1. A client asks the nurse what a third degree laceration is. She was informed that she had one. The nurse explains that this is:
preecplampsia. Which of the following represents an unusual finding for this condition?
a. that extended their anal sphincter b. through the skin and into the muscles c. that involves anterior rectal wall d. that extends through the perineal muscle.
a. generalized edema b. proteinuria 4+ c. blood pressure of 160/110 d. convulsions
2. Betina 30 weeks AOG discharged with a diagnosis of placenta previa. The nurse knows that the client understands her care at home when she says:
8. Nurse Geli explains to the client who is 33 weeks pregnant and is experiencing vaginal bleeding that coitus:
a. I am happy to note that we can have sex occasionally when I have no bleeding. b. I am afraid I might have an operation when my due comes c. I will have to remain in bed until my due date comes d. I may go back to work since I stay only at the office.
3. The uterus has already risen out of the pelvis and is experiencing farther into the abdominal area at about the: a. 8th week of pregnancy b. 10th week of pregnancy c. 12th week of pregnancy d. 18th week of pregnancy
a. Need to be modified in any way by either partner b. Is permitted if penile penetration is not deep. c. Should be restricted because it may stimulate uterine activity. d. Is safe as long as she is in side-lying position.
9. Mrs. Precilla Abuel, a 32 year old mulripara is admitted to labor and delivery. Her last 3 pregnancies in short stage one of labor. The nurses decide to observe her closely. The physician determines that Mrs. Abuel’s cervix is dilated to 6 cm. Mrs. Abuel states that she is extremely uncomfortable. To lessen Mrs. Abuel’s discomfort, the nurse can advise her to: a. lie face down b. not drink fluids c. practice holding breaths between contractions d. assume Sim’s position
4. Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester: 10. Which is true regarding the fontanels of the newborn? a. frequency b. dysuria c. incontinence d. burning
5. Mrs. Jimenez went to the health center for pre-natal check-up. the student nurse took her weight and revealed 142 lbs. She asked the student nurse how much should she gain weight in her pregnancy. a. 20-30 lbs b. 25-35 lbs c. 30- 40 lbs d. 10-15 lbs
6. The nurse is preparing Mrs. Jordan for cesarean delivery. Which of the following key concept should the nurse consider when implementing nursing care? a. Explain the surgery, expected outcome and kind of anesthetics. b. Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth. c. Arrange for a staff member of the anesthesia department to explain what to expect post-operatively. d. Instruct the mother’s support person to remain in the family lounge until after the delivery.
a. The anterior is large in shape when compared to the posterior fontanel. b. The anterior is triangular shaped; the posterior is diamond shaped. c. The anterior is bulging; the posterior appears sunken. d. The posterior closes at 18 months; the anterior closes at 8 to 12 months.
11. Mrs. Quijones gave birth by spontaneous delivery to a full term baby boy. After a minute after birth, he is crying and moving actively. His birth weight is 6.8 lbs. What do you expect baby Quijones to weigh at 6 months? a. 13 -14 lbs b. 16 -17 lbs c. 22 -23 lbs d. 27 -28 lbs
12. During the first hours following delivery, the post partum client is given IVF with oxytocin added to them. The nurse understands the primary reason for this is: a. To facilitate elimination b. To promote uterine contraction c. To promote analgesia d. To prevent infection
7. Bettine Gonzales is hospitalized for the treatment of severe
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13. Nurse Luis is assessing the newborn’s heart rate. Which of the following would be considered normal if the newborn is sleeping? a. 80 beats per minute b. 100 beats per minute c. 120 beats per minute d. 140 beats per minute
14. The infant with Down Syndrome should go through which of the Erikson’s developmental stages first? a. Initiative vs. Self doubt b. Industry vs. Inferiority c. Autonomy vs. Shame and doubt d. Trust vs. Mistrust
c. 5 inches d. 6 inches
20. Alice, 10 years old was brought to the ER because of Asthma. She was immediately put under aerosol administration of Terbutaline. After sometime, you observe that the child does not show any relief from the treatment given. Upon assessment, you noticed that both the heart and respiratory rate are still elevated and the child shows difficulty of exhaling. You suspect: a. Bronchiectasis b. Atelectasis c. Epiglotitis d. Status Asthmaticus
15. The child with phenylketonuria (PKU) must maintain a low phenylalanine diet to prevent which of the following complications?
21. Nurse Jonas assesses a 2 year old boy with a tentative diagnosis of nephroblastoma. Symptoms the nurse observes that suggest this problem include:
a. Irreversible brain damage b. Kidney failure c. Blindness d. Neutropenia
a. Lymphedema and nerve palsy b. Hearing loss and ataxia c. Headaches and vomiting d. Abdominal mass and weakness
16. Which age group is with imaginative minds and creates imaginary friends?
22. Which of the following danger sings should be reported immediately during the antepartum period?
a. Toddler b. Preschool c. School d. Adolescence
a. blurred vision b. nasal stuffiness c. breast tenderness d. constipation
17. Which of the following situations would alert you to a potentially developmental problem with a child?
23. Nurse Jacob is assessing a 15 month old child with acute otitis media. Which of the following symptoms would the nurse anticipate finding?
a. Pointing to body parts at 15 months of age. b. Using gesture to communicate at 18 months. c. Cooing at 3 months. d. Saying ―mama‖ or ―dada‖ for the first time at 18 months of age.
18. Isabelle, a 2 year old girl loves to move around and oftentimes manifests negativism and temper tantrums. What is the best way to deal with her behavior? a. Tell her that she would not be loved by others is she behaves that way.. b. Withholding giving her toys until she behaves properly. c. Ignore her behavior as long as she does not hurt herself and others. d. Ask her what she wants and give it to pacify her.
a. periorbital edema, absent light reflex and translucent tympanic membrane b. irritability, purulent drainage in middle ear, nasal congestion and cough c. diarrhea, retracted tympanic membrane and enlarged parotid gland d. Vomiting, pulling at ears and pearly white tympanic membrane
24. Which of the following is the most appropriate intervention to reduce stress in a preterm infant at 33 weeks gestation? a. Sensory stimulation including several senses at a time b. tactile stimulation until signs of over stimulation develop c. An attitude of extension when prone or side lying d. Kangaroo care
19. Baby boy Villanueva, 4 months old, was seen at the pediatric clinic for his scheduled check-up. By this period, baby Villanueva has already increased his height by how many inches?
25. The parent of a client with albinism would need to be taught which preventive healthcare measure by the nurse:
a. 3 inches b. 4 inches
a. Ulcerative colitis diet b. Use of a high-SPF sunblock
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c. Hair loss monitoring d. Monitor for growth retardation 1. (A) that extended their anal sphincter Third degree laceration involves all in the second degree laceration and the external sphincter of the rectum. Options B, C and D are under the second degree laceration. 2. (C) I will have to remain in bed until my due date comes Placenta previa means that the placenta is the presenting part. On the first and second trimester there is spotting. On the third trimester there is bleeding that is sudden, profuse and painless. 3. (D) 18th week of pregnancy On the 8th week of pregnancy, the uterus is still within the pelvic area. On the 10th week, the uterus is still within the pelvic area. On the 12th week, the uterus and placenta have grown, expanding into the abdominal cavity. On the 18th week, the uterus has already risen out of the pelvis and is expanding into the abdominal area. 4. (A) frequency Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary frequency. Dysuria, incontinence and burning are symptoms associated with urinary tract infection. 5. (B) 25-35 lbs A weight gain of 11. 2 to 15.9 kg (25 to 35 lbs) is currently recommended as an average weight gain in pregnancy. This weight gain consists of the following: fetus- 7.5 lb; placenta- 1.5 lb; amniotic fluid- 2 lb; uterus- 2.5 lb; breasts- 1.5 to 3 lb; blood volume- 4 lb; body fat- 7 lb; body fluid- 7 lb. 6. (B) Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth. A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching to meet the needs of either planned or emergency cesarean birth, the depth and breadth of instruction will depend on circumstances and time available. 7. (D) convulsions Options A, B and C are findings of severe preeclampsia. Convulsions is a finding of eclampsia—an obstetrical emergency. 8. (C) Should be restricted because it may stimulate uterine activity. Coitus is restricted when there is watery discharge, uterine contraction and vaginal bleeding. Also those women with a history of spontaneous miscarriage may be advised to avoid coitus during the time of pregnancy when a previous miscarriage occurred.
11. (A) 13 -14 lbs The birth weight of an infant is doubled at 6 months and is tripled at 12 months. 12. (B) To promote uterine contraction Oxytocin is a hormone produced by the pituitary gland that produces intermittent uterine contractions, helping to promote uterine involution. 13. (B) 100 beats per minute The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute. If the newborn was awake, the normal heart rate would range from 120 to 160 beats per minute. 14. (D) Trust vs. Mistrust The child with Down syndrome will go through the same first stage, trust vs. mistrust, only at a slow rate. Therefore, the nurse should concentrate on developing on bond between the primary caregiver and the child. 15. (A) Irreversible brain damage The child with PKU must maintain a strict low phenylalanine diet to prevent central nervous system damage, seizures and eventual death. 16. (B) Preschool During preschool, this is the time when children do imitative play, imaginative play—the occurrence of imaginative playmates, dramatic play where children like to act, dance and sing. 17. (D) Saying “mama” or “dada” for the first time at 18 months of age. A child should say ―mama‖ or ―dada‖ during 10 to 12 months of age. Options A, B and C are all normal assessments of language development of a child. 18. (C) Ignore her behavior as long as she does not hurt herself and others. If a child is trying to get attention or trying to get something through tantrums—ignore his/her behavior. 19. (B) 4 inches From birth to 6 months, the infant grows 1 inch (2.5 cm) per month. From 6 to 12 months, the infant grows ½ inch (1.25 cm) per month. 20. (D) Status Asthmaticus Status asthmaticus leads to respiratory distress and bronchospasm despite of treatment and interventions. Mechanical ventilation maybe needed due to respiratory failure.
9. (D) assume Sim’s position When the woman is in Sim’s position, this puts the weight of the fetus on bed, not on the woman and allows good circulation in the lower extremities.
21. (D) Abdominal mass and weakness Nephroblastoma or Wilm’s tumor is caused by chromosomal abnormalities, most common kidney cancer among children characterized by abdominal mass, hematuria, hypertension and fever.
10. (A) The anterior is large in shape when compared to the posterior fontanel. The anterior fontanel is larger in size than the posterior fontanel. Additionally, the anterior fontanel, which is diamond shaped closes at 18 month, whereas the posterior fontanel, which is triangular in shape closes at 8 to 12 weeks. Neither fontanel should appear bulging, which may indicate increases ICP or sunken, which may indicate hydration.
22. (A) blurred vision Danger signs that require prompt reporting are leaking of amniotic fluid, blurred vision, vaginal bleeding, rapid weight gain and elevated blood pressure. Nasal stuffiness, breast tenderness, and constipation are common discomforts associated with pregnancy. 23. (B) irritability, purulent drainage in middle ear, nasal congestion and cough
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Irritability, purulent drainage in middle ear, nasal congestion and cough, fever, loss of appetite, vomiting and diarrhea are clinical manifestations of otitis media. Acute otitis media is common in children 6 months to 3 years old and 8 years old and above. Breast fed infants have higher resistance due to protection of Eustachian tubes and middle ear from breast milk. 24. (D) Kangaroo care Kangaroo care is the use of skin-to-skin contact to maintain body heat. This method of care not only supplies heat but also encourages parent-child interaction. 25. (B) Use of a high-SPF sunblock Without melanin production, the child with albinism is at risk for severe sunburns. Maximum sun protection should be taken, including use of hats, long sleeves, minimal time in the sun and high-SPF sunblock, to prevent any problems. 1. May arrives at the health care clinic and tells the nurse that her last menstrual period was 9 weeks ago. She also tells the nurse that a home pregnancy test was positive but she began to have mild cramps and is now having moderate vaginal bleeding. During the physical examination of the client, the nurse notes that May has a dilated cervix. The nurse determines that May is experiencing which type of abortion? a. Inevitable b. Incomplete c. Threatened d. Septic
2. Nurse Reese is reviewing the record of a pregnant client for her first prenatal visit. Which of the following data, if noted on the client’s record, would alert the nurse that the client is at risk for a spontaneous abortion? a. Age 36 years b. History of syphilis c. History of genital herpes d. History of diabetes mellitus
3. Nurse Hazel is preparing to care for a client who is newly admitted to the hospital with a possible diagnosis of ectopic pregnancy. Nurse Hazel develops a plan of care for the client and determines that which of the following nursing actions is the priority? a. Monitoring weight b. Assessing for edema c. Monitoring apical pulse d. Monitoring temperature
4. Nurse Oliver is teaching a diabetic pregnant client about nutrition and insulin needs during pregnancy. The nurse determines that the client understands dietary and insulin needs if the client states that the second half of pregnancy require: a. Decreased caloric intake b. Increased caloric intake c. Decreased Insulin d. Increase Insulin
5. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is aware that one of the following is unassociated with this condition? a. Excessive fetal activity. b. Larger than normal uterus for gestational age. c. Vaginal bleeding d. Elevated levels of human chorionic gonadotropin.
6. A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension (PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is: a. Urinary output 90 cc in 2 hours. b. Absent patellar reflexes. c. Rapid respiratory rate above 40/min. d. Rapid rise in blood pressure.
7. During vaginal examination of Janah who is in labor, the presenting part is at station plus two. Nurse, correctly interprets it as: a. Presenting part is 2 cm above the plane of the ischial spines. b. Biparietal diameter is at the level of the ischial spines. c. Presenting part in 2 cm below the plane of the ischial spines. d. Biparietal diameter is 2 cm above the ischial spines.
8. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is: a. Contractions every 1 ½ minutes lasting 70-80 seconds. b. Maternal temperature 101.2 c. Early decelerations in the fetal heart rate. d. Fetal heart rate baseline 140-160 bpm.
9. Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A nursing action that must be initiated as the plan of care throughout injection of the drug is: a. Ventilator assistance b. CVP readings c. EKG tracings d. Continuous CPR
10. A trial for vaginal delivery after an earlier caesareans, would likely to be given to a gravida, who had: a. First low transverse cesarean was for active herpes type 2 infections; vaginal culture at 39 weeks pregnancy was positive. b. First and second caesareans were for cephalopelvic disproportion. c. First caesarean through a classic incision as a result of severe fetal distress. d. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation.
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11.Nurse Ryan is aware that the best initial approach when trying to take a crying toddler’s temperature is: a. Talk to the mother first and then to the toddler. b. Bring extra help so it can be done quickly. c. Encourage the mother to hold the child. d. Ignore the crying and screaming.
a. Effectiveness b. Efficiency c. Adequacy d. Appropriateness
18.Vangie is a new B.S.N. graduate. She wants to become a Public Health Nurse. Where should she apply? 12.Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the nurse do to prevent trauma to operative site? a. Avoid touching the suture line, even when cleaning. b. Place the baby in prone position. c. Give the baby a pacifier. d. Place the infant’s arms in soft elbow restraints.
a. Department of Health b. Provincial Health Office c. Regional Health Office d. Rural Health Unit
19.Tony is aware the Chairman of the Municipal Health Board is: 13. Which action should nurse Marian include in the care plan for a 2 month old with heart failure? a. Feed the infant when he cries. b. Allow the infant to rest before feeding. c. Bathe the infant and administer medications before feeding. d. Weigh and bathe the infant before feeding.
14.Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5 months. The nurse should advise her to include which foods in her infant’s diet? a. Skim milk and baby food. b. Whole milk and baby food. c. Iron-rich formula only. d. Iron-rich formula and baby food.
15.Mommy Linda is playing with her infant, who is sitting securely alone on the floor of the clinic. The mother hides a toy behind her back and the infant looks for it. The nurse is aware that estimated age of the infant would be:
a. Mayor b. Municipal Health Officer c. Public Health Nurse d. Any qualified physician
20.Myra is the public health nurse in a municipality with a total population of about 20,000. There are 3 rural health midwives among the RHU personnel. How many more midwife items will the RHU need? a. 1 b. 2 c. 3 d. The RHU does not need any more midwife item.
21.According to Freeman and Heinrich, community health nursing is a developmental service. Which of the following best illustrates this statement?
a. 6 months b. 4 months c. 8 months d. 10 months
a. The community health nurse continuously develops himself personally and professionally. b. Health education and community organizing are necessary in providing community health services. c. Community health nursing is intended primarily for health promotion and prevention and treatment of disease. d. The goal of community health nursing is to provide nursing services to people in their own places of residence.
16.Which of the following is the most prominent feature of public health nursing?
22.Nurse Tina is aware that the disease declared through Presidential Proclamation No. 4 as a target for eradication in the Philippines is?
a. It involves providing home care to sick people who are not confined in the hospital. b. Services are provided free of charge to people within the catchments area. c. The public health nurse functions as part of a team providing a public health nursing services. d. Public health nursing focuses on preventive, not curative, services.
a. Poliomyelitis b. Measles c. Rabies d. Neonatal tetanus
17.When the nurse determines whether resources were maximized in implementing Ligtas Tigdas, she is evaluating
a. Integration b. Community organization
23.May knows that the step in community organizing that involves training of potential leaders in the community is:
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c. Community study d. Core group formation
30.Malou was diagnosed with severe preeclampsia is now receiving I.V. magnesium sulfate. The adverse effects associated with magnesium sulfate is:
24.Beth a public health nurse takes an active role in community participation. What is the primary goal of community organizing?
a. Anemia b. Decreased urine output c. Hyperreflexia d. Increased respiratory rate
a. To educate the people regarding community health problems b. To mobilize the people to resolve community health problems c. To maximize the community’s resources in dealing with health problems. d. To maximize the community’s resources in dealing with health problems.
25.Tertiary prevention is needed in which stage of the natural history of disease? a. Pre-pathogenesis b. Pathogenesis c. Prodromal d. Terminal
26.The nurse is caring for a primigravid client in the labor and delivery area. Which condition would place the client at risk for disseminated intravascular coagulation (DIC)? a. Intrauterine fetal death. b. Placenta accreta. c. Dysfunctional labor. d. Premature rupture of the membranes.
31.A 23 year old client is having her menstrual period every 2 weeks that last for 1 week. This type of menstrual pattern is bets defined by: a. Menorrhagia b. Metrorrhagia c. Dyspareunia d. Amenorrhea
32.Jannah is admitted to the labor and delivery unit. The critical laboratory result for this client would be: a. Oxygen saturation b. Iron binding capacity c. Blood typing d. Serum Calcium
33.Nurse Gina is aware that the most common condition found during the second-trimester of pregnancy is: a. Metabolic alkalosis b. Respiratory acidosis c. Mastitis d. Physiologic anemia
27.A fullterm client is in labor. Nurse Betty is aware that the fetal heart rate would be: a. 80 to 100 beats/minute b. 100 to 120 beats/minute c. 120 to 160 beats/minute d. 160 to 180 beats/minute
28.The skin in the diaper area of a 7 month old infant is excoriated and red. Nurse Hazel should instruct the mother to: a. Change the diaper more often. b. Apply talc powder with diaper changes. c. Wash the area vigorously with each diaper change. d. Decrease the infant’s fluid intake to decrease saturating diapers.
29.Nurse Carla knows that the common cardiac anomalies in children with Down Syndrome (tri-somy 21) is: a. Atrial septal defect b. Pulmonic stenosis c. Ventricular septal defect d. Endocardial cushion defect
34.Nurse Lynette is working in the triage area of an emergency department. She sees that several pediatric clients arrive simultaneously. The client who needs to be treated first is: a. A crying 5 year old child with a laceration on his scalp. b. A 4 year old child with a barking coughs and flushed appearance. c. A 3 year old child with Down syndrome who is pale and asleep in his mother’s arms. d. A 2 year old infant with stridorous breath sounds, sitting up in his mother’s arms and drooling.
35.Maureen in her third trimester arrives at the emergency room with painless vaginal bleeding. Which of the following conditions is suspected? a. Placenta previa b. Abruptio placentae c. Premature labor d. Sexually transmitted disease
36.A young child named Richard is suspected of having pinworms. The community nurse collects a stool specimen to confirm the diagnosis. The nurse should schedule the collection of this specimen for:
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a. Just before bedtime b. After the child has been bathe c. Any time during the day d. Early in the morning
a. Less oxygen, and the newborn’s metabolic rate increases. b. More oxygen, and the newborn’s metabolic rate decreases. c. More oxygen, and the newborn’s metabolic rate increases. d. Less oxygen, and the newborn’s metabolic rate decreases.
37.In doing a child’s admission assessment, Nurse Betty should be alert to note which signs or symptoms of chronic lead poisoning?
43.Before adding potassium to an infant’s I.V. line, Nurse Ron must be sure to assess whether this infant has:
a. Irritability and seizures b. Dehydration and diarrhea c. Bradycardia and hypotension d. Petechiae and hematuria
a. Stable blood pressure b. Patant fontanelles c. Moro’s reflex d. Voided
38.To evaluate a woman’s understanding about the use of diaphragm for family planning, Nurse Trish asks her to explain how she will use the appliance. Which response indicates a need for further health teaching?
44.Nurse Carla should know that the most common causative factor of dermatitis in infants and younger children is:
a. ―I should check the diaphragm carefully for holes every time I use it‖ b. ―I may need a different size of diaphragm if I gain or lose weight more than 20 pounds‖ c. ―The diaphragm must be left in place for atleast 6 hours after intercourse‖ d. ―I really need to use the diaphragm and jelly most during the middle of my menstrual cycle‖.
39.Hypoxia is a common complication of laryngotracheobronchitis. Nurse Oliver should frequently assess a child with laryngotracheobronchitis for: a. Drooling b. Muffled voice c. Restlessness d. Low-grade fever
40.How should Nurse Michelle guide a child who is blind to walk to the playroom? a. Without touching the child, talk continuously as the child walks down the hall. b. Walk one step ahead, with the child’s hand on the nurse’s elbow. c. Walk slightly behind, gently guiding the child forward. d. Walk next to the child, holding the child’s hand.
41.When assessing a newborn diagnosed with ductus arteriosus, Nurse Olivia should expect that the child most likely would have an: a. Loud, machinery-like murmur. b. Bluish color to the lips. c. Decreased BP reading in the upper extremities d. Increased BP reading in the upper extremities.
42.The reason nurse May keeps the neonate in a neutral thermal environment is that when a newborn becomes too cool, the neonate requires:
a. Baby oil b. Baby lotion c. Laundry detergent d. Powder with cornstarch 45.During tube feeding, how far above an infant’s stomach should the nurse hold the syringe with formula? a. 6 inches b. 12 inches c. 18 inches d. 24 inches 46. In a mothers’ class, Nurse Lhynnete discussed childhood diseases such as chicken pox. Which of the following statements about chicken pox is correct? a. The older one gets, the more susceptible he becomes to the complications of chicken pox. b. A single attack of chicken pox will prevent future episodes, including conditions such as shingles. c. To prevent an outbreak in the community, quarantine may be imposed by health authorities. d. Chicken pox vaccine is best given when there is an impending outbreak in the community.
47.Barangay Pinoy had an outbreak of German measles. To prevent congenital rubella, what is the BEST advice that you can give to women in the first trimester of pregnancy in the barangay Pinoy? a. Advice them on the signs of German measles. b. Avoid crowded places, such as markets and movie houses. c. Consult at the health center where rubella vaccine may be given. d. Consult a physician who may give them rubella immunoglobulin.
48.Myrna a public health nurse knows that to determine possible sources of sexually transmitted infections, the BEST method that may be undertaken is: a. Contact tracing
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b. Community survey c. Mass screening tests d. Interview of suspects
49.A 33-year old female client came for consultation at the health center with the chief complaint of fever for a week. Accompanying symptoms were muscle pains and body malaise. A week after the start of fever, the client noted yellowish discoloration of his sclera. History showed that he waded in flood waters about 2 weeks before the onset of symptoms. Based on her history, which disease condition will you suspect? a. Hepatitis A b. Hepatitis B c. Tetanus d. Leptospirosis
50.Mickey a 3-year old client was brought to the health center with the chief complaint of severe diarrhea and the passage of ―rice water‖ stools. The client is most probably suffering from which condition? a. Giardiasis b. Cholera c. Amebiasis d. Dysentery
51.The most prevalent form of meningitis among children aged 2 months to 3 years is caused by which microorganism? a. Hemophilus influenzae b. Morbillivirus c. Steptococcus pneumoniae d. Neisseria meningitidis
52.The student nurse is aware that the pathognomonic sign of measles is Koplik’s spot and you may see Koplik’s spot by inspecting the: a. Nasal mucosa b. Buccal mucosa c. Skin on the abdomen d. Skin on neck
53.Angel was diagnosed as having Dengue fever. You will say that there is slow capillary refill when the color of the nailbed that you pressed does not return within how many seconds? a. 3 seconds b. 6 seconds c. 9 seconds d. 10 seconds
54.In Integrated Management of Childhood Illness, the nurse is aware that the severe conditions generally require urgent referral to a hospital. Which of the following severe conditions DOES NOT always require urgent referral to a hospital?
a. Mastoiditis b. Severe dehydration c. Severe pneumonia d. Severe febrile disease
55.Myrna a public health nurse will conduct outreach immunization in a barangay Masay with a population of about 1500. The estimated number of infants in the barangay would be: a. 45 infants b. 50 infants c. 55 infants d. 65 infants
56.The community nurse is aware that the biological used in Expanded Program on Immunization (EPI) should NOT be stored in the freezer? a. DPT b. Oral polio vaccine c. Measles vaccine d. MMR
57.It is the most effective way of controlling schistosomiasis in an endemic area? a. Use of molluscicides b. Building of foot bridges c. Proper use of sanitary toilets d. Use of protective footwear, such as rubber boots
58.Several clients is newly admitted and diagnosed with leprosy. Which of the following clients should be classified as a case of multibacillary leprosy? a. 3 skin lesions, negative slit skin smear b. 3 skin lesions, positive slit skin smear c. 5 skin lesions, negative slit skin smear d. 5 skin lesions, positive slit skin smear
59.Nurses are aware that diagnosis of leprosy is highly dependent on recognition of symptoms. Which of the following is an early sign of leprosy? a. Macular lesions b. Inability to close eyelids c. Thickened painful nerves d. Sinking of the nosebridge
60.Marie brought her 10 month old infant for consultation because of fever, started 4 days prior to consultation. In determining malaria risk, what will you do? a. Perform a tourniquet test. b. Ask where the family resides. c. Get a specimen for blood smear. d. Ask if the fever is present everyday.
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c. 5 years d. Lifetime 61.Susie brought her 4 years old daughter to the RHU because of cough and colds. Following the IMCI assessment guide, which of the following is a danger sign that indicates the need for urgent referral to a hospital?
67.Nurse Ron is aware that unused BCG should be discarded after how many hours of reconstitution?
a. Inability to drink b. High grade fever c. Signs of severe dehydration d. Cough for more than 30 days
a. 2 hours b. 4 hours c. 8 hours d. At the end of the day
62.Jimmy a 2-year old child revealed ―baggy pants‖. As a nurse, using the IMCI guidelines, how will you manage Jimmy?
68.The nurse explains to a breastfeeding mother that breast milk is sufficient for all of the baby’s nutrient needs only up to:
a. Refer the child urgently to a hospital for confinement. b. Coordinate with the social worker to enroll the child in a feeding program. c. Make a teaching plan for the mother, focusing on menu planning for her child. d. Assess and treat the child for health problems like infections and intestinal parasitism.
a. 5 months b. 6 months c. 1 year d. 2 years
63.Gina is using Oresol in the management of diarrhea of her 3-year old child. She asked you what to do if her child vomits. As a nurse you will tell her to:
a. 8 weeks b. 12 weeks c. 24 weeks d. 32 weeks
a. Bring the child to the nearest hospital for further assessment. b. Bring the child to the health center for intravenous fluid therapy. c. Bring the child to the health center for assessment by the physician. d. Let the child rest for 10 minutes then continue giving Oresol more slowly.
64.Nikki a 5-month old infant was brought by his mother to the health center because of diarrhea for 4 to 5 times a day. Her skin goes back slowly after a skin pinch and her eyes are sunken. Using the IMCI guidelines, you will classify this infant in which category? a. No signs of dehydration b. Some dehydration c. Severe dehydration d. The data is insufficient.
