Maternal And Child Health Nursing (Intrapartum And Postpartum)

106 Questions | Total Attempts: 48

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Maternal And Child Health Nursing (Intrapartum And Postpartum)

Welcome to Maternal and Child Health Nursing (HESI EXAMINATION) Prepared by: Jeffrey Viernes The care of childbearing and childrearing families is a major focus of nursing practice, because to have healthy adults you must have healthy children. To have healthy children, it is important to promote the health of the childbearing woman and her family from the time before children are born until they reach adulthood. Both preconceptual and prenatal care are essential contributions to the health of a woman and fetus and to a family’s emo- tional preparation for childbearing and childrearing. As chil- dren grow, families need continued health supervision and support. As children reach maturity and plan for their fam- ilies, a new cycle begins and new suppor


Questions and Answers
  • 1. 
    A client in the 28th week of gestation comes to the emergency department because she thinks that she's in labor. To confirm the diagnosis of PRETERM LABOR, the nurse would expect the physical examinations to reveal: Client's needs category: Physiological integrity Client's need subcategory: Physiological adaptation Cognitive level: Knowledge
    • A. 

      Irregular uterine contractions with no cervical dilation

    • B. 

      Painful contractions with cervical dilation

    • C. 

      Regular uterine dilation with cervical dilation

    • D. 

      Regular uterine contractions without cervical dilation

  • 2. 
    A client in the active phase of labor has a reactive fetal monitor strip and has been encouraged to walk. When she returns to bed for a monitor check, she complains for an urge to push. The nurse notes that the amniotic membranes have ruptured and she can visualize the umbilical cord. What should the nurse do next? Client's needs category: Physiological Integrity Client's needs subcategory: Reduction of risk potential Cognitive level: Analysis
    • A. 

      Put the client in a knee-to-chest position

    • B. 

      Call the physician or midwife because it is emergent

    • C. 

      Push down on the uterine fundus

    • D. 

      Arrange for fetal blood sampling to assess for fetal acidosis

  • 3. 
    A client is attempting to deliver vaginally despite the fact that her previous delivery was by cesarean delivery. Her contractions are 2 to 3 minutes apart, lasting from 75 to 100 seconds. Suddenly, the client complains of intense abdominal pain, and the fetal monitor stops picking up contractions. The nurse recognizes that which of the following events may have occured? Client's needs category: Physiological Integrity Cognitive level: Application
    • A. 

      Abruptio placentae

    • B. 

      Prolapsed cord

    • C. 

      Partial placenta previa

    • D. 

      Complete uterine rupture

  • 4. 
    A client with gravida 3 para 2 at 40 weeks' gestation is admitted with spontaneous contractions. The physician performs an amniotomy to augment her labor. The PRIORITY nursing action is to: Client's needs category: Physiological Integrity Cognitive level: Knowledge
    • A. 

      Explain the rationale for the amniotomy to the patient

    • B. 

      Monitor fetal heart tones after the amniotomy

    • C. 

      Ambulate the client to strengthen the contraction pattern

    • D. 

      Position the client in a lithotomy position to administer perineal care

  • 5. 
    What is the most IMPORTANT determinant of fetal maturity for extrauterine survival? Cognitive level: Application and Knowledge
    • A. 

      An L/S ratio of 2:1

    • B. 

      The presence of IgG antibodies on the fetal bloodstream

    • C. 

      An L/S ratio of 1:2

    • D. 

      The presence of well functioning CNS, cardiovascular and respiratory system

  • 6. 
    The characteristics of the HELLP syndrome are: Select all that apply. Cognitive level: Analysis and Knowledge
    • A. 

      Hemolysis (blood destruction)

    • B. 

      Elevated liver enzyme

    • C. 

      Hypertension and generalized edema

    • D. 

      Low platelet count

    • E. 

      Proteinuria

    • F. 

      It is usually occurring before the 37th weeks' gestation

  • 7. 
    • A. 

      Systolic blood pressure greater than 140 or diastolic blood pressure greater than 90

    • B. 

      Proteinuria

    • C. 

      Weight gain

    • D. 

