Maternity Nursing (OB Maternal & Newborn) NCLEX Practice Quiz #3 | 75 Questions| 21/2022 UPDATE

Maternity Nursing (OB Maternal & Newborn) NCLEX Practice Quiz #3 | 75 Questions 1. 1. Question A newborn who has an asymmetrical Moro reflex response should be further assessed for which of the following? o A. Talipes equinovarus o B. Fractured clavicle o C. Congenital hypothyroidism o D. Increased intracranial pressure Incorrect Correct Answer: B. Fractured clavicle A fractured clavicle would prevent the normal Moro response of symmetrical sequential extension and abduction of the arms followed by flexion and adduction. • Option A: In talipes equinovarus (clubfoot) the foot is turned medially, and in plantar flexion, with the heel elevated. The feet are not involved with the Moro reflex. • Option C: Hypothyroidism has no effect on the primitive reflexes. Hypothyroidism means that the thyroid gland can’t make enough thyroid hormones to keep the body running normally. • Option D: The absence of the Moro reflex is the most significant single indicator of central nervous system status, but it is not a sign of increased intracranial pressure. 2. 2. Question During the first 4 hours after a male circumcision, assessing for which of the following is the priority? • A. Infection • B. Hemorrhage • C. Discomfort • D. Dehydration Incorrect Correct Answer: B. Hemorrhage Hemorrhage is a potential risk following any surgical procedure. Although the infant has been given vitamin K to facilitate clotting, the prophylactic dose is often not sufficient to prevent bleeding. • Option A: Although infection is a possibility, signs will not appear within 4 hours after the surgical procedure. • Option C: The primary discomfort of circumcision occurs during the surgical procedure, not afterward. • Option D: Although feedings are withheld prior to the circumcision, the chances of dehydration are minimal. 3. 3. Question The mother asks the nurse. “What’s wrong with my son’s breasts? Why are they so enlarged?” Which of the following would be the best response by the nurse? • A. “The breast tissue is inflamed from the trauma experienced with birth.” • B. “A decrease in material hormones present before birth causes enlargement,” • C. “You should discuss this with your doctor. It could be a malignancy.” • D. “The tissue has hypertrophied while the baby was in the uterus.” Incorrect Correct Answer: B. “A decrease in material hormones present before birth causes enlargement,” The presence of excessive estrogen and progesterone in the maternal-fetal blood followed by prompt withdrawal at birth precipitates breast engorgement, which will spontaneously resolve in 4 to 5 days after birth. • Option A: The trauma of the birth process does not cause inflammation of the newborn’s breast tissue. • Option C: Newborns do not have breast malignancy. This reply by the nurse would cause the mother to have undue anxiety. • Option D: Breast tissue does not hypertrophy in the fetus or newborns. 4. 4. Question Immediately after birth, the nurse notes the following on a male newborn: respirations 78; apical heart rate 160 BPM, nostril-flaring; mild intercostal retractions; and grunting at the end of expiration. Which of the following should the nurse do? • A. Call the assessment data to the physician’s attention • B. Start oxygen per nasal cannula at 2 L/min. • C. Suction the infant’s mouth and nares. • D. Recognize this as a normal first period of reactivity. Incorrect Correct Answer: D. Recognize this as normal first period of reactivity The first 15 minutes to 1 hour after birth is the first period of reactivity involving respiratory and circulatory adaptation to extrauterine life. The data given reflect the normal changes during this time period. • Option A: The infant’s assessment data reflect normal adaptation. Thus, the physician does not need to be notified. • Option B: Babies with heart or lung problems may need to breathe increased amounts of oxygen to get normal levels of oxygen in their blood. Oxygen therapy provides babies with extra oxygen. • Option C: The data do not indicate the presence of choking, gagging, or coughing, which are signs of excessive secretions. Suctioning is not necessary. 5. 5. Question The nurse hears a mother telling a friend on the telephone about umbilical cord care. Which of the following statements by the mother indicates effective teaching? • A. “Daily soap and water cleansing is best.” • B. “Alcohol helps it dry and kills germs.” • C. “An antibiotic ointment applied daily prevents infection.” • D. “He can have a tub bath each day.” Incorrect Correct Answer: B. “Alcohol helps it dry and kills germs” Application of 70% isopropyl alcohol to the cord minimizes microorganisms (germicidal) and promotes drying. The cord should be kept dry until it falls off and the stump has healed. • Option A: Research now shows that the stump might actually heal faster if left alone. If the stump becomes dirty or sticky, clean it with plain water, after which you dry it by holding a clean, absorbent cloth around it or fanning it with a piece of paper. • Option C: Antibiotic ointment should only be used to treat an infection, not as prophylaxis. • Option D: Infants should not be submerged in a tub of water until the cord falls off and the stump has completely healed. 6. 6. Question A newborn weighing 3000 grams and feeding every 4 hours needs 120 calories/kg of body weight every 24 hours for proper growth and development. How many ounces of 20 cals/oz formula should this newborn receive at each feeding to meet nutritional needs? • A. 2 ounces • B. 3 ounces • C. 4 ounces • D. 6 ounces Incorrect Correct Answer: B. 3 ounces To determine the amount of formula needed, do the following mathematical calculation. 3 kg x 120 cal/kg per day = 360 calories/day feeding q 4 hours = 6 feedings per day = 60 calories per feeding: 60 calories per feeding; 60 calories per feeding with formula 20 cal/oz = 3 ounces per feeding. Based on the calculation. 2, 4 or 6 ounces are incorrect. • Option A: 2 ounces is less than the recommended intake. Newborns will nurse about 8 to 12 times per day during the first weeks of life. In the beginning, mothers may want to try nursing 10–15 minutes on each breast, then adjust the time as necessary. • Option C: With 4 ounces, the newborn would be overfed and not meet the adequate nutritional requirement. A baby who is fussing, crying, seems hungry, and does not appear satisfied after feeding may not be getting enough to eat. A baby is getting enough to eat if he or she seems satisfied, produces about six to eight wet diapers a day, has regular bowel movements, sleeps well, is alert when awake, and is gaining weight. • Option D: 6 ounces is too much intake for a newborn every feeding. Many infants “spit up” a small amount after eating or during burping, but a baby should not vomit after feeding. Vomiting after every feeding might be a sign of an allergy, digestive problem, or other problem that needs medical attention. 7. 7. Question The post-term neonate with meconium-stained amniotic fluid needs care designed to especially monitor for which of the following? • A. Respiratory problems • B. Gastrointestinal problems • C. Integumentary problems • D. Elimination problems Incorrect Correct Answer: A. Respiratory problems Intrauterine anoxia may cause relaxation of the anal sphincter and emptying of meconium into the amniotic fluid. At birth some of the meconium fluid may be aspirated, causing mechanical obstruction or chemical pneumonitis. • Option B: The infant is not at increased risk for gastrointestinal problems. Postmature infants are alert and appear mature. They have a decreased amount of soft-tissue mass, particularly subcutaneous fat. The skin may hang loosely on the extremities and is often dry and peeling. The fingernails and toenails are long. The nails and umbilical cord may be stained with meconium passed in utero. • Option C: Even though the skin is stained with meconium, it is noninfectious (sterile) and non-irritating. • Option D: The post-term meconium-stained infant is not at additional risk for bowel or urinary problems. Failure to pass meconium beyond 48 hours in term neonates may indicate disease or obstruction of the infant’s bowel. The diagnostic differential for the delayed passage of meconium includes Hirschsprung disease, meconium plug syndrome, meconium ileus, anorectal malformations, small left colon syndrome, and intestinal atresias. 