NS 1 QUIZ 5 OB3 & PEDIA

Case Scenario: Nurse Anthony is caring for a 5-year-old boy named Alex, who has been admitted
to the pediatric unit for a routine check-up. Nurse Anthony is responsible for assessing Alex's
growth and development milestones during this visit.

1. Which of the following statements by Nurse Anthony indicates a correct understanding of

age-appropriate growth and development for a 5-year-old child?
A. "At this age, Alex should be able to ride a tricycle independently."
B. "Alex should already have all of his permanent teeth by now."
C. "It's normal for Alex to still have difficulty holding a crayon properly."
D. "At 5 years old, Alex may not be able to understand the concept of time yet."

Answer: a) "At this age, Alex should be able to ride a tricycle independently."

Rationale: At the age of 5, children usually develop the physical coordination and balance
required to ride a tricycle independently. They may still be working on refining their fine motor
skills, such as holding a crayon properly. Understanding the concept of time usually begins to
develop around 7 years of age.

2. Nurse Anthony observes that Alex engages in parallel play while interacting with other
children in the playroom. Which of the following statements best describes parallel play?
A. "Alex prefers to play with toys that do not require the involvement of other
children."
B. "Alex enjoys playing games that involve cooperation and teamwork with other
children."
C. "Alex is playing alongside other children but not actively engaging with them."
D. "Alex only plays with children of the same age group."

Answer: c) "Alex is playing alongside other children but not actively engaging with them."

Rationale: Parallel play is a normal developmental stage in which children play alongside each
other without direct interaction. They may be interested in the same activity or toy but do not
actively engage or cooperate with one another. This is common among toddlers and young
children as they begin to socialize and develop their social skills.

3. Nurse Anthony is conducting a physical examination of Alex to assess his growth. Which of
the following parameters is most appropriate for Nurse Anthony to use in plotting Alex's
growth on a growth chart?
A. Birth weight
B. Birth length
C. Current weight and height
D. Head circumference at 1 year old

Answer: c) Current weight and height

Rationale: To plot Alex's growth on a growth chart accurately, Nurse Anthony should use his
current weight and height. Growth charts are used to monitor a child's growth over time, and
plotting current measurements will help assess his growth trajectory and identify any potential
growth issues or deviations from the expected patterns.

4. Nurse Anthony is providing health education to Alex's parents about age-appropriate

nutrition. Which food item should Nurse Anthony recommend as the best source of iron
for a 5-year-old child?

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 A. Whole milk
B. Apple juice
C. Peanut butter
D. Spinach

Answer: d) Spinach

Rationale: Spinach is an excellent source of iron, which is an essential nutrient for a child's growth
and development. Whole milk, although nutritious, does not contain as much iron as spinach.
Apple juice and peanut butter are not significant sources of iron.

5. Nurse Anthony is conducting a developmental assessment on Alex to evaluate his

language and communication skills. Which of the following behaviors would be a normal
finding for a 5-year-old child?
A. Alex speaks in full, grammatically correct sentences.
B. Alex is still using mostly single words to communicate.
C. Alex can count from 1 to 20 but struggles with the alphabet.
D. Alex is hesitant to speak in front of unfamiliar people.

Answer: c) Alex can count from 1 to 20 but struggles with the alphabet.

Rationale: At 5 years old, children should have developed basic language and communication
skills. They can typically speak in full sentences, engage in conversation, and have a vocabulary of
several thousand words. While counting from 1 to 20 is an age-appropriate skill, struggling with
the alphabet at this age is also within the normal range of development.

6. Nurse Anthony is assessing Alex's cognitive development. Which of the following

behaviors indicates that Alex is at the preoperational stage of cognitive development, as
described by Piaget?
A. Alex understands basic cause-and-effect relationships.
B. Alex can conserve quantity, such as understanding that two glasses of water are
the same, even if poured into different-shaped containers.
C. Alex engages in pretend play and can imagine himself as a superhero.
D. Alex can solve complex mathematical problems involving addition and subtraction.

Answer: c) Alex engages in pretend play and can imagine himself as a superhero.

Rationale: The preoperational stage, according to Piaget's theory, occurs between ages 2 and 7.
During this stage, children engage in symbolic play, pretend play, and can imagine themselves in
different roles, such as superheroes or animals. Understanding cause-and-effect relationships and
conservation of quantity are characteristic of the concrete operational stage, which typically
begins around age 7.

7. Nurse Anthony is discussing appropriate discipline strategies with Alex's parents. Which
approach to discipline is most effective for a 5-year-old child?
A. Time-out as a consequence for misbehavior.
B. Grounding from using electronic devices for a week.
C. Spanking as a deterrent for undesirable behavior.
D. Rewarding good behavior with extra playtime.

Answer: a) Time-out as a consequence for misbehavior.

Rationale: Time-out is considered an effective and age-appropriate discipline strategy for a 5-

year-old child. It provides a brief period of isolation during which the child can reflect on their

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behavior without resorting to physical punishment or severe restrictions. Positive reinforcement,
such as rewarding good behavior, is also effective in promoting positive behaviors and self-
regulation in young children.

