MATERNAL & CHILDHEALTH nursing MCQ 8

1. To decrease the pain associated with an episiotomy immediately after birth, the nurse would:

A) Offer warm blankets

B) Encourage the woman to void

C) Apply an ice pack to the site

D) Offer a warm sitz bath

ANS;C

An ice pack is the first measure used after a vaginal birth to provide perineal comfort from edema, an episiotomy, or
lacerations. Warm blankets would be helpful for the chills that the woman may experience. Encouraging her to void
promotes urinary elimination and uterine involution. A warm sitz bath is effective after the first 24 hours.

2. A postpartum client has a fourth-degree perineal laceration. The nurse would expect which of the following
medications to be ordered?

A) Ferrous sulfate (Feosol)

B) Methylergonovine (Methergine)

C) Docusate (Colace)

D) Bromocriptine (Parlodel)

ANS;C

A stool softener such as docusate (Colace) may promote bowel elimination in a woman with a fourth-degree
laceration, who may fear that bowel movements will be painful. Ferrous sulfate would be used to treat anemia.
However, it is associated with constipation and would increase the discomfort when the woman has a bowel
movement. Methylergonovine would be used to prevent or treat postpartum hemorrhage. Bromocriptine is used to
treat hyperprolactinemia

3. Which statement would alert the nurse to the potential for impaired bonding between mother and newborn?

A) "You have your daddy's eyes."

B) "He looks like a frog to me."

C) "Where did you get all that hair?"

D) "He seems to sleep a lot."

ANS;B

Negative comments may indicate impaired bonding. Pointing out commonalities such as "daddy's eyes" and
expressing pride such as "all that hair" are positive attachment behaviors. The statement about sleeping a lot
indicates that the mother is assigning meaning to the newborn's actions, another positive attachment behavior.

4. After a normal labor and birth, a client is discharged from the hospital 12 hours later. When the community
health nurse makes a home visit 2 days later, which finding would alert the nurse to the need for further
iNtervention?

A) Presence of lochia serosa

B) Frequent scant voidings

C) Fundus firm, below umbilicus

D) Milk filling in both breasts

ANS;B

Infrequent or insufficient voiding may be a sign of infection and is not a normal finding on the second postpartum
day. Lochia serosa, a firm fundus below the umbilicus, and milk filling the breasts are expected findings.

5. A primipara client who is bottle feeding her baby begins to experience breast engorgement on her third
postpartum day. Which instruction would be most appropriate to aid in relieving her discomfort

A) "Express some milk from your breasts every so often to relieve the distention."

B) "Remove your bra to relieve the pressure on your sensitive nipples and breasts."

C) "Apply ice packs to your breasts to reduce the amount of milk being produced."

D) "Take several warm showers daily to stimulate the milk let-down reflex."

ANS;C

For the woman with breast engorgement who is bottle feeding her newborn, encourage the use of ice packs to
decrease pain and swelling. Expressing milk from the breasts and taking warm showers would be appropriate for the
woman who was breast-feeding. Wearing a supportive bra 24 hours a day also is helpful for the woman with
engorgement who is bottle feeding.

6. The nurse administers RhoGAM to an Rh-negative client after delivery of an Rh-positive newborn based on the
understanding that this drug will prevent her from:

A) Becoming Rh positive

B) Developing Rh sensitivity

C) Developing AB antigens in her blood

D) Becoming pregnant with an Rh-positive fetus

ANS;B

The woman who is Rh-negative and whose infant is Rh-positive should be given Rh immune globulin (RhoGAM)
within 72 hours after childbirth to prevent sensitization.

7. Which of the following factors in a client's history would alert the nurse to an increased risk for postpartum
hemorrhage?

