Maternal & Child Health Nursing NCLEX part 3
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1. You performed Leopold’s maneuver and found the
following: breech presentation, fetal back at the right side of the mother.
Based on these findings, you can hear the fetal heart beat (PMI) BEST in which
location?
A. Left lower quadrant
B. Right lower quadrant
C. Left upper quadrant
D. Right upper quadrant
2. In Leopold’s maneuver step #1, you palpated a soft,
broad mass that moves with the rest of the mass. The correct interpretation of
this finding is:
A. The mass palpated at the fundal part is the head
part.
B. The presentation is breech.
C. The mass palpated is the back
D. The mass palpated is the buttocks.
3. In Leopold’s maneuver step # 3 you palpated a hard
round movable mass at the supra pubic area. The correct interpretation is that
the mass palpated is:
A. The buttocks because the presentation is breech.
B. The mass palpated is the head.
C. The mass is the fetal back.
D. The mass palpated is the small fetal part
4. The hormone responsible for a positive pregnancy
test is:
A. Estrogen
B. Progesterone
C. Human Chorionic Gonadotropin
D. Follicle Stimulating Hormone
5. The hormone responsible for the maturation of the
Graafian follicle is:
A. Follicle stimulating hormone
B. Progesterone
C. Estrogen
D. Luteinizing hormone
6. The most common normal position of the fetus in
utero is:
A. Transverse position
B. Vertical position
C. Oblique position
D. None of the above
7. In the later part of the 3rd trimester, the mother
may experience shortness of breath. This complaint maybe explained as:
A. A normal occurrence in pregnancy because the fetus
is using more oxygen
B. The fundus of the uterus is high pushing the
diaphragm upwards
C. The woman is having allergic reaction to the
pregnancy and its hormones
D. The woman maybe experiencing complication of
pregnancy
8. Which of the following findings in a woman would be
consistent with a pregnancy of two months duration?
A. Weight gain of 6-10 lbs. And the presence of striae
gravidarum
B. Fullness of the breast and urinary frequency
C. Braxton Hicks contractions and quickening
D. Increased respiratory rate and ballottement
9. Which of the following is a positive sign of
pregnancy?
A. Fetal movement felt by mother
B. Enlargement of the uterus
C. (+) pregnancy test
D. (+) ultrasound
10. What event occurring in the second trimester helps
the expectant mother to accept the pregnancy?
A. Lightening
B. Ballotment
C. Pseudocyesis
D. Quickening
11. Shoes with low, broad heels, plus a good posture
will prevent which prenatal discomfort?
A. Backache
B. Vertigo
C. Leg cramps
D. Nausea
12. When a pregnant woman experiences leg cramps, the
correct nursing intervention to relieve the muscle cramps is:
A. Allow the woman to exercise
B. Let the woman walk for a while
C. Let the woman lie down and dorsiflex the foot
towards the knees
D. Ask the woman to raise her legs
13. From the 33rd week of gestation till full term, a
healthy mother should have a prenatal check up every:
A. week
B. 2 weeks
C. 3 weeks
D. 4 weeks
14. The expected weight gain in a normal pregnancy
during the 3rd trimester is
A. 1 pound a week
B. 2 pounds a week
C. 10 lbs a month
D. 10 lbs total weight gain in the 3rd trimester
15. In Bartholomew’s rule of 4, when the level of the
fundus is midway between the umbilicus and xiphoid process the estimated age of
gestation (AOG) is:
A. 5th month
B. 6th month
C. 7th month
D. 8th month
16. The following are ways of determining expected
date of delivery (EDD) when the LMP is unknown EXCEPT:
A. Naegele’s rule
B. Quickening
C. McDonald’s rule
D. Batholomew’s rule of 4
17. If the LMP is Jan. 30, the expected date of
delivery (EDD) is
A. Oct. 7
B. Oct. 24
C. Nov. 7
D. Nov. 8
18. Kegel’s exercise is done in pregnancy in order to:
A. Strengthen perineal muscles
B. Relieve backache
C. Strengthen abdominal muscles
D. Prevent leg varicosities and edema
19. Pelvic rocking is an appropriate exercise in
pregnancy to relieve which discomfort?
A. Leg cramps
B. Urinary frequency
C. Orthostatic hypotension
D. Backache
20. The main reason for an expected increased need for
iron in pregnancy is:
A. The mother may have physiologic anemia due to the
increased need for red blood cell mass as well as the fetal requires about
350-400 mg of iron to grow
B. The mother may suffer anemia because of poor
appetite
C. The fetus has an increased need for RBC which the
mother must supply
D. The mother may have a problem of digestion because
of pica
21. The diet that is appropriate in normal pregnancy
should be high in
A. Protein, minerals, and vitamins
B. Carbohydrates and vitamins
C. Proteins, carbohydrates, and fats
D. Fats and minerals
22. Which of the following signs will require a mother
to seek immediate medical attention?
A. When the first fetal movement is felt
B. No fetal movement is felt on the 6th month
C. Mild uterine contraction
D. Slight dyspnea on the last month of gestation
23. You want to perform a pelvic examination on one of
your pregnant clients. You prepare your client for the procedure by:
A. Asking her to void
B. Taking her vital signs and recording the readings
C. Giving the client a perineal care
D. Doing a vaginal prep
24. When preparing the mother who is in her 4th month
of pregnancy for an abdominal ultrasound, the nurse should instruct her to:
A. Observe NPO from midnight to avoid vomiting
B. Do perineal flushing properly before the procedure
C. Drink at least 2 liters of fluid 2 hours before the
procedure and not void until the procedure is done
D. Void immediately before the procedure for better
visualization
25. The nursing intervention to relieve “morning
sickness” in a pregnant woman is by giving
A. Dry carbohydrate food like crackers
B. Low sodium diet
C. Intravenous infusion
D. Antacid
26. The common normal site of nidation/implantation in
the uterus is
A. Upper uterine portion
B. Mid-uterine area
C. Lower uterine segment
D. Lower cervical segment
27. Mrs. Santos is on her 5th pregnancy and has a
history of abortion in the 4th pregnancy, and the first pregnancy was a twin.
She is considered to be
A. G 4 P 3
B. G 5 P 3
C. G 5 P 4
D. G 4 P 4
28. The following are skin changes in pregnancy
EXCEPT:
A. Chloasma
B. Striae gravidarum
C. Linea negra
D. Chadwick’s sign
29. Which of the following statements is TRUE of
conception?
A. Within 2-4 hours after intercourse, conception is
possible in a fertile woman
B. Generally, fertilization is possible 4 days after
ovulation
C. Conception is possible during menstruation in a
long menstrual cycle
D. To avoid conception, intercourse must be avoided 5
days before and 3 days after menstruation
30. Which of the following are the functions of
amniotic fluid?
