following problems correlates with

I. Intrapartum Complications woman's behavior?

a. Power because there is no

1. A nurse is reviewing the physician's "bearing-down" effort.

prescription for a client admitted for ● supported by the statement of

preterm premature rupture of membrane “The woman didn't have

(PROM). The gestational age of fetus is strength anymore and is very

determined to be 34 weeks AOG. Which of tired”

the following nursing actions is b. Passenger, since the sagittal suture of

inappropriate? the baby's head is in an AP position

a. administer ampicillin 1 gram as IV c. Power, due to the contraction of the

piggy back Q6H uterus that is stronger and more

b. Monitor maternal vital signs frequent than usual

frequently (every 4 hrs) d. Passenger because the posterior

c. Monitor fetal heart rate continuously fontanel of the baby's head is below

at least every 30 minutes to assess the bone above the pubis

fetal distress 3. A pregnant woman's membranes ruptured

d. Perform a vaginal examination every prematurely at 34 weeks. She will be

shift discharged to her home for the next few

● due to PROM mother is prone weeks. What would the nurse include in

to infection her discharge instruction plan in teaching

● Normally, we have vaginal the woman?

examination only 4 times a. report any increase in fetal activity

2. A GIPO pregnant woman in labor whose b. Rest in a side-lying position with hips

gestational age is 38 weeks has her fetus in elevated

the LOP position. Later at 07:00 am, the c. Massage her breasts to promote

duration of contraction was recorded at 2 uterine relaxation

minutes for 60, intensity ++, full cervical d. Notify her obstetrician if she has a

dilation, 100% effaced, and station 0. temperature above 37.8C

Membranes ruptured after an hour with ● since PROM poses risk of

the fetal head station at (+2). The bone and infection, elevated temp must

the FHS is 120 bpm. The baby was flexed be reported as it is a sign of

until 09:00 AM, with unnoticeable infection

progression. The woman didn't have 4. A nurse has developed a plan of care for a

strength anymore and is very tired. She client experiencing dystocia and includes

requested C section delivery. Which of the several intervention in the plan of care.
 Which of the following nursing intervention

should the nurse select the highest

1. A client's delivery resulted in uterine inversion
priority?
alongside retained placenta. Which of the ff
a. Changing the clients position
nursing care must be prioritized?
frequently
a. abstain from food and water by
b. Documenting the progress of labor
mouth and IVF
c. Monitor the fetal heart rate
b. Administer IV pain medication
● dystocia is characterized by
according to treatment plan
difficulty birth or pronged
c. Record vital signs and observe signs
labor and this poses risk for
and symptoms of shock
fetal distress. Monitoring FHR
d. Cover sterile gauze with warm saline
helps assess any distress i
solution to prevent the uterus from
fetal.
drying out and immediately report to
d. Providing comfort measures
the doctor
5. Which type of uterine contraction does to
● among other choices, this is
induce uterine rupture?
the most emergency situation.
a. D =60 sec, I= 5 mins, severity = +
2. Upon assessing a 1-hr postpartum woman,
b. 75 sec 2 mins severity ++
her signs and symptoms are as follows: hard,
c. 75 sec 2 mins severity +++
swelling 3 cms diameter in the episiotomy
d. 60 sec 5 min severity ++
area with moderate pain score; T = 37.6
6. Which of the ff as assessment finding
(normal in postpartum clients), PR: 88 bpm ,
would lead the nurse to suspect that a
RR = 22 bpm, BP = 121/74 mmHg. Which of
pregnant woman has developed aminiotic
the ff nursing actions is the most appropriate
fluid embolism
(VITAL SIGNS ARE ALL OKAY)
a. rapid hypertonic contractions
a. Give lactated ringer's 1000 ml IV drip
b. Rapid cervical dilation of 5cm/hr
and prepare for re-suturing
c. Report sudden severe chest pain and
b. Give lactated ringer's 1000 ml IV drip
dyspnea
and notify the doctor
* AFE happens when amniotic fluid
c. Continuously assess the REEDA scale
enters the circulation of the mother.
and use ice packs as compression
This accumulation of amniotic fluid in
● REEDA is used to assess
the blood circulatio causes deprvation
healing and inflamation in
of oxygen to the lungs and heart and
perineum due to episiotomy.
thus dyspnea and severe chest pain
Cold or ice packs help in
occurs.
reducing swelling and
d. Report back pain when ambulating of
inflammation on the
lying in bed
episiotomy site.
II. Postpartum

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 d. Notify the doctor and prepare for cause of the signs and symptoms the client is

re-suturing experiencing?

