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Foundations of Nursing Practice provides students with a comprehensive introduction to the core concepts, principles, and professional standards of nursing care. The course emphasizes the development of fundamental skills such as patient assessment, communication, basic clinical procedures, and evidence-based decision-making. Students explore the historical development of nursing, ethical and legal considerations, safety protocols, and the holistic approach required to address the physiological, psychological, and sociocultural needs of patients. Through theoretical learning and practical simulations, learners are prepared to participate effectively as members of the healthcare team and to deliver compassionate, patient-centered care in diverse settings.
Recommended Textbook
Maternal and Child Nursing Care 5th Edition by Marcia L London
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Q1) The nurse is reviewing the 1973 Supreme Court decision in Roe v. Wade for a patient asking about an abortion. What should the nurse explain about the induction of a legal abortion?
A) It must be performed at a federally funded clinic.
B) It must be performed before the period of viability.
C) It must be performed at a military hospital overseas.
D) It must be performed to provide tissue for therapeutic research.
Answer: B
Q2) Which practices characterize the basic competencies related to evidence-based practice? Select all that apply.
A) Clinical practice supported by data
B) Clinical practice that promotes quality
C) Clinical practice supported by good evidence
D) Clinical practice supported by intuitive evidence
E) Clinical practice that provides a useful approach to problem solving
Answer: A,B,C,E
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Q1) A woman of Korean descent has just given birth to a son. Her partner wishes to give her sips of hot broth from a thermos they brought with them. They have refused your offer of ice chips or other cold drinks for the client. What should the nurse do?
A) Explain to the client that she can have the broth if she will also drink cold water or juice.
B) Encourage the client to have the broth, after the nurse takes it to the kitchen and boils it first.
C) Explain to the couple that food is not allowed to be brought from home, but that the nurse will make hot broth for them.
D) Encourage the partner to feed the client sips of their broth. Ask if the client would like you to bring her some warm water to drink.
Answer: D
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Q1) Two family members are diagnosed with the same genetic disorder but have distinctly different manifestations. What should the nurse consider as being the reason for this occurrence?
A) Imprinting
B) Penetrance
C) New mutation
D) Variable expression
Answer: A
Q2) The nurse learns that a patient from a different country and culture was married to her first cousin before moving to the United States. The couple is expecting their first child in 4 months. What should the nurse consider when counseling this patient?
A) Birth control
B) Carrier testing
C) Pregnancy termination
D) Legal issues in the United States
Answer: B
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Q1) A nurse is teaching a classroom of teenage girls about the female reproductive system. After teaching, the nurse asks the students to describe the release of an ovum during ovulation. Which response indicates that teaching has been effective?
A) "Ovulation is when the uterus releases an unfertilized egg or ovum."
B) "During ovulation, an egg is released from the ovary and enters the fallopian tube."
C) "The endometrium is where the eggs are formed and released into the fallopian tube."
D) "Around the middle of the menstrual cycle, one of the fallopian tubes releases an egg."
Q2) The nurse is explaining the menstrual cycle to a group of women. In which phase should the nurse instruct that the corpus luteum begins to degenerate, estrogen and progesterone levels fall, and the blood supply to the endometrium is reduced?
A) Ischemic phase
B) Secretory phase
C) Menstrual phase
D) Proliferative phase
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Q1) Which client should the nurse document as exhibiting signs and symptoms of primary dysmenorrhea?
A) 17-year-old, has never had a menstrual cycle
B) 19-year-old, regular menses for 5 years that have suddenly become painful
C) 14-year-old, irregular menses for 1 year, experiences cramping every cycle
D) 16-year-old, had regular menses for 4 years, but has had no menses in 4 months
Q2) A client has decided to use the NuvaRing vaginal contraceptive ring as her method of contraception. Which statement suggests the client needs further instruction?
A) "When I store my replacement rings, I should keep them in my refrigerator."
B) "The contraceptive ring provides a sustained release of low-dose contraceptive."
C) "Every 3 months, I will need to remove the contraceptive ring and replace it with a new one."
D) "I do not need to be examined in order to determine the contraceptive ring size that is correct for me."
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Q1) The nurse is caring for a client diagnosed with endometriosis. Which statement by the client requires immediate follow-up?
A) "I've noticed my voice is lower since I started taking danazol."
B) "I am having many hot flashes since I had the Lupron injection."
C) "The pain I experience with intercourse is becoming more severe."
D) "My leg has become painful and swollen since I started taking birth control pills."
Q2) Which statement indicates that client teaching about vaginal infections has been effective?
A) "The fishy vaginal odor I have is caused by a bacterial infection."
B) "I can use this antiyeast medication weekly to prevent another infection."
C) "My diabetes is unrelated to the frequency of my vaginal yeast infections."
D) "I should douche weekly to prevent a recurrence of my bacterial vaginosis."
Q3) Which diagnostic test should the nurse question if prescribed for a client with pelvic inflammatory disease (PID)?
A) RPR (rapid plasma reagin)
B) Throat culture for streptococcus A
C) Vaginal culture for Neisseria gonorrhoeae
D) CBC (complete blood count) with differential
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Q1) After teaching a class about the female reproductive system, the nurse asks the attendees to describe the process of meiosis. Which student response suggests successful comprehension of the material?
A) "At the time of ovulation, the first meiotic division begins."
B) "At the time of puberty, the second meiotic division begins."
C) "Completion of the first meiotic division produces three polar bodies and one primary oocyte."
D) "Completion of the second meiotic division results in formation of three polar bodies and one ovum."
Q2) The nurse is preparing information about reproduction for high school students. What should the nurse include about the production of sperm? Select all that apply.
A) Diploid cells are formed.
