NP1 PT2 aware that one of the following is unassociated

1. May arrives at the health care clinic and tells with this condition?
the nurse that her last menstrual period was 9 A. Excessive fetal activity.
weeks ago. She also tells the nurse that a home B. Larger than normal uterus for gestational
pregnancy test was positive but she began to have age.
mild cramps and is now having moderate vaginal C. Vaginal bleeding
bleeding. During the physical examination of the D. Elevated levels of human chorionic
client, the nurse notes that May has a dilated gonadotropin.
cervix. The nurse determines that May is 6. A pregnant client is receiving magnesium
experiencing which type of abortion? sulfate for severe pregnancy induced
A. Inevitable hypertension (PIH). The clinical findings that
B. Incomplete would warrant use of the antidote , calcium
C. Threatened gluconate is:
D. Septic A. Urinary output 90 cc in 2 hours.
2. Nurse Reese is reviewing the record of a B. Absent patellar reflexes.
pregnant client for her first prenatal visit. Which C. Rapid respiratory rate above 40/min.
of the following data, if noted on the client’s D. Rapid rise in blood pressure.
record, would alert the nurse that the client is at 7. During vaginal examination of Janah who is in
risk for a spontaneous abortion? labor, the presenting part is at station plus two.
A. Age 36 years Nurse, correctly interprets it as:
B. History of syphilis A. Presenting part is 2 cm above the plane of
C. History of genital herpes the ischial spines.
D. History of diabetes mellitus B. Biparietal diameter is at the level of the
3. Nurse Hazel is preparing to care for a client ischial spines.
who is newly admitted to the hospital with a C. Presenting part in 2 cm below the plane of
possible diagnosis of ectopic pregnancy. Nurse the ischial spines.
Hazel develops a plan of care for the client and D. Biparietal diameter is 2 cm above the
determines that which of the following nursing ischial spines.
actions is the priority? 8. A pregnant client is receiving oxytocin
A. Monitoring weight (Pitocin) for induction of labor. A condition that
B. Assessing for edema warrant the nurse in-charge to discontinue I.V.
C. Monitoring apical pulse infusion of Pitocin is:
D. Monitoring temperature A. Contractions every 1 ½ minutes lasting 70-
4. Nurse Oliver is teaching a diabetic pregnant 80 seconds.
client about nutrition and insulin needs during B. Maternal temperature 101.2
pregnancy. The nurse determines that the client C. Early decelerations in the fetal heart rate.
understands dietary and insulin needs if the client D. Fetal heart rate baseline 140-160 bpm.
states that the second half of pregnancy require: 9. Calcium gluconate is being administered to a
A. Decreased caloric intake client with pregnancy induced hypertension
B. Increased caloric intake (PIH). A nursing action that must be initiated as
C. Decreased Insulin the plan of care throughout injection of the drug
D. Increase Insulin is:
5. Nurse Michelle is assessing a 24 year old client A. Ventilator assistance
with a diagnosis of hydatidiform mole. She is B. CVP readings
C. EKG tracings
 D. Continuous CPR D. Iron-rich formula and baby food.
10. A trial for vaginal delivery after an earlier [Link] Linda is playing with her infant, who
caesareans, would likely to be given to a gravida, is sitting securely alone on the floor of the clinic.
who had: The mother hides a toy behind her back and the
A. First low transverse cesarean was for active infant looks for it. The nurse is aware that
herpes type 2 infections; vaginal culture at estimated age of the infant would be:
39 weeks pregnancy was positive. A. 6 months
B. First and second caesareans were for B. 4 months
cephalopelvic disproportion. C. 8 months
C. First caesarean through a classic incision as D. 10 months
a result of severe fetal distress. [Link] of the following is the most prominent
D. First low transverse caesarean was for feature of public health nursing?
breech position. Fetus in this pregnancy is A. It involves providing home care to sick
in a vertex presentation. people who are not confined in the hospital.
[Link] Ryan is aware that the best initial B. Services are provided free of charge to
approach when trying to take a crying toddler’s people within the catchments area.
temperature is: C. The public health nurse functions as part of
A. Talk to the mother first and then to the a team providing a public health nursing
toddler. services.
B. Bring extra help so it can be done quickly. D. Public health nursing focuses on preventive,
C. Encourage the mother to hold the child. not curative, services.
D. Ignore the crying and screaming. [Link] the nurse determines whether resources
[Link] Tina a 3 month old infant just had a cleft were maximized in implementing Ligtas Tigdas,
lip and palate repair. What should the nurse do to she is evaluating
prevent trauma to operative site? A. Effectiveness
A. Avoid touching the suture line, even when B. Efficiency
cleaning. C. Adequacy
B. Place the baby in prone position. D. Appropriateness
C. Give the baby a pacifier. [Link] is a new B.S.N. graduate. She wants to
D. Place the infant’s arms in soft elbow become a Public Health Nurse. Where should she
restraints. apply?
13. Which action should nurse Marian include in A. Department of Health
the care plan for a 2 month old with heart failure? B. Provincial Health Office
A. Feed the infant when he cries. C. Regional Health Office
B. Allow the infant to rest before feeding. D. Rural Health Unit
C. Bathe the infant and administer [Link] is aware the Chairman of the Municipal
medications before feeding. Health Board is:
D. Weigh and bathe the infant before feeding. A. Mayor
[Link] Hazel is teaching a mother who plans to B. Municipal Health Officer
discontinue breast feeding after 5 months. The C. Public Health Nurse
nurse should advise her to include which foods in D. Any qualified physician
her infant’s diet? [Link] is the public health nurse in a
A. Skim milk and baby food. municipality with a total population of about
B. Whole milk and baby food. 20,000. There are 3 rural health midwives among
C. Iron-rich formula only.
the RHU personnel. How many more midwife C. To maximize the community’s resources in
items will the RHU need? dealing with health problems.
A. 1 D. To maximize the community’s resources in
B. 2 dealing with health problems.
C. 3 [Link] prevention is needed in which stage
D. The RHU does not need any more midwife of the natural history of disease?
item. A. Pre-pathogenesis
[Link] to Freeman and Heinrich, B. Pathogenesis
community health nursing is a developmental C. Prodromal
service. Which of the following best illustrates D. Terminal
this statement? [Link] nurse is caring for a primigravid client in
A. The community health nurse continuously the labor and delivery area. Which condition
develops himself personally and would place the client at risk for disseminated
professionally. intravascular coagulation (DIC)?
B. Health education and community A. Intrauterine fetal death.
organizing are necessary in providing B. Placenta accreta.
community health services. C. Dysfunctional labor.
