UPDATED 2022 HESI MATERNITY PEDIATRIC EXAM TEST BANK |
REAL EXAM WITH ANSWER KEY IN THE END
1. Monitoring for fetal position is important because the mother cannot tell you she has back
pain, which is the cardinal sign of persistent posterior fetal position. Why do the regional
blocks, especially epidural and caudal, often result in assisted delivery?
A. inability to push effectively in 3rd stage
B. inability to push effectively in 4th stage
C. inability to push effectively in 1st stage
D. inability to push effectively in 2nd stage
Answer: D. inability to push effectively in 2nd stage
2. Early detection of rheumatoid arthritis can decrease the amount of bone and joint destruction
and often the disease will go into remission. What activity recommendations should the nurse
provide a client with rheumatoid arthritis?
A. Exercise of painful, swollen joints to strengthen them
B. Exercise joint to the point of pain so that the pain lessens
C. Make Jerky movements during the exercise so that the pain lessens
D. Perform exercises slowly and smoothly
Answer: D. Perform exercises slowly and smoothly
3. A patient who is 32 weeks gestation has the following symptoms: dark, red vaginal bleeding,
100 bpm FHR, rigid abdomen, and severe pain. What is the difference between abruptio
placentae and placenta previa?
A. Abruptio placentae: painless bright red bleeding occurring in the third trimester
B. Abruptio placentae: occurs in the second trimester
C. Placenta previa: occurs in the second trimester
D. Placenta previa: painless bright red bleeding occurring in the third trimester
Answer: D. Placenta previa: painless bright red bleeding occurring in the third trimester
4. A patient who is 32 weeks gestation is experiencing dark red vaginal bleeding and the nurse
determines the FHR to be 100 bpm and her abdomen is rigid and board like. What action
should the nurse take first?
A. Administer O2 per face mask
B. Abdominal manipulation
C. vaginal manipulation
D. Abdominal exam
Answer: A. Administer O2 per face mask
5. A nurse must use knowledge base to differentiate between abruptio placentae from placenta
previa. What assessments should be done in case of a patient suspected of abruptio placentae or
placenta previa.
A. abdominal or vaginal manipulation
B. Leopold's maneuvers
C. internal monitoring
D. Monitor for bleeding at IV sites and gums due to increased risk of DIC
Answer: D. Monitor for bleeding at IV sites and gums due to increased risk of DIC
6. A patient suspected of abruptio placentae or placenta previa should be monitored for
bleeding at IV sites and gums due to increased risk of DIC. What isn't DIC related to?
A. cervical carcinoma
B. fetal demise
C. infection/sepsis
D. pregnancy-induced hypertension
Answer: A. cervical carcinoma
7. If a child is on oral iron medication, the family should be taught by the nurse how it should
be administered. Out of the following options, what oral iron administration advise is
inappropriate?
A. Oral iron should be given on empty stomach
B. Oral iron should be given with citrus juices
C. Oral iron should be given with dairy products
D. A dropper or straw should be used to avoid discoloring teeth
Answer: C. Oral iron should be given with dairy products
8. In autosomal recessive disease, both parents must be heterozygous, or carriers of the
recessive trait, for the disease to be expressed in their offspring. If both parents are
heterozygous, what is the chance the baby to have the disease as well?
A. 1:2
B. 1:3
C. 1:4
D. 1:1
Answer: C. 1:4
9. When it comes to X-linked recessive linked recessive trait, the trait is carried on the x
chromosome, therefore, usually affects male offspring. What is the chance for a pregnant
woman carrier her offspring to get the disease?
A. Male child: 75% of having the disease
B. Female child: 50% of having the disease
C. Male child: 50% of having the disease
D. Female child: 25% of having disease
Answer: C. Male child: 50% of having the disease
10. Supplemental iron is not given to clients with sickle cell anemia because the anemia is not
caused by iron deficiency. What aspect is very important in treatment of sickle cell disease
because it promotes hemodilution and circulation of red cells through the blood vessels?
A. HgbAS
B. HGBS
C. Hydration
D. Hydrotherapy
Answer: C. Hydration
11. An infant with hypothyroidism is often described as a "good, quite baby" by the parents.
What early disease detection is essential in preventing mental retardation in infants?
A. Hyperthyroidism
B. Phenylketonuria
C. Diabetes Mellitus
D. Ketoacidosis
Answer: B. Phenylketonuria
12. Diabetes mellitus (DM) in children was typically diagnosed as insulin dependent diabetes
until recently. What diabetes type has been discovered to occur more often in Native
Americans, African Americans, and Hispanic children and adolescents?
A. Type 1
B. Type 2
C. Type 3
D. Type 4
Answer: B. Type 2
13. There has been an increase in the number of children diagnosed with Type 2 diabetes with
the increasing rate of obesity in children thought to be a contributing factor. What other factors
are thought to be contributing in the increase of Type 2 cases?
A. Hypotension
B. Hypokalemia
C. Lack of physical activity
D. Hyperkalemia
Answer: C. Lack of physical activity
14. Fractures in older children are common as they fall during play and are involved in motor
vehicle accidents. What fractures in children are related to child abuse?
A. Greenstick Fracture
B. Growth plate Fracture
C. Torus Fracture
D. Spiral fracture
Answer: D. Spiral fracture
15. Skin traction for fracture reduction should not be removed unless prescribed by healthcare
provider. What fractures have serious consequences in terms of growth of the affected limb?
A. Greenstick fracture
B. Plate fracture
C. Torus fracture
D. Spiral fracture
Answer: B. Plate fracture
16. Corticosteroids are used short term in low doses during exacerbations. What side effect do
corticosteroids have on long term?
A. Adverse effects on growth
B. Adverse effects on bone structure
C. Hypoglycemia
D. Hypocalcaemia
Answer: B. Adverse effects on bone structure
17. Skin traction for fracture reduction should not be removed unless prescribed by healthcare
provider. What do the pin sites usually cause in an infant client?
A. Hypoglycemia
B. Hypocalcaemia
C. Infection
D. Low vitamin K concentration
Answer: C. Infection
18. The menstrual phase varies in length for most women. How many days usually are from
ovulation to the beginning of the next menstrual cycle?
