Maternal

Maternal & Child Nursing Care
Objectives
Identify the nursing roles available to the maternal-newborn and pediatric nurses.
Summarize the use of community-based nursing care in meeting the needs of childbearing and
childrearing families.
Summarize the current status of factors related to health insurance and access to healthcare.
Define the following statistical terms relevant to healthcare: birth rate, infant mortality rate,
neonatal mortality rate, and maternal mortality rate.
Identify the goals for client safety developed by the Joint Commission on the Accreditation of
Healthcare Organizations (JCAHO).
Delineate significant legal and ethical issues that influence the practice of maternal-child
nursing.
Discuss the role of evidence-based practice in improving the quality of nursing care for
childbearing families.
NCLEX RN Review
This activity contains 10 questions.
An adolescent boy asks, "Does the scrotum have a function?" The

nurse's best response is:
"The scrotum maintains a higher temperature then the core body temperature."
"The scrotum is an insensitive structure that houses the testicles."
"The scrotum is the source of ejaculation."
"The scrotum helps to protect the testes and provides an ideal environment to
create sperm."
During a pelvic exam, the nurse practitioner observes a slit with

irregular edges in the client's cervix. She interprets this finding as an
indication of:
A congenitial uterine anomaly.
Cervical trauma from a surgical procedure.

Past pregnancy.
Cervical cancer.
A nurse is teaching a class about the female reproductive system to a

group of women aged 45-55. When she asks a participant to name the
event that is primarily responsible for the initiation of menopause, she
knows the participant has understood when she answers:
The ovaries secrete decreasing amounts of estrogen.
The ovaries secrete decreasing amounts of luteinizing hormone (LH).
The ovaries secrete decreasing amounts of follicle-stimulating hormone (FSH).
The ovaries secrete decreasing amounts of progesterone.
The nurse is assessing the pH level of the vaginal environment of a 26year-old client. Which of the following would be an expected finding for
this client?
pH level of 3.4
pH level of 4.6
pH level of 5.7
pH level of 6.9
A nurse is teaching a class for adolescents about the female

reproductive system. When the nurse asks the class what the function
of the vagina is, she knows that the class has understood when they
answer which of the following? Select all that apply.
"It protects the labia minora."
"It's a passageway for the sperm and the fetus."

"It's a passageway for menstrual flow."
"It protects against infections from pathogenic organisms."
A nurse is teaching a class on the anatomy of the reproductive system.

A student states that she has pain during menstruation. The nurse
knows that painful menstruations may be due to which of the following
ligaments?
Uterosacral ligament
Round ligament
Ovarian ligament
Broad ligament
A male client is having some problems with infertility and is waiting for
a report on his semen sample. The nurse knows that the problem may
not be related to the pH level of the semen based on the following pH
lab value:
7.5
6.5
5.5
4.5
During a discussion about the pelvic bony structure, a client relates

that she has been told by her physician that she has a narrow pubic
arch and wants to know how this might affect childbirth. The nurse's
best response is:
"If the arch is too narrow for the head, it could result in the need for forceps or
cesarean birth"
"The hormones of pregnancy will relax the joint enough to allow passage of the
fetal head through the pubic arch."
"Giving birth in a squatting or sitting position will increase the diameter of the
outlet enough to allow passage of the fetal head."
"The sacrococcygeal joint is flexible and will allow passage of the fetal head
through the outlet."
A nurse is reviewing a client's record and notices a physician's report

of a malformation in one of the fallopian tubes. The nurse knows that
the client is most at risk for:
Ectopic pregnancy.
Urinary tract infections.

Early menopause.
A decrease in estrogen levels.
Which statement by the nurse best describes the correct order of the 4
phases of the menstrual cycle?
Menstrual, follicular, secretory, ischemic
Luteal, follicular, secretory, menstrual
Menstrual, proliferative, secretory, ischemic
Luteal, secretory, ischemic, follicular
Case Study
A nurse works in a women's health clinic. The age range that this clinic serves is 18-69, and
the clinic is located in an urban area. The clinic has asked the nurse to prepare a human
sexuality class for young teenagers who are pregnant.
The nurse plans to include information about the male and female
reproductive systems. What internal structures are included in the
male and female reproductive systems?
To create paragraphs in your essay response, type <p> at the beginning of the paragraph,
and </p> at the end.
What should the nurse include in her discussion about the female
pelvic floor and the different divisions of the pelvic cavity?
One of the females in the class asks about the difference between the
ovarian cycle and the menstrual cycle. What should the nurses
response be?
A person in the class wants to know how long an egg can survive and
how long a sperm can survive. What would be an appropriate
response?
The nurse plans to provide information about female hormones during

the sexuality class. What effect does estrogen have on the female
body? Where is progesterone produced in the female body? What role
does the anterior pituitary gland play in the secretion of hormones?
Care Plan
Cheryl King, 18 years old, reports having severe pain and a heavy flow with menses, irregular
menses, and mood changes. Cheryl started having menses at the age of 12, and regularly
goes 2-3 months between menses. On this visit, the client reports having had no menses for 4
months, and that she was raped approximately 3 months ago. The at-home pregnancy test
came back negative. Develop a nursing Care Plan to assist with her menses problems, which
includes attending to the psychosocial aspects. Fill in the appropriate elements of the Care
Plan for the client in the boxes below.
Assessment and Diagnosis
Planning and Implementation
Evaluation
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Gale Encyclopedia of Public Health:
Maternal and Child Health

Top
Home Library Health Public Health Encyclopedia
Maternal and child health (MCH) refers to the health of mothers,
infants, children, and adolescents. It also refers to a profession
within public health committed to promoting the health status and
future challenges of this vulnerable population.
Historical Development
One of the greatest achievements of public health in the twentieth
century in the United States was the dramatic improvement in the
health of mothers and babies: during this period infant mortality
declined by greater than 90 percent, and maternal mortality
declined by 99 percent. While improvements in living standards,
educational levels, and environmental conditions have contributed
most to these improvements, public health MCH programs have also
played a role.
The development of these MCH programs occurred in the unique
political and social landscape of the United States, where a reliance
on individualism has shaped the attitude that caring for children is
the parents' responsibility, and that government should step in to
help only when families and communities are not able to care for
their own. The concept of federalism has also played a role in
dividing responsibility between the federal government and state
and local authorities. Further, the dominance of the biomedical

model in the United States has directed most of the monies spent on
MCH to the provision of direct clinical services. Some of the major
historical developments in MCH are highlighted in Table 1.
Maternal Health. At the beginning of the twentieth century, for
every one thousand live births, six to nine women died of
pregnancy-related complications. Sepsis was the leading cause of
maternal death, with half of the cases following delivery (often
performed without following the principles of asepsis), and half
associated with illegally induced abortion. Hemorrhage and
preeclampsia (convulsions) were other leading causes of mortality.
In response to the high maternal and infant mortality rates, and to
women's suffrage, Congress passed the Maternity and Infancy Act
Table 1
A Chronology of Maternal and Child Health Services in the United
States
SOURCE: Courtesy of author.
190
9
First White House Conference on Care of Dependent Children
191
2
Children's Bureau created
192
1
Maternity and Infancy Act (Sheppard-Towner Act) enacted
192
9
Sheppard-Towner Act overturned
193
0
American Academy of Pediatrics founded
193
5
Title V legislation enacted as part of Social Security Act
193
5
Crippled Children's Services (CCS) created
194
3
Emergency Maternity and Infant Care enacted (P78-156)
195
1
American College of Obstetricians and Gynecologists founded
196
5
Medicaid (Title XIX) enacted
196
5
Head Start Program started
196
5
Community and Migrant Health Center Program created
197 Special Supplemental Food Program for Women, Infants, & Children
2
created
197 Roe v. Wade legalizes abortion before fetal viability
A Chronology of Maternal and Child Health Services in the United

States
3
197
3
Early and Periodic Screening, Diagnosis and Treatment (EPSDT) created
197 Supplemental Security Income Program for children with disabilities
6
enacted
197
9
Pregnancy-Related Mortality Surveillance System established
198
1
Title V MCH Services Block Grant to states created
198
4
Emergency Medical Services for Children enacted
198
9
OBRA 89 expands coverage of prenatal care for low-income women
199
1
Healthy Start Program started
199
4
Early Head Start Program started
199
6
Temporary Assistance for Needy Families (TANF) program created
199
7
State Children's Health Insurance Program created
(also known as the Sheppard-Towner Act) in 1921. The Fetal,

Newborn, and Maternal Mortality and Morbidity Report of the 1933
White House Conference on Child Health Protection called attention
to the link between poor aseptic practice, excessive and
inappropriate obstetrical interventions (induction of labor, use of
forceps, episiotomy, and cesarean deliveries), and high maternal
mortality. During the 1930s and 1940s, hospital and state maternal
mortality review committees were established. At the same time, a
shift from home to hospital deliveries was occurring. The proportion
of infants born in hospitals increased from 55 percent in 1938 to 90
percent in 1948, which was accompanied by a 71 percent decrease
in maternal mortality. Medical advances (including the use of
antibiotics, the use of oxytocin to induce labor, safe blood
transfusions, and better management of hypertensive disorders)
accelerated the declines in maternal mortality. Liberalization of state
abortion laws, beginning in the 1960s, contributed to an 89 percent
decline in deaths from septic illegal abortions between 1950 and
1973. In 1979, the Centers for Disease Control and Prevention
partnered with the American College of Obstetricians and
Gynecologists in developing the Pregnancy-Related Mortality
Surveillance System, and implementing maternal mortality review

boards across the country. At the end of the twentieth century, for
every 100,000 live births, only seven to eight women died of
pregnancy-related complicationsa 99 percent reduction of the rate
at the beginning of the century.
Infant Health. At the beginning of the twentieth century, for every
one thousand live births, one hundred infants died before age one.
Infant mortality began to decline in the early part of the twentieth
century, following improvements in urban environments (e.g.,
sewage and refuse disposal and safe drinking water), milk
pasteurization, rising standards of living, and declining fertility rates.
The Children's Bureau formed in 1912 called for the establishment of
the National Birth Registry in 1915. The Children's Bureau became
the primary government agency to work toward improving maternal
and infant health and welfare for the next thirty years. In 1935,
Congress enacted Title V of the Social Security Act, which authorized
and appropriated funds for maternal and child health-services
programs. Between 1930 and 1949, infant mortality declined by 52
percent, largely due to antibiotics, development of fluid and
electrolyte replacement therapy, and safe blood transfusions. It
declined further following the implementation of Medicaid,
Community Health Centers, and other federal programs in the
1960s. The Special Supplemental Food Program for Women, Infants,
and Children (WIC) was created in 1972. Infant survival continued to
improve in the 1970s because of technologic advances in neonatal
medicine and the regionalization of perinatal services. Medicaid
eligibility for pregnant women and infants was significantly
expanded in the 1980s to enhance access to, and utilization of,
prenatal care. The development of artificial pulmonary surfactant in
the late 1980s and the use of antenatal corticosteroids in the 1990s
to prevent and treat respiratory distress syndrome in premature
infants also contributed to a decline in infant mortality. Other
improvements in infant health in the 1990s include a 50 percent
decline in the rates of sudden infant death syndrome, advances in
prenatal diagnosis and surgical treatment of birth defects; and
national efforts to encourage reproductive-aged women to consume
folic acid to reduce the incidence of neural tube defects.
Child Health. Industrialization in the late nineteenth century forced
many children into hazardous labor in mills, mines, and factories. In
1909, President Theodore Roosevelt convened the first White House
Conference on Care of Dependent Children, which called attention to
the unacceptably high rate of infant deaths and the detrimental

effects of child labor. This led to the creation of the Children's
Bureau in 1912 to "serve all children, to try to work out standards of
care and protection which shall give to every child his fair chance in
the world." Both the establishment of the Children's Bureau and the
passage of the Sheppard-Towner Act met with formidable resistance.
They were seen by many as governmental intrusion into the
relationship between children and their parents, and they were
opposed by the American Medical Association (AMA) because of
their potential for governmental interference or control over the
practice of medicinedespite an endorsement from the Pediatric
Section, which split off from the AMA in 1930 to form the American
Academy of Pediatrics. The Sheppard-Towner Act was over-turned in
1929. The enactment of Title V in 1935, however, expanded health
and social services to mothers and children.
Medicaid was enacted in 1965 as a federal-state partnership to fund
health services for low-income families with children. The Head Start
program, launched in 1965, provided an intellectually stimulating
and healthful environment for preschool children. The Early and
Periodic Screening, Diagnosis, and Treatment (EPSDT) program was
created in 1967 to fund preventive health services for Medicaideligible children, including physical and developmental exams,
vision and hearing screening, dental referrals, and immunizations.
These advances were followed, however, by a downsizing of federal
involvement and the return of power and responsibility for MCH
policies to the states in the 1980s. The most significant change was
the consolidation of seven categorical MCH programs into the MCH
Services Block Grant. Health care coverage for children was reexpanded in 1997 with the creation of the State Children's Health
Insurance Program.
Children with Special Health Care Needs. Title V of the 1935
Social Security Act created Crippled Children's Services (CCS), which
became the only source of federal funding for the next thirty years
for children with special health care needs. Enactment of Medicaid
(Title XIX) in 1965 relieved CCS of many of its reimbursement and
direct service provision responsibilities. In 1974, the Supplemental
Security Income (SSI) Childhood Disability Program began to provide
monthly cash payments to low-income children with disabilities and
special health care needs. The Omnibus Budget Reconciliation Act of
1989 (OBRA89) directed state Children with Special Health Care
Needs programs (CSHCN, formerly CCS) to develop communitybased systems of services and to promote and provide familycentered, community-based, comprehensive, and culturally
competent services for children with special health care needs.
Thirty percent of the MCH Services Block Grant was to be directed
toward this use. Alarmed by the rapidly increasing SSI enrollment,
Congress redefined disability, restricted eligibility, and reduced cash
assistance to children with disabilities in 1996.
Current Status
Despite significant improvements in the health of mothers, infants,
and children during the twentieth century, the United States
compares poorly with other developed nations on most indicators of
MCH. In 1997, the United States ranked twenty-fifth in infant
mortality and twenty-first in maternal mortality among developed
nations. Table 2 presents a report card of selected indicators of MCH
in the United States, along with national goals set for the year 2010.
There are also significant disparities in MCH among racial, ethnic,
and other sociodemographic categories. For example, AfricanAmerican infants have twice the chance of dying, of low birth
weight, and of being premature, as compared to white infants.
Maternal mortality is five times higher among pregnant African
American women than among pregnant white women. The teen
pregnancy rate is twice as high among Hispanic women, and three
times as high among African-American women, than it is among
white women aged fifteen
Table 2
MCH Report Card, United States
Curre
Indicator
nt
Goal
SOURCE: U.S. Department of Health and Human Services. Healthy People
2010.
Maternal mortality ratio (maternal deaths per 100,000 live
births)
7.1
3.3
Percentage of women with adequate prenatal care
73
90
Percentage of women with maternal complications
25.6 20
Percentage of women who smoke cigarettes during pregnancy 13.9 2
Percentage of low-income women with anemia in third trimester29
23
Percentage of deliveries by cesarean
20.8 15
Infant mortality rate (infant deaths per 1,000 live births)
7.6
5.0
Percentage of low birthweight births (less than 2,500 grams)
7.3
5.0
Percentage of very low birthweight births (less than 1,500
1.4
1.0
MCH Report Card, United States

Indicator
grams)
Percentage of premature births (less than 37 weeks)
Percentage of women who breast-feed their babies early
postpartum
Percentage of women who breast-feed their babies until 1 year
old
Child death rate (deaths per 100,000 children aged 1-14)
Percentage of children 19 to 35 months old fully immunized
Percentage of children under 18 without health care coverage
Percentage of children under 18 who have regular source of
care
Percentage of pregnancies that are planned
Number of pregnancies per 1,000 females aged 15 to 17
Number of women with fertility problems who had sexually
transmitted diseases or pelvic inflammatory disease
Percentage of women with Chlamydia trachomatis infection
Curre
nt
Goal
11.0
7.6
60
75
8.6
35.8
78
15.4
25
33.7
90
0
91
95
49
70
47.6 45
800,00500,0
0
00
12.3 3.0
to seventeen. Causes of these disparities have not been determined,

but they have been attributed to differences in genetics, behavior,
culture, socioeconomic class, and access to health care. Recent
research on neighborhood and community factors, as well as
cumulative life experiences and exposures, may shed light on the
persisting disparities in MCH outcomes.
Mch Programs
A myriad of public health programs have been created over the
years to improve the health of disadvantaged mothers, infants, and
children, and to reduce disparities in health status and health care
access. A few of the major programs are listed below.
MCH Block Grant Program. Title V of the Social Security Act
(1935) authorized the use of federal monies for MCH programs. The
biggest change to the Title V program came in 1981, when seven
MCH programs were consolidated into the MCH block grant.
Administration of MCH programs, which support direct delivery of
MCH services in the public health setting, devolved to the state
level, while state and federal governments share the costs.
Medicaid. Created by Title XIX of Social Security Act in 1965, the
objective of Medicaid is to support the provision of health services to
low-income Americans. The federal and state governments jointly
administer the program and share its costs. Medicaid is really a
financing program rather than a service delivery program. States
are mandated to cover pregnant women and children six years of

age and younger living at up to 133 percent of the federal poverty
level, as well as all children up to age nineteen in families with
incomes below the poverty level. Medicaid is by far the largest MCH
program, funding prenatal and obstetrical care, the EPSDT program,
and health services for children with special health care needs.
Three out of four Medicaid recipients are women and children,
though they consume only one-fourth of total Medicaid
expenditures.
Community and Migrant Health Center Program. Created in
1965, the Community and Migrant Health Center Program provides
basic primary care to medically underserved (largely rural) areas. It
is funded by the federal government and administered at the
community level. These centers place a high priority on reducing
infant mortality and improving the health of mothers and children.
One-third of individuals served by the program are children under
age fifteen, and one in four are women of childbearing age.
The Special Supplemental Food Program for Women, Infants,
and Children (WIC). Created in 1972, WIC provides supplemental
food and nutritional education to low-income pregnant women,
nursing mothers, and children diagnosed as being at nutritional risk.
It is funded by the federal government and administered by the U.S.
Department of Agriculture. Technically speaking, WIC is not a health
care program, but evaluations have found WIC to be effective in
reducing infant mortality, low birth weight, anemia, and other
problems.
Head Start, Early Head Start, and Healthy Start. Project Head
Start was created in 1965 to promote social and behavioral
competence among preschool children from low-income families and
to ensure that the children enter school with a similar foundation as
their more economically advantaged peers. The program includes
comprehensive health services, including preventive health services.
Ten percent of Head Start enrollment is reserved for children with
disabilities. Evaluations have shown reduced juvenile delinquency
and increased school completion rates among children enrolled in
the Head Start program. In 1994, Congress established the Early
Head Start program for low-income families with infants and
toddlers. Both programs are administered by the Head Start Bureau
of the Department of Health and Human Services. The Healthy Start
Initiative was created in 1991 to attack the causes of infant
mortality and low birthweight using a broad range of community-
based interventions in nearly one hundred communities across the

United States. The Healthy Start Initiative is administered by the
Maternal and Child Health Bureau.
Temporary Assistance for Needy Families (TANF) Program. In
1996, the U.S. Congress passed landmark welfare reform legislation
(the Personal Responsibility and Work Opportunity Reconciliation
Act) that replaced the Aid to Families with Dependent Children
(AFDC) Program with the TANF Program. TANF was intended to give
states new opportunities to develop and implement creative and
innovative strategies and approaches to removing families from a
cycle of dependency on public assistance and creating employment
opportunities for them. While reviews of the impact of TANF on the
health of women and children have been mixed, TANF has generated
additional monies for MCH programs. For example, Los Angeles
County created the Long-Term Family Self Sufficiency Plan with its
TANF monies. The plan includes programs to help pregnant women
gain access prenatal care, and to provide additional support
services, such as parenting skills training.
State Children's Health Insurance Program (SCHIP). SCHIP
was established in 1997 to provide insurance for children from
families with incomes too high to qualify for Medicaid, but too low to
afford private health insurance. Of the over 10 million children in the
United States who were uninsured in 1997, only 3 million were
eligible for Medicaid prior to SCHIP. In its first three years, SCHIP has
enrolled over 3 million children. Although enrollment was slow
initially, states have responded with innovative strategies to reach
out to uninsured children and families to increase enrollment. SCHIP
is administered through the Health Care Financing Administration
(HCFA).
State Programs. In addition to the programs described above,
many state and local governments have developed additional MCH
programs of their own. A notable example is the California Children
and Families First Initiative, or Proposition 10. Passed in 1998, the
initiative has raised approximately $700 million annually from a
tobacco surtax to be used to improve early child development for
children up to age five. The money will be used to support health
care services for children and families, parental education and
support services, and child-care programs. Because of the autonomy
of its governance structure and its broadly defined goals, it is
flexible enough to allow for different approaches that cross the
traditional boundaries of MCH, a flexibility that is often not permitted
under categorical funding and grant making. Proposition 10 has the

potential for providing a model for the rest of the nation.
Future Challenges
At the beginning of the twenty-first century, many challenges in
MCH remain. Some of the most important areas of concern are
described below.
Maternal Mortality and Morbidity. The decline in maternal
mortality in the United States has leveled off since 1982. This does
not mean that it has reached an irreducible minimum, as one-third
to one-half of the deaths that still occur are probably preventable.
Maternal deaths are only the tip of the iceberg, however, as one in
four women experience complications during pregnancy, many of
which are preventable. An increased effort to assess and assure the
quality of health care for pregnant women is needed. Likewise, the
connection between maternal health and women's health needs to
be better understood. Improving women's health over the life
course, and not only during pregnancy, is likely to have the greatest
impact on improving maternal and child health.
Infant Mortality and Morbidity. Birth defects are the leading
cause of infant death, affecting approximately 3 percent of all live
births. Because many birth defects occur in the first three months of
pregnancy, they are best prevented by preconceptional and early
prenatal care. The causes of most birth defects are still unknown
and require further research. Low birthweight and prematurity
contribute to most of the infant deaths and congenital neurological
disabilities not related to birth defects. They are also the leading
cause of infant deaths among African Americans. To date, most
interventions during pregnancy designed to prevent low birthweight
and prematurity have not been effective.
Prenatal and Preconceptional Care. Although widely accepted,
the effectiveness of prenatal care in improving pregnancy outcomes,
particularly in preventing low birthweight and prematurity, has not
been conclusively demonstrated. While this may reflect
methodological flaws in research on prenatal care, it could also
suggest that prenatal care is not provided in the proper manner, and
some researchers have begun to question the appropriateness of
the content of prenatal care. Still others have argued that less than
nine months of prenatal care is not enough to reverse the
cumulative impact of lifelong habits and exposures on pregnancy
outcomes. Most women do not obtain preconceptional care before
getting pregnant, and many health care providers do not know how
to provide preconceptional care, or they provide it only to women
who are actively trying to get pregnant, thereby missing
opportunities to improve the outcomes of pregnancies that are
unintended.
Breast-Feeding. The benefits of breast-feeding to the health of
mothers and infants have been well documented, including
enhanced immunity against infections, improved cognitive
development, and stronger maternal-infant bonding. Despite these
benefits, the initiation and duration of breast-feeding in the United
States remains low, particularly among disadvantaged women.
Efforts to promote the WHO/UNICEF "Ten Steps to Successful Breastfeeding" in hospitals have met with little success. Changes in
cultural norms, workplace practices, and social policy are also
needed to encourage breast-feeding among American women.
Immunization. Although the up-to-date immunization rate of
children in the United States has been steadily improving, it still falls
short of the national goal of 90 percent by age two, particularly for
poor children. There is no agreement among public health experts
on a strategy to bring this up to the level at which "herd immunity"
would protect those children who remain without immunization.
Child Care. Over half of U.S. mothers with children under six work
outside the home, and 60 percent of these children receive care
outside their homes. In addition to increased risk for infections and
injuries, children cared for in day-care centers may receive less
support for cognitive and social development than children cared for
at home. Support for parents with child-care needs is low,
particularly for low-income families.
Family Violence. A U.S. woman has a one-in-five chance of being
physically abused at some point in her lifetime. Estimates of the
prevalence of physical abuse by an intimate partner during
pregnancy range from 4 to 8 percent, but it may be as high as 20
percent. Most communities have inadequate resources to help
battered women. Many health care providers do not screen for, or
cannot identify, domestic violence. Within communities, a shortage
of shelter beds, social workers, and other basic services frequently
exists, together with a lack of coordination among health care,
social-service, and judicial systems. Children are abused in half of
the families where women are abused. While little is known or done
about primary prevention of family violence, what is clear is that
family violence cannot be overcome without attention to the social

and economic conditions that put children and families at risk.
Unintentional and Intentional Injury. Injury is the leading cause
of death among children and adolescents, with motor-vehicle injury
being the single leading cause. Other causes include fires/burns and
drowning. Homicides and suicides account for one-fourth of injuryrelated deaths among adolescents. While progress has been made
in preventing deaths related to motor-vehicle injury, largely
attributable to a reduction in alcohol-related fatalities, little progress
has been made in preventing deaths related to homicides and
suicides.
Tobacco, Alcohol, and Other Drugs. Nearly one-third of teens are
current smokers, and half have drunk alcohol within the last month.
Nearly one-third have used marijuana, and 5 percent have used
cocaine. Alcohol and other drugs contribute significantly to
unintentional and intentional injuries among adolescents, including
motor-vehicle accidents, homicide, suicide, as well as unintended
pregnancies, sexually transmitted infections, and a host of other
medical and social problems. Success of clinical interventions at the
individual level is modest; and the effectiveness of neighborhoodand
community-level interventions remains to be demonstrated.
Sexual Behavior and Unintended Pregnancy. One-third of girls
and nearly one-half of boys in the United States have had sexual
intercourse by the ninth grade, and 20 percent of all youth in grades
nine through twelve have had four or more sexual partners. While
these rates are similar to European rates, the rates of sexually
transmitted infections and unintended pregnancies are much higher
among U.S. teens. One in four sexually active adolescents will get a
sexually transmitted infection by age twenty. Nearly one million
adolescent women become pregnant each year in the United States,
with half of these pregnancies resulting in live births. Teen mothers
have lower educational attainment, lower future earnings, and
higher welfare dependency. Two-thirds of these teen births occur
outside of marriage.
Conclusion
Much of the advancement in maternal and child health has been
made outside of public health. Progress in medicine, education,
environment (both physical and social), gender and race relations,
public policy, and many social areas have made, and will continue to
make, important contributions to MCH. An important challenge for
MCH as a profession is to promote change outside the traditional

boundaries of MCH in order to improve the health of mothers,
infants, children, and adolescents.
(SEE ALSO: Alcohol Use and Abuse; Child Care, Daycare; Child Health
Services; Domestic Violence; Head Start
Program; Immunizations; Infant Mortality
Rate; Perinatology; Pregnancy; Prenatal
Care; Reproduction; Sexually Transmitted Diseases; Teenage
Pregnancy; Title V; Tobacco Control; Women, Infants, and Children
Program [WIC]; Women's Health)
Bibliography
Binkin, N. J.; Williams, R. L.; Hogue, C. J. R.; and Chen, P. M. (1985).
"Reducing Black Neonatal Mortality: Will Improvement in Birth
Weight Be Enough?" Journal of the American Medical
Association 253:372375.
Centers for Disease Control and Prevention (1999). "Achievements
in Public Health, 19001999: Healthier Mothers and
Babies." Morbidity and Mortality Weekly Report 48:849858.
Hoffman, J. D., and Ward, K. (1999). "Genetic Factors in Preterm
Delivery." Obstetrics and Gynecological Survey 54:203.
Hutchins, V. L. (1997). "Maternal and Child Health Bureau:
Roots." Pediatrics 94:695699.
Kotch, J. B.; Blakely, C. H.; Brown, S. S.; and Wong, F. Y., eds.
(1992). A Pound of Prevention: The Case for Universal Maternity
Care in the U.S. Washington, DC: American Public Health
Association.
Kotch, J. B., ed. (1997). Maternal and Child Health: Programs,
Problems and Policy in Public Health. Gaithersburg, MD: Aspen
Publishers.
Naylor, A. F., and Myrianthopoulos, N. C. (1967). "The Relation of
Ethnic and Selected Socio-Economic Factors to Human BirthWeight." Annual of Human Genetics 37:7183.
U.S. Department of Health and Human Services, Maternal and Child
Health Bureau (1999). Title V: A Snapshot of Maternal and Child
Health 1997. Rockville, MD: Health Resources and Services
Administration.
U.S. Department of Health and Human Services, Office of Disease
Prevention and Health Promotion (2000). Healthy People 2010, 2nd
edition. Washington, DC: US Government Printing Office.
MICHAEL C. LU; J. ROBERT BRAGONIER
Gale Encyclopedia of US History:
Maternal and Child Health Care

Top
Home Library History, Politics & Society US History Encyclopedia
The story of maternal and child health care in America parallels
major changes not only in medical science, but also in society at
large. Colonial Americans continued European practices
of obstetrics and midwifery, while child health care remained
largely undifferentiated from adult treatments. Complications
from childbirth were the leading killers of young women, and infant
and toddler mortality was high. In 1789, 40 percent of all deaths
were among children under age five. Infants frequently succumbed
to dysentery, diarrhea, and cholera, while epidemics of smallpox,
scarlet fever, typhoid, yellow fever, and diphtheria often killed older
children.
Maternal health was threatened by postpartum bleeding as well as
by deadly ailments such as puerperal ("childbearing") fever,
a bacterial infection contracted during childbirth. Labor pain went
largely untreated until 1853, when Queen Victoria of England
demanded chloroform while delivering her eighth baby. The
smallpox inoculation was introduced to America in 1721, and a
greatly improved smallpox vaccination became available in 1800;
still, infant and child mortality rates remained high well into the midnineteenth century.
By 1850, nearly 17 percent of deaths nationwide were among
infants, although they accounted for less than 3 percent of the total
population. Cities were particularly deadly: between 1854 and 1856,
children under age five accounted for more than 60 percent of New
York City's deaths. Yet the roots of pediatrics and obstetrics were
taking hold. In 1825, William P. Dewees of the University of
Pennsylvania published the first comprehensive treatise on
children's health. Philadelphia opened the first children's hospital in
1855, and in 1860, Dr. Abraham Jacobi, who became known as the
"father of pediatrics," was appointed to head the first children's
clinic at the New York Medical College. Before long, the American
Medical Association had departments devoted to obstetrics and
pediatrics, and in 1888 the American Pediatric Society was formed.
Meanwhile, the problem of child labor was reaching a crisis point. In

1870, some 764,000 childrenabout 13 percent of the nation's 10to 15-year-oldswere working in America's factories, mines, and
fields. Within 30 years, the child workforce had mushroomed to 1.75
million. Child labor abuses, however, also spawned child welfare
programs. In 1874, the Society for the Prevention of Cruelty to
Children was founded, modeled after the Society for the Prevention
of Cruelty to Animals, which had been established in 1866. By the
end of the century, the "sanitary milk movement" had become a
powerful force in combating diarrheal diseases brought on by
spoiled milk, the leading cause of death among young children at
the time. The advent of pasteurization further aided the cause,
allowing for wide distribution of safe milk to fight disease
and malnutrition.
As the Progressive Era ushered in the new century, reform
movements such as the "crusade for children" promoted a range of
maternal and child health issues. Public schools took an active role
in preventative care by introducing school nurses and instituting
general health and eye exams for students. New York City piloted
programs that became national models, including, in 1908, the first
public school lunch program, as well as the establishment of the first
Bureau of Child Hygiene. In 1909, President Theodore Roosevelt
hosted the first White House Conference on Children. He called for
the establishment of what, in 1912, became the Federal Children's
Bureau. Its mission: to "investigate and report upon all matters
pertaining to the welfare of children and child life among all classes
of our people."
The 1921 Maternity and Infancy Care Act provided health services
funding for mothers and children, particularly in rural communities.
The act, though not renewed in 1929, inspired the 1935 Social
Security Act Title V maternal and child health care funding
programs. Later in the century, federal legislation and programs for
maternal and child health care ranged from the Special
Supplemental Nutrition Program for Women, Infants, and Children
(WIC), permanently established in 1974, to the Family and Medical
Leave Act (FMLA) of 1993.
In the private sector, the National Easter Seal Society (formed
originally as the National Society for Crippled Children in 1921; the
first such association was the Ohio Society for Crippled Children,
formed in 1919) and the March of Dimes Birth Defects
Foundation (created as the National Foundation for Infantile

Paralysis in 1938) were among the many organizations formed to
promote maternal and child health through prevention and
treatment.
One of the century's most significant medical advances was Dr.
Jonas Salk's introduction of the polio vaccine in 1952. Salk's fame
also paved the way for a new breed of superstar doctor, including
pediatricians-turned authors Dr. Benjamin Spock and, a generation
later, Dr. T. Barry Brazelton. Best-sellers written by and for women,
including Our Bodies, Ourselves (first published in 1970) and the
"What to Expect" series, gave women a common, personal point of
reference on reproductive health and child rearing.
The evolution of women's roles in society also had a significant
impact on maternal health care in the twentieth century, with
reproductive health issues sparking frequent national debate. Early
in the century, women's rights advocates such as the Planned
Parenthood founder Margaret Sanger fought to overturn the
nineteenth-century Comstock laws (named for anti-vice crusader
Anthony Comstock), which banned contraceptives and related
information as obscene materials. In 1936, a U.S. Circuit Court of
appeals ruling liberalized the interpretation of the Comstock laws as
they applied to contraceptives; a year later, the American Medical
Association officially recognized the importance of birth control in
medical education and practice. The patenting of the birth control
pill in 1960, which quickly became women's birth control method of
choice, kicked off the sexual revolution. The 1960s and 1970s also
spawned natural childbirth and Lamaze movements, which gave
fathers a more prominent role during delivery.
The most bitter war over reproductive rights stemmed from the
1973 Supreme Court decision in Roe v. Wade, which effectively
legalized first and second-trimester abortions in the United States,
using the same privacy standard the court had applied
in overturning Griswold v. Connecticut (1965), which dealt with state
bans on contraceptives. Roeset off a firestorm between "pro-life"
abortion opponents and "pro-choice" advocates of a woman's right
to end a pregnancy.
Medical science also stretched toward the other end of the spectrum
near the end of the century with the advent of fertility treatments
such as in vitro fertilization and other methods of assisted
reproductive therapy. As the twenty-first century began, the ethical
debates about everything from prenatal gene therapy to human
cloning hinted at a new century of cutting-edge science and social

discourse about maternal and child health care.
Bibliography
American Pediatric Society/Society for Pediatric Research. Web

site http://www.aps-spr.org.
King, Charles R. Children's Health in America: A History. New York:
Twayne, 1993.
Kotch, Jonathon B., ed. Maternal and Child Health:
Programs,Problems, and Policy in Public Health. Gaithersburg, Md.:
Aspen, 1997.
Luker, Kristin. Abortion and the Politics of Motherhood. Berkeley:
University of California Press, 1984.
McCann, Carole R. Birth Control Politics in the United States,1916
1945. Ithaca, N.Y.: Cornell University Press, 1994.
Meckel, Richard A. Save the Babies: American Public Health Re-form
and the Prevention of Infant Mortality, 18501929. Baltimore: Johns
Hopkins University Press, 1990.
Quiroga, Virginia Anne Metaxas. Poor Mothers and Babies: A Social
History of Childbirth and Child Care Hospitals in Nineteenth-Century
New York City. New York: Garland, 1990.
Wollons, Roberta, ed. Children at Risk in America: History, Concepts,
and Public Policy. Albany: State University of New York Press, 1993.
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Maternal and Child Health Practice Test Part 1
1. When assessing the adequacy of sperm for conception to occur, which of
the following is the most useful criterion?
A. Sperm count
B. Sperm motility
C. Sperm maturity
D. Semen volume
2. A couple who wants to conceive but has been unsuccessful during the last
2 years has undergone many diagnostic procedures. When discussing the
situation with the nurse, one partner states, We know several friends in our
age group and all of them have their own child already, Why cant we have
one?. Which of the following would be the most pertinent nursing diagnosis
for this couple?
A. Fear related to the unknown
B. Pain related to numerous procedures.
C. Ineffective family coping related to infertility.
D. Self-esteem disturbance related to infertility.
3. Which of the following urinary symptoms does the pregnant woman most
frequently experience during the first trimester?
A. Dysuria
B. Frequency
C. Incontinence
D. Burning
4. Heartburn and flatulence, common in the second trimester, are most likely
the result of which of the following?
A. Increased plasma HCG levels
B. Decreased intestinal motility
C. Decreased gastric acidity
D. Elevated estrogen levels
5. On which of the following areas would the nurse expect to observe
chloasma?
A. Breast, areola, and nipples
B. Chest, neck, arms, and legs
C. Abdomen, breast, and thighs
D. Cheeks, forehead, and nose
6. A pregnant client states that she waddles when she walks. The nurses
explanation is based on which of the following as the cause?
A. The large size of the newborn
B. Pressure on the pelvic muscles

C. Relaxation of the pelvic joints
D. Excessive weight gain
7. Which of the following represents the average amount of weight gained
during pregnancy?
A. 12 to 22 lb
B 15 to 25 lb
C. 24 to 30 lb
D. 25 to 40 lb
8. When talking with a pregnant client who is experiencing aching swollen,
leg veins, the nurse would explain that this is most probably the result of
which of the following?
A. Thrombophlebitis
B. Pregnancy-induced hypertension
C. Pressure on blood vessels from the enlarging uterus
D. The force of gravity pulling down on the uterus
9. Cervical softening and uterine souffle are classified as which of the
following?
A. Diagnostic signs
B. Presumptive signs
C. Probable signs
D. Positive signs
10. Which of the following would the nurse identify as a presumptive sign of
pregnancy?
A. Hegar sign
B. Nausea and vomiting
C. Skin pigmentation changes
D. Positive serum pregnancy test
11. Which of the following common emotional reactions to pregnancy would
the nurse expect to occur during the first trimester?
A. Introversion, egocentrism, narcissism

B. Awkwardness, clumsiness, and unattractiveness
C. Anxiety, passivity, extroversion
D. Ambivalence, fear, fantasies
12. During which of the following would the focus of classes be mainly on
physiologic changes, fetal development, sexuality, during pregnancy, and
nutrition?
A. Prepregnant period
B. First trimester
C. Second trimester
D. Third trimester
13. Which of the following would be disadvantage of breast feeding?
A. Involution occurs more rapidly
B. The incidence of allergies increases due to maternal antibodies
C. The father may resent the infants demands on the mothers body
D. There is a greater chance for error during preparation
14. Which of the following would cause a false-positive result on a pregnancy
test?
A. The test was performed less than 10 days after an abortion
B. The test was performed too early or too late in the pregnancy
C. The urine sample was stored too long at room temperature
D. A spontaneous abortion or a missed abortion is impending
15. FHR can be auscultated with a fetoscope as early as which of the
following?
A. 5 weeks gestation
B. 10 weeks gestation
C. 15 weeks gestation
D. 20 weeks gestation
16. A client LMP began July 5. Her EDD should be which of the following?
A. January 2
B. March 28
C. April 12
D. October 12
17. Which of the following fundal heights indicates less than 12 weeks
gestation when the date of the LMP is unknown?
A. Uterus in the pelvis
B. Uterus at the xiphoid
C. Uterus in the abdomen
D. Uterus at the umbilicus
18. Which of the following danger signs should be reported promptly during
the antepartum period?
A. Constipation
B. Breast tenderness
C. Nasal stuffiness
D. Leaking amniotic fluid
19. Which of the following prenatal laboratory test values would the nurse
consider as significant?
A. Hematocrit 33.5%
B. Rubella titer less than 1:8
C. White blood cells 8,000/mm3
D. One hour glucose challenge test 110 g/dL
20. Which of the following characteristics of contractions would the nurse
expect to find in a client experiencing true labor?
A. Occurring at irregular intervals
B. Starting mainly in the abdomen
C. Gradually increasing intervals
D. Increasing intensity with walking
21. During which of the following stages of labor would the nurse assess
crowning?
A. First stage
B. Second stage
C. Third stage
D. Fourth stage
22. Barbiturates are usually not given for pain relief during active labor for
which of the following reasons?
A. The neonatal effects include hypotonia, hypothermia, generalized
drowsiness, and reluctance to feed for the first few days.
B. These drugs readily cross the placental barrier, causing depressive effects
in the newborn 2 to 3 hours after intramuscular injection.
C. They rapidly transfer across the placenta, and lack of an antagonist make
them generally inappropriate during labor.
D. Adverse reactions may include maternal hypotension, allergic or toxic
reaction or partial or total respiratory failure
23. Which of the following nursing interventions would the nurse perform
during the third stage of labor?
A. Obtain a urine specimen and other laboratory tests.
B. Assess uterine contractions every 30 minutes.
C. Coach for effective client pushing
D. Promote parent-newborn interaction.
24. Which of the following actions demonstrates the nurses understanding
about the newborns thermoregulatory ability?
A. Placing the newborn under a radiant warmer.
B. Suctioning with a bulb syringe
C. Obtaining an Apgar score
D. Inspecting the newborns umbilical cord
25. Immediately before expulsion, which of the following cardinal
movements occur?
A. Descent
B. Flexion
C. Extension
D. External rotation
26. Before birth, which of the following structures connects the right and left
auricles of the heart?
A. Umbilical vein
B. Foramen ovale
C. Ductus arteriosus
D. Ductus venosus
27. Which of the following when present in the urine may cause a reddish
stain on the diaper of a newborn?
A. Mucus
B. Uric acid crystals
C. Bilirubin
D. Excess iron
28. When assessing the newborns heart rate, which of the following ranges
would be considered normal if the newborn were sleeping?
A. 80 beats per minute
B. 100 beats per minute
C. 120 beats per minute
D. 140 beats per minute
29. Which of the following is true regarding the fontanels of the newborn?
A. The anterior is triangular shaped; the posterior is diamond shaped.
B. The posterior closes at 18 months; the anterior closes at 8 to 12 weeks.
C. The anterior is large in size when compared to the posterior fontanel.
D. The anterior is bulging; the posterior appears sunken.
30. Which of the following groups of newborn reflexes below are present at
birth and remain unchanged through adulthood?
A. Blink, cough, rooting, and gag
B. Blink, cough, sneeze, gag

C. Rooting, sneeze, swallowing, and cough
D. Stepping, blink, cough, and sneeze
31. Which of the following describes the Babinski reflex?
A. The newborns toes will hyperextend and fan apart from dorsiflexion of
the big toe when one side of foot is stroked upward from the ball of the heel
and across the ball of the foot.
B. The newborn abducts and flexes all extremities and may begin to cry
when exposed to sudden movement or loud noise.
C. The newborn turns the head in the direction of stimulus, opens the
mouth, and begins to suck when cheek, lip, or corner of mouth is touched.
D. The newborn will attempt to crawl forward with both arms and legs when
he is placed on his abdomen on a flat surface
32. Which of the following statements best describes hyperemesis
gravidarum?
A. Severe anemia leading to electrolyte, metabolic, and nutritional
imbalances in the absence of other medical problems.
B. Severe nausea and vomiting leading to electrolyte, metabolic, and
nutritional imbalances in the absence of other medical problems.
C. Loss of appetite and continuous vomiting that commonly results in
dehydration and ultimately decreasing maternal nutrients
D. Severe nausea and diarrhea that can cause gastrointestinal irritation and
possibly internal bleeding
33. Which of the following would the nurse identify as a classic sign of PIH?
A. Edema of the feet and ankles
B. Edema of the hands and face
C. Weight gain of 1 lb/week
D. Early morning headache
34. In which of the following types of spontaneous abortions would the nurse
assess dark brown vaginal discharge and a negative pregnancy tests?
A. Threatened
B. Imminent
C. Missed
D. Incomplete
35. Which of the following factors would the nurse suspect as predisposing a
client to placenta previa?
A. Multiple gestation
B. Uterine anomalies
C. Abdominal trauma
D. Renal or vascular disease
36. Which of the following would the nurse assess in a client experiencing
abruptio placenta?
A. Bright red, painless vaginal bleeding
B. Concealed or external dark red bleeding
C. Palpable fetal outline
D. Soft and nontender abdomen
37. Which of the following is described as premature separation of a
normally implanted placenta during the second half of pregnancy, usually
with severe hemorrhage?
A. Placenta previa
B. Ectopic pregnancy
C. Incompetent cervix
D. Abruptio placentae
38. Which of the following may happen if the uterus becomes overstimulated
by oxytocin during the induction of labor?
A. Weak contraction prolonged to more than 70 seconds
B. Tetanic contractions prolonged to more than 90 seconds
C. Increased pain with bright red vaginal bleeding
D. Increased restlessness and anxiety
39. When preparing a client for cesarean delivery, which of the following key
concepts should be considered when implementing nursing care?
A. Instruct the mothers support person to remain in the family lounge until
after the delivery
B. Arrange for a staff member of the anesthesia department to explain what
to expect postoperatively
C. Modify preoperative teaching to meet the needs of either a planned or
emergency cesarean birth
D. Explain the surgery, expected outcome, and kind of anesthetics
40. Which of the following best describes preterm labor?
A. Labor that begins after 20 weeks gestation and before 37 weeks gestation
B. Labor that begins after 15 weeks gestation and before 37 weeks gestation
C. Labor that begins after 24 weeks gestation and before 28 weeks gestation
D. Labor that begins after 28 weeks gestation and before 40 weeks gestation
41. When PROM occurs, which of the following provides evidence of the
nurses understanding of the clients immediate needs?
A. The chorion and amnion rupture 4 hours before the onset of labor.
B. PROM removes the fetus most effective defense against infection
C. Nursing care is based on fetal viability and gestational age.
D. PROM is associated with malpresentation and possibly incompetent cervix
42. Which of the following factors is the underlying cause of dystocia?
A. Nurtional
B. Mechanical
C. Environmental
D. Medical
43. When uterine rupture occurs, which of the following would be the
priority?
A. Limiting hypovolemic shock
B. Obtaining blood specimens
C. Instituting complete bed rest
D. Inserting a urinary catheter
44. Which of the following is the nurses initial action when umbilical cord
prolapse occurs?
A. Begin monitoring maternal vital signs and FHR
B. Place the client in a knee-chest position in bed
C. Notify the physician and prepare the client for delivery
D. Apply a sterile warm saline dressing to the exposed cord
45. Which of the following amounts of blood loss following birth marks the
criterion for describing postpartum hemorrhage?
A. More than 200 ml
B. More than 300 ml
C. More than 400 ml
D. More than 500 ml
46. Which of the following is the primary predisposing factor related to
mastitis?
A. Epidemic infection from nosocomial sources localizing in the lactiferous
glands and ducts
B. Endemic infection occurring randomly and localizing in the periglandular
connective tissue
C. Temporary urinary retention due to decreased perception of the urge to
avoid
D. Breast injury caused by overdistention, stasis, and cracking of the nipples
47. Which of the following best describes thrombophlebitis?
A. Inflammation and clot formation that result when blood components
combine to form an aggregate body
B. Inflammation and blood clots that eventually become lodged within the
pulmonary blood vessels
C. Inflammation and blood clots that eventually become lodged within the
femoral vein
D. Inflammation of the vascular endothelium with clot formation on the
vessel wall
48. Which of the following assessment findings would the nurse expect if the
client develops DVT?
A. Midcalf pain, tenderness and redness along the vein

B. Chills, fever, malaise, occurring 2 weeks after delivery
C. Muscle pain the presence of Homans sign, and swelling in the affected
limb
D. Chills, fever, stiffness, and pain occurring 10 to 14 days after delivery
49. Which of the following are the most commonly assessed findings in
cystitis?
A. Frequency, urgency, dehydration, nausea, chills, and flank pain
B. Nocturia, frequency, urgency dysuria, hematuria, fever and suprapubic
pain
C. Dehydration, hypertension, dysuria, suprapubic pain, chills, and fever
D. High fever, chills, flank pain nausea, vomiting, dysuria, and frequency
50. Which of the following best reflects the frequency of reported
postpartum blues?
A. Between 10% and 40% of all new mothers report some form of
postpartum blues
B. Between 30% and 50% of all new mothers report some form of
postpartum blues
C. Between 50% and 80% of all new mothers report some form of
postpartum blues
D. Between 25% and 70% of all new mothers report some form of
postpartum blues
Answer and Rationale- Maternal and Child

Health Practice Test Part 1
<< Back to Questions
1. B. Although all of the factors listed are important, sperm motility is the most significant criterion when
semen volume are all significant, but they are not as significant sperm motility.
2. D. Based on the partners statement, the couple is verbalizing feelings of inadequacy and negative feelin
diagnosis of self-esteem disturbance is most appropriate. Fear, pain, and ineffective family coping also m
3. B. Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible fo
andburning are symptoms associated with urinary tract infections.
4. C. During the second trimester, the reduction in gastric acidity in conjunction with pressure from the gro
and flatulence. HCG levels increase in the first, not the second, trimester. Decrease intestinal motility w
Estrogen levels decrease in the second trimester.
5. D. Chloasma, also called the mask of pregnancy, is an irregular hyperpigmented area found on the face.
legs, abdomen, or thighs.
6. C. During pregnancy, hormonal changes cause relaxation of the pelvic joints, resulting in the typical w
fetus. Pressure on the surrounding muscles causing discomfort is due to the growing uterus. Weight gain
7. C. The average amount of weight gained during pregnancy is 24 to 30 lb. This weight gain consists of th
amniotic fluid 2 lb; uterus 2.5 lb; breasts 3 lb; and increased blood volume 2 to 4 lb; extravascula
whereas a weight gain of 15 to 25 lb is marginal. A weight gain of 25 to 40 lb is considered excessive.
8. C. Pressure of the growing uterus on blood vessels results in an increased risk for venous stasis in the lo
formation may occur. Thrombophlebitis is an inflammation of the veins due to thrombus formation. Preg
symptoms. Gravity plays only a minor role with these symptoms.
9. C. Cervical softening (Goodell sign) and uterine souffl are two probable signs of pregnancy. Probable s
Other probable signs include Hegar sign, which is softening of the lower uterine segment; Piskacek sign
laboratory tests; changes in skin pigmentation; and ultrasonic evidence of a gestational sac. Presumptive
vomiting; urinary frequency; breast tenderness and changes; excessive fatigue; uterine enlargement; and
10. B. Presumptive signs of pregnancy are subjective signs. Of the signs listed, only nausea and vomiting ar
a positive serum pregnancy test are considered probably signs, which are strongly suggestive of pregnan
11. D. During the first trimester, common emotional reactions include ambivalence, fear, fantasies, or anxie
by the increased need to learn about fetal growth and development. Common emotional reactions during
times the woman may seem egocentric and self-centered. During the third trimester, the woman typicall
introverted or reflective of her own childhood.
12. B. First-trimester classes commonly focus on such issues as early physiologic changes, fetal developme
may include pregnant couples. Second and third trimester classes may focus on preparation for birth, pa
13. C. With breast feeding, the fathers body is not capable of providing the milk for the newborn, which ma
for bonding, or he may be jealous of the infants demands on his wifes time and body. Breast feeding is
thus minimizing blood loss. The presence of maternal antibodies in breast milk helps decrease the incide
associated with bottle feeding. No preparation is required for breast feeding.
14. A. A false-positive reaction can occur if the pregnancy test is performed less than 10 days after an aborti
storing the urine sample too long at room temperature, or having a spontaneous or missed abortion impe
15. D. The FHR can be auscultated with a fetoscope at about 20 weeks gestation. FHR usually is ausculatat
transducer at 10 to 12 weeks gestation. FHR, cannot be heard any earlier than 10 weeks gestation.
16. C. To determine the EDD when the date of the clients LMP is known use Nagele rule. To the first day o
applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July) minus 3 = 4 (April). Therefore, the clients
17. A. When the LMP is unknown, the gestational age of the fetus is estimated by uterine size or position (f
less than 12 weeks gestation. At approximately 12 to 14 weeks, the fundus is out of the pelvis above the
approximately 20 weeks gestation and reaches the xiphoid at term or 40 weeks.
18. D. Danger signs that require prompt reporting leaking of amniotic fluid, vaginal bleeding, blurred vision
breast tenderness, and nasal stuffiness are common discomforts associated with pregnancy.
19. B. A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less than 1:8 is significant, indicatin
hematocrit of 33.5% a white blood cell count of 8,000/mm3, and a 1 hour glucose challenge test of 110
20. D. With true labor, contractions increase in intensity with walking. In addition, true labor contractions o
sweeping around to the abdomen. The interval of true labor contractions gradually shortens.
21. B. Crowing, which occurs when the newborns head or presenting part appears at the vaginal opening, o
labor, cervical dilation and effacement occur. During the third stage of labor, the newborn and placenta a
after birth, during which time the mother and newborn recover from the physical process of birth and th
nonpregnant state.
22. C. Barbiturates are rapidly transferred across the placental barrier, and lack of an antagonist makes them
effects of barbiturates include central nervous system depression, prolonged drowsiness, delayed establi
sucking pressure). Tranquilizers are associated with neonatal effects such as hypotonia, hypothermia, ge
days. Narcotic analgesic readily cross the placental barrier, causing depressive effects in the newborn 2
associated with adverse reactions such as maternal hypotension, allergic or toxic reaction, or partial or to
23. D. During the third stage of labor, which begins with the delivery of the newborn, the nurse would prom
mothers abdomen and encouraging the parents to touch the newborn. Collecting a urine specimen and o
of labor. Assessing uterine contractions every 30 minutes is performed during the latent phase of the firs
appropriate during the second stage of labor.
24. A. The newborns ability to regulate body temperature is poor. Therefore, placing the newborn under a r
Suctioning with a bulb syringe helps maintain a patent airway. Obtaining an Apgar score measures the n
the umbilical cord aids in detecting cord anomalies.
25. D. Immediately before expulsion or birth of the rest of the body, the cardinal movement of external rota
restitution (in this order) occur before external rotation.
26. B. The foramen ovale is an opening between the right and left auricles (atria) that should close shortly a
traveling through the vascular system. The umbilical vein, ductus arteriosus, and ductus venosus are obl
27. B. Uric acid crystals in the urine may produce the reddish brick dust stain on the diaper. Mucus would
adaptation.
28. B. The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute. If the new
160 beats per minute.
29. C. The anterior fontanel is larger in size than the posterior fontanel. Additionally, the anterior fontanel, w
posterior fontanel, which is triangular shaped, closes at 8 to 12 weeks. Neither fontanel should appear b
sunken, which may indicate dehydration.
30. B. Blink, cough, sneeze, swallowing and gag reflexes are all present at birth and remain unchanged thro
within the first year.
31. A. With the babinski reflex, the newborns toes hyperextend and fan apart from dorsiflexion of the big to
across the ball of the foot. With the startle reflex, the newborn abducts and flexes all extremities and ma
With the rooting and sucking reflex, the newborn turns his head in the direction of stimulus, opens the m
mouth is touched. With the crawl reflex, the newborn will attempt to crawl forward with both arms and
32. B. The description of hyperemesis gravidarum includes severe nausea and vomiting, leading to electroly
medical problems. Hyperemesis is not a form of anemia. Loss of appetite may occur secondary to the na
deplete the nutrients transported to the fetus. Diarrhea does not occur with hyperemesis.
33. B. Edema of the hands and face is a classic sign of PIH. Many healthy pregnant woman experience foot
indicates a problem. Early morning headache is not a classic sign of PIH.
34. C. In a missed abortion, there is early fetal intrauterine death, and products of conception are not expelle
vaginal discharge, negative pregnancy test, and cessation of uterine growth and breast tenderness. A thre
bleeding in early pregnancy, with no cervical dilation. An incomplete abortion presents with bleeding, c
only expulsion of part of the products of conception and bleeding occurs with cervical dilation.
35. A. Multiple gestation is one of the predisposing factors that may cause placenta previa. Uterine anomali
predispose a client to abruptio placentae.
36. B. A client with abruptio placentae may exhibit concealed or dark red bleeding, possibly reporting sudde
boardlike, and the fetal presenting part may be engaged. Bright red, painless vaginal bleeding, a palpabl
of placenta previa.
37. D. Abruptio placentae is described as premature separation of a normally implanted placenta during the
Placenta previa refers to implantation of the placenta in the lower uterine segment, causing painless blee
refers to the implantation of the products of conception in a site other than the endometrium. Incompete
cervical os without uterine contractions.
38. B. Hyperstimulation of the uterus such as with oxytocin during the induction of labor may result in tetan
lead to such complications as fetal distress, abruptio placentae, amniotic fluid embolism, laceration of th
occur. Pain, bright red vaginal bleeding, and increased restlessness and anxiety are not associated with h
39. C. A key point to consider when preparing the client for a cesarean delivery is to modify the preoperativ
cesarean birth, the depth and breadth of instruction will depend on circumstances and time available. Al
as possible is an important concept, although doing so depends on many variables. Arranging for necess
the clients care is a nursing responsibility. The nurse is responsible for reinforcing the explanations abo
used. The obstetrician is responsible for explaining about the surgery and outcome and the anesthesiolog
anesthesia to be used.
40. A. Preterm labor is best described as labor that begins after 20 weeks gestation and before 37 weeks ge
41. B. PROM can precipitate many potential and actual problems; one of the most serious is the fetus loss o
immediate need at this time. Typically, PROM occurs about 1 hour, not 4 hours, before labor begins. Fet
considerations that affect the plan of care. Malpresentation and an incompetent cervix may be causes of
42. B. Dystocia is difficult, painful, prolonged labor due to mechanical factors involving the fetus (passenge
environment, and medical factors may contribute to the mechanical factors that cause dystocia.
43. A. With uterine rupture, the client is at risk for hypovolemic shock. Therefore, the priority is to prevent
giving oxygen, replacing lost fluids, providing drug therapy as needed, evaluating fetal responses and pr
complete bed rest, and inserting a urinary catheter are necessary in preparation for surgery to remedy the
44. B. The immediate priority is to minimize pressure on the cord. Thus the nurses initial action involves p
knee-chest position or lowering the head of the bed, and elevating the maternal hips on a pillow to minim
and FHR, notifying the physician and preparing the client for delivery, and wrapping the cord with steril
have no effect on minimizing the pressure on the cord.
45. D. Postpartum hemorrhage is defined as blood loss of more than 500 ml following birth. Any amount le
46. D. With mastitis, injury to the breast, such as overdistention, stasis, and cracking of the nipples, is the pr
probable sources of infection for mastitis. Temporary urinary retention due to decreased perception of th
urinary tract infection, not mastitis.
47. D. Thrombophlebitis refers to an inflammation of the vascular endothelium with clot formation on the w
aggregate body describe a thrombus or thrombosis. Clots lodging in the pulmonary vasculature refers to
thrombophlebitis.
48. C. Classic symptoms of DVT include muscle pain, the presence of Homans sign, and swelling of the aff
vein reflect superficial thrombophlebitis. Chills, fever and malaise occurring 2 weeks after delivery refle
occurring 10 to 14 days after delivery suggest femoral thrombophlebitis.
49. B. Manifestations of cystitis include, frequency, urgency, dysuria, hematuria nocturia, fever, and suprapu
associated with cystitis. High fever chills, flank pain, nausea, vomiting, dysuria, and frequency are assoc
50. C. According to statistical reports, between 50% and 80% of all new mothers report some form of postp
to 70% are incorrect.

