4th year B.Sc. COMMUNITY HEALTH NURSING - II Summer

Fourth Basic B.Sc. (Nursing) Examination, Summer - 2023 (Phase-III)

COMMUNITY HEALTH NURSING (II)

(w.e.f. A.Y. 2018-2019 & 2019-2020 Admitted Batch)

Duration: 3 Hours

Max.Marks:75

Instructions:

1) Use black ball point pen only.

2) Do not write anything on the blank portion of the question paper. If written anything, such type of act will be considered as an attempt to resort to unfair means.

3) All questions are compulsory.

4) The number to the right indicates full marks.

5) Draw diagrams wherever necessary.

6) Distribution of syllabus in Question Paper is only meant to cover entire syllabus within the stipulated frame. The question paper pattern is a mere guideline. Questions can be asked from any paper's syllabus into any question paper. Students cannot claim that the question is out of syllabus. As it is only for the placement sake, the distribution has been done.

7) Use a common answer book for all sections.

Section - A

I. Short answer question (Solve any five out of six)

[5x5=25]

a) Write the effects of ovarian tumor on pregnancy and management of ovarian tumor during pregnancy.

b) Explain cardiovascular changes during pregnancy.

c) Amniotic fluid embolism.

d) Care of Preterm Baby.

e) Perineal Tear.

f) Injection Methargin.

a) Effects of ovarian tumor on pregnancy and management

Effects:

May cause abortion or premature labor.
Increased risk of malpresentation (e.g., breech, transverse).
May lead to obstructed labor if tumor lies in pelvis.
Risk of torsion, rupture, or hemorrhage during pregnancy.
Sometimes associated with infertility or delayed conception.

Management:

Careful antenatal monitoring with USG.
If asymptomatic and small → observe.
If large (>6 cm) or suspicious → surgical removal (preferably in 2nd trimester).
Emergency laparotomy if torsion/rupture.
During labor → C-section if tumor obstructs birth canal.

b) Cardiovascular changes during pregnancy

Blood volume ↑ by 30–40% (physiological hemodilution).
Plasma volume increases more than RBC mass → physiological anemia.
Heart rate ↑ by 10–15 bpm.
Cardiac output ↑ 30–40%.
Blood pressure: slight fall in 2nd trimester, returns to normal near term.
Peripheral resistance ↓ due to progesterone.
Venous pressure ↑ in lower limbs → edema, varicose veins, hemorrhoids.

c) Amniotic fluid embolism

Rare but catastrophic obstetric emergency.
Causes/Pathogenesis:
Entry of amniotic fluid into maternal circulation → pulmonary artery obstruction + anaphylactoid reaction.

Clinical features:

Sudden collapse, dyspnea, cyanosis.
Hypotension, shock.
Severe respiratory distress.
Convulsions, coma.
DIC (disseminated intravascular coagulation) with bleeding.

Management:

Immediate resuscitation – oxygen, intubation, CPR.
IV fluids + vasopressors.
Correction of coagulopathy (blood, plasma, fibrinogen).
Termination of pregnancy if needed.
ICU care.

d) Care of Preterm Baby

Thermal regulation – incubator, kangaroo care.
Airway/Respiration – oxygen, CPAP/ventilator if distress.
Feeding – small frequent feeds, NG tube if weak suck, expressed breast milk preferred.
Infection prevention – aseptic handling, limited visitors.
Skin care – gentle handling, prevent injury.
Monitoring – temperature, weight gain, apnea, jaundice.
Parental support and counseling.

e) Perineal Tear

Definition: Laceration of perineal tissue during childbirth.

Types (Degrees):

1st degree – mucosa + skin.
2nd degree – involves perineal muscles.
3rd degree – extends to anal sphincter.
4th degree – extends to rectal mucosa.

Causes:

Rigid perineum, large baby, instrumental delivery, precipitate labor.

Management:

Immediate suturing under aseptic condition.
Pain relief, antibiotics, stool softeners.
Perineal care, sitz bath.
Prevention → episiotomy in selected cases.

f) Injection Methargin (Methylergometrine)

Drug: Methylergometrine maleate (Ergot derivative).

Uses:

Prevention and treatment of postpartum hemorrhage (PPH).
Control of bleeding after abortion.

