1. Puan A, para 2 dengan kelahiran forceps dan berpotensial mendapat pueperal sepsis.

a. Nyatakan kefahaman anda mengenai puerperal sepsis. 2 markah

b. Terangkan LIMA (5) keadaan yang boleh menyebabkan puerperal sepsis. 10 markah

c. Nyatakan TIGA (3) manifestasi klinikal puerperal sepsis. 3 markah

d. Terangkan LIMA (5) peranan Jururawat Bidan dalam mencegah puerperal sepsis. 10 markah

Model answer

1. a. State your understanding about puerperal sepsis (2 marks)

Puerperal sepsis is infection of the genital tract which occurs as a complication of delivery during
puerperium.

b. Explain FIVE (5) conditions that may lead to puerperal sepsis. (10 marks)
- Early rupture of membranes or chorioamnionitis
- Invasive procedures – bladder catherization / Vaginal examination
- Retained fragments of placenta and membranes
- Post partum haemorrhage
- Prolonged labour
- Poor healing of episiotomy wound / laceration at perineum
- Poor body resistant due to anaemia, malnutrition /
uncontrolled diabetes / medical diseases

(2 marks each for any of the four conditions with rationale)

c. State THREE (3) clinical manifestation of puerperal sepsis. (3 marks)

- Local infection – redness, swelling, pus formation, pain at

episiotomy wound or LSCS wound.
- Uterine infection – subinvolution, offensive lochia, tenderness and pelvic pain.
- Deviation of vital signs – tachycardia, tachypnoea.
- Signs of septicaemia – toxic appearance, delirium, pallor,
anorexia, vomiting

(Each fact =1 mark)

d. Explain FIVE (5) roles of a midwife in the prevention of puerperal sepsis (10 marks)
- Obseravation – temparature

- anticipate acute retention of urine or PPH – detect and treat

- Detect subinvolution, offensive lochia, any signs of infection and treat.

- Incidental or group health education to improve health status –

well balanced diet, personal hygiene, rest and sleep.

- Advice – seek medical advice if any deviation from normal physiology of puerperium.

- Perineal care – vulva swabbing, keep perineal dry, change pad PRN.
 1. Puan B, para 1 telah melahirkan bayinya 10 hari yang lalu. Anda merancang untuk melakukan Lawatan Rumah.

a) Nyatakan LIMA (5) objektif lawatan postnatal Puan B. (5 markah)

b) Terangkan aktiviti anda semasa lawatan postnatal kepada:

(i) Ibu (8 markah)
(ii) Bayi (6 markah)

Puan B berminat untuk mengamalkan family planning kaedah oral contraceptive pills
(OCP).

c) Nyatakan ENAM (6) kebaikan oral contraceptive pills (OCP) kepada Puan B. (6 markah)

Model answer

2. a. State five (5) objectives of postnatal visit to Madam B (5 marks)

i. Evaluate health status of mother and baby

ii. Early detection of health problem of mother and baby
iii. Refer when need arises
iv. Provide guidiance and advice to mother
v. Encourage mother to breastfeed exclusively
vi. Reinforce/advise birth spacing

b. Explain the activities during postnatal visit on (8 mark)

i. Mother

1. General condition of mother – physical & emotional status

2. Physical examination from head to toe – detect any deviation from normal.
3. Vital signs – Temperature / pulse / BP.
4. Uterus – involuted / sub involuted.
5. Perineum – intact / episiotomy / tear - detect any signs of infection.
6. Lochia – colour / amount / odour – detect any signs of infection.
7. Health education :
 Postnatal diet.
 Adequate rest and sleep.
 Postnatal exercise.
 Exclusive breast feeding.
 Care of newborn.
 Family spacing.
8. Follow-up care – postnatal clinic & family planning.

ii. Baby

1. General condition of the baby.

2. Pyhsical examination from head to toe – detect any deviation from normal.
3. Check umblical cord – drop / insitu – detect any signs of infection.
4. Infant weighing.
5. Elimination – PU & BO
6. Encourage breast feeding

c. State SIX (6) advantages of OCP. (6 marks)

- Safe (98%), easy to obtain

- Fertility return immediately after stop pill.
- Do not interfere with sexual intercourse
- Regular menses
- Prevent form PID
- Easy to use
 - Can stop if any side effect
- Cheap

