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1. A mother gave birth to a baby 12 hours ago. What kind of assessment would the nurse expect to see?
A. Lochia alba
B. Soft, boggy fundus
C. Transient tachycardia
D. Complaints of hunger
RATIONALE: After delivery, the nurse would expect to find complaints of hunger and thirst due to some degree of fluid loss during
the delivery process. Additional assessment findings include bloody red discharge called lochia rubra; a fundus that is firm and
midline and transient bradycardia.
2. Which of the following is a goal of caring for newborns during the postpartum period?
A. To facilitate development of a close parent-newborn relationship
B. To assist parents in developing healthy attitudes about childbearing practices
C. To identify actual or potential problems requiring immediate or emergency attention.
D. To provide the parents of the newborn with information about well-baby programs
RATIONALE: In the initial postpartum period it is essential to identify actual and potential problems that might require immediate
attention in order to prevent complications or worsening of the newborn’s condition.
3. In a labour and delivery class lecture, What is the process in which the uterus reverts to its pre-pregnancy state in the
postpartum period?
A. Involution
B. Puerperium
C. Uterine atony
D. Lochia rubra
RATIONALE: Involution is the process whereby the uterus returns to its pre-pregnancy state. Puerperium refers to the six- week
period after birth called the 4th trimester of pregnancy. Uterine atony is an abnormal condition where the uterus is soft and boggy.
Lochia rubra is a discharge similar to menstrual flow during the first 2 to 3 days after delivery
4. Which of the following would be considered as normal when evaluating the newborn's heart rate if the infant were sleeping?
A. 80 bpm
B. 100 bpm
C. 120 bpm
D. 140 bpm
RATIONALE: The normal heart rate for a newborn that is sleeping is about 100 bpm. If the newborn were awake, the normal heart
rate would range from 120 to 160 bpm
5. According to Reva Rubin, during which period does the mother frequently review her labor and delivery experience?
A. Letting down
B. Letting go
C. Taking hold
D. Taking in
RATIONALE: Rubin identifies 3 stages postpartum: taking in, taking hold and letting go. According to Rubin, during the taking-in
period, the new mother may review her experiences during delivery.
6. Which of the following 1-day postpartum patients should be given the highest priority by the
nurse?
A. The patient with bright red lochia with blood clots greater than 1 cm.
B. The patient who complains of afterpains
C. The client with a pulse rate of 62 bpm
D. the patient with colostrum discharge from both breasts.
RATIONALE: The patient with bright red lochia and clots greater than 1 cm is experiencing active bleeding. Therefore, this patient
must be given the highest priority by the nurse.
7. Which of the following causes the newborn's first breaths to be taken?
A. A rise in temperature
B. A change in pressure gradients.
C. Increased blood pH
D. Decreased blood CO2 level
RATIONALE: Initial respirations are triggered by physical, sensory and chemical factors. Physical factors include the change in
pressure gradients. Sensory factors include a drop in temperature, noise, light, touch. Chemical factors include the decrease in oxygen,
increased carbon dioxide levels and decreased pH as a result of the transitory asphyxia that occurs during delivery.
8. Which of the following statements regarding the newborn's immune system would the nurse say is
true?
A. The risk of infection in the newborn is relatively low
B. Phagocytosis occurs fairly rapidly in the newborn
C. The newborn is unable to limit the invading organisms at their point of entry.
D. Immunoglobulin A is present in their GI and respiratory tract.
RATIONALE: The newborn cannot limit the invading organisms at their point of entry.