B) Sperm cells develop through meiotic division.
C) Four spermatids are formed during the second meiotic division.
D) Spermatocytes contain either a double-structured X or Y sex chromosome.
E) Two secondary spermatocytes contain 22 double-structured autosomal chromosomes.
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Q1) The partner of a pregnant client at 16 weeks' gestation accompanies her to the clinic. The partner tells you that the baby just does not seem real to him, and he is having a hard time relating to his partner's fatigue and food aversions. Which statement would be best for the nurse to make?
A) "Many men feel this way. Feeling the baby move will help make it real."
B) "My husband had no problem with this. What was your childhood like?"
C) "You might need professional psychologic counseling. Ask your physician."
D) "If you would concentrate harder, you would be aware of the reality of this pregnancy."
Q2) The nurse notes that a client who is 10 weeks pregnant is experiencing changes to the upper respiratory system. What should the nurse explain as being the reason for these changes? Select all that apply.
A) Estrogen-induced edema
B) Hypersecretion of mucus
C) Decreased white blood cell production
D) Vascular congestion of the nasal mucosa
E) Amniotic fluid reducing total fluid volume
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Q1) A pregnant client's quadruple screen shows a risk for the fetus to have Down syndrome. Which test results within the screen were used to make this determination? Select all that apply.
A) Inhibin-A
B) Alpha-fetoprotein (AFP)
C) Unconjugated estriol (UE)
D) Hemoglobin electrophoresis
E) Human chorionic gonadotropin (hCG)
Q2) During a prenatal visit the nurse notes that a client entering the third trimester has gained a total of 8 lb. What action should the nurse take at this time? Select all that apply.
A) Assess for nausea.
B) Refer to a dietitian.
C) Suggest amniocentesis.
D) Assess nutritional intake.
E) Discuss importance of adequate weight gain.
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Q1) The nurse is preparing to perform an initial prenatal assessment of a pregnant client who recently immigrated to the United States. Which cultural aspects should the nurse include during the assessment of this client? Select all that apply.
A) Birth rituals
B) Nutritional practices
C) Use of home remedies
D) Expectations to return to work
E) Beliefs about exercise and activity
Q2) The spouse accompanies a pregnant client to a prenatal visit. Which question should the nurse use to determine the amount of anticipatory guidance the spouse will need?
A) "What kind of work do you do?"
B) "How moody has your wife been lately?"
C) "What furniture have you gotten for the baby?"
D) "How are you feeling about becoming a father?"
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Q1) The nurse reviews nutritional requirements with a breastfeeding mother who is concerned that her milk production has decreased. Which statement indicates that further teaching is required?
A) "I have started cutting back on my protein intake."
B) "At least 3 times a day, I drink a glass of milk."
C) "I am drinking a minimum of 8 to 10 glasses of liquid a day."
D) "I try to take a nap in the morning and afternoon when the baby is sleeping."
Q2) A pregnant client is reviewing the tentative buffet menu for her upcoming baby shower. Which items should the nurse suggest be substituted to ensure the health of the client and developing fetus? Select all that apply.
A) Baked brie with crackers
B) Greek salad with feta cheese
C) Caesar salad with sourdough croutons
D) Salmon pate with toasted bread rounds
E) Grilled orange roughy with summer vegetables
Q3) A client who became pregnant at a weight of 60 kg and a BMI of 16 has gained 4 kg at the end of the 5th gestational month. How many more pounds of weight should the nurse counsel this client to gain to achieve the least amount of weight that an underweight person should gain while pregnant?
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Q1) A 25-year-old client with a learning disability arrives for her first prenatal visit at week 24 of gestation. What should the nurse emphasize when caring for this client? Select all that apply.
A) Ask if the client has any questions.
B) Avoid rushing through the examination.
C) Provide information in small increments.
D) Ask who is going to financially assist the client.
E) Suggest discussing the pregnancy with social services.
Q2) The nurse is caring for a pregnant client who has scoliosis that has affected sensation below the level of the umbilicus. What should the nurse instruct the client to do, to reduce the risk of adverse effects during pregnancy? Select all that apply.
A) Walk slowly and deliberately.
B) Limit the amount of daily exercise.
C) Eat fewer calories to restrict weight gain.
D) Ingest adequate amounts of fruits, vegetables, and water.
E) Review signs of pending labor other than uterine contractions.
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Q1) How should the nurse interpret a pregnant client's lecithin/sphingomyelin (L/S) ratio finding of 2:1 on amniotic fluid?
A) Fetal lungs are mature.
B) Fetal lungs are still immature.
C) The fetus has a congenital anomaly.
D) The fetus is small for gestational age.
Q2) A pregnant woman is having a nipple-stimulated contraction stress test. Which result indicates hyperstimulation?
A) There are more than five fetal movements in a 10-minute period.
B) There are more than three uterine contractions in a 6-minute period.
C) The fetal heart rate accelerates when contractions last up to 60 seconds.
D) The fetal heart rate decelerates when three contractions occur within a 10-minute period.
Q3) The nurse is reviewing nursing documentation related to the care of a client who had an amniocentesis. Which nursing note reflects appropriate client care?
A) Prior to discharge, the client demonstrated vaginal spotting.
B) An Rh-positive client received RhoGAM after the amniocentesis.
C) The client was monitored for 30 minutes after completion of the test.
D) The client reported that she takes insulin before each meal and at bedtime.
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Q1) A 20-year-old woman at 28 weeks' gestation has a history of past drug abuse and her urine screening indicates recent heroin use. What should the nurse recognize this client is at risk for developing?
A) Diabetes mellitus
B) Abruptio placentae
C) Erythroblastosis fetalis
D) Pregnancy-induced hypertension
Q2) A pregnant client who uses cocaine and ecstasy on a regular basis asks why ecstasy should not be used during pregnancy. What should the nurse explain about this drug?