1. Cushions the fetus from abdominal trauma
2. Serves as the fluid for the fetus
3. Maintains the internal temperature
4. Facilitates fetal movement
A. 1 & 3
B. 1, 3, 4
C. 1, 2, 3
D. All of the above
31. You are performing an abdominal exam on a
9th-month pregnant woman. While lying supine, she felt breathless, had pallor,
tachycardia, and cold clammy skin. The correct assessment of the woman’s
condition is that she is:
A. Experiencing the beginning of labor
B. Having supine hypotension
C. Having sudden elevation of BP
D. Going into shock
32. Smoking is contraindicated in pregnancy because
A. Nicotine causes vasodilation of the mother’s blood
vessels
B. Carbon monoxide binds with the hemoglobin of the
mother reducing available hemoglobin for the fetus
C. The smoke will make the fetus, and the mother feel
dizzy
D. Nicotine will cause vasoconstriction of the fetal
blood vessels
33. Which of the following is the most likely effect
on the fetus if the woman is severely anemic during pregnancy?
A. Large for gestational age (LGA) fetus
B. Hemorrhage
C. Small for gestational age (SGA) baby
D. Erythroblastosis fetalis
34. Which of the following signs and symptoms will
most likely make the nurse suspect that the patient has hydatidiform mole?
A. Slight bleeding
B. Passage of clear vesicular mass per vagina
C. Absence of fetal heart beat
D. Enlargement of the uterus
35. Upon assessment, the nurse found the following:
fundus at 2 fingerbreadths above the umbilicus, last menstrual period (LMP) 5
months ago, fetal heart beat (FHB) not appreciated. Which of the following is
the most possible diagnosis of this condition?
A. Hydatidiform mole
B. Missed abortion
C. Pelvic inflammatory disease
D. Ectopic pregnancy
36. When a pregnant woman goes into a convulsive
seizure, the MOST immediate action of the nurse to ensure the safety of the
patient is:
A. Apply restraint so that the patient will not fall
out of bed
B. Put a mouth gag so that the patient will not bite
her tongue and the tongue will not fall back
C. Position the mother on her side to allow the
secretions to drain from her mouth and prevent aspiration
D. Check if the woman is also having a precipitate
labor
37. A gravidocardiac mother is advised to observe bed
rest primarily to
A. Allow the fetus to achieve normal intrauterine
growth
B. Minimize oxygen consumption which can aggravate the
condition of the compromised heart of the mother
C. Prevent perinatal infection
D. Reduce incidence of premature labor
38. A pregnant mother is admitted to the hospital with
the chief complaint of profuse vaginal bleeding, AOG 36 wks, not in labor. The
nurse must always consider which of the following precautions:
A. The internal exam is done only at the delivery
under strict asepsis with a double set-up
B. The preferred manner of delivering the baby is
vaginal
C. An emergency delivery set for vaginal delivery must
be made ready before examining the patient
D. Internal exam must be done following routine
procedure
39. Which of the following signs will distinguish
threatened abortion from imminent abortion?
A. Severity of bleeding
B. Dilation of the cervix
C. Nature and location of pain
D. Presence of uterine contraction
40. The nursing measure to relieve fetal distress due
to maternal supine hypotension is:
A. Place the mother in semi-Fowler’s position
B. Put the mother on left side lying position
C. Place mother on a knee chest position
D. Any of the above
41. To prevent preterm labor from progressing, drugs
are usually prescribed to halt the labor. The drugs commonly given are:
A. Magnesium sulfate and terbutaline
B. Prostaglandin and oxytocin
C. Progesterone and estrogen
D. Dexamethasone and prostaglandin
42. In placenta praevia marginalis, the placenta is
found at the:
A. Internal cervical os partly covering the opening
B. External cervical os slightly covering the opening
C. Lower segment of the uterus with the edges near the
internal cervical os
D. Lower portion of the uterus completely covering the
cervix
43. In which of the following conditions can the
causative agent pass through the placenta and affect the fetus in utero?
A. Gonorrhea
B. Rubella
C. Candidiasis
D. moniliasis
44. Which of the following can lead to infertility in
adult males?
A. German measles
B. Orchitis
C. Chicken pox
D. Rubella
45. Papanicolaou smear is usually done to determine
cancer of
A. Cervix
B. Ovaries
C. Fallopian tubes
D. Breast
46. Which of the following causes of infertility in
the female is primarily psychological in origin?
A. Vaginismus
B. Dyspareunia
C. Endometriosis
D. Impotence
47. Before giving a repeat dose of magnesium sulfate
to a pre-eclamptic patient, the nurse should assess the patient’s condition.
Which of the following conditions will require the nurse to temporarily suspend
a repeat dose of magnesium sulfate?
A. 100 cc. urine output in 4 hours
B. Knee jerk reflex is (+)2
C. Serum magnesium level is 10mEg/L.
D. Respiratory rate of 16/min
48. Which of the following is TRUE in Rh
incompatibility?
A. The condition can occur if the mother is Rh(+) and
the fetus is Rh(-)
B. Every pregnancy of a Rh(-) mother will result to
erythroblastosis fetalis
C. On the first pregnancy of the Rh(-) mother, the
fetus will not be affected
D. RhoGam is given only during the first pregnancy to
prevent incompatibility
49. Which of the following are the most commonly
assessed findings in cystitis?
A. Frequency, urgency, dehydration, nausea, chills, and
flank pain
B. Nocturia, frequency, urgency dysuria, hematuria,
fever and suprapubic pain
C. Dehydration, hypertension, dysuria, suprapubic
pain, chills, and fever
D. High fever, chills, flank pain nausea, vomiting,
dysuria, and frequency
50. Which of the following best reflects the frequency
of reported postpartum “blues”?
A. Between 10% and 40% of all new mothers report some
form of postpartum blues
B. Between 30% and 50% of all new mothers report some
form of postpartum blues
C. Between 50% and 80% of all new mothers report some
form of postpartum blues
D. Between 25% and 70% of all new mothers report some
form of postpartum blues
51. Which of the following conditions will lead to a
small-for-gestational-age fetus due to less blood supply to the fetus?
A. Diabetes in the mother
B. Maternal cardiac condition
C. Premature labor
D. Abruptio placenta
52. The lower limit of viability for infants in terms
of age of gestation is:
A. 21-24 weeks
B. 25-27 weeks
C. 28-30 weeks
D. 38-40 weeks
53. A nurse in the labor room is monitoring a client
with dysfunctional labor for signs of maternal or fetal compromise. Which of
the following assessment findings would alert the nurse to a compromise?