A) Multiparity, age of mother, operative delivery

B) Size of placenta, small baby, operative delivery

C) Uterine atony, placenta previa, operative procedures

D) Prematurity, infection, length of labor

ANS;C

Risk factors for postpartum hemorrhage include a precipitous labor less than three hours, uterine atony, placenta
previa or abruption, labor induction or augmentation, operative procedures such as vacuum extraction, forceps, or
cesarean birth, retained placental fragments, prolonged third stage of labor greater than 30 minutes, multiparity, and
uterine overdistention such as from a large infant, twins, or hydramnios.

8. When teaching parents about their newborn, the nurse describes the development of a close emotional attraction
to a newborn by the parents during the first 30 to 60 minutes after birth, which is termed:

A) Reciprocity

B) Engrossment

C) Bonding

D) Attachment

ANS;C

The development of a close emotional attraction to the newborn by parents during the first 30 to 60 minutes after
birth describes bonding. Reciprocity is the process by which the infant's capabilities and behavioral characteristics
elicit a parental response. Engrossment refers to the intense interest during early contact with a newborn. Attachment
refers to the process of developing strong ties of affection between an infant and significant other.

9. Which practice would be least effective in promoting bonding and attachment?

A) Allowing unlimited visiting hours on maternity units

B) Offering round-the-clock nursery care for all infants

C) Promoting rooming-in

D) Encouraging infant contact immediately after birth

ANS;B

Factors that can affect attachment include separation of the infant and parents for long times during the day, such as
if the infant was being cared for in the nursery throughout the day. Unlimited visiting hours, rooming-in, and infant
contact immediately after birth promote bonding and attachment.

10. Which instructions would the nurse include in discharge teaching for parents of a newborn?

A) Introducing solid foods immediately to increase sleep cycle

B) Demonstrating comfort measures to quiet a crying infant

C) Encouraging daily outings to the shopping mall with the newborn

D) Allowing the infant to cry for at least an hour before picking him or her up

ANS;B

Discharge teaching typically would focus on several techniques to comfort a crying newborn. The nurse needs to
emphasize the importance of responding to the newborn's cues, not allowing the infant to cry for an hour before
being comforted. Information about solid foods is inappropriate for a newborn because solid foods are not
introduced at this time. The mother and newborn need rest periods. Therefore, daily outings to a shopping mall
would be inappropriate. Information about newborn sleep-wake cycles and measures for sensory enrichment and
stimulation would be more appropriate.

11.When developing the plan of care for the parents of a newborn, the nurse identifies interventions to promote
bonding and attachment based on the rationale that bonding and attachment are most supported by which measure?

A) Early parent-infant contact following birth

B) Expert medical care for the labor and birth

C) Good nutrition and prenatal care during pregnancy

D) Grandparent involvement in infant care after birth

ANS; A

Optimal bonding requires a period of close contact between the parents and newborn within the first few minutes to
a few hours after birth. Expert medical care, nutrition and prenatal care, and grandparent involvement are not
associated with the promotion of bonding.

12. Which method would be most effective in evaluating the parents' understanding about their newborn's care?

A) Demonstrate all infant care procedures

B) Allow the parents to state the steps of the care

C) Observe the parents performing the procedures

D) Routinely assess the newborn for cleanliness

ANS;C

The most effective means to evaluate the parents' learning is to observe them performing the procedures. Parental
roles develop and grow through interaction with their newborn. The nurse would involve both parents in the
newborn's care and praise them for their efforts. Demonstrating the procedures to the parents and having the parents
state the steps are helpful but do not guarantee that the parents understand them. Assessing the newborn for
cleanliness would provide little information about parental learning.

13. A postpartum woman is having difficulty voiding for the first time after giving birth. Which of the following
would be least effective in helping to stimulate voiding?

A) Pouring warm water over her perineal area

B) Having her hear the sound of water running nearby

C) Placing her hand in a basin of cool water

D) Standing her in the shower with the warm water on

ANS;C

Helpful measures to stimulate voiding include placing her hand in a basin of warm water, pouring warm water over
her perineal area, hearing the sound of running water nearby, blowing bubbles through a straw, standing in the
shower with the warm water turned on, and drinking fluids.

