Skills Lab 101 & 101a

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Questions and Answers
  • 1. 

    You are working on a medical surgical ward, Celine is one of your patients. She is a 27 year old female who is about to undergo caesarian section for her first baby. The doctor gave you an order for catheterization. As a prudent nurse, what should you prepare

    • A.

      Clean technique.

    • B.

      Bag technique.

    • C.

      Sterile technique.

    • D.

      Septic technique.

    Correct Answer
    C. Sterile technique.
    Explanation
    In this scenario, the nurse is preparing for catheterization for a patient undergoing a caesarian section. Catheterization is an invasive procedure that requires a sterile technique to minimize the risk of infection. Using sterile technique involves maintaining a sterile field, using sterile gloves, and using sterile equipment to prevent the introduction of microorganisms. This is especially important in surgical settings where the risk of infection is higher. Therefore, the nurse should prepare for catheterization using sterile technique.

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  • 2. 

    You went to your patient’s room and started to prepare the necessary materials for catheterization. What technique should you observe?

    • A.

      At the side rails of the bed.

    • B.

      At the bed frame.

    • C.

      At the foot of the bed.

    • D.

      At the head of the bed. d. At the head of the bed.

    Correct Answer
    B. At the bed frame.
    Explanation
    When preparing the necessary materials for catheterization, it is important to observe the technique of placing the materials at the bed frame. Placing them at the bed frame ensures that they are easily accessible and within reach during the procedure. This allows for efficient and safe catheterization without the need to reach over the patient or disrupt their position. Placing the materials at the head of the bed or any other location may cause inconvenience and increase the risk of accidents or complications during the procedure.

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  • 3. 

    You opened the urine bag. Where should you place it?

    • A.

      Open gravity drainage system.

    • B.

      Closed gravity drainage system.

    • C.

      Open-closed drainage system.

    • D.

      None of the above.

    Correct Answer
    B. Closed gravity drainage system.
    Explanation
    The correct answer is Closed gravity drainage system. In a closed gravity drainage system, the urine bag is sealed to prevent any leakage or contamination. This system allows for the collection of urine by gravity, with the bag positioned lower than the patient's bladder. This ensures a smooth and continuous flow of urine without the risk of backflow or infection. Placing the urine bag in a closed gravity drainage system is the correct and appropriate method for managing urine collection.

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  • 4. 

    How will you position the female patient for the catheter insertion?

    • A.

      Supine with legs extended.

    • B.

      Supine with thighs abducted.

    • C.

      Supine with knees flexed about two feet apart.

    • D.

      Supine with legs on the stir ups.

    Correct Answer
    C. Supine with knees flexed about two feet apart.
    Explanation
    Positioning the female patient in a supine position with knees flexed about two feet apart is the correct answer for catheter insertion. This position allows for better access to the urethra and easier insertion of the catheter. The flexed knees help to relax the pelvic muscles and provide a more comfortable position for the patient during the procedure. The two feet apart position allows for better visualization and access to the perineal area, making the catheter insertion easier and more successful.

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  • 5. 

    You will lubricate the catheter prior to insertion. In a female patient, how many inches of the catheter would you lubricate?

    • A.

      1-2 inches

    • B.

      3-4 inches

    • C.

      1 inch

    • D.

      7 inches.

    Correct Answer
    A. 1-2 inches
    Explanation
    The correct answer is 1-2 inches because lubricating the catheter helps to ease its insertion into the patient's body. Lubricating only 1-2 inches of the catheter is sufficient to reduce discomfort and minimize the risk of injury during the insertion process. Lubricating more than 2 inches may lead to excess lubrication, making it difficult to handle the catheter properly. Conversely, lubricating less than 1 inch may not provide enough lubrication to facilitate smooth insertion.

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  • 6. 

    Prior to catheterization, you will render perineal care to a female client. What solution will you use?

    • A.

      Feminine wash.

    • B.

      Antiseptic solution.

    • C.

      Normal saline solution.

    • D.

      Sanitary solution.

    Correct Answer
    B. Antiseptic solution.
    Explanation
    Prior to catheterization, it is important to ensure proper hygiene to prevent infection. Antiseptic solution is commonly used to clean the perineal area before the procedure as it helps to kill or inhibit the growth of microorganisms. Feminine wash, normal saline solution, and sanitary solution may not have the same level of effectiveness in reducing the risk of infection.

