Situation
Vitamin K is needed in the production of certain
A nurse should be knowledgeable and skilled in caring
for families with a newborn.
1. A newborn’s mouth should be wiped first then the
nose. What is the most accurate rationale behind this?
a. Newborns breathe through their mouths
b. Newborns breathe through their nose
c. Newborns may inhale outside air
d. Newborns may drink their amniotic fluid
BABIES UP TO 6 MONTHS-OLIGATE NOSE
BREATHERS
2. When the Moro Reflex is stimulated in an infant,
the infant will _____________the arms with the palms of
the hands turned ___________ and then move the arms
___________ the body.
a. flex, upward, away from
b. extend, upward, back to
c. flex, downward, back to
d. extend, downward, away from
3. Most newborns experience physiologic jaundice 24
hours after delivery, as a result of breakdown of fetal red
blood cells. However, when indirect bilirubin levels
become above normal, this may be potentially dangerous
because it can:
a. Interfere with the chemical synthesis of brain cells,
resulting in permanent cell damage called kernicterus
b. Lead to inadequate levels of red blood cells, resulting
in anemia
c. Impair peripheral circulation, leading to decreased
tissue perfusion and cyanosis
d. Cause build-up of urea under the skin, resulting in
uraemic pruritus
4. Hazel, who just delivered her baby 17 hours ago,
asked you: “Why does my baby’s head look weird?”
What is your most appropriate response?
a. “Your baby’s head does look weird. Let us ask your
doctor why.”
b. “It looks asymmetrical. Was there anything that
happened to your baby’s head?”
c. “Your baby’s head was molded during labor and
delivery. This will go back to normal after a few
days.” MOLDING IS NORMAL IN NEWBORN
d. “I don’t know what you are saying. It does not look
weird.”
5. Baby Nicole was delivered 1 hour ago. You are
tasked to give BCG vaccine, Hepatitis B vaccine, and
Vitamin K injection. What is the best rationale in giving
Vitamin K in newborns?
a. Vitamin K aids in the absorption of calcium and
phosphorus for newborns to develop healthy bones and
teeth. VIT D
b. Vitamin K is a water-soluble nutrient that helps in
repairing red blood cells and boosting the immune
system. VIT.C
c. Vitamin K is used to prevent brain damage in
newborns because it is essential for brain development,
neural myelination, and cognitive function.
d.
coagulation factors in the intestinal tract to prevent
and treat bleeding diseases in newborns.
Vit K IS A COMPONENT IN PRODUCTION OF
COAGULATION FACTORS (2,7,9,10)
Situation
As a nurse, you should have adequate grasp on
developmental milestones in order to effectively assess
and care for pediatric patients.
6. Baby Julie weighed 8 lbs. at birth. How many lbs.
should she weigh at 6 months?
a. 24 lbs
b. 10 lbs
c. 16 lbs 6 MONTHS=X2 THE WEIGHT
d. 32 lbs
7. You noted that Baby Casey is using the pincer grasp
at 10-month-old. Which option below best describes this
milestone?
a. She is able to grasp large objects with the palm and
forefingers.
b. She is able to grasp small objects with the index
finger and thumb. PINCER GRASP = 9-10
MONTHS
c. She is able to grasp small and large objects with the
middle finger and thumb.
d. She is able to grasp large objects with the palm and
thumb.
8.Baby Casey’s mother asks you about car safety: “What
is the best position of a car seat for my baby?” Your
response is:
a. Forward-facing and back seat 4 YEARS OLD +
b. Forward-facing and front seat
c. Rear-facing and front seat
d. Rear-facing and back seat UP TO 4 YEARS OLD
9. You then note that Baby Casey’s anterior fontanelle
is open. How would you document this finding?
a. Abnormal; should be closed at 2 months
b. Abnormal; should be closed at 6 months
c. Normal, should be closed at 12 months
d. Normal; should be closed at 18 months
ANTERIOR FONTANELLE 12-18 MONTHS
POSTERIOR FONTANELLE = 3 MONTHS
10. You are caring for 5 months old Baby John.
Which developmental milestone, if not performed by the
infant, should be further investigated?
a. Rolling over 5 MONTHS
b. Crawling 9 MONTHS
c. Pincer grasp 9-10 MONTHS
d. Sitting without support 8 MONTHS
Situation
Psychosocial development is crucial throughout the
entire lifespan. It emphasizes the social nature of human
beings, develops one’s personality, and influences social
relationships.
11. The school-age child experiences many physical
changes throughout this developmental time period.
Which of the following is not a change experienced by
this age group?
a. The child typically grows about 2.5 inches per year.
b. Most of the child’s 28 permanent teeth will be erupted
by the end of this developmental period.
c. The child’s weight triples from the age of 6 to 12
years. NO, AVERAGE WEIGHT GAIn 5-7
LBS/YEAR
d. The child’s gross motor skills allow them to ride a
bike without training wheels, swim, and skate.
12. Which of the following is the most important
achievement in a school age child?
a. Being able to control their urges to urinate or defecate
b. Being able to learn their sexual identity through
awareness of genital area
c. Being able to establish good relationships with people
of the opposite sex
d. Being able to learn a skill or hobby SCHOOL
AGE INDUSTRY VS INFERIORITY  How to do
things well.
