PNLE II for Community Health Nursing and 6.

A pregnant client is receiving magnesium sulfate for

Care of the Mother and Child severe pregnancy induced hypertension (PIH). The clinical
findings that would warrant use of the antidote , calcium
gluconate is:
1. May arrives at the health care clinic and tells the nurse
that her last menstrual period was 9 weeks ago. She also
tells the nurse that a home pregnancy test was positive but A. Urinary output 90 cc in 2 hours.
she began to have mild cramps and is now having B. Absent patellar reflexes.
moderate vaginal bleeding. During the physical C. Rapid respiratory rate above 40/min.
examination of the client, the nurse notes that May has a D. Rapid rise in blood pressure.
dilated cervix. The nurse determines that May is
experiencing which type of abortion? 7. During vaginal examination of Janah who is in labor, the
presenting part is at station plus two. Nurse, correctly
A. Inevitable interprets it as:
B. Incomplete
C. Threatened A. Presenting part is 2 cm above the plane of the
D. Septic ischial spines.
B. Biparietal diameter is at the level of the ischial
2. Nurse Reese is reviewing the record of a pregnant client spines.
for her first prenatal visit. Which of the following data, if C. Presenting part in 2 cm below the plane of the
noted on the client’s record, would alert the nurse that the ischial spines.
client is at risk for a spontaneous abortion? D. Biparietal diameter is 2 cm above the ischial
spines.
A. Age 36 years
B. History of syphilis 8. A pregnant client is receiving oxytocin (Pitocin) for
C. History of genital herpes induction of labor. A condition that warrant the nurse in-
D. History of diabetes mellitus charge to discontinue I.V. infusion of Pitocin is:

3. Nurse Hazel is preparing to care for a client who is
newly admitted to the hospital with a possible diagnosis of
ectopic pregnancy. Nurse Hazel develops a plan of care for
the client and determines that which of the following
nursing actions is the priority?
A. Contractions every 1 ½ minutes lasting 70-80
seconds.
B. Maternal temperature 101.2
C. Early decelerations in the fetal heart rate.
D. Fetal heart rate baseline 140-160 bpm.

A. Monitoring weight 9. Calcium gluconate is being administered to a client with

B. Assessing for edema pregnancy induced hypertension (PIH). A nursing action
C. Monitoring apical pulse that must be initiated as the plan of care throughout
D. Monitoring temperature injection of the drug is:

4. Nurse Oliver is teaching a diabetic pregnant client about A. Ventilator assistance

nutrition and insulin needs during pregnancy. The nurse B. CVP readings
determines that the client understands dietary and insulin C. EKG tracings
needs if the client states that the second half of pregnancy D. Continuous CPR
require:
10. A trial for vaginal delivery after an earlier caesareans,
A. Decreased caloric intake would likely to be given to a gravida, who had:
B. Increased caloric intake
C. Decreased Insulin A. First low transverse cesarean was for active
D. Increase Insulin herpes type 2 infections; vaginal culture at 39
weeks pregnancy was positive.
5. Nurse Michelle is assessing a 24 year old client with a B. First and second caesareans were for
diagnosis of hydatidiform mole. She is aware that one of cephalopelvic disproportion.
the following is unassociated with this condition? C. First caesarean through a classic incision as a
result of severe fetal distress.
D. First low transverse caesarean was for breech
A. Excessive fetal activity. position. Fetus in this pregnancy is in a vertex
B. Larger than normal uterus for gestational age. presentation.
C. Vaginal bleeding
D. Elevated levels of human chorionic gonadotropin.
11.Nurse Ryan is aware that the best initial approach when
trying to take a crying toddler’s temperature is:
 A. Talk to the mother first and then to the toddler. A. Effectiveness
B. Bring extra help so it can be done quickly. B. Efficiency
C. Encourage the mother to hold the child. C. Adequacy
D. Ignore the crying and screaming. D. Appropriateness