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  • 7. 

    When cleansing the urinary meatus, you will:

    • A.

      Move the swab upward.

    • B.

      Move the swab sideways

    • C.

      Move the swab downwards.

    • D.

      Move the swab in circular motion.

    Correct Answer
    C. Move the swab downwards.
    Explanation
    When cleansing the urinary meatus, moving the swab downwards is the correct technique. This helps to prevent the spread of bacteria from the urethra towards the bladder. By moving the swab in a downward motion, any bacteria or contaminants are wiped away from the urethral opening, reducing the risk of infection.

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  • 8. 

    While attempting to insert the catheter, its tip accidentally came in contact with the labia, as a prudent nurse, what should you do?

    • A.

      Continue on catheter insertion.

    • B.

      Get a new catheter.

    • C.

      Apply lubricant to the tip of the catheter.

    • D.

      Check for the catheters sterility.

    Correct Answer
    B. Get a new catheter.
    Explanation
    If the tip of the catheter accidentally comes in contact with the labia, it is important to prioritize patient safety and prevent the risk of infection. Getting a new catheter is the most appropriate action in this situation as it ensures that a clean and sterile catheter is used to minimize the risk of introducing bacteria into the urinary tract. Continuing with the same catheter may increase the risk of infection and compromise patient safety. Applying lubricant or checking for sterility may not address the potential contamination issue and therefore are not the best course of action.

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  • 9. 

    How many ml of sterile water will you use in inflating the retention balloon to an adult client?

    • A.

      3 ml

    • B.

      5 ml

    • C.

      15 ml

    • D.

      30 ml

    Correct Answer
    B. 5 ml
    Explanation
    The correct answer is 5 ml. When inflating the retention balloon in an adult client, 5 ml of sterile water is used. This amount is sufficient to ensure proper inflation and secure placement of the catheter. Using too little water may result in inadequate inflation, while using too much water may cause discomfort or damage to the client's bladder. Therefore, 5 ml is the appropriate amount for inflating the retention balloon in an adult client.

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  • 10. 

    While trying to inflate the balloon, the patient complained of pain. The appropriate nursing action would be:

    • A.

      Continue on insertion.

    • B.

      Encourage her to take a deep breath.

    • C.

      Aspirate the instilled fluid and advance the catheter further.

    • D.

      Introduce 5 ml of sterile water.

    Correct Answer
    C. Aspirate the instilled fluid and advance the catheter further.
    Explanation
    The patient complained of pain while trying to inflate the balloon, which suggests that the catheter may not be properly placed. Aspirating the instilled fluid and advancing the catheter further can help ensure that the catheter is correctly positioned, reducing the discomfort for the patient.

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  • 11. 

    You have inflated the catheter’s retention balloon, what will you do next?

    • A.

      Aspirate the sterile water.

    • B.

      Tape the catheter on the outer thigh.

    • C.

      Check for patency.

    • D.

      Retract the catheter.

    Correct Answer
    D. Retract the catheter.
    Explanation
    After inflating the catheter's retention balloon, the next step would be to retract the catheter. This is because the retention balloon is used to secure the catheter in place, and once it is inflated, the catheter can be safely pulled back without causing any discomfort or damage to the patient. Aspirating the sterile water or taping the catheter on the outer thigh are not necessary steps after inflating the balloon. Checking for patency should have been done before inflating the balloon, as it ensures that the catheter is properly positioned and allows for the free flow of fluids.

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  • 12. 

    The physician also ordered a cleansing enema for a client. You will be using isotonic solution. An example of this is:

    • A.

      Fleet phosphate.

    • B.

      Castor oil.

    • C.

      Tap water.

    • D.

      Normal saline solution.

    Correct Answer
    D. Normal saline solution.
    Explanation
    The physician ordered a cleansing enema for the client, which requires the use of an isotonic solution. An isotonic solution has the same concentration of solutes as the body's cells, making it safe and compatible with the body. Normal saline solution, which is a solution of sodium chloride in water, is an example of an isotonic solution commonly used for enemas. Fleet phosphate, castor oil, and tap water are not isotonic solutions and may have different concentrations of solutes, making them unsuitable for this purpose.

