MCN 1
P2 REVIEWER
A newborn is submitted into a TORCH screening test, results show that the newborn tested positive for IgG. The
hospital reviews the mother’s file and uncovers the following details: She works as a butcher and has cats in their
household. after checking the file the nurses can conclude that the newborn is most endanger of?
Syphilis
Rubella
Toxoplasmosis
HIV
A mother in labor is positioned supine. She suddenly reports dizziness and nausea. What is the best nursing
intervention?
Encourage deep breathing
Increase IV fluids
Turn her to a left lateral position
Administer oxygen
What is a teratogen?
A medication prescribed during pregnancy
A type of prenatal vitamin
A substance that promotes fetal development
A substance that interferes with normal fetal development
A laboring woman has contractions lasting 90 seconds every 2 minutes. What is the nurse’s priority action?
Encourage ambulation to relieve pain
Discontinue oxytocin infusion if running
Continue monitoring the contraction pattern
Reassure the patient that this is normal
A patient in labor is experiencing intense perineal pressure and burning. What does this indicate?
The placenta is detaching
The baby is crowning
A need for an epidural
The cervix is fully effaced
Why is it important for the uterus to contract after placenta delivery?
To aid in fetal respiration
To increase maternal blood flow
To prevent postpartum hemorrhage
To speed up fetal descent
What is the primary goal of the fourth stage of labor?
Assess fetal viability
Deliver the placenta safely
Ensure complete cervical dilation
Monitor maternal recovery and prevent complications
Why is it important to assess contraction intensity?
To decide when to administer pain medications
To measure fundal height
To monitor labor progress and prevent complications
To determine fetal heart rate
A nurse is monitoring contractions and records the following: Contractions started at 12:00:00, 12:02:30, 12:05:00,
and 12:07:30. What is the contraction frequency?
Every 2 minutes
Every 3 minutes
Every 2.5 minutes
Every 5 minutes
During delivery, the fetal head rotates to align with the shoulders. What is this movement called?
Flexion
Engagement
Extension
Restitution
A woman in the second stage of labor experiences intense rectal pressure. What should the nurse do?
Offer ice chips
Administer IV fluids
Encourage her to push with contractions
Tell her to wait until complete dilation
A primigravida is in active labor with a well-flexed fetus at 0 station. What is the best nursing intervention?
Position the mother in lithotomy
Prepare for a cesarean section
Start oxytocin immediately
Encourage ambulation
A patient’s contractions are 3 minutes apart, lasting 90 seconds, and very intense. What is the priority nursing
action?
Assess fetal heart rate
Offer ice chips
Encourage deep breathing
Administer pain relief medication
A woman in the second stage of labor has been pushing for two hours with minimal progress. What is the best
nursing action?
Prepare for assisted delivery
Continue to encourage pushing
Increase oxytocin
Offer IV hydration
What is the role of the Ferguson reflex during labor?
Encourages maternal pushing efforts
Increases fetal movements
Stimulates uterine relaxation
Inhibits the pushing reflex
A nurse notes the following contraction pattern: Start - 1:00:00, Peak - 1:00:30, End - 1:01:00. What is the duration
of the contraction?
45 seconds
60 seconds
30 seconds
90 seconds
What is the primary function of the true pelvis during labor?
Supports the weight of the fetus
Protects the abdominal organs
Expands the uterine cavity
Provides a passageway for fetal descent
A laboring woman’s contractions are assessed by palpation. The uterus feels like a forehead during contraction.
What is the intensity?
Moderate
Strong
Ineffective
Mild
Why is the latent phase longer for primigravida women?
The fetus is larger
Uterine muscles are weaker
The cervix takes longer to efface and dilate
Labor hormones are lower
What is the ideal pelvic shape for childbirth?
Android
Gynecoid
Platypelloid
Anthropoid
Why is external rotation necessary for delivery?
It repositions the fetal head for proper alignment
It allows the fetal body to follow the head
It prevents shoulder dystocia
It decreases fetal stress
By the end of the first trimester (12 weeks), which fetal development milestone occurs?
Rapid weight gain
Brown fat deposit
Alveolar surfactant production
Formation of all major organs
A patient at 22 weeks gestation asks if her baby could survive if born now. What is the best response?
"No, because the baby’s lungs are not yet developed enough for breathing."
"It depends on your blood pressure and diet."
"Yes, your baby has a good chance of survival."
"Yes, but your baby will need minimal medical intervention."
Which statement correctly defines the duration of a contraction?