A. 12 days
B. 14 days
C. 16 days
D. 18 days
Answer: B. 14 days
19. Sperm lives approximately 3 days and eggs live about 24 hours. Which is the time interval
a couple should avoid unprotected intercourse after the ovulation?
A. 24 hours
B. 48 hours
C. 72 hours
D. 128 hours
Answer: C. 72 hours
20. A woman who is 6 weeks pregnant has the following maternal history: a 2 yr. old healthy
daughter, a miscarriage at 10 weeks, 3 years ago and an elective abortion at 6 weeks, 5 years
ago. Describe gravidity and parity in this case.
A. gravida 1, para 4
B. gravida 2, para 4
C. gravida 4, para 1
D. gravida 4, para 2
Answer: C. gravida 4, para 1
21. The first day of a woman’s last normal menstrual period was October 17. By using Nagele's
rule, what is the EDB?
A. July 10
B. July 24
C. June 10
D. June 24
Answer: B. July 24
22. At approximately 28 - 32 weeks gestation, the maximum plasma volume increase of 25 40% occurs, resulting in normal hemodilution of pregnancy and Hct values of 32 - 42%. What
does Hct in reality represent, even if its values may look "good"?
A. Pregnancy induced hyperglycemia
B. Pregnancy induced hypoglycemia
C. Pregnancy induced hypertension
D. pregnancy induced hypotension
Answer: D. pregnancy induced hypotension
23. A 22 year old primigravida at 12 weeks gestation has a high Hgb of 9.6 g/dl and a Hct of
31% and she has gained 3 pounds during the first trimester, even if the gain of 3.5 to 5 pounds
during the first trimester is recommended. Taking into consideration that the client is anemic,
what supplements should be recommended to her?
A. Potassium
B. Magnesium
C. Iron
D. Calcium
Answer: C. Iron
24. As pregnancy advances, the uterus presses on the abdominal vessels (vena cava and aorta).
What position is best for increasing perfusion according to the latest research?
A. Left side lying position
B. Knee chest position
C. Side lying position
D. Right side lying position
Answer: A. Left side lying position
25. Fetal wellbeing is determined by assessing fundal height, fetal heart tones/rate, fetal
movement, and uterine activity (contractions). What do changes in fetal heart rate indicate?
A. Leukorrhea
B. Compromised blood flow to the fetus
C. Fluid discharge from vagina
D. Change in fetal movement
Answer: B. Compromised blood flow to the fetus
26. Changes in fetal heart rate are the first and most important indicator of compromised blood
flow to the fetus, and these changes require action! What is the normal FHR in a pregnant
woman?
A. 150 - 180 bpm
B. 160 - 190 bpm
C. 110 - 160 bpm
D. 120 - 150 bpm
Answer: C. 110 - 160 bpm
27. A 28 year old pregnant woman has the following symptoms: visual disturbance, persistent
vomiting, swelling of face, fingers or sacrum and severe continuous headache. What do these
symptoms most probably indicate?
A. Preeclampsia/eclampsia
B. Dysuria
C. Chills
D. Fluid discharge from the vagina
Answer: A. Preeclampsia/eclampsia
28. A nurse should teach the pregnant clients to immediately report any of the following danger
signs because early intervention can optimize maternal and fetal outcome. Which are the signs
of infection in a pregnant woman?
A. FHR 110 - 160 bpm
B. Chills
C. Persistent vomiting
D. Visual disturbances
Answer: B. Chills
29. A pregnant client has a temperature over 100.4 F, Dysuria, and fluid discharge from vagina.
What could these signs most probable indicate?
A. Preeclampsia
B. Eclampsia
C. Infection
D. Change in fetal movement
Answer: C. Infection
30. Most providers prescribe prenatal vitamins to ensure that the client receives an adequate
intake of vitamins. However, only the healthcare provider can prescribe prenatal vitamins.
What is the quantity of milk a pregnant woman should drink per day for ensuring that the daily
calcium needs are met?
A. 1/2 quart
B. 1/3 quart
C. 1/4 quart
D. 1 quart
Answer: D. 1 quart
31. The screening for neural tube defects is highly associated with both false positives and false
negatives. Through what does the screening for neural tube defects in some states?
A. Spinal Bifida
B. Maternal serum AFP levels
C. MSAFP
D. distribution curves of maternal serum APP
Answer: B. Maternal serum AFP levels
32. In a 24 year old pregnant woman, the amniocenteses is done in late pregnancy.
How should the bladder be to avoid puncturing the bladder?
A. Empty
B. Full
C. 1/4 empty
D. 1/2 full
Answer: A. Empty
33. Pitocin should be given with caution to clients with hypertension. What drug shouldn't be
given to clients with hypertension due to its vasoconstrictive action?
A. Analgesics
B. Meperidine
C. Codeine
D. Methergine
Answer: D. Methergine
34. Oxytocin should be administered after the placenta is delivered because the drug will cause
the uterus to contract. What can happen if the drug is administered before the placenta is
delivered?
A. Will predispose the client to nausea
B. Will predispose the client to amnesia
C. Will predispose the client to hemorrhage
D. Will predispose the client to hypocalcaemia
Answer: C. Will predispose the client to hemorrhage
35. In the first 12 hours after delivery, the 22 year old client shows signs of hemorrhage. What
is one of the common reasons for uterine atony and/or hemorrhage in the first 24 hours after
delivery?
A. Empty bladder
B. Full bladder
C. Hypoglycemia
D. Low blood pressure
Answer: B. Full bladder
36. When examining a client after delivery, the nurse finds the fundus soft, boggy, and
displaced above and to the right of the umbilicus. What action should the nurse take first in this
case?
A. Have the client empty her bladder
B. Perform fundal massage
C. Administer narcotic analgesics
D. Administer codeine and meperidine
Answer: A. Have the client empty her bladder
37. When examining a client after delivery, the nurse finds the fundus soft, boggy, and
displaced above and to the right of the umbilicus. After performing fundal massage and having
the client empty her bladder when should the nurse recheck fundus?
A. q 15 minutes *4 (1 hour)
B. q 45 minutes *2 (1.5 hour)
C. q 30 minutes *4 (2 hours)
D. q 30 minutes *2 (1 hour)
Answer: A. q 15 minutes *4 (1 hour)
38. Internal rotation is harder to achieve when the pelvic floor is relaxed by anesthesia resulting
in persistent occiput posterior of fetus. What regional blocks often result in assisted delivery
due to the inability to push effectively in the 2nd stage?
