1. A client asks the nurse what a third degree laceration is.

She was
informed that she had one. The nurse explains that this is:

preecplampsia. Which of the following represents an unusual finding

for this condition?

a. that extended their anal sphincter

b. through the skin and into the muscles
c. that involves anterior rectal wall
d. that extends through the perineal muscle.

a. generalized edema
b. proteinuria 4+
c. blood pressure of 160/110
d. convulsions

2. Betina 30 weeks AOG discharged with a diagnosis of placenta

previa. The nurse knows that the client understands her care at home
when she says:

8. Nurse Geli explains to the client who is 33 weeks pregnant and is

experiencing vaginal bleeding that coitus:

a. I am happy to note that we can have sex occasionally when I have

no bleeding.
b. I am afraid I might have an operation when my due comes
c. I will have to remain in bed until my due date comes
d. I may go back to work since I stay only at the office.

3. The uterus has already risen out of the pelvis and is experiencing
farther into the abdominal area at about the:
a. 8th week of pregnancy
b. 10th week of pregnancy
c. 12th week of pregnancy
d. 18th week of pregnancy

a. Need to be modified in any way by either partner

b. Is permitted if penile penetration is not deep.
c. Should be restricted because it may stimulate uterine activity.
d. Is safe as long as she is in side-lying position.

9. Mrs. Precilla Abuel, a 32 year old mulripara is admitted to labor

and delivery. Her last 3 pregnancies in short stage one of labor. The
nurses decide to observe her closely. The physician determines that
Mrs. Abuels cervix is dilated to 6 cm. Mrs. Abuel states that she is
extremely uncomfortable. To lessen Mrs. Abuels discomfort, the
nurse can advise her to:
a. lie face down
b. not drink fluids
c. practice holding breaths between contractions
d. assume Sims position

4. Which of the following urinary symptoms does the pregnant

woman most frequently experience during the first trimester:
10. Which is true regarding the fontanels of the newborn?
a. frequency
b. dysuria
c. incontinence
d. burning

5. Mrs. Jimenez went to the health center for pre-natal check-up. the
student nurse took her weight and revealed 142 lbs. She asked the
student nurse how much should she gain weight in her pregnancy.
a. 20-30 lbs
b. 25-35 lbs
c. 30- 40 lbs
d. 10-15 lbs

6. The nurse is preparing Mrs. Jordan for cesarean delivery. Which of

the following key concept should the nurse consider when
implementing nursing care?
a. Explain the surgery, expected outcome and kind of anesthetics.
b. Modify preoperative teaching to meet the needs of either a planned
or emergency cesarean birth.
c. Arrange for a staff member of the anesthesia department to explain
what to expect post-operatively.
d. Instruct the mothers support person to remain in the family lounge
until after the delivery.

a. The anterior is large in shape when compared to the posterior

fontanel.
b. The anterior is triangular shaped; the posterior is diamond shaped.
c. The anterior is bulging; the posterior appears sunken.
d. The posterior closes at 18 months; the anterior closes at 8 to 12
months.

11. Mrs. Quijones gave birth by spontaneous delivery to a full term

baby boy. After a minute after birth, he is crying and moving
actively. His birth weight is 6.8 lbs. What do you expect baby
Quijones to weigh at 6 months?
a. 13 -14 lbs
b. 16 -17 lbs
c. 22 -23 lbs
d. 27 -28 lbs

12. During the first hours following delivery, the post partum client is
given IVF with oxytocin added to them. The nurse understands the
primary reason for this is:
a. To facilitate elimination
b. To promote uterine contraction
c. To promote analgesia
d. To prevent infection

7. Bettine Gonzales is hospitalized for the treatment of severe

13. Nurse Luis is assessing the newborns heart rate. Which of the
following would be considered normal if the newborn is sleeping?
a. 80 beats per minute
b. 100 beats per minute
c. 120 beats per minute
d. 140 beats per minute

14. The infant with Down Syndrome should go through which of the
Eriksons developmental stages first?
a. Initiative vs. Self doubt
b. Industry vs. Inferiority
c. Autonomy vs. Shame and doubt
d. Trust vs. Mistrust

c. 5 inches
d. 6 inches

20. Alice, 10 years old was brought to the ER because of Asthma.

She was immediately put under aerosol administration of Terbutaline.
After sometime, you observe that the child does not show any relief
from the treatment given. Upon assessment, you noticed that both the
heart and respiratory rate are still elevated and the child shows
difficulty of exhaling. You suspect:
a. Bronchiectasis
b. Atelectasis
c. Epiglotitis
d. Status Asthmaticus

15. The child with phenylketonuria (PKU) must maintain a low

phenylalanine diet to prevent which of the following complications?

21. Nurse Jonas assesses a 2 year old boy with a tentative diagnosis
of nephroblastoma. Symptoms the nurse observes that suggest this
problem include:

a. Irreversible brain damage

b. Kidney failure
c. Blindness
d. Neutropenia

a. Lymphedema and nerve palsy

b. Hearing loss and ataxia
c. Headaches and vomiting
d. Abdominal mass and weakness

16. Which age group is with imaginative minds and creates

imaginary friends?

22. Which of the following danger sings should be reported

immediately during the antepartum period?

a. Toddler
b. Preschool
c. School
d. Adolescence

a. blurred vision
b. nasal stuffiness
c. breast tenderness
d. constipation

17. Which of the following situations would alert you to a potentially

developmental problem with a child?

23. Nurse Jacob is assessing a 15 month old child with acute otitis
media. Which of the following symptoms would the nurse anticipate
finding?

a. Pointing to body parts at 15 months of age.

b. Using gesture to communicate at 18 months.
c. Cooing at 3 months.
d. Saying mama or dada for the first time at 18 months of age.

18. Isabelle, a 2 year old girl loves to move around and oftentimes
manifests negativism and temper tantrums. What is the best way to
deal with her behavior?
a. Tell her that she would not be loved by others is she behaves that
way..
b. Withholding giving her toys until she behaves properly.
c. Ignore her behavior as long as she does not hurt herself and others.
d. Ask her what she wants and give it to pacify her.

a. periorbital edema, absent light reflex and translucent tympanic

membrane
b. irritability, purulent drainage in middle ear, nasal congestion and
cough
c. diarrhea, retracted tympanic membrane and enlarged parotid gland
d. Vomiting, pulling at ears and pearly white tympanic membrane

24. Which of the following is the most appropriate intervention to

reduce stress in a preterm infant at 33 weeks gestation?
a. Sensory stimulation including several senses at a time
b. tactile stimulation until signs of over stimulation develop
c. An attitude of extension when prone or side lying
d. Kangaroo care

19. Baby boy Villanueva, 4 months old, was seen at the pediatric
clinic for his scheduled check-up. By this period, baby Villanueva
has already increased his height by how many inches?

25. The parent of a client with albinism would need to be taught

which preventive healthcare measure by the nurse:

a. 3 inches
b. 4 inches

a. Ulcerative colitis diet

b. Use of a high-SPF sunblock

c. Hair loss monitoring

d. Monitor for growth retardation
1. (A) that extended their anal sphincter
Third degree laceration involves all in the second degree laceration
and the external sphincter of the rectum. Options B, C and D are
under the second degree laceration.
2. (C) I will have to remain in bed until my due date comes
Placenta previa means that the placenta is the presenting part. On the
first and second trimester there is spotting. On the third trimester
there is bleeding that is sudden, profuse and painless.
3. (D) 18th week of pregnancy
On the 8th week of pregnancy, the uterus is still within the pelvic
area. On the 10th week, the uterus is still within the pelvic area. On
the 12th week, the uterus and placenta have grown, expanding into
the abdominal cavity. On the 18th week, the uterus has already risen
out of the pelvis and is expanding into the abdominal area.
4. (A) frequency
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
infection.
5. (B) 25-35 lbs
A weight gain of 11. 2 to 15.9 kg (25 to 35 lbs) is currently
recommended as an average weight gain in pregnancy. This weight
gain consists of the following: fetus- 7.5 lb; placenta- 1.5 lb; amniotic
fluid- 2 lb; uterus- 2.5 lb; breasts- 1.5 to 3 lb; blood volume- 4 lb;
body fat- 7 lb; body fluid- 7 lb.
6. (B) Modify preoperative teaching to meet the needs of either a
planned or emergency cesarean birth.
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 planned or emergency cesarean birth, the depth and breadth of
instruction will depend on circumstances and time available.
7. (D) convulsions
Options A, B and C are findings of severe preeclampsia. Convulsions
is a finding of eclampsiaan obstetrical emergency.
8. (C) Should be restricted because it may stimulate uterine
activity.
Coitus is restricted when there is watery discharge, uterine
contraction and vaginal bleeding. Also those women with a history of
spontaneous miscarriage may be advised to avoid coitus during the
time of pregnancy when a previous miscarriage occurred.

11. (A) 13 -14 lbs

The birth weight of an infant is doubled at 6 months and is tripled at
12 months.
12. (B) To promote uterine contraction
Oxytocin is a hormone produced by the pituitary gland that produces
intermittent uterine contractions, helping to promote uterine
involution.
13. (B) 100 beats per minute
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.
14. (D) Trust vs. Mistrust
The child with Down syndrome will go through the same first stage,
trust vs. mistrust, only at a slow rate. Therefore, the nurse should
concentrate on developing on bond between the primary caregiver
and the child.
15. (A) Irreversible brain damage
The child with PKU must maintain a strict low phenylalanine diet to
prevent central nervous system damage, seizures and eventual death.
16. (B) Preschool
During preschool, this is the time when children do imitative play,
imaginative playthe occurrence of imaginative playmates, dramatic
play where children like to act, dance and sing.
17. (D) Saying mama or dada for the first time at 18 months
of age.
A child should say mama or dada during 10 to 12 months of age.
Options A, B and C are all normal assessments of language
development of a child.
18. (C) Ignore her behavior as long as she does not hurt herself
and others.
If a child is trying to get attention or trying to get something through
tantrumsignore his/her behavior.
19. (B) 4 inches
From birth to 6 months, the infant grows 1 inch (2.5 cm) per month.
From 6 to 12 months, the infant grows inch (1.25 cm) per month.
20. (D) Status Asthmaticus
Status asthmaticus leads to respiratory distress and bronchospasm
despite of treatment and interventions. Mechanical ventilation maybe
needed due to respiratory failure.

9. (D) assume Sims position

When the woman is in Sims position, this puts the weight of the
fetus on bed, not on the woman and allows good circulation in the
lower extremities.

21. (D) Abdominal mass and weakness

Nephroblastoma or Wilms tumor is caused by chromosomal
abnormalities, most common kidney cancer among children
characterized by abdominal mass, hematuria, hypertension and fever.

10. (A) The anterior is large in shape when compared to the

posterior fontanel.
The anterior fontanel is larger in size than the posterior fontanel.
Additionally, the anterior fontanel, which is diamond shaped closes at
18 month, whereas the posterior fontanel, which is triangular in shape
closes at 8 to 12 weeks. Neither fontanel should appear bulging,
which may indicate increases ICP or sunken, which may indicate
hydration.

22. (A) blurred vision

Danger signs that require prompt reporting are leaking of amniotic
fluid, blurred vision, vaginal bleeding, rapid weight gain and elevated
blood pressure. Nasal stuffiness, breast tenderness, and constipation
are common discomforts associated with pregnancy.
23. (B) irritability, purulent drainage in middle ear, nasal
congestion and cough

Irritability, purulent drainage in middle ear, nasal congestion and

cough, fever, loss of appetite, vomiting and diarrhea are clinical
manifestations of otitis media. Acute otitis media is common in
children 6 months to 3 years old and 8 years old and above. Breast
fed infants have higher resistance due to protection of Eustachian
tubes and middle ear from breast milk.
24. (D) Kangaroo care
Kangaroo care is the use of skin-to-skin contact to maintain body
heat. This method of care not only supplies heat but also encourages
parent-child interaction.
25. (B) Use of a high-SPF sunblock
Without melanin production, the child with albinism is at risk for
severe sunburns. Maximum sun protection should be taken, including
use of hats, long sleeves, minimal time in the sun and high-SPF
sunblock, to prevent any problems.
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 Janah who is in labor, the

presenting part is at station plus two. Nurse, correctly interprets it as:
a. Presenting part is 2 cm above the plane of the ischial spines.
b. Biparietal diameter is at the level of the ischial spines.
c. Presenting part in 2 cm below the plane of the ischial spines.
d. Biparietal diameter is 2 cm above the ischial spines.

8. A pregnant client is receiving oxytocin (Pitocin) for induction of

labor. A condition that warrant the nurse in-charge to discontinue I.V.
infusion of Pitocin is:
a. Contractions every 1 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.

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?
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.

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:

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. 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. 6 months
b. 4 months
c. 8 months
d. 10 months

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.

16.Which of the following is the most prominent feature of public

health nursing?

22.Nurse Tina is aware that the disease declared through Presidential

Proclamation No. 4 as a target for eradication in the Philippines is?

a. It involves providing home care to sick people who are not

confined in the hospital.
b. Services are provided free of charge to people within the
catchments area.
c. The public health nurse functions as part of a team providing a
public health nursing services.
d. Public health nursing focuses on preventive, not curative, services.

a. Poliomyelitis
b. Measles
c. Rabies
d. Neonatal tetanus

17.When the nurse determines whether resources were maximized in

implementing Ligtas Tigdas, she is evaluating

a. Integration
b. Community organization

23.May knows that the step in community organizing that involves

training of potential leaders in the community is:

c. Community study
d. Core group formation

30.Malou was diagnosed with severe preeclampsia is now receiving

I.V. magnesium sulfate. The adverse effects associated with
magnesium sulfate is:

24.Beth a public health nurse takes an active role in community

participation. What is the primary goal of community organizing?

a. Anemia
b. Decreased urine output
c. Hyperreflexia
d. Increased respiratory rate

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.

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 second-trimester of pregnancy is:
a. Metabolic alkalosis
b. Respiratory acidosis
c. Mastitis
d. Physiologic anemia

27.A fullterm client is in labor. Nurse Betty is aware that the fetal
heart rate would be:
a. 80 to 100 beats/minute
b. 100 to 120 beats/minute
c. 120 to 160 beats/minute
d. 160 to 180 beats/minute

28.The skin in the diaper area of a 7 month old infant is excoriated

and red. Nurse Hazel should instruct the mother to:
a. Change the diaper more often.
b. Apply talc powder with diaper changes.
c. Wash the area vigorously with each diaper change.
d. Decrease the infants fluid intake to decrease saturating diapers.

29.Nurse Carla knows that the common cardiac anomalies in children

with Down Syndrome (tri-somy 21) is:
a. Atrial septal defect
b. Pulmonic stenosis
c. Ventricular septal defect
d. Endocardial cushion defect

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

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.

37.In doing a childs admission assessment, Nurse Betty should be

alert to note which signs or symptoms of chronic lead poisoning?

43.Before adding potassium to an infants I.V. line, Nurse Ron must

be sure to assess whether this infant has:

a. Irritability and seizures

b. Dehydration and diarrhea
c. Bradycardia and hypotension
d. Petechiae and hematuria

a. Stable blood pressure

b. Patant fontanelles
c. Moros reflex
d. Voided

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?

44.Nurse Carla should know that the most common causative factor
of dermatitis in infants and younger children is:

a. I should check the diaphragm carefully for holes every time I use
it
b. I may need a different size of diaphragm if I gain or lose weight
more than 20 pounds
c. The diaphragm must be left in place for atleast 6 hours after
intercourse
d. I really need to use the diaphragm and jelly most during the
middle of my menstrual cycle.

39.Hypoxia is a common complication of laryngotracheobronchitis.

Nurse Oliver should frequently assess a child with
laryngotracheobronchitis for:
a. Drooling
b. Muffled voice
c. Restlessness
d. Low-grade fever

40.How should Nurse Michelle guide a child who is blind to walk to

the playroom?
a. Without touching the child, talk continuously as the child walks
down the hall.
b. Walk one step ahead, with the 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. 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 Lhynnete discussed childhood diseases
such as chicken pox. Which of the following statements about
chicken pox is correct?
a. The older one gets, the more susceptible he becomes to the
complications of chicken pox.
b. A single attack of chicken pox will prevent future episodes,
including conditions such as shingles.
c. To prevent an outbreak in the community, quarantine may be
imposed by health authorities.
d. Chicken pox vaccine is best given when there is an impending
outbreak in the community.

47.Barangay Pinoy had an outbreak of German measles. To prevent

congenital rubella, what is the BEST advice that you can give to
women in the first trimester of pregnancy in the barangay Pinoy?
a. Advice them on the signs of German measles.
b. Avoid crowded places, such as markets and movie houses.
c. Consult at the health center where rubella vaccine may be given.
d. Consult a physician who may give them rubella immunoglobulin.

48.Myrna a public health nurse knows that to determine possible

sources of sexually transmitted infections, the BEST method that may
be undertaken is:
a. Contact tracing

b. Community survey
c. Mass screening tests
d. Interview of suspects

49.A 33-year old female client came for consultation at the health
center with the chief complaint of fever for a week. Accompanying
symptoms were muscle pains and body malaise. A week after the
start of fever, the client noted yellowish discoloration of his sclera.
History showed that he waded in flood waters about 2 weeks before
the onset of symptoms. Based on her history, which disease condition
will you suspect?
a. Hepatitis A
b. Hepatitis B
c. Tetanus
d. Leptospirosis

50.Mickey a 3-year old client was brought to the health center with
the chief complaint of severe diarrhea and the passage of rice water
stools. The client is most probably suffering from which condition?
a. Giardiasis
b. Cholera
c. Amebiasis
d. Dysentery

51.The most prevalent form of meningitis among children aged 2

months to 3 years is caused by which microorganism?
a. Hemophilus influenzae
b. Morbillivirus
c. Steptococcus pneumoniae
d. Neisseria meningitidis

52.The student nurse is aware that the pathognomonic sign of

measles is 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 nailbed 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.

c. 5 years
d. Lifetime
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?

67.Nurse Ron is aware that unused BCG should be discarded after

how many hours of reconstitution?

a. Inability to drink
b. High grade fever
c. Signs of severe dehydration
d. Cough for more than 30 days

a. 2 hours
b. 4 hours
c. 8 hours
d. At the end of the day

62.Jimmy a 2-year old child revealed baggy pants. As a nurse,

using the IMCI guidelines, how will you manage Jimmy?

