PNLE II for Community Health Nursing and Care of the Mother and Child

1. May arrives at the health care clinic and tells the nurse that her last 6. A pregnant client is receiving magnesium sulfate for severe
menstrual period was 9 weeks ago. She also tells the nurse that a home pregnancy induced hypertension (PIH). The clinical findings that would
pregnancy test was positive but she began to have mild cramps and is warrant use of the antidote , calcium gluconate is:
now having moderate vaginal bleeding. During the physical examination A. Urinary output 90 cc in 2 hours.
of the client, the nurse notes that May has a dilated cervix. The nurse B. Absent patellar reflexes.
determines that May is experiencing which type of abortion? C. Rapid respiratory rate above 40/min.
A. Inevitable D. Rapid rise in blood pressure.
B. Incomplete 7. During vaginal examination of Janah who is in labor, the presenting
C. Threatened part is at station plus two. Nurse, correctly interprets it as:
D. Septic A. Presenting part is 2 cm above the plane of the ischial
2. Nurse Reese is reviewing the record of a pregnant client for her first spines.
prenatal visit. Which of the following data, if noted on the client’s record, B. Biparietal diameter is at the level of the ischial spines.
would alert the nurse that the client is at risk for a spontaneous C. Presenting part in 2 cm below the plane of the ischial
abortion? spines.
A. Age 36 years D. Biparietal diameter is 2 cm above the ischial spines.
B. History of syphilis 8. A pregnant client is receiving oxytocin (Pitocin) for induction of labor.
C. History of genital herpes A condition that warrant the nurse in-charge to discontinue I.V. infusion
D. History of diabetes mellitus of Pitocin is:
3. Nurse Hazel is preparing to care for a client who is newly admitted to A. Contractions every 1 ½ minutes lasting 70-80 seconds.
the hospital with a possible diagnosis of ectopic pregnancy. Nurse B. Maternal temperature 101.2
Hazel develops a plan of care for the client and determines that which C. Early decelerations in the fetal heart rate.
of the following nursing actions is the priority? D. Fetal heart rate baseline 140-160 bpm.
A. Monitoring weight 9. Calcium gluconate is being administered to a client with pregnancy
B. Assessing for edema induced hypertension (PIH). A nursing action that must be initiated as
C. Monitoring apical pulse the plan of care throughout injection of the drug is:
D. Monitoring temperature A. Ventilator assistance
4. Nurse Oliver is teaching a diabetic pregnant client about nutrition and B. CVP readings
insulin needs during pregnancy. The nurse determines that the client C. EKG tracings
understands dietary and insulin needs if the client states that the second D. Continuous CPR
half of pregnancy require: 10. A trial for vaginal delivery after an earlier caesareans, would likely to
A. Decreased caloric intake be given to a gravida, who had:
B. Increased caloric intake A. First low transverse cesarean was for active herpes type 2
C. Decreased Insulin infections; vaginal culture at 39 weeks pregnancy was
D. Increase Insulin positive.
5. Nurse Michelle is assessing a 24 year old client with a diagnosis of B. First and second caesareans were for cephalopelvic
hydatidiform mole. She is aware that one of the following is disproportion.
unassociated with this condition? C. First caesarean through a classic incision as a result of
A. Excessive fetal activity. severe fetal distress.
B. Larger than normal uterus for gestational age. D. First low transverse caesarean was for breech position.
C. Vaginal bleeding Fetus in this pregnancy is in a vertex presentation.
D. Elevated levels of human chorionic gonadotropin.
PNLE II for Community Health Nursing and Care of the Mother and Child
11.Nurse Ryan is aware that the best initial approach when trying to take
a crying toddler’s temperature is:
A. Talk to the mother first and then to the toddler.
B. Bring extra help so it can be done quickly.
C. Encourage the mother to hold the child.
D. Ignore the crying and screaming.
12.Baby Tina a 3 month old infant just had a cleft lip and palate repair.
What should the nurse do to prevent trauma to operative site?
A. Avoid touching the suture line, even when cleaning.
B. Place the baby in prone position.
C. Give the baby a pacifier.
D. Place the infant’s arms in soft elbow restraints.
13. Which action should nurse Marian include in the care plan for a 2
month old with heart failure?