12.Baby Tina a 3 month old infant just had a cleft lip and 18.Vangie is a new B.S.N. graduate. She wants to become a
palate repair. What should the nurse do to prevent trauma Public Health Nurse. Where should she apply?
to operative site?
A. Department of Health
A. Avoid touching the suture line, even when B. Provincial Health Office
cleaning. C. Regional Health Office
B. Place the baby in prone position. D. Rural Health Unit
C. Give the baby a pacifier.
D. Place the infant’s arms in soft elbow restraints. 19.Tony is aware the Chairman of the Municipal Health
Board is:
13. Which action should nurse Marian include in the care
plan for a 2 month old with heart failure? A. Mayor
B. Municipal Health Officer
A. Feed the infant when he cries. C. Public Health Nurse
B. Allow the infant to rest before feeding. D. Any qualified physician
C. Bathe the infant and administer medications
before feeding. 20.Myra is the public health nurse in a municipality with a
D. Weigh and bathe the infant before feeding. total population of about 20,000. There are 3 rural health
midwives among the RHU personnel. How many more
14.Nurse Hazel is teaching a mother who plans to midwife items will the RHU need?
discontinue breast feeding after 5 months. The nurse
should advise her to include which foods in her infant’s A. 1
diet? B. 2
C. 3
A. Skim milk and baby food. D. The RHU does not need any more midwife item.
B. Whole milk and baby food.
C. Iron-rich formula only. 21.According to Freeman and Heinrich, community health
D. Iron-rich formula and baby food. nursing is a developmental service. Which of the following
best illustrates this statement?
15.Mommy Linda is playing with her infant, who is sitting
securely alone on the floor of the clinic. The mother hides a A. The community health nurse continuously
toy behind her back and the infant looks for it. The nurse is develops himself personally and professionally.
aware that estimated age of the infant would be: B. Health education and community organizing are
necessary in providing community health services.
A. 6 months C. Community health nursing is intended primarily
B. 4 months for health promotion and prevention and
C. 8 months treatment of disease.
D. 10 months D. The goal of community health nursing is to
provide nursing services to people in their own
16.Which of the following is the most prominent feature of places of residence.
public health nursing?
22.Nurse Tina is aware that the disease declared through
A. It involves providing home care to sick people Presidential Proclamation No. 4 as a target for eradication
who are not confined in the hospital. in the Philippines is?
B. Services are provided free of charge to people
within the catchments area. A. Poliomyelitis
C. The public health nurse functions as part of a team B. Measles
providing a public health nursing services. C. Rabies
D. Public health nursing focuses on preventive, not D. Neonatal tetanus
curative, services.
23.May knows that the step in community organizing that
17.When the nurse determines whether resources were involves training of potential leaders in the community is:
maximized in implementing Ligtas Tigdas, she is
evaluating A. Integration
 B. Community organization D. Endocardial cushion defect
C. Community study
D. Core group formation 30.Malou was diagnosed with severe preeclampsia is now
receiving I.V. magnesium sulfate. The adverse effects
24.Beth a public health nurse takes an active role in associated with magnesium sulfate is:
community participation. What is the primary goal of
community organizing? A. Anemia
B. Decreased urine output
A. To educate the people regarding community C. Hyperreflexia
health problems D. Increased respiratory rate
B. To mobilize the people to resolve community
health problems 31.A 23 year old client is having her menstrual period
C. To maximize the community’s resources in every 2 weeks that last for 1 week. This type of menstrual
dealing with health problems. pattern is bets defined by:
D. To maximize the community’s resources in
dealing with health problems. A. Menorrhagia
B. Metrorrhagia
25.Tertiary prevention is needed in which stage of the C. Dyspareunia
natural history of disease? D. Amenorrhea