68.The nurse explains to a breastfeeding mother that breast milk is

sufficient for all of the babys nutrient needs only up to:

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.

a. 5 months
b. 6 months
c. 1 year
d. 2 years

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. 8 weeks
b. 12 weeks
c. 24 weeks
d. 32 weeks

a. Bring the child to the nearest hospital for further assessment.

b. Bring the child to the health center for intravenous fluid therapy.
c. Bring the child to the health center for assessment by the physician.
d. Let the child rest for 10 minutes then continue giving Oresol more
slowly.

64.Nikki a 5-month old infant was brought by his mother to the

health center because of diarrhea for 4 to 5 times a day. Her skin goes
back slowly after a skin pinch and her eyes are sunken. Using the
IMCI guidelines, you will classify this infant in which category?
a. No signs of dehydration
b. Some dehydration
c. Severe dehydration
d. The data is insufficient.

65.Chris a 4-month old infant was brought by her mother to the

health center because of cough. His respiratory rate is 42/minute.
Using the Integrated Management of Child Illness (IMCI) guidelines
of assessment, his breathing is considered as:
a. Fast
b. Slow
c. Normal
d. Insignificant

66.Maylene had just received her 4th dose of tetanus toxoid. She is
aware that her baby will have protection against tetanus for
a. 1 year
b. 3 years

69.Nurse Ron is aware that the gestational age of a conceptus that is

considered viable (able to live outside the womb) is:

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 hyposia
b. Hyperthermia due to decreased glycogen stores
c. Hyperglycemia due to decreased glycogen stores
d. Polycythemia probably due to chronic fetal hypoxia
73.Marjorie has just given birth at 42 weeks gestation. When the
nurse assessing the neonate, which physical finding is expected?
a. A sleepy, lethargic baby

b. Lanugo covering the body

c. Desquamation of the epidermis
d. Vernix caseosa covering the body
74.After reviewing the 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

a fourth-degree laceration. Which of the following would be

contraindicated when caring for this client?
a. Applying cold to limit edema during the first 12 to 24 hours.
b. Instructing the client to use two or more peripads to cushion the
area.
c. Instructing the client on the use of sitz baths if ordered.
d. Instructing the client about the importance of perineal (kegel)
exercises.

81. A pregnant woman accompanied by her husband, seeks

admission to the labor and delivery area. She states that she's in labor
and says she attended the facility clinic for prenatal care. Which
question should the nurse Oliver ask her first?
a. Do you have any chronic illnesses?
b. Do you have any allergies?
c. What is your expected due date?
d. Who will be with you during labor?

82.A neonate begins to gag and turns a dusky color. What should the
nurse do first?
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.

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?
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.

a. Observing the pooling of straw-colored fluid.

b. Checking vaginal discharge with nitrazine paper.
c. Conducting a bedside ultrasound for an amniotic fluid index.
d. Observing for flakes of vernix in the vaginal discharge.

84. A baby girl is born 8 weeks premature. At birth, she has no

spontaneous respirations but is successfully resuscitated. Within
several hours she develops respiratory grunting, cyanosis, tachypnea,
nasal flaring, and retractions. She's diagnosed with respiratory
distress syndrome, intubated, and placed on a ventilator. Which
nursing action should be included in the baby's plan of care to
prevent retinopathy of prematurity?
a. Cover his eyes while receiving oxygen.
b. Keep her body temperature low.
c. Monitor partial pressure of oxygen (Pao2) levels.
d. Humidify the oxygen.

79.Which of the following would be least likely to indicate

anticipated bonding behaviors by new parents?
85. Which of the following is normal newborn calorie intake?
a. The parents willingness to touch and hold the new born.
b. The parents expression of interest about the size of the new born.
c. The parents indication that they want to see the newborn.
d. The parents interactions with each other.

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

80.Following a precipitous delivery, examination of the client's

vagina reveals

10

86. Nurse John is knowledgeable that usually individual twins will

grow appropriately and at the same rate as singletons until how many
weeks?

c. I.V. fluids
d. Acetaminophen (Tylenol) for pain

a. 16 to 18 weeks
b. 18 to 22 weeks
c. 30 to 32 weeks
d. 38 to 40 weeks

93. Which of the following drugs is the antidote for magnesium

toxicity?

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

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.

89. Nurse Arnold knows that the following changes in respiratory

functioning during pregnancy is considered normal:

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. Increased tidal volume

b. Increased expiratory volume
c. Decreased inspiratory capacity
d. Decreased oxygen consumption

a. Asymptomatic bacteriuria
b. Bacterial vaginosis
c. Pyelonephritis
d. Urinary tract infection (UTI)

90. Emily has gestational diabetes and it is usually managed by which

of the following therapy?

96. Rh isoimmunization in a pregnant client develops during which

of the following conditions?

a. Diet
b. Long-acting insulin
c. Oral hypoglycemic
d. Oral hypoglycemic drug and insulin

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.

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?

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

a. Antihypertensive agents
b. Diuretic agents

11

98. Celeste who used heroin during her pregnancy delivers a neonate.
When assessing the neonate, the nurse Lhynnette expects to find:
a. Lethargy 2 days after birth.
b. Irritability and poor sucking.
c. A flattened nose, small eyes, and thin lips.
d. Congenital defects such as limb anomalies.

99. The uterus returns to the pelvic cavity in which of the following
time frames?
a. 7th to 9th day postpartum.
b. 2 weeks postpartum.
c. End of 6th week postpartum.
d. When the lochia changes to alba.

100. Maureen, a primigravida client, age 20, has just completed a

difficult, forceps-assisted delivery of twins. Her labor was unusually
long and required oxytocin (Pitocin) augmentation. The nurse who's
caring for her should stay alert for:
a. Uterine inversion
b. Uterine atony
c. Uterine involution
d. Uterine discomfort
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 pregnancyinduced 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, 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

12

Rationale: Efficiency is determining whether the goals were attained

at the least possible cost.

Rationale: Endocardial cushion defects are seen most in children with

Down syndrome, asplenia, or polysplenia.

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.

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.

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 aren't 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

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.

13

41. Answer: (A) Loud, machinery-like murmur.

Rationale: A loud, machinery-like murmur is a characteristic finding
associated with patent ductus arteriosus.

52. Answer: (B) Buccal mucosa

Rationale: Kopliks spot may be seen on the mucosa of the mouth or
the throat.

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.

53. Answer: (A) 3 seconds

Rationale: Adequate blood supply to the area allows the return of the
color of the nailbed within 3 seconds.

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 chicken pox.
Rationale: Chicken pox is usually more severe in adults than in
children. Complications, such as pneumonia, are higher in incidence
in adults.
47. Answer: (D) Consult a physician who may give them rubella
immunoglobulin.
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 amebic and bacillary dysentery are characterized by the
presence of blood and/or mucus in the stools. Giardiasis is
characterized by fat malabsorption and, therefore, steatorrhea.
51. Answer: (A) Hemophilus influenzae
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.

54. Answer: (B) Severe dehydration

Rationale: The order of priority in the management of severe
dehydration is as follows: intravenous fluid therapy, referral to a
facility where IV fluids can be initiated within 30 minutes, Oresol or
nasogastric tube. When the foregoing measures are not possible or
effective, then urgent referral to the hospital is done.
55. 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.

14

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) 1 year
Rationale: The baby will have passive natural immunity by placental
transfer of antibodies. The mother will have active artificial immunity
lasting for about 10 years. 5 doses will give the mother lifetime
protection.
67. Answer: (B) 4 hours
Rationale: While the unused portion of other biologicals in EPI may
be given until the end of the day, only BCG is discarded 4 hours after
reconstitution. This is why BCG immunization is scheduled only in
the morning.
68. Answer: (B) 6 months
Rationale: After 6 months, the babys nutrient needs, especially the
babys iron requirement, can no longer be provided by mothers milk
alone.
69. Answer: (C) 24 weeks
Rationale: At approximately 23 to 24 weeks gestation, the lungs are
developed enough to sometimes maintain extrauterine life. The lungs
are the most immature system during the gestation period. Medical
care for premature labor begins much earlier (aggressively at 21
weeks gestation)
70. 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 isn't prolapsed and that the baby tolerated the procedure
well. The most effective way to do this is to check the fetal heart rate.
Fetal well-being is assessed via a nonstress test. Fetal position is
determined by vaginal examination. Artificial rupture of membranes
doesn't indicate an imminent delivery.
79. Answer: (D) The parents interactions with each other.
Rationale: Parental interaction will provide the nurse with a good
assessment of the stability of the family's home life but it has no
indication for parental bonding. Willingness to touch and hold the
newborn, expressing interest about the newborn's size, and indicating
a desire to see the newborn are behaviors indicating parental bonding.
80. Answer: (B) Instructing the client to use two or more peripads to
cushion the area
Rationale: Using two or more peripads would do little to reduce the
pain or promote perineal healing. Cold applications, sitz baths, and
Kegel
exercises are important measures when the client has a fourth-degree
laceration.
81. Answer: (C) What is your expected due date?
Rationale: When obtaining the history of a client who may be in
labor, the nurse's highest priority is to determine her current status,
particularly her due date, gravidity, and parity. Gravidity and parity
affect the duration of labor and the potential for labor complications.
Later, the nurse should ask about chronic illnesses, allergies, and
support persons.
82. Answer: (D) Aspirate the neonates nose and mouth with a bulb
syringe.

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Rationale: The nurse's first action should be to clear the neonate's

airway with a bulb syringe. After the airway is clear and the neonate's
color improves, the nurse should comfort and calm the neonate. If the
problem recurs or the neonate's color doesn't improve readily, the
nurse should notify the physician. Administering oxygen when the
airway isn't clear would be ineffective.
83. Answer: (C) Conducting a bedside ultrasound for an amniotic
fluid index.
Rationale: It isn't within a nurse's scope of practice to perform and
interpret a bedside ultrasound under these conditions and without
specialized training. Observing for pooling of straw-colored fluid,
checking vaginal discharge with nitrazine paper, and observing for
flakes of vernix are appropriate assessments for determining whether
a client has ruptured membranes.
84. Answer: (C) Monitor partial pressure of oxygen (Pao2) levels.
Rationale: Monitoring PaO2 levels and reducing the oxygen
concentration to keep PaO2 within normal limits reduces the risk of
retinopathy of prematurity in a premature infant receiving oxygen.
Covering the infant's eyes and humidifying the oxygen don't reduce
the risk of retinopathy of prematurity. Because cooling increases the
risk of acidosis, the infant should be kept warm so that his respiratory
distress
isn't aggravated.
85. 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 dicchorionic twins. Cleavage that occurs between days 3
and 8 results in diamniotic monochorionic twins. Cleavage that
occurs between days 8 to 13 result in monoamniotic monochorionic
twins.
88. Answer: (D) Ultrasound
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 RHpositive 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 client's
aorta and inferior vena cava by the fetus. This, in turn, inhibits
maternal
circulation, leading to maternal hypotension and, ultimately, fetal
hypoxia. The other positions promote comfort and aid labor progress.

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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 isn't associated with neonatal
heroin
addiction. A flattened nose, small eyes, and thin lips are seen in
infants with fetal alcohol syndrome. Heroin use during pregnancy
hasn't been linked to specific congenital anomalies.
99. Answer: (A) 7th to 9th day postpartum
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.
Nursing Bullets: Maternal and Child Health Nursing I
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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.
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.
Administering high levels of oxygen to a premature
neonate can cause blindness as a result of retrolental
fibroplasia.
Amniotomy is artificial rupture of the amniotic membranes.
During pregnancy, weight gain averages 25 to 30 lb (11 to
13.5 kg).
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.
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.
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.
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

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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.

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The second stage of labor begins with full cervical dilation

and ends with the neonates birth.
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.
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.
At 20 weeks gestation, the fundus is at the level of the
umbilicus.
At 36 weeks gestation, the fundus is at the lower border of
the rib cage.
A premature neonate is one born before the end of the 37th
week of gestation.
Pregnancy-induced hypertension is a leading cause of
maternal death in the United States.
A habitual aborter is a woman who has had three or more
consecutive spontaneous abortions.
Threatened abortion occurs when bleeding is present
without cervical dilation.
A complete abortion occurs when all products of
conception are expelled.
Hydramnios (polyhydramnios) is excessive amniotic fluid
(more than 2,000 ml in the third trimester).
Stress, dehydration, and fatigue may reduce a breastfeeding mothers milk supply.
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.
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.
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.
A nonstress test is usually performed to assess fetal wellbeing in a pregnant patient with a prolonged pregnancy (42
weeks or more), diabetes, a history of poor pregnancy
outcomes, or pregnancy-induced hypertension.
A pregnant woman should drink at least eight 8-oz glasses
(about 2,000 ml) of water daily.
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.
A low-birth-weight neonate weighs 2,500 g (5 lb 8 oz) or
less at birth.
A very-low-birth-weight neonate weighs 1,500 g (3 lb 5 oz)
or less at birth.
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.
Teenage mothers are more likely to have low-birth-weight

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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.
Linea nigra, a dark line that extends from the umbilicus to
the mons pubis, commonly appears during pregnancy and
disappears after pregnancy.
Implantation in the uterus occurs 6 to 10 days after ovum
fertilization.
Placenta previa is abnormally low implantation of the
placenta so that it encroaches on or covers the cervical os.
In complete (total) placenta previa, the placenta completely
covers the cervical os.
In partial (incomplete or marginal) placenta previa, the
placenta covers only a portion of the cervical os.
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.
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.
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.
Ortolanis sign (an audible click or palpable jerk that
occurs with thigh abduction) confirms congenital hip
dislocation in a neonate.
The first immunization for a neonate is the hepatitis B
vaccine, which is administered in the nursery shortly after
birth.
If a patient misses a menstrual period while taking an oral
contraceptive exactly as prescribed, she should continue
taking the contraceptive.
If a patient misses two consecutive menstrual periods while
taking an oral contraceptive, she should discontinue the
contraceptive and take a pregnancy test.
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.
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.
Eclampsia is the occurrence of seizures that arent caused
by a cerebral disorder in a patient who has pregnancyinduced hypertension.
In placenta previa, bleeding is painless and seldom fatal on
the first occasion, but it becomes heavier with each
subsequent episode.
Treatment for abruptio placentae is usually immediate
cesarean delivery.
Drugs used to treat withdrawal symptoms in neonates
include phenobarbital (Luminal), camphorated opium
tincture (paregoric), and diazepam (Valium).
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.
The failure rate of a contraceptive is determined by the

43.
44.
45.
46.
47.
48.
49.

50.

experience of 100 women for 1 year. Its expressed as

pregnancies per 100 woman-years.
The narrowest diameter of the pelvic inlet is the
anteroposterior (diagonal conjugate).
The chorion is the outermost extraembryonic membrane
that gives rise to the placenta.
The corpus luteum secretes large quantities of
progesterone.
From the 8th week of gestation through delivery, the
developing cells are known as a fetus.
In an incomplete abortion, the fetus is expelled, but parts of
the placenta and membrane remain in the uterus.
The circumference of a neonates head is normally 2 to 3
cm greater than the circumference of the chest.
After administering magnesium sulfate to a pregnant
patient for hypertension or preterm labor, the nurse should
monitor the respiratory rate and deep tendon reflexes.
During the first hour after birth (the period of reactivity),
the neonate is alert and awake.

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When a pregnant patient has undiagnosed vaginal bleeding,

vaginal examination should be avoided until
ultrasonography rules out placenta previa.
After delivery, the first nursing action is to establish the
neonates airway.
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.
The specific gravity of a neonates urine is 1.003 to 1.030.
A lower specific gravity suggests overhydration; a higher
one suggests dehydration.
The neonatal period extends from birth to day 28. Its also
called the first 4 weeks or first month of life.
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.
Breast-feeding mothers should increase their fluid intake to
2 to 3 qt (2,500 to 3,000 ml) daily.
After feeding an infant with a cleft lip or palate, the nurse
should rinse the infants mouth with sterile water.
The nurse instills erythromycin in a neonates eyes
primarily to prevent blindness caused by gonorrhea or
chlamydia.
Human immunodeficiency virus (HIV) has been cultured in
breast milk and can be transmitted by an HIV-positive
mother who breast-feeds her infant.
A fever in the first 24 hours postpartum is most likely
caused by dehydration rather than infection.
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.
During labor, the resting phase between contractions is at
least 30 seconds.
Lochia rubra is the vaginal discharge of almost pure blood

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that occurs during the first few days after childbirth.

15. Lochia serosa is the serous vaginal discharge that occurs 4
to 7 days after childbirth.
16. 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.
17. Colostrum, the precursor of milk, is the first secretion from
the breasts after delivery.
18. The length of the uterus increases from 2 (6.3 cm)
before pregnancy to 12 (32 cm) at term.
19. 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.
20. The smallest outlet measurement of the pelvis is the
intertuberous diameter, which is the transverse diameter
between the ischial tuberosities.
21. Electronic fetal monitoring is used to assess fetal wellbeing during labor. If compromised fetal status is
suspected, fetal blood pH may be evaluated by obtaining a
scalp sample.
22. 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.
23. 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.
24. Neonates who are delivered by cesarean birth have a higher
incidence of respiratory distress syndrome.
25. The nurse should suggest ambulation to a postpartum
patient who has gas pain and flatulence.
26. Massaging the uterus helps to stimulate contractions after
the placenta is delivered.
27. When providing phototherapy to a neonate, the nurse
should cover the neonates eyes and genital area.
28. The narcotic antagonist naloxone (Narcan) may be given to
a neonate to correct respiratory depression caused by
narcotic administration to the mother during labor.
29. In a neonate, symptoms of respiratory distress syndrome
include expiratory grunting or whining, sandpaper breath
sounds, and seesaw retractions.
30. Cerebral palsy presents as asymmetrical movement,
irritability, and excessive, feeble crying in a long, thin
infant.
31. The nurse should assess a breech-birth neonate for
hydrocephalus, hematomas, fractures, and other anomalies
caused by birth trauma.
32. When a patient is admitted to the unit in active labor, the
nurses first action is to listen for fetal heart tones.
33. In a neonate, long, brittle fingernails are a sign of
postmaturity.
34. Desquamation (skin peeling) is common in postmature
neonates.
35. A mother should allow her infant to breast-feed until the
infant is satisfied. The time may vary from 5 to 20 minutes.
36. Nitrazine paper is used to test the pH of vaginal discharge
to determine the presence of amniotic fluid.
37. 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.
38. Neonatal jaundice in the first 24 hours after birth is known

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as pathological jaundice and is a sign of erythroblastosis

fetalis.
A classic difference between abruptio placentae and
placenta previa is the degree of pain. Abruptio placentae
causes pain, whereas placenta previa causes painless
bleeding.
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.
Precipitate labor lasts for approximately 3 hours and ends
with delivery of the neonate.
Methylergonovine (Methergine) is an oxytocic agent used
to prevent and treat postpartum hemorrhage caused by
uterine atony or subinvolution.
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.
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.
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.
Culdoscopy is visualization of the pelvic organs through
the posterior vaginal fornix.
The nurse should teach a pregnant vegetarian to obtain
protein from alternative sources, such as nuts, soybeans,
and legumes.
The nurse should instruct a pregnant patient to take only
prescribed prenatal vitamins because over-the-counter
high-potency vitamins may harm the fetus.
High-sodium foods can cause fluid retention, especially in
pregnant patients.
A pregnant patient can avoid constipation and hemorrhoids
by adding fiber to her diet.

