NURSING PRACTICE 2-PRE-BOARD

EXAMINATION-VMUF.-COLLEGE OF
NURSING- REVALIDA 2021
100 ITEMS

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Situation 1: A 15-year-old client complains of persistent dysmenorhea.

1. The nurse should encourage her to: *

A. Maintain daily activities

B. Have a gynaecologic examination

C. Eat a nutritious diet containing iron

D. Practice relaxation of abdominal muscles

2. A client at the women’s health clinic tells the nurse she has endometriosis. To
best help this client the nurse must understand that endometriosis is
characterized by: *

A. Amenorrhea and insomnia

B. Ecchymoses and petechiae

C. Painful menstruation and backache

D. Early osteoporosis and pelvic inflammation

3. A client undergoing treatment for infertility is diagnosed as having

endometriosis. Which of the following drugs should the nurse expect to be used
for this conditions? *

A. Relaxin (Releasin)

B. Leuprolide (Lupron)

C. Estrogen (Premarin)

D. Ergonovine (Ergotrate)
Situation 2: A thin 68-year-old female client is diagnosed with osteoporosis.

4. What should the nurse include in the discharge plan for this client? *

A. Encouragement of gradual weight grain

B. Monitoring for decreased urine calcium

C. Instructions relative to diet and exercise

D. Safety factors when using opioids and NSAIDs

5. When writing a teaching plan about osteoporosis, the nurse should recall that
osteoporosis is best described as: *

A. Avascular necrosis

B. Pathologic fractures

C. Hyperplasia of osteoblasts

D. Decrease in bone substance

6. Which factor identified by the nurse places the client at increased risk for
developing osteoporosis? *

A. Estrogen therapy

B. Hypoparathyroidism

C. Prolonged immobility

D. Excess calcium intake

7. The nurse plans care for a client with osteoporosis to prevent fractures. What
type of fracture is the nurse trying to prevent? *

A. Fatigue

B. Pathologic

C. Greenstick

D. Compound
8. Select all the statements by a 50-year-old obese client that indicate
understanding of the strategies to prevent bone loss. “I should: A. Go on a strict
diet." B. Take 1200 mg of calcium daily.” C. Take 1000 mg of vitamin D daily.” D.
Join an aerobics class three times a week.” E. Exercise with free weights two
times a week.” *

A. A, B, C

B. B, C, D

C. B & D

D. C & D

Situation 3: After a client has a biopsy for suspected cervical cancer, the
laboratory report reveals a stage 0 lesion.
9. The nurse explains that according to the International Federation of
Gynecology and Obstetrics, stage 0 is indicative of: *

A. Carcinoma in situ

B. Early stromal invasion

C. Parametrial involvement

D. Carcinoma confined to the cervix

10. An early manifestation of cancer of the cervix that should prompt a client to
seek medical care is: *

A. Abdominal heaviness

B. Pressure on the bladder

C. Foul-smelling discharge

D. Bloody spotting after intercourse

Situation 4: A client suspects that she is pregnant, but because she is the only
wage earner in her family she is ambivalent about continuing the pregnancy.
11. The nurse recognizes that the client is in crisis and also remembers that
pregnancy and birth are considered crises because: *

A. Mood changes occur during pregnancy

B. They are periods of change and adjustment to change

C. There are hormonal and physiologic changes in the mother

D. Narcissism in the mother affects the husband-wife relationship

12. After the first 3 months of pregnancy, the chief source of estrogen and
progesterone is the: *

A. Placenta

B. Adrenal cortex

C. Corpus luteum

D. Anterior pituitary gland

13. Anticipatory guidance provided by the nurse during the first trimester of
pregnancy should be primarily directed toward increasing the pregnant woman’s
knowledge of: *

A. Labor and birth

B. Signs and symptoms of complications

C. Role transition into parenthood and its acceptance

D. Physical and emotional changes resulting from pregnancy

14. The nurse at the prenatal clinic examines a client and determines that her
uterus has risen out of the pelvis and is now an abdominal organ. At what week
during pregnancy does this occur? *

A. 8th week of pregnancy

B. 10th week of pregnancy

C. 12th week of pregnancy

D. 18th week of pregnancy

Situation 5: A mothers class was conducted by a group of nursing students in
Barrio Masangkay, their topic is on fertilization and fetal growth and
development.

