OB Nursing Notes

OBSTETRIC NURSING - TOPRANK
Note:
(NORMALS)
● Para: Deliveries
● Gravidy: Pregnancy
GRAVIDY: Number of pregnancy
regardless of outcome and duration
● Abortion is included
● H.Mole
● Ectopic pregnancy G-T-P-A-L-M
PARITY: number of deliveries that reached T-Term (37 weeks and above) -infants born
the age of viability (20 weeks of pregnancy) P- Pre-term (36 weeks and below)
delivered dead or alive ● Note: both Term and Preterm you
● Children delivered dead or alive count the number of infants born
basta 20 weeks A- Abortion (less than 20 weeks)
L- Living
Principles in identifying parity: M- Multiple pregnancy (twins counted as
● Multiple pregnancy - twins counted one, triplets counted as one) Principle: we
as one count the number of pregnancy
● Abortion - not counted (end of
pregnancy before age of viability) Case Sample:
● Stillbirth - still counted Patient X is experiencing her fourth
pregnancy. Her first pregnancy ended in a
spontaneous abortion at 8 weeks, the
Cases:
second resulted in the live birth of twin boys
● Patient A: is pregnant for the first
and carries a twin. at 39 weeks, and the third resulted in the
● Patient B: delivered to an alive live birth of a daughter at 34 weeks.
monozygotic twin.
● Patient C: is now pregnant. Her ● G4 T2 (twins) P1 A1 L-3 M-1
pregnancy three years ago ended ● G4 P2
in abortion.
● Patient D: has delivered an alive
baby girl. Her pregnancy three
years ago ended in abortion. Nabawasan ng current pregnancy, abortion
● Patient E: pregancy three years
ago ended in abortion. She aborts OBSTETRICAL FORMULA AND
for the second time. COMPUTATION
Answer:
NAEGELE’S RULE
1. G1P0 - zero kase hindi pa
● To estimate: Expected date of
nanganganak!!!!
confinement (EDC)
2. G1P1 - nanganak na so P1
● Prerequisite: Last Menstrual Period
3. G2P0A1
○ If ever Jan 11 - Jan 16:
4. G2P1A0
would be the unang patak
5. G2P0A2
nang regla ni lola of the
LMP
○ Ex. May 26 last patak and
lasted for 5 days: so minus Examples Cases:
5; therefore 1st day would be
May 22 (manual 15 weeks AOG it is in the umbilicus - too
computation) rapid = H.Mole (mas mabilis lumaki ang
■ May 21 -1 H.mole compared sa normal)
■ May 22-2 ● Or polyhydramnios
■ May 23-3 ● Gestational diabetes
■ May 24-4
■ May 25-5 36 weeks AOG- between umbilicus and
FOR JANUARY TO MARCH xiphoid process - Abnormal (roo slow_
● Months = +9 ● Cases: Ectopic pregnancy, Maliit
● Day - +7 ang bata, smoking, SGA caused by
● Year - do not touch smoking (Vasoconstriction thus
For APRIL TO DECEMBER prevent nutrients exchange)
● Months -3,
● Days - +7 Note: From 20th week of AOG to 36th week
● Year - +1 of AOG
● Fundal Height (cm) = AOG (weeks)
Case Sample:
Caring for a woman on her 30th week of
● November 20, 2021 - 07, 27, 2021 pregnancy
○ 11 20 2021 ● Expected FH would be 30 cm
○ -3 +7 +1 Caring for a woman with her 24 cm but
○ 07-27-2022 (July 27, 2022) forgot her AOG
● Feb 14, 2021 - Nov 21, 2021 ● Expected AOG would be 24 weeks
○ 02 14 2021
○ +9 +7 0 Problem:
○ 11-21-2021
○ November 21, 2021 40th week = xiphoid process not pa nag
● Feb 28, 2021 - December 5, 2021 lightning so suspect placenta previa
○ 02 28 2021 ● Because it is obstructing the baby
○ +9 +7 0 from crowning
○ 11 35 2021
○ 12 05 2021 Normally = 36 weeks lightening occurs
○ December 5, 2021
Signs and Symptoms of Pregnancy
Bartholomew’s Method
Presumptive Probable Positive
● Symphysis Pubis -
12 weeks Subjective Can be Confirmed the
● Umbilicus - 20 documented/ presence of a
Objective growing baby
weeks
● Xiphoid Process- 36 ● Amenorrhea ● Chadwick’s ● Fetal Heart
weeks
● Nausea and signs - Rate - Doppler ● 16th - 18 weeks / 2nd trimester
vomiting bluish ● Fetal
● Urinary discoloration Movement - Purple Vagina -Chadwick’s
frequency of vagina Nurse/examine
● Breast r Lambot ni Cervix - Goodell’s
changes ● Goodell’s ● Fetal Outline - Lambot ni lower vagina -Heger
● Uterine sign - Ultrasound
enlargement softening of Linea Nigra -
● Quickening - the cervix Striae Gravidarum-
Felt by the
mother, ● Hegar’s sign
tumors has its - COMMON DISCOMFORT DURING
own pulsation Thinning/thin PREGNANCY
ning of the
● Melasma/ lower uterine Principle: Normal no need to notify the
chloasma - segment physician
@face/mask ● Only inform them how to manage it
of pregnancy ● Braxton
● Linea Nigra- Hicks- ● All of these are commonly caused by
line extended painless HCG (cbq- peak production of HCG
to the xiphoid contraction
process to the relieved by “60th to 80th day of pregnancy = 3rd
symphysis walking month of pregnancy”)
pubis ○ Peak of Nausea and
● Striae ● Ballottement
gravidarum- - rebounding Vomiting - end of the 1st tri,
pinkish strike of the fetus 60th to 80 day
in the side of
lower ● Positive ○ It has a relaxing effect -
abdomen pregnancy relaxation of GIT
Note: skin test - H.Mole (regurgitation) and sacral
discoloration are / ectopic
all just a pregnancy joints
presumptive signs ○ Causes Nausea and vomiting
according to ● Urine
pilitteri Pregnancy Morning sickness:
test - 10 ● Instruct to eat small frequent feeding
days after
fertilization Nausea and Vomiting
● Blood
Pregnancy
● Dry craker’s carbohydrates
test - 7 ● Small frequent feeding, fluid in
days of
fertilization between meals
● Avoid fried, fatty, and spicy foods
● Ice chips
When to eat
● Wait until nawala ang
Nausea and Vomiting
Heartburn
● Elevate the head of bed 3 hours
after meal
● Milk in between meals
Constipation
COMMON DISCOMFORT DURING
● Increases oral fluid intake, high fiber
PREGNANCY
diet
● Stool softener / laxative
Skin Discoloration
○ It is safe as long as it is ○ For severe pain
prescribed by the physician ● Warm sitz bath - limited to 40
Principle: celsius
● Not all laxative are safe ○ No pain pero
during pregnancy ○ Promote comfort
● The safest laxative: ○ Hot sitz bath!!! Is not!!!
○ Docusate Sodium ■ Anything is hot
(colace) bawal sa pregnancy
○ Metamucil ■ Vasodilation -
○ Milk of mag hypotension -
○ Bisacodyl (dulcolax) decreased placental
Backache - perfusion
● Pelvic Rocking/til exercise (cbq) Leukorrhea
Lordosis ● Whitish non-foul vagina dischagre
● Sleep in a flat, firm mattress ● Use cotton underpants or perineal
Waddling gait -duck walking ● No:
Sex Position to ensure boy ○ Referral to physician
● Shettles method ○ Purchasing anti-fungal
○ Dog Style 3 MORTAL SINS IN PREGNANCY -
○ Sex done on the day contraindicated during pregnancy
of ovulation ● Using of bathtubs
● Using of tampons
Principle: Causes would be the increase in ● Douching - regardless of its
the level of estrogen pressure
● Increase vascularity ○ Common distractor
● Increase in secretion ■ Avoid
○ Normal to suffer in nasal ■ Limit
congestion (cbq) Limit bathtubs, tampons, douching - BAWAL
Breast Tenderness- PATIN
● Wearing a supportive bra
● Avoid using soap to prevent drying AVOID IS STILL THE BEST
Leg varicosities and pedal edema - ● AVOID BATHTUBS, TAMPONS,
pooling of blood in the lower extremities DOUCHING
● Elevate the legs, use of anti embolic
stocking - if nasa work Example: low pressure douche is still bawal
● Avoid prolonged sitting and standing
● Avoid crossing of the legs Leg Cramps
● Elevating of the legs ● Cause: decrease calcium because
Hemorrhoids baby is taking it in a large amount
● Knee-chest position/ modified sim’s ● Management: Increase CA in the
position diet
● Ice/Cold compress ○ 4 glasses milk/day
○ Both can be use but it ○ 1200 mg CA/day
depend ● Vit. D
○ If prescribe by the physician
○ Dorsiflexion of the foot Increases
Urinary frequency Increase in blood volume, cardiac

● Cause: common in the 1st and 3rd output, and heart rate
trimester as a result of the ● To support the growing focus
compression of symphysis pubis ● Increase in the plasma volume
● Management: Increase fluid intake, ○ This causes pseudoanemia-
and wiping perineum front to back lowering of concentration
Increase in the clotting factors, platelets,
wbc (>20,000), lipid and serum
Urinary frequency in 2nd trimester (not cholesterol
common - because uterus becomes a part ● Prevent infection
of the abdominal cavity) ● Prevent bleeding
● Polyuria - gestational Diabetes ● Sources of energy and neural tube
mellitus ○ For lipid
● H.mole - compression of the
symphysis pubis Increase in GFR and creatinine clearance
and urine output
Supine Hypotension Syndrome: ● To eliminate both maternal and fetal
● Aka vena cava syndrome waste product
● Aorta cava syndrome ● Thus lowering the BUN and plasma
Cause: inferior vena cava compression creatinine (serum waste product)
manifestation : Dizziness while lying supine
Management: left side lying position Lowering
● Why left? Lowering and plasma creatinine
○ Because superior vena cava ● Because all BUN and creat are
in the right so left is much being excreted
preferable Decrease in vaginal pH
● To battle vaginal infection
Round Ligament Pain ● Acid kill bacteria
● Stabbing or jabbing pain in the lower ● 3.8 to 4.8 pH
abdomen aggravated by movement Decrease in protein
● Caused: stretching of the round ● For fetal and placental growth
ligament Decrease in IgG
● Management: to flex the hips; ● Because it is the only antibody that
simply sit; warm compress (only can only pass the placenta
warm not hot) ● Thus it need to decrease the
mother’s IgG
NORMAL PHYSIOLOGIC CHANGES IN ● Antigen Attacks foreign antigen
PREGNANCY ● Baby is a foreign body
○ So IgG must be decrease
PRINCIPLE: muna so it wont taact the
● No need to report just monitor baby
○ Decreases the chances of
Fetal rejection
● Causes mothers to be PSYCHOLOGICAL CHANGES IN
immunocompromised PREGNANCY
Functional Innocent Heart Murmurs 1ST TRIMESTER: Accepting the

Mild Hyperventilation pregnancy
● Needed to increase O2 content ● Ambivalence and anxiety
● 1-2bpm ○ Ambivalence: 2 opposing
feelings felt during pregnancy
Placenta ● Couvade Syndrome
● Start working in the transporting of ○ When the husband
nutrition 3rd months of pregnancy experiencing the signs and
● Starts forming by 12 weeks symptoms of the pregnancy
Nutritional Instruction 2ND TRIMESTER: ACCEPTING THE
● Decrease fats intake BABY
○ Difficult to digest ● Note: easiest part
○ Decrease but not avoid to ○ they now realize that there is
promote neural a baby in the body because
● Proteins increase of the quickening
○ For fetal and placental Quickening
development ● Primi: 20 weeks
● Carbohydrates ● Multipara: 16 weeks
○ 1st weeks: increase - for fetal ● Narcissist
brain development ● Introversion
○ 2nd and 3rd - decrease to ○ Both narcissistic and
prevent hyperglycemia introversion - she is taking
Weight monitoring care of herself and the baby
● Best index of health during ● Extroversion - Husband
pregnancy ○ Husband is now being
Normal weight gain pattern outgoing
● 1st trimester: 1lb/month = 3lbs ○ Father is preparing for the
● 2nd trimesters - 1lb/week = 12 lbs upcoming birth of the baby
● 3rd trimester 1lb/week = 12 lbs ○ Laging nag oovertime sa
● Total = 27 lbs work
Total weight gain 3RD TRIMESTER:

● 25-35 lbs ● PREPARE FOR THE DELIVERY
● Normal BMI ● Nest Building - baby going to the
○ 18.5 to 24.9 - universal BMI mall and buying stuff and arranging
(asian pacific obesity) the room for the baby, naming of the
○ Pregnancy: baby
■ 19.8 to 25.9 ● Mimicry - the woman imitates the
■ Just add lang 1 practice of other pregnant woman
○ Baby speak with other ● Context: All are common
woman complications during pregnancy
therefore it is not really reported to
ALIN ANG NAIIBA GAME: the physician. Unlike letter B which
● Softening of the lower uterine indicates vaginal infection.
segment - heger
● Painless contraction relieved by ALIN ANG NAIIBA GAME:
walking- braxton hick ● Pseudoanemia
● Fetal heart tone confirmed by ● Decrease Vaginal pH
doppler ● Mild Hyperventilation
● Positive serum pregnancy ● Decrease GFR and creatinine
Answer: C clearance
● Context: All are probable signs of Answer: D
pregnancy while letter C is the only ● Context: All are Expected
positive sign. physiological changes during
pregnancy. Additionally, the
ALIN ANG NAIIBA GAME: maternal body is usually expected to
● Limiting vaginal douching to 2 - 3 double up their blood supply as a
times per week to flush out vaginal result the kidney must also double to
discharge excrete toxins.
● Pelvic rocking exercise to relieve
backache
● Docusate sodium PO once a day as
prescribed by physician
● Placing an ice pack fo 15 to 20
minutes on an external hemorrhoid
Answer: A
● Context: We always avoid all the
absolute words such as limit.
Additionally, vaginal douching is
prohibited during pregnancy.
Everything else is recommended
during pregnancy except letter a.
ALIN ANG NAIIBA GAME:
● Dizziness while lying - supine
hypotension
● Frothy, yellowish, foul-smelling
vaginal discharge
● Jabbing pain in the lower abdomen -
round ligament pain
● Leg varicosities and pedal edema -
normal ALIN ANG NAIIBA GAME:
Answer: B ● Increase carbohydrates intake on
the 1st trimester of pregnancy
● A weight gain pattern of 1 lb/month ○ What lies in the fundus
in the 2nd and 3rd trimester Result:
● A weight gain pattern of 1lb per ○ Hard and bound:
week on the 1st trimester ■ Fetal head
● A pregnancy BMI of 16.5 ○ Soft and glandular
Answer: A ■ Fetal buttocks
● Context: Only letter A is correctly Ex:
recommended instruction to be
given to a pregnant woman to allow hard and round smooth object in the fundus
development of the brain. While ● Breech coz ang buli ay nasa baba
others are wrong. and yung head is in the fundus
○ Weight gain 1lb per week for Soft and glandular object in the fundus
2nd and 3rd trimester ● Cephalic presentation
○ 1lb/month during 1st
trimester
○ And a pregnancy BMI of 19.8 ● 2nd Maneuver: Umbilical Grip
- 25.9 Result:
○ Hard and smooth plane
■ Fetal back - where we
OBSTETRICAL PROCEDURES monitor for the FHR
○ Irregular and bony:
Leopold’s Maneuver ■ Fetal extremities
Client Instruction Ex.

● Empty bladder ● Hard and smooth plane on the left
○ Comfort and much accurate side: monitor for the FHR in the left
information
● Client Position ● 3rd maneuver:: Pawlik’s grip
○ Supine position/dorsal Result:
recumbent ○ Movable- head is not yet
● Nursing consideration: use the engage
PALMS ○ Not-Movable- head is
● Position of the Nurse: engage
○ :Left handed (Nurse): Left ■ Do not touch na
side of the woman
○ Right sided (nurse): right side ● 4th Maneuver: Pelvic Grip
of the woman ○ Degree of flexion/attitude of
■ Principle: the baby
● Left to left ■ Determine the fetal
● Right to right attitude
■ Good Attitude:
Proper way of doing Leopolds’ Maneuver Hyperflexed
(Mahiyain/humble);
● 1st maneuver: Fundal grip Complete flexion
■ Mas maliit ang ○ After meals
diameter nang ■ Increase energy of
presenting part the baby to move
(suboccipitobregmatic ○ Position: Left side lying
presentation position
■ Adequate perfusion
FUPawPe ■ Adequate position
● F-Fundal ■ Adequate O2 going
● U-Umbilical ○ Same time each day
● Paw-Paw Links ○ 2 attempts
● Pe-Pelvic ● Normal Fetal Movement count
○ 10-12/hour
Cases:
● Nurse wants to Monitor FHR what Cardiff Methods
maneuver should the nurse perform. ● “Count top ten” in 12 hours
● 2nd- umbilical
● The nurse would want to determine Sandovsky - normally it is counted 10
the attitude or degree of fetal head straight movement
flexion? ● Less than 10- subject woman to
● 4th- Pelvic Grip another test (cardiff)
● The Nurse would want to determine
the presentation of the baby. What FETAL HEART TONE MONITORING
maneuver should the nurse
perform? Principles of Equipement
● 1st maneuver - Fundal Grip ● Heart starts beating at 5 weeks -
ultrasound if want mo at 5 weeks
● The nurse would want to determine ● Doppler: it will amplified the sound
whether or not the fetus has been of FHR
engaged in the pelvic canal. What ○ Use water lubricant jelly
maneuver should the nurse ○ KY jelly
perform? ○ Earliest time: 8-10 weeks of
○ 3rd maneuver - Pawlik’s AOG, 10 week AOG
grip (pillitteri)
■ BE: earliest time to
Determining Fetal Movement Count monitor FHR 8-10
● Done 20th week of pregnancy - weeks
quickening ● Fetoscope: 12-14 weeks
● Stethoscope: 16-20 weeks of
Sandovsky Method gestation
● 12/hr
○ Best time would be early Promote Bonding: let the parent listen to
morning the FHR
■ Woman is rested and Normal Fetal heart Rate: 120-160 bpm
baby is rested
LESS THAN 120 OR MORE THAN 160 = ○ No decrease in the fetal
● Fetal distress (RH incompatibility, heart rate
infection, cord compression) ○ No deceleration in FHR
● Notify the Physician (fetal
distress) for possible CS Cases:
NON-STRESS TEST: ● Nurse noted Episodic fetal heart

● Monitoring FHR in response to acceleration in the Non-stress test
fetal movement ● Document and continue
Result: monitoring
● Reactive Result: Acceleration ○ Because considered
○ Good Result to be normal
○ Indicates: Normally yung HR ● Do not notify physician
would increase
○ Movement-heart is Not all deceleration are abnormal in
compensating Stress Test:
○ Increase 15 bpm in 15
seconds for 2 consecutive Early Deceleration: occurs
readings - Fetal heart rate ● Decrease in FHR during the
acceleration onset of contraction / in the
○ beginning of contraction
● Non-reactive Result: ● Caused by head
○ Bad Result compression - vagal
○ No increase in fetal heart stimulation (CN 10)
rate or increase but less than ○ PinapaVagal ang
15 bmp tibok nang puso
○ May proceed to Contraction ● Nursing consideration:
stress test ○ Continue monitoring
because everything is
normal
STRESS TEST:
● Monitoring for the FHR in Late Deceleration:
response to uterine contraction ● Decrease in FHR during the end of
contraction (relax the yung uterus)
Result: ● Causes:
● Positive ○ Uteroplacental
○ Decrease in FHR insufficiency
○ Drop from 130 to 100 bpm ■ Can cause fetal
■ Drop hypoxia
● Negative (normal)- FHR remains ● Nursing intervention:
the same ○ 1st: Immediately stop giving
○ Normal oxytocin
○ Negative ○ 2nd: Reposition the woman -
Left side lying position
■ To promote blood
return to the heart H- Hepatitis B
○ 3rd: Oxygenate the pregnant I- Inactive form
woman ● Not live attenuated because woman
○ 4th: Notify the MD is immunocompromised
R-Rabies Vaccine
Variable: ● No Rubella/No MMR/AMV 2(highly
● Deceleration occurs anytime during teratogenic)
or in between contractions D-Diphtheria (DPT)
● Cause:
○ Cord Compression Additional safe Vaccine:
● Nursing Implication ● Pneumococcal
○ Reposition the woman ● Meningococcal
(Depending on the position of ● COVID-19 vaccine
the cord) ○ But only be given after the
■ Knee chest position 1st trimester of the
■ Left sim’s position pregnancy - where baby is
fully developed
PREGNANCY AND VACCINATION ○ To prevent fetal malformation
“Third”
PREPARATION FOR CHILDBIRTH
T-Tetanus Toxoid ● Walking
TT1 ASAP Jan Anytime Immediat ○ Best source/form of
Protecte e exercise
d na ● Squatting
TT2 After 1 Feb 3 years 20 ○ Increase blood supply to the
month protectio uterus
n
● Tailor Sitting
TT3 After 6 August 5 years 95 ○ Tigeten the perineal muscle
month protectio ● Kegel’s exercise -
s n
○ Strengthen the perineal
TT4 After 1 August 10 years 99 muscle
year protectio ● Pelvic rocking-
n
○ To prevent and manage
TT5 After 1 August Lifetime 99 backache
year
Note: if hindi na complete - go back to the PREMONITORY/PRODROMAL SIGNS OF

1st TT LABOR
● TT3 (considered as the Booster ● matter of 1 week to two weeks
shot) mag lalakad na
● 2nd booster - TT4
● 3rd booster - TT5 Lightening (engagement): relief of
● TT1- mother is protected dyspnea
● TT2- Baby is protected ● Primi: 1-2 weeks before labor
● Multipara: a day before ○ Radiating from the back to
● Note: this Causes urinary frequency the abdomen
kase naipit si badder
MATERNAL PELVIS
Signs and Symptoms
● Increase in Braxton Hicks
Contraction
● Painless contraction relieved
by walking
● Bloody show-
● Pink tinged cervical spot
PAIN CAUSE BY:
● Ripening of the cervix
● the head is impeding the sacrum of
● As soft as a whipped butter
the mother
Psychosocial Sign:
Pelvic Gestation Measurement:
● Increase Maternal Energy
○ Commonly sa mall
Prerequisite: Determine the ischial spine
naglalakad
1st
○ Needed for the nesting
● Above: -
behavior
○ Fetal head is still floating
○ Brought by the action of
● Below +
adrenaline rush
○ Crowing
○ Instruction: Conserve the
● Within the Ischial Spine
energy needed for the actual
○ Engagement
birthing process (cbq)
Diagonal Conjugate: Determine through

TRUE LABOR CONTRACTION
IE
● D- Decrease in Interval
● The only pelvic measurement
○ Aka Increase in frequency
obtained through vaginal or
● R- Regular Contraction
internal examination
● I- Increase in intensity
● Normally: 11.5 to 13 cm
● P- Progressive cervical dilatation
Obstetric Conjugate: minus 2 lang to
and effacement
determine OC
○ THINNING - effacement
● Problem:
○ DILATION - MOST
○ Dito lalabas ang ulo ng baby
IMPORTANT SIGN
if may nakaharang na
NOTE: Even is mag contract nang contact
sacrum
si uterus if hindi lumaki ang diameter hindi
○ Cannot be directly measured.
lumabas si baby
It needed to initially measure
the Diagonal Conjugate then
Pain Characteristic:
minus it with 2.
● Lumbosacral Pain
● Smallest diameter
● Girdle Like Pain
● Most important pelvic measurement ■ With soft music
- it will determine is baby will be able ○ No pulling of the head of
to go out the baby
● Fetal head Diameter -9.5 cm ■ Facilitate delivery
○ Aka suboccipito bregmatic through ritgen
● OC (cm)=DC (cm) - 2cm maneuver
○ No cutting of the cord
Case: immediately
● If si DC is 11.5 then ■ Delayed cord
○ 11.5-2=9.5 clamping
● Very good ● Waiting for the
pulsation to
Best position for delivery stop to
● Squatting position prevent
○ Reason: Aid for the descend anemia
as a result for gravity; widen ● Wait for 1-3
the pelvic canal mins
● Upright/ any position of comfort ○ No routine suctioning
○ Non-routine suctioning
Lithotomy- not best, but only convenient for only is performed
the physician ○ Best position of the baby:
■ In the symphysis of
6 MAJOR CONCEPT OF NATURAL the mother-you
BIRTH (according to WHO) prone the baby
● Not artificially induced
● No to IC fluids and analgesic STAGES OF LABOR
● Woman can move freely - no
confinement to bed, no bed rest 1ST STAGES OF LABOR: onset of true
○ Lakad lakad to dilate cervix labor contraction to the full cervical
● Woman is supported contraction
● Upright or side lying position Principle:
● Immediate and unlimited ● No pushing!!! It may rupture the
breastfeeding cervix
● Ferguson’s Reflex- uncontrollable
LE BOYER METHOD OF CHILDBIRTH urge to push
● Proposed by Frederick Leboyer- ○ In CBQ- urge to defecate
Birth without violence Ex. the woman wants to go to the room
○ Recommended Birthing room ● Intervention- check for the perineum
Temp: 25 to 28 degree (to determine for possible crowning)
celsius ● During Ferguson's Reflex!!!!
■ Warm;quite;dimmed ○ This is the moment you
■ Prevent transfer the mother in the
hypoglycemia and delivery room
comfort
Prolong labor (medication)
Primip Multipa ● Oxytocin
ara ra ● Prostaglandin- to soften and dilate
the cervix
Bahu- 14 hours 8 hours
biLAT ○ Misoprostol
○ Dinoprostone
Phase Cervical Duration Interval Emotional
dilatatio response
n
1cm/hr WHO’s recommended guideline