C. Community health nursing is intended D. Premature rupture of the membranes.
primarily for health promotion and 27.A fullterm client is in labor. Nurse Betty is
prevention and treatment of disease. aware that the fetal heart rate would be:
D. The goal of community health nursing is to A. 80 to 100 beats/minute
provide nursing services to people in their B. 100 to 120 beats/minute
own places of residence. C. 120 to 160 beats/minute
[Link] Tina is aware that the disease declared D. 160 to 180 beats/minute
through Presidential Proclamation No. 4 as a [Link] skin in the diaper area of a 7 month old
target for eradication in the Philippines is? infant is excoriated and red. Nurse Hazel should
A. Poliomyelitis instruct the mother to:
B. Measles A. Change the diaper more often.
C. Rabies B. Apply talc powder with diaper changes.
D. Neonatal tetanus C. Wash the area vigorously with each diaper
[Link] knows that the step in community change.
organizing that involves training of potential D. Decrease the infant’s fluid intake to
leaders in the community is: decrease saturating diapers.
A. Integration [Link] Carla knows that the common cardiac
B. Community organization anomalies in children with Down Syndrome (tri-
C. Community study somy 21) is:
D. Core group formation A. Atrial septal defect
[Link] a public health nurse takes an active role B. Pulmonic stenosis
in community participation. What is the primary C. Ventricular septal defect
goal of community organizing? D. Endocardial cushion defect
A. To educate the people regarding [Link] was diagnosed with severe
community health problems preeclampsia is now receiving I.V. magnesium
B. To mobilize the people to resolve sulfate. The adverse effects associated with
community health problems magnesium sulfate is:
A. Anemia
 B. Decreased urine output 36.A young child named Richard is suspected of
C. Hyperreflexia having pinworms. The community nurse collects
D. Increased respiratory rate a stool specimen to confirm the diagnosis. The
31.A 23 year old client is having her menstrual nurse should schedule the collection of this
period every 2 weeks that last for 1 week. This specimen for:
type of menstrual pattern is bets defined by: A. Just before bedtime
A. Menorrhagia B. After the child has been bathe
B. Metrorrhagia C. Any time during the day
C. Dyspareunia D. Early in the morning
D. Amenorrhea [Link] doing a child’s admission assessment,
32. Jannah is admitted to the labor and delivery Nurse Betty should be alert to note which signs or
unit. The critical laboratory result for this client symptoms of chronic lead poisoning?
would be: A. Irritability and seizures
A. Oxygen saturation B. Dehydration and diarrhea
B. Iron binding capacity C. Bradycardia and hypotension
C. Blood typing D. Petechiae and hematuria
D. Serum Calcium [Link] evaluate a woman’s understanding about
[Link] Gina is aware that the most common the use of diaphragm for family planning, Nurse
condition found during the second-trimester of Trish asks her to explain how she will use the
pregnancy is: appliance. Which response indicates a need for
A. Metabolic alkalosis further health teaching?
B. Respiratory acidosis A. “I should check the diaphragm carefully for
C. Mastitis holes every time I use it”
D. Physiologic anemia B. “I may need a different size of diaphragm if
[Link] Lynette is working in the triage area of I gain or lose weight more than 20 pounds”
an emergency department. She sees that several C. “The diaphragm must be left in place for
pediatric clients arrive simultaneously. The client atleast 6 hours after intercourse”
who needs to be treated first is: D. “I really need to use the diaphragm and jelly
A. A crying 5 year old child with a laceration most during the middle of my menstrual
on his scalp. cycle”.
B. A 4 year old child with a barking coughs [Link] is a common complication of
and flushed appearance. laryngotracheobronchitis. Nurse Oliver should
C. A 3 year old child with Down syndrome frequently assess a child with
who is pale and asleep in his mother’s arms. laryngotracheobronchitis for:
D. A 2 year old infant with stridorous breath A. Drooling
sounds, sitting up in his mother’s arms and B. Muffled voice
drooling. C. Restlessness
[Link] in her third trimester arrives at the D. Low-grade fever
emergency room with painless vaginal bleeding. [Link] should Nurse Michelle guide a child who
Which of the following conditions is suspected? is blind to walk to the playroom?
A. Placenta previa A. Without touching the child, talk
B. Abruptio placentae continuously as the child walks down the
C. Premature labor hall.
D. Sexually transmitted disease B. Walk one step ahead, with the child’s hand
on the nurse’s elbow.
 C. Walk slightly behind, gently guiding the 46. In a mothers’ class, Nurse Lhynnete discussed
child forward. childhood diseases such as chicken pox. Which
D. Walk next to the child, holding the child’s of the following statements about chicken pox is
hand. correct?
[Link] assessing a newborn diagnosed with A. The older one gets, the more susceptible he
ductus arteriosus, Nurse Olivia should expect that becomes to the complications of chicken
the child most likely would have an: pox.
A. Loud, machinery-like murmur. B. A single attack of chicken pox will prevent
B. Bluish color to the lips. future episodes, including conditions such
C. Decreased BP reading in the upper as shingles.
extremities C. To prevent an outbreak in the community,
D. Increased BP reading in the upper quarantine may be imposed by health
extremities. authorities.
[Link] reason nurse May keeps the neonate in a D. Chicken pox vaccine is best given when
neutral thermal environment is that when a there is an impending outbreak in the
newborn becomes too cool, the neonate requires: community.
A. Less oxygen, and the newborn’s metabolic [Link] Pinoy had an outbreak of German
rate increases. measles. To prevent congenital rubella, what is
B. More oxygen, and the newborn’s metabolic the BEST advice that you can give to women in
rate decreases. the first trimester of pregnancy in the barangay
C. More oxygen, and the newborn’s metabolic Pinoy?
rate increases. A. Advice them on the signs of German
D. Less oxygen, and the newborn’s metabolic measles.
rate decreases. B. Avoid crowded places, such as markets and
[Link] adding potassium to an infant’s I.V. movie houses.
line, Nurse Ron must be sure to assess whether C. Consult at the health center where rubella
this infant has: vaccine may be given.
A. Stable blood pressure D. Consult a physician who may give them
B. Patant fontanelles rubella immunoglobulin.
C. Moro’s reflex [Link] a public health nurse knows that to
D. Voided determine possible sources of sexually
[Link] Carla should know that the most transmitted infections, the BEST method that
common causative factor of dermatitis in infants may be undertaken is:
and younger children is: A. Contact tracing
A. Baby oil B. Community survey
B. Baby lotion C. Mass screening tests
C. Laundry detergent D. Interview of suspects
D. Powder with cornstarch 49.A 33-year old female client came for
[Link] tube feeding, how far above an infant’s consultation at the health center with the chief
stomach should the nurse hold the syringe with complaint of fever for a week. Accompanying
formula? symptoms were muscle pains and body malaise.