The time from the end of one contraction to the beginning of the next
The time from the start of a contraction to its end
The time from the beginning of one contraction to the beginning of the next
The time between the peak of two consecutive contractions
What marks the beginning of the second stage of labor?
The urge to push
Crowning of the fetal head
Full cervical dilation
Which event marks the end of the first stage of labor?
Expulsion of the placenta
Full cervical dilation
Onset of contractions
Rupture of membranes
Why do premature infants born before 28 weeks have difficulty maintaining body temperature?
Immature lungs
Lack of brown fat deposits
Increased fetal movement
Underdeveloped hypothalamus
What is the normal frequency of contractions during the active phase of labor?
Every 5–10 minutes
Every 2–3 minutes
Every 15–20 minutes
Every 10–15 minutes
What is the normal resting uterine tone between contractions?
25–30 mmHg
40–50 mmHg
10–20 mmHg
5–10 mmHg
What does it mean when contractions are occurring every 90 seconds?
The contractions are too frequent and may lead to fetal distress
The patient should begin pushing immediately
The contractions are normal for active labor
The patient is likely in the latent phase of labor
A baby is in the occiput posterior position during labor. What is a likely complication?
Cord prolapse
Prolonged labor with intense back pain
Rapid labor progression
Uterine rupture
A patient receiving oxytocin has contractions occurring every 2 minutes, lasting 80 seconds. Fetal heart rate shows
late decelerations. What is the priority nursing action?
Turn off oxytocin infusion and reposition the patient
Notify the provider after 30 minutes
Increase IV fluid rate
Encourage the patient to bear down
A laboring woman asks what "contraction interval" means. The nurse’s best response is:
"It’s the time from the start of one contraction to the end of the same contraction."
"It’s the time between the peak of two contractions."
"It’s the time from the end of one contraction to the start of the next."
"It’s the number of contractions within 10 minutes."
A laboring mother reports severe back pain. Which fetal position is most likely?
LOA
ROA
LSA
ROP
A laboring mother’s cervix is 100% effaced and 10 cm dilated. She is pushing ineffectively. What should the nurse
do first?
Encourage her to bear down with contractions
Change her position
Administer an epidural
Offer a warm compress
A nurse is assessing a patient in the fourth stage of labor. Which finding requires immediate intervention?
Maternal shivering
Vaginal bleeding of 700 mL
Fundus is firm and midline
Moderate perineal pain
A patient in active labor has contractions occurring every 4 minutes, lasting 60 seconds. What should the nurse
do?
Reassure the patient and continue monitoring
Notify the provider of abnormal labor progress
Encourage pushing with contractions
Discontinue oxytocin infusion
The nurse is documenting contractions for a patient in labor. The start times of contractions are recorded as
follows: 2:05:00, 2:07:45, 2:10:30, 2:13:15. What is the frequency of contractions?
Every 3 minutes
Every 2 minutes
Every 3.5 minutes
Every 2.5 minutes
A primigravida in labor is experiencing maternal exhaustion. The fetal heart rate is Category II. What is the best
intervention?
Discontinue IV fluids
Coach the mother on effective pushing
Offer an epidural
Prepare for an emergency cesarean section
A baby’s head is delivered, but the shoulders remain stuck. What should the nurse do first?
Increase IV fluids
Perform the McRoberts maneuver
Encourage pushing
Apply suprapubic pressure
How many stages of labor are there?
At what week of gestation does the fetal heart begin to beat?
4 weeks
6 weeks
8 weeks
12 weeks
Which fetal structure allows oxygenated blood to bypass the liver and go directly to the inferior vena cava?
Ductus arteriosus
Foramen ovale
Ductus venosus
Umbilical vein
Which assessment finding indicates a moderate contraction?
The uterus is firm and cannot be indented
The uterus feels like the tip of the nose
The uterus feels like the forehead
The uterus is rock hard and painful
Which method is most commonly used to assess contraction intensity?
Leopold’s maneuvers
Intrauterine pressure catheter (IUPC)
Maternal self-report
Fundal height measurement
What cardinal movement allows the smallest fetal head diameter to pass through the pelvis?
Flexion
Extension
Expulsion
Rotation
Which factor prolongs the second stage of labor?
Regular contractions
Maternal pushing efforts
Decreased maternal anxiety
Fetal malpresentation
What occurs during the expulsion phase?
The fetal head flexes to fit through the pelvis
The placenta detaches
The fetal shoulders and body are delivered
The fetus descends into the birth canal
Which cardinal movement occurs when the biparietal diameter of the fetal head reaches the pelvic inlet?
