1. An acute care nurse discharges to home a client who will need services from a home health nurse.

What discharge
information is most important for the acute care nurse to give to the referral agency nurse? *
A. Surgical report DISCHARGE PLANNING
• Dietary consideration
B. Client’s current self care abilities • Medication at home
C. Vital signs on discharge • Complication/ medical
• Conditions to be reported
D. Medications last administered • Access to community resources
• Revisits/ follow up
• Exercise activity
• Psychological care
• treatment
2. An insurance company has required a copy of the client’s chart from the doctor’s office in order to compensate the
physician for the medical care received by the client. Which of the following is the most appropriate nursing action by
the office nurse? → can access only for validation (titingnan lang)
A. Tell the doctor of the insurance company’s request
B. Copy the client’s record and send it to the insurance company
C. Refer the insurance company to the office manager
D. Explain that the client’s medical record is confidential

3. Which of the following statements heard by a nurse during intershift report provides the most useful information
related to priority setting for the upcoming shift?

A. A client who had catheter removed 8 hours ago has not urinated – should be bladder training 6hrs
B. A client who is alert and oriented to person and place
C. A client who is 3 days post operative is experiencing incisional pain
D. A client admitted for congestive heart failure has a blood pressure of 138/80

4. The quality assurance nurse reads several nurses’ notes from different records that refer to clients’ moods.
Examples of these notes are “The client is in good spirits today,” “The client is good spirits today,” “The client feels
depressed today,” and “The client is withdrawn today.” Based on the quality assurance nurse’s findings, which of the
following would be the best action to take?

A. Communicate the findings to nursing administration

B. Report the findings to the Joint commission on Accreditation of Health care Organization
C. Communicate the findings to the agency’s Nursing Staff Development Department
D. Do nothing, as this is acceptable documentation practice

Should be objective
Documentation – concise, actual reaction, behavior response

5. Before going off duty, a nurse is reviewing the notes written for a client. The nurse discovers that there has been an
omission of important assessment findings. Which of the following nursing actions is most appropriate at this
time? tinangal

A. Insert the omitted data in the appropriate area

B. Recopy the entire section, include the missing data and throw the original data away
C. Record the time of the entry, the time of the assessment and the missing data
D. Verbally relay the assessment finding during shift report and leave the record unchanged

SITUATION: Mr. Ibarra is assigned to the triage area and while on duty, he assesses the condition of Mrs. Simon
who came in pregnant G1P2.

6. A nurse is performing an assessment on a Mrs. Simon who is at 38 weeks gestation and notes that the FHR is
174/bpm. On the basis of this finding, the appropriate nursing action is to: *
▪ NORMAL = 120M- 160
1. Notify the physician ▪ TACHYCARDIA – FETAL DISTRESS
2. Document the findings. ▪ FUNIC SUFFLE -→ fetal heart rate
3. Check the mother's heart rate ▪ UTERINE SUFFLE → Supply of blood of the mother
4. Tell the client that the FHR is normal.
going to placenta (maternal heart rate) if heart
decrease 100
FUNCTION OF PLACENTA (organs of fetus) ▪ 12th week → maturity of placenta
▪ Lungs – Provide oxygenated blood and remove
unoxygenated blood
▪ GI sys – Provide nourishment
▪ Kidneys – Removed waste Production
▪ Endocrine – secretes hormones
7. The nurse explains some of the purposes of the placenta to a client during a prenatal visit. The nurse determines
that the client understands some of these purposes when the client states that the placenta:

1. Cushions and protects the baby

2. Maintains the temperature of the baby
3. Is the way the baby gets food and oxygen
4. Prevents all antibodies and viruses from passing to the baby.

8. A nursing instructor asks a nursing student to list the functions of the amniotic fluid. The student responds correctly
by stating that which of the following are functions of the amniotic fluid? SELECT ALL THAT APPLY.

1. Allows for fetal movement

2. Is a measure of kidney function
3. Surrounds, cushions, and protects the fetus
4. Maintains the body temperature of the fetus
5. Prevents large particles such as bacteria from passing to the fetus
6. Provides an exchange of nutrients and waste products between the mother and fetus

AMNIOTIC FLUID → 800 – 1200 mL

Normally – fetus urinates and swallows amniotic
▪ Oligohydramnios – fetus kidney defect (does not urinate but swallow) umuunti
▪ Polyhydramnios – esophageal atresia (closed) →mother has Hyperglycemia (DM) → polyuria

9. Upon prenatal assessment. The client tells a nurse that the first day of her LMP was October 19, 2020. Using
Nagele's rule, the nurse determines the EDD is: *

1. July 12, 2020 9 months + 7days

2. July 26, 2021
3. August 12, 2021
4. August 26, 2021

10. A nurse-midwife is assessing a pregnant client for the presence of ballottement. To make this determination, the
nurse mid-wife does which of the following?10. All of the following are forms of skin infections, except:
Ballottement → Passive movement of a floating or unengaged fetus
1. Auscultates for fetal heart sounds
➔ Gently tap
2. Assesses the cervix for compressibility
➔ After 18 weeks
3. Palpates the abdomen for fetal movement
4. Initiates a gentle upward tap on the cervix

SITUATION: Lesley, tells you that she drinks 4-5 cups of black coffee and diet cola drinks. She also smokes up to a
pack of cigarettes daily. She confesses that she is in her 2nd month of pregnancy but she does not want to become
fat that is why she limits her food intake. She will now undergo non-stress test (NST).