A. 6 inches A week after the start of fever, the client noted
B. 12 inches yellowish discoloration of his sclera. History
C. 18 inches showed that he waded in flood waters about 2
D. 24 inches weeks before the onset of symptoms. Based on
her history, which disease condition will you C. Severe pneumonia
suspect? D. Severe febrile disease
A. Hepatitis A [Link] a public health nurse will conduct
B. Hepatitis B outreach immunization in a barangay Masay with
C. Tetanus a population of about 1500. The estimated
D. Leptospirosis number of infants in the barangay would be:
[Link] a 3-year old client was brought to the A. 45 infants
health center with the chief complaint of severe B. 50 infants
diarrhea and the passage of “rice water” stools. C. 55 infants
The client is most probably suffering from which D. 65 infants
condition? [Link] community nurse is aware that the
A. Giardiasis biological used in Expanded Program on
B. Cholera Immunization (EPI) should NOT be stored in the
C. Amebiasis freezer?
D. Dysentery A. DPT
[Link] most prevalent form of meningitis among B. Oral polio vaccine
children aged 2 months to 3 years is caused by C. Measles vaccine
which microorganism? D. MMR
A. Hemophilus influenzae [Link] is the most effective way of controlling
B. Morbillivirus schistosomiasis in an endemic area?
C. Steptococcus pneumoniae A. Use of molluscicides
D. Neisseria meningitidis B. Building of foot bridges
[Link] student nurse is aware that the C. Proper use of sanitary toilets
pathognomonic sign of measles is Koplik’s spot D. Use of protective footwear, such as rubber
and you may see Koplik’s spot by inspecting the: boots
A. Nasal mucosa [Link] clients is newly admitted and
B. Buccal mucosa diagnosed with leprosy. Which of the following
C. Skin on the abdomen clients should be classified as a case of
D. Skin on neck multibacillary leprosy?
[Link] was diagnosed as having Dengue fever. A. 3 skin lesions, negative slit skin smear
You will say that there is slow capillary refill B. 3 skin lesions, positive slit skin smear
when the color of the nailbed that you pressed C. 5 skin lesions, negative slit skin smear
does not return within how many seconds? D. 5 skin lesions, positive slit skin smear
A. 3 seconds [Link] are aware that diagnosis of leprosy is
B. 6 seconds highly dependent on recognition of symptoms.
C. 9 seconds Which of the following is an early sign of
D. 10 seconds leprosy?
[Link] Integrated Management of Childhood A. Macular lesions
Illness, the nurse is aware that the severe B. Inability to close eyelids
conditions generally require urgent referral to a C. Thickened painful nerves
hospital. Which of the following severe D. Sinking of the nosebridge
conditions DOES NOT always require urgent [Link] brought her 10 month old infant for
referral to a hospital? consultation because of fever, started 4 days prior
A. Mastoiditis to consultation. In determining malaria risk, what
B. Severe dehydration will you do?
 A. Perform a tourniquet test. C. Severe dehydration
B. Ask where the family resides. D. The data is insufficient.
C. Get a specimen for blood smear. [Link] a 4-month old infant was brought by her
D. Ask if the fever is present everyday. mother to the health center because of cough. His
[Link] brought her 4 years old daughter to the respiratory rate is 42/minute. Using the Integrated
RHU because of cough and colds. Following the Management of Child Illness (IMCI) guidelines
IMCI assessment guide, which of the following is of assessment, his breathing is considered as:
a danger sign that indicates the need for urgent A. Fast
referral to a hospital? B. Slow
A. Inability to drink C. Normal
B. High grade fever D. Insignificant
C. Signs of severe dehydration [Link] had just received her 4th dose of
D. Cough for more than 30 days tetanus toxoid. She is aware that her baby will
[Link] a 2-year old child revealed “baggy have protection against tetanus for
pants”. As a nurse, using the IMCI guidelines, A. 1 year
how will you manage Jimmy? B. 3 years
A. Refer the child urgently to a hospital for C. 5 years
confinement. D. Lifetime
B. Coordinate with the social worker to enroll [Link] Ron is aware that unused BCG should
the child in a feeding program. be discarded after how many hours of
C. Make a teaching plan for the mother, reconstitution?
focusing on menu planning for her child. A. 2 hours
D. Assess and treat the child for health B. 4 hours
problems like infections and intestinal C. 8 hours
parasitism. D. At the end of the day
[Link] is using Oresol in the management of [Link] nurse explains to a breastfeeding mother
diarrhea of her 3-year old child. She asked you that breast milk is sufficient for all of the baby’s
what to do if her child vomits. As a nurse you will nutrient needs only up to:
tell her to: A. 5 months
A. Bring the child to the nearest hospital for B. 6 months
further assessment. C. 1 year
B. Bring the child to the health center for D. 2 years
intravenous fluid therapy. [Link] Ron is aware that the gestational age of
C. Bring the child to the health center for a conceptus that is considered viable (able to live
assessment by the physician. outside the womb) is:
D. Let the child rest for 10 minutes then A. 8 weeks
continue giving Oresol more slowly. B. 12 weeks
[Link] a 5-month old infant was brought by his C. 24 weeks
mother to the health center because of diarrhea D. 32 weeks
for 4 to 5 times a day. Her skin goes back slowly [Link] teaching parents of a neonate the proper
after a skin pinch and her eyes are sunken. Using position for the neonate’s sleep, the nurse Patricia
the IMCI guidelines, you will classify this infant stresses the importance of placing the neonate on
in which category? his back to reduce the risk of which of the
A. No signs of dehydration following?
B. Some dehydration A. Aspiration
 B. Sudden infant death syndrome (SIDS) A. Apply peroxide to the cord with each diaper
C. Suffocation change
D. Gastroesophageal reflux (GER) B. Cover the cord with petroleum jelly after
[Link] finding might be seen in baby James a bathing
neonate suspected of having an infection? C. Keep the cord dry and open to air
A. Flushed cheeks D. Wash the cord with soap and water each
B. Increased temperature day during a tub bath.
C. Decreased temperature [Link] John is performing an assessment on a
D. Increased activity level neonate. Which of the following findings is
[Link] Jenny who is small-for-gestation is at considered common in the healthy neonate?
increased risk during the transitional period for A. Simian crease
which complication? B. Conjunctival hemorrhage
A. Anemia probably due to chronic fetal C. Cystic hygroma
hyposia D. Bulging fontanelle
B. Hyperthermia due to decreased glycogen [Link]. Esteves decides to artificially rupture the
stores membranes of a mother who is on labor.