RATIONALE: The anterior fontanel is larger than the posterior. The anterior is diamond-shaped’ the posterior is triangleshaped. The
anterior closes at 18 months, the posterior at 8 to 12 weeks. A bulging fontanel indicates increased intracranial pressure, a sunken
fontanel indicates dehydration
10. Which of the following best describes the first stage of reactivity at birth?
A. This period lasts about 30 minutes.
B. The infant is asleep.
C. A poor suck is present.
D. Respirations may be increased to 110cpm
RATIONALE: Choice A is the only choice that is one of the first period or reactivity
11. Which of the following reflex groups is present at birth and remains unchanged as an adult?
A. Blink, cough, rooting and gag
B. Blink, cough, sneeze and gag.
C. Rooting, sneeze, swallowing and cough
D. Stepping, blink, cough and sneeze
RATIONALE: Blink, cough, sneeze, swallowing and gag are all present at birth and remains unchanged throughout adulthood.
Reflexes such as rooting and stepping disappear within the first year.
12. Which of the following when present in the urine may cause a reddish stain on the diaper of a
newborn?
A. Mucus
B. Uric acid crystals
C. Bilirubin
D. Excess iron
RATIONALE: Uric acid crystals in the urine may produce the reddish “brick dust” stain on the diapers. Mucus would not produce a
stain. Bilirubin and iron are from hepatic adaptation.
13. Before birth, which of the following structures connects the left and right atria of the heart?
A. Umbilical vein
B. Foramen ovale
C. Ductus arteriosus
D. Ductus venosus
RATIONALE: Foramen ovale is an opening between the left and right atria that closes after birth
14. Lochia alba follows lochia serosa about 3-4 days after child birth. Which of the following statements best describes
lochia alba?
A. creamy white-brown, stale odor
B. creamy white to brown, contains decidual cells, may have stale odor.
C. brown to red, tissue fragments, odor
D. brown to red contains decidual cells and leukocytes
RATIONALE: Consists of leukocytes, decidua, epithelial cells, mucus, serum, and bacteria. Lochia can persist for approximately 4 to
8 weeks after birth (pg. 557)
15. On the first postpartum night, a client requests that her baby be sent back to the nursery so she can get some sleep. The
client is most likely in which of the following phases?
A. Depression phase
B. Letting-go phase
C. Taking-hold phase
D. Taking-in phase.
RATIONALE: The taking-in phase occurs in the first 24 hours after birth. The mother is concerned with her own needs and requires
support from staff and relatives. The taking-hold phase occurs when the mother is ready to take responsibility for her care as well as
the infant's care. The letting-go phase begins several weeks later, when the mother incorporates the new infant into the family unit.
16. Which of the following physiological responses is considered normal in the early postpartum period?
A. Urinary urgency and dysuria
B. Rapid diuresis.
C. Decrease in blood pressure
D. Increase motility of the GI system
RATIONALE: In the early PP period, there’s an increase in the glomerular filtration rate and a drop in the progesterone levels, which
result in rapid diuresis. There should be no urinary urgency, though a woman may feel anxious about voiding. There’s a minimal
change in blood pressure following childbirth, and a residual decrease in GI motility.
17. During the 3rd postpartum day, which of the following observations about the client would the nurse be most likely to make?
A. The client appears interested in learning about neonatal care.
B. The client talks a lot about her birth experience
C. The client sleeps whenever the neonate isn’t present
D. The client requests help in choosing a name for the neonate.
RATIONALE: The client appears interested in learning about neonatal care. The third to tenth days of PP care are the “taking-hold”
phase, in which the new mother strives for independence and is eager for her newborn. The other options describe the phase in which
the mother relives her birth experience.
SITUATION: Armed with Rubin’s finding and integrating these findings into practice, nurses became better and able to differentiate
healthy from unhealthy bonding behavior in postpartum women and their newborns.
18. Which of the following findings, during the taking-hold phase, the nurse expects the new mother to do?
A. Let the nurse do everything for her.
B. Call the baby by name.
C. Touch the baby with her fingers
D. Be passive involved with the baby.
19. Which of the following actions would alert you that a new mother is entering a postpartum taking-hold phase?
A. She tells you she was in a lot pain all during labor
B. She sleeps as if exhausted from the efforts of labor
C. She urges the baby to stay awake so that she can breastfeed him or her.
D. She says that she has not selected a name for the baby yet.
20. A patient named BabymoH is gravida 1, para 0. During the first 24 hours after delivery, she does not show consistent interest in
her neonate. How should the nurse interpret her behavior?
