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MATERNAL AND CHILD NURSING 3 Option D: Breast tissue does not hypertrophy in the fetus or
newborns.

4. Immediately after birth, the nurse notes the following on a

1. A newborn who has an asymmetrical Moro reflex response male newborn: respirations 78; apical heart rate 160 BPM,
should be further assessed for which of the following? nostril-flaring; mild intercostal retractions; and grunting at the
end of expiration. Which of the following should the nurse do?
A. Talipes equinovarus
B. Fractured clavicle A. Call the assessment data to the physician’s attention
C. Congenital hypothyroidism B. Start oxygen per nasal cannula at 2 L/min.
D. Increased intracranial pressure C. Suction the infant’s mouth and nares.
D. Recognize this as a normal first period of reactivity.
Answer: B. Fractured clavicle
A fractured clavicle would prevent the normal Moro response of Answer: D. Recognize this as normal first period of
symmetrical sequential extension and abduction of the arms reactivity
followed by flexion and adduction. The first 15 minutes to 1 hour after birth is the first period of
reactivity involving respiratory and circulatory adaptation to
Option A: In talipes equinovarus (clubfoot) the foot is turned extrauterine life. The data given reflect the normal changes
medially, and in plantar flexion, with the heel elevated. The feet during this time period.
are not involved with the Moro reflex.
Option C: Hypothyroidism has no effect on the primitive Option A: The infant’s assessment data reflect normal
reflexes. Hypothyroidism means that the thyroid gland can’t adaptation. Thus, the physician does not need to be notified.
make enough thyroid hormones to keep the body running Option B: Babies with heart or lung problems may need to
normally. breathe increased amounts of oxygen to get normal levels of
Option D: The absence of the Moro reflex is the most oxygen in their blood. Oxygen therapy provides babies with
significant single indicator of central nervous system status, but extra oxygen.
it is not a sign of increased intracranial pressure. Option C: The data do not indicate the presence of choking,
gagging, or coughing, which are signs of excessive secretions.
2. During the first 4 hours after a male circumcision, assessing Suctioning is not necessary.
for which of the following is the priority?
5. The nurse hears a mother telling a friend on the telephone
A. Infection about umbilical cord care. Which of the following statements by
B. Hemorrhage the mother indicates effective teaching?
C. Discomfort
D. Dehydration A. “Daily soap and water cleansing is best.”
B. “Alcohol helps it dry and kills germs.”
Answer: B. Hemorrhage C. “An antibiotic ointment applied daily prevents infection.”
Hemorrhage is a potential risk following any surgical procedure. D. “He can have a tub bath each day.”
Although the infant has been given vitamin K to facilitate
clotting, the prophylactic dose is often not sufficient to prevent Answer: B. “Alcohol helps it dry and kills germs”
bleeding. Application of 70% isopropyl alcohol to the cord minimizes
Option A: Although infection is a possibility, signs will not microorganisms (germicidal) and promotes drying. The cord
appear within 4 hours after the surgical procedure. should be kept dry until it falls off and the stump has healed.
Option C: The primary discomfort of circumcision occurs
during the surgical procedure, not afterward. Option A: Research now shows that the stump might actually
Option D: Although feedings are withheld prior to the heal faster if left alone. If the stump becomes dirty or sticky,
circumcision, the chances of dehydration are minimal. clean it with plain water, after which you dry it by holding a
clean, absorbent cloth around it or fanning it with a piece of
3. The mother asks the nurse. “What’s wrong with my son’s paper.
breasts? Why are they so enlarged?” Which of the following Option C: Antibiotic ointment should only be used to treat an
would be the best response by the nurse? infection, not as prophylaxis.
Option D: Infants should not be submerged in a tub of water
A. “The breast tissue is inflamed from the trauma experienced until the cord falls off and the stump has completely healed.
with birth.”
B. “A decrease in material hormones present before birth 6. A newborn weighing 3000 grams and feeding every 4 hours
causes enlargement,” needs 120 calories/kg of body weight every 24 hours for proper
C. “You should discuss this with your doctor. It could be a growth and development. How many ounces of 20 cals/oz
malignancy.” formula should this newborn receive at each feeding to meet
D. “The tissue has hypertrophied while the baby was in the nutritional needs?
uterus.”
A. 2 ounces
Answer: B. “A decrease in material hormones present B. 3 ounces
before birth causes enlargement,” C. 4 ounces
The presence of excessive estrogen and progesterone in the D. 6 ounces
maternal-fetal blood followed by prompt withdrawal at birth
precipitates breast engorgement, which will spontaneously Answer: B. 3 ounces
resolve in 4 to 5 days after birth. To determine the amount of formula needed, do the following
mathematical calculation. 3 kg x 120 cal/kg per day = 360
Option A: The trauma of the birth process does not cause calories/day feeding q 4 hours = 6 feedings per day = 60
inflammation of the newborn’s breast tissue. calories per feeding: 60 calories per feeding; 60 calories per
Option C: Newborns do not have breast malignancy. This reply feeding with formula 20 cal/oz = 3 ounces per feeding. Based
by the nurse would cause the mother to have undue anxiety. on the calculation. 2, 4 or 6 ounces are incorrect.
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Option A: 2 ounces is less than the recommended intake. of the symphysis pubis, then the woman is at 12 weeks
Newborns will nurse about 8 to 12 times per day during the first gestation.
weeks of life. In the beginning, mothers may want to try nursing Option D: The umbilicus is not an appropriate landmark to use
10–15 minutes on each breast, then adjust the time as necessary. when measuring the height of the fundus (McDonald’s
Option C: With 4 ounces, the newborn would be overfed and measurement). When the fundal height is at the level of the
not meet the adequate nutritional requirement. A baby who is umbilicus, the fundus is at 20 weeks gestation.
fussing, crying, seems hungry, and does not appear satisfied
after feeding may not be getting enough to eat. A baby is getting 9. A client with severe preeclampsia is admitted with BP
enough to eat if he or she seems satisfied, produces about six to 160/110, proteinuria, and severe pitting edema. Which of the
eight wet diapers a day, has regular bowel movements, sleeps following would be most important to include in the client’s
well, is alert when awake, and is gaining weight. plan of care?
Option D: 6 ounces is too much intake for a newborn every
feeding. Many infants “spit up” a small amount after eating or A. Daily weights
during burping, but a baby should not vomit after feeding. B. Seizure precautions
Vomiting after every feeding might be a sign of an allergy, C. Right lateral positioning
digestive problem, or other problem that needs medical D. Stress reduction
attention.
Answer: B. Seizure precautions
7. The post-term neonate with meconium-stained amniotic fluid Women hospitalized with severe preeclampsia need decreased
needs care designed to especially monitor for which of the CNS stimulation to prevent a seizure. Seizure precautions
following? provide environmental safety should a seizure occur.

A. Respiratory problems Option A: Because of edema, daily weight is important but not
B. Gastrointestinal problems the priority. High pregnancy weight gain was more strongly
C. Integumentary problems associated with term preeclampsia than early preterm
D. Elimination problems preeclampsia (eg, 64% versus 43% increased odds per 1 z score
difference in weight gain in normal-weight women, and 30%
Answer: A. Respiratory problems versus 0% in obese women, respectively).
Intrauterine anoxia may cause relaxation of the anal sphincter Option C: Preeclampsia causes vasospasm and therefore can
and emptying of meconium into the amniotic fluid. At birth reduce uteroplacental perfusion. The client should be placed on
some of the meconium fluid may be aspirated, causing her left side to maximize blood flow, reduce blood pressure, and
mechanical obstruction or chemical pneumonitis. promote diuresis.
Option D: Interventions to reduce stress and anxiety are very
Option B: The infant is not at increased risk for gastrointestinal important to facilitate coping and a sense of control, but seizure
problems. Postmature infants are alert and appear mature. They precautions are the priority.
have a decreased amount of soft-tissue mass, particularly
subcutaneous fat. The skin may hang loosely on the extremities 10. A postpartum primipara asks the nurse, “When can we have
and is often dry and peeling. The fingernails and toenails are sexual intercourse again?” Which of the following would be the
long. The nails and umbilical cord may be stained with nurse’s best response?
meconium passed in utero.
Option C: Even though the skin is stained with meconium, it is A. “Anytime you both want to.”
noninfectious (sterile) and non-irritating. B. “As soon as you choose a contraceptive method.”
Option D: The post-term meconium-stained infant is not at C. “When the discharge has stopped, and the incision is
additional risk for bowel or urinary problems. Failure to pass healed.”
meconium beyond 48 hours in term neonates may indicate D. “After your 6 weeks examination.”
disease or obstruction of the infant’s bowel. The diagnostic
differential for the delayed passage of meconium includes Answer: C. “When the discharge has stopped and the
Hirschsprung disease, meconium plug syndrome, meconium incision is healed.”
ileus, anorectal malformations, small left colon syndrome, and Cessation of the lochial discharge signifies healing of the
intestinal atresias. endometrium. The risk of hemorrhage and infection are minimal
3 weeks after a normal vaginal delivery.
8. When measuring a client’s fundal height, which of the
following techniques denotes the correct method of Option A: Telling the client anytime is inappropriate because
measurement used by the nurse? this response does not provide the client with the specific
information she is requesting.
A. From the xiphoid process to the umbilicus. Option B: Choice of a contraceptive method is important, but
B. From the symphysis pubis to the xiphoid process. not the specific criteria for safe resumption of sexual activity.
C. From the symphysis pubis to the fundus. Option D: Culturally, the 6-weeks’ examination has been used
D. From the fundus to the umbilicus. as the time frame for resuming sexual activity, but it may be
resumed earlier.
Answer: C. From the symphysis pubis to the fundus.
The nurse should use a non-elastic, flexible, paper measuring 11. When preparing to administer the vitamin K injection to a
tape, placing the zero point on the superior border of the neonate, the nurse would select which of the following sites as
symphysis pubis and stretching the tape across the abdomen at appropriate for the injection?
the midline to the top of the fundus.
A. Deltoid muscle
Option A: The xiphoid process is an incorrect landmark to use B. Anterior femoris muscle
in measuring for fundal height. If measured correctly, the C. Vastus lateralis muscle
fundus at 36 weeks should be at the xiphoid process. D. Gluteus maximus muscle
Option B: Measuring from the symphysis pubis to the xiphoid
process is incorrect. If the fundal height is measured at the level Answer: C. Vastus lateralis muscle

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The middle third of the vastus lateralis is the preferred injection 14. A client at 8 weeks’ gestation calls complaining of slight
site for vitamin K administration because it is free of blood nausea in the morning hours. Which of the following client
vessels and nerves and is large enough to absorb the medication. interventions should the nurse question?