C. Hyperglycemia due to decreased glycogen Following this procedure, the nurse Hazel checks
stores the fetal heart tones for which the following
D. Polycythemia probably due to chronic fetal reasons?
hypoxia A. To determine fetal well-being.
[Link] has just given birth at 42 weeks’ B. To assess for prolapsed cord
gestation. When the nurse assessing the neonate, C. To assess fetal position
which physical finding is expected? D. To prepare for an imminent delivery.
A. A sleepy, lethargic baby [Link] of the following would be least likely
B. Lanugo covering the body to indicate anticipated bonding behaviors by new
C. Desquamation of the epidermis parents?
D. Vernix caseosa covering the body A. The parents’ willingness to touch and hold
[Link] reviewing the Myrna’s maternal history the new born.
of magnesium sulfate during labor, which B. The parent’s expression of interest about
condition would nurse Richard anticipate as a the size of the new born.
potential problem in the neonate? C. The parents’ indication that they want to
A. Hypoglycemia see the newborn.
B. Jitteriness D. The parents’ interactions with each other.
C. Respiratory depression [Link] a precipitous delivery, examination
D. Tachycardia of the client’s vagina reveals
[Link] symptom would indicate the Baby a fourth-degree laceration. Which of the
Alexandra was adapting appropriately to extra- following would be contraindicated when caring
uterine life without difficulty? for this client?
A. Nasal flaring A. Applying cold to limit edema during the
B. Light audible grunting first 12 to 24 hours.
C. Respiratory rate 40 to 60 breaths/minute B. Instructing the client to use two or more
D. Respiratory rate 60 to 80 breaths/minute peripads to cushion the area.
76. When teaching umbilical cord care for C. Instructing the client on the use of sitz baths
Jennifer a new mother, the nurse Jenny would if ordered.
include which information?
 D. Instructing the client about the importance 85. Which of the following is normal newborn
of perineal (kegel) exercises. calorie intake?
81. A pregnant woman accompanied by her A. 110 to 130 calories per kg.
husband, seeks admission to the labor and B. 30 to 40 calories per lb of body weight.
delivery area. She states that she’s in labor and C. At least 2 ml per feeding
says she attended the facility clinic for prenatal D. 90 to 100 calories per kg
care. Which question should the nurse Oliver ask 86. Nurse John is knowledgeable that usually
her first? individual twins will grow appropriately and at
A. “Do you have any chronic illnesses?” the same rate as singletons until how many
B. “Do you have any allergies?” weeks?
C. “What is your expected due date?” A. 16 to 18 weeks
D. “Who will be with you during labor?” B. 18 to 22 weeks
82.A neonate begins to gag and turns a dusky C. 30 to 32 weeks
color. What should the nurse do first? D. 38 to 40 weeks
A. Calm the neonate. 87. Which of the following classifications applies
B. Notify the physician. to monozygotic twins for whom the cleavage of
C. Provide oxygen via face mask as ordered the fertilized ovum occurs more than 13 days
D. Aspirate the neonate’s nose and mouth with after fertilization?
a bulb syringe. A. conjoined twins
83. When a client states that her “water broke,” B. diamniotic dichorionic twins
which of the following actions would be C. diamniotic monochorionic twin
inappropriate for the nurse to do? D. monoamniotic monochorionic twins
A. Observing the pooling of straw-colored 88. Tyra experienced painless vaginal bleeding
fluid. has just been diagnosed as having a placenta
B. Checking vaginal discharge with nitrazine previa. Which of the following procedures is
paper. usually performed to diagnose placenta previa?
C. Conducting a bedside ultrasound for an A. Amniocentesis
amniotic fluid index. B. Digital or speculum examination
D. Observing for flakes of vernix in the C. External fetal monitoring
vaginal discharge. D. Ultrasound
84. A baby girl is born 8 weeks premature. At 89. Nurse Arnold knows that the following
birth, she has no spontaneous respirations but is changes in respiratory functioning during
successfully resuscitated. Within several hours pregnancy is considered normal:
she develops respiratory grunting, cyanosis, A. Increased tidal volume
tachypnea, nasal flaring, and retractions. She’s B. Increased expiratory volume
diagnosed with respiratory distress syndrome, C. Decreased inspiratory capacity
intubated, and placed on a ventilator. Which D. Decreased oxygen consumption
nursing action should be included in the baby’s 90. Emily has gestational diabetes and it is
plan of care to prevent retinopathy of usually managed by which of the following
prematurity? therapy?
A. Cover his eyes while receiving oxygen. A. Diet
B. Keep her body temperature low. B. Long-acting insulin
C. Monitor partial pressure of oxygen (Pao2) C. Oral hypoglycemic
levels. D. Oral hypoglycemic drug and insulin
D. Humidify the oxygen.
91. Magnesium sulfate is given to Jemma with 96. Rh isoimmunization in a pregnant client
preeclampsia to prevent which of the following develops during which of the following
condition? conditions?
A. Hemorrhage A. Rh-positive maternal blood crosses into
B. Hypertension fetal blood, stimulating fetal antibodies.
C. Hypomagnesemia B. Rh-positive fetal blood crosses into
D. Seizure maternal blood, stimulating maternal
92. Cammile with sickle cell anemia has an antibodies.
increased risk for having a sickle cell crisis during C. Rh-negative fetal blood crosses into
pregnancy. Aggressive management of a sickle maternal blood, stimulating maternal
cell crisis includes which of the following antibodies.
measures? D. Rh-negative maternal blood crosses into
A. Antihypertensive agents fetal blood, stimulating fetal antibodies.
B. Diuretic agents 97. To promote comfort during labor, the nurse
C. I.V. fluids John advises a client to assume certain positions
D. Acetaminophen (Tylenol) for pain and avoid others. Which position may cause
93. Which of the following drugs is the antidote maternal hypotension and fetal hypoxia?
for magnesium toxicity? A. Lateral position
A. Calcium gluconate (Kalcinate) B. Squatting position
B. Hydralazine (Apresoline) C. Supine position
C. Naloxone (Narcan) D. Standing position
D. Rho (D) immune globulin (RhoGAM) 98. Celeste who used heroin during her
94. Marlyn is screened for tuberculosis during her pregnancy delivers a neonate. When assessing the
first prenatal visit. An intradermal injection of neonate, the nurse Lhynnette expects to find:
purified protein derivative (PPD) of the A. Lethargy 2 days after birth.
tuberculin bacilli is given. She is considered to B. Irritability and poor sucking.
have a positive test for which of the following C. A flattened nose, small eyes, and thin lips.
results? D. Congenital defects such as limb anomalies.
A. An indurated wheal under 10 mm in 99. The uterus returns to the pelvic cavity in
diameter appears in 6 to 12 hours. which of the following time frames?
