TEST II - Community Health Nursing and Care of the Mother and Child

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 c. Threatened
b. Incomplete d. Septic

2. Nurse Reese is reviewing the record of a pregnant client for her first prenatal visit. Which of the following data,
if noted on the client’s record, would alert the nurse that the client is at risk for a spontaneous abortion?
a. Age 36 years c. History of genital herpes
b. History of syphilis 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 c. Monitoring apical pulse
b. Assessing for edema 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 c. Decreased Insulin
b. Increased caloric intake d. Increase Insulin

5. Nurse Michelle is assessing a 24 year old client with a diagnosis of hydatidi form mole. She is aware that one of
the following is unassociated with this condition?
a. Excessive fetal activity c. Vaginal bleeding
b. Larger than normal uterus for gestational d. Elevated levels of human chorionic
age 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. c. Rapid respiratory rate above 40/min.
b. Absent patellar reflexes. d. Rapid rise in blood pressure

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

8. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that warrant the nurse in-
charge to discontinue I.V. infusion of Pitocin is:
a. Contractions every 1 ½ minutes lasting 70-80 seconds.
b. Maternal temperature 101.2
c. Early decelerations in the fetal heart rate.
d. Fetal heart rate baseline 140-160 bpm.
 9. Calcium gluconate is being administered to a client with pregnancy induced hypertension (PIH). A nursing action
that must be initiated as the plan of care throughout injection of the drug is:
a. Ventilator assistance c. EKG tracings
b. CVP readings 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 acrying toddler’s temperature is:
a. Talk to the mother first and then to the toddler.
b. Bring extra help so it can be done quickly.
c. Encourage the mother to hold the child.
d. Ignore the crying and screaming.

12. Baby Tina a 3 month old infant just had a cleft lip and palate repair. What should the nurse do to prevent trauma
to operative site?
a. Avoid touching the suture line, even when cleaning.
b. Place the baby in prone position.
c. Give the baby a pacifier.
d. Place the infant’s arms in soft elbow restraints
.
13. Which action should nurse Marian include in the care plan for a 2 month old with heart failure?
a. Feed the infant when he cries.
b. Allow the infant to rest before feeding.
c. Bathe the infant and administer medications before feeding.
d. Weigh and bathe the infant before feeding.

14. Nurse Hazel is teaching a mother who plans to discontinue breast feeding after 5 months. The nurse should
advise her to include which foods in her infant’s diet?
a. Skim milk and baby food. c. Iron-rich formula only.
b. Whole milk and baby food. d. Iron-rich formula and baby food.

15. Mommy Linda is playing with her infant, who is sitting securely alone on the floor of the clinic. The mother hides
a toy behind her back and the infant looks for it. The nurse is aware that estimated age of the infant would be:
a. 6 months c. 8 months
b. 4 months d. 10 months

16. Which of the following is the most prominent feature of public health nursing?
a. It involves providing home care to sick people who are not confined in the hospital.
b. Services are provided free of charge to people within the catchments area.
c. The public health nurse functions as part of a team providing a public health nursing services.
d. Public health nursing focuses on preventive, not curative, services.

17. When the nurse determines whether resources were maximized in implementing Ligtas Tigdas, she is
evaluating?
a. Effectiveness c. Adequacy
b. Efficiency d. Appropriateness
18. Vangie is a new B.S.N. graduate. She wants to become a Public Health Nurse. Where should she apply?
a. Department of Health c. Regional Health Office
b. Provincial Health Office d. Rural Health Unit

19. Tony is aware the Chairman of the Municipal Health Board is:
a. Mayor c. Public Health Nurse
b. Municipal Health Officer 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 c. 3
b. 2 d. The RHU does not need any more midwife item.

21. According to Freeman and Heinrich, community health nursing is a developmental service. Which of the
following best illustrates this statement?
a. The community health nurse continuously develops himself personally and professionally.
b. Health education and community organizing are necessary in providing community health services.
c. Community health nursing is intended primarily for health promotion and prevention and treatment of
disease.
d. The goal of community health nursing is to provide nursing services to people in their own places of
residence.

