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 iron-rich formula and

that they shouldn’t receive solid food, even baby food until age 6 months.

15. Answer: (D) 10 months

Rationale: A 10 month old infant can sit alone and understands object

permanence, so he would look for the hidden toy. At age 4 to 6 months,

infants can’t sit securely alone. At age 8 months, infants can sit securely

alone but cannot understand the permanence of objects.

16. Answer: (D) Public health nursing focuses on preventive, 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.

24. Answer: (D) To maximize the community’s resources in dealing with

health problems.

Rationale: Community organizing is a developmental service, with the goal of

developing the people’s self-reliance in dealing with community health

problems. A, B and C are objectives of contributory objectives to this goal.

25. Answer: (D) Terminal

Rationale: Tertiary prevention involves rehabilitation, prevention of

permanent disability and disability limitation appropriate for convalescents,

the disabled, complicated cases and the terminally ill (those in the terminal

stage of a disease).

26. Answer: (A) Intrauterine fetal death.

Rationale: Intrauterine fetal death, abruptio placentae, septic shock, and

amniotic fluid embolism may trigger normal clotting mechanisms; if clotting

factors are depleted, DIC may occur. Placenta accreta, dysfunctional labor,

and premature rupture of the membranes aren’t associated with DIC.

27. Answer: (C) 120 to 160 beats/minute

Rationale: A rate of 120 to 160 beats/minute in the fetal heart appropriate

for filling the heart with blood and pumping it out to the system.

28. Answer: (A) Change the diaper more often.

Rationale: Decreasing the amount of time the skin comes contact with wet

soiled diapers will help heal the irritation.

29. Answer: (D) Endocardial cushion defect

Rationale: Endocardial cushion defects are seen most in children with Down

syndrome, asplenia, or polysplenia.

30. Answer: (B) Decreased urine output

Rationale: Decreased urine output may occur in clients receiving I.V.

magnesium and should be monitored closely to keep urine output at greater

than 30 ml/hour, because magnesium is excreted through the kidneys and

can easily accumulate to toxic levels.

31. Answer: (A) Menorrhagia

Rationale: Menorrhagia is an excessive menstrual period.

32. Answer: (C) Blood typing

Rationale: Blood type would be a critical value to have because the risk of

blood loss is always a potential complication during the labor and delivery

process. Approximately 40% of a woman’s cardiac output is delivered to the

uterus, therefore, blood loss can occur quite rapidly in the event of

uncontrolled bleeding.

33. Answer: (D) Physiologic anemia

Rationale: Hemoglobin values and hematocrit decrease during pregnancy as

the increase in plasma volume exceeds the increase in red blood cell

production.

34. Answer: (D) A 2 year old infant with stridorous breath sounds, sitting up

in his mother’s arms and drooling.

Rationale: The infant with the airway emergency should be treated first,

because of the risk of epiglottitis.

35. Answer: (A) Placenta previa

Rationale: Placenta previa with painless vaginal bleeding.

36. Answer: (D) Early in the morning

Rationale: Based on the nurse’s knowledge of microbiology, the specimen

should be collected early in the morning. The rationale for this timing is that,

because the female worm lays eggs at night around the perineal area, the
first bowel movement of the day will yield the best results. The specific type

of stool specimen used in the diagnosis of pinworms is called the tape test.

37. Answer: (A) Irritability and seizures

Rationale: Lead poisoning primarily affects the CNS, causing increased

intracranial pressure. This condition results in irritability and changes in level

of consciousness, as well as seizure disorders, hyperactivity, and learning

disabilities.

38. Answer: (D) “I really need to use the diaphragm and jelly most during the

middle of my menstrual cycle”.

Rationale: The woman must understand that, although the “fertile” period is

approximately mid-cycle, hormonal variations do occur and can result in

early or late ovulation. To be effective, the diaphragm should be inserted

before every intercourse.

39. Answer: (C) Restlessness

Rationale: In a child, restlessness is the earliest sign of hypoxia. Late signs of

hypoxia in a child are associated with a change in color, such as pallor or

cyanosis.

40. Answer: (B) Walk one step ahead, with the child’s hand on the nurse’s

elbow.

Rationale: This procedure is generally recommended to follow in guiding a

person who is blind.

41. Answer: (A) Loud, machinery-like murmur.

Rationale: A loud, machinery-like murmur is a characteristic finding

associated with patent ductus arteriosus.

42. Answer: (C) More oxygen, and the newborn’s metabolic rate increases.

Rationale: When cold, the infant requires more oxygen and there is an

increase in metabolic rate. Non-shievering thermogenesis is a complex

process that increases the metabolic rate and rate of oxygen consumption,

therefore, the newborn increase heat production.

