Situation

15 of 46 points
SITUATION: Because pregnancy is a physiologic process, the health sector aims to make pregnancy for the
women and gestation for the fetus as safe and medically uneventful as far as possible.

1. The 2000 Philippine Health Statistics revealed that the main cause of reported
maternal deaths is due to:
1/1

B. Pregnancy with abortive outcomes

C. Hypertension: methergine – can cause hypertension >

D. None of the above

2. Every woman has the right to visit the nearest health care facility for antenatal
registration and to avail prenatal care services. How often should the expectant mother
visit the health center when she is on her 8th month of pregnancy?
1/1
A. Every other day after the 8th month of pregnancy till delivery
B. Every other week at 8th month of pregnancy till delivery
C. Every 2 weeks after the 8th month of pregnancy till delivery

D. None of the above

3. Tetanus toxoid vaccination is important for pregnant women and child bearing
women to prevent them and their baby from acquiring tetanus. How many doses of
Tetanus Toxoid vaccine should be given to the mother to protect the baby from
acquiring neonatal tetanus?
1/1
A. One dose
B. Two doses

C. Three doses
D. Four doses

4. How many doses of Tetanus Toxoid vaccine are needed to protect a mother and
her baby against the disease, during her pregnancy and for lifetime immunity?
1/1
A. Three doses
B. Four doses
C. Five doses

D. Six doses

5. A pregnant woman with hypertension is suffering from postpartum hemorrhage.

The following are the first aid measures to be done by the community health nurse,
except:
1/1
A. Massage uterus and expel clots
B. Give Ergometrine 0.2 mg IM and another dose after 15 minutes -can cause Hypertension

C. Place cupped palmed hands on the uterine fundus and feel for the state of contraction
D. Apply bimanual uterine compression if postpartum bleeding persists

6. The community health nurse should give supportive care to the pregnant
mother during labor. The nurse should do the following, except:
0/1
A. Encourage the mother to take a bath during the onset of labor
B. Encourage the mother to drink and eat when she feels hungry -early stage -soft diet,

C. Remind the mother to empty the bladder every 2 hours

D. Encourage the mother to do breathing exercises for her to have the energy in pushing the
baby out of her birth canal.

7. The nurse should assess the progress of labor. She knows that the pregnant
woman is in false labor if:
0/1
A. The cervix is dilated 4 cm
B. There is an increase in contractions

C. The membranes are not ruptured

D. All of the above
8. The community health nurse should counsel the mother on the recommended
schedule of her first postpartum visit, which is:
0/1
A. 3-5 days after delivery
B. 6 weeks after delivery

C. A day after delivery

D. 3 weeks after delivery

9. During family planning counseling sessions, the nurse should include which
topic in the discussion?
0/1
A. Birth control methods
B. Birth spacing
C. Ideal number of children

D. All of the above

10. It is the nurse’s responsibility to give the couple enough information about the
different methods of contraception. What are the factors that should be considered in
method selection?
0/1
A. The age of the woman
B. The woman's reproductive stage
C. The effectiveness of a method

D. All of the above

11. A population pyramid is a graphical illustration that shows the distribution of

various age groups in a human population which normally forms the shape of a
pyramid. A population pyramid with a broad base indicates:
0/1
A. Higher proportion of children and a low proportion of older people
B. Higher proportion of older people and a low proportion of children
C. Higher female populations

D. Higher male populations

12. A mother who wishes to use Lactation Amenorrhea method as a form of family
planning method should be instructed: - natural method -
Exclusive breastfeeding mom – 6 months give solid month,
A. To use other forms of FP methods after 6 months
B. About the potential side effects

C. To wait for at least 1 month to be more effective as a FP method

D. Alternate breastfeeding with formula feeding to be more effective

13. In providing guidance for a couple wishing to avoid pregnancy, the nurse
reviews the record of a client who has a normal 29-day cycle. On which of the
following days would the nurse expect the client to ovulate?
1/1
A. Day 5 or 6
B. Day 13 or 14
C. Day 15 or 16

D. Day 28 or 29

14. A client who is taking oral contraceptives should immediately report which
symptom is associated with the adverse effect of OC’s?
0/1
A. Blurred vision
B. Nausea
C. Breakthrough bleeding

D. Breast tenderness

15. A mother asks Nurse Basyang about subcutaneous implants and how long will
the implants be effective. Her best response is:
0/1
A. “It is effective for one month”
B. “It is effective for twelve months”

C. “It is effective for up to 5 years”

D. “It is effective for ten years”
16. A client who gave birth to a healthy 8 pound infant 3 hours ago is admitted to
the postpartum unit. Which nursing plan is best in assisting this mother to bond with
her newborn infant?
0/1
A. Encourage the mother to provide total care for her infant.
B. Provide privacy so the mother can develop a relationship with the infant.