A. Epidermis
B. Anal Sphincter
C. Rectal mucosa
D. Caudal
Answer: D. Caudal
39. Nerve block anesthesia (spinal or epidural) during labor blocks motor as well as nerve
fibers. What does result from vasodilation below the level of the block?
A. Maternal hypertension
B. Maternal hypotension
C. Low BP
D. High BP
Answer: B. Maternal hypotension
40. Vasodilation below the nerve block results in pooling in the lower extremities and maternal
hypotension. Which is the quantity of IV lactated ringers the client should be hydrated with 20
minutes prior to operation?
A. 100-200 cc
B. 300-500 cc
C. 500-1000 cc
D. 600-800 cc
Answer: C. 500-1000 cc
41. Approximately 20 minutes prior to nerve block anesthesia, the client should be hydrated
with 500-1000 cc of lactated ringers IV. What should the nurse do if hypotension occurs?
A. Administer Stadol
B. Administer O2 at 10 L/min by face mask
C. Administer CO2 at 10 L/min by face mask
D. Administer Nubain
Answer: B. Administer O2 at 10 L/min by face mask
42. Regardless of who performs the physical assessment, the nurse must know normal versus
abnormal variations of the newborn. What is the difference between caput succedaneum and
cephalhematoma?
A. cephalhematoma crosses suture lines and is usually present at birth
B. Cephalhematoma does NOT cross suture lines and manifests a few hours after birth
C. Cephalhematoma: edema under scalp
D. Caput succedaneum: blood under the periosteum
Answer: B. Cephalhematoma does NOT cross suture lines and manifests a few hours after
birth
43. Postpartum blues are usually normal, especially 5 - 7 days after delivery. In what case is
RhoGAM given to a mother after delivery?
A. If mother is Rh positive
B. If mother is Rh negative
C. If the mother has a positive Coombs
D. If the mother has a Rh negative fetus
Answer: B. If mother is Rh negative
44. The umbilical cord should always be checked at birth. What should the umbilical cord
contain in a newborn?
A. 3 vessels, 2 veins which carry oxygenated blood to the fetus and 1 artery which carries
unoxygenated blood back to placenta
B. 4 vessels, 2 veins which carry oxygenated blood to the fetus and 2 arteries which carries
unoxygenated blood back to placenta
C. 3 vessels, 1 veins which carries oxygenated blood to the fetus and 2 arteries which carries
unoxygenated blood back to placenta
D. 3 vessels, 1 artery which carries oxygenated blood to the fetus and 2 veins which carries
unoxygenated blood back to placenta
Answer: C. 3 vessels, 1 veins which carries oxygenated blood to the fetus and 2 arteries which
carries unoxygenated blood back to placenta
45. The umbilical cord in a newborn should contain 3 vessels, 1 vein which carries oxygenated
blood to the fetus and 2 arteries which carry unoxygenated blood back to the placenta. What do
cord abnormalities usually indicate?
A. Neurologic anomalies
B. Renal anomalies
C. Congenital vertebral anomaly
D. Chromosome anomaly
Answer: B. Renal anomalies
46. Cord abnormalities usually indicate cardiovascular or renal anomalies. What happens if
fetal structures of foramen ovale, ductus arteriosus and ductus venous do no close postnatal?
A. Cardia pulmonary compromise
B. Renal compromise
C. Gastro intestinal compromise
D. Neurological compromise
Answer: A. Cardia pulmonary compromise
47. If the structures of the foramen ovale, ductus arteriosus and ductus venosus don't close
postnatally, cardiac, and pulmonary compromise will develop. What should be suctioned by the
nurse firstly?
A. Nose
B. Mouth
C. Lungs
D. Kidney
Answer: B. Mouth
48. Physiologic jaundice is the normal inability of the immature liver to keep up with normal
RBC destruction. When does jaundice occur in newborns?
A. 5-6 days of life
B. 2-3 days of life
C. 7-8 days of life
D. 9-10 days of life
Answer: B. 2-3 days of life
49. Physiologic jaundice (normal inability of the immature liver to keep up with normal RBC
destruction) occurs 2-3 days of life. When does jaundice become pathologic?
A. When it occurs before 24 hours or persists beyond 7 days
B. When it occurs before 14 hours or persists beyond 8 day
C. When it occurs before 12 hours or persists beyond 3 days
D. When it occurs before 10 hours or persists beyond 2 days
Answer: A. When it occurs before 24 hours or persists beyond 7 days
50. Physiologic jaundice which occurs 2-3 days after birth due to the liver's inability to keep up
with RBC destruction. Who is the culprit in this case?
A. Conjugated bilirubin
B. Unconjugated bilirubin
C. Unconjugated penile
D. Conjugated penile
Answer: B. Unconjugated bilirubin
51. A 7lb 8oz baby would need 50 calories x7lbs=350 calories plus 25 calories= 375 calories
per day. Taking into consideration that most infant formulas contain 20 calories/ ounce, how
many ounces of formula are needed per day?
A. 18.75
B. 14.75
C. 13.75
D. 16.75
Answer: A. 18.75
52. A nurse caring for a 7lb 8oz baby feeds him with 18.75 ounces of infant formula needed per
day. If every infant formula contains 20 calories/ounce, which is the total amount of calories a
baby needs per day?
A. 175 calories per day
B. 375 calories per day
C. 575 calories per day
D. 275 calories per day
Answer: C. 575 calories per day
53. A nurse should teach newbie parents to take both axillary and rectal temperature of the
child. How long should the thermometer be held in place if it is done rectally?
A. 2 minutes
B. 3 minutes
C. 4 minutes
D. 5 minutes
Answer: B. 3 minutes
54. A client with prior traumatic delivery and history of D&C may experience miscarriage or
preterm. What is the most common cause of miscarriages?
A. Incompetent cervix
B. Incompetent pelvis
C. Incompetent uterus
D. Incompetent vagina
Answer: A. Incompetent cervix
55. A woman of childbearing age present at an emergency room with unilateral and bilateral
abdominal pain. What should the nurse correctly suspect in this case?