Nst – Non Stress Test

= fetal heart rate during fetal movement (variability)
➔ Mother hold the button (when the fetal move the mother push the button)
➔ Reactive = FHR increase 10 – 15 bpm lasting 15 sec x 2 in a 10 – 20 min
➔ Non – reactive = no change in FHR with fetal activity

11. Upon nonstress testing she noticed that the baby hasn't moved recently. The results are considered reactive.
What does this mean?

1. The baby has normal heart rate accelerations.

2. The baby does not have any noted birth defects → ultrasound
3. The baby is most likely neurologically impaired.
4. The baby is going to be born preterm.

12. What is metoclopramide (Reglan) administered via IV for?

1. Prevention of constipation and nausea. →morning sickness

2. Induction of vomiting. Hyperemesis Gravidarum – excessive vomiting pregnancy
3. Neutralized acid. *dehydration
4. Management for vertigo. *metabolic alkalosis
13. What is a potential complication of a patient taking clomiphene citrate (Clomid)? → increase ovulation normal is
1 egg

1. Infertility
2. Multiple pregnancy
3. Subfertility
4. Pregnancy

14. Lesley also show signs of stress related to her pregnancy. Which of the following demonstrates the effects of
chronic stress during pregnancy? Select all that apply.

a. 1 and 2
b. 1, 2 and 3
c. 1, 2, 3 and 4
d. All are correct

15. Lesley complains to her nurse midwife about frequent episodes of nausea during the day with occasional
vomiting. She asks what she can do to feel better. The nurse midwife could suggest that the woman: (maghapon
nagsusuka)

1. Drink warm fluids with each of her meals. Fill bloated

2. Eat a high-protein snack before going to bed.
3. Keep crackers and peanut butter at her bedside to eat in the morning before getting out of bed. → for morning
sickness
4. Schedule three meals and one midafternoon snack a day. → small frequent meals

SITUATION: Nurse Angela a nurse practitioner following-up referred clients in their respective homes. Here she
handles a case of PRENATAL, POSTPARTAL MOTHER AND FAMILY focusing on HOMECARE.

16. A woman who has completed one pregnancy with a fetus (or fetuses) reaching the stage of fetal viability is called
a: *
Gravida – Total of # of preg
1. Primipara. - Para – deliveries/ previous pregnancies w/c reached viability
2. Primigravida. Null – 0
3. Multipara. Primi – 1
4. Nulligravida. Multi – 2 and above

17. Cardiovascular system changes occur during pregnancy. Which finding would be considered normal for a woman
in her second trimester?
Supine Hypotensive Syndrome → decrease BP and Hemoglobin
1. Less audible heart sounds (S1, S2). Physiologic Anemia →increase plasma and increase RBC – 35% → hemodilution
2. Increased pulse rate. RR,RBC, FRIBINOGEN
3. Increased blood pressure. → Preg. Induced Hypertension
4. Decreased red blood cell (RBC) production.

18. Nurse Angela teaches a pregnant woman about the presumptive, probable, and positive signs of pregnancy. The
woman demonstrates an understanding of the nurse's instructions if she states that a positive sign of pregnancy is:
Presumptive – subjective → mother weak evidence
1. a positive pregnancy test. - probable Probable – objective → nurse – stonger evidence
2. fetal movement palpated by the nurse-midwife. Positive – absolute 100% →FHT, fetal movement and
3. Braxton Hicks contractions. - probable Ultrasound
4. Quickening. – presumptive “fetal movement tell by the mother”

19. Semen analysis is a common diagnostic procedure related to infertility. In instructing a male patient regarding this
test, the nurse would tell him to: inability to conceive for 1 yr of unprotective sex

1. Ejaculate into a sterile container. Not bacteria

2. Obtain the specimen after a period of abstinence from ejaculation of 2 to 5 days.
3. Transport specimen with container packed in ice. Warm temperature → transport – cup chest of man
4. Ensure that the specimen arrives at the laboratory within 30 minutes of ejaculation.
20. One client is using the basal body temperature (BBT) method of contraception .She calls the clinic and tells the
nurse, "My period is due in a few days, and my temperature has not gone up." The nurse's most appropriate response
is: *
SIGNS OF OVULATION
1. 14 days before the end of mens. Cycle
1. "This probably means you're pregnant." 2. increase body temp – progesterone
2. "Don't worry; it's probably nothing." 3. cervical mucus changes – stretchy
3. "Have you been sick this month?" 4. breast tenderness
4. "You probably didn't ovulate during this cycle." 5. mood swing

SITUATION: Still in your self-managed Maternal Health Nursing Clinic, your encounter these cases pertaining to the
CARE OF MOTHER and CHILDREN.

