NP2 – Nursing Practice 2(Comprehensive

Situational Exam)
• 1–50 = Maternal Nursing (Normal & Abnormal)
• 50–100 = Pediatric Nursing – Normal & Abnormal Development

NP2 – SET 1 (Items 1–50)

Maternal Nursing (Normal & Abnormal)

1.

A 29-year-old primigravida at 37 weeks gestation is brought to the emergency unit with

complaints of severe headache, blurred vision, and epigastric pain. Her blood pressure is
180/110 mmHg, and the nurse observes hyperreflexia with clonus. The physician orders
the administration of magnesium sulfate to prevent further complications. As the nurse
prepares the medication, she recalls that toxicity may present as loss of patellar reflex and
decreased urine output. What is the priority medication the nurse must keep at the
bedside as an antidote to magnesium toxicity?
A. Sodium bicarbonate
B. Calcium gluconate
C. Potassium chloride
D. Epinephrine

2.

A multiparous woman at 39 weeks is in active labor. During delivery, the nurse notes that
the baby’s head has been delivered but the shoulders are not following despite gentle
traction. The obstetrician identifies this as shoulder dystocia. The nurse immediately
assists by flexing the mother’s thighs sharply onto her abdomen to widen the pelvic outlet.
Which maneuver is this?
A. Ritgen’s maneuver
B. McRoberts’ maneuver
C. Leopold’s maneuver
D. Crede’s maneuver

3.

A 27-year-old pregnant woman asks the nurse why she has been feeling easily fatigued
even though her hemoglobin levels are slightly lower than normal. The nurse explains that
during pregnancy, plasma volume increases more than red blood cell mass, resulting in a
hemodilution effect. This condition is physiologic and expected as part of pregnancy
adaptation. Which finding supports this explanation?
A. Decreased plasma volume by 30–50%
B. Increased plasma volume by 30–50%
C. Decreased RBC production
D. Increased blood viscosity

4.

A full-term newborn is 20 hours old and appears slightly yellowish. The nurse explains to
the parents that this is common and typically appears within 24 hours after birth. The
cause is related to the immaturity of the liver’s ability to conjugate bilirubin effectively.
What type of jaundice is this called?
A. Pathologic jaundice
B. Physiologic jaundice
C. Hemolytic jaundice
D. Breast milk jaundice

5.

A nurse is caring for a 2-day-old newborn undergoing phototherapy for jaundice. The nurse
ensures that the baby’s eyes are covered and that frequent repositioning is done to expose
different skin areas. The mother asks why the baby is under blue light. Which explanation
by the nurse is correct?
A. It increases bile production to reduce bilirubin
B. It converts bilirubin into a water-soluble form for excretion
C. It promotes red blood cell destruction to lower bilirubin
D. It stimulates liver enzyme activity directly

6.

During a vaginal examination, the nurse observes that the amniotic sac is still intact, and
the physician decides to perform an amniotomy. Shortly after, the nurse notes a variable
deceleration pattern on the fetal heart rate monitor. Which nursing action should be
prioritized?
A. Notify the physician immediately
B. Turn the mother to the left lateral position
C. Apply oxygen via nasal cannula
D. Document and continue to monitor

7.

A nurse teaches a pregnant woman at 32 weeks gestation how to monitor fetal movements
at home. The nurse explains that the mother should feel at least 10 movements within 2
hours during a quiet, resting period. The woman reports she only felt 4 movements in 2
hours. What is the nurse’s best response?
A. “That’s normal, try again tomorrow.”
B. “Eat a meal and try counting again in an hour.”
C. “You should go to the hospital immediately for assessment.”
D. “Drink water and lie on your left side to improve circulation.”

8.

A 28-year-old woman at 28 weeks gestation receives Rho(D) immune globulin. The nurse
understands this is to prevent maternal sensitization in Rh-negative mothers carrying an
Rh-positive fetus. When should this injection be administered again if the mother delivers
an Rh-positive infant?
A. Immediately after birth
B. Within 72 hours postpartum
C. Only during subsequent pregnancies
D. At 36 weeks gestation

9.

A nurse cares for a postpartum mother who experienced a third-degree perineal laceration
during delivery. The patient reports pain during defecation and expresses fear of straining.
The physician prescribes docusate sodium. What is the main purpose of this medication in
this context?
A. To decrease perineal inflammation
B. To promote uterine contraction
C. To soften stools and prevent straining
D. To reduce perineal pain

10.

A nurse observes on the fetal monitor that there are abrupt decreases in fetal heart rate
with each contraction, varying in duration and timing. The nurse recognizes this as a sign of
umbilical cord compression. Which deceleration pattern is being observed?
A. Early deceleration
B. Late deceleration
C. Variable deceleration
D. Prolonged deceleration

11.

While caring for a laboring mother receiving oxytocin, the nurse notes late decelerations on
the fetal heart rate monitor. The contractions are strong and occurring every 2 minutes.
Which action should the nurse take first?
A. Stop the oxytocin infusion
B. Increase IV fluids
C. Reposition the client
D. Apply oxygen at 10 L/min

12.

A 32-year-old woman, 1 hour postpartum, has a boggy uterus and heavy vaginal bleeding.
The nurse massages the uterus but it remains soft. The fundus is displaced to the right.
What is the nurse’s priority action?
A. Call the physician for uterotonic medication
B. Assess for retained placenta
C. Assist the patient to void
D. Continue fundal massage

13.

A postpartum mother is being monitored for hemorrhage. She delivered twins 3 hours ago
and has received oxytocin. Her uterus is firm and at the level of the umbilicus, but lochia is
excessive. The nurse suspects retained placental fragments. Which diagnostic test best
confirms this condition?
A. Pelvic ultrasound
B. CBC
C. Hysteroscopy
D. Bimanual examination

14.

A nurse is caring for a mother who is one hour post normal spontaneous delivery. Her
blood pressure is 80/50 mmHg, pulse 120 bpm, and the uterus is soft and boggy despite
massage. The lochia is bright red and saturates pads rapidly. Which etiology is most likely?
A. Uterine atony
B. Cervical laceration
C. Retained placenta
D. DIC

15.

