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MCN Post Test
MCN Post Test
MCN Post Test
Archie D. Alviz
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Pressing deeply into the abdomen while compressing the fundus with both hands
Supporting the fundus while massaging the uterus just above the symphysis pubis
Compressing the fundus on one side while supporting the other side of the uterus
Massaging above the symphysis pubis while one hand supports the uterine fundus
Answer B
Rationale: Supporting the fundus while massaging the uterus just above the symphysis pubis
provides support to the lower uterine segment while stimulating contraction of the fundus. It also
prevents inversion of the uterus (uterine inversion), which is an obstetric emergency. The top
(fundus) of the uterus is massaged, not the sides. Massaging at the symphysis pubis would not
provide effective uterine contractions. One hand is used to massage the fundus. It is not
necessary to press deep into the abdomen.
61. The following are nursing interventions to relieve episiotomy wound pain EXCEPT
A. Perineal heat
B. Perineal care
C. Giving analgesic as ordered
D. Sitz bath
Answer: B
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ANTEPARTUM COMPLICATIONS
ABORTION
71. When differentiating the different types of abortion, as a knowledgeable nurse, you know that
the signs that will distinguish threatened abortion from imminent abortion is
A. Dilation of the cervix
B. Presence of uterine contractions
C. Nature and location of pain
D. Severity of bleeding
Answer: A
In imminent abortion, the pregnancy will definitely be terminated because the cervix is already
open unlike in threatened abortion where the cervix is still closed.
72. A young couple attends the prenatal clinic. The wife is 8 weeks' pregnant and asks the clinic
nurse for information about an abortion. The nurse expresses the opinion that abortion is immoral
and that many women have long-term guilt feelings after an abortion. The couple leave the clinic
in a very disturbed state. Legally, the:
A. Physician should have been called in, since nurses should not discuss abortion
B. Nurse's statements need not be based on scientific knowledge
C. Client had a right to receive correct, unbiased information
D. Nurse had a right to state feelings as long as they were identified as the nurse's own
Answer C
Explanation: A. The nurse is capable of giving information about abortion and need not defer to
the physician. B. Nursing practice necessitates scientific knowledge; statements must be based on
fact, not personal feelings or beliefs. C. Nurses with positive attitudes toward abortion should
counsel women who are thinking of undergoing the procedure; they should know what services
are available and the various methods that are used to induce abortion. D. The nurse should give
the client only the information requested and should not state personal feelings.
HEMOLYTIC DISEASE OF THE NEWBORN
73. In the 12th week of gestation, a client completely expels the products of conception. Because
the client is Rh-negative, the nurse must:
A. Administer RhoGAM within 72 hours
B. Make certain she recieves RhoGAM on her first clinic visit
C. Not give RhoGAM, since it is not used with the birth of a stillborn
D. Make certain the client does not receive RhoGAM, since the gestation lasted only 12 weeks
Answer A
Explanation: A. It is given within 72 hours postpartum if the client has not been sensitized
previously. B. It would be useless at this time. C. RhoGAM is always indicated at the termination of
a pregnancy, even with fetal demise. D. RhoGAM is always indicated at the termination of a
pregnancy, even with a short-term pregnancy.
74. Which of the following is TRUE in Rh incompatibility?
A. On the first pregnancy of the Rh(-) mother, the fetus will not be affected
B. RhoGam is given only during the first pregnancy to prevent incompatibility
C. The condition can occur if the mother is Rh(+) and the fetus is Rh(-)
D. Every pregnancy of an Rh(-) mother will result to erythroblastosis fetalis
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Answer: A
On the first pregnancy, the mother still has no contact with Rh(+) blood thus it has not antibodies
against Rh(+). After the first pregnancy, even if terminated into an abortion, there is already the
possibility of mixing of maternal and fetal blood so this can trigger the maternal blood to produce
antibodies against Rh(+) blood. The fetus takes its blood type usually form the father.
75. Which of the following would be the most important action for the nurse to determine if the
prenatal blood panel of a primigravida reveals that she is Rh negative?
A. Hemoglobin and hematocrit levels
B. Previous administration of RhoGAM
C. Blood type of the father of the baby
D. Her religious preference
Answer C
Rationale: If the father is Rh positive (or if his blood type is unknown), an antibody screen is done
to determine if the woman has developed isoimmunity to the Rh antigen. If the father is negative,
there is less chance of this problem. Although hemoglobin and hematocrit are important in
prenatal blood work, they are unrelated to the client's Rh status and possible Rh isoimmunization.
Religious preference would only be pertinent if isoimmunization was severe enough to require
exchange transfusion of the infant (e.g. Jehovahs Witness). RhoGAM is only administered during
or following a pregnancy with a fetus that is Rh positive (or an abortus in which the blood Rh is
unknown) within 24- 48 hours in the clients first pregnancy.
