MATERNAL AND CHILD
that the client needs further instruction?
NURSING
A postpartum patient was in labor for 30 hours and had
ruptured membranes for 24 hours. For which of the
following would the nurse be alert? Endometritis
 Endometritis is an infection of the uterine
lining and can occur after prolonged rupture
of membranes.
 Symptoms include swelling of the abdomen,
abnormal vaginal bleeding or discharge,
fever, discomfort with bowel movement,
and pain in the lower abdomen or pelvic
region.
Option B: Endometriosis does not occur after a strong
labor and prolonged rupture of membranes. It is a
painful disorder in which tissue similar to the tissue that
normally lines the inside of the uterus grows outside of
the uterus.
Option C: Salpingitis is a tubal infection and could
occur if endometritis is not treated. It is an inflammation
of the fallopian tubes caused by bacterial infection.
Option D: Pelvic thrombophlebitis involves a clot
formation, but it is not a complication of prolonged
rupture of membranes. It is an extremely rare condition
that occurs after delivery when an infected blood clot, or
thrombus, causes inflammation in the pelvic vein.
Amniocentesis
Amniocentesis is a test you may be offered during
pregnancy to check if your baby has a genetic or
chromosomal condition, such as Down's syndrome,
Edwards' syndrome or Patau's syndrome. It involves
removing and testing a small sample of cells from
amniotic fluid, the fluid that surrounds the baby in the
womb (uterus).
Amniotic fluid is the clear liquid that surrounds your
baby in the uterus during pregnancy. This fluid
provides a cushion that protects the baby from injury
and allows room for growth, movement and
development. Amniotic fluid also keeps the umbilical
cord from being squeezed between the baby and the
wall of the uterus.
1. A client at 36 weeks’ gestation is scheduled for
a routine ultrasound prior to amniocentesis.
After teaching the client about the purpose of the
ultrasound, which of the following client
statements would indicate to the nurse in charge
Correct Answer: B. The ultrasound identifies blood
flow through the umbilical cord.
Before amniocentesis, a routine ultrasound is valuable in
locating the placenta, locating a pool of amniotic fluid,
and showing the physician where to insert the needle.
Color Doppler imaging ultrasonography identifies blood
flow through the umbilical cord. A routine ultrasound
does not accomplish this.
Option A: As early as 10 weeks, the placenta can be
detected by an ultrasound. The normal placenta is
discoid with uniform echogenicity and rounded margins.
It is usually located along the anterior or posterior
uterine walls, extending into the lateral walls.
Option C: Ultrasound is done before and during
amniocentesis to ensure that the needle can safely pass
through the walls of the abdomen and womb.
Option D: The sample of amniotic fluid is removed
through a fine needle inserted into the uterus through the
abdomen, under ultrasound guidance.
2. While the postpartum client is receiving heparin
for thrombophlebitis, which of the following
drugs would the nurse expect to administer if the
client develops complications related to heparin
therapy?
Correct Answer: B. Protamine sulfate
Protamine sulfate is a heparin antagonist given
intravenously to counteract bleeding complications
caused by heparin overdose.
Option A: Calcium gluconate is the calcium salt
of gluconic acid, an intravenous medication used to treat
conditions arising from calcium deficiencies such as
hypo calcemic tetany and hypocalcemia.
Option C: Methylergonovine is used to prevent
or treat bleeding from the uterus that can happen after
childbirth or an abortion.
Option D: Nitrofurantoin is used to treat urinary
tract infections. It is an antibiotic that works by killing
bacteria that cause infection.
3. When caring for a 3-day-old neonate who is
receiving phototherapy to treat jaundice, the
nurse in charge would expect to do which of the
following?
Correct Answer: D. Check the vital signs every 2 to 4
hours
While caring for an infant receiving phototherapy for
treatment of jaundice, vital signs are checked every 2 to
4 hours because hyperthermia can occur due to the
phototherapy lights.
 Option A: Only one study reported the
significance drop in serum bilirubin and
shorter duration of phototherapy in the
supine group. Keeping the jaundiced
newborn in the supine position
throughout phototherapy is as effective
as turning them periodically based on
appraised studies.
 Option B: The baby may be breastfed
without interruption during
phototherapy. Jaundice in breastfed
babies is not a reason to stop
breastfeeding as long as a baby is
feeding well, gaining weight, and
otherwise growing.
 Option C: Bronze baby syndrome is a
rare complication seen in neonates with
hyperbilirubinemia who are being
treated with phototherapy. Affected
neonates develop gray-brown skin,
serum, and urine within a week of
initiation of phototherapy.
4. A primigravida in active labor is about 9 days
