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College of Nursing
NCM 102
CARE OF MOTHER , CHILD AND FAMILY AT RISKS OR WITH PROBLEMS
MASTERY EXAMINATIONS- FINALS

NAME: _________________________ DATE: _____________ SCORE:______ / 50

MULTIPLE CHOICE: CHOOSE THE BEST ANSWER/S. STRICTLY NO ERASURES PLEASE!!!!!

1. To be considered a PPH, what would the estimated blood loss have to be for a C-section?
A. < 650 ML C. >1000 ML
B. >600 ML D. < 900 ML
2. What types of trauma during labour and birth would lead to PPH risk?
A. Instrumental assisted birth (vacuum or forceps) C. Lacerations of the cervix or vaginal wall
B. C-Section D. All of the above
3. During the past 6 months, a client diagnosed with acquired immunodeficiency syndrome has had chronic
diarrhea and has lost 18 pounds. Additional assessment findings include tented skin turgor, dry mucous
membranes, and listleness. Which nursing diagnosis focuses attention on the clients most immediate problem?
A. Deficient fluid volume related to diarrhea and abnormal fluid loss
B. Imbalanced nutrition: less than body requirements related to nausea and vomiting
C. Disturbed thought processes related to central nervous system effects of disease
D. Diarrhea related to the disease process and acute infection
4. For a male client who has acquired immunodeficiency syndrome with chronic diarrhea, anorexia, a history of
oral candidiasis, and weight loss, which dietary instruction would be included in the teaching plan?
A. Follow a low-protein, high-carbohydrate diet.
B. Eat three large meals per day.
C. Include unpasteurized dairy products in the diet.
D. Follow a high-protein, high-calorie diet.
5. Nurse Mary Jean is assisting in administering immunizations at a health care clinic. The nurse understands that
an immunization will provide:
A. Protection from all disease C. Natural immunity from disease
B. Innate immunity from disease D. Acquired immunity from disease
6. A client with acquired immunodeficiency syndrome has a respiratory infection from Pneumocystis jiroveci and
a nursing diagnosis of Impaired Gas Exchange written in the plan of care. Which of the following indicates that the
expected outcome of care has not yet been achieved?
A. Client has clear breath sounds
B. Client now limits his fluid intake
C. Client expectorates secretions easily
D. Client is free of complaints of shortness of breath
7. Human Papilloma Virus in AIDS patients is manifested as:
A. Cough, evening fever, night sweats, weight loss and anemia
B. Persistent fever, tachypnoea, hypoxia, cyanosis and tachycardia.
C. Genital warts, flat warts, skin warts, neoplasm of cervix, vagina and penis
D. Watery diarrhea, abdominal pain, nausea and vomiting
8. A client is diagnosed with oral candidiasis. Nurse Tina knows that this condition in AIDS is treated with:
A. Trimethoprim + sulfamethoxazole C. Acyclovir
B. Fluconazole D. Zidovudine

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9. The decision to begin antiretroviral therapy is based on:


A. The CD4 cell count C. The intensity of the patients clinical symptoms
B. The plasma viral load D. All of the above
10. Which client problem relating to altered nutrition is a consequence of AIDS?
A. Increased appetite C. Increased secretions of digestive juices
B. Decreased protein absorption D. Decreased gastrointestinal absorption
11. As a knowledgeable nurse, you know that the primary goals of antiretroviral therapy (ART) include all, EXCEPT:
A. Reduce HIV-associated morbidity and prolong the duration and quality of survival
B. Restore and preserve immunologic function
C. Maximally and durably suppress plasma HIV viral load
D. Elimination of HIV entirely from the body
12. Which is the most common HIV-related neurological complication?
A. Tuberculosis B. C. Toxoplasmosis
B. Kaposis sarcoma D. Lymphoma
13. A 16-year-old primigravida arrives at the labor and birthing unit in her 38th week of gestation and states that she
is labor. To verify that the client is in true labor nurse Trina should:
A. Obtain sides for a fern test C. Prepare her for a pelvic examination
B. Time any uterine contractions D. Apply nitrazine paper to moist vaginal tissue
14. Nurse Cathy applies a fetal monitor to the abdomen of a client in active labor. When the client has
contractions, the nurse notes a 15 beat per minute deceleration of the fetal heart rate below the baseline
lasting 15 seconds. Nurse Cathy should:
A. Change the maternal position
B. Prepare for an immediate birth
C. Call the physician immediately
D. Obtain the clients blood pressure
15. When planning care for a client at 30-weeks gestation, admitted to the hospital after vaginal bleeding secondary
to placenta previa, the nurses primary objective would be:
A. Provide a calm, quiet environment
B. Prepare the client for an immediate cesarean birth
C. Prevent situations that may stimulate the cervix or uterus
D. Ensure that the client has regular cervical examinations assess for labor
16. A urinary tract infection is a potential danger with an indwelling catheter. Nurse Gina can best plan to avoid this
complication by:
A. Assessing urine specific gravity C. Collecting a weekly urine specimen
B. Maintaining the ordered hydration D. Emptying the drainage bag frequently
17. Nurse Mary assesses a postpartum client who had an abruption placentae and suspects that disseminated
intravascular coagulation (DIC) is occurring when assessments demonstrate:
A. A boggy uterus C. Hypotension and tachycardia
B. Multiple vaginal clots D. Bleeding from the venipuncture site
18. Before an amniocentesis, nurse Alexandra should:
A. Initiate the intravenous therapy as ordered by the physiscian
B. Inform the client that the procedure could precipitate an infection
C. Assure that informed consent has been obtained from the client
D. Perform a vaginal examination on the client to assess cervical dilation
19. When a client on labor experiences the urge to push a 9cm dilation, the breathing pattern that nurse Rhea should
instruct the client to use is the:
A. Expulsion pattern C. Shallow chest pattern
B. Slow paced pattern D. blowing pattern

