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Here are the answers for the exam. Unfortunately, rationales are not given.

If you need clarifications or disputes, please direct them to the comments section and we’ll be glad to give you an explanation. D. 31 A. 1,2,4 D. BBT is lowest during the secretory phase B. Progesterone B. Trophoblastic cells of the embryo A. Fetal development are felt by Mariah D. Umbilicus A. “The size of your breast will not affect your lactation.” D. Knowledge deficit regarding nutritional requirements pregnancies related to lack of information sources. A. Incorporate her food preferences that are adequately nutritious in her meal plan. C. Thelarche B. The vas deferens D. Herniation of the bladder into the vaginal wall. C. Day 15 D. It is due to learning patterns of the female client where she views sex as bad or sinful. B. She should assess whether her cervical mucus is thin colour, clear and watery. D. Migraine headache C. Five years B. She should insert the condom before any penile penetration A. She has patent fallopian tubes, so fertilized ova can be implanted on them. C. Sperm can no longer reach the ova, because the fallopian tubes are blocked C. a couple has been trying to conceive for 1 year A. endometrial implants can block the fallopian tubes D. She may feel some cramping when the dye is inserted A. Donor sperm are introduced vaginally into the uterus or cervix A. Experienced reduce sensory perception A. Are more sensitive drugs C. Decreased bladder capacity D. Change in the mental status D. Airway, breathing, Circulation D. Only their own C. Both parties involved are committed in solving the conflict A. The presence of a family crisis B. Difficulty swallowing, diminished or absent gag reflex and respiratory distress D. Call the poison control center C. “The pill should cause a normal menstrual period every month. It sounds like your friend has not been taking the pills properly.” B. Failure to pass meconium during the first 24 hours after birth B. Avoid intercourse for three days B. Assess for Prolapse of the umbilical cord A. Avoid covering the area of the topical medication with the diaper C. Effective communication D. increased bleeding can occur from uterine pressure on leg veins

A. Teach care daily and let the caregivers do a return demonstration just before discharge D. Pediatric nurse practitioner C. Subject Matter B. A urine dipstick measurement of 2+ proteinuria or more for 3 days or the child found to have 3-4+ proteinuria plus edema. D. Identity D. Competence D. Left occipito-Posterior Position A. Focus, Organize, Clarify, Understand and Solution B. Some dehydration B. Some dehydration D. Severe Persistent diarrhea C. Give Vitamin A supplement D. All of the above C. Explaining to the individuals, families, groups and community the nature of the disease and its causation. C. Cough of 30 days C. Observing closely the patient for vital signs leading to shock B. Appearance of at least 20 petechiae within 1 cm square B. Replacement of body fluids A. Identify the myths and misconceptions prevailing in the community A. 80 % D. 90 % C. Give DT instead of DPT C. OPV, Hep. B, DPT A. Elimination of conditions causing cancer A. Conduct community assemblies A. Those under early case detection B. Those under supportive care D. Nursing process C. Severe pneumonia A. 40 breaths per minute or more A. Some dehydration D. Do not give any other foods to the child for home treatment C. Pneumonia B. very severe febrile disease C. they do not have as many fat stored as other infants A. headache and vomiting C. give aspirin A. ask what are the child’s problem B. skin Petechiae A. give drugs every 4 hours C respect for person C. beneficence and nonmaleficence C. “Miss, it is better to use a pick up forceps/ bread tong” A. It may affect Pap smear results D. Message, sender, channel, Receiver and Feedback B. Percentages of total body surface area (TBSA) C. A victim of child neglect C. Three types: Prerenal, intrarenal, postrenal C. Sexual contact C. Retrovirus B. Universal precaution B. Prevent infection B. Use gloves when handling specimen B. Bronchial pneumonia

D. Salt C. Inflammation of the nasopharynx B. Droplet D. Comfort measures 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 pregnancy-induced 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 ironrich 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, and 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 Rationale: Efficiency is determining whether the goals were attained at the least possible cost. 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. 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.

prevention of permanent disability and disability limitation appropriate for convalescents. Answer: (A) Intrauterine fetal death. to any client. Answer: (A) Loud. 44. Rationale: Rubella vaccine is made up of attenuated German measles viruses. Answer: (D) “I really need to use the diaphragm and jelly most during the middle of my menstrual cycle”. hormonal variations do occur and can result in early or late ovulation. Rationale: This procedure is generally recommended to follow in guiding a person who is blind. and learning disabilities. Answer: (B) Decreased urine output Rationale: Decreased urine output may occur in clients receiving I. Answer: (D) To maximize the community’s resources in dealing with health problems. 35. 48. 45. 41. therefore. Answer: (C) More oxygen. and the newborn’s metabolic rate increases. but the flow will be slow enough not to overload the stomach too rapidly. the nurse must first check that the client’s kidneys are functioning and that the client is voiding. Answer: (C) Restlessness Rationale: In a child. 38. although the “fertile” period is approximately mid-cycle. 40. 42. This is contraindicated in pregnancy. if clotting factors are depleted. may be given to pregnant women. therefore. blood loss can occur quite rapidly in the event of uncontrolled bleeding. 46. the first bowel movement of the day will yield the best results. Rationale: The infant with the airway emergency should be treated first. magnesium and should be monitored closely to keep urine output at greater than 30 ml/hour. septic shock. Answer: (A) 6 inches Rationale: This distance allows for easy flow of the formula by gravity. Answer: (A) Placenta previa Rationale: Placenta previa with painless vaginal bleeding. abruptio placentae. restlessness is the earliest sign of hypoxia. dysfunctional labor. the diaphragm should be inserted before every intercourse. such as pallor or cyanosis. A. 47. If the client is not voiding. Answer: (A) Contact tracing Rationale: Contact tracing is the most practical and reliable method of finding possible sources of person-to-person transmitted infections. Rationale: Decreasing the amount of time the skin comes contact with wet soiled diapers will help heal the irritation. are higher in incidence in adults. and premature rupture of the membranes aren’t associated with DIC. with the goal of developing the people’s self-reliance in dealing with community health problems. 39. hyperactivity. Rationale: Chickenpox is usually more severe in adults than in children. the specimen should be collected early in the morning. Non-shievering thermogenesis is a complex process that increases the metabolic rate and rate of oxygen consumption. Answer: (D) Consult a physician who may give them rubella immunoglobulin. Answer: (A) Irritability and seizures Rationale: Lead poisoning primarily affects the CNS. 26. 29. because the female worm lays eggs at night around the perineal area. 25. Placenta accreta. 43. 36. Answer: (D) Terminal Rationale: Tertiary prevention involves rehabilitation. as well as seizure disorders. a specific prophylactic against German measles. the disabled. the more susceptible he becomes to the complications of chickenpox. such as sexually transmitted diseases. Rationale: Community organizing is a developmental service. machinery-like murmur. machinery-like murmur is a characteristic finding associated with patent ductus arteriosus. Late signs of hypoxia in a child are associated with a change in color. This condition results in irritability and changes in level of consciousness. 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. The rationale for this timing is that. Answer: (B) Walk one step ahead. 31. the nurse should withhold the potassium and notify the physician. such as pneumonia. Complications. Answer: (D) A 2 year old infant with stridorous breath sounds. or polysplenia. 27. Answer: (D) Voided Rationale: Before administering potassium I. Rationale: The woman must understand that. Immune globulin. Answer: (A) Menorrhagia Rationale: Menorrhagia is an excessive menstrual period. causing increased intracranial pressure. 34. B and C are objectives of contributory objectives to this goal. because of the risk of epiglottitis. and amniotic fluid embolism may trigger normal clotting mechanisms. Answer: (D) Endocardial cushion defect Rationale: Endocardial cushion defects are seen most in children with Down syndrome. complicated cases and the terminally ill (those in the terminal stage of a disease). 33.V. The specific type of stool specimen used in the diagnosis of pinworms is called the tape test. DIC may occur. 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. sitting up in his mother’s arms and drooling. Answer: (D) Leptospirosis . The topical allergen that is the most common causative factor is laundry detergent. Answer: (D) Early in the morning Rationale: Based on the nurse’s knowledge of microbiology. 37. To be effective. 49. Answer: (c) Laundry detergent Rationale: Eczema or dermatitis is an allergic skin reaction caused by an offending allergen. the infant requires more oxygen and there is an increase in metabolic rate. asplenia. Rationale: A loud. Answer: (A) The older one gets.V. Answer: (A) Change the diaper more often. with the child’s hand on the nurse’s elbow. Rationale: When cold. because magnesium is excreted through the kidneys and can easily accumulate to toxic levels. 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. the newborn increase heat production. Rationale: Intrauterine fetal death. 30. Approximately 40% of a woman’s cardiac output is delivered to the uterus.24. 32.

5 doses will give the mother lifetime protection. Answer: (B) 6 months Rationale: After 6 months. Answer: (A) 45 infants Rationale: To estimate the number of infants. Answer: (C) Decreased temperature Rationale: Temperature instability. therefore. Answer: (B) Sudden infant death syndrome (SIDS) Rationale: Supine positioning is recommended to reduce the risk of SIDS in infancy. The neonates are also at . 65. OPV and measles vaccine are highly sensitive to heat and require freezing. Answer: (D) 5 skin lesions. Answer: (C) 24 weeks Rationale: At approximately 23 to 24 weeks’ gestation. 50. where she was brought and whether she stayed overnight in that area. Otherwise. 63. Answer: (D) Let the child rest for 10 minutes then continue giving Oresol more slowly. Both amoebic and bacillary dysentery are characterized by the presence of blood and/or mucus in the stools. Rationale: Because malaria is endemic. 60. Answer: (C) Thickened painful nerves Rationale: The lesion of leprosy is not macular. the lungs are developed enough to sometimes maintain extrauterine life. especially when it results in a low temperature in the neonate. multiply total population by 3%. the baby’s nutrient needs. 59. Oresol or nasogastric tube. Streptococcus pneumoniae and Neisseria meningitidis may cause meningitis. If the area of residence is not a known endemic area. 55. Answer: (A) DPT Rationale: DPT is sensitive to freezing. The neonate with an infection will usually show a decrease in activity level or lethargy. 71. sweating and hair growth over the lesion. Giardiasis is characterized by fat malabsorption and. he vomits everything that he takes in. can no longer be provided by mother’s milk alone. referral to a facility where IV fluids can be initiated within 30 minutes. vomiting is managed by letting the child rest for 10 minutes and then continuing with Oresol administration. than urgent referral to the hospital is done. Answer: (B) Severe dehydration Rationale: The order of priority in the management of severe dehydration is as follows: intravenous fluid therapy. Answer: (A) Haemophilus influenzae Rationale: Hemophilus meningitis is unusual over the age of 5 years. Morbillivirus is the etiology of measles. 64. It is characterized by a change in skin color (either reddish or whitish) and loss of sensation. 69. In developing countries. Teach the mother to give Oresol more slowly. positive slit skin smear Rationale: A multibacillary leprosy case is one who has a positive slit skin smear and at least 5 skin lesions. 58. a respiratory rate of 50/minute or more is fast breathing for an infant aged 2 to 12 months. vomits everything. The appropriate storage temperature of DPT is 2 to 8° C only. When the foregoing measures are not possible or effective. sunken eyes. Rationale: “Baggy pants” is a sign of severe marasmus. he has to be referred urgently to a hospital. 72. 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. 66. 52. Answer: (C) Proper use of sanitary toilets Rationale: The ova of the parasite get out of the human body together with feces. like rats. Answer: (B) 4 hours Rationale: While the unused portion of other biologicals in EPI may be given until the end of the day. steatorrhea. Answer: (A) Refer the child urgently to a hospital for confinement. Inability to close the eyelids (lagophthalmos) and sinking of the nosebridge are late symptoms. The mother will have active artificial immunity lasting for about 10 years. Answer: (A) 10 years Rationale: The baby will have passive natural immunity by placental transfer of antibodies. 57. Rationale: If the child vomits persistently. 56. the skin goes back slow after a skin pinch. 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. Answer: (B) Ask where the family resides. 68. Answer: (B) Some dehydration Rationale: Using the assessment guidelines of IMCI. 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. 62. This is why BCG immunization is scheduled only in the morning. The best management is urgent referral to a hospital. only BCG is discarded 4 hours after reconstitution. The lungs are the most immature system during the gestation period. convulsions. The neonate’s color often changes with an infection process but generally becomes ashen or mottled. 54. the first question to determine malaria risk is where the client’s family resides. Answer: (B) Cholera Rationale: Passage of profuse watery stools is the major symptom of cholera. Answer: (B) Buccal mucosa Rationale: Koplik’s spot may be seen on the mucosa of the mouth or the throat. 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. that is. 51. 67. 53. Answer: (C) Normal Rationale: In IMCI. Cutting the cycle at this stage is the most effective way of preventing the spread of the disease to susceptible hosts. the peak incidence is in children less than 6 months of age. Answer: (A) 3 seconds Rationale: Adequate blood supply to the area allows the return of the color of the nailbed within 3 seconds. may be a sign of infection. abnormally sleepy or difficult to awaken. 61. The risk of aspiration is slightly increased with the supine position. MMR is not an immunization in the Expanded Program on Immunization. especially the baby’s iron requirement. ask if the child had traveled within the past 6 months. but age distribution is not specific in young children. Medical care for premature labor begins much earlier (aggressively at 21 weeks’ gestation) 70.Rationale: Leptospirosis is transmitted through contact with the skin or mucous membrane with water or moist soil contaminated with urine of infected animals.

