Maternal and Child Health Nursing Practice Quiz #6 (50 Questions)

  • October 12, 2020/

Usually, the best critical thinkers are the ones who tend to over-analyze questions and the options. Finding a balance between analyzing and overanalyzing will be a key factor in passing the NCLEX exam. Here’s a 50-question practice NCLEX-RN exam about Maternal and Child Health Nursing for you.

Doing the best at this moment puts you in the best place for the next moment.”
– Oprah Winfrey


Topics or concepts included in this exam are:

  • Pregnancy
  • Female reproductive system
  • Health teaching for pregnant mothers
  • Child development


To make the most out of this quiz, follow the guidelines below:

  • Read each question carefully and choose the best answer.
  • You are given one minute per question. Spend your time wisely!
  • Answers and rationales (if any) are given below. Be sure to read them.
  • If you need more clarifications, please direct them to the comments section.

Practice Mode

Practice Mode: This is an interactive version of the Text Mode. All questions are given in a single page and correct answers, rationales or explanations (if any) are immediately shown after you have selected an answer. No time limit for this exam.

Text Mode

In Text Mode: All questions and answers are given for reading and answering at your own pace. You can also copy this exam and make a print out.

1. 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.

2. 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

3. 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

4. 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

5. 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.”

6. 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. Bowlegged posture
D. Linear growth curve

7. 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

8. 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

9. 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

10. 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

11. 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.”

12. 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

13. 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

14. A hospitalized school ager 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

15. 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. “Schoolagers are more active and adventurous than are younger children.”
B. “Schoolagers 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.”

16. Which of the following skills is the most significant one learned during the school age period?

A. Collecting
B. Ordering
C. Reading
D. Sorting

17. 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 MMR vaccine?

A. In a month from now
B. In a year from now
C. At age 10
D. At age 13

18. 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 diffusion

19. 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

20. 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?”

21. Which of the following should the nurse suspect when noting that a 3-year-old is engaging in explicit sexual behavior during doll play?

A. The child is exhibiting normal pre-school curiosity
B. The child is acting out personal experiences
C. The child does not know how to play with dolls
D. The child is probably developmentally delayed.

22. Which of the following statements by the parents of a child with school phobia would indicate the need for further teaching?

A. “We’ll keep him at home until phobia subsides.”
B. “We’ll work with his teachers and counselors at school.”
C. “We’ll try to encourage him to talk about his problem.”
D. “We’ll discuss possible solutions with him and his counselor.”

23. When developing a teaching plan for a group of high school students about teenage pregnancy, the nurse would keep in mind which of the following?

A. The incidence of teenage pregnancies is increasing.
B. Most teenage pregnancies are planned.
C. Denial of the pregnancy is common early on.
D. The risk for complications during pregnancy is rare.

24. When assessing a child with a cleft palate, the nurse is aware that the child is at risk for more frequent episodes of otitis media due to which of the following?

A. Lowered resistance from malnutrition
B. Ineffective functioning of the Eustachian tubes
C. Plugging of the Eustachian tubes with food particles
D. Associated congenital defects of the middle ear.

25. While performing a neurodevelopmental assessment on a 3-month-old infant, which of the following characteristics would be expected?

A. A strong Moro reflex
B. A strong parachute reflex
C. Rolling from front to back
D. Lifting of head and chest when prone

26. By the end of which of the following would the nurse most commonly expect a child’s birth weight to triple?

A. 4 months
B. 7 months
C. 9 months
D. 12 months

27. Which of the following best describes parallel play between two toddlers?

A. Sharing crayons to color separate pictures
B. Playing a board game with a nurse
C. Sitting near each other while playing with separate dolls
D. Sharing their dolls with two different nurses

28. Which of the following would the nurse identify as the initial priority for a child with acute lymphocytic leukemia?

A. Instituting infection control precautions
B. Encouraging adequate intake of iron-rich foods
C. Assisting with coping with chronic illness
D. Administering medications via IM injections

29. Which of the following information, when voiced by the mother, would indicate to the nurse that she understands home care instructions following the administration of diphtheria, tetanus, and pertussis injection?

