Care of Mother, Child and Adolescent (Well-
Clients)
STUDENT ACTIVITY SHEET BS NURSING / SECOND YEAR
Session # 8
HILARIA, CHRISTY MAE B. SP4
CHECK FOR UNDERSTANDING (25 minutes)
You will answer and rationalize this by pair. This will be recorded as your quiz. One (1) point will be given to correct
answer and another one (1) point for the correct ratio. Superimpositions or erasures in you answer/ratio is not allowed.
Multiple Choice
1. Raisa is scheduled to have an ultrasound examination. To ensure that she understands and is prepared for
the procedure, what instruction should the nurse give her?
A. “Use the restroom immediately before the procedure to reduce your bladder size.”
B. “The intravenous fluid used to dilate your uterus will not harm the baby.”
C. “You will need to drink at least 3 glasses of water before the procedure.”
D. “You can have the medicine for the pain of any contractions caused by the test.”
ANSWER: C
RATIO: You need to drink water before the ultrasound, and don't urinate (pee) before your ultrasound because
having a full bladder will make it easier to see the uterus and ovaries.
2. Nina is scheduled to have an amniocentesis to test for fetal maturity. What instruction is best to give her
prior to the procedure?
A. “Void immediately before the procedure to reduce the size of your bladder.”
B. “The X-ray that will be used to reveal the fetal position will have no long-term fetal effects.”
C. “The IV fluid that is used to dilate your uterus is isotonic saline so it will not hurt your fetus. ”
D. “Your fetus will have less amniotic fluid for the rest of pregnancy.””
ANSWER: A
RATIO: You may or may not be asked to empty your bladder right before the procedure. In early pregnancy, a full
bladder helps move the uterus into a better position for the procedure. In later pregnancy, the bladder should be
empty to lower the risk of puncture with the amniocentesis needle.
3. The client will undergo maternal serum-alphafetoprotein (MSAFP) determination. Which of the following
specimens are required?
A. Maternal blood sample
B. Blood from the chorionic villi
C. Amniotic fluid
D. Cervical secretions
ANSWER: A
RATIO: Maternal Blood means blood samples taken from a pregnant woman. An alpha-fetoprotein (AFP) test is a
blood test done during pregnancy to check the baby's risk for birth defects. AFP is a protein normally produced by
the fetal liver and is present in the fluid surrounding the fetus (amniotic fluid), and crosses the placenta into the
mother's blood.
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4. The nurse is performing Leopold’s Maneuver. During the first maneuver, the fetal part palpated is hard, round
and movable. The nurse concludes that the fetal presentation is:
A. Cephalic
B. Breech
C. Shoulder
D. Footling
ANSWER: B
RATIO: When the mass palpated is hard, round and movable, it is the fetal head. The correct interpretation is that the
mass palpated is: The buttocks because the presentation is breech. The mass palpated is the head.
5. Which of the following statements are correct about amniotic fluid?
A. The normal volume by the end of pregnancy is from 800 to 1200.
B. It surrounds, cushions and protects the fetus and allows for fetal movement
C. It maintains the body temperature of the fetus
D. The pH of the amniotic fluid is acidic, below 7.0
ANSWER: D
RATIO: Amniotic fluid typically has a pH of 7.1–7.3, while normal vaginal secretions have a pH of 4.5–6.0.
6. The nurse measures the fundal height of a client who is at her 20th week of pregnancy. The nurse expects to
note uterine height to be
A. Halfway between the symphysis pubis and the umbilicus
B. At the level of the umbilicus
C. At the level of the xiphoid process
D. Slightly below the xiphoid process
ANSWER: B
RATIO: At 20 weeks gestation, the fundus can be palpable at the level of the umbilicus.
7. Which of the following is the primary purpose of performing a Non-stress test to a pregnant client?
A. To determine fetal well-being
B. To see if the fetus can handle the stress of labor and that medicine is given to make the uterus contract.
C. To assess slowing of fetal heart rate during uterine contractions
D. To count the fetal kicks for a period of time.
ANSWER: C
RATIO: A nonstress test (NST) helps your pregnancy care team determine if the fetus is healthy. An NST gives your
provider information about fetal heart rate in response to movement.
8. Which of the following nursing actions is not included when fetal kick counts will be done to a pregnant client.
A. Instruct the patient to sit or lie down on her side and count fetal kicks for a period of time.
B. Instruct the patient to report to the nurse or physician if there are fewer than 10 kicks in a 12-hour period
C. Secure written consent from the patient before the procedure.
D. Tell the patient that a hard, round, plastic disk called an ultrasound transducer picks up and marks and marks the
fetal heart activity on the paper and is secured over the abdomen.
ANSWER: D
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RATIO: Kick counts are a way to monitor fetal movements. It involves counting how many times you feel
the fetus move in a one-hour period. The nurse in a health care clinic is instructing a pregnant client how to perform
"kick counts." And always secure written consent from the patient before the procedure.
9. During the prenatal visit, the nurse assesses the fetal heart rate. Which of the following rates in bpm is an
expected outcome?
A. 60 to 100
B. 100 to 140
C. 120 to 160
D. 170 to 190
ANSWER: C
RATIO: The fetal heart rate depends in gestational age and ranges from 160-170 BPM in the first trimester but slows
with fetal growth to 120-160 BPM near or at term.
10. After a non-stress test is completed, the nurse is looking at the results on a test strip. The nurse observes
that the fetal heart accelerated 15 bpm for every movement. The accelerations lasted 20 seconds and occurred 3
times during the 20-minute test. The nurse is correct in interpreting the test as a:
A. reactive
B. Non-reactive
C. Positive
D. Negative
ANSWER: A
RATIO: REACTIVE (NORMAL)- 2 accelerations of FHR (by 15 beats or more) lasting for 15 seconds occur after
movement within the chosen time period.
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