A. Pre-pathogenesis 32. Jannah is admitted to the labor and delivery unit. The
B. Pathogenesis critical laboratory result for this client would be:
C. Prodromal
D. Terminal A. Oxygen saturation
B. Iron binding capacity
26.The nurse is caring for a primigravid client in the labor C. Blood typing
and delivery area. Which condition would place the client D. Serum Calcium
at risk for disseminated intravascular coagulation (DIC)?
33.Nurse Gina is aware that the most common condition
A. Intrauterine fetal death. found during the second-trimester of pregnancy is:
B. Placenta accreta.
C. Dysfunctional labor. A. Metabolic alkalosis
D. Premature rupture of the membranes. B. Respiratory acidosis
C. Mastitis
27.A fullterm client is in labor. Nurse Betty is aware that D. Physiologic anemia
the fetal heart rate would be:
34.Nurse Lynette is working in the triage area of an
A. 80 to 100 beats/minute emergency department. She sees that several pediatric
B. 100 to 120 beats/minute clients arrive simultaneously. The client who needs to be
C. 120 to 160 beats/minute treated first is:
D. 160 to 180 beats/minute
A. A crying 5 year old child with a laceration on his
28.The skin in the diaper area of a 7 month old infant is scalp.
excoriated and red. Nurse Hazel should instruct the B. A 4 year old child with a barking coughs and
mother to: flushed appearance.
C. A 3 year old child with Down syndrome who is
A. Change the diaper more often. pale and asleep in his mother’s arms.
B. Apply talc powder with diaper changes. D. A 2 year old infant with stridorous breath sounds,
C. Wash the area vigorously with each diaper sitting up in his mother’s arms and drooling.
change.
D. Decrease the infant’s fluid intake to decrease 35.Maureen in her third trimester arrives at the
saturating diapers. emergency room with painless vaginal bleeding. Which of
the following conditions is suspected?
29.Nurse Carla knows that the common cardiac anomalies
in children with Down Syndrome (tri-somy 21) is: A. Placenta previa
B. Abruptio placentae
A. Atrial septal defect C. Premature labor
B. Pulmonic stenosis D. Sexually transmitted disease
C. Ventricular septal defect
36.A young child named Richard is suspected of having C. Decreased BP reading in the upper extremities
pinworms. The community nurse collects a stool specimen D. Increased BP reading in the upper extremities.
to confirm the diagnosis. The nurse should schedule the
collection of this specimen for: 42.The reason nurse May keeps the neonate in a neutral
thermal environment is that when a newborn becomes too
A. Just before bedtime cool, the neonate requires:
B. After the child has been bathe
C. Any time during the day A. Less oxygen, and the newborn’s metabolic rate
D. Early in the morning increases.
B. More oxygen, and the newborn’s metabolic rate
37.In doing a child’s admission assessment, Nurse Betty decreases.
should be alert to note which signs or symptoms of chronic C. More oxygen, and the newborn’s metabolic rate
lead poisoning? increases.
D. Less oxygen, and the newborn’s metabolic rate
A. Irritability and seizures decreases.
B. Dehydration and diarrhea
C. Bradycardia and hypotension 43.Before adding potassium to an infant’s I.V. line, Nurse
D. Petechiae and hematuria Ron must be sure to assess whether this infant has:

38.To evaluate a woman’s understanding about the use of A. Stable blood pressure
diaphragm for family planning, Nurse Trish asks her to B. Patant fontanelles
explain how she will use the appliance. Which response C. Moro’s reflex
indicates a need for further health teaching? D. Voided

A. “I should check the diaphragm carefully for holes 44.Nurse Carla should know that the most common
every time I use it” causative factor of dermatitis in infants and younger
B. “I may need a different size of diaphragm if I gain children is:
or lose weight more than 20 pounds”
C. “The diaphragm must be left in place for atleast 6 A. Baby oil
hours after intercourse” B. Baby lotion
D. “I really need to use the diaphragm and jelly most C. Laundry detergent
during the middle of my menstrual cycle”. D. Powder with cornstarch

39.Hypoxia is a common complication of 45.During tube feeding, how far above an infant’s stomach
laryngotracheobronchitis. Nurse Oliver should frequently should the nurse hold the syringe with formula?
assess a child with laryngotracheobronchitis for:
A. 6 inches
A. Drooling B. 12 inches
B. Muffled voice C. 18 inches
C. Restlessness D. 24 inches
D. Low-grade fever
46. In a mothers’ class, Nurse Lhynnete discussed
40.How should Nurse Michelle guide a child who is blind to childhood diseases such as chicken pox. Which of the
walk to the playroom? following statements about chicken pox is correct?