A. Measures to reduce fever
B. Need for dietary restrictions
C. Reasons for subsequent rash
D. Measures to control subsequent diarrhea

30. Which of the following actions by a community health nurse is most appropriate when noting multiple bruises and burns on the posterior trunk of an 18-month-old child during a home visit?

A. Report the child’s condition to Protective Services immediately.
B. Schedule a follow-up visit to check for more bruises.
C. Notify the child’s physician immediately.
D. Don nothing because this is a normal finding in a toddler.

31. Which of the following is being used when the mother of a hospitalized child calls the student nurse and states, “You idiot, you have no idea how to care for my sick child”?

A. Displacement
B. Projection
C. Repression
D. Psychosis

32. Which of the following should the nurse expect to note as a frequent complication for a child with congenital heart disease?

A. Susceptibility to respiratory infection
B. Bleeding tendencies
C. Frequent vomiting and diarrhea
D. Seizure disorder

33. Which of the following would the nurse do first for a 3-year-old boy who arrives in the emergency room with a temperature of 105 degrees, inspiratory stridor, and restlessness, who is leaning forward and drooling?

A. Auscultate his lungs and place him in a mist tent.
B. Have him lie down and rest after encouraging fluids.
C. Examine his throat and perform a throat culture
D. Notify the physician immediately and prepare for intubation.

34. Which of the following would the nurse need to keep in mind as a predisposing factor when formulating a teaching plan for a child with a urinary tract infection?

A. A shorter urethra in females
B. Frequent emptying of the bladder
C. Increased fluid intake
D. Ingestion of acidic juices

35. Which of the following should the nurse do first for a 15-year-old boy with a full leg cast who is screaming in unrelenting pain and exhibiting right foot pallor signifying compartment syndrome?

A. Medicate him with acetaminophen.
B. Notify the physician immediately
C. Release the traction
D. Monitor him every 5 minutes

36. At which of the following ages would the nurse expect to administer the varicella zoster vaccine to a child?

A. At birth
B. 2 months
C. 6 months
D. 12 months

37. When discussing normal infant growth and development with parents, which of the following toys would the nurse suggest as most appropriate for an 8-month-old?

A. Push-pull toys
B. Rattle
C. Large blocks
D. Mobile

38. Which of the following aspects of psychosocial development is necessary for the nurse to keep in mind when providing care for the preschool child?

A. The child can use complex reasoning to think out situations.
B. Fear of body mutilation is a common preschool fear
C. The child engages in competitive types of play
D. Immediate gratification is necessary to develop initiative.

39. Which of the following is characteristic of a preschooler with mid-mental retardation?

A. Slow to feed self
B. Lack of speech
C. Marked motor delays
D. Gait disability

40. Which of the following assessment findings would lead the nurse to suspect Down syndrome in an infant?

A. Small tongue
B. Transverse palmar crease
C. Large nose
D. Restricted joint movement

41. While assessing a newborn with cleft lip, the nurse would be alert that which of the following will most likely be compromised?

A. Sucking ability
B. Respiratory status
C. Locomotion
D. GI function

42. When providing postoperative care for the child with a cleft palate, the nurse should position the child in which of the following positions?

A. Supine
B. Prone
C. In an infant seat
D. On the side

43. While assessing a child with pyloric stenosis, the nurse is likely to note which of the following?

A. Regurgitation
B. Steatorrhea
C. Projectile vomiting
D. “Currant jelly” stools

44. Which of the following nursing diagnoses would be inappropriate for the infant with gastroesophageal reflux (GER)?

A. Fluid volume deficit
B. Risk for aspiration
C. Altered nutrition: less than body requirements
D. Altered oral mucous membranes

45. Which of the following parameters would the nurse monitor to evaluate the effectiveness of thickened feedings for an infant with gastroesophageal reflux disease (GERD)?

A. Vomiting
B. Stools
C. Uterine
D. Weight

46. Discharge teaching for a child with celiac disease would include instructions about avoiding which of the following?

A. Rice
B. Milk
C. Wheat
D. Chicken

47. Which of the following would the nurse expect to assess in a child with celiac disease having a celiac crisis secondary to an upper respiratory infection?

