MATERNAL AND CHILD NURSING

Situation: Pre-natal care is essential for ensuring the overall health of newborns and mothers. This is also the best time
to establish baseline data relevant to pregnancy, lactation and newborn care. A nurse is preparing a prenatal assessment
to a group of young and adult pregnant mother.

1. While a pregnant client lies on her back, she reports that she is experiencing dizziness. What is the priority action for
the nurse?
A. Take the client’s blood pressure
B. Position the client on her side
C. Give the client a drink of water
D. Place the client in a Trendelenburg position

2. The nurse is assessing the fundal height of a client at 26 weeks’ gestation. The nurse should expect the fundus to be:
A. Level with the umbilicus.
B. Halfway between the symphysis and umbilicus.
C. Slightly below ensiform cartilage.
D. At 26 cm.

3. When planning care for the client in her third trimester, the nurse would give priority to teaching which topic?
A. Ways to decrease nausea and vomiting
B. Positions to avoid shortness of breath
C. Ways to lessen fatigue
D. The use of a supportive bra for treatment of breast tenderness

Adolescent Pregnancy

4. A nurse is planning to teach a 14-year-old pregnant adolescent at 38 weeks’ gestation. Which topic would be most
helpful at this time in the pregnancy?
A. Nutrition for the third trimester
B. Signs of true labor
C. Abdominal exercises for postpartum
D. Infant bathing

Maternal Nutrition

5. The nurse is assessing the weight of a client who is having a normal pregnancy. The nurse would expect the client to
have gained _____ pounds by 20 weeks’ gestation.
A. 8.5 – 10 lbs.
B. 10.5 – 12 lbs.
C. 12.5 – 15 lbs.
D. 15 – 17 lbs.

6. Which outcome for a client who was underweight at the onset of her pregnancy should be the greatest concern to the
nurse?
A. Weight gain in the first trimester is 4 pounds.
B. Weight gain in the second trimester is 8 pounds.
C. Weight gain in the third trimester is 14 pounds.
D. Total weight gain is 36 pounds.

7. Another client at 30 weeks’ gestation is admitted to the birthing unit with vaginal bleeding. What is the first action
the nurse should take?
A. Administer oxygen.
B. Prepare equipment for examination.
C. Assess family coping skills.
D. Take vital signs.

8. The woman is hospitalized for the treatment of severe pre-eclampsia. Which of the following represents an unusual
finding for this condition?
A. Convulsions
B. Blood pressure 160/100
C. Proteinuria + 4
D. Generalized Edema

9. What type of room should the nurse select for this woman?
A. A room next to the elevator
B. The room farthest from the nursing station
C. The quietest room on the floor
D. The labor suite

10. A woman 32 weeks gestation has developed mild Pregnancy induced hypertension ( PIH ). What statement of the
client would indicate understanding of her treatment regimen?
A. It is most important not to miss any of my BP medication.
B. I will watch my diet restrictions very carefully
C. I will spend most of my time in bed, on my left side
D. I’m happy that this only happens during a first pregnancy

Situation: A delivery room nurse understands that when complications develop, the pregnant woman is considered to
be experiencing a high–risk pregnancy. In the following cases, a nurse’s clinical eye, critical judgment, and competent
assessment skills are required in saving the life of the baby and the mother. As such, the provision of safety for these
types of clients is a minimum criterion for safe nursing care among entry-level nurses.

11. A nurse is assessing a client with rupture of membranes. A pelvic exam reveals the cervix to be 4 cm dilated, and
the presenting part is ballottable. Based on this data, the client is most at risk for:
A. Placenta previa.
B. Amniotic infection.
C. Abruptio placentae.
D. Prolapsed cord.

12. A nurse assesses a laboring client's blood pressure to be 88/60. What nursing intervention is most appropriate based
on this assessment finding?
A. Position the client in a side-lying position.
B. Administer oxygen at 5 liters.
C. Position the client in a supine position.
D. Increase the intravenous drip rate.

13. Information gained using Leopold’s maneuver reveals that the fetus is in a cephalic position. Where should the
nurse place the Doppler to hear the fetal heart tones?
A. The lower quadrant of the maternal abdomen
B. The level of the maternal umbilicus
C. The upper quadrant of the maternal abdomen
D. Above the apex of the fetal heart
14. The nurse is caring for a 38-weeks’-gestation client who was just in a motor vehicle accident. Which assessment
finding is associated with trauma?
A. Decreased uterine resting tone
B. A prolapsed cord
C. An increase in amniotic fluid production
D. An increase in abdominal girth

15. A nurse is monitoring a laboring client whose pelvic diameters are questionable. Based on the nurse’s knowledge of
cephalopelvic disproportion, which nursing intervention is most appropriate to encourage fetal descent?
A. Position the client in a squatting position.
B. Place the client in a supine position.
C. Prepare for a forceps delivery.
D. Maintain the client on bedrest.

