Care of Mother - Well Client (N2024) - Ans Key.pdf

DAILY QUESTIONS MATERNAL AND CHILD NURSING I. Care of Mother (Well client) - 50 items SITUATION 1 – Birth hormones from the mother and fetus work together to guide important changes in the mother’s body which help m...

DAILY QUESTIONS MATERNAL AND CHILD NURSING I. Care of Mother (Well client) - 50 items SITUATION 1 – Birth hormones from the mother and fetus work together to guide important changes in the mother’s body which help make labor and birth go smoothly and safely. 1.) The follicle-stimulating hormone (FSH) stimulates the increase in estrogen, while the luteinizing hormone (LH) stimulates the increase in progesterone. The following are other correct statements about FSH and LH, EXCEPT A. FSH is responsible for oogenesis and spermatogenesis B. LH is responsible for the release of the mature egg C. High levels of estrogen further increase FSH D. LH forms the corpus luteum Rationale: In the menstrual cycle, the follicle-stimulating hormone (FSH) stimulates the growth and development of ovarian follicles, leading to the increase in estrogen production. On the other hand, the luteinizing hormone (LH) triggers ovulation, the release of the mature egg from the ovary. Option C is incorrect because high levels of estrogen in the menstrual cycle exert negative feedback on the hypothalamus and pituitary gland, inhibiting the release of FSH. This helps to regulate the production of FSH and maintain a balance in the hormonal milieu. Topic: The Menstrual Cycle 2.) Outside pregnancy, estrogen and progesterone are produced mainly by the ovaries. During pregnancy, the ovaries rest, and it is the corpus luteum that produces estrogen and progesterone during the first trimester. When placenta matures after three months, it takes over the corpus luteum and produces high levels of estrogen and progesterone. Estrogen is responsible for the following EXCEPT A. Spinnbarkeit and Ferning, leukorrhea, breast tenderness,vascular spiders, congested nose, palmar erythema, rashes and red blotches on skin B. Goodell’s sign, Hegar’s sign, and Chadwick’s sign C. Osteoporosis D. Suppression of FSH and prolactin Rationale: Estrogen is not responsible for causing osteoporosis. Instead, it helps maintain bone density and prevent osteoporosis. Topic: The Menstrual Cycle 3.) You are a clinic nurse who just received a call from one of your clients who has been taking estrogen pills for the past few years. The woman told you that she suddenly experienced a severe headache and blurring of vision. Which of the following would be your priority intervention? A. Allow the client to rest for the day B. Refer the client to an ophthalmologist C. Inform the woman to proceed to the hospital immediately for further evaluation D. Advise taking an over-the-counter analgesic or anti-hypertensive drug Rationale: Sudden severe headache and blurred vision in a client taking estrogen pills could be signs of a serious condition such as a stroke or blood clot, and immediate evaluation at the hospital is necessary to rule out any life-threatening complications. Topic: The Menstrual Cycle 4.) Progesterone is considered as the “Hormone of Mothers”. During pregnancy, it supports the endometrium, thereby maintaining the decidua for nine months. All of the following are effects of progesterone EXCEPT A. Constipation, urinary retention, varicose veins, and heart burn  B. Creation of the mucus plug C. Increased basal body temperature D. Increased vaginal secretions Rationale: Increased vaginal secretions are not an effect of progesterone. However, progesterone does contribute to other effects during pregnancy, such as constipation, urinary retention, varicose veins, and heartburn. These changes occur due to the relaxation of smooth muscles and increased water absorption in different body systems. Topic: The Menstrual Cycle 5.) Progesterone has an inverse relationship with oxytocin, while estrogen has an inverse relationship with prolactin. Which of the following facts is explained by the said relationship? A. The uterus relaxes once the newborn and placenta are delivered B. A breastfeeding mother can take estrogen pills for contraception C. Milk expression reflex is stimulated after the delivery of the fetus and placenta D. During pregnancy, the uterus makes strong contractions and starts increasing milk production Rationale: Milk expression reflex, which allows for milk let-down and breastfeeding, is stimulated by the release of oxytocin. During pregnancy, progesterone levels are high, and there is an inverse relationship between progesterone and oxytocin. Once the fetus and placenta are delivered, progesterone levels decrease, allowing the uterus to relax. This relaxation is necessary for postpartum recovery and the initiation of breastfeeding. Topic: The Menstrual Cycle SITUATION 2 – Pregnancy affects virtually all hormones in the body, mostly because of the effects of hormones produced by the placenta. 6.) The Human Chorionic Gonadotropin (HCG) is the basis of the pregnancy test. It can be detected in the maternal blood and urine within 10 days after fertilization. Which of the following is NOT a correct statement regarding HCG? A. The HCG supports the corpus luteum during the first three months and enhances the production of progesterone B. It causes mild vasoconstriction that results in signs of pregnancy-induced hypertension C. Molar pregnancies reveal enlarging uterus but negative HCG D. HCG is the hormone blamed for morning sickness during pregnancy Rationale: Molar pregnancy is one of a group of conditions known as gestational trophoblastic disease (GTD). It is sometimes called a hydatidiform mole. It happens when the fertilisation of the egg by the sperm goes wrong. This leads to the growth of abnormal cells or clusters of water filled sacs inside the womb. During pregnancy, the placenta releases a hormone called hCG into the bloodstream, and the body eliminates the excess hCG through urine. In the case of molar pregnancies, where there is abnormal growth of placental tissue, the levels of hCG can be significantly higher than normal. By measuring the levels of hCG in both blood and urine, healthcare providers can diagnose a molar pregnancy. Topic: The Menstrual Cycle 7.) The Human Placental Lactogen (HPL) is responsible for maternal breast development for lactation. Which of the following is another effect of HPL? A. HPL also produces lordosis and the waddling gait of the pregnant woman B. It stimulates over-pigmentation such as chloasma and linea nigra C. It enhances fetal nutrition by increasing glucose supply to the fetus via