● Frequency of Internal examination
Latent 0-3 cm 20-40 Q 10 min Excited -
sec ○ Q 4 hours
■ To prevent infection
Active 4-7 cm 40-60 Q5 Anxiety and
sec MINS argumentative Example: admision 4 cm ie at 9 am
● 12 nn and 4pm
Transi 8-10 cm 60-90 Q3 Irritable
tion sec MINS
Case: 5cm; 35 sec; q 7mins(active)

● Expected emotional response:
Argumentative
EX. 6M; 8 MINS; 35SEC

● Active - always put in mind si
cervical dilatation
Ex. 5cm dilation, Example: 8 am at 4cm, 12 nn 5cm, 4pm at
7 cm
Management During: ● Notify the physician- green line (it
has passed throught the action line)
Latent:
● Encourage to walk
● No pushing allowed in the 1st
stage
Active
● Request a modified partograph -
4cm
● Request epidural anesthesia
○ 3cm or more in the active
phase
Transition:
● Prepare for delivery
● Once woman is 8 cm - we do not
transfer them to the delivery room
● Transfer when there’s a
uncontrollable urge to poop ● Precipitous
● red line- prepare for immediate
● Use partograph within 4 cm ● L-Lengthening of the cord
dilation/active phase ○ 1st most indicative sign of
● Graph always remain on the right placental separation
side of the alert lien but must not ○ Modified Crede’s maneuver
pass through the alert line ■ Pressure is applied in
● Q 4 hours I.E the uterus while
gently pulling the cord
EARLY 2ND STAGES OF LABOR
● WHEN CERVIX IS FULLY Ritgen - 2nd stage; Crede’s for 3rd
DILATED: Fetal Delivery
● Usually has a span of 5-10 mins Placental Presentation:
● The usual time for the membrane to Duncan:
rupture (bag of water) ● Placental separated from its edges
● Maternal
Cardinal Movement of Labor ● Dirty
Shultz’s Mechanism
Purpose: to allow the smallest of fetal head ● Separation at the center
to pass thru the smallest diameter ● Fetal Side
(OBSTETRIC CONJUGATE) of the ● Clean and shiny side
maternal pelvis
● E-Engagement 2 Common Uterotonic Agents
● D- Descend ● Oxytocin
● F-Flexion ○ When to admin according
● I- Internal Rotation to WHO
● E-Extension - Do Ritgen ■ “After” cord
○ Cbq- The fetal head is clamping- to prevent
delivered decrease perfusion
(Modified Ritgen Maneuver) During ■ Oxytocin prevent
Extension: using one hand pull the fetal perfusion
chin from between the maternal anus the ○ Mimic natural contraction
coccyx and the other on the fetal occiput ● Ergometrine
control the speed of delivery ○ “After” placental expulsion
● Prevent perineal laceration ○ Action: close the cervix
○ If before baka hinde na ma
● E-External rotation kuha ang retained placental
● E-Expulsion and the placenta itself and
may cause bleeding -
3RD STAGES OF LABOR - Crede’s ○ Cause sustained strong
● 5-10 mins max of 15 min contraction - to prevent
postpartum hemorrhage
Signs of Placental Separation:
● U- Uterus becomes firm and globular Involution
○ Aka Calkin’s sign ● Return of the reproductive organs to
● S-Sudden gush of fluid its pre pregnancy state
● Promotion ○ Dark red
○ Breastfeeding- stimulate ○ NOT BRIGHT RED- active
release of contraction bleeding (postpartum
○ Massage the uterus hemorrhage)
○ Emptying the bladder- is ● Lochia Serosa 4 to 10 days
puno si bladder, uterus can ○ Pink to brown
go down ● Lochia Alba 10 to 14 days
● Normal Location of the Fundus ○ Albino
○ After fetal delivery ○ White
(pushing and contraction
lowers the uterus): below Normal odor: Non-foul smelling
the umbilicus Normal amount: 4 to 8 pads a day
○ After placental delivery ● Change pads q 3 hours
(pushing lowers the Case: if every hour she changes her pad
uterus): between umbilicus ● Indicates heavy bleeding
and symphysis pubis ● 1 pad/hr = heavy bleeding
○ One hour after delivery: at
the level or below the level of
umbilicus POSTPARTUM HEMORRHAGE
■ Babalik ulit!!!!!
○ NEVER ABOVE THE Case Sample:
UMBILICUS BITCH! ● 3rd day of postpartum nurse
■ Last cbq- 3 hours noticed a decreasing BP and
after delivery still increase PR of woman
above the ○ Immediate action: check for
umbilicus!! - nursing the lochia! Assessment 1st
intervention: before intervention
encourage avoidance ● Nurse receives a complaint that she
to promote changes her pad every 1 hour -
involution!!!!! ○ Check for the bp and pr
■ If hindi naka ihi!!! - ● Nurse noted a bright red vaginal
catheterize the bleeding on the 7th day of
woman postpartum
○ Epidural Anesthesia- can ○ Abnormal - active bleeding
cause urine retention ○ Retained fragment of
■ But after 6 hours after placenta
babalik ang normal
reflex of urination POSTPARTUM PSYCHOLOGICAL
● Note: fundus goes down 1cm/day ADAPTATION
TAKING IN: internalization

LOCHIA ● Woman is internalizing the labor and
Principle: the magic of 4 delivery process
● Lochia rubra- 1 to 4 days ● Woman is passive and self-centered
● Woman is dependent and OP fetal position can cause increased
demanding back pain or "back labor." Many fetuses in
● 1-3 days OP position during early labor
● Woman is sensitive spontaneously rotate to occiput anterior
TAKING HOLD: of Responsibility position (occiput facing the mother's anterior
● Taking hold of the responsibility or pubis).
● 3rd to 9th day of postpartum
● Strives to learn to talk of being a Nursing Management:
mother ● The nurse or labor support person
LETTING GO: of Formal Role can apply counterpressure to the
● Letting go of the formal role client's sacrum during contractions
● 10 to 6 weeks to help alleviate back pain
● Resume seXual intimacy associated with OP fetal positioning.
Firm, continuous pressure is applied
When do they resume sexal intimacy? with a closed fist, heel of the hand,
● When lochia discharge has stops or other firm object (eg, tennis ball,
● Or when the episiotomy pain has back massager)
stop/healed
We don't perform routine episiotomy

anymore to prevent trauma anymore!
RETURN OF MENSES
BREASTFEEDING: MENSES WILL

RETURN 3 TO 6 MONTHS
● Increase level of prolactin
○ Inhibit normal menstrual
cycle
○ LAC (Lactation Amenorrhea
Method)- no reliable na
anymore
■ You can still have
ovulation even if you
do breastfeed
NON-BREASTFEEDING: 1 TO 2 MONTHS
Fetal occiput posterior (OP) position is a

common fetal malposition that occurs when
the fetal occiput rotates and faces the
mother's posterior or sacrum.
MATERNAL NURSING (ABNORMALS)
○ Prevent Teratogenic: May
cause gross malformation
Bleeding in Pregnancy
of the baby
Principle: Any bleeding (spotting, gush) it is
● Active production of Surfactant
still and will be abnormal
○ Surfactant- prevent alveoli
from collapse during
expiration
1st and 2nd 2nd Trimester 3rd Trimester
Trimester ● (1st organ to develop) 3rd week
4, 5, 6, 7, 8, 9
1, 2, 3, 4, 5, 6 months months age of gestation - CNS
months ● (2nd organ to develop) 4th weeks-
4P’s Heart
○ (1st functioning organ)
Miscarriage Gestational Placenta
Trophoblastic Previa
Ectopic Diseases
Pregnancy Placental
Incompetent Abruption / Miscarriage (better term)
Cervical Os Abruptio ● Abortion is induced yung meaning
Insufficient/C Placenta nang term
ervic
Placenta Cause:
Accreta
● Abnormal fetal development 6
Preterm
weeks (organogenesis palang) -
Labor mother’s body will excrete the
baby naturally
● Problems within the Implantation
1. First and second Trimester (Month ○ Implantation occurs 8-10
1, 2, 3, 4, 5, 6 ) days
a. Abortion ● Immunologic Factors
i. Interruption/Lost of ○ deoxycorticosterone -
needed in high amount so
Pregnancy before
the body of mother would
age of viability (20-24 not reject the fetus
weeks) ● Viral Infection during the 1st
ii. Age of Viability- peak trimester (TORCH)
of organogenesis and ○ Toxoplasma
active production ○ Other pathogen
and formation of ■ Syphilis
○ Rubella
surfactant
○ CMV
○ Herpes Simplex
Note: ● Decrease in progesterone
○ Hormone of pregnancy
● Peak of Organogenesis: Age of ○ Keeper of endometrial
lining where placenta will
Viability
attach themselves
○ 2nd month/ 6th to 8th ○ Will cause shedding of the
weeks endometrial lining
Other: be difficult
● Teratogenicity ○ No strenuous activities
● Chromosomal aberration and should encourage
● Immunologic light activities
● Implantation abnormality ○ No Tampons to prevent
● Decreased progesterone infection
● Alcohol ○ No Coitus- only resume
● UTI after 2 weeks
○ Link to preterm labor which ● NSG
will lead to abortion during ○ Support
2nd trimester ○ Let patient understand the
● Systemic infection meaning of diagnosis
Type of Abortion: Note: Cervix is not a part of uterus

● Lower segment of uterus - isthmus
Threatened Abortion: ● Body-Corpus
The baby is not yet dead, and there is a ● Upper- Fundus
big chance to save the baby (50%)
Immenent Abortion:
Only threatened 50/50 can be saved, Inevitable Abortion (unavoidable)
baby is still alive and the placenta is still ● Cause
implanted ○ Unknown
● Cause ○ Implantation problem and
○ Unknown poor implantation
○ Chromosomal ● Assessment
abnormalities ○ Hallmark: Open Cervix
○ Uterine abnormalities ○ Slight cramping
● Assessment ○ Bleeding
○ Hallmark: Close Cervix ○ No pain
○ Slight cramping ● Diagnostic
○ Bleeding ○ Bad level of HCG
○ No pain ■ After 48 hours
● Diagnostic (ratio: the HCG
○ Good level of HCG should double
■ After 48 hours every 2 hours or 4
(ratio: the HCG days)
should double ○ (-) FHT
every 2 days or 4 ○ UTZ
days) ■ NO FHT - 5 weeks
■ Principle: The HCG ■ NO Gestational Sac
double every day ● Management
○ (+) FHT ○ Dilatation and Curettage
■ Doppler: 10 weeks ■ Nulli and
○ UTZ adolescent hard to
■ FHT - 5 weeks dilate
■ Doppler - 10 weeks
● Management Pang dilate:
○ No Complete Bed Rest- it ● Laminaria Algae to prevent
can cause cause pooling of scarring and progression of
blood and monitoring will ectopic pregnancy;
● Dilapan-S: acrylic based gel ■ D and C is needed
expands to ultimate diameter of 3 to prevent infection
to 4x that of its dry state; and bleeding not to
● Dilation of cervix with a hegar end the pregnancy
dilator. because the
○ (note: always anchor with pregnancy has
last 2 finger- this is to already ended
prevent uterine perforation
Note:
■ Curettage: as ● Contraction is needed to close the
much as possible uterine bleeding
prevent scarring ● Contraction will not exist if there’s
and by gently a retained placental fragments
scraping it ● There are 100 uterine vessels
according to Pilitteri
How will they know that it is done?
● Bubbling of Blood Complete Abortion:
● Frothy Blood All product of conception is expelled
● Gritting sensation spontaneously and not induced
■ Confirmatory ● Fetus, membranes, placenta
● Serum HCG
- pababa ng ● Cause
pababa ○ Unknown
● ULZ ○ Chromosomal
○ Dilatation and evacuation abnormalities
○ Suction curettage ○ Uterine abnormalities
■ Used in H.Mole ● Assessment
■ Aka Vacuum ○ Hallmark: Open Cervix
Aspiration ○ Slight cramping
■ Can use 60 cc ○ Bleeding
syringe ○ No pain
● NSG ● Diagnostic
○ Save the pads and tissue ○ Decrease level of HCG
fragments ■ After 48 hours
■ Examine and (ratio: the HCG
analyze to should double
differentiate if its every 2 hours or 4
product of days)
conception or ○ UTZ
H.mole (clear ■ No FHT - 5 weeks
transparent) ■ No Doppler - 10
■ H.Mole (needed weeks
extended ● Management
monitoring)-to ○ None
determine if there’s ○ Bleeding will slows down in
a possibility for 2 hours up to few days -
choriocarcinoma just monitor and asses
○ Clarify the meaning of D&C always
procedure and the ● NSG
diagnosis ○ Advise woman to report if
there’s another series of ○ No symptoms of pregnancy
bleeding ■ Decrease nausea
and vomiting -
Incomplete Abortion: lower hcg
When there’s a retained fragments of ○ No expansion and
production of conception enlargement of abdomen
● Typically una lumalabas: Fetus ● Diagnostic
● Retained: Placenta, membrane ○ (-) FHT
○ UTZ
● Cause ■ No FHT - 5 weeks
○ Unknown ■ No Doppler - 10
○ Chromosomal weeks
abnormalities ● Management: prevent bleeding
○ Uterine abnormalities and infection
● Diagnostic ○ D&C, D&E, Suction
○ (-) FHT Curettage - less than 14
○ UTZ weeks / 2nd trimester
■ FHT - 5 weeks ○ Induce labor- above 14
■ Doppler - 10 weeks weeks / 2nd trimester
○ without contraction ■ Prostaglandin
● Management ■ Misoprostol
○ D&C ■ Mifepristone
○ Suction Curettage ■ Oxytocin
● NSG Consideration:
○ Explain the meaning of
diagnostic
○ For without contraction If Above 14 weeks:
■ Removed the ● Baby is huge to be scrapped and
retained fragment exited to the os
Induced labor
Missed Abortion: ● Prostaglandin-dilate cervix os
and soften
The woman will missed the idea and ● Misoprostol / cytotec
signs and symptoms related to (prostaglandin analogue)- route
abortion/miscarriage posterior cervix nang vagina
● Oxytocin - contract uterus
● Retained: Fetus, Placenta, ● Mifepristone - progesterone
membrane (all product of antagonist
conception)
● Cause
○ Unknown misoprostol mifepristone
○ Chromosomal
abnormalities Prostaglandin Progesterone
○ Uterine abnormalities analogue antagonist
● Assessment
○ Vaginal spotting Induce labor To stop the
○ Cramping hormone of
○ No apparent symptoms of Intravaginal route pregnancy
loss of pregnancy
○ D&E
Pros = Lowering the level
○ Suction Curettage
prostaglandin of progesterone it
○ CBR 12-24 hours
will induce regla
● NSG
(shedding of
○ Explain the meaning of
endometrial lining)
diagnostic
-one =
progesterone Note: 1 pad/hour - considered abnormal
and needed inform the physician
● NSG
○ Explain the meaning of b. Ectopic Pregnancy (mother
diagnostic is really in grave in danger)
Ectopic Pregnancy:
Recurrent Pregnancy Loss:
● Old term: Habitual pregnancy
loss- changed because it induced Definition: Implantation occurred outside
guilt toward maternal mother the uterine (bleeding outside the uterus
● 3 or above consecutive such as the peritoneum)
pregnancy loss - same ● Ecto = Outside
approximate AOG
2 Criteria:
● 3 or more Note:
● Same AOG
Normal Location of Fertilization:
● Cause ● Ampula
○ Uterine Scarring Normal Location of Implantation
○ Defective Sperm/OVA ● Inner uterine cavity
○ Endocrine probleme:
● Upper Posterior of the placenta
■ Low Butanol
extractable iodine Note:
(BEI) ● If lower posterior segment nag
■ Protein bound implan si placenta - placenta
iodine (PBI) previa
■ globuline bound Note:
iodine (GBI) ● Zygote: fertilized ovum
○ Uterine abnormality -
● Embryo: implant (8 weeks)
■ septuate, and
bicornuate uterus ● Fetus: 8 weeks to delivery
○ Infection
○ Autoimmune
● Diagnostic
○ (-) FHT
○ UTZ
■ No FHT - 5 weeks
■ No Doppler - 10
weeks
● Management
○ D&C
● Obstruction along the way
○ Adhesions (blocks the way
towards the uterine body and
remain in the fallopian tube.
Some travel outside the
fallopian tube. Adhesion
usually caused by:
■ Previous infection
(chlamydia, syphilis,
Common Site: Tubal ectopic pregnancy gonorrhea, PID,
● Fallopian Tube- more tendency to Salpingitis)
rupture and cannot be delivered ■ Congenital
due to the narrow nature of the malformation
fallopian tube ■ Scars from surgery
○ In the Ampulla (80%) - ● D&C
fertilization occur ■ In vitro fertilization
○ Isthmus (12%) ■ Tumor
○ Fimbriae (8%) ■ Smoking
● Abdominal Pregnancy ■ History of previous
○ 2% - outside the fallopian ectopic
tube Note: Use of oral contraceptives-reduces
○ 60% can reach to term and the incidence of ectopic pregnancy
can be delivered through ● It regulates the endometrium of the
Exploratory Laparotomy female
■ Baby usually die ASSESSMENT:
Management for Abdominal Pregnancy: ● Classic TRIAD
● Usually we don't manually extract ○ Amenorrhea
the placenta because it can ○ Lower Abdomen Pain
macerate the other abdominal organ ○ Vaginal Bleeding - very
which is vital to life scant (because bleeding will
● Placenta is being disregarded and usually occur in the
waited for it to dissolve alone peritoneum)
○ We administer methotrexate ● Signs of Tubal Rupture as a result
(anti-neoplastic & sclerotic of fast growing growth of the body
agent prevent division of ○ Similar with Peritonitis
cells) for the remaining ■ Rigid Abdomen
fragments ■ Cullen’s sign
● Bluish
HETERO-TOPIC PREGNANCY aka discoloration
MULTIFETAL PREGNANCY within the
● One fetus has been implanted inside umbilical area
the uterus while the other one ■ Extensive or dull
outside the uterus vagional and
abdominal pain
CAUSE OF BOTH TOPIC PREGNANCY:
■ + CMT (cervical ○ No D&C and Scraping - to
motion tenderness)- prevent another risk for
chandler sign ectopic pregnancy
● If ginalaw si ○ Monitor serum HCG
cervix may afterwards, followed by
tenderness UTZ and
■ Kehr’s sign - hysterosalpingogram
referred pain in the ● Ruptured Ectopic Pregnancy
shoulder ○ Managed as emergency
● Caused by ■ suture fallopian tube
peritoneal ■ removal of fallopian
irritation tube (salpingectomy)
■ Tender mass - 5% decrease fertility
palpable on Douglas
cul de sac upon VE 2. Second Trimester Bleeding
● Sign of shock ● GTD (Gestational
○ Hypotension Trophoblastic Disease)
○ Tachycardia ● Dfsdf
○ Tachypnea ● Sdfdsf
CONFIRMATORY
● Ultrasound (UTZ) GESTATIONAL TROPHOBLASTIC
● MRI DISEASE
DIAGNOSTIC TEST ● Aka H.Mole
● Urine HCG assay ● Abnormality occurs within the
● Urinalysis trophoblast
● Hemoglobin or hematocrit ● Trophoblast undergo proliferation
● CBC - to assess the white blood cell ○ They keep on producing until
count to determine if may serious such time there are no space
infection na si patient for the fetus to develop
● Note: ● No FHT and No Fetus
○ A positive urine pregnancy ● After proliferate - Degenerate
test result should prompt a
Natural process
seru, beta HCG assay or
those with pain or bleeding ● Ovum (not yet being fertilized)
Management: ● Zygote (Fertilized)
● Note: Usually ectopic pregnancy ● Mitosis (Cell Division)
ends before rupture. They are ● Morula:
usually being reabsorbed back - so ○ They began to form into
no treatment is needed. Mulberry like substance
● However, when UTZ revealed a (+) within 2-3 days
result and there is No ruptured ● Blastocyst
had occurred ○ They begin to fill the
○ Methotrexate (IM.Oral) center with fluid na
○ ready for implant -
Implantation to happen ■ Estrogen
● Trophoblast ■ Inhibin - inhibit
○ It's a blastocyst that are not uterine contraction
being implanted within the ■ Relaxin - pampa
endometrium soffent ng cervix,
○ 8 to 10 days - implantation coxxyal cervix,
(cbq) uterus to stretch.
○ They secrete the HCG
● Progesterone: a. Month 4, 5, 6
○ Corpus Luteum (during b. Gestational trophoblastic
ovulation process) Disease
■ 8 to 10 days
■ responsible for the Modified WHO Classification of GTD
production of
progesterone Molar Trophoblastic
during the ovulation Pregnancies: Tumor
process
● H.Mole ● Choriocarcinoma
■ They die and
○ Complete ● Placental Site
become corpus Trophoblastic
○ Partial
albicans- if no Tumor
○ Invasive Mole
pregnancy exist ● Epithelioid
○ If Blastocyst exists- Trophoblastic
Corpus Luteum will extend Tumor
their work if they detect
HCG. They ensure that Signs and Symptoms:
endometrium is a nice and ● Extremely high HCG
cozy place for the zygote to ○ Hence causes exaggerated
stay for pregnancy until signs and symptoms of
Placenta will exist. pregnancy
○ Anterior Pituitary Gland- ■ Increase morning
sustained the sickness
prostaglandin throughout ■ Frequent nausea and
the fertilization process vomiting
● Placenta - ● Increase Fundal Height
○ full development of ○ More extreme if compared to
placenta- 16 weeks/2nd their AOG
trimester
○ Fully functional - 16
Note:
weeks/2nd trimester
○ Secretes ● During abortion we asked mother
■ Progesterone- to save the pads that mother
hormone of excrete during D and C, vacuum
pregnancy suctioning, suction currettage
○ Anesthesia
● To determine the cause of
abortion ○ IV
● To provide extended monitoring ○ Blood Banking
of the mother- to determine the ○ Karman suction cannula 10-
chance of developing carcinoma in 14mm diameter
H.Mole mothers ○ Oxytocin
○ UTZ to confirm
Causes: ○ Sims curette
● Chromosomally abnormal ○ Others:
fertilization ■ Monitoring pelvic
● 46xx and results from arterial embolism
androgenesis, meaning both set of ■ Uterine packing
chromosomes are paternal ■ Hysterectomy
Normally: Nursing Consideration:
● Dapat may paternal and maternal ● Instruct mother to prevent
side din - 23 pairs each dapat pregnancy - by utilizing oral
● The chromosomes of the ovum are contraceptive pills for 12 months
either absent or inactivated ○ rationale:
■ For monitoring
Assessment purposes- monitoring
● FH larger than AOG the decrease of HCG,
● HCG increase (one mil IU assuring that there is
○ Normal pregnancy level of no trophoblast
400,000IU remained.
● HCG Strongly positive after 100 day ■ Assessed every 2
of pregnancy, weeks
○ Normally: the level of hcg ● Then
normally begin to decline assessed
after 100 days monthly
● Signs of PIH may appear early UTZ: ■ Ratio: this is to
● dense growth (snowflake screen if they have
patterns) no fetal growth choriocarcinoma
● Vaginal bleeding at 16 weeks (tumors)
○ dark brown blood i. H.Mole
○ Resembling prune juice or
as a profuse fresh flow c. Incompetent Cervical Os
○ Accompanied by clear fluid Insufficient/Cervic
filled vesicle/cyst
Examination: Cervical Insufficiency:
● Appearance: Grape size vesicle
with clear fluid Definition:
Management: ● Premature cervical dilatation
● Suction Curettage ● Old Term: incompertent cervical OS
○ Dilate- Laminae Algae
● The cervix itself spontaneously
opens by itself Horizontal and polypropylene
vertical monofilament
Causes: suture
● Unknown Pull tight to close
● Increased maternal age the OS 5 mm mersilene
● Congenital defect tape
● Cervical trauma
Support the bladder
○ Previous C and C pataas- transverse
○ Cone Biopsy incision
○ Defected collagen formation
Assessment:
Nursing consideration:
● Painless Dilatation
● Need to be typically removed the
● Pink - tinged vaginal discharge
suture -
(show)
○ Ratio: to avoid foreign body
● Increased pelvic pressure
compilation
● Rupture of the membrane and
● For woman with elective CS- can be
discharge of the amniotic fluid
removed around 37 weeks of AOG
● Uterine contraction
● Monitor for (al throughout the
● Commonly occurs at
remaining weeks of pregnancy)
approximately 20 weeks AOG
○ Premature Rupture Of
Diagnostic
Membrane
● Early ultrasound before symptoms
○ Preterm Labor
● Usually diagnosed only after the
○ Hemorrhage
pregnancy is lost
○ Infection
Management:
● Analgesia upon extraction
● Cerclage
● Vaginal and abdominal cerclage
Not Candidate for Cerclarge:
○ 12-14 weeks (sutured)
● A pregnant woman has
○ Removed - 36 to 37 weeks
○ ROM
(before delivery)
○ Bleeding
■ To give time for the
○ Contraction
cervix to soften and
dilate
● Mcdonald and Shirodkar suturing
● Not a Candidate (woman
THIRD TRIMESTER BLEEDING
experiencing the following)
○ Contraction
PLACENTA PREVIA
○ Rupture of membrane
Definition:
○ Progressive dilation
● Low implantation in the lower
○ Bleeding from show
segment of uterus
Mcdonald Shirodkar ● Usually it is easy to detach this kind
of placental implantation when
Nylon No. 1 or 2 nylon / braxton hicks contraction occur
● Painless ● MRI
Grading: ● VE/IE but should prepare for Double
● Grade one: Low lying set up
● Grade two: Marginal/ edge ○ CS and NSD
● Grade three: part of placenta is Management
covering the Cervical OS ● Fetal monitoring if no bleeding
● Grade IV: Complete conversing of ● NSD if possible
cervical OS ● Elective CS
● No IE
● No VE
○ Both cause hemorrhage
● No digital examination
● CS for grade 3 and 4
● Natural Spontaneous Delivery
○ For low lying and marginal
Cause: Nursing Management

