1.

May arrives at the health care clinic and tells the nurse that her last menstrual period was 9
weeks ago. She also tells the nurse that a home pregnancy test was positive but she began to
have mild cramps and is now having moderate vaginal bleeding. During the physical
examination of the client, the nurse notes that May has a dilated cervix. The nurse determines
that May is experiencing which type of abortion?
a. Inevitable
b. Incomplete
c. Threatened
d. Septic
1. Answer: (A) Inevitable
Rationale: An inevitable abortion is termination of pregnancy that cannot be prevented. Moderate to
severe bleeding with mild cramping and cervical dilation would be noted in this type of abortion.

2. Nurse Reese is reviewing the record of a pregnant client for her first prenatal visit. Which of
the following data, if noted on the client’s record, would alert the nurse that the client is at risk
for a spontaneous abortion?
a. Age 36 years
b. History of syphilis
c. History of genital herpes
d. History of diabetes mellitus
2. Answer: (B) History of syphilis
Rationale: Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous
abortion.

3. Nurse Hazel is preparing to care for a client who is newly admitted to the hospital with a
possible diagnosis of ectopic pregnancy. Nurse Hazel develops a plan of care for the client and
determines that which of the following nursing actions is the priority?
a. Monitoring weight
b. Assessing for edema
c. Monitoring apical pulse
d. Monitoring temperature
3. Answer: (C) Monitoring apical pulse
Rationale: Nursing care for the client with a possible ectopic pregnancy is focused on preventing or
identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock.

4. Nurse Oliver is teaching a diabetic pregnant client about nutrition and insulin needs during
pregnancy. The nurse determines that the client understands dietary and insulin needs if the
client states that the second half of pregnancy require:
a. Decreased caloric intake
b. Increased caloric intake
c. Decreased Insulin
d. Increase Insulin
4. Answer: (B) Increased caloric intake
Rationale: Glucose crosses the placenta, but insulin does not. High fetal demands for glucose,
combined with the insulin resistance caused by hormonal changes in the last half of pregnancy can
result in elevation of maternal blood glucose levels. This increases the mother’s demand for insulin
and is referred to as the diabetogenic effect of pregnancy.

5. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidiform mole. She is
aware that one of the following is unassociated with this condition?
a. Excessive fetal activity.
b. Larger than normal uterus for gestational age.
c. Vaginal bleeding
d. Elevated levels of human chorionic gonadotropin.
5. Answer: (A) Excessive fetal activity.
Rationale: The most common signs and symptoms of hydatidiform mole includes elevated levels of
human chorionic gonadotropin, vaginal bleeding, larger than normal uterus for gestational age,
failure to detect fetal heart activity even with sensitive instruments, excessive nausea and vomiting,
and early development of pregnancy-induced hypertension. Fetal activity would not be noted.

6. A pregnant client is receiving magnesium sulfate for severe pregnancy induced hypertension
(PIH). The clinical findings that would warrant use of the antidote , calcium gluconate is:
a. Urinary output 90 cc in 2 hours.
b. Absent patellar reflexes.
c. Rapid respiratory rate above 40/min.
d. Rapid rise in blood pressure.
6. Answer: (B) Absent patellar reflexes
Rationale: Absence of patellar reflexes is an indicator of hypermagnesemia, which requires
administration of calcium gluconate.

7. During vaginal examination of Janah who is in labor, the presenting part is at station plus
two. Nurse, correctly interprets it as:
a. Presenting part is 2 cm above the plane of the ischial spines.
b. Biparietal diameter is at the level of the ischial spines.
c. Presenting part in 2 cm below the plane of the ischial spines.
d. Biparietal diameter is 2 cm above the ischial spines.
 7. Answer: (C) Presenting part in 2 cm below the plane of the ischial spines.
Rationale: Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the
ischial spines.

8. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that
warrant the nurse in-charge to discontinue I.V. infusion of Pitocin is:
a. Contractions every 1 ½ minutes lasting 70-80 seconds.
b. Maternal temperature 101.2
c. Early decelerations in the fetal heart rate.
d. Fetal heart rate baseline 140-160 bpm.
8. Answer: (A) Contractions every 1 ½ minutes lasting 70-80 seconds.
Rationale: Contractions every 1 ½ minutes lasting 70-80 seconds, is indicative of hyperstimulation of
the uterus, which could result in injury to the mother and the fetus if Pitocin is not discontinued.

9. Calcium gluconate is being administered to a client with pregnancy induced hypertension

(PIH). A nursing action that must be initiated as the plan of care throughout injection of the
drug is:
a. Ventilator assistance
b. CVP readings
c. EKG tracings
d. Continuous CPR
9. Answer: (C) EKG tracings
Rationale: A potential side effect of calcium gluconate administration is cardiac arrest. Continuous
monitoring of cardiac activity (EKG) throught administration of calcium gluconate is an essential
part of care.

10. A trial for vaginal delivery after an earlier caesareans, would likely to be given to a gravida,
who had:
a. First low transverse cesarean was for active herpes type 2 infections; vaginal culture at 39 weeks
pregnancy was positive.
b. First and second caesareans were for cephalopelvic disproportion.
c. First caesarean through a classic incision as a result of severe fetal distress.
d. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex
presentation.
10. Answer: (D) First low transverse caesarean was for breech position. Fetus in this
pregnancy is in a vertex presentation.
Rationale: This type of client has no obstetrical indication for a caesarean section as she did with her
first caesarean delivery.
11.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.
11. Answer: (A) Talk to the mother first and then to the toddler.
Rationale: When dealing with a crying toddler, the best approach is to talk to the mother and ignore
the toddler first. This approach helps the toddler get used to the nurse before she attempts any
procedures. It also gives the toddler an opportunity to see that the mother trusts the nurse.

12.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.
12. Answer: (D) Place the infant’s arms in soft elbow restraints.
Rationale: Soft restraints from the upper arm to the wrist prevent the infant from touching her lip but
allow him to hold a favorite item such as a blanket. Because they could damage the operative site,
such as objects as pacifiers, suction catheters, and small spoons shouldn’t be placed in a baby’s
mouth after cleft repair. A baby in a prone position may rub her face on the sheets and traumatize the
operative site. The suture line should be cleaned gently to prevent infection, which could interfere
with healing and damage the cosmetic appearance of the repair.

13. 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.
13. Answer: (B) Allow the infant to rest before feeding.
Rationale: Because feeding requires so much energy, an infant with heart failure should rest before
feeding.