post-term. The client desires a bilateral pudendal
block anesthesia before delivery. After the nurse
explains this type of anesthesia to the client,
which of the following locations identified by
the client as the area of relief would indicate to
the nurse that the teaching was effective?
Correct Answer: D. Perineum
A bilateral pudendal block is used for vaginal deliveries
to relieve pain primarily in the perineum and vagina.
Pudendal block anesthesia is adequate for episiotomy
and its repair.
 Option A: A spinal anesthetic is given
into the middle of the lower back and
local anesthetic is injected through the
needle into the fluid that surrounds the
spinal cord. It numbs the nerves that
supply the abdomen, hips, bottom, and
legs.
 Option B: General or regional
anesthesia can be appropriate for
patients undergoing abdominal surgery.
Balanced anesthesia with inhalational
anesthetics, opioids, and neuromuscular
blockers are used in general anesthesia
for abdominal surgical procedures.
 Option C: Spinal anesthesia is one of
the most preferred anesthetic methods
during Cesarean section since it
provides easy and rapid induction,
effective sensory and motor block, and
has little effect on the fetus.
5. The nurse is caring for a primigravida at about 2
months and 1-week gestation. After explaining
self-care measures for common discomforts of
pregnancy, the nurse determines that the client
understands the instructions when she says:
A. “Nausea and vomiting can be decreased if I eat
a few crackers before rising.”
B. “If I start to leak colostrum, I should cleanse my
nipples with soap and water.”
C. “If I have a vaginal discharge, I should wear
nylon underwear.”
D. “Leg cramps can be alleviated if I put an ice
pack on the area.”
Eating dry crackers before arising can assist in
decreasing the common discomfort of nausea and
vomiting. Avoiding strong food odors and eating a high-
protein snack before bedtime can also help.
 Option B: Colostrum is a milky fluid
that’s released by mammals that have
recently given birth before breast milk
production begins.
 Option C: Cotton underwear is
breathable and absorbent, which can
help prevent yeast infections.
 Option D: A heating pad or hot pack
may help relieve tight muscles in leg
cramps.
6. Forty-eight hours after delivery, the nurse in
charge plans discharge teaching for the client
about infant care. By this time, the nurse expects
that the phase of postpartum psychological
adaptation that the client would be in would be
termed which of the following?
Correct Answer: C. Taking hold
Beginning after completion of the taking-in phase, the
taking-hold phase lasts about 10 days. During this phase,
the client is concerned with her need to resume control
of all facets of her life in a competent manner. At this
time, she is ready to learn self-care and infant care skills.
 Option A: The taking-in phase usually
sets 1 to 2 days after delivery. The
 woman prefers to talk about her
experiences during labor and birth and
also her pregnancy. The taking-in phase
provides time for the woman to regain
her physical strength and organize her
rambling thoughts about her new role.
 Option B: During the letting go phase,
the woman finally accepts her new role
and gives up her old roles like being a
childless woman or just mother of one
child.
 Option D: The resolution phase or
ending phase is the final stage of the
nurse-client relationship. After the
client’s problems or issues are
addressed, the relationship needs to be
completed before it can be terminated.
8. A neonate with meconium aspiration syndrome
7. A pregnant client is diagnosed with partial would show which APGAR score at delivery?
placenta previa. In explaining the diagnosis, the
4,5
nurse tells the client that the usual treatment for
partial placenta previa is which of the following? 9. Which statement about fetal alcohol syndrome
should a nurse include in her prenatal teaching?
Correct Answer: A. Activity limited to bed rest
 The risk of teratogenic effects increases
Treatment of partial placenta previa includes bed rest,
hydration, and careful monitoring of the client’s proportionally with increased daily
bleeding. alcohol intake
10. A nurse should anticipate Transient Tachypnea
 Option B: The greatest risk of placenta in Newborn (TTN)to occur in which of the
previa is hemorrhage. Bleeding often following cases? Select all that apply.
occurs as the lower part of the uterus
thins during the third trimester of
pregnancy in preparation for labor. This  Postmature neonate.
may require blood transfusion during
Cesarean section.  Neonate who is born to a diabetic mother.
 Option C: In general, there is a higher
Cesarean rate associated with placental  LGA neonate.
edge-to-cervical of distances of less than
2 cm.
 Neonate delivered thru Caesarian Birth.
 Option D: Labor induction is the
stimulation of uterine contractions
during pregnancy before labor begins on  Neonate that is born rapidly.
its own to achieve a vaginal birth. It is
not an option for placenta previa.  Preterm neonate.