A. Coordinated uterine contractions
B. Meconium in the amniotic fluid
C. Progressive changes in the cervix
D. Maternal fatigue
54. While assessing a G2P2 client who had a normal
spontaneous vaginal delivery 30 minutes ago, the nurse notes a large amount of
red vaginal bleeding. What would be the initial priority nursing action?
A. Notify the physician
B. Encourage to breast-feed soon after birth
C. Monitor vital signs
D. Provide fundal massage
55. The preferred manner of delivering the baby in a
gravido-cardiac is vaginal delivery assisted by forceps under epidural anesthesiA.
The main rationale for this is:
A. To allow atraumatic delivery of the baby
B. To allow a gradual shifting of the blood into the
maternal circulation
C. To make the delivery effort free and the mother
does not need to push with contractions
D. To prevent perineal laceration with the expulsion
of the fetal head
56. When giving narcotic analgesics to mother in
labor, the special consideration to follow is:
A. The progress of labor is well established reaching
the transitional stage
B. Uterine contraction is progressing well, and
delivery of the baby is imminent
C. Cervical dilatation has already reached at least 8
cm. and the station is at least (+)2
D. Uterine contractions are strong and the baby will
not be delivered yet within the next 3 hours.
57. The cervical dilatation taken at 8:00 AM in a G1P0
patient was 6 centimeters. A repeat I.E. done at 10 A. M. showed that cervical
dilation was 7 cm. The correct interpretation of this result is:
A. Labor is progressing as expected
B. The latent phase of Stage 1 is prolonged
C. The active phase of Stage 1 is protracted
D. The duration of labor is normal
58. Which of the following techniques during labor and
delivery can lead to uterine inversion?
A. Fundal pressure applied to assist the mother in
bearing down during delivery of the fetal head
B. Strongly tugging on the umbilical cord to deliver
the placenta and hasten placental separation
C. Massaging the fundus to encourage the uterus to
contract
D. Applying light traction when delivering the
placenta that has already detached from the uterine wall
59. The fetal heart rate is checked following rupture
of the bag of waters in order to:
A. Check if the fetus is suffering from head
compression
B. Determine if cord compression followed the rupture
C. Determine if there is uteroplacental insufficiency
D. Check if fetal presenting part has adequately
descended following the rupture
60. Upon assessment, the nurse got the following
findings: 2 perineal pads highly saturated with blood within 2 hours
postpartum, PR= 80 bpm, fundus soft and boundaries not well defineD. The
appropriate nursing diagnosis is:
A. Normal blood loss
B. Blood volume deficiency
C. Inadequate tissue perfusion related to hemorrhage
D. Hemorrhage secondary to uterine atony
61. The following are signs and symptoms of fetal
distress EXCEPT:
A. Fetal heart rate (FHR) decreased during a
contraction and persists even after the uterine contraction ends
B. The FHR is less than 120 bpm or over 160 bpm
C. The pre-contraction FHR is 130 bpm, FHR during
contraction is 118 bpm and FHR after uterine contraction is 126 bpm
D. FHR is 160 bpm, weak and irregular
62. If the labor period lasts only for 3 hours, the
nurse should suspect that the following conditions may occur:
1.Laceration of cervix
2.Laceration of perineum
3.Cranial hematoma in the fetus
4.Fetal anoxia
A. 1 & 2
B. 2 & 4
C. 2,3,4
D. 1,2,3,4
63. The primary power involved in labor and delivery
is
A. Bearing down ability of mother
B. Cervical effacement and dilatation
C. Uterine contraction
D. Valsalva technique
64. The proper technique to monitor the intensity of a
uterine contraction is
A. Place the palm of the hands on the abdomen and time
the contraction
B. Place the fingertips lightly on the suprapubic area
and time the contraction
C. Put the tip of the fingers lightly on the fundal
area and try to indent the abdominal wall at the height of the contraction
D. Put the palm of the hands on the fundal area and
feel the contraction at the fundal area
65. To monitor the frequency of the uterine
contraction during labor, the right technique is to time the contraction
A. From the beginning of one contraction to the end of
the same contraction
B. From the beginning of one contraction to the
beginning of the next contraction
C. From the end of one contraction to the beginning of
the next contraction
D. From the deceleration of one contraction to the
acme of the next contraction
66. The peak point of a uterine contraction is called
the
A. Acceleration
B. Acme
C. Deceleration
D. Axiom
67. When determining the duration of a uterine
contraction the right technique is to time it from
A. The beginning of one contraction to the end of the
same contraction
B. The end of one contraction to the beginning of
another contraction
C. The acme point of one contraction to the acme point
of another contraction
D. The beginning of one contraction to the end of
another contraction
68. When the bag of waters ruptures, the nurse should
check the characteristic of the amniotic fluiD. The normal color of amniotic
fluid is
A. Clear as water
B. Bluish
C. Greenish
D. Yellowish
69. When the bag of waters ruptures spontaneously, the
nurse should inspect the vaginal introitus for possible cord prolapse. If there
is part of the cord that has prolapsed into the vaginal opening the correct
nursing intervention is:
A. Push back the prolapsed cord into the vaginal canal
B. Place the mother on semi fowlers position to
improve circulation
C. Cover the prolapsed cord with sterile gauze wet
with sterile NSS and place the woman in Trendelenburg position
D. Push back the cord into the vagina and place the
woman on sims position
70. The fetal heart beat should be monitored every 15
minutes during the 2nd stage of labor. The characteristic of a normal fetal
heart rate is
A. The heart rate will decelerate during a contraction
and then go back to its pre-contraction rate after the contraction
B. The heart rate will accelerate during a contraction
and remain slightly above the pre-contraction rate at the end of the
contraction
C. The rate should not be affected by the uterine
contraction.
D. The heart rate will decelerate at the middle of a
contraction and remain so for about a minute after the contraction
71. The mechanisms involved in fetal delivery is
A. Descent, extension, flexion, external rotation
B. Descent, flexion, internal rotation, extension,
external rotation
C. Flexion, internal rotation, external rotation,
extension
D. Internal rotation, extension, external rotation,
flexion
72. The first thing that a nurse must ensure when the
baby’s head comes out is
A. The cord is intact
B. No part of the cord is encircling the baby’s neck
C. The cord is still attached to the placenta
D. The cord is still pulsating
73. To ensure that the baby will breathe as soon as
the head is delivered, the nurse’s priority action is to
A. Suction the nose and mouth to remove mucous
secretions
B. Slap the baby’s buttocks to make the baby cry
C. Clamp the cord about 6 inches from the base
D. Check the baby’s color to make sure it is not
cyanotic
74. When doing perineal care in preparation for
delivery, the nurse should observe the following EXCEPT
A. Use up-down technique with one stroke
B. Clean from the mons veneris to the anus
C. Use mild soap and warm water
D. Paint the inner thighs going towards the perineal
area
75. What are the important considerations that the
nurse must remember after the placenta is delivered?