15. A nursing instructor ask the nursing student to list the function of the
amniotic fluid. The students responds correctly by stating which of the following
are function of amniotic fluid ? Select all that apply A. Allows for fetal movement
B. It is a measure of kidney function C. Surrounds, cushions, and protect the
fetus D. Maintain the body temperature of the fetus E. Prevents large particles
such as bacteria such as bacteria from passing to the fetus F. Provides an
exchange of nutrients and waste products between the mother and the fetus *

A. A,B,C,D

B. B,C,D,E

C. A,D.E.F

D. A,B,C,D,E
16. A nurse midwife is assessing a pregnant client for the presence of
ballotement, to make this determination the nurse-midwife does which of the
following *

A. Auscultates for fetal heart sounds

B. Assesses the cervix for compressibility

C. Palpates the abdomen for fetal movement

D. Initiates a gentle upward tap on the cervix

17. A nurse is providing instructions to a pregnant client who is scheduled for an

amniocentesis. The nurse tells the client that: *

A. Strict bed rest is required after the procedure.

B. An inform consent needs to be signed before the procedure.

C. Hospitalization is necessary for 24 hours after the procedure.

D. A fever is expected after the procedure because of the trauma to the abdomen.
18. A nurse is assisting in performing an assessment on a client who suspects
that she is pregnant and is checking the client for probable signs of pregnancy.
Which of the following are probable signs of pregnancy? Select all that apply. A.
Ballottement B. Chadwick’s sign C. Uterine enlargement D. Braxton Hicks
contraction E. Fetal heart rate detected by a non electronic device F. Outline of
fetus via radiography or ultrasonography *

A. A,C,D,E,F

B. A,B,C,D

C. A,C,D,E

D. A,B,C,D,E,F

Situation 6: A primiparous mother had her first prenatal visit.

19. A rubella titer result of a 1 day post partum client is less than 1:8, and a rubella
virus vaccine Prescribed to be administered before discharge. The nurse
provides which information to the client about the vaccine? Select all that apply.
A. Breast- feeding needs to be stopped for 3 months. B. Pregnancy needs to be
avoided for 1 to 3 months C. The vaccine is administered by the subcutaneous
route. D. A hypersensitivity reaction can occur if the client has an allergy to eggs.
E. Exposure to immunosuppressed individuals needs to be avoided. F. The area of
the injection needs to be covered with a sterile gauze for 1 week. *

A. A, B C, D

B. B, C , D, E, F

C. B, C, D, E

D. B, C, D

Situation 7: A 19-year-old primigravida at 38 week’s gestation is admitted to

the hospital in active labor that began 8 hours ago. Her mother accompanies
her to the labor unit.
20. When the cervix is 6 cm dilated, the client receives a continuous lumbar
epidural block. After administration of this anesthesia , it is most important for
the nurse to assess the *

A. fetal heart rate.

B. amniotic fluid color.

C. level of anesthesia

D. level of consciousness

21. The nurse performs Leopold’s maneuvers. When the client asks what these
maneuvers are for, the nurse’s best response is to explain that they help
determine *

A. fetal presentation

B. a multifetal pregnancy.

C. estimated gestational.

D. intensity of contractions.
22. The nurse formulates a nursing diagnosis for the client in the transitional
phase of labor. The most appropriate diagnosis is *

A. Altered Urinary Elimination Patterns related to physiologic changes of labor.

B. Dizziness related to hyperventilation.

C. Ineffective Family Coping related to lack of confidence.

D. Pain related to increasing frequency and intensity of uterine contractions.

23. On admission, the client is breathing rapidly and complains of feeling dizzy
and lightheaded. The client’s cervix is 5 cm dilated. The nurse determines that
she is most likely experiencing effects of *

A. rapid cervical dilation.

B. elevated blood pressure.

C. hyperventilation.

D. excitement about the labor process.

24. The nurse plans to instruct the client about the gate control theory of pain.
Which of the following statements would be appropriate for the nurse to include
in the teaching plan? *