A. BabymoH is experiencing postpartum depression
B. BabymoH is questioning her role as a mother
C. BabymoH is showing expected behaviors for taking-in phase.
D. BabymoH is failing to attach to the neonate.
21. 8 hours after giving birth the nurse notes that the client is voiding frequently in small amounts, which of the following statements
is true?
22. A 23 year old primigravida has a normal vaginal delivery. The next day, the nurse assesses the client’s lochia for color,
amount and the presence of clots. Which of the following best describes lochia on the first postpartum day?
A. Dark red (lochia rubra) large amount, with many clots.
B. Pink (lochia serosa) moderate amount, no clots
C. White (lochia alba) scant amount, no clots
D. Dark red (lochia rubra) moderate amount, with a few small clots.
23. Which of the following findings would be a source of concern if noted during the assessment of a woman who is 12 hours
postpartum?
A. Postural hypotension
B. Temperature of 100.4°F
C. Bradycardia — pulse rate of 55 BPM
D. Pain in left calf with dorsiflexion of left foot
RATIONALE: Responses A and C are expected related to circulatory changes after birth. A temperature of 100.4°F in the first 24
hours is most likely indicative of dehydration which is easily corrected by increasing oral fluid intake. The findings in response D
indicate a positive Homan sign and are suggestive of thrombophlebitis and should be investigated further.
24. Four hours after a difficult labor and birth, a primiparous woman refuses to feed her baby, stating that she is too tired and just
wants to sleep. The nurse should:
A. Tell the woman she can rest after she feeds her baby
B. Recognize this as a behavior of the taking-hold stage
C. Record the behavior as ineffective maternal-newborn attachment
D. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time
RATIONALE: Response A does not take into consideration the need for the new mother to be nurtured and have her needs met during
the taking-in stage. The behavior described is typical of this stage and not a reflection of ineffective attachment unless the behavior
persists. Mothers need to reestablish their own well-being in order to effectively care for their baby.
25. How can parents help facilitate the adjustment of their other children to a new baby?
A. Having the children choose or make a gift to give to the new baby upon its arrival home
B. Emphasizing activities that keep the new baby and other children together
C. Having the mother carry the new baby into the home so she can show the other children the new baby
D. Reducing stress on other children by limiting their involvement in the care of the new baby
RATIONALE: Special time should be set aside just for the other children without interruption from the newborn. Someone other than
the mother should carry the baby into the home so she can give full attention to greeting her other children. Children should be actively
involved in the care of the baby according to their ability without overwhelming them.
26. According to Piaget, at what stage of development do children typically solve problems through trial and error?
A. Sensorimotor stage
B. Preoperational stage
C. Formal operational stage
D. Concrete operational stage
27. Which statement helps explain the growth and development of children?
A. Development proceeds at a predictable rate.
B. The sequence of developmental milestones is predictable.
C. Rate growth is consistent among children.
D. At times of rapid growth, there is also acceleration of development.
28. A nurse is discussing various developmental theories at a parenting class. Which individual is associated with moral development
theory?
A. Erikson
B. Fowler
C. Kohlberg
D. Freud
29. Based on Piaget’s theory of cognitive development, what is one basic concept a child is expected to attain during the first year of
life?
A. If an object is hidden, that does not mean that it is gone.
B. He or she cannot be fooled by changing shapes
C. Parents are not perfect
D. Most procedures can be reversed.
30. What is the most accurate method of determining the length of a child younger than 12 months of age?
A. Standing height
B. Estimation of length to the nearest centimeter or ½ inch.
C. Recumbent length measured in the prone position
D. Recumbent length measured in supine position
BSN 2_ P3 WEEK 2 POST TEST
NUR 194_LEC_Care of Mother and Child Adolescent (Well Client)
—
GENERAL INSTRUCTIONS:
Shade only those that apply to each question on your answer sheet.