8. 8. Question When measuring a client’s fundal height, which of the following techniques denotes the correct method of measurement used by the nurse? • A. From the xiphoid process to the umbilicus. • B. From the symphysis pubis to the xiphoid process. • C. From the symphysis pubis to the fundus. • D. From the fundus to the umbilicus. Incorrect Correct Answer: C. From the symphysis pubis to the fundus. The nurse should use a non-elastic, flexible, paper measuring tape, placing the zero point on the superior border of the symphysis pubis and stretching the tape across the abdomen at the midline to the top of the fundus. • Option A: The xiphoid process is an incorrect landmark to use in measuring for fundal height. If measured correctly, the fundus at 36 weeks should be at the xiphoid process. • Option B: Measuring from the symphysis pubis to the xiphoid process is incorrect. If the fundal height is measured at the level of the symphysis pubis, then the woman is at 12 weeks gestation. • Option D: The umbilicus is not an appropriate landmark to use when measuring the height of the fundus (McDonald’s measurement). When the fundal height is at the level of the umbilicus, the fundus is at 20 weeks gestation. 9. 9. Question A client with severe preeclampsia is admitted with BP 160/110, proteinuria, and severe pitting edema. Which of the following would be most important to include in the client’s plan of care? • A. Daily weights • B. Seizure precautions • C. Right lateral positioning • D. Stress reduction Incorrect Correct Answer: B. Seizure precautions Women hospitalized with severe preeclampsia need decreased CNS stimulation to prevent a seizure. Seizure precautions provide environmental safety should a seizure occur. • Option A: Because of edema, daily weight is important but not the priority. High pregnancy weight gain was more strongly associated with term preeclampsia than early preterm preeclampsia (eg, 64% versus 43% increased odds per 1 z score difference in weight gain in normal-weight women, and 30% versus 0% in obese women, respectively). • Option C: Preeclampsia causes vasospasm and therefore can reduce uteroplacental perfusion. The client should be placed on her left side to maximize blood flow, reduce blood pressure, and promote diuresis. • Option D: Interventions to reduce stress and anxiety are very important to facilitate coping and a sense of control, but seizure precautions are the priority. 10. 10. Question A postpartum primipara asks the nurse, “When can we have sexual intercourse again?” Which of the following would be the nurse’s best response? • A. “Anytime you both want to.” • B. “As soon as you choose a contraceptive method.” • C. “When the discharge has stopped, and the incision is healed.” • D. “After your 6 weeks examination.” Incorrect Correct Answer: C. “When the discharge has stopped and the incision is healed.” Cessation of the lochial discharge signifies healing of the endometrium. The risk of hemorrhage and infection are minimal 3 weeks after a normal vaginal delivery. • Option A: Telling the client anytime is inappropriate because this response does not provide the client with the specific information she is requesting. • Option B: Choice of a contraceptive method is important, but not the specific criteria for safe resumption of sexual activity. • Option D: Culturally, the 6-weeks’ examination has been used as the time frame for resuming sexual activity, but it may be resumed earlier. 11. 11. Question When preparing to administer the vitamin K injection to a neonate, the nurse would select which of the following sites as appropriate for the injection? • A. Deltoid muscle • B. Anterior femoris muscle • C. Vastus lateralis muscle • D. Gluteus maximus muscle Incorrect Correct Answer: C. Vastus lateralis muscle The middle third of the vastus lateralis is the preferred injection site for vitamin K administration because it is free of blood vessels and nerves and is large enough to absorb the medication. • Option A: The deltoid muscle of a newborn is not large enough for a newborn IM injection. Injections into this muscle in a small child might cause damage to the radial nerve. • Option B: The anterior femoris muscle is the next safest muscle to use in a newborn but is not the safest. The rectus femoris (the middle third of the rectus femoris) is no longer a recommended site because it may cause discomfort and pain. A previous study reported that one disadvantage of this site is that nerves and numerous blood vessels run very close to it • Option D: Because of the proximity of the sciatic nerve, the gluteus maximus muscle should not be until the child has been walking 2 years. 12. 12. Question When performing a pelvic examination, the nurse observes a red swollen area on the right side of the vaginal orifice. The nurse would document this as enlargement of which of the following? • A. Clitoris • B. Parotid gland • C. Skene’s gland • D. Bartholin’s gland Incorrect Correct Answer: D. Bartholin’s gland The Bartholin’s glands are located symmetrically at the posterior region of the vaginal opening and play an important role in the female reproductive system. These two pea-sized glands are involved in mucus secretion and vaginal lubrication. • Option A: The clitoris is female erectile tissue found in the perineal area above the urethra. During sexual stimulation, the clitoris functions much like a man’s penis in that it becomes erect thanks to signals from the brain. The shaft under the skin has erectile tissue, which becomes engorged with increased blood flow. The clitoris is a very sensitive area when stimulated. • Option B: The parotid glands are open into the mouth. The parotid is the largest of the three glands and is bordered superiorly by the zygomatic arch, anteriorly and medially by the masseter, and posteriorly by the sternocleidomastoid. The saliva secreted from these glands moistens the mouth which helps with chewing, swallowing, phonation, and digestion. • Option C: Skene’s glands open into the posterior wall of the female urinary meatus. The Skene’s glands, which are also known as the lesser vestibular glands (homologous to the prostate glands in males), are two glands located on either side of the urethra. These glands are believed to secrete a substance to lubricate the urethra opening. This substance is also believed to act as an antimicrobial. 13. 13. Question To differentiate as a female, the hormonal stimulation of the embryo that must occur involves which of the following? • A. Increase in maternal estrogen secretion • B. Decrease in maternal androgen secretion. • C. Secretion of androgen by the fetal gonad. • D. Secretion of estrogen by the fetal gonad. Incorrect Correct Answer: D. Secretion of estrogen by the fetal gonad. The fetal gonad must secrete estrogen for the embryo to differentiate as a female. • Option A: An increase in maternal estrogen secretion does not affect differentiation of the embryo, and maternal estrogen secretion occurs in every pregnancy. • Option B: Maternal androgen secretion remains the same as before pregnancy and does not affect differentiation. • Option C: Secretion of androgen by the fetal gonad would produce a male fetus. 