PNLE : Maternal and Child Health Nursing Exam 1

1. A client asks the nurse what a third degree laceration is. She was informed that she had one. The nurse explains that this is:

1. that extended their anal sphincter
2. through the skin and into the muscles
3. that involves anterior rectal wall
4. that extends through the perineal muscle.

2. Betina 30 weeks AOG discharged with a diagnosis of placenta previa. The nurse knows that the client understands her care at home when she says:

1. I am happy to note that we can have sex occasionally when I have no bleeding.
2. I am afraid I might have an operation when my due comes
3. I will have to remain in bed until my due date comes
4. I may go back to work since I stay only at the office.

3. The uterus has already risen out of the pelvis and is experiencing farther into the abdominal area at about the:

1. 8th week of pregnancy
2. 10th week of pregnancy
3. 12th week of pregnancy
4. 18th week of pregnancy

4. Which of the following urinary symptoms does the pregnant woman most frequently experience during the first trimester:

1. frequency
2. dysuria
3. incontinence
4. burning

5. Mrs. Jimenez went to the health center for pre-natal check-up. the student nurse took her weight and revealed 142 lbs. She asked the student nurse how much should she gain weight in her pregnancy.

1. 20-30 lbs
2. 25-35 lbs
3. 30- 40 lbs
4. 10-15 lbs

6. The nurse is preparing Mrs. Jordan for cesarean delivery. Which of the following key concept should the nurse consider when implementing nursing care?

1. Explain the surgery, expected outcome and kind of anesthetics.
2. Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth.
3. Arrange for a staff member of the anesthesia department to explain what to expect post-operatively.
4. Instruct the mother’s support person to remain in the family lounge until after the delivery.

7. Bettine Gonzales is hospitalized for the treatment of severe preecplampsia. Which of the following represents an unusual finding for this condition?

1. generalized edema
2. proteinuria 4+
3. blood pressure of 160/110
4. convulsions

8. Nurse Geli explains to the client who is 33 weeks pregnant and is experiencing vaginal bleeding that coitus:

1. Need to be modified in any way by either partner
2. Is permitted if penile penetration is not deep.
3. Should be restricted because it may stimulate uterine activity.
4. Is safe as long as she is in side-lying position.

9. Mrs. Precilla Abuel, a 32 year old mulripara is admitted to labor and delivery. Her last 3 pregnancies in short stage one of labor. The nurses decide to observe her closely. The physician determines that Mrs. Abuel’s cervix is dilated to 6 cm. Mrs. Abuel states that she is extremely uncomfortable. To lessen Mrs. Abuel’s discomfort, the nurse can advise her to:

1. lie face down
2. not drink fluids
3. practice holding breaths between contractions
4. assume Sim’s position

10. Which is true regarding the fontanels of the newborn?

1. The anterior is large in shape when compared to the posterior fontanel.
2. The anterior is triangular shaped; the posterior is diamond shaped.
3. The anterior is bulging; the posterior appears sunken.
4. The posterior closes at 18 months; the anterior closes at 8 to 12 months.

11. Mrs. Quijones gave birth by spontaneous delivery to a full term baby boy. After a minute after birth, he is crying and moving actively. His birth weight is 6.8 lbs. What do you expect baby Quijones to weigh at 6 months?

1. 13 -14 lbs
2. 16 -17 lbs
3. 22 -23 lbs
4. 27 -28 lbs

12. During the first hours following delivery, the post partum client is given IVF with oxytocin added to them. The nurse understands the primary reason for this is:

1. To facilitate elimination
2. To promote uterine contraction
3. To promote analgesia
4. To prevent infection

13. Nurse Luis is assessing the newborn’s heart rate. Which of the following would be considered normal if the newborn is sleeping?

1. 80 beats per minute
2. 100 beats per minute
3. 120 beats per minute
4. 140 beats per minute

14. The infant with Down Syndrome should go through which of the Erikson’s developmental stages first?

1. Initiative vs. Self doubt
2. Industry vs. Inferiority
3. Autonomy vs. Shame and doubt
4. Trust vs. Mistrust

15. The child with phenylketonuria (PKU) must maintain a low phenylalanine diet to prevent which of the following complications?

