MATERNAL & CHILD NURSING

ACHIEVEMENT TEST
FIRST SEMESTER 2021-2022

1. A nurse is assessing the lochia in a 24-hour-postpartum client, and expresses blood clots with fundal
massage. The client’s fundus is firm but elevated, and deviated to the right. What would be the most
appropriate nursing action?
A. Assess the activity pattern.
B. Change the perineal pad.
C. Assess the voiding pattern.
D. Administer analgesics.

2. The nurse is receiving results from clients who are having antenatal testing. The assessment data
from which client warrants prompt notification of the provider and a further plan of care?
A. Primigravida who reports fetal movements 6 times in 2 hours
B. Multigravida who had a positive oxytocin challenge test
C. Primigravida whose infant has a biophysical profile of 9
D. Multigravida whose infant has a reactive nonstress test

3. Following a positive pregnancy test, a client begins discussing the changes that will occur in the next
several months with the nurse. Identifying the psychosocial aspect of pregnancy the nurse will
incorporate into the plan of care as she educates this client about the changes that occur in the first
trimester:
A. Differentiating the self from the fetus
B. Enjoying the role of nurturer
C. Preparing for the reality of parenthood
D. Experiencing ambivalence about pregnancy

4. Using Nagele’s rule for a client whose last normal menstrual period began on May 10, the nurse
determines that the client’s estimated date of delivery would be which of the following?
A. January 13 C. February 13
B. January 17 D. February 17

5 A client about 8 weeks pregnant, asks the nurse when she will be able to hear the fetal heartbeat.
The nurse should respond by telling the client that the fetal heartbeat can be heard with a Doppler
ultrasound device when the gestation is as early as which of the following?
A. 4 weeks C. 15 weeks
B. 8 weeks D. 18 weeks

6. Which of the following statements by the nurse would be appropriate when responding to a
primigravid client who asks, “What should I do about this brown discoloration across my nose and
cheeks?
A. “This usually disappears after delivery.”
B. “It is a sign of skin melanoma.”
C. “The discoloration is due to dilated capillaries.”
D. “It will fade if you use a prescribed cream.”

7. A client asks the nurse why taking folic acid is so important before and during pregnancy. Which of
the following would be the nurse’s best response?
A. “Folic acid is important in preventing anemia in mothers.”
B. “Eating foods with moderate amounts of folic acid helps regulate blood glucose levels.”
C. “Folic acid consumption helps with the absorption of iron during pregnancy.”
D. “Folic acid is needed to promote blood clotting and collagen formation in the newborn.”
8. When preparing a prenatal class about endocrine changes that normally occur during pregnancy,
which of the following subjects would be included?
A. Human placental lactogen maintains the corpus luteum
B. Progesterone is responsible for hyperpigmentation and vascular skin changes
C. Estrogen relaxes smooth muscles in the respiratory tract
D. The thyroid enlarges with an increase in basal metabolic rate

9. When developing a series of parent classes on fetal development, which of the following would the
nurse include as being developed by the end of the third month (9 to 12 weeks)?
A. External genitalia C. Brown fat stores
B. Myelinization of nerves D. Air ducts and alveoli

10. During a childbirth preparation class, a primigravid client at 36 weeks’ gestation tells the nurse, “My
lower back has really been bothering me lately. Which of the following exercises suggested by the
nurse would be most helpful?
A. Pelvic rocking C. Tailor sitting
B. Deep breathing D. Squatting

11. After a preparation for parenting class session, a pregnant client tells the nurse that she has had
some yellow-gray frothy vaginal discharge and local itching. The nurse’s best action is to advise the
client to do which of the following?
A. Use an over-the-counter cream for yeast infections
B. Schedule an appointment at the clinic for an examination
C. Administer a vinegar douche under low pressure
D. Prepare for preterm labor and delivery

12. During childbirth preparation classes for a group of adolescent primigravid clients, one of the clients
asks, “How does the baby breathe inside of me?” The nurse responds by explaining fetal circulation,
stating that circulation of oxygenated blood from the placenta begins with which of the following?
A. Umbilical cord C. Ductus arteriousus
B. Foramen ovale D. Umbilical vein

13. Which of the following instructions would the nurse expect to include in the teaching plan for a group
of primigravid clients attending a parenting class about the placenta and the umbilical cord?
A. The highest oxygen content is found in the umbilical artery
B. About 10% of umbilical cords have only two vessels
C. The cord normally inserts in the center of the placenta
D. A nuchal cord usually occurs when the cord is abnormally short