8. Nurse Anthony is assessing Alex's fine motor skills. Which activity would be most
appropriate to evaluate his fine motor development?
A. Throwing a ball
B. Riding a tricycle
C. Building a tower with blocks
D. Jumping on one foot

Answer: c) Building a tower with blocks

Rationale: Building a tower with blocks requires precise hand-eye coordination and fine motor
control, making it an appropriate activity to assess Alex's fine motor development. Throwing a
ball, riding a tricycle, and jumping on one foot involve gross motor skills rather than fine motor
skills.

9. Nurse Anthony is assessing Alex's gross motor skills. Which activity would be most
appropriate to evaluate his gross motor development?
A. Tying shoelaces
B. Putting together a jigsaw puzzle
C. Skipping with a skipping rope
D. Holding a pencil and writing his name

Answer: c) Skipping with a skipping rope

Rationale: Skipping with a skipping rope involves complex coordination of the arms and legs and is
a good indicator of a child's gross motor development. Tying shoelaces, putting together a jigsaw
puzzle, and holding a pencil and writing his name are more related to fine motor skills.

10. Nurse Anthony is educating Alex's parents about safety measures. Which safety
precaution should be emphasized the most for a 5-year-old child?
A. Properly installing a rear-facing car seat in the vehicle.
B. Teaching Alex how to swim and be water-safe.
C. Keeping small objects and toys out of Alex's reach to prevent choking.
D. Encouraging Alex to explore the neighborhood independently.

Answer: b) Teaching Alex how to swim and be water-safe.

Rationale: Drowning is a significant cause of injury and death in young children, so teaching a 5-
year-old child how to swim and be water-safe is a crucial safety precaution. While all the options
are important safety measures, water safety is particularly critical, especially if Alex spends time
near pools, lakes, or other bodies of water.

11. Nurse Anthony is discussing Erik Erikson's Psychosocial Theory of Development with Alex's
parents. According to Erikson, what is the primary developmental task for a 5-year-old
child?
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Initiative vs. Guilt
D. Industry vs. Inferiority

Answer: c) Initiative vs. Guilt

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Rationale: According to Erikson's Psychosocial Theory, the primary developmental task during the
preschool years (around 3 to 6 years old) is the stage of Initiative vs. Guilt. During this stage,
children develop a sense of purpose and engage in activities that they initiate themselves. Success
in this stage leads to a sense of accomplishment, while failure may lead to feelings of guilt.

12. Nurse Anthony observes that Alex frequently takes the initiative in various activities, such
as organizing games with other children in the playroom. What is the most appropriate
way for Nurse Anthony to support Alex's psychosocial development during this stage?
A. Discourage Alex from taking the lead in activities to avoid overwhelming him.
B. Praise Alex for his efforts and encourage his exploration and creativity.
C. Assign Alex tasks that are beyond his capabilities to foster a sense of challenge.
D. Advise Alex to seek constant approval from adults to boost his self-esteem.

Answer: b) Praise Alex for his efforts and encourage his exploration and creativity.

Rationale: During the Initiative vs. Guilt stage, children are eager to take on new challenges and
demonstrate initiative in their activities. It is essential for caregivers to support and encourage
their efforts. Praising Alex for his initiatives and encouraging his exploration and creativity will
promote a positive self-image and foster a sense of accomplishment.

13. Nurse Anthony is caring for a 6-year-old child who is consistently disruptive and aggressive
towards others. According to Erikson's theory, what might be the underlying psychosocial
issue this child is experiencing?
A. Trust issues due to early life experiences
B. Feelings of inadequacy and low self-esteem
C. Conflict between autonomy and self-doubt
D. A sense of identity crisis during adolescence

Answer: b) Feelings of inadequacy and low self-esteem

Rationale: The behaviors described are characteristic of the psychosocial crisis of Industry vs.
Inferiority, which occurs during middle childhood (around 6 to 12 years old). Children who
experience repeated feelings of failure and inadequacy during this stage may develop a sense of
inferiority. They may become disruptive or aggressive as a way to compensate for their perceived
lack of competence.

14. Nurse Anthony is caring for a toddler who becomes anxious and upset when separated
from their primary caregiver. According to Erikson's theory, which stage of psychosocial
development is the child likely experiencing?
A. Autonomy vs. Shame and Doubt
B. Trust vs. Mistrust
C. Initiative vs. Guilt
D. Identity vs. Role Confusion

Answer: b) Trust vs. Mistrust

Rationale: The behaviors described are characteristic of the psychosocial crisis of Trust vs.
Mistrust, which occurs during infancy (0 to 1 year old). During this stage, infants

15. Nurse Anthony is caring for a 2-year-old boy named Liam. According to Jean Piaget's
Cognitive Development theory, which stage of cognitive development is Liam most likely
experiencing?
A. Sensorimotor

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 B. Preoperational
C. Concrete operational
D. Formal operational

Answer: a) Sensorimotor

Rationale: Piaget's first stage of cognitive development is the sensorimotor stage, which occurs
during infancy (birth to 2 years). During this stage, children like Liam explore the world through
their senses and motor actions. They develop object permanence and begin to understand cause-
and-effect relationships. Symbolic thinking is not yet present at this stage.

16. Nurse Anthony is caring for a newborn baby named Liam. According to the traditional
stages of development, which stage of life does Liam belong to?
A. Early childhood
B. Infancy
C. Adolescence
D. Late adulthood

Answer: b) Infancy

Rationale: Infancy is the stage of life that covers the period from birth to about 2 years of age.
During this stage, infants experience rapid growth and development, forming attachments with
caregivers and developing basic motor and sensory abilities.

