MATERNAL AND CHILD NURSING
INSTRUCTIONS: Select the correct answer for each of the following questions. Mark only one answer for each item y making the o! corres"on#ing corres"on#ing to the letter of your choice on the answer sheet sheet "ro$i#e#. %.
The normal normal "osit "osition ion of the the uter uterus us is: is: &. &nte &ntero rofl fle! e!io ion n '. Retr Retro$ o$er ersi sion on C. &nte$ nte$eersio sion (. &nte &nte$e $ers rsof ofle le!i !ion on
).
*hich *hich orga organ n is res"o res"onsi nsile le for for o$ula o$ulatio tion+ n+ &. Uterus '. ,allo allo"i "ian an tue tue C. O$ary (. -agina
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*hich *hich among among the the follow following ing is is TRU/ TRU/ of "roges "rogesteron terone+ e+ &. Stimulat Stimulation ion of folli follicles cles for for o$ulatio o$ulation n to occur occur '. (e$elo"m (e$elo"ment ent of femal femalee re"ro#u re"ro#ucti$ cti$ee organs organs C. 0re"arat 0re"aration ion of the the uterus uterus to recei$e recei$e a fertil fertili1e# i1e# o$um o$um (. /stalish /stalishment ment of of the secon#ar secon#ary y male se! se! character characteristi istics cs
2.
Com"lete Com"lete orga organogene nogenesis sis takes takes "lace "lace y the the en# en# of 333333 333333 gestati gestation+ on+ &. % month '. ) months C. months (. ,irs ,irstt trim trimes este ter r
4.
*hich *hich of the following following est est #escrie #escriess the asal o#y o#y tem"erat tem"erature ure #uring #uring the o$ulatio o$ulation+ n+ &. 5 #uring #uring o$ulation o$ulation 6 slight slightly ly #ro"s #ro"s #uring #uring the luteal luteal "hase "hase '. 7 #uring "rolife "roliferati rati$e $e "hase then then increase increase following following o$ulation o$ulation an# remain remainss high C. (ecrease (ecrease #uring #uring the "re8menstr "re8menstrual ual "hase an# increase increase followin following g o$ulation o$ulation an# remains remains high (. (ecrease #uring o$ulation9 o$ulation9 then increase following following o$ulation an# #ecrease #uring #uring the luteal "hase "hase
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Once the s"erm s"erm is #e"osite# #e"osite# in the $agina9 $agina9 the s"erm is ca"ale of ferti1ing ferti1ing the o$um for a "erio# "erio# of 33333 hours+ &. %) ; )2 )2 hou hourrs '. )2 ; hour hourss C. 2< ; =) hour hourss (. =) ; >? hour hourss
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& "regnant client client aske# you you aout @autosomes@9 @autosomes@9 which she has rea# rea# aout. Aou will will tell her that autosomes: &. &re &re se! se! chro chromo moso some mess '. Carry Carry the the B an# an# A chromo chromosom somes es C. Carry Carry the ay ays s her here#i e#itar tary y traits traits (. Contai Contain n the en1ym en1ymee hyaluro hyaluroni# ni#ase ase
<.
The most most common common site of im"lant im"lantation ation of the the fertili1e fertili1e# # o$um is in the the 33333333 33333333 "ortion "ortion of the uterus: uterus: &. &nte &nteri rior or u"" u""er er '. 0ost 0oster erio iorr u""e u""err C. &nte &nteri rior or lowe lowerr (. 0ost 0oster erio iorr lowe lower r
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The outer fetal fetal memrane memrane that "ro$i#es "ro$i#es nourishme nourishment nt to to the emryo emryo is is the: the: &. Dang Dangha han nss laye layerr '. &mnion C. Chorion (. Aolk sac
%?. O!ygen mo$es from maternal maternal to fetal loo# y mo$ing from an area of greater greater concentration to an area of lesser concentration. concentration. This mo$ement is referre# to as: &. ,acil ,acilita itates tes Trans Trans"or "ortt '. (iffusion sion C. &cti &cti$e $e tran trans" s"or ortt (. 0inoc inocy ytosi tosiss %%. The est a#$ice a nurse can gi$e gi$e to a "regnant client client on the first first trimester trimester of "regnancy is: is: &. Cut #own on #rugs9 #rugs9 alcohol alcohol an# an# cigaret cigarettes tes '. &#minist &#minister er all #rugs #rugs an# refrain refrain from from smoking smoking an# ingesting ingesting alcohol alcohol &$oi# smoking9 alcohol consum"tion an# #ont take any #rugs without #octors or#er. C. &$oi# Take only "rescri"tion #rugs es"ecially in the )n# an# r# trimester (. Take %). &fter %)wks of "regnancy9 "regnancy9 the chief source source of estrogen estrogen an# "rogesterone is the: &. 0lacenta '. &#re &#rena nall Cor Corte te! !