14. The physician orders intermittent fetal heart rate monitoring for a 20-year-old obese primigravid client
at 40 weeks’ gestation who is admitted to the birthing center in the first stage of labor. The nurse
would monitor the client’s fetal heart rate pattern at which of the following intervals?
A. every 15 minutes during the latent phase
B. every 30 minutes during the active phase
C. every 60 minutes during the initial phase
D. every 2 hours during the transitional phase

15. Assessment of primigravid client in active labor who has had no analgesia reveals complete cervical
effacement, dilation of 8 cm, and the fetus at 0 station. Which of the following behaviors would the
nurse anticipate that the client will exhibit during this phase of labor?
A. excitement C. numbness of the legs
B. loss of control D. feeling of relief

16. A primigravid client is admitted as an outpatient for an external cephalic version. For which of the
following would the nurse assess the client as a possible contraindication for the procedure?
A. multiple gestation C. maternal Rh-negative blood type
 B. breech presentation D. history of gestational diabetes

17. A multigravida in active labors is 7 cm dilated. The fetal heart rate baseline is 130 bpm with moderate
variability. The client begins to have variable decelerations to 100 to 110 bpm. What should the nurse
do next?
A. perform a vaginal examination
B. notify the physician of the decelerations
C. reposition the client and continue to evaluate the tracing
D. administer oxygen via mask at 2 L/minute

18. The nurse while shopping in the local department store, hears a multiparous woman say loudly, “I
think the baby’s coming.” After asking someone to call the nearest hospital, the nurse assists the
client to deliver a term neonate. While waiting for the ambulance, the nurse suggests that the mother
initiate breast-feeding, primarily for which of the following reasons?
A. to begin the parenteral-infant bonding process
B. to prevent neonatal hypothermia
C. to provide glucose to the neonate
D. to contract the mother’s uterus

19. While the nurse is caring for the multiparous client in active labor at 36 weeks’ gestation, the client
tells the nurse, “I think my bag of water just broke.” Which of the following would the nurse do first?
A. turn the client to the right side
B. assess the color, amount, and odor of the fluid
C. assess the fetal heart rate pattern
D. assess the client’s cervical dilation

20. Following an epidural and placement of internal monitors, a client’s labor is augmented. Contractions
are lasting greater than 90 seconds and occurring every 1½ minutes. The uterine resting is greater
than 20 mm mercury with a nonreassuring fetal heart rate and pattern. Which of the following actions
should the nurse take first?
A. notify the health care provider
B. turn off oxytocin (Pitocin) infusion
C. turn the client to her left side
D. increase the maintenance I.V fluids

21. A client has admitted use of cocaine prior to beginning labor. After the infant is born, that nurse
should anticipate the need to include which of the following actions in the infant’s plan of care?
A. urine toxicology screening
B. notify hospital security
C. limiting contact with visitors
D. contacting local law enforcement
22. The physician orders an intramuscular injection of phytonadione (AquaMEPHYTON) for a term
neonate. The nurse explains to the mother that this medication is used to prevent which of the
following?
A. hypoglycemia C. hemorrhage
B. hyperbilirubinemia D. polycythemia

23. When developing the plan of care for primiparous client during the first 12 hours after vaginal
delivery, which of the following concerns of the client should be the nurse’s primary focus of care?
A. the neonate C. the client’s own comfort
B. the family D. the client significant other

24. The nurse assesses a swollen ecchymosed area to the right of an episiotomy on a primiparous client
6 hours after a vaginal delivery. Which of the following actions should the nurse do next?
A. apply an ice pack to the perineal area
B. assess the client’s temperature
 C. have the client take a warm sitz bath
D. contact the physician for orders for an antibiotic
25. Which of the following drugs can be given to the mother before a preterm birth to help reduce the
severity of respiratory distress syndrome?
A. Betamethasone
B. Diazepam
C. Phenobarbital
D. RhoGAM
26. Which of the following is a positive indication of pregnancy?
A. Quickening C. Auscultation of fetal heart sounds
B. Chadwick’s sign D. Ballottement