Maternal and Child Health Practice Test Part 2
1. For the client who is using oral contraceptives, the nurse informs the client about
the need to take the pill at the same time each day to accomplish which of the
following?
A. Decrease the incidence of nausea
B. Maintain hormonal levels
C. Reduce side effects
D. Prevent drug interactions
2. When teaching a client about contraception. Which of the following would the
nurse include as the most effective method for preventing sexually transmitted
infections?
A. Spermicides
B. Diaphragm
C. Condoms
D. Vasectomy
3. When preparing a woman who is 2 days postpartum for discharge,
recommendations for which of the following contraceptive methods would be
avoided?
A. Diaphragm
B. Female condom
C. Oral contraceptives
D. Rhythm method
4. For which of the following clients would the nurse expect that an intrauterine
device would not be recommended?
A. Woman over age 35
B. Nulliparous woman
C. Promiscuous young adult
D. Postpartum client
5. A client in her third trimester tells the nurse, Im constipated all the time!
Which of the following should the nurse recommend?
A. Daily enemas
B. Laxatives
C. Increased fiber intake
D. Decreased fluid intake
6. Which of the following would the nurse use as the basis for the teaching plan
when caring for a pregnant teenager concerned about gaining too much weight
during pregnancy?
A. 10 pounds per trimester
B. 1 pound per week for 40 weeks
C. pound per week for 40 weeks
D. A total gain of 25 to 30 pounds
7. The client tells the nurse that her last menstrual period started on January 14 and
ended on January 20. Using Nageles rule, the nurse determines her EDD to be
A. September 27
B. October 21
C. November 7
D. December 27
8. When taking an obstetrical history on a pregnant client who states, I had a son
born at 38 weeks gestation, a daughter born at 30 weeks gestation and I lost a baby
at about 8 weeks,the nurse should record her obstetrical history as which of the
following?
A. G2 T2 P0 A0 L2
B. G3 T1 P1 A0 L2
C. G3 T2 P0 A0 L2
D. G4 T1 P1 A1 L2
9. When preparing to listen to the fetal heart rate at 12 weeks gestation, the nurse
would use which of the following?
A. Stethoscope placed midline at the umbilicus
B. Doppler placed midline at the suprapubic region
C. Fetoscope placed midway between the umbilicus and the xiphoid process
D. External electronic fetal monitor placed at the umbilicus
10. When developing a plan of care for a client newly diagnosed with gestational
diabetes, which of the following instructions would be the priority?
A. Dietary intake
B. Medication
C. Exercise
D. Glucose monitoring
11. A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of the
following would be the priority when assessing the client?
A. Glucosuria
B. Depression
C. Hand/face edema
D. Dietary intake
12. A client 12 weeks pregnant come to the emergency department with abdominal
cramping and moderate vaginal bleeding. Speculum examination reveals 2 to 3 cms
cervical dilation.The nurse would document these findings as which of the
following?
A. Threatened abortion
B. Imminent abortion
C. Complete abortion
D. Missed abortion
13. Which of the following would be the priority nursing diagnosis for a client with
an ectopic pregnancy?
A. Risk for infection
B. Pain
C. Knowledge Deficit
D. Anticipatory Grieving
14. Before assessing the postpartum clients uterus for firmness and position in
relation to the umbilicus and midline, which of the following shouldthe nurse do
first?
A. Assess the vital signs

B. Administer analgesia
C. Ambulate her in the hall
D. Assist her to urinate
15. Which of the following should the nurse do when a primipara who is lactating
tells the nurse that she has sore nipples?
A. Tell her to breast feed more frequently
B. Administer a narcotic before breast feeding
C. Encourage her to wear a nursing brassiere
D. Use soap and water to clean the nipples
16. The nurse assesses the vital signs of a client, 4 hours postpartum that are as
follows: BP 90/60; temperature 100.4F; pulse 100 weak, thready; R 20 per minute.
Which of the following shouldthe nurse do first?
A. Report the temperature to the physician
B. Recheck the blood pressure with another cuff
C. Assess the uterus for firmness and position
D. Determine the amount of lochia
17. The nurse assesses the postpartum vaginal discharge (lochia) on four clients.
Which of the following assessments would warrant notification of the physician?
A. A dark red discharge on a 2-day postpartum client
B. A pink to brownish discharge on a client who is 5 days postpartum
C. Almost colorless to creamy discharge on a client 2 weeks after delivery
D. A bright red discharge 5 days after delivery
18. A postpartum client has a temperature of 101.4F, with a uterus that is tender
when palpated, remains unusually large, and not descending as normally expected.
Which of the following shouldthe nurse assess next?
A. Lochia
B. Breasts
C. Incision
D. Urine
19. Which of the following is the priority focus of nursing practice with the current
early postpartum discharge?
A. Promoting comfort and restoration of health
B. Exploring the emotional status of the family
C. Facilitating safe and effective self-and newborn care

D. Teaching about the importance of family planning
20. Which of the following actions would be least effective in maintaining a neutral
thermal environment for the newborn?
A. Placing infant under radiant warmer after bathing
B. Covering the scale with a warmed blanket prior to weighing
C. Placing crib close to nursery window for family viewing
D. Covering the infants head with a knit stockinette
21. A newborn who has an asymmetrical Moro reflex response should be further
assessed for which of the following?
A. Talipes equinovarus
B. Fractured clavicle
C. Congenital hypothyroidism
D. Increased intracranial pressure
22. During the first 4 hours after a male circumcision, assessing for which of the
following is the priority?
A. Infection
B. Hemorrhage
C. Discomfort
D. Dehydration
23. The mother asks the nurse. Whats wrong with my sons breasts? Why are they
so enlarged? Whish of the following would be the best response by the nurse?
A. The breast tissue is inflamed from the trauma experienced with birth
B. A decrease in material hormones present before birth causes enlargement,
C. You should discuss this with your doctor. It could be a malignancy
D. The tissue has hypertrophied while the baby was in the uterus
24. Immediately after birth the nurse notes the following on a male newborn:
respirations 78; apical hearth rate 160 BPM, nostril flaring; mild intercostal
retractions; and grunting at the end of expiration. Which of the following shouldthe
nurse do?
A. Call the assessment data to the physicians attention
B. Start oxygen per nasal cannula at 2 L/min.
C. Suction the infants mouth and nares
D. Recognize this as normal first period of reactivity
25. The nurse hears a mother telling a friend on the telephone about umbilical cord
care. Which of the following statements by the mother indicates effective teaching?
A. Daily soap and water cleansing is best
B. Alcohol helps it dry and kills germs
C. An antibiotic ointment applied daily prevents infection
D. He can have a tub bath each day
26. A newborn weighing 3000 grams and feeding every 4 hours needs 120
calories/kg of body weight every 24 hours for proper growth and development. How
many ounces of 20 cal/oz formula should this newborn receive at each feeding to
meet nutritional needs?
A. 2 ounces
B. 3 ounces
C. 4 ounces
D. 6 ounces
27. The postterm neonate with meconium-stained amniotic fluid needs care
designed to especially monitor for which of the following?
A. Respiratory problems
B. Gastrointestinal problems
C. Integumentary problems
D. Elimination problems
28. When measuring a clients fundal height, which of the following techniques
denotes the correct method of measurement used by the nurse?
A. From the xiphoid process to the umbilicus
B. From the symphysis pubis to the xiphoid process
C. From the symphysis pubis to the fundus
D. From the fundus to the umbilicus
29. A client with severe preeclampsia is admitted with of BP 160/110, proteinuria,
and severe pitting edema. Which of the following would be most important to
include in the clients plan of care?
A. Daily weights
B. Seizure precautions
C. Right lateral positioning
D. Stress reduction
30. A postpartum primipara asks the nurse, When can we have sexual intercourse
again? Which of the following would be the nurses best response?
A. Anytime you both want to.
B. As soon as choose a contraceptive method.
C. When the discharge has stopped and the incision is healed.
D. After your 6 weeks examination.
31. When preparing to administer the vitamin K injection to a neonate, the nurse
would select which of the following sites as appropriate for the injection?
A. Deltoid muscle
B. Anterior femoris muscle
C. Vastus lateralis muscle
D. Gluteus maximus muscle
32. When performing a pelvic examination, the nurse observes a red swollen area
on the right side of the vaginal orifice. The nurse would document this as
enlargement of which of the following?
A. Clitoris
B. Parotid gland
C. Skenes gland
D. Bartholins gland
33. To differentiate as a female, the hormonal stimulation of the embryo that must
occur involves which of the following?
A. Increase in maternal estrogen secretion
B. Decrease in maternal androgen secretion
C. Secretion of androgen by the fetal gonad
D. Secretion of estrogen by the fetal gonad
34. A client at 8 weeks gestation calls complaining of slight nausea in the morning
hours. Which of the following client interventions should the nurse question?
A. Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water
B. Eating a few low-sodium crackers before getting out of bed
C. Avoiding the intake of liquids in the morning hours
D. Eating six small meals a day instead of thee large meals
35. The nurse documents positive ballottement in the clients prenatal record. The
nurse understands that this indicates which of the following?
A. Palpable contractions on the abdomen
B. Passive movement of the unengaged fetus

C. Fetal kicking felt by the client
D. Enlargement and softening of the uterus
36. During a pelvic exam the nurse notes a purple-blue tinge of the cervix. The
nurse documents this as which of the following?
A. Braxton-Hicks sign
B. Chadwicks sign
C. Goodells sign
D. McDonalds sign
37. During a prenatal class, the nurse explains the rationale for breathing
techniques during preparation for labor based on the understanding that breathing
techniques are most important in achieving which of the following?
A. Eliminate pain and give the expectant parents something to do
B. Reduce the risk of fetal distress by increasing uteroplacental perfusion
C. Facilitate relaxation, possibly reducing the perception of pain
D. Eliminate pain so that less analgesia and anesthesia are needed
38. After 4 hours of active labor, the nurse notes that the contractions of a
primigravida client are not strong enough to dilate the cervix. Which of the following
would the nurse anticipate doing?
A. Obtaining an order to begin IV oxytocin infusion
B. Administering a light sedative to allow the patient to rest for several hour
C. Preparing for a cesarean section for failure to progress
D. Increasing the encouragement to the patient when pushing begins
39. A multigravida at 38 weeks gestation is admitted with painless, bright red
bleeding and mild contractions every 7 to 10 minutes. Which of the following
assessments should be avoided?
A. Maternal vital sign
B. Fetal heart rate
C. Contraction monitoring
D. Cervical dilation
40. Which of the following would be the nurses most appropriate response to a
client who asks why she must have a cesarean delivery if she has a complete
placenta previa?
A. You will have to ask your physician when he returns.
B. You need a cesarean to prevent hemorrhage.
C. The placenta is covering most of your cervix.

D. The placenta is covering the opening of the uterus and blocking your baby.
41. The nurse understands that the fetal head is in which of the following positions
with a face presentation?
A. Completely flexed
B. Completely extended
C. Partially extended
D. Partially flexed
42. With a fetus in the left-anterior breech presentation, the nurse would expect the
fetal heart rate would be most audible in which of the following areas?
A. Above the maternal umbilicus and to the right of midline
B. In the lower-left maternal abdominal quadrant
C. In the lower-right maternal abdominal quadrant
D. Above the maternal umbilicus and to the left of midline
43. The amniotic fluid of a client has a greenish tint. The nurse interprets this to be
A. Lanugo
B. Hydramnio
C. Meconium
D. Vernix
44. A patient is in labor and has just been told she has a breech presentation. The
nurse should be particularly alert for which of the following?
A. Quickening
B. Ophthalmia neonatorum
C. Pica
D. Prolapsed umbilical cord
45. When describing dizygotic twins to a couple, on which of the following would the
nurse base the explanation?
A. Two ova fertilized by separate sperm
B. Sharing of a common placenta
C. Each ova with the same genotype
D. Sharing of a common chorion
46. Which of the following refers to the single cell that reproduces itself after
conception?
A. Chromosome
B. Blastocyst
C. Zygote
D. Trophoblast
47. In the late 1950s, consumers and health care professionals began challenging
the routine use of analgesics and anesthetics during childbirth. Which of the
following was an outgrowth of this concept?
A. Labor, delivery, recovery, postpartum (LDRP)
B. Nurse-midwifery
C. Clinical nurse specialist
D. Prepared childbirth
48. A client has a midpelvic contracture from a previous pelvic injury due to a motor
vehicle accident as a teenager. The nurse is aware that this could prevent a fetus
from passing through or around which structure during childbirth?
A. Symphysis pubis
B. Sacral promontory
C. Ischial spines
D. Pubic arch
49. When teaching a group of adolescents about variations in the length of the
menstrual cycle, the nurse understands that the underlying mechanism is due to
variations in which of the following phases?
A. Menstrual phase
B. Proliferative phase
C. Secretory phase
D. Ischemic phase
50. When teaching a group of adolescents about male hormone production, which of
the following would the nurse include as being produced by the Leydig cells?
A. Follicle-stimulating hormone
B. Testosterone
C. Leuteinizing hormone
D. Gonadotropin releasing hormone
View Answers and Rationale
Answer and Rationale- Maternal and Child

Health Practice Test Part 2
Maternity Nursing Test II
Answer and Rationale- Maternity Nursing Test II

1. Answer: (B) Maternal cardiac condition

In general, when the heart is compromised such as in maternal cardiac condition, the condition
to the placenta which provides the fetus with the essential nutrients and oxygen. Thus if the blo
hypoxia leading to a small-for-gestational age condition.
2. Answer: (A) 21-24 weeks

Viability means the capability of the fetus to live/survive outside of the uterine environment. Wi
weeks AOG is considered as the minimum fetal age for viability.
3. Answer: (A) Article II section 12

The Philippine Constitution of 1987 guarantees the right of the unborn child from conception eq
Section 12.
4. Answer: (B) Abortion is both immoral and illegal in our country

Induced Abortion is illegal in the country as stated in our Penal Code and any person who perfor
by 10-12 years of imprisonment.
5. Answer: (C) To make the delivery effort free and the mother does not need to push
Forceps delivery under epidural anesthesia will make the delivery process less painful and requ
more effort which a compromised heart may not be able to endure.
6. Answer: (D) Uterine contractions are strong and the baby will not be delivered yet
Narcotic analgesics must be given when uterine contractions are already well established so tha
protracting labor. Also, it should be given when delivery of fetus is imminent or too close becaus
effect of the drug that can pass through placental barrier.
7. Answer: (C) The active phase of Stage 1 is protracted

The active phase of Stage I starts from 4cm cervical dilatation and is expected that the uterus w
already 2 hours, the dilatation is expected to be already 8 cm. Hence, the active phase is protra
8. Answer: (B) Strongly tugging on the umbilical cord to deliver the placenta and has
When the placenta is still attached to the uterine wall, tugging on the cord while the uterus is re
on the cord when placenta has detached is alright in order to help deliver the placenta that is a
9. Answer: (B) Determine if cord compression followed the rupture

After the rupture of the bag of waters, the cord may also go with the water because of the press
cervical opening, before the head is delivered (cephalic presentation), the head can compress o
detected through the fetal heart tone. Thus, it is essential do check the FHB right after rupture o
by the fetal head.
10. Answer: (D) Hemorrhage secondary to uterine atony

All the signs in the stem of the question are signs of hemorrhage. If the fundus is soft and boun
could be uterine atony.
61. Answer: (C) The pre-contraction FHR is 130 bpm, FHR during contraction is 118 b
The normal range of FHR is 120-160 bpm, strong and regular. During a contraction, the FHR usu
rate after the contraction ends.
12. Answer: (D) 1,2,3,4

all the above conditions can occur following a precipitate labor and delivery of the fetus becaus
passageway. If the presentation is cephalic, the fetal head serves as the main part of the fetus t
cranial hematoma, and possible compression of cord may occur which can lead to less blood an
passageway (cervix, vaginal canal and perineum) did not have enough time to stretch which ca
13. Answer: (C) Uterine contraction

Uterine contraction is the primary force that will expel the fetus out through the birth canal Mat
power/force that will help push the fetus out.
14. Answer: (C) Put the tip of the fingers lightly on the fundal area and try to indent t
contraction
In monitoring the intensity of the contraction the best place is to place the fingertips at the fund
and the fingertips are more sensitive than the palm of the hand.
15. Answer: (B) From the beginning of one contraction to the beginning of the next co
Frequency of the uterine contraction is defined as from the beginning of one contraction to the
16. Answer: (B) Acme
Acme is the technical term for the highest point of intensity of a uterine contraction.
17. Answer: (A) The beginning of one contraction to the end of the same contraction
Duration of a uterine contraction refers to one contraction. Thus it is correctly measure from the
contraction and not of another contraction.
18. Answer: (A) Clear as water

The normal color of amniotic fluid is clear like water. If it is yellowish, there is probably Rh incom
meconium stained.
19. Answer: (C) Cover the prolapse cord with sterile gauze wet with sterile NSS and p
The correct action of the nurse is to cover the cord with sterile gauze wet with sterile NSS. Obse
infection. The cord has to be kept moist to prevent it from drying. Dont attempt to put back the
positioning the mother either on trendellenberg or sims position
20.Answer: (A) The heart rate will decelerate during a contraction and then go back t
The normal fetal heart rate will decelerate (go down) slightly during a contraction because of th
rate should go back to the pre-contraction rate as soon as the contraction is over since the com
21. Answer: (B) Descent, flexion, internal rotation, extension, external rotation
The mechanism of fetal delivery begins with descent into the pelvic inlet which may occur seve
Flexion, internal rotation and extension are mechanisms that the fetus must perform as it accom
rotation is done after the head is delivered so that the shoulders will be easily delivered through
22. Answer: (B) No part of the cord is encircling the babys neck
The nurse should check right away for possible cord coil around the neck because if it is presen
will have difficulty being delivered.
23.Answer: (A) Suction the nose and mouth to remove mucous secretions
Suctioning the nose and mouth of the fetus as soon as the head is delivered will remove any ob
breathing. Also, if mucus is in the nose and mouth, aspiration of the mucus is possible which ca
the babys head has come out as given in the situation.)
24. Answer: (D) Paint the inner thighs going towards the perineal area
Painting of the perineal area in preparation for delivery of the baby must always be done but th
the thighs. The perineal area is the one being prepared for the delivery and must be kept clean
25. Answer: (A) 1 and 3

The nurse after delivering the placenta must ensure that all the cotyledons and the membranes
check if the umbilical cord is normal which means it contains the 3 blood vessels, 2 veins and 1
26. Answer: (B) The duration of contraction progressively lengthens over time
In false labor, the contractions remain to be irregular in intensity and duration while in true labo
frequent.
27. Answer: (D) Flexibility of the pelvis

The pelvis is a bony structure that is part of the passageway but is not flexible. The lower uterin
canal and introitus are all part of the passageway in the delivery of the fetus.
28. Answer: (A) 2 arteries and 1 vein
The umbilical cord is composed of 2 arteries and 1 vein.
29. Answer: (A) Stage 1

In stage 1 during a normal vaginal delivery of a vertex presentation, the multigravida may have
to 12 hours labor.
30. Answer: (C) Begins with complete dilatation and effacement of cervix and ends w
Stage 2 of labor and delivery process begins with full dilatation of the cervix and ends with the
and ends with full dilatation and effacement of the cervix.
31. Answer: (D) Mother feels like bearing down
Placental detachment does not require the mother to bear down. A normal placenta will detach
32. Answer: (A) Schultze

There are 2 mechanisms possible during the delivery of the placenta. If the shiny portion comes
the meaty portion comes out first, it is called the Duncan mechanism.
33. Answer: (C) Check if there is cord coiled around the neck
The nurse should check if there is a cord coil because the baby will not be delivered safely if the
be done seconds after you have ensured that there is no cord coil but suctioning of the nose sh
nasal obligate breather. If the nose is suctioned first before the mouth, the mucus plugging th
34. Answer: (B) Ritgens technique

Ritgens technique is done to prevent perineal tear. This is done by the nurse by support the pe
downard with one hand while the other hand is supporting the babys head as it goes out of the
35. Answer: (D) Retractor

For normal vaginal delivery, the nurse needs only the instruments for cutting the umbilical cord
scissors as well as the kidney basin to receive the placenta. The retractor is not part of the basi
forceps are added especially if the woman delivering the baby is a primigravida wherein episiot
36. Answer: (A) Inspect the placenta for completeness including the membranes
The placenta must be inspected for completeness to include the membranes because an incom
placental fragments which can lead to uterine atony. If the uterus does not contract adequately
37. Answer: (B) Oxytocin can make the cervix close and thus trap the placenta inside
The action of oxytocin is to make the uterus contract as well make the cervix close. If it is given
inside because the action of the drug is almost immediate if given parentally.
38. Answer: (A) There is a fluid shift from the placental circulation to the maternal cir
heart.
During the pregnancy, there is an increase in maternal blood volume to accommodate the need
delivered, there is a fluid shift back to the maternal circulation as part of physiologic adaptation
fluid shift occurs faster because the placenta is taken out right after the baby is delivered giving
39. Answer: (B) Pitocin

The common oxytocin given to enhance uterine contraction is pitocin. This is also the drug give
40. Answer: (B) Fluid intake and output

Partograph is a monitoring tool designed by the World Health Organization for use by health wo
high risk ones. For maternal parameters all of the above is placed in the partograph except the
sheet.
41. Answer: (C) Ritgens maneuver

Ritgens method is used to prevent perineal tear/laceration during the delivery of the fetal head
method and Dick-Read method are commonly known natural childbirth procedures which advoc
labor pain.
42. Answer: (B) Full bladder

Full bladder can impede the descent of the fetal head. The nurse can readily manage this proble
43. Answer: (B) During a uterine contraction

The primary power of labor and delivery is the uterine contraction. This should be augmented b
44. Answer: (A) 1.2 cm./hr

For nullipara the normal cervical dilatation should be 1.2 cm/hr. If it is less than that, it is consid
multipara, the normal cervical dilatation is 1.5 cm/hr.
45. Answer: (B) Station 0

Station is defined as the relationship of the fetal head and the level of the ischial spine. At the le
ischial spine it is considered (-) station and below the ischial spine it is (+) station.
46. Answer: (A) LOA

The landmark used in determine fetal position is the posterior fontanel because this is the neare
(O) at the left (L) side of the mother and at the upper/anterior (A) quadrant then the fetal positi
47. Answer: (D) Incomplete

Breech presentation means the buttocks of the fetus is the presenting part. If it is only the foot/
frank breech. If both the feet and the buttocks are presenting it is called complete breech.
48. Answer: (C) Floating

The term floating means the fetal presenting part has not entered/descended into the pelvic inl
to be engaged.
49. Answer: (B) 30 minutes

The placenta is delivered within 30 minutes from the delivery of the baby. If it takes longer, prob
need to refer already to the obstetrician.
50. Answer: (A) Under breast to mid-thigh including the pubic area
Shaving is done to prevent infection and the area usually shaved should sufficiently cover the a
definitely to be included in the shaving

Maternity Nursing- Test III
1. Postpartum Period:
The fundus of the uterus is expected to go down normally postpartally about __ cm per day.
A.1.0 cm
B.2.0 cm
C.2.5 cm
D.3.0 cm
2. The lochia on the first few days after delivery is characterized as
A.Pinkish with some blood clots

B.Whitish with some mucus
C.Reddish with some mucus
D.Serous with some brown tinged mucus
3. Lochia normally disappears after how many days postpartum?
A.5 days
B.7-10 days
C.18-21 days
D.28-30 days
4. After an Rh(-) mother has delivered her Rh (+) baby, the mother is given RhoGam. This is done
A.Prevent the recurrence of Rh(+) baby in future pregnancies

B.Prevent the mother from producing antibodies against the Rh(+) antigen that she may have go
C.Ensure that future pregnancies will not lead to maternal illness
D.To prevent the newborn from having problems of incompatibility when it breastfeeds
5. To enhance milk production, a lactating mother must do the following interventions EXCEPT:
A.Increase fluid intake including milk
B.Eat foods that increases lactation which are called galactagues
C.Exercise adequately like aerobics
D.Have adequate nutrition and rest
6. The nursing intervention to relieve pain in breast engorgement while the mother continues to
A.Apply cold compress on the engorged breast
B.Apply warm compress on the engorged breast
C.Massage the breast
D.Apply analgesic ointment
7. A woman who delivered normally per vagina is expected to void within ___ hours after delivery
A.3 hrs
B.4 hrs.
C.6-8 hrs
D.12-24 hours
8. To ensure adequate lactation the nurse should teach the mother to:
A.Breast feed the baby on self-demand day and night
B.Feed primarily during the day and allow the baby to sleep through the night
C.Feed the baby every 3-4 hours following a strict schedule
D.Breastfeed when the breast are engorged to ensure adequate supply
9. An appropriate nursing intervention when caring for a postpartum mother with thrombophlebit
A.Encourage the mother to ambulate to relieve the pain in the leg

B.Instruct the mother to apply elastic bondage from the foot going towards the knee to improve v
C.Apply warm compress on the affected leg to relieve the pain
D.Elevate the affected leg and keep the patient on bedrest
10. The nurse should anticipate that hemorrhage related to uterine atony may occur postpartally
A.Excessive analgesia was given to the mother
B.Placental delivery occurred within thirty minutes after the baby was born
C.An episiotomy had to be done to facilitate delivery of the head
D.The labor and delivery lasted for 12 hours
11. According to Rubins theory of maternal role adaptation, the mother will go through 3 stages
A.Going through, adjustment period, adaptation period
B.Taking-in, taking-hold and letting-go
C.Attachment phase, adjustment phase, adaptation phase
D.Taking-hold, letting-go, attachment phase
12. The neonate of a mother with diabetes mellitus is prone to developing hypoglycemia because
A.The pancreas is immature and unable to secrete the needed insulin

B.There is rapid diminution of glucose level in the babys circulating blood and his pancreas is no
C.The baby is reacting to the insulin given to the mother
D.His kidneys are immature leading to a high tolerance for glucose
13. Which of the following is an abnormal vital sign in postpartum?
A.Pulse rate between 50-60/min
B.BP diastolic increase from 80 to 95mm Hg
C.BP systolic between 100-120mm Hg
D.Respiratory rate of 16-20/min
14. The uterine fundus right after delivery of placenta is palpable at
A.Level of Xyphoid process
B.Level of umbilicus
C.Level of symphysis pubis

D.Midway between umbilicus and symphysis pubis
15. After how many weeks after delivery should a woman have her postpartal check-up based on
A.2 weeks
B.3 weeks
C.6 weeks
D.12 weeks
16. In a woman who is not breastfeeding, menstruation usually occurs after how many weeks?
A.2-4 weeks
B.6-8 weeks
C.6 months
D.12 months
17. The following are nursing measures to stimulate lactation EXCEPT
A.Frequent regular breast feeding
B.Breast pumping
C.Breast massage
D.Application of cold compress on the breast
18. When the uterus is firm and contracted after delivery but there is vaginal bleeding, the nurse
A.Laceration of soft tissues of the cervix and vagina
B.Uterine atony
C.Uterine inversion
D.Uterine hypercontractility
19. The following are interventions to make the fundus contract postpartally EXCEPT
A.Make the baby suck the breast regularly
B.Apply ice cap on fundus
C.Massage the fundus vigorously for 15 minutes until contracted
D.Give oxytocin as ordered
20. The following are nursing interventions to relieve episiotomy wound pain EXCEPT
A.Giving analgesic as ordered
B.Sitz bath
C.Perineal heat
D.Perineal care
21. Postpartum blues is said to be normal provided that the following characteristics are present.
1. Within 3-10 days only;
2. Woman exhibits the following symptoms- episodic tearfulness, fatigue, oversensitivity, poor ap
3. Maybe more severe symptoms in primpara
A.All of the above
B.1 and 2
C.2 only
D.2 and 3
22. The neonatal circulation differs from the fetal circulation because
A.The fetal lungs are non-functioning as an organ and most of the blood in the fetal circulation is
B.The blood at the left atrium of the fetal heart is shunted to the right atrium to facilitate its pass
C.The blood in left side of the fetal heart contains oxygenated blood while the blood in the right s
D.None of the above
23. The normal respiration of a newborn immediately after birth is characterized as:
A.Shallow and irregular with short periods of apnea lasting not longer than 15 seconds, 30-60 bre
B.20-40 breaths per minute, abdominal breathing with active use of intercostals muscles
C.30-60 breaths per minute with apnea lasting more than 15 seconds, abdominal breathing
D.30-50 breaths per minute, active use of abdominal and intercostal muscles
24. The anterior fontanelle is characterized as:
A.3-4 cm antero-posterior diameter and 2-3 cm transverse diameter, diamond shape
B.2-3 cm antero-posterior diameter and 3-4 cm transverse diameter and diamond shape
C.2-3 cm in both antero-posterior and transverse diameter and diamond shape
D.none of the above
25. The ideal site for vitamin K injection in the newborn is:
A.Right upper arm
B.Left upper arm
C.Either right or left buttocks
D.Middle third of the thigh
26. At what APGAR score at 5 minutes after birth should resuscitation be initiated?
A.1-3
B.7-8
C.9-10
D.6-7
27. Right after birth, when the skin of the babys trunk is pinkish but the soles of the feet and pal
A.Syndactyly
B.Acrocyanosis
C.Peripheral cyanosis
D.Cephalo-caudal cyanosis
28. The minimum birth weight for full term babies to be considered normal is:
A.2,000gms
B.1,500gms
C.2,500gms
D.3,000gms
29. The procedure done to prevent ophthalmia neonatorum is:
A.Marmets technique
B.Credes method
C.Ritgens method
D.Ophthalmic wash
30. Which of the following characteristics will distinguish a postmature neonate at birth?
A.Plenty of lanugo and vernix caseosa
B.Lanugo mainly on the shoulders and vernix in the skin folds
C.Pinkish skin with good turgor
D.Almost leather-like, dry, cracked skin, negligible vernix caseosa
31. According to the Philippine Nursing Law, a registered nurse is allowed to handle mothers in la
1. The pregnancy is normal.;
2. The labor and delivery is uncomplicated;
3. Suturing of perineal laceration is allowed provided the nurse had special training;
4. As a delivery room nurse she is not allowed to insert intravenous fluid unless she had special t
A.1 and 2
B.1, 2, and 3
C.3 and 4
D.1, 2, and 4
32. Birth Control Methods and Infertility:

In basal body temperature (BBT) technique, the sign that ovulation has occurred is an elevation o
A.1.0-1.4 degrees centigrade
B.0.2-0.4 degrees centigrade
C.2.0-4.0 degrees centigrade
D.1.0-4.0 degrees centigrade
33. Lactation Amenorrhea Method(LAM) can be an effective method of natural birth control if
A.The mother breast feeds mainly at night time when ovulation could possibly occur
B.The mother breastfeeds exclusively and regularly during the first 6 months without giving supp
C.The mother uses mixed feeding faithfully
D.The mother breastfeeds regularly until 1 year with no supplemental feedings
34. Intra-uterine device prevents pregnancy by the ff. mechanism EXCEPT
A.Endometrium inflames
B.Fundus contracts to expel uterine contents
C.Copper embedded in the IUD can kill the sperms
D.Sperms will be barred from entering the fallopian tubes
35. Oral contraceptive pills are of different types. Which type is most appropriate for mothers wh
A.Estrogen only
B.Progesterone only
C.Mixed type- estrogen and progesterone
D.21-day pills mixed type
36. The natural family planning method called Standard Days (SDM), is the latest type and easy t
women with regular menstrual cycles between ___ to ___ days.
A.21-26 days
B.26-32 days
C.28-30 days
D.24- 36 days
37. Which of the following are signs of ovulation?
1. Mittelschmerz;
2. Spinnabarkeit;
3. Thin watery cervical mucus;
4. Elevated body temperature of 4.0 degrees centigrade
A.1 & 2
B.1, 2, & 3
C.3 & 4
D.1, 2, 3, 4
38. The following methods of artificial birth control works as a barrier device EXCEPT:
A.Condom
B.Cervical cap
C.Cervical Diaphragm
D.Intrauterine device (IUD)
39. Which of the following is a TRUE statement about normal ovulation?
A.It occurs on the 14th day of every cycle
B.It may occur between 14-16 days before next menstruation
C.Every menstrual period is always preceded by ovulation
D.The most fertile period of a woman is 2 days after ovulation
40. If a couple would like to enhance their fertility, the following means can be done:
1. Monitor the basal body temperature of the woman everyday to determine peak period of fertil
2. Have adequate rest and nutrition;
3. Have sexual contact only during the dry period of the woman;
4. Undergo a complete medical check-up to rule out any debilitating disease
A.1 only
B.1 & 4
C.1,2,4
D.1,2,3,4
41. In sympto-thermal method, the parameters being monitored to determine if the woman is fer
A.Temperature, cervical mucus, cervical consistency
B.Release of ovum, temperature and vagina
C.Temperature and wetness
D.Temperature, endometrial secretion, mucus
42. The following are important considerations to teach the woman who is on low dose (mini-pill)
A.The pill must be taken everyday at the same time

B.If the woman fails to take a pill in one day, she must take 2 pills for added protection
C.If the woman fails to take a pill in one day, she needs to take another temporary method until s
D.If she is breast feeding, she should discontinue using mini-pill and use the progestin-only type
43. To determine if the cause of infertility is a blockage of the fallopian tubes, the test to be done
A.Huhners test
B.Rubins test
C.Postcoital test
D.None of the above
44. Infertility can be attributed to male causes such as the following EXCEPT:
A.Cryptorchidism
B.Orchitis
C.Sperm count of about 20 million per milliliter
D.Premature ejaculation
45. Spinnabarkeit is an indicator of ovulation which is characterized as:
A.Thin watery mucus which can be stretched into a long strand about 10 cm
B.Thick mucus that is detached from the cervix during ovulation
C.Thin mucus that is yellowish in color with fishy odor
D.Thick mucus vaginal discharge influence by high level of estrogen
46. Vasectomy is a procedure done on a male for sterilization. The organ involved in this procedu
A.Prostate gland
B.Seminal vesicle
C.Testes
D.Vas deferens
47. Breast self examination is best done by the woman on herself every month during
A.The middle of her cycle to ensure that she is ovulating

B.During the menstrual period
C.Right after the menstrual period so that the breast is not being affected by the increase in horm
D.Just before the menstrual period to determine if ovulation has occurred
48. A woman is considered to be menopause if she has experienced cessation of her menses for
A.6 months
B.12 months
C.18 months
D.24 months
49. Which of the following is the correct practice of self breast examination in a menopausal wom
A.She should do it at the usual time that she experiences her menstrual period in the past to ens
B.Any day of the month as long it is regularly observed on the same day every month
C.Anytime she feels like doing it ideally every day
D.Menopausal women do not need regular self breast exam as long as they do it at least once ev
50. In assisted reproductive technology (ART), there is a need to stimulate the ovaries to produce
this purpose is:
A.Bromocriptine
B.Clomiphene
C.Provera
D.Esrogen
View Answers and Rationale
Answer and Rationale- Maternity Nursing

test III
1. Answer: (A) 1.0 cm

The uterus will begin involution right after delivery. It is expected to regress/go down by 1 cm. per day and bec
2. Answer: (C) Reddish with some mucus

Right after delivery, the vaginal discharge called lochia will be reddish because there is some blood, endometria
3. Answer: (B) 7-10 days
Normally, lochia disappears after 10 days postpartum. Whats important to remember is that the color of lochia
everyday.
4. Answer: (B) Prevent the mother from producing antibodies against the Rh(+) antigen that she may hav
In Rh incompatibility, an Rh(-) mother will produce antibodies against the fetal Rh (+) antigen which she may h
during labor and delivery. Giving her RhoGam right after birth will prevent her immune system from being perm
5. Answer: (C) Exercise adequately like aerobics

All the above nursing measures are needed to ensure that the mother is in a healthy state. However, aerobics do
6. Answer: (B) Apply warm compress on the engorged breast

Warm compress is applied if the purpose is to relieve pain but ensure lactation to continue. If the purpose is to r
cold.
7. Answer: (C) 6-8 hrs

A woman who has had normal delivery is expected to void within 6-8 hrs. If she is unable to do so after 8 hours
interventions to stimulate spontaneous voiding dont work, the nurse may decide to catheterize the woman.
8. Answer: (A) Breast feed the baby on self-demand day and night
Feeding on self-demand means the mother feeds the baby according to babys need. Therefore, this means there
maintain adequate lactation.
9. Answer: (D) Elevate the affected leg and keep the patient on bedrest
If the mother already has thrombophlebitis, the nursing intervention is bedrest to prevent the possible dislodging
reduce the inflammation.
10. Answer: (A) Excessive analgesia was given to the mother

Excessive analgesia can lead to uterine relaxation thus lead to hemorrhage postpartally. Both B and D are norm
11. Answer: (B) Taking-in, taking-hold and letting-go

Rubins theory states that the 3 stages that a mother goes through for maternal adaptation are: taking-in, takingpassive and dependent on others for care. In taking-hold, the mother begins to assume a more active role in the
adapted to her maternal role.
12. Answer: (B) There is rapid diminution of glucose level in the babys circulating blood and his pancrea
If the mother is diabetic, the fetus while in utero has a high supply of glucose. When the baby is born and is now
glucose from the mother. In the first few hours after delivery, the neonate usually does not feed yet thus this can
13. Answer: (B) BP diastolic increase from 80 to 95mm Hg
All the vital signs given in the choices are within normal range except an increase of 15mm Hg in the diastolic
14. Answer: (B) Level of umbilicus

Immediately after the delivery of the placenta, the fundus of the uterus is expected to be at the level of the umbi
expelled. The fundus is expected to recede by 1 fingerbreadths (1cm) everyday until it becomes no longer palpa
15. Answer: (C) 6 weeks

According to the DOH protocol postpartum check-up is done 6-8 weeks after delivery to make sure complete in
16. Answer: (B) 6-8 weeks

When the mother does not breastfeed, the normal menstruation resumes about 6-8 weeks after delivery. This is
progesterone gradually decrease thus triggering negative feedback to the anterior pituitary to release the Folicle
to again mature a graafian follicle and the menstrual cycle post pregnancy resumes.
17. Answer: (D) Application of cold compress on the breast

To stimulate lactation, warm compress is applied on the breast. Cold application will cause vasoconstriction thu
milk.
18. Answer: (A) Laceration of soft tissues of the cervix and vagina
When uterus is firm and contracted it means that the bleeding is not in the uterus but other parts of the passagew
19. Answer: (C) Massage the fundus vigorously for 15 minutes until contracted
Massaging the fundus of the uterus should not be vigorous and should only be done until the uterus feel firm an
will relax due to over stimulation.
20. Answer: (D) Perineal care

Perineal care is primarily done for personal hygiene regardless of whether there is pain or not; episiotomy woun
21. Answer: (A) All of the above

All the symptoms 1-3 are characteristic of postpartal blues. It will resolve by itself because it is transient and is
adjustment to motherhood. If symptoms lasts more than 2 weeks, this could be a sign of abnormality like postpa
22. Answer: (A) The fetal lungs are non-functioning as an organ and most of the blood in the fetal circula
The fetal lungs is fluid-filled while in utero and is still not functioning. It only begins to function in extra uterin
from the placenta, most of the fetal blood is mixed blood.
23. Answer: (A) Shallow and irregular with short periods of apnea lasting not longer than 15 seconds, 30A newly born baby still is adjusting to xtra uterine life and the lungs are just beginning to function as a respirato
characterized as usually shallow and irregular with short periods of apnea, 30-60 breaths per minute. The apneic
otherwise it will be considered abnormal.
24. Answer: (A) 3-4 cm antero-posterior diameter and 2-3 cm transverse diameter, diamond shape
The anterior fontanelle is diamond shape with the antero-posterior diameter being longer than the transverse dia
25.Answer: (D) Middle third of the thigh

Neonates do not have well developed muscles of the arm. Since Vitamin K is given intramuscular, the site must
26.Answer: (A) 1-3

An APGAR of 1-3 is a sign of fetal distress which requires resuscitation. The baby is alright if the score is 8-10
27. Answer: (B) Acrocyanosis
Acrocyanosis is the term used to describe the babys skin color at birth when the soles and palms are bluish but
28. Answer: (C) 2,500gms
According to the WHO standard, the minimum normal birth weight of a full term baby is 2,500 gms or 2.5 Kg.
29. Answer: (B) Credes method

Credes method/prophylaxis is the procedure done to prevent ophthalmia neonatorum which the baby can acqui
ophthalmic ointment is used.
30. Answer: (D) Almost leather-like, dry, cracked skin, negligible vernix caseosa
A post mature fetus has the appearance of an old person with dry wrinkled skin and the vernix caseosa has alrea
31. Answer: (B) 1, 2, and 3

To be allowed to handle deliveries, the pregnancy must be normal and uncomplicated. And in RA9172, the nurs
has had the special training. Also, in this law, there is no longer an explicit provision stating that the nurse still n
32. Answer: (B) 0.2-0.4 degrees centigrade

The release of the hormone progesterone in the body following ovulation causes a slight elevation of basal body
33. Answer: (B) The mother breastfeeds exclusively and regularly during the first 6 months without givin
A mother who breastfeeds exclusively and regularly during the first 6 months benefits from lactation amenorrhe
of lactation amenorrhea lasts for 6 months provided the woman has not had her first menstruation since delivery
34. Answer: (D) Sperms will be barred from entering the fallopian tubes
An intrauterine device is a foreign body so that if it is inserted into the uterine cavity the initial reaction is to pro
to try to expel the foreign body. Usually IUDs are coated with copper to serve as spermicide killing the sperms
not completely fill up the uterine cavity thus sperms which are microscopic is size can still pass through.
35. Answer: (B) Progesterone only
If mother is breastfeeding, the progesterone only type is the best because estrogen can affect lactation.

Standard Days Method (SDM) requires that the menstrual cycles are regular between 26-32 days. There is no n
method of family planning is very simple since all that the woman pays attention to is her cycle. With the aid of
37. Answer: (B) 1, 2, & 3

Mittelschmerz, spinnabarkeit and thin watery cervical mucus are signs of ovulation. When ovulation occurs, the
elevation of temperature between 0.2-0.4 degrees centigrade and not 4 degrees centigrade.
38. Answer: (D) Intrauterine device (IUD)

Intrauterine device prevents pregnancy by not allowing the fertilized ovum from implanting on the endometrium
not a barrier since the sperms can readily pass through and fertilize an ovum at the fallopian tube.
39. Answer: (B) It may occur between 14-16 days before next menstruation
Not all menstrual cycles are ovulatory. Normal ovulation in a woman occurs between the 14th to the 16th day b
ovulation occurs on the 14th day of the cycle. This is a misconception because ovulation is determined NOT fro
next menstruation.
40. Answer: (C) 1,2,4

All of the above are essential for enhanced fertility except no. 3 because during the dry period the woman is in h
will be no ovulation, thus fertilization is not possible.
41.Answer: (A) Temperature, cervical mucus, cervical consistency

The 3 parameters measured/monitored which will indicate that the woman has ovulated are- temperature increa
and cervical mucus that looks like the white of an egg which makes the woman feel wet.
42. Answer: (B) If the woman fails to take a pill in one day, she must take 2 pills for added protection
If the woman fails to take her usual pill for the day, taking a double dose does not give additional protection. W
is consumed and use at the time another temporary method to ensure that no pregnancy will occur. When a new
temporary method she employed.
43.Answer: (B) Rubins test

Rubins test is a test to determine patency of fallopian tubes. Huhners test is also known as post-coital test to de
sexual partner.
44. Answer: (C) Sperm count of about 20 million per milliliter

Sperm count must be within normal in order for a male to successfully sire a child. The normal sperm count is 2
ejaculate.
45. Answer: (A) Thin watery mucus which can be stretched into a long strand about 10 cm
At the midpoint of the cycle when the estrogen level is high, the cervical mucus becomes thin and watery to allo
fertilize an ovum. This is called spinnabarkeit. And the woman feels wet. When progesterone is secreted by th
dry.
46. Answer: (D) Vas deferens

Vasectomy is a procedure wherein the vas deferens of the male is ligated and cut to prevent the passage of the s
47. Answer: (C) Right after the menstrual period so that the breast is not being affected by the increase in
The best time to do self breast examination is right after the menstrual period is over so that the hormonal level
48. Answer: (B) 12 months

If a woman has not had her menstrual period for 12 consecutive months, she is considered to be in her menopau
49. Answer: (B) Any day of the month as long it is regularly observed on the same day every month
Menopausal women still need to do self examination of the breast regularly. Any day of the month is alright pro
chosen. The hormones estrogen and progesterone are already diminished during menopause so there is no need
50. Answer: (B) Clomiphene

Clomiphene or Clomid acts as an ovarian stimulant to promote ovulation. The mature ova are retrieved and fert
48 hours the fertilized ovum is inserted into the uterus for implantation.