A. Respiratory distress
B. Lethargy
C. Watery diarrhea
D. Weight gain

48. Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea?

A. Notify the physician immediately
B. Administer antidiarrheal medications
C. Monitor child ever 30 minutes
D. Nothing, this is characteristic of Hirschsprung disease

49. A newborn’s failure to pass meconium within the first 24 hours after birth may indicate which of the following?

A. Hirschsprung disease
B. Celiac disease
C. Intussusception
D. Abdominal wall defect

50. When assessing a child for possible intussusception, which of the following would be least likely to provide valuable information?

A. Stool inspection
B. Pain pattern
C. Family history
D. Abdominal palpation

Answers and Rationale

1. 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 normal finding for this age, notifying the physician or performing additional examinations are inappropriate.

2. 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.

3. 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.
  • Option C: Preschoolers develop a sense of guilt when their sense of initiative is thwarted.
  • Option D: Schoolagers develop a sense of inferiority when they do not develop a sense of industry.

4. Answer: D. A colorful busy box

A busy box facilitates the 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.

5. 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.

6. Answer: B. Underdeveloped abdominal muscles

Underdeveloped abdominal musculature gives the toddler a characteristically protruding abdomen.

  • Option A: During toddlerhood, food intake decreases, not increases.
  • Option C: Toddlers are characteristically bowlegged because the leg muscles must bear the weight of the relatively large trunk.
  • Option D: Toddler growth patterns occur in a steplike, not linear pattern.

7. Answer: B. Shame

According to Erikson, toddlers experience a sense of shame when they are not allowed to develop appropriate independence and autonomy.

  • Option A: Infants develop mistrust when their needs are not consistently gratified.
  • Option C: Preschoolers develop guilt when their initiative needs are not met.
  • Option D: While schoolagers develop a sense of inferiority when their industry needs are not met.

8. 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.

9. Answer: D. Verbalizes desire to go to the bathroom

The child must be able to sate the need to go to the bathroom to initiate toilet training.

  • Option A: Usually, a child needs to be dry for only 2 hours, not 4 hours.
  • Option B: The child also must be able to sit, walk, and squat.
  • Option C: A new sibling would most likely hinder toilet training.

10. 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 meal time.
  • 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.

11. 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 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 more difficult to fall asleep.

12. Answer: B. Dress-up clothes

Dress-up clothes enhance imaginative play and imagination, allowing preschoolers to engage in rich fantasy play.

  • Options A and C: Building blocks and wooden puzzles are appropriate for encouraging fine motor development.
  • Option D: Big wheels and tricycles encourage gross motor development.

13. 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.

  • Options A, B, and C: Collecting baseball cards and marbles, ordering dolls by size, and simple problem-solving options are examples of the concrete operational thinking of the schoolager.

14. 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.

15. Answer: C. “Schoolagers are unable to understand potential dangers around them.”

The school ager’s cognitive level is sufficiently developed to enable 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 need less 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.

16. 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.

  • Options A, B, and D: Collective, ordering, and sorting, although important, are not most significant skills learned.

17. 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.

18. Answer: D. Role diffusion

According to Erikson, role diffusion develops when the adolescent does not develop a sense of identity and a sense or where he fits in.

  • Option A: Toddlers develop a sense of shame when they do not achieve autonomy.
  • Option B: Preschoolers develop a sense of guilt when they do not develop a sense of initiative.
  • Option C: School-age children develop a sense of inferiority when they do not develop a sense of industry.

19. 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.

20. 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 and also can help to identify any patient-teaching needs for the adolescent regarding cleansing.

21. Answer: B. The child is acting out personal experiences

Preschoolers should be developmentally incapable of demonstrating explicit sexual behavior. If a child does so, the child has been exposed to such behavior, and sexual abuse should be suspected.

  • Options C and D: Explicit sexual behavior during doll play is not a characteristic of preschool development nor symptomatic of developmental delay. Whether or nor the child knows how to play with dolls is irrelevant.