B. An indurated wheal over 10 mm in A. 7th to 9th day postpartum.
diameter appears in 48 to 72 hours. B. 2 weeks postpartum.
C. A flat circumcised area under 10 mm in C. End of 6th week postpartum.
diameter appears in 6 to 12 hours. D. When the lochia changes to alba.
D. A flat circumcised area over 10 mm in 100. Maureen, a primigravida client, age 20, has
diameter appears in 48 to 72 hours. just completed a difficult, forceps-assisted
95. Dianne, 24 year-old is 27 weeks’ pregnant delivery of twins. Her labor was unusually long
arrives at her physician’s office with complaints and required oxytocin (Pitocin) augmentation.
of fever, nausea, vomiting, malaise, unilateral The nurse who’s caring for her should stay alert
flank pain, and costovertebral angle tenderness. for:
Which of the following diagnoses is most likely? A. Uterine inversion
A. Asymptomatic bacteriuria B. Uterine atony
B. Bacterial vaginosis C. Uterine involution
C. Pyelonephritis D. Uterine discomfort
D. Urinary tract infection (UTI)
Answers and Rationales presenting part is 2 cm below the plane of
the ischial spines.
1. Answer: (A) Inevitable. An inevitable 8. Answer: (A) Contractions every 1 ½
abortion is termination of pregnancy that minutes lasting 70-80 seconds.
cannot be prevented. Moderate to severe Contractions every 1 ½ minutes lasting 70-
bleeding with mild cramping and cervical 80 seconds, is indicative of
dilation would be noted in this type of hyperstimulation of the uterus, which could
abortion. result in injury to the mother and the fetus
2. Answer: (B) History of syphilis. Maternal if Pitocin is not discontinued.
infections such as syphilis, toxoplasmosis, 9. Answer: (C) EKG tracings. A potential side
and rubella are causes of spontaneous effect of calcium gluconate administration
abortion. is cardiac arrest. Continuous monitoring of
3. Answer: (C) Monitoring apical pulse. cardiac activity (EKG) throught
Nursing care for the client with a possible administration of calcium gluconate is an
ectopic pregnancy is focused on preventing essential part of care.
or identifying hypovolemic shock and 10. Answer: (D) First low transverse caesarean
controlling pain. An elevated pulse rate is was for breech position. Fetus in this
an indicator of shock. pregnancy is in a vertex presentation. This
4. Answer: (B) Increased caloric intake. type of client has no obstetrical indication
Glucose crosses the placenta, but insulin for a caesarean section as she did with her
does not. High fetal demands for glucose, first caesarean delivery.
combined with the insulin resistance caused 11. Answer: (A) Talk to the mother first and
by hormonal changes in the last half of then to the toddler. When dealing with a
pregnancy can result in elevation of crying toddler, the best approach is to talk
maternal blood glucose levels. This to the mother and ignore the toddler first.
increases the mother’s demand for insulin This approach helps the toddler get used to
and is referred to as the diabetogenic effect the nurse before she attempts any
of pregnancy. procedures. It also gives the toddler an
5. Answer: (A) Excessive fetal activity. The opportunity to see that the mother trusts the
most common signs and symptoms of nurse.
hydatidiform mole includes elevated levels 12. Answer: (D) Place the infant’s arms in soft
of human chorionic gonadotropin, vaginal elbow restraints. Soft restraints from the
bleeding, larger than normal uterus for upper arm to the wrist prevent the infant
gestational age, failure to detect fetal heart from touching her lip but allow him to hold
activity even with sensitive instruments, a favorite item such as a blanket. Because
excessive nausea and vomiting, and early they could damage the operative site, such
development of pregnancy-induced as objects as pacifiers, suction catheters,
hypertension. Fetal activity would not be and small spoons shouldn’t be placed in a
noted. baby’s mouth after cleft repair. A baby in a
6. Answer: (B) Absent patellar reflexes. prone position may rub her face on the
Absence of patellar reflexes is an indicator sheets and traumatize the operative site.
of hypermagnesemia, which requires The suture line should be cleaned gently to
administration of calcium gluconate. prevent infection, which could interfere
7. Answer: (C) Presenting part in 2 cm below with healing and damage the cosmetic
the plane of the ischial spines. Fetus at appearance of the repair.
station plus two indicates that the
13. Answer: (B) Allow the infant to rest before 23. Answer: (D) Core group formation. In core
feeding. Because feeding requires so much group formation, the nurse is able to
energy, an infant with heart failure should transfer the technology of community
rest before feeding. organizing to the potential or informal
14. Answer: (C) Iron-rich formula only. The community leaders through a training
infants at age 5 months should receive iron- program.
rich formula and that they shouldn’t receive 24. Answer: (D) To maximize the community’s
solid food, even baby food until age 6 resources in dealing with health problems.
months. Community organizing is a developmental
15. Answer: (D) 10 months. A 10 month old service, with the goal of developing the
infant can sit alone and understands object people’s self-reliance in dealing with
permanence, so he would look for the community health problems. A, B and C are
hidden toy. At age 4 to 6 months, infants objectives of contributory objectives to this
can’t sit securely alone. At age 8 months, goal.
infants can sit securely alone but cannot 25. Answer: (D) Terminal. Tertiary prevention
understand the permanence of objects. involves rehabilitation, prevention of
16. Answer: (D) Public health nursing focuses permanent disability and disability
on preventive, not curative, services. The limitation appropriate for convalescents,
catchments area in PHN consists of a the disabled, complicated cases and the
residential community, many of whom are terminally ill (those in the terminal stage of
well individuals who have greater need for a disease).
preventive rather than curative services. 26. Answer: (A) Intrauterine fetal death.
17. Answer: (B) Efficiency. Efficiency is Intrauterine fetal death, abruptio placentae,
determining whether the goals were septic shock, and amniotic fluid embolism
attained at the least possible cost. may trigger normal clotting mechanisms; if
18. Answer: (D) Rural Health Unit. R.A. 7160 clotting factors are depleted, DIC may
devolved basic health services to local occur. Placenta accreta, dysfunctional labor,
government units (LGU’s ). The public and premature rupture of the membranes
health nurse is an employee of the LGU. aren’t associated with DIC.
19. Answer: (A) Mayor. The local executive 27. Answer: (C) 120 to 160 beats/minute. A
serves as the chairman of the Municipal rate of 120 to 160 beats/minute in the fetal
Health Board. heart appropriate for filling the heart with
20. Answer: (A) 1. Each rural health midwife is blood and pumping it out to the system.
given a population assignment of about 28. Answer: (A) Change the diaper more often.
