Correct Answers 2025-2026 GRADED A+
An ,expectant ,father ,tells ,the ,nurse ,he ,fears ,that ,his ,wife ,is ,"losing ,her ,mind." ,He
,states ,that ,she ,is ,constantly ,rubbing ,her ,abdomen ,and ,talking ,to ,the ,baby ,and ,that
,she ,actually ,reprimands ,the ,baby ,when ,it ,moves ,too ,much. ,Which ,recommendation
,should ,the ,nurse ,make ,to ,this ,expectant ,father? ,
A.Suggest ,that ,his ,wife ,seek ,professional ,counseling ,to ,deal ,with ,her ,symptoms. ,
B.Explain ,that ,his ,wife ,is ,exhibiting ,ambivalence ,about ,the ,pregnancy. ,
C. ,Ask ,him ,to ,report ,similar ,abnormal ,behaviors ,at ,the ,next ,prenatal ,visit. ,
D.Reassure ,him ,that ,normal ,maternal-fetal ,bonding ,is ,occurring. ,- ,CORRECT
,ANSWER-D) ,Reassure ,him ,that ,normal ,maternal-fetal ,bonding ,is ,occurring. ,
Rationale: ,
These ,behaviors ,are ,positive ,signs ,of ,maternal-fetal ,bonding ,and ,do ,not ,reflect
,ambivalence. ,No ,intervention ,is ,needed. ,Quickening, ,the ,first ,perception ,of ,fetal
,movement, ,occurs ,at ,17 ,to ,20 ,weeks ,of ,gestation ,and ,begins ,a ,new ,phase ,of
,prenatal ,bonding ,during ,the ,second ,trimester. ,Options ,A ,and ,C ,are ,not ,necessary
,because ,the ,behaviors ,displayed ,are ,normal.
The ,nurse ,is ,preparing ,a ,laboring ,client ,for ,an ,amniotomy. ,Immediately ,after ,the
,procedure ,is ,completed, ,it ,is ,most ,important ,for ,the ,nurse ,to ,obtain ,which
,information?
,
,A.Maternal ,blood ,pressure
,B.Maternal ,temperature
,,C.Fetal ,heart ,rate ,(FHR)
,
,D.White ,blood ,cell ,count ,(WBC) ,- ,CORRECT ,ANSWER-C. ,Fetal ,heart ,rate ,(FHR)
Rationale:
The ,FHR ,should ,be ,assessed ,before ,and ,after ,the ,procedure ,to ,detect ,changes ,that
,may ,indicate ,the ,presence ,of ,cord ,compression ,or ,prolapse. ,An ,amniotomy ,(artificial
,rupture ,of ,membranes ,[AROM]) ,is ,used ,to ,stimulate ,labor ,when ,the ,condition ,of ,the
,cervix ,is ,favorable. ,The ,fluid ,should ,be ,assessed ,for ,color, ,odor, ,and ,consistency.
,Option ,A ,should ,be ,assessed ,every ,15 ,to ,20 ,minutes ,during ,labor ,but ,is ,not ,specific
,for ,AROM. ,Option ,B ,is ,monitored ,hourly ,after ,the ,membranes ,are ,ruptured ,to ,detect
,the ,development ,of ,amnionitis. ,Option ,D ,should ,be ,determined ,for ,all ,clients ,in ,labor.
A ,nurse ,receives ,a ,shift ,change ,report ,for ,a ,newborn ,who ,is ,12 ,hours ,post-vaginal
,delivery. ,In ,developing ,a ,plan ,of ,care, ,the ,nurse ,should ,give ,the ,highest ,priority ,to
,which ,finding?
,A.Cyanosis ,of ,the ,hands ,and ,feet
,B.Skin ,color ,that ,is ,slightly ,jaundiced
,C.Tiny ,white ,papules ,on ,the ,nose ,or ,chin
,D.Red ,patches ,on ,the ,cheeks ,and ,trunk ,- ,CORRECT ,ANSWER-B. ,Skin ,color ,that ,is
,slightly ,jaundiced
Rationale: ,Jaundice, ,a ,yellow ,skin ,coloration, ,is ,caused ,by ,elevated ,levels ,of ,bilirubin,
,which ,should ,be ,further ,evaluated ,in ,a ,newborn ,<24 ,hours ,old. ,Acrocyanosis ,(blue
,color ,of ,the ,hands ,and ,feet) ,is ,a ,common ,finding ,in ,newborns; ,it ,occurs ,because ,the
,capillary ,system ,is ,immature. ,Milia ,are ,small ,white ,papules ,present ,on ,the ,nose ,and
,chin ,that ,are ,caused ,by ,sebaceous ,gland ,blockage ,and ,disappear ,in ,a ,few ,weeks.
