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PNLE : Maternal and Child Health Nursing Exam 2 (PM)
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Question 1
During a prenatal check-up, the nurse explains to a client who is Rh negative that RhoGAM will be given:
A
During the second trimester, if amniocentesis indicates a problem.
B
To her infant immediately after delivery if the Coomb’s test is positive.
C
Within 72 hours after delivery if infant is found to be Rh positive.
D
Weekly during the 8th month because this is her third pregnancy.
Question 1 Explanation:
RhoGAM is given to Rh-negative mothers within 72 hours after birth of Rh-positive baby to prevent development of antibodies in the maternal blood stream, which will be fata to succeeding Rh-positive offspring.
Question 2
Mylene Lopez, a 16 year old girl with scoliosis has recently received an invitation to a pool party. She asks the nurse how she can disguise her impairment when dressed in a bathing suit. Which nursing diagnosis can be justified by Mylene’s statement?
A
Anxiety
B
Social isolation
C
Ineffective individual coping
D
Body image disturbance
Question 2 Explanation:
Mylene is experiencing uneasiness about the curvative of her spine, which will be more evident when she wears a bathing suit. This data suggests a body image disturbance. There is no evidence of anxiety or ineffective coping. The fact that Mylene is planning to attend a pool party dispels a diagnosis of social isolation.
Question 3
When a mother bleeds and the uterus is relaxed, soft and non-tender, you can account the cause to:
A
Laceration of the birth canal
B
Presence of uterine scar
C
Presence of retained placenta fragments
D
Atony of the uterus
Question 3 Explanation:
Uterine atony, or relaxation of the uterus is the most frequent cause of postpartal hemorrhage. It is the inability to maintain the uterus in contracted state.
Question 4
Catherine Diaz is a 14 year old patient on a hematology unit who is being treated for sickle cell crisis. During a crisis such as that seen in sickle cell anemia, aldosterone release is stimulated. In what way might this influence Catherine’s fluid and electrolyte balance?
A
sodium retention, water loss and potassium retention
B
sodium loss, water loss and potassium retention
C
sodium retention, water retention and potassium loss
D
sodium loss, water los and potassium loss
Question 4 Explanation:
Stress stimulates the adrenal cortex to increase the release of aldosterone. Aldosterone promotes the resorption of sodium, the retention of water and the loss of potassium.
Question 5
Which of the following would be a disadvantage of breast feeding?
A
the father may resent the infant’s demands on the mother’s body
B
involution occurs rapidly
C
there is a greater chance of error during preparation
D
the incidence of allergies increases due to maternal antibodies
Question 5 Explanation:
With breast feeding, the father’s body is not capable of providing the milk for the newborn, which may interfere with feeding the newborn, providing fewer chances for bonding, or he may be jealous of the infant’s demands on his wife time and body. Breast feeding is advantageous because uterine involution occurs more rapidly, thus minimizing blood loss. The presence of maternal antibodies in breast milk helps decrease the incidence of allergies in the newborn. A greater chance for error is associated with bottle feeding. No preparation required for breast feeding.
Question 6
Aling Patricia is a patient with preeclampsia. You advise her about her condition, which would tell you that she has not really understood your instructions?
A
“I will come more regularly for check-up.”
B
“I will avoid salty foods in my diet.”
C
“I will restrict my fat in my diet.”
D
“I will limit my activities and rest more frequently throughout the day.”
Question 6 Explanation:
Pregnant woman with preeclampsia should be in a complete bed rest. When body is in recumbent position, sodium tends to be excreted at a faster rate. It is the best method of aiding increased excretion of sodium and encouraging diuresis. Rest should always be in a lateral recumbent position to avoid uterine pressure on the vena cava and prevent supine hypotension.
Question 7
During a 2 hour childbirth focusing on labor and delivery process for primigravida. The nurse describes the second maneuver that the fetus goes through during labor progress when the head is the presenting part as which of the following:
A
Descent
B
External rotation
C
Internal rotation
D
Flexion
Question 7 Explanation:
The 6 cardinal movements of labor are descent, flexion, internal rotation, extension, external rotation and expulsion.
Question 8
Mrs. Bendivin states that she is experiencing aching swollen, leg veins. The nurse would explain that this is most probably the result of which of the following:
A
Thrombophlebitis
B
PIH
C
The force of gravity pulling down on the uterus
D
Pressure on blood vessels from the enlarging uterus
Question 8 Explanation:
Pressure of the growing fetus on blood vessels results in an increase risk for venous stasis in the lower extremities. Subsequently, edema and varicose vein formation may occur.
Question 9
Mrs. Grace Evangelista is admitted with severe preeclampsia. What type of room should the nurse select this patient?
A
A room next to the elevator.
B
The room farthest from the nursing station.
C
The labor suite.
D
The quietest room on the floor.
