PRELIMS

MCN RLE Quiz 1

1) What is fast breathing in a 24 month old child?
- 40 breathes per minute or more

2) An 18 month old Baby Tanya was brought to the Health Center by her Yaya because of diarrhea
occurring 4-5x a day. Her skin goes back slowly after a skin pinch and her eyes are sunken. The
nurse offers fluid to Tanya and she drinks eagerly. Using the IMCI guidelines, you will classify
Tanya as
- Some dehydration

3) Which of the following signs that the child is suffering from severe pneumonia?
- Chest indrawing

4) If a child with diarrhea register 2 signs in the yellow row in the IMCI chart, we can classify the
patient as
- Some dehydration

5) What color is “NO PNEUMONIA COUGH AND COLDS” classified as

- Green

6) For which of the following settings for the IMCI guidelines suitable for use?
- Outpatient department of a hospital

7) Paz is observed to have some palmar pallor. That can be classified as

- Anemia

8) Treatment for chronic ear infection would be

- Instill quinolone otic drops and dry the by wicking

9) Which of the following age groups do the IMCI clinical guidelines address?
- Birth – 5 years
10) If the child only one of the danger signs implicitly stated in the IMCI guidelines, this child will be
classified under what color?
- Pink

11) Mrs. Yelle brought Danica, her 3 year old daughter to the health center due to cough for 1 week,
unusual irritability and vomiting. On your assessment, you noted temp. of 37.6, cough and
respiratory rate of 48 bpm. Using sick child chart Danica can be classified under
- Severe pneumonia

12) Which of the following should you ask to check for the danger signs in a 4 month old with fever
for 4 days?
- Is she able to drink or breastfeed?

13) Which of the following is the important of patient with dengue fever?
- Replacement of body fluids

14) A child with diarrhea is observed for the following except

- Skin petechiae

15) You have observed pus draining from the ear of a 4 year old child and is reported for less than 14
days. These can be classified as.
- Acute ear infection

16) All are signs of measles except

- Stiff neck

17) A follow up visit for 5 days should take place if a child is classified as having which of the
following conditions?
- Ear problem

18) Which of the following are considered 4 general danger sign except?
- Difficulty of breathing

19) In assessing the patient’s condition using the IMCI approach strategy, the first thing that the
nurse should do is to
- Check for the general danger signs
20) Which among the choices is the next step in IMCI after assessing the child of young infant?
- Classify

21) Mommy Jenny is using Oresol in the management of diarrhea of her 18 month old Baby Tanya.
She asked you what to do if baby Tanya vomits. You will tell her.
- Let baby rest for 10 minutes then continue giving Oresol more slowly

22) Patient Rey is a 1 year old and has visible severe wasting and edema on both feet. This can be
classified as.
- Severe Malnutrition

23) A 4 year old child was observed to have tender swelling behind the ear, this can be classified as
- Mastoiditis

24) Which of the following immunization should a 10 weeks old child classified as EAR INFECTION
receive today? Her immunization card shows that she has already received the following
vaccination: BCG, HEP B-1, OPV-1.
- HEP. B-2, HIB-1, OPV-2
MCN RLE Quiz 2
1) What does the color pink indicates in classifying the child’s illness?
- Indicates urgent hospital referral or admission

2) Only a limited number of carefully-selected clinical signs are used, based on evidence of their
sensitivity and specificity to detect disease.
- TRUE

3) Treatment for Dysentery would be:

- Give ciprofloxacin for 3 days

4) In Integrated Management of Childhood Illness, severe conditions generally require urgent

referral to a hospital. Which of the following severe conditions DOES NOT always require urgent
referral to a hospital?
- Severe dehydration

5) Based on assessment, you classified a 3-month-od infant with the chief complaint of diarrhea in
the category of SOME DEHYDRATION. Based on IMCI management guidelines, which of the
following will you do?
- Supervise the mother in giving 200 to 400 mL of Oresol in 4 hours.

6) What does IMCI stands for?

- Integrated Management of Childhood Illness

7) The following illness are covered by IMCI except

- Influenza

8) A 4-month-old infant was brought to the health center because of a cough. Her respiratory rate
is 42/minute. Using the Integrated Management of Child Illness (IMCI) guidelines of assessment,
her breathing is considered.
- Normal

9) Mommy Chen is using Oresol in the management of diarrhea of her 3-year-old Baby Nixon. She
asked you what to do if baby Nixon vomits. You will tell her to…
- Let Baby Nixon rest for 10 minutes then continue giving Oresol more slowly.
10) A mother brought her 4-year-old daughter to the RHU because of cough and colds. Following the
IMCI assessment guide, which of the following is a danger sign that indicates the need for urgent
referral to a hospital?
- Inability to drink

11) Assessment of a 2-year-old child revealed “baggy pants”. Using the IMCI guidelines, how will you
manage this child?
- Refer the child urgently to a hospital for confinement

12) A mother brought her 10-month-old infant for consultation because of fever, which started 4
days prior to consultation. To determine malaria risk, what will you do?
- Ask where the family resides

13) A 3-year-old child was brought by his mother to the health center because of fever of 4-day
duration. The child had a positive tourniquet test result. In the absence of other signs, which is
the most appropriate measure that the PHN may carry out to prevent Dengue shock syndrome?
- Instruct the mother to give the child Oresol.

14) Who founded IMCI?

- WHO and UNICEF

15) It is a strategy that integrates all available measures for disease prevention and health problems
during childhood, for their early detection and effective treatment, and for promoting healthy
habits within the family and community.
- Integrated Management of Childhood Illness

16) What color classification indicate pneumonia?

- Yellow
MCN RLE Quiz 3
1) It is an intervention after a baby is born to help it breathe and to help its heart beat
- Resuscitation

2) In the first minute after birth, as a health care provider you should
- Help the baby breathe

3) Anticipation of problems for delivery should always be part of our consideration as health care
provider before delivery. To prepare for a birth.
- You identify a helper and review the emergency plan.

4) To prepare the area for delivery, how are you going to do it?
- Make sure the area is clean, warm, and well-lighted.

5) Routine care for a healthy baby at birth includes the following in what sequence?
- Drying, removing the wet cloth and positioning the baby to skin-to-skin contact.

6) A baby is quiet, limp, and not breathing at birth. What should you do as your priority?
- Dry the baby thoroughly

7) Which baby cannot receive routine care after birth? SATA

- A baby who is not breathing
- A baby who is gasping
- A baby who is limp

8) A baby is born through meconium-stained amniotic fluid. The baby is crying. Which statement is
TRUE?
- All babies born through meconium-stained amniotic fluid can receive routine care as long as
the baby is crying. Continue to monitor afterwards.

9) What is your priority in the Golden Minute?

