Midwife Licensure Exam High-Risk Pregnancy & Complications (Recognize & Refer) — Hypertensive & Metabolic Disorders of PregnancyExam Answer Templates

Marks

1

Topic

Placenta Previa vs. Abruptio Placentae

Difficulty

easy

Template Id

T1

Examiner Tip

This is a 'discrimination' question — the examiner wants to see that you know the contrast, not just one side. Always pair them. Memorize the mnemonic: Previa = Painless; Abruption = Agonizing.

Model Answer

Placenta previa presents with painless, bright-red vaginal bleeding, while abruptio placentae presents with painful, dark-red vaginal bleeding accompanied by a rigid, board-like uterus.

Question Type

very_short_answer

Answer Structure

• Line 1: State the distinguishing sign for placenta previa (painless, bright-red bleeding) AND abruptio placentae (painful, dark-red bleeding with board-like uterus) — both are needed for full credit [1 mark]

Scoring Breakdown

Common Mark Deductions

• Stating only one condition without the contrasting counterpart
• Omitting the uterine tone finding (board-like rigidity) for abruption
• Writing 'painless' for abruption or 'painful' for previa — a critical factual reversal

Key Phrases To Include

• painless bright-red bleeding
• painful dark-red bleeding
• rigid board-like uterus
• placenta previa
• abruptio placentae

Marks

1

Topic

Types of Abortion

Difficulty

easy

Template Id

T2

Examiner Tip

For any abortion-type question, the cervical os status is the single most important distinguishing criterion. Build your answer around it.

Model Answer

Threatened abortion is a type of spontaneous abortion characterized by slight vaginal bleeding and mild cramping with a closed cervical os, indicating that the pregnancy may still continue.

Question Type

very_short_answer

Answer Structure

• Line 1: Define threatened abortion with its essential distinguishing feature — closed cervical os [1 mark]

Scoring Breakdown

Common Mark Deductions

• Failing to mention 'closed cervical os' — this is the defining finding that separates threatened from inevitable
• Stating the cervix is 'open' — a critical factual error
• Writing a vague definition without the cervical assessment finding

Key Phrases To Include

• spontaneous abortion
• slight vaginal bleeding
• mild cramping
• closed cervical os
• pregnancy may continue

Marks

1

Topic

Ectopic Pregnancy

Difficulty

easy

Template Id

T3

Examiner Tip

PID and prior tubal surgery are the highest-yield risk factors. Lead with PID first — it is the most commonly tested.

Model Answer

Two risk factors for ectopic pregnancy are: (1) history of pelvic inflammatory disease (PID), which causes tubal scarring and impairs ovum transport, and (2) prior tubal surgery or previous ectopic pregnancy.

Question Type

very_short_answer

Answer Structure

• Line 1: Name any two valid, distinct risk factors — one mark is awarded for listing two correct factors [1 mark]

Scoring Breakdown

Common Mark Deductions

• Listing only one risk factor when two are requested
• Writing vague factors like 'infection' without specifying PID
• Repeating essentially the same factor worded differently (e.g., 'tubal surgery' and 'salpingectomy' as two separate answers)

Key Phrases To Include

• pelvic inflammatory disease
• tubal scarring
• prior tubal surgery
• previous ectopic pregnancy
• intrauterine device use

Marks

2

Topic

Priority Nursing Management — Third-Trimester Bleeding

Difficulty

medium

Template Id

T4

Examiner Tip

For 2-mark nursing action questions, the formula is: Action + Rationale. Never just list the action. The examiner is testing your clinical understanding, not just recall.

Model Answer

1. Do NOT perform a vaginal or rectal examination — a digital exam can perforate a low-lying placenta and precipitate massive, life-threatening hemorrhage. Placenta previa must be ruled out by transabdominal ultrasound before any internal exam is attempted. 2. Establish large-bore intravenous (IV) access and begin continuous electronic fetal monitoring — IV access ensures immediate availability of fluid and blood replacement to prevent hypovolemic shock, while fetal monitoring detects non-reassuring fetal heart rate patterns (late decelerations, loss of variability) indicating fetal compromise.