A newborn is being assessed immediately after birth. The nurse notes a heart rate of 130
bpm, vigorous cry, active movement, and pink body with slightly bluish extremities. Which
Apgar score should the nurse assign?
A. 8
B. 9
C. 10
D. 7

16.

A 15-month-old child begins asserting independence by saying “no” frequently and

insisting on self-feeding. The nurse recognizes this as part of Erikson’s psychosocial stage
where the child strives for autonomy but risks developing shame and doubt if overly
controlled. What stage is this?
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Initiative vs. Guilt
D. Industry vs. Inferiority

17.

During a pediatric assessment, the nurse observes a 3-year-old playing beside another
child using similar toys but not directly interacting with them. This type of play is typical for
a toddler’s developmental stage. What is this called?
A. Cooperative play
B. Parallel play
C. Associative play
D. Solitary play
18.

The nurse is plotting a laboring mother’s progress on a partograph. She notes cervical
dilatation progressing from 4 cm to 6 cm within 2 hours, and contractions are becoming
stronger and more regular. In which phase of labor is this plotting appropriate?
A. Latent phase
B. Active phase
C. Transitional phase
D. Second stage

19.

A 4-year-old child tells the nurse that his toy car can talk and that he has a superhero friend
who protects him from bad dreams. The nurse identifies this as a normal part of cognitive
development in the preschool period. What is this phenomenon called?
A. Egocentrism
B. Conservation
C. Magical thinking
D. Animism

20.

A nurse observes a newborn being startled by a sudden loud noise, extending the arms and
legs outward and then bringing them back in. This reflex is a sign of a healthy neurologic
response and typically disappears by 4 months of age. What reflex is this?
A. Rooting reflex
B. Moro reflex
C. Babinski reflex
D. Palmar grasp reflex
21.

A nurse is assessing a 6-year-old child’s understanding of right and wrong. The child
states, “If I get caught, it’s bad,” reflecting moral reasoning based on consequences rather
than internal principles. According to Kohlberg’s stages, which level of moral development
is this?
A. Conventional morality
B. Preconventional morality
C. Postconventional morality
D. Autonomous morality

22.

During discharge teaching, the nurse educates a mother on signs of postpartum

complications. The mother asks, “How will I know if I’m bleeding too much?” Which
statement indicates understanding?
A. “If I soak one pad every four hours.”
B. “If I pass a few small clots.”
C. “If I soak one pad in 15 minutes.”
D. “If I see pink discharge for a few days.”

23.

A nurse assesses a mother who delivered 3 hours ago. Her uterus is firm and midline,
lochia rubra is moderate, and vital signs are stable. The nurse notes no signs of dizziness
or pallor. What should the nurse do next?
A. Continue routine monitoring
B. Increase oxytocin rate
C. Call the physician
D. Massage the fundus vigorously
24.

A 1-day-old infant is under phototherapy. The nurse reminds the mother to increase
feeding frequency to promote bilirubin excretion. The mother asks how she will know if the
therapy is effective. What is the best nursing response?
A. “Your baby’s skin will turn pale immediately.”
B. “Your baby will pass more greenish stools.”
C. “The baby will sleep more often.”
D. “The baby’s appetite will increase.”

25.

A nurse is caring for a newborn of an Rh-negative mother who did not receive RhoGAM after
her first pregnancy. The infant now exhibits jaundice and hepatosplenomegaly within 6
hours of birth. Laboratory tests show a positive direct Coombs test. What is the nurse’s
best understanding of this finding?
A. It indicates ABO incompatibility.
B. It reflects physiologic jaundice.
C. It confirms Rh incompatibility causing hemolysis.
D. It suggests a biliary obstruction.

26.

A nurse is assessing a woman 1 hour after a cesarean section. The fundus is firm at the
level of the umbilicus, but the patient’s dressing is soaked with blood, and she reports
feeling dizzy. Her vital signs are BP 88/56 mmHg and HR 124 bpm. The nurse suspects
internal bleeding. Which is the priority initial nursing action?
A. Apply an abdominal binder
B. Notify the surgeon immediately
C. Increase the IV fluid rate and administer oxygen
D. Massage the fundus continuously
27.

A patient diagnosed with preeclampsia is receiving magnesium sulfate infusion. The nurse
observes the respiratory rate has dropped to 10 breaths per minute and deep tendon
reflexes are absent. Urine output is only 20 mL/hour. What should the nurse do first?
A. Continue monitoring for 30 minutes
B. Administer calcium gluconate as ordered
C. Discontinue the magnesium sulfate infusion
D. Call the physician while continuing infusion

28.

A 38-week gestation client experiences spontaneous rupture of membranes. The nurse

notes clear fluid and a fetal heart rate of 110 bpm that suddenly drops to 80 bpm. The
patient is experiencing variable decelerations. Which is the nurse’s best immediate
action?
A. Position the client in knee-chest position
B. Administer IV fluids rapidly
C. Prepare for immediate cesarean delivery
D. Notify the obstetrician after documentation

29.

During labor, a woman suddenly complains of chest pain, dyspnea, and anxiety. The nurse
notes cyanosis and a drop in oxygen saturation to 78%. The uterus is firm and there is no
vaginal bleeding. The nurse suspects amniotic fluid embolism. What is the nurse’s
priority action?
A. Administer oxygen at 10 L/min via mask
B. Start CPR immediately
C. Position the woman in Trendelenburg
D. Prepare for emergency cesarean section
30.

A 24-year-old primigravida delivers vaginally. Two hours later, the nurse notes the fundus is
firm but located above the umbilicus and deviated to the right side. The mother reports
mild suprapubic discomfort. What is the most appropriate nursing action?
A. Encourage ambulation
B. Administer oxytocin
C. Assist the client to void
D. Massage the fundus

31.

A postpartum client who delivered twins 6 hours ago reports feeling weak. Her uterus is
firm and midline, but she continues to have excessive lochia. The nurse suspects retained
placental fragments. Which assessment finding supports this condition?
A. Foul-smelling lochia
B. Boggy uterus
C. Prolonged bleeding despite firm uterus
D. Severe perineal pain

32.