the mother D. It increases the effectiveness of maternal insulin, thereby protecting the mother from diabetes Rationale: Human Placental Lactogen (HPL) is also known as human chorionic somatomammotropin. It is made by the placenta. It gives nutrition to the fetus. It also stimulates milk glands in the breasts for breastfeeding. Topic: The Menstrual Cycle 8.) The menstrual cycle is composed of the menstrual, proliferative, and secretory phases. The menstrual phase is also called ischemic phase. The proliferative phase is also called estrogenic or follicular phase. The secretory phase is also called the progestational or luteal phase. Based on these clues, which of the following is a valid statement regarding the menstrual cycle phases? A. In the menstrual phase, the supply of estrogen and progesterone is reduced, causing degeneration of the endometrium, as manifested by menstruation B. In the proliferative phase, the endometrium is thinner because of estrogen C. In the luteal phase, the corpus luteum stops producing progesterone after ovulation D. The graafian follicle matures during the secretory phase Rationale: In the menstrual phase, the supply of estrogen and progesterone is reduced, causing degeneration of the endometrium, as manifested by menstruation. During the menstrual phase, the endometrium, which is the lining of the uterus, sheds due to a decrease in hormonal support, particularly estrogen and progesterone. Topic: The Menstrual Cycle 9.) Ovulation does not always happen on the 14th day of the menstrual cycle; it varies depending on the menstrual cycle duration, primarily. Which of the following is a TRUE statement about ovulation in a client who has a 27-day cycle? A. Ovulation may be estimated by subtracting 14 days from the cycle, plus or minus 3 days B. Ovulation is likely to happen on the 13th day of the cycle C. If the first day of menstruation is on June 13, ovulation is likely to happen on June 25 D. All of the above Rationale: Ovulation may vary in timing depending on the menstrual cycle duration. For a client with a 27-day cycle, estimating ovulation by subtracting 14 days from the cycle, plus or minus 3 days, is a general guideline. However, individual variations can occur. Topic: The Menstrual Cycle 10.)When the woman ovulates, she releases a mature egg, ready for fertilization. You are a nurse teaching a nullipara about signs of ovulation to help her determine her safe and unsafe days. Which of the following would you include as a sign of ovulation? A. Thick, sticky, and scanty cervical mucus B. Breast tenderness and increase in libido C. Bilateral abdominal pain and rigidity D. Sudden increase followed by a drastic decrease in basal body temperature Rationale: During ovulation, there are specific hormonal changes in a woman's body that can lead to breast tenderness and an increase in libido. These changes are primarily influenced by the rise in estrogen and progesterone levels during the menstrual cycle. Estrogen, which is produced by the developing ovarian follicles, plays a crucial role in preparing the body for ovulation. It stimulates the growth of the mammary glands in the breasts, causing them to become more sensitive and potentially leading to breast tenderness or soreness. In addition to estrogen, there is also an increase in luteinizing hormone (LH) levels during ovulation. LH triggers the release of the mature egg from the ovarian follicle. This surge in hormones, including estrogen, progesterone, and LH, can have an impact on a woman's libido or sexual desire. Some women may experience an increase in sexual arousal or interest during this time. These changes in breast tenderness and libido serve as indicators or signs of ovulation for women who are tracking their fertility. Topic: The Menstrual Cycle SITUATION 3 – Pregnancy causes many changes in a woman’s body. Most of them disappear after delivery. These changes cause some symptoms, which are normal. 11.) Various cardiovascular changes happen during pregnancy, including increased heart rate, cardiac output, blood volume and RBC. In addition to this, the levels of hemoglobin (Hgb) and hematocrit (Hct) also change. What statement best describes this change in the Hgb and Hct? A. They increase, proportional to marked elevation in the cardiac output, blood volume and RBC B. They decrease because the percentage of increase in plasma is greater than the percentage of increase in RBC C. They increase initially but because of the increased demands of the pregnant woman and the fetus, the Hgb and Hct values eventually go back to normal D. They increase, as the body recognizes the need to increase Hgb and Hct stores to meet the needs of the pregnant woman and fetus, and of labor, delivery and lactation. Rationale: During pregnancy, there is an increase in plasma volume, which is greater than the increase in red blood cell (RBC) production. This leads to hemodilution, where the concentration of RBCs in the blood decreases. As a result, the hemoglobin (Hgb) and hematocrit (Hct) levels decrease. This change is due to the expansion of plasma volume and the body's attempt to accommodate the increased blood volume needed for the developing fetus. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Physiologic Changes in Pregnancy 12.)RBC, fibrinogen and clotting factors increase during pregnancy, making the woman prone to thrombophlebitis and deep vein thrombosis. In order to prevent the development of these conditions, the nurse provides the following health teaching to the woman EXCEPT: A. Have regular leg exercises B. Support and protect the lower leg veins by wearing stockings that reach up to the knees at least C. Avoid prolonged sitting, standing, and bed rest D. Walk every few hours a day during pregnancy and ambulate ASAP on the first postpartum day Rationale: Compression stockings should typically cover the entire length of the legs, not just up to the knees, in order to effectively promote blood circulation and prevent thrombophlebitis and deep vein thrombosis during pregnancy. Wearing stockings that reach only up to the knees may not provide adequate compression and coverage to prevent these conditions effectively. The stockings should ideally cover the entire length of the legs to exert consistent pressure and support to the veins. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Physiologic Changes in Pregnancy 13.)Thrombophlebitis is vein inflammation caused by a clot formation. This is common in pregnancy especially in the lower leg veins, as manifested by pain, warmth, redness and swelling in the affected part. What is a correct intervention for clients with thrombophlebitis? A. Encourage ambulation and assist in passive ROM exercises to prevent further development of thrombus B. Advise the client to wear antiembolic stockings if the client is going out of the house C. Elevate the leg to reduce edema or inflammation D. Assess for the Homan’s sign regularly to evaluate progress of condition Rationale: Elevating the leg below the level of the heart can help improve venous return and reduce swelling in the affected area. This position promotes proper blood flow while minimizing the risk of dislodging the clot. However, elevation of the affected leg should be below the level of the heart to facilitate venous return and reduce edema or inflammation. In the case of thrombophlebitis, ambulation should be avoided to prevent the dislodgment of the clot and its potential travel through the circulatory system. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Physiologic Changes in Pregnancy 14.)Because of the marked increase in cardiac output and blood volume during pregnancy, and because of the compression of the vena cava by the enlarging uterus, certain changes also occur on the blood pressure of the pregnant woman. What statement would be INAPPROPRIATE to describe these changes on the BP?  A. There is a slight decrease in blood pressure in the first half of the pregnancy, owing to the relaxation of smooth muscles and accommodation of increased blood volume, causing vasodilation B. Blood pressure in the second half of pregnancy is normally at the pre-pregnancy level C. The woman experiences supine hypotension because the uterus compresses the superior vena cava when lying supine D. There is an increase in blood pressure due to the elevation in the blood volume and cardiac output Rationale: During pregnancy, there is an increase in blood volume and cardiac output to meet the demands of the growing fetus. This increased blood volume does lead to a slight decrease in systemic vascular resistance and can cause a slight decrease in blood pressure, particularly in the first half of pregnancy. Therefore, the statement describing an increase in blood pressure (BP) due to elevated blood volume and cardiac output is inappropriate. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Physiologic Changes in Pregnancy 15.)Cardiovascular changes, contractions and fetal movements are experienced by the mother during pregnancy, but of course, not all of them are normal. Which of the following would not be considered a normal observation during pregnancy? A. The mother experiences palpitations and burning pain on the chest B. No fetal movement is felt on the third month C. Diastolic blood pressure increased from 80 to 95mm Hg D. Uterine contractions on the 21st week Rationale: During pregnancy, there may be slight variations in blood pressure, but a significant increase in diastolic blood pressure from 80 to 95 mm Hg would not be considered a normal observation. High blood pressure during pregnancy, especially a significant increase, can be an indication of risk of gestational hypertension or preeclampsia, which require further evaluation and monitoring. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Physiologic Changes in Pregnancy SITUATION 4 – Pregnancy is a time of change for everyone – mother, baby, partner, and relationships. It is therefore important that nurses understand these physical changes and help the mother cope with them for a healthy and comfortable pregnancy. 16.)Total weight gain during pregnancy normally ranges from 25 to 35 lbs. During the second and third trimesters, the normal weight gain is 1 lb per week. A client on her third trimester informed the nurse that she gained 4 lbs in the past week. What is the next best nursing intervention for this client? A. Advise the woman to perform rigorous exercise everyday B. Advise the woman to remove salt from her diet C. Inform the woman that 1 lb per week is the ideal, and some allowance is still allowed up to a total 4 lbs per week especially in the third trimester D. Check the blood pressure, assess for abnormal fluid retention, and request an order for urinalysis Rationale: Excessive weight gain in a short period during pregnancy, such as 4 lbs in one week, could be an indication of abnormal fluid retention or other underlying issues. It is essential for the nurse to assess the client's condition further. Checking the blood pressure can help identify if there is any associated hypertension or preeclampsia. Assessing for abnormal fluid retention, such as swelling in the extremities or face, can provide additional information. Requesting an order for urinalysis can help evaluate kidney function and detect any proteinuria, which may be indicative of preeclampsia. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Discomforts of Pregnancy 17.)Morning sickness is best prevented by eating dry toast or crackers before getting out of bed. Which other health teaching would be useful in managing morning sickness? A. Taking at least three large meals to prevent hypoglycemia B. Taking liquids with meals to prevent dehydration C. Immediately replacing foods and fluids after vomiting to prevent imbalances D. Avoiding spicy, fatty, and greasy foods and strong odors Rationale: To manage morning sickness, it is advisable to avoid triggers that can exacerbate the symptoms. Spicy, fatty, and greasy foods, as well as strong odors, are known to contribute to nausea and vomiting. Therefore, advising the woman to avoid these types of foods and odors can help alleviate morning sickness symptoms. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Discomforts of Pregnancy 18.) Heartburn is common in pregnancy because of the relaxing effects of progesterone and the displacement of the gastrointestinal organs due to the enlarging uterus. Which of the following is a helpful health teaching for a mother who asks about ways to manage heartburn? A. Encourage the mother to bend on the waist when picking up something B. Go to bed shortly after dinner to prevent fatigue and stimulation C. Elevate the head of bed and maintain an upright position after meals D. Encourage the woman to take over-the-counter anti-ulcer drugs Rationale: Elevating the head of the bed and maintaining an upright position after meals can help reduce the occurrence of heartburn. These positions help prevent gastric acid from flowing back into the esophagus and minimize discomfort. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Discomforts of Pregnancy 19.)Muscle and leg cramps are common in pregnancy, as well. The client asked the nurse what she must do in order to manage her cramps. The nurse would provide a statement that is based on which correct intervention? A. Extend the knees and perform plantar flexion exercises B. Extend the knees and dorsiflex C. When exercising in the standing position, point the toes regularly D. Avoid calcium-rich foods as they cause cramping Rationale: Muscle cramps, including leg cramps, are common during pregnancy and are thought to be caused by factors such as increased pressure on nerves, changes in blood circulation, and changes in electrolyte balance. The muscles of the legs, particularly the calf muscles, are commonly affected. Dorsiflexion refers to the movement of the foot that brings the toes closer to the shin, stretching the calf muscles. By extending the knees and dorsiflexing the feet, the calf muscles are stretched, helping to relieve muscle tension and reduce the intensity and duration of cramps. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Discomforts of Pregnancy 20.)Backache is normal in pregnancy because of the stretching of the lower back and the growing weight of the abdomen. Which of the following statements made by the client regarding ways to relieve or prevent backache indicates a need for further teaching? A. Sleeping on a soft mattress to ensure comfort B. Performing pelvic rocking and tailor sitting exercises C. Wearing shoes with low, broad heels to reduce tension on the back D. Applying local heat and adopting a good posture Rationale: Sleeping on a soft mattress may not be the most suitable approach to relieve or prevent backache during pregnancy. It is important to maintain proper support for the lower back and abdomen. Using a firm mattress or adding additional support, such as a pregnancy pillow, can help alleviate pressure on the back and provide better alignment. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Discomforts of Pregnancy SITUATION 5 – Alexa, a knowledgeable and compassionate nurse, sat down with Vien and Junie Boy, a pregnant couple, explaining the fascinating yet challenging journey of pregnancy, discussing hormonal shifts, expanding belly, and offering guidance on proper nutrition and exercise to ensure a healthy and joyful experience for both mother and baby. 21.)Varicose veins can be prevented by avoiding long periods of standing, constricting clothes, and knee-high stockings. Legs are elevated while sitting, and support stockings and elastic bandages may  be used. Which of the following would be a correct health teaching regarding the use of support stockings and elastic bandages? A. Support stockings are worn to bed at night B. Support stockings are applied with the leg raised to promote venous emptying C. Elastic bandages are applied to the legs from proximal to distal D. Support stockings are removed after waking up Rationale: Support stockings and elastic bandages are commonly used to provide external compression and support to the veins, helping to improve venous return and reduce the development or worsening of varicose veins. When applying support stockings, it is important to elevate the leg, preferably above the level of the heart, as this position promotes venous emptying and facilitates blood flow back to the heart. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Discomforts of Pregnancy 22.)The enlarging uterus presents pressure on the vena cava and lower leg veins, thereby affecting the rate of venous return. A pregnant client complained that her leg edema is worsening, particularly in the late afternoon. She is on her last trimester, and her job involves prolonged standing and sitting. She asked the nurse what to do about her problem. The nurse’s response would be based on A. The need to lessen salt intake to lessen edema, similar to what’s happening in congestive heart failure B. The severity of the problem, hence the need to contact the physician immediately, as pre-eclampsia could be present C. The danger of her job to her pregnancy, hence the need to start her maternity leave early D. The need to have breaks once in a while so she could elevate her legs Rationale: Prolonged standing and sitting can exacerbate leg edema during pregnancy due to the pressure exerted on the vena cava and lower leg veins by the enlarging uterus. Taking breaks and elevating the legs periodically helps alleviate venous congestion and promotes blood circulation. By elevating the legs, the force of gravity assists in venous return, reducing edema and discomfort. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Discomforts of Pregnancy 23.)Constipation is common in pregnancy due to increased progesterone levels and decreased physical activity. It can also be the side effect of iron supplementation. Which of the following health teaching would be beneficial for the woman who is complaining of constipation? A. Using laxatives or suppositories once a day B. Increasing fluids, including coffee and tea C. Increasing intake of wheat, oats, leafy vegetables, fruits, and milk D. Encouraging the woman to stop taking iron when there is constipation Rationale: Constipation is a common issue during pregnancy, primarily due to increased progesterone levels and decreased physical activity. Providing dietary recommendations that include high-fiber foods, such as whole grains, leafy vegetables, and fruits, helps promote bowel regularity and prevent constipation. These foods add bulk to the stool, making it easier to pass through the digestive system. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Discomforts of Pregnancy 24.)The enlarging uterus also exerts pressure on the rectal veins, resulting in hemorrhoids. In managing the discomfort of hemorrhoids, which of the following would the nurse teach the mother? A. Achieve pain relief by resting on a semi-fowler’s position B. Have a hot steam directed to the perineum and rectum C. Eat low-residue foods to prevent rectal distention D. Increase intake of whole grains and fluids Rationale: Hemorrhoids, which are swollen and inflamed veins in the rectal area, can occur during pregnancy due to increased pressure on the rectal veins from the enlarging uterus. Managing the discomfort of hemorrhoids involves dietary modifications, including increasing fiber intake from whole grains and ensuring an adequate fluid intake. These measures help soften the stool and prevent constipation, reducing strain during bowel movements and alleviating hemorrhoid discomfort. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Discomforts of Pregnancy 25.)The earliest positive sign of pregnancy is the visualization of the fetal heart movement by ultrasound, in as early as 6 weeks. Which of the following is another positive sign of pregnancy? A. Abdominal enlargement B. Positive pregnancy test and ballottement C. Quickening and Braxton-Hick’s contractions D. Fetal outline by Leopold’s maneuver Rationale: The positive sign of pregnancy refers to objective indications that can only be attributed to the presence of a fetus. Leopold's maneuver is a systematic technique used to assess the position and presentation of the fetus in the mother's abdomen. By palpating the abdomen, the healthcare provider can feel the fetal outline, helping to confirm the presence of a fetus and providing a positive sign of pregnancy. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: The confirmation of pregnancy SITUATION 6 – The three main components of prenatal care are risk assessment, health promotion and education, and therapeutic intervention. High-quality prenatal care can prevent or lead to timely recognition and treatment of maternal and fetal complications. 26.)TPAL stands for Term, Preterm, Abortion, and Living children. What is the TPAL score of a woman whose first pregnancy was lost on the 19th week, the second baby was born on the 36th week, and the third baby was delivered at 38 weeks? A. 1-1-1-1 B. 1-1-1-2 C. 1-0-2-2 D. 1-2-0-2 Rationale: TPAL stands for Term, Preterm, Abortion, and Living children, representing the different outcomes of a woman's pregnancies. In this case, the woman's first pregnancy was lost at 19 weeks (considered an abortion), the second baby was born at 36 weeks (considered preterm), and the third baby was delivered at 38 weeks (considered term). Therefore, the TPAL score is 1-1-1-2. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Gravidity and parity 27.)The GP score stands for Gravida and Para. Gravida is the number of pregnancies. Para is the number of pregnancies that have reached the age of viability. What is the GP score of a woman who is in her fifth pregnancy, with a history of abortion in the third pregnancy, and with twins during the fourth pregnancy? A. G5P3 B. G5P4 C. G6P4 D. G6P5 Rationale: The GP score stands for Gravida and Para. Gravida represents the number of pregnancies, and Para represents the number of pregnancies that have reached the age of viability. In this case, the woman is on her fifth pregnancy (Gravida 5). She had an abortion in the third pregnancy, which means it did not reach the age of viability. Therefore, her Para score is 3. So, the GP score is G5P3. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Gravidity and parity 28.)In assessing the fundal height and estimating the age of gestation, the following landmarks are important: the symphysis pubis, umbilicus, and the xiphoid process. After assessing the fundic height of four clients, the nurse would decide to prioritize which of the following clients? A. A woman who is 12 weeks pregnant with a fundic height on the level of the umbilicus B. A woman who is 20 weeks pregnant with a fundic height slightly above the umbilicus C. A woman who is 36 weeks pregnant with a fundic height on the xiphoid process D. A woman who is 40 weeks pregnant with a fundic height below the xiphoid process Rationale: When assessing the fundal height, the nurse measures the distance between the symphysis pubis and the top of the uterus (fundus). The fundal height correlates with the gestational age. Normally, at 12 weeks of gestation, the fundus should be below the umbilicus. Therefore, a woman who is 12 weeks pregnant with a fundic height on the level of the umbilicus would require further assessment and priority. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Fundal height 29.)Nurses are responsible for correctly preparing the clients for various procedures in order to ensure client safety and the accuracy of results. Which of the following is an INCORRECT statement regarding client preparation? A. For Leopold’s maneuver, the bladder should be empty B. For a pelvic exam, the bladder should be full C. For abdominal ultrasound, ensure that the bladder is full D. For a transvaginal ultrasound, the bladder must be empty Rationale: For a pelvic exam, it is important for the bladder to be empty. This allows for a clearer visualization of the pelvic structures and reduces discomfort for the client during the examination. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Fundal height 30.)For Leopold's maneuver, the woman is placed in the dorsal recumbent position, and the nurse warms her hands. Which of the following are correct regarding the procedure? i. The first maneuver determines the presentation ii. The second maneuver determines the fetal back for the assessment of the FHT iii. The third maneuver determines the degree of engagement iv. The fourth maneuver determines the attitude v. The examiner faces the mother’s head for the first three maneuvers, and faces the mother’s feet for the fourth maneuver A. i, ii, iii B. i, ii, iii, v C. i, ii, iv, v D. i, ii, iii, iv, v Rationale: Leopold's maneuver is a systematic abdominal palpation technique used to assess the position, presentation, and engagement of the fetus. The procedure involves four maneuvers. The first maneuver determines the presentation, the second maneuver determines the fetal back for the assessment of the fetal heart tones (FHT), the third maneuver determines the degree of engagement, and the fourth maneuver determines the attitude. During the Leopold's maneuver, the examiner faces the mother's head for the first three maneuvers and faces the mother's feet for the fourth maneuver. Therefore, all options (i, ii, iii, iv, v) are correct. Topic: Assessment During the First, Second, and Third Trimester of Pregnancy: Fundal height SITUATION 7 – As the ultrasound monitor echoed with the soothing sound of their unborn baby's heartbeat, Nurse Olivia gently guided Emily and Mark, explaining the significance of fetal heart tones, how they serve as an indicator of the baby's well-being, and reassuring them of their growing bundle of joy's strong and steady rhythm, filling the room with hope and anticipation. 