. Prescribed antibiotics to be taken throughout the pregnancy
28. A nurse is performing a prenatal examination on a client in the third
trimester. The nurse begins an abdominal examination and performs
Leopold maneuvers. The nurse determines which of the following after
performing the first maneuver?
a. Fetal descent
b. Placenta previa
c.Fetal lie and presentation
d. Strength of uterine contractions
29. Instructions for the seIf-care for a client with preterm premature rupture of
membranes (PPROM) should include which of the
following? Select all that apply
a. Take daily tub baths
b. Sexual activity is allowed
c. Remain on modified bedrest
d. Douche daily with a vinegar solution
e. Report a temperature of more than 38°C
f. Watch for foul-smelling vaginal discharge.
30. During a prenatal visit, a pregnant woman in the second trimester of
pregnancy complains of constipation and describes the home care
measures she is taking to relieve the problem. Which of the following would
the nurse determine is a harmful measure in preventing constipation?
a. Daily activity such as walking or swimming
b.Drinking six to eight glasses of water daily
c. Increasing whole grains and fresh vegetables in the diet
d. Adding 1 tablespoon of mineral oil to a bowl of cereal daily
31. A nurse is reviewing the procedure for vitamin K injection in a newborn
with a nursing student. Which information would the nurse provide to the
student?
a. Inject at a 45-degree angle
b.Use a 22-gauge, 1-inch needle for the injection
c. Do not massage the injection site after administration
d. Inject into skin that has been cleansed with alcohol
32. After surgical evacuation and repair of a paravaginal hematoma, a client is
discharged 3 days postpartum. The nurse determines that the client needs
further discharge instructions when she states:
a. 'I will probably need my mother to help me with housekeeping.“
b. 'Because I am so sore, I will nurse the baby while lying on my side.“
c. 'My husband and I will not have intercourse until the stitches are healed.‘
d. 'The only medications I will take are prenatal vitamins and stool softeners.‘
33. A nurse is assessing a 2-hour-postpartum woman with a diagnosis of
amniotic fluid embolus. Assessment findings include a blood pressure of
80/50 mm Hg, a pulse rate of 100 beats per minute, bruises at the
venipuncture sites, and petechiae around the left middeltoid area. The
client is saturating a peripad every 10 to 15 minutes and is oozing red
serosanguineous fluid from the episiotomy incision. The nurse analyzes that
these findings are consistent with:
a. Pulmonary hypertension secondary to venospasm
b. Circulatory collapse secondary to right ventricular
failure
c. Hemorrhage secondary to coagulation failure
d. Secondary postpartum hemorrhage due to uterine
atony
34. A nurse obtains the vital signs on a mother who delivered a healthy
newborn infant 2 hours ago and notes that the mother‘s temperature is
102°F. The appropriate nursing action would be to:
a. Notify the physician
b. Remove the blanket from the client's bed
c. Document the finding and recheck the temperature in 4 hours
d. Administer acetaminophen (T ylenol) and recheck the temperature in 4 hours
35. A nurse is assisting in admitting a newborn infant to the nursery and notes
that the physician has documented that the newborn has gastroschisis. The
nurse plans care, knowing that in this condition the viscera are:
a. Inside the abdominal cavity and under the skin
b.Inside the abdominal cavity and under the dermis
c. Outside the abdominal cavity and not covered with a sac
d.Outside the abdominal cavity but inside a translucent sac covered with
peritoneum and amniotic membrane
36. The mother of a newborn calls a clinic and reports to a nurse that when
cleaning the umbilical cord, the mother noticed that the cord was moist and
that discharge was present. The appropriate nursing instruction to the
mother is which of the following?
a. Bring the infant to the clinic.
b.This is a normal occurrence.
c. Increase the number of times that the cord is cleaned per day.
d. Monitor the cord for another 24 to 48 hours and call the clinic if the discharge
continues.
37. A newborn male infant is diagnosed with an undescended testicle
(cryptorchidism), and these findings are shared with the parents. The
parents ask questions about the condition. The nurse responds, knowing
that which of the following could have a psychosocial impact if this
condition is not corrected?
a. Atrophy
b. Infertility
c. Malignancy
d. Feminization
38. The nurse is assessing a client for signs of postpartum depression. Which of
the following, if noted in the new mother, would indicate the need for
further assessment related to this form of depression?
a. The mother is caring for the infant in a loving manner.
b. The mother constantly complains of tiredness and fatigue.
c. The mother demonstrates an interest in the surroundings.
d.The mother looks forward to visits from the father of the newborn.
c. The test will determine where to insert the needle
d. The ultrasound locates a pool of amniotic fluid
43. While the postpartum client is receiving heparin for thrombophlebitis,
which of the following drugs would the nurse expect to administer if the
client develops complications related to heparin therapy?
a. Calcium gluconate
b. Protamine sulfate
c. Methylergonovine (Methergine)
d. Nitrofurantoin (Macrodantin)
44. 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?
aTurn the neonate every 6 hours
bEncourage the mother to discontinue breastfeeding
cNotify the physician if the skin becomes bronze in color
dCheck the vital signs every 2 to 4 hours
45. 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?
aBack
bAbdomen
cFundus
dPerineum
46. 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.”

39. A nurse is caring for a jaundiced infant and notes that the serum bilirubin 47. Forty-eight hours after delivery, the nurse in charge plans discharge
levels have been increasing over the past 48 hours. The nurse anticipates teaching for the client about infant care. By this time, the nurse expects
that the serum level today will be at a level appropriate to institute that the phase of postpartum psychological adaptation that the client
phototherapy. After explaining phototherapy to the parents, which would be in would be termed which of the following?
statement would indicate the need for further instruction? a. Taking in
b. Letting go
a. We will bring in clean clothes for our baby to wear today c. Taking hold
b. Our baby will have eye patches on d. Resolution
c. We will be available for feedings every 2 to 3 hours.
d. We understand that home phototherapy is an option 48. A pregnant client is diagnosed with partial placenta previa. In explaining the
diagnosis, the nurse tells the client that the usual treatment for partial
40. A nurse admits a newborn infant to the nursery. On assessment of the placenta previa is which of the following?
infant, the nurse palpates the anterior fontanel and notes that it feels soft. a. Activity limited to bed rest
The nurse determines that this finding indicates: b. Platelet infusion
c. Immediate cesarean delivery
a. Dehydration d. Labor induction with oxytocin
b. A normal finding
c. Increased intracranial pressure 49. The nurse plans to instruct the postpartum client about methods to prevent
d. Decreased intracranial pressure breast engorgement. Which of the following measures would the nurse
include in the teaching plan?