- Warm the baby and help a baby breathe if necessary

10) If neonate is still pale or cyanotic, floppy, no breathing and has HR <100 despite first initial
assessment and interventions, what is the next thing to do?
 - Give 5 initial breath by counting out loud

11) What is the position of the neonate when performing resuscitation?

- Neutral or sniffing position

12) When giving ventilation to the neonate, what should the health care provide assessing?
- Inspect for chest movement

13) If the baby is not responding after giving 5 initial breaths, what maneuver will you perform to the
neonate’s head?
- Jaw thrust

14) Placenta is the organ of exchange during intrauterine life. The lungs assume the responsibility of
gas exchange and oxygenation once the cord is clamed/cut and the baby has its first breath
- TRUE

15) What is the correct sequence of steps when performing the chest compression for neonate?
1. Hold the baby’s chest with two hands while placing the thumbs on the lower third of the
sternum just below the nipple line.
2. Compress straight down at least 1/3 the depth of the chest, about 1 ½ inches.
3. Provide three chest compressions to one breathe with the help of another attendant.
4. Make sure there is time for the chest to recoil.
5. Check for responses by listening to the baby’s heart rate every 30 seconds and see chest
movements with each breath, after each intervention.

- 1,2,3,4,5

16) Another method in giving chest compression for smaller babies is using the ring and middle
fingers to gentle press over the breastbone,
- FALSE

17) Which of the following statements about ventilation with bag valve mask and mouth piece is
TRUE?
- Squeeze the bag with proper recoil to produce gentle movement of the chest.

18) Risk factors that may cause stress on the baby before birth include: SATA
- Post term pregnancy
- Medical conditions of the mother such as HTM, DM, Asthma
 - Difficult delivery or long labor
- Decreased oxygen to the infant while in the uterus

19) It is a problem often seen in premature babies. The condition makes it hard for the baby to
breathe due to under developed lungs.
- Neonatal respiratory distress syndrome

20) How can you stimulate breathing for a neonate? SATA

- Gentle rubbing of the back
- Flicking/ticking the heels of the feet

21) When to cease resuscitation

- When the neonate is not breathing and heartbeat is not detectable beyond 10 min after
effective resuscitation efforts

22) Post resuscitation care include the following. SATA

- Once adequate ventilation and circulation has been established stop ventilation
- Return to mother for skin-to-skin contact as soon as possible
- Closely monitor breathing difficulties or signs of asphyxia
- Continue monitoring and anticipate need for further care

23) What is the safest level of oxygen to deliver for neonate when bag valve mask is connected to O2
oxygen machine/tank.
- 5 LPM

24) Too much oxygen consumption for neonates can lead to neonatal blindness known as
Retinopathy of Prematurity
- TRUE

25) It is an effort to manually preserve intact brain function until further measure are taken to
restore spontaneous blood circulation and breathing.
- Chest compression
MCN RLE Quiz
1) A 34-year-old female is currently 16 weeks pregnant. You’re collecting the patient’s health
history. She has the following health history: gravida 5, para 4, BMI 28, hypertension, depression,
and family history of Type 2 diabetes. Select below all the risk factors in this scenario that
increases this patient’s risk for developing gestational diabetes.
- 34 years old
- Gravida 5, para 4
- BMI 28
- Family history of Type 2 diabetes

2) The best technique to determine if the client has ectopic pregnancy that is done initially is.
- Ultrasound

3) There are three common classifications of anemia. What classification does not require the client
to have iron supplement?
- Sickle cell anemia

4) The student nurse was asked to enumerate the s/s of left sided heart failure. She’s correct if…
- Pulmonary edema
- Weight gain
- Cough

5) This refers to the elevated amount of glucose

- Hyperglycemia

6) Rh (D) immune globulin is being given when? Select all that apply
- 28 weeks gestation
- 40 weeks gestation
- Within 72 hours after delivery

7) You’re providing an educational class for pregnant women about gestational diabetes. You
discuss the role of insulin in the body. Select all the CORRECT statements about the role and
function of insulin.
- “Insulin is a hormone secreted by the beta cells of the pancreas”
- “Insulin influences cells by causing them to uptake glucose from the blood”
8) You’re teaching a pregnant mother with gestational diabetes about the signs and symptoms of
hyperglycemia. What are the signs and symptoms you will include in your education to the
patient? Select all that apply.
- Frequent hunger
- Polydipsia
- Frequent urination

9) When are the most pregnant patients tested for gestational diabetes?
- 24 – 28 weeks gestation

10) A 36 year old woman, who is 38 weeks pregnant, reports having dark red bleeding. The patient
experienced abruptio placentae with her last pregnancy at 29 weeks. What other signs and
symptoms can present with abruptio placentae? Select all that apply.
- Hard abdomen
- Tender uterus
- Fetal distress

11) Select all the signs and symptoms associated with placenta previa
- Painless bright red bleeding
- Normal fetal heart rate
- Abnormal fetal position

12) A patient who is 25 weeks pregnant has partial placental previa. As the nurse you’re educating
the patient about the condition and self-care. Which statement by.
- “ I may start to experience dark red bleeding with pain”

13) The 36th week pregnant client went to the hospital for prenatal check up. She was diagnosed
before to have placental previa. Which of the following interventions should not be observed
during the check-up of the client.
- Monitor vital signs
- Monitoring the position of the baby via ultrasound
- Checking the FHT via doppler

14) Which of the following statement is TRUE regarding abruptio placenta?

- It needs fibrinogen via IV

15) The student nurse is correct when she states that the type of bleeding for a client with placenta
previa is.
- Bright red
16) What do you need to observe when the client has H-mole? Select all that apply.
- Persistent nausea and vomiting
- HCG level is between 1-2 million

17) Which statement is correct about gestational trophoblastic disease? Select all that apply.
- Mole is detected via ultrasound
- Risk to have choriocarcinoma
- Risk to have preeclampsia

18) What are the signs and symptoms that may suggest ectopic pregnancy? Select all that apply.
- Shoulder pain
- Cervical motion tenderness
- Cullen’s sign

19) The drug of choice for unruptured ectopic pregnancy is.

- Oral methotrexate

20) A client is said to be Rh sensitized if, Select all that apply

- History of miscarriage
- Had ectopic pregnancy
- Had amniocentesis
MCN RLE Quizzes:

1) A nurse is caring for a client in labor. The nurse determines that the client is beginning in
the 2nd stage of labor when which of the following assessments in noted?
✓ The cervix is dilated completely

2) Mrs. Chan a primigravida patient is admitted to the labor delivery area. Assessment
reveals that she is in early part of the first stage of labor. Her pain is likely to be most
intense.
✓ Around the pelvic girdle.