14. The nurse is assisting a postpartum woman out of bed to the bathroom for a sitz bath. Which of the following
would be a priority?

A) Placing the call light within her reach

B) Teaching her how the sitz bath works

C) Telling her to use the sitz bath for 30 minutes

D) Cleaning the perineum with the peri-bottle

ANS;A
Tremendous hemodynamic changes are taking place within the woman, and safety must be a priority. Therefore, the
nurse makes sure that the emergency call light is within her reach should she become dizzy or lightheaded. Teaching
her how to use the sitz bath, including using it for 15 to 20 minutes, is appropriate but can be done once the woman's
safety is ensured. The woman should clean her perineum with a peri-bottle before using the sitz bath, but this can be
done once the woman's safety needs are met.

15.Review of a primiparous woman's labor and birth record reveals a prolonged second stage of labor and extended
time in the stirrups. Based on an interpretation of these findings, the nurse would be especially alert for which of the
following?

A) Retained placental fragments

B) Hypertension

C) Thrombophlebitis

D) Uterine subinvolution

ANS;C

The woman is at risk for thrombophlebitis due to the prolonged second stage of labor, necessitating an increased
amount of time in bed, and venous pooling that occurs when the woman's legs are in stirrups for a long period of
time. These findings are unrelated to retained placental fragments, which would lead to uterine subinvolution, or
hypertension.

16. The nurse is describing a transient, self-limiting mood disorder that affects mothers after childbirth,identifying
this as postpartum:

A) Depression

B) Psychosis

C) Bipolar disorder

D) Blues

ANS;D

Postpartum blues are manifested by mild depressive symptoms of anxiety, irritability, mood swings, tearfulness,
increased sensitivity, feelings of being overwhelmed, and fatigue. They are usually self-limiting and require no
formal treatment other than reassurance and validation of the woman's experience as well as assistance in caring for
herself and her newborn. Postpartum depression is a major depressive episode associated with childbirth.
Postpartum psychosis is at the severe end of the continuum of postpartum emotional disorders. Bipolar disorder
refers to a mood disorder typically involving episodes of depression and mania.

17.A woman who is 2 weeks postpartum calls the clinic and says, "My left breast hurts." After further assessment on
the phone, the nurse suspects the woman has mastitis. In addition to pain, the nurse would assess for which of the
following?

A) An inverted nipple on the affected breast

B) No breast milk in the affected breast

C) An ecchymotic area on the affected breast

D) Hardening of an area in the affected breast

ANS;D
Mastitis is characterized by a tender, hot, red, painful area on the affected breast. An inverted nipple is not associated
with mastitis. With mastitis, the breast is distended with milk, the area is inflamed (not ecchymotic), and there is
breast tenderness.

18. When reviewing the causes of late postpartum hemorrhage, which of the following would the nurse identify as
the most common cause?

A) Retained placental fragments

B) Uterine atony

C) Cervical or vaginal lacerations

D) Uterine inversion

ANS;A

Late postpartum hemorrhage is typically due to subinvolution secondary to retained placental fragments, distended
bladder, uterine myoma, and infection. Uterine atony, lacerations, and uterine inversion would most likely lead to
early postpartum hemorrhage.

19. Which of the following would be essential to implement to prevent late postpartum hemorrhage?

A) Administering broad-spectrum antibiotics

B) Inspecting the placenta after delivery for intactness

C) Manually removing the placenta at delivery

D) Applying pressure to the umbilical cord to remove the placenta

ANS;B

After the placenta is expelled, a thorough inspection is necessary to confirm its intactness because tears or fragments
left inside may indicate an accessory lobe or placenta accreta. These can lead to profuse hemorrhage because the
uterus is unable to contract fully. Administering antibiotics would be appropriate for preventing infection, not
postpartum hemorrhage. Manual removal of the placenta or excessive traction on the umbilical cord can lead to
uterine inversion, which in turn would result in hemorrhage.

