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Scholarships For International Students In The United States.

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Scholarships For International Students In The United States.

List of 25 American Universities that offer Scholarships (Full Funding) and have waived TOEFL/IELTS for International Students.

Take Note of the following. Applying to these schools implies you do not have to worry about the English proficiency requirement, and you have a high chance of receiving a scholarship (funding) offer.

These schools are arranged in an alphabetical order.

Refer to attached web links of the institutions for confirmation.

Scholarships in the United States are mostly in forms of Fellowships, Teaching, Research, and Administrative Assistantships, and are not automatic in all schools. Some institutions require you apply for it after getting admission.

If you request for it, most of these schools offer application fee waivers, meaning you can apply without paying (if granted an application fee waiver).

A university may waive English proficiency requirements, but your program of interest may insist you have IELTS/TOEFL/Duolingo test scores. Be sure to double-check with your program.

Getting an English proficiency waiver is good, but if you can afford it, take the English test to boost your chances. I got 6 fully-funded offers from 5 US universities without TOEFL/IELTS, you too can.

  1. Alaska Pacific University

alaskapacific.edu/student-financ…

  1. American University

american.edu/policies/acade…

  1. Arizona State University

graduate.asu.edu/current-studen…

  1. Ball State University

bsu.edu/academics/coll…

  1. Baylor University

studentemployment.web.baylor.edu/students/gradu…

  1. Boise State University

boisestate.edu/graduatecolleg…

  1. Boston College

bc.edu/bc-web/offices…

  1. Boston University

bu.edu/cfa/admissions…

  1. California Baptist University

jobs.calbaptist.edu/postings/searc…

  1. California State University, Fullerton

hr.fullerton.edu/student-assist…

  1. Central Connecticut State University

ccsu.edu/graduate-studi….

  1. Clayton State University

catalog.clayton.edu/admissions-inf…

  1. Clemson University

clemson.edu/graduate/cost-…

  1. Columbia University in the City of New York

tc.columbia.edu/admission/fina…

  1. Dartmouth College

graduate.dartmouth.edu/admissions-fin…

  1. East Tennessee State University

etsu.edu/gradschool/fun…

  1. Eastern Illinois University

eiu.edu/graduate/stude…

  1. Eastern Kentucky University

eku.edu/gradschool/ass…

  1. Florida Atlantic University

fau.edu/graduate/resou…

  1. Florida Institute of Technology

fit.edu/provost/academ…

  1. Florida International University

gradschool.fiu.edu/students/fundi…

  1. Florida State University

gradschool.fsu.edu/funding-awards

  1. Fordham University

fordham.edu/graduate-finan…

  1. Georgetown University

gradadmin.georgetown.edu/financial-supp…

  1. Georgia Institute of Technology

catalog.gatech.edu/financial/assi…

Here are some Schools in the United States that offer full scholarships in industrial chemistry:

  • University of Denver: MS in Chemistry (Denver, CO)
  • University of Ottawa: (link unavailable) in Chemistry (Ottawa, ON, Canada)
  • University of San Francisco: MS in Chemistry
  • University of Saskatchewan: (link unavailable) in Chemistry (Saskatoon, SK)
  • University of Toronto: (link unavailable) in Chemistry (Toronto, ON)
  • Clark Atlanta University
  • California State Polytechnic University Pomona
  • South Carolina State University
  • Indiana University of Pennsylvania
  • University of Northern Colorado

25 Universities in the USA 🇺🇸 with Fully Funded Scholarship for Mass Communication — Master/PhD

  1. University of Wisconsin, Madison
  2. University of South Carolina
  3. University of Georgia
  4. University of Iowa
  5. 5) University of Minnesota
  6. Syracuse University
  7. Ohio University
  8. Liberty University
  9. Columbia University
  10. University of Florida
  11. University of Oklahoma
  12. University of North Carolina
  13. Arizona State University
  14. Pennsylvania State University
  15. Southern Illinois University
  16. University of Washington
  17. University of Kansas
  18. Texas Tech University
  19. University of Oregon
  20. University of Southern Mississippi
  21. University of New Mexico
  22. Rutgers University
  23. Stanford University
  24. Howard University
  25. Texas A&M University
  26. University of Texas at Dallas
  27. University of Houston
  28. University of Kentucky
  29. University of Indiana
  30. Georgia State University

If you are interested in Microbiology or Public Health, check these schools in USA 🇺🇸:

  1. Emory University
  2. University of Florida
  3. Indiana University Bloomington
  4. Ohio State University
  5. University of Kentucky
  6. University of Nebraska-Lincoln
  7. University of Oklahoma
  8. University of Tennessee, Knoxville
  9. University of Vermont
  10. Florida State University

POLITICAL SCIENCE

  1. University of Arizona
  2. University of Pittsburgh
  3. Pennsylvania State University
  4. Syracuse University
  5. University of Oregon
  6. Indiana University Bloomington
  7. University of Georgia
  8. University of Iowa
  9. University of Colorado Boulder
  10. University of California, Irvine (UCI)
  11. University of Kentucky
  12. Arizona State University
  13. University of Kentucky
  14. Georgetown University
  15. University of Utah
  16. University of Kansas
  17. University of Oklahoma

Neonatal Disorders

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Neonatal Disorders

Neonatal disorders mean disturbance of normal state of body, organs and abnormal function of a newborn.

This birth disorders could vary from

  • GIT disorders
  • respiratory tract disorders circulatory tract disorders

GIT DISORDER

CLEFT LIP PALATE

  • This are congenital deformities which occur due to failure of the function of the tissue found in the lips and pallet.
  • this are also congenital facial malformations resulting from the faulty embryonic development
  • Cleft lips and pallet almost invariably affect the upper lips.
  • It may occur alone on it owns
  • It may affect both sides.
  • It may affect one side of the face and nostrils.

CAUSES OF CLEFT LIP AND PALATE

  • One of the major causes is Cortisone inhalation and intoxication
  • Viral infection e.g Rubella
  • Oxygen/vitamin deficiencies
  • Ultraviolet radiation
  • Mutant gene- this is as a result of high incidence in monozygotic twins which is most common in kale twins
  • Terri genius agent e.g drugs that are very halidomite

SIGN AND SYMPTOMS

  • Abnormal breathing pattern
  • Difficult in feeding
  • Sighs of dehydration
  • Nasal cartarh
  • Impaired speech
  • Skin tug-or

MANAGEMENT OF COMMON CLEFT LIP AND PALATE

  1. In cleft lip, treatment is carried out 3-4 months surgically
  2. In preop care the child must be trained on how to take food with a special spoon
  3. Swag got culture and sensitivity both nostril and throat

POST-OP CARE

  • Do all Nursing care as required to other post op care.
  • Fluid observation is strictly in cleft lip and palate.
  • Check if site is bleeding of not before taking to the ward.
  • Observe strictly 15-30-1hr.
  • Observe for sign of pain, facial expressions and cry.
  • Maintenance of personal hygiene with sterile gauze.
  • Give antibiotics as prescribe e.g cefuroxine, ceftriaxone.
  • Clean mouth with convenience. on discharge therefore refer child to special speech therapist.

2. OESOPHAGEAL ATRESIA

  • This is a congenital disorder in which a baby’s esophagus does not form properly during pregnancy.
  • With esophageal atresia, babies have two separate tubes instead of one—and they are not connected to each other.
  • Esophageal atresia comes in several different forms, some of which can cause additional complications for your baby.
  • Up to 90% of babies with esophageal atresia also have another birth defect called a tracheoesophageal fistula: This means their esophagus connects to their trachea — their windpipe — instead of their stomach.
  • This can cause them to inhale or choke on what they swallow.

TYPES OF OESOPHAGEAL ATRESIA

The different types of esophageal atresia (EA), with or without tracheoesophageal fistula (TEF), are defined by where the esophagus is closed and where it connects to the trachea, if it does.

  1. Type A : While it isn’t the most common, Type A is the most classical version of esophageal atresia.
  • This version doesn’t include a tracheoesophageal fistula.
  • Instead, the esophagus is simply closed at the bottom.
  • It ends some distance above the stomach as a closed pouch.

Type B : In Type B, the esophagus is closed at the bottom, and a tracheoesophageal fistula branches off from the upper part of the esophagus, connecting it to the trachea.

Type C : This is the most common type of esophageal atresia.

  • In Type C, the esophagus is in two separate pieces. The upper part that connects to the mouth ends in a closed pouch.
  • The lower part connects to the stomach at the bottom and the trachea at the top.

Type D: This is the rarest type, and also the most severe.

  • In Type D, the esophagus is in two unconnected segments, and both segments have separate tracheoesophageal fistulas.

SIGN AND SYMPTOMS

  • Coughing.
  • Choking.
  • Cyanosis (a bluish tint to the skin, a sign of low oxygen).
    Additional signs and symptoms can include:
  • Foamy mucus in your baby’s mouth.
  • Excess saliva, spitting up or drooling.
  • Gagging when attempting to feed.
  • Respiratory distress.

CAUSES

Esophageal atresia is a congenital malformation, which means something forms differently during fetal development, leaving a defect that’s present at birth.

  • In typical fetal development, the esophagus and trachea begin as one tube, which later separates. Esophageal atresia (and often, tracheoesophageal fistula with it) occurs when this tube doesn’t finish developing and separating. This is the main cause.

MANAGEMENT

Treatment for esophageal atresia includes

  • stabilizing baby’s breathing,
  • providing safe nutrition and ultimately,
  • repairing the malformation through surgery.
  • Some babies may be in the hospital longer than others.

Most of the time, surgery can fix the abnormality soon after the baby is born.

  • Some babies may need to stay a little longer in the hospital, receiving nutrition and breathing support, before they’re ready for the operation.
  • They may need more time to grow if they were born prematurely or if their esophagus is too short to repair.
  • Some may need treatment for other life-threatening conditions first, like heart malformations.

INITIAL MANAGEMENT

  1. Suctioning of fluids from your baby’s esophagus.
  2. Installing a breathing tube to protect their airway.
  3. Installing a feeding tube or IV to deliver nutrition and fluids.
  4. IV antibiotics to prevent or treat pneumonia.

EXTENDED NEONATAL CARE

  • Some babies may need to spend more time in the neonatal intensive care unit (NICU) before they’re ready for esophageal atresia surgery.
  • This includes babies born prematurely, babies with multiple congenital malformations and babies with long-gap esophageal atresia (LGEA).
  • Long-gap EA means that the two segments of the esophagus are too far apart to connect in surgery.
  • They need more time to grow and close the gap.

SURGICAL REPAIR

The goals of esophageal atresia surgery are to:

  • Connect separate segments of the esophagus together (anastomosis).
  • Close off any connections between your baby’s esophagus and airway.
  • Depending on THE baby’s condition, surgery Can be done for all of this, or they surgery in stages, addressing the fistulas first.

Surgery on the baby’s esophagus is called thoracic surgery. which is an incision through the thoracic cavity.

  • When possible, surgeons use minimally invasive surgery methods to repair esophageal atresia.
  • This means the baby’s chest is access through small incisions instead of opening it up.
  • A surgeon inserts a small video camera (thoracoscope) through one micro-incision and operates through another, guided by the video.

COMPLICATION

  • Rarely, the repaired esophagus may continue to leak even after it’s had ample time to heal. This means the anastomosis failed for some reason. An anastomotic leak would require a second surgery to fix it.
  • Another possible complication is that the esophagus develops excessive scar tissue at the site of the anastomosis, which makes it too narrow (esophageal stricture). It might need stretching after surgery.

3. EXOMPHALOS (OMPHALOCELE)

Exomphalos is a type of abdominal wall defect.

  • It occurs when a child’s abdomen does not develop fully while in the womb.
  • Early in all pregnancies, the intestine develops inside the umbilical cord and then usually moves inside the abdomen a few weeks later.
  • In exomphalos, the intestines and sometimes other organs such as the liver, remain inside the umbilical cord but outside the abdomen.

CAUSES OF EXOMPHALOS

  • The causes still remain IDIOPATHIC
  • Although it is becoming more common, affecting around two in every 5,000 children born each year. Exomphalos can be associated with other problems.

GASTROSCHISIS

Gastroschisis is a birth defect in which an infant’s intestines stick out of the body through a defect on one side of the umbilical cord.

  • The child’s intestines can be easily seen.
  • The condition is similar to an omphalocele (EXOMPHALOS), a birth defect in which the infant’s intestine or other abdominal organs stick out of the belly button area.
  • Other associated congenital defects are rare in patients with gastroschisis.

INCIDENCE

The reported incidence of abdominal wall defects in the United States is estimated to be the following:

  1. Gastroschisis: 1 case in 2,229 births (about 1,871 infants each year)
  2. Omphalocele: 1 case in 5,386 births (about 775 babies annually)
  3. Bladder exstrophy: 1 case in 50,000 births
  4. Ectopia cordis: 1 case in 125,000 births
  5. Cloacal exstrophy: 1 case in 10,000 – 70,000 to 1 case in 200,000 – 400,000 births.

CLINICAL MANIFESTATIONS OF EXOMPHALOS

  • Exomphalos is immediately recognisable because the child’s intestines are outside the body and covered in a membrane.
  • The size of the bulging membrane containing the intestines and other organs varies from a small protrusion to quite a large lump.

TYPES
There are two types of exompahlos:

  1. Exomphalos minor: This is where the opening is less than 4cm and only containing the intestine.
  2. Exomphalos major: This is where the opening is greater than 4cm and/or with the liver inside the cord.

DIAGNOSIS

  • In many cases, exomphalos is visible on prenatal ultrasound scanning, which is useful because it gives time for discussions and planning for when and where to give birth.
  • Generally, children are born naturally (vaginal childbirth) but some, especially if they have a very large exomphalos, may need a caesarean section.

MANAGEMENT OF EXOMPHALOS

Exomphalos is a serious condition so needs prompt treatment soon after birth.

  • Children born with exomphalos are usually transferred to a special facility immediately.
  • Immediately after birth, if the membrane covering the intestines is intact, the child will be kept warm and hydrated until they are transferred to a special facility.
  • Depending on the size of the exomphalos, the infant may need to have it repaired in one operation or in several stages.
  • If the exomphalos is small and the child is stable, they may have an operation soon after transfer, where the surgeon replaces the contents back inside the abdomen and closes up the base of the umbilical cord.
  • If the exomphalos is larger, contains the liver and/or the child needs to be stabilised, doctors may place a silo or pouch over the intestines, which is closed over a period of days to weeks, to allow the child to grow so that there is room inside the abdomen.
  • Therefore the basical treatment of exomphalos is SURGERY.

GASTROSCHISIS

In gastroschisis, there appears to be a weakness in the body wall (caused by defective ingrowth of mesoderm, or impaired midline fusion, or inappropriate apoptosis) that allows the intestines to herniate through this defect into the amniotic cavity.

Omphaloceles and gastroschisis

1. Omphaloceles
In infants with omphaloceles, the intestines do not return to the abdominal cavity; rather, they remain within the extra-embryonic coelom (amniotic cavity) bounded by the umbilical ring.

  • There is evidence to suggest that omphaloceles have a genetic etiology, as follows:
  1. Omphaloceles are associated with increased maternal age.
  2. Omphaloceles occur in twins, consecutive children, and different generations of the same family.
  3. Omphaloceles are associated with trisomy 13, 18, and 21 (in 25%-50 % of cases) and with Beckwith-Wiedemann syndrome

2. Gastroschisis
In gastroschisis, there appears to be a weakness in the body wall (caused by defective ingrowth of mesoderm, or impaired midline fusion, or inappropriate apoptosis) that allows the intestines to herniate through this defect into the amniotic cavity..

  • Gastroschisis occurs in young mothers with low gravida; it is associated with prematurity and small-for-gestational-age (SGA) infants, and denotes in utero growth retardation.
  • The clustering of cases (number and severity) suggests a multifactorial etiology, including environmental factors acting upon susceptible hosts.

IMPERFORATE ANUS (ANAL ATRESIAIMPERFORATE ANUS (ANAL ATRESIA)

  • This is the absence of anal opening
  • It is obvious at birth
  • Ensure a Rectal thermometer is inserted at birth to diagnose Imperforate Anus as a midwife
  • Therefore it is a congenital anorectal malformation (ARM) where a normal anal opening is absent at birth.

CAUSES

Imperforate anus may occur in several forms:

  1. The rectum may end in a pouch that does not connect with the colon.
  2. The rectum may have openings to other structures. These may include the urethra, bladder, base of the penis or scrotum in boys, or vagina in girls.
  3. There may be narrowing (stenosis) of the anus or no anus.

Therefore, it is caused by abnormal development of the fetus.

  • Many forms of imperforate anus occur with other birth defects.

Normal Labor

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Normal Labor

INTRODUCTION

The joy of every pregnant mother is to have a safe delivery and a healthy baby. The role of a competent midwife in achieving this cannot be overemphasized. An understanding of the concept/process of labour and management of normal labour, is therefore of utmost importance.

Labour is defined as the process by which the fetus, placenta and membranes are expelled through the birth canal, it involves more than the expulsive muscular effort of the uterus, being a strenuous ordeal in which the woman’s whole body participate. 

Normal labour occurs when the fetus is born at term, and present by the vertex, the process is completed spontaneously (by the natural unaided effort of the mother) the time does not exceed 18hours, no complication arises There are four stages of labour namely: First, second, third and fourth stage of labour.

1. First stage of labour – This is the dilatation phase. It begins with regular rhythmic contraction and is complete with the full dilation of the cervix. Average duration in primigravida is 12 hours and 6 hours in multigravida. This involves

– The latent phase- This occurs from cervical dilatation of 0-3-4cm. This phase begins with mild, irregular uterine contraction that softens and shortens the cervix.   Contractions are mild and short, lasing 20-40 seconds. The latent phase may last up to 6-8 hours in a primipara.

– The active phase – In this phase, the cervix undergoes rapid dilatation. It starts from cervical dilatation of 3- 4cm and is completed when the cervix is fully dilated. Contractions grow stronger lasting 40-60 seconds and occur every 3-5 minutes. Lasts 3hrs in primip and 2 hours in multip It is characterised by rapid cervical dilatation and descent of the presenting part. 

– The transitional phase – This is the stage of labour when the cervix is 8cm dilated  till full dilatation of the cervix. Contractions may reach the peak of intensity occurring every 3 minutes.  There may be a brief lull in the intensity at this time.

2. Second stage of labour – This is the expulsive phase. It begins with the full dilation of the cervix to expulsion of the baby. Average duration is about thirty minutes in primigravida and 15 minutes in multigravida

3. Third stage of labour – This involves the separation and expulsion of placenta and its membranes. It also involves the control of bleeding. It starts from the expulsion of the baby to the expulsion of placenta and its membrane. Duration is 15 minutes

4. Fourth stage of labour – This is the period of one hour following the birth of the baby. It is described by some in order to stress the continued vigilance which is necessary because of the risk of post -partum haemorrhage.

 

DEFINITION OF TERMS

Pregnancy: A condition of having a developing embryo or fetus within the body, the state from conception to delivery of the fetus. The normal duration is 280 days 40weeks or 9 months.

Midwifery: Is the art and science of caring for women undergoing normal pregnancies, labour and puerperium.

Primigravida: A woman pregnant for the first time.

Multigravida: A pregnant woman who has previously had more than one pregnancy.

Grande- multigravida: A pregnant woman who has had 4 or more previous pregnancies.

Multipara: A woman who has given birth to more than one viable infant.

Gravid: means pregnancy

Gravida: a pregnant woman

FACTORS INFLUENCING THE ONSET OF LABOUR

The exact cause of spontaneous labour is not clear, however, it appears to be the result of a combination of factors which can be hormonal and mechanical.

– Hormonal 

– Mechanical factors 

Effect of hormones on onset of labour

OESTROGENS – They have the following effects:

1 Hypertrophy of the myometrium accomplishing the normal growth necessary for forceful contraction of labour and rise in the contractile protein level in the myometrial cells

2  Stimulation of the synthesis, release and effect of oxytocin and prostanglandins. It increases responsiveness to oxytocin by increasing expression of oxytocin receptors

3 Stimulation of the development of progesterone receptors

4 Increased irritability of the myometrium is ascribed generally to oestrogen.

 

2 PROGESTERONE

       Progesterone produced by the placenta relaxes uterine muscles by interfering with the conduction of impulses from one cell to the next. It has an opposite effect to oestrogen, progesterone has a sedative effect on uterine muscles, so its withdrawal at the end of pregnancy may facilitate the onset of labour.

3. OXYTOCIN

Oxytocin from the posterior pituitary gland has a stimulating action on the pregnant uterus and can be used to induce labour.  The number of oxytocin receptors strikingly increase in myometrium and decidua tissues near the end of term. Oxytocin acts on decidua tissue promoting the release of prostaglandin

4 PROSTANGLANDIN

      They are synthesized in the decidua at term in response to the release of oestrogen by the feto placenta unit.  They play a major role in the initiation of labour. Prostaglandin acts by inhibiting calcium binding, thereby increasing free calcium which in turn stimulates uterine contraction.  Both oxytocin and prostaglandin act synergistically inhibiting calcium binding and stimulate uterine contraction. Its synthesis reaches its peak in third stage which helps in placental expulsion and control of post -partum haemorrhage. Its synthesis is triggered by rise in oestrogen level, mechanical stretching, stripping of membranes, altered oestrogen and progesterone balance.

Before labour, Prostaglandin stimulates cervical ripening, the breakdown of cervical connective tissue causing it to be soft, flexible and capable of dilatation.

The level of prostaglandin or their metabolites in amniotic fluid, maternal plasma and maternal urine are increased during labour. During labour, they stimulate myometrial contraction 

Others are:

5 INTRA-AMNIOTIC VOLUME

        Distension of the uterus may play a role. Rupture of membrane with a decrease in uterine volume is used to induce labour.

MECHANICAL– As pregnancy advances, there is an increase in the contractibility of the uterus, which b ecomes more susceptible to stimulation as term approaches. The pressure of the presenting part on the nerve endings in the cervix play some part- experience shows that labour is more likely to start on time when the head is engaged than when it is high. Over distension of the uterus as occurs with twins or polyhydramnios, tends to induce labour.

PREMONITORY SIGNS OF LABOUR

During the three weeks prior to onset of labour, certain changes take place which when manifest are useful to determine the approach of labour, they are;

1. Lightening: This is the sinking of the uterus, which take about two or three weeks before term, because the fundus no longer crowds the lungs, breathing is easier the heart and stomach can function better and the relief experienced by the woman is described as lightening. It occurs because the symphysis pubis widens, the softened, relaxed pelvic floor sags by as much as 4cm allowing the uterus to descend further into the true pelvis. The lower segment stretches and the fetus sinks further down into the uterus. The fundus is therefore at a lower level, the uterus becomes more prominent and if the abdominal muscles are in good tone as found in a primigravid woman, and no disproportion exist, the head will enter the pelvic brim and become engaged. In multiparous women the bracing action of firm abdominal muscles may be absent, and the uterus will then sag further forward, the abdomen becomes pendulous and the fetal head does not as a rule become engaged. Walking is more difficult at this time, relaxation of the pelvic joint may give rise to back ache or pain in the region of the symphysis pubis vague discomfort may be experienced in the lower abdomen, groins and thighs. Vagina secretion becomes more profuse.

2. Frequency of micturition: This may be due to pressure of the fetal head on the bladder limiting its capacity and requiring it to be emptied more often. But sometimes there is a state of mild incontinence or poor control of the urethral sphincter, which may be accounted for by the lax condition of the softened pelvic floor at this time.

3. False pains: These are erratic and irregular contractions, causing the uterus to contract and relax, whereas in true labour the uterus contracts and retracts. They may be unduly troublesome and some consider this to be mild in coordinate uterine action.

4. Taking up of the cervix; Taking up of the cervix occurs because it is being drawn up and merged into the lower uterine segment. Shortening of the cervix is usually looked for, when in the interest of mother or child, labour must be induced.

DIFFERENCES BETWEEN TRUE AND FALSE LABOUR

TRUE LABOUR

FALSE LABOUR

• Marks the onset of labour

Appear days before labour

• Associated with efficient uterine contraction

Inefficient contractions of uterus/painful spasm of uterus, bladder and abdominal wall

• Occur at regular intervals

Irregular intervals

• Increase in frequency and duration

No change

• Bloody show present

No show

• Descent of presenting part

Inefficient to push the presenting part

• Contractions start at the back and radiate to the front

Mainly in the front

• Hardening of uterus

No hardening of the uterus

• Progressive effacement

• and formation of bag of membranes

No change in cervix

• Sedation/enema does not interfere with true labour

Relieves the pain

• Dilatation of the cervical os

No change in size and shape of cervix

MECHANISM OF NORMAL LABOUR

This refers to the series of changes in position and attitude that the fetus adopts during its passage through the birth canal. As the fetus descends, soft tissues and bony structures exert pressures which lead to descent through the birth canal by a series of movement which are referred to as ‘mechanism of labour’. 

Engagement – Engagement is said to have occurred when the widest part of the presenting diameter has successfully passed through the brim of the pelvis. The number of fifths of the fetalhead palpable abdominally is often used to describe whether engagement has occurred. If more than two-fifths of the fetalhead is palpable abdominally, then the head is not engaged.

Denominator – The most identifiable peripheral bony point on the presenting part. In a vertex presentation, the denominator is the occiput, while in a breech presentation, the denominator is the sacrum

Attitude – This refer to the relation of the fetal parts to one another. The normal attitude of the fetus is that of moderate flexion of the head, flexion of the arms onto the chest and flexion of the legs onto the abdomen

Lie – The fetal lie refer to the relationship of the cephalocaudal(long) axis of the fetus to the cephalocaudal(long) axis of the uterus.

Presentation – This is determined by the fetal lie and by the body part of the fetus that enter the pelvic passage first. This portion of the fetus is referred to as the presenting part. This refer to the part of the fetus which lie at the pelvic brim or in the lower pole of the uterus

Station – This refer to the relationship of the presenting part to an imaginary line drawn between the ischial spine of the maternal pelvis. The Ischia spine is being designated as zero station. A negative number is assigned to presenting part higher than the Ischia spine, while a positive number indicate that the presenting part has passed the Ischia spine.

Presenting part – The portion of the presentation overlying the internal os or felt through the cervical canal on internal examination. eg the presenting part in a cephalic presentation could be vertex, face or brow.

Position – This refer to the relationship between the denominator of the presenting part and six parts on the pelvic brim. The occiput is directly laterally to the left in left occipito-anterior (LOA)

Principles common to all mechanisms are:

• Descent takes place

• Whichever part leads and meet the resistance of the pelvic floor will rotate forward until it comes under the symphysis pubis

• Whatever emerges from the pelvis will pivot around the pubic bone.

 

At the onset of labour, the most common presentation is the vertex, and the most common position is either left or right occipito anterior (ROA); 

The mechanism therefore is

• The lie is longitudinal

• The presentation is cephalic

• The position is right or left occipito-anterior

• The attitude is that of good flexion

• The denominator is the occiput

• The presenting part is the posterior part of the anterior parietal bone.

MAIN MOVEMENTS OF THE FETUS

DESCENT – Descent of the fetal head into the pelvis often begin before the onset of labour. Further descent takes place during the first stage of labour, and is brought about by the action of the uterine contractions. When the head meets resistance flexion is increased and the dilating cervix allows the flexed head to descend.

FLEXION – Flexion increases throughout labour, with the sub-occipito-frontal diameter of 10cm lying at the pelvic brim but when flexion is increased the sub-occipito bregmatic diameter of 9.5cm engages, this smaller diameter facilitate descent. The effect of increased flexion of the head is that the occiput becomes the leading part.

INTERNAL ROTATION OF THE HEAD –The occiput which is the leading part reaches the pelvic floor 1st and rotates 1/8th of a circle to appear under the pubic arch, the head is in an anterior posterior diameter of the pelvis. The head slips beneath the sub-pubic arch and crowning occurs. Crowning is the term used when the occipital prominence escapes under the sympysispubis and the head no longer recedes between uterine contraction 

EXTENSION OF THE HEAD –Extension is a movement by which flexion of the head is undone.  The nape of the neck pivot on the lower border of the symphysis pubis, while the sinciput, face and chin sweep the perineum and are born by a movement of extension. 

RESTITUTION –This is a turning of the head to undo the twist in the neck, in a vertex LOA the occiput restitute 1/8th of a circle to the left, back to where it was before internal rotation took place.

INTERNAL ROTATION OF THE SHOULDERS – This is a movement similar to internal rotation of the head, the shoulders in an ‘LOA’ are in the left oblique diameter of the pelvic cavi   ty. The anterior shoulder reaches the pelvic floor 1st and rotates forward 1/8th of a circle bringing the shoulders into the ante- posterior diameter of the outlet.  The anterior shoulder lie under the symphysis pubis 

EXTERNAL ROTATION OF THE HEAD – This is a turning of the head which accompanies internal rotation of the shoulders, the occiput turns a further 1/8th of a circle always in the same direction as in restitution 

LATERAL FLEXION – The shoulders are often born sequentially. The anterior shoulder slips beneath the sub pubic arch/symphysis pubis and the posterior shoulder sweeps/passes over the perineum. The remaining part of the body is born by movement of lateral flexion towards the mother’s abdomen

 

PHYSIOLOGY OF FIRST STAGE OF LABOUR

• UTERINE ACTION

• MECHANICAL FACTORS

              Uterine action – These are the changes that occur in the uterus during labour

1. Fundal dominance – Each of the uterine contraction starts in the fundus, near one of the cornua, and it spreads across and downwards. The area of myometrium near the cornuaact as pacemakers to coordinate the contractions. The contraction last longest in the fundus where it is also most intense and the peak is reached simultaneously over the whole uterus and the contraction fades from all parts together. This pattern allows the  cervix to dilate, and the strongly contracting uterus to expel the fetus.