Dose:

0.2 mg IM (may repeat every 2–4 hrs if needed).
Can also be given IV slowly (in emergency).

Action:

Powerful uterotonic – causes sustained uterine contraction.

Side effects/Contraindications:

Hypertension, nausea, vomiting, headache.
Contraindicated in preeclampsia, hypertension, heart disease.

II. Long Answer Questions (any one out of two)

[1x15=15]

a) Define anemia in pregnancy. Explain the classification of anemia and its causes. Describe the management of anemia in pregnancy. [3 + 7 + 5]

b) Mrs. Savita admitted to postnatal ward, one hour after delivery.

i) Define period of puerperium. [2]

ii) Write immediate assessment to be done for Mrs Savita. [4]

iii) Postnatal care and advices that would give to Mrs. Savita. [4]

iv) Write Nursing care plan for five priority diagnosis for Mrs.Savita. [5]

Perfect 👍. I’ll prepare these in exam-ready, point-wise notes with marks distribution exactly as per your question.

a) Anemia in Pregnancy

Definition (3 marks):

Anemia in pregnancy = Hb <11 g/dl in 1st & 3rd trimester or <10.5 g/dl in 2nd trimester (WHO).
In India (ICMR): Hb <10 g/dl is considered anemia in pregnancy.

Classification and Causes (7 marks):

According to Severity (WHO):
- Mild → Hb 10–10.9 g/dl
- Moderate → Hb 7–9.9 g/dl
- Severe → Hb <7 g/dl
- Very severe → Hb <4 g/dl
According to Etiology:
- Nutritional Deficiency
  - Iron deficiency (most common)
  - Folic acid deficiency
  - Vitamin B12 deficiency
- Hemorrhagic – acute or chronic blood loss.
- Hemolytic – sickle cell anemia, thalassemia, G6PD deficiency.
- Aplastic anemia – bone marrow failure.
- Anemia of chronic disease – infections, renal disease.
Causes in Pregnancy:
- Inadequate dietary intake (iron, folate, B12).
- Increased demand in pregnancy.
- Poor absorption (hookworm, malabsorption).
- Repeated pregnancies with short interval.
- Chronic blood loss (menstrual, parasitic).
- Associated systemic illness.

Management (5 marks):

Prophylaxis:
- Iron + folic acid tablets (100–200 mg elemental iron + 0.5 mg folic acid daily).
- Dietary advice – green leafy vegetables, jaggery, liver, pulses, eggs, vitamin C for absorption.
- Deworming (Albendazole in 2nd trimester).
Treatment (Depends on Severity):
- Mild–Moderate: Oral iron therapy.
- Severe: Parenteral iron (iron sucrose, ferric carboxymaltose).
- Very severe / late pregnancy: Blood transfusion.
Specific Management:
- Folic acid, Vitamin B12 if deficient.
- Treat underlying cause (malaria, hookworm).
Antenatal Care:
- Frequent checkups, Hb monitoring.
- Anticipate complications (PPH, shock).
- Hospital delivery for moderate–severe anemia.

b) Case of Mrs. Savita (Postnatal) – 15 marks

i) Define period of puerperium (2 marks):

Puerperium is the period following childbirth during which the mother’s body, especially reproductive organs, return to the pre-pregnant state.
Duration = about 6 weeks (42 days) after delivery.

ii) Immediate assessment for Mrs. Savita (4 marks):

General condition: Vital signs – pulse, BP, temperature, respiration.
Uterus: Fundal height, tone, contraction, position.
Lochia: Color, amount, odor.
Perineum: Episiotomy/tear status, swelling, hematoma.
Bladder & bowel: Urination, distension.
Breast: Engorgement, nipple condition.
Psychological state: Anxiety, bonding with baby.

iii) Postnatal care & advices (4 marks):

Rest & hygiene: Adequate sleep, perineal care, clean clothing.
Breastfeeding: Initiate early, proper positioning, exclusive breastfeeding for 6 months.
Diet: High protein, iron, calcium, fluids.
Exercises: Pelvic floor exercise after initial rest.
Family planning: Advice on contraception.
Danger signs: Fever, heavy bleeding, pain, foul discharge → report immediately.