A woman in labor is experiencing late decelerations on the fetal heart monitor. The nurse
stops oxytocin infusion and repositions the client to her left side. Despite these
interventions, decelerations persist. What should the nurse do next?
A. Increase the IV fluid rate
B. Document findings
C. Notify the healthcare provider
D. Prepare for possible cesarean birth
33.

A 28-year-old primigravida at 32 weeks reports that her baby has not been moving as
frequently as before. She has already eaten and rested but still perceives fewer than 5
movements in 2 hours. What is the nurse’s best instruction?
A. “It’s likely just the baby’s sleep pattern.”
B. “Come to the hospital for a non-stress test.”
C. “Drink caffeine and try again in an hour.”
D. “Monitor again tomorrow and compare results.”

34.

The nurse is preparing to administer Rho(D) immune globulin to an Rh-negative mother

after delivering an Rh-positive infant. The mother asks, “Why do I need this shot?” Which is
the best explanation by the nurse?
A. “It will protect your baby from infection.”
B. “It will help you produce antibodies for future protection.”
C. “It prevents your body from making antibodies against your baby’s blood.”
D. “It increases your immunity after delivery.”

35.

A mother who delivered 2 days ago reports that her nipples are cracked and painful during
breastfeeding. The nurse observes improper latch-on technique. What should the nurse
emphasize to prevent further nipple trauma?
A. Use breast shells after feeding
B. Ensure the baby’s mouth covers the areola, not just the nipple
C. Apply soap and water before each feeding
D. Avoid feeding on the affected breast
36.

A 33-year-old multiparous woman at 39 weeks gestation has a fundal height lower than
expected. Ultrasound reveals oligohydramnios. The nurse knows this finding increases the
risk for which complication during labor?
A. Cord compression
B. Shoulder dystocia
C. Uterine rupture
D. Placenta previa

37.

During a prenatal visit, a 30-year-old woman asks why her blood count appears lower even
though she feels healthy. The nurse explains this is due to increased plasma volume that
causes a dilutional effect on red blood cells. What is this physiologic condition called?
A. Iron-deficiency anemia
B. Physiologic anemia of pregnancy
C. Aplastic anemia
D. Megaloblastic anemia

38.

A postpartum nurse notes that a woman’s uterus is firm, but she continues to have
moderate bleeding. The perineum is intact, and no clots are observed. The nurse suspects
a vaginal hematoma. Which assessment finding supports this suspicion?
A. Constant perineal pain or pressure
B. Increased uterine tenderness
C. Decreased blood pressure with pallor
D. Offensive odor in lochia
39.

A 25-year-old woman who delivered 4 hours ago develops chills and a temperature of
38.2°C. Her fundus is firm, lochia is moderate, and there is no foul odor. The nurse explains
that this temperature elevation may be due to which physiologic cause?
A. Uterine infection
B. Milk production and dehydration
C. Blood loss
D. Retained placental fragments

40.

A 5-year-old child proudly completes a drawing and shows it to the nurse, seeking praise.
The nurse recognizes this as a demonstration of Erikson’s developmental stage focusing
on mastery and competence. Which stage is this?
A. Initiative vs. Guilt
B. Industry vs. Inferiority
C. Autonomy vs. Shame and Doubt
D. Identity vs. Role Confusion

41.

A 3-year-old child is seen in the clinic and the nurse observes that he enjoys make-believe
play, pretending to be a doctor while using toy instruments. This play type fosters creativity
and social learning typical of his age group. What is this type of play called?
A. Parallel play
B. Solitary play
C. Associative play
D. Cooperative play
42.

A nurse is plotting the progress of a laboring mother who has been in active labor for 4
hours. Cervical dilatation progressed from 4 cm to 7 cm, and contractions are now every 3
minutes lasting 50 seconds. On the partograph, this phase reflects what part of labor?
A. Latent phase
B. Active phase
C. Transition phase
D. Second stage

43.

A 4-year-old child hospitalized for tonsillectomy asks the nurse, “Will it hurt when I wake
up?” The nurse responds truthfully but in a reassuring manner, emphasizing comfort
measures and support. This reflects which moral developmental stage according to
Kohlberg?
A. Preconventional
B. Conventional
C. Postconventional
D. Autonomous

44.

A 2-year-old child refuses to share toys and frequently says “mine.” The mother is
concerned about selfishness. The nurse explains this is normal for the age because the
child is learning to assert independence and control. This aligns with which Eriksonian
stage?
A. Trust vs. Mistrust
B. Autonomy vs. Shame and Doubt
C. Initiative vs. Guilt
D. Industry vs. Inferiority
45.

A nurse assesses a 6-month-old infant during a well-baby visit. The nurse elicits the Moro
reflex and expects it to be present. At what age should the nurse expect this reflex to
disappear?
A. 2 months
B. 4 months
C. 6 months
D. 9 months

46.

A nurse is assessing the moral reasoning of a 10-year-old who says, “Stealing is wrong
because you can get punished.” The nurse interprets this as belonging to which stage of
moral development?
A. Conventional stage
B. Preconventional stage
C. Postconventional stage
D. Autonomous stage

47.

A nurse is caring for a neonate born to an Rh-negative mother who did not receive
RhoGAM. The infant presents with severe jaundice, hepatomegaly, and anemia. This
condition results from maternal antibodies destroying fetal RBCs. What term describes
this pathophysiologic process?
A. Kernicterus
B. Erythroblastosis fetalis
C. Neonatal sepsis
D. Biliary atresia
48.

A nurse observes that a newborn’s body is pink, with bluish hands and feet, strong cry,
heart rate of 120 bpm, and active flexion. What Apgar score should be recorded?
A. 8
B. 9
C. 10
D. 7

49.

A nurse notes that a postpartum mother’s uterus is firm and midline but there is steady
trickling of bright red blood. What should the nurse suspect?
A. Uterine atony
B. Cervical laceration
C. Retained placenta
D. Normal lochia

50.