A. The gating mechanism is located at the pain site.

B. Pain is a matter of perception.

C. Shallow chest breathing can open the gate.

D. The gating mechanism is in the spinal cord.

25. The nurse explains that according to the gate control theory of pain, a closed
gate means that the client should experience *

A. No pain.

B. Sharp pain.

C. Light pain.

D. Reduced pain.
26. The physician has ordered prostaglandin E2 gel for the client. The nurse plans
to explain to the client that the purpose of the gel is to *

A. increase the intensity of uterine contractions.

B. prevent uterine rupture.

C. ripen the cervix.

D. ensure a good fetal outcome.

27. The client complains of severe back pain during labor. The nurse should
instruct the client that her severe back pain is most likely due to the fetal occiput
being in a position termed *

A. Oblique.

B. Transverse.

C. Posterior.

D. Asynclitic.
28. The client‘s contractions and fetal heart rate are monitored with external
electronic equipment. The nurse determines that there is a variable deceleration
pattern on the fetal heart rate. The nurse should first *

A. notify the anesthesiologist.

B. change the client’s position.

C. administer oxygen at 2 liters by mask.

D. prepare the client for a cesarean section.

Situation 8: You are a nurse assigned for nutrition education class in your
barangay. The following questions deals with teaching clients with regards to
improving their health through health promotion.

29. Mr. Rodriguez asks you what is the normal allowable salt intake in a day. Your
best response to Rodriguez is: *

a. 1 teaspoon of salt a day with iodine and sprinkle of monosodium glutamate

b. 5 grams of salt a day or 1 teaspoon of salt a day

c. 1 tablespoon of salt with some fish sauce and soy sauce

d. 1 teaspoon of salt with no fish sauce and soy sauce

30. You would educate Mr. Rodriguez with regards to lowering his salt intake
using which of the following instruction EXCEPT: *

a. Eat foods with little or no salt added

b. Limit table salt but condiments is advisable

c. Minimize the intake of tocino, longanisa and other processed foods

d. Use spices, fruits, vegetables and herbs instead

31. Which of the following is the best method of teaching young mothers with
regards to nutrition education? *

a. Diets limited in salt and fat

b. Harmful effects of drugs and alcohol intake

c. Commercial preparation of dishes

d. Cooking demonstration and meal planning

32. The cure of cancer would depend on: *

a. Knowing the warning signs of cancer

b. Early detection and early treatment

c. Utilization of alternative medicine

d. Performing Testicular self-examination regularly

33. In health education, which of the following is a role of the Nurse? *

a. Focusing on programs on drug rehabilitation and smoking cessation

b. Educate as many people about warning signs of non-communicable diseases

c. Monitoring client with hypertension

d. Reporting cases of TB, Leprosy, AIDS and other communicable diseases

Situation 9: Nurses and sudden unusual incidence

34. Sandra, an R.N., reports to work looking unkempt. Nancy, another R.N.
approaches when she notices her using uncoordinated movements. Sandra's
breath reeks of peppermints and Nancy suspects Sandra may be intoxicated.
What is the best initial nursing action for Nancy to take? *

a. Call the supervisor and report Sandra

b. Confront Sandra, saying that she feels she is intoxicated, and relieve her of her
nursing duties immediately

c. Ignore the situation

d. Give Sandra a lecture about substance abuse and do nothing else

35. As good nurse leader in your ward, you must know how to provide a
therapeutic environment. Your initial approach to creating a therapeutic
environment for any client should give priority to: *

a. Providing for the client's safety

b. Accepting for client's individuality

c. Promoting the client's independence

d. Explaining everything that is being done for the client

36. You must know the proper nursing management for elderly patients. During
the day a nurse puts side rails up on the bed of a 78-year-old client who was
admitted in your ward and has a hip fracture. The reason for this action is: *

a. As a safety measure because of the client's age

b. Because all clients over 65 years old of age should always have use side rails

c. So that it will be used as handholds and to facilitate the mobility while in bed

d. Because elderly are usually disoriented for several days after surgeries and
anesthesia