● unknown ● Preterm delivery - administering
● Multiparity betamethasone
● previous CS (so many times) ○ Given- IM
○ Scarring - placenta avoid ○ 12-12.5 mg (initial)
● History of placenta previa ○ Repeated in 24 hours
● Recurring Scarring ○ Repeated again 1-2 weeks
○ From Previous D and C ● Monitoring 24-48 hours if:
○ CS ○ Bleeding stops
○ Infection ○ VS are good
Assessment ○ Fetus preterm
● Bleeding is Abrupt ● May go home
● Painless ○ If bleeding seize
● Bright red (fresh bleeding) ○ If Vital signs is stable
● Bleeding is not associated with ○ If baby is not distress
activity -
○ Associated with: Nursing consideration is knowing the
■ Contraction risk factors associated with Placenta
■ Enlargement of Previa:
Uterus ● Maternal age above 35
● Bleeding associated only with the ● Multipara
enlargement and contraction of ● Multifetal gestation
uterus ● MSAFP level >2.0 multiples of the
● Soft uterus median (MoM)
Diagnostic ○ Link for neural
● No IE - can cause detachment of tube/abdominal defect,
the uterus if poked accidentally trisomy 21 and Placenta
● UTZ Previa
● CS Assessment:
● Assisted reproductive tech ● Sudden Onset pain- from
● Hysterectomy scar myometrial irritation
● Cigarette smoking ○ Abdominal
d. Placental Abruption Abruptio ○ High in fundus
Placenta/ ○ Sharp
● Abdominal Tenderness
PLACENTAL ABRUPTION (MORE
Note: PAIN IN ABRUPTIO PLACENTA
DEADLY)
● Separation of the placenta from its ● The cause of pain:
implantation site before delivery ● Caused by myometrial irritation
● Premature Separation of from pooling of blood
NORMALLY IMPLANTED ● Vaginal bleeding dark red blood-
PLACENTA from prolonged pooling of blood
○ Placenta Previa- not normally that did not escape
implanted ● Uterine tenderness
● Problem: ● Pain also located on the upper
○ The placenta is normally portion of abdomen - this is
implanted but the it because of the normal
separated so soon implantation of the placenta
● Abruptio is painful! Because the
placenta has detached Types of Abruptio Placenta
○ Pain: caused by contraction ● Concealed
as a result of separation ○ The blood remains to pool
○ Pooling of blood irritates the inside the placenta
Myometrium causes ● Partial
myometrial irritation ○ Characteristic may show few
scanty drops of blood
Cause: ○ Some blood were able to
● Unknown escape
● High parity ● Full Detachment
● Advanced age ○ Heavy bleeding
● Short umbilical cord- madaling Diagnostic
mahila ● No IE
● Hypertension - can cause increase ● Only imaging UTZ
pressure of blood in the placenta Management;
○ Normal ang Hypotension ● Emergency CS
kase placental is developing ○ Heart Rate is good for baby
needed more blood to ○ Mother is deteriorating
support ● Natural spontaneous delivery/
● Trauma Induced labor
● Decrease clotting factor- served as ○ If the fetus died
the placenta glued to the Nursing Consideration:
endometrium ● Oxygenated
● Oxytocin after delivery
● IVF - Fluid Resuscitation
● Strict I and O PLACENTA ACCRETA SPECTRUM (PAS)
○ To assess for signs of shock
● Assess for signs of shocks Definition:
● Checking of FHT ● Lalim ng pagka implant nang
● No I.E placenta
○ Can cause detachment and ● Aberrant placentation characterized
bleeding by abnormally implanted, invasive,
Complication: or adhered placenta
● Couvelaire Uterus
○ Uteroplacental Apoplexy Placenta Accreta spectrum
● DIC e. Acretta- “attach “sa
myometrium
Abruptio Placenta Previa
f. Increta - “invade “in
Bleeding (dark red) Bleeding (fresh- myometrium
bright red) g. Percreta- “penetrate” in
Normal location myometrium
Painless
Pain
Implantation is low
The cause of pain: placement-
● Caused by ● If ever
myometrial magkaroon
irritation (in nang
the fundus) detachment
from pooling nakakawala Both increta and percreta cannot be
of blood agad ang removed in CS/ D and C -
Couvelaire uterus blood ● Resolve only through hysterectomy
and DIC ● No
● Prone to myometrium
Assessment:
DIC- as a irritation
result of
blood Bright red (Fresh) Normally:
pooling ● Placenta delivery: 5-15 mins
For this case: ○ Maximum: 30 mins
Normally: Abnormal:
Usually - with Contraction = pain ● More than 30 mins there is still no
braxton hick and bleeding
sign of placental delivery
contraction: it
allows good Management:
perfusion in the ● Tertiary care facility
body ● Occlude pelvic blood flow - arterial
catheterization
For this case: ● CS- extent of placental invasion is
● Contraction assessed without attempts at
= pain and
manual placenta
bleeding
● Hysterectomy for increta and
OTHER BOOK DEFINITION
percreta
Emergency Nursing Interventions for Early Term 37 to 38 weeks
Bleeding in pregnancy
● Help Term 39 to 40 weeks
○ Ask for assistance Late Term 41 to 42 weeks
● Left lateral
Late Term: Pangit na because the placenta
○ To prevent supine
will halt from functioning and may
hypotension syndrome - that
decrease/halt the nutrient transform
will decrease cardiac output
○ Promote tissue and placental
Causes:
perfusion
● Trauma, violence
● IV - Lactated Ringer
● Substance abuse
○ Alkalinic - to combat acidic
● Dehydration
environment bought by
○ Dehydration causes
tissue damage which
contraction
release large amount of
● UTI
lactic acid
○ UTI can start contraction
● O2
● Hypertension
○ 6-10L/min
● Cervicitis
● CTG
○ Inflammation - increase
● No VE
prostaglandin thus induce
● NPO
contraction
○ For emergency laparotomy
● Multiple gestation
procedure
● Chorioamnionitis
● Type, Cross matching
● Maternal illness
○ O negative if wala cross
Assessment:
matching
● Persistent, dull, and low backache
● I and O
○ Lumbosacral pain
● VS q 15 mins
● Vaginnal Spotting
● Monitoring Bleeding
○ Mucus plug show
● UTZ
● Pelvic pressure or abdominal
● Support
tightening
● Material-like-cramping
PRETERM LABOR AND BIRTH
● Increase vaginal discharge
● Uterine contraction
Definition:
● Intestinal cramping
● Delivery of fetus before 37 weeks
● Ferguson Reflex - Uncontrollable
● Term: 37 weeks
urge to defecate
○ Legal term: 38-42 weeks
○ Average: 40 weeks
Management:
○ >42 weeks (post term)
When Labor can be halted

● Tocolytic- halt contraction
○ Terbutaline - cause uterine ● CS vs NSD
relaxation ○ Cesarean Section
○ Old- Magnesium Sulfate (preferred)-
■ Ratio: Preterm
babies are prone to
Medication that Halt Contraction
(MINTR) subdural and
intraventricular
● M-Magnesium Sulfate hemorrhage
○ But not na highly ■ Reduced fetal head
recommend pressure - subdural
○ Only indicated for Pre-
intraventricular
eclampsia
● I- Indomethacin hemorrhage
○ Prostaglandin inhibitor
● N- Nifedipine (CCB)
○ Half Muscle contraction by
blocking Ca uptake -
Calcium promote muscle
contraction
● T-Terbutaline
○ Not for long term use
○ Has an adverse effect on
the heart of woman
○ for used only for 72
hours
● R-Ritodrine
○ Given in threated
miscarriage
● Betamethasone
○ Corticosteroid- to hasten
lung maturity of the baby
○ Prevent respiratory distress
○ Side Effect:
■ Causes
hyperglycemia
● Halt the Labor if:
○ NO Rupture of Membrane
○ No Fetal Distress
○ No bleeding
○ Cervix should be no more
than 4 to 5 cm dilated
○ Not yet in active phase of
labor
○ Effacement below 50%
When Labor cannot be halted

RH ISOIMMUNIZATION ○ Amniocentesis
○ Chorionic Villi Sampling
Definition: ● Delivery
● Maternal Sensitization from Rh + or ● Abruptio Placenta
Rh - transfusion |
● This allowed the production of Escape of Fetal Blood containing antigen D
Maternal antibody formation against to the mother causes sensitization of the
the Rh antigen baby.
Normally: |
● Mother has no antigen D and baby Sensitization produces Antibodies
Has antigen D |
○ Maternal Blood goes to baby ● Will kill the baby the 2nd baby for
○ While many should not go to this time around the mother’s blood
mother already has a antibody for antigen D
|
Note (Blood Typing)
○ Baby’s RBC will experience
Blood Antigen Blood Type Erythroblastosis
|
● Antigen A ● Type A ■ Oxygenation is a
● Antigen B ● Type B problem
● No antigen ● Type O
A and B Management:
● RhIG (RhoGAM) at 28 weeks
● With ● Presence =
● Given again within 72 hours after
Antigen D RH+
birth
● Absence of ● RH-
○ Inu-unahan natin yung
Rh
immune system nila
○ We want to build protection
Sample cases: by halting the production of
● Antigen A and D antibodies against antigen D.
○ A+ ○ It will protect 1st and 2nd
● No A, No B D pregnancy
○ - O RhIG (RhoGAM)
● Last only 2 weeks to 2 months -
kaya needed to administer every
time
Rh mother’s Blood- pumunta kay baby
○ They have pregnancy
for nutrient distribution
● Test determine if there’s a
● But Fetal blood should not go to fetal
presence of antibodies against
mother’s blood- because it can
Antigen D
stimulate Antibody
What causes can encourage Fetal Blood
Diagnostic Procedure:
Escape to mother:
● Abortion
● Coomb’s test (maternal)
● Invasive procedures
○ Indirect - Mother’s blood Abnormal
determination ● Hypertension
● Management ○ Very abnormal
○ Negative -give rhogam ○ Can detach the placenta
○ positive - dont give . ● Criteria to categorize
Hypertension:
● Direct Coombs test - Fetus ○ Above 140/90 mmHg
○ Determining presence of ○ Systolic pressure - 30 mmHg
Antibodies in the fetal blood above
○ Negative - Do not administer ○ Diastolic Pressure - 15
RhIG until 72 hours after mmHg above
delivery
PIH (Pregnancy Essential
○ Positive - Jaundice Induced Hypertension
■ Hemolysis Hypertension)
■ Erythroblastosis
Fetalis Hypertension that Chronic
● Management: Exchange only appears during Hypertension that
pregnancy exist not during
transfusion - two ways transfusion
hypertension
(removed the antibody d filled blood)
and double the amount of new blood
Cause:
● Kleihauer Betke Test
● Hormones
○ Can determine or
● Unknown
differentiate the maternal
● Antiphospholipid Syndrome
blood vs. fetal blood
(APS) or the presence of
○ Determine if may Fetal blood
antiphospholipid antibodies in
escape
maternal blood
○ Colorless: maternal blood
● Multiple pregnancy
○ Purple/pinkish stain: fetal
● Primiparas younger than 20 years or
blood - may mixing na nang
older than 40 years of age
blood
● Low socioeconomic background
○ No nutritious food
HYPERTENSIVE DISORDERS IN
● Multipara
PREGNANCY
● polyhydramnios
● PIH, Pre-eclampsia, Eclampsia
○ Normal: 800-1200 mL or 500
to 100 mL
PREGNANCY INDUCED HYPERTENSION
○ >2000 mL / 2L -
Polyhydramnios
Normal:
○ Oligohydramnios: <300
● Hypotension:
mL/<200 mL
○ appears during the 2nd
● Increase in blood volume - 30 to
trimester
50%
○ 1st trimester: normal
○ 3rd: go back to normal
○ Very obvious in 2nd trimester ○ Generalized edema
- woman become resistant (systemic)
to vasoconstrictor (normal) ■ Hands (wedding ring
● Some woman experience vascular masikip)
damage as a result of increase ■ Periorbital Edema
volume = vasoconstriction ● Not Ankle Edema because it is
● Causes: HTN only exist during normal
pregnancy
Management:
PRE ECLAMPSIA ● Bed rest
● Promote Well-being
● Fetal Well-being
Category
● Nutrition
Mild BP: <160 systolic and <100 ● Medication
diastolic
Proteinuria: +1 and +2 ECLAMPSIA

Edema: 1 and 2
Definition:
Severe Severe: >160 systolic and ● Maternal Mortality can be as high as
>100 systolic 20%
● Develops convulsion and seizure
Proteinuria: +3 and +4 ○ We must intervene to
Avoid: because it can
Edema: 1 and 2
decrease oxygenation to the
brain of the mother and baby
Causes: ● Seizure came from CEREBRAL
● HTN progressive and leads to EDEMA
kidney malfunction ○ Cause cerebral irritation
Result: Management:
● Kidney Malfunction -> Nephrotic ● Bed rest
Syndrome ● Promote Well-being
○ Massive proteinuria and ● Fetal Well-being
albuminuria (bigger ● Nutrition
molecule will exit easily ● Medication
because kidney is not ● Admission: Room assignment- Sa
working well) dulo nang hallway to prevent
○ Sodium retention cerebral irritation and stimulant
● Nephritic = inflammation ○ Limit room visitors
○ Prevent phone usage
Signs and Symptoms: ○ Dimmed Lighted room
● Swelling (Edema)- shifting of fluid ○ Safety - bed rails up
in the interstitial fluid from proteinuria ○ Removal of things
○ Upper Extremities Drug of Choice: Magnesium Sulfate
● Goal: Prevent/Stop Seizure, not BP
Type 2 Insulin resistance with
lower deficiency in the
● Nursing Responsibility: production of insulin
○ Assess for DTR - to assess
for the toxicity GDM Abnormal glucose
■ 1 = hyporeflexia!!! metabolism during
pregnancy
○ Assess for the Serum - >8 to
10 mg/dl Impaired Between normal and
○ Assess for RR - glucose diabetes
hypoventilation (12 bpm) Homeostasis a. FBS: 110 to 126
■ 12 to 15 mg/dl!!! Alert mg/dl
na bitch b. Impared GTT:
140 to 200 mg/dl
○ Assess for cardiac
conduction (magnesium is
Calcium antagonist - prevent
contraction of muscle) Test Type Pregnant Glucose
■ Cardiac arrest - 25 Level (mg/dl)
mg/dl
○ Oliguria - Fasting 95 mg/dl
■ From decrease 1 hr 180 mg/dl
cardiac conduction
■ Sodium retention = 2 hr 155 mg/dl
water retention
■ Hypertension 3 hr 140 mg/dl
● Antidote: Calcium Gluconate
DIABETES IN PREGNANCY (Gestational Management:
Diabetes)
SHOULDER DYSTOCIA
Risk Factors:
● Obesity Assessment:
● Above 25 years of age ● Fetal head retracts against perineum
● Large babies (10 lb or more) “turtle sign”
● Unexplained fetal or perinatal loss ○ Dobbing of the head in the
● Congenital anomalies PCOS 2nd stage of ;abor
● Family history ● Gentle traction does not affect
● Native american, hispanic, asian delivery
● Proceed to HELPERR
CLASSIFICATION OF DIABETES
MELLITUS Complication:
Type 1 Destruction of the beta Maternal Neonatal

cells in the pancreas
● Soft tissue ● Brachial
● Last Resort (ZAVANELLI
injuries plexus palsy
● Anal ● Clavicle MANEUVER)
sphincter fracture ○ Abdominal replacement
damage ● Humeral ○ Tocolytic helpful- then
● Postpartum fracture proceed to immediate
hemorrhage ● Fetal cesarean
● Uterine acidosis
rupture ● Hypoxic
POSTPARTUM HEMORRHAGE
● Symphyseal brain injury
separation ● 5% to 15% of postpartum woman
4 T’s of Postpartum Hemorrhage

● Tone
Management (HELPERR)
● Trauma
● H-Help
● Tissue
● E- Episiotomy
● Thrombin
● L- Leg (Mc Robert’s)
Causes:
● P- Pressure (suprapubic)
● Uterine Atony
● E- Enter vagina
● Retained Placenta
○ Rubin Maneuver
● Subinvolution
○ Woodscrew
● Disseminated Intravascular
○ Reverse Woodscrew
Coagulation Defects
● R- Remover Posterior Arm
● Cervical Laceration
● R- Roll the patient (Gaskin
● Varinal Laceration
Maneuver_
● Perineal Laceration
Sequence:
● McRoberts and Suprapubic
Pressure Tone
● Rubin Maneuver
Cases/Cause: Management:
● Reverse Wood’s ● Uterine Atony ● Massage
● Remover the Arm ● Subinvolution ● Oxytocin
○ Follow posterior Arm down to ● Carboprost
below - usual anterior to fetal tromethamine(h
chest emabate) or
○ Flex arm at the elbow methylergonovin
e maleate
○ Sweep forearm across fetal
(methergine)
chest - grasping hand directly ● Misoprostol
and pulling outward may lead ● Bimanual
to fractures Compression
● Roll the patient ● BT
○ Attempt to deliver posterior ● Hysterectomy
shoulder first
○ May attempt all “Enter
Trauma
maneuver” in this position
Cases/Cause: Laceration (Perineal) Signs:
● First Degree: ● May ;ie within the uterine cavity or
○ Vaginal mucous the vagina
membrane, skin of the ● Protrude from the vagina
perineal fourchette ● Large amount of blood
● Second Degree: suddenly gushes
○ Vagina, perineal skin, ● Fundus is not palpable in the
fascia, levator and muscle. abdomen
And perineal body
● Third Degree: Management:
○ Entire perineum, extending ● Never replace, Never Remove
to reach the external ● Discontinue Oxytocine
spinchete of the rectum ● Fluid resuscitation
● Fourth Degree: ● O2 administration
○ Entire perineum, rectal ● VS q 15 min
sphincter, and some of the ● CPR if needed
mucous membrane of the ● FA, NGT, or Tocolytic
rectum ● MD replaces the fundus manually
● Antibiotics
● Oxytocin
● Future CS
Causes/Case: uterine rupture
Tissue
Cases/Cause: Vaginal Hematoma ● May not be detected until

● A vaginal hematoma is a collection postpartum day 6 to 10
of blood that pools in the soft
tissues of the vagina or vulva, DIagnostic:
which is the outer part of the ● Ultrasound
vagina. ● HCG
Management:
● D and C
Thrombin
● DIC
Cases/Cause: Uterine Inversion

● Uterus turning inside out with
either from the birth of the fetus or
delivery of the placenta
Situation 1
3 of 3 points
3. RhoGAM is given to Rh-negative women to
Isoimmunization (Rh incompatibility) is a possibility prevent maternal sensitization from occurring. The
when a woman who is Rh negative is sensitized midwife is aware that in addition to pregnancy, Rh-
and carries a fetus who is Rh positive. Maternal negative women would also receive this medication
antibodies form and destroy fetal red blood cells, after which of the following?*
leading to anemia, edema, and jaundice in the
newborn. Being certain that women are screened
for blood type and antibody titer early in pregnancy 1/1
is a nursing responsibility.
1. Which of the following findings in Erika’s a. Unsuccessful artificial insemination procedure

history would identify a need for her to receive Rho
(d) immune globulin?*
b. Blood transfusion after hemorrhage
1/1
c. Therapeutic or spontaneous abortion
a. Rh -, coombs + d. Head injury from a car accident
b. Rh -, Coombs – Rationale:
c. Rh +, Coombs – ● Cases we give RHOGAM - abruptio,

abortion, placental separation
d. Rh +, Coombs +
Situation 2
Rationale:
3 of 3 points
● We give Rhogam to mother with - rhesus Approximately 2% to 3% of all women who do not
and has not yet attained antibody against begin a pregnancy with diabetes develop the
antigen D (- coombs) condition during pregnancy, usually at the midpoint
of pregnancy when insulin resistance becomes
most noticeable. This is termed gestational diabetes
2. The doctor ordered Kleihauer-Betke. The mellitus. It is unknown whether gestational diabetes
nurse knows which of the following to be correct results from inadequate insulin response to
about the test:* carbohydrate, from excessive resistance to insulin,
or from a combination of both.
1/1
a. It is used to identify the amount of antibodies in 4. Patients with gestational diabetes are usually
maternal serum managed by which of the following therapy?*
b. It is used to determine presence of fetal blood 1/1
c. It is used to assess whether the mother is Rh – or a. Diet

Rh +
b. Long-acting insulin
d. It is used to determine fetal blood type and Rh
factor
c. Oral hypoglycemic agents
d. Oral hypoglycemic drug and exercise b. “We will do a 3-hour OGTT to confirm if you have
GDM, please come back again tomorrow, fasting. ”
Rationale:
c. “Your OGCT results are within normal limits, but
continuing your prenatal visits remains essential in
● Are Life - lifestyle. So diet and exercise - order to monitor fetal growth and development”
not medication. Long acting can be used
but what we commonly use is reg and
NPH d. “Your OGCT results indicate that your baby is at
○ Regular: NPH high risk for macrosomia and special considerations
○ 1:2 mat be necessary at delivery”
○ ⅔ of syringe Inject 30 minutes
before breakfast
○ ⅓ of syringe inject Situation 3
○ OHA is prohibited - teratogenic
4 of 6 points
5.Nurse Filipinas is assessing apregnant client, Mrs. Gestational hypertension is a condition in which
Lopez with type 1 DM about her understanding vasospasm occurs in both small and large arteries
regarding changing insulin needs during pregnancy. during pregnancy, causing increased blood
Nurse Filipinas determines that teaching is needed pressure. Preeclampsia is a pregnancy-related
if the client makes which statement?* disease process evidenced by increased blood
pressure and proteinuria.
1/1 7. Mary Hadal Lamb came for prenatal check-up.