22. Nurse Tina is aware that the disease declared through Presidential Proclamation No. 4 as a target for eradication
in the Philippines is?
a. Poliomyelitis c. Rabies
b. Measles d. Neonatal tetanus

23. May knows that the step in community organizing that involves training of potential leaders in the community
is:
a. Integration c. Community study
b. Community organization d. Core group formation

24. Beth a public health nurse takes an active role in community participation. What is the primary goal of
community organizing?
a. To educate the people regarding community health problems
b. To mobilize the people to resolve community health problems
c. To maximize the community’s resources in dealing with health problems.
d. To maximize the community’s resources in dealing with health problems.

25. Tertiary prevention is needed in which stage of the natural history of disease?
a. Pre-pathogenesis c. Prodromal
b. Pathogenesis d. Terminal

26. The nurse is caring for a primi gravid client in the labor and delivery area. Which condition would place the client
at risk for disseminated intravascular coagulation (DIC)?
a. Intrauterine fetal death. c. Dysfunctional labor.
b. Placenta accreta. d. Premature rupture of the membranes.

27. A full term client is in labor. Nurse Betty is aware that the fetal heart rate would be:
a. 80 to 100 beats/minute c. 120 to 160 beats/minute
b. 100 to 120 beats/minute d. 160 to 180 beats/minute
28. The skin in the diaper area of a 7 month old infant is excoriated and red. Nurse Hazel should instruct the mother
to:
a. Change the diaper more often.
b. Apply talc powder with diaper changes.
c. Wash the area vigorously with each diaper change.
d. Decrease the infant’s fluid intake to decrease saturating diapers.

29. Nurse Carla knows that the common cardiac anomalies in children with Down Syndrome (tri-somy 21) is:
a. Atrial septal defect c. Ventricular septal defect
b. Pulmonic stenosis d. Endo cardial cushion defect

30. Malou was diagnosed with severe preeclampsia is now receiving I.V. magnesium sulfate. The adverse effects
associated with magnesium sulfate is:
a. Anemia c. Hyper reflexia
b. Decreased urine output d. Increased respiratory rate

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

32. Jannah is admitted to the labor and delivery unit. The critical laboratory result for this client would be:
a. Oxygen saturation c. Blood typing
b. Iron binding capacity d. Serum Calcium

33. Nurse Gina is aware that the most common condition found during the second-trimester of pregnancy is:
a. Metabolic alkalosis c. Mastitis
b. Respiratory acidosis d. Physiologic anemia

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

35. Maureen in her third trimester arrives at the emergency room with painless vaginal bleeding. Which of the
following conditions is suspected?
a. Placenta previa c. Premature labor
b. Abruptio placentae 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 bed time c. Any time during the day
b. After the child has been bathe d. Early in the morning

37. In doing a child’s admission assessment, Nurse Betty should be alert to note which signs or symptoms of chronic
lead poisoning?
a. Irritability and seizures c. Bradycardia and hypotension
b. Dehydration and diarrhea d. Petechiae and hematuria

38. To evaluate a woman’s understanding about the use of diaphragm for family planning, Nurse Trish asks her to
explain how she will use the appliance. Which response indicates a need for further health teaching?
 a. “I should check the diaphragm carefully for holes every time I use it”
b. “I may need a different size of diaphragm if I gain or lose weight more than 20 pounds”
c. “The diaphragm must be left in place for at least 6 hours after intercourse”
d. “I really need to use the diaphragm and jelly most during the middleof my menstrual cycle”.

39. Hypoxia is a common complication of laryngotracheobronchitis. Nurse Oliver should frequently assess a child
with laryngotracheobronchitis for:
a. Drooling c. Restlessness
b. Muffled voice d. Low-grade fever

40. How should Nurse Michelle guide a child who is blind to walk to the playroom?
a. Without touching the child, talk continuously as the child walks down the hall.
b. Walk one step ahead, with the child’s hand on the nurse’s elbow.
c. Walk slightly behind, gently guiding the child forward.
d. Walk next to the child, holding the child’s hand.