3. A G1P1 woman's newborn weights 4,100 a. appendicitis

grams delivered normally. The height of the b. Cystitis

fundus was measured 6, 5.5 and 5.5 inches c. Endometritis

consecutively for three days. Which of the ff ● since the woman had a PROM

supportive data might result in high-risk she is at risk for infection and

complication for this client? among the choices only

a. hematoma, the height of the fundus: Endometritis is an infection

6 and 5.5 at 1st and 2nd day related to PROM since it is an

● characterized by bleeding and infection in endometrium.

blood clots and can be seen d. Mastitis

during the first 6 hrs after 5. Two days after discharge, the pospartum

birth client calls the emergency room complaining

b. Sub involution, the height of the of a reddened area on her right lower leg,

fundus is 5.5 at the 2nd day and 3rd temperature elevation of 37.8 C, and a (+)

day, newborn weighs of 4,100 Homan' sign. Which of the ff assessment

● Because there is no decrease findings would most likely correlate with the

in size of fundus from 2nd day symptoms?

to 3rd day. The fundus should a. superficial vein thrombosis

be at umbilicus 1 hr after birth b. Cellulitis in the right leg

and must be 1 finger breath c. Deep vein thrombosis

decrease every day (1:1) ● Homan’s sign is used to assess

c. Sheena's syndrome, the height of the DVT. therefore, a positive

fundus is 5.5 inches at the 1st and 2nd result indicates DVT

day d. Puerperal infection

● usually the result of severe 6. A G4P4 gave birth to a newborn weighing

hypotension or shock caused 3,960 through spontaneous vaginal delivery.

by massive hemorrhage The fundal height was recorded for the past 3

during or after delivery. days as follows: day 1 = (-1) FB, day 2 = (-2),

d. Pueperal infection, the height of the day 3 = (-3). The ff day, her pain scale was 3,

fundus 6 inches on 1st day described her lochia discharge as red,

4. Five days after a c section delivery, a woman odorless, and 50% of sanitary pads were

who has had a history of PROM, for 19 hrs saturated with blood. How should the nurse

comes to the emergency room because she formulate the nursing diagnosis that is most

has a fever and persistent cramping, and foul applicable to this woman?

lochia. Which of the ff complication is the

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 a. risk of pueperal infection rt d. G1P1, Latch score = 7. Deducted 3

postpartum delivery AEB 50-80 ml points from the baby's audible suck,

bleeding and odorless dark-red lochia pinch nipple and hold

b. Risk of uterine subinvolution rt

III. Newborn
multigravida history and postpartum

delivery AEB undescend fundus

● multigravity can cause 1. A newborn is screaming and noticeable bruise

subinvolutin. Undescended on the left shoulder. Reflexes noted are: (+)

fundus also cause grasping reflex left shoulder, (-) moro reflex

subinvolution. In the scenario, left shoulder, (+) moro reflex right shoulder.

Undescended fundus is What abnormality this baby could have?

presented by a fundal height a. erb's paralysis

of -2 for two consecutive b. Fractured clavicle

days. c. Cerebral hemorrhage

c. Risk of uterine subinvolution rt d. Brachial plexus injury

pstpartum delivery AEB undescened 2. A term infant is 30 hrs old, has a total serum

fundus, dark-red lochia and 50-80 ml bilirubin level of 13mg/dL, and has visible

bleeding jaundice. What action by the nurse is the most

d. Risk of postpartum hemmorhage rt PP appropriate?

delivery and undescended fundus AEB a. document the findings of intracranial

50-80 ml bleeding hemorrhage

7. Who among the ff postpartum mothers is at b. Assure the parents that this is

risk of breast abcess? temporary

a. G2P2 , Bilateral breast engorged 2 c. Have the mother switch to bottle

days postpartum feeding

b. G1P1, right nipple pain, therefore, let d. Provide phototherapy

the baby suck on the left side only ● Phototherapy is for ptx with

● mastitis (medical term of jaundice.

breast abcess) is common in 3. A 1 month old infant was diagnosed of

primigravida and primipara. gastroesophangeal reflux. The infant vomits

Mastitis is also characterized the gastric contents during and after feeding

by nipple pain. And the baby especially when he cries or changes position

should suck on the engorged and regurgitates partly digested formula.