A. Feed the infant when he cries.
B. Allow the infant to rest before feeding.
C. Bathe the infant and administer medications before
feeding.
D. Weigh and bathe the infant before feeding.
14.Nurse Hazel is teaching a mother who plans to discontinue breast
feeding after 5 months. The nurse should advise her to include which
foods in her infant’s diet?
A. Skim milk and baby food.
B. Whole milk and baby food.
C. Iron-rich formula only.
D. Iron-rich formula and baby food.
15.Mommy Linda is playing with her infant, who is sitting securely alone
on the floor of the clinic. The mother hides a toy behind her back and the
infant looks for it. The nurse is aware that estimated age of the
infant would be:
A. 6 months
B. 4 months
C. 8 months
D. 10 months
16.Which of the following is the most prominent feature of public health
nursing?
A. It involves providing home care to sick people who are not
confined in the hospital.
B. Services are provided free of charge to people within the
catchments area.
C. The public health nurse functions as part of a team
providing a public health nursing services.
D. Public health nursing focuses on preventive, not curative,
services.
17.When the nurse determines whether resources were maximized in
implementing Ligtas Tigdas, she is evaluating
A. Effectiveness
B. Efficiency
C. Adequacy
D. Appropriateness
18.Vangie is a new B.S.N. graduate. She wants to become a Public
Health Nurse. Where should she apply?
A. Department of Health
B. Provincial Health Office
C. Regional Health Office
D. Rural Health Unit
19.Tony is aware the Chairman of the Municipal Health Board is:
A. Mayor
B. Municipal Health Officer
C. Public Health Nurse
D. Any qualified physician
20.Myra is the public health nurse in a municipality with a total
population of about 20,000. There are 3 rural health midwives among
the RHU personnel. How many more midwife items will the RHU need?
A. 1
B. 2
C. 3
D. The RHU does not need any more midwife item.
21.According to Freeman and Heinrich, community health nursing is a
developmental service. Which of the following best illustrates this
statement?
A. The community health nurse continuously develops himself
personally and professionally.
B. Health education and community organizing are necessary
in providing community health services.
C. Community health nursing is intended primarily for health
promotion and prevention and treatment of disease.
D. The goal of community health nursing is to provide nursing
services to people in their own places of residence.
22.Nurse Tina is aware that the disease declared through Presidential
Proclamation No. 4 as a target for eradication in the Philippines is?
PNLE II for Community Health Nursing and Care of the Mother and Child

A. Poliomyelitis A. Change the diaper more often.

B. Measles B. Apply talc powder with diaper changes.
C. Rabies C. Wash the area vigorously with each diaper change.
D. Neonatal tetanus D. Decrease the infant’s fluid intake to decrease saturating
23.May knows that the step in community organizing that involves diapers.
training of potential leaders in the community is: 29.Nurse Carla knows that the common cardiac anomalies in children
A. Integration with Down Syndrome (tri-somy 21) is:
B. Community organization A. Atrial septal defect
C. Community study B. Pulmonic stenosis
D. Core group formation C. Ventricular septal defect
24.Beth a public health nurse takes an active role in community D. Endocardial cushion defect
participation. What is the primary goal of community organizing? 30.Malou was diagnosed with severe preeclampsia is now receiving I.V.
