Maternal and Child Health Nursing 6

Situation 1. Three- month- old Terry Pane, who has history of diarrhea of 36 hours duration, is admitted to the pediatric unit. He is diagnosed as having gastroenteritis and dehydration. Terry is placed on enteric precautions.

1.

a. b. c. d.

In assessing the infant with diarrhea, the nurse should expect to find: Resilient skin turgor A bulging fontanel Marked restlessness Decreased urinary output

2. When assessing Terry, the nurse would expect to find a: a. Specific gravity of 1.014 b. Urinary output of 50 ml/hour c. Depressed anterior fontanel d. History of allergies to various foods

3. The nurse understands that the magnitude of Terrys fluid loss is best ascertained by: a. Comparing his pre-illness weight with current weight. b. Noting the elevation of his hematocrit level. c. Evaluating his skin turgor carefully. d. Assessing the moistness of his mucous membranes.

4. The physician orders ORS 150 ml per kg of body weight per 24 hours for Terry , who weighs 13 pounds. The nurse is aware that Terrys intake of ORS should be: a. 500 ml/24 hr b. 750 ml/24 hr c. 885 ml/24 hr d. 965 ml/24 hr

5. Terry is receiving IV fluids via a scalp vein. The nurse should: a. Check his pupils for reaction every hour. b. Observe behind his ear and inspect for infiltration. c. Explain to the parents why they cannot hold him now. d. Restrain Terrys arms & legs while not with him.

6. Mr. and Mrs. Pane want to be involved with Terrys care. The nurse realizes that they understand the teaching about the maintenance of enteric precautions when they state, We should: a. wear a mask when we are holding Terry. b. close the door of his room most of the time. c. wear gloves each time we change his diaper. d. weigh his diaper each time we change him.

7. The best method of assessing Terrys reaponse to treatment for dehydration is for the nurse to: a. Measure his abdominal girth. b. Weigh him at the same time daily. c. Assess the color of his stools. d. Monitor his skin turgor frequently.

8. Once the severe effects of dehydration are under control, the physician orders Lactinex granules (lactobacilli) to: a. Recolonize the normal flora of the gastrointestinal tract. b. Relieve the pain of gas in the gastrointestinal tract. c. Relieve the pain caused by gastric hyperactivity. d. Diminish inflammatory mucosal edema.

9. As 3-month-old Terry responds to therapy and shows an interest in playing, the nurse appropriately provides him with a: a. Push-pull toy b. Stuffed animals c. Large plastic ball d. Metallic mirror

10. Diarrheal disease is a major cause of mortality in the Philippines. Among children under the age of five, it is a major cause of illness and death. In view of this, the DOH launched a national program known as: a. ORS b. CDD c. VAD d. IDD

Situation 2. Daniel James is admitted to the nursery from the delivery room after a difficult delivery.

11. As the nurse examines Daniel, a positive ortolanis sign is detected. This is indicated by: a. A broadening of the perineum b. An apparent shortening of one leg c. An audible click on hip manipulation d. A unilateral droop of the hip

12. Daniel has congenital jip dysplasia. Daniel is discharged the nurse should teach Mr. and Mrs. James that hip dysplacia could be avoided if Daniel is: a. Tightly swaddled in blankets. b. Carried straddling the hip. c. Periodically strapped to a cradleboard. d. Placed in an infant seat on a set schedule.

13. When Daniel is 6 months old, he is placed in a hip spica cast for the treatment of the congenital hip dysplasia. In planning home care with Mr. and Mrs. James, the nurse should assess that: a. No special precautions will be necessary when diapering him. b. The entire cast should be wrapped in plastic wrap to prevent it from spoiling. c. The edges of the cast in the perineal area should be covered with plastic wrap. d. Baby oil and powder should be used liberally around the diaper rash.

14. At 18 month sof age when Daniel visits the clinic, it is discovered that he is anemic. Considering his diagnosis, age, and dietary needs, the nurse should suggest that Mrs. James feed him: a. Bread pudding with raisins b. Fresh seedless grapes c. A slice of pumpkin pie d. An entire slice of apple

15. This refers to a diet that contains all the nutrients and other substances found naturally in food, in proper amounts and proportion needed by the body to function well. a. Regular diet. b. Bland diet. c. Diabetic diet. d. Balanced diet.