43. Answer: (D) Voided

Rationale: Before administering potassium I.V. to any client, the nurse must

first check that the client’s kidneys are functioning and that the client is

voiding. If the client is not voiding, the nurse should withhold the potassium

and notify the physician.

44. Answer: (c) Laundry detergent

Rationale: Eczema or dermatitis is an allergic skin reaction caused by an

offending allergen. The topical allergen that is the most common causative

factor is laundry detergent.

45. Answer: (A) 6 inches

Rationale: This distance allows for easy flow of the formula by gravity, but

the flow will be slow enough not to overload the stomach too rapidly.

46. Answer: (A) The older one gets, the more susceptible he becomes to the

complications of chickenpox.

Rationale: Chickenpox is usually more severe in adults than in children.

Complications, such as pneumonia, are higher in incidence in adults.

47. Answer: (D) Consult a physician who may give them rubella

immunoglobulin.

Rationale: Rubella vaccine is made up of attenuated German measles viruses.

This is contraindicated in pregnancy. Immune globulin, a specific prophylactic

against German measles, may be given to pregnant women.

48. Answer: (A) Contact tracing

Rationale: Contact tracing is the most practical and reliable method of finding

possible sources of person-to-person transmitted infections, such as sexually

transmitted diseases.

49. Answer: (D) Leptospirosis

Rationale: Leptospirosis is transmitted through contact with the skin or

mucous membrane with water or moist soil contaminated with urine of

infected animals, like rats.

50. Answer: (B) Cholera

Rationale: Passage of profuse watery stools is the major symptom of cholera.

Both amoebic and bacillary dysentery are characterized by the presence of

blood and/or mucus in the stools. Giardiasis is characterized by fat

malabsorption and, therefore, steatorrhea.

51. Answer: (A) Haemophilus influenzae

Rationale: Hemophilus meningitis is unusual over the age of 5 years. In

developing countries, the peak incidence is in children less than 6 months of

age. Morbillivirus is the etiology of measles. Streptococcus pneumoniae and

Neisseria meningitidis may cause meningitis, but age distribution is not

specific in young children.

52. Answer: (B) Buccal mucosa

Rationale: Koplik’s spot may be seen on the mucosa of the mouth or the

throat.

53. Answer: (A) 3 seconds

Rationale: Adequate blood supply to the area allows the return of the color

of the nailbed within 3 seconds.

54. Answer: (B) Severe dehydration

Rationale: The order of priority in the management of severe dehydration is

as follows: intravenous fluid therapy, referral to a facility where IV fluids can

be initiated within 30 minutes, Oresol or nasogastric tube. When the

foregoing measures are not possible or effective, than urgent referral to the

hospital is done.

55. Answer: (A) 45 infants

Rationale: To estimate the number of infants, multiply total population by

3%.

56. Answer: (A) DPT

Rationale: DPT is sensitive to freezing. The appropriate storage temperature

of DPT is 2 to 8° C only. OPV and measles vaccine are highly sensitive to heat
and require freezing. MMR is not an immunization in the Expanded Program

on Immunization.

57. Answer: (C) Proper use of sanitary toilets

Rationale: The ova of the parasite get out of the human body together with

feces. Cutting the cycle at this stage is the most effective way of preventing

the spread of the disease to susceptible hosts.

58. Answer: (D) 5 skin lesions, positive slit skin smear

Rationale: A multibacillary leprosy case is one who has a positive slit skin

smear and at least 5 skin lesions.

59. Answer: (C) Thickened painful nerves

Rationale: The lesion of leprosy is not macular. It is characterized by a change

in skin color (either reddish or whitish) and loss of sensation, sweating and

hair growth over the lesion. Inability to close the eyelids (lagophthalmos) and

sinking of the nosebridge are late symptoms.

60. Answer: (B) Ask where the family resides.

Rationale: Because malaria is endemic, the first question to determine

malaria risk is where the client’s family resides. If the area of residence is not

a known endemic area, ask if the child had traveled within the past 6 months,

where she was brought and whether she stayed overnight in that area.

61. Answer: (A) Inability to drink

Rationale: A sick child aged 2 months to 5 years must be referred urgently to

a hospital if he/she has one or more of the following signs: not able to feed

or drink, vomits everything, convulsions, abnormally sleepy or difficult to

awaken.

62. Answer: (A) Refer the child urgently to a hospital for confinement.

Rationale: “Baggy pants” is a sign of severe marasmus. The best management

is urgent referral to a hospital.

63. Answer: (D) Let the child rest for 10 minutes then continue giving Oresol

more slowly.
Rationale: If the child vomits persistently, that is, he vomits everything that

he takes in, he has to be referred urgently to a hospital. Otherwise, vomiting

is managed by letting the child rest for 10 minutes and then continuing with

Oresol administration. Teach the mother to give Oresol more slowly.