Nursing Bullets: Maternal and Child Health Nursing IV

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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 sidelying position removes pressure on the inferior vena cava.
Oxytocin (Pitocin) promotes lactation and uterine
contractions.
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.
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.
Neonates typically need to consume 50 to 55 cal per pound
of body weight daily.
Because oxytocin (Pitocin) stimulates powerful uterine
contractions during labor, it must be administered under
close observation to help prevent maternal and fetal
distress.

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During fetal heart rate monitoring, variable decelerations

indicate compression or prolapse of the umbilical cord.
Cytomegalovirus is the leading cause of congenital viral
infection.
Tocolytic therapy is indicated in premature labor, but
contraindicated in fetal death, fetal distress, or severe
hemorrhage.
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.
A neonate whose mother has diabetes should be assessed
for hyperinsulinism.
In a patient with preeclampsia, epigastric pain is a late
symptom and requires immediate medical intervention.
After a stillbirth, the mother should be allowed to hold the
neonate to help her come to terms with the death.
Molding is the process by which the fetal head changes
shape to facilitate movement through the birth canal.
If a woman receives a spinal block before delivery, the
nurse should monitor the patients blood pressure closely.
If a woman suddenly becomes hypotensive during labor,
the nurse should increase the infusion rate of I.V. fluids as
prescribed.
The best technique for assessing jaundice in a neonate is to
blanch the tip of the nose or the area just above the
umbilicus.
During fetal heart monitoring, early deceleration is caused
by compression of the head during labor.
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.
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.
A pregnant patient should take folic acid because this
nutrient is required for rapid cell division.
A woman who is taking clomiphene (Clomid) to induce
ovulation should be informed of the possibility of multiple
births with this drug.
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.
Most drugs that a breast-feeding mother takes appear in
breast milk.
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.
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.
A patient with a ruptured ectopic pregnancy commonly has

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sharp pain in the lower abdomen, with spotting and

cramping. She may have abdominal rigidity; rapid, shallow
respirations; tachycardia; and shock.
The mechanics of delivery are engagement, descent and
flexion, internal rotation, extension, external rotation,
restitution, and expulsion.
A probable sign of pregnancy, McDonalds sign is
characterized by an ease in flexing the body of the uterus
against the cervix.
Amenorrhea is a probable sign of pregnancy.
A pregnant womans partner should avoid introducing air
into the vagina during oral sex because of the possibility of
air embolism.
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.
A pregnant patient who has had rupture of the membranes
or who is experiencing vaginal bleeding shouldnt engage
in sexual intercourse.
Milia may occur as pinpoint spots over a neonates nose.
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.
The union of a male and a female gamete produces a
zygote, which divides into the fertilized ovum.
The first menstrual flow is called menarche and may be
anovulatory (infertile).
Spermatozoa (or their fragments) remain in the vagina for
72 hours after sexual intercourse.
Prolactin stimulates and sustains milk production.
Strabismus is a normal finding in a neonate.
A postpartum patient may resume sexual intercourse after
the perineal or uterine wounds heal (usually within 4 weeks
after delivery).
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.
Fetal demise is death of the fetus after viability.
Respiratory distress syndrome develops in premature
neonates because their alveoli lack surfactant.
The most common method of inducing labor after artificial
rupture of the membranes is oxytocin (Pitocin) infusion.
After the amniotic membranes rupture, the initial nursing
action is to assess the fetal heart rate.
The most common reasons for cesarean birth are
malpresentation, fetal distress, cephalopelvic disproportion,
pregnancy-induced hypertension, previous cesarean birth,
and inadequate progress in labor.
Amniocentesis increases the risk of spontaneous abortion,
trauma to the fetus or placenta, premature labor, infection,
and Rh sensitization of the fetus.
After amniocentesis, abdominal cramping or spontaneous
vaginal bleeding may indicate complications.
To prevent her from developing Rh antibodies, an Rhnegative primigravida should receive Rho(D) immune
globulin (RhoGAM) after delivering an Rh-positive
neonate.

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Nursing Bullets: Maternal and Child Health Nursing V

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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.
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.
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.
A pregnant patient should take an iron supplement to help
prevent anemia.
Direct antiglobulin (direct Coombs) test is used to detect
maternal antibodies attached to red blood cells in the
neonate.
Nausea and vomiting during the first trimester of pregnancy
are caused by rising levels of the hormone human chorionic
gonadotropin.
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.
When informed that a patients amniotic membrane has
broken, the nurse should check fetal heart tones and then
maternal vital signs.
The duration of pregnancy averages 280 days, 40 weeks, 9
calendar months, or 10 lunar months.
The initial weight loss for a healthy neonate is 5% to 10%
of birth weight.
The normal hemoglobin value in neonates is 17 to 20 g/dl.
Crowning is the appearance of the fetuss head when its
largest diameter is encircled by the vulvovaginal ring.
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.
In a pregnant patient, preeclampsia may progress to
eclampsia, which is characterized by seizures and may lead
to coma.
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.
Because of the anti-insulin effects of placental hormones,
insulin requirements increase during the third trimester.
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.
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.
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.
The patient with preeclampsia usually has puffiness around

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the eyes or edema in the hands (for example, I cant put

my wedding ring on.).
Kegel exercises require contraction and relaxation of the
perineal muscles. These exercises help strengthen pelvic
muscles and improve urine control in postpartum patients.
Symptoms of postpartum depression range from mild
postpartum blues to intense, suicidal, depressive psychosis.
The preterm neonate may require gavage feedings because
of a weak sucking reflex, uncoordinated sucking, or
respiratory distress.
Acrocyanosis (blueness and coolness of the arms and legs)
is normal in neonates because of their immature peripheral
circulatory system.
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.
The nurse should place the neonate in a 30-degree
Trendelenburg position to facilitate mucus drainage.
The nurse may suction the neonates nose and mouth as
needed with a bulb syringe or suction trap.
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.
The umbilical cord normally has two arteries and one vein.
When providing care, the nurse should expose only one
part of an infants body at a time.
Lightening is settling of the fetal head into the brim of the
pelvis.
If the neonate is stable, the mother should be allowed to
breast-feed within the neonates first hour of life.
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.
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.
The diamond-shaped anterior fontanel usually closes
between ages 12 and 18 months. The triangular posterior
fontanel usually closes by age 2 months.
In the neonate, a straight spine is normal. A tuft of hair over
the spine is an abnormal finding.
Prostaglandin gel may be applied to the vagina or cervix to
ripen an unfavorable cervix before labor induction with
oxytocin (Pitocin).
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.
Meconium is a material that collects in the fetuss intestines
and forms the neonates first feces, which are black and
tarry.
The presence of meconium in the amniotic fluid during
labor indicates possible fetal distress and the need to
evaluate the neonate for meconium aspiration.
To assess a neonates rooting reflex, the nurse touches a

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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.
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.
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.
Mongolian spots are common in non-white infants and
usually disappear by age 2 to 3 years.
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.
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.
Nevus flammeus, or port-wine stain, is a diffuse pink to
dark bluish red lesion on a neonates face or neck.
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.
To assess coordination of sucking and swallowing, the
nurse should observe the neonates first breast-feeding or
sterile water bottle-feeding.
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).

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Nursing Bullets: Maternal and Child Health Nursing VI
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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.
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.
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.
Tocolytic agents used to treat preterm labor include
terbutaline (Brethine), ritodrine (Yutopar), and magnesium
sulfate.
A pregnant woman who has hyperemesis gravidarum may
require hospitalization to treat dehydration and starvation.
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.
Common complications of early pregnancy (up to 20
weeks gestation) include fetal loss and serious threats to
maternal health.
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.

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Visualization in pregnancy is a process in which the mother

imagines what the child shes carrying is like and becomes
acquainted with it.
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.
Mean arterial pressure of greater than 100 mm Hg after 20
weeks of pregnancy is considered hypertension.
The treatment for supine hypotension syndrome (a
condition that sometimes occurs in pregnancy) is to have
the patient lie on her left side.
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).
Hyperpigmentation of the pregnant patients face, formerly
called chloasma and now referred to as melasma, fades
after delivery.
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.
Progesterone maintains the integrity of the pregnancy by
inhibiting uterine motility.
Ladins sign, an early indication of pregnancy, causes
softening of a spot on the anterior portion of the uterus, just
above the uterocervical juncture.
During pregnancy, the abdominal line from the symphysis
pubis to the umbilicus changes from linea alba to linea
nigra.
In neonates, cold stress affects the circulatory, regulatory,
and respiratory systems.
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).
Parity doesnt refer to the number of infants delivered, only
the number of deliveries.
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.
The recommended amount of iron supplement for the
pregnant patient is 30 to 60 mg daily.
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.
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.
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.
In a patient who has hypertonic contractions, the uterus

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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.
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.
During crowning, the presenting part of the fetus remains
visible during the interval between contractions.
Uterine atony is failure of the uterus to remain firmly
contracted.
The major cause of uterine atony is a full bladder.
If the mother wishes to breast-feed, the neonate should be
nursed as soon as possible after delivery.
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.
Before feeding is initiated, an infant should be burped to
expel air from the stomach.
Most authorities strongly encourage the continuation of
breast-feeding on both the affected and the unaffected
breast of patients with mastitis.
Neonates are nearsighted and focus on items that are held
10 to 12 (25 to 30.5 cm) away.
In a neonate, low-set ears are associated with chromosomal
abnormalities such as Down syndrome.
Meconium is usually passed in the first 24 hours; however,
passage may take up to 72 hours.
Boys who are born with hypospadias shouldnt be
circumcised at birth because the foreskin may be needed
for constructive surgery.
In the neonate, the normal blood glucose level is 45 to 90
mg/dl.
Hepatitis B vaccine is usually given within 48 hours of
birth.
Hepatitis B immune globulin is usually given within 12
hours of birth.
HELLP (hemolysis, elevated liver enzymes, and low
platelets) syndrome is an unusual variation of pregnancyinduced hypertension.
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.
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.
A late sign of preeclampsia is epigastric pain as a result of
severe liver edema.
In the patient with preeclampsia, blood pressure returns to
normal during the puerperal period.
To obtain an estriol level, urine is collected for 24 hours.
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.
A pregnant patient with vaginal bleeding shouldnt have a
pelvic examination.

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Nursing Bullets: Maternal and Child Health Nursing VII

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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.
A patient who has premature rupture of the membranes is at
significant risk for infection if labor doesnt begin within
24 hours.
Infants of diabetic mothers are susceptible to macrosomia
as a result of increased insulin production in the fetus.
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.
A patient who has a cesarean delivery is at greater risk for
infection than the patient who gives birth vaginally.
The occurrence of thrush in the neonate is probably caused
by contact with the organism during delivery through the
birth canal.
The nurse should keep the sac of meningomyelocele moist
with normal saline solution.
If fundal height is at least 2 cm less than expected, the
cause may be growth retardation, missed abortion,
transverse lie, or false pregnancy.
Fundal height that exceeds expectations by more than 2 cm
may be caused by multiple gestation, polyhydramnios,
uterine myomata, or a large baby.
A major developmental task for a woman during the first
trimester of pregnancy is accepting the pregnancy.
Unlike formula, breast milk offers the benefit of maternal
antibodies.
Spontaneous rupture of the membranes increases the risk of
a prolapsed umbilical cord.
A clinical manifestation of a prolapsed umbilical cord is
variable decelerations.
During labor, to relieve supine hypotension manifested by
nausea and vomiting and paleness, turn the patient on her
left side.
If the ovum is fertilized by a spermatozoon carrying a Y
chromosome, a male zygote is formed.
Implantation occurs when the cellular walls of the
blastocyte implants itself in the endometrium, usually 7 to 9
days after fertilization.
Implantation occurs when the cellular walls of the
blastocyte implants itself in the endometrium, usually 7 to 9
days after fertilization.
Heart development in the embryo begins at 2 to 4 weeks
and is complete by the end of the embryonic stage.
Methergine stimulates uterine contractions.
The administration of folic acid during the early stages of
gestation may prevent neural tube defects.
With advanced maternal age, a common genetic problem is
Down syndrome.
With early maternal age, cephalopelvic disproportion
commonly occurs.
In the early postpartum period, the fundus should be
midline at the umbilicus.
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.
A 16-year-old girl who is pregnant is at risk for having a
low-birth-weight neonate.
The mothers Rh factor should be determined before an

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amniocentesis is performed.
27. Maternal hypotension is a complication of spinal block.
28. After delivery, if the fundus is boggy and deviated to the
right side, the patient should empty her bladder.
29. Before providing a specimen for a sperm count, the patient
should avoid ejaculation for 48 to 72 hours.
30. The hormone human chorionic gonadotropin is a marker
for pregnancy.
31. Painless vaginal bleeding during the last trimester of
pregnancy may indicate placenta previa.
32. During the transition phase of labor, the woman usually is
irritable and restless.
33. Because women with diabetes have a higher incidence of
birth anomalies than women without diabetes, an alphafetoprotein level may be ordered at 15 to 17 weeks
gestation.
34. To avoid puncturing the placenta, a vaginal examination
shouldnt be performed on a pregnant patient who is
bleeding.
35. A patient who has postpartum hemorrhage caused by
uterine atony should be given oxytocin as prescribed.
36. 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.
37. Hot compresses can help to relieve breast tenderness after
breast-feeding.
38. The fundus of a postpartum patient is massaged to
stimulate contraction of the uterus and prevent hemorrhage.
39. A mother who has a positive human immunodeficiency
virus test result shouldnt breast-feed her infant.
40. Dinoprostone (Cervidil) is used to ripen the cervix.
41. 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.
42. If a pregnant patients rubella titer is less than 1:8, she
should be immunized after delivery.
43. The administration of oxytocin (Pitocin) is stopped if the
contractions are 90 seconds or longer.
44. 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.
45. Subinvolution may occur if the bladder is distended after
delivery.
46. The nurse must place identification bands on both the
mother and the neonate before they leave the delivery
room.
47. Erythromycin is given at birth to prevent ophthalmia
neonatorum.
48. Pelvic-tilt exercises can help to prevent or relieve backache
during pregnancy.
49. Before performing a Leopold maneuver, the nurse should
ask the patient to empty her bladder.
50. According to the Unang Yakap program, the cord should
not be clamped until pulsations have stopped (thats about
1-3 minutes).

Placenta
posted Sep 4, 2012, 11:02 PM by RNpedia.com Administration

PLACENTA-CROSSING SUBSTANCES

"Want My Hot Dog":

Wastes
Antibodies
Nutrients
Teratogens
Microorganisms
Hormones/ HIV
Drugs

Preterm Infant
posted Aug 30, 2012, 11:13 PM by RNpedia.com Administration
Preterm infant: anticipated problems"TRIES"

Temperature regulation (poor)

Resistance to infections (poor)
Immature liver
Elimination problems (necrotizing enterocolitis [NEC])
Sensory-perceptual functions (retinopathy of prematurity [ROP])

Obstetric (Maternity) History

posted Aug 30, 2012, 11:04 PM by RNpedia.com Administration
Obstetric (maternity) history"GTPAL"

Gravida
Term
Preterm
Abortions (SAB, TAB)

25

Living children

Infections during pregnancy

posted Aug 30, 2012, 7:39 PM by RNpedia.com Administration
Infections during pregnancy"TORCH"

Newborn Assessment
posted Aug 30, 2012, 11:02 PM by RNpedia.com Administration
Newborn assessment components"APGAR"

Toxoplasmosis
Other (hepatitis B, syphilis, group B beta strep)

Appearance

Rubella

Pulse

Cytomegalovirus

Grimace

Herpes simplex virus

Activity
Respiratory effort

Episiotomy
posted Aug 29, 2012, 7:04 AM by RNpedia.com Administration
Episiotomy assessment"REEDA"

Family Planning
posted Aug 30, 2012, 8:17 PM by RNpedia.com Administration [
updated Aug 30, 2012, 11:06 PM ]
IUD: potential problems with use"PAINS"

Redness
Edema
Ecchymosis
Discharge

Period (menstrual: late, spotting, bleeding)

Approximation of skin

Abdominal pain, dyspareunia

Infection (abnormal vaginal discharge)

Dystocia
posted Aug 29, 2012, 7:02 AM by RNpedia.com Administration [
updated Aug 29, 2012, 7:02 AM ]

Not feeling well, fever or chills

Dystocia: etiology"3P's"
String missing

Oral contraceptives: signs of potential problems"ACHES"

Abdominal pain (possible liver or gallbladder problem)
Chest pain or shortness of breath (possible pulmonary embolus)

Power
Passageway
Passenger

Headache (possible hypertension, brain attack)

Dystocia: general aspects (maternal)"3P's"
Eye problems (possible hypertension or vascular accident)
Severe leg pain (possible thromboembolic process)
Psych

26

B. HCG
C. Estrogen
D. Placental Lactogen

Placenta
Position

Preeclampsia
posted Aug 29, 2012, 6:41 AM by RNpedia.com Administration [
updated Aug 29, 2012, 6:46 AM ]
Complication of severe preeclampsia"HELLP" syndrome

3. With this pregnancy, Aling Julia is a [1]

A. P3 G3
B. Primigravida
C. P3 G4
D. P0 G3
4. In explaining the development of her baby, you identified in
chronological order of growth of the fetus as it occurs in pregnancy
as [1]

Hemolysis
Elevated Liver enzymes
Low Platelet count

Umbilical Cord
posted Aug 28, 2012, 6:00 AM by RNpedia.com Administration
Blood vessels in umbilical cord"AVA" (2 arteries and 1 vein)

Artery
Vein
Artery
Introduction: The questions are coded according to their sources and
will only be for my personal reference. RED questions are original
questions I created. FATIMA students READ and DIGEST each of
these questions carefully. Goodluck.
SITUATION : [ND89] Aling Julia, a 32 year old fish vendor from
baranggay matahimik came to see you at the prenatal clinic. She
brought with her all her three children. Maye, 1 year 6 months; Joy, 3
and Dan, 7 years old. She mentioned that she stopped taking oral
contraceptives several months ago and now suspects she is pregnant.
She cannot remember her LMP.
1. Which of the following would be useful in calculating Aling Julia's
EDC? [3]
A. Appearance of linea negra
B. First FHT by fetoscope
C. Increase pulse rate
D. Presence of edema
2. Which hormone is necessary for a positive pregnancy test? [1]
A. Progesterone

A. Ovum, embryo, zygote, fetus, infant

B. Zygote, ovum, embryo, fetus, infant
C. Ovum, zygote, embryo, fetus, infant
D. Zygote, ovum, fetus, embryo, infant
5. Aling Julia states she is happy to be pregnant. Which behavior is
elicited by her during your assessment that would lead you to think
she is stressed? [3]
A. She told you about her drunk husband
B. She states she has very meager income from selling
C. She laughs at every advise you give even when its not funny
D. She has difficulty following instructions
6. When teaching Aling Julia about her pregnancy, you should
include personal common discomforts. Which of the following is an
indication for prompt professional supervision? [2]
A. Constipation and hemorrhoids
B. Backache
C. Facial edema
D. frequent urination
7. Which of the following statements would be appropriate for you to
include in Aling Julia's prenatal teaching plan? [1]
A. Exercise is very tiresome, it should be avoided
B. Limit your food intake
C. Smoking has no harmful effect on the growth and development of
fetus
D. Avoid unnecessary fatigue, rest periods should be included in you
schedule
8. The best advise you can give to Aling Julia regarding prevention of
varicosities is [3]
A. Raise the legs while in upright position and put it against the wall
several times a day
B. Lay flat for most hours of the day
C. Use garters with nylon stocking

27

D. Wear support hose

9. In a 32 day menstrual cycle, ovulation usually occurs on the [2]
A. 14th day after menstruation
B. 18th day after menstruation
C. 20th day after menstruation
D. 24th day after menstruation

B. Frequency of urination
C. Braxton hicks contraction
D. Fetal outline by sonography
SITUATION : [FFC] Maternal and child health is the program of the
department of health created to lessen the death of infants and mother
in the philippines. [2]
16. What is the goal of this program?