not jittery. the infant should be kept warm so that his respiratory distress isn’t aggravated. sitz baths. Cleavage in conjoined twins occurs more than 13 days after fertilization. 89. 78. Because cooling increases the risk of acidosis. the nurse should notify the physician. and bradycardia. and the epidermis may become desquamated. 73. The neonate would be floppy. 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. Answer: (A) Increased tidal volume . Later. Cleavage that occurs between days 8 to 13 result in monoamniotic monochorionic twins. Answer: (C) Desquamation of the epidermis Rationale: Postdate fetuses lose the vernix caseosa. After the airway is clear and the neonate’s color improves. Nasal flaring. checking vaginal discharge with nitrazine paper. which may result from blood loss or placenta separation. 84. Answer: (B) Conjunctival hemorrhage Rationale: Conjunctival hemorrhages are commonly seen in neonates secondary to the cranial pressure applied during the birth process. Answer: (D) Aspirate the neonate’s nose and mouth with a bulb syringe. Amniocentesis is contraindicated in placenta previa. Infants aren’t given tub bath but are sponged off until the cord falls off. 85. Peroxide could be painful and isn’t recommended.increased risk for developing hypoglycemia and hypothermia due to decreased glycogen stores. Gravidity and parity affect the duration of labor and the potential for labor complications. particularly her due date. Answer: (A) 110 to 130 calories per kg. Petroleum jelly prevents the cord from drying and encourages infection. and indicating a desire to see the newborn are behaviors indicating parental bonding. Simian creases are present in 40% of the neonates with trisomy 21. Answer: (D) The parents’ interactions with each other. 86. 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. 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. 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. and support persons. 77. These neonates are usually very alert. Administering oxygen when the airway isn’t clear would be ineffective. 79. Answer: (C) Respiratory depression Rationale: Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory depression. although it will detect fetal distress. 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. Cleavage that occurs less than 3 day after fertilization results in diamniotic dichorionic twins. Bulging fontanelles are a sign of intracranial pressure. Artificial rupture of membranes doesn’t indicate an imminent delivery. The serum blood sugar isn’t affected by magnesium sulfate. the nurse should ask about chronic illnesses. Lanugo is missing in the postdate neonate. Answer: (B) To assess for prolapsed cord Rationale: After a client has an amniotomy. 88. 76. and audible grunting are signs of respiratory distress. the nurse should comfort and calm the neonate. so there’s some growth retardation in twins if they remain in utero at 38 to 40 weeks. Answer: (C) 30 to 32 weeks Rationale: Individual twins usually grow at the same rate as singletons until 30 to 32 weeks’ gestation. 82. 81. hypotonia. Willingness to touch and hold the newborn. This level will maintain a consistent blood glucose level and provide enough calories for continued growth and development. Rationale: Calories per kg is the accepted way of determined appropriate nutritional intake for a newborn. the nurse’s highest priority is to determine h er current status. Fetal well-being is assessed via a nonstress test. gravidity. Covering the infant’s eyes and humidifying the oxygen don’t reduce the risk of retinopathy of prematurity. 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. 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. Cystic hygroma is a neck mass that can affect the airway. 75. 83. Cold applications. expressing interest about the newborn’s size. Answer: (B) Instructing the client to use two or more peri pads to cushion the area Rationale: Using two or more peripads would do little to reduce the pain or promote perineal healing. The recommended calorie requirement is 110 to 130 calories per kg of newborn body weight. 87. Answer: (D) Ultrasound Rationale: Once the mother and the fetus are stabilized. and Kegel exercises are important measures when the client has a fourth-degree laceration. allergies. 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. ultrasound evaluation of the placenta should be done to determine the cause of the bleeding. Answer: (C) Monitor partial pressure of oxygen (Pao2) levels. If the problem recurs or the neonate’s color doesn’t improve readily. Answer: (C) “What is your expected due date?” Rationale: When obtaining the history of a client who may be in labor. Fetal position is determined by vaginal examination. 74. Rationale: The nurse’s first action should be to clear the neonate’s airway with a bulb syringe. and parity. Observing for pooling of straw-colored fluid. A digital or speculum examination shouldn’t be done as this may lead to severe bleeding or hemorrhage. Cleavage that occurs between days 3 and 8 results in diamniotic monochorionic twins. External fetal monitoring won’t detect a placenta previa. and observing for flakes of vernix are appropriate assessments for determining whether a client has ruptured membranes. Answer: (C) Conducting a bedside ultrasound for an amniotic fluid index. 80. respiratory rate more than 60 breaths/minute.

In subsequent pregnancies with Rh-positive fetuses. Antihypertensive drugs usually aren’t necessary. Elimination of conditions causing cancer A. The area must be a raised wheal. Answer: (D) Seizure Rationale: The anticonvulsant mechanism of magnesium is believes to depress seizure foci in the brain and peripheral neuromuscular blockade. enhances comfort. The client usually needs a stronger analgesic than acetaminophen to control the pain of a crisis. poor sucking. 92. UTI symptoms include dysuria. Avoid intercourse for three days. The squatting position promotes comfort by taking advantage of gravity. Conduct community assemblies. D. confusion. and restlessness. Hypomagnesemia isn’t a complication of preeclampsia. Rationale: Neonates of heroin-addicted mothers are physically dependent on the drug and experience withdrawal when the drug is no longer supplied. Rationale: Rh isoimmunization occurs when Rh-positive fetal blood cells cross into the maternal circulation and stimulate maternal antibody production. which may lead to postpartum hemorrhage. extended labor stimulation with oxytocin. The increased oxygen consumption in the pregnant client is 15% to 20% greater than in the nonpregnant state. and traumatic delivery commonly are associated with uterine atony. Hydralazine is given for sustained elevated blood pressure in preeclamptic clients. A urine dipstick measurement of 2+ proteinuria or more for 3 days. Uterine involution and some uterine discomfort are normal after delivery. .V. decreased bladder capacity D. Here are the answers for the exam. leading to maternal hypotension and. Oral hypoglycemic drugs are contraindicated in pregnancy. rationales are not given. which increases the tidal volume of gas moved in and out of the respiratory tract with each breath. Cramping may be felt when the dye is inserted A. For instance. This is known as subinvolution. A flattened nose. urgency. Restlessness. 99. 100. Answer: (B) Rh-positive fetal blood crosses into maternal blood. inhibits maternal circulation. 90. Left Occipito-Posterior Position A. the lateral. Rationale: A positive PPD result would be an indurated wheal over 10 mm in diameter that appears in 48 to 72 hours. 96. Bacterial vaginosis causes milky white vaginal discharge but no systemic symptoms. The other positions promote comfort and aid labor progress. Answer: (B) An indurated wheal over 10 mm in diameter appears in 48 to 72 hours. fetal hypoxia. experienced reduce sensory perception A.V. 91. Donor sperm are introduced vaginally into the uterus or cervix A. Assess for Prolapse of the umbilical cord A. airway. The inspiratory capacity increases during pregnancy. Fluids. The standing position also takes advantage of gravity and aligns the fetus with the pelvic angle. Diuretic wouldn’t be used unless fluid overload resulted. Long-acting insulin usually isn’t needed for blood glucose control in the client with gestational diabetes. A significant involutional complication is the failure of the uterus to return to the pelvic cavity within the prescribed time period. The expiratory volume and residual volume decrease as the pregnancy progresses. Answer: (A) 7th to 9th day postpartum Rationale: The normal involutional process returns the uterus to the pelvic cavity in 7 to 9 days. This. Unfortunately. in turn. small eyes. Antihypertensive drug other than magnesium are preferred for sustained hypertension. 95. because the fallopian tubes are blocked C. 94. Naloxone is used to correct narcotic toxicity. Answer: (B) Uterine atony Rationale: Multiple fetuses. Asymptomatic bacteriuria doesn’t cause symptoms. and suprapubic tenderness. B. irritability D. breathing. position improves maternal and fetal circulation.Rationale: A pregnant client breathes deeper. are more sensitive to drugs C. Signs of heroin withdrawal include irritability. avoid covering the area of the topical medication with the diaper C. Magnesium doesn’t help prevent hemorrhage in preeclamptic clients. 93. ultimately. Lethargy isn’t associated with neonatal heroin addiction. or the child found to have 3-4+ proteinuria plus edema. Answer: (C) Supine position Rationale: The supine position causes compression of the client’s aorta and inferior vena cava by the fetus. reduces muscle tension. Answer: (B) Irritability and poor sucking. Answer: (A) Diet Rationale: Clients with gestational diabetes are usually managed by diet alone to control their glucose intolerance. A couple has been trying to conceive for 1 year A. Effortless and non-projectile vomiting B. Endometrial implants can block the fallopian tubes D. please direct them to the comments section and we’ll be glad to give you an explanation. Sperm can no longer reach the ova. maternal antibodies may cross back into the fetal circulation and destroy the fetal blood cells. 98. Answer: (A) Calcium gluconate (Kalcinate) Rationale: Calcium gluconate is the antidote for magnesium toxicity. Rho (D) immune globulin is given to women with Rh-negative blood to prevent antibody formation from RH-positive conceptions. Ten milliliters of 10% calcium gluconate is given L. and thin lips are seen in infants with fetal alcohol syndrome. and L. fluids Rationale: A sickle cell crisis during pregnancy is usually managed by exchange transfusion oxygen. a serious condition in a pregnant client. or side-lying. 97. stimulating maternal antibodies. and eliminates pressure points. Answer: (C) Pyelonephritis Rational: The symptoms indicate acute pyelonephritis. increased bleeding can occur from uterine pressure on leg veins B.V. increases maternal relaxation. push over 3 to 5 minutes. If you need clarifications or disputes. 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. Answer: (C) I. Effective communication D. circulation D. not a flat circumcised area to be considered positive. frequency. C. Heroin use during pregnancy hasn’t been linked to specific congenital anomalies.

Provision of careful assessment C. 2. Droplet D. D 13. Sexual contact C. Fallopian tubes D. and kicking. Alma Ata C. Those under supportive care C. A 14. C 17. Chronic ear infection B. Message. channel. D 7. check for malnutrition C. “Miss. Universal precaution B. D. A contraction over 70 seconds in length. B 6. B 15. The lesions appear as cauliflower like lesions. it is better to use a pick up forceps/ bread tong” A. receiver and feedback C. The examiner feels rebound movement of the fetus. Measles with eye or mouth complications A. B. “Show” or release of the cervical mucus plug. Acute ear infection C. Trichloroacetic acid D. Metabolic Alkalosis C. sudden episode of hypotension. It may affect Pap smear results. A 10. Prevent infection B. and muscle aches B. A 26.” B. C 5. Teach mothers how to recognize early signs and symptoms of pneumonia B. sender. Is there any fever? A. If you need clarifications or disputes. A 2. Condom use D. Rectal B. tachycardia. B9 B. Inflammation of the nasopharynx B. D 21. please direct them to the comments section and we’ll be glad to give you an explanation. Moniliasis B. C 25. B 3. A and c only D. Give Vit. Unfortunately. sleeping. Currant jelly stool C. A victim of child neglect C. apply Gentian violet for mouth ulcers and follow up in 2 days D. B 20. Human Papillomavirus D. Follicle stimulating hormone (FSH) D. C 22. Right occipitoanterior with full flexion. 100. Bronchial pneumonia D. Vit. Fungus A. Salt C.A. A 24. There is gastric peristaltic waves from left to right across the abdomen A. B. C 8. B. A. Clotrimazole (topical) D. D 12. Spirochete A. On the left side A. Refer urgently A. “I will stimulate sucking by rubbing the nipple on the lower lip. Assess the patient using the chart on management of children with cough D. B. A. sucking. E. Severe projectile vomiting A. 10 weeks A. The fetus follows a regular schedule of turning. Male B. Averaging of 266 to 294 days C. Difficulty to awaken D. A and b only E. rationales are not given. Those under early case detection B. Comfort measures D. A 4. When the spermatozoon passes into the ovum and the nuclei fuse into a single cell. Intussusception C. Preventing health problems and promoting optimum health D. Assess the client’s current nutritional status by taking a diet history. VDRL C.5 D. miconazole B. fever. Support the frontline workers and the local health system E. A. Use gloves when handling specimen B. Go to the next question. Visualization of the fetus by ultrasound examination. Vaginal secretions are examined on a wet slide that has been treated with potassium hydroxide. B . D 18. Projectile vomiting with no bile content A. A. D 9. B 11. A 19. D. State of complete physical. Mayor B. Tertiary level of prevention C. C. Health for all Filipinos D. mental and social well being not merely the absence of disease C.000 IU E. C 23. Treponema Pallidum A. Ask checking questions B. Thirty seconds after the start of a contraction. A 16. Here are the answers for the exam. None of the above A. 1. retrovirus B. Sitz baths and lidocaine cream A. Candida Albicans C. Mortality reduction through early detection D.

A 73. What’s important to remember is that the color of lochia gets to be lighter (from reddish to whitish) and scantier everyday. D 42. B 76. D 48. A 66. B 63. C 83. B 44. C 65. A 92.C 61. an Rh(-) mother will produce antibodies against the fetal Rh (+) antigen which she may have gotten because of the mixing of maternal and fetal blood during labor and delivery. 4. which is essential to maintain adequate lactation. the nurse should stimulate the woman to void. A 28. Answer: (A) 1. C 37. B 96. C 1. B 98. A 85. A 67. 8. Since it is not pure blood it is non-clotting. D 80. Answer: (B) Prevent the mother from producing antibodies against the Rh(+) antigen that she may have gotten when she delivered to her Rh(+) baby In Rh incompatibility. C 53. A 55. Answer: (C) 6-8 hrs A woman who has had normal delivery is expected to void within 6-8 hrs. D 87. Answer: (C) Exercise adequately like aerobics All the above nursing measures are needed to ensure that the mother is in a healthy state. B 94. 2. If nursing interventions to stimulate spontaneous voiding don’t work. B 47. D 35. C 68. C 89.27. 3. B 32. If the purpose is to relieve pain as well as suppress lactation. 10. the nurse may decide to catheterize the woman. C 81. D 57. A 88. B 58. D 56. B 72. 9. If she is unable to do so after 8 hours. D 69. D 97. C 29. B 82. A 36. B 30.0 cm The uterus will begin involution right after delivery. D 75. A 62. lochia disappears after 10 days postpartum. A 59. A 54. D 79. C 100. B 33. B 40. D 45. the nursing intervention is bedrest to prevent the possible dislodging of the thrombus and keeping the affected leg elevated to help reduce the inflammation. Answer: (B) Apply warm compress on the engorged breast Warm compress is applied if the purpose is to relieve pain but ensure lactation to continue. Giving her RhoGam right after birth will prevent her immune system from being permanently sensitized to Rh antigen. per day and becomes no longer palpable about 1 week after delivery. C 38. C 71. C 51. D 77. this means there will be regular emptying of the breasts. Answer: (D) Elevate the affected leg and keep the patient on bedrest If the mother already has thrombophlebitis. C 95. B 46. D 34. endometrial tissue and mucus. C 49. Answer: (C) Reddish with some mucus Right after delivery. D 31. the vaginal discharge called lochia will be reddish because there is some blood. D 74. Answer: (A) Breast feed the baby on self-demand day and night Feeding on self-demand means the mother feeds the baby according to baby’s need. A 84. C 86. A 50. 5. Therefore. It is expected to regress/go down by 1 cm. A 39. D 64. C 41. A 90. C 70. D 78. aerobics does not necessarily enhance lactation. Answer: (A) Excessive analgesia was given to the mother . A 91. D 93. the compress applied is cold. Answer: (B) 7-10 days Normally. D 43. 7. However. C 52. 6. B 60. D 99.

