PNLE: Maternal and
Child Health Nursing
Exam 3
1. A pregnant woman who is term is admitted to the
birthing unit in active labor. The client has only
progressed from 2 cm to 3 cm in 8 hours. She is
diagnosed with hypotonic uterine dysfunction and
begins oxytocin (Pitocin) augmentation. Which of the
following is the most important nursing intervention
at this time?
A. Timing and recording length of contractions.
B. Preparing for an emergency cesarean birth.
C. Checking for perineal lacerations.
D. Monitoring the fetal heart rate and uterine contractions.
Answer: D. Monitoring the fetal heart rate and uterine
contractions.
Rationale: The nurse must monitor the fetal heart rate and
uterine contractions continuously during oxytocin
augmentation because oxytocin can cause hyperstimulation
of the uterus, leading to fetal distress. This is the priority
assessment to ensure fetal well-being.
2. A client who is hallucinating is not in touch with
reality. It is important for the nurse to:
A. Isolate the client from other patients.
B. Clarify the client's statements.
C. Orient the client to place, person, and time.
D. Establish a trusting relationship.
Answer: D. Establish a trusting relationship.
Rationale: Establishing a trusting relationship is the
foundation of therapeutic communication with a
hallucinating client. It provides a sense of safety and
security, which is essential before other interventions such
as reality orientation can be effective.
,3. The nurse is caring to a child client who has had a
tonsillectomy. The child complains of having a throat
pain. Which of the following would the nurse do
initially?
A. Cold compress
B. Yellow noncitrus Jello
C. Cool clear liquids
D. Acetaminophen
Answer: D. Acetaminophen.
Rationale: Acetaminophen is the medication of choice for
post-tonsillectomy pain. It is important to manage pain
initially before offering fluids or foods, as pain may inhibit the
child's willingness to swallow. Cold compresses are not
typically applied to the throat, and yellow Jello may be
avoided due to its color, which can mask bleeding.
4. The physician ordered Phenergan (Promethazine)
nasal spray for a 13-year-old client. The nurse is
aware that the client is at risk for Reye's syndrome.
The nurse must ensure that the client has received
which of the following vaccines?
A. Hepatitis B vaccine.
B. Meningococcal vaccine.
C. Varicella vaccine.
D. Pneumococcal vaccine.
Answer: C. Varicella vaccine.
Rationale: Phenergan (promethazine) should not be given
to children who have or are recovering from varicella
(chickenpox) or influenza because of the risk of Reye's
syndrome. The nurse must verify that the child has been
vaccinated against varicella.
5. A child with rubella is admitted to the hospital. The
nurse who will be assigned to care for this client must
be:
A. Immune to rubella.
B. Pregnant.
C. A male nurse.
D. Available to work flexible hours.
Answer: A. Immune to rubella.
,Rationale: Rubella is highly contagious and can cause
severe fetal damage if contracted by a pregnant woman. The
nurse assigned to care for a client with rubella must be
immune to the disease to prevent transmission and protect
any potential fetus.
6. A client with tuberculosis is to be admitted in the
hospital. The nurse who will be assigned to care for
the client must institute appropriate precautions. The
nurse should:
A. Place the client in a private room.
B. Wear an N95 respirator when caring for the client.
C. Wear a gown and gloves when entering the room.
D. Wear a surgical mask when entering the room.
Answer: B. Wear an N95 respirator when caring for
the client.
Rationale: Tuberculosis is transmitted via airborne droplets.
An N95 respirator is required for airborne precautions to filter
out small particles. A private room with negative pressure is
also needed, but the most specific precaution for the nurse is
wearing the N95 respirator.
7. Which of the following is the most frequent cause
of complication to the medical treatment of the client
with bipolar disorder?
A. The nurse has no understanding of the client's condition.
B. The client is not taking the medication as prescribed.
C. The client's family is not supportive.
D. The client has a history of noncompliance.
Answer: B. The client is not taking the medication as
prescribed.
Rationale: Nonadherence to prescribed medication is the
most common cause of relapse and complications in clients
with bipolar disorder. Lithium and other mood stabilizers
require consistent blood levels to be effective.
8. A 16-year-old client is admitted to the hospital with
a diagnosis of acute glomerulonephritis. The nurse
, notes that the client has periorbital edema. Which of
the following would the nurse expect to find in the
client's history?
A. Decreased urinary output.
B. Recent upper respiratory infection.
C. Low-grade fever.
D. Dark, smoky urine.
Answer: B. Recent upper respiratory infection.
Rationale: Acute glomerulonephritis commonly follows a
streptococcal infection, such as an upper respiratory
infection or impetigo. The history typically reveals a recent
infection 1-3 weeks prior to the onset of symptoms.
9. A child with nephrotic syndrome is receiving
prednisone. The nurse should assess the child for
which of the following side effects?
A. Weight loss.
B. Increased appetite.
C. Decreased blood pressure.
D. Bradycardia.
Answer: B. Increased appetite.
Rationale: Prednisone, a corticosteroid, commonly causes
increased appetite, weight gain, and fluid retention. Other
side effects include hypertension, hyperglycemia, and mood
changes.
10. A 3-month-old infant is admitted to the pediatric
unit. During the assessment, the nurse suspects that
the infant may have hydrocephalus when the mother
states that the baby does not:
A. Sit up.
B. Hold a rattle.
C. Roll over.
D. Hold head up.
Answer: D. Hold head up.
