RECALLS 11 (NP2) - STUDENT COPY PDF - November 2024

## TOP RANK REVIEW ACADEMY *NLE* *NCLEX* *CGFNS* *HAAD* *PROMETRICS* *DHA* *MIDWIFERY* *LET* *RAD TECH* *CRIMINOLOGY* *DENTISTRY* *PHARMACY* ### RECALLS EXAMINATION 11 ### NURSING PRACTICE II ### CARE OF HEALTHY / AT RISK MOTHER AND CHILD NOVEMBER 2024 Philippine Nurse Licensure Examination Review...

## TOP RANK REVIEW ACADEMY *NLE* *NCLEX* *CGFNS* *HAAD* *PROMETRICS* *DHA* *MIDWIFERY* *LET* *RAD TECH* *CRIMINOLOGY* *DENTISTRY* *PHARMACY* ### RECALLS EXAMINATION 11 ### NURSING PRACTICE II ### CARE OF HEALTHY / AT RISK MOTHER AND CHILD NOVEMBER 2024 Philippine Nurse Licensure Examination Review **GENERAL INSTRUCTIONS:** 1. This test questionnaire contains 100 test questions 2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalid your answer. 3. AVOID ERASURES. 4. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set. 5. Write the subject title "NURSING PRACTICE II" on the box provided **1. During the phase 1 of menstrual cycle, the follicle-stimulating hormone directly acts on immature follicle to undergo maturation. A matured follicle produces a fluid rich in which hormone?** A. Estrogen B. Progesterone C. Luteinizing hormone D. Follicle-stimulating hormone **2. The events occurring on the phase 2 of the menstrual cycle involves the release of egg cell from the graafian follicle. Which of the following hormones is directly responsible for ovulation?** A. Estrogen B. Progesterone C. Luteinizing hormone D. Follicle-stimulating hormone **3. In which phase of the menstrual cycle does progesterone start to significantly decrease in level?** A. Follicular phase B. Luteal phase C. Ischemic phase D. Menstrual phase **SITUATION:** Nurse Yudi is assigned to perform health teaching on expecting first-time mothers. She competently answers the inquiries, questions, and concerns of her patients regarding the perinatal period. **4. Nurse Yudi is providing health teaching on presumptive signs and symptoms of pregnancy. She encourages them to immediately report the following signs to their OB-GYN except?** A. Positive Homan's sign B. Uncontrollable spasm of the calf C. Pain when the dorsal part of the foot is flexed D. All of the above **5. One of her patients raised concern about increased in urinary frequency. Nurse Yudi knows that this is expected during which time in pregnancy?** A. 1st and 2nd Trimester B. 2nd and 3rd trimester C. 1st and 3rd trimester D. 1st trimester only **6. Nicole is currently 39 weeks pregnant. She is concerned that her fetus is not as actively moving as it did before. Which of the following is the most appropriate response?** A. Don't be paranoid, your baby is just probably asleep. B. You should notify your OB-GYN as soon as possible. C. This is normal and expected considering your AOG. D. You should eat high-caloric food so your baby can have energy to move around. **7. Carol, 13 weeks and 4 days pregnant, raised concern regarding the nausea and vomiting she experiences all throughout the day. Which of the following is the most appropriate response?** A. This is expected and considered as a probable sign of pregnancy B. Eat dry toast and crackers in the morning C. An acupressure wrist band may help suppress vomiting D. Notify your doctor immediately. **8. Joy is 20 weeks pregnant. She raised concern regarding easy fatiguability and shortness of breath. Nurse Yudi knows that this is caused by which of the following events during pregnancy?** A. Decreased glucose level B. Increased blood volume C. Enlarged uterus D. Increased progesterone level **9. Nurse Yudi is providing health teaching regarding iron supplement during pregnancy. She would not include which of the following information in her teaching?** A. Iron supplements are best taken before meals B. Iron supplements are best taken with Vitamin C C. Iron supplements are best taken during the first trimester D. Iron supplements are best taken without milk **10. The nurse is performing an assessment on a client who suspects that she is pregnant and is checking the client for probable signs of pregnancy. The nurse should assess for which probable signs of pregnancy? Select all that apply.** I. Ballottement II. Chadwick's sign III. Uterine enlargement IV. Positive pregnancy test V. Fetal heart rate detected by a nonelectronic device VI. Outline of fetus via ultrasonography A. I, II, III, VI B. I, II, III, IV C. II, II, IV, VI D. I, II, IV, VI **11. A client in her third trimester tells the nurse, "I'm constipated all the time!" Which of the following should Nurse Yudi recommend?