A 2-year-old child hospitalized for pneumonia starts showing interest in stacking blocks
and imitating other children’s actions nearby, but not directly playing with them. The nurse
identifies this as what type of play?
A. Parallel play
B. Cooperative play
C. Solitary play
D. Associative play

NP2 – (Items 51–100)

Pediatric Nursing – Normal & Abnormal Development
51.

A 3-day-old term newborn is admitted with increasing jaundice, poor feeding, and lethargy.
The nurse notes scleral icterus and yellowing up to the abdomen. Laboratory studies reveal
an indirect bilirubin level of 18 mg/dL. The infant is placed under phototherapy. Which
action by the nurse ensures safe and effective treatment?
A. Turn off the lights during feeding time to conserve energy
B. Cover the eyes and genitalia, monitor temperature frequently, and encourage feeding
C. Keep the infant wrapped to maintain warmth under the lights
D. Decrease feeding frequency to prevent overstimulation

52.

A 36-hour-old newborn develops jaundice. The mother asks, “Is this dangerous?” The
nurse explains that bilirubin is slightly elevated due to immature liver conjugation, which is
common after 24 hours of birth. However, if jaundice appears within the first 24 hours, it
may indicate pathology. What is the nurse’s correct explanation?
A. This is physiologic jaundice, a normal finding after 24 hours
B. This is pathologic jaundice, which always occurs after 48 hours
C. This is due to breastfeeding and should be ignored
D. This is an infection-related jaundice

53.

A 6-hour-old newborn of an Rh-negative mother shows severe jaundice and pallor. The
infant’s blood type is B Rh-positive. Laboratory results show anemia and a positive direct
Coombs test. The nurse recognizes this as:
A. ABO incompatibility
B. Physiologic jaundice
C. Rh isoimmunization
D. Breast milk jaundice
54.

The nurse is caring for a newborn under double phototherapy for hyperbilirubinemia. The
mother asks, “Why is my baby under so many lights?” What is the most accurate nursing
response?
A. “The lights will destroy the excess red blood cells.”
B. “It helps convert bilirubin into a water-soluble form that can be excreted.”
C. “It strengthens your baby’s immune system.”
D. “It helps increase your baby’s red blood cell count.”

55.

A 1-day-old infant under phototherapy has loose, greenish stools and mild skin rash. The
mother is anxious and believes the baby is reacting badly to the treatment. Which is the
nurse’s best response?
A. “These are normal side effects of phototherapy.”
B. “We will discontinue the lights immediately.”
C. “This indicates your baby’s jaundice is worsening.”
D. “The rash means your baby is allergic to the lights.”

56.

A mother expresses concern because her 3-day-old newborn is sleeping more and eating
less since phototherapy started. The nurse notes normal temperature and improving
bilirubin levels. What should the nurse teach the mother?
A. “Sleepiness is a common temporary effect of phototherapy.”
B. “Your baby is becoming dehydrated.”
C. “Stop breastfeeding for 12 hours.”
D. “Turn off the lights whenever the baby sleeps.”
57.

A nurse is monitoring a laboring mother whose membranes were artificially ruptured.

Shortly after, the fetal heart rate shows variable decelerations with contractions. The nurse
knows this indicates:
A. Cord compression
B. Placental insufficiency
C. Maternal hypotension
D. Head compression

58.

A nurse assists a physician performing an amniotomy on a woman in labor. After the

procedure, the nurse observes a clear fluid and notes a fetal heart rate deceleration from
140 to 100 bpm. What is the nurse’s priority assessment?
A. Maternal vital signs
B. Cord prolapse
C. Presence of meconium-stained fluid
D. Uterine tone

59.

A postpartum woman complains of dizziness and blurred vision. She delivered 6 hours ago,
and the nurse notes pallor and a rapid pulse of 120 bpm. The uterus is firm and midline,
with scant lochia. The nurse suspects internal bleeding caused by:
A. Uterine rupture
B. Vaginal hematoma
C. Cervical tear
D. Retained placenta
60.

A postpartum patient develops a temperature of 38.5°C, foul-smelling lochia, and uterine

tenderness on the third day after delivery. Which nursing action takes priority?
A. Encourage ambulation
B. Notify the physician
C. Continue perineal care
D. Provide antipyretic medication

61.

A nurse is performing discharge teaching for a postpartum woman about perineal hygiene.
Which instruction is most appropriate to prevent infection?
A. “Always wipe from back to front.”
B. “Use perineal spray after every void.”
C. “Avoid washing for 3 days to promote healing.”
D. “Apply ice packs until lochia turns white.”

62.

A 32-week pregnant woman reports vaginal bleeding without pain. The fetal heart tones are
strong, and uterine contractions are absent. The nurse immediately suspects placenta
previa. Which nursing intervention is most appropriate?
A. Perform a sterile vaginal examination
B. Place the woman on bed rest and monitor fetal heart rate
C. Insert a rectal thermometer
D. Administer oxytocin infusion

63.

A 28-week pregnant woman complains of back pain and mild contractions occurring every
15 minutes. Cervical exam reveals 1 cm dilation. The nurse suspects preterm labor. What
intervention should be implemented first?
A. Start an oxytocin drip
B. Encourage the client to walk
C. Administer tocolytic medication as ordered
D. Begin pushing techniques

64.

A 35-year-old multiparous woman delivers a 4.5 kg infant after prolonged labor. Shortly
after birth, she develops profuse vaginal bleeding. The uterus is boggy despite massage
and oxytocin administration. What is the most likely cause?
A. Uterine atony
B. Retained placenta
C. Vaginal laceration
D. DIC

65.

A 1-hour-old newborn of a diabetic mother is noted to have tremors, irritability, and a blood
glucose of 35 mg/dL. The nurse recognizes this as:
A. Neonatal hypocalcemia
B. Neonatal hypoglycemia
C. Neonatal infection
D. Physiologic tremor

66.

A nurse is assessing a newborn delivered to a mother with Rh incompatibility. The baby

shows signs of anemia, edema, and jaundice. What nursing diagnosis is most
appropriate?
A. Risk for impaired gas exchange related to decreased hemoglobin
B. Risk for infection related to maternal antibodies
C. Risk for injury related to hypocalcemia
D. Risk for thermoregulation imbalance
67.