C. Encourage the father to provide most of the infant's care during hospitalization.
D. Meet the mother's physical needs and demonstrate warmth toward the infant.

17. Which maternal behavior is the nurse most likely to see when a new mother
receives her infant for the first time?
0/1
A. She eagerly reaches for the infant, undresses the infant, and examines the infant completely.
B. Her arms and hands receive the infant and she then traces the infant's profile with her
fingertips.
C. Her arms and hands receive the infant and she then cuddles the infant to her own body.

D. She eagerly reaches for the infant and then holds the infant close to her own body.

18. A client who is attending antepartum classes asks the nurse why her healthcare
provider has prescribed iron tablets. The nurse's response is based on what
knowledge?
0/1
A. Supplementary iron is more efficiently utilized during pregnancy.

B. It is difficult to consume additional iron by diet alone.

C. Iron absorption is decreased in the GI tract during pregnancy.
D. Iron is needed to prevent megaloblastic anemia in the last trimester.

19. When educating a pregnant client about home safety, which of the following
information is least appropriate for the nurse to include in the teaching plan?
1/1
A. When taking a shower, place a non-skid mat on the floor of the tub or shower.
B. Avoid climbing stairs

C. Avoid wearing high heels.

D. Use non-slip rugs on the floors.
20. A woman comes to the health clinic because she thinks she is pregnant. Tests
are performed and the pregnancy is confirmed. The client’s last menstrual period
began on September 8 and lasted for 6 days. The nurse calculates that her expected
date of confinement (EDC) is:
1/1
A. May 15
B. June 15

C. June 21
D. July 8

21. A woman comes to the clinic for routine prenatal check-up at 34 weeks’
gestation. Abdominal palpation reveals the fetal position as right occipital anterior
(ROA). At which of the following sites would the nurse expect to find the fetal heart
tone?
0/1
A. Below the umbilicus, on the mother’s left side
B. Below the umbilicus, on the mother’s right side
C. Above the umbilicus, on the mother’s left side

D. Above the umbilicus, on the mother’s right side

22. Mrs. Dimaano complains about her morning sickness. The nurse provides
health teachings to the client. Which of the following statements made by the client
indicates a need for further instruction by the nurse?
1/1
A. “I will avoid spicy or fatty foods”
B. “I will postpone eating until supper”

C. “I will eat small frequent meals”

D. “I will eat crackers and dry toast before arising”

23. Nurse Mian is preparing to assist in performing Leopold’s maneuver to a

pregnant client. Which of the following should the nurse include in preparing the client
for this procedure?
0/1
A. Tell the client to drink a glass of water before the procedure
B. Locate the fetal heart tones

C. Tell the client to void before beginning the examination

D. Advise the client not to eat anything 4 hours before the exam

24. Mrs. Makiss is scheduled for a nonstress test. After the test, the result
documented on the chart is no accelerations during the 40 minute observation. The
nurse interprets these findings as:
0/1
A. A reactive stress test

B. A nonreactive stress test

C. An unsatisfactory stress test
D. The results are inconclusive

25. Another client had nonstress tests for the past few weeks and the results were
reactive. A few minutes ago, the results were nonreactive. The nurse anticipates that
the client will be prepared for:
1/1
A. A return appointment in 2 to 7 days to repeat the nonstress test
B. A contraction stress test

C. Hospital admission with continuous fetal monitoring

D. Immediate induction of labor

26. Which of the following is the MOST common emotional response among
women during the first trimester of pregnancy?

A. Ambivalence

B. Depression
C. Acceptance
D. Jealousy
27. During her first trimester, a woman experiences many physiologic changes that
lead her to think she is pregnant. Which of the following changes will the nurse likely
tell her are normal changes for an 8-week pregnancy?
0/1
A. Dysuria -abnormal –painful, sign of UTI in mother , normal urinary frequency , compression of
the bladder
B. Colostrum secretion

