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Question 1 of 5

A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation?

Correct Answer: B

Rationale: Normal infant attachment behaviors include responding to touch and wanting to be held. Maternal deprivation behaviors include poor feeding, stiffening and refusal to eat, and inconsistencies in responsiveness. Attachment behavior includes maintaining eye contact. Maternal deprivation behaviors include displeasure with touch and physical contact.

Question 2 of 5

The client is admitted with a diagnosis of molar pregnancy. Which laboratory test is most likely to be ordered?

Correct Answer: A

Rationale: Serum hCG levels are markedly elevated in molar pregnancy and are the primary test for diagnosis and monitoring. CBC and urinalysis may be ordered for general assessment but are less specific.

Question 3 of 5

Which stage of labor lasts from delivery of the baby to delivery of the placenta?

Correct Answer: B

Rationale: This stage is from complete dilatation of the cervix to delivery of the fetus. This is the correct stage for the definition. This stage lasts for about 2 hours after the delivery of the placenta. There is no fifth stage of labor.

Question 4 of 5

A client with a T6 injury six months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?

Correct Answer: B

Rationale: Facial flushing and severe hypertension suggest autonomic dysreflexia, often triggered by a distended bladder in spinal cord injury. Assessing and relieving the trigger (
B) is priority. Notifying the physician (
A), oxygen (
C), or fluids (
D) is secondary.

Question 5 of 5

The nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which finding indicates magnesium toxicity?

Correct Answer: A

Rationale: A respiratory rate of 10 breaths per minute suggests magnesium toxicity as magnesium sulfate depresses the central nervous system including respiratory drive. Normal reflexes adequate urine output and BP of 140/90 do not indicate toxicity.

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