1. Answer A.

Endometritis is an infection of the uterine lining and can occur after prolonged rupture
of membranes. Endometriosis does not occur after a strong labor and prolonged rupture of
membranes. Salpingitis is a tubal infection and could occur if endometritis is not treated. Pelvic
thrombophlebitis involves a clot formation but it is not a complication of prolonged rupture of
membranes.

2. Answer B. Before amniocentesis, a routine ultrasound is valuable in locating the placenta, locating
a pool of amniotic fluid, and showing the physician where to insert the needle. Color Doppler imaging
ultrasonography identifies blood flow through the umbilical cord. A routine ultrasound does not
accomplish this.

3. Answer B. Protamine sulfate is a heparin antagonist given intravenously to counteract bleeding

complications cause by heparin overdose.

4. Answer D. While caring for an infant receiving phototherapy for treatment of jaundice, vital signs
are checked every 2 to 4 hours because hyperthermia can occur due to the phototherapy lights.

5. Answer D. A bilateral pudental block is used for vaginal deliveries to relieve pain primarily in the
perineum and vagina. Pudental block anesthesia is adequate for episiotomy and its repair.

6. Answer A. Eating dry crackers before arising can assist in decreasing the common discomfort of
nausea and vomiting. Avoiding strong food odors and eating a high-protein snack before bedtime
can also help.

7. Answer C. Beginning after completion of the taking-in phase, the taking-hold phase lasts about 10
days. During this phase, the client is concerned with her need to resume control of all facets of her
life in a competent manner. At this time, she is ready to learn self-care and infant care skills.

8. Answer A. Treatment of partial placenta previa includes bed rest, hydration, and careful monitoring
of the client’s bleeding.

9. Answer C. Prevention of breast engorgement is key. The best technique is to empty the breast
regularly with feeding. Engorgement is less likely when the mother and neonate are together, as in
single room maternity care continuous rooming in, because nursing can be done conveniently to
meet the neonate’s and mother’s needs.

10. Answer A. The Moro, or startle, reflex occurs when the neonate responds to stimuli by extending
the arms, hands open, and then moving the arms in an embracing motion. The Moro reflex, present
at birth, disappears at about age 3 months.

11. Answer A. Tailor sitting is an excellent exercise that helps to strengthen the client’s back muscles
and also prepares the client for the process of labor. The client should be encouraged to rest
periodically during the day and avoid standing or sitting in one position for a long time.

12. Answer D. If bleeding occurs after circumcision, the nurse should first apply gently pressure on
the area with sterile gauze. Bleeding is not common but requires attention when it occurs.

13. Answer B. The most common assessment finding in a client with abruption placenta is a rigid or
boardlike abdomen. Pain, usually reported as a sharp stabbing sensation high in the uterine fundus
with the initial separation, also is common.
14. Answer B. The nurse should contact the physician immediately because the client is most likely
experiencing hypotonic uterine contractions. These contractions tend to be painful but ineffective.
The usual treatment is oxytocin augmentation, unless cephalopelvic disproportion exists.

15. Answer A. Providing stimulation and speaking to neonates is important. Some authorities believe
that speech is the most important type of sensory stimulation for a neonate. Neonates respond best
to speech with tonal variations and a high-pitched voice. A neonate can hear all sound louder than
about 55 decibels.

16. Answer D. The transitional phase of labor extends from 8 to 10 cm; it is the shortest but most
difficult and intense for the patient. The latent phase extends from 0 to 3 cm; it is mild in nature. The
active phase extends form 4 to 7 cm; it is moderate for the patient. The expulsive phase begins
immediately after the birth and ends with separation and expulsion of the placenta.

17. Answer B. Castor oil can initiate premature uterine contractions in pregnant women. It also can
produce other adverse effects, but it does not promote sodium retention. Castor oils is not known to
increase absorption of fat-soluble vitamins, although laxatives in general may decrease absorption if
intestinal motility is increased.

18. Answer B. If bleeding and cloth are excessive, this patient may become hypovolemic. Pad count
should be instituted. Although the other diagnoses are applicable to this patient, they are not the
primary diagnosis.

19. Answer A. Fetal attitude—the overall degree of body flexion or extension—determines the type of
molding in the head a neonate. Molding is not influence by maternal age, body frame, weight, parity,
or gravidity or by maternal and paternal ethnic backgrounds.