Maternal and Child Health Review Test
A. A term neonate is to be released from hospital at 2 days of age. The nurse

performs a physical examination before discharge.
1. Nurse Valerie examines the neonates hands and palms. Which of the following
findings requires further assessment?
a) Many crease across the palm.
b) Absence of creases on the palm.
c) A single crease on the palm.
d) Two large creases across the palm.
2.The mother asks when the soft spots close? The nurse explains that the
neonates anterior fontanel will normally close by age
a) 2 to 3 months.
b) 6 to 8 months.
c) 12 to 18 months.
d) 20 to 24 months.
3. When performing the physical assessment, the nurse explains to the mother that
in a term neonate, sole creases are
a) Absent near the heels.
b) Evident under the heels only,
c) Spread over the entire foot.
d) Evident only towards the transverse arch.
4. When assessing the neonates eyes, the nurse notes the following: absence of
tears, corneas of unequal size, constriction of the pupils in response to bright light,
and the presence of red circles on the pupils on ophthalmic examination. Which of
these findings needs further assessment?
a) The absence of tears.
b) Corneas of unequal size.
c) Constriction of the pupils.
d) The presence of red circles on the pupils.
5. After teaching the mother about the neonates positive Babinski reflex, the nurse
determines that the mother understands the instructions when she says that a
positive Babinski reflex indicates.
a) Immature muscle coordination.
b) Immature central nervous system.
c) Possible lower spinal cord defect.
d) Possible injury to nerves that innervate the feet.
B. Nurse Kris is responsible for assessing a male neonate approximately 24 hours
old. The neonate was delivered vaginally.
6. The nurse should plan to assess the neonates physical condition.
a) Midway between feedings.

b) Immediately after a feeding.
c) After the neonate has been NPO for three hours.
d) Immediately before a feeding.
7. The nurse notes a swelling on the neonates scalp that crosses the suture line.
The nurse documents this condition as
a) Cephallic hematoma.
b) Caput succedaneum.
c) Hemorrhage edema.
d) Perinatal caput.
8. The nurse measures the circumference of the neonates heads and chest, and
then explains to the mother that when the two measurements are compared, the
head is normally about
a) The same size as the chest.
b) 2 centimeter larger than the chest.
c) 2 centimeter smaller than the chest.
d) 4 centimeter larger than chest.
9. After explaining the neonates cranial molding, the nurse determines that the
mother needs further instructions from which statement?
a) The molding is caused by an overriding of the cranial bones.
b) The degree of molding is related to the amount of pressure on the head.
c) The molding will disappear in a few days.
d) The fontanels maybe damaged if the molding does not resolved quickly.
10. When instructing the mother about the neonates need for sensory and visual
stimulation, the nurse should plan to explain that the most highly develop sense in
the neonate is
a) Task
b) Smell
c) Touch
d) Hearing
C. Nurse Joan works in a childrens clinic and helps with the care for well and ill
children of various ages.
11. A mother brings her 4 month old infant to the clinic. The mother asks the nurse
when she should wean the infant from breastfeeding and begin using a cup. Nurse
Joan should explain that the infant will show readiness to be weaned by
a) Taking solid foods well.

b) Sleeping through the night.
c) Shortening the nursing time.
d) Eating on a regular schedule.
12. Mother Arlene says the infants physician recommends certain foods but the
infant refuses to eat them after breastfeeding. The nurse should suggest that the
mother alter the feeding plan by
a) Offering desert followed by vegetable and meat.
b) Offering breast milk as long as the infant refuses to eat solid food.
c) Mixing minced food with cows milk and feeding it to the infant through a large
hole nipple.
d) Giving the infant a few minutes of breast and then offering solid food.
13. Which of the following abilities would a nurse expect a 4 month old infant to
perform?
a) Sitting up without support.
b) Responding to pleasure with smiles.
c) Grasping a rattle when it is offered.
d) Turning from either side to the back.
14. The nurse plans to administer the Denver Developmental Screening Test (DDST)
to a five month old infant. The nurse should explain to the mother that the test
measures the infants
a) Intelligence quotient.
b) Emotional development.
c) Social and physical activities.
d) Pre-disposition to genetic and allergic illnesses.
15. When discussing a seven month old infants mother regarding the motor skill
development, the nurse should explain that by age seven months, an infant most
likely will be able to
a) Walk with support.
b) Eat with a spoon.
c) Stand while holding unto a furniture
d) Sit alone using the hands for support.
16. A mother brings her one month old infant to the clinic for check-up. Which of the
following developmental achievements would the nurse assess for?
a) Smiling and laughing out loud.
b) Rolling from back to side.

c) Holding a rattle briefly.
d) Turning the head from side to side.
17. A two month old infant is brought to the clinic for the first immunization against
DPT. The nurse should administer the vaccine via what route?
a) Oral.
b) Intramascular
c) Subcutaneous
d) Intradermal
18. The nurse teaches the clients mother about the normal reaction that the infant
might experience 12 to 24 hours after the DPT immunization, which of the following
reactions would the nurse discuss?
a) Lethargy.
b) Mild fever.
c) Diarrhea
d) Nasal Congestion
19. An infant is observed to be competent in the following developmental skills:
stares at an object, place her hands to the mouth and takes it off, coos and gargles
when talk to and sustains part of her own weight when held to in a standing
position. The nurse correctly assessed infants age as
a) Two months.
b) Four months
c) Six months
d) Eight months.
20. The mother says, the soft spot near the front of her babys head is still big,
when will it close? Nurse Lilibeths correct response would be at
a) 2 to 4 months.
b) 5 to 8 months.
c) 9 to 12 months.
d) 13 to 18 months. prop
21. A mother states that she thinks her 9-month old is developing slowly. When
evaluating the infants development, the nurse would not expect a normal 9-month
old to be able to
a) Creep and crawl.
b) Begin to use imitative verbal expressions.
c) Put an arm through a sleeve while being dressed.

d) Hold a bottle with good hand mouth coordination.
22. The mother of the 9-month old says, it is difficult to add new foods to his diet,
he spits everything out, she says. The nurse should teach the mother to
a) Mix new foods with formula
b) Mix new foods with more familiar foods.
c) Offer new foods one at a time.
d) Offer new foods after formula has been offered.
23. Which of the following tasks is typical for an 18-month old baby?
a) Copying a circle
b) Pulling toys
c) Playing toy with other children
d) Building a tower of eight blocks
24. Mother Riza brings her normally developed 3-year old to the clinic for a checkup. The nurse would expect that the child would be at least skilled in
a) Riding a bicycle
b) Tying shoelaces
c) Stringing large beads
d) Using blunt scissors
25. The mother tells the nurse that she is having problem toilet-training her 2-year
old child. The nurse would tell the mother that the number one reason that toilet
training in toddlers fails because the
a) Rewards are too limited
b) Training equipment is inappropriate
c) Parents ignore accidents that occur during training
d) The child is not develop mentally ready to be trained
26. A child is not developmentally ready to be trained. A 2-1/2 year old child is
brought to the clinic by his father who explains that the child is afraid of the dark
and says no when asked to do something. The nurse would explain that the
negativism demonstrated by toddler is frequently an expression of
a) Quest for autonomy
b) Hyperactivity
c) Separation anxiety
d) Sibling rivalry
27. The nurse would explain to the father which concept of Piagets cognitive
development as the basis for the childs fear of darkness?
a) Reversibility
b) Animism
c) Conservation of matter
d) Object permanence
28. Mother asks the nurse for advice about discipline. The nurse would suggest that
the mother would first use
a) Structured interaction
b) Spanking
c) Reasoning
d) Scolding
29. When a nurse assesses for pain in toddlers, which of the following techniques
would be least effective?
a) Ask them about the pain
b) Observe them for restlessness
c) Watch their face for grimness
d) Listen for pain cues in their cries.
30. The mother reports that her child creates a quite scene every night at bedtime
and asks what she can do to make bedtime a little more pleasant. The nurse should
suggest that the mother to
a) Allow the child to stay up later one or two nights a week.
b) Establish a set bedtime and follow a routine
c) Let the child play toy just before bedtime
d) Give the child a cookie if bedtime is pleasant.
31. The mother asks about dental care for her child. She says that she helps brush
the childs teeth daily. Which of the following responses by the nurse would be most
appropriate?
a) Since you help brush her teeth, theres no need to see a dentist now
b) You should have begun dental appointments last year but it is not too late
c) Your child does not need to see the dentist until she starts school
d) A dental check-up is a good idea, even if no noticeable problems are present
32. The mother says that she will be glad to let her child brush her teeth without
help, but at what age should this begin? Nurse Roselyn should respond at
a) 3 years
b) 5 years
c) 6 years
d) 7 years
33. The mother tells the nurse that her other child, a 4-year old boy, has developed
some strange eating habits, including not finishing her meals and eating the same
foods for several days in a row. She would like to develop a plan to connect this
situation. In developing such a plan, the nurse and mother should consider
a) Deciding on a good reward for finishing a meal
b) Allowing him to make some decisions about the foods he eats
c) Requiring him to eat the foods served at meal times.
d) Not allowing him to play with friends until he eats all the food she served.
34. Nurse Bryan knows that one of the most effective strategies to teach a Four
year old about safety is to
a) Show him potential dangers to avoid
b) Tell him he is bad when they do something dangerous
c) Provide good examples of safety behavior
d) Show him pictures of children who have involve with accidents
35. A 9 year old girl is brought to the pediatricians office for an annual physical
checkup. She has no history of significant health problems. When the nurse asks the
girl about her best friend, the nurse is assessing
a) Language development
b) Motor development
c) Neurological development
d) Social development
36. The child probably tells the nurse that brushing and flossing her teeth is her
responsibility. When responding to this information, the nurse should realize that the
child
a) Is too young to be given this responsibility
b) Is most likely quite capable of this responsibility
c) Should have assumed this responsibility much sooner
d) Is probably just exaggerating the responsibility
37. The mother tells the nurse that the child is continually telling jokes and riddles
to the point of driving the other family members crazy. The nurse should explain
that this behavior is a sign of
a) Inadequately parental attention

b) Mastery of language ambiguities
c) Inappropriate peer influence
d) Excessive television watching
38. The mother relates that the child is beginning to identify behaviors that pleases
others as good behavior. The childs behavior is characteristics of which
Kohlbergs level of moral development?
a) Pre-conventional morality
b) Conventional morality
c) Post conventional morality
d) Autonomous morality
39. The mother asks the nurse about the childs apparent need for between-meals
snacks, especially after school. The nurse and mother develop a nutritional plan for
the child, keeping in mind that the child..
a) Does not need to eat between meals
b) Should eat snacks his mother prepares
c) Should help prepare own snacks
d) Will instinctively select nutritional snacks
40. The mother is concerned about the childs compulsion for collecting things. The
nurse explains that this behavior is related to the cognitive ability to perform.
a) Concrete operations
b) Formal operations
c) Coordination of
d) Tertiary circular reactions
41. The nurse explained to the mother that according to Ericksons framework of
psychosocial development, play as a vehicle of development can help the school
age child develop a sense of
a) Initiative
b) Industry
c) Identity
d) Intimacy
42. The school nurse is planning a series of safety and accident prevention classes
for a group of third grades. What preventive measures should the nurse stress
during the first class, knowing the leading cause of incidental injury and death in
this age?
a) Flame-retardant clothing
b) Life preserves
c) Protective eyewear
d) Auto seat belts
43. The mother of a 10-year old boy expresses concern that he is overweight. When
developing a plan of care with the mother, Nurse Katrina should encourage her to
a) Limit childs between-,meal snacks
b) Prohibit the child from playing outside if he eat snacks
c) Include the child in meal planning and preparation
d) Limit the childs calories intake to 1,200kCal/day
44. When assessing an 18-month old, the nurse notes a characteristics protruding
abdomen. Which of the following would explain the rationale for this findings?
a) Increased food intake owing to age
b) Underdeveloped abdominal muscles
c) Bowlegged posture
d) Linear growth curve
45. If parents keep a toddler dependent in areas where he is capable of using skills,
the toddler will develop a sense of which of the following?
a) Mistrust
b) Shame
c) Guilt
d) Inferiority
46. Which of the following fears would the nurse typically associate with
toddlerhood?
a) Mutilation
b) The dark
c) Ghosts
d) Going to sleep
47. A mother of a 2 year old has just left the hospital to check on her other children.
Which of the following would best help the 2 year old who is now crying
inconsolably?
a) Taking a nap
b) Peer play group
c) Large cuddly dog
d) Favorite blanket
48. Which of the following is an appropriate toy for an 18 month old?
a) Multiple-piece puzzle
b) Miniature Cars
c) Finger paints
d) Comic Book
49. When teaching parents about typical toddler eating patterns, which of the
following should be included?
a) Food jags
b) Preference to eat alone
c) Consistent table manners
d) Increase in appetite
50. Which of the following toys should the nurse recommend for a 5-month old?
a) A big red balloon
b) A teddy bear with button eyes
c) A push-pull wooden truck
d) A colorful busy box
View Answers
Answer to Maternal and Child Health Review Test
1. C
2. C
3. C
4. B
5. B
6. A
7. B
8. B
9. B
10. C
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
C
D
A
C
D
D
B
B
B
D
Answer to Maternal and Child Health

Review Test
21.
22.
23.
24.
25.
26.
27.
28.
29.
30.
C
C
B
B
D
A
B
A
A
B
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
D
C
B
C
D
B
B
B
C
A
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
1. C
2. C
3. C
4. B
5. B
6. A
7. B
8. B
9. B
10. C
Answer to Maternal and Child Health Review Test
1. C
2. C
3. C
4. B
5. B
6. A
7. B
8. B
9. B
10. C 11. C
12. D
13. A
14. C
11. C
12. D
13. A
14. C
15. D
16. D
17. B
18. B
19. B
20. D
21. C
22. C
23. B
24. B
25. D
26. A
27. B
28. A
29. A
30. B
31. D
32. C
33. B
34. C
35. D
36. B
37. B
38. B
39. C
40. A
41. B
42. D
43. C
44. B
45. B
46. D
47. D
48. C
49. A
50. D
15. D
16. D
17. B
18. B
19. B
20. D 21. C
22. C
23. B
24. B
25. D
26. A
27. B
28. A
29. A
30. B 31. D
32. C
33. B
34. C
35. D
36. B
37. B
38. B
39. C
40. A 41. B
42. D
43. C
44. B
45. B
46. D
47. D
48. C
49. A
50. D
Topics or concepts included in this exam are:
Venereal Diseases
Placenta Previa
Community health Nursing
HIV/AIDS
Guidelines
Read each question carefully and choose the best answer.
You are given one minute per question. Spend your time wisely!
Answers and rationales (if any) are given below. Be sure to read them.
If you need more clarifications, please direct them to the comments section.
Questions
Text
Practice
Exam
In Text Mode: All questions and answers are given for reading and answering at your own
pace. You can also copy this exam and make a print out.
Situation : Nurse Macarena is a Family Planning and Infertility Nurse Specialist and
currently attends to FAMILY PLANNING CLIENTS AND INFERTILE COUPLES. The following
conditions pertain to meeting the nursing needs of this particular population group.
1. Daphne, 19 years old, asks nurse Macarena how can pregnancy be prevented
through tubal ligation. Which would be the best answer?
A. Prostaglandins released from the cut fallopian tubes will lead to permanent closure of
the vagina.
B. Sperm can not enter the uterus because the cervical entrance is blocked.
C. Sperm can no longer reach the ova, because the fallopian tubes are blocked
D. The ovary no longer releases ova as there is no where for them to go.
2. The Stevens are a couple undergoing testing for infertility. Infertility is said to exist
when:
A. A woman has no uterus
B. A woman has no children
C. A couple has been trying to conceive for 1 year
D. A couple has wanted a child for 6 months
3. Another client named Cindy is diagnosed as having endometriosis. This condition
interferes with fertility because:
A. Endometrial implants can block the fallopian tubes
B. The uterine cervix becomes inflamed and swollen
C. The endometrial lining becomes inflamed leading to narrowing of the cervix.
D. Inflammation of the endometrium causes release of substance P which kills the sperm.
4. Cindy submits herself to Fatima Medical Center and is scheduled to have
a hysterosalpingogram. Which of the following instructions would you give her
regarding this procedure?
A. Menstruation will be irregular for few months as an effect of the dye but it is just
normal
B. The sonogram of the uterus will reveal any tumors present
C. The women may experience some itchiness in the vagina as an after effect.
D. Cramping may be felt when the dye is inserted
5. Cindys cousin on the other hand, knowing nurse Macarenas specialization asks
what artificial insemination by donor entails. Which would be your best answer if you
were Nurse Macarena?
A. Donor sperm are introduced vaginally into the uterus or cervix
B. Donor sperm are injected intra-abdominally into each ovary
C. Artificial sperm are injected vaginally to test tubal patency
D. The husbands sperm is administered intravenously weekly
6. Pain in geriatric clients require careful assessment because they:
A. experienced reduce sensory perception
B. have increased sensory perception
C. are expected to experience chronic pain
D. have a increased pain sensitivity
7. Administration of aminoglycosides to the older persons requires careful patient
assessment because older people:
A. are more sensitive to drugs
B. have increased hepatic, renal and gastrointestinal function
C. have increased sensory perception
D. mobilize drugs more rapidly
8. Elder clients are often at risk of having impaired skin integrity. One factor is that
they often experience urinary incontinence. The elderly patient is at higher risk for
urinary incontinence because of:
A. increased glomerular filtration
B. decrease elasticity of blood vessels
C. decreased bladder capacity
D. dilated urethra
9. Which of the following is the MOST COMMON sign of infection among the elderly?
A. decreased breath sounds with crackles
B. Increase body temperature
C. pain
D. Restlessness, confusion, irritability
10. Prioritization is important to test a nurses good judgment towards different
situations. Priorities when caring for the elderly trauma patient:
A. circulation, airway, breathing
B. disability (neurologic), airway, breathing
C. airway, breathing, disability (neurologic)
D. airway, breathing, circulation
11. The nurse assessing newborn babies and infants during their hospital stay after
birth will notice which of the following symptoms as a primary manifestation of
Achalasia?
A. Olive shaped mass on abdomen
B. Failure to pass meconium during the first 24 to 48 hours after birth
C. The skin turns yellow and then brown over the first 48 hours of life
D. Effortless and non-projectile vomiting
12. A client is 7 months pregnant and has just been diagnosed as having a partial
placenta previa. She is stable and has minimal spotting and is being sent home. Which
of these instructions to the client may indicate a need for further teaching?
A. Maintain bed rest with bathroom privileges
B. Avoid intercourse for three days.
C. Call if contractions occur.
D. Stay on left side as much as possible when lying down.
13. Ms. Anna has been rushed to the hospital with ruptured membrane. Which of the
following should the nurse check first?
A. Check for the presence of infection
B. Assess for Prolapse of the umbilical cord
C. Check the maternal heart rate
D. Assess the color of the amniotic fluid
14. The nurse notes that the infant is wearing a plastic-coated diaper. If a topical
medication were to be prescribed and it were to go on the stomachs or buttocks, the
nurse would teach the caregivers to:
A. avoid covering the area of the topical medication with the diaper
B. avoid the use of clothing on top of the diaper
C. put the diaper on as usual
D. apply an icepack for 5 minutes to the outside of the diaper
15. Which of the following factors is most important in determining the success of
relationships used in delivering nursing care?
A. Type of illness of the client
B. Transference and countertransference
C. Effective communication
D. Personality of the participants
16. Grace sustained a laceration on her leg from automobile accident. Why are
lacerations of lower extremities potentially more serious among pregnant women than
other?
A. lacerations can provoke allergic responses due to gonadotropic hormone release
B. a woman is less able to keep the laceration clean because of her fatigue
C. healing is limited during pregnancy so these will not heal until after birth
D. increased bleeding can occur from uterine pressure on leg veins
17. You are the nurse assigned to work with a child with acute glomerulonephritis. By
following the prescribed treatment regimen, the child experiences a remission. You
are now checking to make sure the child does not have a relapse. Which finding would
most lead you to the conclusion that a relapse is happening?
A. Elevated temperature, cough, sore throat, changing complete blood count (CBC) with
differential
B. A urine dipstick measurement of 2+ proteinuria or more for 3 days, or the child found
to have 3-4+ proteinuria plus edema.
C. The urine dipstick showing glucose in the urine for 3 days, extreme thirst, increase in
urine output, and a moon face.
D. A temperature of 37.8 degrees (100 degrees F), flank pain, burning frequency, urgency
on voiding, and cloudy urine.
18. The painful phenomenon known as back labor occurs in a client whose fetus in
what position?
A. Brow position
B. Right Occipito-Anterior Position
C. Breech position
D. Left Occipito-Posterior Position
19. Which among the following is the primary focus of prevention of cancer?
A. Elimination of conditions causing cancer
B. Diagnosis and treatment
C. Treatment at early stage
D. Early detection
20. In the prevention and control of cancer, which of the following activities is the
most important function of the community health nurse?
A. Conduct community assemblies.
B. Referral to cancer specialist those clients with symptoms of cancer.
C. Use the nine warning signs of cancer as parameters in our process of detection, control
and treatment modalities.
D. Teach women about proper/correct nutrition.
21. Who among the following are recipients of the secondary level of care for cancer
cases?
A. Those under early case detection
B. Those under post case treatment
C. Those scheduled for surgery
D. Those undergoing treatment
22. Who among the following are recipients of the tertiary level of care for cancer
cases?
A. Those under early treatment C. Those under early detection

B. Those under supportive care D. Those scheduled for surgery
23. Being a community health nurse, you have the responsibility of participating in
protecting the health of people. Consider this situation: Vendors selling bread with
their bare hands. They receive money with these hands. You do not see them washing
their hands. What should you say/do?
A. Miss, may I get the bread myself because you have not washed your hands
B. All of these
C. Miss, it is better to use a pick up forceps/ bread tong
D. Miss, your hands are dirty. Wash your hands first before getting the bread
24. A female client asks the nurse about the use of a cervical cap. Which statement is
correct regarding the use of the cervical cap?
A. It may affect Pap smear results.
B. It does not need to be fitted by the physician.
C. It does not require the use of spermicide.
D. It must be removed within 24 hours.
25. The major components of the communication process are:
A. Verbal, written and nonverbal
B. Speaker, listener and reply
C. Facial expression, tone of voice and gestures
D. Message, sender, channel, receiver and feedback
26. The school nurse notices a child who is wearing old, dirty, poor-fitting clothes is
always hungry, has no lunch money, and is always tired. When the nurse asks the boy
his tiredness, he talks of playing outside until midnight. The nurse will suspect that
this child is:
A. Being raised by a parent of low intelligence quotient (IQ)
B. An orphan
C. A victim of child neglect
D. The victim of poverty
Situation: Milo, a 16-year-old male, has been diagnosed to have AIDS. He worked as
entertainer in a cruise ship.
27. Which method of transmission is common to contract AIDS:
A. Syringe and needles
B. Body fluids
C. Sexual contact
B. Transfusion
28. Causative organism in AIDS is one of the following:
A. Fungus
B. Bacteria
C. retrovirus
D. Parasites
29. You are assigned in a private room of Milo. Which procedure should be of utmost
importance?
A. Alcohol wash
B. Universal precaution
C. Washing Isolation
D. Gloving technique
30. What primary health teaching would you give to Milo?
A. Daily exercise
B. Prevent infection
C. Reverse isolation
D. Proper nutrition
31. Exercise precaution must be taken to protect health worker dealing with the AIDS
patients. Which among these must be done as priority:
A. Boil used syringe and needles
B. Use gloves when handling specimen
C. Label personal belonging

D. Avoid accidental wound
Situation: Michelle is a 6 year old preschooler. She was reported by her sister to have
measles but she is at home because of fever, upper respiratory problem and white sports
in her mouth.
32. Rubeola is an Arabic term meaning Red, the rash appears on the skin in invasive
stage prior to eruption behind the ears. As a nurse, your physical examination must
determine complication especially:
A. Otitis media
B. Bronchial pneumonia
C. Inflammatory conjunctiva
D. Membranous laryngitis
33. To render comfort measure is one of the priorities, Which includes care of the
skin, eyes, ears, mouth and nose. To clean the mouth, your antiseptic solution is in
some form of which one below?
A. Water
B. Sulfur
C. Alkaline
D. Salt
34. As a public health nurse, you teach mother and family members the prevention of
complication of measles. Which of the following should be closely watched?
A. Temperature fails to drop
B. Inflammation of the conjunctiva
C. Inflammation of the nasopharynx
D. Ulcerative stomatitis
35. Source of infection of measles is secretion of nose and throat of infection person.
Filterable virus of measles is transmitted by:
A. Water supply
B. Droplet
C. Food ingestion
D. Sexual contact
36. Method of prevention is to avoid exposure to an infected person. Nursing
responsibility for rehabilitation of patient includes the provision of:
A. Terminal disinfection
B. Injection of gamma globulin
C. Immunization
D. Comfort measures
SITUATION: Sexually Transmitted Diseases are important to identify during pregnancy
because of their potential effect on the pregnancy, fetus, or newborn. The following
questions pertain to STDs.
37. Ms. Reynaldita is a promiscuous woman in Manila submits herself to the clinic for
certain examinations. She is experiencing vaginal irritation, redness, and a thick
cream cheese vaginal discharge. As a nurse, you will suspect that Ms. Reynaldita is
having what disease?
A. Gardnerella Vaginalis
B. Candida Albicans
C. Treponema Pallidum
D. Moniliasis
38. As a knowledgeable nurse, you know that the doctor may prescribe a certain
medications for Ms. Reynaldita. What is the drug of choice for Reynalditas infection?
A. haloperidol
B. miconazole
C. benzathine penicillin
D. metronidazole
39. Based on your learnings, you know that the causative agent of Reynalditas
infection is:
A. Monistat Candida
B. Candida Albicans
C. Albopictus Candidiasis
D. Monakiki
40. The microorganism that causes Reynalditas infection is a:
A. Bacteria
B. Protozoa
C. Fungus
D. Virus
41. Another client in the Maternal Clinic was Ms. Celbong. Her doctor examined Ms.
Celbongs vaginal secretions and found out that she has a Trichomoniasis infection.
Trichomoniasis is diagnosed through which of the following method?
A. Vaginal secretions are examined on a wet slide that has been treated with potassium
hydroxide.
B. Vaginal speculum is used to obtain secretions from the cervix.
C. A litmus paper is used to test if the vaginal secretions are infected with trichomoniasis.
D. Vaginal secretions are examined on a wet slide treated with zephiran solution.
42. Daphne who is on her first trimester of pregnancy is also infected with
trichomoniasis. You know that the drug of choice for Daphne is:
A. Flagyl
B. Clotrimazole (topical)
C. Monistat
D. Zovirax
43. Syphilis is another infection that may impose risk during pregnancy. Since we are
under the practice of health science, you know that Syphilis is caused by:
A. Treponema Syphilis
B. Neisseria gonorrhoeae
C. Chlamydia Trachomatis
D. Treponema Pallidum
44. What type of microorganism is the causative agent of syphilis?

A. Spirochete
B. Fungus
C. Bacteria
D. Protozoan
45. Under the second level of prevention, you know that one of the focuses of care is
the screening of diseases. What is the screening test for syphilis?
A. VDRL
B. Western blot
C. PSA
D. ELISA
46. Jarisch-Herxheimer reaction may be experienced by the client with syphilis after
therapy with benzathine penicillin G. The characteristic manifestations of JarischHerxheimer reaction are:
A. Rashes, itchiness, hives and pruritus
B. Confusion, drowsiness and numbness of extremities
C. sudden episode of hypotension, fever, tachycardia, and muscle aches
D. Episodes of nausea and vomiting, with bradypnea and bradycardia
47. A pregnant woman is in the clinic for consultation with regards to STDs. She
inquires about Venereal warts and asks you about its specific lesion appearance.
Which of the following is your correct response to the client?
A. Why are you asking about it? You might be a prostitute woman.
B. The lesions appear as cauliflower like lesions.
C. It appears as pinpoint vesicles surrounded by erythema.
D. The lesions can possibly obstruct the birth canal.
48. Based on your past learnings in communicable diseases, you know that the
causative agent of venereal warts is:
A. Chlamydia Trachomatis
B. Candida Moniliasis
C. Human Papillomavirus
D. Staphylococcus Aureus
49. As a nurse in charge for this woman, you anticipate that the doctor will prescribe
what medication for this type of infection?
A. Podophyllum (Podofin)
B. Flagyl
C. Monistat
D. Trichloroacetic acid
50. Cryocautery may also be used to remove large lesions. The healing period after
cryocautery may be completed in 4-6 weeks but may cause some discomforts to the
woman. What measures can alleviate these discomforts?
A. Kegels Exercise
B. Cool air
C. Topical steroids
D. Sitz baths and lidocaine cream
51. In order to prevent acquiring sexually transmitted diseases, what is the BEST way
to consider?
A. Condom use
B. Withdrawal
C. vasectomy
D. Abstinence
SITUATION: The Gastrointestinal System is responsible for taking in and processing
nutrients for all parts of the body, any problem can quickly affect other body systems
and, if not adequately treated, can affect overall health, growth, and development. The
following questions are about gastrointestinal disorders in a child.
52. Mr. & Mrs. Alcaras brought their son in the hospital for check up. The child has
failure to thrive and was diagnosed with pyloric stenosis. Which among the following
statements are the characteristic manifestations of pyloric stenosis?
A. Vomiting in the early morning
B. Bile containing vomitus immediately after meal
C. sausage shaped mass in the abdomen
D. Projectile vomiting with no bile content
53. The exact cause of pyloric stenosis is unknown, but multifactorial inheritance is
the likely cause. Being knowledgeable about this disease, you know that pyloric
stenosis is more common in which gender?
A. Male
B. Female
C. Incidence is equal for both sexes
D. None of the above
54. To rule out pyloric stenosis, the definitive diagnosis is made by watching the
infant drink. After the infant drinks, what will be the characteristic sign that will
describe pyloric stenosis?
A. An olive-size lump can be palpated
B. There is gastric peristaltic waves from left to right across the abdomen
C. A hypertrophied sphincter can be seen on ultrasound.
D. A tingling sensation is felt on the lower extremities
55. Shey a 10 months old infant was admitted to the hospital for severe abdominal
pain. The doctor found out that the distal ileal segment of the childs bowel has
invaginated into the cecum. The nurse will suspect what disease condition?
A. Intussusception
B. Pyloric stenosis
C. Hirschsprungs disease
D. Vaginismus
56. In intussusceptions, children suddenly draw up their legs and cry as if they are in
severe pain and possibly vomit. Another manifestation of such disease is the presence
of blood in the stool. What is the characteristic stool of client with intussusception?
A. Coffee ground
B. Black and Tarry
C. Currant jelly stool
D. Watery stool
57. A 4-year-old child is hospitalized because of persistent vomiting. As a nurse, you
must monitor the child closely for:
A. Diarrhea
B. Metabolic Acidosis
C. Metabolic Alkalosis
D. Hyperactive bowel sounds
58. A nurse is monitoring for signs of dehydration in a 1-year-old child who has been
hospitalized for diarrhea. The nurse prepares to take the childs temperature and
avoids which method of measurement?
A. Tympanic
B. Axillary
C. Rectal
D. Electronic
59. A home care nurse provides instructions to the mother of an infant with cleft
palate regarding feeding. Which statement if made by the mother indicates a need for
further instructions?
A. I will use a nipple with a small hole to prevent choking.
B. I will stimulate sucking by rubbing the nipple on the lower lip.
C. I will allow the infant time to swallow.
D. I will allow the infant to rest frequently to provide time for swallowing what has been
placed in the mouth.
60. An infant has just returned to the nursing unit following a surgical repair of a cleft
lip located at the right side of the lip. The nurse places the infant in which most
appropriate position?
A. On the right side
B. On the left side
C. Prone
D. Supine
61. A clinic nurse reviews the record of an infant seen in the clinic. The nurse notes
that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is
suspected. The nurse expects to note which most likely sign of this condition
documented in the record?
A. Severe projectile vomiting
B. Coughing at night time
C. Choking with feedings
D. Incessant crying
SITUATION: Human development is one of the important concepts that a nurse should
learn to be able to deal appropriately with their clients of different developmental
stages.
62. Which statement best describes when fertilization occurs?
A. When the spermatozoon passes into the ovum and the nuclei fuse into a single cell.
B. When the ovum is discharged from the ovary near the fimbriated end of the fallopian
tube.
C. When the embryo attaches to the uterine wall.
D. When the sperm and ova undergo developmental changes resulting in a reduction in
the number of chromosomes.
63. A pregnant client asks you about fetal development. At approximately what
gestational age does the fetuss single chambered heart begin to pump its own blood
cells through main blood vessels?
A. 10 weeks
B. 8 weeks
C. 5 weeks
D. 3 weeks
64. At 17 weeks gestation, a fetus isnt considered to be
ballotable. Ballottement means that:
A. The examiner feels rebound movement of the fetus.
B. The examiner feels fetal movement.
C. The client feels irregular, painless uterine contractions.
D. The client feels fetal movement.
65. Which hormone stimulates the development of the ovum?
A. Follicle stimulating hormone (FSH)
B. Human Chorionic Gonadotropin (HCG)
C. Luteinizing Hormone (LH)
D. Gonadotropin Releasing Hormone (GnRH)
66. How long is the gestational period of a full term pregnancy?
A. Ranging from 245 days to 259 days
B. around 5,554 hours to 5,880 hours
C. More than 294 days
D. Averaging of 266 to 294 days
67. An 18 year old woman in her 18th week of pregnancy is being evaluated. Which
positive sign of pregnancy should the nurse expect to be present?
A. Fetal heart tones detectable by Doppler stethoscope
B. Fetal movement detectable by palpation
C. Visualization of the fetus by ultrasound examination.
D. Fetal heart tones detectable by a fetoscope.
68. During her prenatal visit, a 28 year old client expresses concern about nutrition
during pregnancy. She wants to know what foods she should be eating to ensure the
proper growth and development of her baby. Which step should the nurse take first?
A. Give the client a sample diet plan for a 2,400 calorie diet.
B. Emphasize the importance of avoiding salty and fatty foods.
C. Instruct the client to continue to eat a normal diet.
D. Assess the clients current nutritional status by taking a diet history.
69. A nurse is teaching a class about the reproductive system. She explains that
fertilization most often takes place in the:
A. Ovary
B. Fallopian tubes
C. Uterus
D. vagina
70. A large number of neural tube defects may be prevented if a pregnant woman
includes which supplement in her diet?
A. Vit. A
B. Vit. E
C. Vit. D
D. Vit. B9
71. A 22 year old client is at 20 weeks gestation. She asks the nurse about the
development of her fetus at this stage. Which of the following developments occurs at
20 weeks gestation?
A. The pancreas starts producing insulin and the kidneys produce urine.
B. The fetus follows a regular schedule of turning, sleeping, sucking, and kicking.
C. Swallowing reflex has been mastered, and the fetus sucks its thumb.
D. Surfactant forms in the lungs.
SITUATION: Developing countries such as the Philippines suffer from high infant and child
mortality rates. Thus, as a management to the existing problem, the WHO and UNICEF
launched the IMCI.
72. A 6 month old baby Len was brought to the health center because of fever and
cough for 2 days. She weighs 5 kg. Her temperature is 38.5 taken axillary. Further
examination revealed that she has general rashes, her eyes are red and she has mouth
ulcers non deep and non extensive, There was no pus draining from her eyes. Most
probably Baby Len has:
a. Severe complicated measles
b. Fever: No MALARIA
c. Very severe febrile disease
d. Measles
e. Measles with eye or mouth complications
73. The dosage of Vit. A supplement given to Baby Len would be:
a. 100,000 IU
b. 10,000 IU
c. 200,000 IU
d. 20,000 IU
74. Using IMCI Chart, this child can be manage with:
a. Treat the child with paracetamol and follow up in 2 days if the fever persist
b. Give the first dose of antibiotic, give Vit. A, apply Gentian Violet for mouth ulcers and
refer urgently to hospital
c. Give100, 000 international units of Vit. A
d. Give 200, 000 international units of Vit. A
e. Give Vit. A, apply Gentian violet for mouth ulcers and follow up in 2 days
75. The following are signs of severe complicated measles:
a. Clouding of the cornea
b. Deep or extensive mouth ulcers
c. Pus draining from the eyes
d. A and b only
e. All of the above
76. If the child is having 2 weeks ear discharges, how would you classify and treat
the child:
1. Green
2. Yellow
3. Pink
4. Red
5. Dry the ear by wicking
6. 5 days antibiotic
7. Urgent referral with first dose of antibiotic
a. 4,7
b. 2,5,6
c. 1,5
d. 3,7
e. 2,5
77. The following are treatments for acute ear infections:
a. Dry the ear by wicking
b. Give antibiotics for 5 days
c. Follow up in 5 days
d. A and c only
e. All of the above
78. A child with ear problem should be assessed for the following, except:
a. Ear pain
b. If discharge is present for how long?
c. Ear discharge
d. Is there any fever?
e. None of the above
79. If the child does not have ear problem, using IMCI, what should you do as a nurse?
a. Go to the next question, check for malnutrition
b. Check for ear pain
c. Check for tender swelling behind the ear

d. Check for ear discharge
80. An ear discharge that has been present for more than 14 days can be classified as:
a. Complicated ear infection
b. Acute ear infection
c. Chronic ear infection
d. Mastoiditis
81. An ear discharge that has been present for less than 14 days can be classified as:
a. Complicated ear infection
b. Acute ear infection
c. Chronic ear infection
d. Mastoiditis
82. If the child has severe classification because of ear problem, what would be the
best thing that you should do as a nurse?
a. Dry the ear by wicking
b. Give an antibiotic for 5 days
c. Refer urgently
d. Instruct mother when to return immediately
Situation: Primary Health Care (PHC) is defined by the WHO as essential health care made
universally accessible to individuals, families and communities.
83. The WHO held a meeting in this place where Primary health Care was discussed.
What is this place?
A. Alma Ata
B. Russia
C. Vienna
D. Geneva
Situation: The national objective for maintaining the health of all Filipinos is a primary
responsibility of the DOH.
84. The following are mission of the DOH except:
a. Ensure accessibility
b.Quality of health care
c.Health for all Filipinos
d.Quality of Life of all Filipinos
85. The basic principles to achieve improvement in health include all BUT:
a. Universal access to basic health services must be ensured
b. The health and nutrition of vulnerable groups must be prioritized
c. Performance of the health sector must be enhanced
d. Support the frontline workers and the local health system
86. Which of the following is not a primary strategy to achieve health goals:
a. Support of local health system development
b. Development of national standards for health
c. Assurance of health care for all
d. Support the frontline workers
87. According to the WHO health is:
A. state of complete physical, mental and social well being not merely the absence of
disease
B. A science and art of preventing disease and prolonging life
C. A science that deals the optimum level of functioning of the Individual, family and
community
D. All of the above
88. Assistance in physical therapy of a trauma patient is a:
A. Primary level of prevention

B. Secondary level of prevention
C. Tertiary level of prevention
D. Specialized level of prevention
89. Local health boards were established at the provincial, city and municipal levels.
At the municipal level,the chairman of the board is the:
A.Rural Health physician
B.Governor
C.Mayor
D.Chairman of the Committee on Health
90. The emphasis of community health nursing is on:
A. Treatment of health problems
B. Preventing health problems and promoting optimum health
C. Identification and assessment of health problems
D. Illness end of the wellness-illness continuum.
91. In asking the mother about her childs problem the following communication skills
should be used except:
a. Use words that the mother understand
b. Give time for the mother to answer the questions
c. Listen attentively
d. Ask checking questions
92. Which of the following is the principal focus of the CARI program of the
Department of Health?
a. Teach other community health workers how to assess patients
b. Mortality reduction through early detection
c. Teach mothers how to detect signs and where to refer
d. Enhancement of health team capabilities
93. You were able to identify factors that lead to respiratory problems in the
community where your health facility serves. Your primary role therefore in order to
reduce morbidity due to pneumonia is to?
a. Seek assistance and mobilize the BHWs to have a meeting with mothers
b. Refer cases to hospitals
c. Make home visits to sick children
d. Teach mothers how to recognize early signs and symptoms of pneumonia
94. Which of the following is the most important responsibility of a nurse in the
prevention of unnecessary deaths from pneumonia and other severe disease?
a. Weighing of the child
b. Provision of careful assessment
c. Taking of the temperature of the sick child
d. Giving of antibiotics
95. A 4-month-old child was brought to your clinic because of cough and colds. Which
of the following is your primary action?
a. Teach the mother how to count her childs breathing?
b. Refer to the doctor
c. Assess the patient using the chart on management of children with cough
d. Give cotrimoxazole tablet or syrup
e. All of the above
96. In responding to the care concerns to children with severe disease, referral to the
hospital is of the essence especially if the child manifests which of the following?
a. Stopped feeding well
b. Fast breathing
c. Wheezing
d. Difficulty to awaken
SITUATION: Elvira is a 26 year old woman you admit to a birthing room. Shes been having
contractions 45 seconds long and 3 minutes apart for the last 6 hours. She tells you she
wants to have her baby naturally without any analgesia or anesthesia. Her husband is in
the Army and assigned overseas, so he is not with her. Although her sister lives only two
blocks from the hospital, Elvira doesnt want her called. She asks if she can talk to her
mother on the telephone instead.
97. Elvira didnt recognize for over an hour that she was in labor. A sign of true labor
is:
A. Sudden increase energy from epinephrine release
B. Nagging but constant pain in the lower back.
C. Urinary urgency from increased bladder pressure.
D. Show or release of the cervical mucus plug.
98. Elvira asks you which fetal position and presentation are ideal. Your best answer
would be:
A. Right occipitoanterior with full flexion.
B. Left transverse anterior in moderate flexion.
C. Right occipitoposterior with no flexion.
D. Left sacroanterior with full flexion.
99. Elvira is having long and hard uterine contractions. What length of contraction
would you report as abnormal?
A. Any length over 30 seconds.
B. A contraction over 70 seconds in length.
C. A contraction that peaks at 20 seconds.
D. A contraction shorter than 60 seconds.
100. You assess Elviras uterine contractions. In relation to the contraction, when
does a late deceleration begin?
A. Forty-five seconds after the contraction is over.
B. Thirty seconds after the start of a contraction.
C. After every tenth or more contraction.
D. After a typical contraction ends.
Here are the answers for the exam. Unfortunately, rationales are not given. If you need
clarifications or disputes, please direct them to the comments section and well be glad
to give you an explanation.
1.
C. Sperm can no longer reach the ova, because the fallopian tubes are blocked
2.
C. A couple has been trying to conceive for 1 year
3.
A. Endometrial implants can block the fallopian tubes
4.
D. Cramping may be felt when the dye is inserted
5.
A. Donor sperm are introduced vaginally into the uterus or cervix
6.
A. experienced reduce sensory perception
7.
A. are more sensitive to drugs
8.
C. decreased bladder capacity
9.
D. Restlessness, confusion, irritability
10.
D. airway, breathing, circulation
11.
D. Effortless and non-projectile vomiting
12.
B. Avoid intercourse for three days.
13.
B. Assess for Prolapse of the umbilical cord
14.
A. avoid covering the area of the topical medication with the diaper
15.
C. Effective communication
16.
D. increased bleeding can occur from uterine pressure on leg veins
17.
B. A urine dipstick measurement of 2+ proteinuria or more for 3 days, or the child

found to have 3-4+ proteinuria plus edema.
18.
D. Left Occipito-Posterior Position
19.
A. Elimination of conditions causing cancer
20.
A. Conduct community assemblies.
21.
A. Those under early case detection
22.
B. Those under supportive care
23.
C. Miss, it is better to use a pick up forceps/ bread tong
24.
A. It may affect Pap smear results.
25.
D. Message, sender, channel, receiver and feedback
26.
C. A victim of child neglect
27.
C. Sexual contact
28.
C. retrovirus
29.
B. Universal precaution
30.
B. Prevent infection
31.
B. Use gloves when handling specimen
32.
B. Bronchial pneumonia
33.
D. Salt
34.
C. Inflammation of the nasopharynx
35.
B. Droplet
36.
D. Comfort measures
37.
D. Moniliasis
38.
B. miconazole
39.
B. Candida Albicans
40.
C. Fungus
41.
A. Vaginal secretions are examined on a wet slide that has been treated with
potassium hydroxide.
42.
B. Clotrimazole (topical)
43.
D. Treponema Pallidum
44.
A. Spirochete
45.
A. VDRL
46.
C. sudden episode of hypotension, fever, tachycardia, and muscle aches
47.
B. The lesions appear as cauliflower like lesions.
48.
C. Human Papillomavirus
49.
D. Trichloroacetic acid
50.
D. Sitz baths and lidocaine cream
51.
A. Condom use
52.
D. Projectile vomiting with no bile content
53.
A. Male
54.
B. There is gastric peristaltic waves from left to right across the abdomen
55.
A. Intussusception
56.
C. Currant jelly stool
57.
C. Metabolic Alkalosis
58.
C. Rectal
59.
B. I will stimulate sucking by rubbing the nipple on the lower lip.
60.
B. On the left side
61.
A. Severe projectile vomiting
62.
A. When the spermatozoon passes into the ovum and the nuclei fuse into a single
cell.
63.
A. 10 weeks
64.
A. The examiner feels rebound movement of the fetus.
65.
A. Follicle stimulating hormone (FSH)
66.
D. Averaging of 266 to 294 days
67.
C. Visualization of the fetus by ultrasound examination.
68.
D. Assess the clients current nutritional status by taking a diet history.
69.
B. Fallopian tubes
70.
D. Vit. B9
71.
B. The fetus follows a regular schedule of turning, sleeping, sucking, and kicking.
72.
E. Measles with eye or mouth complications
73.
A. 100,000 IU
74.
E. Give Vit. A, apply Gentian violet for mouth ulcers and follow up in 2 days
75.
D. A and b only
76.
E. 2,5
77.
D. A and c only
78.
D. Is there any fever?
79.
A. Go to the next question, check for malnutrition
80.
C. Chronic ear infection
81.
B. Acute ear infection
82.
C. Refer urgently
83.
A. Alma Ata
84.
C. Health for all Filipinos
85.
D. Support the frontline workers and the local health system
86.
E. None of the above
87.
A. State of complete physical, mental and social well being not merely the
absence of disease
88.
C. Tertiary level of prevention
89.
C. Mayor
90.
B. Preventing health problems and promoting optimum health
91.
D. Ask checking questions
92.
B. Mortality reduction through early detection
93.
D. Teach mothers how to recognize early signs and symptoms of pneumonia
94.
B. Provision of careful assessment
95.
C. Assess the patient using the chart on management of children with cough
96.
D. Difficulty to awaken
97.
D. Show or release of the cervical mucus plug.
98.
A. Right occipitoanterior with full flexion.
99.
B. A contraction over 70 seconds in length.
100.
B. Thirty seconds after the start of a contraction.
Introduction
A 100-item examination about Community Health Nursing and Maternal and Child Health Nursing
covering topics like pregnancy, Expanded Program on Immunization (EPI), and Infectious Diseases
that will help you review for your NCLEX or NLE.
Topics
Community Health Nursing
Expanded Program on Immunization
Integrated Management of Childhood Illnesses (IMCI)
Diseases Affecting Pregnancy
Guidelines
Questions
Text
Practice
Exam
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 clients 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 Janna 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 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 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
toddlers 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 infants 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 infants 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, and not curative, services.
17. When the nurse determines whether resources were maximized in implementing
Ligtas Tigdas (Measles Prevention), she is evaluating:
a. Effectiveness
b. Efficiency
c. Adequacy
d. Appropriateness
18. Vangie is a new B.S.N. graduate. She wants to become a Public Health Nurse.
Where should she apply?
a. Department of Health
b. Provincial Health Office
c. Regional Health Office
d. Rural Health Unit
19. Tony is aware the Chairman of the Municipal Health Board is:
a. Mayor
b. Municipal Health Officer
c. Public Health Nurse
d. Any qualified physician
20. Myra is the public health nurse in a municipality with a total population of about
20,000. There are 3 rural health midwives among the RHU personnel. How many more
midwife items will the RHU need?
a. 1
b. 2
c. 3
d. The RHU does not need any more midwife item.
21. According to Freeman and Heinrich, community health nursing is a developmental
service. Which of the following best illustrates this statement?
a. The community health nurse continuously develops himself personally and
professionally.
b. Health education and community organizing are necessary in providing community
health services.
c. Community health nursing is intended primarily for health promotion and prevention
and treatment of disease.
d. The goal of community health nursing is to provide nursing services to people in their
own places of residence.
22. Nurse Tina is aware that the disease declared through Presidential Proclamation
No. 4 as a target for eradication in the Philippines is?
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 communitys resources in dealing with health problems.
d. To maximize the communitys 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 full term 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 infants fluid intake to decrease saturating diapers.
29. Nurse Carla knows that the common cardiac anomalies in children with Down
Syndrome (trisomy 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
c. Blood typing
d. Serum Calcium
33. Nurse Gina is aware that the most common condition found during the secondtrimester 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 mothers arms.
d. A 2 year old infant with stridorous breath sounds, sitting up in his mothers 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 childs 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 womans 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 at least 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 childs hand on the nurses elbow.
c. Walk slightly behind, gently guiding the child forward.
d. Walk next to the child, holding the childs 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 newborns metabolic rate increases.
b. More oxygen, and the newborns metabolic rate decreases.
c. More oxygen, and the newborns metabolic rate increases.
d. Less oxygen, and the newborns metabolic rate decreases.
43. Before adding potassium to an infants I.V. line, Nurse Ron must be sure to assess
whether this infant has:
a. Stable blood pressure
b. Patent fontanelles
c. Moros 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 infants 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 Lynnette 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
chickenpox.
b. A single attack of chickenpox 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. Advise 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-watery 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. Streptococcus pneumoniae
d. Neisseria meningitidis
52. The student nurse is aware that the pathognomonic sign of measles is Kopliks
spot and you may see Kopliks spot by inspecting the:
a. Nasal mucosa
b. Buccal mucosa
c. Skin on the abdomen

d. Skin on neck
53. Angel was diagnosed as having Dengue fever. You will say that there is slow
capillary refill when the color of the nail bed that you pressed does not return within
how many seconds?
a. 3 seconds
b. 6 seconds
c. 9 seconds
d. 10 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
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
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
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
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
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
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.
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
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.
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.
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. 10 year
b. 5 years
c. 3 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 babys 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 neonates 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 hypoxia
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 Myrnas 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
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 newborn.

b. The parents expression of interest about the size of the newborn.
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 clients 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 peri pads 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 shes 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 neonates 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. Shes
diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator.
Which nursing action should be included in the babys 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 physicians 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)
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 Lynnette 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, forcepsassisted delivery of twins. Her labor was unusually long and required oxytocin
(Pitocin) augmentation. The nurse whos caring for her should stay alert for:
a. Uterine inversion
b. Uterine atony
c. Uterine involution
d. Uterine discomfort
Answers & Rationale
Gauge your performance by counter checking your answers to the answers below. Learn
more about the question by reading the rationale. If you have any disputes or questions,
please direct them to the comments section.
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. Answer: (B) History of syphilis
Rationale: Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of
spontaneous abortion.
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. 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
mothers demand for insulin and is referred to as the diabetogenic effect of pregnancy.
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. Answer: (B) Absent patellar reflexes
Rationale: 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.
Rationale: 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 minutes lasting 70-80 seconds.
Rationale: Contractions every 1 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
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. 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. 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. Answer: (D) Place the infants 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 shouldnt be placed in a babys 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.
Rationale: Because feeding requires so much energy, an infant with heart failure should
rest before feeding.
14. Answer: (C) Iron-rich formula only.

Rationale: The infants at age 5 months should receive iron-rich formula and that they
shouldnt receive solid food, even baby food until age 6 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 cant 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, and 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. Answer: (B) Efficiency
Rationale: Efficiency is determining whether the goals were attained at the least possible
cost.
18. Answer: (D) Rural Health Unit
Rationale: R.A. 7160 devolved basic health services to local government units (LGUs ).
The public health nurse is an employee of the LGU.
19. Answer: (A) Mayor
Rationale: The local executive serves as the chairman of the Municipal Health Board.
20. Answer: (A) 1
Rationale: 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.
Rationale: The community health nurse develops the health capability of people through
health education and community organizing activities.
22. Answer: (B) Measles
Rationale: Presidential Proclamation No. 4 is on the Ligtas Tigdas Program.
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. Answer: (D) To maximize the communitys resources in dealing with health
problems.
Rationale: Community organizing is a developmental service, with the goal of developing
the peoples self-reliance in dealing with community health problems. A, B and C are
objectives of contributory objectives to this goal.
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. 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 arent associated with DIC.
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. 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. Answer: (D) Endocardial cushion defect
Rationale: Endocardial cushion defects are seen most in children with Down syndrome,
asplenia, or polysplenia.
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. Answer: (A) Menorrhagia
Rationale: Menorrhagia is an excessive menstrual period.
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 womans 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
Rationale: 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
mothers arms and drooling.
Rationale: The infant with the airway emergency should be treated first, because of the
risk of epiglottitis.
35. Answer: (A) Placenta previa
Rationale: Placenta previa with painless vaginal bleeding.
36. Answer: (D) Early in the morning
Rationale: Based on the nurses 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
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. 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. 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. Answer: (B) Walk one step ahead, with the childs hand on the nurses elbow.
Rationale: This procedure is generally recommended to follow in guiding a person who is
blind.
41. Answer: (A) Loud, machinery-like murmur.
Rationale: A loud, machinery-like murmur is a characteristic finding associated with
patent ductus arteriosus.
42. Answer: (C) More oxygen, and the newborns 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. Answer: (D) Voided
Rationale: Before administering potassium I.V. to any client, the nurse must first check
that the clients 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
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.
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. Answer: (A) The older one gets, the more susceptible he becomes to the
complications of chickenpox.
Rationale: Chickenpox is usually more severe in adults than in children. Complications,
such as pneumonia, are higher in incidence in adults.
47. Answer: (D) Consult a physician who may give them rubella immunoglobulin.
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. 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. 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. Answer: (B) Cholera
Rationale: Passage of profuse watery stools is the major symptom of cholera. Both
amoebic 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) Haemophilus 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. Answer: (B) Buccal mucosa
Rationale: Kopliks spot may be seen on the mucosa of the mouth or the throat.
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. 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, than urgent referral to the hospital is done.
55. Answer: (A) 45 infants
Rationale: To estimate the number of infants, multiply total population by 3%.
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. 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. 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. 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. Answer: (B) Ask where the family resides.
Rationale: Because malaria is endemic, the first question to determine malaria risk is
where the clients 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
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. 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. 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. 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. 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. Answer: (A) 10 years
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. 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.
Rationale: After 6 months, the babys nutrient needs, especially the babys iron
requirement, can no longer be provided by mothers milk alone.

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. 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. 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 neonates 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
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. 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. Answer: (C) Respiratory depression
Rationale: Magnesium sulfate crosses the placenta and adverse neonatal effects are
respiratory depression, hypotonia, and bradycardia. The serum blood sugar isnt affected
by magnesium sulfate. The neonate would be floppy, not jittery.
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. 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 arent 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 isnt recommended.
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. Answer: (B) To assess for prolapsed cord
Rationale: After a client has an amniotomy, the nurse should assure that the cord isnt
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
doesnt indicate an imminent delivery.
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 familys home life but it has no indication for parental bonding.
Willingness to touch and hold the newborn, expressing interest about the newborns 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 peri pads 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. Answer: (C) What is your expected due date?
Rationale: When obtaining the history of a client who may be in labor, the nurses 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 neonates nose and mouth with a bulb syringe.
Rationale: The nurses first action should be to clear the neonates airway with a bulb
syringe. After the airway is clear and the neonates color improves, the nurse should
comfort and calm the neonate. If the problem recurs or the neonates color doesnt
improve readily, the nurse should notify the physician. Administering oxygen when the
airway isnt clear would be ineffective.
83. Answer: (C) Conducting a bedside ultrasound for an amniotic fluid index.
Rationale: It isnt within a nurses 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.
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 infants eyes and humidifying the oxygen dont 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
isnt aggravated.
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. 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 dont 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 theres some growth retardation in twins if they remain
in utero at 38 to 40 weeks.
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 dichorionic 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
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 shouldnt be done
as this may lead to severe bleeding or hemorrhage. External fetal monitoring wont
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
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. 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 isnt needed for blood glucose control in the client with
gestational diabetes.
91. Answer: (D) Seizure
Rationale: The anticonvulsant mechanism of magnesium is believes to depress seizure foci
in the brain and peripheral neuromuscular blockade. Hypomagnesemia isnt a
complication of preeclampsia. Antihypertensive drug other than magnesium are preferred
for sustained hypertension. Magnesium doesnt help prevent hemorrhage in preeclamptic
clients.
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 arent necessary. Diuretic
wouldnt be used unless fluid overload resulted.
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. 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. 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 doesnt cause symptoms. Bacterial vaginosis causes milky white
vaginal discharge but no systemic symptoms.
96. Answer: (B) Rh-positive fetal blood crosses into maternal blood, stimulating
maternal antibodies.
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. Answer: (C) Supine position
Rationale: The supine position causes compression of the clients 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.
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 isnt 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 hasnt been linked to specific congenital
anomalies.
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. 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.
Introduction
Simulated board examination questions with this 100-item examination about the concepts
of Community Health Nursing and Maternal & Child Health Nursing. Preparing for the NLE or
any board examination would be easier with this study guide.
Topics
Integrated Management of Childhood Illnesses (IMCI)
Postpartum Nursing Care
Documentation and Reporting in Nursing
Family Planning
Nursing Laws (Philippines)
Guidelines
Questions
Text
Practice
Exam
Situation 1 Nurse Minette is an independent nurse practitioner following-up referred
clients in their respective homes. Here she handles a case of POSTPARTUM MOTHER AND
FAMILY focusing on HOME CARE.
1. Nurse Minette needs to schedule a first home visit to OB client Leah. When is a first
home-care visit typically made?
a. Within 4 days after discharge
b. Within 24 hours after discharge
c. Within 1 hour after discharge
d. Within 1 week of discharge
2. Leah is developing constipation from being on bed rest. What measures would you
suggest she take to help prevent this?
a. Eat more frequent small meals instead of three large one daily
b. Walk for at least half an hour daily to stimulate peristalsis
c. Drink more milk, increased calcium intake prevents constipation
d. Drink eight full glasses of fluid such as water daily
3. If you were Minette, which of the following actions, would alert you that a new
mother is entering a postpartum at taking-hold phase?
a. She urges the baby to stay awake so that she can breastfeed him in her
b. She tells you she was in a lot of pain all during labor
c. She says that she has not selected a name for the baby as yet
d. She sleeps as if exhausted from the effort of labor
4. At 6-week postpartum visit what should this postpartum mothers fundic height be?
a. Inverted and palpable at the cervix
b. Six fingerbreadths below the umbilicus
c. No longer palpable on her abdomen
d. One centimeter above the symphysis pubis
5. This postpartum mother wants to lose the weight she gained in pregnancy, so she is
reluctant to increase her caloric intake for breast-feeding. By how much should a
lactating mother increase her caloric intake during the first 6 months after birth?
a. 350 kcal/day
b. 5CO kcal/day
c. 200 kcal/day
d. 1,000 kcal/day
Situation 2 As the CPES is applicable for all professional nurse, the professional growth
and development of Nurses with specialties shall be addressed by a Specialty Certification
Council. The following questions apply to these special groups of nurses.
6. Which of the following serves as the legal basis and statute authority for the Board
of nursing to promulgate measures to effect the creation of a Specialty Certification
Council and promulgate professional development programs for this group of nurseprofessionals?
a. R.A. 7610
b. R.A. 223
c. R.A. 9173
d. R.A. 7164
7. By force of law, therefore, the PRC-Board of Nursing released Resolution No. 14
Series of the entitled: Adoption of a Nursing Specialty Certification Program and
Creation of Nursing Specialty Certification Council. This rule-making power is called:
a. Quasi-Judicial Power
b. Regulatory Power
c. Quasi/Legislative Power
d. Executive/Promulgation Power
8. Under the PRC-Board of Nursing Resolution promulgating the adoption of a Nursing
Specialty-Certification Program and Council, which two (2) of the following serves as
the strongest for its enforcement?
(a) Advances made in science and technology have provided the climate for
specialization in almost all aspects of human endeavor and

(b) As necessary consequence, there has emerged a new concept known as
globalization which seeks to remove barriers in trade, industry and services
imposed by the national laws of countries all over the world; and
(c) Awareness of this development should impel the nursing sector to prepare
our people in the services sector to meet .the above challenges; and
(d) Current trends of specialization in nursing practice recognized by; the
International Council of Nurses (ICN) of which the Philippines is a member for the
benefit of the Filipino in terms of deepening and refining nursing practice and
enhancing the quality of nursing care.
a. b & c are strong justification

b. a & b are strong justification
c. a & c are strong justification
d. a & d are strong justification
9. Which of the following is NOT a correct statement as regards Specialty