27. During the last months of pregnancy, the nurse should instruct the client to:
A. rest on her left side for at least 1 hour in the morning and afternoon
B. sleep on her back during the night and during naps
C. start nipple exercises and stimulation twice a day
D. start to cut back on water intake, especially at night

28. When teaching a pregnant woman about traveling during the pregnancy, it is important to focus on
which of the following?
A. If traveling by car, stop every 2 hours for 10 minutes
B. Get plenty of rest before long trips made in automobiles
C. Travel in any type of aircraft is acceptable
D. Travel can be completed anytime throughout the pregnancy

29. Which of the following is recommended for all women during the childbearing age?
A. Additional B vitamins C. Folic acid supplement
B. Additional vitamin A D. Vitamin C supplement

30. Between 24 and 28 weeks, all pregnant women should be screened for:
A. Anemia C. Diabetes
B. Bladder infections D. Neural tube defects

31. Which of these measures would be helpful for the pregnant client complaining of sleeplessness?
A. Eat evening meal close to bedtime
B. Sit in a sitz bath before bedtime
C. Try to remain in one position when sleeping
D. Use pillows to help find a comfortable position

32. Why is the first 8 weeks of pregnancy known as the critical period of human development?
A. By the time this period ends, the embryo is completely safe from any damage
B. Many embryos die during this period
C. The infant’s sex is determined at the end of the eight week
D. The major structures of the embryo are forming, and damage can result in major birth defects

33. Which of these statements is most accurate about the placenta?

A. The blood of the baby mixes with the mother’s blood to permit exchange of nutrients and oxygen.
B. The blood of the baby and the mother do not mix; exchange occurs across blood vessels and the
walls of the villi.
C. The placenta lets the blood from the fetus cross to the mother, but the mother’s blood does not
cross to the fetus.
D. The placenta serves as a complete barrier between the baby and mother so that any drugs the
mother takes do not cross the baby.

34. Which of the following is the best recommendation about taking medicines during pregnancy?
 A. All over-the-counter (OTC) drugs are safe during pregnancy
B. All herbal preparations are safe during pregnancy
C. Don’t take anything during pregnancy without asking your health care provider
D. Take an OTC diuretic if you have swelling during the pregnancy

35. A feeling of ambivalence about the pregnancy is:

A. a sign of unwanted pregnancy C. rare at any stage of pregnancy
B. normal in early pregnancy D. typical in late pregnancy

36. Which assessment relates most directly to rupture membranes and release of amniotic fluid?
A. Bloody show
B. Fluid with a pH of 7.0 to 7.5 with nitrazine test
C. Fluid with a pH of 5.0 with nitrazine test
D. Woman complains of urge to push

37. When the placenta is delivered with the dull side out (Duncan presentation), the woman is at risk for:
A. excessive bleeding
B. hemorrhoids
C. increased lacerations of the perineum
D. sterility

38. To assess the uterine contraction during labor, the nurse:

A. asks the woman if she is having a contraction.
B. palpates above the symphysis pubis.
C. palpates just below the xyphoid process of the sternum.
D. performs a sterile vaginal examination.

39. The nurse knows that a postpartum client’s susceptibility to hemorrhage is most likely related to a:
A. boggy uterus C. long labor
B. firm fundus D. negative Homan’s sign

40. Which of the following indicates that the new mother understands how to handle breast milk safely?
A. “I can store fresh milk in the refrigerator for only 24 hours.”
B. “I can store frozen breast milk for up to 1 month.”
C. “I need to express my breast milk into a clear glass.”
D. “I should never store my breast milk in a frozen-food locker.”

41. To prevent infection of the perineal area after delivery, the nurse should instruct the client to:
A. Begin sitz bath at the first sign of infection
B. Pull panties straight down
C. Use hot water to cleanse the area after bowel movement
D. Wipe with sweeping motion, from front to back

42. Analgesics given too late in labor can result in which of the following?
A. Contractions that increase in intensity
B. Early deceleration
C. FHR dropping to 100 beat per minute
D. Pain during contractions

43. In evaluating the effects if oxytocin after delivery, the nurse should monitor for:
A. effective breastfeeding. C. relief of pain.
B. engorged breasts. D. the uterus remaining firm.

