Maternal and Child Nursing Questions

8/20/2019 Maternal and Child Nursing Questions

1/87

1. When assessing the adequacy of sperm for conception to occur, which of the following isthe most useful criterion?

A. Sperm countB. Sperm motilityC. Sperm maturityD. Semen volume2. A couple who wants to conceive but has

been unsuccessful during the last 2 yearshas undergone many diagnostic procedures.When discussing the situation with thenurse, one partner states, “We now severalfriends in our age group and all of them havetheir own child already, Why can!t we haveone?". Which of the following would be themost pertinent nursing diagnosis for thiscouple?

A. Fear related to the unknownB. Pain related to numerous procedures.

C. Ineffective family coping related to infertility.D. Selfesteem distur!ance related to infertility.#. Which of the following urinary symptomsdoes the pregnant woman most frequentlye$perience during the first trimester?

A. DysuriaB. Fre"uencyC. IncontinenceD. Burning%. &eartburn and flatulence, common in thesecond trimester, are most liely the result of

which of the following? A. Increased plasma #C$ levelsB. Decreased intestinal motilityC. Decreased gastric acidityD. %levated estrogen levels'. (n which of the following areas would thenurse e$pect to observe chloasma?

A. Breast& areola& and nipplesB. Chest& neck& arms& and legsC. A!domen& !reast& and thighsD. Cheeks& forehead& and nose). A pregnant client states that she “waddles"when she wals. *he nurse!s e$planation isbased on which of the following as thecause?

A. 'he large si(e of the new!ornB. Pressure on the pelvic musclesC. )ela*ation of the pelvic +ointsD. %*cessive weight gain

+. Which of the following represents theaverage amount of weight gained duringpregnancy?

A. ,- to -- l!B , to - l!C. -/ to 01 l!D. - to /1 l!. When taling with a pregnant client who is

e$periencing aching swollen, leg veins, thenurse would e$plain that this is mostprobably the result of which of the following?

A. 'hrom!ophle!itisB. Pregnancyinduced hypertensionC. Pressure on !lood vessels from the enlarginguterusD. 'he force of gravity pulling down on theuterus-. ervical softening and uterine souffle areclassified as which of the following?

A. Diagnostic signsB. Presumptive signsC. Pro!a!le signsD. Positive signs1/. Which of the following would the nurseidentify as a presumptive sign of pregnancy?

A. #egar signB. 2ausea and vomitingC. Skin pigmentation changesD. Positive serum pregnancy test11. Which of the following common emotiona

reactions to pregnancy would the nursee$pect to occur during the first trimester? A. Introversion& egocentrism& narcissismB. Awkwardness& clumsiness& andunattractivenessC. An*iety& passivity& e*troversionD. Am!ivalence& fear& fantasies12. 0uring which of the following would thefocus of classes be mainly on physiologicchanges, fetal development, se$uality, duringpregnancy, and nutrition?

A. Prepregnant periodB. First trimester C. Second trimester D. 'hird trimester 1#. Which of the following would bedisadvantage of breast feeding?

A. Involution occurs more rapidlyB. 'he incidence of allergies increases due tomaternal anti!odiesC. 'he father may resent the infant3s demands


2/87

on the mother3s !odyD. 'here is a greater chance for error duringpreparation1%. Which of the following would cause afalsepositive result on a pregnancy test?

A. 'he test was performed less than ,1 daysafter an a!ortionB. 'he test was performed too early or too late in

the pregnancyC. 'he urine sample was stored too long at roomtemperatureD. A spontaneous a!ortion or a missed a!ortionis impending1'. &3 can be auscultated with a fetoscopeas early as which of the following?

A. weeks gestationB. ,1 weeks gestationC. , weeks gestationD. -1 weeks gestation

1). A client 456 began 7uly '. &er 800should be which of the following? A. 4anuary -B. 5arch -6C. April ,-D. 7cto!er ,-1+. Which of the following fundal heightsindicates less than 12 wees! gestation whenthe date of the 456 is unnown?

A. 8terus in the pelvisB. 8terus at the *iphoid

C. 8terus in the a!domenD. 8terus at the um!ilicus1. Which of the following danger signsshould be reported promptly during theantepartum period?

A. ConstipationB. Breast tendernessC. 2asal stuffinessD. 9eaking amniotic fluid1-. Which of the following prenatal laboratorytest values would the nurse consider assignificant?

A. #ematocrit 00.:B. )u!ella titer less than ,;6C.


3/87

C. Ductus arteriosusD. Ductus venosus2+. Which of the following when present inthe urine may cause a reddish stain on thediaper of a newborn?

A. 5ucusB. 8ric acid crystalsC. Biliru!in

D. %*cess iron2. When assessing the newborn!s heart rate,which of the following ranges would beconsidered normal if the newborn weresleeping?

A. 61 !eats per minuteB. ,11 !eats per minuteC. ,-1 !eats per minuteD. ,/1 !eats per minute2-. Which of the following is true regardingthe fontanels of the newborn?

A. 'he anterior is triangular shaped> the posterior is diamond shaped.B. 'he posterior closes at ,6 months> theanterior closes at 6 to ,- weeks.C. 'he anterior is large in si(e when comparedto the posterior fontanel.D. 'he anterior is !ulging> the posterior appearssunken.#/. Which of the following groups of newbornrefle$es below are present at birth andremain unchanged through adulthood?

A. Blink& cough& rooting& and gagB. Blink& cough& snee(e& gagC. )ooting& snee(e& swallowing& and coughD. Stepping& !link& cough& and snee(e#1. Which of the following describes the9abinsi refle$?

A. 'he new!orn3s toes will hypere*tend and fanapart from dorsifle*ion of the !ig toe when oneside of foot is stroked upward from the !all of theheel and across the !all of the foot.B. 'he new!orn a!ducts and fle*es alle*tremities and may !egin to cry when e*posedto sudden movement or loud noise.C. 'he new!orn turns the head in the direction of stimulus& opens the mouth& and !egins to suckwhen cheek& lip& or corner of mouth is touched.D. 'he new!orn will attempt to crawl forwardwith !oth arms and legs when he is placed onhis a!domen on a flat surface#2. Which of the following statements bestdescribes hyperemesis gravidarum?

A. Severe anemia leading to electrolyte&meta!olic& and nutritional im!alances in thea!sence of other medical pro!lems.B. Severe nausea and vomiting leading toelectrolyte& meta!olic& and nutritional im!alancesin the a!sence of other medical pro!lems.C. 9oss of appetite and continuous vomiting thatcommonly results in dehydration and ultimately

decreasing maternal nutrientsD. Severe nausea and diarrhea that can causegastrointestinal irritation and possi!ly internal!leeding##. Which of the following would the nurseidentify as a classic sign of 6:&?

A. %dema of the feet and anklesB. %dema of the hands and faceC.


4/87

A.


5/87

C. 5uscle pain the presence of #omans sign&and swelling in the affected lim!D. Chills& fever& stiffness& and pain occurring ,1to ,/ days after delivery%-. Which of the following are the mostcommonly assessed findings in cystitis?

A. Fre"uency& urgency& dehydration& nausea&chills& and flank pain

B. 2octuria& fre"uency& urgency dysuria&hematuria& fever and suprapu!ic painC. Dehydration& hypertension& dysuria&suprapu!ic pain& chills& and fever D. #igh fever& chills& flank pain nausea& vomiting&dysuria& and fre"uency'/. Which of the following best reflects thefrequency of reported postpartum “blues"?

A. Between ,1: and /1: of all new mothersreport some form of postpartum !luesB. Between 01: and 1: of all new mothers

report some form of postpartum !luesC. Between 1: and 61: of all new mothersreport some form of postpartum !luesD. Between -: and ?1: of all new mothersreport some form of postpartum !lues


6/87

Awkwardness& clumsiness& and unattractiveness An*iety& passivity& e*troversion Am!ivalence& fear& fantasiesDuring which of the following would the focus ofclasses !e mainly on physiologic changes& fetaldevelopment& se*uality& during pregnancy&and nutritionPrepregnant period

First trimester Second trimester 'hird trimester


7/87

7!taining an Apgar scoreInspecting the new!orn3s um!ilical cordImmediately !efore e*pulsion& which of thefollowing cardinal movements occurDescentFle*ion%*tension%*ternal rotation

Before !irth& which of the following structuresconnects the right and left auricles of the heart8m!ilical veinForamen ovaleDuctus arteriosusDuctus venosus the posterior appearssunken.


8/87


9/87


10/87

Fetoscope placed midway !etween the um!ilicusand the *iphoid process%*ternal electronic fetal monitor placed at theum!ilicus

temperature ,11./F> pulse ,11 weak& thready>) -1 per minute.


11/87

Congenital hypothyroidismIncreased intracranial pressureDuring the first / hours after a male circumcision&assessing for which of the following is thepriorityInfection#emorrhageDiscomfort

Dehydration'he mother asks the nurse. apical hearth rate ,G1 BP5& nostril flaring> mildintercostal retractions> and grunting at the end ofe*piration.


12/87

Increase in maternal estrogen secretionDecrease in maternal androgen secretionSecretion of androgen !y the fetal gonadSecretion of estrogen !y the fetal gonad

A client at 6 weeks3 gestation calls complainingof slight nausea in the morning hours.


13/87

PicaProlapsed um!ilical cord

give her a !ottleIf you leave her alone she will learn how to cryherself to sleep


14/87

Bowlegged posture9inear growth curveIf parents keep a toddler dependent in areaswhere he is capa!le of using skills& the toddle willdevelop a sense of which of the following5istrustShame$uilt

Inferiority


15/87

A female3s first menstruation or menstrualperiods'he first year of menstruation or period'he entire menstrual cycle or from one periodto another 'he onset of uterine maturation or peak growth

A ,/yearold !oy has acne and according to hisparents& dominates the !athroom !y using the

mirror all the time.


16/87

)eport the child3s condition to ProtectiveServices immediately.Schedule a followup visit to check for more!ruises.2otify the child3s physician immediately.Don nothing !ecause this is a normal finding in atoddler.


17/87

In an infant seat7n the side


18/87

C. Increased fi!er intakeD. Decreased fluid intake). Which of the following would the nurse useas the basis for the teaching plan whencaring for a pregnant teenager concernedabout gaining too much weight duringpregnancy?