Read the question carefully and choose the best answer.
STRICTLY NO ERASURES.
—
A. Separation anxiety
B. Stranger anxiety
C. Fear of bodily injury
D. Fear of pain
7. A maternity nurse is providing instruction to a new mother regarding the psychosocial development of the
newborn infant. Using Erikson's psychosocial development theory, the nurse would instruct the mother to
A.2 months
B.6 months
C.4 months
D.12 months
9. The nurse observes a 10-month-old infant using her index finger and thumb to pick up pieces of cereal. This
behavior is evidence that the infant has developed:
10. The nurse discusses child-proofing the home for safety with the mother of a 9-month-old. The
statement made by the mother that indicates an unsafe behavior is:
11. During infancy, at what month does a baby begins to show social smile?
A. 2 months
B. 3 months
C. 4 months
D. 5 months
12. During infancy, at what month does a baby begins to have object permanence?
A.7-8 months
B.8-9 months
C.9-10 months
D.10-11 months
A.Parallel play
B.Independent play
C.Cooperative play
D.Competitive play
A. Repression
B. Regression
C. Suppression
D. Aggression
15. According to the theory of Kohlberg, at what stage does moral reasoning is merely based on external ethics?
A.Pre-conventional
B.Conventional
C.Pre-operational
D.Post-conventional
16. The nurse wanted to teach a mother on toilet training. At what age of the child must the nurse will start to teach
the mother?
A.18 months
B.18-24 months
C.12-16 months
D.-36 months
17. Which of the following is the criteria that a child is ready for toilet training?
A. I, II, V, VI
B. I, IV, V, VI
C. I, II, V, VI
D. I, III, IV, V
18. According to Erikson’s theory, what does a toddler gain if he/she successfully fulfill his/her
developmental stage?
A.Trust
B.Knowledge
C.Identity
D.Confidence
19. When developing a care plan for a child, the nurse identifies which Eriksonian stage as corresponding to Freud's
oral stage of psychosexual development?
20. You're assessing a 10-month-old infant. You note on examination the anterior fontanelle is open. The nurse will:
A. Document this as an abnormal finding because this fontanelle should close at 2 months
B. Document this as a normal finding because this fontanelle closes
at about 18 months
C. Document this as a normal finding because this fontanelle closes at about 12 months
D. Document this as an abnormal finding because this fontanelle should close at 6 months
21. An infant weighed 8 lbs. at birth. How many lbs. should the infant weigh at 6 months?
A. 24 lbs o
B. 10 lbs o
C. 16 lbs
D. 32 lbs
22. At 8-9 months of age, what milestone should an infant be able to successfully perform?
A. Begin walking
B. Say several words like mama or dada
C. sit without support
D. Follow basic commands
23. You note a 10-month-old is using the pincer grasp. Which option below best describes this milestone?
A. The infant is able to grasp large objects with the palm and forefingers.
B. The infant is able to grasp small objects with the index finger
and thumb.
C. The infant is able to grasp small and large objects with the middle finger and thumb.
D. The infant is able to grasp large objects with the palm and thumb.
24. You're developing a plan of care for an infant and you include activities for play. The play activities include
hiding a toy and letting the infant look for it along
while playing peek-a-boo. Which infant below would best benefit from this type of play?
A. 6-month-old
B. 2-month-old
C. 9-month-old
D. 4-month-old
25. Your patient is 5-months-old. Which developmental milestone, if not performed by the infant, should be further
investigated?
A. Crawling
B. Rolling over from back to tummy
C. Using the pincer grasp
D. Sitting without support
26. You're helping develop a meal plan for a 10-month-old. Which foods will you select to be part of the meal
plan? Select all that apply:*
I. Mashed potatoes
II. Grapes
III. Soup
IV. Toast with honey
A. I,III C.I,II,IIII
B. I,IV D. ALL OF THE ABOVE
27. You're teaching a group of new moms about how to assess toilet training readiness in their toddler. Which
statement by a participant demonstrates they did NOT understand the education provided:
A. "I should start potty training once my child has had a dry diaper for 2 hours or more."
B. "It is best to start night-time potty training before day-time potty
training."