1.Check if the placenta is complete including the
membranes
2.Check if the cord is long enough for the baby
3.Check if the umbilical cord has 3 blood vessels
4.Check if the cord has a meaty portion and a shiny
portion
A. 1 and 3
B. 2 and 4
C. 1, 3, and 4
D. 2 and 3
76. The following are correct statements about false
labor EXCEPT
A. The pain is irregular in intensity and frequency.
B. The duration of contraction progressively lengthens
over time
C. There is no bloody vaginal discharge
D. The cervix is still closeD.
77. The passageway in labor and delivery of the fetus
include the following EXCEPT
A. Distensibility of lower uterine segment
B. Cervical dilatation and effacement
C. Distensibility of vaginal canal and introitus
D. Flexibility of the pelvis
78. The normal umbilical cord is composed of:
A. 2 arteries and 1 vein
B. 2 veins and 1 artery
C. 2 arteries and 2 veins
D. none of the above
79. At what stage of labor and delivery does a
primigravida differ mainly from a multigravida?
A. Stage 1
B. Stage 2
C. Stage 3
D. Stage 4
80. The second stage of labor begins with ___ and ends
with __?
A. Begins with full dilatation of cervix and ends with
delivery of placenta
B. Begins with true labor pains and ends with delivery
of baby
C. Begins with complete dilatation and effacement of
cervix and ends with delivery of baby
D. Begins with passage of show and ends with full
dilatation and effacement of cervix
81. The following are signs that the placenta has
detached EXCEPT:
A. Lengthening of the cord
B. Uterus becomes more globular
C. Sudden gush of blood
D. Mother feels like bearing down
82. When the shiny portion of the placenta comes out
first, this is called the ___ mechanism.
A. Schultze
B. Ritgens
C. Duncan
D. Marmets
83. When the baby’s head is out, the immediate action
of the nurse is
A. Cut the umbilical cord
B. Wipe the baby’s face and suction mouth first
C. Check if there is cord coiled around the neck
D. Deliver the anterior shoulder
84. When delivering the baby’s head the nurse supports
the mother’s perineum to prevent a tear. This technique is called
A. Marmet’s technique
B. Ritgen’s technique
C. Duncan maneuver
D. Schultze maneuver
85. The basic delivery set for normal vaginal delivery
includes the following instruments/articles EXCEPT:
A. 2 clamps
B. Pair of scissors
C. Kidney Basin
D. Retractor
86. As soon as the placenta is delivered, the nurse
must do which of the following actions?
A. Inspect the placenta for completeness including the
membranes
B. Place the placenta in a receptacle for disposal
C. Label the placenta properly
D. Leave the placenta in the kidney basin for the
nursing aide to dispose properly
87. In vaginal delivery done in the hospital setting,
the doctor routinely orders an oxytocin to be given to the mother parenterally.
The oxytocin is usually given after the placenta has been delivered and not
before because:
A. Oxytocin will prevent bleeding
B. Oxytocin can make the cervix close and thus trap
the placenta inside
C. Oxytocin will facilitate placental delivery
D. Giving oxytocin will ensure complete delivery of
the placenta
88. In a gravido-cardiac mother, the first 2 hours
postpartum (4th stage of labor and delivery) particularly in a cesarean section
is a critical period because at this stage
A. There is a fluid shift from the placental
circulation to the maternal circulation which can overload the compromised
heart.
B. The maternal heart is already weak and the mother
can die
C. The delivery process is strenuous to the mother
D. The mother is tired and weak which can distress the
heart
89. This drug is usually given parentally to enhance
uterine contraction:
A. Terbutaline
B. Pitocin
C. Magnesium sulfate
D. Lidocaine
90. The partograph is a tool used to monitor labor.
The maternal parameters measured/monitored are the following EXCEPT:
A. Vital signs
B. Fluid intake and output
C. Uterine contraction
D. Cervical dilatation
91. The following are natural childbirth procedures
EXCEPT:
A. Lamaze method
B. Dick-Read method
C. Ritgen’s maneuver
D. Psychoprophylactic method
92. The following are common causes of dysfunctional
labor. Which of these can a nurse, on her own manage?
A. Pelvic bone contraction
B. Full bladder
C. Extension rather than flexion of the head
D. Cervical rigidity
93. At what stage of labor is the mother is advised to
bear down?
A. When the mother feels the pressure at the rectal
area
B. During a uterine contraction
C. In between uterine contraction to prevent uterine
rupture
D. Anytime the mother feels like bearing down
94. The normal dilatation of the cervix during the
first stage of labor in a nullipara is
A. 1.2 cm./hr
B. 1.5 cm./hr.
C. 1.8 cm./hr
D. 2.0 cm./hr
95. When the fetal head is at the level of the ischial
spine, it is said that the station of the head is
A. Station –1
B. Station “0”
C. Station +1
D. Station +2
96. During an internal examination, the nurse palpated
the posterior fontanel to be at the left side of the mother at the upper
quadrant. The interpretation is that the position of the fetus is:
A. LOA
B. ROP
C. LOP
D. ROA
97. The following are types of breech presentation
EXCEPT:
A. Footling
B. Frank
C. Complete
D. Incomplete
98. When the nurse palpates the suprapubic area of the
mother and found that the presenting part is still movable, the right term for
this observation that the fetus is
A. Engaged
B. Descended
C. Floating
D. Internal Rotation
99. The placenta should be delivered normally within
___ minutes after the delivery of the baby.
A. 5 minutes
B. 30 minutes
C. 45 minutes
D. 60 minutes
100. When shaving a woman in preparation for cesarean
section, the area to be shaved should be from ___ to ___
A. Under breast to mid-thigh including the pubic area
B. The umbilicus to the mid-thigh
C. Xyphoid process to the pubic area
D. Above the umbilicus to the pubic area
Answers and Rationale
1. Answer: B. Right lower quadrant
Right lower quadrant. The landmark to look for when
looking for PMI is the location of the fetal back in relation to the right or
left side of the mother and the presentation, whether cephalic or breech. The
best site is the fetal back nearest the head.
2. Answer: D. The mass palpated is the buttocks.
The palpated mass is the fetal buttocks since it is
broad and soft and moves with the rest of the mass.
3. Answer: B. The mass palpated is the head.
When the mass palpated is hard round and movable, it
is the fetal head.
