Answers and Rationale –Test II Community Health Nursing and Care of the Mother and Child part 1

Answers and Rationale –Test II Community Health

Nursing and Care of the Mother and Child part 1

1. Answer: (A) Inevitable

Rationale: An inevitable abortion is termination

of pregnancy that cannot be prevented.

Moderate to severe bleeding with mild

cramping and cervical dilation would be noted

in this type of abortion.

2. Answer: (B) History of syphilis

Rationale: Maternal infections such as syphilis,

toxoplasmosis, and rubella are causes of

spontaneous abortion.

3. Answer: (C) Monitoring apical pulse

Rationale: Nursing care for the client with a

possible ectopic pregnancy is focused on

preventing or identifying hypovolemic shock

and controlling pain. An elevated pulse rate is

an indicator of shock.

4. Answer: (B) Increased caloric intake

Rationale: Glucose crosses the placenta, but

insulin does not. High fetal demands for

glucose, combined with the insulin resistance

caused by hormonal changes in the last half of

pregnancy can result in elevation of maternal

blood glucose levels. This increases the

mother’s demand for insulin and is referred to

as the diabetogenic effect of pregnancy.

5. Answer: (A) Excessive fetal activity.

Rationale: The most common signs and

symptoms of hydatidiform mole includes

elevated levels of human chorionic

gonadotropin, vaginal bleeding, larger than

normal uterus for gestational age, failure to

detect fetal heart activity even with sensitive

instruments, excessive nausea and vomiting,

and early development of pregnancy-induced

hypertension. Fetal activity would not be noted.

6. Answer: (B) Absent patellar reflexes

Rationale: Absence of patellar reflexes is an

indicator of hypermagnesemia, which requires

administration of calcium gluconate.

7. Answer: (C) Presenting part in 2 cm below the

plane of the ischial spines.

Rationale: Fetus at station plus two indicates

that the presenting part is 2 cm below the

plane of the ischial spines.

8. Answer: (A) Contractions every 1 ½ minutes

lasting 70-80 seconds.

Rationale: Contractions every 1 ½ minutes

lasting 70-80 seconds, is indicative of

hyperstimulation of the uterus, which could

result in injury to the mother and the fetus if

Pitocin is not discontinued.

9. Answer: (C) EKG tracings

Rationale: A potential side effect of calcium

gluconate administration is cardiac arrest.

Continuous monitoring of cardiac activity (EKG)

throught administration of calcium gluconate is

an essential part of care.

10. Answer: (D) First low transverse caesarean was

for breech position. Fetus in this pregnancy is in

a vertex presentation.

Rationale: This type of client has no obstetrical

indication for a caesarean section as she did

with her first caesarean delivery.

11. Answer: (A) Talk to the mother first and then to

the toddler.

Rationale: When dealing with a crying toddler,

the best approach is to talk to the mother and

ignore the toddler first. This approach helps the

toddler get used to the nurse before she

attempts any procedures. It also gives the

toddler an opportunity to see that the mother

trusts the nurse.

12. Answer: (D) Place the infant’s arms in soft

elbow restraints.

Rationale: Soft restraints from the upper arm to

the wrist prevent the infant from touching her

lip but allow him to hold a favorite item such as

a blanket. Because they could damage the

operative site, such as objects as pacifiers,

suction catheters, and small spoons shouldn’t

be placed in a baby’s mouth after cleft repair. A

baby in a prone position may rub her face on

the sheets and traumatize the operative site.

The suture line should be cleaned gently to

prevent infection, which could interfere with

healing and damage the cosmetic appearance

of the repair.

13. Answer: (B) Allow the infant to rest before

feeding.

Rationale: Because feeding requires so much

energy, an infant with heart failure should rest

before feeding.

14. Answer: (C) Iron-rich formula only.

Rationale: The infants at age 5 months should

receive iron-rich formula and that they

shouldn’t receive solid food, even baby food

until age 6 months.

15. Answer: (D) 10 months

Rationale: A 10 month old infant can sit alone

and understands object permanence, so he

would look for the hidden toy. At age 4 to 6

85

months, infants can’t sit securely alone. At age

8 months, infants can sit securely alone but

cannot understand the permanence of objects.

16. Answer: (D) Public health nursing focuses on

preventive, not curative, services.

Rationale: The catchments area in PHN consists

of a residential community, many of whom are

well individuals who have greater need for

preventive rather than curative services.

17. Answer: (B) Efficiency

Rationale: Efficiency is determining whether the

goals were attained at the least possible cost.

18. Answer: (D) Rural Health Unit

Rationale: R.A. 7160 devolved basic health

services to local government units (LGU’s ). The

public health nurse is an employee of the LGU.

19. Answer: (A) Mayor

Rationale: The local executive serves as the

chairman of the Municipal Health Board.

20. Answer: (A) 1

Rationale: Each rural health midwife is given a

population assignment of about 5,000.

21. Answer: (B) Health education and community

organizing are necessary in providing

community health services. Rationale: The

community health nurse develops the health

capability of people through health education

and community organizing activities.

22. Answer: (B) Measles

Rationale: Presidential Proclamation No. 4 is on

the Ligtas Tigdas Program.               

23. Answer: (D) Core group formation

Rationale: In core group formation, the nurse is

able to transfer the technology of community

organizing to the potential or informal

community leaders through a training program.

24. Answer: (D) To maximize the community’s

resources in dealing with health problems.

Rationale: Community organizing is a

developmental service, with the goal of

developing the people’s self-reliance in dealing

with community health problems. A, B and C

are objectives of contributory objectives to this

goal.

25. Answer: (D) Terminal

Rationale: Tertiary prevention involves

rehabilitation, prevention of permanent

disability and disability limitations appropriate

for convalescents, the disabled, complicated

cases and the terminally ill (those in the

terminal stage of a disease).