A) "It produces intrauterine growth restriction and meconium aspiration."
B) "It leads to deficiencies of thiamine and folic acid, which help the baby develop."
C) "It produces babies with small heads and short bodies with brain function alterations."
D) "It can cause a high fever in you if high doses are taken and therefore cause the baby harm."
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Q1) The nurse is admitting a client at 28 weeks' gestation to the emergency department following an episode of domestic abuse resulting in ecchymosis and lacerations. Which question is most critical to ask?
A) "Do you have a safe place where you can go?"
B) "What did you do to make your spouse so angry?"
C) "How many times has this happened in the past?"
D) "Will you be pressing charges against your spouse?"
Q2) A pregnant woman is being excavated from the back seat of a motor vehicle after a crash. In which order should this victim receive emergency care?
A) Apply oxygen.
B) Establish an airway.
C) Monitor fetal activity.
D) Position on the left side.
E) Administer intravenous fluids.
Q3) Which maternal-child client should the nurse see first?
A) Blood type B, Rh-positive
B) Blood type O, Rh-negative
C) Direct Coombs test positive
D) Indirect Coombs test negative
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Q1) A client is entering the end of the second stage of labor. What should the nurse expect to assess in this client? Select all that apply.
A) Bulging perineum
B) Parting of the labia
C) Crowning of the fetus
D) Increasing bloody show
E) Increasing rectal pressure
Q2) While caring for a client in labor the nurse determines that the baby's head has internally rotated. The client's spouse asks about other positional changes that will occur during the labor and birth. How should the nurse describe the rest of the cardinal movements for a baby in a vertex presentation?
A) Expulsion, external rotation, and restitution
B) Restitution, flexion, external rotation, and expulsion
C) Extension, restitution, external rotation, and expulsion
D) Flexion, extension, restitution, external rotation, and expulsion
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Q1) The nurse is preparing to monitor the fetal heart rate (FHR) of a pregnant client. What should the nurse explain to a nursing student as being the baseline (BL) of this heart rate?
A) "The baseline FHR excludes periods of marked variability."
B) "Normal baseline FHR ranges from 100 to 180 beats per minute."
C) "The baseline FHR should include periodic or episodic changes in FHR."
D) "The baseline rate is the mean FHR during a 5-minute period rounded to increments of 5 beats per minute."
Q2) The nurse is preparing to assess a client who has just arrived in the labor and birth unit. Which statement indicates that additional education is needed?
A) "When you check my cervix, you will find out how thinned out it is."
B) "After you assess my pelvis, you will be able to tell when I will deliver."
C) "You are going to do a vaginal examination to see how far dilated my cervix is."
D) "The reason for a pelvic examination is to determine how low in the pelvis my baby is."
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Q1) Five minutes after delivery, the neonate's body is pink with blue extremities. The heart rate is
150) The infant demonstrates a vigorous cry and good respiratory effort, and is actively moving. His elbows and hips are flexed, with his knees positioned up toward his abdomen. When the nurse flicks the soles of his feet, the neonate withdraws his leg. Which nursing interventions are appropriate?
A) Rescue breathing and stimulation
B) Stimulation and resuscitative efforts
C) Nasopharyngeal suctioning and blow-by oxygen
D) Oxygen via face mask and endotracheal suctioning
Q2) Upon delivery of the newborn, which action most promotes parental attachment?
A) Placing the newborn under the radiant warmer
B) Placing the newborn on the maternal abdomen
C) Taking the newborn to the nursery for the initial assessment
D) Allowing the mother a chance to rest immediately after delivery
Q3) What should be the nurse's priority when caring for an adolescent in labor?
A) Support persons
B) Developmental level
C) Cultural background
D) Plans for keeping the infant
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Q1) A client experiencing contractions every 8 to 20 minutes that last 20 to 30 seconds requests pain medication. What should the nurse state as the effect of analgesics given at this time?
A) Prolonged labor
B) Maternal hypotension
C) Fetal respiratory depression
D) Decreased analgesic effectiveness at the end of labor
Q2) A client in labor who rates pain as 9 on a scale from 1 to 10 requests pain medication after refusing epidural anesthesia. What action should the nurse take prior to administering butorphanol tartrate (Stadol) as prescribed?
A) Offer epidural anesthesia again.
B) Administer oxygen via face mask at 6 to 10 L per minute.
C) Obtain maternal vital signs and assess the fetal heart rate (FHR).
D) Instruct on the actions and contraindications associated with the medication.
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Q1) A client at 30 weeks' gestation is experiencing painless late vaginal bleeding. What should the nurse expect in the management of this client?
A) Assessing blood pressure every 2 hours
B) Evaluating the fetal heart rate with an internal monitor
C) Limiting vaginal examinations to only one per 24-hour period
D) Monitoring for blood loss, pain, and uterine contractibility
Q2) The nurse is planning an educational program about disseminated intravascular coagulation (DIC) in pregnancy. What risk factors should the nurse include about this health problem? Select all that apply.
A) Multiparity
B) Preterm labor
C) Diabetes mellitus
D) Abruptio placentae
E) Prolonged retention of a fetus after demise
Q3) A client who weighed 60 kg before becoming pregnant with twins is having a routine prenatal examination at gestational week 24. What should be this client's weight in kilograms at this time? (Round to the nearest whole number.)
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Q1) The nurse is assisting in the preparation of a pregnant client in labor for intrauterine resuscitation. For which fetal finding is this intervention indicated? Select all that apply.
