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NOTRE DAME OF TACURONG COLLEGE

COLLEGE OF NURSING

TACURONG CITY

Susan Love Peregrino, RN, MN

Xenia A. Diaz, RN,MN

Elmer G. Organia,RN

NCM 101 Tina T. Lumanag, RN,MN

Midterm Examination

Name:_____________________________________________Date__________________________Score

MULTIPLE CHOICE:

General Instructions: Select the correct answer for each of the following questions. Shade the

letter of your choice on the answer sheet provided.NO ERASURES ALLOWED.

1. When the fetal head is at the level of the ischial spine, it is said that the station of the head is

A. Station1

B. Station 0

C. Station +1

D. Station +2

2.. During an internal examination, the nurse palpated the posterior fontanel to be at the left side of the

mother at the upper quadrant. The interpretation is that the position of the fetus is:

A. LOA

B. ROP

C. LOP

D. ROA

3. When the nurse palpates the suprapubic area of the mother and found that the presenting part is still

movable, the right term for this observation that the fetus is

A. Engaged

B. Descended

C. Floating

D. Internal Rotation

4. You performed the leopolds maneuver and found the following: breech presentation, fetal back at

the right side of the mother. Based on these findings, you can hear the fetal heart beat (PMI) BEST in

which location?

A. Left lower quadrant

B. Right lower quadrant

C. Left upper quadrant

D. Right upper quadrant

5. In Leopolds maneuver step #1, you palpated a soft broad mass that moves with the rest of the mass.

The correct interpretation of this finding is:

A. The mass palpated at the fundal part is the head part.

B. The presentation is breech.

C. The mass palpated is the back

D. The mass palpated is the buttocks.

6. In Leopolds 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

7. The nurse was performing leopolds maneuver. In executing the techniques of the maneuver, which is

least likely done by the nurse?

A.Instruct the patient to drink plenty of fluid before the procedure.

B.Warm the nurses hand before initiating the palpation.

C.Allowing the client to void first before the procedure.D.Close the curtains and provide privacy.

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8. During the first maneuver the nurse feels a round, soft portion at the fundus. This is best

interpretation of this is:

A. The head is at the fundus

B. The abdomen is at the fundus

C. The buttocks is at the fundus

D. The shoulder is at the fundus

9. What is the purpose of doing the fourth maneuver?

A. To know the fetal part at the fundus

B. To assess the degree of flexion or attitude

C. To have an idea what the fetal presenting part is

D. To know if engagement occurred or not

10.With a fetus in the left-anterior breech presentation, the nurse would expect the fetal heart

rate would be most audible in which of the following areas?

A. Above the maternal umbilicus and to the right of midline

B. In the lower-left maternal abdominal quadrant

C. In the lower-right maternal abdominal quadrant

D. Above the maternal umbilicus and to the left of midline

11. You performed the leopolds maneuver and found the following: breech presentation, fetal

back at the right side of the mother. Based on these findings, you can hear the fetal heart beat

(PMI) BEST in which location?

a. . Left lower quadrant

B. Right lower quadrant

C. Left upper quadrant

D. Right upper quadrant

12. The LOA position means that the:

A. lie is longitudinal and the fetal occiput is directed toward the left posterior

portion of the maternal pelvis

B. lie is transverse and the fetal mentum is directed toward the left posterior


C. lie is longitudinal and the fetal occiput is directed toward the left anterior portion

of the maternal pelvis

D. lie is oblique and the fetal anterior fontanel is directed toward the left posterior


13.Which of the following terms is used to describe the thinning and shortening of the cervixthat occurs just before and during labor?

a. Ballottementb. Dilatationc. Effacementd. Multiparous

14.Which of the following fetal positions is most favorable for birth?a. Vertex presentationb. Transverse liec. Frank breech presentationd. Posterior position of the fetal head

15.Which of the following stages of labor is the one in which birth occurs?a. First stage of laborb. Second stage of laborc. 3rd stage of labord. Forth stage of labor

16.Which of the following fetal heart rates would be expected in the fetus of a laboring womanwho is full term.

a.