14.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.
14. Answer: (C) Iron-rich formula only.
Rationale: The infants at age 5 months should receive iron-rich formula and that they shouldn’t
receive solid food, even baby food until age 6 months.

15.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
15. Answer: (D) 10 months
Rationale: A 10 month old infant can sit alone and understands object permanence, so he would look
for the hidden toy. At age 4 to 6 months, infants can’t sit securely alone. At age 8 months, infants can
sit securely alone but cannot understand the permanence of objects.

16.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.
16. Answer: (D) Public health nursing focuses on preventive, not curative, services.
Rationale: The catchments area in PHN consists of a residential community, many of whom are well
individuals who have greater need for
preventive rather than curative services.

17.When the nurse determines whether resources were maximized in implementing Ligtas
Tigdas, she is evaluating
a. Effectiveness
b. Efficiency
c. Adequacy
d. Appropriateness
 17. Answer: (B) Efficiency
Rationale: Efficiency is determining whether the goals were attained at the least possible cost.

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
18. Answer: (D) Rural Health Unit
Rationale: R.A. 7160 devolved basic health services to local government units (LGU’s ). The public
health nurse is an employee of the LGU.

19.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
19. Answer: (A) Mayor
Rationale: The local executive serves as the chairman of the Municipal Health Board.

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.
20. Answer: (A) 1
Rationale: Each rural health midwife is given a population assignment of about 5,000.

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.
21. Answer: (B) Health education and community organizing are necessary in providing
community health services.
Rationale: The community health nurse develops the health capability of people through health
education and community organizing activities.
health problems. A, B and C are objectives of contributory objectives to this goal.

22.Nurse Tina is aware that the disease declared through Presidential Proclamation No. 4 as a
target for eradication in the Philippines is?
a. Poliomyelitis
b. Measles
c. Rabies
d. Neonatal tetanus
22. Answer: (B) Measles
Rationale: Presidential Proclamation No. 4 is on the Ligtas Tigdas Program.

23.May knows that the step in community organizing that involves training of potential leaders
in the community is:
a. Integration
b. Community organization
c. Community study
d. Core group formation
23. Answer: (D) Core group formation
Rationale: In core group formation, the nurse is able to transfer the technology of community
organizing to the potential or informal community leaders through a training program.

24.Beth a public health nurse takes an active role in community participation. What is the
primary goal of community organizing?
a. To educate the people regarding community health problems
b. To mobilize the people to resolve community health problems
c. To maximize the community’s resources in dealing with health problems.
d. To maximize the community’s resources in dealing with health problems.
24. Answer: (D) To maximize the community’s resources in dealing with health problems.
Rationale: Community organizing is a developmental service, with the goal of developing the
people’s self-reliance in dealing with community

25.Tertiary prevention is needed in which stage of the natural history of disease?

a. Pre-pathogenesis
b. Pathogenesis
c. Prodromal
d. Terminal
25. Answer: (D) Terminal
Rationale: Tertiary prevention involves rehabilitation, prevention of permanent disability and
disability limitation appropriate for convalescents, the disabled, complicated cases and the terminally
ill (those in the terminal stage of a disease).

26.The nurse is caring for a primigravid client in the labor and delivery area. Which condition
would place the client at risk for disseminated
intravascular coagulation (DIC)?
a. Intrauterine fetal death.
b. Placenta accreta.
c. Dysfunctional labor.
d. Premature rupture of the membranes.
26. Answer: (A) Intrauterine fetal death.
Rationale: Intrauterine fetal death, abruptio placentae, septic shock, and amniotic fluid embolism
may trigger normal clotting mechanisms; if clotting factors are depleted, DIC may occur. Placenta
accreta, dysfunctional labor, and premature rupture of the membranes aren’t associated with DIC.

27.A fullterm client is in labor. Nurse Betty is aware that the fetal heart rate would be:
a. 80 to 100 beats/minute
b. 100 to 120 beats/minute
c. 120 to 160 beats/minute
d. 160 to 180 beats/minute
27. Answer: (C) 120 to 160 beats/minute
Rationale: A rate of 120 to 160 beats/minute in the fetal heart appropriate for filling the heart with
blood and pumping it out to the system.

28.The skin in the diaper area of a 7 month old infant is excoriated and red. Nurse Hazel
should instruct the mother to:
a. Change the diaper more often.
b. Apply talc powder with diaper changes.
c. Wash the area vigorously with each diaper change.
d. Decrease the infant’s fluid intake to decrease saturating diapers.
 28. Answer: (A) Change the diaper more often.
Rationale: Decreasing the amount of time the skin comes contact with wet soiled diapers will help
heal the irritation.

29.Nurse Carla knows that the common cardiac anomalies in children with Down Syndrome
(tri-somy 21) is:
a. Atrial septal defect
b. Pulmonic stenosis
c. Ventricular septal defect
d. Endocardial cushion defect
29. Answer: (D) Endocardial cushion defect
Rationale: Endocardial cushion defects are seen most in children with Down syndrome, asplenia, or
polysplenia.

30.Malou was diagnosed with severe preeclampsia is now receiving I.V. magnesium sulfate. The
adverse effects associated with magnesium sulfate is:
a. Anemia
b. Decreased urine output
c. Hyperreflexia
d. Increased respiratory rate
30. Answer: (B) Decreased urine output
Rationale: Decreased urine output may occur in clients receiving I.V. magnesium and should be
monitored closely to keep urine output at
greater than 30 ml/hour, because magnesium is excreted through the kidneys and can easily
accumulate to toxic levels.

31.A 23 year old client is having her menstrual period every 2 weeks that last for 1 week. This
type of menstrual pattern is bets defined by:
a. Menorrhagia
b. Metrorrhagia
c. Dyspareunia
d. Amenorrhea
31. Answer: (A) Menorrhagia
Rationale: Menorrhagia is an excessive menstrual period.

32.Jannah is admitted to the labor and delivery unit. The critical laboratory result for this
client would be:
a. Oxygen saturation
b. Iron binding capacity
c. Blood typing
d. Serum Calcium
32. Answer: (C) Blood typing
Rationale: Blood type would be a critical value to have because the risk of blood loss is always a
potential complication during the labor and delivery process. Approximately 40% of a woman’s
cardiac output is delivered to the uterus, therefore, blood loss can occur quite rapidly in the event of
uncontrolled bleeding.