Certification?
a. The Board of Nursing intended to create the Nursing Specialty Certification Program as
a means of perpetuating the creation of an elite force of Filipino Nurse Professionals.
b. The Board of Nursing shall oversee the administration of the NSCP through the various
Nursing Specialty Boards which will eventually, be created.
c. The Board of Nursing at the time exercised their powers under R.A. 7164 in order to
adopt the creation of the Nursing Specialty Certification /council and Program.
d. The Board of Nursing consulted nursing leaders of national nursing associations and
other concerned nursing groups which later decided to ask a special group of nurses of
the program for nursing specialty certification
10. The NSCC was created for the purpose of implementing the Nursing Specialty
policy under the direct supervision and stewardship of the Board of Nursing. Who
shall comprise the NSCC?
a. A Chairperson who is the current President of the APO a member from .the Academe,
and the last member coming from the Regulatory Board
b. The Chairperson and members of the Regulatory Board ipso facto acts as the CPE
Council
c. A Chairperson, chosen from among the Regulatory Board Members, a Vice Chairperson
appointed by the BON at-large; two other members also chosen at-large; and one
representing the consumer group
d. A Chairperson who is the President of the Association from the Academe; a member
from the Regulatory Board, and the last member coming from the APO
Situation 3 Nurse Anna is a new BSEN graduate and has just passed her Licensure
Examination for Nurses in the Philippines. She has likewise been hired as a new
Community Health Nurse in one of the Rural Health Units in their City, which of the
following conditions may be acceptable TRUTHS applied to Community Health Nursing
Practice.
11. Which of the following is the primary focus of community health nursing practice?
a. Cure of illnesses
b. Prevention of illness
c. Rehabilitation back to health

d. Promotion of health
12. In Community Health Nursing, which of the following is our unit of service as
nurses?
a. The community.
b. The extended members of every family.
c. The individual members of the Barangay.
d. The family.
13. A very important part of the Community Health Nursing Assessment Process
includes:
a. the application of professional judgment in estimating importance of facts to family
and community.
b. evaluation structures arid qualifications of health center team.
c. coordination with other sectors in relation to health concerns.
d. carrying out nursing procedures as per plan of action.
14. In community health nursing it is important to take into account the family health
with an equally important need to perform ocular inspection of the areas activities
which are powerful elements of:
a. evaluation
b. assessment
c. implementation
d. planning
15. The initial step in the PLANNING process in order to engage in any nursing project
or parties at the community level involves:
a. goal-setting
b. monitoring
c. evaluation of data
d. provision of data
Situation 4 Please continue responding as a professional nurse in these other health

situations through the following questions.
16. Transmission of HIV from an infected individual to another person occurs:
a. Most frequency in nurses with needlesticks.
b. Only if there is a large viral load in the blood.
c. Most commonly as a result of sexual contact.
d. In all infants born to women with HIV infection.
17. The medical record of a client reveals a condition in which the fetus cannot pass
through the maternal pelvis. The nurse interprets this as:
a. Contracted pelvis
b. Maternal disproportion
c. Cervical insufficiency
d. Fetopelvic disproportion
18. The nurse would anticipate a cesarean birth for a client who has which infection
present at the onset of labor?
a. Herpes simplex virus
b. Human papillomavirus
c. Hepatitis
d. Toxoplasmosis
19. After a vaginal examination, the nurse determines that the clients fetus is in an
occiput posterior position. The nurse would anticipate that the client will have:
a. A precipitous birth
b. Intense back pain
c. Frequent leg cramps
d. Nausea and vomiting
20. The rationales for using a prostaglandin gel for a client prior to the induction of
labor is to:
a. Soften and efface the cervix

b. Numb cervical pain receptors
c. Prevent cervical lacerations
d. Stimulate uterine contractions
Situation 5 Nurse Lorena is a Family Planning and Infertility Nurse Specialist and is
currently attending to a meeting. The following conditions pertain to meeting the nursing
of this particular population group.
21. Dina, 17 years old, asks you how a tubal ligation prevents pregnancy. Which would
be the best answer?
a. Prostaglandins released from the cut fallopian tubes can kill sperm
b. Sperm cannot enter the uterus, because the cervical entrance is blocked
c. Sperm can no longer reach the ova, because the fallopian tubes are blocked
d. The ovary no longer releases ova, as there is no where for them to go
22. The McMichaels are a couple undergoing testing for infertility. Infertility is said to
exist when:
a. a woman has no uterus
b. a woman has no children
c. a couple has been trying to conceive for 1 year
d. a couple has wanted a child for 6 months
23. Another client names Lilia is diagnosed as having endometriosis. This condition
interferes with the fertility because:
a. endometrial implants can block the fallopian tubes
b. the uterine cervix becomes inflamed and swollen
c. ovaries stop producing adequate estrogen
d. pressure on the pituitary leads to decreased FSH levels
24. Lilia is scheduled to have a hysterosalpingogram. Which of the following,
instructions would you give her regarding this procedure?
a. She will not be able to conceive for 3 months after the procedure
b. The sonogram of the uterus will reveal any tumors present
c. Many women experience mild bleeding as an after effect
d. She may feel some cramping when the dye is inserted
25. Lilias cousin on the other hand, knowing nurse Lorenas specialization asks what
artificial insemination by donor entails. Which would be your best answer if you were
Nurse Lorena?
a. Donor sperm are introduced vaginally into the uterus or cervix
b. Donor sperm are injected intra-abdominally into each ovary
c. Artificial sperm are injected vaginally to test tubal patency
d. The husbands sperm is administered intravenously weekly
Situation 6 There are other important basic knowledge in the performance of our task as
Community Health Nurse in relation to IMMUNIZATION these include:
26. The correct temperature to store vaccines in a refrigerator is:
a. between -4 deg C and +8 deg C
b. between 2 deg C and +8 deg C
c. between -8 deg C and 0 deg C
d. between -8 deg C and +8 deg C
27. Which of the following vaccines is not done by intramuscular (IM) injection?
a. Measles vaccine
b. DPT
c. Hepa B vaccines
d. DPT
28. This vaccine content is derived from RNA recombinants:
a. Measles
b. Tetanus toxoids
c. Hepatitis B vaccines
d. DPT
29. This is the vaccine needed before a child reaches one (1) year in order for
him/her to qualify as a fully immunized child.
a. DPT
b. Measles
c. Hepatitis B
d. BCG
30. Which of the following dose of tetanus toxoid is given to the mother to protect
her infant from neonatal tetanus and likewise provide 10 years protection for the
mother?
a. Tetanus toxoid 3
b. Tetanus toxoid 2
c. Tetanus toxoid 1
d. Tetanus toxoid 4
Situation 7 Records contain those, comprehensive descriptions of patients health
conditions and needs and at the same serve as evidences of every nurses accountability
in the, caregiving process. Nursing records normally differ from institution to, institution
nonetheless they follow similar patterns of meeting needs for specifics, types of
information. The following pertains to documentation/records management.
31. This special form used when the patient is admitted to the unit. The nurse
completes, the information in this records particularly his/her basic personal data,
current illness, previous health history, health history of the family, emotional profile,
environmental history as well as physical assessment together with nursing diagnosis
on admission. What do you call this record?
a. Nursing Kardex
b. Nursing Health History and Assessment Worksheet
c. Medicine and Treatment Record
d. Discharge Summary
32. These, are sheets/forms which provide an efficient and time saving way to record
information that must be obtained repeatedly at regular and/or short intervals, of
time. This does not replace the progress notes; instead this record of information on
vital signs, intake and output, treatment, postoperative care, postpartum care, and
diabetic regimen, etc., this is used whenever specific measurements or observations
are needed to-be documented repeatedly. What is this?
a. Nursing Kardex
b. Graphic Flowsheets
c. Discharge Summary
d. Medicine and Treatment Record
33. These records show all medications and treatment provided on a repeated basis.
What do you call this record?
a. Nursing Health History and Assessment Worksheet
b. Discharge Summary
c. Nursing Kardex
d. Medicine and Treatment Record
34. This flip-over card is usually kept in a portable file at the Nurses Station. It has 2parts: the activity and treatment section and a nursing care plan section. This carries
information about basic demographic data, primary medical diagnosis, current orders
of the physician to be carried out by the nurse, written nursing care plan, nursing
orders, scheduled tests and procedures, safety precautions in-patient care and factors
related to daily living activities/ this record is used in the charge-of-shift reports or
during the bedside rounds or walking rounds. What record is this?
a. Discharge Summary
b. Medicine and Treatment Record
c. Nursing Health History and Assessment Worksheet
d. Nursing Kardex
35. Most nurses regard this as conventional recording of the date, time and mode by
which the patient leaves a healthcare unit but this record includes importantly,
directs of planning for discharge that starts soon after the person is admitted to a
healthcare institution, it is accepted that collaboration or multidisciplinary
involvement (of all members of the health team) in discharge results in
comprehensive care. What do you call this?
a. Discharge Summary
b. Nursing Kardex
c. Medicine and Treatment Record
d. Nursing Health History and Assessment Worksheet
Situation 8 As Filipino Professional Nurses we must be knowledgeable, about the Code of
Ethics for Filipino Nurses and practice these by heart. The next questions pertain to this
Code of Ethics.
36. Which of the following is TRUE about the Code of Ethics of Filipino Nurses?
a. The Philippine Nurses Association for being the accredited professional organization
was given the privilege to formulate a Code of Ethics which the Board of Nurses
promulgated
b. Code of Nurses was first formulated in 1982 published in the Proceedings of the Third
Annual Convention of the PNA House of Delegates
c. The present code utilized the Code of Good Governance for the Professions in the
Philippines
d. Certificate of Registration of registered nurses; may be revoked or suspended for
violations of any provisions of the Code of Ethics
37. Based on the Code of Ethics for Filipino Nurses, what is regarded as the hallmark
of nursing responsibility and accountability?
a. Human rights of clients, regardless of creed and gender
b. The privilege of being a registered professional nurses
c. Health, being a fundamental right of every individual
d. Accurate documentation of actions and outcomes
38. Which of the following nurses behavior is regarded as a violation of the Code of
Ethics of Filipino Nurses?
a. A nurse withholding harmful information to the family members of a patient
b. A nurse declining commission sent by a doctor for her referral
c. A nurse endorsing a person running for congress
d. Nurse Reviewers and/or nurse review center managers who pays a considerable amount
of cash for reviewees who would memorize items from the Licensure exams and submit
these to them after the examination
39. A nurse should be cognizant that professional programs for specialty certification
by the Board of Nursing are accredited through the
a. Professional Regulation Commission
b. Nursing Specialty Certification Council
c. Association of Deans of Philippine Colleges of Nursing
d. Philippine Nurse Association
40. Mr. Santos, R.N. works in a nursing home, and he knows that one of his duties is to
be an advocate for his patients. Mr. Santos knows a primary duty of an advocate is to:
a. act as the patients legal representative
b. complete all nursing responsibilities on time
c. safeguard the wellbeing of every patient
d. maintain the patients right to privacy
Situation 9 Nurse Joanna works as an OB-Gyn Nurse and attends to several HIGH-RISK
PREGNANCIES: Particularly women with preexisting or newly acquired illness. The
following conditions apply.
41. Bernadette is a 22-year old woman. Which condition would make her more prone
than others to developing a Candida infection during pregnancy?
a. Her husband plays golf 6 days a week
b. She was over 35 when she became pregnant
c. She usually drinks tomato juice for breakfast
d. She has developed gestational diabetes
42. Bernadette develops a deep-vein thrombosis following an auto accident and is
prescribed heparin sub-Q. What should Joanna educate her about in regard to this?
a. Some infants will be born with allergic symptoms to heparin
b. Her infant will be born with scattered petechiae on his trunk
c. Heparin can cause darkened skin in newborns

d. Heparin does not cross the placenta and so does not affect a fetus
43. The cousin of Bernadette with sickle-cell anemia alerted Joanna that she may
need further instruction on prenatal care. Which statement signifies this fact?
a. Ive stopped jogging so I dont risk becoming dehydrated
b. I take an iron pull every day to help grow new red blood cells
c. I am careful to drink at least eight glasses of fluid everyday
d. 1 understand why folic acid is important for red cell formation
44. Bernadette routinely takes acetylsalicylic acid (aspirin) for arthritis. Why should
she limit or discontinue this toward the end of pregnancy?
a. Aspirin can lead to deep vein thrombosis following birth
b. Newborns develop a red rash from salicylate toxicity
c. Newborns develop withdrawal headaches from salicylates
d. Salicylates can lead to increased maternal bleeding at childbirth
45. Bernadette received a laceration on her leg from her automotive accident. Why
are lacerations of lower extremities potentially more serious in pregnant women than
others?
a. Lacerations can provoke allergic responses because of gonadotropic hormone
b. Increased bleeding can occur from uterine pressure on leg veins
c. A woman is less able to keep the laceration clean because o f her fatigue
d. Healing is limited during pregnancy, so these will not heal until after birth
Situation 10 Still in your self-managed Child Health Nursing Clinic, your encounter these
cases pertaining to the CARE OF CHILDREN WITH PULMONARY AFFECTIONS.
46. Josie brought her 3-months old child to your clinic because of cough and colds.
Which of the following is your primary action?
a. Give cotrimoxazole tablet or syrup
b. Assess the patient using the chart on management of children with cough
c. Refer to the doctor

d. Teach the mother how to count her childs bearing
47. In responding to the care concerns of children with severe disease, referral to the
hospital of the essence especially if the child manifests which of the following?
a. Wheezing
b. Stopped bleeding
c. Fast breathing
d. Difficulty to awaken
48. Which of the following is the most important responsibility of a nurse in the
prevention of necessary deaths from pneumonia and other severe diseases?
a. Giving of antibiotics
b. Taking of the temperature of the sick child
c. Provision of Careful Assessment
d. Weighing of the sick child
49. You were able to identify factors that lead to respiratory problems in the
community where your health facility serves. Your primary role therefore in order to
reduce morbidity due to pneumonia is to:
a. Teach mothers how to recognize early signs and symptoms of pneumonia
b. Make home visits to sick children
c. Refer cases to hospitals
d. Seek assistance and mobilize the BHWs to have a meeting with mothers
50. Which of the following is the principal focus on the CARI program of the
Department of Health?
a. Enhancement of health team capabilities
b. Teach mothers how to detect signs and where to refer
c. Mortality reduction through early detection
d. Teach other community health workers how to assess patients
Situation 11 You are working as a Pediatric Nurse in your own Child Health Nursing
Clinic, the following cases pertain to ASSESSMENT AND CARE OF THE NEWBORN AT RISK
conditions.
51. Theresa, a mother with a 2 year old daughter asks, At what are can I be able to
take the blood pressure of my daughter as a routine procedure since hypertension is
common in the family? Your answer to this is:
a. At 2 years you may
b. As early as 1 year old
c. When shes 3- years old
d. When shes 6 years old
52. You typically gag children to inspect the back of their throat. When is it important
NOT to solicit a gag reflex?
a. when a girl has a geographic tongue
b. when a boy has a possible inguinal hernia
c. when a child has symptoms of epiglottitis
d. when children are under 5 years of age
53. Baby John was given a drug at birth to reverse the effects of a narcotic given to
his mother in labor. What drug is commonly used for this?
a. Naloxone (Narcan)
b. Morphine Sulfate
c. Sodium Chloride
d. Penicillin G
54. Why are small-for-gestational-age newborns at risks for difficulty maintaining body
temperature?
a. They do not have as many fat stores as other infants
b. They are more active than usual so throw off covers
c. Their skin is more susceptible to conduction of cold
d. They are preterm so are born relatively small in size
55. Baby John develops hyperbilirubinemia. What is a method used to treat

hyperbilirubinemia in a newborn?
a. Keeping infants in a warm arid dark environment
b. Administration of a cardiovascular stimulant
c. Gentle exercise to stop muscle breakdown
d. Early feeding to speed passage of meconium
Situation 12 You are the nurse in the Out-Patient-Department and during your shift you
encountered multiple childrens condition. The following questions apply.
56. You assessed a child with visible severe wasting, he has:
a. edema
b. LBM
c. kwashiorkor
d. marasmus
57. Which of the following conditions is NOT true about contraindication to
immunization?
a. do not give DPT2 or DPT3 to a child who has convulsions within 3 days of DPT1
b. do not give BOG if the child has known hepatitis .
c. do not give OPT to a child who has recurrent convulsion or active neurologic disease
d. do not give BCG if the child has known AIDS
58. Which of the following statements about immunization is NOT true:
a. A child with diarrhea who is due for OPV should receive the OPV and make extra dose
on the next visit
b. There is no contraindication to immunization if the child is well enough to go home
c. There is no contraindication to immunization if the child is well enough to go home and
a child should be immunized in the health center before referrals are both correct
d. A child should be immunized in the center before referral
59. A child with visible severe wasting or severe palmar pallor may be classified as:
a. moderate malnutrition/anemia
b. severe malnutrition/anemia
c. not very tow weight no anemia
d. anemia/very low weight
60. A child who has some palmar pallor can be classified as:
a. moderate anemia/normal weight
b. severe malnutrition/anemia
c. anemia/very low weight
d. not very low eight to anemia
Situation 13 Nette, a nurse palpates the abdomen of Mrs. Medina, a primigravida. She is
unsure of the date of her last menstrual period. Leopolds Maneuver is done. The
obstetrician told mat she appears to be 20 weeks pregnant. .
61. Nette explains this because the fundus is:
a. At the level the umbilicus, and the fetal heart can be heard with a fetoscope
b. 18 cm, and the baby is just about to move
c. is just over the symphysis, and fetal heart cannot be heard
d. 28 cm, and fetal heart can be heard with a Doppler
62. In doing Leopolds maneuver palpation which among the following is NOT
considered a good preparation?
a. The woman should lie in a supine position with her knees flexed slightly
b. The hands of the nurse should be cold so that abdominal muscles would contract and
tighten
c. Be certain that your hands are warm (by washing them in warm water first if
necessary)
d. The woman empties her bladder before palpation
63. In her pregnancy, she experienced fatigue and drowsiness. This probably occurs
because:
a. of high blood pressure

b. she is expressing pressure
c. the fetus utilizes her glucose stores and leaves her with a Sow blood glucose
d. of the rapid growth of the fetus
64. The nurse assesses the woman at 20 weeks gestation and expects the woman to
report:
a. Spotting related to fetal implantation
b. Symptoms of diabetes as human placental lactogen is released
c. Feeling fetal kicks
d. Nausea and vomiting related HCG production
65. If Mrs. Medina comes to you for check-up on June 2, her EDO is June 11, what do
you expect during assessment?
a. Fundic ht 2 fingers below xyphoid process, engaged
b. Cervix close, uneffaced, FH-midway between the umbilicus and symphysis pubis
c. Cervix open, fundic ht. 2 fingers below xyphoid process, floating .
d. Fundal height at least at the level of the xyphoid process, engaged
Situation 14: Please continue responding as a professional nurse in varied health
situations through the following questions.
66. Which of the following medications would the nurse expect the physician to order
for recurrent convulsive seizures of a 10-year old child brought to your clinic?
a. Phenobarbital
b. Nifedipine
c. Butorphanol
d. Diazepam
67. RhoGAM is given to Rh-negative women to prevent maternal sensitization from
occurring. The nurse is aware that in addition to pregnancy, Rh-negative women
would also receive this medication after which of the following?
a. Unsuccessful artificial insemination procedure

b. Blood transfusion after hemorrhage
c. Therapeutic or spontaneous abortion
d. Head injury from a car accident
68. Which of the following would the nurse include when describing
the pathophysiology of gestational diabetes?
a. Glucose levels decrease to accommodate fetal growth
b. Hypoinsulinemia develops early in the first trimester
c. Pregnancy fosters the development of carbohydrate cravings
d. There is progressive resistance to the effects of insulin
69. When providing prenatal education to a pregnant woman with asthma, which of
the following would be important for the nurse to do?
a. Demonstrate how to assess her blood glucose
b. Teach correct administration of subcutaneous bronchodilators
c. Ensure she seeks treatment for any acute exacerbation
d. Explain that she should avoid steroids during her pregnancy
70. Which of the following conditions would cause an insulin-dependent diabetic
client the most difficulty during her pregnancy?
a. Rh incompatibility
b. Placenta previa
c. Hyperemesis gravidarum
d. Abruptio placentae
Situation 15 One important toot a community health nurse uses in the conduct of
his/her activities is the CHN Bag. Which of the following BEST DESCRIBES the use of this
vital facility for our practice?
71. The Community/Public Health Bag is:
a. a requirement for home visits
b. an essential and indispensable equipment of the community health nurse
c. contains basic medications and articles used by the community health nurse
d. a tool used by the Community health nurse is rendering effective nursing procedure
during a home visit
72. What is the rationale in the use of bag technique during home visit?
a. It helps render effective nursing care to clients or other members of the family
b. It saves time and effort of the nurse in the performance of nursing procedures
c. It should minimize or prevent the spread of infection from individuals to families
d. It should not overshadow concerns for the patient
73. Which among the following is important in the use of the bag technique during
home visit?
a. Arrangement of the bags contents must be convenient to the nurse
b. The bag should contain all necessary supplies and equipment ready for use
c. Be sure to thoroughly clean your bag especially when exposed to communicable disease
cases
d. Minimize if not totally prevent the spread of infection
74. This is an important procedure of the nurse during home visits?
a. protection of the CHN bag
b. arrangement of the contents of the CHM bag
c. cleaning of the CHN bag
d. proper handwashing
75. In consideration of the steps in applying the bag technique, which side of the
paper lining of the CHN bag is considered clean to make a non-contaminated work
area?
a. The lower lip
b. The outer surface
c. The upper lip
d. The inside surface
Situation 16 As a Community Health Nurse relating with people in different

communities, and in the implementation of health programs and projects you experience
vividly as well the varying forms of leadership and management from the Barangay Level
to the Local Government/Municipal City Level.
76. The following statements can correctly be made about Organization and
management?
A. An organization (or company) is people. Values make people persons: values give
vitality, meaning and direction to a company. As the people of an organization value, so
the company becomes.
B. Management is the process by which administration achieves its mission, goals, and
objectives
C. Management effectiveness can be measured in terms of accomplishment of the
purpose of the organization while management efficiency is measured in terms of the
satisfaction of individual motives
D. Management principles are universal therefore one need not be concerned about
people, culture, values, traditions and human relations.
a. B and C only
b. A, B and D only
c. A and D only
d. B, A, and C only
77. Management by Filipino values advocates the consideration of the Filipino goals
trilogy according to the Filipino priority-values which are:
a. Family goals, national goals, organizational goals
b. Organizational goats, national goals, family goals
c. National goals, organizational goals, family goals
d. Family goals, organizational goals, national goals
78. Since the advocacy for the utilization of Filipino value-system in management has
been encouraged, the Nursing sector is no except, management needs to examine
Filipino values and discover its positive potentials and harness them to achieve:
a. Employee satisfaction
b. Organizational commits .ants, organizational objectives and employee satisfaction
c. Employee objectives/satisfaction, commitments and organizational objectives
d. Organizational objectives, commitments and employee objective/satisfaction
79. The following statements can correctly be made about an effective and efficient
community or even agency managerial-leader.
A. Considers the achievement and advancement of the organization she/he represents as
well as his people
B. Considers the recognition of individual efforts toward the realization of organizational
goals as well as the welfare of his people
C. Considers the welfare of the organization above all other consideration by higher
administration
D. Considers its own recognition by higher administration for purposes of promotion and
prestige
a. Only C and D are correct
b. A, C and D are correct
c. B, C, and D are correct
d. Only A and B are correct
80. Whether management at the community or agency level, there are 3 essential
types of skills managers must have, these are:
A. Human relation skills, technical skills, and cognitive skills
B. Conceptual skills, human relation/behavioral skills, and technical skills
C. Technical skills, budget and accounting skills, skills in fund-raising
D. Manipulative skills, technical skills, resource management skills
a. A and D are correct
b. B is correct
c. A is correct
d. C and D are correct
Situation 17 You are actively practicing nurse who just finished your Graduate Studies.
You earned the value of Research and would like to utilize the knowledge and skills
gained in the application of research to Nursing service. The following questions apply to
research.
81. Which type of research Inquiry investigates the issue of human complexity (e.g.
understanding the human expertise)
a. Logical position
b. Naturalistic inquiry
c. Positivism
d. Quantitative Research
82. Which of the following studies is based on quantitative research?
a. A study examining the bereavement process in spouses of clients with terminal cancer
b. A study exploring factors influencing weight control behavior
c. A study measuring the effects of sleep deprivation on wound healing
d. A study examining clients feelings before, during and after a bone marrow aspiration
83. Which of the following studies is based on qualitative research?
a. A study examining clients reactions to stress after open heart surgery
b. A study measuring nutrition and weight, loss/gain in clients with cancer
c. A study examining oxygen levels after endotracheal suctioning
d. A study measuring differences in blood pressure before during and after a procedure
84. An 85 year old client in a nursing home tells a nurse, I signed the papers for that
research study because the doctor was so insistent and I want: him to continue taking
care of me. Which client right is being violated?
a. Right of self determination
b. Right to privacy and confidentiality
c. Right to full disclosure
d. Right not to be harmed
85. A supposition or system of ideas that is proposed to explain a given
phenomenon, best defines:
a. a paradigm
b. a concept
c. a theory
d. a conceptual framework
Situation 18 Nurse Michelle works with a Family Nursing Team in Calbayog Province
specifically handling a UNICEF project for children. The following conditions pertain, to
CARE OP THE FAMILIES PRESCHOOLERS.
86. Ronnie asks constant questions. How many does a typical 3-year-old ask in a days
time?
a. 1,200 or more
b. Less than 50
c. 100-200
d. 300-400
87. Ronnie will need to change to a new bed because his baby sister will need
Ronnies old crib. What measure would you suggest that his parents take to help
decrease sibling rivalry between Ronnie and his new sister?
a. Move him to the new bed before the baby arrives
b. Explain that new sisters grow up to become best friends
c. Tell him he will have to share with the new baby
d. Ask him to get his crib ready for the new baby
88. Ronnies parents want to know how to react to him when he begins to masturbate
while watching television. What would you suggest?
a. They refuse to allow him to watch television
b. They schedule a health check-up for sex-related disease
c. They remind him that some activities are private
d. They give him timeout when this begins
89. How many words does a typical 12-month-old infant use?
a. About 12 words
b. Twenty or more words
c. About 50 words
d. Two, plus mama and dada
90. As a nurse. You reviewed infant safety procedures with Bryans mother. What are
two of the most common types of accidents among infants?
a. Aspiration and falls
b. Falls and auto accidents
c. Poisoning and burns
d. Drowning and homicide
Situation 19 Among common conditions found in children especially among poor
communities are ear infection/problems. The following questions apply.
91. A child with ear problem should be assessed for the following EXCEPT:
a is there any fever?
b. ear discharge
c. if discharge is present for how long?
d. ear pain
92. If the child does not have ear problem, using IMCI, what should you as the nurse
do?
a. Check for ear discharge
b. Check for tender swellings, behind the ear
c. Check for ear pain
d. Go to the next question, check for malnutrition
93. An ear discharge that has been present for more than 14 days can be classified as:
a. mastoiditis
b. chronic ear infection
c. acute ear infection
d. complicated ear infection
94. An ear discharge that has been present for less than 14 days can be classified as:
a. chronic ear infection
b. mastoiditis
c. acute ear infection
d. complicated ear infection
95. If the child has severe classification because of ear problem, what would be the
best thing that you as the nurse can do?
a. instruct mother when to return immediately
b. refer urgently
c. give an antibiotic for 5 days
d. dry the ear by wicking
Situation 20 If a child with diarrhea registers one sign in the pink row and one in the
yellow; row in the IMCI Chart.
96. We can classify the patient as:
a. moderate dehydration
b. some dehydration
c. no dehydration
d. severe dehydration
97. The child with no dehydration needs home treatment Which of the following is not
included the rules for home treatment in this case:
a. continue feeding the child
b. give oresol every 4 hours
c. know when to return to the health center
d. give the child extra fluids
98. A child who has had diarrhea for 14 days but has no sign of dehydration is
classified as:
a. severe persistent diarrhea

b. dysentery
c. severe dysentery b. dysentery
d. persistent diarrhea
99. If the child has sunken eyes, drinking eagerly, thirsty and skin pinch goes back
slowly, the classification would be:
a. no dehydration
b. moderate dehydration
c. some dehydration
d. severe dehydration
100. Carlo has had diarrhea for 5 days. There is no blood in the stool, he is irritable.
His eyes are sunken the nurse offers fluid to Carlo and he drinks eagerly. When the
nurse pinched the abdomen, it goes back slowly. How will you classify Carlos illness?
a. severe dehydration
b. no dehydration
c. some dehydration
d. moderate dehydration
Answers
Here are the answers for the exam. Unfortunately, rationales are not given. If you need
clarifications or disputes, please direct them to the comments section and well be glad
to give you an explanation.
1. A
2. B
3. A
4. C
5. B
6. D
7. C
8. D
9. A
10. B
11. D
12. D
13. A
14. B
15. A
16. C
17. D
18. A
19. B
20. D
21. C
22. C
23. A
24. C
25. A
26. B
27. A
28. C
29. B
30. D
31. B
32. B
33. D
34. D
35. A
36. C
37. C
38. A
39. B
40. C
41. D
42. D
43. B
44. D
45. B
46. B
47. D
48. C
49. A
50. C
51. C
52. C
53. A
54. A
55. D
56. D
57. B
58. A
59. B
60.C
61. A
62. B
63. D
64. C
65. A
66. A
67. C
68. D
69. C
70. C
71. B
72. A
73. D
74. D
75. B
76. D
77. D
78. D
79. D
80. C
81. B
82. C
83. A
84. A
85. C
86. D
87. A
88. C
89. A
90. A
91. A
92. D
93. B
94. C
95. B
96. D
97. B
98. D
99. C
100. C
Medical-Surgical Nursing Exam 27: NLE Pre-
Introduction
Take the part two challenge of our Maternity Nursing exam with another 50-item question. Go into
deep to the concepts of pregnancy, labor and delivery and more. If you are taking the NLE or NCLEX
then this exam is perfect for your review.
Topics
Laws about Maternal Health
Anesthesia during labor and delivery
Uterine contractions
Cervical dilatations
Preparing for labor and delivery
Guidelines
Questions
Text
Practice
Exam
1. Which of the following conditions will lead to a small-for-gestational age fetus due
to less blood supply to the fetus?
A. Diabetes in the mother
B. Maternal cardiac condition
C. Premature labor
D. Abruptio placenta
2. The lower limit of viability for infants in terms of age of gestation is:
A. 21-24 weeks
B. 25-27 weeks
C. 28-30 weeks
D. 38-40 weeks
3. Which provision of our 1987 constitution guarantees the right of the unborn child
to life from conception is
A. Article II section 12
B. Article II section 15
C. Article XIII section 11
D. Article XIII section 15
4. In the Philippines, if a nurse performs abortion on the mother who wants it done
and she gets paid for doing it, she will be held liable because
A. Abortion is immoral and is prohibited by the church
B. Abortion is both immoral and illegal in our country
C. Abortion is considered illegal because you got paid for doing it
D. Abortion is illegal because majority in our country are catholics and it is prohibited by
the church
5. The preferred manner of delivering the baby in a gravido-cardiac is vaginal delivery
assisted by forceps under epidural anesthesiA. The main rationale for this is:
A. To allow atraumatic delivery of the baby
B. To allow a gradual shifting of the blood into the maternal circulation
C. To make the delivery effort free and the mother does not need to push with
contractions
D. To prevent perineal laceration with the expulsion of the fetal head
6. When giving narcotic analgesics to mother in labor, the special consideration to
follow is:
A. The progress of labor is well established reaching the transitional stage
B. Uterine contraction is progressing well and delivery of the baby is imminent
C. Cervical dilatation has already reached at least 8 cm. and the station is at least (+)2
D. Uterine contractions are strong and the baby will not be delivered yet within the next
3 hours.
7. The cervical dilatation taken at 8:00 AM in a G1P0 patient was 6 centimeters. A

repeat I.E. done at 10 A. M. showed that cervical dilation was 7 cm. The correct
interpretation of this result is:
A. Labor is progressing as expected
B. The latent phase of Stage 1 is prolonged
C. The active phase of Stage 1 is protracted
D. The duration of labor is normal
8. Which of the following techniques during labor and delivery can lead to uterine
inversion?
A. Fundal pressure applied to assist the mother in bearing down during delivery of the
fetal head
B. Strongly tugging on the umbilical cord to deliver the placenta and hasten placental
separation
C. Massaging the fundus to encourage the uterus to contract
D. Applying light traction when delivering the placenta that has already detached from
the uterine wall
9. The fetal heart rate is checked following rupture of the bag of waters in order to:
A. Check if the fetus is suffering from head compression
B. Determine if cord compression followed the rupture
C. Determine if there is utero-placental insufficiency
D. Check if fetal presenting part has adequately descended following the rupture
10. Upon assessment, the nurse got the following findings: 2 perineal pads highly
saturated with blood within 2 hours post partum, PR= 80 bpm, fundus soft and
boundaries not well defineD. The appropriate nursing diagnosis is:
A. Normal blood loss
B. Blood volume deficiency
C. Inadequate tissue perfusion related to hemorrhage
D. Hemorrhage secondary to uterine atony
11. The following are signs and symptoms of fetal distress EXCEPT:
A. Fetal heart rate (FHR) decreased during a contraction and persists even after the
uterine contraction ends
B. The FHR is less than 120 bpm or over 160 bpm
C. The pre-contraction FHR is 130 bpm, FHR during contraction is 118 bpm and FHR after
uterine contraction is 126 bpm
D. FHR is 160 bpm, weak and irregular
12. If the labor period lasts only for 3 hours, the nurse should suspect that the
following conditions may occur:
1.Laceration of cervix
2.Laceration of perineum
3.Cranial hematoma in the fetus
4.Fetal anoxia
A. 1 & 2
B. 2 & 4
C. 2,3,4
D. 1,2,3,4
13. The primary power involved in labor and delivery is
A. Bearing down ability of mother
B. Cervical effacement and dilatation
C. Uterine contraction
D. Valsalva technique
14. The proper technique to monitor the intensity of a uterine contraction is
A. Place the palm of the hands on the abdomen and time the contraction
B. Place the finger tips lightly on the suprapubic area and time the contraction
C. Put the tip of the fingers lightly on the fundal area and try to indent the abdominal
wall at the height of the contraction
D. Put the palm of the hands on the fundal area and feel the contraction at the fundal
area
15. To monitor the frequency of the uterine contraction during labor, the right
technique is to time the contraction
A. From the beginning of one contraction to the end of the same contraction
B. From the beginning of one contraction to the beginning of the next contraction
C. From the end of one contraction to the beginning of the next contraction
D. From the deceleration of one contraction to the acme of the next contraction
16. The peak point of a uterine contraction is called the
A. Acceleration
B. Acme
C. Deceleration
D. Axiom
17. When determining the duration of a uterine contraction the right technique is to
time it from
A. The beginning of one contraction to the end of the same contraction
B. The end of one contraction to the beginning of another contraction
C. The acme point of one contraction to the acme point of another contraction
D. The beginning of one contraction to the end of another contraction
18. When the bag of waters ruptures, the nurse should check the characteristic of the
amniotic fluiD. The normal color of amniotic fluid is
A. Clear as water
B. Bluish
C. Greenish
D. Yellowish
19. When the bag of waters ruptures spontaneously, the nurse should inspect the
vaginal introitus for possible cord prolapse. If there is part of the cord that has
prolapsed into the vaginal opening the correct nursing intervention is:
A. Push back the prolapse cord into the vaginal canal
B. Place the mother on semifowlers position to improve circulation
C. Cover the prolapse cord with sterile gauze wet with sterile NSS and place the woman
on Trendelenburg position
D. Push back the cord into the vagina and place the woman on sims position
20. The fetal heart beat should be monitored every 15 minutes during the 2nd stage
of labor. The characteristic of a normal fetal heart rate is
A. The heart rate will decelerate during a contraction and then go back to its precontraction rate after the contraction
B. The heart rate will accelerate during a contraction and remain slightly above the precontraction rate at the end of the contraction
C. The rate should not be affected by the uterine contraction.
D. The heart rate will decelerate at the middle of a contraction and remain so for about a
minute after the contraction
21. The mechanisms involved in fetal delivery is
A. Descent, extension, flexion, external rotation
B. Descent, flexion, internal rotation, extension, external rotation
C. Flexion, internal rotation, external rotation, extension
D. Internal rotation, extension, external rotation, flexion
22. The first thing that a nurse must ensure when the babys head comes out is
A. The cord is intact
B. No part of the cord is encircling the babys neck
C. The cord is still attached to the placenta
D. The cord is still pulsating
23. To ensure that the baby will breath as soon as the head is delivered, the nurses
priority action is to
A. Suction the nose and mouth to remove mucous secretions
B. Slap the babys buttocks to make the baby cry
C. Clamp the cord about 6 inches from the base
D. Check the babys color to make sure it is not cyanotic
24. When doing perineal care in preparation for delivery, the nurse should observe
the following EXCEPT
A. Use up-down technique with one stroke
B. Clean from the mons veneris to the anus
C. Use mild soap and warm water
D. Paint the inner thighs going towards the perineal area
25. What are the important considerations that the nurse must remember after the
placenta is delivered?
1.Check if the placenta is complete including the membranes
2.Check if the cord is long enough for the baby
3.Check if the umbilical cord has 3 blood vessels
4.Check if the cord has a meaty portion and a shiny portion
A. 1 and 3
B. 2 and 4
C. 1, 3, and 4
D. 2 and 3
26. The following are correct statements about false labor EXCEPT
A. The pain is irregular in intensity and frequency.
B. The duration of contraction progressively lengthens over time
C. There is no vaginal bloody discharge
D. The cervix is still closeD.
27. The passageway in labor and deliver of the fetus include the following EXCEPT
A. Distensibility of lower uterine segment
B. Cervical dilatation and effacement
C. Distensibility of vaginal canal and introitus
D. Flexibility of the pelvis
28. The normal umbilical cord is composed of:
A. 2 arteries and 1 vein

B. 2 veins and 1 artery
C. 2 arteries and 2 veins
D. none of the above
29. At what stage of labor and delivery does a primigravida differ mainly from a
multigravida?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
30. The second stage of labor begins with ___ and ends with __?
A. Begins with full dilatation of cervix and ends with delivery of placenta
B. Begins with true labor pains and ends with delivery of baby
C. Begins with complete dilatation and effacement of cervix and ends with delivery of
baby
D. Begins with passage of show and ends with full dilatation and effacement of cervix
31. The following are signs that the placenta has detached EXCEPT:
A. Lengthening of the cord
B. Uterus becomes more globular
C. Sudden gush of blood
D. Mother feels like bearing down
32. When the shiny portion of the placenta comes out first, this is called the ___
mechanism.
A. Schultze
B. Ritgens
C. Duncan
D. Marmets
33. When the babys head is out, the immediate action of the nurse is
A. Cut the umbilical cord

B. Wipe the babys face and suction mouth first
C. Check if there is cord coiled around the neck
D. Deliver the anterior shoulder
34. When delivering the babys head the nurse supports the mothers perineum to
prevent tear. This technique is called
A. Marmets technique
B. Ritgens technique
C. Duncan maneuver
D. Schultze maneuver
35. The basic delivery set for normal vaginal delivery includes the following
instruments/articles EXCEPT:
A. 2 clamps
B. Pair of scissors
C. Kidney basin
D. Retractor
36. As soon as the placenta is delivered, the nurse must do which of the following
actions?
A. Inspect the placenta for completeness including the membranes
B. Place the placenta in a receptacle for disposal
C. Label the placenta properly
D. Leave the placenta in the kidney basin for the nursing aide to dispose properly
37. In vaginal delivery done in the hospital setting, the doctor routinely orders an
oxytocin to be given to the mother parenterally. The oxytocin is usually given after
the placenta has been delivered and not before because:
A. Oxytocin will prevent bleeding
B. Oxytocin can make the cervix close and thus trap the placenta inside
C. Oxytocin will facilitate placental delivery
D. Giving oxytocin will ensure complete delivery of the placenta
38. In a gravido-cardiac mother, the first 2 hours postpartum (4th stage of labor and
delivery) particularly in a cesarean section is a critical period because at this stage
A. There is a fluid shift from the placental circulation to the maternal circulation which
can overload the compromised heart.
B. The maternal heart is already weak and the mother can die
C. The delivery process is strenuous to the mother
D. The mother is tired and weak which can distress the heart
39. The drug usually given parentally to enhance uterine contraction is:
A. Terbutalline
B. Pitocin
C. Magnesium sulfate
D. Lidocaine
40. The partograph is a tool used to monitor labor. The maternal parameters
measured/monitored are the following EXCEPT:
A. Vital signs
B. Fluid intake and output
C. Uterine contraction
D. Cervical dilatation
41. The following are natural childbirth procedures EXCEPT:
A. Lamaze method
B. Dick-Read method
C. Ritgens maneuver
D. Psychoprophylactic method
42. The following are common causes of dysfunctional labor. Which of these can a
nurse, on her own manage?
A. Pelvic bone contraction
B. Full bladder
C. Extension rather than flexion of the head

D. Cervical rigidity
43. At what stage of labor is the mother is advised to bear down?
A. When the mother feels the pressure at the rectal area
B. During a uterine contraction
C. In between uterine contraction to prevent uterine rupture
D. Anytime the mother feels like bearing down
44. The normal dilatation of the cervix during the first stage of labor in a nullipara is
A. 1.2 cm./hr
B. 1.5 cm./hr.
C. 1.8 cm./hr
D. 2.0 cm./hr
45. When the fetal head is at the level of the ischial spine, it is said that the station of
the head is
A. Station 1
B. Station 0
C. Station +1
D. Station +2
46. During an internal examination, the nurse palpated the posterior fontanel to be at
the left side of the mother at the upper quadrant. The interpretation is that the
position of the fetus is:
A. LOA
B. ROP
C. LOP
D. ROA
47. The following are types of breech presentation EXCEPT:
A. Footling
B. Frank
C. Complete
D. Incomplete
48. When the nurse palpates the suprapubic area of the mother and found that the
presenting part is still movable, the right term for this observation that the fetus is
A. Engaged
B. Descended
C. Floating
D. Internal Rotation
49. The placenta should be delivered normally within ___ minutes after the delivery
of the baby.
A. 5 minutes
B. 30 minutes
C. 45 minutes
D. 60 minutes
50. When shaving a woman in preparation for cesarean section, the area to be shaved
should be from ___ to ___
A. Under breast to mid-thigh including the pubic area
B. The umbilicus to the mid-thigh
C. Xyphoid process to the pubic area
D. Above the umbilicus to the pubic area
Answers and Rationale

Here are the answers and rationale for this exam. Counter check your answers to those
below and tell us your scores. If you have any disputes or need more clarification to a
certain question, please direct them to the comments section.
1. Answer: (B) Maternal cardiac condition

In general, when the heart is compromised such as in maternal cardiac condition, the
condition can lead to less blood supply to the uterus consequently to the placenta which
provides the fetus with the essential nutrients and oxygen. Thus if the blood supply is
less, the baby will suffer from chronic hypoxia leading to a small-for-gestational age
condition.
2. Answer: (A) 21-24 weeks
Viability means the capability of the fetus to live/survive outside of the uterine
environment. With the present technological and medical advances, 21 weeks AOG is
considered as the minimum fetal age for viability.
3. Answer: (A) Article II section 12
The Philippine Constitution of 1987 guarantees the right of the unborn child from
conception equal to the mother as stated in Article II State Policies, Section 12.
4. Answer: (B) Abortion is both immoral and illegal in our country
Induced Abortion is illegal in the country as stated in our Penal Code and any person who
performs the act for a fee commits a grave offense punishable by 10-12 years of
imprisonment.
5. Answer: (C) To make the delivery effort free and the mother does not need to push
with contractions
Forceps delivery under epidural anesthesia will make the delivery process less painful and
require less effort to push for the mother. Pushing requires more effort which a
compromised heart may not be able to endure.
6. Answer: (D) Uterine contractions are strong and the baby will not be delivered yet
within the next 3 hours.
Narcotic analgesics must be given when uterine contractions are already well established
so that it will not cause stoppage of the contraction thus protracting labor. Also, it should
be given when delivery of fetus is imminent or too close because the fetus may suffer
respiratory depression as an effect of the drug that can pass through placental barrier.
7. Answer: (C) The active phase of Stage 1 is protracted
The active phase of Stage I starts from 4cm cervical dilatation and is expected that the
uterus will dilate by 1cm every hour. Since the time lapsed is already 2 hours, the
dilatation is expected to be already 8 cm. Hence, the active phase is protracted.
8. Answer: (B) Strongly tugging on the umbilical cord to deliver the placenta and
hasten placental separation
When the placenta is still attached to the uterine wall, tugging on the cord while the
uterus is relaxed can lead to inversion of the uterus. Light tugging on the cord when
placenta has detached is alright in order to help deliver the placenta that is already
detached.
9. Answer: (B) Determine if cord compression followed the rupture
After the rupture of the bag of waters, the cord may also go with the water because of
the pressure of the rupture and flow. If the cord goes out of the cervical opening, before
the head is delivered (cephalic presentation), the head can compress on the cord causing
fetal distress. Fetal distress can be detected through the fetal heart tone. Thus, it is
essential do check the FHB right after rupture of bag to ensure that the cord is not being
compressed by the fetal head.
10. Answer: (D) Hemorrhage secondary to uterine atony
All the signs in the stem of the question are signs of hemorrhage. If the fundus is soft and
boundaries not well defined, the cause of the hemorrhage could be uterine atony.
61. Answer: (C) The pre-contraction FHR is 130 bpm, FHR during contraction is 118
bpm and FHR after uterine contraction is 126 bpm
The normal range of FHR is 120-160 bpm, strong and regular. During a contraction, the
FHR usually goes down but must return to its pre-contraction rate after the contraction
ends.
12. Answer: (D) 1,2,3,4
all the above conditions can occur following a precipitate labor and delivery of the fetus
because there was little time for the baby to adapt to the passageway. If the presentation
is cephalic, the fetal head serves as the main part of the fetus that pushes through the
birth canal which can lead to cranial hematoma, and possible compression of cord may
occur which can lead to less blood and oxygen to the fetus (hypoxia). Likewise the
maternal passageway (cervix, vaginal canal and perineum) did not have enough time to
stretch which can lead to laceration.
13. Answer: (C) Uterine contraction

Uterine contraction is the primary force that will expel the fetus out through the birth
canal Maternal bearing down is considered the secondary power/force that will help push
the fetus out.
14. Answer: (C) Put the tip of the fingers lightly on the fundal area and try to indent
the abdominal wall at the height of the contraction
In monitoring the intensity of the contraction the best place is to place the fingertips at
the fundal area. The fundus is the contractile part of the uterus and the fingertips are
more sensitive than the palm of the hand.
15. Answer: (B) From the beginning of one contraction to the beginning of the next
contraction
Frequency of the uterine contraction is defined as from the beginning of one contraction
to the beginning of another contraction.
16. Answer: (B) Acme
Acme is the technical term for the highest point of intensity of a uterine contraction.
17. Answer: (A) The beginning of one contraction to the end of the same contraction
Duration of a uterine contraction refers to one contraction. Thus it is correctly measure
from the beginning of one contraction to the end of the same contraction and not of
another contraction.
18. Answer: (A) Clear as water
The normal color of amniotic fluid is clear like water. If it is yellowish, there is probably
Rh incompatibility. If the color is greenish, it is probably meconium stained.
19. Answer: (C) Cover the prolapse cord with sterile gauze wet with sterile NSS and
place the woman on Trendelenburg position
The correct action of the nurse is to cover the cord with sterile gauze wet with sterile
NSS. Observe strict asepsis in the care of the cord to prevent infection. The cord has to
be kept moist to prevent it from drying. Dont attempt to put back the cord into the
vagina but relieve pressure on the cord by positioning the mother either on Trendelenburg
or Sims position
20.Answer: (A) The heart rate will decelerate during a contraction and then go back to
its pre-contraction rate after the contraction
The normal fetal heart rate will decelerate (go down) slightly during a contraction
because of the compression on the fetal head. However, the heart rate should go back to
the pre-contraction rate as soon as the contraction is over since the compression on the
head has also ended.
21. Answer: (B) Descent, flexion, internal rotation, extension, external rotation
The mechanism of fetal delivery begins with descent into the pelvic inlet which may
occur several days before true labor sets in the primigravida. Flexion, internal rotation
and extension are mechanisms that the fetus must perform as it accommodates through
the passageway/birth canal. Eternal rotation is done after the head is delivered so that
the shoulders will be easily delivered through the vaginal introitus.
22. Answer: (B) No part of the cord is encircling the babys neck
The nurse should check right away for possible cord coil around the neck because if it is
present, the baby can be strangulated by it and the fetal head will have difficulty being
delivered.
23.Answer: (A) Suction the nose and mouth to remove mucous secretions
Suctioning the nose and mouth of the fetus as soon as the head is delivered will remove
any obstruction that maybe present allowing for better breathing. Also, if mucus is in the
nose and mouth, aspiration of the mucus is possible which can lead to aspiration
pneumonia. (Remember that only the babys head has come out as given in the situation.)
24. Answer: (D) Paint the inner thighs going towards the perineal area
Painting of the perineal area in preparation for delivery of the baby must always be done
but the stroke should be from the perineum going outwards to the thighs. The perineal
area is the one being prepared for the delivery and must be kept clean
25. Answer: (A) 1 and 3
The nurse after delivering the placenta must ensure that all the cotyledons and the
membranes of the placenta are complete. Also, the nurse must check if the umbilical
cord is normal which means it contains the 3 blood vessels: 1 vein and 2 arteries.
26. Answer: (B) The duration of contraction progressively lengthens over time
In false labor, the contractions remain to be irregular in intensity and duration while in
true labor, the contractions become stronger, longer and more frequent.
27. Answer: (D) Flexibility of the pelvis
The pelvis is a bony structure that is part of the passageway but is not flexible. The lower
uterine segment including the cervix as well as the vaginal canal and introitus are all part
of the passageway in the delivery of the fetus.
28. Answer: (A) 2 arteries and 1 vein
The umbilical cord is composed of 2 arteries and 1 vein.
29. Answer: (A) Stage 1
In stage 1 during a normal vaginal delivery of a vertex presentation, the multigravida may
have about 8 hours labor while the primigravida may have up to 12 hours labor.
30. Answer: (C) Begins with complete dilatation and effacement of cervix and ends
with delivery of baby
Stage 2 of labor and delivery process begins with full dilatation of the cervix and ends
with the delivery of baby. Stage 1 begins with true labor pains and ends with full
dilatation and effacement of the cervix.
31. Answer: (D) Mother feels like bearing down
Placental detachment does not require the mother to bear down. A normal placenta will
detach by itself without any effort from the mother.
32. Answer: (A) Schultze
There are 2 mechanisms possible during the delivery of the placenta. If the shiny portion
comes out first, it is called the Schultze mechanism; while if the meaty portion comes out
first, it is called the Duncan mechanism.
33. Answer: (C) Check if there is cord coiled around the neck
The nurse should check if there is a cord coil because the baby will not be delivered
safely if the cord is coiled around its neck. Wiping of the face should be done seconds
after you have ensured that there is no cord coil but suctioning of the nose should be
done after the mouth because the baby is a nasal obligate breather. If the nose is
suctioned first before the mouth, the mucus plugging the mouth can be aspirated by the
baby.
34. Answer: (B) Ritgens technique
Ritgens technique is done to prevent perineal tear. This is done by the nurse by support
the perineum with a sterile towel and pushing the perineum downard with one hand while
the other hand is supporting the babys head as it goes out of the vaginal opening.
35. Answer: (D) Retractor
For normal vaginal delivery, the nurse needs only the instruments for cutting the
umbilical cord such as: 2 clamps (straight or curve) and a pair of scissors as well as the
kidney basin to receive the placenta. The retractor is not part of the basic set. In the
hospital setting, needle holder and tissue forceps are added especially if the woman
delivering the baby is a primigravida wherein episiotomy is generally done.
36. Answer: (A) Inspect the placenta for completeness including the membranes
The placenta must be inspected for completeness to include the membranes because an
incomplete placenta could mean that there is retention of placental fragments which can
lead to uterine atony. If the uterus does not contract adequately, hemorrhage can occur.
37. Answer: (B) Oxytocin can make the cervix close and thus trap the placenta inside
The action of oxytocin is to make the uterus contract as well make the cervix close. If it
is given prior to placental delivery, the placenta will be trapped inside because the action
of the drug is almost immediate if given parentally.
38. Answer: (A) There is a fluid shift from the placental circulation to the maternal
circulation which can overload the compromised heart.
During the pregnancy, there is an increase in maternal blood volume to accommodate the
need of the fetus. When the baby and placenta have been delivered, there is a fluid shift
back to the maternal circulation as part of physiologic adaptation during the postpartum
period. In cesarean section, the fluid shift occurs faster because the placenta is taken out
right after the baby is delivered giving it less time for the fluid shift to gradually occur.
39. Answer: (B) Pitocin
The common oxytocin given to enhance uterine contraction is pitocin. This is also the
drug given to induce labor.
40. Answer: (B) Fluid intake and output

Partograph is a monitoring tool designed by the World Health Organization for use by
health workers when attending to mothers in labor especially the high risk ones. For
maternal parameters all of the above is placed in the partograph except the fluid intake
since this is placed in a separate monitoring sheet.
41. Answer: (C) Ritgens maneuver
Ritgens method is used to prevent perineal tear/laceration during the delivery of the
fetal head. Lamaze method is also known as psychoprophylactic method and Dick-Read
method are commonly known natural childbirth procedures which advocate the use of
non-pharmacologic measures to relieve labor pain.
42. Answer: (B) Full bladder
Full bladder can impede the descent of the fetal head. The nurse can readily manage this
problem by doing a simple catheterization of the mother.
43. Answer: (B) During a uterine contraction
The primary power of labor and delivery is the uterine contraction. This should be
augmented by the mothers bearing down during a contraction.
44. Answer: (A) 1.2 cm./hr
For nullipara the normal cervical dilatation should be 1.2 cm/hr. If it is less than that, it
is considered a protracted active phase of the first stage. For multipara, the normal
cervical dilatation is 1.5 cm/hr.
45. Answer: (B) Station 0
Station is defined as the relationship of the fetal head and the level of the ischial spine.
At the level of the ischial spine, the station is 0. Above the ischial spine it is considered
(-) station and below the ischial spine it is (+) station.
46. Answer: (A) LOA
The landmark used in determine fetal position is the posterior fontanel because this is the
nearest to the occiput. So if the nurse palpated the occiput (O) at the left (L) side of the
mother and at the upper/anterior (A) quadrant then the fetal position is LOA.
47. Answer: (D) Incomplete
Breech presentation means the buttocks of the fetus is the presenting part. If it is only
the foot/feet, it is considered footling. If only the buttocks, it is frank breech. If both the
feet and the buttocks are presenting it is called complete breech.
48. Answer: (C) Floating
The term floating means the fetal presenting part has not entered/descended into the
pelvic inlet. If the fetal head has entered the pelvic inlet, it is said to be engaged.
49. Answer: (B) 30 minutes
The placenta is delivered within 30 minutes from the delivery of the baby. If it takes
longer, probably the placenta is abnormally adherent and there is a need to refer already
to the obstetrician.
50. Answer: (A) Under breast to mid-thigh including the pubic area
Shaving is done to prevent infection and the area usually shaved should sufficiently cover
the area for surgery, cesarean section. The pubic hair is definitely to be included in the
shaving
Introduction
The last part of our Maternity Nursing exam! This is a 50-item test that covers topics about the
postpartum period of pregnancy.
Topics
Postpartum period
Lochia
Theories about postpartum
Newborn care
Newborn screening
APGAR
Family Planning Methods
Guidelines
Questions
Text
Practice
Exam
1. Postpartum Period:
The fundus of the uterus is expected to go down normally postpartally about __ cm
per day.
A. 1.0 cm
B. 2.0 cm
C. 2.5 cm
D. 3.0 cm
2. The lochia on the first few days after delivery is characterized as
A. Pinkish with some blood clots
B. Whitish with some mucus
C. Reddish with some mucus
D. Serous with some brown tinged mucus
3. Lochia normally disappears after how many days postpartum?
A. 5 days
B. 7-10 days
C. 18-21 days
D. 28-30 days
4. After an Rh(-) mother has delivered her Rh (+) baby, the mother is given RhoGam.
This is done in order to:
A. Prevent the recurrence of Rh(+) baby in future pregnancies
B. Prevent the mother from producing antibodies against the Rh(+) antigen that she may
have gotten when she delivered to her Rh(+) baby
C. Ensure that future pregnancies will not lead to maternal illness
D. To prevent the newborn from having problems of incompatibility when it breastfeeds
5. To enhance milk production, a lactating mother must do the following interventions
EXCEPT:
A. Increase fluid intake including milk
B. Eat foods that increases lactation which are called galactagues
C. Exercise adequately like aerobics
D. Have adequate nutrition and rest
6. The nursing intervention to relieve pain in breast engorgement while the mother
continues to breastfeed is
A. Apply cold compress on the engorged breast
B. Apply warm compress on the engorged breast
C. Massage the breast
D. Apply analgesic ointment
7. A woman who delivered normally per vagina is expected to void within ___ hours
after delivery.
A. 3 hrs
B. 4 hrs.
C. 6-8 hrs
D. 12-24 hours
8. To ensure adequate lactation the nurse should teach the mother to:
A. Breast feed the baby on self-demand day and night
B. Feed primarily during the day and allow the baby to sleep through the night
C. Feed the baby every 3-4 hours following a strict schedule
D. Breastfeed when the breast are engorged to ensure adequate supply
9. An appropriate nursing intervention when caring for a postpartum mother with
thrombophlebitis is:
A. Encourage the mother to ambulate to relieve the pain in the leg
B. Instruct the mother to apply elastic bondage from the foot going towards the knee to
improve venous return flow
C. Apply warm compress on the affected leg to relieve the pain
D. Elevate the affected leg and keep the patient on bedrest
10. The nurse should anticipate that hemorrhage related to uterine atony may occur
postpartally if this condition was present during the delivery:
A. Excessive analgesia was given to the mother
B. Placental delivery occurred within thirty minutes after the baby was born
C. An episiotomy had to be done to facilitate delivery of the head
D. The labor and delivery lasted for 12 hours
11. According to Rubins theory of maternal role adaptation, the mother will go
through 3 stages during the post partum perioD. These stages are:
A. Going through, adjustment period, adaptation period
B. Taking-in, taking-hold and letting-go
C. Attachment phase, adjustment phase, adaptation phase
D. Taking-hold, letting-go, attachment phase
12. The neonate of a mother with diabetes mellitus is prone to developing
hypoglycemia because:
A. The pancreas is immature and unable to secrete the needed insulin
B. There is rapid diminution of glucose level in the babys circulating blood and his
pancreas is normally secreting insulin