10. Placenta is the organ that provides exchange of nutrients and

waste products between mother and fetus. This develops by [4]
A. First month
B. Third month
C. Fifth month
D. Seventh month

A. Promote mother and infant health especially during the gravida

stage
B. Training of local hilots
C. Direct supervision of midwives during home delivery
D. Health teaching to mother regarding proper newborn care
17. One philosophy of the maternal and child health nursing is [1]

11. In evaluating the weight gain of Aling Julia, you know the
minimum weight gain during pregnancy is [3]
A. 2 lbs/wk
B. 5 lbs/wk
C. 7 lbs/wk
D. 10 lbs/wk

A. All pregnancy experiences are the same for all woman

B. Culture and religious practices have little effect on pregnancy of a
woman
C. Pregnancy is a part of the life cycle but provides no meaning
D. The father is as important as the mother
18. In maternal care, the PHN responsibility is [2]

12. The more accurate method of measuring fundal height is [2]

A. Millimeter
B. Centimeter
C. Inches
D. Fingerbreadths

A. To secure all information that would be needing in birth certificate

B. To protect the baby against tetanus neonatorum by immunizing the
mother with DPT
C. To reach all pregnant woman
D. To assess nutritional status of existing children

13. To determine fetal position using Leopold's maneuvers, the first

maneuver is to [1]

19. This is use when rendering prenatal care in the rural health unit. It
serves as a guide in Identification of risk factors [1]

A. Determine degree of cephalic flexion and engagement

B. Determine part of fetus presenting into pelvis
C. Locate the back,arms and legs
D. Determine what part of fetus is in the fundus

A. Underfive clinic chart

B. Home based mother's record
C. Client list of mother under prenatal care
D. Target list of woman under TT vaccination

14. Aling julia has encouraged her husband to attend prenatal classes
with her. During the prenatal class, the couple expressed fear of pain
during labor and delivery. The use of touch and soothing voice often
promotes comfort to the laboring patient. This physical intervention
is effective because [2]

20. The schedule of prenatal visit in the RHU unit is [4]

A. Pain perception is interrupted

B. Gate control fibers are open
C. It distracts the client away from the pain
D. Empathy is communicated by a caring person
15. Which of the following could be considered as a positive sign of
pregnancy ? [1]

A. Once from 1st up to 8th month, weekly on the 9th month

B. Twice in 1st and second trimester, weekly on third trimester
C. Once in each trimester, more frequent for those at risk
D. Frequent as possible to determine the presence of FHT each week
SITUATION : Knowledge of the menstrual cycle is important in
maternal health nursing. The following questions pertains to the
process of menstruation
21. Menarche occurs during the pubertal period, Which of the
following occurs first in the development of female sex
characteristics? [2]

A. Amenorrhea, nausea, vomiting

28

A. Menarche
B. Accelerated Linear Growth
C. Breast development
D. Growth of pubic hair
22. Which gland is responsible for initiating the menstrual cycle? [3]
A. Ovaries
B. APG
C. PPG
D. Hypothalamus
23. The hormone that stimulates the ovaries to produce estrogen is [1]
A. GnRH
B. LH
C. LHRF
D. FSH
24. Which hormone stimulates oocyte maturation? [2]
A. GnRH
B. LH
C. LHRF
D. FSH
25. When is the serum estrogen level highest in the menstrual cycle?
[4]
A. 3rd day
B. 13th day
C. 14th day
D. End of menstrual cycle

D. 1/3 cup
29. Menstruation occurs because of which following mechanism? [2]
A. Increase level of estrogen and progesterone level
B. Degeneration of the corpus luteum
C. Increase vascularity of the endothelium
D. Surge of hormone progesterone
30. If the menstrual cycle of a woman is 35 day cycle, she will
approximately [2]
A. Ovulate on the 21st day with fertile days beginning on the 16th
day to the 26th day of her cycle
B. Ovulate on the 21st day with fertile days beginning on the 16th
day to the 21th day of her cycle
C. Ovulate on the 22st day with fertile days beginning on the 16th
day to the 26th day of her cycle
D. Ovulate on the 22st day with fertile days beginning on the 14th
day to the 30th day of her cycle
SITUATION : Wide knowledge about different diagnostic tests
during pregnancy is an essential arsenal for a nurse to be successful.
31. The Biparietal diameter of a fetus is considered matured if it is
atleast [4]
A. 9.8 cm
B. 8.5 cm
C. 7.5 cm
D. 6 cm
32. Quickening is experienced first by multigravida clients. At what
week of gestation do they start to experience quickening? [4]

26. To correctly determine the day of ovulation, the nurse must [2]
A. Deduct 14 days at the mid of the cycle
B. Subtract two weeks at cycle's end
C. Add 7 days from mid of the cycle
D. Add 14 days from the end of the cycle
27. The serum progesterone is lowest during what day of the
menstrual cycle? [4]
A. 3rd day
B. 13th day
C. 14th day
D. End of menstrual cycle
28. How much blood is loss on the average during menstrual period?
[4]
A. Half cup
B. 4 tablespoon
C. 3 ounces

A. 16th
B. 20th
C. 24th
D. 28th
33. Before the start of a non stress test, The FHR is 120 BPM. The
mother ate the snack and the practitioner noticed an increase from
120 BPM to 135 BPM for 15 seconds. How would you read the
result? [3]
A. Abnormal
B. Non reactive
C. Reactive
D. Inconclusive, needs repeat
34. When should the nurse expect to hear the FHR using a fetoscope?
[4]
A. 2nd week
B. 8th week

29

C. 2nd month
D. 4th month

health concept? [3]

35. When should the nurse expect to hear FHR using doppler
Ultrasound? [4]

A. To achieve healthy sexual development and maturation

B. To prevent specific RH problem through counseling
C. Provide care, treatment and rehabilitation
D. To practice RH as a way of life of every man and woman

A. 8th week
B. 8th month
C. 2nd week
D. 4th month

42. Which of the following is NOT an element of the reproductive

health? [4]

36. The mother asks, What does it means if her maternal serum alpha
feto protein is 35 ng/ml? The nurse should answer [4]

A. Maternal and child health and nutrition

B. Family planning
C. Prevention and management of abortion complication
D. Healthy sexual development and nutrition

A. It is normal
B. It is not normal
C. 35 ng/ml indicates chromosomal abberation
D. 35 ng/ml indicates neural tube defect

43. In the international framework of RH, which one of the following

is the ultimate goal? [3]

37. Which of the following mothers needs RHOGAM? [1]

A. RH + mother who delivered an RH - fetus
B. RH - mother who delivered an RH + fetus
C. RH + mother who delivered an RH + fetus
D. RH - mother who delivered an RH - fetus
38. Which family planning method is recommended by the
department of health more than any other means of contraception? [4]
A. Fertility Awareness Method
B. Condom
C. Tubal Ligation
D. Abstinence
39. How much booster dose does tetanus toxoid vaccination for
pregnant women has? [4]
A. 2
B. 5
C. 3
D. 4
40. Baranggay pinoybsn.tk has 70,000 population. How much nurse
is needed to service this population? [4]
A. 5
B. 7
C. 50
D. 70

A. Women's health in reproduction

B. Attainment of optimum health
C. Achievement of women's status
D. Quality of life
44. Which one of the following is a determinant of RH affecting
woman's ability to participate in social affairs? [3]
A. Gender issues
B. Socio-Economic condition
C. Cultural and psychosocial factors
D. Status of women
45. In the philippine RH Framework. which major factor affects RH
status? [4]
A. Women's lower level of literacy
B. Health service delivery mechanism
C. Poor living conditions lead to illness
D. Commercial sex workers are exposed to AIDS/STD.
46. Which determinant of reproductive health advocates nutrition for
better health promotion and maintain a healthful life? [4]
A. Socio-Economic conditions
B. Status of women
C. Social and gender issues
D. Biological, Cultural and Psychosocial factors
47. Which of the following is NOT a strategy of RH? [3]

SITUATION : [ND2I246] Reproductive health is the exercise of

reproductive right with responsibility. A married couple has the
responsibility to reproduce and procreate.

A. Increase and improve contraceptive methods

B. Achieve reproductive intentions
C. Care provision focused on people with RH problems
D. Prevent specific RH problem through information dessemination

41. Which of the following is ONE of the goals of the reproductive

48. Which of the following is NOT a goal of RH? [3]

30

D. 14 days after the beginning of the next period

A. Achieve healthy sexual development and maturation
B. Avoid illness/diseases, injuries, disabilities related to sexuality and
reproduction
C. Receive appropriate counseling and care of RH problems
D. Strengthen outreach activities and the referral system
49. What is the VISION of the RH? [2]
A. Attain QUALITY OF LIFE
B. Practice RH as a WAY OF LIFE
C. Prevent specific RH problem
D. Health in the hands of the filipino
SITUATION : [SORANGE19] Baby G, a 6 hours old newborn is
admitted to the NICU because of low APGAR Score. His mother had
a prolonged second stage of labor
50. Which of the following is the most important concept associated
with all high risk newborn? [1]
A. Support the high-risk newborn's cardiopulmonary adaptation by
maintaining adequate airway
B. Identify complications with early intervention in the high risk
newborn to reduce morbidity and mortality
C. Assess the high risk newborn for any physical complications that
will assist the parent with bonding
D. Support mother and significant others in their request toward
adaptation to the high risk newborn
51. Which of the following would the nurse expect to find in a
newborn with birth asphyxia? [1]
A. Hyperoxemia
B. Acidosis
C. Hypocapnia
D. Ketosis
52. When planning and implementing care for the newborn that has
been successfully resuscitated, which of the following would be
important to assess? [1]
A. Muscle flaccidity
B. Hypoglycemia
C. Decreased intracranial pressure
D. Spontaneous respiration

54. A factor in infertility maybe related to the PH of the vaginal

canal. A medication that is ordered to alter the vaginal PH is: [2]
A. Estrogen therapy
B. Sulfur insufflations
C. Lactic acid douches
D. Na HCO3 Douches
55. A diagnostic test used to evaluate fertility is the postcoital test. It
is best timed [2]
A. 1 week after ovulation
B. Immediately after menses
C. Just before the next menstrual period
D. Within 1 to 2 days of presumed ovulation
56. A tubal insufflation test is done to determine whether there is a
tubal obstruction. Infertility caused by a defect in the tube is most
often related to a [3]
A. Past infection
B. Fibroid Tumor
C. Congenital Anomaly
D. Previous injury to a tube
57. Which test is commonly used to determine the number, motility
and activity of sperm is the [2]
A. Rubin test
B. Huhner test
C. Friedman test
D. Papanicolau test
58. In the female, Evaluation of the pelvic organs of reproduction is
accomplished by [2]
A. Biopsy
B. Cystoscopy
C. Culdoscopy
D. Hysterosalpingogram
59. When is the fetal weight gain greatest? [3]

SITUATION : [P-I/46] Nurses should be aware of the different

reproductive problems.

A. 1st trimester
B. 2nd trimester
C. 3rd trimester
D. from 4th week up to 16th week of pregnancy

53. When is the best time to achieve pregnancy? [2]

60. In fetal blood vessel, where is the oxygen content highest? [3]

A. Midway between periods

B. Immediately after menses end
C. 14 days before the next period is expected

A. Umbilical artery
B. Ductus Venosus
C. Ductus areteriosus

31

D. Pulmonary artery
61. The nurse is caring for a woman in labor. The woman is irritable,
complains of nausea and vomits and has heavier show. The
membranes rupture. The nurse understands that this indicates [1]
A. The woman is in transition stage of labor
B. The woman is having a complication and the doctor should be
notified
C. Labor is slowing down and the woman may need oxytocin
D. The woman is emotionally distraught and needs assistance in
dealing with labor
SITUATION : [J2I246] Katherine, a 32 year old primigravida at 3940 weeks AOG was admitted to the labor room due to hypogastric
and lumbo-sacral pains. IE revealed a fully dilated, fully effaced
cervix. Station 0.
62. She is immediately transferred to the DR table. Which of the
following conditions signify that delivery is near? [2]
I - A desire to defecate
II - Begins to bear down with uterine contraction
III - Perineum bulges
IV - Uterine contraction occur 2-3 minutes intervals at 50 seconds
duration
A. I,II,III
B. I,II,III,IV
C. I,III,IV
D. II,III,IV
63. Artificial rupture of the membrane is done. Which of the
following nursing diagnoses is the priority? [2]
A. High risk for infection related to membrane rupture
B. Potential for injury related to prolapse cord
C. Alteration in comfort related to increasing strength of uterine
contraction
D. Anxiety related to unfamiliar procedure
64. Katherine complains of severe abdominal pain and back pain
during contraction. Which two of the following measures will be
MOST effective in reducing pain? [4]
I - Rubbing the back with a tennis ball
II- Effleurage
III-Imagery
IV-Breathing techniques
A. II,IV
B. II,III
C. I,IV
D. I,II

65. Lumbar epidural anesthesia is administered. Which of the

following nursing responsibilities should be done immediately
following procedure? [1]
A. Reposition from side to side
B. Administer oxygen
C. Increase IV fluid as indicated
D. Assess for maternal hypotension
66. Which is NOT the drug of choice for epidural anesthesia? [4]
A. Sensorcaine
B. Xylocaine
C. Ephedrine
D. Marcaine
SITUATION : [SORANGE217] Alpha, a 24 year old G4P3 at full
term gestation is brought to the ER after a gush of fluid passes
through here vagina while doing her holiday shopping.
67. She is brought to the triage unit. The FHT is noted to be 114 bpm.
Which of the following actions should the nurse do first? [2]
A. Monitor FHT ever 15 minutes
B. Administer oxygen inhalation
C. Ask the charge nurse to notify the Obstetrician
D. Place her on the left lateral position
68. The nurse checks the perineum of alpha. Which of the following
characteristic of the amniotic fluid would cause an alarm to the
nurse? [1]
A. Greenish
B. Scantly
C. Colorless
D. Blood tinged
69. Alpha asks the nurse. "Why do I have to be on complete bed rest?
I am not comfortable in this position." Which of the following
response of the nurse is most appropriate? [3]
A. Keeping you on bed rest will prevent possible cord prolapse
B. Completed bed rest will prevent more amniotic fluid to escape
C. You need to save your energy so you will be strong enough to
push later
D. Let us ask your obstetrician when she returns to check on you
70. Alpha wants to know how many fetal movements per hour is
normal, the correct response is [4]
A. Twice
B. Thrice
C. Four times
D. 10-12 times

32

71. Upon examination by the obstetrician, he charted that Alpha is in

the early stage of labor. Which of the following is true in this state?
[1]
A. Self-focused
B. Effacement is 100%
C. Last for 2 hours
D. Cervical dilation 1-3 cm
SITUATION : Maternal and child health nursing a core concept of
providing health in the community. Mastery of MCH Nursing is a
quality all nurse should possess.
72. When should be the 2nd visit of a pregnant mother to the RHU?
[2]
A. Before getting pregnant
B. As early in pregnancy
C. Second trimester
D. Third trimester
73. Which of the following is NOT a standard prenatal physical
examination? [1]
A. Neck examination for goiter
B. Examination of the palms of the hands for pallor
C. Edema examination of the face hands, and lower extremeties
D. Examination of the legs for varicosities
74. Which of the following is NOT a basic prenatal service delivery
done in the BHS? [2]

A. 300 mg / twice a month for 9 months

B. 200 mg / once a week for 5 months
C. 150 mg / twice a week for the duration of pregnancy
D. 100 mg / twice a week for the last trimester of pregnancy
78. Which of the following mothers are qualified for home delivery?
[2]
A. Pre term
B. 6th pregnancy
C. Has a history of hemorrhage last pregnancy
D. 2nd pregnancy, Has a history of 20 hours of labor last pregnancy.
79. Which of the following is not included on the 3 Cs of delivery?
[2]
A. Clean Surface
B. Clean Hands
C. Clean Equipments
D. Clean Cord
80. Which of the following is unnecessary equipment to be included
in the home delivery kit? [4]
A. Boiled razor blade
B. 70% Isopropyl Alcohol
C. Flashlight
D. Rectal and oral thermometer

A. Oral / Dental check up

B. Laboratory examination
C. Treatment of diseases
D. Iron supplementation

SITUATION : [NBLUE166] Pillar is admitted to the hospital with

the following signs : Contractions coming every 10 minutes, lasting
30 seconds and causing little discomfort. Intact membranes without
any bloody shows. Stable vital signs. FHR = 130bpm. Examination
reveals cervix is 3 cm dilated with vertex presenting at minus 1
station.