Option A: The deltoid muscle of a newborn is not large enough A. Taking 1 teaspoon of bicarbonate of soda in an 8-ounce
for a newborn IM injection. Injections into this muscle in a glass of water.
small child might cause damage to the radial nerve. B. Eating a few low-sodium crackers before getting out of bed.
Option B: The anterior femoris muscle is the next safest muscle C. Avoiding the intake of liquids in the morning hours.
to use in a newborn but is not the safest. The rectus femoris (the D. Eating six small meals a day instead of three large meals.
middle third of the rectus femoris) is no longer a recommended
site because it may cause discomfort and pain. A previous study Answer: A. Taking 1 teaspoon of bicarbonate of soda in an
reported that one disadvantage of this site is that nerves and 8-ounce glass of water.
numerous blood vessels run very close to it Using bicarbonate would increase the amount of sodium
Option D: Because of the proximity of the sciatic nerve, the ingested, which can cause complications.
gluteus maximus muscle should not be until the child has been
walking 2 years. Option B: Eating low-sodium crackers would be appropriate.
Foods high in starch — such as saltines, bread, and toast — help
12. When performing a pelvic examination, the nurse observes a absorb gastric acid and settle a queasy stomach. The bland
red swollen area on the right side of the vaginal orifice. The nature of a cracker helps to satisfy hunger (excessive hunger can
nurse would document this as enlargement of which of the exacerbate nausea) without the strong smells or tastes that may
following? increase nausea.
Option C: Since liquids can increase nausea avoiding them in
A. Clitoris the morning hours when nausea is usually the strongest is
B. Parotid gland appropriate.
C. Skene’s gland Option D: Eating six small meals a day would keep the stomach
D. Bartholin’s gland full, which often decreases nausea.

Answer: D. Bartholin’s gland 15. The nurse documents positive ballottement in the client’s
The Bartholin’s glands are located symmetrically at the prenatal record. The nurse understands that this indicates which
posterior region of the vaginal opening and play an important of the following?
role in the female reproductive system. These two pea-sized
glands are involved in mucus secretion and vaginal lubrication. A. Palpable contractions on the abdomen.
B. Passive movement of the unengaged fetus.
Option A: The clitoris is female erectile tissue found in the C. Fetal kicking felt by the client.
perineal area above the urethra. During sexual stimulation, the D. Enlargement and softening of the uterus.
clitoris functions much like a man’s penis in that it becomes
erect thanks to signals from the brain. The shaft under the skin Answer: B. Passive movement of the unengaged fetus.
has erectile tissue, which becomes engorged with increased Ballottement indicates passive movement of the unengaged
blood flow. The clitoris is a very sensitive area when stimulated. fetus. Ballottement is when the lower uterine segment or the
Option B: The parotid glands are open into the mouth. The cervix is tapped by the examiner’s finger and left there, the fetus
parotid is the largest of the three glands and is bordered floats upward, then sinks back and a gentle tap is felt on the
superiorly by the zygomatic arch, anteriorly and medially by the finger.
masseter, and posteriorly by the sternocleidomastoid. The saliva
secreted from these glands moistens the mouth which helps with Option A: Ballottement is not a contraction. Contractions can be
chewing, swallowing, phonation, and digestion. felt by placing a hand on the abdomen and feeling when the
Option C: Skene’s glands open into the posterior wall of the uterus becomes hard, and when it relaxes. It is therefore possible
female urinary meatus. The Skene’s glands, which are also to assess the length of a contraction by taking the time at the
known as the lesser vestibular glands (homologous to the beginning and end of the contraction.
prostate glands in males), are two glands located on either side Option C: Fetal kicking felt by the client represents quickening.
of the urethra. These glands are believed to secrete a substance Usually, quickening occurs naturally at about the middle of a
to lubricate the urethra opening. This substance is also believed pregnancy. A woman pregnant for the first time (i.e., a
to act as an antimicrobial. primigravida woman) typically feels fetal movements at about
18–20 weeks, whereas a woman who has given birth at least
13. To differentiate as a female, the hormonal stimulation of the once (i.e., a para woman) will typically feel movements around
embryo that must occur involves which of the following? 15–17 weeks.
Option D: Enlargement and softening of the uterus is known as
A. Increase in maternal estrogen secretion Piskacek’s sign. The Piskacek’s sign is an indication of
B. Decrease in maternal androgen secretion. pregnancy. Specifically, Piskacek’s sign consists of noting a
C. Secretion of androgen by the fetal gonad. palpable lateral bulge or soft prominence at one of the locations
D. Secretion of estrogen by the fetal gonad. where the uterine tube meets the uterus. Piskacek’s sign can be
noted in the seventh to eighth week of gestation.
Answer: D. Secretion of estrogen by the fetal gonad.
The fetal gonad must secrete estrogen for the embryo to 16. During a pelvic exam, the nurse notes a purple-blue tinge of
differentiate as a female. the cervix. The nurse documents this as which of the following?

Option A: An increase in maternal estrogen secretion does not A. Braxton-Hicks sign