20. Answer A. Internal EFM can be applied only after the patient’s membranes have ruptures, when
the fetus is at least at the -1 station, and when the cervix is dilated at least 2 cm. although the patient
may receive anesthesia, it is not required before application of an internal EFM device.

21. Answer A.During most of the first stage of labor, pain centers around the pelvic girdle. During the
late part of this stage and the early part of the second stage, pain spreads to the upper legs and
perineum. During the late part of the second stage and during childbirth, intense pain occurs at the
perineum. Upper arm pain is not common during ant stage of labor.

22. Answer D. Women taking the minipill have a higher incidence of tubal and ectopic pregnancies,
possibly because progestin slows ovum transport through the fallopian tubes. Endometriosis, female
hypogonadism, and premenstrual syndrome are not associated with progestin-only oral
contraceptives.

23. Answer C. A patient with pregnancy-induced hypertension complains of headache, double vision,
and sudden weight gain. A urine specimen reveals proteinuria. Vaginal bleeding and uterine
contractions are not associated with pregnancy-induces hypertension.

24. Answer A. The nurse should monitor fluid intake and output because prolonged oxytoxin infusion
may cause severe water intoxication, leading to seizures, coma, and death. Excessive thirst results
form the work of labor and limited oral fluid intake—not oxytoxin. Oxytoxin has no nephrotoxic or
diuretic effects. In fact, it produces an antidiuretic effect.
25. Answer C. Common source of radiant heat loss includes cool incubator walls and windows. Low
room humidity promotes evaporative heat loss. When the skin directly contacts a cooler object, such
as a cold weight scale, conductive heat loss may occur. A cool room temperature may lead to
convective heat loss.

26. Answer D. Bethanechol will increase GI motility, which may cause nausea, belching, vomiting,
intestinal cramps, and diarrhea. Peristalsis is increased rather than decreased. With high doses of
bethanechol, cardiovascular responses may include vasodilation, decreased cardiac rate, and
decreased force of cardiac contraction, which may cause hypotension. Salivation or sweating may
gently increase.

27. Answer D. The transitional phase, which lasts 1 to 3 hours, is the shortest but most difficult part
of the first stage of labor. This phase is characterized by intense uterine contractions that occur
every 1 ½ to 2 minutes and last 45 to 90 seconds. The active phase lasts 4 ½ to 6 hours; it is
characterized by contractions that starts out moderately intense, grow stronger, and last about 60
seconds. The complete phase occurs during the second, not first, stage of labor. The latent phase
lasts 5 to 8 hours and is marked by mild, short, irregular contractions.

28. Answer B. Measures that help relieve nipple soreness in a breast-feeding patient include
lubrication the nipples with a few drops of expressed milk before feedings, applying ice compresses
just before feeding, letting the nipples air dry after feedings, and avoiding the use of soap on the
nipples.

29. Answer B. A pregnant woman usually can detect fetal movement (quickening) between 16 and
20 weeks’ gestation. Before 16 weeks, the fetus is not developed enough for the woman to detect
movement. After 20 weeks, the fetus continues to gain weight steadily, the lungs start to produce
surfactant, the brain is grossly formed, and myelination of the spinal cord begins.

30. Answer A. Lochia should never contain large clots, tissue fragments, or membranes. A foul odor
may signal infection, as may absence of lochia.

. Answer D. Labor is divided into four stages: first stage, onset of labor to full dilation; second
stage, full dilation to birth of the baby; third stage, birth of the placenta; and fourth stage, 1-hour
postpartum. The first stage is divided into three phases: early, active, and transition.

2. Answer B. The second stage of labor begins with complete cervical dilation and ends with
delivery of the neonate.

3. Answer A. Hypotensive crisis may occur after epidural anesthesia administration as the
anesthetic agent spreads through the spinal canal, blocking sympathetic innervation. Other signs
and symptoms of hypotensive crisis associated with epidural anesthesia may include fetal
bradycardia (not tachycardia) and decreased (not increased) beat-to-beat variability in the FHR.
Urine retention, not renal toxicity, may occur during the postpartum period.