Nurse Goldilocks assessed her weight, fundic
height and her blood pressure. Which of the
following indicates she could be developing
a. “I will need to increase my insulin dosage during
gestational hypertension?*
the first 3 months of pregnancy” - no coz needed for
brain development, and women are more prone to
hypoglycemia.
1/1
b. “My insulin dose will likely need to be increased

during the second and third trimester” a. A BP reading of 130/80mmHg
c. “Episodes of hypoglycemia are more likely to b. Her systolic pressure is 28mmHg higher than her
occur during the first 3 months of pregnancy” previous BP readings
d. “My insulin needs should return to normal within c. Her diastolic pressure is 16mmHg higher than her
7 to 10 days after birth if I am bottle-feeding” previous BP readings
d. She experiences headache, fatigue, and ankle

edema
6. Nurse Filipinas is in the OB clinic reviewing the

current prenatal history of a pregnant client who is 8. Magnesium sulfate is ordered per IV. Which of
being seen for a routine prenatal visit. She the following should prompt the nurse to refer to the
discovers the client’s 1-hour OGCT result to be 163 obstetricians prior to administration of the drug?*
mg/dL. The nurse’s best response to the client
would be:*
1/1
1/1
a. BP 180/100
a. “Your OGCT results indicate that you are positive b. Urine output 40 ml/hour
for gestational diabetes. You will be scheduled for a
dietitian consultation to plan your daily dietary
intake” c. RR 12 cpm
d. (+) 2 Deep tendon reflex 12. Mary Hadal Lilam developed severe
preeclampsia. Nurse Lulu monitors for
complications associated with the diagnosis and
9. Nurse Goldilocks knows that Mary Hadal Lilamb assesses the client for:*
has a knowledge about the occurrence of PIH when
she remarks:*
0/1
1/1
a. Edema in the hands and face - this is not a
complication but rather an expected signs and
a. “PIH occurs after 20th weeks AOG” symptoms associated with preeclampsia
b. “PIH can appear anytime during the pregnancy” b. Complaints if feeling hot when the room is cool -
because of mag sulfate (normal). Nursing
consideration is to provide well ventilated room
c. “PIH is similar to cardiovascular disease”
c. Periods of fetal movement followed by quiet

d. “PIH occurs during the 1st trimester”
periods
10. Nurse Goldilocks instructs Mary Hadal Lilamb to

d. Evidence of bleeding such as in the gums,
report prodromal symptoms of seizures associated
petechiae and purpura - development of HELLP
with PIH. Which of the following will she likely
syndrome from low platelet
identify?*
Situation 4
0/1
2 of 3 points
a. Urine output of 15 ml/hour Abortion is a medical term for any interruption of a

pregnancy before a fetus is viable. A viable fetus is
usually defined as a fetus of more than 20 to 24
b. (-) deep tendon reflex weeks of gestation or one that weighs at least 500
g.
c. Sudden increase in BP
d. Epigastric pain- aura, liver problem, HELLP

(Hemolysis Elevated Liver enzyme Low 13.All except one describes Ectopic Pregnancy:*
Platelets)
1/1
11. Patient Mary was ordered Magnesium Sulfate
infusion. Which of the following drugs will you
prepare to be available if the patient developed a. It occurs in 2% of pregnancies
MgSo4 toxicity?*
b. second most frequent cause of bleeding early in

1/1 pregnancy
a. Apresoline c. in vitro fertilization can cause ectopic pregnancies
b. Kalcinate d. 1oral contraceptives increases incidence of

ectopic pregnancy
c. Narcan
d. RhoGAM
14.Which of the following statements is correct increasing
regarding Recurrent Pregnancy Loss?* IV. Symptoms of PIH may appear early
V. UTZ reveals snowflake pattern with fetal growth
VI. Vaginal bleeding at 8 weeks (at secontrimester
0/1 or 16 weeks), dark-brown blood resembling prune
juice*
a. Nurses should use the word “habitual abortion”

so patients may have a better understanding of it 1/1
b. 3 miscarriages (induced and a.I, II, III

spontaneous)regardless of gestational age - dapat
20 weeks
b. I and II only
c. occurs in about 1% and can be caused by

resistance to uterine artery blood flow c. I, II and IV
d. caused by incompetent cervical os d. I, II, III and VI
15.Emergency nursing interventions FOR Situation 6

BLEEDING IN PREGNANCY includes the following.
Select all that applies. 3 of 3 points
I. Trendelenberg position
II. Oxygenation at 6LPM Literally, dystocia means difficult labor and many
III. Vaginal examination to monitor labor antepartum and intrapartum factors can cause
IV. Monitor V/S and I&O q1 dapat q15 dysfunctional labor.
V. NPO patient*
17. “Turtle sign” during delivery of the fetus
indicates which of the following complications of
1/1 labor and delivery?*
a. I,II and IV 1/1
b. I, II, III and IV A. Precipitous Labor1 <3 hrs
c. II only B. Malpresentation
d. II, and V onl C. Shoulder Dystocia - anterior shoulder and was

stuck in the symphysis pubis
Situation 5
D. Cephalopelvic Disproportion
1 of 1 points
Gestational trophoblastic disease is abnormal 18. One of the maneuvers to address impacted
proliferation and then degeneration of the shoulder of the fetus from the maternal symphysis
trophoblastic villi. Abnormal trophoblast cells must pubis is to flex the maternal hips so that the thighs
be identified because they are associated with are on the abdomen, called:*
choriocarcinoma, a rapidly metastasizing
malignancy.
1/1
16. Choose the correct statements regarding
Hydatidiform Mole in pregnancy.
I. Fundic height is larger than AOG A. Pawlick’s Grip
II. HCG increased compared to normal values
III. HCG declines after 100 days where it should be
B. McRobert’s
C. Mc Donald’s Rule 1/1
D. Rubin’s Maneuver A. Retained placenta
19. HELPERR mnemonic is developed by ACOG to B. Uterine atony

address shoulder dystocia which is a common
obstetrical emergency since anticipation and
preparation are keys to prevent maternal and C. Afterpains
neonatal injuries and death. If this still fails, cephalic
replacement followed by Emergency CS is done,
called which maneuver?* D. Boggy uterus
22. The nurse educator Adalynn reviewed the risk

1/1
factors for postpartum hemorrhage for the mothers.
Which of the following factors is NOT included?*
a. Mc Robert’s maneuver
1/1
b. Rubin’s Maneuver
A. Ruptured uterus
c. Zavanelli Maneuver
B. Uterine atony
d. Reverse Woodscrew Maneuver
C. Overdistended uterus
Situation 7
4 of 5 points D. Retroversion of the uterus
Nurse Zara is caring for a postpartum patient.

Routine postpartum care is rendered to the patient.
20. Which assessment finding would lead the nurse

to suspect a postpartum hemorrhage? Blood loss of 23. Nurse Sarah reads the physician’s prescription
______* to administer methylergonovine maleate
( methergine) intramuscularly after delivery. The
rationale for giving this medication is which ofthe
0/1 following?*
A. More than 300 ml/1 hou 1/1
B. More than 400 ml/24 hours A. Reduces the amount of lochia drainage.
C. More than 500 ml/1 hour B. Prevents postpartum hemorrhage
D. More than 500 ml/ 24 hours C. Decreases uterine contractions.
21. Which of the following is caused by the D. Maintains normal blood pressure.
markedly distended uterus and intermittent uterine
contraction within 2 to 3 days after birth?*
24.All postpartum women are at risk for uterine
hemorrhage. What assessment data should Nurse
Sarah first collect when appraising a patient’s risk . wash may hands well before breastfeeding
for hemorrhage? *
B. breastfeed every 2- 3 hours

1/1
C. change the breast pads frequently
a. Ask her to describe her perineal care.
D. wash my nipples with soap and water prior to
feeding
b. Assess the skin integrity of her abdomen.
27. Considering her level of knowledge and the

c. Assess her oxygen saturation level. anxiety of her condition, patient Lovely raised
questions on possible ways of relieving her breast
d. Assess her uterus for height and tone. discomfort. Which of the statements NEEDS further
instructions?*
1/1
SITUATION 8
A. “ I have to stop breastfeeding until this condition
2 of 3 points resolves.”
Lovely 2-week postpartum mother is seen in the
health center. Redness on the left breast, and the B. “ I can take antibiotics, and should begin to feel
mother is diagnosed with mastitis. better in 24 to 48 hours.”
25. Lovely asks Nurse Brenda the cause of this

ailments. Which of the following would the nurse C. “I can use analgesic to assist in alleviating some
explain as predisposing factors of mastitis? (Select of these discomforts.”
all that apply)
I. Milk stasis
II. Nipple trauma D. “ I have to wear a supportive bra to relieve the
III. Using alcohol in cleaning nipples discomfort.”
IV. Baby’s sitting position*
Situation
1/1 2 of 3 points
Any woman who is extremely stressed or who gives

A. II and IV birth to an infant who in any way does not meet her
expectations such as being the wrong sex, being
physically or cognitively challenged, or being ill may
B. I and IV become so depressed she has difficulty bonding
with her infant. Both depression and an inability to
C. I and II bond is a postpartal complication with far-reaching
implications, possibly affecting the future health of
the entire family.
D. II and III
28. Postpartum psychosis occurs during which time
frame?*
26. Nurse Brenda provides instructions about
measures to prevent postpartum mastitis who is
breast feeding her newborn. Which of the following 0/1
would indicate that patient Lovely needs further
instruction? “ I should___________.”*
a. 1-12 months postpartum
0/1
b. 6 weeks postpartum
c. 1-10 days postpartum Administer an oral glucose feeding of 10% dextrose
in water
d. Within first year after birth

Wrap the neonate warmly and place her in an open
crib
29. Which statement by Mary Had a Little Lamb is
most suggestive of a woman developing postpartal
psychosis?* Obtain an order for IV fluid administration
1/1 Question 1 Explanation: Assessment findings

indicate that the neonate is in respiratory distress—
most likely from transient tachypnea, which is
a. “I wish my baby had more hair.” common after cesarean delivery. A neonate with a
rate of 80 breaths a minute shouldn’t be fed but
should receive IV fluids until the respiratory rate
b. “I’m happy not to have any children.” returns to normal. To allow for close observation for
worsening respiratory distress, the neonate should
be kept unclothed in the radiant warmer.
c. “I feel exhausted since birth.”
Question 1CORRECT
d. “Breastfeeding is harder than I thought.”
A healthy term neonate born by C-section was

30. It occurs in 10% of all postpartum women and admitted to the transitional nursery 30 minutes ago
men caused by , hormonal response, ineffective or and placed under a radiant warmer. The neonate
lack of social support, troubled childhood, low self- has an axillary temperature of 99.5*F, a respiratory
esteem and stress in the home or at work.* rate of 80 breaths/minute, and a heel stick glucose
value of 60 mg/dl. Which action should the nurse
take?
1/1
Increase the temperature setting on the radiant

a. Postpartum Blues warmer
b. Postpartum Depression Administer an oral glucose feeding of 10% dextrose

in water
c. Postpartum Subinvolution
crib
d. Postpartum Psychosis
Obtain an order for IV fluid administration
Question 1 Explanation: Assessment findings

Question 1CORRECT indicate that the neonate is in respiratory distress—
common after cesarean delivery. A neonate with a
A healthy term neonate born by C-section was rate of 80 breaths a minute shouldn’t be fed but
admitted to the transitional nursery 30 minutes ago should receive IV fluids until the respiratory rate
and placed under a radiant warmer. The neonate returns to normal. To allow for close observation for
has an axillary temperature of 99.5*F, a respiratory worsening respiratory distress, the neonate should
rate of 80 breaths/minute, and a heel stick glucose be kept unclothed in the radiant warmer.
take?
Question 2CORRECT
warmer A nurse on the newborn nursery floor is caring for a
neonate. On assessment the infant is exhibiting
signs of cyanosis, tachypnea, nasal flaring, and Question 2CORRECT
grunting. Respiratory distress syndrome is
diagnosed, and the physician prescribes surfactant
replacement therapy. The nurse would prepare to A nurse on the newborn nursery floor is caring for a
administer this therapy by: neonate. On assessment the infant is exhibiting
signs of cyanosis, tachypnea, nasal flaring, and
Intramuscular injection diagnosed, and the physician prescribes surfactant
replacement therapy. The nurse would prepare to
administer this therapy by:
Subcutaneous injection
Intramuscular injection
Intravenous injection
Instillation of the preparation into the lungs
through an endotracheal tube
Question 2 Explanation: The aim of therapy in RDS

is to support the disease until the disease runs its Instillation of the preparation into the lungs through
course with the subsequent development of an endotracheal tube
surfactant. The infant may benefit from surfactant
replacement therapy. In surfactant replacement, an
exogenous surfactant preparation is instilled into the Question 2 Explanation: The aim of therapy in RDS
lungs through an endotracheal tube. is to support the disease until the disease runs its
course with the subsequent development of
Question 1CORRECT replacement therapy. In surfactant replacement, an
exogenous surfactant preparation is instilled into the
lungs through an endotracheal tube.
admitted to the transitional nursery 30 minutes ago
and placed under a radiant warmer. The neonate Question 3CORRECT
has an axillary temperature of 99.5*F, a respiratory
rate of 80 breaths/minute, and a heel stick glucose
value of 60 mg/dl. Which action should the nurse The nurse decides on a teaching plan for a new
take? mother and her infant. The plan should include:
Increase the temperature setting on the radiant Discussing the matter with her in a non-threatening
warmer manner
Administer an oral glucose feeding of 10% dextrose Supplying the emotional support to the mother and
in water encouraging her independence
Wrap the neonate warmly and place her in an open Setting up a schedule for teaching the mother how
crib to care for her baby
Obtain an order for IV fluid administration Showing by example and explanation how to care
for the infant

indicate that the neonate is in respiratory distress— Question 3 Explanation: Teaching the mother by
most likely from transient tachypnea, which is example is a non-threatening approach that allows
common after cesarean delivery. A neonate with a her to proceed at her own pace.
Question 4CORRECT
returns to normal. To allow for close observation for
A postpartum nurse is providing instructions to the A nurse on the newborn nursery floor is caring for a
mother of a newborn infant with hyperbilirubinemia neonate. On assessment the infant is exhibiting
who is being breastfed. The nurse provides which signs of cyanosis, tachypnea, nasal flaring, and
most appropriate instructions to the mother? grunting. Respiratory distress syndrome is
Continue to breast-feed every 2-4 hours administer this therapy by:
Feed the newborn infant less frequently Intramuscular injection
Switch to bottle feeding the baby for 2 weeks Subcutaneous injection
Stop the breast feedings and switch to bottle- Intravenous injection

feeding permanently
Instillation of the preparation into the lungs through

Question 4 Explanation: Breast feeding should be an endotracheal tube
initiated within 2 hours after birth and every 2-4
hours thereafter. The other options are not
necessary. Question 2 Explanation: The aim of therapy in RDS
is to support the disease until the disease runs its
Question 1CORRECT surfactant. The infant may benefit from surfactant
and placed under a radiant warmer. The neonate
has an axillary temperature of 99.5*F, a respiratory Question 3CORRECT
take? The nurse decides on a teaching plan for a new
mother and her infant. The plan should include:

warmer Discussing the matter with her in a non-threatening
manner
Administer an oral glucose feeding of 10% dextrose

in water Supplying the emotional support to the mother and
encouraging her independence

crib Setting up a schedule for teaching the mother how
to care for her baby

Showing by example and explanation how to care
for the infant
most likely from transient tachypnea, which is Question 3 Explanation: Teaching the mother by
common after cesarean delivery. A neonate with a example is a non-threatening approach that allows
rate of 80 breaths a minute shouldn’t be fed but her to proceed at her own pace.
worsening respiratory distress, the neonate should Question 4CORRECT
A postpartum nurse is providing instructions to the
Question 2CORRECT mother of a newborn infant with hyperbilirubinemia
who is being breastfed. The nurse provides which
most appropriate instructions to the mother?
Continue to breast-feed every 2-4 hours Question 1CORRECT
Feed the newborn infant less frequently A healthy term neonate born by C-section was
and placed under a radiant warmer. The neonate
Switch to bottle feeding the baby for 2 weeks has an axillary temperature of 99.5*F, a respiratory
Stop the breast feedings and switch to bottle-
take?
feeding permanently

Question 4 Explanation: Breast feeding should be
warmer
necessary. Administer an oral glucose feeding of 10% dextrose
in water
Question 5CORRECT
crib
The nurse is aware that a healthy newborn’s
respirations are:
Irregular, abdominal, 30-60 per minute, shallow
Regular, abdominal, 40-50 per minute, deep
Regular, initiated by the chest wall, 40-60 per rate of 80 breaths a minute shouldn’t be fed but
minute, shallow should receive IV fluids until the respiratory rate
Irregular, initiated by chest wall, 30-60 per minute, be kept unclothed in the radiant warmer.
deep
Question 2CORRECT
Question 5 Explanation: Normally the newborn’s
breathing is abdominal and irregular in depth and
rhythm; the rate ranges from 30-60 breaths per A nurse on the newborn nursery floor is caring for a
minute. neonate. On assessment the infant is exhibiting
The expected respiratory rate of a neonate within 3 diagnosed, and the physician prescribes surfactant
minutes of birth may be as high as: replacement therapy. The nurse would prepare to
80
60
50
100
an endotracheal tube
Question 6 Explanation: The respiratory rate is
associated with activity and can be as rapid as 60
breaths per minute; over 60 breaths per minute are Question 2 Explanation: The aim of therapy in RDS
considered tachypneic in the infant. is to support the disease until the disease runs its
surfactant. The infant may benefit from surfactant The nurse is aware that a healthy newborn’s
replacement therapy. In surfactant replacement, an respirations are:
Question 3CORRECT
The nurse decides on a teaching plan for a new

mother and her infant. The plan should include: Regular, initiated by the chest wall, 40-60 per
minute, shallow
Discussing the matter with her in a non-threatening

manner Irregular, initiated by chest wall, 30-60 per minute,
deep
Supplying the emotional support to the mother and

encouraging her independence Question 5 Explanation: Normally the newborn’s
rhythm; the rate ranges from 30-60 breaths per
Setting up a schedule for teaching the mother how minute.
Question 6CORRECT
for the infant
The expected respiratory rate of a neonate within 3
minutes of birth may be as high as:
Question 3 Explanation: Teaching the mother by
example is a non-threatening approach that allows
her to proceed at her own pace. 80
Question 4CORRECT 60
A postpartum nurse is providing instructions to the 50

mother of a newborn infant with hyperbilirubinemia
100

Continue to breast-feed every 2-4 hours
breaths per minute; over 60 breaths per minute are
Feed the newborn infant less frequently considered tachypneic in the infant.
Switch to bottle feeding the baby for 2 weeks Question 7CORRECT
Stop the breast feedings and switch to bottle- A nurse in a newborn nursery is performing an
feeding permanently assessment of a newborn infant. The nurse is
preparing to measure the head circumference of the
infant. The nurse would most appropriately:
hours thereafter. The other options are not Place the tape measure under the infants head at
necessary. the base of the skull and wrap around to the front
just above the eyes
Question 5CORRECT
Place the tape measure under the infants head,
wrap around the occiput, and measure just
above the eyes
Wrap the tape measure around the infant’s head Intramuscular injection
and measure just above the eyebrows.
Place the tape measure at the back of the infant’s
head, wrap around across the ears, and measure
across the infant’s mouth. Intravenous injection
Question 7 Explanation: To measure the head Instillation of the preparation into the lungs through
circumference, the nurse should place the tape an endotracheal tube
measure under the infant’s head, wrap the tape
around the occiput, and measure just above the
eyebrows so that the largest area of the occiput is
included.
take?

manner
warmer

in water
Setting up a schedule for teaching the mother how

crib

for the infant

her to proceed at her own pace.
should receive IV fluids until the respiratory rate Question 4CORRECT
be kept unclothed in the radiant warmer. A postpartum nurse is providing instructions to the
Question 2CORRECT most appropriate instructions to the mother?
A nurse on the newborn nursery floor is caring for a Continue to breast-feed every 2-4 hours
grunting. Respiratory distress syndrome is Feed the newborn infant less frequently
administer this therapy by: Switch to bottle feeding the baby for 2 weeks
Stop the breast feedings and switch to bottle- preparing to measure the head circumference of the
feeding permanently infant. The nurse would most appropriately:
Question 4 Explanation: Breast feeding should be Place the tape measure under the infants head at
initiated within 2 hours after birth and every 2-4 the base of the skull and wrap around to the front
hours thereafter. The other options are not just above the eyes
necessary.

Question 5CORRECT wrap around the occiput, and measure just above
the eyes

respirations are: Wrap the tape measure around the infant’s head

Regular, abdominal, 40-50 per minute, deep across the infant’s mouth.
Regular, initiated by the chest wall, 40-60 per Question 7 Explanation: To measure the head
minute, shallow circumference, the nurse should place the tape
Irregular, initiated by chest wall, 30-60 per minute,
deep
included.

Question 8CORRECT
minute. A baby is born precipitously in the ER. The nurses
initial action should be to:
Question 6CORRECT
Quickly tie and cut the umbilical cord
minutes of birth may be as high as: Establish an airway for the baby
80 Ascertain the condition of the fundus
60 Move mother and baby to the birthing unit
50 Question 8 Explanation: The nurse should position

the baby with head lower than chest and rub the
infant’s back to stimulate crying to promote
100
oxygenation. There is no haste in cutting the cord.

Which neonatal behavior is most commonly
associated with fetal alcohol syndrome (FAS)?
considered tachypneic in the infant.
High threshold of stimulation
Question 7CORRECT
High birth weight
A nurse in a newborn nursery is performing an
assessment of a newborn infant. The nurse is
Poor wake and sleep patterns Subcutaneous injection
Hypoactivity Intravenous injection
Question 9 Explanation: Altered sleep patterns are Instillation of the preparation into the lungs through
caused by disturbances in the CNS from alcohol an endotracheal tube
exposure in utero. Hyperactivity is a characteristic
generally noted. Low birth weight is a physical
defect seen in neonates with FAS. Neonates with Question 2 Explanation: The aim of therapy in RDS
FAS generally have a low threshold for stimulation. is to support the disease until the disease runs its
value of 60 mg/dl. Which action should the nurse The nurse decides on a teaching plan for a new
take? mother and her infant. The plan should include:
Increase the temperature setting on the radiant Discussing the matter with her in a non-threatening
warmer manner
Administer an oral glucose feeding of 10% dextrose Supplying the emotional support to the mother and
in water encouraging her independence
Wrap the neonate warmly and place her in an open Setting up a schedule for teaching the mother how
crib to care for her baby
Obtain an order for IV fluid administration Showing by example and explanation how to care
for the infant

indicate that the neonate is in respiratory distress— Question 3 Explanation: Teaching the mother by
most likely from transient tachypnea, which is example is a non-threatening approach that allows
common after cesarean delivery. A neonate with a her to proceed at her own pace.
Question 4CORRECT
be kept unclothed in the radiant warmer. A postpartum nurse is providing instructions to the
Question 2CORRECT
A nurse on the newborn nursery floor is caring for a

Continue to breast-feed every 2-4 hours
administer this therapy by: Switch to bottle feeding the baby for 2 weeks
Stop the breast feedings and switch to bottle- preparing to measure the head circumference of the
feeding permanently infant. The nurse would most appropriately:
Question 4 Explanation: Breast feeding should be Place the tape measure under the infants head at
initiated within 2 hours after birth and every 2-4 the base of the skull and wrap around to the front
hours thereafter. The other options are not just above the eyes
necessary.

Question 5CORRECT wrap around the occiput, and measure just above
the eyes

respirations are: Wrap the tape measure around the infant’s head

Regular, abdominal, 40-50 per minute, deep across the infant’s mouth.
Regular, initiated by the chest wall, 40-60 per Question 7 Explanation: To measure the head
minute, shallow circumference, the nurse should place the tape
deep
included.