64. Answer: (B) Some dehydration

Rationale: Using the assessment guidelines of IMCI, a child (2 months to 5

years old) with diarrhea is classified as having SOME DEHYDRATION if he

shows 2 or more of the following signs: restless or irritable, sunken eyes, the

skin goes back slow after a skin pinch.

65. Answer: (C) Normal

Rationale: In IMCI, a respiratory rate of 50/minute or more is fast breathing

for an infant aged 2 to 12 months.

66. Answer: (A) 10 years

Rationale: The baby will have passive natural immunity by placental transfer

of antibodies. The mother will have active artificial immunity lasting for

about 10 years. 5 doses will give the mother lifetime protection.

67. Answer: (B) 4 hours

Rationale: While the unused portion of other biologicals in EPI may be given

until the end of the day, only BCG is discarded 4 hours after reconstitution.

This is why BCG immunization is scheduled only in the morning.

68. Answer: (B) 6 months

Rationale: After 6 months, the baby’s nutrient needs, especially the baby’s

iron requirement, can no longer be provided by mother’s milk alone.

69. Answer: (C) 24 weeks

Rationale: At approximately 23 to 24 weeks’ gestation, the lungs are

developed enough to sometimes maintain extrauterine life. The lungs are the

most immature system during the gestation period. Medical care for

premature labor begins much earlier (aggressively at 21 weeks’ gestation)

70. Answer: (B) Sudden infant death syndrome (SIDS)

Rationale: Supine positioning is recommended to reduce the risk of SIDS in

infancy. The risk of aspiration is slightly increased with the supine position.

Suffocation would be less likely with an infant supine than prone and the

position for GER requires the head of the bed to be elevated.

71. Answer: (C) Decreased temperature

Rationale: Temperature instability, especially when it results in a low

temperature in the neonate, may be a sign of infection. The neonate’s color

often changes with an infection process but generally becomes ashen or

mottled. The neonate with an infection will usually show a decrease in

activity level or lethargy.

72. Answer: (D) Polycythemia probably due to chronic fetal hypoxia

Rationale: The small-for-gestation neonate is at risk for developing

polycythemia during the transitional period in an attempt to

decrease hypoxia. The neonates are also at increased risk for developing

hypoglycemia and hypothermia due to decreased glycogen stores.

73. Answer: (C) Desquamation of the epidermis

Rationale: Postdate fetuses lose the vernix caseosa, and the epidermis may

become desquamated. These neonates are usually very alert. Lanugo is

missing in the postdate neonate.

74. Answer: (C) Respiratory depression

Rationale: Magnesium sulfate crosses the placenta and adverse neonatal

effects are respiratory depression, hypotonia, and bradycardia. The serum

blood sugar isn’t affected by magnesium sulfate. The neonate would be

floppy, not jittery.

75. Answer: (C) Respiratory rate 40 to 60 breaths/minute

Rationale: A respiratory rate 40 to 60 breaths/minute is normal for a neonate

during the transitional period. Nasal flaring, respiratory rate more than 60

breaths/minute, and audible grunting are signs of respiratory distress.

76. Answer: (C) Keep the cord dry and open to air
Rationale: Keeping the cord dry and open to air helps reduce infection and

hastens drying. Infants aren’t given tub bath but are sponged off until the

cord falls off. Petroleum jelly prevents the cord from drying and encourages

infection. Peroxide could be painful and isn’t recommended.

77. Answer: (B) Conjunctival hemorrhage

Rationale: Conjunctival hemorrhages are commonly seen in neonates

secondary to the cranial pressure applied during the birth process. Bulging

fontanelles are a sign of intracranial pressure. Simian creases are present in

40% of the neonates with trisomy 21. Cystic hygroma is a neck mass that can

affect the airway.

78. Answer: (B) To assess for prolapsed cord

Rationale: After a client has an amniotomy, the nurse should assure that the

cord isn’t prolapsed and that the baby tolerated the procedure well. The

most effective way to do this is to check the fetal heart rate. Fetal well-being

is assessed via a nonstress test. Fetal position is determined by vaginal

examination. Artificial rupture of membranes doesn’t indicate an imminent

delivery.

79. Answer: (D) The parents’ interactions with each other.

Rationale: Parental interaction will provide the nurse with a good assessment

of the stability of the family’s home life but it has no indication for parental

bonding. Willingness to touch and hold the newborn, expressing interest

about the newborn’s size, and indicating a desire to see the newborn are

behaviors indicating parental bonding.

80. Answer: (B) Instructing the client to use two or more peri pads to cushion

the area

Rationale: Using two or more peripads would do little to reduce the pain or

promote perineal healing. Cold applications, sitz baths, and Kegel exercises

are important measures when the client has a fourth-degree laceration.