C. Cor" Cor"us us lute luteum um (. &nte &nteri rior or hy"o hy"o"hy "hysi siss %. In fetal circulation9 circulation9 the fetal structure structure that #irects the loo# from from the "lacenta to the I-C I-C is: &. Umi Umili lica call arte artery ry '. Umi Umili lica call $ei $ein n C. (uct (uctus us $eno $enosu suss (. (uct (uctus us arte arteri rios osus us %2. The fetal heart egins to eat y the en# of 333333 lunar month: &. ,irst '. Secon# C. Thir# (. ,ourth %4. On her first clinic $isit9 $isit9 a "regnant client tells tells the nurse that she is nauseate# nauseate# in the morning an# sometimes sometimes $omits her reakfast. reakfast. The nurse shoul# suggest that ? minutes efore arising9 she shoul#: &. /at /at some some crac cracker kerss an# an# Eam Eam '. Nile Nile on on some some "otato "otato chi"s or corn corn chi"s chi"s C. (rin (rink k a gla glass ss of of warm warm mil milk k (. Chew Chew a sti stick ck of gum gum Situation: & newly we# cou"le is e!"ecting their first ay. They are atten#ing "re"are# chil#irth classes. Se$eral e!ercises were taught in "re"aration for the chil# irth. %. The nurse e!"laine# to the cou"le cou"le that the most im"ortant im"ortant e!"ecte# outcome of chil#irth chil#irth "re"aration "re"aration is to: &. Make laor laor "ainl "ainless ess y elimi eliminati nating ng fear fear of the unknown unknown '. Fel" Fel" husan husan# # feel feel useful useful #uri #uring ng irth irth C. 0re$ent 0re$ent woman woman from taking taking analge analgesics sics that that may harm the the fetus #uring #uring laor laor (. 0ro$i#e 0ro$i#e "ossile "ossile tools tools to hel" the the woman co"e co"e with the the laor "rocess "rocess.. %=. ¬her ¬her e!ercise e!ercise that "regnant "regnant client was taught to "ractice "ractice is the "el$ic "el$ic rock. This will e hel"ful hel"ful at any time in her life if she #e$elo"s: &. Deg cr cram"s m"s '. Urin Urinar ary y incon inconti tine nenc ncee C. Dow ac ack "a "ain (. Femor morrhoi hoi#s Situation: & "regnant client sought consultation for the first time9 No$.)4.Fer chief com"laints were o#y malaise9 nausea an# $omiting. 'ase# on the nursing history9 her last menstrual "erio# was Guly )48)<. Fer O' history is as follows: (eli$ere# NS(9 li$e ay oy9 &OH wks Miscarriage ; (6C was #one 0resently "regnancy %<. ,rom her her O' history history99 she is consi#er consi#ere# e# a : &. Mult ulti"ara "ara '. Hran Hran# # multi multi"a "ara ra C. Mult Multig igra ra$i $i#a #a (. Hran Hran# # Mult Multig igra ra$i $i#a #a %>. Fer gra$ity gra$ity an# an# "arity "arity is: &. H0 '. H0 C. H02 (. H04 )?. )?. Fer Fer &OH &OH is: is: &. <8> wks '. %?8%% wks C. % ; %= wks (. %=; %< wks )%. Fer nausea nausea an# $omiting $omiting is consi# consi#ere# ere# as: as: &. Normal '. &normal )). *hich of the following following #ata gi$en gi$en y the client client is most in#icati$e in#icati$e of "regnancy+ "regnancy+ &. 'o#y o#y Mala Malais isee '. &meno enorrhe rrheaa C. Naus Nausea ea 6 -o -omiti miting ng (. uick uickeening ning
). If "a" smear is is to e #one9 the the nurse shoul# "re"are "re"are the ff articles e!ce"t: e!ce"t: &. Hoos Hoosee neck neck lam" lam" '. Sli#es C. micro icrosc sco" o"ee (. S"eculum )2. The client clientss ne!t clinic clinic $isit $isit will will e on: &. (ec. '. (ec.%? C. (ec.)4 (. &nytime Situation: ¬her ¬her client9 Mrs. 9 came to the ante8"artal clinic. She is % years ol#9 "regnant for the first time an# is on her )2 th to )4th week of "regnancy. )4. She further further tol# the nurse that she has gaine# 2ls in one month an# "lans to #iet y ski""ing ski""ing meals. *hich *hich res"onse res"onse woul# e most a""ro"riate+ &. Fa$e you you notice# notice# that your your han#s han#s an# feet feet ha$e ecome ecome swolle swollen+ n+ '. Aou Aou shoul# cut #own on on high calorie foo#s like can#ies9 can#ies9 cakes an# ice cream ut you you shoul# not ski" meals meals C. Aour Aour weight gain is Eust Eust right for this "erio# of "regnancy9 "regnancy9 you are #oing fine (. Aou Aou are su""ose# to gain a lot of weight. weight. Its goo# for the ay. ay. Aoull Aoull lose lose it all after the ay is is orn ). Deo"ol#s maneu$er was #one. #one. The "ur"ose "ur"ose of which is to #etermine: %. ,etal a ack ). ,etal etal "re "rese sent ntat atio ion n . ,etal lie 2. ,etal #e #escent &. '. C. (.