A) Prolonged decelerations
B) Persistent late decelerations
C) Last fetal movement 5 minutes ago
D) Fetal heart rate 140 beats per minute
E) Persistent and severe variable decelerations
Q2) A client with a suspected small pelvis is dilated at 6 cm. The fetus has an estimated weight of 4200 g (9 lb, 4 oz). What is the most important action for the client at this time?
A) Encourage oral fluids and carbohydrate intake.
B) Assess the cervix for change every 8 hours.
C) Inform the couple that labor might be prolonged.
D) Assist the client to squat during the second stage.
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Q1) The nurse is preparing a client with cephalopelvic disproportion (CPD) for an immediate cesarean birth. What is the last assessment that the nurse should make before the client is draped for surgery?
A) Vaginal examination
B) Fetal heart tones
C) Maternal temperature
D) Maternal urine output
Q2) A client in the midst of labor and delivery of twins is being considered for a podalic version. What should the nurse assess in order for this version to be considered? Select all that apply.
A) Previous cesarean birth
B) Second fetus does not descend
C) Premature rupture of membranes
D) Presence of third-trimester bleeding
E) Second fetus heart rate nonreassuring
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Q1) The new father asks what his baby will experience while sleeping and awake. How should the nurse respond?
A) "Babies have several sleep and alert states. Keep watching and you will notice them."
B) "Newborns have two stages of sleep: deep or quiet sleep and rapid eye movement sleep."
C) "You may have noticed that your child was in an alert awake state for an hour after his birth."
D) "Birth is hard work for babies; it takes them a week or 2 to recover and become more awake."
Q2) A newborn weighing 8.8 lb is prescribed bottle-feedings every 3 hours to achieve the caloric intake of 120 calories/kg each day. How many calories should be in each ounce of feeding? (Calculate to the nearest whole number.)
Q3) A newborn weighing 7.7 lb has an estimated bladder capacity of 20 mL. If 25 mL/kg of urine is expected to be produced each day, how many diaper changes will this baby need? (Calculate by rounding to the nearest whole number.)
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Q1) A new parent asks why the baby appears to be occasionally cross-eyed. When should the nurse instruct the parent that this finding will resolve?
A) 1 year
B) 2 weeks
C) 2 months
D) 4 months
Q2) A mother of a 16-week-old infant is concerned because she cannot feel the posterior fontanelle on her infant. Which response by the nurse would be most appropriate?
A) "Your baby must be dehydrated."
B) "Bring your infant to the clinic immediately."
C) "This is due to overriding of the cranial bones during labor."
D) "It is normal for the posterior fontanelle to close by 8 to 12 weeks after birth."
Q3) The nurse is making an initial assessment of a newborn. Which data would be considered normal? 1. Chest circumference 30 cm, head circumference 29 cm
A) Chest circumference 38 cm, head circumference 31.5 cm
B) Chest circumference 32.5 cm, head circumference 38 cm
C) Chest circumference 31.5 cm, head circumference 33.5 cm
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Q1) The nurse is assisting a mother to bottle-feed her newborn, who has been crying. What should the nurse instruct the client to do before feeding the infant?
A) Offer a pacifier.
B) Burp the newborn.
C) Unwrap the newborn.
D) Stroke the newborn's spine and feet.
Q2) Which information is least likely recorded as a part of the initial newborn assessment?
A) Presence or absence of meconium-stained fluid
B) Blood draw for phenylketonuria (PKU) screening
C) Resuscitative measures required in the birthing area
D) Parents' desires regarding circumcision for a male infant
Q3) A client who delivered a day ago has chosen to breastfeed her infant. Which observation best indicates that the client understands breastfeeding?
A) The infant is crying when brought to the breast.
B) The client takes off her gown to achieve skin-to-skin contact.
C) The infant is held so that the nipple is accessed by turning the head.
D) The client puts the infant to breast when the baby is asleep to help wake the baby up.
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Q1) A client with type 2 diabetes mellitus delivered a fetus weighing 7 lb, 14 oz 2 hours ago. The infant's blood glucose is currently 45 mg/dL. What should the nurse do?
A) Begin an IV of 10% dextrose.
B) Document the findings in the chart.
C) Feed the baby 1 oz of formula.
D) Recheck the blood sugar in 4 hours.
Q2) The nurse is caring for a newborn born to a client who abused drugs while pregnant. Which assessment findings would be common for this newborn? Select all that apply.
A) Hyperirritability
B) Transient tachypnea
C) Exaggerated reflexes
D) Decreased muscle tone
E) Depressed respiratory effort
Q3) A small-for-gestational-age (SGA) newborn weighing 2000 g is prescribed to receive 130 kcal/kg/day of oral feeding to achieve a daily weight gain of 30 g.What should this newborn weigh after 2 weeks of receiving these feedings? (Calculate to the nearest whole number.)
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Q1) A newborn is admitted to the neonatal intensive care unit with suspected meconium aspiration. What care should the nurse expect to provide to this client? Select all that apply.
A) Dopamine infusion
B) High-pressure ventilation
C) High-level oxygen therapy
D) Surfactant replacement therapy
E) High-volume intravenous fluids
Q2) At birth, an infant newborn has a heart rate of 100, is not breathing, and is limp and bluish in color. What nursing action is best?
A) Assess blood pressure.
B) Deep suction the airways.
C) Begin chest compressions.
D) Begin bag-and-mask ventilation.
Q3) An infant weighing 1500 g is prescribed intravenous normal saline 10 mL/kg. How many milliliters of fluid should the nurse expect to provide this infant? (Calculate to the nearest whole number.)
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Q1) On the first postpartum day, the nurse teaches a client about breastfeeding. Two hours later, the mother seems to remember very little of the teaching. What should the nurse identify as the reason for the client's memory lapse?