4. Answer A. Tetanic contractions are the most serious adverse effect associated with
administering oxytocin. When tetanic contractions occur, the fetus is at high risk for hypoxia and the
mother is at risk for uterine rupture. The client may be at risk for pulmonary edema if large amounts
of oxytocin have been administered, and this drug can also increase blood pressure. However,
pulmonary edema and increased blood pressure aren’t the most serious adverse effects. Early
decelerations of fetal heart rate aren’t associated with oxytocin administration.
5. Answer D. An increased pulse rate followed by an increased respiratory rate and decreased
blood pressure may be the first signs of postpartum hemorrhage and hypovolemic shock.

6. Answer C. The supine position causes compression of the client’s aorta and inferior vena cava
by the fetus. This, in turn, inhibits maternal circulation, leading to maternal hypotension and,
ultimately, fetal hypoxia. The other positions promote comfort and aid labor progress. For instance,
the lateral, or side-lying, position improves maternal and fetal circulation, enhances comfort,
increases maternal relaxation, reduces muscle tension, and eliminates pressure points. The
squatting position promotes comfort by taking advantage of gravity. The standing position also takes
advantage of gravity and aligns the fetus with the pelvic angle.

7. Answer B. After delivery of the placenta, the fundus is normally firmly contracted at the midline,
0.4" to 0.8" (1 to 2 cm) below the umbilicus.

8. Answer B. Amniotomy increases the risk of cord prolapse. If the prolapsed cord is compressed
by the presenting fetal part, the fetal blood supply may be impaired, jeopardizing the fetal oxygen
supply. Because lack of oxygen to the fetus may cause fetal death, the nursing diagnosis of
Ineffective fetal cerebral tissue perfusion takes priority over diagnoses of Deficient knowledge, Pain,
and Risk for infection.

9. Answer D. For a client with active genital herpes, cesarean birth helps avoid infection
transmission to the neonate, which would occur during a vaginal birth. Mid forceps and low forceps
are types of vaginal births that could transmit the herpes infection to the neonate. Induction is used
only during vaginal birth; therefore, it’s inappropriate for this client.

10. Answer C. Port-wine-colored amniotic fluid isn’t normal and may indicate abruptio placentae.
Increased bloody show is a normal finding and causes light pink amniotic fluid. Meconium turns
amniotic fluid green

11. Answer B. The latent phase of the first stage of labor is associated with irregular, short, mild
contractions; cervical dilation of 3 to 4 cm; and abdominal cramps or lower back discomfort. During
the active phase, the cervix dilates to 7 cm and moderately intense contractions of 40 to 50 seconds’
duration occur every 2 to 5 minutes. Fetal descent continues throughout the active phase and into
the transitional phase, when the cervix dilates from 8 to 10 cm and intense contractions of 45 to 60
seconds’ duration occur every 1½ to 2 minutes. The first stage of labor doesn’t include an expulsive
phase.

12. Answer A. Pushing (bearing down) before the cervix is completely dilated may cause edema
and tissue damage and may impede fetal descent. Telling the client not to push because the nurse-
midwife isn’t ready to assist is inappropriate and unprofessional. If the cervix were completely
dilated, the nurse-midwife could assist the client in changing position to help reposition the fetus.
The client’s membranes should have ruptured already.

13. Answer A. When used properly, a vacuum extractor is a safer delivery with fewer complications
for the mother and the baby than a forceps delivery. Cephalohematomas occur more often in
assisted births than in unassisted births. Instruments are used during delivery when individually
necessary. No additional nursing interventions are needed during the postpartum period.

14. Answer C. Relaxation isn’t an indication for detachment of the placenta. An abrupt lengthening
of the cord, an increase in the number of contractions, and an increase in vaginal bleeding are all
indications that the placenta has detached from the wall of the uterus.
15. Answer A. In a nonreassuring pattern, the FHR accelerates to baseline tachycardia as the fetus
attempts to compensate for a growing oxygen deficit. A reassuring variable pattern has an abrupt
onset and end. The baseline FHR doesn’t increase and short-term variability doesn’t decrease.

16. Answer A. Possible fetal adverse reactions include both moderate central nervous system
depression and decreased beat-to-beat variability. Bradycardia and late decelerations don’t occur as
a result of meperidine administration.