      Decreased urine output

    • E. 

      Presence of HELLP syndrome

    • F. 

      Headaches, blurred vision, hyperreflexia, nausea, vomiting

  • 8. 
    A 36 years old pregnant patient (is on her 36th weeks of gestation) has been diagnosed with hypertension with a blood pressure of 140/90 for the past two weeks has been admitted to the labor and delivery department. Suddenly within the first 24 hours of her stay, the patient described a bright red bleeding on her drape. The nurse ask about her pain level, the patient rated her pain as 1 out of 10. What are the necessary nursing intervention you need to provide for this patient? Select all that apply. 
    • A. 

      Monitor maternal Vital Signs, including uterine activity

    • B. 

      Monitor signs of infection

    • C. 

      Monitor fetal heart rate

    • D. 

      Obtain a blood glucose from the patient

    • E. 

      Provide vitamin K because the patient is bleeding severely

    • F. 

      Administer 2 Tylenol as needed order

  • 9. 
    Older adults are vulnerable to diseases because of decreased physiologic reserve, less flexible homeostatic processes, and less effective body defenses. What are the most common physiologic changes that is related to aging? Select all that apply.
    • A. 

      Chronic illness becomes more prevalent as one ages

    • B. 

      Resistance to stressors diminishes as one ages

    • C. 

      Decreased absorption of vitamins B1 and B2

    • D. 

      Decreased peristalsis and impaired absorption contribute to constipation problems

    • E. 

      Increased thirst sensation

    • F. 

      Increased hunger sensation

  • 10. 
    An 86 years old patient has been admitted into the Long Term Care facility. She has an admitting diagnosis of Hypertensio, diabetes mellitus, and she has a history of falls at home. Last night, the patient was trying to climb the rails and suddenly she fell with her face first on the floor. No blood was found on the scene. the physician ordere a MRI to check f there is internal bleeding on the patient. When the nurse assessed the patient's level of consciousness, she cannot identify her name and time. The patient is currently taking Atenolol 200 mg PO to control her blood pressure. The physician diagnosed a Transient Ischemic Attack for the patient. As a nurse, you know that TIA has the following hallmark signs and symptoms. Select all that apply.
    • A. 

      Weakness

    • B. 

      Persistent nausea and vomiting

    • C. 

      Blackouts

    • D. 

      Presence or leakage of CSF

    • E. 

      Difficulty speaking

    • F. 

      Tremors

  • 11. 
    What are the ways to help prevent or decrease the occurence of falls in the older adult? Select all that apply.
    • A. 

      Remove throw rugs

    • B. 

      Paint the edges of stairs red color

    • C. 

      Administer his antihypertensive medications during the night

    • D. 

      Ambulate the patient with a gait belt

    • E. 

      Ensure adequate lighting

    • F. 

      Wear proper footwear that supports the foot

  • 12. 
    What is the condition called whereby the placenta is implanted in the lower uterine segment. It can be classified as partially, totally, or marginal.?
  • 13. 
    It is th partial or complete premature detachment of the placenta from its site of implantation in the uterus. It is usually occuring in the late third trimester or in labor.
  • 14. 
    What the do you call the procedure whereby the OB/GYN physician removes amniotic fluid sample from the uterus during 14th to 16 th weeks of gestation?
  • 15. 
    What is the procedure called whereby the physician removes a small piece of villi between 8 to 12 weeks' gestation under ultrasound guidance?
  • 16. 
    If there is a decrease of alpha-fetoprotein in the amniotic fluid, it would signify what disease is the fetus risk for?
  • 17. 
    If there is an INCREASE in alpha-fetoprotein 
  • 18. 
    The LPN is helping the RN to complete the necessary assessment data on the Biophysical Profile (BPP) to detect if the fetus is healthy and well. What are the necessary components of this profile?
    • A. 

      Fetal breathing movement

    • B. 

      Fetal tone

    • C. 

      Gross body movement

    • D. 

      L/S ratio

    • E. 

      Reactivity of fetal heart rate

    • F. 

      Amniotic fluid volume

    • G. 