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20. While a client is on intravenous magnesium sulfate therapy for preeclampsia, it is essential for nurse Amy to
monitor the clients deep tendon reflexes to:
A. Determine her level of consciousness C. Determine her response to painful stimuli
B. Evaluate the mobility of the extremities D. Prevent development of respiratory distress
21. The clients history that alerts nurse Henry to assess closely for signs of postpartum infection would be:
A. Three spontaneous abortions D. Maternal temperature of 99.9 F 12 hours after
B. negative maternal blood type delivery
C. Blood loss of 850 ml after a vaginal birth
22. Nurse Wilma recognizes that failure of a newborn to make the appropriate adaptation to extrauterine life would
be indicated by:
A. flexed extremities C. A heart rate of 130 beats per minute
B. Cyanotic lips and face D. A respiratory rate of 40 breath per minute
23. - 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 C. Threatened
B. Incomplete D. Septic
24. 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 C. History of genital herpes
B. History of syphilis D. History of diabetes mellitus
25. 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 C. Monitoring apical pulse
B. . Assessing for edema D. Monitoring temperature
26. 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 C. Decreased Insulin
B. Increased caloric intake D. Increase Insulin
27. 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. C. Vaginal bleeding
B. Larger than normal uterus for gestational age. D. Elevated levels of human chorionic gonadotropin
28. 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 C. Rapid respiratory rate above 40/min.
B. . Absent patellar reflexes. D. Rapid rise in blood pressure.
29. 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.

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30. 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 C. Early decelerations in the fetal heart rate.
seconds. D. Fetal heart rate baseline 140-160 bpm.
B. Maternal temperature 101.2
31. 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 C. EKG tracings
B. CVP readings D. Continuous CPR
32. 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.
33. Malou was diagnosed with severe preeclampsia is now receiving I.V. magnesium sulfate. The adverse effects
associated with magnesium sulfate is:
A. Anemia C. Hyperreflexia
B. Decreased urine output D. Increased respiratory rate
34. 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 C. Dyspareunia
B. Metrorrhagia D. Amenorrhea
35. Jannah is admitted to the labor and delivery unit. The critical laboratory result for this client would be:
A. Oxygen saturation C. Blood typing
B. Iron binding capacity D. Serum Calcium
36. Nurse Gina is aware that the most common condition found during the second-trimester of pregnancy is:
A. Metabolic alkalosis C. Mastitis
B. Respiratory acidosis D. Physiologic anemia
37. Maureen in her third trimester arrives at the emergency room with painless vaginal bleeding. Which of the following
conditions is suspected?
A. Placenta previa C. Premature labor
B. Abruptio placentae D. Sexually transmitted disease
38. 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.
39. 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.

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40. 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 C. Mass screening tests
B. Community survey D. Interview of suspects
41. 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 C. Tetanus
B. Hepatitis B D. Leptospirosis
42. 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 C. Amebiasis
B. Cholera D. Dysentery
43. The most prevalent form of meningitis among children aged 2 months to 3 years is caused by which microorganism?
A. Hemophilus influenza C. Streptococcus pneumonia
B. Morbillivirus D. Neisseria meningitidis
44. 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 C. Skin on the abdomen
B. Buccal mucosa D. Skin on neck
45. It is the most effective way of controlling schistosomiasis in an endemic area?
A. Use of molluscicides C. Proper use of sanitary toilets
B. Building of foot bridges D. Use of protective footwear, such as rubber boots
46. 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 C. Desquamation of the epidermis
B. Lanugo covering the body D. Vernix caseosa covering the body
47. 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 C. Respiratory depression
B. Jitteriness D. Tachycardia
48. 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. C. To assess fetal position
B. To assess for prolapsed cord D. To prepare for an imminent delivery.
49. 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.
50. 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.
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C. Instructing the client on the use of sitz baths if ordered.


D. Instructing the client about the importance of perineal (kegel) exercises.
ANSWER KEY: MASTERY FINALS 2017

1. C. . 1000 ml
2. D ALL OF THE ABOVE
3. A. Deficient fluid volume related to diarrhea and abnormal fluid loss
Based on the clients assessment findings, the most immediate problem is dehydration because of chronic diarrhea. The nursing
diagnosis of deficient fluid volume is the priority, and interventions are geared to improving the clients fluid status. Although
imbalanced nutrition, disturbed thought processes, and diarrhea are involved, they assume a lower priority at this time.
4. D. Follow a high-protein, high-calorie diet.
Dietary instructions should include the need for a high-protein, high-calorie diet. The patient should be taught to eat small, frequent
meals and include low-microbial foods, such as pasteurized dairy products, washed and peeled fruits and vegetables, and well-
cooked meats.
5. D. Acquired immunity from disease
Acquired immunity can occur by receiving an immunization that causes antibodies to a specific pathogen to form. Natural (innate)
immunity is present at birth. No immunization protects the client from all diseases.
6. B. Client now limits his fluid intake
The status of the client with a diagnosis of Impaired gas exchange would be evaluated against the standard outcome criteria for this
nursing diagnosis. These would include the client stating that breathing is easier and is coughing up secretions effectively, and has
clear breath sounds. The client should not limit fluid intake because fluids are needed to decrease the viscosity of secretions for
expectoration.
7. C. Genital warts, flat warts, skin warts, neoplasm of cervix, vagina and penis
Dermatologic human papillomavirus (HPV) infection in HIV patients manifests as both anogenital and nongenital skin disease.
Cutaneous HPV-related disease in nongenital skin is also increased in HIV-positive patients, in the form of benign common warts,
epidermodysplasia verruciformis-like skin lesions, and nonmelanoma skin cancers.
8. B. Fluconazole
Oral candidiasis usually responds to topical treatments such as clotrimazole troches and nystatin suspension (nystatin swish and
swallow). Systemic antifungal medication such as fluconazole or itraconazole may be necessary for oropharyngeal infections that do
not respond to these treatments.
9. D. All of the above
A persons CD4 count is an important factor in the decision to start ART. A low or falling CD4 count indicates that HIV is advancing
and damaging the immune system. A rapidly decreasing CD4 count increases the urgency to start ART. Regardless of CD4 count,
there is greater urgency to start ART when a person has a high viral load or any of the following conditions: pregnancy, AIDS, and
certain HIV-related illnesses and co infections.
10. B. Decreased protein absorption
Often the complications of the acquired immunodeficiency syndrome (AIDS) have a negative impact on nutritional status. Weight loss
and protein depletion are commonly seen among the AIDS population.
11. D. Elimination of HIV entirely from the body.
Eradication of HIV infection cannot be achieved with available antiretroviral (ARV) regimens even when new, potent drugs are added
to a regimen that is already suppressing plasma viral load below the limits of detection of commercially available assays.
12. C. Toxoplasmosis
Toxoplasmosis is the most common central nervous system infection in patients with the acquired immunodeficiency syndrome (AIDS)
who are not receiving appropriate prophylaxis. This infection has a worldwide distribution and is caused by the intracellular protozoan
parasite, Toxoplasma gondii.
13. C. Prepare her for a pelvic examination
Pelvic examination would reveal dilation and effacement
14. A. Change the maternal position
Stimulation of the sympathetic nervous system is an initial response to mild hypoxia that accompanies partial cord compression
(umbilical vein) during contractions; changing the maternal position can alleviate the compression.
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15. C. Prevent situations that may stimulate the cervix or uterus