3) A laboring client is in the first stage of labor and has progressed from 4 to 7 cm in cervical
dilation. In which of the following phases of the first stage does cervical dilation occur
most rapidly?
✓ Active phase

4) The physician asks the nurse the frequency of a laboring client’s contractions. The nurse
assesses the client’s contractions by timing from the beginning of one contraction:
✓ To the beginning of the next contraction

5) When determining the duration of a uterine contraction the right technique is to time it
from.
✓ The beginning of one contraction to the end of the same contraction.

6) Which component must nurse Jean evaluate when assisting Mommy’s Sue’s labor
contractions?
✓ Contraction, duration, frequency, intensity.

7) The proper technique to monitor the intensity of the uterine contraction is:
✓ Put the tip of the fingers lightly on the fundal area and try to indent the abdominal
wall at the height of the contraction.

8) In the labor room, nurse Lea explains the rationale for breathing techniques during
preparation for labor based on the understanding that breathing techniques are most
important in achieving which of the following?
 ✓ Facilitate relaxation, possibly reducing the perception of pain.

9) Stage 2 of labor begins with the delivery of the baby and ends with the delivery of the
placenta.
✓ FALSE

10) To monitor the frequency of the uterine contraction during labor, the right technique is to
time the contraction.
✓ From the beginning of one contraction to the beginning of the next contraction.

11) What statement is FALSE about the transition phase of stage 1?

✓ The transition phase is the longest phase of stage 1 and contractions are very
intense and long in duration.

12) As soon as the placenta is delivered, the nurse must do which of the following actions?
✓ Inspect the placenta for completeness including the membranes.

13) A nurse is monitoring a client in active labor and notes that the client is having
contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate
between contractions is 90 BPM. Which of the following nursing actions is most
appropriate?
✓ Notify the physician or nurse midwife.

14) The power in uterine contractions includes the following EXCEPT:

✓ Integrity.

15) Which of the following is the primary power involved in labor and delivery?
✓ Uterine contraction.

16) Stage 1 of labor includes which phases in the correct order?

✓ Latent, Active, Transition

17) A client arrives at a birthing center in active labor. Her membranes are still intact, and the
health care provider prepares to perform an amniotomy. What will the nurse relay to the
client as the most likely outcome of the amniotomy?
 ✓ Increased efficiency of contractions.

18) Which of the following describes the term fetal position?

✓ Relationship of the fetus’s presenting part to the mother’s pelvis.

1) The primary critical observation for Apgar scoring is the:

✓ Heart rate

2) The nurse admitting a preterm newborn to the nursery should give the highest priority to
the newborn for which of the following?
✓ Respiratory distress

3) A pre-term newborn is to be fed breast milk through nasogastric tube. The nurse
recognizes that breast milk is preferred to formula because it?
✓ Provide antibodies.

4) A nurse is assessing the reflexes of a newborn. The nurse assesses which of the following
reflexes by placing a finger in the newborn’s mouth?
✓ Sucking reflex

5) A nurse in a delivery room is assisting with the delivery of a newborn infant. After the
delivery, the nurse prepares to prevent heat loss in the newborn resulting from
evaporation by:
✓ Drying the infant in a warm blanket.

6) Within 3 minutes after birth the normal heart rate of the infant may range between:
✓ 120 and 160

7) While assessing a 2-hour old neonate, the nurse observes the neonate to have
acrocyanosis. Which of the following nursing action should be performed initially?
✓ Keep monitoring because acrocyanosis is normal in the neonate.
8) The vaccine is indicated to promote active immunity in individuals at high risk of potential
exposure to hepatitis B virus or NBsAg-positive materials.
✓ Hep B

9) This drug is indicated for Prevention, treatment of hemorrhagic states in neonates.

✓ Vit K

10) A woman delivers a 3.250 g neonate at 42 weeks’ gestation. Which physical finding is
expected during an examination of this neonate?
✓ Leathery, cracked, and wrinkled skin.

11) When teaching umbilical cord care to a new mother, the nurse would include which
information?
✓ Keep the cord dry and open to air.

12) The nurse decides on a teaching plan for a new mother and her infant. The plan should
include:
✓ Showing by example and explanation how to care for the infant.

13) The nurse is aware that a healthy newborn’s respirations are:

✓ Irregular, abdominal, 30-60 per minute shallow.

14) You’re assessing the one-minute APGAR score of a newborn baby. On assessment, you
note the following about your newborn patient: heart rate 130, pink body and hands with
cyanotic feet, weak cry, flexion of the arms and legs, active movement and crying when
stimulated. What is your patient’s APGAR score?
✓ APGAR 8

15) You’re assessing the one minute APGAR score of a newborn baby. On assessment, you
note the following about your newborn patient: heart rate 101, cyanotic body and
extremities, no response to simulation, no flexion of extremities, and strong cry. What is
your patient’s APGAR score?
✓ APGAR 3

16) A newborn five minute APGAR score is 5. Which of the following nursing interventions will
you provide to this newborn?
 ✓ Some resuscitation assistance such as oxygen and rubbing baby’s back and
reassess APGAR score.

17) You’re assessing the five minute APGAR score of a newborn baby. On assessment, you
note the following about your newborn patient: heart rate 97, no response to stimulation,
flaccid, absent respirations, cyanotic throughout. What is your patient’s APGAR score?
✓ APGAR 1

18) The following nursing diagnosis used in the Learning packet for Newborn care
✓ Risk for infection
✓ Risk for imbalanced nutrition
✓ Risk for ineffective thermoregulation

19) In order to prevent hypothermia to the newborn, the ff nursing implementations are vital.
SATA
✓ Monitor temperature every hour
✓ Encourage skin-to-skin contact of the baby with the mother
✓ Instruct the mother to maintain thermal neutral environment and avoid situations
that may cause the infant heat loss such as cool air, drafts, bathing and cold
bedding.

20) What nursing interventions are needed in monitoring for infant who has a nursing
diagnosis for Risk for imbalanced nutrition r/t ineffective feeding pattern? SATA
✓ Weigh the newborn using the standard weighing scale.
✓ Assess the infant’s sucking pattern during breastfeeding.
✓ Check for infant signs of dehydration such as poor skin turgor, dry mucous
membranes, decreased urine, and sunken fontanels and eyeballs.
✓ Teach the mother on the proper positioning and latching on breastfeeding.

1) Nursing care for individuals and families during child bearing include the following: SATA
✓ Health promotion
✓ Disease prevention
✓ Restoration and maintenance
✓ Rehabilitation emphasizing the care on newborn.
2) Patient Michele, G1P0 experiences abdominal irregular, painless contraction that started on
her 20th weeks of pregnancy. She worries about this during her prenatal check up. What
would be your best response?
✓ “Abdominal irregular, painless contraction that started on 20 weeks of pregnancy is
normal. This is what we call Braxton Hicks Contraction”

3) Patient Jelly is in her 26th weeks of pregnancy and was advised to check her urinalysis.
Result reveals presence of glucose. As health care provider, how would you interpret the
result?
✓ When blood sugar level in the body is too high, excess sugar can end up in the
urine. Presence of glucose in the urine indicates gestational diabetes.