affect differentiation of the embryo, and maternal estrogen B. Chadwick’s sign
secretion occurs in every pregnancy. C. Goodell’s sign
Option B: Maternal androgen secretion remains the same as D. McDonald’s sign
before pregnancy and does not affect differentiation.
Option C: Secretion of androgen by the fetal gonad would Answer: B. Chadwick’s sign
produce a male fetus.
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Chadwick’s sign is a bluish discoloration of the cervix, vagina, Option B: Administering a light sedative would be done for
and labia resulting from increased blood flow. It can be hypertonic uterine contractions.
observed as early as 6 to 8 weeks after conception, and its Option C: Preparing for a cesarean section is unnecessary at this
presence is an early sign of pregnancy. time.
Option D: Oxytocin would increase the uterine contractions and
Option A: Braxton Hicks contractions are painless contractions hopefully progress labor before a cesarean would be necessary.
beginning around the 4th month. Braxton Hicks contractions are It is too early to anticipate client pushing with contractions.
sporadic contractions and relaxation of the uterine muscle.
Sometimes, they are referred to as prodromal or “false labor” 19. A multigravida at 38 weeks’ gestation is admitted with
pains. It is believed they start around 6 weeks gestation but painless, bright red bleeding and mild contractions every 7 to 10
usually are not felt until the second or third trimester of the minutes. Which of the following assessments should
pregnancy. Braxton Hicks contractions are the body’s way of be avoided?
preparing for true labor, but they do not indicate that labor has
begun or is going to start. A. Maternal vital sign
Option C: Goodell sign is an indication of pregnancy. It is a B. Fetal heart rate
significant softening of the vaginal portion of the cervix from C. Contraction monitoring
increased vascularization. This vascularization is a result of D. Cervical dilation
hypertrophy and engorgement of the vessels below the growing
uterus. This sign occurs at approximately four weeks’ gestation. Answer: D. Cervical dilation
Option D: Flexibility of the uterus against the cervix is known The signs indicate placenta previa and vaginal exam to
as McDonald’s sign. determine cervical dilation would not be done because it could
cause hemorrhage.
17. During a prenatal class, the nurse explains the rationale for Option A: Assessing maternal vital signs can help determine
breathing techniques during preparation for labor based on the maternal physiologic status.
understanding that breathing techniques are most important in Option B: Fetal heart rate is important to assess fetal well-being
achieving which of the following? and should be done.
Option C: Monitoring the contractions will help evaluate the
A. Eliminate pain and give expectant parents something to do. progress of labor.
B. Reduce the risk of fetal distress by increasing uteroplacental
perfusion. 20. Which of the following would be the nurse’s most
C. Facilitate relaxation, possibly reducing the perception of appropriate response to a client who asks why she must have a
pain. cesarean delivery if she has a complete placenta previa?
D. Eliminate pain so that less analgesia and anesthesia are
needed. A. “You will have to ask your physician when he returns.”
B. “You need a cesarean to prevent hemorrhage.”
Answer: C. Facilitate relaxation, possibly reducing the C. “The placenta is covering most of your cervix.”
perception of pain. D. “The placenta is covering the opening of the uterus and
Breathing techniques can raise the pain threshold and reduce the blocking your baby.”
perception of pain. They also promote relaxation.
Answer: D. “The placenta is covering the opening of the
Option A: Breathing techniques do not eliminate pain, but they uterus and blocking your baby.”
can reduce it. Focused breathing might work by interrupting the A complete placenta previa occurs when the placenta covers the
transmission of pain signals to the brain by giving the woman opening of the uterus, thus blocking the passageway for the
something positive to focus on. It may also work by stimulating baby. This response explains what a complete previa is and the
the release of endorphins, which are natural pain-relieving reason the baby cannot come out except by cesarean delivery.
hormones, and by helping her reframe her thinking about labor Option A: Telling the client to ask the physician is a poor
so that she can view it as positive, productive, and manageable. response and would increase the patient’s anxiety.
Option B: Positioning, not breathing, increases uteroplacental Option B: Although a cesarean would help to prevent
perfusion. Side-lying position aids in better blood circulation. hemorrhage, the statement does not explain why the hemorrhage
Option D: Breathing techniques do not eliminate pain. Many could occur.
different childbirth classes include components of breathing in Option C: With a complete previa, the placenta is covering all
their class curriculum. The techniques may vary but many the cervix, not just most of it.
classes today teach that breathing should be slow, deep,
controlled, and conscious or voluntary, not automatic. 21. The nurse understands that the fetal head is in which of the
following positions with a face presentation?
18. After 4 hours of active labor, the nurse notes that the
contractions of a primigravida client are not strong enough to A. Completely flexed
dilate the cervix. Which of the following would the nurse B. Completely extended
anticipate doing? C. Partially extended
D. Partially flexed
A. Obtaining an order to begin IV oxytocin infusion.
B. Administering a light sedative to allow the patient to rest for Answer: B. Completely extended
several hours In a face presentation, the fetal head and neck are
C. Preparing for a cesarean section for failure to progress hyperextended, causing the occiput to come in contact with the
upper back of the fetus while lying on a longitudinal axis.
Answer: A. Obtaining an order to begin IV oxytocin
infusion. Option A: With a vertex presentation, the head is completely or
The client’s labor is hypotonic. The nurse should call the partially flexed.
physical and obtain an order for an infusion of oxytocin, which Option C: With a brow (forehead) presentation, the head would
will assist the uterus to contract more forcefully in an attempt to be partially extended.
dilate the cervix. Option D: Partially flexed fetal head is categorized as a sinciput
presentation.
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22.With a fetus in the left anterior breech presentation, the nurse 25. When describing dizygotic twins to a couple, on which of
would expect the fetal heart rate would be most audible in the following would the nurse base the explanation?
which of the following areas?
A. Two ova fertilized by separate sperm.
A. Above the maternal umbilicus and to the right of midline. B. Sharing of a common placenta.
B. In the lower-left maternal abdominal quadrant. C. Each ova with the same genotype.
C. In the lower-right maternal abdominal quadrant. D. Sharing of a common chorion.
D. Above the maternal umbilicus and to the left of the midline.
Answer: A. Two ova fertilized by separate sperm
Answer: D. Above the maternal umbilicus and to the left of Dizygotic (fraternal) twins involve two ova fertilized by
midline separate sperm. Monozygotic (identical) twins involve a
With this presentation, the fetal upper torso and back face the common placenta, same genotype, and common chorion.
left upper maternal abdominal wall. The fetal heart rate would
be most audible above the maternal umbilicus and to the left of Option B: Monozygotic multiples form from a single egg and
the middle. The other positions would be incorrect. sperm combination that splits after conception. if the split is
delayed for a few days, the embryos will develop with a single,
Option A: The fetal heart rate would be most audible above the shared placenta.
maternal umbilicus but to the left of the midline. Option C: Identical twins share all of their genes and are always
Option B: It should not be at the lower-left of the maternal of the same sex.
abdominal quadrant. Fetal heart rate heard in this area may be Option D: In the majority of cases, these multiples will be
inaccurate or maybe the maternal heart rate. enclosed within a shared chorion (the outer layer of the sac that
Option C: This would be an inaccurate area to check for the contains a fetus).
fetal heart rate. Since the baby is in breech position, the fetal
back may be located at the upper maternal abdominal wall. 26. Which of the following refers to the single cell that
reproduces itself after conception?
23. The amniotic fluid of a client has a greenish tint. The nurse A. Chromosome
interprets this to be the result of which of the following? B. Blastocyst
C. Zygote
A. Lanugo D. Trophoblast
B. Hydramnios
C. Meconium Answer: C. Zygote
D. Vernix The zygote is the single cell that reproduces itself after
conception. It is the union of the sperm cell and the egg cell.
Answer: C. Meconium Also known as a fertilized ovum, the zygote begins as a single
The greenish tint is due to the presence of meconium. cell but divides rapidly in the days following fertilization. After
Meconium is a thick, green, tar-like substance that lines the this two-week period of cell division, the zygote eventually
baby’s intestines during pregnancy. Typically this substance is becomes an embryo. If this goes well, the embryo becomes a
not released in the baby’s bowel movements until after birth. fetus.
However, sometimes a baby will have a bowel movement prior
to birth, excreting the meconium into the amniotic fluid. Option A: The chromosome is the material that makes up the
cell and is gained from each parent. Chromosomes are
Option A: Lanugo is the soft, downy hair on the shoulders and thread-like structures located inside the nucleus of animal and
back of the fetus. This downy, unpigmented hair is the first type plant cells. Each chromosome is made of protein and a single
of hair that grows from hair follicles. It can be found molecule of deoxyribonucleic acid (DNA). Passed from parents
everywhere on a baby’s body, except on the palms, lips, and to offspring, DNA contains the specific instructions that make
soles of the feet. Most fetuses develop lanugo around the fourth each type of living creature unique.
or fifth month of pregnancy. Option B: The blastocyst consists of cells forming an outer
Option B: Hydramnios represents excessive amniotic fluid. trophectoderm (TE, trophoblast) layer, an inner cell mass (ICM,
Option D: Vernix is the white, cheesy substance covering the embryo blast), and a blastocoel (fluid-filled cavity). The inner
fetus. It is produced by dedicated cells and is thought to have cell mass will form the entire embryo and is the source of true
some protective roles during fetal development and for a few embryonic stem cells capable of forming all cell types within
hours after birth. the embryo.
Option D: In early development, the blastocyst outer
24. A patient is in labor and has just been told she has a breech trophectoderm (TE) layer will generate all the extraembryonic
presentation. The nurse should be particularly alert for which of trophoblast cell types: cytotrophoblast, syncytiotrophoblast,
the following? trophoblastic column, and extravillous trophoblast cells. These
cells have an important contribution to extra-embryonic tissues
A. Quickening (fetal placenta and membranes) and processes of early
B. Ophthalmia neonatorum development (adplantation, implantation, and endocrine support
C. Pica of pregnancy).
D. Prolapsed umbilical cord
27. In the late 1950s, consumers and health care professionals
Answer: D. Prolapsed umbilical cord began challenging the routine use of analgesics and anesthetics
In a breech position, because of the space between the during childbirth. Which of the following was an outgrowth of
presenting part and the cervix, prolapse of the umbilical cord is this concept?
common.
A. Labor, delivery, recovery, postpartum (LDRP)
Option A: Quickening is the woman’s first perception of fetal B. Nurse-midwifery
movement. C. Clinical nurse specialist
Option B: Ophthalmia neonatorum usually results from D. Prepared childbirth
maternal gonorrhea and is conjunctivitis.
Option C: Pica refers to the oral intake of nonfood substances. Answer: D. Prepared childbirth
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Prepared childbirth was the direct result of the 1950s the uterus (endometrial cells), and mucus. The average length of
challenging the routine use of analgesic and anesthetics during a period is between three days and one week.
childbirth. Option C: The secretory phase always occurs from day 14 to
day 28 of the cycle. Progesterone stimulated by LH is the
Option A: The LDRP was a much later concept and was not a dominant hormone during this phase to prepare the corpus
direct result of the challenging of routine use of analgesics and luteum and the endometrium for possible fertilized ovum
anesthetics during childbirth. implantation
Option B: A nurse-midwife is a licensed healthcare professional Option D: The final part of the secretory phase is the ischemic
who specializes in women’s reproductive health and childbirth. phase. The endometrium becomes pale and arteries constrict due
In addition to attending births, they perform annual exams, give to lower hormone release by the disintegrating corpus luteum.
counseling, and write prescriptions. According to the ACNM,
the vast majority of midwives in the U.S. are CNMs. 30. When teaching a group of adolescents about male hormone
Option C: Clinical nurse specialists (CNS) are advanced production, which of the following would the nurse include as
practice registered nurses (APRNs) that serve as experts in being produced by the Leydig cells?
evidence-based nursing practice within one of a number of
different specialty areas. They integrate their advanced A. Follicle-stimulating hormone
knowledge of disease processes in assessing, diagnosing, and B. Testosterone
treating patient illnesses, but their role extends beyond C. Luteinizing hormone
providing patient care. D. Gonadotropin-releasing hormone