A. To educate the people regarding community health magnesium sulfate. The adverse effects associated with magnesium
problems sulfate is:
B. To mobilize the people to resolve community health A. Anemia
problems B. Decreased urine output
C. To maximize the community’s resources in dealing with C. Hyperreflexia
health problems. D. Increased respiratory rate
D. To maximize the community’s resources in dealing with 31.A 23 year old client is having her menstrual period every 2 weeks that
health problems. last for 1 week. This type of menstrual pattern is bets defined by:
25.Tertiary prevention is needed in which stage of the natural history of A. Menorrhagia
disease? B. Metrorrhagia
A. Pre-pathogenesis C. Dyspareunia
B. Pathogenesis D. Amenorrhea
C. Prodromal 32. Jannah is admitted to the labor and delivery unit. The critical
D. Terminal laboratory result for this client would be:
26.The nurse is caring for a primigravid client in the labor and delivery A. Oxygen saturation
area. Which condition would place the client at risk for B. Iron binding capacity
disseminated intravascular coagulation (DIC)? C. Blood typing
A. Intrauterine fetal death. D. Serum Calcium
B. Placenta accreta. 33.Nurse Gina is aware that the most common condition found during
C. Dysfunctional labor. the second-trimester of pregnancy is:
D. Premature rupture of the membranes. A. Metabolic alkalosis
27.A fullterm client is in labor. Nurse Betty is aware that the fetal heart B. Respiratory acidosis
rate would be: C. Mastitis
A. 80 to 100 beats/minute D. Physiologic anemia
B. 100 to 120 beats/minute 34.Nurse Lynette is working in the triage area of an emergency
C. 120 to 160 beats/minute department. She sees that several pediatric clients arrive
D. 160 to 180 beats/minute simultaneously. The client who needs to be treated first is:
28.The skin in the diaper area of a 7 month old infant is excoriated and A. A crying 5 year old child with a laceration on his scalp.
red. Nurse Hazel should instruct the mother to:
PNLE II for Community Health Nursing and Care of the Mother and Child

B. A 4 year old child with a barking coughs and flushed B. Muffled voice
appearance. C. Restlessness
C. A 3 year old child with Down syndrome who is pale and D. Low-grade fever
asleep in his mother’s arms. 40.How should Nurse Michelle guide a child who is blind to walk to the
D. A 2 year old infant with stridorous breath sounds, sitting up playroom?
in his mother’s arms and drooling. A. Without touching the child, talk continuously as the child
35.Maureen in her third trimester arrives at the emergency room with walks down the hall.
painless vaginal bleeding. Which of the following conditions is B. Walk one step ahead, with the child’s hand on the nurse’s
suspected? elbow.
A. Placenta previa C. Walk slightly behind, gently guiding the child forward.
B. Abruptio placentae D. Walk next to the child, holding the child’s hand.
C. Premature labor 41.When assessing a newborn diagnosed with ductus arteriosus, Nurse
D. Sexually transmitted disease Olivia should expect that the child most likely would have an:
36.A young child named Richard is suspected of having pinworms. The A. Loud, machinery-like murmur.
community nurse collects a stool specimen to confirm the diagnosis. B. Bluish color to the lips.
The nurse should schedule the collection of this specimen for: C. Decreased BP reading in the upper extremities
A. Just before bedtime D. Increased BP reading in the upper extremities.
B. After the child has been bathe 42.The reason nurse May keeps the neonate in a neutral thermal
C. Any time during the day environment is that when a newborn becomes too cool, the neonate
D. Early in the morning requires:
37.In doing a child’s admission assessment, Nurse Betty should be alert A. Less oxygen, and the newborn’s metabolic rate increases.
to note which signs or symptoms of chronic lead poisoning? B. More oxygen, and the newborn’s metabolic rate decreases.
A. Irritability and seizures C. More oxygen, and the newborn’s metabolic rate increases.
B. Dehydration and diarrhea D. Less oxygen, and the newborn’s metabolic rate decreases.
C. Bradycardia and hypotension 43.Before adding potassium to an infant’s I.V. line, Nurse Ron must be
D. Petechiae and hematuria sure to assess whether this infant has:
38.To evaluate a woman’s understanding about the use of diaphragm A. Stable blood pressure
for family planning, Nurse Trish asks her to explain how she will use the B. Patant fontanelles
appliance. Which response indicates a need for further health teaching? C. Moro’s reflex
A. “I should check the diaphragm carefully for holes every time D. Voided
I use it” 44.Nurse Carla should know that the most common causative factor of
B. “I may need a different size of diaphragm if I gain or lose dermatitis in infants and younger children is:
weight more than 20 pounds” A. Baby oil
C. “The diaphragm must be left in place for atleast 6 hours B. Baby lotion
after intercourse” C. Laundry detergent
D. “I really need to use the diaphragm and jelly most during the D. Powder with cornstarch
middle of my menstrual cycle”. 45.During tube feeding, how far above an infant’s stomach should the
39.Hypoxia is a common complication of laryngotracheobronchitis. nurse hold the syringe with formula?