4) Patient Lilibeth in the Case Scenario of our Learning Packet has small physique stature.
This assessment indicates her pregnancy as high risk for.
✓ Cephalopelvic disproportion.

5) Who among the following are considered as high risk pregnant client along with the given
situations?
✓ Amella, 28 years old, 12 weeks pregnant with blood pressure of 170/110, BMI 24
✓ Lita, G6P5, 38 years old, 8 weeks pregnant.
✓ Mary, 32 years old, G2P1, 36 weeks pregnant, weighs 43 kgs.

6) A risk factor for high risk pregnancy where a women has previously given birth several
times having 4 or more pregnancies and deliveries.
✓ Multiparity

7) The following are factors putting potential complications at pregnancy that could affect
both mother and the fetus.
✓ Maternal age
✓ Poverty
✓ Height
✓ Weight
✓ Lifestyle

8) Jina, 18 y/o, G1P0, 4 weeks pregnant asks the nurse on duty what is the safest amount to
consume alcoholic beverages now that she is pregnant. The nurse’s best response will be.
✓ “it is best to quit drinking alcohol during pregnancy”
9) This is a diagnostic test performed to high risk pregnant client to confirm normal anatomy
and gender/sex of the baby.
✓ Ultrasound

10) Lilibeth, as reflected in our Case Scenario in the LP1, has Iron Deficiency Anemia having
hemoglobin result of 10 mg/dl. As future nurses, maternal nutrition is vital all throughout
duration of pregnancy. Nutritional imbalance can lead to the ff. SATA
✓ Risk of intrauterine growth restriction
✓ Impaired neonatal growth
✓ Impaired neonatal cognitive development
✓ Greater maternal morbidity
✓ Risk of poor pregnancy outcomes such as pre term birth, miscarriages.

11) Nurse Ana fully understands that during high risk pregnancies the focus of nursing care
is/are the ff. SATA.
✓ Preventing disorders from affecting the health of the fetus.
✓ Helping client regain her health as quickly as possible so she can continue a
healthy pregnancy and prepare herself psychologically and physically for labor and
birth and the arrival of her newborn.
✓ Helping client to learn more about her chronic illness so she can continue to
safeguard her health during her childbearing years.

12) Nurse Deeya assists the pregnant client during the Non-Stress test. The result was NON-
REACTIVE. You interpret this result as
✓ The heart does not beat faster upon movement.

13) Amniocentesis is performed to patient Ellah on her 20th weeks of pregnancy for genetic
studying. Your Clinical Instructor ask you to prepare NCP. As future nurses, one nursing
diagnosis applicable for amniocentesis procedure is:
✓ Risk for infection

14) Making responsible decision related to assessment of the clients status is necessary in
providing nursing care to our high risk pregnant client. What behavior is this?
✓ Teaching and learning

15) Lilibeth, who is on her 24 weeks of pregnancy is taking Dexamethasone 6 mg IM every 12

hours x 4 doses due to early contraction. As health care provider, you understand its drug
indication.
 ✓ To promote fetal lung maturation

16) Lilibeth has been prescribed with Ferrous Sulfate 1 tab daily. For better absorption of this
drug, your health teaching should include the following:
✓ Take ferrous sulfate on an empty stomach at least 1 hour before meal.

17) The following are nursing responsibilities before, during, and after amniocentesis; SATA.
✓ Monitor FHR
✓ Assess for cramping or mild pelvic discomfort.
✓ Instruct client to have a full bladder before the procedure.
✓ Monitor for infection.
✓ Monitor for bleeding or leakage of amniotic fluid.

18) Lilibeth has low hemoglobin of 10 mg/dl. As a nurse, you should instruct her to increase
her nutritional intake particularly foods rich in vitamin b12. SATA.
✓ Dark green leafy vegetables
✓ Red meat and poultry
✓ Fortified breakfast cereals or pasta.

19) Nurse Jen is monitoring a case of pregnant client who has RH- incompatibility. You
understand this condition as:
✓ A condition that develops when a pregnant woman has RH – negative blood and the
baby in her womb has RH – positive blood.

20) A first time teenage mother ask your advise if she will just deliver at home because his
husband could not afford hospitalization. As a healthcare provider what will be your best
advice?
✓ “you are among those whom we categorize as high-risk pregnant because of your
age and it will be your first time. It will be dangerous for you and your baby if you
will not deliver in the hospital”

21) Nurse Samantha noticed her pregnant patient, 34 weeks of gestation is looking pale and
seems gasping. What would be Nurse Samantha’s best nursing intervention?
✓ Hook her on oxygen inhalation, check her vital signs and notify AMD immediately.
22) Biophysical Profile is a recommended test during high risk pregnancy that measures the
health of the fetus during pregnancy, further it is recommended especially if Non stress
test has non reactive result. What are your nursing responsibilities during the procedure?

✓ Monitoring FHT and breathing

✓ Monitoring amniotic fluid
✓ Monitor the fetus’ muscle tone
✓ Interpret result, documentation

23) Nurse Marco plans to provide conform and rest his client diagnosed with severe
preeclampsia who has a BP of 180/120. He should instruct which of the following. SATA.
✓ Limit visitors in the bedside.
✓ Provide quiet environment.
✓ Provided guided imagery.
✓ Encouraged deep breathing technique.

24) A client who came to ER complains of headache. Her vital signs are the ff: BP 160/90, HR
103. T – 37.4 C, RR – 19, O2sat 98%, FHT 128 BPM. Initial plan of care for the client is.
✓ Lower the blood pressure.

25) Calcium + Vitamin D tablets are given as antidote during Magnesium sulfate toxicity.
✓ FALSE

26) Nurse Holly is handling a pregnant client who is manifesting s/s of anxiety. What is the
appropriate nursing intervention?
✓ Acknowledge the patients anxiety.

27) Hand tremors, constant questioning, apprehension, increased tension. These data should
be seen in which part of your NCP?
✓ Objective assessment

28) Controlling blood pressure is the optimal intervention to prevent deaths due to stroke in
women with preeclampsia.
✓ The first statement is true, the second statement is true.

29) The following are applicable nursing diagnosis for the case of patient B.E.A. in our LP
scenario.
✓ Fluid volume excess
 ✓ Anxiety
✓ Risk for skin integrity
✓ Risk for infection
✓ Ineffective tissue perfusion

30) It is characterized by hemolysis (the breakdown of red blood cells), elevated liver enzymes,
and low platelets.
✓ HELLP

31) The resident doctor ordered “monitor I and O q shift”. How will you execute this order?
✓ Instruct client to record the amount of fluid drink and the amount of her urination
within 8 hour duty.