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  • 13. 

    You will perform a high cleansing enema. How many position changes would you tell the client to do?

    • A.

      Two.

    • B.

      Three.

    • C.

      One.

    • D.

      Four.

    Correct Answer
    B. Three.
    Explanation
    The correct answer is three because during a high cleansing enema, it is recommended to change positions three times. The first position is lying on the left side, then the second position is lying on the back, and finally, the third position is lying on the right side. These position changes help to ensure that the enema solution reaches all areas of the colon and facilitates a thorough cleansing.

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  • 14. 

    What is the safest solution to use in enema administration?

    • A.

      Saline solution.

    • B.

      Oil.

    • C.

      Fleet phosphate.

    • D.

      Tap water.

    Correct Answer
    A. Saline solution.
    Explanation
    Saline solution is the safest solution to use in enema administration. Saline solution, also known as normal saline, is a sterile solution of sodium chloride in water. It is isotonic, meaning it has the same concentration of salts as the body's cells and fluids. This makes it safe to use and minimizes the risk of electrolyte imbalances or damage to the rectal lining. Oil, Fleet phosphate, and tap water can all have potential risks and side effects, such as irritation, dehydration, or electrolyte imbalances, making saline solution the safest choice.

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  • 15. 

    Prior to enema, what will you place on the client’s bed?

    • A.

      Rubber sheet.

    • B.

      Fenestrated drapes.

    • C.

      Sterile drapes.

    • D.

      Wet packs.

    Correct Answer
    A. Rubber sheet.
    Explanation
    Prior to performing an enema, it is important to place a rubber sheet on the client's bed. This is done to protect the bed linens and mattress from any potential leakage or spillage during the procedure. The rubber sheet acts as a waterproof barrier, preventing any fluids from seeping through and causing damage to the bed. It also helps in maintaining hygiene and cleanliness during the procedure.

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  • 16. 

    As a competent nurse, you would know that the appropriate height of the enema can from the patient’s anus is:

    • A.

      12-24 inches.

    • B.

      12-18 inches.

    • C.

      16-20 inches.

    • D.

      10-12 inches.

    Correct Answer
    B. 12-18 inches.
    Explanation
    The appropriate height of the enema can from the patient's anus is 12-18 inches. This is the recommended range for the height of the enema can to ensure proper flow and distribution of the enema solution. It allows for a sufficient amount of pressure to facilitate the flow without causing discomfort or injury to the patient.

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  • 17. 

    What is the main purpose of enema administration in a patient who is about to undergo laparotomy?

    • A.

      To avoid accidental contamination of the abdominal contents.

    • B.

      To relieve flatulence.

    • C.

      To expel flatus and impacted stools.

    • D.

      To expel stools and impacted cerumen.

    Correct Answer
    A. To avoid accidental contamination of the abdominal contents.
    Explanation
    The main purpose of enema administration in a patient who is about to undergo laparotomy is to avoid accidental contamination of the abdominal contents. Laparotomy is a surgical procedure that involves opening the abdomen, and it is important to maintain a sterile environment to prevent infection. By administering an enema, the patient's bowels are emptied, reducing the risk of fecal matter contaminating the surgical site. This helps to ensure a safe and successful surgery.

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  • 18. 

    How will you position the patient during enema administration?

    • A.

      Left sims position.

    • B.

      Right sims position.

    • C.

      Dorsal recumbent position.

    • D.

      Side lying position.

    Correct Answer
    A. Left sims position.
    Explanation
    The left sims position is the most appropriate position for administering an enema. This position involves lying on the left side with the right knee flexed towards the chest. It allows for easy insertion of the enema tube into the rectum and promotes the flow of the enema solution. The left sims position also helps to minimize discomfort and ensure the effective administration of the enema.

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  • 19. 

    You primed the enema tubing’s and rectal tube before introducing the solution to the patient. The rationale behind this action is:

    • A.

      To avoid unnecessary distention.

    • B.

      To promote asepsis.

    • C.

      To expel air in the tubing.

    • D.

      To instill air into the rectum.

    Correct Answer
    C. To expel air in the tubing.
    Explanation
    Priming the enema tubing and rectal tube before introducing the solution helps to expel any air that may be present in the tubing. This is important because if air is introduced into the rectum, it can cause unnecessary distention and discomfort for the patient. Additionally, expelling air from the tubing helps to ensure that the enema solution is delivered properly and effectively. It does not promote asepsis or instill air into the rectum.

