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,MULTIPLE CHOICE
1. A 32-week gestation client reports persistent headache, visual disturbances, and right upper quadrant pain.
Her blood pressure is 158/96 mmHg and urine dipstick shows 3+ protein. Which medication should the nurse
anticipate administering first?
A) Magnesium sulfate
B) Nifedipine
C) Labetalol
D) Hydralazine
Correct Answer: A
Rationale: The presentation suggests severe preeclampsia with possible impending eclampsia. Magnesium
sulfate is the first-line medication for seizure prophylaxis in preeclampsia with severe features.
Antihypertensives may be used adjunctively, but seizure prevention is the priority.
2. A 15-year-old female client with type 1 diabetes reports feeling shaky, diaphoretic, and confused. Her blood
glucose is 52 mg/dL. Which intervention should the nurse implement immediately?
A) Administer 50% dextrose IV push
B) Give 4 oz of orange juice orally
C) Administer glucagon 1 mg IM
D) Check blood glucose again in 15 minutes
Correct Answer: B
Rationale: For a conscious patient with hypoglycemia, the initial treatment is 15 grams of fast-acting
carbohydrate such as 4 oz of orange juice. IV dextrose or glucagon is reserved for unconscious patients or those
unable to swallow.
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,3. A postpartum client who delivered 6 hours ago has saturated two perineal pads in the past hour and reports a
"gush" of blood. Her fundus is boggy and palpated at the umbilicus. What is the nurse's priority action?
A) Administer oxytocin IV push
B) Massage the fundus until firm
C) Insert a Foley catheter
D) Notify the provider immediately
Correct Answer: B
Rationale: A boggy fundus with heavy bleeding indicates uterine atony, the most common cause of early
postpartum hemorrhage. The priority is fundal massage to stimulate uterine contraction and reduce bleeding,
followed by additional interventions if bleeding persists.
4. A 6-month-old infant is brought to the clinic with fever, irritability, and a bulging fontanel. The mother reports
the infant has been lethargic and refusing feeds. Which diagnostic test should the nurse anticipate first?
A) Complete blood count
B) Lumbar puncture
C) Head CT scan
D) Blood culture
Correct Answer: B
Rationale: The presentation of fever, bulging fontanel, and lethargy in an infant suggests possible meningitis. A
lumbar puncture is the definitive diagnostic test for meningitis to obtain CSF for analysis and culture.
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, 5. A 28-week gestation client reports vaginal bleeding accompanied by abdominal pain that is continuous and
severe. Her uterus is firm and tender to palpation. Which condition should the nurse suspect?
A) Placenta previa
B) Abruptio placentae
C) Preterm labor
D) Uterine rupture
Correct Answer: B
Rationale: Abruptio placentae is characterized by painful vaginal bleeding with a firm, tender uterus. Unlike
placenta previa, which typically presents with painless bleeding, abruptio involves bleeding with abdominal pain
and uterine irritability.
6. A 2-year-old child is admitted with acute gastroenteritis and has had 8 episodes of diarrhea and 5 episodes of
vomiting in the past 12 hours. The child is lethargic, has sunken eyes, and skin tenting is present. Which
assessment finding indicates the most severe dehydration?
A) Heart rate of 130 bpm
B) Blood pressure of 85/55 mmHg
C) Respiratory rate of 32 breaths/min
D) Capillary refill of 3 seconds
Correct Answer: B
4|Page
,MULTIPLE CHOICE
1. A 32-week gestation client reports persistent headache, visual disturbances, and right upper quadrant pain.
Her blood pressure is 158/96 mmHg and urine dipstick shows 3+ protein. Which medication should the nurse
anticipate administering first?
A) Magnesium sulfate
B) Nifedipine
C) Labetalol
D) Hydralazine
Correct Answer: A
Rationale: The presentation suggests severe preeclampsia with possible impending eclampsia. Magnesium
sulfate is the first-line medication for seizure prophylaxis in preeclampsia with severe features.
Antihypertensives may be used adjunctively, but seizure prevention is the priority.
2. A 15-year-old female client with type 1 diabetes reports feeling shaky, diaphoretic, and confused. Her blood
glucose is 52 mg/dL. Which intervention should the nurse implement immediately?
A) Administer 50% dextrose IV push
B) Give 4 oz of orange juice orally
C) Administer glucagon 1 mg IM
D) Check blood glucose again in 15 minutes
Correct Answer: B
Rationale: For a conscious patient with hypoglycemia, the initial treatment is 15 grams of fast-acting
carbohydrate such as 4 oz of orange juice. IV dextrose or glucagon is reserved for unconscious patients or those
unable to swallow.
2|Page
,3. A postpartum client who delivered 6 hours ago has saturated two perineal pads in the past hour and reports a
"gush" of blood. Her fundus is boggy and palpated at the umbilicus. What is the nurse's priority action?
A) Administer oxytocin IV push
B) Massage the fundus until firm
C) Insert a Foley catheter
D) Notify the provider immediately
Correct Answer: B
Rationale: A boggy fundus with heavy bleeding indicates uterine atony, the most common cause of early
postpartum hemorrhage. The priority is fundal massage to stimulate uterine contraction and reduce bleeding,
followed by additional interventions if bleeding persists.
4. A 6-month-old infant is brought to the clinic with fever, irritability, and a bulging fontanel. The mother reports
the infant has been lethargic and refusing feeds. Which diagnostic test should the nurse anticipate first?
A) Complete blood count
B) Lumbar puncture
C) Head CT scan
D) Blood culture
Correct Answer: B
Rationale: The presentation of fever, bulging fontanel, and lethargy in an infant suggests possible meningitis. A
lumbar puncture is the definitive diagnostic test for meningitis to obtain CSF for analysis and culture.
3|Page
, 5. A 28-week gestation client reports vaginal bleeding accompanied by abdominal pain that is continuous and
severe. Her uterus is firm and tender to palpation. Which condition should the nurse suspect?
A) Placenta previa
B) Abruptio placentae
C) Preterm labor
D) Uterine rupture
Correct Answer: B
Rationale: Abruptio placentae is characterized by painful vaginal bleeding with a firm, tender uterus. Unlike
placenta previa, which typically presents with painless bleeding, abruptio involves bleeding with abdominal pain
and uterine irritability.
6. A 2-year-old child is admitted with acute gastroenteritis and has had 8 episodes of diarrhea and 5 episodes of
vomiting in the past 12 hours. The child is lethargic, has sunken eyes, and skin tenting is present. Which
assessment finding indicates the most severe dehydration?
A) Heart rate of 130 bpm
B) Blood pressure of 85/55 mmHg
C) Respiratory rate of 32 breaths/min
D) Capillary refill of 3 seconds
Correct Answer: B
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