41. When assessing a newborn diagnosed with ductus arteriosus, Nurse Olivia should expect that the child most
likely would have an:
a. Loud, machinery-like murmur. c. Decreased BP reading in the upper extremities
b. Bluish color to the lips. d. Increased BP reading in the upper extremities
.
42. The reason nurse May keeps the neonate in a neutral thermal environment is that when a newborn becomes
too cool, the neonate requires:
a. Less oxygen, and the newborn’s metabolic rate increases.
b. More oxygen, and the newborn’s metabolic rate decreases.
c. More oxygen, and the newborn’s metabolic rate increases.
d. Less oxygen, and the newborn’s metabolic rate decreases.

43. Before adding potassium to an infant’s I.V. line, Nurse Ron must be sure to assess whether this infant has:
a. Stable blood pressure c. Moro’s reflex
b. Patant fontanelles d. Voided

44. Nurse Carla should know that the most common causative factor of dermatitis in infants and younger children is:
a. Baby oil c. Laundry detergent
b. Baby lotion d. Powder with cornstarch

45. During tube feeding, how far above an infant’s stomach should the nurse hold the syringe with formula?
a. 6 inches c. 18 inches
b. 12 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 poxis 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. Advise them on the signs of German measles.
b. Avoid crowded places, such as markets and movie houses.
c. Consult at the health center where rubella vaccine may be given.
d. Consult a physician who may give them rubella immunoglobulin.
48. Myrna a public health nurse knows that to determine possible sources of sexually transmitted infections, the
BEST method that may be undertaken is:
a. Contact tracing c. Mass screening tests
b. Community survey 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 c. Tetanus
b. Hepatitis B d. Leptospirosi

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 c. Amebiasis
b. Cholera d. Dysentery

51. The most prevalent form of meningitis among children aged 2 months to 3years is caused by which
microorganism?
a. Hemophilus influenza c. Steptococcus pneumonia
b. Morbillivirus d. Neisseria meningitides

52. The student nurse is aware that the pathognomonic sign of measles is Koplik’s spot and you may see Koplik’s
spot by inspecting the:
a. Nasal mucosa c. Skin on the abdomen
b. Buccal mucosa d. Skin on neck

53. Angel was diagnosed as having Dengue fever. You will say that there is slow capillary refill when the color of the
nail bed that you pressed does not return within how many seconds?
a. 3 seconds c. 9 seconds
b. 6 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 c. Severe pneumonia
b. Severe dehydration 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 c. 55 infants
b. 50 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 c. Measles vaccine
b. Oral polio vaccine d. MMR

57. It is the most effective way of controlling schistosomias is 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 c. 5 skin lesions, negative slit skin smear
b. 3 skin lesions, positive 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 c. Thickened painful nerves
b. Inability to close eyelids d. Sinking of the nose bridge

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. c. Get a specimen for blood smear.
b. Ask where the family resides. d. Ask if the fever is present every day.

61. Susie brought her 4 years old daughter to the RHU because of cough and colds. Following the IMCI assessment
guide, which of the following is a danger sign that indicates the need for urgent referral to a hospital?
a. Inability to drink c. Signs of severe dehydration
b. High grade fever d. Cough for more than 30 days

62. Jimmy a 2-year old child revealed “baggy pants”. As a nurse, using the IMCI guidelines, how will you manage
Jimmy?
a. Refer the child urgently to a hospital for confinement.
b. Coordinate with the social worker to enroll the child in a feeding program.
c. Make a teaching plan for the mother, focusing on menu planning for her child.
d. Assess and treat the child for health problems like infections and intestinal parasitism.

63. Gina is using Oresol in the management of diarrhea of her 3-year old child. She asked you what to do if her child
vomits. As a nurse you will tell her to:
a. Bring the child to the nearest hospital for further assessment.
b. Bring the child to the health center for intravenous fluid therapy.
c. Bring the child to the health center for assessment by the physician.
d. Let the child rest for 10 minutes then continue giving Oresol more slowly.