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  • 20. 

    Prior to insertion of the rectal tube, you will:

    • A.

      Cleanse the patient’s buttocks.

    • B.

      Cleanse the tip of the rectal tube.

    • C.

      Lubricate at least 2 inches of the tube.

    • D.

      Lubricate the entire tube.

    Correct Answer
    C. Lubricate at least 2 inches of the tube.
    Explanation
    The correct answer is to lubricate at least 2 inches of the tube. Lubrication is necessary to ease the insertion of the rectal tube and minimize discomfort for the patient. However, lubricating the entire tube is not necessary and may result in excess lubrication, which can be messy and uncomfortable for the patient. By lubricating at least 2 inches of the tube, it ensures that the portion of the tube that will be inserted into the rectum is adequately lubricated.

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  • 21. 

    You placed the patient in left side lying position with the right leg as acutely flexed as possible,during enema because:

    • A.

      This position facilitates the flow of solution to the stomach.

    • B.

      This position facilitates the flow of solution to the small intestines.

    • C.

      This position facilitates the flow of solution to the colons.

    • D.

      This position facilitates the flow of solution to the anus.

    Correct Answer
    C. This position facilitates the flow of solution to the colons.
    Explanation
    The correct answer is that placing the patient in the left side lying position with the right leg acutely flexed facilitates the flow of solution to the colon. This position helps to promote gravity-assisted movement of the enema solution through the descending colon and into the sigmoid colon, which is located on the left side of the abdomen. This position allows for better distribution of the solution throughout the colon, aiding in the effectiveness of the enema.

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  • 22. 

    Upon insertion of the rectal tube, you instructed your client to take a deep breath, because

    • A.

      This will relieve her anxiety.

    • B.

      This will relax the rectum

    • C.

      This will relax the internal anal sphincter.

    • D.

      This will alleviate her pain.

    Correct Answer
    C. This will relax the internal anal sphincter.
    Explanation
    Taking a deep breath can help relax the internal anal sphincter. The internal anal sphincter is a smooth muscle that surrounds the anal canal and is responsible for involuntary control of bowel movements. Deep breathing activates the parasympathetic nervous system, which promotes relaxation and can help relax the muscles, including the internal anal sphincter. This can be beneficial during the insertion of a rectal tube, as it can help reduce discomfort and facilitate the procedure.

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  • 23. 

    While inserting the rectal tube, you encountered resistance. The appropriate action will be:

    • A.

      Assess for bowel sounds and check the tubes patency.

    • B.

      Slowly administer the enema solution.

    • C.

      Run a small amount of solution to the tube.

    • D.

      Lower the enema can.

    Correct Answer
    C. Run a small amount of solution to the tube.
    Explanation
    When encountering resistance while inserting a rectal tube, running a small amount of solution through the tube is the appropriate action. This helps to lubricate the tube and facilitate its insertion. Assessing for bowel sounds and checking the tube's patency should be done before attempting to insert the tube. Slowly administering the enema solution and lowering the enema can are not appropriate actions in this situation.

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  • 24. 

    The appropriate length of rectal tube to be inserted a 27 year old client is:

    • A.

      3-4 inches.

    • B.

      2-2.5 inches.

    • C.

      1-2 inches.

    • D.

      5 inches

    Correct Answer
    A. 3-4 inches.
    Explanation
    The appropriate length of a rectal tube to be inserted into a 27-year-old client is 3-4 inches. This length is suitable for reaching the rectum and allowing for effective drainage or administration of medication. A shorter length may not reach the desired area, while a longer length may cause discomfort or injury to the client. Therefore, 3-4 inches is the correct choice for this situation.

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  • 25. 

    While instilling the solution for enema, your patient  suddenly complained of fullness. The appropriate nursing action to do is:

    • A.

      Slow the flow of the solution.

    • B.

      Stop the flow of the solution for 1 minute.

    • C.

      Twist the tube to facilitate the flow.

    • D.

      Raise the enema can.