Question Type

short_answer

Answer Structure

• Action 1: State the intervention clearly + give the clinical rationale [1 mark]
• Action 2: State the second intervention clearly + give the clinical rationale [1 mark]

Scoring Breakdown

Common Mark Deductions

• Writing 'monitor vital signs' without specifying what parameters to watch or why — too vague
• Recommending a vaginal exam (a dangerous and incorrect action for third-trimester bleeding)
• Stating the intervention without any rationale — most 2-mark questions require action + reason
• Listing irrelevant actions like 'ambulate the patient' or 'encourage oral fluids'

Key Phrases To Include

• no vaginal examination
• placenta previa must be ruled out
• large-bore IV access
• continuous electronic fetal monitoring
• hypovolemic shock
• transabdominal ultrasound

Marks

2

Topic

Rho(D) Immune Globulin Pharmacology

Difficulty

medium

Template Id

T5

Examiner Tip

Memorize RhoGAM as a two-dose regimen: 28 weeks AND within 72 hours postpartum. The examiner will often ask for 'both' — if you only state one, you lose the mark.

Model Answer

Rho(D) immune globulin is administered to an Rh-negative, unsensitized mother to prevent Rh isoimmunization. It works by providing passive antibodies that destroy any Rh-positive fetal red blood cells that enter the maternal circulation before the mother can mount her own immune response. This protects future pregnancies from hemolytic disease of the newborn. Standard dose and timing: 300 mcg intramuscularly (IM) at 28 weeks gestation AND within 72 hours after delivery of an Rh-positive infant.

Question Type

short_answer

Answer Structure

• Sentence 1–2: Explain the purpose (prevent Rh isoimmunization, protect future pregnancies) [1 mark]
• Sentence 3: State the exact dose (300 mcg IM), timing (28 weeks and within 72 hours postpartum) [1 mark]

Scoring Breakdown

Common Mark Deductions

• Stating the dose as '50 mcg' — the 50 mcg microdose is only for first-trimester events under 13 weeks
• Omitting the 28-week antenatal dose and only mentioning the postpartum dose
• Stating the route as 'IV' instead of 'IM'
• Not specifying 'within 72 hours' — the timing window is a tested detail

Key Phrases To Include

• Rh-negative unsensitized mother
• Rh isoimmunization
• passive antibodies
• Rh-positive fetal red blood cells
• 300 mcg IM
• 28 weeks gestation
• within 72 hours after delivery
• hemolytic disease of the newborn

Marks

2

Topic

Hydatidiform Mole

Difficulty

medium

Template Id

T6

Examiner Tip

The examiner loves 'preeclampsia before 20 weeks' because it requires you to know the normal baseline (after 20 weeks) to recognize the abnormality. Always include it.

Model Answer

Three classic manifestations of hydatidiform mole are: 1. Uterus larger than expected for gestational age — due to abnormal trophoblastic proliferation. 2. Excessively elevated serum beta-hCG levels — the mole produces far more hCG than a normal pregnancy. 3. Signs of preeclampsia appearing before 20 weeks gestation — this is pathognomonic, as preeclampsia normally does not occur until after 20 weeks.

Question Type

short_answer

Answer Structure

• Point 1: Uterus large-for-dates with brief reason [half mark]
• Point 2: Very high beta-hCG with brief reason [half mark]
• Point 3: Early preeclampsia before 20 weeks — the 'red flag' sign [1 mark — highest yield]

Scoring Breakdown

Common Mark Deductions

• Listing only signs shared with normal pregnancy (e.g., nausea, spotting) without the distinctive mole-specific signs
• Stating preeclampsia 'after 20 weeks' — this is the normal timeline, not the mole's red flag
• Not mentioning the characteristic 'very high' hCG level

Key Phrases To Include

• uterus larger than expected for gestational age
• excessively elevated beta-hCG
• preeclampsia before 20 weeks
• dark brown prune juice bleeding
• passage of vesicles
• snowstorm pattern on ultrasound
• no fetal heart tones

Marks

2

Topic

Types of Abortion

Difficulty

medium

Template Id

T7

Examiner Tip

Use parallel structure: describe the same features (expulsion status, os status, bleeding, management) for both types. This makes it easy for the examiner to award both marks.