      Presence of alpha-fetoprotein

  • 19. 
    Infection that occurs during pregnancy is very compromising for the fetus. A 12 weeks pregant Asian female is asking the LPN what TORCH disease is. As a knowledgable LPN, you know that TORCH disease includes:  
    • A. 

      Rubella

    • B. 

      Cytomegalovirus

    • C. 

      Tuberculosis

    • D. 

      Influenza

    • E. 

      Chlamydia

    • F. 

      Human papilloma virus

    • G. 

      Herpes Simplex

  • 20. 
    • A. 

      Able to continue usual activities

    • B. 

      Contractions mild, initially 10 to 20 minutes apart

    • C. 

      Contractions moderate to severe, 2 to 3 minutes apart

    • D. 

      Nausea, hiccups

  • 21. 
    An LPN is watching a nurse practitioner performs an abdominal palpation that is used to determine fetal presentatio, lie, postion, and engagement. As an LPN, you know that this is procedure is called:
  • 22. 
    A nursing student is discussing the normal findings in labor to a 39 weeks pregnant patient. What are the normal findings common to laboring client and the fetus? Select all that apply.
    • A. 

      FHR of 130

    • B. 

      maternal blood pressure of 139/89

    • C. 

      Maternal pulse of 100

    • D. 

      Maternal temperature of 100.4

    • E. 

      Dehydration due to work of labor

    • F. 

      Leukorrhea

  • 23. 
    Which of the following characteristics of contractions would the nurse expect to find in a client experiencing true labor?
    • A. 

      Occurring at irregular intervals

    • B. 

      Starting mainly in the abdomen

    • C. 

      Gradually increasing intervals

    • D. 

      Increasing intensity with walking

  • 24. 
    During which of the following stages of labor would the nurse assess “crowning”?
    • A. 

      First stage

    • B. 

      Second stage

    • C. 

      Third stage

    • D. 

      Fourth stage

  • 25. 
    Barbiturates are usually not given for pain relief during active labor for which of the following reasons?
    • A. 

      The neonatal effects include hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the first few days.

    • B. 

      These drugs readily cross the placental barrier, causing depressive effects in the newborn 2 to 3 hours after intramuscular injection.

    • C. 

      They rapidly transfer across the placenta, and lack of an antagonist make them generally inappropriate during labor.

    • D. 

      Adverse reactions may include maternal hypotension, allergic or toxic reaction or partial or total respiratory failure

  • 26. 
    Which of the following nursing interventions would the nurse perform during the third stage of labor?
    • A. 

      Obtain a urine specimen and other laboratory tests.

    • B. 

      Assess uterine contractions every 30 minutes.

    • C. 

      Coach for effective client pushing

    • D. 

      Promote parent-newborn interaction.

  • 27. 
    Which of the following is described as premature separation of a normally implanted placenta during the second half of pregnancy, usually with severe hemorrhage?
    • A. 

      Placenta previa

    • B. 

      Ectopic pregnancy

    • C. 

      Incompetent cervix

    • D. 

      Abruptio placentae

  • 28. 
    Which of the following would the nurse assess in a client experiencing abruptio placenta?
    • A. 

      Bright red, painless vaginal bleeding

    • B. 

      Concealed or external dark red bleeding

    • C. 

      Palpable fetal outline

    • D. 

      Soft and nontender abdomen

  • 29. 
    Which of the following best describes preterm labor?    
    • A. 

      Labor that begins after 20 weeks gestation and before 37 weeks gestation

    • B. 

      Labor that begins after 15 weeks gestation and before 37 weeks gestation

    • C. 

      Labor that begins after 24 weeks gestation and before 28 weeks gestation

    • D. 

      Labor that begins after 28 weeks gestation and before 40 weeks gestation

  • 30. 
    Which of the following is the nurse’s initial action when umbilical cord prolapse occurs?
    • A. 

      Begin monitoring maternal vital signs and FHR

    • B. 

      Place the client in a knee-chest position in bed

    • C. 

      Notify the physician and prepare the client for delivery

    • D. 