11. Which intervention should a nurse do first for a

neonate who becomes apneic?

 Administer oxygen

 Flick the sole

 Document the length of the apneic episode

 Begin CPR

12. Which statement about the respiratory status of
neonates is accurate?
 Tachypnea is defined as respirations greater than
40/minute while sleeping.
 Nasal flaring is normal in neonates.
 Tachypnea is abnormal after the initial 4 to 6
hours of life.
 This is normal in the first 24 hours after birth.
13. Unusually large and small neonates are at
particularly high risk for?
 Bradycardia
 Hypoglycemia.
 Hypothermia.
 Tachypnea.
14. The neonatal nurse notices that a newborn's
glucose level is 50 mg/He or she should:
 Prepare for placement of an orogastric tube.
 Initiate dextrose in water bottle feedings.
 Assess sucking reflex.
 Check the baby's temperature for hyperthermia.
15. Nurses in birthing centers are expected to be
competent in assessing newborn from all of the
following except:
 Respiratory difficulty.
 Thermal instability.
 Failure to thrive.
 Cardiac anomalies
16. Which of the following statements best
describes the clinical manifestations of the
preterm infant?
 Head is proportionately small in relation to the
body.
 Extremities remain in attitude of flexion
 Thermostability is well established.
 Sucking reflex is absent, weak or ineffectual.
17. Nurse Ada is assigned in the nursery when she
received a call and is informed that a newborn
with APGAR score of 1 and 4 will brought to
the nursery. Nurse Ada quickly prepares for the
arrival of the newborn and determines that the
priority intervention is to:
 Prepare for the insertion of IV line with 5%
dextrose in water.
 Connect the resuscitation bag to the oxygen.
 Set up radiant warmer control temperature at
36.5 degree Celsius.
 Turn on the apnea and cardiorespiratory
monitor.
18. Nurse Mona is monitoring a preterm newborn
infant for signs of respiratory distress syndrome.
The nurse monitors the infant for?
 Acrocyanosis, emphysema, interstitial edema.
 Cyanosis, tachypnea, retractions, grunting
respirations and nasal flaring
 Acrocyanosis, apnea, pneumothorax and
grunting
 Barrel shaped chest, hypotension and
bradycardia
19. Nurse Bea is providing instructions to Dina a
mother of a newborn infant with
hyperbilirubinemia who is being breastfed. She
provides which most appropriate instructions to
Dina?
 Stop the breastfeeding and switch to bottle
feeding permanently.
 Switch to bottle feeding the baby for 2 weeks.
 Continue to breastfeed every 2-4 hours.
 Feed the newborn less frequently.
20. Which action best explains the main role of
surfactant in the neonate?
 Helps the lungs remain expanded after the
initiation of breathing.
 Helps maintain a rhythmic breathing pattern.
 Assist with ciliary maturation in the upper
airways.
 Promotes clearing mucus from the respiratory
tract.
21. The nurse assigned in the nursery is assessing a
2-hour old neonate, she 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.
 Immediately take the neonate’s temperature.
 Facilitate resuscitation
 Notify the physician for cardiologic consult.
22. Which condition or treatment best ensures lung
maturity in an infant?
 None of the above
 Absence of phosphatidylglycerol in amniotic
fluid
 Lecithin to sphingomyelin ration more than
2:1
 Presence of meconium in the amniotic fluid.
23. Baby AM is admitted in the nursery. Her vital
signs are: temperature = 35.8 degrees Celsius.,
heart rate = 121 bpm, and respirations =
40/minute. The infant is pink with slight
acrocyanosis. The priority nursing diagnosis for
Baby AM is:
 Potential for infection related to lack of
immunity.
 Ineffective thermoregulation related to
fluctuating environmental temperature.
 Altered elimination pattern related to lack of
nourishment.
 Altered nutrition less than body requirements
related to diminished sucking reflex.
24. Nurse Ola is assessing Baby Jas, a preterm
infant. She understands that compared to term
infant Baby Jas has:
 More subcutaneous fat
 Few blood vessels through the skin.
 Well-developed flexor muscles.
 Greater surface area in proportion to weight
25. What nursing diagnosis should the nurse include
in a plan of care for a preterm infant given that
this infant has decreased immune function?
 Imbalanced nutrition
 Risk for infection
 Ineffective thermoregulation
 Ineffective airway clearance
26. Mrs. PM delivered a preterm baby in a 30th
week of gestation. Which nursing measures
must be performed by Nurse Gigi?
 Place the baby under isollete care.
 None of the above
 Carrying the baby frequently.
  Place the baby in basinet