%9 )9 %9 9 2 )9 9 2 &ll
)=. Mrs. com"laine# com"laine# that she has a hemorrhoi# hemorrhoi# an# aske# how her anal #iscomfort #iscomfort can e relie$e#. relie$e#. The nurse est res"onse res"onse woul# e: &. To use use an an ice ice ag ag '. To a$oi a$oi# # knee knee ches chestt "osit "osition ion C. To "urchase "urchase a hemorrhoi# hemorrhoi# su""osito su""ository ry (. Not to to attem"t attem"t to to reinsert reinsert the the hemorrh hemorrhoi# oi# hersel herself f )<. She also aske# the nurse nurse if she nee#s to take take her iron su""lement. The Nurse Nurse res"onse shoul# shoul# e: &. Det us "lan "lan a menu that will will "ro$i#e "ro$i#e e!tra e!tra iron you nee# nee# #uring this this semester semester '. Iron is is a mineral mineral an# is not not to e e consi#er consi#ere# e# a me#icat me#ication ion C. Det us check the results results of your loo# test test ecause if you are are not anemic9 anemic9 you will will not nee# nee# e!tra iron iron (. Iron is "rescrie# ecause it it is $ery #ifficult #ifficult to otain enough enough "alatale #istriution )>. Mrs. has sto""e# #rinking #rinking orange Euice ecause she elie$es that it gi$es gi$es her hearturn. *hich *hich of the ff statement statement of the nurse woul# e most a""ro"riate+ &. If you take take your multi$it multi$itamin aminss e$ery#ay e$ery#ay99 you can ski" the the orange orange Euice '. Try Try #rinking #rinking your your orange orange Euice after after eating eating an# an# not when when you are are hungry hungry C. Ill Ill gi$e you you a list of other other foo#s foo#s that that you you can eat eat instea# instea# orange Euice9 you really #o nee# it. The hearturn will only last for a (. <hough a lot of "regnant women get hearturn from orange short time. ?. *hen #iscussing #iscussing nutritio nutrition9 n9 Mrs. asks the nurse if she must continue continue to #rink #rink 4 cu"s of milk a #ay. #ay. *hich res"onse res"onse woul# e most a""ro"riate+ &. 2 cu"s are enough9 enough9 ut if you you nee# to nurse nurse the ay9 ay9 you will will nee# 4 cu"sJ#ay cu"sJ#ay '. cu"s an# an# a## 4ts" 4ts" of "ow#ere "ow#ere# # milk to sou" sou" an# eat eat a slice slice of cheese cheese C. < cu"s cu"s a #ay9 #ay9 ecause ecause you you are still still a teenag teenager er (. 2 cu"s cu"s "lus meat9 meat9 fruits fruits an# an# yellow yellow $eget $egetale aless %. &n ultrasoun# has een or#ere# or#ere# for Mrs. . 'efore 'efore she lea$es the unit9 what instructions instructions shoul# the nurse nurse gi$e her+ &. -oi# efor eforee the "roce# "roce#ure ure '. Not to to eat from from mi#nig mi#night ht until until after after the "roce "roce#ure #ure is is #one C. Inges Ingestt an a#equ a#equate ate amou amount nt of of water water (. &$oi# &$oi# "erinea "erineall flushing flushing ) hrs efor eforee the "roce#ur "roce#uree Situation: & client ha# een a#mitte# to the laor an# #eli$ery suite. Fer uterine contractions are 4 minutes a"art lasting ? sec. The fetal monitor has een a""lie#. The client was "racticing the reathing techniques she has learne#. ). -aginal -aginal e!amination re$eals re$eals 4cm #ilatation. #ilatation. *hich reathing reathing technique shoul# the nurse instruct instruct her to use+ &. Shal Shallo low w9ligh lightt '. Slow low9Chest hest C. Ryth Rythmi mic9 c999 a#om a#omin inal al (. Ra"i Ra"i#9 #9 "ant "antin ing g
. The nurse recogni1es that that the "atient is ha$ing a "rolem "rolem using the reathing technique technique effecti$ely effecti$ely when she states: &. My finge fingers rs are are ting tinglin ling g '. I ha$ ha$ee to to $om $omit it C. My li"s li"s feel feel #ry #ry (. I ha$ ha$ee to to "us "ush h 2. %? hours ha$e "asse# since the client client was a#mitte# a#mitte# at the laor room an# her contractions contractions continue# continue# to e mil# an# irregular irregular.. O!ytocin %? @ U @ in %??? CC of Normal Saline was a#ministere# $ia "iggyack an# infuse# at the rate of < #ro"s J minute. The nurse oser$e# ) contractions9 =? secon#s a"art lasting % K minutes. The nurse shoul#: &. Dower Dower the rate rate to #ro"s #ro"s J min min '. Mainta Maintain in the the same same flow flow rate rate C. Sto" Sto" the infu infusio sion n 6 call call the the "hysic "hysician ian (. Dower Dower the the rate rate of flow flow to to ) gttsJm gttsJmin in 4. &out ? minutes9 minutes9 the client tells the nurse that she has the urge to "ush. &fter &fter a $aginal e!am that in#icates in#icates that her cer$i! is fully #ilate#9 the nurse shoul# instruct her to: &. 'reathe 'reathe more re"eat re"eate#ly e#ly with with her thoracic thoracic muscles muscles an# ear ear #own '. Die on her si#e si#e an# concentr concentrate ate on total total rela!atio rela!ation n while reath reathing ing #ee"ly #ee"ly C. Take Take a #ee" reathL reathL hol# it for a count of %? an# "ush. Re"eat Re"eat until contraction en#s. en#s. (. Gust try to urinate an# then continue continue with the "anting an# lowing ty"e of reathing. reathing. . The client clientss /(C was was su""ose# su""ose# to e ) weeks weeks ago. The The #octor #octor or#ere# or#ere# an O!ytocin O!ytocin Challe Challenge nge Tes Testt or#ere# to hel" #etermine: &. ,etal etal &ge '. Matern Maternal al "el$ic "el$ic a#equa a#equacy cy C. ,etal etal wel welll ei eing ng (. Natur Natural al uter uterine ine irr irrita itail ility ity
OCT . . The OCT OCT was