75. How many days and how much dosage will the IRON
supplementation be taken? [4]

81. On the basis of the data provided above, You can conclude the
pillar is in the [1]

A. 365 days / 300 mg

B. 210 days / 200 mg
C. 100 days/ 100mg
D. 50 days / 50 mg

A. In false labor
B. In the active phase of labor
C. In the latent phase of labor
D. In the transitional phase of labor

76. When should the iron supplementation starts and when should it
ends? [4]

82. Pitocin drip is started on Pilar. Possible side effects of pitocin

administration include all of the following except [3]

A. 5th month of pregnancy to 2nd month post partum

B. 1st month of pregnancy to 5th month post partum
C. As early in pregnancy up to 9th month of pregnancy
D. From 1st trimester up to 6 weeks post partum

A. Diuresis
B. Hypertension
C. Water intoxication
D. Cerebral hemorrhage

77. In malaria infested area, how is chloroquine given to pregnant

women? [4]

83. The normal range of FHR is approximately [3]

33

A. 90 to 140 bpm
B. 120 to 160 bpm
C. 100 to 140 bpm
D. 140 to 180 bpm
84. A negative 1 [-1] station means that [1]
A. Fetus is crowning
B. Fetus is floating
C. Fetus is engaged
D. Fetus is at the ischial spine
85. Which of the following is characteristics of false labor [1]

is to lay him [3]

A. Prone with head slightly elevated
B. On his back, flat
C. On his side with his head flat on bed
D. On his back with head slightly elevated
91. Baby boy perez has a large sebaceous glands on his nose, chin,
and forehead. These are known as [1]
A. Milia
B. Lanugo
C. Hemangiomas
D. Mongolian spots

A. Bloody show
B. Contraction that are regular and increase in frequency and duration
C. Contraction are felt in the back and radiates towards the abdomen
D. None of the above

92. Baby boy perez must be carefully observed for the first 24 hours
for [2]

86. Who's Theory of labor pain that states that PAIN in labor is cause
by FEAR [4]

A. Respiratory distress
B. Duration of cry
C. Frequency of voiding
D. Range in body temperature

A. Bradley
B. Simpson
C. Lamaze
D. Dick-Read

93. According to the WHO , when should the mother starts

breastfeeding the infant? [4]

87. Which sign would alert the nurse that Pillar is entering the second
stage of labor? [1]

A. Within 30 minutes after birth

B. Within 12 hours after birth
C. Within a day after birth
D. After infant's condition stabilizes

A. Increase frequency and intensity of contraction

B. Perineum bulges and anal orifice dilates
C. Effacement of internal OS is 100%
D. Vulva encircles the largest diameter of presenting part

94. What is the BEST and most accurate method of measuring the
medication dosage for infants and children? [3]

88. Nursing care during the second stage of labor should include [1]
A. Careful evaluation of prenatal history
B. Coach breathing, Bear down with each contraction and encourage
patient.
C. Shave the perineum
D. Administer enema to the patient
SITUATION : [NBLUE170] Baby boy perez was delivered
spontaneously following a term pregnancy. Apgar scores are 8 and 9
respectively. Routine procedures are carried out.

A. Weight
B. Height
C. Nomogram
D. Weight and Height
95. The first postpartum visit should be done by the mother within [4]
A. 24 hours
B. 3 days
C. a week
D. a month
96. The major cause of maternal mortality in the philippines is [3]

89. When is the APGAR Score taken? [1]

A. Immediately after birth and at 30 minutes after birth
B. At 5 minutes after birth and at 30 minutes after birth
C. At 1 minute after birth and at 5 minutes after birth
D. Immediately after birth and at 5 minutes after birth
90. The best way to position a newboarn during the first week of life

A. Infection
B. Hemorrhage
C. Hypertension
D. Other complications related to labor,delivery and puerperium
97. According to the WHO, what should be the composition of a
commercialized Oral rehydration salt solution? [4]

34

A. Potassium : 1.5 g. ; Sodium Bicarbonate 2.5g ; Sodium Chloride

3.5g; Glucose 20 g.
A. Potassium : 1.5 g. ; Sodium Bicarbonate 2.5g ; Sodium Chloride
3.5g; Glucose 10 g.
A. Potassium : 2.5 g. ; Sodium Bicarbonate 3.5g ; Sodium Chloride
4.5g; Glucose 20 g.
A. Potassium : 2.5 g. ; Sodium Bicarbonate 3.5g ; Sodium Chloride
4.5g; Glucose 10 g.
98. In preparing ORESOL at home, The correct composition
recommnded by the DOH is [4]
A. 1 glass of water, 1 pinch of salt and 2 tsp of sugar
B. 1 glass of water, 2 pinch of salt and 2 tsp of sugar
C. 1 glass of water, 3 pinch of salt and 4 tsp of sugar
D. 1 glass of water, 1 pinch of salt and 1 tsp of sugar
99. Milk code is a law that prohibits milk commercialization or
artificial feeding for up to 2 years. Which law provides its legal
basis? [4]
A. Senate bill 1044
B. RA 7600
C. Presidential Proclamation 147
D. EO 51
100. A 40 year old mother in her third trimester should avoid [4]
A. Traveling
B. Climbing
C. Smoking
D. Exercising
1.

Which of the following would be useful in calculating

Aling Julia's EDC? [3]
A. Appearance of linea negra
B. First FHT by fetoscope
C. Increase pulse rate
D. Presence of edema
* The answer of some people is A because they say linea
negra appears at 2nd trimester. Appearance of Linea negra
is not the same with all women. Some will have it as early
as first trimester while other on the 2nd trimester. It is very
subjective and non normative.
However, First FHT by fetoscope is UNIVERSAL and it is
arbitrarily accepted that it starts at the 4th month of
gestation. Therefore, If I heard the First FHT by fetoscope,
I can say that Aling Julia's EDC is at 4th month and the
EDC will be around 5 months from now.Pulse rate and
Edema will never suggest the estimated date of
confinement nor age of gestation.

2. Which hormone is necessary for a positive pregnancy

test? [1]
A. Progesterone
B. HCG
C. Estrogen
D. Placental Lactogen
* HCG is responsible for positive pregnancy test. But it is
NOT a positive sign of pregnancy. Only PROBABLE.
Purpose of HCG is to maintain the secretion of progestrone
by the corpus luteum. It will deteriorate by 2nd trimester as
the placenta resumes its funciton. HCG is also use to
stimulate descend of the testes in case of cryptorchidism or
undescended testes. HCG peaks at 10 weeks then decline
for the rest of the pregnancy. Non pregnant females will
have less than 5 mIU/ml and can reach up to 100,000
mIU/ml in pregnant women. By the way, undescended
testes repair is done when the child is 1 year old according
to Lippinncots, the doctor will try to wait baka kasi bumaba
pa before they do surgery.
3. With this pregnancy, Aling Julia is a [1]
A. P3 G3
B. Primigravida
C. P3 G4
D. P0 G3
* She has 3 children, so para 3. Since she is pregnant, this
is her 4th gravida. Remember that even if the pregancy is
beyond the age of viability [ >7 months ] consider it as
PARA and not GRAVIDA as long as the baby is still inside
the uterus. A common error of the old nurses in a
puericulture center where I dutied in is that they count the
child inside the mother's womb as GRAVIDA when it is
greater than 7 months! [ kawawang nanay, mali na ang
home based mothers record mo ] I tried to correct it but
they still INSISTED. I read pillitteri thinking that I might
be wrong nakakahiya naman... but I was right.
4. In explaining the development of her baby, you
identified in chronological order of growth of the fetus as it
occurs in pregnancy as [1]
A. Ovum, embryo, zygote, fetus, infant
B. Zygote, ovum, embryo, fetus, infant
C. Ovum, zygote, embryo, fetus, infant
D. Zygote, ovum, fetus, embryo, infant
* The Ovum is the egg cell from the mother, the sperm will
fertilize it to form a zygote. This usually happens in the
AMPULLA or the distal third of the fallopian tube.
Hyalorunidase is secreted by the sperm to dissolve the

35

outer memberane of the ovum. The zygote now containes

46 chromosomes. 23 from each germ cell. The zygote is
now termed as an embryo once it has been implanted.
Implantation takes 3-4 days. When the embryo reach 8th
weeks, it is now termed as a FETUS until it has been
delivered and then, neonate then infant.

Constipation and hemorrhoids are relieved by increasing

fluid intake and hot sitz bath.

5. Aling Julia states she is happy to be pregnant. Which

behavior is elicited by her during your assessment that
would lead you to think she is stressed? [3]

A. Exercise is very tiresome, it should be avoided

B. Limit your food intake
C. Smoking has no harmful effect on the growth and
development of fetus
D. Avoid unnecessary fatigue, rest periods should be
included in you schedule

A. She told you about her drunk husband

B. She states she has very meager income from selling
C. She laughs at every advise you give even when its not
funny
D. She has difficulty following instructions
* Stressed is manifested in different ways and one of them,
is difficulty following instructions. Telling you that her
husband is drunk and has meager income from selling is
not enough for you to conclude she is stressed. Assessment
is always based on factual and specific manifestations. A
diagnosis is made from either ACTUAL or
POTENTIAL/RISK problems. A and B are both potential
problems, but not actual like D. C is automatically
eliminated first because laughing is not indicative of stress.
6. When teaching Aling Julia about her pregnancy, you
should include personal common discomforts. Which of the
following is an indication for prompt professional
supervision? [2]
A. Constipation and hemorrhoids
B. Backache
C. Facial edema
D. frequent urination
*Facial edema is NOT NORMAL. Facial edema is one sign
of MILD PRE ECLAMPSIA and prompt professional
supervision is needed to lower down the client's blood
pressure. Blood pressure in Mild Pre Eclampsia is around
140/90 and 160/110 in severe. Treatment involves bed rest,
Magnesium sulfate, Hydralazine, Diazoxide and Diazepam
[ usually a combination of Magsul + Apresoline [
Hydralazine ] ] Calcium gluconate is always at the client's
bed side when magnesium toxicity occurs. It works by
exchanging Calcium ions for magnesium ions. A,B and D
are all physiologic change in pregnancy that do not need
prompt professional supervision. Frequent urination will
disappear as soon as the pressure of the uterus is released
against the bladder and as soon as the client's blood volume
has returned to normal. Backache is a common complaint
of women with an OCCIPUT POSTERIOR presentation
due to pressure on the back. Intervention includes pelvic
rocking or running a tennis ball at the client's back.

7. Which of the following statements would be appropriate

for you to include in Aling Julia's prenatal teaching plan?
[1]

* Exercise is not avoided in pregnancy, therfore eliminate

A. Food is never limited in pregnancy. Calories are even
increased by around 300 cal a day as well as vitamins and
minerals. Smoking, alcohol and drug use are avoided for
the rest of the pregnancy because of their harmful effects
on the growth and development of the fetus. Rest period
and avoiding unecessary fatigue is one of the pillars in
health teaching of the pregnant client.
8. The best advise you can give to Aling Julia regarding
prevention of varicosities is [3]
A. Raise the legs while in upright position and put it against
the wall several times a day
B. Lay flat for most hours of the day
C. Use garters with nylon stocking
D. Wear support hose
* A thigh high stocking or a support hose WORN BEFORE
GETTING UP in the morning is effective in prevention of
varicosities. Stocking should have NO GARTERS because
it impedes blood flow, they should be made of COTTON
not nylon to allow the skin to breathe. Lying flat most of
the day WILL PREVENT VARICOSITIES but will not be
helpful for the client's overall health and function. Raising
the legs and putting it against the wall will still create
pressure in the legs.

9. In a 32 day menstrual cycle, ovulation usually occurs on

the [2]
A. 14th day after menstruation
B. 18th day after menstruation
C. 20th day after menstruation
D. 24th day after menstruation
* To get the day of ovulation, A diary is made for around 6
months to determine the number of days of menstrual cycle
[ from onset of mens to the next onset of mens ] and the
average is taken from that cycles. 14 days are subtracted

36

from the total days of the menstrual cycle. This signifies

the ovulation day. A couple would abstain having sex 5
days before and 5 days after the ovulation day. Therefore, a
32 day cycle minus 14 days equals 18, hence... ovulation
occurs at the 18th day.
10. Placenta is the organ that provides exchange of
nutrients and waste products between mother and fetus.
This develops by [4]
A. First month
B. Third month
C. Fifth month
D. Seventh month
* The placenta is formed at around 3 months. It is a latin
word for PANCAKE because of it's appearance. It arises
from the trophoblast from the chorionic villi and decidua
basalis. It functions as the fetal lungs, kidney, GI tract and
an endocrine organ.
11. In evaluating the weight gain of Aling Julia, you know
the minimum weight gain during pregnancy is [3]
A. 2 lbs/wk
B. 5 lbs/wk
C. 7 lbs/wk
D. 10 lbs/wk

determines whether the fetal head or breech is in the

fundus. A head is round and hard. Breech is less well
defined.
14. Aling julia has encouraged her husband to attend
prenatal classes with her. During the prenatal class, the
couple expressed fear of pain during labor and delivery.
The use of touch and soothing voice often promotes
comfort to the laboring patient. This physical intervention
is effective because [2]
A. Pain perception is interrupted
B. Gate control fibers are open
C. It distracts the client away from the pain
D. Empathy is communicated by a caring person
* Touch and soothing voice promotes pain distraction.
Instead of thinking too much of the pain in labor, The
mother is diverted away from the pain sensation by the use
of touch and voice. Pain perception is not interrupted, pain
is still present. When gate control fibers are open, Pain is
felt according to the gate control theory of pain. Although
empathy is communicated by the caring person, this is not
the reason why touch and voice promotes comfort to a
laboring patient.
15. Which of the following could be considered as a
positive sign of pregnancy ? [1]

* Weight gain should be 1 to 2 lbs per week during the 2nd

and 3rd trimester and 3 to 5 lbs gain during the first
trimester for a total of 25-35 lbs recommended weight gain
during the gravida state.

A. Amenorrhea, nausea, vomiting

B. Frequency of urination
C. Braxton hicks contraction
D. Fetal outline by sonography

12. The more accurate method of measuring fundal height

is [2]

* Fetal outline by sonography or other imaging devices is

considered a positive sign of pregnancy along with the
presence of fetal heart rate and movement felt by a
qualified examiner. All those signs with the discoverer's
name on them [ chadwick, hegars, braxton hicks, goodells ]
are considered probable and All the physiologic changes
brought about by pregnancy like hyperpigmentation,
fatgiue, uterine enlargement, nausea, vomiting, breast
changes, frequent urination are considered presumptive.

A. Millimeter
B. Centimeter
C. Inches
D. Fingerbreadths
* Fundal height is measured in cm not mm. centimeters is
the more accurate method of measuring fundic height than
inches or fingerbreadths.
13. To determine fetal position using Leopold's maneuvers,
the first maneuver is to [1]
A. Determine degree of cephalic flexion and engagement
B. Determine part of fetus presenting into pelvis
C. Locate the back,arms and legs
D. Determine what part of fetus is in the fundus
* Leopold's one determines what is it in the fundus. This

Sonographic evidence of the gestational sac is not

POSITIVE sign but rather, PROBABLE.
SITUATION : [FFC] Maternal and child health is the
program of the department of health created to lessen the
death of infants and mother in the philippines. [2]
16. What is the goal of this program?
A. Promote mother and infant health especially during
the gravida stage

37

B. Training of local hilots

C. Direct supervision of midwives during home delivery
D. Health teaching to mother regarding proper newborn
care

they are different. GOAL : to promote and maintain

optimum health for women and their newborn HOW?
OBJECTIVE : By reaching all pregnant women to give
sufficient care ensuring healthy pregnancy and baby.

* The goal of the MCHN program of the DOH is the

PROMOTION AND MAINTENANCE OF OPTIMUM
HEALTH OF WOMAN AND THEIR NEWBORN. To
achieve this goal, B,C and D are all carried out. Even
without the knowledge of the MCHN goal you SHOULD
answer this question correctly. Remember that GOALS are
your plans or things you MUST ATTAIN while
STRATEGIES are those that must be done [ ACTIONS ] to
attain your goal.

19. This is use when rendering prenatal care in the rural

health unit. It serves as a guide in Identification of risk
factors [1]

Looking at B,C and D they are all ACTIONS. Only A

correctly followed the definition of a goal.
17. One philosophy of the maternal and child health
nursing is [1]
A. All pregnancy experiences are the same for all woman
B. Culture and religious practices have little effect on
pregnancy of a woman
C. Pregnancy is a part of the life cycle but provides no
meaning
D. The father is as important as the mother
* Knowing that not all individuals and pregnancy are the
same for all women, you can safely eliminate letter A.
Personal, culture and religious attitudes influence the
meaning of pregnancy and that makes pregnancy unique for
each individual. Culture and religious practice have a great
impact on pregnancy, eliminate B. Pregnancy is meaningful
to each individuals, not only the mother but also the father
and the family and the father of the child is as important as
the mother. MATERNAL AND CHILD HEALTH IS
FAMILY CENTERED and thid will guide you in
correctly answering D.