65.Chris a 4-month old infant was brought by her mother to the health center because of cough. His respiratory rate is 42/minute. Using the Integrated Management of Child Illness (IMCI) guidelines of assessment, his breathing is considered as: a. Fast b. Slow c. Normal d. Insignificant
66.Maylene had just received her 4th dose of tetanus toxoid. She is aware that her baby will have protection against tetanus for a. 1 year b. 3 years
69.Nurse Ron is aware that the gestational age of a conceptus that is considered viable (able to live outside the womb) is:
70.When teaching parents of a neonate the proper position for the neonate’s sleep, the nurse Patricia stresses the importance of placing the neonate on his back to reduce the risk of which of the following? a. Aspiration b. Sudden infant death syndrome (SIDS) c. Suffocation d. Gastroesophageal reflux (GER)
71.Which finding might be seen in baby James a neonate suspected of having an infection? a. Flushed cheeks b. Increased temperature c. Decreased temperature d. Increased activity level
72.Baby Jenny who is small-for-gestation is at increased risk during the transitional period for which complication? a. Anemia probably due to chronic fetal hyposia b. Hyperthermia due to decreased glycogen stores c. Hyperglycemia due to decreased glycogen stores d. Polycythemia probably due to chronic fetal hypoxia 73.Marjorie has just given birth at 42 weeks’ gestation. When the nurse assessing the neonate, which physical finding is expected? a. A sleepy, lethargic baby
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b. Lanugo covering the body c. Desquamation of the epidermis d. Vernix caseosa covering the body 74.After reviewing the Myrna’s maternal history of magnesium sulfate during labor, which condition would nurse Richard anticipate as a potential problem in the neonate? a. Hypoglycemia b. Jitteriness c. Respiratory depression d. Tachycardia
75.Which symptom would indicate the Baby Alexandra was adapting appropriately to extra-uterine life without difficulty? a. Nasal flaring b. Light audible grunting c. Respiratory rate 40 to 60 breaths/minute d. Respiratory rate 60 to 80 breaths/minute
a fourth-degree laceration. Which of the following would be contraindicated when caring for this client? a. Applying cold to limit edema during the first 12 to 24 hours. b. Instructing the client to use two or more peripads to cushion the area. c. Instructing the client on the use of sitz baths if ordered. d. Instructing the client about the importance of perineal (kegel) exercises.
81. A pregnant woman accompanied by her husband, seeks admission to the labor and delivery area. She states that she's in labor and says she attended the facility clinic for prenatal care. Which question should the nurse Oliver ask her first? a. ―Do you have any chronic illnesses?‖ b. ―Do you have any allergies?‖ c. ―What is your expected due date?‖ d. ―Who will be with you during labor?‖
82.A neonate begins to gag and turns a dusky color. What should the nurse do first? 76. When teaching umbilical cord care for Jennifer a new mother, the nurse Jenny would include which information? a. Apply peroxide to the cord with each diaper change b. Cover the cord with petroleum jelly after bathing c. Keep the cord dry and open to air d. Wash the cord with soap and water each day during a tub bath.
a. Calm the neonate. b. Notify the physician. c. Provide oxygen via face mask as ordered d. Aspirate the neonate’s nose and mouth with a bulb syringe.
83. When a client states that her "water broke," which of the following actions would be inappropriate for the nurse to do? 77.Nurse John is performing an assessment on a neonate. Which of the following findings is considered common in the healthy neonate? a. Simian crease b. Conjunctival hemorrhage c. Cystic hygroma d. Bulging fontanelle
78.Dr. Esteves decides to artificially rupture the membranes of a mother who is on labor. Following this procedure, the nurse Hazel checks the fetal heart tones for which the following reasons? a. To determine fetal well-being. b. To assess for prolapsed cord c. To assess fetal position d. To prepare for an imminent delivery.
a. Observing the pooling of straw-colored fluid. b. Checking vaginal discharge with nitrazine paper. c. Conducting a bedside ultrasound for an amniotic fluid index. d. Observing for flakes of vernix in the vaginal discharge.
84. A baby girl is born 8 weeks premature. At birth, she has no spontaneous respirations but is successfully resuscitated. Within several hours she develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and retractions. She's diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator. Which nursing action should be included in the baby's plan of care to prevent retinopathy of prematurity? a. Cover his eyes while receiving oxygen. b. Keep her body temperature low. c. Monitor partial pressure of oxygen (Pao2) levels. d. Humidify the oxygen.
79.Which of the following would be least likely to indicate anticipated bonding behaviors by new parents? 85. Which of the following is normal newborn calorie intake? a. The parents’ willingness to touch and hold the new born. b. The parent’s expression of interest about the size of the new born. c. The parents’ indication that they want to see the newborn. d. The parents’ interactions with each other.
a. 110 to 130 calories per kg. b. 30 to 40 calories per lb of body weight. c. At least 2 ml per feeding d. 90 to 100 calories per kg
80.Following a precipitous delivery, examination of the client's vagina reveals
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86. Nurse John is knowledgeable that usually individual twins will grow appropriately and at the same rate as singletons until how many weeks?
c. I.V. fluids d. Acetaminophen (Tylenol) for pain
a. 16 to 18 weeks b. 18 to 22 weeks c. 30 to 32 weeks d. 38 to 40 weeks
93. Which of the following drugs is the antidote for magnesium toxicity?
87. Which of the following classifications applies to monozygotic twins for whom the cleavage of the fertilized ovum occurs more than 13 days after fertilization? a. conjoined twins b. diamniotic dichorionic twins c. diamniotic monochorionic twin d. monoamniotic monochorionic twins
88. Tyra experienced painless vaginal bleeding has just been diagnosed as having a placenta previa. Which of the following procedures is usually performed to diagnose placenta previa? a. Amniocentesis b. Digital or speculum examination c. External fetal monitoring d. Ultrasound
a. Calcium gluconate (Kalcinate) b. Hydralazine (Apresoline) c. Naloxone (Narcan) d. Rho (D) immune globulin (RhoGAM)
94. Marlyn is screened for tuberculosis during her first prenatal visit. An intradermal injection of purified protein derivative (PPD) of the tuberculin bacilli is given. She is considered to have a positive test for which of the following results? a. An indurated wheal under 10 mm in diameter appears in 6 to 12 hours. b. An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. c. A flat circumcised area under 10 mm in diameter appears in 6 to 12 hours. d. A flat circumcised area over 10 mm in diameter appears in 48 to 72 hours.
89. Nurse Arnold knows that the following changes in respiratory functioning during pregnancy is considered normal:
95. Dianne, 24 year-old is 27 weeks’ pregnant arrives at her physician’s office with complaints of fever, nausea, vomiting, malaise, unilateral flank pain, and costovertebral angle tenderness. Which of the following diagnoses is most likely?
a. Increased tidal volume b. Increased expiratory volume c. Decreased inspiratory capacity d. Decreased oxygen consumption
a. Asymptomatic bacteriuria b. Bacterial vaginosis c. Pyelonephritis d. Urinary tract infection (UTI)
90. Emily has gestational diabetes and it is usually managed by which of the following therapy?
96. Rh isoimmunization in a pregnant client develops during which of the following conditions?
a. Diet b. Long-acting insulin c. Oral hypoglycemic d. Oral hypoglycemic drug and insulin
a. Rh-positive maternal blood crosses into fetal blood, stimulating fetal antibodies. b. Rh-positive fetal blood crosses into maternal blood, stimulating maternal antibodies. c. Rh-negative fetal blood crosses into maternal blood, stimulating maternal antibodies. d. Rh-negative maternal blood crosses into fetal blood, stimulating fetal antibodies.
91. Magnesium sulfate is given to Jemma with preeclampsia to prevent which of the following condition? a. Hemorrhage b. Hypertension c. Hypomagnesemia d. Seizure
92. Cammile with sickle cell anemia has an increased risk for having a sickle cell crisis during pregnancy. Aggressive management of a sickle cell crisis includes which of the following measures?
97. To promote comfort during labor, the nurse John advises a client to assume certain positions and avoid others. Which position may cause maternal hypotension and fetal hypoxia? a. Lateral position b. Squatting position c. Supine position d. Standing position
a. Antihypertensive agents b. Diuretic agents
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98. Celeste who used heroin during her pregnancy delivers a neonate. When assessing the neonate, the nurse Lhynnette expects to find: a. Lethargy 2 days after birth. b. Irritability and poor sucking. c. A flattened nose, small eyes, and thin lips. d. Congenital defects such as limb anomalies.
99. The uterus returns to the pelvic cavity in which of the following time frames? a. 7th to 9th day postpartum. b. 2 weeks postpartum. c. End of 6th week postpartum. d. When the lochia changes to alba.
100. Maureen, a primigravida client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was unusually long and required oxytocin (Pitocin) augmentation. The nurse who's caring for her should stay alert for: a. Uterine inversion b. Uterine atony c. Uterine involution d. Uterine discomfort 1. Answer: (A) Inevitable Rationale: An inevitable abortion is termination of pregnancy that cannot be prevented. Moderate to severe bleeding with mild cramping and cervical dilation would be noted in this type of abortion. 2. Answer: (B) History of syphilis Rationale: Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion. 3. Answer: (C) Monitoring apical pulse Rationale: Nursing care for the client with a possible ectopic pregnancy is focused on preventing or identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock. 4. Answer: (B) Increased caloric intake Rationale: Glucose crosses the placenta, but insulin does not. High fetal demands for glucose, combined with the insulin resistance caused by hormonal changes in the last half of pregnancy can result in elevation of maternal blood glucose levels. This increases the mother’s demand for insulin and is referred to as the diabetogenic effect of pregnancy. 5. Answer: (A) Excessive fetal activity. Rationale: The most common signs and symptoms of hydatidiform mole includes elevated levels of human chorionic gonadotropin, vaginal bleeding, larger than normal uterus for gestational age, failure to detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting, and early development of pregnancyinduced hypertension. Fetal activity would not be noted. 6. Answer: (B) Absent patellar reflexes Rationale: Absence of patellar reflexes is an indicator of hypermagnesemia, which requires administration of calcium gluconate.
7. Answer: (C) Presenting part in 2 cm below the plane of the ischial spines. Rationale: Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the ischial spines. 8. Answer: (A) Contractions every 1 ½ minutes lasting 70-80 seconds. Rationale: Contractions every 1 ½ minutes lasting 70-80 seconds, is indicative of hyperstimulation of the uterus, which could result in injury to the mother and the fetus if Pitocin is not discontinued. 9. Answer: (C) EKG tracings Rationale: A potential side effect of calcium gluconate administration is cardiac arrest. Continuous monitoring of cardiac activity (EKG) throught administration of calcium gluconate is an essential part of care. 10. Answer: (D) First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex presentation. Rationale: This type of client has no obstetrical indication for a caesarean section as she did with her first caesarean delivery. 11. Answer: (A) Talk to the mother first and then to the toddler. Rationale: When dealing with a crying toddler, the best approach is to talk to the mother and ignore the toddler first. This approach helps the toddler get used to the nurse before she attempts any procedures. It also gives the toddler an opportunity to see that the mother trusts the nurse. 12. Answer: (D) Place the infant’s arms in soft elbow restraints. Rationale: Soft restraints from the upper arm to the wrist prevent the infant from touching her lip but allow him to hold a favorite item such as a blanket. Because they could damage the operative site, such as objects as pacifiers, suction catheters, and small spoons shouldn’t be placed in a baby’s mouth after cleft repair. A baby in a prone position may rub her face on the sheets and traumatize the operative site. The suture line should be cleaned gently to prevent infection, which could interfere with healing and damage the cosmetic appearance of the repair. 13. Answer: (B) Allow the infant to rest before feeding. Rationale: Because feeding requires so much energy, an infant with heart failure should rest before feeding. 14. Answer: (C) Iron-rich formula only. Rationale: The infants at age 5 months should receive iron-rich formula and that they shouldn’t receive solid food, even baby food until age 6 months. 15. Answer: (D) 10 months Rationale: A 10 month old infant can sit alone and understands object permanence, so he would look for the hidden toy. At age 4 to 6 months, infants can’t sit securely alone. At age 8 months, infants can sit securely alone but cannot understand the permanence of objects. 16. Answer: (D) Public health nursing focuses on preventive, not curative, services. Rationale: The catchments area in PHN consists of a residential community, many of whom are well individuals who have greater need for preventive rather than curative services. 17. Answer: (B) Efficiency
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Rationale: Efficiency is determining whether the goals were attained at the least possible cost.
Rationale: Endocardial cushion defects are seen most in children with Down syndrome, asplenia, or polysplenia.
18. Answer: (D) Rural Health Unit Rationale: R.A. 7160 devolved basic health services to local government units (LGU’s ). The public health nurse is an employee of the LGU.
30. Answer: (B) Decreased urine output Rationale: Decreased urine output may occur in clients receiving I.V. magnesium and should be monitored closely to keep urine output at greater than 30 ml/hour, because magnesium is excreted through the kidneys and can easily accumulate to toxic levels.
19. Answer: (A) Mayor Rationale: The local executive serves as the chairman of the Municipal Health Board. 20. Answer: (A) 1 Rationale: Each rural health midwife is given a population assignment of about 5,000. 21. Answer: (B) Health education and community organizing are necessary in providing community health services. Rationale: The community health nurse develops the health capability of people through health education and community organizing activities. 22. Answer: (B) Measles Rationale: Presidential Proclamation No. 4 is on the Ligtas Tigdas Program. 23. Answer: (D) Core group formation Rationale: In core group formation, the nurse is able to transfer the technology of community organizing to the potential or informal community leaders through a training program. 24. Answer: (D) To maximize the community’s resources in dealing with health problems. Rationale: Community organizing is a developmental service, with the goal of developing the people’s self-reliance in dealing with community health problems. A, B and C are objectives of contributory objectives to this goal. 25. Answer: (D) Terminal Rationale: Tertiary prevention involves rehabilitation, prevention of permanent disability and disability limitation appropriate for convalescents, the disabled, complicated cases and the terminally ill (those in the terminal stage of a disease). 26. Answer: (A) Intrauterine fetal death. Rationale: Intrauterine fetal death, abruptio placentae, septic shock, and amniotic fluid embolism may trigger normal clotting mechanisms; if clotting factors are depleted, DIC may occur. Placenta accreta, dysfunctional labor, and premature rupture of the membranes aren't associated with DIC. 27. Answer: (C) 120 to 160 beats/minute Rationale: A rate of 120 to 160 beats/minute in the fetal heart appropriate for filling the heart with blood and pumping it out to the system. 28. Answer: (A) Change the diaper more often. Rationale: Decreasing the amount of time the skin comes contact with wet soiled diapers will help heal the irritation. 29. Answer: (D) Endocardial cushion defect
31. Answer: (A) Menorrhagia Rationale: Menorrhagia is an excessive menstrual period. 32. Answer: (C) Blood typing Rationale: Blood type would be a critical value to have because the risk of blood loss is always a potential complication during the labor and delivery process. Approximately 40% of a woman’s cardiac output is delivered to the uterus, therefore, blood loss can occur quite rapidly in the event of uncontrolled bleeding. 33. Answer: (D) Physiologic anemia Rationale: Hemoglobin values and hematocrit decrease during pregnancy as the increase in plasma volume exceeds the increase in red blood cell production. 34. Answer: (D) A 2 year old infant with stridorous breath sounds, sitting up in his mother’s arms and drooling. Rationale: The infant with the airway emergency should be treated first, because of the risk of epiglottitis. 35. Answer: (A) Placenta previa Rationale: Placenta previa with painless vaginal bleeding. 36. Answer: (D) Early in the morning Rationale: Based on the nurse’s knowledge of microbiology, the specimen should be collected early in the morning. The rationale for this timing is that, because the female worm lays eggs at night around the perineal area, the first bowel movement of the day will yield the best results. The specific type of stool specimen used in the diagnosis of pinworms is called the tape test. 37. Answer: (A) Irritability and seizures Rationale: Lead poisoning primarily affects the CNS, causing increased intracranial pressure. This condition results in irritability and changes in level of consciousness, as well as seizure disorders, hyperactivity, and learning disabilities. 38. Answer: (D) ―I really need to use the diaphragm and jelly most during the middle of my menstrual cycle‖. Rationale: The woman must understand that, although the ―fertile‖ period is approximately mid-cycle, hormonal variations do occur and can result in early or late ovulation. To be effective, the diaphragm should be inserted before every intercourse. 39. Answer: (C) Restlessness Rationale: In a child, restlessness is the earliest sign of hypoxia. Late signs of hypoxia in a child are associated with a change in color, such as pallor or cyanosis. 40. Answer: (B) Walk one step ahead, with the child’s hand on the nurse’s elbow. Rationale: This procedure is generally recommended to follow in guiding a person who is blind.
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41. Answer: (A) Loud, machinery-like murmur. Rationale: A loud, machinery-like murmur is a characteristic finding associated with patent ductus arteriosus.
52. Answer: (B) Buccal mucosa Rationale: Koplik’s spot may be seen on the mucosa of the mouth or the throat.
42. Answer: (C) More oxygen, and the newborn’s metabolic rate increases. Rationale: When cold, the infant requires more oxygen and there is an increase in metabolic rate. Non-shievering thermogenesis is a complex process that increases the metabolic rate and rate of oxygen consumption, therefore, the newborn increase heat production.
53. Answer: (A) 3 seconds Rationale: Adequate blood supply to the area allows the return of the color of the nailbed within 3 seconds.
43. Answer: (D) Voided Rationale: Before administering potassium I.V. to any client, the nurse must first check that the client’s kidneys are functioning and that the client is voiding. If the client is not voiding, the nurse should withhold the potassium and notify the physician. 44. Answer: (c) Laundry detergent Rationale: Eczema or dermatitis is an allergic skin reaction caused by an offending allergen. The topical allergen that is the most common causative factor is laundry detergent. 45. Answer: (A) 6 inches Rationale: This distance allows for easy flow of the formula by gravity, but the flow will be slow enough not to overload the stomach too rapidly. 46. Answer: (A) The older one gets, the more susceptible he becomes to the complications of chicken pox. Rationale: Chicken pox is usually more severe in adults than in children. Complications, such as pneumonia, are higher in incidence in adults. 47. Answer: (D) Consult a physician who may give them rubella immunoglobulin. Rationale: Rubella vaccine is made up of attenuated German measles viruses. This is contraindicated in pregnancy. Immune globulin, a specific prophylactic against German measles, may be given to pregnant women. 48. Answer: (A) Contact tracing Rationale: Contact tracing is the most practical and reliable method of finding possible sources of person-to-person transmitted infections, such as sexually transmitted diseases. 49. Answer: (D) Leptospirosis Rationale: Leptospirosis is transmitted through contact with the skin or mucous membrane with water or moist soil contaminated with urine of infected animals, like rats. 50. Answer: (B) Cholera Rationale: Passage of profuse watery stools is the major symptom of cholera. Both amebic and bacillary dysentery are characterized by the presence of blood and/or mucus in the stools. Giardiasis is characterized by fat malabsorption and, therefore, steatorrhea. 51. Answer: (A) Hemophilus influenzae Rationale: Hemophilus meningitis is unusual over the age of 5 years. In developing countries, the peak incidence is in children less than 6 months of age. Morbillivirus is the etiology of measles. Streptococcus pneumoniae and Neisseria meningitidis may cause meningitis, but age distribution is not specific in young children.
54. Answer: (B) Severe dehydration Rationale: The order of priority in the management of severe dehydration is as follows: intravenous fluid therapy, referral to a facility where IV fluids can be initiated within 30 minutes, Oresol or nasogastric tube. When the foregoing measures are not possible or effective, then urgent referral to the hospital is done. 55. Answer: (A) 45 infants Rationale: To estimate the number of infants, multiply total population by 3%. 56. Answer: (A) DPT Rationale: DPT is sensitive to freezing. The appropriate storage temperature of DPT is 2 to 8° C only. OPV and measles vaccine are highly sensitive to heat and require freezing. MMR is not an immunization in the Expanded Program on Immunization. 57. Answer: (C) Proper use of sanitary toilets Rationale: The ova of the parasite get out of the human body together with feces. Cutting the cycle at this stage is the most effective way of preventing the spread of the disease to susceptible hosts. 58. Answer: (D) 5 skin lesions, positive slit skin smear Rationale: A multibacillary leprosy case is one who has a positive slit skin smear and at least 5 skin lesions. 59. Answer: (C) Thickened painful nerves Rationale: The lesion of leprosy is not macular. It is characterized by a change in skin color (either reddish or whitish) and loss of sensation, sweating and hair growth over the lesion. Inability to close the eyelids (lagophthalmos) and sinking of the nosebridge are late symptoms. 60. Answer: (B) Ask where the family resides. Rationale: Because malaria is endemic, the first question to determine malaria risk is where the client’s family resides. If the area of residence is not a known endemic area, ask if the child had traveled within the past 6 months, where she was brought and whether she stayed overnight in that area. 61. Answer: (A) Inability to drink Rationale: A sick child aged 2 months to 5 years must be referred urgently to a hospital if he/she has one or more of the following signs: not able to feed or drink, vomits everything, convulsions, abnormally sleepy or difficult to awaken. 62. Answer: (A) Refer the child urgently to a hospital for confinement. Rationale: ―Baggy pants‖ is a sign of severe marasmus. The best management is urgent referral to a hospital. 63. Answer: (D) Let the child rest for 10 minutes then continue giving Oresol more slowly.
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Rationale: If the child vomits persistently, that is, he vomits everything that he takes in, he has to be referred urgently to a hospital. Otherwise, vomiting is managed by letting the child rest for 10 minutes and then continuing with Oresol administration. Teach the mother to give Oresol more slowly. 64. Answer: (B) Some dehydration Rationale: Using the assessment guidelines of IMCI, a child (2 months to 5 years old) with diarrhea is classified as having SOME DEHYDRATION if he shows 2 or more of the following signs: restless or irritable, sunken eyes, the skin goes back slow after a skin pinch. 65. Answer: (C) Normal Rationale: In IMCI, a respiratory rate of 50/minute or more is fast breathing for an infant aged 2 to 12 months. 66. Answer: (A) 1 year Rationale: The baby will have passive natural immunity by placental transfer of antibodies. The mother will have active artificial immunity lasting for about 10 years. 5 doses will give the mother lifetime protection. 67. Answer: (B) 4 hours Rationale: While the unused portion of other biologicals in EPI may be given until the end of the day, only BCG is discarded 4 hours after reconstitution. This is why BCG immunization is scheduled only in the morning. 68. Answer: (B) 6 months Rationale: After 6 months, the baby’s nutrient needs, especially the baby’s iron requirement, can no longer be provided by mother’s milk alone. 69. Answer: (C) 24 weeks Rationale: At approximately 23 to 24 weeks’ gestation, the lungs are developed enough to sometimes maintain extrauterine life. The lungs are the most immature system during the gestation period. Medical care for premature labor begins much earlier (aggressively at 21 weeks’ gestation) 70. Answer: (B) Sudden infant death syndrome (SIDS) Rationale: Supine positioning is recommended to reduce the risk of SIDS in infancy. The risk of aspiration is slightly increased with the supine position. Suffocation would be less likely with an infant supine than prone and the position for GER requires the head of the bed to be elevated. 71. Answer: (C) Decreased temperature Rationale: Temperature instability, especially when it results in a low temperature in the neonate, may be a sign of infection. The neonate’s color often changes with an infection process but generally becomes ashen or mottled. The neonate with an infection will usually show a decrease in activity level or lethargy. 72. Answer: (D) Polycythemia probably due to chronic fetal hypoxia Rationale: The small-for-gestation neonate is at risk for developing polycythemia during the transitional period in an attempt to decrease hypoxia. The neonates are also at increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores. 73. Answer: (C) Desquamation of the epidermis
Rationale: Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated. These neonates are usually very alert. Lanugo is missing in the postdate neonate. 74. Answer: (C) Respiratory depression Rationale: Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression, hypotonia, and bradycardia. The serum blood sugar isn’t affected by magnesium sulfate. The neonate would be floppy, not jittery. 75. Answer: (C) Respiratory rate 40 to 60 breaths/minute Rationale: A respiratory rate 40 to 60 breaths/minute is normal for a neonate during the transitional period. Nasal flaring, respiratory rate more than 60 breaths/minute, and audible grunting are signs of respiratory distress. 76. Answer: (C) Keep the cord dry and open to air Rationale: Keeping the cord dry and open to air helps reduce infection and hastens drying. Infants aren’t given tub bath but are sponged off until the cord falls off. Petroleum jelly prevents the cord from drying and encourages infection. Peroxide could be painful and isn’t recommended. 77. Answer: (B) Conjunctival hemorrhage Rationale: Conjunctival hemorrhages are commonly seen in neonates secondary to the cranial pressure applied during the birth process. Bulging fontanelles are a sign of intracranial pressure. Simian creases are present in 40% of the neonates with trisomy 21. Cystic hygroma is a neck mass that can affect the airway. 78. Answer: (B) To assess for prolapsed cord Rationale: After a client has an amniotomy, the nurse should assure that the cord isn't prolapsed and that the baby tolerated the procedure well. The most effective way to do this is to check the fetal heart rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal examination. Artificial rupture of membranes doesn't indicate an imminent delivery. 79. Answer: (D) The parents’ interactions with each other. Rationale: Parental interaction will provide the nurse with a good assessment of the stability of the family's home life but it has no indication for parental bonding. Willingness to touch and hold the newborn, expressing interest about the newborn's size, and indicating a desire to see the newborn are behaviors indicating parental bonding. 80. Answer: (B) Instructing the client to use two or more peripads to cushion the area Rationale: Using two or more peripads would do little to reduce the pain or promote perineal healing. Cold applications, sitz baths, and Kegel exercises are important measures when the client has a fourth-degree laceration. 81. Answer: (C) ―What is your expected due date?‖ Rationale: When obtaining the history of a client who may be in labor, the nurse's highest priority is to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illnesses, allergies, and support persons. 82. Answer: (D) Aspirate the neonate’s nose and mouth with a bulb syringe.
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Rationale: The nurse's first action should be to clear the neonate's airway with a bulb syringe. After the airway is clear and the neonate's color improves, the nurse should comfort and calm the neonate. If the problem recurs or the neonate's color doesn't improve readily, the nurse should notify the physician. Administering oxygen when the airway isn't clear would be ineffective. 83. Answer: (C) Conducting a bedside ultrasound for an amniotic fluid index. Rationale: It isn't within a nurse's scope of practice to perform and interpret a bedside ultrasound under these conditions and without specialized training. Observing for pooling of straw-colored fluid, checking vaginal discharge with nitrazine paper, and observing for flakes of vernix are appropriate assessments for determining whether a client has ruptured membranes. 84. Answer: (C) Monitor partial pressure of oxygen (Pao2) levels. Rationale: Monitoring PaO2 levels and reducing the oxygen concentration to keep PaO2 within normal limits reduces the risk of retinopathy of prematurity in a premature infant receiving oxygen. Covering the infant's eyes and humidifying the oxygen don't reduce the risk of retinopathy of prematurity. Because cooling increases the risk of acidosis, the infant should be kept warm so that his respiratory distress isn't aggravated. 85. Answer: (A) 110 to 130 calories per kg. Rationale: Calories per kg is the accepted way of determined appropriate nutritional intake for a newborn. The recommended calorie requirement is 110 to 130 calories per kg of newborn body weight. This level will maintain a consistent blood glucose level and provide enough calories for continued growth and development. 86. Answer: (C) 30 to 32 weeks Rationale: Individual twins usually grow at the same rate as singletons until 30 to 32 weeks’ gestation, then twins don’t’ gain weight as rapidly as singletons of the same gestational age. The placenta can no longer keep pace with the nutritional requirements of both fetuses after 32 weeks, so there’s some growth retardation in twins if they remain in utero at 38 to 40 weeks. 87. Answer: (A) conjoined twins Rationale: The type of placenta that develops in monozygotic twins depends on the time at which cleavage of the ovum occurs. Cleavage in conjoined twins occurs more than 13 days after fertilization. Cleavage that occurs less than 3 day after fertilization results in diamniotic dicchorionic twins. Cleavage that occurs between days 3 and 8 results in diamniotic monochorionic twins. Cleavage that occurs between days 8 to 13 result in monoamniotic monochorionic twins. 88. Answer: (D) Ultrasound Rationale: Once the mother and the fetus are stabilized, ultrasound evaluation of the placenta should be done to determine the cause of the bleeding. Amniocentesis is contraindicated in placenta previa. A digital or speculum examination shouldn’t be done as this may lead to severe bleeding or hemorrhage. External fetal monitoring won’t detect a placenta previa, although it will detect fetal distress, which may result from blood loss or placenta separation. 89. Answer: (A) Increased tidal volume Rationale: A pregnant client breathes deeper, which increases the tidal volume of gas moved in and out of the respiratory tract with
each breath. The expiratory volume and residual volume decrease as the pregnancy progresses. The inspiratory capacity increases during pregnancy. The increased oxygen consumption in the pregnant client is 15% to 20% greater than in the nonpregnant state. 90. Answer: (A) Diet Rationale: Clients with gestational diabetes are usually managed by diet alone to control their glucose intolerance. Oral hypoglycemic drugs are contraindicated in pregnancy. Long-acting insulin usually isn’t needed for blood glucose control in the client with gestational diabetes. 91. Answer: (D) Seizure Rationale: The anticonvulsant mechanism of magnesium is believes to depress seizure foci in the brain and peripheral neuromuscular blockade. Hypomagnesemia isn’t a complication of preeclampsia. Antihypertensive drug other than magnesium are preferred for sustained hypertension. Magnesium doesn’t help prevent hemorrhage in preeclamptic clients. 92. Answer: (C) I.V. fluids Rationale: A sickle cell crisis during pregnancy is usually managed by exchange transfusion oxygen, and L.V. Fluids. The client usually needs a stronger analgesic than acetaminophen to control the pain of a crisis. Antihypertensive drugs usually aren’t necessary. Diuretic wouldn’t be used unless fluid overload resulted. 93. Answer: (A) Calcium gluconate (Kalcinate) Rationale: Calcium gluconate is the antidote for magnesium toxicity. Ten milliliters of 10% calcium gluconate is given L.V. push over 3 to 5 minutes. Hydralazine is given for sustained elevated blood pressure in preeclamptic clients. Rho (D) immune globulin is given to women with Rh-negative blood to prevent antibody formation from RHpositive conceptions. Naloxone is used to correct narcotic toxicity. 94. Answer: (B) An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. Rationale: A positive PPD result would be an indurated wheal over 10 mm in diameter that appears in 48 to 72 hours. The area must be a raised wheal, not a flat circumcised area to be considered positive. 95. Answer: (C) Pyelonephritis Rational: The symptoms indicate acute pyelonephritis, a serious condition in a pregnant client. UTI symptoms include dysuria, urgency, frequency, and suprapubic tenderness. Asymptomatic bacteriuria doesn’t cause symptoms. Bacterial vaginosis causes milky white vaginal discharge but no systemic symptoms. 96. Answer: (B) Rh-positive fetal blood crosses into maternal blood, stimulating maternal antibodies. Rationale: Rh isoimmunization occurs when Rh-positive fetal blood cells cross into the maternal circulation and stimulate maternal antibody production. In subsequent pregnancies with Rh-positive fetuses, maternal antibodies may cross back into the fetal circulation and destroy the fetal blood cells. 97. Answer: (C) Supine position Rationale: The supine position causes compression of the client's aorta and inferior vena cava by the fetus. This, in turn, inhibits maternal circulation, leading to maternal hypotension and, ultimately, fetal hypoxia. The other positions promote comfort and aid labor progress.