37. An elderly client is apprehensive about being hospitalized. The nurse realizes
that one of the stresses in the hospital that she must know how to manage is the
patient's strangeness of the new environment and activities. Stress of the patient
can best be prevented or limited by? *

a. Calling the patient by their first name

b. Explaining what behavior is expected

c. Visiting with the client frequently

d. Listening to what the client has to say

38. The civil rights of the client would not be jeopardized in which of the
following situation? *

a. Trying to forcibly detain a client who may suffer great harm by leaving the hospital

b. Giving emergency medical care to a client's without his or her consent of the family

c. Giving psychiatric client's letter addressed to the physician

d. Giving the client's insurance broker access to his chart

Situation: Candida Alba was promoted to become the head nurse of Maternity
Ward in Panthom Hospital. She uses the principles of caring a pregnant woman
during her antepartum period which are implied in the following questions.

39. Which of the following best defines childbirth education? *

a. The minimal level of teaching requirements for prenatal care in this country, as
advocated by health care professionals

b. Approach to childbirth involving the use of a coach and advocation of “natural

childbirth” without analgesia

c. Achievement of a positive, safe and rewarding labor and birth experience for
parents and family members

d. Information, exercises, and techniques to deal with the discomforts of pregnancy,

labor, and birth
40. Which of the following approaches to childbirth education advocates slow
breathing, deep relaxation, and a person to act as coach? *

a. Dick-Read method

b. “New childbirth” method

c. Bradley method

d. Lamaze method

41. A client, about 8 weeks pregnant, asks the nurse when she will be able to hear
the fetal heartbeat. The nurse would respond by telling the client that the fetal
heartbeat can be heard with a Doppler ultrasound device when the gestation is
as early as which of the following? *

a. 4 weeks

b. 8 weeks

c. 15 weeks

d. 18 weeks
42. A primiparous client at 10 weeks’ gestation questions the nurse about the
need for an ultrasound. She states “I don’t have health insurance and I can’t
afford it. I feel fine, so why should I have *

a. Identification of fetal parts and possible down syndrome

b. Determination of gestational age

c. View the heart beating to indicate that fetus is healthy

d. Determination of fetal position

43. Which of the following best describes the effectiveness of childbirth

education? *

a. It provides expectant parents with knowledge and skills necessary to cope with
pregnancy

b. It prepares expectant parents to be informed consumers of birthing attendants and

facilities

c. It provides a long time for expectant parents to express their concerns and fears

d. It improves newborn health, parent-newborn bonding, and ability to cope with labor.
44. A patient at a prenatal class asks the nurse, “How do my baby’s lungs get air
now that I’m pregnant?” The nurse’s correct response is: *

a. “Your baby gets air from the placenta.”

b. “No one knows how babies get air in the uterus. This is a good question.”

c. “Your lungs provide enough air for your baby to breathe.”

d. “Your baby’s lungs don’t need air at this time; the fetal lungs don’t function as lungs
until birth.”

45. The client tells the nurse that her last menstrual period started on January 20.
Using Nagele’s rule, the nurse determines her EDD to be which of the following? *

a. September 27

b. October 21

c. November 7

d. December 27
46. When taking an obstetrical history on a pregnant client who states, “I had a
son born at 38 weeks’ gestation, a daughter born at 30 weeks’ gestation, and i
lost a baby at about 8 weeks,” the nurse should record her obstetrical history as
which of the following? *

a. G2 T2 P0 A0 L2

b. G3 T1 P1 A0 L2

c. G3 T2 P0 A0 L2

d. G4 T1 P1 A1 L2

47. When preparing to listen to the fetal heart rate at 12 weeks’ gestation, the
nurse would use which of the following? *

a. Stethoscope placed midline at the umbilicus

b. Doppler placed midline at the suprapubic region

c. Fetoscope placed midway between the umbilicus and the xiphoid process

d. External electronic fetal monitor placed at the umbilicus.