21. 18. Answer: (B) BP diastolic increase from 80 to 95mm Hg All the vital signs given in the choices are within normal range except an increase of 15mm Hg in the diastolic which is a possible sign of hypertension in pregnancy. Answer: (B) Acrocyanosis Acrocyanosis is the term used to describe the baby’s skin color at birth when the soles and palms are bluish but the trunk is pinkish. 2. Answer: (A) All of the above All the symptoms 1-3 are characteristic of postpartal blues. an ophthalmic ointment is used.5 Kg. the fetus while in utero has a high supply of glucose. Usually. 13. If massaging is vigorous and prolonged. most of the fetal blood is mixed blood. warm compress is applied on the breast.500gms According to the WHO standard. Cold application will cause vasoconstriction thus reducing the blood supply consequently the production of milk. and 3 To be allowed to handle deliveries.Answer: (A) 1-3 An APGAR of 1-3 is a sign of fetal distress which requires resuscitation. The fetal lungs is fluid-filled while in utero and is still not functioning. the mother is more passive and dependent on others for care. this could be a sign of abnormality like postpartum depression and needs treatment. 23. 12. Answer: (B) Crede’s method Crede’s method/prophylaxis is the procedure done to prevent ophthalmia neonatorum which the baby can acquire as it passes through the birth canal of the mother. Answer: (C) 2. dry. 15. Answer: (A) Shallow and irregular with short periods of apnea lasting not longer than 15 seconds. 29. 17. 28. Answer: (A) 3-4 cm antero-posterior diameter and 2-3 cm transverse diameter. The apneic periods should be brief lasting not more than 15 seconds otherwise it will be considered abnormal. the fundus of the uterus is expected to be at the level of the umbilicus because the contents of the pregnancy have already been expelled. The fundus is expected to recede by 1 fingerbreadths (1cm) everyday until it becomes no longer palpable above the symphysis pubis.Answer: (D) Middle third of the thigh Neonates do not have well developed muscles of the arm. cracked skin. Answer: (A) Laceration of soft tissues of the cervix and vagina When uterus is firm and contracted it means that the bleeding is not in the uterus but other parts of the passageway such as the cervix or the vagina. the mother begins to assume a more active role in the care of the child and in letting-go. 24. And in RA9172. In the taking-in stage. 26. the neonate usually does not feed yet thus this can lead to hypoglycemia.Excessive analgesia can lead to uterine relaxation thus lead to hemorrhage postpartally. the hormones estrogen and progesterone gradually decrease thus triggering negative feedback to the anterior pituitary to release the FolicleStimulating Hormone (FSH) which in turn stimulates the ovary to again mature a graafian follicle and the menstrual cycle post pregnancy resumes. When the baby is born and is now separate from the mother. in this law. 20. It only begins to function in extra uterine life. In the first few hours after delivery. taking-hold and letting-go Rubin’s theory states that the 3 stages that a mother goes through for maternal adaptation are: taking-in. Also. 11. episiotomy wound or not. This is due to the fact that after delivery. diamond shape The anterior fontanelle is diamond shape with the anteroposterior diameter being longer than the transverse diameter. Answer: (D) Application of cold compress on the breast To stimulate lactation. there is no longer an . It will resolve by itself because it is transient and is due to a number of reasons like changes in hormonal levels and adjustment to motherhood. the mother has become adapted to her maternal role. The posterior fontanelle is triangular shape. Answer: (B) Taking-in. Both B and D are normal and C is at the vaginal introitus thus will not affect the uterus. the pregnancy must be normal and uncomplicated. Answer: (D) Perineal care Perineal care is primarily done for personal hygiene regardless of whether there is pain or not. 25. 14. 31. it no longer receives a high dose of glucose from the mother. Answer: (B) Level of umbilicus Immediately after the delivery of the placenta. Answer: (D) Almost leather-like. The respiration of the baby at this time is characterized as usually shallow and irregular with short periods of apnea. Except for the blood as it enters the fetus immediately from the placenta.500 gms or 2. 19. Answer: (A) The fetal lungs are non-functioning as an organ and most of the blood in the fetal circulation is mixed blood. 22. the site must have sufficient muscles like the middle third of the thigh. Answer: (B) 1. 3060 breaths per minute. Answer: (B) 6-8 weeks When the mother does not breastfeed. 27. 30. The baby is alright if the score is 8-10. negligible vernix caseosa A post mature fetus has the appearance of an old person with dry wrinkled skin and the vernix caseosa has already diminished. 30-60 breaths per minute A newly born baby still is adjusting to xtra uterine life and the lungs are just beginning to function as a respiratory organ. the normal menstruation resumes about 6-8 weeks after delivery. Answer: (B) There is rapid diminution of glucose level in the baby’s circulating blood and his pancreas is normally secreting insulin If the mother is diabetic. the minimum normal birth weight of a full term baby is 2. Answer: (C) 6 weeks According to the DOH protocol postpartum check-up is done 6-8 weeks after delivery to make sure complete involution of the reproductive organs has be achieved. If symptoms lasts more than 2 weeks. Answer: (C) Massage the fundus vigorously for 15 minutes until contracted Massaging the fundus of the uterus should not be vigorous and should only be done until the uterus feel firm and contracted. Since Vitamin K is given intramuscular. 16. the uterus will relax due to over stimulation. the nurse is now allowed to suture perineal lacerations provided s/he has had the special training. taking-hold and letting-go. In taking-hold.

the woman can easily monitor her cycles. 45. When progesterone is secreted by the ovary. Answer: (D) Sperms will be barred from entering the fallopian tubes An intrauterine device is a foreign body so that if it is inserted into the uterine cavity the initial reaction is to produce inflammatory process and the uterus will contract in order to try to expel the foreign body. 47. When a new pack is started.2-0.4 degrees centigrade The release of the hormone progesterone in the body following ovulation causes a slight elevation of basal body temperature of about 0. she is considered to be in her menopausal stage. 2. 48. 40.2-0.4 All of the above are essential for enhanced fertility except no. 32. 36. But the IUD does not completely fill up the uterine cavity thus sperms which are microscopic is size can still pass through. 34. 37. Answer: (B) Any day of the month as long it is regularly observed on the same day every month Menopausal women still need to do self examination of the breast regularly. 42. This is called spinnabarkeit. Answer: (B) 1. the cervical mucus becomes thin and watery to allow the sperm to easily penetrate and get to the fallopian tubes to fertilize an ovum. cervical consistency The 3 parameters measured/monitored which will indicate that the woman has ovulated are. Answer: (C) Right after the menstrual period so that the breast is not being affected by the increase in hormones particularly estrogen The best time to do self breast examination is right after the menstrual period is over so that the hormonal level is low thus the breasts are not tender. There is evidence to support the observation that the benefits of lactation amenorrhea lasts for 6 months provided the woman has not had her first menstruation since delivery of the baby. softness of the cervix and cervical mucus that looks like the white of an egg which makes the woman feel “wet”. Normal ovulation in a woman occurs between the 14th to the 16th day before the NEXT menstruation. she can already discontinue using the second temporary method she employed. Answer: (B) 26-32 days Standard Days Method (SDM) requires that the menstrual cycles are regular between 26-32 days.temperature increase of about 0. spinnabarkeit and thin watery cervical mucus are signs of ovulation. the hormone progesterone is released which can cause a slight elevation of temperature between 0. 43. It is not a barrier since the sperms can readily pass through and fertilize an ovum at the fallopian tube. This natural method of family planning is very simple since all that the woman pays attention to is her cycle. Answer: (B) Progesterone only If mother is breastfeeding. 35. 46. With the aid of CycleBeads. The hormones estrogen and progesterone are already diminished during menopause so there is no need to consider the time to do it in relation to the menstrual cycle. Answer: (B) It may occur between 14-16 days before next menstruation Not all menstrual cycles are ovulatory. taking a double dose does not give additional protection. 39.2-0. This is a misconception because ovulation is determined NOT from the first day of the cycle but rather 14-16 days BEFORE the next menstruation. 49. There is no need to monitor temperature or mucus secretion. Answer: (C) 1. 41. Answer: (D) Intrauterine device (IUD) Intrauterine device prevents pregnancy by not allowing the fertilized ovum from implanting on the endometrium.4 degrees centigrade 33. thus fertilization is not possible. 3 because during the dry period the woman is in her infertile period thus even when sexual contact is done. The normal sperm count is 20 million per milliliter of seminal fluid or 50 million per ejaculate. A common misconception is that ovulation occurs on the 14th day of the cycle. When ovulation occurs. there will be no ovulation. & 3 Mittelschmerz. Answer: (B) If the woman fails to take a pill in one day.Answer: (B) Rubin’s test Rubin’s test is a test to determine patency of fallopian tubes. Huhner’s test is also known as post-coital test to determine compatibility of the cervical mucus with sperms of the sexual partner.4 degrees centigrade and not 4 degrees centigrade. Answer: (D) Vas deferens Vasectomy is a procedure wherein the vas deferens of the male is ligated and cut to prevent the passage of the sperms from the testes to the penis during ejaculation. Answer: (C) Sperm count of about 20 million per milliliter Sperm count must be within normal in order for a male to successfully sire a child. Answer: (B) Clomiphene Clomiphene or Clomid acts as an ovarian stimulant to promote ovulation. 50. What she needs to do is to continue taking the pills until the pack is consumed and use at the time another temporary method to ensure that no pregnancy will occur. 44.explicit provision stating that the nurse still needs special training for IV insertion. Any day of the month is alright provided that she practices it monthly on the same day that she has chosen. Answer: (B) 0.Answer: (A) Temperature. the progesterone only type is the best because estrogen can affect lactation. Answer: (A) Thin watery mucus which can be stretched into a long strand about 10 cm At the midpoint of the cycle when the estrogen level is high. And the woman feels “wet”. the mucus becomes thick and the woman will feel “dry”. she must take 2 pills for added protection If the woman fails to take her usual pill for the day. Answer: (B) The mother breastfeeds exclusively and regularly during the first 6 months without giving supplemental feedings A mother who breastfeeds exclusively and regularly during the first 6 months benefits from lactation amenorrhea. Some IUDs have copper added to it which is spermicidal.2. cervical mucus.4 degrees centigrade. Answer: (B) 12 months If a woman has not had her menstrual period for 12 consecutive months. 38.2 – 0. The mature ova are retrieved and fertilized outside the fallopian tube (in-vitro fertilization) and . Usually IUDs are coated with copper to serve as spermicide killing the sperms deposited into the female reproductive tract.

17. If the color is greenish.3. Thus if the blood supply is less. Here are the answers and rationale for this exam. 12. Answer: (A) Article II section 12 The Philippine Constitution of 1987 guarantees the right of the unborn child from conception equal to the mother as stated in Article II State Policies. Light tugging on the cord when placenta has detached is alright in order to help deliver the placenta that is already detached. 7. Answer: (B) Maternal cardiac condition In general. 10. Answer: (C) Cover the prolapse cord with sterile gauze wet with sterile NSS and place the woman on Trendelenburg position . If it is yellowish. 19. 21 weeks AOG is considered as the minimum fetal age for viability. the FHR usually goes down but must return to its pre-contraction rate after the contraction ends. Section 12. Answer: (C) Uterine contraction Uterine contraction is the primary force that will expel the fetus out through the birth canal Maternal bearing down is considered the secondary power/force that will help push the fetus out. and possible compression of cord may occur which can lead to less blood and oxygen to the fetus (hypoxia). Answer: (D) Uterine contractions are strong and the baby will not be delivered yet within the next 3 hours. Answer: (C) To make the delivery effort free and the mother does not need to push with contractions Forceps delivery under epidural anesthesia will make the delivery process less painful and require less effort to push for the mother. the dilatation is expected to be already 8 cm. 8. 4. Answer: (D) Hemorrhage secondary to uterine atony All the signs in the stem of the question are signs of hemorrhage. the baby will suffer from chronic hypoxia leading to a small-for-gestational age condition. If you have any disputes or need more clarification to a certain question. FHR during contraction is 118 bpm and FHR after uterine contraction is 126 bpm The normal range of FHR is 120-160 bpm. Answer: (B) Acme Acme is the technical term for the highest point of intensity of a uterine contraction. 13. the cord may also go with the water because of the pressure of the rupture and flow. Answer: (B) Abortion is both immoral and illegal in our country Induced Abortion is illegal in the country as stated in our Penal Code and any person who performs the act for a fee commits a grave offense punishable by 10-12 years of imprisonment. Answer: (B) Strongly tugging on the umbilical cord to deliver the placenta and hasten placental separation When the placenta is still attached to the uterine wall. If the fundus is soft and boundaries not well defined. it should be given when delivery of fetus is imminent or too close because the fetus may suffer respiratory depression as an effect of the drug that can pass through placental barrier.4 all the above conditions can occur following a precipitate labor and delivery of the fetus because there was little time for the baby to adapt to the passageway. Answer: (A) The beginning of one contraction to the end of the same contraction Duration of a uterine contraction refers to one contraction. 2. Answer: (C) The active phase of Stage 1 is protracted The active phase of Stage I starts from 4cm cervical dilatation and is expected that the uterus will dilate by 1cm every hour.2. the cause of the hemorrhage could be uterine atony. Answer: (C) The pre-contraction FHR is 130 bpm. the fetal head serves as the main part of the fetus that pushes through the birth canal which can lead to cranial hematoma. Pushing requires more effort which a compromised heart may not be able to endure. please direct them to the comments section. vaginal canal and perineum) did not have enough time to stretch which can lead to laceration. 15. Answer: (D) 1. 5. 9. Thus. 18. before the head is delivered (cephalic presentation). Since the time lapsed is already 2 hours. Hence. Narcotic analgesics must be given when uterine contractions are already well established so that it will not cause stoppage of the contraction thus protracting labor. 61. strong and regular. Likewise the maternal passageway (cervix. 3. Answer: (A) 21-24 weeks Viability means the capability of the fetus to live/survive outside of the uterine environment. Fetal distress can be detected through the fetal heart tone. Answer: (A) Clear as water The normal color of amniotic fluid is clear like water. If the cord goes out of the cervical opening.after 48 hours the fertilized ovum is inserted into the uterus for implantation. During a contraction. the head can compress on the cord causing fetal distress. 16. If the presentation is cephalic. tugging on the cord while the uterus is relaxed can lead to inversion of the uterus. the active phase is protracted. The fundus is the contractile part of the uterus and the fingertips are more sensitive than the palm of the hand. it is probably meconium stained. With the present technological and medical advances. Counter check your answers to those below and tell us your scores. 6. Also. it is essential do check the FHB right after rupture of bag to ensure that the cord is not being compressed by the fetal head. 1. 14. there is probably Rh incompatibility. Thus it is correctly measure from the beginning of one contraction to the end of the same contraction and not of another contraction. Answer: (B) Determine if cord compression followed the rupture After the rupture of the bag of waters. Answer: (C) Put the tip of the fingers lightly on the fundal area and try to indent the abdominal wall at the height of the contraction In monitoring the intensity of the contraction the best place is to place the fingertips at the fundal area. when the heart is compromised such as in maternal cardiac condition. the condition can lead to less blood supply to the uterus consequently to the placenta which provides the fetus with the essential nutrients and oxygen. Answer: (B) From the beginning of one contraction to the beginning of the next contraction Frequency of the uterine contraction is defined as from the beginning of one contraction to the beginning of another contraction.