      Apply a sterile warm saline dressing to the exposed cord

  • 31. 
    Which of the following best describes thrombophlebitis?
    • A. 

      Inflammation and clot formation that result when blood 4 b. PROM removes the fetus most effective defense against infection c. Nursing care is based on fetal viability and gestational components combine to form an aggregate body

    • B. 

      Inflammation and blood clots that eventually become lodged within the pulmonary blood vessels

    • C. 

      Inflammation and blood clots that eventually become lodged within the femoral vein

    • D. 

      Inflammation of the vascular endothelium with clot formation on the vessel wall

  • 32. 
    Which of the following assessment findings would the nurse expect if the client develops DVT? 
    • A. 

      Midcalf pain, tenderness and redness along the vein

    • B. 

      Chills, fever, malaise, occurring 2 weeks after delivery

    • C. 

      Muscle pain the presence of Homans sign, and swelling in the affected limb

    • D. 

      Chills, fever, stiffness, and pain occurring 10 to 14 days after delivery

  • 33. 
    Which of the following statement about L/S ratio in amniotic fluid is correct?    
    • A. 

      A slight variation in technique does not significantly affect the accuracy of result

    • B. 

      a L/S ratio of 2:1 is incompatible with life

    • C. 

      A L/S ratio of less than 1:0 is compatible with fetal survival

    • D. 

      When L/S ratio is 2:1 below, majority of infants develop respiratory distress

  • 34. 
     Which of the following is not true regarding the third stage of labor?    
    • A. 

      Care should be taken in the administration of bolus of oxytocin because it can cause hypertension

    • B. 

      Signs of placental separation are lengthening of the cord, sudden gush of blood and sudden change in shape of the uterus

    • C. 

      It ranges from the time of expulsion of the fetus to the delivery of the placenta

    • D. 

      The placenta is delivered approximately 5-15 minutes after delivery of the baby

  • 35. 
    Calculate the heart rate of the patient using the ECG strip above.
  • 36. 
    Calculate the heart rate of the patient using the ECG strip provided above.
  • 37. 
    How would you correctly document this ECG strip on the client's chart using the correct medical terminology?
  • 38. 
    Basing on the normal Conduction System of the heart, numer 2 is called the:
  • 39. 
  • 40. 
    A second year nursing student has just suf- fered a needlestick while working with a patient that is positive for AIDS. Which of the following is the most important action that nursing student should take? 
    • A. 

      Immediately see a social worker

    • B. 

      Start prophylactic AZT treatment

    • C. 

      Start prophylactic Pentamide treatment

    • D. 

      Seek counseling

  • 41. 
    A patient asks a nurse, “My doctor recom- mended I increase my intake of folic acid. What type of foods contain the highest concentration of folic acids?” 
    • A. 

      Green vegetables and liver

    • B. 

      Yellow vegetables and red meat

    • C. 

      Carrots

    • D. 

      Milk

  • 42. 
    A 65 year old man has been admitted to the hospital for spinal stenosis surgery. When does the discharge training and planning begin for this patient? 
    • A. 

      Following surgery

    • B. 

      Upon admit

    • C. 

      Within 48 hours of discharge

    • D. 

      Preoperative discussion

  • 43. 
    A nurse is making rounds taking vital signs. Which of the following vital signs is abnormal? 
    • A. 

      11 year old male – 90 b.p.m, 22 resp/min. , 100/70 mm Hg

    • B. 

      13 year old female – 105 b.p.m., 22 resp/min., 105/60 mm Hg

    • C. 

      5 year old male- 102 b.p.m, 24 resp/min., 90/65 mm Hg

    • D. 

      6 year old female- 100 b.p.m., 26 resp/min., 90/70mm Hg

  • 44. 
    A patient’s chart indicates a history of hyperkalemia. Which of the following would you not expect to see with this patient if this condition were acute? 
    • A. 

      Decrease HR

    • B. 

      Paresthesia

    • C. 

      Muscle weakness of the extremities

    • D. 

      Migranes

  • 45. 
    A nurse is administering a shot of Vitamin K to a 30 day-old infant. Which of the following tar- get areas is the most appropriate? 
    • A. 