A. Appendicitis
B. Ectopic pregnancy
C. Entopic pregnancy
D. Ectopic pregnancy
Answer: B. Ectopic pregnancy
56. The early decelerations in fetal heart rate monitoring are the transient decrease in heart rate
which coincides with the onset of the uterine contraction. Between what cm do the early
decelerations caused by head compression and fetal descent usually occur in the 2nd stage?
A. 2 and 6 cm
B. 4 and 7 cm
C. 3 and 8 cm
D. 7 and 10 cm
Answer: D. 7 and 10 cm
57. A nurse consults a mother and detects cord prolapse. How should the examiner position the
pregnant woman to relieve pressure on the cord?
A. Side lying position
B. Right side lying position
C. High Fowlers position
D. Knee chest position
Answer: D. Knee chest position
58. A nurse consults a pregnant mother and detects late decelerations which indicate
uteroplacental insufficiency. What conditions are late decelerations associated with?
A. Down Syndrome, AIDS, abruptio placentae
B. Post maturity, preeclampsia, diabetes mellitus, cardiac disease, and abruptio placentae
C. Autism, renal insufficiency, and cardiac disease
D. Kidney failure, cardiac disease, Digitalis toxicity
Answer: B. Post maturity, preeclampsia, diabetes mellitus, cardiac disease, and abruptio
placentae
59. At the examination of a expecting woman, the deceleration patterns are associated with
decreased or absent variability and tachycardia. What should be done immediately in this case?
A. Position the mother in High Fowlers position
B. Position the mother in knee chest position
C. Immediate intervention and fetal assessment
D. Spontaneous abortion
Answer: C. Immediate intervention and fetal assessment
60. Which of the following neonates is at highest risk for cold stress syndrome?
A. Infant of diabetic mother
B. Infant with Rh incompatibility
C. Postdates neonate
D. Down syndrome neonate
Answer: A. Infant of diabetic mother
61. Which of the following would lead the nurse to suspect cold stress syndrome in a newborn
with a temperature of 96.5 F?
A. Blood glucose of 50 mg/dL
B. Acrocyanosis
C. Tachypnea
D. Oxygen saturation of 96%
Answer: C. Tachypnea
62. Four babies are in the newborn nursery. The nurse pages the neonatologist to see the baby
who exhibits which of the following?
A. Intercostal retraction
B. Erythema toxicum
C. Pseudo strabismus
D. Vernix caseosa
Answer: A. Intercostal retraction
63. A baby is grunting in the neonatal nursery. Which of the following actions by the nurse is
appropriate?
A. Place pacifier in the baby's mouth
B. Check the babies diaper
C. Have the mother feed the baby
D. Assess the respiratory rate
Answer: D. Assess the respiratory rate
64. A 1 day old neonate, 32 weeks gestation, is in an overhead warmer. The nurse assesses the
morning axillary temperature as 96.9 F. Which of the following could explain this assessment
finding?
A. This is a normal temperature for a preterm neonate
B. Axillary temperatures are not valid for preterm babies
C. The supply of brown adipose tissue is incomplete
D. Conduction heat loss is pronounced in the baby
Answer: C. The supply of brown adipose tissue is incomplete
65. A 6 month old child developed kernicterus immediately after birth. Which of the following
test should be done to determine whether or not this child has developed and sequelae to the
illness?
A. Blood urea nitrogen and serum creatinine
B. Alkaline phosphatase and bilirubin
C. Hearing testing and vision assessment
D. Peak expiratory flow and blood gas assessments
Answer: C. Hearing testing and vision assessment
66. A baby with hemolytic jaundice is being treated with fluorescent phototherapy. To provide
safe newborn care, which of the following actions should the nurse perform?
A. Cover the baby's eyes with eye pads
B. Turn the lights on for ten minutes every hour
C. Clothe the baby in a shirt and diaper only
D. Tightly swaddle the baby in a baby blanket
Answer: A. Cover the baby's eyes with eye pads
67. A baby is born with erythroblastosis fetalis. Which of the following signs/symptoms would
the nurse expect to see?
A. Ruddy complexion
B. Anasarca
C. Alopecia
D. Erythema toxicum
Answer: B. Anasarca
68. Which of the following laboratory findings would the nurse expect to see in a baby
diagnosed with erythroblastosis fetalis?
A. Hematocrit 24%
B. Leukocyte count 45,000 cells/mm
C. Sodium 125 mEq/L
D. Potassium 5.5 mEq/L
Answer: B. Leukocyte count 45,000 cells/mm
69. A baby's blood type is B negative. The baby is at risk for hemolytic jaundice if the mother
has which of the following blood types?
A. Type O negative
B. Type A negative
C. Type B positive
D. Type AB positive
Answer: D. Type AB positive
70. A baby, born at 3,199 grams, now weighs 2,746 grams. The baby is being monitored for
dehydration because of the following percent weight loss? (calculate to the nearest hundredth)
_________________%
Answer: 14.16%
71. A baby exhibits weak rooting and sucking reflexes. Which of the following nursing
diagnoses would be appropriate?
A. Risk for deficient fluid volume
B. Activity intolerance
C. Risk for aspiration
D. Feeding self-care deficit
Answer: A. Risk for deficient fluid volume
72. The macrosomic baby in the nursery is suspected of having a fractured clavicle from a
traumatic delivery. Which of the following signs/symptoms would the nurse expect to see?
(Select all the apply)
A. Pain with movement
B. Hard lump at the fracture site
C. Malpositioning of the arm
D. Asymmetrical Moro reflex
E. Marked localized ecchymosis
Answer: A. Pain with movement
B. Hard lump at the fracture site
C. Malpositioning of the arm
D. Asymmetrical Moro reflex
73. Four babies in the well baby nursery were born with congenital defects. Which of the
babies' complications developed as a result of the delivery method?
A. Clubfoot
B. Brachial palsy
C. Gastroschisis
D. Hydrocele
Answer: B. Brachial palsy
74. A nurse working with a 24 hour old neonate is the well-baby nursery has made the
following nursing diagnosis: Risk for altered growth. Which of the following assessments
would warrant this diagnosis?