17. Answer B. The client and her husband are working together for a common goal. He’s offering
support, and they’re sharing the experience of childbirth, making Readiness for enhanced family
coping related to participation in pregnancy and delivery an appropriate nursing diagnosis. The other
options suggest that the couple have a problem that isn’t indicated in the question.

18. Answer A. Dizziness, circumoral numbness, and slurred speech indicate anesthesia overdose.
Transition to the second stage of labor is marked by an increased urge to push, an increase in
bloody show, grunting, gaping of the anus, involuntary defecation, thrashing about, loss of control
over breathing techniques, and nausea and vomiting. Anxiety and dehydration rarely cause
dizziness or circumoral numbness.

19. Answer C. Because the fetus is at risk for complications, frequent and close monitoring is
necessary. Therefore, the client shouldn’t be allowed to ambulate. Carefully titrating the oxytocin,
monitoring vital signs, including fetal well-being, and assisting with breathing exercises are
appropriate actions to include.

20. Answer B. If the unprepared client has a support person, the nurse should focus on that
person’s supporting role, demonstrating touch, massage, and simple breathing patterns. The other
options are inappropriate at this time because they may make the client and her husband more
anxious.

21. Answer B. During contractions, blood pressure increases and blood flow to the intervillous
spaces decreases, compromising the fetal blood supply. Therefore, the nurse should frequently
assess the client’s blood pressure to determine whether it returns to precontraction levels and allows
adequate fetal blood flow. During pain and contractions, the maternal blood pressure usually
increases, rather than decreases. Preeclampsia causes the blood pressure to increase — not
decrease.

22. Answer A. Uterine atony should be carefully assessed during the fourth stage. The second
stage of labor begins with complete cervical dilation and ends with birth. The third stage begins
immediately after birth and ends with the separation and expulsion of the placenta. Immediately after
delivery, the placenta is evaluated carefully for completeness, and the client is assessed for
excessive bleeding or a relaxed uterus. Umbilical cord prolapse, displacement of the umbilical cord
to a position at or below the fetus’s presenting part, occurs most commonly when amniotic
membranes rupture before fetal descent. The client should be assessed for a visible or palpable
umbilical cord in the birth canal, violent fetal activity, or fetal bradycardia with variable deceleration
during contractions. The presence of umbilical cord prolapse requires an emergency delivery.

23. Answer B. Placental separation is characterized by a sudden gush or trickle of blood from the
vagina, further protrusion of the umbilical cord from the vagina, a globular-shaped uterus, and an
increase in fundal height. With cervical or vaginal laceration, the nurse notes a consistent flow of
bright red blood from the vagina. With postpartum hemorrhage, usually caused by uterine atony, the
uterus isn’t globular. Uterine involution can’t begin until the placenta has been delivered.
24. Answer A. After the baby’s head is delivered, the nurse should check for the cord around the
baby’s neck. If the cord is around the neck, it should be gently lifted over the baby’s head. Antibiotic
ointment is administered to the baby after birth, not during delivery of the head, to prevent
gonorrheal conjunctivitis. The baby’s head isn’t turned during delivery. After delivery, the baby is held
with the head lowered to help with drainage of secretions. If a bulb syringe is available, it can be
used to gently suction the baby’s mouth. Assessing the baby’s respiratory status should be done
immediately after delivery.

25. Answer C. Gentle pressure applied to the baby’s head as it’s delivered prevents rapid
expulsion, which can cause brain damage to the baby and perineal tearing in the mother. Never pull
at the baby’s head or hold the head back. Placing the mother in the Trendelenburg position won’t
halt labor and may cause respiratory difficulties.

1. Answer: A.
Effects of estrogen:
• Inhibits the production of FSH
• Causes hypertrophy of the myometrium
• Increases the quantity and pH of cervical mucus, causing it to become thin and watery and can
be stretched to a distance of 10-13 cm.
Effects of Progesterone
• Inhibits the production of LH
• Increases endometrial tortuosity
• Increased endometrial secretions
• Facilitates transport of the fertilized ovum through the fallopian tubes

2. Answer: A
Abnormalities of Menstruation
1. Amenorrhea – absence of menstrual flow
2. Dysmenorrhea – painful menstruation
3. Oligomenorrhea – scanty menstruation
4. Menorrhagia -excessive menstrual bleeding
5. Metrorrhagia – bleeding between periods of less than 2 weeks

3. Answer: D. Gynecoid is the “normal” female pelvis. The inlet is well rounded. This is the most
ideal pelvis for childbirth.
• Android – “male” pelvis. Inlet has a narrow, shallow posterior portion and pointed anterior portion.
• Anthropoid – transverse diameter is narrow and anteroposterior (AP) diameter of this pelvis is
larger than normal.
• Platypelloid – inlet is oval while AP diameter of this pelvis is shallow.