C. Nosebleeds -normal-
D. Dependent edema

28 Following her baby’s birth, the woman’s uterine fundus is soft, midline, 2 cm
above the umbilicus, and she has saturated two pads within 30 minutes. Which
immediate need by the client should be addressed?
0/1
A. Be cleaned and have another pad change
B. Empty her bladder

C. Have an increase in her IV fluids of Ringer’s Lactate

D. Have her fundus massaged

29. Nurse Junifer is caring for a woman who is having labor induced with an
oxytocin (Pitocin) drip. Which assessment of the client indicates there is a problem?
1/1
A. The fetal heart rate is 160 beats per minute – normal 110- 160 FHR
B. The woman has three contractions in 5 minutes

C. Contraction duration is 60 seconds

D. Early fetal rate decelerations are occurring

30. Mrs. Fortalejo is in labor and taking three cleansing breaths followed by four,
slow, deep breaths with each contraction. She is experiencing much discomfort with
her contractions. What action is most appropriate for the nurse to take?
1/1
A. Demonstrate to Mrs. Fortalejo a different breathing pattern during contractions

B. Ask the physician for an order of pain medication

C. Have the man take a break and instruct Mrs. Fortalejo in another breathing pattern
D. Leave the couple alone as they have their routine established

31. Nurse Kristine is teaching childbirth education classes. What topic should be
included during the second trimester?
0/1
A. Overview of the conception -1 st trimester

B. Medication and breastfeeding

C. Infant care
D. Strategies to relieve the discomforts of pregnancy – 2nd trimester , leg edema, varicose veins,

32. Nurse Esther is caring for a woman in labor who suddenly complains of
dizziness, becomes pale, and has a 30-point drop in her BP with an increase in pulse
rate. What is the most appropriate initial nursing action?
decrease BP without bleeding: vena cava syndrome – position the client
A. Turn her to her left side
B. Have her breathe into a paper bag

C. Notify her physician

D. Increase her IV fluids

33. A woman is 25% over her ideal weight of 140 pounds. She would like to lose
weight before becoming pregnant. The woman is 2 months into her weight loss
program. Which indicates she is following proper weight management principles?
0/1
A. Carefully selects only carbohydrate and fat choices for meals
B. Has lost a total of 4 pounds
C. Is now 5% over her ideal weight

D. Goes to beginning aerobics for three times a week

34. A 38-week primigravida who works as a secretary and sits at a computer 8

hours each day tells the nurse that her feet have begun to swell. Which instruction
would be most effective in preventing the pooling of blood in the lower extremities?
0/1
A. Wear support stockings
B. Reduce salt in her diet
C. Move about every hour
D. Avoid constrictive clothing

35. A client receiving epidural anesthesia begins to experience nausea and

becomes pale and clammy. What intervention should the nurse implement first?
0/1
A. Raise the foot of the bed
B. Assess for vaginal bleeding
C. Evaluate the fetal heart rate

D. Take the client's blood pressure

36. A 34 week pregnant client calls the clinic complaining of severe headache,
blurred vision, and swollen feet. The nurse expects the physician to tell the client to:
0/1
A. Have it checked in the hospital
B. Come to the clinic tomorrow morning
C. Decrease salt intake and increase fluids

D. Rest for 4 hours a day for 3 days and come to the clinic if symptoms persist

37. Nurse Grasya went to give her morning care to a postpartum mother, she
observed the mother talking to the baby, checking diapers, and asking infant care
questions. Nurse Grasya determines that the client is in which postpartum phase of
psychological adaptation?
0/1
A. Taking in
B. Taking on

C. Taking hold
D. Letting go

38. During an initial prenatal visit, a pregnant client states she has had 2
miscarriages at 12 weeks and 13 weeks, one child delivered at 38 weeks, and another
child delivered at 40 weeks. The nurse documents this as:
0/1
A. G4P2/T2A2
B. G3P3/T2A1

C. G3P2/T2A2
D. G4P3/T3A0

39. A woman who is 24-hours postpartum and who has an episiotomy would be
instructed to report which of the following findings immediately?
0/1
A. Decrease in urine output
B. Absence of a daily bowel movement

C. Presence of lochia rubra

D. Increase in perineal pain sensation

40. A client in active labor is admitted with preeclampsia. Which assessment finding
is most significant in planning this client's care?
0/1
A. Patellar reflex 4+ - normal patellar reflex (+ 2) (hyperactive, seizure if increases normal
patellar reflex)
B. Blood pressure 158/80.