48. A group of women are concerned about what “full term” means related to
pregnancy. The nurse correctly explains that full term is: *

a. 27 to 30 weeks’ gestation

b. 37 to 42 weeks’ gestation

c. 41 to 43 weeks’ gestation

d. 32 to 36 weeks’ gestation

Situation: Annie Butongbacal was assigned in Labor and Delivery Room

because of her knowledge on the different stages of labor and the nursing
care and management given to the parturient mothers. The following
questions are examples of the situations that requires nursing assessment and
interventions during intrapartum period.
49. The normal female pelvis is well suited for labor and birth and has: *

a. A rounded inlet, nonprominent ischial spines, straight side walls, and a deep and
roomy posterior segment

b. A heart-shaped inlet, prominent ischial spines, convergent side walls, and a shallow
posterior segment

c. An oval inlet, variable ischial spines, straight side walls, and a deep posterior
segment

d. A transversely oval inlet, variable ischial spines, parallel side walls, and a wide
transverse diameter

50. Which of the following best defines the intrapartum period? *

a. Time from complete cervical dilation through delivery of the newborn

b. Period from the onset of contractions through complete cervical dilation

c. Period from the onset of contractions to the first 1 to 4 hours after delivery

d. Time from the 28th week of gestation through 28 days after birth of the newborn

Situation 10: A multiparous client thought to be at 14 weeks’ gestation (based

on uterine size) visits the prenatal that she is experiencing such severe
morning sickness that “she has not been able to keep anything down for a
week”.
51. Due to the client’s excessive vomiting, the nurse assesses the client’s
urinalysis results for *

A. White blood cells

B. Albumin

C. Glucose

D. Acetone

52. Because the client states she has been vomiting for 1 week, the nurse should
assess for symptoms of *

A. Hypercalmia

B. Hyponatremia

C. Hypokalemia

D. Hyperglycemia
53. The nurse explains to the client that hyperemesis gravidarum is thought to be
related to high levels of the hormone *

A. Progesterone

B. Estrogen

C. Somatotropin

D. Aldosterone

Situation 11: A 38-year-old client about 14 weeks’ gestation is admitted to the

hospital with diagnosis of complete hydatidiform mole.

54. Soon after admission, the nurse should assess the client for symptoms of *

A. PIH.

B. diabetes mellitus.

C. hyperthyroidism.

D. polycythemia.

Situation 12: Pharmacology in Child Health Nursing

55. A 7-year-old child with cystic fibrosis is receiving an intravenous antibiotic.
The medication is supplied in a 125-mL bag of normal saline. It is to be infused
over 30 minutes. At what rate should the infusion pump be set to deliver the
medication at the prescribed time? *

A. 250 mL/hour

B. 300 mL/hour

C. 150 mL/hour

D. 260 mL/hour

56. An infant is receiving parenteral therapy. The IV orders are 400 mL of D50.45
NS to run in 8 hours. At what rate should the nurse maintain the hourly rate? *

A. 20 mL/hr

B. 30mL/hr

C. 40 mL/hr

D. 50mL/hr

Situation 13: Care of Client with CAST.

57. A 4-month-old infant is in a spica cast. What should the nurse include in the
discharge instructions? *

A. Obtain a specially design car seat

B. Change infant’s position every 8 hours

C. Diapers alone should be used to reduce soiling of the cast

D. Use the abduction bar between the infant’s legs for position changes

58. When elevating the head of an infant in a spica cast, the nurse should: *

A. Place 2 pillows under the shoulders

B. Limit this positions to 1 hour at the time

C. Pad the edge of the cast with folded diapers

D. Raise the entire mattress at the head of the crib

Situation 14: Care of Clients with Cretinism.

59. A 3-month-old infant has been diagnosed with congenital hypothyroidism.
What is the probable effect on the child’s future i treatment is not begun in early
infancy? *

A. Lifelong myxedema

B. More severe mental retardation

C. Development of spastic paralysis

D. Repeated episode of thyrotoxicosis

Situation 15: Care of Client with Cleft lip.

