Maternal and Child Nursing

Dr. Yanga’s Colleges, Inc.

Wakas, Bocaue, Bulacan

College of Health Sciences

REGIE P. DE JESUS, PhDNS

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Situation: Tanya, a 6 year old child is rushed to the ER due to

cyanosis after playing with her older sister. She is known to have
Tetralogy of Fallot since birth.
1. Three of the following are congenital defects associated
with tetralogy of Fallot. Which is not included?
a. Deviation of the aorta
b. Stenosis of the mitral valve
c. Stenosis of the pulmonary artery
d. Intraventricular septal defect

2. Upon seeing the nurse, Tanya starts to cry, turns blue and
her RR increases to 50. The nurse should immediately.
a. Administer oxygen inhalation
b. Leave the room and ask for help
c. Transfer her to the intensive care unit
d. Place the child in knee chest position

Situation: Rosario consults her obstetrician due to amenorrhea for

one month.
3. Which of the following hormones serves as the basis for
the positive pregnancy test?
a. Progesterone
b. HCG
c. FSH
d. Estrogen

4. On one of her clinic visits, Rosario told you that she wants
to return to her vegetarian diet. You told her to do it after
pregnancy as vegetarianism can lead to a deficiency in:
a. Vitamin A
b. Vitamin B12
c. Iron deficiency anemia
d. Folic acid deficiency anemia

5. When advised against a vegetarian diet, Rosario said she

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would just simply triple her Vitamin B12 supplementation.

You tell Jane that excessive ingestion of Vitamin B12 can
result in a deficiency of:
a. Vitamin A
b. Vitamin B6
c. Folic acid
d. Vitamin C

6. Which of the following statements about the changes in

the blood of pregnant women like Rosario is incorrect?
a. Physiologic anemia is expected and normal
b. The rise in plasma volume precedes the increase in
RBC
c. Normally the WBC is decreased during pregnancy
d. Pregnant woman’s blood is hypercoagulable

7. You advised Rosario to avoid smoking during pregnancy as

babies of mothers who smoke tend to be
a. smaller in size and lighter in weight
b. have heart disease
c. have lower blood count
d. have more birth defects

8. During her subsequent visits, Rosario receives her third

dose of TT. She asks you what type of immunity and how
long will she be protected by it. Your response is:
a. It provides active natural immunity and she will be
protected for 5 years.
b. It provides active artificial immunity and she will be
protected for 5 years.
c. It provides passive natural immunity and she will be
protected for 5 years.
d. It provides passive artificial immunity and she will be
protected for 5 years.

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9. Rosario asked you how big her baby is now. The rough
estimate of fetal length in centimeters from crown to heel
during the eight month can be obtained by:
a. square number of lunar months
b. number of lunar months multiplied by five
c. number of weeks of menstrual age
d. number of days multiplied by two

10. A woman whose obstetrical score is 4-1-0-3 has how many

surviving children?
a. 4
b. 3
c. 0
d. 1

Situation: Vicky, 28 years old, is admitted to the high risk

obstetrical unit due to passage of fluid at 20 weeks gestation. This
is her third pregnancy that terminated in abortion.
11. Which of the following is a characteristic of incompetent
cervix?
a. expulsion of immature fetus
b. all of these
c. painless cervical dilatation in the second and early
third trimester
d. rupture of membranes

12. A gravido-cardiac mother is advised to observe bedrest

primarily to
a. Allow the fetus to achieve normal intrauterine
growth
b. Minimize oxygen consumption which can aggravate
the condition of the compromised heart of the
mother
c. Prevent perinatal infection

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d. Reduce incidence of premature labor

Situation: Connie, 34 years old and 24 weeks pregnant, is admitted

for evacuation of hydatidiform mole.
13. Which of the following signs and symptoms will you not
consider in H-mole?
a. Vaginal bleeding
b. Excessive vomiting
c. FHT at 80BPM
d. Hypertension

14. The most dangerous complication of h-mole is:

a. Placental site trophoblastic tumor
b. Invasive mole
c. Choriocarcinoma
d. Endometrial cancer