21. The retractor is not part of the basic set. the nurse needs only the instruments for cutting the umbilical cord such as: 2 clamps (straight or curve) and a pair of scissors as well as the kidney basin to receive the placenta. Answer: (B) The duration of contraction progressively lengthens over time In false labor. Answer: (B) Descent. This is done by the nurse by support the perineum with a sterile towel and pushing the perineum downard with one hand while the other hand is supporting the baby’s head as it goes out of the vaginal opening. internal rotation and extension are mechanisms that the fetus must perform as it accommodates through the passageway/birth canal.Answer: (A) The heart rate will decelerate during a contraction and then go back to its pre-contraction rate after the contraction The normal fetal heart rate will decelerate (go down) slightly during a contraction because of the compression on the fetal head. (Remember that only the baby’s head has come out as given in the situation. 30. needle holder and tissue forceps are added especially if the woman delivering the baby is a primigravida wherein episiotomy is generally done. 28. 37. Don’t attempt to put back the cord into the vagina but relieve pressure on the cord by positioning the mother either on Trendelenburg or Sims position 20. 35. 31. If it is given prior to placental delivery. If the nose is suctioned first before the mouth. external rotation The mechanism of fetal delivery begins with descent into the pelvic inlet which may occur several days before true labor sets in the primigravida. If the uterus does not contract adequately. Answer: (D) Flexibility of the pelvis The pelvis is a bony structure that is part of the passageway but is not flexible. the multigravida may have about 8 hours labor while the primigravida may have up to 12 hours labor. Eternal rotation is done after the head is delivered so that the shoulders will be easily delivered through the vaginal introitus. Answer: (D) Retractor For normal vaginal delivery. internal rotation. the mucus plugging the mouth can be aspirated by the baby. Answer: (B) Oxytocin can make the cervix close and thus trap the placenta inside The action of oxytocin is to make the uterus contract as well make the cervix close. Answer: (A) Schultze There are 2 mechanisms possible during the delivery of the placenta. the baby can be strangulated by it and the fetal head will have difficulty being delivered. Stage 1 begins with true labor pains and ends with full dilatation and effacement of the cervix. the contractions remain to be irregular in intensity and duration while in true labor. Also. Answer: (A) Inspect the placenta for completeness including the membranes The placenta must be inspected for completeness to include the membranes because an incomplete placenta could mean that there is retention of placental fragments which can lead to uterine atony. aspiration of the mucus is possible which can lead to aspiration pneumonia. 33. . the nurse must check if the umbilical cord is normal which means it contains the 3 blood vessels: 1 vein and 2 arteries. 32. Answer: (A) 2 arteries and 1 vein The umbilical cord is composed of 2 arteries and 1 vein. it is called the Duncan mechanism. Answer: (D) Paint the inner thighs going towards the perineal area Painting of the perineal area in preparation for delivery of the baby must always be done but the stroke should be from the perineum going outwards to the thighs. it is called the Schultze mechanism. Observe strict asepsis in the care of the cord to prevent infection. flexion. A normal placenta will detach by itself without any effort from the mother. Answer: (C) Check if there is cord coiled around the neck The nurse should check if there is a cord coil because the baby will not be delivered safely if the cord is coiled around its neck.) 24. 36. The lower uterine segment including the cervix as well as the vaginal canal and introitus are all part of the passageway in the delivery of the fetus. 22. Wiping of the face should be done seconds after you have ensured that there is no cord coil but suctioning of the nose should be done after the mouth because the baby is a “nasal obligate” breather. 26. Answer: (D) Mother feels like bearing down Placental detachment does not require the mother to bear down. the contractions become stronger. If the shiny portion comes out first. Answer: (A) 1 and 3 The nurse after delivering the placenta must ensure that all the cotyledons and the membranes of the placenta are complete.The correct action of the nurse is to cover the cord with sterile gauze wet with sterile NSS. The perineal area is the one being prepared for the delivery and must be kept clean 25. In the hospital setting. while if the meaty portion comes out first. the heart rate should go back to the precontraction rate as soon as the contraction is over since the compression on the head has also ended. 34. Answer: (B) Ritgen’s technique Ritgen’s technique is done to prevent perineal tear. Answer: (B) No part of the cord is encircling the baby’s neck The nurse should check right away for possible cord coil around the neck because if it is present. if mucus is in the nose and mouth. Flexion. Also. extension. 23. Answer: (C) Begins with complete dilatation and effacement of cervix and ends with delivery of baby Stage 2 of labor and delivery process begins with full dilatation of the cervix and ends with the delivery of baby. longer and more frequent. hemorrhage can occur. 27. the placenta will be trapped inside because the action of the drug is almost immediate if given parentally. The cord has to be kept moist to prevent it from drying.Answer: (A) Suction the nose and mouth to remove mucous secretions Suctioning the nose and mouth of the fetus as soon as the head is delivered will remove any obstruction that maybe present allowing for better breathing. Answer: (A) Stage 1 In stage 1 during a normal vaginal delivery of a vertex presentation. However. 29.

it is considered a protracted active phase of the first stage. D. Answer: (B) Fluid intake and output Partograph is a monitoring tool designed by the World Health Organization for use by health workers when attending to mothers in labor especially the high risk ones. “We know several friends in our age group and all of them have their own child already. common in the second trimester. The nurse’s explanation is based on which of the following as the cause? A. and legs C. If the fetal head has entered the pelvic inlet. If it takes longer. and thighs D. Answer: (A) LOA The landmark used in determine fetal position is the posterior fontanel because this is the nearest to the occiput. forehead. the station is “0”. A couple who wants to conceive but has been unsuccessful during the last 2 years has undergone many diagnostic procedures. Answer: (B) Station “0” Station is defined as the relationship of the fetal head and the level of the ischial spine. Answer: (C) Ritgen’s maneuver Ritgen’s method is used to prevent perineal tear/laceration during the delivery of the fetal head.2 cm/hr. Answer: (B) During a uterine contraction The primary power of labor and delivery is the uterine contraction. Excessive weight gain 7. 44. there is an increase in maternal blood volume to accommodate the need of the fetus. it is considered footling. Fear related to the unknown B. 46. cesarean section. Answer: (B) 30 minutes The placenta is delivered within 30 minutes from the delivery of the baby. Pain related to numerous procedures. the normal cervical dilatation is 1. Why can’t we have one?”. Pressure on the pelvic muscles C. Sperm count B. 40. Sperm maturity D. probably the placenta is abnormally adherent and there is a need to refer already to the obstetrician. 43. 47. Cheeks. and nipples B. If it is only the foot/feet.38. Elevated estrogen levels 5. Answer: (A) There is a fluid shift from the placental circulation to the maternal circulation which can overload the compromised heart. For multipara. the fluid shift occurs faster because the placenta is taken out right after the baby is delivered giving it less time for the fluid shift to gradually occur. If only the buttocks. Lamaze method is also known as psychoprophylactic method and Dick-Read method are commonly known natural childbirth procedures which advocate the use of non-pharmacologic measures to relieve labor pain. In cesarean section. The large size of the newborn B. 50. The pubic hair is definitely to be included in the shaving 1. Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester? A. Dysuria B. Incontinence D. If both the feet and the buttocks are presenting it is called complete breech. one partner states. Answer: (D) Incomplete Breech presentation means the buttocks of the fetus is the presenting part. 39. Heartburn and flatulence. Chest. Abdomen. Answer: (A) Under breast to mid-thigh including the pubic area Shaving is done to prevent infection and the area usually shaved should sufficiently cover the area for surgery. Increased plasma HCG levels B. Answer: (B) Full bladder Full bladder can impede the descent of the fetal head. neck.2 cm. breast. When assessing the adequacy of sperm for conception to occur. there is a fluid shift back to the maternal circulation as part of physiologic adaptation during the postpartum period. Semen volume 2. Breast. 42. Ineffective family coping related to infertility. 45. 41. This is also the drug given to induce labor. Above the ischial spine it is considered ( -) station and below the ischial spine it is (+) station. Which of the following would be the most pertinent nursing diagnosis for this couple? A. 49. Decreased gastric acidity D. arms. it is frank breech. At the level of the ischial spine. Relaxation of the pelvic joints D. Sperm motility C. During the pregnancy. If it is less than that. areola. On which of the following areas would the nurse expect to observe chloasma? A. which of the following is the most useful criterion? A. A pregnant client states that she “waddles” when she walks. When discussing the situation with the nurse. Which of the following represents the average amount of weight gained during pregnancy? A. are most likely the result of which of the following? A. So if the nurse palpated the occiput (O) at the left (L) side of the mother and at the upper/anterior (A) quadrant then the fetal position is LOA. When the baby and placenta have been delivered. The nurse can readily manage this problem by doing a simple catheterization of the mother. 3. and nose 6. 48. Burning 4. Decreased intestinal motility C. Answer: (C) Floating The term floating means the fetal presenting part has not entered/descended into the pelvic inlet. Answer: (A) 1. 12 to 22 lb .5 cm/hr. it is said to be engaged./hr For nullipara the normal cervical dilatation should be 1. Frequency C. C. This should be augmented by the mother’s bearing down during a contraction. Answer: (B) Pitocin The common oxytocin given to enhance uterine contraction is pitocin. Self-esteem disturbance related to infertility. For maternal parameters all of the above is placed in the partograph except the fluid intake since this is placed in a separate monitoring sheet.

A spontaneous abortion or a missed abortion is impending 15. Nausea and vomiting C. and lack of an antagonist make them generally inappropriate during labor. D. Which of the following common emotional reactions to pregnancy would the nurse expect to occur during the first trimester? A. There is a greater chance for error during preparation 14. causing depressive effects in the newborn 2 to 3 hours after intramuscular injection. sexuality.B 15 to 25 lb C. First stage B. narcissism B. Increasing intensity with walking 21. October 12 17. The father may resent the infant’s demands on the mother’s body D. Positive serum pregnancy test 11. Third trimester 13. 25 to 40 lb 8. Obtaining an Apgar score D. Constipation B. The test was performed too early or too late in the pregnancy C. 20 weeks gestation 16. Starting mainly in the abdomen C. 24 to 30 lb D. clumsiness. leg veins. Which of the following actions demonstrates the nurse’s understanding about the newborn’s thermoregulatory ability? A. the nurse would explain that this is most probably the result of which of the following? A. fear. Ambivalence. B. Uterus at the umbilicus 18. Cervical softening and uterine souffle are classified as which of the following? A. 24. Second stage C. Descent . They rapidly transfer across the placenta. The incidence of allergies increases due to maternal antibodies C. Placing the newborn under a radiant warmer. Presumptive signs C. Promote parent-newborn interaction. Prepregnant period B. Barbiturates are usually not given for pain relief during active labor for which of the following reasons? A. Uterus in the abdomen D. egocentrism. Third stage D. Skin pigmentation changes D. and unattractiveness C. B. Pregnancy-induced hypertension C. and nutrition? A. The test was performed less than 10 days after an abortion B. extroversion D. Second trimester D. Fourth stage 22. Anxiety. March 28 C. Introversion. January 2 B. Occurring at irregular intervals B. hypothermia. Involution occurs more rapidly B. Adverse reactions may include maternal hypotension. during pregnancy. Hematocrit 33. Which of the following danger signs should be reported promptly during the antepartum period? A. Which of the following fundal heights indicates less than 12 weeks’ gestation when the date of the LMP is unknown? A. Gradually increasing intervals D. Uterus in the pelvis B. A client LMP began July 5. 10 weeks gestation C. generalized drowsiness. fetal development. Positive signs 10. One hour glucose challenge test 110 g/dL 20. Obtain a urine specimen and other laboratory tests. Nasal stuffiness D. Suctioning with a bulb syringe C. Which of the following prenatal laboratory test values would the nurse consider as significant? A. Assess uterine contractions every 30 minutes. Which of the following would cause a false-positive result on a pregnancy test? A. 15 weeks gestation D. fantasies 12. Diagnostic signs B. Thrombophlebitis B. Which of the following nursing interventions would the nurse perform during the third stage of labor? A. The force of gravity pulling down on the uterus 9. Hegar sign B. Her EDD should be which of the following? A. Leaking amniotic fluid 19. allergic or toxic reaction or partial or total respiratory failure 23. Which of the following would be disadvantage of breast feeding? A. White blood cells 8. These drugs readily cross the placental barrier. Breast tenderness C.5% B. Coach for effective client pushing D. The neonatal effects include hypotonia. During which of the following stages of labor would the nurse assess “crowning”? A. Which of the following would the nurse identify as a presumptive sign of pregnancy? A. FHR can be auscultated with a fetoscope as early as which of the following? A. Probable signs D. C. During which of the following would the focus of classes be mainly on physiologic changes. passivity. First trimester C. April 12 D. Immediately before expulsion. The urine sample was stored too long at room temperature D. C. Uterus at the xiphoid C. Awkwardness. Pressure on blood vessels from the enlarging uterus D. When talking with a pregnant client who is experiencing aching swollen. Inspecting the newborn’s umbilical cord 25.000/mm3 D. Which of the following characteristics of contractions would the nurse expect to find in a client experiencing true labor? A. 5 weeks gestation B. Rubella titer less than 1:8 C. and reluctance to feed for the first few days. which of the following cardinal movements occur? A. B.