** A. Daily enemas B. Laxatives C. Increased fiber intake D. Decreased fluid intake **12. A 10-week pregnant patient verbalized that she noticed a bluish discoloration of her vagina. Nurse Yudi knows that this sign is also known as?** A. Chadwick's sign B. McDonald's sign C. Goodell's sign D. Homan's sign **13. Anna, 8 weeks pregnant, reports that she has noticed a thin, colorless vaginal drainage. Nurse Yudi knows to provide which statement to the patient?** A. You have to notify your doctor immediately. B. The vaginal discharge may be bothersome, but is a normal occurrence. C. Report to the emergency department at the maternity center immediately. D. Use tampons if the discharge is bothersome, but be sure to change the tampons every 2 hours. **14. You performed the Leopold's maneuver on one of your patients and found the following: breech presentation, fetal back at the left side of the mother. Based on these findings, you can hear the fetal heart beat BEST in which location?** A. Left lower quadrant B. Right lower quadrant C. Left upper quadrant D. Right upper quadrant **15. During fundal grip, you palpated a soft, broad mass that moves with the rest of the presenting part would be:** A. Fetal buttocks B. Fetal head C. Fetal extremities D. Fetal back **16. With a fetus in the left-anterior breech presentation, the nurse would expect the fetal heart rate would be most audible in which of the following areas?** A. Above the maternal umbilicus and to the right of midline B. In the lower-left maternal abdominal quadrant C. In the lower-right maternal abdominal quadrant D. Above the maternal umbilicus and to the left of midline **17. During vaginal examination of Janah who is in labor, the presenting part is at station plus two. The nurse correctly interprets that the presenting part is at:** A. Presenting part is 2 cm above the plane of the ischial spines. B. Biparietal diameter is at the level of the ischial spines. C. Presenting part in 2 cm below the plane of the ischial spines. D. Biparietal diameter is 2 cm above the ischial spines **18. During auscultation of the fetal heart rate, you noted a rate of 90 bpm in one full minute. Which of the following is the most appropriate action?** A. Notify the doctor immediately. B. Count the FHR within 30 seconds, then multiply it by 2. C. Check the FHR while assessing the maternal radial pulse. D. Perform Leopold's maneuver to awaken the baby. **19. A non-stress test is performed on a client who is pregnant, and the results of the test indicate nonreactive findings. The primary health care provider prescribes a contraction stress test, and the results are documented as negative. How would the nurse interpret the result of CST?** A. Abnormal test result B. Normal test result C. A high risk for fetal demise D. The need for a cesarean section **20. A Contraction Stress Test (CST) is used to determine the relationship of the fetal heart rhythm to the uterine contraction. Which of the following is considered normal in CST?** A. Early deceleration B. Late deceleration variable deceleration C. Any deceleration is abnormal in pregnancy. **21. The nurse is assisting in Contraction Stress Test. During the test, she noted a late decrease in fetal heart rhythm. She knows that this is most likely caused by which of the following?** A. Head compression B. Insufficient placental circulation C. Compression of the cord D. Decrease in amniotic fluid **22. When a late deceleration is noted during CST, which of the following is the most appropriate action?** A. Stop the test B. Place the patient on left side-lying position C. Provide oxygen support D. All of the above **23. Leila is now 26 weeks pregnant. She had a miscarriage at 10 weeks gestation 5 years ago. She has a 3-year-old who was born at 38 weeks. What is her GTPAL score?** A. G3 T2 PO A1 L2 B. G2 T2 P1 A1 L1 C. G3 T1 PO A1 L2 D. G3 T1 PO A1 L1 **24. Sheila is 25 weeks pregnant with twins. She has 5 kids at home. Four of them were born at 39 weeks. Her youngest was born at 27 weeks. 2 years ago, she had a miscarriage at 12 weeks. What is her GTPAL score?** A. G6 T4 P1 A1 L5 B. G5 T5 P1 A1 L5 C. G7 T5 PO A1 L5 D. G6 T5 P1 A1 L5 **25. Meila is currently 13 weeks pregnant with a history of miscarriage at 10 weeks and 9 weeks. She has 3 living children. Her first born was delivered via normal spontaneous delivery at 39 weeks. The second time she delivered a twin at 36 weeks by low transverse cesarean section due to premature rupture of membrane. What is her GTPALI score?** A. G5 T1 P1 A2 L3 B. G5 T2 P1 A2 L3 C. G5 T1 P2 A2 L3 D. G5 T1 P3 A2 L3 **26. When taking an obstetrical history on a pregnant client who states, "I had a son born at 38 weeks gestation, a daughter born at 30 weeks gestation and I lost a baby at about 8 weeks," the nurse should record her obstetrical history as which of the following?