5,000. Decreasing the amount of time the skin
21. Answer: (B) Health education and comes contact with wet soiled diapers will
community organizing are necessary in help heal the irritation.
providing community health services. The 29. Answer: (D) Endocardial cushion defect.
community health nurse develops the Endocardial cushion defects are seen most
health capability of people through health in children with Down syndrome, asplenia,
education and community organizing or polysplenia.
activities. 30. Answer: (B) Decreased urine output.
22. Answer: (B) Measles. Presidential Decreased urine output may occur in clients
Proclamation No. 4 is on the Ligtas Tigdas receiving I.V. magnesium and should be
Program. monitored closely to keep urine output at
 greater than 30 ml/hour, because of my menstrual cycle”. The woman must
magnesium is excreted through the kidneys understand that, although the “fertile”
and can easily accumulate to toxic levels. period is approximately mid-cycle,
31. Answer: (A) Menorrhagia. Menorrhagia is hormonal variations do occur and can result
an excessive menstrual period. in early or late ovulation. To be effective,
32. Answer: (C) Blood typing. Blood type the diaphragm should be inserted before
would be a critical value to have because every intercourse.
the risk of blood loss is always a potential 39. Answer: (C) Restlessness. In a child,
complication during the labor and delivery restlessness is the earliest sign of hypoxia.
process. Approximately 40% of a woman’s Late signs of hypoxia in a child are
cardiac output is delivered to the uterus, associated with a change in color, such as
therefore, blood loss can occur quite rapidly pallor or cyanosis.
in the event of uncontrolled bleeding. 40. Answer: (B) Walk one step ahead, with the
33. Answer: (D) Physiologic anemia. child’s hand on the nurse’s elbow. This
Hemoglobin values and hematocrit procedure is generally recommended to
decrease during pregnancy as the increase follow in guiding a person who is blind.
in plasma volume exceeds the increase in 41. Answer: (A) Loud, machinery-like murmur.
red blood cell production. A loud, machinery-like murmur is a
34. Answer: (D) A 2 year old infant with characteristic finding associated with patent
stridorous breath sounds, sitting up in his ductus arteriosus.
mother’s arms and drooling. The infant 42. Answer: (C) More oxygen, and the
with the airway emergency should be newborn’s metabolic rate increases. When
treated first, because of the risk of cold, the infant requires more oxygen and
epiglottitis. there is an increase in metabolic rate. Non-
35. Answer: (A) Placenta previa. Placenta shievering thermogenesis is a complex
previa with painless vaginal bleeding. process that increases the metabolic rate
36. Answer: (D) Early in the morning. Based and rate of oxygen consumption, therefore,
on the nurse’s knowledge of microbiology, the newborn increase heat production.
the specimen should be collected early in 43. Answer: (D) Voided. Before administering
the morning. The rationale for this timing is potassium I.V. to any client, the nurse must
that, because the female worm lays eggs at first check that the client’s kidneys are
night around the perineal area, the first functioning and that the client is voiding. If
bowel movement of the day will yield the the client is not voiding, the nurse should
best results. The specific type of stool withhold the potassium and notify the
specimen used in the diagnosis of physician.
pinworms is called the tape test. 44. Answer: (C) Laundry detergent. Eczema or
37. Answer: (A) Irritability and seizures. Lead dermatitis is an allergic skin reaction
poisoning primarily affects the CNS, caused by an offending allergen. The
causing increased intracranial pressure. topical allergen that is the most common
This condition results in irritability and causative factor is laundry detergent.
changes in level of consciousness, as well 45. Answer: (A) 6 inches. This distance allows
as seizure disorders, hyperactivity, and for easy flow of the formula by gravity, but
learning disabilities. the flow will be slow enough not to
38. Answer: (D) “I really need to use the overload the stomach too rapidly.
diaphragm and jelly most during the middle
46. Answer: (A) The older one gets, the more 53. Answer: (A) 3 seconds. Adequate blood
susceptible he becomes to the supply to the area allows the return of the
complications of chicken pox. Chicken pox color of the nailbed within 3 seconds.
is usually more severe in adults than in 54. Answer: (B) Severe dehydration. The order
children. Complications, such as of priority in the management of severe
pneumonia, are higher in incidence in dehydration is as follows: intravenous fluid
adults. therapy, referral to a facility where IV
47. Answer: (D) Consult a physician who may fluids can be initiated within 30 minutes,
give them rubella immunoglobulin. Rubella Oresol or nasogastric tube. When the
vaccine is made up of attenuated German foregoing measures are not possible or
measles viruses. This is contraindicated in effective, then urgent referral to the hospital
pregnancy. Immune globulin, a specific is done.
prophylactic against German measles, may 55. Answer: (A) 45 infants. To estimate the
be given to pregnant women. number of infants, multiply total population
48. Answer: (A) Contact tracing. Contact by 3%.
tracing is the most practical and reliable 56. Answer: (A) DPT. DPT is sensitive to
method of finding possible sources of freezing. The appropriate storage
person-to-person transmitted infections, temperature of DPT is 2 to 8° C only. OPV
such as sexually transmitted diseases. and measles vaccine are highly sensitive to
49. Answer: (D) Leptospirosis. Leptospirosis is heat and require freezing. MMR is not an
transmitted through contact with the skin or immunization in the Expanded Program on
mucous membrane with water or moist soil Immunization.
contaminated with urine of infected 57. Answer: (C) Proper use of sanitary toilets.
animals, like rats. The ova of the parasite get out of the human
50. Answer: (B) Cholera. Passage of profuse body together with feces. Cutting the cycle
watery stools is the major symptom of at this stage is the most effective way of
cholera. Both amebic and bacillary preventing the spread of the disease to
dysentery are characterized by the presence susceptible hosts.
of blood and/or mucus in the stools. 58. Answer: (D) 5 skin lesions, positive slit
Giardiasis is characterized by fat skin smear. A multibacillary leprosy case is
malabsorption and, therefore, steatorrhea. one who has a positive slit skin smear and
51. Answer: (A) Hemophilus influenzae. at least 5 skin lesions.
Hemophilus meningitis is unusual over the 59. Answer: (C) Thickened painful nerves. The
age of 5 years. In developing countries, the lesion of leprosy is not macular. It is
peak incidence is in children less than 6 characterized by a change in skin color
months of age. Morbillivirus is the etiology (either reddish or whitish) and loss of
of measles. Streptococcus pneumoniae and sensation, sweating and hair growth over
Neisseria meningitidis may cause the lesion. Inability to close the eyelids
meningitis, but age distribution is not (lagophthalmos) and sinking of the
specific in young children. nosebridge are late symptoms.