17. Nurse Anthony is conducting a health promotion workshop for parents of preschool-age
children. According to Jean Piaget's theory of cognitive development, which stage of
cognitive development do preschool-age children fall into?
A. Sensorimotor stage
B. Preoperational stage
C. Concrete operational stage
D. Formal operational stage

Answer: b) Preoperational stage

Rationale: According to Piaget's theory, the preoperational stage occurs between ages 2 and 7.
During this stage, children develop language and symbolic thinking but have difficulty with logical
reasoning and understanding others' perspectives.

18. Nurse Anthony is assisting with the delivery of a newborn baby. After the baby is born,
what is the appropriate time frame for performing the APGAR scoring?
A. Immediately after birth
B. 5 minutes after birth
C. 10 minutes after birth
D. 15 minutes after birth

Answer: b) 5 minutes after birth

Rationale: The APGAR scoring is typically performed 1 minute and 5 minutes after birth. The first
score is obtained at 1 minute to assess the baby's initial response to birth, and the second score
at 5 minutes evaluates the baby's overall condition and adaptation to the extrauterine life. In
some cases, an additional score may be obtained at 10 minutes if the 5-minute score is low.

19. Nurse Anthony is assessing a newborn baby's heart rate for the APGAR scoring. The baby's
heart rate is above 100 beats per minute. What score should Nurse Anthony assign for this
parameter?

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 A. 0
B. 1
C. 2
D. 3

Answer: c) 2

Rationale: In the APGAR scoring, a heart rate above 100 beats per minute is considered normal,
and the baby should be assigned a score of 2 for this parameter. A score of 0 is given for absent
heart rate, and a score of 1 is given for a heart rate below 100 beats per minute.

20. Nurse Anthony observes that a newborn baby has acrocyanosis (bluish discoloration of the
hands and feet) but the rest of the body appears pink. What score should Nurse Anthony
assign for the baby's color during the APGAR scoring?
A. 0
B. 1
C. 2
D. 3

Answer: b) 1

Rationale: In the APGAR scoring, a baby with acrocyanosis (bluish discoloration of the hands and
feet) but a pink body is assigned a score of 1 for color. A score of 0 is given for a completely blue
or pale body, and a score of 2 is given for a completely pink body.

21. Nurse Anthony observes that a newborn baby has weak muscle tone and is demonstrating
minimal movement of the arms and legs. What score should Nurse Anthony assign for this
parameter during the APGAR scoring?
A. 0
B. 1
C. 2
D. 3

Answer: b) 1

Rationale: In the APGAR scoring, a baby with weak muscle tone and minimal movement of the
arms and legs is assigned a score of 1 for muscle tone. A score of 0 is given for flaccid (limp)
muscle tone, and a score of 2 is given for active movement and flexion of the arms and legs.

22. Nurse Anthony observes that a newborn baby is crying vigorously and has a strong cry.
What score should Nurse Anthony assign for the baby's cry during the APGAR scoring?
A. 0
B. 1
C. 2
D. 3

Answer: c) 2

Rationale: In the APGAR scoring, a baby with a strong and vigorous cry is assigned a score of 2 for
cry. A score of 0 is given for no cry or a weak, feeble cry, and a score of 1 is given for a weak cry
with some grimacing.

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 23. Nurse Anthony is performing a physical examination on a newborn baby. He shines a
bright light into the baby's eyes and observes that the pupils constrict in response to the
light. Which reflex is Nurse Anthony assessing?
A. Moro reflex
B. Rooting reflex
C. Blink reflex
D. Pupillary reflex

Answer: d) Pupillary reflex

Rationale: The pupillary reflex is tested by shining a light into the newborn's eyes. The normal
response is for the pupils to constrict (get smaller) in response to the bright light. This reflex helps
protect the newborn's eyes from excessive light exposure.

24. Nurse Anthony is assessing the presence of a red reflex in a newborn's eyes. He uses an
ophthalmoscope to look into the baby's eyes and observes a reddish-orange glow. What
does the presence of a red reflex indicate?
A. Normal eye development
B. Cataracts
C. Strabismus (crossed eyes)
D. Nystagmus (involuntary eye movement)

Answer: a) Normal eye development

Rationale: The red reflex is an important screening test used to assess the presence of
abnormalities in the eyes, particularly cataracts. A normal red reflex indicates that light is
reflecting off the retina properly, suggesting normal eye development. An absent or abnormal red
reflex could be indicative of conditions like cataracts or other eye abnormalities.

25. Nurse Anthony is observing a newborn baby's eyes as he moves a finger toward the baby's
cheek. The baby turns his head and opens his mouth, rooting in the direction of the
stimulus. Which reflex is Nurse Anthony assessing?
A. Moro reflex
B. Rooting reflex
C. Blink reflex
D. Sucking reflex

Answer: b) Rooting reflex

Rationale: The rooting reflex is tested by lightly touching or stroking the baby's cheek or corner of
the mouth. In response, the baby turns his head and opens his mouth, as if searching for
something to suck. This reflex helps the newborn locate the mother's breast or a feeding source.