14. 14. Question A client at 8 weeks’ gestation calls complaining of slight nausea in the morning hours. Which of the following client interventions should the nurse question? • A. Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water. • B. Eating a few low-sodium crackers before getting out of bed. • C. Avoiding the intake of liquids in the morning hours. • D. Eating six small meals a day instead of three large meals. Incorrect Correct Answer: A. Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water. Using bicarbonate would increase the amount of sodium ingested, which can cause complications. • Option B: Eating low-sodium crackers would be appropriate. Foods high in starch — such as saltines, bread, and toast — help absorb gastric acid and settle a queasy stomach. The bland nature of a cracker helps to satisfy hunger (excessive hunger can exacerbate nausea) without the strong smells or tastes that may increase nausea. • Option C: Since liquids can increase nausea avoiding them in the morning hours when nausea is usually the strongest is appropriate. • Option D: Eating six small meals a day would keep the stomach full, which often decreases nausea. 15. 15. Question The nurse documents positive ballottement in the client’s prenatal record. The nurse understands that this indicates which of the following? • A. Palpable contractions on the abdomen. • B. Passive movement of the unengaged fetus. • C. Fetal kicking felt by the client. • D. Enlargement and softening of the uterus. Incorrect Correct Answer: B. Passive movement of the unengaged fetus. Ballottement indicates passive movement of the unengaged fetus. Ballottement is when the lower uterine segment or the cervix is tapped by the examiner’s finger and left there, the fetus floats upward, then sinks back and a gentle tap is felt on the finger. • Option A: Ballottement is not a contraction. Contractions can be felt by placing a hand on the abdomen and feeling when the uterus becomes hard, and when it relaxes. It is therefore possible to assess the length of a contraction by taking the time at the beginning and end of the contraction. • Option C: Fetal kicking felt by the client represents quickening. Usually, quickening occurs naturally at about the middle of a pregnancy. A woman pregnant for the first time (i.e., a primigravida woman) typically feels fetal movements at about 18–20 weeks, whereas a woman who has given birth at least once (i.e., a para woman) will typically feel movements around 15–17 weeks. • Option D: Enlargement and softening of the uterus is known as Piskacek’s sign. The Piskacek’s sign is an indication of pregnancy. Specifically, Piskacek’s sign consists of noting a palpable lateral bulge or soft prominence at one of the locations where the uterine tube meets the uterus. Piskacek’s sign can be noted in the seventh to eighth week of gestation. 16. 16. Question During a pelvic exam, the nurse notes a purple-blue tinge of the cervix. The nurse documents this as which of the following? • A. Braxton-Hicks sign • B. Chadwick’s sign • C. Goodell’s sign • D. McDonald’s sign Incorrect Correct Answer: B. Chadwick’s sign Chadwick’s sign is a bluish discoloration of the cervix, vagina, and labia resulting from increased blood flow. It can be observed as early as 6 to 8 weeks after conception, and its presence is an early sign of pregnancy. • Option A: Braxton Hicks contractions are painless contractions beginning around the 4th month. Braxton Hicks contractions are sporadic contractions and relaxation of the uterine muscle. Sometimes, they are referred to as prodromal or “false labor” pains. It is believed they start around 6 weeks gestation but usually are not felt until the second or third trimester of the pregnancy. Braxton Hicks contractions are the body’s way of preparing for true labor, but they do not indicate that labor has begun or is going to start. • Option C: Goodell sign is an indication of pregnancy. It is a significant softening of the vaginal portion of the cervix from increased vascularization. This vascularization is a result of hypertrophy and engorgement of the vessels below the growing uterus. This sign occurs at approximately four weeks’ gestation. • Option D: Flexibility of the uterus against the cervix is known as McDonald’s sign. 17. 17. Question During a prenatal class, the nurse explains the rationale for breathing techniques during preparation for labor based on the understanding that breathing techniques are most important in achieving which of the following? • A. Eliminate pain and give expectant parents something to do. • B. Reduce the risk of fetal distress by increasing uteroplacental perfusion. • C. Facilitate relaxation, possibly reducing the perception of pain. • D. Eliminate pain so that less analgesia and anesthesia are needed. Incorrect Correct Answer: C. Facilitate relaxation, possibly reducing the perception of pain. Breathing techniques can raise the pain threshold and reduce the perception of pain. They also promote relaxation. • Option A: Breathing techniques do not eliminate pain, but they can reduce it. Focused breathing might work by interrupting the transmission of pain signals to the brain by giving the woman something positive to focus on. It may also work by stimulating the release of endorphins, which are natural pain-relieving hormones, and by helping her reframe her thinking about labor so that she can view it as positive, productive, and manageable. • Option B: Positioning, not breathing, increases uteroplacental perfusion. Side-lying position aids in better blood circulation. • Option D: Breathing techniques do not eliminate pain. Many different childbirth classes include components of breathing in their class curriculum. The techniques may vary but many classes today teach that breathing should be slow, deep, controlled, and conscious or voluntary, not automatic. 18. 18. Question 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 hours • C. Preparing for a cesarean section for failure to progress Incorrect Correct Answer: A. Obtaining an order to begin IV oxytocin infusion. The client’s labor is hypotonic. The nurse should call the physical and obtain an order for an infusion of oxytocin, which will assist the uterus to contract more forcefully in an attempt to dilate the cervix. • Option B: Administering a light sedative would be done for hypertonic uterine contractions. • Option C: Preparing for a cesarean section is unnecessary at this time. • Option D: Oxytocin would increase the uterine contractions and hopefully progress labor before a cesarean would be necessary. It is too early to anticipate client pushing with contractions. 19. 19. Question A multigravida at 38 weeks’ gestation is admitted with painless, bright red bleeding and mild contractions every 7 to 10 minutes. Which of the following assessments should be avoided? • A. Maternal vital sign • B. Fetal heart rate • C. Contraction monitoring • D. Cervical dilation Incorrect Correct Answer: D. Cervical dilation The signs indicate placenta previa and vaginal exam to determine cervical dilation would not be done because it could cause hemorrhage. • Option A: Assessing maternal vital signs can help determine maternal physiologic status. • Option B: Fetal heart rate is important to assess fetal well-being and should be done. • Option C: Monitoring the contractions will help evaluate the progress of labor. 20. 