1. Irreversible brain damage
2. Kidney failure
3. Blindness
4. Neutropenia

16. Which age group is with imaginative minds and creates imaginary friends?

1. Toddler
2. Preschool
3. School
4. Adolescence

17. Which of the following situations would alert you to a potentially developmental problem with a child?

1. Pointing to body parts at 15 months of age.
2. Using gesture to communicate at 18 months.
3. Cooing at 3 months.
4. Saying “mama” or “dada” for the first time at 18 months of age.

18. Isabelle, a 2 year old girl loves to move around and oftentimes manifests negativism and temper tantrums. What is the best way to deal with her behavior?

1. Tell her that she would not be loved by others is she behaves that way..
2. Withholding giving her toys until she behaves properly.
3. Ignore her behavior as long as she does not hurt herself and others.
4. Ask her what she wants and give it to pacify her.

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

1. 3 inches
2. 4 inches
3. 5 inches
4. 6 inches

20. Alice, 10 years old was brought to the ER because of Asthma. She was immediately put under aerosol administration of Terbutaline. After sometime, you observe that the child does not show any relief from the treatment given. Upon assessment, you noticed that both the heart and respiratory rate are still elevated and the child shows difficulty of exhaling. You suspect:

1. Bronchiectasis
2. Atelectasis
3. Epiglotitis
4. Status Asthmaticus

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

1. Lymphedema and nerve palsy
2. Hearing loss and ataxia
3. Headaches and vomiting
4. Abdominal mass and weakness

22. Which of the following danger sings should be reported immediately during the antepartum period?

1. blurred vision
2. nasal stuffiness
3. breast tenderness
4. constipation

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

1. periorbital edema, absent light reflex and translucent tympanic membrane
2. irritability, purulent drainage in middle ear, nasal congestion and cough
3. diarrhea, retracted tympanic membrane and enlarged parotid gland
4. Vomiting, pulling at ears and pearly white tympanic membrane

24. Which of the following is the most appropriate intervention to reduce stress in a preterm infant at 33 weeks gestation?

1. Sensory stimulation including several senses at a time
2. tactile stimulation until signs of over stimulation develop
3. An attitude of extension when prone or side lying
4. Kangaroo care

