Manila Adventist College

School of Nursing
Online Assignment

Name: Kheak,Kimlay

Instruction: Write the correct answer on the space provided and then write your rationale cited from
textbooks, manuals, etc., as a support to your answer.

1. A young primigravida at 12 weeks gestation tells the nurse that she is having a hard time to quit
smoking. The nurse explains to her that smoking during pregnancy is associated with:
A. Low Birth weights C. placenta previa on the third trimester
B. Large for gestational age infants D. Early decelerations during labor

Answer: A

Rationale:

Smoking during pregnancy increases the risk of health problems for developing babies, including
preterm birth, low birth weight, and birth defects of the mouth and lip.

2. What is the proteolytic enzyme released by the sperm cell to achieve active penetration in the egg
cell’s protective cell membrane?
A. Hyaluronidase C. Spermatogenesis
B. Chlironidase D. Corona radiate

Answer: A

Rationale:

Hyaluronidase (a proteolytic enzyme) is released by the spermatozoa which acts to dissolve the layer of
cells protecting the ovum.

3. Continuous assessment of fetal well-being after umbilical cord proplapse is accomplished

primarily by?
A. Palpating the cord to determine FHR
B. Observing the patient’s emotional status
C. Determining the station of the presenting part
D. Ensuring that the amniotic fluid contains no meconium

Answer: A

Rationale:

Continuous electronic fetal heart rate monitoring is a useful adjunct in assessing fetal wellbeing and to
assess whether the technique being used to eliminate cord compression are successful.
 4. Which of the following assessment findings done by the nurse after birth of the newborn should
be reported to the physician?
A. Newborn has irregular beating C. Fontanelles are slightly elevated
B. Newborn is pink in color D. newborn has vernix caseosa

Answer: A

Rationale:

Infants with abnormal heart rhythms may seem extra irritable or fussy, have feeding difficulties, appear
pale, and lack energy. So that the nurse should report it to the physician.

5. A pregnant diabetic client at 16 weeks gestation has her first prenatal check-up. Which of the
following information would be provided if the client undergoes an ultrasound examination?
A. Placental maturity C. gestational age
B. Estimated fetal weight D. Fetal lung maturity

Answer: B

Rationale:

If a mother with gestational diabetes has other complicating factors, such as obesity or preeclampsia,
prenatal testing should be more frequent and a planned delivery may need to occur at an earlier date

6. Maternal care according to the DOH guidelines consists of the following except:
A. Care of the pregnant woman
B. Safe delivery of the mother
C. Postnatal care of the infant
D. That the child receives adequate nourishment

Answer: D

Rationale:

7. Nurse Evelyn is assigned to handle postpartum mothers focusing on home care. She is scheduled
to do a first home visit to Mrs. Sandoval. When is the first postpartum visit typically done?
A. Within a week after discharge C. 6 weeks postpartum
B. 1 week postpartum D. immediately after delivery

Answer: C

Rationale:

Typically, many doctors want to schedule the first postpartum visit six weeks after you deliver.
 8. Postpartum haemorrhage is defined as loss of how many ml of blood documented in the first 24
hours postpartum?
A. 200 C. 400
B. 300 D. 500

Answer: D

Rationale:

Blood loss in excess of 500 ml following birth within the first 24 hours of delivery.

9. Mrs. Marciano undergoes bilateral tubal ligation after the birth of her 6 th baby. After the
procedure, she is discharged and given instructions. She understood her discharge instructions
when she says..
A. Rest for one week C. Not carry her youngest child
B. Take a bath immediately D. Have a sexual contact with her husband immediately

Answer: A

Rationale:

Rest for one week. Avoid strenuous activities such as lifting heavy objects and intense exercise for 7 days
after your surgery. Ask when it is safe for you to drive, return to work, and return to other regular
activities. Do not have sex for at least 1 week.

10. Kathleen at 32 weeks gestation is advised to have an ultrasound. She has understood the
procedure if she says:
A. Turn client on her left lateral position C. Increased IVF rate
B. Administer oxygen to the patient D. Assess client for maternal hypotension

Answer: ____

Rationale:

11. In doing postpartum assessment, the first hour is most critical. Which of the following
interventions is a priority?
A. Massage uterine fundus gently at the slightest sign of relaxation.
B. Check vital signs until stable.
C. Administer oxytocin as ordered
D. Infuse intravenous fluids as ordered.

Answer: A

Rationale:
The first hour, after placental separation and birth, observation of bleeding signs and symptoms by
palpating the fundus of the uterus through the abdominal wall.

12. Kelly asks about supplemental vitamins that she should take during her pregnancy. Which of the
following should she advised to take in order to enhanced absorption of iron?
A. Warm milk C. Prune juice
B. Orange juice D. Coffee

Answer: B

Rationale:

Vitamin C can help prevent cell damage and assist with iron absorption. Folate can help prevent neural
tube defects, which can cause brain and spinal cord abnormalities in a baby.

13. A nurse on duty at the labor room is assessing Mrs. Arevalo’s amniotic fluid fluid. Which
characteristics of the amniotic fluid indicates fetal distress?
A. Mucus-tinged C. Greenish
B. Colorless D. Pinkish

Answer: C

Rationale:

Green-tinged amniotic fluid is indicative of meconium staining. This finding indicates fetal distress

14. Client Sharon delivered a healthy term baby boy. She asks the nurse why her baby’s hands and
feet are bluish in color. The nurse refers to this condition as:
A. Port wine stain C. Epstein pearls
B. Acrocyanosis D. Mongolian spots

Answer: B

Rationale:

Acrocyanosis means bluish discoloration of the extremities due to decreased amount of oxygen delivered to
the peripheral part.

