Community Health Nursing,Maternal And Child Nursing Practice Test

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.

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.

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

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.

Answer: (B) Buccal mucosa
Rationale: Koplik’s spot may be seen on the
mucosa of the mouth or the throat.

Answer: (A) Placenta previa
Rationale: Placenta previa with painless vaginal
bleeding.

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.

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.

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.

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.

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.

Answer: (A) Menorrhagia
Rationale: Menorrhagia is an excessive
menstrual period.

Answer: (B) Efficiency
Rationale: Efficiency is determining whether the
goals were attained at the least possible cost.

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.

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.

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.

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.

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.

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.

Answer: (A) 1
Rationale: Each rural health midwife is given a
population assignment of about 5,000.

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.

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.

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.

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.

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.

Answer: (B) Absent patellar reflexes
Rationale: Absence of patellar reflexes is an indicator of hypermagnesemia, which requires administration of calcium gluconate.

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.

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.

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.

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.

Answer: (A) Loud, machinery-like murmur.
Rationale: A loud, machinery-like murmur is a
characteristic finding associated with patent
ductus arteriosus.

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.

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.

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.

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)

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Answer: (D) Endocardial cushion defect
Rationale: Endocardial cushion defects are seen
most in children with Down syndrome,
asplenia, or polysplenia.

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.

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.

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 months, infants can’t sit securely alone. At age 8 months, infants can sit securely alone but cannot understand the permanence of objects.