28. A client has a mid pelvic contracture from a previous pelvic Answer: B. Testosterone
injury due to a motor vehicle accident as a teenager. The nurse Testosterone is produced by the Leydig cells in the seminiferous
is aware that this could prevent a fetus from passing through or tubules. The Leydig cells make and secrete testosterone, in
around which structure during childbirth? response to luteinizing hormone from the pituitary. This process
does not start until puberty when LH stimulates the Leydig cells
A. Symphysis pubis to produce testosterone. FSH stimulates the Sertoli cells to
B. Sacral promontory secrete androgen-binding protein into the lumen of the
C. Ischial spines seminiferous tubules.
D. Pubic arch
Option A: FSH is made by the pituitary gland, a small gland
Answer: C. Ischial spines located underneath the brain. FSH plays an important role in
The ischial spines are located in the mid-pelvic region and could sexual development and functioning. In women, FSH helps
be narrowed due to the previous pelvic injury. control the menstrual cycle and stimulates the growth of eggs in
the ovaries.
Option A: The pubic symphysis is a secondary cartilaginous Option C: Luteinizing hormone (LH) is produced and released
joint (a joint made of hyaline cartilage and fibrocartilage) in the anterior pituitary gland. This hormone is considered a
located between the left and right pubic bones near the midline gonadotropic hormone because of its role in controlling the
of the body. More specifically, it is located above any external function of ovaries in females and testes in males, which are
genitalia and in front of the bladder. known as the gonads.
Option B: Superiorly, there is an anterior projection of bone, Option D: The hypothalamus is responsible for releasing
known as the sacral promontory. It forms the posterior margin gonadotropin-releasing hormone.
of the pelvic inlet and as a result, it is serially continuous with
the margin of the ala of the sacrum, arcuate line of the ilium, 31. While performing a physical assessment of a 12 month-old,
and the pectin pubis and pubic crest of the pubic bone. the nurse notes that the infant’s anterior fontanel is still slightly
Option D: The pubic arch, also referred to as the ischiopubic open. Which of the following is the nurse’s most appropriate
arch, is part of the pelvis. It is formed by the convergence of the action?
inferior rami of the ischium and pubis on either side, below the
pubic symphysis. The angle at which they converge is known as A. Notify the physician immediately because there is a
the subpubic angle. problem.
B. Perform an intensive neurological examination.
29. When teaching a group of adolescents about variations in C. Perform an intensive developmental examination.
the length of the menstrual cycle, the nurse understands that the D. Do nothing because this is a normal finding for the age.
underlying mechanism is due to variations in which of the
following phases? Answer: D. Do nothing because this is a normal finding for
the age.
A. Menstrual phase The anterior fontanelle typically closes anywhere between 12 to
B. Proliferative phase 18 months of age. Thus, assessing the anterior fontanelle as still
C. Secretory phase being slightly open is a normal finding requiring no further
D. Ischemic phase action. Because it is a normal finding for this age, notifying the
physician or performing additional examinations is
Answer: B. Proliferative phase inappropriate.
Variations in the length of the menstrual cycle are due to
variations in the proliferative phase. In addition to ovarian Option A: The average size of the anterior fontanel is 2.1 cm,
follicle maturation, changes also occur in the endometrium and the median time of closure is 13.8 months. The most
during the first 14 days of the cycle, hence the term common causes of a large anterior fontanel or delayed fontanel
‘proliferative phase.’ The increasing concentrations of estradiol closure are achondroplasia, hypothyroidism, Down syndrome,
strongly influence the endometrial changes that happen before increased intracranial pressure, and rickets.
ovulation. Option B: During a neurological exam, the child’s healthcare
provider will test the functioning of the nervous system. The
Option A: Menstruation is the elimination of the thickened nervous system is very complex and controls many parts of the
lining of the uterus (endometrium) from the body through the body. The nervous system consists of the brain, spinal cord, 12
vagina. Menstrual fluid contains blood, cells from the lining of nerves that come from the brain, and the nerves that come from
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the spinal cord. The nervous system regulates the muscles. The Option C: Preschoolers develop a sense of guilt when their
circulation to the brain, arising from the arteries in the neck, is sense of initiative is thwarted. Initiative versus guilt is the third
also frequently examined. In infants and younger children, a stage of Erik Erikson’s theory of psychosocial development.
neurological exam includes the measurement of the head During the initiative versus guilt stage, children assert
circumference. themselves more frequently through directing play and other
Option C: The newborn’s skull is molded during birth. The social interactions.
frontal bone flattens, the occipital bone is pulled outward, and Option D: Schoolagers develop a sense of inferiority when they
the parietal bones override. These changes aid delivery through do not develop a sense of industry. Erikson’s fourth
the birth canal and usually resolve after three to five days. The psychosocial crisis, involving industry (competence) vs.
newborn’s skull should be evaluated for shape, circumference, Inferiority occurs during childhood between the ages of five and
suture ridges, and size of anterior and posterior fontanels. Size is twelve.
calculated by the average of the anteroposterior and transverse
dimensions. 34. Which of the following toys should the nurse recommend
for a 5-month-old?
32. When teaching a mother about introducing solid foods to her
child, which of the following indicates the earliest age at which A. A big red balloon
this should be done? B. A teddy bear with button eyes
C. A push-pull wooden truck
A. 1 month D. A colorful busy box
B. 2 months
C. 3 months Answer: D. A colorful busy box
D. 4 months A busy box facilitates fine motor development that occurs
between 4 and 6 months.
Answer: D. 4 months
Solid foods are not recommended before age 4 to 6 months Option A: Balloons are contraindicated because small children
because of the sucking reflex and the immaturity of the may aspirate balloons.
gastrointestinal tract and immune system. Therefore, the earliest Option B: Because the button eyes of a teddy bear may detach
age at which to introduce foods is 4 months. Any time earlier and be aspirated, this toy is unsafe for children younger than 3
would be inappropriate. years.
Option C: A 5-month-old is too young to use a push-pull toy.
Option A: 1-month old infants should stick to breast milk. Most Toddlers are full of energy, eager to explore everything around
doctors recommend waiting until at least 6 months before giving them. They love all kinds of physical activities such as pulling,
water. A 1-month-old may feed every 2-3 hours. The infant will pushing, lugging, knocking down, emptying, and filling.
know when to stop feeding by stopping, moving away from the
breast, or falling asleep. 35. The mother of a 2-month-old is concerned that she may be
Option B: At about 2 months of age, babies usually take 4 to 5 spoiling her baby by picking her up when she cries. Which of
ounces per feeding every 3 to 4 hours. the following would be the nurse’s best response?
Option C: How much formula for a 3-month-old baby?
Typically five ounces about six to eight times a day. How often A. “ Let her cry for a while before picking her up, so you don’t
should a 3-month-old nurse? Feedings are typically about every spoil her.”
three or four hours at this age but each breastfed baby may be B. “Babies need to be held and cuddled; you won’t spoil her
slightly different. To double-check that the baby’s getting this way.”
enough breast milk, check the diapers. How many wet diapers C. “Crying at this age means the baby is hungry; give her a
for a 3-month-old baby? About four or five very wet ones per bottle.”
day. D. “If you leave her alone she will learn how to cry herself to
sleep.”
33. The infant of a substance-abusing mother is at risk for Correct
developing a sense of which of the following? Correct Answer: B. “Babies need to be held and cuddled; you
won’t spoil her this way.”
Infants need to have their security needs met by being held and
A. Mistrust cuddled. At 2 months of age, they are unable to make the
B. Shame connection between crying and attention. This association does
C. Guilt not occur until late infancy or early toddlerhood.
D. Inferiority Option A: Letting the infant cry for a time before picking up the
infant or leaving the infant alone to cry herself to sleep
Answer: A. Mistrust interferes with meeting the infant’s need for security at this very
According to Erikson, infants need to have their needs met young age.
consistently and effectively to develop a sense of trust. An Option C: Infants cry for many reasons. Assuming that the child
infant whose needs are consistently unmet or who experiences Is hungry may cause overfeeding problems such as obesity.
significant delays in having them met, such as in the case of the Option D: If the care the infant receives is consistent,
infant of a substance-abusing mother, will develop a sense of predictable, and reliable, they will develop a sense of trust
uncertainty, leading to mistrust of caregivers and the which will carry with them to other relationships, and they will
environment. be able to feel secure even when threatened.