 

2. Polarity – This is used to describe the neuro-muscular harmony between the upper and lower uterine segment of the uterus throughout labour. These two poles act harmoniously during labour. The upper pole contract strongly and retracts to expel the fetus; the lower pole contract slightly and dilates to allow for expulsion. Once polarity is disorganised, the progress of labour will be inhibited.

 

3. Retraction – Uterine muscles have a unique property, during labour, the contraction does not pass off totally, but muscle fibres retain some of the shortening of the contraction instead of becoming completely relaxed, this is referred to as ‘retraction’. It assists in progressive expulsion of the fetus; the upper segment becomes progressively shorter and thicker and the cavity diminishes. Uterine contraction occurs in early labour every 15-20 mins and may last for about 30 secs, they are fairly weak and bearable. 

 

4. Formation of upper and lower uterine segments – The body of the uterus divides into two segment which are anatomically distinct by the end of pregnancy. The upper uterine  segment is mainly concerned with contraction and is thick and muscular. The lower uterine segment is the thinner distensible area. The lower segment develops from the isthmus and is about 8-10cm in length. When labour begins, the retracted longitudinal fibres in the upper segment pull on the lower segment causing it to stretch; this is aided by the force applied by the descending head or breech.

 

5. The retraction ring – Retraction ring is a ridge that forms between the upper and lower uterine segment, this is physiological in origin. The term ‘Bandl’s ring is used for an exaggerated degree of this phenomenom. It becomes visible above the symphysis pubis in obstructed labour. The normal retraction ring gradually rises as the upper uterine segment contracts and retracts and the lower uterine segment thins out to accommodate the growing fetus. Once the cervix is fully dilated and the fetus can leave the uterus, the retraction ring rises no further.

 

6. Cervical effacement – This may take place during the last few days of pregnancy or during labour. The muscle fibres surrounding the internal os are drawn upwards by the retracted upper segment and the cervix merges into the lower uterine segment. The cervical canal widens at the level of the internal os. In the primip, cervical dilatation does not begin until effacement is complete while in multip, the external os begin to dilate before effacement is complete.

 

7. Cervical dilatation – Dilatation of the cervix is the process of enlargement of the os uteri from a tightly closed aperture to an opening large enough to permit passage of the fetalhead. Cervical dilatation is measured in centimetres and full dilatation equates about 10cm. Dilatation occur as a result of uterine action, counter pressure applied by the bag of membranes and the presenting part.

 

8. Show – As a result of the dilatation of the cervix, the operculum which is formed by the cervical plug during pregnancy will be lost. It is a blood stained mucoid discharge seen few hours before or few hours after labour starts. The blood comes from ruptured capillaries in the parietal decidua where the chorion has become detached and from the dilating cervix.

MECHANICAL FACTORS

1. Formation of fore waters – As the lower uterine segment forms, the chorion becomes detached from it and the increased intrauterine pressure causes the loosened part of the sac of fluid to bulge downwards into the dilating internal os to the depth of 6-12mm. The well flexed head fits snugly into the cervix and cuts off the fluid from the front of the head from that which surrounds the body, the former is referred to as the fore water and the latter, the hind water. The effect of separation of the fore waters is to prevent the pressure applied to the hind water during uterine contraction from being

applied to the fore waters thus keeping the integrity of the membranes during the first stage of labour.

 

2. General fluid pressure – with the membranes intact, the pressure of the uterine contraction is exerted on the fluid, and because fluid is not compressible, the pressure is equalised throughout the whole uterus and over the fetalbody, this is referred to as

the general fluid pressure. Preserving the integrity of the membranes during labour optimises the oxygen supply to the fetus and also prevents intra uterine infection.

 

3. Rupture of the membranes – Physiologically, the ideal time for rupture of membranes is at the end of the first stage of labour, when the cervix becomes fully dilated and no longer supports the bag of membranes with increasing force of t        he uterine contraction. Membranes may however rupture days before labour begins or during the first stage of labour. Occasionally the membranes do not rupture even till the second stage of labour and they appear as a bulging sac at the vulva covering the baby’s head as the baby is born, this is referred to as ‘caul’. 

 

4. Fetal axis pressure – With each contraction, the uterus rears forward and the force of the fundal contraction is transmitted to the upper pole of the fetus down the long axis of the fetus and is applied by the presenting part to the cervix. This is referred to as fetal axis pressure, it becomes more significant after rupture of membranes and during the second stage of labour.

MANAGEMENT OF FIRST STAGE OF LABOUR

When a patient arrives the hospital, she should be welcomed in a friendly manner and made to feel that she is expected. Reassure the patient and relatives and make patient comfortable.

A welcoming attitude and a comfortable environment will encourage couple to relax and respond positively to the forces of labour. The midwife must make an immediate assessment of whether delivery is imminent and if so, admission procedures and preparation for the birth is made

 

The bio data i.e Name, Age, etc of the patient should be confirmed with the patient’s chart. Gestational age, parity, history of previous and present pregnancies, weight of previous babies, full social medical and obstetric history must have been obtained and recorded in patient’s ante natal card. In case patient is un-booked, all of this information will have to be obtained afresh.

The history of labour taken by the midwife includes the following

1. The uterine contraction

2. Show

3. Rupture of membranes

4. Sleep, rest and food

 

– The uterine contraction

The midwife ask the woman when regular uterine contraction started, how often they are coming and if she experience backache, discomfort or pain in the lower abdomen. The severity or character of the uterine contraction should be ascertained whether it is expulsive in nature or not.

 

– Show

The woman is asked if she has seen show at home or if her undergarment is stained with mucoid blood.

– Rupture of membranes

 

Abdominal examination – The shape of the abdomen is observed by the midwife, if it is pendulous, round, small or large for gestational age. This is noted by the midwife

With the woman in a lying down position, the midwife examines the abdomen she also looks out for oedema- pretibial oedema or puffiness of the fingers or face.

An abdominal examination is conducted to determine

– The lie of the fetus

– The presentation

– The position as well as engagement of the fetal head

– The fetal heart sounds are listened to, and recorded

The abdominal examination is repeated at intervals to identify progress and recognise any deviation from normal.

 

Vagina examination – This is carried out to know the baseline data and also assess the cervical effacement and dilatation, presentation, assess progress and determine any deviation from normal

 

General management

Knowing well that labour is an event having great physiological, social and emotional meaning for the mother and her family, the midwife who is the caregiver should display tact, sensitivity, skill, imagination, patience, integrity, and respect the needs of each individual and provide a conducive environment within which each woman can labour and give birth with dignity. Good management of labour calls for a lot of understanding from the midwife. The areas of management includes the following

• Environment – The environment in which a woman delivers should be conducive physically and psychologically. The physical environment should be free from harm and infection. Facilities and necessary materials should be made available. The attitude of the staff should be welcoming and not repulsive, intimidating or abusive. Anxiety will affect the woman negatively all through the process of labour. 

• Emotional support – Apart from the traditional role a midwife plays that includes being ‘with woman’. She has the role of imparting confidence, giving care to her     patient and being dependable. The midwife should be tolerant, non-judgemental and being an advocate for the childbearing woman. The labouring woman must be free to ask questions and midwives must give necessary information by explaining procedures to be done and also explaining findings. Privacy must also be strictly provided for a woman in labour

• Prevention of infection – The midwife must make sure infection is reduced to the barest minimum for a woman in labour. This should start ante-natally as the woman should have been educated on the factors which affect resistance to infection, which include; nutritional status, hygiene, rest, blood, skin and membranes. Since nosocomial infection can be contacted, it is the responsibility of the midwife to make sure that high standards of cleanliness are maintained in the wards even if she does not have managerial control over domestic services. Protective materials eg gloves, apron etc should be worn by the midwife. Soiled materials, pads and body fluids should be well discarded. Invasive procedures eg vaginal examination should be reduced to the barest minimum to limit the spread of infection.

• Position and mobility – The midwife must be flexible during labour and allow the woman to adopt any position suitable for her during labour. She may walk about, rock, adopt a kneeling position or squat unless there’s a contraindication eg ruptured membrane, APH, auto cavalocclusion, narcotic analgesia etc.

• Nutrition – Different hospitals have different policies regarding feeding in labour, but a woman can take light diet in labour if tolerated. Most patients in labour have poor appetite but dehydration must be avoided at all cost. Women need energy in labour, therefore juice, tea, toast, sips of ice etc which are easily digestible can be taken to give energy. Alternatively, an intravenous infusion can be put up to provide glucose and fluid to reduce risk of conditions like gluconeogenesis and keto-acidosis.

• Bladder care – The woman should be encouraged to empty her bladder every 2 hours in labour because a full bladder may impede descent of the fetal head and inhibit effective uterine contraction. All efforts should be made to make the woman void naturally after which a catheter is passed if it fails.

• Observations – The vital signs of the woman is observed during labour to detect any deviation from normal. Pulse is taken every 1-2 hours, a rise in pulse may indicate infection, ketosis, and haemorrhage or ruptured uterus. Temperature is taken 4 hourly; a rise in temperature may suggest infection or ketosis. Blood pressure is also taken 4hourly. Hypotension may be caused by supine position, shock, or epidural analgesia. Urine must be tested for glucose, ketones and protein during labour. Ketones may occur as a result of starvation or maternal distress. Fluid balance must be maintained by keeping strict intake and output charts. 

The progress of labour is monitored by noting; contractions, descent of the presenting part, vaginal examination, effacement and dilatation, flexion and rotation.

The fetal condition is also monitored during labour by assessing the fetal heart rate, fetal blood sampling, rupture of membranes-colour and quantity, signs of fetal distress are also observed eg fetal tachycardia, fetal bradycardia, and meconium stained liquor

• Relief of pain – Every labour is accompanied by a certain amount of pain. The degree of pain and the ability to withstand it vary in women. Labour can be relieved with pharmacological and non -pharmacological means of relieving pain in labour. Example, analgesics egPentazocine injection (fortwin), Pethidine etc.

• Records – Accurate record is essential to monitor progress and for early detection of complications. The midwife must keep proper records of all events- the woman’s physical and psychological condition, fetal condition etc.  All the recordings should be made on a Partograph

 

• Parthograph

Introduction

Every normal pregnancy is expected to lead to normal labour and delivery.  It is recommended that progress of labour is monitored using a partograph. Health care providers caring for women in labour are responsible for making observations and recording information on the partograph.

Definition

• A tool adapted by World Health Organisation (WHO) as a tool to monitor, document and manage labour. 

• It is a managerial tool for prevention of prolonged and obstructed labour by early and timely recognition and reduce complications.

• It is also a chart of record where all labour observations are charted in a clear way and these observations are interpreted to detect abnormalities.

•  

        Importance

• Gives a complete picture of how the mother, baby and labour are doing.

• Provides guidelines on when labour is no longer normal and what to do.

• Helps give continuity of care.

RELIEF OF PAIN IN LABOUR

Every labour is accompanied by a certain amount of pain and discomfort. The degree of pain and the ability to withstand it vary in women. Therefore, every woman in labour should be given maximum relief from pain consistent with her personality, her safety and that of her infant.

 

ANATOMY OF PAIN PATHWAYS

Pain can be defined as a feeling of distress, suffering or agony caused by stimulation of specialized nerve endings. Pain stimulates pain receptors and this stimulus is transferred via specialized nerve endings to the spinal cord and from there to the brain.

Pain is felt over the anterior abdomen below the umbilicus during the first stage of labour. The referred pain felt is caused by dilatation of the cervix and lower uterine segment with each uterine contraction. 

The pain pathway or ascending sensory tract originates in the sensory nerve endings at the site of trauma. The impulse travels along the sensory nerves to the dorsal root ganglion of the relevant spinal cord – the first neuron. The second neurone arise in the posterior horn, crosses over within the spinal cord and transmits the impulses via the medulla oblongata, pons varolii and the mid brain to the thalamus. From here, it transmits along the third neurone to the sensory cortex

The stretching of muscles and ligaments of the pelvic cavity and the pressure of the descending fetus during the birthing process causes to varying degree, pain in labour. This sensation is transmitted by afferent or visceral pain being caused by the stretching or irritation of the viscera.

 

Types of pain relief

There are two methods of pain relief in labour; Pharmacological and non-pharmacological pain relief.

1. Pharmacological pain relief – This is the use of drugs in relief of pain in labour. These drugs work by blocking the pain pathway at the nerve endings to reduce the transmission of pain to the brain thereby reducing the sensitivity of body to pain. The common drugs used include

– Opiate drugs – They are given during childbirth because of their powerful analgesic properties as they bind with receptor cells in the CNS. The receptor sites are found commonly in the dorsal horn of the spinal cord. Others are found in the midbrain, thalamus and hypothalamus The most commonly used opioids are – pethidine, diamorphine and meptazinol. Side effects includes nausea, vomiting and drowsiness and depression of baby’s respiratory centre. An antiemetic may be given to reduce the side effect

Pethidine is the most frequently used. It is a synthetic compound that acts on the receptors in the brain. The dose is 50 -150mg intramuscularly. It takes about 20 mins to have effect and last for about 2-3hours.

Diamorphine on the other hand provides effective analgesia for up to 4hrs in labour, meptazinol also given in dose of 100-150mg intramuscularly is fast acting and last for about 4hrs. 

 

– Inhalational analgesia (Entonox)– This is made up of premixed gas of 50 % nitrous oxide and 50 % oxygen administered via the entonox apparatus. The cylinder is blue with a blue and white cylinder. It acts by limiting neuronal synaptic transmission within the CNS. It takes effect within 20 secs hence it is used before a contraction. Maximum efficiency is at about 45-50 secs at the height of contraction. The main advantage is that it is under the patient’s control. It is highly effective. It could however cause nausea and vomiting, confusion or disorientation.

 

– Regional epidural – This is the process of introducing local or narcotic analgesia into the epidural space of the spinal cord through a Tuohy needle for the purpose of administering regional analgesia/anaesthesia (Bupivacaine) The usual site is between the 3rd lumbar and 4th lumbar vertebrae. It works by blocking conduction of impulses along sensory nerves as they enter the spinal cord. It is the most effective way of relieving pain in labour. They are used for vagina births and caesarean section. However, it could cause dizziness or shivering and could prolong the length of the second stage.  

 

–                                                                                     

2. Non pharmacological pain relief – they include

 

– Homeopathy – It’s a way of reinforcing the body’s physiological responses. Homeopathy remedies are prepared from plant extracts and minerals

–  

– Hydrotherapy – This is immersion in water during labour as a means of analgesia. It  is soothing and calms the nerves. Heat relieves muscle spasm and subsequently pain. It was discovered that mothers require less augmentation with hydrotherapy and the use of analgesia was consistently lower.

 

– Transcutaneous Electrical Nerve Stimulation (TENS) – This stimulate the production of natural endomorphinsand also its ability to impede incoming pain stimuli. (Endomorphins are opiate like substances produced naturally by the body at various points in the CNS to modulate/inhibit the transmission of pain perception in these areas) its widely used and it has the advantage of including the partner in care 

 

– Massaging – This is a form of diversional therapy. It is done by giving a soothing backrub to the woman either by the midwife or the partner. This promotes relaxation and distracts attention from pain.

 

– Music therapy – Music in different forms give distraction to pain during birth. Its specially used during the early stages of labour

 

– Mobility and positioning – Mobility during labour has been shown to improve the woman’s experience and outcome of labour

COMPLEMENTARY CARE – labour doulas are sometimes hired by women to avoid pharmacologic pain relief during labour. The role of the doula is to provide continouslabour support and be an advocate. She specializes in assisting the woman to maintain comfort and control throughout labour and birth, 

 

ADVANTAGES OF PAIN RELIEF

1. Reverses or reduces body’s response to labour pains

2. Patient stays awake/alert to witness labour

 

DISADVANTAGES

1. Likely to prolong labour

2. May likely cause low blood pressure

3. Epidurals could cause skin itching

Medical Officer (Coordinator Polio Eradication & VPD Surveillance) at World Health Organization (WHO)

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Medical Officer (Coordinator Polio Eradication & VPD Surveillance) at World Health Organization (WHO)

We are the directing and coordinating authority on international health within the United Nations’ system. We do this by: providing leadership on matters critical to health and engaging in partnerships where joint action is needed; shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge; setting norms and standards and promoting and monitoring their implementation; articulating ethical and evidence-based policy options; providing technical support, catalysing change, and building sustainable institutional capacity; and monitoring the health situation and assessing health trends. Leadership priorities For each 6-year programme of work priority areas are identified where our leadership is most needed.

  • Job Type: Full Time
  • Qualification: BA/BSc/HND
  • Experience: 10 years
  • Location: Abuja
  • Job Field: Medical / Healthcare , NGO/Non-Profit

OBJECTIVES OF THE PROGRAMME

  • To stop the longstanding polio and other vaccine-preventable disease outbreaks and sustain polio eradication and reduce childhood morbidity and mortality attributable to all vaccine preventable diseases.
  • Lay the foundation and programme direction towards achieving measles and rubella elimination and other vaccine preventable disease elimination and control goals.
  • This will be achieved by supporting implementation of high-quality polio eradication activities and high, equitable coverage of routine and supplemental immunization activities for all people along the life-course and introduction of underutilized and new lifesaving vaccines, in accordance with the global and regional goals and commitment and the Immunization Agenda 2030

Description Of Duties

The incumbent will perform the following duties:

  • Take lead in the provision of a strategic vision and technical advice to the country on stopping the long-running outbreaks of polio, measles, and other vaccine-preventable diseases, strengthening routine Immunization, and sustaining polio eradication.
  • Coordinate immunization and polio eradication donors and partners to support immunization and polio eradication in Nigeria, including resource mobilization, timely utilization of funds and timely donor reporting. Coordinate support for polio eradication activities in Nigeria with IST, AFRO and GPEI through the Incidence Management Support Unit (IMST) hosted by IST, AFRO.
  • Strengthen national decision-making processes through the National Immunization Technical Advisory Group (NITAG). Guide the development and updating of the National Emergency Action Plan for Polio, the National Strategic Plan Comprehensive multi-year plan(cMYP) for immunization and the annual national work plan. Manage and ensure the quality of District micro plans for Polio eradication and EPI addressing bottlenecks equity, quality, and high coverage, leaving no one behind.
  • Lead a strategy and action plan for monitoring, evaluation system, and data quality improvements at federal and state levels.
  • Oversee planning and implementation of the vaccine preventable disease eradication, elimination and control activities to meet global, regional and national goals, including planning and implementing single and multi-antigen integrated supplementary immunization activities according to national strategies (e.g. Polio, measles/rubella, MNTetc.).
  • Maintain preparedness for early detection and response to outbreaks of polio and other vaccine-preventable diseases, and coordinate outbreak response with government and key stakeholders. Establish a system to monitor polio eradication and measles elimination indicators. Improve and sustain quality of acute flaccid paralysis and environmental surveillance for poliovirus as an essential function to achieve and maintain polio-free status. Implement Measles & Rubella case-

Required Qualifications

Education

Essential

  • Medical degree with post graduate degree in Public  Health and/or Epidemiology

Desirable

  • Higher Diploma in Epidemiology/Communicable Diseases (Doctorate Degree, DrPH).

Experience
Essential

  • At least 10 years of extensive and practical experience in immunization programmes and vaccine preventable disease control or polio eradication at senior management position at national and international levels with focus on policy, planning and strategic actions for improving immunization and surveillance programme performance in large/complex countries/countries with active/protracted humanitarian crisis.

Desirable

  • Experience in control of communicable diseases in general and surveillance of vaccine preventable diseases.
  • Experience with resource mobilization and policy development.
  • Experience of working in developing countries with low performing immunization programmes.
  • Experience with measles elimination and polio eradication initiative.

Skills

  • Proven track record of exhibition of competencies essential to lead a large team and to produce results.
  • Demonstrated in-depth knowledge of principles, practices, methodology and techniques of immunization, disease eradication, epidemiology, disease prevention and control of communicable diseases.
  • Excellent knowledge in analyzing vaccine preventable diseases surveillance and immunization data, synthesizing information, and presenting clear and concise conclusions and recommendations for decision making.
  • Demonstrated capacity in developing strategies and plans related to immunization and disease eradication programmes.
  • Good interpersonal skills.
  • Demonstrated ability to work constructively with people of different cultural and educational backgrounds

Click here to apply

BIMANUAL COMPRESSION OF THE UTERUS SKILL CHECKLIST

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BIMANUAL COMPRESSION OF THE UTERUS SKILL CHECKLIST


1. Tell the woman (and her support person) what is going to be done.  Listen to her. Respond attentively to her questions and concerns.

2. Provide continual emotional support and reassurance, as possible.

3. (If able to give IV at your facility) Ask an assistant to start Ringer’s Lactate or Normal Saline IV with 20 IU oxytocin and run it quickly.

4. Put on personal protective equipment.

EXTERNAL BIMANUAL COMPRESSION

5. Put one hand on the abdomen behind the top of the uterus and the other hand just above the pubic bone.

6. Press hands together firmly, making sure the uterus is directly between your 2 hands.

7. Look to see if bleeding slows or stops. If after 1 minute the bleeding is not stopped, proceed to internal bimanual compression

8. If bleeding slows to a small amount or stops, continue to give external bimanual compression for at least 5 minutes.

9. If continuing to internal bimanual compression; instruct an assistant or the support person to continue external bimanual compression while preparing for internal bimanual compression.

 

INTERNAL BIMANUAL COMPRESSION

11. Put high-level disinfected or sterile surgical gloves on both hands.

12. Clean the vulva and perineum with antiseptic solution.

13. Do digital evacuation of clots:

14. Gently slide index and middle fingers into the cervix through the vagina.

a. Gather all clots and tissue

b. Remove hand from cervix with clots

15. Reinsert gloved hand into vagina, feel for anterior vaginal fornix.

16. Form hand into fist.

17. If the cervix is in the way, move it posteriorly

18. Put the fist into the anterior vaginal fornix and apply pressure against the anterior wall of the uterus, not on the cervix.

19. Put the external hand on the abdomen behind the fundus of the uterus.

20. Press the abdominal hand deeply into the abdomen and apply pressure against the posterior wall of the uterus.

21. Press internal and external hands together firmly, making sure pressure is put on the uterus between your 2 hands.

POST PROCEDURE TASKS

1. Dispose of waste materials (e.g. blood-contaminated swabs) in a leak proof container or plastic bag.

2. Decontaminate open instruments by placing in a plastic container filled with 0.5% Chlorine (Chlorine (Jik)) solution for 10 minutes.

3. Dispose of needles and syringes in a puncture proof container.

4. Dispose of gloves

a. Remove gloves by slowly pulling them down from the cuff, turning them inside out, being careful not to splash.

b. Note: If waste disposal system not effective in facility, first rinse gloves while on hands in Chlorine (Jik) 0.5% decontamination solution before removing.

Put gloves in plastic waste container or plastic bag.

5. Wash hands thoroughly with soap and water and dry with a clean cloth or air dry.

6. Teach the woman (and support person) how to feel and massage the uterus and to call a health care provider if the uterus does not stay hard or if she feels bleeding.

7. Monitor vaginal bleeding and take the woman’s vital signs:

• Every 15 minutes for 2 hours

• Then every 30 minutes for 1 hour.

8. Make sure that the uterus is firmly contracted.

9. Record information about estimated blood loss, medicines given and what procedures you did (i.e. IV with oxytocin, bimanual compression).

10. Immediately refer once on bleeding. It’s stable for further investigations for anaemia and IV antibiotics.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PELVIC EXAMINATION PROCEDURE

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PELVIC EXAMINATION PROCEDURE

AIMS

  • To assess and evaluate pelvic organs
  • To help in making diagnosis e.g ruptured ectopic pregnancy
  • As a pre requisite in procedures such as IUCD insertion and MVA
  • For collection of specimen

Preparation

  • Explains procedure to client and gain consent
  • Provides privacy
  • Wash hands, observe aseptic technique
  • Position in prone position with knees flexed
  • Provide good source of light.
  • Expose the vulva and abdomen.
  • Ensure instruments needed are ready

➢ Trolley

➢ Lubricant

➢ Cuscos vaginal speculum

➢ Sim’s vaginal speculum

➢ Swabs, galli pot

➢ Sponge holding forcep

➢ Sterile water

Steps

It involves the following steps:

  • Inspection
  • Bimanual examination – V.E.
  • Speculum examination
  • Rectal examination

1. Inspection: inspect the vulva for scar, tear, discharge, lesions, ulcers, sores.

  • Ask woman to cough – to observe bulging e.g. urethrocele, rectocele, cystocele.
  • Also observe for leaking of urine.

2. Bimanual examination: through V.E. and abdominal palpation to assess vagina, cervix, position of cervix, consistency, whether open or closed, laceration, mass/growth, position of uterus.

  • Place abdominal hand on lower abdomen above symphysis pubis and exert downward pressure.
  • Insert two gloved fingers gently into vagina.
  • Use vaginal finger to quickly palpate the fornices for any mass, feel whether cervix is open or closed.
  • For assessing position of uterus, use fingers in the vagina (in front) to lift the cervix towards the abdominal hand to feel whether the uterus can be felt between two hands.
  • If felt, the uterus is in the anterior position.
  • If not felt, place vaginal fingers behind cervix and lift uterus towards abdominal hand. If felt, uterus is mid position.
  • If uterus is not felt by both techniques, the uterus is retroverted i.e. in posterior position.
  • With vaginal and abdominal fingers, feel for tenderness, swelling, thickening etc.

3. Speculum examination

  • This is done to visualize the vagina and cervix and to take specimen.
  • Inform client of insertion of speculum.
  • Lubricate speculum but use sterile water if specimen is to be collected.
  • Insert closed speculum obliquely into vagina. Avoid pressure to clitoris and urethra.
  • Do not catch skin or hair.
  • ½ way, turn speculum horizontally towards cervix.
  • Put downward pressure (if Sim’s speculum)
  • Secure the speculum (if Cuscos)
  • Visualize cervix and vagina for color, growth.
  • Collect specimen for cervix using non-touch technique (if indicated).
  • Carry out concurrent procedure (e.g. IUD insertion or MVA).
  • Unsecure, close and remove speculum gently as inserted.

4. Rectal examination

  • Wear sterile gloves
  • Lubricate index finger
  • Insert index finger gently through the anus to the rectum
  • Gently but palpate to feel for any pelvic abnormalities
  • Withdraw finger
  • Dispose soiled gloves
  • Clean patient and make comfortable.
  • Document findings and inform patient of findings.
  • Dispose used materials according to protocol and decontaminate and sterilize used instruments

OBJECTIVES: PELVIC EXAMINATION/ OBSTETRIC PROCEDURES

1. Pelvic examination is a perquisite to the following procedures EXCEPT

a. Manual vacuum aspiration

b. Insertion of IUCD

c. The use of hormonal contraceptives

d. Vacuum extraction

2. Pelvic examination can assist in the diagnosis of the following EXCEPT

a. Pregnancy

b. Ectopic pregnancy

c. Placenta previa

d. Pelvic tumor

3. The steps in pelvic examination are

a. Inspection, bimanual examination, speculum examination and rectal examination

b. Inspection, abdominal examination, speculum examination and rectal examination

c. Bimanual examination, speculum examination, inspection , rectal examination

d. Vaginal examination, speculum examination and rectal examination

4. Abnormalities that can be detected through inspection duringpelvic examination include

a. Uterine cancer, ovarian cyst and incompetent cervix

b. Urethrocele, VVF, RVF and cystocele

c. Uterine enlargement, ectopic pregnancy and molar pregnancy

d. Ruptured uterus, placenta previa, and ovarian cyst

5. During rectal examination, …………………………………. Inserted  into the rectum to palpate abnormalities

a. Index and middle fingers are

b. Index finger is

c. Rectal dilator is

d. An enema tube

6. Before MVA, pelvic examination is carried out to ascertain……………………………….……………………………….

a. Position and size of the uterus

b. Height of fundus

c. The amount of bleeding

d. He depth of the fornices

 

ANSWER TRUE OR FALSE

7. The uterine sound is used to measure the width of the uterus

TRUE/ FALSE

8. During MVA, the canulla can be used to dilate the cervical os

TRUE/ FALSE

9. MVA can also be used to evacuate hydatidiform more

TRUE/ FALSE

10. If the uterus is not felt during bimanual examination, the position of the uterus is anterior

TRUE/ FALSE

 

MARKING GUIDE

1. D

2. C

3. A

4. B

5. B

6. A

7. FALSE

8. TRUE

9. TRUE

10. FALSE

VACUUM EXTRACTION PROCEDURE

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VACUUM EXTRACTION PROCEDURE
  • Explain the procedure to the woman and family and the reason for carrying it out, then gain conscent.
  • Provides privacy
  • Wash hands
  • Evaluate the woman’s condition abdominally and vaginally to ensure that the conditions for carrying vacuum extraction are present.
  • The doctor or midwife practicing vacuum extraction must be skilled and experienced.
  • The baby is alive or fetal heart (FH) stopped during labor.
  • The fetus must be a term baby.
  • The presentation should be vertex.
  • Ensure ruptured membranes
  • Exclude CPD, caput succedenum, excessive moulding.
  • Descent should be 1/5 or 0/5 on abdominal palpation.
  • There must be good uterine contractions.
  • Position of fetal head must be certain
  • Full dilatation and effacement of the cervix (anterior lip may be an exception).
  • Instruments must be in good working order.
  • Adequate analgesia
  • Make sure there is a backup doctor or midwife.
  • Must be carried out in well equipped facility in case it fails or there must be proper referral system.