      Gluteus maximus

    • B. 

      Gluteus minimus

    • C. 

      Vastus lateralis

    • D. 

      Vastus medialis

  • 46. 
    A client is prescribed warfarin sodium (Coumadin) to be continued at home. Which focus is critical to be included in the nurse’s discharge instruction? 
    • A. 

      Maintain a consistent intake of green leafy foods

    • B. 

      Report any nose or gum bleeds

    • C. 

      Take Tylenol for minor pains

    • D. 

      Use a soft toothbrush

  • 47. 
    At a senior citizens meeting a nurse talks with a client who has Type 1 diabetes mellitus. Which statement by the client during the conversation is most predictive of a potential for impaired skin integrity? 
    • A. 

      “I give my insulin to myself in my thighs.”

    • B. 

      “Sometimes when I put my shoes on I don’t know where my toes are.”

    • C. 

      “Here are my up and down glucose readings that I wrote on my calendar.”

    • D. 

      “If I bathe more than once a week my skin feels too dry.”

  • 48. 
    A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms? 
    • A. 

      Drink small amounts of liquids frequently

    • B. 

      Eat the evening meal just before retiring

    • C. 

      Take sodium bicarbonate after each meal

    • D. 

      Sleep with head propped on several pillows

  • 49. 
    The nurse is caring for a client with extracellular fluid volume deficit. Which of the following assessments would the nurse anticipate finding? 
    • A. 

      Bounding pulse

    • B. 

      Rapid respiration

    • C. 

      Oliguria

    • D. 

      Neck vein distention

  • 50. 
    The client tells the nurse that her last menstrual period started on January 14 and ended on January 20. Using Nagele’s rule, the nurse determines her EDD to be which of the following? 
    • A. 

      September 27

    • B. 

      October 21

    • C. 

      November 7

    • D. 

      December 27

  • 51. 
    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 P0 A0 L2

    • B. 

      G3 T1 P1 A0 L2

    • C. 

      G3 T2 P0 A0 L2

    • D. 

      G4 T1 P1 A1 L2

  • 52. 
    The hormone responsible for a positive pregnancy test is: 
    • A. 

      Estrogen

    • B. 

      Progesterone

    • C. 

      Human chorionic gonadotrophin

    • D. 

      Follicle stimulating hormone

  • 53. 
    In the later part of the 3rd trimester, the mother may experience shortness of breath. This complaint maybe explained as: 
    • A. 

      A normal occurrence in pregnancy because the fetus is using more oxygen

    • B. 

      The fundus of the uterus is high pushing the diaphragm upwards

    • C. 

      The woman is having allergic reaction to the pregnancy and its hormones

    • D. 

      The woman maybe experiencing complication of pregnancy

  • 54. 
    • A. 

      Fetal movement felt by mother

    • B. 

      Enlargement of the uterus

    • C. 

      (+) pregnancy test

    • D. 

      (+) ultrasound

  • 55. 
    The main reason for an expected increased need for iron in pregnancy is: 
    • A. 

      The mother may have physiologic anemia due to the increased need for red blood cell mass as well as the fetal requires about 350-400 mg of iron to grow

    • B. 

      The mother may suffer anemia because of poor appetite

    • C. 

      The fetus has an increased need for RBC which the mother must supply

    • D. 

      The mother may have a problem of digestion because of pica

  • 56. 
    When preparing the mother who is on her 4th month of pregnancy for abdominal ultrasound, the nurse should instruct her to: 
    • A. 

      Observe NPO from midnight to avoid vomiting

    • B. 

      Do perineal flushing properly before the procedure

    • C. 

      Drink at least 2 liters of fluid 2 hours before the procedure and not void until the procedure is done

    • D. 

      Void immediately before the procedure for better visualization

  • 57. 
    The nurse is preparing to take vital sign in an alert client admitted to the hospital with dehydration secondary to vomiting and diarrhea. What is the best method used to assess the client’s temperature? 
    • A. 

      Oral

    • B. 

      Axillary

    • C. 