Nurse Oliver should frequently assess a child with A. 6 inches
laryngotracheobronchitis for: B. 12 inches
A. Drooling C. 18 inches
PNLE II for Community Health Nursing and Care of the Mother and Child

D. 24 inches A. Giardiasis
46. In a mothers’ class, Nurse Lhynnete discussed childhood diseases B. Cholera
such as chicken pox. Which of the following statements about chicken C. Amebiasis
pox is correct? D. Dysentery
A. The older one gets, the more susceptible he becomes to the 51.The most prevalent form of meningitis among children aged 2
complications of chicken pox. months to 3 years is caused by which microorganism?
B. A single attack of chicken pox will prevent future episodes, A. Hemophilus influenzae
including conditions such as shingles. B. Morbillivirus
C. To prevent an outbreak in the community, quarantine may C. Steptococcus pneumoniae
be imposed by health authorities. D. Neisseria meningitidis
D. Chicken pox vaccine is best given when there is an 52.The student nurse is aware that the pathognomonic sign of measles
impending outbreak in the community. is Koplik’s spot and you may see Koplik’s spot by inspecting the:
47.Barangay Pinoy had an outbreak of German measles. To prevent A. Nasal mucosa
congenital rubella, what is the BEST advice that you can give to women B. Buccal mucosa
in the first trimester of pregnancy in the barangay Pinoy? C. Skin on the abdomen
A. Advice them on the signs of German measles. D. Skin on neck
B. Avoid crowded places, such as markets and movie houses. 53.Angel was diagnosed as having Dengue fever. You will say that there
C. Consult at the health center where rubella vaccine may be is slow capillary refill when the color of the nailbed that you pressed
given. does not return within how many seconds?
D. Consult a physician who may give them rubella A. 3 seconds
immunoglobulin. B. 6 seconds
48.Myrna a public health nurse knows that to determine possible C. 9 seconds
sources of sexually transmitted infections, the BEST method that may D. 10 seconds
be undertaken is: 54.In Integrated Management of Childhood Illness, the nurse is aware
A. Contact tracing that the severe conditions generally require urgent referral to a hospital.
B. Community survey Which of the following severe conditions DOES NOT always require
C. Mass screening tests urgent referral to a hospital?
D. Interview of suspects A. Mastoiditis
49.A 33-year old female client came for consultation at the health center B. Severe dehydration
with the chief complaint of fever for a week. Accompanying symptoms C. Severe pneumonia
were muscle pains and body malaise. A week after the start of fever, the D. Severe febrile disease
client noted yellowish discoloration of his sclera. History showed that 55.Myrna a public health nurse will conduct outreach immunization in a
he waded in flood waters about 2 weeks before the onset of symptoms. barangay Masay with a population of about 1500. The estimated
Based on her history, which disease condition will you suspect? number of infants in the barangay would be:
A. Hepatitis A A. 45 infants
B. Hepatitis B B. 50 infants
C. Tetanus C. 55 infants
D. Leptospirosis D. 65 infants
50.Mickey a 3-year old client was brought to the health center with the 56.The community nurse is aware that the biological used in Expanded
chief complaint of severe diarrhea and the passage of “rice water” Program on Immunization (EPI) should NOT be stored in the freezer?
stools. The client is most probably suffering from which condition? A. DPT
PNLE II for Community Health Nursing and Care of the Mother and Child

B. Oral polio vaccine B. Coordinate with the social worker to enroll the child in a
C. Measles vaccine feeding program.
D. MMR C. Make a teaching plan for the mother, focusing on menu
57.It is the most effective way of controlling schistosomiasis in an planning for her child.
endemic area? D. Assess and treat the child for health problems like
A. Use of molluscicides infections and intestinal parasitism.
B. Building of foot bridges 63.Gina is using Oresol in the management of diarrhea of her 3-year old
C. Proper use of sanitary toilets child. She asked you what to do if her child vomits. As a nurse you will
D. Use of protective footwear, such as rubber boots tell her to:
58.Several clients is newly admitted and diagnosed with leprosy. Which A. Bring the child to the nearest hospital for further
of the following clients should be classified as a case of multibacillary assessment.