81. Answer: (C) “What is your expected due date?”

Rationale: When obtaining the history of a client who may be in labor, the

nurse’s highest priority is to determine her current status, particularly her

due date, gravidity, and parity. Gravidity and parity affect the duration of

labor and the potential for labor complications. Later, the nurse should ask

about chronic illnesses, allergies, and support persons.

82. Answer: (D) Aspirate the neonate’s nose and mouth with a bulb syringe.

Rationale: The nurse’s first action should be to clear the neonate’s airway

with a bulb syringe. After the airway is clear and the neonate’s color

improves, the nurse should comfort and calm the neonate. If the problem

recurs or the neonate’s color doesn’t improve readily, the nurse should

notify the physician. Administering oxygen when the airway isn’t clear would

be ineffective.

83. Answer: (C) Conducting a bedside ultrasound for an amniotic fluid index.

Rationale: It isn’t within a nurse’s scope of practice to perform and interpret

a bedside ultrasound under these conditions and without specialized

training. Observing for pooling of straw-colored fluid, checking vaginal

discharge with nitrazine paper, and observing for flakes of vernix are

appropriate assessments for determining whether a client has ruptured

membranes.

84. Answer: (C) Monitor partial pressure of oxygen (Pao2) levels.

Rationale: Monitoring PaO2 levels and reducing the oxygen concentration to

keep PaO2 within normal limits reduces the risk of retinopathy of

prematurity in a premature infant receiving oxygen. Covering the infant’s

eyes and humidifying the oxygen don’t reduce the risk of retinopathy of

prematurity. Because cooling increases the risk of acidosis, the infant should

be kept warm so that his respiratory distress

isn’t aggravated.

85. Answer: (A) 110 to 130 calories per kg.

Rationale: Calories per kg is the accepted way of determined appropriate

nutritional intake for a newborn. The recommended calorie requirement is

110 to 130 calories per kg of newborn body weight. This level will maintain a

consistent blood glucose level and provide enough calories for continued

growth and development.

86. Answer: (C) 30 to 32 weeks

Rationale: Individual twins usually grow at the same rate as singletons until

30 to 32 weeks’ gestation, then twins don’t’ gain weight as rapidly as

singletons of the same gestational age. The placenta can no longer keep pace

with the nutritional requirements of both fetuses after 32 weeks, so there’s

some growth retardation in twins if they remain in utero at 38 to 40 weeks.

87. Answer: (A) conjoined twins

Rationale: The type of placenta that develops in monozygotic twins depends

on the time at which cleavage of the ovum occurs. Cleavage in conjoined

twins occurs more than 13 days after fertilization. Cleavage that occurs less

than 3 day after fertilization results in diamniotic dichorionic twins. Cleavage

that occurs between days 3 and 8 results in diamniotic monochorionic twins.

Cleavage that occurs between days 8 to 13 result in monoamniotic

monochorionic twins.

88. Answer: (D) Ultrasound

Rationale: Once the mother and the fetus are stabilized, ultrasound

evaluation of the placenta should be done to determine the cause of the

bleeding. Amniocentesis is contraindicated in placenta previa. A digital or

speculum examination shouldn’t be done as this may lead to severe bleeding

or hemorrhage. External fetal monitoring won’t detect a placenta previa,

although it will detect fetal distress, which may result from blood loss or

placenta separation.

89. Answer: (A) Increased tidal volume

Rationale: A pregnant client breathes deeper, which increases the tidal

volume of gas moved in and out of the respiratory tract with each breath.
The expiratory volume and residual volume decrease as the pregnancy

progresses. The inspiratory capacity increases during pregnancy. The

increased oxygen consumption in the pregnant client is 15% to 20% greater

than in the nonpregnant state.

90. Answer: (A) Diet

Rationale: Clients with gestational diabetes are usually managed by diet

alone to control their glucose intolerance. Oral hypoglycemic drugs are

contraindicated in pregnancy. Long-acting insulin usually isn’t needed for

blood glucose control in the client with gestational diabetes.

91. Answer: (D) Seizure

Rationale: The anticonvulsant mechanism of magnesium is believes to

depress seizure foci in the brain and peripheral neuromuscular blockade.

Hypomagnesemia isn’t a complication of preeclampsia. Antihypertensive

drug other than magnesium are preferred for sustained hypertension.

Magnesium doesn’t help prevent hemorrhage in preeclamptic clients.

92. Answer: (C) I.V. fluids

Rationale: A sickle cell crisis during pregnancy is usually managed by

exchange transfusion oxygen, and L.V. Fluids. The client usually needs a

stronger analgesic than acetaminophen to control the pain of a crisis.

Antihypertensive drugs usually aren’t necessary. Diuretic wouldn’t be used

unless fluid overload resulted.