Rationale: A 3-month-old infant should be able to hold the
head up steadily. In hydrocephalus, increased intracranial
pressure and enlarged head size may cause the infant to
Child Health Nursing
Exam 3
1. A pregnant woman who is term is admitted to the
birthing unit in active labor. The client has only
progressed from 2 cm to 3 cm in 8 hours. She is
diagnosed with hypotonic uterine dysfunction and
begins oxytocin (Pitocin) augmentation. Which of the
following is the most important nursing intervention
at this time?
A. Timing and recording length of contractions.
B. Preparing for an emergency cesarean birth.
C. Checking for perineal lacerations.
D. Monitoring the fetal heart rate and uterine contractions.
Answer: D. Monitoring the fetal heart rate and uterine
contractions.
Rationale: The nurse must monitor the fetal heart rate and
uterine contractions continuously during oxytocin
augmentation because oxytocin can cause hyperstimulation
of the uterus, leading to fetal distress. This is the priority
assessment to ensure fetal well-being.
2. A client who is hallucinating is not in touch with
reality. It is important for the nurse to:
A. Isolate the client from other patients.
B. Clarify the client's statements.
C. Orient the client to place, person, and time.
D. Establish a trusting relationship.
Answer: D. Establish a trusting relationship.
Rationale: Establishing a trusting relationship is the
foundation of therapeutic communication with a
hallucinating client. It provides a sense of safety and
security, which is essential before other interventions such
as reality orientation can be effective.
,3. The nurse is caring to a child client who has had a
tonsillectomy. The child complains of having a throat
pain. Which of the following would the nurse do
initially?
A. Cold compress
B. Yellow noncitrus Jello
C. Cool clear liquids
D. Acetaminophen
Answer: D. Acetaminophen.
Rationale: Acetaminophen is the medication of choice for
post-tonsillectomy pain. It is important to manage pain
initially before offering fluids or foods, as pain may inhibit the
child's willingness to swallow. Cold compresses are not
typically applied to the throat, and yellow Jello may be
avoided due to its color, which can mask bleeding.
4. The physician ordered Phenergan (Promethazine)
nasal spray for a 13-year-old client. The nurse is
aware that the client is at risk for Reye's syndrome.
The nurse must ensure that the client has received
which of the following vaccines?
A. Hepatitis B vaccine.
B. Meningococcal vaccine.
C. Varicella vaccine.
D. Pneumococcal vaccine.
Answer: C. Varicella vaccine.
Rationale: Phenergan (promethazine) should not be given
to children who have or are recovering from varicella
(chickenpox) or influenza because of the risk of Reye's
syndrome. The nurse must verify that the child has been
vaccinated against varicella.
5. A child with rubella is admitted to the hospital. The
nurse who will be assigned to care for this client must
be:
A. Immune to rubella.
B. Pregnant.
C. A male nurse.
D. Available to work flexible hours.
Answer: A. Immune to rubella.
,Rationale: Rubella is highly contagious and can cause
severe fetal damage if contracted by a pregnant woman. The
nurse assigned to care for a client with rubella must be
immune to the disease to prevent transmission and protect
any potential fetus.
6. A client with tuberculosis is to be admitted in the
hospital. The nurse who will be assigned to care for
the client must institute appropriate precautions. The
nurse should:
A. Place the client in a private room.
B. Wear an N95 respirator when caring for the client.
C. Wear a gown and gloves when entering the room.
D. Wear a surgical mask when entering the room.
Answer: B. Wear an N95 respirator when caring for
the client.
Rationale: Tuberculosis is transmitted via airborne droplets.
An N95 respirator is required for airborne precautions to filter
out small particles. A private room with negative pressure is
also needed, but the most specific precaution for the nurse is
wearing the N95 respirator.
7. Which of the following is the most frequent cause
of complication to the medical treatment of the client
with bipolar disorder?
A. The nurse has no understanding of the client's condition.
B. The client is not taking the medication as prescribed.
C. The client's family is not supportive.
D. The client has a history of noncompliance.
Answer: B. The client is not taking the medication as
prescribed.
Rationale: Nonadherence to prescribed medication is the
most common cause of relapse and complications in clients
with bipolar disorder. Lithium and other mood stabilizers
require consistent blood levels to be effective.
8. A 16-year-old client is admitted to the hospital with
a diagnosis of acute glomerulonephritis. The nurse
, notes that the client has periorbital edema. Which of
the following would the nurse expect to find in the
client's history?
A. Decreased urinary output.
B. Recent upper respiratory infection.
C. Low-grade fever.
D. Dark, smoky urine.
Answer: B. Recent upper respiratory infection.
Rationale: Acute glomerulonephritis commonly follows a
streptococcal infection, such as an upper respiratory
infection or impetigo. The history typically reveals a recent
infection 1-3 weeks prior to the onset of symptoms.
9. A child with nephrotic syndrome is receiving
prednisone. The nurse should assess the child for
which of the following side effects?
A. Weight loss.
B. Increased appetite.
C. Decreased blood pressure.
D. Bradycardia.
Answer: B. Increased appetite.
Rationale: Prednisone, a corticosteroid, commonly causes
increased appetite, weight gain, and fluid retention. Other
side effects include hypertension, hyperglycemia, and mood
changes.
10. A 3-month-old infant is admitted to the pediatric
unit. During the assessment, the nurse suspects that
the infant may have hydrocephalus when the mother
states that the baby does not:
A. Sit up.
B. Hold a rattle.
C. Roll over.
D. Hold head up.
Answer: D. Hold head up.
Rationale: A 3-month-old infant should be able to hold the
head up steadily. In hydrocephalus, increased intracranial
pressure and enlarged head size may cause the infant to