20. A multipara client develops thrombophlebitis after delivery. Which of the following would alert the nurse to the
need for immediate intervention?

A) Dyspnea, diaphoresis, hypotension, and chest pain

B) Dyspnea, bradycardia, hypertension, and confusion

C) Weakness, anorexia, change in level of consciousness, and coma

D) Pallor, tachycardia, seizures, and jaundice

ANS;A

Sudden unexplained shortness of breath and complaints of chest pain along with diaphoresis and hypotension
suggest pulmonary embolism, which requires immediate action. Other signs and symptoms include tachycardia,
apprehension, hemoptysis, syncope, and sudden change in the woman's mental status secondary to hypoxemia.
Anorexia, seizures, and jaundice are unrelated to a pulmonary embolism.
21. A client experienced prolonged labor with prolonged premature rupture of membranes. The nurse would be
alert for which of the following in the mother and the newborn?

A) Infection

B) Hemorrhage

C) Trauma

D) Hypovolemia

ANS;A

Although hemorrhage, trauma, and hypovolemia may be problems, the prolonged labor with the prolonged
premature rupture of membranes places the client at high risk for a postpartum infection. The rupture of membranes
removes the barrier of amniotic fluid so bacteria can ascend.

22. When assessing the postpartum woman, the nurse uses indicators other than pulse rate and blood pressure for
postpartum hemorrhage because:

A) These measurements may not change until after the blood loss is large

B) The body's compensatory mechanisms activate and prevent any changes

C) They relate more to change in condition than to the amount of blood lost

D) Maternal anxiety adversely affects these vital signs

ANS;A

The typical signs of hemorrhage do not appear in the postpartum woman until as much as 1,800 to 2,100 mL of
blood has been lost. In addition, accurate determination of actual blood loss is difficult because of blood pooling
inside the uterus and on perineal pads, mattresses, and the floor.

23. The nurse would be alert for which of the following immediately after a woman with abruptio placentae gives
birth?

A) Severe uterine pain

B) Board-like abdomen

C) Appearance of petechiae

D) Inversion of the uterus

ANS;C

A complication of abruptio placentae is disseminated intravascular coagulation (DIC), which is manifested by

petechiae, ecchymoses, and other signs of impaired clotting. Severe uterine pain, a board-like abdomen, and uterine
inversion are not associated with abruptio placentae.

24. Which of the following assessment findings in a postpartum client would be most alarming?

A) Leg pain on ambulation with mild ankle edema

B) Calf pain with dorsiflexion of the foot.

C) Perineal pain with swelling along the episiotomy

D) Sharp stabbing chest pain with shortness of breath

ANS; D

Sharp stabbing chest pain with shortness of breath suggests pulmonary embolism, an emergency that requires
immediate action. Leg pain on ambulation with mild edema suggests superficial venous thrombosis. Calf pain on
dorsiflexion of the foot may indicate deep vein thrombosis or a strained muscle or contusion. Perineal pain with
swelling along the episiotomy might be a normal finding or suggest an infection. Of the conditions, pulmonary
embolism is the most urgent..

25. Which of the following would the nurse least expect to administer to a woman experiencing postpartum
hemorrhage?

A) Oxytocin

B) Methylergonovine

C) Carboprost

D) Terbutaline

ANS;D

Terbutaline is a tocolytic agent used to halt preterm labor. It would not be used to treat postpartum hemorrhage.
Oxytocin, methylergonovine, and carboprost are drugs used to manage postpartum hemorrhage.

26 .A client asks the nurse what a third degree laceration is. She was informed that she had one. The nurse explains
that this is:

a. that extended their anal sphincter

b. through the skin and into the muscles

c. that involves anterior rectal wall

d. that extends through the perineal muscle.

ANS; (A)

that extended their anal sphincter

Third degree laceration involves all in the second degree laceration and the external sphincter of the rectum. Options
B, C and D are under the second degree laceration.