25. The parent of a client with albinism would need to be taught which preventive healthcare measure by the nurse:

1. Ulcerative colitis diet
2. Use of a high-SPF sunblock
3. Hair loss monitoring
4. Monitor for growth retardation

Answers and Rationales

1. (A) that extended their anal sphincter. Third degree laceration involves all in the second degree laceration and the external sphincter of the rectum. Options B, C and D are under the second degree laceration.
2. (C) I will have to remain in bed until my due date comes. Placenta previa means that the placenta is the presenting part. On the first and second trimester there is spotting. On the third trimester there is bleeding that is sudden, profuse and painless.
3. (D) 18th week of pregnancy. On the 8th week of pregnancy, the uterus is still within the pelvic area. On the 10th week, the uterus is still within the pelvic area. On the 12th week, the uterus and placenta have grown, expanding into the abdominal cavity. On the 18th week, the uterus has already risen out of the pelvis and is expanding into the abdominal area.
4. (A) frequency. Pressure and irritation of the bladder by the growing uterus during the first trimester is responsible for causing urinary frequency. Dysuria, incontinence and burning are symptoms associated with urinary tract infection.
5. (B) 25-35 lbs. A weight gain of 11. 2 to 15.9 kg (25 to 35 lbs) is currently recommended as an average weight gain in pregnancy. This weight gain consists of the following: fetus- 7.5 lb; placenta- 1.5 lb; amniotic fluid- 2 lb; uterus- 2.5 lb; breasts- 1.5 to 3 lb; blood volume- 4 lb; body fat- 7 lb; body fluid- 7 lb.
6. (B) Modify preoperative teaching to meet the needs of either a planned or emergency cesarean birth. A key point to consider when preparing the client for a cesarean delivery is to modify the preoperative teaching to meet the needs of either planned or emergency cesarean birth, the depth and breadth of instruction will depend on circumstances and time available.
7. (D) convulsions. Options A, B and C are findings of severe preeclampsia. Convulsions is a finding of eclampsia—an obstetrical emergency.
8. (C) Should be restricted because it may stimulate uterine activity.. Coitus is restricted when there is watery discharge, uterine contraction and vaginal bleeding. Also those women with a history of spontaneous miscarriage may be advised to avoid coitus during the time of pregnancy when a previous miscarriage occurred.
9. (D) assume Sim’s position. When the woman is in Sim’s position, this puts the weight of the fetus on bed, not on the woman and allows good circulation in the lower extremities.
10. (A) The anterior is large in shape when compared to the posterior fontanel.. The anterior fontanel is larger in size than the posterior fontanel. Additionally, the anterior fontanel, which is diamond shaped closes at 18 month, whereas the posterior fontanel, which is triangular in shape closes at 8 to 12 weeks. Neither fontanel should appear bulging, which may indicate increases ICP or sunken, which may indicate hydration.
11. (A) 13 -14 lbs. The birth weight of an infant is doubled at 6 months and is tripled at 12 months.
12. (B) To promote uterine contraction. Oxytocin is a hormone produced by the pituitary gland that produces intermittent uterine contractions, helping to promote uterine involution.
13. (B) 100 beats per minute. The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute. If the newborn was awake, the normal heart rate would range from 120 to 160 beats per minute.
14. (D) Trust vs. Mistrust. The child with Down syndrome will go through the same first stage, trust vs. mistrust, only at a slow rate. Therefore, the nurse should concentrate on developing on bond between the primary caregiver and the child.
15. (A) Irreversible brain damage. The child with PKU must maintain a strict low phenylalanine diet to prevent central nervous system damage, seizures and eventual death.
16. (B) Preschool. During preschool, this is the time when children do imitative play, imaginative play—the occurrence of imaginative playmates, dramatic play where children like to act, dance and sing.
17. (D) Saying “mama” or “dada” for the first time at 18 months of age.. A child should say “mama” or “dada” during 10 to 12 months of age. Options A, B and C are all normal assessments of language development of a child.
18. (C) Ignore her behavior as long as she does not hurt herself and others.. If a child is trying to get attention or trying to get something through tantrums—ignore his/her behavior.
19. (B) 4 inches. From birth to 6 months, the infant grows 1 inch (2.5 cm) per month. From 6 to 12 months, the infant grows ½ inch (1.25 cm) per month.
20. (D) Status Asthmaticus. Status asthmaticus leads to respiratory distress and bronchospasm despite of treatment and interventions. Mechanical ventilation maybe needed due to respiratory failure.
21. (D) Abdominal mass and weakness. Nephroblastoma or Wilm’s tumor is caused by chromosomal abnormalities, most common kidney cancer among children characterized by abdominal mass, hematuria, hypertension and fever.
22. (A) blurred vision. Danger signs that require prompt reporting are leaking of amniotic fluid, blurred vision, vaginal bleeding, rapid weight gain and elevated blood pressure. Nasal stuffiness, breast tenderness, and constipation are common discomforts associated with pregnancy.
23. (B) irritability, purulent drainage in middle ear, nasal congestion and cough. Irritability, purulent drainage in middle ear, nasal congestion and cough, fever, loss of appetite, vomiting and diarrhea are clinical manifestations of otitis media. Acute otitis media is common in children 6 months to 3 years old and 8 years old and above. Breast fed infants have higher resistance due to protection of Eustachian tubes and middle ear from breast milk.
24. (D) Kangaroo care. Kangaroo care is the use of skin-to-skin contact to maintain body heat. This method of care not only supplies heat but also encourages parent-child interaction.
25. (B) Use of a high-SPF sunblock. Without melanin production, the child with albinism is at risk for severe sunburns. Maximum sun protection should be taken, including use of hats, long sleeves, minimal time in the sun and high-SPF sunblock, to prevent any problems.