Question 8CORRECT
minute. A baby is born precipitously in the ER. The nurses
Question 6CORRECT
minutes of birth may be as high as: Establish an airway for the baby
80 Ascertain the condition of the fundus
60 Move mother and baby to the birthing unit
50 Question 8 Explanation: The nurse should position

100

Question 9WRONG
considered tachypneic in the infant. Which neonatal behavior is most commonly
Question 7CORRECT
A nurse in a newborn nursery is performing an
High birth weight Wrap the neonate warmly and place her in an open
crib
Poor wake and sleep patterns

Hypoactivity
Question 9 Explanation: Altered sleep patterns are most likely from transient tachypnea, which is
caused by disturbances in the CNS from alcohol common after cesarean delivery. A neonate with a
exposure in utero. Hyperactivity is a characteristic rate of 80 breaths a minute shouldn’t be fed but
generally noted. Low birth weight is a physical should receive IV fluids until the respiratory rate
defect seen in neonates with FAS. Neonates with returns to normal. To allow for close observation for
FAS generally have a low threshold for stimulation. worsening respiratory distress, the neonate should
Question 10CORRECT
Question 2CORRECT
A nurse in the newborn nursery is monitoring a
preterm newborn infant for respiratory distress A nurse on the newborn nursery floor is caring for a
syndrome. Which assessment signs if noted in the neonate. On assessment the infant is exhibiting
newborn infant would alert the nurse to the signs of cyanosis, tachypnea, nasal flaring, and
possibility of this syndrome? grunting. Respiratory distress syndrome is
Hypotension and Bradycardia
Acrocyanosis and grunting

Tachypnea and retractions

The presence of a barrel chest with grunting

Question 10 Explanation: The infant with respiratory

distress syndrome may present with signs of
an endotracheal tube
cyanosis, tachypnea or apnea, nasal flaring, chest
wall retractions, or audible grunts.
Question 1CORRECT
A healthy term neonate born by C-section was replacement therapy. In surfactant replacement, an
admitted to the transitional nursery 30 minutes ago exogenous surfactant preparation is instilled into the
and placed under a radiant warmer. The neonate lungs through an endotracheal tube.
Question 3CORRECT
take?
warmer
manner
in water
Setting up a schedule for teaching the mother how Question 6CORRECT

Showing by example and explanation how to care minutes of birth may be as high as:
for the infant
80
her to proceed at her own pace. 60
Question 4CORRECT 50
A postpartum nurse is providing instructions to the 100

Continue to breast-feed every 2-4 hours considered tachypneic in the infant.
Feed the newborn infant less frequently Question 7CORRECT
Switch to bottle feeding the baby for 2 weeks A nurse in a newborn nursery is performing an
Stop the breast feedings and switch to bottle- infant. The nurse would most appropriately:
feeding permanently
Place the tape measure under the infants head at

Question 4 Explanation: Breast feeding should be the base of the skull and wrap around to the front
initiated within 2 hours after birth and every 2-4 just above the eyes
necessary.
wrap around the occiput, and measure just above
Question 5CORRECT the eyes
The nurse is aware that a healthy newborn’s Wrap the tape measure around the infant’s head
respirations are: and measure just above the eyebrows.
Irregular, abdominal, 30-60 per minute, shallow Place the tape measure at the back of the infant’s
across the infant’s mouth.
Question 7 Explanation: To measure the head

Regular, initiated by the chest wall, 40-60 per circumference, the nurse should place the tape
minute, shallow measure under the infant’s head, wrap the tape
included.
deep
Question 8CORRECT
rhythm; the rate ranges from 30-60 breaths per A baby is born precipitously in the ER. The nurses
minute. initial action should be to:
Quickly tie and cut the umbilical cord Question 10 Explanation: The infant with respiratory
Establish an airway for the baby wall retractions, or audible grunts.
Ascertain the condition of the fundus Question 11CORRECT
Move mother and baby to the birthing unit A mother of a term neonate asks what the thick,
white, cheesy coating is on his skin. Which correctly
describes this finding?
Question 8 Explanation: The nurse should position
infant’s back to stimulate crying to promote Vernix
Nevus flammeus
Question 9WRONG
Lanugo
Which neonatal behavior is most commonly
Milia

Question 1CORRECT
High birth weight

Poor wake and sleep patterns and placed under a radiant warmer. The neonate
Hypoactivity
take?
Question 9 Explanation: Altered sleep patterns are
caused by disturbances in the CNS from alcohol
exposure in utero. Hyperactivity is a characteristic
warmer
generally noted. Low birth weight is a physical
defect seen in neonates with FAS. Neonates with
FAS generally have a low threshold for stimulation. Administer an oral glucose feeding of 10% dextrose
in water
Question 10CORRECT
crib
A nurse in the newborn nursery is monitoring a
preterm newborn infant for respiratory distress
syndrome. Which assessment signs if noted in the Obtain an order for IV fluid administration
newborn infant would alert the nurse to the
possibility of this syndrome?
Hypotension and Bradycardia most likely from transient tachypnea, which is
Tachypnea and retractions worsening respiratory distress, the neonate should

Question 2CORRECT
A nurse on the newborn nursery floor is caring for a Continue to breast-feed every 2-4 hours
Switch to bottle feeding the baby for 2 weeks
Stop the breast feedings and switch to bottle-

feeding permanently
Intravenous injection hours thereafter. The other options are not
necessary.
Instillation of the preparation into the lungs

through an endotracheal tube Question 5CORRECT
Question 2 Explanation: The aim of therapy in RDS The nurse is aware that a healthy newborn’s
is to support the disease until the disease runs its respirations are:
lungs through an endotracheal tube. Regular, abdominal, 40-50 per minute, deep
Question 3CORRECT Regular, initiated by the chest wall, 40-60 per

minute, shallow
mother and her infant. The plan should include: Irregular, initiated by chest wall, 30-60 per minute,
deep
manner Question 5 Explanation: Normally the newborn’s
minute.
Question 6CORRECT
Setting up a schedule for teaching the mother how
minutes of birth may be as high as:
Showing by example and explanation how to
care for the infant
80
example is a non-threatening approach that allows 60
her to proceed at her own pace.
50
Question 4CORRECT
100
A postpartum nurse is providing instructions to the
who is being breastfed. The nurse provides which Question 6 Explanation: The respiratory rate is
most appropriate instructions to the mother? associated with activity and can be as rapid as 60
breaths per minute; over 60 breaths per minute are Which neonatal behavior is most commonly
considered tachypneic in the infant. associated with fetal alcohol syndrome (FAS)?
Question 7CORRECT High threshold of stimulation
A nurse in a newborn nursery is performing an High birth weight

infant. The nurse would most appropriately: Poor wake and sleep patterns
Place the tape measure under the infants head at Hypoactivity

the base of the skull and wrap around to the front
just above the eyes
Question 9 Explanation: Altered sleep patterns are
caused by disturbances in the CNS from alcohol
Place the tape measure under the infants head, exposure in utero. Hyperactivity is a characteristic
wrap around the occiput, and measure just generally noted. Low birth weight is a physical
above the eyes defect seen in neonates with FAS. Neonates with
FAS generally have a low threshold for stimulation.
Wrap the tape measure around the infant’s head

and measure just above the eyebrows. Question 10CORRECT
Place the tape measure at the back of the infant’s A nurse in the newborn nursery is monitoring a
head, wrap around across the ears, and measure preterm newborn infant for respiratory distress
across the infant’s mouth. syndrome. Which assessment signs if noted in the
newborn infant would alert the nurse to the
possibility of this syndrome?
Question 7 Explanation: To measure the head
circumference, the nurse should place the tape
measure under the infant’s head, wrap the tape Hypotension and Bradycardia
included.
Tachypnea and retractions

Question 8CORRECT

A baby is born precipitously in the ER. The nurses
Question 10 Explanation: The infant with respiratory
wall retractions, or audible grunts.
Establish an airway for the baby
Question 11CORRECT
Ascertain the condition of the fundus
A mother of a term neonate asks what the thick,
Move mother and baby to the birthing unit white, cheesy coating is on his skin. Which correctly
describes this finding?
Question 8 Explanation: The nurse should position

the baby with head lower than chest and rub the Vernix
Nevus flammeus
Question 9WRONG
Lanugo
Milia Question 14 Explanation: Bilirubin is excreted via
the GI tract; if meconium is retained, the bilirubin is
reabsorbed.
Question 12WRONG
When teaching umbilical cord care to a new mother,

A client has just given birth at 42 weeks’ gestation. the nurse would include which information?
When assessing the neonate, which physical
finding is expected?
Wash the cord with soap and water each day during
a tub bath
Lanugo covering the body
Keep the cord dry and open to air- eeping the

A sleepy, lethargic baby cord dry and open to air helps reduce infection
and hastens drying.
Vernix caseosa covering the body
Cover the cord with petroleum jelly after bathing
Desquamation of the epidermis
Apply peroxide to the cord with each diaper change
A newborn has small, whitish, pinpoint spots over
the nose, which the nurse knows are caused by A nurse in a newborn nursery receives a phone call
retained sebaceous secretions. When charting this to prepare for the admission of a 43-week-gestation
observation, the nurse identifies it as: newborn with Apgar scores of 1 and 4. In planning
for the admission of this infant, the nurse’s highest
priority should be to:
Milia
Connect the resuscitation bag to the oxygen

Whiteheads
outlet
Lanugo
Set the radiant warmer control temperature at 36.5º
C (97.6ºF)
Mongolian spots
Set up the intravenous line with 5% dextrose in
Question 13 Explanation: Milia occur commonly, are water
not indicative of any illness, and eventually
disappear.
Turn on the apnea and cardiorespiratory monitors
Question 16 Explanation: The highest priority on

admission to the nursery for a newborn with low
To help limit the development of hyperbilirubinemia Apgar scores is airway, which would involve
in the neonate, the plan of care should include: preparing respiratory resuscitation equipment. The
other options are also important, although they are
of lower priority.
Substituting breastfeeding for formula during the
2nd day after birth
A nurse prepares to administer a vitamin K injection
to a newborn infant. The mother asks the nurse why
Monitoring for the passage of meconium each her newborn infant needs the injection. The best
shift response by the nurse would be:
Instituting phototherapy for 30 minutes every 6 “You infant needs vitamin K to develop immunity.”
hours
“Newborn infants have sterile bowels, and vitamin K

Supplementing breastfeeding with glucose water promotes the growth of bacteria in the bowel.”
during the first 24 hours
“Newborn infants are deficient in vitamin K, and Question 19 Explanation: A yellow exudate may be
this injection prevents your infant from noted in 24 hours, and this is a part of normal
abnormal bleeding.” healing. The nurse would expect that the area
would be red with a small amount of bloody
drainage. If the bleeding is excessive, the nurse
“The vitamin K will protect your infant from being would apply gentle pressure with sterile gauze. If
jaundiced.” bleeding is not controlled, then the blood vessel
may need to be ligated, and the nurse would
contact the physician. Because the findings
Question 17 Explanation: Vitamin K is necessary for
identified in the question are normal, the nurse
the body to synthesize coagulation factors. Vitamin
would document the assessment.
K is administered to the newborn infant to prevent
abnormal bleeding. Newborn infants are vitamin K
deficient because the bowel does not have the A nursing instructor asks a nursing student to
bacteria necessary for synthesizing fat-soluble describe the procedure for administering
vitamin K. The infant’s bowel does not have support erythromycin ointment into the eyes if a neonate.
the production of vitamin K until bacteria adequately The instructor determines that the student needs to
colonizes it by food ingestion. research this procedure further if the student states:
The nurse is aware that a neonate of a mother with “Administration of the eye ointment may be delayed
diabetes is at risk for what complication? until an hour or so after birth so that eye contact
and parent-infant attachment and bonding can
occur.”
Hypoglycemia
“I will flush the eyes after instilling the ointment.”

Nitrogen loss
“I will cleanse the neonate’s eyes before instilling

Anemia
ointment.”
Thrombosis
“I will instill the eye ointment into each of the
neonate’s conjunctival sacs within one hour after
Question 18 Explanation: Neonates of mothers with birth.”
diabetes are at risk for hypoglycemia due to
increased insulin levels. During gestation, an
Question 20 Explanation: Eye prophylaxis protects
increased amount of glucose is transferred to the
the neonate against Neisseria gonorrhoeae and
fetus across the placenta. The neonate’s liver
Chlamydia trachomatis. The eyes are not flushed
cannot initially adjust to the changing glucose levels
after instillation of the medication because the flush
after birth. This may result in an overabundance of
will wash away the administered medication.
insulin in the neonate, resulting in hypoglycemia.
Which condition or treatment best ensures lung

A nurse is assessing a newborn infant following
maturity in an infant?
circumcision and notes that the circumcised area is
red with a small amount of bloody drainage. Which
of the following nursing actions would be most Glucocorticoid treatment just before delivery
appropriate?
Meconium in the amniotic fluid

Contact the physician
Absence of phosphatidylglycerol in amniotic fluid

Document the findings
Lecithin to sphingomyelin ratio more than 2:1

Circle the amount of bloody drainage on the
dressing and reassess in 30 minutes
Question 21 Explanation: Lecithin and
sphingomyelin are phospholipids that help compose
Reinforce the dressing surfactant in the lungs; lecithin peaks at 36 weeks
and sphingomyelin concentrations remain stable.
After reviewing the client’s maternal history of Question 24 Explanation: Hypothermic neonates
magnesium sulfate during labor, which condition become bradycardic proportional to the degree of
would the nurse anticipate as a potential problem in core temperature. Hypoglycemia is seen in
the neonate? hypothermic neonates.
Hypoglycemia When performing nursing care for a neonate after a

birth, which intervention has the highest nursing
priority?
Tachycardia
Obtain a dextrostix
Jitteriness
Give the vitamin K injection

Respiratory depression
Give the initial bath

Question 22 Explanation: Magnesium sulfate
crosses the placenta and adverse neonatal effects
are respiratory depression, hypotonia, and Cover the neonates head with a cap
Bradycardia.
Question 25 Explanation: Covering the neonates

When attempting to interact with a neonate head with a cap helps prevent cold stress due to
experiencing drug withdrawal, which behavior would excessive evaporative heat loss from the neonate’s
indicate that the neonate is willing to interact? wet head. Vitamin K can be given up to 4 hours
after birth.
Yawning
Which action best explains the main role of
surfactant in the neonate?
Hiccups
Helps maintain a rhythmic breathing pattern

Quiet alert state
Assists with ciliary body maturation in the upper

Gaze aversion airways
Question 23 Explanation: When caring for a Helps the lungs remain expanded after the
neonate experiencing drug withdrawal, the nurse initiation of breathing
needs to be alert for distress signals from the
neonate. Stimuli should be introduced one at a time
when the neonate is in a quiet and alert state. Gaze Promotes clearing mucus from the respiratory tract
aversion, yawning, sneezing, hiccups, and body
arching are distress signals that the neonate cannot
handle stimuli at that time. Question 26 Explanation: Surfactant works by
reducing surface tension in the lung. Surfactant
allows the lung to remain slightly expanded,
When performing an assessment on a neonate, decreasing the amount of work required for
which assessment finding is most suggestive of inspiration.
hypothermia?
When newborns have been on formula for 36-48

Metabolic alkalosis hours, they should have a:
Bradycardia Screening for PKU
Shivering Vitamin K injection
Hyperglycemia Test for necrotizing enterocolitis

Heel stick for blood glucose level Macrosomia
Question 27 Explanation: By now the newborn will Microcephaly

have ingested an ample amount of the amino acid
phenylalanine, which, if not metabolized because of
a lack of the liver enzyme, can deposit injurious Atelectasis
metabolites into the bloodstream and brain; early
detection can determine if the liver enzyme is
Question 30 Explanation: Neonates of mothers with
absent.
diabetes are at increased risk for macrosomia
(excessive fetal growth) as a result of the
Within 3 minutes after birth the normal heart rate of combination of the increased supply of maternal
the infant may range between: glucose and an increase in fetal insulin.
130 and 170 A nurse in a delivery room is assisting with the

delivery of a newborn infant. After the delivery, the
nurse prepares to prevent heat loss in the newborn
100 and 130 resulting from evaporation by:
100 and 180 Closing the doors to the room
120 and 160 Turning on the overhead radiant warmer
Question 28 Explanation: The heart rate varies with Warming the crib pad
activity; crying will increase the rate, whereas deep
sleep will lower it; a rate between 120 and 160 is
expected. Drying the infant in a warm blanket
When performing a newborn assessment, the nurse Question 31 Explanation: Evaporation of moisture
should measure the vital signs in the following from a wet body dissipates heat along with the
sequence: moisture. Keeping the newborn dry by drying the
wet newborn infant will prevent hypothermia via
evaporation.
Respirations, temperature, pulse
Vitamin K is prescribed for a neonate. A nurse

Respirations, pulse, temperature prepares to administer the medication in which
muscle site?
Pulse, respirations, temperature

Triceps
Temperature, pulse, respirations

Vastus lateralis
Question 29 Explanation: This sequence is least

disturbing. Touching with the stethoscope and Biceps
inserting the thermometer increase anxiety and
elevate vital signs.
Deltoid
A client with group AB blood whose husband has

group O has just given birth. The major sign of ABO
Neonates of mothers with diabetes are at risk for blood incompatibility in the neonate is which
which complication following birth? complication or test result?
Pneumothorax Bleeding from the nose and ear

Negative Coombs test It’s a collection of blood between the skull and the
periosteum-cephalhematoma.
Jaundice within the first 24 hours of life

It involves swelling of tissue over the presenting
part of the presenting head
Jaundice after the first 24 hours of life
It doesn’t cross the cranial suture line

Question 33 Explanation: The neonate with ABO
blood incompatibility with its mother will have
jaundice (pathologic) within the first 24 hours of life. It usually resolves in 3-6 weeks
The neonate would have a positive Coombs test
result.
Question 36 Explanation: Caput succedaneum is
the swelling of tissue over the presenting part of the
By keeping the nursery temperature warm and fetal scalp due to sustained pressure; it resolves in
wrapping the neonate in blankets, the nurse is 3-4 days.
preventing which type of heat loss?
While assessing a 2-hour old neonate, the nurse

Convection observes the neonate to have acrocyanosis. Which
of the following nursing actions should be
performed initially?
Conduction
Immediately take the newborn’s temperature

Evaporation according to hospital policy
Radiation Activate the code blue or emergency system
Question 34 Explanation: Convection heat loss is Notify the physician of the need for a cardiac
the flow of heat from the body surface to the cooler consult
air.\
Do nothing because acrocyanosis is normal in

The most common neonatal sepsis and meningitis the neonate
infections seen within 24 hours after birth are
caused by which organism?
Question 37 Explanation: Acrocyanosis, or bluish
discoloration of the hands and feet in the neonate
Escherichia coli (also called peripheral cyanosis), is a normal finding
and shouldn’t last more than 24 hours after birth.
Group B beta-hemolytic streptococci
The primary critical observation for Apgar scoring is
the:
Chlamydia trachomatis
Heart rate
Candida albicans
Presence of meconium
Question 35 Explanation: Transmission of Group B
beta-hemolytic streptococci to the fetus results in
respiratory distress that can rapidly lead to septic Respiratory rate - respiratory effect only not rate
shock.
Evaluation of the Moro reflex

A neonate has been diagnosed with caput
succedaneum. Which statement is correct about
this condition? Question 38 Explanation: The heart rate is vital for
life and is the most critical observation in Apgar
scoring. Respiratory effect rather than rate is
included in the Apgar score; the rate is very erratic.
4. Abruptio placenta
A nurse is assessing a newborn infant who was

born to a mother who is addicted to drugs. Which of
2. The lower limit of viability for infants in terms of
the following assessment findings would the nurse
age of gestation is:
expect to note during the assessment of this
newborn?
Incessant crying
1. 21-24 weeks
Cuddles when being held

2. 25-27 weeks
3. 28-30 weeks
Lethargy 4. 38-40 weeks
Sleepiness
3. Which provision of our 1987 constitution

Question 39 Explanation: A newborn infant born to guarantees the right of the unborn child to life from
a woman using drugs is irritable. The infant is conception is
overloaded easily by sensory stimulation. The infant
may cry incessantly and posture rather than cuddle
when being held.
A woman delivers a 3.250 g neonate at 42 weeks’

1. Article II section 12
gestation. Which physical finding is expected during 2. Article II section 15
an examination if this neonate?
3. Article XIII section 11
4. Article XIII section 15
Absence of sole creases
Leathery, cracked, and wrinkled skin

4. In the Philippines, if a nurse performs abortion on
Abundant lanugo the mother who wants it done and she gets paid for
doing it, she will be held liable because
Breast bud of 1-2 mm in diameter
Question 40 Explanation: Neonatal skin thickens 1. Abortion is immoral and is prohibited

with maturity and is often peeling by post term by the church
2. Abortion is both immoral and illegal in
Text Mode – Text version of the exam our country
3. Abortion is considered illegal because
1. Which of the following conditions will lead to a you got paid for doing it
small-for-gestational age fetus due to less blood
supply to the fetus? 4. Abortion is illegal because majority in
our country are catholics and it is
prohibited by the church
1. Diabetes in the mother

2. Maternal cardiac condition 5. The preferred manner of delivering the baby in a
gravido-cardiac is vaginal delivery assisted by forceps
3. Premature labor
under epidural anesthesia. The main rationale for this 8. Which of the following techniques during labor and
is: delivery can lead to uterine inversion?
1. To allow atraumatic delivery of the 1. Fundal pressure applied to assist the

baby mother in bearing down during delivery
2. To allow a gradual shifting of the blood of the fetal head
into the maternal circulation 2. Strongly tugging on the umbilical cord
3. To make the delivery effort free and the to deliver the placenta and hasten
placental separation
mother does not need to push with
contractions 3. Massaging the fundus to encourage the
4. To prevent perineal laceration with the uterus to contract
expulsion of the fetal head 4. Applying light traction when delivering
the placenta that has already detached
from the uterine wall
6. When giving narcotic analgesics to mother in labor,

the special consideration to follow is:
9. The fetal heart rate is checked following rupture of
the bag of waters in order to:
1. The progress of labor is well

established reaching the transitional
stage 1. Check if the fetus is suffering from
2. Uterine contraction is progressing well head compression
and delivery of the baby is imminent 2. Determine if cord compression
3. Cervical dilatation has already reached followed the rupture
at least 8 cm. and the station is at least 3. Determine if there is utero-placental
(+)2 insufficiency
4. Uterine contractions are strong and the 4. Check if fetal presenting part has
baby will not be delivered yet within the adequately descended following the
next 3 hours. rupture
7. The cervical dilatation taken at 8:00 A.M. in a G1P0 10. Upon assessment, the nurse got the following
patient was 6 cm. A repeat I.E. done at 10 A.M. findings: 2 perineal pads highly saturated with blood
showed that cervical dilation was 7 cm. The correct within 2 hours post partum, PR= 80 bpm, fundus soft
interpretation of this result is: and boundaries not well defined. The appropriate
nursing diagnosis is:
1. Labor is progressing as expected

2. The latent phase of Stage 1 is
1. Normal blood loss
prolonged 2. Blood volume deficiency
3. The active phase of Stage 1 is 3. Inadequate tissue perfusion related to
protracted hemorrhage
4. The duration of labor is normal 4. Hemorrhage secondary to uterine atony
11. The following are signs and symptoms of fetal
distress EXCEPT:
1. Place the palm of the hands on the
abdomen and time the contraction
2. Place the finger tips lightly on the
suprapubic area and time the
contraction
1. Fetal heart rate (FHR) decreased during
3. Put the tip of the fingers lightly on the
a contraction and persists even after
fundal area and try to indent the
the uterine contraction ends
abdominal wall at the height of the
2. The FHR is less than 120 bpm or over contraction
160 bpm 4. Put the palm of the hands on the fundal
3. The pre-contraction FHR is 130 bpm, area and feel the contraction at the
FHR during contraction is 118 bpm and fundal area
FHR after uterine contraction is 126
bpm
4. FHR is 160 bpm, weak and irregular
15. To monitor the frequency of the uterine
contraction during labor, the right technique is to time
the contraction
12. If the labor period lasts only for 3 hours, the nurse
should suspect that the following conditions may
occur:
1. From the beginning of one contraction
to the end of the same contraction
2. From the beginning of one contraction
1. Laceration of cervix to the beginning of the next contraction
2. Laceration of perineum 3. From the end of one contraction to the
3. Cranial hematoma in the fetus beginning of the next contraction
4. Fetal anoxia
4. From the deceleration of one
contraction to the acme of the next
1. 1&2 contraction
2. 2&4
3. 2,3,4
4. 1,2,3,4 16. The peak point of a uterine contraction is called
the
13. The primary power involved in labor and delivery is

1. Acceleration
2. Acme
1. Bearing down ability of mother

3. Deceleration
2. Cervical effacement and dilatation

4. Axiom
3. Uterine contraction
4. Valsalva technique
17. When determining the duration of a uterine
contraction the right technique is to time it from
14. The proper technique to monitor the intensity of a

uterine contraction is
1. The beginning of one contraction to the 1. The heart rate will decelerate during a
end of the same contraction contraction and then go back to its pre-
2. The end of one contraction to the contraction rate after the contraction
beginning of another contraction 2. The heart rate will accelerate during a
3. The acme point of one contraction to contraction and remain slightly above
the pre-contraction rate at the end of
the acme point of another contraction
the contraction
4. The beginning of one contraction to the
3. The rate should not be affected by the
end of another contraction
uterine contraction.
4. The heart rate will decelerate at the
middle of a contraction and remain so
for about a minute after the contraction
18. When the bag of waters ruptures, the nurse should
check the characteristic of the amniotic fluid. The
normal color of amniotic fluid is
21. The mechanisms involved in fetal delivery is
1. Clear as water
2. Bluish
1. Descent, extension, flexion, external
3. Greenish rotation
4. Yellowish 2. Descent, flexion, internal rotation,
extension, external rotation
3. Flexion, internal rotation, external
rotation, extension
19. When the bag of waters ruptures spontaneously, 4. Internal rotation, extension, external
the nurse should inspect the vaginal introitus for rotation, flexion
possible cord prolapse. If there is part of the cord that
has prolapsed into the vaginal opening the correct
nursing intervention is:
22. The first thing that a nurse must ensure when the
baby’s head comes out is
1. Push back the prolapse cord into the

vaginal canal
2. Place the mother on semifowler’s
1. The cord is intact
position to improve circulation
3. Cover the prolapse cord with sterile
2. No part of the cord is encircling the
baby’s neck
gauze wet with sterile NSS and place
the woman on trendellenberg position 3. The cord is still attached to the
4. Push back the cord into the vagina and placenta
place the woman on sims position 4. The cord is still pulsating
20. The fetal heart beat should be monitored every 15 23. To ensure that the baby will breath as soon as the
minutes during the 2nd stage of labor. The head is delivered, the nurse’s priority action is to
characteristic of a normal fetal heart rate is
1. Suction the nose and mouth to remove

mucous secretions
2. Slap the baby’s buttocks to make the 1. The pain is irregular in intensity and
baby cry frequency.
3. Clamp the cord about 6 inches from the 2. The duration of contraction
base progressively lengthens over time
4. Check the baby’s color to make sure it 3. There is no vaginal bloody discharge
is not cyanotic 4. The cervix is still closed.
24. When doing perineal care in preparation for