C. The baby is reacting to the insulin given to the mother
D. His kidneys are immature leading to a high tolerance for glucose
13. Which of the following is an abnormal vital sign in postpartum?
A. Pulse rate between 50-60/min
B. BP diastolic increase from 80 to 95mm Hg
C. BP systolic between 100-120mm Hg
D. Respiratory rate of 16-20/min
14. The uterine fundus right after delivery of placenta is palpable at
A. Level of Xyphoid process
B. Level of umbilicus
C. Level of symphysis pubis
D. Midway between umbilicus and symphysis pubis
15. After how many weeks after delivery should a woman have her postpartal checkup based on the protocol followed by the DOH Philippines?
A. 2 weeks
B. 3 weeks
C. 6 weeks
D. 12 weeks
16. In a woman who is not breastfeeding, menstruation usually occurs after how many
weeks?
A. 2-4 weeks
B. 6-8 weeks
C. 6 months
D. 12 months
17. The following are nursing measures to stimulate lactation EXCEPT
A. Frequent regular breast feeding

B. Breast pumping
C. Breast massage
D. Application of cold compress on the breast
18. When the uterus is firm and contracted after delivery but there is vaginal
bleeding, the nurse should suspect
A. Laceration of soft tissues of the cervix and vagina
B. Uterine atony
C. Uterine inversion
D. Uterine hypercontractility
19. The following are interventions to make the fundus contract postpartally EXCEPT
A. Make the baby suck the breast regularly
B. Apply ice cap on fundus
C. Massage the fundus vigorously for 15 minutes until contracted
D. Give oxytocin as ordered
20. The following are nursing interventions to relieve episiotomy wound pain EXCEPT
A. Giving analgesic as ordered
B. Sitz bath
C. Perineal heat
D. Perineal care
21. Postpartum blues is said to be normal provided that the following characteristics
are present. These are
1. Within 3-10 days only;
2. Woman exhibits the following symptoms- episodic tearfulness, fatigue, oversensitivity,
poor appetite;
3. Maybe more severe symptoms in primpara
A. All of the above
B. 1 and 2
C. 2 only
D. 2 and 3
22. The neonatal circulation differs from the fetal circulation because
A. The fetal lungs are non-functioning as an organ and most of the blood in the fetal
circulation is mixed blooD.
B. The blood at the left atrium of the fetal heart is shunted to the right atrium to
facilitate its passage to the lungs
C. The blood in left side of the fetal heart contains oxygenated blood while the blood in
the right side contains unoxygenated blooD.
23. The normal respiration of a newborn immediately after birth is characterized as:
A. Shallow and irregular with short periods of apnea lasting not longer than 15 seconds,
30-60 breaths per minute
B. 20-40 breaths per minute, abdominal breathing with active use of intercostals muscles
C. 30-60 breaths per minute with apnea lasting more than 15 seconds, abdominal
breathing
D. 30-50 breaths per minute, active use of abdominal and intercostal muscles
24. The anterior fontanelle is characterized as:
A. 3-4 cm antero-posterior diameter and 2-3 cm transverse diameter, diamond shape
B. 2-3 cm antero-posterior diameter and 3-4 cm transverse diameter and diamond shape
C. 2-3 cm in both antero-posterior and transverse diameter and diamond shape
D. none of the above
25. The ideal site for vitamin K injection in the newborn is:
A. Right upper arm
B. Left upper arm
C. Either right or left buttocks
D. Middle third of the thigh
26. At what APGAR score at 5 minutes after birth should resuscitation be initiated?
A. 1-3
B. 7-8
C. 9-10
D. 6-7
27. Right after birth, when the skin of the babys trunk is pinkish but the soles of the
feet and palm of the hands are bluish this is called:
A. Syndactyly
B. Acrocyanosis
C. Peripheral cyanosis
D. Cephalo-caudal cyanosis
28. The minimum birth weight for full term babies to be considered normal is:
A. 2,000gms
B. 1,500gms
C. 2,500gms
D. 3,000gms
29. The procedure done to prevent ophthalmia neonatorum is:
A. Marmets technique
B. Credes method
C. Ritgens method
D. Ophthalmic wash
30. Which of the following characteristics will distinguish a postmature neonate at
birth?
A. Plenty of lanugo and vernix caseosa
B. Lanugo mainly on the shoulders and vernix in the skin folds
C. Pinkish skin with good turgor
D. Almost leather-like, dry, cracked skin, negligible vernix caseosa
31. According to the Philippine Nursing Law, a registered nurse is allowed to handle
mothers in labor and delivery with the following considerations:
1. The pregnancy is normal.;

2. The labor and delivery is uncomplicated;
3. Suturing of perineal laceration is allowed provided the nurse had special training;
4. As a delivery room nurse she is not allowed to insert intravenous fluid unless she had
special training for it.
A. 1 and 2
B. 1, 2, and 3
C. 3 and 4
D. 1, 2, and 4
32. Birth Control Methods and Infertility:
In basal body temperature (BBT) technique, the sign that ovulation has occurred is an
elevation of body temperature by
A. 1.0-1.4 degrees centigrade
B. 0.2-0.4 degrees centigrade
C. 2.0-4.0 degrees centigrade
D. 1.0-4.0 degrees centigrade
33. Lactation Amenorrhea Method(LAM) can be an effective method of natural birth
control if
A. The mother breast feeds mainly at night time when ovulation could possibly occur
B. The mother breastfeeds exclusively and regularly during the first 6 months without
giving supplemental feedings
C. The mother uses mixed feeding faithfully
D. The mother breastfeeds regularly until 1 year with no supplemental feedings
34. Intra-uterine device prevents pregnancy by the ff. mechanism EXCEPT
A. Endometrium inflames
B. Fundus contracts to expel uterine contents
C. Copper embedded in the IUD can kill the sperms
D. Sperms will be barred from entering the fallopian tubes
35. Oral contraceptive pills are of different types. Which type is most appropriate for
mothers who are breastfeeding?
A. Estrogen only
B. Progesterone only
C. Mixed type- estrogen and progesterone
D. 21-day pills mixed type
36. The natural family planning method called Standard Days (SDM), is the latest type
and easy to use methoD. However, it is a method applicable only to women with
regular menstrual cycles between ___ to ___ days.
A. 21-26 days
B. 26-32 days
C. 28-30 days
D. 24- 36 days
37. Which of the following are signs of ovulation?
1. Mittelschmerz;
2. Spinnabarkeit;
3. Thin watery cervical mucus;
4. Elevated body temperature of 4.0 degrees centigrade
A. 1 & 2
B. 1, 2, & 3
C. 3 & 4
D. 1, 2, 3, 4
38. The following methods of artificial birth control works as a barrier device EXCEPT:
A. Condom
B. Cervical cap
C. Cervical Diaphragm
D. Intrauterine device (IUD)
39. Which of the following is a TRUE statement about normal ovulation?
A. It occurs on the 14th day of every cycle

B. It may occur between 14-16 days before next menstruation
C. Every menstrual period is always preceded by ovulation
D. The most fertile period of a woman is 2 days after ovulation
40. If a couple would like to enhance their fertility, the following means can be done:
1. Monitor the basal body temperature of the woman everyday to determine peak
period of fertility;
2. Have adequate rest and nutrition;
3. Have sexual contact only during the dry period of the woman;
4. Undergo a complete medical check-up to rule out any debilitating disease
A. 1 only
B. 1 & 4
C. 1,2,4
D. 1,2,3,4
41. In sympto-thermal method, the parameters being monitored to determine if the
woman is fertile or infertile are:
A. Temperature, cervical mucus, cervical consistency
B. Release of ovum, temperature and vagina
C. Temperature and wetness
D. Temperature, endometrial secretion, mucus
42. The following are important considerations to teach the woman who is on low
dose (mini-pill) oral contraceptive EXCEPT:
A. The pill must be taken everyday at the same time
B. If the woman fails to take a pill in one day, she must take 2 pills for added protection
C. If the woman fails to take a pill in one day, she needs to take another temporary
method until she has consumed the whole pack
D. If she is breast feeding, she should discontinue using mini-pill and use the progestinonly type
43. To determine if the cause of infertility is a blockage of the fallopian tubes, the
test to be done is
A. Huhners test
B. Rubins test
C. Postcoital test
44. Infertility can be attributed to male causes such as the following EXCEPT:
A. Cryptorchidism
B. Orchitis
C. Sperm count of about 20 million per milliliter
D. Premature ejaculation
45. Spinnabarkeit is an indicator of ovulation which is characterized as:
A. Thin watery mucus which can be stretched into a long strand about 10 cm
B. Thick mucus that is detached from the cervix during ovulation
C. Thin mucus that is yellowish in color with fishy odor
D. Thick mucus vaginal discharge influence by high level of estrogen
46. Vasectomy is a procedure done on a male for sterilization. The organ involved in
this procedure is
A. Prostate gland
B. Seminal vesicle
C. Testes
D. Vas deferens
47. Breast self examination is best done by the woman on herself every month during
A. The middle of her cycle to ensure that she is ovulating
B. During the menstrual period
C. Right after the menstrual period so that the breast is not being affected by the
increase in hormones particularly estrogen
D. Just before the menstrual period to determine if ovulation has occurred
48. A woman is considered to be menopause if she has experienced cessation of her

menses for a period of
A. 6 months
B. 12 months
C. 18 months
D. 24 months
49. Which of the following is the correct practice of self breast examination in a
menopausal woman?
A. She should do it at the usual time that she experiences her menstrual period in the
past to ensure that her hormones are not at its peak
B. Any day of the month as long it is regularly observed on the same day every month
C. Anytime she feels like doing it ideally every day
D. Menopausal women do not need regular self breast exam as long as they do it at least
once every 6 months
50. In assisted reproductive technology (ART), there is a need to stimulate the ovaries
to produce more than one mature ovA. The drug commonly used for this purpose is:
A. Bromocriptine
B. Clomiphene
C. Provera
D. Estrogen

Here are the answers and rationale for this exam. Counter check your answers to those
below and tell us your scores. If you have any disputes or need more clarification to a
certain question, please direct them to the comments section.
1. Answer: (A) 1.0 cm
The uterus will begin involution right after delivery. It is expected to regress/go down by
1 cm. per day and becomes no longer palpable about 1 week after delivery.
2. Answer: (C) Reddish with some mucus

Right after delivery, the vaginal discharge called lochia will be reddish because there is
some blood, endometrial tissue and mucus. Since it is not pure blood it is non-clotting.
Normally, lochia disappears after 10 days postpartum. Whats important to remember is
that the color of lochia gets to be lighter (from reddish to whitish) and scantier everyday.
4. Answer: (B) Prevent the mother from producing antibodies against the Rh(+)
antigen that she may have gotten when she delivered to her Rh(+) baby
In Rh incompatibility, an Rh(-) mother will produce antibodies against the fetal Rh (+)
antigen which she may have gotten because of the mixing of maternal and fetal blood
during labor and delivery. Giving her RhoGam right after birth will prevent her immune
system from being permanently sensitized to Rh antigen.
5. Answer: (C) Exercise adequately like aerobics
All the above nursing measures are needed to ensure that the mother is in a healthy
state. However, aerobics does not necessarily enhance lactation.
6. Answer: (B) Apply warm compress on the engorged breast
Warm compress is applied if the purpose is to relieve pain but ensure lactation to
continue. If the purpose is to relieve pain as well as suppress lactation, the compress
applied is cold.
7. Answer: (C) 6-8 hrs
A woman who has had normal delivery is expected to void within 6-8 hrs. If she is unable
to do so after 8 hours, the nurse should stimulate the woman to void. If nursing
interventions to stimulate spontaneous voiding dont work, the nurse may decide to
catheterize the woman.
8. Answer: (A) Breast feed the baby on self-demand day and night
Feeding on self-demand means the mother feeds the baby according to babys need.
Therefore, this means there will be regular emptying of the breasts, which is essential to
maintain adequate lactation.
9. Answer: (D) Elevate the affected leg and keep the patient on bedrest
If the mother already has thrombophlebitis, the nursing intervention is bedrest to prevent
the possible dislodging of the thrombus and keeping the affected leg elevated to help
reduce the inflammation.
10. Answer: (A) Excessive analgesia was given to the mother
Excessive analgesia can lead to uterine relaxation thus lead to hemorrhage postpartally.
Both B and D are normal and C is at the vaginal introitus thus will not affect the uterus.
11. Answer: (B) Taking-in, taking-hold and letting-go
Rubins theory states that the 3 stages that a mother goes through for maternal
adaptation are: taking-in, taking-hold and letting-go. In the taking-in stage, the mother is
more passive and dependent on others for care. In taking-hold, the mother begins to
assume a more active role in the care of the child and in letting-go, the mother has
become adapted to her maternal role.
12. Answer: (B) There is rapid diminution of glucose level in the babys circulating
blood and his pancreas is normally secreting insulin
If the mother is diabetic, the fetus while in utero has a high supply of glucose. When the
baby is born and is now separate from the mother, it no longer receives a high dose of
glucose from the mother. In the first few hours after delivery, the neonate usually does
not feed yet thus this can lead to hypoglycemia.
13. Answer: (B) BP diastolic increase from 80 to 95mm Hg
All the vital signs given in the choices are within normal range except an increase of
15mm Hg in the diastolic which is a possible sign of hypertension in pregnancy.
14. Answer: (B) Level of umbilicus
Immediately after the delivery of the placenta, the fundus of the uterus is expected to be
at the level of the umbilicus because the contents of the pregnancy have already been
expelled. The fundus is expected to recede by 1 fingerbreadths (1cm) everyday until it
becomes no longer palpable above the symphysis pubis.
According to the DOH protocol postpartum check-up is done 6-8 weeks after delivery to
make sure complete involution of the reproductive organs has be achieved.
16. Answer: (B) 6-8 weeks
When the mother does not breastfeed, the normal menstruation resumes about 6-8 weeks
after delivery. This is due to the fact that after delivery, the hormones estrogen and
progesterone gradually decrease thus triggering negative feedback to the anterior
pituitary to release the Folicle-Stimulating Hormone (FSH) which in turn stimulates the
ovary to again mature a graafian follicle and the menstrual cycle post pregnancy resumes.
17. Answer: (D) Application of cold compress on the breast
To stimulate lactation, warm compress is applied on the breast. Cold application will
cause vasoconstriction thus reducing the blood supply consequently the production of
milk.
18. Answer: (A) Laceration of soft tissues of the cervix and vagina
When uterus is firm and contracted it means that the bleeding is not in the uterus but
other parts of the passageway such as the cervix or the vagina.
19. Answer: (C) Massage the fundus vigorously for 15 minutes until contracted
Massaging the fundus of the uterus should not be vigorous and should only be done until
the uterus feel firm and contracted. If massaging is vigorous and prolonged, the uterus
will relax due to over stimulation.
20. Answer: (D) Perineal care
Perineal care is primarily done for personal hygiene regardless of whether there is pain or
not; episiotomy wound or not.
21. Answer: (A) All of the above
All the symptoms 1-3 are characteristic of postpartal blues. It will resolve by itself
because it is transient and is due to a number of reasons like changes in hormonal levels
and adjustment to motherhood. If symptoms lasts more than 2 weeks, this could be a sign
of abnormality like postpartum depression and needs treatment.
22. Answer: (A) The fetal lungs are non-functioning as an organ and most of the blood
in the fetal circulation is mixed blood.
The fetal lungs is fluid-filled while in utero and is still not functioning. It only begins to
function in extra uterine life. Except for the blood as it enters the fetus immediately
from the placenta, most of the fetal blood is mixed blood.
23. Answer: (A) Shallow and irregular with short periods of apnea lasting not longer
than 15 seconds, 30-60 breaths per minute
A newly born baby still is adjusting to xtra uterine life and the lungs are just beginning to
function as a respiratory organ. The respiration of the baby at this time is characterized
as usually shallow and irregular with short periods of apnea, 30-60 breaths per minute.
The apneic periods should be brief lasting not more than 15 seconds otherwise it will be
considered abnormal.
24. Answer: (A) 3-4 cm antero-posterior diameter and 2-3 cm transverse diameter,
diamond shape
The anterior fontanelle is diamond shape with the antero-posterior diameter being longer
than the transverse diameter. The posterior fontanelle is triangular shape.
25.Answer: (D) Middle third of the thigh
Neonates do not have well developed muscles of the arm. Since Vitamin K is given
intramuscular, the site must have sufficient muscles like the middle third of the thigh.
26.Answer: (A) 1-3
An APGAR of 1-3 is a sign of fetal distress which requires resuscitation. The baby is alright
if the score is 8-10.
27. Answer: (B) Acrocyanosis
Acrocyanosis is the term used to describe the babys skin color at birth when the soles
and palms are bluish but the trunk is pinkish.
28. Answer: (C) 2,500gms
According to the WHO standard, the minimum normal birth weight of a full term baby is
2,500 gms or 2.5 Kg.
29. Answer: (B) Credes method
Credes method/prophylaxis is the procedure done to prevent ophthalmia neonatorum
which the baby can acquire as it passes through the birth canal of the mother. Usually, an
ophthalmic ointment is used.
30. Answer: (D) Almost leather-like, dry, cracked skin, negligible vernix caseosa
A post mature fetus has the appearance of an old person with dry wrinkled skin and the
vernix caseosa has already diminished.
31. Answer: (B) 1, 2, and 3
To be allowed to handle deliveries, the pregnancy must be normal and uncomplicated.
And in RA9172, the nurse is now allowed to suture perineal lacerations provided s/he has
had the special training. Also, in this law, there is no longer an explicit provision stating
that the nurse still needs special training for IV insertion.
32. Answer: (B) 0.2-0.4 degrees centigrade
The release of the hormone progesterone in the body following ovulation causes a slight
elevation of basal body temperature of about 0.2 0.4 degrees centigrade
33. Answer: (B) The mother breastfeeds exclusively and regularly during the first 6
months without giving supplemental feedings
A mother who breastfeeds exclusively and regularly during the first 6 months benefits
from lactation amenorrhea. There is evidence to support the observation that the
benefits of lactation amenorrhea lasts for 6 months provided the woman has not had her
first menstruation since delivery of the baby.
34. Answer: (D) Sperms will be barred from entering the fallopian tubes
An intrauterine device is a foreign body so that if it is inserted into the uterine cavity the
initial reaction is to produce inflammatory process and the uterus will contract in order to
try to expel the foreign body. Usually IUDs are coated with copper to serve as spermicide
killing the sperms deposited into the female reproductive tract. But the IUD does not
completely fill up the uterine cavity thus sperms which are microscopic is size can still
pass through.
35. Answer: (B) Progesterone only
If mother is breastfeeding, the progesterone only type is the best because estrogen can
affect lactation.
Standard Days Method (SDM) requires that the menstrual cycles are regular between 26-32
days. There is no need to monitor temperature or mucus secretion. This natural method
of family planning is very simple since all that the woman pays attention to is her cycle.
With the aid of CycleBeads, the woman can easily monitor her cycles.
37. Answer: (B) 1, 2, & 3
Mittelschmerz, spinnabarkeit and thin watery cervical mucus are signs of ovulation. When
ovulation occurs, the hormone progesterone is released which can cause a slight elevation
of temperature between 0.2-0.4 degrees centigrade and not 4 degrees centigrade.
38. Answer: (D) Intrauterine device (IUD)

Intrauterine device prevents pregnancy by not allowing the fertilized ovum from
implanting on the endometrium. Some IUDs have copper added to it which is spermicidal.
It is not a barrier since the sperms can readily pass through and fertilize an ovum at the
fallopian tube.
39. Answer: (B) It may occur between 14-16 days before next menstruation
Not all menstrual cycles are ovulatory. Normal ovulation in a woman occurs between the
14th to the 16th day before the NEXT menstruation. A common misconception is that
ovulation occurs on the 14th day of the cycle. This is a misconception because ovulation
is determined NOT from the first day of the cycle but rather 14-16 days BEFORE the next
menstruation.
40. Answer: (C) 1,2,4
All of the above are essential for enhanced fertility except no. 3 because during the dry
period the woman is in her infertile period thus even when sexual contact is done, there
will be no ovulation, thus fertilization is not possible.
41.Answer: (A) Temperature, cervical mucus, cervical consistency
The 3 parameters measured/monitored which will indicate that the woman has ovulated
are- temperature increase of about 0.2-0.4 degrees centigrade, softness of the cervix and
cervical mucus that looks like the white of an egg which makes the woman feel wet.
42. Answer: (B) If the woman fails to take a pill in one day, she must take 2 pills for
added protection
If the woman fails to take her usual pill for the day, taking a double dose does not give
additional protection. What she needs to do is to continue taking the pills until the pack
is consumed and use at the time another temporary method to ensure that no pregnancy
will occur. When a new pack is started, she can already discontinue using the second
temporary method she employed.
43.Answer: (B) Rubins test
Rubins test is a test to determine patency of fallopian tubes. Huhners test is also known
as post-coital test to determine compatibility of the cervical mucus with sperms of the
sexual partner.
44. Answer: (C) Sperm count of about 20 million per milliliter

Sperm count must be within normal in order for a male to successfully sire a child. The
normal sperm count is 20 million per milliliter of seminal fluid or 50 million per ejaculate.
45. Answer: (A) Thin watery mucus which can be stretched into a long strand about 10
cm
At the midpoint of the cycle when the estrogen level is high, the cervical mucus becomes
thin and watery to allow the sperm to easily penetrate and get to the fallopian tubes to
fertilize an ovum. This is called spinnabarkeit. And the woman feels wet. When
progesterone is secreted by the ovary, the mucus becomes thick and the woman will feel
dry.
46. Answer: (D) Vas deferens
Vasectomy is a procedure wherein the vas deferens of the male is ligated and cut to
prevent the passage of the sperms from the testes to the penis during ejaculation.
47. Answer: (C) Right after the menstrual period so that the breast is not being
affected by the increase in hormones particularly estrogen
The best time to do self breast examination is right after the menstrual period is over so
that the hormonal level is low thus the breasts are not tender.
If a woman has not had her menstrual period for 12 consecutive months, she is considered
to be in her menopausal stage.
49. Answer: (B) Any day of the month as long it is regularly observed on the same day
every month
Menopausal women still need to do self examination of the breast regularly. Any day of
the month is alright provided that she practices it monthly on the same day that she has
chosen. The hormones estrogen and progesterone are already diminished during
menopause so there is no need to consider the time to do it in relation to the menstrual
cycle.
50. Answer: (B) Clomiphene
Clomiphene or Clomid acts as an ovarian stimulant to promote ovulation. The mature ova
are retrieved and fertilized outside the fallopian tube (in-vitro fertilization) and after 48
hours the fertilized ovum is inserted into the uterus for implantation.
Introduction
Take our 50-item examination about Maternal and Child Health Nursing. Is your knowledge about the
concept enough?
Topics
Reproductive system
Pregnancy
Family Planning
Complications of pregnancy
Guidelines
Answers and rationales are given below. Be sure to read them.
Questions
Text
Practice
Exam
1. When assessing the adequacy of sperm for conception to occur, which of the
following is the most useful criterion?
A. Sperm count
B. Sperm motility
C. Sperm maturity
D. Semen volume
2. A couple who wants to conceive but has been unsuccessful during the last 2 years
has undergone many diagnostic procedures. When discussing the situation with the
nurse, one partner states, We know several friends in our age group and all of them
have their own child already, Why cant we have one?. Which of the following would
be the most pertinent nursing diagnosis for this couple?
A. Fear related to the unknown
B. Pain related to numerous procedures.
C. Ineffective family coping related to infertility.
D. Self-esteem disturbance related to infertility.
3. Which of the following urinary symptoms does the pregnant woman most
frequently experience during the first trimester?
A. Dysuria
B. Frequency
C. Incontinence
D. Burning
4. Heartburn and flatulence, common in the second trimester, are most likely the
result of which of the following?
A. Increased plasma HCG levels
B. Decreased intestinal motility
C. Decreased gastric acidity
D. Elevated estrogen levels
5. On which of the following areas would the nurse expect to observe chloasma?
A. Breast, areola, and nipples

B. Chest, neck, arms, and legs
C. Abdomen, breast, and thighs
D. Cheeks, forehead, and nose
6. A pregnant client states that she waddles when she walks. The nurses
explanation is based on which of the following as the cause?
A. The large size of the newborn
B. Pressure on the pelvic muscles
C. Relaxation of the pelvic joints
D. Excessive weight gain
7. Which of the following represents the average amount of weight gained during
pregnancy?
A. 12 to 22 lb
B 15 to 25 lb
C. 24 to 30 lb
D. 25 to 40 lb
8. When talking with a pregnant client who is experiencing aching swollen, leg veins,
the nurse would explain that this is most probably the result of which of the
following?
A. Thrombophlebitis
B. Pregnancy-induced hypertension
C. Pressure on blood vessels from the enlarging uterus
D. The force of gravity pulling down on the uterus
9. Cervical softening and uterine souffle are classified as which of the following?
A. Diagnostic signs
B. Presumptive signs
C. Probable signs
D. Positive signs
10. Which of the following would the nurse identify as a presumptive sign of
pregnancy?
A. Hegar sign
B. Nausea and vomiting
C. Skin pigmentation changes
D. Positive serum pregnancy test
11. Which of the following common emotional reactions to pregnancy would the nurse
expect to occur during the first trimester?
A. Introversion, egocentrism, narcissism
B. Awkwardness, clumsiness, and unattractiveness
C. Anxiety, passivity, extroversion
D. Ambivalence, fear, fantasies
12. During which of the following would the focus of classes be mainly on physiologic
changes, fetal development, sexuality, during pregnancy, and nutrition?
A. Prepregnant period
B. First trimester
C. Second trimester
D. Third trimester
13. Which of the following would be disadvantage of breast feeding?
A. Involution occurs more rapidly
B. The incidence of allergies increases due to maternal antibodies
C. The father may resent the infants demands on the mothers body
D. There is a greater chance for error during preparation
14. Which of the following would cause a false-positive result on a pregnancy test?
A. The test was performed less than 10 days after an abortion
B. The test was performed too early or too late in the pregnancy
C. The urine sample was stored too long at room temperature
D. A spontaneous abortion or a missed abortion is impending
15. FHR can be auscultated with a fetoscope as early as which of the following?
A. 5 weeks gestation
B. 10 weeks gestation
C. 15 weeks gestation
D. 20 weeks gestation
16. A client LMP began July 5. Her EDD should be which of the following?
A. January 2
B. March 28
C. April 12
D. October 12
17. Which of the following fundal heights indicates less than 12 weeks gestation
when the date of the LMP is unknown?
A. Uterus in the pelvis
B. Uterus at the xiphoid
C. Uterus in the abdomen
D. Uterus at the umbilicus
18. Which of the following danger signs should be reported promptly during the
antepartum period?
A. Constipation
B. Breast tenderness
C. Nasal stuffiness
D. Leaking amniotic fluid
19. Which of the following prenatal laboratory test values would the nurse consider as
significant?
A. Hematocrit 33.5%
B. Rubella titer less than 1:8
C. White blood cells 8,000/mm3
D. One hour glucose challenge test 110 g/dL
20. Which of the following characteristics of contractions would the nurse expect to
find in a client experiencing true labor?
A. Occurring at irregular intervals
B. Starting mainly in the abdomen
C. Gradually increasing intervals
D. Increasing intensity with walking
21. During which of the following stages of labor would the nurse assess crowning?
A. First stage
B. Second stage
C. Third stage
D. Fourth stage
22. Barbiturates are usually not given for pain relief during active labor for which of
the following reasons?
A. The neonatal effects include hypotonia, hypothermia, generalized drowsiness, and
reluctance to feed for the first few days.
B. These drugs readily cross the placental barrier, causing depressive effects in the
newborn 2 to 3 hours after intramuscular injection.
C. They rapidly transfer across the placenta, and lack of an antagonist make them
generally inappropriate during labor.
D. Adverse reactions may include maternal hypotension, allergic or toxic reaction or
partial or total respiratory failure
23. Which of the following nursing interventions would the nurse perform during the
third stage of labor?
A. Obtain a urine specimen and other laboratory tests.
B. Assess uterine contractions every 30 minutes.
C. Coach for effective client pushing
D. Promote parent-newborn interaction.
24. Which of the following actions demonstrates the nurses understanding about the
newborns thermoregulatory ability?
A. Placing the newborn under a radiant warmer.

B. Suctioning with a bulb syringe
C. Obtaining an Apgar score
D. Inspecting the newborns umbilical cord
25. Immediately before expulsion, which of the following cardinal movements occur?
A. Descent
B. Flexion
C. Extension
D. External rotation
26. Before birth, which of the following structures connects the right and left auricles
of the heart?
A. Umbilical vein
B. Foramen ovale
C. Ductus arteriosus
D. Ductus venosus
27. Which of the following when present in the urine may cause a reddish stain on the
diaper of a newborn?
A. Mucus
B. Uric acid crystals
C. Bilirubin
D. Excess iron
28. When assessing the newborns heart rate, which of the following ranges would be
considered normal if the newborn were sleeping?
A. 80 beats per minute
B. 100 beats per minute
C. 120 beats per minute
D. 140 beats per minute
29. Which of the following is true regarding the fontanels of the newborn?
A. The anterior is triangular shaped; the posterior is diamond shaped.

B. The posterior closes at 18 months; the anterior closes at 8 to 12 weeks.
C. The anterior is large in size when compared to the posterior fontanel.
D. The anterior is bulging; the posterior appears sunken.
30. Which of the following groups of newborn reflexes below are present at birth and
remain unchanged through adulthood?
A. Blink, cough, rooting, and gag
B. Blink, cough, sneeze, gag
C. Rooting, sneeze, swallowing, and cough
D. Stepping, blink, cough, and sneeze
31. Which of the following describes the Babinski reflex?
A. The newborns toes will hyperextend and fan apart from dorsiflexion of the big toe
when one side of foot is stroked upward from the ball of the heel and across the ball of
the foot.
B. The newborn abducts and flexes all extremities and may begin to cry when exposed to
sudden movement or loud noise.
C. The newborn turns the head in the direction of stimulus, opens the mouth, and begins
to suck when cheek, lip, or corner of mouth is touched.
D. The newborn will attempt to crawl forward with both arms and legs when he is placed
on his abdomen on a flat surface
32. Which of the following statements best describes hyperemesis gravidarum?
A. Severe anemia leading to electrolyte, metabolic, and nutritional imbalances in the
absence of other medical problems.
B. Severe nausea and vomiting leading to electrolyte, metabolic, and nutritional
imbalances in the absence of other medical problems.
C. Loss of appetite and continuous vomiting that commonly results in dehydration and
ultimately decreasing maternal nutrients
D. Severe nausea and diarrhea that can cause gastrointestinal irritation and possibly
internal bleeding
33. Which of the following would the nurse identify as a classic sign of PIH?
A. Edema of the feet and ankles

B. Edema of the hands and face
C. Weight gain of 1 lb/week
D. Early morning headache
34. In which of the following types of spontaneous abortions would the nurse assess
dark brown vaginal discharge and a negative pregnancy tests?
A. Threatened
B. Imminent
C. Missed
D. Incomplete
35. Which of the following factors would the nurse suspect as predisposing a client to
placenta previa?
A. Multiple gestation
B. Uterine anomalies
C. Abdominal trauma
D. Renal or vascular disease
36. Which of the following would the nurse assess in a client experiencing abruptio
placenta?
A. Bright red, painless vaginal bleeding
B. Concealed or external dark red bleeding
C. Palpable fetal outline
D. Soft and nontender abdomen
37. Which of the following is described as premature separation of a normally
implanted placenta during the second half of pregnancy, usually with severe
hemorrhage?
A. Placenta previa
B. Ectopic pregnancy
C. Incompetent cervix
D. Abruptio placentae
38. Which of the following may happen if the uterus becomes overstimulated by
oxytocin during the induction of labor?
A. Weak contraction prolonged to more than 70 seconds
B. Tetanic contractions prolonged to more than 90 seconds
C. Increased pain with bright red vaginal bleeding
D. Increased restlessness and anxiety
39. When preparing a client for cesarean delivery, which of the following key
concepts should be considered when implementing nursing care?
A. Instruct the mothers support person to remain in the family lounge until after the
delivery
B. Arrange for a staff member of the anesthesia department to explain what to expect
postoperatively
C. Modify preoperative teaching to meet the needs of either a planned or emergency
cesarean birth
D. Explain the surgery, expected outcome, and kind of anesthetics
40. Which of the following best describes preterm labor?
A. Labor that begins after 20 weeks gestation and before 37 weeks gestation
B. Labor that begins after 15 weeks gestation and before 37 weeks gestation
C. Labor that begins after 24 weeks gestation and before 28 weeks gestation
D. Labor that begins after 28 weeks gestation and before 40 weeks gestation
41. When PROM occurs, which of the following provides evidence of the nurses
understanding of the clients immediate needs?
A. The chorion and amnion rupture 4 hours before the onset of labor.
B. PROM removes the fetus most effective defense against infection
C. Nursing care is based on fetal viability and gestational age.
D. PROM is associated with malpresentation and possibly incompetent cervix
42. Which of the following factors is the underlying cause of dystocia?
A. Nurtional
B. Mechanical
C. Environmental
D. Medical
43. When uterine rupture occurs, which of the following would be the priority?
A. Limiting hypovolemic shock
B. Obtaining blood specimens
C. Instituting complete bed rest
D. Inserting a urinary catheter
44. Which of the following is the nurses initial action when umbilical cord prolapse
occurs?
A. Begin monitoring maternal vital signs and FHR
B. Place the client in a knee-chest position in bed
C. Notify the physician and prepare the client for delivery
D. Apply a sterile warm saline dressing to the exposed cord
45. Which of the following amounts of blood loss following birth marks the criterion
for describing postpartum hemorrhage?
A. More than 200 ml
B. More than 300 ml
C. More than 400 ml
D. More than 500 ml
46. Which of the following is the primary predisposing factor related to mastitis?
A. Epidemic infection from nosocomial sources localizing in the lactiferous glands and
ducts
B. Endemic infection occurring randomly and localizing in the periglandular connective
tissue
C. Temporary urinary retention due to decreased perception of the urge to avoid
D. Breast injury caused by overdistention, stasis, and cracking of the nipples
47. Which of the following best describes thrombophlebitis?

A. Inflammation and clot formation that result when blood components combine to form
an aggregate body
B. Inflammation and blood clots that eventually become lodged within the pulmonary
blood vessels
C. Inflammation and blood clots that eventually become lodged within the femoral vein
D. Inflammation of the vascular endothelium with clot formation on the vessel wall
48. Which of the following assessment findings would the nurse expect if the client
develops DVT?
A. Midcalf pain, tenderness and redness along the vein
B. Chills, fever, malaise, occurring 2 weeks after delivery
C. Muscle pain the presence of Homans sign, and swelling in the affected limb
D. Chills, fever, stiffness, and pain occurring 10 to 14 days after delivery
49. Which of the following are the most commonly assessed findings in cystitis?
A. Frequency, urgency, dehydration, nausea, chills, and flank pain
B. Nocturia, frequency, urgency dysuria, hematuria, fever and suprapubic pain
C. Dehydration, hypertension, dysuria, suprapubic pain, chills, and fever
D. High fever, chills, flank pain nausea, vomiting, dysuria, and frequency
50. Which of the following best reflects the frequency of reported postpartum
blues?
A. Between 10% and 40% of all new mothers report some form of postpartum blues
B. Between 30% and 50% of all new mothers report some form of postpartum blues
C. Between 50% and 80% of all new mothers report some form of postpartum blues
D. Between 25% and 70% of all new mothers report some form of postpartum blues
Answers & Rationale
Here are the answers and rationale for this exam. Compare your answers to those below
and be sure to read the rationales for additional learning. If you have any disputes or
clarifications, please direct them to the comments section.
1.
B. Although all of the factors listed are important, sperm motility is the most
significant criterion when assessing male infertility. Sperm count, sperm maturity, and
semen volume are all significant, but they are not as significant sperm motility.
2.
D. Based on the partners statement, the couple is verbalizing feelings of

inadequacy and negative feelings about themselves and their capabilities. Thus, the
nursing diagnosis of self-esteem disturbance is most appropriate. Fear, pain, and
ineffective family coping also may be present but as secondary nursing diagnoses.
3.
B. Pressure and irritation of the bladder by the growing uterus during the first
trimester is responsible for causing urinary frequency. Dysuria, incontinence, and
burning are symptoms associated with urinary tract infections.
4.
C. During the second trimester, the reduction in gastric acidity in conjunction with
pressure from the growing uterus and smooth muscle relaxation, can cause heartburn
and flatulence. HCG levels increase in the first, not the second, trimester. Decrease
intestinal motility would most likely be the cause of constipation and bloating.
Estrogen levels decrease in the second trimester.
5.
D. Chloasma, also called the mask of pregnancy, is an irregular hyperpigmented

area found on the face. It is not seen on the breasts, areola, nipples, chest, neck,
arms, legs, abdomen, or thighs.
6.
C. During pregnancy, hormonal changes cause relaxation of the pelvic joints,

resulting in the typical waddling gait. Changes in posture are related to the growing
fetus. Pressure on the surrounding muscles causing discomfort is due to the growing
uterus. Weight gain has no effect on gait.
7.
C. The average amount of weight gained during pregnancy is 24 to 30 lb. This

weight gain consists of the following: fetus 7.5 lb; placenta and membrane 1.5 lb;
amniotic fluid 2 lb; uterus 2.5 lb; breasts 3 lb; and increased blood volume 2 to
4 lb; extravascular fluid and fat 4 to 9 lb. A gain of 12 to 22 lb is insufficient,
whereas a weight gain of 15 to 25 lb is marginal. A weight gain of 25 to 40 lb is
considered excessive.
8.
C. Pressure of the growing uterus on blood vessels results in an increased risk for
venous stasis in the lower extremities. Subsequently, edema and varicose vein
formation may occur. Thrombophlebitis is an inflammation of the veins due to
thrombus formation. Pregnancy-induced hypertension is not associated with these

symptoms. Gravity plays only a minor role with these symptoms.
9.
C. Cervical softening (Goodell sign) and uterine souffl are two probable signs of
pregnancy. Probable signs are objective findings that strongly suggest pregnancy.
Other probable signs include Hegar sign, which is softening of the lower uterine
segment; Piskacek sign, which is enlargement and softening of the uterus; serum
laboratory tests; changes in skin pigmentation; and ultrasonic evidence of a
gestational sac. Presumptive signs are subjective signs and include amenorrhea;
nausea and vomiting; urinary frequency; breast tenderness and changes; excessive
fatigue; uterine enlargement; and quickening.
10.
B. Presumptive signs of pregnancy are subjective signs. Of the signs listed, only
nausea and vomiting are presumptive signs. Hegar sign,skin pigmentation changes,
and a positive serum pregnancy test are considered probably signs, which are strongly
suggestive of pregnancy.
11.
D. During the first trimester, common emotional reactions include ambivalence,

fear, fantasies, or anxiety. The second trimester is a period of well-being accompanied
by the increased need to learn about fetal growth and development. Common
emotional reactions during this trimester include narcissism, passivity, or introversion.
At times the woman may seem egocentric and self-centered. During the third
trimester, the woman typically feels awkward, clumsy, and unattractive, often
becoming more introverted or reflective of her own childhood.
12.
B. First-trimester classes commonly focus on such issues as early physiologic

changes, fetal development, sexuality during pregnancy, and nutrition. Some early
classes may include pregnant couples. Second and third trimester classes may focus
on preparation for birth, parenting, and newborn care.
13.
C. With breast feeding, the fathers body is not capable of providing the milk for
the newborn, which may interfere with feeding the newborn, providing fewer chances
for bonding, or he may be jealous of the infants demands on his wifes time and body.
Breast feeding is advantageous because uterine involution occurs more rapidly, thus
minimizing blood loss. The presence of maternal antibodies in breast milk helps
decrease the incidence of allergies in the newborn. A greater chance for error is
associated with bottle feeding. No preparation is required for breast feeding.
14.
A. A false-positive reaction can occur if the pregnancy test is performed less than
10 days after an abortion. Performing the tests too early or too late in the pregnancy,
storing the urine sample too long at room temperature, or having a spontaneous or
missed abortion impending can all produce false-negative results.
15.
D. The FHR can be auscultated with a fetoscope at about 20 weeks gestation. FHR
usually is ausculatated at the midline suprapubic region with Doppler ultrasound
transducer at 10 to 12 weeks gestation. FHR, cannot be heard any earlier than 10
weeks gestation.
16.
C. To determine the EDD when the date of the clients LMP is known use Nagele
rule. To the first day of the LMP, add 7 days, subtract 3 months, and add 1 year (if
applicable) to arrive at the EDD as follows: 5 + 7 = 12 (July) minus 3 = 4 (April).
Therefore, the clients EDD is April 12.
17.
A. When the LMP is unknown, the gestational age of the fetus is estimated by
uterine size or position (fundal height). The presence of the uterus in the pelvis
indicates less than 12 weeks gestation. At approximately 12 to 14 weeks, the fundus
is out of the pelvis above the symphysis pubis. The fundus is at the level of the
umbilicus at approximately 20 weeks gestation and reaches the xiphoid at term or 40
weeks.
18.
D. Danger signs that require prompt reporting leaking of amniotic fluid, vaginal
bleeding, blurred vision, rapid weight gain, and elevated blood pressure.
Constipation, breast tenderness, and nasal stuffiness are common discomforts
associated with pregnancy.
19.
B. A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less than 1:8 is
significant, indicating that the client may not possess immunity to rubella. A
hematocrit of 33.5% a white blood cell count of 8,000/mm3, and a 1 hour glucose
challenge test of 110 g/dl are with normal parameters.
20.
D. With true labor, contractions increase in intensity with walking. In addition,

true labor contractions occur at regular intervals, usually starting in the back and
sweeping around to the abdomen. The interval of true labor contractions gradually
shortens.
21.
B. Crowing, which occurs when the newborns head or presenting part appears at
the vaginal opening, occurs during the second stage of labor. During the first stage of
labor, cervical dilation and effacement occur. During the third stage of labor, the
newborn and placenta are delivered. The fourth stage of labor lasts from 1 to 4 hours
after birth, during which time the mother and newborn recover from the physical
process of birth and the mothers organs undergo the initial readjustment to the
nonpregnant state.
22.
C. Barbiturates are rapidly transferred across the placental barrier, and lack of an
antagonist makes them generally inappropriate during active labor. Neonatal side
effects of barbiturates include central nervous system depression, prolonged
drowsiness, delayed establishment of feeding (e.g. due to poor sucking reflex or poor
sucking pressure). Tranquilizers are associated with neonatal effects such
as hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the
first few days. Narcotic analgesic readily cross the placental barrier, causing
depressive effects in the newborn 2 to 3 hours after intramuscular injection. Regional
anesthesia is associated with adverse reactions such as maternal hypotension, allergic
or toxic reaction, or partial or total respiratory failure.
23.
D. During the third stage of labor, which begins with the delivery of the newborn,
the nurse would promote parent-newborn interaction by placing the newborn on the
mothers abdomen and encouraging the parents to touch the newborn. Collecting a
urine specimen and other laboratory tests is done on admission during the first stage
of labor. Assessing uterine contractions every 30 minutes is performed during the
latent phase of the first stage of labor. Coaching the client to push effectively is
appropriate during the second stage of labor.
24.
A. The newborns ability to regulate body temperature is poor. Therefore, placing

the newborn under a radiant warmer aids in maintaining his or her body temperature.
Suctioning with a bulb syringe helps maintain a patent airway. Obtaining an Apgar
score measures the newborns immediate adjustment to extrauterine life. Inspecting
the umbilical cord aids in detecting cord anomalies.
25.
D. Immediately before expulsion or birth of the rest of the body, the cardinal
movement of external rotation occurs. Descent flexion, internal rotation, extension,
and restitution (in this order) occur before external rotation.
26.
B. The foramen ovale is an opening between the right and left auricles (atria) that
should close shortly after birth so the newborn will not have a murmur or mixed blood
traveling through the vascular system. The umbilical vein, ductus arteriosus, and
ductus venosus are obliterated at birth.
27.
B. Uric acid crystals in the urine may produce the reddish brick dust stain on the
diaper. Mucus would not produce a stain. Bilirubin and iron are from hepatic
adaptation.
28.
B. The normal heart rate for a newborn that is sleeping is approximately 100 beats
per minute. If the newborn was awake, the normal heart rate would range from 120
to 160 beats per minute.
29.
C. The anterior fontanel is larger in size than the posterior fontanel. Additionally,
the anterior fontanel, which is diamond shaped, closes at 18 months, whereas the
posterior fontanel, which is triangular shaped, closes at 8 to 12 weeks. Neither
fontanel should appear bulging, which may indicate increased intracranial pressure, or
sunken, which may indicate dehydration.
30.
B. Blink, cough, sneeze, swallowing and gag reflexes are all present at birth and
remain unchanged through adulthood. Reflexes such as rooting and stepping subside
within the first year.
31.
A. With the babinski reflex, the newborns toes hyperextend and fan apart from
dorsiflexion of the big toe when one side of foot is stroked upward form the heel and
across the ball of the foot. With the startle reflex, the newborn abducts and flexes all
extremities and may begin to cry when exposed to sudden movement of loud noise.
With the rooting and sucking reflex, the newborn turns his head in the direction of
stimulus, opens the mouth, and begins to suck when the cheeks, lip, or corner of
mouth is touched. With the crawl reflex, the newborn will attempt to crawl forward
with both arms and legs when he is placed on his abdomen on a flat surface.
32.
B. The description of hyperemesis gravidarum includes severe nausea and

vomiting, leading to electrolyte, metabolic, and nutritional imbalances in the absence
of other medical problems. Hyperemesis is not a form of anemia. Loss of appetite may
occur secondary to the nausea and vomiting of hyperemesis, which, if it continues,
can deplete the nutrients transported to the fetus. Diarrhea does not occur with
hyperemesis.
33.
B. Edema of the hands and face is a classic sign of PIH. Many healthy pregnant
woman experience foot and ankle edema. A weight gain of 2 lb or more per week
indicates a problem. Early morning headache is not a classic sign of PIH.
34.
C. In a missed abortion, there is early fetal intrauterine death, and products of

conception are not expelled. The cervix remains closed; there may be a dark brown
vaginal discharge, negative pregnancy test, and cessation of uterine growth and
breast tenderness. A threatened abortion is evidenced with cramping and vaginal
bleeding in early pregnancy, with no cervical dilation. An incomplete abortion
presents with bleeding, cramping, and cervical dilation. An incomplete abortion
involves only expulsion of part of the products of conception and bleeding occurs with
cervical dilation.
35.
A. Multiple gestation is one of the predisposing factors that may cause placenta
previa. Uterine anomalies abdominal trauma, and renal or vascular disease may
predispose a client to abruptio placentae.
36.
B. A client with abruptio placentae may exhibit concealed or dark red bleeding,
possibly reporting sudden intense localized uterine pain. The uterus is typically firm
to board-like, and the fetal presenting part may be engaged. Bright red, painless
vaginal bleeding, a palpable fetal outline and a soft non-tender abdomen are
manifestations of placenta previa.
37.
D. Abruptio placentae is described as premature separation of a normally

implanted placenta during the second half of pregnancy, usually with severe
hemorrhage. Placenta previa refers to implantation of the placenta in the lower
uterine segment, causing painless bleeding in the third trimester of pregnancy.
Ectopic pregnancy refers to the implantation of the products of conception in a site
other than the endometrium. Incompetent cervix is a conduction characterized by
painful dilation of the cervical os without uterine contractions.
38.
B. Hyperstimulation of the uterus such as with oxytocin during the induction of

labor may result in tetanic contractions prolonged to more than 90seconds, which
could lead to such complications as fetal distress, abruptio placentae, amniotic fluid
embolism, laceration of the cervix, and uterine rupture. Weak contractions would not
occur. Pain, bright red vaginal bleeding, and increased restlessness and anxiety are
not associated with hyperstimulation.
39.
C. A key point to consider when preparing the client for a cesarean delivery is to
modify the preoperative teaching to meet the needs of either a planned or emergency
cesarean birth, the depth and breadth of instruction will depend on circumstances
and time available. Allowing the mothers support person to remain with her as much
as possible is an important concept, although doing so depends on many variables.
Arranging for necessary explanations by various staff members to be involved with the
clients care is a nursing responsibility. The nurse is responsible for reinforcing the
explanations about the surgery, expected outcome, and type of anesthetic to be used.
The obstetrician is responsible for explaining about the surgery and outcome and the
anesthesiology staff is responsible for explanations about the type of anesthesia to be
used.
40.
A. Preterm labor is best described as labor that begins after 20 weeks gestation
and before 37 weeks gestation. The other time periods are inaccurate.
41.
B. PROM can precipitate many potential and actual problems; one of the most
serious is the fetus loss of an effective defense against infection. This is the clients
most immediate need at this time. Typically, PROM occurs about 1 hour, not 4 hours,
before labor begins. Fetal viability and gestational age are less immediate
considerations that affect the plan of care. Malpresentation and an incompetent
cervix may be causes of PROM.
42.
B. Dystocia is difficult, painful, prolonged labor due to mechanical factors

involving the fetus (passenger), uterus (powers), pelvis (passage), or psyche.
Nutritional, environment, and medical factors may contribute to the mechanical

factors that cause dystocia.
43.
A. With uterine rupture, the client is at risk for hypovolemic shock. Therefore, the
priority is to prevent and limit hypovolemic shock. Immediate steps should include
giving oxygen, replacing lost fluids, providing drug therapy as needed, evaluating fetal
responses and preparing for surgery. Obtaining blood specimens, instituting complete
bed rest, and inserting a urinary catheter are necessary in preparation for surgery to
remedy the rupture.
44.
B. The immediate priority is to minimize pressure on the cord. Thus the nurses
initial action involves placing the client on bed rest and then placing the client in a
knee-chest position or lowering the head of the bed, and elevating the maternal hips
on a pillow to minimize the pressure on the cord. Monitoring maternal vital signs and
FHR, notifying the physician and preparing the client for delivery, and wrapping the
cord with sterile saline soaked warm gauze are important. But these actions have no
effect on minimizing the pressure on the cord.
45.
D. Postpartum hemorrhage is defined as blood loss of more than 500 ml following

birth. Any amount less than this not considered postpartum hemorrhage.
46.
D. With mastitis, injury to the breast, such as overdistention, stasis, and cracking
of the nipples, is the primary predisposing factor. Epidemic and endemic infections
are probable sources of infection for mastitis. Temporary urinary retention due to
decreased perception of the urge to void is a contributory factor to the development
of urinary tract infection, not mastitis.
47.
D. Thrombophlebitis refers to an inflammation of the vascular endothelium with

clot formation on the wall of the vessel. Blood components combining to form an
aggregate body describe a thrombus or thrombosis. Clots lodging in the pulmonary
vasculature refers to pulmonary embolism; in the femoral vein, femoral
thrombophlebitis.
48.
C. Classic symptoms of DVT include muscle pain, the presence of Homans sign, and
swelling of the affected limb. Midcalf pain, tenderness, and redness, along the vein
reflect superficial thrombophlebitis. Chills, fever and malaise occurring 2 weeks after
delivery reflect pelvic thrombophlebitis. Chills, fever, stiffness and pain occurring 10
to 14 days after delivery suggest femoral thrombophlebitis.
49.
B. Manifestations of cystitis include, frequency, urgency, dysuria, hematuria

nocturia, fever, and suprapubic pain. Dehydration, hypertension, and chills are not
typically associated with cystitis. High fever chills, flank pain, nausea, vomiting,
dysuria, and frequency are associated with pvelonephritis.
50.
C. According to statistical reports, between 50% and 80% of all new mothers report
some form of postpartum blues. The ranges of 10% to 40%, 30% to 50%, and 25% to 70%
are incorrect.
Introduction
If you are preparing to take the board examination, take our 50-item examination about the concepts
covering Maternal and Child Health Nursing. This exam will gauge your knowledge about care of the
mother and her young.
Topics
Pregnancy
Obstetrics nursing
Contraceptives
Neonatal reflexes
Postpartum care
Guidelines
Answers and rationales are given below. Be sure to read them.
Questions
Text
Practice
Exam
1. For the client who is using oral contraceptives, the nurse informs the client about
the need to take the pill at the same time each day to accomplish which of the
following?
A. Decrease the incidence of nausea
B. Maintain hormonal levels
C. Reduce side effects
D. Prevent drug interactions
2. When teaching a client about contraception. Which of the following would the
nurse include as the most effective method for preventing sexually transmitted
infections?
A. Spermicides
B. Diaphragm
C. Condoms
D. Vasectomy
3. When preparing a woman who is 2 days postpartum for discharge,
recommendations for which of the following contraceptive methods would be
avoided?
A. Diaphragm
B. Female condom
C. Oral contraceptives
D. Rhythm method
4. For which of the following clients would the nurse expect that an intrauterine
device would not be recommended?
A. Woman over age 35
B. Nulliparous woman
C. Promiscuous young adult
D. Postpartum client
5. A client in her third trimester tells the nurse, Im constipated all the time! Which
of the following should the nurse recommend?
A. Daily enemas
B. Laxatives
C. Increased fiber intake
D. Decreased fluid intake
6. Which of the following would the nurse use as the basis for the teaching plan when
caring for a pregnant teenager concerned about gaining too much weight during
pregnancy?
A. 10 pounds per trimester
B. 1 pound per week for 40 weeks
C. pound per week for 40 weeks
D. A total gain of 25 to 30 pounds
7. The client tells the nurse that her last menstrual period started on January 14 and
ended on January 20. Using Nageles rule, the nurse determines her EDD to be which
of the following?
A. September 27
B. October 21
C. November 7
D. December 27
8. When taking an obstetrical history on a pregnant client who states, I had a son
born at 38 weeks gestation, a daughter born at 30 weeks gestation and I lost a baby at
about 8 weeks,the nurse should record her obstetrical history as which of the
following?
A. G2 T2 P0 A0 L2
B. G3 T1 P1 A0 L2
C. G3 T2 P0 A0 L2
D. G4 T1 P1 A1 L2
9. When preparing to listen to the fetal heart rate at 12 weeks gestation, the nurse
would use which of the following?
A. Stethoscope placed midline at the umbilicus
B. Doppler placed midline at the suprapubic region
C. Fetoscope placed midway between the umbilicus and the xiphoid process
D. External electronic fetal monitor placed at the umbilicus
10. When developing a plan of care for a client newly diagnosed with gestational
diabetes, which of the following instructions would be the priority?
A. Dietary intake
B. Medication
C. Exercise
D. Glucose monitoring
11. A client at 24 weeks gestation has gained 6 pounds in 4 weeks. Which of the
following would be the priority when assessing the client?
A. Glucosuria
B. Depression
C. Hand/face edema
D. Dietary intake
12. A client 12 weeks pregnant come to the emergency department with abdominal
cramping and moderate vaginal bleeding. Speculum examination reveals 2 to 3 cms
cervical dilation.The nurse would document these findings as which of the following?
A. Threatened abortion
B. Imminent abortion
C. Complete abortion
D. Missed abortion
13. Which of the following would be the priority nursing diagnosis for a client with an
ectopic pregnancy?
A. Risk for infection