A. ,1 pounds per trimester

B. , pound per week for /1 weeksC. pound per week for /1 weeksD. A total gain of - to 01 pounds+. *he client tells the nurse that her lastmenstrual period started on 7anuary 1% andended on 7anuary 2/. =sing >agele!s rule,the nurse determines her 800 to be which ofthe following?

A. Septem!er -?B. 7cto!er -,C. 2ovem!er ?

D. Decem!er -?. When taing an obstetrical history on apregnant client who states, “: had a son bornat # wees gestation, a daughter born at #/wees gestation and : lost a baby at about wees,"the nurse should record herobstetrical history as which of the following?

A. $- '- P1 A1 9-B. $0 ', P, A1 9-C. $0 '- P1 A1 9-D. $/ ', P, A, 9-

-. When preparing to listen to the fetal heartrate at 12 wees! gestation, the nurse woulduse which of the following?

A. Stethoscope placed midline at the um!ilicusB. Doppler placed midline at the suprapu!icregionC. Fetoscope placed midway !etween theum!ilicus and the *iphoid processD. %*ternal electronic fetal monitor placed at theum!ilicus1/. When developing a plan of care for aclient newly diagnosed with gestationaldiabetes, which of the following instructionswould be the priority?

A. Dietary intakeB. 5edicationC. %*erciseD. $lucose monitoring11. A client at 2% wees gestation has gained) pounds in % wees. Which of the following

would be the priority when assessing theclient?

A. $lucosuriaB. DepressionC. #and=face edemaD. Dietary intake12. A client 12 wees! pregnant come to theemergency department with abdominal

cramping and moderate vaginal bleeding.peculum e$amination reveals 2 to # cmscervical dilation.*he nurse would documentthese findings as which of the following?

A. 'hreatened a!ortionB. Imminent a!ortionC. Complete a!ortionD. 5issed a!ortion1#. Which of the following would be thepriority nursing diagnosis for a client with anectopic pregnancy?

A. )isk for infectionB. PainC. Hnowledge DeficitD. Anticipatory $rieving1%. 9efore assessing the postpartum client!suterus for firmness and position in relation tothe umbilicus and midline, which of thefollowing shouldthe nurse do first?

A. Assess the vital signsB. Administer analgesiaC. Am!ulate her in the hall

D. Assist her to urinate1'. Which of the following should the nursedo when a primipara who is lactating tells thenurse that she has sore nipples?

A. 'ell her to !reast feed more fre"uentlyB. Administer a narcotic !efore !reast feedingC. %ncourage her to wear a nursing !rassiereD. 8se soap and water to clean the nipples1). *he nurse assesses the vital signs of aclient, % hours! postpartum that are asfollows@ 96 -/)/B temperature 1//.%CB pulse1// wea, threadyB 3 2/ per minute. Which ofthe following shouldthe nurse do first?

A. )eport the temperature to the physicianB. )echeck the !lood pressure with another cuffC. Assess the uterus for firmness and positionD. Determine the amount of lochia1+. *he nurse assesses the postpartumvaginal discharge DlochiaE on four clients.Which of the following assessments wouldwarrant notification of the physician?


19/87

A. A dark red discharge on a -day postpartumclientB. A pink to !rownish discharge on a client whois days postpartumC. Almost colorless to creamy discharge on aclient - weeks after deliveryD. A !right red discharge days after delivery1. A postpartum client has a temperature of

1/1.%C, with a uterus that is tender whenpalpated, remains unusually large, and notdescending as normally e$pected. Which ofthe following shouldthe nurse assess ne$t?

A. 9ochiaB. BreastsC. IncisionD. 8rine1-. Which of the following is the priorityfocus of nursing practice with the currentearly postpartum discharge?

A. Promoting comfort and restoration of healthB. %*ploring the emotional status of the familyC. Facilitating safe and effective selfandnew!orn careD. 'eaching a!out the importance of familyplanning2/. Which of the following actions would beleast effective in maintaining a neutralthermal environment for the newborn?

A. Placing infant under radiant warmer after!athing

B. Covering the scale with a warmed !lanketprior to weighingC. Placing cri! close to nursery window for familyviewingD. Covering the infant3s head with a knitstockinette21. A newborn who has an asymmetrical5oro refle$ response should be furtherassessed for which of the following?

A. 'alipes e"uinovarusB. Fractured clavicleC. Congenital hypothyroidismD. Increased intracranial pressure22. 0uring the first % hours after a malecircumcision, assessing for which of thefollowing is the priority?

A. InfectionB. #emorrhageC. DiscomfortD. Dehydration

2#. *he mother ass the nurse. “What!swrong with my son!s breasts? Why are theyso enlarged?" Whish of the following wouldbe the best response by the nurse?

A. 'he !reast tissue is inflamed from the traumae*perienced with !irthB. A decrease in material hormones present!efore !irth causes enlargement&

C. Lou should discuss this with your doctor. Itcould !e a malignancyD. 'he tissue has hypertrophied while the !a!ywas in the uterus2%. :mmediately after birth the nurse notesthe following on a male newborn@respirations +B apical hearth rate 1)/ 965,nostril flaringB mild intercostal retractionsBand grunting at the end of e$piration. Whichof the following shouldthe nurse do?

A. Call the assessment data to the physician3s

attentionB. Start o*ygen per nasal cannula at - 9=min.C. Suction the infant3s mouth and naresD. )ecogni(e this as normal first period ofreactivity2'. *he nurse hears a mother telling a friendon the telephone about umbilical cord care.Which of the following statements by themother indicates effective teaching?

A. Daily soap and water cleansing is !estB. MAlcohol helps it dry and kills germs

C. An anti!iotic ointment applied daily preventsinfectionD. #e can have a tu! !ath each day2). A newborn weighing #/// grams andfeeding every % hours needs 12/ caloriesgof body weight every 2% hours for propergrowth and development. &ow many ouncesof 2/ caloF formula should this newbornreceive at each feeding to meet nutritionalneeds?

A. - ouncesB. 0 ouncesC. / ouncesD. G ounces2+. *he postterm neonate with meconiumstained amniotic fluid needs care designed toespecially monitor for which of thefollowing?

A. )espiratory pro!lemsB. $astrointestinal pro!lems


20/87

C. Integumentary pro!lemsD. %limination pro!lems2. When measuring a client!s fundal height,which of the following techniques denotesthe correct method of measurement used bythe nurse?

A. From the *iphoid process to the um!ilicusB. From the symphysis pu!is to the *iphoid

processC. From the symphysis pu!is to the fundusD. From the fundus to the um!ilicus2-. A client with severe preeclampsia isadmitted with of 96 1)/11/, proteinuria, andsevere pitting edema. Which of the followingwould be most important to include in theclient!s plan of care?

A. Daily weightsB. Sei(ure precautionsC. )ight lateral positioning

D. Stress reduction#/. A postpartum primipara ass the nurse,“When can we have se$ual intercourseagain?" Which of the following would be thenurse!s best response?

A. Anytime you !oth want to.B. As soon as choose a contraceptive method.C.


21/87

patient to rest for several hour C. Preparing for a cesarean section for failure toprogressD. Increasing the encouragement to the patientwhen pushing !egins#-. A multigravida at # wees! gestation isadmitted with painless, bright red bleedingand mild contractions every + to 1/ minutes.

Which of the following assessments shouldbe avoided? A. 5aternal vital signB. Fetal heart rateC. Contraction monitoringD. Cervical dilation%/. Which of the following would be thenurse!s most appropriate response to a clientwho ass why she must have a cesareandelivery if she has a complete placentaprevia?

A. Lou will have to ask your physician when hereturns.B. Lou need a cesarean to preventhemorrhage.C. 'he placenta is covering most of your cervi*.D. 'he placenta is covering the opening of theuterus and !locking your !a!y.%1. *he nurse understands that the fetal headis in which of the following positions with aface presentation?

A. Completely fle*ed

B. Completely e*tendedC. Partially e*tendedD. Partially fle*ed%2. With a fetus in the leftanterior breechpresentation, the nurse would e$pect thefetal heart rate would be most audible inwhich of the following areas?

A. A!ove the maternal um!ilicus and to the rightof midlineB. In the lowerleft maternal a!dominal "uadrantC. In the lowerright maternal a!dominal"uadrantD. A!ove the maternal um!ilicus and to the leftof midline%#. *he amniotic fluid of a client has agreenish tint. *he nurse interprets this to bethe result of which of the following?

A. 9anugoB. #ydramnioC. 5econiumD. erni*

%%. A patient is in labor and has Hust been toldshe has a breech presentation. *he nurseshould be particularly alert for which of thefollowing?

A. NuickeningB. 7phthalmia neonatorumC. PicaD. Prolapsed um!ilical cord

%'. When describing diFygotic twins to acouple, on which of the following would thenurse base the e$planation?

A. 'wo ova fertili(ed !y separate spermB. Sharing of a common placentaC. %ach ova with the same genotypeD. Sharing of a common chorion%). Which of the following refers to the singlecell that reproduces itself after conception?

A. ChromosomeB. Blastocyst

C. OygoteD. 'ropho!last%+. :n the late 1-'/s, consumers and healthcare professionals began challenging theroutine use of analgesics and anestheticsduring childbirth. Which of the following wasan outgrowth of this concept?

A. 9a!or& delivery& recovery& postpartum J9D)PKB. 2ursemidwiferyC. Clinical nurse specialistD. Prepared child!irth

%. A client has a midpelvic contracture froma previous pelvic inHury due to a motorvehicle accident as a teenager. *he nurse isaware that this could prevent a fetus frompassing through or around which structureduring childbirth?

A. Symphysis pu!isB. Sacral promontoryC. Ischial spinesD. Pu!ic arch%-. When teaching a group of adolescentsabout variations in the length of themenstrual cycle, the nurse understands thatthe underlying mechanism is due tovariations in which of the following phases?

A. 5enstrual phaseB. Proliferative phaseC. Secretory phaseD. Ischemic phase'/. When teaching a group of adolescentsabout male hormone production, which of th


22/87

following would the nurse include as beingproduced by the 4eydig cells?