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For instance, the lateral, or side-lying, position improves maternal and fetal circulation, enhances comfort, increases maternal relaxation, reduces muscle tension, and eliminates pressure points. The squatting position promotes comfort by taking advantage of gravity. The standing position also takes advantage of gravity and aligns the fetus with the pelvic angle. 98. Answer: (B) Irritability and poor sucking. Rationale: Neonates of heroin-addicted mothers are physically dependent on the drug and experience withdrawal when the drug is no longer supplied. Signs of heroin withdrawal include irritability, poor sucking, and restlessness. Lethargy isn't associated with neonatal heroin addiction. A flattened nose, small eyes, and thin lips are seen in infants with fetal alcohol syndrome. Heroin use during pregnancy hasn't been linked to specific congenital anomalies. 99. Answer: (A) 7th to 9th day postpartum Rationale: The normal involutional process returns the uterus to the pelvic cavity in 7 to 9 days. A significant involutional complication is the failure of the uterus to return to the pelvic cavity within the prescribed time period. This is known as subinvolution. 100. Answer: (B) Uterine atony Rationale: Multiple fetuses, extended labor stimulation with oxytocin, and traumatic delivery commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine inversion may precede or follow delivery and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine discomfort are normal after delivery. Nursing Bullets: Maternal and Child Health Nursing I 1.
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Unlike false labor, true labor produces regular rhythmic contractions, abdominal discomfort, progressive descent of the fetus, bloody show, and progressive effacement and dilation of the cervix. To help a mother break the suction of her breast-feeding infant, the nurse should teach her to insert a finger at the corner of the infant’s mouth. Administering high levels of oxygen to a premature neonate can cause blindness as a result of retrolental fibroplasia. Amniotomy is artificial rupture of the amniotic membranes. During pregnancy, weight gain averages 25 to 30 lb (11 to 13.5 kg). Rubella has a teratogenic effect on the fetus during the first trimester. It produces abnormalities in up to 40% of cases without interrupting the pregnancy. Immunity to rubella can be measured by a hemagglutination inhibition test (rubella titer). This test identifies exposure to rubella infection and determines susceptibility in pregnant women. In a woman, a titer greater than 1:8 indicates immunity. When used to describe the degree of fetal descent during labor, floating means the presenting part isn’t engaged in the pelvic inlet, but is freely movable (ballotable) above the pelvic inlet. When used to describe the degree of fetal descent, engagement means when the largest diameter of the
presenting part has passed through the pelvic inlet. 10. Fetal station indicates the location of the presenting part in relation to the ischial spine. It’s described as –1, –2, –3, –4, or –5 to indicate the number of centimeters above the level of the ischial spine; station –5 is at the pelvic inlet. 11. Fetal station also is described as +1, +2, +3, +4, or +5 to indicate the number of centimeters it is below the level of the ischial spine; station 0 is at the level of the ischial spine. 12. During the first stage of labor, the side-lying position usually provides the greatest degree of comfort, although the patient may assume any comfortable position. 13. During delivery, if the umbilical cord can’t be loosened and slipped from around the neonate’s neck, it should be clamped with two clamps and cut between the clamps. 14. An Apgar score of 7 to 10 indicates no immediate distress, 4 to 6 indicates moderate distress, and 0 to 3 indicates severe distress. 15. To elicit Moro’s reflex, the nurse holds the neonate in both hands and suddenly, but gently, drops the neonate’s head backward. Normally, the neonate abducts and extends all extremities bilaterally and symmetrically, forms a C shape with the thumb and forefinger, and first adducts and then flexes the extremities. 16. Pregnancy-induced hypertension (preeclampsia) is an increase in blood pressure of 30/15 mm Hg over baseline or blood pressure of 140/95 mm Hg on two occasions at least 6 hours apart accompanied by edema and albuminuria after 20 weeks’ gestation. 17. Positive signs of pregnancy include ultrasound evidence, fetal heart tones, and fetal movement felt by the examiner (not usually present until 4 months’ gestation 18. Goodell’s sign is softening of the cervix. 19. Quickening, a presumptive sign of pregnancy, occurs between 16 and 19 weeks’ gestation. 20. Ovulation ceases during pregnancy. 21. Any vaginal bleeding during pregnancy should be considered a complication until proven otherwise. To estimate the date of delivery using Nägele’s rule, the nurse counts backward 3 months from the first day of the last menstrual period and then adds 7 days to this date. 22. At 12 weeks’ gestation, the fundus should be at the top of the symphysis pubis. 23. Cow’s milk shouldn’t be given to infants younger than age 1 because it has a low linoleic acid content and its protein is difficult for infants to digest. 24. If jaundice is suspected in a neonate, the nurse should examine the infant under natural window light. If natural light is unavailable, the nurse should examine the infant under a white light. 25. The three phases of a uterine contraction are increment, acme, and decrement. 26. The intensity of a labor contraction can be assessed by the indentability of the uterine wall at the contraction’s peak. Intensity is graded as mild (uterine muscle is somewhat tense), moderate (uterine muscle is moderately tense), or strong (uterine muscle is boardlike). 27. Chloasma, the mask of pregnancy, is pigmentation of a circumscribed area of skin (usually over the bridge of the nose and cheeks) that occurs in some pregnant women. 28. The gynecoid pelvis is most ideal for delivery. Other types include platypelloid (flat), anthropoid (apelike), and android (malelike). 29. Pregnant women should be advised that there is no safe
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level of alcohol intake. 30. The frequency of uterine contractions, which is measured in minutes, is the time from the beginning of one contraction to the beginning of the next. 31. Vitamin K is administered to neonates to prevent hemorrhagic disorders because a neonate’s intestine can’t synthesize vitamin K. Before internal fetal monitoring can be performed, a pregnant patient’s cervix must be dilated at least 2 cm, the amniotic membranes must be ruptured, and the fetus’s presenting part (scalp or buttocks) must be at station –1 or lower, so that a small electrode can be attached. 32. Fetal alcohol syndrome presents in the first 24 hours after birth and produces lethargy, seizures, poor sucking reflex, abdominal distention, and respiratory difficulty. 33. Variability is any change in the fetal heart rate (FHR) from its normal rate of 120 to 160 beats/minute. Acceleration is increased FHR; deceleration is decreased FHR. 34. In a neonate, the symptoms of heroin withdrawal may begin several hours to 4 days after birth. 35. In a neonate, the symptoms of methadone withdrawal may begin 7 days to several weeks after birth. 36. In a neonate, the cardinal signs of narcotic withdrawal include coarse, flapping tremors; sleepiness; restlessness; prolonged, persistent, high-pitched cry; and irritability. 37. The nurse should count a neonate’s respirations for 1 full minute. 38. Chlorpromazine (Thorazine) is used to treat neonates who are addicted to narcotics. 39. The nurse should provide a dark, quiet environment for a neonate who is experiencing narcotic withdrawal. 40. In a premature neonate, signs of respiratory distress include nostril flaring, substernal retractions, and inspiratory grunting. 41. Respiratory distress syndrome (hyaline membrane disease) develops in premature infants because their pulmonary alveoli lack surfactant. Whenever an infant is being put down to sleep, the parent or caregiver should position the infant on the back. (Remember back to sleep.) 42. The male sperm contributes an X or a Y chromosome; the female ovum contributes an X chromosome. 43. Fertilization produces a total of 46 chromosomes, including an XY combination (male) or an XX combination (female). 44. The percentage of water in a neonate’s body is about 78% to 80%. 45. To perform nasotracheal suctioning in an infant, the nurse positions the infant with his neck slightly hyperextended in a ―sniffing‖ position, with his chin up and his head tilted back slightly. 46. Organogenesis occurs during the first trimester of pregnancy, specifically, days 14 to 56 of gestation. 47. After birth, the neonate’s umbilical cord is tied 1″ (2.5 cm) from the abdominal wall with a cotton cord, plastic clamp, or rubber band. 48. Gravida is the number of pregnancies a woman has had, regardless of outcome. 49. Para is the number of pregnancies that reached viability, regardless of whether the fetus was delivered alive or stillborn. A fetus is considered viable at 20 weeks’ gestation. An ectopic pregnancy is one that implants abnormally, outside the uterus.
50. The first stage of labor begins with the onset of labor and ends with full cervical dilation at 10 cm.
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The second stage of labor begins with full cervical dilation and ends with the neonate’s birth. The third stage of labor begins after the neonate’s birth and ends with expulsion of the placenta. In a full-term neonate, skin creases appear over two-thirds of the neonate’s feet. Preterm neonates have heel creases that cover less than two-thirds of the feet. The fourth stage of labor (postpartum stabilization) lasts up to 4 hours after the placenta is delivered. This time is needed to stabilize the mother’s physical and emotional state after the stress of childbirth. At 20 weeks’ gestation, the fundus is at the level of the umbilicus. At 36 weeks’ gestation, the fundus is at the lower border of the rib cage. A premature neonate is one born before the end of the 37th week of gestation. Pregnancy-induced hypertension is a leading cause of maternal death in the United States. A habitual aborter is a woman who has had three or more consecutive spontaneous abortions. Threatened abortion occurs when bleeding is present without cervical dilation. A complete abortion occurs when all products of conception are expelled. Hydramnios (polyhydramnios) is excessive amniotic fluid (more than 2,000 ml in the third trimester). Stress, dehydration, and fatigue may reduce a breastfeeding mother’s milk supply. During the transition phase of the first stage of labor, the cervix is dilated 8 to 10 cm and contractions usually occur 2 to 3 minutes apart and last for 60 seconds. A nonstress test is considered nonreactive (positive) if fewer than two fetal heart rate accelerations of at least 15 beats/minute occur in 20 minutes. A nonstress test is considered reactive (negative) if two or more fetal heart rate accelerations of 15 beats/minute above baseline occur in 20 minutes. A nonstress test is usually performed to assess fetal wellbeing in a pregnant patient with a prolonged pregnancy (42 weeks or more), diabetes, a history of poor pregnancy outcomes, or pregnancy-induced hypertension. A pregnant woman should drink at least eight 8-oz glasses (about 2,000 ml) of water daily. When both breasts are used for breast-feeding, the infant usually doesn’t empty the second breast. Therefore, the second breast should be used first at the next feeding. A low-birth-weight neonate weighs 2,500 g (5 lb 8 oz) or less at birth. A very-low-birth-weight neonate weighs 1,500 g (3 lb 5 oz) or less at birth. When teaching parents to provide umbilical cord care, the nurse should teach them to clean the umbilical area with a cotton ball saturated with alcohol after every diaper change to prevent infection and promote drying. Teenage mothers are more likely to have low-birth-weight
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neonates because they seek prenatal care late in pregnancy (as a result of denial) and are more likely than older mothers to have nutritional deficiencies. Linea nigra, a dark line that extends from the umbilicus to the mons pubis, commonly appears during pregnancy and disappears after pregnancy. Implantation in the uterus occurs 6 to 10 days after ovum fertilization. Placenta previa is abnormally low implantation of the placenta so that it encroaches on or covers the cervical os. In complete (total) placenta previa, the placenta completely covers the cervical os. In partial (incomplete or marginal) placenta previa, the placenta covers only a portion of the cervical os. Abruptio placentae is premature separation of a normally implanted placenta. It may be partial or complete, and usually causes abdominal pain, vaginal bleeding, and a boardlike abdomen. Cutis marmorata is mottling or purple discoloration of the skin. It’s a transient vasomotor response that occurs primarily in the arms and legs of infants who are exposed to cold. The classic triad of symptoms of preeclampsia are hypertension, edema, and proteinuria. Additional symptoms of severe preeclampsia include hyperreflexia, cerebral and vision disturbances, and epigastric pain. Ortolani’s sign (an audible click or palpable jerk that occurs with thigh abduction) confirms congenital hip dislocation in a neonate. The first immunization for a neonate is the hepatitis B vaccine, which is administered in the nursery shortly after birth. If a patient misses a menstrual period while taking an oral contraceptive exactly as prescribed, she should continue taking the contraceptive. If a patient misses two consecutive menstrual periods while taking an oral contraceptive, she should discontinue the contraceptive and take a pregnancy test. If a patient who is taking an oral contraceptive misses a dose, she should take the pill as soon as she remembers or take two at the next scheduled interval and continue with the normal schedule. If a patient who is taking an oral contraceptive misses two consecutive doses, she should double the dose for 2 days and then resume her normal schedule. She also should use an additional birth control method for 1 week. Eclampsia is the occurrence of seizures that aren’t caused by a cerebral disorder in a patient who has pregnancyinduced hypertension. In placenta previa, bleeding is painless and seldom fatal on the first occasion, but it becomes heavier with each subsequent episode. Treatment for abruptio placentae is usually immediate cesarean delivery. Drugs used to treat withdrawal symptoms in neonates include phenobarbital (Luminal), camphorated opium tincture (paregoric), and diazepam (Valium). Infants with Down syndrome typically have marked hypotonia, floppiness, slanted eyes, excess skin on the back of the neck, flattened bridge of the nose, flat facial features, spadelike hands, short and broad feet, small male genitalia, absence of Moro’s reflex, and a simian crease on the hands. The failure rate of a contraceptive is determined by the
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experience of 100 women for 1 year. It’s expressed as pregnancies per 100 woman-years. The narrowest diameter of the pelvic inlet is the anteroposterior (diagonal conjugate). The chorion is the outermost extraembryonic membrane that gives rise to the placenta. The corpus luteum secretes large quantities of progesterone. From the 8th week of gestation through delivery, the developing cells are known as a fetus. In an incomplete abortion, the fetus is expelled, but parts of the placenta and membrane remain in the uterus. The circumference of a neonate’s head is normally 2 to 3 cm greater than the circumference of the chest. After administering magnesium sulfate to a pregnant patient for hypertension or preterm labor, the nurse should monitor the respiratory rate and deep tendon reflexes. During the first hour after birth (the period of reactivity), the neonate is alert and awake.
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When a pregnant patient has undiagnosed vaginal bleeding, vaginal examination should be avoided until ultrasonography rules out placenta previa. After delivery, the first nursing action is to establish the neonate’s airway. Nursing interventions for a patient with placenta previa include positioning the patient on her left side for maximum fetal perfusion, monitoring fetal heart tones, and administering I.V. fluids and oxygen, as ordered. The specific gravity of a neonate’s urine is 1.003 to 1.030. A lower specific gravity suggests overhydration; a higher one suggests dehydration. The neonatal period extends from birth to day 28. It’s also called the first 4 weeks or first month of life. A woman who is breast-feeding should rub a mild emollient cream or a few drops of breast milk (or colostrum) on the nipples after each feeding. She should let the breasts air-dry to prevent them from cracking. Breast-feeding mothers should increase their fluid intake to 2½ to 3 qt (2,500 to 3,000 ml) daily. After feeding an infant with a cleft lip or palate, the nurse should rinse the infant’s mouth with sterile water. The nurse instills erythromycin in a neonate’s eyes primarily to prevent blindness caused by gonorrhea or chlamydia. Human immunodeficiency virus (HIV) has been cultured in breast milk and can be transmitted by an HIV-positive mother who breast-feeds her infant. A fever in the first 24 hours postpartum is most likely caused by dehydration rather than infection. Preterm neonates or neonates who can’t maintain a skin temperature of at least 97.6° F (36.4° C) should receive care in an incubator (Isolette) or a radiant warmer. In a radiant warmer, a heat-sensitive probe taped to the neonate’s skin activates the heater unit automatically to maintain the desired temperature. During labor, the resting phase between contractions is at least 30 seconds. Lochia rubra is the vaginal discharge of almost pure blood
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that occurs during the first few days after childbirth. 15. Lochia serosa is the serous vaginal discharge that occurs 4 to 7 days after childbirth. 16. Lochia alba is the vaginal discharge of decreased blood and increased leukocytes that’s the final stage of lochia. It occurs 7 to 10 days after childbirth. 17. Colostrum, the precursor of milk, is the first secretion from the breasts after delivery. 18. The length of the uterus increases from 2½‖ (6.3 cm) before pregnancy to 12½‖ (32 cm) at term. 19. To estimate the true conjugate (the smallest inlet measurement of the pelvis), deduct 1.5 cm from the diagonal conjugate (usually 12 cm). A true conjugate of 10.5 cm enables the fetal head (usually 10 cm) to pass. 20. The smallest outlet measurement of the pelvis is the intertuberous diameter, which is the transverse diameter between the ischial tuberosities. 21. Electronic fetal monitoring is used to assess fetal wellbeing during labor. If compromised fetal status is suspected, fetal blood pH may be evaluated by obtaining a scalp sample. 22. In an emergency delivery, enough pressure should be applied to the emerging fetus’s head to guide the descent and prevent a rapid change in pressure within the molded fetal skull. 23. After delivery, a multiparous woman is more susceptible to bleeding than a primiparous woman because her uterine muscles may be overstretched and may not contract efficiently. 24. Neonates who are delivered by cesarean birth have a higher incidence of respiratory distress syndrome. 25. The nurse should suggest ambulation to a postpartum patient who has gas pain and flatulence. 26. Massaging the uterus helps to stimulate contractions after the placenta is delivered. 27. When providing phototherapy to a neonate, the nurse should cover the neonate’s eyes and genital area. 28. The narcotic antagonist naloxone (Narcan) may be given to a neonate to correct respiratory depression caused by narcotic administration to the mother during labor. 29. In a neonate, symptoms of respiratory distress syndrome include expiratory grunting or whining, sandpaper breath sounds, and seesaw retractions. 30. Cerebral palsy presents as asymmetrical movement, irritability, and excessive, feeble crying in a long, thin infant. 31. The nurse should assess a breech-birth neonate for hydrocephalus, hematomas, fractures, and other anomalies caused by birth trauma. 32. When a patient is admitted to the unit in active labor, the nurse’s first action is to listen for fetal heart tones. 33. In a neonate, long, brittle fingernails are a sign of postmaturity. 34. Desquamation (skin peeling) is common in postmature neonates. 35. A mother should allow her infant to breast-feed until the infant is satisfied. The time may vary from 5 to 20 minutes. 36. Nitrazine paper is used to test the pH of vaginal discharge to determine the presence of amniotic fluid. 37. A pregnant patient normally gains 2 to 5 lb (1 to 2.5 kg) during the first trimester and slightly less than 1 lb (0.5 kg) per week during the last two trimesters. 38. Neonatal jaundice in the first 24 hours after birth is known
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as pathological jaundice and is a sign of erythroblastosis fetalis. A classic difference between abruptio placentae and placenta previa is the degree of pain. Abruptio placentae causes pain, whereas placenta previa causes painless bleeding. Because a major role of the placenta is to function as a fetal lung, any condition that interrupts normal blood flow to or from the placenta increases fetal partial pressure of arterial carbon dioxide and decreases fetal pH. Precipitate labor lasts for approximately 3 hours and ends with delivery of the neonate. Methylergonovine (Methergine) is an oxytocic agent used to prevent and treat postpartum hemorrhage caused by uterine atony or subinvolution. As emergency treatment for excessive uterine bleeding, 0.2 mg of methylergonovine (Methergine) is injected I.V. over 1 minute while the patient’s blood pressure and uterine contractions are monitored. Braxton Hicks contractions are usually felt in the abdomen and don’t cause cervical change. True labor contractions are felt in the front of the abdomen and back and lead to progressive cervical dilation and effacement. The average birth weight of neonates born to mothers who smoke is 6 oz (170 g) less than that of neonates born to nonsmoking mothers. Culdoscopy is visualization of the pelvic organs through the posterior vaginal fornix. The nurse should teach a pregnant vegetarian to obtain protein from alternative sources, such as nuts, soybeans, and legumes. The nurse should instruct a pregnant patient to take only prescribed prenatal vitamins because over-the-counter high-potency vitamins may harm the fetus. High-sodium foods can cause fluid retention, especially in pregnant patients. A pregnant patient can avoid constipation and hemorrhoids by adding fiber to her diet.
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If a fetus has late decelerations (a sign of fetal hypoxia), the nurse should instruct the mother to lie on her left side and then administer 8 to 10 L of oxygen per minute by mask or cannula. The nurse should notify the physician. The sidelying position removes pressure on the inferior vena cava. Oxytocin (Pitocin) promotes lactation and uterine contractions. Lanugo covers the fetus’s body until about 20 weeks’ gestation. Then it begins to disappear from the face, trunk, arms, and legs, in that order. In a neonate, hypoglycemia causes temperature instability, hypotonia, jitteriness, and seizures. Premature, postmature, small-for-gestational-age, and large-for-gestational-age neonates are susceptible to this disorder. Neonates typically need to consume 50 to 55 cal per pound of body weight daily. Because oxytocin (Pitocin) stimulates powerful uterine contractions during labor, it must be administered under close observation to help prevent maternal and fetal distress.
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During fetal heart rate monitoring, variable decelerations indicate compression or prolapse of the umbilical cord. Cytomegalovirus is the leading cause of congenital viral infection. Tocolytic therapy is indicated in premature labor, but contraindicated in fetal death, fetal distress, or severe hemorrhage. Through ultrasonography, the biophysical profile assesses fetal well-being by measuring fetal breathing movements, gross body movements, fetal tone, reactive fetal heart rate (nonstress test), and qualitative amniotic fluid volume. A neonate whose mother has diabetes should be assessed for hyperinsulinism. In a patient with preeclampsia, epigastric pain is a late symptom and requires immediate medical intervention. After a stillbirth, the mother should be allowed to hold the neonate to help her come to terms with the death. Molding is the process by which the fetal head changes shape to facilitate movement through the birth canal. If a woman receives a spinal block before delivery, the nurse should monitor the patient’s blood pressure closely. If a woman suddenly becomes hypotensive during labor, the nurse should increase the infusion rate of I.V. fluids as prescribed. The best technique for assessing jaundice in a neonate is to blanch the tip of the nose or the area just above the umbilicus. During fetal heart monitoring, early deceleration is caused by compression of the head during labor. After the placenta is delivered, the nurse may add oxytocin (Pitocin) to the patient’s I.V. solution, as prescribed, to promote postpartum involution of the uterus and stimulate lactation. Pica is a craving to eat nonfood items, such as dirt, crayons, chalk, glue, starch, or hair. It may occur during pregnancy and can endanger the fetus. A pregnant patient should take folic acid because this nutrient is required for rapid cell division. A woman who is taking clomiphene (Clomid) to induce ovulation should be informed of the possibility of multiple births with this drug. If needed, cervical suturing is usually done between 14 and 18 weeks’ gestation to reinforce an incompetent cervix and maintain pregnancy. The suturing is typically removed by 35 weeks’ gestation. During the first trimester, a pregnant woman should avoid all drugs unless doing so would adversely affect her health. Most drugs that a breast-feeding mother takes appear in breast milk. The Food and Drug Administration has established the following five categories of drugs based on their potential for causing birth defects: A, no evidence of risk; B, no risk found in animals, but no studies have been done in women; C, animal studies have shown an adverse effect, but the drug may be beneficial to women despite the potential risk; D, evidence of risk, but its benefits may outweigh its risks; and X, fetal anomalies noted, and the risks clearly outweigh the potential benefits. A patient with a ruptured ectopic pregnancy commonly has sharp pain in the lower abdomen, with spotting and cramping. She may have abdominal rigidity; rapid, shallow respirations; tachycardia; and shock. A patient with a ruptured ectopic pregnancy commonly has
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sharp pain in the lower abdomen, with spotting and cramping. She may have abdominal rigidity; rapid, shallow respirations; tachycardia; and shock. The mechanics of delivery are engagement, descent and flexion, internal rotation, extension, external rotation, restitution, and expulsion. A probable sign of pregnancy, McDonald’s sign is characterized by an ease in flexing the body of the uterus against the cervix. Amenorrhea is a probable sign of pregnancy. A pregnant woman’s partner should avoid introducing air into the vagina during oral sex because of the possibility of air embolism. The presence of human chorionic gonadotropin in the blood or urine is a probable sign of pregnancy. Radiography isn’t usually used in a pregnant woman because it may harm the developing fetus. If radiography is essential, it should be performed only after 36 weeks’ gestation. A pregnant patient who has had rupture of the membranes or who is experiencing vaginal bleeding shouldn’t engage in sexual intercourse. Milia may occur as pinpoint spots over a neonate’s nose. The duration of a contraction is timed from the moment that the uterine muscle begins to tense to the moment that it reaches full relaxation. It’s measured in seconds. The union of a male and a female gamete produces a zygote, which divides into the fertilized ovum. The first menstrual flow is called menarche and may be anovulatory (infertile). Spermatozoa (or their fragments) remain in the vagina for 72 hours after sexual intercourse. Prolactin stimulates and sustains milk production. Strabismus is a normal finding in a neonate. A postpartum patient may resume sexual intercourse after the perineal or uterine wounds heal (usually within 4 weeks after delivery). A pregnant staff member shouldn’t be assigned to work with a patient who has cytomegalovirus infection because the virus can be transmitted to the fetus. Fetal demise is death of the fetus after viability. Respiratory distress syndrome develops in premature neonates because their alveoli lack surfactant. The most common method of inducing labor after artificial rupture of the membranes is oxytocin (Pitocin) infusion. After the amniotic membranes rupture, the initial nursing action is to assess the fetal heart rate. The most common reasons for cesarean birth are malpresentation, fetal distress, cephalopelvic disproportion, pregnancy-induced hypertension, previous cesarean birth, and inadequate progress in labor. Amniocentesis increases the risk of spontaneous abortion, trauma to the fetus or placenta, premature labor, infection, and Rh sensitization of the fetus. After amniocentesis, abdominal cramping or spontaneous vaginal bleeding may indicate complications. To prevent her from developing Rh antibodies, an Rhnegative primigravida should receive Rho(D) immune globulin (RhoGAM) after delivering an Rh-positive neonate.
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Nursing Bullets: Maternal and Child Health Nursing V 1.
