Practice Test 2 MCN
Practice Test 2 MCN
Practice Test 2 MCN
She was informed that she had one. The nurse explains
that this is:
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.
3. The uterus has already risen out of the pelvis and is experiencing farther into the abdominal area at about the:
A. frequency
B. dysuria
C. incontinence
D. burning
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 gain weight in her pregnancy.
A. 20-30 lbs
B. 25-35 lbs
C. 30- 40 lbs
D. 10-15 lbs
6. The nurse is preparing Mrs. Jordan for cesarean delivery. Which of the following key concept should the nurse
consider when implementing nursing care?
A. generalized edema
B. proteinuria 4+
C. blood pressure of 160/110
D. convulsions
8. Nurse Geli explains to the client who is 33 weeks pregnant and is experiencing vaginal bleeding that coitus:
A. To facilitate elimination
B. To promote uterine contraction
C. To promote analgesia
D. To prevent infection
13. Nurse Luis is assessing the newborn’s heart rate. Which of the following would be considered normal if the
newborn is sleeping?
A. Toddler
B. Preschool
C. School
D. Adolescence
17. Which of the following situations would alert you to a potentially developmental problem with a child?
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.
19. 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
20. 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
21. Nurse Jonas assesses a 2 year old boy with a tentative diagnosis of nephroblastoma. Symptoms the nurse
observes that suggest this problem include:
A. blurred vision
B. nasal stuffiness
C. breast tenderness
D. constipation
23. Nurse Jacob is assessing a 15 month old child with acute otitis media. Which of the following symptoms would
the nurse anticipate finding?
1. Nurse Bella explains to a 28 year old pregnant woman undergoing a non-stress test that the test is a way of
evaluating the condition of the fetus by comparing the fetal heart rate with:
A. Fetal lie
B. Fetal movement
C. Maternal blood pressure
D. Maternal uterine contractions
2. During a 2 hour childbirth focusing on labor and delivery process for primigravida. The nurse describes the
second maneuver that the fetus goes through during labor progress when the head is the presenting part as which of
the following:
A. Flexion
B. Internal rotation
C. Descent
D. External rotation
3. Mrs. Jovel Diaz went to the hospital to have her serum blood test for alpha-fetoprotein. The nurse informed her
about the result of the elevation of serum AFP. The patient asked her what was the test for:
A. 5 weeks of gestation
B. 10 weeks of gestation
C. 15 weeks of gestation
D. 20 weeks of gestation
5. Mrs. Bendivin states that she is experiencing aching swollen, leg veins. The nurse would explain that this is most
probably the result of which of the following:
A. Thrombophlebitis
B. PIH
C. Pressure on blood vessels from the enlarging uterus
D. The force of gravity pulling down on the uterus
6. Mrs. Ella Santoros is a 25 year old primigravida who has Rheumatic heart disease lesion. Her pregnancy has just
been diagnosed. Her heart disease has not caused her to limit physical activity in the past. Her cardiac disease and
functional capacity classification is:
A. Class I
B. Class II
C. Class III
D. class IV
7. The client asks the nurse, “When will this soft spot at the top of the head of my baby will close?” The nurse
should instruct the mother that the neonate’s anterior fontanel will normally close by age:
A. 2-3 months
B. 6-8 months
C. 10-12 months
D. 12-18 months
8. When a mother bleeds and the uterus is relaxed, soft and non-tender, you can account the cause to:
A. Hematocrit 33.5%
B. WBC 8,000/mm3
C. Rubella titer less than 1:8
D. One hour glucose challenge test 110 g/dL
11. Aling Patricia is a patient with preeclampsia. You advise her about her condition, which would tell you that she
has not really understood your instructions?
A. Weekly during the 8th month because this is her third pregnancy.
B. During the second trimester, if amniocentesis indicates a problem.
C. To her infant immediately after delivery if the Coomb’s test is positive.
D. Within 72 hours after delivery if infant is found to be Rh positive.
14. A baby boy was born at 8:50pm. At 8:55pm, the heart rate was 99 bpm. She has a weak cry, irregular
respiration. She was moving all extremities and only her hands and feet were still slightly blue. The nurse should
enter the APGAR score as:
A. 5
B. 6
C. 7
D. 8
15. Billy is a 4 year old boy who has an IQ of 140 which means:
A. average normal
B. very superior
C. above average
D. genius
16. A newborn is brought to the nursery. Upon assessment, the nurse finds that the child has short palpebral fissures,
thinned upper lip. Based on this data, the nurse suspects that the newborn is MOST likely showing the effects of:
A. Chronic toxoplasmosis
B. Lead poisoning
C. Congenital anomalies
D. Fetal alcohol syndrome
17. A priority nursing intervention for the infant with cleft lip is which of the following:
A. an excess of RBC
B. an excess of WBC
C. a deficiency of clotting factor VIII
D. a deficiency of clotting factor IX
19. Celine, a mother of a 2 year old tells the nurse that her child “cries and has a fit when I have to leave him with a
sitter or someone else.” Which of the following statements would be the nurse’s most accurate analysis of the
mother’s comment?