A. Folliclestimulating hormoneB. 'estosteroneC. 9euteini(ing hormoneD. $onadotropin releasing hormone,. give her a !ottle

D. If you leave her alone she will learn how tocry herself to sleepG.


23/87

,-.


24/87

B.


25/87

cultureD. 2otify the physician immediately and preparefor intu!ation.0/.


26/87

/?.


27/87

separationC. 5assaging the fundus to encourage theuterus to contractD. Applying light traction when delivering theplacenta that has already detached from theuterine wall-. *he fetal heart rate is checed followingrupture of the bag of waters in order to@

A. Check if the fetus is suffering from headcompressionB. Determine if cord compression followed theruptureC. Determine if there is uteroplacentalinsufficiencyD. Check if fetal presenting part has ade"uatelydescended following the rupture1/. =pon assessment, the nurse got thefollowing findings@ 2 perineal pads highlysaturated with blood within 2 hours post

partum, 63J / bpm, fundus soft andboundaries not well define0. *he appropriatenursing diagnosis is@

A. 2ormal !lood lossB. Blood volume deficiencyC. Inade"uate tissue perfusion related tohemorrhageD. #emorrhage secondary to uterine atony11. *he following are signs and symptoms offetal distress 8K86*@

A. Fetal heart rate JF#)K decreased during a

contraction and persists even after the uterinecontraction endsB. 'he F#) is less than ,-1 !pm or over ,G1!pmC. 'he precontraction F#) is ,01 !pm& F#)during contraction is ,,6 !pm and F#) afteruterine contraction is ,-G !pmD. F#) is ,G1 !pm& weak and irregular 12. :f the labor period lasts only for # hours,the nurse should suspect that the followingconditions may occur@,.9aceration of cervi*-.9aceration of perineum0.Cranial hematoma in the fetus/.Fetal ano*ia

A. , R -B. - R /C. -&0&/D. ,&-&0&/1#. *he primary power involved in labor anddelivery is

A. Bearing down a!ility of mother B. Cervical effacement and dilatationC. 8terine contractionD. alsalva techni"ue1%. *he proper technique to monitor theintensity of a uterine contraction is

A. Place the palm of the hands on the a!domenand time the contraction

B. Place the finger tips lightly on the suprapu!icarea and time the contractionC. Put the tip of the fingers lightly on the fundalarea and try to indent the a!dominal wall at theheight of the contractionD. Put the palm of the hands on the fundal areaand feel the contraction at the fundal area1'. *o monitor the frequency of the uterinecontraction during labor, the right techniqueis to time the contraction

A. From the !eginning of one contraction to the

end of the same contractionB. From the !eginning of one contraction to the!eginning of the ne*t contractionC. From the end of one contraction to the!eginning of the ne*t contractionD. From the deceleration of one contraction tothe acme of the ne*t contraction1). *he pea point of a uterine contraction iscalled the

A. AccelerationB. Acme

C. DecelerationD. A*iom1+. When determining the duration of auterine contraction the right technique is totime it from

A. 'he !eginning of one contraction to the end othe same contractionB. 'he end of one contraction to the !eginning oanother contractionC. 'he acme point of one contraction to theacme point of another contractionD. 'he !eginning of one contraction to the end oanother contraction1. When the bag of waters ruptures, thenurse should chec the characteristic of theamniotic flui0. *he normal color of amnioticfluid is

A. Clear as water B. BluishC. $reenishD. Lellowish


28/87

1-. When the bag of waters rupturesspontaneously, the nurse should inspect thevaginal introitus for possible cord prolapse. :f there is part of the cord that has prolapsedinto the vaginal opening the correct nursingintervention is@

A. Push !ack the prolapse cord into the vaginalcanal

B. Place the mother on semifowler3s position toimprove circulationC. Cover the prolapse cord with sterile gau(ewet with sterile 2SS and place the woman on'rendelen!urg positionD. Push !ack the cord into the vagina and placethe woman on sims position2/. *he fetal heart beat should be monitoredevery 1' minutes during the 2nd stage oflabor. *he characteristic of a normal fetalheart rate is

A. 'he heart rate will decelerate during acontraction and then go !ack to its precontraction rate after the contractionB. 'he heart rate will accelerate during acontraction and remain slightly a!ove the precontraction rate at the end of the contractionC. 'he rate should not !e affected !y the uterinecontraction.D. 'he heart rate will decelerate at the middle ofa contraction and remain so for a!out a minuteafter the contraction

21. *he mechanisms involved in fetal deliveryis A. Descent& e*tension& fle*ion& e*ternal rotationB. Descent& fle*ion& internal rotation& e*tension&e*ternal rotationC. Fle*ion& internal rotation& e*ternal rotation&e*tensionD. Internal rotation& e*tension& e*ternal rotation&fle*ion22. *he first thing that a nurse must ensurewhen the baby!s head comes out is

A. 'he cord is intactB. 2o part of the cord is encircling the !a!y3sneckC. 'he cord is still attached to the placentaD. 'he cord is still pulsating2#. *o ensure that the baby will breath assoon as the head is delivered, the nurse!spriority action is to

A. Suction the nose and mouth to removemucous secretions

B. Slap the !a!y3s !uttocks to make the !a!y cryC. Clamp the cord a!out G inches from the !aseD. Check the !a!y3s color to make sure it is notcyanotic2%. When doing perineal care in preparationfor delivery, the nurse should observe thefollowing 8K86*

A. 8se updown techni"ue with one stroke

B. Clean from the mons veneris to the anusC. 8se mild soap and warm water D. Paint the inner thighs going towards theperineal area2'. What are the important considerationsthat the nurse must remember after theplacenta is delivered?1.hec if the placenta is complete includingthe membranes2.hec if the cord is long enough for thebaby

#.hec if the umbilical cord has # bloodvessels%.hec if the cord has a meaty portion and ashiny portion

A. , and 0B. - and /C. ,& 0& and /D. - and 02). *he following are correct statementsabout false labor 8K86*

A. 'he pain is irregular in intensity and

fre"uency.B. 'he duration of contraction progressivelylengthens over timeC. 'here is no vaginal !loody dischargeD. 'he cervi* is still closeD.2+. *he passageway in labor and deliver ofthe fetus include the following 8K86*

A. Distensi!ility of lower uterine segmentB. Cervical dilatation and effacementC. Distensi!ility of vaginal canal and introitusD. Fle*i!ility of the pelvis2. *he normal umbilical cord is composedof@

A. - arteries and , veinB. - veins and , arteryC. - arteries and - veinsD. none of the a!ove2-. At what stage of labor and delivery does aprimigravida differ mainly from amultigravida?


29/87

A. Stage ,B. Stage -C. Stage 0D. Stage /#/. *he second stage of labor begins with

LLL and ends with LL? A. Begins with full dilatation of cervi* and endswith delivery of placenta

B. Begins with true la!or pains and ends withdelivery of !a!yC. Begins with complete dilatation andeffacement of cervi* and ends with delivery of!a!yD. Begins with passage of show and ends withfull dilatation and effacement of cervi*#1. *he following are signs that the placentahas detached 8K86*@

A. 9engthening of the cordB. 8terus !ecomes more glo!ular

C. Sudden gush of !loodD. 5other feels like !earing down#2. When the shiny portion of the placentacomes out first, this is called the LLLmechanism.

A. Schult(eB. )itgensC. DuncanD. 5armets##. When the baby!s head is out, theimmediate action of the nurse is

A. Cut the um!ilical cordB.


30/87

%2. *he following are common causes ofdysfunctional labor. Which of these can anurse, on her own manage?

A. Pelvic !one contractionB. Full !ladder C. %*tension rather than fle*ion of the headD. Cervical rigidity%#. At what stage of labor is the mother is

advised to bear down? A.


31/87

c. 2otify the physician if the skin !ecomes!ron(e in color d. Check the vital signs every - to / hours. A primigravida in active la!or is a!out @ dayspostterm. 'he client desires a !ilateral pudendal!lock anesthesia !efore delivery. After the nursee*plains this type of anesthesia to the client&which of the following locations identified !y the

client as the area of relief would indicate to thenurse that the teaching was effectivea. Back!. A!domenc. Fundusd. PerineumG. 'he nurse is caring for a primigravida at a!out- months and , week gestation. After e*plainingselfcare measures for common discomforts ofpregnancy& the nurse determines that the clientunderstands the instructions when she says;

a. 2ausea and vomiting can !e decreased if Ieat a few crackers !efore arising!. If I start to leak colostrum& I should cleansemy nipples with soap and waterc. If I have a vaginal discharge& I should wearnylon underweard. 9eg cramps can !e alleviated if I put an icepack on the area?. 'hirty hours after delivery& the nurse in chargeplans discharge teaching for the client a!outinfant care. By this time& the nurse e*pects that

the phase of postpartal psychological adaptationthat the client would !e in would !e termedwhich of the followinga. 'aking in!. 9etting goc. 'aking holdd. )esolution6. A pregnant client is diagnosed with partialplacenta previa. In e*plaining the diagnosis& thenurse tells the client that the usual treatment forpartial placenta previa is which of the followinga. Activity limited to !ed rest!. Platelet infusionc. Immediate cesarean deliveryd. 9a!or induction with o*ytocin@. 2urse 4ulia plans to instruct the postpartumclient a!out methods to prevent !reastengorgement.


32/87

d. #ave the client pant!low during thecontractions,. A client tells the nurse& I think my !a!y likesto hear me talk to him.


33/87

-?. 'he nurse in charge is caring for a patientwho is in the first stage of la!or.


34/87

C. JQK pregnancy testD. JQK ultrasound1/. What event occurring in the secondtrimester helps the e$pectant mother toaccept the pregnancy?