93. Answer: (A) Calcium gluconate (Kalcinate)

Rationale: Calcium gluconate is the antidote for magnesium toxicity. Ten

milliliters of 10% calcium gluconate is given L.V. push over 3 to 5 minutes.

Hydralazine is given for sustained elevated blood pressure in preeclamptic

clients. Rho (D) immune globulin is given to women with Rh-negative blood

to prevent antibody formation from RH-positive conceptions. Naloxone is

used to correct narcotic toxicity.

94. Answer: (B) An indurated wheal over 10 mm in diameter appears in 48 to

72 hours.

Rationale: A positive PPD result would be an indurated wheal over 10 mm in

diameter that appears in 48 to 72 hours. The area must be a raised wheal,

not a flat circumcised area to be considered positive.

95. Answer: (C) Pyelonephritis

Rational: The symptoms indicate acute pyelonephritis, a serious condition in

a pregnant client. UTI symptoms include dysuria, urgency, frequency, and

suprapubic tenderness. Asymptomatic bacteriuria doesn’t cause symptoms.

Bacterial vaginosis causes milky white vaginal discharge but no systemic

symptoms.

96. Answer: (B) Rh-positive fetal blood crosses into maternal blood,

stimulating maternal antibodies.

Rationale: Rh isoimmunization occurs when Rh-positive fetal blood cells cross

into the maternal circulation and stimulate maternal antibody production. In

subsequent pregnancies with Rh-positive fetuses, maternal antibodies may

cross back into the fetal circulation and destroy the fetal blood cells.

97. Answer: (C) Supine position

Rationale: The supine position causes compression of the client’s aorta and

inferior vena cava by the fetus. This, in turn, inhibits maternal circulation,

leading to maternal hypotension and, ultimately, fetal hypoxia. The other

positions promote comfort and aid labor progress. For instance, the lateral,

or side-lying, position improves maternal and fetal circulation, enhances

comfort, increases maternal relaxation, reduces muscle tension, and

eliminates pressure points. The squatting position promotes comfort by

taking advantage of gravity. The standing position also takes advantage of

gravity and aligns the fetus with the pelvic angle.

98. Answer: (B) Irritability and poor sucking.

Rationale: Neonates of heroin-addicted mothers are physically dependent on

the drug and experience withdrawal when the drug is no longer supplied.
Signs of heroin withdrawal include irritability, poor sucking, and restlessness.

Lethargy isn’t associated with neonatal heroin addiction. A flattened nose,

small eyes, and thin lips are seen in infants with fetal alcohol syndrome.

Heroin use during pregnancy hasn’t been linked to specific congenital

anomalies.

99. Answer: (A) 7th to 9th day postpartum

Rationale: The normal involutional process returns the uterus to the pelvic

cavity in 7 to 9 days. A significant involutional complication is the failure of

the uterus to return to the pelvic cavity within the prescribed time period.

This is known as subinvolution.

100. Answer: (B) Uterine atony

Rationale: Multiple fetuses, extended labor stimulation with oxytocin, and

traumatic delivery commonly are associated with uterine atony, which may

lead to postpartum hemorrhage. Uterine inversion may precede or follow

delivery and commonly results from apparent excessive traction on the

umbilical cord and attempts to deliver the placenta manually. Uterine

involution and some uterine discomfort are normal after delivery.

B. Although all of the factors listed are important, sperm motility is the most

significant criterion when assessing male infertility. Sperm count, sperm

maturity, and semen volume are all significant, but they are not as significant

sperm motility.

D. Based on the partner’s statement, the couple is verbalizing feelings of

inadequacy and negative feelings about themselves and their capabilities.

Thus, the nursing diagnosis of self-esteem disturbance is most appropriate.

Fear, pain, and ineffective family coping also may be present but as

secondary nursing diagnoses.

B. Pressure and irritation of the bladder by the growing uterus during the

first trimester is responsible for causing urinary frequency. Dysuria,

incontinence, and burning are symptoms associated with urinary tract

infections.

C. During the second trimester, the reduction in gastric acidity in conjunction

with pressure from the growing uterus and smooth muscle relaxation, can

cause heartburn and flatulence. HCG levels increase in the first, not the

second, trimester. Decrease intestinal motility would most likely be the cause

of constipation and bloating. Estrogen levels decrease in the second

trimester.

D. Chloasma, also called the mask of pregnancy, is an irregular

hyperpigmented area found on the face. It is not seen on the breasts, areola,

nipples, chest, neck, arms, legs, abdomen, or thighs.

C. During pregnancy, hormonal changes cause relaxation of the pelvic joints,

resulting in the typical “waddling” gait. Changes in posture are related to the

growing fetus. Pressure on the surrounding muscles causing discomfort is

due to the growing uterus. Weight gain has no effect on gait.