32) The following is/are risk/danger to the mother who is diagnosed with eclampsia.
✓ Seizure
✓ Stroke
✓ Organ damage
✓ Death

33) It is necessary to inform client regarding dietary regimen, what food will be best selected
for patient with preeclampsia? SATA.
✓ Fortified cereals
✓ Whole grains
✓ Low fat yogurt
✓ Lean chicken breast
✓ Poultry products such as eggs, cheese.

34) Following the admission of client with pre eclampsia, you would expect that the doctor will
order diagnostic tests for the client. SATA.
✓ Complete blood count
✓ Liver function test
✓ BUN and creatine
✓ Urinalysis
✓ Platelet count

35) Patient Elena, G2P1 diagnosed with severe pre eclampsia has shortness of breath. What
could be the indication?
✓ Patient has pulmonary edema
36) Instruct pre eclamptic patient who has edema to elevate dependent extremities. What is
the rationale for this?
✓ To increase venous return for better circulation

37) In administering anti hypertensive medication to patients, what findings will alert you to
refer to the doctor immediately?
✓ A BP of 80/40

38) Magnesium sulfate is the drug of choice for convulsive pregnant client. What will be your
highest nursing responsibility here?
✓ Assess for deep tendon reflexes every hour.

39) You know that it is your nursing responsibility to notify the doctor if any of the following
signs for magnesium toxicity is/are present. SATA.
✓ Depressed or absent reflexes
✓ Respirations less than 12 per minute
✓ Urinary output of less than 30 mL
✓ Hypotension
✓ Increased drowsiness

40) Preeclampsia may affect the placenta. This could lead to the ff. SATA.
✓ Placental abruption
✓ Preterm delivery
✓ Intrauterine growth restriction
✓ Stillbirth

1) A 40-year-old woman with a high body mass index (BMI) is to 10 weeks pregnant. Which
diagnostic tool is appropriate to suggest to her at this time?
✓ Transvaginal ultrasound

2) What is an indicator for performing a contraction stress test?

✓ Maternal diabetes mellitus and postmaturity.
3) A nurse providing care for antepartum woman should understand that the contraction
stress test (CST).
✓ Is considered negative if no late decelerations are observed with the contractions.

4) The health care provider has ordered a magnetic resonance imaging (MRI) study to be done
on a pregnant to evaluate fetal structure and growth. The nurse should include which
instructions when preparing the patient for this test? (Select all that apply)
✓ Jewelry must be removed before the test.
✓ Remain still throughout the test.

5) A nonstress test (NST) is ordered on a pregnant woman at 37 weeks gestation. What are
the most appropriate teaching points to include when explaining the procedure to the
patient? (Select all that apply)
✓ After 30 minutes, a reactive reading indicates the test is complete.
✓ Two sensors are placed on the abdomen to measure contractions and fetal heart tones.
✓ A nonreactive test suggest further investigation to check for possible fetal
complication.

6) The nurse is assessing a multigravida, 36 weeks gestation for symptoms of pregnancy-

induced hypertension and pre eclampsia. The nurse should give priority to assessing the
client for:
✓ Facial swelling

7) A woman has just been admitted to the emergency department subsequent to a head-on
automobile accident. Her body appears to be uninjured. The nurse carefully monitors the
woman for which of the following complications of pregnancy? (Select all that apply)
✓ Placental abruption
✓ Preterm labor

8) An obese gravid woman is being seen in the prenatal clinical. The nurse will monitor this
client carefully throughout her pregnancy because she is high risk for which of the
following complications of pregnancy? Select all that apply.
✓ Gestational diabetes
✓ Pre eclampsia

9) An obsess client is being seen by the nurse during her prenatal visit. Which of the following
comments by the nurse is appropriate at this time?
 ✓ “We suggest that you gain weight throughout your pregnancy but not quite as much
as other women”

10) A 39-year-old, 16-week-gravid woman has had an amniocentesis. Before discharge, the
nurse teaches the woman to call her doctor if she experiences any of the following side
effects? Select all that apply.
✓ Fever or chills
✓ Lack of fetal movement
✓ Abdominal pain
✓ Vaginal bleeding

11) A client is being taught fetal kick counting. Which of the following should be included in the
patient teaching?
✓ The woman should lie on her side with her head elevated about 30 degrees.

12) A 14-year-old woman is seeking obstetric care. Which of the following is an appropriate
nursing care goal for this young woman? The young woman will:
✓ Continue her education

13) A client has been admitted with a diagnosis of hyperemesis gravidarum. Which of the
following orders written by the primary health care provider is highest priority for the
nurse to complete?
✓ Check admission weight and continuously monitor signs of dehydration.

14) The nurse is developing a plan of care for a woman who is pregnant with twins. The nurse
includes interventions focusing on which of the following because of the woman’s
increased risk?
✓ Preeclampsia

15) After reviewing a client’s history, which factor would the nurse identify as placing her at
risk for gestational hypertension?
✓ Mother had gestational hypertension during pregnancy.

16) Biochemical examination if the amniotic fluid of a pregnant patient yields the following
results: lecithin-to-sphingomyelin (L/S) ratio, 2:1; surfactant-to-albumin (S/A) ration, 60
mg/g; and phosphatidylglycerol (PG) present. What conclusions will the nurse draw from
this report?
 ✓ The fetal lungs are well developed

1) A woman who is at 36 weeks of gestation is having a nonstress test. Which statement by

the woman would indicate a correct understanding of the test?
✓ The baby’s heart rate is monitored to see how it responds to the baby’s movements.

2) A 40-year-old woman with high body mass index (BMI) is 10 weeks pregnant. Which
diagnostic tool is appropriate to suggest to her at this time?
✓ Transvaginal ultrasound

3) What is an indicator for performing a contraction stress test?

✓ Maternal diabetes mellitus and postmaturity.

4) A nurse providing care for the antepartum woman should understand that the contraction
stress test (CST):
✓ Is considered negative if no late decelerations are observed with the contractions.

5) A client with pregnancy-induced hypertension (PIH) receives magnesium sulfate, 4 g in

50% solution I.V. over 20 minutes, what is the purpose of administering magnesium sulfate
to this client?
✓ To prevent seizures

6) Pre-eclampsia (aka toxemia and PIH) consists of what symptoms? (SATA)

✓ Proteinuria
✓ Edema
✓ Hypertension

7) Pre-eclampsia can evolve into eclampsia with seizures as fatal symptom.

✓ TRUE

8) Why is magnesium sulfate used for pre-eclampsia and eclampsia?

✓ To prevent sever pre-eclampsia from becoming eclampsia.
9) When a pregnant woman goes into a convulsive seizure, the most immediate action of the
nurse to ensure safety of the patient is.
✓ Position the mother on her side to allow secretions to drain from her mouth and
prevent aspiration.