41. A postpartum patient was in labor for 30 hours and had ruptured a. Feeding the neonate a maximum of 5 minutes per side on the first day
membranes for 24 hours. For which of the following would the nurse be b. Wearing a supportive brassiere with nipple shields
alert? c. Breast-feeding the neonate at frequent intervals
a. Endometritis d. Decreasing fluid intake for the first 24 to 48 hours
b. Endometriosis
c. Salpingitis 50. When the nurse on duty accidentally bumps the bassinet, the neonate
d. Pelvic thrombophlebitis throws out its arms, hands opened, and begins to cry. The nurse interprets
this reaction as indicative of which of the following reflexes?
42. A client at 36 weeks gestation is scheduled for a routine ultrasound prior to a. Startle reflex
an amniocentesis. After teaching the client about the purpose for the b. Babinski reflex
ultrasound, which of the following client statements would indicate to the c. Grasping reflex
nurse in charge that the client needs further instruction? d. Tonic neck reflex
a. The ultrasound will help to locate the placenta
b. The ultrasound identifies blood flow through the umbilical cord
51. A primigravida client at 25 weeks gestation visits the clinic and tells the a. The membranes must rupture
nurse that her lower back aches when she arrives home from work. The b. The fetus must be at 0 station
nurse should suggest that the client perform: c. The cervix must be dilated fully
a. Tailor sitting d. The patient must receive anesthesia
b. Leg lifting
c. Shoulder circling 61. When assessing the adequacy of sperm for conception to occur, which of
d. Squatting exercises the following is the most useful criterion?
a. Sperm count
52. Which of the following would the nurse in charge do first after observing a b. Sperm motility
2-cm circle of bright red bleeding on the diaper of a neonate who just had a c. Sperm maturity
circumcision? d. Semen volume
a. Notify the neonate’s pediatrician immediately 62. A couple who wants to conceive but has been unsuccessful during the last 2
b. Check the diaper and circumcision again in 30 minutes years has undergone many diagnostic procedures. When discussing the
c. Secure the diaper tightly to apply pressure on the site situation with the nurse, one partner states, ―We know several friends in
d. Apply gentle pressure to the site with a sterile gauze pad our age group and all of them have their own child already, Why can‘t we
have one?‖. Which of the following would be the most pertinent nursing
53. Which of the following would the nurse most likely expect to find when diagnosis for this couple?
assessing a pregnant client with abruption placenta? a. Fear related to the unknown
a. Excessive vaginal bleeding b. Pain related to numerous procedures.
b. Rigid, board-like abdomen c. Ineffective family coping related to infertility.
c. Titanic uterine contractions d. Self-esteem disturbance related to infertility.
d. Premature rupture of membranes 63. Which of the following urinary symptoms does the pregnant woman most
frequently experience during the first trimester?
54. While the client is in active labor with twins and the cervix is 5 cm dilates, a. Dysuria
the nurse observes contractions occurring at a rate of every 7 to 8 minutes b. Frequency
in a 30-minute period. Which of the following would be the nurse’s most c. Incontinence d. Burning
appropriate action? 64. Heartburn and flatulence, common in the second trimester, are most likely
a. Note the fetal heart rate patterns the result of which of the following?
b. Notify the physician immediately a. Increased plasma HCG levels
c. Administer oxygen at 6 liters by mask b. Decreased intestinal motility
d. Have the client pant-blow during the contractions c. Decreased gastric acidity
d. Elevated estrogen levels
55. A client tells the nurse, “I think my baby likes to hear me talk to him.” When 65. On which of the following areas would the nurse expect to observe
discussing neonates and stimulation with sound, which of the following chloasma?
would the nurse include as a means to elicit the best response? a. Breast, areola, and nipples
a. High-pitched speech with tonal variations b. Chest, neck, arms, and legs
b. Low-pitched speech with a sameness of tone c. Abdomen, breast, and thighs
c. Cooing sounds rather than words d. Cheeks, forehead, and nose
d. Repeated stimulation with loud sounds 66. A pregnant client states that she ―waddles‖ when she walks. The nurse‘s
explanation is
56. A 31-year-old multipara is admitted to the birthing room after initial based on which of the following as the cause?
examination reveals her cervix to be at 8 cm, completely effaced (100 %), a. The large size of the newborn
and at 0 station. What phase of labor is she in? b. Pressure on the pelvic muscles
a. Active phase c. Relaxation of the pelvic joints
b. Latent phase d. Excessive weight gain
c. Expulsive phase 67. Which of the following represents the average amount of weight gained
d. Transitional phase during pregnancy?
a. 12 to 22 lb
57. A pregnant patient asks the nurse if she can take castor oil for her b. 15 to 25 lb
constipation. How should the nurse respond? c. 24 to 30 lb
a. “Yes, it produces no adverse effect.” d. 25 to 40 lb
b. “No, it can initiate premature uterine contractions.” 68. When talking with a pregnant client who is experiencing aching swollen, leg
c. “No, it can promote sodium retention.” veins, the nurse would explain that this is most probably the result of which
d. “No, it can lead to increased absorption of fat-soluble vitamins.” of the following?
a. Thrombophlebitis
58. A patient in her 14th week of pregnancy has presented with abdominal b. Pregnancy-induced hypertension
cramping and vaginal bleeding for the past 8 hours. She has passed several c. Pressure on blood vessels from the enlarging uterus d. The force of
clots. What is the primary nursing diagnosis for this patient? gravity pulling down on the uterus
a. Knowledge deficit 69. Cervical softening and uterine souffle are classified as which of the
b. Fluid volume deficit following?