26. Nurse Anthony is examining a newborn baby's eyes and observes that the baby's eyes
cross or turn inward occasionally. What term is used to describe this condition, and when
is it considered normal in newborns?
A. Amblyopia, persists up to 6 months old
B. Nystagmus, persists up to 1 year old
C. Strabismus, persists up to 3 months old
D. Retinopathy of prematurity, persists up to 2 years old

Answer: c) Strabismus, persists up to 3 months old

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Rationale: Strabismus, also known as crossed eyes, is a condition where the eyes do not align
properly. In newborns, slight misalignment or crossing of the eyes is relatively common and
considered normal up to around 3 months of age. However, if the condition persists beyond this
age or is significantly pronounced, it should be further evaluated by a healthcare professional.

27. Nurse Anthony is providing education to new parents about the primary factors that
influence a child's growth and development. Which of the following factors is considered a
genetic factor affecting growth?
A. Nutrition
B. Environmental stimuli
C. Socioeconomic status
D. Family history

Answer: d) Family history

Rationale: Family history and genetics play a significant role in a child's growth and development.
Genes inherited from parents influence various aspects of growth, such as height, weight, and
certain physical characteristics. However, it's essential to note that genetic factors interact with
environmental factors in shaping a child's growth and development.

28. Nurse Anthony is discussing the impact of nutrition on a child's growth and development
with parents. Which of the following nutrients is most crucial for supporting brain
development during infancy and early childhood?
A. Vitamin C
B. Iron
C. Vitamin D
D. Calcium

Answer: b) Iron

Rationale: Iron is a crucial nutrient for supporting brain development and cognitive function
during infancy and early childhood. Iron is necessary for the production of neurotransmitters and
myelin, which are essential for proper brain function and communication. Iron deficiency during
this critical period can lead to cognitive impairments and developmental delays.

29. Nurse Anthony is counseling parents on promoting optimal growth and development in
their child. Which of the following environmental factors is considered important for
fostering positive social development?
A. Exposure to lead-based paints
B. Low-quality childcare
C. Frequent exposure to violent media
D. Secure and nurturing family environment

Answer: d) Secure and nurturing family environment

Rationale: A secure and nurturing family environment is essential for fostering positive social
development in children. The family provides the primary socialization and emotional support for
a child, laying the foundation for healthy relationships and social interactions later in life.
Exposure to lead-based paints, low-quality childcare, and violent media can have negative effects
on a child's development.

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 30. Nurse Anthony is discussing the importance of early childhood education with parents.
Which of the following aspects of development is significantly influenced by high-quality
early childhood education programs?
A. Physical growth
B. Cognitive development
C. Genetic factors
D. Socioeconomic status

Answer: b) Cognitive development

Rationale: High-quality early childhood education programs can have a significant positive impact
on a child's cognitive development. These programs provide stimulating and age-appropriate
activities that promote language development, problem-solving skills, and social interactions, all
of which contribute to enhanced cognitive abilities in children.

31. The nurse is aware that the age at which the posterior fontanelle closes is _____ months.

A. 2 to 3
B. 3 to 6
C. 6 to 9
D. 9 to 12

Rationale: A) The posterior fontanelle closes between 2 and 3 months of age.

32. A nurse is evaluating the developmental level of a 2-year-old. Which of the following does the
nurse expect to observe in this child?
A. Uses a fork to eat
B. Uses a cup to drink
C. Uses a knife for cutting food
D. Pours own milk into a cup

Rationale: B.) By age 2 years, the child can use a cup and can use a spoon correctly but with
some spilling. By ages 3 to 4, the child begins to use a fork. By the end of the preschool period,
the child should be able to pour milk into a cup and begin to use a knife for cutting.
33. A nurse, who is performing the preliminary physical examination of a female patient, notes the
physical changes shown in the figures above. The nurse should interview the child about which of
the following information at this time? The young woman’s:
A. Readiness for menstruation to begin.
B. Sexual activity
C. Menstrual cycle
D. Feelings about her bodily changes.

Rationale: D. It would be appropriate for the nurse to interview the child about her feelings
about her bodily changes.
34. A client, now 37 weeks pregnant, calls the clinic because she's concerned about being short of breath
and is unable to sleep unless she places three pillows under her head. After listening to the client's
concerns, the nurse should take which action?
A. Make an appointment because the dent needs to be evaluated.
B. Explain that these are expected problems for the latter stages of pregnancy.
C. Arrange for the dent to be admitted to the birth center and prepare for birth.
D. Tell the client to go to the hospital; she may be experiencing signs of heart failure.
RATIONALE: The nurse must distinguish between normal physiologic complaints of the latter stages of
pregnancy and those that need referral to the health care provider. In this case, the client indicates
normal physiologic changes caused by the growing uterus and pressure on the diaphragm. These signs
don't indicate heart failure. The client doesn't need to be seen or admitted to the birth center.
Reference: Maternal & Child Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed.
Philadelphia: Lippincott Williams & Wilkins, 2007, p. 230.

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 35. During the first trimester, a nurse evaluates a pregnant client for factors that suggest she might abuse a
child. Which parental characteristic is of most concern to the nurse?
A. The client didn’t graduate high school.
B. The client states she is stupid and ugly.
C. The client is carrying twins.
D. None of the above
The client eats fast food every day.
RATIONALE: Typically, the abusive parent has low self-esteem, which may be evident by self-deprecating
statements, and many unmet needs. Lack of nurturing experience and inadequate knowledge of
childhood growth and development may also contribute to the potential for child abuse. A low
educational level, multiple gestations, and poor diet aren't direct risk factors for committing child abuse.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 1743.