80 to 100 beats/minuteb. 100 to 120 beats/minute

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c. 120 to 160 beats/minuted. 160 to 180 beats/minute

17.A laboring client has external electronic fetal monitoring in place. Which of the followingassessment data can be determined by examining the fetal heart rate strip produced by the

Central electronic fetal monitor?

a. Gender of the fetusb. Fetal positionc. Labor progressd. Oxygenation

18.Which of the following Leopolds maneuver assesses the descent of the presenting partsJust into the pelvis.

a. Firstb. Secondc. Thirdd. Fourth

19.Which of the following descriptions best fits the term effacement?a. Enlargement of the cervical canalb. Expulsion of the mucus plugc. Shortening and thinning of the cervical canald. Downward movement of the fetal head

20.During which of the following stages of labor does a crowning take place?a. Firstb. Secondc. Thirdd. Fourth

21.A laboring client is in the first stage of labor and has pro progressed from 4-7 cm in cervicalDilation, In which of the following phases of the first stage does cervical dilatation occurs

rapidly?

a. Preparatory faceb. Latent facec. Active phasesd. Transitional phase

22.A multiparous client who has been in the labor for 2 hours states that she feels the urge tomove her bowels. How should the nurse respond?

a. Fetal body part that enters the maternal pelvis firstb. Allow the client to use a bedpanc. Perform a pelvic examinationd. Check the fetal fetal rate

23.Which of the following characteristics best describes variable decelerations?a. Predictableb. Indicators of fetal well beingc. Indicative of cord compressiond. Periodic decreases in fetal heart rate resulting from pressure on the fetal head.

24.Fetal presentation refers to which of the following descriptions?a. Fetal body part that enters the maternal pelvis firstb. Relationship of the presenting part to the maternal pelvisc. Relationship of the long axis of the fetus to the long axis of the fetus to

the long axis of the mother.

d. A classification according to the fetal part25. Fetal lie is the relationship of the long axis of the fetus to the long axis of the mother.

Which fetal lie is the most common and best suited for vaginal delivery?

a. Transverseb. Longitudinalc.

Oblique

d. Compound

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26. Which of the following abilities would the nurse not expect a 4-month-old infant to

perform?

a. Sitting up without support

b. Responding to pleasures with smile

c. Grasping a rattle when it is offered

d. Turning from either side to the back

27.An infant is observed to be competent in the following developmental skills: stares at an

object placed in her hand and take it to her mouth, coos and gurgles when talked to,

and sustains part of her own weight when held in a standing position. The nurse

correctly assesses this infants age as:

a. 2 months

b. 4 months

c. 6 months

d. 8 months

28. A mother states that she thinks her 9-month-old is developing slowly. When evaluating the

infants development, the nurse would expect a normal 9 months old to be able to:

a. Creep and crawl

b. Begin to use a repetitive verbal expressions

c. Put an arm through a sleeve while being dressed

d. Hold a bottle with good hand-mouth coordination

29. A mother brings her 18-month-old to the clinic because he eats ashes, crayons, and

papers. The nurse would first assess whether the toddler is:

a. Cutting large teeth

b. Experiencing a growth spurt

c. Experiencing changes in the home environment

d. Eating a soft, low-roughage diet

30. Which of the following task typical of an 18-month-old would the nurse assess for?

a. Copying a circle

b. Pulling toys

c. Playing tag with other children

d. Building a tower or 8 blocks

31 .A mother brings her normally developed 3-year-old child to the clinic for a check-up. The

nurse would expect the child would be less skilled in:

a. Riding a tricycle

b. Tying shoe laces

c. Stringing large beads

d. Using blunt scissors

32. The mother of a 4-year-old child expresses concern that her child may be hyperactive. She

describes the child as always in motion, constantly dropping and spilling things which

nursing intervention would be most appropriate at this time?

a. Determine if there have been any changes at home

b. Explain that this is not unusual behavior

c. Explore the possibility that the child is being abused

d. Suggest that the child be seen by a pediatric neurologist

33. Which of the following activities would the nurse recommend to the mother to help

channel the childs energy?