leprosy? B. Bring the child to the health center for intravenous fluid
A. 3 skin lesions, negative slit skin smear therapy.
B. 3 skin lesions, positive slit skin smear C. Bring the child to the health center for assessment by the
C. 5 skin lesions, negative slit skin smear physician.
D. 5 skin lesions, positive slit skin smear D. Let the child rest for 10 minutes then continue giving Oresol
59.Nurses are aware that diagnosis of leprosy is highly dependent on more slowly.
recognition of symptoms. Which of the following is an early sign 64.Nikki a 5-month old infant was brought by his mother to the health
of leprosy? center because of diarrhea for 4 to 5 times a day. Her skin goes back
A. Macular lesions slowly after a skin pinch and her eyes are sunken. Using the IMCI
B. Inability to close eyelids guidelines, you will classify this infant in which category?
C. Thickened painful nerves A. No signs of dehydration
D. Sinking of the nosebridge B. Some dehydration
60.Marie brought her 10 month old infant for consultation because of C. Severe dehydration
fever, started 4 days prior to consultation. In determining malaria risk, D. The data is insufficient.
what will you do? 65.Chris a 4-month old infant was brought by her mother to the health
A. Perform a tourniquet test. center because of cough. His respiratory rate is 42/minute. Using the
B. Ask where the family resides. Integrated Management of Child Illness (IMCI) guidelines of
C. Get a specimen for blood smear. assessment, his breathing is considered as:
D. Ask if the fever is present everyday. A. Fast
61.Susie brought her 4 years old daughter to the RHU because of cough B. Slow
and colds. Following the IMCI assessment guide, which of the following C. Normal
is a danger sign that indicates the need for urgent referral to a hospital? D. Insignificant
A. Inability to drink 66.Maylene had just received her 4th dose of tetanus toxoid. She is
B. High grade fever aware that her baby will have protection against tetanus for
C. Signs of severe dehydration A. 1 year
D. Cough for more than 30 days B. 3 years
62.Jimmy a 2-year old child revealed “baggy pants”. As a nurse, using C. 5 years
the IMCI guidelines, how will you manage Jimmy? D. Lifetime
A. Refer the child urgently to a hospital for confinement. 67.Nurse Ron is aware that unused BCG should be discarded after how
many hours of reconstitution?
PNLE II for Community Health Nursing and Care of the Mother and Child

A. 2 hours 74.After reviewing the Myrna’s maternal history of magnesium sulfate

B. 4 hours during labor, which condition would nurse Richard anticipate as a
C. 8 hours potential problem in the neonate?
D. At the end of the day A. Hypoglycemia
68.The nurse explains to a breastfeeding mother that breast milk is B. Jitteriness
sufficient for all of the baby’s nutrient needs only up to: C. Respiratory depression
A. 5 months D. Tachycardia
B. 6 months 75.Which symptom would indicate the Baby Alexandra was adapting
C. 1 year appropriately to extra-uterine life without difficulty?
D. 2 years A. Nasal flaring
69.Nurse Ron is aware that the gestational age of a conceptus that is B. Light audible grunting
considered viable (able to live outside the womb) is: C. Respiratory rate 40 to 60 breaths/minute
A. 8 weeks D. Respiratory rate 60 to 80 breaths/minute
B. 12 weeks 76. When teaching umbilical cord care for Jennifer a new mother, the
C. 24 weeks nurse Jenny would include which information?
D. 32 weeks A. Apply peroxide to the cord with each diaper change
70.When teaching parents of a neonate the proper position for the B. Cover the cord with petroleum jelly after bathing
neonate’s sleep, the nurse Patricia stresses the importance of placing C. Keep the cord dry and open to air
the neonate on his back to reduce the risk of which of the following? D. Wash the cord with soap and water each day during a tub