Mentions any 4

STEPS

  • Prepare instruments: requirements for normal delivery, connect pump, tubing and cup, resuscitation requirements.
  • Test vacuum on the palm to ensure it is effective in creating a vacuum.
  • Position the woman in a lithotomy position (legs apart with knees flexed).
  • Ensure bladder is empty. Catheterize if necessary.
  • Perform V.E., confirm presentation and position.
  • A local anaesthetic in form of pudendal block or an epidural analgesia is topped up if already in situ.If not available, infilteration of the perineum might suffice.
  • Fetal heart rate should be monitored regularly.
  • Gently pull down the perineum to make space for cup.
  • Through V.E., locate the posterior fontanelle and gently place the cup on the flexion point of the fetal head i.e 2cm anterior to the posterior fontanelle.
  • Pass a finger around the edge of the cup to ensure that none of the mother’s tissue has been caught under the cap.
  • The vacuum in the cup is increased gradually to achieve close application to fetal head by squeezing the handle to raise the pressure to 100mmHg. or 0.2Kg/cm2.
  • With achievement of vacuum and good contractions, traction is applied in a downwards and backwards direction, forwards and upwards, following the “curve of Caurus.”
  • When contraction fades, reduce traction.
  • As the next contraction begins, raise vacuum by 100mmHg to 400mmHg the maximum pressure should NEVER exceed 600mmHg or 0.8kg/cm2.
  • Continue applying traction with contraction until the head has crowned,
  • Encourage woman to breathe deeply when contractions stop.
  • Encourage mother to push with contraction for the final part /of delivery.
  • Release vacuum after crowning of head or pull downwards in the direction of normal delivery.
  • Do not twist or turn cup or handle as this may lead to loss of vacuum and injury to baby’s scalp.
  • Continue care as in normal delivery, reassure mother.
  • Active management of third stage should be done.
  • Check perineum for lacerations and repair.
  • Manage equipments properly

N.B:  when contractions stop, reduce pressure by 100mmHg. do not allow pressure to remain at maximum levels (600mmHg) for more than 10 minutes.

A vacuum extractor has failed if:

  • Fetal head does not advance with each pull.
  • Fetus is not delivered with three pulls or no descent in 30 minutes.
  • Cup pops off the head twice at the proper direction of pull with appropriate pressure.
  • STOP the procedure and prepare for Caesarean section
  • Record outcome of procedure

OBJECTIVE STATION: VACUUM EXTRACTION/INSTUMENTAL DELIVERIES

1. A vacuum extractor has failed if the following occurs EXCEPT

a. Fetal head does not advance with each pull.

b. The perineum is rigid

c. Fetus is not delivered with three pulls or no descent in 30 minutes.

d. Cup pops off the head twice at the proper direction of pull with appropriate pressure.

2. The following are conditions to be met before carrying out vacuum extraction EXCEPT

a. The fetus must be a term baby.

b. The presentation should be vertex.

c. Ensure intact membranes

d. Descent should be 1/5 or 0/5 on abdominal palpation.

3. During vacuum extraction, the cup should be placed at the …………………….. of  the fetal head

a. Extension point

b. Occiput

c. Flexion point

d. Anterior fontanelle

4. During the procedure, when contraction fades, 

a. Apply traction on the head

b. Reduce traction on the head

c. Rotate the head

d. Flex the head

 

5. The vacuum practitioner should not exceed a vacuum pressure of ………………… during vacuum extraction

a. 500mmHg

b. 400 mmHg

c. 600 mmHg

d. 700 mmHg

6. When the vacuum cup stays for more than10 minutes on the fetal scalp, it may cause

a. Sub periostal haemorrhage

b. Ruptured sinuses

c. Damage to the brain cells

d. Facial haematoma

7. During vacuum extraction, the vacuum can be released when 

a. The head has descended

b. The face is delivered

c. Restitution has takenplace

d. The head has crowned

8. The following are contra indications to the use of vacuum extraction except

a) No contractions

b) Incomplete cervical dilatation

c) Gestational age less than 37 weeks

d) Vertex presentation

9. Women who use epidural as a form of pain relief are at increased risk of having 

a) an instrumental assisted birth

b) obstructed labour

c) sepsis

d) intra partum eclampsia

10. In current obstetric, forceps are also used to assist 

a) To deliver an un engaged head

b) To withdraw the head up and out of the pelvis during caesarean section.

c) Delivery of a woman with shoulder dystocia

d) To deliver the buttocks in breech presentation

11. The cephalic curve is the curve on the flat surface of the obstetric forcep which when articulated

a) grasps the fetal chest without compression.

b) grasps the fetal neck without compression.

c) grasps the fetal head without compression.

d) grasps the frontal bone without compression.

12. Conditions to be met before forceps delivery are the following except

a) Full dilatation

b) Skilled practitioner

c) Adequate pelvis

d) Descent of 5/5

13. During forceps delivery, 

a) The forceps are inserted separately

b) The forceps are locked before inserting into vagina

c) The position of  fetal head  must not be known

d) The forceps should remain on fetal head after delivery of the head

14. After application of the forceps, the head should be pulled with contractions along the

a) Pelvic inclination

b) Curve of caurus

c) Station 0 of presenting part

d) Pubic arc

15. The midwife must be very vigilant during and after forcep delivery to detect major complications like ………………………..

a) Eclampsia

b) Ruptured uterus

c) Hyperglycaemia

d) Drop foot

 

MARKING GUIDE

1. B

2. C

3. C

4. B

5. C

6. A

7. D

8. D

9. A

10. B

11. C

12. D

13. A

14. B

15. B

CONTRACEPTION & FAMILY PLANNING

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CONTRACEPTION & FAMILY PLANNING


Individual Indications for Birth Control
Contraception is practiced by most couples for personal reasons.
Many couples use contraception to space their children or to limit the size of their family.
Others desire to avoid childbearing because of the effects of preexisting illness on the pregnancy, such as severe diabetes, or heart disease, such as severe aortic stenosis.
As a matter of public policy some countries, especially those that are less developed, promote contraception in an effort to curb undesired population growth.

Methods of contraception


− The available methods of contraception may be classified in many ways.
− For the sake of this discussion, traditional or folk methods are coitus interruptus, postcoital douche, lactational amenorrhea, and periodic abstinence (rhythm or natural family planning).
− Barrier methods include condoms (male and female), diaphragm, cervical cap, vaginal sponge, and spermicides
− Hormonal methods encompass oral contraceptives and injectable or implantable long-acting progestins.
− In addition, the intrauterine contraceptive device (IUD) and sterilization (tubal ligation or vasectomy) contraceptive armamentarium.

A. PERIODIC ABSTINENCE

  1. Coitus Interruptus
    Definition

Coitus interruptus involves withdrawal of the entire penis from the vagina before ejaculation.
Fertilization is prevented by lack of contact between spermatozoa and the ovum.
Efficacy
Effectiveness depends largely on the man’s capability to withdraw prior to ejaculation.
The failure rate is estimated to be approximately 4% in the first year of perfect use.
In typical use, the rate is approximately 19% during the first year of use.
Advantages
− Advantages include immediate availability, no devices, no cost, no chemical involvement, and a theoretical reduced risk of transmission of sexually transmitted diseases (STDs).
Disadvantages
− The probability of pregnancy is high with incorrect or inconsistent use.
− Failure may result from escape of semen before orgasm or the deposition of semen on the external female genitalia near the vagina.

  1. Lactational Amenorrhea
    Definition:
    − Elevated prolactin levels and a reduction of gonadotropin- releasing hormone from the hypothalamus during lactation suppress ovulation.
    − This leads to a reduction in luteinizing hormone (LH) release and inhibition of follicular maturation.

− The duration of this suppression varies and is influenced by the frequency and duration of breastfeeding and the length of time since birth.
− Mothers only need to use breastfeeding to be successful; however, as soon as the first menses occurs, she must begin to use another method of birth control to avoid pregnancy.
Efficacy
− The perfect-use failure rate within the first 6 months is 0.5%.
− The typical-use failure rate within the first 6 months is 2%. Advantages
− Involution of the uterus occurs more rapidly.
− Menses are suppressed.
− This method can be used immediately after childbirth.
− This method facilitates postpartum weight loss.
Disadvantages
− Return to fertility is uncertain.
− Frequent breastfeeding may be inconvenient.
− This method should not be used if the mother has human
immunodeficiency virus (HIV) infection.

  1. Natural Family Planning
    Definition
    − This method involves periodic abstinence, with couples attempting to avoid intercourse during a woman’s fertile period, which is around the time of ovulation.
    − Techniques to determine the fertile period include the calendar method, cervical mucus method, or the symptothermal method.

− The calendar method is based on 3 assumptions as follows: (1) A human ovum is capable of fertilization only for approximately 24 hours after ovulation, (2) spermatozoa can retain their fertilizing ability for only 48 hours after coitus, and (3) ovulation usually occurs 12-16 days before the onset of the subsequent menses.
− The menses is recorded for 6 cycles to approximate the fertile period.
− The earliest day of the fertile period is determined by the number of days in the shortest menstrual cycle subtracted by 18.
− The latest day of the fertile period is calculated by the number of days in the longest cycle subtracted by 11.
− With the cervical mucus method, the woman attempts to predict her fertile period by quantifying the cervical mucus with her fingers.
− Under the influence of estrogen, the mucus increases in quantity and becomes progressively more elastic and copious until a peak day is reached.
− This is followed by scant and dry mucus, secondary to the influence of progesterone, which remains until the onset of the next menses.
− Intercourse is allowed 4 days after the maximal cervical mucus until menstruation.
− The symptothermal method predicts the first day of abstinence by using either the calendar method or the first day mucus is detected, whichever is noted first.
− The end of the fertile period is predicted by measuring basal body temperature.
− The basal body temperature of a woman is relatively low during the follicular phase and rises in the luteal phase of the menstrual cycle in response to the thermogenic effect of progesterone.
− The rise in temperature can vary from 0.2-0.5°C.
− The elevated temperatures begin 1-2 days after ovulation
and correspond to the rising level of progesterone.
− Intercourse can resume 3 days after the temperature rise.

Efficacy
− The failure rate in typical use is estimated to be approximately 25%.
Advantages
− No adverse effects from hormones occur.
− This may be the only method acceptable to couples for
cultural or religious reasons.
− Immediate return of fertility occurs with cessation of use.
Disadvantages
− This is most suitable for women with regular and predictable cycles.
− Complete abstinence is necessary during the fertile period unless backup contraception is used.
− This method requires discipline.
− The method is not effective with improper use.
− The failure rate is relatively high.
− This method does not protect against STDs.
− Epidemiologic studies of women using the rhythm method
have suggested an increased incidence of congenital anomalies such as anencephaly and Down’s syndrome among children resulting from unplanned pregnancies.
− Delayed fertilization has been shown in animal experiments to result in an increased incidence of aneuploidy and polyploidy in offspring, thus suggesting a possible explanation for similar human fetal anomalies.

B. MECHANICAL BARRIERS

  1. Male Condom
    Definition

− The condom consists of a thin sheath placed over the glans and the shaft of the penis that is applied before any vaginal insertion.
− Among all of the barrier methods, the condom provides the most effective protection of the genital tract from STDs.
− It prevents pregnancy by acting as a barrier to the passage of semen into the vagina.
Efficacy
− The failure rate of condoms in couples that use them consistently and correctly during the first year of use is estimated to be approximately 3%.
− However, the true failure rate is estimated to be approximately 14% during the first year of typical use.
− This marked difference of failure rates reflects errors in usage.
− Common errors with condoms usage include failure to use condoms with every act of intercourse and throughout intercourse, improper lubricant use with latex condoms (e.g. oil-based lubricants), incorrect placement of the condom on the penis, and poor withdrawal technique.
Advantages
− Condoms are readily available and are usually inexpensive.
− This method involves the male partner in the contraceptive choice.
− Condoms are effective against both pregnancy and STDs. Disadvantages
− Condoms possibly decrease enjoyment of sex.
− Some users may have a latex allergy.
− Condom breakage and slippage decrease effectiveness.
− Oil-based lubricants may damage the condom.

  1. Female Condom
    Definition
    − The Reality female condom is a polyurethane sheath intended for one-time use, similar to the male condom.
    − It contains 2 flexible rings and measures 7.8 cm in diameter and 17 cm long.
    − The ring at the closed end of the sheath serves as an insertion mechanism and internal anchor that is placed inside the vaginal canal.
    − The other ring forms the external patent edge of the device and remains outside of the canal after insertion.
    − The female condom prevents pregnancy by acting as a
    barrier to the passage of semen into the vagina.
    − Simultaneous use of both the female and male condom is
    not recommended because they may adhere to each other, leading to slippage or displacement of either device.
    Efficacy
    − Efficacy trials are limited.
    − Initial trials have demonstrated a pregnancy rate of 15%
    in 6 months.
    Advantages
    − The female condom provides some protection to the labia and the base of the penis during intercourse.
    − The sheath is coated on the inside with a silicone-based lubricant.
    − It does not deteriorate with oil-based lubricants.
    − It can be inserted as long as 8 hours before intercourse.
    Disadvantages

− The lubricant does not contain spermicide.
− The device is difficult to place in the vagina.
− The inner ring may cause discomfort.
− Some users consider the female condom cumbersome.
− The female condom may cause a urinary tract infection if
left in vagina for a prolonged period.
− Significant disadvantages may be their cost and overall
bulkiness.

  1. Diaphragm
    Definition
    − The diaphragm is a shallow latex cup with a spring mechanism in its rim to hold it in place in the vagina.
    − Diaphragms are manufactured in various diameters.
    − A pelvic examination and measurement of the diagonal
    length of the vaginal canal determines the correct
    diaphragm size.
    − It is inserted before intercourse so that the posterior rim
    fits into the posterior fornix and the anterior rim is placed
    behind the pubic bone.
    − Spermicidal cream or jelly is applied to the inside of the
    dome, which then covers the cervix.
    − It prevents pregnancy by acting as a barrier to the
    passage of semen into the cervix.
    − Once in position, the diaphragm provides effective
    contraception for 6 hours.
    − If a longer interval has elapsed without removal of the
    diaphragm, fresh spermicide is added with an applicator.
    − After intercourse, the diaphragm must be left in place for
    at least 6 hours.
    Efficacy

− Effectiveness of the diaphragm depends on the age of the user, experience with its use, continuity of use, and the use of spermicide.
− The typical-use failure rate within the first year is estimated to be 20%.
Advantages
− The diaphragm does not entail hormonal usage.
− Contraception is controlled by the woman.
− The diaphragm may be placed by the woman in
anticipation of intercourse.
Disadvantages
− Prolonged use during multiple acts of intercourse may increase the risk of urinary tract infections.
− Usage for longer than 24 hours is not recommended due to the possible risk of toxic shock syndrome (TSS).
− The diaphragm requires professional fitting.
− Poorly fitted diaphragms may cause vaginal erosions.
− Diaphragms have a high failure rate. Use of a diaphragm
requires brief, formal training. The diaphragm may develop an odor if not properly cleansed.

  1. Cervical Cap
    Definition
    − The cervical cap is a cup-shaped latex device that fits over the base of the cervix.
    − A groove along the inner circumference of the rim improves the seal between the inner rim of the cap and the base of the cervix.
    − The cap must be filled one third full with spermicide prior to insertion.
    − It is inserted as long as 8 hours before coitus and can be left in place for as long as 48 hours.

− A cervical cap acts as both a mechanical barrier to sperm migration into the cervical canal and as a chemical agent with the use of spermicide.
Efficacy
− Effectiveness depends on the parity of women due to the shape of the cervical os.
− With perfect use in the first year, the failure rate for nulliparous women is 9%, as opposed to 20% in parous women.
− With typical use within the first year, the failure rate is 20% in nulliparous women and 40% in parous women.
Advantages

It provides continuous contraceptive protection for its duration of use regardless of the number of intercourse acts.
Unlike with the diaphragm, additional spermicide is not necessary for repeated intercourse.
The cervical cap does not involve ongoing use of hormones.
Disadvantages
− Cervical erosion may lead to vaginal spotting.
− The cervical cap is associated with a theoretical risk of
TSS if it is left in place longer than the prescribed period.
− The cervical cap requires professional fitting and training
for use.
− Severe obesity may make placement difficult.
− It has a relatively high failure rate.
− Candidates must have history of normal results on
Papanicolaou (Pap) tests.

  1. Spermicidal Agents

Definition
− Vaginal spermicides consist of a base combined with either nonoxynol-9 or octoxynol.
− The actual spermicidal agent consists of a surfactant that destroys the sperm cell membrane.
− Bases include vaginal foams, suppositories, jellies, films, foaming tablets, and creams.
− These must be inserted into the vagina prior to each coital act.
− Use of spermicidal agents also reduces the risk of infection by both viral and bacterial organisms that cause STDs; however, clinical data on their efficacy for preventing the transmission of HIV are limited.
− Nonoxynol-9 is toxic to the lactobacilli that are part of the normal vaginal flora.
− Adverse effects include increased vaginal colonization with the bacteria Escherichia coli, which may predispose to bacteriuria after intercourse.
− Spermicides prevent sperm from entering the cervical os by attacking the sperm’s flagella and body, reducing their mobility, and disrupting their fructolytic activity, thereby inhibiting their nourishment.
Efficacy
− The perfect-use failure rate within the first year is 6%.
− The typical-use failure rate within the first year is 26%.
Advantages
− The lubrication provided by spermicides may heighten satisfaction in both partners.
− Another advantage is the ease of application.
− Either partner can purchase and apply spermicide
because it is easily accessible, available over the counter,
and inexpensive.
− Applying spermicide requires minimal patient education.

− It augments contraceptive efficacy of the cervical cap and diaphragm.
− Spermicides produce no adverse systemic effects. Disadvantages
− Spermicides provide minimal protection from STDs.
− Insertion may be uncomfortable for some couples.
− Vaginal irritation is possible, and spermicides may cause
an allergic reaction.

C. HORMONAL CONTRACEPTIVES

  1. Implants
    Definition
    − The levonorgestrel implants (Norplant) consists of 6 silicone rubber rods, each measuring 34 mm long and 2.4 mm in diameter and each containing 36 mg of levonorgestrel.
    − The implant releases approximately 80 mcg of levonorgestrel per 24 hours during the first year of use, achieving effective serum concentrations of 0.4-0.5 ng/mL within the first 24 hours.
    − The rate of release decreases to an average of 30 mcg/d in the latter years of use.
    − Release of the progestational agent by diffusion provides effective contraception for 5 years.
    − Contraceptive protection begins within 24 hours of insertion if inserted during the first week of the menstrual cycle.
    − The rods are inserted subcutaneously, usually in the woman’s upper arm, where they are visible under the skin and can be easily palpated.
    Mechanism of action

− The mechanism of action is a combination of suppression of the LH surge, suppression of ovulation, development of viscous and scant cervical mucus to deter sperm penetration, and prevention of endometrial growth and development.
Efficacy
− The contraceptive efficacy of the method is equivalent to that of surgical sterilization.
− Overall, pregnancy rates increase from 0.2% in the first year to 1.1% by the fifth year.
Advantages
− The longevity of its effectiveness is an advantage.
− Its effectiveness is not related to its use in regards to
coitus.
− Exogenous estrogen is absent.
− Prompt return to the previous state of fertility occurs upon
removal.
− No adverse effect on breast milk production occurs.
Disadvantages
− A minor surgical procedure is necessary for incision.
− Difficulty in removal is a disadvantage.
− Menstrual irregularities are common along with other
adverse effects, including headaches, mood changes,
hirsutism, galactorrhea, and acne.
− Absolute contraindications include active thrombophlebitis
or thromboembolic disease, undiagnosed genital bleeding, acute liver disease, benign or malignant liver tumors, known or suspected breast cancer, and a history of idiopathic intracranial hypertension.
− Relative contraindications include heavy cigarette smoking, a history of ectopic pregnancy, diabetes mellitus, hypercholesterolemia, severe acne,

hypertension, and a history of cardiovascular disease, severe vascular or migraine headaches, and severe depression.
− Appropriate candidates are women who are postpartum or breastfeeding, women who have difficulty with contraceptive compliance, women in whom pregnancy is contraindicated due to a medical condition, and patients with contraindications to the use of estrogen.
− Adverse effects they may experience, including nausea, headaches, irregular menstrual bleeding, ovarian cysts, weight gain, removal problems, and depression.
− Norplant II (Jadelle) is approved for 3 years of use but has been shown to be effective for as long as 5 years.
− Implanon is a single-rod implant that is 4 cm long and 2 mm in diameter.
− It consists of 68 mg of etonogestrel in an ethylene vinyl acetate copolymer core.
− Etonogestrel is a biologically active metabolite of desogestrel.
− Desogestrel is significantly more potent than levonorgestrel; a serum concentration of 0.09 ng/mL can inhibit ovulation in most women.
− Serum concentrations are adequate for contraception coverage for approximately 3 years.
− Compared with the Norplant system, Implanon is associated with a higher frequency of amenorrhea and oligomenorrhea, a decrease in the prevalence of frequent and prolonged bleeding, and a decrease in the frequency of adverse effects such as weight gain, headache, and acne.
− When the rod is removed, the return to fertility is rapid, with the return of ovulation within 3 weeks.
− Implanon is not associated with loss of bone mineral density (BMD).

  1. Injectable Depomedroxyprogesterone Acetate (Depo-Provera)

Definition
− Depo Provera is a synthetic derivative of progesterone administered as an acetate salt (medroxyprogesterone acetate)
− DMPA is a suspension of microcrystals of a synthetic progestin that is injected intramuscularly.
− A progestogen-only hormonal contraceptive birth control drug injected every 3 months
− Very similar to progesterone, a hormone normally produced by the ovaries every month
− Pharmacologically active levels are achieved within 24 hours after injection, and serum concentrations of 1 ng/mL are maintained for 3 months.
− During the fifth or sixth month after injection, the levels decrease to 0.2 ng/mL, and they become undetectable by 7-9 months after injection.
Mechanism
− DMPA acts by the inhibition of ovulation with the suppression of follicle-stimulating hormone (FSH) and LH levels and eliminates the LH surge.
− Similar to oral contraceptives in that it inhibits ovulation
− Synthetic progesterone also causes thickening of cervical
mucous, effectively impeding progress of sperm through
cervical canal
− This results in a relative hypoestrogenic state.
− Single doses of 150 mg suppress ovulation in most women
for as long as 14 weeks.
− The contraceptive regimen consists of 1 dose every 3
months.
− During Pregnancy, Progesterone levels remain high in
order to prevent release of further eggs, as well as
priming the lining of the uterus.
− When not pregnant, Progesterone levels fall and luteolysis
occurs

− Depo Provera mimics the effects of Progesterone, thus, pregnancy.
Efficacy
− DMPA is an extremely effective contraceptive option.
− Neither varying weight nor use of concurrent medications
has been noted to alter efficacy.
− Within the first year of use, the failure rate is 0.3%.
Advantages
− DMPA does not produce the serious adverse effects of estrogen, such as thromboembolism.
− Diminished anemia occurs.
− Dysmenorrhea is decreased.
− The risks of endometrial and ovarian cancer are
decreased.
− It contains no estrogen, thus making it suitable for women
who cannot or will not take estrogen products.
− It also is safe for breastfeeding mothers.
Disadvantages
− Disruption of the menstrual cycle to eventual amenorrhea occurs in 50% of women within the first year.
− Persistent irregular bleeding can be treated by administering the subsequent dose earlier or by prescribing temporary low-dose estrogen therapy.
− Because DMPA persists in the body for several months in women who have used it on a long-term basis, it can delay the return to fertility.
− Approximately 70% of former users desiring pregnancy conceive within 12 months, and 90% of former users conceive within 24 months.
− Similar to the delay in fertility after discontinuation of DMPA, other adverse effects, such as weight gain, depression, and menstrual irregularities, may continue for
as long as 1 year after the last injection.
− The main limitation, from the patient’s point of view, has
been the intramuscular (IM) route of injection, which requires an office visit every 12-14 weeks for administration.
− A subcutaneous version of the drug is now available (depo-subQ provera 104) that delivers a lower dose of medroxyprogesterone acetate (MPA) than does the intramuscular formulation (104 mg vs 150 mg).
− The subcutaneous route opens the possibility for home self-injections, and the lower dose could decrease suppression of pituitary function and ovarian estradiol production.
− Decreases in bone mineral density
− Long-term use has shown to cause bone loss which may
be irreversible
− Affects menstrual bleeding
− After 1 year of use 55% of women encounter amenorrhea
− Delayed return of fertility
− Infants exposed to Depo-provera during pregnancy may
have an increased risk of low birth weight and chance of
death
− Once use is terminated continuous bleeding is possible

  1. Progestin-Only Oral Contraceptives
    Definition
    − Progestin-only oral contraceptives, also known as minipills
    − Candidates for use include women who are breastfeeding
    and women with contraindications to estrogen use.
    − Two formulations are available, both of which have lower
    doses of progestin than combined oral contraceptives.
    − One formulation contains 75 mcg of norgestrel.
    − The other has 350 mcg of norethindrone.

Mechanism
− Prevention of contraception involves a combination of mechanisms similar to, but not as efficacious as, combination oral contraceptives.
− Mechanisms of action include (1) suppression of ovulation (not uniformly in all cycles); (2) a variable dampening effect on the midcycle peaks of LH and FSH; (3) an increase in cervical mucus viscosity by a reduction in its volume and an alteration of its structure; (4) a reduction in the number and size of endometrial glands, leading to an atrophic endometrium not suitable for ovum implantation; and (5) a reduction in cilia motility in the fallopian tube, thus slowing the rate of ovum transport.
Efficacy
− Serum progestin levels peak approximately 2 hours after administration.
− Within 24 hours, rapid distribution and elimination returns the level to baseline.
− Greater efficacy is achieved with consistent administration.
− Failure rates with typical use are estimated to be 7% in the first year of use.
− However, any variation can increase the failure rate.
Advantages
− Due to the lack of estrogen, evidence of serious complications to which estrogen can contribute (i.e. thromboembolism) is minimal.
− Noncontraceptive benefits include decreased dysmenorrhea, decreased menstrual blood loss, and decreased premenstrual syndrome symptoms.
− Unlike DMPA, fertility is immediately reestablished after the cessation of progestin-only oral contraceptives.

Disadvantages
− The most significant disadvantage is the continuous need for compliance with usage.
− Users need to be counseled on the need for a backup method of contraception if a pill is missed or taken late.
− A pill is considered late if ingestion occurs 3 hours after the established time of administration.
− If a pill is missed, it should be taken as soon as possible; the next pill should be taken at the scheduled time.
− Backup contraception should be used for the next 48 hours. Unscheduled bleeding and spotting are common even with correct use.
− Other adverse effects include nausea, breast tenderness, headache, and amenorrhea.

  1. Combination Oral Contraceptives
    Definition
    − Prior to 1992, the estrogenic component of oral contraceptives consisted of either ethinyl estradiol or mestranol.
    − Today, ethinyl estradiol is used in all preparations containing 35 mcg or less of estrogen in the United States.
    − The progestin component consists of norethindrone, levonorgestrel, norgestrel, norethindrone acetate, ethynodiol diacetate, norgestimate, and desogestrel.
    − The most recent addition to the progestin group is the addition of drospirenone, found in Yasmin birth control pills.
    − The other major new development is the reduction in the dosage of ethinyl estradiol to 20 mcg.
    − The major impetus for this change is to improve the safety and reduce adverse effects.
    − These lower doses are associated with a decrease in the incidence of estrogen-related adverse effects, such as weight gain, breast tenderness, and nausea.

− Monophasic oral contraceptives have a constant dose of both estrogen and progestin in each of the hormonally active pills.
− Phasic combinations can alter either or both hormonal components.
− Use should be initiated either on the first day of the menses or the first Sunday after menses has begun.
− Most of the formulations have 21 hormonally active pills followed by 7 placebo pills.
− This facilitates consistent daily pill intake.
− If a woman misses 1 or 2 pills, she should take 1 tablet as
soon as she remembers.
− She then takes 1 tablet twice daily until coverage of the
missed pills is achieved.
− Women who have missed more than 2 consecutive pills
should be advised to use a backup method of contraception simultaneous to finishing up the packet of pills until their next menses.

Mechanism of action
− Prevention of ovulation is considered the dominant mechanism of action.
− Either estrogen or progesterone alone is capable of inhibiting both FSH and LH sufficiently to prevent ovulation.
− The combination of the 2 steroids creates a synergistic effect that greatly increases their antigonadotropic and ovulation-inhibitory effects.
− They also alter the consistency of cervical mucus, affect the endometrial lining, and alter tubal transport.
Efficacy
− Failure rates are correlated to individual compliance.
− Rates range from 0.1% with perfect use to 5% with typical
use.

