FREE NLE REVIEW QUESTIONS: NP 2- OB, CHN, Peds

( Taken from sample questions posted on april & late march)

Mr. Angeles went to visit the health center to ask about exclusive breastfeeding. Which of the
following foods may be allowed to be given to her three-month-old child?
1. Beastmilk
2. Water
3. Fuits and vegetables
4. Vitamin and mineral supplements
A. 1,2,3
B. 1,4
C. 1,2,4
D. 1 only
Correct answer is D.. RATIONALE- the word EXCLUSIVE is referring on BREASTMILK only.. BUT hindi bawal
magbigay ng vitamins and minerals sa baby.

Mrs. Doldol has experienced a posrpartal hemorrhage based upon her total blood loss in the first 24
hrs.How much must be lost to be considered hemmorhage?
A.300ml
B.1000ml
C.500ml
D.800ml
Correct ans C

he Nurse is conducting a home visit..What should the nurse do first?

A. Prepare equipments needed
B. Introduce your purpose of visit
C. Knock on the door
D. Do health teaching
Ilang araw na lang Nurse na kayo.. smile emoticon
--------------------------------------
A. Prepare equipments - conducting na ibig sabihin naglalakad ka na para sa home visit ready ka na
naka prepare na yung mga gagamitin mo...
Pero kung ang tanong ay 
"will conduct." Prepare equipments ang sagot..
B. Introduce yourself - "kapag andun ka na sa mismong chosen family" na gagawan mo ng health
assessment.,
C. Knock on the door - Simple lang syempre paano ka makakapasok sa bahay ng family na napili
mo kung hindi ka kakatok o magtataopo..
D. Health Teaching - Lagi itong nasa huli kapag home visit dito nakapaloob kung kelan ka babalik sa
next visit mo, ano ang gagawin nila kung sakaling may nagkasakit ..
Answer: Letter C...
Yup, ayan ang sagot may pagkapilosopo right? Pero isipin nyo kung ang sinagot nyo ay introduce
yourself? Sinong kausap mo? Unless kumatok ka...Baka mamaya introduce yourself ka agad wala
namang tao diba? Haha!
Sana nakuha nyo yung rationale kung bakit letter C ang sagot... smile emoticon
Goodluck sa inyong lahat, Kaya nyo yang Quiz na yan... smile emoticon

A mother was accompanied by his son to the hospital and verbalizes "Nagsuka at nahilo ang nanay
ko pagkatapos naming kumain ng tahong"....What kind of data does the nurse collect?
A. Subjective Data, Primary 
B. Subjective Data, Secondary
C. Objective Data, Primary
D. Objective Data, Secondary
----------------------------------
Subjective Data - Verbalizes by the pt.
Example: Masakit tiyan ko, Masakit yung ulo ko...
Objective Data - Observation of the nurse to the pt..
Example: Facial Grimaces- Malungkot, Masaya, etc...
Primary- galing sa pt. mismo yung mga Data na nakuha ng nurse..
Secondary- galing sa kasama ng pt. yung mga data na nakuha ng Nurse., means hindi mismo yung
pt ang nag verbalize sa nurse kung hindi may isang relatives na nag verbalize para sa kanya...
Answer:
Letter B. Subjective Data, Secondary..

Mrs Doldol is treated for syphilis during first trimester with IM injections of penicilin.The baby
diagnosis at birth would most likely be.
A. Stillborn
B.congenital syphilis
C.normal newborn
D.pretmature newborn
Correct Answer C.There is a placental barrier to syphilis until the 18th wk of pregnancy.If the mother
is treated b4 the 18wk the baby will not be affected.However titers will be positive at birth.

The nurse may best obtain a moro reflex by:

A.creating a loud noise suddenly
B changing the infant equilibrium
C.stimulating the infants feet
D.grasping the infants hand
Correct Ans B. This neurologic reflex an infant under the age of 6 mons, the movements should be
bilateral and symmetric: aloud noise causes the same reaction (startle reflex) but using noise as
stimulates really tests hearing.

Constipation during pregnancy is best treated by:

A.regular laxative
B.regular use of dulcolax suppositories
C.limit excessive wt.gain
D.increased bulk and fluid in the diet
Correct Answer D..It help increase peristalsis.. Prevention is more desirable than treatment
Patient's with Alzheimer's Disease will most likely exhibit the four A's namely: agnosia, aphasia,
amnesia, and apraxia.
In connection with this, the nurse plans to include which of the following interventions in the
patients's plan of care?
A. Perform frequent memory testing
B. Provide new names for unrecognized objects
C. Lessen stimulating activities that require step-by-step instructions
D. Initiate motion with gentle guidance and touch
.
.
.
.
.
ANSWER: D
Assistance or supervision that is as unobtrusive (mahinhin) as possible protects clients from injury
while preserving their dignity.

The nurse should teach the client that breastfeeding is always contraindicated with:
a. Mastitis
b. Hepatitis C
c. Inverted nipples
d. HERPES GENITALIS

Probably B or C ************

You suspected your client with disseminated intravascular coagulation (DIC) to have microvascular
thrombosis. As her nurse, you expect to see which of the following manifestations?
A. hematuria
B. hemoptysis
C. petechiae
D. acute ulceration
.
.
.
ANSWER: D - acute ulceration
Microvascular thrombosis destroys clotting factors and as a result of this, hemorrhage and
thromboembolism occurs. Clinical manifestations of microvascular thrombosis are those that indicate
a blockage of blood flow and oxygenation to the tissues which results in death of the organ.
Examples of microvascular thrombosis include acute respiratory distress syndrome, focal ischemia,
superficial gangrene, oliguria, azotemia, cortical necrosis, acute ulceration, delirium and coma.
Hemoptysis, petechiae and hematuria are signs of hemorrhage.

If Andrea's cycle is regular and her last menstrual period is June 20, 2008, when is the expected
date of delivery?
A. March 20, 2009
B. March 27, 2009
C. March 13, 2009
D. March 25, 2009
Answer is B minus 3 the month plus 7 the date and plus 1 the year he he pasayloa lang daan sa sentence..

hich of the following are considered non time-bound procedures?

1. Immediate drying
2. Immunization 
3. Vitamin K administration
4. Clamping cord
5. Administration of pre-lacteals
6. Breastfeeding initiation
7. Foot printing
A. 1, 4, 6
B. 2, 3, 5, 7
C. 1, 2, 4, 6, 7
D. 2 & 3 only
ANSWER: D

2010 NP2 July Question

6. A nurse is going to give a rectal suppository as a preoperative medication to a 4-year-old boy. The
boy is very anxious and frightened. Which of the following statement by the nurse would be most
appropriate to gain the child’s cooperation?
A) “Be a big kid! Everyone’s waiting for you.”
B) “Lie still now and I’ll let you have one of your presents before you even have your operation.”
C) “Take a nice, big, deep breath and then let me hear you count to five.”
D) “You look so scared. Want to know a secret? This won’t hurt a bit!”
- Anser: C

P 2: Obstetrics Nursing
The Antepartal Period
A pregnant client is admitted to the hospital for preterm labor. The nurse's FIRST intervention is to
A. obtain a complete history and update the physician.
B. initiate IV hydration and begin tocolytic medication.
C. obtain a fetal fibronectin and a CBC.
D. monitor for contractions and fetal well being.
Ans: d

The postpartal period includes maternal changes that are both progressive and retrogressive.Eight
hours aftes vaginal delivery,the fundus of a woman is 1cm above the umbilicus and palpable at the
right side.Which actions should the Nurse take? 
A.Massage the fundus
B.Catheterize the woman C.Assist her to the toilet D. Encourage more fluids
ns: C Assist her to the toilet.The fundus is normally palpated at the midline of the abdomen.Finding slightly deviated
to the right side may be caused by a full bladder,which keeps it from contraction and pushing it upward. Uterine
contraction begins immediately after placental delivery causing the fundus to be palpated halfway between the
umbilicus and symphisis pubis.After an hour,the fundus can be palpated at the level of the umbilicus and decreases
one fingerbreath per day until returned to pre pregnancy state.

Community health nursing mainly is associated with:

A. Delivering home health-care services
B. Assisting economically disadvantaged high-risk group
C. Addressing the nursing needs of a specific individual or group within the community
D. Providing interventions that help people on the health end of the health-illness continuum
---
Test Taking Tip: Identify the key word in the stem that sets a priority. Identify the clue in the stem.
• The word "mainly" in the stem sets a priority. The word "community in option C is directly
associated with the words "community health nursing" in the stem. The word "community" and in
option C is a clang association.
Correct answer: C
Rationale: Community health nursing reaches out to people and groups outside of acute-care
facilities. Services are provided in neighborhoods, which includes the home.
Silverman-Andersen score is a system for evaluation of breathing performance of premature infants.
It consists of five items
:
(1) chest retraction as compared with abdominal retraction during inhalation; 
(2) retraction of the lower intercostal muscles; 
(3) xiphoid retraction; 
(4) flaring of the nares with inhalation; 
(5) grunting on exhalation.
Each of the five factors is graded 0, 1, or 2.
The sum of these factors yields the score. Adequate ventilation is indicated by a 0, severe
respiratory distress is indicated by a score of 10.