A. Without touching the child, talk continuously as
the child walks down the hall.
B. Walk one step ahead, with the child’s hand on the
nurse’s elbow.
C. Walk slightly behind, gently guiding the child
forward.
D. Walk next to the child, holding the child’s hand.
41.When assessing a newborn diagnosed with ductus
arteriosus, Nurse Olivia should expect that the child most
likely would have an:
A. Loud, machinery-like murmur.
B. Bluish color to the lips.
A. The older one gets, the more susceptible he
becomes to the complications of chicken pox.
B. A single attack of chicken pox will prevent future
episodes, including conditions such as shingles.
C. To prevent an outbreak in the community,
quarantine may be imposed by health authorities.
D. Chicken pox vaccine is best given when there is an
impending outbreak in the community.
47.Barangay Pinoy had an outbreak of German measles. To
prevent congenital rubella, what is the BEST advice that
you can give to women in the first trimester of pregnancy
in the barangay Pinoy?
 A. Advice them on the signs of German measles. 53.Angel was diagnosed as having Dengue fever. You will
B. Avoid crowded places, such as markets and movie say that there is slow capillary refill when the color of the
houses. nailbed that you pressed does not return within how many
C. Consult at the health center where rubella vaccine seconds?
may be given.
D. Consult a physician who may give them rubella A. 3 seconds
immunoglobulin. B. 6 seconds
C. 9 seconds
48.Myrna a public health nurse knows that to determine D. 10 seconds
possible sources of sexually transmitted infections, the
BEST method that may be undertaken is: 54.In Integrated Management of Childhood Illness, the
nurse is aware that the severe conditions generally require
A. Contact tracing urgent referral to a hospital. Which of the following severe
B. Community survey conditions DOES NOT always require urgent referral to a
C. Mass screening tests hospital?
D. Interview of suspects
A. Mastoiditis
49.A 33-year old female client came for consultation at the B. Severe dehydration
health center with the chief complaint of fever for a week. C. Severe pneumonia
Accompanying symptoms were muscle pains and body D. Severe febrile disease
malaise. A week after the start of fever, the client noted
yellowish discoloration of his sclera. History showed that 55.Myrna a public health nurse will conduct outreach
he waded in flood waters about 2 weeks before the onset immunization in a barangay Masay with a population of
of symptoms. Based on her history, which disease about 1500. The estimated number of infants in the
condition will you suspect? barangay would be:

A. Hepatitis A A. 45 infants
B. Hepatitis B B. 50 infants
C. Tetanus C. 55 infants
D. Leptospirosis D. 65 infants

50.Mickey a 3-year old client was brought to the health 56.The community nurse is aware that the biological used
center with the chief complaint of severe diarrhea and the in Expanded Program on Immunization (EPI) should NOT
passage of “rice water” stools. The client is most probably be stored in the freezer?
suffering from which condition?
A. DPT
A. Giardiasis B. Oral polio vaccine
B. Cholera C. Measles vaccine
C. Amebiasis D. MMR
D. Dysentery
57.It is the most effective way of controlling
51.The most prevalent form of meningitis among children schistosomiasis in an endemic area?
aged 2 months to 3 years is caused by which
microorganism? A. Use of molluscicides
B. Building of foot bridges
A. Hemophilus influenzae C. Proper use of sanitary toilets
B. Morbillivirus D. Use of protective footwear, such as rubber boots
C. Steptococcus pneumoniae
D. Neisseria meningitidis 58.Several clients is newly admitted and diagnosed with
leprosy. Which of the following clients should be classified
52.The student nurse is aware that the pathognomonic as a case of multibacillary leprosy?
sign of measles is Koplik’s spot and you may see Koplik’s
spot by inspecting the: A. 3 skin lesions, negative slit skin smear
B. 3 skin lesions, positive slit skin smear
A. Nasal mucosa C. 5 skin lesions, negative slit skin smear
B. Buccal mucosa D. 5 skin lesions, positive slit skin smear
C. Skin on the abdomen
D. Skin on neck
59.Nurses are aware that diagnosis of leprosy is highly A. No signs of dehydration
dependent on recognition of symptoms. Which of the B. Some dehydration
following is an early sign of leprosy? C. Severe dehydration
D. The data is insufficient.
A. Macular lesions
B. Inability to close eyelids 65.Chris a 4-month old infant was brought by her mother
C. Thickened painful nerves to the health center because of cough. His respiratory rate
D. Sinking of the nosebridge is 42/minute. Using the Integrated Management of Child
Illness (IMCI) guidelines of assessment, his breathing is
60.Marie brought her 10 month old infant for consultation considered as:
because of fever, started 4 days prior to consultation. In
determining malaria risk, what will you do? A. Fast
B. Slow
A. Perform a tourniquet test. C. Normal
B. Ask where the family resides. D. Insignificant
C. Get a specimen for blood smear.
D. Ask if the fever is present everyday. 66.Maylene had just received her 4th dose of tetanus
toxoid. She is aware that her baby will have protection
61.Susie brought her 4 years old daughter to the RHU against tetanus for
because of cough and colds. Following the IMCI assessment
guide, which of the following is a danger sign that indicates A. 1 year
the need for urgent referral to a hospital? B. 3 years
C. 5 years
A. Inability to drink D. Lifetime
B. High grade fever
C. Signs of severe dehydration 67.Nurse Ron is aware that unused BCG should be
D. Cough for more than 30 days discarded after how many hours of reconstitution?

62.Jimmy a 2-year old child revealed “baggy pants”. As a A. 2 hours

nurse, using the IMCI guidelines, how will you manage B. 4 hours
Jimmy? C. 8 hours
D. At the end of the day
A. Refer the child urgently to a hospital for
confinement. 68.The nurse explains to a breastfeeding mother that
B. Coordinate with the social worker to enroll the breast milk is sufficient for all of the baby’s nutrient needs
child in a feeding program. only up to:
C. Make a teaching plan for the mother, focusing on
menu planning for her child. A. 5 months
D. Assess and treat the child for health problems like B. 6 months
infections and intestinal parasitism. C. 1 year
D. 2 years
63.Gina is using Oresol in the management of diarrhea of
her 3-year old child. She asked you what to do if her child 69.Nurse Ron is aware that the gestational age of a
vomits. As a nurse you will tell her to: conceptus that is considered viable (able to live outside the
womb) is:
A. Bring the child to the nearest hospital for further
assessment. A. 8 weeks
B. Bring the child to the health center for B. 12 weeks
intravenous fluid therapy. C. 24 weeks
C. Bring the child to the health center for assessment D. 32 weeks
by the physician.
D. Let the child rest for 10 minutes then continue 70.When teaching parents of a neonate the proper position
giving Oresol more slowly. for the neonate’s sleep, the nurse Patricia stresses the
importance of placing the neonate on his back to reduce
64.Nikki a 5-month old infant was brought by his mother the risk of which of the following?
to the health center because of diarrhea for 4 to 5 times a
day. Her skin goes back slowly after a skin pinch and her A. Aspiration
eyes are sunken. Using the IMCI guidelines, you will B. Sudden infant death syndrome (SIDS)
classify this infant in which category? C. Suffocation
 D. Gastroesophageal reflux (GER) 77.Nurse John is performing an assessment on a neonate.
Which of the following findings is considered common in
71.Which finding might be seen in baby James a neonate the healthy neonate?
suspected of having an infection?
A. Simian crease
A. Flushed cheeks B. Conjunctival hemorrhage
B. Increased temperature C. Cystic hygroma
C. Decreased temperature D. Bulging fontanelle
D. Increased activity level
78.Dr. Esteves decides to artificially rupture the
72.Baby Jenny who is small-for-gestation is at increased membranes of a mother who is on labor. Following this
risk during the transitional period for which complication? procedure, the nurse Hazel checks the fetal heart tones for
which the following reasons?
A. Anemia probably due to chronic fetal hyposia
B. Hyperthermia due to decreased glycogen stores A. To determine fetal well-being.
C. Hyperglycemia due to decreased glycogen stores B. To assess for prolapsed cord
D. Polycythemia probably due to chronic fetal C. To assess fetal position
hypoxia D. To prepare for an imminent delivery.