Question 9 Explanation:
A loud noise such as a crying baby, or a dropped tray of equipment may be sufficient to trigger a seizure initiating eclampsia, a woman with severe preeclampsia should be admiotted to a private room so she can rest as undisturbed as possible. Darken the room if possible because bright light can trigger seizures.
Question 10
Fetal heart rate can be auscultated with a fetoscope as early as:
A
20 weeks of gestation
B
10 weeks of gestation
C
15 weeks of gestation
D
5 weeks of gestation
Question 10 Explanation:
The FHR can be auscultated with a fetoscope at about 20 weeks of gestation. FHR is usually auscultated at the midline suprapubic region with Doppler ultrasound at 10 to 12 weeks of gestation. FHR cannot be heard any earlier than 10 weeks of gestation.
Question 11
A 4 year old boy most likely perceives death in which way:
A
An insignificant event unless taught otherwise
B
Temporary separation from the loved one.
C
Punishment for something the individual did
D
Something that just happens to older people
Question 11 Explanation:
The predominant perception of death by preschool age children is that death is temporary separation. Because that child is losing someone significant and will not see that person again, it’s inaccurate to infer death is insignificant, regardless of the child’s response.
Question 12
Mrs. Pichie Gonzales’s LMP began April 4, 2010. Her EDD should be which of the following:
A
December 12, 2010
B
January 11, 20111
C
November 14, 2010
D
February 11, 2011
Question 12 Explanation:
Using the Nagel’s rule, he use this formula ( -3 calendar months + 7 days).
Question 13
Billy is a 4 year old boy who has an IQ of 140 which means:
A
genius
B
very superior
C
average normal
D
above average
Question 13 Explanation:
IQ= mental age/chronological age x 100. Mental age refers to the typical intelligence level found for people at a give chronological age. OQ of 140 and above is considered genius.
Question 14
Mrs. Ella Santoros is a 25 year old primigravida who has Rheumatic heart disease lesion. Her pregnancy has just been diagnosed. Her heart disease has not caused her to limit physical activity in the past. Her cardiac disease and functional capacity classification is:
A
class IV
B
Class I
C
Class III
D
Class II
Question 14 Explanation:
Clients under class I has no physical activity limitation. There is a slight limitation of physical activity in class II, ordinary activity causes fatigue, palpitation, dyspnea or angina. Class III is moderate limitation of physical activity; less than ordinary activity causes fatigue. Unable to carry on any activity without experiencing discomfort is under class IV.
Question 15
A client is noted to have lymphedema, webbed neck and low posterior hairline. Which of the following diagnoses is most appropriate?
A
Klinefelter’s syndrome
B
Marfan’s syndrome
C
Down’s syndrome
D
Turner’s syndrome
Question 15 Explanation:
Lymphedema, webbed neck and low posterior hairline, these are the 3 key assessment features in Turner’s syndrome. If the child is diagnosed early in age, proper treatment can be offered to the family. All newborns should be screened for possible congenital defects.
Question 16
A priority nursing intervention for the infant with cleft lip is which of the following:
A
Monitoring for adequate nutritional intake
B
Teaching high-risk newborn care
C
Assessing for respiratory distress
D
Preventing injury
Question 16 Explanation:
The infant with cleft lip is unable to create an adequate seal for sucking. The child is at risk for inadequate nutritional intake as well as aspiration.
Question 17
Which of the following prenatal laboratory test values would the nurse consider as significant?
A
Rubella titer less than 1:8
B
WBC 8,000/mm3
C
One hour glucose challenge test 110 g/dL
D
Hematocrit 33.5%
Question 17 Explanation:
A rubella titer should be 1:8 or greater. Thus, a finding of a titer less than 1:8 is significant, indicating that the client may not possess immunity to rubella. A hematocrit of 33.5%, WBC of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dL are within normal parameters.
Question 18
The client asks the nurse, “When will this soft spot at the top of the head of my baby will close?” The nurse should instruct the mother that the neonate’s anterior fontanel will normally close by age:
A
12-18 months
B
10-12 months
C
6-8 months
D
2-3 months
Question 18 Explanation:
Anterior fontanel closes at 12-18 months while posterior fontanel closes at birth until 2 months.
Question 19
Celine, a mother of a 2 year old tells the nurse that her child “cries and has a fit when I have to leave him with a sitter or someone else.” Which of the following statements would be the nurse’s most accurate analysis of the mother’s comment?
A
The child is expressing a physical need, such as hunger.
B
The mother is describing her child’s separation anxiety.
C
The mother has nurtured overdependence in the child.
D
The child has not experienced limit-setting or structure.
Question 19 Explanation:
Before coming to any conclusion, the nurse should ask the mother focused questions; however, based on initial information, the analysis of separation anxiety would be most valid. Separation anxiety is a normal toddler response. When the child senses he is being sent away from those who most provide him with love and security. Crying is one way a child expresses a physical need; however, the nurse would be hasty in drawing this as first conclusion based on what the mother has said. Nurturing overdependence or not providing structure for the toddler are inaccurate conclusions based on the information provided.