64. Nikki a 5-month old infant was brought by his mother to the health center because of diarrhea for 4 to 5 times a
day. Her skin goes back slowly after a skin pinch and her eyes are sunken. Using the IMCI guidelines, you will
classify this infant in which category?
a. No signs of dehydration c. Severe dehydration
b. Some 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 c. Normal
b. Slow 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 c. 5 years
b. 3 years d. Lifetime
67. Nurse Ron is aware that unused BCG should be discarded after how many hours of reconstitution?
a. 2 hours c. 8 hours
b. 4 hours d. At the end of the day

68. The nurse explains to a breastfeeding mother that breast milk is sufficient for all of the baby’s nutrient needs
only up to:
a. 5 months c. 1 year
b. 6 months d. 2 years

69. Nurse Ron is aware that the gestational age of a concept us that is considered viable (able to live outside the
womb) is:
a. 8 weeks c. 24 weeks
b. 12 weeks d. 32 weeks

70. When teaching parents of a neonate the proper position for the neonate’s sleep, the nurse Patricia stresses the
importance of placing the neonate on his back to reduce the risk of which of the following?
a. Aspiration c. Suffocation
b. Sudden infant death syndrome (SIDS) d. Gastroesophageal reflux (GER)

71. Which finding might be seen in baby James a neonate suspected of having an infection?
a. Flushed cheeks c. Decreased temperature
b. Increased 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 c. Hyperglycemia due to decreased glycogen
hyposia stores
b. Hyperthermia due to decreased glycogen d. Polycythemia probably due to chronic fetal
stores 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 c. Desquamation of the epidermis
b. Lanugo covering the body d. Vernix caseosa covering the body

74. After reviewing the Myrna’s maternal history of magnesium sulfate during labor, which condition would nurse
Richard anticipate as a potential problem in the neonate?
a. Hypoglycemia c. Respiratory depression
b. Jitteriness d. Tachycardia

75. Which symptom would indicate the Baby Alexandra was adapting appropriately to extra-uterine life without
difficulty?
a. Nasal flaring c. Respiratory rate 40 to 60 breaths/minute
b. Light audible grunting d. Respiratory rate 60 to 80 breaths/minute

76. When teaching umbilical cord care for Jennifer a new mother, the nurseJenny would include which information?
a. Apply peroxide to the cord with each diaper change
b. Cover the cord with petroleum jelly after bathing
c. Keep the cord dry and open to air
d. Wash the cord with soap and water each day during a tub bath.

77. Nurse John is performing an assessment on a neonate. Which of the following findings is considered common in
the healthy neonate?
 a. Simian crease c. Cystic hygroma
b. Conjunctival hemorrhage 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. c. To assess fetal position
b. To assess for prolapsed cord d. To prepare for an imminent delivery.

79. Which of the following would be least likely to indicate anticipated bonding behaviors by new parents?
a. The parents’ willingness to touch and hold the new born.
b. The parent’s expression of interest about the size of the new born.
c. The parents’ indication that they want to see the newborn.
d. The parents’ interactions with each other.

80. Following a precipitous delivery, examination of the client's vagina reveals a fourth-degree laceration. Which of
the following would be contraindicated when caring for this client?
a. Applying cold to limit edema during the first 12 to 24 hours.
b. Instructing the client to use two or more peripads to cushion the area.
c. Instructing the client on the use of sitz baths if ordered.
d. Instructing the client about the importance of perineal (kegel) exercises.

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

82. A neonate begins to gag and turns a dusky color. What should the nurse do first?
a. Calm the neonate.
b. Notify the physician.
c. Provide oxygen via face mask as ordered
d. Aspirate the neonate’s nose and mouth with a bulb syringe.

83. When a client states that her "water broke," which of the following actions would be inappropriate for the nurse
to do?
a. Observing the pooling of straw-colored fluid.
b. Checking vaginal discharge with nitrazine paper.
c. Conducting a bedside ultrasound for an amniotic fluid index.
d. Observing for flakes of vernix in the vaginal discharge.