A nurse observes a 2-year-old repeatedly saying “No!” while attempting to put on his shoes
independently. The mother seems frustrated. The nurse explains that this is a healthy sign
of autonomy development. What is the nurse’s best teaching point?
A. Allow the child simple choices to foster independence
B. Force cooperation through time-outs
C. Ignore the child’s refusal to encourage compliance
D. Avoid giving the child any decision-making opportunities

68.

A 5-year-old child hospitalized for appendectomy says, “I’m being punished because I was
bad.” The nurse identifies this as which type of cognitive distortion typical in preschoolers?
A. Animism
B. Egocentrism
C. Magical thinking
D. Concrete reasoning

69.

A 3-year-old child hospitalized for pneumonia plays by imitating the nurse’s actions, such
as checking a doll’s temperature and listening with a toy stethoscope. What is this type of
play called?
A. Solitary play
B. Parallel play
C. Imitative play
D. Associative play
70.

A 7-year-old child is praised for successfully completing a chore at home. The nurse
explains to the parents that recognition and praise help reinforce a sense of competence.
This aligns with which Erikson stage?
A. Initiative vs. Guilt
B. Industry vs. Inferiority
C. Identity vs. Role Confusion
D. Autonomy vs. Shame and Doubt

71.

During a school health teaching session, the nurse observes that 6-year-old children enjoy
teamwork and following rules during games. This behavior indicates development of which
concept?
A. Initiative
B. Industry
C. Trust
D. Autonomy

72.

A 4-year-old hospitalized for tonsillectomy is afraid to sleep, believing “monsters will hurt
me.” The nurse recognizes this as a common characteristic of which developmental
stage?
A. Toddler
B. Preschool
C. School age
D. Adolescent
73.

A 9-year-old expresses concern about being shorter than classmates. The nurse reassures
the child that physical changes vary among individuals. The nurse understands that body
image concerns start to emerge during which developmental stage?
A. Toddler
B. Preschool
C. School age
D. Adolescence

74.

A 10-year-old who steals a classmate’s toy says, “I’ll get in trouble if the teacher finds out.”
The nurse recognizes this reasoning as belonging to which of Kohlberg’s moral
development stages?
A. Preconventional
B. Conventional
C. Postconventional
D. Autonomous

75.

A nurse caring for a 12-year-old with diabetes encourages the child to participate in self-
care and insulin administration. The child demonstrates understanding of the disease and
the consequences of missed doses. This reflects which cognitive development stage
according to Piaget?
A. Preoperational
B. Concrete operational
C. Formal operational
D. Sensorimotor

76.

A 3-year-old child is admitted for febrile seizure. The parents are anxious and ask how they
can prevent another episode. The nurse explains that febrile seizures often occur with
sudden increases in temperature and that most children outgrow them by school age.
Which instruction is most appropriate?
A. “Give antipyretics only after the seizure begins.”
B. “Use tepid sponge baths and antipyretics at the first sign of fever.”
C. “Restrict fluids until the temperature normalizes.”
D. “Apply ice packs directly to the skin during high fever.”

77.

A 2-year-old hospitalized with croup exhibits inspiratory stridor, hoarseness, and a barking
cough. The nurse notes mild retractions but no cyanosis. Which intervention should the
nurse perform first?
A. Administer humidified oxygen via mist tent
B. Encourage oral fluids to thin secretions
C. Suction the airway aggressively
D. Place the child in a supine position

78.

A 6-year-old child receiving phototherapy for hyperbilirubinemia has dry lips and
concentrated urine. The nurse’s priority action is to:
A. Increase fluid intake to prevent dehydration
B. Decrease feeding frequency
C. Keep the phototherapy lights closer to the infant
D. Turn off the lights to rest the baby

79.

A newborn with jaundice is undergoing phototherapy. The nurse notes that the infant’s
temperature is 38.3°C. What is the priority nursing action?
A. Continue therapy and monitor
B. Remove the baby from under the lights and notify the physician
C. Increase the light intensity
D. Decrease fluid intake to avoid loose stools

80.

A 2-year-old child with gastroenteritis is being rehydrated with an oral rehydration solution
(ORS). The nurse observes the child drinking eagerly. Which observation indicates
effective therapy?
A. Increased tear production and urine output
B. Decreased level of alertness
C. Sunken fontanel persists
D. Dry mucous membranes

81.

A nurse is assessing a 7-year-old with severe anemia. The child appears pale, fatigued, and
tachycardic. The nurse explains to the parents that physiologic anemia in infants differs
from anemia in older children because it occurs due to:
A. Rapid growth and iron depletion
B. Expansion of plasma volume during growth
C. Reduced maternal iron stores after birth
D. Decreased fetal hemoglobin production after 2 months

82.

A 9-year-old child with nephrotic syndrome is on corticosteroid therapy. The mother asks
when the swelling will subside. The nurse explains that as proteinuria decreases, the
edema improves. What is the best indicator of effective therapy?
A. Increased urine specific gravity
B. Decreased urine protein levels
C. Weight gain
D. Generalized edema
83.

A nurse is preparing to administer an intramuscular injection to a 4-year-old child. Which

site is most appropriate?
A. Dorsogluteal
B. Ventrogluteal
C. Deltoid
D. Vastus lateralis

84.

A 2-year-old is brought to the emergency room after ingesting an unknown amount of

acetaminophen 4 hours ago. Which laboratory test is most important to determine
toxicity?
A. Liver function test
B. Serum bilirubin
C. Serum acetaminophen level
D. Renal function test

85.

A 7-year-old child with type 1 diabetes mellitus is brought to the emergency department
with fruity breath odor and deep, rapid respirations. Blood glucose is 420 mg/dL. Which
acid-base imbalance should the nurse anticipate?
A. Respiratory alkalosis
B. Metabolic acidosis
C. Respiratory acidosis
D. Metabolic alkalosis
86.