21. One effective relief measure for primary dysmenorrhea would be to: *
1. Reduce physical activity level until menstruation ceases.
2. Begin taking prostaglandin synthesis inhibitors on the first day of the menstrual flow.
3. Decrease intake of salt and refined sugar about 1 week before menstruation is about to occur.
4. Use barrier methods rather than the oral contraceptive pill (OCP) for birth control. – dependent (need doctor’s
order)

Primary
Increase Prostaglandin
▪ Vasoconstriction, Uterine Contraction
Secondary
Endometriosis – endometrial tissue outside the iterus

22. When caring for Alice, a client in the first stage of labor, the nurse documents cervical dilation of 9 cm and intense
contractions lasting 45 to 60 seconds and occurring about every 2 minutes. Based on these findings, the nurse should
recognize that the client is in which phase of labor? *
Stage I – Dilatation = 20o – Primi
2. Latent phase 14o – Multi
3. Descent phase Latent Active Transition
4. Transitional phase Cervic 0-3cm 4-7cm 8-10cm
Freq 10-15min 3-5min 2-3min
Duration 10-15sec 40-60sec 60-90sec

23. During labor, a client asks the nurse why her blood pressure must be measured so often. Which explanation
should the nurse provide?
Increase BP = decrease blood
Decrease BP = bleeding → decrease blood fetus

1. Blood pressure reflects changes in cardiovascular function, which may affect the fetus.
2. Increased blood pressure indicates that the client is experiencing pain.
3. Increased blood pressure signals the peak of the contraction.
4. Medications given during labor affect blood pressure.

24. Because cervical effacement and dilation aren't progressing in a client in labor, the physician orders I.V.
administration of oxytocin (Pitocin). Why must the nurse monitor the client's fluid intake and output closely during
oxytocin administration?
Oxytocin stimulate ADH
No urine = Water intoxication → cerebral edema

1. Oxytocin causes water intoxication.

2. Oxytocin causes excessive thirst.
3. Oxytocin is toxic to the kidneys.
4. Oxytocin has a diuretic effect.

SITUATION: In most cases, the membranes have ruptured (spontaneously or artificially) by this stage of labor.
Positioning for effective pushing, preparing for delivery, and assessing vital signs is important.

25. Assessment of a client in active labor reveals meconium-stained amniotic fluid and fetal heart sounds in the upper
right quadrant. Which of the following is the most likely cause of this situation? *
First Stool = within 24hrs after delivery
1. Breech position → normal if with meconium; buttock first + meconium – during labor
→ nasa taas ang ulo kaya FHR ay nasa taas ng abdomen
2. Late decelerations Fetus decrease oxygen → increase peristalsis → + relax
anal sphincter → (+) meconium
3. Entrance into the second stage of labor
4. Multiple gestation

26. A client with intrauterine growth retardation is admitted to the labor and delivery unit and started on an I.V.
infusion of oxytocin (Pitocin). Which of the following is least likely to be included in her care plan? Normal →
decrease 90 sec duration; increase 2 min interval

1. Carefully titrating the oxytocin based on her pattern of labor→ regulating

2. Monitoring vital signs, including assessment of fetal well-being, every 15 to 30 minutes.
3. Allowing the client to ambulate as tolerated.
4. Helping the client use breathing exercises to manage her contractions.

27. When caring for a client who's having her second baby, the nurse can anticipate the client's labor will be which of
the following? *

1. Shorter than her first labor.

2. About half as long as her first labor.
3. About the same length of time as her first labor.
4. A length of time that can't be determined based on her first labor.

28. The nurse is evaluating a client who is 34 weeks pregnant for premature rupture of the membranes (PROM).
Which findings indicate that PROM has occurred? Select all that apply: Ruptured of membrane without contraction.

MANAGEMENT
1. Check FHR
2. Assess AF (amniotic fluid)
a. 1, 3 and 4 Nitrazine test – ph fluid
b. 1, 3 and 5 Fern test – check for crystallization
(AMNIOTIC should be alkaline ph)

29. After admission to the labor and delivery area, a client undergoes routine tests, including a complete blood count,
urinalysis, Venereal Disease Research Laboratory test, and gonorrhea culture. The gonorrhea culture is positive,
although the client lacks signs and symptoms of this disease. What is the significance of this finding? *

1. Maternal gonorrhea may cause a neural tube defect in the fetus.

2. Maternal gonorrhea may cause an eye infection in the neonate. → OPTHALMIA NEONATARUM lead to blindness
CREDE’s prophylaxis → administration of ophthalmic antibiotic after delivery
Causative Agent → Gonorrhea
3. Maternal gonorrhea may cause acute liver changes in the fetus.
4. Maternal gonorrhea may cause anemia in the neonate.

30. The physician decides to artificially rupture the membranes. Following this procedure, the nurse checks the fetal
heart tones for which reason? *

1. To determine fetal well-being. MANAGEMENT = RUPTURED MEMBRANE

2. To assess for fetal bradycardia. 1. Check fhr → cord prolapse → FHR decrease variable deceleration
3. To assess fetal position. 2. Amniotic Fluid
4. To prepare for an imminent delivery.