Post-Partum:

16. Three hours postpartum, a primiparous client’s fundus is firm and midline. On perineal inspection, the nurse
observes a small, constant trickle of blood. Which of the following conditions should the nurse suspect?
A. retained placental tissue
B. uterine inversion
C. bladder distention
D. perineal lacerations

17. While making a home visit to a postpartum client on day 11, the nurse would anticipate that the client’s lochia
would be which of the following colors?
A. dark red
B. pink
C. brown
D. white

18. During a home visit on the fourth postpartum day, a primiparous client tells the nurse that she has been
experiencing breast engorgement. To relieve engorgement, the nurse teaches the client that before nursing her baby; the
client should do which of the following?
A. apply an ice cube to the nipples
B. rub her nipples gently with lanolin cream
C. express a small amount of breast milk
D. offer the neonate a small amount of formula

19. A nurse is assessing the lochia in a 24-hour-postpartum client, and expresses blood clots with fundal massage. The
client’s fundus is firm but elevated, and deviated to the right. What would be the most appropriate nursing action?

A. Assess the activity pattern.

B. Change the perineal pad.
C. Assess the voiding pattern.
D. Administer analgesics.

Situation: Martha the MCN Nurse is preparing a Mother’s class to be conducted in a Health Center.

20. To facilitate understanding for pregnant mothers regarding reproductive organs involve in pregnancy Martha is
discussing with the pregnant mothers the differences between the male and female organs, emphasizing the
organs/parts that are analogous; which is INCORRECT?
A. Penis-vagina
B. Scrotum-labia majora
C. Glans penis-Vagina
D. Spermatogenesis- oogenesis

21. The clitoris is the seat of sexual excitement in the female. Its significance is valuable for obstetrics is that it:
A. guides catheterization.
B. serves as the sexual organ of stimulation.
C. guides internal examination.
D. protects vestibular parts.

22. The pregnant mothers ask about external organs of reproduction and are collectively called:
A. Vulva
B. Perineum
C. Vagina
D. External organs

23. One of the mothers ask why the vagina is acidic with pH of 4-6. The appropriate respond of the Nurse would be
because of the function of which bacteria?
A. Streptococci
B. Doderlein’s bacilli
C. Escherichia coli
D. Staphylococci

Situation: The Mothers’ Class is also one of the ways where students can impart learning to pregnant mothers. The
following topics were discussed to them.

24. The nursing students emphasized that the most common site of implantation is which part of the uterus?
A. Uterine fundus, posterior portion
B. Uterine isthmus
C. Uterine corpus
D. Outer portion of the uterine tube

25. The topic of great interest for the pregnant mothers are fertilization and conception which occurs in the fallopian
tube, the most common site of which is the:

A. ampulla.
B. fundus.
C. uterine isthmus.
D. corpus.

26. To test the knowledge of the mothers the student nurses ask them which of the following is a function of the
ovarian hormone estrogen?
A. It is responsible for development of secondary sex characteristics
B. It decreases vascularity
C. It elevates basal body temperature during ovulation
D. It is responsible for infertile mucus

27. The mothers are excited to know the onset of labor and delivery. In which the exact cause of labor is unknown.
However, some of the theories were explain to them which include:
A. 1, 2 and 4
B. 1, 3 and 4
C. 2 and 4
D. 2, 3 and 4

28. The Supervisor in the Health center is teaching a small group of pregnant women who are in their third trimester.
During the open forum, Cory a pregnant woman for the first time asks how she would know if labor is near. The
Supervisor response reflects an understanding of the premonitory signs of labor, which include all of the following,
except:
A. weight gain and edema
B. decreased dyspnea, increased leg varicosities and frequency of voiding
C. lightening around two weeks before labor
D. increased maternal activity and abdominal muscle tightening

29. The supervisor evaluates client Cory for signs of true labor, which include:

A. 1 and 2
B. 1 and 4
C. 2 and 3
D. 2 and 4

30. A Head Nurse assigned in a OB ward gave a scenario while teaching trainees regarding signs of immediate labor
during emergency such as strong typhoon. She ask the trainees specific signs for labor and delivery that they need to
immediately attend to?
A. Contractions are progressive and strong
B. Cervical dilatation has begun
C. The cervix is effacing
D. The membranes have ruptured

31. Delia a Nurse, assigned in an emergency first aid shelter after a Habagat weather disturbance. She will determine
priority of care on the basis of which of the following?
A. Expected date of confinement
B. Survival potential
C. Client’s requests
D. Age and parity

32. Nurse Delia is assessing the characteristics of active labor contractions of a multiparous woman, just admitted in a
labor unit. Delia would assess the frequency between which of the following? *
A. acme of one contraction to the beginning of the next contraction
B. beginning of one contraction to the end of the next contraction
C. end of one contraction to the end of the next contraction
D. beginning of one contraction to the beginning of the next contraction
33. A client 39 weeks pregnant has been admitted in the Labor room in the first stage of labor. Which of the following
clinical manifestations would be considered abnormal and should be reported to the Physician immediately?
A. Expulsion of a blood tinged mucous plug
B. Continuous contraction of 2 minutes duration
C. Feeling of pressure on perineum causing her to bear down
D. Expulsion of clear fluid from the vagina