iv) Nursing Care Plan (5 marks)
Five Priority Nursing Diagnoses for Mrs. Savita:

Risk for hemorrhage related to uterine atony.
- Goal: Prevent excessive bleeding.
- Intervention: Monitor lochia, massage uterus, administer oxytocics.
Acute pain related to perineal tear/episiotomy.
- Goal: Pain relief.
- Intervention: Analgesics, sitz bath, comfortable position.
Risk for infection related to episiotomy wound/lochia.
- Goal: Prevent infection.
- Intervention: Perineal hygiene, handwashing, sterile dressing.
Imbalanced nutrition: less than body requirement related to increased demand.
- Goal: Adequate nutrition.
- Intervention: Provide high-protein, iron-rich diet, supplements.
Knowledge deficit related to newborn care and self-care.
- Goal: Mother gains knowledge.
- Intervention: Educate on breastfeeding, hygiene, family planning.

Section - B

III. Short Answer Questions (any four out of five)

[4 x 5= 20]

a) Write etiology and diagnosis of foetal distress.

b) Rh-isoimmunization.

c) Antenatal advices.

d) Diet in pregnancy.

e) Minor aliments in pregnancy.

a) Etiology and diagnosis of Fetal Distress

Etiology (Causes):

Maternal factors: Anemia, preeclampsia, diabetes, fever, dehydration.
Placental factors: Placental insufficiency, abruption, placenta previa.
Umbilical cord factors: Cord prolapse, cord compression, true knot.
Fetal factors: IUGR, postmaturity, congenital anomalies.
Iatrogenic: Oxytocin overuse, anesthesia complications.

Diagnosis:

Clinical: Meconium-stained liquor, reduced fetal movements.
Fetal heart rate (FHR) monitoring:
- Tachycardia >160/min, bradycardia <110/min.
- Irregular FHR, late decelerations.
CTG (Cardiotocography): Non-reassuring/abnormal patterns.
Biophysical profile & Doppler study of umbilical flow.

b) Rh-isoimmunization

Definition: Condition where an Rh-negative mother carries an Rh-positive fetus, leading to maternal antibody formation against fetal RBCs.
Pathophysiology: Fetal RBCs enter maternal circulation → mother produces anti-D antibodies → cross placenta → hemolysis of fetal RBCs.
Effects: Hemolytic disease of newborn (HDN), hydrops fetalis, stillbirth.
Prevention:
- Administration of anti-D immunoglobulin (RhIg) within 72 hrs of delivery of Rh-positive baby.
- Also given after abortion, ectopic, amniocentesis, trauma.
Management:
- Monitor antibody titers.
- Serial USG and Doppler.
- Intrauterine transfusion if severe.
- Early delivery if fetal distress/hydrops.

c) Antenatal Advices

Diet: Balanced diet, iron & folic acid supplements, calcium, protein-rich foods.
Rest & exercise: Adequate rest, light exercise/walking, avoid heavy work.
Hygiene: Daily bath, dental care, clean clothes, handwashing.
Danger signs: Report bleeding, swelling, headache, blurred vision, pain abdomen, reduced fetal movement.
Immunization: 2 doses of Tetanus toxoid (or Tdap).
Regular antenatal check-ups: Every month till 28 weeks, every 2 weeks till 36 weeks, weekly till delivery.
Avoid: Smoking, alcohol, drugs, self-medication.
Preparation for delivery: Hospital delivery, financial/social arrangements, newborn care awareness.

d) Diet in Pregnancy

Caloric requirement: Extra 300 kcal/day.
Protein: +15–20 g/day (total 75–90 g/day) for fetal growth.
Iron: 1000 mg total needed in pregnancy → supplement with 100–200 mg/day.
Folic acid: 0.5 mg/day to prevent neural tube defects.
Calcium: 1200–1500 mg/day.
Vitamins: Vitamin A, D, C, B-complex, Iodine.
Fluids: At least 2–3 liters/day.
Dietary advice:
- Balanced diet with cereals, pulses, milk, fruits, vegetables, meat/eggs (if non-veg).
- Avoid junk food, excess caffeine, unpasteurized milk, raw meat/fish.

e) Minor Ailments in Pregnancy

Nausea & vomiting: Due to hormonal changes → small frequent meals, avoid oily/spicy food.
Heartburn/Acidity: Progesterone effect → eat small meals, avoid lying down immediately after food.
Constipation: Progesterone-induced → high-fiber diet, fluids, mild exercise.
Backache: Weight & posture → correct posture, abdominal support, avoid prolonged standing.
Leg cramps: Due to calcium deficiency → calf massage, calcium supplements.
Varicose veins & edema: Elevate legs, avoid standing long, support stockings.
Frequency of micturition: Due to pressure → reassure, maintain hydration.
Leucorrhea: Due to estrogen → maintain hygiene, cotton undergarments.