Question 20
A newborn is brought to the nursery. Upon assessment, the nurse finds that the child has short palpebral fissures, thinned upper lip. Based on this data, the nurse suspects that the newborn is MOST likely showing the effects of:
A
Chronic toxoplasmosis
B
Congenital anomalies
C
Fetal alcohol syndrome
D
Lead poisoning
Question 20 Explanation:
The newborn with fetal alcohol syndrome has a number of possible problems at birth. Characteristics that mark the syndrome include pre and postnatal growth retardation; CNS involvement such as cognitive challenge, microcephally and cerebral palsy; and a distinctive facial feature of a short palpebral fissure and thin upper lip.
Question 21
Mrs. Jovel Diaz went to the hospital to have her serum blood test for alpha-fetoprotein. The nurse informed her about the result of the elevation of serum AFP. The patient asked her what was the test for:
A
Down Syndrome
B
Congenital Adrenal Hyperplasia
C
Neural tube defects
D
PKU
Question 21 Explanation:
Alpha-fetoprotein is a substance produces by the fetal liver that is present in amniotic fluid and maternal serum. The level is abnormally high in the maternal serum if the fetus has an open spinal or abdominal defect because the open defect allows more AFP to appear.
Question 22
The foul-smelling, frothy characteristic of the stool in cystic fibrosis results from the presence of large amounts of which of the following:
A
lipase, trypsin and amylase
B
semi-digested carbohydrates
C
undigested fat
D
sodium and chloride
Question 22 Explanation:
The client with cystic fibrosis absorbs fat poorly because of the think secretions blocking the pancreatic duct. The lack of natural pancreatic enzyme leads to poor absorption of predominantly fats in the duodenum. Foul-smelling, frothy stool is termed steatorrhea.
Question 23
A baby boy was born at 8:50pm. At 8:55pm, the heart rate was 99 bpm. She has a weak cry, irregular respiration. She was moving all extremities and only her hands and feet were still slightly blue. The nurse should enter the APGAR score as:
A
8
B
7
C
5
D
6
Question 23 Explanation:
Heart rate of 99 bpm-1; weak cry-1; irregular respiration-1; moving all extremities-2; extremities are slightly blue-1; with a total score of 6.
Question 24
Nurse Bella explains to a 28 year old pregnant woman undergoing a non-stress test that the test is a way of evaluating the condition of the fetus by comparing the fetal heart rate with:
A
Maternal uterine contractions
B
Fetal movement
C
Maternal blood pressure
D
Fetal lie
Question 24 Explanation:
Non-stress test measures response of the FHR to the fetal movement. With fetal movement, FHR increase by 15 beats and remain for 15 seconds then decrease to average rate. No increase means poor oxygenation perfusion to fetus.
Question 25
Nurse Jacob is assessing a 12 year old who has hemophilia A. Which of the following assessment findings would the nurse anticipate?
A
an excess of RBC
B
a deficiency of clotting factor VIII
C
a deficiency of clotting factor IX
D
an excess of WBC
Question 25 Explanation:
Hemophillia A (classic hemophilia) is a deficiency in factor VIII (an alpha globulin that stabilizes fibrin clots).
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PNLE : Maternal and Child Health Nursing Exam 2 (EM)
Choose the letter of the correct answer. You got 25 minutes to finish the exam .Good luck!
Start
Congratulations - you have completed PNLE : Maternal and Child Health Nursing Exam 2 (EM).
You scored %%SCORE%% out of %%TOTAL%%.
Your performance has been rated as %%RATING%%
Your answers are highlighted below.
Question 1
Mrs. Pichie Gonzales’s LMP began April 4, 2010. Her EDD should be which of the following:
A
November 14, 2010
B
December 12, 2010
C
February 11, 2011
D
January 11, 20111
Question 1 Explanation:
Using the Nagel’s rule, he use this formula ( -3 calendar months + 7 days).
Question 2
Mrs. Ella Santoros is a 25 year old primigravida who has Rheumatic heart disease lesion. Her pregnancy has just been diagnosed. Her heart disease has not caused her to limit physical activity in the past. Her cardiac disease and functional capacity classification is:
A
Class I
B
class IV
C
Class III
D
Class II
Question 2 Explanation:
Clients under class I has no physical activity limitation. There is a slight limitation of physical activity in class II, ordinary activity causes fatigue, palpitation, dyspnea or angina. Class III is moderate limitation of physical activity; less than ordinary activity causes fatigue. Unable to carry on any activity without experiencing discomfort is under class IV.
Question 3
The client asks the nurse, “When will this soft spot at the top of the head of my baby will close?” The nurse should instruct the mother that the neonate’s anterior fontanel will normally close by age:
A
6-8 months
B
10-12 months
C
12-18 months
D
2-3 months
Question 3 Explanation:
Anterior fontanel closes at 12-18 months while posterior fontanel closes at birth until 2 months.