34. The MCN nurse is preparing the mother for a Leopold’s Maneuver the nurse plans to perform Leopold’s Maneuver
(LM) to Mrs. Fe. What would be the priority nursing actions that can be included in the nursing care plan before the
Leopold’s maneuver?
A. Locate the site of FHT auscultation before performing the procedure
B. Have the client drink 8 oz. of water one hour before the exam
C. Warm the sonogram gel before the procedure
D. Have the client empty her bladder before beginning the exam

35. As the nurse performs Leopold’s maneuver one, she palpates a hard, round ballottable mass. Which of the
following is an appropriate interpretation of the findings?
A. The fetus is in cephalic presentation
B. The fetus is in breech presentation
C. The presenting part is engaged
D. The fetal back is on the left abdominal wall

36. A G2P1 woman in labor (parturient) asked if she can still walk around in the labor room-DR-nursery area. Which
of the following is the most important criterion to consider before allowing her to ambulate?
A. station
B. status of the bag of waters
C. permission by the physician
D. cervical effacement

37. The Physician advised pregnant mother to ambulate around labor room and to be re-assessed after 45 minutes.
Which assessment distinguishes between true and false labor?
A. confirmation of spontaneous rupture of membranes
B. signs and symptoms of increasing discomfort
C. evidence of cervical dilation
D. presence of copious bloody vaginal discharge

Situation: Mrs. Katerina has just delivered to a 7.5 lbs. healthy baby boy. While in the post-partum ward the nurse is
preparing to assess her to identify problems and prevent complications.

38. Katerina asks the nurse when can she report to the office. The nurse’s response is based on the Involution process.
Which describes the following?

A. Involution is a progressive descent of the uterus into the pelvic cavity, occurring approximately 1 cm per day as it
returns to its non pregnant weight.
B. Involution refers to the gradual reversal of the uterine muscle into the abdominal cavity
C. Involution refers to the descent of the uterus into the pelvic cavity, occurring at a rate of 2cm daily
D. Involution refers to the inverted uterus that is beginning to return to normal

39. Katerina is to receive Ergonovine maleate (Methergine) by mouth during the first to third postpartum days. Before
administering Methergine, it is most important to check her:
A. lochia
B. deep tendon reflexes
C. blood pressure
D. uterine tone

40. Five hours postpartum, the client’s temperature is 101F (38°C). If you are the OB nurse what would be your
appropriate nursing action is to:
A. continue to monitor the temperature
B. apply cool packs to the abdomen
C. notify the physician
D. remove the blanket from the client’s bed

41. Jo a post-partum mother wants to breast feed her baby. As part of your nursing care to prevent sore nipple soreness
during breastfeeding, you would determine that the client needs further instruction when she states which of the
following?
A. “I should position the baby the same way for each feeding.”
B. “I should make sure the baby grasps the entire areola and nipple.”
C. “I should air dry my breast and nipples for 10-15 minutes after the feeding.”
D. “I shouldn’t use a hand breast pump if my nipples get sore.”

Situation: Juvy is three days postpartum. Her vital signs are stable; her fundus is three fingerbreadths below the
umbilicus, and her lochia rubra is moderate.

42. The breasts are hard and warm to touch. What would be the analysis of these findings?
A. is showing early signs of breast infection.
B. is normal for three days postpartum.
C. needs ice packs applied on breasts.
D. should remove her nursing bra t reduce discomfort.

43. A G4 P3 client who is breastfeeding complains of severe cramps or after pains 30 hours after cesarean delivery. The
nurse explains that these are caused by which of the following?
A. flatulence accumulation after a cesarean delivery
B. healing of the abdominal incision after cesarean delivery
C. side effects of the medications administered after delivery
D. release of oxytocin during the breastfeeding session

44. Primigravida Nora is seen crying in the postpartum ward. As a MCN nurse what would be your priority assessment
for a postpartum mother experiencing depression?
A. comfort measures to foster feelings of general well-being
B. privacy and reassurance that crying is therapeutic and normal
C. to see and make tactile contact with her baby
D. to talk about her labor experience

45. Following episiotomy and delivery of a newborn infant, the nurse performs a perineal assessment to Nora. The
nurse notes a trickle of bright red blood coming from the perineum. The nurse further assesses the fundus and notes that
it is well contracted. What would the nurse suspect?

A. this is a normal expectation following episiotomy

B. the perineal assessment should be performed more frequently
C. the bright red bleeding is abnormal and should be reported
D. the mother should be allowed bathroom privileges only
Situation: As a MCN nurse in the community it is expected that you will conduct a post-partum visit after delivery.
The following findings were noted during the visit: her left calf is swollen, warm to touch, reddened and painful.
Temperature is 37.9C.