      Radial

    • D. 

      Heat sensitive tape

  • 58. 
    A client had oral surgery following a motor vehicle accident. The nurse assessing the client finds the skin flushed and warm. Which of the following would be the best method to take the client’s body temperature? 
    • A. 

      Oral

    • B. 

      Axillary

    • C. 

      Arterial line

    • D. 

      Rectal

  • 59. 
    A walk-in client enters into the clinic with a chief complaint of abdominal pain and diarrhea. The nurse takes the client’s vital sign hereafter. What phrase of nursing process is being implemented here by the nurse? 
    • A. 

      Assessment

    • B. 

      Diagnosis

    • C. 

      Planning

    • D. 

      Implementation

  • 60. 
    It is best describe as a systematic, rational method of planning and providing nursing care for individual, families, group and community 
    • A. 

      Critical thinking

    • B. 

      Scientific method

    • C. 

      Nursing process

    • D. 

      Nursing diagnosis

  • 61. 
    The nurse must verify the client’s identity before administration of medication. Which of the following is the safest way to identify the client? 
    • A. 

      Ask the client his name

    • B. 

      Check the client's ID band

    • C. 

      State the client's name aloud and have the client repeat it

    • D. 

      Check the room number

  • 62. 
    The nurse prepare IM injection that is irritating to the subcutaneous tissue. Which of the following is the best action in order to prevent tracking of the medication 
    • A. 

      Use a small gauge needle

    • B. 

      Apply ice on the injection site

    • C. 

      Administer at a 45 degree angle

    • D. 

      Use the Z track technique

  • 63. 
    If nurse administers an injection to a patient who refuses that injection, she has committed: 
    • A. 

      Assault and battery

    • B. 

      Negligence

    • C. 

      Malpractice

    • D. 

      None of the above

  • 64. 
    If patient asks the nurse her opinion about a particular physicians and the nurse replies that the physician is incompetent, the nurse could be held liable for: 
    • A. 

      Slander

    • B. 

      Libel

    • C. 

      Assault

    • D. 

      Respondent superior

  • 65. 
    A registered nurse reaches to answer the telephone on a busy pediatric unit, momentarily turning away from a 3 month-old infant she has been weighing. The infant falls off the scale, suffering a skull fracture. The nurse could be charged with: 
    • A. 

      Defamation

    • B. 

      Assault

    • C. 

      Battery

    • D. 

      Malpractice

  • 66. 
    • A. 

      The nurse administers penicillin to a patient with a documented history of allergy to the drug. The patient experiences an allergic reaction and has cerebral damage resulting from anoxia.

    • B. 

      The nurse applies a hot water bottle or a heating pad to the abdomen of a patient with abdominal cramping.

    • C. 

      The nurse assists a patient out of bed with the bed locked in position; the patient slips and fractures his right humerus

    • D. 

      The nurse administers the wrong medication to a patient and the patient vomits. This information is documented and reported to the physician and the nursing supervisor.

  • 67. 
    • A. 

      An alert, chronic arthritic patient treated with steroids and aspirin

    • B. 

      An 88-year old incontinent patient with gastric cancer who is confined to his bed at home

    • C. 

      An apathetic 63-year old COPD patient receiving nasal oxygen via cannula

    • D. 

      A confused 78-year old patient with congestive heart failure (CHF) who requires assistance to get out of bed.

  • 68. 
    A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. An appropriate nursing diagnosis would be: 
    • A. 

      Ineffective airway clearance related to thick, tenacious secretions.

    • B. 

      Ineffective airway clearance related to dry, hacking cough.

    • C. 

      Ineffective individual coping to COPD.

    • D. 

      Pain related to immobilization of affected leg.

  • 69. 
    Mrs. Lim begins to cry as the nurse discusses hair loss. The best response would be: 
    • A. 

      “Don’t worry. It’s only temporary”

    • B. 

      “Why are you crying? I didn’t get to the bad news yet”

    • C. 

      “Your hair is really pretty”

    • D. 

      “I know this will be difficult for you, but your hair will grow back after the completion of chemotheraphy”

  • 70. 
     After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most significant symptom of his disorder? 
    • A. 