c. Anticipatory grieving a. Diagnostic signs
d. Pain b. Presumptive signs
c. Probable signs
59. Immediately after delivery, the nurse-midwife assesses the neonate’s head d. Positive signs
for signs of molding. Which factors determine the type of molding? 70. Which of the following would the nurse identify as a presumptive sign of
a. Fetal body flexion or extension pregnancy?
b. Maternal age, body frame, and weight a. Hegar sign
c. Maternal and paternal ethnic backgrounds b. Nausea and vomiting
d. Maternal parity and gravidity c. Skin pigmentation changes
d. Positive serum pregnancy test
60. For a patient in active labor, the nurse-midwife plans to use an internal 71. Which of the following common emotional reactions to pregnancy would
electronic fetal monitoring (EFM) device. What must occur before the the nurse expect to occur during the first trimester?
internal EFM can be applied? a. Introversion, egocentrism, narcissism
 b. Awkwardness, clumsiness, and unattractiveness c. Coach for effective client pushing
c. Anxiety, passivity, extroversion d. Promote parent-newborn interaction.
d. Ambivalence, fear, fantasies 84. Which of the following actions demonstrates the nurse‘s understanding
72. During which of the following would the focus of classes be mainly on about the newborn‘s thermoregulatory ability?
physiologic changes, fetal development, sexuality, during pregnancy, and a. Placing the newborn under a radiant warmer.
nutrition? b. Suctioning with a bulb syringe
a. Pre-pregnant period c. Obtaining an Apgar score
b. First trimester d. Inspecting the newborn‘s umbilical cord
c. Second trimester 85. Immediately before expulsion, which of the following cardinal movements
d. Third trimester occur?
73. Which of the following would be disadvantage of breast feeding? a. Descent
a. Involution occurs more rapidly b. Flexion
b. The incidence of allergies increases due to maternal antibodies c. Extension
c. The father may resent the infant‘s demands on the mother‘s body d. External rotation
d. There is a greater chance for error during preparation 86. Before birth, which of the following structures connects the right and left
74. Which of the following would cause a false-positive result on a pregnancy auricles of the heart?
test? a. Umbilical vein
a. The test was performed less than 10 days after an abortion b. Foramen ovale
b. The test was performed too early or too late in the pregnancy c. Ductusarteriosus
c. The urine sample was stored too long at room temperature d. Ductusvenosus
d. A spontaneous abortion or a missed abortion is impending 87. Which of the following when present in the urine may cause a reddish stain
75. FHR can be auscultated with a fetoscope as early as which of the following? on the diaper of a newborn?
a. 5 weeks gestation a. Mucus
b. 10 weeks gestation b. Uric acid crystals
c. 15 weeks gestation c. Bilirubin
d. 20 weeks gestation d. Excess iron
76. A client LMP began July 5. Her EDD should be which of the following? 88. When assessing the newborn‘s heart rate, which of the following ranges
a. January 2 would be considered normal if the newborn were sleeping?
b. March 28 a. 80 beats per minute
c. April 12 b. 100 beats per minute
d. October 12 c. 120 beats per minute
77. Which of the following fundal heights indicates less than 12 weeks’ d. 140 beats per minute
gestation when the date of the LMP is unknown? 89. Which of the following is true regarding the fontanels of the newborn?
a. Uterus in the pelvis a. The anterior is triangular shaped; the posterior is diamond shaped.
b. Uterus at the xiphoid c. Uterus in the abdomen d. Uterus at the umbilicus b. The posterior closes at 18 months; the anterior closes at 8 to 12 weeks.
78. Which of the following danger signs should be reported promptly during c. The anterior is large in size when compared to the posterior fontanel.
the antepartum period? d. The anterior is bulging; the posterior appears sunken.
a. Constipation 90. Which of the following groups of newborn reflexes below are present at
b. Breast tenderness birth and remain unchanged through adulthood?
c. Nasal stuffiness a. Blink, cough, rooting, and gag
d. Leaking amniotic fluid b. Blink, cough, sneeze, gag
79. Which of the following prenatal laboratory test values would the nurse c. Rooting, sneeze, swallowing, and cough
consider as significant? d. Stepping, blink, cough, and sneeze
a. Hematocrit 33.5% 91. Which of the following describes the Babinski reflex?
b. Rubella titer less than 1:8 a. The newborn‘s toes will hyperextend and fan apart from dorsiflexion of
c. White blood cells 8,000/mm3 the big toe when one side of foot is stroked upward from the ball of the
d. One hour glucose challenge test 110 g/dL heel and across the ball of the foot.
80. Which of the following characteristics of contractions would the nurse b. The newborn abducts and flexes all extremities and may begin to cry
expect to find in a client experiencing true labor? when exposed to sudden movement or loud noise.
a. Occurring at irregular intervals c. The newborn turns the head in the direction of stimulus, opens the
b. Starting mainly in the abdomen c. Gradually increasing intervals mouth, and begins to suck when cheek, lip, or corner of mouth is touched.
d. Increasing intensity with walking d. The newborn will attempt to crawl forward with both arms and legs
81. During which of the following stages of labor would the nurse assess when he is placed on his abdomen on a flat surface
―crowning‖? 92. Which of the following statements best describes hyperemesis gravidarum?
a. First stage a. Severe anemia leading to electrolyte, metabolic, and nutritional
b. Second stage imbalances in the absence of other medical problems.
c. Third stage b. Severe nausea and vomiting leading to electrolyte, metabolic, and
d. Fourth stage nutritional imbalances in the absence of other medical problems.
