Answers and Rationale –Test II Community Health Nursing and Care of the Mother and Child part 2

Answers and Rationale –Test II Community Health

Nursing and Care of the Mother and Child part 2

51. Answer: (A) Hemophilus influenzae

Rationale: Hemophilus meningitis is unusual

over the age of 5 years. In developing countries,

the peak incidence is in children less than 6

months of age. Morbillivirus is the etiology of

measles. Streptococcus pneumonia and

Neisseria meningitidis may cause meningitis,

but age distribution is not specific in young

children.

52. Answer: (B) Buccal mucosa

Rationale: Koplik’s spot may be seen on the

mucosa of the mouth or the throat.

53. Answer: (A) 3 seconds

Rationale: Adequate blood supply to the area

allows the return of the color of the nailbed

within 3 seconds.

54. Answer: (B) Severe dehydration

Rationale: The order of priority in the

management of severe dehydration is as

follows: intravenous fluid therapy, referral to a

facility where IV fluids can be initiated within 30

minutes, Oresol or nasogastric tube. When the

foregoing measures are not possible or

effective, then urgent referral to the hospital is

done.

55. Answer: (A) 45 infants

Rationale: To estimate the number of infants,

multiply total population by 3%.

56. Answer: (A) DPT

Rationale: DPT is sensitive to freezing. The

appropriate storage temperature of DPT is 2 to

8° C only. OPV and measles vaccine are highly

sensitive to heat and require freezing. MMR is

not an immunization in the Expanded Program

on Immunization.

57. Answer: (C) Proper use of sanitary toilets

Rationale: The ova of the parasite get out of the

human body together with feces. Cutting the

cycle at this stage is the most effective way of

preventing the spread of the disease to

susceptible hosts.

58. Answer: (D) 5 skin lesions, positive slit skin smear

Rationale: A multibacillary leprosy case is one

who has a positive slit skin smear and at least 5

skin lesions.

59. Answer: (C) Thickened painful nerves

Rationale: The lesion of leprosy is not macular.

It is characterized by a change in skin color

(either reddish or whitish) and loss of sensation,

sweating and hair growth over the lesion.

Inability to close the eyelids (lagophthalmos)

and sinking of the nosebridge are late

symptoms.

60. Answer: (B) Ask where the family resides.

Rationale: Because malaria is endemic, the first

question to determine malaria risk is where the

client’s family resides. If the area of residence is

not a known endemic area, ask if the child had

traveled within the past 6 months, where she

was brought and whether she stayed overnight

in that area.

61. Answer: (A) Inability to drink

Rationale: A sick child aged 2 months to 5 years

must be referred urgently to a hospital if

he/she has one or more of the following signs:

not able to feed or drink, vomits everything,

convulsions, abnormally sleepy or difficult to

awaken.

62. Answer: (A) Refer the child urgently to a

hospital for confinement.

Rationale: “Baggy pants” is a sign of severe

marasmus. The best management is urgent

referral to a hospital.

63. Answer: (D) Let the child rest for 10 minutes

then continue giving Oresol more slowly.

Rationale: If the child vomits persistently, that

is, he vomits everything that he takes in, he has

to be referred urgently to a hospital. Otherwise,

vomiting is managed by letting the child rest for

10 minutes and then continuing with Oresol

administration. Teach the mother to give Oresol

more slowly.

64. Answer: (B) Some dehydration

Rationale: Using the assessment guidelines of

IMCI, a child (2 months to 5 years old) with

diarrhea is classified as having SOME

DEHYDRATION if he shows 2 or more of the

following signs: restless or irritable, sunken

eyes, the skin goes back slow after a skin pinch.

65. Answer: (C) Normal

Rationale: In IMCI, a respiratory rate of

50/minute or more is fast breathing for an

infant aged 2 to 12 months.

66. Answer: (A) 1 year

Rationale: The baby will have passive natural

immunity by placental transfer of antibodies.

The mother will have active artificial immunity

lasting for about 10 years. 5 doses will give the

mother lifetime protection.