20. Question Which of the following would be the nurse’s most appropriate response to a client who asks why she must have a cesarean delivery if she has a complete placenta previa? • A. “You will have to ask your physician when he returns.” • B. “You need a cesarean to prevent hemorrhage.” • C. “The placenta is covering most of your cervix.” • D. “The placenta is covering the opening of the uterus and blocking your baby.” Incorrect Correct Answer: D. “The placenta is covering the opening of the uterus and blocking your baby.” A complete placenta previa occurs when the placenta covers the opening of the uterus, thus blocking the passageway for the baby. This response explains what a complete previa is and the reason the baby cannot come out except by cesarean delivery. • Option A: Telling the client to ask the physician is a poor response and would increase the patient’s anxiety. • Option B: Although a cesarean would help to prevent hemorrhage, the statement does not explain why the hemorrhage could occur. • Option C: With a complete previa, the placenta is covering all the cervix, not just most of it. 21. 21. Question The nurse understands that the fetal head is in which of the following positions with a face presentation? • A. Completely flexed • B. Completely extended • C. Partially extended • D. Partially flexed Incorrect Correct Answer: B. Completely extended In a face presentation, the fetal head and neck are hyperextended, causing the occiput to come in contact with the upper back of the fetus while lying on a longitudinal axis. • Option A: With a vertex presentation, the head is completely or partially flexed. • Option C: With a brow (forehead) presentation, the head would be partially extended. • Option D: Partially flexed fetal head is categorized as a sinciput presentation. 22. 22. Question 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 the midline. Incorrect Correct Answer: D. Above the maternal umbilicus and to the left of midline With this presentation, the fetal upper torso and back face the left upper maternal abdominal wall. The fetal heart rate would be most audible above the maternal umbilicus and to the left of the middle. The other positions would be incorrect. • Option A: The fetal heart rate would be most audible above the maternal umbilicus but to the left of the midline. • Option B: It should not be at the lower-left of the maternal abdominal quadrant. Fetal heart rate heard in this area may be inaccurate or maybe the maternal heart rate. • Option C: This would be an inaccurate area to check for the fetal heart rate. Since the baby is in breech position, the fetal back may be located at the upper maternal abdominal wall. 23. 23. Question The amniotic fluid of a client has a greenish tint. The nurse interprets this to be the result of which of the following? • A. Lanugo • B. Hydramnios • C. Meconium • D. Vernix Incorrect Correct Answer: C. Meconium The greenish tint is due to the presence of meconium. Meconium is a thick, green, tar-like substance that lines the baby’s intestines during pregnancy. Typically this substance is not released in the baby’s bowel movements until after birth. However, sometimes a baby will have a bowel movement prior to birth, excreting the meconium into the amniotic fluid. • Option A: Lanugo is the soft, downy hair on the shoulders and back of the fetus. This downy, unpigmented hair is the first type of hair that grows from hair follicles. It can be found everywhere on a baby’s body, except on the palms, lips, and soles of the feet. Most fetuses develop lanugo around the fourth or fifth month of pregnancy. • Option B: Hydramnios represents excessive amniotic fluid. • Option D: Vernix is the white, cheesy substance covering the fetus. It is produced by dedicated cells and is thought to have some protective roles during fetal development and for a few hours after birth. 24. 24. Question A patient is in labor and has just been told she has a breech presentation. The nurse should be particularly alert for which of the following? • A. Quickening • B. Ophthalmia neonatorum • C. Pica • D. Prolapsed umbilical cord Incorrect Correct Answer: D. Prolapsed umbilical cord In a breech position, because of the space between the presenting part and the cervix, prolapse of the umbilical cord is common. • Option A: Quickening is the woman’s first perception of fetal movement. • Option B: Ophthalmia neonatorum usually results from maternal gonorrhea and is conjunctivitis. • Option C: Pica refers to the oral intake of nonfood substances. 25. 25. Question When describing dizygotic twins to a couple, on which of the following would the nurse base the explanation? • A. Two ova fertilized by separate sperm. • B. Sharing of a common placenta. • C. Each ova with the same genotype. • D. Sharing of a common chorion. Incorrect Correct Answer: A. Two ova fertilized by separate sperm Dizygotic (fraternal) twins involve two ova fertilized by separate sperm. Monozygotic (identical) twins involve a common placenta, same genotype, and common chorion. • Option B: Monozygotic multiples form from a single egg and sperm combination that splits after conception. If the split is delayed for a few days, the embryos will develop with a single, shared placenta. • Option C: Identical twins share all of their genes and are always of the same sex. • Option D: In the majority of cases, these multiples will be enclosed within a shared chorion (the outer layer of the sac that contains a fetus). 26. 26. Question Which of the following refers to the single cell that reproduces itself after conception? • A. Chromosome • B. Blastocyst • C. Zygote • D. Trophoblast Incorrect Correct Answer: C. Zygote The zygote is the single cell that reproduces itself after conception. It is the union of the sperm cell and the egg cell. Also known as a fertilized ovum, the zygote begins as a single cell but divides rapidly in the days following fertilization. After this two-week period of cell division, the zygote eventually becomes an embryo. If this goes well, the embryo becomes a fetus. • Option A: The chromosome is the material that makes up the cell and is gained from each parent. Chromosomes are thread-like structures located inside the nucleus of animal and plant cells. Each chromosome is made of protein and a single molecule of deoxyribonucleic acid (DNA). Passed from parents to offspring, DNA contains the specific instructions that make each type of living creature unique. • Option B: The blastocyst consists of cells forming an outer trophectoderm (TE, trophoblast) layer, an inner cell mass (ICM, embryo blast), and a blastocoel (fluid-filled cavity). The inner cell mass will form the entire embryo and is the source of true embryonic stem cells capable of forming all cell types within the embryo. • Option D: In early development, the blastocyst outer trophectoderm (TE) layer will generate all the extraembryonic trophoblast cell types: cytotrophoblast, syncytiotrophoblast, trophoblastic column, and extravillous trophoblast cells. These cells have an important contribution to extra-embryonic tissues (fetal placenta and membranes) and processes of early development (adplantation, implantation, and endocrine support of pregnancy). 27. 27. Question In the late 1950s, consumers and health care professionals began challenging the routine use of analgesics and anesthetics during childbirth. Which of the following was an outgrowth of this concept? • A. Labor, delivery, recovery, postpartum (LDRP) • B. Nurse-midwifery • C. Clinical nurse specialist • D. Prepared childbirth Incorrect Correct Answer: D. Prepared childbirth Prepared childbirth was the direct result of the 1950s challenging the routine use of analgesic and anesthetics during childbirth. • Option A: The LDRP was a much later concept and was not a direct result of the challenging of routine use of analgesics and anesthetics during childbirth. • Option B: A nurse-midwife is a licensed healthcare professional who specializes in women’s reproductive health and childbirth. In addition to attending births, they perform annual exams, give counseling, and write prescriptions. According to the ACNM, the vast majority of midwives in the U.S. are CNMs. • Option C: Clinical nurse specialists (CNS) are advanced practice registered nurses (APRNs) that serve as experts in evidence-based nursing practice within one of a number of different specialty areas. They integrate their advanced knowledge of disease processes in assessing, diagnosing, and treating patient illnesses, but their role extends beyond providing patient care. 28. 