Internal rotation
Engagement
Descent
Extension
Which of the following theories of labor states that the onset of labor is due to the increasing estrogen-to-
progesterone ratio in the maternal bloodstream?
Prostaglandin theory
Oxytocin theory
Progesterone withdrawal theory
Uterine Stretch theory
P3
At what age should a toddler be expected to use two-word phrases?
12 months
24 months
36 months
18 months
When preparing a bottle of formula for an infant, what should the nurse advise the parents to do?
Prepare formula only when feeding the baby
Test the temperature by placing a drop on the inside of the wrist
Warm the formula in the microwave
Always use boiling water to mix the formula
A nurse is assessing a 6-month-old infant. The infant is able to sit with minimal support but cannot sit
independently. How should the nurse interpret this observation?
The infant should be able to sit unsupported by this age.
The infant needs early intervention for muscle weakness.
The infant has delayed gross motor development.
The infant’s motor development is progressing normally.
On the third postpartum day, Mrs. Jessa tells the nurse that she sometimes has difficulty getting her infant to suck.
She describes the infant opening her mouth when the breast touches her face but turning her head in the opposite
direction. The nurse would explain that this behavior is related to:
The extrusion reflex, normal for newborns, and demonstrates the need for much assistance to ensure adequate
nutrition.
The infant’s immaturity and unfamiliarity with the technique of feeding.
The rooting reflex, which suggests improper technique when placing the infant on the breast.
Turning neck reflex, which suggests that breastfed infants are most sensitive to tactile stimulation.
A nurse is conducting a hearing screening on a newborn. Which of the following findings would indicate a
potential hearing impairment?
The newborn responds to loud noises by startling
The newborn turns towards the direction of voices
The newborn does not respond to soft sounds
The newborn demonstrates a normal startle reflex
Which of the following cognitive milestones would the nurse expect in a typical 4-year-old preschooler?
Speaking in short sentences of two words
Understanding the concept of time (e.g., today, tomorrow)
Ability to count to 20
Ability to read simple words
A 6-month-old infant is being introduced to solid foods. Which food is most appropriate to start with?
Whole milk
Egg whites
Mashed fruits
Rice cereal
A parent expresses concern that their 2-year-old child frequently says "no" and refuses to comply with requests.
How should the nurse explain this behavior?
It indicates a behavior disorder
It is a sign of developmental delay
It is a normal part of asserting independence
It requires disciplinary action
Timmy’s parents are concerned that he might not be developing a strong sense of confidence and competence in
his schoolwork. They ask the nurse how they can help him succeed at this developmental stage. How should
parents help Timmy succeed in resolving Erikson’s Industry vs. Inferiority crisis?
Ignore his accomplishments to prevent arrogance.
Set strict rules for his performance.
Constantly compare his achievements with others.
Provide positive reinforcement to build his sense of competence.
A nurse is educating parents on the signs of teething in an infant. Which of the following is a common sign?
Increased drooling
High fever
Excessive sleep
Diarrhea
Nathan, an 8-year-old, is learning about healthy eating habits in school. His teacher uses visual aids to explain
which foods are nutritious and balanced. His mother asks why the teacher relies heavily on visual demonstrations.
Why is using visual aids effective when teaching school-age children about nutrition?
They are better at abstract thinking.
They can memorize complex concepts easily.
They have developed abstract reasoning skills.
They respond well to concrete examples
Sarah, a 10-year-old, enjoys playing board games and often challenges her friends to chess matches, where she
excels in strategizing. Which game type best supports Sarah’s development of ego mastery?
Pretend play with dolls
Watching TV
Handicraft activities
Quiet games like board games
During the assessment of a newborn, the nurse notes the presence of Mongolian spots on the lower back and
buttocks. What should the nurse explain to the parents?
"These marks indicate a serious skin condition and need immediate attention."
"These spots are a result of poor circulation and will disappear within a few days."
"They are caused by trauma during delivery and may require treatment."
"Mongolian spots are harmless and common in darker-skinned newborns."
A parent is concerned because their 12-month-old infant cannot walk unassisted. Which response would be most
appropriate?
"Most infants start walking between 12 and 15 months, so there is still time for this milestone."
"Walking usually begins between 9 and 10 months; we need to investigate this further."
"It's concerning that your child isn't walking yet. We should consult a neurologist."
"Your child should have started walking by 12 months; early intervention is recommended."
A pediatrician observes that a 10-month-old infant has not yet started crawling. What should the pediatrician do
to best evaluate if this is a cause for concern?