A. Aspiration bath.
B. Sudden infant death syndrome (SIDS) 77.Nurse John is performing an assessment on a neonate. Which of the
C. Suffocation following findings is considered common in the healthy neonate?
D. Gastroesophageal reflux (GER) A. Simian crease
71.Which finding might be seen in baby James a neonate suspected of B. Conjunctival hemorrhage
having an infection? C. Cystic hygroma
A. Flushed cheeks D. Bulging fontanelle
B. Increased temperature 78.Dr. Esteves decides to artificially rupture the membranes of a mother
C. Decreased temperature who is on labor. Following this procedure, the nurse Hazel checks the
D. Increased activity level fetal heart tones for which the following reasons?
72.Baby Jenny who is small-for-gestation is at increased risk during the A. To determine fetal well-being.
transitional period for which complication? B. To assess for prolapsed cord
A. Anemia probably due to chronic fetal hyposia C. To assess fetal position
B. Hyperthermia due to decreased glycogen stores D. To prepare for an imminent delivery.
C. Hyperglycemia due to decreased glycogen stores 79.Which of the following would be least likely to indicate anticipated
D. Polycythemia probably due to chronic fetal hypoxia bonding behaviors by new parents?
73.Marjorie has just given birth at 42 weeks’ gestation. When the nurse A. The parents’ willingness to touch and hold the new born.
assessing the neonate, which physical finding is expected? B. The parent’s expression of interest about the size of the
A. A sleepy, lethargic baby new born.
B. Lanugo covering the body C. The parents’ indication that they want to see the newborn.
C. Desquamation of the epidermis D. The parents’ interactions with each other.
D. Vernix caseosa covering the body
PNLE II for Community Health Nursing and Care of the Mother and Child

80.Following a precipitous delivery, examination of the client’s vagina D. Humidify the oxygen.
reveals 85. Which of the following is normal newborn calorie intake?
a fourth-degree laceration. Which of the following would be A. 110 to 130 calories per kg.
contraindicated when caring for this client? B. 30 to 40 calories per lb of body weight.
A. Applying cold to limit edema during the first 12 to 24 hours. C. At least 2 ml per feeding
B. Instructing the client to use two or more peripads to cushion D. 90 to 100 calories per kg
the area. 86. Nurse John is knowledgeable that usually individual twins will grow
C. Instructing the client on the use of sitz baths if ordered. appropriately and at the same rate as singletons until how many weeks?
D. Instructing the client about the importance of perineal A. 16 to 18 weeks
(kegel) exercises. B. 18 to 22 weeks
81. A pregnant woman accompanied by her husband, seeks admission C. 30 to 32 weeks
to the labor and delivery area. She states that she’s in labor and says D. 38 to 40 weeks
she attended the facility clinic for prenatal care. Which question should 87. Which of the following classifications applies to monozygotic twins
the nurse Oliver ask her first? for whom the cleavage of the fertilized ovum occurs more than 13 days
A. “Do you have any chronic illnesses?” after fertilization?
B. “Do you have any allergies?” A. conjoined twins
C. “What is your expected due date?” B. diamniotic dichorionic twins
D. “Who will be with you during labor?” C. diamniotic monochorionic twin
82.A neonate begins to gag and turns a dusky color. What should the D. monoamniotic monochorionic twins
nurse do first? 88. Tyra experienced painless vaginal bleeding has just been diagnosed
A. Calm the neonate. as having a placenta previa. Which of the following procedures is usually
B. Notify the physician. performed to diagnose placenta previa?
C. Provide oxygen via face mask as ordered A. Amniocentesis
D. Aspirate the neonate’s nose and mouth with a bulb syringe. B. Digital or speculum examination
83. When a client states that her “water broke,” which of the following C. External fetal monitoring
actions would be inappropriate for the nurse to do? D. Ultrasound
A. Observing the pooling of straw-colored fluid. 89. Nurse Arnold knows that the following changes in respiratory
B. Checking vaginal discharge with nitrazine paper. functioning during pregnancy is considered normal:
C. Conducting a bedside ultrasound for an amniotic fluid A. Increased tidal volume
index. B. Increased expiratory volume
D. Observing for flakes of vernix in the vaginal discharge. C. Decreased inspiratory capacity
84. A baby girl is born 8 weeks premature. At birth, she has no D. Decreased oxygen consumption
spontaneous respirations but is successfully resuscitated. Within 90. Emily has gestational diabetes and it is usually managed by which
several hours she develops respiratory grunting, cyanosis, tachypnea, of the following therapy?