C. Four-hour urine output 240 ml. -30-60 ml per hr urine output

D. Respiration 12/minute.

41. When explaining "postpartum blues" to a client who is 1 day postpartum, which
symptoms should the nurse include in the teaching plan?
1. Mood swings
2. Panic attacks
3. Tearfulness
4. Decreased need for sleep
5. Disinterest in the infant
1/1
A. 1 and 3

B. 1, 3, 4
C. All except 2
D. All of the above
42. A primigravida client with severe preeclampsia is receiving magnesium sulfate
via continuous IV infusion. Which assessment data indicates to the nurse that the
client is experiencing magnesium sulfate toxicity?
0/1
A. Deep tendon reflexes 2+.

B. Blood pressure 140/90.

C. Respiratory rate 18/minute.
D. Urine output 90 ml/4 hours.

43. A woman with severe PIH was delivered 2 hours ago. Which nursing action
should be included in the plan of care for her postpartum hospital stay?
1/1
A. Continuing to monitor blood pressure, respirations and reflexes

B. Encouraging frequent family visits

C. Keeping her NPO
D. Maintain an IV access to the circulatory system

44. Discharge instructions are given to a woman who had been admitted with
placenta previa. Which statement by the client to her husband best demonstrates she
understands the teaching?
0/1
A. “We can’t have sex”
B. “I have to return in a few days for a vaginal exam”

C. “I will have to have a caesarian delivery for this and other pregnancies”
D. “I can go back to part-time work beginning tomorrow”

45. The nurse is caring for a woman who is 35 weeks pregnant. She comes to the
emergency room with painless, vaginal bleeding. This is her third pregnancy and she
states that this has never happened before. What would be avoided in caring for this
client?
0/1
A. Allowing her husband to stay with her
B. Keeping her at rest

C. Shaving the perineum

D. Performing vaginal examination

46. Nurse Hannah is caring for a woman with a placenta previa who has been
hospitalized for several weeks. She is now at 38 weeks’ gestation and her membranes
have ruptured. The amniotic fluid has a greenish color and the woman has started to
bleed again. What would the nurse’s first action?
0/1
A. Administer oxygen
B. Place her in trendelenburg’s position

C. Call the doctor and prepare for a cesarian birth

D. Move her to the delivery room immediately

Situation
5 of 19 points
SITUATION: Nursing Process always must be implemented with an awareness of the interrelationship, during
childbearing, of the maternal and fetal needs and their manifestations. The nurse needs to keep in mind that
interventions for the mother may have an impact on the developing fetus and vice versa.

47. To preserve the reproductive health of the woman and man, guidelines for safer
sex practices were established. Which of the following statements is not included?
0/1
A. The use of condoms is the best protection against infection. Condoms are latex, use oil-based
lubricant rather than water-based lubricant because it can weaken the rubber
B. Be selective in choosing sexual partners
C. For safer oral-vaginal sex, a condom split in two or a plastic dental dam covering the mouth
should be used to protect against the exchange of body fluids
D. Use condom every sexual intercourse

48. A 22-year old woman has missed two of her regular menstrual periods. Her
doctor confirms an early, intrauterine pregnancy. To determine her expected due date,
which of the following assessments is most important?
0/1
A. Date of her first menstrual period
B. Date of sexual intercourse

C. Date of last normal menstrual period

D. Age of menarche
49. A primigravid client asks Nurse Isabelle how the action of hormones during
pregnancy affects her body. Nurse Isabelle responds on the basis that hormones:
1/1
A. Raises resistance to insulin
B. Blocks the release of insulin from the pancreas