YPES OF IMMUNIZATION
ACTIVE IMMUNIZATION- antibodies are produced by the body in response to infection
*NATURAL- antibodies are formed in the presence of active infection in the body. It is lifelong.
(Recovery from mumps , chicken pox)
*ARTIFICIAL- antigens(vaccines or toxoids) are administered to stimulate antibody production.
Requires booster inoculation after many years. ( tetanus toxoids, oral polio vaccines)
PASSIVE IMMUNIZATION- antibodies are produced by another source such as animal or human
*NATURAL- antibodies are transferred from the mother to her newborn through the placenta or in
the colustrums
*ARTIFICIAL-immune serum(antibody)from an animal or another human is injected to a
person(tetanus immunoglobulin human TIGH)

As a rural health nurse, your most important function in polio prevention is to:
a. Educate the public on the advantages of immunization
b. Distribute leaflets about the causes of polio
c. Call all mother for lecture
d. Refer all children to the doctor
A. Health Education is responsibility/obligation of CHN Nurse. A part of Health Promotion & Disease Prevention-
PRIMARY PREVENTION.

A client with severe preeclampsia is admitted with of BP 160/110, proteinuria, and severe pitting
edema. Which of the following would be most important to include in the client’s plan of care?
A. Daily weights 
B. Seizure precautions 
C. Right lateral positioning 
D. Stress reduction
.
.
.
ANSWER: B
Women hospitalized with severe preeclampsia need decreased CNS stimulation to prevent a
seizure. Seizure precautions provide environmental safety should a seizure occur. Because of
edema, daily weight is important but not the priority. Preclampsia causes vasospasm and therefore
can reduce utero-placental perfusion. The client should be placed on her left side to maximize blood
flow, reduce blood pressure, and promote diuresis. Interventions to reduce stress and anxiety are
very important to facilitate coping and a sense of control, but seizure precautions are the priority.

When measuring a client’s fundal height, which of the following techniques denotes the correct
method of measurement used by the nurse?
A. From the xiphoid process to the umbilicus 
B. From the symphysis pubis to the xiphoid process 
C. From the symphysis pubis to the fundus 
D. From the fundus to the umbilicus
.
.
.
ANSWER: C
The nurse should use a nonelastic, flexible, paper measuring tape, placing the zero point on the
superior border of the symphysis pubis and stretching the tape across the abdomen at the midline to
the top of the fundus. The xiphoid and umbilicus are not appropriate landmarks to use when
measuring the height of the fundus (McDonald’s measurement).

1. A male client suspected of having colorectal cancer will require which diagnostic study to confirm
the diagnosis?
a. Stool Hematest
b. Carcinoembryonic antigen (CEA)
c. Sigmoidoscopy
d. Abdominal computed tomography (CT) scan
2. During a breast examination, which finding most strongly suggests that the Luz has breast
cancer?
a. Slight asymmetry of the breasts.
b. A fixed nodular mass with dimpling of the overlying skin
c. Bloody discharge from the nipple
d. Multiple firm, round, freely movable masses that change with the menstrual cycle
CORRECT ANSWER= CB
RATIONALE:
1. Answer: (C) Sigmoidoscopy
Rationale: Used to visualize the lower GI tract, sigmoidoscopy and proctoscopy aid in the detection
of two-thirds of all colorectal cancers. Stool Hematest detects blood, which is a sign of colorectal
cancer; however, the test doesn't confirm the diagnosis. CEA may be elevated in colorectal cancer
but isn't considered a confirming test. An abdominal CT scan is used to stage the presence of
colorectal cancer.
2. Answer: (B) A fixed nodular mass with dimpling of the overlying skin
Rationale: A fixed nodular mass with dimpling of the overlying skin is common during late stages of
breast cancer. Many women have slightly asymmetrical breasts. Bloody nipple discharge is a sign of
intraductal papilloma, a benign condition. Multiple firm, round, freely movable masses that change
with the menstrual cycle indicate fibrocystic breasts, a benign condition.

When planning nursing care for a 5 y.o with acute glomerulonephritis,the nurse realizes that the child
needs help in understanding the necessary restrictions,one of which is
a.daily doses of IM penicillin
b.a bland diet high in protien
c.bed rest for at least 4 weeks
d.isolation from other children with infections

Ans: D daw

The nurse explains to a pregnant client at 37 weeks a gestation that a Bishop score is being
completed to determine which of the following?
A. The client’s readiness for labor
B.the fetus’s readiness for labor
C. Progress during induction
D. Cervical changes induction
Correct Answer D

Before assessing the postpartum client’s uterus for firmness and position in relation to the umbilicus
and midline, which of the following should the nurse do first?
A. Assess the vital signs 
B. Administer analgesia 
C. Ambulate her in the hall 
D. Assist her to urinate
.
.
.
ANSWER: D
Before uterine assessment is performed, it is essential that the woman empty her bladder. A full
bladder will interfere with the accuracy of the assessment by elevating the uterus and displacing to
the side of the midline. Vital sign assessment is not necessary unless an abnormality in uterine
assessment is identified. Uterine assessment should not cause acute pain that requires
administration of analgesia. Ambulating the client is an essential component of postpartum care, but
is not necessary prior to assessment of the uteru
An HIV-positive client in active labor with ruptured membranes is being transported to the hospital
via ambulance. The labor and delivery nurse anticipates priority administration of which medication
to this client?
A.Antibiotics .
B. Immune globulin.
C. oxytocin (pitocin).
D. Zidovudine (retrovir).
Correct Answer D.
Rationale: the rate of transmission of HIV to the newborn is decreased from 17 % to less than 7 % if
the mother is given prophylactic zidovudine (retrovir) orally during pregnancy and by IV during labor.

A client has been scheduled for an amniocentesis. Which of the following actions should the nurse
plan to take in the car of this client?
A. Arrange for the client’s admission to the hospital.
B. Arrange for access to an ultrasound machine for use during the procedure.
C. Assist the woman in assuming a supine position.
D. Arrange for administration of general anesthetic.
Correct Answer B Rationale: the test completed on an outpatient basis is done under guidance of
ultrasound visualization. The test is done without anesthetic. The client is positioned on her back
with a wedge under her left hip to avoid hypotension from pressure of the uterus on the vena cava.

The doctor is to perform episiotomy. When is the most appropriate time to perform episiotomy?
A. engagement
B. crowning
C. station 0
D. station +3
.
.
.
ANSWER: B
Episiotomy is usually performed when the head is at the outlet already (crowning). The pressure of
the fetal presenting part is so intense that the nerve endings in the perineum are momentarily
deadened. This lack of sensation allows episiotomy to be performed without anesthesia. Other
options are incorrect.

The nurse anticipates that a pregnant client with a history of which of the following might benefit from
a scheduled cesarean birth to achieve an improved outcome for the infant?
A. Diabetes mellitus.
B. Herpes simplex type II.
C. Human immunodeficiency virus.
D. Systemic lupus erythematosus.
Correct Answer C. The transmission of HIV is less than 1 % if the infant is delivered by cesarean
prior to membrane rupture. Only the client with active herpes lesions should be delivered by
cesarean to prevent transmission of the virus during vaginal birth.
The postpartum nurse is caring for a couplet four hours after a vaginal delivery with a partial
abruption of the placenta prior to delivery. The nurse would immediately notify the health care
provider (HCP) based on which of the following data?
A. Maternal hemoglobin result is 10.4 g
B. Maternal urine output is 280 mL/8 hours
C. Infant is Rh positive
D. Maternal D-dimer test result is increased
----------------------------------------------
Answer is D..
Rationale:
√An increased D-dimer test following a partial abruption raises the concern of disseminated
intravascular coagulation; the HCP should be notified right away. The urine output is a bit low; the
nurse should continue to monitor this. Infant Rh+ would need to be addressed if the mother is Rh (-)
but there’s nothing to indicate the mother is Rh negative. Even so, this is not an immediate concern
since this drug can be given within 72 hours following birth. Hemoglobin of 10.4 g is adequate for a
postpartum client, especially one who experienced increased bleeding due to an abruption. A
hemoglobin less than 8 g might require a transfusion, but you don’t know if this lab value is stable or
decreasing.

* When Nurse Mario calls 8y/o Maria by her name,clothes her appropriately and gives her age-
appropriate task, which of the ff. does Maria accomplish?
A. Develop sense of Competence
B. Learns to Trust in self and in others
C. Develop sense of Identity
D. Acquires a sense of Personal Power
Anser: A

Which of the following would the nurse identify as a classic sign of PIH? 
A. Edema of the feet and ankles 
B. Edema of the hands and face 
C. Weight gain of 1 lb/week 
D. Early morning headache
.
.
.
ANSWER: B
Edema of the hands and face is a classic sign of PIH. Many healthy pregnant woman experience
foot and ankle edema. A weight gain of 2 lb or more per week indicates a problem. Early morning
headache is not a classic sign of PIH.
The nurse explains to a parent group that the most important complication of mumps in postpubertal
males is
a. Sterility
b. Decrease in Libido
c. Hypopituitarism
d. A decrease in ADROGEN

Answer: A

When caring for the child with Cystic fibrosis the nurse should
a.prevent coughing
b.perform postural drainage
c.encourage active excercise
d.provide small frequent feedings

Answer: B

The nurse is reading the results of the client's Mantoux tuberculin skin test and palpates a 4-mm
area of induration at the test site. The nurse should document which result?
A. Confirms tuberculosis
B.Is positive for tuberculosis
C.Is negative for tuberculosis
D Provides a conclusive determination of tuberculosis

Question: a 14 yrs.old child ingested half a bottle of aspirin tablets.which of the following would the
nurse expect to see in the child? A.hyporthermia B.edema C.dyspnea D.epistaxis Correct answer
:D:>>>>>>>>>>>>>epistaxis.a large dose of aspirin inhibits prothrombin formation and lowers
platelets level with an overdose,clotting time is prolonged

Public health nurse is an approach that the nurse can apply in order to achieve health and longevity.
Which of the following is mark of success of nursing effort in public health?
A. Barangay officials participate actively in health-related activities
B. The people are able to attain the highest level through their own effort.
C. The people utilize health service accdg to their needs.
D. Health workers are able to provide efficient and acceptable service.