Option B: Toddlers develop a sense of shame when their 36. When assessing an 18-month-old, the nurse notes a
autonomy needs are not met consistently. Autonomy versus characteristic protruding abdomen. Which of the following
shame and doubt is the second stage of Erik Erikson’s stages of would explain the rationale for this finding?
psychosocial development. This stage occurs between the ages
of 18 months to approximately 3 years. According to Erikson, A. Increased food intake owing to age.
children at this stage are focused on developing a sense of B. Underdeveloped abdominal muscles.
personal control over physical skills and a sense of C. Bow Legged posture.
independence. D. Linear growth curve.
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Answer: B. Underdeveloped abdominal muscles Answer: C. Finger paints
Underdeveloped abdominal musculature gives the toddler a Young trent textures. Thus, finger paints would be an
characteristically protruding abdomen. It is generally normal for appropriate toy choice.
toddlers to have potbellies. By the time children reach school
age, the potbelly will most often disappear and their bodies Option A: Multiple-piece toddlers are still sensorimotor learners
seem more proportionate. The belly should feel soft and NOT and they enjoy the experience of feeling dizzy, such as puzzle,
tender. are too difficult to manipulate and may be hazardous if the
pieces are small enough to be aspirated.
Option A: During toddlerhood, food intake decreases, not Option B: Miniature cars also have a high potential for
increases. Feeding toddlers (ages 1 to 3) can often be aspiration.
challenging. That’s because several developmental changes are Option D: Comic books are on too high a level for toddlers.
happening at this time. Toddlers are striving for independence Although they may enjoy looking at some of the pictures,
and control. Their growth rate slows down and with this comes toddlers are more likely to rip a comic book apart.
a decrease in appetite.
Option C: Toddlers are characteristically bowlegged because the 39. When teaching parents about the child’s readiness for toilet
leg muscles must bear the weight of the relatively large trunk. training, which of the following signs should the nurse instruct
When babies are born with bow legs it’s because some of the them to watch for in the toddler?
bones had to rotate (twist) slightly when they were growing in
the womb to fit into the small space. This is called physiological A. Demonstrates dryness for 4 hours.
bow legs. It’s considered a normal part of a child’s growth and B. Demonstrates ability to sit and walk.
development. C. Has a new sibling for stimulation.
Option D: Toddler growth patterns occur in a steplike, not linear D. Verbalizes desire to go to the bathroom.
pattern. Between ages 1 and 2, a toddler will gain only about 5
pounds (2.2 kilograms). Weight gain will remain at about 5 Answer: D. Verbalizes desire to go to the bathroom
pounds (2.2 kilograms) per year between ages 2 to 5. Between The child must be able to sate the need to go to the bathroom to
ages 2 to 10 years, a child will grow at a steady pace. A final initiate toilet training. Toilet training is teaching the child to
growth spurt begins at the start of puberty, sometime between recognize their body signals for urinating and having a bowel
ages 9 to 15. movement. It also means teaching the child to use a potty chair
or toilet correctly and at the appropriate times.
37. If parents keep a toddler dependent in areas where he is
capable of using skills, the toddler will develop a sense of which Option A: Usually, a child needs to be dry for only 2 hours, not
of the following? 4 hours. Children develop at different rates. A child younger
than 12 months has no control over bladder or bowel
A. Mistrust movements. There is very little control between 12 to 18 months.
B. Shame Most children don’t have bowel and bladder control until 24 to
C. Guilt 30 months. The average age of toilet training is 27 months.
D. Inferiority Option B: The child also must be able to sit, walk, and squat.
Toilet training should start when your child shows signs that he
Answer: B. Shame or she is ready. There is no right age to begin. If you try to toilet
According to Erikson, toddlers experience a sense of shame train before your child is ready, it can be a battle for both you
when they are not allowed to develop appropriate independence and your child. The ability to control bowel and bladder muscles
and autonomy. If children are criticized, overly controlled, or comes with proper growth and development.
not given the opportunity to assert themselves, they begin to feel Option C: A new sibling would most likely hinder toilet training.
inadequate in their ability to survive, and may then become If there are older siblings, ask them to let the younger child see
overly dependent upon others, lack self-esteem, and feel a sense you praising them for using the toilet.
of shame or doubt in their abilities.
40. When teaching parents about typical toddler eating patterns,
Option A: Infants develop mistrust when their needs are not which of the following should be included?
consistently gratified. Failing to acquire the virtue of hope will
lead to the development of fear. This infant will carry the basic A . Food “jags.”
sense of mistrust with them to other relationships. It may result B. Preference to eat alone
in anxiety, heightened insecurities, and an over the feeling of C. Consistent table manners
mistrust in the world around them. D. Increase in appetite
Option C: Preschoolers develop guilt when their initiative needs
are not met. If this tendency is squelched, either through Answer: A. Food “jags.”
criticism or control, children develop a sense of guilt. The child Toddlers become picky eaters, experiencing food jags, and
will often overstep the mark in his forcefulness, and the danger eating large amounts one day and very little the next. A
is that the parents will tend to punish the child and restrict his toddler’s food gags express a preference for the ritualism of
initiatives too much. eating one type of food for several days at a time.
Option D: While school-agers develop a sense of inferiority Option B: Toddlers typically enjoy socialization and limiting
when their industry needs are not met. If this initiative is not others at mealtime.
encouraged, if it is restricted by parents or teachers, then the Option C: Toddlers prefer to feed themselves and thus are too
child begins to feel inferior, doubting his own abilities and young to have table manners.
therefore may not reach his or her potential. Option D: A toddler’s appetite and the need for calories, protein,
and fluid decrease due to the dramatic slowing of growth rate.
38. Which of the following is an appropriate toy for an
18-month-old? 41. Which of the following suggestions should the nurse offer
A. Multiple-piece puzzle the parents of a 4-year-old boy who resists going to bed at
B. Miniature cars night?
C. Finger paints A. “Allow him to fall asleep in your room, then move him to
D. Comic book his own bed.”

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B. “Tell him that you will lock him in his room if he gets out of reversible concrete thought. The ability to consider the future
bed one more time.” requires formal thought operations, which are not developed
C. “Encourage active play at bedtime to tire him out so he will until adolescence.
fall asleep faster.”
D. “Read him a story and allow him to play quietly in his bed Option A: Collecting baseball cards and marbles is an example
until he falls asleep.” of concrete operational thinking. Piaget considered the concrete
stage a major turning point in the child’s cognitive development
Answer: D. “Read him a story and allow him to play because it marks the beginning of logical or operational thought.
quietly in his bed until he falls asleep.” Option B: Children can conserve number (age 6), mass (age 7),
Preschoolers commonly have fears of the dark, being left alone and weight (age 9). Conservation is the understanding that
especially at bedtime, and ghosts, which may affect the child’s something stays the same in quantity even though its appearance
going to bed at night. Quiet play and time with parents is a changes.
positive bedtime routine that provides security and also readies Option C: Simple problem-solving options is an example of the
the child for sleep. concrete operational thinking of the school age.

Option A: The child should sleep in his own bed. 44. A hospitalized school ager states: “I’m not afraid of this
Option B: Telling the child about locking him in his room will place, I’m not afraid of anything.” This statement is most likely
be viewed by the child as a threat. Additionally, a locked door is an example of which of the following?
frightening and potentially hazardous.
Option C: Vigorous activity at bedtime stirs up the child and A. Regression
makes it more difficult to fall asleep. B. Repression
C. Reaction formation
42. When providing therapeutic play, which of the following D. Rationalization
toys would best promote imaginative play in a 4-year-old?
Answer: C. Reaction formation
A. Large blocks Reaction formation is the school ager’s typical defensive
B. Dress-up clothes response when hospitalized. In reaction formation, expression of
C. Wooden puzzle unacceptable thoughts or behaviors is prevented (or overridden)
D. Big wheels by the exaggerated expression of opposite thoughts or types of
behaviors.
Answer: B. Dress-up clothes
Dress-up clothes enhance imaginative play and imagination, Option A: Regression is seen in toddlers and preschoolers when
allowing preschoolers to engage in rich fantasy play. Play they retreat or return to an earlier level of development.
therapy is a form of therapy primarily geared toward children. Option B: Repression refers to the involuntary blocking of
In this form of therapy, a therapist encourages a child to explore unpleasant feelings and experiences from one’s awareness.
life events that may have an effect on current circumstances, in Option D: Rationalization is the attempt to make excuses to
a manner and pace of the child’s choosing, primarily through justify unacceptable feelings or behaviors.
play but also through language.
45. After teaching a group of parents about accident prevention
Option A: Though play is often regarded simply as a way for for school agers, which of the following statements by the group
individuals, particularly children, to relax, scientific research would indicate the need for more teaching?
has proven that play is a crucial factor in healthy child
development. Large blocks are good for developing fine motor A. “School Agers are more active and adventurous than are
development. younger children.”
Option C: Wooden puzzles are appropriate for encouraging fine B. “School Agers are more susceptible to home hazards than
motor development. Play is considered to be especially are younger children.”
important for the healthy development of children who have C. “Schoolagers are unable to understand potential dangers
experienced stressful events or past trauma. While the effects of around them.”
trauma tend to reside in the nonverbal areas of the brain—the D. “Schoolargers are less subject to parental control than are
hippocampus, amygdala, thalamus, and brain stem—a person’s younger children.”
capacity to communicate and process adverse issues resides in
the brain’s frontal lobes. Answer: C. “Schoolagers are unable to understand potential
Option D: Big wheels and tricycles encourage gross motor dangers around them.”
development. Play therapy is thought to be one of the most The school ager’s cognitive level is sufficiently developed to
beneficial means of helping children who are experiencing enable a good understanding of and adherence to rules. Thus,
emotional or behavioral challenges. Though the approach may school-agers should be able to understand the potential dangers
benefit people of all ages, it is specially designed to treat around them.
children under 12.
Option A: With growth comes greater freedom and children
43. Which of the following activities, when voiced by the become more adventurous and daring.
parents following a teaching session about the characteristics of Option B: The school-aged child is also still prone to accidents
school-age cognitive development would indicate the need for and home hazards, especially because of increased motor
additional teaching? abilities and independence. Plus the home hazards differ from
other age groups. These hazards, which are potentially lethal but
A. Collecting baseball cards and marbles. tempting, may include firearms, alcohol, and medications.
B. Ordering dolls according to size. Option D: School-age children begin to internalize their own
C. Considering simple problem-solving options. controls and needless outside direction. Plus the child is away
D. Developing plans for the future. from home more often. Some parental or caregiver assistance is
still needed to answer questions and provide guidance for
Answer: D. Developing plans for the future decisions and responsibilities.
The school-aged child is in the stage of concrete operations,
marked by inductive reasoning, logical operations, and
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46.Which of the following skills is the most significant one overly dependent upon others, lack self-esteem, and feel a sense
learned during the school-age period? of shame or doubt in their abilities.
Option B: Preschoolers develop a sense of guilt when they do
A. Collecting not develop a sense of initiative. If this tendency is squelched,
B. Ordering either through criticism or control, children develop a sense of
C. Reading guilt. The child will often overstep the mark in his forcefulness,
D. Sorting and the danger is that the parents will tend to punish the child
and restrict his initiatives too much.
Answer: C. Reading Option C: School-age children develop a sense of inferiority
The most significant skill learned during the school-age period when they do not develop a sense of industry. If this initiative is
is reading. During this time the child develops formal adult not encouraged, if it is restricted by parents or teachers, then the
articulation patterns and learns that words can be arranged in child begins to feel inferior, doubting his own abilities and
structure. therefore may not reach his or her potential.