B. Pain
C. Knowledge Deficit
D. Anticipatory Grieving
14. Before assessing the postpartum clients uterus for firmness and position in
relation to the umbilicus and midline, which of the following shouldthe nurse do first?
A. Assess the vital signs
B. Administer analgesia
C. Ambulate her in the hall
D. Assist her to urinate
15. Which of the following should the nurse do when a primipara who is lactating tells
the nurse that she has sore nipples?
A. Tell her to breast feed more frequently
B. Administer a narcotic before breast feeding
C. Encourage her to wear a nursing brassiere
D. Use soap and water to clean the nipples
16. The nurse assesses the vital signs of a client, 4 hours postpartum that are as
follows: BP 90/60; temperature 100.4F; pulse 100 weak, thready; R 20 per minute.
Which of the following shouldthe nurse do first?
A. Report the temperature to the physician
B. Recheck the blood pressure with another cuff
C. Assess the uterus for firmness and position
D. Determine the amount of lochia
17. The nurse assesses the postpartum vaginal discharge (lochia) on four clients.
Which of the following assessments would warrant notification of the physician?
A. A dark red discharge on a 2-day postpartum client
B. A pink to brownish discharge on a client who is 5 days postpartum
C. Almost colorless to creamy discharge on a client 2 weeks after delivery
D. A bright red discharge 5 days after delivery
18. A postpartum client has a temperature of 101.4F, with a uterus that is tender
when palpated, remains unusually large, and not descending as normally expected.
Which of the following shouldthe nurse assess next?
A. Lochia
B. Breasts
C. Incision
D. Urine
19. Which of the following is the priority focus of nursing practice with the current
early postpartum discharge?
A. Promoting comfort and restoration of health
B. Exploring the emotional status of the family
C. Facilitating safe and effective self-and newborn care
D. Teaching about the importance of family planning
20. Which of the following actions would be least effective in maintaining a neutral
thermal environment for the newborn?
A. Placing infant under radiant warmer after bathing
B. Covering the scale with a warmed blanket prior to weighing
C. Placing crib close to nursery window for family viewing
D. Covering the infants head with a knit stockinette
21. A newborn who has an asymmetrical Moro reflex response should be further
assessed for which of the following?
A. Talipes equinovarus
B. Fractured clavicle
C. Congenital hypothyroidism
D. Increased intracranial pressure
22. During the first 4 hours after a male circumcision, assessing for which of the
following is the priority?
A. Infection
B. Hemorrhage
C. Discomfort
D. Dehydration
23. The mother asks the nurse. Whats wrong with my sons breasts? Why are they so
enlarged? Whish of the following would be the best response by the nurse?
A. The breast tissue is inflamed from the trauma experienced with birth
B. A decrease in material hormones present before birth causes enlargement,
C. You should discuss this with your doctor. It could be a malignancy
D. The tissue has hypertrophied while the baby was in the uterus
24. Immediately after birth the nurse notes the following on a male newborn:
respirations 78; apical hearth rate 160 BPM, nostril flaring; mild intercostal
retractions; and grunting at the end of expiration. Which of the following shouldthe
nurse do?
A. Call the assessment data to the physicians attention
B. Start oxygen per nasal cannula at 2 L/min.
C. Suction the infants mouth and nares
D. Recognize this as normal first period of reactivity
25. The nurse hears a mother telling a friend on the telephone about umbilical cord
care. Which of the following statements by the mother indicates effective teaching?
A. Daily soap and water cleansing is best
B. Alcohol helps it dry and kills germs
C. An antibiotic ointment applied daily prevents infection
D. He can have a tub bath each day
26. A newborn weighing 3000 grams and feeding every 4 hours needs 120 calories/kg
of body weight every 24 hours for proper growth and development. How many ounces
of 20 cal/oz formula should this newborn receive at each feeding to meet nutritional
needs?
A. 2 ounces
B. 3 ounces
C. 4 ounces
D. 6 ounces
27. The postterm neonate with meconium-stained amniotic fluid needs care designed
to especially monitor for which of the following?
A. Respiratory problems
B. Gastrointestinal problems
C. Integumentary problems
D. Elimination problems
28. When measuring a clients fundal height, which of the following techniques
denotes the correct method of measurement used by the nurse?
A. From the xiphoid process to the umbilicus
B. From the symphysis pubis to the xiphoid process
C. From the symphysis pubis to the fundus
D. From the fundus to the umbilicus
29. A client with severe preeclampsia is admitted with of BP 160/110, proteinuria,
and severe pitting edema. Which of the following would be most important to include
in the clients plan of care?
A. Daily weights
B. Seizure precautions
C. Right lateral positioning
D. Stress reduction
30. A postpartum primipara asks the nurse, When can we have sexual intercourse
again? Which of the following would be the nurses best response?
A. Anytime you both want to.
B. As soon as choose a contraceptive method.
C. When the discharge has stopped and the incision is healed.
D. After your 6 weeks examination.
31. When preparing to administer the vitamin K injection to a neonate, the nurse
would select which of the following sites as appropriate for the injection?
A. Deltoid muscle
B. Anterior femoris muscle
C. Vastus lateralis muscle
D. Gluteus maximus muscle
32. When performing a pelvic examination, the nurse observes a red swollen area on
the right side of the vaginal orifice. The nurse would document this as enlargement of
A. Clitoris
B. Parotid gland
C. Skenes gland
D. Bartholins gland
33. To differentiate as a female, the hormonal stimulation of the embryo that must
occur involves which of the following?
A. Increase in maternal estrogen secretion
B. Decrease in maternal androgen secretion
C. Secretion of androgen by the fetal gonad
D. Secretion of estrogen by the fetal gonad
34. A client at 8 weeks gestation calls complaining of slight nausea in the morning
hours. Which of the following client interventions should the nurse question?
A. Taking 1 teaspoon of bicarbonate of soda in an 8-ounce glass of water
B. Eating a few low-sodium crackers before getting out of bed
C. Avoiding the intake of liquids in the morning hours
D. Eating six small meals a day instead of thee large meals
35. The nurse documents positive ballottement in the clients prenatal record. The
nurse understands that this indicates which of the following?
A. Palpable contractions on the abdomen

B. Passive movement of the unengaged fetus
C. Fetal kicking felt by the client
D. Enlargement and softening of the uterus
36. During a pelvic exam the nurse notes a purple-blue tinge of the cervix. The nurse
documents this as which of the following?
A. Braxton-Hicks sign
B. Chadwicks sign
C. Goodells sign
D. McDonalds sign
37. During a prenatal class, the nurse explains the rationale for breathing techniques
during preparation for labor based on the understanding that breathing techniques
are most important in achieving which of the following?
A. Eliminate pain and give the expectant parents something to do
B. Reduce the risk of fetal distress by increasing uteroplacental perfusion
C. Facilitate relaxation, possibly reducing the perception of pain
D. Eliminate pain so that less analgesia and anesthesia are needed
38. After 4 hours of active labor, the nurse notes that the contractions of a
primigravida client are not strong enough to dilate the cervix. Which of the following
would the nurse anticipate doing?
A. Obtaining an order to begin IV oxytocin infusion
B. Administering a light sedative to allow the patient to rest for several hour
C. Preparing for a cesarean section for failure to progress
D. Increasing the encouragement to the patient when pushing begins
39. A multigravida at 38 weeks gestation is admitted with painless, bright red
bleeding and mild contractions every 7 to 10 minutes. Which of the following
assessments should be avoided?
A. Maternal vital sign
B. Fetal heart rate
C. Contraction monitoring
D. Cervical dilation
40. Which of the following would be the nurses most appropriate response to a client
who asks why she must have a cesarean delivery if she has a complete placenta
previa?
A. You will have to ask your physician when he returns.
B. You need a cesarean to prevent hemorrhage.
C. The placenta is covering most of your cervix.
D. The placenta is covering the opening of the uterus and blocking your baby.
41. The nurse understands that the fetal head is in which of the following positions
with a face presentation?
A. Completely flexed
B. Completely extended
C. Partially extended
D. Partially flexed
42. With a fetus in the left-anterior breech presentation, the nurse would expect the
fetal heart rate would be most audible in which of the following areas?
A. Above the maternal umbilicus and to the right of midline
B. In the lower-left maternal abdominal quadrant
C. In the lower-right maternal abdominal quadrant
D. Above the maternal umbilicus and to the left of midline
43. The amniotic fluid of a client has a greenish tint. The nurse interprets this to be
A. Lanugo
B. Hydramnio
C. Meconium
D. Vernix
44. A patient is in labor and has just been told she has a breech presentation. The
nurse should be particularly alert for which of the following?
A. Quickening
B. Ophthalmia neonatorum
C. Pica
D. Prolapsed umbilical cord
45. When describing dizygotic twins to a couple, on which of the following would the
nurse base the explanation?
A. Two ova fertilized by separate sperm
B. Sharing of a common placenta
C. Each ova with the same genotype
D. Sharing of a common chorion
46. Which of the following refers to the single cell that reproduces itself after
conception?
A. Chromosome
B. Blastocyst
C. Zygote
D. Trophoblast
47. In the late 1950s, consumers and health care professionals began challenging the
routine use of analgesics and anesthetics during childbirth. Which of the following was
an outgrowth of this concept?
A. Labor, delivery, recovery, postpartum (LDRP)
B. Nurse-midwifery
C. Clinical nurse specialist
D. Prepared childbirth
48. A client has a midpelvic contracture from a previous pelvic injury due to a motor
vehicle accident as a teenager. The nurse is aware that this could prevent a fetus
from passing through or around which structure during childbirth?
A. Symphysis pubis
B. Sacral promontory
C. Ischial spines
D. Pubic arch
49. When teaching a group of adolescents about variations in the length of the
menstrual cycle, the nurse understands that the underlying mechanism is due to
variations in which of the following phases?
A. Menstrual phase
B. Proliferative phase
C. Secretory phase
D. Ischemic phase
50. When teaching a group of adolescents about male hormone production, which of
the following would the nurse include as being produced by the Leydig cells?
A. Follicle-stimulating hormone
B. Testosterone
C. Leuteinizing hormone
D. Gonadotropin releasing hormone

The answers and rationale for this exam are given below, be sure to counter check your
answers. Tell us your scores in the comments section.
1.
B. Regular timely ingestion of oral contraceptives is necessary to maintain

hormonal levels of the drugs to suppress the action of the hypothalamus and anterior
pituitary leading to inappropriate secretion of FSH and LH. Therefore, follicles do not
mature, ovulation is inhibited, and pregnancy is prevented. The estrogen content of
the oral site contraceptive may cause the nausea, regardless of when the pill is taken.
Side effects and drug interactions may occur withoral contraceptives regardless of the
time the pill is taken.
2.
C. Condoms, when used correctly and consistently, are the most effective
contraceptive method or barrier against bacterial and viral sexually transmitted
infections. Although spermicides kill sperm, they do not provide reliable protection
against the spread of sexually transmitted infections, especially intracellular
organisms such as HIV. Insertion and removal of the diaphragm along with the use of
the spermicides may cause vaginal irritations, which could place the client at risk for
infection transmission. Male sterilization eliminates spermatozoa from the ejaculate,
but it does not eliminate bacterial and/or viral microorganisms that can cause
sexually transmitted infections.
3.
A. The diaphragm must be fitted individually to ensure effectiveness. Because of

the changes to the reproductive structures during pregnancy and following delivery,
the diaphragm must be refitted, usually at the 6 weeks examination following
childbirth or after a weight loss of 15 lbs or more. In addition, for maximum
effectiveness, spermicidal jelly should be placed in the dome and around the rim.
However, spermicidal jelly should not be inserted into the vagina until involution is
completed at approximately 6 weeks. Use of a female condom protects
thereproductive system from the introduction of semen or spermicides into the vagina
and may be used after childbirth. Oral contraceptives may be started within the first
postpartum week to ensure suppression of ovulation . For the couple who has
determined the females fertile period, using the rhythm method, avoidance of
intercourse during this period, is safe and effective.
4.
C. An IUD may increase the risk of pelvic inflammatory disease, especially in

women with more than one sexual partner, because of the increased risk of sexually
transmitted infections. An UID should not be used if the woman has an active or
chronic pelvic infection, postpartum infection, endometrial hyperplasia or carcinoma,
or uterine abnormalities. Age is not a factor in determining the risks associated with
IUD use. Most IUD users are over the age of 30. Although there is a slightly higher risk
for infertility in women who have never been pregnant, the IUD is an acceptable
option as long as the risk-benefit ratio is discussed. IUDs may be inserted immediately
after delivery, but this is not recommended because of the increased risk and rate of
expulsion at this time.
5.
C. During the third trimester, the enlarging uterus places pressure on the
intestines. This coupled with the effect of hormones on smooth muscle relaxation
causes decreased intestinal motility (peristalsis). Increasing fiber in the diet will help
fecal matter pass more quickly through the intestinal tract, thus decreasing the
amount of water that is absorbed. As a result, stool is softer and easier to pass.
Enemas could precipitate preterm labor and/or electrolyte loss and should be
avoided. Laxatives may cause preterm labor by stimulating peristalsis and may
interfere with the absorption of nutrients. Use for more than 1 week can also lead to
laxative dependency. Liquid in the diet helps provide a semisolid, soft consistency to
the stool. Eight to ten glasses of fluid per day are essential to maintain hydration and
promote stool evacuation.
6.
D. To ensure adequate fetal growth and development during the 40 weeks of a

pregnancy, a total weight gain 25 to 30 pounds is recommended: 1.5 pounds in the
first 10 weeks; 9 pounds by 30 weeks; and 27.5 pounds by 40 weeks. The pregnant
woman should gain less weight in the first and second trimester than in the third.
During the first trimester, the client should only gain 1.5 pounds in the first 10 weeks,
not 1 pound per week. A weight gain of pound per week would be 20 pounds for the
total pregnancy, less than the recommended amount.
7.
B. To calculate the EDD by Nageles rule, add 7 days to the first day of the last
menstrual period and count back 3 months, changing the year appropriately. To obtain
a date of September 27, 7 days have been added to the last day of the LMP (rather
than the first day of the LMP), plus 4 months (instead of 3 months) were counted
back. To obtain the date of November 7, 7 days have been subtracted (instead of
added) from the first day of LMP plus November indicates counting back 2 months
(instead of 3 months) from January. To obtain the date of December 27, 7 days were
added to the last day of the LMP (rather than the first day of the LMP) and December
indicates counting back only 1 month (instead of 3 months) from January.
8.
D. The client has been pregnant four times, including current pregnancy (G). Birth
at 38 weeks gestation is considered full term (T), while birth form 20 weeks to 38
weeks is considered preterm (P). A spontaneous abortion occurred at 8 weeks (A). She
has two living children (L).
9.
B. At 12 weeks gestation, the uterus rises out of the pelvis and is palpable above
the symphysis pubis. The Doppler intensifies the sound of the fetal pulse rate so it is
audible. The uterus has merely risen out of the pelvis into the abdominal cavity and is
not at the level of the umbilicus. The fetal heart rate at this age is not audible with a
stethoscope. The uterus at 12 weeks is just above the symphysis pubis in the
abdominal cavity, not midway between the umbilicus and the xiphoid process. At 12
weeks the FHR would be difficult to auscultate with a fetoscope. Although the
external electronic fetal monitor would project the FHR, the uterus has not risen to
the umbilicus at 12 weeks.
10.
A. Although all of the choices are important in the management of diabetes, diet
therapy is the mainstay of the treatment plan and should always be the priority.
Women diagnosed with gestational diabetes generally need only diet therapy without
medication to control their blood sugar levels. Exercise, is important for all pregnant
women and especially for diabetic women, because it burns up glucose, thus
decreasing blood sugar. However, dietary intake, not exercise, is the priority. All
pregnant women with diabetes should have periodic monitoring of serum glucose.
However, those with gestational diabetes generally do not need daily glucose
monitoring. The standard of care recommends a fasting and 2-hour postprandial blood
sugar level every 2 weeks.
11.
C. After 20 weeks gestation, when there is a rapid weight gain, preeclampsia

should be suspected, which may be caused by fluid retention manifested by edema,
especially of the hands and face. The three classic signs of preeclampsia are
hypertension, edema, and proteinuria. Although urine is checked for glucose at each
clinic visit, this is not the priority. Depression may cause either anorexia or excessive
food intake, leading to excessive weight gain or loss. This is not, however, the priority
consideration at this time. Weight gain thought to be caused by excessive food intake
would require a 24-hour diet recall. However, excessive intake would not be the
primary consideration for this client at this time.
12.
B. Cramping and vaginal bleeding coupled with cervical dilation signifies that
termination of the pregnancy is inevitable and cannot be prevented. Thus, the nurse
would document an imminent abortion. In a threatened abortion, cramping and
vaginal bleeding are present, but there is no cervical dilation. The symptoms may
subside or progress to abortion. In a complete abortion all the products of conception
are expelled. A missed abortion is early fetal intrauterine death without expulsion of
the products of conception.
13.
B. For the client with an ectopic pregnancy, lower abdominal pain, usually
unilateral, is the primary symptom. Thus, pain is the priority. Although the potential
for infection is always present, the risk is low in ectopic pregnancy because
pathogenic microorganisms have not been introduced from external sources. The
client may have a limited knowledge of the pathology and treatment of the condition
and will most likely experience grieving, but this is not the priority at this time.
14.
D. Before uterine assessment is performed, it is essential that the woman empty

her bladder. A full bladder will interfere with the accuracy of the assessment by
elevating the uterus and displacing to the side of the midline. Vital sign assessment is
not necessary unless an abnormality in uterine assessment is identified. Uterine
assessment should not cause acute pain that requires administration of analgesia.
Ambulating the client is an essential component of postpartum care, but is not
necessary prior to assessment of the uterus.
15.
A. Feeding more frequently, about every 2 hours, will decrease the infants frantic,
vigorous sucking from hunger and will decrease breast engorgement, soften the
breast, and promote ease of correct latching-on for feeding. Narcotics administered
prior to breast feeding are passed through the breast milk to the infant, causing
excessive sleepiness. Nipple soreness is not severe enough to warrant narcotic
analgesia. All postpartum clients, especially lactating mothers, should wear a
supportive brassiere with wide cotton straps. This does not, however, prevent or
reduce nipple soreness. Soaps are drying to the skin of the nipples and should not be
used on the breasts of lactating mothers. Dry nipple skin predisposes to cracks and
fissures, which can become sore and painful.
16.
D. A weak, thready pulse elevated to 100 BPM may indicate impending

hemorrhagic shock. An increased pulse is a compensatory mechanism of the body in
response to decreased fluid volume. Thus, the nurse should check the amount of
lochia present. Temperatures up to 100.48F in the first 24 hours after birth are
related to the dehydrating effects of labor and are considered normal. Although
rechecking the blood pressure may be a correct choice of action, it is not the first
action that should be implemented in light of the other data. The data indicate a
potential impending hemorrhage. Assessing the uterus for firmness and position in
relation to the umbilicus and midline is important, but the nurse should check the
extent of vaginal bleeding first. Then it would be appropriate to check the uterus,
which may be a possible cause of the hemorrhage.
17.
D. Any bright red vaginal discharge would be considered abnormal, but especially 5
days after delivery, when the lochia is typically pink to brownish. Lochia rubra, a dark
red discharge, is present for 2 to 3 days after delivery. Bright red vaginal bleeding at
this time suggests late postpartum hemorrhage, which occurs after the first 24 hours
following delivery and is generally caused by retained placental fragments or bleeding
disorders. Lochia rubra is the normal dark red discharge occurring in the first 2 to 3
days after delivery, containing epithelial cells, erythrocyes, leukocytes and decidua.
Lochia serosa is a pink to brownish serosanguineous discharge occurring from 3 to 10
days after delivery that contains decidua, erythrocytes, leukocytes, cervical mucus,
and microorganisms. Lochia alba is an almost colorless to yellowish discharge
occurring from 10 days to 3 weeks after delivery and containing leukocytes, decidua,
epithelial cells, fat, cervical mucus, cholesterol crystals, and bacteria.
18.
A. The data suggests an infection of the endometrial lining of the uterus. The
lochia may be decreased or copious, dark brown in appearance, and foul smelling,
providing further evidence of a possible infection. All the clients data indicate a
uterine problem, not a breast problem. Typically, transient fever, usually 101F, may
be present with breast engorgement. Symptoms of mastitis include influenza-like
manifestations. Localized infection of an episiotomy or C-section incision rarely
causes systemic symptoms, and uterine involution would not be affected. The client
data do not include dysuria, frequency, or urgency, symptoms of urinary tract
infections, which would necessitate assessing the clients urine.
19.
C. Because of early postpartum discharge and limited time for teaching, the
nurses priority is to facilitate the safe and effective care of the client and newborn.
Although promoting comfort and restoration of health, exploring the familys
emotional status, and teaching about family planning are important in
postpartum/newborn nursing care, they are not the priority focus in the limited time
presented by early post-partum discharge.
20.
C. Heat loss by radiation occurs when the infants crib is placed too near cold walls
or windows. Thus placing the newborns crib close to the viewing window would be
least effective. Body heat is lost through evaporation during bathing. Placing the
infant under the radiant warmer after bathing will assist the infant to be rewarmed.
Covering the scale with a warmed blanket prior to weighing prevents heat loss
through conduction. A knit cap prevents heat loss from the head a large head, a large
body surface area of the newborns body.
21.
B. A fractured clavicle would prevent the normal Moro response of symmetrical

sequential extension and abduction of the arms followed by flexion and adduction. In
talipes equinovarus (clubfoot) the foot is turned medially, and in plantar flexion, with
the heel elevated. The feet are not involved with the Moro reflex. Hypothyroiddism
has no effect on the primitive reflexes. Absence of the Moror reflex is the most
significant single indicator of central nervous system status, but it is not a sign of
increased intracranial pressure.
22.
B. Hemorrhage is a potential risk following any surgical procedure. Although the

infant has been given vitamin K to facilitate clotting, the prophylactic dose is often
not sufficient to prevent bleeding. Although infection is a possibility, signs will not
appear within 4 hours after the surgical procedure. The primary discomfort of
circumcision occurs during the surgical procedure, not afterward. Although feedings
are withheld prior to the circumcision, the chances of dehydration are minimal.
23.
B. The presence of excessive estrogen and progesterone in the maternal-fetal

blood followed by prompt withdrawal at birth precipitates breast engorgement, which
will spontaneously resolve in 4 to 5 days after birth. The trauma of the birth process
does not cause inflammation of the newborns breast tissue. Newborns do not have
breast malignancy. This reply by the nurse would cause the mother to have undue
anxiety. Breast tissue does not hypertrophy in the fetus or newborns.
24.
D. The first 15 minutes to 1 hour after birth is the first period of reactivity
involving respiratory and circulatory adaptation to extrauterine life. The data given
reflect the normal changes during this time period. The infants assessment data
reflect normal adaptation. Thus, the physician does not need to be notified and
oxygen is not needed. The data do not indicate the presence of choking, gagging or
coughing, which are signs of excessive secretions. Suctioning is not necessary.
25.
B. Application of 70% isopropyl alcohol to the cord minimizes microorganisms

(germicidal) and promotes drying. The cord should be kept dry until it falls off and the
stump has healed. Antibiotic ointment should only be used to treat an infection, not
as a prophylaxis. Infants should not be submerged in a tub of water until the cord falls
off and the stump has completely healed.
26.
B. To determine the amount of formula needed, do the following mathematical

calculation. 3 kg x 120 cal/kg per day = 360 calories/day feeding q 4 hours = 6
feedings per day = 60 calories per feeding: 60 calories per feeding; 60 calories per
feeding with formula 20 cal/oz = 3 ounces per feeding. Based on the calculation. 2, 4
or 6 ounces are incorrect.
27.
A. Intrauterine anoxia may cause relaxation of the anal sphincter and emptying of
meconium into the amniotic fluid. At birth some of the meconium fluid may be
aspirated, causing mechanical obstruction or chemical pneumonitis. The infant is not
at increased risk for gastrointestinal problems. Even though the skin is stained with
meconium, it is noninfectious (sterile) and nonirritating. The postterm meconiumstained infant is not at additional risk for bowel or urinary problems.
28.
C. The nurse should use a nonelastic, flexible, paper measuring tape, placing the
zero point on the superior border of the symphysis pubis and stretching the tape
across the abdomen at the midline to the top of the fundus. The xiphoid and umbilicus
are not appropriate landmarks to use when measuring the height of the fundus
(McDonalds measurement).
29.
B. Women hospitalized with severe preeclampsia need decreased CNS stimulation

to prevent a seizure. Seizure precautions provide environmental safety should a
seizure occur. Because of edema, daily weight is important but not the priority.
Preclampsia causes vasospasm and therefore can reduce utero-placental perfusion.
The client should be placed on her left side to maximize blood flow, reduce blood
pressure, and promote diuresis. Interventions to reduce stress and anxiety are very
important to facilitate coping and a sense of control, but seizure precautions are the
priority.
30.
C. Cessation of the lochial discharge signifies healing of the endometrium. Risk of

hemorrhage and infection are minimal 3 weeks after a normal vaginal delivery. Telling
the client anytime is inappropriate because this response does not provide the client
with the specific information she is requesting. Choice of a contraceptive method is
important, but not the specific criteria for safe resumption of sexual activity.
Culturally, the 6-weeks examination has been used as the time frame for resuming
sexual activity, but it may be resumed earlier.
31.
C. The middle third of the vastus lateralis is the preferred injection site for
vitamin K administration because it is free of blood vessels and nerves and is large
enough to absorb the medication. The deltoid muscle of a newborn is not large
enough for a newborn IM injection. Injections into this muscle in a small child might
cause damage to the radial nerve. The anterior femoris muscle is the next safest
muscle to use in a newborn but is not the safest. Because of the proximity of the
sciatic nerve, the gluteus maximus muscle should not be until the child has been
walking 2 years.
32.
D. Bartholins glands are the glands on either side of the vaginal orifice. The
clitoris is female erectile tissue found in the perineal area above the urethra. The
parotid glands are open into the mouth. Skenes glands open into the posterior wall of
the female urinary meatus.
33.
D. The fetal gonad must secrete estrogen for the embryo to differentiate as a
female. An increase in maternal estrogen secretion does not effect differentiation of
the embryo, and maternal estrogen secretion occurs in every pregnancy. Maternal
androgen secretion remains the same as before pregnancy and does not effect
differentiation. Secretion of androgen by the fetal gonad would produce a male fetus.
34.
A. Using bicarbonate would increase the amount of sodium ingested, which can
cause complications. Eating low-sodium crackers would be appropriate. Since liquids
can increase nausea avoiding them in the morning hours when nausea is usually the
strongest is appropriate. Eating six small meals a day would keep the stomach full,
which often decrease nausea.
35.
B. Ballottement indicates passive movement of the unengaged fetus. Ballottement

is not a contraction. Fetal kicking felt by the client represents quickening.
Enlargement and softening of the uterus is known as Piskaceks sign.
36.
B. Chadwicks sign refers to the purple-blue tinge of the cervix. Braxton Hicks
contractions are painless contractions beginning around the 4th month. Goodells sign
indicates softening of the cervix. Flexibility of the uterus against the cervix is known
as McDonalds sign.
37.
C. Breathing techniques can raise the pain threshold and reduce the perception of
pain. They also promote relaxation. Breathing techniques do not eliminate pain, but
they can reduce it. Positioning, not breathing, increases uteroplacental perfusion.
38.
A. The clients labor is hypotonic. The nurse should call the physical and obtain an
order for an infusion of oxytocin, which will assist the uterus to contact more
forcefully in an attempt to dilate the cervix. Administering light sedative would be
done for hypertonic uterine contractions. Preparing for cesarean section is
unnecessary at this time. Oxytocin would increase the uterine contractions and
hopefully progress labor before a cesarean would be necessary. It is too early to
anticipate client pushing with contractions.
39.
D. The signs indicate placenta previa and vaginal exam to determine cervical
dilation would not be done because it could cause hemorrhage. Assessing maternal
vital signs can help determine maternal physiologic status. Fetal heart rate is
important to assess fetal well-being and should be done. Monitoring the contractions
will help evaluate the progress of labor.
40.
D. A complete placenta previa occurs when the placenta covers the opening of the
uterus, thus blocking the passageway for the baby. This response explains what a
complete previa is and the reason the baby cannot come out except by cesarean
delivery. Telling the client to ask the physician is a poor response and would increase
the patients anxiety. Although a cesarean would help to prevent hemorrhage, the
statement does not explain why the hemorrhage could occur. With a complete previa,
the placenta is covering all the cervix, not just most of it.
41.
B. With a face presentation, the head is completely extended. With a vertex

presentation, the head is completely or partially flexed. With a brow (forehead)
presentation, the head would be partially extended.
42.
D. With this presentation, the fetal upper torso and back face the left upper
maternal abdominal wall. The fetal heart rate would be most audible above the
maternal umbilicus and to the left of the middle. The other positions would be
incorrect.
43.
C. The greenish tint is due to the presence of meconium. Lanugo is the soft, downy
hair on the shoulders and back of the fetus. Hydramnios represents excessive amniotic
fluid. Vernix is the white, cheesy substance covering the fetus.
44.
D. In a breech position, because of the space between the presenting part and the
cervix, prolapse of the umbilical cord is common. Quickening is the womans first
perception of fetal movement. Ophthalmia neonatorum usually results from maternal

gonorrhea and is conjunctivitis. Pica refers to the oral intake of nonfood substances.
45.
A. Dizygotic (fraternal) twins involve two ova fertilized by separate sperm.

Monozygotic (identical) twins involve a common placenta, same genotype, and
common chorion.
46.
C. The zygote is the single cell that reproduces itself after conception. The
chromosome is the material that makes up the cell and is gained from each parent.
Blastocyst and trophoblast are later terms for the embryo after zygote.
47.
D. Prepared childbirth was the direct result of the 1950s challenging of the
routine use of analgesic and anesthetics during childbirth. The LDRP was a much later
concept and was not a direct result of the challenging of routine use of analgesics and
anesthetics during childbirth. Roles for nurse midwives and clinical nurse specialists
did not develop from this challenge.
48.
C. The ischial spines are located in the mid-pelvic region and could be narrowed
due to the previous pelvic injury. The symphysis pubis, sacral promontory, and pubic
arch are not part of the mid-pelvis.
49.
B. Variations in the length of the menstrual cycle are due to variations in the
proliferative phase. The menstrual, secretory and ischemic phases do not contribute
to this variation.
50.
B. Testosterone is produced by the Leyding cells in the seminiferous tubules.

Follicle-stimulating hormone and leuteinzing hormone are released by the anterior
pituitary gland. The hypothalamus is responsible for releasing gonadotropin-releasing
hormone.
Introduction
Test your knowledge about the concepts of Maternal and Child Health Nursing. Take our 50-item
exam all about the topic of pregnancy and child care. If you are taking the NLE or NCLEX, then these
questions are perfect for your review!
Topics
Pregnancy
Female reproductive system
Health teaching for pregnant mothers
Child development
Guidelines
Questions
Text
Practice
Exam
1. While performing physical assessment of a 12 month-old, the nurse notes that the
infants anterior fontanel is still slightly open. Which of the following is the nurses
most appropriate action?
A. Notify the physician immediately because there is a problem.
B. Perform an intensive neurological examination.
C. Perform an intensive developmental examination.
D. Do nothing because this is a normal finding for the age.
2. When teaching a mother about introducing solid foods to her child, which of the
following indicates the earliest age at which this should be done?
A. 1 month
B. 2 months
C. 3 months
D. 4 months
3. The infant of a substance-abusing mother is at risk for developing a sense of which
of the following?
A. Mistrust
B. Shame
C. Guilt
D. Inferiority
4. Which of the following toys should the nurse recommend for a 5-month-old?
A. A big red balloon
B. A teddy bear with button eyes
C. A push-pull wooden truck
D. A colorful busy box
5. The mother of a 2-month-old is concerned that she may be spoiling her baby by
picking her up when she cries. Which of the following would be the nurses best
response?
A. Let her cry for a while before picking her up, so you dont spoil her
B. Babies need to be held and cuddled; you wont spoil her this way
C. Crying at this age means the baby is hungry; give her a bottle
D. If you leave her alone she will learn how to cry herself to sleep
6. When assessing an 18-month-old, the nurse notes a characteristic protruding
abdomen. Which of the following would explain the rationale for this finding?
A. Increased food intake owing to age
B. Underdeveloped abdominal muscles
C. Bowlegged posture
D. Linear growth curve
7. If parents keep a toddler dependent in areas where he is capable of using skills, the
toddle will develop a sense of which of the following?
A. Mistrust
B. Shame
C. Guilt
D. Inferiority
8. Which of the following is an appropriate toy for an 18-month-old?
A. Multiple-piece puzzle
B. Miniature cars
C. Finger paints
D. Comic book
9. When teaching parents about the childs readiness for toilet training, which of the
following signs should the nurse instruct them to watch for in the toddler?
A. Demonstrates dryness for 4 hours
B. Demonstrates ability to sit and walk
C. Has a new sibling for stimulation
D. Verbalizes desire to go to the bathroom
10. When teaching parents about typical toddler eating patterns, which of the
following should be included?
A .Food jags
B. Preference to eat alone
C. Consistent table manners
D. Increase in appetite
11. Which of the following suggestions should the nurse offer the parents of a 4-yearold boy who resists going to bed at night?
A. Allow him to fall asleep in your room, then move him to his own bed.
B. Tell him that you will lock him in his room if he gets out of bed one more time.
C. Encourage active play at bedtime to tire him out so he will fall asleep faster.
D. Read him a story and allow him to play quietly in his bed until he falls asleep.
12. When providing therapeutic play, which of the following toys would best promote
imaginative play in a 4-year-old?
A. Large blocks
B. Dress-up clothes
C. Wooden puzzle
D. Big wheels
13. Which of the following activities, when voiced by the parents following a teaching
session about the characteristics of school-age cognitive development would indicate
the need for additional teaching?
A. Collecting baseball cards and marbles
B. Ordering dolls according to size
C. Considering simple problem-solving options
D. Developing plans for the future
14. A hospitalized schoolager states: Im not afraid of this place, Im not afraid of
anything. This statement is most likely an example of whichof the following?
A. Regression
B. Repression
C. Reaction formation
D. Rationalization
15. After teaching a group of parents about accident prevention for schoolagers,
which of the following statements by the group would indicate the need for more
teaching?
A. Schoolagers are more active and adventurous than are younger children.
B. Schoolagers are more susceptible to home hazards than are younger children.
C. Schoolagers are unable to understand potential dangers around them.
D. Schoolargers are less subject to parental control than are younger children.
16. Which of the following skills is the most significant one learned during the
schoolage period?
A. Collecting
B. Ordering
C. Reading
D. Sorting
17. A child age 7 was unable to receive the measles, mumps, and rubella (MMR)
vaccine at the recommended scheduled time. When would the nurse expect to
administer MMR vaccine?
A. In a month from now
B. In a year from now
C. At age 10
D. At age 13
18. The adolescents inability to develop a sense of who he is and what he can
become results in a sense of which of the following?
A. Shame
B. Guilt
C. Inferiority
D. Role diffusion
19. Which of the following would be most appropriate for a nurse to use when
describing menarche to a 13-year-old?
A. A females first menstruation or menstrual periods
B. The first year of menstruation or period
C. The entire menstrual cycle or from one period to another
D. The onset of uterine maturation or peak growth
20. A 14-year-old boy has acne and according to his parents, dominates the bathroom
by using the mirror all the time.
Which of the following remarks by the nurse would be least helpful in talking to the
boy and his parents?
A. This is probably the only concern he has about his body. So dont worry about it or the
time he spends on it.
B. Teenagers are anxious about how their peers perceive them. So they spend a lot of
time grooming.
C. A teen may develop a poor self-image when experiencing acne. Do you feel this way
sometimes?
D. You appear to be keeping your face well washed. Would you feel comfortable
discussing your cleansing method?
21. Which of the following should the nurse suspect when noting that a 3-year-old is
engaging in explicit sexual behavior during doll play?
A. The child is exhibiting normal pre-school curiosity
B. The child is acting out personal experiences
C. The child does not know how to play with dolls
D. The child is probably developmentally delayed.
22. Which of the following statements by the parents of a child with school phobia
would indicate the need for further teaching?
A. Well keep him at home until phobia subsides.
B. Well work with his teachers and counselors at school.
C. Well try to encourage him to talk about his problem.
D. Well discuss possible solutions with him and his counselor.
23. When developing a teaching plan for a group of high school students about
teenage pregnancy, the nurse would keep in mind which of the following?
A. The incidence of teenage pregnancies is increasing.
B. Most teenage pregnancies are planned.
C. Denial of the pregnancy is common early on.
D. The risk for complications during pregnancy is rare.
24. When assessing a child with a cleft palate, the nurse is aware that the child is at
risk for more frequent episodes of otitis media due to whichof the following?
A. Lowered resistance from malnutrition

B. Ineffective functioning of the Eustachian tubes
C. Plugging of the Eustachian tubes with food particles
D. Associated congenital defects of the middle ear.
25. While performing a neurodevelopmental assessment on a 3-month-old infant,
which of the following characteristics would be expected?
A. A strong Moro reflex
B. A strong parachute reflex
C. Rolling from front to back
D. Lifting of head and chest when prone
26. By the end of which of the following would the nurse most commonly expect a
childs birth weight to triple?
A. 4 months
B. 7 months
C. 9 months
D. 12 months
27. Which of the following best describes parallel play between two toddlers?
A. Sharing crayons to color separate pictures
B. Playing a board game with a nurse
C. Sitting near each other while playing with separate dolls
D. Sharing their dolls with two different nurses
28. Which of the following would the nurse identify as the initial priority for a child
with acute lymphocytic leukemia?
A. Instituting infection control precautions
B. Encouraging adequate intake of iron-rich foods
C. Assisting with coping with chronic illness
D. Administering medications via IM injections
29. Which of the following information, when voiced by the mother, would indicate to
the nurse that she understands home care instructions following the administration of
a diphtheria, tetanus, and pertussis injection?
A. Measures to reduce fever
B. Need for dietary restrictions
C. Reasons for subsequent rash
D. Measures to control subsequent diarrhea
30. Which of the following actions by a community health nurse is most appropriate
when noting multiple bruises and burns on the posterior trunk of an 18-month-old
child during a home visit?
A. Report the childs condition to Protective Services immediately.
B. Schedule a follow-up visit to check for more bruises.
C. Notify the childs physician immediately.
D. Don nothing because this is a normal finding in a toddler.
31. Which of the following is being used when the mother of a hospitalized child calls
the student nurse and states, You idiot, you have no idea how to care for my sick
child?
A. Displacement
B. Projection
C. Repression
D. Psychosis
32. Which of the following should the nurse expect to note as a frequent complication
for a child with congenital heart disease?
A. Susceptibility to respiratory infection
B. Bleeding tendencies
C. Frequent vomiting and diarrhea
D. Seizure disorder
33. Which of the following would the nurse do first for a 3-year-old boy who arrives in
the emergency room with a temperature of 105 degrees, inspiratory stridor, and
restlessness, who is learning forward and drooling?
A. Auscultate his lungs and place him in a mist tent.
B. Have him lie down and rest after encouraging fluids.
C. Examine his throat and perform a throat culture
D. Notify the physician immediately and prepare for intubation.
34. Which of the following would the nurse need to keep in mind as a predisposing
factor when formulating a teaching plan for child with a urinary tract infection?
A. A shorter urethra in females
B. Frequent emptying of the bladder
C. Increased fluid intake
D. Ingestion of acidic juices
35. Which of the following should the nurse do first for a 15-year-old boy with a full
leg cast who is screaming in unrelenting pain and exhibiting right foot pallor signifying
compartment syndrome?
A. Medicate him with acetaminophen.
B. Notify the physician immediately
C. Release the traction
D. Monitor him every 5 minutes
36. At which of the following ages would the nurse expect to administer the varicella
zoster vaccine to child?
A. At birth
B. 2 months
C. 6 months
D. 12 months
37. When discussing normal infant growth and development with parents, which of
the following toys would the nurse suggest as most appropriate for an 8-month-old?
A. Push-pull toys
B. Rattle
C. Large blocks
D. Mobile
38. Which of the following aspects of psychosocial development is necessary for the
nurse to keep in mind when providing care for the preschool child?
A. The child can use complex reasoning to think out situations.
B. Fear of body mutilation is a common preschool fear
C. The child engages in competitive types of play
D. Immediate gratification is necessary to develop initiative.
39. Which of the following is characteristic of a preschooler with mid mental
retardation?
A. Slow to feed self
B. Lack of speech
C. Marked motor delays
D. Gait disability
40. Which of the following assessment findings would lead the nurse to suspect Down
syndrome in an infant?
A. Small tongue
B. Transverse palmar crease
C. Large nose
D. Restricted joint movement
41. While assessing a newborn with cleft lip, the nurse would be alert that which of
the following will most likely be compromised?
A. Sucking ability
B. Respiratory status
C. Locomotion
D. GI function
42. When providing postoperative care for the child with a cleft palate, the nurse
should position the child in which of the following positions?
A. Supine
B. Prone
C. In an infant seat
D. On the side
43. While assessing a child with pyloric stenosis, the nurse is likely to note which of
the following?
A. Regurgitation
B. Steatorrhea
C. Projectile vomiting
D. Currant jelly stools
44. Which of the following nursing diagnoses would be inappropriate for the infant
with gastroesophageal reflux (GER)?
A. Fluid volume deficit
B. Risk for aspiration
C. Altered nutrition: less than body requirements
D. Altered oral mucous membranes
45. Which of the following parameters would the nurse monitor to evaluate the
effectiveness of thickened feedings for an infant with gastroesophageal reflux (GER)?
A. Vomiting
B. Stools
C. Uterine
D. Weight
46. Discharge teaching for a child with celiac disease would include instructions about
avoiding which of the following?
A. Rice
B. Milk
C. Wheat
D. Chicken
47. Which of the following would the nurse expect to assess in a child with celiac
disease having a celiac crisis secondary to an upper respiratory infection?
A. Respiratory distress
B. Lethargy
C. Watery diarrhea
D. Weight gain
48. Which of the following should the nurse do first after noting that a child with
Hirschsprung disease has a fever and watery explosive diarrhea?
A. Notify the physician immediately
B. Administer antidiarrheal medications
C. Monitor child ever 30 minutes
D. Nothing, this is characteristic of Hirschsprung disease
49. A newborns failure to pass meconium within the first 24 hours after birth may
indicate which of the following?
A. Hirschsprung disease
B. Celiac disease
C. Intussusception
D. Abdominal wall defect
50. When assessing a child for possible intussusception, which of the following would
be least likely to provide valuable information?
A. Stool inspection
B. Pain pattern
C. Family history
D. Abdominal palpation
Answers and rationale
Here are the answers and rationale for this examination. If you have any disputes or need
clarifications, please direct them to the comments section. Tell us also your scores!
1. D. The anterior fontanelle typically closes anywhere between 12 to 18 months of age.
Thus, assessing the anterior fontanelle as still being slightly open is a normal finding
requiring no further action. Because it is normal finding for this age, notifying
he physician or performing additional examinations are inappropriate.
2. D. Solid foods are not recommended before age 4 to 6 months because of the sucking
reflex and the immaturity of the gastrointestinal tract and immune system. Therefore,
the earliest age at which to introduce foods is 4 months. Any time earlier would be
inappropriate.
3. A. According to Erikson, infants need to have their needs met consistently and
effectively to develop a sense of trust. An infant whose needs are consistently unmet or
who experiences significant delays in having them met, such as in the case of the infant
of a substance-abusing mother, will develop a sense of uncertainty, leading to mistrust of
caregivers and the environment. Toddlers develop a sense of shame when their autonomy
needs are not met consistently. Preschoolers develop a sense of guilt when their sense of
initiative is thwarted. Schoolagers develop a sense of inferiority when they do not
develop a sense of industry.
4. D. A busy box facilitates the fine motor development that occurs between 4 and 6
months. Balloons are contraindicated because small children may aspirate balloons.
Because the button eyes of a teddy bear may detach and be aspirated, this toy is unsafe
for children younger than 3 years. A 5-month-old is too young to use a push-pull toy.
5. B. Infants need to have their security needs met by being held and cuddled. At 2
months of age, they are unable to make the connection between crying and attention.
This association does not occur until late infancy or early toddlerhood. Letting the infant
cry for a time before picking up the infant or leaving the infant alone to cry herself to
sleep interferes with meeting the infants need for security at this very young age. Infants
cry for many reasons. Assuming that the child s hungry may cause overfeeding problems
such as obesity.
6. B. Underdeveloped abdominal musculature gives the toddler a characteristically
protruding abdomen. During toddlerhood, food intake decreases, not increases. Toddlers
are characteristically bowlegged because the leg muscles must bear the weight of the
relatively large trunk. Toddler growth patterns occur in a steplike, not linear pattern.
7. B. According to Erikson, toddlers experience a sense of shame when they are not
allowed to develop appropriate independence and autonomy. Infants develop mistrust
when their needs are not consistently gratified. Preschoolers develop guilt when their
initiative needs are not met while schoolagers develop a sense of inferiority when their
industry needs are not met.
8. C. Young toddlers are still sensorimotor learners and they enjoy the experience of
feeling different textures. Thus, finger paints would be an appropriate toy choice.
Multiple-piece toys, such as puzzle, are too difficult to manipulate and may be hazardous
if the pieces are small enough to be aspirated. Miniature cars also have a high potential
for aspiration. Comic books are on too high a level for toddlers. Although they may enjoy
looking at some of the pictures, toddlers are more likely to rip a comic book apart.
9. D. The child must be able to sate the need to go to the bathroom to initiate toilet
training. Usually, a child needs to be dry for only 2 hours, not 4 hours. The child also must
be able to sit, walk, and squat. A new sibling would most likely hinder toilet training.
10. A. Toddlers become picky eaters, experiencing food jags and eating large amounts
one day and very little the next. A toddlers food gags express a preference for the
ritualism of eating one type of food for several days at a time. Toddlers typically enjoy
socialization and limiting others at meal time. Toddlers prefer to feed themselves and
thus are too young to have table manners. A toddlers appetite and need for calories,
protein, and fluid decrease due to the dramatic slowing of growth rate.
11. D. Preschoolers commonly have fears of the dark, being left alone especially at
bedtime, and ghosts, which may affect the childs going to bed at night. Quiet play and
time with parents is a positive bedtime routine that provides security and also readies the
child for sleep. The child should sleep in his own bed. Telling the child about locking him
in his room will viewed by the child as a threat. Additionally, a locked door is frightening
and potentially hazardous. Vigorous activity at bedtime stirs up the child and makes more
difficult to fall asleep.
12. B. Dress-up clothes enhance imaginative play and imagination, allowing preschoolers
to engage in rich fantasy play. Building blocks and wooden puzzles are appropriate for
encouraging fine motordevelopment. Big wheels and tricycles encourage gross motor
development.
13. D. The school-aged child is in the stage of concrete operations, marked by inductive
reasoning, logical operations, and reversible concrete thought. The ability to consider the
future requires formal thought operations, which are not developed until adolescence.
Collecting baseball cards and marbles, ordering dolls by size, and simple problem-solving
options are examples of the concrete operational thinking of the schoolager.
14. C. Reaction formation is the schoolagers typical defensive response when
hospitalized. In reaction formation, expression of unacceptable thoughts or behaviors is
prevented (or overridden) by the exaggerated expression of opposite thoughts or types of
behaviors. Regression is seen in toddlers and preshcoolers when they retreat or return to
an earlier level ofdevelopment . Repression refers to the involuntary blocking of
unpleasant feelings and experiences from ones awareness. Rationalization is the attempt
to make excuses to justify unacceptable feelings or behaviors.
15. C. The schoolagers cognitive level is sufficiently developed to enable good
understanding of and adherence to rules. Thus, schoolagers should be able to understand
the potential dangers around them. With growth comes greater freedom andchildren
become more adventurous and daring. The school-aged child is also still prone
to accidents and home hazards, especially because of increased motor abilities and
independence. Plus the home hazards differ from other age groups. These hazards, which
are potentially lethal but tempting, may include firearms, alcohol, and medications.
School-agechildren begin to internalize their own controls and need less outside
direction. Plus the child is away from home more often. Some parental or caregiver
assistance is still needed to answer questions and provide guidance for decisions
and responsibilities.
16. C. The most significant skill learned during the school-age period is reading. During
this time the child develops formal adult articulation patterns and learns that words can
be arranged in structure. Collective, ordering, and sorting, although important, are not
most significant skills learned.
17. C. Based on the recommendations of the American Academy of Family Physicians and
the American Academy of Pediatrics, the MMR vaccine should be given at the age of 10 if
the child did not receive it between the ages of 4 to 6 years as recommended.
Immunization for diphtheria and tetanus is required at age 13.
18. D. According to Erikson, role diffusion develops when the adolescent does not develop
a sense of identity and a sense or where he fits in. Toddlers develop a sense of shame
when they do not achieve autonomy. Preschoolers develop a sense of guilt when they do
not develop a sense of initiative. School-agechildren develop a sense of inferiority when
they do not develop a sense of industry.
19. A. Menarche refers to the onset of the first menstruation or menstrual period and
refers only to the first cycle. Uterine growth and broadening of the pelvic girdle occurs
before menarche.
20. A. Stating that this is probably the only concern the adolescent has and telling the
parents not to worry about it or the time her spends on it shuts off further investigation
and is likely to make the adolescent and his parents feel defensive. The statement about
peer acceptance and time spent in front of the mirror for the development of self image
provides information about the adolescents needs to the parents and may help to gain
trust with the adolescent. Asking the adolescent how he feels about the acne will
encourage the adolescent to share his feelings. Discussing the cleansing method shows
interest and concern for the adolescent and also can help to identify any patient-teaching
needs for the adolescent regarding cleansing.
21. B. Preschoolers should be developmentally incapable of demonstrating explicit sexual
behavior. If a child does so, the child has been exposed to such behavior, and sexual abuse
should be suspected. Explicit sexual behavior during doll play is not a characteristic of
preschool development nor symptomatic of developmental delay. Whether or nor the
child knows how to play with dolls is irrelevant.
22. A. The parents need more teaching if they state that they will keep the child home
until the phobia subsides. Doing so reinforces the childs feelings of worthlessness and
dependency. The child should attend school even during resolution of the problem.
Allowing the child to verbalize helps the child to ventilate feelings and may help to
uncover causes and solutions. Collaboration with the teachers and counselors at school
may lead to uncovering the cause of the phobia and to the development of solutions. The
child should participate and play an active role in developing possible solutions.
23. C. The adolescent who becomes pregnant typically denies the pregnancy early on.
Early recognition by a parent or health care provider may be crucial to timely initiation of
prenatal care. The incidence of adolescent pregnancy has declined since 1991, yet
morbidity remains high. Most teenage pregnancies are unplanned and occur out of
wedlock. The pregnant adolescent is at high risk for physical complications including
premature labor and low-birth-weight infants, high neonatal mortality, iron deficiency
anemia, prolonged labor, and fetopelvic disproportion as well as numerous psychological
crises.
24. B. Because of the structural defect, children with cleft palate may have ineffective
functioning of their Eustachian tubes creating frequent bouts of otitis media. Most
children with cleft palate remain well-nourished and maintain adequate nutrition through
the use of proper feeding techniques. Food particles do not pass through the cleft and
into the Eustachian tubes. There is no association between cleft palate and congenial ear
deformities.
25. D. A 3-month-old infant should be able to lift the head and chest when prone. The
Moro reflex typically diminishes or subsides by 3 months. The parachute reflex appears at
9 months. Rolling from front to back usually is accomplished at about 5 months.
26. D. A childs birth weight usually triples by 12 months and doubles by 4 months. No
specific birth weight parameters are established for 7 or 9 months.
27. C. Toddlers engaging in parallel play will play near each other, but not with each
other. Thus, when two toddlers sit near each other but play with separate dolls, they are
exhibiting parallel play. Sharing crayons, playing a board game with a nurse, or sharing
dolls with two different nurses are all examples of cooperative play.
28. A. Acute lymphocytic leukemia (ALL) causes leukopenia, resulting in
immunosuppression and increasing the risk of infection, a leading cause of death in
children with ALL. Therefore, the initial priority nursing intervention would be to institute
infection control precautions to decrease the risk of infection. Iron-rich foods help with
anemia, but dietary iron is not an initial intervention. The prognosis of ALL usually is
good. However, later on, the nurse may need to assist the child and family with coping
since death and dying may still be an issue in need of discussion. Injections should be
discouraged, owing to increased risk from bleeding due to thrombocytopenia.
29. A. The pertusis component may result in fever and the tetanus component may result
in injection soreness. Therefore, the mothers verbalization of information about
measures to reduce fever indicates understanding. No dietary restrictions are necessary
after this injection is given. A subsequent rash is more likely to be seen 5 to 10 days after
receiving the MMR vaccine, not the diphtheria, pertussis, and tetanus vaccine. Diarrhea is
not associated with this vaccine.
30. A. Multiple bruises and burns on a toddler are signs child abuse. Therefore, the nurse
is responsible for reporting the case to Protective Services immediately to protect the
child from further harm. Scheduling a follow-up visit is inappropriate because additional
harm may come to the child if the nurse waits for further assessment data. Although the
nurse should notify the physician, the goal is to initiate measures to protect the childs
safety. Notifying the physician immediately does not initiate the removal of the child
from harm nor does it absolve the nurse from responsibility. Multiple bruises and burns
are not normal toddler injuries.
31. B. The mother is using projection, the defense mechanism used when a person
attributes his or her own undesirable traits to another. Displacement is the transfer of
emotion onto an unrelated object, such as when the mother would kick a chair or bang
the door shut. Repression is the submerging of painful ideas into the unconscious.
Psychosis is a state of being out of touch with reality.
32. A. Children with congenital heart disease are more prone to respiratory infections.
Bleeding tendencies, frequent vomiting, and diarrhea and seizure disorders are not
associated with congenital heart disease.
33. D. The child is exhibiting classic signs of epiglottitis, always a pediatric emergency.
The physician must be notified immediately and the nurse must be prepared for an
emergency intubation or tracheostomy. Further assessment with auscultating lungs and
placing the child in a mist tent wastes valuable time. The situation is a possible lifethreatening emergency. Having the child lie down would cause additional distress and
may result in respiratory arrest. Throat examination may result in laryngospasm that
could be fatal.
34. A. In females, the urethra is shorter than in males. This decreases the distance for
organisms to travel, thereby increasing the chance of the child developing a urinary tract
infection. Frequent emptying of the bladder would help to decrease urinary tract
infections by avoiding sphincter stress. Increased fluid intake enables the bladder to be
cleared more frequently, thus helping to prevent urinary tract infections. The intake of
acidic juices helps to keep the urine pH acidic and thus decrease the chance of flora
development.
35. B. Compartment syndrome is an emergent situation and the physician needs to be
notified immediately so that interventions can be initiated to relieve the increasing
pressure and restore circulation. Acetaminophen (Tylenol) will be ineffective since the
pain is related to the increasing pressure and tissue ischemia. The cast, not traction, is
being used in this situation for immobilization, so releasing the traction would be
inappropriate. In this situation, specific action not continued monitoring is indicated.
36. D. The varicella zoster vaccine (VZV) is a live vaccine given after age 12 months. The
first dose of hepatitis B vaccine is given at birth to 2 months, then at 1 to 4 months, and
then again at 6 to 18 months. DtaP is routinely given at 2, 4, 6, and 15 to 18 months and a
booster at 4 to 6 years.
37. C. Because the 8-month-old is refining his gross motor skills, being able to sit
unsupported and also improving his fine motor skills, probably capable of making hand-tohand transfers, large blocks would be the most appropriate toy selection. Push-pull toys
would be more appropriate for the 10 to 12-month-old as he or she begins to cruise the
environment. Rattles and mobiles are more appropriate for infants in the 1 to 3 month
age range. Mobiles pose a danger to older infants because of possible strangulation.
38. B. During the preschool period, the child has mastered a sense of autonomy and goes
on to master a sense of initiative. During this period, the child commonly experiences
more fears than at any other time. One common fear is fear of the body mutilation,
especially associated with painful experiences. The preschool child uses simple, not
complex, reasoning, engages in associative, not competitive, play (interactive and
cooperative play with sharing), and is able to tolerate longer periods of delayed
gratification.
39. A. Mild mental retardation refers to development disability involving an IQ 50 to 70.
Typically, the child is not noted as being retarded, but exhibits slowness in performing
tasks, such as self-feeding, walking, and taking. Little or no speech, marked motor
delays, and gait disabilities would be seen in more severe forms mental retardation.
40. B. Down syndrome is characterized by the following a transverse palmar crease