a. Participate in parallel play

b. Play a game like Simon says

c. Ride a tricycle

d. String large beads

34. The mother reports that her child creates quite a scene every night at bedtime and asks

what she can do to make bedtime a little more pleasant. The nurse should suggest that

the mother:

a. Allow the child to stay up later one or two night a week

b. Establish a set bedtime and follow a routi nec. Let the child play tag just before bedtime

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d. Give the child a cookie if bedtime is pleasant

35. The mother of a 9-year-old girl that the child is continually telling jokes and riddles to the

point of driving the family members crazy. The nurse should explain that this behavior is

a sign of:

A .Mastery of language ambiguities

b. Inadequate parental attention

c. Inappropriate peer influence

d. Excessive television watching

36. The mother is concerned about the childs compulsion for collecting things. The nurse

explains that this behavior is related to the cognitive ability to perform:

a. Concrete operations

b. Formal operations

c. Coordination of secondary schemata

d. Tertiary circular reactions

37. The nurse is invited to attend a meeting with several parents. Some parents express

frustration with the amount of time their adolescents spend in front of the mirror and

the length of time it takes them to get dressed. The nurse should explain that this

behavior is:

a. An indication of an abnormal concern with self

b. A method of procrastination commonly seen in adolescents

c. A method of testing parents limit-setting

d. A result of rapid body changes and developing self-concept

38. Which behavior indicates that an 18-month-old infant is developing a non adaptive reaction

to hospitalization?

a. Cries when the mother leavesb. Ignores neither when she arrives to visitc. Eat using finger rather than utensilsd. Is afraid of play the dark

39. what are the appropriate toys for an 18 months old infant to have for play while in a croup

tents?

a. rattles

b. stacking rings

c. crayonsg

d. soap bubbles

40. A parent brings a 19 month old toddler to the clinic for a well-child check-up. When

palpating the toddlers fontanels the nurse would expect to find:

a. Close anterior-fontannel and open posterior fontanels\\

b. open anterior fontanel and closed posterior fontanel

c. closed anterior and posterior funtanels

d. open anterior and posterior fontannels

41. The nurse is instructing a mother about the nutritional needs of her full term, breast feeding

Infant, age 2 months. Which of the following responses that the mother understands the

infants dietary needs?

a. We wont start any new foods now.b. Well start the baby on skim milk.c. Well introduce cereal into the diet nowd. We should add new fruits to the diet one at atime.

42. A preschooler is admitted to the hospital the day before scheduled surgery, this is the first

childs hospitalization. Which of the following actions will best help reduce the childs anxiety

about the upcoming surgery?

a. begin preoperative teaching immediately.

b. Describe preoperative and postoperative procedures in details.

b. Give the child dolls and medical equipment to play out the experience.c. Explain that the child will be put to sleep during surgery and wont feel anything.

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43. Before a well check-up in the pediatricians office, an 8 month old infant is sitting anthe

following steps should the nurse do first?

a. obtain body weight

b. Auscultate heart and breath sounds

c. check pupillary response

d. Measure the head conference

44. The nurse is teaching a mother who plans to discontinue breast feeding after 5 months. The

nurse should advise her to include which of the following foods in her infants diet?

a. iron-rich formula and baby food

b. whole milk and baby food

c. skim milk and baby food.

d. Iron-rich formula only

45. A mother tells the nurse about her 22 months-old child saysno to everything . When

scolded, the toddler becomes angry and starts crying loudly, but then immediately wants to be

held. What is the best interpretation of this behavior?

a. The toddler isnt effectively coping with stress.

b. the toddlers need for affection isnt being met

c. This is normal behavior for a 2 year old child

d. This behavior suggests the need for counseling.

46. The nurse has assessed four children of varying ages: which one requires further evaluation?

a. A 7 months-old who is afraid of stranger.

b. A 4 year old who talks to an imaginary playmate.

c. A 9 year old with enuresis

d. A 16 years old male who had nocturnal emissions.

47. The parent of a 3 year old child brings the child to the clinic for well-child check-up. The

history and assessment reveals the following findings. Which of these assessment findings

made by the nurse is an area of concern and requires further investigation.

a. unable to ride a tricycle

b. Has ability to hop on one foot

c. Uses gestures to indicate wants.

d. weight gain of 4 month old infant during a well-child visit. The nurse makes all of the

following observations. Which of the following assessments made by the nurse is an area of

concern indicating a need for further evaluation?

a. Absence of Moro reflexb. Close posterior fontanelc. Three pound weight gain in 2 monthsd. Moderate head las when pulled to sitting position.