1. Puan C, para 3 telah melahirkan anaknya di rumah 3 hari yang lalu. Beliau dimasukkan ke wad postnatal kerana
mengalami pendarahan per vagina.

a. Nyatakan TIGA (3) faktor pradispos pendarahan per vagina. 6 markah

Semasa asesmen ke atas Puan C, didapati beliau berada dalam keadaan renjatan.

b. Terangkan pengurusan segera ke atas Puan C. 12 markah

Puan C berminat untuk mengamalkan progesterone only pills (POP) sebagai kaedah menjarakkan kehamilan.

C. Terangkan bagaimana anda mengajar Puan C cara pengambilan POP 7 markah

a. State THREE (3) predisposing causes per vaginal bleeding. 6 marks

1. Retained product of conception – fragment of placental tissue/membrane
2. Sub involution of uterus due to:
 Large uterine blood clots
3. Acute retention of urine – distended bladder.
4. Genital tract infection due to PPROM/infected perineal wound
5. Bleeding disorder due to coagulation disorder.

During assessment Madam C, is found in the state of shock.

b. Explain immediate management for Madam C. 12 marks

1. Call for help / active red alert
2. Psychological support
- nursing caring attitude
- reassurance

3. Stop the bleeding

 Status uterus- for signs of subinvolution
 Expel the clots
 Rub up the fundus of the uterus to stimulate contractions
 injection syntometrine
 Status of bladder – distention – catheterize
- monitor urinary output.
 Check and repair if any tears immediately
 40 units pitocin in 1 pint Normal Saline
4. Resuscitate the mother
- airway –maintain airway if unconscious
- breathing – assist breathing by giving oxygen if
cyanosis, breathing is laboured , or dyspnoe
- circulation – set up 2 IV line with branula size
16 , transfuse IV normal saline fast.
5. Stabilise the mother
6. Investigate and treat the cause
7. Keep the patient warm and nil by mouth
8. Blood investigations
- Hb gm/dl, Bleeding profile
- GXM
9. Close monitoring of vital signs
10. Continue close monitoring in HDW/
 11. Documentation
 Report and record
C. Explain how you would teach Madam C in taking POP. 7 marks
1. Show mother how to take the first pill from the pack and follow the arrows on the pack
to take the rest of the 28 pills.
2. Take one pill each day until the pack is empty.
3. Take the pill at the same time each day.
4. Take the new pack on the next day after finish the first pack.
5. If vomit /diarrhoea or missed one pill more than 3 hours:
 take 1 pill immediately when she remember,
 continue to take next pill as usual.
 Avoid sexual intercouse / use barrier method for 2 days.
(No.1 – 4 one mark & no.5 –two marks)
Puan D 25 tahun gravida 2 para 1 layak untuk bersalin dirumah. Sebagai Jururawat bidan, anda merancang untuk
melakukan antenatal home visit.

a. Terangkan persediaan untuk antenatal home visit. 10 markah

b. Nyatakan bagaimana anda mengajar Puan D memanggil Jururawat bidan untuk 4 markah
bersalin di rumah.

Puan D selamat melahirkan bayi. Anda melakukan lawatan 6 jam selepas bersalin.

c. Nyatakan pemerhatian yang anda lakukan pada:

i. ibu
ii. bayi 6 markah
5 markah

Model answer

1. a. Explain the preparation for antenatal home visit. (10 marks)

o study antenatal card

o set the objectives
o booking transport
o prepare antenatal home visit bag
o make appoinment with mother
o enter particular in notis board

b. State how you would teach Madam D to call the nurse midwife for
home delivery. (4 marks)

Teach Madam D to tell her husband how to call midwife as follow :

i. Call midwife on call at the clinic / their house when she has labour pain.
ii. Bring the prenatal card.
iii. Show the prenatal card to the midwife on call.
iv. Give the identification card (IC) to the midwife.
c. State the observation to be done on:
i. mother
 general condition
 vital signs
 state of uterus - contration and retraction
 bladder empty
 vagina bleeding / lochia
 perineum

ii. baby
 general condition
 breathing
 colour
 observe umbilical cord-bleeding
 sucking reflex
 PU, BO
  keep warm