27. Betina 30 weeks AOG discharged with a diagnosis of placenta previa. The nurse knows that the client
understands her care at home when she says:

a. I am happy to note that we can have sex occasionally when I have no bleeding.

b. I am afraid I might have an operation when my due comes

c. I will have to remain in bed until my due date comes

d. I may go back to work since I stay only at the office.

ANS; (C)

I will have to remain in bed until my due date comes

Placenta previa means that the placenta is the presenting part. On the first and second trimester there is spotting. On
the third trimester there is bleeding that is sudden, profuse and painless.

28. The uterus has already risen out of the pelvis and is experiencing farther into the abdominal area at about the:

a. 8th week of pregnancy

b. 10th week of pregnancy

c. 12th week of pregnancy

d. 18th week of pregnancy

ANS; (D)

18th week of pregnancy

On the 8th week of pregnancy, the uterus is still within the pelvic area. On the 10th week, the uterus is still within
the pelvic area. On the 12th week, the uterus and placenta have grown, expanding into the abdominal cavity. On the
18th week, the uterus has already risen out of the pelvis and is expanding into the abdominal area.

29. Which of the following urinary symptoms does the pregnant woman most frequently experience during the first
trimester:

a. frequency

b. dysuria

c. incontinence

d. burning

ANS; (A)

frequency

Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing
urinary frequency. Dysuria, incontinence and burning are symptoms associated with urinary tract infection

5. Mrs. Jimenez went to the health center for pre-natal check-up. the student nurse took her weight and revealed 142
lbs. She asked the student nurse how much should she 30.gain weight in her pregnancy.

a. 20-30 lbs

b. 25-35 lbs

c. 30- 40 lbs

d. 10-15 lbs

ANS; (B) 25-35 lbs

A weight gain of 11. 2 to 15.9 kg (25 to 35 lbs) is currently recommended as an average weight gain in pregnancy.
This weight gain consists of the following: fetus- 7.5 lb; placenta- 1.5 lb; amniotic fluid- 2 lb; uterus- 2.5 lb; breasts-
1.5 to 3 lb; blood volume- 4 lb; body fat- 7 lb; body fluid- 7 lb.

31. The nurse is preparing Mrs. Jordan for cesarean delivery. Which of the following key concept should the nurse
consider when implementing nursing care?

a. Explain the surgery, expected outcome and kind of anesthetics.

b. Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth.

c. Arrange for a staff member of the anesthesia department to explain what to expect post-operatively.

d. Instruct the mothers support person to remain in the family lounge until after the delivery.

ANS; (B)

Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth.

A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching to
meet the needs of either planned or emergency cesarean birth, the depth and breadth of instruction will depend on
circumstances and time available.

32. Bettine Gonzales is hospitalized for the treatment of severe preecplampsia. Which of the following represents an
unusual finding for this condition?

a. generalized edema

b. proteinuria 4+

c. blood pressure of 160/110

d. convulsions

ANS; (D)

convulsions

Options A, B and C are findings of severe preeclampsia. Convulsions is a finding of eclampsiaan obstetrical
emergency.

33. Nurse Geli explains to the client who is 33 weeks pregnant and is experiencing vaginal bleeding that coitus:

a. Need to be modified in any way by either partner

b. Is permitted if penile penetration is not deep.

c. Should be restricted because it may stimulate uterine activity.

d. Is safe as long as she is in side-lying position.

ANS; (C)

Should be restricted because it may stimulate uterine activity.