31.)The fetal heart tone is a priority assessment in determining the fetal well-being. Which of the following interventions would most ensure accuracy of auscultating the fetal heart sounds? A. Using the correct instrument to auscultate the FHT depending on the age of gestation: at 10 weeks: Doppler; 16 weeks: fetoscope; and 20 weeks: stethoscope B. Placing the stethoscope’s diaphragm on the mother’s abdomen C. Performing Leopold’s maneuver first to assess the location of the fetal back D. Palpating the maternal radial pulse while listening to the FHT Rationale: When auscultating the fetal heart tones (FHT), it is important to differentiate the maternal pulse from the fetal heart sounds. Palpating the maternal radial pulse simultaneously helps in distinguishing the two and ensures accuracy in identifying the fetal heart rate. This technique helps prevent any confusion between the maternal and fetal pulses. Topic: Intrapartal Nursing Assessment: Labor and Delivery 32.)The fetal heart beat should be monitored every 5 minutes during the 2nd stage of labor. Which of the following would characterize normal fetal heart beat?  i. The heart rate will decelerate during a contraction and then go back to its pre-contraction rate after the contraction ii. The baseline heart rate is normal and accelerates by at least 15 bpm with fetal movement iii. The heart rate decelerates but it is not related to uterine contractions iv. The heart rate will decelerate at the middle of a contraction and remain that way for a minute or so v. The heart rate will accelerate during a contraction and remain above the pre-contraction rate at the end of the contraction A. i and ii only B. iii only C. ii and iv only D. ii, iv and v Rationale: Normal fetal heart rate characteristics include a baseline heart rate that is normal and accelerates by at least 15 beats per minute (bpm) with fetal movement (ii). Decelerations during contractions are not considered normal. The heart rate should recover and return to its pre-contraction rate after the contraction (i). Therefore, options i and ii accurately describe normal fetal heart rate characteristics during the second stage of labor. Topic: Intrapartal Nursing Assessment: Labor and Delivery 33.)Decelerations are not always abnormal particularly when the head has descended and uterine contractions are compressing the head during late labor. What is an INCORRECT statement regarding the various types of deceleration? A. Late deceleration is dangerous as it signals decreased blood flow to the uterus and placenta as a result of the contraction B. Variable deceleration is unpredictable relative to contractions, as it is caused by cord compression C. Early deceleration is most dangerous because it signals fetal distress even at the start of the contraction D. Important interventions during abnormal decelerations are positioning, stopping the oxytocin infusion, and oxygenating the mother Rationale: Early decelerations are typically considered benign and are caused by head compression during labor. They mirror the contraction pattern and are not associated with fetal distress. Late decelerations (A) occur after the peak of the contraction and are a concerning sign of uteroplacental insufficiency. Variable decelerations (B) are caused by umbilical cord compression and can occur at any time during the contraction pattern. Topic: Antepartum diagnostic testing: Antepartum diagnostic testing 34.)Non-stress Test (NST) does not use oxytocin or stimulus to the fetus. It only tests the reaction of the FHT to fetal movement. What is a correct statement regarding the NST? A. The normal result is NON-REACTIVE B. The normal result is NEGATIVE C. If the result of this test is unfavorable, emergency delivery is necessary D. FHR should accelerate by at least 15 bpm during fetal movement, twice in a 20-30-minute period Rationale: The Non-Stress Test (NST) is a method of evaluating fetal well-being by assessing the fetal heart rate (FHR) in response to fetal movement. A normal NST result is "reactive" rather than "non-reactive" (A) or "negative" (B). In a reactive NST, the FHR should demonstrate accelerations of at least 15 bpm for at least 15 seconds, twice within a 20-30 minute period (D). This is an indication of a healthy, responsive fetus. Topic: Antepartum diagnostic testing: Antepartum diagnostic testing 35.)Contraction Stress Test (CST) uses oxytocin either via IV or nipple stimulation to induce uterine contractions and to assess the nature of decelerations. It assesses uterine contractions for 60-90 minutes. What is an INCORRECT statement regarding CST? A. The normal result is NON-REACTIVE  B. The normal result is REACTIVE C. There should be no repetitive late decelerations D. A positive result means that the fetus is no longer receiving adequate oxygen during contractions, and needs to be delivered Rationale: A contraction stress test (CST) is performed if there are concerns about the fetus' well-being. It is done after abnormal non-stress test or biophysical profile results. Multiple CSTs may be conducted during pregnancy to assess the baby's response to contractions. The test involves stimulating contractions and monitoring the fetal heart rate. During a contraction stress test (CST), normal test results are referred to as negative. A negative result indicates that the baby's heart rate does not decelerate and stay slow after contractions, particularly late decelerations. It is normal for the heart rate to briefly slow down during the test, as long as it returns to normal afterwards. A negative result suggests that the baby is expected to handle the stress of labor well, as long as there are no late decelerations observed in the heart rate during three contractions within a 10-minute period. On the other hand, abnormal test results are called positive. In a positive result, the baby's heart rate shows decelerations and stays slow after contractions, specifically late decelerations. If late decelerations occur in more than half of the contractions, it suggests that the baby may experience difficulties during normal labor. Abnormal findings during the CST, particularly the presence of late decelerations, raise concerns about the baby's well-being and may require further assessment or interventions. An abnormal test (nonreactive NST, positive CST) is sometimes associated with adverse fetal or neonatal outcomes, while a normal test (reactive NST, negative CST) is usually associated with a neurologically intact and adequately oxygenated fetus. Topic: Antepartum diagnostic testing: Antepartum diagnostic testing SITUATION 8 – Nurse Elisa took the time to educate Viy and Cong on the critical signs of fetal distress, including persistent abdominal pain, sudden swelling, and significant changes in fetal movement, equipping the couple with the knowledge and confidence to promptly seek medical assistance if any of these warning signs appeared, ensuring the well-being of both mother and baby. 36.)General signs of fetal distress are abnormal FHR, abnormal frequency of fetal movements, and abnormal color of the amniotic fluid. Which of the following is a sign of fetal distress? A. FHR of 160 bpm B. 30 fetal