2. Puan E, 28 tahun para 3 telah dimasukkan ke wad pada hari ketiga puerperium kerana pueperal pyrexia.

a. Nyatakan EMPAT (4) penyebab puerperal pyrexia. 8 markah

b. Terangkan pengurusan untuk Puan E dengan puerperal pyrexia. 12 markah

Puan E berminat untuk menggunakan implan untuk perancang keluarga.

c. Terangkan pendidikan kesihatan selepas pemasangan implan kepada Puan E. 5 markah

1. Madam E, 28 years old para 3 admitted to the ward on the third day because of pueperal pyrexia.

a. State FOUR (4) causes of puerperal pyrexia arising from :

 Infection such as URTI, UTI, Mastitis, Breast abscess, dengue fever, malaria, deep vein
thrombosis during puerperium will give rise to pyrexia.
 Anaemia – low body resistance susceptible to infection.
8 marks
 Traumatic delivery – tissue damage – easy access for breeding to microrganism.
 Retained POC – sub involution, endometritis.

b. Explain management for Madam E with puerperal pyrexia. 12 marks

1. Psychological support
 Nursing care attitude
 Reassurance
2. Perform nursing intervention to reduce body temperature
 Cold compress/tepid sponging
 Antipyretic as prescribed
3. Collect data to find the cause of puerperal pyrexia.
3.1.Assessment
3.1.1. on interview
3.1.1.1. Antenatal history – any infection / obsterical condition / anaemia.
3.1.1.2. History of labour & delivery.
 Onset of labour – spontaneous/induced
 Ruptured of membrane > 12 hours
 1st, 2nd & 3rd stage – prolonged labour.
 Repeated VE & catheterization
 Type of delivery – SVD/assisted
 Any invasive procedure – MRP/exploration
 Any perineal trauma
3.1.2. Perform physical examination & observation to detect signs of infection.
3.1.2.1. Asses general condition
 Vital signs – temperature / pulse / BP
3.1.2.2. Physical examination from head to toe to detect
  Anaemia
 Breast complication – breast engorgement/breast abscess
 Genital tract infection – palpate :
o Uterus/abdomen – tenderness/pain
o Lochia – amount – scanty / profuse
o Colour – bright red / brownish / pus
o Smell – foul smelly.

 Check bladder for distension

 Micturation - dysuria
 Defaecation – constipation
 Check perineal wound.
3.1.3. Data from investigation to detect infection
 HVS for C & S if infection is suspected
 Ultrasound – uterine cavity – POC
4. Nursing management according to the underlying causes
 Breast engorgement – relieve engorgement & advice on proper technique of breast
feeding.
 UTI – reassurance – encourage oral fluid intake.
 Served medication as prescribed.
5. Adequate rest & sleep
6. Nutrition – well ballanced diet.
7. Personal hygiene
8. Continue breast feeding
9. Observation – report any deviation from normal.
10. Support group – encourage husband & family to visit.
11. Documentation.
12. Health education prior to discharge.
13. TCA .

Madam E is interested to use implanon for family planning.

c. Explain the health education after the insertion of implanon to Madam E. 5 marks
1. Keep arm dry - She should keep the insertion area dry for 4 days. She can take off the
elastic bandage or gauze after 2 days and the adhesive bandage after 5 days.

Expect soreness, bruising - After the anesthetic wears off, her

arm may be sore for a few days. She also may have swelling and
bruising at the insertion site. This is common and will go away
without treatment.

3. Give her the following information in writing on a reminder

Card :
- The type of implant she has
- Date of insertion
- Month and year when implants will need to be removed or
replaced
- Where to go if she has problems or questions with her
Implants
Give TCA
- TCA 1/52 to check the site of implant
- TCA prn if any abnormalities –redness, severe pain, pus, sees
the a rod coming out
- Routine visit - 1 per year
 2. Puan F, telah selamat melahirkan anak pertamanya. Anda perlu melakukan lawatan postnatal.

a. Nyatakan lima ( 5 ) objektif lawatan postnatal. 5 markah

b. Terangkan tanggungjawab anda sebelum lawatan postnatal. 8 markah

Puan F defisit pengetahuan mengenai pendaftaran anaknya.