28. Question A client has a mid pelvic contracture from a previous pelvic injury due to a motor vehicle accident as a teenager. The nurse is aware that this could prevent a fetus from passing through or around which structure during childbirth? • A. Symphysis pubis • B. Sacral promontory • C. Ischial spines • D. Pubic arch Incorrect Correct Answer: C. Ischial spines The ischial spines are located in the mid-pelvic region and could be narrowed due to the previous pelvic injury. • Option A: The pubic symphysis is a secondary cartilaginous joint (a joint made of hyaline cartilage and fibrocartilage) located between the left and right pubic bones near the midline of the body. More specifically, it is located above any external genitalia and in front of the bladder. • Option B: Superiorly, there is an anterior projection of bone, known as the sacral promontory. It forms the posterior margin of the pelvic inlet and as a result, it is serially continuous with the margin of the ala of the sacrum, arcuate line of the ilium, and the pectin pubis and pubic crest of the pubic bone. • Option D: The pubic arch, also referred to as the ischiopubic arch, is part of the pelvis. It is formed by the convergence of the inferior rami of the ischium and pubis on either side, below the pubic symphysis. The angle at which they converge is known as the subpubic angle. 29. 29. Question When teaching a group of adolescents about variations in the length of the menstrual cycle, the nurse understands that the underlying mechanism is due to variations in which of the following phases? • A. Menstrual phase • B. Proliferative phase • C. Secretory phase • D. Ischemic phase Incorrect Correct Answer: B. Proliferative phase Variations in the length of the menstrual cycle are due to variations in the proliferative phase. In addition to ovarian follicle maturation, changes also occur in the endometrium during the first 14 days of the cycle, hence the term ‘proliferative phase.’ The increasing concentrations of estradiol strongly influence the endometrial changes that happen before ovulation. • Option A: Menstruation is the elimination of the thickened lining of the uterus (endometrium) from the body through the vagina. Menstrual fluid contains blood, cells from the lining of the uterus (endometrial cells), and mucus. The average length of a period is between three days and one week. • Option C: The secretory phase always occurs from day 14 to day 28 of the cycle. Progesterone stimulated by LH is the dominant hormone during this phase to prepare the corpus luteum and the endometrium for possible fertilized ovum implantation • Option D: The final part of the secretory phase is the ischemic phase. The endometrium becomes pale and arteries constrict due to lower hormone release by the disintegrating corpus luteum. 30. 30. Question When teaching a group of adolescents about male hormone production, which of the following would the nurse include as being produced by the Leydig cells? • A. Follicle-stimulating hormone • B. Testosterone • C. Luteinizing hormone • D. Gonadotropin-releasing hormone Incorrect Correct Answer: B. Testosterone Testosterone is produced by the Leydig cells in the seminiferous tubules. The Leydig cells make and secrete testosterone, in response to luteinizing hormone from the pituitary. This process does not start until puberty when LH stimulates the Leydig cells to produce testosterone. FSH stimulates the Sertoli cells to secrete androgen-binding protein into the lumen of the seminiferous tubules. • Option A: FSH is made by the pituitary gland, a small gland located underneath the brain. FSH plays an important role in sexual development and functioning. In women, FSH helps control the menstrual cycle and stimulates the growth of eggs in the ovaries. • Option C: Luteinizing hormone (LH) is produced and released in the anterior pituitary gland. This hormone is considered a gonadotropic hormone because of its role in controlling the function of ovaries in females and testes in males, which are known as the gonads. • Option D: The hypothalamus is responsible for releasing gonadotropin-releasing hormone. 31. 31. Question While performing a physical assessment of a 12 month-old, the nurse notes that the infant’s anterior fontanel 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 neurological examination. • C. Perform an intensive developmental examination. • D. Do nothing because this is a normal finding for the age. Incorrect Correct Answer: D. Do nothing because this is a normal finding for the age. The anterior fontanelle typically closes anywhere between 12 to 18 months of age. Thus, assessing the anterior fontanelle as still being slightly open is a normal finding requiring no further action. Because it is a normal finding for this age, notifying the physician or performing additional examinations is inappropriate. • Option A: The average size of the anterior fontanel is 2.1 cm, and the median time of closure is 13.8 months. The most common causes of a large anterior fontanel or delayed fontanel closure are achondroplasia, hypothyroidism, Down syndrome, increased intracranial pressure, and rickets. • Option B: During a neurological exam, the child’s healthcare provider will test the functioning of the nervous system. The nervous system is very complex and controls many parts of the body. The nervous system consists of the brain, spinal cord, 12 nerves that come from the brain, and the nerves that come from the spinal cord. The nervous system regulates the muscles. The circulation to the brain, arising from the arteries in the neck, is also frequently examined. In infants and younger children, a neurological exam includes the measurement of the head circumference. • Option C: The newborn’s skull is molded during birth. The frontal bone flattens, the occipital bone is pulled outward, and the parietal bones override. These changes aid delivery through the birth canal and usually resolve after three to five days. The newborn’s skull should be evaluated for shape, circumference, suture ridges, and size of anterior and posterior fontanels. Size is calculated by the average of the anteroposterior and transverse dimensions. 32. 32. Question When teaching a mother about introducing solid foods to her child, which of the following indicates the earliest age at which this should be done? • A. 1 month • B. 2 months • C. 3 months • D. 4 months Incorrect Correct Answer: D. 4 months Solid foods are not recommended before age 4 to 6 months because of the sucking reflex and the immaturity of the gastrointestinal tract and immune system. Therefore, the earliest age at which to introduce foods is 4 months. Any time earlier would be inappropriate. • Option A: 1-month old infants should stick to breast milk. Most doctors recommend waiting until at least 6 months before giving water. A 1-month-old may feed every 2-3 hours. The infant will know when to stop feeding by stopping, moving away from the breast, or falling asleep. • Option B: At about 2 months of age, babies usually take 4 to 5 ounces per feeding every 3 to 4 hours. • Option C: How much formula for a 3-month-old baby? Typically five ounces about six to eight times a day. How often should a 3-month-old nurse? Feedings are typically about every three or four hours at this age but each breastfed baby may be slightly different. To double-check that the baby’s getting enough breast milk, check the diapers. How many wet diapers for a 3-month-old baby? About four or five very wet ones per day. 33. 