67. Answer: (B) 4 hours

Rationale: While the unused portion of other

biologicals in EPI may be given until the end of

the day, only BCG is discarded 4 hours after

reconstitution. This is why BCG immunization is

scheduled only in the morning.

68. Answer: (B) 6 months

Rationale: After 6 months, the baby’s nutrient

needs, especially the baby’s iron requirement,

can no longer be provided by mother’s milk

alone.

69. Answer: (C) 24 weeks

Rationale: At approximately 23 to 24 weeks’

gestation, the lungs are developed enough to

sometimes maintain extrauterine life. The lungs

are the most immature system during the

gestation period. Medical care for premature

labor begins much earlier (aggressively at 21

weeks’ gestation)

70. Answer: (B) Sudden infant death syndrome

(SIDS)

Rationale: Supine positioning is recommended

to reduce the risk of SIDS in infancy. The risk of

aspiration is slightly increased with the supine

position. Suffocation would be less likely with

an infant supine than prone and the position

for GER requires the head of the bed to be

elevated.

71. Answer: (C) Decreased temperature

Rationale: Temperature instability, especially

when it results in a low temperature in the

neonate, may be a sign of infection. The

neonate’s color often changes with an infection

process but generally becomes ashen or

mottled. The neonate with an infection will

usually show a decrease in activity level or

lethargy.

72. Answer: (D) Polycythemia probably due to

chronic fetal hypoxia

Rationale: The small-for-gestation neonate is at

risk for developing polycythemia during the

transitional period in an attempt to decrease

hypoxia. The neonates are also at increased risk

for developing hypoglycemia and hypothermia

due to decreased glycogen stores.

73. Answer: (C) Desquamation of the epidermis

Rationale: Postdate fetuses lose the vernix

caseosa, and the epidermis may become

desquamated. These neonates are usually very

alert. Lanugo is missing in the postdate

neonate.

74. Answer: (C) Respiratory depression

Rationale: Magnesium sulfate crosses the

placenta and adverse neonatal effects are

respiratory depression, hypotonia, and

bradycardia. The serum blood sugar isn’t

affected by magnesium sulfate. The neonate

would be floppy, not jittery.

75. Answer: (C) Respiratory rate 40 to 60

breaths/minute

Rationale: A respiratory rate 40 to 60

breaths/minute is normal for a neonate during

the transitional period. Nasal flaring,

respiratory rate more than 60 breaths/minute,

and audible grunting are signs of respiratory

distress.

76. Answer: (C) Keep the cord dry and open to air

Rationale: Keeping the cord dry and open to air

helps reduce infection and hastens drying.

Infants aren’t given tub bath but are sponged

off until the cord falls off. Petroleum jelly

prevents the cord from drying and encourages

infection. Peroxide could be painful and isn’t

recommended.

77. Answer: (B) Conjunctival hemorrhage

Rationale: Conjunctival hemorrhages are

commonly seen in neonates secondary to the

cranial pressure applied during the birth

process. Bulging fontanelles are a sign of

intracranial pressure. Simian creases are

present in 40% of the neonates with trisomy 21.

Cystic hygroma is a neck mass that can affect

the airway.

78. Answer: (B) To assess for prolapsed cord

Rationale: After a client has an amniotomy, the

nurse should assure that the cord isn't

prolapsed and that the baby tolerated the

procedure well. The most effective way to do

this is to check the fetal heart rate. Fetal wellbeing

is assessed via a nonstress test. Fetal

position is determined by vaginal examination.

Artificial rupture of membranes doesn't

indicate an imminent delivery.

79. Answer: (D) The parents’ interactions with each other.

Rationale: Parental interaction will provide the

nurse with a good assessment of the stability of

the family's home life but it has no indication

for parental bonding. Willingness to touch and

hold the newborn, expressing interest about

the newborn's size, and indicating a desire to

see the newborn are behaviors indicating

parental bonding.

80. Answer: (B) Instructing the client to use two or

more peripads to cushion the area

Rationale: Using two or more peripads would

do little to reduce the pain or promote perineal

healing. Cold applications, sitz baths, and Kegel

exercises are important measures when the

client has a fourth-degree laceration.