82. Barbiturates are usually not given for pain relief during active labor for c. Loss of appetite and continuous vomiting that commonly results in
which of the following reasons? dehydration and ultimately decreasing maternal nutrients
a. The neonatal effects include hypotonia, hypothermia, generalized d. Severe nausea and diarrhea that can cause gastrointestinal irritation and
drowsiness, and reluctance to feed for the first few days. possibly internal bleeding
b. These drugs readily cross the placental barrier, causing depressive effects 93. Which of the following would the nurse identify as a classic sign of PIH?
in the newborn 2 to 3 hours after intramuscular injection. a. Edema of the feet and ankles
c. They rapidly transfer across the placenta, and lack of an antagonist make b. Edema of the hands and face
them generally inappropriate during labor. c. Weight gain of 1 lb/week
d. Adverse reactions may include maternal hypotension, allergic or toxic d. Early morning headache
reaction or partial or total respiratory failure 94. In which of the following types of spontaneous abortions would the nurse
83. Which of the following nursing interventions would the nurse perform assess dark brown vaginal discharge and a negative pregnancy test?
during the third stage of labor? a. Threatened b. Imminent c. Missed
a. Obtain a urine specimen and other laboratory tests. d. Incomplete
b. Assess uterine contractions every 30 minutes. 95. Which of the following factors would the nurse suspect as predisposing a
client to placenta previa?
 a. Multiple gestation b. Endemic infection occurring randomly and localizing in the periglandular
b. Uterine anomalies connective tissue
c. Abdominal trauma c. Temporary urinary retention due to decreased perception of the urge to
d. Renal or vascular disease avoid
96. Which of the following would the nurse assess in a client experiencing d. Breast injury caused by overdistention, stasis, and cracking of the nipples
abruptio placenta? 107. Which of the following best describes thrombophlebitis?
a. Bright red, painless vaginal bleeding a. Inflammation and clot formation that result when blood components
b. Concealed or external dark red bleeding combine to form an aggregate body
c. Palpable fetal outline b. Inflammation and blood clots that eventually become lodged within the
d. Soft and nontender abdomen pulmonary blood vessels
97. Which of the following is described as premature separation of a normally c. Inflammation and blood clots that eventually become lodged within the
implanted placenta during the second half of pregnancy, usually with femoral vein
severe hemorrhage? d. Inflammation of the vascular endothelium with clot formation on the
a. Placenta previa vessel wall
b. Ectopic pregnancy 108. Which of the following assessment findings would the nurse expect if the
c. Incompetent cervix client develops
d. Abruptio placentae DVT?
98. Which of the following may happen if the uterus becomes overstimulated a. Midcalf pain, tenderness and redness along the vein
by oxytocin during the induction of labor? b. Chills, fever, malaise, occurring 2 weeks after delivery
a. Weak contraction prolonged to more than 70 seconds c. Muscle pain the presence of Homans sign, and swelling in the affected
b. Tetanic contractions prolonged to more than 90 seconds c. Increased limb
pain with bright red vaginal bleeding d. Chills, fever, stiffness, and pain occurring 10 to 14 days after delivery
d. Increased restlessness and anxiety 109. Which of the following are the most commonly assessed findings in cystitis?
99. When preparing a client for cesarean delivery, which of the following key a. Frequency, urgency, dehydration, nausea, chills, and flank pain
concepts should be considered when implementing nursing care? b. Nocturia, frequency, urgency dysuria, hematuria, fever and suprapubic
a. Instruct the mother‘s support person to remain in the family lounge until pain
after the delivery c. Dehydration, hypertension, dysuria, suprapubic pain, chills, and fever
b. Arrange for a staff member of the anesthesia department to explain what d. High fever, chills, flank pain nausea, vomiting, dysuria, and frequency
to expect postoperatively 110. Which of the following best reflects the frequency of reported postpartum
c. Modify preoperative teaching to meet the needs of either a planned or ―blues‖?
emergency cesarean birth a. Between 10% and 40% of all new mothers report some form of
d. Explain the surgery, expected outcome, and kind of anesthetics postpartum blues
100. Which of the following best describes preterm labor? b. Between 30% and 50% of all new mothers report some form of
a. Labor that begins after 20 weeks gestation and before 37 weeks postpartum blues
gestation c. Between 50% and 80% of all new mothers report some form of
b. Labor that begins after 15 weeks gestation and before 37 weeks postpartum blues
gestation d. Between 25% and 70% of all new mothers report some form of
c. Labor that begins after 24 weeks gestation and before 28 weeks gestation postpartum blues
d. Labor that begins after 28 weeks gestation and before 40 weeks 111. For the client who is using oral contraceptives, the nurse informs the client
gestation about the need to take the pill at the same time each day to accomplish
101. When PROM occurs, which of the following provides evidence of the which of the following?
nurse‘s understanding of the client‘s immediate needs? a. Decrease the incidence of nausea
a. The chorion and amnion rupture 4 hours before the onset of labor. b. Maintain hormonal levels
b. PROM removes the fetus most effective defense against infection c. Reduce side effects
c. Nursing care is based on fetal viability and gestational age. d. Prevent drug interactions
d. PROM is associated with malpresentation and possibly incompetent 112. When teaching a client about contraception. Which of the following would
cervix the nurse include as the most effective method for preventing sexually
102. Which of the following factors is the underlying cause of dystocia? transmitted infections?
a. Nutritional a. Spermicides
b. Mechanical b. Diaphragm
c. Environmental c. Condoms
d. Medical d. Vasectomy
103. When uterine rupture occurs, which of the following would be the priority? 113. When preparing a woman who is 2 days postpartum for discharge,
a. Limiting hypovolemic shock recommendations for which of the following contraceptive methods would
b. Obtaining blood specimens be avoided?
c. Instituting complete bed rest a. Diaphragm
d. Inserting a urinary catheter b. Female condom
104. Which of the following is the nurse‘s initial action when umbilical cord c. Oral contraceptives
prolapse occurs? d. Rhythm method
a. Begin monitoring maternal vital signs and FHR 114. For which of the following clients would the nurse expect that an
b. Place the client in a knee-chest position in bed intrauterine device would not be recommended?
c. Notify the physician and prepare the client for delivery a. Woman over age 35
d. Apply a sterile warm saline dressing to the exposed cord b. Nulliparous woman
105. Which of the following amounts of blood loss following birth marks the c. Promiscuous young adult
criterion for describing postpartum hemorrhage? d. Postpartum client
a. More than 200 ml 115. A client in her third trimester tells the nurse, ―I‘m constipated all the
b. More than 300 ml time!‖ Which of the following should the nurse recommend?