Model Answer

In an incomplete abortion, some products of conception have been expelled but some are still retained in the uterus; the cervical os remains open and heavy bleeding continues, necessitating dilation and curettage (D&C) to remove retained tissue. In a complete abortion, all products of conception have been expelled; bleeding and cramping subside, and the cervical os closes — no surgical intervention is required.

Question Type

short_answer

Answer Structure

• Sentence 1: Define incomplete abortion — retained products, open os, heavy bleeding, needs D&C [1 mark]
• Sentence 2: Define complete abortion — all products expelled, bleeding subsides, closed os, no surgery needed [1 mark]

Scoring Breakdown

Common Mark Deductions

• Confusing the cervical os status — stating the os is closed in incomplete abortion
• Not mentioning the management implication (D&C for incomplete; none for complete) — examiners reward clinical application
• Using the terms interchangeably without a clear contrast

Key Phrases To Include

• products of conception
• retained
• cervical os open
• dilation and curettage
• all products expelled
• bleeding subsides
• cervical os closed

Marks

3

Topic

Ectopic Pregnancy

Difficulty

hard

Template Id

T8

Examiner Tip

Three-mark questions test three distinct competencies. Organize your answer clearly into three parts. The examiner is looking for: diagnosis, pathophysiology rationale, and clinical action — one mark each.

Model Answer

The condition is a ruptured ectopic pregnancy. Significance of shoulder pain (Kehr sign): The blood from the ruptured fallopian tube pools under the diaphragm and irritates the phrenic nerve, causing referred pain to the tip of the shoulder. This is a clinical indicator of intraperitoneal hemorrhage and signals a surgical emergency. Priority nursing action: The priority is to treat impending hypovolemic shock — immediately establish two large-bore IV lines, administer isotonic IV fluids (0.9% NaCl or Lactated Ringer's) and oxygen via face mask, monitor vital signs continuously, and prepare the client urgently for emergency surgical intervention (salpingostomy or salpingectomy) as ordered.

Question Type

short_answer

Answer Structure

• Part 1: Correctly identify the condition — ruptured ectopic pregnancy [1 mark]
• Part 2: Explain Kehr sign with the pathophysiologic mechanism (diaphragmatic irritation by intraperitoneal blood → phrenic nerve → shoulder pain) [1 mark]
• Part 3: State the priority nursing action with clinical rationale — IV access, fluids, oxygen, prep for surgery [1 mark]

Scoring Breakdown

Common Mark Deductions

• Identifying the condition as 'threatened abortion' — ignoring the shock signs and shoulder pain
• Explaining shoulder pain as 'muscle strain' without the phrenic nerve mechanism
• Listing 'monitor vital signs' as the sole priority without IV access and surgical preparation
• Omitting oxygen administration

Key Phrases To Include

• ruptured ectopic pregnancy
• Kehr sign
• intraperitoneal hemorrhage
• diaphragmatic irritation
• phrenic nerve
• referred shoulder tip pain
• hypovolemic shock
• large-bore IV access
• isotonic IV fluids
• salpingostomy or salpingectomy
• surgical emergency

Marks

3

Topic

Hydatidiform Mole

Difficulty

hard

Template Id

T9

Examiner Tip

The 'avoid pregnancy for 1 year' instruction is the most commonly tested NLE point for molar pregnancy — but you MUST include the reason. Without the reason, you earn partial credit at best.

Model Answer

After suction curettage to evacuate a hydatidiform mole, post-evacuation management focuses on monitoring for malignant transformation into choriocarcinoma. 1. Serial serum beta-hCG monitoring is performed every 1–2 weeks until levels normalize, then monthly for 6–12 months. A rising or plateauing hCG after evacuation indicates possible malignant change requiring chemotherapy (methotrexate). 2. Chest X-ray and pelvic ultrasound are done periodically to detect metastatic spread. 3. The critical patient teaching: the client must avoid pregnancy for at least one year after the molar evacuation. A new pregnancy would cause a physiologic rise in hCG, making it impossible to distinguish from a rising hCG caused by choriocarcinoma. The nurse must ensure the client uses reliable contraception (oral contraceptives are preferred; IUDs are avoided initially).