Stimulation of the cervix or uterus may cause bleeding or hemorrhage and should be avoided.
16. B. Maintaining the ordered hydration
Promoting hydration maintains urine production at a higher rate, which flushes the bladder and prevents urinary stasis and
possible infection.
17. D. Bleeding from the venipuncture site
This indicates a fibrinogenemia; massive clotting in the area of the separation has resulted in a lowered circulating fibrinogen.
18. C. Assure that informed consent has been obtained from the client
An invasive procedure such as amniocentesis requires informed consent.
19. D. blowing pattern
Clients should use a blowing pattern to overcome the premature urge to push.
20. D. Prevent development of respiratory distress
Respiratory distress or arrest may occur when the serum level of magnesium sulfate reaches 12 to 15 mg/dl; deep tendon
reflexes disappear when the serum level is 10 to 12 mg/dl; the drug is withheld in the absence of deep tendon reflexes; the
therapeutic serum level is 5 to 8 mg/dl.
21. C. Blood loss of 850 ml after a vaginal birth
Excessive blood loss predisposes the client to an increased risk of infection because of decreased maternal resistance; they
expected blood loss is 350 to 500 ml.
22. B. Cyanotic lips and face
Central cyanosis (blue lips and face) indicates lowered oxygenation of the blood, caused by either decreased lung expansion or
23. (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.
24. (B) History of syphilis
Rationale: Maternal infections such as syphilis, toxoplasmosis, and rubella are causes of spontaneous abortion.
25. (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.
26. (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.
27. (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.
28. B) Absent patellar reflexes
Rationale: Absence of patellar reflexes is an indicator of hypermagnesemia, which requires administration of calcium gluconate.
29. (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.
30. (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.
31. 9 (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.
32. (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.
33. 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.
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34. (A) Menorrhagia


Rationale: Menorrhagia is an excessive menstrual period.
35. (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.
36. (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.
37. (A) Placenta previa
Rationale: Placenta previa with painless vaginal bleeding.
38. 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.
39. (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.
40. (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.
41. (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.
42. (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.
43. (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.
44. (B) Buccal mucosa---- Kopliks spot may be seen on the mucosa of the mouth or the throat.
45. (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.
46. (C) Desquamation of the epidermis--: Postdate fetuses lose the vernix caseosa, and the epidermis may become desquamated.
These neonates are usually very alert. Lanugo is missing in the postdate neonate.
47. (C) Respiratory depression---: 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.
48. (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.
49. 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.
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50. (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.
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Siena College Taytay


College of Nursing
NCM 102

CARE OF MOTHER, CHILD AND FAMILY AT RISKS OR WITH PROBLEMS


FINAL EXAMINATIONS

NAME: _________________________ DATE: _____________ SCORE:____ / ____

TEST 1: MULTIPLE CHOICE: CHOOSE THE BEST ANSWER STRICTLY NO ERASURES PLEASE!!!!!