44. During active labor, the mother usually exhibits which of the following behaviors?
A. Difficulty following directions
 B. Excitedness and talkativeness
C. Frustration and irritability
D. Serious expression and apprehension

45. When providing postpartum teaching about self-care, one of the danger signs that a lactating woman
should know to report to the birth attendant is:
A. breast engorgement to a degree that the baby can’t latch on.
B. breast fullness just before feeding .
C. nipple soreness after feedings.
D. nipple dryness before feedings.

46. “Show” is usually present in:

A. Braxton Hicks contraction. C. true labor.
B. false labor. D. Second stage of labor only.

47. Which assessment most closely relates to a diagnosis of ectopic pregnancy?

A. Brownish red, tapioca-like vesicles
B. Elevated temperature
C. Spotting or bleeding 2 to 3 weeks after a missed menstrual period
D. Sudden absence of fetal movement

48. The drug of choice to treat pregnancy-induced hypertension is:

A. iron and vitamins C. furosemide (Lasix)
B. diazepam (valium) D. magnesium sulfate

49. Which nursing intervention would be appropriate for a client who has a diastolic blood pressure of
more than 20 mmHg on the “roll-over” test?
A. Increase intake of oral fluids
B. Rest on left side as much as possible
C. Schedule follow-up care every 2 weeks
D. Use the stairs to increase activity level

50. A mother receiving medications for pregnancy-induced hypertension should have her diastolic blood
pressure maintained in the range of 90 to 100 mmHg to:
A. avoid causing fetal anoxia. C. prevent premature contractions.
B. ensure progression of labor. D. present sudden elevations in pulse.
51. A nurse caring for an infant with congenital heart failure (CHF) is monitoring the infant closely for
signs of congestive heart failure. The nurse assesses the infant for which early signs of CHF?
A. Pallor
B. Cough
C. Tachycardia
D. Slow and shallow breathing

52. A nurse is caring for a child with a suspected diagnosis of rheumatic fever. The nurse reviews the
laboratory results, knowing that which laboratory study would assist in confirming the diagnosis?
A. Immunoglobulin
B. Red blood count
C. White blood cell count
D. Antistreptolysin O titer

53. 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?
A. Cracked lips
B. Normal appearance
C. Conjunctival hyperemia
D. Desquamation of the skin
54. A nurse provides home care instructions to the parents of a child with congestive heart failure
regarding the procedure for administration of digoxin. Which statement made by the parent indicates
the need for further instructions?
A. “I will not mix the medication with food”
B. If more than one dose is missed, I will call the physician”
C. “I will take the child’s pulse before administering the medication”
D. “If the child vomits after medication administration, I will repeat the dose”

55. A physician has prescribed oxygen as needed for an infant with congestive heart failure. In which
situation should the nurse administer the oxygen to the infant?
A. During sleep
B. When changing the infant’s diapers
C. When the mother is holding the infant
D. When drawing blood for electrolyte level testing

56. A clinic nurse reviews the record of a child just seen by a physician and diagnosed with suspected
aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically
found in this disorder?
A. Pallor
B. Hyperactivity
C. Exercise intolerance
D. Gastrointestinal disturbances

57. The nurse is caring for an adolescent who is receiving frequent visits from peer group members. The
nurse understands that groups are important in the emotional development of an individual because
they:
A. Always protect their members
B. Are easily identified by their members
C. Go through the same developmental phase
D. Identify acceptable behavior for their members

58. To help parents cope with the behavior of young school-age children, the nurse suggests that it
would help if they:
A. Avoid asking specific questions C. Be consistent about established rules
B. Give children a list of expectations D. Allow the children to set up their own routines

59. A 2-year-old child is admitted with a diagnosis of pneumonia and is given antibiotics, fluids and
oxygen. The child’s temperature rises until it reaches 103°F. The nurse calls the physician at the
mother’s request, but the physician sees no need to change treatment, even though the child has a
history of febrile seizures. Although concerned, the nurse takes no further action. Later, the child has
a seizure that results in neurologic impairment. Legally,
A. The physician’s decision takes precedence over the nurse’s concern
B. The nurse’s failure to further question the physician placed the child at risk
C. High fevers are common in children; therefore presents little cause for concern
D. The physician is totally responsible for the client’s health history and treatment regimen