Question Type

short_answer

Answer Structure

• Part 1: Serial beta-hCG monitoring — frequency, purpose (detect choriocarcinoma), and action if rising (chemotherapy) [1 mark]
• Part 2: Other surveillance measures (chest X-ray, ultrasound) [half mark]
• Part 3: Key patient teaching — avoid pregnancy for 1 year with rationale (masks rising hCG from malignancy) [1.5 marks — highest yield]

Scoring Breakdown

Common Mark Deductions

• Stating 'avoid pregnancy for 6 months' — the correct period is at least 1 year
• Not explaining WHY pregnancy must be avoided (the hCG masking rationale is the key teaching point)
• Failing to mention serial beta-hCG monitoring as the cornerstone of follow-up
• Recommending IUD as the preferred contraception — IUDs are generally avoided until hCG normalizes

Key Phrases To Include

• serial beta-hCG monitoring
• choriocarcinoma
• avoid pregnancy for at least one year
• rising hCG
• methotrexate
• masks malignant change
• reliable contraception
• suction curettage

Marks

3

Topic

Missed Abortion and DIC

Difficulty

hard

Template Id

T10

Examiner Tip

DIC is the 'hidden danger' in missed abortion because there may be no visible bleeding for weeks. Examiners test whether you can anticipate it proactively. Show you know the timeline: 4–6 weeks of retention = DIC risk.

Model Answer

Missed abortion is the death of the fetus in utero with retention of the products of conception; the client initially has no bleeding but the uterus stops growing and fetal heart tones are absent. Nursing management: 1. Emotional support is the immediate priority — acknowledge the grief, allow the parents to ask questions, avoid minimizing the loss, and refer to chaplaincy or counseling services as appropriate. 2. Prepare the client for uterine evacuation (suction D&C or induction of labor depending on gestational age) to remove the retained products. 3. Save all passed tissue for laboratory examination. Major complication to anticipate: Disseminated intravascular coagulation (DIC) — if retained products remain beyond 4–6 weeks, thromboplastin from the degenerating placental tissue enters the maternal circulation and triggers the DIC cascade. Monitor coagulation studies (platelet count, fibrinogen, PT/aPTT, D-dimer), watch for oozing from IV sites, petechiae, and hematuria, and prepare blood products (fresh frozen plasma, cryoprecipitate, platelets) for administration as ordered.

Question Type

short_answer

Answer Structure

• Part 1: Brief definition of missed abortion [half mark]
• Part 2: Two to three nursing management actions — emotional support, prep for evacuation, save tissue [1 mark]
• Part 3: Name DIC as the major complication with the pathophysiologic mechanism and monitoring parameters [1.5 marks]

Scoring Breakdown

Common Mark Deductions

• Not identifying DIC as the complication — writing 'hemorrhage' alone is incomplete
• Failing to explain the DIC mechanism (retained products + thromboplastin)
• Omitting emotional support — grief care is a nursing priority and examiners deduct marks if it is absent
• Listing coagulation tests without explaining what abnormal results indicate

Key Phrases To Include

• missed abortion
• retained products of conception
• no fetal heart tones
• suction D&C
• disseminated intravascular coagulation
• thromboplastin
• 4 to 6 weeks
• fibrinogen
• PT/aPTT
• D-dimer
• emotional support
• grief care

Marks

5

Topic

Placenta Previa vs. Abruptio Placentae

Difficulty

hard

Template Id

T11

Examiner Tip

For a 5-mark comparison question, use a table format OR clearly labeled subheadings — this tells the examiner at a glance that your answer is organized. Each heading should earn approximately one mark. End with a nursing diagnosis to show synthesis thinking.