C. Prevents the liver from metabolizing glycogen

D. Enhances the conversion of food to glucose

50. Nurse Hannah is caring for a young diabetic woman who is in her first trimester
of pregnancy. As the pregnancy continues Nurse Hannah should anticipate which
change in her medication needs?
0/1
A. A decrease in the need for short-acting insulins
B. A steady increase in insulin requirements
C. Oral hypoglycemic drugs will be given several times daily
D. The variable pattern of insulin absorption throughout the pregnancy requires constant
adjustment

51. Maricar asks Nurse Sarah at what age of gestation is the product of conception
prone to teratogenic insults to the cardiovascular system?
0/1
A. 4th week

B. 8th week
C. 12th week
D. 16th week

52. Nurse Mian discusses the fetal circulation to the students. To check whether the
student understands her teaching she asks, “What is the fetal structure that carries
oxygenated blood from the umbilical cord to the inferior vena cava”. The student
correctly answers, “It is the:
1/1
A. Ductus Venosus

B. Ductus Arteriosus
C. Pulmonary Artery
D. Formane Ovale

53. Lillian asks the nurse the cause of this ailments. Which of the following would the
nurse explain as predisposing factors of mastitis? (Select all that apply)
I. Milk stasis
II. Nipple trauma
III. Using alcohol in cleaning nipples
IV. Baby’s sitting position
0/1 – mastitis- infection of nipple> naiipon ang milk in nipple. .milk statis
A. II and IV
B. I and IV

C. I and II
D. II and III

54. A nurse is working with a particular cultural group in which it is not uncommon
for grandparents to live with their married children and to assist with child rearing and
discipline issues. This is an example of which of the following?
0/1
A. Blended family-

B. Traditional family -wife is husband, husband with work, child.

C. Two-career family - father, mother, both working , and a child
D. Intragenerational family

55. Nurse Isabel is conducting a family assessment to a pregnant client and asks
the following question: "How, as a family, do you deal with disappointments or stressful
changes that occur and affect the members of your family?" The nurse is trying to
identify:
0/1
A. Health beliefs

B. Family communication patterns

C. Family coping mechanisms
D. Potential family problems
56. During the secretory phase of the menstrual cycle, the glands of the uterine
endometrium become corkscrew in appearance and dilated with quantities of glycogen
and mucin. This activity is stimulated by which hormone?
0/1
A. Progesterone
B. Estrogen
C. Glycogen

D. Prolactin

57. The nurse working in a family planning clinic is aware that oral contraceptives
are not contraindicated for which of the following patients?
1/1
A. A 30-year old woman who smokes more than 15 cigarettes a day
B. A 30-year old diabetic woman
C. A 10 week postpartum client who is not breastfeeding

D. A client who experiences migraine with aura

58. An Intrauterine device is being fitted to a client. The nurse understands that IUD
prevents pregnancy by:
0/1
A. Creating a sterile inflammatory process that prevents implantation
B. Suppressing secretion of FSH and LH

C. Blocking the fallopian tube to prevent entry of the ovum -bilateral tubal ligation -ishtmus
D. Killing the spermatozoa before they can enter the cervix

59. The nurse will advise a pregnant client, who is scheduled for amniocentesis, to
perform which of the following?
0/1
A. Increase the fluid intake to help aspirate more amniotic fluid during the procedure
B. Lie in side lying-position to avoid supine hypotension during the procedure
C. Ask the client to take a deep breath and hold it during insertion of needle

D. Rest for 30 minutes after the procedure

60. A high-risk pregnant client will go through a non-stress test. The result indicates
a reactive non-stress test. The client asks the nurse what it means. The nurse aptly
replies by saying:
0/1
A. “The fetus is receiving adequate oxygen”
B. “The fetal heart rate is decreasing, instead of increasing, with every contraction”

C. “There is no fetal movement during stimulation”

D. “You are at risk for premature labor; the doctor may prescribe tocolytic drug”

61. Which of the following common emotional reactions to pregnancy would the
nurse expect to occur during the first trimester?
1/1
A. Introversion, egocentrism, narcissism
B. Awkwardness, clumsiness, and unattractiveness

C. Anxiety, passivity, extroversion

D. Ambivalence, fear, fantasies

62. Which of the following statements, if made by a woman who is 12 weeks

pregnant, would be essential for a nurse to further evaluate?
0/1
A. “I thought I wanted to be pregnant, but now I don’t know”