60. What should nursing care for an infant after the surgical repair of a cleft lip
include? *

A. Preventing the infant from crying

B. Placing the infant in a semi-sitting position

C. Keeping the infant NPO for 1 day after surgery

D. Feeding the infant with a spoon for 2 days after surgery

61. For an infant born with a unilateral cleft lip and palate, feeding will probably
be: *

A. Limited to IV fluids

B. Accomplished with a cross-cut nipple

C. Achieved with a rubber-tipped syringe or medicine dropper

D. Different from feeding an infant with a bilateral cleft lip or palate

Situation 16: Care of Client with Pyloric Stenosis.

62. An infant with hypertrophic pyloric stenosis (HPS) is admitted to the pediatric
unit. When palpating this infant’s abdomen, the nurse expects: *

A. A distended colon

B. Marked tenderness around the umbilicus

C. An olive-sized mass in the right upper quadrant

D. Rhythmic peristaltic waves in the lower abdomen

63. The nurse should carefully observe the infant with a tentative diagnosis of
hypertrophic pyloric stenosis for; *

A. Signs of dehydration

B. The quality of the cry

C. Coughing after feeding

D. The character of the stool

64. An infant has had corrective surgery for hypertrophic pyloric stenosis. To
reduce vomiting, the nurse should teach the mother that immediately after
feeding the infant, she should: *

A. Rock the infant

B. Place the infant in an seat

C. Place the infant flat on the right side

D. Keep the infant awake with sensory stimulation

Situation 17: Intake of Adequate Nourishment

65. A newly delivered mother tells the nurse she thinks she wants to breastfeed
because she has read that breast milk is easier to digest and provides immunity
for her baby. The nurse knows that this mother should succeed in breastfeeding
because she’s *

a. Obviously educated

b. Informed

c. Young

d. Obviously motivated

66. A student nurse asks, “What causes milk let-down?” The nurse’s correct
response is: *

a. Prolactin

b. Oxytocin

c. Estrogen

d. Progesterone

Situation 18: Breastfeeding is essential in Newborn Care

67. The nurse should explain to a client that breastfeeding is always
contraindicated with: *

A. Mastitis

B. Hepatitis C

C. Inverted nipples

D. Herpes genitalis

68. The client response that indicates understanding of teaching regarding

breast care for the mother who is breastfeeding is, “I will: *

A. Use a mild soap for washing.”

B. Remove my brassiere at night.”

C. Air dry my nipples after feeding.”

D. Line my breast pads with plastic.”

69. A client who is breastfeeding is being discharged. The client tells the nurse
that she is worried because her neighbor’s breast “dried up” when she got home
and had to discontinue breastfeeding. What should the nurse reply? *

A. “Once lactation is established, this rarely happens.”

B. “You have little to worry about because you already have a good milk supply.”

C. “This can happen with the excitement of going home, but putting the baby to breast
more often should re-establish lactation.”

D. “This commonly happens, so we will give you a bottle of formula to take home so
the baby won’t go hungry until your milk supply returns.”

70. To limit the development of hyperbilirubinemia in the breast neonate, the

plan of care should include: *

A. Instituting phototherapy for 30 minutes every 6 hours

B. Substituting breastfeeding for formula during the second day after birth

C. Supplementing breastfeeding with glucose-water during the first 24 hours

D. Encouraging more frequent breastfeeding during the first 2 days after birth
71. The nurse identifies that a woman needs further teaching about
breastfeeding her newborn when she: *

A. Leans forward to put her breast and in a side-lying position

B. Holds the infant level with her breast and in a side-lying position

C. Touches her nipple to the infant’s lips when beginning the feeding

D. Puts her finger in the infant’s mouth to break the suction when switching breasts

72. A client asks about the difference between cow’s milk and the milk from her
breasts. The nurse should respond that cow’s milk differs from human milk in that
it contains: *

A. Less protein, less calcium and more carbohydrates

B. Less protein, more calcium, and more carbohydrates

C. More protein, less calcium, and fewer carbohydrates

D. More protein, more calcium, and fewer carbohydrates

Situation 19: At 12 weeks’ gestation, a client who is Rh-negative completely

expels the products of conception.
73. After determining that she has not been previously sensitized, the nurse
should: *