Model Answer

PLACENTA PREVIA vs. ABRUPTIO PLACENTAE I. TYPE OF PAIN Placenta Previa: Painless — there is no uterine contracting or tearing; the bleeding occurs as the lower uterine segment is formed and the placental edge separates passively. Abruptio Placentae: Painful — sudden, severe abdominal pain that may be constant or cramping, caused by retroplacental hemorrhage and uterine muscle distension. II. CHARACTER AND APPEARANCE OF BLEEDING Placenta Previa: Bright-red, frank vaginal bleeding — blood escapes freely because there is no clot retention; bleeding may be intermittent and recurrent. Abruptio Placentae: Dark-red vaginal bleeding — old retroplacental blood; bleeding may be concealed behind the placenta, so visible blood loss underestimates true hemorrhage. External blood loss does not reflect total maternal blood loss. III. UTERINE FINDINGS Placenta Previa: Uterus is soft, relaxed, and non-tender with normal tone; malpresentation (breech or transverse lie) is common because the placenta blocks engagement of the presenting part. Abruptio Placentae: Uterus is rigid, board-like (wooden), hypertonic, and exquisitely tender to palpation — caused by blood infiltrating the myometrium (Couvelaire uterus in severe cases). Uterus may be increasing in fundal height, suggesting concealed bleeding. IV. PRIORITY NURSING ACTION Placenta Previa: NEVER perform a vaginal or rectal examination. Maintain complete bed rest, initiate continuous electronic fetal monitoring, establish large-bore IV access with blood typed and crossmatched, and confirm placental location by transabdominal ultrasound. Administer betamethasone 12 mg IM every 24 hours for 2 doses if delivery is anticipated before 34 weeks to promote fetal lung maturity. Prepare for cesarean section for complete (total) previa. Abruptio Placentae: This is an obstetric emergency. Position client in left lateral tilt to improve uteroplacental perfusion, administer high-flow oxygen via non-rebreather mask, establish two large-bore IV lines for rapid fluid and blood replacement, monitor vital signs and urine output (target >30 mL/hr) every 15 minutes, perform continuous electronic fetal monitoring, measure fundal height serially for concealed bleeding, and obtain coagulation studies (platelets, fibrinogen, PT/aPTT, D-dimer) to detect DIC. Prepare for emergency cesarean delivery if there is significant abruption or fetal compromise. Priority Nursing Diagnosis (Maslow-Based): For both conditions, the highest-priority NANDA diagnosis is: Deficient Fluid Volume related to active maternal hemorrhage as evidenced by tachycardia, hypotension, and heavy vaginal bleeding — this addresses Maslow's physiologic survival need and takes precedence over all other diagnoses.

Question Type

long_answer

Answer Structure

• Introduction/Organization: State you will compare the two conditions under four headings [sets up full-mark answer]
• Section I — Pain: Painless (previa) vs. Painful/Severe (abruption) with mechanism [1 mark]
• Section II — Bleeding Character: Bright-red/frank (previa) vs. Dark-red/concealed (abruption) [1 mark]
• Section III — Uterine Findings: Soft/non-tender/malpresentation (previa) vs. Board-like/hypertonic/tender/expanding fundus (abruption) [1 mark]
• Section IV — Priority Nursing Actions: No vaginal exam + bedrest + USS + betamethasone + CS prep for previa; VS + O2 + IV access + lateral tilt + DIC monitoring + emergency CS for abruption [1.5 marks]
• Nursing Diagnosis: NANDA-format diagnosis with Maslow rationale [0.5 mark]

Scoring Breakdown

Common Mark Deductions

• Not using a structured comparative format — writing in running prose without headings loses organization marks
• Omitting the 'no vaginal exam' rule for previa — this is a patient safety point that examiners specifically look for
• Failing to mention concealed hemorrhage in abruption — this is the key clinical danger
• Not including any nursing diagnosis or Maslow-based prioritization in a long-answer question
• Mixing up the uterine findings (rigid uterus for previa, soft for abruption) — a critical factual error

Key Phrases To Include

• painless bright-red bleeding
• painful dark-red bleeding
• rigid board-like uterus
• malpresentation
• concealed hemorrhage
• no vaginal examination
• transabdominal ultrasound
• betamethasone 12 mg IM
• fetal lung maturity
• cesarean section
• left lateral tilt
• DIC
• fundal height measurement
• Deficient Fluid Volume
• continuous electronic fetal monitoring

Marks

5

Topic

Ectopic Pregnancy — Medical Management

Difficulty

hard

Template Id

T12

Examiner Tip

For 5-mark case study questions, always use organized section headings. Examiners award marks per competency domain — you should mentally divide the 5 marks into 3 sections and ensure each section is substantive. Incomplete answers in any one section cost you marks even if the others are perfect.