      Lethargy

    • B. 

      Increased pulse rate and blood pressure

    • C. 

      Muscle weakness

    • D. 

      Muscle irritability

  • 71. 
    • A. 

      Continuity of patient care promotes efficient, cost-effective nursing care

    • B. 

      Autonomy and authority for planning are best delegated to a nurse who knows the patient well

    • C. 

      Accountability is clearest when one nurse is responsible for the overall plan and its implementation.

    • D. 

      The holistic approach provides for a therapeutic relationship, continuity, and efficient nursing care.

  • 72. 
    Which of the following constitutes a break in sterile technique while preparing a sterile field for a dressing change? 
    • A. 

      Using sterile forceps, rather than sterile gloves, to handle a sterile item

    • B. 

      Touching the outside wrapper of sterilized material without sterile gloves

    • C. 

      Placing a sterile object on the edge of the sterile field

    • D. 

      Pouring out a small amount of solution (15 to 30 ml) before pouring the solution into a sterile container

  • 73. 
    Sterile technique is used whenever: 
    • A. 

      Strict isolation is required

    • B. 

      Terminal disinfection is performed

    • C. 

      Invasive procedures are performed

    • D. 

      Protective isolation is necessary

  • 74. 
    After 5 days of diuretic therapy with 20mg of furosemide (Lasix) daily, a patient begins to exhibit fatigue, muscle cramping and muscle weakness. These symptoms probably indicate that the patient is experiencing: 
    • A. 

      Hypokalemia

    • B. 

      Hyperkalemia

    • C. 

      Anorexia

    • D. 

      Dysphagia

  • 75. 
    The appropriate needle gauge for intradermal injection is: 
    • A. 

      20G

    • B. 

      22G

    • C. 

      25G

    • D. 

      26G

  • 76. 
    The appropriate needle size for insulin injection is: 
    • A. 

      18G, 1 ½” long

    • B. 

      22G, 1” long

    • C. 

      22G, 1 ½” long

    • D. 

      25G, 5/8” long

  • 77. 
    The physician orders an IV solution of dextrose 5% in water at 100ml/hour. What would the flow rate be if the drop factor is 15 gtt = 1 ml? 
    • A. 

      5 gtt/minute

    • B. 

      13 gtt/minute

    • C. 

      25 gtt/minute

    • D. 

      50 gtt/minute

  • 78. 
    S1 is heard best at the: 
    • A. 

      5th left intercoastal space along the midclavicular line

    • B. 

      3rd intercoastal space to the left of the midclavicular line

    • C. 

      Second right intercoastal space at the sternal border

    • D. 

      Second left intercoastal space at the sternal border

  • 79. 
    Cassandra asked you : How many air is there in the oxygen and how many does human requires? Which of the following is the best response :
    • A. 

      God is good, Man requires 21% of oxygen and we have 21% available in our air

    • B. 

      Man requires 16% of oxygen and we have 35% available in our air

    • C. 

      Man requires 10% of oxygen and we have 50% available in our air

    • D. 

      Human requires 21% of oxygen and we have 21% available in our air

  • 80. 
    • A. 

      Vitamin B1

    • B. 

      Vitamin B2

    • C. 

      Vitamin B3

    • D. 

      Vitamin B6

  • 81. 
    • A. 

      Vitamin B1

    • B. 

      Vitamin B2

    • C. 

      Vitamin B3

    • D. 

      Vitamin B6

  • 82. 
    A vitamin taken in conjunction with ISONIAZID to prevent peripheral neuritis
    • A. 

      Vitamin B1

    • B. 

      Vitamin B2

    • C. 

      Vitamin B3

    • D. 

      Vitamin B6

  • 83. 
    The inflammation of the Lips, Palate and Tongue is associated in the deficiency of this vitamin
    • A. 

      Vitamin B1

    • B. 

      Vitamin B2

    • C. 

      Vitamin B3

    • D. 

      Vitamin B6

  • 84. 
    Beri beri is caused by the deficiency of which Vitamin?
    • A. 