Advantages
− Oral contraceptives are used as treatment for menstrual irregularity because menses is more regular and predictable.
− In the prevention of ovulation, oral contraceptives can reduce and sometimes eliminate mittelschmerz.
− Women with anemia secondary to menorrhagia increase their iron stores.
− Women can manipulate the cycle to avoid menses during certain events, such as vacations or weekends, by extending the number intake days of hormonally active pills or by skipping the placebo pill week.
− Oral contraceptives prevent benign conditions, such as benign breast disease, pelvic inflammatory disease (PID), and functional cysts.
− Functional cysts are reduced by the suppression of stimulation of the ovaries by FSH and LH.
− Ectopic pregnancies are prevented by the cessation of ovulation.
− Oral contraceptives are noted to prevent epithelial ovarian and endometrial carcinoma.
− Studies have noted an approximate 40% reduced risk of malignant and borderline ovarian epithelial cancer.
− This protection appears to last for at least 15 years
following discontinuation of use and increases with
duration of use.
− Use of oral contraceptives is associated with a 50%
reduction of risk of endometrial adenocarcinoma.
− Protection appears to persist for at least 15 years
following discontinuation of use.
Disadvantages
− Adverse effects include nausea, breast tenderness, breakthrough bleeding, amenorrhea, and headaches.
− Oral contraceptives do not provide protection from STDs.

− Daily administration is necessary, and inconsistent use may increase the failure rate.
− A few months of delay of normal ovulatory cycles may occur after discontinuation of oral contraceptives.
Metabolic effects and safety
− Venous thrombosis: The estrogen component of oral contraceptives has the capability of activating the blood clotting mechanism.
− Hypertension: Oral contraceptives have a dose-related effect on blood pressure.
− This elevation is believed to be secondary to an estrogen- induced increase in renin substrate in susceptible individuals.
− Atherogenesis and stroke: Although androgens and a few of the progestins actually may increase low-density lipoproteins and decrease high-density lipoproteins, past use of oral contraceptives does not increase the risk of cardiovascular disease.
− The patient who is sedentary, is overweight, smokes heavily, is hypertensive, is diabetic, or has hypercholesterolemia is clearly at risk.
− Hepatocellular adenoma: These benign liver tumors have been associated with the use of oral contraceptives.
− Cancer: The association of oral contraceptive use and breast cancer in young women is controversial.
− The results demonstrated that current oral contraceptive users, and those who had used oral contraceptives within the past 1-4 years, had a slightly increased risk of breast cancer.
− Thus, although the consensus states that oral contraceptives can lead to breast cancer, the risk is small and the resulting tumors spread less aggressively than usual.
− Current thought is that oral contraceptive use may be a cofactor that can interact with another primary cause to stimulate breast cancer.

− The relationship between oral contraceptive use and cervical cancer is also quite controversial.
− A weak association may exist between oral contraceptive use and squamous cell cancer of the cervix.
Contraindications
− Contraindications to use include cerebrovascular disease or coronary artery disease; a history of deep vein thrombosis, pulmonary embolism, or congestive heart failure; untreated hypertension; diabetes with vascular complications; estrogen-dependent neoplasia; breast cancer; undiagnosed abnormal vaginal bleeding; known or suspected pregnancy; active liver disease; and age older than 35 years and cigarette smoking.
− Lastly, drospirenone has antimineralocorticoid properties.
− It is contraindicated in patients with kidney or adrenal
gland insufficiency or liver problems.

  1. Ninety-One–Day Combination Oral Contraceptives
    − Currently on the market, 91-day combination oral contraceptives have touted a reduction in menstrual cycles per year.
    − Seasonale is a 91-day oral contraceptive regimen in which tablets containing the active hormones are taken for 12 weeks (84 d), followed by 1 week (7 d) of placebo tablets.
    − Conventional oral contraceptive use is based on a 28-day regimen (21 d of active tablets followed by 7 d of placebo tablets).
    − Seasonale contains a progestin (levonorgestrel) and an estrogen (ethinyl estradiol), which are active ingredients in already approved oral contraceptives.
    − With the Seasonale dosing regimen, the expected menstrual periods that a woman usually experiences are reduced from once a month to approximately once every 3 months.

− As with the conventional 28-day regimen, women experience menses while taking placebo tablets.
− Although Seasonale users have fewer scheduled menstrual cycles, the data from clinical trials show that many women, especially in the first few cycles of use, had more unplanned bleeding and spotting between the expected menstrual periods than women taking a conventional 28-day cycle of oral contraceptive.
− To counteract the unplanned bleeding, a newer version of Seasonale (Seasonique) was developed.
− This new brand completely eliminates the hormone-free interval. Seasonique also has 84 active pills (30 mcg of ethinyl estradiol and 150 mcg of levonorgestrel) but is followed by 7 more active pills (10 mcg ethinyl estradiol) instead of the traditional placebo.
− Therefore, no hormone-free weeks occur.
− The 2 main advantages to replacing the placebo week
with a week of low-dose estrogen are a diminished amount of unplanned bleeding and spotting and fewer or no symptoms (e.g., cramping, bloating, headaches) for women who are sensitive to the placebo-week hormone fluctuations (in particular, low estrogen).
− The risks of using Seasonale are similar to the risks of other conventional combination oral contraceptives and include an increased risk of blood clots, heart attack, and stroke.

  1. Combination Patch Contraceptive
    − Available in the United States since 2001, the contraceptive transdermal patch releases estrogen and progesterone directly into the skin (Ortho Evra, Ortho- McNeil Pharmaceutical; Raritan, NJ).
    − Each patch contains a 1-week supply of hormones of both norelgestromin and ethinyl estradiol.
    − It releases a sustained low daily dose of steroids equivalent to the lowest-dose oral contraceptive.

− Advantages include greater compliance and decreased adverse effects, such as nausea and vomiting, due to the avoidance of the first-pass effect.
− However, the patch may cause skin irritation, and, if it is removed unnoticed, such as from showering, this may compromise efficacy.
− Disadvantages and contraindications are similar to those of combination oral contraceptives.
− It may be less effective for women who weigh more than 198 pounds.

  1. Contraceptive Vaginal Ring
    − The vaginal rings can deliver progesterone or progesterone-estrogen combinations.
    − The outer diameter of the ring is 54 mm and the cross- sectional diameter is 4 mm.
    − The ring contains 11.7 mg of etonogestrel and 2.7 mg of ethinyl estradiol.
    − It releases 120 mcg of etonogestrel and 15 mcg of ethinyl estradiol each day.
    − The hormones are released slowly and are absorbed directly by the reproductive organs.
    − The ring is used in the same schedule as oral contraceptives, with 3 weeks of ring usage (ring is left in place for 3 wk) and 1 week without to produce a withdrawal bleed.
    − The ring can be inserted any time during the first 5 days of the menstrual cycle.
    − The ring should be placed in the vagina even if the woman has not finished bleeding, and she should use a backup contraceptive method for 7 days.
    − A new ring should be inserted each month. If the ring comes out during the first 3 weeks of use, it should be washed with lukewarm water and replaced.
    − If the ring-free interval is more than 3 hours, a backup contraceptive method should be used for 7 days.

− The ring should never be left in the vagina for more than 4 weeks.
− If left in for more than 4 weeks, pregnancy should be excluded before inserting a new ring and a backup contraceptive method should be used for 7 days after inserting a new ring.
Advantages
− NuvaRing is highly effective because it results in complete suppression of ovulation.
− The steady release of hormone provides exceptional cycle control.
− The ring is a very effective reversible method of birth control.
− Because daily intake is not a component of NuvaRing contraception, because it is easily inserted and removed by the woman herself, and because return of fertility is rapid upon discontinuation, NuvaRing is a highly acceptable method for women and their partners.
− Because the hormones are absorbed directly into the blood through the vaginal mucosa, the hepatic first-pass metabolism of progestin is prevented.
− The ring delivers the lowest dose of ethinyl estradiol compared with other combined hormonal contraceptives.
− Unlike combined oral contraceptives, the adverse effects of nausea and vomiting are avoided with ring use.
Disadvantages
− Adverse effects include headaches and vaginal irritation or discharge.
− The ring may accidentally slip out during intercourse and either the user or the partner may feel the ring during sexual intercourse.
− Contraindications are similar to those of combined oral contraceptives.

D. INTRAUTERINE DEVICES


− Until as recently as 2000, the only 2 IUDs available in the United States were the Copper T380 (Pregna International; Mumbai, India) and the progesterone-releasing form, Progestasert (Alza; Mountain View, Calif).
− In December 2000, the FDA approved another form of IUD, the levonorgestrel intrauterine system termed Mirena (Berlex Laboratories; Montville, NJ).
− More than 2 million women in Europe have used this form of contraception in the past decade with great success.
Description
− The T-shaped progesterone-releasing IUD Progestasert, which is placed into the uterine cavity, is made of ethylene vinyl acetate copolymer.
− It contains 38 mg of progesterone and minimal amounts of barium sulfate for greater visibility on x-ray films.
− The vertical limbs are 36 mm long, and the horizontal arms are 32 mm wide.
− It has a pair of dark-blue double-strings that hang from the lower limb.
− Approximately 65 mcg/d of progesterone is released from the progesterone form from a reservoir in its stem.
− This is a sufficient amount of hormone to last for 400 days; therefore, this IUD must be replaced yearly.
− The Copper T380 was introduced in 1988.
− The T-shaped IUD is made of polyethylene with fine
copper wire wrapped around the vertical stem.
− The string is clear or white and hangs from the lower limb
of the IUD.
− This device consists of 308 mg of copper covering portions
of its stem and arms.
− Contraceptive effectiveness continues for 10 years, after
which time it must be replaced.

− Mirena is similar in shape to the Copper T380 in that it also consists of a small T-shaped frame with a reservoir that contains levonorgestrel, a progesterone.
− This intrauterine system releases 20 mcg of levonorgestrel per day into the uterine cavity for as long as 5 years.
− An IUD causes cervical mucus to be thicker in consistency, thereby altering sperm migration.
− Uterotubal fluid and motility changes inhibit sperm migration.
− IUDs also result in endometrial suppression.
Efficacy
− The failure rate is 2% with Progestasert (the progesterone form), 0.6% with the Copper T380, and of 0.1 % with Mirena.
Advantages
− IUDs produce no adverse systemic effects.
− Ectopic pregnancies are reduced overall; however, the
ratio of extrauterine to intrauterine pregnancy is
increased if conception does occur.
− Menstrual blood loss and dysmenorrhea are decreased
with Progestasert.
− Twenty percent of women experience amenorrhea with
Mirena.
Disadvantages
− IUDs are associated with a risk of uterine perforation at the time of insertion.
− Increased dysmenorrhea occurs with the Copper T380.
− Increased menstrual blood loss occurs in the first few
cycles with use of the Copper T380 and Mirena IUDs.
− Whether IUDs increase the risk of PID is controversial.

− IUDs have none of the potential noncontraceptive benefits of hormonal contraceptives.
− IUDs may be expelled unnoticed, and they do not protect against STDs.
− Ectopic pregnancies are half as likely in IUD users as they are in women using no birth control.
− Ectopic pregnancies are more likely in women who use Progestasert than the Copper T380; however, the overall risk still remains less than for women who do not use birth control.
− Of those using Progestasert who become pregnant, approximately half of the pregnancies are ectopic.
− However, to reiterate, the risk of ectopic pregnancy is much less than it is in women who do not use any contraception.
− Contraindications include a history of previous PID in the past year or active PID, an abnormal or distorted uterine cavity, undiagnosed genital bleeding, uterine or cervical malignancy, a history of ectopic pregnancy, increased susceptibility to infection (eg, those with leukemia, diabetes, valvular heart disease, or AIDS), Wilson disease, known or suspected pregnancy, a history of genital actinomyces, and active cervical or endometrial infections.

E. STERILIZATION


− Sterilization is considered an elective permanent method of contraception.
− In regard to reversal of sterilization, success is noted to be greater with tubal reanastomosis than with reanastomosis of the vas deferens.

  1. Female Sterilization
    − Female sterilization prevents fertilization by interrupting the fallopian tubes.

− Sterilization can be performed surgically in the postpartum period with a small transverse infraumbilical incision or during the interval period.
− Sterilization during the interval period can be performed with laparoscopy, laparotomy, or colpotomy.
− The methods of fallopian tube sterilization include occlusion with Falope rings, clips, or bands; segmental destruction with electrocoagulation; or suture ligation with partial salpingectomy.
− The latest form of female permanent sterilization is the Essure system.
− This form of sterilization prevents fertilization by interrupting the fallopian tubes; however, the Essure system does not require surgical incisions and can be performed with the patient under local anesthesia.
− It is performed hysteroscopically, and a microinsert is placed directly into the fallopian tubes. During the first 3 months after the procedure, the fallopian tube and the microinsert create a tissue barrier that prevents sperm from reaching the egg.
− After the 3-month period, patients must undergo a hysterosalpingogram to ensure placement.
Efficacy
− Rates vary according to the procedure performed.
− The cumulative 10-year failure rate with each method of
tubal ligation is as follows: spring clip method, 3.7%; bipolar coagulation, 2.5%; interval partial salpingectomy, 2%; silicone rubber bands, 2%; and postpartum salpingectomy, 0.8%.
Advantages
− Female sterilization does not involve hormones.
− It is a permanent form of contraception.
− No data indicate that change in libido, menstrual cycle, or
lactation occurs.

− Female sterilization is usually a same-day procedure.
Disadvantages
− Female sterilization is a procedure that involves general or regional anesthesia.
− Patients who undergo the Essure system procedure require a backup method of contraception for the first 3 months.
− It is permanent contraception, and patients may regret the decision later, especially women younger than 30 years.
− If the Essure microinserts must be removed for any reason, major surgery is necessary, requiring an abdominal incision and, most likely, general anesthesia.
− Sterilization does not protect the patient from STDs.
− Sterilization causes short-term discomfort, and it involves
all the risks of surgery.

  1. Vasectomy
    − Vasectomy involves incision of the scrotal sac, transection of the vas deferens, and occlusion of both severed ends by suture ligation or fulguration.
    − The procedure is usually performed with the patient under local anesthesia in an outpatient setting.
    − Complications include hematoma formation and sperm granulomas.
    − Spontaneous resolution is rare.
    − After sterilization, remnant sperm remains in the
    ejaculatory ducts.
    − The man is not considered sterile until he has produced
    sperm-free ejaculates as documented by semen analysis.
    − This usually requires 15-20 ejaculations.
    − Vasectomy prevents the passage of sperm into seminal
    fluid by blocking the vas deferens.

Efficacy
− The failure rate is approximately 0.1%.
Advantages
− Vasectomy involves no hormones, is permanent, is an outpatient procedure, is quick, and carries minimal risk with regard to the procedure.
Disadvantages
− Patients may regret their decision after the procedure.
− Alternative contraception is required until the ejaculate is
deemed free of sperm.
− Vasectomy does not prevent STDs.
− Short-term discomfort occurs.

F. EMERGENCY POSTCOITAL CONTRACEPTIVES


− Emergency postcoital contraception is defined as the use of a drug or device to prevent pregnancy after unprotected sexual intercourse.
− A variety of different methods of emergency contraception have been described.
− Emergency contraceptives available in the United States include the emergency contraceptive pills (ECP), the Copper T380 IUD, and the minipill emergency contraception method (MECM).
− Both the Preven kit and the Plan B kit are marketed as emergency contraceptives.
− Candidates for emergency contraception include reproductive-aged women who have had unprotected sexual intercourse within 72 hours of presentation independent of the menstrual cycle.
− No known absolute contraindications to any of these methods have been described because exposure to the high dose of hormones is short lived.

− However, cases of deep vein thrombosis have been documented in women using the ECP method.

  1. Emergency Contraceptive Pills and the Minipill Emergency Contraception Method
    − The ECP mode is marketed as Preven.
    − It consists of 2 pills, which each contain 0.5 mg of
    levonorgestrel and 100 mcg of ethinyl estradiol, ingested
    12 hours apart for a total of 4 pills.
    − The first dose should be taken within the first 72 hours
    after unprotected intercourse; however, studies demonstrate effectiveness if the pills are taken after that period.
    − Only the progestin levonorgestrel has been studied for the use in MECM.
    − It is marketed as Plan B.
    − Its treatment schedule comprises 1 dose of 750 mcg
    levonorgestrel taken as soon as possible and no later than 48 hours after unprotected intercourse and a second dose taken 12 hours later.
    − The mechanism action of either the ECP or MECM is not clearly established.
    − If administered before ovulation, both methods may inhibit follicular development and maturation, resulting in anovulation and deficient luteal function.
    − Treatment following ovulation may affect the endometrium, thus inhibiting implantation.
    − They also may affect tubal transport of the sperm or ova.
    − However, menses and fertility return with the next cycle.
    Efficacy
    − Most studies cite an effectiveness rate of 55-94%, with the true effectiveness rate likely to be approximately 75%.
    − Based on one randomized trial comparing the ECP protocol with the MECM, the MECM seems to be just as effective with far less nausea and emesis.

− Patients must understand that the effective rate of 75% does not translate to a 25% failure rate.
− Instead, when considering 100 women who have had unprotected sexual intercourse during the middle 2 weeks of their cycle, approximately 8 will become pregnant.
− Of those 8 who have used ECPs, only 2 will then become pregnant.
− Despite this significant reduction in the rate of pregnancy, patients must understand that this method of contraception should be used only in emergencies and that they should be encouraged to use other more consistent forms of contraception.
− Several factors complicate the calculation of a failure rate.
− Factors include dependence on the patient’s history of
their last menstrual period and day of exposure, effect of regular and irregular menstrual cycles on the calculation of the estimated time of ovulation, the possibility of the patient being pregnant, and the possibility that more than one unprotected coitus has occurred during that period.
Disadvantages
− Adverse effects include nausea and emesis, minor changes in menses, breast tenderness, fatigue, headache, abdominal pain, and dizziness.
− Ectopic pregnancy is possible if treatment fails.

  1. Copper T380 Intrauterine Device
    − The Copper T380 IUD can be inserted as many as 7 days after unprotected sexual intercourse to prevent pregnancy.
    − Insertion of the IUD is significantly more effective than either the ECP or MECP regimen, reducing the risk of pregnancy following unprotected intercourse by more than 99%.

NURSING PAST QUESTIONS AND ANSWERS ON ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM

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NURSING PAST QUESTIONS AND ANSWERS ON ANATOMY AND PHYSIOLOGY OF THE RESPIRATORY SYSTEM

SECTION 1

1. Question

Aminophylline (theophylline) is prescribed for a client with acute bronchitis. A nurse administers the medication, knowing that the primary action of this medication is to:

A. Promote expectoration.

B. Suppress the cough.

C. Relax smooth muscles of the bronchial airway.

D. Prevent infection.

Incorrect

Correct Answer: C. Relax smooth muscles of the bronchial airway.

2. Question

A client is receiving isoetharine hydrochloride (Bronkosol) via a nebulizer. The nurse monitors the client for which side effect of this medication?

A. Constipation

B. Diarrhea

C. Bradycardia

D. Tachycardia

Correct

Correct Answer: D. Tachycardia

3. Question

A nurse teaches a client about the use of a respiratory inhaler. Which action by the client indicated a need for further teaching?

A. Removes the cap and shakes the inhaler well before use.

B. Press the canister down with your finger as he breathes in.

C. Inhales the mist and quickly exhales.

D. Waits 1 to 2 minutes between puffs if more than one puff has been prescribed.

Incorrect

Correct Answer: C. Inhales the mist and quickly exhales.

4. Question

A female client is scheduled to have a chest radiograph. Which of the following questions is of most importance to the nurse assessing this client?

A. “Is there any possibility that you could be pregnant?”

B. “Are you wearing any metal chains or jewelry?”

C. “Can you hold your breath easily?”

D. “Are you able to hold your arms above your head?”

Incorrect

Correct Answer: A. “Is there any possibility that you could be pregnant?”

5. Question

A client has just returned to a nursing unit following bronchoscopy. A nurse would implement which of the following nursing interventions for this client?

A. Encouraging additional fluids for the next 24 hours

B. Ensuring the return of the gag reflex before offering foods or fluids

C. Administering atropine intravenously

D. Administering small doses of midazolam (Versed).

Incorrect

Correct Answer: B. Ensuring the return of the gag reflex before offering foods or fluids

6. Question

A client has an order to have radial ABG drawn. Before drawing the sample, a nurse occludes the:

A. Brachial and radial arteries, and then releases them and observes the circulation of the hand.

B. Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the process with the other artery.

C. Radial artery and observes for color changes in the affected hand.

D. Ulnar artery and observes for color changes in the affected hand.

Incorrect

Correct Answer: B. Radial and ulnar arteries, releases one, evaluates the color of the hand, and repeats the process with the other artery.

7. Question

A nurse is assessing a client with chronic airflow limitation and notes that the client has a “barrel chest.” The nurse interprets that this client has which of the following forms of chronic airflow limitation?

A. Chronic obstructive bronchitis

B. Emphysema

C. Bronchial asthma

D. Bronchial asthma and bronchitis

Incorrect

Correct Answer: B. Emphysema

8. Question

A client has been taking benzonatate (Tessalon Perles) as prescribed. A nurse concludes that the medication is having the intended effect if the client experiences:

A. Decreased anxiety level.

B. Increased comfort level.

C. Reduction of N/V.

D. Decreased frequency and intensity of cough.

Correct

Correct Answer: D. Decreased frequency and intensity of cough.

9. Question

Which of the following would be an expected outcome for a client recovering from an upper respiratory tract infection? The client will:

A. Maintain a fluid intake of 800 ml every 24 hours.

B. Experience chills only once a day.

C. Cough productively without chest discomfort.

D. Experience less nasal obstruction and discharge.

Correct

Correct Answer: D. Experience less nasal obstruction and discharge.

10. Question

Which of the following individuals would the nurse consider to have the highest priority for receiving an influenza vaccination?

A. A 60-year-old man with a hiatal hernia.

B. A 36-year-old woman with 3 children.

C. A 50-year-old woman caring for a spouse with cancer.

D. A 60-year-old woman with osteoarthritis.

Incorrect

Correct Answer: C. A 50-year-old woman caring for a spouse with cancer.

11. Question

A client with allergic rhinitis asks the nurse what he should do to decrease his symptoms. Which of the following instructions would be appropriate for the nurse to give the client?

A. “Use your nasal decongestant spray regularly to help clear your nasal passages.”

B. “Ask the doctor for antibiotics. Antibiotics will help decrease the secretion.”

C. “It is important to increase your activity. A daily brisk walk will help promote drainage.”

D. “Keep a diary when your symptoms occur. This can help you identify what precipitates your attacks.”

Incorrect

Correct Answer: D. “Keep a diary when your symptoms occur. This can help you identify what precipitates your attacks.”

12. Question

An elderly client has been ill with the flu, experiencing headache, fever, and chills. After 3 days, she developed a cough productive of yellow sputum. The nurse auscultates her lungs and hears diffuse crackles. How would the nurse best interpret these assessment findings?

A. It is likely that the client is developing a secondary bacterial pneumonia.

B. The assessment findings are consistent with influenza and are to be expected.

C. The client is getting dehydrated and needs to increase her fluid intake to decrease secretions

D. The client has not been taking her decongestants and bronchodilators as prescribed.

Incorrect

Correct Answer: A. It is likely that the client is developing a secondary bacterial pneumonia.

13. Question

Guaifenesin 300 mg four times daily has been ordered as an expectorant. The dosage strength of the liquid is 200mg/5ml. How many mL should the nurse administer each dose? Fill in the blank and record your final answer using one decimal place.

Answer:  mL

Correct

Correct Answer: 7.5 ml

14. Question

Pseudoephedrine (Sudafed) has been ordered as a nasal decongestant. Which of the following is a possible side effect of this drug?

A. Constipation

B. Bradycardia

C. Diplopia

D. Restlessness

Correct

Correct Answer: D. Restlessness

15. Question

A client with COPD reports steady weight loss and being “too tired from just breathing to eat.” Which of the following nursing diagnoses would be most appropriate when planning nutritional interventions for this client?

A. Altered nutrition: Less than body requirements related to fatigue.

B. Activity intolerance related to dyspnea.

C. Weight loss related to COPD.

D. Ineffective breathing pattern related to alveolar hypoventilation.

Incorrect

Correct Answer: A. Altered nutrition: Less than body requirements related to fatigue.

16. Question

When developing a discharge plan to manage the care of a client with COPD, the nurse should anticipate that the client will do which of the following?

A. Develop infections easily.

B. Maintain current status.

C. Require less supplemental oxygen.

D. Show permanent improvement.

Incorrect

Correct Answer: A. Develop infections easily.

17. Question

Which of the following outcomes would be appropriate for a client with COPD who has been discharged to home? The client:

A. Promises to do pursed lip breathing at home.

B. States actions to reduce pain.

C. States that he will use oxygen via a nasal cannula at 5 L/minute.

D. Agrees to call the physician if dyspnea on exertion increases.

Correct

Correct Answer: D. Agrees to call the physician if dyspnea on exertion increases.

18. Question

Which of the following physical assessment findings would the nurse expect to find in a client with advanced COPD?

A. Increased anteroposterior chest diameter.

B. Underdeveloped neck muscles.

C. Collapsed neck veins.

D. Increased chest excursions with respiration.

Incorrect

Correct Answer: A. Increased anteroposterior chest diameter.

19. Question

Which of the following is the primary reason to teach pursed-lip breathing to clients with emphysema?

A. To promote oxygen intake.

B. To strengthen the diaphragm.

C. To strengthen the intercostal muscles.

D. To promote carbon dioxide elimination.

Correct

Correct Answer: D. To promote carbon dioxide elimination.

20. Question

Which of the following is a priority goal for the client with COPD?

A. Maintaining functional ability.

B. Minimizing chest pain.

C. Increasing carbon dioxide levels in the blood.

D. Treating infectious agents.

Incorrect

Correct Answer: A. Maintaining functional ability

21. Question

A client’s arterial blood gas levels are as follows: pH 7.31; PaO2 80 mm Hg, PaCO2 65 mm Hg; HCO3- 36 mEq/L. Which of the following signs or symptoms would the nurse expect?

A. Cyanosis

B. Flushed skin

C. Irritability

D. Anxiety

Incorrect

Correct Answer: B. Flushed skin

22. Question

When teaching a client with COPD to conserve energy, the nurse should teach the client to lift objects:

A. While inhaling through an open mouth.

B. While exhaling through pursed lips.

C. After exhaling but before inhaling.

D. While taking a deep breath and holding it.

Incorrect

Correct Answer: B. While exhaling through pursed lips.

23. Question

The nurse teaches a client with COPD to assess for s/s of right-sided heart failure. Which of the following s/s would be included in the teaching plan?

A. Clubbing of nail beds

B. Hypertension

C. Peripheral edema

D. Increased appetite

Incorrect

Correct Answer: C. Peripheral edema

24. Question

The nurse assesses the respiratory status of a client who is experiencing an exacerbation of COPD secondary to an upper respiratory tract infection. Which of the following findings would be expected?

Normal breath sounds

A. Normal breath sounds

B. Prolonged inspiration

C. Normal chest movement

D. Coarse crackles and rhonchi

Incorrect

Correct Answer: D. Coarse crackles and rhonchi

25. Question

Which of the following ABG abnormalities should the nurse anticipate in a client with advanced COPD?

A. Increased PaCO2

B. Increased PaO2

C. Increased pH

D. Increased oxygen saturation

Incorrect

Correct Answer: A. Increased PaCO2

26. Question

Which of the following diets would be most appropriate for a client with COPD?

A. Low fat, low cholesterol

B. Bland, soft diet

C. Low-Sodium diet

D. High calorie, high-protein diet

Correct

Correct Answer: D. High-calorie, high-protein diet

27. Question

The nurse is planning to teach a client with COPD how to cough effectively. Which of the following instructions should be included?

A. Take a deep abdominal breath, bend forward, and cough 3 to 4 times on exhalation.

B. Lie flat on back, splint the thorax, take two deep breaths and cough.

C. Take several rapid, shallow breaths and then cough forcefully.

D. Assume a side-lying position, extend the arm over the head, and alternate deep breathing with coughing.

Incorrect

Correct Answer: A. Take a deep abdominal breath, bend forward, and cough 3 to 4 times on exhalation.

28. Question

A 34-year-old woman with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/minute, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. Based on these findings, what action should the nurse take to initiate care of the client?

A. Initiate oxygen therapy and reassess the client in 10 minutes.

B. Draw blood for an ABG analysis and send the client for a chest x-ray.

C. Encourage the client to relax and breathe slowly through the mouth.

D. Administer bronchodilators.

Incorrect

Correct Answer: D. Administer bronchodilators.

29. Question

The nurse would anticipate which of the following ABG results in a client experiencing a prolonged, severe asthma attack?

A. Decreased PaCO2, increased PaO2, and decreased pH.

B. Increased PaCO2, decreased PaO2, and decreased pH.

C. Increased PaCO2, increased PaO2, and increased pH.

D. Decreased PaCO2, decreased PaO2, and increased pH.

Incorrect

Correct Answer: B. Increased PaCO2, decreased PaO2, and decreased pH.

30. Question

A client with acute asthma is prescribed short-term corticosteroid therapy. What is the rationale for the use of steroids in clients with asthma?

A. Corticosteroids promote bronchodilation.

B. Corticosteroids act as an expectorant.

C. Corticosteroids have an anti-inflammatory effect.

D. Corticosteroids prevent development of respiratory infections.

Incorrect

Correct Answer: C. Corticosteroids have an anti-inflammatory effect.

