(2026) Q&A
1. Which of the following is a crucial factor affecting development that a nurse should assess
during the prenatal period?
A) Maternal nutrition
B) Financial status
C) Neighborhood safety
D) Religious affiliation
Correct Answer: Maternal nutrition
Rationale: Maternal nutrition is a crucial factor that directly affects fetal growth and
development, including brain development and birth weight. While financial status,
neighborhood safety, and religious affiliation can influence health behaviors, maternal
nutrition has the most direct impact on the developing fetus.
2. A nurse is teaching a pregnant client about the dangers of alcohol consumption. Which
condition is associated with heavy alcohol use during pregnancy?
A) Fetal alcohol spectrum disorder
B) Down syndrome
C) Phenylketonuria
D) Sickle cell anemia
Correct Answer: Fetal alcohol spectrum disorder
Rationale: Fetal alcohol spectrum disorder (FASD) is a range of physical, behavioral, and
cognitive impairments caused by maternal alcohol consumption during pregnancy. Down
syndrome is a chromosomal abnormality, while phenylketonuria and sickle cell anemia are
genetic disorders unrelated to alcohol exposure.
,3. A nurse is assessing a pregnant client who is HIV-positive. Which intervention is the
priority to prevent transmission to the fetus?
A) Administer antiretroviral therapy to the mother
B) Perform a cesarean section at 38 weeks
C) Avoid breastfeeding
D) Monitor fetal heart tones
Correct Answer: Administer antiretroviral therapy to the mother
Rationale: Antiretroviral therapy during pregnancy significantly reduces the risk of mother-
to-child transmission of HIV. A cesarean section and avoiding breastfeeding are additional
measures, but maternal antiretroviral therapy is the primary intervention for prevention.
4. A pregnant client is at 38 weeks' gestation and her baby is in the breech position. What is
the priority nursing action?
A) Prepare the client for a cesarean section
B) Attempt external version
C) Encourage ambulation
D) Prepare for vaginal delivery
Correct Answer: Prepare the client for a cesarean section
Rationale: A full-term breech presentation is typically delivered by cesarean section to
prevent complications such as umbilical cord prolapse and head entrapment. External version
may be attempted earlier in pregnancy but is not the priority at 38 weeks.
5. A nurse is evaluating the development of a 6-month-old infant. Which milestone should the
infant be able to achieve?
A) Sitting without support
B) Rolling from back to front
C) Crawling
, D) Walking with assistance
Correct Answer: Rolling from back to front
Rationale: Rolling from back to front is a gross motor milestone typically achieved by 6
months. Sitting without support is a 6–8 month milestone, crawling is 8–10 months, and
walking with assistance is 12–15 months.
6. A nurse is teaching parents about the Apgar score. Which five areas are assessed?
A) Heart rate, respiratory effort, muscle tone, reflex irritability, and color
B) Weight, length, head circumference, heart rate, and respiratory rate
C) Muscle tone, reflexes, cry, feeding, and sleep
D) Heart rate, blood pressure, temperature, respiratory rate, and oxygen saturation
Correct Answer: Heart rate, respiratory effort, muscle tone, reflex irritability, and color
Rationale: The Apgar score is a rapid assessment tool used immediately after birth to
evaluate the newborn's physical condition. It assesses heart rate, respiratory effort, muscle
tone, reflex irritability, and color, each scored from 0 to 2.
7. A nurse is assessing a 2-week-old infant. Which finding requires immediate follow-up?
A) Respiratory rate of 40 breaths per minute
B) Heart rate of 130 beats per minute
C) Yellow discoloration of the sclera
D) Soft, flat anterior fontanel
Correct Answer: Yellow discoloration of the sclera
Rationale: Yellow discoloration of the sclera indicates jaundice, which can be physiological
or pathological. If it appears within the first 24 hours of life or persists beyond 2 weeks, it
requires immediate evaluation for potential complications such as kernicterus.