B. “My husband is angry because I got pregnant”

C. “Being pregnant makes me feel very tried”
D. “I don’t want to get too fat while I’m pregnant”

63. Eliza complains of “after pains” . What should be the nurse IMMEDIATE action?
0/1
A.Advise her to stop breast-feeding for a day

B.Encourage her to drink more water

C.Assess vital signs and pain level
D.Administer an analgesic STAT
64. Eliza is to be discharged 3 days after CS delivery. Which of the following
observation of the nurse would cause the delay of her discharge and would warrant
notification to the physician?
0/1
A.Moderate amount of lochia rubra

B.Fundus is firm and umbilicus

C.Pulse rate of 61 beats/minute taken in 24 hours
D.Five voiding totaling 240 cc in 24 hours

65. On the third postpartum day, Eliza reports that she has voided five times that
morning. What should the nurse INITIALLY do?
1/1
A.Insert a Foley catheter
B.Collect the next voiding and measure the urine amount

C.Catheterize the client to check for residual urine

D.Call the physician

Situation
2 of 6 points
Situation 3- Patient Carlita, 19 years old, is in her first trimester of pregnancy. Because it is her pregnancy ,
she went for her prenatal check-up with her mother. She asked a lot of questions which she expects the nurse
to answer her.

66. The nurse asked for personal data of the patient which, to some, Carlita did not like
to answer. And so she asked: “ why do you need to know I am married?” what should
be a good response of the nurse? “ I asked you marital status because___________.
1/1
A.If you do not have husband, then that can pose a big problem for you”
B.If you are married then your husband will also suffer from discomfort like you”
C.You need your husband to accompany you every prenatal check-up”
D.Your husband is your best support system during your pregnancy”

67. The patient asked what is the term for signs such as breast changes, urinary
frequency, fatigue, morning sickness and amenorrhea?
0/1
A.Probable sign

B. Presumptive sign
C. Possible sign
D. Positive sign

68. The patient complained that every morning , she becomes nauseated and often
times , she would vomit excessively. “What could be the cause of this,” she asked?
The nurse’s answer is: “it is due to increase level of _____________”.
0/1
A.Heart burn
B.Estrogen

C. Heart rate
D. Progesterone -can cause morning sickness

69. The nurse advised patient Carlita to report to her physician which of the following
MOST important sign, if ever she will suffer from it?
0/1
A.Cough
B.Vaginal-bleeding
C. Headache

D. Strong fetal movement

70. When practicing rooming-in , how long should the baby stay with the mother?
____hours.
0/1
A.8
B.24
C. 12

D. 10

71. Erlyn learned that new born infants should ONLY be given , which of the following?
1/1
A.Fruit juice
B.Breast milk

C. Water
D. Cow’s Milk

Situaition
1 of 4 points
Situation 5- Jane is 23 years old. She and her boyfriend, Kevin , are planning to get married in a couple of
months. Thereafter , they plan to have three babies. For this reason they sought reproductive health
counseling for their benefit and the proper growth and development of their future children. Nurse Nilda was
there to help them.

72. Jane asks what she must do in order to be healthy in case she becomes pregnant.
Which among the answers of Nurse Nilda should NOT be followed by jane?
0/1
A.Get support from husband and family
B.May have a message from a lady midwife -it may lead to clot formation
C.To readily accept her pregnancy

D.Early prenatal check-up

73. Kevin asks what possible contribution he could give for the normal development of
the baby. Nurse Jane agreed that his BEST contribution would be the following
EXCEPT __________.
0/1
A.Stroke Jane’s abdomen and talk to baby
B.Provide jane nutritious foods and drinks

C.Join wife during prenatal check-up

D.May smoke once in a while

74. For the normal development of the fetus, Nurse Nilda taught the couple that jane
prevent Folic Acid Deficiency Anemia by good diet , correct way of cooking vegetables
and taking Folic Acid supplements. Which of the following is NOT included among the
outcomes of Folic acid deficiency to the baby?
0/1
A.Cleft lip
B.Cleft palate
C. Neutral tube defect
D. Fractures of all types