4. Answer: C. Ischial spines are the point of reference in determining the station (relationship of
the fetal presenting part to the ischial spines). When the fetal head is at the level of the ischial spines
the station is zero. When it is 1 cm above the ischial spines it is -1 and if 1 cm below the ischial
spines it is +1.

5. Answer: B. The keyword here is “permanent cessation”. Thus, menopause is the correct answer.
Amenorrhea is a temporary cessation of menses. Oligomenorrhea is a menstruation with scanty
blood flow. Hypomenorrhea is an abnormally short duration of menstruation.

6. Answer: C.
• Gravida (G) – number of pregnancy
• Term (T) – number of full-term infants born (born at 37 weeks or after)
• Para (P) – number of preterm infants born (born before 37 weeks)
• Abortion (A) – number of spontaneous or induced abortions (pregnancy terminated before the
age of viability). Age of viability is 24 weeks.
• Living children (L) – number of living children.
• (Source: Maternal and Child Health Nursing by Adelle Pillitteri, 5th Ed. P.252)

Since Mrs Donna has two previous pregnancies and is presently pregnant (16 weeks), G is 3. Mark,
her only child was born at 35 weeks AOG which falls under the preterm category. Thus, T is zero and
P is 1. The other pregnancy was terminated at 20 weeks AOG which falls under abortion, hence
A=1. Mark is her only living child, thereby, L=1. Her GTPAL score is:
30111, G=3 T=0 P=1 A=1 L=1

7. Answer: B. Morning sickness characterized by nausea and vomiting is only noted during the
FIRST TRIMESTER of pregnancy (first 3 months). Excessive nausea and vomiting which persists
more than 3 months is a condition called Hyperemesis gravidarum that requires immediate
intervention to prevent starvation and dehydration. Management for hyperemesis gravidarum
includes the administration of D5NSS 3L in 24 hours and complete bed rest.
Easy fatigability is a consequence of the physiologic anemia of pregnancy (physiologic meaning it is
normally expected during pregnancy, thus A is incorrect). Edema of the upper extremities not the
lower extremities should alert the nurse because of the possibility of toxemia, hence C is incorrect.
Heartburn during pregnancy is due to the increase progesterone which decreases gastric motility
causing a reversed peristaltic wave leading to regurgitation of the stomach contents through the
cardiac sphincter into the esophagus, causing irritation.

8. Answer: C. The client is in her second trimester of pregnancy (16 weeks AOG or 4 months),
thus, she perceived the baby as a separate entity. Presenting denial and disbelief and sometime
repression is the psychological/emotional response of a pregnant woman on her first trimester.
Identifying the fetus and setting realistic plans for the child’s future is noted during the third trimester
of pregnancy. It is during this time also that the woman verbalizes fear of death.

9. Answer: A. Mrs. Donna’s gestational age is 16 weeks (4 months). During this time, the fetal
heart rate is audible with a Doppler apparatus. A fetal heart beat can be detected with a Doppler
apparatus starting at 12 weeks AOG. By 8 weeks AOG, fetal heartbeat can be detected with an
ultrasound. A fetal heart beat is detectable with fetoscope by the 20th week AOG. (Source:
Foundations of Maternal-Newborn Nursing by Murray and McKinney/Saunders 4th Ed.)

10. Answer: A. Fetal heart starts beating at 3 weeks AOG. The heart at this time is consisting of
two parallel tubes. By 8 weeks AOG, fetal heartbeat can be detected with an ultrasound. During 12
weeks AOG, the fetal heart rate is audible with a Doppler apparatus. A fetal heart beat is detectable
with fetoscope by the 20th week AOG. (Source: Foundations of Maternal-Newborn Nursing by
Murray and McKinney/Saunders 4th Ed.)