C. The average amount of weight gained during pregnancy is 24 to 30 lb. This

weight gain consists of the following: fetus – 7.5 lb; placenta and membrane

– 1.5 lb; amniotic fluid – 2 lb; uterus – 2.5 lb; breasts – 3 lb; and increased
blood volume – 2 to 4 lb; extravascular fluid and fat – 4 to 9 lb. A gain of 12

to 22 lb is insufficient, whereas a weight gain of 15 to 25 lb is marginal. A

weight gain of 25 to 40 lb is considered excessive.

C. Pressure of the growing uterus on blood vessels results in an increased risk

for venous stasis in the lower extremities. Subsequently, edema and varicose

vein formation may occur. Thrombophlebitis is an inflammation of the veins

due to thrombus formation. Pregnancy-induced hypertension is not

associated with these symptoms. Gravity plays only a minor role with these

symptoms.

C. Cervical softening (Goodell sign) and uterine soufflé are two probable

signs of pregnancy. Probable signs are objective findings that strongly

suggest pregnancy. Other probable signs include Hegar sign, which is

softening of the lower uterine segment; Piskacek sign, which is enlargement

and softening of the uterus; serum laboratory tests; changes in skin

pigmentation; and ultrasonic evidence of a gestational sac. Presumptive signs

are subjective signs and include amenorrhea; nausea and vomiting; urinary

frequency; breast tenderness and changes; excessive fatigue; uterine

enlargement; and quickening.

B. Presumptive signs of pregnancy are subjective signs. Of the signs listed,

only nausea and vomiting are presumptive signs. Hegar sign,skin

pigmentation changes, and a positive serum pregnancy test are considered

probably signs, which are strongly suggestive of pregnancy.

D. During the first trimester, common emotional reactions include

ambivalence, fear, fantasies, or anxiety. The second trimester is a period of

well-being accompanied by the increased need to learn about fetal growth

and development. Common emotional reactions during this trimester include

narcissism, passivity, or introversion. At times the woman may seem

egocentric and self-centered. During the third trimester, the woman typically

feels awkward, clumsy, and unattractive, often becoming more introverted

or reflective of her own childhood.

B. First-trimester classes commonly focus on such issues as early physiologic

changes, fetal development, sexuality during pregnancy, and nutrition. Some

early classes may include pregnant couples. Second and third trimester

classes may focus on preparation for birth, parenting, and newborn care.

C. With breast feeding, the father’s body is not capable of providing the milk

for the newborn, which may interfere with feeding the newborn, providing

fewer chances for bonding, or he may be jealous of the infant’s demands on

his wife’s time and body. Breast feeding is advantageous because uterine

involution occurs more rapidly, thus minimizing blood loss. The presence of

maternal antibodies in breast milk helps decrease the incidence of allergies

in the newborn. A greater chance for error is associated with bottle feeding.

No preparation is required for breast feeding.

A. A false-positive reaction can occur if the pregnancy test is performed less

than 10 days after an abortion. Performing the tests too early or too late in

the pregnancy, storing the urine sample too long at room temperature, or

having a spontaneous or missed abortion impending can all produce falsenegative results.

D. The FHR can be auscultated with a fetoscope at about 20 week’s

gestation. FHR usually is ausculatated at the midline suprapubic region with

Doppler ultrasound transducer at 10 to 12 week’s gestation. FHR, cannot be

heard any earlier than 10 weeks’ gestation.

C. To determine the EDD when the date of the client’s LMP is known use

Nagele rule. To the first day of the LMP, add 7 days, subtract 3 months, and

add 1 year (if applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July)

minus 3 = 4 (April). Therefore, the client’s EDD is April 12.

A. When the LMP is unknown, the gestational age of the fetus is estimated by

uterine size or position (fundal height). The presence of the uterus in the

pelvis indicates less than 12 weeks’ gestation. At approximately 12 to 14

weeks, the fundus is out of the pelvis above the symphysis pubis. The fundus
is at the level of the umbilicus at approximately 20 weeks’ gestation and

reaches the xiphoid at term or 40 weeks.

D. Danger signs that require prompt reporting leaking of amniotic fluid,

vaginal bleeding, blurred vision, rapid weight gain, and elevated blood

pressure. Constipation, breast tenderness, and nasal stuffiness are common

discomforts associated with pregnancy.

B. A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less than

1:8 is significant, indicating that the client may not possess immunity to

rubella. A hematocrit of 33.5% a white blood cell count of 8,000/mm3, and a

1 hour glucose challenge test of 110 g/dl are with normal parameters.

D. With true labor, contractions increase in intensity with walking. In

addition, true labor contractions occur at regular intervals, usually starting in

the back and sweeping around to the abdomen. The interval of true labor

contractions gradually shortens.