31. Question

The nurse is teaching the client how to use a metered-dose inhaler (MDI) to administer a Corticosteroid drug. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply.

A. The inhaler is held upright.

B. Head is tilted down while inhaling the medication.

C. Client waits 5 minutes between puffs.

D. Mouth is rinsed with water following administration.

E. Client lies supine for 15 minutes following administration.

Incorrect

Correct Answers: A & D.

32. Question

A client is prescribed metaproterenol (Alupent) via a metered-dose inhaler (MDI), two puffs every 4 hours. The nurse instructs the client to report side effects. Which of the following are potential side effects of metaproterenol?

A. Irregular heartbeat

B. Constipation

C. Pedal edema

D. Decreased heart rate.

Correct Answer: A. Irregular heartbeat

33. Question

A client has been taking flunisolide (Aerobid), two inhalations a day, for treatment of asthma. He tells the nurse that he has painful, white patches in his mouth. Which response by the nurse would be the most appropriate?

A. “This is an anticipated side-effect of your medication. It should go away in a couple of weeks.”

B. “You are using your inhaler too much and it has irritated your mouth.”

C. “You have developed a fungal infection from your medication. It will need to be treated with an antifungal.”

D. “Be sure to brush your teeth and floss daily. Good oral hygiene will treat this problem.”

Incorrect

Correct Answer: C. “You have developed a fungal infection from your medication. It will need to be treated with an antifungal.”

34. Question

Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma?

A. Incorporate physical exercise as tolerated into the treatment plan.

B. Monitor peak flow numbers after meals and at bedtime.

C. Eliminate stressors in the work and home environment.

D. Use sedatives to ensure uninterrupted sleep at night.

Incorrect

Correct Answer: A. Incorporate physical exercise as tolerated into the treatment plan.

35. Question

The client with asthma should be taught which of the following is one of the most common precipitating factors of an acute asthma attack?

A. Occupational exposure to toxins.

B. Viral respiratory infections.

C. Exposure to cigarette smoke.

D. Exercising in cold temperatures.

Incorrect

Correct Answer: B. Viral respiratory infections.

36. Question

A female client comes into the emergency room complaining of SOB and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her VS are: 140/80, P 110, R 40. The physician orders ABG’s, results are as follows: pH: 7.50; PaCO2 29 mm Hg; PaO2 60 mm Hg; HCO3- 24 mEq/L; SaO2 86%. Considering these results, the first intervention is to:

A. Begin mechanical ventilation.

B. Place the client on oxygen.

C. Give the client sodium bicarbonate.

D. Monitor for pulmonary embolism.

Incorrect

Correct Answer: B. Place the client on oxygen

37. Question

Basilar crackles are present in a client’s lungs on auscultation. The nurse knows that these are discrete, non continuous sounds that are:

A. Caused by the sudden opening of alveoli.

B. Usually more prominent during expiration.

C. Produced by airflow across passages narrowed by secretions.

D. Found primarily in the pleura.

Incorrect

Correct Answer: A. Caused by the sudden opening of alveoli

38. Question

A cyanotic client with an unknown diagnosis is admitted to the E.R. In relation to oxygen, the first nursing action would be to:

A. Wait until the client’s lab work is done.

B. Not administer oxygen unless ordered by the physician.

C. Administer oxygen at 2 L flow per minute.

D. Administer oxygen at 10 L flow per minute and check the client’s nail beds.

Incorrect

Correct Answer: C. Administer oxygen at 2 L flow per minute.

39. Question

Immediately following a thoracentesis, which clinical manifestations indicate that a complication has occurred and the physician should be notified?

A. Serosanguineous drainage from the puncture site.

B. Increased temperature and blood pressure.

C. Increased pulse and pallor.

D. Hypotension and hypothermia.

Incorrect

Correct Answer: C. Increased pulse and pallor

40. Question

If a client continues to hypoventilate, the nurse will continually assess for a complication of:

A. Respiratory acidosis

B. Respiratory alkalosis

C. Metabolic acidosis

D. Metabolic alkalosis

Correct Answer: A. Respiratory acidosis

41. Question

A client is admitted to the hospital with acute bronchitis. While taking the client’s VS, the nurse notices he has an irregular pulse. The nurse understands that cardiac arrhythmias in chronic respiratory distress are usually the result of:

A. Respiratory acidosis

B. A build-up of carbon dioxide

C. A build-up of oxygen without adequate expelling of carbon dioxide.

D. An acute respiratory infection.

Incorrect

Correct Answer: B. A build-up of carbon dioxide.

42. Question

Auscultation of a client’s lungs reveals crackles in the left posterior base. The nursing intervention is to:

A. Repeat auscultation after asking the client to deep breathe and cough.

B. Instruct the client to limit fluid intake to less than 2000 ml/day.

C. Inspect the client’s ankles and sacrum for the presence of edema.

D. Place the client on bedrest in a semi-Fowler’s position.

Incorrect

Correct Answer: A. Repeat auscultation after asking the client to deep breathe and cough.

43. Question

The most reliable index to determine the respiratory status of a client is to:

A. Observe the chest rising and falling.

B. Observe the skin and mucous membrane color.

C. Listen and feel the air movement.

D. Determine the presence of a femoral pulse.

Incorrect

Correct Answer: C. Listen and feel the air movement.

44. Question

A client with COPD has developed secondary polycythemia. Which nursing diagnosis would be included in the plan of care because of the polycythemia?

A. Fluid volume deficit related to blood loss.

B. Impaired tissue perfusion related to thrombosis.

C. Activity intolerance related to dyspnea.

D. Risk for infection related to suppressed immune response.

Correct Answer: B. Impaired tissue perfusion related to thrombosis.

45. Question

The physician has scheduled a client for a left pneumonectomy. The position that will most likely be ordered postoperatively for his is the:

A. Nonoperative side or back

B. Operative side or back

C. Back only

D. Back or either side.

Correct Answer: B. Operative side or back

46. Question

Assessing a client who has developed atelectasis postoperatively, the nurse will most likely find:

A. A flushed face.

B. Dyspnea and pain.

C. Decreased temperature.

D. Severe cough and no pain.

Incorrect

Correct Answer: B. Dyspnea and pain

47. Question

A fifty-year-old client has a tracheostomy and requires tracheal suctioning. The first intervention in completing this procedure would be to:

A. Change the tracheostomy dressing.

B. Provide humidity with a trach mask.

C. Apply oral or nasal suction.

D. Deflate the tracheal cuff.

Correct Answer: C. Apply oral or nasal suction.

48. Question

A client states that the physician said the tidal volume is slightly diminished and asks the nurse what this means. The nurse explains that the tidal volume is the amount of air:

A. Exhaled forcibly after a normal expiration.

B. Exhaled after there is a normal inspiration.

C. Trapped in the alveoli that cannot be exhaled.

D. Forcibly inspired over and above a normal respiration.

Incorrect

Correct Answer: B. Exhaled after there is a normal inspiration.

49. Question

An acceleration in oxygen dissociation from hemoglobin, and thus oxygen delivery to the tissues, is caused by:

A. A decreasing oxygen pressure in the blood.

B. An increasing carbon dioxide pressure in the blood.

C. A decreasing oxygen pressure and/or an increasing carbon dioxide pressure in the blood.

D. An increasing oxygen pressure and/or a decreasing carbon dioxide pressure in the blood.

Incorrect

Correct Answer: C. A decreasing oxygen pressure and/or an increasing carbon dioxide pressure in the blood.

50. Question

The best method of oxygen administration for client with COPD uses:

A. Cannula

B. Simple Face mask

C. Non-rebreather mask

D. Venturi mask

Correct Answer: D. Venturi mask

SECTION 2

1. Question

Dr. Jones prescribes albuterol sulfate (Proventil) for a patient with newly diagnosed asthma. When teaching the patient about this drug, the nurse should explain that it may cause:

A. Nasal congestion

B. Nervousness

C. Lethargy

D. Hyperkalemia

Incorrect

Correct Answer: B. Nervousness

2. Question

Miriam, a college student with acute rhinitis sees the campus nurse because of excessive nasal drainage. The nurse asks the patient about the color of the drainage. In acute rhinitis, nasal drainage normally is:

A. Yellow

B. Green

C. Clear

D. Gray

Incorrect

Correct Answer: C. Clear

3. Question

A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

A. Nausea or vomiting

B. Abdominal pain or diarrhea

C. Hallucinations or tinnitus

D. Lightheadedness or parenthesis 

Correct Answer: D. Lightheadedness or paresthesia

4. Question

Before administering ephedrine, Nurse Tony assesses the patient’s history. Because of ephedrine’s central nervous system (CNS) effects, it is not recommended for:

A. Patients with an acute asthma attack.

B. Patients with narcolepsy.

C. Patients under age

D. Elderly patients.

Correct Answer: D. Elderly patients

5. Question

A female patient suffers acute respiratory distress syndrome as a consequence of shock. The patient’s condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator, alarm sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

A. Kinking of the ventilator tubing.

B. A disconnected ventilator tube.

C. An endotracheal cuff leak.

D. A change in the oxygen concentration without resetting the oxygen level alarm.

Correct Answer: A. Kinking of the ventilator tubing.

6. Question

A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose?

Leg movement

A. Leg movement

B. Finger movement

C. Lip movement

D. Fighting the ventilator

Correct Answer: D. Fighting the ventilator

7. Question

On auscultation, which finding suggests a right pneumothorax?

A. Bilateral inspiratory and expiratory crackles.

B. Absence of breaths sound in the right thorax.

C. Inspiratory wheezes in the right thorax.

D. Bilateral pleural friction rub.

Incorrect

Correct Answer: B. Absence of breaths sound in the right thorax

8. Question

Rhea, confused and short breath, is brought to the emergency department by a family member. The medical history reveals chronic bronchitis and hypertension. To learn more about the current respiratory problem, the doctor orders a chest x-ray and arterial blood gas (ABG) analysis. When reviewing the ABG report, the nurses see many abbreviations. What does a lowercase “a” in ABG value present?

A. Acid-base balance

B. Arterial Blood

C. Arterial oxygen saturation

D. Alveoli

Correct Answer: B. Arterial Blood

9. Question

A male patient is admitted to the healthcare facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient?

A. Activity intolerance related to fatigue.

B. Anxiety related to actual threat to health status.

C. Risk for infection related to retained secretions.

D. Impaired gas exchange related to airflow obstruction.

Correct Answer: D. Impaired gas exchange related to airflow obstruction.

10. Question

Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the:

A. Contralateral side in a simple pneumothorax.

B. Affected side in a hemothorax.

C. Affected side in a tension pneumothorax.

D. Contralateral side in hemothorax.

Correct Answer: D. Contralateral side in hemothorax.

11. Question

After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must:

A. Monitor fluctuations in the water-seal chamber.

B. Clamp the chest tube once every shift.

C. Encourage coughing and deep breathing.

D. Milk the chest tube every 2 hours.

Incorrect

Correct Answer: C. Encourage coughing and deep breathing

12. Question

When caring for a male patient who has just had a total laryngectomy, the nurse should plan to:

A. Encourage oral feeding as soon as possible.

B. Develop an alternative communication method.

C. Keep the tracheostomy cuff fully inflated.

D. Keep the patient flat in bed.

Correct Answer: B. Develop an alternative communication method.

13. Question

A male patient has a sucking stab wound to the chest. Which action should the nurse take first?

A. Drawing blood for a hematocrit and hemoglobin level.

B. Applying a dressing over the wound and taping it on three sides.

C. Preparing a chest tube insertion tray.

D. Preparing to start an I.V. line.

Correct Answer: B. Applying a dressing over the wound and taping it on three sides.

14. Question

For a patient with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?

A. Encouraging the patient to drink three glasses of fluid daily.

B. Keeping the patient in semi-Fowler’s position.

C. Using a high-flow venturi mask to deliver oxygen as prescribed.

D. Administering a sedative, as prescribed.

Correct Answer: C. Using a high-flow venturi mask to deliver oxygen as prescribe

15. Question

A male patient’s X-ray result reveals bilateral white-outs, indicating acute respiratory distress syndrome (ARDS). This syndrome results from:

A. Cardiogenic pulmonary edema

B. Respiratory alkalosis

C. Increased pulmonary capillary permeability

D. Renal failure

Correct Answer: C. Increased pulmonary capillary permeability

16. Question

For a female patient with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway?

A. Restricting fluid intake to 1,000 ml per day.

B. Enforcing absolute bed rest.

C. Teaching the patient how to perform controlled coughing.

D. Administering prescribed sedatives regularly and in large amounts.

Correct Answer: C. Teaching the patient how to perform controlled coughing.

17. Question

Nurse Lei, caring for a client with a pneumothorax and who has had a chest tube inserted, continues gentle bubbling in the suction control chamber. What action is appropriate?

A. Do nothing, because this is an expected finding.

B. Immediately clamp the chest tube and notify the physician.

C. Check for an air leak because the bubbling should be intermittent.

D. Increase the suction pressure so that the bubbling becomes vigorous.

Correct Answer: A. Do nothing, because this is an expected finding.

18. Question

Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate?

A. Inform the physician.

B. Continue to monitor the client.

C. Reinforce the occlusive dressing.

D. Encourage the client to deep breathe.

Correct Answer: B. Continue to monitor the client.

19. Question

Nurse Reynolds caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to:

A. Call the physician.

B. Place the tube in a bottle of sterile water.

C. Immediately replace the chest tube system.

D. Place a sterile dressing over the disconnection site.

Correct Answer: B. Place the tube in a bottle of sterile water.

20. Question

A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to:

A. Exhale slowly

B. Stay very still

C. Inhale and exhale quickly

D. Perform the Valsalva maneuver

Correct Answer: D. Perform the Valsalva maneuver.

21. Question

While changing the tapes on a tracheostomy tube, the male client coughs and the tube is dislodged. The initial nursing action is to:

A. Call the physician to reinsert the tube.

B. Grasp the retention sutures to spread the opening.

C. Call the respiratory therapy department to reinsert the tracheotomy.

D. Cover the tracheostomy site with a sterile dressing to prevent infection.

Correct Answer: B. Grasp the retention sutures to spread the opening.

22. Question

Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?

A. Stridor

B. Occasional pink-tinged sputum

C. A few basilar lung crackles on the right

D. Respiratory rate 24 breaths/min

Correct Answer: A. Stridor

23. Question

An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?

A. A low respiratory rate.

B. Diminished breath sounds.

C. The presence of a barrel chest.

D. A sucking sound at the site of injury.

Correct Answer: B. Diminished breath sounds.

24. Question

Nurse Reese is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client?

A. Hypocapnia

B. A hyperinflated chest noted on the chest x-ray.

C. Increased oxygen saturation with exercise.

D. A widened diaphragm noted on the chest x-ray.

Correct Answer: B. A hyperinflated chest noted on the chest x-ray.

25. Question

An oxygen delivery system is prescribed for a male client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed?

A. Face tent

B. Venturi mask

C. Aerosol mask

D. Tracheostomy collar

Correct Answer: B. Venturi mask

26. Question

Blessy, a community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is:

A. Dyspnea

B. Chest pain

C. A bloody, productive cough.

D. A cough with the expectoration of mucoid sputum.

Correct Answer: D. A cough with the expectoration of mucoid sputum

27. Question

A nurse performs an admission assessment on a female client with a diagnosis of tuberculosis. The nurse reviews the result of which diagnosis test that will confirm this diagnosis?

A. Bronchoscopy

B. Sputum culture

C. Chest x-ray

D. Tuberculin skin test

I

Correct Answer: B. Sputum culture

28. Question

A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed:

A. 1 L/min

B. 2 L/min

C. 6 L/min

D. 10 L/min

Correct Answer: B. 2 L/min

29. Question

A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to:

A. Promote oxygen intake.

B. Strengthen the diaphragm.

C. Strengthen the intercostal muscles.

D. Promote carbon dioxide elimination.

Correct Answer: D. Promote carbon dioxide elimination.

30. Question

A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client?

A. Pallor

B. Low arterial PaO2

C. Elevated arterial PaO2

D. Decreased respiratory rate

Correct Answer: B. Low arterial PaO2

31. Question

A nurse is preparing to obtain a sputum specimen from a male client. Which of the following nursing actions will facilitate obtaining the specimen?

A. Limiting fluid.

B. Having the client take deep breaths.

C. Asking the client to spit into the collection container.

D. Asking the client to obtain the specimen after eating.

Correct Answer: B. Having the client take deep breaths.

32. Question

Nurse Joy is caring for a client after a bronchoscopy and biopsy. Which of the following signs, if noticed in the client, should be reported immediately to the physician?

A. Dry cough

B. Hematuria

C. Bronchospasm

D. Blood-streaked sputum

Correct Answer: C. Bronchospasm

33. Question

A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of:

A. 1 minute

B. 5 seconds

C. 10 seconds

D. 30 seconds

Correct Answer: C. 10 seconds

34. Question

A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which if the following is the appropriate nursing intervention?

A. Continue to suction.

B. Notify the physician immediately.

C. Stop the procedure and reoxygenate the client.

D. Ensure that the suction is limited to 15 seconds.

Correct Answer: C. Stop the procedure and reoxygenate the client.

35. Question

A male adult client is suspected of having a pulmonary embolism. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism?

A. Dyspnea

B. Bradypnea

C. Bradycardia

D. Decreased respirations

Correct Answer: A. Dyspnea

36. Question

A slightly obese female client with a history of allergy-induced asthma, hypertension, and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination, paying special attention to the cardiovascular and respiratory systems. When percussing the client’s chest wall, the nurse expects to elicit:

A. Resonant sounds.

B. Hyperresonant sounds.

C. Dull sounds.

D. Flat sounds.

Correct Answer: A. Resonant sounds.

37. Question

A male client who weighs 175 lb (79.4 kg) is receiving aminophylline (Aminophylline) (400 mg in 500 ml) at 50 ml/hour. The theophylline level is reported as 6 mcg/ml. The nurse calls the physician who instructs the nurse to change the dosage to 0.45 mg/kg/hour. The nurse should:

A. Question the order because it’s too low.

B. Question the order because it’s too high.

C. Set the pump at 45 ml/hour.

D. Stop the infusion and have the laboratory repeat the theophylline measurement.

Correct Answer: A. Question the order because it’s too low.

38. Question

The nurse is teaching a male client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?

A. Make inhalation longer than exhalation.

B. Exhale through an open mouth.

C. Use diaphragmatic breathing.

D. Use chest breathing.

Correct Answer: C. Use diaphragmatic breathing.

39. Question

Which phrase is used to describe the volume of air inspired and expired with a normal breath?

A. Total lung capacity

B. Forced vital capacity

C. Tidal volume

D. Residual volume

Correct Answer: C. Tidal volume

40. Question

A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations?

A. Simple mask

B. Non-rebreather mask

C. Face tent

D. Nasal cannula

Correct Answer: B. Non-rebreather mask

41. Question

A female client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if a health concern occurs?

A. Impaired color discrimination

B. Increased urinary frequency

C. Decreased hearing acuity

D. Increased appetite

Correct Answer: C. Decreased hearing acuity

42. Question

A male client is asking the nurse a question regarding the Mantoux test for tuberculosis. The nurse should base her response on the fact that the:

A. Area of redness is measured in 3 days and determines whether tuberculosis is present.

B. Skin test doesn’t differentiate between active and dormant tuberculosis infection.

C. Presence of a wheal at the injection site in 2 days indicates active tuberculosis.

D. Test stimulates a reddened response in some clients and requires a second test in 3 months.

Correct Answer: B. Skin test doesn’t differentiate between active and dormant tuberculosis infection.

43. Question

A female adult client has a tracheostomy but doesn’t require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:

A. 15 to 60 seconds.

B. 5 to 20 minutes.

C. 30 to 40 minutes.

D. 45 to 60 minutes.

Correct Answer: B. B. 5 to 20 minutes.

44. Question

Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

A. The system is functioning normally.

B. The client has a pneumothorax.

C. The system has an air leak.

D. The chest tube is obstructed.

Correct Answer: C. The system has an air leak.

45. Question

A black client with asthma seeks emergency care for acute respiratory distress. Because of this client’s dark skin, the nurse should assess for cyanosis by inspecting the:

A. Lips

B. Mucous membranes

C. Nail beds

D. Earlobes

Correct Answer: B. Mucous membranes

46. Question

For a male client with an endotracheal (ET) tube, which nursing action is most essential?

A. Auscultating the lungs for bilateral breath sounds.

B. Turning the client from side to side every 2 hours.

C. Monitoring serial blood gas values every 4 hours.

D. Providing frequent oral hygiene.

Correct Answer: A. Auscultating the lungs for bilateral breath sounds.

47. Question

The nurse assesses a male client’s respiratory status. Which observation indicates that the client is experiencing difficulty breathing?

A. Diaphragmatic breathing

B. Use of accessory muscles

C. Pursed-lip breathing

D. Controlled breathing

Correct Answer: B. Use of accessory muscles

48. Question

A female client is undergoing a complete physical examination as a requirement for college. When checking the client’s respiratory status, the nurse observes respiratory excursion to help assess:

A. Lung vibrations

B. Vocal sounds

C. Breath sounds

D. Chest movements.

Correct Answer: D. Chest movements

49. Question

A male client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client’s history and physical findings, the physician suspects Legionnaires’ disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What is the drug of choice for treating Legionnaires’ disease?

A. erythromycin (Erythrocin)

B. rifampin (Rifadin)

C. amantadine (Symmetrel)

D. amphotericin B (Fungizone)

Correct Answer: A. Erythromycin (Erythrocin)

50. Question

A male client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can’t produce an effective cough, the nurse should monitor closely for:

A. Pleural effusion

B. Pulmonary edema

C. Atelectasis

D. Oxygen toxicity

Correct Answer: C. Atelectasis

SECTION 3

1. Question

An elderly client with pneumonia may appear with which of the following symptoms first?

A. Altered mental status and dehydration

B. Fever and chills

C. Hemoptysis and dyspnea

D. Pleuritic chest pain and cough

Correct Answer: A. Altered mental status and dehydration

2. Question

Which of the following pathophysiological mechanisms that occur in the lung parenchyma allows pneumonia to develop?

A. Atelectasis

B. Bronchiectasis

C. Effusion

D. Inflammation

Correct Answer: D. Inflammation

3. Question

A 7-year-old client is brought to the E.R. He’s tachypneic and afebrile and has a respiratory rate of 36 breaths/minute and a nonproductive cough. He recently had a cold. From his history, the client may have which of the following?

A. Acute asthma

B. Bronchial pneumonia

C. Chronic obstructive pulmonary disease (COPD)

D. Emphysema

Correct Answer: A. Acute asthma

4. Question

Which of the following assessment findings would help confirm a diagnosis of asthma in a client suspected of having the disorder?

A. Circumoral cyanosis

B. Increased forced expiratory volume

C. Inspiratory and expiratory wheezing

D. Normal breath sounds

Incorrect

Correct Answer: C. Inspiratory and expiratory wheezing

5. Question

Which of the following types of asthma involves an acute asthma attack brought on by an upper respiratory infection?

A. Emotional

B. Extrinsic

C. Intrinsic

D. Mediated

Incorrect

Correct Answer: C. Intrinsic

6. Question

A client with acute asthma showing inspiratory and expiratory wheezes and a decreased expiratory volume should be treated with which of the following classes of medication right away?

A. Beta-adrenergic blockers

B. Bronchodilators

C. Inhaled steroids

D. Oral steroids

Correct Answer: B. Bronchodilators

7. Question

A 19-year-old comes into the emergency department with acute asthma. His respiratory rate is 44 breaths/minute, and he appears to be in acute respiratory distress. Which of the following actions should be taken first?

A. Take a full medication history.

B. Give a bronchodilator by nebulizer.

C. Apply a cardiac monitor to the client.

D. Provide emotional support to the client.

Correct Answer: B. Give a bronchodilator by nebulizer.

8. Question

A 58-year-old client with a 40-year history of smoking one to two packs of cigarettes a day has a chronic cough producing thick sputum, peripheral edema, and cyanotic nail beds. Based on this information, he most likely has which of the following conditions?

A. Adult respiratory distress syndrome (ARDS)

B. Asthma

C. Chronic obstructive bronchitis

D. Emphysema

Correct Answer: C. Chronic obstructive bronchitis

9. Question

The term “blue bloater” refers to which of the following conditions?

A. Adult respiratory distress syndrome (ARDS)

B. Asthma

C. Chronic obstructive bronchitis

D. Emphysema

Correct Answer: C. Chronic obstructive bronchitis

10. Question

The term “pink puffer” refers to the client with which of the following conditions?

A. ARDS

B. Asthma

C. Chronic obstructive bronchitis

D. Emphysema

Correct

Correct Answer: D. Emphysema

11. Question

A 66-year-old client has marked dyspnea at rest, is thin, and uses accessory muscles to breathe. He’s tachypneic, with a prolonged expiratory phase. He has no cough. He leans forward with his arms braced on his knees to support his chest and shoulders for breathing. This client has symptoms of which of the following respiratory disorders?

A. ARDS

B. Asthma

C. Chronic obstructive bronchitis

D. Emphysema

Correct Answer: D. Emphysema

12. Question

It’s highly recommended that clients with asthma, chronic bronchitis, and emphysema have Pneumovax and flu vaccinations for which of the following reasons?

A. All clients are recommended to have these vaccines.

B. These vaccines produce bronchodilation and improve oxygenation.

C. These vaccines help reduce the tachypnea these clients experience.

D. Respiratory infections can cause severe hypoxia and possibly death in these clients.

Correct Answer: D. Respiratory infections can cause severe hypoxia and possibly death in these clients.

13. Question

Exercise has which of the following effects on clients with asthma, chronic bronchitis, and emphysema?

A. It enhances cardiovascular fitness.

B. It improves respiratory muscle strength.

C. It reduces the number of acute attacks.

D. It worsens respiratory function and is discouraged.

Correct Answer: A. It enhances cardiovascular fitness.

14. Question

Clients with chronic obstructive bronchitis are given diuretic therapy. Which of the following reasons best explains why?

A. Reducing fluid volume reduces oxygen demand.

B. Reducing fluid volume improves clients’ mobility.

C. Restricting fluid volume reduces sputum production.

D. Reducing fluid volume improves respiratory function.

Incorrect

Correct Answer: A. Reducing fluid volume reduces oxygen demand.

15. Question

A 69-year-old client appears thin and cachectic. He’s short of breath at rest and his dyspnea increases with the slightest exertion. His breath sounds are diminished even with deep inspiration. These signs and symptoms fit which of the following conditions?

A. ARDS

B. Asthma

C. Chronic obstructive bronchitis

D. Emphysema

Correct Answer: D. Emphysema

16. Question

A client with emphysema should receive only 1 to 3 L/minute of oxygen if needed, or he may lose his hypoxic drive. Which of the following statements is correct about hypoxic drive?

A. The client doesn’t notice he needs to breathe.

B. The client breathes only when his oxygen levels climb above a certain point.

C. The client breathes only when his oxygen levels dip below a certain point.

D. The client breathes only when his carbon dioxide level dips below a certain point.

Incorrect

Correct Answer: C. The client breathes only when his oxygen levels dip below a certain point.

17. Question

Teaching for a client with chronic obstructive pulmonary disease (COPD) should include which of the following topics?

A. How to have his wife learn to listen to his lungs with a stethoscope from Wal-Mart.

B. How to increase his oxygen therapy.

C. How to treat respiratory infections without going to the physician.

D. How to recognize the signs of an impending respiratory infection.

Correct Answer: D. How to recognize the signs of an impending respiratory infection.

18. Question

Which of the following respiratory disorders is most common in the first 24 to 48 hours after surgery?

A. Atelectasis

B. Bronchitis

C. Pneumonia

D. Pneumothorax

Correct Answer: A. Atelectasis

19. Question

Which of the following measures can reduce or prevent the incidence of atelectasis in a postoperative client?

A. Chest physiotherapy

B. Mechanical ventilation

C. Reducing oxygen requirements

D. Use of an incentive spirometer.

Correct Answer: D. Use of an incentive spirometer.

20. Question

Emergency treatment of a client in status asthmaticus includes which of the following medications?

A. Inhaled beta-adrenergic agents

B. Inhaled corticosteroids

C. I.V. beta-adrenergic agents

D. Oral corticosteroids

Correct Answer: A. Inhaled beta-adrenergic agents

21. Question

Which of the following treatment goals is best for the client with status asthmaticus?

A. Avoiding intubation.

B. Determining the cause of the attack.

C. Improving exercise tolerance.

D. Reducing secretions.

Correct Answer: A. Avoiding intubation

22. Question

Dani was given Dilaudid for pain. She’s sleeping and her respiratory rate is 4 breaths/minute. If action isn’t taken quickly, she might have which of the following reactions?

A. Asthma attack

B. Respiratory arrest

C. Improve cardiac output

D. Constipation

Correct Answer: B. Respiratory arrest

23. Question

Which of the following additional assessment data should immediately be gathered to determine the status of a client with a respiratory rate of 4 breaths/minute?

A. Arterial blood gas (ABG) and breath sounds.

B. Level of consciousness and a pulse oximetry value.

C. Breath sounds and reflexes.

D. Pulse oximetry value and heart sounds.

Correct Answer: B. Level of consciousness and a pulse oximetry value.