22. Answer: A. “We’ll keep him at home until phobia subsides.”

The parents need more teaching if they state that they will keep the child home until the phobia subsides. Doing so reinforces the child’s feelings of worthlessness and dependency.

  • Option B: The child should attend school even during resolution of the problem.
  • Option C: Allowing the child to verbalize helps the child to ventilate feelings and may help to uncover causes and solutions.
  • Option D: Collaboration with the teachers and counselors at school may lead to uncovering the cause of the phobia and to the development of solutions. The child should participate and play an active role in developing possible solutions.

23. Answer: C. Denial of the pregnancy is common early on.

The adolescent who becomes pregnant typically denies the pregnancy early on. Early recognition by a parent or health care provider may be crucial to timely initiation of prenatal care.

  • Option A: The incidence of adolescent pregnancy has declined since 1991, yet morbidity remains high.
  • Option B: Most teenage pregnancies are unplanned and occur out of wedlock.
  • Option D: The pregnant adolescent is at high risk for physical complications including premature labor and low-birth-weight infants, high neonatal mortality, iron deficiency anemia, prolonged labor, and fetopelvic disproportion as well as numerous psychological crises.

24. Answer: B. Ineffective functioning of the Eustachian tubes

Because of the structural defect, children with cleft palate may have ineffective functioning of their Eustachian tubes creating frequent bouts of otitis media.

  • Option A: Most children with cleft palate remain well-nourished and maintain adequate nutrition through the use of proper feeding techniques.
  • Option C: Food particles do not pass through the cleft and into the Eustachian tubes.
  • Option D: There is no association between cleft palate and congenital ear deformities.

25. Answer: D. Lifting of head and chest when prone

A 3-month-old infant should be able to lift the head and chest when prone.

  • Option A: The Moro reflex typically diminishes or subsides by 3 months.
  • Option B: The parachute reflex appears at 9 months.
  • Option C: Rolling from front to back usually is accomplished at about 5 months.

26. Answer: D. 12 months

A child’s birth weight usually triples by 12 months and doubles by 4 months. No specific birth weight parameters are established for 7 or 9 months.

27. Answer: C. Sitting near each other while playing with separate dolls

Toddlers engaging in parallel play will play near each other, but not with each other. Thus, when two toddlers sit near each other but play with separate dolls, they are exhibiting parallel play.

  • Options A, B, and D: Sharing crayons, playing a board game with a nurse, or sharing dolls with two different nurses are all examples of cooperative play.

28. Answer: A. Instituting infection control precautions

Acute lymphocytic leukemia (ALL) causes leukopenia, resulting in immunosuppression and increasing the risk of infection, a leading cause of death in children with ALL. Therefore, the initial priority nursing intervention would be to institute infection control precautions to decrease the risk of infection.

  • Option B:  Iron-rich foods help with anemia, but dietary iron is not an initial intervention.
  • Option C: The prognosis of ALL usually is good. However, later on, the nurse may need to assist the child and family with coping since death and dying may still be an issue in need of discussion.
  • Option D: Injections should be discouraged, owing to increased risk of bleeding due to thrombocytopenia.

29. Answer: A. Measures to reduce fever

The pertussis component may result in fever and the tetanus component may result in injection soreness. Therefore, the mother’s verbalization of information about measures to reduce fever indicates understanding.

  • Option B: No dietary restrictions are necessary after this injection is given.
  • Option C: Subsequent rash is more likely to be seen 5 to 10 days after receiving the MMR vaccine, not diphtheria, pertussis, and tetanus vaccine.
  • Option D: A Diarrhea is not associated with this vaccine.

30. Answer: A. Report the child’s condition to Protective Services immediately.

Multiple bruises and burns on a toddler are signs child abuse. Therefore, the nurse is responsible for reporting the case to Protective Services immediately to protect the child from further harm.

  • Option B: Scheduling a follow-up visit is inappropriate because additional harm may come to the child if the nurse waits for further assessment data.
  • Option C: Although the nurse should notify the physician, the goal is to initiate measures to protect the child’s safety. Notifying the physician immediately does not initiate the removal of the child from harm nor does it absolve the nurse from responsibility.
  • Option D: Multiple bruises and burns are not normal toddler injuries.