33.Nurse Gina is aware that the most common condition found during the second-trimester of
pregnancy is:
a. Metabolic alkalosis
b. Respiratory acidosis
c. Mastitis
d. Physiologic anemia
33. Answer: (D) Physiologic anemia
Rationale: Hemoglobin values and hematocrit decrease during pregnancy as the increase in plasma
volume exceeds the increase in red blood cell production.

34.Nurse Lynette is working in the triage area of an emergency department. She sees that
several pediatric clients arrive simultaneously. The client who needs to be treated first is:
a. A crying 5 year old child with a laceration on his scalp.
b. A 4 year old child with a barking coughs and flushed appearance.
c. A 3 year old child with Down syndrome who is pale and asleep in
his mother’s arms.
d. A 2 year old infant with stridorous breath sounds, sitting up in his
mother’s arms and drooling.
34. Answer: (D) A 2 year old infant with stridorous breath sounds, sitting up in his mother’s
arms and drooling.
Rationale: The infant with the airway emergency should be treated first, because of the risk of
epiglottitis.

35.Maureen in her third trimester arrives at the emergency room with painless vaginal
bleeding. Which of the following conditions is suspected?
a. Placenta previa
b. Abruptio placentae
c. Premature labor
d. Sexually transmitted disease
35. Answer: (A) Placenta previa
Rationale: Placenta previa with painless vaginal bleeding.

36.A young child named Richard is suspected of having pinworms. The community nurse
collects a stool specimen to confirm the diagnosis. The nurse should schedule the collection of
this specimen for:
a. Just before bedtime
b. After the child has been bathe
c. Any time during the day
d. Early in the morning
36. Answer: (D) Early in the morning
Rationale: Based on the nurse’s knowledge of microbiology, the specimen should be collected early
in the morning. The rationale for this
timing is that, because the female worm lays eggs at night around the perineal area, the first bowel
movement of the day will yield the best
results. The specific type of stool specimen used in the diagnosis of pinworms is called the tape test.

37.In doing a child’s admission assessment, Nurse Betty should be alert to note which signs or
symptoms of chronic lead poisoning?
a. Irritability and seizures
b. Dehydration and diarrhea
c. Bradycardia and hypotension
d. Petechiae and hematuria
37. Answer: (A) Irritability and seizures
Rationale: Lead poisoning primarily affects the CNS, causing increased intracranial pressure. This
condition results in irritability and changes in level of consciousness, as well as seizure disorders,
hyperactivity, and learning disabilities.

38.To evaluate a woman’s understanding about the use of diaphragm for family planning,
Nurse Trish asks her to explain how she will use the appliance. Which response indicates a need
for further health teaching?
a. “I should check the diaphragm carefully for holes every time I use it”
b. “I may need a different size of diaphragm if I gain or lose weight more than 20 pounds”
c. “The diaphragm must be left in place for atleast 6 hours after intercourse”
d. “I really need to use the diaphragm and jelly most during the middle of my menstrual cycle”.
 38. Answer: (D) “I really need to use the diaphragm and jelly most during the middle of my
menstrual cycle”.
Rationale: The woman must understand that, although the “fertile” period is approximately mid-
cycle, hormonal variations do occur and can result in early or late ovulation. To be effective, the
diaphragm should be inserted before every intercourse.

39.Hypoxia is a common complication of laryngotracheobronchitis. Nurse Oliver should

frequently assess a child with laryngotracheobronchitis for:
a. Drooling
b. Muffled voice
c. Restlessness
d. Low-grade fever
39. Answer: (C) Restlessness
Rationale: In a child, restlessness is the earliest sign of hypoxia. Late signs of hypoxia in a child are
associated with a change in color, such as pallor or cyanosis.

40.How should Nurse Michelle guide a child who is blind to walk to the playroom?
a. Without touching the child, talk continuously as the child walks down the hall.
b. Walk one step ahead, with the child’s hand on the nurse’s elbow.
c. Walk slightly behind, gently guiding the child forward.
d. Walk next to the child, holding the child’s hand.
40. Answer: (B) Walk one step ahead, with the child’s hand on the nurse’s elbow.
Rationale: This procedure is generally recommended to follow in guiding a person who is blind.

41.When assessing a newborn diagnosed with ductus arteriosus, Nurse Olivia should expect
that the child most likely would have an:
a. Loud, machinery-like murmur.
b. Bluish color to the lips.
c. Decreased BP reading in the upper extremities
d. Increased BP reading in the upper extremities.
41. Answer: (A) Loud, machinery-like murmur.
Rationale: A loud, machinery-like murmur is a characteristic finding associated with patent ductus
arteriosus.

42.The reason nurse May keeps the neonate in a neutral thermal environment is that when a
newborn becomes too cool, the neonate requires:
a. Less oxygen, and the newborn’s metabolic rate increases.
b. More oxygen, and the newborn’s metabolic rate decreases.
c. More oxygen, and the newborn’s metabolic rate increases.
d. Less oxygen, and the newborn’s metabolic rate decreases.
42. Answer: (C) More oxygen, and the newborn’s metabolic rate increases.
Rationale: When cold, the infant requires more oxygen and there is an increase in metabolic rate.
Non-shievering thermogenesis is a complex process that increases the metabolic rate and rate of
oxygen consumption, therefore, the newborn increase heat production.

43.Before adding potassium to an infant’s I.V. line, Nurse Ron must be sure to assess whether
this infant has:
a. Stable blood pressure
b. Patant fontanelles
c. Moro’s reflex
d. Voided
43. Answer: (D) Voided
Rationale: Before administering potassium I.V. to any client, the nurse must first check that the
client’s kidneys are functioning and that the client is voiding. If the client is not voiding, the nurse
should withhold the potassium and notify the physician..

44.Nurse Carla should know that the most common causative factor of dermatitis in infants
and younger children is:
a. Baby oil
b. Baby lotion
c. Laundry detergent
d. Powder with cornstarch
44. Answer: (c) Laundry detergent
Rationale: Eczema or dermatitis is an allergic skin reaction caused by an offending allergen. The
topical allergen that is the most common causative factor is laundry detergent.
46. Answer: (A) The older one gets, the more susceptible he becomes to the complications of chicken
pox.
Rationale: Chicken pox is usually more severe in adults than in children. Complications, such as
pneumonia, are higher in incidence in adults.

45.During tube feeding, how far above an infant’s stomach should the nurse hold the syringe
with formula?
a. 6 inches
b. 12 inches
c. 18 inches
d. 24 inches
 45. Answer: (A) 6 inches
Rationale: This distance allows for easy flow of the formula by gravity, but the flow will be slow
enough not to overload the stomach too rapidly.

46. In a mothers’ class, Nurse Lhynnete discussed childhood diseases such as chicken pox.
Which of the following statements about chicken pox is correct?
a. The older one gets, the more susceptible he becomes to the complications of chicken pox.
b. A single attack of chicken pox will prevent future episodes, including conditions such as shingles.
c. To prevent an outbreak in the community, quarantine may be imposed by health authorities.
d. Chicken pox vaccine is best given when there is an impending outbreak in the community.

47.Barangay Pinoy had an outbreak of German measles. To prevent congenital rubella, what is
the BEST advice that you can give to women in the first trimester of pregnancy in the barangay
Pinoy?
a. Advice them on the signs of German measles.
b. Avoid crowded places, such as markets and movie houses.
c. Consult at the health center where rubella vaccine may be given.
d. Consult a physician who may give them rubella immunoglobulin.
47. Answer: (D) Consult a physician who may give them rubella immunoglobulin.
Rationale: Rubella vaccine is made up of attenuated German measles viruses. This is contraindicated
in pregnancy. Immune globulin, a specific prophylactic against German measles, may be given to
pregnant women.

48.Myrna a public health nurse knows that to determine possible sources of sexually
transmitted infections, the BEST method that may be undertaken is:
a. Contact tracing
b. Community survey
c. Mass screening tests
d. Interview of suspects
48. Answer: (A) Contact tracing
Rationale: Contact tracing is the most practical and reliable method of finding possible sources of
person-to-person transmitted infections, such as sexually transmitted diseases

49.A 33-year old female client came for consultation at the health center with the chief
complaint of fever for a week. Accompanying symptoms were muscle pains and body malaise. A
week after the start of fever, the client noted yellowish discoloration of his sclera. History
showed that he waded in flood waters about 2 weeks before the onset of symptoms. Based on
her history, which disease condition will you suspect?
a. Hepatitis A
b. Hepatitis B
c. Tetanus
d. Leptospirosis
49. Answer: (D) Leptospirosis
Rationale: Leptospirosis is transmitted through contact with the skin or mucous membrane with
water or moist soil contaminated with urine of infected animals, like rats.

50.Mickey a 3-year old client was brought to the health center with the chief complaint of
severe diarrhea and the passage of “rice water” stools. The client is most probably suffering
from which condition?
a. Giardiasis
b. Cholera
c. Amebiasis
d. Dysentery
50. Answer: (B) Cholera
Rationale: 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.The most prevalent form of meningitis among children aged 2 months to 3 years is caused
by which microorganism?
a. Hemophilus influenzae
b. Morbillivirus
c. Steptococcus pneumoniae
d. Neisseria meningitidis
51. Answer: (A) Hemophilus influenzae
Rationale: Hemophilus meningitis is unusual over the age of 5 years. In developing countries, the
peak incidence is in children less than 6 months of age. Morbillivirus is the etiology of measles.
Streptococcus pneumoniae and Neisseria meningitidis may cause meningitis, but age distribution is
not specific in young children.

52.The student nurse is aware that the pathognomonic sign of measles is Koplik’s spot and you
may see Koplik’s spot by inspecting the:
a. Nasal mucosa
b. Buccal mucosa
c. Skin on the abdomen
d. Skin on neck
52. Answer: (B) Buccal mucosa
Rationale: Koplik’s spot may be seen on the mucosa of the mouth or the throat

53.Angel was diagnosed as having Dengue fever. You will say that there is slow capillary refill
when the color of the nailbed that you pressed does not return within how many seconds?
a. 3 seconds
b. 6 seconds
c. 9 seconds
d. 10 seconds
53. Answer: (A) 3 seconds
Rationale: Adequate blood supply to the area allows the return of the color of the nailbed within 3
seconds.

54.In Integrated Management of Childhood Illness, the nurse is aware that the severe
conditions generally require urgent referral to a hospital. Which of the following severe
conditions DOES NOT always require urgent referral to a hospital?
a. Mastoiditis
b. Severe dehydration
c. Severe pneumonia
d. Severe febrile disease
54. Answer: (B) Severe dehydration
Rationale: The order of priority in the management of severe dehydration is as follows: intravenous
fluid therapy, referral to a facility where IV fluids can be initiated within 30 minutes, Oresol or
nasogastric tube. When the foregoing measures are not possible or effective, then urgent referral to
the hospital is done.

55.Myrna a public health nurse will conduct outreach immunization in a barangay Masay with
a population of about 1500. The estimated number of infants in the barangay would be:
a. 45 infants
b. 50 infants
c. 55 infants
d. 65 infants
55. Answer: (A) 45 infants
Rationale: To estimate the number of infants, multiply total population by 3%.
56.The community nurse is aware that the biological used in Expanded Program on
Immunization (EPI) should NOT be stored in the freezer?
a. DPT
b. Oral polio vaccine
c. Measles vaccine
d. MMR
56. Answer: (A) DPT
Rationale: DPT is sensitive to freezing. The appropriate storage temperature of DPT is 2 to 8° C only.
OPV and measles vaccine are highly
sensitive to heat and require freezing. MMR is not an immunization in the Expanded Program on
Immunization.

57.It is the most effective way of controlling schistosomiasis in an endemic area?

a. Use of molluscicides
b. Building of foot bridges
c. Proper use of sanitary toilets
d. Use of protective footwear, such as rubber boots
57. Answer: (C) Proper use of sanitary toilets
Rationale: The ova of the parasite get out of the human body together with feces. Cutting the cycle at
this stage is the most effective way of preventing the spread of the disease to susceptible hosts.

58.Several clients is newly admitted and diagnosed with leprosy. Which of the following clients
should be classified as a case of multibacillary leprosy?
a. 3 skin lesions, negative slit skin smear
b. 3 skin lesions, positive slit skin smear
c. 5 skin lesions, negative slit skin smear
d. 5 skin lesions, positive slit skin smear
58. Answer: (D) 5 skin lesions, positive slit skin smear
Rationale: A multibacillary leprosy case is one who has a positive slit skin smear and at least 5 skin
lesions.

59.Nurses are aware that diagnosis of leprosy is highly dependent on recognition of symptoms.
Which of the following is an early sign of
leprosy?
a. Macular lesions
b. Inability to close eyelids
c. Thickened painful nerves
d. Sinking of the nosebridge
 59. Answer: (C) Thickened painful nerves
Rationale: The lesion of leprosy is not macular. It is characterized by a change in skin color (either
reddish or whitish) and loss of sensation, sweating and hair growth over the lesion. Inability to close
the eyelids (lagophthalmos) and sinking of the nosebridge are late symptoms.

60.Marie brought her 10 month old infant for consultation because of fever, started 4 days
prior to consultation. In determining malaria risk, what will you do?
a. Perform a tourniquet test.
b. Ask where the family resides.
c. Get a specimen for blood smear.
d. Ask if the fever is present everyday.
60. Answer: (B) Ask where the family resides.
Rationale: Because malaria is endemic, the first question to determine malaria risk is where the
client’s family resides. If the area of residence is not a known endemic area, ask if the child had
traveled within the past 6 months, where she was brought and whether she stayed overnight in that
area.

61.Susie brought her 4 years old daughter to the RHU because of cough and colds. Following
the IMCI assessment guide, which of the following is a danger sign that indicates the need for
urgent referral to a hospital?
a. Inability to drink
b. High grade fever
c. Signs of severe dehydration
d. Cough for more than 30 days
61. Answer: (A) Inability to drink
Rationale: A sick child aged 2 months to 5 years must be referred urgently to a hospital if he/she has
one or more of the following signs: not able to feed or drink, vomits everything, convulsions,
abnormally sleepy or difficult to awaken.

62.Jimmy a 2-year old child revealed “baggy pants”. As a nurse, using the IMCI guidelines,
how will you manage Jimmy?
a. Refer the child urgently to a hospital for confinement.
b. Coordinate with the social worker to enroll the child in a feeding program.
c. Make a teaching plan for the mother, focusing on menu planning for her child.
d. Assess and treat the child for health problems like infections and intestinal parasitism.
62. Answer: (A) Refer the child urgently to a hospital for confinement.
Rationale: “Baggy pants” is a sign of severe marasmus. The best management is urgent referral to a
hospital.
63.Gina is using Oresol in the management of diarrhea of her 3-year old child. She asked you
what to do if her child vomits. As a nurse you will tell her to:
a. Bring the child to the nearest hospital for further assessment.
b. Bring the child to the health center for intravenous fluid therapy.
c. Bring the child to the health center for assessment by the physician.
d. Let the child rest for 10 minutes then continue giving Oresol more slowly.
63. Answer: (D) Let the child rest for 10 minutes then continue giving Oresol more slowly.
Rationale: If the child vomits persistently, that is, he vomits everything that he takes in, he has to be
referred urgently to a hospital. Otherwise, vomiting is managed by letting the child rest for 10
minutes and then continuing with Oresol administration. Teach the mother to give Oresol more
slowly.

64.Nikki a 5-month old infant was brought by his mother to the health center because of
diarrhea for 4 to 5 times a day. Her skin goes back slowly after a skin pinch and her eyes are
sunken. Using the IMCI guidelines, you will classify this infant in which category?
a. No signs of dehydration
b. Some dehydration
c. Severe dehydration
d. The data is insufficient.
64. Answer: (B) Some dehydration
Rationale: Using the assessment guidelines of IMCI, a child (2 months to 5 years old) with diarrhea
is classified as having SOME DEHYDRATION if he shows 2 or more of the following signs: restless
or irritable, sunken eyes, the skin goes back slow after a skin pinch.

65.Chris a 4-month old infant was brought by her mother to the health center because of
cough. His respiratory rate is 42/minute. Using the Integrated Management of Child Illness
(IMCI) guidelines of assessment, his breathing is considered as:
a. Fast
b. Slow
c. Normal
d. Insignificant
65. Answer: (C) Normal
Rationale: In IMCI, a respiratory rate of 50/minute or more is fast breathing for an infant aged 2 to
12 months.

66.Maylene had just received her 4th dose of tetanus toxoid. She is aware that her baby will
have protection against tetanus for
a. 1 year
b. 3 years
c. 5 years
d. Lifetime
66. Answer: (A) 1 year
Rationale: The baby will have passive natural immunity by placental transfer of antibodies. The
mother will have active artificial immunity
lasting for about 10 years. 5 doses will give the mother lifetime protection.

67.Nurse Ron is aware that unused BCG should be discarded after how many hours of
reconstitution?
a. 2 hours
b. 4 hours
c. 8 hours
d. At the end of the day
67. Answer: (B) 4 hours
Rationale: While the unused portion of other biologicals in EPI may be given until the end of the day,
only BCG is discarded 4 hours after
reconstitution. This is why BCG immunization is scheduled only in the morning.

68.The nurse explains to a breastfeeding mother that breast milk is sufficient for all of the
baby’s nutrient needs only up to:
a. 5 months
b. 6 months
c. 1 year
d. 2 years
68. Answer: (B) 6 months
Rationale: After 6 months, the baby’s nutrient needs, especially the baby’s iron requirement, can no
longer be provided by mother’s milk
alone.

69.Nurse Ron is aware that the gestational age of a conceptus that is considered viable (able to
live outside the womb) is:
a. 8 weeks
b. 12 weeks
c. 24 weeks
d. 32 weeks
 69. Answer: (C) 24 weeks
Rationale: At approximately 23 to 24 weeks’ gestation, the lungs are developed enough to sometimes
maintain extrauterine life. The lungs are the most immature system during the gestation period.
Medical care for premature labor begins much earlier (aggressively at 21 weeks’ gestation)

70.When teaching parents of a neonate the proper position for the neonate’s sleep, the nurse
Patricia stresses the importance of placing the neonate on his back to reduce the risk of which
of the following?
a. Aspiration
b. Sudden infant death syndrome (SIDS)
c. Suffocation
d. Gastroesophageal reflux (GER)
70. Answer: (B) Sudden infant death syndrome (SIDS)
Rationale: Supine positioning is recommended to reduce the risk of SIDS in infancy. The risk of
aspiration is slightly increased with the supine position. Suffocation would be less likely with an
infant supine than prone and the position for GER requires the head of the bed to be elevated.

71.Which finding might be seen in baby James a neonate suspected of having an infection?
a. Flushed cheeks
b. Increased temperature
c. Decreased temperature
d. Increased activity level
71. Answer: (C) Decreased temperature
Rationale: Temperature instability, especially when it results in a low temperature in the neonate,
may be a sign of infection. The neonate’s
color often changes with an infection process but generally becomes ashen or mottled. The neonate
with an infection will usually show a
decrease in activity level or lethargy.

72.Baby Jenny who is small-for-gestation is at increased risk during the transitional period for
which complication?
a. Anemia probably due to chronic fetal hyposia
b. Hyperthermia due to decreased glycogen stores
c. Hyperglycemia due to decreased glycogen stores
d. Polycythemia probably due to chronic fetal hypoxia
72. Answer: (D) Polycythemia probably due to chronic fetal hypoxia
Rationale: The small-for-gestation neonate is at risk for developing polycythemia during the
transitional period in an attempt to decrease
hypoxia. The neonates are also at increased risk for developing hypoglycemia and hypothermia due
to decreased glycogen stores.

73.Marjorie has just given birth at 42 weeks’ gestation. When the nurse assessing the neonate,
which physical finding is expected?
a. A sleepy, lethargic baby
b. Lanugo covering the body
c. Desquamation of the epidermis
d. Vernix caseosa covering the body
73. Answer: (C) Desquamation of the epidermis
Rationale: Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated.
These neonates are usually very alert. Lanugo is missing in the postdate neonate.

74.After reviewing the Myrna’s maternal history of magnesium sulfate during labor, which
condition would nurse Richard anticipate as a potential problem in the neonate?
a. Hypoglycemia
b. Jitteriness
c. Respiratory depression
d. Tachycardia
74. Answer: (C) Respiratory depression
Rationale: Magnesium sulfate crosses the placenta and adverse neonatal effects are respiratory
depression, hypotonia, and bradycardia. The serum blood sugar isn’t affected by magnesium sulfate.
The neonate would be floppy, not jittery.

75.Which symptom would indicate the Baby Alexandra was adapting appropriately to extra-
uterine life without difficulty?
a. Nasal flaring
b. Light audible grunting
c. Respiratory rate 40 to 60 breaths/minute
d. Respiratory rate 60 to 80 breaths/minute
75. Answer: (C) Respiratory rate 40 to 60 breaths/minute
Rationale: A respiratory rate 40 to 60 breaths/minute is normal for a neonate during the transitional
period. Nasal flaring, respiratory rate more than 60 breaths/minute, and audible grunting are signs of
respiratory distress.

76. When teaching umbilical cord care for Jennifer a new mother, the nurse Jenny would
include which information?
a. Apply peroxide to the cord with each diaper change
b. Cover the cord with petroleum jelly after bathing
c. Keep the cord dry and open to air
d. Wash the cord with soap and water each day during a tub bath.
76. Answer: (C) Keep the cord dry and open to air
Rationale: Keeping the cord dry and open to air helps reduce infection and hastens drying. Infants
aren’t given tub bath but are sponged off until the cord falls off. Petroleum jelly prevents the cord
from drying and encourages infection. Peroxide could be painful and isn’t recommended.

77.Nurse John is performing an assessment on a neonate. Which of the following findings is

considered common in the healthy neonate?
a. Simian crease
b. Conjunctival hemorrhage
c. Cystic hygroma
d. Bulging fontanelle
77. Answer: (B) Conjunctival hemorrhage
Rationale: Conjunctival hemorrhages are commonly seen in neonates secondary to the cranial
pressure applied during the birth process. Bulging fontanelles are a sign of intracranial pressure.
Simian creases are present in 40% of the neonates with trisomy 21. Cystic hygroma is a neck mass
that can affect the airway.

78.Dr. Esteves decides to artificially rupture the membranes of a mother who is on labor.
Following this procedure, the nurse Hazel checks the fetal heart tones for which the following
reasons?
a. To determine fetal well-being.
b. To assess for prolapsed cord
c. To assess fetal position
d. To prepare for an imminent delivery.
78. Answer: (B) To assess for prolapsed cord
Rationale: After a client has an amniotomy, the nurse should assure that the cord isn’t prolapsed and
that the baby tolerated the procedure well. The most effective way to do this is to check the fetal
heart rate. Fetal well-being is assessed via a nonstress test. Fetal position is determined by vaginal
examination. Artificial rupture of membranes doesn’t indicate an imminent delivery.

79.Which of the following would be least likely to indicate anticipated bonding behaviors by
new parents?
a. The parents’ willingness to touch and hold the new born.
b. The parent’s expression of interest about the size of the new born.
c. The parents’ indication that they want to see the newborn.
d. The parents’ interactions with each other.
79. Answer: (D) The parents’ interactions with each other.
Rationale: Parental interaction will provide the nurse with a good assessment of the stability of the
family’s home life but it has no indication for parental bonding. Willingness to touch and hold the
newborn, expressing interest about the newborn’s size, and indicating a desire to see the newborn are
behaviors indicating parental bonding.

80.Following a precipitous delivery, examination of the client’s vagina reveals

a fourth-degree laceration. Which of the following would be contraindicated when caring for
this client?
a. Applying cold to limit edema during the first 12 to 24 hours.
b. Instructing the client to use two or more peripads to cushion the area.
c. Instructing the client on the use of sitz baths if ordered.
d. Instructing the client about the importance of perineal (kegel) exercises.
80. Answer: (B) Instructing the client to use two or more peripads to cushion the area
Rationale: Using two or more peripads would do little to reduce the pain or promote perineal healing.
Cold applications, sitz baths, and Kegel
exercises are important measures when the client has a fourth-degree laceration

81. A pregnant woman accompanied by her husband, seeks admission to the labor and delivery
area. She states that she’s in labor and says she attended the facility clinic for prenatal care.
Which question should the nurse Oliver ask her first?
a. “Do you have any chronic illnesses?”
b. “Do you have any allergies?”
c. “What is your expected due date?”
d. “Who will be with you during labor?”
81. Answer: (C) “What is your expected due date?”
Rationale: When obtaining the history of a client who may be in labor, the nurse’s highest priority is
to determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity
affect the duration of labor and the potential for labor complications. Later, the nurse should ask
about chronic illnesses, allergies, and support persons.

82.A neonate begins to gag and turns a dusky color. What should the nurse do first?
a. Calm the neonate.
b. Notify the physician.
c. Provide oxygen via face mask as ordered
d. Aspirate the neonate’s nose and mouth with a bulb syringe.
 82. Answer: (D) Aspirate the neonate’s nose and mouth with a bulb syringe.
Rationale: The nurse’s first action should be to clear the neonate’s airway with a bulb syringe. After
the airway is clear and the neonate’s color improves, the nurse should comfort and calm the neonate.
If the problem recurs or the neonate’s color doesn’t improve readily, the nurse should notify the
physician. Administering oxygen when the airway isn’t clear would be ineffective.

83. When a client states that her “water broke,” which of the following actions would be
inappropriate for the nurse to do?
a. Observing the pooling of straw-colored fluid.
b. Checking vaginal discharge with nitrazine paper.
c. Conducting a bedside ultrasound for an amniotic fluid index.
d. Observing for flakes of vernix in the vaginal discharge.
83. Answer: (C) Conducting a bedside ultrasound for an amniotic fluid index.
Rationale: It isn’t within a nurse’s scope of practice to perform and interpret a bedside ultrasound
under these conditions and without
specialized training. Observing for pooling of straw-colored fluid, checking vaginal discharge with
nitrazine paper, and observing for flakes of vernix are appropriate assessments for determining
whether a client has ruptured membranes.

84. A baby girl is born 8 weeks premature. At birth, she has no spontaneous respirations but is
successfully resuscitated. Within several hours she develops respiratory grunting, cyanosis,
tachypnea, nasal flaring, and retractions. She’s diagnosed with respiratory distress syndrome,
intubated, and placed on a ventilator. Which nursing action should be included in the baby’s
plan of care to
prevent retinopathy of prematurity?
a. Cover his eyes while receiving oxygen.
b. Keep her body temperature low.
c. Monitor partial pressure of oxygen (Pao2) levels.
d. Humidify the oxygen.
84. Answer: (C) Monitor partial pressure of oxygen (Pao2) levels.
Rationale: Monitoring PaO2 levels and reducing the oxygen concentration to keep PaO2 within
normal limits reduces the risk of retinopathy of prematurity in a premature infant receiving oxygen.
Covering the infant’s eyes and humidifying the oxygen don’t reduce the risk of retinopathy of
prematurity. Because cooling increases the risk of acidosis, the infant should be kept warm so that his
respiratory distress
isn’t aggravated.
85. Which of the following is normal newborn calorie intake?
a. 110 to 130 calories per kg.
b. 30 to 40 calories per lb of body weight.
c. At least 2 ml per feeding
d. 90 to 100 calories per kg
85. Answer: (A) 110 to 130 calories per kg.
Rationale: Calories per kg is the accepted way of determined appropriate nutritional intake for a
newborn. The recommended calorie requirement is 110 to 130 calories per kg of newborn body
weight. This level will maintain a consistent blood glucose level and provide enough calories for
continued growth and development.

86. Nurse John is knowledgeable that usually individual twins will grow appropriately and at
the same rate as singletons until how many weeks?
a. 16 to 18 weeks
b. 18 to 22 weeks
c. 30 to 32 weeks
d. 38 to 40 weeks
86. Answer: (C) 30 to 32 weeks
Rationale: Individual twins usually grow at the same rate as singletons until 30 to 32 weeks’
gestation, then twins don’t’ gain weight as rapidly as singletons of the same gestational age. The
placenta can no longer keep pace with the nutritional requirements of both fetuses after 32 weeks, so
there’s some growth retardation in twins if they remain in utero at 38 to 40 weeks.

87. Which of the following classifications applies to monozygotic twins for whom the cleavage
of the fertilized ovum occurs more than 13 days after fertilization?
a. conjoined twins
b. diamniotic dichorionic twins
c. diamniotic monochorionic twin
d. monoamniotic monochorionic twins
87. Answer: (A) conjoined twins
Rationale: The type of placenta that develops in monozygotic twins depends on the time at which
cleavage of the ovum occurs. Cleavage in conjoined twins occurs more than 13 days after
fertilization. Cleavage that occurs less than 3 day after fertilization results in diamniotic 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. Tyra experienced painless vaginal bleeding has just been diagnosed as having a placenta
previa. Which of the following procedures is usually performed to diagnose placenta previa?
a. Amniocentesis
b. Digital or speculum examination
c. External fetal monitoring
d. Ultrasound
88. Answer: (D) Ultrasound
Rationale: Once the mother and the fetus are stabilized, ultrasound evaluation of the placenta should
be done to determine the cause of the bleeding. Amniocentesis is contraindicated in placenta previa.
A digital or speculum examination shouldn’t be done as this may lead to severe bleeding or
hemorrhage. External fetal monitoring won’t detect a placenta previa, although it will detect fetal
distress, which may result from blood loss or placenta separation.

89. Nurse Arnold knows that the following changes in respiratory functioning during
pregnancy is considered normal:
a. Increased tidal volume
b. Increased expiratory volume
c. Decreased inspiratory capacity
d. Decreased oxygen consumption
89. Answer: (A) Increased tidal volume
Rationale: A pregnant client breathes deeper, which increases the tidal volume of gas moved in and
out of the respiratory tract with each breath. The expiratory volume and residual volume decrease as
the pregnancy progresses. The inspiratory capacity increases during pregnancy. The increased
oxygen consumption in the pregnant client is 15% to 20% greater than in the nonpregnant state.

90. Emily has gestational diabetes and it is usually managed by which of the following therapy?
a. Diet
b. Long-acting insulin
c. Oral hypoglycemic
d. Oral hypoglycemic drug and insulin
90. Answer: (A) Diet
Rationale: Clients with gestational diabetes are usually managed by diet alone to control their
glucose intolerance. Oral hypoglycemic drugs are contraindicated in pregnancy. Long-acting insulin
usually isn’t needed for blood glucose control in the client with gestational diabetes.

91. Magnesium sulfate is given to Jemma with preeclampsia to prevent which of the following
condition?
a. Hemorrhage
b. Hypertension
c. Hypomagnesemia
d. Seizure
91. Answer: (D) Seizure
Rationale: The anticonvulsant mechanism of magnesium is believes to depress seizure foci in the
brain and peripheral neuromuscular blockade. Hypomagnesemia isn’t a complication of
preeclampsia. Antihypertensive drug other than magnesium are preferred for sustained hypertension.
Magnesium doesn’t help prevent hemorrhage in preeclamptic clients.

92. Cammile with sickle cell anemia has an increased risk for having a sickle cell crisis during
pregnancy. Aggressive management of a sickle cell crisis includes which of the following
measures?
a. Antihypertensive agents
b. Diuretic agents
c. I.V. fluids
d. Acetaminophen (Tylenol) for pain
92. Answer: (C) I.V. fluids
Rationale: A sickle cell crisis during pregnancy is usually managed by exchange transfusion oxygen,
and L.V. Fluids. The client usually needs a stronger analgesic than acetaminophen to control the pain
of a crisis. Antihypertensive drugs usually aren’t necessary. Diuretic wouldn’t be used unless fluid
overload resulted.

93. Which of the following drugs is the antidote for magnesium toxicity?
a. Calcium gluconate (Kalcinate)
b. Hydralazine (Apresoline)
c. Naloxone (Narcan)
d. Rho (D) immune globulin (RhoGAM)
93. Answer: (A) Calcium gluconate (Kalcinate)
Rationale: Calcium gluconate is the antidote for magnesium toxicity. Ten milliliters of 10% calcium
gluconate is given L.V. push over 3 to 5 minutes. Hydralazine is given for sustained elevated blood
pressure in preeclamptic clients. Rho (D) immune globulin is given to women with Rh-negative
blood to prevent antibody formation from RH-positive conceptions. Naloxone is used to correct
narcotic toxicity.

94. Marlyn is screened for tuberculosis during her first prenatal visit. An intradermal injection
of purified protein derivative (PPD) of the tuberculin bacilli is given. She is considered to have
a positive test for which of the following results?
a. An indurated wheal under 10 mm in diameter appears in 6 to 12 hours.
b. An indurated wheal over 10 mm in diameter appears in 48 to 72 hours.
c. A flat circumcised area under 10 mm in diameter appears in 6 to 12 hours.
d. A flat circumcised area over 10 mm in diameter appears in 48 to 72 hours.
94. Answer: (B) An indurated wheal over 10 mm in diameter appears in 48 to 72 hours.
Rationale: A positive PPD result would be an indurated wheal over 10 mm in diameter that appears
in 48 to 72 hours. The area must be a raised wheal, not a flat circumcised area to be considered
positive.

95. Dianne, 24 year-old is 27 weeks’ pregnant arrives at her physician’s office with complaints
of fever, nausea, vomiting, malaise, unilateral flank pain, and costovertebral angle tenderness.
Which of the following diagnoses is most likely?
a. Asymptomatic bacteriuria
b. Bacterial vaginosis
c. Pyelonephritis
d. Urinary tract infection (UTI)
95. Answer: (C) Pyelonephritis
Rational: The symptoms indicate acute pyelonephritis, a serious condition in a pregnant client. UTI
symptoms include dysuria, urgency, frequency, and suprapubic tenderness. Asymptomatic bacteriuria
doesn’t cause symptoms. Bacterial vaginosis causes milky white vaginal discharge but no systemic
symptoms.

96. Rh isoimmunization in a pregnant client develops during which of the following conditions?
a. Rh-positive maternal blood crosses into fetal blood, stimulating fetal
antibodies.
b. Rh-positive fetal blood crosses into maternal blood, stimulating
maternal antibodies.
c. Rh-negative fetal blood crosses into maternal blood, stimulating
maternal antibodies.
d. Rh-negative maternal blood crosses into fetal blood, stimulating fetal
antibodies.
96. Answer: (B) Rh-positive fetal blood crosses into maternal blood, stimulating maternal
antibodies.
Rationale: Rh isoimmunization occurs when Rh-positive fetal blood cells cross into the maternal
circulation and stimulate maternal antibody
production. In subsequent pregnancies with Rh-positive fetuses, maternal antibodies may cross back
into the fetal circulation and destroy the fetal blood cells.

97. To promote comfort during labor, the nurse John advises a client to assume certain
positions and avoid others. Which position may cause maternal hypotension and fetal hypoxia?
a. Lateral position
b. Squatting position
c. Supine position
d. Standing position
97. Answer: (C) Supine position
Rationale: The supine position causes compression of the client’s aorta and inferior vena cava by the
fetus. This, in turn, inhibits maternal
circulation, leading to maternal hypotension and, ultimately, fetal hypoxia. The other positions
promote comfort and aid labor progress. For instance, the lateral, or side-lying, position improves
maternal and fetal circulation, enhances comfort, increases maternal relaxation, reduces muscle
tension, and eliminates pressure points. The squatting position promotes comfort by taking advantage
of gravity. The standing position also takes advantage of gravity and aligns the fetus with the pelvic
angle.

98. Celeste who used heroin during her pregnancy delivers a neonate. When assessing the
neonate, the nurse Lhynnette expects to find:
a. Lethargy 2 days after birth.
b. Irritability and poor sucking.
c. A flattened nose, small eyes, and thin lips.
d. Congenital defects such as limb anomalies.
98. Answer: (B) Irritability and poor sucking.
Rationale: Neonates of heroin-addicted mothers are physically dependent on the drug and experience
withdrawal when the drug is no
longer supplied. Signs of heroin withdrawal include irritability, poor sucking, and restlessness.
Lethargy isn’t associated with neonatal heroin
addiction. A flattened nose, small eyes, and thin lips are seen in infants with fetal alcohol syndrome.
Heroin use during pregnancy hasn’t been linked to specific congenital anomalies.

99. The uterus returns to the pelvic cavity in which of the following time frames?
a. 7th to 9th day postpartum.
b. 2 weeks postpartum.
c. End of 6th week postpartum.
d. When the lochia changes to alba.
99. Answer: (A) 7th to 9th day postpartum
Rationale: The normal involutional process returns the uterus to the pelvic cavity in 7 to 9 days. A
significant involutional complication is the failure of the uterus to return to the pelvic cavity within
the prescribed time period. This is known as subinvolution.
100. Maureen, a primigravida client, age 20, has just completed a difficult, forceps-assisted
delivery of twins. Her labor was unusually long and required oxytocin (Pitocin) augmentation.
The nurse who’s caring for her should stay alert for:
a. Uterine inversion
b. Uterine atony
c. Uterine involution
d. Uterine discomfort
100. Answer: (B) Uterine atony
Rationale: Multiple fetuses, extended labor stimulation with oxytocin, and traumatic delivery
commonly are associated with uterine atony, which may lead to postpartum hemorrhage. Uterine
inversion may precede or follow delivery and commonly results from apparent excessive traction on
the umbilical cord and attempts to deliver the placenta manually. Uterine involution and some uterine
discomfort are normal after delivery.