81. Answer: (C) “What is your expected due date?”

Rationale: When obtaining the history of a

client who may be in labor, the nurse's highest

priority is to determine her current status,

particularly her due date, gravidity, and parity.

Gravidity and parity affect the duration of labor

and the potential for labor complications. Later,

the nurse should ask about chronic illnesses,

allergies, and support persons.

82. Answer: (D) Aspirate the neonate’s nose and

mouth with a bulb syringe.

Rationale: The nurse's first action should be to

clear the neonate's airway with a bulb syringe.

After the airway is clear and the neonate's color

improves, the nurse should comfort and calm

the neonate. If the problem recurs or the

neonate's color doesn't improve readily, the

nurse should notify the physician.

Administering oxygen when the airway isn't

clear would be ineffective.

83. Answer: (C) Conducting a bedside ultrasound

for an amniotic fluid index.

Rationale: It isn't within a nurse's scope of

practice to perform and interpret a bedside

ultrasound under these conditions and without

specialized training. Observing for pooling of

straw-colored fluid, checking vaginal discharge

with nitrazine paper, and observing for flakes of

vernix are appropriate assessments for

determining whether a client has ruptured

membranes.

84. Answer: (C) Monitor partial pressure of oxygen

(Pao2) levels.

Rationale: Monitoring PaO2 levels and reducing

the oxygen concentration to keep PaO2 within

normal limits reduces the risk of retinopathy of

prematurity in a premature infant receiving

oxygen. Covering the infant's eyes and

humidifying the oxygen don't reduce the risk of

retinopathy of prematurity. Because cooling

increases the risk of acidosis, the infant should

be kept warm so that his respiratory distress

isn't aggravated.

85. Answer: (A) 110 to 130 calories per kg.

Rationale: Calories per kg is the accepted way

of determined appropriate nutritional intake

for a newborn. The recommended calorie

requirement is 110 to 130 calories per kg of

newborn body weight. This level will maintain a

consistent blood glucose level and provide

enough calories for continued growth and

development.

86. Answer: (C) 30 to 32 weeks

Rationale: Individual twins usually grow at the

same rate as singletons until 30 to 32 weeks’

gestation, then twins don’t’ gain weight as

rapidly as singletons of the same gestational

age. The placenta can no longer keep pace with

the nutritional requirements of both fetuses

after 32 weeks, so there’s some growth

retardation in twins if they remain in utero at

38 to 40 weeks.

87. Answer: (A) conjoined twins

Rationale: The type of placenta that develops in

monozygotic twins depends on the time at

which cleavage of the ovum occurs. Cleavage in

conjoined twins occurs more than 13 days after

fertilization. Cleavage that occurs less than 3

day after fertilization results in diamniotic

dicchorionic twins. Cleavage that occurs

between days 3 and 8 results in diamniotic

monochorionic twins. Cleavage that occurs

between days 8 to 13 result in monoamniotic

monochorionic twins.

88. Answer: (D) Ultrasound

Rationale: Once the mother and the fetus are

stabilized, ultrasound evaluation of the

placenta should be done to determine the

cause of the bleeding. Amniocentesis is

contraindicated in placenta previa. A digital or

speculum examination shouldn’t be done as

this may lead to severe bleeding or

hemorrhage. External fetal monitoring won’t

detect a placenta previa, although it will detect

fetal distress, which may result from blood loss

or placenta separation.

89. Answer: (A) Increased tidal volume

Rationale: A pregnant client breathes deeper,

which increases the tidal volume of gas moved

in and out of the respiratory tract with each

breath. The expiratory volume and residual

volume decrease as the pregnancy progresses.

The inspiratory capacity increases during

pregnancy. The increased oxygen consumption

in the pregnant client is 15% to 20% greater

than in the nonpregnant state.

90. Answer: (A) Diet

Rationale: Clients with gestational diabetes are

usually managed by diet alone to control their

glucose intolerance. Oral hypoglycemic drugs

are contraindicated in pregnancy. Long-acting

insulin usually isn’t needed for blood glucose

control in the client with gestational diabetes.