A. 9ighteningB. BallotmentC. Pseudocyesis

D. Nuickening11. hoes with low, broad heels, plus a goodposture will prevent which prenataldiscomfort?

A. BackacheB. ertigoC. 9eg crampsD. 2ausea12. When a pregnant woman e$periences legcramps, the correct nursing intervention torelieve the muscle cramps is@

A. Allow the woman to e*erciseB. 9et the woman walk for a whileC. 9et the woman lie down and dorsifle* the foottowards the kneesD. Ask the woman to raise her legs1#. rom the ##rd wee of gestation till fullterm, a healthy mother should have prenatalchec up every@

A. weekB. - weeksC. 0 weeks

D. / weeks1%. *he e$pected weight gain in a normalpregnancy during the #rd trimester is

A. , pound a weekB. - pounds a weekC. ,1 l!s a monthD. ,1 l!s total weight gain in the 0rd trimester 1'. :n the 9artholomew!s rule of %, when thelevel of the fundus is midway between theumbilicus and $yphoid process the estimatedage of gestation DA(IE is@

A. th monthB. Gth monthC. ?th monthD. 6th month1). *he following are ways of determininge$pected date of delivery D800E when the456 is unnown 8K86*@

A. 2aegele3s ruleB. Nuickening

C. 5cDonald3s ruleD. Batholomew3s rule of /1+. :f the 456 is 7an. #/, the e$pected date ofdelivery D800E is

A. 7ct. ?B. 7ct. -/C. 2ov. ?D. 2ov. 6

1. Gegel!s e$ercise is done in pregnancy inorder to@ A. Strengthen perineal musclesB. )elieve !ackacheC. Strengthen a!dominal musclesD. Prevent leg varicosities and edema1-. 6elvic rocing is an appropriate e$ercisein pregnancy to relieve which discomfort?

A. 9eg crampsB. 8rinary fre"uencyC. 7rthostatic hypotension

D. Backache2/. *he main reason for an e$pectedincreased need for iron in pregnancy is@

A. 'he mother may have physiologic anemia duto the increased need for red !lood cell mass aswell as the fetal re"uires a!out 01/11 mg ofiron to growB. 'he mother may suffer anemia !ecause ofpoor appetiteC. 'he fetus has an increased need for )BCwhich the mother must supply

D. 'he mother may have a pro!lem of digestion!ecause of pica21. *he diet that is appropriate in normalpregnancy should be high in

A. Protein& minerals and vitaminsB. Car!ohydrates and vitaminsC. Proteins& car!ohydrates and fatsD. Fats and minerals22. Which of the following signs will require amother to see immediate medical attention?

A.


35/87

C. $iving the client a perineal careD. Doing a vaginal prep2%. When preparing the mother who is on her%th month of pregnancy for abdominalultrasound, the nurse should instruct her to@

A. 7!serve 2P7 from midnight to avoid vomitingB. Do perineal flushing properly !efore theprocedure

C. Drink at least - liters of fluid - hours !eforethe procedure and not void until the procedure isdoneD. oid immediately !efore the procedure for!etter visuali(ation2'. *he nursing intervention to relieve“morning sicness" in a pregnant woman isby giving

A. Dry car!ohydrate food like crackersB. 9ow sodium dietC. Intravenous infusion

D. Antacid2). *he common normal site ofnidationimplantation in the uterus is

A. 8pper uterine portionB. 5iduterine areaC. 9ower uterine segmentD. 9ower cervical segment2+. 5rs. antos is on her 'th pregnancy andhas a history of abortion in the %th pregnancyand the first pregnancy was a twin. he isconsidered to be

A. $ / P 0B. $ P 0C. $ P /D. $ / P /2. *he following are sin changes inpregnancy 8K86*@

A. ChloasmaB. Striae gravidarumC. 9inea negraD. Chadwick3s sign2-. Which of the following statements is*3=8 of conception?

A.


36/87

appreciated. Which of the following is themost possible diagnosis of this condition?

A. #ydatidiform moleB. 5issed a!ortionC. Pelvic inflammatory diseaseD. %ctopic pregnancy#). When a pregnant woman goes into aconvulsive seiFure, the 5(* immediate

action of the nurse to ensure safety of thepatient is@ A. Apply restraint so that the patient will not fallout of !edB. Put a mouth gag so that the patient will not!ite her tongue and the tongue will not fall !ackC. Position the mother on her side to allow thesecretions to drain from her mouth and preventaspirationD. Check if the woman is also having aprecipitate la!or

#+. A gravidocardiac mother is advised toobserve bed rest primarily to A. Allow the fetus to achieve normal intrauterinegrowthB. 5inimi(e o*ygen consumption which canaggravate the condition of the compromisedheart of the mother C. Prevent perinatal infectionD. )educe incidence of premature la!or #. A pregnant mother is admitted to thehospital with the chief complaint of profuse

vaginal bleeding, A(I #) ws, not in labor.*he nurse must always consider which of thefollowing precautions@

A. 'he internal e*am is done only at the deliveryunder strict asepsis with a dou!le setupB. 'he preferred manner of delivering the !a!y isvaginalC. An emergency delivery set for vaginal deliverymust !e made ready !efore e*amining thepatientD. Internal e*am must !e done following routineprocedure#-. Which of the following signs willdistinguish threatened abortion fromimminent abortion?

A. Severity of !leedingB. Dilation of the cervi*C. 2ature and location of painD. Presence of uterine contraction

%/. *he nursing measure to relieve fetaldistress due to maternal supine hypotensionis@

A. Place the mother on semifowler3s positionB. Put the mother on left side lying positionC. Place mother on a knee chest positionD. Any of the a!ove%1. *o prevent preterm labor from

progressing, drugs are usually prescribed tohalt the labor. *he drugs commonly givenare@

A. 5agnesium sulfate and ter!utalineB. Prostaglandin and o*ytocinC. Progesterone and estrogenD. De*amethasone and prostaglandin%2. :n placenta praevia marginalis, theplacenta is found at the@

A. Internal cervical os partly covering theopening

B. %*ternal cervical os slightly covering theopeningC. 9ower segment of the uterus with the edgesnear the internal cervical osD. 9ower portion of the uterus completelycovering the cervi*%#. :n which of the following conditions canthe causative agent pass through theplacenta and affect the fetus in utero?

A. $onorrheaB. )u!ella

C. CandidiasisD. moniliasis%%. Which of the following can lead toinfertility in adult males?

A. $erman measlesB. 7rchitisC. Chicken po*D. )u!ella%'. 6apanicolaou smear is usually done todetermine cancer of

A. Cervi*B. 7variesC. Fallopian tu!esD. Breast%). Which of the following causes of infertilitin the female is primarily psychological inorigin?

A. aginismusB. DyspareuniaC. %ndometriosisD. Impotence


37/87

%+. 9efore giving a repeat dose ofmagnesium sulfate to a preeclamptic patient,the nurse should assess the patient!scondition. Which of the following conditionswill require the nurse to temporarily suspenda repeat dose of magnesium sulfate?

A. ,11 cC. urine output in / hoursB. Hnee +erk refle* is JQK-

C. Serum magnesium level is ,1m%g=9.D. )espiratory rate of ,G=min%. Which of the following is *3=8 in 3hincompatibility?

A. 'he condition can occur if the mother is )hJQKand the fetus is )hJKB. %very pregnancy of an )hJK mother will resultto erythro!lastosis fetalisC. 7n the first pregnancy of the )hJK mother& thefetus will not !e affectedD. )ho$am is given only during the first

pregnancy to prevent incompati!ility%-. Which of the following are the mostcommonly assessed findings in cystitis?

A. Fre"uency& urgency& dehydration& nausea&chills& and flank painB. 2octuria& fre"uency& urgency dysuria&hematuria& fever and suprapu!ic painC. Dehydration& hypertension& dysuria&suprapu!ic pain& chills& and fever D. #igh fever& chills& flank pain nausea& vomiting&dysuria& and fre"uency

'/. Which of the following best reflects thefrequency of reported postpartum “blues"? A. Between ,1: and /1: of all new mothersreport some form of postpartum !luesB. Between 01: and 1: of all new mothersreport some form of postpartum !luesC. Between 1: and 61: of all new mothersreport some form of postpartum !luesD. Between -: and ?1: of all new mothersreport some form of postpartum !lues1. 5ay arrives at the health care clinic andtells the nurse that her last menstrual periodwas - wees ago. he also tells the nursethat a home pregnancy test was positive butshe began to have mild cramps and is nowhaving moderate vaginal bleeding. 0uring thephysical e$amination of the client, the nursenotes that 5ay has a dilated cervi$. *henurse determines that 5ay is e$periencingwhich type of abortion?

a. Inevita!le!. Incompletec. 'hreatenedd. Septic2. >urse 3eese is reviewing the record of apregnant client for her first prenatal visit.Which of the following data, if noted on theclient!s record, would alert the nurse that the

client is at ris for a spontaneous abortion?a. Age 0G years!. #istory of syphilisc. #istory of genital herpesd. #istory of dia!etes mellitus#. >urse &aFel is preparing to care for a clienwho is newly admitted to the hospital with apossible diagnosis of ectopic pregnancy.>urse &aFel develops a plan of care for theclient and determines that which of thefollowing nursing actions is the priority?

a. 5onitoring weight!. Assessing for edemac. 5onitoring apical pulsed. 5onitoring temperature%. >urse (liver is teaching a diabeticpregnant client about nutrition and insulinneeds during pregnancy. *he nursedetermines that the client understandsdietary and insulin needs if the client statesthat the second half of pregnancy require@a. Decreased caloric intake

!. Increased caloric intakec. Decreased Insulind. Increase Insulin'. >urse 5ichelle is assessing a 2% year oldclient with a diagnosis of hydatidiform mole.he is aware that one of the following isunassociated with this condition?a. %*cessive fetal activity.!. 9arger than normal uterus for gestational agec. aginal !leedingd. %levated levels of human chorionicgonadotropin.). A pregnant client is receiving magnesiumsulfate for severe pregnancy inducedhypertension D6:&E. *he clinical findings thatwould warrant use of the antidote , calciumgluconate is@a. 8rinary output @1 cc in - hours.!. A!sent patellar refle*es.c. )apid respiratory rate a!ove /1=min.d. )apid rise in !lood pressure.