46. You would advise her for immediate check and instructed her not to:
A. decrease leg movement
B. apply warmth to the leg
C. elevate the leg
D. gently massage the painful area of the leg

47. Cathy G3 P2 delivered a full-term newborn 14 hours ago. The Obstetric nurse noted an atonic uterus, high and
deviated to the right. What would be the most appropriate nursing intervention?
A. notify the physician
B. place the client on a pad count
C. massage the uterus and reevaluate in 30 minutes
D. have the client void and reevaluate the fundus

48 A baby born from a primipara woman 6 hours ago. The mother asks the nurse the white cheese-like substance under
the baby’s arms. The appropriate response of the nurse would be:
A. “This is a normal skin variation in newborn that goes away in a few weeks.”
B. “The baby may have a skin infection.”
C. “This material, called vernix, covered the baby before it was born. It will disappear in few days.”
D. “Babies sometimes have sebaceous glands that get plugged at birth. This substance is an example of that
condition.”

Situation: The Nurse is assessing a post-partum mother after delivery. One of the major postpartum areas to be
assessed is the bladder.

49. Which of the following signs would the nurse determine a full bladder?
A. increased uterine contractions
B. fundus 2F above umbilicus to the side
C. decreased lochia
D. pulse 52 bpm

50. Mrs. Fe G2, P2, just undergone post Cesarean Section and is diagnosed with Thrombophlebitis. The Physician
started treatment on her condition. The client’s response to treatment will be evaluated regularly assessing the client
for:
A. dysuria, frequency, urgency
B. red, swollen, painful calf
C. hematuria, ecchymosis, and epistaxis
D. sudden chest pains and dyspnea

51. While an Obstetric nurse is assessing the mother’s perineum on her third postpartum day after having a vaginal
delivery. She notes a large ecchymotic area located to the left of the mother’s perineum. Which one of the following
interventions should the OB nurse initiates at this time?
A. Have the client expose the area to air
B. Apply ice to the perineum
C. Encourage the client to take warm sitz baths.
D. Inform the physician STAT
Situation: The neonatal period is recognized internationally as the period from the birth of the child up to 28 days, but
under the R.A. 9288, otherwise known as The Newborn Screening (NBS) Act of 2004.

52. The newborn is a child from the time of complete delivery to how many days old?
A. 45
B. 25
C. 30
D. 7

53. Diseases that are screened under the Newborn Screening Act of the Philippines do not include:
A. hypothyroidism
B. phenylketonuria
C. Down’s syndrome
D. congenital adrenal hyperplasia (CAH)

54. Which of the following physical signs would support a diagnosis of Down’s syndrome?
A. constipation, subnormal temperature, apnea, bradycardia
B. hypotonia, simian crease, epicanthal fold, flat occiput
C. blue eyes, blond hair, fair skin
D. mental retardation, lethargy, irritability

55. When teaching parents-to-be about the development of their baby, the nurse includes the fact that the:
A. Gender of the baby is determined by the father’s sperm.
B. Gender of the baby is determined by the mother’s ovum.
C. Gender of the baby is determined by maternal.
D. Gender of the baby is determined by paternal hormones.

56. Which of the following statements made by the pregnant client would the nurse need to explore further?
A. “I would to have an amniocentesis.”
B. “The child might have a fetal anomaly.”
C. “I blame my husband for this pregnancy.”
D. “I hope to spend time with my neighbor who is pregnant.”

Situation 2: Nurse Josie is assigned in the rural health clinic. The nurse often encounters mothers who need health
teaching in order to promote a healthy pregnancy.

57. A 12-week pregnant client asked how to reduce the risk of Spina bifida during pregnancy. The nurse instructs the
client to increase which of the following foods during pregnancy?
A. Dried fruits
B. Fresh seafood
C. Brown rice
D. Green leafy vegetables

58. Nurse Josie is evaluating a return demonstration on a client performing breast self-examination. Which of the
following techniques require further teaching from the Registered Nurse?
A. Client compresses the nipple with the thumb and finger.
B. Client uses palm of hand to palpate breast tissue.
C. Client palpates tissue from the axilla to the sternum.
D. Client inspects breast by lifting arms over her head.

Situation 3: It is important that the nurse is able to identify the process of pregnancy, and the care and considerations
needed. Nurse Susan is assigned in a Tertiary maternal Clinic with advance obstetrical technology in monitoring the
welfare of the mother and child.
59. When assessing the Fetal heart rate using the Doppler, the nurse finds it to be the same as the maternal heart rate.
The nurse will:
A. Count the rate again for 30 seconds.
B. Reposition the Doppler.
C. Call the physician.
D. Document the rate in the client’s chart.