36. A client in her 15th week of pregnancy has presented with abdominal cramping and vaginal bleeding for
the past 8 hours. She has passed several clots. What is the primary nursing diagnosis for this client?
A. Deficient knowledge of pregnancy
B. Deficient fluid volume
C. Anticipatory grieving
D. Acute pain
RATIONALE: If bleeding and clots are excessive, this client may become hypovolemic , leading to a
nursing diagnosis of Deficient fluid volume. Although Deficient knowledge (pregnancy), Anticipatory
grieving, and Acute pain are applicable to this client, they aren't the primary diagnosis
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 400.

37. A nurse is obtaining a prenatal history from a client who's 8 weeks pregnant. To help determine whether
the client is at risk for a TORCH infection , the nurse should ask:
A. “Have you ever had osteomyelitis?”
B. “Do you have any cats at home?
C. “Do you have any birds at home?’
D. “Have you recently had a rubeola vaccination?”
RATIONALE: Toxoplasmosis, Other Rubella virus, Cytomegalovirus, and Herpes simplex virus and agents
that may infect the fetus or neonate, causing numerous ill effects. Toxoplasmosis is transmitted to
humans through contact with the feces of infected cats (which may occur when emptying a litter box),
through ingesting raw meat, or through contact with raw meat followed by improper hand washing.
Osteomyelitis , a serious bone infection; histoplasmosis, which can be transmitted by birds; and rubeola
aren't TORCH infections
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 288.

38. A client, 38 weeks pregnant, arrives in the emergency department complaining of contractions. To help
confirm that she's in true labor, the nurse should assess for:
A. irregular contractions.
B. increased fetal movement.
C. changes in cervical effacement and dilation atter 1 to 2 hours.
D. contractions that feel like pressure in the abdomen and qroin.
E. Both C & D

RATIONALE: True labor is characterized by progressive cervical effacement and dilation after 1 to 2
hours, regular contractions, discomfort that moves from the back to the front of the abdomen and,
possibly, bloody show. False labor causes irregular contractions that are felt primarily in the abdomen and
groin and commonly decrease with walking, increased fetal movement, and lack of change in cervical
effacement or dilation even after 1 or 2 hours.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 227.

39. A nurse is caring for a client during the first postpartum day. The client asks the nurse how to relieve pain
from her episiotomy . What should the nurse instruct the woman to do?
A. Apply an ice pack to her perineum.
B. Take a sitz bath.
C. Perform perineal care after voiding or a bowel movement.
D. Drink plenty of fluids.

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 RATIONALE: A cold pack applied to an episiotomy during the first 24 hours after chidbirth may reduce
edema and tension on the incision line, thereby reducing pain. After the first 24 hours, a sitz bath may
reduce discomfort by promoting circulation and healing. Although perineal care should be performed
after each voiding and bowel movement, its purpose is to prevent infection — not reduce
discomfort. Drinking plenty of fluids is also important, especially for the breast-feeding woman, but it
doesn't relieve perineal discomfort.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 637.
40. A client who's 24 weeks pregnant has sickle cell anemia . When preparing the care plan, the nurse should
identify which factor as a potential trigger for a sickle cell crisis during pregnancy?
A. Sedative use
B. Dehydration
C. Hypertension
D. Tachycardia
RATIONALE: Factors that may precipitate a sickle cell crisis during pregnancy include dehydration ,
infection , stress, trauma, fever, fatigue, and strenuous activity. Sedative use, hypertension, and
tachycardia aren't known to precipitate a sickle cell crisis
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 363.
41. A nurse is caring for a 1-day postpartum mother who's very talkative but isn't confident in her decision-
making skills. The nurse is aware that this is a normal phase for the mother. What is this phase called?
A. Taking-in phase
B. Taking-hold phase
C. Letting-go phase
D. Taking-over phase
RATIONALE: The taking-in phase is a normal first phase for a mother when she's feeling overwhelmed by
the responsibilities of caring for the neonate while still fatigued from childbirth. Taking hold is the next
phase, when the mother has rested and she can think and learn mothering skills with confidence. During
the letting-go or taking-over phase, the mother gives up her previous role. She separates herself from the
neonate, giving up the fantasy of birth, and readjusting to the reality of caring for the neonate.
Depression may occur during this stage.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 624.

42. Which intervention listed in the care plan for a client with an ectopic pregnancy requires revision?
A. Assessing vital signs
B. Providing for dietary needs
C. Managing pain
D. Providing emotional support
RATIONALE: Providing for the client's dietary needs isn't appropriate because the client shouldn't eat or
drink anything pending surgery. Assessing vital signs for indicators of potential shock , managing pain,
and providing emotional support are essential nursing interventions in caring for a client with an ectopic
pregnancy.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 409.

43. A client who's 19 weeks pregnant comes to the clinic for a routine prenatal visit. In addition to checking the
client's fundal height, weight, and blood pressure, what should the nurse assess for at each prenatal visit?
A. Edema
B. Pelvic adequacy
C. Rh factor changes
D. Hemoglobin alterations
RATIONALE: At each prenatal visit, the nurse should assess the client for edema because edema,
increased blood pressure, and proteinuria are cardinal signs of gestational hypertension. Pelvic
measurements and Rh typing are determined at the first visit only because they don't change. The nurse
should monitor the hemoglobin level on the client's first visit, at 24 to 28 weeks' gestation, and at 36
weeks' gestation.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 257.