    Correct Answer
    B. Stop the flow of the solution for 1 minute.
    Explanation
    When a patient complains of fullness during an enema, it indicates that the solution is filling the rectum too quickly. Stopping the flow of the solution for 1 minute allows the patient's body to adjust and accommodate the solution. This pause gives the patient a chance to relax and prevents discomfort or potential injury from excessive pressure. Once the minute is up, the enema can be resumed at a slower rate to ensure the patient's comfort and safety.

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  • 26. 

    After a few minutes of administration of solution, the patient complained of fullness and urge to defecate. Your intervention would be:

    • A.

      Lower the enema can and continue administering the solution.

    • B.

      Remove the tube and encourage the patient to defecate.

    • C.

      Remove the tube and encourage the patient to retain the solution.

    • D.

      Place Celine in a side lying position.

    Correct Answer
    C. Remove the tube and encourage the patient to retain the solution.
  • 27. 

    How long will you encourage the patient to hold the solution after enema administration?

    • A.

      At least 30 minutes.

    • B.

      At least 5-10 minutes.

    • C.

      For an hour.

    • D.

      For 3 hours.

    Correct Answer
    B. At least 5-10 minutes.
    Explanation
    After enema administration, it is recommended to encourage the patient to hold the solution for at least 5-10 minutes. This allows the solution to be effectively absorbed by the colon and increases the chances of successful treatment. Holding the solution for a longer period of time, such as an hour or 3 hours, may not provide any additional benefits and could potentially cause discomfort or unnecessary strain on the patient. Therefore, it is sufficient to hold the solution for 5-10 minutes to achieve the desired results.

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  • 28. 

    A commonly used hypertonic enema is:

    • A.

      Castile soap.

    • B.

      Mineral oil.

    • C.

      Tap water.

    • D.

      Fleet phosphate.

    Correct Answer
    D. Fleet phosphate.
    Explanation
    Fleet phosphate is a commonly used hypertonic enema. Hypertonic enemas are used to draw water into the colon, resulting in increased bowel movements. Fleet phosphate is a type of saline laxative that works by causing water to be retained in the colon, thus stimulating bowel movements. Castile soap and tap water are examples of isotonic enemas, which do not have the same osmotic effect as hypertonic enemas. Mineral oil is a lubricant laxative and does not have the same mechanism of action as hypertonic enemas.

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  • 29. 

    All enema solutions have side effects, except:

    • A.

      Soapsuds.

    • B.

      Saline.

    • C.

      Tap water.

    • D.

      Mineral oil

    Correct Answer
    D. Mineral oil
    Explanation
    Mineral oil is the only option among the given choices that does not have any reported side effects when used as an enema solution. Soapsuds, saline, and tap water can all cause side effects such as irritation, electrolyte imbalance, or damage to the intestinal lining. However, mineral oil is a gentle lubricant that helps soften the stool and facilitate bowel movements without causing any known side effects.

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  • 30. 

    You are going to give fleet phosphate enema. How many ml of solution will you administer?

    • A.

      90-120 ml.

    • B.

      500 ml.

    • C.

      500-100 ml

    • D.

      200 ml

    Correct Answer
    A. 90-120 ml.
    Explanation
    The correct answer is 90-120 ml. This range is the recommended amount of solution to administer for a fleet phosphate enema. The enema is used to relieve constipation and cleanse the bowels. Administering too little solution may not be effective in relieving constipation, while administering too much may cause discomfort or complications. Therefore, it is important to adhere to the recommended range of 90-120 ml for optimal results.

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  • 31. 

    You are aware that upon enema tube insertion, you will direct it:

    • A.

      Towards the rectum.

    • B.

      Towards the umbilicus

    • C.

      Along the spine

    • D.

      Towards the cecum.

    Correct Answer
    B. Towards the umbilicus
    Explanation
    The correct answer is towards the umbilicus. When inserting an enema tube, it should be directed towards the umbilicus (belly button). This is because the goal of an enema is to administer fluid into the lower part of the colon, and directing it towards the umbilicus helps ensure that the fluid reaches the desired area.

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  • 32. 

    Celine’s last menstrual period was on November 3, 2008. What is her EDD?

    • A.

      August 10, 2009

    • B.

      August 15, 2009

    • C.

      August 10,2008

    • D.