breast to reduce pain and Which of the ff nursing care is the most

engorgment. appropriate?

c. G3P2, mother. Massages and taps the a. provide IV and prepulsid drug

breast every time before giving the b. Reduce crying before and after

baby to suck feeding time

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 c. Prepare the child for surgery 6. The nurse is admitting a newly delivered

(Fundoplication) neonate with meningocele into the nursery.

d. Place the infant in left side-lying Which of the ff assessments is priority for the

position with the head elevated at 30 nurse to perform?

degrees (Lying on a. hard palate assessment

● left side-lying allows acidic b. Trunk incurvation reflex

contents to pass through the c. assessment of the red reflexes

lower esophageal sphincter d. Head and chest circumference

into the stomach. Elevation of ● because meningocele is

the head prevent characterized by

regurgitation hydrocephaly, and can be

4. A 6 month old infant was diagnosed with cleft assessed through head and

palate and pending palate repair surgery, chest circumference

which of the ff nursing care for feeding is the 7. The nurse has taken a health history from a

most appropriate? school age child who is being assessed 6

a. suck from the breast by pushing the weeks post surgery for a benign brain tumor.

head Which of the ff findings should the nurse

b. Feed by glass feeding method report?

c. Use long, soft nipples a. Child states that he has had no

● to preserve energy of the baby headaches all week

especially with this condition. b. Child states that he fell at school 3x

It also promotes maintain last week

nutrition through continuous c. Child state that he did very well on

breastfeeding yesterday's history test

d. Use soft squeeze bottle d. Child states that he has decided to

5. A pediatric nurse is taking care of a child who join the school's swim team

has a heart defect when suddenly the child 8. A nurse is educating a young boy about the

has a "tet spell". How would the nurse initially assessment required to make a diagnosis of

intervene in this situation? growth hormone deficiency. Which of the ff

a. low flow O2 via mask information should the nurse include in his or

b. Avoid exacerbating distress her teaching?

c. Morphine 0.2 mg/kg IM as ordered by a. a biopsy of the child's testes will be

the doctor (morphine is a depressant) considered

d. Place the child in the knee-chest b. An x-ray of the child's wrists will be

position performed

● This promotes venous return ● choose the cheapest and basic

and increase cardiac output assessment to the patient first

so that If the GHD is scanned

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 in the X ray there is no need ● hematologic disorder is

for MRI) characterized by loe level of

c. The child will have an MRI of his rbc (carry oxygen). Thus there

hypothalamus will limit in blood flow which

d. The child will receive IV dye for an can cause reduced perfusion

adrenal fluoroscopy to vital organs and distal

9. A child with type 1 DM has been diagnosed extremities. This reduced

with keto acidosis. Which of the ff laboratory blood flow can result in tissue

findings is consistent with diagnosis death.

a. serum Ph 7.24 12. A 7 month old infant was diagnosed with

● (ketoacidosis, acid so ang pH undescended testis. How should treatment be

sang blood ang gina check given?

b. Hemoglobin A1C: 5.5% a. you don't have to do anything yet. The

c. K + level: 3.9 mEq/L doctor will schedule surgery at the

d. FBS/CBG: 125 mg/dL age of 3 years

10. A 2 year old came to the hospital with a fever, b. Surgery should be performed

sore throat, and difficulty swallowing. The immediately because there may be

mother gave a history that the child had a complications

frequent cough and sor throat. Streptococcus c. Observe the symptoms before 1 year

group A was detected, T= 38.5, PR= 112 bpm, if testes has not yet entered the

RR= 26bpm. How should the nurse provide scrotum,

care? d. gonadotropic hormone is

a. insert orogastric tube for feeding recommended.

b. NPO for 24 hrs ● since the infant is only 7

c. Provide a liquid diet month old less invasive

d. Gargle with salt and water procedure is preferedr

11. Nurse Ana is caring for a 7 year old child with (gonado hormone).

a hematologic disorder. Which of the ff is the

priority nursing diagnosis what must be

included.

a. acute pain rt to bleeding into tissues

b. Anxiety rt fear of the unknown and

disease process

c. Decreased cardiac output rt

inadequate fluid volume

d. Altered tissue perfusion rt diminished

blood volume

Faithful He has been, Faithful He will be.