c.More than 400 ml a. Daily enemas
d.More than 500 ml b. Laxatives
106. Which of the following is the primary predisposing factor related to c. Increased fiber intake
mastitis? d. Decreased fluid intake
a. Epidemic infection from nosocomial sources localizing in the lactiferous 116. Which of the following would the nurse use as the basis for the teaching
glands and ducts plan when caring for a pregnant teenager concerned about gaining too
 much weight during pregnancy? 127. The nurse assesses the postpartum vaginal discharge (lochia) on four
a. 10 pounds per trimester clients. Which of
b. 1 pound per week for 40 weeks the following assessments would warrant notification of the physician?
c. 1⁄2 pound per week for 40 weeks a. A dark red discharge on a 2-day postpartum client
d. A total gain of 25 to 30 pounds b. A pink to brownish discharge on a client who is 5 days postpartum
117. The client tells the nurse that her last menstrual period started on January c. Almost colorless to creamy discharge on a client 2 weeks after delivery
14 and ended on January 20. Using Nagele‘s rule, the nurse determines her d. A bright red discharge 5 days after delivery
EDD to be which of the following? 128. A postpartum client has a temperature of 101.4oF, with a uterus that is
a. September 27 tender when palpated, remains unusually large, and not descending as
b. October 21 normally expected. Which of the following should the nurse assess next?
c. November 7 a. Lochia b. Breasts c. Incision d. Urine
d. December 27 129. Which of the following is the priority focus of nursing practice with the
118. When taking an obstetrical history on a pregnant client who states, ―I had current early postpartum discharge?
a son born at 38 weeks gestation, a daughter born at 30 weeks gestation a. Promoting comfort and restoration of health
and I lost a baby at about 8 weeks,‖ the nurse should record her obstetrical b. Exploring the emotional status of the family
history as which of the following? c. Facilitating safe and effective self-and newborn care
a. G2 T2 P0 A0 L2 d. Teaching about the importance of family planning
b. G3 T1 P1 A0 L2 130. Which of the following actions would be least effective in maintaining a
c. G3 T2 P0 A0 L2 neutral thermal environment for the newborn?
d. G4 T2 P1 A1 L2 a. Placing infant under radiant warmer after bathing
119. When preparing to listen to the fetal heart rate at 12 weeks‘ gestation, the b. Covering the scale with a warmed blanket prior to weighing
nurse would use which of the following? c. Placing crib close to nursery window for family viewing
a. Stethoscope placed midline at the umbilicus d. Covering the infant‘s head with a knit stockinette
b. Doppler placed midline at the suprapubic region 131. A newborn that has an asymmetrical Moro reflex response should be
c. Fetoscope placed midway between the umbilicus and the xiphoid process further assessed for which of the following?
d. External electronic fetal monitor placed at the umbilicus a. Talipesequinovarus
120. When developing a plan of care for a client newly diagnosed with b. Fractured clavicle
gestational diabetes, which of the following instructions would be the c. Congenital hypothyroidism
priority? d. Increased intracranial pressure
a. Dietary intake 132. During the first 4 hours after a male circumcision, assessing for which of the
b. Medication following is
c. Exercise the priority?
d. Glucose monitoring a. Infection
121. A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of the b. Hemorrhage c. Discomfort d. Dehydration
following would be the priority when assessing the client? 133. The mother asks the nurse. ―What‘s wrong with my son‘s breasts? Why
a. Glucosuria are they so enlarged?‖ Whish of the following would be the best response
b. Depression by the nurse?
c. Hand/face edema a. The breast tissue is inflamed from the trauma experienced with birth‖
d. Dietary intake b. A decrease in material hormones present before birth causes
122. A client 12 weeks‘pregnant come to the emergency department with enlargement,‖
abdominal cramping and moderate vaginal bleeding. Speculum examination c. You should discuss this with your doctor. It could be a malignancy‖
reveals 2 to 3 cm cervical dilation. The nurse would document these d. The tissue has hypertrophied while the baby was in the uterus‖
findings as which of the following? 134. Immediately after birth the nurse notes the following on a male newborn:
a. Threatened abortion respirations 78; apical hearth rate 160 BPM, nostril flaring; mild intercostal
b. Imminent abortion retractions; and grunting at
c. Complete abortion the end of expiration. Which of the following should the nurse do?
d. Missed abortion a. Call the assessment data to the physician‘s attention
123. Which of the following would be the priority nursing diagnosis for a client b. Start oxygen per nasal cannula at 2 L/min.
with an ectopic pregnancy? c. Suction the infant‘s mouth and nares
a. Risk for infection d. Recognize this as normal first period of reactivity
b. Pain 135. The nurse hears a mother telling a friend on the telephone about umbilical
c. Knowledge Deficit cord care. Which of the following statements by the mother indicates
d. Anticipatory Grieving effective teaching?
124. Before assessing the postpartum client‘s uterus for firmness and position in a. ―Daily soap and water cleansing is best‖
relation to the umbilicus and midline, which of the following should the b. A
̳ lcohol helps it dry and kills germs‖
nurse do first? c. ―An antibiotic ointment applied daily prevents infection‖
a. Assess the vital signs d. ―He can have a tub bath each day‖
b. Administer analgesia 136. A newborn weighing 3000 grams and feeding every 4 hours needs 120
c. Ambulate her in the hall calories/kg of body weight every 24 hours for proper growth and
d. Assist her to urinate development. How many ounces of 20
125. Which of the following should the nurse do when a primipara who is cal/oz formula should this newborn receive at each feeding to meet
lactating tells the nurse that she has sore nipples? nutritional needs?