ECTOPIC PREGNANCY
76. Which assessment most closely relates to a diagnosis of ectopic pregnancy?
A. Brownish red, tapioca-like vesicles
B. Elevated temperature
C. Spotting or bleeding 2 to 3 weeks after a missed menstrual period
D. Sudden absence of fetal movement
Answer: C
77. Nurse Alvin is preparing to care for a client who is newly admitted to the hospital with a
possible diagnosis of ectopic pregnancy. Nurse alvin develops a plan of care for the client and
determines that which of the following nursing actions is the priority?
a. Monitoring weight
b. Assessing for edema
c. Monitoring apical pulse
d. Monitoring temperature
Answer: C
Rationale: Nursing care for the client with a possible ectopic pregnancy is focused on preventing
or identifying hypovolemic shock and controlling pain. An elevated pulse rate is an indicator of
shock.
GESTATIONAL DIABETES
78. When obtaining an intake history from a new client in the antepartum clinic, which of the
following factors, if found in the multigravida's history, would identify her as being at increased
risk for gestational diabetes?
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A. Age of 25
B. Five living children
C. Prior birth of a large infant
D. Smoking two packs a day
Answer C
Rationale: An elevated glucose level stimulates the secretion of fetal insulin and results in
macrosomia and an infant with a birth weight greater than 9 pounds. Thus, a history suggesting
previous birth of a large infant would be a risk factor. Maternal age over 30 years is a risk factor
for gestational diabetes. Increased number of pregnancies is not a risk factor for gestational
diabetes. Smoking does not alter glucose metabolism. Because of the vasoconstrictive effects of
nicotine, a substance contained in cigarettes, these infants usually have a low birth weight.
79. During a prenatal visit, the nurse is explaining dietary management to a client with gestational
diabetes mellitus. The nurse determines that teaching has been effective if the client makes which
statement?
A. I will need to eat 600 more calories every day since I am pregnant.
B. I can continue with the same diet as before pregnancy, as long as it is well-balanced.
C. I will plan my diet based on the results of urine glucose testing.
D. Diet and insulin needs change during pregnancy.
Answer: D
The diet for a pregnant client with GDM is individualized to allow for increased fetal and metabolic
requirements, whi consideration to such factors as prepregnancy weight and dietary habits,
overall health, ethnic background, lifestyle, stage of pregnancy, and insulin therapy. Option A is
not required. In the 3rd trimester, insulin needs increase. Option C is incorrect because blood, not
urine testing, is more reliable.
80. The neonate of a mother with diabetes mellitus is prone to developing hypoglycemia because:
A. His kidneys are immature leading to a high tolerance for glucose
B. The pancreas is immature and unable to secrete the needed insulin
C. There is rapid diminution of glucose level in the babys circulating blood and his
pancreas is normally secreting insulin
D. The baby is reacting to the insulin given to the mother
Answer: C
If the mother is diabetic, the fetus while in utero has a high supply of glucose. When the baby is
born and is now separate from the mother, it no longer receives a high dose of glucose from the
mother. In the first few hours after delivery, the neonate usually does not feed yet thus this can
lead to hypoglycemia.
PREGNANCY-INDUCED HYPERTENSION
81. A pre-eclamptic client is for repeat dose of magnesium sulfate. Before giving a repeat dose,
the nurse should assess the patients condition. Which of the following conditions will require the
nurse to temporarily suspend a repeat dose of magnesium sulfate?
A. Knee jerk reflex is (+)1
B. 100 ml of urine in 4 hours
C. BP of 105/70mmHg
D. RR of 16/cpm
Answer: B
The minimum urine output expected for a repeat dose of MgSO4 is 30 cc/hr. If in 4 hours the urine
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ANEMIA
84. The nurse recognizes that an expected change in the hematologic system that occurs during
the second trimester of pregnancy is:
A. A decrease in WBCs
B. An icrease in blood volume
C. An increase in blood volume
D. A decrease in sedimanation rate
Answer C
Explanation: A. White blood cell values remain stable during the antepartum period. B. The
hematocrit decreases as a result of hemodilution. C. The blood volume increases by approximately
50% during pregnancy. Peak blood volume occurs between 30 and 34 weeks of gestation. D. The
sedimentation rate increases because of a decrease in plasma proteins.
INFECTIONS
85. Which of the following is the primary predisposing factor related to mastitis?
A. Epidemic infection from nosocomial sources localizing in the lactiferous glands and ducts
B. Endemic infection occurring randomly and localizing in the periglandular connective tissue
C. Temporary urinary retention due to decreased perception of the urge to avoid
D. Breast injury caused by overdistention, stasis, and cracking of the nipples
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Archie D. Alviz