C. "Having regular bowel movements is a sign of potty training readiness."
D. "My child can sit on the toilet for at least 10 minutes without fussy, so I think I will trying potty training soon."
28. You're providing caring to a 2-year-old and have noted negativism. Which statement by the nurse to the
toddler will help decrease negativism when administering medications to the toddler?
29. A toddler is hospitalized and the parent had to temporarily leave the child. The child was inconsolable when the
parent left, but now is quite and withdrawn. This is known as what stage of separation anxiety?
A. Detachment
B. Denial
C. Despair
D. Protest
30. A 3-year-old is hospitalized. The parent verbalizes to you that at home the child was potty trained but now the
child is refusing to use the toilet and is voiding on themselves. The parent expresses concern. As the nurse you
should tell the parent?
1. The school-age child experiences many physical changes throughout this developmental time period. Which of the following
is NOT a change experienced by this age group?
2. A 10-year-old is hospitalized for the treatment of a broken arm. The child is becoming restless and bored. The nurse asks the child
if they would like to do an activity. Which activity below would be appropriate for the nurse to suggest to the child?
A. Stacking blocks
B. Writing poems
D. Watching a movie
3. A 10-year-old is being prepped for heart surgery to replace a heart valve. What fears or stressors does the nurse anticipate
this child could experience during this hospitalization?
A. Fear of strangers
C. Fear of pain/injury
D. Invasion of privacy
4. According to Kohlberg’s Stages of Moral Development, what would be the reason for conformity to the rules for a 9- year-old
child?
A. The child conforms to the rules because of the rewards given for good behavior.
B. The child conforms to the rules because it maintains social order.
C. The child conforms to the rules because it provides a mutual benefit.
D. The child conforms to the rules because it causes others to view them as being good.
5. What’s the first area of the body that’s easily recognized as the beginning of the growth in puberty?
RATIONALE:Different areas of the body reach their peak growth at different times. Changes are easily recognized in the feet, which
are the first part of the body to experience growth. Increased foot size is followed by a rapid increase in leg length and then trunk
growth.
6. Which statement by your female adolescent patient reveals an early sign of anorexia nervosa?
RATIONALE:Excessive exercise, consumption of very small amounts of food, and food rituals are all signs of anorexia nervosa.
Menstruation commonly stops, and the patient’s weight is below normal.
RATIONALE:C. Major organs double in size during adolescence; the exception is the lymphoid tissue, which decreases in mass.
RATIONALE: Iron is needed in the production of the protein hemoglobin, which is vital to carrying oxygen in the blood and is lost
during menses
RATIONALE: B. Russell’s sign includes calluses on the knuckles or abrasions and scars on the dorsum of the hand due to induced
vomiting with bulimia
10. The school-age child experiences many physical changes throughout this developmental time period. Which of the following
is NOT a change experienced by this age group?
RATIONALE:The answer is C. This statement is INCORRECT. The weight gained for a school-age child is about 4.5 to 7 lbs. a year
(average: 45 lbs. at 6 years to 90 lbs. by 12 years and this depends on the child). However, it doesn’t triple.
11. The nurse is assessing a 10-year-old’s risk factors for obesity. Which findings assessed by the nurse are risk factors for obesity in
this child? Select all that apply:
A. II,III,IV C. II,III
B. I,II,III,IV D. III,IV
12. The nurse is developing a plan of care to help the school-age child and their caregiver implement diet changes to help decrease the
child’s obesity risk. Which intervention below should be avoided?
A. Include the family members with setting weight and food goals
B. Use a reward system that includes food rewards
C. Substitute the child’s favorite food with healthier options
D. Consider team sports for the child
RATIONALE:. A reward system that awards the child with food should be avoided. It teaches the child to associate food with
rewards. Other rewards could be used other than food.