11. Answer: B. The keyword is INITIAL ACTION. The important consideration before answering the
question is to take a look at the situation. SITUATION: THE WOMAN IS IN THE Emergency Room
or is seeking admission.
A woman in labor seeking admission to the hospital (in the ER) and saying that her BOW has
ruptured should BE PUT TO BED IMMEDIATELY and the fetal heart tones taken consequently. If a
woman in the Labor Room says that her membranes have ruptured, the initial nursing action is to
take the fetal heart tone.
12. Answer: B. The nurse would expect that the client’s cervical dilatation is 4-7 cm as the
contraction duration and interval is noted for clients who are in the active phase of the first stage of
labor. The maximum cervical dilatation is 10 cm, thus, letter D should be eliminated first. The first
stage of labor (stage of dilatation) is divided into three phases.
• Latent phase – 0-3 cm cervical dilatation; contractions are short and mild lasting 20-40 seconds
and occurring approximately every 5-10 minutes.
• Active phase – 4-7 cm cervical dilatation; contractions grow stronger, lasting 40-60 seconds and
occur at approximately every 3-5 minutes.
• Transition phase – 8-10 cm cervical dilatation; contractions reach their peak of intensity, occurring
every 2-3 minutes with a duration of 60-90 seconds.

13. Answer: C. Station -1 means that the fetal presenting part is above the level of the ischial
spines. Letter A is wrong because engagement is described as Station 0. Letter B is incorrect
because the statement of nurse is describing the occurrence of engagement that is again station 0.
Prior to engagement the fetus is said to be "floating" or ballottable, thus letter C is the best option.
Letter D, is describing crowning which is described as Station +3 or +4.

14. Answer: A. Multiparas are transported to the DR when the cervical dilatation is 7-8 cm because
in multiparas dilatation may proceed before effacement is completed. Effacement must occur at the
end of dilatation, however, before the fetus can be safely pushed through the cervical canal;
otherwise, cervical tearing could result. Primiparas are transported to the DR when the cervical
dilatation is 9-10 cm.

15. Answer: D. The nurse should spread his/her fingers lightly over the fundus to monitor the
uterine contractions.

16. Answer: C. Prolactin is the hormone that produces milk in mammary glands. Uterine
contractions can occur because of the interplay of the contractile enzyme adenosine triphosphate
and the influence some hormones and major electrolytes which are the following:
• Calcium
• Sodium
• Potassium
• Specific contractile proteins (actin and myosin)
• Epinephrine and norepinephrine
• Oxytocin
• Estrogen and progesterone
• Prostaglandins

17. Answer: D.
Dysfunctional Labor is caused by the ff:
• Inappropriate use of analgesia
• Pelvic bone contraction that has narrowed the pelvic diameter so that a client can’t pass (e.g. in a
client with rickets)
• Poor fetal position
• Extension rather then extension of the fetal head
• Overdistention of the uterus
• Cervical rigidity
• Presence of a full rectum or bladder
• Mother becoming exhausted from labor
• Primigravid status
18. Answer: D. When the contractions are hypotonic, the length of labor is increased. When the
cervix is dilated for a long period of time, both the uterus and fetus are at greater risk of infection.
Hypotonic contractions are not exceedingly painful because of their lack of intensity. Monitoring of
bleeding through evaluation of lochia is done during the postpartum period not the intrapartum
period.

19. Answer: A. Initially, the nurse should obtain an ultrasonic confirmation ruling out a CPD or
cephalopelvic disproportion. Thus, A is the best answer. Oxytocin is infused after the CPD is ruled
out, because if CPD is present CS will be done. Analgesic administration will further decrease the
intensity of uterine contractions as its inappropriate use is one of the reasons why hypotonic
contractions occur. Amniotomy (artificial rupture of membrane) may be done after oxytocin is infused
to speed up the labor

20. Answer: B. During the postpartum period, the uterus should be palpated and lochia should be
assessed because contractions after birth may also be hypotonic that will result to bleeding.

21. Answer: C. In placenta previa the bleeding that occurs is abrupt, painless, bright-red and
sudden to frighten a woman. With abruption placenta, the bleeding is painful, the abdomen is rigid or
board-like and the blood is dark-red or filled with clots.