Coitus is restricted when there is watery discharge, uterine contraction and vaginal bleeding. Also those women with
a history of spontaneous miscarriage may be advised to avoid coitus during the time of pregnancy when a previous
miscarriage occurred.
34. Mrs. Precilla Abuel, a 32 year old mulripara is admitted to labor and delivery. Her last 3 pregnancies in short
stage one of labor. The nurses decide to observe her closely. The physician determines that Mrs. Abuels cervix is
dilated to 6 cm. Mrs. Abuel states that she is extremely uncomfortable. To lessen Mrs. Abuels discomfort, the nurse
can advise her to:

a. lie face down

b. not drink fluids

c. practice holding breaths between contractions

d. assume Sims position

ANS; (D)

assume Sims position

When the woman is in Sims position, this puts the weight of the fetus on bed, not on the woman and allows good
circulation in the lower extremities

35. Which is true regarding the fontanels of the newborn?

a. The anterior is large in shape when compared to the posterior fontanel.

b. The anterior is triangular shaped; the posterior is diamond shaped.

c. The anterior is bulging; the posterior appears sunken.

d. The posterior closes at 18 months; the anterior closes at 8 to 12 months.

ANS; (A)

The anterior is large in shape when compared to the posterior fontanel.

The anterior fontanel is larger in size than the posterior fontanel. Additionally, the anterior fontanel, which is
diamond shaped closes at 18 month, whereas the posterior fontanel, which is triangular in shape closes at 8 to 12
weeks. Neither fontanel should appear bulging, which may indicate increases ICP or sunken, which may indicate
hydration.

36. Mrs. Quijones gave birth by spontaneous delivery to a full term baby boy. After a minute after birth, he is crying
and moving actively. His birth weight is 6.8 lbs. What do you expect baby Quijones to weigh at 6 months?

a. 13 -14 lbs

b. 16 -17 lbs

c. 22 -23 lbs

d. 27 -28 lbs

ANS; (A)

13 -14 lbs

The birth weight of an infant is doubled at 6 months and is tripled at 12 months

37. During the first hours following delivery, the post partum client is given IVF with oxytocin added to them. The
nurse understands the primary reason for this is:

a. To facilitate elimination

b. To promote uterine contraction

c. To promote analgesia

d. To prevent infection

ANS; (B)

To promote uterine contraction

Oxytocin is a hormone produced by the pituitary gland that produces intermittent uterine contractions, helping to
promote uterine involution.

38. Nurse Luis is assessing the newborns heart rate. Which of the following would be considered normal if the
newborn is sleeping?

a. 80 beats per minute

b. 100 beats per minute

c. 120 beats per minute

d. 140 beats per minute

ANS; (B)

100 beats per minute

The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute. If the newborn was
awake, the normal heart rate would range from 120 to 160 beats per minute.

.39. The infant with Down Syndrome should go through which of the Eriksons developmental stages first?

a. Initiative vs. Self doubt

b. Industry vs. Inferiority

c. Autonomy vs. Shame and doubt

d. Trust vs. Mistrust

ANS; (D)

Trust vs. Mistrust

The child with Down syndrome will go through the same first stage, trust vs. mistrust, only at a slow rate. Therefore,
the nurse should concentrate on developing on bond between the primary caregiver and the child

40. The child with phenylketonuria (PKU) must maintain a low phenylalanine diet to prevent which of the following
complications?

a. Irreversible brain damage

b. Kidney failure

c. Blindness

d. Neutropenia

ANS; (A)

Irreversible brain damage

The child with PKU must maintain a strict low phenylalanine diet to prevent central nervous system damage,
seizures and eventual death

41. Which age group is with imaginative minds and creates imaginary friends?

a. Toddler

b. Preschool

c. School

d. Adolescence

ANS; (B)

Preschool

During preschool, this is the time when children do imitative play, imaginative playthe occurrence of imaginative
playmates, dramatic play where children like to act, dance and sing42. Which of the following situations would alert
you to a potentially developmental problem with a child?

a. Pointing to body parts at 15 months of age.

b. Using gesture to communicate at 18 months.

c. Cooing at 3 months.

d. Saying mama or dada for the first time at 18 months of age.

ANS; (D)

Saying mama or dada for the first time at 18 months of age.

A child should say mama or dada during 10 to 12 months of age. Options A, B and C are all normal assessments
of language development of a child.