** A. G2 T2 PO AO L2 B. G3 T1 P1 A0 L2 C. G3 T2 PO AO L2 D. G4 T1 P1 A1 L2 **27. Nurse Yudi is providing instructions to a pregnant patient who is scheduled for amniocentesis. What instruction should the nurse provide?** A. You should be on strict bed rest after the procedure. B. You need to stay in the hospital for the next 24 hours for monitoring. C. An informed consent must be signed prior to the procedure. D. You can expect a mild fever after the procedure. **28. One of the reasons why amniocentesis is performed is to check for the lecithin-sphingomyelin ratio to assess for fetal lung maturity. Which of the following is considered a normal finding** A. 1.5:1 B. 2:1 C. 1:2 D. 2:2 **29. Shanna reported that the first day of her last normal menstrual period was November 16, 2021. Using Naegele's rule, which expected date of delivery should the nurse document in the client's chart?** A. July 12, 2021 B. August 23, 2022 C. August 21, 2022 D. July 23, 2022 **30. The nurse is caring for a client in labor. Which assessment findings indicate to the nurse that the client is beginning the second stage of labor? Select all that apply.** I. The contractions are regular. II. The membranes have ruptured. III. The cervix is dilated completely. IV. The client begins to expel clear vaginal fluid. V. The Ferguson reflex is initiated from perineal pressure. A. III, V B. I, II C. I, IV D. III, IV **31. The nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 beats per minute. Which nursing action is most appropriate?** A. Notify the primary health care provider B. Continue monitoring the fetal heart rate C. Encourage the client to continue pushing with each contraction D. Instruct the client's coach to continue to encourage breathing techniques. **32. The nurse is reviewing true and false labor signs with a multiparous client. The nurse determines that the client understands the signs of true labor if she makes which statement?** A. "I won't be in labor until my baby drops." B. "My contractions will be felt in my abdominal area." C. "My contractions will not be as painful if I walk around." D. "My contractions will increase in duration and intensity." **33. After 4 hours of active labor, the nurse notes that the contractions of a primigravida client are not strong enough to dilate the cervix. Which of the following would the nurse anticipate doing?** A. Obtaining an order to begin IV oxytocin infusion B. Administering a light sedative to allow the patient to rest for several hour C. Preparing for a cesarean section for failure to progress D. Increasing the encouragement to the patient when pushing begins **34. The nurse in a labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. What is the first nursing action with this finding?** A. Gently push the cord into the vagina. B. Place the client in Trendelenburg's position. C. Find the closest telephone and page the primary health care provider STAT. D. Call the delivery room to notify the staff that the client will be transported immediately. **35. Fatima, 16 weeks pregnant, is diagnosed with pregnancy-induced hypertension. Nurse Yudi knows that the following conditions are possible complications of PIH except?** A. Poor renal perfusion B. Hypoalbuminemia C. Proteinuria D. None of the above **36. A pregnant client is diagnosed with preeclampsia. Which assessment finding indicates a worsening of the preeclampsia and the need to notify the doctor?** A. Urinary output has increased. B. Dependent edema has resolved. C. Blood pressure reading is at the prenatal baseline. D. The client complains of a headache and blurred vision. **37. Christine is currently 34 weeks pregnant. Which of the following assessment findings could indicate the development of preeclampsia and the need to be reported to the physician? Select all that apply.** A. 1600H: BP 110/70mmHg, 1800H: BP 120/80mmHg B. +2 dipstick urine protein C. 1 hour glucose tolerance test 90 mg/DI D. <300 mg/dL 24-hour urine protein **38. Nurse Myx is assigned to manage patients diagnosed with pre-eclampsia. Which of the following assessment findings is relevant in monitoring the patient's condition?** A. Intake and output deep tendon reflex B. Respiratory rate C. All of the above **39. A 37-week pregnant patient is in labor and is diagnosed with preeclampsia. The patient is receiving IV Magnesium Sulfate. The nurse knows to have what medication on standby?