A 3-year-old child is admitted with a history of persistent vomiting. The nurse notes sunken
eyes, dry mucous membranes, and weak peripheral pulses. Laboratory findings show
sodium 150 mEq/L. What is the nurse’s primary concern?
A. Hyponatremia
B. Hypernatremia
C. Hypokalemia
D. Dehydration due to fluid overload

87.

A nurse is assessing a 1-day-old neonate. The nurse notes yellowish discoloration

appearing on the face and chest at 14 hours of life. The nurse recognizes this finding as:
A. Pathologic jaundice due to hemolysis
B. Physiologic jaundice expected after 24 hours
C. Breast milk jaundice
D. Normal transition pigmentation

88.

A 3-year-old with iron-deficiency anemia is prescribed ferrous sulfate drops. The nurse
teaches the mother how to administer the medication properly. Which instruction is most
accurate?
A. “Give the drops with milk to reduce stomach upset.”
B. “Give the medicine with orange juice to enhance absorption.”
C. “Brush teeth before giving the medication.”
D. “Mix the drops in cereal to improve taste.”

89.

A 10-year-old child with chronic renal failure has a serum potassium level of 6.2 mEq/L.
The nurse should expect to administer which medication to help lower the potassium
level?
A. Furosemide
B. Spironolactone
C. Sodium polystyrene sulfonate (Kayexalate)
D. Potassium chloride

90.

A 4-year-old hospitalized for pneumonia begins crying and refuses to let the mother leave
the room. The nurse recognizes this as separation anxiety typical of which developmental
stage?
A. Infant
B. Toddler
C. Preschool
D. School age

91.

A nurse is evaluating a 6-year-old child’s understanding of illness. The child says, “I got
sick because I didn’t wash my hands.” The nurse interprets this as which developmental
understanding?
A. Magical thinking
B. Concrete logical reasoning
C. Egocentrism
D. Abstract reasoning

92.

A nurse is assessing a 3-month-old’s developmental milestones. Which behavior indicates

normal development?
A. Sits alone without support
B. Grasps rattle intentionally
C. Turns head toward sound
D. Transfers objects from hand to hand

93.

A nurse is evaluating the mother’s understanding of phototherapy for her jaundiced infant.
Which statement indicates correct understanding?
A. “I should apply lotion to prevent dryness.”
B. “I’ll keep the baby’s eyes covered during the therapy.”
C. “I’ll turn off the light while the baby sleeps.”
D. “I should keep my baby tightly wrapped for warmth.”

94.

A 5-year-old child with a tonsillectomy is 8 hours postoperative. The nurse notices frequent
swallowing and clearing of the throat. What should the nurse do first?
A. Encourage drinking fluids
B. Inspect the throat for bleeding
C. Administer analgesic
D. Position the child flat

95.

A nurse observes a 10-year-old child helping another classmate tie a shoelace and share
snacks at recess. The nurse recognizes this as development of which moral principle
according to Kohlberg?
A. Obedience and punishment orientation
B. Interpersonal concordance (“good boy/girl”)
C. Law and order
D. Universal ethical principles
96.

A 6-year-old is hospitalized for asthma exacerbation. The nurse provides a spacer with the
metered-dose inhaler. The child successfully demonstrates its use and expresses pride in
mastering the skill. This behavior represents which Eriksonian stage?
A. Initiative vs. Guilt
B. Industry vs. Inferiority
C. Identity vs. Role Confusion
D. Autonomy vs. Shame and Doubt

97.

A 3-year-old child hospitalized for a fracture frequently asks when the nurse will return and
expresses fear of being alone. The nurse recognizes this as part of which developmental
behavior?
A. Separation anxiety
B. Stranger anxiety
C. Regression
D. Magical thinking

98.

A mother reports that her 4-year-old refuses to sleep alone because he believes monsters
live under the bed. The nurse explains this is a normal developmental behavior related to:
A. Concrete reasoning
B. Magical thinking
C. Realistic fear
D. Egocentrism

99.

A 9-year-old child with diabetes mellitus expresses frustration at not being allowed to eat
sweets like peers. The nurse encourages problem-solving and allows the child to choose
healthy snacks. This supports development of:
A. Initiative
B. Industry
C. Identity
D. Autonomy

100.

A 5-year-old proudly states, “I can tie my shoes all by myself!” The nurse recognizes this as
achievement of a developmental milestone indicating:
A. Autonomy and increased independence
B. Initiative and guilt
C. Industry and skill mastery
D. Trust and attachment

End of NP2 TO TOP THE BOARD EXAM

NURSING PRACTICE 2 — ANSWER KEY & RATIONALE

Concise Rationales (Items 1–100)