24. Question

A client is in danger of respiratory arrest following the administration of a narcotic analgesic. An arterial blood gas value is obtained. The nurse would expect PaCO2 to be which of the following values?

A. 15 mm Hg

B. 30 mm Hg

C. 40 mm Hg

D. 80 mm Hg

Correct Answer: D. 80 mm Hg

25. Question

A client has started a new drug for hypertension. Thirty minutes after he takes the drug, he develops chest tightness and becomes short of breath and tachypnea. He has a decreased level of consciousness. These signs indicate which of the following conditions?

A. Asthma attack

B. Pulmonary embolism

C. Respiratory failure

D. Rheumatoid arthritis

Correct Answer: C. Respiratory Failure

26. Question

Emergency treatment for a client with impending anaphylaxis secondary to hypersensitivity to a drug should include which of the following actions first?

A. Administering oxygen.

B. Inserting an I.V. catheter.

C. Obtaining a complete blood count (CBC).

D. Taking vital signs.

Correct Answer: A. Administering oxygen.

27. Question

Following the initial care of a client with asthma and impending anaphylaxis from hypersensitivity to a drug, the nurse should take which of the following steps next?

A. Administer beta-adrenergic blockers.

B. Administer bronchodilators.

C. Obtain serum electrolyte levels.

D. Have the client lie flat in the bed.

Correct Answer: B. Administer bronchodilators.

28. Question

A client’s ABG results are as follows: pH: 7.16; PaCO2 80 mm Hg; PaO2 46 mm Hg; HCO3- 24 mEq/L; SaO2 81%. This ABG result represents which of the following conditions?

A. Metabolic acidosis

B. Metabolic alkalosis

C. Respiratory acidosis

D. Respiratory alkalosis

Correct Answer: C. Respiratory acidosis

29. Question

A nurse plans care for a client with chronic obstructive pulmonary disease, knowing that the client is most likely to experience what type of acid-base imbalance?

A. Respiratory acidosis

B. Respiratory alkalosis

C. Metabolic acidosis

D. Metabolic alkalosis

Correct Answer: A. Respiratory acidosis

30. Question

A nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a PCO2 of 30 mm Hg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition?

A. Sodium level of 145 mEq/L

B. Potassium level of 3.0 mEq/L

C. Magnesium level of 2.0 mg/L

D. Phosphorus level of 4.0 mg/dl

Correct Answer: B. Potassium level of 3.0 mEq/L

SECTION 4 

1. The nurse is caring for a male client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do?  

A. 

Place the end of the chest tube in a container of sterile saline.

B. 

Apply an occlusive dressing and notify the physician.

C. 

Clamp the chest tube immediately.

D. 

Secure the chest tube with tape.

Correct Answer

A. Place the end of the chest tube in a container of sterile saline.

2. A male elderly client is admitted to an acute care facility with influenza. The nurse monitors the client closely for complications. What is the most common complication of influenza?

A. Septicemia

B. Pneumonia

C. Meningitis

D. Pulmonary edema

Correct Answer

B. Pneumonia

3. A female client has a tracheostomy but doesn’t require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:

A. 5 to 60 seconds.

B. 5 to 20 minutes.

C. 30 to 40 minutes.

D. 45 to 60 minutes.

Correct Answer

B. 5 to 20 minutes.

4. Gina, a home health nurse, is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?

A. Hypoxia

B. Delirium

C. Hyperventilation

D. Semiconsciousness

Correct Answer

A. Hypoxia

5. A male client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

A. PH 5.0; PaCO2 30 mm Hg

B. PH 7.40; PaCO2 35 mm Hg

C. PH 7.35; PaCO2 40 mm Hg

D. PH 7.25; PaCO2 50 mm Hg

Correct Answer

D. PH 7.25; PaCO2 50 mm Hg

6. A female client with interstitial lung disease is prescribed prednisone (Deltasone) to control inflammation. During client teaching, the nurse stresses the importance of taking prednisone exactly as prescribed and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience:

A. Hyperglycemia and glycosuria.

B. Acute adrenocortical insufficiency.

C. GI bleeding.

D. Restlessness and seizures.

Correct Answer

B. Acute adrenocortical insufficiency.

7. A male client is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client?

A. Activity intolerance related to fatigue.

B. Anxiety related to actual threat to health status.

C. Risk for infection related to retained secretions.

D. Impaired gas exchange related to airflow obstruction.

Correct Answer

D. Impaired gas exchange related to airflow obstruction.

8. A male client abruptly sits up in bed, reports having difficulty breathing and have an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations?

A. Simple mask

B. Non-rebreather mask

C. Face tent

D. Nasal cannula

Correct Answer

B. Non-rebreather mask

9. A male adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure?

A. Immediately before a meal

B. At least 2 hours after a meal

C. When bronchospasms occur

D. When secretions have mobilized

Correct Answer

B. At least 2 hours after a meal

10. On arrival at the intensive care unit, a critically ill female client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client’s arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values?

A. Fever

B. Tachypnea

C. Tachycardia

D. Hypotension

Correct Answer

D. Hypotension

11. The nurse is caring for a male client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:

A. Helping him communicate

B. Keeping his airway patent

C. Encouraging him to perform activities of daily living

D. Preventing him from developing an infection

Correct Answer

B. Keeping his airway patent

12. For a male client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway?

A. Restricting fluid intake to 1,000 ml/day

B. Enforcing absolute bed rest

C. Teaching the client how to perform controlled coughing

D. Administering prescribed sedatives regularly and in large amounts

Correct Answer

C. Teaching the client how to perform controlled coughing

13. The amount of air inspired and expired with each breath is called:

A. Tidal volume.

B. Residual volume.

C. Vital capacity.

D. Dead-space volume.

Correct Answer

A. Tidal volume.

14. A male client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He’s placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than:

A. 0.21

B. 0.35

C. 0.5

D. 0.7

Correct Answer

C. 0.5

15. Nurse Mickey is administering a purified protein derivative (PPD) test to a homeless client. Which of the following statements concerning PPD testing is true?

A. A positive reaction indicates that the client has active tuberculosis (TB).

B. A positive reaction indicates that the client has been exposed to the disease.

C. A negative reaction always excludes the diagnosis of TB.

D. The PPD can be read within 12 hours after the injection.

Correct Answer

B. A positive reaction indicates that the client has been exposed to the disease.

16. Nurse Murphy administers albuterol (Proventil), as prescribed to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

A. Respiratory rate of 22 breaths/minute.

B. Dilated and reactive pupils.

C. Urine output of 40 ml/hour.

D. Heart rate of 100 beats/minute.

Correct Answer

A. Respiratory rate of 22 breaths/minute.

17. What is the normal pH range for arterial blood?

A. 7 to 7.49

B. 7.35 to 7.45

C. 7.50 to 7.60

D. 7.55 to 7.65

Correct Answer

B. 7.35 to 7.45

18. Before weaning a male client from a ventilator, which assessment parameter is most important for the nurse to review?

A. Fluid intake for the last 24 hours.

B. Baseline arterial blood gas (ABG) levels.

C. Prior outcomes of weaning.

D. Electrocardiogram (ECG) results.

Correct Answer

B. Baseline arterial blood gas (ABG) levels.

19. Which of the following would be most appropriate for a male client with an arterial blood gas (ABG) of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3 24 mEq/L, and PaO2 94 mm Hg?

A. Administer a prescribed decongestant.

B. Instruct the client to breathe into a paper bag.

C. Offer the client fluids frequently.

D. Administer prescribed supplemental oxygen.

Correct Answer

B. Instruct the client to breathe into a paper bag.

20. A female client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

A. PH

B. Bicarbonate (HCO3–)

C. Partial pressure of arterial oxygen (PaO2)

D. Partial pressure of arterial carbon dioxide (PaCO2)

Correct Answer

C. Partial pressure of arterial oxygen (PaO2)

21. Nurse Julia is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which of the following interventions will most likely lower the client’s arterial blood oxygen saturation?

A. Endotracheal suctioning.

B. Encouragement of coughing.

C. Use of a cooling blanket.

D. Incentive spirometry.

Correct Answer

A. Endotracheal suctioning.

22. For a male client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the plan of care?

A. Measuring and documenting the drainage in the collection chamber.

B. Maintaining continuous bubbling in the water-seal chamber.

C. Keeping the collection chamber at chest level.

D. Stripping the chest tube every hour.

Correct Answer

A. Measuring and documenting the drainage in the collection chamber.

23. Nurse Eve formulates a nursing diagnosis of Activity intolerance related to inadequate oxygenation and dyspnea for a client with chronic bronchitis. To minimize this problem, the nurse instructs the client to avoid conditions that increase oxygen demands. Such conditions include:

A. Drinking more than 1,500 ml of fluid daily.

B. Being overweight.

C. Eating a high-protein snack at bedtime.

D. Eating more than three large meals a day.

Correct Answer

B. Being overweight.

24. A black male client with asthma seeks emergency care for acute respiratory distress. Because of this client’s dark skin, the nurse should assess for cyanosis by inspecting the:

A. Lips

B. Mucous membranes

C. Nail beds

D. Earlobes

Correct Answer

B. Mucous membranes

25. A female client with asthma is receiving a theophylline preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client’s serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range?

A. 1 to 2 mcg/ml

B. 2 to 5 mcg/ml

C. 5 to 10 mcg/ml

D. 10 to 20 mcg/ml

Correct Answer

D. 10 to 20 mcg/ml

26. A male client is to receive I.V. vancomycin (Vancocin). When preparing to administer this drug, the nurse should keep in mind that:

A. Vancomycin should be infused over 60 to 90 minutes in a large volume of fluid.

B. Vancomycin may cause irreversible neutropenia.

C. Vancomycin should be administered rapidly in a large volume of fluid.

D. Vancomycin should be administered over 1 to 2 minutes as an I.V. bolus.

Correct Answer

A. Vancomycin should be infused over 60 to 90 minutes in a large volume of fluid.

27. Before seeing a newly assigned female client with respiratory alkalosis, the nurse quickly reviews the client’s medical history. Which condition is a predisposing factor for respiratory alkalosis?

A. Myasthenia gravis.

B. Type 1 diabetes mellitus.

C. Extreme anxiety.

D. Narcotic overdose.

Correct Answer

C. Extreme anxiety.

28. At 11 p.m., a male client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He’s anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-Medrol) I.V. At 11:30 p.m., the client’s arterial blood oxygen saturation is 86% and he’s still wheezing. The nurse should plan to administer:

A. Alprazolam (Xanax)

B. Propranolol (Inderal)

C. Morphine

D. Albuterol (Proventil)

Correct Answer

D. Albuterol (Proventil)

29. Pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?

A. Encouraging the client to drink three glasses of fluid daily.

B. Keeping the client in semi-Fowler’s position.

C. Using a high-flow Venturi mask to deliver oxygen as prescribed.

D. Administering a sedative as prescribed.

Correct Answer

C. Using a high-flow Venturi mask to deliver oxygen as prescribed.

30. Nurse Joana is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?

A. It increases inspiratory muscle strength.

B. It decreases use of accessory breathing muscles.

C. It prolongs the inspiratory phase of respiration.

D. It helps prevent early airway collapse.

Correct Answer

D. It helps prevent early airway collapse.

SECTION 5

1.A male patient has a sucking stab wound to the chest. Which action should the nurse take first?

ADrawing blood for a hematocrit and hemoglobin level

BApplying a dressing over the wound and taping it on three sides

CPreparing a chest tube insertion tray

DPreparing to start an I.V. line

B

2.A male patient is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient?

AActivity intolerance related to fatigue

BAnxiety related to actual threat to health status

CRisk for infection related to retained secretions

DImpaired gas exchange related to airflow obstruction

D

3.A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

A Nausea or vomiting

BAbdominal pain or diarrhea

CHallucinations or tinnitus

DLightheadedness or parenthesis 

D

4.Before administering ephedrine, Nurse Tony assesses the patient’s history. Because of ephedrine’s central nervous system (CNS) effects, it is not recommended for:

A Patients with an acute asthma attack

B Patients with narcolepsy

C Patients under age 6

D Elderly patients

D

5.A female patient suffers adult respiratory distress syndrome as a consequence of shock. The patient’s condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated. When the high pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high pressure alarm?

A Kinking of the ventilator tubing

B A disconnected ventilator tube

C An endotracheal cuff leak

D A change in the oxygen concentration without resetting the oxygen level alarm

A

6. A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose?

A Leg movement

B Finger movement

C Lip movement

D Fighting the ventilator

D

7.On auscultation, which finding suggests a right pneumothorax?

A Bilateral inspiratory and expiratory crackles

B Absence of breaths sound in the right thorax

C Inspiratory wheezes in the right thorax

D Bilateral pleural friction rub

B

8.Rhea, confused and short breath, is brought to the emergency department by a family member. The medical history reveals chronic bronchitis and hypertension. To learn more about the current respiratory problem, the doctor orders a chest x-ray and arterial blood gas (ABG) analysis. When reviewing the ABG report, the nurses sees many abbreviations. What does a lowercase “a” in ABG value present?

A Acid-base balance

B Arterial Blood

C Arterial oxygen saturation

D Alveol

B.

9. Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the:

A Contralateral side in a simple pneumothorax

B Affected side in a hemothorax

C Affected side in a tension pneumothorax

D Contralateral side in hemothorax

D. 

10. After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must:

A Monitor fluctuations in the water-seal chamber

B Clamp the chest tube once every shift

C Encourage coughing and deep breathing

D Milk the chest tube every 2 hours

C

11. For a patient with advance chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?

A Encouraging the patient to drink three glasses of fluid daily

B Keeping the patient in semi-fowler’s position

C Using a high-flow venturi mask to deliver oxygen as prescribe

D Administering a sedative, as prescribe

C

12. A male patient’s X-ray result reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from:

A Cardiogenic pulmonary edema

B Respiratory alkalosis

C Increased pulmonary capillary permeability

D Renal failure

C

13. Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes continues gentle bubbling in the suction control chamber. What action is appropriate?

A Do nothing, because this is an expected finding

B Immediately clamp the chest tube and notify the physician

C Check for an air leak because the bubbling should be intermittent

D Increase the suction pressure so that the bubbling becomes vigorous

A

14 .Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate?

A Inform the physician

B Continue to monitor the client

C Reinforce the occlusive dressing

D Encourage the client to deep-breathe

B

15. Nurse Reynolds caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to:

A Call the physician

B Place the tube in bottle of sterile water

C Immediately replace the chest tube system

D Place a sterile dressing over the disconnection site

B

16.A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to:

A Exhale slowly

B Stay very still

C Inhale and exhale quickly

D Perform the Valsalva maneuver

D

17. While changing the tapes on a tracheostomy tube, the male client coughs and tube is dislodged. The initial nursing action is to:

A Call the physician to reinsert the tube

B Grasp the retention sutures to spread the opening

C Call the respiratory therapy department to reinsert the tracheotomy

D Cover the tracheostomy site with a sterile dressing to prevent infection

B

18. Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?

A Stridor

B Occasional pink-tinged sputum

C A few basilar lung crackles on the right

D Respiratory rate 24 breaths/min

A

19. An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client?

A A low respiratory rate

B Diminished breath sounds

C The presence of a barrel chest

D A sucking sound at the site of injury

B

20.Nurse Reese is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client?

A Hypocapnia

B A hyperinflated chest noted on the chest x-ray

C Increased oxygen saturation with exercise

D A widened diaphragm noted on the chest x-ray

B

21.An oxygen delivery system is prescribed for a male client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed?

A Face tent

B Venturi mask

C Aerosol mask

D Tracheostomy collar

B

22.Blessy, a community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is:

A Dyspnea

B Chest pain

C A bloody, productive cough

D A cough with the expectoration of mucoid sputum

D

23. A nurse performs an admission assessment on a female client with a diagnosis of tuberculosis. The nurse reviews the result of which diagnosis test that will confirm this diagnosis?

A Bronchoscopy

B Sputum culture

C Chest x-ray

D Tuberculin skin test

B

23.A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed:

A 1 L/min

B 2 L/min

C 6 L/min

D 10 L/min

B

24. A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to:

A Promote oxygen intake

B Strengthen the diaphragm

C Strengthen the intercostal muscles

D Promote carbon dioxide elimination

D

25. A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client?

A Pallor

B Low arterial PaO2

C Elevated arterial PaO2

D Decreased respiratory rate

B

26. A nurse is preparing to obtain a sputum specimen from a male client. Which of the following nursing actions will facilitate obtaining the specimen?

ALimiting fluid

BHaving the client take deep breaths

CAsking the client to spit into the collection container

DAsking the client to obtain the specimen after eating

B

27. Nurse Joy is caring for a client after a bronchoscopy and biopsy. Which of the following signs, if noticed in the client, should be reported immediately to the physician?

A Dry cough

B Hematuria

CBronchospasm

DBlood-streaked sputum

C

28. A nurse is suctioning fluids from a male client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of:

A1 minute

B5 seconds

C10 seconds

D30 seconds

C

29. A nurse is suctioning fluids from a female client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which if the following is the appropriate nursing intervention?

AContinue to suction

BNotify the physician immediately

C Stop the procedure and reoxygenate the client

DEnsure that the suction is limited to 15 seconds

C

30. A male adult client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism?

A Dyspnea

B Bradypnea

C Bradycardia

D Decreased respirations

A

31. A slightly obese female client with a history of allergy-induced asthma, hypertension, and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination, paying special attention to the cardiovascular and respiratory systems. When percussing the client’s chest wall, the nurse expects to elicit:

A Resonant sounds

B Hyperresonant sounds

C Dull sounds

D Flat sounds

A 

32. Which phrase is used to describe the volume of air inspired and expired with a normal breath?

Tidal volume

33. A male client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations?

A Simple mask

B Non-rebreather mask

C Face tent

D Nasal cannula

B

34. A female client must take streptomycin for tuberculosis. Before therapy begins, the nurse should instruct the client to notify the physician if which health concern occurs?

A Impaired color discrimination

B Increased urinary frequency

C Decreased hearing acuity

D Increased appetite

C

35. A male client is asking the nurse a question regarding the Mantoux test for tuberculosis. The nurse should base her response on the fact that the:

A Area of redness is measured in 3 days and determines whether tuberculosis is present.

B Skin test doesn’t differentiate between active and dormant tuberculosis infection.

C Presence of a wheal at the injection site in 2 days indicates active tuberculosis.

D Test stimulates a reddened response in some clients and requires a second test in 3 months.

B

36. A female adult client has a tracheostomy but doesn’t require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:

A15 to 60 seconds

B 5 to 20 minutes

C30 to 40 minutes

D 45 to 60 minutes

B

37. Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

AThe system is functioning normally

B The client has a pneumothorax

C The system has an air leak

D The chest tube is obstructed

C

38. A black client with asthma seeks emergency care for acute respiratory distress. Because of this client’s dark skin, the nurse should assess for cyanosis by inspecting the:

A Lips

B Mucous membranes

C Nail beds

D Earlobes

B

39. For a male client with an endotracheal (ET) tube, which nursing action is most essential?

A Auscultating the lungs for bilateral breath sounds

B Turning the client from side to side every 2 hours

C Monitoring serial blood gas values every 4 hours

D Providing frequent oral hygiene

A

40. A male client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can’t produce an effective cough, the nurse should monitor closely for:

A Pleural effusion

B Pulmonary edema

C Atelectasis

D Oxygen toxicity

C

41. The nurse in charge is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?

A It helps prevent early airway collapse

B It increases inspiratory muscle strength

C It decreases use of accessory breathing muscles

D It prolongs the inspiratory phase of respiration

A

42. A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

A pH, 5.0; PaCO2 30 mm Hg

B pH, 7.40; PaCO2 35 mm Hg

C pH, 7.35; PaCO2 40 mm Hg

D pH, 7.25; PaCO2 50 mm Hg

D 

ANATOMY AND PHYSIOLOGY OF THE CNS

SECTION 1

1. Question

A 68-year-old male patient who had a left-sided stroke is admitted to the hospital. The patient has right-sided weakness and is unable to perform activities of daily living without assistance. The nurse is providing oral hygiene to the patient and is preparing to use a padded tongue blade to open the patient’s mouth. Which nursing measure is inappropriate when providing oral hygiene to the patient who had a stroke?

A. Placing the client on the back with a small pillow under the head.

B. Keeping portable suctioning equipment at the bedside.

C. Opening the client’s mouth with a padded tongue blade.

D. Cleaning the client’s mouth and teeth with a toothbrush.

Correct Answer: A. 

2. Question

A 64-year-old client with a history of hypertension is admitted to the emergency department with sudden onset right-sided weakness, facial droop, and difficulty speaking. Which nursing intervention is the highest priority in the initial management of this client?

A. Prepare to administer recombinant tissue plasminogen activator (rt-PA).

B. Discuss the precipitating factors that caused the symptoms.

C. Schedule for A STAT computer tomography (CT) scan of the head.

D. Notify the speech pathologist for an emergency consultation.

Correct Answer: C. 

3. Question

A client arrives in the emergency department with an ischemic stroke and receives tissue plasminogen activator (t-PA) administration. Which is the priority nursing assessment?

A. Time of onset of current stroke

B. Complete physical and history

C. Current medications

D. Upcoming surgical procedures

Correct Answer: A. Time of onset of current stroke

4. Question

During the first 24 hours after thrombolytic therapy for ischemic stroke, the primary goal is to control the client’s:

A. Pulse

B. Respirations

C. Blood pressure

D. Temperature

Correct Answer: C. Blood pressure

5. Question

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?

A. Cholesterol level

B. Pupil size and pupillary response

C. Bowel sounds

D. Echocardiogram

Correct Answer: B. Pupil size and pupillary response

6. Question

What is the expected outcome of thrombolytic drug therapy?

A. Increased vascular permeability

B. Vasoconstriction

C. Dissolved emboli

D. Prevention of hemorrhage

Correct Answer: C. Dissolved emboli.

7. Question

The client diagnosed with atrial fibrillation has experienced a transient ischemic attack (TIA). Which medication would the nurse anticipate being ordered for the client on discharge?

A. A thrombolytic medication

B. A beta-blocker medication

C. An anti-hyperuricemic medication

D. An oral anticoagulant medication

Correct Answer: D. An oral anticoagulant medication.

8. Question

Which client would the nurse identify as being most at risk for experiencing a CVA?

A. A 39-year-old pregnant female.

B. A 67-year-old Caucasian male.

C. An 84-year-old Japanese female.

D. A 55-year-old African American male

Correct Answer: D. A 55-year-old African American male.

9. Which assessment data would indicate to the nurse that the client would be at risk for a hemorrhagic stroke?

A. A blood glucose level of 480 mg/dl.

B. A right-sided carotid bruit.

C. A blood pressure of 220/120 mmHg.

D. The presence of bronchogenic carcinoma.

Correct Answer: C. A blood pressure of 220/120 mmHg.

10. Question

The nurse and unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?

A. The assistant places a gait belt around the client’s waist prior to ambulating.

B. The assistant places the client on the back with the client’s head to the side.

C. The assistant places her hand under the client’s right axilla to help him/her move up in bed.

D. The assistant praises the client for attempting to perform ADL’s independently.

Correct Answer: C. The assistant places her hand under the client’s right axilla to help him/her move up in bed.

11. Question

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances?

A. Vomiting continues.

B. Intracranial pressure (ICP) is increased.

C. The client needs mechanical ventilation.

D. Blood is anticipated in the cerebrospinal fluid (CSF).

Correct Answer: B. Intracranial pressure (ICP) is increased.

12. Question

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons?

A. To reduce intraocular pressure.

B. To prevent acute tubular necrosis.

C. To promote osmotic diuresis to decrease ICP.

D. To draw water into the vascular system to increase blood pressure.

Correct Answer: C. To promote osmotic diuresis to decrease ICP.

13 A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective?

A. Urine output increases.

B. Pupils are 8 mm and nonreactive.

C. Systolic blood pressure remains at 150 mm Hg.

D. BUN and creatinine levels return to normal

Correct Answer: A. Urine output increases.

14. Question

Which of the following values is considered normal for ICP?

A. 0 to 15 mm Hg

B. 25 mm Hg

C. 35 to 45 mm Hg

D. 120/80 mm Hg

Correct Answer: A. 0 to 15 mm Hg

15. Question

Which of the following symptoms may occur with a phenytoin level of 32 mg/dl?

A. Ataxia and confusion

B. Sodium depletion

C. Tonic-clonic seizure

D. Urinary incontinence

Correct Answer: A. Ataxia and confusion

16. Question

Which of the following signs and symptoms of increased ICP after head trauma would appear first?

A. Bradycardia

B. Large amounts of very dilute urine

C. Restlessness and confusion

D. Widened pulse pressure

Correct Answer: C. Restlessness and confusion

17. Question

Problems with memory and learning would relate to which of the following lobes?

A. Frontal

B. Occipital

C. Parietal

D. Temporal

Correct Answer: D. Temporal

18. Question

While cooking, your client couldn’t feel the temperature of a hot oven. Which lobe could be dysfunctional?

A. Frontal

B. Occipital

C. Parietal

D. Temporal

Correct Answer: C. Parietal

19. Question

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client’s peripheral response to pain?

A. Sternal rub

B. Pressure on the orbital rim

C. Squeezing the sternocleidomastoid muscle

D. Nail bed pressure

Correct Answer: D. Nail bed pressure

20. Question

The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?

A. Side-lying, with legs pulled up and head bent down onto the chest.

B. Side-lying, with a pillow under the hip.

C. Prone, in a slight Trendelenburg’s position.

D. Prone, with a pillow under the abdomen.

Correct Answer: A. Side-lying, with legs pulled up and head bent down onto the chest

21. Question

A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has:

A. A cerebral lesion

B. A temporal lesion

C. An intact brainstem

D. Brain death

Correct Answer: C. An intact brainstem

22. Question

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?

A. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure.

B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.

C. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure.

D. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

Correct Answer: B. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.

23. Question

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits:

A. A negative Kernig’s sign.

B. A positive Brudzinski’s sign.

C. Absence of nuchal rigidity.

D. A Glascow Coma Scale score of 15.

Correct Answer: B. A positive Brudzinski’s sign

24. Question

A client is arousing from a coma and keeps saying, “Just stop the pain.” The nurse responds based on the knowledge that the human body typically and automatically responds to pain first with attempts to:

A. Tolerate the pain.

B. Decrease the perception of pain.

C. Escape the source of pain.

D. Divert attention from the source of pain.

Correct Answer: C. Escape the source of pain.

25. Question

During the acute stage of meningitis, a 3-year-old child is restless and irritable. Which of the following would be most appropriate to institute?

A. Limiting conversation with the child.

B. Allowing the child to play in the bathtub.

C. Keeping extraneous noise to a minimum.

D. Performing treatments quickly.

Correct Answer: C. Keeping extraneous noise to a minimum

26. Question

Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?

A. Hemorrhagic skin rash

B. Edema

C. Cyanosis

D. Dyspnea on exertion

Correct Answer: A. Hemorrhagic skin rash

27. Question

When interviewing the parents of a 2-year-old child, a history of which of the following illnesses would lead the nurse to suspect pneumococcal meningitis?

A. Bladder infection

B. Middle ear infection

C. Fractured clavicle

D. Septic arthritis

Correct Answer: B. Middle ear infection

28. Question

The nurse is assessing a child diagnosed with a brain tumor. Which of the following signs and symptoms would the nurse expect the child to demonstrate? Select all that apply.

A. Increased appetite

B. Vomiting

C. Polydipsia

D. Lethargy

E. Head tilt

F. Increased pulse

Correct Answer: B, D & E

29. Question

A lumbar puncture is performed on a child suspected of having bacterial meningitis. CSF is obtained for analysis. A nurse reviews the results of the CSF analysis and determines which of the following results would verify the diagnosis?

A. Cloudy CSF, decreased protein, and decreased glucose.

B. Cloudy CSF, elevated protein, and decreased glucose.

C. Clear CSF, elevated protein, and decreased glucose.

D. Clear CSF, decreased pressure, and elevated protein.

Correct Answer: B. Cloudy CSF, elevated protein, and decreased glucose.

30. Question

A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care?

A. No precautions are required as long as antibiotics have been started.

B. Maintain enteric precautions.

C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics.

D. Maintain neutropenic precautions.

Correct Answer: C. Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics

31. Question

A nurse is reviewing the record of a child with increased ICP and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse would expect to note which of the following if this type of posturing was present?

A. Abnormal flexion of the upper extremities and extension of the lower extremities.

B. Rigid extension and pronation of the arms and legs.

C. Rigid pronation of all extremities.

D. Flaccid paralysis of all extremities.

Correct Answer: B. Rigid extension and pronation of the arms and legs.

32. Question

Which of the following assessment data indicated nuchal rigidity?

A. Positive Kernig’s sign

B. Negative Brudzinski’s sign

C. Positive homan’s sign

D. Negative Kernig’s sign

Correct Answer: A. Positive Kernig’s sign

33. Question

Meningitis occurs as an extension of a variety of bacterial infections due to which of the following conditions?

A. Congenital anatomic abnormality of the meninges.

B. Lack of acquired resistance to the various etiologic organisms.

C. Occlusion or narrowing of the CSF pathway.

D. Natural affinity of the CNS to certain pathogens.

Correct Answer: B. Lack of acquired resistance to the various etiologic organisms.