Which of the following may happen if the uterus becomes overstimulated by oxytocin during the induction of labor? A. usually with severe hemorrhage? A. Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth D. sneeze. The newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement or loud noise. C. Labor that begins after 20 weeks gestation and before 37 weeks gestation B. metabolic. Renal or vascular disease 36. Edema of the hands and face C. Imminent C. Labor that begins after 24 weeks gestation and before 28 weeks gestation . Rooting. metabolic. Multiple gestation B. The anterior is large in size when compared to the posterior fontanel. Stepping. Before birth. cough. External rotation 26. Extension D. B. Weight gain of 1 lb/week D. The newborn’s toes will hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward from the ball of the heel and across the ball of the foot. Which of the following when present in the urine may cause a reddish stain on the diaper of a newborn? A. which of the following ranges would be considered normal if the newborn were sleeping? A. the anterior closes at 8 to 12 weeks. Mucus B. sneeze. Loss of appetite and continuous vomiting that commonly results in dehydration and ultimately decreasing maternal nutrients D.B. Abdominal trauma D. B. Blink. Instruct the mother’s support person to remain in the family lounge until after the delivery B. swallowing. Uterine anomalies C. Explain the surgery. Placenta previa B. blink. Incomplete 35. Which of the following factors would the nurse suspect as predisposing a client to placenta previa? A. and sneeze 31. and gag B. D. Increased pain with bright red vaginal bleeding D. Soft and nontender abdomen 37. When assessing the newborn’s heart rate. Increased restlessness and anxiety 39. Foramen ovale C. Which of the following groups of newborn reflexes below are present at birth and remain unchanged through adulthood? A. gag C. and cough D. and nutritional imbalances in the absence of other medical problems. or corner of mouth is touched. Bilirubin D. painless vaginal bleeding B. Severe nausea and diarrhea that can cause gastrointestinal irritation and possibly internal bleeding 33. C. Severe nausea and vomiting leading to electrolyte. When preparing a client for cesarean delivery. Palpable fetal outline D. Which of the following is described as premature separation of a normally implanted placenta during the second half of pregnancy. expected outcome. D. Which of the following would the nurse identify as a classic sign of PIH? A. Arrange for a staff member of the anesthesia department to explain what to expect postoperatively C. Umbilical vein B. The anterior is triangular shaped. 120 beats per minute D. and begins to suck when cheek. The anterior is bulging. Ectopic pregnancy C. which of the following structures connects the right and left auricles of the heart? A. Which of the following is true regarding the fontanels of the newborn? A. Abruptio placentae 38. the posterior appears sunken. which of the following key concepts should be considered when implementing nursing care? A. Which of the following best describes preterm labor? A. B. Early morning headache 34. In which of the following types of spontaneous abortions would the nurse assess dark brown vaginal discharge and a negative pregnancy tests? A. and kind of anesthetics 40. Labor that begins after 15 weeks gestation and before 37 weeks gestation C. 30. lip. Flexion C. cough. Concealed or external dark red bleeding C. The newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface 32. C. Blink. Edema of the feet and ankles B. the posterior is diamond shaped. 140 beats per minute 29. Weak contraction prolonged to more than 70 seconds B. Which of the following describes the Babinski reflex? A. Uric acid crystals C. Threatened B. Ductus venosus 27. rooting. 80 beats per minute B. Ductus arteriosus D. opens the mouth. The newborn turns the head in the direction of stimulus. Bright red. and nutritional imbalances in the absence of other medical problems. Severe anemia leading to electrolyte. Which of the following would the nurse assess in a client experiencing abruptio placenta? A. Incompetent cervix D. Which of the following statements best describes hyperemesis gravidarum? A. Missed D. Excess iron 28. 100 beats per minute C. cough. The posterior closes at 18 months. Tetanic contractions prolonged to more than 90 seconds C.

hormonal changes cause relaxation of the pelvic joints. areola. Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary frequency. and semen volume are all significant. and ineffective family coping also may be present but as secondary nursing diagnoses. resulting in the typical “waddling” gait. chest.D. Begin monitoring maternal vital signs and FHR B. HCG levels increase in the first. Endemic infection occurring randomly and localizing in the periglandular connective tissue C. Between 10% and 40% of all new mothers report some form of postpartum blues B. Thus. Dysuria. Sperm count. dysuria. also called the mask of pregnancy. but they are not as significant sperm motility. Fear. and swelling in the affected limb D. Compare your answers to those below and be sure to read the rationales for additional learning. Dehydration. Limiting hypovolemic shock B. When uterine rupture occurs. High fever. dehydration. legs. Inflammation and clot formation that result when blood components combine to form an aggregate body B. Which of the following is the primary predisposing factor related to mastitis? A. the reduction in gastric acidity in conjunction with pressure from the growing uterus and smooth muscle relaxation. Medical 43. When PROM occurs. Which of the following is the nurse’s initial action when umbilical cord prolapse occurs? A. D. frequency. malaise. nipples. nausea. Notify the physician and prepare the client for delivery D. More than 500 ml 46. Nursing care is based on fetal viability and gestational age. stasis. Which of the following best describes thrombophlebitis? A. It is not seen on the breasts. If you have any disputes or clarifications. Obtaining blood specimens C. B. Environmental D. chills. not the second. Although all of the factors listed are important. which of the following provides evidence of the nurse’s understanding of the client’s immediate needs? A. C. neck. and pain occurring 10 to 14 days after delivery 49. stiffness. tenderness and redness along the vein B. the nursing diagnosis of self-esteem disturbance is most appropriate. Which of the following best reflects the frequency of reported postpartum “blues”? A. Instituting complete bed rest D. Apply a sterile warm saline dressing to the exposed cord 45. suprapubic pain. sperm maturity. hypertension. B. Frequency. More than 400 ml D. Which of the following factors is the underlying cause of dystocia? A. Inserting a urinary catheter 44. vomiting. PROM removes the fetus most effective defense against infection C. Place the client in a knee-chest position in bed C. C. Pressure on the surrounding muscles causing discomfort is due to the growing uterus. urgency. hematuria. D. Which of the following assessment findings would the nurse expect if the client develops DVT? A. occurring 2 weeks after delivery C. and burning are symptoms associated with urinary tract infections. arms. Which of the following are the most commonly assessed findings in cystitis? A. and cracking of the nipples 47. B. . chills. Chills. Weight gain has no effect on gait. flank pain nausea. Between 30% and 50% of all new mothers report some form of postpartum blues C. chills. Which of the following amounts of blood loss following birth marks the criterion for describing postpartum hemorrhage? A. the couple is verbalizing feelings of inadequacy and negative feelings about themselves and their capabilities. Labor that begins after 28 weeks gestation and before 40 weeks gestation 41. During the second trimester. Chills. pain. and frequency 50. The chorion and amnion rupture 4 hours before the onset of labor. Muscle pain the presence of Homans sign. During pregnancy. fever and suprapubic pain C. Between 25% and 70% of all new mothers report some form of postpartum blues Here are the answers and rationale for this exam. Midcalf pain. trimester. fever. More than 200 ml B. which of the following would be the priority? A. Chloasma. Based on the partner’s statement. Between 50% and 80% of all new mothers report some form of postpartum blues D. abdomen. and flank pain B. please direct them to the comments section. Inflammation and blood clots that eventually become lodged within the femoral vein D. Changes in posture are related to the growing fetus. sperm motility is the most significant criterion when assessing male infertility. Breast injury caused by overdistention. is an irregular hyperpigmented area found on the face. Estrogen levels decrease in the second trimester. Epidemic infection from nosocomial sources localizing in the lactiferous glands and ducts B. urgency dysuria. Mechanical C. or thighs. incontinence. Inflammation and blood clots that eventually become lodged within the pulmonary blood vessels C. Nurtional B. fever. D. Nocturia. dysuria. Inflammation of the vascular endothelium with clot formation on the vessel wall 48. can cause heartburn and flatulence. Decrease intestinal motility would most likely be the cause of constipation and bloating. and fever D. PROM is associated with malpresentation and possibly incompetent cervix 42. Temporary urinary retention due to decreased perception of the urge to avoid D. More than 300 ml C.

D. amniotic fluid – 2 lb.5 lb. C. First-trimester classes commonly focus on such issues as early physiologic changes. The fundus is at the level of the umbilicus at approximately 20 weeks’ gestation and reaches the xiphoid at term or 40 weeks. excessive fatigue. due to poor sucking reflex or poor sucking pressure).g. A. the fundus is out of the pelvis above the symphysis pubis. only nausea and vomiting are presumptive signs. urinary frequency. Of the signs listed. the newborn and placenta are delivered. During the third stage of labor. Neonatal side effects of barbiturates include central nervous system depression. When the LMP is unknown. With breast feeding.5 lb. C. Crowing. Piskacek sign. causing depressive effects in the newborn 2 to 3 hours after intramuscular injection. the client’s EDD is April 12. generalized drowsiness. and a positive serum pregnancy test are considered probably signs. cervical dilation and effacement occur. and quickening. At approximately 12 to 14 weeks. Regional anesthesia is associated with adverse reactions such as maternal hypotension. Barbiturates are rapidly transferred across the placental barrier. The presence of maternal antibodies in breast milk helps decrease the incidence of allergies in the newborn. delayed establishment of feeding (e. often becoming more introverted or reflective of her own childhood. C. Thurs. B. a finding of a titer less than 1:8 is significant. and reluctance to feed for the first few days. B. During the first trimester. rapid weight gain. or having a spontaneous or missed abortion impending can all produce false-negative results. To determine the EDD when the date of the client’s LMP is known use Nagele rule. C. and elevated blood pressure. add 7 days. and nasal stuffiness are common discomforts associated with pregnancy. Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy. B. placenta and membrane – 1. Danger signs that require prompt reporting leaking of amniotic fluid. D. occurs during the second stage of labor. fear. and a 1 hour glucose challenge test of 110 g/dl are with normal parameters. prolonged drowsiness. which may interfere with feeding the newborn. A gain of 12 to 22 lb is insufficient. vaginal bleeding. Tranquilizers are associated with neonatal effects such as hypotonia. With true labor. Pressure of the growing uterus on blood vessels results in an increased risk for venous stasis in the lower extremities. Other probable signs include Hegar sign. Performing the tests too early or too late in the pregnancy. The presence of the uterus in the pelvis indicates less than 12 weeks’ gestation. During the third trimester. passivity. and add 1 year (if applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July) minus 3 = 4 (April). or he may be jealous of the infant’s demands on his wife’s time and body. uterus – 2. In addition. uterine enlargement. the father’s body is not capable of providing the milk for the newborn. changes in skin pigmentation. or introversion. Second and third trimester classes may focus on preparation for birth. extravascular fluid and fat – 4 to 9 lb. fetal development. which are strongly suggestive of pregnancy.skin pigmentation changes. A rubella titer should be 1:8 or greater. Pregnancy-induced hypertension is not associated with these symptoms. Constipation. FHR. common emotional reactions include ambivalence. A weight gain of 25 to 40 lb is considered excessive. which begins with the delivery of the newborn. thus minimizing blood loss. parenting. Presumptive signs are subjective signs and include amenorrhea. fantasies. A greater chance for error is associated with bottle feeding. A false-positive reaction can occur if the pregnancy test is performed less than 10 days after an abortion.000/mm3. true labor contractions occur at regular intervals.5% a white blood cell count of 8. No preparation is required for breast feeding. Collecting a urine specimen and other laboratory tests is done . and unattractive.5 lb. and newborn care. This weight gain consists of the following: fetus – 7. and ultrasonic evidence of a gestational sac. cannot be heard any earlier than 10 weeks’ gestation. storing the urine sample too long at room temperature. sexuality during pregnancy. D. The interval of true labor contractions gradually shortens. A. edema and varicose vein formation may occur. Common emotional reactions during this trimester include narcissism. The second trimester is a period of well-being accompanied by the increased need to learn about fetal growth and development. C. which is enlargement and softening of the uterus. To the first day of the LMP. and lack of an antagonist makes them generally inappropriate during active labor. serum laboratory tests. nausea and vomiting. hypothermia. usually starting in the back and sweeping around to the abdomen. Therefore. and nutrition. Some early classes may include pregnant couples.C. The average amount of weight gained during pregnancy is 24 to 30 lb. D. FHR usually is ausculatated at the midline suprapubic region with Doppler ultrasound transducer at 10 to 12 week’s gestation. clumsy. Narcotic analgesic readily cross the placental barrier. during which time the mother and newborn recover from the physical process of birth and the mother’s organs undergo the initial readjustment to the nonpregnant state. indicating that the client may not possess immunity to rubella. contractions increase in intensity with walking. The FHR can be auscultated with a fetoscope at about 20 week’s gestation. During the first stage of labor. Hegar sign. the woman typically feels awkward. During the third stage of labor. breast tenderness and changes. or anxiety. A hematocrit of 33. Breast feeding is advantageous because uterine involution occurs more rapidly. The fourth stage of labor lasts from 1 to 4 hours after birth. blurred vision. At times the woman may seem egocentric and self-centered. subtract 3 months. which is softening of the lower uterine segment. D. the gestational age of the fetus is estimated by uterine size or position (fundal height). breasts – 3 lb. or partial or total respiratory failure. B. providing fewer chances for bonding. whereas a weight gain of 15 to 25 lb is marginal. which occurs when the newborn’s head or presenting part appears at the vaginal opening. Gravity plays only a minor role with these symptoms. breast tenderness. and increased blood volume – 2 to 4 lb. Probable signs are objective findings that strongly suggest pregnancy. Presumptive signs of pregnancy are subjective signs. Subsequently. the nurse would promote parentnewborn interaction by placing the newborn on the mother’s abdomen and encouraging the parents to touch the newborn. Thrombophlebitis is an inflammation of the veins due to thrombus formation. allergic or toxic reaction.