A) Epidural anesthesia
B) The taking-in phase
C) The taking-hold phase
D) Postpartum hemorrhage
Q2) A new mother rarely interacts with the infant unless the infant begins to cry vigorously and she appears relieved when the nurse comes to check on the infant. What is the appropriate nursing intervention for this patient?
A) Contact Social Services with concerns of neglect.
B) Teach the client how to interact appropriately with the infant.
C) Take the infant to the nursery so the baby can receive more consistent care.
D) Provide the care the infant needs while continuing to evaluate the mother's actions.
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Q1) The nurse is teaching a postpartum client information regarding weaning her infant from breastfeeding. Which client statement suggests a need for further teaching?
A) "Slow weaning should take place over a period of several months."
B) "By weaning my baby slowly, I'm giving him time to change his eating method at his own pace."
C) "If I wean my baby slowly, I am less likely to develop breast engorgement."
D) "Slowly weaning my baby is recommended to allow time for my psychologic adjustment."
Q2) Which will the nurse include in the family assessment for the postpartum client? Select all that apply.
A) Parental roles
B) Bonding behaviors
C) Sibling adjustment
D) Signs and symptoms of infection
E) Level of comfort with newborn care
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Q1) A client is experiencing excessive bleeding immediately after the birth of her newborn. After increasing the IV fluids containing oxytocin, with no noticeable decrease in the bleeding, the nurse anticipates which prescriptions from the healthcare provider? Select all that apply.
A) methylergonovine maleate (Methergine)
B) butorphanol tartrate (Stadol)
C) misoprostol (Cytotec)
D) betamethasone (Diprolene)
E) fentanyl (Duragesic)
Q2) The nurse is assessing a postpartum client's risk for early postpartum hemorrhage. Which findings in the client's health history place this client at an increase risk for early postpartum hemorrhage? Select all that apply.
A) Microsomia
B) Grand multiparity
C) African American heritage
D) Oxytocin induction of labor
E) History of anorexia nervosa
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Q1) As children grow and develop, their style of play changes. Place the descriptions of play styles in order from infancy to school age.
A) Plays beside but not with other children
B) Plays games with other children and is able to follow the rules of the game
C) Plays alone with play directed by others
D) Plays with others in loose groups
Q2) Two hospitalized pediatric clients are working on a puzzle together in the hospital playroom. Which type of play are the clients exhibiting?
A) Solitary play
B) Associative play
C) Parallel play
D) Cooperative play
Q3) Which nursing actions are developmentally appropriate when caring for a hospitalized school-age child? Select all that apply.
A) Knocking on the school-age child's hospital room door prior to entering
B) Giving clear instructions about details of treatment
C) Providing brochures regarding sexuality
D) Offering medical equipment to play with prior to a procedure
E) Using toys for distraction during a painful procedure
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Q1) An adolescent is admitted to the eating disorders unit with a 2-year history of anorexia nervosa. Assessment data indicate that the adolescent has recently sustained additional weight loss and electrolyte imbalances. Which is the priority when planning care for this client?
A) Individual counseling
B) Family therapy
C) Regulation of antidepressant drugs
D) Nutritional support
Q2) Which statement should the nurse include when teaching parents of an infant about normal growth and development regarding weight gain?
A) "Your baby's weight should triple by 9 months of age."
B) "Your baby's weight should double by 5 months of age."
C) "Your baby's weight should triple by 6 months of age."
D) "Your baby's weight should double by 1 year of age."
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Q1) The nurse is completing a physical examination of a 4-year-old girl. Which is the best position to place the child in to assess the genitalia?
A) Supine, with legs at a 50-degree angle
B) Right side-lying
C) In prone position, with knees drawn up under the body
D) Frog-legged position
Q2) The nurse is conducting a health history for the family of a 3-year-old child. Which statements or questions by the nurse would establish rapport and elicit an accurate response from the family? Select all that apply.
A) "Hello, I would like to talk with you and get some information on you and your child."
B) "Does any member of your family have a history of asthma, heart disease, or diabetes?"
C) "Tell me about the concerns that brought you to the clinic today."
D) "You will need to fill out these forms; make sure that the information is as complete as possible."
E) Asking the child, "What is your doll's name?"
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Q1) A nurse assesses the height and weight measurements on an infant and documents these measurements at the 75th percentile. The nurse notes that the measurements 2 months ago were at the 25th percentile. Which interpretation of these data by the nurse is accurate?
A) The infant is not gaining enough weight.
B) The infant has gained a significant amount of weight.
C) These measurements most likely are inaccurate.
D) The previous measurements were most likely inaccurate.
Q2) Which nursing actions are appropriate for the 2-month-old infant during a scheduled health maintenance visit? Select all that apply.
A) Reviewing infant fluid needs with the parents
B) Reinforcing the importance of heating bottles with water versus the microwave
C) Demonstrating proper gum care to the parents
D) Educating the parents to begin introducing solid foods, such as rice cereal
E) Recommending that juice be introduced in a sippy cup
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Q1) At which age will the nurse begin to calculate body mass index (BMI) as a part of the nursing assessment process?
A) 12 months
B) 18 months
C) 2 years
D) 4 years
Q2) The parents of a 2-year-old girl inquire about information to help their child transition to bed each night. Which response by the nurse is appropriate?
A) Let the child cry self to sleep a few nights to adjust to the transition.
B) Play a favorite video at bedtime on a television in the child's room to enhance relaxation.
C) Read a book to the child just before bedtime each night.
D) Let the child fall asleep while playing and then put the child in bed.
Q3) Which is the priority nursing action when performing a physical assessment on a toddler?