a. Tell her to breast feed more frequently a. 2 ounces
b. Administer a narcotic before breast feeding b. 3 ounces
c. Encourage her to wear a nursing brassiere c. 4 ounces
d. Use soap and water to clean the nipples d. 6 ounces
126. The nurse assesses the vital signs of a client, 4 hours‘postpartum that are as 137. The postterm neonate with meconium-stained amniotic fluid needs care
follows: BP 90/60; temperature 100.4oF; pulse 100 weak, thready; R 20 per designed to especially monitor for which of the following?
minute. Which of the following should the nurse do first? a. Respiratory problems
a. Report the temperature to the physician b. Gastrointestinal problems
b. Recheck the blood pressure with another cuff c. Integumentary problems
c. Assess the uterus for firmness and position d. Elimination problems
d. Determine the amount of lochia
138. When measuring a client‘s fundal height, which of the following techniques 149. A multigravida at 38 weeks‘ gestation is admitted with painless, bright red
denotes the correct method of measurement used by the nurse? bleeding and mild contractions every 7 to 10 minutes. Which of the
a. From the xiphoid process to the umbilicus following assessments should be avoided?
b. From the symphysis pubis to the xiphoid process c.From the symphysis a. Maternal vital sign
pubis to the fundus b. Fetal heart rate
d.From the fundus to the umbilicus c. Contraction monitoring
139. A client with severe preeclampsia is admitted with of BP 160/110, d. Cervical dilation
proteinuria, and severe pitting edema. Which of the following would be 150. Which of the following would be the nurse‘s most appropriate response to
most important to include in the client‘s plan of care? a client who asks why she must have a cesarean delivery if she has a
a. Daily weights complete placenta previa?
b. Seizure precautions a. You will have to ask your physician when he returns
c. Right lateral positioning d. Stress reduction b. You need a cesarean to prevent hemorrhage.‖
140. A postpartum primipara asks the nurse, ―When can we have sexual c. The placenta is covering most of your cervix.‖
intercourse again?‖ Which of the following would be the nurse‘s best d. The placenta is covering the opening of the uterus and blocking your
response? baby.‖
a. Anytime you both want to.‖ 151. The nurse understands that the fetal head is in which of the following
b. As soon as choose a contraceptive method.‖ positions with a face presentation?
c. When the discharge has stopped and the incision is healed.‖ a. Completely flexed
d. After your 6 weeks examination.‖ b. Completely extended
141. When preparing to administer the vitamin K injection to a neonate, the c. Partially extended
nurse would select which of the following sites as appropriate for the d. Partially flexed
injection? 152. With a fetus in the left-anterior breech presentation, the nurse would
a. Deltoid muscle expect the fetal heart rate would be most audible in which of the following
b. Anteriorfemoris muscle areas?
c. Vastuslateralis muscle a. Above the maternal umbilicus and to the right of midline
d. Gluteus maximus muscle b. In the lower-left maternal abdominal quadrant
142. When performing a pelvic examination, the nurse observes a red swollen c. In the lower-right maternal abdominal quadrant
area on the right side of the vaginal orifice. The nurse would document this d. Above the maternal umbilicus and to the left of midline
as enlargement of which of the following? 153. The amniotic fluid of a client has a greenish tint. The nurse interprets this to
a. Clitoris be the result of which of the following?
b. Parotid gland a. Lanugo
c. Skene‘s gland b. Hydramnio
d. Bartholin‘s gland c. Meconium
143. To differentiate as a female, the hormonal stimulation of the embryo that d. Vernix
must occur involves which of the following? 154. A patient is in labor and has just been told she has a breech presentation.
a. Increase in maternal estrogen secretion The nurse should be particularly alert for which of the following?
b. Decrease in maternal androgen secretion a. Quickening
c. Secretion of androgen by the fetal gonad b. Ophthalmianeonatorum c. Pica
d. Secretion of estrogen by the fetal gonad d. Prolapsed umbilical cord
144. A client at 8 weeks‘ gestation calls complaining of slight nausea in the 155. When describing dizygotic twins to a couple, on which of the following
morning hours. Which of the following client interventions should the nurse would the nurse base the explanation?
question? a. Two ova fertilized by separate sperm
a. Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water b. Sharing of a common placenta
b. Eating a few low-sodium crackers before getting out of bed c. Each ova with the same genotype
c. Avoiding the intake of liquids in the morning hours d. Sharing of a common chorion
d. Eating six small meals a day instead of thee large meals 156. Which of the following refers to the single cell that reproduces itself after
145. The nurse documents positive ballottement in the client‘s prenatal record. conception?
The nurse understands that this indicates which of the following? a. Chromosome
a. Palpable contractions on the abdomen b. Blastocyst
b. Passive movement of the unengaged fetus c. Zygote
c. Fetal kicking felt by the client d. Trophoblast
d. Enlargement and softening of the uterus 157. In the late 1950s, consumers and health care professionals began
146. During a pelvic exam the nurse notes a purple-blue tinge of the cervix. The challenging the routine use of analgesics and anesthetics during childbirth.
nurse documents this as which of the following? Which of the following was an outgrowth of this concept?
a. Braxton-Hicks sign a. Labor, delivery, recovery, postpartum (LDRP)
b. Chadwick‘s sign b. Nurse-midwifery
c. Goodell‘s sign c. Clinical nurse specialist
d. McDonald‘s sign d. Prepared childbirth
147. During a prenatal class, the nurse explains the rationale for breathing 158. A client has a midpelvic contracture from a previous pelvic injury due to a
techniques during preparation for labor based on the understanding that motor vehicle accident as a teenager. The nurse is aware that this could
breathing techniques are most important in achieving which of the prevent a fetus from passing through or around which structure during
following? childbirth?
a. Eliminate pain and give the expectant parents something to do a. Symphysis Pubis
b. Reduce the risk of fetal distress by increasing uteroplacental perfusion c. b. Sacral Promontory
Facilitate relaxation, possibly reducing the perception of pain c. Ischial Spines
d. Eliminate pain so that less analgesia and anesthesia are needed d. Pubic Arch
148. After 4 hours of active labor, the nurse notes that the contractions of a 159. When teaching a group of adolescents about variations in the length of the
primigravida client are not strong enough to dilate the cervix. Which of the menstrual
following would the nurse anticipate doing? the nurse understands that the underlying mechanism is due to variations
a. Obtaining an order to begin IV oxytocin infusion in which following phases?