A. Anxiety
B. Body image disturbance
C. Ineffective individual coping
D. Social isolation
21. The foul-smelling, frothy characteristic of the stool in cystic fibrosis results from the presence of large amounts
of which of the following:
A. Turner’s syndrome
B. Down’s syndrome
C. Marfan’s syndrome
D. Klinefelter’s syndrome
24. A 4 year old boy most likely perceives death in which way:
1. (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.
2. (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.
3. (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.
4. (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. (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.
6. (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.
7. (D) convulsions. Options A, B and C are findings of severe preeclampsia. Convulsions is a finding of
eclampsia—an obstetrical emergency.
8. (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.
9. (D) assume Sim’s position. When the woman is in Sim’s position, this puts the weight of the fetus on bed, not
on the woman and allows good circulation in the lower extremities.
10. (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.
11. (A) 13 -14 lbs. The birth weight of an infant is doubled at 6 months and is tripled at 12 months.
12. (B) To promote uterine contraction. Oxytocin is a hormone produced by the pituitary gland that produces
intermittent uterine contractions, helping to promote uterine involution.
13. (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.
14. (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.
15. (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.
16. (B) Preschool. During preschool, this is the time when children do imitative play, imaginative play—the
occurrence of imaginative playmates, dramatic play where children like to act, dance and sing.
17. (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.
18. (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 tantrums—ignore his/her behavior.
19. (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 ½ inch (1.25 cm) per month.
20. (D) Status Asthmaticus. Status asthmaticus leads to respiratory distress and bronchospasm despite of treatment
and interventions. Mechanical ventilation maybe needed due to respiratory failure.
21. (D) Abdominal mass and weakness. Nephroblastoma or Wilm’s tumor is caused by chromosomal
abnormalities, most common kidney cancer among children characterized by abdominal mass, hematuria,
hypertension and fever.
22. (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.
23. (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.
24. (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.
25. (B) Use of a high-SPF sunblock. Without melanin production, the child with albinism is at risk for severe
sunburns. Maximum sun protection should be taken, including use of hats, long sleeves, minimal time in the
sun and high-SPF sunblock, to prevent any problems.
Answers and Rationales
1. (B) Fetal movement. Non-stress test measures response of the FHR to the fetal movement. With fetal
movement, FHR increase by 15 beats and remain for 15 seconds then decrease to average rate. No increase
means poor oxygenation perfusion to fetus.
2. (A) Flexion. The 6 cardinal movements of labor are descent, flexion, internal rotation, extension, external
rotation and expulsion.
3. (D) Neural tube defects. Alpha-fetoprotein is a substance produces by the fetal liver that is present in amniotic
fluid and maternal serum. The level is abnormally high in the maternal serum if the fetus has an open spinal or
abdominal defect because the open defect allows more AFP to appear.
4. (D) 20 weeks of gestation. The FHR can be auscultated with a fetoscope at about 20 weeks of gestation. FHR
is usually auscultated at the midline suprapubic region with Doppler ultrasound at 10 to 12 weeks of gestation.
FHR cannot be heard any earlier than 10 weeks of gestation.
5. (C) Pressure on blood vessels from the enlarging uterus. Pressure of the growing fetus on blood vessels results
in an increase risk for venous stasis in the lower extremities. Subsequently, edema and varicose vein formation
may occur.
6. (A) Class I. Clients under class I has no physical activity limitation. There is a slight limitation of physical
activity in class II, ordinary activity causes fatigue, palpitation, dyspnea or angina. Class III is moderate
limitation of physical activity; less than ordinary activity causes fatigue. Unable to carry on any activity
without experiencing discomfort is under class IV.
7. (D) 12-18 months. Anterior fontanel closes at 12-18 months while posterior fontanel closes at birth until 2
months.
8. (A) Atony of the uterus. Uterine atony, or relaxation of the uterus is the most frequent cause of postpartal
hemorrhage. It is the inability to maintain the uterus in contracted state.
9. (B) January 11, 20111. Using the Nagel’s rule, he use this formula ( -3 calendar months + 7 days).