Option A: School-age children most often have smooth and 49. Which of the following would be most appropriate for a
strong motor skills. However, their coordination (especially nurse to use when describing menarche to a 13-year-old?
eye-hand), endurance, balance, and physical abilities vary.
Option B: An ability to pay attention is important for success A. A female’s first menstruation or menstrual “periods.”
both at school and at home. A 6-year-old should be able to focus B. The first year of menstruation or “period."
on a task for at least 15 minutes. By age 9, a child should be C. The entire menstrual cycle or from one “period” to another.
able to focus attention for about an hour. D. The onset of uterine maturation or peak growth.
Option D: Fine motor skills may also vary widely. These skills
can affect a child’s ability to write neatly, dress appropriately, Answer: A. A female’s first menstruation or menstrual
and perform certain chores, such as making beds or doing “periods”.
dishes. Menarche refers to the onset of the first menstruation or
menstrual period and refers only to the first cycle. Uterine
47. A child age 7 was unable to receive the measles, mumps, growth and broadening of the pelvic girdle occur before
and rubella (MMR) vaccine at the recommended scheduled time. menarche. The average age of onset of menarche is 12.4 years.
When would the nurse expect to administer MMR vaccine?
Option B: Pulsatile hypothalamic production of
A. In a month from now gonadotropin-releasing hormone (GnRH) at puberty stimulates
B. In a year from now the pituitary production of follicle-stimulating hormone (FSH)
C. At age 10 and luteinizing hormone (LH). This pulsatile secretion pattern
D. At age 13 appears to be necessary as continuous secretion of GnRH, or its
synthetic analogs, inhibits pituitary production of FSH and LH
Answer: C. At age 10 and delays menarche.
Based on the recommendations of the American Academy of Option C: Most menstrual periods last between 3 and 7 days,
Family Physicians and the American Academy of Pediatrics, the and menses that last more than 10 days is considered abnormal.
MMR vaccine should be given at the age of 10 if the child did Option D: Menarche signals maturation of the adolescent female
not receive it between the ages of 4 to 6 years as recommended. body. It commonly is associated with the ability to ovulate and
Immunization for diphtheria and tetanus is required at age 13. reproduce. However, the appearance of menarche does not
guarantee either ovulation or fertility.
Option A: Children should get two doses of MMR vaccine,
starting with the first dose at 12 to 15 months of age, and the 50. A 14-year-old boy has acne and according to his parents,
second dose at 4 through 6 years of age. dominates the bathroom by using the mirror all the time. Which
Option B: Children can receive the second dose earlier as long of the following remarks by the nurse would be least helpful in
as it is at least 28 days after the first dose. talking to the boy and his parents?
Option D: MMR vaccine is given later than some other
childhood vaccines because antibodies transferred from the A. “This is probably the only concern he has about his body. So
mother to the baby can provide some protection from disease don’t worry about it or the time he spends on it.”
and make the MMR vaccine less effective until about 1 year of B. “Teenagers are anxious about how their peers perceive them.
age. So they spend a lot of time grooming.”
C. “A teen may develop a poor self-image when experiencing
48. The adolescent’s inability to develop a sense of who he is acne. Do you feel this way sometimes?”
and what he can become results in the sense of which of the D. “You appear to be keeping your face well washed. Would
following? you feel comfortable discussing your cleansing method?”

A. Shame Answer: A. “This is probably the only concern he has

B. Guilt about his body. So don’t worry about it or the time he
C. Inferiority spends on it.”
D. Role confusion Stating that this is probably the only concern the adolescent has
and telling the parents not to worry about it or the time he
Answer: D. Role confusion spends on it shuts off further investigation and is likely to make
According to Erikson, role cunfusion develops when the the adolescent and his parents feel defensive.
adolescent does not develop a sense of identity and a sense of
where he fits in. Option B: The statement about peer acceptance and time spent
in front of the mirror for the development of self-image provides
Option A: Toddlers develop a sense of shame when they do not information about the adolescent’s needs to the parents and may
achieve autonomy. If children are criticized, overly controlled, help to gain trust with the adolescent.
or not given the opportunity to assert themselves, they begin to Option C: Asking the adolescent how he feels about the acne
feel inadequate in their ability to survive, and may then become will encourage the adolescent to share his feelings.

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Option D: Discussing the cleansing method shows interest and Option A: The incidence of adolescent pregnancy has declined
concern for the adolescent and also can help to identify any since 1991, yet morbidity remains high.
patient-teaching needs for the adolescent regarding cleansing. Option B: Most teenage pregnancies are unplanned and occur
out of wedlock.
51. Which of the following should the nurse suspect when Option D: The pregnant adolescent is at high risk for physical
noting that a 3-year-old is engaging in explicit sexual behavior complications including premature labor and low-birth-weight
during doll play? infants, high neonatal mortality, iron deficiency anemia,
prolonged labor, and fetopelvic disproportion as well as
A. The child is exhibiting normal preschool curiosity. numerous psychological crises.
B. The child is acting out personal experiences.
C. The child does not know how to play with dolls. 54. When assessing a child with a cleft palate, the nurse is aware
D. The child is probably developmentally delayed. that the child is at risk for more frequent episodes of otitis media
due to which of the following?
Answer: B. The child is acting out personal experiences
Preschoolers should be developmentally incapable of A. Lowered resistance from malnutrition.
demonstrating explicit sexual behavior. If a child does so, the B. Ineffective functioning of the Eustachian tubes.
child has been exposed to such behavior, and sexual abuse C. Plugging of the Eustachian tubes with food particles.
should be suspected. D. Associated congenital defects of the middle ear.

Option A: As preschoolers seek independence, it’s normal for Answer: B. Ineffective functioning of the Eustachian tubes
them to argue and exercise their right to say “no.” They Because of the structural defect, children with cleft palate may
commonly vacillate between demanding they are a big kid who have ineffective functioning of their Eustachian tubes creating
can do everything on their own, to using baby talk to declare frequent bouts of otitis media.
they need help with a simple task.
Option C: Explicit sexual behavior during doll play is not a Option A: Most children with cleft palate remain well-nourished
characteristic of preschool development nor symptomatic of and maintain adequate nutrition through the use of proper
developmental delay. Whether or not the child knows how to feeding techniques.
play with dolls is irrelevant. Option C: Food particles do not pass through the cleft and into
Option D: Preschoolers may exhibit the occasional tantrum, but the Eustachian tubes. Otitis media with effusion is ubiquitous in
they should be gaining more control over their emotions and children who have a cleft palate. The cause is simply the lack of
impulses compared to when they were toddlers. Any temper proper insertion of the tensor veli palatini muscle in the soft
tantrums at this stage should be shorter and less intense than the palate. The muscle is, therefore, unable to open the eustachian
toddler years. tube on swallowing or wide mouth opening.
Option D: There is no association between cleft palate and
52. Which of the following statements by the parents of a child congenital ear deformities. The prevalence of associated
with school phobia would indicate the need for further teaching? anomalies with orofacial clefts can differ among different
populations. At birth, the black population has a lower
A. “We’ll keep him at home until phobia subsides.” prevalence of oral clefts compared to whites; Sullivan found
B. “We’ll work with his teachers and counselors at school.” that oral clefts in the black population are more commonly
C. “We’ll try to encourage him to talk about his problem.” associated with clubfoot and polydactyly compared to other
D. “We’ll discuss possible solutions with him and his ethnic populations.
counselor.”
55. While performing a neurodevelopmental assessment on a
Answer: A. “We’ll keep him at home until phobia subsides.” 3-month-old infant, which of the following characteristics
The parents need more teaching if they state that they will keep would be expected?
the child home until the phobia subsides. Doing so reinforces
the child’s feelings of worthlessness and dependency. A. A strong Moro reflex.
B. A strong parachute reflex.
Option B: The child should attend school even during resolution C. Rolling from front to back.
of the problem. D. Lifting of head and chest when prone.
Option C: Allowing the child to verbalize helps the child to
ventilate feelings and may help to uncover causes and solutions. Answer: D. Lifting of head and chest when prone
Option D: Collaboration with the teachers and counselors at A 3-month-old infant should be able to lift the head and chest
school may lead to uncovering the cause of the phobia and to when prone.
the development of solutions. The child should participate and
play an active role in developing possible solutions. Option A: The Moro reflex typically diminishes or subsides by
3 months. The Moro reflex is a normal primitive, infantile reflex.
53. When developing a teaching plan for a group of high school The Moro reflex is an involuntary protective motor response
students about teenage pregnancy, the nurse would keep in mind against abrupt disruption of body balance or extremely sudden
which of the following? stimulation.
Option B: The parachute reflex appears at 9 months. This reflex
A. The incidence of teenage pregnancies is increasing. occurs in slightly older infants when the child is held upright
B. Most teenage pregnancies are planned. and the baby’s body is rotated quickly to face forward (as in
C. Denial of the pregnancy is common early on. falling). The baby will extend his arms forward as if to break a
D. The risk for complications during pregnancy is rare. fall, even though this reflex appears long before the baby walks.
Option C: Rolling from front to back usually is accomplished at
Answer: C. Denial of the pregnancy is common early on. about 5 months.
The adolescent who becomes pregnant typically denies the
pregnancy early on. Early recognition by a parent or health care
provider may be crucial to timely initiation of prenatal care.

