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    Exam Review

    1. A nurse is caring for a pregnant client and reviewing signs of complications that should be promptly reported to the provider. Which of the following should be included?
      A)
      Vaginal bleeding.
      B)
      Lightheadedness when lying on back.
      C)
      Heartburn after eating.
      D)
      Swelling of the ankles.
    2. A nurse is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation. Which of the following interventions should the nurse include in the plan of care?
      A)
      Keep the head of the bed at a 30-degree angle.
      B)
      Initiate the use of a PCA pump for pain control.
      C)
      Reposition the client by log rolling every 4 hours.
      D)
      Place the client in protective isolation.
    3. A nurse is providing care to multiple clients on the postpartum unit. Which of the following clients is at the greatest risk for developing a puerperal infection?
      A)
      A client who has a cesarean incision that is well-approximated with no drainage.
      B)
      A client who does not wash her hands between perineal care and breastfeeding.
      C)
      A client who has an episiotomy that is erythematous and has extended into a third-degree laceration.
      D)
      A client who is not breastfeeding and is using measures to suppress lactation.
    4. A nurse midwife is examining a client who is a primigravida at 42 weeks of gestation and states that she believes she is in labor. Which of the following findings confirm to the nurse that the client is in labor?
      A)
      Cervical dilation.
      B)
      Report of pain above the umbilicus.
      C)
      Brownish vaginal discharge.
      D)
      Amniotic fluid in the vaginal vault.
    Page 1 of 14

    Exam Review

    1. A community health nurse is developing a pamphlet about breast self-examination (BSE) for a local health fair. Which of the following instructions should the nurse include?
      A)
      Expect some breast dimpling or discharge with age.
      B)
      Using the palm of the hand, feel for lumps using a circular motion.
      C)
      Breasts can be examined in the shower with soapy hands.
      D)
      For those who have a menstrual cycle, perform a BSE every month, 2 or 3 days before menstruation.
    2. A nurse is assessing a postpartum client who is exhibiting tearfulness, insomnia, lack of appetite, and a feeling of letdown. The nurse knows these findings are characteristics of:
      A)
      Postpartum depression.
      B)
      The letting-go phase.
      C)
      Postpartum psychosis.
      D)
      Postpartum fatigue.
    3. Which of the following heart diseases are considered acquired? Select all that apply.
      (SATA)
      A)
      Infective endocarditis
      B)
      Kawasaki disease
      C)
      Hypoplastic left heart syndrome
      D)
      Cardiomyopathy
      E)
      Transposition of the great vessels
    4. A nurse is attending to an 8-year-old child diagnosed with acute rheumatic fever. What should be the nurse’s immediate priority assessment after admission?
      A)
      Identifying the level of parental anxiety related to the diagnosis
      B)
      Auscultating the rate and characteristics of the child’s heart sounds
      C)
      Using a pain-rating tool to evaluate the severity of the joint pain
      D)
      Assessing the client’s erythematous rash
    Page 2 of 14

    Exam Review

    1. A nurse is caring for a client in labor who is experiencing incomplete uterine relaxation between hypertonic contractions. What adverse effect does the nurse recognize as a result of this contraction pattern?
      A)
      Reduced fetal oxygen supply
      B)
      Delayed cervical dilation
      C)
      Prolonged labor
      D)
      Increased maternal stress.
    2. A nurse is providing care for a 6-month-old infant who underwent a cardiac catheterization. The child was diagnosed with pulmonary stenosis early in infancy and was admitted today for a balloon angioplasty procedure. Which of the following should the nurse plan to include in the discharge teaching?
      A)
      Apply pressure dressing four hours after discharge.
      B)
      Call the provider if the patient’s leg feels cool to touch compared to the left extremity.
      C)
      Administer acetaminophen or ibuprofen oral solution if needed for pain.
      D)
      Maintain a clear liquid diet for 24 hours after discharge.
    3. A nurse is caring for a newborn and hears an apical heart rate of 130/min. What should the nurse do next?
      A)
      Document this as an expected finding.
      B)
      Call the provider to further assess the newborn.
      C)
      Prepare the newborn for transport to the NICU.
      D)
      Ask another nurse to verify the heart rate.
    4. A client at 36 weeks gestation has just delivered a stillborn baby. What should the nurse say?
      A)
      “You may hold your baby as long as you want.”.
      B)
      “This is for the best. Your baby was very ill.”.
      C)
      “I understand your grief. I lost a baby also.”.
      D)
      “I have called for the chaplain to come and stay with you.”.
    Page 3 of 14