Prescribe physical therapy to aid motor development
Wait until the infant is 12 months before addressing it
Schedule an immediate neurological exam
Compare the infant's progress with standard developmental milestones
Kevin, a 9-year-old, has been struggling in school and often feels like he is not good enough. His parents notice that
he is becoming more withdrawn and less enthusiastic about learning. What is the impact of a sense of inferiority
in a school-age child?
Difficulty making friends
Difficulty learning and working
Aggression and defiance
Increased dependence on parents
A 2-year-old toddler is brought to the clinic for a checkup. Which developmental milestone should the nurse
expect the toddler to have achieved?
Tying shoelaces
Riding a tricycle
Speaking in full sentences
Walking without assistance
A nurse is assessing a 2-year-old during a well-child visit. The mother is concerned that her child still uses a bottle
and shows little interest in self-feeding. Which action should the nurse take next?
Assess the child’s ability to grasp and manipulate utensils
Provide reassurance that this is normal at 2 years
Encourage the mother to wean the child off the bottle
Suggest limiting food choices to encourage self-feeding
A 4-year-old child presents with the ability to hop on one foot, draw a person with four parts, and use sentences of
six words. However, the child struggles with sharing and throws tantrums when asked to take turns. Based on
these findings, how would the nurse interpret the child’s development?
The child has advanced gross motor skills but social developmental delay
The child has a delay in fine motor skills
The child is developmentally delayed in all areas
The child has typical gross motor and language skills but may require intervention for social behavior
Seven-year-old John is showing a strong preference for using his right hand while writing and drawing. His parents
are wondering if this is normal for his age. At what age does handedness become established?
6 years old
7 years old
4 years old
5 years old
The nurse is conducting a skin assessment on a newborn and observes erythema toxicum on the chest and back.
Which statement by the nurse is most appropriate when explaining this finding to the parents?
"This is a normal newborn rash that will go away without treatment."
"This rash could be a sign of an infection and requires further testing."
"We will need to apply medicated ointment to reduce the rash."
"Your baby may be experiencing an allergic reaction to the environment."
The nurse observes that when the newborn is startled by a loud noise, they extend their arms and legs and then
quickly bring them back to their body. Which reflex is being exhibited?
Moro reflex
Rooting reflex
Tonic neck reflex
Grasp reflex
After watching news about violence and disasters, Alex, a 10-year-old, shows signs of anxiety and fear. His parents
are concerned about how much media exposure is appropriate for him. Why should parents monitor their school-
age child’s exposure to media violence?
It can cause stress and fear in children.
It might reduce their academic performance.
It can lead to rebellious behavior.
Children might start mimicking violent behaviors.
When the nurse strokes the sole of the newborn's foot, the toes fan out and the big toe extends upward. Which
reflex does this demonstrate?
Moro reflex
Grasp reflex
Babinski reflex
Plantar reflex
A parent is concerned because their toddler is not yet speaking in two-word phrases. What should the nurse
advise?
Refer to a speech therapist
Monitor closely for other delays
Reassure that this is a normal variation
Start language development activities
A parent of a 3-year-old preschooler expresses concern about their child's temper tantrums. How should the nurse
respond?
"The child should be punished whenever a tantrum occurs."
"Tantrums are unusual at this age and require medical evaluation."
"You should give in to the child's demands to prevent tantrums."
Temper tantrums are common in toddlers and preschoolers as they learn to cope with frustration."
When do infants typically begin to show a social smile?
2 months
4 months
8 months
6 months
By what age can most infants say their first words (like "mama" or "dada") with meaning?
9 months
6 months
12 months
18 months
When the nurse strokes the sole of the newborn's foot, the toes fan out and the big toe extends upward. Which
reflex does this demonstrate?
Moro reflex
Babinski reflex
Plantar reflex
Grasp reflex
When assessing a newborn’s respiratory rate, the nurse should primarily observe the:
Diaphragm
Abdomen
Mouth
Nostrils
Joey, a 7-year-old boy, recently started organizing his toy cars by size and color. His parents notice that he’s able to
think logically when solving simple problems. At which cognitive development stage is Joey, according to Piaget?
Sensorimotor
Concrete operations
Preoperational
Formal operations
During the first physical examination, the nurse observes that the newborn has a cephalohematoma. What is the
most appropriate nursing action?