c. Nyatakan maklumat yang anda berikan berkaitan pendaftaran kelahiran anaknya. 5 markah

Pada hari ke 20 postnatal, anda melakukan Lawatan Rumah pada Puan F.

d. Nyatakan pengurusan spesifik semasa lawatan tersebut. 7 markah

SKEMA JAWAPAN ( Soalan 2 )

a) Objectives of home nursing

1. To assess and evaluate general health of both mother and infant.
2. Detect early health problems of mothers and infants during the puerperium – PPH, puerperal sepsis, neonatal
jaundice and signs of infection.
3. Making the initial reference if there are any problem experienced by mother and child
4. Provide guidance and advice to the mother
5. Encorage mother to breastfeed exclusively
6. Provide health education related to birth spacing

b) Responsibility before home nursing

1. Identify the case
2. Inform mother
3. Set the objective
4. Preparation instrument
5. Preparation transport
6. Identify the location of the house
7. Documentation

c) Registration of the baby (5 marks)

1. Fill the registration form.
2. Documentation required :
 Notification form
 Antenatal card.
 Home based card - baby.
 Identification card / passport - father & mother.
 Marriage certification.
3. Register of birth within 14 days at the Jabatan Pendaftaran Negara
4. If registered after 14 days – will be compound RM5.
5. If more than 42 days – registered RM10 & compound RM50.

d) Specific management at 20th day at home nursing (8 marks)

1. Observed general condition,
2. Vital sign for mother
3. Examine the flow of breast milk and breast condition
4. Examine fundal height and the lochia
5. Ask any problem or complain from the mother, ADL-sleep, diet
6. General condition of the baby – vital sign, behavior and activity
7. Physical examination baby - including umbilical cord
8. Weighing the baby
9. Giving health education
10. Follow up to the clinic
 11. Documentation

1. Puan Mala primigravida, 34 minggu gestasi datang ke klinik antenatal untuk lawatan susulan. Pemeriksaan
abdomen jururawat mendapati saiz uterus lebih besar dari jangkamasa gestasi

a. Nyatakan DUA ( 2 ) keadaan saiz uterus lebih besar dari jangkamasa gestasi selain (2 markah )
polyhydramnios

Puan Mala dirujuk kepada doctor. Ujian ultrasonografi mengesahkan Puan Mala mengalami polyhydramnios.

a. Beri definisi polyhydramnios ( 2 markah )

c. Nyatakan pengurusan spesifik terhadap Puan Mala

sepanjang kehamilan sehingga labor bermula mengikut tajuk berikut :-
i. maternal monitoring
ii. Fetal monitoring ( 6 markah )
( 6 markah )

d. Senaraikan EMPAT ( 4 ) komplikasi yang mungkin berlaku semasa labor kepada Puan ( 4 markah )
Mala dan bayinya.

1. Puan Mala primigravida, 34 weeks gestation comes to antenatal clinic for follow up. Abdominal examination by
midwife found that the size of uterus is bigger than period of gestation.

a. State TWO ( 2 ) condition that size of uterus bigger than period of gestation other than ( 2 marks )
polyhydramnios.

Puan Mala is referred to the doctor. Ultrasound examination confirm Puan Mala is having polyhydramnios

b. Give the definition of polyhydramnios ( 2 marks )

c. State the specific management to Puan Mala during

the pregnancy until labor begins according to following
topics :-
i. maternal monitoring
ii. Fetal monitoring ( 6 marks )
( 6 marks )

d. List FOUR ( 4 ) complications that might occur to Puan Mala and her baby during labour. ( 4 marks )
SKEMA JAWAPAN : POLYHYDRAMNIOS

a. Nyatakan DUA ( 2 ) keadaan saiz uterus lebih besar dari jangkamasa gestasi selain (2 markah )
diatas
1. twin pregnancy
2. big baby

Puan Mala dirujuk kepada doktor. Ujian ultrasonografi mengesahkan Puan Mala mengalami polyhydramnios.

a. Beri definisi polyhydramnios ( 2 markah )