44. A nurse is caring for a client whose membranes ruptured prematurely 12 hours ago. When assessing this
client, the nurse's highest priority is to evaluate:
A. cervical effacement and dation.
B. maternal vital signs and fetal heart rate (FHR).
C. frequency and duration of contractions.

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 D. white blood cell (WBC) count.
RATIONALE: After premature rupture of the membranes (PROM), monitoring maternal vital signs and FHR
takes priority. Maternal vital signs, especially temperature and pulse, may suggest maternal infection
caused by PROM. FHR is the most accurate indicator of fetal status after PROM and may suggest sepsis
caused by ascending pathogens. Assessing cervical effacement and dilation should be avoided in this
client because it requires a pelvic examination, which may introduce pathogens into the birth canal.
Evaluating the frequency and duration of contractions doesn't provide insight into fetal status. The WBC
count may suggest maternal infection; however, it can't be measured as often as maternal vital signs and
FHR can and therefore provides less current information
REFERENCE: Ricci, S.S. Essentials of Maternity, Newborn, and Women’s Health Nursing. Philadelphia:
Lippincott Williams & Wilkins, 2007, p. 531.

45. A client is told that she needs to have a nonstress test to determine fetal well-being. After 20 minutes of
monitoring, the nurse reviews the strip and finds two 15-beat accelerations that lasted for 15 seconds.
What should the nurse do next ?
A. Continue to monitor the baby for fetal distress.
B. Notify the physician and transfer the mother to labor and delivery for imminent delivery.
C. Inform the physician and prepare for discharge: this client has a reassuring strip.
D. Ask the mother to eat something and return for a repeat test; the results are inconclusive.
RATIONALE: Fetal well-being is determined during a nonstress test by two accelerations occurring
within 20 minutes that demonstrate a rise in heart rate of at least 15 beats. This fetus has successfully
demonstrated that the intrauterine environment is still favorable. The test results don't suggest fetal
distress, so immediate delivery is unnecessary. In research studies, eating foods or drinking fluids
hasn't been shown to influence the outcome of a nonstress test. REFERENCE: Pillitteri, A. Maternal
& Child
Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams
& Wilkins, 2007, p. 203.

46. A nurse is caring for four clients who gave birth 12 hours ago. Which client is at greatest risk for
complications?
A. Gravida 2 para 2002, cesarean bith, incision site intact, hemoglobin level 9.8 g/dl
B. Gravida 2 para 1011, cesarean birth, incision site intact, pulse 84 beats/minute
C. Gravida 1 para 1001, vaginal delivery, midline episiotomy, temperature of 99.8° F (37.7C)
D. Gravida 1 para 1001, vaginal delivery, membranes ruptured 10 hours before birth
RATIONALE: Women who have anemia during pregnancy (defined as a hemoglobin less than 10 g/dl) may
experience more complications such as poor wound healing and inability to tolerate activity. An intact
incision site and a pulse of 84 beats/minute after a cesarean birth and a temperature of 99.8F after a
vaginal delivery with episiotomy are findings within normal limits. Dehydration can cause a slightly
elevated temperature. Although women whose membranes are ruptured more than 24 hours before birth
are more prone to developing chorioamnionitis, the client with anemia is at greater risk for complications.
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 362.

47. Which measure included in the care plan for a client in the fourth stage of labor requires revision?
A. Check vital signs and fundal checks every 15 minutes.
B. Have the client spend time with the neonate to initiate breast-feeding.
C. Obtain an order for catheterization to protect the bladder from trauma.
D. Perform perineal assessments for swelling and bleeding.
RATIONALE: Catheterization isn't routinely done to protect the bladder from trauma. It's done, however,
for a postpartum complication of urinary retention. The other options are appropriate measures to
include in the care plan during the fourth stage of labor. CLIENT NEEDS CATEGORY: Physiological integrity
Basic care and comfort
REFERENCE: Ricci, S.S. Essentials of Maternity, Newborn, and Women’s Health Nursing. Philadelphia:
Lippincott Williams & Wilkins, 2007, p. 370.

48. A client who's 4 weeks pregnant comes to the clinic for her first prenatal visit. When obtaining her health
history, the nurse explores her use of drugs, alcohol, and cigarettes. Which client outcome identifies a safe
level of alcohol intake for this client?
A. “The clent consumes no more than 2 oz of alcohol dady.”
B. “The client consumes no more than 4 oz of alcohol dady.”
C. “The client consumes 2 to 6 oz of alcohol daily, dependlng on body weight."
D. “The client consumes no alcohol.”
RATIONALE: A safe level of alcohol intake during pregnancy hasn't been established. Therefore,
authorities recommend that pregnant women abstain from alcohol entirely. Excessive alcohol intake has
serious harmful effects on the fetus, especially between the 16th and 18th weeks of pregnancy. Affected

12
 neonates exhibit fetal alcohol syndrome, which includes microcephaly, growth retardation, short
palpebral fissures, and maxillary hypoplasia. Alcohol intake may also affect the client's nutrition and may
predispose her to complications in early pregnancy. REFERENCE: Pillitteri, A. Maternal & Child Health
Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams &
Wilkins, 2007, p. 291.