15. A client at 37 weeks gestation, started to have a bloody vaginal discharge while doing errands and
was immediately rushed to the ER. What is the nurse’s initial intervention?
A. Monitor FHR every 15 minutes C. Administer oxygen therapy
B. Position the client on her left lateral position D. Start the client on IV tocolytic

Answer: A

Rationale:
One out of 10 women will have vaginal bleeding during their 3rd trimester. At times, it may be a sign of a
more serious problem. In the last few months of pregnancy, you should always report bleeding to your
health care provider right away.

16. Julia, a primigravida is admitted at the medical facility in labor. Which finding indicates that Julia
has achieved the first stage of labor?

A. Presenting part is in station +1

B. Cervical dilatation of 10 cm
C. Cervix is 75% effaced
D. There is severe back pain radiating to the hypogastrium

Answer: B

During this stage, your cervix will widen to about 10 centimeters. This first stage of labor usually lasts
about 12 to 13 hours for a first baby, and 7 to 8 hours for a second child.

Rationale:

17. Julia is then brought to the delivery room after the physician has examined her. Which of the
following routine procedures should not be done considering her cervical dilatation?
A. Do perineal prep C. Monitor vital signs and FHT
B. Place her on NPO D. Doing a cleansing enema
Answer: B

Rationale:

There is no need to put the patient into NPO.

18. While assessing a client in labor, which of the following observations should the nurse refer
immediately to the physician?
A. Frequent urination C. Sudden gush of amniotic fluid
B. Blood streaked mucus in the vaginal discharge D. FHT 130/min after uterine
contraction

Answer: C

Rationale:

The main symptom of Premature Rupture of Membranes at Term (PROM) is fluid leaking from the
vagina. You may experience a sudden gush of fluid or a slow, constant trickle. It can be difficult to
distinguish between a slow amniotic trickle or urine.

19. Which of the following indicates placental separation after delivery of the baby?
 1. Protrusion of the umbilical cord
2. Descent of the uterus into the pelvis
3. Uterus becomes firm and rounded
4. Sudden gush of blood

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

Answer: C

Signs of Placental Separation

20. A newly delivered baby manifest with outlined color change. When the infant lies on one side,
the lower half of the body becomes pink and the upper half becomes pale. The nurse is correct
when she says that this known as:

A. Erythema toxicum C. Acrocyanosis

B. Harlequin sign D. Mongolian spot

Answer: B

Rationale:

Harlequin sign A benign, transient color change seen in neonates in which one half of the body blanches
while the other half becomes redder, with a clear line of demarcation.

21. A 28 weeks gestation primigravida is diagnosed with Class 2 heart disease. The nurse instructs
her to contact her physician immediately if she experiences :

A. Mild ankle edema C. Weight gain of one pound a week

B. Emotional stress on the job D. Increase dyspnea at rest

Answer: D

Rationale:

Peripartum cardiomyopathy should be considered in any pregnant or puerperal woman who complains of
increasing shortness of breath, especially on lying flat or at night.

22. Susan’s last LMP was started on October 12. on her first prenatal check-up, the nurse informs her
that her EDC will be on:

A. June 5 C. July 5
B. June 19 D. July 19

Answer: D
Rationale:

EDC = LMP - 3months + 7 days

23. In a childbirth preparation class, the nurse explains that in the postpartum period the process
where the uterus shrinks to it’s prepregnant state is known as:

A. Puerperium C. Involution
B. Subinvolution D. Uterine Atony

Answer: A

Rationale:

first 6 weeks “40 days” following the birth of an infant are known as the post-partum period or
puerperium, in which maternal body in general and genital organs in particular return to nearly pre-
pregnant state.

24. On her first trimester of pregnancy, which of the following hormones is responsible for
maintaining Susan’s pregnancy?

A. HCG C. Estrogen
B. Relaxin D. Progesterone

Answer: A

Rationale:

Human chorionic gonadotrophin (HCG) is the embryonic hormone that ensures the corpus luteum
continues to produce progesterone throughout the first trimester of pregnancy.

25. A sign of pregnancy that relaxes to painless, irregular false labor is known as:

A. Goodell’s sign C. Fetal movement

B. Braxton Hick’s D. Leukorrhea

Answer: B

Rationale:

Braxton Hicks contractions are sporadic contractions and relaxation of the uterine muscle. Sometimes,
they are referred to as prodromal or “false labor" pains.
PART 2 (NCP)

Case: Pregnacy Induced Hypertension

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONAL EVALUATION
E
Hypertension Decreased • After 8 Independent: Compariso After 8 hours of
cardiac hours • Monitor blood n of nursing
output of nursing pressure of the pressures interventions,
related to interventio patient. Measure provides a the patient was
decreased ns, in both arms or more able to
venous the patient thighs three complete participate in
return. will times, 3-5 picture of activities that
participate minutes apart vascular reduce blood
Inference: in while patient is at involvemen pressure or
Preeclamps activities rest, then sitting, t or cardiac work
ia is a that then standing for scope of load.
common reduce initial evaluation. the
problem blood problem.
during pressure or
pregnancy. cardiac
The work • Observe skin • Presence
condition — load. color, moisture, of
sometimes temperature and pallor,
referred capillary refill cool,
to as time. moist skin
pregnancy- and
induced delayed
hypertensio capillary
n refill
time may
be
due to
peripheral
Vasoconstri
ction

• Note dependent
or general • May
edema. indicate
heart
failure,
renal or
vascular
impairment
.

• Provide calm,
restful • Help
surroundings, reduce
minimize sympatheti
environmental c
activity or noise. stimulation
,
promotes
relaxation.

• Maintain
activity • Reduces
restrictions. physical
stress
and
tension
that
affect
blood
pressure
and
course of
hypertensi
on.

• Instruct in • Can
relaxation reduce
techniques, and stressful
guided imagery. stimuli,