=. Se$eral hours later9 later9 the clients clients cer$i! is 4 cm #ilate#. She tells tells the nurse that she has se$ere ack "ain. The The nurse assesses that the "resentation of the fetus is: &. 'reech '. Occi Occi"i "ito to ante anteri rior or C. ,ace (. Occi Occi"i "ito to "ost "oster erio ior r <. 'io 0hysical 0hysical Scoring re$eals re$eals equi$ocal fin#ings9This fin#ings9This means means that the ostetrician ostetrician ga$e a score score of: &. . The wi#est anteriorJ anteriorJ "osterior "osterior #iameter of the irth canal canal is known as the: the: &. 'i8i 'i8isc schi hial al #iame #iamete terr '. (iag (iagon onal al conE conEug ugat atee C. Trans rans$e $ers rsee #iame #iamete terr (. Trans rans$e $ers rsee conE conEug ugat atee 2?. (uring laor9 laor9 station station % in#icates in#icates that the "resenting "resenting "art is: is: &. On the the "er "erin ineu eum m '. Figh Figh in in the the fals falsee "el$ "el$is is C. Sligh Slightly tly elo elow w the the ischi ischial al s"ine s"ine (. Sligh Slightly tly ao$ ao$ee the isch ischial ial s"in s"inee 2%. One hour after the #eli$ery #eli$ery99 the client informs informs the nurse that her e"isioto e"isiotomy my is $ery "ainful. "ainful. The nurse oser$es oser$es that it is e#ematosis an# the sutures are intact. The nurse shoul# then: &. /ncour /ncourage age her her to to lie lie on her her si#e si#e '. 0ro$i 0ro$i#e #e her her with with a sit1a sit1ath th as or#er or#ere# e# C. Noti Notify fy her her oste ostetr tric icia ian n (. Offer Offer her a ruer ruer ring ring #ough #oughnut nut for for sittin sitting g 2). The client asks the nurse how she can est relie$e relie$e reast engorgement. engorgement. &fter assessing9 assessing9 her reast feels firm firm an# warm9 the nurse shoul# suggest that she: &. Hi$e the the ay formu formula la for a #ay or or two until until her her reast reast soften soften '. &""ly warm com"re com"ress ss aout aout %? minute minutess efore efore each each fee#ing fee#ing C. 0ractice 0ractice "re$iou "re$iously sly learne# learne# inhalati inhalation on technique techniquess an# e!ercise e!ercisess (. &""ly ice "acks "acks imme# imme#iate iately ly after after each each fee#ing fee#ing 2. (uring #ischarge #ischarge "lanning9 the client asks asks the nurse which weight weight loss #iet may she utili1e to return to her "re8"regnant "re8"regnant weight. The nurse shoul# counsel that she: &. Return to to her "re8"regnant calorie intake after after lactation lactation has een fully estalishe# '. /at the same same amount amount as #uring #uring "regnancy "regnancy ut elimin eliminate ate cakes cakes an# sweets sweets C. Not consi#e consi#err #ieting #ieting until until after after she has has sto""e# sto""e# reast reast fee#ing fee#ing (. 0lan a weigh weightt watchers watchers ty"e ty"e of #iet after after "ost "ost "artum "artum weeks weeks
22. To a client seeking a#$ice aout aout the use of IU(9 the nurse e!"lains e!"lains that the IU( "ro$i#es "ro$i#es contrace"tion y: y: &. 'locking the cer$i! '. Incre Increase ase the the moil moility ity of of the uter uterus us C. 0re$enti 0re$enting ng the the s"erm s"erm from from reachi reaching ng the the uterus uterus (. Setting Setting a non8s"ecif non8s"ecific ic inflammat inflammatory ory reaction reaction in the en#ometr en#ometrium ium 24. The nurse shoul# e!"lain that a $ery common "rolem "rolem that has een een associate# with with the use of IU( IU( is: &. Uter Uterin inee "erfo "erfora rati tion on '. (isco (iscomfo mforts rts assoc associat iate# e# with with coitus coitus C. (e$el (e$elo"m o"ment entss of $aginal $aginal infec infectio tions ns (. S"onta S"ontaneo neous us e!"uls e!"ulsion ion of of the #e$ic #e$icee Situation: Mrs. is ha$ing her first ay an# is at term. She is ha$ing uterine contractions when a#mitte# to the hos"ital. 2. *hich of the following following questions questions that the nurse nurse asks Mrs. u"on a#mission is is least "ertinent+ "ertinent+ &. *hen *hen #i# #i# you you las lastt eat+ eat+ '. Fa$e Fa$e you you e$er e$er ha# an enema enema++ C. Fa$e your memrane memrane ru"ture# ru"ture# alrea#y alrea#y++ (. *hen *hen #i# your your contr contract action ion star start+ t+ 2=. She is to ha$e a $aginal e!amination. e!amination. The nurse nurse shoul# hel" "re"are for Mrs. s $aginal $aginal e!amination y: y: &. Fa$in Fa$ing g steri sterile le glo$ glo$es es rea# rea#y y '. /m"t /m"ty y her her la# la##e #err C. 0lacing 0lacing the "atient "atient in in lithot lithotomy omy "osition "osition (. Cleani Cleaning ng the the "atien "atient tss $ul$a $ul$a 2<. (uring (uring which of the followi following ng stages stages of laor laor shoul# shoul# the nurse nurse antici antici"at "atee that that Mrs. Mrs. will will or#ina or#inaril rily y nee# nee# the most encouragement an# su""ort+ &. (uring (uring the the early early "art "art of stag stagee % '. (uring (uring the the trans transiti ition on "art "art of stag stagee % C. (urin uring g sta stage ge ) (. (uri (uring ng stag stagee 2>. Mrs. egins egins amulation amulation aout hours after after #eli$ery. #eli$ery. This ty"e of acti$ity acti$ity is es"ecially es"ecially eneficial eneficial to hel" "re$ent "re$ent "rolems associate# with the "atients: &. Circ Circul ulat ator ory y syst system em '. 0roc 0roces esss of in$ in$ol olut utio ion n C. Milk Milk "ro# "ro#uc ucin ing g aili aility ty (. Muscul Musculo8s o8skel keleta etall syste system m 4?. ,i$e #ays after #eli$ery #eli$ery99 the nurse notes notes that Mrs. is ha$ing ha$ing re##ish $aginal $aginal #ischarge #ischarge with clots9 This assessmen assessmentt fin#ing fin#ing is in#icati$e of: &. 'lee 'lee#i #ing ng com"i com"ica cati tion on '. Infection C. Norm Normal al fin# fin#in ings gs (. Dacera cerati tio on 4%. *hat is the earliest earliest sign of "uerty that may e oser$e# in a %? %? year ol#+ &. ,at #e" #e"os osit itio ion n '. &""e &""ear aran ance ce of "u "uic ic hair hair C. Menarche (. 