10) A 34-year-old female patient who is 36 weeks pregnant is diagnosed with mild
preeclampsia. The nurse will include what information in the patient’s education? Select all
that apply.
✓ Report weight gain of >4 lbs in one week to physician.
✓ Follow a no salt diet.

11) Developing high blood pressure during pregnancy always means you have preeclampsia.
✓ FALSE

12) Preeclampsia can cause seizures in a pregnant woman.

✓ TRUE

13) Your patient with preeclampsia is started on Magnesium Sulfate. The nurse knows to have
what medication on standby?
✓ Calcium gluconate

14) A 39 week pregnant is in labor. The patient has preeclampsia. The patient is receiving IV
Magnesium Sulfate. Which finding below indicates Magnesium Sulfate toxicity and requires
you to notify the physician?
✓ Deep tendon reflex 4+

15) A pregnant client is receiving magnesium sulfate therapy for the control of preeclampsia. A
nurse discover that the client is encountering toxicity from the medication in which of the
following assessment?
✓ Respirations of 10 breaths per minute.

16) A pregnant client in the last trimester has been admitted to the hospital with a diagnosis of
severe preeclampsia. A nurse monitors for complications associated with the diagnosis
and assesses the client for:
✓ Any bleeding, such as in the gums, petechiae, and purpura.
17) A homecare nurse visits a pregnant client who has a diagnosis of mild Preeclampsia and
who is being monitored for pregnancy induced hypertension (PIH). Which assessment
finding indicates a worsening of the Preeclampsia and the need to notify the physician?
✓ The client complains of headache and blurred vision.

18) Mrs. Caluza, 32 weeks gestation has developed PIH. The nurse evaluates that the client
understands her treatment regimen when the client states.
✓ “I will spend most of my time in bed, in my left side”.

19) A nurse is monitoring a pregnant client with pregnancy induced hypertension who is at risk
for preeclampsia. The nurse checks the client for which specific signs of Preeclampsia?
(Select all that apply).
✓ Elevated blood pressure
✓ Facial edema

20) A woman hospitalized with severe preeclampsia is being treated with hydralazine to
control blood pressure. Which of the following would the lead the nurse to suspect that the
client is having an adverse effect associated with this drug?
✓ Tachycardia

21) A woman with gestational hypertension experiences a seizure. Which of the following
would be the priority?
✓ Oxygenation

22) Nurse Ella is caring for a client with abruptio placenta and is monitoring the client for
disseminated intravascular coagulopathy. Which of the following assessment findings are
most likely to be associated with HELLP Syndrome which associated with DIC?
✓ Hemolysis
✓ Increased liver enzymes
✓ Thrombocytopenia

23) Nurse Merely is caring for Mrs. Caluza. Nurse Merely develops a plan of care knowing that
if Mrs. Caluza progresses from preeclampsia to eclampsia, her first action is to.
✓ Clear and maintain an open airway.
1) Which of the following groups of newborn reflexes below are present at brith and remain
unchanged through adulthood?
✓ Blink, cough, sneeze, gag reflex

2) Which of the following actions would be effective in maintaining a neutral thermal

environment for the newborn? Select all that apply.
✓ Placing infant under radiant warmer after bathing
✓ Covering the scale with a warmed blanket prior to weighing
✓ Covering the infant’s head with a bonnet

3) One or 2 small round, glistening well circumscribed cysts are present at palate which is a
result of extra load of calcium that was deposited in the utero; this structure is called:
✓ Eptein’s Pearls

4) A baby is born precipitously in the ER. The nurses initial action should be to:
✓ Establish an airway for the baby

5) While assessing a 2-hour old neonate, the nurse observes the neonate to have
acrocyanosis. Which of the following nursing actions should be performed initially?
✓ Do nothing because acrocyanosis is normal in the neonate.

6) A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-
week-gestation newborn with Apgar scores of 1 and 4. In planning for the admission for
this infant, the nurse’s highest priority should be to:
✓ Connect the resuscitation bag to the oxygen outlet.

7) A pre-term newborn is to be fed breast milk through nasogastric tube. The nurse
recognizes that breast milk is preferred to formula because it?
✓ Provides antibodies

8) A client has just given birth at 42 weeks’ gestation. When assessing the neonate, which
physical finding is expected?
✓ Desquamation of the epidermis

9) Which of the following is true regarding the fontanels of the newborn?

✓ The anterior is large in size when compared to the posterior fontanel.
10) This is the standardized infant evaluation and serves as a baseline for further evaluation
done at 1 minute and 5 minutes after birth.
✓ APGAR scoring

11) Immediate after birth the nurse notes the following on a male newborn: respiration 78; rate
and rhythm are irregular with short periods of apnea, apical heart rate 160 BPM, BP 80/40
mmHg, and Temperature of 99 F. which of the following should the nurse do?
✓ Recognize this as normal first period of reactivity.

12) Which sign would indicate the neonate was adapting appropriately to extra uterine life
without difficulty?
✓ Respiratory rate 40-60 breaths/min

13) When preparing to administer the vitamin K injection to a neonate, the nurse would select
which of the following sites as appropriate for the injection?
✓ Vastus lateralis muscle

14) The nurse hears a mother telling a friend on the telephone about umbilical cord care.
Which of the following statements by the mother indicates need for more effective
teaching? Select all that apply.
✓ “Daily soap and warm water cleansing is best”
✓ “An antibiotic ointment applied daily prevents infection”
✓ He can have a tub bath each day”

15) The mother asks the nurse. “What’s wrong with my son’s breasts? Why are they so
enlarged?”. Which of the following would be the best response by the nurse?
✓ “A decrease in material hormones present before birth causes enlargement”

1) Pre-eclampsia (aka toxemia and PIH) consists of what symptoms? (SATA)

✓ Severe headache
✓ Edema
✓ Hypertension
✓ Changes in vision, usually in the form of flashing lights or inability to tolerate bright
2) Why is magnesium sulfate used for pre-eclampsia and eclampsia?
✓ To prevent severe pre-eclampsia from becoming eclampsia

3) What are some of the most common side effects of magnesium sulfate?
✓ Flushing
✓ Nausea
✓ Vomiting
✓ Lethargy
✓ General muscle weakness

4) A nurse is caring for a pregnant client with sever preeclampsia who is receiving IV
magnesium sulfate. Select all nursing interventions that apply in the care for the client.
✓ Monitor renal function and cardiac function closely.
✓ Keep calcium gluconate on hand in case of a magnesium sulfate overdose.
✓ Monitor deep tendon reflexes hourly.
✓ Monitor I and O’s hourly
✓ Notify the physician if urinary output is less than 30 ml per hour.