b. Administering a light sedative to allow the patient to rest for several hour a. Menstrual phase
c. Preparing for a cesarean section for failure to progress b. Proliferative phase
d. Increasing the encouragement to the patient when pushing begins
 c. Secretory phase 170. In malaria infested area, how is chloroquine given to pregnant women? [4]
d. Ischemic phase
160. The following would the nurse include as being produced by the Leydig A. 300 mg / twice a month for 9 months
cells? B. 200 mg / once a week for 5 months
a. Follicle-stimulating hormone C. 150 mg / twice a week for the duration of pregnancy
b. Testosterone D. 100 mg / twice a week for the last trimester of pregnancy
c. Leuteinizing hormone
d. Gonadotropin releasing hormone 171. Which of the following mothers are qualified for home delivery? [2]
161. While performing physical assessment of a 12 month-old, the nurse notes
that the infant‘s anterior fontanelle is still slightly open. Which of the A. Pre term
following is the nurse‘s most appropriate action? B. 6th pregnancy
a. Notify the physician immediately because there is a problem. C. Has a history of hemorrhage last pregnancy
b. Perform an intensive neurologic examination. D. 2nd pregnancy, Has a history of 20 hours of labor last pregnancy.
c. Perform an intensive developmental examination.
d. Do nothing because this is a normal finding for the age. 172. Which of the following is not included on the 3 Cs of delivery? [2]
162. When teaching a mother about introducing solid foods to her child, which
of the A. Clean Surface
following indicates the earliest age at which this should be done? B. Clean Hands
a. 1 month C. Clean Equipments
b. 2 months D. Clean Cord
c. 3 months 173. Which of the following is unnecessary equipment to be included in the
d. 4 months home delivery kit? [4]
163. Alpha wants to know how many fetal movements per hour is normal, the
correct response is [4] A. Boiled razor blade
B. 70% Isopropyl Alcohol
a. Twice C. Flashlight
b. Thrice D. Rectal and oral thermometer
c. Four times
d. 10-12 times 174. On the basis of the data provided above, You can conclude the pillar is in
the [1]
164. Upon examination by the obstetrician, he charted that Alpha is in the early
stage of labor. Which of the following is true in this state? [1] A. In false labor
B. In the active phase of labor
a. Self-focused C. In the latent phase of labor
b. Effacement is 100% D. In the transitional phase of labor
c. Last for 2 hours
d. Cervical dilation 1-3 cm 175. Pitocin drip is started on Pilar. Possible side effects of pitocin administration
include all of the following except [3]
165. When should be the 2nd visit of a pregnant mother to the RHU? [2]
A. Diuresis
a. Before getting pregnant B. Hypertension
b. As early in pregnancy C. Water intoxication
c. Second trimester D. Cerebral hemorrhage
d. Third trimester
176. The normal range of FHR is approximately [3]
166. Which of the following is NOT a standard prenatal physical examination? [1]
A. 90 to 140 bpm
a. Neck examination for goiter B. 120 to 160 bpm
b. Examination of the palms of the hands for pallor C. 100 to 140 bpm
c. Edema examination of the face hands, and lower extremities D. 140 to 180 bpm
d. Examination of the legs for varicosities
167. Which of the following is NOT a basic prenatal service delivery done in the 177. A negative 1 [-1] station means that [1]
BHS? [2]
A. Fetus is crowning
a. Oral / Dental check-up B. Fetus is floating
b. Laboratory examination C. Fetus is engaged
c. Treatment of diseases D. Fetus is at the ischial spine
d. Iron supplementation
168. How many days and how much dosages will the IRON supplementation are 178. Which of the following is characteristics of false labor [1]
taken? [4]
A. Bloody show
A. 365 days / 300 mg B. Contraction that are regular and increase in frequency and duration
B. 210 days / 200 mg C. Contraction are felt in the back and radiates towards the abdomen
C. 100 days/ 100mg D. None of the above
D. 50 days / 50 mg
179. Who's Theory of labor pain that states that PAIN in labor is cause by FEAR
169. When should the iron supplementation starts and when should it ends? [4] [4]

A. 5th month of pregnancy to 2nd month post-partum A. Bradley

B. 1st month of pregnancy to 5th month post-partum B. Simpson
C. As early in pregnancy up to 9th month of pregnancy C. Lamaze
D. From 1st trimester up to 6 weeks post-partum D. Dick-Read
180. Which sign would alert the nurse that Pillar is entering the second stage of
labor? [1]
A. Increase frequency and intensity of contraction
B. Perineum bulges and anal orifice dilates
C. Effacement of internal OS is 100%
D. Vulva encircles the largest diameter of presenting part
181. Nursing care during the second stage of labor should include [1]
A. Careful evaluation of prenatal history
B. Coach breathing, Bear down with each contraction and encourage
patient.
C. Shave the perineum
D. Administer enema to the patient
182. When is the APGAR Score taken? [1]
A. Immediately after birth and at 30 minutes after birth
B. At 5 minutes after birth and at 30 minutes after birth
C. At 1 minute after birth and at 5 minutes after birth
D. Immediately after birth and at 5 minutes after birth
183. The registered nurse is planning to delegate tasks to unlicensed assistive
personnel (UAP). Which of the following task could the registered nurse
safely assigned to a UAP?