Question 4
Billy is a 4 year old boy who has an IQ of 140 which means:
A
very superior
B
above average
C
average normal
D
genius
Question 4 Explanation:
IQ= mental age/chronological age x 100. Mental age refers to the typical intelligence level found for people at a give chronological age. OQ of 140 and above is considered genius.
Question 5
Fetal heart rate can be auscultated with a fetoscope as early as:
A
20 weeks of gestation
B
15 weeks of gestation
C
5 weeks of gestation
D
10 weeks of gestation
Question 5 Explanation:
The FHR can be auscultated with a fetoscope at about 20 weeks of gestation. FHR is usually auscultated at the midline suprapubic region with Doppler ultrasound at 10 to 12 weeks of gestation. FHR cannot be heard any earlier than 10 weeks of gestation.
Question 6
Catherine Diaz is a 14 year old patient on a hematology unit who is being treated for sickle cell crisis. During a crisis such as that seen in sickle cell anemia, aldosterone release is stimulated. In what way might this influence Catherine’s fluid and electrolyte balance?
A
sodium loss, water los and potassium loss
B
sodium loss, water loss and potassium retention
C
sodium retention, water retention and potassium loss
D
sodium retention, water loss and potassium retention
Question 6 Explanation:
Stress stimulates the adrenal cortex to increase the release of aldosterone. Aldosterone promotes the resorption of sodium, the retention of water and the loss of potassium.
Question 7
Mrs. Bendivin states that she is experiencing aching swollen, leg veins. The nurse would explain that this is most probably the result of which of the following:
A
PIH
B
The force of gravity pulling down on the uterus
C
Pressure on blood vessels from the enlarging uterus
D
Thrombophlebitis
Question 7 Explanation:
Pressure of the growing fetus on blood vessels results in an increase risk for venous stasis in the lower extremities. Subsequently, edema and varicose vein formation may occur.
Question 8
During a 2 hour childbirth focusing on labor and delivery process for primigravida. The nurse describes the second maneuver that the fetus goes through during labor progress when the head is the presenting part as which of the following:
A
External rotation
B
Flexion
C
Descent
D
Internal rotation
Question 8 Explanation:
The 6 cardinal movements of labor are descent, flexion, internal rotation, extension, external rotation and expulsion.
Question 9
Aling Patricia is a patient with preeclampsia. You advise her about her condition, which would tell you that she has not really understood your instructions?
A
“I will come more regularly for check-up.”
B
“I will avoid salty foods in my diet.”
C
“I will limit my activities and rest more frequently throughout the day.”
D
“I will restrict my fat in my diet.”
Question 9 Explanation:
Pregnant woman with preeclampsia should be in a complete bed rest. When body is in recumbent position, sodium tends to be excreted at a faster rate. It is the best method of aiding increased excretion of sodium and encouraging diuresis. Rest should always be in a lateral recumbent position to avoid uterine pressure on the vena cava and prevent supine hypotension.
Question 10
Mylene Lopez, a 16 year old girl with scoliosis has recently received an invitation to a pool party. She asks the nurse how she can disguise her impairment when dressed in a bathing suit. Which nursing diagnosis can be justified by Mylene’s statement?
A
Ineffective individual coping
B
Anxiety
C
Body image disturbance
D
Social isolation
Question 10 Explanation:
Mylene is experiencing uneasiness about the curvative of her spine, which will be more evident when she wears a bathing suit. This data suggests a body image disturbance. There is no evidence of anxiety or ineffective coping. The fact that Mylene is planning to attend a pool party dispels a diagnosis of social isolation.
Question 11
A 4 year old boy most likely perceives death in which way:
A
Punishment for something the individual did
B
Something that just happens to older people
C
Temporary separation from the loved one.
D
An insignificant event unless taught otherwise
Question 11 Explanation:
The predominant perception of death by preschool age children is that death is temporary separation. Because that child is losing someone significant and will not see that person again, it’s inaccurate to infer death is insignificant, regardless of the child’s response.
Question 12
A priority nursing intervention for the infant with cleft lip is which of the following:
A
Preventing injury
B
Teaching high-risk newborn care
C
Monitoring for adequate nutritional intake
D
Assessing for respiratory distress
Question 12 Explanation:
The infant with cleft lip is unable to create an adequate seal for sucking. The child is at risk for inadequate nutritional intake as well as aspiration.
Question 13
When a mother bleeds and the uterus is relaxed, soft and non-tender, you can account the cause to:
A
Presence of uterine scar
B
Atony of the uterus
C
Laceration of the birth canal
D
Presence of retained placenta fragments
Question 13 Explanation:
Uterine atony, or relaxation of the uterus is the most frequent cause of postpartal hemorrhage. It is the inability to maintain the uterus in contracted state.
Question 14
Which of the following would be a disadvantage of breast feeding?
A
the father may resent the infant’s demands on the mother’s body
B
involution occurs rapidly
C
the incidence of allergies increases due to maternal antibodies
D
there is a greater chance of error during preparation
Question 14 Explanation:
With breast feeding, the father’s body is not capable of providing the milk for the newborn, which may interfere with feeding the newborn, providing fewer chances for bonding, or he may be jealous of the infant’s demands on his wife time and body. Breast feeding is advantageous because uterine involution occurs more rapidly, thus minimizing blood loss. The presence of maternal antibodies in breast milk helps decrease the incidence of allergies in the newborn. A greater chance for error is associated with bottle feeding. No preparation required for breast feeding.
Question 15
Nurse Jacob is assessing a 12 year old who has hemophilia A. Which of the following assessment findings would the nurse anticipate?
A
an excess of RBC
B
an excess of WBC
C
a deficiency of clotting factor VIII
D
a deficiency of clotting factor IX
Question 15 Explanation:
Hemophillia A (classic hemophilia) is a deficiency in factor VIII (an alpha globulin that stabilizes fibrin clots).
Question 16
Nurse Bella explains to a 28 year old pregnant woman undergoing a non-stress test that the test is a way of evaluating the condition of the fetus by comparing the fetal heart rate with:
A
Fetal lie
B
Maternal uterine contractions
C
Maternal blood pressure
D
Fetal movement
Question 16 Explanation:
Non-stress test measures response of the FHR to the fetal movement. With fetal movement, FHR increase by 15 beats and remain for 15 seconds then decrease to average rate. No increase means poor oxygenation perfusion to fetus.
Question 17
A newborn is brought to the nursery. Upon assessment, the nurse finds that the child has short palpebral fissures, thinned upper lip. Based on this data, the nurse suspects that the newborn is MOST likely showing the effects of:
A
Congenital anomalies
B
Chronic toxoplasmosis
C
Fetal alcohol syndrome
D
Lead poisoning
Question 17 Explanation:
The newborn with fetal alcohol syndrome has a number of possible problems at birth. Characteristics that mark the syndrome include pre and postnatal growth retardation; CNS involvement such as cognitive challenge, microcephally and cerebral palsy; and a distinctive facial feature of a short palpebral fissure and thin upper lip.
Question 18
The foul-smelling, frothy characteristic of the stool in cystic fibrosis results from the presence of large amounts of which of the following:
A
semi-digested carbohydrates
B
sodium and chloride
C
lipase, trypsin and amylase
D
undigested fat
Question 18 Explanation:
The client with cystic fibrosis absorbs fat poorly because of the think secretions blocking the pancreatic duct. The lack of natural pancreatic enzyme leads to poor absorption of predominantly fats in the duodenum. Foul-smelling, frothy stool is termed steatorrhea.
Question 19
Mrs. Grace Evangelista is admitted with severe preeclampsia. What type of room should the nurse select this patient?
A
The labor suite.
B
The room farthest from the nursing station.
C
The quietest room on the floor.
D
A room next to the elevator.
Question 19 Explanation:
A loud noise such as a crying baby, or a dropped tray of equipment may be sufficient to trigger a seizure initiating eclampsia, a woman with severe preeclampsia should be admiotted to a private room so she can rest as undisturbed as possible. Darken the room if possible because bright light can trigger seizures.
Question 20
Which of the following prenatal laboratory test values would the nurse consider as significant?
A
WBC 8,000/mm3
B
Rubella titer less than 1:8
C
Hematocrit 33.5%
D
One hour glucose challenge test 110 g/dL
Question 20 Explanation:
A rubella titer should be 1:8 or greater. Thus, a finding of a titer less than 1:8 is significant, indicating that the client may not possess immunity to rubella. A hematocrit of 33.5%, WBC of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dL are within normal parameters.
Question 21
Mrs. Jovel Diaz went to the hospital to have her serum blood test for alpha-fetoprotein. The nurse informed her about the result of the elevation of serum AFP. The patient asked her what was the test for:
A
PKU
B
Down Syndrome
C
Congenital Adrenal Hyperplasia
D
Neural tube defects
Question 21 Explanation:
Alpha-fetoprotein is a substance produces by the fetal liver that is present in amniotic fluid and maternal serum. The level is abnormally high in the maternal serum if the fetus has an open spinal or abdominal defect because the open defect allows more AFP to appear.
Question 22
During a prenatal check-up, the nurse explains to a client who is Rh negative that RhoGAM will be given:
A
Weekly during the 8th month because this is her third pregnancy.
B
Within 72 hours after delivery if infant is found to be Rh positive.
C
To her infant immediately after delivery if the Coomb’s test is positive.
D
During the second trimester, if amniocentesis indicates a problem.
Question 22 Explanation:
RhoGAM is given to Rh-negative mothers within 72 hours after birth of Rh-positive baby to prevent development of antibodies in the maternal blood stream, which will be fata to succeeding Rh-positive offspring.
Question 23
A client is noted to have lymphedema, webbed neck and low posterior hairline. Which of the following diagnoses is most appropriate?
A
Turner’s syndrome
B
Marfan’s syndrome
C
Klinefelter’s syndrome
D
Down’s syndrome
Question 23 Explanation:
Lymphedema, webbed neck and low posterior hairline, these are the 3 key assessment features in Turner’s syndrome. If the child is diagnosed early in age, proper treatment can be offered to the family. All newborns should be screened for possible congenital defects.
Question 24
Celine, a mother of a 2 year old tells the nurse that her child “cries and has a fit when I have to leave him with a sitter or someone else.” Which of the following statements would be the nurse’s most accurate analysis of the mother’s comment?
A
The mother is describing her child’s separation anxiety.
B
The child is expressing a physical need, such as hunger.
C
The child has not experienced limit-setting or structure.
D
The mother has nurtured overdependence in the child.
Question 24 Explanation:
Before coming to any conclusion, the nurse should ask the mother focused questions; however, based on initial information, the analysis of separation anxiety would be most valid. Separation anxiety is a normal toddler response. When the child senses he is being sent away from those who most provide him with love and security. Crying is one way a child expresses a physical need; however, the nurse would be hasty in drawing this as first conclusion based on what the mother has said. Nurturing overdependence or not providing structure for the toddler are inaccurate conclusions based on the information provided.
Question 25
A baby boy was born at 8:50pm. At 8:55pm, the heart rate was 99 bpm. She has a weak cry, irregular respiration. She was moving all extremities and only her hands and feet were still slightly blue. The nurse should enter the APGAR score as:
A
5
B
7
C
8
D
6
Question 25 Explanation:
Heart rate of 99 bpm-1; weak cry-1; irregular respiration-1; moving all extremities-2; extremities are slightly blue-1; with a total score of 6.
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1. Nurse Bella explains to a 28 year old pregnant woman undergoing a non-stress test that the test is a way of evaluating the condition of the fetus by comparing the fetal heart rate with:
Fetal lie
Fetal movement
Maternal blood pressure
Maternal uterine contractions
2. During a 2 hour childbirth focusing on labor and delivery process for primigravida. The nurse describes the second maneuver that the fetus goes through during labor progress when the head is the presenting part as which of the following:
Flexion
Internal rotation
Descent
External rotation
3. Mrs. Jovel Diaz went to the hospital to have her serum blood test for alpha-fetoprotein. The nurse informed her about the result of the elevation of serum AFP. The patient asked her what was the test for:
Congenital Adrenal Hyperplasia
PKU
Down Syndrome
Neural tube defects
4. Fetal heart rate can be auscultated with a fetoscope as early as:
5 weeks of gestation
10 weeks of gestation
15 weeks of gestation
20 weeks of gestation
5. Mrs. Bendivin states that she is experiencing aching swollen, leg veins. The nurse would explain that this is most probably the result of which of the following:
Thrombophlebitis
PIH
Pressure on blood vessels from the enlarging uterus
The force of gravity pulling down on the uterus
6. Mrs. Ella Santoros is a 25 year old primigravida who has Rheumatic heart disease lesion. Her pregnancy has just been diagnosed. Her heart disease has not caused her to limit physical activity in the past. Her cardiac disease and functional capacity classification is:
Class I
Class II
Class III
class IV
7. The client asks the nurse, “When will this soft spot at the top of the head of my baby will close?” The nurse should instruct the mother that the neonate’s anterior fontanel will normally close by age:
2-3 months
6-8 months
10-12 months
12-18 months
8. When a mother bleeds and the uterus is relaxed, soft and non-tender, you can account the cause to:
Atony of the uterus
Presence of uterine scar
Laceration of the birth canal
Presence of retained placenta fragments
9. Mrs. Pichie Gonzales’s LMP began April 4, 2010. Her EDD should be which of the following:
February 11, 2011
January 11, 20111
December 12, 2010
Nowember 14, 2010
10. Which of the following prenatal laboratory test values would the nurse consider as significant?
Hematocrit 33.5%
WBC 8,000/mm3
Rubella titer less than 1:8
One hour glucose challenge test 110 g/dL
11. Aling Patricia is a patient with preeclampsia. You advise her about her condition, which would tell you that she has not really understood your instructions?
“I will restrict my fat in my diet.”
“I will limit my activities and rest more frequently throughout the day.”
“I will avoid salty foods in my diet.”
“I will come more regularly for check-up.”
12. Mrs. Grace Evangelista is admitted with severe preeclampsia. What type of room should the nurse select this patient?
A room next to the elevator.
The room farthest from the nursing station.
The quietest room on the floor.
The labor suite.
13. During a prenatal check-up, the nurse explains to a client who is Rh negative that RhoGAM will be given:
Weekly during the 8th month because this is her third pregnancy.
During the second trimester, if amniocentesis indicates a problem.
To her infant immediately after delivery if the Coomb’s test is positive.
Within 72 hours after delivery if infant is found to be Rh positive.
14. A baby boy was born at 8:50pm. At 8:55pm, the heart rate was 99 bpm. She has a weak cry, irregular respiration. She was moving all extremities and only her hands and feet were still slightly blue. The nurse should enter the APGAR score as:
5
6
7
8
15. Billy is a 4 year old boy who has an IQ of 140 which means:
average normal
very superior
above average
genius
16. A newborn is brought to the nursery. Upon assessment, the nurse finds that the child has short palpebral fissures, thinned upper lip. Based on this data, the nurse suspects that the newborn is MOST likely showing the effects of:
Chronic toxoplasmosis
Lead poisoning
Congenital anomalies
Fetal alcohol syndrome
17. A priority nursing intervention for the infant with cleft lip is which of the following:
Monitoring for adequate nutritional intake
Teaching high-risk newborn care
Assessing for respiratory distress
Preventing injury
18. Nurse Jacob is assessing a 12 year old who has hemophilia A. Which of the following assessment findings would the nurse anticipate?
an excess of RBC
an excess of WBC
a deficiency of clotting factor VIII
a deficiency of clotting factor IX
19. Celine, a mother of a 2 year old tells the nurse that her child “cries and has a fit when I have to leave him with a sitter or someone else.” Which of the following statements would be the nurse’s most accurate analysis of the mother’s comment?
The child has not experienced limit-setting or structure.
The child is expressing a physical need, such as hunger.
The mother has nurtured overdependence in the child.
The mother is describing her child’s separation anxiety.
20. Mylene Lopez, a 16 year old girl with scoliosis has recently received an invitation to a pool party. She asks the nurse how she can disguise her impairment when dressed in a bathing suit. Which nursing diagnosis can be justified by Mylene’s statement?
Anxiety
Body image disturbance
Ineffective individual coping
Social isolation
21. The foul-smelling, frothy characteristic of the stool in cystic fibrosis results from the presence of large amounts of which of the following:
sodium and chloride
undigested fat
semi-digested carbohydrates
lipase, trypsin and amylase
22. Which of the following would be a disadvantage of breast feeding?
involution occurs rapidly
the incidence of allergies increases due to maternal antibodies
the father may resent the infant’s demands on the mother’s body
there is a greater chance of error during preparation
23. A client is noted to have lymphedema, webbed neck and low posterior hairline. Which of the following diagnoses is most appropriate?
Turner’s syndrome
Down’s syndrome
Marfan’s syndrome
Klinefelter’s syndrome
24. A 4 year old boy most likely perceives death in which way:
An insignificant event unless taught otherwise
Punishment for something the individual did
Something that just happens to older people
Temporary separation from the loved one.
25. Catherine Diaz is a 14 year old patient on a hematology unit who is being treated for sickle cell crisis. During a crisis such as that seen in sickle cell anemia, aldosterone release is stimulated. In what way might this influence Catherine’s fluid and electrolyte balance?
sodium loss, water loss and potassium retention
sodium loss, water los and potassium loss
sodium retention, water loss and potassium retention
sodium retention, water retention and potassium loss
Answers and Rationales
(B) Fetal movement. Non-stress test measures response of the FHR to the fetal movement. With fetal movement, FHR increase by 15 beats and remain for 15 seconds then decrease to average rate. No increase means poor oxygenation perfusion to fetus.
(A) Flexion. The 6 cardinal movements of labor are descent, flexion, internal rotation, extension, external rotation and expulsion.
(D) Neural tube defects. Alpha-fetoprotein is a substance produces by the fetal liver that is present in amniotic fluid and maternal serum. The level is abnormally high in the maternal serum if the fetus has an open spinal or abdominal defect because the open defect allows more AFP to appear.
(D) 20 weeks of gestation. The FHR can be auscultated with a fetoscope at about 20 weeks of gestation. FHR is usually auscultated at the midline suprapubic region with Doppler ultrasound at 10 to 12 weeks of gestation. FHR cannot be heard any earlier than 10 weeks of gestation.
(C) Pressure on blood vessels from the enlarging uterus. Pressure of the growing fetus on blood vessels results in an increase risk for venous stasis in the lower extremities. Subsequently, edema and varicose vein formation may occur.
(A) Class I. Clients under class I has no physical activity limitation. There is a slight limitation of physical activity in class II, ordinary activity causes fatigue, palpitation, dyspnea or angina. Class III is moderate limitation of physical activity; less than ordinary activity causes fatigue. Unable to carry on any activity without experiencing discomfort is under class IV.