49. A nurse is teaching a client about hormonal contraceptive therapy. If a client misses three or more pills in
a row, the nurse should instruct the client to:
A. take all the missed doses as soon as she discovers the oversight.
B. take two pills for the next 2 days and use an alternative contraceptive method until the next cycle.
C. take three pills for the next 3 days and use an alternative contraceptive method until the next cycle.
D. discard the pack, use an atternative contraceptive method untii her period begins, and start a new
pack on the regular schedule.
RATIONALE: A client who misses three or more pills in a row should discard the pack, use an alternative
contraceptive method until her period begins, and start a new pack on the regular schedule. Taking all the
missed doses, taking two pills for the next 2 days, or taking three pills for the next 3 days doesn't ensure
effectiveness and can increase the risk of adverse reactions. REFERENCE: Pillitteri, A. Maternal & Child
Health Nursing: Care of the Childbearing and Childrearing Family, 5th ed. Philadelphia: Lippincott Williams
& Wilkins, 2007, p. 112.

50. A nurse is caring for a client in labor. The external fetal monitor shows a pattern of variable decelerations in
fetal heart rate. What should the nurse do first ?
A. Change the client's position.
B. Prepare for emergency cesarean birth.
C. Check for placenta previa.
D. Administer oxygen.
RATIONALE: Variable decelerations in fetal heart rate are an ominous sign, indicating compression of the
umbilical cord. Changing the client's position may immediately correct the problem. An emergency
cesarean birth is necessary only if other measures, such as changing position and amnioinfusion with
sterile saline, prove unsuccessful. Placenta previa doesn't cause variable decelerations. Administering
oxygen may be helpful, but the priority is to change the woman's position and relieve cord compression
REFERENCE: Pillitteri, A. Maternal & Child Health Nursing: Care of the Childbearing and Childrearing
Family, 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2007, p. 526.

13
51. Immediately after an amniotomy has been performed, the nurse should first assess:
a) For bladder distention
b) For cervical dilation
c) The maternal blood pressure
d) The fetal heart rate (FHR) pattern
RATIONALE: The FHR is assessed immediately after amniotomy to detect any changes that may indicate
cord compression or prolapse. Bladder distention or maternal blood pressure would not be the first things
to check after an amniotomy. Once the membranes are ruptured, minimal vaginal examinations will be
done because of the risk of infection.
REFERENCES: Lowdermilk, D., & Perry, S. (2004).

Maternity and women’s health care

(8th ed., p. 1009). St. Louis: Mosby.

52. A nurse in the labor room is caring for a client in the active stage of labor. The nurse is assessing the fetal
patterns and notes a late deceleration on the monitor strip. The appropriate nursing action is to:
a) Administer oxygen via face mask.
b) Place the mother in a supine position.
c) Increase the rate of the oxytocin (Pitocin) IV infusion.
d) Document the findings and continue to monitor the fetal patterns.
RATIONALE: Late decelerations are the result of uteroplacental insufficiency as the result of decreased
blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore,
oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus.
The client should be turned onto her side to displace pressure of the gravid uterus on the inferior vena
cava. An intravenous oxytocin infusion is discontinued when a late deceleration is noted. The oxytocin
would cause further hypoxemia because of increased uteroplacental insufficiency resulting from
stimulation of contractions by this medication. Option 4 would delay necessary treatment.
REFERENCES: Lowdermilk, D., & Perry, S. (2006).
Maternity nursing (7th ed., p. 386). St. Louis: Mosby.

53. A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which
assessment finding would indicate a need to contact the physician?
a) Hemoglobin of 11.0 g/dL
b) Fetal heart rate of 180 beats/min
c) Maternal pulse rate of 85 beats/min
d) White blood cell count of 12,000/mm3
RATIONALE: A normal fetal heart rate is 120 to 160 beats/min. A count of 180 beats/min could indicate
fetal distress and would warrant physician notification. White blood cell counts in a normal pregnancy
begin to rise in the second trimester and peak in the third trimester, with a normal range of 11,000 to
15,000/mm3
, up to 18,000/mm3. During the immediate postpartum period, the count may be as high as 25,000 to
30,000/mm3 as a result of increased leukocytosis during delivery. By full term, a normal maternal
hemoglobin range is 11 to 13 g/dL as a result of the hemodilution caused by an increase in plasma volume
during pregnancy. The maternal pulse rate during pregnancy increases 10 to 15 beats/min over
prepregnancy readings to facilitate increased cardiac output, oxygen transport, and kidney filtration.
REFERENCES: Lowdermilk, D., & Perry, S. (2004). Maternity and women’s health care (8th ed., pp. 356,
358, 518). St. Louis: Mosby.

54. A nurse has provided discharge instructions to a client who delivered a healthy newborn infant by
cesarean delivery. Which statement, if made by the client, indicates a need for further instructions?
a) “I will begin abdominal exercises immediately.”
b) “I will notify the physician if I develop a fever.”
c) “I will turn on my side and push up with my arms to get out of bed.”
d) “I will lift nothing heavier than the newborn infant for at least 2 weeks.”
RATIONALE: Abdominal exercises should not start immediately following abdominal surgery, and the
client should wait at least 3 to 4 weeks postoperatively to allow for healing of the incision. Options 2, 3,
and 4 are appropriate instructions for the client following a cesarean delivery.
REFERENCES: Lowdermilk, D., & Perry, S. (2006). Maternity nursing (7th ed., p. 804). St. Louis: Mosby.