B. A client with abruptio placentae may exhibit concealed or dark red bleeding. Blink. which could lead to such complications as fetal distress. Hyperstimulation of the uterus such as with oxytocin during the induction of labor may result in tetanic contractions prolonged to more than 90seconds. although doing so depends on many variables. B. B. causing painless bleeding in the third trimester of pregnancy. closes at 8 to 12 weeks. and cervical dilation. Mucus would not produce a stain. one of the most serious is the fetus loss of an effective defense against infection. The umbilical vein. The cervix remains closed. Early morning headache is not a classic sign of PIH. Many healthy pregnant woman experience foot and ankle edema. B. Inspecting the umbilical cord aids in detecting cord anomalies. C. expected outcome. Edema of the hands and face is a classic sign of PIH. Coaching the client to push effectively is appropriate during the second stage of labor. Therefore. and the fetal presenting part may be engaged. C. D. and uterine rupture. and ductus venosus are obliterated at birth. amniotic fluid embolism. The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute. or sunken. the depth and breadth of instruction will depend on circumstances and time available. The nurse is responsible for reinforcing the explanations about the surgery. possibly reporting sudden intense localized uterine pain. The description of hyperemesis gravidarum includes severe nausea and vomiting. The obstetrician is responsible for explaining about the surgery and outcome and the anesthesiology staff is responsible for explanations about the type of anesthesia to be used. B. the normal heart rate would range from 120 to 160 beats per minute. The foramen ovale is an opening between the right and left auricles (atria) that should close shortly after birth so the newborn will not have a murmur or mixed blood traveling through the vascular system. or corner of mouth is touched. a palpable fetal outline and a soft nontender abdomen are manifestations of placenta previa. which may indicate dehydration. usually with severe hemorrhage. the newborn turns his head in the direction of stimulus. and products of conception are not expelled. An incomplete abortion involves only expulsion of part of the products of conception and bleeding occurs with cervical dilation. the newborn will attempt to crawl forward with both arms and legs when he is placed on his abdomen on a flat surface. Immediately before expulsion or birth of the rest of the body. cramping. B. C.on admission during the first stage of labor. and restitution (in this order) occur before external rotation. With the crawl reflex. cough. Uric acid crystals in the urine may produce the reddish “brick dust” stain on the diaper. 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 a planned or emergency cesarean birth. leading to electrolyte. Bilirubin and iron are from hepatic adaptation. A. A. the cardinal movement of external rotation occurs. Pain. there is early fetal intrauterine death. which is diamond shaped. With the rooting and sucking reflex. and type of anesthetic to be used. ductus arteriosus. extension. This is the client’s most immediate . with no cervical dilation. An incomplete abortion presents with bleeding. Multiple gestation is one of the predisposing factors that may cause placenta previa. the newborn abducts and flexes all extremities and may begin to cry when exposed to sudden movement of loud noise. there may be a dark brown vaginal discharge. can deplete the nutrients transported to the fetus. A. Hyperemesis is not a form of anemia. In a missed abortion. Uterine anomalies abdominal trauma. Diarrhea does not occur with hyperemesis. Arranging for necessary explanations by various staff members to be involved with the client’s care is a nursing responsibility. B. With the startle reflex. D. B. Additionally. sneeze. The anterior fontanel is larger in size than the posterior fontanel. which. Bright red. With the babinski reflex. B. A. Loss of appetite may occur secondary to the nausea and vomiting of hyperemesis. Suctioning with a bulb syringe helps maintain a patent airway. the newborn’s toes hyperextend and fan apart from dorsiflexion of the big toe when one side of foot is stroked upward form the heel and across the ball of the foot. and cessation of uterine growth and breast tenderness. Weak contractions would not occur. Preterm labor is best described as labor that begins after 20 weeks’ gestation and before 37 weeks’ gestation. The uterus is typically firm to board-like. and renal or vascular disease may predispose a client to abruptio placentae. bright red vaginal bleeding. painless vaginal bleeding. abruptio placentae. Descent flexion. placing the newborn under a radiant warmer aids in maintaining his or her body temperature. which is triangular shaped. Reflexes such as rooting and stepping subside within the first year. metabolic. negative pregnancy test. A threatened abortion is evidenced with cramping and vaginal bleeding in early pregnancy. The other time periods are inaccurate. Obtaining an Apgar score measures the newborn’s immediate adjustment to extrauterine life. Assessing uterine contractions every 30 minutes is performed during the latent phase of the first stage of labor. Placenta previa refers to implantation of the placenta in the lower uterine segment. A weight gain of 2 lb or more per week indicates a problem. Ectopic pregnancy refers to the implantation of the products of conception in a site other than the endometrium. lip. Abruptio placentae is described as premature separation of a normally implanted placenta during the second half of pregnancy. and increased restlessness and anxiety are not associated with hyperstimulation. and nutritional imbalances in the absence of other medical problems. whereas the posterior fontanel. and begins to suck when the cheeks. opens the mouth. the anterior fontanel. if it continues. which may indicate increased intracranial pressure. laceration of the cervix. closes at 18 months. PROM can precipitate many potential and actual problems. Incompetent cervix is a conduction characterized by painful dilation of the cervical os without uterine contractions. Neither fontanel should appear bulging. Allowing the mother’s support person to remain with her as much as possible is an important concept. swallowing and gag reflexes are all present at birth and remain unchanged through adulthood. internal rotation. The newborn’s ability to regulate body temperature is poor. If the newborn was awake.

evaluating fetal responses and preparing for surgery. and chills are not typically associated with cystitis. and suprapubic pain. 30% to 50%. vomiting. frequency. painful. but it does not eliminate bacterial and/or viral microorganisms that can cause sexually transmitted infections. In addition. The immediate priority is to minimize pressure on the cord. dysuria. However. This coupled with the effect of . Clots lodging in the pulmonary vasculature refers to pulmonary embolism. Most IUD users are over the age of 30. the enlarging uterus places pressure on the intestines. notifying the physician and preparing the client for delivery. A. when used correctly and consistently. Oral contraceptives may be started within the first postpartum week to ensure suppression of ovulation . An UID should not be used if the woman has an active or chronic pelvic infection. C. Male sterilization eliminates spermatozoa from the ejaculate. is safe and effective. and medical factors may contribute to the mechanical factors that cause dystocia. Age is not a factor in determining the risks associated with IUD use. along the vein reflect superficial thrombophlebitis. Although spermicides kill sperm. Blood components combining to form an aggregate body describe a thrombus or thrombosis. A. Therefore. between 50% and 80% of all new mothers report some form of postpartum blues. the IUD is an acceptable option as long as the risk-benefit ratio is discussed. flank pain. postpartum infection. C. Tell us your scores in the comments section. before labor begins. Chills. or uterine abnormalities. Postpartum hemorrhage is defined as blood loss of more than 500 ml following birth. Fetal viability and gestational age are less immediate considerations that affect the plan of care. Because of the changes to the reproductive structures during pregnancy and following delivery. The answers and rationale for this exam are given below. But these actions have no effect on minimizing the pressure on the cord. spermicidal jelly should not be inserted into the vagina until involution is completed at approximately 6 weeks.need at this time. Use of a female condom protects thereproductive system from the introduction of semen or spermicides into the vagina and may be used after childbirth. and 25% to 70% are incorrect. Side effects and drug interactions may occur withoral contraceptives regardless of the time the pill is taken. An IUD may increase the risk of pelvic inflammatory disease. and elevating the maternal hips on a pillow to minimize the pressure on the cord. uterus (powers). B. femoral thrombophlebitis. Typically. B. nausea. for maximum effectiveness. the presence of Homans sign. the diaphragm must be refitted. using the rhythm method. Dystocia is difficult. the priority is to prevent and limit hypovolemic shock. For the couple who has determined the female’s fertile period. pelvis (passage). providing drug therapy as needed. C. C. Classic symptoms of DVT include muscle pain. follicles do not mature. Midcalf pain. Temporary urinary retention due to decreased perception of the urge to void is a contributory factor to the development of urinary tract infection. Although there is a slightly higher risk for infertility in women who have never been pregnant. especially in women with more than one sexual partner. urgency. D. such as overdistention. and cracking of the nipples. instituting complete bed rest. dysuria. Condoms. and frequency are associated with pvelonephritis. stiffness and pain occurring 10 to 14 days after delivery suggest femoral thrombophlebitis. Obtaining blood specimens. hypertension. Epidemic and endemic infections are probable sources of infection for mastitis. is the primary predisposing factor. but this is not recommended because of the increased risk and rate of expulsion at this time. tenderness. avoidance of intercourse during this period. fever. replacing lost fluids. The ranges of 10% to 40%. environment. not mastitis. usually at the 6 weeks’ examination following childbirth or after a weight loss of 15 lbs or more. and wrapping the cord with sterile saline soaked warm gauze are important. fever and malaise occurring 2 weeks after delivery reflect pelvic thrombophlebitis. Regular timely ingestion of oral contraceptives is necessary to maintain hormonal levels of the drugs to suppress the action of the hypothalamus and anterior pituitary leading to inappropriate secretion of FSH and LH. Dehydration. The diaphragm must be fitted individually to ensure effectiveness. Monitoring maternal vital signs and FHR. Chills. Immediate steps should include giving oxygen. hematuria nocturia. and inserting a urinary catheter are necessary in preparation for surgery to remedy the rupture. The estrogen content of the oral site contraceptive may cause the nausea. Nutritional. Any amount less than this not considered postpartum hemorrhage. be sure to counter check your answers. Manifestations of cystitis include. Malpresentation and an incompetent cervix may be causes of PROM. B. spermicidal jelly should be placed in the dome and around the rim. because of the increased risk of sexually transmitted infections. Therefore. the client is at risk for hypovolemic shock. regardless of when the pill is taken. With mastitis. not 4 hours. ovulation is inhibited. fever. which could place the client at risk for infection transmission. they do not provide reliable protection against the spread of sexually transmitted infections. With uterine rupture. especially intracellular organisms such as HIV. and swelling of the affected limb. D. Thrombophlebitis refers to an inflammation of the vascular endothelium with clot formation on the wall of the vessel. PROM occurs about 1 hour. During the third trimester. endometrial hyperplasia or carcinoma. Insertion and removal of the diaphragm along with the use of the spermicides may cause vaginal irritations. stasis. C. B. Thus the nurse’s initial action involves placing the client on bed rest and then placing the client in a knee-chest position or lowering the head of the bed. prolonged labor due to mechanical factors involving the fetus (passenger). and pregnancy is prevented. in the femoral vein. or psyche. D. are the most effective contraceptive method or barrier against bacterial and viral sexually transmitted infections. IUDs may be inserted immediately after delivery. According to statistical reports. High fever chills. and redness. injury to the breast.

C. The symptoms may subside or progress to abortion. . is the priority. Before uterine assessment is performed. the uterus has not risen to the umbilicus at 12 weeks. B. diet therapy is the mainstay of the treatment plan and should always be the priority. edema. Exercise. cramping and vaginal bleeding are present. Birth at 38 weeks’ gestation is considered full term (T). At 12 weeks gestation. The fetal heart rate at this age is not audible with a stethoscope. A spontaneous abortion occurred at 8 weeks (A).5 pounds by 40 weeks. soft consistency to the stool. To obtain a date of September 27. To ensure adequate fetal growth and development during the 40 weeks of a pregnancy. Women diagnosed with gestational diabetes generally need only diet therapy without medication to control their blood sugar levels. the risk is low in ectopic pregnancy because pathogenic microorganisms have not been introduced from external sources. To obtain the date of December 27. not exercise. thus decreasing the amount of water that is absorbed. Use for more than 1 week can also lead to laxative dependency. D. it is essential that the woman empty her bladder. Although urine is checked for glucose at each clinic visit. and promote ease of correct latching-on for feeding. Enemas could precipitate preterm labor and/or electrolyte loss and should be avoided. The Doppler intensifies the sound of the fetal pulse rate so it is audible. The client may have a limited knowledge of the pathology and treatment of the condition and will most likely experience grieving. pain is the priority. including current pregnancy (G). 7 days have been subtracted (instead of added) from the first day of LMP plus November indicates counting back 2 months (instead of 3 months) from January. dietary intake. plus 4 months (instead of 3 months) were counted back. This is not. especially of the hands and face. Nipple soreness is not severe enough to warrant narcotic analgesia. The client has been pregnant four times. The uterus has merely risen out of the pelvis into the abdominal cavity and is not at the level of the umbilicus. As a result. Thus. The pregnant woman should gain less weight in the first and second trimester than in the third. usually unilateral. but is not necessary prior to assessment of the uterus. and 27. while birth form 20 weeks to 38 weeks is considered preterm (P). is important for all pregnant women and especially for diabetic women. However. Weight gain thought to be caused by excessive food intake would require a 24-hour diet recall. stool is softer and easier to pass. will decrease the infant’s frantic. which may be caused by fluid retention manifested by edema. however. D. Thus. 9 pounds by 30 weeks. Laxatives may cause preterm labor by stimulating peristalsis and may interfere with the absorption of nutrients. especially lactating mothers. changing the year appropriately. about every 2 hours. Feeding more frequently. leading to excessive weight gain or loss. add 7 days to the first day of the last menstrual period and count back 3 months. is the primary symptom. B. Increasing fiber in the diet will help fecal matter pass more quickly through the intestinal tract. causing excessive sleepiness. A missed abortion is early fetal intrauterine death without expulsion of the products of conception. All pregnant women with diabetes should have periodic monitoring of serum glucose. a total weight gain 25 to 30 pounds is recommended: 1.hormones on smooth muscle relaxation causes decreased intestinal motility (peristalsis). A. The standard of care recommends a fasting and 2-hour postprandial blood sugar level every 2 weeks. should wear a supportive brassiere with wide cotton straps. not 1 pound per week. To calculate the EDD by Nagele’s rule. and proteinuria. At 12 weeks the FHR would be difficult to auscultate with a fetoscope. the priority consideration at this time. the uterus rises out of the pelvis and is palpable above the symphysis pubis. However. vigorous sucking from hunger and will decrease breast engorgement. D. those with gestational diabetes generally do not need daily glucose monitoring. Although all of the choices are important in the management of diabetes. Eight to ten glasses of fluid per day are essential to maintain hydration and promote stool evacuation. excessive intake would not be the primary consideration for this client at this time. B. the nurse would document an imminent abortion. Uterine assessment should not cause acute pain that requires administration of analgesia. All postpartum clients. Dry nipple skin predisposes to cracks and fissures. This does not. the client should only gain 1. less than the recommended amount. B. prevent or reduce nipple soreness. which can become sore and painful. preeclampsia should be suspected. A full bladder will interfere with the accuracy of the assessment by elevating the uterus and displacing to the side of the midline. because it burns up glucose. In a threatened abortion. She has two living children (L). Narcotics administered prior to breast feeding are passed through the breast milk to the infant. The three classic signs of preeclampsia are hypertension. but there is no cervical dilation. Cramping and vaginal bleeding coupled with cervical dilation signifies that termination of the pregnancy is inevitable and cannot be prevented. A. For the client with an ectopic pregnancy. this is not the priority. After 20 weeks’ gestation. The uterus at 12 weeks is just above the symphysis pubis in the abdominal cavity. when there is a rapid weight gain. Soaps are drying to the skin of the nipples and should not be used on the breasts of lactating mothers. To obtain the date of November 7. Vital sign assessment is not necessary unless an abnormality in uterine assessment is identified. lower abdominal pain.5 pounds in the first 10 weeks. Although the potential for infection is always present. Although the external electronic fetal monitor would project the FHR. however. However. Depression may cause either anorexia or excessive food intake. but this is not the priority at this time. 7 days have been added to the last day of the LMP (rather than the first day of the LMP). 7 days were added to the last day of the LMP (rather than the first day of the LMP) and December indicates counting back only 1 month (instead of 3 months) from January.5 pounds in the first 10 weeks. Liquid in the diet helps provide a semisolid. not midway between the umbilicus and the xiphoid process. soften the breast. In a complete abortion all the products of conception are expelled. Ambulating the client is an essential component of postpartum care. A weight gain of ½ pound per week would be 20 pounds for the total pregnancy. During the first trimester. thus decreasing blood sugar.