43. Isabelle, a 2 year old girl loves to move around and oftentimes manifests negativism and temper tantrums. What
is the best way to deal with her behavior?

a. Tell her that she would not be loved by others is she behaves that way..

b. Withholding giving her toys until she behaves properly.

c. Ignore her behavior as long as she does not hurt herself and others.

d. Ask her what she wants and give it to pacify her.

ANS; (C)

Ignore her behavior as long as she does not hurt herself and others.
If a child is trying to get attention or trying to get something through tantrumsignore his/her behavior

44. Baby boy Villanueva, 4 months old, was seen at the pediatric clinic for his scheduled check-up. By this period,
baby Villanueva has already increased his height by how many inches?

a. 3 inches

b. 4 inches

c. 5 inches

d. 6 inches

ANS; (B)

4 inches

From birth to 6 months, the infant grows 1 inch (2.5 cm) per month. From 6 to 12 months, the infant grows inch
(1.25 cm) per month

45. Alice, 10 years old was brought to the ER because of Asthma. She was immediately put under aerosol
administration of Terbutaline. After sometime, you observe that the child does not show any relief from the
treatment given. Upon assessment, you noticed that both the heart and respiratory rate are still elevated and the child
shows difficulty of exhaling. You suspect:

a. Bronchiectasis

b. Atelectasis

c. Epiglotitis

d. Status Asthmaticus

ANS; (D) Status Asthmaticus

Status asthmaticus leads to respiratory distress and bronchospasm despite of treatment and interventions.
Mechanical ventilation maybe needed due to respiratory failure.

46. Nurse Jonas assesses a 2 year old boy with a tentative diagnosis of nephroblastoma. Symptoms the nurse
observes that suggest this problem include:

a. Lymphedema and nerve palsy

b. Hearing loss and ataxia

c. Headaches and vomiting

d. Abdominal mass and weakness

ANS; (D)

Abdominal mass and weakness

Nephroblastoma or Wilms tumor is caused by chromosomal abnormalities, most common kidney cancer among
children characterized by abdominal mass, hematuria, hypertension and fever

47. Which of the following danger sings should be reported immediately during the antepartum period?
a. blurred vision

b. nasal stuffiness

c. breast tenderness

d. constipation

ANS; (A)

blurred vision

Danger signs that require prompt reporting are leaking of amniotic fluid, blurred vision, vaginal bleeding, rapid
weight gain and elevated blood pressure. Nasal stuffiness, breast tenderness, and constipation are common
discomforts associated with pregnancy.

48. Nurse Jacob is assessing a 15 month old child with acute otitis media. Which of the following symptoms would
the nurse anticipate finding?

a. periorbital edema, absent light reflex and translucent tympanic membrane

b. irritability, purulent drainage in middle ear, nasal congestion and cough

c. diarrhea, retracted tympanic membrane and enlarged parotid gland

d. Vomiting, pulling at ears and pearly white tympanic membrane

ANS; (B)

irritability, purulent drainage in middle ear, nasal congestion and cough

Irritability, purulent drainage in middle ear, nasal congestion and cough, fever, loss of appetite, vomiting and
diarrhea are clinical manifestations of otitis media. Acute otitis media is common in children 6 months to 3 years old
and 8 years old and above. Breast fed infants have higher resistance due to protection of Eustachian tubes and
middle ear from breast milk.

49. Which of the following is the most appropriate intervention to reduce stress in a preterm infant at 33 weeks
gestation?

a. Sensory stimulation including several senses at a time

b. tactile stimulation until signs of over stimulation develop

c. An attitude of extension when prone or side lying

d. Kangaroo care

ANS; (D)

Kangaroo care

Kangaroo care is the use of skin-to-skin contact to maintain body heat. This method of care not only supplies heat
but also encourages parent-child interaction

50. The parent of a client with albinism would need to be taught which preventive healthcare measure by the nurse: