Maternal child nursing latest update
2024/2025
Q1. A 10-year-old child with asthma is treated for acute exacerbation in the emergency department.
The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of
the condition?
1. Warm, dry skin
2. Decreased wheezing*
3. Pulse rate of 90 beats/minute
4. Respirations of 18 breaths/minute - ANSWER-2. Decreased wheezing*
* Decreased wheezing in a child with asthma may be interpreted incorrectly as an improving sign
when it may actually signal an inability to move air. "A silence chest" is a worsening sign during an
asthma episode. With treatment, increased wheezing actually may signal that the child's condition is
improving
Q1. A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely
for which problem?
1. Diarrhea
2. Metabolic acidosis
3. Metabolic alkalosis
4. Hyperactive bowel sounds - ANSWER-3. Metabolic alkalosis
Q1. A child with rubeola (measles) is being admitted to the hospital. In preparing for the admission of
the child, the nurse should plan to place the child on which precautions?
1. Enteric
2. Airborne
3. Protective
4. Neutropenic - ANSWER-2. Airborne
Q1. A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The
school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which
should the school nurse tell the child to do?
1. Eat twice the amount normally eaten at lunchtime.
2. Take half the amount of prescribed insulin on practice days.
3. Take the prescribed insulin at noontime rather than in the morning.
4. Eat a small box of raisins or drink a cup of orange juice before soccer practice. - ANSWER-4. Eat a
small box of raisins or drink a cup of orange juice before soccer practice.
,Maternal child nursing latest update
2024/2025
Q1. After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial
action?
1. Maintain NPO status.
2. Turn the child to the side.
3. Administer the prescribed antiemetic.
4. Notify the health care provider (HCP) - ANSWER-2. Turn the child to the side.
Q1. The mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant
to the clinic for a routine checkup. The health care provider has documented that the infant is
asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased
that the infant will not get HIV. The nurse should make which most appropriate response to the
mother ?
1. "I am so pleased also that everything has turned out fine. "
2. "Because symptoms have not developed, it is unlikely that your infant will develop HIV infection. "
3. "Everything looks great, but be sure that you return with your infant next month for the scheduled
visit. "
4. "Most children infected with HIV develop symptoms within the first 9 months of life, and some
become symptomatic sometime before they are 3 years old. " - ANSWER-4. "Most children infected
with HIV develop symptoms within the first 9 months of life, and some become symptomatic
sometime before they are 3 years old. "
Q1. The nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that
which result will most likely be abnormal in this child? 1. Platelet count
2. Hematocrit level
3. Hemoglobin level
4. Partial thromboplastin time (PTT) - ANSWER-4. Partial thromboplastin time (PTT)
Q1. The nurse assisted with the delivery of a newborn. Which nursing action is most effective in
preventing heat loss by evaporation?
1. Warming the crib pad
2. Closing the doors to the room
3. Drying the infant with a warm blanket
4. Turning on the overhead radiant warmer - ANSWER-3. Drying the infant with a warm blanket
Q1. The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the
admission of a 43 weeks gestation newborn with Apgar scores of 1 and 4. In planning for admission
of this newborn, what is the nurse's highest priority?
1. Turn on the apnea and cardiorespiratory monitors.
,Maternal child nursing latest update
2024/2025
2. Connect the resuscitation bag to the oxygen outlet.
3. Set up the intravenous line with 5% dextrose in water.
4. Set the radiant warmer control temperature at 36.5 °C (97.6 °F). - ANSWER-2. Connect the
resuscitation bag to the oxygen outlet.
Q1. The nurse is assisting a health care provider (HCP) examining an infant with developmental
dysplasia of the hip perform an Ortolani maneuver. The nurse understands that this maneuver is
performed for which purpose?
1. To assess for hip instability
2. To assess for movement of the hips
3. To push the femoral head out of the acetabulum
4. To ensure that hyperextension and full range of motion exist - ANSWER-1. To assess for hip
instability
Q1. The nurse is monitoring a child for bleeding after surgery for removal of a brain tumor. The nurse
checks the head dressing for the presence of blood and notes a colorless drainage on the back of the
dressing. Which intervention should the nurse perform immediately?
1. Reinforce the dressing.
2. Notify the health care provider (HCP).
3. Document the findings and continue to monitor.
4. Circle the area of drainage and continue to monitor. - ANSWER-2. Notify the health care provider
(HCP).