1. 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? C. What is your expected due date?
B. Do you have any allergies? D. . Who will be with you during labor?
2. 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 discharg
3. 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 C. diamniotic monochorionic twin
B. diamniotic dichorionic twins D. monoamniotic monochorionic twins
4. 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 C. External fetal monitoring
B. Digital or speculum examination D. Ultrasound
5. Nurse Arnold knows that the following changes in respiratory functioning during pregnancy is considered normal:
A. Increased tidal volume C. Decreased inspiratory capacity
B. Increased expiratory volume D. Decreased oxygen consumption
6. Emily has gestational diabetes and it is usually managed by which of the following therapy?
A. Diet C. Oral hypoglycemic
B. Long-acting insulin D. Oral hypoglycemic drug and insulin
7. 91. Magnesium sulfate is given to Jemma with preeclampsia to prevent which of the following condition?
A. Hemorrhage C. Hypomagnesemia
B. Hypertension D. Seizure
8. 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 C. I.V. fluids
B. Diuretic agents D. Acetaminophen (Tylenol) for pain
9. Which of the following drugs is the antidote for magnesium toxicity?
A. Calcium gluconate (Kalcinate) C. Naloxone (Narcan)
B. Hydralazine (Apresoline) D. Rho (D) immune globulin (RhoGAM)
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10. 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.
11. 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 C. Pyelonephritis
B. Bacterial vaginosis D. Urinary tract infection (UTI)
12. 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.
13. 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 C. Supine position
B. Squatting position D. Standing position
14. 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 C. A flattened nose, small eyes, and thin lips.
B. . Irritability and poor sucking. D. Congenital defects such as limb anomalies.
15. The uterus returns to the pelvic cavity in which of the following time frames?
A. 7th to 9th day postpartum. C. End of 6th week postpartum.
B. 2 weeks postpartum. D. When the lochia changes to alba.
16. Maureen, a primigravida client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was
unusually long and required oxytocin (Pitocin) augmentation. The nurse whos caring for her should stay alert for:
A. Uterine inversion C. Uterine involution
B. Uterine atony D. Uterine discomfort
17. The nurse is teaching exercises that are good for pregnant women increasing tone and fitness and decreasing lower
backache. Which of the following should the nurse exclude in the exercise program?
A. Stand with legs apart and touch hands to floor three times per day.
B. Ten minutes of walking per day with an emphasis on good posture.
C. Ten minutes of swimming or leg kicking in pool per day.
D. Pelvic rock exercise and squats three times a day.
18. 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

19. When preparing a client for cesarean delivery, which of the following key concepts should be considered when
implementing nursing care?
12

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
20. 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
21. . 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 C. Exercise
B. Medication D. Glucose monitoring
22. 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 C. Hand/face edema
B. Depression D. Dietary intake
23. Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy?
A. Risk for infection C. Knowledge Deficit
B. Pain D. Anticipatory Grieving
24. 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 should the nurse do first?
A. Report the temperature to the physician C. Assess the uterus for firmness and position
B. Recheck the blood pressure with another cuff D. Determine the amount of lochia
25. 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 C. Contraction monitoring
B. Fetal heart rate D. Cervical dilation
26. Rachel, a diabetic woman at 36 weeks gestation is scheduled for biophysical profile in order to:
A. ascertain correct gestational age D. determine fetal size and obvious congenital
B. determine fetal lung maturity anomaly
C. determine fetal well being
27. Which of the following changes in Dianes BP would nurse Grace not expect?
A. it tends to be highest in sitting D. It is normal for blood pressure to increase as
B. BP may increase a little in the 2nd tri much as 33 in systolic in the 3rd tri when a
C. It should be taken at every visit at the clinic woman is near delivery
28. The OB history of a woman is recorded as gravida 5 Para 3114. This indicates that the woman has
A. One abortion, one preterm delivery, 4 living children
B. three full-term deliveries, 1 post-mature delivery, four pregnancies
C. five pregnancies, three living children
D. four living children, 3 premature deliveries, 1 full-term delivery
29. The pregnant client will undergo Alpha-fetoprotein level determination. Which of the following specimen is required?
A. maternal blood sample C. amniotic fluid
B. blood from chorionic villi D. cervical secretions
30. Which of the following potential problems should the nurse be alert for in a client with pregnancy-induced hypertension (PIH)
A. abruptio placenta B. post term delivery
13

C. uterine inversion D. placenta previa


31. The nurse is caring for several clients who are in active labor. Which among these clients should she give highest priority?
A. the client with prolapsed cord C. the client with oliguria
B. the client with BP of 160/100 mmHg D. the client with headache and blurred vision
32. A client is diagnosed to have placenta previa. What warning sign should be placed by the nurse in client's unit?
A. no abdominal palpation C. no BP-taking
B. no vaginal examination D. no cigarette smoking
33. A. client experiences abruptio placenta. Which of the following signs and symptoms supports the diagnosis?
A. painless vaginal bleeding C. soft uterus
B. rising fundal height D. elevated BP
34. The nurse is caring for a mother who experiences fetal distress. Which of the following should not be included in her nursing
care plan?
A. continue pitocin drip C. turn to left side
B. administer oxygen by face mask D. prepare for cesarean section
35. The mother delivered a dead fetus. Which of the following will not help the couple progress through the grieving process?
A. encourage the couple to give name to the new born
B. the social worker visits the couple at home
C. advise the couple to have another child
D. encourage the couple to join a support grou
36. Before advising a 24 year-old client desiring oral contraceptives for family planning, the nurse would assess the client for signs
and symptoms of which of the following?
A. anemia C. dysmenorrheal
B. hypertension D. acne vulgaris
37. A newly diagnosed pregnant client tells the nurse, "If I'm going to have all of these discomforts, I'm not sure I want to be
pregnant!" The nurse interprets the client's statement as an indication of which of the following?
A. fear of pregnancy outcome C. normal ambivalence
B. rejection of pregnancy D. inability to care for the newborn
38. Which of the following findings would lead the prenatal clinic nurse to suspect that the client has mild pre-eclampsia? Select all
that apply
A. hypertension D. edema
B. seizures E. proteinuria
C. hypotension F. blurry vision
39. Several female patients want to have Papanicolaou examination. Who among these patients should the nurse advise not to
have the examination? The patient who states
A. the first day of my menstruation came this morning and I am bleeding profusely
B. I am 21 years old, and have not had any sex at all
C. I had the test 3 months ago and it was positive
D. I have herpes simplex virus (HSV) and had sex 2 weeks ago
40. A primigravida client at 8 weeks gestation tells the nurse that since having had sexual relations with a new partner 2 weeks
ago, she has noticed flu-like symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina. The nurse refers the
client to a physician because the nurse suspects which of the following sexually transmitted diseases.
A. gonorrhea B. Syphilis
B. chlamydia trachomatis D. herpes genitalis
41. The client had been diagnosed to have PIH (pregnancy-induced hypertension). Which of the following should be included in
her care? Select all that apply
A. administer magnesium sulfate IV drip as B. check urine for presence of protein
ordered C. have calcium gluconate readily available
14

