1.
A client asks the nurse what a third degree laceration is. She was
informed that she had one. The nurse explains that this is:
Correct Answer
A. That extended their anal spHincter
Explanation
Third degree laceration involves all in the second degree laceration and the external sphincter of the rectum. Options B, C and D are under the second degree laceration.
2.
Betina 30 weeks AOG discharged with a diagnosis of placenta previa.
The nurse knows that the client understands her care at home when she
says:
Correct Answer
C. I will have to remain in bed until my due date comes
Explanation
Placenta previa means that the placenta is the presenting part. On the first and second trimester there is spotting. On the third trimester there is bleeding that is sudden, profuse and painless.
3.
The uterus has already risen out of the pelvis and is experiencing farther into the abdominal area at about the:
Correct Answer
D. 18th week of pregnancy
Explanation
On the 8th week of pregnancy, the uterus is still within the pelvic area. On the 10th week, the uterus is still within the pelvic area. On the 12th week, the uterus and placenta have grown, expanding into the abdominal cavity. On the 18th week, the uterus has already risen out of the pelvis and is expanding into the abdominal area.
4.
Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester:
Correct Answer
A. Frequency
Explanation
Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary frequency. Dysuria, incontinence and burning are symptoms associated with urinary tract infection.
5.
Mrs. Jimenez went to the health center for pre-natal check-up. the
student nurse took her weight and revealed 142 lbs. She asked the
student nurse how much should she gain weight in her pregnancy.
Correct Answer
B. 25-35 lbs
Explanation
A weight gain of 11. 2 to 15.9 kg (25 to 35 lbs) is currently recommended as an average weight gain in pregnancy. This weight gain consists of the following: fetus- 7.5 lb; placenta- 1.5 lb; amniotic fluid- 2 lb; uterus- 2.5 lb; breasts- 1.5 to 3 lb; blood volume- 4 lb; body fat- 7 lb; body fluid- 7 lb.
6.
The nurse is preparing Mrs. Jordan for cesarean delivery. Which of
the following key concept should the nurse consider when implementing
nursing care?
Correct Answer
B. Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth.
Explanation
A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching to meet the needs of either planned or emergency cesarean birth, the depth and breadth of instruction will depend on circumstances and time available.
7.
Bettine Gonzales is hospitalized for the treatment of severe
preecplampsia. Which of the following represents an unusual finding for
this condition?
Correct Answer
D. Convulsions
Explanation
Options A, B and C are findings of severe preeclampsia. Convulsions is a finding of eclampsia—an obstetrical emergency.
8.
Nurse Geli explains to the client who is 33 weeks pregnant and is experiencing vaginal bleeding that coitus:
Correct Answer
C. Should be restricted because it may stimulate uterine activity.
Explanation
Coitus is restricted when there is watery discharge, uterine contraction and vaginal bleeding. Also those women with a history of spontaneous miscarriage may be advised to avoid coitus during the time of pregnancy when a previous miscarriage occurred.
9.
Mrs. Precilla Abuel, a 32 year old mulripara is admitted to labor and
delivery. Her last 3 pregnancies in short stage one of labor. The
nurses decide to observe her closely. The physician determines that Mrs.
Abuel’s cervix is dilated to 6 cm. Mrs. Abuel states that she is
extremely uncomfortable. To lessen Mrs. Abuel’s discomfort, the nurse
can advise her to:
Correct Answer
D. Assume Sim’s position
Explanation
When the woman is in Sim’s position, this puts the weight of the fetus on bed, not on the woman and allows good circulation in the lower extremities.
10.
Which is true regarding the fontanels of the newborn?
Correct Answer
A. The anterior is large in shape when compared to the posterior fontanel.
Explanation
The anterior fontanel is larger in size than the posterior fontanel. Additionally, the anterior fontanel, which is diamond shaped closes at 18 month, whereas the posterior fontanel, which is triangular in shape closes at 8 to 12 weeks. Neither fontanel should appear bulging, which may indicate increases ICP or sunken, which may indicate hydration.
11.
Mrs. Quijones gave birth by spontaneous delivery to a full term baby
boy. After a minute after birth, he is crying and moving actively. His
birth weight is 6.8 lbs. What do you expect baby Quijones to weigh at 6
months?
Correct Answer
A. 13 -14 lbs
Explanation
The birth weight of an infant is doubled at 6 months and is tripled at 12 months.
12.
During the first hours following delivery, the post partum client is
given IVF with oxytocin added to them. The nurse understands the
primary reason for this is:
Correct Answer
B. To promote uterine contraction
Explanation
Oxytocin is a hormone produced by the pituitary gland that produces intermittent uterine contractions, helping to promote uterine involution.