Bright red vaginal bleeding at this time suggests late postpartum hemorrhage. Suctioning is not necessary. dark brown in appearance. All the client’s data indicate a uterine problem. which occurs after the first 24 hours following delivery and is generally caused by retained placental fragments or bleeding disorders. it is noninfectious (sterile) and nonirritating. fat. when the lochia is typically pink to brownish. Any bright red vaginal discharge would be considered abnormal. D. Covering the scale with a warmed blanket prior to weighing prevents heat loss through conduction. which would necessitate assessing the client’s urine. not afterward. Lochia rubra. Because of early postpartum discharge and limited time for teaching. Although feedings are withheld prior to the circumcision. The feet are not involved with the Moro reflex. The data do not indicate the presence of choking. but the nurse should check the extent of vaginal bleeding first. The client data do not include dysuria. thready pulse elevated to 100 BPM may indicate impending hemorrhagic shock. Lochia rubra is the normal dark red discharge occurring in the first 2 to 3 days after delivery. and in plantar flexion. Temperatures up to 100. Even though the skin is stained with meconium. Based on the calculation. may be present with breast engorgement. and bacteria. frequency. containing epithelial cells. A weak. it is not the first action that should be implemented in light of the other data. A. leukocytes. Although the infant has been given vitamin K to facilitate clotting. In talipes equinovarus (clubfoot) the foot is turned medially. Lochia serosa is a pink to brownish serosanguineous discharge occurring from 3 to 10 days after delivery that contains decidua. the nurse should check the amount of lochia present. a large body surface area of the newborn’s body. The trauma of the birth process does not cause inflammation of the newborn’s breast tissue. not as a prophylaxis. signs will not appear within 4 hours after the surgical procedure. usually 101ºF. A fractured clavicle would prevent the normal Moro response of symmetrical sequential extension and abduction of the arms followed by flexion and adduction. This reply by the nurse would cause the mother to have undue anxiety. At birth some of the meconium fluid may be aspirated. the nurse’s priority is to facilitate the safe and effective care of the client and newborn. but especially 5 days after delivery. An increased pulse is a compensatory mechanism of the body in response to decreased fluid volume. The data given reflect the normal changes during this time period. Although rechecking the blood pressure may be a correct choice of action. Placing the infant under the radiant warmer after bathing will assist the infant to be rewarmed. A. and uterine involution would not be affected. C. a dark red discharge. with the heel elevated. decidua. Localized infection of an episiotomy or Csection incision rarely causes systemic symptoms. The primary discomfort of circumcision occurs during the surgical procedure. the prophylactic dose is often not sufficient to prevent bleeding. cholesterol crystals. A knit cap prevents heat loss from the head a large head. 4 or 6 ounces are incorrect. and microorganisms. 2. but it is not a sign of increased intracranial pressure. causing mechanical obstruction or chemical pneumonitis. 60 calories per feeding with formula 20 cal/oz = 3 ounces per feeding. and teaching about family planning are important in postpartum/newborn nursing care. transient fever. is present for 2 to 3 days after delivery. B. do the following mathematical calculation. Then it would be appropriate to check the uterus. Heat loss by radiation occurs when the infant’s crib is placed too near cold walls or windows. erythrocyes. The cord should be kept dry until it falls off and the stump has healed. Typically. Symptoms of mastitis include influenza-like manifestations. exploring the family’s emotional status. Although infection is a possibility. which are signs of excessive secretions. symptoms of urinary tract infections. The lochia may be decreased or copious. Infants should not be submerged in a tub of water until the cord falls off and the stump has completely healed. they are not the priority focus in the limited time presented by early postpartum discharge. epithelial cells. D. 3 kg x 120 cal/kg per day = 360 calories/day feeding q 4 hours = 6 feedings per day = 60 calories per feeding: 60 calories per feeding. B. B. cervical mucus. Absence of the Moror reflex is the most significant single indicator of central nervous system status. providing further evidence of a possible infection. which may be a possible cause of the hemorrhage. The infant is not at increased risk for gastrointestinal problems. Lochia alba is an almost colorless to yellowish discharge occurring from 10 days to 3 weeks after delivery and containing leukocytes. or urgency. The infant’s assessment data reflect normal adaptation. Application of 70% isopropyl alcohol to the cord minimizes microorganisms (germicidal) and promotes drying. Thus. and foul smelling. the physician does not need to be notified and oxygen is not needed. leukocytes and decidua. Thus. . To determine the amount of formula needed. not a breast problem. The presence of excessive estrogen and progesterone in the maternal-fetal blood followed by prompt withdrawal at birth precipitates breast engorgement.48F in the first 24 hours after birth are related to the dehydrating effects of labor and are considered normal. Intrauterine anoxia may cause relaxation of the anal sphincter and emptying of meconium into the amniotic fluid. which will spontaneously resolve in 4 to 5 days after birth. The postterm meconium-stained infant is not at additional risk for bowel or urinary problems. erythrocytes. C. the chances of dehydration are minimal. Assessing the uterus for firmness and position in relation to the umbilicus and midline is important. gagging or coughing. B. Breast tissue does not hypertrophy in the fetus or newborns. Thus placing the newborn’s crib close to the viewing window would be least effective. B. The data indicate a potential impending hemorrhage. The data suggests an infection of the endometrial lining of the uterus. Although promoting comfort and restoration of health. Body heat is lost through evaporation during bathing. Antibiotic ointment should only be used to treat an infection. Hypothyroiddism has no effect on the primitive reflexes. Hemorrhage is a potential risk following any surgical procedure. Newborns do not have breast malignancy. cervical mucus.D. The first 15 minutes to 1 hour after birth is the first period of reactivity involving respiratory and circulatory adaptation to extrauterine life.

Seizure precautions provide environmental safety should a seizure occur. Assessing maternal vital signs can help determine maternal physiologic status. the head would be partially extended. Fetal heart rate is important to assess fetal well-being and should be done. Using bicarbonate would increase the amount of sodium ingested. This response explains what a complete previa is and the reason the baby cannot come out except by cesarean delivery. Injections into this muscle in a small child might cause damage to the radial nerve. Fetal kicking felt by the client represents quickening. The client’s labor is hypotonic. Preclampsia causes vasospasm and therefore can reduce utero-placental perfusion. Although a cesarean would help to prevent hemorrhage. not just most of it. A complete placenta previa occurs when the placenta covers the opening of the uterus. D. C. which often decrease nausea. A. With a brow (forehead) presentation. D. Braxton Hicks contractions are painless contractions beginning around the 4th month. Enlargement and softening of the uterus is known as Piskacek’s sign. which can cause complications. Secretion of androgen by the fetal gonad would produce a male fetus. the fetal upper torso and back face the left upper maternal abdominal wall. Goodell’s sign indicates softening of the cervix. The fetal gonad must secrete estrogen for the embryo to differentiate as a female. but it may be resumed earlier. With a complete previa. the statement does not explain why the hemorrhage could occur. D. Flexibility of the uterus against the cervix is known as McDonald’s sign. Bartholin’s glands are the glands on either side of the vaginal orifice. but seizure precautions are the priority. Because of edema. C. the placenta is covering all the cervix. In a breech position. Ballottement is not a contraction. The chromosome is the material that makes up the cell and is gained from each parent. and promote diuresis. C. Blastocyst and trophoblast are later terms for the embryo after zygote. An increase in maternal estrogen secretion does not effect differentiation of the embryo. downy hair on the shoulders and back of the fetus. flexible. With a vertex presentation. Interventions to reduce stress and anxiety are very important to facilitate coping and a sense of control. Preparing for cesarean section is unnecessary at this time. Maternal androgen secretion remains the same as before pregnancy and does not effect differentiation. Chadwick’s sign refers to the purple-blue tinge of the cervix. and maternal estrogen secretion occurs in every pregnancy. the head is completely extended. Breathing techniques do not eliminate pain. Cessation of the lochial discharge signifies healing of the endometrium. They also promote relaxation. Telling the client to ask the physician is a poor response and would increase the patient’s anxiety. Lanugo is the soft. Vernix is the white. B. Eating six small meals a day would keep the stomach full. paper measuring tape. It is too early to anticipate client pushing with contractions. Dizygotic (fraternal) twins involve two ova fertilized by separate sperm. cheesy substance covering the fetus. Risk of hemorrhage and infection are minimal 3 weeks after a normal vaginal delivery. Because of the proximity of the sciatic nerve. The nurse should use a nonelastic. the gluteus maximus muscle should not be until the child has been walking 2 years. Hydramnios represents excessive amniotic fluid. The other positions would be incorrect. Positioning. D. which will assist the uterus to contact more forcefully in an attempt to dilate the cervix. The fetal heart rate would be most audible above the maternal umbilicus and to the left of the middle. because of the space between the presenting part and the cervix. Choice of a contraceptive method is important. increases uteroplacental perfusion.C. B. prolapse of the umbilical cord is common. The parotid glands are open into the mouth. same genotype. thus blocking the passageway for the baby. Culturally. The xiphoid and umbilicus are not appropriate landmarks to use when measuring the height of the fundus (McDonald’s measurement). reduce blood pressure. Oxytocin would increase the uterine contractions and hopefully progress labor before a cesarean would be necessary. Women hospitalized with severe preeclampsia need decreased CNS stimulation to prevent a seizure. Ballottement indicates passive movement of the unengaged fetus. not breathing. Pica refers to the oral intake of nonfood substances. Breathing techniques can raise the pain threshold and reduce the perception of pain. A. the 6-weeks’ examination has been used as the time frame for resuming sexual activity. Skene’s glands open into the posterior wall of the female urinary meatus. Telling the client anytime is inappropriate because this response does not provide the client with the specific information she is requesting. The signs indicate placenta previa and vaginal exam to determine cervical dilation would not be done because it could cause hemorrhage. The greenish tint is due to the presence of meconium. With this presentation. Administering light sedative would be done for hypertonic uterine contractions. D. the head is completely or partially flexed. D. A. but not the specific criteria for safe resumption of sexual activity. B. The middle third of the vastus lateralis is the preferred injection site for vitamin K administration because it is free of blood vessels and nerves and is large enough to absorb the medication. Since liquids can increase nausea avoiding them in the morning hours when nausea is usually the strongest is appropriate. Quickening is the woman’s first perception of fetal movement. placing the zero point on the superior border of the symphysis pubis and stretching the tape across the abdomen at the midline to the top of the fundus. The clitoris is female erectile tissue found in the perineal area above the urethra. Ophthalmia neonatorum usually results from maternal gonorrhea and is conjunctivitis. The deltoid muscle of a newborn is not large enough for a newborn IM injection. Monozygotic (identical) twins involve a common placenta. The nurse should call the physical and obtain an order for an infusion of oxytocin. C. and common chorion. Monitoring the contractions will help evaluate the progress of labor. Eating low-sodium crackers would be appropriate. C. B. The anterior femoris muscle is the next safest muscle to use in a newborn but is not the safest. but they can reduce it. . The zygote is the single cell that reproduces itself after conception. With a face presentation. The client should be placed on her left side to maximize blood flow. daily weight is important but not the priority.

10. B. 12. 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. Variations in the length of the menstrual cycle are due to variations in the proliferative phase. The anterior fontanelle typically closes anywhere between 12 to 18 months of age. D. 5. Young toddlers are still sensorimotor learners and they enjoy the experience of feeling different textures. assessing the anterior fontanelle as still being slightly open is a normal finding requiring no further action. D. Testosterone is produced by the Leyding cells in the seminiferous tubules. Comic books are on too high a level for toddlers. The symphysis pubis. Because it is normal finding for this age. A. If you have any disputes or need clarifications. The child should sleep in his own bed. Infants need to have their security needs met by being held and cuddled. A. During toddlerhood. Therefore. are too difficult to manipulate and may be hazardous if the pieces are small enough to be aspirated. notifying he physician or performing additional examinations are inappropriate. Toddler growth patterns occur in a steplike. toddlers are more likely to rip a comic book apart. a child needs to be dry for only 2 hours. Usually. Although they may enjoy looking at some of the pictures. not linear pattern. Any time earlier would be inappropriate. Dress-up clothes enhance imaginative play and imagination. Toddlers typically enjoy socialization and limiting others at meal time. The child also must be able to sit. infants need to have their needs met consistently and effectively to develop a sense of trust. The school-aged child is in the stage of concrete operations. Here are the answers and rationale for this examination. A 5month-old is too young to use a push-pull toy. Toddlers become picky eaters. The hypothalamus is responsible for releasing gonadotropin-releasing hormone. Vigorous activity at bedtime stirs up the child and makes more difficult to fall asleep. Underdeveloped abdominal musculature gives the toddler a characteristically protruding abdomen. Quiet play and time with parents is a positive bedtime routine that provides security and also readies the child for sleep. Multiplepiece toys. 11. B. experiencing food jags and eating large amounts one day and very little the next. According to Erikson. such as in the case of the infant of a substance-abusing mother. Collecting baseball cards and marbles. In reaction formation. please direct them to the comments section. The menstrual. Additionally. toddlers experience a sense of shame when they are not allowed to develop appropriate independence and autonomy. 9. C. B. B. and fluid decrease due to the dramatic slowing of growth rate. D. a locked door is frightening and potentially hazardous. and squat. Miniature cars also have a high potential for aspiration. A busy box facilitates the fine motor development that occurs between 4 and 6 months. Thus. ordering dolls by size. The ischial spines are located in the mid-pelvic region and could be narrowed due to the previous pelvic injury. Balloons are contraindicated because small children may aspirate balloons. will develop a sense of uncertainty. This association does not occur until late infancy or early toddlerhood. 2. leading to mistrust of caregivers and the environment. D. Roles for nurse midwives and clinical nurse specialists did not develop from this challenge. sacral promontory. Prepared childbirth was the direct result of the 1950’s challenging of the routine use of analgesic and anesthetics during childbirth. protein. and pubic arch are not part of the mid-pelvis. Thus. The child must be able to sate the need to go to the bathroom to initiate toilet training. C. logical operations. Infants cry for many reasons. 4. 6. Schoolagers develop a sense of inferiority when they do not develop a sense of industry. Big wheels and tricycles encourage gross motor development. Preschoolers develop a sense of guilt when their sense of initiative is thwarted. At 2 months of age. such as puzzle. and ghosts. Telling the child about locking him in his room will viewed by the child as a threat. Follicle-stimulating hormone and leuteinzing hormone are released by the anterior pituitary gland. An infant whose needs are consistently unmet or who experiences significant delays in having them met. which may affect the child’s going to bed at night. Reaction formation is the schoolager’s typical defensive response when hospitalized. secretory and ischemic phases do not contribute to this variation. this toy is unsafe for children younger than 3 years. D. 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. Toddlers are characteristically bowlegged because the leg muscles must bear the weight of the relatively large trunk. 3. food intake decreases. Infants develop mistrust when their needs are not consistently gratified. allowing preschoolers to engage in rich fantasy play. 13. B. and simple problem-solving options are examples of the concrete operational thinking of the schoolager. The LDRP was a much later concept and was not a direct result of the challenging of routine use of analgesics and anesthetics during childbirth. A toddler’s appetite and need for calories. Tell us also your scores! 1. C. . Preschoolers commonly have fears of the dark. which are not developed until adolescence. Because the button eyes of a teddy bear may detach and be aspirated. not increases. Assuming that the child s hungry may cause overfeeding problems such as obesity. being left alone especially at bedtime. Toddlers prefer to feed themselves and thus are too young to have table manners.D. marked by inductive reasoning. According to Erikson. Preschoolers develop guilt when their initiative needs are not met while schoolagers develop a sense of inferiority when their industry needs are not met. they are unable to make the connection between crying and attention. D. Building blocks and wooden puzzles are appropriate for encouraging fine motordevelopment. 7. and reversible concrete thought. A toddler’s food gags express a preference for the ritualism of eating one type of food for several days at a time. walk. 14. the earliest age at which to introduce foods is 4 months. A new sibling would most likely hinder toilet training. Toddlers develop a sense of shame when their autonomy needs are not met consistently. 8. B. not 4 hours. finger paints would be an appropriate toy choice. The ability to consider the future requires formal thought operations.