A. The baby has lost 8% of weight since birth
B. The baby has not urinated since birth
C. The baby weighed 3,000 grams at birth
D. The baby exhibited signs of torticollis
Answer: A. The baby has lost 8% of weight since birth
75. The nurse is caring for an infant with congenital cardiac defect, she is monitoring the child
for which of the following early signs of congestive heart failure? (Select all that apply)
A. Palpitation
B. Tachypnea
C. Tachycardia
D. Diaphoresis
E. Irritability
Answer: B. Tachypnea
C. Tachycardia
D. Diaphoresis
E. Irritability
76. A baby, admitted to the nursery, was diagnosed with galactosemia from an amniocentesis.
Which of the following actions must the nurse take?
A. Feed the baby a specialty formula
B. Monitor the baby for central cyanosis
C. Do hemoccult testing on every stool
D. Monitor the baby for signs of abdominal pain
Answer: A. Feed the baby a specialty formula
77. A neonate is in the warming crib for poor thermoregulation. Which of the following sites is
appropriate for the placement of the skin thermal sensor?
A. Xiphoid process
B. Forehead
C. Abdominal Wall
D. Great toe
Answer: C. Abdominal Wall
78. A full term infant admitted to the newborn nursery has a blood glucose level of 35 mg/ dL.
The nurse should monitor this baby carefully for which of the following?
A. Jaundice
B. Jitters
C. Erythema toxicum
D. Subconjunctival hemorrhages
Answer: B. Jitters
79. A jaundice neonate must have a heel stick to assess bilirubin levels. Which of the following
actions should the nurse make during the procedure?
A. Cover the foot with an iced wrap for one minute prior to the procedure
B. Avoid puncturing the lateral heel to prevent damaging sensitive structures
C. Blot the site with a dry gauze after rubbing it with an alcohol swab
D. Firmly grasp the calf of the baby during the procedure to prevent injury
Answer: B. Avoid puncturing the lateral heel to prevent damaging sensitive structures
80. A newborn admitted to the nursery has a positive direct Coombs' test. Which of the
following is an appropriate action by the nurse?
A. Monitor the baby for jitters
B. Assess the blood glucose level
C. Assess the rectal temperature
D. Monitor the baby for jaundice
Answer: D. Monitor the baby for jaundice
81. An 18 hour old baby is placed under the bili lights with an elevated bilirubin level. Which
of the following is an expected nursing action in these circumstances?
A. Give the baby oral rehydration therapy after all feedings
B. Rotate the baby from side to back to side to front every two hours
C. Apply restraints to keep the baby under the light source
D. Administer intravenous fluids via pump per doctor orders
Answer: B. Rotate the baby from side to back to side to front every two hours
82. A nurse makes the following observations when admitting a full term, breastfeeding baby,
into the neonatal nursery: 9lb 2 oz, 21 inches long, TPR: 96.6 F, 158,62, jittery, pink body with
bluish hands and feet, crying. Which of the following actions is of highest probability?
A. Swaddle the baby to provide warmth
B. Assess the glucose level of the baby
C. Take the baby to the mother for feeding
D. Administer the neonatal medications
Answer: B. Assess the glucose level of the baby
83. During cardiopulmonary resuscitation, which of the following actions should be
performed?
A. Provide assisted ventilation at 40 to 60 breaths per minute
B. Begin chest compressions when heart rate is 0 to 20 bpm
C. Compress the chest using the three finger technique
D. Administer compressions and breaths in a 5:1 ratio
Answer: A. Provide assisted ventilation at 40 to 60 breaths per minute
84. A baby has been admitted to the neonatal intensive care unit with a diagnosis of post
maturity. The nurse expects to find which of the following during the initial newborn
assessment?
A. Abundant lanugo
B. Flat breast tissue
C. Prominent clitoris
D. Wrinkled skin
Answer: D. Wrinkled skin
85. A baby has been admitted to the neonatal nursery whose mother is hepatitis B surface
antigen positive. Which of the following actions by the nurse should be taken at this time?
A. Monitor the baby for signs of hepatitis B
B. Place the baby on contact isolation
C. Obtain an order for the hepatitis B vaccine and the immune globulin
D. Advise the mother that breast feeding is absolutely contraindicated
Answer: C. Obtain an order for the hepatitis B vaccine and the immune globulin
86. A baby is suspected of having esophageal atresia. The nurse would expect to see which of
the following signs/symptoms? (Select all that apply)
A. Frequent vomiting
B. Excessive mucus
C. Ruddy complexion
D. Abdominal distention
E. Pigeon chest
Answer: A. Frequent vomiting
B. Excessive mucus
D. Abdominal distention
87. A fetus is in the LOA position in utero. Which of the following findings would the nurse
observe when doing Leopold's maneuvers?
A. Hard, round object in the fundal region
B. Flat object above the symphysis pubis
C. Soft, round object on the left side of the uterus
D. Small objects on the right side of the uterus
Answer: C. Soft, round object on the left side of the uterus
88. A woman is being interviewed by a triage nurse at a medical doctor's office. Which of the
following signs/symptoms by the client would warrant the nurse to suggest that a pregnancy
test be done? (Select all that apply)
A. Amenorrhea
B. Fever
C. Fatigue
D. Nausea
E. Dysuria
Answer: A. Amenorrhea
C. Fatigue
D. Nausea
89. The nurse is caring for a client, 37 weeks gestation, who was just told that she is group B
strep positive. The client states, "How could that happen? I only have sex with my husband.
Will my baby be OK?" Based on this information, which of the following should the nurse
communicate to the client?
A. The client's partner must have acquired the bacteria during a sexual encounter
B. The bacteria do not injure babies, but they could cause the client to have a bad sore throat
C. The client is high risk for developing pelvic inflammatory disease from the bacteria
D. Antibiotics will be administered during labor to prevent vertical transmission of the bacteria
Answer: D. Antibiotics will be administered during labor to prevent vertical transmission of
the bacteria
90. The nurse is caring for a client in labor and delivery with the following history: G2 P1, 39
weeks gestation in transition phase, FH 135 with the early decelerations. The client states, I'm
so scared. Please make sure the baby is OK!" Which of the following responses by the nurse is
appropriate?
A. There is absolutely nothing to worry about
B. The fetal heart rate is within normal limits
C. How did your first baby die
D. Was your first baby preterm
Answer: B. The fetal heart rate is within normal limits
91. A woman is seeking counseling regarding tubal ligation. Which of the following should the
nurse include in her discussion?