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If a pregnant patient’s test results are negative for glucose but positive for acetone, the nurse should assess the patient’s diet for inadequate caloric intake. If a pregnant patient’s test results are negative for glucose but positive for acetone, the nurse should assess the patient’s diet for inadequate caloric intake. Rubella infection in a pregnant patient, especially during the first trimester, can lead to spontaneous abortion or stillbirth as well as fetal cardiac and other birth defects. A pregnant patient should take an iron supplement to help prevent anemia. Direct antiglobulin (direct Coombs’) test is used to detect maternal antibodies attached to red blood cells in the neonate. Nausea and vomiting during the first trimester of pregnancy are caused by rising levels of the hormone human chorionic gonadotropin. Before discharging a patient who has had an abortion, the nurse should instruct her to report bright red clots, bleeding that lasts longer than 7 days, or signs of infection, such as a temperature of greater than 100° F (37.8° C), foul-smelling vaginal discharge, severe uterine cramping, nausea, or vomiting. When informed that a patient’s amniotic membrane has broken, the nurse should check fetal heart tones and then maternal vital signs. The duration of pregnancy averages 280 days, 40 weeks, 9 calendar months, or 10 lunar months. The initial weight loss for a healthy neonate is 5% to 10% of birth weight. The normal hemoglobin value in neonates is 17 to 20 g/dl. Crowning is the appearance of the fetus’s head when its largest diameter is encircled by the vulvovaginal ring. A multipara is a woman who has had two or more pregnancies that progressed to viability, regardless of whether the offspring were alive at birth. In a pregnant patient, preeclampsia may progress to eclampsia, which is characterized by seizures and may lead to coma. The Apgar score is used to assess the neonate’s vital functions. It’s obtained at 1 minute and 5 minutes after delivery. The score is based on respiratory effort, heart rate, muscle tone, reflex irritability, and color. Because of the anti-insulin effects of placental hormones, insulin requirements increase during the third trimester. Gestational age can be estimated by ultrasound measurement of maternal abdominal circumference, fetal femur length, and fetal head size. These measurements are most accurate between 12 and 18 weeks’ gestation. Skeletal system abnormalities and ventricular septal defects are the most common disorders of infants who are born to diabetic women. The incidence of congenital malformation is three times higher in these infants than in those born to nondiabetic women. Skeletal system abnormalities and ventricular septal defects are the most common disorders of infants who are born to diabetic women. The incidence of congenital malformation is three times higher in these infants than in those born to nondiabetic women. The patient with preeclampsia usually has puffiness around
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the eyes or edema in the hands (for example, ―I can’t put my wedding ring on.‖). Kegel exercises require contraction and relaxation of the perineal muscles. These exercises help strengthen pelvic muscles and improve urine control in postpartum patients. Symptoms of postpartum depression range from mild postpartum blues to intense, suicidal, depressive psychosis. The preterm neonate may require gavage feedings because of a weak sucking reflex, uncoordinated sucking, or respiratory distress. Acrocyanosis (blueness and coolness of the arms and legs) is normal in neonates because of their immature peripheral circulatory system. To prevent ophthalmia neonatorum (a severe eye infection caused by maternal gonorrhea), the nurse may administer one of three drugs, as prescribed, in the neonate’s eyes: tetracycline, silver nitrate, or erythromycin. Neonatal testing for phenylketonuria is mandatory in most states. The nurse should place the neonate in a 30-degree Trendelenburg position to facilitate mucus drainage. The nurse may suction the neonate’s nose and mouth as needed with a bulb syringe or suction trap. To prevent heat loss, the nurse should place the neonate under a radiant warmer during suctioning and initial delivery-room care, and then wrap the neonate in a warmed blanket for transport to the nursery. The umbilical cord normally has two arteries and one vein. When providing care, the nurse should expose only one part of an infant’s body at a time. Lightening is settling of the fetal head into the brim of the pelvis. If the neonate is stable, the mother should be allowed to breast-feed within the neonate’s first hour of life. The nurse should check the neonate’s temperature every 1 to 2 hours until it’s maintained within normal limits. At birth, a neonate normally weighs 5 to 9 lb (2 to 4 kg), measures 18″ to 22″ (45.5 to 56 cm) in length, has a head circumference of 13½‖ to 14″ (34 to 35.5 cm), and has a chest circumference that’s 1″ (2.5 cm) less than the head circumference. In the neonate, temperature normally ranges from 98° to 99° F (36.7° to 37.2° C), apical pulse rate averages 120 to 160 beats/minute, and respirations are 40 to 60 breaths/minute. The diamond-shaped anterior fontanel usually closes between ages 12 and 18 months. The triangular posterior fontanel usually closes by age 2 months. In the neonate, a straight spine is normal. A tuft of hair over the spine is an abnormal finding. Prostaglandin gel may be applied to the vagina or cervix to ripen an unfavorable cervix before labor induction with oxytocin (Pitocin). Supernumerary nipples are occasionally seen on neonates. They usually appear along a line that runs from each axilla, through the normal nipple area, and to the groin. Meconium is a material that collects in the fetus’s intestines and forms the neonate’s first feces, which are black and tarry. The presence of meconium in the amniotic fluid during labor indicates possible fetal distress and the need to evaluate the neonate for meconium aspiration. To assess a neonate’s rooting reflex, the nurse touches a
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finger to the cheek or the corner of the mouth. Normally, the neonate turns his head toward the stimulus, opens his mouth, and searches for the stimulus. Harlequin sign is present when a neonate who is lying on his side appears red on the dependent side and pale on the upper side. Mongolian spots can range from brown to blue. Their color depends on how close melanocytes are to the surface of the skin. They most commonly appear as patches across the sacrum, buttocks, and legs. Mongolian spots are common in non-white infants and usually disappear by age 2 to 3 years. Vernix caseosa is a cheeselike substance that covers and protects the fetus’s skin in utero. It may be rubbed into the neonate’s skin or washed away in one or two baths. Caput succedaneum is edema that develops in and under the fetal scalp during labor and delivery. It resolves spontaneously and presents no danger to the neonate. The edema doesn’t cross the suture line. Nevus flammeus, or port-wine stain, is a diffuse pink to dark bluish red lesion on a neonate’s face or neck. The Guthrie test (a screening test for phenylketonuria) is most reliable if it’s done between the second and sixth days after birth and is performed after the neonate has ingested protein. To assess coordination of sucking and swallowing, the nurse should observe the neonate’s first breast-feeding or sterile water bottle-feeding. To establish a milk supply pattern, the mother should breast-feed her infant at least every 4 hours. During the first month, she should breast-feed 8 to 12 times daily (demand feeding).
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To avoid contact with blood and other body fluids, the nurse should wear gloves when handling the neonate until after the first bath is given. If a breast-fed infant is content, has good skin turgor, an adequate number of wet diapers, and normal weight gain, the mother’s milk supply is assumed to be adequate. In the supine position, a pregnant patient’s enlarged uterus impairs venous return from the lower half of the body to the heart, resulting in supine hypotensive syndrome, or inferior vena cava syndrome. Tocolytic agents used to treat preterm labor include terbutaline (Brethine), ritodrine (Yutopar), and magnesium sulfate. A pregnant woman who has hyperemesis gravidarum may require hospitalization to treat dehydration and starvation. Diaphragmatic hernia is one of the most urgent neonatal surgical emergencies. By compressing and displacing the lungs and heart, this disorder can cause respiratory distress shortly after birth. Common complications of early pregnancy (up to 20 weeks’ gestation) include fetal loss and serious threats to maternal health. Fetal embodiment is a maternal developmental task that occurs in the second trimester. During this stage, the mother may complain that she never gets to sleep because the fetus always gives her a thump when she tries.
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Visualization in pregnancy is a process in which the mother imagines what the child she’s carrying is like and becomes acquainted with it. Hemodilution of pregnancy is the increase in blood volume that occurs during pregnancy. The increased volume consists of plasma and causes an imbalance between the ratio of red blood cells to plasma and a resultant decrease in hematocrit. Mean arterial pressure of greater than 100 mm Hg after 20 weeks of pregnancy is considered hypertension. The treatment for supine hypotension syndrome (a condition that sometimes occurs in pregnancy) is to have the patient lie on her left side. A contributing factor in dependent edema in the pregnant patient is the increase of femoral venous pressure from 10 mm Hg (normal) to 18 mm Hg (high). Hyperpigmentation of the pregnant patient’s face, formerly called chloasma and now referred to as melasma, fades after delivery. The hormone relaxin, which is secreted first by the corpus luteum and later by the placenta, relaxes the connective tissue and cartilage of the symphysis pubis and the sacroiliac joint to facilitate passage of the fetus during delivery. Progesterone maintains the integrity of the pregnancy by inhibiting uterine motility. Ladin’s sign, an early indication of pregnancy, causes softening of a spot on the anterior portion of the uterus, just above the uterocervical juncture. During pregnancy, the abdominal line from the symphysis pubis to the umbilicus changes from linea alba to linea nigra. In neonates, cold stress affects the circulatory, regulatory, and respiratory systems. Obstetric data can be described by using the F/TPAL system: F/T: Full-term delivery at 38 weeks or longer P: Preterm delivery between 20 and 37 weeks A: Abortion or loss of fetus before 20 weeks L: Number of children living (if a child has died, further explanation is needed to clarify the discrepancy in numbers). Parity doesn’t refer to the number of infants delivered, only the number of deliveries. Women who are carrying more than one fetus should be encouraged to gain 35 to 45 lb (15.5 to 20.5 kg) during pregnancy. The recommended amount of iron supplement for the pregnant patient is 30 to 60 mg daily. Drinking six alcoholic beverages a day or a single episode of binge drinking in the first trimester can cause fetal alcohol syndrome. Chorionic villus sampling is performed at 8 to 12 weeks of pregnancy for early identification of genetic defects. In percutaneous umbilical blood sampling, a blood sample is obtained from the umbilical cord to detect anemia, genetic defects, and blood incompatibility as well as to assess the need for blood transfusions. The period between contractions is referred to as the interval, or resting phase. During this phase, the uterus and placenta fill with blood and allow for the exchange of oxygen, carbon dioxide, and nutrients. In a patient who has hypertonic contractions, the uterus
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doesn’t have an opportunity to relax and there is no interval between contractions. As a result, the fetus may experience hypoxia or rapid delivery may occur. Two qualities of the myometrium are elasticity, which allows it to stretch yet maintain its tone, and contractility, which allows it to shorten and lengthen in a synchronized pattern. During crowning, the presenting part of the fetus remains visible during the interval between contractions. Uterine atony is failure of the uterus to remain firmly contracted. The major cause of uterine atony is a full bladder. If the mother wishes to breast-feed, the neonate should be nursed as soon as possible after delivery. A smacking sound, milk dripping from the side of the mouth, and sucking noises all indicate improper placement of the infant’s mouth over the nipple. Before feeding is initiated, an infant should be burped to expel air from the stomach. Most authorities strongly encourage the continuation of breast-feeding on both the affected and the unaffected breast of patients with mastitis. Neonates are nearsighted and focus on items that are held 10″ to 12″ (25 to 30.5 cm) away. In a neonate, low-set ears are associated with chromosomal abnormalities such as Down syndrome. Meconium is usually passed in the first 24 hours; however, passage may take up to 72 hours. Boys who are born with hypospadias shouldn’t be circumcised at birth because the foreskin may be needed for constructive surgery. In the neonate, the normal blood glucose level is 45 to 90 mg/dl. Hepatitis B vaccine is usually given within 48 hours of birth. Hepatitis B immune globulin is usually given within 12 hours of birth. HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome is an unusual variation of pregnancyinduced hypertension. Maternal serum alpha-fetoprotein is detectable at 7 weeks of gestation and peaks in the third trimester. High levels detected between the 16th and 18th weeks are associated with neural tube defects. Low levels are associated with Down syndrome. An arrest of descent occurs when the fetus doesn’t descend through the pelvic cavity during labor. It’s commonly associated with cephalopelvic disproportion, and cesarean delivery may be required. A late sign of preeclampsia is epigastric pain as a result of severe liver edema. In the patient with preeclampsia, blood pressure returns to normal during the puerperal period. To obtain an estriol level, urine is collected for 24 hours. An estriol level is used to assess fetal well-being and maternal renal functioning as well as to monitor a pregnancy that’s complicated by diabetes. A pregnant patient with vaginal bleeding shouldn’t have a pelvic examination.
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25. Nursing Bullets: Maternal and Child Health Nursing VII
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In the early stages of pregnancy, the finding of glucose in the urine may be related to the increased shunting of glucose to the developing placenta, without a corresponding increase in the reabsorption capability of the kidneys. A patient who has premature rupture of the membranes is at significant risk for infection if labor doesn’t begin within 24 hours. Infants of diabetic mothers are susceptible to macrosomia as a result of increased insulin production in the fetus. To prevent heat loss in the neonate, the nurse should bathe one part of his body at a time and keep the rest of the body covered. A patient who has a cesarean delivery is at greater risk for infection than the patient who gives birth vaginally. The occurrence of thrush in the neonate is probably caused by contact with the organism during delivery through the birth canal. The nurse should keep the sac of meningomyelocele moist with normal saline solution. If fundal height is at least 2 cm less than expected, the cause may be growth retardation, missed abortion, transverse lie, or false pregnancy. Fundal height that exceeds expectations by more than 2 cm may be caused by multiple gestation, polyhydramnios, uterine myomata, or a large baby. A major developmental task for a woman during the first trimester of pregnancy is accepting the pregnancy. Unlike formula, breast milk offers the benefit of maternal antibodies. Spontaneous rupture of the membranes increases the risk of a prolapsed umbilical cord. A clinical manifestation of a prolapsed umbilical cord is variable decelerations. During labor, to relieve supine hypotension manifested by nausea and vomiting and paleness, turn the patient on her left side. If the ovum is fertilized by a spermatozoon carrying a Y chromosome, a male zygote is formed. Implantation occurs when the cellular walls of the blastocyte implants itself in the endometrium, usually 7 to 9 days after fertilization. Implantation occurs when the cellular walls of the blastocyte implants itself in the endometrium, usually 7 to 9 days after fertilization. Heart development in the embryo begins at 2 to 4 weeks and is complete by the end of the embryonic stage. Methergine stimulates uterine contractions. The administration of folic acid during the early stages of gestation may prevent neural tube defects. With advanced maternal age, a common genetic problem is Down syndrome. With early maternal age, cephalopelvic disproportion commonly occurs. In the early postpartum period, the fundus should be midline at the umbilicus. A rubella vaccine shouldn’t be given to a pregnant woman. The vaccine can be administered after delivery, but the patient should be instructed to avoid becoming pregnant for 3 months. A 16-year-old girl who is pregnant is at risk for having a low-birth-weight neonate. The mother’s Rh factor should be determined before an
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amniocentesis is performed. 27. Maternal hypotension is a complication of spinal block. 28. After delivery, if the fundus is boggy and deviated to the right side, the patient should empty her bladder. 29. Before providing a specimen for a sperm count, the patient should avoid ejaculation for 48 to 72 hours. 30. The hormone human chorionic gonadotropin is a marker for pregnancy. 31. Painless vaginal bleeding during the last trimester of pregnancy may indicate placenta previa. 32. During the transition phase of labor, the woman usually is irritable and restless. 33. Because women with diabetes have a higher incidence of birth anomalies than women without diabetes, an alphafetoprotein level may be ordered at 15 to 17 weeks’ gestation. 34. To avoid puncturing the placenta, a vaginal examination shouldn’t be performed on a pregnant patient who is bleeding. 35. A patient who has postpartum hemorrhage caused by uterine atony should be given oxytocin as prescribed. 36. Laceration of the vagina, cervix, or perineum produces bright red bleeding that often comes in spurts. The bleeding is continuous, even when the fundus is firm. 37. Hot compresses can help to relieve breast tenderness after breast-feeding. 38. The fundus of a postpartum patient is massaged to stimulate contraction of the uterus and prevent hemorrhage. 39. A mother who has a positive human immunodeficiency virus test result shouldn’t breast-feed her infant. 40. Dinoprostone (Cervidil) is used to ripen the cervix. 41. Breast-feeding of a premature neonate born at 32 weeks’ gestation can be accomplished if the mother expresses milk and feeds the neonate by gavage. 42. If a pregnant patient’s rubella titer is less than 1:8, she should be immunized after delivery. 43. The administration of oxytocin (Pitocin) is stopped if the contractions are 90 seconds or longer. 44. For an extramural delivery (one that takes place outside of a normal delivery center), the priorities for care of the neonate include maintaining a patent airway, supporting efforts to breathe, monitoring vital signs, and maintaining adequate body temperature. 45. Subinvolution may occur if the bladder is distended after delivery. 46. The nurse must place identification bands on both the mother and the neonate before they leave the delivery room. 47. Erythromycin is given at birth to prevent ophthalmia neonatorum. 48. Pelvic-tilt exercises can help to prevent or relieve backache during pregnancy. 49. Before performing a Leopold maneuver, the nurse should ask the patient to empty her bladder. 50. According to the Unang Yakap program, the cord should not be clamped until pulsations have stopped (that’s about 1-3 minutes).
Placenta posted Sep 4, 2012, 11:02 PM by RNpedia.com Administration
PLACENTA-CROSSING SUBSTANCES
"Want My Hot Dog": Wastes Antibodies Nutrients Teratogens Microorganisms Hormones/ HIV Drugs
Preterm Infant posted Aug 30, 2012, 11:13 PM by RNpedia.com Administration Preterm infant: anticipated problems—"TRIES"
Temperature regulation (poor) Resistance to infections (poor) Immature liver Elimination problems (necrotizing enterocolitis [NEC]) Sensory-perceptual functions (retinopathy of prematurity [ROP])
Obstetric (Maternity) History posted Aug 30, 2012, 11:04 PM by RNpedia.com Administration Obstetric (maternity) history—"GTPAL"
Gravida Term Preterm Abortions (SAB, TAB)
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Living children
Infections during pregnancy posted Aug 30, 2012, 7:39 PM by RNpedia.com Administration Infections during pregnancy—"TORCH"
Newborn Assessment posted Aug 30, 2012, 11:02 PM by RNpedia.com Administration Newborn assessment components—"APGAR"
Toxoplasmosis Other (hepatitis B, syphilis, group B beta strep)
Appearance
Rubella
Pulse
Cytomegalovirus
Grimace
Herpes simplex virus
Activity Respiratory effort
Episiotomy posted Aug 29, 2012, 7:04 AM by RNpedia.com Administration Episiotomy assessment—"REEDA"
Family Planning posted Aug 30, 2012, 8:17 PM by RNpedia.com Administration [ updated Aug 30, 2012, 11:06 PM ] IUD: potential problems with use—"PAINS"
Redness Edema Ecchymosis Discharge
Period (menstrual: late, spotting, bleeding)
Approximation of skin
Abdominal pain, dyspareunia Infection (abnormal vaginal discharge)
Dystocia posted Aug 29, 2012, 7:02 AM by RNpedia.com Administration [ updated Aug 29, 2012, 7:02 AM ]
Not feeling well, fever or chills Dystocia: etiology—"3P's" String missing
Oral contraceptives: signs of potential problems—"ACHES" Abdominal pain (possible liver or gallbladder problem) Chest pain or shortness of breath (possible pulmonary embolus)
Power Passageway Passenger
Headache (possible hypertension, brain attack) Dystocia: general aspects (maternal)—"3P's" Eye problems (possible hypertension or vascular accident) Severe leg pain (possible thromboembolic process) Psych
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B. HCG C. Estrogen D. Placental Lactogen
Placenta Position
Preeclampsia posted Aug 29, 2012, 6:41 AM by RNpedia.com Administration [ updated Aug 29, 2012, 6:46 AM ] Complication of severe preeclampsia—"HELLP" syndrome
3. With this pregnancy, Aling Julia is a [1] A. P3 G3 B. Primigravida C. P3 G4 D. P0 G3 4. In explaining the development of her baby, you identified in chronological order of growth of the fetus as it occurs in pregnancy as [1]
Hemolysis Elevated Liver enzymes Low Platelet count
Umbilical Cord posted Aug 28, 2012, 6:00 AM by RNpedia.com Administration Blood vessels in umbilical cord—"AVA" (2 arteries and 1 vein)
Artery Vein Artery Introduction: The questions are coded according to their sources and will only be for my personal reference. RED questions are original questions I created. FATIMA students READ and DIGEST each of these questions carefully. Goodluck. SITUATION : [ND89] Aling Julia, a 32 year old fish vendor from baranggay matahimik came to see you at the prenatal clinic. She brought with her all her three children. Maye, 1 year 6 months; Joy, 3 and Dan, 7 years old. She mentioned that she stopped taking oral contraceptives several months ago and now suspects she is pregnant. She cannot remember her LMP. 1. Which of the following would be useful in calculating Aling Julia's EDC? [3] A. Appearance of linea negra B. First FHT by fetoscope C. Increase pulse rate D. Presence of edema 2. Which hormone is necessary for a positive pregnancy test? [1] A. Progesterone
A. Ovum, embryo, zygote, fetus, infant B. Zygote, ovum, embryo, fetus, infant C. Ovum, zygote, embryo, fetus, infant D. Zygote, ovum, fetus, embryo, infant 5. Aling Julia states she is happy to be pregnant. Which behavior is elicited by her during your assessment that would lead you to think she is stressed? [3] A. She told you about her drunk husband B. She states she has very meager income from selling C. She laughs at every advise you give even when its not funny D. She has difficulty following instructions 6. When teaching Aling Julia about her pregnancy, you should include personal common discomforts. Which of the following is an indication for prompt professional supervision? [2] A. Constipation and hemorrhoids B. Backache C. Facial edema D. frequent urination 7. Which of the following statements would be appropriate for you to include in Aling Julia's prenatal teaching plan? [1] A. Exercise is very tiresome, it should be avoided B. Limit your food intake C. Smoking has no harmful effect on the growth and development of fetus D. Avoid unnecessary fatigue, rest periods should be included in you schedule 8. The best advise you can give to Aling Julia regarding prevention of varicosities is [3] A. Raise the legs while in upright position and put it against the wall several times a day B. Lay flat for most hours of the day C. Use garters with nylon stocking
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D. Wear support hose 9. In a 32 day menstrual cycle, ovulation usually occurs on the [2] A. 14th day after menstruation B. 18th day after menstruation C. 20th day after menstruation D. 24th day after menstruation
B. Frequency of urination C. Braxton hicks contraction D. Fetal outline by sonography SITUATION : [FFC] Maternal and child health is the program of the department of health created to lessen the death of infants and mother in the philippines. [2] 16. What is the goal of this program?
10. Placenta is the organ that provides exchange of nutrients and waste products between mother and fetus. This develops by [4] A. First month B. Third month C. Fifth month D. Seventh month
A. Promote mother and infant health especially during the gravida stage B. Training of local hilots C. Direct supervision of midwives during home delivery D. Health teaching to mother regarding proper newborn care 17. One philosophy of the maternal and child health nursing is [1]
11. In evaluating the weight gain of Aling Julia, you know the minimum weight gain during pregnancy is [3] A. 2 lbs/wk B. 5 lbs/wk C. 7 lbs/wk D. 10 lbs/wk
A. All pregnancy experiences are the same for all woman B. Culture and religious practices have little effect on pregnancy of a woman C. Pregnancy is a part of the life cycle but provides no meaning D. The father is as important as the mother 18. In maternal care, the PHN responsibility is [2]
12. The more accurate method of measuring fundal height is [2] A. Millimeter B. Centimeter C. Inches D. Fingerbreadths
A. To secure all information that would be needing in birth certificate B. To protect the baby against tetanus neonatorum by immunizing the mother with DPT C. To reach all pregnant woman D. To assess nutritional status of existing children
13. To determine fetal position using Leopold's maneuvers, the first maneuver is to [1]
19. This is use when rendering prenatal care in the rural health unit. It serves as a guide in Identification of risk factors [1]
A. Determine degree of cephalic flexion and engagement B. Determine part of fetus presenting into pelvis C. Locate the back,arms and legs D. Determine what part of fetus is in the fundus
A. Underfive clinic chart B. Home based mother's record C. Client list of mother under prenatal care D. Target list of woman under TT vaccination
14. Aling julia has encouraged her husband to attend prenatal classes with her. During the prenatal class, the couple expressed fear of pain during labor and delivery. The use of touch and soothing voice often promotes comfort to the laboring patient. This physical intervention is effective because [2]
20. The schedule of prenatal visit in the RHU unit is [4]
A. Pain perception is interrupted B. Gate control fibers are open C. It distracts the client away from the pain D. Empathy is communicated by a caring person 15. Which of the following could be considered as a positive sign of pregnancy ? [1]
A. Once from 1st up to 8th month, weekly on the 9th month B. Twice in 1st and second trimester, weekly on third trimester C. Once in each trimester, more frequent for those at risk D. Frequent as possible to determine the presence of FHT each week SITUATION : Knowledge of the menstrual cycle is important in maternal health nursing. The following questions pertains to the process of menstruation 21. Menarche occurs during the pubertal period, Which of the following occurs first in the development of female sex characteristics? [2]
A. Amenorrhea, nausea, vomiting
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A. Menarche B. Accelerated Linear Growth C. Breast development D. Growth of pubic hair 22. Which gland is responsible for initiating the menstrual cycle? [3] A. Ovaries B. APG C. PPG D. Hypothalamus 23. The hormone that stimulates the ovaries to produce estrogen is [1] A. GnRH B. LH C. LHRF D. FSH 24. Which hormone stimulates oocyte maturation? [2] A. GnRH B. LH C. LHRF D. FSH 25. When is the serum estrogen level highest in the menstrual cycle? [4] A. 3rd day B. 13th day C. 14th day D. End of menstrual cycle
D. 1/3 cup 29. Menstruation occurs because of which following mechanism? [2] A. Increase level of estrogen and progesterone level B. Degeneration of the corpus luteum C. Increase vascularity of the endothelium D. Surge of hormone progesterone 30. If the menstrual cycle of a woman is 35 day cycle, she will approximately [2] A. Ovulate on the 21st day with fertile days beginning on the 16th day to the 26th day of her cycle B. Ovulate on the 21st day with fertile days beginning on the 16th day to the 21th day of her cycle C. Ovulate on the 22st day with fertile days beginning on the 16th day to the 26th day of her cycle D. Ovulate on the 22st day with fertile days beginning on the 14th day to the 30th day of her cycle SITUATION : Wide knowledge about different diagnostic tests during pregnancy is an essential arsenal for a nurse to be successful. 31. The Biparietal diameter of a fetus is considered matured if it is atleast [4] A. 9.8 cm B. 8.5 cm C. 7.5 cm D. 6 cm 32. Quickening is experienced first by multigravida clients. At what week of gestation do they start to experience quickening? [4]
26. To correctly determine the day of ovulation, the nurse must [2] A. Deduct 14 days at the mid of the cycle B. Subtract two weeks at cycle's end C. Add 7 days from mid of the cycle D. Add 14 days from the end of the cycle 27. The serum progesterone is lowest during what day of the menstrual cycle? [4] A. 3rd day B. 13th day C. 14th day D. End of menstrual cycle 28. How much blood is loss on the average during menstrual period? [4] A. Half cup B. 4 tablespoon C. 3 ounces
A. 16th B. 20th C. 24th D. 28th 33. Before the start of a non stress test, The FHR is 120 BPM. The mother ate the snack and the practitioner noticed an increase from 120 BPM to 135 BPM for 15 seconds. How would you read the result? [3] A. Abnormal B. Non reactive C. Reactive D. Inconclusive, needs repeat 34. When should the nurse expect to hear the FHR using a fetoscope? [4] A. 2nd week B. 8th week
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C. 2nd month D. 4th month
health concept? [3]
35. When should the nurse expect to hear FHR using doppler Ultrasound? [4]
A. To achieve healthy sexual development and maturation B. To prevent specific RH problem through counseling C. Provide care, treatment and rehabilitation D. To practice RH as a way of life of every man and woman
A. 8th week B. 8th month C. 2nd week D. 4th month
42. Which of the following is NOT an element of the reproductive health? [4]
36. The mother asks, What does it means if her maternal serum alpha feto protein is 35 ng/ml? The nurse should answer [4]
A. Maternal and child health and nutrition B. Family planning C. Prevention and management of abortion complication D. Healthy sexual development and nutrition
A. It is normal B. It is not normal C. 35 ng/ml indicates chromosomal abberation D. 35 ng/ml indicates neural tube defect
43. In the international framework of RH, which one of the following is the ultimate goal? [3]
37. Which of the following mothers needs RHOGAM? [1] A. RH + mother who delivered an RH - fetus B. RH - mother who delivered an RH + fetus C. RH + mother who delivered an RH + fetus D. RH - mother who delivered an RH - fetus 38. Which family planning method is recommended by the department of health more than any other means of contraception? [4] A. Fertility Awareness Method B. Condom C. Tubal Ligation D. Abstinence 39. How much booster dose does tetanus toxoid vaccination for pregnant women has? [4] A. 2 B. 5 C. 3 D. 4 40. Baranggay pinoybsn.tk has 70,000 population. How much nurse is needed to service this population? [4] A. 5 B. 7 C. 50 D. 70
A. Women's health in reproduction B. Attainment of optimum health C. Achievement of women's status D. Quality of life 44. Which one of the following is a determinant of RH affecting woman's ability to participate in social affairs? [3] A. Gender issues B. Socio-Economic condition C. Cultural and psychosocial factors D. Status of women 45. In the philippine RH Framework. which major factor affects RH status? [4] A. Women's lower level of literacy B. Health service delivery mechanism C. Poor living conditions lead to illness D. Commercial sex workers are exposed to AIDS/STD. 46. Which determinant of reproductive health advocates nutrition for better health promotion and maintain a healthful life? [4] A. Socio-Economic conditions B. Status of women C. Social and gender issues D. Biological, Cultural and Psychosocial factors 47. Which of the following is NOT a strategy of RH? [3]
SITUATION : [ND2I246] Reproductive health is the exercise of reproductive right with responsibility. A married couple has the responsibility to reproduce and procreate.