SITUATION: A client's ability to cope during labor and delivery may be hampered by fear of a painful or difficult
childbirth, fear of loss of control or self-esteem during childbirth, or fear of fetal death.

31. The nurse notices that a client in the first stage of labor seems agitated. When the nurse asks why she's upset, she
begins to cry and says, "I guess I'm a little worried. The last time I gave birth, I was in labor for 32 hours." Based on
this information, the nurse should include which nursing diagnosis in the client's care plan? *

1. Anxiety related to the facility environment.

2. Fear related to a potentially difficult childbirth.
3. Compromised family coping related to hospitalization.
4. Acute pain related to labor contractions.

32. A primigravid client, age 20, has just completed a difficult, forceps-assisted delivery of twins. Her labor was
unusually long and required oxytocin (Pitocin) augmentation. The nurse who's caring for her should stay alert for: *

1. Uterine inversion.
2. Uterine atony. → Postpartum hemorrhage (soft, boggy relax uterus → blood loss of above 500 mL
3. Uterine involution.
4. Uterine discomfort.

33. The third stage of labor ends with which of the following?
true labor → full dilatation → delivery of fetus → delivery of placenta

1. The birth of the baby.

2. When the client is fully dilated.
3. After the delivery of the placenta.
4. When the client is transferred to her postpartum bed.

34. During labor, a client's cervix fails to dilate progressively, despite her uncomfortable uterine contractions. To
augment labor, the physician orders oxytocin (Pitocin). When preparing the client for oxytocin administration, the
nurse describes the contractions the client is likely to feel when she starts to receive the drug. Which description is
accurate?
Oxytocin Given if Hypotonic Contraction → weak, irregular, painless during active labbor

1. Contractions will be stronger and more uncomfortable and will peak more abruptly.
2. Contractions will be weaker, longer, and more effective.
3. Contractions will be stronger, shorter, and less uncomfortable.
4. Contractions will be stronger and shorter and will peak more slowly.

35. A client is admitted to the labor and delivery department in preterm labor. To help manage preterm labor the
nurse would expect to administer: below 37 weeks

1. ritodrine (Yutopar). → Bricanyl → TOCOLYTICS (relax uterus)

2. bromocriptine (Parlodel).
3. magnesium sulfate.
4. betamethasone (Celestone).

SITUATION: Amniotomy increases the risk of cord prolapse. If the prolapsed cord is compressed by the presenting
fetal part, the fetal blood supply may be impaired, jeopardizing the fetal oxygen supply.

36. During the active phase of the first stage of labor, a client undergoes an amniotomy. After this procedure, which
nursing diagnosis takes the highest priority? increase contraction → Artificial rupture of membrane

1. Deficient knowledge (testing procedure) related to amniotomy.

2. Ineffective fetal cerebral tissue perfusion related to cord compression
3. Acute pain related to increasing strength of contractions
4. Risk for infection related to rupture of membranes

37. A diabetic client in labor tells the nurse she has had trouble controlling her blood glucose level recently. She says
she didn't take her insulin when the contractions began because she felt nauseated; about an hour later, when she
felt better, she ate some soup and crackers but didn't take insulin. Now, she reports increased nausea and a flushed
feeling. The nurse notes a fruity odor to her breath. What do these findings suggest? Acetone = Ketone
Liposis = Glucose from lipids → ketones = Acid
NO Insulin – Type 1

1. Diabetic ketoacidosis → Acidosis + Hyperglycemia, ketosis, Dehydration

2. Hypoglycemia
3. Infection
4. Transition to the active phase of labor

38. During labor, a client tells the nurse that her last baby "came out really fast." The nurse can help control a
precipitous delivery by: NORMAL DILATION 5cm/1hr
Complication → maternal (laceration – vagina and cervix)
fetus (cerebral hemorrhage)

1. applying counterpressure to the fetus's head.

2. encouraging the client to push.
3. massaging and supporting the perineum.
4. instructing the client to contract the perineal muscles.
39. When assessing a client who has just delivered a neonate, the nurse finds that the fundus is boggy and deviated to
the right. What should the nurse do? *

1. Have the client void. Side – full bladder → void

2. Assess the client's vital signs.
3. Evaluate lochia characteristics.
4. Massage the fundus.

40. Which of the following describes the term fetal position? *

1. Relationship of the fetus's presenting part to the mother's pelvis = LOA → Normal
2. Fetal posture → Presentation
3. Fetal head or breech at cervical os → Lie
4. Relationship of the fetal long axis to the mother's long axis

SITUATION: A child's nutrition is very important for optimum growth and development. Breastfeeding is said to be
the best food for children ages 0 and beyond, however, nutrients such as Iron is lacking on human milk thus,
introduction of complementary food is necessary.