15. You provide information to Connie about treatment of H-

mole. Which statement from Connie necessitates
additional teaching?
a. I will undergo D and C to ensure that all grapelike
vesicles are removed from my uterus
b. I will take contraceptive pills so that I will not get
pregnant for at least a year
c. I will take methotrexate for at least one year to
prevent regrowth
d. I will return to the clinic regularly to have my HCG
monitored

16. Connie asked you why is it that her elder sister who is 43
years old underwent hysterectomy and not D and C when
she had H-mole. Your response is:
a. Women over 40 years old have higher incidence of
choriocarcinoma

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b. More damage is sustained by the endometrium in

women above 40 years old
c. They have a higher risk of uterine perforation with D
and C
d. Maybe her sister does not want to get pregnant
anymore

Situation: Kining, 27 years old, is 6 moths pregnant but on

measurement of her fundic height; it is already size of 8 months
gestation. Ultrasound shows she has hydramnios.
17. Kining asked what would have caused her condition. Your
reply will be based on the following conditions except:
a. Twin pregnancy
b. Diabetes mellitus
c. Fetal esophageal atresia
d. Renal agenesis

18. In contrast to polyhydramnios, oligohydramnios is a

condition where amniotic fluid is
a. Less than 300 ml
b. Between 500 to 1000 ml
c. More than 1500 ml
d. More than 3000 ml

Situation: Miss Mary Jane Fernandez is having twin pregnancy.

19. Which of the following classification applies to
monozygotic twins in which the cleavage of the fertilized
ovum occurs more than 13 days after fertilization?
a. Conjoined twins
b. Diamniotic dichorionic twins
c. Diamniotic monochorionic twins
d. Monoamniotic monochorionic twins

20. Which of the following is a complication associated with

multifetal pregnancy?
a. Increased perinatal mortality

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b. All of these
c. Placental accidents
d. Cord accidents

Situation: Vanessa came to the clinic for check-up. She missed her
period about 2 weeks already and she complains of excessive
vomiting.
21. Vanessa asked the midwife why she is having excessive
nausea and vomiting. Your answer would include which of
the following?
a. H-mole
b. Increase HCG level
c. Increase estrogen level
d. Psychogenic factor

22. Nausea and vomiting is the most common complaint of

pregnancy. If it becomes sever it is diagnosed as:
a. Hyperemesis gravidarum
b. Pica
c. Ptyalism
d. Pseudocyesis

23. Because of the excessive vomiting, Vanessa was

hospitalized. The physician ordered 1000 ml of Ringer’s
lactate intravenously over an 8-hours period. The midwife
would administer the intravenous infusion at which of the
following rates?
a. 60 ml per hour
b. 125 ml per hour
c. 100 ml per hour
d. 150 ml per hour

24. Which among the following is not included in the care of

women with Vanessa’s condition?
a. When introducing oral foods, clear fluids must be
given first
b. Vanessa should be placed on NPO initially

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c. Intravenous fluids are given to correct dehydration

d. Oral feedings should not be withheld at anytime but
given in small amount

Situation: Xan, 20 years old, 34 weeks gestation is rushed to the

emergency room because of strong uterine contractions and
passage of fluid per vagina.
25. The midwife knows that Xan is having premature labor if
she experience all of the following except:
a. Uterine contractions lasting 30 seconds
b. Cervical dilation 4 cm
c. Rupture of BOW
d. Gestational age 19 weeks

Situation: Angie is a 4 year old child with cystic fibrosis. She has
been in and out of the hospital since infancy.
26. Which condition/observation is not associated with cystic
fibrosis?
a. Mother complains that the child’s skin tastes salty
when she kisses him.
b. The child had meconium ileus during infancy.
c. Rectal prolapse
d. Excessive weight gain

27. During hot weather, the nurse instruct the mother to:
a. Add a little salt on the child’s food
b. Bathe the child at least three times a day to combat
heat
c. Call the physician for special medication to prevent
excessive perspiration.
d. Limit fluid intake to prevent edema and
overhydration.