(simian crease), separated sagittal suture, oblique palpebral fissures, small nose,
depressed nasal bridge, high-arched palate, excess and lax skin, wide spacing and plantar
crease between the second and big toes, hyperextensible and lax joints, large protruding
tongue, and muscle weakness.
41. A. Because of the defect, the child will be unable to from the mouth adequately
around nipple, thereby requiring special devices to allow for feeding and sucking
gratification. Respiratory status may be compromised if the child is fed improperly or
during postoperative period, Locomotion would be a problem for the older infant because
of the use of restraints. GI functioning is not compromised in the child with a cleft lip.
42. B. Postoperatively children with cleft palate should be placed on their abdomens to
facilitate drainage. If the child is placed in the supine position, he or she may aspirate.
Using an infant seat does not facilitate drainage. Side-lying does not facilitate drainage as
well as the prone position.
43. C. Projectile vomiting is a key symptom of pyloric stenosis. Regurgitation is seen more
commonly with GER. Steatorrhea occurs in malabsorption disorders such as celiac disease.
Currant jelly stools are characteristic of intussusception.
44. D. GER is the backflow of gastric contents into the esophagus resulting from
relaxation or incompetence of the lower esophageal (cardiac) sphincter. No alteration in
the oral mucous membranes occurs with this disorder. Fluid volume deficit, risk for
aspiration, and altered nutrition are appropriate nursing diagnoses.
45. A. Thickened feedings are used with GER to stop the vomiting. Therefore, the nurse
would monitor the childs vomiting to evaluate the effectiveness of using the thickened
feedings. No relationship exists between feedings and characteristics of stools and
uterine. If feedings are ineffective, this should be noted before there is any change in the
childs weight.
46. C. Children with celiac disease cannot tolerate or digest gluten. Therefore, because
of its gluten content, wheat and wheat-containing products must be avoided. Rice, milk,
and chicken do not contain gluten and need not be avoided.
47. C. Episodes of celiac crises are precipitated by infections, ingestion of gluten,

prolonged fasting, or exposure to anticholinergic drugs. Celiac crisis is typically
characterized by severe watery diarrhea. Respiratory distress is unlikely in a routine
upper respiratory infection. Irritability, rather than lethargy, is more likely. Because of
the fluid loss associated with the severe watery diarrhea, the childs weight is more likely
to be decreased.
48. A. For the child with Hirschsprung disease, fever and explosive diarrhea indicate
enterocolitis, a life-threatening situation. Therefore, the physician should be notified
immediately. Generally, because of the intestinal obstruction and inadequate propulsive
intestinal movement, antidiarrheals are not used to treat Hirschsprung disease. The child
is acutely ill and requires intervention, with monitoring more frequently than every 30
minutes. Hirschsprung disease typically presents with chronic constipation.
49. A. Failure to pass meconium within the first 24 hours after birth may be an indication
of Hirschsprung disease, a congenital anomaly resulting in mechanical obstruction due to
inadequate motility in an intestinal segment. Failure to pass meconium is not associated
with celiac disease, intussusception, or abdominal wall defect.
50. C. Because intussusception is not believed to have a familial tendency, obtaining a
family history would provide the least amount of information. Stool inspection, pain
pattern, and abdominal palpation would reveal possible indicators of intussusception.
Current, jelly-like stools containing blood and mucus are an indication of intussusception.
Acute, episodic abdominal pain is characteristics of intussusception. A sausage-shaped
mass may be palpated in the right upper quadrant.
TAGS
MATERNAL & CHILD HEALTH NURSING
MATERNAL & CHILD HEALTH NURSING EXAM
MCN EXAM
TEXT EXAMS
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Maternal & Child Health Nursing Exam 2 (50 Items)
Introduction
Understanding how a person grows can provide hints on what to normally (and not normally) expect
during his maturation. Are you knowledgeable about the concepts of growth and development? Take
this 20-item NCLEX exam and find out!
Topics
Growth and Development
Guidelines
Questions
Text
Practice
Exam
NCLEX Exam: Growth and Development

2 (20 Items)
1. The nurse is caring for the mother of a newborn. The nurse recognizes that the
mother needs more teaching regarding cord care because she
a. keeps the cord exposed to the air.
b. washes her hands before sponge bathing her baby.
c. washes the cord and surrounding area well with water at each diaper change.
d. checks it daily for bleeding and drainage.
2. A client telephones the clinic to ask about a home pregnancy test she used this
morning. The nurse understands that the presence of which hormone strongly
suggests a woman is pregnant?
a. Estrogen
b. HCG
c. Alpha-fetoprotein
d. Progesterone
3. The nurse is assessing a six-month-old child. Which developmental skills are normal
and should be expected?
a. Speaks in short sentences.
b. Sits alone.
c. Can feed self with a spoon.
d. Pulling up to a standing position.
4. While teaching a 10 year-old child about their impending heart surgery, the nurse
should
a. Provide a verbal explanation just prior to the surgery
b. Provide the child with a booklet to read about the surgery
c. Introduce the child to another child who had heart surgery three days ago
d. Explain the surgery using a model of the heart
5. When caring for an elderly client it is important to keep in mind the changes in
color vision that may occur. What colors are apt to be most difficult for the elderly to
distinguish?
a. Red and blue.
b. Blue and gold.
c. Red and green.
d. Blue and green.
6. While giving nursing care to a hospitalized adolescent, the nurse should be aware
that the MAJOR threat felt by the hospitalized adolescent is
a. Pain management
b. Restricted physical activity
c. Altered body image
d. Separation from family
7. A woman who is 32 years old and 35 weeks pregnant has had rupture of membranes
for eight hours and is 4 cm dilated. Since she is a candidate for infection, the nurse
should include which of the following in the care plan?
a. Universal precautions.
b. Oxytocin administration.
c. Frequent temperature monitoring.
d. More frequent vaginal examinations.
8. The nurse prepares for a Denver Screening test with a 3 year-old child in the clinic.
The mother asks the nurse to explain the purpose of the test. The BEST response is to
tell her that the test
a. Measures potential intelligence
b. Assesses a childs development
c. Evaluates psychological responses
d. Diagnoses specific problems
9. A 27-year-old woman has Type I diabetes mellitus. She and her husband want to
have a child so they consulted her diabetologist, who gave her information on
pregnancy and diabetes. Of primary importance for the diabetic woman who is
considering pregnancy should be
a. a review of the dietary modifications that will be necessary.
b. early prenatal medical care.
c. adoption instead of conception.
d. understanding that this is a major health risk to the mother.
10. The nurse is planning care for an 18 month-old child. Which of the following
should be included the in the childs care?
a. Hold and cuddle the child often
b. Encourage the child to feed himself finger food
c. Allow the child to walk independently on the nursing unit
d. Engage the child in games with other children
11. The nurse in an infertility clinic is discussing the treatment routine. The nurse
advises the couple that the major stressor for couples being treated for infertility is
usually
a. having to tell their families.
b. the cost of the interventions.
c. the inconvenience of multiple tests.
d. the right scheduling of sexual intercourse.
12. The nurse is assessing a four month-old infant. The nurse would anticipate finding
that the infant would be able to
a. Hold a rattle
b. Bang two blocks
c. Drink from a cup
d. Wave bye-bye
13. The nurse is evaluating a new mother feeding her newborn. Which observation
indicates the mother understands proper feeding methods for her newborn?
a. Holding the bottle so the nipple is always filled with formula.

b. Allowing her seven pound baby to sleep after taking 1 ounces from the bottle.
c. Burping the baby every ten minutes during the feeding.
d. Warming the formula bottle in the microwave for 15 seconds and giving it directly to
the baby.
14. The nurse is caring for a pregnant client. The client asks how the doctor could tell
she was pregnant just by looking inside. The nurse tells her the most likely
explanation is that she had a positive Chadwicks sign, which is a
a. Bluish coloration of the cervix and vaginal walls
b. Pronounced softening of the cervix
c. Clot of very thick mucous that obstructs the cervical canal
d. Slight rotation of the uterus to the right
15. When caring for an elderly client it is important to keep in mind the changes in
color vision that may occur. What colors are apt to be most difficult for the elderly to
distinguish?
a. Red and blue.
b. Blue and gold.
c. Red and green.
d. Blue and green.
16. The nurses FIRST step in nutritional counseling/teaching for a pregnant woman is
to
a. Teach her how to meet the needs of self and her family
b. Explain the changes in diet necessary for pregnant women
c. Question her understanding and use of the food pyramid
d. Conduct a diet history to determine her normal eating routines
17. A woman who is six months pregnant is seen in antepartal clinic. She states she is
having trouble with constipation. To minimize this condition, the nurse should
instruct her to
a. increase her fluid intake to three liters/day.

b. request a prescription for a laxative from her physician.
c. stop taking iron supplements.
d. take two tablespoons of mineral oil daily.
18. The nurse is observing children playing in the hospital playroom. She would
expect to see 4 year-old children playing
a. Competitive board games with older children
b. With their own toys along side with other children
c. Alone with hand held computer games
d. Cooperatively with other preschoolers
19. The nurse is caring for residents in a long term care setting for the elderly. Which
of the following activities will be MOST effective in meeting the growth and
development needs for persons in this age group?
a. Aerobic exercise classes
b. Transportation for shopping trips
c. Reminiscence groups
d. Regularly scheduled social activities
20. A pregnant woman is advised to alter her diet during pregnancy by increasing her
protein and Vitamin C to meet the needs of the growing fetus. Which diet BEST meets
the clients needs?
a. Scrambled egg, hash browned potatoes, half-glass of buttermilk, large nectarine
b. 3oz. chicken, C. corn, lettuce salad, small banana
c. 1 C. macaroni, C. peas, glass whole milk, medium pear
d. Beef, C. lima beans, glass of skim milk, C. strawberries

1. Answer C.
Exposure to air helps dry the cord. Good hand washing is the prime mechanism for
preventing infection. Washing the surrounding area is fine but wetting the cord keeps it
moist and predisposes it to infection. It is important to check for complications of

bleeding and drainage that might occur.
2. Answer B.
Human chorionic gonadotropin (HCG) is the biologic marker on which pregnancy tests are
based. Reliability is about 98%, but the test does not positively confirm pregnancy.
3. Answer B.
The child develops language skills between the ages of one and three. A six-month-old
child is learning to sit alone. The child begins to use a spoon at 12-15 months of age. The
baby pulls himself to a standing position about ten months of age.
4. Answer D.
According to Piaget, the school age child is in the concrete operations stage of cognitive
development. Using something concrete, like a model will help the child understand the
explanation of the heart surgery.
5. Answer D.
The elderly are better able to distinguish between red and blue because of the difference
in wavelengths. The elderly are better able to distinguish between blue and gold because
of the difference in wavelengths. The elderly are better able to distinguish between red
and green because of the difference in wavelengths. Red and green color blindness is an
inherited disorder that is unrelated to age. The elderly have poor blue-green
discrimination. The effects of age are greatest on short wavelengths. These changes are
related to the yellowing of the lens with age.
6. Answer C.
The hospitalized adolescent may see each of these as a threat, but the major threat that
they feel when hospitalized is the fear of altered body image, because of the emphasis on
physical appearance.
7. Answer C.
Universal precautions are necessary for all clients but a specific assessment of the clients
temperature will give an indication the client is becoming infected. Oxytocin may be
needed to induce labor if it is not progressing, but it is not done initially.Temperature
elevation will indicate beginning infection. This is the most important measure to help
assess the client for infections, since the lost mucous plug and the ruptured membranes
increase the potential for ascending bacteria from the reproductive tract. This will infect
the fetus, membranes, and uterine cavity. More frequent vaginal examinations are not
recommended, as frequent vaginal exams can increase chances of infection.
8. Answer B.
The Denver Developmental Test II is a screening test to assess children from birth through
6 years in personal/social, fine motor adaptive, language and gross motor development. A
child experiences the fun of play during the test.
9. Answer B.
A review of dietary modifications is important once the woman is pregnant. However, it is
not of primary importance when considering pregnancy. Pregnancy makes metabolic
control of diabetes more difficult. It is essential that the client start prenatal care early
so that potential complications can be controlled or minimized by the efforts of the client
and health care team. The alternative of adoption is not necessary just because the client
is a diabetic. Many diabetic women have pregnancies with successful outcomes if they
receive good care. While there is some risk to the pregnant diabetic woman, it is not
considered a major health risk. The greater risk is to the fetus.
10. Answer B.
According to Erikson, the toddler is in the stage of autonomy versus shame and doubt.
The nurse should encourage increasingly independent activities of daily living.
11. Answer D.
Having to tell families may also be a factor contributing to stress but is not the major
stressor. Cost may also be a contributing factor to stress but is not usually the major
factor. The inconvenience of multiple tests may also be a factor contributing to stress but
is not usually the major factor. Sexual activity on demand is the major cause of stress
for most infertile couples.
12. Answer A.
The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.
13. Answer A.
Holding the bottle so the nipple is always filled with formula prevents the baby from
sucking air. Sucking air can cause gastric distention and intestinal gas pains. A sevenpound baby should be getting 50 calories per pound: 350 calories per day. Standardized
formulas have 20 calories per ounce. This seven-pound baby needs 17.5 ounces per day.
17.5 ounces per day divided by 6-8 feedings equals 2-3 ounces per feeding. A normal
newborn without feeding problems could be burped halfway through the feeding and
again at the end. If burping needs to be at intervals, it should be done by ounces or half
ounces, not minutes. Microwaving is not recommended as a method of warming due to
the uneven heating of the formula. If used, the formula should be shaken after warming
and the temperature then checked with a drop on the wrist. The recommended method
of warming is to place the bottle in a pan of hot water to warm, and then check the
temperature on the wrist before feeding.
14. Answer A.
Chadwicks sign is a bluish-purple coloration of the cervix and vaginal walls, occurring at
4 weeks of pregnancy, that is caused by vasocongestion.
15. Answer D.
The elderly are better able to distinguish between red and blue because of the difference
in wavelengths. Red and green color blindness is an inherited disorder that is unrelated to
age. The elderly have poor blue-green discrimination. The effects of age are greatest on
short wavelengths. These changes are related to the yellowing of the lens with age.
16. Answer D.
Assessment is always the first step in planning teaching for any client.
17. Answer A.
In pregnancy, constipation results from decreased gastric motility and increased water
reabsorption in the colon caused by increased levels of progesterone. Increasing fluid
intake to three liters a day will help prevent constipation. The client should increase fluid
intake, increase roughage in the diet, and increase exercise as tolerated. Laxatives are
not recommended because of the possible development of laxative dependence or
abdominal cramping. Iron supplements are necessary during pregnancy, as ordered, and
should not be discontinued. The client should increase fluid intake, increase roughage in
the diet, and increase exercise as tolerated. Laxatives are not recommended because of
the possible development of laxative dependence or abdominal cramping. Mineral oil is
especially bad to use as a laxative because it decreases the absorption of fat-soluble
vitamins (A, D, E, K) if taken near mealtimes.
18. Answer D.
Cooperative play is typical of the preschool period.
19. Answer C.
According to Eriksons theory, older adults need to find and accept the meaningfulness of
their lives, or they may become depressed, angry, and fear death. Reminiscing
contributes to successful adaptation by maintaining self-esteem, reaffirming identity, and
working through loss.
20. Answer D.
Beef and beans are an excellent source of protein as is skim milk. Strawberries are a good
source of Vitamin C.
TAGS
GROWTH AND DEVELOPMENT
NCLEX EXAMS
PEDIATRIC NURSING
Introduction
The second set of questions about Maternal and Child Health Nursing. Another 30 NCLEX-style
questionsabout the topic.
Topics
Family Planning
Breastfeeding
Various questions pertaining to Pregnancy
Guidelines
Questions
Text
Practice
Exam
MCN
1. Accompanied by her husband, a patient seeks admission to the labor and delivery
area. The client states that she is in labor and says she attended the hospital clinic for
prenatal care. Which question should the nurse ask her first?
a. Do you have any chronic illness?
b. Do you have any allergies?
c. What is your expected due date?
d. Who will be with you during labor?
2. A patient is in the second stage of labor. During this stage, how frequently should
the nurse in charge assess her uterine contractions?
a. Every 5 minutes
b. Every 15 minutes
c. Every 30 minutes
d. Every 60 minutes
3. A patient is in her last trimester of pregnancy. Nurse Vickie should instruct her to
notify her primary health care provider immediately if she notices:
a. Blurred vision
b. Hemorrhoids
c. Increased vaginal mucus
d. Shortness of breath on exertion
4. The nurse in-charge is reviewing a patients prenatal history. Which finding
indicates a genetic risk factor?
a. The patient is 25 years old
b. The patient has a child with cystic fibrosis
c. The patient was exposed to rubella at 36 weeks gestation
d. The patient has a history of preterm labor at 32 weeks gestation
5. A adult female patient is using the rhythm (calendar-basal body temperature)
method of family planning. In this method, the unsafe period for sexual intercourse is
indicated by:
a. Return preovulatory basal body temperature
b. Basal body temperature increase of 0.1 degrees to 0.2 degrees on the 2nd or 3rd day of
cycle
c. 3 full days of elevated basal body temperature and clear, thin cervical mucus
d. Breast tenderness and mittelschmerz
6. During a nonstress test (NST), the electronic tracing displays a relatively flat line
for fetal movement, making it difficult to evaluate the fetal heart rate (FHR). To mark
the strip, the nurse in charge should instruct the client to push the control button at
which time?
a. At the beginning of each fetal movement
b. At the beginning of each contraction
c. After every three fetal movements
d. At the end of fetal movement
7. When evaluating a clients knowledge of symptoms to report during her pregnancy,

which statement would indicate to the nurse in charge that the client understands the
information given to her?
a. Ill report increased frequency of urination.
b. If I have blurred or double vision, I should call the clinic immediately.
c. If I feel tired after resting, I should report it immediately.
d. Nausea should be reported immediately.
8. When assessing a client during her first prenatal visit, the nurse discovers that the
client had a reduction mammoplasty. The mother indicates she wants to breast-feed.
What information should the nurse give to this mother regarding breastfeeding
success?
a. Its contraindicated for you to breastfeed following this type of surgery.
b. I support your commitment; however, you may have to supplement each feeding with
formula.
c. You should check with your surgeon to determine whether breast-feeding would be
possible.
d. You should be able to breastfeed without difficulty.
9. Following a precipitous delivery, examination of the clients 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 peri pads 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
10. A client makes a routine visit to the prenatal clinic. Although she is 14 weeks
pregnant, the size of her uterus approximates that in an 18- to 20-week pregnancy.
Dr. Charles diagnoses gestational trophoblastic disease and orders ultrasonography.
The nurse expects ultrasonography to reveal:
a. an empty gestational sac.
b. grapelike clusters.
c. a severely malformed fetus.

d. an extrauterine pregnancy.
11. After completing a second vaginal examination of a client in labor, the nursemidwife determines that the fetus is in the right occiput anterior position and at (1)
station. Based on these findings, the nurse-midwife knows that the fetal presenting
part is:
a. 1 cm below the ischial spines.
b. directly in line with the ischial spines.
c. 1 cm above the ischial spines.
d. in no relationship to the ischial spines.
12. Which of the following would be inappropriate to assess in a mother whos
breastfeeding?
a. The attachment of the baby to the breast.
b. The mothers comfort level with positioning the baby.
c. Audible swallowing.
d. The babys lips smacking
13. During a prenatal visit at 4 months gestation, a pregnant client asks whether tests
can be done to identify fetal abnormalities. Between 18 and 40 weeks gestation,
which procedure is used to detect fetal anomalies?
a. Amniocentesis.
b. Chorionic villi sampling.
c. Fetoscopy.
d. Ultrasound
14. A client, 30 weeks pregnant, is scheduled for a biophysical profile (BPP) to
evaluate the health of her fetus. Her BPP score is 8. What does this score indicate?
a. The fetus should be delivered within 24 hours.
b. The client should repeat the test in 24 hours.
c. The fetus isnt in distress at this time.
d. The client should repeat the test in 1 week.
15. A client who is 36 weeks pregnant comes to the clinic for a prenatal checkup. To
assess the clients preparation for parenting, the nurse might ask which question?
a. Are you planning to have epidural anesthesia?
b. Have you begun prenatal classes?
c. What changes have you made at home to get ready for the baby?
d. Can you tell me about the meals you typically eat each day?
16. A client whos admitted to labor and delivery has the following assessment
findings: gravida 2 para 1, estimated 40 weeks gestation, contractions 2 minutes
apart, lasting 45 seconds, vertex +4 station. Which of the following would be the
priority at this time?
a. Placing the client in bed to begin fetal monitoring.
b. Preparing for immediate delivery.
c. Checking for ruptured membranes.
d. Providing comfort measures.
17. The nurse is caring for a client in labor. The external fetal monitor shows a
pattern of variable decelerations in fetal heart rate. What should the nurse do first?
a. Change the clients position.
b. Prepare for emergency cesarean section.
c. Check for placenta previa.
d. Administer oxygen.
18. The nurse in charge is caring for a postpartum client who had a vaginal delivery
with a midline episiotomy. Which nursing diagnosis takes priority for this client?
a. Risk for deficient fluid volume related to hemorrhage
b. Risk for infection related to the type of delivery
c. Pain related to the type of incision
d. Urinary retention related to periurethral edema
19. Which change would the nurse identify as a progressive physiological change in
postpartum period?
a. Lactation
b. Lochia
c. Uterine involution
d. Diuresis
20. A 39-year-old at 37 weeks gestation is admitted to the hospital with complaints of
vaginal bleeding following the use of cocaine 1 hour earlier. Which complication is
most likely causing the clients complaint of vaginal bleeding?
a. Placenta previa
b. Abruptio placentae
c. Ectopic pregnancy
d. Spontaneous abortion
21. A client with type 1 diabetes mellitus who is a multigravida visits the clinic at 27
weeks gestation. The nurse should instruct the client that for most pregnant women
with type 1 diabetes mellitus:
a. Weekly fetal movement counts are made by the mother.
b. Contraction stress testing is performed weekly.
c. Induction of labor is begun at 34 weeks gestation.
d. Nonstress testing is performed weekly until 32 weeks gestation
22. When administering magnesium sulfate to a client with preeclampsia, the nurse
understands that this drug is given to:
a. Prevent seizures
b. Reduce blood pressure
c. Slow the process of labor
d. Increase dieresis
23. What is the approximate time that the blastocyst spends traveling to the uterus
for implantation?
a. 2 days
b. 7 days
c. 10 days
d. 14 weeks
24. After teaching a pregnant woman who is in labor about the purpose of the
episiotomy, which of the following purposes stated by the client would indicate to the
nurse that the teaching was effective?
a. Shortens the second stage of labor
b. Enlarges the pelvic inlet
c. Prevents perineal edema
d. Ensures quick placenta delivery
25. A primigravida client at about 35 weeks gestation in active labor has had no
prenatal care and admits to cocaine use during the pregnancy. Which of the following
persons must the nurse notify?
a. Nursing unit manager so appropriate agencies can be notified
b. Head of the hospitals security department
c. Chaplain in case the fetus dies in utero
d. Physician who will attend the delivery of the infant
26. When preparing a teaching plan for a client who is to receive a rubella vaccine
during the postpartum period, the nurse in charge should include which of the
following?
a. The vaccine prevents a future fetus from developing congenital anomalies
b. Pregnancy should be avoided for 3 months after the immunization
c. The client should avoid contact with children diagnosed with rubella
d. The injection will provide immunity against the 7-day measles.
27. A client with eclampsia begins to experience a seizure. Which of the following
would the nurse in charge do first?
a. Pad the side rails
b. Place a pillow under the left buttock
c. Insert a padded tongue blade into the mouth
d. Maintain a patent airway
28. While caring for a multigravida client in early labor in a birthing center, which of
the following foods would be best if the client requests a snack?
a. Yogurt
b. Cereal with milk
c. Vegetable soup
d. Peanut butter cookies
29. The multigravida mother with a history of rapid labor who us in active labor calls
out to the nurse, The baby is coming! which of the following would be the nurses
first action?
a. Inspect the perineum
b. Time the contractions
c. Auscultate the fetal heart rate
d. Contact the birth attendant
30. While assessing a primipara during the immediate postpartum period, the nurse in
charge plans to use both hands to assess the clients fundus to:
a. Prevent uterine inversion
b. Promote uterine involution
c. Hasten the puerperium period
d. Determine the size of the fundus

1. Answer C.
When obtaining the history of a patient who may be in labor, the nurses 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 illness, allergies, and support
persons.
2. Answer B.
During the second stage of labor, the nurse should assess the strength, frequency, and
duration of contraction every 15 minutes. If maternal or fetal problems are detected,

more frequent monitoring is necessary. An interval of 30 to 60 minutes between
assessments is too long because of variations in the length and duration of patients labor.
3. Answer A.
Blurred vision or other visual disturbance, excessive weight gain, edema, and increased
blood pressure may signal severe preeclampsia. This condition may lead to eclampsia,
which has potentially serious consequences for both the patient and fetus. Although
hemorrhoids may be a problem during pregnancy, they do not require immediate
attention. Increased vaginal mucus and dyspnea on exertion are expected as pregnancy
progresses.
4. Answer B.
Cystic fibrosis is a recessive trait; each offspring has a one in four chance of having the
trait or the disorder. Maternal age is not a risk factor until age 35, when the incidence of
chromosomal defects increases. Maternal exposure to rubella during the first trimester
may cause congenital defects. Although a history or preterm labor may place the patient
at risk for preterm labor, it does not correlate with genetic defects.
5. Answer C.
Ovulation (the period when pregnancy can occur) is accompanied by a basal body
temperature increase of 0.7 degrees F to 0.8 degrees F and clear, thin cervical mucus. A
return to the preovulatory body temperature indicates a safe period for sexual
intercourse. A slight rise in basal temperature early in the cycle is not significant. Breast
tenderness and mittelschmerz are not reliable indicators of ovulation.
6. Answer A.
An NST assesses the FHR during fetal movement. In a healthy fetus, the FHR accelerates
with each movement. By pushing the control button when a fetal movement starts, the
client marks the strip to allow easy correlation of fetal movement with the FHR. The FHR
is assessed during uterine contractions in the oxytocin contraction test, not the NST.
Pushing the control button after every three fetal movements or at the end of fetal
movement wouldnt allow accurate comparison of fetal movement and FHR changes.
7. Answer B.
Blurred or double vision may indicate hypertension or preeclampsia and should be
reported immediately. Urinary frequency is a common problem during pregnancy caused
by increased weight pressure on the bladder from the uterus. Clients generally
experience fatigue and nausea during pregnancy.
8. Answer B.
Recent breast reduction surgeries are done in a way to protect the milk sacs and ducts, so
breast-feeding after surgery is possible. Still, its good to check with the surgeon to
determine what breast reduction procedure was done. There is the possibility that
reduction surgery may have decreased the mothers ability to meet all of her babys
nutritional needs, and some supplemental feeding may be required. Preparing the mother
for this possibility is extremely important because the clients psychological adaptation to
mothering may be dependent on how successfully she breast-feeds.
9. Answer B.
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.
10. Answer B.
In a client with gestational trophoblastic disease, an ultrasound performed after the 3rd
month shows grapelike clusters of transparent vesicles rather than a fetus. The vesicles
contain a clear fluid and may involve all or part of the decidual lining of the uterus.
Usually no embryo (and therefore no fetus) is present because it has been absorbed.
Because there is no fetus, there can be no extrauterine pregnancy. An extrauterine
pregnancy is seen with an ectopic pregnancy.
11. Answer C.
Fetal station the relationship of the fetal presenting part to the maternal ischial spines
is described in the number of centimeters above or below the spines. A presenting part
above the ischial spines is designated as 1, 2, or 3. A presenting part below the ischial
spines, as +1, +2, or +3.
12. Answer D.
Assessing the attachment process for breast-feeding should include all of the answers
except the smacking of lips. A baby whos smacking his lips isnt well attached and can
injure the mothers nipples.
13. Answer D.
Ultrasound is used between 18 and 40 weeks gestation to identify normal fetal growth
and detect fetal anomalies and other problems. Amniocentesis is done during the third
trimester to determine fetal lung maturity. Chorionic villi sampling is performed at 8 to
12 weeks gestation to detect genetic disease. Fetoscopy is done at approximately 18
weeks gestation to observe the fetus directly and obtain a skin or blood sample.
14. Answer C.
The BPP evaluates fetal health by assessing five variables: fetal breathing movements,
gross body movements, fetal tone, reactive fetal heart rate, and qualitative amniotic
fluid volume. A normal response for each variable receives 2 points; an abnormal response
receives 0 points. A score between 8 and 10 is considered normal, indicating that the
fetus has a low risk of oxygen deprivation and isnt in distress. A fetus with a score of 6 or
lower is at risk for asphyxia and premature birth; this score warrants detailed
investigation. The BPP may or may not be repeated if the score isnt within normal limits.
15. Answer C.
During the third trimester, the pregnant client typically perceives the fetus as a separate
being. To verify that this has occurred, the nurse should ask whether she has made
appropriate changes at home such as obtaining infant supplies and equipment. The type
of anesthesia planned doesnt reflect the clients preparation for parenting. The client
should have begun prenatal classes earlier in the pregnancy. The nurse should have
obtained dietary information during the first trimester to give the client time to make
any necessary changes.
16. Answer B.
This question requires an understanding of station as part of the intrapartum assessment
process. Based on the clients assessment findings, this client is ready for delivery, which
is the nurses top priority. Placing the client in bed, checking for ruptured membranes,
and providing comfort measures could be done, but the priority here is immediate
delivery.
17. Answer A.
Variable decelerations in fetal heart rate are an ominous sign, indicating compression of
the umbilical cord. Changing the clients position from supine to side-lying may
immediately correct the problem. An emergency cesarean section is necessary only if
other measures, such as changing position and amnioinfusion with sterile saline, prove
unsuccessful. Administering oxygen may be helpful, but the priority is to change the
womans position and relieve cord compression.
18. Answer A.
Hemorrhage jeopardizes the clients oxygen supply the first priority among human
physiologic needs. Therefore, the nursing diagnosis of Risk for deficient fluid volume
related to hemorrhage takes priority over diagnoses of Risk for infection, Pain, and
Urinary retention.
19. Answer A.
Lactation is an example of a progressive physiological change that occurs during the
postpartum period.
20. Answer B.
The major maternal adverse reactions from cocaine use in pregnancy include spontaneous
abortion first, not third, trimester abortion and abruptio placentae.
21. Answer D.
For most clients with type 1 diabetes mellitus, nonstress testing is done weekly until 32
weeks gestation and twice a week to assess fetal well-being.
22. Answer A.
The chemical makeup of magnesium is similar to that of calcium and, therefore,
magnesium will act like calcium in the body. As a result, magnesium will block seizure
activity in a hyper stimulated neurologic system by interfering with signal transmission at
the neuromascular junction.
23. Answer B.
The blastocyst takes approximately 1 week to travel to the uterus for implantation.
24. Answer A.
An episiotomy serves several purposes. It shortens the second stage of labor, substitutes a
clean surgical incision for a tear, and decreases undue stretching of perineal muscles. An
episiotomy helps prevent tearing of the rectum but it does not necessarily relieves
pressure on the rectum. Tearing may still occur.
25. Answer D.
The fetus of a cocaine-addicted mother is at risk for hypoxia, meconium aspiration, and
intrauterine growth retardation (IUGR). Therefore, the nurse must notify the physician of
the clients cocaine use because this knowledge will influence the care of the client and
neonate. The information is used only in relation to the clients care.
26. Answer B.
After administration of rubella vaccine, the client should be instructed to avoid
pregnancy for at least 3 months to prevent the possibility of the vaccines toxic effects to
the fetus.
27. Answer D.
The priority for the pregnant client having a seizure is to maintain a patent airway to
ensure adequate oxygenation to the mother and the fetus. Additionally, oxygen may be
administered by face mask to prevent fetal hypoxia.
28. Answer A.
In some birth settings, intravenous therapy is not used with low-risk clients. Thus, clients
in early labor are encouraged to eat healthy snacks and drink fluid to avoid dehydration.
Yogurt, which is an excellent source of calcium and riboflavin, is soft and easily digested.
During pregnancy, gastric emptying time is delayed. In most hospital settings, clients are
allowed only ice chips or clear liquids.
29. Answer A.
When the client says the baby is coming, the nurse should first inspect the perineum and
observe for crowning to validate the clients statement. If the client is not delivering
precipitously, the nurse can calm her and use appropriate breathing techniques.
30. Answer A.
Using both hands to assess the fundus is useful for preventing uterine inversion.
TAGS
BREASTFEEDING
FAMILY PLANNING
NCLEX EXAMS
Description
Extend and further strengthen your knowledge about the concepts of Pediatric Nursing with these 40
Nursing Bullets. These Nursing Bullets are bite-sized information that are easy to absorb and best to
be read during your reviews for NCLEX or the board exams.
Topics
Included topics are:
HIV
Roseola
Tractions
Various diseases afflicting the pediatric clients
Bullets
1.
A child with HIV-positive blood should receive inactivated poliovirus vaccine (IPV) rather than
oral poliovirus vaccine (OPV) immunization.
2.
To achieve postural drainage in an infant, place a pillow on the nurses lap and lay the infant
across it.
3.
A child with cystic fibrosis should eat more calories, protein, vitamins, and minerals than a
child without the disease.
4.
Infants subsisting on cows milk only dont receive a sufficient amount of iron (ferrous sulfate),
which will eventually result in iron deficiency anemia.
5.
A child with an undiagnosed infection should be placed in isolation.
6.
An infant usually triples his birth weight by the end of his first year.
7.
Clinical signs of a dehydrated infant include lethargy, irritability, dry skin decreased tearing,
decreased urinary output, and increased pulse.
8.
Appropriate care of a child with meningitis includes frequent assessment of neurologic signs
(such as decreasing levels of consciousness, difficulty to arouse) and measuring the
circumference of the head because subdural effusions and obstructive hydrocephalus can
develop.
9.
Expected clinical findings in a newborn with cerebral palsy include reflexive hypertonicity and
criss-crossing or scissoring leg movements.
10.
Papules, vesicles, and crust are all present at the same time in the early phase of
chickenpox.
11.
Topical corticosteroids shouldnt be used on chickenpox lesions.
12.
A serving size of a food is usually 1 tablespoon for each year of age.
13.
The characteristic of fifth disease (erythema infectiosum) is erythema on the face, primarily
the cheeks, giving a slapped face appearance.
14.
Adolescents may brave pain, especially in front of peers. Therefore, offer analgesics if pain is
suspected or administer the medication if the client asks for it.
15.
Signs that a child with cystic fibrosis is responding to pancreatic enzymes are the absence of
steatorrhea, improved appetite, and absence of abdominal pain.
16.
Roseola appears as discrete rose-pink macules that first appear on the trunk and that fade
when pressure is applied.
17.
A ninety degree-ninety degree traction is used for fracture of a childs femur or tibia.
18.
One sign of developmental dysplasia is limping during ambulation.
19.
Circumcision wouldnt be performed on a male child with hypospadias because the foreskin
may be needed during surgical reconstruction.
20.
Neonatal abstinence syndrome is manifested in central nervous system hyperirritability (for

example, hyperactive Moro reflex) and gastrointestinal symptoms (watery stools).
21.
Classic signs of shaken baby syndrome are seizures, slow apical pulse difficulty breathing,
and retinal hemorrhage.
22.
An infant born to an HIV-positive mother will usually receive AZT (zidovudine) for the first 6
weeks of life.
23.
Infants born to an HIV-positive mother should receive all immunizations of schedule.
24.
Blood pressure in the arms and legs is essentially the same in infants.
25.
When bottle-feeding a newborn with a cleft palate, hold the infants head in an upright
position.
26.
Because of circulating maternal antibodies that will decrease the immune response, the
measles, mumps, and rubella (MMR) vaccine shouldnt be given until the infant has reached 1
year of age.
27.
Before feeding an infant any fluid that has been warmed, test a drop of the liquid on your own
skin to prevent burning the infant.
28.
A newborn typically wets 6 to 10 diapers per day.
29.
Although microwaving food and fluids isnt recommend for infants, its commonplace in the
United States. Therefore the family should be toughs to test the temperature of the food or fluid
against their own skin before allowing it to be consumed by the infant.
30.
The most adequate diet for an infant in the first 6 months of life is breast milk.
31.
An infant can usually chew food by 7 months, hold spoon by 9 month, and drink fluid from a
cup by 1 year of age.
32.
Choking from mechanical obstruction is the leading cause of death (by suffocation) for
infants younger than 1 year of age.
33.
Failure to thrive is a term used to describe an infant who falls below the fifth percentile for
weight and height on a standard measurement chart.
34.
Developmental theories include Havighursts age periods and developmental tasks; Freuds
five stages of development;
35.
Kohlbergs stages of moral development; Eriksons eight stages of development; and Piagets
phases of cognitive development.
36.
The primary concern with infusing large volumes of fluid is circulatory overload. This is
especially true in children and infants, and in clients with renal disease.
37.
Certain hazards present increased risk of harm to children and occur more often at different
ages. For infants, more falls, burns, and suffocation occur; for toddlers, there are more burns,
poisoning, and drowning for preschoolers, more playground equipment accidents, choking,
poisoning, and drowning; and for adolescents, more automobile accidents, drowning, fires, and
firearm accidents.
38.
A child in Bryants traction whos younger than age 3 or weighs less than 30 lb (13.6 kg)
should have the buttocks slightly elevated and clear or the bed. The knees should be slightly
flexed, and the legs should be extended at a right angle to the body.
39.
The body provides the traction mechanism.
40.
In an infant, a bulging fontanel is the most significant sign of increasing intracranial pressure.
See Also
Nursing Bullets
Nursing Bullets: Pediatric Nursing Reviewer 1 (40 Items)
Nursing Bullets: Maternal & Child Health Nursing Reviewer 1 (350 Items)
Nursing Bullets: Fundamentals of Nursing Reviewer 1 (220 Items)
Nursing Bullets: Medical-Surgical Nursing Reviewer 1 (160 Items)
Nursing Bullets: Psychiatric Nursing Reviewer 1 (225 Items)
TAGS
NURSING BULLETS
PEDIATRIC NURSING
Description
Increase your knowledge and confidence for the Nursing Licensure Exam (NLE) or NCLEX with this
easy to digest information regarding the concepts of Maternal and Child Health Nursing. This
covers topic about labor, pregnancy, nursing care of the newborn, developmental stages and many
more! This post contains 350 nursing bullets!
Topics
Labor, Delivery
Pregnancy
Breastfeeding
Abortion
Conditions affecting the pregnant women
Bullets
1.
Unlike false labor, true labor produces regular rhythmic contractions, abdominal discomfort,
progressive descent of the fetus, bloody show, and progressive effacement and dilation of the
cervix.
2.
To help a mother break the suction of her breast-feeding infant, the nurse should teach her to
insert a finger at the corner of the infants mouth.
3.
Administering high levels of oxygen to a premature neonate can cause blindness as a result
of retrolental fibroplasia.
4.
Amniotomy is artificial rupture of the amniotic membranes.
5.
During pregnancy, weight gain averages 25 to 30 lb (11 to 13.5 kg).
6.
Rubella has a teratogenic effect on the fetus during the first trimester. It produces
abnormalities in up to 40% of cases without interrupting the pregnancy.
7.
Immunity to rubella can be measured by a hemagglutination inhibition test (rubella titer). This
test identifies exposure to rubella infection and determines susceptibility in pregnant women. In a
woman, a titer greater than 1:8 indicates immunity.
8.
When used to describe the degree of fetal descent during labor, floating means the
presenting part isnt engaged in the pelvic inlet, but is freely movable (ballotable) above the
pelvic inlet.
9.
When used to describe the degree of fetal descent, engagement means when the largest
diameter of the presenting part has passed through the pelvic inlet.
10.
Fetal station indicates the location of the presenting part in relation to the ischial spine. Its
described as 1, 2, 3, 4, or 5 to indicate the number of centimeters above the level of the
ischial spine; station 5 is at the pelvic inlet.
11.
Fetal station also is described as +1, +2, +3, +4, or +5 to indicate the number of centimeters
it is below the level of the ischial spine; station 0 is at the level of the ischial spine.
12.
During the first stage of labor, the side-lying position usually provides the greatest degree of
comfort, although the patient may assume any comfortable position.
13.
During delivery, if the umbilical cord cant be loosened and slipped from around the neonates
neck, it should be clamped with two clamps and cut between the clamps.
14.
An Apgar score of 7 to 10 indicates no immediate distress, 4 to 6 indicates moderate

distress, and 0 to 3 indicates severe distress.
15.
To elicit Moros reflex, the nurse holds the neonate in both hands and suddenly, but gently,
drops the neonates head backward. Normally, the neonate abducts and extends all extremities
bilaterally and symmetrically, forms a C shape with the thumb and forefinger, and first adducts
and then flexes the extremities.
16.
Pregnancy-induced hypertension (preeclampsia) is an increase in blood pressure of 30/15

mm Hg over baseline or blood pressure of 140/95 mm Hg on two occasions at least 6 hours
apart accompanied by edema and albuminuria after 20 weeks gestation.
17.
Positive signs of pregnancy include ultrasound evidence, fetal heart tones, and fetal
movement felt by the examiner (not usually present until 4 months gestation
18.
Goodells sign is softening of the cervix.
19.
Quickening, a presumptive sign of pregnancy, occurs between 16 and 19 weeks gestation.
20.
Ovulation ceases during pregnancy.
21.
Any vaginal bleeding during pregnancy should be considered a complication until proven
otherwise.
To estimate the date of delivery using Ngeles rule, the nurse counts backward 3 months from
the first day of the last menstrual period and then adds 7 days to this date.
22.
At 12 weeks gestation, the fundus should be at the top of the symphysis pubis.
23.
Cows milk shouldnt be given to infants younger than age 1 because it has a low linoleic acid
content and its protein is difficult for infants to digest.
24.
If jaundice is suspected in a neonate, the nurse should examine the infant under natural
window light. If natural light is unavailable, the nurse should examine the infant under a white
light.
25.
The three phases of a uterine contraction are increment, acme, and decrement.
26.
The intensity of a labor contraction can be assessed by the indentability of the uterine wall at
the contractions peak. Intensity is graded as mild (uterine muscle is somewhat tense), moderate
(uterine muscle is moderately tense), or strong (uterine muscle is boardlike).
27.
Chloasma, the mask of pregnancy, is pigmentation of a circumscribed area of skin (usually

over the bridge of the nose and cheeks) that occurs in some pregnant women.
28.
The gynecoid pelvis is most ideal for delivery. Other types include platypelloid (flat),
anthropoid (apelike), and android (malelike).
29.
Pregnant women should be advised that there is no safe level of alcohol intake.
30.
The frequency of uterine contractions, which is measured in minutes, is the time from the
beginning of one contraction to the beginning of the next.
31.
Vitamin K is administered to neonates to prevent hemorrhagic disorders because a neonates

intestine cant synthesize vitamin K.
Before internal fetal monitoring can be performed, a pregnant patients cervix must be dilated at
least 2 cm, the amniotic membranes must be ruptured, and the fetuss presenting part (scalp or
buttocks) must be at station 1 or lower, so that a small electrode can be attached.
32.
Fetal alcohol syndrome presents in the first 24 hours after birth and produces lethargy,
seizures, poor sucking reflex, abdominal distention, and respiratory difficulty.
33.
Variability is any change in the fetal heart rate (FHR) from its normal rate of 120 to 160
beats/minute. Acceleration is increased FHR; deceleration is decreased FHR.
34.
In a neonate, the symptoms of heroin withdrawal may begin several hours to 4 days after
birth.
35.
In a neonate, the symptoms of methadone withdrawal may begin 7 days to several weeks
after birth.
36.
In a neonate, the cardinal signs of narcotic withdrawal include coarse, flapping tremors;
sleepiness; restlessness; prolonged, persistent, high-pitched cry; and irritability.
37.
The nurse should count a neonates respirations for 1 full minute.
38.
Chlorpromazine (Thorazine) is used to treat neonates who are addicted to narcotics.
39.
The nurse should provide a dark, quiet environment for a neonate who is experiencing
narcotic withdrawal.
40.
In a premature neonate, signs of respiratory distress include nostril flaring, substernal

retractions, and inspiratory grunting.
41.
Respiratory distress syndrome (hyaline membrane disease) develops in premature infants

because their pulmonary alveoli lack surfactant.
Whenever an infant is being put down to sleep, the parent or caregiver should position the infant
on the back. (Remember back to sleep.)
42.
The male sperm contributes an X or a Y chromosome; the female ovum contributes an X

chromosome.
43.
Fertilization produces a total of 46 chromosomes, including an XY combination (male) or an

XX combination (female).
44.
The percentage of water in a neonates body is about 78% to 80%.
45.
To perform nasotracheal suctioning in an infant, the nurse positions the infant with his neck
slightly hyperextended in a sniffing position, with his chin up and his head tilted back slightly.
46.
Organogenesis occurs during the first trimester of pregnancy, specifically, days 14 to 56 of

gestation.
47.
After birth, the neonates umbilical cord is tied 1 (2.5 cm) from the abdominal wall with a
cotton cord, plastic clamp, or rubber band.
48.
Gravida is the number of pregnancies a woman has had, regardless of outcome.
49.
Para is the number of pregnancies that reached viability, regardless of whether the fetus was
delivered alive or stillborn. A fetus is considered viable at 20 weeks gestation.
An ectopic pregnancy is one that implants abnormally, outside the uterus.
50.
The first stage of labor begins with the onset of labor and ends with full cervical dilation at 10
cm.
51.
The second stage of labor begins with full cervical dilation and ends with the neonates birth.
52.
The third stage of labor begins after the neonates birth and ends with expulsion of the
placenta.
In a full-term neonate, skin creases appear over two-thirds of the neonates feet. Preterm
neonates have heel creases that cover less than two-thirds of the feet.
53.
The fourth stage of labor (postpartum stabilization) lasts up to 4 hours after the placenta is
delivered. This time is needed to stabilize the mothers physical and emotional state after the
stress of childbirth.
54.
At 20 weeks gestation, the fundus is at the level of the umbilicus.
55.
At 36 weeks gestation, the fundus is at the lower border of the rib cage.
56.
A premature neonate is one born before the end of the 37th week of gestation.
57.
Pregnancy-induced hypertension is a leading cause of maternal death in the United States.
58.
A habitual aborter is a woman who has had three or more consecutive spontaneous
abortions.
59.
Threatened abortion occurs when bleeding is present without cervical dilation.
60.
A complete abortion occurs when all products of conception are expelled.
61.
Hydramnios (polyhydramnios) is excessive amniotic fluid (more than 2,000 ml in the third
trimester).
62.
Stress, dehydration, and fatigue may reduce a breast-feeding mothers milk supply.
63.
During the transition phase of the first stage of labor, the cervix is dilated 8 to 10 cm and
contractions usually occur 2 to 3 minutes apart and last for 60 seconds.
64.
A nonstress test is considered nonreactive (positive) if fewer than two fetal heart rate
accelerations of at least 15 beats/minute occur in 20 minutes.
65.
A nonstress test is considered reactive (negative) if two or more fetal heart rate accelerations
of 15 beats/minute above baseline occur in 20 minutes.
66.
A nonstress test is usually performed to assess fetal well-being in a pregnant patient with a
prolonged pregnancy (42 weeks or more), diabetes, a history of poor pregnancy outcomes, or
pregnancy-induced hypertension.
67.
A pregnant woman should drink at least eight 8-oz glasses (about 2,000 ml) of water daily.
68.
When both breasts are used for breast-feeding, the infant usually doesnt empty the second
breast. Therefore, the second breast should be used first at the next feeding.
69.
A low-birth-weight neonate weighs 2,500 g (5 lb 8 oz) or less at birth.
70.
A very-low-birth-weight neonate weighs 1,500 g (3 lb 5 oz) or less at birth.
71.
When teaching parents to provide umbilical cord care, the nurse should teach them to clean
the umbilical area with a cotton ball saturated with alcohol after every diaper change to prevent
infection and promote drying.
72.
Teenage mothers are more likely to have low-birth-weight neonates because they seek
prenatal care late in pregnancy (as a result of denial) and are more likely than older mothers to
have nutritional deficiencies.
73.
Linea nigra, a dark line that extends from the umbilicus to the mons pubis, commonly
appears during pregnancy and disappears after pregnancy.
74.
Implantation in the uterus occurs 6 to 10 days after ovum fertilization.
75.
Placenta previa is abnormally low implantation of the placenta so that it encroaches on or

covers the cervical os.
76.
In complete (total) placenta previa, the placenta completely covers the cervical os.
77.
In partial (incomplete or marginal) placenta previa, the placenta covers only a portion of the
cervical os.
78.
Abruptio placentae is premature separation of a normally implanted placenta. It may be

partial or complete, and usually causes abdominal pain, vaginal bleeding, and a boardlike
abdomen.
79.
Cutis marmorata is mottling or purple discoloration of the skin. Its a transient vasomotor
response that occurs primarily in the arms and legs of infants who are exposed to cold.
80.
The classic triad of symptoms of preeclampsia are hypertension, edema, and proteinuria.
Additional symptoms of severe preeclampsia include hyperreflexia, cerebral and vision
disturbances, and epigastric pain.
81.
Ortolanis sign (an audible click or palpable jerk that occurs with thigh abduction) confirms
congenital hip dislocation in a neonate.
82.
The first immunization for a neonate is the hepatitis B vaccine, which is administered in the
nursery shortly after birth.
83.
If a patient misses a menstrual period while taking an oral contraceptive exactly as

prescribed, she should continue taking the contraceptive.
84.
If a patient misses two consecutive menstrual periods while taking an oral contraceptive, she
should discontinue the contraceptive and take a pregnancy test.
85.
If a patient who is taking an oral contraceptive misses a dose, she should take the pill as
soon as she remembers or take two at the next scheduled interval and continue with the normal
schedule.
86.
If a patient who is taking an oral contraceptive misses two consecutive doses, she should
double the dose for 2 days and then resume her normal schedule. She also should use an
additional birth control method for 1 week.
87.
Eclampsia is the occurrence of seizures that arent caused by a cerebral disorder in a patient
who has pregnancy-induced hypertension.
88.
In placenta previa, bleeding is painless and seldom fatal on the first occasion, but it becomes
heavier with each subsequent episode.
89.
Treatment for abruptio placentae is usually immediate cesarean delivery.
90.
Drugs used to treat withdrawal symptoms in neonates include phenobarbital (Luminal),

camphorated opium tincture (paregoric), and diazepam (Valium).
91.
Infants with Down syndrome typically have marked hypotonia, floppiness, slanted eyes,
excess skin on the back of the neck, flattened bridge of the nose, flat facial features, spadelike
hands, short and broad feet, small male genitalia, absence of Moros reflex, and a simian crease
on the hands.
92.
The failure rate of a contraceptive is determined by the experience of 100 women for 1 year.
Its expressed as pregnancies per 100 woman-years.
93.
The narrowest diameter of the pelvic inlet is the anteroposterior (diagonal conjugate).
94.
The chorion is the outermost extraembryonic membrane that gives rise to the placenta.
95.
The corpus luteum secretes large quantities of progesterone.
96.
From the 8th week of gestation through delivery, the developing cells are known as a fetus.
97.
In an incomplete abortion, the fetus is expelled, but parts of the placenta and membrane
remain in the uterus.
98.
The circumference of a neonates head is normally 2 to 3 cm greater than the circumference

of the chest.
99.
After administering magnesium sulfate to a pregnant patient for hypertension or preterm

labor, the nurse should monitor the respiratory rate and deep tendon reflexes.
100.
During the first hour after birth (the period of reactivity), the neonate is alert and awake.
101.
When a pregnant patient has undiagnosed vaginal bleeding, vaginal examination should be
avoided until ultrasonography rules out placenta previa.

102.
After delivery, the first nursing action is to establish the neonates airway.
103.
Nursing interventions for a patient with placenta previa include positioning the patient on her
left side for maximum fetal perfusion, monitoring fetal heart tones, and administering I.V. fluids
and oxygen, as ordered.
104.
The specific gravity of a neonates urine is 1.003 to 1.030. A lower specific gravity suggests
overhydration; a higher one suggests dehydration.

105.
The neonatal period extends from birth to day 28. Its also called the first 4 weeks or first
month of life.
106.
A woman who is breast-feeding should rub a mild emollient cream or a few drops of breast
milk (or colostrum) on the nipples after each feeding. She should let the breasts air-dry to
prevent them from cracking.
107.
Breast-feeding mothers should increase their fluid intake to 2 to 3 qt (2,500 to 3,000 ml)
daily.
108.
After feeding an infant with a cleft lip or palate, the nurse should rinse the infants mouth with
sterile water.
109.
The nurse instills erythromycin in a neonates eyes primarily to prevent blindness caused by
gonorrhea or chlamydia.
110.
Human immunodeficiency virus (HIV) has been cultured in breast milk and can be
transmitted by an HIV-positive mother who breast-feeds her infant.

111.
A fever in the first 24 hours postpartum is most likely caused by dehydration rather than
infection.
112.
Preterm neonates or neonates who cant maintain a skin temperature of at least 97.6 F
(36.4 C) should receive care in an incubator (Isolette) or a radiant warmer. In a radiant warmer,
a heat-sensitive probe taped to the neonates skin activates the heater unit automatically to
maintain the desired temperature.
113.
During labor, the resting phase between contractions is at least 30 seconds.
114.
Lochia rubra is the vaginal discharge of almost pure blood that occurs during the first few
days after childbirth.

115.
Lochia serosa is the serous vaginal discharge that occurs 4 to 7 days after childbirth.
116.
Lochia alba is the vaginal discharge of decreased blood and increased leukocytes thats the
final stage of lochia. It occurs 7 to 10 days after childbirth.

117.
Colostrum, the precursor of milk, is the first secretion from the breasts after delivery.
118.
The length of the uterus increases from 2 (6.3 cm) before pregnancy to 12 (32 cm) at
term.
119.
To estimate the true conjugate (the smallest inlet measurement of the pelvis), deduct 1.5 cm
from the diagonal conjugate (usually 12 cm). A true conjugate of 10.5 cm enables the fetal head
(usually 10 cm) to pass.
120.
The smallest outlet measurement of the pelvis is the intertuberous diameter, which is the
transverse diameter between the ischial tuberosities.

121.
Electronic fetal monitoring is used to assess fetal well-being during labor. If compromised
fetal status is suspected, fetal blood pH may be evaluated by obtaining a scalp sample.
122.
In an emergency delivery, enough pressure should be applied to the emerging fetuss head
to guide the descent and prevent a rapid change in pressure within the molded fetal skull.
123.
After delivery, a multiparous woman is more susceptible to bleeding than a primiparous
woman because her uterine muscles may be overstretched and may not contract efficiently.
124.
Neonates who are delivered by cesarean birth have a higher incidence of respiratory distress
syndrome.
125.
The nurse should suggest ambulation to a postpartum patient who has gas pain and
flatulence.
126.
Massaging the uterus helps to stimulate contractions after the placenta is delivered.
127.
When providing phototherapy to a neonate, the nurse should cover the neonates eyes and
genital area.
128.
The narcotic antagonist naloxone (Narcan) may be given to a neonate to correct respiratory
depression caused by narcotic administration to the mother during labor.

129.
In a neonate, symptoms of respiratory distress syndrome include expiratory grunting or
whining, sandpaper breath sounds, and seesaw retractions.

130.
Cerebral palsy presents as asymmetrical movement, irritability, and excessive, feeble crying
in a long, thin infant.
131.
The nurse should assess a breech-birth neonate for hydrocephalus, hematomas, fractures,
and other anomalies caused by birth trauma.

132.
When a patient is admitted to the unit in active labor, the nurses first action is to listen for
fetal heart tones.

133.
In a neonate, long, brittle fingernails are a sign of postmaturity.
134.
Desquamation (skin peeling) is common in postmature neonates.
135.
A mother should allow her infant to breast-feed until the infant is satisfied. The time may vary
from 5 to 20 minutes.
136.
Nitrazine paper is used to test the pH of vaginal discharge to determine the presence of
amniotic fluid.
137.
A pregnant patient normally gains 2 to 5 lb (1 to 2.5 kg) during the first trimester and slightly
less than 1 lb (0.5 kg) per week during the last two trimesters.
138.
Neonatal jaundice in the first 24 hours after birth is known as pathological jaundice and is a
sign of erythroblastosis fetalis.