60. The nurse has requested the client to return tomorrow for an ultrasound. Which of the following instructions is most
appropriate prior to the ultrasound?
A. Do not eat prior to the ultrasound.
B. Empty your bladder right before the ultrasound.
C. Drink 1 quart of water 2 hours before the ultrasound.
D. Do not drink fluids prior to the ultrasound.

61. Nurse Susan is assisting with a nonstress test and asks the client if she understands the procedure. She knows that
the client has a proper understanding of the procedure when the client says she will:
A. Take slow deep breaths during the test.
B. Remain flat on her back during the test.
C. Avoid emptying her bladder.
D. Identify any fetal movement.

PRENATAL

Situation 4: While the mother is adapting both physically and psychologically to the changes associated with
pregnancy, it is important that Nurse Sarah identifies and anticipate the progress so that complications may be
prevented.

62. Nurse Sarah is trying to determine the estimated date of delivery for a client whose last menstrual period began on
May 6 and ended on May 11. The estimated date of delivery using Naegele’s rule is which of the following dates in
February?
A. 6
B. 11
C. 13
D. 18

63. A pregnant client states she had a boy at 40 weeks’ gestation and a girl at 38 weeks’ gestation. Nurse Sarah
documents this as:
A. G3P2/T2A0
B. G2P2/T2A0
C. G2P1/T1A0
D. G3P1/T1A0

64. Nurse Sarah is discussing interventions with a client complaining of varicose veins. Which of the following
statements made by the client requires further teaching?

A. “I will decrease intake of foods high in sodium.”

B. “When I am sitting, I will not cross my legs.”
C. “I will start wearing support hose.”
D. “After work, I will elevate my feet and rest.”
65. A pregnant client states that maternity clothing is not necessary. Which of the following recommendations should
Nurse Sarah advise the client to include when selecting clothing?
A. Select comfortable shoes with heels.
B. Wear a loose-fitting bra.
C. Avoid knee high stockings.
D. Wear firm fitting pants.

HIGH-RISK PREGNANCY

Situation 5: The nurse will need to provide basic physiologic and emotional care for the woman with a pregnancy at
risk because of obstetric risk factors or complication.

66. A pregnant client needs to increase calcium in her daily diet. The nurse suggests she increase her intake of which of
the following vitamins?
A. vitamin A
B. vitamin B
C. vitamin C
D. vitamin D

SITUATION: Because pregnancy is a physiologic process, the health sector aims to make pregnancy for the women
and gestation for the fetus as safe and medically uneventful as far as possible.

67. Tetanus toxoid vaccination is important for pregnant women and child bearing women to prevent them and their
baby from acquiring tetanus. How many doses of Tetanus Toxoid vaccine should be given to the mother in order to
protect the baby from acquiring neonatal tetanus?
A. One dose
B. Two doses
C. Three doses
D. Four doses

68. How many doses of Tetanus Toxoid vaccine are needed to protect a mother and her baby against the disease, during
her pregnancy and for lifetime immunity?
A. Three doses
B. Four doses
C. Five doses
D. Six doses

69. The community health nurse should give supportive care to the pregnant mother during labor. The nurse should do
the following, except:
A. Encourage the mother to take a bath during the onset of labor
B. Encourage the mother to drink and eat when she feels hungry
C. Remind the mother to empty the bladder every 2 hours
D. Encourage the mother to do breathing exercises for her to have energy in pushing the baby out of her birth canal.

70. The nurse should assess the progress of labor. She knows that the pregnant woman is in false labor if:
A. The cervix is dilated 4 cm
B. There is an increase in contractions
C. The membranes are not ruptured
D. All of the above
71. The community health nurse should counsel the mother on the recommended schedule of her first postpartum visit,
which is:
A. 3-5 days after delivery
B. 6 weeks after delivery
C. A day after delivery
D. 3 weeks after delivery

72. A mother who wishes to use Lactation Amenorrhea method as a form of family planning method should be
instructed:
A. To use other forms of FP methods after 6 months
B. About the potential side effects
C. To wait for at least 1 month to be more effective as a FP method
D. Alternate breastfeeding with formula feeding to be more effective

73. In providing guidance for a couple wishing to avoid pregnancy, the nurse reviews the record of a client who has a
normal 29-day cycle. On which of the following days would the nurse expect the client to ovulate?
A. Day 5 or 6
B. Day 13 or 14
C. Day 15 or 16
D. Day 28 or 29

74. A client who is taking oral contraceptives should immediately report which symptom associated with the adverse
effect of OC’s?
A. Blurred vision
B. Nausea
C. Breakthrough bleeding
D. Breast tenderness

75. A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to the postpartum unit. Which nursing
plan is best in assisting this mother to bond with her newborn infant?
A. Encourage the mother to provide total care for her infant.
B. Provide privacy so the mother can develop a relationship with the infant.
C. Encourage the father to provide most of the infant's care during hospitalization.
D. Meet the mother's physical needs and demonstrate warmth toward the infant.