B. Crowing, which occurs when the newborn’s head or presenting part

appears at the vaginal opening, occurs during the second stage of labor.

During the first stage of labor, cervical dilation and effacement occur. During

the third stage of labor, the newborn and placenta are delivered. The fourth

stage of labor lasts from 1 to 4 hours after birth, 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.

C. Barbiturates are rapidly transferred across the placental barrier, and lack

of an antagonist makes them generally inappropriate during active labor.

Neonatal side effects of barbiturates include central nervous system

depression, prolonged drowsiness, delayed establishment of feeding (e.g.

due to poor sucking reflex or poor sucking pressure). Tranquilizers are

associated with neonatal effects such as hypotonia, hypothermia,

generalized drowsiness, and reluctance to feed for the first few days.

Narcotic analgesic readily cross the placental barrier, causing depressive

effects in the newborn 2 to 3 hours after intramuscular injection. Regional

anesthesia is associated with adverse reactions such as maternal

hypotension, allergic or toxic reaction, or partial or total respiratory failure.

D. During the third stage of labor, which begins with the delivery of the

newborn, the nurse would promote parent-newborn interaction by placing

the newborn on the mother’s abdomen and encouraging the parents to

touch the newborn. Collecting a urine specimen and other laboratory tests is

done on admission during the first stage of labor. Assessing uterine

contractions every 30 minutes is performed during the latent phase of the

first stage of labor. Coaching the client to push effectively is appropriate

during the second stage of labor.

A. The newborn’s ability to regulate body temperature is poor. Therefore,

placing the newborn under a radiant warmer aids in maintaining his or her

body temperature. Suctioning with a bulb syringe helps maintain a patent

airway. Obtaining an Apgar score measures the newborn’s immediate

adjustment to extrauterine life. Inspecting the umbilical cord aids in

detecting cord anomalies.

D. Immediately before expulsion or birth of the rest of the body, the cardinal

movement of external rotation occurs. Descent flexion, internal rotation,

extension, and restitution (in this order) occur before external rotation.

B. 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. The umbilical vein,

ductus arteriosus, and ductus venosus are obliterated at birth.

B. Uric acid crystals in the urine may produce the reddish “brick dust” stain

on the diaper. Mucus would not produce a stain. Bilirubin and iron are from

hepatic adaptation.

B. The normal heart rate for a newborn that is sleeping is approximately 100

beats per minute. If the newborn was awake, the normal heart rate would
range from 120 to 160 beats per minute.

C. The anterior fontanel is larger in size than the posterior fontanel.

Additionally, the anterior fontanel, which is diamond shaped, closes at 18

months, whereas the posterior fontanel, which is triangular shaped, closes

at 8 to 12 weeks. Neither fontanel should appear bulging, which may

indicate increased intracranial pressure, or sunken, which may indicate

dehydration.

B. Blink, cough, sneeze, swallowing and gag reflexes are all present at birth

and remain unchanged through adulthood. Reflexes such as rooting and

stepping subside within the first year.

A. With the babinski reflex, 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. With the startle reflex, the newborn

abducts and flexes all extremities and may begin to cry when exposed to

sudden movement of loud noise. With the rooting and sucking reflex, the

newborn turns his head in the direction of stimulus, opens the mouth, and

begins to suck when the cheeks, lip, or corner of mouth is touched. With the

crawl reflex, the newborn will attempt to crawl forward with both arms and

legs when he is placed on his abdomen on a flat surface.

B. The description of hyperemesis gravidarum includes severe nausea and

vomiting, leading to electrolyte, metabolic, and nutritional imbalances in the

absence of other medical problems. Hyperemesis is not a form of anemia.

Loss of appetite may occur secondary to the nausea and vomiting of

hyperemesis, which, if it continues, can deplete the nutrients transported to

the fetus. Diarrhea does not occur with hyperemesis.

B. Edema of the hands and face is a classic sign of PIH. Many healthy

pregnant woman experience foot and ankle edema. A weight gain of 2 lb or

more per week indicates a problem. Early morning headache is not a classic

sign of PIH.
C. In a missed abortion, there is early fetal intrauterine death, and products

of conception are not expelled. The cervix remains closed; there may be a

dark brown vaginal discharge, negative pregnancy test, and cessation of

uterine growth and breast tenderness. A threatened abortion is evidenced

with cramping and vaginal bleeding in early pregnancy, with no cervical

dilation. An incomplete abortion presents with bleeding, cramping, and

cervical dilation. An incomplete abortion involves only expulsion of part of

the products of conception and bleeding occurs with cervical dilation.

A. Multiple gestation is one of the predisposing factors that may cause

placenta previa. Uterine anomalies abdominal trauma, and renal or vascular

disease may predispose a client to abruptio placentae.