A. Increase and improve contraceptive methods B. Achieve reproductive intentions C. Care provision focused on people with RH problems D. Prevent specific RH problem through information dessemination
41. Which of the following is ONE of the goals of the reproductive
48. Which of the following is NOT a goal of RH? [3]
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D. 14 days after the beginning of the next period A. Achieve healthy sexual development and maturation B. Avoid illness/diseases, injuries, disabilities related to sexuality and reproduction C. Receive appropriate counseling and care of RH problems D. Strengthen outreach activities and the referral system 49. What is the VISION of the RH? [2] A. Attain QUALITY OF LIFE B. Practice RH as a WAY OF LIFE C. Prevent specific RH problem D. Health in the hands of the filipino SITUATION : [SORANGE19] Baby G, a 6 hours old newborn is admitted to the NICU because of low APGAR Score. His mother had a prolonged second stage of labor 50. Which of the following is the most important concept associated with all high risk newborn? [1] A. Support the high-risk newborn's cardiopulmonary adaptation by maintaining adequate airway B. Identify complications with early intervention in the high risk newborn to reduce morbidity and mortality C. Assess the high risk newborn for any physical complications that will assist the parent with bonding D. Support mother and significant others in their request toward adaptation to the high risk newborn 51. Which of the following would the nurse expect to find in a newborn with birth asphyxia? [1] A. Hyperoxemia B. Acidosis C. Hypocapnia D. Ketosis 52. When planning and implementing care for the newborn that has been successfully resuscitated, which of the following would be important to assess? [1] A. Muscle flaccidity B. Hypoglycemia C. Decreased intracranial pressure D. Spontaneous respiration
54. A factor in infertility maybe related to the PH of the vaginal canal. A medication that is ordered to alter the vaginal PH is: [2] A. Estrogen therapy B. Sulfur insufflations C. Lactic acid douches D. Na HCO3 Douches 55. A diagnostic test used to evaluate fertility is the postcoital test. It is best timed [2] A. 1 week after ovulation B. Immediately after menses C. Just before the next menstrual period D. Within 1 to 2 days of presumed ovulation 56. A tubal insufflation test is done to determine whether there is a tubal obstruction. Infertility caused by a defect in the tube is most often related to a [3] A. Past infection B. Fibroid Tumor C. Congenital Anomaly D. Previous injury to a tube 57. Which test is commonly used to determine the number, motility and activity of sperm is the [2] A. Rubin test B. Huhner test C. Friedman test D. Papanicolau test 58. In the female, Evaluation of the pelvic organs of reproduction is accomplished by [2] A. Biopsy B. Cystoscopy C. Culdoscopy D. Hysterosalpingogram 59. When is the fetal weight gain greatest? [3]
SITUATION : [P-I/46] Nurses should be aware of the different reproductive problems.
A. 1st trimester B. 2nd trimester C. 3rd trimester D. from 4th week up to 16th week of pregnancy
53. When is the best time to achieve pregnancy? [2]
60. In fetal blood vessel, where is the oxygen content highest? [3]
A. Midway between periods B. Immediately after menses end C. 14 days before the next period is expected
A. Umbilical artery B. Ductus Venosus C. Ductus areteriosus
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D. Pulmonary artery 61. The nurse is caring for a woman in labor. The woman is irritable, complains of nausea and vomits and has heavier show. The membranes rupture. The nurse understands that this indicates [1] A. The woman is in transition stage of labor B. The woman is having a complication and the doctor should be notified C. Labor is slowing down and the woman may need oxytocin D. The woman is emotionally distraught and needs assistance in dealing with labor SITUATION : [J2I246] Katherine, a 32 year old primigravida at 3940 weeks AOG was admitted to the labor room due to hypogastric and lumbo-sacral pains. IE revealed a fully dilated, fully effaced cervix. Station 0. 62. She is immediately transferred to the DR table. Which of the following conditions signify that delivery is near? [2] I - A desire to defecate II - Begins to bear down with uterine contraction III - Perineum bulges IV - Uterine contraction occur 2-3 minutes intervals at 50 seconds duration A. I,II,III B. I,II,III,IV C. I,III,IV D. II,III,IV 63. Artificial rupture of the membrane is done. Which of the following nursing diagnoses is the priority? [2] A. High risk for infection related to membrane rupture B. Potential for injury related to prolapse cord C. Alteration in comfort related to increasing strength of uterine contraction D. Anxiety related to unfamiliar procedure 64. Katherine complains of severe abdominal pain and back pain during contraction. Which two of the following measures will be MOST effective in reducing pain? [4] I - Rubbing the back with a tennis ball II- Effleurage III-Imagery IV-Breathing techniques A. II,IV B. II,III C. I,IV D. I,II
65. Lumbar epidural anesthesia is administered. Which of the following nursing responsibilities should be done immediately following procedure? [1] A. Reposition from side to side B. Administer oxygen C. Increase IV fluid as indicated D. Assess for maternal hypotension 66. Which is NOT the drug of choice for epidural anesthesia? [4] A. Sensorcaine B. Xylocaine C. Ephedrine D. Marcaine SITUATION : [SORANGE217] Alpha, a 24 year old G4P3 at full term gestation is brought to the ER after a gush of fluid passes through here vagina while doing her holiday shopping. 67. She is brought to the triage unit. The FHT is noted to be 114 bpm. Which of the following actions should the nurse do first? [2] A. Monitor FHT ever 15 minutes B. Administer oxygen inhalation C. Ask the charge nurse to notify the Obstetrician D. Place her on the left lateral position 68. The nurse checks the perineum of alpha. Which of the following characteristic of the amniotic fluid would cause an alarm to the nurse? [1] A. Greenish B. Scantly C. Colorless D. Blood tinged 69. Alpha asks the nurse. "Why do I have to be on complete bed rest? I am not comfortable in this position." Which of the following response of the nurse is most appropriate? [3] A. Keeping you on bed rest will prevent possible cord prolapse B. Completed bed rest will prevent more amniotic fluid to escape C. You need to save your energy so you will be strong enough to push later D. Let us ask your obstetrician when she returns to check on you 70. Alpha wants to know how many fetal movements per hour is normal, the correct response is [4] A. Twice B. Thrice C. Four times D. 10-12 times
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71. Upon examination by the obstetrician, he charted that Alpha is in the early stage of labor. Which of the following is true in this state? [1] A. Self-focused B. Effacement is 100% C. Last for 2 hours D. Cervical dilation 1-3 cm SITUATION : Maternal and child health nursing a core concept of providing health in the community. Mastery of MCH Nursing is a quality all nurse should possess. 72. When should be the 2nd visit of a pregnant mother to the RHU? [2] A. Before getting pregnant B. As early in pregnancy C. Second trimester D. Third trimester 73. Which of the following is NOT a standard prenatal physical examination? [1] A. Neck examination for goiter B. Examination of the palms of the hands for pallor C. Edema examination of the face hands, and lower extremeties D. Examination of the legs for varicosities 74. Which of the following is NOT a basic prenatal service delivery done in the BHS? [2]
A. 300 mg / twice a month for 9 months B. 200 mg / once a week for 5 months C. 150 mg / twice a week for the duration of pregnancy D. 100 mg / twice a week for the last trimester of pregnancy 78. Which of the following mothers are qualified for home delivery? [2] A. Pre term B. 6th pregnancy C. Has a history of hemorrhage last pregnancy D. 2nd pregnancy, Has a history of 20 hours of labor last pregnancy. 79. Which of the following is not included on the 3 Cs of delivery? [2] A. Clean Surface B. Clean Hands C. Clean Equipments D. Clean Cord 80. Which of the following is unnecessary equipment to be included in the home delivery kit? [4] A. Boiled razor blade B. 70% Isopropyl Alcohol C. Flashlight D. Rectal and oral thermometer
A. Oral / Dental check up B. Laboratory examination C. Treatment of diseases D. Iron supplementation
SITUATION : [NBLUE166] Pillar is admitted to the hospital with the following signs : Contractions coming every 10 minutes, lasting 30 seconds and causing little discomfort. Intact membranes without any bloody shows. Stable vital signs. FHR = 130bpm. Examination reveals cervix is 3 cm dilated with vertex presenting at minus 1 station.
75. How many days and how much dosage will the IRON supplementation be taken? [4]
81. On the basis of the data provided above, You can conclude the pillar is in the [1]
A. 365 days / 300 mg B. 210 days / 200 mg C. 100 days/ 100mg D. 50 days / 50 mg
A. In false labor B. In the active phase of labor C. In the latent phase of labor D. In the transitional phase of labor
76. When should the iron supplementation starts and when should it ends? [4]
82. Pitocin drip is started on Pilar. Possible side effects of pitocin administration include all of the following except [3]
A. 5th month of pregnancy to 2nd month post partum B. 1st month of pregnancy to 5th month post partum C. As early in pregnancy up to 9th month of pregnancy D. From 1st trimester up to 6 weeks post partum
A. Diuresis B. Hypertension C. Water intoxication D. Cerebral hemorrhage
77. In malaria infested area, how is chloroquine given to pregnant women? [4]
83. The normal range of FHR is approximately [3]
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A. 90 to 140 bpm B. 120 to 160 bpm C. 100 to 140 bpm D. 140 to 180 bpm 84. A negative 1 [-1] station means that [1] A. Fetus is crowning B. Fetus is floating C. Fetus is engaged D. Fetus is at the ischial spine 85. Which of the following is characteristics of false labor [1]
is to lay him [3] A. Prone with head slightly elevated B. On his back, flat C. On his side with his head flat on bed D. On his back with head slightly elevated 91. Baby boy perez has a large sebaceous glands on his nose, chin, and forehead. These are known as [1] A. Milia B. Lanugo C. Hemangiomas D. Mongolian spots
A. Bloody show B. Contraction that are regular and increase in frequency and duration C. Contraction are felt in the back and radiates towards the abdomen D. None of the above
92. Baby boy perez must be carefully observed for the first 24 hours for [2]
86. Who's Theory of labor pain that states that PAIN in labor is cause by FEAR [4]
A. Respiratory distress B. Duration of cry C. Frequency of voiding D. Range in body temperature
A. Bradley B. Simpson C. Lamaze D. Dick-Read
93. According to the WHO , when should the mother starts breastfeeding the infant? [4]
87. Which sign would alert the nurse that Pillar is entering the second stage of labor? [1]
A. Within 30 minutes after birth B. Within 12 hours after birth C. Within a day after birth D. After infant's condition stabilizes
A. Increase frequency and intensity of contraction B. Perineum bulges and anal orifice dilates C. Effacement of internal OS is 100% D. Vulva encircles the largest diameter of presenting part
94. What is the BEST and most accurate method of measuring the medication dosage for infants and children? [3]
88. Nursing care during the second stage of labor should include [1] A. Careful evaluation of prenatal history B. Coach breathing, Bear down with each contraction and encourage patient. C. Shave the perineum D. Administer enema to the patient SITUATION : [NBLUE170] Baby boy perez was delivered spontaneously following a term pregnancy. Apgar scores are 8 and 9 respectively. Routine procedures are carried out.
A. Weight B. Height C. Nomogram D. Weight and Height 95. The first postpartum visit should be done by the mother within [4] A. 24 hours B. 3 days C. a week D. a month 96. The major cause of maternal mortality in the philippines is [3]
89. When is the APGAR Score taken? [1] A. Immediately after birth and at 30 minutes after birth B. At 5 minutes after birth and at 30 minutes after birth C. At 1 minute after birth and at 5 minutes after birth D. Immediately after birth and at 5 minutes after birth 90. The best way to position a newboarn during the first week of life
A. Infection B. Hemorrhage C. Hypertension D. Other complications related to labor,delivery and puerperium 97. According to the WHO, what should be the composition of a commercialized Oral rehydration salt solution? [4]
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A. Potassium : 1.5 g. ; Sodium Bicarbonate 2.5g ; Sodium Chloride 3.5g; Glucose 20 g. A. Potassium : 1.5 g. ; Sodium Bicarbonate 2.5g ; Sodium Chloride 3.5g; Glucose 10 g. A. Potassium : 2.5 g. ; Sodium Bicarbonate 3.5g ; Sodium Chloride 4.5g; Glucose 20 g. A. Potassium : 2.5 g. ; Sodium Bicarbonate 3.5g ; Sodium Chloride 4.5g; Glucose 10 g. 98. In preparing ORESOL at home, The correct composition recommnded by the DOH is [4] A. 1 glass of water, 1 pinch of salt and 2 tsp of sugar B. 1 glass of water, 2 pinch of salt and 2 tsp of sugar C. 1 glass of water, 3 pinch of salt and 4 tsp of sugar D. 1 glass of water, 1 pinch of salt and 1 tsp of sugar 99. Milk code is a law that prohibits milk commercialization or artificial feeding for up to 2 years. Which law provides its legal basis? [4] A. Senate bill 1044 B. RA 7600 C. Presidential Proclamation 147 D. EO 51 100. A 40 year old mother in her third trimester should avoid [4] A. Traveling B. Climbing C. Smoking D. Exercising 1.
Which of the following would be useful in calculating Aling Julia's EDC? [3] A. Appearance of linea negra B. First FHT by fetoscope C. Increase pulse rate D. Presence of edema * The answer of some people is A because they say linea negra appears at 2nd trimester. Appearance of Linea negra is not the same with all women. Some will have it as early as first trimester while other on the 2nd trimester. It is very subjective and non normative. However, First FHT by fetoscope is UNIVERSAL and it is arbitrarily accepted that it starts at the 4th month of gestation. Therefore, If I heard the First FHT by fetoscope, I can say that Aling Julia's EDC is at 4th month and the EDC will be around 5 months from now.Pulse rate and Edema will never suggest the estimated date of confinement nor age of gestation.
2. Which hormone is necessary for a positive pregnancy test? [1] A. Progesterone B. HCG C. Estrogen D. Placental Lactogen * HCG is responsible for positive pregnancy test. But it is NOT a positive sign of pregnancy. Only PROBABLE. Purpose of HCG is to maintain the secretion of progestrone by the corpus luteum. It will deteriorate by 2nd trimester as the placenta resumes its funciton. HCG is also use to stimulate descend of the testes in case of cryptorchidism or undescended testes. HCG peaks at 10 weeks then decline for the rest of the pregnancy. Non pregnant females will have less than 5 mIU/ml and can reach up to 100,000 mIU/ml in pregnant women. By the way, undescended testes repair is done when the child is 1 year old according to Lippinncots, the doctor will try to wait baka kasi bumaba pa before they do surgery. 3. With this pregnancy, Aling Julia is a [1] A. P3 G3 B. Primigravida C. P3 G4 D. P0 G3 * She has 3 children, so para 3. Since she is pregnant, this is her 4th gravida. Remember that even if the pregancy is beyond the age of viability [ >7 months ] consider it as PARA and not GRAVIDA as long as the baby is still inside the uterus. A common error of the old nurses in a puericulture center where I dutied in is that they count the child inside the mother's womb as GRAVIDA when it is greater than 7 months! [ kawawang nanay, mali na ang home based mothers record mo ] I tried to correct it but they still INSISTED. I read pillitteri thinking that I might be wrong nakakahiya naman... but I was right. 4. In explaining the development of her baby, you identified in chronological order of growth of the fetus as it occurs in pregnancy as [1] A. Ovum, embryo, zygote, fetus, infant B. Zygote, ovum, embryo, fetus, infant C. Ovum, zygote, embryo, fetus, infant D. Zygote, ovum, fetus, embryo, infant * The Ovum is the egg cell from the mother, the sperm will fertilize it to form a zygote. This usually happens in the AMPULLA or the distal third of the fallopian tube. Hyalorunidase is secreted by the sperm to dissolve the
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outer memberane of the ovum. The zygote now containes 46 chromosomes. 23 from each germ cell. The zygote is now termed as an embryo once it has been implanted. Implantation takes 3-4 days. When the embryo reach 8th weeks, it is now termed as a FETUS until it has been delivered and then, neonate then infant.
Constipation and hemorrhoids are relieved by increasing fluid intake and hot sitz bath.
5. Aling Julia states she is happy to be pregnant. Which behavior is elicited by her during your assessment that would lead you to think she is stressed? [3]
A. Exercise is very tiresome, it should be avoided B. Limit your food intake C. Smoking has no harmful effect on the growth and development of fetus D. Avoid unnecessary fatigue, rest periods should be included in you schedule
A. She told you about her drunk husband B. She states she has very meager income from selling C. She laughs at every advise you give even when its not funny D. She has difficulty following instructions * Stressed is manifested in different ways and one of them, is difficulty following instructions. Telling you that her husband is drunk and has meager income from selling is not enough for you to conclude she is stressed. Assessment is always based on factual and specific manifestations. A diagnosis is made from either ACTUAL or POTENTIAL/RISK problems. A and B are both potential problems, but not actual like D. C is automatically eliminated first because laughing is not indicative of stress. 6. When teaching Aling Julia about her pregnancy, you should include personal common discomforts. Which of the following is an indication for prompt professional supervision? [2] A. Constipation and hemorrhoids B. Backache C. Facial edema D. frequent urination *Facial edema is NOT NORMAL. Facial edema is one sign of MILD PRE ECLAMPSIA and prompt professional supervision is needed to lower down the client's blood pressure. Blood pressure in Mild Pre Eclampsia is around 140/90 and 160/110 in severe. Treatment involves bed rest, Magnesium sulfate, Hydralazine, Diazoxide and Diazepam [ usually a combination of Magsul + Apresoline [ Hydralazine ] ] Calcium gluconate is always at the client's bed side when magnesium toxicity occurs. It works by exchanging Calcium ions for magnesium ions. A,B and D are all physiologic change in pregnancy that do not need prompt professional supervision. Frequent urination will disappear as soon as the pressure of the uterus is released against the bladder and as soon as the client's blood volume has returned to normal. Backache is a common complaint of women with an OCCIPUT POSTERIOR presentation due to pressure on the back. Intervention includes pelvic rocking or running a tennis ball at the client's back.
7. Which of the following statements would be appropriate for you to include in Aling Julia's prenatal teaching plan? [1]
* Exercise is not avoided in pregnancy, therfore eliminate A. Food is never limited in pregnancy. Calories are even increased by around 300 cal a day as well as vitamins and minerals. Smoking, alcohol and drug use are avoided for the rest of the pregnancy because of their harmful effects on the growth and development of the fetus. Rest period and avoiding unecessary fatigue is one of the pillars in health teaching of the pregnant client. 8. The best advise you can give to Aling Julia regarding prevention of varicosities is [3] A. Raise the legs while in upright position and put it against the wall several times a day B. Lay flat for most hours of the day C. Use garters with nylon stocking D. Wear support hose * A thigh high stocking or a support hose WORN BEFORE GETTING UP in the morning is effective in prevention of varicosities. Stocking should have NO GARTERS because it impedes blood flow, they should be made of COTTON not nylon to allow the skin to breathe. Lying flat most of the day WILL PREVENT VARICOSITIES but will not be helpful for the client's overall health and function. Raising the legs and putting it against the wall will still create pressure in the legs.
9. In a 32 day menstrual cycle, ovulation usually occurs on the [2] A. 14th day after menstruation B. 18th day after menstruation C. 20th day after menstruation D. 24th day after menstruation * To get the day of ovulation, A diary is made for around 6 months to determine the number of days of menstrual cycle [ from onset of mens to the next onset of mens ] and the average is taken from that cycles. 14 days are subtracted
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from the total days of the menstrual cycle. This signifies the ovulation day. A couple would abstain having sex 5 days before and 5 days after the ovulation day. Therefore, a 32 day cycle minus 14 days equals 18, hence... ovulation occurs at the 18th day. 10. Placenta is the organ that provides exchange of nutrients and waste products between mother and fetus. This develops by [4] A. First month B. Third month C. Fifth month D. Seventh month * The placenta is formed at around 3 months. It is a latin word for PANCAKE because of it's appearance. It arises from the trophoblast from the chorionic villi and decidua basalis. It functions as the fetal lungs, kidney, GI tract and an endocrine organ. 11. In evaluating the weight gain of Aling Julia, you know the minimum weight gain during pregnancy is [3] A. 2 lbs/wk B. 5 lbs/wk C. 7 lbs/wk D. 10 lbs/wk
determines whether the fetal head or breech is in the fundus. A head is round and hard. Breech is less well defined. 14. Aling julia has encouraged her husband to attend prenatal classes with her. During the prenatal class, the couple expressed fear of pain during labor and delivery. The use of touch and soothing voice often promotes comfort to the laboring patient. This physical intervention is effective because [2] A. Pain perception is interrupted B. Gate control fibers are open C. It distracts the client away from the pain D. Empathy is communicated by a caring person * Touch and soothing voice promotes pain distraction. Instead of thinking too much of the pain in labor, The mother is diverted away from the pain sensation by the use of touch and voice. Pain perception is not interrupted, pain is still present. When gate control fibers are open, Pain is felt according to the gate control theory of pain. Although empathy is communicated by the caring person, this is not the reason why touch and voice promotes comfort to a laboring patient. 15. Which of the following could be considered as a positive sign of pregnancy ? [1]
* Weight gain should be 1 to 2 lbs per week during the 2nd and 3rd trimester and 3 to 5 lbs gain during the first trimester for a total of 25-35 lbs recommended weight gain during the gravida state.
A. Amenorrhea, nausea, vomiting B. Frequency of urination C. Braxton hicks contraction D. Fetal outline by sonography
12. The more accurate method of measuring fundal height is [2]
* Fetal outline by sonography or other imaging devices is considered a positive sign of pregnancy along with the presence of fetal heart rate and movement felt by a qualified examiner. All those signs with the discoverer's name on them [ chadwick, hegars, braxton hicks, goodells ] are considered probable and All the physiologic changes brought about by pregnancy like hyperpigmentation, fatgiue, uterine enlargement, nausea, vomiting, breast changes, frequent urination are considered presumptive.
A. Millimeter B. Centimeter C. Inches D. Fingerbreadths * Fundal height is measured in cm not mm. centimeters is the more accurate method of measuring fundic height than inches or fingerbreadths. 13. To determine fetal position using Leopold's maneuvers, the first maneuver is to [1] A. Determine degree of cephalic flexion and engagement B. Determine part of fetus presenting into pelvis C. Locate the back,arms and legs D. Determine what part of fetus is in the fundus * Leopold's one determines what is it in the fundus. This
Sonographic evidence of the gestational sac is not POSITIVE sign but rather, PROBABLE. SITUATION : [FFC] Maternal and child health is the program of the department of health created to lessen the death of infants and mother in the philippines. [2] 16. What is the goal of this program? A. Promote mother and infant health especially during the gravida stage
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B. Training of local hilots C. Direct supervision of midwives during home delivery D. Health teaching to mother regarding proper newborn care
they are different. GOAL : to promote and maintain optimum health for women and their newborn HOW? OBJECTIVE : By reaching all pregnant women to give sufficient care ensuring healthy pregnancy and baby.
* The goal of the MCHN program of the DOH is the PROMOTION AND MAINTENANCE OF OPTIMUM HEALTH OF WOMAN AND THEIR NEWBORN. To achieve this goal, B,C and D are all carried out. Even without the knowledge of the MCHN goal you SHOULD answer this question correctly. Remember that GOALS are your plans or things you MUST ATTAIN while STRATEGIES are those that must be done [ ACTIONS ] to attain your goal.
19. This is use when rendering prenatal care in the rural health unit. It serves as a guide in Identification of risk factors [1]
Looking at B,C and D they are all ACTIONS. Only A correctly followed the definition of a goal. 17. One philosophy of the maternal and child health nursing is [1] A. All pregnancy experiences are the same for all woman B. Culture and religious practices have little effect on pregnancy of a woman C. Pregnancy is a part of the life cycle but provides no meaning D. The father is as important as the mother * Knowing that not all individuals and pregnancy are the same for all women, you can safely eliminate letter A. Personal, culture and religious attitudes influence the meaning of pregnancy and that makes pregnancy unique for each individual. Culture and religious practice have a great impact on pregnancy, eliminate B. Pregnancy is meaningful to each individuals, not only the mother but also the father and the family and the father of the child is as important as the mother. MATERNAL AND CHILD HEALTH IS FAMILY CENTERED and thid will guide you in correctly answering D.
A. Underfive clinic chart B. Home based mother's record C. Client list of mother under prenatal care D. Target list of woman under TT vaccination * The HBMR is used in rendring prenatal care as guide in identifying risk factors. It contains health promotion message and information on the danger signs of pregnancy. 20. The schedule of prenatal visit in the RHU unit is [4] A. Once from 1st up to 8th month, weekly on the 9th month B. Twice in 1st and second trimester, weekly on third trimester C. Once in each trimester, more frequent for those at risk D. Frequent as possible to determine the presence of FHT each week * Visit to the RHU should be ONCE each trimester and more frequent for those who are high risks. The visit to the BHS or health center should be ONCE for 1st to 6th months of pregnancy, TWICE for the 7th to 8th month and weekly during the 9th month. They are different and are not to be confused with. SITUATION : Knowledge of the menstrual cycle is important in maternal health nursing. The following questions pertains to the process of menstruation
18. In maternal care, the PHN responsibility is [2]
21. Menarche occurs during the pubertal period, Which of the following occurs first in the development of female sex characteristics? [2]
A. To secure all information that would be needing in birth certificate B. To protect the baby against tetanus neonatorum by immunizing the mother with DPT C. To reach all pregnant woman D. To assess nutritional status of existing children
A. Menarche B. Accelerated Linear Growth C. Breast development D. Growth of pubic hair
* The sole objective of the MCHN of the DOH is to REACH ALL PREGNANT WOMEN AND GIVE SUFFICIENT CARE TO ENSURE A HEALTHY PREGNANCY AND THE BIRTH OF A FULL TERM HEALTH BABY. As not to confuse this with the GOAL of the MCHN, The OBJECTIVE should answer the GOAL,
* Remember TAMO or THELARCHE, ADRENARCHE, MENARCHE and OVULATION. Telarche is the beginning of the breast development which is influenced by the increase in estrogen level during puberty. Adrenarche is the development of axillary and pubic hair due to androgen stimulation. Menarche is the onset of first menstruation that averagely occurs at around 12 to 13 years old. Ovulation
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then occurs last. However, prior to TAMO, Accelerated LINEAR GROWTH will occur first in GIRLS while WEIGHT INCREASE is the first one to occur in boys. 22. Which gland is responsible for initiating the menstrual cycle? [3] A. Ovaries B. APG C. PPG D. Hypothalamus * Hypothalamus secretes many different hormones and one of them is the FSHRF or the FOLLICLE STIMULATING HORMONE RELEASING FACTOR. This will instruct the ANTERIOR PITUITARY GLAND to secrete FSH that will stimulate the ovary to release egg and initiate the menstrual cycle. The PPG or the posterior pituitary only secretes two hormones : OXYTOCIN and ADH. It plays an important factor in labor as well as in the pathophysiology of diabetes insipidus. 23. The hormone that stimulates the ovaries to produce estrogen is [1] A. GnRH B. LH C. LHRF D. FSH * FSH stimulates the ovaries to secrete estrogen. This hormone is a 3 substance compounds known as estrone [e1], estradiol [2] and estriol [3] responsible for the development of female secondary sex characteristics. It also stimulates the OOCYTES to mature. During pregnancy, Estrogen is secreted by the placenta that stimulates uterine growth to accomodate the fetus. 24. Which hormone stimulates oocyte maturation? [2] A. GnRH B. LH C. LHRF D. FSH
D. End of menstrual cycle * There are only 3 days to remember in terms of hormonal heights during pregnancy. 3,13 and 14. During the 3rd day, Serum estrogen is the lowest. During the 13th day, Serum estrogen is at it's peak while progestrone is at it's lowest and this signifies that a mature oocyte is ready for release. At 14th day, Progesterone will surge and this is the reason why there is a sudden increase of temperature during the ovulation day and sudden drop during the previous day. This will not stimulate the release of the mature egg or what we call, OVULATION.