76. Which maternal behavior is the nurse most likely to see when a new mother receives her infant for the first time?
A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely.
B. Her arms and hands receive the infant and she then traces the infant's profile with her fingertips.
C. Her arms and hands receive the infant and she then cuddles the infant to her own body.
D. She eagerly reaches for the infant and then holds the infant close to her own body.

77. A client who is attending antepartum classes asks the nurse why her healthcare provider has prescribed iron tablets.
The nurse's response is based on what knowledge?
A. Supplementary iron is more efficiently utilized during pregnancy.
B. It is difficult to consume 200 mg of additional iron by diet alone.
C. Iron absorption is decreased in the GI tract during pregnancy.
D. Iron is needed to prevent megaloblastic anemia in the last trimester.

78. When educating a pregnant client about home safety, which of the following information is least appropriate for the
nurse to include in the teaching plan?
A. When taking a shower, place a non-skid mat on the floor of the tub or shower.
B. Avoid climbing stairs
C. Avoid wearing high heels.
D. Use non-slip rugs on the floors.

79. A woman comes to the clinic for routine prenatal check-up at 34 weeks’ gestation. Abdominal palpation reveals the
fetal position as right occipital anterior (ROA). At which of the following sites would the nurse expect to find the fetal
heart tone?
A. Below the umbilicus, on the mother’s left side
B. Below the umbilicus, on the mother’s right side
C. Above the umbilicus, on the mother’s left side
D. Above the umbilicus, on the mother’s right side

80. Mrs. Dimaano complains about her morning sickness. The nurse provides health teachings to the client. Which of
the following statements made by the client indicates a need for further instruction by the nurse?
A. “I will avoid spicy or fatty foods”
B. “I will postpone eating until supper”
C. “I will eat small frequent meals”
D. “I will eat crackers and dry toast before arising”

81. Mrs. Makiss is scheduled for a nonstress test. After the test, the result documented on the chart is no accelerations
during the 40 minute observation. The nurse interprets these findings as:
A. A reactive stress test
B. A nonreactive stress test
C. An unsatisfactory stress test
D. The results are inconclusive

82. Another client had a nonstress tests for the past few weeks and the results were reactive. A few minutes ago, the
results were nonreactive. The nurse anticipates that the client will be prepared for:
A. A return appointment in 2 to 7 days to repeat the nonstress test
B. A contraction stress test
C. Hospital admission with continuous fetal monitoring
D. Immediate induction of labor

83. During her first trimester, a woman experiences many physiologic changes that lead her to think she is pregnant.
Which of the following changes will the nurse likely tell her are normal changes for an 8 week pregnancy?
A. Dysuria
B. Colostrum secretion
C. Nosebleeds
D. Dependent edema

84 Following her baby’s birth, the woman’s uterine fundus is soft, midline, 2 cm above the umbilicus, and she has
saturated two pads within 30 minutes. Which immediate need by the client should be addressed?
A. Be cleaned and have another pad change
B. Empty her bladder
C. Have an increase in her IV fluids of Ringer’s Lactate
D. Have her fundus massaged

85. Nurse Junifer is caring for a woman who is having labor induced with an oxytocin (Pitocin) drip. Which assessment
of the client indicates there is a problem?
A. The fetal heart rate is 160 beats per minute
B. The woman has three contractions in 5 minutes
C. Contraction duration is 60 seconds
D. Early fetal rate decelerations are occurring
86. Mrs. Fortalejo is in labor and taking three cleansing breaths followed by four, slow, deep breaths with each
contraction. She is experiencing much discomfort with her contractions. What action is most appropriate for the nurse
to take?
A. Demonstrate to Mrs. Fortalejo a different breathing pattern during contractions
B. Ask the physician for an order of pain medication
C. Have the man take a break and instruct Mrs. Fortalejo in another breathing pattern
D. Leave the couple alone as they have their routine established

87. Nurse Kristine is teaching childbirth education classes. What topic should be included during the second trimester?
A. Overview of the conception
B. Medication and breastfeeding
C. Infant care
D. Strategies to relieve the discomforts of pregnancy

88. A 38-week primigravida who works as a secretary and sits at a computer 8 hours each day tells the nurse that her
feet have begun to swell. Which instruction would be most effective in preventing pooling of blood in the lower
extremities?
A. Wear support stockings
B. Reduce salt in her diet
C. Move about every hour
D. Avoid constrictive clothing

89. A client receiving epidural anesthesia begins to experience nausea and becomes pale and clammy. What
intervention should the nurse implement first?
A. Raise the foot of the bed
B. Assess for vaginal bleeding
C. Evaluate the fetal heart rate
D. Take the client's blood pressure

90. A 34 week pregnant client calls the clinic complaining of severe headache, blurred vision, and swollen feet. The
nurse expects the physician to tell the client to:
A. Have it checked in the hospital
B. Come to the clinic tomorrow morning
C. Decrease salt intake and increase fluids
D. Rest for 4 hours a day for 3 days and come to the clinic if symptoms persist