      August 15, 2008

    Correct Answer
    A. August 10, 2009
    Explanation
    Based on the given information, Celine's last menstrual period was on November 3, 2008. To calculate her estimated due date (EDD), we need to add 280 days (approximately 40 weeks) to the first day of her last menstrual period. Adding 280 days to November 3, 2008, the estimated due date would be August 10, 2009.

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  • 33. 

    Celine’s fundic height is 32cm. What would be her estimated AOG?

    • A.

      28 weeks and 5 days.

    • B.

      37 weeks and 7 days.

    • C.

      28 weeks and 6 days

    • D.

      30 weeks and 5 days.

    Correct Answer
    B. 37 weeks and 7 days.
    Explanation
    The fundic height is a measurement of the distance between the pubic bone and the top of the uterus. It is often used to estimate the gestational age of a fetus. In this case, Celine's fundic height is 32cm, which suggests a gestational age of 37 weeks and 7 days. This is because the fundic height typically corresponds to the number of weeks of pregnancy. Therefore, the correct answer is 37 weeks and 7 days.

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  • 34. 

    What would be the client’s fundic height if her AOG is 24 weeks?

    • A.

      At the level of the umbilicus.

    • B.

      Below the symphysis pubis.

    • C.

      Two finger breaths above the umbilicus.

    • D.

      At the xiphoid process.

    Correct Answer
    C. Two finger breaths above the umbilicus.
    Explanation
    The client's fundic height refers to the measurement of the height of the uterus above the pubic bone. At 24 weeks AOG, the fundic height is typically measured at two finger breaths above the umbilicus. This measurement is a standard way to estimate the gestational age and growth of the fetus.

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  • 35. 

    You performed Leopold’s maneuver. The third maneuver is also known as the:

    • A.

      Pelvic grip

    • B.

      Pawlick’s grip

    • C.

      Pavlick grip

    • D.

      Paulick’s grip.

    Correct Answer
    B. Pawlick’s grip
    Explanation
    The correct answer is Pawlick's grip. Leopold's maneuver is a series of four maneuvers used to determine the position of a fetus in the uterus. The third maneuver involves grasping the lower abdomen with both hands to assess the mobility and engagement of the fetal head. Pawlick's grip is another term used to refer to this maneuver. The other options, pelvic grip, Pavlick grip, and Paulick's grip, are not commonly used terms in relation to Leopold's maneuver.

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  • 36. 

    The third maneuver, aims to determine:

    • A.

      Determine the fetal’s degree of flexion.

    • B.

      Determine the location of back and extremities of the fetus.

    • C.

      Determine if the fetus is already engaged.

    • D.

      Determine the fetal attitude.

    Correct Answer
    C. Determine if the fetus is already engaged.
    Explanation
    The third maneuver aims to determine if the fetus is already engaged. This refers to whether the baby's head has descended into the pelvis and is engaged in the birth canal. This information is important for assessing the progress of labor and determining the readiness for delivery. It helps the healthcare provider to understand the position of the baby and plan the appropriate course of action during labor.

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  • 37. 

    After the cesarean section, a client gave birth to a baby boy. What is your immediate priority?

    • A.

      Place the infant in a side lying position and suction.

    • B.

      Place the infant in a trendelenburg position and suction.

    • C.

      Place the infant tin a side lying position and rub dry.

    • D.

      Place the infant in a side lying position under a drop light.

    Correct Answer
    D. Place the infant in a side lying position under a drop light.
    Explanation
    Placing the infant in a side lying position under a drop light is the immediate priority after a cesarean section. This position allows for proper drainage of fluids from the infant's mouth and nose, and the drop light helps to provide adequate lighting for the healthcare provider to assess the baby's condition. Suctioning may also be necessary to clear the airway if there is any mucus or amniotic fluid present. Placing the infant in a trendelenburg position or rubbing dry are not immediate priorities in this situation.

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  • 38. 

    <!--[if !supportLists]-->what would the nurse suction first and why?

    • A.

      The mouth because it has more secretions than the nose.

    • B.

      The nose because it has less secretions than the mouth.

    • C.

      The nose to prevent aspiration.

    • D.

      The mouth to prevent aspiration.

    Correct Answer
    D. The mouth to prevent aspiration.
    Explanation
    The nurse would suction the mouth first to prevent aspiration. Aspiration occurs when secretions or foreign objects enter the lungs, which can lead to respiratory complications. Suctioning the mouth helps to remove any excess secretions that could potentially be aspirated into the lungs.