28. When pancrealipase (Pancrease) is part of the treatment

plan, which of the following responses in a child indicates
that the medication has been effective?
a. Increase in appetite

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b. Weight gain
c. Thinning of respiratory secretions
d. Absent lung sound

Situation: Felicity, an 18 year old student visits the health center

due to amenorrhea for 3 months.
29. Upon interview, the nurse estimated the gestational age of
Felicity to be at 11-12 weeks. She claims that she
experience nausea and vomiting every morning. She
appears to be pale and has lost 2 lb since a month ago.
Which of the following nursing diagnoses is a priority?
a. Ineffective individual coping related to lack of
support system
b. Fear related to physiologic changes in pregnancy
c. Anxiety related to outcome of pregnancy
d. Altered nutrition, less than body requirements
related to physiologic changes in pregnancy.

30. Felicity asks, when will she be able to feel the movement of
her baby. How many months AOG will be the response of
the nurse?
a. 2
b. 3
c. 4
d. 5

31. The nurse instructs her to observe the occurrence of

normal physiologic change in pregnancy which include?
a. Increased blood pressure
b. Palpitations
c. Anemia
d. Blurring of visions

32. Felicity is now on fifth month of pregnancy. She should be

advised to visit the health center for prenatal check up
every:
a. Once a week

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b. Twice a month
c. Once a month
d. Every 2 months

Situation: Tinay, a 19 year old primigravida has gained a total of

20 pounds since her last clinic visit. Upon, examination, the nurse
has obtained the following findings: blood pressure at 130/90,
proteinuria +2, puffiness of the face and lower extremity edema.
33. After knowing that the findings about her are not within
normal range, Tinay worried about her baby. As a nurse,
you are aware that the following complications are
possible except:
a. Intrauterine growth retardation
b. Myelomeningocele
c. Abruptio placenta
d. Prematurity

34. The nurse referred Tinay to the doctor who ordered

hospitalization for further evaluation and treatment. The
most important intervention for Tiany would be:
a. Keep her on bedrest at sidelying position
b. Monitor her BP
c. Take her I and O every hour
d. Administer antihypertensive medications

35. Upon admission, Tinay’s BP was monitored and it

continues and it continues to increase. The physician
orders intravenous magnesium sulfate. Which of the
following medications would the nurse has readily
available at the patient’s bedside?
a. Diazepam (Valium)
b. Calcium gluconate
c. Hydralazine (apresoline)
d. Phenytoin (Dilantin)

36. Which of the following should prompt the nurse to refer to

the obstetrician prior to drug administration?

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a. BP = 180 / 100
b. Urine output is 35 ml/hr
c. RR = 11 heaths for minute
d. (+) Deep tendon reflex

37. In Leopold’s maneuver step # 3 you palpated a hard round

movable mass at the supra pubic area. The correct
interpretation is that the mass palpated is:
a. The buttocks because the presentation is breech.
b. The mass palpated is the head.
c. The mass is the fetal back.
d. The mass palpated is the fetal small part.

38. To determine fetal wellbeing, the physician orders oxytocin

challenge test (OCT) to be conducted on Tinay. Which of
the following will not prompt you to defer the doctor’s
order for IV oxytocin?
a. Abnormal FHT
b. History of threatened preterm labor at 28 weeks
c. Previous classical CS
d. Previous multiple pregnancy

39. Pregnancy induced hypertension (PIH) that is characterized

by edema, proteinuria and convulsions is known as:
a. Eclampsia
b. Preeclampsia
c. Chronic hypertension
d. Gestational hypertension

Situation: Mica, 3 months old, had cleft lip on the left side of the
mouth. She is scheduled for surgical correction of the defect.
40. Because Mica cannot suck properly, the nurse instructed
the mother to do the following when feeding Mica except:
a. Feed Mica in upright position.
b. Not to breastfeed Mica but use a rubber tipped
syringe to drip formula on the child’s mouth.
c. Use large holed nipple when bottle feeding Mica

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d. Burp Mica frequently during feeding

41. All of the following nursing interventions are included in

the care plan for Mica who has just undergone cleft lip
repair. Which of the following actions by the mother
should not be allowed by the nurse:
a. Offer a pacifier when the infant is fussing
b. Avoid placing the infant in the prone position
c. Clean the suture line after feeding the infant
d. Apply elbow restraints when the infant is unattended

42. Mica had cheiloplasty. Post-operative care for Mica would

include:
a. Place Mica in semi-fowlers in left side lying position
after surgery to prevent saliva aspiration and
facilitate breathing.
b. Use a soft rubber straw to feed Mica so she can just
sip the milk.
c. Do not remove the crust at the suture line as it will
cause improper healing.
d. Do not let the infant cry. Hold and cuddle Mica
frequently.