49. Which parent-child interaction does NOT warrant further assessment when child abuse is

suspected? The parent who

a. appears tired and disheveled.

b. is hypercritical of the child

c. pushes the frightened child away

d. expresses far more concern than the situation warrants.

50. JR is a second year Nursing Student, giving health teaching to a group of parents. Which of

the following statement is NOT true of DDST?

A. DDST is a widely used assessment for examining the developmental progress of

children from birth until the age of six devised in 1969.

B. DDST was revised in 1994

C. DDST was originally designed at the University of Colorado Medical Center, Denver

USA.

D. DDST is also known as Denver Developmental Screening Test

51. The main purpose of DDST depends on the age of the child which includes the following

EXCEPT:

A. Tests may detect neurological problems such as cerebral palsy in the neonate.

B. Tests may reassure parents or detect problems in early infancy.

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C. Testing in late childhood can help detect academic and social problems early enough

to minimize possible negative consequences

D. Test may detect if child is abnormal

52. Which of the following statements about DDST administration is NOT TRUE:

A. No special training is required.

B. The test takes approximately 20 minutes to administer and interpret.

C. The 125 items are recorded through direct observations of the child plus for some

points, the mother reports whether the child is capable of performing a given task.

D. The test should be given slowly.

53. The items needed for DDST administration includes the following, EXCEPT:

1. Bell 2.Glass bottle 3.Set of 10 blocks 4.Rattle 5. Pencil 6.Tennis ball

A. All of the above B. None of the above C. All except 1 D. 1,3, and 5

54. Which of the following test administration techniques is NOT correct?

1. When prone lifts head up, using forearm support (with or without hands).

2. Throws balls overhand 3 feet to within your reach.

3. Bounce a ball. He must catch it. Allow up to three tries.

4. Child grasps raisin between thumb and index finger

5. "Copy this" (circle). Do state name or demonstrate

A. All except 5 B. None of the above C. All of the above D. 1 and 5

56. The approximate age to conduct DDST is:

1. 3-4 months 2. 10 months 3. 36 Months

A. All of the above B. None of the above C. All except 3 D. All except 2

57. The following are parameters of Fine motor skills assessment:

1. Grasp rattle 2. Thumb finger grasp 3. Hops 4. Make a tower of cubes


58. The following are parameters of personal-social skills assessment:

1. smile responsively 2. Feed doll 3. Copy square 4. Put on clothing


59. The following are parameters of language skills assessment:

1. Vocalizes 2. Names 1 picture 3. Copy + 4. Imitate speech sounds


60. The following are parameters of gross motor skills assessment:

1. Roll over 2. Broad jump 3. Drink from cup 4. Heel to toe walk


61. In scoring test behavior, the following statements are true, EXCEPT:

1. P for PASS, the child successfully performs or the caregiver reports (as appropriate)

2. F for FAIL, the child does not successfully perform an item or the caregiver reports

3. N.O. for NO OPPORTUNITY (this is used on report items only)

4. R for REFUSAL, the child refuses to attempt item (can be used on report items)


61. In all items to administer, it is allowed to continue testing until 3 fails occur.

A. True B. False C. Maybe D. Not Stated

62. The nurse plans to administer the Denver Developmental Screening test to a 5-month-old

infant. The nurse should explain to the mother that the test measures the infants:

a. Intelligence quotient

b. Emotional development

c. Social and physical abilities

d. Predisposition to genetic and allergic illness

63. The Denver developmental screening test is composed of the following categories, EXCEPT:

a. Personal-social

b. Fine motor-adaptive

c. Language

d. Cognitive

64. For personal-social category, which of the following aspects is being assessed?

a. Smiling of the childb. Grasping an object

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c. Building blocks

d. Looking at pom-pom

65. For fine motor-adaptive category, which of the following aspects is being assessed?

a. Grasping or drawing

b. Smiling of the child

c. Building blocks

d. Looking at pom-pom

66. For the language category, the following areas is being assessed, EXCEPT:

a. production of sounds

b. ability to recognize words

c. understand and use a language and the ability to combine words

d. drawing a picture

67. For the gross motor category, which of the following aspects is not included to be assessed?

a. playing with another kid

b. sitting

c. walking

d. jumping

68. How can you tell that a child passed the test when using a rattle?

a. If the child will throw away immediately the rattle

b. If the child grasps rattle when it is touched to the backs or tips of fingers

c. If the child ignores the rattle

d. None of the above

69. How can you tell that an infant passed the red yarn test?

a. If the child continues to look where yarn disappeared or tries to see where it went

b. If the child ignores the yarn

c. If the child grasp the yarn

d. If the child brings the yarn to his mouth

70. How can you tell that a child passed the cheese curls test?

a. If the child eats the cheese curls

b. If the child picks up cheese curl with any part of the thumb and finger

c. If the child cries when nurse gets the curls

d. All of the above

71. How can you tell if the child passed when instructed to draw a circle?

a. If circle is in enclosed form

b. If circle is in continuous round motion

c. If circle is not connected

d. All of the above

72. What if a child failed to perform activity which completely falls to the left of the age line?

What does it implies?

a. Passed

b. Not done

c. A delay

d. Abnormal

73. Before the test will be started, the nurse will make sure that:

a. Rapport was established

b. Child is comfortable as much as possible

c. Materials are available

d. All of the above

Situation 1: Jofel, a 40 year old construction worker developed cough, night sweats and fever. He

was brought to the nursing unit for diagnostic studies. He told the nurse he did not receive a BCG

vaccine during childhood

74. The nurse performs a Mantoux Test. The nurse knows that Mantoux Test is also

known as:

a. PPD

b. PDPc. PDD

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d. DPP

75. The nurse would inject the solution in what route?

a. IM

b. IV

c. ID

d. SC

76. The nurse notes that a positive result for Jofel is:

a. 5 mm wheal

b. 5 mm Induration

c. 10 mm Wheal

d. 10 mm Induration

77. The nurse told Jofel to come back after:

a. a week

b. 48 hours

c. 1 day

d. 4 days

78. Mang Jofel returns after the Mantoux Test. The test result read POSITIVE. What

should be the nurses next action?

a. Call the Physician

b. Notify the radiology dept. for CXR evaluation

c. Isolate the patient

d. Order for a sputum exam

79. Why is Mantoux test not routinely done in the Philippines?

a. It requires a highly skilled nurse to perform a Mantoux test

b. The sputum culture is the gold standard of PTB Diagnosis and it will definitively

determine the extent of the cavitary lesions

c. Chest X Ray Can diagnose the specific microorganism responsible for the lesions

d. Almost all Filipinos will test positive for Mantoux Test

80. According to the DOH, the most hazardous period for development of clinical disease

is during the first :

a. 6-12 months after

b.3-6 months after

c.1-2 months after

d. 2-4 weeks after

Situation 2: Mr. Lamery is a newly assigned registered nurse in Purok Dahlia. As a nurse assigned

in that area, he must be knowledgeable on he possible questions that the mothers would ask

about immunization.

81. To prevent whooping cough, which of the following vaccines should be given to infants?

a. BCG

b. DPT

c. OPV

d. d. IPV

80. The mother of an infant with pertussis should be instructed of the following except:

a. Provide abdominal support

b. Feed the child during an attack

c. Allow the child to rest

d. Special attention to diet is needed when the child vomits after cough paroxysms.

81. Mrs. Larazabal brought her 2 month old baby to the health center for immunization. On

assessment, the infants temperature registered 38 degrees C. Which is the best action that you

will take?

a. Give paracetamol and wait for his fever to subside.

b. Refer the infant to the physician for further evaluation.

c. Proceed with the infants immunization.

d. Tell the mother to bring her baby back at the health center when her baby is feeling

well.