26. To correctly determine the day of ovulation, the nurse must [2] A. Deduct 14 days at the mid of the cycle B. Subtract two weeks at cycle's end C. Add 7 days from mid of the cycle D. Add 14 days from the end of the cycle * Refer to # 9 Big thanks to marisse for the correction in this number. 27. The serum progesterone is lowest during what day of the menstrual cycle? [4] A. 3rd day B. 13th day C. 14th day D. End of menstrual cycle * At 3rd day, The serum estrogen is at it's lowest. At the 13th day, serum estrogen is at it's peak while progesterone is at it's lowest. At the 13th day of the cycle, An available matured ovum is ready for fertilization and implantation. The slight sharp drop of temperature occurs during this time due to the very low progestrone level. The next day, 14th day, The serum progestrone sharply rises and this causes the release of the matured ovum. Temperature also rises at this point because of the sudden increase in the progestrone level. 28. How much blood is loss on the average during menstrual period? [4]
* Refer to #23 25. When is the serum estrogen level highest in the menstrual cycle? [4] A. 3rd day B. 13th day C. 14th day
A. Half cup B. 4 tablespoon C. 3 ounces D. 1/3 cup * The average blood loss during pregnancy is 60 cc. A, half cup is equivalent to 120 cc. C, is equivalent to 90 cc while
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D, is equivalent to 80 cc. 1 tablespoon is equal to 15 ml. 4 tablespoon is exactly 60 cc. 29. Menstruation occurs because of which following mechanism? [2] A. Increase level of estrogen and progesterone level B. Degeneration of the corpus luteum C. Increase vascularity of the endothelium D. Surge of hormone progesterone * Degeneration of the corpus luteum is the cause of menstruation. Menstruation occurs because of the decrease of both estrogen and progestrone. This is caused by the regression of the corpus luteum inside the ovary 8 to 10 days in absence of fertilization after an ovum was released. With the absence of progestrone, the endometrium degenerates and therefore, vascularity will decrease at approximately 25th day of the cycle which causes the external manifestation of menstruation. 30. If the menstrual cycle of a woman is 35 day cycle, she will approximately [2] A. Ovulate on the 21st day with fertile days beginning on the 16th day to the 26th day of her cycle B. Ovulate on the 21st day with fertile days beginning on the 16th day to the 21th day of her cycle C. Ovulate on the 22st day with fertile days beginning on the 16th day to the 26th day of her cycle D. Ovulate on the 22st day with fertile days beginning on the 14th day to the 30th day of her cycle * Formula for getting the fertile days and ovulation day is : Number of days of cycle MINUS 14 [ Ovulation day ] Minus 5 Plus 5 [ Possible fertile days ]. Since the client has a 35 day cycle, we subtract 14 days to get the ovulation day which is 21. Minus 5 days is equal to [21 - 5 = 16 ] 16 , Plus 5 days [ 21 + 5 = 26 ] is equal to 26. Therefore, Client is fertile during the 16th to the 26th day of her cycle. This is the same principle and formula used in the calendar / rhythm method.
* BPD is considered matured at 8.5 cm and at term when it reaches 9.6 cm. 32. Quickening is experienced first by multigravida clients. At what week of gestation do they start to experience quickening? [4] A. 16th B. 20th C. 24th D. 28th * Multigravid clients experience quickening at around 16 weeks or 4 months. Primigravid clients experience this 1 month later, at the 5th month or 20th week. 33. Before the start of a non stress test, The FHR is 120 BPM. The mother ate the snack and the practitioner noticed an increase from 120 BPM to 135 BPM for 15 seconds. How would you read the result? [3] A. Abnormal B. Non reactive C. Reactive D. Inconclusive, needs repeat * Normal non stress test result is REACTIVE. Non stress test is a diagnostic procedure in which the FHR is compared with the child's movement. A normal result is an increase of 15 BPM sustained for 15 seconds at every fetal movement. The mother is told to eat a light snack during the procedure while the examiner carefully monitors the FHR. The mother will tell the examiner that she felt a movement as soon as she feels it while the examiner take note of the time and the FHR of the fetus. 34. When should the nurse expect to hear the FHR using a fetoscope? [4] A. 2nd week B. 8th week C. 2nd month D. 4th month
SITUATION : Wide knowledge about different diagnostic tests during pregnancy is an essential arsenal for a nurse to be successful.
* The FHR is heard at about 4 months using a fetoscope. Remember the word FeFOUR to relate fetoscope to four.
31. The Biparietal diameter of a fetus is considered matured if it is atleast [4]
35. When should the nurse expect to hear FHR using doppler Ultrasound? [4]
A. 9.8 cm B. 8.5 cm C. 7.5 cm D. 6 cm
A. 8th week B. 8th month C. 2nd week D. 4th month
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* The FHR is heard as early as 8th week [ some books, 12 to 14 weeks ] using doppler ultrasound. Remember the word DOPPLE RATE, [ DOPPLER 8 ] to relate dopple ultrasound to the number 8. 36. The mother asks, What does it means if her maternal serum alpha feto protein is 35 ng/ml? The nurse should answer [4] A. It is normal B. It is not normal C. 35 ng/ml indicates chromosomal abberation D. 35 ng/ml indicates neural tube defect * The normal maternal alpha feto protein is 38-45 ng/ml. Less 38 than this indicates CHROMOSOMAL ABBERATION [Down,Klinefelters] and more than 45 means NEURAL TUBE DEFECTS [Spina Bifida]. Remember the word CLINICAL NURSE. C for chromosomal abberation for <38>N for neural tube defect for >45. C<38>45 Clinic Nurse. CLINIC NURSE is also an important mnemonics to differentiate COUNTER TRANSFERENCE from TRANSFERENCE. Counter transference is the special feeling of the CLINIC NURSE or CLINICIAN to the patient while transference is the development of personal feelings of the patient to the nurse.
* Abstinence is never advocated as a family planning method. Though, It is probably the BEST METHOD to prevent STD and pregnancy, it is inhumane and supresses the reproductive rights of the people. It is also unrealistic. FAM is advocated by the DOH more than any other kind of contraception. It is a combination of symptothermal and billings method. CALENDAR method is the only method advocated by the catholic church. 39. How much booster dose does tetanus toxoid vaccination for pregnant women has? [4] A. 2 B. 5 C. 3 D. 4 * TT1 and TT2 are both primary dosages. While TT3 up to TT5 represents the booster dosages. 40. Baranggay pinoybsn.tk has 70,000 population. How much nurse is needed to service this population? [4] A. 5 B. 7 C. 50 D. 70
37. Which of the following mothers needs RHOGAM? [1]
* For every 10,000 population , 1 nurse is needed. therefore, a population of 70,000 people needs a service of 7 nurses.
A. RH + mother who delivered an RH - fetus B. RH - mother who delivered an RH + fetus C. RH + mother who delivered an RH + fetus D. RH - mother who delivered an RH - fetus
SITUATION : [ND2I246] Reproductive health is the exercise of reproductive right with responsibility. A married couple has the responsibility to reproduce and procreate.
* Rhogam is given to RH - Mothers That delivers an RH + Fetus. Rhogam prevents ISOIMMUNIZATION or the development of maternal antibodies against the fetal blood due to RH incompatibility. Once the mother already develops an antibody against the fetus, Rhogam will not anymore be benificial and the mother is advised no to have anymore pregnancies. Rhogam is given within 72 hours after delivery.
41. Which of the following is ONE of the goals of the reproductive health concept? [3]
38. Which family planning method is recommended by the department of health more than any other means of contraception? [4] A. Fertility Awareness Method B. Condom C. Tubal Ligation D. Abstinence
A. To achieve healthy sexual development and maturation B. To prevent specific RH problem through counseling C. Provide care, treatment and rehabilitation D. To practice RH as a way of life of every man and woman * EVERY ACHIEVER AVOIDS RECEIVER : Remember this mnemonics and it will guide you in differentiating which is which from the goals, visions and strategies. If a sentence begins with these words, it is automatically a GOAL. Usually, The trend in the board is that they will mix up the vision, strategies and goals to confuse you. D is the only vision of the RH program. Anything else aside from the vision and goals are more
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likely strategies. [ B and C ] Strategies, even without knowing them or memorizing them can easily be seperated as they convey ACTIONS and ACTUAL INTERVENTIONS. This is universal and also applies to other DOH programs. Notice that B and C convey actions and interventions. 42. Which of the following is NOT an element of the reproductive health? [4] A. Maternal and child health and nutrition B. Family planning C. Prevention and management of abortion complication D. Healthy sexual development and nutrition * Achieving healthy sexual development and nutrition is a GOAL of the RH. Knowledge of the elements, goals, strategies and vision of RH are important in answering this question. I removed the word ACHIEVE to let you know that it is possible for the board of nursing not to include those keywords [ although it never happened as of yet ]. 43. In the international framework of RH, which one of the following is the ultimate goal? [3] A. Women's health in reproduction B. Attainment of optimum health C. Achievement of women's status D. Quality of life * Quality of life is the ultimate goal of the RH in the international framework. Way of life is the ultimate goal of RH in the local framework. 44. Which one of the following is a determinant of RH affecting woman's ability to participate in social affairs? [3] A. Gender issues B. Socio-Economic condition C. Cultural and psychosocial factors D. Status of women
A. Women's lower level of literacy B. Health service delivery mechanism C. Poor living conditions lead to illness D. Commercial sex workers are exposed to AIDS/STD. * Health services delivery mechanism is the major factor that affect RH status. Other factors are women's behavior, Sanitation and water supply, Employment and working conditions etc. 46. Which determinant of reproductive health advocates nutrition for better health promotion and maintain a healthful life? [4] A. Socio-Economic conditions B. Status of women C. Social and gender issues D. Biological, Cultural and Psychosocial factors * Refer to # 44 47. Which of the following is NOT a strategy of RH? [3] A. Increase and improve contraceptive methods B. Achieve reproductive intentions C. Care provision focused on people with RH problems D. Prevent specific RH problem through information dessemination * Refer to #41 48. Which of the following is NOT a goal of RH? [3] A. Achieve healthy sexual development and maturation B. Avoid illness/diseases, injuries, disabilities related to sexuality and reproduction C. Receive appropriate counseling and care of RH problems D. Strengthen outreach activities and the referral system * Refer to #41
* This is an actual board question, Gender issues affects the women participation in the social affairs. Socio economic condition is the determinant for education, employment, poverty, nutrition, living condition and family environment. Status of women evolves in women's rights. Cultural and psychosocial factors refers to the norms, behaviors, orientation, values and culture. Refer to your DOH manual to read more about this.
49. What is the VISION of the RH? [2]
45. In the philippine RH Framework. which major factor affects RH status? [4]
SITUATION : [SORANGE19] Baby G, a 6 hours old newborn is admitted to the NICU because of low APGAR Score. His mother had a prolonged second stage of labor
A. Attain QUALITY OF LIFE B. Practice RH as a WAY OF LIFE C. Prevent specific RH problem D. Health in the hands of the filipino * Refer to #43
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50. Which of the following is the most important concept associated with all high risk newborn? [1] A. Support the high-risk newborn's cardiopulmonary adaptation by maintaining adequate airway B. Identify complications with early intervention in the high risk newborn to reduce morbidity and mortality C. Assess the high risk newborn for any physical complications that will assist the parent with bonding D. Support mother and significant others in their request toward adaptation to the high risk newborn * The 3 major and initial and immediate needs of newborns both normal and high risks are AIR/BREATHING, CIRCULATION and TEMPERATURE. C and D are both eliminated because they do not address the immediate newborn needs. Identifying complication with early intervention is important, however, this does not address the IMMEDIATE and MOST IMPORTANT newborn needs. 51. Which of the following would the nurse expect to find in a newborn with birth asphyxia? [1] A. Hyperoxemia B. Acidosis C. Hypocapnia D. Ketosis * Birth Asphyxia is a term used to describe the inability of an infant to maintain an adequate respiration within 1 minute after birth that leads so acidosis, hypoxia, hypoxemia and tissue anoxia. This results to Hypercapnia not Hypocapnia due to the increase in carbonic acid concentration in the fetal circulation because the carbon dioxide fails to get eliminated from the infant's lungs because of inadequate respiration. Ketosis is the presence of ketones in the body because of excessive fat metabolism. This is seen in diabetic ketoacidosis. 52. When planning and implementing care for the newborn that has been successfully resuscitated, which of the following would be important to assess? [1] A. Muscle flaccidity B. Hypoglycemia C. Decreased intracranial pressure D. Spontaneous respiration * There is no need to assess for spontaneous respiration because OF the word SUCCESSFULLY RESUSCITATED. What is it to assess is the quality and quantity of respiration. Infants who undergone tremendous physical challenges during birth like asphyxia, prolonged
labor, RDS are all high risk for developing hypoglycemia because of the severe depletion of glucose stores to sustain the demands of the body during those demanding times. SITUATION : [P-I/46] Nurses should be aware of the different reproductive problems. 53. When is the best time to achieve pregnancy? [2] A. Midway between periods B. Immediately after menses end C. 14 days before the next period is expected D. 14 days after the beginning of the next period * The best time to achieve pregnancy is during the ovulation period which is about 14 days before the next period is expected. A Menstrual cycle is defined as the number of days from the start of the menstruation period, up to the start of another menstrual period. To obtain the ovulation day, Subtract 14 days from the end of each cycle. Example, The start of the menstrual flow was July 12, 2006. The next flow was experienced August 11, 2006. The length of the menstrual cycle is then 30 days [ August 11 minus July 12 ]. We then subtract 14 days from that total length of the cycle and that will give us 16 days [ 30 minus 14 ] Count 16 days from July 12, 2006 and that will give us July 28, 2006 as the day of ovulation. [ July 12 + 16 days ] This is the best time for coitus if the intention is getting pregnant, worst time if not. 54. A factor in infertility maybe related to the PH of the vaginal canal. A medication that is ordered to alter the vaginal PH is: [2] A. Estrogen therapy B. Sulfur insufflations C. Lactic acid douches D. Na HCO3 Douches * Sperm is innately ALKALINE. Too much acidity is the only PH alteration in the vagina that can kill sperm cells. Knowing this will direct you to answering letter D. Sodium Bicarbonate douches will make the vagina less acidic because of it's alkaline property, making the vagina's environment more conducive and tolerating to the sperm cells. Estrogen therapy will not alter the PH of the vaginal canal. HRT [ Hormone replacement therapy ] is now feared by many women because of the high risk in acquiring breast, uterine and cervical cancer. Research on this was even halted because of the significant risk on the sample population. Lactic acid douches will make the vagina more acidic, further making the environment hostile to the alkaline sperm. Sulfur insufflation is a procedure used to treat vaginal infections. A tube is inserted in the vagina and
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sulfur is introduced to the body. The yeasts, fungi and other microorganisms that are sensitive to sulfur are all immediately killed by it on contact. 55. A diagnostic test used to evaluate fertility is the postcoital test. It is best timed [2] A. 1 week after ovulation B. Immediately after menses C. Just before the next menstrual period D. Within 1 to 2 days of presumed ovulation * A poscoital test evaluates both ovulation detection and sperm analysis. When the woman ovulates [ by using the FAM method or commercial ovulation detection kits, woman should know she ovulates ] The couple should have coitus and then, the woman will go to the clinic within 2 to 8 hours after coitus. The woman is put on a lithotomy position. A specimen for cervical mucus is taken and examined for spinnbarkeit [ ability to stretch 15 cm before breaking ] and sperm count. Postcoital test is now considered obsolete because a single sperm and cervical mucus analysis provides more accurate data. 56. A tubal insufflation test is done to determine whether there is a tubal obstruction. Infertility caused by a defect in the tube is most often related to a [3] A. Past infection B. Fibroid Tumor C. Congenital Anomaly D. Previous injury to a tube * PID [ Most common cause of tubal obstruction ] due to untreated gonorrhea, chlamydia or other infections that leads to chronic salphingitis often leads to scarring of the fallopian tube thereby causing tubal obstuction. This one of the common cause of infertility, the most common is Anovulation in female and low sperm count in males. A ruptured appendix, peritonitis and abdominal surgery that leads to infection and adhesion of the fallopian tube can also lead to tubal obstruction. 57. Which test is commonly used to determine the number, motility and activity of sperm is the [2] A. Rubin test B. Huhner test C. Friedman test D. Papanicolau test * Huhner test is synonymous to postcoital test. This test evaluates the number, motility and status of the sperm cells in the cervical mucus. refer to # 55 for more information. Rubin test is a test to determine the tubal patency by
introducing carbon dioxide gas via a cannula to the client's cervix. The sound is then auscultated in the client's abdomen at the point where the outer end of the fallopian tube is located, near the fimbriae. Absent of sound means that the tube is not patent. Friedman test involves a FROG to determine pregnancy that is why it is also called as FROG TEST. Papanicolaou test [Correct spelling], discovered by Dr. George Papanicolaou during the 1930's is a cytolgic examination of the epithelial lining of the cervix. It is important in diagnosis cervical cancer. 58. In the female, Evaluation of the pelvic organs of reproduction is accomplished by [2] A. Biopsy B. Cystoscopy C. Culdoscopy D. Hysterosalpingogram * Biopsy is acquiring a sample tissue for cytological examination. Usually done in cancer grading or detecting atypical, abnormal and neoplastic cells. Cystoscopy is the visualization of the bladder using a cystoscope. This is inserted via the urethra. TURP or the transurethral resection of the prostate is frequently done via cystoscopy to remove the need for incision in resecting the enlarged prostate in BPH. Culdoscopy is the insertion of the culdoscope through the posterior vaginal wall between the rectum and uterus to visualize the douglas cul de sac. This is an important landmark because this is the lowest point in the pelvis, fluid or blood tends to collect in this place. Hysterosalpingogram is the injection of a blue dye, or any radio opaque material through the cervix under pressure. X ray is then taken to visualize the pelvic organs. This is done only after menstruation to prevent reflux of the menstrual discharge up into the fallopian tube and to prevent an accidental irradiation of the zygote. As usual, as with all other procedures that ends in GRAM, assess for iodine allergy. 59. When is the fetal weight gain greatest? [3] A. 1st trimester B. 2nd trimester C. 3rd trimester D. from 4th week up to 16th week of pregnancy * Vital organs are formed during the first trimester, The greatest LENGTH gain occurs during the second trimester while the greatest weight gain occurs during the last trimester. This is the time when brown fats starts to be deposited in preparation for the upcoming delivery. 60. In fetal blood vessel, where is the oxygen content highest? [3]
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of the following conditions signify that delivery is near? [2] A. Umbilical artery B. Ductus Venosus C. Ductus areteriosus D. Pulmonary artery * Ductus venosus is directly connected to the umbilical vein, Which is directly connected to the highly oxygenated placenta. This vessel supplies blood to the fetal liver. Umbilical arteries carries UNOXYGENATED BLOOD, they carry the blood away from the fetal body. Ductus arteriosus shunts the blood away from the fetal lungs, this carries an oxygenated blood but not as concentrated as the blood in the ductus venosus who have not yet service any of the fetal organ for oxygen except the liver. Knowing that the fetal lungs is not yet functional and expanded will guide you to automatically eliminate the pulmonary artery which is responsible for carrying UNOXYGENATED BLOOD away from the lungs. 61. The nurse is caring for a woman in labor. The woman is irritable, complains of nausea and vomits and has heavier show. The membranes rupture. The nurse understands that this indicates [1] A. The woman is in transition stage of labor B. The woman is having a complication and the doctor should be notified C. Labor is slowing down and the woman may need oxytocin D. The woman is emotionally distraught and needs assistance in dealing with labor * The clue to the answer is MEMBRANES RUPTURE. Membranes, as a rule, rupture at full dilation [ 10 cm ] unless ruptured by amniotomy or ruptured at an earlier time. The last of the mucus plug from the cervix is also released during the transition phase of labor. We call that the OPERCULUM as signaled by a HEAVIER SHOW. During the transition phase, Cervix is dilated at around 8 to 10 cm and contractions reaches their peak of intensity occuring every 2 to 3 minutes with a 60 to 90 second duration. At the transition phase, woman also experiences nausea and vomiting with intense pain. This question is LIFTED from the previous board and the question was patterned EXACTLY WORD PER WORD from pillitteri. SITUATION : [J2I246] Katherine, a 32 year old primigravida at 39-40 weeks AOG was admitted to the labor room due to hypogastric and lumbo-sacral pains. IE revealed a fully dilated, fully effaced cervix. Station 0. 62. She is immediately transferred to the DR table. Which
I - A desire to defecate II - Begins to bear down with uterine contraction III - Perineum bulges IV - Uterine contraction occur 2-3 minutes intervals at 50 seconds duration A. I,II,III B. I,II,III,IV C. I,III,IV D. II,III,IV * Again, lifted word per word from Pillitteri and this is from the NLE. A is the right answer. A woman near labor experiences desire to defecate because of the pressure of the fetal head that forces the stool out from the anus. She cannot help but bear down with each of the contractions and as crowning occurs, The perineum bulges. A woman with a 50 second contraction is still at the ACTIVE PHASE labor [ 40 to 60 seconds duration, 3 to 5 minutes interval ] Women who are about to give birth experience 60-90 seconds contraction occuring at 2-3 minutes interval. 63. Artificial rupture of the membrane is done. Which of the following nursing diagnoses is the priority? [2] A. High risk for infection related to membrane rupture B. Potential for injury related to prolapse cord C. Alteration in comfort related to increasing strength of uterine contraction D. Anxiety related to unfamiliar procedure * Nursing diagnosis is frequently ask. In any case that INFECTION was one of the choices, remove it as soon as you see it in ALL CASES during the intra and pre operative nursing care. Infection will only occur after 48 hours of operation or event. B is much more immediate and more likely to occur than A, and is much more FATAL. Prioritization and Appropriateness is the key in correctly answering this question. High risk for infection is an appropriate nursing diagnosis, but as I said, Infection will occur in much later time and not as immediate as B. Readily remove D and C because physiologic needs of the mother and fetus take precedence over comfort measures and psychosocial needs. 64. Katherine complains of severe abdominal pain and back pain during contraction. Which two of the following measures will be MOST effective in reducing pain? [4] I - Rubbing the back with a tennis ball II- Effleurage III-Imagery IV-Breathing techniques
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A. II,IV B. II,III C. I,IV D. I,II * Remove B. Imagery is not used in severe pain. This is a labor pain and the mother will never try to imagine a nice and beautiful scenery with you at this point because the pain is all encompassing and severe during the transition phase of labor. Remove A and C Because breathing techniques is not a method to ELIMINATE PAIN but a method to reduce anxiety, improve pushing and prevent rapid expulsion of the fetus during crowning [ By PANTING ] Back pain is so severe during labor in cases of Posterior presentations [ ROP,LOP,RMP,LSaP, etc... ] Mother is asked to pull her knees towards her chest and rock her back. [ As in a rocking chair ] A Tennis ball rubbed at the client's back can relieve the pain due to the pressure of the presenting part on the posterior part of the birth canal. Also, rubbing a tennis ball to the client's back OPENS THE LARGE FIBER NERVE GATE. Effleurage or a simple rotational massage on the abdomen simply relieves the client's pain by opening the large fiber nerve gate and closing the the small fiber nerve gate. [ Please read about Gate control theory by Mezack and Wall ]. 65. Lumbar epidural anesthesia is administered. Which of the following nursing responsibilities should be done immediately following procedure? [1] A. Reposition from side to side B. Administer oxygen C. Increase IV fluid as indicated D. Assess for maternal hypotension * Hypotension is one of the side effects of an epidural anesthesia. An epidural anesthesia is injected on the L3 L4 or L4 - L5 area. The injection lies just above the dura and must not cross the dura [ spinal anesthesia crosses the dura ]. Nursing intervention revolves in assesing RR, BP and other vital signs for possible complication and side effects. There is no need to position the client from side to side, The preferred position during the transition phase of labor is LITHOTOMY. Oxygen is not specific after administration of an epidural anesthesia. IV fluid is not increased without doctor's order. AS INDICATED is different from AS ORDERED. 66. Which is NOT the drug of choice for epidural anesthesia? [4] A. Sensorcaine
B. Xylocaine C. Ephedrine D. Marcaine * A,B and D are all drugs of choice for epidural anesthesia. Ephedrine is the drug use to reverse the symptom of hypotension caused by epidural anesthesia. It is a sympathomimetic agent that causes vasoconstriction, bronchodilation [ in asthma ] and can increase the amount of energy and alertness. Ephedrine is somewhat similar to epinephrine in terms of action as well as it's adverse effects of urinary retention, tremor, hypersalivation, dyspnea, tachycardia, hypertension. SITUATION : [SORANGE217] Alpha, a 24 year old G4P3 at full term gestation is brought to the ER after a gush of fluid passes through here vagina while doing her holiday shopping. 67. She is brought to the triage unit. The FHT is noted to be 114 bpm. Which of the following actions should the nurse do first? [2] A. Monitor FHT ever 15 minutes B. Administer oxygen inhalation C. Ask the charge nurse to notify the Obstetrician D. Place her on the left lateral position * Remove A. A FHR of 114 bpm is 6 beats below normal. Though monitoring is continuous and appropriate, This is not your immediate action. B, Oxygen inhalation needs doctor's order and therefore, is a DEPENDENT nursing action and won't be your first option. Although administration of oxygen by the nurse is allowed when given at the lowest setting during emergency situation. C is appropriate, but should not be your IMMEDIATE action. The best action is to place the client on the LEFT LATERAL POSITION to decrease the pressure in the inferior vena cava [ by the gravid uterus ] thereby increasing venus return and giving an adequate perfusion to the fetus. Your next action is to call and notify the obstetrician. Remember to look for an independent nursing action first before trying to call the physician. 68. The nurse checks the perineum of alpha. Which of the following characteristic of the amniotic fluid would cause an alarm to the nurse? [1] A. Greenish B. Scantly C. Colorless D. Blood tinged * A greenish amniotic fluid heralds fetal distress not unless the fetus is in breech presentation and pressure is present on
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the bowel. Other color that a nurse should thoroughly evaluate are : Tea colored or strong yellow color that indicates hemolytic anemia , as in RH incompatibility. 69. Alpha asks the nurse. "Why do I have to be on complete bed rest? I am not comfortable in this position." Which of the following response of the nurse is most appropriate? [3] A. Keeping you on bed rest will prevent possible cord prolapse B. Completed bed rest will prevent more amniotic fluid to escape C. You need to save your energy so you will be strong enough to push later D. Let us ask your obstetrician when she returns to check on you * Once the membrane ruptures, as in the situation of alpha, The immediate and most appropriate nursing diagnosis is risk for injury related to cord prolapse. Keeping the client on bed rest is one of the best intervention in preventing cord prolapse. Other interventions are putting the client in a modified T position or Kneed chest position. Once the amniotic fluid escapes, It is allowed to escape. Although bed rest does saves energy, It is not the most appropriate response why bed rest is prescribed after membranes have ruptured. Not answering the client's question now will promote distrust and increase client's anxiety. It will also make the client think that the nurse is incompetent for not knowing the answer. 70. Alpha wants to know how many fetal movements per hour is normal, the correct response is [4] A. Twice B. Thrice C. Four times D. 10-12 times * According to Sandovsky, To count for the fetal movement, Mother is put on her LEFT SIDE to decrease placental insufficiency. This is usually done after meals. The mother is asked to record the number of fetal movements per hour. A fetus moves Twice every 10 minutes and 10 to 12 times times an hour. In SIA'S Book, She answered this question with letter B. But according to Pillitteri, A movement fewer than 5 in an hour is to be reported to the health care provider. The Board examiners uses Pillitteri as their reference and WORD PER WORD, Their question are answered directly from the Pillitteri book. 10-12 times according to Pillitteri, is the normal fetal movement per minute.
71. Upon examination by the obstetrician, he charted that Alpha is in the early stage of labor. Which of the following is true in this state? [1] A. Self-focused B. Effacement is 100% C. Last for 2 hours D. Cervical dilation 1-3 cm * The earliest phase of labor is the first stage of labor : latent phase characterized by a cervical dilation of 0-3 cm, Mild contraction lasting for 20 to 40 seconds. This lasts approximately 6 hours in primis and 4.5 hours in multis. C is the characteristic of ACTIVE PHASE of labor, Characterized by a cervical dilation of 4-7 cm and contractions of 40 to 60 seconds. This phase lasts at around 3 hours in primis and 2 hours in multis. Effacement of 100% is a characteristic of the TRANSITION PHASE as well as being self focused.