Answer: B
The department of health is promoting the breastfeeding program to all newly mothers. The nurse is
formulating a plan of care to a woman who gave birth to a baby girl. The nursing care plan for a
breast-feeding mother takes into account that breast-feeding is contraindicated when the woman:
A. Is pregnant
B. Has genital herpes infection
C. Develops mastitis
D. Has inverted nipples
Ans: (A) pregnancy is one contraindicàtion to breast-feeding. Milk secretion is inhibited and the
baby's sucking may stimulate uterine contractions.

The partograph is a tool used to monitor labor. The maternal parameters measured/monitored are
the following EXCEPT:
A. Vital sign
B. Fluid intake and output
C. Uterine contraction
D. Cervical dilatation
Ans: B partograph is a monitoring tool designed by WHO for the use by health workers when attending to mothers in
labor especially the high risk one. For maternal parameters all of the above is placed in the partograph except the
fluid intake since this is placed in a separate monitoring sheet

1. Which of the following characteristics of contractions would the nurse expect to find in a client
experiencing true labor?
A. Occurring at irregular intervals
B. Starting mainly in the abdomen
C. Gradually increasing intervals
D. Increasing intensity with walking
2. During which of the following stages of labor would the nurse assess “crowning”?
A. First stage
B. Second stage
C. Third stage
D. Fourth stage
3. Barbiturates are usually not given for pain relief during active labor for which of the following
reasons?
A. The neonatal effects include hypotonia, hypothermia, generalized drowsiness, and reluctance to
feed for the first few days.
B. These drugs readily cross the placental barrier, causing depressive effects in the newborn 2 to 3
hours after intramuscular injection.
C. They rapidly transfer across the placenta, and lack of an antagonist make them generally
inappropriate during labor.
D. Adverse reactions may include maternal hypotension, allergic or toxic reaction or partial or total
respiratory failure
4. Which of the following nursing interventions would the nurse perform during the third stage of
labor?
A. Obtain a urine specimen and other laboratory tests.
B. Assess uterine contractions every 30 minutes.
C. Coach for effective client pushing
D. Promote parent-newborn interaction.
5. Which of the following actions demonstrates the nurse’s understanding about the newborn’s
thermoregulatory ability?
A. Placing the newborn under a radiant warmer.
B. Suctioning with a bulb syringe
C. Obtaining an Apgar score
D. Inspecting the newborn’s umbilical cord
6. Immediately before expulsion, which of the following cardinal movements occur?
A. Descent
B. Flexion
C. Extension
D. External rotation
7. Before birth, which of the following structures connects the right and left auricles of the heart?
A. Umbilical vein
B. Foramen ovale
C. Ductus arteriosus
D. Ductus venosus
8. Which of the following when present in the urine may cause a reddish stain on the diaper of a
newborn?
A. Mucus
B. Uric acid crystals
C. Bilirubin
D. Excess iron
9. When assessing the newborn’s heart rate, which of the following ranges would be considered
normal if the newborn were sleeping?
A. 80 beats per minute
B. 100 beats per minute
C. 120 beats per minute
D. 140 beats per minute
10. Which of the following is true regarding the fontanels of the newborn?
A. The anterior is triangular shaped; the posterior is diamond shaped.
B. The posterior closes at 18 months; the anterior closes at 8 to 12 weeks.
C. The anterior is large in size when compared to the posterior fontanel.
D. The anterior is bulging; the posterior appears sunken.
11. Which of the following groups of newborn reflexes below are present at birth and remain
unchanged through adulthood?
A. Blink, cough, rooting, and gag
B. Blink, cough, sneeze, gag
C. Rooting, sneeze, swallowing, and cough
D. Stepping, blink, cough, and sneeze
Correct Answers:D B C D A D B B B C B
1.D. With true labor, contractions increase in intensity with walking. In addition, true labor
contractions occur at regular intervals, usually starting in the back and sweeping around to the
abdomen. The interval of true labor contractions gradually shortens.
2.B. Crowing, which occurs when the newborn’s head or presenting part appears at the vaginal
opening, occurs during the second stage of labor. During the first stage of labor, cervical dilation and
effacement occur. During the third stage of labor, the newborn and placenta are delivered. The
fourth stage of labor lasts from 1 to 4 hours after birth, during which time the mother and newborn
recover from the physical process of birth and the mother’s organs undergo the initial readjustment
to the nonpregnant state.
3. C. Barbiturates are rapidly transferred across the placental barrier, and lack of an antagonist
makes them generally inappropriate during active labor. Neonatal side effects of barbiturates include
central nervous system depression, prolonged drowsiness, delayed establishment of feeding (e.g.
due to poor sucking reflex or poor sucking pressure). Tranquilizers are associated with neonatal
effects such as hypotonia, hypothermia, generalized drowsiness, and reluctance to feed for the first
few days. Narcotic analgesic readily cross the placental barrier, causing depressive effects in the
newborn 2 to 3 hours after intramuscular injection. Regional anesthesia is associated with adverse
reactions such as maternal hypotension, allergic or toxic reaction, or partial or total respiratory
failure.
4. D. During the third stage of labor, which begins with the delivery of the newborn, the nurse would
promote parent-newborn interaction by placing the newborn on the mother’s abdomen and
encouraging the parents to touch the newborn. Collecting a urine specimen and other laboratory
tests is done on admission during the first stage of labor. Assessing uterine contractions every 30
minutes is performed during the latent phase of the first stage of labor. Coaching the client to push
effectively is appropriate during the second stage of labor.
5.A. The newborn’s ability to regulate body temperature is poor. Therefore, placing the newborn
under a radiant warmer aids in maintaining his or her body temperature. Suctioning with a bulb
syringe helps maintain a patent airway. Obtaining an Apgar score measures the newborn’s
immediate adjustment to extrauterine life. Inspecting the umbilical cord aids in detecting cord
anomalies.
6. D. Immediately before expulsion or birth of the rest of the body, the cardinal movement of external
rotation occurs. Descent flexion, internal rotation, extension, and restitution (in this order) occur
before external rotation.
7. B. The foramen ovale is an opening between the right and left auricles (atria) that should close
shortly after birth so the newborn will not have a murmur or mixed blood traveling through the
vascular system. The umbilical vein, ductus arteriosus, and ductus venosus are obliterated at birth.
8. B. Uric acid crystals in the urine may produce the reddish “brick dust” stain on the diaper. Mucus
would not produce a stain. Bilirubin and iron are from hepatic adaptation.
9. B. The normal heart rate for a newborn that is sleeping is approximately 100 beats per minute. If
the newborn was awake, the normal heart rate would range from 120 to 160 beats per minute.
10. C. The anterior fontanel is larger in size than the posterior fontanel. Additionally, the anterior
fontanel, which is diamond shaped, closes at 18 months, whereas the posterior fontanel, which is
triangular shaped, closes at 8 to 12 weeks. Neither fontanel should appear bulging, which may
indicate increased intracranial pressure, or sunken, which may indicate dehydration.
11. B. Blink, cough, sneeze, swallowing and gag reflexes are all present at birth and remain
unchanged through adulthood. Reflexes such as rooting and stepping subside within the first year....

Which of the ff. Techniques during labor and delivery can lead to uterine inversion?
A.) Fundal pressure applied to assist the mother in bearing down during the delivery of the fetal head
B.) Strongly tugging on the umbilical cord to deliver the placenta and hasten placental separation
C.) Massaging the fundus to encourage the uterus to contract
D.) Applying light traction when delivering the placenta that has already detached from the uterine
wall
Ans: B

Which of the following blood transfusion matches would cause a hemolytic reaction?
A. A-negative blood to an A-positive patient
B. A-positive blood to an AB-positive patient
C. O-negative blood to a B-negative patient
D. B-positive blood to a B-negative patient
--------------------------------------------
Answer is D
Rationale:
•A hemolytic reaction occurs with a Rh or ABO incompatibility.
•Giving Rh-positive blood to an Rh-negative patient would cause a reaction, but giving Rh-negative
blood to an Rh-positive patient is safe if there is an ABO compatibility.
•O-negative is the universal donor.
•AB patients can receive both A & B blood types, as long as there is an Rh compatibility.