A. Underfive clinic chart

B. Home based mother's record
C. Client list of mother under prenatal care
D. Target list of woman under TT vaccination
* The HBMR is used in rendring prenatal care as guide in
identifying risk factors. It contains health promotion
message and information on the danger signs of pregnancy.
20. The schedule of prenatal visit in the RHU unit is [4]
A. Once from 1st up to 8th month, weekly on the 9th month
B. Twice in 1st and second trimester, weekly on third
trimester
C. Once in each trimester, more frequent for those at
risk
D. Frequent as possible to determine the presence of FHT
each week
* Visit to the RHU should be ONCE each trimester and
more frequent for those who are high risks. The visit to the
BHS or health center should be ONCE for 1st to 6th
months of pregnancy, TWICE for the 7th to 8th month and
weekly during the 9th month. They are different and are not
to be confused with.
SITUATION : Knowledge of the menstrual cycle is
important in maternal health nursing. The following
questions pertains to the process of menstruation

18. In maternal care, the PHN responsibility is [2]

21. Menarche occurs during the pubertal period, Which of

the following occurs first in the development of female sex
characteristics? [2]

A. To secure all information that would be needing in birth

certificate
B. To protect the baby against tetanus neonatorum by
immunizing the mother with DPT
C. To reach all pregnant woman
D. To assess nutritional status of existing children

A. Menarche
B. Accelerated Linear Growth
C. Breast development
D. Growth of pubic hair

* The sole objective of the MCHN of the DOH is to

REACH ALL PREGNANT WOMEN AND GIVE
SUFFICIENT CARE TO ENSURE A HEALTHY
PREGNANCY AND THE BIRTH OF A FULL TERM
HEALTH BABY. As not to confuse this with the GOAL
of the MCHN, The OBJECTIVE should answer the GOAL,

* Remember TAMO or THELARCHE, ADRENARCHE,

MENARCHE and OVULATION. Telarche is the
beginning of the breast development which is influenced by
the increase in estrogen level during puberty. Adrenarche is
the development of axillary and pubic hair due to androgen
stimulation. Menarche is the onset of first menstruation that
averagely occurs at around 12 to 13 years old. Ovulation

38

then occurs last. However, prior to TAMO, Accelerated

LINEAR GROWTH will occur first in GIRLS while
WEIGHT INCREASE is the first one to occur in boys.
22. Which gland is responsible for initiating the menstrual
cycle? [3]
A. Ovaries
B. APG
C. PPG
D. Hypothalamus
* Hypothalamus secretes many different hormones and one
of them is the FSHRF or the FOLLICLE STIMULATING
HORMONE RELEASING FACTOR. This will instruct the
ANTERIOR PITUITARY GLAND to secrete FSH that
will stimulate the ovary to release egg and initiate the
menstrual cycle.
The PPG or the posterior pituitary only secretes two
hormones : OXYTOCIN and ADH. It plays an important
factor in labor as well as in the pathophysiology of diabetes
insipidus.
23. The hormone that stimulates the ovaries to produce
estrogen is [1]
A. GnRH
B. LH
C. LHRF
D. FSH
* FSH stimulates the ovaries to secrete estrogen. This
hormone is a 3 substance compounds known as estrone
[e1], estradiol [2] and estriol [3] responsible for the
development of female secondary sex characteristics. It
also stimulates the OOCYTES to mature. During
pregnancy, Estrogen is secreted by the placenta that
stimulates uterine growth to accomodate the fetus.
24. Which hormone stimulates oocyte maturation? [2]
A. GnRH
B. LH
C. LHRF
D. FSH

D. End of menstrual cycle

* There are only 3 days to remember in terms of hormonal
heights during pregnancy. 3,13 and 14. During the 3rd day,
Serum estrogen is the lowest. During the 13th day, Serum
estrogen is at it's peak while progestrone is at it's lowest
and this signifies that a mature oocyte is ready for release.
At 14th day, Progesterone will surge and this is the reason
why there is a sudden increase of temperature during the
ovulation day and sudden drop during the previous day.
This will not stimulate the release of the mature egg or
what we call, OVULATION.

26. To correctly determine the day of ovulation, the nurse

must [2]
A. Deduct 14 days at the mid of the cycle
B. Subtract two weeks at cycle's end
C. Add 7 days from mid of the cycle
D. Add 14 days from the end of the cycle
* Refer to # 9
Big thanks to marisse for the correction in this number.
27. The serum progesterone is lowest during what day of
the menstrual cycle? [4]
A. 3rd day
B. 13th day
C. 14th day
D. End of menstrual cycle
* At 3rd day, The serum estrogen is at it's lowest. At the
13th day, serum estrogen is at it's peak while progesterone
is at it's lowest. At the 13th day of the cycle, An available
matured ovum is ready for fertilization and implantation.
The slight sharp drop of temperature occurs during this
time due to the very low progestrone level. The next day,
14th day, The serum progestrone sharply rises and this
causes the release of the matured ovum. Temperature also
rises at this point because of the sudden increase in the
progestrone level.
28. How much blood is loss on the average during
menstrual period? [4]

* Refer to #23
25. When is the serum estrogen level highest in the
menstrual cycle? [4]
A. 3rd day
B. 13th day
C. 14th day

A. Half cup
B. 4 tablespoon
C. 3 ounces
D. 1/3 cup
* The average blood loss during pregnancy is 60 cc. A, half
cup is equivalent to 120 cc. C, is equivalent to 90 cc while

39

D, is equivalent to 80 cc. 1 tablespoon is equal to 15 ml. 4

tablespoon is exactly 60 cc.
29. Menstruation occurs because of which following
mechanism? [2]
A. Increase level of estrogen and progesterone level
B. Degeneration of the corpus luteum
C. Increase vascularity of the endothelium
D. Surge of hormone progesterone
* Degeneration of the corpus luteum is the cause of
menstruation. Menstruation occurs because of the decrease
of both estrogen and progestrone. This is caused by the
regression of the corpus luteum inside the ovary 8 to 10
days in absence of fertilization after an ovum was released.
With the absence of progestrone, the endometrium
degenerates and therefore, vascularity will decrease at
approximately 25th day of the cycle which causes the
external manifestation of menstruation.
30. If the menstrual cycle of a woman is 35 day cycle, she
will approximately [2]
A. Ovulate on the 21st day with fertile days beginning
on the 16th day to the 26th day of her cycle
B. Ovulate on the 21st day with fertile days beginning on
the 16th day to the 21th day of her cycle
C. Ovulate on the 22st day with fertile days beginning on
the 16th day to the 26th day of her cycle
D. Ovulate on the 22st day with fertile days beginning on
the 14th day to the 30th day of her cycle
* Formula for getting the fertile days and ovulation day is :
Number of days of cycle MINUS 14 [ Ovulation day ]
Minus 5 Plus 5 [ Possible fertile days ].
Since the client has a 35 day cycle, we subtract 14 days to
get the ovulation day which is 21. Minus 5 days is equal to
[21 - 5 = 16 ] 16 , Plus 5 days [ 21 + 5 = 26 ] is equal to 26.
Therefore, Client is fertile during the 16th to the 26th day
of her cycle. This is the same principle and formula used in
the calendar / rhythm method.

* BPD is considered matured at 8.5 cm and at term when it

reaches 9.6 cm.
32. Quickening is experienced first by multigravida clients.
At what week of gestation do they start to experience
quickening? [4]
A. 16th
B. 20th
C. 24th
D. 28th
* Multigravid clients experience quickening at around 16
weeks or 4 months. Primigravid clients experience this 1
month later, at the 5th month or 20th week.
33. Before the start of a non stress test, The FHR is 120
BPM. The mother ate the snack and the practitioner noticed
an increase from 120 BPM to 135 BPM for 15 seconds.
How would you read the result? [3]
A. Abnormal
B. Non reactive
C. Reactive
D. Inconclusive, needs repeat
* Normal non stress test result is REACTIVE. Non stress
test is a diagnostic procedure in which the FHR is
compared with the child's movement. A normal result is an
increase of 15 BPM sustained for 15 seconds at every fetal
movement. The mother is told to eat a light snack during
the procedure while the examiner carefully monitors the
FHR. The mother will tell the examiner that she felt a
movement as soon as she feels it while the examiner take
note of the time and the FHR of the fetus.
34. When should the nurse expect to hear the FHR using a
fetoscope? [4]
A. 2nd week
B. 8th week
C. 2nd month
D. 4th month

SITUATION : Wide knowledge about different diagnostic

tests during pregnancy is an essential arsenal for a nurse to
be successful.

* The FHR is heard at about 4 months using a fetoscope.

Remember the word FeFOUR to relate fetoscope to four.

31. The Biparietal diameter of a fetus is considered matured

if it is atleast [4]

35. When should the nurse expect to hear FHR using

doppler Ultrasound? [4]

A. 9.8 cm
B. 8.5 cm
C. 7.5 cm
D. 6 cm

A. 8th week
B. 8th month
C. 2nd week
D. 4th month

40

* The FHR is heard as early as 8th week [ some books, 12

to 14 weeks ] using doppler ultrasound. Remember the
word DOPPLE RATE, [ DOPPLER 8 ] to relate dopple
ultrasound to the number 8.
36. The mother asks, What does it means if her maternal
serum alpha feto protein is 35 ng/ml? The nurse should
answer [4]
A. It is normal
B. It is not normal
C. 35 ng/ml indicates chromosomal abberation
D. 35 ng/ml indicates neural tube defect
* The normal maternal alpha feto protein is 38-45 ng/ml.
Less 38 than this indicates CHROMOSOMAL
ABBERATION [Down,Klinefelters] and more than 45
means NEURAL TUBE DEFECTS [Spina Bifida].
Remember the word CLINICAL NURSE. C for
chromosomal abberation for <38>N for neural tube defect
for >45. C<38>45 Clinic Nurse.
CLINIC NURSE is also an important mnemonics to
differentiate COUNTER TRANSFERENCE from
TRANSFERENCE. Counter transference is the special
feeling of the CLINIC NURSE or CLINICIAN to the
patient while transference is the development of personal
feelings of the patient to the nurse.

* Abstinence is never advocated as a family planning

method. Though, It is probably the BEST METHOD to
prevent STD and pregnancy, it is inhumane and supresses
the reproductive rights of the people. It is also unrealistic.
FAM is advocated by the DOH more than any other kind
of contraception. It is a combination of symptothermal and
billings method. CALENDAR method is the only method
advocated by the catholic church.
39. How much booster dose does tetanus toxoid
vaccination for pregnant women has? [4]
A. 2
B. 5
C. 3
D. 4
* TT1 and TT2 are both primary dosages. While TT3 up to
TT5 represents the booster dosages.
40. Baranggay pinoybsn.tk has 70,000 population. How
much nurse is needed to service this population? [4]
A. 5
B. 7
C. 50
D. 70

37. Which of the following mothers needs RHOGAM? [1]

* For every 10,000 population , 1 nurse is needed.

therefore, a population of 70,000 people needs a service of
7 nurses.

A. RH + mother who delivered an RH - fetus

B. RH - mother who delivered an RH + fetus
C. RH + mother who delivered an RH + fetus
D. RH - mother who delivered an RH - fetus

SITUATION : [ND2I246] Reproductive health is the

exercise of reproductive right with responsibility. A
married couple has the responsibility to reproduce and
procreate.

* Rhogam is given to RH - Mothers That delivers an RH

+ Fetus. Rhogam prevents ISOIMMUNIZATION or the
development of maternal antibodies against the fetal blood
due to RH incompatibility. Once the mother already
develops an antibody against the fetus, Rhogam will not
anymore be benificial and the mother is advised no to have
anymore pregnancies. Rhogam is given within 72 hours
after delivery.

41. Which of the following is ONE of the goals of the

reproductive health concept? [3]

38. Which family planning method is recommended by the

department of health more than any other means of
contraception? [4]
A. Fertility Awareness Method
B. Condom
C. Tubal Ligation
D. Abstinence

A. To achieve healthy sexual development and

maturation
B. To prevent specific RH problem through counseling
C. Provide care, treatment and rehabilitation
D. To practice RH as a way of life of every man and
woman
* EVERY ACHIEVER AVOIDS RECEIVER :
Remember this mnemonics and it will guide you in
differentiating which is which from the goals, visions and
strategies. If a sentence begins with these words, it is
automatically a GOAL. Usually, The trend in the board is
that they will mix up the vision, strategies and goals to
confuse you. D is the only vision of the RH program.
Anything else aside from the vision and goals are more

41

likely strategies. [ B and C ]

Strategies, even without knowing them or memorizing
them can easily be seperated as they convey ACTIONS and
ACTUAL INTERVENTIONS. This is universal and also
applies to other DOH programs. Notice that B and C
convey actions and interventions.
42. Which of the following is NOT an element of the
reproductive health? [4]
A. Maternal and child health and nutrition
B. Family planning
C. Prevention and management of abortion complication
D. Healthy sexual development and nutrition
* Achieving healthy sexual development and nutrition is a
GOAL of the RH. Knowledge of the elements, goals,
strategies and vision of RH are important in answering this
question. I removed the word ACHIEVE to let you know
that it is possible for the board of nursing not to include
those keywords [ although it never happened as of yet ].
43. In the international framework of RH, which one of the
following is the ultimate goal? [3]
A. Women's health in reproduction
B. Attainment of optimum health
C. Achievement of women's status
D. Quality of life
* Quality of life is the ultimate goal of the RH in the
international framework. Way of life is the ultimate goal of
RH in the local framework.
44. Which one of the following is a determinant of RH
affecting woman's ability to participate in social affairs? [3]
A. Gender issues
B. Socio-Economic condition
C. Cultural and psychosocial factors
D. Status of women

A. Women's lower level of literacy

B. Health service delivery mechanism
C. Poor living conditions lead to illness
D. Commercial sex workers are exposed to AIDS/STD.
* Health services delivery mechanism is the major factor
that affect RH status. Other factors are women's behavior,
Sanitation and water supply, Employment and working
conditions etc.
46. Which determinant of reproductive health advocates
nutrition for better health promotion and maintain a
healthful life? [4]
A. Socio-Economic conditions
B. Status of women
C. Social and gender issues
D. Biological, Cultural and Psychosocial factors
* Refer to # 44
47. Which of the following is NOT a strategy of RH? [3]
A. Increase and improve contraceptive methods
B. Achieve reproductive intentions
C. Care provision focused on people with RH problems
D. Prevent specific RH problem through information
dessemination
* Refer to #41
48. Which of the following is NOT a goal of RH? [3]
A. Achieve healthy sexual development and maturation
B. Avoid illness/diseases, injuries, disabilities related to
sexuality and reproduction
C. Receive appropriate counseling and care of RH
problems
D. Strengthen outreach activities and the referral
system
* Refer to #41

* This is an actual board question, Gender issues affects the

women participation in the social affairs. Socio economic
condition is the determinant for education, employment,
poverty, nutrition, living condition and family environment.
Status of women evolves in women's rights. Cultural and
psychosocial factors refers to the norms, behaviors,
orientation, values and culture. Refer to your DOH manual
to read more about this.

49. What is the VISION of the RH? [2]

45. In the philippine RH Framework. which major factor

affects RH status? [4]

SITUATION : [SORANGE19] Baby G, a 6 hours old

newborn is admitted to the NICU because of low APGAR
Score. His mother had a prolonged second stage of labor

A. Attain QUALITY OF LIFE

B. Practice RH as a WAY OF LIFE
C. Prevent specific RH problem
D. Health in the hands of the filipino
* Refer to #43

42

50. Which of the following is the most important concept

associated with all high risk newborn? [1]
A. Support the high-risk newborn's cardiopulmonary
adaptation by maintaining adequate airway
B. Identify complications with early intervention in the
high risk newborn to reduce morbidity and mortality
C. Assess the high risk newborn for any physical
complications that will assist the parent with bonding
D. Support mother and significant others in their request
toward adaptation to the high risk newborn
* The 3 major and initial and immediate needs of newborns
both normal and high risks are AIR/BREATHING,
CIRCULATION and TEMPERATURE. C and D are
both eliminated because they do not address the immediate
newborn needs. Identifying complication with early
intervention is important, however, this does not address
the IMMEDIATE and MOST IMPORTANT newborn
needs.
51. Which of the following would the nurse expect to find
in a newborn with birth asphyxia? [1]
A. Hyperoxemia
B. Acidosis
C. Hypocapnia
D. Ketosis
* Birth Asphyxia is a term used to describe the inability of
an infant to maintain an adequate respiration within 1
minute after birth that leads so acidosis, hypoxia,
hypoxemia and tissue anoxia. This results to Hypercapnia
not Hypocapnia due to the increase in carbonic acid
concentration in the fetal circulation because the carbon
dioxide fails to get eliminated from the infant's lungs
because of inadequate respiration. Ketosis is the presence
of ketones in the body because of excessive fat metabolism.
This is seen in diabetic ketoacidosis.
52. When planning and implementing care for the newborn
that has been successfully resuscitated, which of the
following would be important to assess? [1]
A. Muscle flaccidity
B. Hypoglycemia
C. Decreased intracranial pressure
D. Spontaneous respiration
* There is no need to assess for spontaneous respiration
because OF the word SUCCESSFULLY
RESUSCITATED. What is it to assess is the quality and
quantity of respiration. Infants who undergone tremendous
physical challenges during birth like asphyxia, prolonged

labor, RDS are all high risk for developing hypoglycemia

because of the severe depletion of glucose stores to sustain
the demands of the body during those demanding times.
SITUATION : [P-I/46] Nurses should be aware of the
different reproductive problems.
53. When is the best time to achieve pregnancy? [2]
A. Midway between periods
B. Immediately after menses end
C. 14 days before the next period is expected
D. 14 days after the beginning of the next period
* The best time to achieve pregnancy is during the
ovulation period which is about 14 days before the next
period is expected. A Menstrual cycle is defined as the
number of days from the start of the menstruation period,
up to the start of another menstrual period. To obtain the
ovulation day, Subtract 14 days from the end of each cycle.
Example, The start of the menstrual flow was July 12,
2006. The next flow was experienced August 11, 2006. The
length of the menstrual cycle is then 30 days [ August 11
minus July 12 ]. We then subtract 14 days from that total
length of the cycle and that will give us 16 days [ 30 minus
14 ] Count 16 days from July 12, 2006 and that will give us
July 28, 2006 as the day of ovulation. [ July 12 + 16 days ]
This is the best time for coitus if the intention is getting
pregnant, worst time if not.
54. A factor in infertility maybe related to the PH of the
vaginal canal. A medication that is ordered to alter the
vaginal PH is: [2]
A. Estrogen therapy
B. Sulfur insufflations
C. Lactic acid douches
D. Na HCO3 Douches
* Sperm is innately ALKALINE. Too much acidity is the
only PH alteration in the vagina that can kill sperm cells.
Knowing this will direct you to answering letter D. Sodium
Bicarbonate douches will make the vagina less acidic
because of it's alkaline property, making the vagina's
environment more conducive and tolerating to the sperm
cells. Estrogen therapy will not alter the PH of the vaginal
canal. HRT [ Hormone replacement therapy ] is now feared
by many women because of the high risk in acquiring
breast, uterine and cervical cancer. Research on this was
even halted because of the significant risk on the sample
population. Lactic acid douches will make the vagina more
acidic, further making the environment hostile to the
alkaline sperm. Sulfur insufflation is a procedure used to
treat vaginal infections. A tube is inserted in the vagina and