** A. Acetylcysteine B. Calcium carbonate C. Epinephrine D. Calcium gluconate **40. Which of the following nursing actions must be initiated as the plan of care for a patient receiving the antidote for Magnesium sulfate toxicity?** A. Ventilator assistance B. CVP readings C. EKG tracings D. Continuous CPR **41. A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH). Which clinical findings would warrant use of the antidote?** A. Urinary output 90 ml in 2 hours. B. Absent patellar reflexes. C. Rapid respiratory rate above 40/min D. Rapid rise in blood pressure. **42. A client at 36 weeks gestation is schedule for a routine ultrasound prior to an amniocentesis. After teaching the client about the purpose for the ultrasound, which of the following client statements would indicate to the client needs further instruction?** A. The ultrasound will help to locate the placenta B. The ultrasound identifies blood flow through the umbilical cord C. The test will determine where to insert the needle D. The ultrasound locates a pool of amniotic fluid **43. While the postpartum client is receiving heparin for thrombophlebitis, which of the following drugs would the nurse expect to administer if the client develops complications related to heparin therapy?** A. Calcium gluconate B. Protamine sulfate C. Methylergonovine (Methergine) D. Nitrofurantoin (macrodantin) **44. Because cervical effacement and dilation are not progressing in a patient in labor, the doctor orders I.V. administration of oxytocin (Pitocin). Why must the nurse monitor the patient's fluid intake and output closely during oxytocin administration?** A. Oxytocin causes water intoxication B. Oxytocin causes excessive thirst C. Oxytocin is toxic to the kidneys D. Oxytocin has a diuretic effect **45. Rh isoimmunization in a pregnant client develops during which of the following conditions?** A. Rh-positive maternal blood crosses into fetal blood, stimulating fetal antibodies. B. Rh-positive fetal blood crosses into maternal blood, stimulating maternal antibodies. C. Rh-negative fetal blood crosses into maternal blood, stimulating maternal antibodies. D. Rh-negative maternal blood crosses into fetal blood, stimulating fetal antibodies. **46. You are caring for a newborn patient of an Rh (-) maternal blood. Which of the following laboratory tests would you anticipate to be ordered for the newborn?** A. Direct Coomb's B. Indirect Coomb's C. Blood culture D. Platelet count **47. The nurse is assessing a pregnant client in the second trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which assessment finding should the nurse expect to note if this condition is present?** A. Soft abdomen B. Uterine tenderness C. Absence of abdominal pain D. Painless, bright red vaginal bleeding **48. The maternity nurse is preparing for the admission of a client in the third trimester of pregnancy who is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the primary health care provider's prescriptions and should question which prescription?** A. Prepare the client for an ultrasound. B. Obtain equipment for a manual pelvic examination. C. Prepare to draw a hemoglobin and hematocrit blood sample. D. Obtain equipment for external electronic fetal heart rate monitoring. **49. An ultrasound is performed on a client at term gestation who is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that abruptio placentae is present. On the basis of these findings, the nurse should prepare the client for which anticipated prescription?** A. Delivery of the fetus B. Strict monitoring of intake and output C. Complete bed rest for the remainder of the pregnancy D. The need for weekly monitoring of coagulation studies until the time of delivery **50. Maureen, a primigravida client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin (Pitocin) augmentation. The nurse who's caring for her should stay alert for?** A. Uterine inversion B. Uterine atony C. Uterine involution D. Uterine discomfort **51. The nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which risk associated with placenta previa?** A. Infection B. Hemorrhage C. Chronic hypertension D. Disseminated intravascular coagulation **52. The nurse is performing an assessment on a client diagnosed with placenta previa. Which assessment findings should the nurse expect to note? Select all that apply.** I. Uterine rigidity II. Uterine tenderness III. Severe abdominal pain IV. Bright red vaginal bleeding V. Soft, relaxed, nontender uterus VI. Fundal height may be greater than expected for gestational A. I, III, IV B. II, IV, V C. IV, V, VI D. I, IV, VI **53. May arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. She also tells the nurse that a home pregnancy test was positive but she began to have mild cramps and is now having moderate vaginal bleeding. During the physical examination of the client, the nurse notes that May has a dilated cervix. The nurse determines that May is experiencing which type of abortion?