The home care nurse evaluates a client diagnosed with tuberculosis (TB) receiving isoniazid (INH),
rifampin (Rifadin), and pyrazinamide. Which client statement indicates to the nurse further teaching
is required?
A. "I have gained 5 pounds since I started taking the medication."
B. "I cover my nose and mouth when I cough or sneeze.
C. "I drink a glass of wine with dinner each night."
D. "I have stopped eating tuna salad sandwiches."
Good luck future co-RN's 2015:-)
-CORRECT ANSWER- C
The home care nurse evaluates a client diagnosed with tuberculosis (TB) receiving isoniazid (INH),
rifampin (Rifadin), and pyrazinamide. Which client statement indicates to the nurse further teaching
is required?
A. "I have gained 5 pounds since I started taking the medication."
B. "I cover my nose and mouth when I cough or sneeze."
C. "I drink a glass of wine with dinner each night."
D. "I have stopped eating tuna salad sandwiches."
CORRECT ANSWER:C
Explanation:
Strategy: "further teaching is required" indicated incorrect information.
(1.) weight loss is a symptom of TB; gaining weight indicates the client is able to eat and is having
minimal gastrointestinal (GI) upset due to medications
(2.) prevents spread to disease
(3.) adverse reaction of INH is hepatitis; instruct client to avoid ingesting alcohol when taking drug;
INH is an antitubercular agent
(4.) avoid tuna, aged cheese, red wine, yeast extracts; may cause flushing, hypotension,
palpitations, and diaphoresis

Tuberculosis (TB) is considered as the world’s deadliest disease and remains a major public health
problem in the Philippines.
A patient is presented to you. He is a new smear-negative PTB with minimal parenchymal lesions on
his CXR as assessed by the TBDC. He belongs to what TB category?
A. Category IV 
B. Category III 
C. Category II 
D. Category I
................................................................................................................................................................
................................................................................................................................................................
.........................
ANSWER: B
Category III – new smear-negative PTB with minimal parenchymal lesions on CXR as assessed by
TBDC.
Category I – new smear-positive PTB and new smear-negative PTB, with extensive parenchymal
lesions on CXR as assessed by the TBDC, EPTB, and severe concomitant HIV disease.
Category II – treatment failure, relapse, return after default, other. 
Category IV – chronic (still smear-positive after supervised re-treatment)
A post term infant is one born after the 42nd week of pregnancy. Which of the following assessment
findings is least likely seen in a post term infant?
A. meconium aspiration 
B. decreased hematocrit 
C. hypoglycemia 
D. polycythemia
.
.
.
ANSWER: B. decreased hematocrit
In a post term infant, meconium aspiration is more likely to occur as fetal intestinal contents are
more likely to reach the rectum. Hypoglycemia may develop because the fetus had to use stores of
glycogen for nourishment in the last weeks of intrauterine life, since the placenta functions only up to
40-42nd weeks, also, polycythemia may have developed from decreased oxygenation. The
hematocrit therefore is elevated because of the polycythemia and dehydration, which lowers the
circulating plasma level. (Pilitteri)

A 60year old client comes to the primary clinic to have an initial pneumococcal. He asks the nurse,
"when should i get back for my next dose?" the nurse best responce would be:
A.after 6months
B.after a year
C.after 5years
D.no futher dose required
Answer: C 
In 2004,the center for disease control recommended that adullts be immunized with pneumococcal vaccine at age 65
or older with a single dose of the vaccine; if the pneumococcal vaccine was given before 65 years of age,
revaccination should occur 5years after the initial vaccination.

Situation: Tuberculosis (TB) is a respiratory disease common among malnourished individuals living
in a crowded places caused by mycobacterium tuberculosis.
20. The period of communicability occurs as long as viable tubercle bacilli are being discharge in the
sputum. But these groups of persons with PTB are generally not infectious.
A. Elderly with minimal PTB
B. Children with primary PTB
C. Adult with advanced PTB
D. Adult with PTB cavitations and hemoptysis
21. Treatment of all PTB cases shall be given free and shall be on ambulatory/domiciliary basis
except those with acute complications and emergencies. Category I include
A. Intensive phase – Rifampicin, Isoniazid, Pyrazinamide, Ethambutol
B. Intensive phase – Rifampicin, Isoniazid, Pyrazinamide, Streptomycin
C. Intensive phase – Rifampicin, Isoniazid, Pyrazinamide
D. Intensive phase – Isoniazid (INH) only
22. The toxic effect of INH is 
A. Kidney toxicity
B. Eye neuritis
C. Peripheral neuropathy
D. Ototoxicity
23. To treat the toxic effects of INH, it will managed by
A. Vitamin B1 B. Vitamin B9 C. Vitamin B6 D. Vitamin B12
24. The name for a comprehensive strategy which primary health services around the world are
using to detect and cure TB patients.
A. DOTS B. ASAP C. COPAR D. CARI
Reference Book: Comprehensive Review for Philippine Nurse Licensure Examination
Author/Owner: Erickson E. Marquez, MAED, MAN, RPT, RN, RN-PMH

A preschooler with a history of cleft palate repair comes to the clinic for a routine well child check up.
To determine whether this child is experiencing a long term effect of cleft palate, the nurse asks the
parent which question?
A) "Does the child play with an imaginary friend?"
B) "Was the child recently treated for pneumonia?"
C)"Is the child unresponsive when given directions?"
D)"Has the child had any difficulty swallowing food?"
 Letter C is the correct answer po
Rationale: Unresponsiveness may be an indication that the child is experiencing hearing loss. A child who has a
history of cleft palate should be routinely checked for hearing loss. Option B and D are unrelated to cleft palate after
repair. Option A is normal behavior for a preschool child. Many preschoolers with vivid imagination have imaginary
friends.
Test taking strategy: Use the process of elimination, focusing on the subjet--- a long term effect. Recalling that
hearing loss can occur in a child with cleft palate will direct you to option C. 

The NURSE in a day care center is notified that a tornado is approaching.the nurse evaluates the
children to a safe room with a freestanding gas heater.which of the following actions should the
NURSE take first?.. A.offer the children fruit juice B.turn off the gas heater C.provide diversional
activities D.comfort the frightened children CORRECT ANSWER B:--in confined areas,heaters can
increase carbon monoxide level;if cold,turn heaters on intermittently

A client has just undergone tubal ligation. Nurse Reviecca should inform the client that:

A. She needs to use another form of contraception for a week

B. Coitus can be resumed after a week or until the incision heals

C. Coitus can be resumed 2-3 days after the procedure

D. Tubal ligation is associated with an increased incidence of ovarian cancer

.
.

Answer: C.

A woman may resume coitus as soon as 2-3 days after the procedure because it provides immediate
contraception which makes option A and B incorrect. Option D is incorrect because although the reason
is not clear, the procedure is associated with a decreased incidence of ovarian cancer.

"decreased gastric m0tility occuring around midpregnancy may 0ccur because of:
A. Estrogen
B. Progester0ne
C. Relaxin
D. Folic Acid

Anaser: C RELAXIN (A h0rm0ne pr0duced by the ovaries) can c0ntribute to decrease gastric m0tility, wh!ch may
caus

Which condition could a mother have and still be allowed to breastfeed her child 1.endometritis
2.positive HIV 3.active TB 4.cardiac disease CORRECT ANSWER is A:of the listed
conditions,endometritis is the only one in which a.mother can continue to breastfeed provided that
the antibiotics shes taking arent contraindicated in breastfeeding.a mother who has a HIV or active
TB is strongly discouraged from breastfeeding bcoz of concern about transmitting the infection to the
neonate.clienta with cardiac disease are also discouraged from breastfeeding bcoz of the strain on
the mothers defective heart

Placenta previa is low implantation of the placenta instead of in the upper portion of the uterus. 
A patient who has placenta previa and in her 32nd week of pregnancy shows signs of labor and was
given Betamethasone (Celestone) 12 mg IM. The patient's husband asked nurse Joseph what is the
purpose of this drug. The most appropriate response would be:
A. "It protects your wife and your baby from infection." 
B. "It decreases likelihood of occurence of bleeding since your wife is prone to it. 
C. "It decreases the occurence of painful contractions" 
D. "It hastens the maturity of your baby's lungs"
.
ANSWER: D
Bethamethasone is a corticosteroid that acts as an anti-inflammatory and immunosuppressive agent.
It is given in pregnant women 12 to 24 hours before birth to hasten fetal lung maturity if the fetus is
less than 34 weeks' gestation and help prevent respiratory distress syndrome in newborn

Which assignment would be most appropriate to assign to the pregnant nurse?. A.client with CMV
B.client with syphilis C.client with a cervical radium implant D.client with HIV CORRECT ANSWER
D:an HIV client would not present a risk to the pregnant woman if she does not comes in contact
with the body secretions.all other options could result in teratogenic effects to fetus
 22yrs.old client is at 20wks gestation, she ask the nurse about the developmental of her fetus at this
stage. which of the ff. Developments occurs at 20wks gestations
A.) The pancreas starts producing insulin and the kidneys produces urine.
B.) The fetus follows regular schedule of turning, sleeping, sucking, and kicking
C.) Swallowing reflex has been mastered, and the fetus sucks its thumb.
D.) Surfactant forms in the lungs
ANSWER B

A nurse is preparing to administer methylergonovine (Methergine) 0.2 mg IM to a client who is

experiencing postpartum bleeding due to a hypotonic uterus. Which of the following actions should the
nurse implement first?