'reas reastt u# u##i #ing ng 4). Formones influence a womans womans se!ual maturation. Of im"ortance im"ortance is "rogesterone9 which is normally normally secrete# in relati$ely large large quantities y the: &. /#ome #ometr triu ium m '. 0itu 0ituit itar ary y Hlan Hlan# # C. &#re &#rena nall cor corte te! ! (. Cor" Cor"us us lute luteum um 4. If a woman woman has a )4 #ay cycle9 cycle9 o$ulation occurs on what #ay+ #ay+ &. %%th '. %)th C. %th (. %2th 42. *hich *hich of the following following #escrie #escriess menstrual menstrual loo#+ loo#+ &. It contai contains ns clot clotss an# an# mucus mucus '. It is is o#orl o#orless ess an# #ark #ark re# re# in color color C. It is non8fou non8foull emitting emitting99 saturatin saturating g a "a# in less less than an hour hour (. It ears ears a fleshy fleshy o#or o#or an# contains contains en#ome en#ometria triall cells cells 44. *hich *hich is not true regar#ing regar#ing the human human se!ual res"onse res"onse++ &. In general9 general9 males males ha$e one asic "attern "attern99 whereas whereas females females may ha$e $ariale $ariale res"onses res"onses '. 'ecause of the homologous homologous male an# an# female structures9 male an# female female res"onses res"onses are more more alike than than #ifferent #ifferent
C. Sym"athetic stimulation causes erection9 whereas "ara8sym"athetic "ara8sym"athetic causes causes eEaculation. eEaculation. (. Males ha$e a refractory refractory "erio# which makes makes them inca"ale of multi"le orgasms 4. (uring the "rocess of gametogenesis9 gametogenesis9 the male an# an# female se! cells #e$i#e #e$i#e an# each mature se! cell contain: contain: &. )) "air "airss of auto autosom somes es nucl nuclei ei '. 2 "air "airss of autoso autosomes mes nuclei nuclei C. (i"lo (i"loi# i# num numer er of of chrom chromoso osomes mes (. Fa"lo Fa"loi# i# num numer er of chromo chromosom somes es 4=. & client client asks what #etermines #etermines her ays se!. se!. Aou Aou will e!"lain e!"lain that: &. Pygote Pygote contains contains )) "airs "airs of of autosomes autosomes that that #etermi #etermine ne the se! se! '. Union of B an# A chromosomes #etermines the se! C. Pygote Pygote forme# forme# within within )2 hours hours of o$ulati o$ulation on will will "roaly "roaly e female female (. The se! se! of the ay ay is #etermin #etermine# e# y the the s"erm s"erm 4<. & client sought sought consultation ecause of misse# "erio#s. She un#erwent a urine test for "regnancy. "regnancy. Aou Aou know that this is ase# on the "resence of which hormone+ &. 0rog 0roges este tero rone ne '. Dactoge ogen C. FCH (. F0D 4>. The "lace "lacenta nta #oes #oes not not "ro#uce: "ro#uce: &. Soma Somato totr tro" o"in in '. Chorio Chorionic nic gona#o gona#otro tro"in "in C. ,SF (. 0rog 0roges este tero rone ne ?. Aou Aou will caution a "regnant "regnant client against e!"osure e!"osure of teratogens. The greatest greatest ha1ar# to the ay is #uring #uring the "erio# of the: &. O$um '. /mryo C. ,etus (. Pygote %. & "regnant "regnant client e!"resses e!"resses her concern aout her #ark ni""les. ni""les. The nurse e!"lains e!"lains that this a#a"tation a#a"tation is #ue to the hy"eracti$ity hy"eracti$ity of the: &. O$aries '. Thy Thyroi# roi# glan glan# # C. &#re &#rena nall glan glan# # (. 0itu 0ituit itar ary y glan glan# # ). In fetal #e$elo" #e$elo"ment ment99 growth is most most ra"i# in the: &. %st %st tri trime mest ster er '. )n# trimester C. r# trimester (. Im"l Im"lan anta tati tion on "eri "erio# o# . ,etal mo$ement mo$ement will first e felt y the the "regnant women &. ) week weekss ef efore ore #eli$e #eli$ery ry '. 2 wks wks efo efore re #eli #eli$e $ery ry C. &t aou aoutt < ; %) %) wks wks &OH (. &t aou aoutt % ; )? wks wks &OH &OH 2. *hich *hich are true true of fetal fetal #e$elo"me #e$elo"ment+ nt+ %. The fetus fetus is is ale ale to res" res"on# on# to soun soun# # ). The fetus fetus acqui acquires res matern maternal al antio#i antio#ies es y "lace "lacental ntal trans transfer fer . The "resenc "resencee of surfactant surfactantss in the amniotic amniotic flui# flui# can e use# use# to #etermine #etermine lung lung maturity maturity 2. The last last three three months months of "regnancy "regnancy allow allowss the fetus fetus to to "ut on weight. weight. &. '. C. (.
%9 )9 %9 9 2 )9 9 2 all
4. & client client com"lains of consti"ation consti"ation an# occasional leg cram"s. *hich *hich of the ff measures measures woul# e most a""ro"riate to minimi1e minimi1e consti"ation+ %. (rin (rink k a#eq a#equa uate te amo amoun untt of milk milk ). &$oi# &$oi# intake intake of of caffe caffeine ine contai containing ning e$erage e$erage . Take %? ; )? cc cc of miner mineral al oil oil to softe soften n stools stools 2. /at /at fruits fruits like like "a"a "a"aya ya99 "runes9 "runes9 "ine "inea"" a""le le &. '. C. (.
2 only %6) =2 &ll
Situation: & newly8we# cou"le is e!"ecting their first ay. They are atten#ing "re"are# chil#irth classes. Se$eral e!ercises were taught in "re"aration for the chil# irth. . The nurse tol# the "regnant client client to "ractice "ractice Qegel e!ercise e!ercise after she ha# ha# the ay to: &. Dimi Dimitt loc lochi hial al flow flow '. Relie$ Relie$ee e"isio e"isiotom tomy y "ain "ain C. Re#uce Re#uce u""er u""er leg leg $ar $arico icose se $ein $einss (. &lle &lle$i $iat atee afte afterr "ains "ains =. In "re"aration for for chil# irth9 which e!ercises e!ercises will strengthen strengthen an# stretch her her "erineal muscles+ muscles+ %. Squatting ). walking . Qege Qegel lss e!e e!erc rcis isee 2. Tailor ilor sitt itting ing &. '. C. (.