31. Answer: B. Projection

The mother is using projection, the defense mechanism used when a person attributes his or her own undesirable traits to another.

  • Option A: Displacement is the transfer of emotion onto an unrelated object, such as when the mother would kick a chair or bang the door shut.
  • Option C: Repression is the submerging of painful ideas into the unconscious.
  • Option D: Psychosis is a state of being out of touch with reality.

32. Answer: A. Susceptibility to respiratory infection

Children with congenital heart disease are more prone to respiratory infections.

  • Options B, C, and D: Bleeding tendencies, frequent vomiting, and diarrhea and seizure disorders are not associated with congenital heart disease.

33. Answer: D. Notify the physician immediately and prepare for intubation.

The child is exhibiting classic signs of epiglottitis, always a pediatric emergency. The physician must be notified immediately and the nurse must be prepared for an emergency intubation or tracheostomy.

  • Option A: Further assessment with auscultating lungs and placing the child in a mist tent wastes valuable time. The situation is a possible life-threatening emergency.
  • Option B: Having the child lie down would cause additional distress and may result in respiratory arrest.
  • Option C: Throat examination may result in laryngospasm that could be fatal.

34. Answer: A. A shorter urethra in females

In females, the urethra is shorter than in males. This decreases the distance for organisms to travel, thereby increasing the chance of the child developing a urinary tract infection.

  • Option B: Frequent emptying of the bladder would help to decrease urinary tract infections by avoiding sphincter stress.
  • Option C: Increased fluid intake enables the bladder to be cleared more frequently, thus helping to prevent urinary tract infections.
  • Option D: The intake of acidic juices helps to keep the urine pH acidic and thus decrease the chance of flora development.

35. Answer: B. Notify the physician immediately

Compartment syndrome is an emergent situation and the physician needs to be notified immediately so that interventions can be initiated to relieve the increasing pressure and restore circulation.

  • Option A: Acetaminophen (Tylenol) will be ineffective since the pain is related to the increasing pressure and tissue ischemia.
  • Option C: The cast, not traction, is being used in this situation for immobilization, so releasing the traction would be inappropriate.
  • Option D:  In this situation, specific action not continued monitoring is indicated.

36. Answer: D. 12 months

The varicella zoster vaccine (VZV) is a live vaccine given after age 12 months. The first dose of hepatitis B vaccine is given at birth to 2 months, then at 1 to 4 months, and then again at 6 to 18 months. DTaP is routinely given at 2, 4, 6, and 15 to 18 months and a booster at 4 to 6 years.

37. Answer: C. Large blocks

Because the 8-month-old is refining his gross motor skills, being able to sit unsupported and also improving his fine motor skills, probably capable of making hand-to-hand transfers, large blocks would be the most appropriate toy selection.

  • Option A: Push-pull toys would be more appropriate for the 10 to 12-month-old as he or she begins to cruise the environment.
  • Options B and D: Rattles and mobiles are more appropriate for infants in the 1 to 3 month age range. Mobiles pose a danger to older infants because of possible strangulation.

38. Answer: B. Fear of body mutilation is a common preschool fear

During the preschool period, the child has mastered a sense of autonomy and goes on to master a sense of initiative. During this period, the child commonly experiences more fears than at any other time. One common fear is fear of the body mutilation, especially associated with painful experiences.

  • Options A, C, and D: The preschool child uses simple, not complex, reasoning, engages in associative, not competitive, play (interactive and cooperative play with sharing), and is able to tolerate longer periods of delayed gratification.

39. Answer: A. Slow to feed self

Mild mental retardation refers to development disability involving an IQ 50 to 70. Typically, the child is not noted as being retarded, but exhibits slowness in performing tasks, such as self-feeding, walking, and taking.

  • Options B, C, and D: Little or no speech, marked motor delays, and gait disabilities would be seen in more severe forms mental retardation.