(D) 12-18 months. Anterior fontanel closes at 12-18 months while posterior fontanel closes at birth until 2 months.
(A) Atony of the uterus. Uterine atony, or relaxation of the uterus is the most frequent cause of postpartal hemorrhage. It is the inability to maintain the uterus in contracted state.
(B) January 11, 20111. Using the Nagel’s rule, he use this formula ( -3 calendar months + 7 days).
(C) Rubella titer less than 1:8. A rubella titer should be 1:8 or greater. Thus, a finding of a titer less than 1:8 is significant, indicating that the client may not possess immunity to rubella. A hematocrit of 33.5%, WBC of 8,000/mm3, and a 1 hour glucose challenge test of 110 g/dL are within normal parameters.
(B) “I will limit my activities and rest more frequently throughout the day.”Pregnant woman with preeclampsia should be in a complete bed rest. When body is in recumbent position, sodium tends to be excreted at a faster rate. It is the best method of aiding increased excretion of sodium and encouraging diuresis. Rest should always be in a lateral recumbent position to avoid uterine pressure on the vena cava and prevent supine hypotension.
(C) The quietest room on the floor.A loud noise such as a crying baby, or a dropped tray of equipment may be sufficient to trigger a seizure initiating eclampsia, a woman with severe preeclampsia should be admiotted to a private room so she can rest as undisturbed as possible. Darken the room if possible because bright light can trigger seizures.
(D) Within 72 hours after delivery if infant is found to be Rh positive. RhoGAM is given to Rh-negative mothers within 72 hours after birth of Rh-positive baby to prevent development of antibodies in the maternal blood stream, which will be fata to succeeding Rh-positive offspring.
(B) 6. Heart rate of 99 bpm-1; weak cry-1; irregular respiration-1; moving all extremities-2; extremities are slightly blue-1; with a total score of 6.
(D) genius. IQ= mental age/chronological age x 100. Mental age refers to the typical intelligence level found for people at a give chronological age. OQ of 140 and above is considered genius.
(D) Fetal alcohol syndrome. The newborn with fetal alcohol syndrome has a number of possible problems at birth. Characteristics that mark the syndrome include pre and postnatal growth retardation; CNS involvement such as cognitive challenge, microcephally and cerebral palsy; and a distinctive facial feature of a short palpebral fissure and thin upper lip.
(A) Monitoring for adequate nutritional intake. The infant with cleft lip is unable to create an adequate seal for sucking. The child is at risk for inadequate nutritional intake as well as aspiration.
(C) a deficiency of clotting factor VIII. Hemophillia A (classic hemophilia) is a deficiency in factor VIII (an alpha globulin that stabilizes fibrin clots).
(D) The mother is describing her child’s separation anxiety. Before coming to any conclusion, the nurse should ask the mother focused questions; however, based on initial information, the analysis of separation anxiety would be most valid. Separation anxiety is a normal toddler response. When the child senses he is being sent away from those who most provide him with love and security. Crying is one way a child expresses a physical need; however, the nurse would be hasty in drawing this as first conclusion based on what the mother has said. Nurturing overdependence or not providing structure for the toddler are inaccurate conclusions based on the information provided.
(B) Body image disturbance. Mylene is experiencing uneasiness about the curvative of her spine, which will be more evident when she wears a bathing suit. This data suggests a body image disturbance. There is no evidence of anxiety or ineffective coping. The fact that Mylene is planning to attend a pool party dispels a diagnosis of social isolation.
(B) undigested fat. The client with cystic fibrosis absorbs fat poorly because of the think secretions blocking the pancreatic duct. The lack of natural pancreatic enzyme leads to poor absorption of predominantly fats in the duodenum. Foul-smelling, frothy stool is termed steatorrhea.
(C) the father may resent the infant’s demands on the mother’s body. With breast feeding, the father’s body is not capable of providing the milk for the newborn, which may interfere with feeding the newborn, providing fewer chances for bonding, or he may be jealous of the infant’s demands on his wife time and body. Breast feeding is advantageous because uterine involution occurs more rapidly, thus minimizing blood loss. The presence of maternal antibodies in breast milk helps decrease the incidence of allergies in the newborn. A greater chance for error is associated with bottle feeding. No preparation required for breast feeding.
(A) Turner’s syndrome. Lymphedema, webbed neck and low posterior hairline, these are the 3 key assessment features in Turner’s syndrome. If the child is diagnosed early in age, proper treatment can be offered to the family. All newborns should be screened for possible congenital defects.
(D) Temporary separation from the loved one. The predominant perception of death by preschool age children is that death is temporary separation. Because that child is losing someone significant and will not see that person again, it’s inaccurate to infer death is insignificant, regardless of the child’s response.
(D) sodium retention, water retention and potassium loss. Stress stimulates the adrenal cortex to increase the release of aldosterone. Aldosterone promotes the resorption of sodium, the retention of water and the loss of potassium.