Cecair amniotik melebihi 1500 mls / 1.5 liter.
Fisiologikal / patologikal

c. Nyatakan pengurusan spesifik terhadap Puan Mala sepanjang kehamilan sehingga labor
bermula mengikut tajuk:-
(6 markah )
berikut :-
i. maternal monitoring
– keadaan am
– tanda vital – bp / pulse / pernafasan / suhu
– progress kehamilan – berat badan / edema / simtom
tekanan, ketinggian fundus.
– potensi PROM
xviii. – komplikasi – premature labour / cord prolapse.
- tindakan jika berlak
ii. Fetal monitoring
– FHR – Fetoskop
– Non stress CTG
xxiii. - FM
- refer for ultrasound
- tanda tanda fetal distress

d. Senaraikan EMPAT ( 4 ) komplikasi yang mungkin berlaku semasa labor kepada Puan
Mala dan bayinya.
( 4 markah )
Ibu :
- cord prolapse
- abruption placenta
2 markah
- PPH
Fetus
- spontaneous version
- fetal distress
2 markah
- IUD
 - Neonatal death

ABNORMAL LABOUR

1. Puan A telah bersalin di hospital. Beliau mengalami pendarahan yang banyak sebaik sahaja plasenta dikeluarkan.
a. Definisikan postpartum haemorrhage ( 2 markah)
Perdarahan dari trek genitalia sebanyak 500 mls dan lebih. Berlaku selepas kelahiran
bayi.
Primary PPH - dalam tempoh 24 jam
b. Nyatakan tiga (3) sebab kemungkinan postpartum haemorrhage ( 3 markah )
1. Atony uterus
 grandmultigravida - lax uterine muscles due to fibrosis
 after delivery of big baby, twins, polyhydramnios - overdistension.
 Prolonged labor, precipitate labor - uterine inertia/exhaustion.
 Abruption - couvaleire uterus
2. Retained partially separated placenta/ cotyledon and membranes.
3. Bleeding due to :-
 vaginal wall tear, cervical tear, bleeding from episiotomy wound.
 Rupture uterus
 Placental praevia - site of placenta at the lower segment.
 Placenta accrete.
Coagulation defect - abruption, ITP, DIVC.
c. (12 markah)
Nyatakan tindakan serta merta anda sementara menunggu ketibaan doktor.
1. Initiate RAT, dr, senior and experienced staff
2. Ressucitate
i. Do quick asseemen first
o general condition
o airway
o breathing
o circulation
ii. Position - supine with head down.
iii.Oxygen administration if necessary
iv. close monitoring of b/p, pulse rate - use dinamap.
v. NBM
3. Giving of oxytocic drug - I/M syntometrine - if not given yet /2nd.dose
4. If already given :-
i. check state of uterus
o well contracted and retracted
o hard and mobile
o fundal height 14 -15 cm.
ii. if soft and boggy - massage/rub up uterus - stimulate
contraction - expelled blood clots
iii. check bladder - if distended , catheterise
5. Intervension to find the cause/source of bleeding :-
i. Check for bad tears and bleeding from the vaginal
mucosa, cervix, clitoris and perineum. Extended
episiotomy wound
ii. examine placenta - check for the completeness of
placenta and membranes,
abnormalities - extra lobe & measurement of total
blood loss.
6. Setting of iv lines - volume expander/ maintainance for administration of drugs /
oxytocin / infusion.
7. Always keep mother warm.
8. Reassurance
Keadaan Puan A beransur pulih. Infusi intravena Syntocinon 40 unit dimasukkan kedalam larutan Hartman’s 500mls.
d.
Nyatakan kepentingan kegunaan Infusi intravena Syntocinon 40 unit ( 3 markah )
 Untuk menggalakkan kontraksi & retraksi uterus yang sempurna.
 Mengelakan pendarahan dari berlaku.
ABNORMAL PUERPERIUM

1. Puan Azah melahirkan bayi keempatnya dengan bantuan forceps. Beliau berada dalam hari keempat
puerperium. Semasa lawatan postnatal, anda dapati beliau mengalami demam 390 C

a. Nyatakan 4 ( EMPAT ) objektif lawatan postnatal ke rumah. ( 4 markah )

b. Senaraikan 4 ( EMPAT ) sebab kemungkinan puerperal pyrexia. ( 2 markah )

Setelah asesmen dilakukan, anda mengesyaki beliau mengalami puerperal sepsis.