A. Obtain the client’s blood pressure.

B. Check the most recent Hgb and Hct.

C. Determine the number of perineal pads used.

D. Inform the client nausea and vomiting can occur.

ANSWER: A
RATIONALE:
A. [CORRECT] Prior to the administration of the medication methylergonovine, the client’s blood pressure should be
obtained and the medication held if the blood pressure is greater than 140/90 mm Hg. This medication produces
sustained uterine contractions and is administered to decrease postpartum vaginal bleeding due to a hypotonic
uterus. However, because it is a vasoconstrictor it can cause hypertension and is contraindicated in the presence of
high blood pressure.
B. Checking the most recent Hbg and Hct is appropriate, but it should not be the first action for the nurse to take. It
can provide baseline information and help determine the severity of blood loss. The administration of
methylergonovine is a priority to decrease bleeding and the blood pressure should be obtained before it can be given.
C. Determining the number of perineal pads used by the client is appropriate, but it should not be the first action for
the nurse to take. Although it can help determine the amount of vaginal bleeding the client is experiencing, the nurse
is not assessing the amount of bleeding at this point. The nurse is preparing to administer methylergonovine to
decrease bleeding and the blood pressure should be obtained before it can be given.
D. Nausea and vomiting are potential side effects of methylergonovine, but if this client’s blood pressure is greater
than 140/90 mm Hg, the client will not be receiving the medication.

Situation: Sonia, on the 3rd trimester of pregnancy experienced blurring of vision and occipital
headache during early morning. She consulted the doctor and the diagnosis is pregnancy induced
hypertension (PIH).
30. PIH cause is essentially unknown, but incidence is high in
A. Multigravida
B. Maternal age of 27
C. Maternal age under 17
D. Good nutrition
31. Classic triad of symptoms includes edema, hypertension and
A. Proteinuria B. Hematuria C. Oliguria D. Anuria
32. You found later on that Sonia is at risk for severe pre-eclampsia, and that she is also risk for the
development of
A. Bleeding
B. Gestational diabetes
C. Ectopic pregnancy
D. Convulsion and seizures
33. The drug of choice for this risk is
A. Propanolol Hydrochloride B. Magnesium Sulfate C. Calcium Gluconate D. Ferrous Sulfate
34. One of the major effects of the drug of choice for PIH is CNS depression. The nurse should
prioritize
A. Blood pressure depression
B. Respiratory depression
C. Diminished deep tendon reflexes
D. Increasing urinary output
CORRECT ANSWERS: C-A-D-B-B

Menses is actually the end of an arbitrarily defined menstrual cycle. Which of the following
statements best describe menses?
A. Both B and C 
B. It contains only little amount of blood flow, approximately 30 to 80 ml of blood. 
C. The last day of the menstrual flow marks the beginning of a new menstrual cycle. 
D. The iron loss is so small that the body is still able to adequately replace the iron loss.
.
.
.
ANSWER: B. It contains only little amount of blood flow, approximately 30 to 80 ml of blood. 
Contrary to common belief, a menstrual flow contains only approximately 30 to 80 ml of blood. If it
seems like more, it is because of the accompanying mucus and endometrial shreds. The iron loss in
a typical menstrual flow is approximately 11 mg and is enough loss that many women need to take a
daily iron supplement to prevent iron depletion during the menstruating years. Menses is the only
external marker of the menstruation cycle so the first day of the menstrual flow is used to mark the
beginning day of the new menstrual cycle. (Pilliterri)

During a session, Girlie throws her toy at the nurse named Mario Jello. It is best for the nurse to say one
of the following statements:

Select one:

a. “Did I do something wrong?”

b. “You did not mean to do that Girlie.”

c. “If you will do that again, I will get you toy.”

d. “Do not do that thing Girlie.”

...

just use your sense of "abs"

answer : C. obviously, for Setting Limits. according to the situation.

a - d (are distractions only!)

Which of the following findings indicate severe dehydration in child?

A. Gray skin and decreased tears
B. Capillary refill less than 2seconds
C. Mottled skin and tenting of the skin
D. Pale skin with dry mucous membranes
Answer: C
When there is dehydration, the skin's color, temperature, moisture and tugor is mainly affected leading to letter C.
Source:fundamentals of nsg. 7th ed. By kozier

Nurse Kareen is conducting a nutritional counseling to a pregnant clients. A client ask the nurse,
"Why is it necessary to take adequate amounts of folic acid during pregnancy?". What would be the
nurse's most appropriate reply?
A. Folic acid is important for bone development
B. It is needed to build high levels of hemoglobin
C. It is important to prevent neural tube defect
D. It is necessary for the proper functioning of the thyroid gland
.
ANSWER: C
An adequate amount of folic acid (04-1.0 mg) is necessary to prevent neural tube defects on the
baby. Option A is the function of CALCIUM. Option B is the fuction of IRON, and option D is the
function of IODINE.

Situation: Community Health Nursing utilizes the nursing process that lead to desired outcome of
health status. 
5. Assessment process involves participation of clients. Which step determines the health status of
families regarding family dynamics and patterns of coping?
A. analysis of data
B. collection of data
C. interpretation of data
D. presentation of data
6. To categorize health problem, this condition leads to disease or injury
A. forseeable crisis B. health treat C. health need D. health deficit
7. Which of the following is a health deficit?
A. history of repeated infection
B. use of nuclear medicine
C. death of illness in the family
D. population is inadequately immunized
8. There are many ways to collect data. This one is the face to face interaction of the researcher and
the individual.
A. review of statistics
B. laboratory and screening test
C. survey
D. interview
9. The data collected is systematically recorded to facilitate
A. confidentiality
B. correct and accurate records
C. research
D. retrieval
Bibliography: Comprehensive Review on Philippine Nurse Licensure Exam; Unit II: Diagnostic
Exams pages 7-8.
Answers: B-B-A-D-D

When the nurse palpate the suprapubic area of the mother and found that the presenting part is still
movable, the right term for this observation that the fetus is
A.) Engaged
B.) Descended
C.) Floating
D.) Internal rotation
Ans: C . duh?

Mrs. Lich, an elder woman, asks Nurse Reviecca about changes in the body with regards to sexual
function. “Why is there pain when we have sex with my husband? Is there something wrong with me
or is it just normal?” she asked. Nurse Reviecca's best answer is:
A. “Painful intercourse in an elderly woman is usually caused by changes in vaginal secretion
production. I recommend using lubricating jellies and if the pain is still present, address it to me or to
your doctor.” 
B. “Better get yourself checked out by your gynecologist as soon as you can. That may be a sign of
an infection or tumor which should be treated immediately.” 
C. “Painful intercourse is common in aging women. Don’t worry because almost everyone that gets
old experiences it. I’d have to ask your husband some questions because he might be doing
something not right.” 
D. “I don’t think that is normal for an aging woman. Have you been taking any new medications
recently?”
.
.
.
ANSWER. A
Women experience different changes related to intercourse. One of these changes is related to
vaginal secretions. It takes longer for a woman to produce vaginal secretions during intercourse and
also the production is decreased, which can be the cause of painful intercourse. Lubricating jellies
can be recommended. These changes are only normal. Going to a gynecologist is unnecessary
since the problem can be addressed by using artificial lubricants. The husband has nothing to do
with the problem.

Nurse Nhoj Llemos Dibal. Is aware that the disease declared through Presidential Proclamation No.4
as a target for eradication in the Philippines is? A. Poliomyelitis. B. Measles. C. Rabies. D. Neonatal
tetanus 2. Nhoj knows that the step in community organizing that involves training of potential
leaders in the community is: A. Integration. B. Community organization. C. Community study. D.
Core group formation. 3. Tertiary prevention is needed in which stage of the natural history of
disease? A. Pre- pathogenesis. B. Pathogenesis. C. Prodromal. D. Terminal. 4. The nurse is caring
for a premigravid client in the labor and delivery area. Which condition would place the client at risk
for disseminated intravascular coagulation (DIC)? A. Intrauterine fetal death. B. Placenta accreta. C.
Dysfunctional labor. D. Premature rupture of the membranes. 5. The skin in the diaper area of a 7
month old infant is excoriated and red. Nurse Jucel should instruct the mother to: A. Change the
diaper more often. B. Apply talc powder with diaper changes. C. Wash the area vigorously with each
diaper change. D. Decrease the infants fluid intake to decrease saturating diapers. ..... ..... ..... .....
Answers: 1. Answer B. Presidential Proclamation No.4 is on the Ligtas Tigdas Program. 2. Answer
D. Core group formation. In core group formation, the nurse is able to transfer the technology of
community organizing to the potential or informal community leader through a training program. 3.
Answer D. Tertiary prevention involves rehabilitation, prevention of permanent disability and
disability limitation appropriate for convalescents, the disabled, complicated cases and the terminally
ill ( those in the terminal stage of a disease). 4. Answer A. Intrauterine fetal death. Intrauterine fetal
death, abruptio placentae, septic shock, and amniotic fluid embolism may trigger normal clotting
mechanisms; if clotting factors are depleted, DIC may occur. Placenta accreta, dysfunctional labor,
and premature rupture of membranes aren't associated with DIC. 5. Answer A. Change the diaper
more often. Decreasing the amount of time the skin comes contact with the soiled diapers will help
heal the irritation.