      Vitamin B1

    • B. 

      Vitamin B2

    • C. 

      Vitamin B3

    • D. 

      Vitamin C

  • 85. 
     A client taking Coumadin is to be educated on his diet. As a nurse, which of the following food should you instruct the client to avoid?
    • A. 

      Spinach, Green leafy vegetables, Cabbage, Liver

    • B. 

      Salmon, Sardines, Tuna

    • C. 

      Butter, Egg yolk, breakfast cereals

    • D. 

      Banana, Yeast, Wheat germ, Chicken

  • 86. 
    Incident of prostate cancer is found to have been reduced on a population exposed in tolerable amount of sunlight. Which vitamin is associated with this phenomenon?
    • A. 

      Vitamin A

    • B. 

      Vitamin B

    • C. 

      Vitamin C

    • D. 

      Vitamin D

  • 87. 
    Micronutrients are those nutrients needed by the body in a very minute amount. Which of the following vitamin is considered as a MICRONUTRIENT
    • A. 

      Phosphorus

    • B. 

      Iron

    • C. 

      Calcium

    • D. 

      Sodium

  • 88. 
    Deficiency of this mineral results in tetany, osteomalacia, osteoporosis and rickets.
    • A. 

      Vitamin D

    • B. 

      Iron

    • C. 

      Calcium

    • D. 

      Sodium

  • 89. 
    Among the following foods, which has the highest amount of potassium per area of their meat?
    • A. 

      Cantaloupe

    • B. 

      Avocado

    • C. 

      Raisin

    • D. 

      Banana

  • 90. 
    • A. 

      Egg yolk

    • B. 

      Liver

    • C. 

      Fish

    • D. 

      Peanuts

  • 91. 
    A nurse is assisting with evaluating the deep tendon reflexes of a pregnant client. The nurse exposes the woman's lower leg, places one hand under the woman's knee to raise it slightly off the bed, and uses the percussion hammer to strike the patellar tendon just below the patella. The nurse documents the response as 4+. This response is interpreted as:
    • A. 

      Normal

    • B. 

      Diminished

    • C. 

      Very brisk or hyperactive

    • D. 

      Increased or brisker than average

  • 92. 
    A woman is seen in the prenatal clinic and complains of morning sickness. Which self care measures will the nurse suggest to the client?
    • A. 

      To eat eggs for breakfast

    • B. 

      To eat three well balanced meals every day

    • C. 

      To eat fatty or spicy foods only at the noontime meal

    • D. 

      To eat a dry crackers before getting out of bed in the morning

  • 93. 
    A nrse teaches a pregnant client with HIV about measures to prevent an opportunistic infection. Which client statement indicates an understanding of these measures?
    • A. 

      "I plan to have natural childbirth experience"

    • B. 

      "My husband is taking care of the cat's litter box"

    • C. 

      "I know I must have a cesarean section to avoid infecting my baby"

    • D. 

      "I am trying to lead a normal life. Tomorrow I will go to my niece's sixth birthday party"

  • 94. 
    A client with diabetes mellitus is receiving prenatal care, and the nurse teaches the client about the early signs of hyperglycemia. The nurse determines that the teaching is effective when the client states that an early sign of hyperglycemia is which of the following?
    • A. 

      Hunger

    • B. 

      Polyuria

    • C. 

      Shakiness

    • D. 

      Nervousness

  • 95. 
    An LPN assists a registered nurse in developing a teaching plan for a pregnant client newly diagnosed with diabetes mellitus. Which of the following is inappropriate to include in the plan?
    • A. 

      Effects of diabetes on the pregnancy and fetus

    • B. 

      Nutritional requirements for pregnancy and diabetic control

    • C. 

      Avoidance of exercise because of the negative effects on insulin production

    • D. 

      Awareness of any infections and reporting these immediately to the health care provider

  • 96. 
    An iron supplement is prescribed for a pregnant client. The nurse tells the client that it is best to take the iron supplemet with:
    • A. 

      Milk

    • B. 

      Water

    • C. 

      Tea

    • D. 

      Orange juice