A. Monitor the I&O of a comatose toddler client with salicylate poisoning
B. Perform a complete bed bath on a 2-year-old with multiple injuries from
a serious fall
C. Check the IV of a preschooler with Kawasaki disease
D. Give an out meal bath to an infant with eczema
184. A mother in labor told the nurse that she was expecting that her baby has
no chance to survive and expects that the baby will be born dead. The
mother accepts the fate of the baby and informs the nurse that when the
baby is born and requires resuscitation, the mother refuses any treatment
to her baby and expresses hostility toward the nurse while the pediatric
team is taking care of the baby. The nurse is legally obligated to:
A. Notify the pediatric team that the mother has refused resuscitation and
any treatment for the baby and take the baby to the mother
B. Get a court order making the baby a ward of the court.
C. Record the statement of the mother, notify the pediatric team, and
observe carefully for signs of impaired bonding and neglect as a reasonable
suspicion of child abuse
D. Do nothing; except record the mother’s statement in the medical record
185. The nurse is caring to a client who just gave birth to a healthy baby boy.
The nurse may not disclose confidential information when:
A. The nurse discusses the condition of the client in a clinical conference
with other nurses
B. The client asks the nurse to discuss the her condition with the family
C. The father of a woman who just delivered a baby is on the phone to find
out the sex of the baby
D. A researcher from an institutionally approved research study reviews the
medical record of a patient
186. An infant is admitted and diagnosed with pneumonia and suspicious-
looking red marks on the swollen face resembling a handprint. The nurse
does further assessment to the client. How would the nurse document the
finding?
A. Facial edema with ecchymosis and handprint mark: crackles and wheezes
B. Facial edema, with red marks; crackles in the lung
C. Facial edema with ecchymosis that looks like a handprint
D. Red bruise mark and ecchymosis on face
187. An infant is brought to the emergency department and diagnosed with
pyloric stenosis. The parents of the client ask the nurse, “Why does my
baby continue to vomit?” Which of the following would be the best nursing
response of the nurse?
A. “Your baby eats too rapidly and overfills the stomach, which causes
vomiting
B. “Your baby can’t empty the formula that is in the stomach into the
bowel”
C. “The vomiting is due to the nausea that accompanies pyloric stenosis”
D. “Your baby needs to be burped more thoroughly after feeding”
188. After a birth, the physician cut the cord of the baby, and before the baby is
given to the mother, what would be the initial nursing action of the nurse?
A. Examine the infant for any observable abnormalities
B. Confirm identification of the infant and apply bracelet to mother and
infant
C. Instill prophylactic medication in the infant’s eyes
D. Wrap the infant in a pre-warmed blanket and cover the head
189. Which of the following would be the most important goal in the nursing
care of an infant client with eczema?
A. preventing infection
B. Maintaining the comfort level
C. Providing for adequate nutrition
D. Decreasing the itching
190. The mother of the client tells the nurse, “I’m not going to have my baby get
any immunization”. What would be the best nursing response to the
mother?
A. “You and I need to review your rationale for this decision”
B. “Your baby will not be able to attend day care without immunizations”
C. “Your decision can be viewed as a form of child abuse and neglect”
D. “You are needlessly placing other people at risk for communicable
diseases”
191. The nurse is teaching the client about breast self-examination. Which
observation should the client be taught to recognize when doing the
examination for detection of breast cancer?
A. Tender, movable lump
B. Pain on breast self-examination
C. round, well-defined lump
D. Dimpling of the breast tissue
192. The tumor infiltrates nearby tissue, it can cause retraction of the
overlying skin and create a dimpling appearance.
A. Every other day after the 8th month of pregnancy till delivery
B. Every week after the 8th month of pregnancy till delivery
C. Every 2 weeks after the 8th month of pregnancy till delivery
D. None of the above
193. Tetanus toxoid vaccination is important for pregnant women and child
bearing women to prevent them and their baby from acquiring tetanus.
How many doses of Tetanus Toxoid should be given to the mother in order
to protect the baby from acquiring neonatal tetanus?
A. One Dose B. Two Doses
C. Three Doses D. Four Doses
194. How many doses of Tetanus Toxoid should be given to the mother in order
to protect her and the baby against the disease, during pregnancy and for
lifetime immunity?
A. Three Doses B. Four Doses
C. Five Doses D. Six Doses
195. A pregnant woman with hypertension is suffering from postpartum
hemorrhage. The following are first aid measures to be done by the
community health nurse except:
A. Massage Uterus and expel clots
B. Give Ergometrine .2 mg IM and another dose after 15mins
C. Place cupped palmed hands on the uterine fundus and feel for the state
of contraction
D. Apply bimanual uterine compression if postmartum bleeding still
persists.
196. The community health nurse should give supportive care to the pregnant
mother during labor. The nurse should do the following except:
A. Encourage the mother to take a bath during the onset of a labor
B. Encourage the mother to drink and eat when she feels hungry
C. Remind the mother to empty her bladder every 2hours
D. Encourage the mother to do breathing exercises for her to have energy
in pushing the baby out of her canal.
197. The nurse should assess the progress of labor. She knows that the pregnant
woman is in false labor if:
A. Cervix is dilated 4cm
B. There is an increase in contractions
C. The membranes are not ruptured
D. All of the above
198. The community health nurse should counsel the mother on the
recommended schedule of her first postpartum visit, which is;
A. 3-5 days after delivery
B. 6 weeks after delivery
C. Day after delivery
D. 3 weeks after
199. During family planning counseling sessions, the nurse should include which
topic in the discussion?
 A. Birth Control Method
B. Birth Spacing
C. Ideal Number of Children
D. All of the Above
200. In providing guidance for a couple wishing to avoid pregnancy, the nurse
reviews the record of a client who has a 29-day normal cycle. On which days
would the nurse expect the client to ovulate?
A. Day 5/6 B. Day 13/14
C. Day 15/16 D. Day 28/29
201. A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted
to the postpartum unit. Which nursing plan is best in assisting this mother
to bond with her newborn infant?
A. Encourage the mother to provide total care for her infant.
B. Provide privacy so the mother can develop a relationship with the infant.
C. Encourage the father to provide most of the infant’s care during
hospitalization.
D. Meet the mother’s physical needs and demonstrate warmth towards the
infant.
202. Which maternal behavior is the nurse most likely to see when a new
mother receives her infant for the first time?
A. She eagerly reaches for the infant, undresses the infant and examines
the infant completely.
B. Her arms and hands receive the infant and then she traces the infant’s
profile with fingertips.
C. Her arms and hands receive the infant and then she cuddles the infant to
her own body.
D. She eagerly reaches for the infant and holds the infant close to her body.