Situation 3. Ronald Taft, 1 month old, is admitted to the hospital with diagnosis of hydrocephalus. 16. Because of the admission diagnosis, the abnormal finding the nurse would expect to observe during assessment of Ronald would be that: a. He is unable to support his head and shoulders while prone. b. His anterior fontanel is tense on palpation. c. His head circumference is larger than his chest circumference. d. He demonstrates poor eye-muscle coordination.

17. Ronald is scheduled for surgery and VP shunt is to be inserted. A short-term preoperative goal for Ronald would be to: a. Keep him as comfortable as possible to limit crying. b. Establish and maintain a strict fixed feeding schedule to ensure hydration. c. Use a thick head bandage to protect his head from injury. d. Provide a wide variety of play objects to maintain age-appropriate ion.stimulat

18. Preoperatively, after teaching Mr. and Mrs. Taft, the nurse can evaluate their understanding of the immediate postoperative positioning when they state, We will avoid putting pressure on Ronalds valve site by positioning him: a. In the position that provides him the most comfort. b. On his back with a small support beneath his neck. c. Flat with a small support against the right side of his head and back. d. On his abdomen with a small support against the left side of his head,

19. On the day after surgery, Ronalds temperature rises to 103F. The nurse should first notify the physician and then: a. Recheck the temperature 12 hours. b. Record the temperature on Ronalds chart. c. Remove any excess clothing from Ronald. d. Sponge Ronald with tepid alcohol.

Situation 4. John Lemel, 4 years old, is admitted to pediatric unit with nephrotic syndrome. His parents, Ida and Henry Lemel, are with him.
20. On Johns admission, the nurse should assess for: a. Flushed, ruddy complexion b. Dark frothy urine output c. Severe lethargy d. Chronic hypertension

21. When admitting John, the nurse assigns him to a room with a: a. 2-year-old boy with croup b. 3-year-old boy with impetigo c. 4-year-old boy with conjunctivitis d. 5-year-old boy with fractured femur

22. When planning care for John, the nurse includes: a. A diet low in carbohydrates and protein b. Restriction of fluids to 500 ml each shift c. Provision of meticulous skin care d. A lab test for blood type and cross match

23. The nurse realizes that Mr. and Mrs. Lemel need further instruction for discharge when they state: a. We know we need to test Johns eyelids every morning. b. We will look at Johns eyelids every morning. c. We will ignore any weight gain of Johns since it is normal. d. We will give John his prednisone with mea;s or milk.

24. The nurse has been teaching Mr. and Mrs. Lemel about urine testing at home. The statement by them that alerts the nurse to the fact that the teaching has been effective is: a. We will discard the first urine before we test for acetone. b. John is old enough to learn how to test his own urine. c. We should notify the doctor if there is protein in the urine. d. We realize his urine will show a false positive if it is cloudy.

25. A few years later, John, who has chronic renal failure, is admitted to the hospital critically ill. John develops Cheyne-Stokes respirations and the nurse suspects an increasing acid-base balance related to: a. Respiratory alkalosis from over breathing and excess carbon dioxide output b. Metabolic alkalosis from an increase in base bicarbonate due to his primary health problem c. Respiratory acidosis from impeded breathing and the retention of the CO2. d. Metabolic acidosis from the concentration of cations in body fluids, which displace bicarbonate.

Situation 5. Eric Santos, 18 months old, suddenly develops a left earache, slight nasal congestion, and high fever. At the pediatricians office his parents, Elisa and Allen Santos, are informed that for the 2nd time their son has developed a middle ear infection.

26. The nurse knows that among infants and children otitis media is considered the most common: a. Bacterial infection b. Rickettsial infection c. Fungal infection d. Viral infection

27. Mr. and Mrs. Santos are anxious to know why Eric has another episode of suppurative otitis media. In replying the nurse should explain the: a. Functional difference between an infants eustachian tube and that of an older child. b. Difference between the size of the middle ear cavity in infants and older children. c. Structural difference between the Eustachian tube younger and older children. d. Immunologic difference between the young child and the adult.

28. The most important nursing responsibility during the myringotomy procedure is to: a. Have his mother stay and hold Eric in her arms. b. Keep Eric restrained and completely immobilized. c. Collect the aspirated drainage in a culture tube. d. Maintain the continuous flow of local anesthetic.