14
55. A nurse is caring for a client in labor who is receiving oxytocin (Pitocin) by intravenous infusion to
stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion
needs to be discontinued?
a) Increased urinary output
b) A fetal heart rate of 90 beats/min
c) Three contractions occurring within a 10-minute period
d) Adequate resting tone of the uterus palpated between contractions
RATIONALE: A normal fetal heart rate is 120 to 160 beats/min. Bradycardia or late or variable
decelerations indicate fetal distress and the need to discontinue the oxytocin. The goal of labor
augmentation is to achieve three good-quality contractions (appropriate intensity and duration) in a 10-
minute period. The uterus should return to resting tone between contractions, and there should be no
evidence of fetal distress. Increased urinary output is unrelated to the use of oxytocin.
REFERENCES: McKinney, E., James, S., Murray, S., & Ashwill, J. (2005).
Maternal-child nursing
(2nd ed., p. 448). St. Louis: W.B. Saunders.

56. A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the
following is noted on the external monitor tracing during a contraction?
a) Late decelerations
b) Early decelerations
c) Short-term variability
d) Variable decelerations
RATIONALE: Variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood
flow between the placenta and the fetus. Early decelerations result from pressure on the fetal head
during a contraction. Late decelerations are an ominous pattern in labor because they suggest
uteroplacental insufficiency during a contraction. Short-term variability refers to the beat-to-beat range in
the fetal heart rate.
REFERENCES: Lowdermilk, D., & Perry, S. (2006).

Maternity nursing
(7th ed., p. 378). St. Louis: Mosby.

57. A labor and delivery room nurse has just received report on four clients. The nurse should assess which
client first?
a) A primiparous client in the active stage of labor
b) A multiparous client who was admitted for induction of labor
c) A client who is not contracting, but has suspected premature rupture of the membranes
d) A client who has just received an IV loading dose of magnesium sulfate to stop preterm
labor RATIONALE: Magnesium sulfate is a central nervous system (CNS) depressant and the
client could experience adverse effects that includes depressed respiratory rate (below 12
breaths/min), severe hypotension, and absent deep tendon reflexes (DTRs). This client should
be seen before the clients in options 1, 2, and 3 because these clients conditions represent
stable ones.
REFERENCES: Lowdermilk, D., & Perry, S. (2006).

Maternity nurs
ing (7th ed., p. 778). St. Louis: Mosby.

58. A nurse is reviewing the physician’s orders for a client admitted for premature rupture of the membranes.
Gestational age of the fetus is determined to be 37 weeks. Which physician’s order should the nurse
question?
a) Perform a vaginal examination every shift.
b) Monitor maternal vital signs every 4 hours.
c) Monitor fetal heart rate (FHR) continuously.
d) Administer ampicillin 1 gm as an intravenous piggyback (IVPB) every 6 hours.
RATIONALE: Vaginal examinations should not be done routinely on a client with premature rupture of the
membranes because of the risk of infection. The nurse would expect to administer an antibiotic, monitor
maternal vital signs, and monitor the FHR.
REFERENCES: Lowdermilk, D., & Perry, S. (2006).

Maternity nurs
ing (7th ed., p. 782). St. Louis: Mosby.

59. Fetal distress is occurring with a laboring client. As the nurse prepares the client for a cesarean birth, what
other intervention should be done?

15
a) Slow the intravenous (IV) flow rate.
b) Place the client in a high-Fowler’s position.

16
 c) Continue the oxytocin (Pitocin) drip if infusing.
d) Administer oxygen at 8 to 10 L/min via face mask.
RATIONALE: Oxygen is administered at 8 to 10 L/min via face mask to optimize oxygenation of the circulating blood.
Option 1 is incorrect because the IV infusion should be increased to increase the maternal blood volume. Option 2 is
incorrect because the client is placed in the lateral position with her legs raised to increase maternal blood volume and
improve fetal perfusion. Option 3 is incorrect because the oxytocin stimulation of the uterus is discontinued if fetal
heart rate patterns change for any reason. REFERENCES: Lowdermilk, D., & Perry, S. (2006).
Maternity nursing
(7th ed., p. 386). St. Louis: Mosby.

60. A nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of
the umbilical cord protruding from the vagina. Which of the following is the initial nursing action?
a) Gently push the cord into the vagina.
b) Place the client in Trendelenburg’s position.
c) Find the closest telephone and page the physician stat.
d) Call the delivery room to notify the staff that the client will be transported immediately.
RATIONALE: When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal
oxygenation. The client should be positioned with the hips higher than the head to shift the fetal presenting part toward
the diaphragm. The nurse should push the call light to summon help, and other staff members should call the physician
and notify the delivery room. If the cord is protruding from the vagina, no attempt should be made to replace it because
to do so could traumatize it and further reduce blood flow. The examiner, however, may place a gloved hand into the
vagina and hold the presenting part off the umbilical cord. Oxygen at 8 to 10 L/min by face mask is administered to the
client to increase fetal oxygenation.
REFERENCES: Lowdermilk, D., & Perry, S. (2006).Maternity nursing (7th ed., p. 811). St. Louis: Mosby.