A. The woman will no longer menstruate
B. The surgery should be done when the woman is ovulating
C. The surgery is easily reversible
D. The woman will be under anesthesia during the procedure
Answer: D. The woman will be under anesthesia during the procedure
92. A woman is admitted to the labor and delivery unit with active TB. She has not been under
a physician's care and is not on medication. Which of the following actions should the nursery
nurse perform when the neonate is delivered?
A. Isolate the baby from the other babies is a special care nursery
B. Keep the baby in the regular care nursery but separated from the mother
C. Isolate the baby with the mother in the mother's room
D. Obtain an order from the doctor for antituberculosis medications for the baby
Answer: A. Isolate the baby from the other babies is a special care nursery
93. A client has just received synthetic prostaglandins for the induction of labor. The nurse
plans to monitor the client for which of the following side effects?
A. Nausea and uterine tetany
B. Hypertension and vaginal bleeding
C. Urinary retention and severe headache
D. Bradycardia and hypothermia
Answer: A. Nausea and uterine tetany
94. The triage nurse in an obstetric clinic received the following four messages during the
lunch hour. Which of the woman should the nurse telephone first?
A. " My section incision from last week is leaking a whitish yellow discharge and I have a
fever. What should I do?"
B. " I am 39 weeks pregnant with my first baby. I am having contractions about every 10
minutes."
C. " My boyfriend and I had intercourse this morning and our condom broke. What should we
do?"
D. " I started my period yesterday. I need some medicine for these terrible menstrual cramps."
Answer: A. " My section incision from last week is leaking a whitish yellow discharge and I
have a fever. What should I do?"
95. A patient is placed on bed rest at home for mild preeclampsia at 38 weeks gestation. Which
of the following must the nurse teach the patient regarding her condition?
A. Eat a sodium restricted diet
B. Check her temperature 4 times daily
C. Report swollen hand and face
D. Limit fluids to 1 liter per day
Answer: C. Report swollen hand and face
96. The umbilical cord is being clamped by the obstetrician. Which of the following
physiological changes is taking place at this time?
A. The baby’s' blood bypasses its pulmonary system
B. The baby’s oxygen level begins to drop
C. Bacteria begin to invade the baby’s bowel
D. Bilirubin rises in the baby’s bloodstream
Answer: B. The baby’s oxygen level begins to drop
97. A nurse has just received report on 4 neonates in the newborn nursery. Which of the babies
should the nurse assess first?
A. Neonate whose mother is HIV positive
B. Neonates whose mother is group B streptococcus positive
C. Neonates whose mother's labor was 12 hours long
D. Neonates whose mother gained 45 pounds during her pregnancy
Answer: B. Neonates whose mother is group B streptococcus positive
98. A woman who states she smokes 2 pack of cigarettes each day is admitted to the labor and
delivery suite in labor. The nurse should monitor this labor for which of the following?
A. Delayed placental separation
B. Late decelerations
C. Shoulder dystocia
D. Precipitous fetal descent
Answer: B. Late decelerations
99. A client who is 18 weeks gestation has been diagnosed with hydatidiform mole (gestational
trophoblastic disease). In addition to vaginal loss, which of the following signs/symptoms
would the nurse expect to see?
A. Hyperemesis and hypertension
B. Diarrhea and hyperthermia
C. Polycythemia
D. Polydipsia
Answer: A. Hyperemesis and hypertension
100. A client with type 1 diabetes mellitus is 6 weeks pregnant. Her fasting glucose and
hemoglobin A1c are noted to be 168 mg/dL and 12%, respectively. Which of the following
nursing diagnoses is appropriate for the nurse to make at this time?
A. Altered maternal skin integrity
B. Deficient maternal fluid volume
C. Risk for fetal injury
D. Fetal urinary retention
Answer: C. Risk for fetal injury
101. A nurse who has just performed a vaginal examination notes that the fetus is in the LOP
position. Which of the following clinical assessments would the nurse expect to note at this
time?
A. Complaints of severe back pain
B. Rapid descent and effacement
C. Irregular and hypotonic contractions
D. Rectal pressure with blood show
Answer: A. Complaints of severe back pain
102. A 3-month-old infant develops oral thrush. Which pharmacologic agent should the nurse
plan to administer for treatment of this disorder?
Answer: Nystatin
103. The nurse is teaching the parents of a 5-year-old child with cystic fibrosis about
respiratory treatments. Which statement indicates to the nurse that the parents understand?
A. Perform postural drainage before starting the aerosol therapy.
B. Give respiratory treatments when the child is coughing a lot.
C. Administer aerosol therapy followed by postural drainage before meals.
D. Ensure respiratory therapy is done daily during any respiratory infection.
Answer: A. Perform postural drainage before starting the aerosol therapy.
104. The mother of a preschool-aged child asks the nurse if it is all right to administer bismuth
subsalicylate (Pepto Bismol, Bismylate) to her son when he "has a tummy ache." After
reminding the mother to check the label of all over-the-counter drugs for the presence of
aspirin, which instruction should the nurse include when replying to this mother's question?
A. If the child's tongue darkens, discontinue the Pepto Bismol immediately.
B. Do not give if the child has chickenpox, the flu, or any other viral illness.
C. Avoid the use of Pepto Bismol until the child is at least 16 years old.
D. Pepto Bismol may cause a rebound hyperacidity, worsening
Answer: B. Do not give if the child has chickenpox, the flu, or any other viral illness.
105. The nurse is assessing an 8-month-old child who has a medical diagnosis of Tetralogy of
Fallot. Which symptom is this client most likely to exhibit?
A. Bradycardia
B. Machinery murmur
C. Weak pedal pulses
D. Clubbed fingers
Answer: D. Clubbed fingers
106. During routine screening at a school clinic, an otoscope examination of a child's ear
reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable.
What action should the nurse take next?
A. No action required, as this is an expected finding for a school-aged child.
B. Ask the child if he/she has had a cold, runny nose, or any ear pain lately.
C. Send a note home advising the parents to have the child evaluated by a healthcare provider
as soon as possible.
D. Call the parents and have them take the child home from school for the rest of the day.
Answer: B. Ask the child if he/she has had a cold, runny nose, or any ear pain lately.
107. A female teenager is taking oral tetracycline HCL (Achromycin V) for acne vulgaris. What
is the most important instruction for the nurse to include in this client's teaching plan?