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82 . During immunization week in the health center, the parent of a 6-month-old infant asks the

health nurse, Why is our baby going to receive so many immunizations over a long time

period? The best nursing response would be:

a. The number of immunizations your baby will receive shows how many pediatric

communicable and infectious diseases can now be prevented.

b. You need to ask the physician

c. The number of immunizations your baby will receive is determined by your babys

health history and age

d. It is easier on your baby to receive several immunizations rather than one at a time

83 . A mother brought her child in the health center for hepatitis B vaccination in a series. The

mother informs the nurse that the child missed an appointment last month to have the third

hepatitis B vaccination. Which of the following statements is the appropriate nursing response

to the mother?

A) I will examine the child for symptoms of hepatitis B

B) Your child will start the series again

C) Your childwill get the next dose as soon as possible

D) Your child will have a hepatitis titer done to determine if immunization has taken

place.

87. The nurse administers a wrong medicine to a client. Which of the following actions

should the nurse take?

a. do nothing

b. immediately report the error to the nurse manager and the clients physician

c. monitor the client for adverse effects

d. tell the client that a wrong medicine was given

88.before administering a medication to a client, the nurse needs to identify the client. Which of

the following methods of identification should the nurse perform?

a. Ask the clients first name

b. Check the clients ID bracelet

c. Check the clients name on the medication administration record

d. Check the clients name with family or a significant other

89. The adult client has an order for Penicillin to be given intramuscularly. Which of the

following angles would be the correct one to use into the ventrogluteal muscle site?

a. 45o angle

b. 60o angle

c. 75o anlge

d. 90o angle

90. When administering a flu vaccine, how does the nurse locate the deltoid muscle?

a. By locating the center of the arm between the elbow and the shoulder

b. By locating the midpoint of the lateral aspect of the upper arm

c. By palpating the lower edge of the acromion process and measuring four inches

below the center of the lateral aspect of the upper arm

d. By palpating the lower edge of the acromion process and measuring fou finger-

widths below to the midpoint and center of the lateral aspect of the upper arm

91. The nurse hands the oral medication to the client and the client states that the

medication is the wrong color. The nurse will take which of the following actions?

a. Return to the medicine room and check the medicine administration sheet with

the physicians order

b. Reassure the client that the medicine is same other than the fact that it comes

from a diferrent pharmacy company

c. Explain that the medicine comes in differentr colors but that it is the correct

medicine

d. Tell the client that the correct medicine has been ordered by the physician and

the client should take itDrug Calculations

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91. A client is ordered 35 milligrams of Codeine phosphate by subcutaneous injection. 50

milligrams in 1 millilitre of liquid for SC Injection is available. How many millilitres will you

administer?

a. 0.7 ml

b. 1 ml

c. 0.4 ml

d. 2 ml

92. A client is ordered 50 milligrams of Amoxicillin trihydrate orally. 125 milligrams in 5 millilitres

of Syrup is available. How many millilitres will you administer?

a. 0.7 ml

b. 1 ml

c. 0.4 ml

d. 2 ml

93. A client is ordered 30 milligrams of Frusemide intravenously. 10 milligrams in 1 millilitre of

liquid for IV Injection is available. How many millilitres will you administer?

a. 2 ml

b. 3 ml

c. 5 ml

d. 4 ml

94. A client is ordered 20 milligrams of Haloperidol decanoate by intramuscular injection. 50

milligrams in 1 millilitre of liquid for IM Injection is available. How many millilitres will you

administer?

a. 0.6 ml

b. 2 ml

c. 4 ml

d. 0.4 ml

95. A client is ordered 50 milligrams of Aminophylline intravenously. 250 milligrams in 10

millilitres of liquid for IV Injection is available. How many millilitres will you administer?

a. 2 ml

b. 3 ml

c. 5 ml

d. 6 ml

96. A client is ordered 75 milligrams of Pethidine HCL by subcutaneous injection. 50 milligrams

in 1 millilitre of liquid for SC Injection is available. How many millilitres will you administer?

a. 3 ml

b. 1.5 ml

c. 2.5 ml

d. 2 ml

97. A client is ordered 25 milligrams of Methyldopa intravenously. 50 milligrams in 5 millilitres of

liquid for IV Injection is available. How many millilitres will you administer?

a. 3 ml

b. 1.5 ml

c. 2.5 ml

d. 2 ml

98. A client is ordered 5 milligrams of Flupenthixol decanoate by intramuscular injection. 40

milligrams in 2 millilitres of liquid for IM Injection is available. How many millilitres will youadminister?