38/87

+. 0uring vaginal e$amination of 7anna whois in labor, the presenting part is at stationplus two. >urse, correctly interprets it as@a. Presenting part is - cm a!ove the plane of theischial spines.!. Biparietal diameter is at the level of the ischialspines.c. Presenting part in - cm !elow the plane of the

ischial spines.d. Biparietal diameter is - cm a!ove the ischialspines.. A pregnant client is receiving o$ytocinD6itocinE for induction of labor. A conditionthat warrant the nurse incharge todiscontinue :.;. infusion of 6itocin is@a. Contractions every , minutes lasting ?161seconds.!. 5aternal temperature ,1,.-c. %arly decelerations in the fetal heart rate.

d. Fetal heart rate !aseline ,/1,G1 !pm.-. alcium gluconate is being administeredto a client with pregnancy inducedhypertension D6:&E. A nursing action thatmust be initiated as the plan of carethroughout inHection of the drug is@a. entilator assistance!. CP readingsc. %H$ tracingsd. Continuous CP)1/. A trial for vaginal delivery after an earlier

caesareans, would liely to be given to agravida, who had@a. First low transverse cesarean was for activeherpes type - infections> vaginal culture at 0@weeks pregnancy was positive.!. First and second caesareans were forcephalopelvic disproportion.c. First caesarean through a classic incision as aresult of severe fetal distress.d. First low transverse caesarean was for !reechposition. Fetus in this pregnancy is in a verte*presentation.11. >urse 3yan is aware that the best initialapproach when trying to tae a cryingtoddler!s temperature is@a. 'alk to the mother first and then to the toddler.!. Bring e*tra help so it can !e done "uickly.c. %ncourage the mother to hold the child.d. Ignore the crying and screaming.

12. 9aby *ina a # month old infant Hust had acleft lip and palate repair. What should thenurse do to prevent trauma to operative site?a. Avoid touching the suture line& even whencleaning.!. Place the !a!y in prone position.c. $ive the !a!y a pacifier.d. Place the infant3s arms in soft el!ow restraints

1#. Which action should nurse 5arian includin the care plan for a 2 month old with heartfailure?a. Feed the infant when he cries.!. Allow the infant to rest !efore feeding.c. Bathe the infant and administer medications!efore feeding.d. urse &aFel is teaching a mother whoplans to discontinue breast feeding after 'months. *he nurse should advise her to

include which foods in her infant!s diet?a. Skim milk and !a!y food.!.


39/87

c. Ade"uacyd. Appropriateness1. ;angie is a new 9..>. graduate. hewants to become a 6ublic &ealth >urse.Where should she apply?a. Department of #ealth!. Provincial #ealth 7fficec. )egional #ealth 7ffice

d. )ural #ealth 8nit1-. *ony is aware the hairman of the5unicipal &ealth 9oard is@a. 5ayor !. 5unicipal #ealth 7fficer c. Pu!lic #ealth 2ursed. Any "ualified physician2/. 5yra is the public health nurse in amunicipality with a total population of about2/,///. *here are # rural health midwivesamong the 3&= personnel. &ow many more

midwife items will the 3&= need?a. ,!. -c. 0d. 'he )#8 does not need any more midwifeitem.21. According to reeman and &einrich,community health nursing is a developmentalservice. Which of the following bestillustrates this statement?a. 'he community health nurse continuously

develops himself personally and professionally.!. #ealth education and community organi(ingare necessary in providing community healthservices.c. Community health nursing is intendedprimarily for health promotion and preventionand treatment of disease.d. 'he goal of community health nursing is toprovide nursing services to people in their ownplaces of residence.22. >urse *ina is aware that the diseasedeclared through 6residential 6roclamation>o. % as a target for eradication in the6hilippines is?a. Poliomyelitis!. 5easlesc. )a!iesd. 2eonatal tetanus2#. 5ay nows that the step in communityorganiFing that involves training of potentialleaders in the community is@

a. Integration!. Community organi(ationc. Community studyd. Core group formation2%. 9eth a public health nurse taes an activerole in community participation. What is theprimary goal of community organiFing?a. 'o educate the people regarding community

health pro!lems!. 'o mo!ili(e the people to resolve communityhealth pro!lemsc. 'o ma*imi(e the community3s resources indealing with health pro!lems.d. 'o ma*imi(e the community3s resources indealing with health pro!lems.2'. *ertiary prevention is needed in whichstage of the natural history of disease?a. Prepathogenesis!. Pathogenesis

c. Prodromald. 'erminal2). *he nurse is caring for a primigravidclient in the labor and delivery area. Whichcondition would place the client at ris fordisseminated intravascular coagulationD0:E?a. Intrauterine fetal death.!. Placenta accreta.c. Dysfunctional la!or.d. Premature rupture of the mem!ranes.

2+. A full term client is in labor. >urse 9etty isaware that the fetal heart rate would be@a. 61 to ,11 !eats=minute!. ,11 to ,-1 !eats=minutec. ,-1 to ,G1 !eats=minuted. ,G1 to ,61 !eats=minute2. *he sin in the diaper area of a + monthold infant is e$coriated and red. >urse &aFelshould instruct the mother to@a. Change the diaper more often.!. Apply talc powder with diaper changes.c. urse arla nows that the commoncardiac anomalies in children with 0ownyndrome Dtrisomy 21E is@a. Atrial septal defect!. Pulmonic stenosis


40/87

c. entricular septal defectd. %ndocardial cushion defect#/. 5alou was diagnosed with severepreeclampsia is now receiving :.;.magnesium sulfate. *he adverse effectsassociated with magnesium sulfate is@a. Anemia!. Decreased urine output

c. #yperrefle*iad. Increased respiratory rate#1. A 2# year old client is having hermenstrual period every 2 wees that last for 1wee. *his type of menstrual pattern is betsdefined by@a. 5enorrhagia!. 5etrorrhagiac. Dyspareuniad. Amenorrhea#2. 7annah is admitted to the labor and

delivery unit. *he critical laboratory result for this client would be@a. 7*ygen saturation!. Iron !inding capacityc. Blood typingd. Serum Calcium##. >urse Iina is aware that the mostcommon condition found during the secondtrimester of pregnancy is@a. 5eta!olic alkalosis!. )espiratory acidosis

c. 5astitisd. Physiologic anemia#%. >urse 4ynette is woring in the triagearea of an emergency department. he seesthat several pediatric clients arrivesimultaneously. *he client who needs to betreated first is@a. A crying year old child with a laceration onhis scalp.!. A / year old child with a !arking coughs andflushed appearance.c. A 0 year old child with Down syndrome who ispale and asleep in his mother3s arms.d. A - year old infant with stridorous !reathsounds& sitting up in his mother3s arms anddrooling.#'. 5aureen in her third trimester arrives atthe emergency room with painless vaginalbleeding. Which of the following conditionsis suspected?

a. Placenta previa!. A!ruptio placentaec. Premature la!or d. Se*ually transmitted disease#). A young child named 3ichard issuspected of having pinworms. *hecommunity nurse collects a stool specimento confirm the diagnosis. *he nurse should

schedule the collection of this specimen for@a. 4ust !efore !edtime!. After the child has !een !athec. Any time during the dayd. %arly in the morning#+. :n doing a child!s admission assessment,>urse 9etty should be alert to note whichsigns or symptoms of chronic leadpoisoning?a. Irrita!ility and sei(ures!. Dehydration and diarrhea

c. Bradycardia and hypotensiond. Petechiae and hematuria#. *o evaluate a woman!s understandingabout the use of diaphragm for familyplanning, >urse *rish ass her to e$plainhow she will use the appliance. Whichresponse indicates a need for further healthteaching?a. I should check the diaphragm carefully forholes every time I use it!. I may need a different si(e of diaphragm if I

gain or lose weight more than -1 poundsc. 'he diaphragm must !e left in place for atleast G hours after intercoursed. I really need to use the diaphragm and +ellymost during the middle of my menstrual cycle.#-. &ypo$ia is a common complication oflaryngotracheobronchitis. >urse (livershould frequently assess a child withlaryngotracheobronchitis for@a. Drooling!. 5uffled voicec. )estlessnessd. 9owgrade fever %/. &ow should >urse 5ichelle guide a childwho is blind to wal to the playroom?a.


41/87

d. urse (livia shoulde$pect that the child most liely would havean@a. 9oud& machinerylike murmur.!. Bluish color to the lips.

c. Decreased BP reading in the uppere*tremitiesd. Increased BP reading in the upper e*tremities.%2. *he reason nurse 5ay eeps the neonatein a neutral thermal environment is that whena newborn becomes too cool, the neonaterequires@a. 9ess o*ygen& and the new!orn3s meta!olicrate increases.!. 5ore o*ygen& and the new!orn3s meta!olicrate decreases.

c. 5ore o*ygen& and the new!orn3s meta!olicrate increases.d. 9ess o*ygen& and the new!orn3s meta!olicrate decreases.%#. 9efore adding potassium to an infant!s:.;. line, >urse 3on must be sure to assesswhether this infant has@a. Sta!le !lood pressure!. Patent fontanellesc. 5oro3s refle*d. oided

%%. >urse arla should now that the mostcommon causative factor of dermatitis ininfants and younger children is@a. Ba!y oil!. Ba!y lotionc. 9aundry detergentd. Powder with cornstarch%'. 0uring tube feeding, how far above aninfant!s stomach should the nurse hold thesyringe with formula?a. G inches!. ,- inchesc. ,6 inchesd. -/ inches%). :n a mothers! class, >urse 4ynnettediscussed childhood diseases such aschicen po$. Which of the followingstatements about chicen po$ is correct?a. 'he older one gets& the more suscepti!le he!ecomes to the complications of chickenpo*.!. A single attack of chickenpo* will prevent

future episodes& including conditions such asshingles.c. 'o prevent an out!reak in the community&"uarantine may !e imposed !y healthauthorities.d. Chicken po* vaccine is !est given when thereis an impending out!reak in the community.%+. 9arangay 6inoy had an outbrea of

Ierman measles. *o prevent congenitalrubella, what is the 98* advice that you cangive to women in the first trimester ofpregnancy in the 9arangay 6inoy?a. Advise them on the signs of $erman measles!. Avoid crowded places& such as markets andmovie houses.c. Consult at the health center where ru!ellavaccine may !e given.d. Consult a physician who may give themru!ella immunoglo!ulin.

%. 5yrna a public health nurse nows that todetermine possible sources of se$uallytransmitted infections, the 98* method thatmay be undertaen is@a. Contact tracing!. Community surveyc. 5ass screening testsd. Interview of suspects%-. A ##year old female client came forconsultation at the health center with thechief complaint of fever for a wee.