84. A baby girl is born 8 weeks premature. At birth, she has no spontaneous respirations but is successfully
resuscitated. Within several hours she develops respiratory grunting, cyanosis, tachypnea, nasal flaring, and
retractions. She's diagnosed with respiratory distress syndrome, intubated, and placed on a ventilator. Which
nursing action should be included in the baby's plan of care to prevent retinopathy of prematurity?
a. Cover his eyes while receiving oxygen.
b. Keep her body temperature low.
c. Monitor partial pressure of oxygen (Pao2) levels.
d. Humidify the oxygen.

85. Which of the following is normal newborn calorie intake?

a. 110 to 130 calories per kg. c. At least 2 ml per feeding
b. 30 to 40 calories per lb of body weight. d. 90 to 100 calories per kg
86. Nurse John is knowledgeable that usually individual twins will growappropriately and at the same rate as
singletons until how many weeks?
a. 16 to 18 weeks c. 30 to 32 weeks
b. 18 to 22 weeks d. 38 to 40 weeks

87. Which of the following classifications applies to monozygotic twins for whom the cleavage of the fertilized ovum
occurs more than 13 days after fertilization?
a. conjoined twins c. diamniotic monochorionic twin
b. diamniotic dichorionic twins 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 c. External fetal monitoring
b. Digital or speculum examination d. Ultrasound

89. Nurse Arnold knows that the following changes in respiratory functioning during pregnancy is considered
normal:
a. Increased tidal volume c. Decreased inspiratory capacity
b. Increased expiratory volume d. Decreased oxygen consumption

90. Emily has gestational diabetes and it is usually managed by which of the following therapy?
a. Diet c. Oral hypoglycemic
b. Long-acting insulin d. Oral hypoglycemic drug and insulin

91. Magnesium sulfate is given to Jemma with preeclampsia to prevent which of the following condition?
a. Hemorrhage c. Hypomagnesemia
b. Hypertension d. Seizure

92. Cammile with sickle cell anemia has an increased risk for having a sickle cell crisis during pregnancy. Aggressive
management of a sickle cell crisis includes which of the following measures?
a. Antihypertensive agents c. I.V. fluids
b. Diuretic agents d. Acetaminophen (Tylenol) for pain

93. Which of the following drugs is the antidote for magnesium toxicity?
a. Calcium gluconate (Kalcinate) c. Naloxone (Narcan)
b. Hydralazine (Apresoline) d. Rho (D) immune globulin (RhoGAM)

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 12hours.
d. A flat circumcised area over 10 mm in diameter appears in 48 to 72hours.

95. Dianne, 24 year-old is 27 weeks’ pregnant arrives at her physician’s office with complaints of fever, nausea,
vomiting, malaise, unilateral flank pain, and costovertebral angle tenderness. Which of the following diagnoses
is most likely?
a. Asymptomatic bacteriuria c. Pyelonephritis
b. Bacterial vaginosis d. Urinary tract infection (UTI)

96. Rh isoimmunization in a pregnant client develops during which of the following conditions?
a. Rh-positive maternal blood crosses into fetal blood, stimulating fetal antibodies.
 b. Rh-positive fetal blood crosses into maternal blood, stimulating maternal antibodies.
c. Rh-negative fetal blood crosses into maternal blood, stimulating maternal antibodies.
d. Rh-negative maternal blood crosses into fetal blood, stimulating fetal antibodies.

97. To promote comfort during labor, the nurses John advises a client to assume certain positions and avoid others.
Which position may cause maternal hypotension and fetal hypoxia?
a. Lateral position c. Supine position
b. Squatting position d. Standing position

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. c. A flattened nose, small eyes, and thin lips.
b. Irritability and poor sucking. 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. c. End of 6th week postpartum.
b. 2 weeks 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 c. Uterine involution
b. Uterine atony d. Uterine discomfort