91. Nurse Grasya went to give her morning care to a postpartum mother, she observed the mother talking to the baby,
checking diaper, and asking infant care questions. Nurse Grasya determines that the client is in which postpartal phase
of psychological adaptation?
A. Taking in
B. Taking on
C. Taking hold
D. Letting go

92. A client in active labor is admitted with preeclampsia. Which assessment finding is most significant in planning this
client's care?
A. Patellar reflex 4+.
B. Blood pressure 158/80.
C. Four-hour urine output 240 ml.
D. Respiration 12/minute.
93. A primigravida client with severe preeclampsia is receiving magnesium sulfate via continuous IV infusion. Which
assessment data indicates to the nurse that the client is experiencing magnesium sulfate toxicity?
A. Deep tendon reflexes 2+.
B. Blood pressure 140/90.
C. Respiratory rate 18/minute.
D. Urine output 90 ml/4 hours.

94. Discharge instructions are given to a woman who had been admitted with placenta previa. Which statement by the
client to her husband best demonstrates she understands the teaching?
A. “We can’t have sex”
B. “I have to return in a few days for a vaginal exam”
C. “I will have to have a caesarian delivery for this and other pregnancies”
D. “I can go back to part-time work beginning tomorrow”

95. The nurse is caring for a woman who is 35 weeks pregnant. She comes to the emergency room with painless,
vaginal bleeding. This is her third pregnancy and she states that this has never happened before. What would be
avoided in caring for this client?
A. Allowing her husband to stay with her
B. Keeping her at rest
C. Shaving the perineum
D. Performing vaginal examination

96. Nurse Hannah is caring for a woman with a placenta previa who has been hospitalized for several weeks. She is
now at 38 weeks’ gestation and her membranes have ruptured. The amniotic fluid has a greenish color and the woman
has started to bleed again. What would the nurse’s first action?
A. Administer oxygen
B. Place her in trendelenburg’s position
C. Call the doctor and prepare for a cesarian birth
D. Move her to the delivery room immediately

SITUATION: Nursing Process always must be implemented with an awareness of the interrelationship, during
childbearing, of the maternal and fetal needs and their manifestations. The nurse needs to keep in mind that
interventions for the mother may have an impact on the developing fetus and vice versa.

97. To preserve the reproductive health of the woman and man, guidelines for safer sex practices were established.
Which of the following statements is not included?
A. The use of condoms is the best protection against infection. Condoms are latex, use oil -based lubricant rather than
water-based lubricant because it can weaken the rubber
B. Be selective in choosing sexual partners
C. For safer oral-vaginal sex, a condom split in two or a plastic dental dam covering the mouth should be used to
protect against the exchange of body fluids
D. Use condom every sexual intercourse

98. Maricar asks Nurse Sarah at what age of gestation is the product of conception prone to teratogenic insults to the
cardiovascular system?
A. 4th week
B. 8th week
C. 12th week
D. 16th week
99. Nurse Mian discusses the fetal circulation to the students. To check whether the student understands her teaching
she asks, “What is the fetal structure that carries oxygenated blood from the umbilical cord to the inferior vena cava”.
The student correctly answers, “It is the:
A. Ductus Venosus
B. Ductus Arteriosus
C. Pulmonary Artery
D. Formane Ovale

100. A nurse is working with a particular cultural group in which it is not uncommon for grandparents to live with their
married children and to assist with child rearing and discipline issues. This is an example of which of the following?
A. Blended family
B. Traditional family
C. Two-career family
D. Intragenerational family

101. Nurse Isabel is conducting a family assessment to a pregnant client and asks the following question: "How, as a
family, do you deal with disappointments or stressful changes that occur and affect the members of your family?" The
nurse is trying to identify:
A. Health beliefs
B. Family communication patterns
C. Family coping mechanisms
D. Potential family problems

102. A client expresses concern about his son who is a homosexual. He states, "Nag-aalala ako sa kanya, alam ko sa
impyerno ang tuloy nya.” In responding to this client, the nurse should consider which of the following important
information?
A. Sexual development is genetically determined and not affected by environment.
B. What constitutes normal sexual expression varies among cultures and religions.
C. Normal sexuality is described as whatever behaviors give pleasure and satisfaction to those adults involved.
D. Since alternative lifestyles are now so well accepted in society, this parent should not feel so much concern.