Q1. The nurse is monitoring a child with burns during treatment for burn shock. The nurse
understands that which assessment provides the most accurate guide to determine the adequacy of
fluid resuscitation?
1. Skin turgor
2. Neurological assessment
3. Level of edema at burn site
4. Quality of peripheral pulses - ANSWER-2. Neurological assessment
Q1. The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure
(HF). The nurse should assess the infant for which early sign of HF?
1. Pallor
2. Cough
3. Tachycardia
4. Slow and shallow breathing - ANSWER-3. Tachycardia
, Maternal child nursing latest update
2024/2025
1.2.4-late sign of HF
Q1. The nurse reviews the record of a child who is suspected to have glomerulonephritis and expects
to note which finding that is associated with this diagnosis?
1. Hypotension
2. Brown-colored urine
3. Low urinary specific gravity
4. Low blood urea nitrogen level - ANSWER-2. Brown-colored urine
Q1. The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder.
The nurse bases the response on the understanding that cerebral palsy is which type of condition?
1. An infectious disease of the central nervous system
2. An inflammation of the brain as a result of a viral illness
3. A congenital condition that results in moderate to severe retardation
4. A chronic disability characterized by impaired muscle movement and posture - ANSWER-4. A
chronic disability characterized by impaired muscle movement and posture
Q10. A child has been diagnosed with acute otitis media (AOM) of the right ear. Which interventions
should the nurse include in the plan of care ? Select all that apply.
1. Provide a soft diet.
2. Position the child on the left side.
3. Administer an antihistamine twice daily.
4. Irrigate the right ear with normal saline every 8 hours.
5. Administer ibuprofen (Motrin IB) for fever every 4 hours as prescribed and as needed.
6. Instruct the parents about the need to administer the prescribed antibiotics for the full course of
therapy. - ANSWER-1. Provide a soft diet.
5. Administer ibuprofen (Motrin IB) for fever every 4 hours as prescribed and as needed.
6. Instruct the parents about the need to administer the prescribed antibiotics for the full course of
therapy.
Q10. An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority
nursing intervention in the preoperative period ?
1. Test the urine for protein.
2. Reposition the infant frequently
3. Provide a stimulating environment.
2024/2025
Q1. A 10-year-old child with asthma is treated for acute exacerbation in the emergency department.
The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of
the condition?
1. Warm, dry skin
2. Decreased wheezing*
3. Pulse rate of 90 beats/minute
4. Respirations of 18 breaths/minute - ANSWER-2. Decreased wheezing*
* Decreased wheezing in a child with asthma may be interpreted incorrectly as an improving sign
when it may actually signal an inability to move air. "A silence chest" is a worsening sign during an
asthma episode. With treatment, increased wheezing actually may signal that the child's condition is
improving
Q1. A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely
for which problem?
1. Diarrhea
2. Metabolic acidosis
3. Metabolic alkalosis
4. Hyperactive bowel sounds - ANSWER-3. Metabolic alkalosis
Q1. A child with rubeola (measles) is being admitted to the hospital. In preparing for the admission of
the child, the nurse should plan to place the child on which precautions?
1. Enteric
2. Airborne
3. Protective
4. Neutropenic - ANSWER-2. Airborne
Q1. A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The
school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which
should the school nurse tell the child to do?
1. Eat twice the amount normally eaten at lunchtime.
2. Take half the amount of prescribed insulin on practice days.
3. Take the prescribed insulin at noontime rather than in the morning.
4. Eat a small box of raisins or drink a cup of orange juice before soccer practice. - ANSWER-4. Eat a
small box of raisins or drink a cup of orange juice before soccer practice.
,Maternal child nursing latest update
2024/2025
Q1. After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial
action?
1. Maintain NPO status.
2. Turn the child to the side.
3. Administer the prescribed antiemetic.
4. Notify the health care provider (HCP) - ANSWER-2. Turn the child to the side.
Q1. The mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant
to the clinic for a routine checkup. The health care provider has documented that the infant is
asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased
that the infant will not get HIV. The nurse should make which most appropriate response to the
mother ?