c. Beri definisi puerperal sepsis. ( 2 markah )

d. Terangkan tindakan anda sebelum menemani Puan Azah ke hospital. ( 12 markah )

1. Puan Azah delivered her fourth baby by assisted forcep. She was at fourth day of puerperium. During postnatal
visit, you notice she having pyrexia at 390C.

a. State 4 ( FOUR ) objectives postnatal visit at home. ( 4 marks )

b. List 4 ( FOUR ) possilble causes of puerperal pyrexia. ( 2 marks )

After assessment has done, you suspected she has puerperal sepsis.

c. Give the definition of puerperal sepsis. ( 2 marks )

d. Explain the your action before accompany Puan Azah to the hospital. ( 12 marks )
SKEMA JAWAPAN

1. Puan Azah melahirkan bayi keempatnya dengan bantuan forceps. Beliau berada dalam hari keempat
puerperium. Semasa lawatan postnatal, anda dapati beliau mengalami demam 390 C

a. Nyatakan 4 ( EMPAT ) objektif lawatan postnatal ke rumah. ( 4 markah )

b. Senaraikan 4 ( EMPAT ) sebab kemungkinan puerperal pyrexia. ( 2 markah )

1) URTI
2) UTI
3) Breast engogerment
4) Puerperial sepsis
5) Deep vein thrombosis
6) Mastitis

Setelah asesmen dilakukan, anda mengesyaki beliau mengalami puerperal sepsis.

c. Beri definisi puerperal sepsis. ( 2 markah )

Adalah infeksi pada trek genitalia yang berlaku selepas kelahiran atau keguguran
semasa puerperium. Ianya dicirikan dengan kenaikan suhu badan 380C dan lebih
dengan 2 kali bacaan dalam tempoh 4 jam dalam masa 24 jam.

d. Terangkan tindakan anda sebelum menemani Puan Azah ke hospital. ( 12 markah )

1) Asesmen
 Lakukan pemerhatian kepada Puan Azah mengenai :
 Keadaan am – resah gelisah / dehidrasi & tidak terurus chills / rigor.
 Mengambil tanda vital – suhu badan – 380C, nadi – tachycardia &
pernafasan – takipnea.
2 markah
2) Temubual Puan Azah untuk kenalpasti punca puerperal sepsis berlaku : -
 Sejarah PROM, severe bleeding, prolonged labour 5 markah
 Sejarah kelahian – secra forsep, retained plasenta, MRP
 Retained POC – exploration done & frequent VE / catheterasation. ½ markah untuk
 Aduan keadaan lokia – warna, amaun & baunya. 1 jawapan diberi

 Perineum – episiotomi wound break down / laceration – tear vaginal wall,

cervix.
 Keadaan uterus – kontraak dengan baik / subinvolution.
 Alami sakit bahagian bawah abdomen.
 Ada dysuria – infeksi trek urinari.
 Bila mula demam & berapa lama.
 Nature – ada chill’s / rigor.
3) Pemeriksaan fizikal
 Lakukan pemeriksaan fizikal dari kepala ke kaki – kesan sebarang 2 markah
keadaan luarbiasa seperti breast engorgement / calf tenderness – punca
sepsis.
1 markah
4) Langkah menurunkan suhu
 Lakukan tepid sponging & berikan tab PCM 2 stat.
5) Dokumentasi
1 markah
 Catat semua maklumat secara terperinci dalam kad ibu dan surat rujukan
untuk ke hospital bagi pengurusan seterusnya.
6) Hantar ke hospital
 Hantar & iringi Puan Azah ke hospital. ½ markah
MATERNAL & CHILD HEALTH

1. Puan S telah ditempah unutk kelahiran dirumah.

a) Nyatakan EMPAT (4) kriteria obstetrik yang sesuai untuk bersalin di rumah. ( 8 markah )

Puan S mengalami ruptur membran secara spontan semasa usia kandungan 39 minggu, dan tali pusat
prolaps di luar vagina. Komplikasi kemungkinan adalah hipoksia fetus.

b) Nyatakan DUA (2) sebab kemungkinan hipoksia fetus boleh berlaku dalam situasi ( 2 markah )
di atas.