%9 2 %9 9 2 )9 9 2 &ll
Situation: & "regnant client sought consultation for the first time. Fer chief com"laints were o#y malaise9 nausea an# $omiting. 'ase# on the nursing history9 history9 her last menstrual "erio# was Oct. )48)<. Fer O' history history are as follows: (eli$ere# NS(9 li$e ay oy9 &OH wks Miscarriage ; ( 6 C was #one (eli$ere# NS(9 li$e ay oy9 #ie# after #ays9 &OH ; 2 wks (eli$ere# NS(9 li$e ay oy9 &OH > wks Miscarriage ; (6C was #one 0resent "regnancy <. Fer numerical numerical O' history history is T808&8D 808&8D + &. )8%8)8 '. )8%8)8) C. %8)8)8 (. %8)8)8) >. Using Using the Naegel Naegelss Rule9 Rule9 her /(C will will e on: &. &ugust % '. Guly C. Guly ? (. &ugust 2 =?. Using the 'artholonew 'artholonewss rule. Fer Fer fun#ic height is is e!"ecte# to e: &. &t the the le$el le$el of of sym"h sym"hysi ysiss "uis "uis '. ao$ ao$ee the the sym"hy sym"hysis sis "uis "uis C. K ao$ ao$ee the the sym"hy sym"hysis sis "uis "uis (. el elow ow the the um umil ilic icus us =%. The est est way to relie$e relie$e her nausea nausea an# an# $omiting $omiting is to: &. Take ice ice chi chi"s "s '. Fa$e Fa$e a#eq a#equa uate te rest rest C. Dimi Dimitt flui flui# # inta intake ke (. eat in in small small amoun amount9 t9 ut ut freque frequentl ntly y =). *hich of the following following "roce#ures "roce#ures woul# the client client un#ergo #uring #uring her $isit+ %. -agina ginall s"ec s"ecul ulum um e!am e!am ). 'iman imanua uall e!am !am . &nthro &nthro"om "ometr etric ic measur measureme ements nts 2. ,FT &uscu uscult ltat atio ion n &. '. C. (.
9 2 %9 )9 %9 )9 2 &ll
=. The client refuses refuses to return to the clinic for her her sche#ule# $isit. The The nurse tells the client client that each $isit is im"ortant: im"ortant: &. /$en though though "rolem "rolemss rarely rarely occur #uring #uring the secon# secon# trimest trimester er '. 'ecause 'ecause to!emia to!emia usually usually occurs occurs at this an# an# can e controlle controlle# # if recogni1e# recogni1e# early early C. /$en though though she she ha# no "rolem "rolemss an# her nausea nausea an# an# $omiting $omiting #isa""e #isa""eare# are# (. 'ecause at her age com"lications that coul# affect her an# the ay are more more likely to to occur Situation: ¬her ¬her client9 Mrs. Q9 came to the ante8"artal clinic. She is %< years ol#9 "regnant for the first time an# is on her 2 th to 4th week of "regnancy.
=2. Mrs. Q aske# the nurse how how much weight gain gain she can e!"ect to gain #uring her her "regnancy. "regnancy. The nurse most most a""ro"riate res"onse res"onse woul# e: &. The a$erag a$eragee weight weight gain #uring #uring "regnan "regnancy cy shoul# shoul# e )4 ; ? ls. ls. '. (e"en#ing on the height an# "re8"regnant "re8"regnant weight9 the the a$erage weight gain gain shoul# e etween %? ; %) kgs. C. Nutrition is $ery im"ortant im"ortant to the fetus that maternal maternal weight weight gain nee# not e restricte# restricte# (. The caloric caloric intake will will e restricte# restricte# to to limit weight gain gain thus conser$ing conser$ing car#iac loa# =4. The a$erage a$erage weight weight gain gain for Mrs Mrs Q is: &. % kg J wk '. % l J wk C. ?.4 ?.4 kg kg J mont month h (. ) ls ls J month onth =. (uring (uring leo"ol#s maneu$er maneu$er99 a har# roun#e# roun#e# mass was "al"ate# "al"ate# at the fun#us fun#us an# a no#ular une$en une$en surface surface at the left a#ominal a#ominal wall. *ith these fin#ings9 the ,FR can e hear# at what "art of the mothers a#omen+ &. DU '. DD C. RU (. RD ==. She further $erali1es $erali1es that when her mother was "regnant9 she ha# $aricose $aricose $eins that e$entually necessitate# necessitate# surgery. surgery. She aske# how that con#ition can e "re$ente#. The nurse can tell her: &. Sit with with the legs legs together together an# an# with with the knees knees higher higher than than the "el$is "el$is '. *e *ear ar su""or su""ortt stocki stockings ngs #ay #ay an# night night C. *a *alk lk slowl slowly y on le$el le$el grou groun#s n#s only only (. /le$ate /le$ate the the legs legs ao$e the the hi"s hi"s whene$er whene$er "ossi "ossile le =<. Iron "ills are are est asore# in the HIT if taken with a glass of Euice Euice rich in: &. -it. & '. -it. C C. -it. ' com com"l "le! e! (. Calcium =>. Mrs. Q an# the nurse "lan menu menu that woul# increase the clients clients iron consum"tion. consum"tion. *hich snack foo# has high high iron content+ &. 'anana9 'anana9 che##ar che##ar cheese9 cheese9 wheat wheat wafer waferss '. Carrot9 Carrot9 har#8o har#8oile# ile# egg9 milk with rye toast toast C. 0runes9 0runes9 mi!es mi!es "eanuts "eanuts an# an# raisins9 raisins9 li$er li$er s"rea# s"rea# on wheat wheat roast roast (. Celery Celery stalk9 stalk9 a""le9 a""le9 cottage cottage cheese9 cheese9 orange orange marmala# marmala#ee on rye toast wks C. )% ; )) wks (. ? ; % wk wks <%. Urinalysis was was also or#ere#. or#ere#. *hich of the following is not true aout urine urine collection+ collection+ &. &n early early mi#term mi#term urine urine is collecte collecte# # '. Rece"tacl Rece"taclee for collecti collection on shoul# shoul# e steri sterile le C. &$oi# &$oi# coitus coitus %) %) ; )2 hrs efor eforee the collecti collection on (. 