A) Leaving intrusive procedures such as eye and ear examinations until the end
B) Explaining each part of the examination to the child before performing it
C) Performing the assessment from head to toe
D) Asking the mother to tell the child not to be afraid
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Q1) Which nursing action is appropriate when providing care to an adolescent client who is accompanied to an appointment by a parent?
A) Instructing the parent to stay in the waiting room with the explanation that the adolescent will provide a report after the examination
B) Telling the parent it is against policy for a parent to accompany the adolescent to the examination room
C) Reassuring the parent that the nurse will discuss any parental concerns or questions after the examination
D) Allowing the parent to come into the examination room with the adolescent
Q2) The nurse is assessing an adolescent client during a scheduled health maintenance appointment. Which issues should the nurse address when the parents are not present?
A) The adolescent's role in the family
B) Teen job responsibilities
C) Possible domestic violence
D) Activities done as a family
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Q1) A community assessment conducted by the nurse reveals that the number of serious injuries in children has doubled in the past year. Which is the most appropriate nursing diagnosis when planning care to address the increased number of injuries?
A) Altered Family Processes related to hospitalization of an injured child
B) Risk for Injury related to inadequate use of bicycle helmets
C) Noncompliance related to inappropriate use of child safety seats
D) Knowledge Deficit related to injury prevention in children
Q2) The nurse is developing an ecomap for a pediatric client and family. Which explanation should the nurse provide prior to beginning this task?
A) "It provides information about your family structure including family life events, health, and illness."
B) "It illustrates your family relationships and interactions with community activities including school, parental jobs, and children's activities."
C) "It is a short questionnaire of five questions that measures your family's growth, affection, and resolve."
D) "It is an assessment that consists of three categories of information about your family's strengths and problems."
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Q1) The nurse is working with the parents of a child with a chronic condition. Which statement made by the child's parents indicates the need for intervention related to overwhelming caregiver burden?
A) "My mother moved in and helps us with the care of our family."
B) "I chose to quit my job to be home with my child, and my husband helps in the evening when he can."
C) "I have to care for my child day and night, which leaves little time for me."
D) "Our health insurer sent us a rejection letter for my child's brand-name medication, and we must fill out forms to get the generic."
Q2) The nurse is planning care for a school-age child who requires oxygen, enteral tube feedings, and IV medications during the school day. To which category of chronic illness does this child belong?
A) Dependent on special diet
B) Dependent on medical technology
C) Increased use of healthcare services
D) Functional limitations
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Q1) An adolescent tells the nurse that the new diagnosis of diabetes has him "stressed out." Which stress-reduction activities will the nurse recommend to this adolescent?
Select all that apply.
A) Daily exercise, such as walking
B) Learning more about his illness
C) Practicing deep breathing and other relaxation techniques
D) Not thinking about his diagnosis
E) Allowing the parents control of his disease
Q2) Which is a common fear, in addition to separation anxiety, for the hospitalized pediatric client between the ages of 6 and 18 months?
A) Disfigurement
B) Death
C) Stranger anxiety
D) Bodily injury
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Q1) A 6-year-old postoperative client's IV infiltrates and has to be restarted immediately for medication. There is no time for placing local anesthetic cream on the skin. Which complementary therapy would be helpful when placing this IV?
A) Restraints
B) Moderate sedation
C) Anesthesia
D) Distraction
Q2) Which are discharge criteria the nurse includes in the plan of care for a client who has received sedation? Select all that apply.
A) Stable vital signs
B) Patent airway
C) Ability to sit up without assistance
D) Adequate fluid intake
E) Ability to urinate
Q3) The healthcare provider prescribes hydromorphine (Dilaudid) intravenously for the postoperative 4-year-old child. The therapeutic range for Dilaudid has been determined to be 0.01 to 0.015 mg/kg/dose every 3 to 4 hours. What is the maximum therapeutic dose of Dilaudid if the child weighs 30 pounds? Round your answer to the nearest hundredth.
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Q1) A school bus carrying children in grades K-12 crashed into a ravine. The critically injured children are transported by ambulance and admitted to the pediatric intensive care unit (PICU). Which is the most effective nursing intervention to calm the frightened children?
A) Explain that the equipment being used is state-of-the-art.
B) Tell the children that the providers are competent.
C) Call the children's parents to come to the unit.
D) Assure the children that the nurses are caring.
Q2) Which defense mechanisms should the nurse include in the parental teaching session regarding common pediatric responses to a life-threatening illness? Select all that apply.
A) Regression
B) Anticipating
C) Denial
D) Repression
E) Bargaining
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Q1) Which adolescent behavior, reported by a parent, would cause the nurse to suspect possible substance abuse?
A) Becoming very involved with friends and in activities related to basketball
B) Becoming moody, crying, and weeping one minute and then cheerful and excited the next
C) Receiving numerous detentions for sleeping in class
D) Wearing baggy, oversized clothing and dyeing hair black
Q2) Which nursing interventions should the nurse implement for a school-age child who is the victim of physical abuse by a parent? Select all that apply.
A) Referring members of the family for appropriate counseling
B) Protecting the child from further injury
C) Allowing the child to wear clothing during the examination process
D) Discouraging parental participation in the plan of care
E) Documenting the child's response to parental interaction
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Q1) A mother brings in her 4-month-old infant for a routine checkup and vaccinations. The mother reports that her child was exposed to the flu. Which nursing action is accurate based on the current data?
A) Withhold the DTaP vaccination but give the others as scheduled.
B) Give the infant the flu vaccination but withhold the others.
C) Give the vaccinations as scheduled.
D) Withhold the vaccinations.
Q2) Which vaccines should the nurse prepare to administer to a 6-month-old infant during a scheduled well-child visit? Select all that apply.