29. To help Mrs. Santos promote the effectiveness of Erics myringotomy, the nurse should suggest that Mrs. Santos: a. Position Eric with his affected ear down. b. Keep Eric flat on his back. c. Position Eric with his affected ear uppermost. d. Observe Eric for bleeding from operative site.

30. The nurse discusses the expected effects of myringotomy and local manifestation of complications with Mr. and Mrs. Santos. The occurrences that should be reported at once are: a. Mild or moderate hearing loss b. Lack of drainage and increased pain c. Bleeding and diminished pain. d. Low-grade temperature and headache.

Situation 6: Kent 2 years old, has a fractured femur and is in Bryants traction. 31. After giving him morning care, the nurse checks the traction to be sure that the hip angle is maintained at: a. 45 degrees b. 60 degrees c. 90 degrees d. 180 degrees

32. Nursing care specific for a child in Bryants traction should include: a. Checking the sites of pins for bleeding or infection. b. Applying topical or antibiotic ointments as ordered. c. Assessing that the elastic bandages daily to the lubricate the skin. d. Removing the bandages daily to lubricate the skin.

Situation 7. Regina Velasquez brings her 2-yearold son, Alvin to the pediatric clinic because he has been irritable, lethargic, and pale. He has had abdominal cramps and vomited this morning. After a thorough physical examination, Alvin is admitted to the pediatric unit with lead poisoning (plumbism).

33. The nurse should be aware that a high level of lead in the blood leads to: a. Marked anemia b. Increased urination c. Severe malnutrition d. Liver damage

34. developmentally, young children such as Alvin are at risk for lead poisoning primarily: a. Their vascular system is very fragile. b. They have a high level of oral activity. c. Lead is easily available to them. d. Motor vehicle pollution has increased.

35. The nursing diagnosis that is used most commonly with children with lead poisoning is: a. Potential for injury b. Alteration in nutrition c. Alteration in comfort d. Unilateral neglect

Situation 8: Janet Lee is a nurse who works in the teenage clinic of a large county hospital. Ms. Lee is aware that during the adolescent period there may be sexual experimentation.

36. One day, 16-year-old Martin Agustin comes to the clinic with a complaint of a thick urethral discharge. To confirm the suspected diagnosis of gonorrhea the nurse should: a. Obtain a urine specimen. b. Draw blood for a VDRL. c. Get a sexual history. d. Take a urethral culture.

37. Because Martin is allergic to penicillin, the physician orders tetracycline (Sumycin) to treat the infection. The nurse would know that the teaching about the administration of tetracycline was effective when Martin says he should take the drug: a. With meals or milk. b. At least 1 hour before meals. c. Approximately 30 minutes after meals. d. Just before meals.

38. The nurse would determine that the teaching about the side effects of tetracycline was understood when Martin says that the medication could cause: a. Constipation b. Diarrhea c. Vertigo d. Tinnitus

39. Another client, Abe Gold, 16 years old, comes to the clinic. He is sexually active and is worried about having syphilis. The nurse is aware that an early diagnosis of syphilis is important and its presence is often detremined by: a. A discharge from the penis b. Evidence of a rash c. Multiple gummatous lesions d. A lesion on the penis

40. The Dr. diagnoses that Abe does in fact have syphilis and orders penicillin G (Pentids) and probenicid (Benemid). The nurse explains to Abe the rationale for both drugs being used is: a. Each drug attacks the organism during different stages of cell multiplication. b. Probenecid decreases the potential for an allergic reaction developing to the penicillin, which treats the syphilis. c. The penicillin treats his syphilis while the probenecid relieves his severe urethritis. d. Probenecid delays excretion of penecillin by the kidneys to maintain effective blood levels for longer periods.