    Exam Review

    1. A nurse is assisting with the assessment of a newborn who was born at 32 weeks of gestation. The newborn’s birth weight is 1,100 g. What are the expected findings in this newborn? (Select all that apply.)
      A)
      Plump face
      B)
      Dehydration
      C)
      Long nails
      D)
      Weak grasp reflex
      E)
      Presence of lanugo .
    2. A nurse is monitoring a patient in labor who has received epidural anesthesia for pain management. What should the nurse recognize as a potential complication from the epidural block?
      A)
      Vomiting
      B)
      Tachycardia
      C)
      Hypotension
      D)
      Respiratory depression.
    3. A nurse is attending to a patient who is in preterm labor at 32 weeks of gestation. The patient asks the nurse, “Will my baby be okay?” What should the nurse respond?
      A)
      “We have a neonatal unit here that’s equipped to handle emergencies.”.
      B)
      “Everyone worries about their baby when they’re in labor.”.
      C)
      “You must be feeling scared and powerless.”.
      D)
      “Your pregnancy is advanced so your baby should be fine.”.
    4. A nurse is caring for a laboring patient with an external fetal monitor. The nurse notices late decelerations on the monitor strip. What does the nurse interpret this as indicating?
      A)
      Maternal bradycardia
      B)
      Uteroplacental insufficiency
      C)
      Umbilical cord compression
      D)
      Fetal head compression
    Page 4 of 14

    Exam Review

    1. A nurse is discharging a child who has recovered from an acute crisis episode of sickle cell anemia. What instructions should the nurse include in the teaching?
      A)
      “Offer fluids to your child multiple times every day.”.
      B)
      “Monitor your child’s temperature daily.”.
      C)
      “Apply cold compresses when your child expresses pain.”.
      D)
      “Restrict outdoor play activity to 1 hour per day.”.
    2. A nurse is caring for a newborn who was born at 38 weeks of gestation, weighs 3,200 g, and is in the 60th percentile for weight. How should the nurse classify this neonate based on the weight and gestational age?
      A)
      Low birth weight
      B)
      Appropriate for gestational age
      C)
      Large for gestational age
      D)
      Small for gestational age
    3. A nurse is preparing to administer digoxin to a 6-month-old infant. Before administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant’s apical heart rate is less than what rate? .
    4. A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an anti-streptolysin O (ASO) titer. The parent asks the nurse the purpose of the test. What should the nurse respond?
      A)
      “This test will indicate if your child has rheumatic fever.”.
      B)
      “This test will confirm if your child had a recent streptococcal infection.”.
      C)
      “This test will indicate if your child has a therapeutic blood level of an aminoglycoside.”.
      D)
      “This test will confirm if your child has immunity to streptococcal bacteria.”.
    Page 5 of 14

    Exam Review

    1. A newborn baby boy’s vital signs at 1 minute are as follows: Heart rate- 160 bpm, Respiratory effort - good, crying vigorously, Muscle tone - active movement, well flexed, Reflex irritability - cries with stimulation of soles of feet, Color - body pink, feet and hands cyanotic. What is the correct Apgar score for this newborn?
      A)
      5
      B)
      3
      C)
      8
      D)
      9
    2. A nurse is educating the parents of a toddler about iron deficiency anemia. Which of the following should the nurse suggest as a method of preventing iron deficiency anemia?
      A)
      Administer fat-soluble vitamins daily.
      B)
      Limit intake of high-protein foods.
      C)
      Include fluoridated water in the toddler’s diet.
      D)
      Avoid a diet that consists primarily of milk.
    3. A nurse is caring for a child who has Kawasaki disease. Which of the following systems should the nurse monitor in response to this diagnosis?
      A)
      Gastrointestinal
      B)
      Integumentary
      C)
      Respiratory
      D)
      Cardiovascular
    4. A nurse is preparing to assist with applying a cast to a preschooler’s arm. Which of the following actions should the nurse take?
      A)
      Support the casted arm with a firm grasp.
      B)
      Place a heated fan at the bedside to facilitate drying.
      C)
      Tell the child, “This will make your arm feel better.”.
      D)
      Wrap the arm of the child’s doll or toy prior to the procedure.
    Page 6 of 14