4. Answer: C. Human Chorionic Gonadotropin
Human chorionic gonadotropin (HCG) is the hormone
secreted by the chorionic villi which is the precursor of the placenta. In the
early stage of pregnancy, while the placenta is not yet fully developed, the
major hormone that sustains the pregnancy is HCG.
5. Answer: A. Follicle stimulating hormone
The hormone that stimulates the maturation if the of
the graafian follicle is the Follicle Stimulating Hormone which is released by
the anterior pituitary gland.
6. Answer: B. Vertical position
Vertical position means the fetal spine is parallel to
the maternal spine thus making it easy for the fetus to go out the birth canal.
Options A and C: If transverse or oblique, the fetus
can’t be delivered normally per vagina.
7. Answer: B. The fundus of the uterus is high pushing
the diaphragm upwards
From the 32nd week of the pregnancy, the fundus of the
enlarged uterus is pushing the respiratory diaphragm upwards. Thus, the lungs
have reduced space for expansion consequently reducing the oxygen supply.
8. Answer: B. Fullness of the breast and urinary
frequency
The fullness of the breast is due to the increased
amount of progesterone in pregnancy. The urinary frequency is caused by the
compression of the urinary bladder by the gravid uterus which is still within
the pelvic cavity during the first trimester.
9. Answer: D. (+) ultrasound
A positive ultrasound will confirm that a woman is
pregnant since the fetus in utero is directly visualized.
10. Answer: D. Quickening
Quickening is the first fetal movement felt by the
mother makes the woman realize that she is truly pregnant. In early pregnancy,
the fetus is moving but too weak to be felt by the mother. In the 18th-20th
week of gestation, the fetal movements become stronger thus the mother already
feels the movements.
11. Answer: A. Backache
Backache usually occurs in the lumbar area and becomes
more problematic as the uterus enlarges. The pregnant woman in her third
trimester usually assumes a lordotic posture to maintain balance causing an
exaggeration of the lumbar curvature. Low broad heels provide the pregnant
woman with a good support.
12. Answer: C. Let the woman lie down and dorsiflex
the foot towards the knees
Leg cramps is caused by the contraction of the
gastrocnimeus (leg muscle). Thus, the intervention is to stretch the muscle by
dosiflexing the foot of the affected leg towards the knee.
13. Answer: A. week
In the 9th month of pregnancy the mother needs to have
a weekly visit to the prenatal clinic to monitor fetal condition and to ensure
that she is adequately prepared for the impending labor and delivery.
14. Answer: A. 1 pound a week
During the 3rd trimester the fetus is gaining more
subcutaneous fat and is growing fast in preparation for extra uterine life.
Thus, one pound a week is expected.
15. Answer: C. 7th month
In Bartholomew’s Rule of 4, the landmarks used are the
symphysis pubis, umbilicus and xyphoid process. At the level of the umbilicus,
the AOG is approximately 5 months and at the level of the xyphoid process 9
months. Thus, midway between these two landmarks would be considered as 7
months AOG.
16. Answer: A. Naegele’s rule
Naegele’s Rule is determined based on the last
menstrual period of the woman.
17. Answer: C. Nov. 7
Based on the last menstrual period, the expected date
of delivery is Nov. 7. The formula for the Naegele’s Rule is subtract 3 from
the month and add 7 to the day.
18. Answer: A.
Strengthen perineal muscles
Kegel’s exercise is done by contracting and relaxing
the muscles surrounding the vagina and anus in order to strengthen the perineal
muscles
19.Answer: D. Backache
Backache is caused by the stretching of the muscles of
the lower back because of the pregnancy. Pelvic rocking is good to relieve
backache.
20. Answer: A. The mother may have physiologic anemia
due to the increased need for red blood cell mass, as well as the fetal,
requires about 350-400 mg of iron to grow
About 400 mgs of Iron is needed by the mother in order
to produce more RBC mass to be able to provide the needed increase in blood
supply for the fetus. Also, about 350-400 mgs of iron is need for the normal
growth of the fetus. Thus, about 750-800 mgs iron supplementation is needed by
the mother to meet this additional requirement.
21. Answer: A. Protein, minerals and vitamins
In normal pregnancy there is a higher demand for
protein (body building foods), vitamins (esp. vitamin A, B, C, folic acid) and
minerals (esp. iron, calcium, phosphorous, zinc, iodine, magnesium) because of
the need of the growing fetus.
22. Answer: B. No fetal movement is felt on the 6th
month
Fetal movement is usually felt by the mother during
4.5 – 5 months. If the pregnancy is already in its 6th month and no fetal
movement is felt, the pregnancy is not normal either the fetus is already dead
intra-uterine or it is an H-mole.
23. Answer: A. Asking her to void
A pelvic examination includes abdominal palpation. If
the pregnant woman has a full bladder, the manipulation may cause discomfort
and accidental urination because of the pressure applied during the abdominal
palpation. Also, a full bladder can impede the accuracy of the examination
because the bladder (which is located in front of the uterus) can block the
uterus.
24. Answer: C. Drink at least 2 liters of fluid 2
hours before the procedure and not void until the procedure is done
Drinking at least 2 liters of water 2 hours before the
procedure will result to a distended bladder. A full bladder is needed when
doing an abdominal ultrasound to serve as a “window” for the ultrasonic sound
waves to pass through and allow visualization of the uterus (located behind the
urinary bladder).
25. Answer: A. Dry carbohydrate food like crackers
Morning sickness maybe caused by hypoglycemia early in
the morning thus giving carbohydrate food will help.
26. Answer: A. Upper uterine portion
The embryo’s normal nidation site is the upper portion
of the uterus. If the implantation is in the lower segment, this is an abnormal
condition called placenta previa.
27. Answer: B. G 5 P 3
Gravida refers to the total number of pregnancies
including the current one. Para refers to the number of pregnancies that have
reached viability. Thus, if the woman has had one abortion, she would be
considered Para 3. Twin pregnancy is counted only as 1.
28. Answer: D. Chadwick’s sign
Chadwick’s sign is bluish discoloration of the vaginal
mucosa as a result of the increased vascularization in the area.
29.Answer: A. Within 2-4 hours after intercourse
conception is possible in a fertile woman
The sperms when deposited near the cervical os will be
able to reach the fallopian tubes within 4 hours. If the woman has just
ovulated (within 24hours after the rupture of the graafian follicle),
fertilization is possible.
30. Answer: D. All of the above
All the four functions enumerated are true of amniotic
fluid.
31. Answer: B. Having supine hypotension
Supine hypotension is characterized by breathlessness,
pallor, tachycardia and cold, clammy skin. This is due to the compression of
the abdominal aorta by the gravid uterus when the woman is in a supine
position.