** A. Inevitable B. Incomplete C. Threatened D. Septic **54. Nurse Reese is caring for a pregnant client on her first trimester. The client presents with vaginal bleeding and is suspected of threatened abortion. Which statement by the client indicates a need for further teaching?** A. I will watch to see if I pass any tissue B. I will maintain strict bed rest throughout the remained of my pregnancy C. I will count the number of perineal pads used daily D. I will avoid sexual intercourse until 2 weeks after the last episode of bleeding **55. Nurse Reese is reviewing the record of a pregnant client for her first prenatal visit. Which of the following data, if noted on the client's record, would alert the nurse that the client is at risk for a spontaneous abortion?** A. Age 36 years B. History of rubella C. History of genital herpes D. History of pre-eclampsia **56. You are caring for an 8-week pregnant patient who came in for episodes of vaginal bleeding. Which of the following would cause the nurse to suspect for miscarriage?** A. Dropping hCG level B. Severe hypotension C. Febrile episodes D. Rigid, board-like abdomen **57. Which of the following medications indicated for the medical management of abortion causes cervical ripening?** A. Misoprostol B. Oxytocin C. Magnesium sulfate D. All of the above **58. Adele, 17 weeks pregnant, came to the clinic and reports fast, fresh vaginal bleeding that started a week ago. During assessment, you noted that the fundic height is larger than expected for her AOG. Which of the following complications in pregnancy would the nurse suspect?** A. Gestational trophoblastic disease B. Placenta previa C. Abruptio placenta D. Ectopic pregnancy **59. Nurse Michelle is assessing a 24-year-old client with a diagnosis of hydatidiform mole. She is aware that one of the following is unassociated with this condition?** A. Excessive fetal activity B. Larger than normal uterus for gestational age C. Vaginal bleeding D. Elevated levels of human chorionic gonadotropin **60. Nurse Oliver is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy requires:** A. Decreased caloric intake B. Increased caloric intake C. Decreased Insulin D. Increase Insulin **61. The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy newborn. The client complains to the nurse of feelings of faintness and dizziness. Which nursing action is most appropriate?** A. Raise the head of the client's bed. B. Obtain hemoglobin and hematocrit levels. C. Instruct the client to request help when getting out of bed. D. Inform the nursery room nurse to avoid bringing the newborn to the client until the client's symptoms have subsided. **62. The postpartum nurse is providing instructions to a client after birth of a healthy newborn. Which time frame should the nurse relay to the client regarding the return of bowel function?** A. 3 days postpartum B. 7 days postpartum C. On the day of birth D. Within 2 weeks postpartum **63. The nurse is planning care for a postpartum client who had a vaginal delivery 2 hours ago. The client required an episiotomy and has several hemorrhoids. What is the priority nursing consideration for this client?** A. Client pain level B. Inadequate urinary output C. Client perception of body changes D. Potential for imbalanced body fluid volume **64. The nurse is preparing to assess the uterine fundus of a client in the immediate postpartum period. After locating the fundus, the nurse notes that the uterus feels soft and boggy. Which nursing intervention is appropriate?** A. Elevate the client's legs. B. Massage the fundus until it is firm C. Ask the client to turn on her left side. D. Push on the uterus to assist in expressing clots **65. When performing a postpartum assessment on a client, the nurse notes the presence of clots in the lochia. The nurse examines the clots and notes that they are larger than 1 cm. Which nursing action is most appropriate?** A. Document the findings. B. Notify the doctor. C. Reassess the client in 2 hours. D. Encourage increased oral intake of fluids. **66. The nurse is monitoring the amount of lochia drainage in a client who is 2 hours postpartum and notes that the client has saturated a perineal pad in 15 minutes. How should the nurse respond to this finding initially?