Manila Adventist College

School of Nursing
Online Assignment

Name: Kurfessa Abdisa H.

Instruction: Write the correct answer on the space provided and then write your rationale cited from
textbooks, manuals, etc., as a support to your answer.

1. A young primigravida at 12 weeks gestation tells the nurse that she is having a hard time to quit
smoking. The nurse explains to her that smoking during pregnancy is associated with:
A. Low Birth weights C. placenta previa on the third trimester
B. Large for gestational age infants D. Early decelerations during labor

Answer: A

Rationale: Smoking during pregnancy increases the risk of health problems for developing babies,
including preterm birth, low birth weight, and birth defects of the mouth and lip. sudden infant death
syndrome (SID

2. What is the proteolytic enzyme released by the sperm cell to achieve active penetration in the egg
cell’s protective cell membrane?
A. Hyaluronidase C. Spermatogenesis
B. Chlironidase D. Corona radiate

Answer: A

Rationale: hydrolysis in granular cells and the zona pellucida of the egg in order to assist the penetration
of the sperm and the merger with the egg

3. Continuous assessment of fetal well-being after umbilical cord proplapse is accomplished

primarily by?
A. Palpating the cord to determine FHR
B. Observing the patient’s emotional status
C. Determining the station of the presenting part
D. Ensuring that the amniotic fluid contains no meconium

Answer: A

Rationale: Continuous electronic fetal heart rate monitoring is a useful adjunct in assessing fetal
wellbeing and to assess whether the technique being used to eliminate cord compression are successful.
 4. Which of the following assessment findings done by the nurse after birth of the newborn should
be reported to the physician?
A. Newborn has irregular beating C. Fontanelles are slightly elevated
B. Newborn is pink in color D. newborn has vernix caseosa

Answer: A

Rationale:

Infants with abnormal heart rhythms may seem extra irritable or fussy, have feeding difficulties, appear
pale, and lack energy. So that the nurse should report it to the physician.

5. A pregnant diabetic client at 16 weeks gestation has her first prenatal check-up. Which of the
following information would be provided if the client undergoes an ultrasound examination?
A. Placental maturity C. gestational age
B. Estimated fetal weight D. Fetal lung maturity

Answer: B

Rationale: Fetal growth and fetal size in diabetic pregnancy is a major concern for perinatologists. Most,
if not all, obstetricians rely on ultrasound to estimate fetal weight. In diabetic pregnancy, due to maternal
hyperglycemia, high maternal–fetal glucose transfer leads to excessive insulin production in the fetus

6. Maternal care according to the DOH guidelines consists of the following except:
A. Care of the pregnant woman
B. Safe delivery of the mother
C. Postnatal care of the infant
D. That the child receives adequate nourishment

Answer: D

Rationale: “Children with Moderate Acute Malnutrition have a higher risk of mortality associated with
nutrition-related deaths.

7. Nurse Evelyn is assigned to handle postpartum mothers focusing on home care. She is scheduled
to do a first home visit to Mrs. Sandoval. When is the first postpartum visit typically done?
A. Within a week after discharge C. 6 weeks postpartum
B. 1 week postpartum D. immediately after delivery

Answer: C

Rationale: many doctors want to schedule the first postpartum visit six weeks after you deliver. But in my
opinion, that's too late. If a woman has a vaginal delivery and doesn't have any complications during or
after giving birth, I like to see her at two to four weeks postpartum
 8. Postpartum haemorrhage is defined as loss of how many ml of blood documented in the first 24
hours postpartum?
A. 200 C. 400
B. 300 D. 500

Answer: D

Rationale:

Blood loss in excess of 500 ml following birth within the first 24 hours of delivery.