A) DTaP vaccine
B) Hib vaccine
C) HPV4 vaccine
D) MMR vaccine
E) PCV13 vaccine
Q3) Which should the nurse use when reconstituting vaccines?
A) The diluents provided
B) Normal saline
C) Any solution available
D) Sterile water
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Q1) The nurse is assessing a pediatric client who is experiencing metabolic alkalosis. Which assessment questions should the nurse include when interviewing the child's parents? Select all that apply.
A) "Has your child consumed any aspirin?"
B) "Has your child consumed any boric acid?"
C) "Has your child consumed any antifreeze?"
D) "Has your child consumed any baking soda?"
E) "Has your child consumed any antacids?"
Q2) A child is admitted to the hospital for hypercalcemia and is placed on diuretic therapy. Which diuretic would the nurse expect to give?
A) Furosemide (Lasix)
B) Hydrochlorothiazide (Aquazide)
C) Spironolactone (Aldactone)
D) Mannitol (Osmitrol)
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Q1) Which should the nurse include in the plan of care for a pediatric client diagnosed with otitis media with effusion? Select all that apply.
A) Administration of antibiotic drops per order
B) Administration of pain relief measures
C) Assessment of hearing acuity over several months
D) Assessment of speech
E) Assessment of development
Q2) Which is the rationale for why young children are more prone to otitis media that the nurse should include in the teaching session with a parent?
A) The eustachian tube is shorter, wider, and horizontal in younger children.
B) The eustachian tube is shorter, more narrow, and horizontal in younger children.
C) The eustachian tube is longer, wider, and vertical in younger children.
D) The eustachian tube is longer, more narrow, and vertical in younger children.
Q3) Which assessment finding is considered normal for a school-age client?
A) Tonsils are large and seem to fill the throat
B) Child is complaining of sore throat and drooling
C) White patches are observed on the tonsils
D) Throat appears red, and child has a low-grade fever
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Q1) Which is the priority nursing action for a premature neonate who is experiencing apnea?
A) Administering oxygen
B) Performing back blows and chest thrusts
C) Calling a code blue
D) Providing stimulation by stroking the back
Q2) Which nursing actions are appropriate when providing care to a pediatric client who has sustained a smoke-inhalation injury? Select all that apply.
A) Assessing for respiratory distress
B) Auscultating the lungs for wheezing
C) Prescribing oxygen for low saturations
D) Administering prescribed prophylactic antibiotic therapy
E) Providing support to the family
Q3) Which parental statement indicates correct understanding regarding pancreatic enzyme administration in the treatment of cystic fibrosis?
A) "I will administer this medication 4 times each day."
B) "I will administer this medication twice each day."
C) "I will administer this medication with meals and snacks."
D) "I will administer this medication every 6 hours around the clock."
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Q1) Which feeding techniques should the nurse include in the teaching session for the parents of an infant who is being discharged in order to gain weight for the corrective surgery needed for a congenital heart defect? Select all that apply.
A) Breastfeed if possible.
B) Complete each feeding within 30 minutes.
C) Position the infant flat to promote swallowing.
D) Dilute the formula with extra water to ensure adequate fluid intake.
E) Burp the infant frequently.
Q2) Which assessment data would cause the nurse to suspect that a pediatric client is experiencing hypovolemic shock? Select all that apply.
A) Dyspnea
B) Bradycardia
C) Tachycardia
D) Capillary refill time greater than 3 seconds.
E) Blood pressure 72/42 mmHg
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Q1) The nurse is providing education to a family whose child experiences anaphylaxis when exposed to any amount of latex. Which items, often found in the home or school environment, should the nurse include in the teaching session? Select all that apply.
A) Art supplies
B) Toothpaste
C) Balloons
D) Perfumes
E) Chewing gum
Q2) Which is the rationale for ensuring the irrigation of blood products and ensuring that they are cytomegalovirus (CMV)-negative prior to administering a blood transfusion for a pediatric client diagnosed with severe combined immune deficiency (SCID)?
A) Transfusion reaction from lymphocytes and platelets in the donor blood.
B) Transfusion reaction and infection from lymphocytes in the donor blood.
C) Infection and graft-versus-host disease from lymphocytes in the donor blood.
D) Infection and graft-versus-host disease from erythrocytes in the donor blood.
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Q1) Which is the priority nursing intervention when providing care to a pediatric client who is experiencing disseminated intravascular coagulation (DIC)?
A) Preparing the child for radiographic procedures
B) Implementing the prescribed fluid restriction for the child
C) Encouraging the child to frequently ambulate
D) Monitoring the child's oxygen saturation and vital signs
Q2) A child is diagnosed with lymphocytopenia. Which parental statements indicate understanding of this diagnosis? Select all that apply.
A) "My child may be prone to allergic reactions."
B) "My child may have trouble initiating an inflammatory response."
C) "My child may require iron supplements to treat this disorder."
D) "My child may require further testing for leukemia."
E) "My child may have been exposed to tuberculosis."
Q3) Which is the priority nursing diagnosis for the child diagnosed with idiopathic thrombocytopenic purpura (ITP)?
A) Ineffective Breathing Pattern
B) Nausea
C) Fluid Volume Deficit
D) Risk for Injury

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Q1) The nurse is preparing to assist with a lumbar puncture for a pediatric client who is diagnosed with cancer. Which statements should the nurse include in the teaching session for the client and family? Select all that apply.
A) "This procedure assesses the bone marrow."
B) "This procedure assesses cerebrospinal fluid."
C) "This procedure confirms the diagnosis of acute lympoblastic leukemia."
D) "The procedure determines if malignant cells are affecting the nervous system."
E) "This procedure assesses cellular components of the blood."