SITUATION : Maternal and child health nursing a core concept of providing health in the community. Mastery of MCH Nursing is a quality all nurse should possess. 72. When should be the 2nd visit of a pregnant mother to the RHU? [2] A. Before getting pregnant B. As early in pregnancy C. Second trimester D. Third trimester * Visit to the RHU are once every trimester and more frequent for those women at risk. Visit to the health center is once during the 0-6th month of pregnancy, twice during the 7th-8th month and weekly at the last trimester.
73. Which of the following is NOT a standard prenatal physical examination? [1] A. Neck examination for goiter B. Examination of the palms of the hands for pallor C. Edema examination of the face hands, and lower extremeties D. Examination of the legs for varicosities 74. Which of the following is NOT a basic prenatal service delivery done in the BHS? [2] A. Oral / Dental check up B. Laboratory examination C. Treatment of diseases
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D. Iron supplementation
more than 24 hours and for multigravidas, it is more than 12 hours. Knowing this will allow you to choose D.
* A is done at the RHU not in BHS. 75. How many days and how much dosage will the IRON supplementation be taken? [4] A. 365 days / 300 mg B. 210 days / 200 mg C. 100 days/ 100mg D. 50 days / 50 mg * Iron supplementation is taken for 210 days starting at the 5th month of pregnancy up to 2nd month post partum. Dosage can range from 100 to 200 mg. 76. When should the iron supplementation starts and when should it ends? [4] A. 5th month of pregnancy to 2nd month post partum B. 1st month of pregnancy to 5th month post partum C. As early in pregnancy up to 9th month of pregnancy D. From 1st trimester up to 6 weeks post partum * Refer to #75 77. In malaria infested area, how is chloroquine given to pregnant women? [4] A. 300 mg / twice a month for 9 months B. 200 mg / once a week for 5 months C. 150 mg / twice a week for the duration of pregnancy D. 100 mg / twice a week for the last trimester of pregnancy * Always remember that chloroquine is given twice a week for the whole duration of pregnancy. This knowledge alone will lead you to correctly identifying letter C. 78. Which of the following mothers are qualified for home delivery? [2] A. Pre term B. 6th pregnancy C. Has a history of hemorrhage last pregnancy D. 2nd pregnancy, Has a history of 20 hours of labor last pregnancy. * Knowing that a preterm mother is not qualified for home delivery will help you eliminate A. History of complications like bleeding, CPD, Eclampsia and diseases like TB, CVD, Anemia also nulls this qualification. A qualified woman for home delivery should only had less than 5 pregnancies. More than 5 disqualifies her from home delivery. High risk length of labor for primigravidas ls
79. Which of the following is not included on the 3 Cs of delivery? [2] A. Clean Surface B. Clean Hands C. Clean Equipments D. Clean Cord * 3 Cs of delivery are CLEAN SURFACE,HANDS AND CORD. " Kinamay ni Cordapya ang labada gamit ang Surf - Budek " 80. Which of the following is unnecessary equipment to be included in the home delivery kit? [4] A. Boiled razor blade B. 70% Isopropyl Alcohol C. Flashlight D. Rectal and oral thermometer * Home delivery kit should contain the following : Clamps, Scissors, Blade, Antiseptic, Soap and hand brush, Bp app, Clean towel or cloth and Flashlight. Optional equipments include : Plastic sheet, Suction bulb, Weighing scale, Ophthalmic ointment, Nail cutter, Sterile gloves, Rectal and oral thermometers.
SITUATION : [NBLUE166] Pillar is admitted to the hospital with the following signs : Contractions coming every 10 minutes, lasting 30 seconds and causing little discomfort. Intact membranes without any bloody shows. Stable vital signs. FHR = 130bpm. Examination reveals cervix is 3 cm dilated with vertex presenting at minus 1 station. 81. On the basis of the data provided above, You can conclude the pillar is in the [1] A. In false labor B. In the active phase of labor C. In the latent phase of labor D. In the transitional phase of labor * Refer to #71 82. Pitocin drip is started on Pilar. Possible side effects of pitocin administration include all of the following except [3] A. Diuresis
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B. Hypertension C. Water intoxication D. Cerebral hemorrhage * Oxytocin [ Pitocin ] is a synthetic form of hormone naturally released by the PPG. It is used to augment labor and delivery. Dosage is about 1 to 2 milli units per minute and this can be doubled until the desired contraction is met. Side effects are Water intoxication, Diuresis, Hypertonicity of the uterus, Uterine rupture, Precipitated labor, Walang kamatayang Nausea and Vomiting and Fetal bradycardia. Diuresis occurs because of water intoxication, The kidney will try to compensate to balance the fluid in the body. NEVER give pitocin when FHR is below 120. Even without knowing anything about Pitocin, A cerebral hemorrhage is LETHAL and DAMAGE IS IRREVERSIBLE and if this is a side effect of a drug, I do not think that FDA or BFAD will approve it.
* A,B and C are all charactertistics of a true labor. True labor is heralded by LIGHTENING. This makes the uterus lower and more anterior. This occrs 2 weeks prior to labor. At the morning of labor, women experiences BURST OF ENERGY because of adrenaline rush induced by the decrease progestrone secretion of the deteriorating placenta. The pain in labor is felt at the back and radiates towards the abdomen and becomes regular, increasing frequency and duration. As the cervix softens and dilates, The OPERCULUM or the mucus plug is expelled. False labor is characterized by Irregular uterine contraction that is relieved by walking, Pain felt at the abdomen and confined there and in the groin, The cervix do not achieve dilation and Pain that is relieved by sleep and do not increase in intensity and duration.
86. Who's Theory of labor pain that states that PAIN in labor is cause by FEAR [4]
83. The normal range of FHR is approximately [3] A. 90 to 140 bpm B. 120 to 160 bpm C. 100 to 140 bpm D. 140 to 180 bpm * A normal fetal heart rate is 120-160 bpm. 84. A negative 1 [-1] station means that [1] A. Fetus is crowning B. Fetus is floating C. Fetus is engaged D. Fetus is at the ischial spine * At the negative station, The fetus is not yet engaged and floating. At 0 station, it means that the fetus is engaged to the ischial spine. Crowning occurs when the fetus is at the +3,+4 Station. Stations signifies distance of the presensting part below or above ischial spine. + denoted below while denotes above. The number after the sign denotes length in cm. +1 station therefore means that the presenting part is 1 cm below the ischial spine. 85. Which of the following is characteristics of false labor [1] A. Bloody show B. Contraction that are regular and increase in frequency and duration C. Contraction are felt in the back and radiates towards the abdomen D. None of the above
A. Bradley B. Simpson C. Lamaze D. Dick-Read * Believe it or not, this is an actual board question. Grantley Dick-Read is just one person. Usually a two name theory means two theorist. He published a book in 1933 "CHILDBIRTH WITHOUT FEAR". He believes that PAIN in labor is caused by FEAR that causes muscle tension, thereby halting the blood towards the uterus and causing decreased oxygenation which causes the PAIN. 1950s French obstetrician, Dr. Ferdinand Lamaze perhaps is the most popular theorist when it comes to labor. The theory behind Lamaze is that birth is a normal, natural and healthy event that should occur without unnecessary medical intervention. Rather than resorting to pain medication, different breathing techniques are used for each stage of labor to control pain. Fathers are assigned the role of labor coach, and are responsible for monitoring and adjusting their partner's breathing pattern throughout childbirth. In 1965, obstetrician Robert A. Bradley, MD wrote "Husband Coached Childbirth." The Bradley method perhaps is the easiest to remember, BRAD ley necessitates the presence of the FATHER during labor. Bradley Method views birth as a natural process. This method also emphasizes the importance of actively involving fathers in the labor process. Fathers are taught ways to help ease their partner's pain during childbirth through guided relaxation and slow abdominal breathing.
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James Young Simpson is an english doctor and the first to apply anesthesia during labor and child birth. He uses ETHER to alleviate labor pain. He then discovered the effects of chloroform as an anesthetic agent. Because of his works, He was recognized by Queen Victoria because the queen herself uses Simpson's chloroform in alleviating labor pain when she gave birth to prince leopold. 87. Which sign would alert the nurse that Pillar is entering the second stage of labor? [1] A. Increase frequency and intensity of contraction B. Perineum bulges and anal orifice dilates C. Effacement of internal OS is 100% D. Vulva encircles the largest diameter of presenting part * The second stage of labor begins as the cervical internal os is 100% effaced and fully dilated. It ends after the fetus has been delivered. Crowning, as in letter B and D is too late of a sign to alert the nurse that Pillar is entering the second stage of labor. A occurs during the first stage of labor. 88. Nursing care during the second stage of labor should include [1] A. Careful evaluation of prenatal history B. Coach breathing, Bear down with each contraction and encourage patient. C. Shave the perineum D. Administer enema to the patient * The second stage of labor begins with a full cervical dilation and effacement and finishes when the baby is fully delivered. Careful evaluation of prenatal history is done on admission and check ups and is never done in the second stage of labor. Shaving the perineum and enema are done during the first stage of labor in preparation for delivery or before labor begins when client is admitted. Enema is not a routine procedure before delivery, but can be done to prevent defecation during labor. B is appropriate during the second stage of labor when the client's contraction is at it's peak and dilation and effacement are at maximum to help client accomplish the task of giving birth. SITUATION : [NBLUE170] Baby boy perez was delivered spontaneously following a term pregnancy. Apgar scores are 8 and 9 respectively. Routine procedures are carried out.
C. At 1 minute after birth and at 5 minutes after birth D. Immediately after birth and at 5 minutes after birth * APGAR score taken 1 minute after birth determines the initial status of the newborn while the 5 minute assessment after birth determines how well the newborn is adjusting to the extrauterine life. 90. The best way to position a newborn during the first week of life is to lay him [3] A. Prone with head slightly elevated B. On his back, flat C. On his side with his head flat on bed D. On his back with head slightly elevated * Sudden infant death syndrome occurs when the fetus is in prone position. Knowing this will allow you to eliminate A first. During the first week of life, The fetus has an immature cardiac sphincter and musculature for swallowing, Knowing this will let you eliminate B and D. Side lying position is the best position for a neonate during the first few weeks of life. This will decrease the risk of aspiration of secretion. 91. Baby boy perez has a large sebaceous glands on his nose, chin, and forehead. These are known as [1] A. Milia B. Lanugo C. Hemangiomas D. Mongolian spots * Newborn sebaceous glands are sometimes unopened or plugged. They are called MILIA. They will disappear once the gland opens at around 2 weeks after delivery. They are characterized by a pinpoint white papule. Lanugo is the fine hair that covers the newborn. It disappears starting 2 weeks after birth. A premature infant has more lanugo than a post mature infant. Hemangiomas are vascular tumors of the skin. Mongolian spots are patches that are gray in color and are often found in sacrum or buttocks. They disappear as the child grows older. 92. Baby boy perez must be carefully observed for the first 24 hours for [2] A. Respiratory distress B. Duration of cry C. Frequency of voiding D. Range in body temperature
89. When is the APGAR Score taken? [1] A. Immediately after birth and at 30 minutes after birth B. At 5 minutes after birth and at 30 minutes after birth
* Range in body temperature needs to be observed and carefully monitored for the first 24 hours after delivery. A newborn has an inadequate and immature temperature
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regulating mechanism. RDS is observed immediately after delivery, not in a continuous 24 hour observation. Once the fetus establish a normal breathing pattern it is not anymore of a concern. RDS occurs when the Surfactants are absent or insufficient. The adequacy of these surfactants is measured by the L:S ratio [ Lecithin : Spingomyelin ] An L:S ratio of 2:1 is considered, mature and adequate to sustain fetal lung expansion and ventilation. Therefore, A child born without RDS is unlikely to have RDS in 24 hours. Another thing that is carefully observed during the first 24 hours is the meconium. Absent of meconium during the first 24 hours after birth warrants further investigation by the attending physician. 93. According to the WHO , when should the mother starts breastfeeding the infant? [4] A. Within 30 minutes after birth B. Within 12 hours after birth C. Within a day after birth D. After infant's condition stabilizes * According to the world health organization, The mother should start breastfeeding her infant within 30 minutes after birth. 94. What is the BEST and most accurate method of measuring the medication dosage for infants and children? [3] A. Weight B. Height C. Nomogram D. Weight and Height * A nomogram is the most accurate method for measuring medication dosage for infants and children. It estimates the body surface area by drawing a line in the first column [ child's height ] towards the third column [ child's weight ]. The point in which it crosses the middle column [ BSA ] is the child's surface area.
visit will be at 1 week after delivery and the third visit is done 2 to 4 weeks after delivery. 96. The major cause of maternal mortality in the philippines is [3] A. Infection B. Hemorrhage C. Hypertension D. Other complications related to labor,delivery and puerperium * Refer to the latest survey of FHSIS in the DOH website. 97. According to the WHO, what should be the composition of a commercialized Oral rehydration salt solution? [4] A. Potassium : 1.5 g. ; Sodium Bicarbonate 2.5g ; Sodium Chloride 3.5g; Glucose 20 g. A. Potassium : 1.5 g. ; Sodium Bicarbonate 2.5g ; Sodium Chloride 3.5g; Glucose 10 g. A. Potassium : 2.5 g. ; Sodium Bicarbonate 3.5g ; Sodium Chloride 4.5g; Glucose 20 g. A. Potassium : 2.5 g. ; Sodium Bicarbonate 3.5g ; Sodium Chloride 4.5g; Glucose 10 g. * This is the WHO ORESOL formula for the commercialized ORS. Remember PA BCG Which stands for POTASSIUM [ Pa ] SODIUM BICARBONATE [ B ] SODIUM CHLORIDE [ C ] GLUCOSE [ G ]. The numbers are easy to remember because they are just increased by 1.0 g increment starting from 1.5. Glucose however is at 20 g. So the MNEMONIC is PA BCG 1.5 2.5 3.5 20. This is the mnemonic I use and it is easy to remember that way. It is original by the way. 98. In preparing ORESOL at home, The correct composition recommnded by the DOH is [4] A. 1 glass of water, 1 pinch of salt and 2 tsp of sugar B. 1 glass of water, 2 pinch of salt and 2 tsp of sugar C. 1 glass of water, 3 pinch of salt and 4 tsp of sugar D. 1 glass of water, 1 pinch of salt and 1 tsp of sugar
95. The first postpartum visit should be done by the mother within [4] A. 24 hours B. 3 days C. a week D. a month * Mother should visit the health facility 4 weeks to 6 weeks after delivery. The first post partum visit by the birth attendant is done within 24 hours after delivery, the next
99. Milk code is a law that prohibits milk commercialization or artificial feeding for up to 2 years. Which law provides its legal basis? [4] A. Senate bill 1044 B. RA 7600 C. Presidential Proclamation 147 D. EO 51
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* Executive order # 51 prohibits milk commercialization or artificial feeding up to 2 years. That is why the milk commercials in the country has " BREAST MILK IS STILL BEST FOR BABIES UP TO 2 YEARS " After their presentation in accordance with EO 51. RA 7600 is the ROOMING IN / BREAST FEEDING ACT which requires the heatlh professionals to bring the baby to the mother for breastfeeding as early as possible. Senate bill # 1044 was created to implement RA 7600. Presidential Proclamation # 147 made WEDNESDAY as the national immunization day.
100. A 40 year old mother in her third trimester should avoid [4] A. Traveling B. Climbing C. Smoking D. Exercising * Mother's are not prohibited to travel, climb or exercise. If long travels are expected, Mother should have a 30 minute rest period for every 2 hours of travel [ LIPPINCOTT ]. Climbing is a very vague term used by the board examiners though I assume they are referring to climbing a flight of stairs. Anyhow, SMOKING is detrimental for both mother and child no question about it and so is ALCOHOL. In thousands of questions I answered, it never fails that HANDWASHING, AVOID SMOKING, AVOID ALCOHOL are always the answer. It still depends on the question so THINK.
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1. While performing physical assessment of a 12 month-old, the nurse notes that the infant’s anterior fontanelle is still slightly open. Which of the following is the nurse’s most appropriate action? a. Notify the physician immediately because there is a problem. b. Perform an intensive neurologic examination. c. Perform an intensive developmental examination. d. Do nothing because this is a normal finding for the age. 2. When teaching a mother about introducing solid foods to her child, which of the following indicates the earliest age at which this should be done? a. 1 month b. 2 months c. 3 months d. 4 months 3. The infant of a substance-abusing mother is at risk for developing a sense of which of the following? a. Mistrust b. Shame c. Guilt d. Inferiority 4. Which of the following toys should the nurse recommend for a 5-month-old? a. A big red balloon b. A teddy bear with button eyes c. A push-pull wooden truck d. A colorful busy box 5. The mother of a 2-month-old is concerned that she may be spoiling her baby by picking her up when she cries. Which of the following would be the nurse’s best response? a. “ Let her cry for a while before picking her up, so you don’t spoil her” b. “Babies need to be held and cuddled; you won’t spoil her this way” c. “Crying at this age means the baby is hungry; give her a bottle” d. “If you leave her alone she will learn how to cry herself to sleep” 6. When assessing an 18-month-old, the nurse notes a characteristic protruding abdomen.
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Which of the following would explain the rationale for this finding? a. Increased food intake owing to age b. Underdeveloped abdominal muscles c. Bowlegged posture d. Linear growth curve If parents keep a toddler dependent in areas where he is capable of using skills, the toddle will develop a sense of which of the following? a. Mistrust b. Shame c. Guilt d. Inferiority Which of the following is an appropriate toy for an 18-month-old? a. Multiple-piece puzzle b. Miniature cars c. Finger paints d. Comic book When teaching parents about the child’s readiness for toilet training, which of the following signs should the nurse instruct them to watch for in the toddler? a. Demonstrates dryness for 4 hours b. Demonstrates ability to sit and walk c. Has a new sibling for stimulation d. Verbalizes desire to go to the bathroom When teaching parents about typical toddler eating patterns, which of the following should be included? a. Food “jags” b. Preference to eat alone c. Consistent table manners d. Increase in appetite Which of the following suggestions should the nurse offer the parents of a 4-year-old boy who resists going to bed at night? a. “Allow him to fall asleep in your room, then move him to his own bed.” b. “Tell him that you will lock him in his room if he gets out of bed one more time.” c. “Encourage active play at bedtime to tire him out so he will fall asleep faster.” d. “Read him a story and allow him to play quietly in his bed until he falls asleep.”
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12. When providing therapeutic play, which of the following toys would best promote imaginative play in a 4-year-old? a. Large blocks b. Dress-up clothes c. Wooden puzzle d. Big wheels 13. Which of the following activities, when voiced by the parents following a teaching session about the characteristics of school-age cognitive development would indicate the need for additional teaching? a. Collecting baseball cards and marbles b. Ordering dolls according to size c. Considering simple problem-solving options d. Developing plans for the future 14. A hospitalized schoolager states: “I’m not afraid of this place, I’m not afraid of anything.” This statement is most likely an example of which of the following? a. Regression b. Repression c. Reaction formation d. Rationalization 15. After teaching a group of parents about accident prevention for schoolagers, which of the following statements by the group would indicate the need for more teaching? a. “Schoolagers are more active and adventurous than are younger children.” b. “Schoolagers are more susceptible to home hazards than are younger children.” c. “Schoolagers are unable to understand potential dangers around them.” d. “Schoolargers are less subject to parental control than are younger children.” 16. Which of the following skills is the most significant one learned during the schoolage period? a. Collecting b. Ordering c. Reading d. Sorting
17. A child age 7 was unable to receive the measles, mumps, and rubella (MMR) vaccine at the recommended scheduled time. When would the nurse expect to administer MMR vaccine? a. In a month from now b. In a year from now c. At age 10 d. At age 13 18. The adolescent’s inability to develop a sense of who he is and what he can become results in a sense of which of the following? a. Shame b. Guilt c. Inferiority d. Role diffusion 19. Which of the following would be most appropriate for a nurse to use when describing menarche to a 13-year-old? a. A female’s first menstruation or menstrual “periods” b. The first year of menstruation or “period” c. The entire menstrual cycle or from one “period” to another d. The onset of uterine maturation or peak growth 20. A 14-year-old boy has acne and according to his parents, dominates the bathroom by using the mirror all the time. Which of the following remarks by the nurse would be least helpful in talking to the boy and his parents? a. “This is probably the only concern he has about his body. So don’t worry about it or the time he spends on it.” b. “Teenagers are anxious about how their peers perceive them. So they spend a lot of time grooming.” c. “A teen may develop a poor self-image when experiencing acne. Do you feel this way sometimes?” d. “You appear to be keeping your face well washed. Would you feel comfortable discussing your cleansing method?” 21. Which of the following should the nurse suspect when noting that a 3-year-old is engaging in explicit sexual behavior during doll play?
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a. The child is exhibiting normal preschool curiosity b. The child is acting out personal experiences c. The child does not know how to play with dolls d. The child is probably developmentally delayed. Which of the following statements by the parents of a child with school phobia would indicate the need for further teaching? a. “We’ll keep him at home until phobia subsides.” b. “We’ll work with his teachers and counselors at school.” c. “We’ll try to encourage him to talk about his problem.” d. “We’ll discuss possible solutions with him and his counselor.” When developing a teaching plan for a group of high school students about teenage pregnancy, the nurse would keep in mind which of the following? a. The incidence of teenage pregnancies is increasing. b. Most teenage pregnancies are planned. c. Denial of the pregnancy is common early on. d. The risk for complications during pregnancy is rare. When assessing a child with a cleft palate, the nurse is aware that the child is at risk for more frequent episodes of otitis media due to which of the following? a. Lowered resistance from malnutrition b. Ineffective functioning of the Eustachian tubes c. Plugging of the Eustachian tubes with food particles d. Associated congenital defects of the middle ear. While performing a neurodevelopmental assessment on a 3-month-old infant, which of the following characteristics would be expected? a. A strong Moro reflex b. A strong parachute reflex c. Rolling from front to back
d. Lifting of head and chest when prone 26. By the end of which of the following would the nurse most commonly expect a child’s birth weight to triple? a. 4 months b. 7 months c. 9 months d. 12 months 27. Which of the following best describes parallel play between two toddlers? a. Sharing crayons to color separate pictures b. Playing a board game with a nurse c. Sitting near each other while playing with separate dolls d. Sharing their dolls with two different nurses 28. Which of the following would the nurse identify as the initial priority for a child with acute lymphocytic leukemia? a. Instituting infection control precautions b. Encouraging adequate intake of ironrich foods c. Assisting with coping with chronic illness d. Administering medications via IM injections 29. Which of the following information, when voiced by the mother, would indicate to the nurse that she understands home care instructions following the administration of a diphtheria, tetanus, and pertussis injection? a. Measures to reduce fever b. Need for dietary restrictions c. Reasons for subsequent rash d. Measures to control subsequent diarrhea 30. Which of the following actions by a community health nurse is most appropriate when noting multiple bruises and burns on the posterior trunk of an 18-month-old child during a home visit? a. Report the child’s condition to Protective Services immediately. b. Schedule a follow-up visit to check for more bruises. c. Notify the child’s physician immediately. 55
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d. Don nothing because this is a normal finding in a toddler. Which of the following is being used when the mother of a hospitalized child calls the student nurse and states, “You idiot, you have no idea how to care for my sick child”? a. Displacement b. Projection c. Repression d. Psychosis Which of the following should the nurse expect to note as a frequent complication for a child with congenital heart disease? a. Susceptibility to respiratory infection b. Bleeding tendencies c. Frequent vomiting and diarrhea d. Seizure disorder Which of the following would the nurse do first for a 3-year-old boy who arrives in the emergency room with a temperature of 105 degrees, inspiratory stridor, and restlessness, who is learning forward and drooling? a. Auscultate his lungs and place him in a mist tent. b. Have him lie down and rest after encouraging fluids. c. Examine his throat and perform a throat culture d. Notify the physician immediately and prepare for intubation. Which of the following would the nurse need to keep in mind as a predisposing factor when formulating a teaching plan for child with a urinary tract infection? a. A shorter urethra in females b. Frequent emptying of the bladder c. Increased fluid intake d. Ingestion of acidic juices Which of the following should the nurse do first for a 15-year-old boy with a full leg cast who is screaming in unrelenting pain and exhibiting right foot pallor signifying compartment syndrome? a. Medicate him with acetaminophen. b. Notify the physician immediately c. Release the traction d. Monitor him every 5 minutes
36. At which of the following ages would the nurse expect to administer the varicella zoster vaccine to child? a. At birth b. 2 months c. 6 months d. 12 months 37. When discussing normal infant growth and development with parents, which of the following toys would the nurse suggest as most appropriate for an 8-month-old? a. Push-pull toys b. Rattle c. Large blocks d. Mobile 38. Which of the following aspects of psychosocial development is necessary for the nurse to keep in mind when providing care for the preschool child? a. The child can use complex reasoning to think out situations. b. Fear of body mutilation is a common preschool fear c. The child engages in competitive types of play d. Immediate gratification is necessary to develop initiative. 39. Which of the following is characteristic of a preschooler with mid mental retardation? a. Slow to feed self b. Lack of speech c. Marked motor delays d. Gait disability 40. Which of the following assessment findings would lead the nurse to suspect Down syndrome in an infant? a. Small tongue b. Transverse palmar crease c. Large nose d. Restricted joint movement 41. While assessing a newborn with cleft lip, the nurse would be alert that which of the following will most likely be compromised? a. Sucking ability b. Respiratory status c. Locomotion d. GI function
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42. When providing postoperative care for the child with a cleft palate, the nurse should position the child in which of the following positions? a. Supine b. Prone c. In an infant seat d. On the side 43. While assessing a child with pyloric stenosis, the nurse is likely to note which of the following? a. Regurgitation b. Steatorrhea c. Projectile vomiting d. “Currant jelly” stools 44. Which of the following nursing diagnoses would be inappropriate for the infant with gastroesophageal reflux (GER)? a. Fluid volume deficit b. Risk for aspiration c. Altered nutrition: less than body requirements d. Altered oral mucous membranes 45. Which of the following parameters would the nurse monitor to evaluate the effectiveness of thickened feedings for an infant with gastroesophageal reflux (GER)? a. Vomiting b. Stools c. Uterine d. Weight 46. Discharge teaching for a child with celiac disease would include instructions about avoiding which of the following? a. Rice b. Milk c. Wheat d. Chicken 47. Which of the following would the nurse expect to assess in a child with celiac disease having a celiac crisis secondary to an upper respiratory infection? a. Respiratory distress b. Lethargy c. Watery diarrhea d. Weight gain 48. Which of the following should the nurse do first after noting that a child with Hirschsprung disease has a fever and watery explosive diarrhea?