D. monitor for elevated liver enzymes F. none of the above


E. all of the above
42. A clinic nurse is teaching a pregnant client about the warning signs in pregnancy. Which of the following, if identified as a
warning sign by the client would indicate that she understands the teaching?
A. purplish discoloration of the vulva C. irregular, painless contractions
B. visual disturbances D. urinary frequency
43. Which of the following drugs is the antidote for magnesium toxicity?
A. Calcium gluconate (Kalcinate) C. Naloxone (Narcan)
B. Hydralazine (Apesoline) D. Rho (D) immuneglobulin (RhoGAM)
44. 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 C. Complete abortion
B. Imminent abortion D. Missed abortion
45. 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
46. Before assessing the postpartum clients uterus for firmness and position in relation to the umbilicus and midline,
which of the following should the nurse do first?
A. Assess the vital signs B. Administer analgesia
C. Ambulate her in the hall D. Assist her to urinate
47. A 16-year-old primigravida arrives at the labor and birthing unit in her 38th week of gestation and states that she is
labor. To verify that the client is in true labor nurse Trina should:
A. Obtain sides for a fern test C. Prepare her for a pelvic examination
B. Time any uterine contractions D. Apply nitrazine paper to moist vaginal tissue
48. Nurse Cathy applies a fetal monitor to the abdomen of a client in active labor. When the client has contractions, the
nurse notes a 15 beat per minute deceleration of the fetal heart rate below the baseline lasting 15 seconds. Nurse
Cathy should:
A. Change the maternal position C. Call the physician immediately
B. Prepare for an immediate birth D. Obtain the clients blood pressure
49. 16-year-old primigravida arrives at the labor and birthing unit in her 38th week of gestation and states that she is labor.
To verify that the client is in true labor nurse Trina should:
A.Obtain sides for a fern test C. Prepare her for a pelvic examination
B. Time any uterine contractions D. Apply nitrazine paper to moist vaginal tissue
50. Nurse Cathy applies a fetal monitor to the abdomen of a client in active labor. When the client has contractions, the
nurse notes a 15 beat per minute deceleration of the fetal heart rate below the baseline lasting 15 seconds. Nurse
Cathy should:
A. Change the maternal position C. Call the physician immediately
B. Prepare for an immediate birth D. Obtain the clients blood pressure
51. When planning care for a client at 30-weeks gestation, admitted to the hospital after vaginal bleeding secondary to
placenta previa, the nurses primary objective would be:
A.Provide a calm, quiet environment
B. Prepare the client for an immediate cesarean birth
C. Prevent situations that may stimulate the cervix or uterus
D. Ensure that the client has regular cervical examinations assess for labor
52. A urinary tract infection is a potential danger with an indwelling catheter. Nurse Gina can best plan to avoid this
complication by:
A. Assessing urine specific gravity C. Collecting a weekly urine specimen
B. Maintaining the ordered hydration D. Emptying the drainage bag frequently

53. Nurse Mary assesses a postpartum client who had an abruption placentae and suspects that disseminated
intravascular coagulation (DIC) is occurring when assessments demonstrate:
A. A boggy uterus C. Hypotension and tachycardia
B. Multiple vaginal clots D. Bleeding from the venipuncture site
54. Before an amniocentesis, nurse Alexandra should:
15

A.Initiate the intravenous therapy as ordered by the physiscian


B. Inform the client that the procedure could precipitate an infection
C. Assure that informed consent has been obtained from the client
D. Perform a vaginal examination on the client to assess cervical dilation
55. When a client on labor experiences the urge to push a 9cm dilation, the breathing pattern that nurse Rhea should
instruct the client to use is the:
A.Expulsion pattern C. Shallow chest pattern
B. Slow paced pattern D. blowing pattern
56. While a client is on intravenous magnesium sulfate therapy for preeclampsia, it is essential for nurse Amy to monitor
the clients deep tendon reflexes to:
A. Determine her level of consciousness C. Determine her response to painful stimuli
B. Evaluate the mobility of the extremities D. Prevent development of respiratory distress
57. The clients history that alerts nurse Henry to assess closely for signs of postpartum infection would be:
A.Three spontaneous abortions D. Maternal temperature of 99.9 F 12 hours after
B. negative maternal blood type delivery
C. Blood loss of 850 ml after a vaginal birth
58. Nurse Wilma recognizes that failure of a newborn to make the appropriate adaptation to extrauterine life would be
indicated by:
A. flexed extremities C. A heart rate of 130 beats per minute
B. Cyanotic lips and face D. A respiratory rate of 40 breath per minute
59. 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 C. Threatened
B. Incomplete D. Septic
60. 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 D. Monitoring temperature
B. Assessing for edema
C. Monitoring apical pulse
61. Dr. RIVERA 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. C. To assess fetal position
B. To assess for prolapsed cord D. To prepare for an imminent delivery.
62. 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 C. The parents indication that they want to see the
newborn. newborn.
B. The parents expression of interest about the size of D. The parents interactions with each other.
the newborn.
63. 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.
64. 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? C. Who will be with you in labor?
B. What is your expected due date? D. Do you have any allergie
65. The pregnant woman with a known cardiac condition must be watched carefully during labor. To prevent cardiac decomposition,
the client should be
A. Maintained with oxytocin to increase contractions C. Maintained with an IV solutions
B. Monitored more frequently D. Position on her side with her shoulders elevated.
66. 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.
67. 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
68. Which of the following would the nurse identify as a classic sign of PIH?
A. Edema of the feet and ankles C. Weight gain of 1 lb/week
B. Edema of the hands and face D. Early morning headache
69. 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
70. 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
71. 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
72. 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 C. Exercise
B. Medication D. Glucose monitoring
73. 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 C. Hand/face edema
B. Depression D. Dietary intake

74. Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy?
A. Risk for infection C. Knowledge Deficit
B. Pain D. Anticipatory Grieving
75. 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 should the 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
JESMAR S. ESPIRITU MAN RN RM 16
D. Determine the amount of lochia
76. 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 C. Contraction monitoring
B. Fetal heart rate D. Cervical dilation
77. Rachel, a diabetic woman at 36 weeks gestation is scheduled for biophysical profile in order to:
A. ascertain correct gestational age
B. determine fetal lung maturity
C. determine fetal well being
D. determine fetal size and obvious congenital anomaly
78. Which of the following changes in Dianes BP would nurse Grace not expect?
a. it tends to be highest in sitting
b. BP may increase a little in the 2nd tri
c. It should be taken at every visit at the clinic
d. It is normal for blood pressure to increase as much as 33 in systolic in the 3rd tri when a woman is near delivery
79. Nurse Tsunade referred to Diane to an Obstetrician. At 8 months she was orderd for a contraction stress test and the result is
negative. Diane asked when she should be back for her next check up?
a. Monthly b. Within 24-hours
c. Within a week d. Weekly for 2 wks then monthly
80. The OB history of a woman is recorded as gravida 5 Para 3114. This indicates that the woman has
A. One abortion, one preterm delivery, 4 living children
B. three full-term deliveries, 1 post-mature delivery, four pregnancies
C. five pregnancies, three living children
D. four living children, 3 premature deliveries, 1 full-term delivery
81. The pregnant client will undergo Alpha-fetoprotein level determination. Which of the following specimen is required?
a. maternal blood sample b. blood from chorionic villi
c. amniotic fluid d.. cervical secretions
82. Which of the following potential problems should the nurse be alert for in a client with pregnancy-induced hypertension (PIH)
a)abruptio placenta b) post term delivery
c) uterine inversion d) placenta previa
83. The nurse is caring for several clients who are in active labor. Which among these clients should she give highest priority?
a) the client with prolapsed cord
b) the client with BP of 160/100 mmHg
c) the client with oliguria
d) the client with headache and blurred vision
84. The client is diagnosed to have placenta previa. What warning sign should be placed by the nurse in client's unit?
a) no abdominal palpation b) no vaginal examination
c) no BP-taking d) no cigarette smoking
85. The client experiences abruptio placenta. Which of the following signs and symptoms supports the diagnosis?
a) painless vaginal bleeding b) rising fundal height
c) soft uterus d) elevated BP
86. The nurse is caring for a mother who experiences fetal distress. Which of the following should not be included in her nursing
care plan?
a) continue pitocin drip b) administer oxygen by face mask
c) turn to left side d) prepare for cesarean section

87. The mother delivered a dead fetus. Which of the following will not help the couple progress through the grieving process?
a) encourage the couple to give name to the new born
b) the social worker visits the couple at home
c) advise the couple to have another child
d) encourage the couple to join a support group
88. Before advising a 24 year-old client desiring oral contraceptives for family planning, the nurse would assess the client for signs
and symptoms of which of the following?
a) anemia b) hypertension
c) dysmenorrheal d) acne vulgaris
JESMAR S. ESPIRITU MAN RN RM 17
89. A newly diagnosed pregnant client tells the nurse, "If I'm going to have all of these discomforts, I'm not sure I want to be
pregnant!" The nurse interprets the client's statement as an indication of which of the following?
a) fear of pregnancy outcome
b) rejection of pregnancy
c) normal ambivalence
d) inability to care for the newborn
90. 26. Which of the following findings would lead the prenatal clinic nurse to suspect that the client has mild pre-eclampsia? Select
all that apply
a) hypertension b) seizures
c) hypotension d) edema
e) proteinuria f) blurry vision
91. Several female patients want to have Papanicolaou examination. Who among these patients should the nurse advise not to
have the examination? The patient who states
a) the first day of my menstruation came this morning and I am bleeding profusely
b) I am 21 years old, and have not had any sex at all
c) I had the test 3 months ago and it was positive
d) I have herpes simplex virus (HSV) and had sex 2 weeks ago
92. A primigravida client at 8 weeks gestation tells the nurse that since having had sexual relations with a new partner 2 weeks ago,
she has noticed flu-like symptoms, enlarged lymph nodes, and clusters of vesicles on her vagina. The nurse refers the client to a
physician because the nurse suspects which of the following sexually transmitted diseases.
a) gonorrhea b) chlamydia trachomatis
c) syphilis d) herpes genitalis
93. The client had been diagnosed to have PIH (pregnancy-induced hypertension). Which of the following should be included in her
care? Select all that apply
a) administer magnesium sulfate IV drip as ordered
b) check urine for presence of protein
c) have calcium gluconate readily available
d) monitor for elevated liver enzymes
e) observe for elevated platelet counts
f) encourage ambulation
94. A clinic nurse is teaching a pregnant client about the warning signs in pregnancy. Which of the following, if identified as a
warning sign by the client would indicate that she understands the teaching?
a) purplish discoloration of the vulva c) irregular, painless contractions
b) visual disturbances d) urinary frequenc
95. A trial for vaginal delivery after an earlier caesarean, 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.
d

ANSWER KEY : NCM 102 FINALS

1. (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.
2. (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

JESMAR S. ESPIRITU MAN RN RM 18


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.
3. (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.
4. 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.
5. (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.
6. (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.
7. (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.
8. (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.
9. (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.
10. (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.
11. (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.
12. (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

JESMAR S. ESPIRITU MAN RN RM 19


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.
13. 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.
14. (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.
15. (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.
16. (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.
17. . A. Bending from the waist in pregnancy tends to make backache worse.
18. 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.
19. 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.
20. 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.
21. 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