139.
A classic difference between abruptio placentae and placenta previa is the degree of pain.
Abruptio placentae causes pain, whereas placenta previa causes painless bleeding.
140.
Because a major role of the placenta is to function as a fetal lung, any condition that
interrupts normal blood flow to or from the placenta increases fetal partial pressure of arterial
carbon dioxide and decreases fetal pH.
141.
Precipitate labor lasts for approximately 3 hours and ends with delivery of the neonate.
142.
Methylergonovine (Methergine) is an oxytocic agent used to prevent and treat postpartum
hemorrhage caused by uterine atony or subinvolution.

143.
As emergency treatment for excessive uterine bleeding, 0.2 mg of methylergonovine
(Methergine) is injected I.V. over 1 minute while the patients blood pressure and uterine
contractions are monitored.
144.
Braxton Hicks contractions are usually felt in the abdomen and dont cause cervical change.
True labor contractions are felt in the front of the abdomen and back and lead to progressive
cervical dilation and effacement.
145.
The average birth weight of neonates born to mothers who smoke is 6 oz (170 g) less than
that of neonates born to nonsmoking mothers.

146.
Culdoscopy is visualization of the pelvic organs through the posterior vaginal fornix.
147.
The nurse should teach a pregnant vegetarian to obtain protein from alternative sources,
such as nuts, soybeans, and legumes.

148.
The nurse should instruct a pregnant patient to take only prescribed prenatal vitamins
because over-the-counter high-potency vitamins may harm the fetus.

149.
High-sodium foods can cause fluid retention, especially in pregnant patients.
150.
A pregnant patient can avoid constipation and hemorrhoids by adding fiber to her diet.
151.
If a fetus has late decelerations (a sign of fetal hypoxia), the nurse should instruct the mother
to lie on her left side and then administer 8 to 10 L of oxygen per minute by mask or cannula.
The nurse should notify the physician. The side-lying position removes pressure on the inferior
vena cava.
152.
Oxytocin (Pitocin) promotes lactation and uterine contractions.
153.
Lanugo covers the fetuss body until about 20 weeks gestation. Then it begins to disappear
from the face, trunk, arms, and legs, in that order.

154.
In a neonate, hypoglycemia causes temperature instability, hypotonia, jitteriness, and
seizures. Premature, postmature, small-for-gestational-age, and large-for-gestational-age

neonates are susceptible to this disorder.
155.
Neonates typically need to consume 50 to 55 cal per pound of body weight daily.
156.
Because oxytocin (Pitocin) stimulates powerful uterine contractions during labor, it must be
administered under close observation to help prevent maternal and fetal distress.
157.
During fetal heart rate monitoring, variable decelerations indicate compression or prolapse of
the umbilical cord.

158.
Cytomegalovirus is the leading cause of congenital viral infection.
159.
Tocolytic therapy is indicated in premature labor, but contraindicated in fetal death, fetal
distress, or severe hemorrhage.

160.
Through ultrasonography, the biophysical profile assesses fetal well-being by measuring fetal
breathing movements, gross body movements, fetal tone, reactive fetal heart rate (nonstress
test), and qualitative amniotic fluid volume.
161.
A neonate whose mother has diabetes should be assessed for hyperinsulinism.
162.
In a patient with preeclampsia, epigastric pain is a late symptom and requires immediate
medical intervention.
163.
After a stillbirth, the mother should be allowed to hold the neonate to help her come to terms
with the death.

164.
Molding is the process by which the fetal head changes shape to facilitate movement through
the birth canal.

165.
If a woman receives a spinal block before delivery, the nurse should monitor the patients
blood pressure closely.

166.
If a woman suddenly becomes hypotensive during labor, the nurse should increase the
infusion rate of I.V. fluids as prescribed.

167.
The best technique for assessing jaundice in a neonate is to blanch the tip of the nose or the
area just above the umbilicus.
168.
During fetal heart monitoring, early deceleration is caused by compression of the head
during labor.
169.
After the placenta is delivered, the nurse may add oxytocin (Pitocin) to the patients I.V.
solution, as prescribed, to promote postpartum involution of the uterus and stimulate lactation.
170.
Pica is a craving to eat nonfood items, such as dirt, crayons, chalk, glue, starch, or hair. It
may occur during pregnancy and can endanger the fetus.

171.
A pregnant patient should take folic acid because this nutrient is required for rapid cell
division.
172.
A woman who is taking clomiphene (Clomid) to induce ovulation should be informed of the
possibility of multiple births with this drug.

173.
If needed, cervical suturing is usually done between 14 and 18 weeks gestation to reinforce
an incompetent cervix and maintain pregnancy. The suturing is typically removed by 35 weeks
gestation.
During the first trimester, a pregnant woman should avoid all drugs unless doing so would
adversely affect her health.
174.
Most drugs that a breast-feeding mother takes appear in breast milk.
175.
The Food and Drug Administration has established the following five categories of drugs
based on their potential for causing birth defects: A, no evidence of risk; B, no risk found in
animals, but no studies have been done in women; C, animal studies have shown an adverse
effect, but the drug may be beneficial to women despite the potential risk; D, evidence of risk, but
its benefits may outweigh its risks; and X, fetal anomalies noted, and the risks clearly outweigh
the potential benefits.
176.
A patient with a ruptured ectopic pregnancy commonly has sharp pain in the lower abdomen,
with spotting and cramping. She may have abdominal rigidity; rapid, shallow respirations;
tachycardia; and shock.
177.
A patient with a ruptured ectopic pregnancy commonly has sharp pain in the lower abdomen,
with spotting and cramping. She may have abdominal rigidity; rapid, shallow respirations;
tachycardia; and shock.
178.
The mechanics of delivery are engagement, descent and flexion, internal rotation, extension,
external rotation, restitution, and expulsion.

179.
A probable sign of pregnancy, McDonalds sign is characterized by an ease in flexing the
body of the uterus against the cervix.

180.
Amenorrhea is a probable sign of pregnancy.
181.
A pregnant womans partner should avoid introducing air into the vagina during oral sex
because of the possibility of air embolism.
182.
The presence of human chorionic gonadotropin in the blood or urine is a probable sign of
pregnancy.
Radiography isnt usually used in a pregnant woman because it may harm the developing fetus.
If radiography is essential, it should be performed only after 36 weeks gestation.
183.
A pregnant patient who has had rupture of the membranes or who is experiencing vaginal
bleeding shouldnt engage in sexual intercourse.

184.
Milia may occur as pinpoint spots over a neonates nose.
185.
The duration of a contraction is timed from the moment that the uterine muscle begins to
tense to the moment that it reaches full relaxation. Its measured in seconds.
186.
The union of a male and a female gamete produces a zygote, which divides into the fertilized
ovum.
187.
The first menstrual flow is called menarche and may be anovulatory (infertile).
188.
Spermatozoa (or their fragments) remain in the vagina for 72 hours after sexual intercourse.
189.
Prolactin stimulates and sustains milk production.
190.
Strabismus is a normal finding in a neonate.
191.
A postpartum patient may resume sexual intercourse after the perineal or uterine wounds
heal (usually within 4 weeks after delivery).

192.
A pregnant staff member shouldnt be assigned to work with a patient who has
cytomegalovirus infection because the virus can be transmitted to the fetus.

193.
Fetal demise is death of the fetus after viability.
194.
Respiratory distress syndrome develops in premature neonates because their alveoli lack
surfactant.
195.
The most common method of inducing labor after artificial rupture of the membranes is
oxytocin (Pitocin) infusion.

196.
After the amniotic membranes rupture, the initial nursing action is to assess the fetal heart
rate.
197.
The most common reasons for cesarean birth are malpresentation, fetal distress,
cephalopelvic disproportion, pregnancy-induced hypertension, previous cesarean birth, and

inadequate progress in labor.
198.
Amniocentesis increases the risk of spontaneous abortion, trauma to the fetus or placenta,
premature labor, infection, and Rh sensitization of the fetus.

199.
After amniocentesis, abdominal cramping or spontaneous vaginal bleeding may indicate
complications.
200.
To prevent her from developing Rh antibodies, an Rh-negative primigravida should receive
Rho(D) immune globulin (RhoGAM) after delivering an Rh-positive neonate.
201.
If a pregnant patients test results are negative for glucose but positive for acetone, the nurse
should assess the patients diet for inadequate caloric intake.

202.
If a pregnant patients test results are negative for glucose but positive for acetone, the nurse
should assess the patients diet for inadequate caloric intake.

203.
Rubella infection in a pregnant patient, especially during the first trimester, can lead to
spontaneous abortion or stillbirth as well as fetal cardiac and other birth defects.
204.
A pregnant patient should take an iron supplement to help prevent anemia.
205.
Direct antiglobulin (direct Coombs) test is used to detect maternal antibodies attached to red
blood cells in the neonate.

206.
Nausea and vomiting during the first trimester of pregnancy are caused by rising levels of the
hormone human chorionic gonadotropin.

207.
Before discharging a patient who has had an abortion, the nurse should instruct her to report
bright red clots, bleeding that lasts longer than 7 days, or signs of infection, such as a
temperature of greater than 100 F (37.8 C), foul-smelling vaginal discharge, severe uterine
cramping, nausea, or vomiting.
208.
When informed that a patients amniotic membrane has broken, the nurse should check fetal
heart tones and then maternal vital signs.

209.
The duration of pregnancy averages 280 days, 40 weeks, 9 calendar months, or 10 lunar
months.
210.
The initial weight loss for a healthy neonate is 5% to 10% of birth weight.
211.
The normal hemoglobin value in neonates is 17 to 20 g/dl.
212.
Crowning is the appearance of the fetuss head when its largest diameter is encircled by the
vulvovaginal ring.
213.
A multipara is a woman who has had two or more pregnancies that progressed to viability,
regardless of whether the offspring were alive at birth.

214.
In a pregnant patient, preeclampsia may progress to eclampsia, which is characterized by
seizures and may lead to coma.

215.
The Apgar score is used to assess the neonates vital functions. Its obtained at 1 minute and
5 minutes after delivery. The score is based on respiratory effort, heart rate, muscle tone, reflex
irritability, and color.
216.
Because of the anti-insulin effects of placental hormones, insulin requirements increase
during the third trimester.

217.
Gestational age can be estimated by ultrasound measurement of maternal abdominal
circumference, fetal femur length, and fetal head size. These measurements are most accurate
between 12 and 18 weeks gestation.
218.
Skeletal system abnormalities and ventricular septal defects are the most common disorders
of infants who are born to diabetic women. The incidence of congenital malformation is three
times higher in these infants than in those born to nondiabetic women.
219.
Skeletal system abnormalities and ventricular septal defects are the most common disorders
of infants who are born to diabetic women. The incidence of congenital malformation is three
times higher in these infants than in those born to nondiabetic women.
220.
The patient with preeclampsia usually has puffiness around the eyes or edema in the hands
(for example, I cant put my wedding ring on.).

221.
Kegel exercises require contraction and relaxation of the perineal muscles. These exercises
help strengthen pelvic muscles and improve urine control in postpartum patients.
222.
Symptoms of postpartum depression range from mild postpartum blues to intense, suicidal,
depressive psychosis.
223.
The preterm neonate may require gavage feedings because of a weak sucking reflex,
uncoordinated sucking, or respiratory distress.

224.
Acrocyanosis (blueness and coolness of the arms and legs) is normal in neonates because
of their immature peripheral circulatory system.

225.
To prevent ophthalmia neonatorum (a severe eye infection caused by maternal gonorrhea),
the nurse may administer one of three drugs, as prescribed, in the neonates eyes: tetracycline,
silver nitrate, or erythromycin.
Neonatal testing for phenylketonuria is mandatory in most states.
226.
The nurse should place the neonate in a 30-degree Trendelenburg position to facilitate
mucus drainage.
227.
The nurse may suction the neonates nose and mouth as needed with a bulb syringe or
suction trap.
228.
To prevent heat loss, the nurse should place the neonate under a radiant warmer during
suctioning and initial delivery-room care, and then wrap the neonate in a warmed blanket for
transport to the nursery.
229.
The umbilical cord normally has two arteries and one vein.
230.
When providing care, the nurse should expose only one part of an infants body at a time.
231.
Lightening is settling of the fetal head into the brim of the pelvis.
232.
If the neonate is stable, the mother should be allowed to breast-feed within the neonates first
hour of life.
233.
The nurse should check the neonates temperature every 1 to 2 hours until its maintained
within normal limits.

At birth, a neonate normally weighs 5 to 9 lb (2 to 4 kg), measures 18 to 22 (45.5 to 56 cm) in
length, has a head circumference of 13 to 14 (34 to 35.5 cm), and has a chest circumference
thats 1 (2.5 cm) less than the head circumference.
234.
In the neonate, temperature normally ranges from 98 to 99 F (36.7 to 37.2 C), apical
pulse rate averages 120 to 160 beats/minute, and respirations are 40 to 60 breaths/minute.
235.
The diamond-shaped anterior fontanel usually closes between ages 12 and 18 months. The
triangular posterior fontanel usually closes by age 2 months.

236.
In the neonate, a straight spine is normal. A tuft of hair over the spine is an abnormal finding.
237.
Prostaglandin gel may be applied to the vagina or cervix to ripen an unfavorable cervix
before labor induction with oxytocin (Pitocin).

238.
Supernumerary nipples are occasionally seen on neonates. They usually appear along a line
that runs from each axilla, through the normal nipple area, and to the groin.
239.
Meconium is a material that collects in the fetuss intestines and forms the neonates first
feces, which are black and tarry.

240.
The presence of meconium in the amniotic fluid during labor indicates possible fetal distress
and the need to evaluate the neonate for meconium aspiration.

241.
To assess a neonates rooting reflex, the nurse touches a finger to the cheek or the corner of
the mouth. Normally, the neonate turns his head toward the stimulus, opens his mouth, and
searches for the stimulus.
242.
Harlequin sign is present when a neonate who is lying on his side appears red on the
dependent side and pale on the upper side.

243.
Mongolian spots can range from brown to blue. Their color depends on how close
melanocytes are to the surface of the skin. They most commonly appear as patches across the
sacrum, buttocks, and legs.
244.
Mongolian spots are common in non-white infants and usually disappear by age 2 to 3 years.
245.
Vernix caseosa is a cheeselike substance that covers and protects the fetuss skin in utero. It
may be rubbed into the neonates skin or washed away in one or two baths.
246.
Caput succedaneum is edema that develops in and under the fetal scalp during labor and
delivery. It resolves spontaneously and presents no danger to the neonate. The edema doesnt
cross the suture line.
247.
Nevus flammeus, or port-wine stain, is a diffuse pink to dark bluish red lesion on a neonates
face or neck.
248.
The Guthrie test (a screening test for phenylketonuria) is most reliable if its done between
the second and sixth days after birth and is performed after the neonate has ingested protein.
249.
To assess coordination of sucking and swallowing, the nurse should observe the neonates
first breast-feeding or sterile water bottle-feeding.
250.
To establish a milk supply pattern, the mother should breast-feed her infant at least every 4
hours. During the first month, she should breast-feed 8 to 12 times daily (demand feeding).
251.
To avoid contact with blood and other body fluids, the nurse should wear gloves when
handling the neonate until after the first bath is given.

252.
If a breast-fed infant is content, has good skin turgor, an adequate number of wet diapers,
and normal weight gain, the mothers milk supply is assumed to be adequate.
253.
In the supine position, a pregnant patients enlarged uterus impairs venous return from the
lower half of the body to the heart, resulting in supine hypotensive syndrome, or inferior vena
cava syndrome.
254.
Tocolytic agents used to treat preterm labor include terbutaline (Brethine), ritodrine (Yutopar),
and magnesium sulfate.

255.
A pregnant woman who has hyperemesis gravidarum may require hospitalization to treat
dehydration and starvation.

256.
Diaphragmatic hernia is one of the most urgent neonatal surgical emergencies. By
compressing and displacing the lungs and heart, this disorder can cause respiratory distress
shortly after birth.
257.
Common complications of early pregnancy (up to 20 weeks gestation) include fetal loss and
serious threats to maternal health.

258.
Fetal embodiment is a maternal developmental task that occurs in the second trimester.
During this stage, the mother may complain that she never gets to sleep because the fetus
always gives her a thump when she tries.
259.
Visualization in pregnancy is a process in which the mother imagines what the child shes
carrying is like and becomes acquainted with it.

260.
Hemodilution of pregnancy is the increase in blood volume that occurs during pregnancy.
The increased volume consists of plasma and causes an imbalance between the ratio of red
blood cells to plasma and a resultant decrease in hematocrit.
261.
Mean arterial pressure of greater than 100 mm Hg after 20 weeks of pregnancy is
considered hypertension.
262.
The treatment for supine hypotension syndrome (a condition that sometimes occurs in
pregnancy) is to have the patient lie on her left side.

263.
A contributing factor in dependent edema in the pregnant patient is the increase of femoral
venous pressure from 10 mm Hg (normal) to 18 mm Hg (high).

264.
Hyperpigmentation of the pregnant patients face, formerly called chloasma and now referred
to as melasma, fades after delivery.
265.
The hormone relaxin, which is secreted first by the corpus luteum and later by the placenta,
relaxes the connective tissue and cartilage of the symphysis pubis and the sacroiliac joint to
facilitate passage of the fetus during delivery.
266.
Progesterone maintains the integrity of the pregnancy by inhibiting uterine motility.
267.
Ladins sign, an early indication of pregnancy, causes softening of a spot on the anterior
portion of the uterus, just above the uterocervical juncture.

268.
During pregnancy, the abdominal line from the symphysis pubis to the umbilicus changes
from linea alba to linea nigra.

269.
In neonates, cold stress affects the circulatory, regulatory, and respiratory systems.
270.
Obstetric data can be described by using the F/TPAL system:
F/T: Full-term delivery at 38 weeks or longer

P: Preterm delivery between 20 and 37 weeks
A: Abortion or loss of fetus before 20 weeks
L: Number of children living (if a child has died, further explanation is needed to clarify the
discrepancy in numbers).
271.
Parity doesnt refer to the number of infants delivered, only the number of deliveries.
272.
Women who are carrying more than one fetus should be encouraged to gain 35 to 45 lb
(15.5 to 20.5 kg) during pregnancy.

273.
The recommended amount of iron supplement for the pregnant patient is 30 to 60 mg daily.
274.
Drinking six alcoholic beverages a day or a single episode of binge drinking in the first
trimester can cause fetal alcohol syndrome.

Chorionic villus sampling is performed at 8 to 12 weeks of pregnancy for early identification of
genetic defects.
275.
In percutaneous umbilical blood sampling, a blood sample is obtained from the umbilical cord
to detect anemia, genetic defects, and blood incompatibility as well as to assess the need for
blood transfusions.
276.
The period between contractions is referred to as the interval, or resting phase. During this
phase, the uterus and placenta fill with blood and allow for the exchange of oxygen, carbon
dioxide, and nutrients.
277.
In a patient who has hypertonic contractions, the uterus doesnt have an opportunity to relax
and there is no interval between contractions. As a result, the fetus may experience hypoxia or
rapid delivery may occur.
278.
Two qualities of the myometrium are elasticity, which allows it to stretch yet maintain its tone,
and contractility, which allows it to shorten and lengthen in a synchronized pattern.

279.
During crowning, the presenting part of the fetus remains visible during the interval between
contractions.
280.
Uterine atony is failure of the uterus to remain firmly contracted.
281.
The major cause of uterine atony is a full bladder.
282.
If the mother wishes to breast-feed, the neonate should be nursed as soon as possible after
delivery.
283.
A smacking sound, milk dripping from the side of the mouth, and sucking noises all indicate
improper placement of the infants mouth over the nipple.

284.
Before feeding is initiated, an infant should be burped to expel air from the stomach.
285.
Most authorities strongly encourage the continuation of breast-feeding on both the affected
and the unaffected breast of patients with mastitis.

286.
Neonates are nearsighted and focus on items that are held 10 to 12 (25 to 30.5 cm) away.
287.
In a neonate, low-set ears are associated with chromosomal abnormalities such as Down
syndrome.
288.
Meconium is usually passed in the first 24 hours; however, passage may take up to 72 hours.
289.
Boys who are born with hypospadias shouldnt be circumcised at birth because the foreskin
may be needed for constructive surgery.

290.
In the neonate, the normal blood glucose level is 45 to 90 mg/dl.
291.
Hepatitis B vaccine is usually given within 48 hours of birth.
292.
Hepatitis B immune globulin is usually given within 12 hours of birth.
293.
HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome is an unusual
variation of pregnancy-induced hypertension.

294.
Maternal serum alpha-fetoprotein is detectable at 7 weeks of gestation and peaks in the third
trimester. High levels detected between the 16th and 18th weeks are associated with neural tube
defects. Low levels are associated with Down syndrome.
295.
An arrest of descent occurs when the fetus doesnt descend through the pelvic cavity during
labor. Its commonly associated with cephalopelvic disproportion, and cesarean delivery may be
required.
296.
A late sign of preeclampsia is epigastric pain as a result of severe liver edema.
297.
In the patient with preeclampsia, blood pressure returns to normal during the puerperal
period.
298.
To obtain an estriol level, urine is collected for 24 hours.
299.
An estriol level is used to assess fetal well-being and maternal renal functioning as well as to
monitor a pregnancy thats complicated by diabetes.

300.
A pregnant patient with vaginal bleeding shouldnt have a pelvic examination.
301.
In the early stages of pregnancy, the finding of glucose in the urine may be related to the
increased shunting of glucose to the developing placenta, without a corresponding increase in

the reabsorption capability of the kidneys.
302.
A patient who has premature rupture of the membranes is at significant risk for infection if
labor doesnt begin within 24 hours.

303.
Infants of diabetic mothers are susceptible to macrosomia as a result of increased insulin
production in the fetus.

304.
To prevent heat loss in the neonate, the nurse should bathe one part of his body at a time
and keep the rest of the body covered.

305.
A patient who has a cesarean delivery is at greater risk for infection than the patient who
gives birth vaginally.

306.
The occurrence of thrush in the neonate is probably caused by contact with the organism
during delivery through the birth canal.

307.
The nurse should keep the sac of meningomyelocele moist with normal saline solution.
308.
If fundal height is at least 2 cm less than expected, the cause may be growth retardation,
missed abortion, transverse lie, or false pregnancy.

309.
Fundal height that exceeds expectations by more than 2 cm may be caused by multiple
gestation, polyhydramnios, uterine myomata, or a large baby.

310.
A major developmental task for a woman during the first trimester of pregnancy is accepting
the pregnancy.
311.
Unlike formula, breast milk offers the benefit of maternal antibodies.
312.
Spontaneous rupture of the membranes increases the risk of a prolapsed umbilical cord.
313.
A clinical manifestation of a prolapsed umbilical cord is variable decelerations.
314.
During labor, to relieve supine hypotension manifested by nausea and vomiting and
paleness, turn the patient on her left side.

315.
If the ovum is fertilized by a spermatozoon carrying a Y chromosome, a male zygote is
formed.
316.
Implantation occurs when the cellular walls of the blastocyte implants itself in the
endometrium, usually 7 to 9 days after fertilization.

317.
Implantation occurs when the cellular walls of the blastocyte implants itself in the
endometrium, usually 7 to 9 days after fertilization.

318.
Heart development in the embryo begins at 2 to 4 weeks and is complete by the end of the
embryonic stage.
319.
Methergine stimulates uterine contractions.
320.
The administration of folic acid during the early stages of gestation may prevent neural tube
defects.
321.
With advanced maternal age, a common genetic problem is Down syndrome.
322.
With early maternal age, cephalopelvic disproportion commonly occurs.
323.
In the early postpartum period, the fundus should be midline at the umbilicus.
324.
A rubella vaccine shouldnt be given to a pregnant woman. The vaccine can be administered
after delivery, but the patient should be instructed to avoid becoming pregnant for 3 months.
325.
A 16-year-old girl who is pregnant is at risk for having a low-birth-weight neonate.
326.
The mothers Rh factor should be determined before an amniocentesis is performed.
327.
Maternal hypotension is a complication of spinal block.
328.
After delivery, if the fundus is boggy and deviated to the right side, the patient should empty
her bladder.
329.
Before providing a specimen for a sperm count, the patient should avoid ejaculation for 48 to
72 hours.
330.
The hormone human chorionic gonadotropin is a marker for pregnancy.
331.
Painless vaginal bleeding during the last trimester of pregnancy may indicate placenta
previa.
332.
During the transition phase of labor, the woman usually is irritable and restless.
333.
Because women with diabetes have a higher incidence of birth anomalies than women
without diabetes, an alpha-fetoprotein level may be ordered at 15 to 17 weeks gestation.

334.
To avoid puncturing the placenta, a vaginal examination shouldnt be performed on a
pregnant patient who is bleeding.

335.
A patient who has postpartum hemorrhage caused by uterine atony should be given oxytocin
as prescribed.
336.
Laceration of the vagina, cervix, or perineum produces bright red bleeding that often comes
in spurts. The bleeding is continuous, even when the fundus is firm.

337.
Hot compresses can help to relieve breast tenderness after breast-feeding.
338.
The fundus of a postpartum patient is massaged to stimulate contraction of the uterus and
prevent hemorrhage.
339.
A mother who has a positive human immunodeficiency virus test result shouldnt breast-feed
her infant.
340.
Dinoprostone (Cervidil) is used to ripen the cervix.
341.
Breast-feeding of a premature neonate born at 32 weeks gestation can be accomplished if
the mother expresses milk and feeds the neonate by gavage.

342.
If a pregnant patients rubella titer is less than 1:8, she should be immunized after delivery.
343.
The administration of oxytocin (Pitocin) is stopped if the contractions are 90 seconds or
longer.
344.
For an extramural delivery (one that takes place outside of a normal delivery center), the
priorities for care of the neonate include maintaining a patent airway, supporting efforts to
breathe, monitoring vital signs, and maintaining adequate body temperature.
345.
Subinvolution may occur if the bladder is distended after delivery.
346.
The nurse must place identification bands on both the mother and the neonate before they
leave the delivery room.

347.
Erythromycin is given at birth to prevent ophthalmia neonatorum.
348.
Pelvic-tilt exercises can help to prevent or relieve backache during pregnancy.
349.
Before performing a Leopold maneuver, the nurse should ask the patient to empty her
bladder.
350.
According to the Unang Yakap program (Essential Newborn Care), the cord should not be
clamped until pulsations have stopped (thats about 1-3 minutes).
See Also
Nursing Bullets
Nursing Bullets: Pediatric Nursing Reviewer 1 (40 Items)
Nursing Bullets: Maternal & Child Health Nursing Reviewer 1 (350 Items)
Nursing Bullets: Medical-Surgical Nursing Reviewer 1 (160 Items)
Nursing Bullets: Psychiatric Nursing Reviewer 1 (225 Items)
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MATERNAL AND CHILD HEALTH NURSING
NURSING BULLETS
Learn the three stages of labor and the different nursing interventions for each stage.
The process of labor and birth are divided into three stages and in this post well discuss the
changes and the nursing interventions and considerations for each.
Contents [show]
First Stage
The first stage starts at the onset of regular uterine contractions and ends at full dilatation and
effacement. The first stage of labor is divided into three phases: the latent, the active, and the
transition phase.
3 Phases of the Stage of Labor
Latent Preparatory Phase

The latent stage starts at the onset of regularly perceived uterine contractions and ends when rapid
cervical dilation begins. This is also called the preparatory phase.
Contractions
Mild and short
Duration of
Contractions
20 to 40 seconds
Cervical Dilation
Duration
0-3 cm
Nullipara: 6
hoursMultipara: 4.5 hours
Nursing Considerations
Woman with a non-ripe cervix will have a longer than usual latent phase
Analgesia given too early during this period may prolong this phase
Woman who is psychologically prepared for labor only have minimal discomfort
Best time to reinforce health teachings
Active Phase
During the active phase, cervical dilatation occurs more rapidly and contractions grow stronger.
Contractions
Stronger, longer and
causes true discomfort
Duration of
Cervical Dilation
Contractions
40 to 60 seconds every 3 4 to 7 cm
to 5 minutes
Duration
Nullipara: 3
hoursMultipara: 2 hours
Nursing Considerations:
It is an exciting time because a woman realizes something dramatic is happening
Administration of analgesic at this point has little effect on the progress of labor
Show and spontaneous rupture of membranes occur during this time
Transition Phase
During this phase, the contractions reach their peak intensity, cervix to maximum dilatation and to full
effacement.
Contractions
At peak intensity
Duration of
Cervical Dilation
Contractions
60 to 90 seconds every 2-3 8 to 10 cm
minutes
Duration
Until full cervical dilation
Nursing Considerations:
If membranes have not previously ruptured or been ruptured by amniotomy, they will rupture
as a rule at full dilation.
Both full dilation and cervical effacement have occurred at this stage
Woman may have intense discomfort and may be accompanied by nausea and vomiting.
Woman may experience a feeling of loss of control, anxiety, panic or irritability.
Her focus is on the entirety of delivering her baby.
This stage ends at 10 cm of dilatation and feels a new sensation (i.e., irresistible urge to
push).
Cervical Effacement
Second Stage
The second stage starts from full dilatation and cervical effacement to birth of the infant; with
uncomplicated birth, this stage takes about 1 hour. Contractions change to an overwhelming,
uncontrollable urge to push or bear down with each contraction as if to move her bowels. Patient
may experience nausea and vomiting at this point.
The fetal head touches the internal side of the perineum; the perineum begins to bulge and appears
tense. The anus may become everted and stool may be expelled.
As the fetal head pushes against the perineum, the vaginal introitus opens and the fetal scalp
appears at the opening to the vagina. At first, it appears slit-like then becomes oval and then circular.
This is called crowning.
All of her energy and her thoughts are being directed towards giving birth. As she pushes, using her
abdominal muscles to aid the involuntary uterine contractions, the fetus is pushed out of the birth
canal.
Third Stage
The third stage is called the placental stage. It begins with the birth of the infant and ends with the
delivery of the placenta. Two separate phases are involved: placental separation and placental
expulsion.
After birth, the uterus can be palpated as a firm round mass just inferior to the level of the umbilicus.
After a few minutes, the uterus begins to contract again and assumes a discoid shape. It retains this
shape until placenta is separated, approximately 5 minutes after birth of the infant.
Placental Separation
As the uterus further contracts down on an almost empty interior causing disproportion between the
placenta and the contracting wall of the uterus ultimately causing separation of the placenta.
The following are the signs indicating that placenta has loosened and is ready to deliver:
Lengthening of the umbilical cord
Sudden gush of vaginal blood
Change in the shape of the uterus
Firm contraction of the uterus
Appearance of the placenta at the vaginal opening
Bleeding occurs as a normal consequence of placental separation. The normal blood loss is 500 mL.
Placental Expulsion
After separation, the placenta is delivered either by the natural bearing-down effort of the mother or
by gentle pressure on the contracted uterine fundus by the physician or nurse-midwife (Credes
maneuver).
Pressure must never be applied to post-partal uterus in a non-contracted state, because doing so
would cause uterus to evert and maternal blood sinuses are open and gross hemorrhage could
occur.
If the placenta does not deliver spontaneously, It can be removed manually.
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8 Inspiring Prayers for Nurses
Immediate Nursing Care of the Newborn
Nursing Notes
Maternal & Child Health Nursing
2012/01/09
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32
42
74
Newborns undergo profound physiologic changes at the

moment of birth, as they are released from a warm, snug, dark liquid-filed environment that has met
all of their basic needs, into a chilly, unbounded, brightly lit, gravity based outside world.
Within minutes after being plunged into this strange environment, a newborns body must initiate
respirations and accommodate a circulatory system to extrauterine oxygenation.
How well the newborn makes these major adjustments depends on his or her genetic composition,
the competency of the recent intrauterine environment, the care received during the labor and birth
period, and the care received during the newborn or neonatal periodfrom birth through the first 28
days of life. (Adele Pillitteri, 2007)
Two thirds of all deaths that occur during the first year of life occur in the neonatal period. More than
half occur in the first 24 hours after birthan indication of how hazardous this time is for an infant.
Close observation of a newborn for this indication of distress is essential during this period (National
Center for Health Statistics, 2005).
For the new Guidelines regarding Newborn Care. Please read the Essential Newborn Care or the
Unang Yakap Program here.
Contents [show]
Establish and Maintain a Patent Airway

1.
Never stimulate a baby to cry unless secretions have been drained out.
2.
Mucus should be sustained from a newborns mouth by a bulb syringe as soon as the head
is delivered.
3.
As soon as an infant is born, he/she should be held for a few seconds with the head lightly
lowered for further drainage of secretion.
4.
Suction the newborn properly:

1.
Turn the babys head to one side
2.
Suction gently and quickly.
3.
Suction the mouth first before the nose.
4.
Occlude one nostril at a time when testing for airway patency.
5.
Record the first cry.
6.
Maintain appropriate body temperature as chilling will increase the bodys need for
oxygen.
7.
Newborn suffers large losses of heat because he is wet at birth, the delivery room is
cold he does not have enough adipose tissues and does not know how to shiver.
Keep Newborn Warm

Effects of Cold Stress
Metabolic acidosis
Hypoglycemia
1.
Dry the newborn immediately
2.
Wrap him with a warm blanket but not too tight as not to compromise respiratory effort
3.
Lay infant on his side in a warmed bassinet or place under a droplight
4.
Place a head cap to conserve heat especially if they are in an open crib.
5.
All nursing care should be accomplished quickly as possible to minimize exposure of the
infant.
6.
Apgar scorestandardized evaluation of the newborns condition. Done at one minute after
birth to determine the general condition and then at 5 minutes to determine how well the
newborn is adjusting to extrauterine life.
1.
Colorall infants appear cyanotic at birth and grow pink with or shortly after the first
breath
2.
Heart Rateauscultation of the newborns heart
3.
Reflex irritabilityresponse to a suction catheter or having the soles of their feet

slapped.
4.
Muscle tonenewborn hold the extremity tightly flex. They should resist any effort to
extend their extremities
5.
Respiratory efforta mature newborn usually cries spontaneously at about 30

seconds after birth. At one minute, the infant is maintaining regular although rapid
respirations.
Immediate Assessment of the Newborn

Sign
Appearance: Color
0
Pale, Blue all over
Pulse: Pulse Rate

Grimace: Reflex
Irritability
Absent
No response to
stimulation
Activity: Muscle Tone
Limp, flaccid
Respiration: Breathing
Absent
1
2
Pinky body, blue
Pink all over
extremities
Less than 100
More than 100
Grimace/feeble cry when Sneeze/Coughs/Pulls away
stimulated
when stimulated; good
strong cry
Some flexion of
Well-flexed extremities
extremities
Weak or irregular
Good, strong cry
Scoring
0-3 pointsthe baby is serious danger and need immediate resuscitation.
4-6 pointsthe babys condition is guarded and may need more extensive clearing of the
airway and supplementary oxygen.
7-10 pointsare considered good and in the best possible health.
Vital Statistics/Anthropometric Measurements

Vital Statistic
Weight
Length
Head Circumference
Chest Circumference
Average
6.5 to 7.5 lbs
50cms (20in)
33 to 35 inches.
31-33cms or 2cms less than head circumference
Abdominal Circumference
31 to 33 cms
Low or Arbitrary Low

less than 5.5 lbs.
46cms (18in)
Vital Signs
Vital Sign
Temperature
Pulse
Respiration
Blood Pressure
1.
Immediately At Birth
36.5 to 37.2 Celsius
180 beats/minute
80 breaths/minute
80/46 mmHg
After Birth
120-140 beats/minute ave.
30-50 breaths/minute
100/50 mmHg (by 10th day)
Proper Identification and Charting

1.
Proper identification of the newborn and footprints must be taken and kept in the
chart.
2.
Attach ID bracelet with a number that corresponds to the mothers hospital number,
mothers full name, sex, date and time of birth.
3.
Inspect for the presence of 2 arteries and 1 vein. Suspect a congenital anomaly if
blood vessels are not complete.
4.
Apply triple dye or Betadine for faster healing effect.
5.
This is to cleanse the baby of blood mucus and vernix, and then followed with
sponge bath. Dry infant, wrap and keep him warm.
6.
Credes Prophylaxisprophylactic treatment of the newborns eyes against

gonorrheal conjunctivitis aka opthalmia neonatarum, which the baby acquires as he passes
through the birth canal of the mother who has untreated gonorrhea.
Care of the Umbilical Cord

Give Initial Oil Bath
Administer Eye Care
Procedure
Wipe the face dry.
Shade the eyes from light and open one eye at a time by exerting gentle pressure on the
upper and lower lids.
Apply Erythromycin/Terramycin Opthalmic ointment from the inner to outer canthus of the
eye. The antibiotic will eliminate gonorrhea and Chlamydia as well.
Administration of Vitamin K
1.
Vitamin K facilitates production of the clotting factor, thus preventing bleeding.
Method: Aquamephyton 1mg (Phytonadione), a synthetic Vitamin K is injected IM into the lateral
aspect of the anterior thigh (vastus lateralis).
Document Birth Record

1.
Accomplish the form properly.
Continue Physical Assessment
Characteristics of a Newborn
1. General Appearanceposition and activity
2. Skin
1.
a. Colorruddy complexion due to increased RBC concentration and decreased

subcutaneous fat which makes blood vessels more visible.
1.
Acrocyanosis
2.
Physiologic Jaundice
3.
Textureslight desquamation for the first 2 to 4 weeks of life
4.
Skin Turgorgood elasticity
5.
Vernix Caseosawhite cream-cheese like that serves as a skin lubricant
6.
Miliapinpoint size white spots seen on the nose and chin due to obstruction of the
sebaceous glands.
7.
Erythema Toxicumnewborn rash. It begins with a papule and eventually to an

erythematic appearance.
8.
Lanugois the fine downy hair that covers a newborns shoulders, back and upper
arms. Immature newborns have more lanugo than mature infant.
9.
Birthmarks
1.
Hemangiomasare vascular tumors of the skin.

1.
Nevus flammeusmuscular purple or dark red lesion. Generally

appear on the face and thighs.
2.
Strawberry hemangiomaselevated areas formed by immature

capillaries and endothelial cells.
3.
Cavernous hemangiomasthese are dilated vascular spaces.
4.
Mongolian spotsslate gray patches across the sacrum or buttocks

and consist of a collection of pigment cells.
5.
Forceps marksthese are circular or linease contusion matching the

rim of the blade forceps on the infants cheeks.
3. Headnewborns head is disproportionately large

1.
Fontanellesspaces or opening where the skull bones join
2.
Moldingthe part of the infants head that engages the cervix. It is molded to fit the cervix
contours.
3.
Caput Succedaneumis edema of the scalp at the presenting part of the head.
4.
Cephalhematomais a collection of blood between the periosteum of the skull bone and the
bone itself caused by rupture of the periosteum capillary due to the pressure of birth.
5.
Craniotabesis a localized softening of the cranial bones.
4. Eyesvision is present as evidence of blinking reflex

5. Earshearing is present as soon as amniotic fluid is drained or is absorbed from the middle ear.
6. Nosemay appear large for the face.
7. Mouthshould open evenly when the baby cries.
8. Neckis short and chubby, creased with skin folds and head rotate freely.
9. Chestappear small in proportion to infants head.
1.
Abdomencontour is slightly protuberant (sticking out from the surroundings)
2.
Anogenital Areaanus should not be covered by a membrane. Take note of the time
meconium is first passed.
1.
Backthe spine appears flat in the lumbar and sacral areas
2.
Extremities
1.
Arms and legs appear short
2.
Hands are plump and clinch into fists
3.
Should move symmetrically
4.
Fingernails are soft, smooth
5.
Good muscle tone, arms always in flexed position
6.
Palm of hands should have three creases.
7.
Legs are bowed as well short
8.
Soles of the feet appears to be flat
9.
Presence of crisscrossed lines on the soles of the foot.
3.
Feeding
Provide Discharge Instructions

1.
Breast-fed babies are fed immediately after birth and can be fed on demand or at least every
2 hours for the first few days of life. Advice to alternate both breast at 10-15 minutes each.
2.
Bottle-fed babies routinely received an initial feeding of about 1oz of sterile water at 4-6
hours of age to be certain the infant can swallow without gagging and aspirating. The newborn is
then fed every four hours.
1.
Sleep patternsnewborns sleep 16-20 hours a day
2.
Bathingmay be given anytime convenient as long as it is not within 30 minutes after

feeding as handling might cause regurgitation. Sponge baths are done until cord falls off.
3.
Cord Care
1.
Dab rubbing alcohol (70% soln) two or three times a day for faster drying.
2.
Fold down diapers so that cord does not get wet during voiding.
3.
Small, pink granulating area may be seen on the day the cord falls off. If it remains
moist or with foul discharge, advise mother to bring baby to the doctors clinic.
4.
Car Safety. Until a child reaches a weight of 20lbs, the best type of car seat is an infant only
seat that faces the back of the car.
References
Pillitteri, A. (2007). Maternal and Child Health Nursing:Care of the Childbearing and Childrearing
Family.Winsconsin: Lippincott Williams & Wilkins.
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Pregnancy Induced Hypertension (PIH)

Nursing Management
Nursing Notes
Maternal & Child Health Nursing
2012/01/07
0
13
13
Contents [show]
Definition
Pregnancy Induced Hypertension is a form of high blood pressure in pregnancy.
It occurs in about 5 percent to 8 percent of all pregnancies.
It is a condition in which vasospasm occurs during pregnancy in both small and large
arteries. With high blood pressure, there is an increase in the resistance of blood vessels. This
may hinder blood flow in many different organ systems in the expectant mother including the
liver, kidneys, brain, uterus, and placenta.
It occurs in about 5 percent to 8 percent of all pregnancies.
Originally, it was called toxaemia because researchers pictured a toxin of some kind being
produced by woman in response to the foreign protein of the growing fetus, the toxin leading to
the typical symptoms. No such toxin has ever been identified.
Causes
Possible causes may include:
Insufficient blood flow to the uterus
Damage to the blood vessels
A problem with the immune system
Poor diet
Genes
Risk factors
Preeclampsia develops only during pregnancy. Risk factors include:
History of preeclampsia -A personal or family history of preeclampsia increases the risk of

developing the condition.
First pregnancy The risk of developing preeclampsia is highest during the first pregnancy
or the first pregnancy with a new partner.
Age The risk of preeclampsia is higher for pregnant women who are older than age 35.
Obesity The risk of preeclampsia is higher if the pregnant woman is obese.
Multiple pregnancies Preeclampsia is more common in women who are carrying twins,
triplets or other multiples.
Gestational diabetes Women who develop gestational diabetes have a higher risk of
developing preeclampsia as the pregnancy progresses.
History of certain conditions Having certain conditions before becoming pregnant such as
chronic high blood pressure, diabetes, kidney disease or lupus.
Signs and Symptoms
Hypertension -Elevated blood pressure
Signs and symptoms of PIH. Source:

pennmedicine.org
Proteinuria presence of excess protein in the urine after 20 weeks of pregnancy.
Other signs and symptoms of Preeclampsia, which can develop gradually or strike suddenly, often in
the last few weeks of pregnancy, may include:
Severe headaches
Changes in vision, including temporary loss of vision, blurred vision or light sensitivity
Upper abdominal pain, usually under the ribs on the right side
Nausea or vomiting
Dizziness
Decreased urine output
Agitation
Sudden weight gain, typically more than 2 pounds a week
Edema swelling particularly in the face and hands, often accompanies preeclampsia as
well. Swelling isnt considered a reliable sign of preeclampsia, however, because it also occurs in
many normal pregnancies.
Classifications
1. Gestational Hypertension
A woman is said to have Gestational Hypertension when she develops an elevated blood pressure
(140/90 mmHg) but has no proteinuria or edema. Perinatal mortality is not increased with simple
gestational hypertension, so no drug therapy is necessary. Systolic blood pressure greater than 30
mmHg and diastolic blood pressure greater than 15 mmHg above pregnancy values. No edema, no
proteinuria and blood pressure returns to normal after birth.
2. Mild Pre-eclampsia
A woman is said to be mildly pre-eclamptic when her blood pressure rises to 140/90 mmHg, taken on
two occasions atleast 6 hours apart. Systolic blood pressure greater than 30 mmHg and diastolic
blood pressure greater than 15 mmHg above pregnancy values. In addition to the hypertension, a
woman has proteinuria (1+ or 2+ on a reagent test strip on a random sample). A weight gain of more
than 2 lbs/week in the second trimester or 1 lb/week in the third trimester usually indicates abnormal
tissue fluid retention.
3. Severe Pre-eclampsia
A woman has passed from mild to severe preeclampsia when her blood pressure has risen to 160
mmHg systolic and 110 mmHg diastolic or above on atleast two occasions 6 hours apart at bed rest.
Marked proteinuria. 3+ or 4+ on a random urine sample or more than 5 g in a 24 hour sample and
extensive edema are also present. With the severe preeclampsia, the extreme edema will be
noticeable as puffiness in a womans face and hands. It is most readily palpated over bony surfaces.
The woman may manifest oliguria (altered renal function), elevated serum creatinine (more than 1.2
mg/dL); cerebral or visual disturbances (blurred vision); thrombocytophenia and epigastric pain.
4. Eclampsia
This is the most severe classification of PIH. A woman has passed into this stage when cerebral
edema is so acute that seizure or coma occurs. With eclampsia, the maternal mortality is high from
cause such as cerebral hemorrhage, circulatory collapse or renal failure. The fetal prognosis in
eclampsia is poor because of hypoxia and consequent fetal acidosis. The manifestations are the
same accompanied by seizures.
HELLP Syndrome
HELLP syndrome is a complication of severe preeclampsia or eclampsia. HELLP syndrome is a
group of physical changes including the breakdown of red blood cells, changes in the liver and low
platelets (cells found in the blood that are needed to help the blood to clot in order to control
bleeding).
Nursing Responsibilities
A woman with mild PIH
Promote bedrest
Promote good condition
Provide emotional support
Nursing Intervention for a woman with sever PIH
Support bed rest
Monitor maternal and well being
Monitor Fetal Well being
Support a Nutritious Diet
Administer medications to prevent eclampsia
Prevention
Theres no known way to prevent preeclampsia. Eating less salt or changing your activities during
pregnancy doesnt reduce the risk. The best way to take care of yourself and your baby is to
seek early and regular prenatal care. If preeclampsia is detected early, you and your doctor can work
together to prevent complications and make the best choices for you and your baby.
In a preliminary 2006 study, women who took multivitamins and maintained a healthy weight before
conception reduced the risk of developing preeclampsia during pregnancy by more than 70 percent
compared with women of a healthy weight who didnt take multivitamins or with women who took
multivitamins but were overweight before conception.
Several earlier studies suggested that specific nutritional supplements could prevent preeclampsia,
but these studies havent stood the test of time. Although a healthy weight before pregnancy has
clear benefits for both mother and baby, more research is needed to determine the preventive effects
of multivitamins and other nutritional supplements.
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Maternal health
Methylphenidate HCl (Ritalin) Drug Study
From Wikipedia, the free encyclopedia
See also: Reproductive health and Women's health

Maternal health is the health of women during pregnancy, childbirth, and the postpartum period. It
encompasses the health care dimensions of family planning, preconception,prenatal,
and postnatal care in order to reduce maternal morbidity and mortality.[1]
Preconception care can include education, health promotion, screening and other interventions
among women of reproductive age to reduce risk factors that might affect future pregnancies. The
goal of prenatal care is to detect any potential complications of pregnancy early, to prevent them if
possible, and to direct the woman to appropriate specialist medical services as appropriate.
Postnatal care issues include recovery from childbirth, concerns about newborn care,
nutrition, breastfeeding, and family planning.
MATERNAL CARE
Maternal care covers all aspects of the mother's caretaking activity from her child's birth until it reaches
the age of twelve to fifteen months, or, in the view of some authors, such as John Bowlby, the age of three
years. Primarily, it is the quality of the relationship established by the mother with her infant and
maintained throughout this period. While "the mother" usually means the woman who has carried the
child to term and looks after it after birth, in the present context it may also denote any person who fulfils
the maternal role in a continuous fashion from birth on (mother substitute).
The concept of maternal care is essentially post-Freudian. Freud assigned the mother no primary
structuring role in the mental development of the child, nor did he view the loss of the mother as a
traumatic event of particular import when it occurred in the child's earliest years. He did, however, make
mention of maternal care in a footnote on the "autistic" fiction of a shell in his paper on the "Two Principles
of Mental Functioning" (1911b, pp. 219-220n). And towards the end of his life, he intuited the importance
of the mother-infant relationship, describing it as "unique," and as "the prototype of all later love-relations"
(1940a [1938], p. 188), and suggesting the existence of an early sexualized relationship centered in
particular on the oral satisfactions the infant obtains from feeding.
The idea of maternal care was developed during the 1950s, starting from two different, if overlapping,
areas. The first was a concern with the fact that the mother's extended absencethe effective loss of the
mothercould lead to a depressive response on the part of the child (Spitz, 1946), to anxiety reactions,
or to developmental delays. The term was used in the same sense but in a somewhat more official way in
John Bowlby's report to the World Health Organization (1951), which provided a critical review of clinical
studies and research on the harmful results of deficiencies in maternal care. Bowlby's monograph
precipitated major changes in the practices of institutions and childcare centers in many countries.
In the second place, the pediatrician and psychoanalyst Donald Winnicott contributed much to the
establishment of the idea of maternal care by describing a particular state that he called "primary
maternal preoccupation" (1956/1958): a hyperacute state that allowed the mother to respond with
sensitivity and delicacy to the very first demands of her infant. Winnicott also placed great stress on the
need to recognize and describe what he called the "good-enough mother," who by virtue of her constant
presence was able to meet the child's basic needs, present the world to it in acceptable doses, and
protect it from stimuli, whether of internal or of external provenance, that were too intense. And lastly he
underscored the reciprocal nature of mother-infant interaction.
Before long, since a "lack" or "deprivation" of maternal care came to connote a great variety of situations,
it was necessary to distinguish between inadequate of interaction with the mother (and the specific
shortcomings of such interaction), and discontinuities within the mother-child relationship caused by
frequent or permanent separations (Ainsworth, 1962).
This early work addressed both the failures of maternal care and the importance of high-quality motherinfant interaction. Subsequent research increasingly focused on the systematic observation of day-to-day
relations between mother and infant. The outcome was a characterization of various well-defined phases.
Thus the first three months of life were said to see the development of a synchronicity between mother
and child founded upon waking and sleeping patterns, while the period between three and six months of
age witnessed the emergence of reciprocal exchanges pleasurable to both parties, and the six-to-nine-
month stage was marked by much more initiative by the child in its interaction with the mother (Sander,
1964).
Following the path opened up by Bowlby's theory of attachment (1969), numerous studies were made of
various behaviors indicating the child's attachment to the maternal figure: smiling, vocalization, tears at
moments of separation, the tendency to follow the mother no matter how little she moved, and so on.
Little by little, the notion of maternal care was defined more precisely in terms of the availability of the
mother figure, her accessibility to the expressed needs of the child, and her degree of sensitivity to, and
comprehension of, those needs (Ainsworth et al, 1978). Daniel Stern (1985) has employed the
word attunement to describe the bond made between mother and child in the first months. Regularity,
continuity, and consistency seem to be the qualities essential to the satisfactory unfolding of mother
infant interaction.
It has become clear that a close correlation exists between the quality of the maternal care received in the
first year of life and the quality of the attachment manifested by the child on reaching the age of one. A
young child is "secure" when the mother has managed to be sensitive to its needs and respond to them in
an adequate and consistent manner, "insecure-resistant" when the mother has generally responded
erratically to its needs and signals, and "insecure-avoiding" when its care has been mediocre or where it
has been simply rejected. (Ainsworth et al., 1978).
Several studies have observed that, as the child becomes more sociable, mother and infant react a great
deal to each other's affective states. Because mother-child interaction seems so emotional, studies
emphasize the major role played by positive and negative affects in the child's overall development.
Research since the 1990s (Fonagy et al., 1993) seems to show quite clearly that the quality of maternal
care throughout the first year of life is largely determined by the quality of the mother's attachment to her
own mother.
Yvon Gauthier
See also: Maternal.
Bibliography
Ainsworth, Mary D. Salter. (1962). The effects of maternal deprivation: A review of findings and
controversy in the context of research strategy. In Mary D. Ainsworth and R. G. Andry, Deprivation of
maternal care. Geneva: World Health Organization.
Ainsworth, Mary D. Salter, Blehar, M. C., Waters, E., and Wall, S. (1978).Patterns of attachment: A
psychological study of the strange situation.Hillsdale, NJ: Lawrence Erlbaum.
Bowlby, John. (1951). Maternal care and mental health. Geneva: World Health Organization.
. (1969). Attachment and loss, Vol. I: Attachment. New York: Basic Books.
Fonagy, Peter, Steele, Miriam, Moran, George S., et al. (1993). Measuring the ghost in the nursery: An
empirical study of the relation between parents' mental representations of childhood experiences and
their infants' security of attachment. Journal of the American Psychoanalytic Association 41, 957-989.
Freud, Sigmund. (1911b). Formulations on the two principles of mental functioning. SE, 12: 213-226.
. (1940a [1938]). An outline of psycho-analysis. SE, 23: 139-207.
Sander, Louis W. (1964). Adapative relationships in early mother-child interaction. Journal of the
American Academy of Child Psychiatry, 3, 231-64.
Spitz, Ren A. (1946). Anaclitic depression. Psychoanalytic Study of the Child, 2, 313-42.
Stern, Daniel N. (1985). The interpersonal world of the infant: A view from psychoanalysis and
developmental psychology. New York: Basic Books.
Winnicott, Donald W. (1958). Primary maternal preoccupation. In Collected papers: Through paediatrics
to psychoanalysis (pp. 300-305). London: Tavistock. (Original work published 1956)
U.S. National Library of Medicine

1.
Maternal-Child Nursing
The nursing specialty that deals with the care of women throughout their pregnancy and
childbirth and the care of their newborn children.
maternal-child nursing. (n.d.). Definitions.net. Retrieved July 24, 2014,
fromhttp://www.definitions.net/definition/maternal-child nursing.

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and local authorities. Further, the dominance of the biomedical

A Chronology of Maternal and Child Health Services in the United

(also known as the Sheppard-Towner Act) in 1921. The Fetal,

Surveillance System, and implementing maternal mortality review

the unacceptably high rate of infant deaths and the detrimental

MCH Report Card, United States

to seventeen. Causes of these disparities have not been determined,

are mandated to cover pregnant women and children six years of

based interventions in nearly one hundred communities across the

under categorical funding and grant making. Proposition 10 has the

family violence cannot be overcome without attention to the social

MCH as a profession is to promote change outside the traditional

Gale Encyclopedia of US History:

Maternal and Child Health Care

Meanwhile, the problem of child labor was reaching a crisis point. In

Foundation (created as the National Foundation for Infantile

cloning hinted at a new century of cutting-edge science and social

American Pediatric Society/Society for Pediatric Research. Web

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B. Pressure on the pelvic muscles

A. Introversion, egocentrism, narcissism

B. Blink, cough, sneeze, gag

A. Midcalf pain, tenderness and redness along the vein

Answer and Rationale- Maternal and Child

cervical os without uterine contractions.

occurring 10 to 14 days after delivery suggest femoral thrombophlebitis.

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A. Assess the vital signs

C. Facilitating safe and effective self-and newborn care

B. Passive movement of the unengaged fetus

C. The placenta is covering most of your cervix.

View Answers and Rationale

Answer and Rationale- Maternal and Child

Answer and Rationale- Maternity Nursing Test II

1. Answer: (B) Maternal cardiac condition

2. Answer: (A) 21-24 weeks

3. Answer: (A) Article II section 12

4. Answer: (B) Abortion is both immoral and illegal in our country

7. Answer: (C) The active phase of Stage 1 is protracted

9. Answer: (B) Determine if cord compression followed the rupture

10. Answer: (D) Hemorrhage secondary to uterine atony

12. Answer: (D) 1,2,3,4