Situation 9: Gerald Chu, 6 months old, has eczema. He is admitted to the hospital because of secondary infection of his face and head from constant scratching. 41. The nurse is aware that eczema is a nonspecific ailment that is: a. Associated with chronic respiratory infections b. Predominantly found in infants c. Easily treated d. Highly contagious

42. The most important nursing care for infants with eczema is: a. Prevention of secondary infections b. Identification of causative factors c. Provision of sufficient hydration d. Promotion of physical growth

43. Allergic reactions in eczematous clients are most often caused by: a. wools, house dust, and dog hairs b. fruits., eggs, and wheat c. Milk, eggs, and peanuts d. Wools, meat, and milk

44. An assessment of Gerald's growth and developmental level should reveal that he could: a. Hold his bottle by himself b. Crawl forward c. Say mama d. Turn pages in a book

45. The nurse evaluates that Geralds mother needs more teaching regarding Geralds care when she states: a. I will be careful not to cuts Geralds nails short. b. I am going to buy him a whole new set of cotton clothing. c. I will make sure not to give him any whole milk products. d. I have given all his woolen blankets to my nephew.

Situation 10: Daniel and Florence Smiths new infant daughter Lara, is born with a cleft lip. 46. Immediate nursing care for Lara should be directed primarily toward: a. Preventing the occurrence of infection. b. Modifying feeding methods. c. Keeping the baby from crying. d. Minimizing handling by parents.

47. Mrs. Smith bottle-feeds Lara with a special nipple. To minimize regurgitation of the feedings, the nurse instructs Mrs. Smith to: a. Feed Lara while sitting her up in an infant seat. b. Hold and burp Lara frequently while feeding. c. Give Lara the thickened formula as ordered. d. Lay Lara on her side with the bottle firmly propped.

48. Mr. and Mrs. Smith ask when Laras cleft lip will be repaired. The nurse responds: a. When the baby is 8 to 12 weeks old. b. Usually at about 18 months of age. c. Not until she has teeth in her mouth. d. As soon as she starts to lose weight.

49. Laras lip is repaired surgically. Postoperatively, the nurse will provide nutrition for the baby via: a. A plastic teaspoon b. Intravenous feeding c. A rubber-tipped syringe d. Nasogastric tube feedings

50. Following each feeding, the first action by the nurse should be to: a. Cuddle Lara for a few minutes. b. Place Lara on her abdomen. c. Burp Lara several times. d. Clean and rinse Laras suture line.

Situation 11. Ellaine Mariano, 4 years old, is brought to the pediatricians office with complains of earache, sore throat, low grade fever, a cough, and general malaise. The nurse prepares the nescessary equipment to perform an otoscopic examination, a throat examination, and throat culture.

51. To properly visualize the canal during the otoscopic examination, the pinna of the ear must be pulled: a. Down and forward b. Up and back c. Up and forward d. Down and back

52. When examining Elaines throat, the nurse should position a tongue blade to the side of the childs tongue primarily to avoid: a. Interfering with the visual examination. b. Eliciting the gag reflex. c. Hurting any of the teeth. d. Obstructing the airway.

53. Dorcol cough syrup is ordered for Elaine. Each teaspoonful contains dextromethorphan hydrobromide 7.5 mg. When administering the cough syrup, the nurse should administer: a. 5 ml b. 3.75 ml c. 2.5 ml d. 7.5 ml
2.5/5 x 7.5= 3.7 ml

54. In assessing 4-year-old Elaine, the nurse would expect her to: a. Have a vocabulary of 1,500 words. b. Use just three-or four-word sentences. c. Ask the definitions of new words. d. Name two or three different colors.

55. When Elaine is 8 years old she has a tonsillectomy under general anesthesia without any untoward sequelae. During the immediate postoperative period, a nursing intervention for Elaine would be to maintain: a. hydration by providing cool liquids frequently b. consciousness by encouraging interaction with her mother c. airway patency by positioning her on the side d. aeration by assisting with coughing and deep breathing

56. When taking the history and assessing Karl, the nurse would expect to find: a. Constipation, abdominal pain, flatulence, rickets b. Constipation, abdominal distention, peripheral edema, increased clotting time c. Diarrhea, muscle wasting, anemia, osteomalacia, steatorrhea d. Diarrhea, malnutrition, rickets, anemia, steatorrhea, and increased stools.