41. If a mother is breast feeding, Which of the four signs of good breast-infant attachment is true in this statement?

1. the chin should touch the breast while the mouth is wide open and while the lower lip is turned inward more
areola is visible above than below
2. the chin should touch the breast, the mouth is wide open while the lower lip turned outward and more areola
visible above than below. NIPPLE + AREOLA (LATCHING)
3. the chin should touch the breast while the mouth is wide open while the lower lip turned outward and more
areola visible below than above
4. the chin should touch the breast while the mouth is wide open and the lower lip turned inward, more areola is
visible above than below

42. When should the mother give complementary foods to a 5 months old infant? SOLID FOOD

1. if the child gives adequate weight for his age 4 mos – 6 mos → Solid food
1. Fe store is depleted at 6 mos
2. if the child shows interest in semi solid foods
2. Milk is a poor source of Fe
3. supplementary foods should be given before breastfeeding
3. Extrusion reflex fades at 4 months
4. if the child is breastfed less than 8 times in 24 hours

43. Lochia alba follows lochia serosa and usually lasts from the 1st to 3rd week PP. Which of the following statements
best describes lochia alba? *

1. creamy white-brown, stale odor 1. Rubia – red

2. creamy white to brown, contains decidual cells, may have stale odor 2. 2. Serosa – brown
3. brown to red, tissue fragments, odor 3. Alba - white

4. brown to red contains decidual cells and leukocytes

44. Neonates born to women infected with hepatitis B should undergo which treatment regimen.

1. Hep B vaccine at birth and 1 month

2. Hep B immune globulin at birth, no hepatitis B vaccine
3. Hepatits B immune globulin within 48 hours of birth and Hep B vaccine at 1 month
4. Hep B immune globulin within 12 hours of birth and Hep B vaccine at birth, 1 month, 6 months → antibodies

45. Two days after circumcision, the nurse notes a yellow - white exudate around the head of the neonates penis.
What would be the most appropriate nursing intervention?

1. Leave the area alone as this is a normal finding

2. Report findings to physician and document it
3. Take the neonate's temperature bc an infection is suspected
4. Try to remove the exudate with a warm washcloth

SITUATION: The health history is a current collection of organized information unique to an individual. Relevant
aspects of the history include biographical, demographic, physical, mental, emotional, sociocultural, sexual, an d
spiritual data.
46. Prior to taking the health history the nurse should first do which of the following?

1. Establish a rapport with the client

2. Offer the client a beverage of choice
3. Establish that insurance coverage exists
4. Ask the client to disrobe and put on a gown

47. The nurse would use which of the following skills first when examining the abdomen of the client?

1. Palpation
2. Auscultation
3. Percussion
4. Inspection → I A Pe Pa

48. The nurse would conduct a health history on a newly admitted client primarily to accomplish which of the
following?

1. Determine the client’s correct health status

2. Demonstrate concern for the client’s situation
3. Identify several ways in which the client can maintain a healthier lifestyle
4. Obtain data, both overt and subtle, from the client and/or the family

49. As the client describes the chief complaint, the nurse should do which of the following?

1. Document verbatim what the client has to say about the problem
2. Paraphrase in the nurse’s own words that the problem is
3. Refrain from note-taking to appear focused
4. Ask the client to repeat the data to assure reliability

50. The nurse selects which of the following pieces of equipment to test for a cremasteric reflex?

1. Blood pressure cuff

2. Cotton applicator → Scrotum will be go up
3. Sharp end of a needle
4. Percussion hammer

SITUATION: Therapeutic communication is defined as the face-to-face process of interacting that focuses on
advancing the physical and emotional well-being of a patient. Nurses use therapeutic communication techniques to
provide support and information to patients.

51. A nurse enters the room of a female client and asks her how she is doing. The client states, “I am a little nervous
this morning.” The nurse’s best reply would be which of the following?

a. “Why are you feeling nervous?”

b. “You certainly look like you are nervous.”
c. “Can I give you a backrub to calm your nerves?”
d. “What do you mean by the word nervous?” →exploration

52. A client tells the nurse that her husband is an alcoholic and hasn’t worked for the last 3 months. The nurse’s best
response would be which of the following?

A. “Have you tried Al-Anon meetings?” Alcoholic anonymous

B. “I’m really sorry to hear that.”
C. “You sound worried, I think you should talk to the chaplain.”
D. “What have you done before to cope with the problem?”

53. During the introductory phase of communication with a client, the nurse becomes acquainted with the client and
does which of the following?

A. Provides the client with advice

B. Refers the client to offer care providers for follow-up
C. Identifies goals and objectives → at the beginning
D. Prepares for the interview
54. Using a mannequin, the nurse has demonstrated wound care for a client. To promote client teaching, which of the
following would be the best nursing action?

A. Complete the wound care on the client, explaining the procedure while performing it
B. Watch a video explaining sterile technique that will be used for the client’s wound care
C. Have the client perform the wound care with the nurse present to supervise
D. Ask the client to review written literature and perform the care at a later time

55. Which of the following methods would be most effective for an ambulatory care nurse to use when trying to
determine the priority health-related learning needs of a client?

A. Carefully review the physician’s order

B. Conduct a thorough nursing assessment
C. Determine the amount of time required to present the information
D. Ask the client what learning needs he or she has about current state of health

Situation: Jane, is a 79-year-old woman admitted to intensive care unit after left thoracotomy and partial
pneumonectomy, episodic dyspnea and apnea is noted to patient.

56. Before an institution operates license must be obtain. Hospital Licensure Act is known as:

a. RA 7305 → Magna Carta

B. RA 4226 → Hospital Licensure Act
C. RA 7610 → Protection Against Child Abuse
D. RA 4442 → Petroleum Act

57. A client who had a “Do Not Resuscitate” order passed away. After verifying there is no pulse or respirations, the
nurse should next:

a. Have family members say goodbye to the deceased.

b. Call the transplant team to retrieve vital organs.
c. Remove all tubes and equipment (unless organ donation is to take place), clean the body, and position
appropriately.
d. Call the funeral director to come and get the body.

58. There are rare cases where in a nurse cannot obtain the BP of the patient using the brachial artery (eq. burns). If
such cases occur, the nurse must make a variation in BP determination using the thigh (thigh BP). Which of the
following is true regarding thigh BP?

a. The client must be placed in a sim’s position. If the client cannot assume this, measure the BP while the client is in
supine position with knee slightly flexed
b. Femoral artery is used in thigh BP determination
c. The systolic pressure in the popliteal artery is usually 20-30mmHg higher than that in the brachial artery while the
diastolic pressure is usually 10-15 mmHg higher in the popliteal artery compared to brachial artery
d. The systolic pressure in the popliteal artery is usually 20-30mmHg higher than in than in the brachial artery while
the diastolic pressure is usually the same

59. According to the National Institutes of Health stepped-care approach to treating PRIMARY hypertension, the FIRST
step involves: unknown cause

a. Correcting the underlying cause

b. Modifying lifestyle
c. Using drug monotherapy
d. Using combination drug therapy

60. A multiparous client tells the nurse that she is using medroxyprogesterone (Depo-Provera) for contraception. The
nurse instructs the client to increase her intake of which of the following?
Progesterone only → Given IM x 3 months → No ovulation

A. Folic acid.
B. Vitamin C.
C. Magnesium.
D. Calcium.
Situation: Nurse J. a newly licensed nurse is providing care to Mike Pierce, a 45-year-old steel-mill worker, is
admitted through emergency room with complaints of stabbing chest pain that becomes worse with coughing,
hypertension, chills, diaphoresis and rusty-colored sputum.

61. Dr. M is stuck in EDSA when the referral was made through text by Nurse J. about his patient’s BP of 180/100. She
would like to give her orders by phone. What should Nurse J do?

a. Tell her to text her order to his phone.

b. Tell her to call the landline so that 2 nurses in the station could also listen to her.
c. Received the order by the phone since the case is urgent and need immediate management.
d. Refer the situation to the head nurse.

62. Nurse J is aware that the National Health Insurance Bill ultimately aims:

a. Increase health source availability.

b. Health service for those insured.
c. Health coverage for all Filipinos.
d. Health priority for the poor.

63. What is the minimum requirement of the state to become a nurse?

A. Willingness to practice the profession

B. A nursing license
C. A BSN degree
D. An NCLEX and CGFNS passer

64. This Act aims to promote and improve the socio-economic well-being of health workers, their living and working
conditions and terms of employment; to developed their skills and capabilities in order that they will be more
responsive and better equipped to deliver health project and programs; and to encourage those with proper
qualifications and excellent abilities to join and remain in government service.

A. RA 7305
B. RA 7035
C. RA 7610
D. RA 7877

65. When implementing a health promotion plan, it is most important to develop the individual’s:

a. Self respect
b. Body image
c. Self-worth
d. Self-image

Situation: Nurses are facing various personal, interpersonal, professional, and institutional and socio cultural
challenges related to professional performance. Dealing with these issues may not be always clear and correct
approach in addressing different contextual issues may lead or prevent ethical dilemmas.

66. Registered nurses can be identified as a:

A. Organization → PNA
B. Culture
C. Group
D. Subculture

67. The use of interpersonal decision making, psychomotor skills, and application of knowledge expected in the role
of a licensed health care professional in the context of public health welfare and safety is an example of:

A. Delegation
b. Supervision
c. Responsibility
d. Competence
68. When the head nurse in your ward plots and approves your work schedules and directs your work, she is
demonstrating:

A. Responsibility
B. Delegation
C. Accountability
D. Authority

69. The obligation to correctly perform one’s assigned duty is: → delegation

A. Responsibility
b. Delegation
c. Accountability
d. Assignment

70. You made a mistake in giving the medicine to the wrong client. You notify the client’s doctor and write an incident
report. You are demonstrating:

A. Responsibility
b. Accountability
c. Authority
D. Autocratic

SITUATION: Evaporation of moisture from a wet body dissipates heat along with the moisture. Keeping the
newborn dry by drying the wet newborn infant will prevent hypothermia via evaporation

71. A nurse in a delivery room is assisting with the delivery of a newborn infant. After the delivery, the nurse prepares
to prevent heat loss in the newborn resulting from evaporation by:
HEAT LOSS → transfer of heat from Newborn
1. Warming the crib pad → conduction 1. Conduction → to direct contact
2. Turning on the overhead radiant warmer → radiation 2. Radiation → to a cold object indirect contact
3. Closing the doors to the room → convection 3. Convection → to air current
4. Drying the infant in a warm blanket 4. Evaporation → to water vapor

72. A nurse is assessing a newborn infant following circumcision and notes that the circumcised area is red with a
small amount of bloody drainage. Which of the following nursing actions would be most appropriate?