40. Answer: B. Transverse palmar crease

Down syndrome is characterized by the following a transverse palmar crease (simian crease), separated sagittal suture, oblique palpebral fissures, small nose, depressed nasal bridge, high arched palate, excess and lax skin, wide spacing and plantar crease between the second and big toes, hyperextensible and lax joints, large protruding tongue, and muscle weakness.

41. Answer: A. Sucking ability

Because of the defect, the child will be unable to from the mouth adequately around the nipple, thereby requiring special devices to allow for feeding and sucking gratification.

  • Option B: Respiratory status may be compromised if the child is fed improperly or during postoperative period
  • Option C: Locomotion would be a problem for the older infant because of the use of restraints.
  • Option D: GI functioning is not compromised in the child with a cleft lip.

42. Answer: B. Prone

Postoperatively children with cleft palate should be placed on their abdomens to facilitate drainage.

  • Option A: If the child is placed in the supine position, he or she may aspirate.
  • Option C: Using an infant seat does not facilitate drainage.
  • Option D: Side-lying does not facilitate drainage as well as the prone position.

43. Answer: C. Projectile vomiting

Projectile vomiting is a key symptom of pyloric stenosis.

  • Option A: Regurgitation is seen more commonly with GERD.
  • Option B: Steatorrhea occurs in malabsorption disorders such as celiac disease.
  • Option D: “Currant jelly” stools are characteristic of intussusception.

44. Answer: D. Altered oral mucous membranes

GERD is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac) sphincter. No alteration in the oral mucous membranes occurs with this disorder.

  • Options A, B, and C: Fluid volume deficit, risk for aspiration, and altered nutrition are appropriate nursing diagnoses.

45. Answer: A. Vomiting

Thickened feedings are used with GER to stop the vomiting. Therefore, the nurse would monitor the child’s vomiting to evaluate the effectiveness of using the thickened feedings.

  • Options B and C: No relationship exists between feedings and characteristics of stools and uterine.
  • Option D:  If feedings are ineffective, this should be noted before there is any change in the child’s weight.

46. Answer: C. Wheat

Children with celiac disease cannot tolerate or digest gluten. Therefore, because of its gluten content, wheat and wheat-containing products must be avoided.

  • Options A, B, and D: Rice, milk, and chicken do not contain gluten and need not be avoided.

47. Answer: C. Watery diarrhea

Episodes of celiac crises are precipitated by infections, ingestion of gluten, prolonged fasting, or exposure to anticholinergic drugs. Celiac crisis is typically characterized by severe watery diarrhea.

  • Option A: Respiratory distress is unlikely in a routine upper respiratory infection.
  • Option B: Irritability, rather than lethargy, is more likely.
  • Option D: Because of the fluid loss associated with the severe watery diarrhea, the child’s weight is more likely to be decreased.

48. Answer: A. Hirschsprung disease

For the child with Hirschsprung disease, fever and explosive diarrhea indicate enterocolitis, a life-threatening situation. Therefore, the physician should be notified immediately.

  • Option B:  Generally, because of the intestinal obstruction and inadequate propulsive intestinal movement, antidiarrheals are not used to treat Hirschsprung disease.
  • Option C: The child is acutely ill and requires intervention, with monitoring more frequently than every 30 minutes.
  • Option D: Hirschsprung disease typically presents with chronic constipation.

49. Answer: A. Hirschsprung disease

Failure to pass meconium within the first 24 hours after birth may be an indication of Hirschsprung disease, a congenital anomaly resulting in mechanical obstruction due to inadequate motility in an intestinal segment.

  • Options B, C, and D: Failure to pass meconium is not associated with celiac disease, intussusception, or abdominal wall defect.

50. Answer: C. Family history

Because intussusception is not believed to have a familial tendency, obtaining a family history would provide the least amount of information.

  • Options A, B, and D: Stool inspection, pain pattern, and abdominal palpation would reveal possible indicators of intussusception. Current, jelly-like stools containing blood and mucus are an indication of intussusception. Acute, episodic abdominal pain is characteristics of intussusception. A sausage-shaped mass may be palpated in the right upper quadrant.

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