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  • 39. 

    You are performing APGAR scoring. The baby is acrocyanotic, apical pulse rate of 138 bpm, good vigorous cry, with good muscle tone and respiration of 40 cpm. What is the initial apgar score?

    • A.

      8

    • B.

      6

    • C.

      9

    • D.

      7

    Correct Answer
    C. 9
    Explanation
    The baby's acrocyanosis indicates that there is slight bluish discoloration of the extremities, which is a normal finding in newborns. The apical pulse rate of 138 bpm is within the normal range for a newborn. The good vigorous cry indicates that the baby has a strong respiratory effort. The good muscle tone suggests that the baby has good muscle strength and is not floppy. The respiration rate of 40 cpm is also within the normal range. Based on these findings, the baby has a score of 9 on the APGAR scoring system, which indicates that the baby is in excellent condition at birth.

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  • 40. 

    The nurse checked for the infant’s temperature using the rectal route. This is done because:

    • A.

      Rectal route is most convenient.

    • B.

      Rectal route is accurate and it also determines the presence of imperforate anus.

    • C.

      Rectal route is accurate and effective.

    • D.

      Rectal route is the safest.

    Correct Answer
    B. Rectal route is accurate and it also determines the presence of imperforate anus.
    Explanation
    The rectal route is used to check the infant's temperature because it is accurate and can also determine the presence of imperforate anus. The rectal route provides a more accurate measurement of body temperature compared to other routes, such as oral or axillary. Additionally, by using the rectal route, the nurse can also assess the presence of imperforate anus, a condition where the anus is not properly formed or is blocked. This information is important for the infant's overall health assessment and appropriate medical intervention if needed.

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  • 41. 

    You are using aseptic technique upon cleaning the infants umbilical cord in order to:

    • A.

      Promote the infants well-being.

    • B.

      To keep the cord from exposure.

    • C.

      To prevent infection

    • D.

      To speed up drying process.

    Correct Answer
    C. To prevent infection
    Explanation
    The aseptic technique is used to prevent infection. When cleaning the infant's umbilical cord, it is important to maintain a sterile environment to minimize the risk of introducing bacteria or other pathogens that could cause an infection. By following aseptic technique, healthcare professionals can reduce the likelihood of complications and promote the infant's overall health and well-being.

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  • 42. 

    After cleaning the cord, the nurse applied a sterile cord clamp. This is done in order to:

    • A.

      Prevent bleeding.

    • B.

      Hasten the drying process.

    • C.

      Aid in infants breathing.

    • D.

      Keep the cord fresh

    Correct Answer
    A. Prevent bleeding.
    Explanation
    After the cord is cleaned, applying a sterile cord clamp helps to prevent bleeding. This is because the cord clamp tightly secures the cord, cutting off the blood supply and preventing any further bleeding. It is a standard procedure to ensure that the baby does not lose excess blood and to promote proper healing of the cord stump.

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  • 43. 

    The nurse gave crede’s prophylaxis to the fetus. You are aware that this will:

    • A.

      Prevent conjunctivitis due to syphilis.

    • B.

      Prevent blindness secondary to herpes.

    • C.

      Prevent blindness secondary to gonorrhea.

    • D.

      Prevent blindness due to candidiasis.

    Correct Answer
    C. Prevent blindness secondary to gonorrhea.
    Explanation
    Crede's prophylaxis is a preventive measure used to prevent ophthalmia neonatorum, which is a type of conjunctivitis in newborns. It involves the administration of silver nitrate or erythromycin ointment to the eyes of the newborn immediately after birth. Ophthalmia neonatorum can be caused by various bacteria, including Neisseria gonorrhoeae, which causes gonorrhea. Therefore, giving Crede's prophylaxis to the fetus can prevent blindness secondary to gonorrhea.

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  • 44. 

    The nurse gave Vit K IM to the infant’s vastus lateralis muscle. You are aware that this action is appropriate because:

    • A.

      This muscle the most convenient site for injection.

    • B.

      Because this is the most developed muscle in the infant’s body.

    • C.

      Because vit K is irritating to the subcutaneous tissue.

    • D.