Model Answer

MEDICAL MANAGEMENT — METHOTREXATE THERAPY Because the ectopic pregnancy is small (2.5 cm) and the client is hemodynamically stable with no rupture, methotrexate is the drug of choice for medical (non-surgical) management. Methotrexate is a folic acid antagonist that inhibits dihydrofolate reductase, disrupting DNA synthesis and halting trophoblastic cell proliferation, thereby dissolving the ectopic tissue. Administration: Single-dose protocol — methotrexate 50 mg/m² body surface area given intramuscularly (IM). Serial serum beta-hCG is drawn on days 4 and 7 post-injection; a >15% decline in hCG from day 4 to day 7 indicates successful treatment. If hCG does not decline adequately, a second dose may be given. NURSING RESPONSIBILITIES DURING TREATMENT 1. Baseline assessments before administration: Verify CBC, liver function tests (LFTs), renal function (creatinine/BUN), and chest X-ray — methotrexate is hepatotoxic, nephrotoxic, and myelosuppressive; abnormal baselines are contraindications. 2. Administer methotrexate IM as ordered, using correct aseptic technique. 3. Monitor for adverse effects: mucositis (oral ulcers), nausea/vomiting, abdominal pain (transient pain increase in days 3–7 is expected), bone marrow suppression. 4. Monitor serial beta-hCG levels and report failure to decline. 5. Teach the client to report severe or worsening abdominal pain immediately — this could indicate tubal rupture, which requires emergency surgery. 6. Administer Rho(D) immune globulin 50 mcg IM (microdose) if the client is Rh-negative and unsensitized, since fetal cells may have entered the maternal circulation. PATIENT EDUCATION 1. Avoid folic acid supplements during and for at least 1 week after methotrexate — folic acid counteracts the drug's mechanism and reduces its efficacy. 2. Avoid alcohol — increases the risk of hepatotoxicity. 3. Avoid prolonged sun exposure — methotrexate increases photosensitivity. 4. Avoid NSAIDs and aspirin — they increase methotrexate toxicity. 5. Abstain from sexual intercourse until hCG levels reach zero. 6. Use reliable contraception for at least 3 months after treatment before attempting pregnancy. 7. Report immediately: severe abdominal pain, shoulder pain, dizziness, or fainting — these indicate possible rupture requiring emergency intervention. 8. Attend all scheduled follow-up appointments for serial beta-hCG monitoring until hCG is undetectable.

Question Type

case_study

Answer Structure

• Section 1 — Medical Management: Name methotrexate, classify it, state mechanism (folic acid antagonist), dose protocol, and hCG monitoring criteria [1.5 marks]
• Section 2 — Nursing Responsibilities: Baseline labs before administration, correct IM administration, monitoring for adverse effects, serial hCG tracking, RhoGAM if Rh-negative [2 marks]
• Section 3 — Patient Education: Avoid folic acid, alcohol, sun, NSAIDs; report severe pain (rupture); contraception for 3 months; follow-up for serial hCG [1.5 marks]

Scoring Breakdown

Common Mark Deductions

• Not including baseline lab requirements before methotrexate — this is a safety step that examiners specifically test
• Stating '300 mcg RhoGAM' instead of '50 mcg microdose' for a first-trimester event — dose error
• Omitting the instruction to avoid folic acid — the most critical and commonly tested patient teaching point
• Not specifying the hCG monitoring criteria for treatment success (>15% decline from day 4 to day 7)
• Recommending methotrexate for a ruptured ectopic — this is a critical safety error; methotrexate is only for unruptured, stable cases

Key Phrases To Include

• methotrexate
• folic acid antagonist
• 50 mg per m2 body surface area
• intramuscularly
• serial beta-hCG
• 15% decline day 4 to day 7
• CBC and LFTs baseline
• hepatotoxicity
• avoid folic acid
• avoid alcohol
• sun exposure
• Rho(D) immune globulin 50 mcg microdose
• report severe abdominal pain
• contraception for 3 months

Marks

1

Topic

Hypovolemic Shock Recognition

Difficulty

easy

Template Id

T13

Examiner Tip

This question tests whether you know that hypotension appears LATE in shock. Many candidates lose this mark by writing 'blood pressure drops' as the first sign. Always lead with tachycardia.