Anda telah dipanggil untuk merawat Puan S di rumahnya.

c) Terangkan intervensi kejururawatan untuk mengelakkan hipoksia fetus. ( 10 markah )

SKEMA JAWAPAN : HOME DELIVERY

1. Puan S telah ditempah unutk kelahiran dirumah.

a) Nyatakan EMPAT (4) kriteria obstetrik yang sesuai untuk bersalin di rumah. ( 8 markah )
1. Gravida 2 – 5
 adalah sesuai kerana trek pelahiran telah dilalui secara normal tanpa
masalah – dibenarkan bersalin dirumah.
2. Tiada masalah obstetrik yang lalu
Mana mana 4
 ibu tiada mengalami masalah obstetrik yang lalu semasa hamil, bersalin jawapan dengan
& puerperium seperti PIH, PPH dan puerperal sepsis, ibu ini dibenarkan penerangan
bersalin dirumah. markah 2 setiap
jawapan yang
3. Tiada mengalami masalah medikal diberi.
 Ibu tiada mengalami masalah medikal semasa hamil yang lalu seperti –
anaemia, Diabetes dll.
4. Usia ibu > 18 tahun & < 35 tahun.
 Usia ibu yang kurang 18 tahun kurang kematangan dari segi fizikal &
mental sementara > 35 tahun adalah berisiko mendapat masalah medikal
seperti HPT, DM.
5. Berat lahir anak > 2.5kg & < 4 kg
 Jika berat lahir kurang 2.5kg – terlalu kecil bermasalah dari segi sistem
pernafasan – RDS & jika > 4 kg – big baby risiko mendapat shoulder
dystocia kesukaran semasa labor.
6. Ketinggian > 145 cm.
 Jika kurang dari 145 cm berisiko mengalami kesukaran semasa labor
kerana di syakki mengalami CPD.
7. Berat badan ibu < 80 kg & > 45 kg.
 Jika > 80 kg – obesiti risiko ibu mendapat GDM & jika < 45 kg
undernutrition – risiko IUGR / IUD.
Puan S mengalami ruptur membran secara spontan semasa usia kandungan 39 minggu, dan tali pusat
prolaps di luar vagina. Komplikasi kemungkinan adalah hipoksia fetus.

b) Nyatakan DUA (2) sebab kemungkinan hipoksia fetus boleh berlaku dalam situasi ( 2 markah )
di atas.

Anda telah dipanggil untuk merawat Puan S di rumahnya.

c) Terangkan intervensi kejururawatan untuk mengelakkan hipoksia fetus. ( 10 markah )

1. a. State the possible causes for Madam Salmi’s vagina bleeding. 5 marks
 - Infected product of conception 1 mark for 1
- Infected placental site respond
- Shedding of dead tissue following obstructed labour
- Breakdown of uterine wound
- Acute urinary retention
During assessment, Madam Salmi is found to be in shock.
b. Explain the nursing management for Madam Salmi. 12 marks
- Call for medical aid 1 mark
- Stop bleeding
 Rub up a contraction by massaging the uterus 2 marks
 Give a uterotonic drug (oxytocin 10u IV); if bleeding persists add 20u
oxytocin per litre IVF at 40 drops per minute
- Resuscitation
 Obtain blood specimen for Hb, group and cross-match
 Treat for shock 2 marks
 IVF
 Oxygen therapy
 Blood transfusion
- Medications
 Antibiotics 2 marks
 Ampicillin 2gm IV 6H
 Gentamycin 80mg 8H
 Metronidazole 500mg 8H
- Removal of placental remnants
 Empty uterus
If cervix is dilated, explore uterus and remove retained POC and blood clots 3 marks
If cervix not dilated prepare patient for OT
- Surgical intervention
If there is no improvement with the above interventions, referral for further
assessment and probably surgery will be needed urgently. Prepare patient for OT.
- Monitor vital signs
 Temperature
 BP & pulse 1 mark
 Respiration
 PV loss
 General condition
 I/O
- Provide good nursing care
 Physical comfort 1 mark
 Emotional support
Prior to discharge, Madam Salmi is keen to use the combined oral contraceptives as a method of
birth spacing.
c. State the information that should be given to Madam Salmi regarding 8 marks
intrauterine contraceptive device (IUCD).
What is IUCD
Is a small, flexible plastic frame with copper sleeves around it.
Almost all types of IUCDs have one or two strings.
The strings hang through the cervix into the vagina 1 mark
The type of IUCD
Multiload Cu 250 (3 years) / Multiload Cu 375 (5 years)
The copper-bearing intrauterine device (IUCD)
- Works primarily by causing a chemical change that damages sperm and 2 marks
egg before they can meet. Prevents sperm from fertilizing egg.
- Works primarily by suppressing the growth of the lining of uterus
(endometrium).