Situation: Annabelle, an 18-yea-old primigravida patient at 39-40

weeks gestation is admitted to the hospital in active labor. Her
cervical dilatation is 7 cm, 90% effaced, station 0, intact BOW.
43. Soon after Annabelle is admitted, she had a bloody mucoid
vaginal discharge. Which of the following is the best action
of the nurse?
a. Call the obstetrician
b. Perform IE to determine the cervical dilatation
c. Prepare for a double set-up procedure
d. Check if there is a rupture of the bag of water

44. After several minutes of doing the pant-blow breathing,

Isabelle complained of tingling sensation in her fingers. The
nurse should:

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a. Refer the patient to the obstetrician

b. Let Isabel breathe in a paper bag
c. Administer oxygen
d. Stop the IV infusion

45. Her cervical dilatation is now 10cm, 100% effaced and

station +1. The BOW ruptured spontaneously with clear
amniotic fluid. Which of the following actions of the nurse
is a priority?
a. Check the FHT
b. Start an intravenous fluid line
c. Notify the obstetrician
d. Transfer Annabelle to the delivery table

46. Which of the following is the nurse’s initial action when

umbilical cord prolapse occurs?
a. monitor maternal vital signs
b. place the client in a knee – chest position in bed
c. notify the physician and prepare client for delivery
d. apply a sterile warm saline dressing to the exposed
cord

47. Despite the episiotomy. Anabel sustained a third degree

laceration. This means that the damage to the tissue
reached the:
a. Fourchette
b. Anal sphincter
c. Rectum
d. Perineum

Situation: A newborn has been diagnosed with esophageal

atresia.
48. The mother asks the nurse why he baby vomits whenever
she feeds him. The nurse appropriate response is that
esophageal atresia is a condition in which:
a. Esophagus ends in a blind pouch and it is not
continuous with the stomach.

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b. Open connection between trachea and esophagus

c. Esophagus ends in blind pouch; stomach end of
esophagus connects with trachea
d. The esophagus is very narrow it has difficulty allowing
passage of milk to the stomach.

49. Which finding will not be expected in the newborn:

a. Excessive drooling
b. Vomiting during feeding
c. Intermittent cyanosis
d. Distended abdomen

50. The most important nursing care during the preoperative

period is:
a. Never feed the child.
b. Keep the child flat on bed.
c. Administer IV fluids.
d. Give oxygen by mask

Situation: Mel, a primigravida is brought to the lying in center.

Upon assessment, you obtained the following IE findings. Cervical
dilation 5cm, fully effaced, +1 AOG, 39-40 weeks.
51. The nurse checks the perineum of Mel. Which of the
following characteristics of the amniotic fluid would cause
alarm to the midwife?
a. Greenish
b. Scantly
c. Colorless
d. Blood-tinged

52. You observed Mel to be bearing down every uterine

contraction. You told her not to do so and taught her how
to perform breathing exercises. She asked you when will
she start to push. Your reply is when she has entered the
second stage. The second stage begins with:
a. Presenting part is at station +1
b. Cervix is 10 cm dilated

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c. Uterine contractions occur every 2-3 min. interval

d. Cervix is fully effaced

53. The nurse assessed the FHT and noted it to be 114 beats
per minute. Which of the following actions of the nurse
should be done FIRST?
a. Monitor FHT every 15 minutes
b. Administer oxygen inhalation
c. Ask the charge nurse to notify the obstetrician
d. Place Mel on left lateral position

54. Mel asks the nurse “Why do I have to be on complete bed

rest? I am not comfortable in this position.” Which of the
following response of the nurse is MOST appropriate?
a. “Keeping you on the bed rest will prevent possible
cord prolapse”
b. “Completed bed rest will prevent more amniotic fluid
to escape”
c. “You need to save your energy so you will be strong
enough to push later”
d. “Let us ask your obstetrician when she willcome to
check on you”

55. The nurse performed a nitrazine paper test to determine if

membranes have already ruptured. Which would make the
test result inaccurate?
a. Contamination of specimen by cervical mucus
b. Presence of vaginal infection
c. Specimen has mixed with bloody show
d. Prolonged labor