75. Nurse Nilda advised the couple that the BEST way to check the condition of the
mother and the baby is to have __________.
1/1
A.Regular well-selected exercise
B.Regular prenatal check-up

C.Music therapy
D.Good food

Situation
1 of 5 points
Situation 7- Any pregnancy may pose a risk. A pregnant woman must therefore submit for her regular prenatal
consultation in any health facility near her place of abode. A nurse can play an important role in making these
pregnant women aware of these risks risk in all stages of pregnancy

76. What CHIEF ingredient of prenatal vitamin for pregnancy nutrition that the patient
should look for?
0/1
A.Vitamin B!2

B.Potassium
C. Vitamin C
D. Folic Acid – vitamin B9-

77. A woman in labor is at risk abruption placenta. Which of the following assessments
would MOST convince you and the pregnant woman to believe that this has
happened?
0/1
A.Painless vaginal bleeding and downward trend of BP
B.An increased blood pressure and scanty urination

C.Pain at the lower quadrant and increase pulse rate

D.Sharp fundal pain and discomfort between contractions
78. A woman 2 ½ months pregnant calls you by telephone because passed out some
“berry-like” blood clots and now has continued dark brown vaginal bleeding. Which of
the following is the BEST instruction you should give her?
0/1 -hemorrhage
A.“continue normal activity but take your pulse and respiratory rate every 4 hours”

B.Come to the health facility if uterine contractions starts”

C.Come to the health facility with any vaginal material passed out”
D.Maintain bedrest and count the number of perineal pads used every hour”

79. A woman , 33 weeks pregnant, with preterm rupture of membranes had blood work
ordered daily. Which laboratory report would be MOST important to read daily?
0/1
A.Serum creatinine
B.Red blood cell count

C.Sodium and potassium levels

D.White blood cell count

80. An 18 years old delivers to an 8-pounds baby after 10 hours of labor. In the pos-
partial period, which of the following would be a PRIORITY concern to assess for by
the nurse?
1/1
A.Endometritis
B.Thrombophlebitis
C. Bleeding

D. Amniotic embolus
Situation 9- Head nurse Carmen supervises Nurse Donna who is assigned to take care of a new born baby
boy named Henrich with a cleft palate.

81. The mother asks the head nurse why the peadiatrician recommended that closure
of palate should be done before he is 6 months old. She asked Nurse Donna to
answer her. Which of the following is Nurse Donna’s APPROPRIATE response?

A.“After age 2, surgery is very frightening and should be avoided if possible”

B.“The eruption of the 2 year molars often complicates the surgical procedure”

C.“Surgery should be performed before the child starts to use faulty speech patterns”
D.“As he gets older the palate gets wider and more difficult to repair”

82. The Head nurse continued to ask Nurse Donna , A cleft lip predisposes to
infections PRIMARILY because of which of the following reasons?”
0/1
A.Wasted products that accumulate along the defect
B.Inadequate circulation in defective area

C.Deficient nutrition from ineffective feeding

D.Mouth breathing that dries the oropharyngeal mucous membranes

83. Which SIGNIFICANT statement of the mother predisposes her son to cleft lip or
palate?
0/1
A.“On my 6 months of pregnancy , I saw a rabbit with the same case of my son”

B.“ I am asthmatic and I usually take steroids”

C.“ My mother-in-law doesn’t like m e, that’s why she cursed me.”
D.“I believe my enemy did some forms of witchcraft on me”

84. For an infant born with a unilateral cleft lip and palate , which of the following type
of feeding will be BEST to use?
0/1
A.Rubber-tipped syringe or medicine dropper
B.Full breast feeding
C.IV fluids on limited number of ounces

D.Cross-cut rubber nipple -large bore nipple

85. Which of the following is the number ONE consideration in the care of an infant
after the surgical repair of a cleft lip ?
-side-lying , unaffected side
A.Preventing the infant from crying
B.Feeding the infant with spoon for 2 days after surgery
C.Placing the infant in a semi-sitting position

D.Keeping the infant NPO for 1 day after surgery

Situation
1 of 5 points
Situation 10- Miel, on her 35 weeks of gestation, is admitted because of hypertension, BP of 185/110, severe
headache and blurred vision. She was placed on imposed bed rest without toilet privileges. The physician
orders MgSo4. Erika is the nurse assigned to her.