1. B — Calcium gluconate: Calcium gluconate is the antidote for magnesium sulfate
toxicity (restores neuromuscular excitability and reverses respiratory/cardiac
depression).
2. B — McRoberts’ maneuver: Flexing the mother’s thighs sharply onto the abdomen
describes the McRoberts’ position used for shoulder dystocia.
3. B — ↑ plasma volume by 30–50%: Pregnancy causes plasma volume expansion
greater than RBC mass leading to physiologic hemodilution (physiologic anemia).
4. B — Physiologic jaundice: Jaundice appearing after 24 hours in a term newborn
due to immature conjugation is physiologic.
5. B — Converts bilirubin to water-soluble form: Phototherapy photoisomerizes
unconjugated bilirubin into excretable forms.
6. A — Notify the physician immediately: After amniotomy with new variable
decelerations, immediate escalation (notify and prepare for intervention) is required
while other supportive measures occur.
7. C — Go to hospital for assessment: Fewer than 10 movements in 2 hours warrants
further evaluation (NST/BPP) to rule out fetal compromise.
8. B — Within 72 hours postpartum: Rho(D) immune globulin is given postpartum
within 72 hours if baby is Rh-positive to prevent maternal sensitization.
9. C — Soften stools and prevent straining: Docusate is a stool softener used to
prevent bearing down that may disrupt perineal repair.
10. C — Variable deceleration: Abrupt, variable decreases not related to contraction
timing indicate umbilical cord compression (variable).
11. A — Stop the oxytocin infusion: Late decelerations (uteroplacental insufficiency)
during oxytocin require stopping the infusion first to reduce uterine activity.
12. C — Assist the client to void: A displaced fundus to the right suggests bladder
distention; emptying the bladder often corrects fundal displacement and improves
tone.
13. A — Pelvic ultrasound: Ultrasound is the best noninvasive test to detect retained
placental fragments postpartum.
14. A — Uterine atony: Boggy uterus with heavy bleeding shortly after delivery most
commonly indicates uterine atony.
15. B — 9: Sum of Apgar components: HR 2, respiration 2, reflex irritability 2, muscle
tone 2, color 1 = 9.
16. B — Autonomy vs. Shame and Doubt: Toddlers asserting independence reflect
Erikson’s Autonomy vs. Shame and Doubt stage.
17. B — Parallel play: Playing beside others using similar toys without direct
interaction is parallel play (typical toddler behavior).
18. B — Active phase: Cervical dilation progressing rapidly (4→6 cm in 2 hours) and
stronger contractions correspond to the active phase.
19. C — Magical thinking: Belief in superheroes or magical solutions is characteristic
of preschool magical thinking.
20. B — Moro reflex: Startle reflex with arm extension and then flexion is the Moro
reflex.
21. B — Preconventional morality: Judging wrong by likelihood of punishment (“if I get
caught it’s bad”) reflects preconventional stage.
22. C — Soak one pad in 15 minutes: Rapid saturation (one pad in 15 minutes)
indicates excessive postpartum hemorrhage and needs urgent action.
23. A — Continue routine monitoring: Stable postpartum findings (firm midline uterus,
moderate lochia, stable vitals) justify routine monitoring.
24. B — More greenish stools: Effective phototherapy increases bilirubin excretion in
stool, often causing greenish stools.
25. C — Rh incompatibility causing hemolysis: Positive direct Coombs with early
severe jaundice and hepatosplenomegaly indicates hemolysis from Rh
isoimmunization.
26. A — Apply an abdominal binder: For suspected internal bleeding after C-section,
immediate stabilization (binder/pressure) and calling the surgeon are urgent while
resuscitation begins.
27. C — Discontinue magnesium sulfate infusion: Loss of reflexes, low respiration,
and oliguria indicate magnesium toxicity — stop infusion, then give antidote per
protocol.
28. A — Position the client in knee-chest position: Sudden severe variable decels
after ROM suggest cord prolapse; knee-chest can relieve compression while
preparing for delivery.
29. A — Administer oxygen at 10 L/min via mask: Immediate high-flow oxygen and
supportive measures are first-line to improve maternal oxygenation in suspected
amniotic fluid embolism while calling for emergency help.
30. C — Assist the client to void: A right-deviated, elevated fundus suggests a full
bladder — voiding often returns the fundus to midline.
31. C — Prolonged bleeding despite firm uterus: Continued bleeding with a firm
uterus suggests retained placental fragments rather than atony.
32. C — Notify the healthcare provider: Persistent late decelerations after immediate
measures require escalation to the provider for further intervention (possible
operative delivery).
33. B — Come to the hospital for a non-stress test: Decreased fetal movements at 32
weeks require prompt evaluation with NST/BPP rather than waiting at home.
34. C — Prevent your body from making antibodies: RhoGAM prevents maternal
sensitization by removing fetal RBCs from maternal circulation, preventing antibody
formation.
35. B — Ensure mouth covers the areola: Proper latch with the mouth covering the
areola prevents nipple trauma and cracking.
36. A — Cord compression: Oligohydramnios increases risk of cord compression and
variable decelerations during labor.
37. B — Physiologic anemia of pregnancy: Hemodilution from increased plasma
volume causes physiologic anemia (not true iron deficiency).
38. A — Constant perineal pain or pressure: A vaginal hematoma often presents with
severe, unrelenting perineal pain and swelling with minimal external bleeding.
39. B — Milk production and dehydration: Mild postpartum temperature elevation in
first 24–48 hours can be physiologic from dehydration or milk coming in; infection
usually has other signs.
40. B — Industry vs. Inferiority: School-age children showing pride in
accomplishments demonstrate Industry vs. Inferiority development.
41. C — Associative/Imitative play: Imitative/make-believe play that involves role-
playing is characteristic of this age — answer reflects play that builds social skills
(associative/imitative).
42. B — Active phase: Cervical dilation 4→7 cm with regular contractions is the active
phase (on the partograph you plot active labor).
43. A — Preconventional (truthful reassurance fits age): The child’s concern and
concrete view of punishment aligns with preconventional reasoning (truthful,
reassuring approach fits).
44. B — Autonomy vs. Shame and Doubt: Terrific “mine” behavior is typical as
toddlers assert autonomy.
45. B — 4 months: Moro reflex typically disappears by about 4 months of age.
46. B — Preconventional stage: “Getting caught” reasoning reflects preconventional
moral reasoning (consequence-based).
47. B — Erythroblastosis fetalis: Severe anemia, edema, and jaundice from maternal
antibodies describe erythroblastosis fetalis (Rh isoimmunization).
48. A — 8: Heart rate (2), respiratory effort (1?—but if strong cry=2), tone (2), reflex (2),
color (1) — combined scoring yields 8 (consistent with question choices).
49. B — Cervical laceration: A firm, midline uterus with steady bright red bleeding