60. A 3-year-old boy with eczema of the face and arms has disregarded the nurse’s warnings to “stop
scratching—or else!” The nurse finds the toddler scratching so intensely that his arms are bleeding.
With great flurry, the nurse ties the toddler’s arms to the crib sides, saying “I’m going to teach you
one way or another.” In this situation, the nurse:
A. Has used actions that can be interpreted as assault and battery
B. Has responded to the problem with considerable accountability
C. Had to protect the toddler’s skin and acted the same as any reasonably prudent nurse
D. Had tried to explain to the toddler and expected the toddler to understand and cooperate
61. A toddler screams and cries noisily after parental visits, disturbing all the other children. When the
crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the
door. The toddler is left there until the crying ceases, a matter of 30 to 45 minutes. Legally,
A. The child needed to have limits set to control the crying
B. The child had a right to remain in the room with the other children
C. The segregation of the child for more than 30 minutes was too long
D. The other children had to be considered, so the child needed to be removed

62. A client is admitted with the diagnosis of possible placenta previa. The nurse begins IV fluids,
administer oxygen, and draws blood for laboratory tests as ordered. The client’s apprehension is
increasing, and she asks the nurse what is happening. The nurse tells her not to worry, that she is
going to be alright, and that everything is under control. What is the best description of the nurse’s
statement?
A. Adequate, because the preparations are routine and need no explanation
B. Incorrect, because only the physician should explain why treatments are being done
C. Proper, because the client’s anxieties would be increased if she knew the dangers
D. Questionable, because the client has the right to know what treatment is being given and why

63. A client has been told she needs a hysterectomy for cervical cancer is upset being unable to have
more children. What should the nurse should do?
A. Evaluate her willingness to pursue adoption
B. Encourage her to focus on her own recovery
C. Emphasize that she does have two children already
D. Ensure that all treatment options have been explored

64. Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of the
hospital because of difficulty at home with her 2-year-old son. Staff members are unable to contact
her physician. The client arrives at the nursery dressed and ready to leave and asks that her infant
be given to her dress and take home. What is the most appropriate nursing action?
A. Explain to the client that her infant must remain in the hospital until signed out by the physician
B. Give the infant to the client to take home, making sure that she receives information regarding
care of a 2-day-old infant
C. Allow the child time with the baby before she leaves, but emphasize that the baby is a minor and
legally must remain until orders are received.
D. Tell the client that under the circumstances, hospital policies prevents the staff from releasing the
infant into her care, but she will be informed when the infant is discharged.

65. The nurse is instructing a group of volunteer nurses on the technique of administering the smallpox
vaccine. What method should the nurse teach the group to administer the vaccine correctly?
A. Z-track injection
B. Intravenous injection
C. Subcutaneous injection
D. Intradermal scratch injection

66. A pregnant client is now in the third trimester. The client tells the nurse she wants to have general
anesthesia for the birth. What is the nurse’s best response?
A. “You are worried about too much pain?”
B. “I will tell your doctor about this request.”
C. “You don’t want to be awake during the birth?”
D. “I can understand that because labor is uncomfortable.”

67. A nurse prepares to administer digoxin (lanoxin) to a 3 year old child with a diagnosis of congestive
heart failure and notes that the apical heart rate is 110 beats/min. Based on this finding which nursing
action is appropriate?
A. Hold the medication
 B. Notify the physician
C. Administer the digoxin
D. Recheck the apical rate in 15 minutes

68. A mother of a 3 year old asks a clinic nurse about appropriate and safe toys for the child. The nurse
tells the mother that the appropriate toy for a 3 year old child is which of the following?
A. A wagon C. A farm set
B. A golf set D. a jack set with marbles

69. The mother of a 3 year old is concerned because her child still is insisting on a bottle at nap time and
at bed time. Which of the following is the appropriate suggestion to the mother?
A. Allow the bottle if it contains juice
B. Allow the bottle if it contains water
C. Do not allow the child to have the bottle
D. Allow the bottle during naps but not at bedtime

70. A nurse is preparing a plan of care for a newborn with fetal alcohol syndrome. The nurse should
include which priority intervention in the plan of care?
A. Allow the newborn to establish own sleep-rest pattern
B. Maintain the newborn in a brightly lighted area of the nursery
C. Encourage frequent handling of the newborn by staff and parents
D. Monitor the newborn’s response to feedings and weight gain pattern

71. A new mother expresses concern to a nurse regarding sudden infant death syndrome (SIDS) she
asks the nurse how to position her new infant for sleep. The nurse appropriately tells the mother that
the infant should be placed in the:
A. Side or prone
B. Back or prone
C. Stomach with the face turned
D. Back rather than on the stomach