Advantages of IUCD
 Highly effective (99%) and safe
Reversible (fertility restored immediately after removal)
Safe to use by lactating mother
Choice for those whereby OCP is contraindicated 1 marks
Safe to use by HIV positive mothers
Long duration of use
Coitally independent
Suitable time for IUCD insertion
Having menstrual cycles
Any time within 12 days after the start of her monthly bleeding
Soon after childbirth 1 mark
- Any time within 48 hours after giving birth
delay IUD insertion until4 weeks or more after giving birth.
Fully or nearly fully breastfeeding
Instruction after insertion of IUCD
During the first month after insertion, check the strings several times,
particularly after your menstrual period.
After the first month, you only need to check the strings after menses if you have :
 cramping in the lower part of the abdomen, 2 marks
 spotting between periods or after intercourse, or
 pain after intercourse (or if your partner experiences discomfort during sex).
Removal of the Copper T 380A is necessary after 10 years but may be done sooner
if you wish.
Return to the clinic if you :-
 cannot feel the strings,
 feel the hard part of the IUD
 expel the IUD
Give TCA
6/52 – after the 1st period to make sure IUCD insitu
3/12 – make sure the IUCD insitu and side effects 1 mark
6/12 – to review
Every year till due for removal
Pap smear appointment – associated with antinomies ( bacterial infection)
1. a. State four ( 4) objectives of home nursing. (4 marks)

1. to assess and evaluate general health of both mother and infant.

2. Detect early health problems of mothers and infants during the puerperium Any 4
– PPH, puerperal sepsis, neonatal jaundice and signs of infection.
3. Making the initial reference if there are any problem experienced by
mother and child
4. Provide guidance and advice to the mother
5. Encourage mother to breastfeed exclusively
6. Provide health education related to birth spacing
b. Explain your responsibility when carrying out home nursing. 7 marks
1. Identify the case
2. Set the objective 1 m for 1 respond
3. Preparation instrument/transport
4. Identify the location of the house
5. Provide appropriate health education
6. Referral if needed
7. Documentation
During the 20th postnatal day you are performing a home nursing for Puan Zila.
c. State the nursing intervention to be carry out during the home nursing. (6marks)
1. Check general condition of vital sign for mother ½m
2. Check the flow of breast milk and breast condition ½m
3. Check fundal height and the lochia 1m
4. Ask any problem or complain from the mother ½m
5. General condition of the baby - vital sign, behavior and activity ½m
6. Physical examination including umbilical cord ½m
7. Weighing the baby 1m
8. Giving health education ½m
9. Follow up to the clinic ½m
10. Documentation ½m

Madam zila is interested use progesterone only pill as a method of family planning.
d. Explain the information about progresteron only pill to Madam Zila. ( 8 marks )
1. Start - taking pill 6 weeks after giving birth ½m
2. Advice on side effects
 Do not have monthly bleeding for several month after giving birth
 May have freguent/irregular bleeding 1m
 Headaches, dizziness or breast tenderness
 Side effects become less/stop within the first few months.
3. Explain how to use the POP
 Give the pills 2m
 Explain pill pack
 Show how to take the first pill from the pack and follow the direction of the
arrows
4. Give instruction 1m
 Take one pill each day and at the same time
5. Explain how to start the next pack 1m
 When she finishes one pack, she should take the first pill from the next
pack on the next day.
6. If missed pills
If miss 3 hours late taking a pill or if she missed a pill completely
 Take the miss pill as soon as possible 2m
 Keep taking pill as usual, one pill each day
 Avoid sex or use a back up method for next 2 days

 If having sex within that 2 days she should take emergency

contraceptive pill.
7. Pill available at MCH clinic, KK, KD and LPPKN ½m