Accompanying symptoms were muscle painsand body malaise. A wee after the start offever, the client noted yellowish discolorationof his sclera. &istory showed that he wadedin flood waters about 2 wees before theonset of symptoms. 9ased on her history,which disease condition will you suspect?a. #epatitis A!. #epatitis Bc. 'etanusd. 9eptospirosis'/. 5icey a #year old client was brought tothe health center with the chief complaint ofsevere diarrhea and the passage of “ricewatery" stools. *he client is most probablysuffering from which condition?a. $iardiasis!. Cholerac. Ame!iasisd. Dysentery


42/87

'1. *he most prevalent form of meningitisamong children aged 2 months to # years iscaused by which microorganism?a. #emophilus influen(ae!. 5or!illivirusc. Streptococcus pneumoniaed. 2eisseria meningitidis'2. *he student nurse is aware that the

pathognomonic sign of measles is Gopli!sspot and you may see Gopli!s spot byinspecting the@a. 2asal mucosa!. Buccal mucosac. Skin on the a!domend. Skin on neck'#. Angel was diagnosed as having 0enguefever. Mou will say that there is slow capillaryrefill when the color of the nail bed that youpressed does not return within how many

seconds?a. 0 seconds!. G secondsc. @ secondsd. ,1 seconds'%. :n :ntegrated 5anagement of hildhood:llness, the nurse is aware that the severeconditions generally require urgent referral toa hospital. Which of the following severeconditions 0(8 >(* always require urgentreferral to a hospital?

a. 5astoiditis!. Severe dehydrationc. Severe pneumoniad. Severe fe!rile disease''. 5yrna a public health nurse will conductoutreach immuniFation in a barangay 5asaywith a population of about 1'//. *heestimated number of infants in the barangaywould be@a. / infants!. 1 infantsc. infantsd. G infants'). *he community nurse is aware that thebiological used in 8$panded 6rogram on:mmuniFation D86:E should >(* be stored inthe freeFer?a. DP'!. 7ral polio vaccinec. 5easles vaccined. 55)

'+. :t is the most effective way of controllingschistosomiasis in an endemic area?a. 8se of molluscicides!. Building of foot !ridgesc. Proper use of sanitary toiletsd. 8se of protective footwear& such as ru!!er!oots'. everal clients is newly admitted and

diagnosed with leprosy. Which of thefollowing clients should be classified as acase of multibacillary leprosy?a. 0 skin lesions& negative slit skin smear !. 0 skin lesions& positive slit skin smear c. skin lesions& negative slit skin smear d. skin lesions& positive slit skin smear '-. >urses are aware that diagnosis ofleprosy is highly dependent on recognition osymptoms. Which of the following is an earlysign of leprosy?

a. 5acular lesions!. Ina!ility to close eyelidsc. 'hickened painful nervesd. Sinking of the nose!ridge)/. 5arie brought her 1/ month old infant forconsultation because of fever, started % daysprior to consultation. :n determining malariaris, what will you do?a. Perform a tourni"uet test.!. Ask where the family resides.c. $et a specimen for !lood smear.

d. Ask if the fever is present everyday.)1. usie brought her % years old daughter tothe 3&= because of cough and colds.ollowing the :5: assessment guide, whichof the following is a danger sign thatindicates the need for urgent referral to ahospital?a. Ina!ility to drink!. #igh grade fever c. Signs of severe dehydrationd. Cough for more than 01 days)2. 7immy a 2year old child revealed “baggypants". As a nurse, using the :5: guidelineshow will you manage 7immy?a. )efer the child urgently to a hospital forconfinement.!. Coordinate with the social worker to enroll thechild in a feeding program.c. 5ake a teaching plan for the mother& focusingon menu planning for her child.


43/87

d. Assess and treat the child for health pro!lemslike infections and intestinal parasitism.)#. Iina is using (resol in the managementof diarrhea of her #year old child. he asedyou what to do if her child vomits. As a nurseyou will tell her to@a. Bring the child to the nearest hospital forfurther assessment.

!. Bring the child to the health center forintravenous fluid therapy.c. Bring the child to the health center forassessment !y the physician.d. 9et the child rest for ,1 minutes then continuegiving 7resol more slowly.)%. >ii a 'month old infant was brought byhis mother to the health center because ofdiarrhea for % to ' times a day. &er sin goesbac slowly after a sin pinch and her eyesare sunen. =sing the :5: guidelines, you

will classify this infant in which category?a. 2o signs of dehydration!. Some dehydrationc. Severe dehydrationd. 'he data is insufficient.)'. hris a %month old infant was brought byher mother to the health center because ofcough. &is respiratory rate is %2minute.=sing the :ntegrated 5anagement of hild:llness D:5:E guidelines of assessment, hisbreathing is considered as@

a. Fast!. Slowc. 2ormald. Insignificant)). 5aylene had Hust received her %th dose of tetanus to$oid. he is aware that her babywill have protection against tetanus for a. ,1 year !. yearsc. 0 yearsd. 9ifetime)+. >urse 3on is aware that unused 9Ishould be discarded after how many hours of reconstitution?a. - hours!. / hoursc. 6 hoursd. At the end of the day). *he nurse e$plains to a breastfeedingmother that breast mil is sufficient for all ofthe baby!s nutrient needs only up to@

a. months!. G monthsc. , year d. - years)-. >urse 3on is aware that the gestationalage of a conceptus that is considered viableDable to live outside the wombE is@a. 6 weeks

!. ,- weeksc. -/ weeksd. 0- weeks+/. When teaching parents of a neonate theproper position for the neonate!s sleep, thenurse 6atricia stresses the importance ofplacing the neonate on his bac to reduce thris of which of the following?a. Aspiration!. Sudden infant death syndrome JSIDSKc. Suffocation

d. $astroesophageal reflu* J$%)K+1. Which finding might be seen in baby7ames a neonate suspected of having aninfection?a. Flushed cheeks!. Increased temperaturec. Decreased temperatured. Increased activity level+2. 9aby 7enny who is smallforgestation isat increased ris during the transitionalperiod for which complication?

a. Anemia pro!a!ly due to chronic fetal hypo*ia!. #yperthermia due to decreased glycogenstoresc. #yperglycemia due to decreased glycogenstoresd. Polycythemia pro!a!ly due to chronic fetalhypo*ia+#. 5arHorie has Hust given birth at %2 wees!gestation. When the nurse assessing theneonate, which physical finding is e$pected?a. A sleepy& lethargic !a!y!. 9anugo covering the !odyc. Des"uamation of the epidermisd. erni* caseosa covering the !ody+%. After reviewing the 5yrna!s maternalhistory of magnesium sulfate during labor,which condition would nurse 3ichardanticipate as a potential problem in theneonate?a. #ypoglycemia!. 4itteriness


44/87

c. )espiratory depressiond. 'achycardia+'. Which symptom would indicate the 9abyAle$andra was adapting appropriately toe$trauterine life without difficulty?a. 2asal flaring!. 9ight audi!le gruntingc. )espiratory rate /1 to G1 !reaths=minute

d. )espiratory rate G1 to 61 !reaths=minute+). When teaching umbilical cord care for7ennifer a new mother, the nurse 7ennywould include which information?a. Apply pero*ide to the cord with each diaperchange!. Cover the cord with petroleum +elly after!athingc. Heep the cord dry and open to air d. urse 7ohn is performing an assessmenton a neonate. Which of the following findingsis considered common in the healthyneonate?a. Simian crease!. Con+unctival hemorrhagec. Cystic hygromad. Bulging fontanelle+. 0r. 8steves decides to artificially rupturethe membranes of a mother who is on labor.ollowing this procedure, the nurse &aFel

checs the fetal heart tones for which thefollowing reasons?a. 'o determine fetal well!eing.!. 'o assess for prolapsed cordc. 'o assess fetal positiond. 'o prepare for an imminent delivery.+-. Which of the following would be leastliely to indicate anticipated bondingbehaviors by new parents?a. 'he parents3 willingness to touch and hold thenew!orn.!. 'he parent3s e*pression of interest a!out thesi(e of the new!orn.c. 'he parents3 indication that they want to seethe new!orn.d. 'he parents3 interactions with each other./. ollowing a precipitous delivery,e$amination of the client!s vagina reveals afourthdegree laceration. Which of thefollowing would be contraindicated whencaring for this client?

a. Applying cold to limit edema during the first ,-to -/ hours.!. Instructing the client to use two or more peripads to cushion the area.c. Instructing the client on the use of sit( !aths ifordered.d. Instructing the client a!out the importance ofperineal JkegelK e*ercises.

1. A pregnant woman accompanied by herhusband, sees admission to the labor anddelivery area. he states that she!s in laborand says she attended the facility clinic forprenatal care. Which question should thenurse (liver as her first?a. Do you have any chronic illnesses!. Do you have any allergiesc.


45/87

'. Which of the following is normal newborncalorie intae?a. ,,1 to ,01 calories per kg.!. 01 to /1 calories per l! of !ody weight.c. At least - ml per feedingd. @1 to ,11 calories per kg). >urse 7ohn is nowledgeable that usuallyindividual twins will grow appropriately and

at the same rate as singletons until howmany wees?a. ,G to ,6 weeks!. ,6 to -- weeksc. 01 to 0- weeksd. 06 to /1 weeks+. Which of the following classificationsapplies to monoFygotic twins for whom thecleavage of the fertiliFed ovum occurs morethan 1# days after fertiliFation?a. con+oined twins

!. diamniotic dichorionic twinsc. diamniotic monochorionic twind. monoamniotic monochorionic twins. *yra e$perienced painless vaginalbleeding has Hust been diagnosed as havinga placenta previa. Which of the followingprocedures is usually performed to diagnoseplacenta previa?a. Amniocentesis!. Digital or speculum e*aminationc. %*ternal fetal monitoring

d. 8ltrasound-. >urse Arnold nows that the followingchanges in respiratory functioning duringpregnancy is considered normal@a. Increased tidal volume!. Increased e*piratory volumec. Decreased inspiratory capacityd. Decreased o*ygen consumption-/. 8mily has gestational diabetes and it isusually managed by which of the followingtherapy?a. Diet!. 9ongacting insulinc. 7ral hypoglycemicd. 7ral hypoglycemic drug and insulin-1. 5agnesium sulfate is given to 7emmawith preeclampsia to prevent which of thefollowing condition?a. #emorrhage!. #ypertension

c. #ypomagnesemiad. Sei(ure-2. ammile with sicle cell anemia has anincreased ris for having a sicle cell crisisduring pregnancy. Aggressive managementof a sicle cell crisis includes which of thefollowing measures?a. Antihypertensive agents