27. The passageway in labor and deliver of the fetus
delivery, the nurse should observe the following
include the following EXCEPT
EXCEPT
1. Use up-down technique with one stroke

1. Distensibility of lower uterine segment
2. Clean from the mons veneris to the

2. Cervical dilatation and effacement
anus 3. Distensibility of vaginal canal and
3. Use mild soap and warm water introitus
4. Paint the inner thighs going towards the

4. Flexibility of the pelvis
perineal area
28. The normal umbilical cord is composed of:

25. What are the important considerations that the
nurse must remember after the placenta is delivered?
1. 2 arteries and 1 vein

2. 2 veins and 1 artery
1. Check if the placenta is complete
3. 2 arteries and 2 veins
including the membranes
2. Check if the cord is long enough for the
4. none of the above
baby
3. Check if the umbilical cord has 3 blood
vessels
29. At what stage of labor and delivery does a
4. Check if the cord has a meaty portion primigravida differ mainly from a multigravida?
and a shiny portion
1. 1 and 3
2. 2 and 4
3. 1, 3, and 4 1. Stage 1
4. 2 and 3 2. Stage 2
3. Stage 3
4. Stage 4
26. The following are correct statements about false

labor EXCEPT
30. The second stage of labor begins with ___ and
ends with __?
1. Begins with full dilatation of cervix and 34. When delivering the baby’s head the nurse
supports the mother’s perineum to prevent tear. This
ends with delivery of placenta
technique is called
2. Begins with true labor pains and ends
with delivery of baby
3. Begins with complete dilatation and
effacement of cervix and ends with
delivery of baby
1. Marmet’s technique
4. Begins with passage of show and ends

2. Ritgen’s technique
with full dilatation and effacement of 3. Duncan maneuver
cervix 4. Schultze maneuver
31. The following are signs that the placenta has

35. The basic delivery set for normal vaginal delivery
detached EXCEPT:
includes the following instruments/articles EXCEPT:
1. Lengthening of the cord

1. 2 clamps
2. Uterus becomes more globular
2. Pair of scissors
3. Sudden gush of blood
3. Kidney basin
4. Mother feels like bearing down
4. Retractor
32. When the shiny portion of the placenta comes out

36. As soon as the placenta is delivered, the nurse
first, this is called the ___ mechanism.
must do which of the following actions?
1. Schultze
1. Inspect the placenta for completeness
2. Ritgens including the membranes
3. Duncan 2. Place the placenta in a receptacle for
4. Marmets disposal
3. Label the placenta properly
4. Leave the placenta in the kidney basin
for the nursing aide to dispose properly
33. When the baby’s head is out, the immediate action
of the nurse is
37. In vaginal delivery done in the hospital setting, the

doctor routinely orders an oxytocin to be given to the
1. Cut the umbilical cord mother parenterally. The oxytocin is usually given
after the placenta has been delivered and not before
2. Wipe the baby’s face and suction because:
mouth first
3. Check if there is cord coiled around the
neck
4. Deliver the anterior shoulder 1. Oxytocin will prevent bleeding
2. Oxytocin can make the cervix close and 4. Cervical dilatation
thus trap the placenta inside
3. Oxytocin will facilitate placental
delivery
4. Giving oxytocin will ensure complete 41. The following are natural childbirth procedures
delivery of the placenta EXCEPT:
38. In a gravido-cardiac mother, the first 2 hours 1. Lamaze method

postpartum (4th stage of labor and delivery) 2. Dick-Read method
particularly in a cesarean section is a critical period
because at this stage 3. Ritgen’s maneuver
4. Psychoprophylactic method
1. There is a fluid shift from the placental

circulation to the maternal circulation 42. The following are common causes of
which can overload the compromised dysfunctional labor. Which of these can a nurse, on
heart. her own manage?
2. The maternal heart is already weak and
the mother can die
3. The delivery process is strenuous to the
mother 1. Pelvic bone contraction
4. The mother is tired and weak which can 2. Full bladder
distress the heart
3. Extension rather than flexion of the
head
4. Cervical rigidity
39. The drug usually given parentally to enhance
uterine contraction is:
43. At what stage of labor is the mother is advised to

bear down?
1. Terbutalline
2. Pitocin
3. Magnesium sulfate 1. When the mother feels the pressure at
4. Lidocaine the rectal area
2. During a uterine contraction
3. In between uterine contraction to
prevent uterine rupture
40. The partograph is a tool used to monitor labor. 4. Anytime the mother feels like bearing
The maternal parameters measured/monitored are
down
the following EXCEPT:
44. The normal dilatation of the cervix during the first

1. Vital signs stage of labor in a nullipara is
2. Fluid intake and output
3. Uterine contraction
1. 1.2 cm./hr 1. Engaged
2. 1.5 cm./hr. 2. Descended
3. 1.8 cm./hr 3. Floating
4. 2.0 cm./hr 4. Internal Rotation
45. When the fetal head is at the level of the ischial 49. The placenta should be delivered normally within
spine, it is said that the station of the head is ___ minutes after the delivery of the baby.
1. Station –1 1. 5 minutes
2. Station “0” 2. 30 minutes
3. Station +1 3. 45 minutes
4. Station +2 4. 60 minutes
46. During an internal examination, the nurse palpated 50. When shaving a woman in preparation for
the posterior fontanel to be at the left side of the cesarean section, the area to be shaved should be
mother at the upper quadrant. The interpretation is from ___ to ___
that the position of the fetus is:
1. Under breast to mid-thigh including the

1. LOA pubic area
2. ROP 2. The umbilicus to the mid-thigh
3. LOP 3. Xyphoid process to the pubic area
4. ROA 4. Above the umbilicus to the pubic area
47. The following are types of breech presentation Answers and Rationales
EXCEPT:
1. Footling
1. Answer: (B) Maternal cardiac condition.
In general, when the heart is
2. Frank compromised such as in maternal
cardiac condition, the condition can
3. Complete
lead to less blood supply to the uterus
4. Incomplete consequently to the placenta which
provides the fetus with the essential
nutrients and oxygen. Thus if the blood
supply is less, the baby will suffer from
chronic hypoxia leading to a small-for-
48. When the nurse palpates the suprapubic area of gestational age condition.
the mother and found that the presenting part is still
movable, the right term for this observation that the 2. Answer: (A) 21-24 weeks. Viability
fetus is means the capability of the fetus to
live/survive outside of the uterine alright in order to help deliver the
environment. With the present placenta that is already detached.
technological and medical advances,
21 weeks AOG is considered as the
9. Answer: (B) Determine if cord
compression followed the rupture. After
minimum fetal age for viability.
the rupture of the bag of waters, the
3. Answer: (A) Article II section 12. The cord may also go with the water
Philippine Constitution of 1987 because of the pressure of the rupture
guarantees the right of the unborn child and flow. If the cord goes out of the
from conception equal to the mother as cervical opening, before the head is
stated in Article II State Policies, delivered (cephalic presentation), the
Section 12. head can compress on the cord
4. Answer: (B) Abortion is both immoral causing fetal distress. Fetal distress
can be detected through the fetal heart
and illegal in our country. Induced
tone. Thus, it is essential do check the
Abortion is illegal in the country as
FHB right after rupture of bag to ensure
stated in our Penal Code and any
that the cord is not being compressed
person who performs the act for a fee
by the fetal head.
commits a grave offense punishable by
10-12 years of imprisonment. 10. Answer: (D) Hemorrhage secondary
5. Answer: (C) To make the delivery effort to uterine atony. All the signs in the
stem of the question are signs of
free and the mother does not need to
hemorrhage. If the fundus is soft and
push with contractions. Forceps
boundaries not well defined, the cause
delivery under epidural anesthesia will
of the hemorrhage could be uterine
make the delivery process less painful
atony.
and require less effort to push for the
mother. Pushing requires more effort 11. Answer: (C) The pre-contraction
which a compromised heart may not be FHR is 130 bpm, FHR during
able to endure. contraction is 118 bpm and FHR after
6. Answer: (D) Uterine contractions are uterine contraction is 126 bpm. The
normal range of FHR is 120-160 bpm,
strong and the baby will not be
strong and regular. During a
delivered yet within the next 3 hours..
contraction, the FHR usually goes down
Narcotic analgesics must be given
but must return to its pre-contraction
when uterine contractions are already
rate after the contraction ends.
well established so that it will not cause
stoppage of the contraction thus 12. Answer: (D) 1,2,3,4. all the above
protracting labor. Also, it should be conditions can occur following a
given when delivery of fetus is precipitate labor and delivery of the
imminent or too close because the fetus because there was little time for
fetus may suffer respiratory depression the baby to adapt to the passageway. If
as an effect of the drug that can pass the presentation is cephalic, the fetal
through placental barrier. head serves as the main part of the
7. Answer: (C) The active phase of Stage fetus that pushes through the birth
canal which can lead to cranial
1 is protracted. The active phase of
hematoma, and possible compression
Stage I starts from 4cm cervical
of cord may occur which can lead to
dilatation and is expected that the
less blood and oxygen to the fetus
uterus will dilate by 1cm every hour.
(hypoxia). Likewise the maternal
Since the time lapsed is already 2
passageway (cervix, vaginal canal and
hours, the dilatation is expected to be
perineum) did not have enough time to
already 8 cm. Hence, the active phase
stretch which can lead to laceration.
is protracted.
8. Answer: (B) Strongly tugging on the
13. Answer: (C) Uterine contraction.
Uterine contraction is the primary force
umbilical cord to deliver the placenta
that will expel the fetus out through the
and hasten placental separation. When
birth canal Maternal bearing down is
the placenta is still attached to the
considered the secondary power/force
uterine wall, tugging on the cord while
that will help push the fetus out.
the uterus is relaxed can lead to
inversion of the uterus. Light tugging on 14. Answer: (C) Put the tip of the
the cord when placenta has detached is fingers lightly on the fundal area and try
to indent the abdominal wall at the
height of the contraction. In monitoring
the intensity of the contraction the best
21. Answer: (B) Descent, flexion,
internal rotation, extension, external
place is to place the fingertips at the
rotation. The mechanism of fetal
fundal area. The fundus is the
delivery begins with descent into the
contractile part of the uterus and the
pelvic inlet which may occur several
fingertips are more sensitive than the
days before true labor sets in the
palm of the hand.
primigravida. Flexion, internal rotation
15. Answer: (B) From the beginning of and extension are mechanisms that the
one contraction to the beginning of the fetus must perform as it
next contraction. Frequency of the accommodates through the
uterine contraction is defined as from passageway/birth canal. Eternal
the beginning of one contraction to the rotation is done after the head is
beginning of another contraction. delivered so that the shoulders will be
16. Answer: (B) Acme. Acme is the easily delivered through the vaginal
introitus.
technical term for the highest point of
intensity of a uterine contraction. 22. Answer: (B) No part of the cord is
17. Answer: (A) The beginning of one encircling the baby’s neck. The nurse
should check right away for possible
contraction to the end of the same
cord coil around the neck because if it
contraction. Duration of a uterine
is present, the baby can be strangulated
contraction refers to one contraction.
by it and the fetal head will have
Thus it is correctly measure from the
difficulty being delivered.
beginning of one contraction to the end
of the same contraction and not of 23. Answer: (A) Suction the nose and
another contraction. mouth to remove mucous secretions.
18. Answer: (A) Clear as water. The Suctioning the nose and mouth of the
fetus as soon as the head is delivered
normal color of amniotic fluid is clear
will remove any obstruction that maybe
like water. If it is yellowish, there is
present allowing for better breathing.
probably Rh incompatibility. If the color
Also, if mucus is in the nose and mouth,
is greenish, it is probably meconium
aspiration of the mucus is possible
stained.
which can lead to aspiration
19. Answer: (C) Cover the prolapse pneumonia. (Remember that only the
cord with sterile gauze wet with sterile baby’s head has come out as given in
NSS and place the woman on the situation.)
trendellenberg position. The correct
action of the nurse is to cover the cord
24. Answer: (D) Paint the inner thighs
going towards the perineal area.
with sterile gauze wet with sterile NSS.
Painting of the perineal area in
Observe strict asepsis in the care of the
preparation for delivery of the baby
cord to prevent infection. The cord has
must always be done but the stroke
to be kept moist to prevent it from
should be from the perineum going
drying. Don’t attempt to put back the
outwards to the thighs. The perineal
cord into the vagina but relieve
area is the one being prepared for the
pressure on the cord by positioning the
delivery and must be kept clean
mother either on trendellenberg or sims
position 25. Answer: (A) 1 and 3. The nurse after
20. Answer: (A) The heart rate will delivering the placenta must ensure
that all the cotyledons and the
decelerate during a contraction and
membranes of the placenta are
then go back to its pre-contraction rate
complete. Also, the nurse must check if
after the contraction. The normal fetal
the umbilical cord is normal which
heart rate will decelerate (go down)
means it contains the 3 blood vessels,
slightly during a contraction because of
2 veins and 1 artery.
the compression on the fetal head.
However, the heart rate should go back 26. Answer: (B) The duration of
to the pre-contraction rate as soon as contraction progressively lengthens
the contraction is over since the over time. In false labor, the
compression on the head has also contractions remain to be irregular in
ended. intensity and duration while in true
labor, the contractions become
stronger, longer and more frequent.
27. Answer: (D) Flexibility of the pelvis. towel and pushing the perineum
downard with one hand while the other
The pelvis is a bony structure that is
hand is supporting the baby’s head as it
part of the passageway but is not
goes out of the vaginal opening.
flexible. The lower uterine segment
including the cervix as well as the 35. Answer: (D) Retractor. For normal
vaginal canal and introitus are all part vaginal delivery, the nurse needs only
of the passageway in the delivery of the the instruments for cutting the
fetus. umbilical cord such as: 2 clamps
28. Answer: (A) 2 arteries and 1 vein. (straight or curve) and a pair of
scissors as well as the kidney basin to
The umbilical cord is composed of 2
receive the placenta. The retractor is
arteries and 1 vein.
not part of the basic set. In the hospital
29. Answer: (A) Stage 1. In stage 1 setting, needle holder and tissue
during a normal vaginal delivery of a forceps are added especially if the
vertex presentation, the multigravida woman delivering the baby is a
may have about 8 hours labor while the primigravida wherein episiotomy is
primigravida may have up to 12 hours generally done.
labor. 36. Answer: (A) Inspect the placenta for
30. Answer: (C) Begins with complete completeness including the
dilatation and effacement of cervix and membranes. The placenta must be
ends with delivery of baby. Stage 2 of inspected for completeness to include
labor and delivery process begins with the membranes because an incomplete
full dilatation of the cervix and ends placenta could mean that there is
with the delivery of baby. Stage 1 retention of placental fragments which
begins with true labor pains and ends can lead to uterine atony. If the uterus
with full dilatation and effacement of does not contract adequately,
the cervix. hemorrhage can occur.
31. Answer: (D) Mother feels like 37. Answer: (B) Oxytocin can make the
bearing down. Placental detachment cervix close and thus trap the placenta
does not require the mother to bear inside. The action of oxytocin is to
down. A normal placenta will detach by make the uterus contract as well make
itself without any effort from the the cervix close. If it is given prior to
mother. placental delivery, the placenta will be
32. Answer: (A) Schultze. There are 2 trapped inside because the action of
the drug is almost immediate if given
mechanisms possible during the
parentally.
delivery of the placenta. If the shiny
portion comes out first, it is called the 38. Answer: (A) There is a fluid shift
Schultze mechanism; while if the meaty from the placental circulation to the
portion comes out first, it is called the maternal circulation which can
Duncan mechanism. overload the compromised heart..
33. Answer: (C) Check if there is cord During the pregnancy, there is an
increase in maternal blood volume to
coiled around the neck. The nurse
accommodate the need of the fetus.
should check if there is a cord coil
When the baby and placenta have been
because the baby will not be delivered
delivered, there is a fluid shift back to
safely if the cord is coiled around its
the maternal circulation as part of
neck. Wiping of the face should be
physiologic adaptation during the
done seconds after you have ensured
postpartum period. In cesarean section,
that there is no cord coil but suctioning
the fluid shift occurs faster because the
of the nose should be done after the
placenta is taken out right after the
mouth because the baby is a “nasal
baby is delivered giving it less time for
obligate” breather. If the nose is
the fluid shift to gradually occur.
suctioned first before the mouth, the
mucus plugging the mouth can be 39. Answer: (B) Pitocin. The common
aspirated by the baby. oxytocin given to enhance uterine
34. Answer: (B) Ritgen’s technique. contraction is pitocin. This is also the
drug given to induce labor.
Ritgen’s technique is done to prevent
perineal tear. This is done by the nurse 40. Answer: (B) Fluid intake and output.
by support the perineum with a sterile Partograph is a monitoring tool
designed by the World Health both the feet and the buttocks are
Organization for use by health workers presenting it is called complete breech.
when attending to mothers in labor
especially the high risk ones. For
48. Answer: (C) Floating. The term
floating means the fetal presenting part
maternal parameters all of the above is
has not entered/descended into the
placed in the partograph except the
pelvic inlet. If the fetal head has entered
fluid intake since this is placed in a
the pelvic inlet, it is said to be engaged.
separate monitoring sheet.
41. Answer: (C) Ritgen’s maneuver.
49. Answer: (B) 30 minutes. The
placenta is delivered within 30 minutes
Ritgen’s method is used to prevent
from the delivery of the baby. If it takes
perineal tear/laceration during the
longer, probably the placenta is
delivery of the fetal head. Lamaze
abnormally adherent and there is a
method is also known as
need to refer already to the
psychoprophylactic method and Dick-
obstetrician.
Read method are commonly known
natural childbirth procedures which 50. Answer: (A) Under breast to mid-
advocate the use of non-pharmacologic thigh including the pubic area. Shaving
measures to relieve labor pain. is done to prevent infection and the
42. Answer: (B) Full bladder. Full area usually shaved should sufficiently
cover the area for surgery, cesarean
bladder can impede the descent of the
section. The pubic hair is definitely to
fetal head. The nurse can readily
be included in the shaving
manage this problem by doing a simple
catheterization of the mother.
43. Answer: (B) During a uterine
contraction. The primary power of labor
and delivery is the uterine contraction. 1. While performing physical assessment of a 12
This should be augmented by the month-old, the nurse notes that the infant’s anterior
mother’s bearing down during a fontanelle is still slightly open. Which of the following
contraction. is the nurse’s most appropriate action?
44. Answer: (A) 1.2 cm./hr. For

nullipara the normal cervical dilatation
should be 1.2 cm/hr. If it is less than
that, it is considered a protracted active 1. Notify the physician immediately
phase of the first stage. For multipara, because there is a problem.
the normal cervical dilatation is 1.5
cm/hr.
2. Perform an intensive neurologic
examination.
45. Answer: (B) Station “0”. Station is
3. Perform an intensive developmental
defined as the relationship of the fetal
head and the level of the ischial spine. examination.
At the level of the ischial spine, the 4. Do nothing because this is a normal
station is “0”. Above the ischial spine it finding for the age.
is considered (-) station and below the
ischial spine it is (+) station.
46. Answer: (A) LOA. The landmark
used in determine fetal position is the 2. When teaching a mother about introducing solid
posterior fontanel because this is the foods to her child, which of the following indicates the
nearest to the occiput. So if the nurse earliest age at which this should be done?
palpated the occiput (O) at the left (L)
side of the mother and at the
upper/anterior (A) quadrant then the
fetal position is LOA.
47. Answer: (D) Incomplete. Breech 1. 1 month
presentation means the buttocks of the 2. 2 months
fetus is the presenting part. If it is only
the foot/feet, it is considered footling. If 3. 3 months
only the buttocks, it is frank breech. If 4. 4 months
3. The infant of a substance-abusing mother is at risk
for developing a sense of which of the following?
3. Bowlegged posture
4. Linear growth curve
1. Mistrust
7. If parents keep a toddler dependent in areas where
2. Shame he is capable of using skills, the toddle will develop a
3. Guilt sense of which of the following?
4. Inferiority
1. Mistrust
4. Which of the following toys should the nurse 2. Shame
recommend for a 5-month-old? 3. Guilt
4. Inferiority
1. A big red balloon

2. A teddy bear with button eyes 8. Which of the following is an appropriate toy for an
3. A push-pull wooden truck 18-month-old?
4. A colorful busy box
1. Multiple-piece puzzle
5. The mother of a 2-month-old is concerned that she 2. Miniature cars
may be spoiling her baby by picking her up when she
cries. Which of the following would be the nurse’s
3. Finger paints
best response? 4. Comic book
1. “ Let her cry for a while before picking 9. When teaching parents about the child’s readiness
her up, so you don’t spoil her” for toilet training, which of the following signs should
the nurse instruct them to watch for in the toddler?
2. “Babies need to be held and cuddled;
you won’t spoil her this way”
3. “Crying at this age means the baby is
hungry; give her a bottle”
1. Demonstrates dryness for 4 hours
4. “If you leave her alone she will learn
2. Demonstrates ability to sit and walk
how to cry herself to sleep”
3. Has a new sibling for stimulation
4. Verbalizes desire to go to the bathroom
6. When assessing an 18-month-old, the nurse notes a

characteristic protruding abdomen. Which of the
following would explain the rationale for this finding?
10. When teaching parents about typical toddler
eating patterns, which of the following should be
included?
1. Increased food intake owing to age

2. Underdeveloped abdominal muscles
1. Food “jags” 4. Developing plans for the future
2. Preference to eat alone
3. Consistent table manners
4. Increase in appetite 14. A hospitalized schoolager states: “I’m not afraid of
this place, I’m not afraid of anything.” This statement
is most likely an example of whichof the following?
11. Which of the following suggestions should the

nurse offer the parents of a 4-year-old boy who resists
going to bed at night? 1. Regression
2. Repression
3. Reaction formation
1. “Allow him to fall asleep in your room, 4. Rationalization
then move him to his own bed.”
2. “Tell him that you will lock him in his
room if he gets out of bed one more
time.” 15. After teaching a group of parents about accident
3. “Encourage active play at bedtime to prevention for schoolagers, which of the following
tire him out so he will fall asleep statements by the group would indicate the need for
faster.” more teaching?
4. “Read him a story and allow him to play

quietly in his bed until he falls asleep.”
1. “Schoolagers are more active and

adventurous than are younger children.”
12. When providing therapeutic play, which of the 2. “Schoolagers are more susceptible to
following toys would best promote imaginative play in home hazards than are younger
a 4-year-old? children.”
3. “Schoolagers are unable to understand
potential dangers around them.”
4. “Schoolargers are less subject to
1. Large blocks parental control than are younger
2. Dress-up clothes children.”
3. Wooden puzzle
4. Big wheels
16. Which of the following skills is the most
significant one learned during the schoolage period?
13. Which of the following activities, when voiced by

the parents following a teaching session about the
characteristics of school-age cognitive development
would indicate the need for additional teaching?
1. Collecting
2. Ordering
3. Reading
4. Sorting
1. Collecting baseball cards and marbles
2. Ordering dolls according to size
3. Considering simple problem-solving
options
17. A child age 7 was unable to receive the measles,
mumps, and rubella (MMR) vaccine at the
1. “This is probably the only concern he
has about his body. So don’t worry
recommended scheduled time. When would the nurse
about it or the time he spends on it.”
expect to administer MMR vaccine?
2. “Teenagers are anxious about how their
peers perceive them. So they spend a
lot of time grooming.”
1. In a month from now

3. “A teen may develop a poor self-image
when experiencing acne. Do you feel
2. In a year from now this way sometimes?”
3. At age 10 4. “You appear to be keeping your face
4. At age 13 well washed. Would you feel
comfortable discussing your cleansing
method?”
18. The adolescent’s inability to develop a sense of

who he is and what he can become results in a sense
21. Which of the following should the nurse suspect
of which of the following?
when noting that a 3-year-old is engaging in explicit
sexual behavior during doll play?
1. Shame
2. Guilt 1. The child is exhibiting normal pre-
3. Inferiority school curiosity
4. Role diffusion
2. The child is acting out personal
experiences
3. The child does not know how to play
with dolls
19. Which of the following would be most appropriate 4. The child is probably developmentally
for a nurse to use when describing menarche to a 13- delayed.
year-old?
22. Which of the following statements by the parents