27. A client has delivered a small for gestation age
(SGA) newborn. Which of the following would
the nurse expect to assess?
 Protuberant abdomen
 More lanugo
 Round flashed face
28. A nurse is taking the Apgar score of a newborn
at 1 minute after birth. The following are the
findings: Heart rate of 122 bpm, good cry, with
some flexion of the extremities, coughs when
suctioned, bluish coloring of the hands and feet.
The score would be.
 C. 8
29. Which of the following data of a term newborn
would help the suspicious of
heart problem?
 Apical pulse rate between 128 and 140 per
minute.
 Hematocrit of 45%
 Shallow, irregular respirations between 36 and
50 per minute.
 Circumoral cyanosis during feeding
30. When suctioning a neonate, using a suction
apparatus, the proper technique to be done to
avoid depriving the child of the much-needed
oxygen during suctioning is to;
 Pinch the catheter when inserting into the
nose.
 Suction only the buccal cavity
 Insert the catheter only to the nostril.
 Pinch the nostrils.
31. Mother Lala, 25 years old, is admitted to the
hospital due to labor pain. She is estimated to be
37 weeks pregnant and had 1 prenatal checkup.
She says that she gave herself a narcotic 2 hours
ago. She has multiple marks on her arms that
suggest narcotics abuse. With her history, it is
important to assess her for the signs of:
 Hypotensive syndrome
 Infection
 Cerebral edema
 Hyporeflexia
32. Baby Lala is being observed for symptoms of
narcotic withdrawal, which of following signs
and symptoms must the nurse consider as her
assessment for narcotic withdrawal?
 A loud, hoarse cry
 Hyperactivity
 Facial petechiae
 Erythema toxicum
33. You are the student nurse assigned to a 1 hour
old neonate. There is doctor’s order to be
carried out for suctioning. As you assess this
neonate which of the following findings will you
consider that you have to perform suctioning.
Select all that apply.
 decreased consciousness
 visible secretions that obstruct the airflow
 Inability to suck.
 difficulty coughing up secretions and
swallowing
 secretion regurgitation
34. On the other hand, there are also
contraindications for the said procedure. As a
student nurse, you know that one of the
following is a contraindication for suctioning:
 The patient has chest infection
 The patient is able to tolerate an oropharyngeal
airway
 The patient has a fractured base of skull
 The patient is hypoxemic
35. As a future pediatric nurse, it is your
responsibility to ensure that you are using the
appropriate size for suctioning across ages, most
especially for ages 0-18 days. Which of the
following tube sizes is used for infants?
 5 to 6 French
 3 to 4 French
 5 to 8 French
 1 to 2 French
36. You learned that smaller French size for
suctioning is suitable among neonates to:
 prevent neonates from being stimulated further
via suctioning
 avoid costly purchase since they are cheaper
 avoid mucosal injury
 prevent neuro related injuries
37. In performing suctioning, which of the
following is the best independent nursing
responsibility that you should do to ensure that
infection can be prevented?
 Perform hand hygiene.
 Wear sterile gloves.
 Prepare a sterile solution.
 Use sterile technique and equipment
38. In performing proper suctioning, it is crucial to
assess the patient during the procedure. Proper
oxygenation prior to and after suctioning is an
important nursing responsibility. Which of the
following would be the BEST way for you to
assess oxygen levels of the baby?
 Pulse oximetry
 Lung auscultation
 Spirometry
 Percussion on the back
39. A nurse on duty was in charge of the pediatric
ward, and she noticed that one of her neonate
patients’ nasal prongs of the nasal cannula was
dislodged. For how many minutes can the brain
tolerate hypoxia before sustaining permanent
damage?
 30 seconds
 2 minutes
 3 minutes
 1 minute
40. Which of the following signs and symptoms
should a nurse be not alarmed in caring for a a
pediatric client who is in need of oxygen
administration?
 Bradycardia, tachypnea, pallor
 Tachycardia, hypotension, dyspnea
 Tachycardia, hypotension, cyanosis
 Tachycardia, cough, dyspnea
41. Nurse Kit was doing his rounds on the NICU
when he suddenly found an unresponsive
neonate client. What would be his next step?
 Initiate a code
 Call the physician
 Do a shout-tap-shout to check the patient's
responsiveness
 Ignore and continue doing his rounds
42. After checking the baby's responsiveness, the
baby is still unconscious and was found
pulseless. What would Nurse Kit do?
 Give epinephrine 5mg STAT
 Run outside and call a fellow nurse  To be sure tube is in the stomach (G1 track).