!. Diuretic agentsc. I.. fluidsd. Acetaminophen J'ylenolK for pain-#. Which of the following drugs is theantidote for magnesium to$icity?a. Calcium gluconate JHalcinateK!. #ydrala(ine JApresolineKc. 2alo*one J2arcanKd. )ho JDK immune glo!ulin J)ho$A5K-%. 5arlyn is screened for tuberculosisduring her first prenatal visit. An intradermal

inHection of purified protein derivative D660Eof the tuberculin bacilli is given. he isconsidered to have a positive test for whichof the following results?a. An indurated wheal under ,1 mm in diameterappears in G to ,- hours.!. An indurated wheal over ,1 mm in diameterappears in /6 to ?- hours.c. A flat circumcised area under ,1 mm indiameter appears in G to ,- hours.d. A flat circumcised area over ,1 mm in

diameter appears in /6 to ?- hours.-'. 0ianne, 2% yearold is 2+ wees! pregnantarrives at her physician!s office withcomplaints of fever, nausea, vomiting,malaise, unilateral flan pain, andcostovertebral angle tenderness. Which ofthe following diagnoses is most liely?a. Asymptomatic !acteriuria!. Bacterial vaginosisc. Pyelonephritisd. 8rinary tract infection J8'IK-). 3h isoimmuniFation in a pregnant clientdevelops during which of the followingconditions?a. )hpositive maternal !lood crosses into fetal!lood& stimulating fetal anti!odies.!. )hpositive fetal !lood crosses into maternal!lood& stimulating maternal anti!odies.c. )hnegative fetal !lood crosses into maternal!lood& stimulating maternal anti!odies.


46/87

d. )hnegative maternal !lood crosses into fetal!lood& stimulating fetal anti!odies.-+. *o promote comfort during labor, thenurse 7ohn advises a client to assumecertain positions and avoid others. Whichposition may cause maternal hypotensionand fetal hypo$ia?a. 9ateral position

!. S"uatting positionc. Supine positiond. Standing position-. eleste who used heroin during herpregnancy delivers a neonate. Whenassessing the neonate, thenurse 4ynnette e$pects to find@a. 9ethargy - days after !irth.!. Irrita!ility and poor sucking.c. A flattened nose& small eyes& and thin lips.d. Congenital defects such as lim! anomalies.

--. *he uterus returns to the pelvic cavity inwhich of the following time frames?a. ?th to @th day postpartum.!. - weeks postpartum.c. %nd of Gth week postpartum.d.


47/87

?. By force of law& therefore& the P)CBoard of2ursing released )esolution 2o. ,/ Series of theentitled; Adoption of a 2ursing SpecialtyCertification Program and Creation of 2ursingSpecialty Certification Council. 'his rulemakingpower is called;a. Nuasi4udicial Power !. )egulatory Power

c. Nuasi=9egislative Power d. %*ecutive=Promulgation Power 6. 8nder the P)CBoard of 2ursing )esolutionpromulgating the adoption of a 2ursingSpecialtyCertification Program and Council&which two J-K of the following serves as thestrongest for its enforcementJaK Advances made in science and technologyhave provided the climate for speciali(ation inalmost all aspects of human endeavor andJ!K As necessary conse"uence& there has

emerged a new concept known as glo!ali(ationwhich seeks to remove !arriers in trade& industryand services imposed !y the national laws ofcountries all over the world> andJcK Awareness of this development should impelthe nursing sector to prepare our people in theservices sector to meet .the a!ove challenges>andJdK Current trends of speciali(ation in nursingpractice recogni(ed !y> the International Councilof 2urses JIC2K of which the Philippines is a

mem!er for the !enefit of the Filipino in terms ofdeepening and refining nursing practice andenhancing the "uality of nursing care.a. ! R c are strong +ustification!. a R ! are strong +ustificationc. a R c are strong +ustificationd. a R d are strong +ustification@.


48/87

health center team.c. coordination with other sectors in relation tohealth concerns.d. carrying out nursing procedures as per plan of action.,/. In community health nursing it is important totake into account the family health with ane"ually important need to perform ocular

inspection of the areas activities which arepowerful elements of;a. evaluation!. assessmentc. implementationd. planning,. 'he initial step in the P9A22I2$ process inorder to engage in any nursing pro+ect or partiesat the community level involves;a. goalsetting!. monitoring

c. evaluation of datad. provision of dataSituation / Please continue responding as aprofessional nurse in these other healthsituations through the following "uestions.,G. 'ransmission of #I from an infectedindividual to another person occurs;a. 5ost fre"uency in nurses with needlesticks.!. 7nly if there is a large viral load in the !lood.c. 5ost commonly as a result of se*ual contact.d. In all infants !orn to women with #I infection.

,?. 'he medical record of a client reveals acondition in which the fetus cannot pass throughthe maternal pelvis. 'he nurse interprets this as;a. Contracted pelvis!. 5aternal disproportionc. Cervical insufficiencyd. Fetopelvic disproportion,6. 'he nurse would anticipate a cesarean !irthfor a client who has which infection present atthe onset of la!ora. #erpes simple* virus!. #uman papillomavirusc. #epatitisd. 'o*oplasmosis,@. After a vaginal e*amination& the nursedetermines that the client3s fetus is in an occiputposterior position. 'he nurse would anticipatethat the client will have;a. A precipitous !irth!. Intense !ack pain

c. Fre"uent leg crampsd. 2ausea and vomiting-1. 'he rationales for using a prostaglandin gelfor a client prior to the induction of la!or is to;a. Soften and efface the cervi*!. 2um! cervical3 pain receptorsc. Prevent cervical lacerationsd. Stimulate uterine contractions

Situation 2urse 9orena is a Family Planningand Infertility 2urse Specialist and is currentlyattending to a meeting. 'he following conditionspertain to meeting the nursing of this particularpopulation group.-,. Dina& ,? years old& asks you how a tu!alligation prevents pregnancy.


49/87

after effectd. She may feel some cramping when the dye isinserted-. 9ilia3s cousin on the other hand& knowingnurse 9orena3s speciali(ation asks what artificialinsemination !y donor entails.


50/87

care plan section. 'his carries information a!out!asic demographic data& primary medicaldiagnosis& current orders of the physician to !ecarried out !y the nurse& written nursing careplan& nursing orders& scheduled tests andprocedures& safety precautions inpatient careand factors related to daily living activities= thisrecord is used in the chargeofshift reports or

during the !edside rounds or walking rounds.


51/87

a. #er hus!and plays golf G days a week!. She was over 0 when she !ecame pregnantc. She usually drinks tomato +uice for !reakfastd. She has developed gestational dia!etes/-. Bernadette develops a deepvein throm!osisfollowing an auto accident and is prescri!edheparin su!N.


52/87

the following cases pertain to ASS%SS5%2' A2D CA)% 7F '#% 2%


53/87

d. -6 cm& and fetal heart can !e heard with aDoppler G-. In doing 9eopold3s maneuver palpation whichamong the following is 27' considered a goodpreparationa. 'he woman should lie in a supine position withher knees fle*ed slightly!. 'he hands of the nurse should !e cold so that

a!dominal muscles would contract and tightenc. Be certain that your hands are warm J!ywashing them in warm water first if necessaryKd. 'he woman empties her !ladder !eforepalpationG0. In her pregnancy& she e*perienced fatigueand drowsiness. 'his pro!a!ly occurs !ecause;a. of high !lood pressure!. she is e*pressing pressurec. the fetus utili(es her glucose stores andleaves her with a Sow !lood glucose

d. of the rapid growth of the fetusG/. 'he nurse assesses the woman at -1weeks gestation and e*pects the woman toreport;a. Spotting related to fetal implantation!. Symptoms of dia!etes as human placentallactogen is releasedc. Feeling fetal kicksd. 2ausea and vomiting related #C$ productionG. If 5rs. 5edina comes to you for checkup on4une -& her %D7 is 4une ,,& what do you e*pect

during assessmenta. Fundic ht - fingers !elow *yphoid process&engaged!. Cervi* close& uneffaced& F#midway !etweenthe um!ilicus and symphysis pu!isc. Cervi* open& fundic ht. - fingers !elow *yphoidprocess& floating .d. Fundal height at least at the level of the*yphoid process& engagedSituation ,/; Please continue responding as aprofessional nurse in varied health situationsthrough the following "uestions.GG.


54/87

?-.


55/87

D. Considers its own recognition !y higheradministration for purposes of promotion andprestigea. 7nly C and D are correct!. A& C and D are correctc. B& C& and D are correctd. 7nly A and B are correct61.


56/87

privated. 'hey give him timeout when this !egins6@. #ow many words does a typical ,-monthold infant usea. A!out ,- words!. 'wenty or more wordsc. A!out 1 wordsd. 'wo& plus mama and dada

@1. As a nurse. Lou reviewed infant safetyprocedures with Bryan3s mother.


57/87

!.%very , minutesc.%very 01 minutesd.%very G1 minutes0.A patient is in last trimester of pregnancy.2urse 4ane should instruct her to notify herprimary health care provider immediately if shenotices;a.Blurred vision

!.#emorrhoidsc.Increased vaginal mucusd.Shortness of !reath on e*ertion/.'he nurse in charge is reviewing a patient3sprenatal history. a.)eturn preovulatory !asal !ody temperature!.Basal !ody temperature increase of 1.,degrees to 1.- degrees on the -nd or 0rdday ofcyclec.0 full days of elevated !asal !ody temperatureand clear& thin cervical mucus

d.Breast tenderness and mittelschmer(G.During a nonstress test J2S'K& the electronictracing displays a relatively flat line for fetalmovement& making it difficult to evaluate the fetalheart rate JF#)K. 'o mark the strip& the nurse incharge should instruct the client to push thecontrol !utton at which timea.At the !eginning of each fetal movement!.At the !eginning of each contractionc.After every three fetal movementsd.At the end of fetal movement?.