52. Answer: (B) Buccal mucosa. Koplik’s spot 60. Answer: (B) Ask where the family resides.
may be seen on the mucosa of the mouth or Because malaria is endemic, the first
the throat. question to determine malaria risk is where
the client’s family resides. If the area of
residence is not a known endemic area, ask
 if the child had traveled within the past 6 is why BCG immunization is scheduled
months, where she was brought and only in the morning.
whether she stayed overnight in that area. 68. Answer: (B) 6 months. After 6 months, the
61. Answer: (A) Inability to drink. A sick child baby’s nutrient needs, especially the baby’s
aged 2 months to 5 years must be referred iron requirement, can no longer be provided
urgently to a hospital if he/she has one or by mother’s milk alone.
more of the following signs: not able to feed 69. Answer: (C) 24 weeks. At approximately
or drink, vomits everything, convulsions, 23 to 24 weeks’ gestation, the lungs are
abnormally sleepy or difficult to awaken. developed enough to sometimes maintain
62. Answer: (A) Refer the child urgently to a extrauterine life. The lungs are the most
hospital for confinement. “Baggy pants” is immature system during the gestation
a sign of severe marasmus. The best period. Medical care for premature labor
management is urgent referral to a hospital. begins much earlier (aggressively at 21
63. Answer: (D) Let the child rest for 10 weeks’ gestation)
minutes then continue giving Oresol more 70. Answer: (B) Sudden infant death syndrome
slowly. If the child vomits persistently, that (SIDS). Supine positioning is
is, he vomits everything that he takes in, he recommended to reduce the risk of SIDS in
has to be referred urgently to a hospital. infancy. The risk of aspiration is slightly
Otherwise, vomiting is managed by letting increased with the supine position.
the child rest for 10 minutes and then Suffocation would be less likely with an
continuing with Oresol administration. infant supine than prone and the position
Teach the mother to give Oresol more for GER requires the head of the bed to be
slowly. elevated.
64. Answer: (B) Some dehydration. Using the 71. Answer: (C) Decreased temperature.
assessment guidelines of IMCI, a child (2 Temperature instability, especially when it
months to 5 years old) with diarrhea is results in a low temperature in the neonate,
classified as having SOME may be a sign of infection. The neonate’s
DEHYDRATION if he shows 2 or more of color often changes with an infection
the following signs: restless or irritable, process but generally becomes ashen or
sunken eyes, the skin goes back slow after mottled. The neonate with an infection will
a skin pinch. usually show a decrease in activity level or
65. Answer: (C) Normal. In IMCI, a respiratory lethargy.
rate of 50/minute or more is fast breathing 72. Answer: (D) Polycythemia probably due to
for an infant aged 2 to 12 months. chronic fetal hypoxia. The small-for-
66. Answer: (A) 1 year. The baby will have gestation neonate is at risk for developing
passive natural immunity by placental polycythemia during the transitional period
transfer of antibodies. The mother will have in an attempt to decreasehypoxia. The
active artificial immunity lasting for about neonates are also at increased risk for
10 years. 5 doses will give the mother developing hypoglycemia and hypothermia
lifetime protection. due to decreased glycogen stores.
67. Answer: (B) 4 hours. While the unused 73. Answer: (C) Desquamation of the
portion of other biologicals in EPI may be epidermis. Postdate fetuses lose the vernix
given until the end of the day, only BCG is caseosa, and the epidermis may become
discarded 4 hours after reconstitution. This desquamated. These neonates are usually
 very alert. Lanugo is missing in the postdate 79. Answer: (D) The parents’ interactions with
neonate. each other. Parental interaction will provide
74. Answer: (C) Respiratory depression. the nurse with a good assessment of the
Magnesium sulfate crosses the placenta and stability of the family’s home life but it has
adverse neonatal effects are respiratory no indication for parental bonding.
depression, hypotonia, and bradycardia. Willingness to touch and hold the newborn,
The serum blood sugar isn’t affected by expressing interest about the newborn’s
magnesium sulfate. The neonate would be size, and indicating a desire to see the
floppy, not jittery. newborn are behaviors indicating parental
75. Answer: (C) Respiratory rate 40 to 60 bonding.
breaths/minute. A respiratory rate 40 to 60 80. Answer: (B) Instructing the client to use
breaths/minute is normal for a neonate two or more peripads to cushion the area.
during the transitional period. Nasal flaring, Using two or more peripads would do little
respiratory rate more than 60 to reduce the pain or promote perineal
breaths/minute, and audible grunting are healing. Cold applications, sitz baths, and
signs of respiratory distress. Kegel exercises are important measures
76. Answer: (C) Keep the cord dry and open to when the client has a fourth-degree
air. Keeping the cord dry and open to air laceration.
helps reduce infection and hastens drying. 81. Answer: (C) “What is your expected due
Infants aren’t given tub bath but are date?” When obtaining the history of a
sponged off until the cord falls off. client who may be in labor, the nurse’s
Petroleum jelly prevents the cord from highest priority is to determine her current
drying and encourages infection. Peroxide status, particularly her due date, gravidity,
could be painful and isn’t recommended. and parity. Gravidity and parity affect the
77. Answer: (B) Conjunctival hemorrhage. duration of labor and the potential for labor
Conjunctival hemorrhages are commonly complications. Later, the nurse should ask
seen in neonates secondary to the cranial about chronic illnesses, allergies, and
pressure applied during the birth process. support persons.
Bulging fontanelles are a sign of 82. Answer: (D) Aspirate the neonate’s nose
intracranial pressure. Simian creases are and mouth with a bulb syringe. The nurse’s
present in 40% of the neonates with trisomy first action should be to clear the neonate’s
21. Cystic hygroma is a neck mass that can airway with a bulb syringe. After the airway
affect the airway. is clear and the neonate’s color improves,
78. Answer: (B) To assess for prolapsed cord. the nurse should comfort and calm the
After a client has an amniotomy, the nurse neonate. If the problem recurs or the
should assure that the cord isn’t prolapsed neonate’s color doesn’t improve readily,
and that the baby tolerated the procedure the nurse should notify the physician.
well. The most effective way to do this is to Administering oxygen when the airway
check the fetal heart rate. Fetal well-being isn’t clear would be ineffective.
is assessed via a nonstress test. Fetal 83. Answer: (C) Conducting a bedside
position is determined by vaginal ultrasound for an amniotic fluid index. It
examination. Artificial rupture of isn’t within a nurse’s scope of practice to
membranes doesn’t indicate an imminent perform and interpret a bedside ultrasound
delivery. under these conditions and without
specialized training. Observing for pooling
 of straw-colored fluid, checking vaginal diamniotic monochorionic twins. Cleavage
discharge with nitrazine paper, and that occurs between days 8 to 13 result in
observing for flakes of vernix are monoamniotic monochorionic twins.