0erineal 0erineal flushi flushing ng is #one "rior "rior to collec collection tion Situation: & client ha# een a#mitte# to the laor an# #eli$ery suite. Fer uterine contractions are 4 minutes a"art lasting 4 sec. The fetal monitor has een a""lie#. The client was "racticing the reathing techniques she has learne#. <). &fter a contraction9 contraction9 what is the first instruction instruction the nurse shoul# gi$e gi$e the client+ &. Turn urn on your your lef leftt si#e si#e '. Close Close your your eye eyess an# an# rela! rela! C. Take a clea cleansi nsing ng reath reath (. Take som somee ice ice chi" chi"ss <. hours later9 later9 the nurse offers offers the client client a e#"an. e#"an. The client tells tells the nurse that she #oes not ha$e the urge to $oi#. The nurse shoul#: &. &sk her her to call call for hel" when when she has the the nee# to urinate urinate '. /ncourag /ncouragee her to $oi# $oi# y turning turning on the ta" ta" water water an# ensurin ensuring g "ri$acy "ri$acy C. Tell Tell her that that if she cannot cannot $oi# $oi# she will will ha$e ha$e to e cathet catheteri1e eri1e# # (. Increase Increase the the rate rate of I- flow flow to to %4? ccJ hr hr <2. *hen her cer$i! has #ilate# #ilate# to < cm. the client tells tells her husan# an# the nurse nurse that the reathing reathing technique she has has een using no longer controls the "ain. The nurse shoul# tell her that she has entere# the transition "hase of laor an# that she shoul#: &. &ssume &ssume a sitting sitting "osition "osition while while focusing focusing on her concent concentrati ration on "oint '. 'egin 'egin the shallo shallow w "anting "anting an# an# lowing lowing reath reathing ing "attern "attern C. Use the the a#ominal a#ominal muscles muscles while while reat reathing hing more more ra"i#ly ra"i#ly (. Continue the same reathing reathing "attern an# that a small amount of analgesic will will e a#ministere# a#ministere#
<4. (uring the transitional "hase of laor9 laor9 the clients memrane ru"ture#. The The color of the amniotic flui# is green. The ,FR on the electronic monitor #ro"s to %%? eatsJmin #uring the ne!t contraction an# returns to %2? eats J min. % minute after the contraction was o$er. The nurse shoul#: &. Inform Inform the client client that that laor laor is "rogres "rogressing sing as e!"ect e!"ecte# e# '. Notify Notify the the #octor #octor 6 recor recor# # the fin#i fin#ings ngs C. Check Check the amnioti amnioticc flui# flui# for meconiu meconium m with nitra nitra1ine 1ine "a"er "a"er (. Oser$e Oser$e the fetal fetal heart heart rate rate #uring #uring the ne!t ne!t ) contrac contraction tionss <. *hen a#mitte# to the laor laor room9 she asks the nurse what what can e #one to ease her "ain an# hel" laor "rogress "rogress more ra"i#ly. ra"i#ly. Fow shoul# the nurse res"on#+ &. /$ery womans womans laor is #ifferent 6 the #octor #octor will ha$e to #eci#e #eci#e if you you nee# any me#icine me#icine '. ,irst laor laor is usually usually long an# #ifficult. #ifficult. *ell *ell try to make make you as comfortale as "ossile C. The #octor will will "rescrie a me#icine to hel" hel" you rest. *hen you awaken awaken your contraction shoul# shoul# ecome more more regular. regular. (. O!ytocin is usually usually a#ministere#. a#ministere#. It will will make your contraction contraction more effecti$e effecti$e an# allow allow laor to "rogress "rogress more ra"i#ly. ra"i#ly. <=. *hich comfort measure measure is most effecti$e effecti$e for relie$ing the clients clients "ain "ain #uring contraction: contraction: &. /ffleur leuraage '. Sitt Sittin ing g u"ri u"righ ghtt C. Sacr Sacral al "re "ress ssur uree (. Ra"i Ra"i# # 'rea 'reath thin ing g <<. The ischial s"ine is #esignate# #esignate# as an im"ortant im"ortant lan#mark in laor 6 #eli$ery #eli$ery ecause the #istance etween etween the s"ine is: &. The narr narrowe owest st #iame #iameter ter of the the "el$is "el$is '. The wi#e wi#est st measu measurem rement ent of of the "el$ "el$is is C. & measurem measurement ent of of the floor of the the "el$is "el$is (. & measu measureme rement nt of the the inlet inlet of the the irth irth canal canal <>. The client in acti$e acti$e laor egins to tremle9 tremle9 ecomes $ery tense with contractions contractions an# is quite irritale. irritale. She frequently frequently states9 @I cannot stan# this minute any longer @. This kin# of eha$ior maye in#icati$e of the fact that the client: &. Is enteri entering ng the the transit transition ion "hase "hase of laor laor '. Nee#s Nee#s imme#iate imme#iate a#mini a#ministra stration tion of an analges analgesic ic or aesthetic aesthetic.. C. Fas een een $ery "oorly "oorly "re"ar "re"are# e# for laor laor in the the "arent "arentss class class (. Is #e$elo"ing #e$elo"ing some some anormal anormality ity in terms terms of uterine uterine contract contractions. ions. >?. (uring the "erio# of in#uction in#uction of laor with o!ytocin9 o!ytocin9 a client shoul# e oser$e# oser$e# carefully for signs of: &. Se$er $ere "ai "ain n '. Uter Uterin inee aton atony y C. Fy"o Fy"ogl gly ycemi cemiaa (. 