58/87

a.'he attachment of the !a!y to the !reast.!.'he mother3s comfort level with positioning the!a!y.c.Audi!le swallowing.d.'he !a!y3s lips smacking,0.During a prenatal visit at / months gestation&a pregnant client asks whether tests can !e doneto identify fetal a!normalities. Between ,6 and

/1 weeks3 gestation& which procedure is used todetect fetal anomaliesa.Amniocentesis.!.Chorionic villi sampling.c.Fetoscopy.d.8ltrasound,/.A client& 01 weeks pregnant& is scheduled fora !iophysical profile JBPPK to evaluate the healthof her fetus. #er BPP score is 6.


59/87

c.,1 daysd.,/ weeks-/.After teaching a pregnant woman who is inla!or a!out the purpose of the episiotomy& whichof the following purposes stated !y the clientwould indicate to the nurse that the teaching waseffectivea.Shortens the second stage of la!or

!.%nlarges the pelvic inletc.Prevents perineal edemad.%nsures "uick placenta delivery-.A primigravida client at a!out 0 weeksgestation in active la!or has had no prenatalcare and admits to cocaine use during thepregnancy.


60/87

A. 'o allow atraumatic delivery of the !a!yB. 'o allow a gradual shifting of the !lood intothe maternal circulationC. 'o make the delivery effort free and themother does not need to push with contractionsD. 'o prevent perineal laceration with thee*pulsion of the fetal head). When giving narcotic analgesics to mother

in labor, the special consideration to followis@ A. 'he progress of la!or is well esta!lishedreaching the transitional stageB. 8terine contraction is progressing well anddelivery of the !a!y is imminentC. Cervical dilatation has already reached atleast 6 cm. and the station is at least JQK-D. 8terine contractions are strong and the !a!ywill not !e delivered yet within the ne*t 0 hours.+. *he cervical dilatation taen at @// A5 in

a I16/ patient was ) centimeters. A repeat:.8. done at 1/ A. 5. showed that cervicaldilation was + cm. *he correct interpretationof this result is@

A. 9a!or is progressing as e*pectedB. 'he latent phase of Stage , is prolongedC. 'he active phase of Stage , is protractedD. 'he duration of la!or is normal. Which of the following techniques duringlabor and delivery can lead to uterineinversion?

A. Fundal pressure applied to assist the motherin !earing down during delivery of the fetal headB. Strongly tugging on the um!ilical cord todeliver the placenta and hasten placentalseparationC. 5assaging the fundus to encourage theuterus to contractD. Applying light traction when delivering theplacenta that has already detached from theuterine wall-. *he fetal heart rate is checed followingrupture of the bag of waters in order to@

A. Check if the fetus is suffering from headcompressionB. Determine if cord compression followed theruptureC. Determine if there is uteroplacentalinsufficiencyD. Check if fetal presenting part has ade"uatelydescended following the rupture

1/. =pon assessment, the nurse got thefollowing findings@ 2 perineal pads highlysaturated with blood within 2 hours postpartum, 63J / bpm, fundus soft andboundaries not well define0. *he appropriatenursing diagnosis is@

A. 2ormal !lood lossB. Blood volume deficiency

C. Inade"uate tissue perfusion related tohemorrhageD. #emorrhage secondary to uterine atony11. *he following are signs and symptoms offetal distress 8K86*@

A. Fetal heart rate JF#)K decreased during acontraction and persists even after the uterinecontraction endsB. 'he F#) is less than ,-1 !pm or over ,G1!pmC. 'he precontraction F#) is ,01 !pm& F#)

during contraction is ,,6 !pm and F#) afteruterine contraction is ,-G !pmD. F#) is ,G1 !pm& weak and irregular 12. :f the labor period lasts only for # hours,the nurse should suspect that the followingconditions may occur@,.9aceration of cervi*-.9aceration of perineum0.Cranial hematoma in the fetus/.Fetal ano*ia

A. , R -

B. - R /C. -&0&/D. ,&-&0&/1#. *he primary power involved in labor anddelivery is

A. Bearing down a!ility of mother B. Cervical effacement and dilatationC. 8terine contractionD. alsalva techni"ue1%. *he proper technique to monitor theintensity of a uterine contraction is

A. Place the palm of the hands on the a!domenand time the contractionB. Place the finger tips lightly on the suprapu!icarea and time the contractionC. Put the tip of the fingers lightly on the fundalarea and try to indent the a!dominal wall at theheight of the contractionD. Put the palm of the hands on the fundal areaand feel the contraction at the fundal area


61/87

1'. *o monitor the frequency of the uterinecontraction during labor, the right techniqueis to time the contraction

A. From the !eginning of one contraction to theend of the same contractionB. From the !eginning of one contraction to the!eginning of the ne*t contractionC. From the end of one contraction to the

!eginning of the ne*t contractionD. From the deceleration of one contraction tothe acme of the ne*t contraction1). *he pea point of a uterine contraction iscalled the

A. AccelerationB. AcmeC. DecelerationD. A*iom1+. When determining the duration of auterine contraction the right technique is to

time it from A. 'he !eginning of one contraction to the end of the same contractionB. 'he end of one contraction to the !eginning of another contractionC. 'he acme point of one contraction to theacme point of another contractionD. 'he !eginning of one contraction to the end of another contraction1. When the bag of waters ruptures, thenurse should chec the characteristic of the

amniotic flui0. *he normal color of amnioticfluid is A. Clear as water B. BluishC. $reenishD. Lellowish1-. When the bag of waters rupturesspontaneously, the nurse should inspect thevaginal introitus for possible cord prolapse. :f there is part of the cord that has prolapsedinto the vaginal opening the correct nursingintervention is@

A. Push !ack the prolapse cord into the vaginalcanalB. Place the mother on semifowler3s position toimprove circulationC. Cover the prolapse cord with sterile gau(ewet with sterile 2SS and place the woman on'rendelen!urg positionD. Push !ack the cord into the vagina and placethe woman on sims position

2/. *he fetal heart beat should be monitoredevery 1' minutes during the 2nd stage oflabor. *he characteristic of a normal fetalheart rate is

A. 'he heart rate will decelerate during acontraction and then go !ack to its precontraction rate after the contractionB. 'he heart rate will accelerate during a

contraction and remain slightly a!ove the precontraction rate at the end of the contractionC. 'he rate should not !e affected !y the uterinecontraction.D. 'he heart rate will decelerate at the middle ofa contraction and remain so for a!out a minuteafter the contraction21. *he mechanisms involved in fetal deliveryis

A. Descent& e*tension& fle*ion& e*ternal rotationB. Descent& fle*ion& internal rotation& e*tension&

e*ternal rotationC. Fle*ion& internal rotation& e*ternal rotation&e*tensionD. Internal rotation& e*tension& e*ternal rotation&fle*ion22. *he first thing that a nurse must ensurewhen the baby!s head comes out is

A. 'he cord is intactB. 2o part of the cord is encircling the !a!y3sneckC. 'he cord is still attached to the placenta

D. 'he cord is still pulsating2#. *o ensure that the baby will breath assoon as the head is delivered, the nurse!spriority action is to

A. Suction the nose and mouth to removemucous secretionsB. Slap the !a!y3s !uttocks to make the !a!y cryC. Clamp the cord a!out G inches from the !aseD. Check the !a!y3s color to make sure it is notcyanotic2%. When doing perineal care in preparationfor delivery, the nurse should observe thefollowing 8K86*

A. 8se updown techni"ue with one strokeB. Clean from the mons veneris to the anusC. 8se mild soap and warm water D. Paint the inner thighs going towards theperineal area2'. What are the important considerationsthat the nurse must remember after theplacenta is delivered?


62/87

1.hec if the placenta is complete includingthe membranes2.hec if the cord is long enough for thebaby#.hec if the umbilical cord has # bloodvessels%.hec if the cord has a meaty portion and ashiny portion

A. , and 0B. - and /C. ,& 0& and /D. - and 02). *he following are correct statementsabout false labor 8K86*

A. 'he pain is irregular in intensity andfre"uency.B. 'he duration of contraction progressivelylengthens over timeC. 'here is no vaginal !loody discharge

D. 'he cervi* is still closeD.2+. *he passageway in labor and deliver ofthe fetus include the following 8K86*

A. Distensi!ility of lower uterine segmentB. Cervical dilatation and effacementC. Distensi!ility of vaginal canal and introitusD. Fle*i!ility of the pelvis2. *he normal umbilical cord is composedof@

A. - arteries and , veinB. - veins and , artery

C. - arteries and - veinsD. none of the a!ove2-. At what stage of labor and delivery does aprimigravida differ mainly from amultigravida?

A. Stage ,B. Stage -C. Stage 0D. Stage /#/. *he second stage of labor begins with

LLL and ends with LL? A. Begins with full dilatation of cervi* and endswith delivery of placentaB. Begins with true la!or pains and ends withdelivery of !a!yC. Begins with complete dilatation andeffacement of cervi* and ends with delivery of!a!yD. Begins with passage of show and ends withfull dilatation and effacement of cervi*

#1. *he following are signs that the placentahas detached 8K86*@

A. 9engthening of the cordB. 8terus !ecomes more glo!ular C. Sudden gush of !loodD. 5other feels like !earing down#2. When the shiny portion of the placentacomes out first, this is called the LLL

mechanism. A. Schult(eB. )itgensC. DuncanD. 5armets##. When the baby!s head is out, theimmediate action of the nurse is

A. Cut the um!ilical cordB.


63/87

C. 7*ytocin will facilitate placental deliveryD. $iving o*ytocin will ensure complete deliveryof the placenta#. :n a gravidocardiac mother, the first 2hours postpartum D%th stage of labor anddeliveryE particularly in a cesarean section isa critical period because at this stage

A. 'here is a fluid shift from the placental

circulation to the maternal circulation which canoverload the compromised heart.B. 'he maternal heart is already weak and themother can dieC. 'he delivery process is strenuous to themother D. 'he mother is tired and weak which candistress the heart#-. *he drug usually given parentally toenhance uterine contraction is@

A. 'er!utalline

B. PitocinC. 5agnesium sulfateD. 9idocaine%/. *he partograph is a tool used to monitorlabor. *he maternal parameters

Maternal and Child Nursing Questions

Documents

Transcript of Maternal and Child Nursing Questions