22. Answer: C. Never attempt a pelvic or rectal examination with painless bleeding late in
pregnancy because any agitation of the cervix when there is placenta previa may initiate massive
hemorrhage, possibly fatal to both the mother and the fetus.
The perineum should be assessed or observed or inspected for bleeding by looking over the
perenial pads. An Apt or Kleihauer-Betke test (test strip procedures) can be used to detect whether
the blood is of fetal or maternal origin.

23. Answer: A. placenta previa presents bleeding without pain whilst the bleeding in abruptio
placenta is painful.

24. Answer: D. Signs of fetal distress include: tachycardia, bradycardia, fetal thrashing and
meconium-stained amniotic fluid.

25. Answer: B. Predisposing factors for abruptio placenta:

• Advanced maternal age
• Short-umbilical cord
• Chronic hypertensive disease
• PIH
• Direct trauma
• Vasoconstriction from cocaine or cigarette use

1. Answer C. A recent episode of pharyngitis is the most important factor in establishing the
diagnosis of rheumatic fever. Although the child may have a history of fever or vomiting or lack
interest in food, these findings are not specific to rheumatic fever.
2. Answer C. In an emergency, intraosseous drug administration is typically used when a child
is critically ill and under age 3.
3. Answer D. A family’s behavioral patterns and values are passed from one generation to the
next. Cultural background commonly plays a major role in determining a family’s health
practices. Physical characteristics do not indicate a child’s culture. Although heritage plays a role
 in culture, it does not dictate a group’s shared values and its effect on culture is weaker than that
of behavioral patterns.
4. Answer A. Because the anterior fontanel normally closes between ages 12 and 18 months,
the nurse should notify the doctor promptly of this finding. An open fontanel does not indicate
abuse and is not associated with Tay-Sachs disease.
5. Answer B. Ulcerative colitis causes profuse diarrhea, intense abdominal cramps, anal
fissures, and abdominal distentions are more common in Crohn’s disease.
6. Answer D. The recommended injection site for an infant is the vastus lateralis or rectus
femoris muscles. The deltoid is inappropriate. The dorsogluteal and ventrogluteal sites can be
used only in toddlers who have been walking for about 1 year.
7. Answer C. A negative nitrogen balance may result from inadequate protein intake and is best
detected by measuring the total protein level. Measuring total iron-bi8nding capacity,
hemoglobin, and serum transferring levels would help detect iron-deficiency anemia, not a
negative nitrogen balance.
8. Answer B. According to Erikson, the primary psychosocial task during adolescence is to
establish a personal identity confusion. The adolescent attempts to establish a group identity by
seeking acceptance and approval from peers, and strives to attain a personal identity by
becoming more independent form the family. Becoming industrious is the developmental task of
the school-age child, achieving intimacy is the task of the young adult, and developing initiative
is the task of the preschooler.
9. Answer B. Preschool-age children are most likely to view illness as a punishment for
misdeeds. Separation anxiety, although seen in all age group, is most common in older infants.
Fear of death is typical of older school-age children and adolescents. Adolescents also fear
mutilation.
10. Answer C. The nurse should obtain objective information about the child’s nutritional intake,
such as by asking about what the child ate for a specific meal. The other options ask for
subjective replies that would be open to interpretation.
1. Answer A. The most important data to obtain on a child’s arrival in the emergency
department are vital sign measurements. The nurse should gather the other data later.
2. Answer D. The stress of starting nursery school may trigger a return to a level of successful
behavior from earlier stages of development. A child’s skills remain intact, although increased
stress may prevent the child from using these skills. Growth occurs when the child does not
regress. Parents rarely desire less mature behaviors.
3. Answer D. A child’s poor progress in school may indicate a visual disturbance. The other
options are more appropriate questions to ask when assessing vision in a geriatric patient.
4. Answer C. Rice cereal is the first solid food an infant should receive because it is easy to
digest and is associated with few allergies. Next, the infant can receive pureed fruits, such as
bananas, applesauce, and pears, followed by pureed vegetables, egg yolks, cheese, yogurt, and
finally, meat. Egg whites should not be given until age 9 months because they may trigger a food
allergy.
5. Answer C. Succinycholine is an ultra-short-acting depolarizing agent used for rapid-