nasal flaring, and retractions. She’s diagnosed with respiratory distress A. Diet
syndrome, intubated, and placed on a ventilator. Which nursing action B. Long-acting insulin
should be included in the baby’s plan of care to prevent retinopathy of C. Oral hypoglycemic
prematurity? D. Oral hypoglycemic drug and insulin
A. Cover his eyes while receiving oxygen. 91. Magnesium sulfate is given to Jemma with preeclampsia to prevent
B. Keep her body temperature low. which of the following condition?
C. Monitor partial pressure of oxygen (Pao2) levels. A. Hemorrhage
PNLE II for Community Health Nursing and Care of the Mother and Child

B. Hypertension C. Rh-negative fetal blood crosses into maternal blood,

C. Hypomagnesemia stimulating maternal antibodies.
D. Seizure D. Rh-negative maternal blood crosses into fetal blood,
92. Cammile with sickle cell anemia has an increased risk for having a stimulating fetal antibodies.
sickle cell crisis during pregnancy. Aggressive management of a sickle 97. To promote comfort during labor, the nurse John advises a client to
cell crisis includes which of the following measures? assume certain positions and avoid others. Which position may cause
A. Antihypertensive agents maternal hypotension and fetal hypoxia?
B. Diuretic agents A. Lateral position
C. I.V. fluids B. Squatting position
D. Acetaminophen (Tylenol) for pain C. Supine position
93. Which of the following drugs is the antidote for magnesium toxicity? D. Standing position
A. Calcium gluconate (Kalcinate) 98. Celeste who used heroin during her pregnancy delivers a neonate.
B. Hydralazine (Apresoline) When assessing the neonate, the nurse Lhynnette expects to find:
C. Naloxone (Narcan) A. Lethargy 2 days after birth.
D. Rho (D) immune globulin (RhoGAM) B. Irritability and poor sucking.
94. Marlyn is screened for tuberculosis during her first prenatal visit. An C. A flattened nose, small eyes, and thin lips.
intradermal injection of purified protein derivative (PPD) of the D. Congenital defects such as limb anomalies.
tuberculin bacilli is given. She is considered to have a positive test for 99. The uterus returns to the pelvic cavity in which of the following time
which of the following results? frames?
A. An indurated wheal under 10 mm in diameter appears in 6 A. 7th to 9th day postpartum.
to 12 hours. B. 2 weeks postpartum.
B. An indurated wheal over 10 mm in diameter appears in 48 C. End of 6th week postpartum.
to 72 hours. D. When the lochia changes to alba.
C. A flat circumcised area under 10 mm in diameter appears 100. Maureen, a primigravida client, age 20, has just completed a
in 6 to 12 hours. difficult, forceps-assisted delivery of twins. Her labor was unusually long
D. A flat circumcised area over 10 mm in diameter appears in and required oxytocin (Pitocin) augmentation. The nurse who’s caring
48 to 72 hours. for her should stay alert for:
95. Dianne, 24 year-old is 27 weeks’ pregnant arrives at her physician’s A. Uterine inversion
office with complaints of fever, nausea, vomiting, malaise, unilateral B. Uterine atony
flank pain, and costovertebral angle tenderness. Which of the following C. Uterine involution
diagnoses is most likely? D. Uterine discomfort
A. Asymptomatic bacteriuria
B. Bacterial vaginosis Answers and Rationales
C. Pyelonephritis
D. Urinary tract infection (UTI) 1. Answer: (A) Inevitable. An inevitable abortion is termination of pregnancy that
96. Rh isoimmunization in a pregnant client develops during which of cannot be prevented. Moderate to severe bleeding with mild cramping
the following conditions? and cervical dilation would be noted in this type of abortion.
A. Rh-positive maternal blood crosses into fetal blood, 2. Answer: (B) History of syphilis. Maternal infections such as syphilis,
stimulating fetal antibodies. toxoplasmosis, and rubella are causes of spontaneous abortion.