IV. Long Answer Questions (any one out of two)

[1x5=15]

a) Define oligohydramnios. Discuss the causes of oligohydraominos and effects on the fetus. Write the management of a client with oligohydraminos. [3 + 7 + 5]

b) i) List the types and indications of caesarean section. [4]

ii) Describe pre-operative and post-operative care of patient undergoing caesarean section. [7]

iii) Write the common complications of caesarean section and its Management. [4]

a) Oligohydramnios

Definition (3 marks):

Oligohydramnios = reduced amount of amniotic fluid.
Diagnosed when AFI < 5 cm or Single Deepest Pocket < 2 cm on ultrasound.
Normal amniotic fluid: 500–2000 ml at term.

Causes (7 marks):

Maternal causes:

Hypertension, preeclampsia.
Dehydration.
Drugs – ACE inhibitors, prostaglandin synthetase inhibitors.

Placental causes:

Placental insufficiency.
Post-term pregnancy (>42 weeks).

Fetal causes:

Renal agenesis (Potter’s syndrome).
Obstructive uropathy (PUJ obstruction, posterior urethral valves).
Intrauterine growth restriction (IUGR).
Rupture of membranes (PROM/PPROM).

Effects on Fetus:

Fetal hypoxia, growth restriction.
Pulmonary hypoplasia (due to less fluid).
Musculoskeletal deformities (clubfoot, contractures).
Increased risk of cord compression → fetal distress.
Increased perinatal morbidity & mortality.

Management (5 marks):

Antenatal:
- Identify and treat cause (e.g., control hypertension).
- Hydration therapy (oral or IV fluids).
- Amnioinfusion (saline via amniocentesis in selected cases).
- Regular ultrasound for AFI & fetal growth.
- NST/CTG for fetal well-being.
During labor:
- Continuous fetal heart monitoring.
- Amnioinfusion to reduce variable decelerations.
- Induction of labor or cesarean if fetal distress present.
Delivery planning: If term or severe compromise → early delivery.

b) Caesarean Section

i) Types and Indications (4 marks):
Types:

Lower Segment CS (LSCS) – common, transverse incision.
Classical CS – vertical incision on upper segment.
Other modifications – extraperitoneal CS, cesarean hysterectomy.

Indications:

Maternal indications: Cephalopelvic disproportion, obstructed labor, previous CS scar, eclampsia.
Fetal indications: Fetal distress, malpresentation (breech, transverse), multiple pregnancy.
Placental causes: Placenta previa, abruption.
Others: Failed induction, bad obstetric history.

ii) Pre-operative & Post-operative Care (7 marks):
Pre-operative care:

Explain procedure, consent.
Baseline vitals, blood grouping & cross match.
Pre-anesthetic check-up.
Shaving, catheterization, IV line.
Prophylactic antibiotics.
Antacid prophylaxis (ranitidine, metoclopramide).

Post-operative care:

Monitor vitals, uterine contraction, lochia.
Pain relief, IV fluids, maintain input-output chart.
Early ambulation to prevent DVT.
Remove catheter after 12–24 hrs.
Wound care, dressing change.
Breastfeeding support.
Discharge advice: hygiene, diet, contraception, danger signs.

iii) Complications & Management (4 marks):
Immediate:

Hemorrhage → uterotonics, transfusion.
Shock → IV fluids, blood.
Anesthetic complications → supportive care.

Early:

Wound infection → antibiotics, dressing.
Puerperal sepsis → antibiotics, fluids.
DVT/PE → anticoagulants, mobilization.

Late:

Adhesions, incisional hernia.
Scar dehiscence/rupture in next pregnancy.
Placenta previa/accreta risk in future.

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