sequence intubation. Bradycardia can occur, especially in children. Atropine is the drug of choice
in treating succinylcholine-induced bradycardia. Lidocaine is used in adults only. Epineprine
bolus and isoproterenol are not used in rapid-sequence intubation because of their profound
cardiac effects.
6. Answer A. Bryant’s traction is used to treat femoral fractures of congenital hip dislocation in
children under age 2 who weigh less than 30 lb (13.6 kg). Buck’s extension traction is skin
traction used for short-term immobilization or to correct bone deformities or contractures;
overhead suspension traction is used to treat fractures of the humerus; and 90-90 traction is
used to treat femoral fracture in children over age 2.
7. Answer D. Because adolescents absorb less information through reading, providing age-
appropriate reading materials is the least effective way to teach parenting skills to an adolescent.
 The other options engage more than one of the senses and therefore serve as effective teaching
strategies.
8. Answer D. Normally the top of the ear aligns with an imaginary line drawn across the inner
and outer canthus of the eye. Ears set below this line are associated with renal anomalies or
mental retardation. Low-set ears do not accompany otogenous tetanus, tracheoesophageal
fistula, or congenital heart defects.
9. Answer A. At age 3, gross motor development and refinement in eye-hand coordination
enable a child to ride a tricycle. The fine motor skills required to tie shoelaces and the gross
motor skills requires for roller-skating and jumping rope develop around age 5.
10. Answer A. In a child, Eustachian tubes are short and lie in a horizontal plane, promoting
entry of nasopharyngeal secretions into the tubes and thus setting the stage for otitis media. The
nosopharynx, tympanic membrane, external ear canal have no unusual features that would
predispose a child to otitis media.
11. Answer A. Increased urine output, a sign of improving kidney function, typically is the first
sign that a child with acute poststreptoccocal glomerulonephritis (APSGN) is improving.
Increased appetite, an increased energy level, and decreased diarrhea are not specific to
APSGN.
12. Answer C. The primary purpose of administering corticosteroids to a child with nephritic
syndrome is to decrease proteinuria. Corticosteroids have no effect on blood pressure. Although
they help reduce inflammation, this is not the reason for their use in patients with nephritic
syndrome. Corticosteroids may predispose a patient to infection.
13. Answer A. In an infant, signs of fluid volume deficit (dehydration) include sunken fontanels,
increased pulse rate, and decreased blood pressure. They occur when the body can no longer
maintain sufficient intravascular fluid volume. When this happens, the kidneys conserve water to
minimize fluid loss, which results in concentrated urine with a high specific gravity.
14. Answer C. The nurse should shake a suspension before administration to dispersed drug
particles uniformly. Diluting the suspension and crushing particles are not recommended for this
drug form.
15. Answer A. Fluid volume replacement must be calculated to the child’s weight to avoid over-
hydration. Initial fluid bolus is administered at 20 ml/kg, followed by another 20 ml/kg bolus if
there is no improvement in fluid status.
16. Answer B. According to the American Association on Mental Deficiency, a person with an
intelligence quotient (IQ) between 50 and 70 is classified as mildly mentally retarded but
educable. One with an IQ between 35 and 50 is classified as moderately retarded but trainable.
One with an IQ below 36 is severely and profoundly impaired, requiring custodial care.
17. Answer C. Role and relationship patterns focus on body image and the patient’s relationship
with others, which commonly interrelated with food intake. Questions about activities and food
preferences elicit information about health promotion and health protection behaviors. Questions
about food allergies elicit information about health and illness patterns.
18. Answer B. SIDS can occur any time between 1 week and 1 year of age. The incidence peaks
at 2 to 4 months of age.
19. Answer D. An adolescent who demonstrates a preoccupation with death (such as by talking
about death frequently) should be considered at high risk for suicide. Although depression,
excessive sleepiness, and a history of cocaine use may occur in suicidal adolescents, they also
occur in adolescents who are not suicidal.
20. Answer D. The most common sign of Wilms’ tumor is a painless, palpable abdominal mass,
sometimes accompanied by an increase in abdominal girth. Gross hematuria is uncommon,
although microscopic hematuria may be present. Dysuria is not associated with Wilms’ tumor.
Nausea and vomiting are rare in children with Wilms’ tumor.