A. Administer RhoGAM within 72 hours

B. Make certain the client receives RhoGAM at her first clinic visit

C. Withhold the RhoGAM, because it is not used after the birth of a stillborn

D. Withhold administration of the RhoGAM, because the gestation lasted only 12

weeks

74. A client who has type O Rh-positive blood gives birth. The neonate has type B
Rh-negative blood. When the nurse assesses the neonate 11 hours after birth, the
infant’s skin appears yellow. This is most likely caused by: *

A. Neonatal sepsis

B. Rh incompatibility

C. Physiologic jaundice

D. ABO incompatibility
75. The nurse in the newborn nursery observes a yellowish skin color of an infant
whose mother had a caesarean birth. The immediate nursing action should be to:
*

A. Notify the practitioner

B. Ascertain the age of neonate

C. Take a heel blood sample and send it to the laboratory

D. Cover the eyes and place the infant under the ultraviolet light

76. When observing a newborn for signs of pathologic jaundice, the nurse should
be alert for: *

A. Muscular irritability at birth

B. Neurologic signs during the first 24 hours

C. Jaundice developing between 48 and 72 hours after birth

D. Jaundice developing between the first 12 and 24 hours

Situation 20: Care of the Pre-term Newborn

77. The nurse must continuously monitor a preterm infant’s temperature and
provide appropriate nursing care because the preterm infant, unlike the full-term
infant, has: *

A. An inability to use shivering to produce heat

B. An inability to break down glycogen to glucose

C. A limited supply of brown fat available to provide heat

D. A limited amount of pituitary hormones to control internal heat

78. When meeting a preterm infant’s hydration needs, the nurse should know that
the preterm infant’s urinary function: *

A. Is the same as in a full-term newborn

B. Results in the loss of large amounts of urine

C. Leads to urine with an elevated specific gravity

D. Adequately maintains an acid-base and electrolyte balance

79. When caring for preterm infants with respiratory distress, the nurse should
keep: *

A. Them prone to prevent aspiration

B. Them in a high-humidity environment

C. Their caloric intake low to decrease metabolic rate

D. Their oxygen concentration low to prevent eye damage

Situation 21: Aringking King, a graduating nursing student is reviewing her

notes on maternity nursing in preparation for her Licensure Examination. If you
were her, what will be your answers to the following test questions that
Aringking King is practicing?
80. A patient’s remark during a discussion of sexuality and reproduction indicates
to the nurse that he needs further information. Which of the following is the
patient’s statement? *

a. “Simultaneous orgasm isn’t essential for conception to occur”

b. “The woman determines the sex of the offspring”

c. “Urination after intercourse won’t prevent pregnancy”

d. “With advancing age, sex can be very gratifying”

81. When providing sexual care to clients, the nurse knows that the most
common nursing diagnosis is which of the following? *

a. Sexual dysfunction related to psychological factors

b. Self-esteem disturbance related to guilt

c. Body image disturbance related to negative feelings

d. Knowledge deficit related to altered sexual function

82. When taking a sexual history, which of the following denotes the correct
manner from which the nurse would proceed? *

a. Specific to general problems

b. Common to unusual problems

c. Physical to psychological problems

d. Simple to complex problems

83. Which of the following should the nurse do first when dealing with a couple
having sexual problems after 20 years of marriage? *

a. Provide the couple with information about common sexual problems

b. Arrange a physical examination for both partners

c. Refer the couple to a support group for sexual dysfunction

d. Allow the couple to talk about their sexual problems

84. Female reproductive cells are produced by the: *

a. Uterus

b. Fallopian tubes

c. Ovaries

d. Pituitary gland

Situation 22: Mrs. Celine Crisanto, a registered nurse-midwife together with

her colleagues works hand in hand to conduct a seminar on the Growth and
Development of the individual. They considered the following questions to be
included in the discussion.