56. The meaning of station 1 is:

a. The level of ischial spines
b. 1 cm above level of ischial spines
c. 1 cm below level of ischial spines
d. 1 cm above pelvic inlet

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57. In determining the frequency of uterine contractions, the

nurse should measure the time from the:
a. Beginning of one contraction to the beginning of the
next
b. Acme of one contraction to the beginning of the next
c. Beginning to the completion of one contraction
d. Completion of one contraction to the beginning of
the next

58. Mel may be taken to the DR when the:

a. Bag of water ruptures
b. Cervical effacement occurs
c. Cervix is fully dilated at 10 cm
d. Transition phase occurs

59. As a crowning begin, the nurse should:

a. Encourage Mel to take prolonged deep breaths
b. Apply gentle perineal pressure
c. Instruct her to push down vigorously
d. Press lightly on the fundus

60. When the fetal head is delivered, the nurse should:

a. Prepare to clamp the cord
b. Use bulb syringe to clear the mouth and nose of
secretions
c. Apply abdominal pressure
d. Apply Ritgen’s maneuver

61. As soon as the placenta is delivered, the nurse inspects for

completeness of cotyledons and takes note of the time of
placental delivery which is:
a. Immediately after the baby cries
b. As soon as the mother feels like bearing down once
more
c. One hour after the baby’s delivery
d. Twenty minutes after the delivery of the baby

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62. The nurse is aware that the trend nowadays in delivering

normal babies is to encourage placental blood flow to the
baby by:
a. Milking the cord towards the placenta
b. Clamping and cutting the cord immediately after
delivery
c. Waiting for pulsations of the cord to stop before
clamping and cutting the cord
d. Milking the cord towards the baby

63. Which of the following should the nurse plan to do to

facilitate placental expulsion?
a. Instruct the mother to vigorously bear down
b. Have the mother breastfeed the baby
c. Gentle continuous tension on the cord
d. Push down slowly on the fundus

64. After placental delivery, oxytocin is administered to the

mother to promote uterine contractions. Bolus
administration should be avoided because it can result in
a. Bradycardia
b. Hypotension
c. Oliguria
d. Hypertension

65. The following are danger signs of labor:

1. Fetal hyperactivity during labor
2. Fetal heart rate of 150 beats/min.
3. Maternal blood pressure of 160/90 mmHg
4. uterine contraction lasting for 60 seconds
a. 2 and 3
b. 2 and 4
c. 4
d. 1, 2 and 3

66. A 31 week preterm labor client dilated to 4 cm has been

started on MgSo4 and contractions have stopped. If the

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client’s labor can be inhibited for the next 48 hours, what

medication does the nurse anticipate will be prescribed?
a. Nubain
b. Cytotec
c. Betamethasone
d. RhoGAM

67. A nurse is providing instructions to a pregnant client who is

scheduled for amniocentesis. The nurse tells the client
that:
a. Strict bed rest is required following the procedure
b. An informed consent will need to be signed before
the procedure
c. Hospitalization is necessary for 24 hours after the
procedure
d. A fever is expected following the procedure because
of the trauma to the abdomen

68. A nurse in delivery room is assisting with the delivery of a

newborn infant. After the delivery of the newborn, the
nurse assists in delivering the placenta. Which observation
would indicate that the placenta has separated from the
uterine wall and is ready for delivery?
a. The umbilical cord shortens in length and changes in
color
b. A soft and boggy uterus
c. Maternal complaints of severe and uterine cramping
d. Changes in the shape of uterus

69. Mrs. Granger is scheduled for caesarean section with

reference to spinal anesthesia. While signing the consent
forms, she asks the nurse about the possible post-
anesthetic headaches. The nurse’s appropriate response is:
a. “Headaches rarely occur and are usually mild.”
b. “If there is an allergy to the agent used, headaches
may occur.”
c. “Medication is given to counteract headaches.”

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d. “This problem may be prevented by keeping the bed

flat.”

70. A primigravida client at 25 weeks’ gestation visits the clinic

and tells the nurse that her lower back aches when she
arrives home from work. The nurse should suggest that the
client perform:
a. Tailor sitting
b. Leg lifting
c. Shoulder circling
d. Squatting exercises

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