9. Mrs. Marciano undergoes bilateral tubal ligation after the birth of her 6th baby. After the
procedure, she is discharged and given instructions. She understood her discharge instructions
when she says..
A. Rest for one week C. Not carry her youngest child
B. Take a bath immediately D. Have a sexual contact with her husband immediately

Answer: A

Rationale: Avoid strenuous activities such as lifting heavy objects and intense exercise for 7 days after
your surgery. Ask when it is safe for you to drive, return to work, and return to other regular activities. Do
not have sex for at least 1 week.

10. Kathleen at 32 weeks gestation is advised to have an ultrasound. She has understood the
procedure if she says:
A. Turn client on her left lateral position C. Increased IVF rate
B. Administer oxygen to the patient D. Assess client for maternal
hypotension

Answer: __A__

Rationale: Because your liver is on the right side of your abdomen, lying on your left side helps keep the
uterus off that large organ. Sleeping on the left side also improves circulation to the heart and allows for
the best blood flow to the fetus, uterus, and kidneys

11. In doing postpartum assessment, the first hour is most critical. Which of the following
interventions is a priority?
A. Massage uterine fundus gently at the slightest sign of relaxation.
B. Check vital signs until stable.
C. Administer oxytocin as ordered
D. Infuse intravenous fluids as ordered.

Answer: A
Rationale: The first hour, after placental separation and birth, observation of bleeding signs and symptoms
by palpating the fundus of the uterus through the abdominal wall.

12. Kelly asks about supplemental vitamins that she should take during her pregnancy. Which of the
following should she advised to take in order to enhanced absorption of iron?
A. Warm milk C. Prune juice
B. Orange juice D. Coffee

Answer: B

Rationale: Vitamin C can help prevent cell damage and assist with iron absorption. Vitamin C helps your
body absorb nonheme iron better when you eat both at the same meal. On the other hand, certain drinks
and foods prevent your body from absorbing iron.

13. A nurse on duty at the labor room is assessing Mrs. Arevalo’s amniotic fluid fluid. Which
characteristics of the amniotic fluid indicates fetal distress?
A. Mucus-tinged C. Greenish
B. Colorless D. Pinkish

Answer: C

Rationale: Green-tinged amniotic fluid is indicative of meconium staining. This finding indicates fetal
distress

14. Client Sharon delivered a healthy term baby boy. She asks the nurse why her baby’s hands and
feet are bluish in color. The nurse refers to this condition as:
A. Port wine stain C. Epstein pearls
B. Acrocyanosis D. Mongolian spots

Answer: B

Rationale:Acrocyanosis means bluish discoloration of the extremities due to decreased amount of oxygen
delivered to the peripheral part.

15. A client at 37 weeks gestation, started to have a bloody vaginal discharge while doing errands and
was immediately rushed to the ER. What is the nurse’s initial intervention?
A. Monitor FHR every 15 minutes C. Administer oxygen therapy
B. Position the client on her left lateral position D. Start the client on IV tocolytic

Answer: A

Rationale: One out of 10 women will have vaginal bleeding during their 3rd trimester. At times, it may be
a sign of a more serious problem. .
 16. Julia, a primigravida is admitted at the medical facility in labor. Which finding indicates that Julia
has achieved the first stage of labor?

A. Presenting part is in station +1

B. Cervical dilatation of 10 cm
C. Cervix is 75% effaced
D. There is severe back pain radiating to the hypogastrium

Answer: B

Rationale: The first stage of labor and birth occurs when you begin to feel regular contractions, which
cause the cervix to open (dilate) and soften, shorten and thin (effacement). This allows the baby to move
into the birth canal

17. Julia is then brought to the delivery room after the physician has examined her. Which of the
following routine procedures should not be done considering her cervical dilatation?
A. Do perineal prep C. Monitor vital signs and FHT
B. Place her on NPO D. Doing a cleansing enema
Answer: B

Rationale: There is no need to put the patient into NPO.