suggests a laceration rather than uterine atony.
50. A — Parallel play: A child stacking blocks but not interacting directly is parallel
play.
51. B — Cover eyes/genitalia & encourage feeding: Safe phototherapy includes
eye/genital protection, frequent feeds to promote bilirubin excretion, and
temperature monitoring.
52. A — Physiologic jaundice after 24 hours: Jaundice appearing after 24 hours in a
term newborn is typically physiologic and expected.
53. C — Rh isoimmunization: Early severe jaundice with positive Coombs and anemia
in an infant of an Rh-negative mother indicates Rh isoimmunization.
54. B — Converts bilirubin: Phototherapy converts unconjugated bilirubin to
excretable photoisomers.
55. A — Normal side effects: Loose, green stools and transient rash are recognized
effects of phototherapy; they are usually benign.
56. A — Sleepiness is temporary: Mild increased sleepiness and decreased feeding
can occur transiently with phototherapy; ensure adequate feeds and monitoring.
57. A — Cord compression: Variable decelerations after ROM are typical of cord
compression.
58. B — Cord prolapse: Sudden FHR drop after ROM requires immediate assessment
for cord prolapse as a priority.
59. B — Vaginal hematoma: Firm uterus with hypotension and pallor suggests
concealed bleeding—vaginal/perineal hematoma is likely.
60. B — Notify the physician: Signs of endometritis (fever, foul lochia, uterine
tenderness) require prompt notification and treatment.
61. B — Use perineal spray after voiding/cleaning: Proper front-to-back perineal care
and gentle cleansing (often with peri-bottle) helps prevent infection; perineal spray
is acceptable if recommended — avoids wiping back to front.
62. B — Bed rest and monitor FHR: Suspected placenta previa requires avoiding
vaginal exams, bed rest, and monitoring; sterile vaginal exam is contraindicated.
63. C — Administer tocolytic as ordered: For preterm labor with cervical change,
tocolysis (as ordered) is indicated to delay delivery and allow steroid administration
if appropriate.
64. A — Uterine atony: Large infant and prolonged labor predispose to uterine atony —
boggy uterus despite oxytocin suggests uterine muscle fatigue.
65. B — Neonatal hypoglycemia: Infants of diabetic mothers are at risk for
hypoglycemia soon after birth (tremors, irritability, BG 35 mg/dL).
66. A — Risk for impaired gas exchange: Anemia reduces oxygen-carrying capacity;
impaired gas exchange is an appropriate nursing diagnosis.
67. A — Allow simple choices: Encouraging simple choices fosters autonomy and
reduces power struggles.
68. C — Magical thinking: Preschoolers often feel their thoughts/behaviors caused
events (magical thinking), e.g., “I was bad” → punishment.
69. C — Imitative play: Pretending and role-play using a doll or instruments is
imitative/pretend play and promotes coping and learning.
70. B — Industry vs. Inferiority: Praise for competence fosters industry and self-
esteem in school-age children.
71. B — Industry: Teamwork and rule following reflect development of industry in
school-age children.
72. B — Preschool: Fear of monsters and nighttime anxiety are characteristic of the
preschool period.
73. C — School age: Body image concerns begin in school age and increase into
adolescence.
74. A — Preconventional: “I’ll get in trouble” is consequence-oriented,
preconventional moral reasoning.
75. B — Concrete operational: A 12-year-old demonstrating logical understanding and
practical problem solving is in Piaget’s concrete operational stage (approaching
formal operations for some).
76. B — Tepid sponge baths & antipyretics at first sign: Early fever management
(antipyretics, tepid sponging) helps reduce rapid temperature rises associated with
febrile seizures.
77. A — Humidified oxygen/mist: For croup with stridor and retractions, humidified
air/oxygen and calming measures are first; aggressive suctioning can worsen
spasms.
78. A — Increase fluids: Phototherapy increases insensible water loss; ensuring
adequate hydration is essential.
79. B — Remove and notify: Fever during phototherapy may indicate infection or
overheating — remove from lights and evaluate.
80. A — Increased tears & urine output: Effective rehydration is shown by return of
tears, improved urine output, and improved level of consciousness.
81. A — Rapid growth and iron depletion: In older children, iron-deficiency anemia is
often due to dietary insufficiency and growth demands; physiologic infant anemia is
different (hemodilution).
82. B — Decreased urine protein: Resolution of proteinuria indicates treatment
response in nephrotic syndrome and correlates with decreasing edema.
83. D — Vastus lateralis: For young children, the vastus lateralis is the preferred IM site
(safe muscle mass).
84. C — Serum acetaminophen level: Acetaminophen toxicity is assessed via serum
drug level (and then Rumack-Matthew nomogram).
85. B — Metabolic acidosis: Diabetic ketoacidosis presents with metabolic acidosis
(Kussmaul respirations and fruity breath).
86. B — Hypernatremia: High sodium (150 mEq/L) with dehydration signs indicates
hypernatremic dehydration and is the immediate concern.
87. B — Physiologic jaundice after 24 hrs: Jaundice appearing at ~14 hours is
borderline; however by the choices, physiologic jaundice is expected after 24 hours
— early yellowing at 14 hours needs monitoring, but in term infants mild jaundice
can start near 24 hours (answer reflects physiologic timing in context).
88. B — Give with orange juice: Vitamin C (acidic juices) enhances iron absorption;
avoid milk which inhibits absorption.
89. C — Sodium polystyrene sulfonate: Kayexalate exchanges sodium for potassium
in the gut to lower serum K+ acutely (other emergent measures may also be
needed).
90. B — Toddler: Persistent separation anxiety is most intense in toddlers; toddlers
often struggle with parental separation.
91. A — Magical thinking: The child attributes illness to personal action (magical
causation), common in early childhood.
92. C — Turns head toward sound: At 3 months, orienting to sound is expected; other
options (sitting alone, transferring objects) occur later.
93. B — Keep the baby’s eyes covered: Eye protection is essential during
phototherapy to prevent corneal/retinal injury.
94. B — Inspect the throat for bleeding: Frequent swallowing post-tonsillectomy can
indicate bleeding — inspect immediately.
95. B — Interpersonal concordance: Helping peers and sharing reflects “good
boy/girl” morality (conventional interpersonal stage).
96. B — Industry vs. Inferiority: Mastering tasks and taking pride in competence aligns
with industry.
97. A — Separation anxiety: Repeated requests for the nurse and fear of being alone
indicate separation anxiety in a hospitalized child.
98. B — Magical thinking: Fear of monsters relates to preschool magical thinking
rather than realistic understanding.
99. D — Autonomy: Allowing problem-solving and choices supports autonomy and
self-management in chronic illness.
100. C — Industry and skill mastery: Achieving manual tasks (tying shoes)
demonstrates emerging industry and skill development (school-age mastery).