43

sulfur is introduced to the body. The yeasts, fungi and other

microorganisms that are sensitive to sulfur are all
immediately killed by it on contact.
55. A diagnostic test used to evaluate fertility is the
postcoital test. It is best timed [2]
A. 1 week after ovulation
B. Immediately after menses
C. Just before the next menstrual period
D. Within 1 to 2 days of presumed ovulation
* A poscoital test evaluates both ovulation detection and
sperm analysis. When the woman ovulates [ by using the
FAM method or commercial ovulation detection kits,
woman should know she ovulates ] The couple should have
coitus and then, the woman will go to the clinic within 2 to
8 hours after coitus. The woman is put on a lithotomy
position. A specimen for cervical mucus is taken and
examined for spinnbarkeit [ ability to stretch 15 cm before
breaking ] and sperm count. Postcoital test is now
considered obsolete because a single sperm and cervical
mucus analysis provides more accurate data.
56. A tubal insufflation test is done to determine whether
there is a tubal obstruction. Infertility caused by a defect in
the tube is most often related to a [3]
A. Past infection
B. Fibroid Tumor
C. Congenital Anomaly
D. Previous injury to a tube
* PID [ Most common cause of tubal obstruction ] due to
untreated gonorrhea, chlamydia or other infections that
leads to chronic salphingitis often leads to scarring of the
fallopian tube thereby causing tubal obstuction. This one of
the common cause of infertility, the most common is
Anovulation in female and low sperm count in males. A
ruptured appendix, peritonitis and abdominal surgery that
leads to infection and adhesion of the fallopian tube can
also lead to tubal obstruction.
57. Which test is commonly used to determine the number,
motility and activity of sperm is the [2]
A. Rubin test
B. Huhner test
C. Friedman test
D. Papanicolau test
* Huhner test is synonymous to postcoital test. This test
evaluates the number, motility and status of the sperm cells
in the cervical mucus. refer to # 55 for more information.
Rubin test is a test to determine the tubal patency by

introducing carbon dioxide gas via a cannula to the client's

cervix. The sound is then auscultated in the client's
abdomen at the point where the outer end of the fallopian
tube is located, near the fimbriae. Absent of sound means
that the tube is not patent. Friedman test involves a FROG
to determine pregnancy that is why it is also called as
FROG TEST. Papanicolaou test [Correct spelling],
discovered by Dr. George Papanicolaou during the 1930's
is a cytolgic examination of the epithelial lining of the
cervix. It is important in diagnosis cervical cancer.
58. In the female, Evaluation of the pelvic organs of
reproduction is accomplished by [2]
A. Biopsy
B. Cystoscopy
C. Culdoscopy
D. Hysterosalpingogram
* Biopsy is acquiring a sample tissue for cytological
examination. Usually done in cancer grading or detecting
atypical, abnormal and neoplastic cells. Cystoscopy is the
visualization of the bladder using a cystoscope. This is
inserted via the urethra. TURP or the transurethral resection
of the prostate is frequently done via cystoscopy to remove
the need for incision in resecting the enlarged prostate in
BPH. Culdoscopy is the insertion of the culdoscope
through the posterior vaginal wall between the rectum and
uterus to visualize the douglas cul de sac. This is an
important landmark because this is the lowest point in the
pelvis, fluid or blood tends to collect in this place.
Hysterosalpingogram is the injection of a blue dye, or any
radio opaque material through the cervix under pressure. X
ray is then taken to visualize the pelvic organs. This is done
only after menstruation to prevent reflux of the menstrual
discharge up into the fallopian tube and to prevent an
accidental irradiation of the zygote. As usual, as with all
other procedures that ends in GRAM, assess for iodine
allergy.
59. When is the fetal weight gain greatest? [3]
A. 1st trimester
B. 2nd trimester
C. 3rd trimester
D. from 4th week up to 16th week of pregnancy
* Vital organs are formed during the first trimester, The
greatest LENGTH gain occurs during the second trimester
while the greatest weight gain occurs during the last
trimester. This is the time when brown fats starts to be
deposited in preparation for the upcoming delivery.
60. In fetal blood vessel, where is the oxygen content
highest? [3]

44

of the following conditions signify that delivery is near? [2]

A. Umbilical artery
B. Ductus Venosus
C. Ductus areteriosus
D. Pulmonary artery
* Ductus venosus is directly connected to the umbilical
vein, Which is directly connected to the highly oxygenated
placenta. This vessel supplies blood to the fetal liver.
Umbilical arteries carries UNOXYGENATED BLOOD,
they carry the blood away from the fetal body. Ductus
arteriosus shunts the blood away from the fetal lungs, this
carries an oxygenated blood but not as concentrated as the
blood in the ductus venosus who have not yet service any
of the fetal organ for oxygen except the liver. Knowing that
the fetal lungs is not yet functional and expanded will guide
you to automatically eliminate the pulmonary artery which
is responsible for carrying UNOXYGENATED BLOOD
away from the lungs.
61. The nurse is caring for a woman in labor. The woman is
irritable, complains of nausea and vomits and has heavier
show. The membranes rupture. The nurse understands that
this indicates [1]
A. The woman is in transition stage of labor
B. The woman is having a complication and the doctor
should be notified
C. Labor is slowing down and the woman may need
oxytocin
D. The woman is emotionally distraught and needs
assistance in dealing with labor
* The clue to the answer is MEMBRANES RUPTURE.
Membranes, as a rule, rupture at full dilation [ 10 cm ]
unless ruptured by amniotomy or ruptured at an earlier
time. The last of the mucus plug from the cervix is also
released during the transition phase of labor. We call that
the OPERCULUM as signaled by a HEAVIER SHOW.
During the transition phase, Cervix is dilated at around 8 to
10 cm and contractions reaches their peak of intensity
occuring every 2 to 3 minutes with a 60 to 90 second
duration.
At the transition phase, woman also experiences nausea and
vomiting with intense pain. This question is LIFTED from
the previous board and the question was patterned
EXACTLY WORD PER WORD from pillitteri.
SITUATION : [J2I246] Katherine, a 32 year old
primigravida at 39-40 weeks AOG was admitted to the
labor room due to hypogastric and lumbo-sacral pains. IE
revealed a fully dilated, fully effaced cervix. Station 0.
62. She is immediately transferred to the DR table. Which

I - A desire to defecate
II - Begins to bear down with uterine contraction
III - Perineum bulges
IV - Uterine contraction occur 2-3 minutes intervals at 50
seconds duration
A. I,II,III
B. I,II,III,IV
C. I,III,IV
D. II,III,IV
* Again, lifted word per word from Pillitteri and this is
from the NLE. A is the right answer. A woman near labor
experiences desire to defecate because of the pressure of
the fetal head that forces the stool out from the anus. She
cannot help but bear down with each of the contractions
and as crowning occurs, The perineum bulges. A woman
with a 50 second contraction is still at the ACTIVE
PHASE labor [ 40 to 60 seconds duration, 3 to 5 minutes
interval ] Women who are about to give birth experience
60-90 seconds contraction occuring at 2-3 minutes interval.
63. Artificial rupture of the membrane is done. Which of
the following nursing diagnoses is the priority? [2]
A. High risk for infection related to membrane rupture
B. Potential for injury related to prolapse cord
C. Alteration in comfort related to increasing strength of
uterine contraction
D. Anxiety related to unfamiliar procedure
* Nursing diagnosis is frequently ask. In any case that
INFECTION was one of the choices, remove it as soon as
you see it in ALL CASES during the intra and pre
operative nursing care. Infection will only occur after 48
hours of operation or event. B is much more immediate and
more likely to occur than A, and is much more FATAL.
Prioritization and Appropriateness is the key in correctly
answering this question. High risk for infection is an
appropriate nursing diagnosis, but as I said, Infection will
occur in much later time and not as immediate as B.
Readily remove D and C because physiologic needs of the
mother and fetus take precedence over comfort measures
and psychosocial needs.
64. Katherine complains of severe abdominal pain and back
pain during contraction. Which two of the following
measures will be MOST effective in reducing pain? [4]
I - Rubbing the back with a tennis ball
II- Effleurage
III-Imagery
IV-Breathing techniques

45

A. II,IV
B. II,III
C. I,IV
D. I,II
* Remove B. Imagery is not used in severe pain. This is a
labor pain and the mother will never try to imagine a nice
and beautiful scenery with you at this point because the
pain is all encompassing and severe during the transition
phase of labor. Remove A and C Because breathing
techniques is not a method to ELIMINATE PAIN but a
method to reduce anxiety, improve pushing and prevent
rapid expulsion of the fetus during crowning [ By
PANTING ]
Back pain is so severe during labor in cases of Posterior
presentations [ ROP,LOP,RMP,LSaP, etc... ] Mother is
asked to pull her knees towards her chest and rock her
back. [ As in a rocking chair ] A Tennis ball rubbed at the
client's back can relieve the pain due to the pressure of the
presenting part on the posterior part of the birth canal. Also,
rubbing a tennis ball to the client's back OPENS THE
LARGE FIBER NERVE GATE. Effleurage or a simple
rotational massage on the abdomen simply relieves the
client's pain by opening the large fiber nerve gate and
closing the the small fiber nerve gate. [ Please read about
Gate control theory by Mezack and Wall ].
65. Lumbar epidural anesthesia is administered. Which of
the following nursing responsibilities should be done
immediately following procedure? [1]
A. Reposition from side to side
B. Administer oxygen
C. Increase IV fluid as indicated
D. Assess for maternal hypotension
* Hypotension is one of the side effects of an epidural
anesthesia. An epidural anesthesia is injected on the L3 L4 or L4 - L5 area. The injection lies just above the dura
and must not cross the dura [ spinal anesthesia crosses the
dura ]. Nursing intervention revolves in assesing RR, BP
and other vital signs for possible complication and side
effects. There is no need to position the client from side to
side, The preferred position during the transition phase of
labor is LITHOTOMY. Oxygen is not specific after
administration of an epidural anesthesia. IV fluid is not
increased without doctor's order. AS INDICATED is
different from AS ORDERED.
66. Which is NOT the drug of choice for epidural
anesthesia? [4]
A. Sensorcaine

B. Xylocaine
C. Ephedrine
D. Marcaine
* A,B and D are all drugs of choice for epidural anesthesia.
Ephedrine is the drug use to reverse the symptom of
hypotension caused by epidural anesthesia. It is a
sympathomimetic agent that causes vasoconstriction,
bronchodilation [ in asthma ] and can increase the amount
of energy and alertness. Ephedrine is somewhat similar to
epinephrine in terms of action as well as it's adverse effects
of urinary retention, tremor, hypersalivation, dyspnea,
tachycardia, hypertension.
SITUATION : [SORANGE217] Alpha, a 24 year old G4P3
at full term gestation is brought to the ER after a gush of
fluid passes through here vagina while doing her holiday
shopping.
67. She is brought to the triage unit. The FHT is noted to be
114 bpm. Which of the following actions should the nurse
do first? [2]
A. Monitor FHT ever 15 minutes
B. Administer oxygen inhalation
C. Ask the charge nurse to notify the Obstetrician
D. Place her on the left lateral position
* Remove A. A FHR of 114 bpm is 6 beats below normal.
Though monitoring is continuous and appropriate, This is
not your immediate action. B, Oxygen inhalation needs
doctor's order and therefore, is a DEPENDENT nursing
action and won't be your first option. Although
administration of oxygen by the nurse is allowed when
given at the lowest setting during emergency situation. C is
appropriate, but should not be your IMMEDIATE action.
The best action is to place the client on the LEFT
LATERAL POSITION to decrease the pressure in the
inferior vena cava [ by the gravid uterus ] thereby
increasing venus return and giving an adequate perfusion to
the fetus. Your next action is to call and notify the
obstetrician. Remember to look for an independent nursing
action first before trying to call the physician.
68. The nurse checks the perineum of alpha. Which of the
following characteristic of the amniotic fluid would cause
an alarm to the nurse? [1]
A. Greenish
B. Scantly
C. Colorless
D. Blood tinged
* A greenish amniotic fluid heralds fetal distress not unless
the fetus is in breech presentation and pressure is present on

46

the bowel. Other color that a nurse should thoroughly

evaluate are : Tea colored or strong yellow color that
indicates hemolytic anemia , as in RH incompatibility.
69. Alpha asks the nurse. "Why do I have to be on
complete bed rest? I am not comfortable in this position."
Which of the following response of the nurse is most
appropriate? [3]
A. Keeping you on bed rest will prevent possible cord
prolapse
B. Completed bed rest will prevent more amniotic fluid to
escape
C. You need to save your energy so you will be strong
enough to push later
D. Let us ask your obstetrician when she returns to check
on you
* Once the membrane ruptures, as in the situation of alpha,
The immediate and most appropriate nursing diagnosis is
risk for injury related to cord prolapse. Keeping the client
on bed rest is one of the best intervention in preventing
cord prolapse. Other interventions are putting the client in a
modified T position or Kneed chest position. Once the
amniotic fluid escapes, It is allowed to escape. Although
bed rest does saves energy, It is not the most appropriate
response why bed rest is prescribed after membranes have
ruptured. Not answering the client's question now will
promote distrust and increase client's anxiety. It will also
make the client think that the nurse is incompetent for not
knowing the answer.
70. Alpha wants to know how many fetal movements per
hour is normal, the correct response is [4]
A. Twice
B. Thrice
C. Four times
D. 10-12 times
* According to Sandovsky, To count for the fetal
movement, Mother is put on her LEFT SIDE to decrease
placental insufficiency. This is usually done after meals.
The mother is asked to record the number of fetal
movements per hour. A fetus moves Twice every 10
minutes and 10 to 12 times times an hour.
In SIA'S Book, She answered this question with letter B.
But according to Pillitteri, A movement fewer than 5 in an
hour is to be reported to the health care provider. The
Board examiners uses Pillitteri as their reference and
WORD PER WORD, Their question are answered
directly from the Pillitteri book. 10-12 times according to
Pillitteri, is the normal fetal movement per minute.

71. Upon examination by the obstetrician, he charted that

Alpha is in the early stage of labor. Which of the following
is true in this state? [1]
A. Self-focused
B. Effacement is 100%
C. Last for 2 hours
D. Cervical dilation 1-3 cm
* The earliest phase of labor is the first stage of labor :
latent phase characterized by a cervical dilation of 0-3 cm,
Mild contraction lasting for 20 to 40 seconds. This lasts
approximately 6 hours in primis and 4.5 hours in multis. C
is the characteristic of ACTIVE PHASE of labor,
Characterized by a cervical dilation of 4-7 cm and
contractions of 40 to 60 seconds. This phase lasts at around
3 hours in primis and 2 hours in multis. Effacement of
100% is a characteristic of the TRANSITION PHASE as
well as being self focused.

SITUATION : Maternal and child health nursing a core

concept of providing health in the community. Mastery of
MCH Nursing is a quality all nurse should possess.
72. When should be the 2nd visit of a pregnant mother to
the RHU? [2]
A. Before getting pregnant
B. As early in pregnancy
C. Second trimester
D. Third trimester
* Visit to the RHU are once every trimester and more
frequent for those women at risk. Visit to the health center
is once during the 0-6th month of pregnancy, twice during
the 7th-8th month and weekly at the last trimester.

73. Which of the following is NOT a standard prenatal

physical examination? [1]
A. Neck examination for goiter
B. Examination of the palms of the hands for pallor
C. Edema examination of the face hands, and lower
extremeties
D. Examination of the legs for varicosities
74. Which of the following is NOT a basic prenatal service
delivery done in the BHS? [2]
A. Oral / Dental check up
B. Laboratory examination
C. Treatment of diseases

47

D. Iron supplementation

more than 24 hours and for multigravidas, it is more than

12 hours. Knowing this will allow you to choose D.

* A is done at the RHU not in BHS.

75. How many days and how much dosage will the IRON
supplementation be taken? [4]
A. 365 days / 300 mg
B. 210 days / 200 mg
C. 100 days/ 100mg
D. 50 days / 50 mg
* Iron supplementation is taken for 210 days starting at the
5th month of pregnancy up to 2nd month post partum.
Dosage can range from 100 to 200 mg.
76. When should the iron supplementation starts and when
should it ends? [4]
A. 5th month of pregnancy to 2nd month post partum
B. 1st month of pregnancy to 5th month post partum
C. As early in pregnancy up to 9th month of pregnancy
D. From 1st trimester up to 6 weeks post partum
* Refer to #75
77. In malaria infested area, how is chloroquine given to
pregnant women? [4]
A. 300 mg / twice a month for 9 months
B. 200 mg / once a week for 5 months
C. 150 mg / twice a week for the duration of pregnancy
D. 100 mg / twice a week for the last trimester of
pregnancy
* Always remember that chloroquine is given twice a week
for the whole duration of pregnancy. This knowledge alone
will lead you to correctly identifying letter C.
78. Which of the following mothers are qualified for home
delivery? [2]
A. Pre term
B. 6th pregnancy
C. Has a history of hemorrhage last pregnancy
D. 2nd pregnancy, Has a history of 20 hours of labor
last pregnancy.
* Knowing that a preterm mother is not qualified for home
delivery will help you eliminate A. History of
complications like bleeding, CPD, Eclampsia and diseases
like TB, CVD, Anemia also nulls this qualification. A
qualified woman for home delivery should only had less
than 5 pregnancies. More than 5 disqualifies her from home
delivery. High risk length of labor for primigravidas ls

79. Which of the following is not included on the 3 Cs of

delivery? [2]
A. Clean Surface
B. Clean Hands
C. Clean Equipments
D. Clean Cord
* 3 Cs of delivery are CLEAN SURFACE,HANDS AND
CORD. " Kinamay ni Cordapya ang labada gamit ang
Surf - Budek "
80. Which of the following is unnecessary equipment to be
included in the home delivery kit? [4]
A. Boiled razor blade
B. 70% Isopropyl Alcohol
C. Flashlight
D. Rectal and oral thermometer
* Home delivery kit should contain the following : Clamps,
Scissors, Blade, Antiseptic, Soap and hand brush, Bp app,
Clean towel or cloth and Flashlight.
Optional equipments include : Plastic sheet, Suction bulb,
Weighing scale, Ophthalmic ointment, Nail cutter, Sterile
gloves, Rectal and oral thermometers.