73.Marjorie has just given birth at 42 weeks’ gestation. 79.Which of the following would be least likely to indicate
When the nurse assessing the neonate, which physical anticipated bonding behaviors by new parents?
finding is expected?
A. The parents’ willingness to touch and hold the
A. A sleepy, lethargic baby new born.
B. Lanugo covering the body B. The parent’s expression of interest about the size
C. Desquamation of the epidermis of the new born.
D. Vernix caseosa covering the body C. The parents’ indication that they want to see the
newborn.
74.After reviewing the Myrna’s maternal history of D. The parents’ interactions with each other.
magnesium sulfate during labor, which condition would
nurse Richard anticipate as a potential problem in the 80.Following a precipitous delivery, examination of the
neonate? client’s vagina reveals

A. Hypoglycemia a fourth-degree laceration. Which of the following would

B. Jitteriness be contraindicated when caring for this client?
C. Respiratory depression
D. Tachycardia A. Applying cold to limit edema during the first 12 to
24 hours.
75.Which symptom would indicate the Baby Alexandra B. Instructing the client to use two or more peripads
was adapting appropriately to extra-uterine life without to cushion the area.
difficulty? C. Instructing the client on the use of sitz baths if
ordered.
A. Nasal flaring D. Instructing the client about the importance of
B. Light audible grunting perineal (kegel) exercises.
C. Respiratory rate 40 to 60 breaths/minute
D. Respiratory rate 60 to 80 breaths/minute 81. A pregnant woman accompanied by her husband, seeks
admission to the labor and delivery area. She states that
76. When teaching umbilical cord care for Jennifer a new she’s in labor and says she attended the facility clinic for
mother, the nurse Jenny would include which information? prenatal care. Which question should the nurse Oliver ask
her first?
A. Apply peroxide to the cord with each diaper
change A. “Do you have any chronic illnesses?”
B. Cover the cord with petroleum jelly after bathing B. “Do you have any allergies?”
C. Keep the cord dry and open to air C. “What is your expected due date?”
D. Wash the cord with soap and water each day D. “Who will be with you during labor?”
during a tub bath.
82.A neonate begins to gag and turns a dusky color. What
should the nurse do first?
 A. Calm the neonate. following procedures is usually performed to diagnose
B. Notify the physician. placenta previa?
C. Provide oxygen via face mask as ordered
D. Aspirate the neonate’s nose and mouth with a A. Amniocentesis
bulb syringe. B. Digital or speculum examination
C. External fetal monitoring
83. When a client states that her “water broke,” which of D. Ultrasound
the following actions would be inappropriate for the nurse
to do? 89. Nurse Arnold knows that the following changes in
respiratory functioning during pregnancy is considered
A. Observing the pooling of straw-colored fluid. normal:
B. Checking vaginal discharge with nitrazine paper.
C. Conducting a bedside ultrasound for an amniotic A. Increased tidal volume
fluid index. B. Increased expiratory volume
D. Observing for flakes of vernix in the vaginal C. Decreased inspiratory capacity
discharge. D. Decreased oxygen consumption