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a. 0.25 ml

b. 0.35 ml

c. 1 ml

d. 2.2 ml

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ANSWER AND RATIONALE:

13. C. Effacement is cervical shortening and thinning while dilation is widening of the cervix; both

facilitate opening the cervix in preparation for delivery. Ballottement is the ability of another individual

to move the fetus by externally manipulating the maternal abdomen. A ballotable fetus hasnt yet

engaged in the maternal pelvis. Multiparous refers to a woman who has had previous live birth.

14. A. Vertex presentation (flexion of the fetal head) Is the optimal presentation for passage through

the birth canal. Transverse lie is an unacceptable fetal position for vaginal birth and requires a cesarean

birth delivery. Frank breech presentation, in which the buttocks present first, can be a difficult vaginal

delivery. Posterior positioning of the fetal head can make it difficult for the fetal head to pass under the

maternal symphysis pubis bone.

15. B. The second stage of labor begins with complete dilatation (10 cm) and ends with the expulsion of

the fetus. The first stage of labor is the stage of dilatation, which is divided into three distinct phases:

latent, active, and transition.

16. C. A rate of 120 to 160 beats /minute in the fetal heart is appropriate for filling the heart with blood

and pumping it out to the system. Faster or slower rates dont accomplish perfusion adequately and

could indicate fetal compromise.

17. D. Oxygenation of the fetus may be indirectly assessed through fetal monitoring by closely

examining the fetal heart rate strip. Accelerations in the fetal heart rate strips indicate good

oxygenation, while decelerations in the fetal heart rate sometimes indicate poor fetal oxygenation. Thefetal heart rate strip cant determine the gender of the fetus or assess fetal position. Labor progress can

be directly assessed only through cervical examination.

18. D. The fourth maneuver assesses the descent of the presenting part into the pelvis. The first

maneuver determines the shape, size consistency and mobility of the format part is that is found. The

second maneuver determines the location of the fetal back and fetal extremities. The third maneuver

reveals what part is presenting above the pelvic inlet.

19. C. with effacement, the cervical canal shortens and thins due to longitudinal traction from the

contracting uterine fundus. Dilation is the enlargement of the cervical is from 1 to 10 cm. Expulsion of

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the cervical mucus plug followed by seepage of cervical capillary blood is called show. Descent is a

mechanism of labor whereby presenting part of the fetus descends into the pelvic inlet.

20. B. The second stage of labor begins at full cervical dilation (10cm) and ends when the infant is born.

introitus to open. Allowing the fetal scalp to be visible. The first stage begins with true labor

contractions and ends with complete cervical dilation. The third stage is from the time the infant is bornuntil the delivery of the placenta, the fourth stage is the first 1-4 hours following delivery of the

placenta.

21. C. Cervical dilation occurs more rapidly during the active phase than any of the previous phases, the

active phase is characterized by cervical dilation that progresses from 4-7 cm. The preparatory or latent

phase begins with the onset of regular uterine contraction and ends when rapid cervical dilation begins.

Transition is defined as cervical dilation beginning at 8 cm and lasting until 10 cm or complete dilation.

22. C. A complaint of rectal pressure usually indicates a low presenting fetal part, signaling imminent

delivery. The nurse should perform a pelvic examination to assess the dilation of the cervix and station

of the presenting parts.

23. C. Variable decelerations are common in labor when the membranes are ruptured, which decrease

to protect the cord, as the fetus descends the birth canal. Variable decelerations are unpredictable,

24. A. Presentation is the fetal body part that enters the pelvis first; its classified by the presenting

parts; the three main presentations are cephalic, breech and shoulder. These factors must work in

concert for labor to progress, smoothly.

25. B. A longitudinal lie is the only lie that can result in a vaginal birth. Generally an oblique lie converts

to a longitudinal lie, enabling vaginal delivery. Transverse and compound lies are incompatible with a

vaginal birth and necessitate cesarean delivery.

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