57. The effectiveness of gluten-restricted diet in a child with celiac disease can be assessed on the 2nd day by having the nurse and mother evaluate the child for: a. Decreased irritability b. Maintenance of weight c. Normal bowel movements d. Disappearance of steatorrhea

58. Karl is anemic. The nurse suspects that the anemia is caused by: a. An inadequate amount of the intrinsic factor b. The small amount of iron included in his diet c. The poor absorption of iron and folic acid d. His minimal appetite and low food intake

59. The delivery room nurse explains to Mrs. Lustig and her husband, Ira, that an Apgar score recorded 5 minutes after birth helps to evaluate the: a. Effectiveness of the labor and delivery b. Adequacy of transition to extrauterine life c. Possibility of respiratory distress syndrome d. Gestational age of the infant

60. The nurse is aware that the nursing action would best promote parent-infant attachment behaviors would be: a. Encouraging rooming-in, with parental infant care. b. Keeping the new family together immediately postpartum. c. Restricting visitation on the postpartum unit. d. Supporting the parents choice of breastfeeding.

61. Mrs. Lustig is breastfeeding her infant on the delivery table. The nurse assists her by: a. Touching the infants cheek adjacent to the nipple to elicit the rooting reflex. b. Leaving them alone and allowing the infant to nurse as long as desired. c. Positioning the infant to grasp the nipple so as to express milk. d. Giving the infant a bottle first to evaluate the babys ability to suck.

62. Mr. and Mrs. Lustig note petechiae on the newborns face and neck. The nurse informs them that this is a result of: a. Increased intravascular pressure during delivery. b. Decreased vitamin K level in the newborn infant. c. A rash called erythema toxicum. d. Excessive superficial capillaries.

63. Mrs. Lustig asks the nurse what she can do to ease the discomfort caused by a cracked left nipple. She should be instructed to: a. Use a breast shield to keep the baby from direct contact with the nipple. b. Nurse the baby on the right side first until the left side heals. c. Stop nursing for 2 day to allow the nipple to heal. d. Manually express milk and feed it to the baby from a bottle.

64. When changing her infant, Mrs. Lustig notices a reddened area on the infants buttocks. The nurse should: Have staff nurses, instead of Mrs. Lustig, change the infant. Use both lotion and powder to protect the involved area. Encourage Mrs. Lustig to cleanse and change the infant more often. Notify the Dr. and request an order for a topical ointment.

65. The nurse is aware that during the taking-in phase of the postpartum period, the area of health teaching that Mrs. Lustig will be most responsive to is: a. Family planning b. Infant feeding c. Infant hygiene d. Perineal care

66. Mrs. Evans eventually decides to use oral contraceptives. When obtaining the health history, the nurse should consider that oral contraceptives are contraindicated in the client who: a. Has a family history of CVA b. Is over 30 years of age c. Smokes a pack of cigarettes per day d. Has a history of a multiple pregnancy

67. The physician orders progesterone oral contraceptives (minipills). The nurse instructs Mrs. Evans to take one pill daily: a. During the first 5 days of the menstrual cycle. b. During the 5 days surrounding ovulation. c. Throughout the menstrual cycle. d. Throughout the first 21 days of the menstrual cycle.

68. The nurse would know that Mrs. Evans understood the teaching about the side effects of excessive estrogen when she indicates it would cause: a. Nausea and vomiting b. Amenorrhea c. Depression and lethargy d. Hypomenorrhea

69. The nurse recognizes that Mrs. Evans understands the teaching about minipills when she states that she will discontinue the oral contraceptive at once if she experiences: a. Increased leukorrhea b. Chest pain c. Mittelschrmerz d. Menorrhagia

70. The nurse uses nitrazine paper to test the pH of the leaking fluid. If amniotic fluid is present, the nitrazine paper will become: a. Red b. Orange c. Blue d. Purple

71. Ms. Clancys labor does not progress, and a cesarean delivery is performed. Afterward, she tells the nurse that she is a natural childbirth flunkie. The postpartal phase of adjustment that this statement most closely typifies is: a. Taking hold b. Working through c. Taking in d. Letting go

72. Baby boy Clancy weighed 2450 gm (5.5 lb) at delivery. He would be classified as being: a. Average for gestational age b. Small for gestational age c. Average for gestational age but preterm d. Preterm and immature

73. After baby Clancy is admitted to the newborn nursery, the nurse observes that he has a weak high-pitched cry, seems jittery, and has irregular respirations. The nurse should associate these symptoms with: a. Hypoglycemia b. Hypercalcemia c. Hypovolemia d. Hypothyroidism

74. Ms. Clancy chooses to bottle feed her newborn because this will cause the least interference with full resumption of her law practice. Before discharge the nurse should teach Ms. Clancy that if breast engorgement occurs, she should: a. Take 2 aspirins every 4 hours. b. Apply hot compresses to the breasts. c. Wear a tightly fitted brassiere. d. Cease drinking milk for 2 weeks.