1. A female’s first menstruation or of a child with school phobia would indicate the need
for further teaching?
menstrual “periods”
2. The first year of menstruation or
“period”
3. The entire menstrual cycle or from one
1. “We’ll keep him at home until phobia
“period” to another
subsides.”
4. The onset of uterine maturation or peak
2. “We’ll work with his teachers and
growth
counselors at school.”
3. “We’ll try to encourage him to talk about
his problem.”
20. A 14-year-old boy has acne and according to his 4. “We’ll discuss possible solutions with
parents, dominates the bathroom by using the mirror him and his counselor.”
all the time. Which of the following remarks by the
nurse would be least helpful in talking to the boy and
his parents?
23. When developing a teaching plan for a group of
high school students about teenage pregnancy, the
1. 4 months
nurse would keep in mind which of the following? 2. 7 months
3. 9 months
4. 12 months
1. The incidence of teenage pregnancies

is increasing.
2. Most teenage pregnancies are planned. 27. Which of the following best describes parallel play
3. Denial of the pregnancy is common between two toddlers?
early on.
4. The risk for complications during
pregnancy is rare.
1. Sharing crayons to color separate
pictures
2. Playing a board game with a nurse
24. When assessing a child with a cleft palate, the
nurse is aware that the child is at risk for more
3. Sitting near each other while playing
with separate dolls
frequent episodes of otitis media due to whichof the
following? 4. Sharing their dolls with two different
nurses
1. Lowered resistance from malnutrition

28. Which of the following would the nurse identify as
2. Ineffective functioning of the the initial priority for a child with acute lymphocytic
Eustachian tubes leukemia?
3. Plugging of the Eustachian tubes with
food particles
4. Associated congenital defects of the
middle ear. 1. Instituting infection control precautions
2. Encouraging adequate intake of iron-
rich foods
25. While performing a neurodevelopmental

3. Assisting with coping with chronic
illness
assessment on a 3-month-old infant, which of the
following characteristics would be expected? 4. Administering medications via IM
injections
1. A strong Moro reflex

29. Which of the following information, when voiced
2. A strong parachute reflex by the mother, would indicate to the nurse that she
3. Rolling from front to back understands home care instructions following the
administration of a diphtheria, tetanus, and pertussis
4. Lifting of head and chest when prone injection?
26. By the end of which of the following would the

nurse most commonly expect a child’s birth weight to
1. Measures to reduce fever
triple? 2. Need for dietary restrictions
3. Reasons for subsequent rash
4. Measures to control subsequent 33. Which of the following would the nurse do first for
a 3-year-old boy who arrives in the emergency room
diarrhea
with a temperature of 105 degrees, inspiratory stridor,
and restlessness, who is learning forward and
drooling?
30. Which of the following actions by a community

health nurse is most appropriate when noting multiple
bruises and burns on the posterior trunk of an 18-
month-old child during a home visit? 1. Auscultate his lungs and place him in a
mist tent.
2. Have him lie down and rest after
encouraging fluids.
1. Report the child’s condition to 3. Examine his throat and perform a
Protective Services immediately. throat culture
2. Schedule a follow-up visit to check for 4. Notify the physician immediately and
more bruises. prepare for intubation.
3. Notify the child’s physician
immediately.
4. Do nothing because this is a normal
34. Which of the following would the nurse need to
finding in a toddler.
keep in mind as a predisposing factor when
formulating a teaching plan for child with a urinary
tract infection?
31. Which of the following is being used when the

mother of a hospitalized child calls the student nurse
and states, “You idiot, you have no idea how to care
for my sick child”? 1. A shorter urethra in females
2. Frequent emptying of the bladder
3. Increased fluid intake
1. Displacement
4. Ingestion of acidic juices
2. Projection
3. Repression
4. Psychosis 35. Which of the following should the nurse do first
for a 15-year-old boy with a full leg cast who is
screaming in unrelenting pain and exhibiting right foot
pallor signifying compartment syndrome?
32. Which of the following should the nurse expect to

note as a frequent complication for a child with
congenital heart disease?
1. Medicate him with acetaminophen.
2. Notify the physician immediately
3. Release the traction
1. Susceptibility to respiratory infection 4. Monitor him every 5 minutes
2. Bleeding tendencies
3. Frequent vomiting and diarrhea
4. Seizure disorder
36. At which of the following ages would the nurse
expect to administer the varicella zoster vaccine to
child?
1. At birth 40. Which of the following assessment findings would
lead the nurse to suspect Down syndrome in an
2. 2 months infant?
3. 6 months
4. 12 months
1. Small tongue
2. Transverse palmar crease
37. When discussing normal infant growth and 3. Large nose
development with parents, which of the following toys
would the nurse suggest as most appropriate for an 4. Restricted joint movement
8-month-old?
41. While assessing a newborn with cleft lip, the nurse

1. Push-pull toys would be alert that which of the following will most
likely be compromised?
2. Rattle
3. Large blocks
4. Mobile
1. Sucking ability
2. Respiratory status
3. Locomotion
38. Which of the following aspects of psychosocial
development is necessary for the nurse to keep in 4. GI function
mind when providing care for the preschool child?
42. When providing postoperative care for the child

1. The child can use complex reasoning to with a cleft palate, the nurse should position the child
in which of the following positions?
think out situations.
2. Fear of body mutilation is a common
preschool fear
3. The child engages in competitive types
1. Supine
of play
4. Immediate gratification is necessary to
2. Prone
develop initiative. 3. In an infant seat
4. On the side
39. Which of the following is characteristic of a

preschooler with mid mental retardation?
43. While assessing a child with pyloric stenosis, the
nurse is likely to note which of the following?
1. Slow to feed self

2. Lack of speech 1. Regurgitation
3. Marked motor delays 2. Steatorrhea
4. Gait disability 3. Projectile vomiting
4. Currant jelly” stools
44. Which of the following nursing diagnoses would
be inappropriate for the infant with gastroesophageal
4. Weight gain
reflux (GER)?
48. Which of the following should the nurse do first

after noting that a child with Hirschsprung disease
1. Fluid volume deficit has a fever and watery explosive diarrhea?
2. Risk for aspiration
3. Altered nutrition: less than body
requirements
4. Altered oral mucous membranes 1. Notify the physician immediately
2. Administer antidiarrheal medications
3. Monitor child ever 30 minutes
45. Which of the following parameters would the

4. Nothing, this is characteristic of
Hirschsprung disease
nurse monitor to evaluate the effectiveness of
thickened feedings for an infant with
gastroesophageal reflux (GER)?
49. A newborn’s failure to pass meconium within the

first 24 hours after birth may indicate which of the
following?
1. Vomiting
2. Stools
3. Uterine
4. Weight 1. Hirschsprung disease
2. Celiac disease
3. Intussusception
46. Discharge teaching for a child with celiac disease

4. Abdominal wall defect
would include instructions about avoiding which of
the following?
50. When assessing a child for possible

intussusception, which of the following would be least
likely to provide valuable information?
1. Rice
2. Milk
3. Wheat
4. Chicken 1. Stool inspection
2. Pain pattern
3. Family history
47. Which of the following would the nurse expect to

4. Abdominal palpation
assess in a child with celiac disease having a celiac
crisis secondary to an upper respiratory infection?
Answers and Rationales
1. Respiratory distress
2. Lethargy
3. Watery diarrhea
1. D. The anterior fontanelle typically reasons. Assuming that the child s
hungry may cause overfeeding
closes anywhere between 12 to 18
problems such as obesity.
months of age. Thus, assessing the
anterior fontanelle as still being 6. B. Underdeveloped abdominal
slightly open is a normal finding musculature gives the toddler a
requiring no further action. Because it characteristically protruding
is normal finding for this age, notifying abdomen. During toddlerhood, food
he physician or performing additional intake decreases, not increases.
examinations are inappropriate. Toddlers are characteristically
2. D. Solid foods are not recommended bowlegged because the leg muscles
must bear the weight of the relatively
before age 4 to 6 months because of
large trunk. Toddler growth patterns
the sucking reflex and the immaturity
occur in a steplike, not linear pattern.
of the gastrointestinal tract and
immune system. Therefore, the 7. B. According to Erikson, toddlers
earliest age at which to introduce experience a sense of shame when
foods is 4 months. Any time earlier they are not allowed to develop
would be inappropriate. appropriate independence and
3. A. According to Erikson, infants need autonomy. Infants develop mistrust
when their needs are not consistently
to have their needs met consistently
gratified. Preschoolers develop guilt
and effectively to develop a sense of
when their initiative needs are not met
trust. An infant whose needs are
while schoolagers develop a sense of
consistently unmet or who
inferiority when their industry needs
experiences significant delays in
are not met.
having them met, such as in the case
of the infant of a substance-abusing 8. C. Young toddlers are still
mother, will develop a sense of sensorimotor learners and they enjoy
uncertainty, leading to mistrust of the experience of feeling different
caregivers and the environment. textures. Thus, finger paints would be
Toddlers develop a sense of shame an appropriate toy choice. Multiple-
when their autonomy needs are not piece toys, such as puzzle, are too
met consistently. Preschoolers difficult to manipulate and may be
develop a sense of guilt when their hazardous if the pieces are small
sense of initiative is thwarted. enough to be aspirated. Miniature cars
Schoolagers develop a sense of also have a high potential for
inferiority when they do not develop a aspiration. Comic books are on too
sense of industry. high a level for toddlers. Although they
4. D. A busy box facilitates the fine may enjoy looking at some of the
pictures, toddlers are more likely to rip
motor development that occurs
a comic book apart.
between 4 and 6 months. Balloons are
contraindicated because small 9. D. The child must be able to sate the
children may aspirate balloons. need to go to the bathroom to initiate
Because the button eyes of a teddy toilet training. Usually, a child needs to
bear may detach and be aspirated, be dry for only 2 hours, not 4 hours.
this toy is unsafe for children younger The child also must be able to sit,
than 3 years. A 5-month-old is too walk, and squat. A new sibling would
young to use a push-pull toy. most likely hinder toilet training.
5. B. Infants need to have their security 10. A. Toddlers become picky eaters,
needs met by being held and cuddled. experiencing food jags and eating
At 2 months of age, they are unable to large amounts one day and very little
make the connection between crying the next. A toddler’s food gags
and attention. This association does express a preference for the ritualism
not occur until late infancy or early of eating one type of food for several
toddlerhood. Letting the infant cry for days at a time. Toddlers typically
a time before picking up the infant or enjoy socialization and limiting others
leaving the infant alone to cry herself at meal time. Toddlers prefer to feed
to sleep interferes with meeting the themselves and thus are too young to
infant’s need for security at this very have table manners. A toddler’s
young age. Infants cry for many appetite and need for calories, protein,
and fluid decrease due to the dramatic to rules. Thus, schoolagers should be
slowing of growth rate. able to understand the potential
11. D. Preschoolers commonly have dangers around them. With growth
comes greater freedom andchildren
fears of the dark, being left alone
become more adventurous and
especially at bedtime, and ghosts,
daring. The school-aged child is also
which may affect the child’s going to
still prone to accidents and home
bed at night. Quiet play and time with
hazards, especially because of
parents is a positive bedtime routine
increased motor abilities and
that provides security and also readies
independence. Plus the home hazards
the child for sleep. The child should
differ from other age groups. These
sleep in his own bed. Telling the child
hazards, which are potentially lethal
about locking him in his room will
but tempting, may include firearms,
viewed by the child as a threat.
alcohol, and medications. School-
Additionally, a locked door is
agechildren begin to internalize their
frightening and potentially hazardous.
own controls and need less outside
Vigorous activity at bedtime stirs up
direction. Plus the child is away from
the child and makes more difficult to
home more often. Some parental or
fall asleep.
caregiver assistance is still needed to
12. B. Dress-up clothes enhance answer questions and provide
imaginative play and imagination, guidance for decisions and
allowing preschoolers to engage in responsibilities.
rich fantasy play. Building blocks and
wooden puzzles are appropriate for
16. C. The most significant skill
learned during the school-age period
encouraging fine motordevelopment.
is reading. During this time the child
Big wheels and tricycles encourage
develops formal adult articulation
gross motor development.
patterns and learns that words can be
13. D. The school-aged child is in the arranged in structure. Collective,
stage of concrete operations, marked ordering, and sorting, although
by inductive reasoning, logical important, are not most significant
operations, and reversible concrete skills learned.
thought. The ability to consider the
future requires formal thought
17. C. Based on the recommendations
of the American Academy of Family
operations, which are not developed
Physicians and the American
until adolescence. Collecting baseball
Academy of Pediatrics, the MMR
cards and marbles, ordering dolls by
vaccine should be given at the age of
size, and simple problem-solving
10 if the child did not receive it
options are examples of the concrete
between the ages of 4 to 6 years as
operational thinking of the schoolager.
recommended. Immunization for
14. C. Reaction formation is the diphtheria and tetanus isrequired at
schoolager’s typical defensive age 13.
response when hospitalized. In
reaction formation, expression of
18. D. According to Erikson, role
diffusion develops when the
unacceptable thoughts or behaviors is
adolescent does not develop a sense
prevented (or overridden) by the
of identity and a sense or where he fits
exaggerated expression of opposite
in. Toddlers develop a sense of shame
thoughts or types of behaviors.
when they do not achieve autonomy.
Regression is seen in toddlers and
Preschoolers develop a sense of guilt
preshcoolers when they retreat or
when they do not develop a sense of
return to an earlier level
initiative. School-agechildren develop
ofdevelopment . Repression refers to
a sense of inferiority when they do not
the involuntary blocking of unpleasant
develop a sense of industry.
feelings and experiences from one’s
awareness. Rationalization is the 19. A. Menarche refers to the onset of
attempt to make excuses to justify the first menstruation or menstrual
unacceptable feelings or behaviors. period and refers only to the first
15. C. The schoolager’s cognitive level cycle. Uterine growth and broadening
of the pelvic girdle occurs before
is sufficiently developed to enable
menarche.
good understanding of and adherence
20. A. Stating that this is probably the unplanned and occur out of wedlock.
The pregnant adolescent is at high
only concern the adolescent has and
risk for physical complications
telling the parents not to worry about
including premature labor and low-
it or the time her spends on it shuts
birth-weight infants, high neonatal
off further investigation and is likely to
mortality, iron deficiency anemia,
make the adolescent and his parents
prolonged labor, and fetopelvic
feel defensive. The statement about
disproportion as well as numerous
peer acceptance and time spent in
psychological crises.
front of the mirror for the development
of self image provides information 24. B. Because of the structural defect,
about the adolescent’s needs to the children with cleft palate may have
parents and may help to gain trust ineffective functioning of their
with the adolescent. Asking the Eustachian tubes creating frequent
adolescent how he feels about the bouts of otitis media. Most children
acne will encourage the adolescent to with cleft palate remain well-nourished
share his feelings. Discussing the and maintain adequate nutrition
cleansing method shows interest and through the use of proper feeding
concern for the adolescent and also techniques. Food particles do not
can help to identify any patient- pass through the cleft and into the
teaching needs for the adolescent Eustachian tubes. There is no
regarding cleansing. association between cleft palate and
21. B. Preschoolers should be congenial ear deformities.
developmentally incapable of 25. D. A 3-month-old infant should be
demonstrating explicit sexual able to lift the head and chest when
behavior. If a child does so, the child prone. The Moro reflex typically
has been exposed to such behavior, diminishes or subsides by 3 months.
and sexual abuse should be The parachute reflex appears at 9
suspected. Explicit sexual behavior months. Rolling from front to back
during doll play is not a characteristic usually is accomplished at about 5
of preschool development nor months.
symptomatic of developmental delay.
Whether or nor the child knows how to
26. D. A child’s birth weight usually
triples by 12 months and doubles by 4
play with dolls is irrelevant.
months. No specific birth weight
22. A. The parents need more teaching parameters are established for 7 or 9
if they state that they will keep the months.
child home until the phobia subsides.
Doing so reinforces the child’s
27. C. Toddlers engaging in parallel
play will play near each other, but not
feelings of worthlessness and
with each other. Thus, when two
dependency. The child should attend
toddlers sit near each other but play
school even during resolution of the
with separate dolls, they are exhibiting
problem. Allowing the child to
parallel play. Sharing crayons, playing
verbalize helps the child to ventilate
a board game with a nurse, or sharing
feelings and may help to uncover
dolls with two different nurses are all
causes and solutions. Collaboration
examples of cooperative play.
with the teachers and counselors at
school may lead to uncovering the 28. A. Acute lymphocytic leukemia
cause of the phobia and to the (ALL) causes leukopenia, resulting in
development of solutions. The child immunosuppression and increasing
should participate and play an active the risk of infection, a leading cause of
role in developing possible solutions. death in children with ALL. Therefore,
23. C. The adolescent who becomes the initial priority nursing intervention
would be to institute infection control
pregnant typically denies the
precautions to decrease the risk of
pregnancy early on. Early recognition
infection. Iron-rich foods help with
by a parent or health care provider
anemia, but dietary iron is not an initial
may be crucial to timely initiation of
intervention. The prognosis of ALL
prenatal care. The incidence of
usually is good. However, later on, the
adolescent pregnancy has declined
nurse may need to assist the child and
since 1991, yet morbidity remains
family with coping since death and
high. Most teenage pregnancies are
dying may still be an issue in need of notified immediately and the nurse
discussion. Injections should be must be prepared for an emergency
discouraged, owing to increased risk intubation or tracheostomy. Further
from bleeding due to assessment with auscultating lungs
thrombocytopenia. and placing the child in a mist tent
29. A. The pertusis component may wastes valuable time. The situation is
a possible life-threatening emergency.
result in fever and the tetanus
Having the child lie down would cause
component may result in injection
additional distress and may result in
soreness. Therefore, the mother’s
respiratory arrest. Throat examination
verbalization of information about
may result in laryngospasm that could
measures to reduce fever indicates
be fatal.
understanding. No dietary restrictions
are necessary after this injection is 34. A. In females, the urethra is shorter
given. A subsequent rash is more than in males. This decreases the
likely to be seen 5 to 10 days after distance for organisms to travel,
receiving the MMR vaccine, not the thereby increasing the chance of the
diphtheria, pertussis, and tetanus child developing a urinary tract
vaccine. Diarrhea is not associated infection. Frequent emptying of the
with this vaccine. bladder would help to decrease
30. A. Multiple bruises and burns on a urinary tract infections by avoiding
sphincter stress. Increased fluid
toddler are signs child abuse.
intake enables the bladder to be
Therefore, the nurse is responsible for
cleared more frequently, thus helping
reporting the case to Protective
to prevent urinary tract infections. The
Services immediately to protect the
intake of acidic juices helps to keep
child from further harm. Scheduling a
the urine pH acidic and thus decrease
follow-up visit is inappropriate
the chance of flora development.
because additional harm may come to
the child if the nurse waits for further 35. B. Compartment syndrome is an
assessment data. Although the nurse emergent situation and the physician
should notify the physician, the goal is needs to be notified immediately so
to initiate measures to protect the that interventions can be initiated to
child’s safety. Notifying the physician relieve the increasing pressure and
immediately does not initiate the restore circulation. Acetaminophen
removal of the child from harm nor (Tylenol) will be ineffective since the
does it absolve the nurse from pain is related to the increasing
responsibility. Multiple bruises and pressure and tissue ischemia. The
burns are not normal toddler injuries. cast, not traction, is being used in this
31. B. The mother is using projection, situation for immobilization, so
releasing the traction would be
the defense mechanism used when a
inappropriate. In this situation,
person attributes his or her own
specific action not continued
undesirable traits to another.
monitoring is indicated.
Displacement is the transfer of
emotion onto an unrelated object, 36. D. The varicella zoster vaccine
such as when the mother would kick a (VZV) is a live vaccine given after age
chair or bang the door shut. 12 months. The first dose of hepatitis
Repression is the submerging of B vaccine is given at birth to 2 months,
painful ideas into the unconscious. then at 1 to 4 months, and then again
Psychosis is a state of being out of at 6 to 18 months. DtaP is routinely
touch with reality. given at 2, 4, 6, and 15 to 18 months
32. A. Children with congenital heart and a booster at 4 to 6 years.
disease are more prone to respiratory 37. C. Because the 8-month-old is
infections. Bleeding tendencies, refining his gross motor skills, being
frequent vomiting, and diarrhea and able to sit unsupported and also
seizure disorders are not associated improving his fine motor skills,
with congenital heart disease. probably capable of making hand-to-
33. D. The child is exhibiting classic hand transfers, large blocks would be
the most appropriate toy selection.
signs of epiglottitis, always a pediatric
Push-pull toys would be more
emergency. The physician must be
appropriate for the 10 to 12-month-old
as he or she begins to cruise the he or she may aspirate. Using an
environment. Rattles and mobiles are infant seat does not facilitate
more appropriate for infants in the 1 drainage. Side-lying does not facilitate
to 3 month age range. Mobiles pose a drainage as well as the prone position.
danger to older infants because of
possible strangulation.
43. C. Projectile vomiting is a key
symptom of pyloric stenosis.
38. B. During the preschool period, the Regurgitation is seen more commonly
child has mastered a sense of with GER. Steatorrhea occurs in
autonomy and goes on to master a malabsorption disorders such as
sense of initiative. During this period, celiac disease. “Currant jelly” stools
the child commonly experiences more are characteristic of intussusception.
fears than at any other time. One
common fear is fear of the body
44. D. GER is the backflow of gastric
contents into the esophagus resulting
mutilation, especially associated with
from relaxation or incompetence of
painful experiences. The preschool
the lower esophageal (cardiac)
child uses simple, not complex,
sphincter. No alteration in the oral
reasoning, engages in associative, not
mucous membranes occurs with this
competitive, play (interactive and
disorder. Fluid volume deficit, risk for
cooperative play with sharing), and is
aspiration, and altered nutrition are
able to tolerate longer periods of
appropriate nursing diagnoses.
delayed gratification.
39. A. Mild mental retardation refers to
45. A. Thickened feedings are used
with GER to stop the vomiting.
development disability involving an IQ
Therefore, the nurse would monitor
50 to 70. Typically, the child is not
the child’s vomiting to evaluate the
noted as being retarded, but exhibits
effectiveness of using the thickened
slowness in performing tasks, such as
feedings. No relationship exists
self-feeding, walking, and taking. Little
between feedings and characteristics
or no speech, marked motor delays,
of stools and uterine. If feedings are
and gait disabilities would be seen in
ineffective, this should be noted
more severe forms mental retardation.
before there is any change in the
40. B. Down syndrome is characterized child’s weight.
by the following a transverse palmar
crease (simian crease), separated
46. C. Children with celiac disease
cannot tolerate or digest gluten.
sagittal suture, oblique palpebral
Therefore, because of its gluten
fissures, small nose, depressed nasal
content, wheat and wheat-containing
bridge, high-arched palate, excess and
products must be avoided. Rice, milk,
lax skin, wide spacing and plantar
and chicken do not contain gluten and
crease between the second and big
need not be avoided.
toes, hyperextensible and lax joints,
large protruding tongue, and muscle 47. C. Episodes of celiac crises are
weakness. precipitated by infections, ingestion of
41. A. Because of the defect, the child gluten, prolonged fasting, or exposure
to anticholinergic drugs. Celiac crisis
will be unable to from the mouth
is typically characterized by severe
adequately around nipple, thereby
watery diarrhea. Respiratory distress
requiring special devices to allow for
is unlikely in a routine upper
feeding and sucking gratification.
respiratory infection. Irritability, rather
Respiratory status may be
than lethargy, is more likely. Because
compromised if the child is fed
of the fluid loss associated with the
improperly or during postoperative
severe watery diarrhea, the child’s
period, Locomotion would be a
weight is more likely to be decreased.
problem for the older infant because
of the use of restraints. GI functioning 48. A. For the child with Hirschsprung
is not compromised in the child with a disease, fever and explosive diarrhea
cleft lip. indicate enterocolitis, a life-
42. B. Postoperatively children with threatening situation. Therefore, the
physician should be notified
cleft palate should be placed on their
immediately. Generally, because of the
abdomens to facilitate drainage. If the
intestinal obstruction and inadequate
child is placed in the supine position,
propulsive intestinal movement,
antidiarrheals are not used to treat
Hirschsprung disease. The child is
1. cystitis
acutely ill and requires intervention, 2. diabetes
with monitoring more frequently than 3. eclampsia
every 30 minutes. Hirschsprung
disease typically presents with chronic 4. hypertension
constipation.
49. A. Failure to pass meconium within
the first 24 hours after birth may be an
indication of Hirschsprung disease, a 3. Methergine or pitocin are prescribed for a client
congenital anomaly resulting in with PP hemorrhage. Before administering the
mechanical obstruction due to medication(s), the nurse contacts the health provider
inadequate motility in an intestinal who prescribed the medication(s) in which of the
segment. Failure to pass meconium is following conditions is documented in the client’s
not associated with celiac disease, medical history?
intussusception, or abdominal wall
defect.
50. C. Because intussusception is not
believed to have a familial tendency,
obtaining a family history would
1. Peripheral vascular disease
provide the least amount of 2. Hypothyroidism
information. Stool inspection, pain
pattern, and abdominal palpation
3. Hypotension
would reveal possible indicators of 4. Type 1 diabetes
intussusception. Current, jelly-like
stools containing blood and mucus
are an indication of intussusception.
Acute, episodic abdominal pain is
characteristics of intussusception. A 4.A pregnant client in the last trimester has been
sausage-shaped mass may be admitted to the hospital with a diagnosis of severe
palpated in the right upper quadrant. preeclampsia. A nurse monitors for complications
associated with the diagnosis and assesses the client
for:
Text Mode – Text version of the exam