movements per hour C. 4 fetal movements per hour D. Greenish amniotic fluid in a breech presentation Rationale: In normal circumstances, a fetus typically moves at least twice in a 10-minute period or 10 to 12 times within an hour. If a pregnant woman feels fewer than 10 movements in an hour, it is advisable for her to repeat the procedure for the next hour to ensure an adequate assessment. To monitor fetal movements, the Cardiff method, also known as the "Count-to-Ten" method, can be used. With this method, the woman records the time interval between every 10 fetal movements felt within a 60-minute timeframe. By keeping track of the intervals, any changes or deviations from the normal pattern of movement can be identified. It's important to note that variations in fetal movement can occur, influenced by factors such as the baby's sleep-wake cycle and maternal activity level. Topic: Intrapartal Nursing Assessment: Labor and Delivery 37.)Malpractice happens when a professional performs something that is outside his authority, or he has no license or training to allow him to safely perform the act. Based on the Philippine Nursing Law (RA 9173), which of the following would be considered a malpractice? A. The nurse handles a client who has a normal pregnancy, and with an uncomplicated labor and delivery B. The nurse sutures the perineal lacerations of the client after the nurse completed a special training  C. The nurse skillfully and carefully performs vaginal examination when there is light bleeding. IE is contraindicated when there is heavy bleeding. D. None -- All of the above are within the scope of nursing practice Rationale: IE is contraindicated when there is heavy bleeding. According to the Philippine Nursing Law (RA 9173), performing a vaginal examination (IE) when there is heavy bleeding would be considered malpractice. It is important for nurses to adhere to contraindications and guidelines for procedures to ensure patient safety and prevent harm. Topic: Intrapartal Nursing Assessment: Labor and Delivery 38.)Rupture of membranes is a sign of impending labor. With the release of fluids, uterine contractions will be stronger, leading to fetal descent and cervical dilatation. Which of the following assessment would you prioritize upon the rupture of membranes? A. Perform the nitrazine paper test on the amniotic fluid B. Perform the fern test on the amniotic fluid C. Determine cervical dilatation D. Assess the fetal heart tone Rationale: Upon rupture of membranes, assessing the fetal heart tone would be a priority. Rupture of membranes can introduce risks to the baby, such as umbilical cord prolapse or compression, which may affect fetal well-being. Assessing the fetal heart tone helps to determine the baby's current status and detect any signs of distress. Topic: Intrapartal Nursing Assessment: Labor and Delivery 39.)The most accurate measure of the progress of labor is cervical dilatation and effacement. Prior to full cervical dilatation, what other signs and symptoms would support that true labor is happening? A. Pain begins at the lower back and radiates to the abdomen B. Walking makes the contractions longer C. Contractions get stronger, longer, and closer together regardless of position D. All of the above Rationale: In true labor, all of the mentioned signs and symptoms are expected. Pain beginning at the lower back and radiating to the abdomen, contractions becoming stronger, longer, and closer together regardless of position, and walking making the contractions longer are indicative of true labor. These signs suggest that the cervix is progressively dilating and effacing, and labor is progressing. Topic: Intrapartal Nursing Assessment: Labor and Delivery 40.)Uterine contractions and the pressure of the presenting part bring about cervical dilatation. Hence, uterine contractions are the first sign that labor has begun, while the bloody show is the first sign that the cervix is beginning to dilate. A primigravida client is showing signs of labor. Upon conducting vaginal exam, the cervical dilatation at 10:00 am was 5 cm, and at 2pm it was 7 cm. The correct interpretation of this result is A. Labor is progressing normally B. The progress of labor is slow and abnormal C. This is expected in the active phase D. The client has entered the transition phase Rationale: The interpretation of the cervical dilatation progress from 5 cm at 10:00 am to 7 cm at 2:00 pm indicates a slow and abnormal progress of labor. In a healthy labor, the cervix is expected to dilate at a rate of about 1 cm per hour for a primigravida woman. The minimal increase of 2 cm over a 4-hour period suggests a slower progression, which may require further assessment and intervention to ensure the well-being of both the mother and baby. Topic: Intrapartal Nursing Assessment: Labor and Delivery SITUATION 9 – Intrapartum nursing care is the care given by nurses and midwives for laboring mother during labor and delivery. In this stage, the nurse assesses the following: vital signs, physical exam, contraction pattern (frequency, interval, duration, and intensity), intactness of membranes through vaginal exam, and fetal well-being through fetal heart rate, characteristic of amniotic fluid, and contractions. 41.)Which of the following clients would you prioritize for transfer from the labor room to the delivery room? A. A G5P4 who is 8 cm dilated B. A G1P0 who is 8 cm dilated C. A client who is 6 cm dilated with a cervical dilatation of 1 cm per hour for the past 3 hours D. A client who is 7 cm dilated and is not pushing with contractions Rationale: In this case, the client is at an advanced stage of labor (8 cm dilated), which suggests that delivery is imminent. Multiparous clients, like G5P4, tend to have shorter labors compared to primiparous clients. Therefore, this client should be prioritized for transfer to the delivery room for active management and to ensure a timely and safe delivery. Topic: Intrapartal Nursing Assessment: Prioritization 42.)The station denotes the degree of engagement of the fetal head as it navigates the maternal pelvis. The landmark for determining the Station is the maternal ischial spine. Which of the following is INCORRECT about the different Stations? A. At station 0, the fetal head engages in the maternal pelvis, which could happen 2 weeks before labor B. Clients may show no changes in station in case of cephalopelvic disproportion even with full cervical dilatation C. After station 0, the client feels the lesser pressure and pain on the pelvic bone and vaginal area D. At (+) 3 to (+) 5, the baby’s head is crowning Rationale: As the fetal head descends and moves beyond station 0, the pressure and pain on the pelvic bone and vaginal area typically increase. This is because the presenting part of the fetus is lower in the pelvis, exerting more pressure on the surrounding structures. Therefore, the client would usually experience increased pressure and discomfort as the station progresses. Topic: Intrapartal Nursing Assessment: Fetal Stations 43.)Position refers to the relationship of the presenting part to its location in the maternal pelvis. Nurse Irene has just received a client who is in early labor and whose fetal position is ROP. The nurse would expect which of the following when planning care for the client? A. It will be easy to get the FHT B. The client will experience severe lumbar pain C. The position is favorable as it will result in less pain and shorter labor D. The stethoscope will be placed on the left side of the mother’s abdomen when assessing the FHT Rationale: ROP position is associated with increased back pain during labor due to the position of the fetal head and the pressure it exerts on the mother's lower back. Topic: Intrapartal Nursing Assessment: Fetal position 44.)A woman who is 9 cm dilated is complaining of pain, is hyperventilating, and is not responding well to your coaching on the breathing technique. She complained of feeling dizzy, lightheaded, and weak. Which of the following would be your best intervention? A. Force the woman to take slow abdominal breaths to avoid complications B. Get a brown paper bag and ask the woman to breath in to it C. Ask the woman if she is requesting for a cesarean delivery instead D. Administer meperidine (Demerol) for pain Rationale: The symptoms described suggest that the woman may be experiencing hyperventilation, which can lead to respiratory alkalosis. Breathing into a paper bag helps to rebreathe carbon dioxide and restore the balance of gases in the body, alleviating the symptoms of hyperventilation. Topic: Intrapartal Nursing Assessment: Management of Hyperventilation in Labor 45.)The most common means used to induce labor are amniotomy, oxytocin administration, and the use of prostaglandin E. In which of the following cases would you expect induction of labor? A. Cord prolapse  B. Active genital herpes C. Dystocia D. Fetal death Rationale: In the case of fetal death, it is important to initiate labor to deliver the fetus and prevent potential complications. Induction of labor in such cases is necessary to avoid prolonging the period of fetal demise and reduce the risk of infection or other adverse maternal outcomes. Topic: Intrapartal Nursing Assessment: Labor induction SITUATION 10 – In a warm and informative session, Nurse Emily enlightened Rachel and Mark about the vital role of oxytocin and other hormones during pregnancy, elucidating how oxytocin facilitates labor and bonding, while also discussing the functions of progesterone and estrogen in supporting a healthy pregnancy, leaving the expectant couple feeling enlightened and more connected to the miraculous processes occurring within Rachel's body. 46.)Oxytocin (Pitocin) is used to induce labor and also to prevent post-partum hemorrhage by causing uterine contractions. A pregnant client at term is receiving oxytocin infusion for the induction of labor. During the nursing rounds, the nurse finds the client lying flat on bed, and states that she finds the position most comfortable to her. Upon assessing the client, the nurse finds that contractions last 60 seconds and the fetal heart rate is 180 bpm. What is the priority intervention by the nurse? A. Record it as normal B. Stop the oxytocin infusion C. Turn the mother to the left side D. Call the doctor immediately Rationale: The client lying flat on the bed can cause compression of the inferior vena cava, reducing blood flow to the placenta and potentially leading to fetal distress. Turning the mother to the left side helps to alleviate this compression and improve blood flow. Topic: Nursing care during labor and delivery: Oxytocin 47.)You are taking care of four clients who are receiving oxytocin via IV piggyback for the induction of labor. Which of the following clients would be your least priority? A. A woman with heart rate of 110 bpm B. A woman with contractions lasting more than 90 seconds C. A client with a fetal heart rate of 190 that does not return to baseline after the contraction D.A client experiencing contractions every minute Rationale: A heart rate of 110 bpm is within the normal range for an adult. The other options indicate abnormal findings that require closer monitoring and intervention. Topic: Nursing care during labor and delivery: Assessment and prioritization 48.)Spinal and epidural anesthesia are commonly used regional anesthesia during labor and delivery. With these, the client is awake and able to participate in the birthing process. The priority intervention of the nurse prior to induction of anesthesia is A. Ask the client to sign the consent form- B. Assist the client to void C. Prepare the skin aseptically for anesthesia administration D. Place the client in a shrimp position for the administration of the anesthesia Rationale: Emptying the bladder before administering spinal or epidural anesthesia helps to prevent bladder distension and potential complications, such as urinary retention or injury during the procedure. Topic: Nursing care during labor and delivery: Anesthesia 49.)Anesthetic drugs also cause muscles to relax, including the muscles of blood vessels which expand and accommodate more blood. Knowing the effect of anesthesia, the nurse would watch out for the following complications of early or excessive administration of anesthesia EXCEPT A. Hypertension B. Fetal respiratory depression  C. Uterine atony D. Prolonged labor Rationale: Anesthetic drugs tend to cause muscle relaxation, including the smooth muscles of blood vessels, which can lead to hypotension rather than hypertension. Topic: Nursing care during labor and delivery: Anesthesia 50.)The primary purpose of episiotomy is to enlarge the vaginal opening and assist childbirth. It is done with local anesthesia and then sutured after delivery. Episiotomy is performed A. While the client is bearing down B. Before crowning to prepare the passage C. When the head is crowning D. While Ritgen’s maneuver is performed to extensive lacerations Rationale: At this stage, the perineal tissues have stretched sufficiently, and an episiotomy can be performed to enlarge the vaginal opening and facilitate the delivery of the baby's head. Topic: Nursing care during labor and delivery: Episiotomy