Situation: Analyn, 33 years old, is 20 weeks pregnant.

You are discussing to Analyn the discomforts commonly felt during pregnancy. Which of the
following if complained by the client would alert the nurse?
A. constipation
B. easy fatigability
C. varicosities
D. nausea and vomiting
................................................................................................................................................................
................................................................................................................................................................
.........................
ANSWER: D
Most women notice the sensation of nausea as early as the 1st missed menstrual period and
experience it through the 1st 3 months and usually disappear spontaneously as the woman enters
the 4th month.
If it persists, it may indicate the development of HYPEREMESIS GRAVIDARUM.
(Option A)Constipation - occurs as a result of the weight of the growing uterus pressed against the
bowel.
(Option B)Easy fatigability - is probably due to the increased metabolic requirement.
(Option C)Varicosities - is due to the weight of the distended uterus that puts pressure on the veins
returning blood from the lower extremities.

Community Health Nursing aims primarily to promote and preserve the health of the people in the
community. The community health nurse collaborates with other members of the health care team to
assist the clients in developing and enhancing their skills and abilities in solving their own problems
and improving their lives. 
Nurse Reviecca is conducting an evaluation after a month stay in Barangay Malitam. Whose
response to the nursing interventions is being evaluated in this phase of the nursing process?
a. Individual Response 
b. Leader’s Response
c. Community Response 
d. Public Official Response
.
.
.
ANSWER: C. COMMUNITY RESPONSE 
In community health nursing, the community is the primary client because it has a direct influence on
the health of the individual, families and sub-populations. Further, it is at this level that most health
service provision occurs. 
Public Health Nurses are primarily responsible for evaluating the nursing care rendered to clients –
the community itself

Mark, a 4-year old boy, has been brought to the RHU with complaints of diarrhea for 3 days now.
The nurse tries to interview the boy but he does not respond. Nurse Reviecca tries to awaken the
boy by shaking his shoulder but Mark does not respond. Skin returns to normal in 5 seconds after
pinched. The eyes appear sunken. Cough/DOB, fever, ear problem and anemia/malnutrition are not
present. Nurse Grace is correct when she classifies Mark as:
a. persistent diarrhea 
b. severe diarrhea 
c. no dehydration 
d. severe dehydration
.
.
.
CORRECT ANSWER: D. SEVERE DEHYDRATION 
When a child has diarrhea and exhibits 2 or more of the following: sleepy/difficult to awaken, sunken
eyes, drinks poorly/not able to drink, and skin goes back very slowly when pinched (>2seconds),
severe dehydration is present. 
Persistent diarrhea is present when no dehydration is present but the diarrhea has been present for
14 days or more. 
No dehydration is present when there are not enough signs. 
There is no such classification as severe diarrhea.
Collection of data regarding the family’s home and environment is part of the nurse’s first-level
assessment. It includes information on housing and sanitation facilities; kind of neighborhood and
availability of social, health, communication and transportation facilities in the community. 
Nurse Reviecca observed the Salting family placing their garbage in a pit and covering it when filled
up. Nurse Reviecca documents this as what method of waste disposal?
a. Burial Pit 
b. Open dumping 
c. Open pit privy
d. Composting
................................................................................................................................................................
................................................................................................................................................................
.........................
ANSWER. A
In burial pit, garbage is placed in a pit and covered when filled up. There is no intention to dig it up
later for use as fertilizer. 
(Option B) In open dumping, garbage is piled in a dumping place (with or without pit) with no soil
covering. 
(Option D) Composting involves burying or stacking of alternating layers of organic-based garbage
and “treated soil” arranged so as to hasten rapid decay and decomposition into compost. This
organic mixture can later be used as fertilizer.
(Option C) Open pit privy is a type of toilet consisting of a pit covered by a platform with a hole.

A woman with any degree of bleeding needs to be evaluated for the possibility that she is
experiencing a significant blood loss and for hypovolemic shock. 
As a nurse in the ER, Nurse Reviecca would anticipate that the least appropriate emergency
intervention for bleeding during pregnancy is:
a. Withholding oral fluids 
b. Assisting in vaginal examination. 
c. Administration of oxygen as necessary at 6-10 L/minute. 
d. Setting aside 5ml of blood drawn intravenously in a clean test tube and observing it for any clot
formation for 5 minutes.
.
.
.
Correct Answer: B Assisting in vaginal examination. 
Vaginal examination should not be done during emergency situations to prevent tearing of placenta
if placenta previa (low-lying placenta) is the cause of the bleeding. 
Withholding oral fluids anticipate the need for emergency surgery. 
Administration of oxygen provides adequate fetal oxygenation despite lowered maternal circulating
blood volume. 
Observation of blood clot tests for possible blood coagulation problems such as disseminated
intravascular coagulation, which must be suspected if no clot forms within time limit.

The nurse has developed a plan of care for a client with a diagnosis of anterior cord syndrome.
Which intervention should the nurse include in the plan of care?
A. Remind the client to change positions slowly
B. Assess the client for decreased sensation to touch
C. Assess the client for decreased sensation to vibration
D. Teach the client about loss of motor function and decreased pain sensation
ANSWER D
Clinical findings related to anterior cord syndrome iclude loss of motor function and decreased pain
sensation below the level of injury. The syndrome does not affect sensations of touch motion
position and vibration

The normal dilatation of the cervix during first stage of labor in a nullipara is
A. 1.2 cm/hr
B. 1.5 cm/hr
C. 1.8 cm/hr
D. 2.0 cm/hr

ANSWER A- 1.2cm/hr for nullipara the normal cervical dilatation should be 1.2cm/hr,if it is less than that,it is
considered a protracted active phase of the first stage. For multipara, the normal cervical dilatation is 1.5 cm/hr

In the self care deficit theory by dorothea orem, nursing care becomes necessary when a patient is
unable to fulfill his physiological, psychological and social needs. A pregnant client needing prenatal
check-up is classified as:
A. Wholly Compensatory
B. Supportive Educative
C. Partially Compensatory
D. Non Compensatory
Correct answer is B Supportive Educative

A nurse provides discharge teaching to the parents of a newborn who has a cast in place for talipes
equinovarus. Which of the following statements indicate a need for additional teaching? “We will...
A. avoid tub baths while the cast is in place.”
B. perform range of motion exercises to the affected foot.”
C. bring the baby to the doctor next week for a cast change.”
D. check the toes frequently for color and temperature changes.”

Ans: B RATIONALE:

Talipes equinovarus is a congenital bone deformity with malposition of the ankle and foot with contracture of soft
tissue. It is also referred to as congenital clubfoot. Serial casting is a common treatment and is initiated before
discharge. Maximum correction with casting is usually achieved within 8 to 12 weeks.
A. Tub baths are avoided while the cast is in place. The cast should be kept clean and dry. This statement does not
require additional teaching.

B. CORRECT: Range of motion exercises are not performed while the cast is in place. The purpose of the cast is to
gradually stretch the skin and structures on the medial side of the foot to correct the clubfoot.

C. The cast is removed every few days for 1 to 2 weeks and then at 1 to 2 week intervals. This is continued until
maximum correction is achieved, typically within 8 to 12 weeks.

D. Circulation of the toes is assessed frequently throughout the day including color and temperature of the toes. Pale,
cyanotic and cold toes should be reported immediately.

Nursing Practice 2: Community Health Nursing and Care of the Mother and Child
Obstetrics Nursing (The Antepartal Period)
The nurse is assessing a client who states her last menstrual period was March 16, and she has
missed one period. She reports episodes of nausea and vomiting. Pregnancy is confirmed by a urine
test. What will the nurse calculate as the estimated date of delivery (EDD)?
A) April 8
B) January 15
C) February 11
D) December 23
The correct answer is D: December 23 
Naegele's rule: add 7 days and subtract 3 months from the first day of the last regular menstrual
period to calculate the estimated date of delivery.

Nursing Practice 2: Community Health Nursing and Care of the Mother and Child
Communicable Diseases in Nursing (Respiratory Disorders)
Situation: The burden of infectious disease in our country is still heavy, as denounced by the
Department of Health. One of the leading causes of morbidity is still pulmonary tuberculosis (PTB).
1. Tuberculosis is a primary disease caused by Tubercle bacilli. Which mode of transmission is
extremely contagious?
A. Ingestion of food
B. Airborne
C. Animal handling
D. Skin contact
2. Which one of the following should a nurse do to detect the prevalence of PTB?
A. Bladder smear
B. Organ biopsy
C. Skin scraping
D. PPD testing
3. Which of the following is a priority objective in PTB control?
A. Sputum treatment
B. Reduction of risk
C. BCG immunization
D. Identification of positive case
Correct answers: B-D-B

Pediatrics Nursing (Growth and Development)

1. The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding?
A) Hold a rattle
B) Bang two blocks
C) Drink from a cup
D) Wave "bye-bye"
2. The nurse is teaching the parents of a 3 month-old infant about nutrition. What is the main source
of fluids for an infant until about 12 months of age?
A) Formula or breast milk
B) Dilute nonfat dry milk
C) Warmed fruit juice
D) Fluoridated tap water
1. The correct answer is A: Hold a rattle 
The age at which a baby will develop the skill of grasping a toy with help is 4 to 6 months.
2. The correct answer is A: Formula or breast milk 
Formula or breast milk are the perfect food and source of nutrients and liquids up until 1 year.