5) When preparing a schedule of follow-up visits for a pregnant woman with chronic
hypertension, which of the following would be most appropriate?
✓ Bi-monthly visits until 28 weeks, then weekly visits

6) The nurse is reviewing the laboratory test results of a pregnant client. Which one of the
following findings would alert the nurse to the development of HELLP syndrome?
✓ Elevated liver enzymes

7) A nurse is teaching a pregnant woman with preterm premature rupture of membranes who
is about to be discharged home about caring herself. Which statement by the woman
indicated a need for additional teaching?
✓ “It’s okay for my husband and me to have sexual intercourse”
MCN RLE QUIZ 1 (FINALS)
1) Which of the following are risk factors for shoulder dystocia? Select all that apply:
- Raised BMI
- Previous shoulder dystocia
- Diabetes

2) Fill in the blank: The most effective manoeuvre to resolve shoulder dystocia is
- McRobert’s Maneuver

3) Which of the following are warning signs of shoulder dystocia?

- Long 1st stage of labor
- ‘Turtle neck’ sign
- Long 2nd stage of labor

4) Which of the following IS a potential complication of Gestational Diabetes for the

MOTHER?
- C – section

5) What part of the baby does a shoulder dystocia usually involve?

- Anterior shoulder

6) When documenting the birth it is important to document which of the following?

- Time the head was born

7) What is the most common injury to the baby following a shoulder dystocia?
- Brachial Plexus Injury

8) Causes of PROM includes all. Select all that apply.

- Weakening of membranes
- Extreme force of contraction of uterus
- Fetal movement
9) Complete the following statement: First and foremost management of Gestational
Diabetes should be through…
- Healthy diet plan and exercise

10) In occult umbilical cord prolapse (contained within the uterus), the umbilical cord is
often compressed by a shoulder or the head. A fetal heart rate pattern that suggest
cord compression and progression to hypoxemia may be the only due. Which of the
following characterizes that heart rate pattern?
- Severe variable decelerations

11) Who is screened for Gestational Diabetes?

- All pregnant women

12) Which of the following is the BEST way Gestational Diabetes can be prevented?
- Practicing a healthy lifestyle before getting pregnant.

13) Which of the following is the main cause of nuchal cord?

- Excessive fetal movement

14) This type of rupture occurs before 24 weeks of gestational age fetus (Also known
as mid-trimester)
- Pre-viable Preterm PROM

15) Which of the following is NOT a risk factor for Gestational Diabetes?
- Previous pregnancy loss

16) Which of the following is the most common risk of nuchal cord?
- Decrease heart rate

17) A type of PROM in which membranes rupture before the 37 weeks of gestational
age
- Preterm PROM
18) The following are risks factor of premature rupture of the membrane except:
- Bleeding

19) The potentially life – threatening condition in which the umbilical cord blood vessels
can shift underneath the baby and lead to bleeding is called which one of the
following?
- Umbilical cord prolapse

MCN RLE QUIZ 2. (FINALS)

1. Baby Nicks has surfactant administered at birth. The purpose of surfactant is to.
- Prevent alveoli from collapsing on expiration.

2. When developing the initial plan of care for a neonate who was born at 41 weeks '
gestation, was diagnosed with meconium aspiration syndrome (MAS) and requires
mechanical ventilation, which of the following should the nurse include.
- Care of an umbilical arterial line

3. Which of the following are typical signs and symptoms of pneumonia? SATA
- coarse crackles
- oxygen saturation less than 90%
- elevated wbc
- tachypnea

4. A nurse in the nursery is caring for a neonate. On assessment the infant is exhibiting
grunting, tachypnea, nasal flaring and grunting. Respiratory distress syndrome is
diagnosed and the physician prescribes surfactant replacement therapy. The nurse
would prepare to administer this therapy by
- instillation of the preparation into the lungs through an endotracheal tube.
5. The system plays a major role in maintaining fluid, electrolyte, and acid-base balance.
The GI - b system often is involved with two severe acid base imbalances which is
-metabolic acidosis and metabolic alkalosis

6. A two-month -old is showing signs and symptoms of heart failure. An echocardiogram

is ordered. The test shows the infant has a ventricular septal defect (SD). Which
statement below best describes the blood flow in the heart due to this congenital heart
defect?
- the blood in the heart is shunting from the left ventricle to the right ventricle, which is
increasing pulmonary blood flow

7. While assessing a newborn's heart sounds you note a loud murmur at the left upper
sternal border. You report this to the physician who suspects the infant may have patent
ductus arteriosus. The physician asks you to obtain a pulse pressure. If patent ductus
arteriosus is present the pulse pressure would be______.
- wide

8. Atrial septal defects can lead to a decrease in lung blood flow.

- false

9. In Hypertonic Dehydration water is lost in a greater proportion than electrolytes and

it occurs when fluid intake decreases in conjunction with a fluid loss increase. It occurs
in a child with: Select all that apply.
- nausea (preventing fluid intake)
-fever (increased fluid loss through perspiration)
-profuse diarrhea - where there is a greater loss of fluid than salt
-renal disease - associated with polyuria such as nephrosis with diuresis.

10. An echocardiogram shows that your patient has an atrial septal defect located at the
bottom of the septum near the tricuspid and mitral valves. As the nurse you know this
is what type of atrial septal defect (ASD)?
-Ostium Primum

11. Interpret the ABG's . PH = 7.36 ; PaCO2=55; HCO 3; =28

-respiratory acidosis fully compensated

12. Overhydration is serious as dehydration because the ECF overload can lead to
cardiovascular overload and cardiac failure. All of the following are true about
overhydration except
- The excess fluid in these instances is usually intravascular and interstitial.

13. the following are included in the Assessment in Metabolic alkalosis. Select all the
apply.
-The child will breathe slowly and shallowly
-pH will be elevated (near or above .45)
-HCO3 level will be near or above 28mEq / L.

14. The level of bicarbonate (HCO3) in arterial blood is normally

-22 to 26 mEq/L.

15. MAS (Macrophage activation syndrome) can be prevented by

- tracheal suctioning once baby is delivered.

16. the family is caring for their youngest child Justin who is suffering from Tetralogy of
Fallot Which of the following are deects associated with this congenital heart condition?
- Ventricular septal defect overriding aorta pulmonic stenosis and right ventricular
hypertrophy.
17. Hypotonic Dehydration occurs when there is a disproportionately high loss of
electrolytes relative to fluid lost. The plasma concentration of sodium and chloride will
be low. This could result from all of the following except
- excessive intake of salt associated with great gain through intake.

18. When diarrhea occurs, or when a child becomes diaphoretic because of fever, the
fluid output can be markedly decreased.
-false

19. Select all the correct options that represent the pathophysiology of an asthma attack.
-the mucosa lining experiences severe inflammation
-The goblet cells within the mucosa lining produce excessive amounts of mucous.

20. Metabolic acidosis may result from diarrhea. When diarrhea occurs, a great deal of
sodium is lost with stool. This excessive loss of Na, in turn, causes the body to conserve
Hions in an attempt to keep the total number of positive and negative ions in serum
balanced. As a result, all of the following will occur except
- arterial blood gas analysis will reveal increase pH.