      Aquamephyton is the generic name of vit k.

    Correct Answer
    B. Because this is the most developed muscle in the infant’s body.
    Explanation
    The correct answer is because this is the most developed muscle in the infant's body. The vastus lateralis muscle is one of the largest and most developed muscles in infants. It is located in the thigh and is commonly used for intramuscular injections in infants. This muscle provides a good amount of muscle mass and is less likely to cause discomfort or injury compared to other injection sites. Therefore, it is considered the most appropriate site for administering Vitamin K intramuscularly to infants.

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  • 45. 

    The nurse is bathing the infant, while cleansing the abdominal area, she is taking caution not to wet the umbilical cord, she is aware that:

    • A.

      The cord can get contaminated.

    • B.

      Wet cord is a good breeding ground for antibodies.

    • C.

      Wet cord is a good breeding ground for bacteria.

    • D.

      Wet cord can be a source of malnutrition.

    Correct Answer
    C. Wet cord is a good breeding ground for bacteria.
    Explanation
    Wet cord is a good breeding ground for bacteria because bacteria thrive in moist environments. If the umbilical cord remains wet, it provides an ideal condition for bacteria to grow and multiply, increasing the risk of infection. Keeping the cord dry helps to minimize the growth of bacteria and reduces the chances of infection.

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  • 46. 

    While examining the newborn, you noticed a soft spot between his parietal and frontal bones, you are aware that this is the:

    • A.

      Suture lines.

    • B.

      Cranium

    • C.

      Anterior fontanel.

    • D.

      Posterior fontanel.

    Correct Answer
    C. Anterior fontanel.
    Explanation
    The correct answer is the anterior fontanel. The anterior fontanel is a soft spot located between the parietal and frontal bones of a newborn's skull. It is a membrane-covered opening that allows for the growth and expansion of the skull during the early stages of development. The fontanel is palpable and can be used as a reference point for assessing the baby's hydration status and intracranial pressure. The suture lines refer to the junctions between the skull bones, while the cranium is the skull as a whole. The posterior fontanel is a different soft spot located at the back of the skull.

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  • 47. 

    You are aware that the posterior fontanel is:

    • A.

      At the temporal bone.

    • B.

      At the frontal bone.

    • C.

      Diamond in shape.

    • D.

      Triangular in shape.

    Correct Answer
    D. Triangular in shape.
    Explanation
    The posterior fontanel is triangular in shape. Fontanels are soft spots on a baby's skull where the bones have not yet fully fused together. The posterior fontanel is located at the back of the head, towards the base of the skull. It is triangular in shape, with the apex pointing towards the front of the head. This fontanel allows for flexibility and growth of the skull during infancy.

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  • 48. 

    Premature closure of the fontanels is known as:

    • A.

      A. Craniosystosis

    • B.

      B. Craniostenosis.

    • C.

      C. Craniumsystosis.

    • D.

      D. Craniophlebitis.

    Correct Answer
    B. B. Craniostenosis.
    Explanation
    Premature closure of the fontanels is known as craniostenosis. The fontanels are the soft spots on a baby's skull that allow for growth and flexibility. When they close too early, it can lead to abnormal skull shape and potential developmental issues. Craniosystosis, craniumsystosis, and craniophlebitis are not the correct terms for this condition.

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  • 49. 

    The neonate’s normal body length is:

    • A.

      44-52cm

    • B.

      46-57cm

    • C.

      46-54cm

    • D.

      42-54cm

    Correct Answer
    C. 46-54cm
    Explanation
    The correct answer is 46-54cm. This range represents the normal body length of a neonate, which refers to a newborn baby within the first 28 days of life. It is important to note that individual variations may occur, but generally, a neonate's body length falls within this range.

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  • 50. 

    You advised your classmate to do a pregnancy test, the result came positive, you are aware that her urine contains:

    • A.

      Somatrophin

    • B.

      Gonadotrophin

    • C.

      Androgen

    • D.

      Albumin

    Correct Answer
    B. Gonadotrophin
    Explanation
    Gonadotrophin is a hormone that is produced during pregnancy. Its presence in the urine indicates that the person is pregnant. Therefore, advising the classmate to take a pregnancy test was the correct course of action and the positive result confirms the presence of gonadotrophin in her urine, confirming the pregnancy.

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