Maternity Nursing Part 2

(Answers & Ratio after 2 hrs)
11. Which of the following common emotional reactions to pregnancy would the nurse expect to
occur duringthe first trimester? 
a. Introversion, egocentrism, narcissism 
b. Awkwardness, clumsiness, and unattractiveness 
c. Anxiety, passivity, extroversion 
d. Ambivalence, fear, fantasies
12. During which of the following would the focus of classes be mainly on physiologic changes,
fetaldevelopment, sexuality, during pregnancy, and nutrition? 
a. Prepregnant period 
b. First trimester 
c. Second trimester 
d. Third trimester
13. Which of the following would be disadvantage of breast feeding? 
a. Involution occurs more rapidly 
b. The incidence of allergies increases due to maternal antibodies 
c. The father may resent the infant’s demands on the mother’s body 
d. There is a greater chance for error during preparation
14. Which of the following would cause a false-positive result on a pregnancy test? 
a. The test was performed less than 10 days after an abortion 
b. The test was performed too early or too late in the pregnancy 
c. The urine sample was stored too long at room temperature 
d. A spontaneous abortion or a missed abortion is impending
15. FHR can be auscultated with a fetoscope as early as which of the following? 
a. 5 weeks gestation 
b. 10 weeks gestation 
c. 15 weeks gestation 
d. 20 weeks gestation
16. A client LMP began July 5. Her EDD should be which of the following? 
a. January 2 
b. March 28 
c. April 12 
d. October 12
17. Which of the following fundal heights indicates less than 12 weeks’ gestation when the date of
the LMP
is unknown? 
a. Uterus in the pelvis 
b. Uterus at the xiphoid 
c. Uterus in the abdomen 
d. Uterus at the umbilicus
18. Which of the following danger signs should be reported promptly during the antepartum period? 
a. Constipation 
b. Breast tenderness 
c. Nasal stuffiness 
d. Leaking amniotic fluid
19. Which of the following prenatal laboratory test values would the nurse consider as significant? 
a. Hematocrit 33.5% 
b. Rubella titer less than 1:8 
c. White blood cells 8,000/mm3 
d. One hour glucose challenge test 110 g/dL
20. Which of the following characteristics of contractions would the nurse expect to find in a
clientexperiencing true labor? 
a. Occurring at irregular intervals 
b. Starting mainly in the abdomen 
c. Gradually increasing intervals
d. Increasing intensity with walking
ANSWERS and RATIONALES for MATERNITY NURSING Part 2
11. D. During the first trimester, common emotional reactions include ambivalence, fear, fantasies,
or
anxiety. The second trimester is a period of well-being accompanied by the increased need to learn
about
fetal growth and development. Common emotional reactions during this trimester include narcissism,
passivity, or introversion. At times the woman may seem egocentric and self-centered. During the
third
trimester, the woman typically feels awkward, clumsy, and unattractive, often becoming more
introverted
or reflective of her own childhood. 
12. B. First-trimester classes commonly focus on such issues as early physiologic changes, fetal
development,
sexuality during pregnancy, and nutrition. Some early classes may include pregnant couples.
Second andthird trimester classes may focus on preparation for birth, parenting, and newborn care.
13. C. With breast feeding, the father’s body is not capable of providing the milk for the newborn,
which may
interfere with feeding the newborn, providing fewer chances for bonding, or he may be jealous of the
infant’s demands on his wife’s time and body. Breast feeding is advantageous because uterine
involution
occurs more rapidly, thus minimizing blood loss. The presence of maternal antibodies in breast milk
helps
decrease the incidence of allergies in the newborn. A greater chance for error is associated with
bottle
feeding. No preparation is required for breast feeding. 
14. A. A false-positive reaction can occur if the pregnancy test is performed less than 10 days after
an
abortion. Performing the tests too early or too late in the pregnancy, storing the urine sample too
long at
room temperature, or having a spontaneous or missed abortion impending can all produce false-
negative
results. 
15. D. The FHR can be auscultated with a fetoscope at about 20 week’s gestation. FHR usually is
ausculatated at the midline suprapubic region with Doppler ultrasound transducer at 10 to 12 week’s
gestation. FHR, cannot be heard any earlier than 10 weeks’ gestation. 
16. C. To determine the EDD when the date of the client’s LMP is known use Nagele rule. To the
first day of
the LMP, add 7 days, subtract 3 months, and add 1 year (if applicable) to arrive at the EDD as
follows: 5
+ 7 = 12 (July) minus 3 = 4 (April). Therefore, the client’s EDD is April 12. 
17. A. When the LMP is unknown, the gestational age of the fetus is estimated by uterine size or
position
(fundal height). The presence of the uterus in the pelvis indicates less than 12 weeks’ gestation. At
approximately 12 to 14 weeks, the fundus is out of the pelvis above the symphysis pubis. The
fundus is at
the level of the umbilicus at approximately 20 weeks’ gestation and reaches the xiphoid at term or 40
weeks. 
18. D. Danger signs that require prompt reporting leaking of amniotic fluid, vaginal bleeding, blurred
vision,
rapid weight gain, and elevated blood pressure. Constipation, breast tenderness, and nasal
stuffiness are
common discomforts associated with pregnancy. 
19. B. A rubella titer should be 1:8 or greater. Thurs, a finding of a titer less than 1:8 is significant,
indicating
that the client may not possess immunity to rubella. A hematocrit of 33.5% a white blood cell count
of
8,000/mm3, and a 1 hour glucose challenge test of 110 g/dl are with normal parameters. 
20. D. With true labor, contractions increase in intensity with walking. In addition, true labor
contractions
occur at regular intervals, usually starting in the back and sweeping around to the abdomen. The
interval
of true labor contractions gradually shortens.

ursing Practice 2: Community Health Nursing and Care of the Mother and Child
Pediatrics Nursing (Musculoskeletal Disorders)
When screening children for scoliosis, at what time of development would the nurse expect early
signs to appear?
A) Prenatally on ultrasound
B) In early infancy
C) When the child begins to bear weight
D) During the preadolescent growth spurt
The correct answer is D: During the preadolescent growth spurt 
Idiopathic scoliosis is seldom apparent before 10 years of age and is most noticeable at the
beginning of the preadolescent growth spurt. It is more common in females than in males.