13. A 9-year-old arrives at the clinic for a well visit. What are some safety educational topics the nurse should discuss during this
visit? Select all that apply:
A. I,II,III,IV,V C. I,II,III,V,VI
B. I,III,IV,V,VI D. ALL OF THE ABOVE
14. Your patient is 7-years-old. What stage of psychosocial development, according to Erikson’s Theory, should this child be in?
15. according to Erikson’s Stages of Psychosocial Development what is the outcome for the school-age child to obtain during this
stage?
A. Competency B. Trust
C. Sense of Purpose D. Love
RATIONALE:The school-age child is yearning to accomplish things through developed skills they will or have acquired.
Accomplishments give them a sense of satisfaction and they feel confident, which makes them feel like a competent person in the
world they live in. The goal from this stage is competency.
16. Fill in the blank: According to Piaget’s Theory of Cognitive Development a 10-year-old child would be in the
stage.
A. Preoperational
B. Concrete Operational
C. Sensorimotor
D. Formal Operational
A. Accident prevention
B. Keeping a night light on to allay fears
C. Normalcy of fears about body integrity
D. Encouraging the child to dress
without help
19. A nurse is planning activities to help children learn about good nutritional practices. Which of the following strategies should the
nurse implement?
RATIONALE: Children frequently prepare their own snacks and are more likely to learn from activities that foster active
participation .
20. child who has a BMI of 34 visits the school nurse. Which of the following factors does the nurse recognize that the child may be
experiencing?
22. The moral development of school-age children, as described by Kohlberg, is reflected in all the following statements except one,
Which one?
A. School age children believe that rules are established by others.
B. School age children learn the standards, and feel guilty when they violate these standards.
C. School age children judge an act by the intentions that prompted it rather than just by its consequences.
D. School age children are likely to interpret accidents and misfortunes as punishment for misdeeds.
23. Which of the following statements about causes of accidents during the school-age years is inaccurate?
A. School-age children are more active and become more adventurous and daring.
B. School- age children are more susceptible to hazards in the home environment
C. School age children are unable to understand potential dangers
D. School age children are less subject to parental control over their behavior.
24. Which of the following should the nurse include when instructing a mother to administer vitamins to a preschooler?
A. Give the vitamins with a sips of milk
B. Give preschoolers half a vitamin
C. Store the vitamins in a locked cabinet that the child cannot access
D. Allow the child to be independent by self-administering the vitamins
25. Based on the growth and development of adolescent girls, the school nurse understands which of the following is the priority
regarding body image/
A. Most girls are satisfied with their physical appearance
B. Few girls are satisfied with their physical appearance
C. The majority of girls think they are too thin abdomen and hips.
D. Girls are only concerned with their abdomen and hips
26. The nurse is teaching a class of adolescents to improve their diets. Which of the following approaches would be the most helpful
in achieving this goal?
A. Send dietary information to the parents of the adolescents
B. Have the adolescents get involved in meal planning after receiving information on dietary needs.
C. Show a film on dietary needs and what happens to the body if those needs are not met
D. Conduct a series of lectures by a variety of health specialists on dietary needs of adolescents.
27. Which of the following factors does not have an effect on the onset of menstruation?
A. Climate
B. Urban vs. rural
C. Genetics
D. Nutrition
28. Nearly half of the accidents in the adolescent age group are caused by which of the following?
A. Poisoning
B. Motor vehicles
C. Burn
D. Nutrition
29. Which of the following statements regarding adolescents' sexual maturation is correct?
A. Boys begin developing at different ages but develop at about the same rate.
B. Boys finish maturing before girls
C. The rate of development differs greatly from individual to individual
D. Boys usually mature faster than girls
30. Which concept of Piaget cognitive development is the basis for the child's fear of darkness?
A. Reversibility
B. Animism
C. Conversation of matter
D. Object permanence