84. A baby girl is born 8 weeks premature. At birth, she has 90. Emily has gestational diabetes and it is usually
no spontaneous respirations but is successfully managed by which of the following therapy?
resuscitated. Within several hours she develops
respiratory grunting, cyanosis, tachypnea, nasal flaring, A. Diet
and retractions. She’s diagnosed with respiratory distress B. Long-acting insulin
syndrome, intubated, and placed on a ventilator. Which C. Oral hypoglycemic
nursing action should be included in the baby’s plan of D. Oral hypoglycemic drug and insulin
care to prevent retinopathy of prematurity?
91. Magnesium sulfate is given to Jemma with
A. Cover his eyes while receiving oxygen. preeclampsia to prevent which of the following condition?
B. Keep her body temperature low.
C. Monitor partial pressure of oxygen (Pao2) levels.
D. Humidify the oxygen. A. Hemorrhage
B. Hypertension
C. Hypomagnesemia
85. Which of the following is normal newborn calorie D. Seizure
intake?
92. Cammile with sickle cell anemia has an increased risk
A. 110 to 130 calories per kg. for having a sickle cell crisis during pregnancy. Aggressive
B. 30 to 40 calories per lb of body weight. management of a sickle cell crisis includes which of the
C. At least 2 ml per feeding following measures?
D. 90 to 100 calories per kg
A. Antihypertensive agents
86. Nurse John is knowledgeable that usually individual B. Diuretic agents
twins will grow appropriately and at the same rate as C. I.V. fluids
singletons until how many weeks? D. Acetaminophen (Tylenol) for pain

A. 16 to 18 weeks 93. Which of the following drugs is the antidote for

B. 18 to 22 weeks magnesium toxicity?
C. 30 to 32 weeks
D. 38 to 40 weeks
A. Calcium gluconate (Kalcinate)
B. Hydralazine (Apresoline)
87. Which of the following classifications applies to C. Naloxone (Narcan)
monozygotic twins for whom the cleavage of the fertilized D. Rho (D) immune globulin (RhoGAM)
ovum occurs more than 13 days after fertilization?
94. Marlyn is screened for tuberculosis during her first
A. conjoined twins prenatal visit. An intradermal injection of purified protein
B. diamniotic dichorionic twins derivative (PPD) of the tuberculin bacilli is given. She is
C. diamniotic monochorionic twin considered to have a positive test for which of the
D. monoamniotic monochorionic twins following results?

88. Tyra experienced painless vaginal bleeding has just

been diagnosed as having a placenta previa. Which of the
 A. An indurated wheal under 10 mm in diameter 100. Maureen, a primigravida client, age 20, has just
appears in 6 to 12 hours. completed a difficult, forceps-assisted delivery of twins.
B. An indurated wheal over 10 mm in diameter Her labor was unusually long and required oxytocin
appears in 48 to 72 hours. (Pitocin) augmentation. The nurse who’s caring for her
C. A flat circumcised area under 10 mm in diameter should stay alert for:
appears in 6 to 12 hours.
D. A flat circumcised area over 10 mm in diameter A. Uterine inversion
appears in 48 to 72 hours. B. Uterine atony
C. Uterine involution
95. Dianne, 24 year-old is 27 weeks’ pregnant arrives at D. Uterine discomfort
her physician’s office with complaints of fever, nausea,
vomiting, malaise, unilateral flank pain, and costovertebral
angle tenderness. Which of the following diagnoses is most
likely?

A. Asymptomatic bacteriuria
B. Bacterial vaginosis
C. Pyelonephritis
D. Urinary tract infection (UTI)

96. Rh isoimmunization in a pregnant client develops

during which of the following conditions?

A. Rh-positive maternal blood crosses into fetal

blood, stimulating fetal antibodies.
B. Rh-positive fetal blood crosses into maternal
blood, stimulating maternal antibodies.
C. Rh-negative fetal blood crosses into maternal
blood, stimulating maternal antibodies.
D. Rh-negative maternal blood crosses into fetal
blood, stimulating fetal antibodies.

97. To promote comfort during labor, the nurse John

advises a client to assume certain positions and avoid
others. Which position may cause maternal hypotension
and fetal hypoxia?

A. Lateral position
B. Squatting position
C. Supine position
D. Standing position

98. Celeste who used heroin during her pregnancy delivers

a neonate. When assessing the neonate, the nurse
Lhynnette expects to find:

A. Lethargy 2 days after birth.

B. Irritability and poor sucking.
C. A flattened nose, small eyes, and thin lips.
D. Congenital defects such as limb anomalies.

99. The uterus returns to the pelvic cavity in which of the

following time frames?

A. 7th to 9th day postpartum.

B. 2 weeks postpartum.
C. End of 6th week postpartum.
D. When the lochia changes to alba.