32. Answer: B. Carbon monoxide binds with the
hemoglobin of the mother reducing available hemoglobin for the fetus
Carbon monoxide is one of the substances found in
cigarette smoke. This substance diminishes the ability of the hemoglobin to
bind with oxygen thus reducing the amount of oxygenated blood reaching the
fetus.
33. Answer: C. Small for gestational age (SGA) baby
Anemia is a condition where there is a reduced amount
of hemoglobin. Hemoglobin is needed to supply the fetus with adequate oxygen.
Oxygen is needed for normal growth and development of the fetus.
34. Answer: B. Passage of clear vesicular mass per vagina
Hydatidiform mole (H-mole) is characterized by the
degeneration of the chorionic villi wherein the villi becomes vesicle-like.
These vesicle-like substances when expelled per vagina and is a definite sign
that the woman has H-mole.
35. Answer: A. Hydatidiform mole
Hydatidiform mole begins as a pregnancy but early in
the development of the embryo degeneration occurs. The proliferation of the
vesicle-like substances is rapid causing the uterus to enlarge bigger than the
expected size based on ages of gestation (AOG). In the situation given, the
pregnancy is only 5 months but the size of the uterus is already above the
umbilicus which is compatible with 7 months AOG. Also, no fetal heart beat is
appreciated because the pregnancy degenerated thus there is no appreciable
fetal heart beat.
36. Answer: C. Position the mother on her side to
allow the secretions to drain from her mouth and prevent aspiration
Positioning the mother on her side will allow the
secretions that may accumulate in her mouth to drain by gravity thus preventing
aspiration pneumonia.
Option B: Putting a mouth gag is not safe since during
the convulsive seizure the jaw will immediately lock.
Option C: The mother may go into labor also during the
seizure, but the immediate concern of the nurse is the safety of the baby.
After the seizure, check the perineum for signs of precipitate labor.
37. Answer: B. Minimize oxygen consumption which can
aggravate the condition of the compromised heart of the mother
Activity of the mother will require more oxygen
consumption. Since the heart of a gravido-cardiac is compromised, there is a
need to put a mother on bedrest to reduce the need for oxygen.
38. Answer: A. The internal exam is done only at the
delivery under strict asepsis with a double set-up
Painless vaginal bleeding during the third trimester
maybe a sign of placenta praevia.
Option B: If
the bleeding is due to soft tissue injury in the birth canal, immediate vaginal
delivery may still be possible so the set up for vaginal delivery will be used.
Option C: A double set-up means there is a set up for
cesarean section and a set-up for vaginal delivery to accommodate immediately
the necessary type of delivery needed. In both cases, strict asepsis must be
observed.
Option D: If an internal examination is done in this
kind of condition, this can lead to even more bleeding and may require
immediate delivery of the baby by cesarean section.
39. Answer: B. Dilation of the cervix
In imminent abortion, the pregnancy will definitely be
terminated because the cervix is already open unlike in threatened abortion
where the cervix is still closed.
40. Answer: B. Put the mother on left side lying
position
When a pregnant woman lies on supine position, the
weight of the gravid uterus would be compressing on the vena cava against the
vertebrae obstructing blood flow from the lower extremities. This causes a
decrease in blood return to the heart and consequently immediate decreased
cardiac output and hypotension. Hence, putting the mother on side lying will relieve
the pressure exerted by the gravid uterus on the vena cava.
41. Answer: A. Magnesium sulfate and terbutaline
Magnesium sulfate acts as a CNS depressant as well as
a smooth muscle relaxant. Terbutaline is a drug that inhibits the uterine
smooth muscles from contracting. On the other hand, oxytocin and prostaglandin
stimulates contraction of smooth muscles.
42. Answer: C. Lower segment of the uterus with the
edges near the internal cervical os
Placenta marginalis is a type of placenta previa
wherein the placenta is implanted at the lower segment of the uterus thus the
edges of the placenta are touching the internal cervical opening/os. The normal
site of placental implantation is the upper portion of the uterus.
43. Answer: B. Rubella
Rubella is caused by a virus and viruses have low
molecular weight thus can pass through the placental barrier.
Options A, C, and D: Gonorrhea, candidiasis and
moniliasis are conditions that can affect the fetus as it passes through the
vaginal canal during the delivery process.
44. Answer: B. Orchitis
Orchitis is a complication that may accompany mumps in
adult males. This condition is characterized by unilateral inflammation of one
of the testes which can lead to atrophy of the affected testis. About 20-30% of
males who gets mumps after puberty may develop this complication.
45. Answer: A. Cervix
Papanicolaou (Paps) smear is done to detect cervical
cancer. It can’t detect cancer in ovaries and fallopian tubes because these
organs are outside of the uterus and the abnormal cells from these organs will
not be detected from a smear done on the cervix.
46. Answer: A. Vaginismus
Vaginismus is primarily psychological in origin.
Option B: Dyspareunia is usually caused by infection,
endometriosis or hormonal changes in menopause although may sometimes be
psychological in origin.
Option C: Endometriosis is a condition that is caused
by organic abnormalities.
47. Answer: A. 100 cc. urine output in 4 hours
The minimum urine output expected for a repeat dose of
MgSO4 is 30 cc/hr. If in 4 hours the urine output is only 100 cc this is low
and can lead to poor excretion of Magnesium with a possible cumulative effect,
which can be dangerous to the mother.
48. Answer: C. On the first pregnancy of the Rh(-)
mother, the fetus will not be affected
On the first pregnancy, the mother still has no
contact with Rh(+) blood thus it has not antibodies against Rh(+). After the
first pregnancy, even if terminated into an abortion, there is already the
possibility of mixing of maternal and fetal blood so this can trigger the
maternal blood to produce antibodies against Rh(+) blood. The fetus takes it’s
blood type usually form the father.
49. Answer: B.
Manifestations of cystitis include, frequency, urgency, dysuria,
hematuria nocturia, fever, and suprapubic pain.
Dehydration, hypertension, and chills are not
typically associated with cystitis. High fever chills, flank pain, nausea,
vomiting, dysuria, and frequency are associated with pyelonephritis.
50. Answer: (C) According to statistical reports,
between 50% and 80% of all new mothers report some form of postpartum blues.
The ranges of 10% to 40%, 30% to 50%, and 25% to 70% are incorrect.
51. Answer: B. Maternal cardiac condition
In general, when the heart is compromised such as in
maternal cardiac condition, the condition can lead to less blood supply to the
uterus consequently to the placenta which provides the fetus with the essential
nutrients and oxygen. Thus if the blood supply is less, the baby will suffer
from chronic hypoxia leading to a small-for-gestational-age condition.