Model Answer

The earliest sign of hypovolemic shock is tachycardia (increased heart rate), which represents the body's compensatory response to maintain cardiac output as intravascular volume falls — it appears before hypotension, which is a late and ominous sign.

Question Type

very_short_answer

Answer Structure

• Line 1: Name tachycardia as the earliest sign and state that hypotension is a LATE sign [1 mark]

Scoring Breakdown

Common Mark Deductions

• Stating 'hypotension' as the earliest sign — hypotension is a LATE, decompensated sign
• Writing 'pallor' or 'cool clammy skin' without naming tachycardia first
• Not distinguishing compensated from decompensated shock

Key Phrases To Include

• tachycardia
• earliest sign
• compensatory response
• hypotension is a late sign
• intravascular volume

Marks

2

Topic

Placenta Previa — Safety

Difficulty

medium

Template Id

T14

Examiner Tip

The key word is 'mechanism' — do not just say it is dangerous. Explain WHY: placenta is in the os, fingers disrupt the vessels, hemorrhage follows. The ultrasound alternative shows you know the clinical solution.

Model Answer

A vaginal examination is strictly contraindicated in suspected placenta previa because the placenta is implanted in the lower uterine segment and may partially or completely cover the internal cervical os. Digital examination of the cervix can mechanically disrupt the placental tissue, severing the large sinuses and maternal blood vessels within the placenta. This can trigger sudden, massive, and uncontrollable hemorrhage that is life-threatening to both the mother and the fetus before any intervention can be initiated. Instead, placental location is confirmed by transabdominal ultrasound, which is safe and definitive.

Question Type

short_answer

Answer Structure

• Sentence 1–2: Explain the anatomical reason — placenta over the os; digital exam disrupts placental tissue and blood vessels [1 mark]
• Sentence 3: State the consequence — sudden, massive uncontrollable hemorrhage [0.5 mark]
• Sentence 4: State the safe alternative — transabdominal ultrasound [0.5 mark]

Scoring Breakdown

Common Mark Deductions

• Writing 'it is dangerous' without explaining the anatomical mechanism
• Not mentioning the safe alternative (ultrasound)
• Confusing the rationale — some students incorrectly state it causes infection

Key Phrases To Include

• internal cervical os
• lower uterine segment
• digital examination disrupts placental tissue
• massive hemorrhage
• transabdominal ultrasound
• safe alternative
• life-threatening

Marks

5

Topic

Abruptio Placentae — Emergency Nursing Care and DIC

Difficulty

hard

Template Id

T15

Examiner Tip

For 5-mark long-answer questions in NCM (Nursing Care Management), the examiner is evaluating your use of the full nursing process. Structure your answer as Assessment → Diagnosis → Intervention (with rationale) → Evaluation. Reference Philippine law (RA 9173) where appropriate — it shows professional awareness and earns bonus recognition.