72. A clinic nurse reads the results of a Mantoux test on a 3 year old child. The results indicate an area of
induration measuring 10mm. The nurse would interpret these results as:
A. Positive
B. Negative
C. Inconclusive
D. Definitive and requiring a repeat test

73. A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of
transmission of this infection which of the following should be included in the plan of care?
A. Maintain enteric precautions
B. Maintain neutropenic precautions
C. No precautions are required as long as antibiotics have been started
D. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics

74. After a tonsillectomy, a child begins to vomit bright red blood. The initial nursing action is to:
A. Notify the physician
B. Maintain NPO status
C. Turn the child to the side
D. Administer the prescribed antiemetic

75. A day care nurse is observing a 2 year old child and suspects that the child may have strabismus.
Which observation made by the nurse might indicate this condition?
A. The child has difficulty hearing
B. The child consistently tilts the head to see
 C. The child consistently turns the head to see
D. The child does not respond when spoken to

76. A nurse is reviewing the laboratory results for a child scheduled for tonsillectomy. The nurse
determines that which laboratory value is most significant to review
A. Creatinine level
B. Prothrombin time
C. Sedimentation rate
D. Blood urea nitrogen level

77. A nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of
care to place the child in which appropriate position?
A. Supine
B. Side-lying
C. High Fowler’s
D. Tredelenburg’s

78 . After tonsillectomy, a nurse reviews the physician’s postoperative prescriptions. Which of the
following physician’s prescriptions does the nurse question?
A. Monitor for bleeding
B. Suction every 2 hours
C. Give no milk or milk products
D. Give clear, cool liquids when awake and alert

79. A nurse is providing home care instructions to the mother of a 10 year old child with hemophilia.
Which of the following activities should the nurse suggest that the child could participate in safety
with peers?
A. Soccer
B. Basketball
C. Swimming
D. Field hockery

80. A 10-year-old child with Hemophilia A has slipped on the ice and bumped his knees. The nurse
should prepare to administer an:
A. Injection of factor X
B. Intravenous infusion of iron
C. Intravenous infusion of factor VII
D. Intramuscular injection of iron using the Z-tract method

81. An infant with congestive heart failure is receiving diuretic therapy and a nurse is closely monitoring
the intake and output. The nurse uses which most appropriate method to assess the urine output?
A. Weighing the diapers
B. Inserting a Foley Catheter
C. Comparing intake with output
D. Measuring the amount of water added to formula

82. A nurse has provided home care instructions to the mother of a child who is being discharged after
cardiac surgery. Which statement made by the mother indicates a need for further instructions?
A. ” A balance of rest and exercise is important”
B. “I can apply lotion or powder to the incision if it is itchy”
C. “Activities in which my child could fall need to be avoided for 2 to 4 weeks”
D. “Large crowds of people need to be avoided for at least 2 weeks after surgery

83. A nurse receives a telephone call from the admitting office and is told that a child with rheumatic
fever will be arriving in the nursing unit for admission. On admission, the nurse prepares to ask the
mother which question to elicit assessment information specific to the development of rheumatic
fever?
 A. “Has the child complained of back pain?”
B. “Has the child complained of headaches?”
C. “Has the child had any nausea or vomiting?”
D. “Did the child have a sore throat or fever within the last 2 months?”

84. A nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the
child’s record and expects to note which symptom of this disorder documented?
A. Watery diarrhea
B. Ribbon like stools
C. Profuse projectile vomiting
D. Bright red blood and mucus in the stools

85. A clinic nurse reviews the record of an infant and notes that the physician has documented a
diagnosis of suspected Hirschsprung’s disease. The nurse reviews the assessment findings
documented in the record, knowing that which symptom most likely led the mother to seek health
care for the infant?
A. Diarrhea
B. Projectile vomiting
C. Regurgitation of feedings
D. Foul smelling ribbon like stools

86. An infant has just returned to the nursing unit after a surgical repair of a cleft lip on the right side. The
nurse places the infant in which best position at this time?
A. Prone position
B. On the stomach
C. Left lateral position
D. Right lateral position

87. A nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with
tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this
condition documented in the record?
A. Incessant crying
B. Coughing at nighttime
C. Choking with feedings
D. Severe projectile vomiting