** A. Document the finding. B. Encourage the client to ambulate. C. Encourage the client to increase fluid intake. D. Contact the obstetrician (OB) and inform him or her of this finding. **67. The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?** A. Temperature of 38°C B. Increase in the pulse rate from 88 to 112 beats per minute C. Blood pressure change from 130/88 to 124/80 mmHg D. Both B and C **68. The nurse is preparing a list of self-care instructions for a postpartum client who was diagnosed with mastitis. Which instructions should be included on the list? Select all that apply.** I. Wear a supportive bra. II. Rest during the acute phase. III. Maintain a fluid intake of at least 3000 mL/day. IV. Continue to breast-feed if the breasts are not too sore. V. Take the prescribed antibiotics until the soreness subsides. VI. Avoid decompression of the breasts by breast-feeding or breast pump A. I, II, III, VI B. I, II, IV V C. I, II, III, IV D. III, IV, V, VI **69. The nurse is providing instructions about measures to prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need for further instruction?** A. "I should breast-feed every 2 to 3 hours." B. "I should change the breast pads frequently." C. "I should wash my hands well before breast- feeding." D. "I should wash my nipples daily with soap and water." **70. Before assessing the postpartum client's uterus for firmness and position in relation to the umbilicus and midline, which of the following should the nurse do first?** A. Assess the vital signs B. Administer analgesia C. Ambulate her in the hall D. Assist her to urinate **71. The postpartum nurse is assessing a client who delivered a healthy infant by cesarean section for signs and symptoms of superficial venous thrombosis. Which sign should the nurse note if superficial venous thrombosis were present?** A. Paleness of the calf area B. Coolness of the calf area C. Enlarged, hardened veins D. Palpable dorsalis pedis pulses **72. A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action?** A. Initiate an intravenous line. B. Assess the client's blood pressure. C. Prepare to administer morphine sulfate. D. Administer oxygen, 8 to 10 L/minute, by face mask **73. Andre, a 6 year's old preparatory pupil is seen at the school clinic for growth and development monitoring. Which of the following is characterized the rate of growth during this period?** A. most rapid period of growth B. a decline in growth rate C. growth spurt D. slow uniform growth rate **74. In assessing Andre's growth and development, the nurse is guided by principles of growth and development. Which is not included?** A. All individuals follow cephalo-caudal and proximo-distal B. Different parts of the body grows at different rate C. All individual follow standard growth rate D. Rate and pattern of growth can be modified **75. What type of play will be ideal for Andre at this period?** A. Make believe B. Hide and seek C. Peek-a-boo D. Building blocks **76. Which of the following information indicate that Andre is normal for his age?** A. Determine own sense self B. Develop sense of whether he can trust the world C. Has the ability to try new things D. Learn basic skills within his culture **77. Based on Kohlberg's theory, what is the stage of moral development of Andre?** A. Punishment-obedience B. "good boy-Nice girl" C. naïve instrumental orientation D. social contact **78. Nurse Nikka is assigned to the care and management of pediatric patients. She knows that the psychosexual development of her 2-year-old patient would be?** A. Explored the world using mouth B. Control urination and defecation C. Sexual identity through awareness of genital area D. Sexual maturity and relationships with the opposite sex **79. While performing physical assessment of a 12-month-old, the nurse notes that the infant's anterior fontanelle is still slightly open. Which of the following is the nurse's most appropriate action?** A. Notify the physician immediately because there is a problem. B. Perform an intensive neurologic examination. C. Perform an intensive developmental examination. D. Do nothing because this is a normal finding for the age. **80. If parents keep a toddler dependent in areas where he is capable of using skills, the toddler will develop a sense of which of the following?** A. Mistrust B. Shame C. Guilt D. Inferiority **81. When teaching parents about the child's readiness for toilet training, which of the following signs should the nurse instruct them to watch for in the toddler?** A. Demonstrates dryness for 4 hours B. Demonstrates ability to sit and walk C. Has a new sibling for stimulation D. Verbalizes desire to go to the bathroom **82. When assessing a child with a cleft palate, the nurse is aware that the child is at risk for more frequent episodes of otitis media due to which of the following?