10. (C) Rubella titer less than 1:8. A rubella titer should be 1:8 or greater. Thus, a finding of a titer less than 1:8 is
significant, indicating that the client may not possess immunity to rubella. A hematocrit of 33.5%, WBC of
8,000/mm3, and a 1 hour glucose challenge test of 110 g/dL are within normal parameters.
11. (B) “I will limit my activities and rest more frequently throughout the day.”Pregnant woman with
preeclampsia should be in a complete bed rest. When body is in recumbent position, sodium tends to be
excreted at a faster rate. It is the best method of aiding increased excretion of sodium and encouraging diuresis.
Rest should always be in a lateral recumbent position to avoid uterine pressure on the vena cava and prevent
supine hypotension.
12. (C) The quietest room on the floor.A loud noise such as a crying baby, or a dropped tray of equipment may be
sufficient to trigger a seizure initiating eclampsia, a woman with severe preeclampsia should be admiotted to a
private room so she can rest as undisturbed as possible. Darken the room if possible because bright light can
trigger seizures.
13. (D) Within 72 hours after delivery if infant is found to be Rh positive. RhoGAM is given to Rh-negative
mothers within 72 hours after birth of Rh-positive baby to prevent development of antibodies in the maternal
blood stream, which will be fata to succeeding Rh-positive offspring.
14. (B) 6. Heart rate of 99 bpm-1; weak cry-1; irregular respiration-1; moving all extremities-2; extremities are
slightly blue-1; with a total score of 6.
15. (D) genius. IQ= mental age/chronological age x 100. Mental age refers to the typical intelligence level found
for people at a give chronological age. OQ of 140 and above is considered genius.
16. (D) Fetal alcohol syndrome. The newborn with fetal alcohol syndrome has a number of possible problems at
birth. Characteristics that mark the syndrome include pre and postnatal growth retardation; CNS involvement
such as cognitive challenge, microcephally and cerebral palsy; and a distinctive facial feature of a short
palpebral fissure and thin upper lip.
17. (A) Monitoring for adequate nutritional intake. The infant with cleft lip is unable to create an adequate seal for
sucking. The child is at risk for inadequate nutritional intake as well as aspiration.
18. (C) a deficiency of clotting factor VIII. Hemophillia A (classic hemophilia) is a deficiency in factor VIII (an
alpha globulin that stabilizes fibrin clots).
19. (D) The mother is describing her child’s separation anxiety. Before coming to any conclusion, the nurse should
ask the mother focused questions; however, based on initial information, the analysis of separation anxiety
would be most valid. Separation anxiety is a normal toddler response. When the child senses he is being sent
away from those who most provide him with love and security. Crying is one way a child expresses a physical
need; however, the nurse would be hasty in drawing this as first conclusion based on what the mother has said.
Nurturing overdependence or not providing structure for the toddler are inaccurate conclusions based on the
information provided.
20. (B) Body image disturbance. Mylene is experiencing uneasiness about the curvative of her spine, which will
be more evident when she wears a bathing suit. This data suggests a body image disturbance. There is no
evidence of anxiety or ineffective coping. The fact that Mylene is planning to attend a pool party dispels a
diagnosis of social isolation.
21. (B) undigested fat. The client with cystic fibrosis absorbs fat poorly because of the think secretions blocking
the pancreatic duct. The lack of natural pancreatic enzyme leads to poor absorption of predominantly fats in
the duodenum. Foul-smelling, frothy stool is termed steatorrhea.
22. (C) the father may resent the infant’s demands on the mother’s body. With breast feeding, the father’s body is
not capable of providing the milk for the newborn, which may interfere with feeding the newborn, providing
fewer chances for bonding, or he may be jealous of the infant’s demands on his wife time and body. Breast
feeding is advantageous because uterine involution occurs more rapidly, thus minimizing blood loss. The
presence of maternal antibodies in breast milk helps decrease the incidence of allergies in the newborn. A
greater chance for error is associated with bottle feeding. No preparation required for breast feeding.
23. (A) Turner’s syndrome. Lymphedema, webbed neck and low posterior hairline, these are the 3 key assessment
features in Turner’s syndrome. If the child is diagnosed early in age, proper treatment can be offered to the
family. All newborns should be screened for possible congenital defects.
24. (D) Temporary separation from the loved one. The predominant perception of death by preschool age children
is that death is temporary separation. Because that child is losing someone significant and will not see that
person again, it’s inaccurate to infer death is insignificant, regardless of the child’s response.
25. (D) sodium retention, water retention and potassium loss. Stress stimulates the adrenal cortex to increase the
release of aldosterone. Aldosterone promotes the resorption of sodium, the retention of water and the loss of
potassium.