34. Question

Which of the following pathologic processes is often associated with aseptic meningitis?

A. Ischemic infarction of cerebral tissue.

B. Childhood diseases of viral causation such as mumps.

C. Brain abscesses caused by a variety of pyogenic organisms.

D. Cerebral ventricular irritation from a traumatic brain injury.

Correct Answer: B. Childhood diseases of viral causation such as mumps.

35. Question

You are preparing to admit a patient with a seizure disorder. Which of the following actions can you delegate to LPN/LVN?

A. Complete admission assessment.

B. Place a padded tongue blade at the bedside.

C. Set up oxygen and suction equipment.

D. Pad the side rails before the patient arrives.

Correct Answer: C. Set up oxygen and suction equipment.

36. Question

If a male client experienced a cerebrovascular accident (CVA) that damaged the hypothalamus, the nurse would anticipate that the client has problems with:

A. Body temperature control

B. Balance and equilibrium

C. Visual acuity

D. Thinking and reasoning

Correct Answer: A. Body temperature control

37. Question

A female client admitted to an acute care facility after a car accident develops signs and symptoms of increased intracranial pressure (ICP). The client is intubated and placed on mechanical ventilation to help reduce ICP. To prevent a further rise in ICP caused by suctioning, the nurse anticipates administering which drug endotracheally before suctioning?

A. phenytoin (Dilantin)

B. mannitol (Osmitrol)

C. lidocaine (Xylocaine)

D. furosemide (Lasix)

Correct Answer: C. lidocaine (Xylocaine)

38. Question

After striking his head on a tree while falling from a ladder, a young man age 18 is admitted to the emergency department. He’s unconscious and his pupils are nonreactive. Which intervention would be the most dangerous for the client?

A. Give him a barbiturate.

B. Place him on mechanical ventilation.

C. Perform a lumbar puncture.

D. Elevate the head of his bed.

Correct Answer: C. Perform a lumbar puncture.

39. Question

When obtaining the health history from a male client with retinal detachment, the nurse expects the client to report:

A. Light flashes and floaters in front of the eye.

B. A recent driving accident while changing lanes.

C. Headaches, nausea, and redness of the eyes.

D. Frequent episodes of double vision.

Correct Answer: A. Light flashes and floaters in front of the eye.

40. Question

Which nursing diagnosis takes highest priority for a client with Parkinson’s crisis?

A. Imbalanced nutrition: Less than body requirements

B. Ineffective airway clearance

C. Impaired urinary elimination

D. Risk for injury

Correct Answer: B. Ineffective airway clearance

41. Question

The nurse has given the male client with Bell’s palsy instructions on preserving muscle tone in the face and preventing denervation. The nurse determines that the client needs additional information if the client states that he or she will:

A. Wrinkle the forehead, blow out the cheeks, and whistle.

B. Massage the face with a gentle upward motion.

C. Perform facial exercises.

D. Exposure to cold and drafts.

Correct Answer: D. Exposure to cold and drafts.

42. Question

A female client is admitted to the hospital with a diagnosis of Guillain-Barre syndrome. The nurse inquires during the nursing admission interview if the client has a history of:

A. Seizures or trauma to the brain.

B. Meningitis during the last five (5 years).

C. Back injury or trauma to the spinal cord.

D. Respiratory or gastrointestinal infection during the previous month.

Answer: D. Respiratory or gastrointestinal infection during the previous month.

43. Question

A female client with Guillain-Barre syndrome has ascending paralysis and is intubated and receiving mechanical ventilation. Which of the following strategies would the nurse incorporate in the plan of care to help the client cope with this illness?

A. Giving the client full control over care decisions and restricting visitors.

B. Providing positive feedback and encouraging active range of motion.

C. Providing information, giving positive feedback and encouraging relaxation.

D. Providing intravenously administered sedatives, reducing distractions and limiting visitors.

Correct Answer: C. Providing information, giving positive feedback, and encouraging relaxation.

44. Question

A male client has an impairment of cranial nerve II. Specific to this impairment, the nurse would plan to do which of the following to ensure the client to ensure client safety?

A. Speak loudly to the client.

B. Test the temperature of the shower water.

C. Check the temperature of the food on the delivery tray.

D. Provide a clear path for ambulation without obstacles.

Correct Answer: D. Provide a clear path for ambulation without obstacles.

45. Question

A female client has a neurological deficit involving the limbic system. Specific to this type of deficit, the nurse would document which of the following information related to the client’s behavior.

A. Is disoriented to person, place, and time.

B. Affect is flat, with periods of emotional lability.

C. Cannot recall what was eaten for breakfast today.

D. Demonstrate inability to add and subtract; does not know who is the president.

Correct Answer: B. Affect is flat, with periods of emotional lability.

46. Question

A client is admitted with a diagnosis of Sturge-Weber syndrome. Which of the following information would you expect to find in this client?

A. It is a dysfunction of the trigeminal nerve causing a severe sharp pain in the nose, lips, gums, or across the cheeks.

B. It is a non-progressive neurological disorder of the seventh cranial nerve causing paralysis of one of the sides of the face.

C. It is a rare degenerative brain disorder characterized by sudden development of progressive neurological and neuromuscular symptoms.

D. It is a neurocutaneous disorder with angiomas causing abnormalities in the skin, brain, and eyes from birth.

Correct Answer: D. It is a neurocutaneous disorder with angiomas causing abnormalities in the skin, brain, and eyes from birth.

47. Question

A client is admitted to the emergency room with a spinal cord injury. The client is complaining of lightheadedness, flushed skin above the level of the injury, and headache. The client’s blood pressure is 160/90 mm Hg. Which of the following is a priority action for the nurse to take?

A. Loosen tight clothing or accessories

B. Assess for any bladder distention

C. Raise the head of the bed

D. Administer anti hypertensive  

Correct Answer: C. Raise the head of the bed

48. Question

A client who had a stroke is seen bumping into things on the side and is having difficulty picking up the beginning of the next line of what he is reading. The client is experiencing which of the following conditions?

A. Visual neglect

B. Astigmatism

C. Blepharitis

D. Homonymous Hemianopsia

Correct Answer: D. Homonymous Hemianopsia

49. Question

Which of the following medical treatments should the nurse anticipate administering to a client with increased intracranial pressure due to brain hemorrhage, except?

A. acetaminophen (Tylenol)

B. dexamethasone (Decadron)

C. mannitol (Osmitrol)

D. phenytoin (Dilantin)

E. nitroglycerin (Nitrostat)

Correct Answer: E. nitroglycerin (Nitrostat)

50. Question

Which of the following symptoms would you expect to a client with a phenytoin level of 35 mg/dL?

A. Ataxia

B. Potassium deficit

C. Neglect syndrome

D. Tetraplegia

Correct Answer: A. Ataxia

SECTION 2

1. Question

To encourage adequate nutritional intake for a female client with Alzheimer’s disease, the nurse should:

A. Stay with the client and encourage him to eat.

B. Help the client fill out his menu.

C. Give the client privacy during meals.

D. Fill out the menu for the client.

Correct Answer: A. Stay with the client and encourage him to eat.

2. Question

The nurse is performing a mental status examination on a male client diagnosed with a subdural hematoma. This test assesses which of the following?

A. Cerebellar function

B. Intellectual function

C. Cerebral function

D. Sensory function

Correct Answer: C. Cerebral function

3. Question

Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer the second dose of diazepam, if needed and prescribed?

A. In 30 to 45 seconds

B. In 10 to 15 minutes

C. In 30 to 45 minutes

D. In 1 to 2 hours

Correct Answer: B. In 10 to 15 minutes

4. Question

A female client complains of periorbital aching, tearing, blurred vision, and photophobia in her right eye. Ophthalmologic examination reveals a small, irregular, nonreactive pupil — a condition resulting from acute iris inflammation (iritis). As part of the client’s therapeutic regimen, the physician prescribes atropine sulfate (Atropisol), two drops of 0.5% solution in the right eye twice daily. Atropine sulfate belongs to which drug classification?

A. Parasympathomimetic agent

B. Sympatholytic agent

C. Adrenergic blocker

D. Cholinergic blocker

Correct Answer: D. Cholinergic blocker

5. Question

Emergency medical technicians transport a 27-year-old ironworker to the emergency department. They tell the nurse, “He fell from a two-story building. He has a large contusion on his left chest and a hematoma in the left parietal area. He has a compound fracture of his left femur and he’s comatose. We intubated him and he’s maintaining an arterial oxygen saturation of 92% by pulse oximeter with a manual resuscitation bag.” Which intervention by the nurse has the highest priority?

A. Assessing the left leg.

B. Assessing the pupils.

C. Placing the client in Trendelenburg’s position.

D. Assessing level of consciousness.

Correct Answer: A. Assessing the left leg.

6. Question

An auto mechanic accidentally has battery acid splashed in his eyes. His coworkers irrigate his eyes with water for 20 minutes, and then take him to the emergency department of a nearby hospital, where he receives emergency care for the corneal injury. The physician prescribes dexamethasone (Maxidex Ophthalmic Suspension), two drops of 0.1% solution to be instilled initially into the conjunctival sacs of both eyes every hour; and polymyxin B sulfate (Neosporin Ophthalmic), 0.5% ointment to be placed in the conjunctival sacs of both eyes every 3 hours. Dexamethasone exerts its therapeutic effect by:

A. Increasing the exudative reaction of ocular tissue.

B. Decreasing leukocyte infiltration at the site of ocular inflammation.

C. Inhibiting the action of carbonic anhydrase.

D. Producing a miotic reaction by stimulating and contracting the sphincter muscles of the iris.

Correct Answer: B. Decreasing leukocyte infiltration at the site of ocular inflammation.

7. Question

Nurse Amber is caring for a client who underwent a lumbar laminectomy two (2) days ago. Which of the following findings should the nurse consider abnormal?

A. More back pain than the first postoperative day.

B. Paresthesia in the dermatomes near the wounds.

C. Urine retention or incontinence.

D. Temperature of 99.2° F (37.3° C).

Correct Answer: C. Urine retention or incontinence.

8. Question

After an eye examination, a male client is diagnosed with open-angle glaucoma. The physician prescribes Pilocarpine ophthalmic solution (Pilocar), 0.25% gtt i, OU q.i.D. Based on this prescription, the nurse should teach the client or a family member to administer the drug by:

A. Instilling one drop of pilocarpine 0.25% into both eyes daily.

B. Instilling one drop of pilocarpine 0.25% into both eyes four times daily.

C. Instilling one drop of pilocarpine 0.25% into the right eye daily.

D. Instilling one drop of pilocarpine 0.25% into the left eye four times daily.

Correct Answer: B. Instilling one drop of pilocarpine 0.25% into both eyes four times daily.

9. Question

A female client who’s paralyzed on the left side has been receiving physical therapy and attending teaching sessions about safety. Which behavior indicates that the client accurately understands safety measures related to paralysis?

A. The client leaves the side rails down.

B. The client uses a mirror to inspect the skin.

C. The client repositions only after being reminded to do so.

D. The client hangs the left arm over the side of the wheelchair.

Correct Answer: B. The client uses a mirror to inspect the skin.

10. Question

A male client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client’s feet make a half-circle. To document the client’s gait, the nurse should use which term?

A. Ataxic

B. Dystrophic

C. Helicopod

D. Steppage

Correct Answer: C. Helicopod

11. Question

A client, age 22, is admitted with bacterial meningitis. Which hospital room would be the best choice for this client?

A. A private room down the hall from the nurses’ station.

B. An isolation room three doors from the nurses’ station.

C. A semi-private room with a 32-year-old client who has viral meningitis.

D. A two-bedroom with a client who previously had bacterial meningitis.

Correct Answer: B. An isolation room three doors from the nurses’ station

12. Question

A physician diagnoses a client with myasthenia gravis, prescribing pyridostigmine (Mestinon), 60 mg P.O. every 3 hours. Before administering this anticholinesterase agent, the nurse reviews the client’s history. Which preexisting condition would contraindicate the use of pyridostigmine?

A. Ulcerative colitis

B. Blood dyscrasia

C. Intestinal obstruction

D. Spinal cord injury

Correct Answer: C. Intestinal obstruction

13. Question

A female client is admitted to the facility for investigation of balance and coordination problems, including possible Ménière’s disease. When assessing this client, the nurse expects to note:

A. Vertigo, tinnitus, and hearing loss.

B. Vertigo, vomiting, and nystagmus.

C. Vertigo, pain, and hearing impairment.

D. Vertigo, blurred vision, and fever.

Correct Answer: A. Vertigo, tinnitus, and hearing loss.

14. Question

A male client with a conductive hearing disorder caused by ankylosis of the stapes in the oval window undergoes a stapedectomy to remove the stapes and replace the impaired bone with a prosthesis. After the stapedectomy, the nurse should provide which client instruction?

A. “Lie in bed with your head elevated, and refrain from blowing your nose for 24 hours.”

B. “Try to ambulate independently after about 24 hours.”

C. “Shampoo your hair every day for ten (10) days to help prevent ear infection.”

D. “Don’t fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days.”

Correct Answer: D. “Don’t fly in an airplane, climb to high altitudes, make sudden movements, or expose yourself to loud sounds for 30 days.”

15. Question

Nurse Marty is monitoring a client for adverse reactions to dantrolene (Dantrium). Which adverse reaction is most common?

A. Excessive tearing

B. Urine retention

C. Muscle weakness

D. Slurred speech

Correct Answer: C. Muscle weakness

16. Question

The nurse is monitoring a male client for adverse reactions to atropine sulfate (Atropine Care) eyedrops. Systemic absorption of atropine sulfate through the conjunctiva can cause which adverse reaction?

A. Tachycardia

B. Increased salivation

C. Hypotension

D. Apnea

Correct Answer: A. Tachycardia

17. Question

A male client is admitted with a cervical spine injury sustained during a diving accident. When planning this client’s care, the nurse should assign the highest priority to which nursing diagnosis?

A. Impaired physical mobility

B. Ineffective breathing pattern

C. Disturbed sensory perception (tactile)

D. Self-care deficit: Dressing/grooming

Correct Answer: B. Ineffective breathing pattern

18. Question

A male client has a history of painful, continuous muscle spasms. He has taken several skeletal muscle relaxants without experiencing relief. His physician prescribes diazepam (Valium), two (2) mg P.O. twice daily. In addition to being used to relieve painful muscle spasms, Diazepam also is recommended for:

A. Long-term treatment of epilepsy.

B. Postoperative pain management of laminectomy clients.

C. Postoperative pain management of diskectomy clients.

D. Treatment of spasticity associated with spinal cord lesions.

Correct Answer: D. Treatment of spasticity associated with spinal cord lesions.

19. Question

A female client who was found unconscious at home is brought to the hospital by a rescue squad. In the intensive care unit, the nurse checks the client’s oculocephalic (doll’s eye) response by:

A. Introducing ice water into the external auditory canal.

B. Touching the cornea with a wisp of cotton.

C. Turning the client’s head suddenly while holding the eyelids open.

D. Shining a bright light into the pupil.

Correct Answer: C. Turning the client’s head suddenly while holding the eyelids open.

20. Question

While reviewing a client’s chart, the nurse notices that the female client has myasthenia gravis. Which of the following statements about neuromuscular blocking agents is true for a client with this condition?

A. The client may be less sensitive to the effects of a neuromuscular blocking agent.

B. Succinylcholine shouldn’t be used; pancuronium may be used in a lower dosage.

C. Pancuronium shouldn’t be used; succinylcholine may be used in a lower dosage.

D. Pancuronium and succinylcholine both require cautious administration.

Correct Answer: D. Pancuronium and succinylcholine both require cautious administration.

21. Question

A male client is color blind. The nurse understands that this client has a problem with:

A. Rods.

B. Cones.

C. Lens.

D. Aqueous humor.

Correct Answer: B. Cones.

22. Question

A female client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?

A. Diencephalon

B. Medulla

C. Midbrain

D. Cortex

Correct Answer: C. Midbrain

23. Question

The nurse is assessing a 37-year-old client diagnosed with multiple sclerosis. Which of the following symptoms would the nurse expect to find?

A. Vision changes

B. Absent deep tendon reflexes

C. Tremors at rest

D. Flaccid muscles

Correct Answer: A. Vision changes

24. Question

The nurse is caring for a male client diagnosed with a cerebral aneurysm who reports a severe headache. Which action should the nurse perform?

A. Sit with the client for a few minutes.

B. Administer an analgesic.

C. Inform the nurse manager.

D. Call the physician immediately.

Correct Answer: D. Call the physician immediately.

25. Question

During recovery from a cerebrovascular accident (CVA), a female client is given nothing by mouth, to help prevent aspiration. To determine when the client is ready for a liquid diet, the nurse assesses the client’s swallowing ability once each shift. This assessment evaluates:

A. Cranial nerves I and II.

B. Cranial nerves III and V.

C. Cranial nerves VI and VIII.

D. Cranial nerves IX and X.

Correct Answer: D. Cranial nerves IX and X.

26. Question

A white female client is admitted to an acute care facility with a diagnosis of cerebrovascular accident (CVA). Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for CVA?

A. Caucasian race

B. Female sex

C. Obesity

D. Bronchial asthma

Correct Answer: C. Obesity

27. Question

The nurse is teaching a female client with multiple sclerosis. When teaching the client how to reduce fatigue, the nurse should tell the client to:

A. Take a hot bath.

B. Rest in an air-conditioned room.

C. Increase the dose of muscle relaxants.

D. Avoid naps during the day.

Correct Answer: B. Rest in an air-conditioned room.

28. Question

A male client is having tonic-clonic seizures. What should the nurse do first?

A. Elevate the head of the bed.

B. Restrain the client’s arms and legs.

C. Place a tongue blade in the client’s mouth.

D. Take measures to prevent injury.

Correct Answer: D. Take measures to prevent injury.

29. Question

A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond?

A. “You may have difficulty believing this, but the paralysis caused by this disease is temporary.”

B. “You’ll have to accept the fact that you’re permanently paralyzed. However, you won’t have any sensory loss.”

C. “It must be hard to accept the permanency of your paralysis.”

D. “You’ll first regain use of your legs and then your arms.”

Correct Answer: A. “You may have difficulty believing this, but the paralysis caused by this disease is temporary.”

30. Question

The nurse is working on a surgical floor. The nurse must log roll a male client following a:

A. Laminectomy.

B. Thoracotomy.

C. Hemorrhoidectomy.

D. Cystectomy.

Correct Answer: A. Laminectomy.

31. Question

A female client with a suspected brain tumor is scheduled for computed tomography (CT). What should the nurse do when preparing the client for this test?

A. Immobilize the neck before the client is moved onto a stretcher.

B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish.

C. Place a cap on the client’s head.

D. Administer a sedative as ordered.

Correct Answer: B. Determine whether the client is allergic to iodine, contrast dyes, or shellfish.

32. Question

During a routine physical examination to assess a male client’s deep tendon reflexes, the nurse should make sure to:

A. Use the pointed end of the reflex hammer when striking the Achilles’ tendon.

B. Support the joint where the tendon is being tested.

C. Tap the tendon slowly and softly.

D. Hold the reflex hammer tightly.

Correct Answer: B. Support the joint where the tendon is being tested.

33. Question

A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority for this client’s plan of care?

A. Disturbed sensory perception (visual)

B. Self-care deficit: Dressing/grooming

C. Impaired verbal communication

D. Risk for injury

Correct Answer: D. Risk for injury

34. Question

A female client with amyotrophic lateral sclerosis (ALS) tells the nurse, “Sometimes I feel so frustrated. I can’t do anything without help!” This comment best supports which nursing diagnosis?

A. Anxiety

B. Powerlessness

C. Ineffective denial

D. Risk for disuse syndrome

Correct Answer: B. Powerlessness

35. Question

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to:

A. Prevent respiratory alkalosis.

B. Lower arterial pH.

C. Promote carbon dioxide elimination.

D. Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg.

Correct Answer: C. Promote carbon dioxide elimination.

36. Question

Nurse Mary witnesses a neighbor’s husband sustain a fall from the roof of his house. The nurse rushes to the victim and determines the need to open the airway in this victim by using which method?

A. Flexed position

B. Head tilt-chin lift

C. Jaw-thrust maneuver

D. Modified head tilt-chin lift

Correct Answer: C. Jaw-thrust maneuver

37. Question

The nurse is assessing the motor function of an unconscious male client. The nurse would plan to use which of the following to test the client’s peripheral response to pain?

A. Sternal rub

B. Nail bed pressure

C. Pressure on the orbital rim

D. Squeezing of the sternocleidomastoid muscle

Correct Answer: B. Nail bed pressure

38. Question

A female client admitted to the hospital with a neurological problem asks the nurse whether magnetic resonance imaging may be done. The nurse interprets that the client may be ineligible for this diagnostic procedure based on the client’s history of:

A. Hypertension

B. Heart failure

C. Prosthetic valve replacement

D. Chronic obstructive pulmonary disorder

Correct Answer: C. Prosthetic valve replacement

39. Question

A male client is having a lumbar puncture performed. The nurse would plan to place the client in which position?

A. Side-lying, with a pillow under the hip.

B. Prone, with a pillow under the abdomen.

C. Prone, in slight-Trendelenburg’s position.

D. Side-lying, with the legs, pulled up and head bent down onto the chest.

Correct Answer: D. Side-lying, with the legs, pulled up and head bent down onto the chest.

40. Question

The nurse is positioning the female client with increased intracranial pressure. Which of the following positions would the nurse avoid?

A. Head midline

B. Head turned to the side

C. Neck in neutral position

D. Head of bed elevated 30 to 45 degrees

Correct Answer: B. Head turned to the side

41. Question

A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid:

A. Is clear and tests negative for glucose.

B. Is grossly bloody in appearance and has a pH of 6.

C. Clumps together on the dressing and has a pH of 7.

D. Separates into concentric rings and tests positive for glucose.

Correct Answer: D. Separates into concentric rings and tests positive for glucose.

42. Question

A male client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?

A. Strict adherence to a bowel retraining program.

B. Keeping the linen wrinkle-free under the client.

C. Preventing unnecessary pressure on the lower limbs.

D. Limiting bladder catheterization to once every 12 hours.

Correct Answer: D. Limiting bladder catheterization to once every 12 hours

43. Question

The nurse is caring for the male client who begins to experience seizure activity while in bed. Which of the following actions by the nurse would be contraindicated?

A. Loosening restrictive clothing.

B. Restraining the client’s limbs.

C. Removing the pillow and raising padded side rails.

D. Positioning the client to the side, if possible, with the head flexed forward.

Correct Answer: B. Restraining the client’s limbs.

44. Question

The nurse is assigned to care for a female client with complete right-sided hemiparesis. The nurse plans care knowing that this condition:

A. The client has complete bilateral paralysis of the arms and legs.

B. The client has weakness on the right side of the body, including the face and tongue.

C. The client has lost the ability to move the right arm but can walk independently.

D. The client has lost the ability to move the right arm but can walk independently.

Correct Answer: B. The client has weakness on the right side of the body, including the face and tongue.

45. Question

The client with a brain attack (stroke) has residual dysphagia. When a diet order is initiated, the nurse avoids doing which of the following?

A. Giving the client thin liquids.

B. Thickening liquids to the consistency of oatmeal.

C. Placing food on the unaffected side of the mouth.

D. Allowing plenty of time for chewing and swallowing.

Correct Answer: A. Giving the client thin liquids.

46. Question

The nurse is assessing the adaptation of the female client to changes in functional status after a brain attack (stroke). The nurse assesses that the client is adapting most successfully if the client:

A. Gets angry with family if they interrupt a task.

B. Experiences bouts of depression and irritability.

C. Has difficulty with using modified feeding utensils.

D. Consistently uses adaptive equipment in dressing self.

Correct Answer: D. Consistently uses adaptive equipment in dressing self

47. Question

Nurse Kristine is trying to communicate with a client with brain attack (stroke) and aphasia. Which of the following actions by the nurse would be least helpful to the client?

A. Speaking to the client at a slower rate.

B. Allowing plenty of time for the client to respond.

C. Completing the sentences that the client cannot finish.

D. Looking directly at the client during attempts at speech.

Correct Answer: C. Completing the sentences that the client cannot finish.

48. Question

A female client has experienced an episode of myasthenic crisis. The nurse would assess whether the client has precipitating factors such as:

A. Getting too little exercise.

B. Taking excess medication.

C. Omitting doses of medication.

D. Increasing intake of fatty foods.

Correct Answer: C. Omitting doses of medication.

49. Question

The nurse is teaching the female client with myasthenia gravis about the prevention of myasthenic and cholinergic crisis. The nurse tells the client that this is most effectively done by:

A. Eating large, well-balanced meals.

B. Doing muscle-strengthening exercises.

C. Doing all chores early in the day while less fatigued.

D. Taking medications on time to maintain therapeutic blood levels.

Correct Answer: D. Taking medications on time to maintain therapeutic blood levels

50. Question

A male client with Bell’s Palsy asks the nurse what has caused this problem. The nurse’s response is based on an understanding that the cause is:

A. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem.

B. Unknown, but possibly includes long-term tissue malnutrition and cellular hypoxia.

C. Primary genetic in origin, triggered by exposure to meningitis.

D. Primarily genetic in origin, triggered by exposure to neurotoxins.

Correct Answer: A. Unknown, but possibly includes ischemia, viral infection, or an autoimmune problem

200 Midwifery Past Questions And Answers

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200 Midwifery Past Questions And Answers

PAPER III
Instructions: Enter your examination number and login Time allowed: 3 hours
Answer ALL questions

  1. A break in the continuity of the skin or mucous membrane is ……….?
    (a) Infection
    (b) Haemorrhage
    (c) Wound
    (d) Fracture
  2. Type of shock where there is loss of blood or fluid is ……….?
    (a) Oligemic shock
    (b) Bacteriaemic shock
    (c) Anaphylactic shock
    (d) Neurogenic shock
  3. The best form of tourniquet is …………?
    (a) Broad rubber band
    (b) Piece of rag
    (c) A twing
    (d) Elastic band
  4. If a tourniquet is not tight enough it will only limit………………. Flow of blood
    (a) Venous
    (b) Capillary
    (c) Arterial
    (d) Aortic
  5. Haemorrhage occurring 24 hours after an injury or surgery is …………………?
    (a) Primary haemorrhage
    (b) Secondary haemorrhage
    (c) Capillary haemorrhage
    (d) Reactionary haemorrhage
  6. Blood in urine may result from…………….?
    (a) Anaemia
    (b) Infection of the bladder
    (c) Reproductive tract infection

(d) Shock

  1. Secondary haemorrhage may be due to …………………..?
    (a) Reaction of the body
    (b) Lowered blood pressure
    (c) Lack of clot formation
    (d) Infection
  2. Blood or fluid loss may result in…………….?
    (a) Hypovolaemic shock
    (b) Bacteriamic shock
    (c) Cardiogenic shock
    (d) Neurogenic shock
  3. Methods of artificial respiration include the following EXCEPT (a) Month-to-month
    (b) Hagel method
    (c) Eve’s rocking method
    (d) Silvester’s method
  4. ……………. Is used to check for urine specific gravity (a) Litmus paper
    (b) Urinometer
    (c) Bath thermometer
    (d) Pulse oximeter
  5. The normal volume of urine per hour should be at least…………… (a) 400mls
    (b) 200mls
    (c) 30mls
    (d) 100mls
  6. Normal colour of urine is………………… (a) Coffee straw
    (b) Crayfish
    (c) Yellow
    (d) Amber
  7. The normal reaction of urine is……….?
    (a) Slightly acidic
    (b) Strongly acidic (c) Slightly alkaline

(d) Strongly alkaline

  1. Acidic urine will turn blue litmus paper…………? (a) Brown
    (b) Green
    (c) Red
    (d) Reddish brown
  2. Normal finding in urine include all EXCEPT (a) Water
    (b) Urea
    (c) Phosphate
    (d) Sugar
  3. The standard scale for measuring temperature is…………….? (a) Thermometer
    (b) Gram
    (c) Kilogram
    (d) Centigrade
  4. A state of heat or coldness of a substance measured against a standard scale is called……………?
    (a) Blood pressure (b) Respiration
    (c) Temperature (d) Pulse
  5. The pressure exerted by the blood on the vessels is……………….? (a) Respiration
    (b) Blood pressure
    (c) Temperature
    (d) Pulse
  6. Green stick fracture occurs mostly in ……………………..? (a) Elderly
    (b) Adolescents
    (c) Children
    (d) Congenital disorders
  7. The most accurate site for obtaining body temperature is………..? (a) Axilla
    (b) Groin
    (c) Mouth (d) Rectum
  1. Normal body temperature is……………? (a) 38 – 39oC
    (b) 36.6 – 37.2oC
    (c) 35 – 36oC
    (d) 38 – 39oC
  2. The wave of distension felt on the wall of an artery is called ……………….? (a) Respiration
    (b) Blood pressure
    (c) Pulse
    (d) Temperature
  3. General principles of first aid treatment include all EXCEPT…………….? (a) Remove source of danger
    (b) Undo tight clothing around the neck, chest and waist
    (c) Bath victim with either warm or cold water
    (d) Clear airway of any obstruction
  4. A life saving technique used in emergencies is known as ……………? (a) Restoration
    (b) Resurrection
    (c) Revigoration
    (d) Resuscitation
  5. Adverse reactionto a drug can cause………? (a) Anaemia
    (b) Malaria
    (c) Septic shock
    (d) Anaphylactic shock
  6. The combination of carbon monoxide and haemoglogin is termed……….? (a) Haemoglobinopathies
    (b) Carboxyhaemoglobin
    (c) Carboxyglobulin
    (d) Carbohydroxylhaemoglobin
  7. Epitaxis refers to ………….?
    (a) Bleeding from the nose
    (b) Bleeding from the ear (c) Blood in urine