26. Answer: (A) Intrauterine fetal death.

Rationale: Intrauterine fetal death, abruptio

placentae, septic shock, and amniotic fluid

embolism may trigger normal clotting

mechanisms; if clotting factors are depleted,

DIC may occur. Placenta accreta, dysfunctional

labor, and premature rupture of the

membranes aren't associated with DIC.

27. Answer: (C) 120 to 160 beats/minute

Rationale: A rate of 120 to 160 beats/minute in

the fetal heart appropriate for filling the heart

with blood and pumping it out to the system.

28. Answer: (A) Change the diaper more often.

Rationale: Decreasing the amount of time the

skin comes contact with wet soiled diapers will

help heal the irritation.

29. Answer: (D) Endocardial cushion defect

Rationale: Endocardial cushion defects are seen

most in children with Down syndrome,

asplenia, or polysplenia.

30. Answer: (B) Decreased urine output

Rationale: Decreased urine output may occur in

clients receiving I.V. magnesium and should be

monitored closely to keep urine output at

greater than 30 ml/hour, because magnesium is

excreted through the kidneys and can easily

accumulate to toxic levels.

31. Answer: (A) Menorrhagia

Rationale: Menorrhagia is an excessive

menstrual period.

32. Answer: (C) Blood typing

Rationale: Blood type would be a critical value

to have because the risk of blood loss is always

a potential complication during the labor and

delivery process. Approximately 40% of a

woman’s cardiac output is delivered to the

uterus, therefore, blood loss can occur quite

rapidly in the event of uncontrolled bleeding.

33. Answer: (D) Physiologic anemia

Rationale: Hemoglobin values and hematocrit

decrease during pregnancy as the increase in

plasma volume exceeds the increase in red

blood cell production.

34. Answer: (D) A 2 year old infant with stridorous

breath sounds, sitting up in his mother’s arms

and drooling.

Rationale: The infant with the airway

emergency should be treated first, because of

the risk of epiglottitis.

35. Answer: (A) Placenta previa

Rationale: Placenta previa with painless vaginal

bleeding.

36. Answer: (D) Early in the morning

Rationale: Based on the nurse’s knowledge of

microbiology, the specimen should be collected

early in the morning. The rationale for this

timing is that, because the female worm lays

eggs at night around the perineal area, the first

bowel movement of the day will yield the best

results. The specific type of stool specimen

used in the diagnosis of pinworms is called the

tape test.

37. Answer: (A) Irritability and seizures

Rationale: Lead poisoning primarily affects the

CNS, causing increased intracranial pressure.

This condition results in irritability and changes

in level of consciousness, as well as seizure

disorders, hyperactivity, and learning

disabilities.

38. Answer: (D) “I really need to use the diaphragm

and jelly most during the middle of my

menstrual cycle”.

Rationale: The woman must understand that,

although the “fertile” period is approximately

mid-cycle, hormonal variations do occur and

can result in early or late ovulation. To be

effective, the diaphragm should be inserted

before every intercourse.

39. Answer: (C) Restlessness

Rationale: In a child, restlessness is the earliest

sign of hypoxia. Late signs of hypoxia in a child

are associated with a change in color, such as

pallor or cyanosis.

40. Answer: (B) Walk one step ahead, with the

child’s hand on the nurse’s elbow.

Rationale: This procedure is generally

recommended to follow in guiding a person

who is blind.

41. Answer: (A) Loud, machinery-like murmur.

Rationale: A loud, machinery-like murmur is a

characteristic finding associated with patent

ductus arteriosus.

42. Answer: (C) More oxygen, and the newborn’s

metabolic rate increases.

Rationale: When cold, the infant requires more

oxygen and there is an increase in metabolic

rate. Non-shievering thermogenesis is a

complex process that increases the metabolic

rate and rate of oxygen consumption,

therefore, the newborn increase heat

production.

43. Answer: (D) Voided

Rationale: Before administering potassium I.V.

to any client, the nurse must first check that the

client’s kidneys are functioning and that the

client is voiding. If the client is not voiding, the

nurse should withhold the potassium and notify

the physician.

44. Answer: (c) Laundry detergent

Rationale: Eczema or dermatitis is an allergic

skin reaction caused by an offending allergen.

The topical allergen that is the most common

causative factor is laundry detergent.

45. Answer: (A) 6 inches

Rationale: This distance allows for easy flow of

the formula by gravity, but the flow will be slow

enough not to overload the stomach too

rapidly.

46. Answer: (A) The older one gets, the more

susceptible he becomes to the complications of

chicken pox.

Rationale: Chicken pox is usually more severe in

adults than in children. Complications, such as

pneumonia, are higher in incidence in adults.

47. Answer: (D) Consult a physician who may give

them rubella immunoglobulin.

Rationale: Rubella vaccine is made up of

attenuated German measles viruses. This is

contraindicated in pregnancy. Immune globulin,

a specific prophylactic against German measles,

may be given to pregnant women.

48. Answer: (A) Contact tracing

Rationale: Contact tracing is the most practical

and reliable method of finding possible sources

of person-to-person transmitted infections,

such as sexually transmitted diseases.

49. Answer: (D) Leptospirosis

Rationale: Leptospirosis is transmitted through

contact with the skin or mucous membrane

with water or moist soil contaminated with

urine of infected animals, like rats.

50. Answer: (B) Cholera

Rationale: Passage of profuse watery stools is

the major symptom of cholera. Both amebic

and bacillary dysentery are characterized by the

presence of blood and/or mucus in the stools.

Giardiasis is characterized by fat malabsorption

and, therefore, steatorrhea.