0rola 0rola"se "se of of the the umil umilica icall cor# cor# >%. She also tells tells the nurse that that she fin#s it #ifficult #ifficult to sit. The The nurse shoul# then: then: &. (isco (iscoura urage ge her her to to amu amulat latee '. 0ro$i 0ro$i#e #e her her a cush cushion ion when when sitt sitting ing C. /ncourag /ncouragee her to squee1 squee1ee the uttocks uttocks together together (. /ncourag /ncouragee her turn turn to si#es si#es e$ery e$ery %8 ) hours hours >). The nurse e$aluates e$aluates that the client un#erstan#s un#erstan#s the asic "rinci"le "rinci"le in$ol$e# in reast reast care9 es"ecially #uring #uring engorgement9 engorgement9 when she is oser$e#: &. *e *earing aring a tight9 tight9 su""ort su""orti$e i$e rassie rassiere re etween etween fee#ings fee#ings '. Using Using a reast reast "um" "um" to colle collect ct milk milk for ottle ottle fee#ings fee#ings C. /!ercisi /!ercising ng y rotati rotating ng her e!ten# e!ten#e# e# arms arms in wi#e wi#e swings swings (. Using Using a ni""le shoul# shoul# force force the ay to fee# fee# Eust 4 minutes minutes at at each reast reast >. The family "lanning nurse9 nurse9 when aske# aout the ''T9 ''T9 e!"lains that that its efficiency as a form of irth irth control rests on some factors. factors. &mong these is the: &. 0res 0resen ence ce of stre stress ss '. Deng Dength th of of as asti tine nenc ncee C. &ge &ge of thos thosee in$ in$ol ol$e $e# # (. ,requ ,requenc ency y of of inter intercou course rse >2. The nurse teaches further further that the most frequent frequent si#e effect associate# associate# with the use of IU( IU( is: &. /cto"ic "regnancy '. /!"u /!"uls lsio ion n of IU( C. Uter Uterin inee ru" ru"tu ture re (. /!cess /!cessi$e i$e menstr menstrual ual flow flow >4. & i"hasic i"hasic anti8o$ulatory me#icine me#icine of comine# "rogestin "rogestin 6 lactogen is "rescrie# for a female female client. The nurse nurse instructing the client aout the me#icine shoul# inclu#e the nee# to: &. Re"ort Re"ort any $agina $aginall lee# lee#ing ing '. Fa$e Fa$e imont imonthly hly "a" smear smear C. Incre Increase ase her intake intake of calc calcium ium (. Tem"ora Tem"orarily rily restrict restrict se!ual se!ual acti$it acti$ities ies
Situation: Mrs. is ha$ing her first ay an# is at term. She is ha$ing uterine contractions when a#mitte# to the hos"ital. >. Mrs. thinks her memranes memranes ha$e ru"ture# ru"ture# ut she is not sure. sure. The nurse in charge "erforms "erforms a Nitra1ine Nitra1ine test. The "rimary "rimary "ur"ose of this test test is to: &. (iffere (ifference nce etwee etween n urine urine an# amniotic amniotic flui# '. (iffere (ifferentiat ntiatee etween etween amniotic amniotic flui# flui# an# an# $aginal $aginal mucus mucus C. (etermin (eterminee whether whether there there is loo# in the amniotic amniotic flui# flui# (. (etermin (eterminee whether whether there there is meconium meconium in in the amnioti amnioticc flui# flui# >=. The nurse who "erforms the $aginal $aginal e!am on Mrs. recor#e# that the cer$i! cer$i! is 2 cm #ilate#. In terms of cer$ical cer$ical #ilatation9 it can e inter"rete# inter"rete# that Mrs. is: &. &t a $ery $ery early early stag stagee of #ilat #ilatati ation on '. &""roach &""roaching ing half half of the total total amount amount of #ilatation #ilatation C. Neari Nearing ng total total #ilata #ilatatio tion n (. In laor ut an inter"retation inter"retation of #ilatation #ilatation cannot e ma#e with with a$ailale a$ailale information information ><. Shortly after #eli$ery9 #eli$ery9 Mrs. com"lains of chilliness an# says she is hungry. hungry. This coul# e #ue which of the following reasons: &. 0atient 0atient is reacti reacting ng unfa$oral unfa$oraly y to an analgesic analgesic use# use# #uring laor laor '. 0atients 0atients hormona hormonall system system is in a "erio# of a#Eust a#Eustment ment after after #eli$ery #eli$ery C. 0atient 0atient has e!"eri e!"erience ence# # a ra"i# cooling cooling of her o#y o#y imme#iate imme#iately ly after after #eli$ery #eli$ery (. 0atients 0atients tem"erature tem"erature control control center is tem"orarily tem"orarily $ery sensiti$e sensiti$e to en$ironmental coolness after #eli$ery >>. Mrs. . has a tem"erature tem"erature of =.< centigra#e on her first "ost"artum "ost"artum #ay. #ay. The most likely likely reason for this ele$ate# ele$ate# tem"erature is that Mrs. is: &. /!"eri /!"erienc encing ing #ehy# #ehy#rat ration ion '. /!"eri /!"erienc encing ing suin$ suin$olu oluti tion on C. (e$el (e$elo"i o"ing ng a rea reast st infe infecti ction on (. (e$el (e$elo"i o"ing ng a urina urinary ry infe infecti ction on %??. The nurse uses measures to hel" Mrs. Mrs. to $oi# after #eli$ery. #eli$ery. If Mrs. is allowe# allowe# to ha$e an o$er8#isten#e# o$er8#isten#e# la##er9 she is at risk for #e$elo"ing: &. & hemat ematom omaa '. Thro Throm mo" o"hl hle eit itis is C. 'la# 'la##e #err her herni niat atio ion n (. 'la# 'la##e #err inf infec ecti tion on