18. While assessing a client in labor, which of the following observations should the nurse refer
immediately to the physician?
A. Frequent urination C. Sudden gush of amniotic
fluid
B. Blood streaked mucus in the vaginal discharge D. FHT 130/min after uterine
contraction

Answer: C

Rationale: The main symptom of Premature Rupture of Membranes at Term (PROM) is fluid leaking
from the vagina. You may experience a sudden gush of fluid or a slow, constant trickle. It can be
difficult to distinguish between a slow amniotic trickle or urine.

19. Which of the following indicates placental separation after delivery of the baby?

1. Protrusion of the umbilical cord

2. Descent of the uterus into the pelvis
3. Uterus becomes firm and rounded
4. Sudden gush of blood
 A. 1, 3, 4 C. 2, 3, 4
B. 1, 2, 4 D. 1, 2, 3

Answer: C

Rationale:Signs of Placental Separation

20. A newly delivered baby manifest with outlined color change. When the infant lies on one side,
the lower half of the body becomes pink and the upper half becomes pale. The nurse is correct
when she says that this known as:

A. Erythema toxicum C. Acrocyanosis

B. Harlequin sign D. Mongolian spot

Answer: B

Rationale: Harlequin sign A benign, transient color change seen in neonates in which one half of the body
blanches while the other half becomes redder, with a clear line of demarcation.

21. A 28 weeks gestation primigravida is diagnosed with Class 2 heart disease. The nurse instructs
her to contact her physician immediately if she experiences :

A. Mild ankle edema C. Weight gain of one pound a week

B. Emotional stress on the job D. Increase dyspnea at rest

Answer: D

Rationale: Peripartum cardiomyopathy should be considered in any pregnant or puerperal woman who
complains of increasing shortness of breath, especially on lying flat or at night.

22. Susan’s last LMP was started on October 12. on her first prenatal check-up, the nurse informs her
that her EDC will be on:

A. June 5 C. July 5
B. June 19 D. July 19

Answer: D

Rationale: EDC = LMP - 3months + 7 days

23. In a childbirth preparation class, the nurse explains that in the postpartum period the process
where the uterus shrinks to it’s prepregnant state is known as:
 A. Puerperium C. Involution
B. Subinvolution D. Uterine Atony

Answer: A

Rationale: the period of about six weeks after childbirth during which the mother's reproductive organs
return to their original nonpregnant condition.

24. On her first trimester of pregnancy, which of the following hormones is responsible for
maintaining Susan’s pregnancy?

A. HCG C. Estrogen
B. Relaxin D. Progesterone

Answer: A

Rationale: Human chorionic gonadotrophin is the embryonic hormone that ensures the corpus luteum
continues to produce progesterone throughout the first trimester of pregnancy

25. A sign of pregnancy that relaxes to painless, irregular false labor is known as:

A. Goodell’s sign C. Fetal movement

B. Braxton Hick’s D. Leukorrhea

Answer: B

Rationale: Braxton Hicks are when the womb contracts and relaxes. Sometimes they are known as false
labor pains. Not all women will have Braxton Hicks contractions.
PART 2 (NCP)

Case: Pregnacy Induced Hypertension

Assessment Nursing Outcome Interventions Rationale

diagnosis

Subjective: Decreased cardiac After 8 hours of Monitor blood Comparison of

output related
not applicable nursing pressure of the pressures provide a
To interventions, the more complete
Objective: patient. Measure
pregnancy induced Hypovolemia/decr patient will picture of vascular
in both arms or
hypertention eased venous participate in involvement or
thighs three times,
return activities that scope of the
3-5
reduce blood problem.
pressure or minutes apart
cardiac workload
while patient is at
rest, then sitting
then standing for

initial evaluation.

2. Observe skin Presence of

color, moisture, pallor, cool, moist

temperature and skin and delayed
capillary refill capillary refill time
time. may be due to
peripheral
vasoconstriction

3.Institute bedrest Improves venous

with patient in return, cardiac
lateral position output, and
renal/placental
perfusion.