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56. By the end of which of the following would the it can be absorbed in the greatest amount of iron is to take it in
nurse most commonly expect a child’s birth weight to triple? two or more doses during the day.
Option C: The prognosis of ALL usually is good. However,
A. 4 months later on, the nurse may need to assist the child and family with
B. 7 months coping since death and dying may still be an issue in need of
C. 9 months discussion.
D. 12 months Option D: Injections should be discouraged, owing to increased
risk of bleeding due to thrombocytopenia.
Answer: D. 12 months
A child’s birth weight usually triples by 12 months and doubles 59. Which of the following information, when voiced by the
by 4 months. No specific birth weight parameters are mother, would indicate to the nurse that she understands home
established for 7 or 9 months. care instructions following the administration of diphtheria,
tetanus, and pertussis injection?
Option A: Most infants will gain about a pound over their birth
weight by month one. At this age, infants are not as sleepy, they A. Measures to reduce fever.
begin developing a regular feeding pattern, and they have a B. Need for dietary restrictions.
stronger suck during feedings. C. Reasons for subsequent rash.
Option B: On average, babies gain about one pound each month D. Measures to control subsequent diarrhea.
for the first six months. The average weight at six months is
about 16 pounds 2 ounces (7.3 kg) for girls and 17 pounds 8 Answer: A. Measures to reduce fever
ounces (7.9 kg) for boys. The pertussis component may result in fever and the tetanus
Option C: Between six months and one year, weight gain slows component may result in injection soreness. Therefore, the
down a little. Most babies double their birth weight by five to mother’s verbalization of information about measures to reduce
six months of age and triple it by the time they are a year old. fever indicates understanding.
By one year, the average weight of a baby girl is approximately
19 pounds 10 ounces (8.9 kg), with boys weighing about 21 Option B: No dietary restrictions are necessary after this
pounds 3 ounces (9.6 kg). injection is given.
Option C: Subsequent rash is more likely to be seen 5 to 10 days
57. Which of the following best describes parallel play between after receiving the MMR vaccine, not diphtheria, pertussis, and
two toddlers? tetanus vaccine.
Option D: Diarrhea is not associated with this vaccine. Common
A. Sharing crayons to color separate pictures. side effects include soreness or swelling where the shot was
B. Playing a board game with a nurse. given, fever, irritability, feeling tired, loss of appetite, and
C. Sitting near each other while playing with separate dolls. vomiting.
D. Sharing their dolls with two different nurses.
60. Which of the following actions by a community health nurse
Answer: C. Sitting near each other while playing with is most appropriate when noting multiple bruises and burns on
separate dolls the posterior trunk of an 18-month-old child during a home
Toddlers engaging in parallel play will play near each other, but visit?
not with each other. Thus, when two toddlers sit near each other
but play with separate dolls, they are exhibiting parallel play. A. Report the child’s condition to Protective Services
immediately.
Option A: Cooperative play involves children playing and B. Schedule a follow-up visit to check for more bruises.
working with others towards a common goal or purpose. C. Notify the child’s physician immediately.
Option B: Being able to participate in cooperative play is D. Don nothing because this is a normal finding in a toddler.
extremely important. It means that the child has the skills they’ll
need later to collaborate and cooperate at school and in other Answer: A. Report the child’s condition to Protective
typical social settings, like sports. Services immediately.
Option D: Sharing dolls with two different nurses is an example Multiple bruises and burns on a toddler are signs of child abuse.
of cooperative play. Therefore, the nurse is responsible for reporting the case to
Protective Services immediately to protect the child from further
58. Which of the following would the nurse identify as harm.
the initial priority for a child with acute lymphocytic leukemia?
Option B: Scheduling a follow-up visit is inappropriate because
A. Instituting infection control precautions. additional harm may come to the child if the nurse waits for
B. Encouraging adequate intake of iron-rich foods. further assessment data.
C. Assisting with coping with chronic illness. Option C: Although the nurse should notify the physician, the
D. Administering medications via IM injections. goal is to initiate measures to protect the child’s safety.
Notifying the physician immediately does not initiate the
Answer: A. Instituting infection control precautions removal of the child from harm nor does it absolve the nurse
Acute lymphocytic leukemia (ALL) causes leukopenia, from responsibility.
resulting in immunosuppression and increasing the risk of Option D: Multiple bruises and burns are not normal toddler
infection, a leading cause of death in children with ALL. injuries. Bruises form when the soft tissues of the body get
Therefore, the initial priority nursing intervention would be to bumped. When they do, small veins and capillaries (the tiniest
institute infection control precautions to decrease the risk of blood vessels) under the skin sometimes break. Red blood cells
infection. leak out of these blood vessels. These red blood cells that collect
under your skin cause that bluish, purplish, reddish, or blackish
Option B: Iron-rich foods help with anemia, but dietary iron is marks.
not an initial intervention. For the treatment of iron deficiency
anemia in adults, 100 to 200 mg of elemental iron per day has
been recommended. The best way to take the supplement so that

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61. Which of the following is being used when the mother of a immediately and the nurse must be prepared for an emergency
hospitalized child calls the student nurse and states, “You idiot, intubation or tracheostomy.
you have no idea how to care for my sick child”?
Option A: Further assessment with auscultating lungs and
A. Displacement placing the child in a mist tent wastes valuable time. The
B. Projection situation is a possible life-threatening emergency. In children,
C. Repression stridor may become louder in the supine position. Causes of
D. Psychosis stridor are pertussis, croup, epiglottis, aspirations. The
recommended auscultation position for the stethoscope is the
Answer: B. Projection chest wall position.
The mother is using projection, the defense mechanism used Option B: Having the child lie down would cause additional
when a person attributes his or her own undesirable traits to distress and may result in respiratory arrest. Inspiratory stridor is
another. often a medical emergency. Assessment of vital signs and
degree of respiratory distress is the first step. In some cases,
Option A: Displacement is the transfer of emotion onto an securing the airway may be necessary before or in parallel with
unrelated object, such as when the mother would kick a chair or the physical examination.
bang the door shut. Option C: Throat examination may result in laryngospasm that
Option C: Repression is the submerging of painful ideas into the could be fatal. Physical examination of a patient with suspected
unconscious. Repression is an unconscious mechanism acute epiglottitis is contraindicated. The patient may prefer
employed by the ego to keep disturbing or threatening thoughts certain positions that alleviate the stridor.
from becoming conscious.
Option D: Psychosis is a state of being out of touch with reality. 64. Which of the following would the nurse need to keep in
During a period of psychosis, a person’s thoughts and mind as a predisposing factor when formulating a teaching plan
perceptions are disturbed and the individual may have difficulty for a child with a urinary tract infection?
understanding what is real and what is not. Symptoms of A. A shorter urethra in females.
psychosis include delusions (false beliefs) and hallucinations B. Frequent emptying of the bladder.
(seeing or hearing things that others do not see or hear). C. Increased fluid intake.
D. Ingestion of acidic juices.
62. Which of the following should the nurse expect to note as a
frequent complication for a child with congenital heart disease? Answer: A. A shorter urethra in females
A. Susceptibility to respiratory infection In females, the urethra is shorter than in males. This decreases
B. Bleeding tendencies the distance for organisms to travel, thereby increasing the
C. Frequent vomiting and diarrhea chance of the child developing a urinary tract infection.
D. Seizure disorder
Option B: Frequent emptying of the bladder would help to
Answer: A. Susceptibility to respiratory infection decrease urinary tract infections by avoiding sphincter stress.
Children with congenital heart disease are more prone to Option C: Increased fluid intake enables the bladder to be
respiratory infections. Children with congenital heart disease cleared more frequently, thus helping to prevent urinary tract
(CHD) are at risk for increased morbidity from viral lower infections.
respiratory tract infections because of anatomical cardiac lesions Option D: The intake of acidic juices helps to keep the urine pH
that can worsen an already compromised respiratory status. acidic and thus decrease the chance of flora development.

Option B: It has been recognized that patients with Cyanotic 65. Which of the following should the nurse do first for a
Congenital Heart Disease (CCHD) show significant bleeding 15-year-old boy with a full leg cast who is screaming in
tendency which can be secondary to coagulopathies in these unrelenting pain and exhibiting right foot pallor signifying
patients. Some coagulation abnormalities are thrombocytopenia, compartment syndrome?
factor deficiencies, fibrinolysis, and Disseminated Intravascular A. Medicate him with acetaminophen.
Coagulation (DIC). B. Notify the physician immediately.
Option C: Vomiting and diarrhea are most likely experienced C. Release the traction.
with a heart attack. Women are somewhat more likely than men D. Monitor him every 5 minutes.
to experience some of the other common symptoms, particularly
shortness of breath, nausea/vomiting, and back or jaw pain. Answer: B. Notify the physician immediately
Option D: Although neurological morbidity has been Compartment syndrome is an emergent situation and the
consistently described in the congenital heart disease (CHD) physician needs to be notified immediately so that interventions
population,1 no studies to date have examined the long-term can be initiated to relieve the increasing pressure and restore
risk of epilepsy in subjects with CHD compared with the circulation. Compartment syndrome is a painful condition that
general population. occurs when pressure within the muscles builds to dangerous
levels. This pressure can decrease blood flow, which prevents
63. Which of the following would the nurse do first for a nourishment and oxygen from reaching nerve and muscle cells.
3-year-old boy who arrives in the emergency room with a
temperature of 105 degrees, inspiratory stridor, and restlessness, Option A: Acetaminophen (Tylenol) will be ineffective since
who is leaning forward and drooling? the pain is related to the increasing pressure and tissue ischemia.
Acute compartment syndrome is a surgical emergency. There is
A. Auscultate his lungs and place him in a mist tent. no effective non-surgical treatment.
B. Have him lie down and rest after encouraging fluids. Option C: The cast, not traction, is being used in this situation
C. Examine his throat and perform a throat culture. for immobilization, so releasing the traction would be
D. Notify the physician immediately and prepare for intubation. inappropriate. Casts and tight bandages may lead to
compartment syndrome. If symptoms of compartment syndrome
Answer: D. Notify the physician immediately and prepare develop, remove or loosen any constricting bandages. If there is
for intubation. a cast, contact the doctor immediately.
The child is exhibiting classic signs of epiglottitis, always a Option D: In this situation, specific action not continued
pediatric emergency. The physician must be notified monitoring is indicated. In acute compartment syndrome, unless
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the pressure is relieved quickly, permanent disability and tissue any other time. One common fear is the fear of body mutilation,
death may result. especially associated with painful experiences.