A. "Use sunscreen when lying by the pool."
B. "Cleanse the skin at least 4 times a day."
C. "Take the medication with a glass of milk."
D. "Menstrual periods may become irregular."
Answer: A. "Use sunscreen when lying by the pool."
108. At 8 a.m. the unlicensed assistive personnel (UAP) informs the charge nurse that a female
adolescent client with acute glomerulonephritis has a blood pressure of 210/110. The 4 a.m.
blood pressure reading was 170/88. The client reports to the UAP that she is upset because her
boyfriend did not visit last night. What action should the nurse take first?
A. Give the client her 9 a.m. prescription for an oral diuretic early.
B. Administer PRN prescription of nifedipine (Procardia) sublingually.
C. Notify the healthcare provider and inform the nursing supervisor of the client's condition.
D. Attempt to calm the client and retake the blood pressure in thirty minutes.
Answer: C. Notify the healthcare provider and inform the nursing supervisor of the client's
condition.
109. The nurse is assessing a 2-year-old. What behavior indicates that the child's language
development is within normal limits?
A. Is able to name four colors.
B. Can count five blocks.
C. Is capable of making a three word sentence.
D. Half of child's speech is understandable.
Answer: D. Half of child's speech is understandable.
110. During discharge teaching of a child with juvenile rheumatoid arthritis, the nurse should
stress to the parents the importance of obtaining which diagnostic testing?
A. Hearing tests
B. Eye exams
C. CXR
D. Fasting blood glucose tests
Answer: B. Eye exams
111. The nurse is teaching a 12-year-old male adolescent and his family about taking injections
of growth hormone for idiopathic hypopituitarism. Which adverse symptoms, commonly
associated with growth hormone therapy, should the nurse plan to describe to the child and his
family?
A. Polyuria and polydipsia
B. Lethargy and fatigue
C. Increased facial hair
D. Facial bone structure changes
Answer: A. Polyuria and polydipsia
112. A 17-year-old male student reports to the school clinic one morning for a scheduled health
exam. He tells the nurse that he just finished football practice and is on his way to class. The
nurse assesses his vital signs: temperature 100 F, pulse 80, respirations 20, and blood pressure
122/82. What is the best action for the nurse to take?
A. Tell the student to proceed directly to the regularly scheduled class.
B. Call the parent and suggest re-taking the student's temperature at home.
C. Give the student a glass of cool fluids, then retake his temperature.
D. Send the student to class but re-verify his temperature after lunch.
Answer: C. Give the student a glass of cool fluids, then retake his temperature.
113. A 3-week-old newborn is brought to the clinic for follow-up after a home birth. The
mother reports that her child bottle feeds for 5 minutes only and then falls asleep. The nurse
auscultates a loud murmur characteristic of a ventricular septal defect (VSD), and finds the
newborn is acyanotic with a respiratory rate of 64 breaths per minute. What instruction should
the nurse provide the mother to ensure the infant is receiving adequate intake? (Select all that
apply.)
A. Monitor the infant's weight and number of wet diapers per day.
B. Increase the infant's intake per feeding by 1 to 2 ounces per week.
C. Mix the dose of prophylactic antibiotic in a full bottle of formula.
D. Allow the infant to rest and refeed on demand or every 2 hours.
E. Use a softer nipple or increase the size of the nipple opening.
Answer: A. Monitor the infant's weight and number of wet diapers per day.
114. A 14-year-old female client tells the nurse that she is concerned about the acne she has
recently developed. Which recommendation should the nurse provide?
A. Remove all blackheads and follow with an alcohol scrub.
B. Use medicated cosmetics only to help hide the blemishes.
C. Wash the hair and skin frequently with soap and hot water.
D. Encourage her to see a dermatologist as soon as possible.
Answer: D. Encourage her to see a dermatologist as soon as possible.
115. A 4-year-old girl continues to interrupt her mother during a routine clinic visit. The mother
appears irritated with the child and asks the nurse, "Is this normal behavior for a child this
age?" The nurse's response should be based on which information?
A. Children need to retain a sense of initiative without impinging on the rights and privileges of
others.
B. Negative feelings of doubt and shame are characteristic of 4-year-old children.
C. Role conflict is a common problem of children this age. She is just wondering where she fits
into society.
D. At this age children compete and like to produce and carry through with tasks. She is just
competing with her mother.
Answer: A. Children need to retain a sense of initiative without impinging on the rights and
privileges of others.
116. Which measurements should be used to accurately calculate a pediatric medication
dosage? (Select all that apply)
A. child's height and weight
B. adult dosage of medication
C. body surface area of child
D. average adult's body surface area
E. average pediatric dosage of medication
F. nomogram determined mathematical constant.
Answer: A. child's height and weight
C. body surface area of child
117. The nurse is assessing the neurovascular status of a child in Russell's traction. Which
finding should the nurse report to the healthcare provider?
A. pale bluish coloration of the toes
B. skin is warm and dry to the touch
C. toes are wiggled upon command
D. capillary refill less than 3 seconds
Answer: A. pale bluish coloration of the toes
118. The nurse is teaching a mother to give 4 mL of liquid antibiotic to a 10 month old infant.
Which statement by the parent indicates a need for further teaching?
A. I will give this antibiotic to my child until it is finished
B. using a teaspoon will help me measure this correctly.
C. I will call the clinic if my child develops a rash or itching
D. my baby should begin to feel better within a few days
Answer: B. using a teaspoon will help me measure this correctly.
119. A child falls on the playground and is brought to the school nurse with a small laceration
on the forearm. Which action should the nurse implement first?
A. slowly pour hydrogen peroxide over the open wound
B. apply ice to the area before rinsing with cold water
C. wash the wound gently with mild soap and water
D. gently cleanse with a sterile pad using povidone-iodine
Answer: C. wash the wound gently with mild soap and water
120. A 4-year old boy was admitted to the emergency room with a fractured right ulna and a
short arm cast was applied. When preparing the parents to take the child home, which discharge
instruction has the highest priority?
A. call the healthcare provider immediately if his nail beds appear blue.
B. check his fingers hourly for the first 48 hours to see that he is able to move them without
pain.
C. Be sure your child's arm remains above his heart for the first 24 hours.
D. Take his temperature every four hours for the next two days and call if an elevation is noted.
Answer: A. call the healthcare provider immediately if his nail beds appear blue.