JESMAR S. ESPIRITU MAN RN RM 20


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.
22. 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.
23. 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.
24. 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.
25. 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.
26. c determine fetal well being
27. d normal for blood pressure to inc. as much as 33 in systolic in the 3rd tri when near delivery
28. A - to determine gravidity and parity, use GTPAL. G-gravida (the number of pregnancies regardless of the
number of fetus); T-term deliveries; P-preterm deliveries; A-abortion; L-living children. Gravida 5 Para 3 1 1 4
means that the woman had 5 pregnancies, 3 term deliveries, 1 preterm delivery, 1 abortion, and 4 living
children.
29. A - maternal blood sample is required for alpha-fetoprotein (AFP) level determination. High levels of AFP may
indicate presence of neural tube defect (e.g. spina bifida) or chromosomal defect (Down's syndrome).
30. A - abruptio placenta, which is premature separation of normally implanted placenta in the third trimester is a
potential complication of PIH (gestational hypertension). This is due to impaired circulation and oxygenation to
the placenta and uterus.
31. .A - the client with prolapsed cord should be given highest priority by the nurse. Prolapsed cord decreases
blood flow and oxygen available to and from the placenta and to the fetus
32. B - : placenta previa is characterized by improperly implanted placenta in the lower uterine segment near or
over the internal cervical os. Therefore nursing intervention should include avoidance of invasive procedures
like vaginal examination and internal fetal heart rate monitoring
33. B - abruptio placenta is premature separation of placenta from the uterine wall after the 20th week of gestation
and before the fetus is delivered. It is usually caused by poor uteroplacental circulation due to hypertension,
smoking, alcohol, cocaine abuse. A manifestation is rising fundal height from blood trapped behind placenta.

JESMAR S. ESPIRITU MAN RN RM 21


Other signs and symptoms are as follows: painful vaginal bleeding; hypertonic to tetanic, enlarged uterus;
boardlike rigidity of abdomen; abnormal or absent fetal heart tones; bloody amniotic fluid; signs of shock
34. .A -: during fetal distress, pitocin drip should be discontinued. This is because uterine contractions will further
reduce fetal oxygenation. Therefore, choice no. 1 should not be included in the client's nursing care plan
35. C -: advising the couple to have another child is non-therapeutic. The couple should be encouraged to give
name to the dead newborn to make him realize that their child is real. The social worker visits the couple to
further assess their perception of their current situation and to provide psychosocial support. Encouraging the
couple will realize that their problem is not unique. The environment is non-threatening and the couple will be
encouraged to verbalize their feelings, fears, and concerns
36. B-: before starting oral contraceptives, the nurse should assess the client for signs and symptoms of
hypertension. The estrogen component of the oral contraceptive stimulates angiotensinogen production which
is converted into angiotensin I and II. Angiotensin II causes vasoconstriction and stimulates adrenal cortex to
increase aldosterone secretion. Aldosterone increases sodium and water retention, thus increasing plasma
volume. Vasoconstriction and increased plasma volume cause hypertension. Another contraindication of oral
contraceptives is thrombophlebitis
37. .C-: During the first trimester, it is normal for the pregnant woman to experience ambivalence. After the first
trimester, the woman moves towards acceptance of the pregnancy.
38. A,D,E: mild pre-eclampsia is characterized by hypertension, edema, and proteinuria. Seizures are signs of
eclampsia. Abdominal pain, blurry vision and decreased urine output are signs of severe pre-eclampsia.
39. B- papanicolaou examination is done in all sexually active women at any age. If the woman is not sexually
active, baseline examination is at age 40.
40. D- herpes genitalis is characterized by clusters of vesicles in the vaginal area. Trachomatis infection is often
asymptomatic in women, but symptoms may include yellowish discharge and dysuria. Some women
41. A, B, C, D these are appropriate nursing care for a client with PIH. PIH may lead to HELLP syndrome
(hemolysis, elevated liver enzymes, low platelet count). Magnesium sulfate is given to the patient to prevent
seizures. Calcium gluconate is administered if magnesium toxicity occurs. The client with PIH should be on
complete bedrest to prevent further elevation of blood pressure and to prevent seizures.
42. B - visual disturbances may indicate presence of pregnancy-induced hypertension (PIH). Choices 1, 3, and 4
are normal assessment findings in pregnancy
43. A- calcium gluconate
44. 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.
45. 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.
46. 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
47. C. Prepare her for a pelvic examination Pelvic examination would reveal dilation and effacement
48. A. Change the maternal position. Stimulation of the sympathetic nervous system is an initial response to mild hypoxia
that accompanies partial cord compression (umbilical vein) during contractions; changing the maternal position can
alleviate the compression.