52. Answer: A. 21-24 weeks
Viability means the capability of the fetus to
live/survive outside of the uterine environment. With the present technological
and medical advances, 21 weeks AOG is considered as the minimum fetal age for
viability.
53. Answer: B. Meconium in the amniotic fluid
Signs of maternal or fetal compromise include passage
of meconium, decreased movement felt by the mother, nonreassuring fetal heart
rate, and fetal metabolic acidosis.
Options A and C: Coordinated uterine contractions and
progressive changes in the cervix are a reassuring pattern in labor.
Option D: Maternal fatigue can occur with prolonged
labor, but do not indicate maternal or fetal compromise.
54. Answer: D. Provide fundal massage
Fundal massage also called uterine massage is done to
reduce bleeding and cramping of the uterus after childbirth. This would be the
priority nursing action since it directly addresses the problem.
Options A and C are appropriate nursing actions, but
do nothing to stop the immediate bleeding.
Option B: Breastfeeding the baby will stimulate the
release of oxytocin, which will cause uterine contraction, but it will be
slower to do so than the fundal massage.
55. Answer: C. To make the delivery effort free and
the mother does not need to push with contractions
Forceps delivery under epidural anesthesia will make
the delivery process less painful and require less effort to push for the
mother. Pushing requires more effort which a compromised heart may not be able
to endure.
56. Answer: D. Uterine contractions are strong and the
baby will not be delivered yet within the next 3 hours.
Narcotic analgesics must be given when uterine
contractions are already well established so that it will not cause stoppage of
the contraction thus protracting labor. Also, it should be given when delivery
of fetus is imminent or too close because the fetus may suffer respiratory
depression as an effect of the drug that can pass through placental barrier.
57. Answer: C. The active phase of Stage 1 is
protracted
The active phase of Stage I starts from 4cm cervical
dilatation and is expected that the uterus will dilate by 1cm every hour. Since
the time elapsed is already 2 hours, the dilatation is expected to be already 8
cm. Hence, the active phase is protracted.
58. Answer: B. Strongly tugging on the umbilical cord
to deliver the placenta and hasten placental separation
When the placenta is still attached to the uterine
wall, tugging on the cord while the uterus is relaxed can lead to inversion of
the uterus. Light tugging on the cord when placenta has detached is alright in
order to help deliver the placenta that is already detached.
59. Answer: B. Determine if cord compression followed
the rupture
After the rupture of the bag of waters, the cord may
also go with the water because of the pressure of the rupture and flow. If the
cord goes out of the cervical opening, before the head is delivered (cephalic
presentation), the head can compress on the cord causing fetal distress. Fetal
distress can be detected through the fetal heart tone. Thus, it is essential do
check the FHB right after rupture of bag to ensure that the cord is not being
compressed by the fetal head.
60. Answer: D. Hemorrhage secondary to uterine atony
All the signs in the stem of the question are signs of
hemorrhage. If the fundus is soft and boundaries not well defined, the cause of
the hemorrhage could be uterine atony.
61. Answer: C. The pre-contraction FHR is 130 bpm, FHR
during contraction is 118 bpm and FHR after uterine contraction is 126 bpm
The normal range of FHR is 120-160 bpm, strong and
regular. During a contraction, the FHR usually goes down but must return to its
pre-contraction rate after the contraction ends.
62. Answer: D. 1,2,3,4
all the above conditions can occur following a
precipitate labor and delivery of the fetus because there was little time for
the baby to adapt to the passageway. If the presentation is cephalic, the fetal
head serves as the main part of the fetus that pushes through the birth canal
which can lead to cranial hematoma, and possible compression of the cord may
occur which can lead to less blood and oxygen to the fetus (hypoxia). Likewise,
the maternal passageway (cervix, vaginal canal and perineum) did not have
enough time to stretch which can lead to a laceration.
63. Answer: C. Uterine contraction
Uterine contraction is the primary force that will
expel the fetus out through the birth canal Maternal bearing down is considered
the secondary power/force that will help push the fetus out.
64. Answer: C. Put the tip of the fingers lightly on
the fundal area and try to indent the abdominal wall at the height of the
contraction
In monitoring the intensity of the contraction the
best place is to place the fingertips at the fundal area. The fundus is the
contractile part of the uterus and the fingertips are more sensitive than the
palm of the hand.
65. Answer: B. From the beginning of one contraction
to the beginning of the next contraction
The frequency of the uterine contraction is defined as
from the beginning of one contraction to the beginning of another contraction.
66. Answer: B. Acme
Acme is the technical term for the highest point of
intensity of a uterine contraction.
67. Answer: A. The beginning of one contraction to the
end of the same contraction
Duration of a uterine contraction refers to one
contraction. Thus it is correctly measure from the beginning of one contraction
to the end of the same contraction and not of another contraction.
68. Answer: A. Clear as water
The normal color of the amniotic fluid is clear like
water. If it is yellowish, there is probably Rh incompatibility. If the color
is greenish, it is probably meconium stained.
69. Answer: C. Cover the prolapse cord with sterile
gauze wet with sterile NSS and place the woman in Trendelenburg position
The correct action of the nurse is to cover the cord
with sterile gauze wet with sterile NSS. Observe strict asepsis in the care of
the cord to prevent infection. The cord has to be kept moist to prevent it from
drying. Don’t attempt to put back the cord into the vagina but relieve pressure
on the cord by positioning the mother either on Trendelenburg or Sims position
70.Answer: A. The heart rate will decelerate during a
contraction and then go back to its pre-contraction rate after the contraction
The normal fetal heart rate will decelerate (go down)
slightly during a contraction because of the compression on the fetal head.
However, the heart rate should go back to the pre-contraction rate as soon as
the contraction is over since the compression on the head has also ended.
71. Answer: B. Descent, flexion, internal rotation,
extension, external rotation
The mechanism of fetal delivery begins with descent
into the pelvic inlet which may occur several days before true labor sets in
the primigravida. Flexion, internal rotation, and extension are mechanisms that
the fetus must perform as it accommodates through the passageway/birth canal.
Eternal rotation is done after the head is delivered so that the shoulders will
be easily delivered through the vaginal introitus.
72. Answer: B. No part of the cord is encircling the
baby’s neck
The nurse should check right away for possible cord
coil around the neck because if it is present, the baby can be strangulated by
it and the fetal head will have difficulty being delivered.
73.Answer: A. Suction the nose and mouth to remove
mucous secretions
Suctioning the nose and mouth of the fetus as soon as
the head is delivered will remove any obstruction that may be present allowing
for better breathing. Also, if mucus is in the nose and mouth, aspiration of
the mucus is possible which can lead to aspiration pneumonia. (Remember that
only the baby’s head has come out as given in the situation.)