Mrs. Tan is admitted for severe bleeding. 75. After placing Mrs. Tan in the bed, the nurse should: a. Perform a vaginal examination. b. Check fetal heart tones. c. Administer a fleets enema. d. Obtain an amniotomy set up.

76. Mrs. Tans bleeding increases, and an emergency cesarean delivery is performed. Baby Tan is suctioned, dried, and transported to the NICU. The admitting nurse assesses baby Tans Silverman-Anderson index to be 3. This value reflects the babys need for: a. Increase caloric intake and fluids b. Respiratory support and observation c. Continuous cardiac monitoring d. Assessment of neurologic reflexes

77. A finding of the physical assessment that may indicate that baby Tan is preterm is: a. Many superficial veins b. A positive babinski reflex c. Absent femoral pulses d. Flexion of extremities

78. Eight hours after birth, Baby Tan is observed to have a respiratory rate of 68 per minute with nasal flaring and cyanosis. He is diagnosed as having respiratory distress syndrome. A finding consistent with this diagnosis is: a. Pulse rate 100 b. Arterial blood pH 7.50 c. Diminished breath sounds d. Inspiratory stridor

79. Supplemental O2 is ordered as part of Baby Tans treatment. To prevent retrolental fibroplasias the nurse plans to: a. Analyze O2 concentration frequently. b. Warm and humidify all O2 flow. c. Apply eye patches to both eyes. d. Administer O2 by blood.

80. The primary nurse in the NICU is caring for baby Tan suspects that he has necrotizing enterocolitis (NEC) when: a. Several severe bouts of projectile vomiting are observed. b. Large amounts of residual formula are withdrawn before gavage. c. An increased number of explosive stools are noted. d. Circumoral pallor develops during gastric feeding.

81. When admitting Mrs. Murray, one of the first question the nurse should ask is: a. How frequent are your contractions and how long do they last? b. What time was your last meal and what did you eat? c. Are you planning to breastfeed or to bottle feed? d. What is your expected date of delivery?

82. Mrs. Murrays Dr. arrives and examines her. The Dr. states that her cervix is completely effaced, dilation is 4 cm and station is 0. On the basis of this information, the nurse should: a. Check the FHR every 5 minutes and record it on her chart. b. Continue to tell Mr. Murray to coach her in the use of breathing techniques. c. Call anesthesia department and alert them to an imminent delivery. d. Ask Mrs. Murray how bad her pain is and whether she wants medication.

83. The teaching plan for Mr. Murray should include the information that it would be best for him: a. Leave Mrs. Murray alone periodically so that she can rest between contractions. b. See that Mrs. Murray remains supine so that the monitoring equipment is not disturbed. c. Keep the conversation in the labor room to a minimum so that Mrs. Murray can concentrate. d. Let Mrs. Murray know the progress she is making and that she is doing a good job.

84. During the labor, Mrs. Murray says, Were so worried about our baby because Im a whole month early. The nurses best response would be: a. Dont worry, the care of preterm babies has greatly improved. b. I can understand why you and your husband are worried. c. Your Dr. is very good, try not to worry about it now. d. I dont blame you for worrying; there is some danger.

85. Later in labor an internal cardiac monitor is attached to the fetal scalp. The nurse should be concerned about a fetal heart rate that: a. Varied from 130 to 140 beats per minute b. Dropped to 110 beats during Mrs. Murrays contractions c. Occasionally dropped to 90 beats unrelated to contractions d. Did not drop during Mrs. Murrays contractions

Situation 12: Colleen Reyes, age 32, delivers a baby girl who is admitted to the newborn nursey.

86. later, while inspecting her baby, Mrs. Reyes asked the nurse if her newborn has flat feet. The nurse recalls that: a. Flat feet are common in children and infants. b. This is difficult to assess because the feet are too small. c. The arch of the newborns foot is covered with fat pad, giving the appearance of being flat. d. Flat feet are associated with major deformities of the bones of the feet such as clubfoot.