B. A client with abruptio placentae may exhibit concealed or dark red

bleeding, possibly reporting sudden intense localized uterine pain. The uterus

is typically firm to board-like, and the fetal presenting part may be engaged.

Bright red, painless vaginal bleeding, a palpable fetal outline and a soft nontender abdomen are
manifestations of placenta previa.

D. Abruptio placentae is described as premature separation of a normally

implanted placenta during the second half of pregnancy, usually with severe

hemorrhage. Placenta previa refers to implantation of the placenta in the

lower uterine segment, causing painless bleeding in the third trimester of

pregnancy. Ectopic pregnancy refers to the implantation of the products of

conception in a site other than the endometrium. Incompetent cervix is a

conduction characterized by painful dilation of the cervical os without

uterine contractions.

B. Hyperstimulation of the uterus such as with oxytocin during the induction

of labor may result in tetanic contractions prolonged to more than

90seconds, which could lead to such complications as fetal distress, abruptio

placentae, amniotic fluid embolism, laceration of the cervix, and uterine

rupture. Weak contractions would not occur. Pain, bright red vaginal
bleeding, and increased restlessness and anxiety are not associated with

hyperstimulation.

C. 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, the depth and breadth of instruction will depend

on circumstances and time available. Allowing the mother’s support person

to remain with her as much as possible is an important concept, although

doing so depends on many variables. Arranging for necessary explanations by

various staff members to be involved with the client’s care is a nursing

responsibility. The nurse is responsible for reinforcing the explanations about

the surgery, expected outcome, and type of anesthetic to be used. 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.

A. Preterm labor is best described as labor that begins after 20 weeks’

gestation and before 37 weeks’ gestation. The other time periods are

inaccurate.

B. PROM can precipitate many potential and actual problems; one of the

most serious is the fetus loss of an effective defense against infection. This is

the client’s most immediate need at this time. Typically, PROM occurs about

1 hour, not 4 hours, before labor begins. Fetal viability and gestational age

are less immediate considerations that affect the plan of care.

Malpresentation and an incompetent cervix may be causes of PROM.

B. Dystocia is difficult, painful, prolonged labor due to mechanical factors

involving the fetus (passenger), uterus (powers), pelvis (passage), or psyche.

Nutritional, environment, and medical factors may contribute to the

mechanical factors that cause dystocia.

A. With uterine rupture, the client is at risk for hypovolemic shock.

Therefore, the priority is to prevent and limit hypovolemic shock. Immediate

steps should include giving oxygen, replacing lost fluids, providing drug

therapy as needed, evaluating fetal responses and preparing for surgery.

Obtaining blood specimens, instituting complete bed rest, and inserting a

urinary catheter are necessary in preparation for surgery to remedy the

rupture.

B. The immediate priority is to minimize pressure on the cord. 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, and

elevating the maternal hips on a pillow to minimize the pressure on the cord.

Monitoring maternal vital signs and FHR, notifying the physician and

preparing the client for delivery, and wrapping the cord with sterile saline

soaked warm gauze are important. But these actions have no effect on

minimizing the pressure on the cord.

D. Postpartum hemorrhage is defined as blood loss of more than 500 ml

following birth. Any amount less than this not considered postpartum

hemorrhage.

D. With mastitis, injury to the breast, such as overdistention, stasis, and

cracking of the nipples, is the primary predisposing factor. Epidemic and

endemic infections are probable sources of infection for mastitis. Temporary

urinary retention due to decreased perception of the urge to void is a

contributory factor to the development of urinary tract infection, not

mastitis.

D. Thrombophlebitis refers to an inflammation of the vascular endothelium

with clot formation on the wall of the vessel. Blood components combining

to form an aggregate body describe a thrombus or thrombosis. Clots lodging

in the pulmonary vasculature refers to pulmonary embolism; in the femoral

vein, femoral thrombophlebitis.

C. Classic symptoms of DVT include muscle pain, the presence of Homans

sign, and swelling of the affected limb. Midcalf pain, tenderness, and
redness, along the vein reflect superficial thrombophlebitis. Chills, fever and

malaise occurring 2 weeks after delivery reflect pelvic thrombophlebitis.

Chills, fever, stiffness and pain occurring 10 to 14 days after delivery suggest

femoral thrombophlebitis.

B. Manifestations of cystitis include, frequency, urgency, dysuria, hematuria

nocturia, fever, and suprapubic pain. Dehydration, hypertension, and chills

are not typically associated with cystitis. High fever chills, flank pain, nausea,

vomiting, dysuria, and frequency are associated with pvelonephritis.

C. According to statistical reports, between 50% and 80% of all new mothers

report some form of postpartum blues. The ranges of 10% to 40%, 30% to

50%, and 25% to 70% are incorrect.