Maternal Child NCLEX Review Questions and Answers Graded A+
Answer: A
A nurse is assessing a premature infant. What would ini-
tially alert the nurse that the infant is having respiratory Rationale:
distress? In attempt to increase intake of oxygen, the respiratory
rate increases with flaring of nostrils as a cardinal sign. It
A. Flaring nostrils is significant to note that when a neonate is in respiratory
B. Sporadic crying distress, the rate of respirations will increase. Sporadic
C. Inettective cough crying, inettective cough, and decreased pulse rate may
D. Decreased pulse rate be indicative of infant distress but are not classic signs of
respiratory distress.
Answer: B
Rationale:
Defects that result in increased pulmonary blood flow
such as patent ductus arteriosus (PDA) and other atrial
A newborn infant is diagnosed with a patent ductus arte- and ventricular septal defects may cause congestive heart
riosus (PDA). The nurse is aware that this is indicative of a failure. PDA is a vascular connection that during fetal life
defect that: bypasses the pulmonary vascular bed and directs blood
from the pulmonary artery to the aorta. Defects that involve
A. typically results in cyanosis
decreased pulmonary blood (such as tetralogy of Fallot)
B. may result in congestive heart failure
or obstruction to blood flow out of the heart (such as
C. also causes pulmonary stenosis
pulmonary stenosis) typically result in cyanosis. PDA does
D. normally does not close after birth
not cause pulmonary stenosis. A PDA normally closes soon
after birth. If the ductus does remain open after birth, the
direction of blood flow in the ductus is reversed by the
higher pressure in the aorta, so there may not be any signs
of the disorder.
Which of the following signs would alert a nurse to with- Answer: B
drawal in the infant of a mother addicted to heroin?
Rationale:
A. lethargy and a lack of appetite Heroin does cross the placental barrier; therefore the in-
, Maternal Child NCLEX Review Questions and Answers Graded A+
fant is born addicted to heroin and will display signs of
B. restlessness, irritability, and tremors
withdrawal such as restlessness, irritability, and tremors.
C. no crying and hypoactive reflexes
The items listed in answer options A, C, and D are not
D. hyperactive reflexes and diaphoresis
associated with heroin withdrawal.
A neonate weights 8 lb, 1 oz at birth. At age 3 days, the
weight has decreased to 7 lb, 12 oz. The nurse should
instruct the mother to: Answer: B
A. increase the amount of formula to prevent further de- Rationale:
hydration and weight loss Neonates tend to lose 5% -- 10% of their birth weight
B. continue feeding on demand because the noted weight during the first few days after birth, mostly because of
loss is within normal limits decreased, but acceptable, nutrition and extracellular fluid
C. give additional feedings because the weight loss indi- loss. Increasing formula volumes and feedings or chang-
cates inadequate caloric intake ing the formula is not necessary in this situation.
D. switch to a ditterent formula because the current one
is inadequate to maintain weight
A nurse explains to a new mother reasons for her new-
born's cranial molding and determines that the mother Answer: C
needs further instruction when she makes which of the
following statements? Rationale:
Brain damage is not directly associated with cranial mold-
A. "The molding should disappear within a few days." ing. During vaginal delivery, the cranial bones tend to
B. "The molding is caused by an overriding of the cranial override when the head accommodates the size of the
bones." mother's birth canal. The amount and length of pressure
C. "The brain may be damaged if the molding doesn't influence the degree of molding, which usually disap-
resolve quickly." pears in a few days without any other interventions or
D. "The amount of molding is related to the amount and long-lasting ettects.
length of pressure on the head."
Answer: C
Rationale:
Answer: A
A nurse is assessing a premature infant. What would ini-
tially alert the nurse that the infant is having respiratory Rationale:
distress? In attempt to increase intake of oxygen, the respiratory
rate increases with flaring of nostrils as a cardinal sign. It
A. Flaring nostrils is significant to note that when a neonate is in respiratory
B. Sporadic crying distress, the rate of respirations will increase. Sporadic
C. Inettective cough crying, inettective cough, and decreased pulse rate may
D. Decreased pulse rate be indicative of infant distress but are not classic signs of
respiratory distress.
Answer: B
Rationale:
Defects that result in increased pulmonary blood flow
such as patent ductus arteriosus (PDA) and other atrial
A newborn infant is diagnosed with a patent ductus arte- and ventricular septal defects may cause congestive heart
riosus (PDA). The nurse is aware that this is indicative of a failure. PDA is a vascular connection that during fetal life
defect that: bypasses the pulmonary vascular bed and directs blood
from the pulmonary artery to the aorta. Defects that involve
A. typically results in cyanosis
decreased pulmonary blood (such as tetralogy of Fallot)
B. may result in congestive heart failure
or obstruction to blood flow out of the heart (such as
C. also causes pulmonary stenosis
pulmonary stenosis) typically result in cyanosis. PDA does
D. normally does not close after birth
not cause pulmonary stenosis. A PDA normally closes soon
after birth. If the ductus does remain open after birth, the
direction of blood flow in the ductus is reversed by the
higher pressure in the aorta, so there may not be any signs
of the disorder.
Which of the following signs would alert a nurse to with- Answer: B
drawal in the infant of a mother addicted to heroin?
Rationale:
A. lethargy and a lack of appetite Heroin does cross the placental barrier; therefore the in-
, Maternal Child NCLEX Review Questions and Answers Graded A+
fant is born addicted to heroin and will display signs of
B. restlessness, irritability, and tremors
withdrawal such as restlessness, irritability, and tremors.
C. no crying and hypoactive reflexes
The items listed in answer options A, C, and D are not
D. hyperactive reflexes and diaphoresis
associated with heroin withdrawal.
A neonate weights 8 lb, 1 oz at birth. At age 3 days, the
weight has decreased to 7 lb, 12 oz. The nurse should
instruct the mother to: Answer: B
A. increase the amount of formula to prevent further de- Rationale:
hydration and weight loss Neonates tend to lose 5% -- 10% of their birth weight
B. continue feeding on demand because the noted weight during the first few days after birth, mostly because of
loss is within normal limits decreased, but acceptable, nutrition and extracellular fluid
C. give additional feedings because the weight loss indi- loss. Increasing formula volumes and feedings or chang-
cates inadequate caloric intake ing the formula is not necessary in this situation.
D. switch to a ditterent formula because the current one
is inadequate to maintain weight
A nurse explains to a new mother reasons for her new-
born's cranial molding and determines that the mother Answer: C
needs further instruction when she makes which of the
following statements? Rationale:
Brain damage is not directly associated with cranial mold-
A. "The molding should disappear within a few days." ing. During vaginal delivery, the cranial bones tend to
B. "The molding is caused by an overriding of the cranial override when the head accommodates the size of the
bones." mother's birth canal. The amount and length of pressure
C. "The brain may be damaged if the molding doesn't influence the degree of molding, which usually disap-
resolve quickly." pears in a few days without any other interventions or
D. "The amount of molding is related to the amount and long-lasting ettects.
length of pressure on the head."
Answer: C
Rationale:
