PNLE II for Community Health Nursing and Care of the Mother and Child (set 1)
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
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
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
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
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.
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.
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.
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.
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
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
PNLE II for Community Health Nursing and Care of the Mother and Child (set 1)
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.
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
PNLE II for Community Health Nursing and Care of the Mother and Child (set 1)
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?
A. Poliomyelitis
B. Measles
C. Rabies
D. Neonatal tetanus
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
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.
25.Tertiary prevention is needed in which stage
of the natural history of disease?
A. Pre-pathogenesis
B. Pathogenesis
C. Prodromal
D. Terminal
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.
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
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.
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
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
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
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
PNLE II for Community Health Nursing and Care of the Mother and Child (set 1)
C. Blood typing
D. Serum Calcium
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
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.
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
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
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
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”.
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
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.
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.
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.
PNLE II for Community Health Nursing and Care of the Mother and Child (set 1)
C. More oxygen, and the newborn’s
metabolic rate increases.
D. Less oxygen, and the newborn’s metabolic
rate decreases.
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
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
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
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.
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
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
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
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
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
PNLE II for Community Health Nursing and Care of the Mother and Child (set 1)

B. Buccal mucosa clients should be classified as a case of

C. Skin on the abdomen multibacillary leprosy?
D. Skin on neck A. 3 skin lesions, negative slit skin smear
53.Angel was diagnosed as having Dengue B. 3 skin lesions, positive slit skin smear
fever. You will say that there is slow capillary C. 5 skin lesions, negative slit skin smear
refill when the color of the nailbed that you D. 5 skin lesions, positive slit skin smear
pressed does not return within how many 59.Nurses are aware that diagnosis of leprosy is
seconds? highly dependent on recognition of symptoms.
A. 3 seconds Which of the following is an early sign
B. 6 seconds of leprosy?
C. 9 seconds A. Macular lesions
D. 10 seconds B. Inability to close eyelids
54.In Integrated Management of Childhood C. Thickened painful nerves
Illness, the nurse is aware that the severe D. Sinking of the nosebridge
conditions generally require urgent referral to a 60.Marie brought her 10 month old infant for
hospital. Which of the following severe consultation because of fever, started 4 days
conditions DOES NOT always require urgent prior to consultation. In determining malaria
referral to a hospital? risk, what will you do?
A. Mastoiditis A. Perform a tourniquet test.
B. Severe dehydration B. Ask where the family resides.
C. Severe pneumonia C. Get a specimen for blood smear.
D. Severe febrile disease D. Ask if the fever is present everyday.
55.Myrna a public health nurse will conduct 61.Susie brought her 4 years old daughter to
outreach immunization in a barangay Masay the RHU because of cough and colds. Following
with a population of about 1500. The estimated the IMCI assessment guide, which of the
number of infants in the barangay would be: following is a danger sign that indicates the
A. 45 infants need for urgent referral to a hospital?
B. 50 infants A. Inability to drink
C. 55 infants B. High grade fever
D. 65 infants C. Signs of severe dehydration
56.The community nurse is aware that the D. Cough for more than 30 days
biological used in Expanded Program on 62.Jimmy a 2-year old child revealed “baggy
Immunization (EPI) should NOT be stored in the pants”. As a nurse, using the IMCI guidelines,
freezer? how will you manage Jimmy?
A. DPT A. Refer the child urgently to a hospital for
B. Oral polio vaccine confinement.
C. Measles vaccine B. Coordinate with the social worker to enroll
D. MMR the child in a feeding program.
57.It is the most effective way of controlling C. Make a teaching plan for the mother,
schistosomiasis in an endemic area? focusing on menu planning for her child.
A. Use of molluscicides D. Assess and treat the child for health
B. Building of foot bridges problems like infections and intestinal
C. Proper use of sanitary toilets parasitism.
D. Use of protective footwear, such as rubber 63.Gina is using Oresol in the management of
boots diarrhea of her 3-year old child. She asked you
58.Several clients is newly admitted and what to do if her child vomits. As a nurse you
diagnosed with leprosy. Which of the following will tell her to:
PNLE II for Community Health Nursing and Care of the Mother and Child (set 1)
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.
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.
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
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
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
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
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
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)
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
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
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
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
PNLE II for Community Health Nursing and Care of the Mother and Child (set 1)
D. Tachycardia
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
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.
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
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.
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.
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.
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?”
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.
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.
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
PNLE II for Community Health Nursing and Care of the Mother and Child (set 1)
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.
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
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
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
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
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
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
91. Magnesium sulfate is given to Jemma with
preeclampsia to prevent which of the following
condition?
A. Hemorrhage
B. Hypertension
C. Hypomagnesemia
D. Seizure
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
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)
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.
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)
PNLE II for Community Health Nursing and Care of the Mother and Child (set 1)

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.
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
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.
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.
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
PNLE II for Community Health Nursing and Care of the Mother and Child (set 1)
Answers and Rationales
1. Answer: (A) Inevitable. An inevitable
abortion is termination of pregnancy that
cannot be prevented. Moderate to severe
bleeding with mild cramping and cervical
dilation would be noted in this type of
abortion.
2. Answer: (B) History of syphilis. Maternal
infections such as syphilis, toxoplasmosis,
and rubella are causes of spontaneous
abortion.
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
PNLE II for Community Health Nursing and Care of the Mother and Child (set 1)
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 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.
PNLE II for Community Health Nursing and Care of the Mother and Child (set 1)
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.
PNLE II for Community Health Nursing and Care of the Mother and Child (set 1)
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.
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
PNLE II for Community Health Nursing and Care of the Mother and Child (set 1)
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 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.
PNLE II for Community Health Nursing and Care of the Mother and Child (set 1)
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
PNLE II for Community Health Nursing and Care of the Mother and Child (set 1)
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
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
PNLE II for Community Health Nursing and Care of the Mother and Child (set 1)

symptoms include dysuria, urgency, process returns the uterus to the pelvic
frequency, and suprapubic tenderness. cavity in 7 to 9 days. A significant
Asymptomatic bacteriuria doesn’t cause involutional complication is the failure of
symptoms. Bacterial vaginosis causes milky the uterus to return to the pelvic cavity
white vaginal discharge but no systemic within the prescribed time period. This is
symptoms. known as subinvolution.
96. Answer: (B) Rh-positive fetal blood crosses 100. Answer: (B) Uterine atony. Multiple
into maternal blood, stimulating maternal fetuses, extended labor stimulation with
antibodies. Rh isoimmunization occurs oxytocin, and traumatic delivery
when Rh-positive fetal blood cells cross commonly are associated with uterine
into the maternal circulation and stimulate atony, which may lead to postpartum
maternal antibody production. In hemorrhage. Uterine inversion may
subsequent pregnancies with Rh-positive precede or follow delivery and commonly
fetuses, maternal antibodies may cross results from apparent excessive traction
back into the fetal circulation and destroy on the umbilical cord and attempts to
the fetal blood cells. deliver the placenta manually. Uterine
97. Answer: (C) Supine position. The supine involution and some uterine discomfort
position causes compression of the client’s are normal after delivery.
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