85. When assessing a client from a culture different than nurse’s own, which of
the following should the nurse do first? *

a. Be sensitive to the family’s beliefs

b. Understand his or her own beliefs

c. Enact Western values on the family

d. Modify family’s cultural beliefs

86. When caring for a child and family with a different cultural background, which
of the following would be an appropriate goal? *

a. Striving to keep background from influencing health needs

b. Discouraging continuation of cultural practices in the hospital

c. Gently attempting to change family’s cultural beliefs

d. Adapting family’s health needs to family’s cultural practices as necessary

87. Which of the following factors plays the greatest role in adversely affecting a
child’s health? *

a. Cultural background

b. Religious influences

c. Environmental influences

d. Socioeconomic status
88. When assisting families in identifying their needs and goals, the nurse
assumes which of the following roles? *

a. Advocate

b. Health promoter

c. Health teacher

d. Counselor

89. The sequence of events that leads parents to seek health care for their child
is called which of the following? *

a. Chief complaint

b. Present illness (health)

c. Past history

d. Review of systems

Situation 23: A 1-month-old infant is admitted to the pediatric unit with a

tentative diagnosis of Hirschsprung’s disease (congenital aganglionic
megacolon).
90. What procedure will probably be ordered to confirm the diagnosis? *

A. Rectal tube

B. Suction biopsy

C. Multiple saline enemas

D. Fiberoptic nasoenteric tube

91. The practitioner orders a tap-water enema for a 6-month-old infant with
suspected Hirschsprung’s disease. What rationale would cause the nurse to
question the order? *

A. The result could be loss of necessary nutrients

B. It could cause a fluid and electrolyte imbalance

C. It could increase the fear of intrusive procedures

D. The result could cause shock from a sudden drop in temperature

92. An order is written for an isotonic enema for a 2-year-old child. What is the
maximum amount of fluid the nurse should give to this child without a
practitioner’s specific order? *

A. 100 to 150 mL

B. 155 to 250 mL

C. 255 to 360 mL

D. 365 to 500 mL

Situation 24: A 5-month-old infant is brought to the pediatric clinic for a

routine monthly examination.

93. What is a common finding that the nurse can identify in most children with
symptomatic cardiac malformations? *

A. Mental retardation

B. Inherited genetic factors

C. Delayed physical growth

D. Clubbing of the fingertips

94. A 2-year-old child has a congenital cardiac malformation that causes right-
to-left shunting of blood through the heart. What clinical finding should the
nurse expect? *

A. Proteinuria

B. Peripheral edema

C. Elevated hematocrit

D. Absence of pedal pulses

95. Anticipating that a 4-year-old child, scheduled for open-heart surgery, will
have chest tubes in place postoperatively the nurse informs the parents that the
chest tubes will: *

A. Increase tidal volumes

B. Promote drainage of air and fluid

C. Maintain positive intrapleural pressure

D. Regulate pressure on the pericardium and chest wall

96. After a discussion with the pediatric cardiologist, the parents of an infant with
patent ductus arteriosus (PDA) ask the nurse to explain once again what PDA is.
The nurse explains that it is: *

A. An enlarged diameter of the aorta

B. A narrowing of the entrance to the pulmonary artery

C. A connection between the pulmonary artery and the aorta

D. An opening in the wall between the right and left ventricles

97. The nurse caring for a child with a cardiac malformation associated with left-
to-right shunting should be aware that the major characteristics of this type of
congenital disorder is: *

A. Severe growth retardation

B. Clubbing of the fingers and toes

C. Increased blood flow to the lungs

D. Polycythemia and elevated hematocrit

98. A young child has coarctation of the aorta. What should the nurse expect to
identify when taking the child’s vital signs? *

A. A weak radial pulse

B. An irregular heartbeat

C. A bounding femoral pulse

D. An elevated blood pressure in the arm

99. A 2-week-old boy is admitted with a tentative diagnosis of a ventricular

septal defect. The parents report that their baby has had difficulty feeding since
he has been home. The nurse explains that: *

A. Feeding problems are common in neonates

B. Inadequate sucking is not significant in the absence of cyanosis

C. Ineffective sucking and swallowing may be early indications of a heart defect

D. Many neonates retain mucus and this may interfere with feeding for several weeks
 100. The laboratory analysis for a 5-year-old child admitted for repair of
tetralogy of Fallor indicates an elevated RBC count. This polycythemia is a
compensatory mechanism for: *

A. Tissue O2 need

B. Low blood pressure

C. Diminished iron level

D. Hypertrophic cardiac muscle

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