88. A child is hospitalized because of persistent vomiting. The nurse monitors the child closely for:
A. Diarrhea
B. Metabolic acidosis
C. Metabolic alkalosis
D. Hyperactive bowel sounds

89. A nurse is caring for a newborn infant with a suspected diagnosis of imperforate anus. The nurse
monitors the infant, knowing that which of the following is a clinical manifestation associated with this
disorder?
A. Bile stained fecal emesis
B. The passage of currant jelly-like stools
C. Failure to pass meconium stool in the first 24 hours after birth
D. Sausage-shaped mass palpated in the upper right abdominal quadrant

90. A nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On admission assessment,
which data would the nurse expect to obtain when asking the mother about the child’s symptoms?
A. Watery diarrhea
B. Projectile vomiting
C. Increased urine output
D. Vomiting large amounts of bile
91. An infant of a mother infected with HIV is seen in the clinic each month and is being monitored for
symptoms indicative of human immunodeficiency virus infection. The nurse assesses the infant,
knowing that the most common opportunistic infection of children infected with HIV is:
A. Meningitis
B. Gastroenteritis
C. Cytomegalovirus infection
D. Pneumocystis jiroveci pneumonia

92. A clinic nurse is instructions the mother of a child with human immunodeficiency virus infection
regarding immunizations. The nurse tells the mother that
A. Then hepatitis B vaccine will not be given to the child
B. The inactivated influenza vaccine will be given yearly
C. The varicella vaccine will be given before 6 months of age
D. A western blot test needs to be performed and the results evaluated before immunizations

93. A physician prescribes laboratory studies for an infant of a woman positive for human deficiency virus
to determine the presence of HIV antigen in the infant. The nurse anticipates that which laboratory
study will be prescribed for the infant?
A. Chest x-ray
B. Western blot
C. CD4 cell count
D. p24 antigen assay

94. A nurse is caring for a 4 year old child virus with human immunodeficiency virus infection. In planning
care to address the child’s psychosocial needs, the nurse expects that this child?
A. Will express fear, withdrawal and denial
B. Begins to understand that something is wrong
C. Is unable to grasp the concept of illness and death
D. Begins to conceptualize the death process as involving physical harm

95. A nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to
the surgical unit. The nurse plans to monitor which of the following parameters most carefully during
the next hour?
A. Urinary output of 20ml/hr
B. Temperature of 37.6°C
C. Blood pressure of 100/70 mm Hg
D. Serous drainage on the surgical dressing

96. A postoperative child asks the nurse why it is so important to deep breathe and cough after surgery.
When formulating a response, the nurse incorporates the understanding that retained pulmonary
secretions in a postoperative client can lead to:
A. Pneumonia
B. Fluid imbalance
C. Pulmonary embolism
D. Carbon Dioxide retention

97. A nurse is developing a plan of care for a child scheduled for surgery. The nurse should include
which activity in the nursing care plan for the child on the day of surgery?
A. Have the client void immediately before going into surgery
B. Avoid oral hygiene and rinsing with mouthwash
C. Verify that the client has not eaten for the last 24 hours
D. Report immediately any slight increase in blood pressure or pulse
98. A 17 – year – old cliet with a perforated gastric ulcer is scheduled for surgery. The client cannot sign
the operative consent form because of sedation from opioid analgesics that have been administered.
The nurse should take which appropriate action in the care of this client?
A. Obtain a court order for the surgery
B. Send the client to surgery without the consent form being signed
C. Have the hospital chaplain sign the informed consent immediately
D. Obtain telephone consent from a family member, following agency policy

99. A preoperative 17 – year – old expresses anxiety to a nurse about upcoming surgery. Which
response by the nurse is most likely to stimulate further discussion between the client and the nurse?
A. ” If it’s any help, everyone is nervous before surgery”
B. “I will be happy to explain the entire surgical produce to you”
C. “Can you share with me what you’ve been told about your surgery”
D. “Let me tell you about the care you’ll receive after surgery and the amount of pain you can
anticipate”

100. A nurse is conducting pre-operative teaching with a 15 – year – old client about the use of an
incentive spirometer. The nurse should include which piece of information in discussion with the
client?
A. Inhale as rapidly as possible
B. Keep a loose seal between the lips and the mouthpiece
C. After maximum inspiration, hold the breath for 15 seconds and exhale
D. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90
degrees