91. Answer: (D) Seizure

Rationale: The anticonvulsant mechanism of

magnesium is believes to depress seizure foci in

the brain and peripheral neuromuscular

blockade. Hypomagnesemia isn’t a

complication of preeclampsia. Antihypertensive

drug other than magnesium are preferred for

sustained hypertension. Magnesium doesn’t

help prevent hemorrhage in preeclamptic

clients.

92. Answer: (C) I.V. fluids

Rationale: A sickle cell crisis during pregnancy is

usually managed by exchange transfusion

oxygen, and L.V. Fluids. The client usually needs

a stronger analgesic than acetaminophen to

control the pain of a crisis. Antihypertensive

drugs usually aren’t necessary. Diuretic

wouldn’t be used unless fluid overload resulted.

93. Answer: (A) Calcium gluconate (Kalcinate)

Rationale: Calcium gluconate is the antidote for

magnesium toxicity. Ten milliliters of 10%

calcium gluconate is given L.V. push over 3 to 5

minutes. Hydralazine is given for sustained

elevated blood pressure in preeclamptic clients.

Rho (D) immune globulin is given to women

with Rh-negative blood to prevent antibody

formation from RH-positive conceptions.

Naloxone is used to correct narcotic toxicity.

94. Answer: (B) An indurated wheal over 10 mm in

diameter appears in 48 to 72 hours.

Rationale: A positive PPD result would be an

indurated wheal over 10 mm in diameter that

appears in 48 to 72 hours. The area must be a

raised wheal, not a flat circumcised area to be

considered positive.

95. Answer: (C) Pyelonephritis

Rationale The symptoms indicate acute

pyelonephritis, a serious condition in a

pregnant client. UTI symptoms include dysuria,

urgency, frequency, and suprapubic

tenderness. Asymptomatic bacteriuria doesn’t

cause symptoms. Bacterial vaginosis causes

milky white vaginal discharge but no systemic

symptoms.

96. Answer: (B) Rh-positive fetal blood crosses into

maternal blood, stimulating maternal

antibodies.

Rationale: Rh isoimmunization occurs when Rhpositive

fetal blood cells cross into the maternal

circulation and stimulate maternal antibody

production. In subsequent pregnancies with Rhpositive

fetuses, maternal antibodies may cross

back into the fetal circulation and destroy the

fetal blood cells.

97. Answer: (C) Supine position

Rationale: The supine position causes

compression of the client's aorta and inferior

vena cava by the fetus. This, in turn, inhibits

maternal circulation, leading to maternal

hypotension and, ultimately, fetal hypoxia. The

other positions promote comfort and aid labor

progress. For instance, the lateral, or side-lying,

position improves maternal and fetal

circulation, enhances comfort, increases

maternal relaxation, reduces muscle tension,

and eliminates pressure points. The squatting

position promotes comfort by taking advantage

of gravity. The standing position also takes

advantage of gravity and aligns the fetus with

the pelvic angle.

98. Answer: (B) Irritability and poor sucking.

Rationale: Neonates of heroin-addicted

mothers are physically dependent on the drug

and experience withdrawal when the drug is no

longer supplied. Signs of heroin withdrawal

include irritability, poor sucking, and

restlessness. Lethargy isn't associated with

neonatal heroin addiction. A flattened nose,

small eyes, and thin lips are seen in infants with

fetal alcohol syndrome. Heroin use during

pregnancy hasn't been linked to specific

congenital anomalies.

99. Answer: (A) 7th to 9th day postpartum

Rationale: The normal involutional process

returns the uterus to the pelvic cavity in 7 to 9

days. A significant involutional complication is

the failure of the uterus to return to the pelvic

cavity within the prescribed time period. This is

known as subinvolution.

100. Answer: (B) Uterine atony

Rationale: Multiple fetuses, extended labor

stimulation with oxytocin, and traumatic

delivery commonly are associated with uterine

atony, which may lead to postpartum

hemorrhage. Uterine inversion may precede or

follow delivery and commonly results from

apparent excessive traction on the umbilical

cord and attempts to deliver the placenta

manually. Uterine involution and some uterine

discomfort are normal after delivery.