(d) Coughing out blood

  1. A condition which arise when an individual is unable to inhale or exhale air is …………? (a) Shock
    (b) Fainting
    (c) Asphyxia
    (d) Asthma
  2. Which of the following is a general antidote?
    (a) Charcoal
    (b) Naxolone
    (c) Normal saline (d) 50% dextrose
  3. When an artery is injured, the blood is…….? (a) Dark red
    (b) Bright red
    (c) Pale brown
    (d) Oozes
  4. Blood spurting from a wound, indicates ……….. bleeding?
    (a) Arterial
    (b) Capillary (c) Venous (d) Primary
  5. These instances are related to carbon monoxide poisoning EXCEPT…..? (a) If a tap on gas appliance is not turn-off properly
    (b) Drowning or choking
    (c) Poorly ventilated space where carbon fuel is burnt
    (d) Working in an enclosed space with car engine running
  6. Nature’s method of arresting haemorrhage include the following EXCEPT……..? (a) Formation of clot
    (b) Elastic coat of the blood vessel recoil and turn in
    (c) Depression of the vital centers
    (d) Blood pressure is lowered
  7. Normal respiratory rate in an adult is…………..? (a) 30 – 50 c/m
    (b) 16 – 18 c/m
    (c) 20 – 30 c/m

(d) 10 – 12 c/m

  1. The group of people mostly at risk of swallowing foreign objects are………….?
    (a) Infants / toddlers
    (b) Adult
    (c) Adolescents (d) Adult
  2. One of these group of wound is of greater depth and danger to internal organs (a) Incised
    (b) Lacerated
    (c) Punctured
    (d) Contused
  3. Vomiting blood is called……..? (a) Haemoptysis
    (b) Haematemesis
    (c) Haematuria
    (d) Melena
  4. Bone cells include the following EXCEPT…..
    (a) Normoblasts
    (b) Fibroblasts (c) Osteoblasts (d) Osteoclasts
  5. Burns affecting the anterior trunk of children account for………….
    (a) 18%
    (b) 9% (c) 14% (d) 20%
  6. Insulating materials include the following EXCEPT……………. (a) Rubber matting
    (b) Rubber gloves
    (c) Dry clothes
    (d) Fresh wood
  7. A condition where there is depression of the vital centers in the brain is……………? (a) Heart failure
    (b) Shock
    (c) Renal failure

(d) Haemorrhage

  1. Which of these will happen due to insufficient blood supply to the brain? (a) Stupor
    (b) Stridor
    (c) Fainting
    (d) Coma
  2. The following can cause unconsciousness EXCEPT? (a) Asphyxia
    (b) Cerebral anaemia
    (c) Schizophrenia
    (d) Cerebro – vascular accident
  3. The phase that precedes loss of unconsciousness in epilepsy is …………..? (a) Clonic phase
    (b) Tonic phase
    (c) Aura phase
    (d) Coma phase
  4. The body of spermatozoa is packed with …………..?
    (a) Mitochondria
    (b) Ribosome
    (c) Ribonucleic acid
    (d) Deoxyriboneuleic acid
  5. At term, platelets are high in amount at the ……………………? (a) Uterus
    (b) Cervical site
    (c) Placental site
    (d) Fundus
  6. Near term, the uterus is divided into …………………. Segments (a) 4
    (b) 2
    (c) 3
    (d) 6
  7. The following are signs of shock EXCEPT (a) Bradycardia
    (b) Tachycardia
    (c) Hypotension

(d) Cold and clamming skin

  1. Which of the following is an important source for identification of research problem in Midwifery.
    (a) Research textbooks
    (b) Midwifery practice
    (c) Nursing ethics (d) Codes of conduct
  2. The life span of erythrocyte is ……………………? (a) Less than 120 days
    (b) 120 days
    (c) 20 days
    (d) 90days
  3. The vagina in normal labour is …………………? (a) Hot and dry
    (b) Warm and moist
    (c) Cool and wet
    (d) Hot and soft
  4. The detrusor muscle is found at the ……………….? (a) Uterus
    (b) Ovaries
    (c) Kidneys
    (d) Bladder
  5. Which of the following are component of Central Processing Unit (CPU) …………………..?
    (a) Arithmetic logic unit, mouse
    (b) Arithmetic logic unit, integrated circuit
    (c) Control unit, monitor
    (d) Arithmetic logic unit, control unit
  6. A portion of memory that serves as a temporarily repository for data as it await for a given action is known as ……………………?
    (a) Memory pool
    (b) Memory processor
    (c) Antenna

(d) Cache

  1. The difference between the structure of deoxyribonucleic acid and ribonucleicacid is the absence of ………………
    (a) Nitrogen (b) Carbon (c) Oxygen (d) Hydrogen
  2. The major modes of HIV transmission is …………………….?
    (a) Sexual intercourse and sharing of sharps
    (b) Blood transfusion (c) Mother – to – child (d) Kissing and saliva
  3. The window period in HIV is ………………..?
    (a) The period between HIV infection and detection of virus in the blood
    (b) The earliest stage of infection
    (c) The time the body respond to the infection (d) The time condom burst during intercourse
  4. The group of drugs used in management of HIV infection is called ……………………..? (a) Antifungal
    (b) Antivirals
    (c) Antiretrovirals
    (d) Antibacterial
  5. Babies born to HIV positive mothers are called …? (a) Infected infant
    (b) Affect infant
    (c) Exposed infant
    (d) Exceptional infant
  6. The following are criteria for the Apgar Score EXCEPT?
    (a) Temperature
    (b) Heart rate
    (c) Respiratory rate
    (d) Muscle tone
  7. The following reflexes are present at birth EXCEPT? (a) Rooting reflex
    (b) Grasping reflex
    (c) Moro reflex
    (d) Stepping reflex
  8. Normal infant double in weight by ………….? (a) 1 year
    (b) 3 months
    (c) 6months
    (d) 18 months
  9. Collapse of the lungs is referred to as ……………? (a) Lobectomy
    (b) Bronchiectasis
    (c) Homeostasis
    (d) Atelectasis
  10. The state of physiologic equilibrium between the external and internal environment is called ……………….?
    (a) Hemoptysis
    (b) Homeostasis
    (c) hemostasis (d) Atelectasis
  11. The school health nurse provides the following care EXCEPT? (a) Preventive
    (b) Promotive
    (c) Rehabilitative
    (d) Diagnostic and curative
  12. The following are the aims and objectives of integrated management of neonatal and childhood illnesses except?
    (a) To focus on child as a whole
    (b) To promote growth & development
    (c) To reduce illness and disabilities
    (d) Help in planning of the family
  13. The best index for assessing a child’s growth and development is …………………….?
    (a) Weight
    (b) Height
    (c) Width
    (d) Circumference
  14. The type of consent obtained from client is known as ……………………? (a) Informed consent
    (b) Implied consent
    (c) Agreed consent
    (d) Coerced consent
  15. The type of nursing audit that monitors the setting in which client care occurs is …….?
    (a) Outcome audit
    (b) Process audit (c) Structural audit (d) Tool audit
  16. Which of the following propounded the Health Promotion Model?
    (a) Nola Pender
    (b) Dorothea Orem (c) Jean Watson (d) Imogene King
  17. One of these theorists is associated with the environmental model
    (a) FlorenceNightingale
    (b) Betty Nauman (c) Levine
    (d) Henderson
  18. The sequential order of lochia is ……………… (a) Alba, serosa, rubra
    (b) Rubra, serosa, alba
    (c) Serosa, alba, rubra
    (d) Rubra, alba, serosa
  19. The upright position in labour has the advantage of …………….? (a) Restricting mobility
    (b) Shorter duration of labour
    (c) Preventing complication
    (d) Shorter third stage of labor
  20. The following hormonal contraception can be used during lactation EXCEPT? (a) Mini pills
    (b) Combined oral contraceptive pills
    (c) Implanon
    (d) Depot medroxyl progesterone acetate (DMPA)
  21. The following are neurotransmitters except? (a) Serotonin
    (b) Dopamine
    (c) Oestrogen
    (d) Substance P
  22. The combination of 3 or more antiretroviral agents in HIV management is known as ….?
    (a) Highly active antiretroviral therapy
    (b) Highly active antiviral therapy (c) Highly active viral therapy
    (d) Highly active bactericidal
  23. The following are methods of collecting data in research EXCEPT? (a) Questionnaire
    (b) Observation
    (c) Demonstration
    (d) Experiment
  24. A citation to the source of information used by a researcher at the completion of his/her work is called
    (a) Table of content
    (b) autography
    (c) References (d) Referendum
  25. A statement of the expected relationship between two or more variables is known as……?
    (a) Statement of the problem
    (b) Concept definition
    (c) Research questions
    (d) Hypothesis
  26. When a pressure area becomes inflamed, break down and ulcerates, it is called ……. (a) Cold sore
    (b) Inflammation
    (c) Ulcer
    (d) Pressure sore
  27. The following are rules for bed – making EXCEPT
    (a) All requirements should be gathered before procedure (b) Two nurses are required and should work in harmony (c) The patient’s face and body should be slightly exposed (d) Extra assistant may be required to lift the patient
  28. Rules for filling hot water bottle include all EXCEPT
    (a) Fill the bottle directly from the kettle
    (b) Fill the bottle three quarters full
    (c) Invert and inspect the bottle for leaks
    (d) Blanket should be tucked – in between the patient and the bottle
  29. The first step in processing instruments and other items for re–use is ………………
    (a) Decontamination
    (b) Cleaning
    (c) High level disinfection (d) Sterilization
  30. One of these processes eliminates all microorganisms including bacterial endospores (a) Boiling
    (b) Steaming
    (c) Autoclaving
    (d) Cleaning
  31. Obstetric forceps were invented by ……………….. (a) Ambiose pare
    (b) Soranus of Ephesus
    (c) Peter Chamberlin
    (d) Aristotle
  32. In Maslow’s hierarchy of needs, self-actualization connotes …………………….? (a) Reaching societal recognition
    (b) Achieving one’s ambition in life
    (c) An endeavour to reach the peak
    (d) Self esteem
  33. Expected outcome of the client’s health status in the nursing care plan is represented by …………………?
    (a) Nursing diagnosis
    (b) Nursing objectives
    (c) Nursing orders
    (d) Scientific rationale
  34. A professional in midwifery is known as ………………….. (a) Expert
    (b) Midwife
    (c) Polyvalent nurse
    (d) Midwifery
  35. A client problem that is present at the time of nursing assessment is called ………? (a) Possible diagnosis
    (b) Illness diagnosis
    (c) Risk nursing diagnosis
    (d) Actual nursing diagnosis
  36. Which of the following is associated with psychosexual theory of development. (a) Abraham Maslow
    (b) Albert Bandura
    (c) Erick Erikson
    (d) Sigmund Freud
  37. The functional unit of the kidney is……..? (a) Bowman’s capsule
    (b) Nephron
    (c) Glomerulus
    (d) Hilum
  38. The smallest cell in the human body is………………? (a) Ovum
    (b) Sperm cell
    (c) Nerve cell
    (d) Bone cell
  39. The largest cell in the human body is …….? (a) Bone cell
    (b) Ovum
    (c) Sperm cell
    (d) Nerve cell
  40. The basic building blocks of life are….? (a) Tissues
    (b) Cells
    (c) Oxygen
    (d) Hydrogen
  41. Which of the following is NOT a type of epithelial tissue (a) Simple squamous epithelium
    (b) Simple cuboidal epithelium
    (c) Simple columnar, pseudo stratified epithelium
    (d) Connective tissue
  42. Overlapping of the fetal skull bone at the sutures is called………..? (a) Caput
    (b) Chignon
    (c) Cephalhematoma
    (d) Moulding
  43. The following are examples of connective tissues EXCEPT (a) Bone
    (b) Blood
    (c) Lymph
    (d) Skin
  44. The following vaccines are contra-indicated in pregnancy EXCEPT (a) Varicella
    (b) Measles, mumps and rubella
    (c) Live Influenza
    (d) Hepatitis B
  45. The following are brands of Covid-19 vaccine EXCEPT (a) Moderna
    (b) Pfizer/ Bio Ntech
    (c) Oxford/ Astrazeneca
    (d) mRNA vaccines
  46. Unsafe injection practices include the following EXCEPT (a)Re-use of injection device without sterilization
    (b) Re-use of opened vials and ampoules of drugs
    (c)Rinsing syringes and needles in antiseptic lotion
    (d) Collection and disposal of dirty injection equipments
  47. Which of the following is NOT the duty of Nursing and Midwifery Council of Nigeria
    (a) Prosecute legal training institutions
    (b) Registration and licensing for all categories of nurses
    (c) Ensure professional standards of practice
    (d) Accreditation of training schools
  48. A shared pattern of behaviour that is found in the majority of people
    is _ a. Community b. Society
    c. Culture d. Tradition
  49. An individual that fails to conform to the norms of the society is a a. Conformist b. Reformist c. Deviant d. Congruence
  50. The back bone of the society is _ a. Police b. Constitution c. Armforce d. Family
  51. A Pattern of behaviour that is found worldwide is known as _ a. Culturalpattern b. Cultural universal c. Culturalbeliefs d. Cultural diversity
  52. Which of this is the father of moral development theory? a. Laurette Kohlberg b. Lawrence Kohlberg c. SigmundFreud d. Simeon Ford
  53. The stages of moral development are a. 4 b. 3 c. 5 d. 6
  54. The first socialization agent to a child is _ a. Community b. Siblings c. Mother d. Father
  55. What an individual holds to be true is a. Tradition b. Culture c. Beliefs d. Norms
  56. The process of learning culture is known as _ a. Acculturation b. Enculturation c. Socialization d. Integration
  57. Culture is dynamic means that _a. Cultures interact and change b. Culture is holism c. Culture is based on symbols d. Culture is biological
  58. The Germ Theory of disease causation is associated with a. CharlesDarwin b. Louise Pasteur c. LazzaroSpallanzani d. John T. Needham
  59. The father of evolution theory is _ a. LouisPasteur b. Charles Darwin c. George Louise Lecierce d. Lazzo Spallanzani
  60. Disease causing microorganisms are also known as a. Pathogens b. Teratogens c. Carcinogen d. Bacteria
  61. The international body that regulates the practice of midwifery is _ a. International Council for Nurses b. International Council for Midwives c. International Associations of Nurse and Midwives d. Nursing and Midwifery Council International
  62. Sharps are discarded into __ a. Injection safety box b. The kidney dish c. The dump site of the hospital d. The waste bin outside the ward
  63. The male type of pelvis that does not favours delivery is _ a. Android pelvis b. Justo-minor pelvis c. Gyneacoidpelvis d. Anthropoid pelvis
  64. Group of drugs that can be carried and administered independently by the midwife include all EXCEPT a. Analgesic b. Oxytocic agents c. Cytotoxic drugs d. Antibiotics
  65. Methods of rehabilitation of the mentally ill include all Except _ a. Half-way house or home b. Perambulation of the district c. Dayandnighthospital d. Occasional leave/trial leave 120
  66. PMCT means ___ a. Prevention of Mother to Child Transmission b. Postpartum Maternal Communication Transmission c. Prevention of Malaria to Child Transmission d. Postpartum Maternal Cervical Treatment
  67. NIC means _ a. Neonatal Intervention Care b. Nursing Intervention Classification c. Nursing Identification Communications d. Nursing Intervention Care
  68. NIC means— a. Nursing Observation of Care b. Nursing Obstetric Care c. Nursing Outcome Classification d. Nose Occiput Circumference

123 The imaginary flat surface at the brim, cavity and outlet of the pelvis are referred to as
a. Axis of the pelvis
b. Planes of the pelvis
c. Diameter of the pelvis
d. Angles of the pelvis

124 The following are methods of assessment of nutritional status of under 5 years old EXCEPT
a. anthropometric measurement
b. mid-armcircumference
c. weight measurement
d. assessment of height

125Domiciliary midwifery is known as
a. home delivery undertaken by a community midwife
b. home delivery undertaken by a student midwife
c. home delivery carried out by an obstetrician
d. home delivery carried out by all the health care team

126 Health visitor can perform the following duties EXCEPT
a. Safe motherhood duties
b. Health education
c. Environmentalsanitation
d. Socio-medical Care

127 Which of the following is the most critical period of foetal development? a. Firstweekofpregnancy
b. 2nd – 12th week of pregnancy
c. 13th – 24th week of pregnancy
d. 25th – 36th week of pregnancy

128 In the community, monitoring of growth of children 0 – 8 years is best
done through
a. Mid upper arm circumference
b. Adequate feeding
c. Weighing
d. Medical hygiene inspection

129 One of the following diseases is endemic in the tropics of Africa.
a. Malaria
b. Measles c. Cholera d. Tetanus

130 Unimke has just been stung by bees on the face and runs to you a third year student midwife. You will administer one of the following group of drugs
a. Antibiotics
b. Anti-inflammatory c. Analgesics
d. Antihistamines

131 Ugbe fell off a motor cycle and fractured the leg. The edges of the bone pierced the tissues and can be seen externally. This type of fracture is _ a. Compound fracture b. Greenstick fracture c. Simple fracture d. Comminuted fracture

132 Chain of spread of infection process include all except
a. causative agent
b. reservoirs/carries
c. kemptenvironment
d. portal of exit

133 The progressive increase in size of a child is called a. Development b. Maturation c. Growth d. Growth and development

134 The principles of infectious diseases control include the following EXCEPT _
a. Proper hand washing with liquid soap
b. Proper handling and disposal of sharp
c. Improper aseptic technique
d. Disinfection/waste disposal

135 Libel and slander are examples of a. unintentionaltort
b. intentional tort
c. criminallaw
d. cultural law

136__________ is a serious nature as murder or armed robbery
a. Felony
b. Misdemeanour c. Negligence
d. Libel

137 Decontamination of instruments with 0.5% chlorine/jik solution for _ minutes before cleaning destroys most microorganisms including Hepatitis B, Hepatitis C and HIV viruses. a. 10 b. 15 c. 20 d. 30

138 Baby Umun 3kg was born on 10th December, 2021 to a healthy mother. You will advise the mother to start complementary foods after
a. June10,2022
b. March 10, 2022 c. April 10, 2022 d. May 10, 2022

139 The consistency of complementary foods should be the following EXCEPT
a. solid
b. semi solid
c. finelymashed d. pureed

140 Prolong milk feeding without timely introduction of weaning or complementary foods is the commonest cause of in young children.
a. sickle cell anaemia
b. iron deficiency
c. folic acid deficiency
d. haemolytic anaemia

141 Patient consent can be obtained from significant others in exceptional cases
EXCEPT
a. mentallyillpatientwhoisawake
b. conscious adult who can read and write
c. a child under a guardian
d. unconscious patient

142 A midwife is expected to renew her licence every
a. twoyears
b. three years
c. four years
d. six years

143 The nursing care plan for each patient should be reviewed ____
a. assoonasthepatient’sconditionchanges
b. every 24 hours
c. when the nursing officer in charge orders a change d. When the patient is ready for discharge

144 One of the following is not a member of the emergency team.
a. Nurse/midwife
b. Doctor
c. Wardorderly
d. Laboratoryscientist

145 Tetanus Toxoid vaccine is given to protect women against tetanus and also prevent the disease in their new born infants. The 5th course of TT vaccine provides duration of protection for the mother a. 10years b. 5 years c. 3years d. Life time

146 A six month old baby, who has not been immunized since birth, is brought to your clinic. Which of the following vaccines will you not give to the baby? a. BCGVaccine b. Pentavalent vaccine c. Oralpoliovaccine d. Measles vaccines

147 The tier of government responsible for Primary Health Care is
a. The community
b. Local government
c. State government
d. Federal government

148 A doctor prescribes 1000ml of normal saline to be infused for a period of
10 hours. The drop factor is 15 drops per ml. How many drops per minute
will the midwife set as the rate of flow?
a. 21 drops per minute
b. 23 drops per minute
c. 25drops per minute
d. 27 drops per minute

149 Legal safe-guards in nursing/midwifery practice include all but one.
a. Recordandincidentreport b. Providing competent report c. Non-professionalliability d. Health insurance

150 Mrs. Adie a 27 years old G2, P1 with 40weeks gestation is brought into the labour ward in 2nd stage of labour. You will advise her to lie in ___ position for delivery.

a. Trendelenburgposition b. Supine position
c. Lithotomyposition
d. Left lateral position

151 The following are the nursing responsibilities in the emergency unit for a patient presenting with symptoms of hyperglycaemia EXCEPT
(a) Loosen tight clothing.
(b) Give sweet drinks.
(c) Call for help if condition seems to worsen. (d) Give insulin.

152 The following are emergency treatment for snake bite EXCEPT (a) Calm the casualty and keep him as still as possible
(b) Refer the casualty quickly
(c) Tie a tourniquet above the area
(d) Cut the area and allow it to bleed freely

153 A rule of conduct established and enforced by the government for a society
(a) Tort
(b) Law
(c) Ethics
(d) Midwife’s right

154 Benefit of Nursing Processing including the following except:
(a) It provides unity of language for the nursing profession
(b) It facilitate documentation of care
(c) It delivers holistic patient focused care
(d) It provides disorderly method of planning and providing care

155 Components of assessment include the following except
(a) Nursing history
(b) Physical examination
(c) Diagnosing the condition
(d) Review of relevant document and report

156 Physical examination is accomplished via all the following except:
(a) Inspection
(b) Palpation
(c) Vagina examination
(d) Percussion and auscultation

157 A syndrome diagnosis is associated with a
(a) Cluster of actual or high risk signs and symptoms
(b) Single actual or high risk sig and symptoms
(c) Cluster of potential or low risk signs and symptoms
(d) Single potential or low risk sign and symptoms

158 Subjective data refers to all the following except (a) Feelings
(b) Discoloration
(c) Sensations
(d) Attitudes

159 Objective data are also referred to as:
(a) Signs or overt data
(b) Symptoms verbalized
(c) Values of the patient
(d) Beliefs of all patients

160 If a midwife interferes with a person’s freedom to move about at will without legal authority to do so, the midwife can be charged with (a) Crime (b) Assault (c) Malpractice (d) Slander

161 Midwife Paula admitted a G21P woman, 12 weeks gestation with a blood pressure of 160/100Hg into the antenatal ward without information doctor. This is case of:
(a) Battery
(b) Assault
(c) False imprisonment
(d) Defamation

162 The principle that defines action as being right or wrong is
(a) Philosophy
(b) Ethics
(c) Standard (d) Legislation

163 The systemic, problem-solving approach that provides nursing care to individual, families and communities is
(a) Nursing theory
(b) Qualities
(c) Nursing process
(d) Nursing audit

164 The theorist who first used the term “Nursing Process is:
(a) Lydia Hall
(b) Dorathea Orem
(c) Callista Roy
(d) Hildegard Peplau

165 The proponent of the theory of cognitive development is
(a) Abraham Maslow
(b) Jean Piaget
(c) Eric Erickson
(d) Von Berthlanffy

166 The functional health approaches used in the collection of assessment data
were developed in 1982 by
(a) Dorathea Orem
(b) Virginia Henderson
(c) Majorie Gordon
(d) Imogene King

167 A clinical judgement about an individual, family or community responses to actual or potential health problems is:
(a) Assessment
(b) Planning
(c) Diagnosis
(d) Evaluation

168 The theorist who categorized human needs according to the order of importance is:
(a) Imogene King
(b) Abraham Maslow
(c) Evelyn Duvall
(d) Callista Roy

169 There are _ main types of nursing care plans
(a) Two
(b) Three
(c) Four
(d) Six

170 The nursing care plan for each patient should be reviewed:
(a) As soon as the patient condition change
(b) Every 24 hours
(c) When the nursing officer in charge orders a change
(d) When the patient is about to be discharged

171 Social effects of substance abuse include all except:
(a) Poor school performance
(b) Brilliant school performance
(c) Lying or giving excuses
(d) Unprotected or risky sex/unwanted pregnancies

172 One of the following is to a characteristics of a well stated outcome criteria
(a) Specific
(b) Unattainable
(c) Measurable
(d) Time bound

173 A nurse/midwife is expected renew her license every
(a) Six years
(b) Four years
(c) Three years
(d) Two years

174 In order to achieve its healthcare reform agenda, the N&MCN work closely with the following sister organization under Federal Ministry of Health except
(a) Medical and Dental Council of Nigeria
(b) Pharmacist Council of Nigeria
(c) Local Government Commission
(d) Primary Health Care Development Agency

175 The student nursing care plan for each patient has……….. Major columns
(a) Two
(b) Three
(c) Four
(d) Five

176 The third subsystem in the sequence of Nursing Process is:
(a) Nursing diagnosis
(b) Assessment Phase
(c) Planning phase
(d) Outcome identification

177 The process of prioritizing nursing diagnosis, identifying the objectives and
selecting appropriate intervention is the __ phase of the nursing process
(a) Assessment
(b) Diagnosing
(c) Planning
(d) Implementation

178 One of the following is not a purpose for regulating midwife practice
(a) Protect the public from unsafe practices
(b) Confer accountability status upon the midwife
(c) Ensure quality of care
(d) Ensure competency of the midwife

179 Primary Healthcare aims at:
(a) Providing enough social amenities to people at the grass root level.
(b) Creating political awareness
(c) Eradicate basic health services at the grass level
(d) Bringing basic health services to meet people’s needs at the grass root
level

180 Non-maleficence is associated with
(a) Promotion of standards of the profession
(b) Doing no intentional harm
(c) Self governance
(d) Risks and cost

181 The nursing process terminates or begin again after
(a) Objectives
(b) Intervention
(c) Assessment
(d) Evaluation

182 The chairman of the board of Nursing and Midwife Council of Nigeria is appointed by the

(a) Head of Nursing Services, Federal Ministry of Health
(b) Minister of State for Health
(c) Honourable Minister of Health
(d) The Secretary of board

183 The governing board of Nursing and Midwife Council of Nigeria is made up of:
(a) 9 members
(b) 19 members
(c) 91 members
(d) 99 members

184 The officer who is responsible for the day to day administration of Nursing and
Midwife Council of Nigeria is:
(a) Secretary General/Registrar
(b) The chairman, education committee
(c) The Director, Examination Committee
(d) The Directors standard and Accreditation Committee

185 Function of the Nursing and Midwife Council of Nigeria include
(a) Registration of qualified nurses/midwives
(b) Admission of student into the various schools (c) Conduction of semester examinations
(d) Mentoring of student nurses/midwives in the clinical areas.

186 Mrs. Eze who was discharge six weeks ago following a safe vaginal delivery of a baby boy has just arrived the hospital for postnatal checkup. What type of assessment are you going to carry out on her?
(a) Ongoing assessment
(b) Initial assessment
(c) Time lapse assessment
(d) Emergency assessment

187 In order to bring her services to all states of the country for easy access, the
Nursing and Midwifery Council of Nigeria created __ additional zonal offices across the geopolitical zones.
(a) 16
(b) 12
(c) 10
(d) 1

188 Sometimes one drug will increase the effect of another drug if taken at the same time , this is referred to as :
(a) Potentiation
(b) Simple summation (c) Efficacy (d) Tolerance

189 One of these vitamins enhances the absorption of iron.
(a) vitamin C
(b) vitamin A (c) vitamin K (d) vitamin D

190 Which is the most widely used anthropometric measurement of Nutrition value
(a) Weight
(b) Height (c) Age (d) Gender

191 What is the body mass index (BMT) of a youth with weight of 50kg and height of 1.79m2
(a) 15kg/m2
(b) 15.6kg/m2
(c) 20.2kg/m2 (d) 10.5kg/m2

192 Other Parameters used to measure growth in children include all EXCEPT: (a) Height
(b) Head circumference (c) Chest circumference (d) Age

193 Deficiency of fiber in the diet can cause all of the following EXCEPT:

(a) Loss of appetite
(b) Diarrhea
(c) Constipation
(d) Rectal prolapsed

194 One of these is only a good source of fat (a) Woos milk
(b) Whole pulses (c) Whole cereals (d) Eggs

195 One of these is a unit used to measure energy content of food as well energy expenditure by the body
(a) Joule
(b) Pulsumeter
(c) Thermometer
(d) Calorie

196 The narcotics are habit forming drugs: This means they are drugs of
(a) Addiction
(b) Routine use (c) Relaxation (d) Wellbeing

197 As Nebules the route of administration of salbutamol or ventolin is through (a) Injection
(b) Rectum
(c) Inhalation
(d) Topically

198 One of the following is not an indication for the use of Neurogenic ointment (a) Muscle aches
(b) Open wounds
(c) swelling and stiffness
(d) sprains

199 Mrs. Oko is given two tablets of paracetamol tds for three days in addition to other drugs, this means she is taking __ per dose.
(a) 500mg
(b) 1000mg
(c) 960mg (d) 600mg

200 Mrs. Ogah is rushed to your health facility with excessive vomiting and weakness of the body , the fastest route that will help to reduce vomiting and prevent further electrolyte loss is:
(a) Oral route
(b) Intramuscular route (c) Intravenous route
(d) Subcutaneous route

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