1. Any bleeding, such as in the gums,
1. A pregnant client is receiving magnesium sulfate petechiae, and purpura.
therapy for the control of preeclampsia. A nurse
discover that the client is encountering toxicity from 2. Enlargement of the breasts
the medication in which of the following assessment? 3. Periods of fetal movement followed by
quiet periods
4. Complaints of feeling hot when the
room is cool
1. Urine output of 25 ml/hr.
2. The presence of deep tendon reflex.
3. Respirations of 10 breaths per minute.
5. A homecare nurse visits a pregnant client who has
4. Serum magnesium level of 7 mEq/L. a diagnosis of mild Preeclampsia and who is being
monitored for pregnancy induced hypertension (PIH).
Which assessment finding indicates a worsening of
the Preeclampsia and the need to notify the
physician?
2.Which of the following conditions is associated with
elevated serum chloride levels?
1. Blood pressure reading is at the 3. Proteinuria of +3
prenatal baseline 4. Respirations of 10 per minute
2. Urinary output has increased
3. The client complains of a headache and
blurred vision
4. Dependent edema has resolved 9. A woman with preeclampsia is receiving
magnesium sulfate. The nurse assigned to care for
the client determines that the magnesium therapy is
effective if:
6. A nurse is caring for a pregnant client with

Preeclampsia. The nurse prepares a plan of care for
the client and documents in the plan that if the client
progresses from Preeclampsia to eclampsia, the 1. Ankle clonus in noted
nurse’s first action is to: 2. The blood pressure decreases
3. Seizures do not occur
4. Scotomas are present
1. Administer magnesium sulfate
intravenously
2. Assess the blood pressure and fetal
heart rate 10. A nurse is caring for a pregnant client with severe
preeclampsia who is receiving IV magnesium sulfate.
3. Clean and maintain an open airway Select all nursing interventions that apply in the care
4. Administer oxygen by face mask for the client.
7. A nurse is monitoring a pregnant client with 1. Monitor maternal vital signs every 2
pregnancy induced hypertension who is at risk for hours
Preeclampsia. The nurse checks the client for which 2. Notify the physician if respirations are
specific signs of Preeclampsia (select all that apply)?
less than 18 per minute.
3. Monitor renal function and cardiac
function closely
1. Elevated blood pressure

4. Keep calcium gluconate on hand in
case of a magnesium sulfate overdose
2. Negative urinary protein
5. Monitor deep tendon reflexes hourly
3. Facial edema
6. Monitor I and O’s hourly
4. Increased respirations
7. Notify the physician if urinary output is
less than 30 ml per hour.
8. A pregnant client is receiving magnesium sulfate

for the management of preeclampsia. A nurse
Answers & Rationales
determines the client is experiencing toxicity from the
medication if which of the following is noted on
assessment? 1.Answer: C. Respirations of 10 breaths per minute.
Magnesium sulfate is a central nervous system
depressant and anticonvulsant. It can cause smooth
muscle relaxation. Signs of magnesium sulfate
toxicity relate to the central nervous system
1. Presence of deep tendon reflexes depressant effects of the medication and include
respiratory depression, decreased urine output, loss
2. Serum magnesium level of 6 mEq/L
of deep tendon reflexes, hypotension and a decrease Proteinuria of +3 would be noted in a client with
maternal and fetal heart rate. preeclampsia.
9.Answer: C. Seizures do not occur. For a client with

preeclampsia, the goal of care is directed at
preventing eclampsia (seizures). Magnesium sulfate
● Option A: Urine output should be
is an anticonvulsant, not an antihypertensive agent.
maintained at 25-30ml/hr. Although a decrease in blood pressure may be noted
● Option B: Deep tendon reflexes must be initially, this effect is usually transient. Ankle clonus
present. indicated hyperreflexia and may precede the onset of
eclampsia. Scotomas are areas of complete or partial
● Option D: Normal range for magnesium
blindness. Visual disturbances, such as scotomas,
is between 4-7 mEq/L often precede an eclamptic seizure.
10. Answers: C, D, E, F, and G. When caring for a client

receiving magnesium sulfate therapy, the nurse would
2.Answer: C. eclampsia. Eclampsia is associated with monitor maternal vital signs, especially respirations,
increased levels of serum chloride. every 30-60 minutes and notify the physician if
respirations are less than 12, because this would
3.Answer: A. Peripheral vascular disease. These indicate respiratory depression. Calcium gluconate is
medications are avoided in clients with significant kept on hand in case of magnesium sulfate overdose,
cardiovascular disease, peripheral disease, because calcium gluconate is the antidote for
hypertension, eclampsia, or preeclampsia. These magnesium sulfate toxicity. Deep tendon reflexes are
conditions are worsened by the vasoconstriction assessed hourly. Cardiac and renal function is
effects of these medications. monitored closely. The urine output should be
maintained at 30 ml per hour because the medication
is eliminated through the kidneys.
4.Answer: A. Any bleeding, such as in the gums,
petechiae, and purpura. Severe Preeclampsia can
trigger disseminated intravascular coagulation
because of the widespread damage to vascular
integrity. Bleeding is an early sign of DIC and should
be reported to the M.D. 1.A senior high school student asks the school nurse,
“How will I know that I am fertile?” The school nurse would
be inaccurate if she states that one of the signs of
5. Answer: C. The client complains of a headache and ovulation is:*
blurred vision. If the client complains of a headache
and blurred vision, the physician should be notified
because these are signs of worsening Preeclampsia. 0/1
6.Answer: C. Clean and maintain an open airway. The

a.Your cervical mucus is elastic
immediate care during a seizure (eclampsia) is to
ensure a patent airway. The other options are actions
that follow or will be implemented after the seizure b.Your cervical mucus is clear, thin, and watery
has ceased.
c.You will experience a diffused lower abdominal
7.Answers: A Elevated blood pressure and 3 Facial discomfort that radiates to the back
edema. The three classic signs of preeclampsia are
hypertension, generalized edema, and proteinuria.
Increased respirations are not a sign of preeclampsia. d.There will be a sudden drop in you temperature followed
by an increase for .7 - .80C for 3 full days
8. Answer: D. Respirations of 10 per minute.

Magnesium toxicity can occur from magnesium
sulfate therapy. Signs of toxicity relate to the central
nervous system depressant effects of the medication
and include respiratory depression, loss of deep
tendon reflexes, and a sudden drop in the fetal heart
rate and maternal heart rate and blood pressure.
Therapeutic levels of magnesium are 4-7 mEq/L. 2.Right after discussing the different signs of ovulation,
one of the participants was curious on why there is an
increased on the body temperature after ovulation, the
nurse would explain to the group that which of the
following hormones is responsible for the increase in
temperature?* b.8-10 times per hour
1/1 c.Twice every hour
a.Estrogen d.10 times per day
b.Progesterone
5.Gravity is counted by:*
c.Follicle Stimulating hormone 1/1
d.Oxytocin
a.The number of pregnancies that reach the age of
viability
b.The number of pregnancies in which the fetus has been

born alive
3.A post-partum woman has just given birth to her 4th
baby. She had a missed abortion 4 years ago and her
second baby was born pre-term. Her first child died of c.The number of pregnancies regardless of duration of
pneumonia last month. The post-partum woman will be outcome
coded as:*
1/1
d.The number of pregnant women visiting a pre-natal

a.G3, P2 clinic every week
b.G3, P1
c.G4, P3
6.A participant inquired. “What is the average normal
weight gain during pregnancy?” Which of the following
responses would be appropriate?*
1/1
d.G4, P2
a.12 to 22 lbs
b.15 to 25 lbs
4.A pregnant woman on her 34th week of pregnancy
asked you what is the normal fetal movement, so that she
knows what she should be expecting to feel, and knows c.14 to 45 lbs
what she should report. You should let her know that the
normal fetal movement count is:*
d.25 to 35 lbs
1/1
a.10-12 times per hour

7.A woman on her 2nd trimester of pregnancy complains b.Abdominal or chest pain
of pyrosis, all of the following are helpful nursing
interventions except:*
c.Vaginal bleeding
1/1 d.Chills and fever
a.Drinking milk in between meals
b.Lying down with two pillows

10.An 8-month pregnant woman complains of dizziness
especially when she lies on her back. Which of the
c.Lying down after meals following would be the best instruction given to the client
to address her complaint?*
1/1
d.Eat small frequent meals

a.Elevate legs on the wall for 30 minutes
b.Wear loose bra
8.A 32-week multigravida shared to the group that her c.Drink in between meals
doctor informed her that the amount of her amniotic fluid is
less than normal. Which of the following fetal complication
might be present?* d.Rest in a left side-lying position
1/1
a.Hypospadias
b.Esophageal atresia
11. A gravida woman told the nurse that a whitish mucus
non-foul discharge in her vagina causes her some
c.Presence of babinski reflex discomfort. The best management would be:*
d.Renal malformation 1/1
a.Vaginal douche
b.Nystatin (Mycostatin)
c.Wearing cotton perineal pads

9.The pregnant woman is in her first trimester is
experiencing discomforts of pregnancy. Which of the
following is NOT a danger sign of pregnancy:*
1/1 d.Penicillin (erythromycin)
a.Round ligament pain Option 1

a.The fetus is in a cephalic presentation
b.The fetus is engaged

12.A 28-week primigravida has ankle edema by the end of
the day. Which statement by her would reveal that she
understands what causes this:* c.The best site for fetal heart tone assessment would be
at the right side of the abdomen
1/1
a.“I know this is a beginning complication; I’ll call my

doctor tonight.” d.The placenta is on the upper left portion of the uterus
b.“I understand this is from eating too much salt; I’ll

restrict than more.”
c.“I’ll rest with my legs elevated to take pressure off lower 15.Signs that are highly subjective during pregnancy
extremity veins.” include all except :*
1/1
d.“I walk for half an hour everyday to relieve this; I’ll try a.Dark pigmentation on the face and nose
walking more.”
b.Quickening
c.Striae Gravidarum
13.Which of the following statements made by an 8-week

primigravida woman would require further teaching?* d.Braxton Hick’s contractions
1/1
a.“I should eat more food rich in protein like monggo.”
b.“I should lessen my intake of fatty foods.”

16.The best time for a pregnant woman do the fetal
movement count is:*
c.“I should eat food rich in carbohydrates like cassava.”
1/1
d.“I should lessen my intake of carbohydrate rich foods.”
a.Early morning, after meals
b.Anytime during the day when the mother feels

14.The nurse does the Umbillical Grip or Leopolds comfortable
Manuever number 2. She palpated a hard, smooth and
resistant plane on the right side of the mother’s abdomen.
This implies:* c.Before bed time
d.After a 30-minute walk

1/1
b.A room across from the nurses’ station so that she can
be observed closely
17.A client has been subjected for a 3 hour glucose

tolerance test after having obtaining an above normal
result for a 50 gram screening test. 2 hours after the
ingestion of an oral glucose for 3-hourse glucose tolerance
test, the normal blood sugar level would be:* c.In a back hallway where there’s a quiet private room
d.Close to the nursery so she’ll maintain hope of a positive

1/1 outcome
a.140 mg/dl
b.150 mg/dl
20.When caring for a client with preeclampsia, which
action is a priority?*
1/1
c.180 mg/dl
a.Monitoring the client’s labor carefully and preparing for a

d.90 mg/dl fast delivery
b.Continually assessing the fetal tracing for signs of fetal

distress
18.A nurse in a prenatal clinic is assessing a 28 y/o c.Checking vital signs every 15 minutes to watch for
woman who’s 24 weeks pregnant. Which findings would increasing blood pressure
lead this nurse to suspect that the client has mild
preeclampsia?*
d.Reducing visual and auditory stimulation
1/1
a.Glycosuria, hypertension, seizure
b.Hematuria, blurry vision, reduced urine output
21. A client with severe preeclamsia is receiving

c.Burning on urination, hypotension, abdominal pain intravenous magnesium sulfate. The nurse is reviewing
the laboratory results and determines that which of the
following magnesium levels is within the therapeutic
Hypertension, edema, proteinuria range?*
0/1
a.1 mg/dl
19.Which labor room assignment would the nurse give to

a client diagnosed with gestational hypertension?*
b.15 mg/dl
1/1
c.5 mg/dl
a.Near the elevator so she can be transported quickly

d.10 mg/dl 1/1
a.Placenta previa
22.The best position for both clients with placenta previa b.Abruption placentae
and abruptio placenta would be:*
1/1
c.Ectopic pregnancy
a.Reverse trendelenburg postion to reverse possible
development shock d.Spontaneous abortion
b.Semi-fowlers to prevent accumulation of blood in the

uterine cavity
c.Knee-chest position to prevent cord prolapse 25.The nurse plans to teach the client how to do Kegel’s
exercise several times a day. The nurse should explain
that the primary purpose of these exercise is to:*
Left lateral recumbent position ensure adequate
fetoplacental perfusion
1/1
a.Prevent vulvar edema
b.Relieve lower back discomfort
23.The nurse is caring for a client with mild active bleeding

c.Strengthen the perineal muscles
from placenta previa. Which assessment factor indicates
that an emergency cesarean section may be necessary?*
1/1
d.Increasing blood supply to the uterus
a.ncreased maternal blood pressure of 150/90 mm Hg
b.Decreased amount of vaginal bleeding
26.Which of the following is considered a premonitory sign

c.Fetal heart rate of 80 beats/minute of labor:*
1/1
d.Maternal heart rate of 65 beats/minute a.Absence of Braxton Hicks’ contractions
b.Increased maternal energy
24.A 40 y/o at 37 weeks’ gestation is admitted to the

hospital with complaints of vaginal bleeding following the
use of cocaine 1 hour earlier. Which complication is most
likely causing the client’s complaint of vaginal bleeding?* c.Decreased maternal energy
d.Goodell’s sign 29. The nurse is caring for a woman in labor. The woman
is irritable, complains of nausea and vomiting and has
irresistible urge to push. The membranes rupture. The
nurse understands that this indicates:*
27.A 15-year old primigravida arrives at the birthing unit in 1/1

early labor. On admission, the client’s cervix is 2 cm
dilated and 50% effaced, and contractions are occurring
every 7 to 8 minutes, with membranes intact. After a.The woman is in transition stage of labor
admission, the nurse instructs the client that the most
effective position for dilating the cervix is*
1/1
b.The woman is having a complication and the doctor
should be notified
a.Right lateral recumbent
c.Labor is slowing down and the woman may need
b.Modified Trendelenburg position oxytocin
c.Standing d.The woman is probably pregnant
d.Sitting in a comfortable chair 30.A woman in labor shouts to the nurse, "My baby is
coming right now! I feel like I have to push!" An immediate
assessment reveals that the head of the fetus is crowning,
which intervention is most appropriate?*
28.A 20-year old obese primigravida at 40 weeks’ 0/1

gestation is admitted to the birthing center in the first stage
of labor, the client is admitted to the birthing center with
contractions lasting 60 seconds and occurring every 5 a.Gently pulling at the baby's head as it's delivered
minutes. The client’s cervix dilated 5 cm. In assessing
the client’s emotional status, the nurse anticipates that she
will be:*
0/1 b.Holding the baby's head back until the physician arrives
a.Serious c.Applying gentle pressure to the baby's head as it's

delivered
b.Argumentative
d.Placing the mother in the Trendelenburg position until
the physician arrives
c.Joyful
d.Panicky
31.A nurse has developed a plan of care for a client

experiencing dystocia and includes several interventions
in the plan of care. The nurse prioritizes the plan of care
and selects which intervention as the highest priority?*
1/1
a.Providing comfort measures d.Reversed trendelenburg position
b.Monitoring the fetal heart rate
34.Assessment of client diagnosed to have hyatidiform

mole would incude:*
c.Changing the client’s position frequently
1/1
d.Keeping the significant other informed on the progress
of the labor
a.Falling blood pressure with increased cardiac rate
b.Absence of fetal heart sounds
32.A 31-year old multigravida at 39 week’s gestation is

admitted to the hospital in active labor. While the nurse
begins the admission process, the amniotic membrane
ruptures spontaneously. The client’s cervix is 5 cm dilated
and the presenting head part is at 0 station. The nurse c.Diaphoresis
should first:*
d.Dellusions
1/1
a.Perform a vaginal examination to determine dilation

35.A 43 year old woman is scheduled for suction and
b.Administer Ritodrine hydrochloride curettage following a diagnosis of molar pregnancy. Along
with suction and curettage, the physician may perform
which of the following procedures to prevent
c.Note the color, amount, and odor of the amniotic fluid choriocarcinoma?*
1/1
d.Prepare the client for imminent delivery a.Vasectomy
b.Colpotomy
c.Tubal Ligation
33.The best position a pregnant woman assumes during
fetal movement count would be:*
d.Hysterectomy
1/1
a.Left Side-lying position
36.The bleeding in placenta previa is contrasted to that of

abruption placenta is such a way that:*
b.Supine position pillow under the neck
c.Supine position pillow under the hips 1/1

a.Bleeding in abruptio placenta is painful while bleeding in d.G-2, T-2, P-1, A-1, L-1
placenta previa is painless
39.A primigravida woman who visited the pre-natal clinic

b.Bleeding in abruptio placenta is internal while bleeding in asked you “When will I be giving birth?” To be able to
placenta previa external respond accurately, what information should you obtain
from the client?*
c.There is more blood loss in abruption placenta
1/1
d.There is more blood loss in placenta previa
a.The last time she had menses
b.When did she have sex with her husband

37.Before surgery to remove ectopic pregnancy, which of
the following would alert the nurse to the possibility of c.When did she know about her pregnancy
tubal rupture?*
d.First day of her last menstrual period

1/1
a.Amount of vaginal bleeding
b.Increased hcb and hct
c.Rapid pulse 40.During the client’s seventh month of pregnancy, she

complains of backache. The nurse teaches her to*
1/1
d.Marked abdominal edema

a.Sleep on a soft mattress
b.Walk barefoot at least once/day
38.A 34-year old post-partum woman has given birth to c.Perform Kegel exercises once/day
healthy twins three years ago. Her second pregnancy was
a molar pregnancy. What is the woman’s obstetrical
score?* d.Perform pelvic rocking exercises
1/1
a.G-1, T-2, P-0, A-1, L-2
b.G-2, T-2, P-0, A-0, L-2

41.Pyrosis and flatulence, common in the first trimester,
are most likely the result of which of the following?*
1/1
c.G-1, T-1, P-0, A-1, L-2
a.Increased levels of HCG

44.A pregnant client states that she “waddles” when she
walks. The nurse’s explanation based on which of the
following as the cause?*
b.Increased intestinal motility
1/1
c.Elevated human placental lactogen
a.The large size of the newborn

d.Elevated estrogen levels
b.Pressure on the pelvic muscles
c.Relaxation of the pelvic joints

42.An adolescent who attended a fertility awareness
seminar informed you that she had an intercourse with her
husband 3 days ago. If fertilization took place, the fertilized
ovum would probably be implanted:*
d.Excessive weight gain

0/1
a.3 days after the intercourse
45.Which of the following urinary symptoms does the

pregnant woman most frequently experience during the
first and third trimester?*
b.8 weeks after fertilization

1/1
c.8 hours after fertilization

a.Dysuria
d.A week after fertilization
b.Frequency
43.Nursing management for prolapsed umbilical cord

would include:* c.Incontinence
1/1 d.Burning
a.Push the cord gently back to the uterine cavity
b.Try to rotate the fetus by maneuvering the abdomen 46.To achieve fertilization, ovum and spermatozoa meets
at the distal third of the fallopian tube termed as:*
c.Cover the cord with sterile gauze wet with warm saline
1/1
a.Ampulla
d.Advise the mother to assume a reverse trendelenburg
position
b.Infundibulum
c.Insterstitial 1/1
d.Isthmus a.Ovum, embryo, zygote, fetus, infant
b.Zygote, ovum, embryo, fetus, infant
47.Which is NOT considered as a positive sign of c.Zygote, ovum, fetus, embryo, infant
pregnancy?*
d.Ovum, zygote, embryo, fetus, infant
1/1
a.Sonographic evidence of fetal outline
b.Fetal movement felt by the examiner
50.A multigravid client at 34 weeks’ gestation visits the

c.Audible fetal heart tone hospital because she suspects that her water has broken.
After testing the leaking fluid with nitrazine paper, the
nurse confirms that the client’s membranes have ruptured
d.Positive pregnancy test when the paper turns which of the following colors?*
1/1
a.Yellow
48.Before the start of a non stress test, The FHR is 120 b.Green
BPM. The mother ate the snack and the practitioner
noticed an increase from 120 BPM to 135 BPM for 15
seconds. How would you read the result?* c.Blue
1/1
d.Red
a.Reactive
b.Abnormal
c.Non reactive
d.Inconclusive, needs repeat
49.Explaining the development of a baby, you identified in

chronological order the growth of the fetus as it occurs in
pregnancy as:*

OB Nursing Notes

Uploaded by

Copyright:

Available Formats

OB Nursing Notes

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

OB Nursing Notes

Uploaded by

Copyright:

Available Formats

OBSTETRIC NURSING - TOPRANK

Urinary frequency Increase in blood volume, cardiac

Functional Innocent Heart Murmurs 1ST TRIMESTER: Accepting the

Total weight gain 3RD TRIMESTER:

Client Instruction Ex.

NON-STRESS TEST: ● Nurse noted Episodic fetal heart

Note: if hindi na complete - go back to the PREMONITORY/PRODROMAL SIGNS OF

Diagonal Conjugate: Determine through

1cm/hr WHO’s recommended guideline

Case: 5cm; 35 sec; q 7mins(active)

EX. 6M; 8 MINS; 35SEC

TAKING IN: internalization

We don't perform routine episiotomy

BREASTFEEDING: MENSES WILL

Fetal occiput posterior (OP) position is a

Type of Abortion: Note: Cervix is not a part of uterus

Cause: Nursing Management

When Labor can be halted

When Labor cannot be halted

Proteinuria: +1 and +2 ECLAMPSIA

Type 1 Destruction of the beta Maternal Neonatal

4 T’s of Postpartum Hemorrhage

Causes/Case: uterine rupture

Cases/Cause: Vaginal Hematoma ● May not be detected until

Cases/Cause: Uterine Inversion

1. Which of the following findings in Erika’s a. Unsuccessful artificial insemination procedure

a. Rh -, coombs + d. Head injury from a car accident

c. Rh +, Coombs – ● Cases we give RHOGAM - abruptio,

b. It is used to determine presence of fetal blood 1/1

c. It is used to assess whether the mother is Rh – or a. Diet

1/1 7. Mary Hadal Lamb came for prenatal check-up.

b. “My insulin dose will likely need to be increased

d. She experiences headache, fatigue, and ankle

6. Nurse Filipinas is in the OB clinic reviewing the

c. Periods of fetal movement followed by quiet

10. Nurse Goldilocks instructs Mary Hadal Lilamb to

a. Urine output of 15 ml/hour Abortion is a medical term for any interruption of a

d. Epigastric pain- aura, liver problem, HELLP

b. second most frequent cause of bleeding early in

a. Apresoline c. in vitro fertilization can cause ectopic pregnancies

b. Kalcinate d. 1oral contraceptives increases incidence of

a. Nurses should use the word “habitual abortion”

b. 3 miscarriages (induced and a.I, II, III

c. occurs in about 1% and can be caused by

d. caused by incompetent cervical os d. I, II, III and VI

15.Emergency nursing interventions FOR Situation 6

a. I,II and IV 1/1

b. I, II, III and IV A. Precipitous Labor1 <3 hrs

d. II, and V onl C. Shoulder Dystocia - anterior shoulder and was

D. Rubin’s Maneuver A. Retained placenta

19. HELPERR mnemonic is developed by ACOG to B. Uterine atony

22. The nurse educator Adalynn reviewed the risk

4 of 5 points D. Retroversion of the uterus

Nurse Zara is caring for a postpartum patient.

20. Which assessment finding would lead the nurse

A. More than 300 ml/1 hou 1/1

C. More than 500 ml/1 hour B. Prevents postpartum hemorrhage

D. More than 500 ml/ 24 hours C. Decreases uterine contractions.

B. breastfeed every 2- 3 hours

27. Considering her level of knowledge and the