appropriate assessments for determining 88. Answer: (D) Ultrasound. Once the mother
whether a client has ruptured membranes. and the fetus are stabilized, ultrasound
84. Answer: (C) Monitor partial pressure of evaluation of the placenta should be done to
oxygen (Pao2) levels. Monitoring PaO2 determine the cause of the bleeding.
levels and reducing the oxygen Amniocentesis is contraindicated in
concentration to keep PaO2 within normal placenta previa. A digital or speculum
limits reduces the risk of retinopathy of examination shouldn’t be done as this may
prematurity in a premature infant receiving lead to severe bleeding or hemorrhage.
oxygen. Covering the infant’s eyes and External fetal monitoring won’t detect a
humidifying the oxygen don’t reduce the placenta previa, although it will detect fetal
risk of retinopathy of prematurity. Because distress, which may result from blood loss
cooling increases the risk of acidosis, the or placenta separation.
infant should be kept warm so that his 89. Answer: (A) Increased tidal volume. A
respiratory distress isn’t aggravated. pregnant client breathes deeper, which
85. Answer: (A) 110 to 130 calories per kg. increases the tidal volume of gas moved in
Calories per kg is the accepted way of and out of the respiratory tract with each
determined appropriate nutritional intake breath. The expiratory volume and residual
for a newborn. The recommended calorie volume decrease as the pregnancy
requirement is 110 to 130 calories per kg of progresses. The inspiratory capacity
newborn body weight. This level will increases during pregnancy. The increased
maintain a consistent blood glucose level oxygen consumption in the pregnant client
and provide enough calories for continued is 15% to 20% greater than in the
growth and development. nonpregnant state.
86. Answer: (C) 30 to 32 weeks. Individual 90. Answer: (A) Diet. Clients with gestational
twins usually grow at the same rate as diabetes are usually managed by diet alone
singletons until 30 to 32 weeks’ gestation, to control their glucose intolerance. Oral
then twins don’t’ gain weight as rapidly as hypoglycemic drugs are contraindicated in
singletons of the same gestational age. The pregnancy. Long-acting insulin usually
placenta can no longer keep pace with the isn’t needed for blood glucose control in the
nutritional requirements of both fetuses client with gestational diabetes.
after 32 weeks, so there’s some growth 91. Answer: (D) Seizure. The anticonvulsant
retardation in twins if they remain in utero mechanism of magnesium is believes to
at 38 to 40 weeks. depress seizure foci in the brain and
87. Answer: (A) conjoined twins. The type of peripheral neuromuscular blockade.
placenta that develops in monozygotic Hypomagnesemia isn’t a complication of
twins depends on the time at which preeclampsia. Antihypertensive drug other
cleavage of the ovum occurs. Cleavage in than magnesium are preferred for sustained
conjoined twins occurs more than 13 days hypertension. Magnesium doesn’t help
after fertilization. Cleavage that occurs less prevent hemorrhage in preeclamptic clients.
than 3 day after fertilization results in 92. Answer: (C) I.V. fluids. A sickle cell crisis
diamniotic dicchorionic twins. Cleavage during pregnancy is usually managed by
that occurs between days 3 and 8 results in exchange transfusion oxygen, and L.V.
 Fluids. The client usually needs a stronger aorta and inferior vena cava by the fetus.
analgesic than acetaminophen to control the This, in turn, inhibits maternal circulation,
pain of a crisis. Antihypertensive drugs leading to maternal hypotension and,
usually aren’t necessary. Diuretic wouldn’t ultimately, fetal hypoxia. The other
be used unless fluid overload resulted. positions promote comfort and aid labor
93. Answer: (A) Calcium gluconate (Kalcinate). progress. For instance, the lateral, or side-
Calcium gluconate is the antidote for lying, position improves maternal and fetal
magnesium toxicity. Ten milliliters of 10% circulation, enhances comfort, increases
calcium gluconate is given L.V. push over maternal relaxation, reduces muscle tension,
3 to 5 minutes. Hydralazine is given for and eliminates pressure points. The
sustained elevated blood pressure in squatting position promotes comfort by
preeclamptic clients. Rho (D) immune taking advantage of gravity. The standing
globulin is given to women with Rh- position also takes advantage of gravity and
negative blood to prevent antibody aligns the fetus with the pelvic angle.
formation from RH-positive conceptions. 98. Answer: (B) Irritability and poor sucking.
Naloxone is used to correct narcotic Neonates of heroin-addicted mothers are
toxicity. physically dependent on the drug and
94. Answer: (B) An indurated wheal over 10 experience withdrawal when the drug is no
mm in diameter appears in 48 to 72 hours. longer supplied. Signs of heroin withdrawal
A positive PPD result would be an include irritability, poor sucking, and
indurated wheal over 10 mm in diameter restlessness. Lethargy isn’t associated with
that appears in 48 to 72 hours. The area neonatal heroin addiction. A flattened nose,
must be a raised wheal, not a flat small eyes, and thin lips are seen in infants
circumcised area to be considered positive. with fetal alcohol syndrome. Heroin use
95. Answer: (C) Pyelonephritis. The symptoms during pregnancy hasn’t been linked to
indicate acute pyelonephritis, a serious specific congenital anomalies.
condition in a pregnant client. UTI 99. Answer: (A) 7th to 9th day postpartum. The
symptoms include dysuria, urgency, normal involutional process returns the
frequency, and suprapubic tenderness. uterus to the pelvic cavity in 7 to 9 days. A
Asymptomatic bacteriuria doesn’t cause significant involutional complication is the
symptoms. Bacterial vaginosis causes failure of the uterus to return to the pelvic
milky white vaginal discharge but no cavity within the prescribed time period.
systemic symptoms. This is known as subinvolution.
96. Answer: (B) Rh-positive fetal blood crosses 100. Answer: (B) Uterine atony. Multiple
into maternal blood, stimulating maternal fetuses, extended labor stimulation with
antibodies. Rh isoimmunization occurs oxytocin, and traumatic delivery commonly
when Rh-positive fetal blood cells cross are associated with uterine atony, which
into the maternal circulation and stimulate may lead to postpartum hemorrhage.
maternal antibody production. In Uterine inversion may precede or follow
subsequent pregnancies with Rh-positive delivery and commonly results from
fetuses, maternal antibodies may cross back apparent excessive traction on the umbilical
into the fetal circulation and destroy the cord and attempts to deliver the placenta
fetal blood cells. manually. Uterine involution and some
97. Answer: (C) Supine position. The supine uterine discomfort are normal after delivery.
position causes compression of the client’s