1. Document the findings

2. Contact the physician
3. Circle the amount of bloody drainage on the dressing and reassess in 30 minutes
4. Reinforce the dressing

73. A nurse in the newborn nursery is monitoring a preterm newborn infant for respiratory distress syndrome. Which
assessment signs if noted in the newborn infant would alert the nurse to the possibility of this syndrome? → LUNGS

1. Hypotension and Bradycardia

2. Tachypnea and retractions
3. Acrocyanosis and grunting
4. The presence of a barrel chest with grunting

74. A nurse in a newborn nursery is performing an assessment of a newborn infant. The nurse is preparing to measure
the head circumference of the infant. The nurse would most appropriately:

1. Wrap the tape measure around the infant’s head and measure just above the eyebrows.
2. Place the tape measure under the infants head at the base of the skull and wrap around to the front just above
the eyes
3. Place the tape measure under the infants head, wrap around the occiput, and measure just above the eyes
→increase HC result to Increase Intracranial Pressure

4. Place the tape measure at the back of the infant’s head, wrap around across the ears, and measure across the
infant’s mouth.

75. A postpartum nurse is providing instructions to the mother of a newborn infant with hyperbilirubinemia who is
being breastfed. The nurse provides which most appropriate instructions to the mother?
JAUNDICE
Pathologic → after 24hours → sepsis, blood incompatibility (Exchange to transfusion)
Physiologic → more than 24 hrs → inner image, breast feed, disappear at 5-7 days (Phototherapy continuous
Breastfeed)

1. Switch to bottle feeding the baby for 2 weeks

2. Stop the breast feedings and switch to bottle-feeding permanently
3. Feed the newborn infant less frequently
4. Continue to breast-feed every 2 – 4 hours

SITUATION: Breast feeding should be initiated within 2 hours after birth and every 2-4 hours thereafter.

76. A nurse on the newborn nursery floor is caring for a neonate. On assessment the infant is exhibiting signs of
cyanosis, tachypnea, nasal flaring, and grunting. Respiratory distress syndrome is diagnosed, and the physician
prescribes surfactant replacement therapy. The nurse would prepare to administer this therapy by: → prevent lung
collapse

1. Subcutaneous injection
2. Intravenous injection
3. Instillation of the preparation into the lungs through an endotracheal tube
4. Intramuscular injection

77. A nurse is assessing a newborn infant who was born to a mother who is addicted to drugs. Which of the following
assessment findings would the nurse expect to note during the assessment of this newborn?

1. Sleepiness → decrease
2. Cuddles when being held → normal
3. Lethargy → decrease
4. Incessant crying → hyper (withdrawal symptoms)

78. A nurse prepares to administer a vitamin K injection to a newborn infant. The mother asks the nurse why her
newborn infant needs the injection. The best response by the nurse would be:
Vitamin K
Stimulate Liver → clotting factor to prevent bleeding

1. “You infant needs vitamin K to develop immunity.”

2. “The vitamin K will protect your infant from being jaundiced.”
3. “Newborn infants are deficient in vitamin K, and this injection prevents your infant from abnormal bleeding.”
4. “Newborn infants have sterile bowels, and vitamin K promotes the growth of bacteria in the bowel.” → Vitamin K
- synthesize normal flora bacteria at GI system

79. A nurse in a newborn nursery receives a phone call to prepare for the admission of a 43-week-gestation newborn
with Apgar scores of 1 and 4. In planning for the admission of this infant, the nurse’s highest priority should be to:
8 – 10 = good
4 – 7 = guarded
0 – 3 = resuscitate

1. Connect the resuscitation bag to the oxygen outlet

2. Turn on the apnea and cardiorespiratory monitors
3. Set up the intravenous line with 5% dextrose in water
4. Set the radiant warmer control temperature at 36.5* C (97.6*F)

80. Vitamin K is prescribed for a neonate. A nurse prepares to administer the medication in which muscle site?

1. Deltoid
2. Triceps
3. Vastus lateralis
4. Biceps

SITUATION: The heart rate is vital for life and is the most critical observation in Apgar scoring to check for the
newborn response to the extrauterine life.

81. A nursing instructor asks a nursing student to describe the procedure for administering erythromycin ointment
into the eyes if a neonate. The instructor determines that the student needs to research this procedure further if the
student states:

1. “I will cleanse the neonate’s eyes before instilling ointment.”

2. “I will flush the eyes after instilling the ointment.”
3. “I will instill the eye ointment into each of the neonate’s conjunctival sacs within one hour after birth.”
4. “Administration of the eye ointment may be delayed until an hour or so after birth so that eye contact and par ent-
infant attachment and bonding can occur.”