Collaborative:

4.Give
antihypertensive If BP does not
drug such as respond to
hydralazine conservative
(Apresoline) measures, short-
PO/IV, so that term medication
diastolic readings may be needed in
are between 90 conjunction with
and 105 mm Hg. other therapies,
Begin e.g., fluid
maintenance replacement and
therapy as MgSO4.
needed, e.g., Antihypertensive
methyldopa drugs work directly
(Aldomet) or on arterioles to
nifedipine promote relaxation
(Procardia). of cardiovascular
smooth muscle and
help increase blood
supply to cerebrum,
kidneys, uterus, and
placenta.
Hydralazine is the
drug of choice
because it does not
produce effects on
the fetus

Implement dietary

sodium, fat, and

5.Implement cholesterol
dietary sodium,
fat, and restrictions as

cholesterol indicated.

restrictions as hypertension.

indicated.
Assessment Nursing diagnosis Outcome Intervention Rationale

Subjective: Impaired Tissue After 4 hours of Independent Reduced placental

Perfusion related nursing blood flow results
not applicable 1.Provide
to Interruption of intervention in reduced gas
information to
Objective: blood flow Patient will exchange and
client/couple
pregnancy (progressive demonstrates impaired
regarding home
induced vasospasm of normal CNS nutritional
assessment/recor
hypertension spiral arteries) reactivity on functioning of the
ding g of daily fetal
nonstress test placenta.
movements and
(NST)
when to seek
immediate
medical attention.

2. Identify factors
affecting fetal Cigarette
activity. smoking,
medication/drug
use, serum
glucose levels,
environmental
sounds, time of
day, and sleep-
wake cycle of the
fetus can increase
or decrease fetal
movement.

Prompt
recognition and
intervention
increases the
3. Review signs of likelihood of a
abruptio positive outcome
placentae (i.e.,
vaginal bleeding,
uterine
tenderness,
abdominal pain,
and decreased
fetal activity).

BPP helps
evaluate fetus and
4. Collaborative
fetal environment
on five specific
parameters to
Assess fetal
assess CNS
response to BPP
function and fetal
criteria or CST, as
contribution to
maternal status
amniotic fluid
indicates. (Refer
volume. CST
to ND: Injury, risk
assesses placental
for maternal.)
functioning and
reserves.

Corticosteroids
are thought to
induce fetal
pulmonary
maturity
(surfactant
production) and
prevent
5.Administer
corticosteroid respiratory
(dexamethasone, distress
betamethasone syndrome, at least
in a fetus
delivered
prematurely
because of
condition or
inadequate
placental
functioning
Assessment Nursing Outcome Intervention Rationale
diagnosis
Fluid Volume After 8hours of Independent. Sudden,
deficit may be nursing 1.Weigh client significant weight
related to Plasma intervention the routinely. gain (e.g., more
protein loss, patient will Encourage client than monitor
decreasing plasma Verbalize to monitor weight weight at home
colloid osmotic understanding of at home between between visits.
pressure, allowing need for close visits
monitoring of
fluid shifts out of
weight, BP, urine
the vascular 2.Distinguish
protein, and
compartment. between The presence o f
edema.
physiological and pitting edema
pathological (mild, 1+ to 2+ 3+
severe, edema of to 4+) of face ,
pregnancy. hands, legs, sacral
Monitor location area, or abdo-
and degree of minal wall, or
pitting. edema that does
not disappear
after 12 hr of
bedrest is
significant.

3. Note changes in Identifies degree

Hct/Hb levels of
hemoconcentratio
n caused by fluid
shift. If Hct is less
than 3 times Hb
level,
hemoconcentratio
n exists.
Collaborative:
4.Schedule Necessary to
prenatal visit monitor changes
every 1–2 wk if more closely for
PIH is mild; weekly the well-being of
if severe the client and
fetus.
5Refer to dietitian Nutritional
as indicated consult may be
beneficial in
determining
individual
needs/dietary
plan.