87. The nurse palpates the femoral pulses of baby Reyes. This procedure is done to detect the presence of: a. Ventricular septal defect b. Coarctation of the aorta c. Patent ductus arteriosus d. Atrial septal defect

88. The nurse also assesses baby Reyes for central cyanosis as indicative congenital heart defects that affect cardiac circulation by: a. Shunting of blood right to left b. Shunting of blood left to right c. Obstructing the floe of blood between the left and right sides of the heart. d. Preventing shunting of blood between the left and right sides of the heart.

89. The nurse understands that CHF is the usual sequela to congenital congenital defects that result from left to right shunting of blood in the heart. With this knowledge, the nurse would be aware that a sign that would be most indicative of early onset of CHF in the infant would be: a. Decreased heart rate b. Increased respiratory rate c. Liver 2 cm below the costal margin d. Cyanosis of skin

Situation 13: Accompanied by her husband, Joan Carey, gravida ii para i is admitted in early labor. 90. As the nurse inspects her perineum, Mrs. Carey suddenly turns pale and says that she feels as if she is going to faint, although she is lying float on her back. The nurse should: a. Elevate her head. b. Elevate her feet. c. Start O2 IV fluids. d. Turn her on her left side.

91. During labor Mrs. Carey begins to experience dizziness and tingling of her hands. The nurse tells Mr. Carey to instruct his wife to: a. Hold her breath with the next contraction. b. Breath into her cupped hands or a paper bag. c. Use a fast deep-breathing pattern. d. Pant during the next three contractions.

92. Mrs. Carey has been in labor for 4 hours and her cervix is 5 cm dilated. She had been having good contractions until the past 30 minutes, when her contractions until the past 30 minutes, when her contractions gradually became irregular and of fair quality. In caring for her, the nurse should first check her for: a. Uterine dysfunction b. False labor c. A full bladder d. A breech presentation

93. In assessing Mrs. Carey for signs that the transitional phase is beginning , the nurse would expect her to have: a. Bulging of the perineum b. Crowning of the fetal head c. Pinkish vaginal discharge d. Rectal pressure during contraction

Situation 14: Arlene Dannon is 17 years old and is 36 weeks pregnant. When she comes to prenatal clinic she found to have a mild pregnancy-induced hypertension. The physician plans to treat her on an out patient basis.

94. Although the exact cause of PIH is unknown, the nurse knows that it is often associated with: a. A limited amount of calories b. A vitamin deficiency c. An inadequate intake of protein d. An inability to absorb minerals

95. When providing health teaching concerning PIH, a therapeutic instruction that the nurse should give Mrs. Dannon is: a. Rest frequently in the side lying position. b. Eat sodium-free diet. c. Limit fluid intake to 1000 ml a day. d. Walk at least a mile a day.

96. Mrs. Dannons physical status gets progressively worse and she is admitted to the high-risk prenatal unit at the local community hospital. During the admitting history and physical assessment the nurse should expect to find: a. Difficulty in breathing b. Vaginal spotting c. BP of 130/80 d. Proteinuria of 3+

97. The physician orders a large dose of magnesium sulfate. To evaluate the therapeutic effectiveness of this therapy, the nurse should assess for: a. Excessive urinary output b. Absent deep tendon reflexes c. A decreased respiratory rate d. An increased in BP

Situation n15: Kimberly Abrams, 32 years old, develops severe pain in her left leg during her 29th week of pregnancy. Thrombophlebitis is diagnosed, and she is admitted to the hospital, prescribed bed rest, and started on anticoagulant. 98. The nurse should be aware that the only anticoagulant that Mrs. Abrams can safely receive: a. Heparin sodium b. Warfarin sodium c. Dicumarol d. Embolex

99. Mrs. Abrams has blood drawn for activated partial thromboplastin time (APTT). One day her APTT is reported to be 98 seconds. The nurse notifies the Dr. because the anti coagulant should be: a. Increased for better clotting results. b. Omitted for today and the APTT rechecked tomorrow. c. Changed to one of the other effected anticoagulants d. Discontinued because the APTT is normal.

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