B. Rh-positive fetal blood crosses into maternal blood,
stimulating maternal antibodies.
PNLE II for Community Health Nursing and Care of the Mother and Child
3. Answer: (C) Monitoring apical pulse. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Because feeding requires so
much energy, an infant with heart failure should rest before feeding.
14. Answer: (C) Iron-rich formula only. 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. 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, not curative,
services. 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. Efficiency is determining whether the goals were attained
at the least possible cost.
18. Answer: (D) Rural Health Unit. 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. The local executive serves as the chairman of the Municipal
Health Board.
20. Answer: (A) 1. 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. The community health nurse develops the
health capability of people through health education and community organizing
activities.
22. Answer: (B) Measles. Presidential Proclamation No. 4 is on the Ligtas Tigdas
Program.
23. Answer: (D) Core group formation. 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. 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. Tertiary prevention involves rehabilitation, prevention of
permanent disability and disability limitation appropriate for convalescents, the
PNLE II for Community Health Nursing and Care of the Mother and Child
disabled, complicated cases and the terminally ill (those in the terminal stage of
a disease).
26. Answer: (A) Intrauterine fetal death. 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. 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. Decreasing the amount of time the skin
comes contact with wet soiled diapers will help heal the irritation.
29. Answer: (D) Endocardial cushion defect. Endocardial cushion defects are seen
most in children with Down syndrome, asplenia, or polysplenia.
30. Answer: (B) Decreased urine output. 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. Menorrhagia is an excessive menstrual period.
32. Answer: (C) Blood typing. 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. 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. The infant with the airway emergency should be
treated first, because of the risk of epiglottitis.
35. Answer: (A) Placenta previa. Placenta previa with painless vaginal bleeding.
36. Answer: (D) Early in the morning. 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. 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”. 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. 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. This
procedure is generally recommended to follow in guiding a person who is blind.
41. Answer: (A) Loud, machinery-like murmur. 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. 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. 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. 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. 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 chicken pox. Chicken pox 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. 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. Contact tracing is the most practical and reliable
method of finding possible sources of person-to-person transmitted infections,
such as sexually transmitted diseases.
PNLE II for Community Health Nursing and Care of the Mother and Child
49. Answer: (D) Leptospirosis. 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. Passage of profuse watery stools is the major symptom of
cholera. Both amebic 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) Hemophilus influenzae. 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. Koplik’s spot may be seen on the mucosa of the mouth
or the throat.
53. Answer: (A) 3 seconds. Adequate blood supply to the area allows the return of the
color of the nailbed within 3 seconds.
54. Answer: (B) Severe dehydration. 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, then urgent referral
to the hospital is done.
55. Answer: (A) 45 infants. To estimate the number of infants, multiply total population
by 3%.
56. Answer: (A) DPT. 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. 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. 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. 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. 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. 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. “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. 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. 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. In IMCI, a respiratory rate of 50/minute or more is fast
breathing for an infant aged 2 to 12 months.
66. Answer: (A) 1 year. 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. 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. 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. 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). 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. Temperature instability, especially when it
results in a low temperature in the neonate, may be a sign of infection. The
PNLE II for Community Health Nursing and Care of the Mother and Child
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. The small-for-
gestation neonate is at risk for developing polycythemia during the transitional
period in an attempt to decreasehypoxia. The neonates are also at increased risk
for developing hypoglycemia and hypothermia due to decreased glycogen stores.
73. Answer: (C) Desquamation of the epidermis. 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. 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. 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. 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. 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. 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. 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 peripads to cushion the
area. 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?” 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. 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. 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. 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. 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. 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. The type of placenta that develops in monozygotic
twins depends on the time at which cleavage of the ovum occurs. Cleavage in
PNLE II for Community Health Nursing and Care of the Mother and Child
conjoined twins occurs more than 13 days after fertilization. Cleavage that occurs
less than 3 day after fertilization results in diamniotic dicchorionic 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. 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. 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. 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. 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. 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). 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. 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. 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. 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. 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. 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. 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. 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.