33. Question The infant of a substance-abusing mother is at risk for developing a sense of which of the following? • A. Mistrust • B. Shame • C. Guilt • D. Inferiority Incorrect Correct Answer: A. Mistrust According to Erikson, infants need to have their needs met consistently and effectively to develop a sense of trust. An infant whose needs are consistently unmet or who experiences significant delays in having them met, such as in the case of the infant of a substance-abusing mother, will develop a sense of uncertainty, leading to mistrust of caregivers and the environment. • Option B: Toddlers develop a sense of shame when their autonomy needs are not met consistently. Autonomy versus shame and doubt is the second stage of Erik Erikson’s stages of psychosocial development. This stage occurs between the ages of 18 months to approximately 3 years. According to Erikson, children at this stage are focused on developing a sense of personal control over physical skills and a sense of independence. • Option C: Preschoolers develop a sense of guilt when their sense of initiative is thwarted. Initiative versus guilt is the third stage of Erik Erikson’s theory of psychosocial development. During the initiative versus guilt stage, children assert themselves more frequently through directing play and other social interactions. • Option D: Schoolagers develop a sense of inferiority when they do not develop a sense of industry. Erikson’s fourth psychosocial crisis, involving industry (competence) vs. Inferiority occurs during childhood between the ages of five and twelve. 34. 34. Question Which of the following toys should the nurse recommend for a 5-month-old? • A. A big red balloon • B. A teddy bear with button eyes • C. A push-pull wooden truck • D. A colorful busy box Incorrect Correct Answer: D. A colorful busy box A busy box facilitates fine motor development that occurs between 4 and 6 months. • Option A: Balloons are contraindicated because small children may aspirate balloons. • Option B: Because the button eyes of a teddy bear may detach and be aspirated, this toy is unsafe for children younger than 3 years. • Option C: A 5-month-old is too young to use a push-pull toy. Toddlers are full of energy, eager to explore everything around them. They love all kinds of physical activities such as pulling, pushing, lugging, knocking down, emptying, and filling. 35. 35. Question The mother of a 2-month-old is concerned that she may be spoiling her baby by picking her up when she cries. Which of the following would be the nurse’s best response? • A. “ Let her cry for a while before picking her up, so you don’t spoil her.” • B. “Babies need to be held and cuddled; you won’t spoil her this way.” • C. “Crying at this age means the baby is hungry; give her a bottle.” • D. “If you leave her alone she will learn how to cry herself to sleep.” Incorrect Correct Answer: B. “Babies need to be held and cuddled; you won’t spoil her this way.” Infants need to have their security needs met by being held and cuddled. At 2 months of age, they are unable to make the connection between crying and attention. This association does not occur until late infancy or early toddlerhood. • Option A: Letting the infant cry for a time before picking up the infant or leaving the infant alone to cry herself to sleep interferes with meeting the infant’s need for security at this very young age. • Option C: Infants cry for many reasons. Assuming that the child Is hungry may cause overfeeding problems such as obesity. • Option D: If the care the infant receives is consistent, predictable, and reliable, they will develop a sense of trust which will carry with them to other relationships, and they will be able to feel secure even when threatened. 36. 36. Question When assessing an 18-month-old, the nurse notes a characteristic protruding abdomen. Which of the following would explain the rationale for this finding? • A. Increased food intake owing to age. • B. Underdeveloped abdominal muscles. • C. Bow Legged posture. • D. Linear growth curve. Incorrect Correct Answer: B. Underdeveloped abdominal muscles Underdeveloped abdominal musculature gives the toddler a characteristically protruding abdomen. It is generally normal for toddlers to have potbellies. By the time children reach school age, the potbelly will most often disappear and their bodies seem more proportionate. The belly should feel soft and NOT tender. • Option A: During toddlerhood, food intake decreases, not increases. Feeding toddlers (ages 1 to 3) can often be challenging. That’s because several developmental changes are happening at this time. Toddlers are striving for independence and control. Their growth rate slows down and with this comes a decrease in appetite. • Option C: Toddlers are characteristically bowlegged because the leg muscles must bear the weight of the relatively large trunk. When babies are born with bow legs it’s because some of the bones had to rotate (twist) slightly when they were growing in the womb to fit into the small space. This is called physiological bow legs. It’s considered a normal part of a child’s growth and development. • Option D: Toddler growth patterns occur in a steplike, not linear pattern. Between ages 1 and 2, a toddler will gain only about 5 pounds (2.2 kilograms). Weight gain will remain at about 5 pounds (2.2 kilograms) per year between ages 2 to 5. Between ages 2 to 10 years, a child will grow at a steady pace. A final growth spurt begins at the start of puberty, sometime between ages 9 to 15. 37. 37. Question 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 Incorrect Correct Answer: B. Shame According to Erikson, toddlers experience a sense of shame when they are not allowed to develop appropriate independence and autonomy. If children are criticized, overly controlled, or not given the opportunity to assert themselves, they begin to feel inadequate in their ability to survive, and may then become overly dependent upon others, lack self-esteem, and feel a sense of shame or doubt in their abilities. • Option A: Infants develop mistrust when their needs are not consistently gratified. Failing to acquire the virtue of hope will lead to the development of fear. This infant will carry the basic sense of mistrust with them to other relationships. It may result in anxiety, heightened insecurities, and an over feeling of mistrust in the world around them. • Option C: Preschoolers develop guilt when their initiative needs are not met. If this tendency is squelched, either through criticism or control, children develop a sense of guilt. The child will often overstep the mark in his forcefulness, and the danger is that the parents will tend to punish the child and restrict his initiatives too much. • Option D: While school-agers develop a sense of inferiority when their industry needs are not met. If this initiative is not encouraged, if it is restricted by parents or teachers, then the child begins to feel inferior, doubting his own abilities and therefore may not reach his or her potential. 38. 