103. The nurse working in a family planning clinic is aware that oral contraceptives are not contraindicated for which
of the following patients?
A. A 30-year old woman who smokes more than 15 cigarettes a day
B. A 30-year old diabetic woman
C. A 10 week postpartum client who is not breastfeeding
D. A client who experiences migraine with aura

104. An Intrauterine device is being fitted to a client. The nurse understands that IUD prevents pregnancy by:
A. Creating a sterile inflammatory process that prevents implantation
B. Suppressing secretion of FSH and LH
C. Blocking the fallopian tube to prevent entry of the ovum
D. Killing the spermatozoa before they can enter the cervix

105. The nurse will advise a pregnant client, who is scheduled for amniocentesis, to perform which of the following?

A. Increase the fluid intake to help aspirate more amniotic fluid during the procedure
B. Lie in side lying-position to avoid supine hypotension during the procedure
C. Ask the client to take a deep breath and hold it during insertion of needle
D. Rest for 30 minutes after the procedure
106. Which of the following common emotional reactions to pregnancy would the nurse expect to occur during the first
trimester?
A. Introversion, egocentrism, narcissism
B. Awkwardness, clumsiness, and unattractiveness
C. Anxiety, passivity, extroversion
D. Ambivalence, fear, fantasies

107. Which of the following statements, if made by a woman who is 12 weeks pregnant, would be essential for a nurse
to further evaluate?
A. “I thought I wanted to be pregnant, but now I don’t know”
B. “My husband is angry because I got pregnant”
C. “Being pregnant makes me feel very tried”
D. “I don’t want to get too fat while I’m pregnant”

SITUATION: Today’s pediatric nurse faces an array of challenges in providing care for children and their families. A
nurse requires competent skills form wide spectrum of both technological and psychosocial disciplines.

108. Nurse Hannah is assessing a healthy neonate upon admission to the nursery. Which characteristic would the
admitting nurse record as normal?
A. Hypertonia
B. Irregular respiratory rate of 50 bpm
C. Head circumference measuring 31 cm
D. High-pitched or shrill cry

109. The nurse is caring for a child with hemophilia who is actively bleeding. Which nursing action is most important
in the prevention of the crippling effects of bleeding?
A. Active range of motion
B. Avoidance of all dental care
C. Encourage genetic counseling
D. Elevate and immobilize the affected extremity

110. A young child is admitted with acute epiglotittis. Which is of the highest priority as the nurse plans care?
A. Assessing the airway frequently
B. Turning, coughing, and deep breathing
C. Administering cough medicine as ordered
D. Encouraging the child to eat

111. Which finding would alert the nurse to potential problems in a newly delivered term infant of a mother whose
blood type is O negative?
A. Jaundice
B. Negative direct Coombs
C. Infant’s blood type is O negative
D. Resting heart rate is 155

112. Immediately after birth a newborn infant is suctioned, dried, and placed under a radiant warmer. The infant has
spontaneous respirations and the nurse assesses an apical heart rate of 80 beats/minute and respirations of 20
breaths/minute. What action should the nurse perform next?
A. Initiate positive pressure ventilation.
B. Intervene after the one minute Apgar is assessed.
C. Initiate CPR on the infant.
D. Assess the infant's blood glucose level.
113. A newborn, whose mother is HIV positive, is scheduled for follow-up assessments. The nurse knows that the most
likely presenting symptom for a pediatric client with AIDS is:
A. Shortness of breath
B. Joint pain
C. A persistent cold
D. Organomegaly

114. A 37-week gestation neonate has just been born to a woman with insulin-dependent diabetes mellitus and is
admitted to the nursery. Which of the following is most essential when planning immediate care for the infant?
A. Glucose monitoring
B. Daily weights
C. Supplemental formula feedings
D. An apnea monitor

115. The nurse should refer the parents of an 8-month-old child to a health care provider if the child is unable to do
which of the following?
A. Stand momentarily without holding onto furniture.
B. Standalone well for long period of time.
C. Stoop to recover an object.
D. Sit without support for long periods of time.

116. When taking a diet history from the mother of a 7-year-old child with phenylketonuria, a report of an intake of
which of the following foods should cause the nurse to become concerned?

A. Coke Zero
B. Carrots
C. Orange juice
D. Bananas

117. A toddler who has been treated for a foreign body aspiration begins to fuss and cry when the parents attempt to
leave the hospital for an hour. The nurse interprets this behavior as indicating separation anxiety involving which of the
following?
A. Protest
B. Despair
C. Regression
D. Detachment

118. Which of the following foods should the nurse encourage the mother to offer to her child with iron deficiency
anemia?
A. Rice cereal, whole milk, and yellow vegetables
B. Potato, peas, and chicken
C. Macaroni, cheese, and ham
D. Pudding, green vegetables, and rice

119.The nurse is assessing a primigravida at 34 weeks for signs of pregnancy-induced hypertension (PIH). In addition
to her blood pressure of 140/92 mm Hg, what other assessment finding would make the nurse suspect PIH?
A. Hematuria
B. Proteinuria
C. Fatigue
D. Palpitations
120. Where should a client’s uterine fundus be located 12 hours after delivery?
A. At 2 cm below the umbilicus
B. At 3 cm above the umbilicus
C. To the right of the umbilicus
D. At or slightly above the umbilicus