,Small ,red ,patches ,on ,the ,cheeks ,and ,trunk ,are ,called ,erythema ,toxicum ,neonatorum,
,a ,common ,finding ,in ,newborns.
A ,breastfeeding ,postpartum ,client ,is ,diagnosed ,with ,mastitis, ,and ,antibiotic ,therapy ,is
,prescribed. ,Which ,instruction ,should ,the ,nurse ,provide ,to ,this ,client?
A.Breastfeed ,the ,infant, ,ensuring ,that ,both ,breasts ,are ,completely ,emptied.
,B.Feed ,expressed ,breast ,milk ,to ,avoid ,the ,pain ,of ,the ,infant ,latching ,onto ,the
,infected ,breast.
,C.Breastfeed ,on ,the ,unaffected ,breast ,only ,until ,the ,mastitis ,subsides.
,D.Dilute ,expressed ,breast ,milk ,with ,sterile ,water ,to ,reduce ,the ,antibiotic ,effect ,on ,the
,infant. ,- ,CORRECT ,ANSWER-A.Breastfeed ,the ,infant, ,ensuring ,that ,both ,breasts ,are
,completely ,emptied.
,Rationale:Mastitis, ,caused ,by ,plugged ,milk ,ducts, ,is ,related ,to ,breast ,engorgement,
,and ,breastfeeding ,during ,mastitis ,facilitates ,the ,complete ,emptying ,of ,engorged
,breasts, ,eliminating ,the ,pressure ,on ,the ,inflamed ,breast ,tissue. ,Option ,B ,is ,less
,painful ,but ,does ,not ,facilitate ,complete ,emptying ,of ,the ,breast ,tissue. ,Option ,C ,will
,not ,relieve ,the ,engorgement ,on ,the ,affected ,side. ,Option ,D ,will ,not ,decrease
,antibiotic ,effects ,on ,the ,infant.
A ,38-week ,primigravida ,who ,works ,as ,a ,secretary ,and ,sits ,at ,a ,computer ,8 ,hours
,each ,day ,tells ,the ,nurse ,that ,her ,feet ,have ,begun ,to ,swell. ,Which ,instruction ,will ,aid
,in ,the ,prevention ,of ,pooling ,of ,blood ,in ,the ,lower ,extremities?
,A.Wear ,support ,stockings.
,B.Reduce ,salt ,in ,the ,diet.
,C.Move ,about ,every ,hour.
,D.Avoid ,constrictive ,clothing. ,- ,CORRECT ,ANSWER-C.Move ,about ,every ,hour.
Rationale:
Pooling ,of ,blood ,in ,the ,lower ,extremities ,results ,from ,the ,enlarged ,uterus ,exerting
,pressure ,on ,the ,pelvic ,veins. ,Moving ,about ,every ,hour ,will ,relieve ,pressure ,on ,the
,pelvic ,veins ,and ,increase ,venous ,return. ,Option ,A ,would ,increase ,venous ,return ,from
,varicose ,veins ,in ,the ,lower ,extremities ,but ,would ,be ,of ,little ,help ,with ,swelling. ,Option
,B ,might ,be ,helpful ,with ,generalized ,edema ,but ,is ,not ,specific ,for ,edematous ,lower
,extremities. ,Option ,D ,does ,not ,address ,venous ,return, ,and ,there ,is ,no ,indication ,in
,the ,question ,that ,constrictive ,clothing ,is ,a ,problem.
Twenty-four ,hours ,after ,admission ,to ,the ,newborn ,nursery, ,a ,full-term ,male ,infant
,develops ,localized ,swelling ,on ,the ,right ,side ,of ,his ,head. ,In ,a ,newborn, ,what ,is ,the
,most ,likely ,cause ,of ,this ,accumulation ,of ,blood ,between ,the ,periosteum ,and ,skull
,that ,does ,not ,cross ,the ,suture ,line?