Notify the physician for immediate intervention
Encourage the parents to massage the area
Apply ice packs to reduce swelling
Document the finding and continue to monitor
The following are methods to prevent cold stress in a newborn, except:
Dry and wrap the baby
Place the baby near the wall
Place them under a radiant heat source
Skin-to-skin contact
Tim, an 8-year-old boy, enjoys working on puzzles and helping his father fix things around the house. His parents
are curious about the developmental stage he is in, especially in terms of psychosocial development. According to
Erikson, what psychosocial stage is Tim undergoing?
Identity vs. Role Confusion
Autonomy vs. Shame and Doubt
Trust vs. Mistrust
Industry vs. Inferiority
A nurse is teaching a new mother about the importance of breastfeeding. Which statement made by the mother
demonstrates understanding of the benefits of breastfeeding?
"Breastfeeding is mainly for bonding with my baby."
"Breastfeeding will prevent my baby from getting sick."
"I can replace breastfeeding with formula after a few weeks."
"Breast milk provides the best nutrition and immunity for my baby."
A parent asks about the expected physical growth of their 2-year-old toddler. Which of the following statements is
correct regarding weight gain during this stage?
Toddlers experience a growth spurt during this period
Toddlers double their birth weight by age 2
Toddlers gain about 4-6 lbs. per year
Toddlers grow at the same rate as infants
Maria, a 10-year-old girl, has started experiencing physical changes associated with puberty, such as breast
development and increased height. Her mother is concerned that Maria might be starting puberty earlier than
expected. What is the normal age for puberty in girls?
12 years old
10 years old
8 years old
9 years old
At what age does the growth rate generally slow down after infancy?
3 years
1 year
5 years
2 years
Lily, a 9-year-old, recently lost her pet dog. She expresses great sadness and talks about how death means she’ll
never see her dog again. Her parents are concerned about how she views death. Which fear is most prominent in
school-age children?
Fear of image alteration
Fear of separation from parents
Fear of strangers
Fear of death
During a health visit, a parent is worried that their 3-year-old is not yet able to recite the alphabet. What is the
nurse's best response regarding language development?
The child is showing signs of cognitive impairment
Most children can recite the alphabet by age 3
Many children develop language skills at different rates
The child should be evaluated for a speech delay
The nurse is educating a parent about safety for their toddler. Which statement by the parent requires further
teaching?
"We use a rear-facing car seat for our child."
"I always supervise my child around water."
"Our toddler knows not to touch electrical outlets."
"We have locked all medications in a cabinet."
A 10-year-old exhibits both physical and emotional growth. What principle does this reflect?
Development is holistic.
Growth is only physical.
Development is only emotional.
Growth is unidirectional.
Which of the following gross motor skills is typically achieved by 9 months of age?
Walking without support
Standing on one foot
Running
Pulling to stand
The nurse is educating a mother about diaper rash prevention. Which of the following is an appropriate
recommendation?
Use cloth diapers exclusively
Apply a thick layer of baby powder at each change
Cleanse the area with baby wipes containing alcohol
Change diapers frequently and allow the skin to air dry
Michael, a 7-year-old boy, often talks about how much he admires his teacher and how important his classmates
are to him. His parents are surprised by how significant these figures have become in his life. Who is the most
significant person to a school-age child?
Parents
Community leaders
Teachers and classmates
Older siblings
During the assessment of a newborn, the nurse observes the presence of vernix caseosa and lanugo on the infant's
skin. What is the significance of these findings?
They suggest the infant is overdue and needs immediate intervention.
They indicate an increased risk of skin infections.
They are normal findings that provide protection and warmth.
They are signs of dehydration and require further assessment.
At what age do most children typically begin to exhibit skills such as hopping on one foot and catching a ball?
4 years
3 years
5 years
2 years
The parent of a 2-year-old is concerned about toilet training. What advice should the nurse provide to assist in
toilet training?
"Begin toilet training only after the child is able to stay dry for at least two hours."
"Force the child to sit on the toilet for 10 minutes after every meal."
"Delay toilet training until the child is in preschool."
"Start toilet training as soon as the child can walk."
A parent asks the nurse how to manage their 2-year-old’s newfound independence, which often leads to power
struggles. What would be the most effective suggestion?
Give the toddler limited choices to foster autonomy
Enforce strict rules with no flexibility
Let the child make all decisions to avoid conflicts
Avoid giving the child any choices to prevent power struggles
While assessing a 2-hour-old neonate, the nurse observes the neonate to have acrocyanosis. Which of the
following nursing actions should be performed initially?
Activate the blue code or emergency system
Immediately take the neonate’s temperature according to hospital policy
Notify the physician of the need for a cardiac consult
Do nothing because acrocyanosis is normal in the neonate