1. "I am so pleased also that everything has turned out fine. "
2. "Because symptoms have not developed, it is unlikely that your infant will develop HIV infection. "
3. "Everything looks great, but be sure that you return with your infant next month for the scheduled
visit. "
4. "Most children infected with HIV develop symptoms within the first 9 months of life, and some
become symptomatic sometime before they are 3 years old. " - ANSWER-4. "Most children infected
with HIV develop symptoms within the first 9 months of life, and some become symptomatic
sometime before they are 3 years old. "
Q1. The nurse analyzes the laboratory results of a child with hemophilia. The nurse understands that
which result will most likely be abnormal in this child? 1. Platelet count
2. Hematocrit level
3. Hemoglobin level
4. Partial thromboplastin time (PTT) - ANSWER-4. Partial thromboplastin time (PTT)
Q1. The nurse assisted with the delivery of a newborn. Which nursing action is most effective in
preventing heat loss by evaporation?
1. Warming the crib pad
2. Closing the doors to the room
3. Drying the infant with a warm blanket
4. Turning on the overhead radiant warmer - ANSWER-3. Drying the infant with a warm blanket
Q1. The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the
admission of a 43 weeks gestation newborn with Apgar scores of 1 and 4. In planning for admission
of this newborn, what is the nurse's highest priority?
1. Turn on the apnea and cardiorespiratory monitors.
,Maternal child nursing latest update
2024/2025
2. Connect the resuscitation bag to the oxygen outlet.
3. Set up the intravenous line with 5% dextrose in water.
4. Set the radiant warmer control temperature at 36.5 °C (97.6 °F). - ANSWER-2. Connect the
resuscitation bag to the oxygen outlet.
Q1. The nurse is assisting a health care provider (HCP) examining an infant with developmental
dysplasia of the hip perform an Ortolani maneuver. The nurse understands that this maneuver is
performed for which purpose?
1. To assess for hip instability
2. To assess for movement of the hips
3. To push the femoral head out of the acetabulum
4. To ensure that hyperextension and full range of motion exist - ANSWER-1. To assess for hip
instability
Q1. The nurse is monitoring a child for bleeding after surgery for removal of a brain tumor. The nurse
checks the head dressing for the presence of blood and notes a colorless drainage on the back of the
dressing. Which intervention should the nurse perform immediately?
1. Reinforce the dressing.
2. Notify the health care provider (HCP).
3. Document the findings and continue to monitor.
4. Circle the area of drainage and continue to monitor. - ANSWER-2. Notify the health care provider
(HCP).
Q1. The nurse is monitoring a child with burns during treatment for burn shock. The nurse
understands that which assessment provides the most accurate guide to determine the adequacy of
fluid resuscitation?
1. Skin turgor
2. Neurological assessment
3. Level of edema at burn site
4. Quality of peripheral pulses - ANSWER-2. Neurological assessment
Q1. The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure
(HF). The nurse should assess the infant for which early sign of HF?
1. Pallor
2. Cough
3. Tachycardia
4. Slow and shallow breathing - ANSWER-3. Tachycardia
, Maternal child nursing latest update
2024/2025
1.2.4-late sign of HF
Q1. The nurse reviews the record of a child who is suspected to have glomerulonephritis and expects
to note which finding that is associated with this diagnosis?
1. Hypotension
2. Brown-colored urine
3. Low urinary specific gravity
4. Low blood urea nitrogen level - ANSWER-2. Brown-colored urine
Q1. The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder.
The nurse bases the response on the understanding that cerebral palsy is which type of condition?
1. An infectious disease of the central nervous system
2. An inflammation of the brain as a result of a viral illness
3. A congenital condition that results in moderate to severe retardation
4. A chronic disability characterized by impaired muscle movement and posture - ANSWER-4. A
chronic disability characterized by impaired muscle movement and posture
Q10. A child has been diagnosed with acute otitis media (AOM) of the right ear. Which interventions
should the nurse include in the plan of care ? Select all that apply.
1. Provide a soft diet.
2. Position the child on the left side.
3. Administer an antihistamine twice daily.
4. Irrigate the right ear with normal saline every 8 hours.
5. Administer ibuprofen (Motrin IB) for fever every 4 hours as prescribed and as needed.
6. Instruct the parents about the need to administer the prescribed antibiotics for the full course of
therapy. - ANSWER-1. Provide a soft diet.
5. Administer ibuprofen (Motrin IB) for fever every 4 hours as prescribed and as needed.
6. Instruct the parents about the need to administer the prescribed antibiotics for the full course of
therapy.
Q10. An infant with a diagnosis of hydrocephalus is scheduled for surgery. Which is the priority
nursing intervention in the preoperative period ?
1. Test the urine for protein.
2. Reposition the infant frequently
3. Provide a stimulating environment.