1. When assessing the adequacy of sperm for conception to occur, which of the following is the most
useful criterion? 
a. Sperm count 
b. Sperm motility 
c. Sperm maturity 
d. Semen volume
2. A couple who wants to conceive but has been unsuccessful during the last 2 years has undergone
manydiagnostic procedures. When discussing the situation with the nurse, one partner states, “We
know several
friends in our age group and all of them have their own child already, Why can’t we have one?”.
Whichof the following would be the most pertinent nursing diagnosis for this couple? 
a. Fear related to the unknown 
b. Pain related to numerous procedures. 
c. Ineffective family coping related to infertility. 
d. Self-esteem disturbance related to infertility.
3. Which of the following urinary symptoms does the pregnant woman most frequently experience
duringthe first trimester? 
a. Dysuria 
b. Frequency 
c. Incontinence 
d. Burning
4. Heartburn and flatulence, common in the second trimester, are most likely the result of which of
the following? 
a. Increased plasma HCG levels 
b. Decreased intestinal motility 
c. Decreased gastric acidity 
d. Elevated estrogen levels
5. On which of the following areas would the nurse expect to observe chloasma? 
a. Breast, areola, and nipples 
b. Chest, neck, arms, and legs 
c. Abdomen, breast, and thighs 
d. Cheeks, forehead, and nose
6. A pregnant client states that she “waddles” when she walks. The nurse’s explanation is based on
which of
the following as the cause? 
a. The large size of the newborn 
b. Pressure on the pelvic muscles 
c. Relaxation of the pelvic joints 
d. Excessive weight gain
7. Which of the following represents the average amount of weight gained during pregnancy? 
a. 12 to 22 lb 
b. 15 to 25 lb 
c. 24 to 30 lb 
d. 25 to 40 lb
8. When talking with a pregnant client who is experiencing aching swollen, leg veins, the nurse
wouldexplain that this is most probably the result of which of the following? 
a. Thrombophlebitis 
b. Pregnancy-induced hypertension
c. Pressure on blood vessels from the enlarging uterus 
d. The force of gravity pulling down on the uterus
9. Cervical softening and uterine souffle are classified as which of the following? 
a. Diagnostic signs 
b. Presumptive signs 
c. Probable signs 
d. Positive signs
10. Which of the following would the nurse identify as a presumptive sign of pregnancy?
a. Hegar sign 
b. Nausea and vomiting 
c. Skin pigmentation changes 
d. Positive serum pregnancy test
ANSWERS and RATIONALES for MATERNITY NURSING Part 1
1. B. Although all of the factors listed are important, sperm motility is the most significant criterion
whenassessing male infertility. Sperm count, sperm maturity, and semen volume are all significant,
but they arenot as significant sperm motility. 
2. D. Based on the partner’s statement, the couple is verbalizing feelings of inadequacy and
negativefeelings about themselves and their capabilities. Thus, the nursing diagnosis of self-esteem
disturbance is
most appropriate. Fear, pain, and ineffective family coping also may be present but as secondary
nursingdiagnoses. 
3. B. Pressure and irritation of the bladder by the growing uterus during the first trimester is
responsible forcausing urinary frequency. Dysuria, incontinence, and burning are symptoms
associated with urinary tract infections. 
4. C. During the second trimester, the reduction in gastric acidity in conjunction with pressure from
thegrowing uterus and smooth muscle relaxation, can cause heartburn and flatulence. HCG levels
increase inthe first, not the second, trimester. Decrease intestinal motility would most likely be the
cause ofconstipation and bloating. Estrogen levels decrease in the second trimester. 
5. D. Chloasma, also called the mask of pregnancy, is an irregular hyperpigmented area found on
the face. Itis not seen on the breasts, areola, nipples, chest, neck, arms, legs, abdomen, or thighs. 
6. C. During pregnancy, hormonal changes cause relaxation of the pelvic joints, resulting in the
typical“waddling” gait. Changes in posture are related to the growing fetus. Pressure on the
surrounding musclescausing discomfort is due to the growing uterus. Weight gain has no effect on
gait. 
7. C. The average amount of weight gained during pregnancy is 24 to 30 lb. This weight gain
consists of thefollowing: fetus – 7.5 lb; placenta and membrane – 1.5 lb; amniotic fluid – 2 lb; uterus
– 2.5 lb; breasts –3 lb; and increased blood volume – 2 to 4 lb; extravascular fluid and fat – 4 to 9 lb.
A gain of 12 to 22 lbis insufficient, whereas a weight gain of 15 to 25 lb is marginal. A weight gain of
25 to 40 lb is considered excessive. 
8. C. Pressure of the growing uterus on blood vessels results in an increased risk for venous stasis
in thelower extremities. Subsequently, edema and varicose vein formation may occur.
Thrombophlebitis is aninflammation of the veins due to thrombus formation. Pregnancy-induced
hypertension is not associated
with these symptoms. Gravity plays only a minor role with these symptoms. 
9. C. Cervical softening (Goodell sign) and uterine soufflé are two probable signs of pregnancy.
Probablesigns are objective findings that strongly suggest pregnancy. Other probable signs include
Hegar sign,
which is softening of the lower uterine segment; Piskacek sign, which is enlargement and softening
of the uterus; serum laboratory tests; changes in skin pigmentation; and ultrasonic evidence of a
gestational sac.Presumptive signs are subjective signs and include amenorrhea; nausea and
vomiting; urinary frequency;
breast tenderness and changes; excessive fatigue; uterine enlargement; and quickening. 
10. B. Presumptive signs of pregnancy are subjective signs. Of the signs listed, only nausea and
vomiting arepresumptive signs. Hegar sign, skin pigmentation changes, and a positive serum
pregnancy test are
considered probably signs, which are strongly suggestive of pregnancy.

Fundamentals of Nursing (Safety and Infection Control)

A nurse who is reassigned to the emergency department needs to understand that gastric lavage is
a priority in which situation?

A) An infant who has been identified to have botulism

B) A toddler who ate a number of ibuprofen tablets
C) A preschooler who swallowed powdered plant food
D) A school aged child who took a handful of vitamins
The correct answer is A: An infant who has been identified to have botulism 
C. botulinum forms a toxin in improperly processed foods in anaerobic conditions. It is a neurotoxin
that impairs autonomic and voluntary neurotransmission and causes muscular paralysis. Findings
appear within 36 hours of ingestion. Be aware that all of the options may be candidates for gastric
lavage or for activated charcoal administration.

nfectious and Communicable Disorders

Parents of a 7 year-old child call the clinic nurse because their daughter was sent home from school
because of a rash. The child had been seen the day before by the health care provider and
diagnosed with Fifth Disease (erythema infectiosum). What is the most appropriate action by the
nurse?
A) Tell the parents to bring the child to the clinic for further evaluation
B) Refer the school officials to printed materials about this viral illness
C) Inform the teacher that the child is receiving antibiotics for the rash
D) Explain that this rash is not contagious and does not require isolation
he correct answer is D: Explain that this rash is not contagious and does not require isolation 
Fifth Disease is a viral illness with an uncertain period of communicability (perhaps 1 week prior to and 1 week after
onset). Isolation of the child with Fifth Disease is not necessary except in cases of hospitalized children who are
immunosuppressed or having aplastic crises. The parents may need written confirmation of this from the health care
provider.

Growth and Development

When observing 4 year-old children playing in the hospital playroom, what activity would the nurse
expect to see the children participating in?
A) Competitive board games with older children
B) Playing with their own toys along side with other children
C) Playing alone with hand held computer games
D) Playing cooperatively with other preschoolers
The nurse is assessing a 4 month-old infant. Which motor skill would the nurse anticipate finding?
A) Hold a rattle
B) Bang two blocks
C) Drink from a cup
D) Wave "bye-bye"
When teaching a 10 year-old child about their impending heart surgery, which form of explaination
meets the developmental needs of this age child?
A) Provide a verbal explanation just prior to the surgery
B) Provide the child with a booklet to read about the surgery
C) Introduce the child to another child who had heart surgery 3 days ago
D) Explain the surgery using a model of the heart
 Congrats to all. You passed my post-test in pediatric nursing. The correct answers are D,A,D.

The mother of a 2 month-old baby calls the nurse 2 days after the first DTaP, IPV, Hepatitis B and
HIB immunizations. She reports that the baby feels very warm, cries inconsolably for as long as 3
hours, and has had several shaking spells. In addition to referring her to the emergency room, the
nurse should document the reaction on the baby's record and expect which immunization to be most
associated to the findings in the infant? A) DTaP B) Hepatitis B C) Polio D) H. Influenza : The correct
answer is A: DTaP The majority of reactions occur with the administration of the DTaP vaccination.
Contradictions to giving repeat DTaP immunizations include the occurrence of severe side effects
after a previous dose as well as signs of encephalopathy within 7 days of the immunization.

A nurse is caring for an infant who has diarrhea. The nurse monitors the infant for which early sign of
dehydration?
a) cool extremities
b) gray, mottled skin
c) capillary refill of 2 seconds
d) apical pulse rate of 200 beats per minute
- Correct Answer D -Dehydration causes interstitial fluid to shift to the vascular compartment in an
attempt to maintain fluid volume. When the body is unable to compensate for fluid lost, circulatory
failure occurs. The blood pressure will decrease and the pulse rate will increase. This will be
followed by peripheral symptoms. Options A, B, and C are incorrect, and these assessment findings
relate to peripheral circulatory status.

Which of these clients who call the community health clinic would the nurse ask to come in that day
to be seen by the health care provider? A) I started my period and now my urine has turned bright
red. B) I am an diabetic and today I have been going to the bathroom every hour. C) I was started on
medicine yesterday for a urine infection. Now my lower belly hurts when I go to the bathroom. D) I
went to the bathroom and my urine looked very red and i didnt The correct answer is D: I went to the
bathroom and my urine looked very red and it didn’t hurt when I went. With this history this client
needs to be seen that day since painless gross hematuria is closely associated with bladder cancer.
The other complaints can be handled over the phone.

1. A man diagnosed with epididymitis 2 days ago calls the nurse at a health clinic to discuss the
problem. What information is most important for the nurse to ask about at this time? A) What are you
taking for pain and does it provide total relief? B) What does the skin on the testicles look and feel
like? C) Do you have any questions about your care? D) Did you know a consequence of
epididymitis is infertility? : The correct answer is B: What does the skin on the testicles look and feel
like? All of the questions should be asked. However, the one about the problem is the most
important to start with at this time

10. A 2 year-old child is brought to the emergency department at 2:00 in the afternoon. The mother
states: “My child has not had a wet diaper all day.” The nurse finds the child is pale with a heart rate
of 132. What assessment data should the nurse obtain next? A) Status of the eyes and the tongue
B) Description of play activity C) History of fluid intake D) Dietary pattern: The correct answer is A:
Status of skin turgor Clinical findings of dehydration include sunken eyes, dry tongue, lethargy,
irritability, dry skin, decreased play activity, and increased pulse. The normal pulse rate in this age
child is 70-110.

A pediatric nurse receives a telephone call from the admission office and is informed that a child with
Reye's Syndrome is being admitted to the hospital. The nurse develops a plan of care for the child
and should include which priority nursing action in the plans?
a. monitoring for hearing loss
b. monitoring intake and output
c. repositioning the child every 2 hours
d. providing a quiet environment with low, dimmed lighting
Answer: D
Rationale: 
Cerebral edema is a progressive part of the diesease process of Reye's Syndrome. A priority
component of care for a child with Reye's Syndrome is maintaining effective cerebral perfussion and
controlling intracranial pressure. Decreasing stimuli in the environment would decrease the stress on
teh cerebral tissue as well as neuron responses. Hearing loss does not occur in client with this
disorder. Although monitoring I&O may be a component of the plan, it is not priority nursing action.
Changing body position every 2 hours would not affect the cerebral edema and intracranial pressure
directly. The child should be head elevated position to decrease the progression of cerebral edema
and promote the drainage of CSF.