** A. Lowered resistance from malnutrition B. Ineffective functioning of the Eustachian tubes C. Plugging of the Eustachian tubes with food particles D. Associated congenital defects of the middle ear. **83. Which of the following would the nurse identify as the initial priority for a child with acute lymphocytic leukemia?** A. Instituting infection control precautions B. Encouraging adequate intake of iron-rich foods C. Assisting with coping with chronic illness D. Administering medications via IM injections **84. While assessing a child with pyloric stenosis, the nurse is likely to note which of the following?** A. Regurgitation B. Steatorrhea C. Currant jelly stools D. Projectile vomiting **85. Discharge teaching for a child with celiac disease would include instructions about avoiding which of the following?** A. Rice B. Milk C. Wheat D. Chicken **86. The nurse is caring for an infant with neurologic disorder. The patient presents with headache, incessant crying, and bulging fontanel. Which of the following nursing interventions is inappropriate for this patient?** A. Promote adequate rest B. Decrease stimulus C. Promote calm and quiet environment D. Temporarily hold feeding to prevent aspiration **87. The Santos Family is caring for their youngest child, Justin, who is suffering from tetralogy of Fallot. Which of the following are defects associated with this congenital heart condition?** A. Aorta exits from the right ventricle, pulmonary artery exits from the left ventricle, and two noncommunicating circulations B. Ventricular septal defect, overriding aorta, pulmonic stenosis (PS), and right ventricular hypertrophy C. Coarctation of aorta, aortic valve stenosis, mitral valve stenosis, and patent ductus arteriosus D. Tricuspid valve atresia, atrial septal defect, ventricular septal defect, and hypoplastic right ventricle **88. Agata, 2 years old is rushed to the ER due to cyanosis precipitated by crying. Her mother observed that after playing she gets tired. She was diagnosed with Tetralogy of Fallot. The goal of nursing care for Agata is to:** A. Prevent infection B. Promote normal growth and development C. Decrease hypoxic spells D. Hydrate adequately **89. Which of the following is not an indicator that Agata experiences separation anxiety brought about her hospitalization?** A. Friendly with the nurse B. Prolonged loud crying, consoled only by mother C. Occasional temper tantrums and always says NO D. Repeatedly verbalizes desire to go home **90. The nurse is caring for a pediatric patient diagnosed with rheumatic fever. Which of the following signs and symptoms belongs to the major criteria of RF?** A. Polyarthritis B. Elevated ESR C. Positive C-reactive protein D. Prolonged PR interval **91. Which of the following instructions would Nurse Courtney include in a teaching plan that focuses on initial prevention for Sheri who is diagnosed with rheumatic fever?** A. Treating streptococcal throat infections with an antibiotic B. Giving penicillin to patients with rheumatic fever C. Using corticosteroid to reduce inflammation D. Providing an antibiotic before dental work **92. Mr. and Mrs. Smith's child has hemophilia; which of the following actions would you instruct them to avoid?** A. Immobilizing the joint B. Lowering the injured area C. Applying cold to the area D. Applying pressure **93. The nurse is caring for a pediatric patient diagnosed with Coarctation of the Aorta. Which of the following assessment findings would the nurse expect to find?** A. Elevated lower body blood pressure B. Loud machine-like murmur C. Bulging fontanel D. Bounding radial pulse and absent femoral pulse **94. The nurse is caring for a patient diagnosed with Transposition of the Great Arteries. The nurse expects the patient to be cyanotic because of which of the following anatomical defect?** A. Aorta is connected to the left ventricle B. Pulmonary artery connected to the left ventricle C. Narrowing at the entrance to the pulmonary artery D. Total fusion of the pulmonary artery **95. In the pediatric surgical ward, you have been assigned to a one-month-old child with cleft lip and palate. You have to teach the mother a proper way of providing nutrition to the child. The following are correct steps except:** A. Use rubber nipples with a small opening in order to prevent aspiration B. Place the child in a semi-upright position when feeding C. Feeding session should be done slowly D. Teach the mother to stimulate the sucking reflex by rubbing the nipple against the lower lip of the baby