 Do nothing  Enhances cooperation and participation; reduces

anxiety and fear.
 Initiate a code and immediately do a high-
quality CPR  To determine if tube can be easily passed

 Promotes organization and efficiency.

43. Baby Boy Zack, a full-term newborn, is
receiving phototherapy. While he is on this 51. A newborn in the nursery is exhibiting signs of
therapy, which of these measures should be neonatal abstinence syndrome. Which of the
included in his care? following signs/symptoms is the nurse
observing?
 Testing his voiding for bilirubin
 Hyporeflexia
 Applying an emollient to his skin.
 Prolonged periods of sleep
 Checking hid stool for occult blood
 Persistent shill cry
 Giving him supplementary fluids
 Lethargy
44. With cardiac rate but with no spontaneous
52. On day 3 of life, a newborn continues to require
respiration
100% oxygen by nasal cannula. The parents ask
whether they can hold their infant during his
 Pulmonary resuscitation
next gavage feeding. Given that this newborn is
physiologically stable, what response would the
45. An abnormal breath of a newborn that usually
nurse give?
occurs during expiration that represents
breathing against a partially closed glottis.
 "Parents are not allowed to hold infants who
depend on oxygen."
 Grunting
 "You may hold only your baby's hand during the
46. Characterized by an agonal breathing
feeding."
 Gasping
 "Feedings cause more physiologic stress, so the
47. It is a high pitch breathing sound that usually
baby must be closely monitored. Therefore, I
signifies obstruction of the upper airway
don't think you should hold the baby."
 Stridor
 "You may hold your baby during the
48. Checking of infant’s breathing upon birth.
feeding."
 at least 5 seconds and no more than 10
seconds 53. An infant born at 33 weeks of gestation is
classified as:
49. Size of tube to be used for premature infant for
gavage feeding.
 Late preterm
 French 5
 Moderate preterm
50. Why is it necessary for the nurse to select an
 Extremely preterm
appropriate size and type of nasogastric tube?
  Term

54. Nurse Anna must perform nasopharyngeal

suctioning on a newborn with profuse
secretions. Place the following nursing actions
for nasopharyngeal suctioning in chronological
order.

1. Slowly rotate and remove the suction catheter

2. Place thumb over the suction control on the catheter
3. Assess type and amount of secretions
4. Insert free end of the tubing through the nose

4,2,1,3

55. Nurse Jaz who’s working with a 24-hour-old

neonate in the nursery, has made the following
nursing diagnosis: Risk for altered growth.
Which of the following assessments would
warrant this diagnosis?

 The baby has lost 8% of weight since birth

 The baby has not urinated since birth

 The baby weight 3,000 grams at birth

 All of the above

56. Which physical findings would be of most

concern in a newborn with respiratory distress?

 Tachypnea.

 Mild retractions.

 Wheezing.

 Grunting.