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4 | Page 53. When caring for a client in a post-partum, “Taking-in” psychological adaptation phase, the nurse should plan to do which of the following? A. Promote self care activities. B. Expect control of elimination functions. C. Provide nourishment and rest. D. Teach newborn care skills. 54. Three hours after delivery, Mrs. Maeh Ngay tells the nurse that she feels dirty and wants to take a shower. She says that she never feels clean after bed baths. The nurse’s best response would be: A. “You require bed rest for the first 24 hours after delivery.” B. “You can shower but I must stay nearby.” C. “Bathing or showering isn’t permitted because they may cause chills.” D. “I’m sorry, but your not allowed to shower, I’ll give you a bed bath instead.” 55. When the nurse helps Mahee Leg decides on the “correct” contraceptive method, which of the following must she consider as the most important concerns for her patient? A. Comfort with the method. B. Religion C. Number of sexual partners D. Frequency of coitus. 56. A client is in the fourth stage of labor. What assessment would the nurse make? A. Fetal heart rate, fetal position and station. B. Dilation, effacement and station. C. Fundal location, lochia and perineum. D. Placental separation, fundal location, and uterine tone. SITUATION: Bea Ghra, a graduating nursing student wants to know more about nursing assessment and management of mothers who are high risk. She tried to answer the following questions to assess her knowledge. 57. Which of the following would the nurse assess in a client experiencing abruption placenta? A. Bright red, painless vaginal bleeding B. Concealed or external dark red bleeding. C. Palpable fetal outline. D. Soft and nontender abdomen. 58. Before surgery to remove an ectopic pregnancy, which of the following would alert nurse Stephanie to the possibility of the tubal rupture? A. Amount of the vaginal bleeding and discharge. B. Falling hematocrit and hemoglobin levels. C. Slow bounding pulse rate of 80 beats per minute. D. Marked abdominal edema. 59. Which of the following body system should the nurse assess first in a patient with abruption placenta? A. Endocrine B. Cardiovascular C. Neuromuscular D. Renal 60. The nurse should assess Maely Ngin for clinical manifestations of magnesium sulfate toxicity which include: A. Headache, blurred vision and +3 proteiniria B. Respiratory depression and loss of deep tendon reflexes. C. Flushing and sweating D. Ringing in the ears and a metallic taste in the mouth. 61. Nurse Hannah is trying to determine the frequency of uterine contractions. To determine the frequency of uterine contractions, Nurse Hannah is expected to time from the: A. Onset of one contraction until the onset of next. B. End of one contraction until the end of the end. C. Beginning of one contraction until the end of the next. D. Onset of the contraction until it ends. 62. Which of this is not a manifestation of H-mole? A. Hyperemesis gravidarum B. Absence of fetal heart beat C. Positive HCG D. Presence of fetal heart beat 63. Mrs. Mahee Leg is on 8th months pregnant and was admitted due to premature uterine contraction. During the Physical examination, the physician confirms positive for cervical dilatation. Which of the following drug should the nurse anticipate to be administered? A. Betamethasone B. Bricanyl C. Terbutaline D. Ritrodine HCL 64. Rh- incompatibility is suspected once the women is Rh negative having an Rh positive husband. If the newborn is positive for blood test and negative for direct coomb,s test. What should the nurse anticipate: A. Administer RhoGam 300 mg IM first 72 hours. B. Submit the newborn to indirect comb’s test. C. RhoGam is already useless. D. Terminate the pregnancy. 65. A patient who is 37 weeks gestation, is admitted to the hospital with the diagnosis of severe preeclampsia. In planning care for this client, the nurse would set the following priority goal. The client will: A. Conform to the nutritional regimen. B. Be a seizure- free prior to delivery C. Have a decreased B/P within 24 hours D. Maintain a sodium restriction diet. SITUATION: Reproductive life planning includes all the decisions an individual or couple make about having a children. Nurses should make the couple understands every method of contraception with complete understanding about the advantages, disadvantages and side effects of various options. 66. Mrs. Mah Hilig, who has history of toxic shock syndrome, come to the reproductive clinic seeking contraception. Based on this information, which method should the nurse avoid recommending for this client? A. Condoms B. Spermicide C. Norplant D. Cervical cap 67. Following a teaching session on how to use the diaphragm as a contraceptive method, the nurse evaluates the client’s understanding. Which statement, if made by the client, demonstrate a need for further teaching? A. “I need to leave the diaphragm for at least 6 hours after having intercourse.” B. “I will need to inspect the diaphragm after I take it out and clean it.’ C. “When I want to get pregnant, I can just stop using my diaphragm.” D. “If a choose a diaphragm, I won’t need to use any spermicide.” 68. When teaching the client with diabetes concerning the use of birth control methods, the nurse should encourage the client to use: A. Oral contraceptives B. Condoms C. Contraceptive patches D. IUD 69. During a pelvic examination, Nurse Biluan notes a purple notes a purple-blue discoloration of the vagina. The nurse documents this as: A. Braxton-Hicks sign B. Chadwick’s sign C. Goodel’s sign D. Mc Donald’s sign 70. Nurse KABA, who works in a prenatal clinic, review Mrs.Secs Wal’s chart and notes the physician documented that the client has a gynecoid pelvis. Nurse KABA then plans care for this client knowing that this type of pelvis: A. Is not favorable for labor. B. Has a narrow pubic arch C. Is a wide pelvis with a short diameter. D. Is the most favorable for labor and birth 71. Mrs. Secs Wal tells Nurse KABA that she wants to know the sex of the fetus as soon as it can be determined. Nurse KABA responds to the client, knowing that the sex of the fetus can be visually recognized as early as week: A. 4 B. 6 C. 8 D. 12

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