Model Answer

NURSING ASSESSMENT Subjective: Client reports sudden, severe abdominal pain; possible history of hypertension, cocaine use, or recent trauma (major risk factors). Objective findings to assess: - Vital signs: tachycardia, hypotension (late sign), tachypnea, fever if sepsis coexists - Abdomen: rigid, board-like, exquisitely tender uterus; increased fundal height suggesting concealed bleeding (measure and record fundal height every 30 minutes) - Vaginal bleeding: dark-red; note amount (count and weigh pads — 1 g = 1 mL) — remember that visible blood loss may underestimate true hemorrhage in concealed abruption - Fetal status: continuous electronic fetal monitoring for late decelerations, loss of variability, prolonged decelerations indicating fetal distress - Signs of DIC: petechiae, ecchymosis, bleeding from IV sites, hematuria, gum oozing - Urine output: insert Foley catheter; target output >30 mL/hr - Laboratory: CBC, platelet count, fibrinogen, PT/aPTT, D-dimer, serum creatinine, type and crossmatch FOUR PRIORITY NURSING INTERVENTIONS 1. Optimize circulation and oxygenation (Maslow Physiologic Priority): Position client in left lateral tilt to relieve aortocaval compression and improve uteroplacental perfusion. Administer high-flow oxygen at 8–10 L/min via non-rebreather mask to maintain maternal SpO₂ above 95% and improve fetal oxygenation. Establish two large-bore IV lines (16–18 gauge); administer ordered isotonic IV fluids (0.9% NaCl or Lactated Ringer's) rapidly; prepare packed red blood cells and other blood products for transfusion. Nursing Diagnosis: Deficient Fluid Volume related to active uterine hemorrhage as evidenced by tachycardia, hypotension, and rigid tender uterus. 2. Continuous fetal monitoring: Apply external electronic fetal monitor. Assess fetal heart rate continuously for non-reassuring patterns (late decelerations, prolonged decelerations, loss of variability, sinusoidal pattern). Report any deterioration immediately. Document findings per Philippine DOH/hospital protocols. Prepare for emergency cesarean delivery if fetal compromise is detected. Nursing Diagnosis: Risk for Impaired Fetal Gas Exchange related to uteroplacental insufficiency secondary to placental separation. 3. Monitor for and prevent DIC progression: Obtain and monitor coagulation profile every 4 hours or as ordered: platelet count, fibrinogen (<150 mg/dL is abnormal), PT/aPTT (prolonged = coagulopathy), and D-dimer (elevated = fibrinolysis). Assess all body surfaces for bleeding signs (IV sites, oral mucosa, skin, urine). Administer blood products as ordered: fresh frozen plasma (FFP) for clotting factors, cryoprecipitate for fibrinogen, and platelet concentrates for thrombocytopenia. The definitive treatment for DIC is delivery — assist with preparations. Nursing Diagnosis: Risk for Ineffective Tissue Perfusion related to consumptive coagulopathy. 4. Emotional support and preparation for delivery: Acknowledge the client's and family's fear and anxiety; provide clear, honest, calm explanations of all procedures. Ensure informed consent is obtained per RA 9173 standards (the nurse is responsible for ensuring the client understands). Prepare the operating room team for emergency cesarean section as ordered. Involve the husband/support person within the limits of facility policy and the client's consent. Nursing Diagnosis: Anxiety related to perceived threat to maternal and fetal wellbeing. EVALUATION CRITERIA: Mother: Vital signs stabilizing, urine output >30 mL/hr, no new bleeding, coagulation values trending toward normal. Fetus: Fetal heart rate with reassuring pattern, delivery of viable infant.

Question Type

long_answer

Answer Structure

• Assessment Section: Vital signs, uterine assessment, fundal height, fetal monitoring, DIC signs, lab work — structured and comprehensive [1 mark]
• Intervention 1: Left lateral tilt + oxygen + IV access + fluid/blood replacement + NANDA diagnosis [1 mark]
• Intervention 2: Continuous EFM + reporting criteria + emergency CS readiness + NANDA diagnosis [1 mark]
• Intervention 3: DIC monitoring (specific labs + values) + blood products + delivery as definitive treatment + NANDA diagnosis [1 mark]
• Intervention 4: Emotional support + RA 9173 informed consent + delivery prep + NANDA diagnosis + evaluation criteria [1 mark]

Scoring Breakdown

Common Mark Deductions

• Providing only a list of interventions without NANDA nursing diagnoses — long-answer questions at BSN/NLE level require nursing process application
• Not specifying lab values for DIC (e.g., not knowing fibrinogen <150 mg/dL is the cutoff)
• Omitting the reference to RA 9173 and the nurse's informed consent responsibilities — a Philippine-specific professional standard
• Failing to mention that delivery is the definitive treatment for DIC in obstetric hemorrhage
• Not including evaluation criteria — a complete nursing process answer requires an evaluation component

Key Phrases To Include

• left lateral tilt
• large-bore IV access
• high-flow oxygen non-rebreather mask
• isotonic IV fluids
• count and weigh pads
• fundal height measurement
• continuous electronic fetal monitoring
• late decelerations
• DIC
• fibrinogen
• PT/aPTT
• D-dimer
• fresh frozen plasma
• cryoprecipitate
• Deficient Fluid Volume
• RA 9173
• informed consent
• urine output greater than 30 mL/hr
• emergency cesarean section