SITUATION : [NBLUE166] Pillar is admitted to the

hospital with the following signs : Contractions coming
every 10 minutes, lasting 30 seconds and causing little
discomfort. Intact membranes without any bloody shows.
Stable vital signs. FHR = 130bpm. Examination reveals
cervix is 3 cm dilated with vertex presenting at minus 1
station.
81. On the basis of the data provided above, You can
conclude the pillar is in the [1]
A. In false labor
B. In the active phase of labor
C. In the latent phase of labor
D. In the transitional phase of labor
* Refer to #71
82. Pitocin drip is started on Pilar. Possible side effects of
pitocin administration include all of the following except
[3]
A. Diuresis

48

B. Hypertension
C. Water intoxication
D. Cerebral hemorrhage
* Oxytocin [ Pitocin ] is a synthetic form of hormone
naturally released by the PPG. It is used to augment labor
and delivery. Dosage is about 1 to 2 milli units per minute
and this can be doubled until the desired contraction is met.
Side effects are Water intoxication, Diuresis,
Hypertonicity of the uterus, Uterine rupture,
Precipitated labor, Walang kamatayang Nausea and
Vomiting and Fetal bradycardia. Diuresis occurs because
of water intoxication, The kidney will try to compensate to
balance the fluid in the body.
NEVER give pitocin when FHR is below 120. Even
without knowing anything about Pitocin, A cerebral
hemorrhage is LETHAL and DAMAGE IS
IRREVERSIBLE and if this is a side effect of a drug, I do
not think that FDA or BFAD will approve it.

* A,B and C are all charactertistics of a true labor. True

labor is heralded by LIGHTENING. This makes the uterus
lower and more anterior. This occrs 2 weeks prior to labor.
At the morning of labor, women experiences BURST OF
ENERGY because of adrenaline rush induced by the
decrease progestrone secretion of the deteriorating
placenta. The pain in labor is felt at the back and radiates
towards the abdomen and becomes regular, increasing
frequency and duration. As the cervix softens and dilates,
The OPERCULUM or the mucus plug is expelled.
False labor is characterized by Irregular uterine contraction
that is relieved by walking, Pain felt at the abdomen and
confined there and in the groin, The cervix do not achieve
dilation and Pain that is relieved by sleep and do not
increase in intensity and duration.

86. Who's Theory of labor pain that states that PAIN in

labor is cause by FEAR [4]

83. The normal range of FHR is approximately [3]

A. 90 to 140 bpm
B. 120 to 160 bpm
C. 100 to 140 bpm
D. 140 to 180 bpm
* A normal fetal heart rate is 120-160 bpm.
84. A negative 1 [-1] station means that [1]
A. Fetus is crowning
B. Fetus is floating
C. Fetus is engaged
D. Fetus is at the ischial spine
* At the negative station, The fetus is not yet engaged and
floating. At 0 station, it means that the fetus is engaged to
the ischial spine. Crowning occurs when the fetus is at the
+3,+4 Station. Stations signifies distance of the presensting
part below or above ischial spine. + denoted below while denotes above. The number after the sign denotes length in
cm. +1 station therefore means that the presenting part is 1
cm below the ischial spine.
85. Which of the following is characteristics of false labor
[1]
A. Bloody show
B. Contraction that are regular and increase in frequency
and duration
C. Contraction are felt in the back and radiates towards the
abdomen
D. None of the above

A. Bradley
B. Simpson
C. Lamaze
D. Dick-Read
* Believe it or not, this is an actual board question.
Grantley Dick-Read is just one person. Usually a two name
theory means two theorist. He published a book in 1933
"CHILDBIRTH WITHOUT FEAR". He believes that
PAIN in labor is caused by FEAR that causes muscle
tension, thereby halting the blood towards the uterus and
causing decreased oxygenation which causes the PAIN.
1950s French obstetrician, Dr. Ferdinand Lamaze perhaps
is the most popular theorist when it comes to labor. The
theory behind Lamaze is that birth is a normal, natural and
healthy event that should occur without unnecessary
medical intervention. Rather than resorting to pain
medication, different breathing techniques are used for each
stage of labor to control pain. Fathers are assigned the role
of labor coach, and are responsible for monitoring and
adjusting their partner's breathing pattern throughout
childbirth.
In 1965, obstetrician Robert A. Bradley, MD wrote
"Husband Coached Childbirth." The Bradley method
perhaps is the easiest to remember, BRAD ley necessitates
the presence of the FATHER during labor. Bradley
Method views birth as a natural process. This method also
emphasizes the importance of actively involving fathers in
the labor process. Fathers are taught ways to help ease their
partner's pain during childbirth through guided relaxation
and slow abdominal breathing.

49

James Young Simpson is an english doctor and the first to

apply anesthesia during labor and child birth. He uses
ETHER to alleviate labor pain. He then discovered the
effects of chloroform as an anesthetic agent. Because of his
works, He was recognized by Queen Victoria because the
queen herself uses Simpson's chloroform in alleviating
labor pain when she gave birth to prince leopold.
87. Which sign would alert the nurse that Pillar is entering
the second stage of labor? [1]
A. Increase frequency and intensity of contraction
B. Perineum bulges and anal orifice dilates
C. Effacement of internal OS is 100%
D. Vulva encircles the largest diameter of presenting part
* The second stage of labor begins as the cervical internal
os is 100% effaced and fully dilated. It ends after the fetus
has been delivered. Crowning, as in letter B and D is too
late of a sign to alert the nurse that Pillar is entering the
second stage of labor. A occurs during the first stage of
labor.
88. Nursing care during the second stage of labor should
include [1]
A. Careful evaluation of prenatal history
B. Coach breathing, Bear down with each contraction
and encourage patient.
C. Shave the perineum
D. Administer enema to the patient
* The second stage of labor begins with a full cervical
dilation and effacement and finishes when the baby is fully
delivered. Careful evaluation of prenatal history is done on
admission and check ups and is never done in the second
stage of labor. Shaving the perineum and enema are done
during the first stage of labor in preparation for delivery or
before labor begins when client is admitted. Enema is not a
routine procedure before delivery, but can be done to
prevent defecation during labor. B is appropriate during the
second stage of labor when the client's contraction is at it's
peak and dilation and effacement are at maximum to help
client accomplish the task of giving birth.
SITUATION : [NBLUE170] Baby boy perez was delivered
spontaneously following a term pregnancy. Apgar scores
are 8 and 9 respectively. Routine procedures are carried
out.

C. At 1 minute after birth and at 5 minutes after birth

D. Immediately after birth and at 5 minutes after birth
* APGAR score taken 1 minute after birth determines the
initial status of the newborn while the 5 minute assessment
after birth determines how well the newborn is adjusting to
the extrauterine life.
90. The best way to position a newborn during the first
week of life is to lay him [3]
A. Prone with head slightly elevated
B. On his back, flat
C. On his side with his head flat on bed
D. On his back with head slightly elevated
* Sudden infant death syndrome occurs when the fetus is in
prone position. Knowing this will allow you to eliminate A
first. During the first week of life, The fetus has an
immature cardiac sphincter and musculature for
swallowing, Knowing this will let you eliminate B and D.
Side lying position is the best position for a neonate during
the first few weeks of life. This will decrease the risk of
aspiration of secretion.
91. Baby boy perez has a large sebaceous glands on his
nose, chin, and forehead. These are known as [1]
A. Milia
B. Lanugo
C. Hemangiomas
D. Mongolian spots
* Newborn sebaceous glands are sometimes unopened or
plugged. They are called MILIA. They will disappear once
the gland opens at around 2 weeks after delivery. They are
characterized by a pinpoint white papule. Lanugo is the fine
hair that covers the newborn. It disappears starting 2 weeks
after birth. A premature infant has more lanugo than a post
mature infant. Hemangiomas are vascular tumors of the
skin. Mongolian spots are patches that are gray in color and
are often found in sacrum or buttocks. They disappear as
the child grows older.
92. Baby boy perez must be carefully observed for the first
24 hours for [2]
A. Respiratory distress
B. Duration of cry
C. Frequency of voiding
D. Range in body temperature

89. When is the APGAR Score taken? [1]

A. Immediately after birth and at 30 minutes after birth
B. At 5 minutes after birth and at 30 minutes after birth

* Range in body temperature needs to be observed and

carefully monitored for the first 24 hours after delivery. A
newborn has an inadequate and immature temperature

50

regulating mechanism. RDS is observed immediately after

delivery, not in a continuous 24 hour observation. Once the
fetus establish a normal breathing pattern it is not anymore
of a concern. RDS occurs when the Surfactants are absent
or insufficient. The adequacy of these surfactants is
measured by the L:S ratio [ Lecithin : Spingomyelin ] An
L:S ratio of 2:1 is considered, mature and adequate to
sustain fetal lung expansion and ventilation. Therefore, A
child born without RDS is unlikely to have RDS in 24
hours.
Another thing that is carefully observed during the first 24
hours is the meconium. Absent of meconium during the
first 24 hours after birth warrants further investigation by
the attending physician.
93. According to the WHO , when should the mother starts
breastfeeding the infant? [4]
A. Within 30 minutes after birth
B. Within 12 hours after birth
C. Within a day after birth
D. After infant's condition stabilizes
* According to the world health organization, The mother
should start breastfeeding her infant within 30 minutes after
birth.
94. What is the BEST and most accurate method of
measuring the medication dosage for infants and children?
[3]
A. Weight
B. Height
C. Nomogram
D. Weight and Height
* A nomogram is the most accurate method for measuring
medication dosage for infants and children. It estimates the
body surface area by drawing a line in the first column [
child's height ] towards the third column [ child's weight ].
The point in which it crosses the middle column [ BSA ] is
the child's surface area.

visit will be at 1 week after delivery and the third visit is

done 2 to 4 weeks after delivery.
96. The major cause of maternal mortality in the
philippines is [3]
A. Infection
B. Hemorrhage
C. Hypertension
D. Other complications related to labor,delivery and
puerperium
* Refer to the latest survey of FHSIS in the DOH website.
97. According to the WHO, what should be the
composition of a commercialized Oral rehydration salt
solution? [4]
A. Potassium : 1.5 g. ; Sodium Bicarbonate 2.5g ;
Sodium Chloride 3.5g; Glucose 20 g.
A. Potassium : 1.5 g. ; Sodium Bicarbonate 2.5g ; Sodium
Chloride 3.5g; Glucose 10 g.
A. Potassium : 2.5 g. ; Sodium Bicarbonate 3.5g ; Sodium
Chloride 4.5g; Glucose 20 g.
A. Potassium : 2.5 g. ; Sodium Bicarbonate 3.5g ; Sodium
Chloride 4.5g; Glucose 10 g.
* This is the WHO ORESOL formula for the
commercialized ORS. Remember PA BCG Which stands
for POTASSIUM [ Pa ] SODIUM BICARBONATE [ B
] SODIUM CHLORIDE [ C ] GLUCOSE [ G ]. The
numbers are easy to remember because they are just
increased by 1.0 g increment starting from 1.5. Glucose
however is at 20 g. So the MNEMONIC is PA BCG 1.5 2.5
3.5 20. This is the mnemonic I use and it is easy to
remember that way. It is original by the way.
98. In preparing ORESOL at home, The correct
composition recommnded by the DOH is [4]
A. 1 glass of water, 1 pinch of salt and 2 tsp of sugar
B. 1 glass of water, 2 pinch of salt and 2 tsp of sugar
C. 1 glass of water, 3 pinch of salt and 4 tsp of sugar
D. 1 glass of water, 1 pinch of salt and 1 tsp of sugar

95. The first postpartum visit should be done by the mother

within [4]
A. 24 hours
B. 3 days
C. a week
D. a month
* Mother should visit the health facility 4 weeks to 6 weeks
after delivery. The first post partum visit by the birth
attendant is done within 24 hours after delivery, the next

99. Milk code is a law that prohibits milk

commercialization or artificial feeding for up to 2 years.
Which law provides its legal basis? [4]
A. Senate bill 1044
B. RA 7600
C. Presidential Proclamation 147
D. EO 51

51

* Executive order # 51 prohibits milk commercialization or

artificial feeding up to 2 years. That is why the milk
commercials in the country has " BREAST MILK IS
STILL BEST FOR BABIES UP TO 2 YEARS " After
their presentation in accordance with EO 51. RA 7600 is
the ROOMING IN / BREAST FEEDING ACT which
requires the heatlh professionals to bring the baby to the
mother for breastfeeding as early as possible. Senate bill #
1044 was created to implement RA 7600. Presidential
Proclamation # 147 made WEDNESDAY as the national
immunization day.

100. A 40 year old mother in her third trimester should

avoid [4]
A. Traveling
B. Climbing
C. Smoking
D. Exercising
* Mother's are not prohibited to travel, climb or exercise. If
long travels are expected, Mother should have a 30 minute
rest period for every 2 hours of travel [ LIPPINCOTT ].
Climbing is a very vague term used by the board examiners
though I assume they are referring to climbing a flight of
stairs. Anyhow, SMOKING is detrimental for both mother
and child no question about it and so is ALCOHOL. In
thousands of questions I answered, it never fails that
HANDWASHING, AVOID SMOKING, AVOID
ALCOHOL are always the answer. It still depends on the
question so THINK.

52

1. While performing physical assessment of a 12

month-old, the nurse notes that the infants
anterior fontanelle 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 neurologic
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.

7.

8.

9.

10.

11.

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
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
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
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
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
Which of the following suggestions should the
nurse offer the parents of a 4-year-old 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.

53

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 which of
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?

54

22.

23.

24.

25.

a. The child is exhibiting normal preschool 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.
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.
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.
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 which
of 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.
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 ironrich 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.
55

31.

32.

33.

34.

35.

d. Don nothing because this is a normal

finding in a toddler.
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
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
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.
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
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

56

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.
b.
c.
d.

49.

50.

51.

52.

53.

Notify the physician immediately

Administer antidiarrheal medications
Monitor child ever 30 minutes
Nothing, this is characteristic of
Hirschsprung disease
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
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
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.
57

54.

55.

56.

57.

58.

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

59.

60.

61.

62.

would be an appropriate toy choice. Multiplepiece 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
58

wooden puzzles are appropriate for

encouraging fine motor development. Big
wheels and tricycles encourage gross motor
development.
63. 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.
64. 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
of development. 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.
65. 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 and children 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-age children begin to
internalize their own controls and need less

66.

67.

68.

69.

70.

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-age
children 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
59

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.
71. 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.
72. 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.
73. 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

74.

75.

76.

77.

78.

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
60

79.

80.

81.

82.

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

83.

84.

85.

86.

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 life-threatening
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
61

87.

88.

89.

90.

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-to-hand
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

91.

92.

93.

94.

95.

96.

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. Sidelying 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
62

its gluten content, wheat and wheat-containing

products must be avoided. Rice, milk, and
chicken do not contain gluten and need not be
avoided.
97. 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.
98. 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.
99. 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.
100.
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.
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.
63

d) Evident only towards the

transverse arch.

a) Midway between feedings.

b) Immediately after a feeding.

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) 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

c) Constriction of the pupils.

a) Cephallic hematoma.

d) The presence of red circles on

the pupils.

b) Caput succedaneum.
c) Hemorrhage edema.

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.

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

6. The nurse should plan to assess the

neonates physical condition.
64

mother needs further instructions from

which statement?

a) Taking solid foods well.

b) Sleeping through the night.

a) The molding is caused by an

overriding of the cranial
bones.

c) Shortening the nursing time.

d) Eating on a regular schedule.

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.
14. 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

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.

b) Smell
c) Touch

d) Giving the infant a few

minutes of breast and then
offering solid food.

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

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.

65

d) Turning from either side to

the back.

b) Rolling from back to side.

c) Holding a rattle briefly.

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.

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?

b) Emotional development.
a) Oral.
c) Social and physical activities.
b) Intramascular
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.

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?

b) Eat with a spoon.

a) Lethargy.
c) Stand while holding unto a
furniture
d) Sit alone using the hands for
support.

b) Mild fever.
c) Diarrhea
d) Nasal Congestion

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.

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
66

a) Two months.

b) Mix new foods with more

familiar foods.

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

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

a) 2 to 4 months.
b) Pulling toys
b) 5 to 8 months.
c) 9 to 12 months.
d) 13 to 18 months. prop
21. A mother states that she thinks her 9month old is developing slowly. When
evaluating the infants development,
the nurse would not expect a normal 9month old to be able to

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
check-up. The nurse would expect that
the child would be at least skilled in

a) Creep and crawl.

a) Riding a bicycle

b) Begin to use imitative verbal

expressions.

b) Tying shoelaces
c) Stringing large beads

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

d) Using blunt scissors

25. The mother tells the nurse that she is
having problem toilet-training her 2year 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

a) Mix new foods with formula

67

b) Training equipment is
inappropriate

a) Structured interaction
b) Spanking

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) 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) 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

c) Let the child play toy just

before bedtime
d) Give the child a cookie if
bedtime is pleasant.

68

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?

In developing such a plan, the nurse

and mother should consider
a) Deciding on a good reward
for finishing a meal

a) Since you help brush her

teeth, theres no need to see
a dentist now

b) Allowing him to make some

decisions about the foods he
eats

b) You should have begun

dental appointments last year
but it is not too late

c) Requiring him to eat the

foods served at meal times.

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

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

b) 5 years
c) 6 years

d) Show him pictures of children

who have involve with
accidents

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.

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

69

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

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 betweenmeals 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.

c) Inappropriate peer influence

a) Concrete operations
d) Excessive television watching
b) Formal operations
38. The mother relates that the child is
beginning to identify behaviors that
pleases others as good behavior. The

c) Coordination of

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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

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?

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) Increased food intake owing

to age
b) Underdeveloped abdominal
muscles
c) Bowlegged posture
d) Linear growth curve

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

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
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b) The dark

50. Which of the following toys should the

nurse recommend for a 5-month old?

c) Ghosts
a) A big red balloon
d) Going to sleep
b) A teddy bear with button
eyes

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?

c) A push-pull wooden truck

d) A colorful busy box
Answer Key:

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

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
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

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

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