66. At which of the following ages would the nurse expect to Option A: In addition to the social aspects of play with peers
administer the varicella zoster vaccine to a child? already described, the type of play a child prefers reflects
A. At birth cognitive, fine and gross motor, and visual perceptual motor
B. 2 months skills. Children will not play for long at activities that frustrate
C. 6 months them because of a lack of ability. Fine motor and visual
D. 12 months perceptual motor skills are being refined during these years, but
there is a broad range of time for normal acquisition.
Answer: D. 12 months Option C: By age 4, children usually can play with three others
The varicella zoster vaccine (VZV) is a live vaccine given after fairly well. Fantasy or pretend play gains prominence at about
age 12 months. The first dose of hepatitis B vaccine is given at age 3. Children can play out longer stories as they mature, with
birth to 2 months, then at 1 to 4 months, and then again at 6 to each child taking a specific role. By age 5, the child has many
18 months. DTaP is routinely given at 2, 4, 6, and 15 to 18 social skills expected of adults, such as responding to the good
months and a booster at 4 to 6 years. fortune of others spontaneously with positive verbal messages,
apologizing for unintentional mistakes, and relating to a group
Option A: CDC recommends two doses of chickenpox vaccine of friends.
for children, adolescents, and adults. Children should receive Option D: Almost all preschool children are noncompliant, at
two doses of the vaccine—the first dose at 12 through 15 least some of the time—on the average, they comply with adult
months old and a second dose at 4 through 6 years old. requests about 50% of the time. This struggle for autonomy can
Option B: If the second dose is administered after the 7th be viewed as a positive milestone of development, with
birthday, the minimum interval between doses is ?3 months for passivity representing a potential symptom of depression or
children age <13 years and 4 weeks for persons age ?13 years intimidation.
Option C: If it has been more than 8 weeks since the first dose,
the second dose may be given without restarting the schedule. 69. Which of the following is characteristic of a preschooler
with mid-mental retardation?
67. When discussing normal infant growth and development A. Slow to feed self.
with parents, which of the following toys would the nurse B. Lack of speech.
suggest as most appropriate for an 8-month-old? C. Marked motor delays.
A. Push-pull toys D. Gait disability.
B. Rattle
C. Large blocks Answer: A. Slow to feed self.
D. Mobile Mild mental retardation refers to developmental disability
involving an IQ of 50 to 70. Typically, the child is not noted as
Answer: C. Large blocks being retarded, but exhibits slowness in performing tasks, such
Because the 8-month-old is refining his gross motor skills, being as self-feeding, walking, and taking.
able to sit unsupported, and also improving his fine motor skills,
probably capable of making hand-to-hand transfers, large blocks Option B: A speech delay might be due to an oral impairment,
would be the most appropriate toy selection. like problems with the tongue or palate (the roof of the mouth)
or a short frenulum (the fold beneath the tongue), which can
Option A: Push-pull toys would be more appropriate for the 10 limit tongue movement.
to 12-month-old as he or she begins to cruise the environment. Option C: Gross motor delays are common and vary in severity
Push toys provide support for babies who aren’t quite ready to and outcome. Some children with gross motor delays attain
stand or walk on their own. Teetering behind a push toy helps typical milestones at a later age. Other children have a
build strength, balance, and confidence — three essential permanent motor disability, such as cerebral palsy, which has a
ingredients to becoming a champion walker. Like push toys, prevalence of 3.3 per 1000.
pull toys and ride-ons also boost balance and coordination. Option D: Gait disabilities would be seen in more severe forms
Option B: Rattles are more appropriate for infants in the 1 to 3 of mental retardation. During a child’s first few years walking,
month age range. The sounds rattles make can also alert babies they may have obvious gait abnormalities — disturbances in
to noise. If they hear the sound of a rattle, babies will eventually what is considered the normal walking cycle for that age group.
turn their heads towards the sound. Many rattles also have
moving parts that can be twisted, turned, and spun, which can 70. Which of the following assessment findings would lead the
help further develop a baby’s attention span and fine motor nurse to suspect Down syndrome in an infant?
skills. A. Small tongue
Option D: Mobiles pose a danger to older infants because of B. Transverse palmar crease
possible strangulation. C. Large nose
D. Restricted joint movement
68. Which of the following aspects of psychosocial
development is necessary for the nurse to keep in mind when Answer: B. Transverse palmar crease
providing care for the preschool child? Down syndrome is characterized by the following a transverse
palmar crease (simian crease), separated sagittal suture, oblique
A. The child can use complex reasoning to think out situations. palpebral fissures, small nose, depressed nasal bridge, high
B. Fear of body mutilation is a common preschool fear. arched palate, excess and lax skin, wide spacing and plantar
C. The child engages in competitive types of play. crease between the second and big toes, hyperextensible and lax
D. Immediate gratification is necessary to develop initiative. joints, large protruding tongue, and muscle weakness.

Answer: B. Fear of body mutilation is a common preschool Option A: Tongue-tie, also known as ankyloglossia, is a
fear condition some babies are born with that limits their tongue
During the preschool period, the child has mastered a sense of movements. But for babies with tongue-tie, there’s a problem
autonomy and goes on to master a sense of initiative. During with the lingual frenulum. That’s the small stretch of tissue that
this period, the child commonly experiences more fears than at connects the underside of the tongue to the bottom of the mouth.
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It might be too short and tight or attached way up near the tip of approximately 80% of GERD patients. This symptom is usually
the tongue. described as a sour taste in the mouth or a sense of fluid moving
Option C: A newborn’s nose may be pushed in or flat because up and down in the chest.
of the tight squeeze during labor and delivery. It may take a Option B: Steatorrhea occurs in malabsorption disorders such as
week or longer before his or her nose looks more normal. celiac disease. During celiac disease, steatorrhea was caused by
Option D: Muscle tone represents one of the important concepts the decreased enzymatic function of the pancreas, asynchronism
for characterizing changes in the state of the developing nervous of the food, and bile supply to the intestinal lumen, disorders of
system. It can be manifested in the level of activity of flexors absorption of lipolysis products.
and extensors and in muscle reactions to its passive stretching Option D: “Currant jelly” stools are characteristic of
(StR) or shortening (ShR). intussusception. The trapped section of the bowel may have its
blood supply cut off, which causes ischemia. The mucosa is
71. While assessing a newborn with cleft lip, the nurse would be sensitive to ischemia and responds by causing sloughing off into
alert that which of the following will most likely be the gut. This creates a “red currant jelly” stool, which is
compromised? sloughed mucosa, blood, and mucus.
A. Sucking ability
B. Respiratory status 74. Which of the following nursing diagnoses would
C. Locomotion be inappropriate for the infant with gastroesophageal reflux
D. GI function (GER)?
A. Fluid volume deficit
Answer: A. Sucking ability B. Risk for aspiration
Because of the defect, the child will be unable to form the C. Altered nutrition: less than body requirements
mouth adequately around the nipple, thereby requiring special D. Altered oral mucous membranes
devices to allow for feeding and sucking gratification.
Answer: D. Altered oral mucous membranes
Option B: Respiratory status may be compromised if the child is GERD is the backflow of gastric contents into the esophagus
fed improperly or during the postoperative period resulting from relaxation or incompetence of the lower
Option C: Locomotion would be a problem for the older infant esophageal (cardiac) sphincter. No alteration in the oral mucous
because of the use of restraints. membranes occurs with this disorder.
Option D: GI functioning is not compromised in the child with a
cleft lip. One of the most immediate concerns after birth is Option A: Another common symptom of GERD is bringing
feeding. While most babies with cleft lips can breast-feed, a swallowed food up again to the mouth (regurgitation). Some
cleft palate may make sucking difficult. people can have trouble swallowing.
Option B: GERD can cause stomach contents to flow back into
72. When providing postoperative care for the child with a cleft the esophagus and dysphagia can cause food and/or liquid to
palate, the nurse should position the child in which of the remain in the esophagus after swallowing. If these substances
following positions are inhaled and move into the lungs, it can lead to serious
A. Supine respiratory problems, such as aspiration pneumonia.
B. Prone Option C: It is equally important to receive prompt treatment for
C. In an infant seat each of these disorders, as undiagnosed GERD can lead to
D. On the side Barrett’s esophagus and untreated gastroparesis can result in
malnutrition and weight loss.
Answer: B. Prone
Postoperatively children with cleft palate should be placed on 75. Which of the following parameters would the nurse monitor
their abdomens to facilitate drainage. A child who has had a to evaluate the effectiveness of thickened feedings for an infant
cleft lip repair should be positioned on their back to keep them with gastroesophageal reflux disease (GERD)?
from rubbing their face in the bed. A child with only a cleft A. Vomiting
palate repair may sleep on their stomach. B. Stools
C. Uterine
Option A: If the child is placed in the supine position, he or she D. Weight
may aspirate. The goal after surgery is to protect the new repair
and stitches. For this reason, there will be some changes in the Answer: A. Vomiting
child’s feeding, positioning, and activity for a short time. Thickened feedings are used with GER to stop the vomiting.
Option C: Using an infant seat does not facilitate drainage. Therefore, the nurse would monitor the child’s vomiting to
Option D: Side-lying does not facilitate drainage as well as the evaluate the effectiveness of using the thickened feedings.
prone position.
Option B: Feed thickeners are commonly used for managing
73. While assessing a child with pyloric stenosis, the nurse is infants with GOR despite the lack of strong supporting evidence.
likely to note which of the following? It is postulated that feed thickener reduces GOR by increasing
A. Regurgitation the viscosity or ‘stickiness’ of the liquid content, enabling the
B. Steatorrhea feed to be retained in the stomach.
C. Projectile vomiting Option C: However, feed thickeners can increase the energy
D. “Currant jelly” stools density and osmolality of the feed which may increase the
frequency of relaxation of the lower esophageal sphincter and
Answer: C. Projectile vomiting delay gastric emptying, worsening GOR.
Projectile vomiting is a key symptom of pyloric stenosis. Option D: If feedings are ineffective, this should be noted
Vomiting intensity also increases until pathognomonic projectile before there is any change in the child’s weight
vomiting ensues. Although vomiting may initially be infrequent,
over several days it becomes more predictable, occurring at
nearly every feeding.

Option A: Regurgitation is seen more commonly with GERD. “TRUST and BELIEVE!”
Regurgitation occurs with varying degrees of severity in
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