13.
Nurse Luis is assessing the newborn’s heart rate. Which of the
following would be considered normal if the newborn is sleeping?
Correct Answer
B. 100 beats per minute
Explanation
The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute. If the newborn was awake, the normal heart rate would range from 120 to 160 beats per minute.
14.
The infant with Down Syndrome should go through which of the Erikson’s developmental stages first?
Correct Answer
D. Trust vs. Mistrust
Explanation
The child with Down syndrome will go through the same first stage, trust vs. mistrust, only at a slow rate. Therefore, the nurse should concentrate on developing on bond between the primary caregiver and the child.
15.
The child with phenylketonuria (PKU) must maintain a low
phenylalanine diet to prevent which of the following complications?
Correct Answer
A. Irreversible brain damage
Explanation
The child with PKU must maintain a strict low phenylalanine diet to prevent central nervous system damage, seizures and eventual death.
16.
Which age group is with imaginative minds and creates imaginary friends?
Correct Answer
B. Preschool
Explanation
During preschool, this is the time when children do imitative play, imaginative play—the occurrence of imaginative playmates, dramatic play where children like to act, dance and sing.
17.
Which of the following situations would alert you to a potentially developmental problem with a child?
Correct Answer
D. Saying “mama” or “dada” for the first time at 18 months of age.
Explanation
A child should say “mama” or “dada” during 10 to 12 months of age. Options A, B and C are all normal assessments of language development of a child.
18.
Isabelle, a 2 year old girl loves to move around and oftentimes
manifests negativism and temper tantrums. What is the best way to deal
with her behavior?
Correct Answer
C. Ignore her behavior as long as she does not hurt herself and others.
Explanation
If a child is trying to get attention or trying to get something through tantrums—ignore his/her behavior.
19.
Baby boy Villanueva, 4 months old, was seen at the pediatric clinic
for his scheduled check-up. By this period, baby Villanueva has already
increased his height by how many inches?
Correct Answer
B. 4 inches
Explanation
From birth to 6 months, the infant grows 1 inch (2.5 cm) per month. From 6 to 12 months, the infant grows ½ inch (1.25 cm) per month.
20.
Alice, 10 years old was brought to the ER because of Asthma. She was
immediately put under aerosol administration of Terbutaline. After
sometime, you observe that the child does not show any relief from the
treatment given. Upon assessment, you noticed that both the heart and
respiratory rate are still elevated and the child shows difficulty of
exhaling. You suspect:
Correct Answer
D. Status Asthmaticus
Explanation
Status asthmaticus leads to respiratory distress and bronchospasm despite of treatment and interventions. Mechanical ventilation maybe needed due to respiratory failure.
21.
Nurse Jonas assesses a 2 year old boy with a tentative diagnosis of
nephroblastoma. Symptoms the nurse observes that suggest this problem
include:
Correct Answer
D. Abdominal mass and weakness
Explanation
Nephroblastoma or Wilm’s tumor is caused by chromosomal abnormalities, most common kidney cancer among children characterized by abdominal mass, hematuria, hypertension and fever.
22.
Which of the following danger sings should be reported immediately during the antepartum period?
Correct Answer
A. Blurred vision
Explanation
Danger signs that require prompt reporting are leaking of amniotic fluid, blurred vision, vaginal bleeding, rapid weight gain and elevated blood pressure. Nasal stuffiness, breast tenderness, and constipation are common discomforts associated with pregnancy.
23.
Nurse Jacob is assessing a 15 month old child with acute otitis
media. Which of the following symptoms would the nurse anticipate
finding?
Correct Answer
B. Irritability, purulent drainage in middle ear, nasal congestion and cough
Explanation
Irritability, purulent drainage in middle ear, nasal congestion and cough, fever, loss of appetite, vomiting and diarrhea are clinical manifestations of otitis media. Acute otitis media is common in children 6 months to 3 years old and 8 years old and above. Breast fed infants have higher resistance due to protection of Eustachian tubes and middle ear from breast milk.
24.
Which of the following is the most appropriate intervention to reduce stress in a preterm infant at 33 weeks gestation?
Correct Answer
D. Kangaroo care
Explanation
Kangaroo care is the use of skin-to-skin contact to maintain body heat. This method of care not only supplies heat but also encourages parent-child interaction.
25.
The parent of a client with albinism would need to be taught which preventive healthcare measure by the nurse:
Correct Answer
B. Use of a high-SPF sunblock
Explanation
Without melanin production, the child with albinism is at risk for severe sunburns. Maximum sun protection should be taken, including use of hats, long sleeves, minimal time in the sun and high-SPF sunblock, to prevent any problems.