38. Question Which of the following is an appropriate toy for an 18-month-old? • A. Multiple-piece puzzle • B. Miniature cars • C. Finger paints • D. Comic book Incorrect Correct Answer: C. Finger paints Young trent textures. Thus, finger paints would be an appropriate toy choice. • Option A: Multiple-piece toddlers are still sensorimotor learners and they enjoy the experience of feeling dizzy, such as puzzle, are too difficult to manipulate and may be hazardous if the pieces are small enough to be aspirated. • Option B: Miniature cars also have a high potential for aspiration. • Option D: Comic books are on too high a level for toddlers. Although they may enjoy looking at some of the pictures, toddlers are more likely to rip a comic book apart. 39. 39. Question 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. Incorrect Correct Answer: D. Verbalizes desire to go to the bathroom The child must be able to state the need to go to the bathroom to initiate toilet training. Toilet training is teaching the child to recognize their body signals for urinating and having a bowel movement. It also means teaching the child to use a potty chair or toilet correctly and at the appropriate times. • Option A: Usually, a child needs to be dry for only 2 hours, not 4 hours. Children develop at different rates. A child younger than 12 months has no control over bladder or bowel movements. There is very little control between 12 to 18 months. Most children don’t have bowel and bladder control until 24 to 30 months. The average age of toilet training is 27 months. • Option B: The child also must be able to sit, walk, and squat. Toilet training should start when your child shows signs that he or she is ready. There is no right age to begin. If you try to toilet train before your child is ready, it can be a battle for both you and your child. The ability to control bowel and bladder muscles comes with proper growth and development. • Option C: A new sibling would most likely hinder toilet training. If there are older siblings, ask them to let the younger child see you praising them for using the toilet. 40. 40. Question When teaching parents about typical toddler eating patterns, which of the following should be included? • A . Food “jags.” • B. Preference to eat alone • C. Consistent table manners • D. Increase in appetite Incorrect Correct Answer: A. Food “jags.” Toddlers become picky eaters, experiencing food jags, and eating large amounts one day and very little the next. A toddler’s food gags express a preference for the ritualism of eating one type of food for several days at a time. • Option B: Toddlers typically enjoy socialization and limiting others at mealtime. • Option C: Toddlers prefer to feed themselves and thus are too young to have table manners. • Option D: A toddler’s appetite and the need for calories, protein, and fluid decrease due to the dramatic slowing of growth rate. 41. 41. Question Which of the following suggestions should the nurse offer the parents of a 4-year-old boy who resists going to bed at night? • A. “Allow him to fall asleep in your room, then move him to his own bed.” • B. “Tell him that you will lock him in his room if he gets out of bed one more time.” • C. “Encourage active play at bedtime to tire him out so he will fall asleep faster.” • D. “Read him a story and allow him to play quietly in his bed until he falls asleep.” Incorrect Correct Answer: D. “Read him a story and allow him to play quietly in his bed until he falls asleep.” Preschoolers commonly have fears of the dark, being left alone especially at bedtime, and ghosts, which may affect the child’s going to bed at night. Quiet play and time with parents is a positive bedtime routine that provides security and also readies the child for sleep. • Option A: The child should sleep in his own bed. • Option B: Telling the child about locking him in his room will be viewed by the child as a threat. Additionally, a locked door is frightening and potentially hazardous. • Option C: Vigorous activity at bedtime stirs up the child and makes it more difficult to fall asleep. 42. 42. Question When providing therapeutic play, which of the following toys would best promote imaginative play in a 4-year-old? • A. Large blocks • B. Dress-up clothes • C. Wooden puzzle • D. Big wheels Incorrect Correct Answer: B. Dress-up clothes Dress-up clothes enhance imaginative play and imagination, allowing preschoolers to engage in rich fantasy play. Play therapy is a form of therapy primarily geared toward children. In this form of therapy, a therapist encourages a child to explore life events that may have an effect on current circumstances, in a manner and pace of the child’s choosing, primarily through play but also through language. • Option A: Though play is often regarded simply as a way for individuals, particularly children, to relax, scientific research has proven that play is a crucial factor in healthy child development. Large blocks are good for fine motor development. • Option C: Wooden puzzles are appropriate for encouraging fine motor development. Play is considered to be especially important for the healthy development of children who have experienced stressful events or past trauma. While the effects of trauma tend to reside in the nonverbal areas of the brain—the hippocampus, amygdala, thalamus, and brain stem—a person’s capacity to communicate and process adverse issues resides in the brain’s frontal lobes. • Option D: Big wheels and tricycles encourage gross motor development. Play therapy is thought to be one of the most beneficial means of helping children who are experiencing emotional or behavioral challenges. Though the approach may benefit people of all ages, it is specially designed to treat children under 12. 43. 43. Question Which of the following activities, when voiced by the parents following a teaching session about the characteristics of school-age cognitive development would indicate the need for additional teaching? • A. Collecting baseball cards and marbles. • B. Ordering dolls according to size. • C. Considering simple problem-solving options. • D. Developing plans for the future. Incorrect Correct Answer: D. Developing plans for the future The school-aged child is in the stage of concrete operations, marked by inductive reasoning, logical operations, and reversible concrete thought. The ability to consider the future requires formal thought operations, which are not developed until adolescence. • Option A: Collecting baseball cards and marbles is an example of concrete operational thinking. Piaget considered the concrete stage a major turning point in the child’s cognitive development because it marks the beginning of logical or operational thought. • Option B: Children can conserve number (age 6), mass (age 7), and weight (age 9). Conservation is the understanding that something stays the same in quantity even though its appearance changes. • Option C: Simple problem-solving options is an example of the concrete operational thinking of the school age. 44. 44. Question A hospitalized school age child states: “I’m not afraid of this place, I’m not afraid of anything.” This statement is most likely an example of which of the following? • A. Regression • B. Repression • C. Reaction formation • D. Rationalization Incorrect Correct Answer: C. Reaction formation Reaction formation is the school ager’s typical defensive response when hospitalized. In reaction formation, expression of unacceptable thoughts or behaviors is prevented (or overridden) by the exaggerated expression of opposite thoughts or types of behaviors. • Option A: Regression is seen in toddlers and preschoolers when they retreat or return to an earlier level of development. • Option B: Repression refers to the involuntary blocking of unpleasant feelings and experiences from one’s awareness. • Option D: Rationalization is the attempt to make excuses to justify unacceptable feelings or behaviors. 45. 