A.Cephalhematoma, ,which ,is ,caused ,by ,forceps ,trauma
,B.Subarachnoid ,hematoma, ,which ,requires ,immediate ,drainage
,C.Molding, ,which ,is ,caused ,by ,pressure ,during ,labor
,D.Subdural ,hematoma, ,which ,can ,result ,in ,lifelong ,damage ,- ,CORRECT ,ANSWER-
A.Cephalhematoma, ,which ,is ,caused ,by ,forceps ,trauma
Rationale: ,Cephalhematoma, ,a ,slight ,abnormal ,variation ,of ,the ,newborn, ,usually
,arises ,within ,the ,first ,24 ,hours ,after ,delivery. ,Trauma ,from ,delivery ,causes ,capillary
,bleeding ,between ,the ,periosteum ,and ,skull. ,Option ,C ,is ,a ,cranial ,distortion ,lasting ,5
, ,to ,7 ,days, ,caused ,by ,pressure ,on ,the ,cranium ,during ,vaginal ,delivery, ,and ,is ,a
,common ,variation ,of ,the ,newborn. ,Options ,B ,and ,D ,both ,involve ,intracranial ,bleeding
,and ,could ,not ,be ,detected ,by ,physical ,assessment ,alone.
Prior ,to ,discharge, ,what ,instructions ,should ,the ,nurse ,give ,to ,parents ,regarding ,the
,newborn's ,umbilical ,cord ,care ,at ,home?
A.Wash ,the ,cord ,frequently ,with ,mild ,soap ,and ,water.
,
B.Cover ,the ,cord ,with ,a ,sterile ,dressing.
,C.Allow ,the ,cord ,to ,air-dry ,as ,much ,as ,possible.
,
,D.Apply ,baby ,lotion ,after ,the ,baby's ,daily ,bath ,- ,CORRECT ,ANSWER-C.Allow ,the
,cord ,to ,air-dry ,as ,much ,as ,possible.
Rationale:Recent ,studies ,have ,indicated ,that ,air ,drying ,or ,plain ,water ,application ,may
,be ,equal ,to ,or ,more ,effective ,than ,alcohol ,in ,the ,cord ,healing ,process. ,Options ,A, ,B,
,and ,D ,are ,incorrect ,because ,they ,promote ,moisture ,and ,increase ,the ,potential ,for
,infection.
A ,mother ,expresses ,fear ,about ,changing ,the ,infant's ,diaper ,after ,circumcision. ,What
,information ,should ,the ,nurse ,include ,in ,the ,teaching ,plan?
A.Cleanse ,the ,penis ,with ,prepackaged ,diaper ,wipes ,every ,3 ,to ,4 ,hours.
,B.Wash ,off ,the ,yellow ,exudate ,on ,the ,glans ,once ,every ,day ,to ,prevent ,infection.
,C.Place ,petroleum ,ointment ,around ,the ,glans ,with ,each ,diaper ,change ,and
,cleansing.
,D.Apply ,pressure ,by ,squeezing ,the ,penis ,with ,the ,fingers ,for ,5 ,minutes ,if ,bleeding
,occurs. ,- ,CORRECT ,ANSWER-C.Place ,petroleum ,ointment ,around ,the ,glans ,with
,each ,diaper ,change ,and ,cleansing.
Rationale:
With ,each ,diaper ,change, ,the ,glans ,penis ,should ,be ,washed ,with ,warm ,water ,to
,remove ,any ,urine ,or ,feces, ,and ,petroleum ,ointment ,should ,be ,applied ,to ,prevent ,the
,diaper ,from ,sticking ,to ,the ,healing ,surface. ,Prepackaged ,wipes ,often ,contain ,other
,products ,that ,may ,irritate ,the ,site. ,The ,yellow ,exudate, ,which ,covers ,the ,glans ,penis
,as ,the ,area ,heals ,and ,epithelializes, ,is ,not ,an ,infective ,process ,and ,should ,not ,be
,removed. ,If ,bleeding ,occurs ,at ,home, ,the ,client ,should ,be ,instructed ,to ,apply ,gentle
,pressure ,to ,the ,site ,of ,the ,bleeding ,with ,sterile ,gauze ,squares ,and ,call ,the ,health
,care ,provider.
A ,26-year-old ,gravida ,2, ,para ,1, ,client ,is ,admitted ,to ,the ,hospital ,at ,28 ,weeks ,of
,gestation ,in ,preterm ,labor. ,She ,is ,given ,three ,doses ,of ,terbutaline ,sulfate ,(Brethine),