21. Isotonic Dehydration is when a child's body loses more water than it absorbs (as with
diarrhea) or absorbs less fluid than it excretes (as with nausea and vomiting). As a
result, all of the following will occur Select all that apply
- there will be a decrease in the volume of blood plasma.
-the body compensates for this rapidly by shifting interstitial fluid into the blood vessels.

22. You're caring for a 2 years old patient who has a large atrial septal defect that needs
repair This defect is causing complications These complications are arising from an
abnormal shunting of blood throughout the heart. As the nurse, you know that a shunt
is occurring in the heart due to the defect.
-left to right.
23. Fluid shifts from the blood stream to interstitial and intracellular spaces (from areas
of great osmotic pressure to areas of lesser pressure).
-false

25. You're working on a unit that provides specialized cardiac care to the pediatric
population. Which patient below would be the best candidate for Indomethacin from the
treatment of patent ductus arteriosus?
- A premature infant

26. What is the interpretation of the ABG if the pH = 7.60; PaCO2=33^ prime HCO3=16?
-metabolic alkalosis partially compensated.

27. A nurse in the nursery is monitoring a preterm infant for respiratory distress
syndrome. Which assessment signs if noted in the newborn would alert the nurse to the
possibility of this syndrome
- tachycardia and retractions

28. A two -month- old is showing signs and symptoms of heart failure. An
echocardiogram is ordered. The test shows the infant has a ventricular septal defect
(VSD). Which statement below best describes the blood flow in the heart due to this
congenital heart defect?
- The blood in the heart is shunting from the left ventricle to the right ventricle, which is
increasing pulmonary blood flow.

29. You're caring for a 2- day-old infant with a large patent ductus arteriosus. The mother
of the infant is anxious and asks you to explain her child's condition to her again. Which
statement below BEST describes this condition?
-The vessel connecting the aorta and pulmonary artery has failed to close at birth, which
is leading to a left-to-right shunt of blood.
MCN RLE MAJOR EXAM (FINALS)

1) When are most pregnant patients tested for gestational diabetes?

- 24 – 28 weeks gestation

2) You’re providing an educational class for pregnant woman about gestational

diabetes. You discuss the role of insulin in the body. Select all the CORRECT
statements about the role and function of insulin.
- “Insulin is a hormone secreted by the beta cells of the pancrease that thelps cells
use up glucose from the food we eat”.
- “Insulin influences cells by causing them to uptake glucose from the blood”.

3) A 38-year-old female is currently 16 weeks pregnant. You’re collecting the patient’s

health history: Gravida 5, para 4, BMI 28, depression, and family history of Type 2
diabetes. Select below all the risk factors in this scenario that increases this patient’s
risk for developing gestational diabetes?
- 38 years old
- Gravida 5, para 4
- BMI 28
- Family history of Type 2 diabetes.

4) A 36-year-old pregnant female is diagnosed with gestational diabetes at 28 weeks

gestation. You’re educating the patient about this condition. Which statement by the
patient demonstrates they need FURTHER teaching about gestational diabetes?
- “Once I deliver the baby, it will go away, and I will not need any further testing”
- “There are no risks or complications related to gestational diabetes other than
hyperglycemia”
- “I’m at risk for delivering a baby too small for its gestational age due to this
condition”

5) A nurse is monitoring a new mother in the PP period for signs of hemorrhage. Which
of the following signs, if noted in the mother, would be an early sign of excessive
blood loss?
- Pallor and cold and clammy extremities
6) A baby is born at 37 weeks gestation to a mother with gestational diabetes. As the
nurse you know at birth that the newborn is at risk for? Select all that apply:
- Hypoglycemia
- Respiratory distress
- Macrosomia

7) When to most patients tend to develop gestational diabetes during pregnancy?

- Usually during 2-3 trimester of pregnancy

8) It has been 24 hours since the client’s deliver of a newborn. The nursed assesses the
client for the process of involution and documenting that is progressing normally
when palpation of the client’s fundus is noted at which level?
- One fingerbreath below the umbilicus

9) To be considered a PPH, what would be the estimated blood loss have to be for a C-
section?
- >1000 mL

10) What types of trauma during labour and birth would lead to PPH risk?
- Instrumental assistant (vacuum or forceps)
- C-section surgical incision
- Lacerations of the cervix or vaginal wall
- Episiontomy.

11) A 32-year-old female is diagnosed with gestational diabetes. As the nurse you know
that what test below is used to diagnose a patient with this condition?
- 3 hour oral glucose tolerance test

12) In occult umbilical cord prolapse (contained within the uterus), the umbilical cord is
often compressed by a shoulder or the head. A fetal heart rate pattern that suggests
cord compression and progression to hypoxemia may be the only cue. Which of the
following characterizes that heart rate pattern?
- Severe variable decelerations
13) Which of the following are risk factors for shoulder dystocia? Select all that apply:
- Macrosomia
- Previous shoulder dystocia
- Diabetes
- CPD

14) Which measure would be least effective in preventing postpartum hemorrhage?

- Massage the fundus every hour for the first 24 hours following birth.

15) A type of PROM in which membranes rupture before the 37 weeks of gestational age
- Preterm PROM

16) A patient has gestational diabetes and is currently 34 weeks pregnant. Which
assessment findings below should you immediately report to the physician? Select
all that apply:
- Blood pressure 190/102
- Proteinuria
- Positive glycosuria

17) Which of the following are warning signs of shoulder dystocia?

- Long 1st stage of labour
- ‘Turtle neck’ sign
- Long 2nd stage of labour

18) Which of the following is the main cause of nuchal cord?

- Excessive fetal movement

19) A 26-year-old client is 26 weeks pregnant. Her previous births include two-large-
for-gestational-age babies and one unexplained stillbirth. Which tests would the
nurse anticipate as being most definitive in diagnosing gestational diabetes?
- 100g, 3-hour glucose tolerance test

20) Causes of PROM includes which of the following. Select all that apply:
- Weakening of membranes
 - Extreme force of contraction of uterus
- Fetal movement
- Cervical insufficiency

21) You’re teaching a pregnant mother with gestational diabetes about the signs and
symptoms of hyperglycemia. What are the signs and symptoms you will include in
your education to the patient? Select all that apply:
- Frequent hunger
- Polydipsia
- Frequent urination
- Fruity breath

22) Which of the following circumstances is most likely to cause uterine atony and lead
to PP hemorrhage?
- Urine retention

23) What is the most common injury to the baby following a shoulder dystocia?
- Brachial Palsy

24) Which of the following is the most common risk of nuchal cord?
- Decrease heart rate

25) Which of the following complications is most likely responsible for a delayed
postpartum hemorrhage? SATA
- Uterine subinvolution
- Retained placenta