121. Preoperative nursing care for a child with Wilms’s tumor should include which
intervention?
A. gently percuss the abdomen for evidence of trapped air
B. observe the abdomen for any noticeable discolorations
C. apply cold compresses to the abdomen to reduce edema
D. Put a sign on the bed reading, "DO NOT PALPATE ABDOMEN."
Answer: D. Put a sign on the bed reading, "DO NOT PALPATE ABDOMEN."
122. The mother of a 6-month old asks the nurse when her baby will get the first measles,
mumps, and rubella (MMR) vaccine. Based on the recommended childhood immunization
schedule published by the Centers for Disease Control, which response is accurate?
A. 3-6 months
B. 12-15 months
C. 18-24 months
D. 4-6 years
Answer: B. 12-15 months
123. Which menu selection by a child with celiac disease indicates to the nurse that the child
understands necessary dietary considerations?
A. oven-baked potato chips and cola.
B. peanut butter and banana sandwich
C. oatmeal-raisin cookies and milk
D. graham crackers and fruit juice
Answer: A. oven-baked potato chips and cola.
124. A three-month old boy weighing 10 lbs, 15 oz has an axillary temperature of 98.9 degrees
F. The nurse determines the daily caloric need for this child is approximately:
A. 400 cal/day
B. 500 cal/day
C. 600 cal/day
D. 700 cal/day
Answer: C. 600 cal/day
125. The nurse is giving preoperative instructions to a 14-year old female client who is
scheduled for surgery to correct a spinal curvature. Which statement by the client best
demonstrates that learning has taken place?
A. I will read all the literature you gave me before surgery.
B. I have had surgery before when I broke my wrist in a bike accident, so I know what to
expect.
C. All the things people have told me will help me take care of my back.
D. I understand that I will be in a body cast and I will show you how you taught me to turn.
Answer: D. I understand that I will be in a body cast and I will show you how you taught me
to turn.
126. The nurse is giving an intramuscular injection of an antibiotic to a 16-month toddler with
pneumonia. The toddler does not have any known allergies and has been walking without
assistance for one-month, Which technique should the nurse select for administration?
A. Used a needle length of ½ inch to avoid deep tissue damage
B. Administer the injection into the middle of the lateral aspect of the thigh
C. Give in the arm, one to 2 inches below the acromion process
D. Divide the gluteal area into quarters and give IM into the upper outer quadrant
Answer: B. Administer the injection into the middle of the lateral aspect of the thigh
127. The nurse is performing a routine assessment of a 3-year-old at a community health center.
Which behavior by the child should alert the nurse to request a follow-up for possible autistic
spectrum disorder (ASD)?
A. Performs odd repetitive behaviors
B. Strokes the hair of a handheld doll
C. Has a history of temper tantrums
D. Shows indifference to verbal stimulation
Answer: D. Shows indifference to verbal stimulation
128. The parents of a 3-year-old boy who has Duchenne muscular dystrophy (DMD) asks, "
How can our son have this disease? We are wondering if we should have any more children."
Which information should the nurse provide to these parents?
A. The striated muscle group of males can be impacted by a lack of the protein dystrophin in
their mothers
B. Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening
the muscles
C. The male infant had a viral infection that went unnoticed and untreated, so muscle damage
was incurred
D. This is an inherited X- Linked recessive disorder, which primarily affects male children in
the family
Answer: D. This is an inherited X- Linked recessive disorder, which primarily affects male
children in the family
129. A male infant is admitted to the pediatric unit with pertussis and is exhibiting a
"whooping-like-cough." The mother brings the infant to the nurse's station to seek assistance.
Which intervention should the nurse implement first?
A. Explain the need to maintain droplet precautions to prevent spread to others on the unit
B. Give the infant an oral dose of a prescribed antitussive and analgesic/antipyretic
C. Cover the infant's mouth and assist the mother to take the infant back to the room
D. Ask the mother if a cool mist humidifier at the bedside is functioning and releasing mist
Answer: A. Explain the need to maintain droplet precautions to prevent spread to others on the
unit
130. The nurse knows that teaching has been successful when the parent of a child with muscle
weakness states that the diagnostic test for muscular dystrophy is which of the following?
A. Electromyelogram.
B. Nerve conduction velocity.
C. Muscle biopsy.
D. Creatine kinase level.
Answer: D. Creatine kinase level.
131. Which should a nurse in the ED be prepared for in a child with a possible spinal cord
injury?
A. Severe pain.
B. Elevated temperature.
C. Respiratory depression.
D. Increased intracranial pressure
Answer: C. Respiratory depression.
132. The nurse evaluates the teaching as successful when a parent states that which of the
following can cause autonomic dysreflexia?
A. Exposure to cold temperatures.
B. Distended bowel or bladder.
C. Bradycardia.
D. Headache.
Answer: B. Distended bowel or bladder.
133. An adolescent with a T4 spinal cord injury suddenly becomes dangerously hypertensive
and bradycardic. Which intervention is appropriate?
A. Call the neurosurgeon immediately, as this sounds like sudden intracranial hypertension.
B. Check to be certain that the patient's bladder is not distended.
C. Administer Hyperstat to treat the blood pressure.
D. Administer atropine for bradycardia.
Answer: B. Check to be certain that the patient's bladder is not distended.
134. The nurse is planning care for a child with a T12 spinal cord injury. Which lifelong
complications should the child and family know about? (Select all that apply.)
A. Skin integrity.
B. Incontinence.
C. Loss of large and small motor activity.
D. Loss of voice.
E. Flaccid paralysis.
Answer: A. Skin integrity.
B. Incontinence.
135. Which should the nurse expect in a 2-week-old with a brachial plexus injury? (Select all
that apply.)
A. History of a normal vaginal delivery.
B. Small infant.
C. Absent Moro reflex on one side.
D. No sensory loss.
E. Associated clavicle fracture.
Answer: C. Absent Moro reflex on one side.
E. Associated clavicle fracture.
136. Causes of autonomic dysreflexia include which of the following? (Select all that apply.)
A. Decrease in blood pressure.
B. Abdominal distention.
C. Bladder distention.
D. Diarrhea.
E. Tight clothing.
F. Hypothermia.
Answer: B. Abdominal distention.
C. Bladder distention.
E. Tight clothing.