School-agechildren develop a sense of inferiority when they do not develop a sense of industry. 16. C. C. The incidence of adolescent pregnancy has declined since 1991. The parents need more teaching if they state that they will keep the child home until the phobia subsides. owing to increased risk from bleeding due to thrombocytopenia. The school-aged child is also still prone to accidents and home hazards. Rationalization is the attempt to make excuses to justify unacceptable feelings or behaviors. Iron-rich foods help with anemia. Acute lymphocytic leukemia (ALL) causes leukopenia. Asking the adolescent how he feels about the acne will encourage the adolescent to share his feelings. Immunization for diphtheria and tetanus is required at age 13. Menarche refers to the onset of the first menstruation or menstrual period and refers only to the first cycle. Sharing crayons. 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 schoolager’s cognitive level is sufficiently developed to enable good understanding of and adherence to rules. B. The parachute reflex appears at 9 months. Plus the home hazards differ from other age groups. when two toddlers sit near each other but play with separate dolls.expression of unacceptable thoughts or behaviors is prevented (or overridden) by the exaggerated expression of opposite thoughts or types of behaviors. 28. 24. Some parental or caregiver assistance is still needed to answer questions and provide guidance for decisions and responsibilities. During this time the child develops formal adult articulation patterns and learns that words can be arranged in structure. and medications. the initial priority nursing intervention would be to institute infection control precautions to decrease the risk of infection. A. A child’s birth weight usually triples by 12 months and doubles by 4 months. 18. Thus. may include firearms. C. Most children with cleft palate remain well-nourished and maintain adequate nutrition through the use of proper feeding techniques. 19. These hazards. D. high neonatal mortality. prolonged labor. Collaboration with the teachers and counselors at school may lead to uncovering the cause of the phobia and to the development of solutions. A 3-month-old infant should be able to lift the head and chest when prone. 15. although important. According to Erikson. Toddlers engaging in parallel play will play near each other. they are exhibiting parallel play. 22. yet morbidity remains high. Collective. 27. Explicit sexual behavior during doll play is not a characteristic of preschool development nor symptomatic of developmental delay. 20. iron deficiency anemia. 21. children with cleft palate may have ineffective functioning of their Eustachian tubes creating frequent bouts of otitis media. Thus. . the child has been exposed to such behavior. alcohol. a leading cause of death in children with ALL. Early recognition by a parent or health care provider may be crucial to timely initiation of prenatal care. Plus the child is away from home more often. If a child does so. C. Injections should be discouraged. Regression is seen in toddlers and preshcoolers when they retreat or return to an earlier level ofdevelopment . No specific birth weight parameters are established for 7 or 9 months. Uterine growth and broadening of the pelvic girdle occurs before menarche. The child should attend school even during resolution of the problem. 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 needs to the parents and may help to gain trust with the adolescent. A. The child should participate and play an active role in developing possible solutions. There is no association between cleft palate and congenial ear deformities. which are potentially lethal but tempting. Therefore. but not with each other. Because of the structural defect. The adolescent who becomes pregnant typically denies the pregnancy early on. Allowing the child to verbalize helps the child to ventilate feelings and may help to uncover causes and solutions. 26. The prognosis of ALL usually is good. A. D. Whether or nor the child knows how to play with dolls is irrelevant. role diffusion develops when the adolescent does not develop a sense of identity and a sense or where he fits in. D. 23. or sharing dolls with two different nurses are all examples of cooperative play. B. However. 25. especially because of increased motor abilities and independence. C. The Moro reflex typically diminishes or subsides by 3 months. Preschoolers develop a sense of guilt when they do not develop a sense of initiative. The pregnant adolescent is at high risk for physical complications including premature labor and low-birthweight infants. playing a board game with a nurse. but dietary iron is not an initial intervention. the nurse may need to assist the child and family with coping since death and dying may still be an issue in need of discussion. schoolagers should be able to understand the potential dangers around them. are not most significant skills learned. and sexual abuse should be suspected. Food particles do not pass through the cleft and into the Eustachian tubes. later on. The most significant skill learned during the school-age period is reading. and fetopelvic disproportion as well as numerous psychological crises. Doing so reinforces the child’s feelings of worthlessness and dependency. A. With growth comes greater freedom andchildren become more adventurous and daring. Most teenage pregnancies are unplanned and occur out of wedlock. School-agechildren begin to internalize their own controls and need less outside direction. 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. ordering. Preschoolers should be developmentally incapable of demonstrating explicit sexual behavior. and sorting. 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. resulting in immunosuppression and increasing the risk of infection. Based on the recommendations of the American Academy of Family Physicians and the American Academy of Pediatrics. Rolling from front to back usually is accomplished at about 5 months. Repression refers to the involuntary blocking of unpleasant feelings and experiences from one’s awareness. Toddlers develop a sense of shame when they do not achieve autonomy. 17.

B. 4. large blocks would be the most appropriate toy selection. and 15 to 18 months and a booster at 4 to 6 years. thereby requiring special devices to allow for feeding and sucking gratification. Rattles and mobiles are more appropriate for infants in the 1 to 3 month age range. not the diphtheria. 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. D. 44. thereby increasing the chance of the child developing a urinary tract infection. 36. The intake of acidic juices helps to keep the urine pH acidic and thus decrease the chance of flora development. the child will be unable to from the mouth adequately around nipple. not complex. 42. depressed nasal bridge. Repression is the submerging of painful ideas into the unconscious. frequent vomiting. 39. Projectile vomiting is a key symptom of pyloric stenosis. Regurgitation is seen more commonly with GER. A. especially associated with painful experiences. 31. The mother is using projection. but exhibits slowness in performing tasks. the nurse would monitor the child’s vomiting to evaluate the effectiveness of using the thickened feedings. Therefore. 45. B. walking. A. Fluid volume deficit. Multiple bruises and burns on a toddler are signs child abuse. Therefore. and diarrhea and seizure disorders are not associated with congenital heart disease. A. always a pediatric emergency. The first dose of hepatitis B vaccine is given at birth to 2 months. the child is not noted as being retarded. The varicella zoster vaccine (VZV) is a live vaccine given after age 12 months. not competitive. Frequent emptying of the bladder would help to decrease urinary tract infections by avoiding sphincter stress. D. During this period. B. In females. large protruding tongue. he or she may aspirate. Scheduling a follow-up visit is inappropriate because additional harm may come to the child if the nurse waits for further assessment data. Because of the defect. Multiple bruises and burns are not normal toddler injuries. Bleeding tendencies. Thickened feedings are used with GER to stop the vomiting. and then again at 6 to 18 months. not traction. A. Throat examination may result in laryngospasm that could be fatal. thus helping to prevent urinary tract infections. high-arched palate. Mild mental retardation refers to development disability involving an IQ 50 to 70. 33. Locomotion would be a problem for the older infant because of the use of restraints. is being used in this situation for immobilization. so releasing the traction would be inappropriate. the nurse is responsible for reporting the case to Protective Services immediately to protect the child from further harm. D. Down syndrome is characterized by the following a transverse palmar crease (simian crease). GI functioning is not compromised in the child with a cleft lip. Steatorrhea occurs in malabsorption disorders such as celiac disease. Increased fluid intake enables the bladder to be cleared more frequently. No alteration in the oral mucous membranes occurs with this disorder. B. Respiratory status may be compromised if the child is fed improperly or during postoperative period. 6. In this situation. The pertusis component may result in fever and the tetanus component may result in injection soreness. the mother’s verbalization of information about measures to reduce fever indicates understanding. oblique palpebral fissures. and muscle weakness. Notifying the physician immediately does not initiate the removal of the child from harm nor does it absolve the nurse from responsibility. The child is exhibiting classic signs of epiglottitis. One common fear is fear of the body mutilation. A subsequent rash is more likely to be seen 5 to 10 days after receiving the MMR vaccine. pertussis. 38. specific action not continued monitoring is indicated. The cast. such as when the mother would kick a chair or bang the door shut. Therefore. the child commonly experiences more fears than at any other time. 37. This decreases the distance for organisms to travel. B. A. Having the child lie down would cause additional distress and may result in respiratory arrest. separated sagittal suture. Psychosis is a state of being out of touch with reality. Using an infant seat does not facilitate drainage. excess and lax skin. Typically. No dietary restrictions are necessary after this injection is given. and tetanus vaccine. 30. Mobiles pose a danger to older infants because of possible strangulation. Acetaminophen (Tylenol) will be ineffective since the pain is related to the increasing pressure and tissue ischemia. Side-lying does not facilitate drainage as well as the prone position. and taking. being able to sit unsupported and also improving his fine motor skills. The situation is a possible lifethreatening emergency. The physician must be notified immediately and the nurse must be prepared for an emergency intubation or tracheostomy. Push-pull toys would be more appropriate for the 10 to 12-month-old as he or she begins to cruise the environment. During the preschool period. small nose. and altered nutrition are appropriate nursing diagnoses. Displacement is the transfer of emotion onto an unrelated object. The preschool child uses simple. C. Although the nurse should notify the physician. the child has mastered a sense of autonomy and goes on to master a sense of initiative. wide spacing and plantar crease between the second and big toes. 32. If feedings are . 41. A. reasoning. Children with congenital heart disease are more prone to respiratory infections. 35. DtaP is routinely given at 2. and is able to tolerate longer periods of delayed gratification. If the child is placed in the supine position. such as self-feeding. and gait disabilities would be seen in more severe forms mental retardation. No relationship exists between feedings and characteristics of stools and uterine. the defense mechanism used when a person attributes his or her own undesirable traits to another. play (interactive and cooperative play with sharing). then at 1 to 4 months. 40. Further assessment with auscultating lungs and placing the child in a mist tent wastes valuable time. probably capable of making hand-to-hand transfers. the urethra is shorter than in males. GER is the backflow of gastric contents into the esophagus resulting from relaxation or incompetence of the lower esophageal (cardiac) sphincter. hyperextensible and lax joints. the goal is to initiate measures to protect the child’s safety. C. risk for aspiration. Because the 8-month-old is refining his gross motor skills. marked motor delays.29. “Currant jelly” stools are characteristic of intussusception. Postoperatively children with cleft palate should be placed on their abdomens to facilitate drainage. 43. A. engages in associative. 34. Diarrhea is not associated with this vaccine. Little or no speech.

Acute. Current. Failure to pass meconium within the first 24 hours after birth may be an indication of Hirschsprung disease. ingestion of gluten. Stool inspection. . wheat and wheat-containing products must be avoided. fever and explosive diarrhea indicate enterocolitis. and chicken do not contain gluten and need not be avoided. 48. Failure to pass meconium is not associated with celiac disease. Respiratory distress is unlikely in a routine upper respiratory infection. obtaining a family history would provide the least amount of information. Irritability. a life-threatening situation. intussusception. The child is acutely ill and requires intervention. A. or exposure to anticholinergic drugs. episodic abdominal pain is characteristics of intussusception. 50. rather than lethargy. Because of the fluid loss associated with the severe watery diarrhea. Children with celiac disease cannot tolerate or digest gluten. For the child with Hirschsprung disease. because of the intestinal obstruction and inadequate propulsive intestinal movement. jelly-like stools containing blood and mucus are an indication of intussusception. the child’s weight is more likely to be decreased. prolonged fasting. is more likely. Celiac crisis is typically characterized by severe watery diarrhea. C. this should be noted before there is any change in the child’s weight. 46. C. Hirschsprung disease typically presents with chronic constipation. because of its gluten content. Therefore. and abdominal palpation would reveal possible indicators of intussusception. the physician should be notified immediately. Because intussusception is not believed to have a familial tendency. Therefore. Generally. 49. C. pain pattern. A sausage-shaped mass may be palpated in the right upper quadrant.ineffective. with monitoring more frequently than every 30 minutes. Rice. a congenital anomaly resulting in mechanical obstruction due to inadequate motility in an intestinal segment. or abdominal wall defect. antidiarrheals are not used to treat Hirschsprung disease. 47. Episodes of celiac crises are precipitated by infections. milk. A.