Q2) Which general manifestations should the nurse monitor for when conducting a physical assessment for a pediatric client who is diagnosed with cancer? Select all that apply.
A) Infection
B) Polycythemia
C) Petechiae
D) Pain
E) Cachexia
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Q1) A toddler is admitted to the surgical unit for a planned closure of a temporary colostomy. Which medical prescription should the nurse question?
A) Clear liquids today. NPO tomorrow
B) Type and cross-match for 1 unit of packed red blood cells.
C) Rectal temperatures every 4 hours
D) Start an intravenous line with D<sub>5</sub>NS at 20 mL per hour.
Q2) The nurse is planning care for a school-age client who is postoperative for the surgical removal of the appendix. In addition to pharmacologic pain management, which should the nurse include in the plan of care to address pain?
A) Applying a warm, moist pack every 4 hours
B) Applying EMLA cream to the incision site prior to ambulation
C) Applying a cold, moist pack every 2 hours
D) Applying a pillow against the abdomen to splint the incision site when coughing
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Q1) Which risks of undescended testes should the nurse include in the teaching session for the parents of a newborn diagnosed with this condition? Select all that apply.
A) Sperm production will be affected after puberty.
B) Abdominal testes are subject to injury.
C) Abdominal testes have a higher risk of developing cancer.
D) Hormonal production will be affected.
E) The testes are at greater risk of torsion.
Q2) Which actions should the nurse implement when assessing the physical growth for a child who is diagnosed with chronic renal failure? Select all that apply.
A) Asking the child to step on the scale
B) Measuring the child's height
C) Measuring the child's head circumference
D) Using the Denver II with the child
E) Monitoring the child's blood pressure
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Q1) Which type of nutrition should the nurse include when planning care for a newborn who is diagnosed with galactosemia?
A) Goat's milk formula
B) Breast milk
C) Cow's milk-based formula
D) Lactose-free formula
Q2) The nurse is giving discharge instructions to the parents of a child whose adrenal glands have been removed due to a tumor. Which parental statement indicates the need for further education?
A) "I will call the doctor if my child has restlessness and confusion."
B) "If my child has any gastric irritation, I will give him antacids."
C) "If my child has vomiting and diarrhea, I will hold his hydrocortisone."
D) "I will give my child his hydrocortisone in the morning."
Q3) The nurse is providing care to a newborn who is suspected of having Turner syndrome. Which should the nurse assess the newborn for based on the current diagnosis?
A) Club foot (talipes equinovarus)
B) Congenital heart anomalies
C) Hyperbilirubinemia due to liver abnormalities
D) Diaphragmatic hernia

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Q1) The nurse is providing care to a child who was treated with aspirin during a viral infection. Which clinical manifestations should cause the nurse concern?
A) Nausea, vomiting, and confusion
B) Headache, vomiting, and seizures
C) Sore throat, moist respirations, and cough
D) Fever, rash, and photophobia
Q2) Which should the nurse include in the plan of care for a hospitalized school-age child with myelodysplasia? Select all that apply.
A) Implementing interventions for a client of normal intelligence
B) Using latex precautions when providing client care
C) Allowing the client to self-catheterize
D) Ensuring that the client has a low-fiber diet
E) Encouraging the client to shift positions hourly when in the wheelchair
Q3) Which assessment finding for a 4-month-old infant would require further action by the nurse?
A) The posterior fontanel is open.
B) The infant has good head control when held upright.
C) The infant is able to roll only from abdomen to back.
D) The anterior fontanel is open and soft.
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Q1) Which items noted in a pediatric client's medical record indicate the child may be experiencing a learning disability? Select all that apply.
A) Dyslexia
B) Dysphagia
C) Dyspraxia
D) Scoliosis
E) Hypotonia
Q2) Which activities should the nurse include in the plan of care for a child diagnosed with attention deficit/hyperactivity disorder (ADHD) to improve behavior and learning? Select all that apply.
A) Asking the mother to seek a prescription for methylphenidate (Ritalin) for the child
B) Placing the child's desk at the back of the room to reduce distractions
C) Developing a consistent routine for the classroom
D) Limiting the decorations in the classroom
E) Determining areas where the child performs well and using these areas to promote self-esteem
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Q1) A school nurse suspects that a child who fell at recess has a fractured arm. Which should the nurse consider when applying a splint to transport the child to the hospital?
A) The splint is applied firmly enough to prevent swelling.
B) The arm is fully extended in the splint.
C) The splint is fully padded to prevent skin damage.
D) The joints above and below the suspected fracture are immobilized by the splint.
Q2) Which are appropriate interventions for the nurse to include in the plan of care for a child who is receiving traction? Select all that apply.
A) Monitoring breath sounds
B) Assessing neurovascular status every 2 hours
C) Repositioning every 2 to 3 hours
D) Using moleskin to protect the skin from rough edges
E) Encouraging the parents cuddle with their child
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Q1) Which preventative strategies for tinea pedis, a fungal infection, also known as athlete's foot, should the nurse include in a teaching session for an adolescent client? Select all that apply.
A) Wear 100% white cotton socks, changed twice a day.
B) Use talc on feet daily.
C) Use an over-the-counter corticosteroid cream to treat the area.
D) Wear foot covers such as flip flops in the locker room and shower.
E) Apply heat to the area twice a day.
Q2) A child had an appendectomy and was discharged home at 48 hours postoperative. A week later, the child is readmitted for delayed wound healing. Which causes of delayed wound healing will the nurse review prior to assessing the child? Select all that apply.
A) Infection
B) Predisposing chronic condition, such as diabetes
C) Hypervolemia
D) Inadequate nutrition
E) Hypoxemia
To view all questions and flashcards with answers, click on the resource link above. Page 59