82. A baby is born precipitously in the ER. The nurses initial action should be to:

1. Establish an airway for the baby

2. Ascertain the condition of the fundus
3. Quickly tie and cut the umbilical cord
4. Move mother and baby to the birthing unit

83. The primary critical observation for Apgar scoring is the:

1. Heart rate
2. Respiratory rate
3. Presence of meconium
4. Evaluation of the Moro reflex

84. When performing a newborn assessment, the nurse should measure the vital signs in the following sequence:

1. Pulse, respirations, temperature

2. Temperature, pulse, respirations
3. Respirations, temperature, pulse
4. Respirations, pulse, temperature

85. Within 3 minutes after birth the normal heart rate of the infant may range between:

1. 100 and 180

2. 130 and 170
3. 120 and 160
4. 100 and 130

SITUATION: The heart and respiratory rate varies with activity; crying will increase the rate, whereas deep sleep
will lower it.

86. The expected respiratory rate of a neonate within 3 minutes of birth may be as high as:

1. 50
2. 60
3. 80
4. 100

87. The nurse is aware that a healthy newborn’s respirations are:

1. Regular, abdominal, 40-50 per minute, deep

2. Irregular, abdominal, 30-60 per minute, shallow
3. Irregular, initiated by chest wall, 30-60 per minute, deep
4. Regular, initiated by the chest wall, 40-60 per minute, shallow

88. To help limit the development of hyperbilirubinemia in the neonate, the plan of care should include:
Phototherapy + continuous BF

1. Monitoring for the passage of meconium each shift

2. Instituting phototherapy for 30 minutes every 6 hours
3. Substituting breastfeeding for formula during the 2nd day after birth
4. Supplementing breastfeeding with glucose water during the first 24 hours

89. A newborn has small, whitish, pinpoint spots over the nose, which the nurse knows are caused by retained
sebaceous secretions. When charting this observation, the nurse identifies it as:

1. Milia
2. Lanugo
3. Whiteheads
4. Mongolian spot
90. When newborns have been on formula for 36-48 hours, they should have a:
Increase Phenylalanine (spill to the urine) → Brain Damage

1. Screening for PKU → Phenylketonuria→ Formula Amino Acid = Phenylalanine → Tyrosine → Increase Enzyme
2. Vitamin K injection → immediately
3. Test for necrotizing enterocolitis → Preterm
4. Heel stick for blood glucose level → NPO, LGA

SITUATION: Teaching the mother by example is a non-threatening approach that allows her to proceed and care for
her newborn.

91. The nurse decides on a teaching plan for a new mother and her infant. The plan should include:

1. Discussing the matter with her in a non-threatening manner

2. Showing by example and explanation how to care for the infant
3. Setting up a schedule for teaching the mother how to care for her baby
4. Supplying the emotional support to the mother and encouraging her independence

92. Which action best explains the main role of surfactant in the neonate?

1. Assists with ciliary body maturation in the upper airways

2. Helps maintain a rhythmic breathing pattern
3. Promotes clearing mucus from the respiratory tract
4. Helps the lungs remain expanded after the initiation of breathing

93. While assessing a 2-hour old neonate, the nurse observes the neonate to have acrocyanosis. Which of the
following nursing actions should be performed initially?
Acrocyanosis → Blue – extremities; Pink – Trunk (immature peripheral)

1. Activate the code blue or emergency system

2. Do nothing because acrocyanosis is normal in the neonate
3. Immediately take the newborn’s temperature according to hospital policy
4. Notify the physician of the need for a cardiac consult

94. The nurse is aware that a neonate of a mother with diabetes is at risk for what complication?

1. Anemia
2. Hypoglycemia
3. Nitrogen loss
4. Thrombosis

95. A client with group AB blood whose husband has group O has just given birth. The major sign of ABO blood
incompatibility in the neonate is which complication or test result? → Hemolysis → Jaundice

1. Negative Coombs test.

2. Bleeding from the nose and ear
3. Jaundice after the first 24 hours of life
4. Jaundice within the first 24 hours of life

SITUATION: Teaching parents of a neonate the proper position for the neonates sleep, the nurse stresses the
importance of placing the neonate on his back to reduce the risk of infant death syndrome.

96. A client has just given birth at 42 weeks’ gestation. When assessing the neonate, which physical finding is
expected?

1. A sleepy, lethargic baby

2. Lanugo covering the body
3. Desquamation of the epidermis → Peeling
4. Vernix caseosa covering the body

97. After reviewing the client’s maternal history of magnesium sulfate during labor, which condition would the nurse
anticipate as a potential problem in the neonate?

1. Hypoglycemia
2. Jitteriness
3. Respiratory depression
4. Tachycardia

98. Neonates of mothers with diabetes are at risk for which complication following birth?

1. Atelectasis
2. Microcephaly
3. Pneumothorax
4. Macrosomia

99. By keeping the nursery temperature warm and wrapping the neonate in blankets, the nurse is preventing which
type of heat loss?

1. Conduction
2. Convection
3. Evaporation
4. Radiation

100. A neonate has been diagnosed with caput succedaneum. Which statement is correct about this condition?

1. It usually resolves in 3-6 weeks

2. It doesn’t cross the cranial suture line
3. It’s a collection of blood between the skull and the periosteum
4. It involves swelling of tissue over the presenting part of the presenting head