1. Question

While assessing a one-month-old infant, which of the findings warrants further investigation by the 

nurse? Select all that apply.

 A. Abdominal respirations

 B. Irregular breathing rate

 C. Inspiratory grunt

 D. Increased heart rate with crying

 E. Nasal flaring

 F. Cyanosis

 G. Asymmetric chest movement

Correct Answers: C, E, F, & G

 Option C. Grunting occurs when an infant attempts to maintain an adequate functional 

residual capacity in the face of poorly compliant lungs by partial glottic closure. As the infant 

prolongs the expiratory phase against this partially closed glottis, there is a prolonged and 

increased residual volume that maintains the airway opening and also an audible expiratory 

sound.

 Option E: Nasal flaring occurs when the nostrils widen while breathing and is a sign of troubled 

breathing or respiratory distress.

 Option F: Cyanosis refers to the bluish discoloration of the skin and indicates a decrease in 

oxygen attached to the red blood cells in the bloodstream.

 Option G: Asymmetric chest movement occurs when the abnormal side of the lungs expands 

less and lags behind the normal side. This indicates respiratory distress.

 Option A: Abdominal respiration is normal among infants and young children. Since their 

intercostal muscles are not yet fully developed, they use their abdominal muscles much more to 

pull the diaphragm down for breathing.

 Option B: Newborns can have irregular breathing patterns ranging from 30 to 60 breaths per 

minute with short periods of apnea (15 seconds).

 Option D: An increase in heart rate is normal for an infant during activity (including crying). 

Fluctuations in heart rate follow the changes in the newborn‘s behavioral state – crying, 

movement, or wakefulness corresponds to an increase in heart rate.

2. Question

A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropisol) 0.4 

mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a preoperative client. List the order in 

which the nurse must carry out the following actions prior to the administration of 

preoperative medications.

 Have the client empty bladder

 Instruct the client to remain in bed

 Raise the side rails on the bed

 Place the call bell within reach

Correct order is shown above.

1. Have the client empty the bladder. The first step in the process is to have the client void prior 

to administering the pre-operative medication. If the client does not have a catheter, it is 

important to empty the bladder before receiving preoperative medications to prevent bladder 

injury (especially in pelvic surgeries). Else, a straight catheter or an indwelling catheter may be 

ordered to ensure the bladder is empty.

2. Instruct the client to remain in bed. Preoperative medications can cause drowsiness and 

lightheadedness which may put the client at risk for injury.

3. Raise the side rails on the bed. Raising the side rails on the bed helps prevent accidental falls 

and injury when the client decides to get out of the bed without assistance.

4. Place the call bell within reach. Call bells should always be within the reach of a client.

3. Question

A 32-year-old pregnant woman comes to the clinic for her prenatal visit. The nurse gathers data 

about her obstetric history, which includes 3-year-old twins at home and a miscarriage 10 years ago 

at 12 weeks gestation. How would the nurse accurately document this information? Fill in the blanks.

 Answer: Gravida (3) para (1)

Incorrect

Correct Answer: Gravida 3 para 1

Gravida is the number of confirmed pregnancies and each pregnancy is only counted one time, even 

if the pregnancy was a multiple gestation (i.e., twins, triplets). Para (parity) indicates the total number 

of pregnancies that have reached viability (20 weeks) regardless of whether the infants were born 

alive. Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).