45. Question After teaching a group of parents about accident prevention for school agers, which of the following statements by the group would indicate the need for more teaching? • A. “School Agers are more active and adventurous than younger children.” • B. “School Agers are more susceptible to home hazards than are younger children.” • C. “Schoolagers are unable to understand potential dangers around them.” • D. “Schoolargers are less subject to parental control than are younger children.” Incorrect Correct Answer: C. “Schoolagers are unable to understand potential dangers around them.” The school age’s cognitive level is sufficiently developed to enable a good understanding of and adherence to rules. Thus, school-agers should be able to understand the potential dangers around them. • Option A: With growth comes greater freedom and children become more adventurous and daring. • Option B: The school-aged child is also still prone to accidents and home hazards, especially because of increased motor abilities and independence. Plus the home hazards differ from other age groups. These hazards, which are potentially lethal but tempting, may include firearms, alcohol, and medications. • Option D: School-age children begin to internalize their own controls and needless outside direction. Plus the child is away from home more often. Some parental or caregiver assistance is still needed to answer questions and provide guidance for decisions and responsibilities. 46. 46. Question Which of the following skills is the most significant one learned during the school-age period? • A. Collecting • B. Ordering • C. Reading • D. Sorting Incorrect Correct Answer: C. Reading The most significant skill learned during the school-age period is reading. During this time the child develops formal adult articulation patterns and learns that words can be arranged in structure. • Option A: School-age children most often have smooth and strong motor skills. However, their coordination (especially eye-hand), endurance, balance, and physical abilities vary. • Option B: An ability to pay attention is important for success both at school and at home. A 6-year-old should be able to focus on a task for at least 15 minutes. By age 9, a child should be able to focus attention for about an hour. • Option D: Fine motor skills may also vary widely. These skills can affect a child’s ability to write neatly, dress appropriately, and perform certain chores, such as making beds or doing dishes. 47. 47. Question A child age 7 was unable to receive the measles, mumps, and rubella (MMR) vaccine at the recommended scheduled time. When would the nurse expect to administer the MMR vaccine? • A. In a month from now • B. In a year from now • C. At age 10 • D. At age 13 Incorrect Correct Answer: C. At age 10 Based on the recommendations of the American Academy of Family Physicians and the American Academy of Pediatrics, the MMR vaccine should be given at the age of 10 if the child did not receive it between the ages of 4 to 6 years as recommended. Immunization for diphtheria and tetanus is required at age 13. • Option A: Children should get two doses of MMR vaccine, starting with the first dose at 12 to 15 months of age, and the second dose at 4 through 6 years of age. • Option B: Children can receive the second dose earlier as long as it is at least 28 days after the first dose. • Option D: MMR vaccine is given later than some other childhood vaccines because antibodies transferred from the mother to the baby can provide some protection from disease and make the MMR vaccine less effective until about 1 year of age. 48. 48. Question The adolescent’s inability to develop a sense of who he is and what he can become results in the sense of which of the following? • A. Shame • B. Guilt • C. Inferiority • D. Role confusion Incorrect Correct Answer: D. Role confusion According to Erikson, role cunfusion develops when the adolescent does not develop a sense of identity and a sense of where he fits in. • Option A: Toddlers develop a sense of shame when they do not achieve autonomy. If children are criticized, overly controlled, or not given the opportunity to assert themselves, they begin to feel inadequate in their ability to survive, and may then become overly dependent upon others, lack self-esteem, and feel a sense of shame or doubt in their abilities. • Option B: Preschoolers develop a sense of guilt when they do not develop a sense of initiative. If this tendency is squelched, either through criticism or control, children develop a sense of guilt. The child will often overstep the mark in his forcefulness, and the danger is that the parents will tend to punish the child and restrict his initiatives too much. • Option C: School-age children develop a sense of inferiority when they do not develop a sense of industry. If this initiative is not encouraged, if it is restricted by parents or teachers, then the child begins to feel inferior, doubting his own abilities and therefore may not reach his or her potential. 49. 49. Question Which of the following would be most appropriate for a nurse to use when describing menarche to a 13-year-old? • A. A female’s first menstruation or menstrual “periods.” • B. The first year of menstruation or “period." • C. The entire menstrual cycle or from one “period” to another. • D. The onset of uterine maturation or peak growth. Incorrect Correct Answer: A. A female’s first menstruation or menstrual “periods”. Menarche refers to the onset of the first menstruation or menstrual period and refers only to the first cycle. Uterine growth and broadening of the pelvic girdle occur before menarche. The average age of onset of menarche is 12.4 years. • Option B: Pulsatile hypothalamic production of gonadotropin-releasing hormone (GnRH) at puberty stimulates the pituitary production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH). This pulsatile secretion pattern appears to be necessary as continuous secretion of GnRH, or its synthetic analogs, inhibits pituitary production of FSH and LH and delays menarche. • Option C: Most menstrual periods last between 3 and 7 days, and menses that last more than 10 days is considered abnormal. • Option D: Menarche signals maturation of the adolescent female body. It commonly is associated with the ability to ovulate and reproduce. However, the appearance of menarche does not guarantee either ovulation or fertility. 50. 50. Question A 14-year-old boy has acne and according to his parents, dominates the bathroom by using the mirror all the time. Which of the following remarks by the nurse would be least helpful in talking to the boy and his parents? • A. “This is probably the only concern he has about his body. So don’t worry about it or the time he spends on it.” • B. “Teenagers are anxious about how their peers perceive them. So they spend a lot of time grooming.” • C. “A teen may develop a poor self-image when experiencing acne. Do you feel this way sometimes?” • D. “You appear to be keeping your face well washed. Would you feel comfortable discussing your cleansing method?” Incorrect Correct Answer: A. “This is probably the only concern he has about his body. So don’t worry about it or the time he spends on it.” Stating that this is probably the only concern the adolescent has and telling the parents not to worry about it or the time he spends on it shuts off further investigation and is likely to make the adolescent and his parents feel defensive. • Option B: The statement about peer acceptance and time spent in front of the mirror for the development of self-image provides information about the adolescent’s needs to the parents and may help to gain trust with the adolescent. • Option C: Asking the adolescent how he feels about the acne will encourage the adolescent to share his feelings. • Option D: Discussing the cleansing method shows interest and concern for the adolescent an