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Notify the physician immediately Administer antidiarrheal medications Monitor child ever 30 minutes Nothing, this is characteristic of Hirschsprung disease A newborn’s failure to pass meconium within the first 24 hours after birth may indicate which of the following? a. Hirschsprung disease b. Celiac disease c. Intussusception d. Abdominal wall defect When assessing a child for possible intussusception, which of the following would be least likely to provide valuable information? a. Stool inspection b. Pain pattern c. Family history d. Abdominal palpation 1. D. The anterior fontanelle typically closes anywhere between 12 to 18 months of age. Thus, assessing the anterior fontanelle as still being slightly open is a normal finding requiring no further action. Because it is normal finding for this age, notifying he physician or performing additional examinations are inappropriate. 2. D. Solid foods are not recommended before age 4 to 6 months because of the sucking reflex and the immaturity of the gastrointestinal tract and immune system. Therefore, the earliest age at which to introduce foods is 4 months. Any time earlier would be inappropriate. 3. A. According to Erikson, infants need to have their needs met consistently and effectively to develop a sense of trust. An infant whose needs are consistently unmet or who experiences significant delays in having them met, such as in the case of the infant of a substance-abusing mother, will develop a sense of uncertainty, leading to mistrust of caregivers and the environment. Toddlers develop a sense of shame when their autonomy needs are not met consistently. Preschoolers develop a sense of guilt when their sense of initiative is thwarted. 57
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Schoolagers develop a sense of inferiority when they do not develop a sense of industry. 4. D. A busy box facilitates the fine motor development that occurs between 4 and 6 months. Balloons are contraindicated because small children may aspirate balloons. Because the button eyes of a teddy bear may detach and be aspirated, this toy is unsafe for children younger than 3 years. A 5-month-old is too young to use a push-pull toy. 5. B. Infants need to have their security needs met by being held and cuddled. At 2 months of age, they are unable to make the connection between crying and attention. This association does not occur until late infancy or early toddlerhood. Letting the infant cry for a time before picking up the infant or leaving the infant alone to cry herself to sleep interferes with meeting the infant’s need for security at this very young age. Infants cry for many reasons. Assuming that the child s hungry may cause overfeeding problems such as obesity. 6. B. Underdeveloped abdominal musculature gives the toddler a characteristically protruding abdomen. During toddlerhood, food intake decreases, not increases. Toddlers are characteristically bowlegged because the leg muscles must bear the weight of the relatively large trunk. Toddler growth patterns occur in a steplike, not linear pattern. 7. B. According to Erikson, toddlers experience a sense of shame when they are not allowed to develop appropriate independence and autonomy. Infants develop mistrust when their needs are not consistently gratified. Preschoolers develop guilt when their initiative needs are not met while schoolagers develop a sense of inferiority when their industry needs are not met. 8. C. Young toddlers are still sensorimotor learners and they enjoy the experience of feeling different textures. Thus, finger paints
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would be an appropriate toy choice. Multiplepiece toys, such as puzzle, are too difficult to manipulate and may be hazardous if the pieces are small enough to be aspirated. Miniature cars also have a high potential for aspiration. Comic books are on too high a level for toddlers. Although they may enjoy looking at some of the pictures, toddlers are more likely to rip a comic book apart. 9. D. The child must be able to sate the need to go to the bathroom to initiate toilet training. Usually, a child needs to be dry for only 2 hours, not 4 hours. The child also must be able to sit, walk, and squat. A new sibling would most likely hinder toilet training. 10. A. Toddlers become picky eaters, experiencing food jags and eating large amounts one day and very little the next. A toddler’s food gags express a preference for the ritualism of eating one type of food for several days at a time. Toddlers typically enjoy socialization and limiting others at meal time. Toddlers prefer to feed themselves and thus are too young to have table manners. A toddler’s appetite and need for calories, protein, and fluid decrease due to the dramatic slowing of growth rate. 11. D. Preschoolers commonly have fears of the dark, being left alone especially at bedtime, and ghosts, which may affect the child’s going to bed at night. Quiet play and time with parents is a positive bedtime routine that provides security and also readies the child for sleep. The child should sleep in his own bed. Telling the child about locking him in his room will viewed by the child as a threat. Additionally, a locked door is frightening and potentially hazardous. Vigorous activity at bedtime stirs up the child and makes more difficult to fall asleep. 12. B. Dress-up clothes enhance imaginative play and imagination, allowing preschoolers to engage in rich fantasy play. Building blocks and 58
wooden puzzles are appropriate for encouraging fine motor development. Big wheels and tricycles encourage gross motor development. 63. 13. D. The school-aged child is in the stage of concrete operations, marked by inductive reasoning, logical operations, and reversible concrete thought. The ability to consider the future requires formal thought operations, which are not developed until adolescence. Collecting baseball cards and marbles, ordering dolls by size, and simple problem-solving options are examples of the concrete operational thinking of the schoolager. 64. 14. C. Reaction formation is the schoolager’s typical defensive response when hospitalized. In reaction formation, expression of unacceptable thoughts or behaviors is prevented (or overridden) by the exaggerated expression of opposite thoughts or types of behaviors. Regression is seen in toddlers and preshcoolers when they retreat or return to an earlier level of development. Repression refers to the involuntary blocking of unpleasant feelings and experiences from one’s awareness. Rationalization is the attempt to make excuses to justify unacceptable feelings or behaviors. 65. 15. C. The schoolager’s cognitive level is sufficiently developed to enable good understanding of and adherence to rules. Thus, schoolagers should be able to understand the potential dangers around them. With growth comes greater freedom and children become more adventurous and daring. The school-aged child is also still prone to accidents and home hazards, especially because of increased motor abilities and independence. Plus the home hazards differ from other age groups. These hazards, which are potentially lethal but tempting, may include firearms, alcohol, and medications. School-age children begin to internalize their own controls and need less
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outside direction. Plus the child is away from home more often. Some parental or caregiver assistance is still needed to answer questions and provide guidance for decisions and responsibilities. 16. C. The most significant skill learned during the school-age period is reading. During this time the child develops formal adult articulation patterns and learns that words can be arranged in structure. Collective, ordering, and sorting, although important, are not most significant skills learned. 17. C. Based on the recommendations of the American Academy of Family Physicians and the American Academy of Pediatrics, the MMR vaccine should be given at the age of 10 if the child did not receive it between the ages of 4 to 6 years as recommended. Immunization for diphtheria and tetanus is required at age 13. 18. D. According to Erikson, role diffusion develops when the adolescent does not develop a sense of identity and a sense or where he fits in. Toddlers develop a sense of shame when they do not achieve autonomy. Preschoolers develop a sense of guilt when they do not develop a sense of initiative. School-age children develop a sense of inferiority when they do not develop a sense of industry. 19. A. Menarche refers to the onset of the first menstruation or menstrual period and refers only to the first cycle. Uterine growth and broadening of the pelvic girdle occurs before menarche. 20. A. Stating that this is probably the only concern the adolescent has and telling the parents not to worry about it or the time her spends on it shuts off further investigation and is likely to make the adolescent and his parents feel defensive. The statement about peer acceptance and time spent in front of the mirror for the development of self image provides information about the adolescent’s 59
needs to the parents and may help to gain trust with the adolescent. Asking the adolescent how he feels about the acne will encourage the adolescent to share his feelings. Discussing the cleansing method shows interest and concern for the adolescent and also can help to identify any patient-teaching needs for the adolescent regarding cleansing. 71. 21. B. Preschoolers should be developmentally incapable of demonstrating explicit sexual behavior. If a child does so, the child has been exposed to such behavior, and sexual abuse should be suspected. Explicit sexual behavior during doll play is not a characteristic of preschool development nor symptomatic of developmental delay. Whether or nor the child knows how to play with dolls is irrelevant. 72. 22. A. The parents need more teaching if they state that they will keep the child home until the phobia subsides. Doing so reinforces the child’s feelings of worthlessness and dependency. The child should attend school even during resolution of the problem. Allowing the child to verbalize helps the child to ventilate feelings and may help to uncover causes and solutions. Collaboration with the teachers and counselors at school may lead to uncovering the cause of the phobia and to the development of solutions. The child should participate and play an active role in developing possible solutions. 73. 23. C. The adolescent who becomes pregnant typically denies the pregnancy early on. Early recognition by a parent or health care provider may be crucial to timely initiation of prenatal care. The incidence of adolescent pregnancy has declined since 1991, yet morbidity remains high. Most teenage pregnancies are unplanned and occur out of wedlock. The pregnant adolescent is at high risk for physical complications including premature labor and low-birth-weight infants, high neonatal mortality, iron deficiency anemia, prolonged
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labor, and fetopelvic disproportion as well as numerous psychological crises. 24. B. Because of the structural defect, children with cleft palate may have ineffective functioning of their Eustachian tubes creating frequent bouts of otitis media. Most children with cleft palate remain well-nourished and maintain adequate nutrition through the use of proper feeding techniques. Food particles do not pass through the cleft and into the Eustachian tubes. There is no association between cleft palate and congenial ear deformities. 25. D. A 3-month-old infant should be able to lift the head and chest when prone. The Moro reflex typically diminishes or subsides by 3 months. The parachute reflex appears at 9 months. Rolling from front to back usually is accomplished at about 5 months. 26. D. A child’s birth weight usually triples by 12 months and doubles by 4 months. No specific birth weight parameters are established for 7 or 9 months. 27. C. Toddlers engaging in parallel play will play near each other, but not with each other. Thus, when two toddlers sit near each other but play with separate dolls, they are exhibiting parallel play. Sharing crayons, playing a board game with a nurse, or sharing dolls with two different nurses are all examples of cooperative play. 28. A. Acute lymphocytic leukemia (ALL) causes leukopenia, resulting in immunosuppression and increasing the risk of infection, a leading cause of death in children with ALL. Therefore, the initial priority nursing intervention would be to institute infection control precautions to decrease the risk of infection. Iron-rich foods help with anemia, but dietary iron is not an initial intervention. The prognosis of ALL usually is good. However, later on, the nurse may need to assist the child and family with coping since death and dying may still be an issue in need of 60
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discussion. Injections should be discouraged, owing to increased risk from bleeding due to thrombocytopenia. 29. A. The pertusis component may result in fever and the tetanus component may result in injection soreness. Therefore, the mother’s verbalization of information about measures to reduce fever indicates understanding. No dietary restrictions are necessary after this injection is given. A subsequent rash is more likely to be seen 5 to 10 days after receiving the MMR vaccine, not the diphtheria, pertussis, and tetanus vaccine. Diarrhea is not associated with this vaccine. 30. A. Multiple bruises and burns on a toddler are signs child abuse. Therefore, the nurse is responsible for reporting the case to Protective Services immediately to protect the child from further harm. Scheduling a follow-up visit is inappropriate because additional harm may come to the child if the nurse waits for further assessment data. Although the nurse should notify the physician, the goal is to initiate measures to protect the child’s safety. Notifying the physician immediately does not initiate the removal of the child from harm nor does it absolve the nurse from responsibility. Multiple bruises and burns are not normal toddler injuries. 31. B. The mother is using projection, the defense mechanism used when a person attributes his or her own undesirable traits to another. Displacement is the transfer of emotion onto an unrelated object, such as when the mother would kick a chair or bang the door shut. Repression is the submerging of painful ideas into the unconscious. Psychosis is a state of being out of touch with reality. 32. A. Children with congenital heart disease are more prone to respiratory infections. Bleeding tendencies, frequent vomiting, and diarrhea
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and seizure disorders are not associated with congenital heart disease. 33. D. The child is exhibiting classic signs of epiglottitis, always a pediatric emergency. The physician must be notified immediately and the nurse must be prepared for an emergency intubation or tracheostomy. Further assessment with auscultating lungs and placing the child in a mist tent wastes valuable time. The situation is a possible life-threatening emergency. Having the child lie down would cause additional distress and may result in respiratory arrest. Throat examination may result in laryngospasm that could be fatal. 34. A. In females, the urethra is shorter than in males. This decreases the distance for organisms to travel, thereby increasing the chance of the child developing a urinary tract infection. Frequent emptying of the bladder would help to decrease urinary tract infections by avoiding sphincter stress. Increased fluid intake enables the bladder to be cleared more frequently, thus helping to prevent urinary tract infections. The intake of acidic juices helps to keep the urine pH acidic and thus decrease the chance of flora development. 35. B. Compartment syndrome is an emergent situation and the physician needs to be notified immediately so that interventions can be initiated to relieve the increasing pressure and restore circulation. Acetaminophen (Tylenol) will be ineffective since the pain is related to the increasing pressure and tissue ischemia. The cast, not traction, is being used in this situation for immobilization, so releasing the traction would be inappropriate. In this situation, specific action not continued monitoring is indicated. 36. D. The varicella zoster vaccine (VZV) is a live vaccine given after age 12 months. The first dose of hepatitis B vaccine is given at birth to 2 months, then at 1 to 4 months, and then again 61
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at 6 to 18 months. DtaP is routinely given at 2, 4, 6, and 15 to 18 months and a booster at 4 to 6 years. 37. C. Because the 8-month-old is refining his gross motor skills, being able to sit unsupported and also improving his fine motor skills, probably capable of making hand-to-hand transfers, large blocks would be the most appropriate toy selection. Push-pull toys would be more appropriate for the 10 to 12-month-old as he or she begins to cruise the environment. Rattles and mobiles are more appropriate for infants in the 1 to 3 month age range. Mobiles pose a danger to older infants because of possible strangulation. 38. B. During the preschool period, the child has mastered a sense of autonomy and goes on to master a sense of initiative. During this period, the child commonly experiences more fears than at any other time. One common fear is fear of the body mutilation, especially associated with painful experiences. The preschool child uses simple, not complex, reasoning, engages in associative, not competitive, play (interactive and cooperative play with sharing), and is able to tolerate longer periods of delayed gratification. 39. A. Mild mental retardation refers to development disability involving an IQ 50 to 70. Typically, the child is not noted as being retarded, but exhibits slowness in performing tasks, such as self-feeding, walking, and taking. Little or no speech, marked motor delays, and gait disabilities would be seen in more severe forms mental retardation. 40. B. Down syndrome is characterized by the following a transverse palmar crease (simian crease), separated sagittal suture, oblique palpebral fissures, small nose, depressed nasal bridge, high-arched palate, excess and lax skin, wide spacing and plantar crease between the second and big toes, hyperextensible and lax
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joints, large protruding tongue, and muscle weakness. 41. A. Because of the defect, the child will be unable to from the mouth adequately around nipple, thereby requiring special devices to allow for feeding and sucking gratification. Respiratory status may be compromised if the child is fed improperly or during postoperative period, Locomotion would be a problem for the older infant because of the use of restraints. GI functioning is not compromised in the child with a cleft lip. 42. B. Postoperatively children with cleft palate should be placed on their abdomens to facilitate drainage. If the child is placed in the supine position, he or she may aspirate. Using an infant seat does not facilitate drainage. Sidelying does not facilitate drainage as well as the prone position. 43. C. Projectile vomiting is a key symptom of pyloric stenosis. Regurgitation is seen more commonly with GER. Steatorrhea occurs in malabsorption disorders such as celiac disease. “Currant jelly” stools are characteristic of intussusception. 44. D. GER is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac) sphincter. No alteration in the oral mucous membranes occurs with this disorder. Fluid volume deficit, risk for aspiration, and altered nutrition are appropriate nursing diagnoses. 45. A. Thickened feedings are used with GER to stop the vomiting. Therefore, the nurse would monitor the child’s vomiting to evaluate the effectiveness of using the thickened feedings. No relationship exists between feedings and characteristics of stools and uterine. If feedings are ineffective, this should be noted before there is any change in the child’s weight. 46. C. Children with celiac disease cannot tolerate or digest gluten. Therefore, because of 62
its gluten content, wheat and wheat-containing products must be avoided. Rice, milk, and chicken do not contain gluten and need not be avoided. 97. 47. C. Episodes of celiac crises are precipitated by infections, ingestion of gluten, prolonged fasting, or exposure to anticholinergic drugs. Celiac crisis is typically characterized by severe watery diarrhea. Respiratory distress is unlikely in a routine upper respiratory infection. Irritability, rather than lethargy, is more likely. Because of the fluid loss associated with the severe watery diarrhea, the child’s weight is more likely to be decreased. 98. 48. A. For the child with Hirschsprung disease, fever and explosive diarrhea indicate enterocolitis, a life-threatening situation. Therefore, the physician should be notified immediately. Generally, because of the intestinal obstruction and inadequate propulsive intestinal movement, antidiarrheals are not used to treat Hirschsprung disease. The child is acutely ill and requires intervention, with monitoring more frequently than every 30 minutes. Hirschsprung disease typically presents with chronic constipation. 99. 49. A. Failure to pass meconium within the first 24 hours after birth may be an indication of Hirschsprung disease, a congenital anomaly resulting in mechanical obstruction due to inadequate motility in an intestinal segment. Failure to pass meconium is not associated with celiac disease, intussusception, or abdominal wall defect. 100. 50. C. Because intussusception is not believed to have a familial tendency, obtaining a family history would provide the least amount of information. Stool inspection, pain pattern, and abdominal palpation would reveal possible indicators of intussusception. Current, jelly-like stools containing blood and mucus are an indication of intussusception. Acute, episodic
abdominal pain is characteristics of intussusception. A sausage-shaped mass may be palpated in the right upper quadrant. A. A term neonate is to be released from hospital at 2 days of age. The nurse performs a physical examination before discharge. 1. Nurse Valerie examines the neonate’s hands and palms. Which of the following findings requires further assessment? a) Many crease across the palm. b) Absence of creases on the palm. c) A single crease on the palm. d) Two large creases across the palm. 2. The mother asks when the “soft spots” close? The nurse explains that the neonate’s anterior fontanel will normally close by age… a) 2 to 3 months. b) 6 to 8 months. c) 12 to 18 months. d) 20 to 24 months. 3. When performing the physical assessment, the nurse explains to the mother that in a term neonate, sole creases are… a) Absent near the heels. b) Evident under the heels only, c) Spread over the entire foot. 63
d) Evident only towards the transverse arch.
a) Midway between feedings. b) Immediately after a feeding.
4. When assessing the neonate’s eyes, the nurse notes the following: absence of tears, corneas of unequal size, constriction of the pupils in response to bright light, and the presence of red circles on the pupils on ophthalmic examination. Which of these findings needs further assessment? a) The absence of tears. b) Corneas of unequal size.
c) After the neonate has been NPO for three hours. d) Immediately before a feeding. 7. The nurse notes a swelling on the neonate’s scalp that crosses the suture line. The nurse documents this condition as…
c) Constriction of the pupils.
a) Cephallic hematoma.
d) The presence of red circles on the pupils.
b) Caput succedaneum. c) Hemorrhage edema.
5. After teaching the mother about the neonate’s positive Babinski reflex, the nurse determines that the mother understands the instructions when she says that a positive Babinski reflex indicates…. a) Immature muscle coordination. b) Immature central nervous system. c) Possible lower spinal cord defect. d) Possible injury to nerves that innervate the feet. B. Nurse Kris is responsible for assessing a male neonate approximately 24 hours old. The neonate was delivered vaginally.
d) Perinatal caput. 8.
The nurse measures the circumference of the neonate’s heads and chest, and then explains to the mother that when the two measurements are compared, the head is normally about… a) The same size as the chest. b) 2 centimeter larger than the chest. c) 2 centimeter smaller than the chest. d) 4 centimeter larger than chest.
9. After explaining the neonate’s cranial molding, the nurse determines that the
6. The nurse should plan to assess the neonate’s physical condition…. 64
mother needs further instructions from which statement?
a) Taking solid foods well. b) Sleeping through the night.
a) “The molding is caused by an overriding of the cranial bones.”
c) Shortening the nursing time. d) Eating on a regular schedule.
b) “The degree of molding is related to the amount of pressure on the head.” c) “The molding will disappear in a few days.” d) “The fontanels maybe damaged if the molding does not resolved quickly.” 14. When instructing the mother about the neonate’s need for sensory and visual stimulation, the nurse should plan to explain that the most highly develop sense in the neonate is… a) Task
12. Mother Arlene says the infant’s physician recommends certain foods but the infant refuses to eat them after breastfeeding. The nurse should suggest that the mother alter the feeding plan by… a) Offering desert followed by vegetable and meat. b) Offering breast milk as long as the infant refuses to eat solid food. c) Mixing minced food with cow’s milk and feeding it to the infant through a large hole nipple.
b) Smell c) Touch
d) Giving the infant a few minutes of breast and then offering solid food.
d) Hearing C. Nurse Joan works in a children’s clinic and helps with the care for well and ill children of various ages. 11. A mother brings her 4 month old infant to the clinic. The mother asks the nurse when she should wean the infant from breastfeeding and begin using a cup. Nurse Joan should explain that the infant will show readiness to be weaned by…
13. Which of the following abilities would a nurse expect a 4 month old infant to perform? a) Sitting up without support. b) Responding to pleasure with smiles. c) Grasping a rattle when it is offered.
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d) Turning from either side to the back.
b) Rolling from back to side. c) Holding a rattle briefly.
14. The nurse plans to administer the Denver Developmental Screening Test (DDST) to a five month old infant. The nurse should explain to the mother that the test measures the infants… a) Intelligence quotient.
d) Turning the head from side to side. 17. A two month old infant is brought to the clinic for the first immunization against DPT. The nurse should administer the vaccine via what route?
b) Emotional development. a) Oral. c) Social and physical activities. b) Intramascular d) Pre-disposition to genetic and allergic illnesses. 15. When discussing a seven month old infant’s mother regarding the motor skill development, the nurse should explain that by age seven months, an infant most likely will be able to… a) Walk with support.
c) Subcutaneous d) Intradermal 18. The nurse teaches the client’s mother about the normal reaction that the infant might experience 12 to 24 hours after the DPT immunization, which of the following reactions would the nurse discuss?
b) Eat with a spoon. a) Lethargy. c) Stand while holding unto a furniture d) Sit alone using the hands for support.
b) Mild fever. c) Diarrhea d) Nasal Congestion
16. A mother brings her one month old infant to the clinic for check-up. Which of the following developmental achievements would the nurse assess for? a) Smiling and laughing out loud.
19. An infant is observed to be competent in the following developmental skills: stares at an object, place her hands to the mouth and takes it off, coos and gargles when talk to and sustains part of her own weight when held to in a standing position. The nurse correctly assessed infant’s age as… 66
a) Two months.
b) Mix new foods with more familiar foods.
b) Four months c) Six months d) Eight months. 20. The mother says, “the soft spot near the front of her baby’s head is still big, when will it close?” Nurse Lilibeth’s correct response would be at…
c) Offer new foods one at a time. d) Offer new foods after formula has been offered. 23. Which of the following tasks is typical for an 18-month old baby? a) Copying a circle
a) 2 to 4 months. b) Pulling toys b) 5 to 8 months. c) 9 to 12 months. d) 13 to 18 months. prop 21. A mother states that she thinks her 9month old is ‘developing slowly’. When evaluating the infant’s development, the nurse would not expect a normal 9month old to be able to…
c) Playing toy with other children d) Building a tower of eight blocks 24. Mother Riza brings her normally developed 3-year old to the clinic for a check-up. The nurse would expect that the child would be at least skilled in…
a) Creep and crawl.
a) Riding a bicycle
b) Begin to use imitative verbal expressions.
b) Tying shoelaces c) Stringing large beads
c) Put an arm through a sleeve while being dressed. d) Hold a bottle with good hand – mouth coordination. 22. The mother of the 9-month old says, “it is difficult to add new foods to his diet, he spits everything out”, she says. The nurse should teach the mother to…
d) Using blunt scissors 25. The mother tells the nurse that she is having problem toilet-training her 2year old child. The nurse would tell the mother that the number one reason that toilet training in toddlers fails because the… a) Rewards are too limited
a) Mix new foods with formula 67
b) Training equipment is inappropriate
a) Structured interaction b) Spanking
c) Parents ignore “accidents” that occur during training d) The child is not develop mentally ready to be trained 26. A child is not developmentally ready to be trained. A 2-1/2 year old child is brought to the clinic by his father who explains that the child is afraid of the dark and says “no” when asked to do something. The nurse would explain that the negativism demonstrated by toddler is frequently an expression of… a) Quest for autonomy b) Hyperactivity c) Separation anxiety d) Sibling rivalry 27. The nurse would explain to the father which concept of Piaget’s cognitive development as the basis for the child’s fear of darkness? a) Reversibility b) Animism
c) Reasoning d) Scolding 29. When a nurse assesses for pain in toddlers, which of the following techniques would be least effective? a) Ask them about the pain b) Observe them for restlessness c) Watch their face for grimness d) Listen for pain cues in their cries. 30. The mother reports that her child creates a quite scene every night at bedtime and asks what she can do to make bedtime a little more pleasant. The nurse should suggest that the mother to… a) Allow the child to stay up later one or two nights a week. b) Establish a set bedtime and follow a routine
c) Conservation of matter d) Object permanence 28. Mother asks the nurse for advice about discipline. The nurse would suggest that the mother would first use…
c) Let the child play toy just before bedtime d) Give the child a cookie if bedtime is pleasant.
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31. The mother asks about dental care for her child. She says that she helps brush the child’s teeth daily. Which of the following responses by the nurse would be most appropriate?
In developing such a plan, the nurse and mother should consider… a) Deciding on a good reward for finishing a meal
a) “Since you help brush her teeth, there’s no need to see a dentist now”
b) Allowing him to make some decisions about the foods he eats
b) “You should have begun dental appointments last year but it is not too late”
c) Requiring him to eat the foods served at meal times.
c) “Your child does not need to see the dentist until she starts school” d) “A dental check-up is a good idea, even if no noticeable problems are present” 32. The mother says that she will be glad to let her child brush her teeth without help, but at what age should this begin? Nurse Roselyn should respond at… a) 3 years
d) Not allowing him to play with friends until he eats all the food she served. 34. Nurse Bryan knows that one of the most effective strategies to teach a Four year old about safety is to… a) Show him potential dangers to avoid b) Tell him he is bad when they do something dangerous c) Provide good examples of safety behavior
b) 5 years c) 6 years
d) Show him pictures of children who have involve with accidents
d) 7 years 33. The mother tells the nurse that her other child, a 4-year old boy, has developed some “strange eating habits”, including not finishing her meals and eating the same foods for several days in a row. She would like to develop a plan to connect this situation.
35. A 9 year old girl is brought to the pediatrician’s office for an annual physical checkup. She has no history of significant health problems. When the nurse asks the girl about her best friend, the nurse is assessing… a) Language development
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b) Motor development c) Neurological development d) Social development 36. The child probably tells the nurse that brushing and flossing her teeth is her responsibility. When responding to this information, the nurse should realize that the child… a)
Is too young to be given this responsibility
b) Is most likely quite capable of this responsibility c) Should have assumed this responsibility much sooner d) Is probably just exaggerating the responsibility 37. The mother tells the nurse that the child is continually telling jokes and riddles to the point of driving the other family members crazy. The nurse should explain that this behavior is a sign of… a)
Inadequately parental attention
b) Mastery of language ambiguities
child’s behavior is characteristics of which Kohlberg’s level of moral development? a) Pre-conventional morality b) Conventional morality c) Post conventional morality d) Autonomous morality 39. The mother asks the nurse about the child’s apparent need for betweenmeals snacks, especially after school. The nurse and mother develop a nutritional plan for the child, keeping in mind that the child.. a) Does not need to eat between meals b) Should eat snacks his mother prepares c) Should help prepare own snacks d) Will instinctively select nutritional snacks 40. The mother is concerned about the child’s compulsion for collecting things. The nurse explains that this behavior is related to the cognitive ability to perform.
c) Inappropriate peer influence a) Concrete operations d) Excessive television watching b) Formal operations 38. The mother relates that the child is beginning to identify behaviors that pleases others as “good behavior”. The
c) Coordination of
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d) Tertiary circular reactions 41. The nurse explained to the mother that according to Erickson’s framework of psychosocial development, play as a vehicle of development can help the school age child develop a sense of… a) Initiative b) Industry c) Identity
b) Prohibit the child from playing outside if he eat snacks c) Include the child in meal planning and preparation d) Limit the child’s calories intake to 1,200kCal/day 44. When assessing an 18-month old, the nurse notes a characteristics protruding abdomen. Which of the following would explain the rationale for this findings?
d) Intimacy 42. The school nurse is planning a series of safety and accident prevention classes for a group of third grades. What preventive measures should the nurse stress during the first class, knowing the leading cause of incidental injury and death in this age?
a) Increased food intake owing to age b) Underdeveloped abdominal muscles c) Bowlegged posture d) Linear growth curve
a) Flame-retardant clothing b) Life preserves c) Protective eyewear d) Auto seat belts 43. The mother of a 10-year old boy expresses concern that he is overweight. When developing a plan of care with the mother, Nurse Katrina should encourage her to… a) Limit child’s between-,meal snacks
45. If parents keep a toddler dependent in areas where he is capable of using skills, the toddler will develop a sense of which of the following? a) Mistrust b) Shame c) Guilt d) Inferiority 46. Which of the following fears would the nurse typically associate with toddlerhood? a) Mutilation 71
b) The dark
50. Which of the following toys should the nurse recommend for a 5-month old?
c) Ghosts a) A big red balloon d) Going to sleep b) A teddy bear with button eyes
47. A mother of a 2 year old has just left the hospital to check on her other children. Which of the following would best help the 2 year old who is now crying inconsolably?
c) A push-pull wooden truck d) A colorful busy box Answer Key:
a) Taking a nap b) Peer play group c) Large cuddly dog d) Favorite blanket 48. Which of the following is an appropriate toy for an 18 month old? a) Multiple-piece puzzle
1. C 2. C 3. C 4. B 5. B 6. A 7. B 8. B 9. B 10. C
11. C 12. D 13. A 14. C 15. D 16. D 17. B 18. B 19. B 20. D
21. C 22. C 23. B 24. B 25. D 26. A 27. B 28. A 29. A 30. B
31. D 32. C 33. B 34. C 35. D 36. B 37. B 38. B 39. C 40. A
41. B 42. D 43. C 44. B 45. B 46. D 47. D 48. C 49. A 50. D
b) Miniature Cars c) Finger paints d) Comic Book 49. When teaching parents about typical toddler eating patterns, which of the following should be included? a) Food “jags” b) Preference to eat alone c) Consistent table manners d) Increase in appetite
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