JESMAR S. ESPIRITU MAN RN RM 22


49. C. Prepare her for a pelvic examination
Pelvic examination would reveal dilation and effacement
50. A. Change the maternal position
Stimulation of the sympathetic nervous system is an initial response to mild hypoxia that accompanies partial cord
compression (umbilical vein) during contractions; changing the maternal position can alleviate the compression.
51. C. Prevent situations that may stimulate the cervix or uterus
Stimulation of the cervix or uterus may cause bleeding or hemorrhage and should be avoided.
52. B. Maintaining the ordered hydration
Promoting hydration maintains urine production at a higher rate, which flushes the bladder and prevents urinary
stasis and possible infection.
53. D. Bleeding from the venipuncture site This indicates a fibrinogenemia; massive clotting in the area of the
separation has resulted in a lowered circulating fibrinogen.
54. C. Assure that informed consent has been obtained from the client
An invasive procedure such as amniocentesis requires informed consent.
55. D. blowing pattern Clients should use a blowing pattern to overcome the premature urge to push.
56. D. Prevent development of respiratory distress
Respiratory distress or arrest may occur when the serum level of magnesium sulfate reaches 12 to 15 mg/dl; deep
tendon reflexes disappear when the serum level is 10 to 12 mg/dl; the drug is withheld in the absence of deep tendon
reflexes; the therapeutic serum level is 5 to 8 mg/dl.
57. C. Blood loss of 850 ml after a vaginal birth
Excessive blood loss predisposes the client to an increased risk of infection because of decreased maternal
resistance; they expected blood loss is 350 to 500 ml.
58. B. Cyanotic lips and face Central cyanosis (blue lips and face) indicates lowered oxygenation of the blood, caused
by either decreased lung expansion or
59. (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.
60. (C) Monitoring apical pulse---Nursing care for the client with a possible ectopic pregnancy is focused on preventing or
identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of shock.
61. (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.
62. 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.
63. (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.
64. (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.
65. 1.D. Position on her side with her shoulders elevated.
66. 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.
67. 3.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.

JESMAR S. ESPIRITU MAN RN RM 23


68. 4.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.
69. 5.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.
70. 6.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.
71. 7.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.
72. 8.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.
73. 9.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.
74. 10.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.
75. 11.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
76. 12.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.
77. 13.c determine fetal well being
78. 14.d normal for blood pressure to inc. as much as 33 in systolic in the 3rd tri when near deLIVERY
79. 15.C. WITHIN THE WEEK
80. 16.A - to determine gravidity and parity, use GTPAL. G-gravida (the number of pregnancies regardless of the number
of fetus); T-term deliveries; P-preterm deliveries; A-abortion; L-living children. Gravida 5 Para 3 1 1 4 means that the
woman had 5 pregnancies, 3 term deliveries, 1 preterm delivery, 1 abortion, and 4 living children.
81. 17.A - maternal blood sample is required for alpha-fetoprotein (AFP) level determination. High levels of AFP may
indicate presence of neural tube defect (e.g. spina bifida) or chromosomal defect (Down's syndrome).

JESMAR S. ESPIRITU MAN RN RM 24


82. 18.A - abruptio placenta, which is premature separation of normally implanted placenta in the third trimester is a
potential complication of PIH (gestational hypertension). This is due to impaired circulation and oxygenation to the
placenta and uterus.
83. 19.A - the client with prolapsed cord should be given highest priority by the nurse. Prolapsed cord decreases blood
flow and oxygen available to and from the placenta and to the fetus
84. 20.B - : placenta previa is characterized by improperly implanted placenta in the lower uterine segment near or over
the internal cervical os. Therefore nursing intervention should include avoidance of invasive procedures like vaginal
examination and internal fetal heart rate monitoring
85. 21.B - abruptio placenta is premature separation of placenta from the uterine wall after the 20th week of gestation
and before the fetus is delivered. It is usually caused by poor uteroplacental circulation due to hypertension, smoking,
alcohol, cocaine abuse. A manifestation is rising fundal height from blood trapped behind placenta. Other signs and
symptoms are as follows: painful vaginal bleeding; hypertonic to tetanic, enlarged uterus; boardlike rigidity of
abdomen; abnormal or absent fetal heart tones; bloody amniotic fluid; signs of shock
86. 22.A -: during fetal distress, pitocin drip should be discontinued. This is because uterine contractions will further
reduce fetal oxygenation. Therefore, choice no. 1 should not be included in the client's nursing care plan
87. 23.C -: advising the couple to have another child is non-therapeutic. The couple should be encouraged to give name
to the dead newborn to make him realize that their child is real. The social worker visits the couple to further assess
their perception of their current situation and to provide psychosocial support. Encouraging the couple will realize that
their problem is not unique. The environment is non-threatening and the couple will be encouraged to verbalize their
feelings, fears, and concerns
88. 24.B-: before starting oral contraceptives, the nurse should assess the client for signs and symptoms of hypertension.
The estrogen component of the oral contraceptive stimulates angiotensinogen production which is converted into
angiotensin I and II. Angiotensin II causes vasoconstriction and stimulates adrenal cortex to increase aldosterone
secretion. Aldosterone increases sodium and water retention, thus increasing plasma volume. Vasoconstriction and
increased plasma volume cause hypertension. Another contraindication of oral contraceptives is thrombophlebitis
89. 25.C-: During the first trimester, it is normal for the pregnant woman to experience ambivalence. After the first
trimester, the woman moves towards acceptance of the pregnancy.
90. .A,D,E: mild pre-eclampsia is characterized by hypertension, edema, and proteinuria. Seizures are signs of
eclampsia. Abdominal pain, blurry vision and decreased urine output are signs of severe pre-eclampsia.
91. 27.B- papanicolaou examination is done in all sexually active women at any age. If the woman is not sexually active,
baseline examination is at age 40.
92. 28.D- herpes genitalis is characterized by clusters of vesicles in the vaginal area. Trachomatis infection is often
asymptomatic in women, but symptoms may include yellowish discharge and dysuria. Some women
93. 29.A, B, C, D these are appropriate nursing care for a client with PIH. PIH may lead to HELLP syndrome (hemolysis,
elevated liver enzymes, low platelet count). Magnesium sulfate is given to the patient to prevent seizures. Calcium
gluconate is administered if magnesium toxicity occurs. The client with PIH should be on complete bedrest to prevent
further elevation of blood pressure and to prevent seizures.
94. 30.B - visual disturbances may indicate presence of pregnancy-induced hypertension (PIH). Choices 1, 3, and 4 are
normal assessment findings in pregnancy
95. (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

JESMAR S. ESPIRITU MAN RN RM 25


GODBLESS!!!!!

JESMAR S. ESPIRITU MAN RN RM 26


JESMAR S. ESPIRITU MAN RN RM 27