74. Answer: D. Paint the inner thighs going towards
the perineal area
Painting of the perineal area in preparation for
delivery of the baby must always be done but the stroke should be from the
perineum going outwards to the thighs. The perineal area is the one being
prepared for the delivery and must be kept clean
75. Answer: A. 1 and 3
The nurse after delivering the placenta must ensure
that all the cotyledons and the membranes of the placenta are complete. Also,
the nurse must check if the umbilical cord is normal which means it contains
the 3 blood vessels: 1 vein and 2 arteries.
76. Answer: B. The duration of contraction
progressively lengthens over time
In false labor, the contractions remain to be
irregular in intensity and duration while in true labor, the contractions
become stronger, longer and more frequent.
77. Answer: D. Flexibility of the pelvis
The pelvis is a bony structure that is part of the
passageway but is not flexible. The lower uterine segment including the cervix
as well as the vaginal canal and introitus are all part of the passageway in
the delivery of the fetus.
78. Answer: A. 2 arteries and 1 vein
The umbilical cord is composed of 2 arteries and 1
vein.
79. Answer: A. Stage 1
In stage 1 during a normal vaginal delivery of a
vertex presentation, the multigravida may have about 8 hours labor while the
primigravida may have up to 12 hours labor.
80. Answer: C. Begins with complete dilatation and
effacement of cervix and ends with delivery of baby
Stage 2 of labor and delivery process begins with full
dilatation of the cervix and ends with the delivery of the baby. Stage 1 begins
with true labor pains and ends with full dilatation and effacement of the
cervix.
81. Answer: D. Mother feels like bearing down
Placental detachment does not require the mother to
bear down. A normal placenta will detach by itself without any effort from the
mother.
82. Answer: A. Schultze
There are 2 mechanisms possible during the delivery of
the placenta. If the shiny portion comes out first, it is called the Schultze
mechanism; while if the meaty portion comes out first, it is called the Duncan
mechanism.
83. Answer: C. Check if there is cord coiled around
the neck
The nurse should check if there is a cord coil because
the baby will not be delivered safely if the cord is coiled around its neck.
Wiping off the face should be done seconds after you have ensured that there is
no cord coil but suctioning of the nose should be done after the mouth because
the baby is a “nasal obligate” breather. If the nose is suctioned first before
the mouth, the mucus plugging the mouth can be aspirated by the baby.
84. Answer: B. Ritgen’s technique
Ritgen’s technique is done to prevent the perineal
tear. This is done by the nurse by support the perineum with a sterile towel
and pushing the perineum downward with one hand while the other hand is
supporting the baby’s head as it goes out of the vaginal opening.
85. Answer: D. Retractor
For normal vaginal delivery, the nurse needs only the
instruments for cutting the umbilical cord such as 2 clamps (straight or curve)
and a pair of scissors as well as the kidney basin to receive the placenta. The
retractor is not part of the basic set. In the hospital setting, needle holder
and tissue forceps are added especially if the woman delivering the baby is a
primigravida wherein episiotomy is generally done.
86. Answer: A. Inspect the placenta for completeness
including the membranes
The placenta must be inspected for completeness to
include the membranes because an incomplete placenta could mean that there is
retention of placental fragments which can lead to uterine atony. If the uterus
does not contract adequately, hemorrhage can occur.
87. Answer: B. Oxytocin can make the cervix close and
thus trap the placenta inside
The action of oxytocin is to make the uterus contract
as well make the cervix close. If it is given prior to placental delivery, the
placenta will be trapped inside because the action of the drug is almost
immediate if given parentally.
88. Answer: A. There is a fluid shift from the
placental circulation to the maternal circulation which can overload the
compromised heart.
During the pregnancy, there is an increase in maternal
blood volume to accommodate the need of the fetus. When the baby and placenta
have been delivered, there is a fluid shift back to the maternal circulation as
part of physiologic adaptation during the postpartum period. In a cesarean
section, the fluid shift occurs faster because the placenta is taken out right
after the baby is delivered giving it less time for the fluid shift to
gradually occur.
89. Answer: B. Pitocin
The common oxytocin given to enhance uterine
contraction is Pitocin. This is also the drug given to induce labor.
90. Answer: B. Fluid intake and output
Partograph is a monitoring tool designed by the World
Health Organization for use by health workers when attending to mothers in
labor, especially the high risk ones. For maternal parameters all of the above
is placed in the partograph except the fluid intake since this is placed in a
separate monitoring sheet.
91. Answer: C. Ritgen’s maneuver
Ritgen’s method is used to prevent perineal
tear/laceration during the delivery of the fetal head. Lamaze method is also
known as psychoprophylactic method and Dick-Read method are commonly known
natural childbirth procedures which advocate the use of non-pharmacologic
measures to relieve labor pain.
92. Answer: B. Full bladder
A full bladder can impede the descent of the fetal
head. The nurse can readily manage this problem by doing a simple
catheterization of the mother.
93. Answer: B. During a uterine contraction
The primary power of labor and delivery is the uterine
contraction. This should be augmented by the mother’s bearing down during a
contraction.
94. Answer: A. 1.2 cm./hr
For nullipara, the normal cervical dilatation should
be 1.2 cm/hr. If it is less than that, it is considered a protracted active
phase of the first stage. For multipara, the normal cervical dilatation is 1.5
cm/hr.
95. Answer: B. Station “0”
determining is defined as the relationship of the
fetal head and the level of the ischial spine. At the level of the ischial
spine, the station is “0”. Above the ischial spine it is considered (-) station
and below the ischial spine it is (+) station.
96. Answer: A. LOA
The landmark used in determine fetal position is the
posterior fontanel because this is the nearest to the occiput. So if the nurse
palpated the occiput (O) at the left (L) side of the mother and at the
upper/anterior (A) quadrant then the fetal position is LOA.
97. Answer: D. Incomplete
Breech presentation means the buttocks of the fetus is
the presenting part. If it is only the foot/feet, it is considered footling. If
only the buttocks, it is frank breech. If both the feet and the buttocks are
presenting it is called complete breech.
98. Answer: C. Floating
The term floating means the fetal presenting part has
not entered/descended into the pelvic inlet. If the fetal head has entered the
pelvic inlet, it is said to be engaged.
99. Answer: B. 30 minutes
The placenta is delivered within 30 minutes from the
delivery of the baby. If it takes longer, probably the placenta is abnormally
adherent and there is a need to refer already to the obstetrician.
100. Answer: A. Under breast to mid-thigh including
the pubic area
Shaving is done to prevent infection and the area
usually shaved should sufficiently cover the area for surgery, cesarean
section. The pubic hair is definitely to be included in the shaving
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