86. Which of the following would Nurse Erika anticipate in the patient’s maternal
history?
1/1
A.On and off vaginal spotting
B.Esophageal discomfort is experienced after heavy meal
C.Weight gain of 20 lbs in the 1st and 2nd trimester

D.Fetus moves very frequently

87. When a patient is on an imposed bed rest , which of the following can help the
patient cope? These are the following , EXCEPT _____________.
0/1
A.Let the patient lie on her side to allow more blood to the uterus
B.Increase fluid intake to 8 glasses a day to prevent constipation

C.Discourage participation of family in patient care to prevent further anxiety

D.Use relaxation techniques to help cope with stress such as music and books

88. MgSo4 injections are painful to the patient. which of the following is the BEST
route for injection to prevent such a negative experience for patient miel?
0/1
A.Intravenous injection at the main IV line
B.Intravenous injection given through “piggy back”
C.Intramuscular on each of the deltoid muscle

D. Deep intramuscular using Z-track technique on buttocks

89. The nurse must be alert to MgSo4 toxicity . which of the following is NOT
included?
0/1
A.Fetal bradycardia
B.Urine outputt of <30 ml per hour
C.Respiration of <12 per min
D.Increase in maternal pulse rate

90. Which of the following hospital environmen will be MOST conductive to Miel’s
condition? A room that is/with ___________.
0/1
A.Bright and well-ventilated
B.2 or three patients

C.Quiet and non-simulating

D.A call button for watcher’s use

Situation
3 of 10 points
Situation 12- Mrs. Geminy related , 2o years old , visited prenatal clinic with her husband George . Nurse
Connie noted that the fundus is at the level of the umbilicus. Being her first pregnancy , the patient asks the
clinic nurse about pregnancy ang childbearing. Umbilicus- / 20 weeks pregnant

Bartolomes rule

91. Based from the assessment of the nurse , what should be the estimated age of
gestation ,in WEEKS, if the fundus is at the level of the umbilicus?
1/1
A.12
B.20

C. 16
D. 28

92. When is the placenta , which is the source of estrogen and progesterone, fully
developed ? it is on the _________weeks of pregnancy.
0/1
A.8
B.10
C. 6

D. 12

93. Mrs. Geminy related that she oftentimes feel nauseated in the afternoon. Which of
the following should Nurse Connie advise her to do?
1/1
A.Eat sky flakes and follow it up with water

B.Drink iced carbonated drinks

C.Drink hot chocolate or coffee
D.Eat frequently but small amount of foods

94. Which of the following periods of pregnancy does organogenesis occur?

- Trimester – periods of pregnancy
A.Third
B.First

C. Second
D. Fourth

95. What sign of pregnancy is morning sickness characterized by nausea?

0/1
A.Probable, Subjective
B.Presumptive, Subjective
C. Probable, objective

D. Presumptive, objective

96. While assessing a newborn with cleft lip, the nurse should be alerted on which of
the following that will MOST likely to be compromised?
0/1
A.Locomotion
B.Respiratory Status

C. GI Function
D. Sucking ability

97. What is the MOST APPROPRIATE response of the nurse to the mother’ question
as to when the child will be ready for cleft palate repair?
0/1
A.When a large-holed feeding bottle is ineffective for his feeding
B.When the child is completely weaned from bottle feeding
C.Prior to the development of speech
D.After the child has been toilet trained

98. Elbow restraints are the choice during the patient’s operation. When is the right
time to introduce the use of these restraints? It should be during the _________-
phase
0/1
A.Pre-operative
B.Rehabilitative

C. intra-operative
D. post-operative -elbow restraint

99. The false statement about physiologic jaundice in the statement below is____.
0/1
A. Caused by impairment in the removal of bilirubin deficiency in the production of glucoronide
transferase.
B. Begins to decrease by 6th or 7th day.

C. Is visible in skin and sclera

D. Begins after 24 hours of life

100. Neonatal jaundice FIRST becomes visible in which of the following parts?(Select
all that apply)
1. Face
2. Forehead
3. Trunk
4. Extremities

A. 3 & 4
B. 1 & 2

C. 1 & 4
D. 2 & 3