13. What would be your best advice for parents of a
school age child?
a. Allow the child to complete a project and make
them feel rewarded for the accomplishment
INDUSTRY
b. Praise the child’s ability to make decisions rather than
judging the correctness of their decisions
AUTONOMY TODDLER
c. Allow the child to create bonds and friendship with
peers of the opposite sex ADOLESCENT
d. Provide visual stimulation for active child involvement
INFANTS
14. A 10-year-old is being prepped for heart surgery
to replace a heart valve. What fears or stressors does the
nurse anticipate this child could experience during this
hospitalization? SCHOOL AGE
a. Fear of strangers INFANT TODDLER
b. Fear of punishment PRESCHOOLER
c. Fear of having no privacy ADOLESCENT
d. Fear of pain
15. According to Kohlberg’s Stages of Moral
Development, what would be the reason for conformity
to the rules for a 9-year-old child?
a. The child conforms to the rules because of the rewards
given for good behavior.
b. The child conforms to the rules because it maintains
social order. POST CONVENTIONAL
c. The child conforms to the rules because it causes
others to view them as being good.
CONVENTIONAL  GOOD BOY/GOOD GIRL
ATTITUDE
d. The child conforms to the rules because it provides a
mutual benefit. POST CONVENTIONAL
16. Jean Piaget (1896–1980), a Swiss psychologist,
introduced concepts of cognitive development or the way
children learn and think. According to his theory, all but
one are expected in an infant:
a. Infants play peek-a-boo because they realize the
person playing with them exists behind his or her hands.
(+)
b. Infants can recognize that their toy has broken
parts.
INDUCTIVE REASONING  SCHOOL AGE
c. Infants learn they are a separate entity from objects.
(+)
d. Infants can recognize that a parent remains the same
person whether dressed in a robe and slippers or pants
and a T-shirt.(+)
17. According to Piaget's Theory of Cognitive
Development a 11-year-old child would be in the
_________________ stage:
a. Preoperational
b. Concrete Operational UNDECIDED
c. Sensorimotor
d. Formal Operational
18. Which of the following cognitive abilities is
expected in an 11-year old child?
a. Centering
b. Decentering
c. Abstract thinking
d. Reversibility
19. Suppose Carl, 5 years old, tells you that his arm is
asking for a warm blanket to get better. What type of
cognition is he using?
a. Deductive reasoning
b. Magical thinking PRESCHOOLER INANIMATE
OBJECTS HAVE LIFE
c. Inductive reasoning
d. Sensorial thought
20. Carl’s mother told you that she is concerned
because she saw her son masturbating while taking a
bath. As a nurse, what would be your most appropriate
response?
a. This is normal behavior for Carl.
PRESCOOLER PHALLIC STAGE NORMAL
b. This behavior should begin by 10 years old.
c. It is recommended that you have him checked with a
psychiatrist.
d. Carl may have a disease in his genitalia.
Situation
Chrisa is an 8-year-old child born with asthma and celiac
disease. She was brought to the hospital with vital signs
of BP 100/70, PR 99, RR 30, and T 36.8 deg C. She has
wheezes, pallor, and rashes on her chest .
21. You asked Chrisa’s mother about her allergies. She
responded that Chrisa is allergic to seafood, which the
child accidentally ate prior to her asthma attack. What
drug should be immediately given to the patient for her
allergic reaction?
a. Epinephrine EMERGENCY DRUG FOR
ALLERGY
b. Albuterol
c. Montelukast
d. Theophylline
22.What are the three processes behind asthma?
a. Increased bronchial secretions, alveolar collapse,
airway constriction
b. Bronchospasm, increased mucus production, upper
airway obstruction
c. Bronchospasm, inflammation of bronchial mucosa,
and increased bronchial secretions
d. Abnormal production of mucus, blockage of exocrine
glands, airway constriction
23. Which of the following breakfast meals should you
give to Chrisa?
a. Oatmeal with banana and peanut butter
b. Whole wheat toast with fried egg and cheese
c. Rice with beef tapa and fried egg
d. Vegetable salad with shrimp and apples
NO TO CELIAC DISEASE = BROW – BARLEY, RYE,
OATS, WHEAT
24. Chrisa was prescribed take home medications –
inhaled Salmeterol and Fluticasone – for long-term
management of asthma. Which of the following
responses show that her mother understands the correct
order of taking these medications?
a. Chrisa inhales the Salmeterol first and then waits 5
minutes before inhaling the Fluticasone.
b. Chrisa inhales the Fluticasone first and then waits 5
minutes before inhaling the Salmeterol.
c. Chrisa inhales the Salmeterol first and then waits 1
minute before inhaling the Fluticasone.
d. Chrisa inhales the Fluticasone and immediately inhales
the Salmeterol.
25. All but one are expected signs and symptoms in
patients with gluten sensitivity:
a. Cachexia
b. Steatorrhea
c. Abdominal distention
d. None of the above
Situation
One of the most common congenital diseases are
cardiovascular diseases. Nursing interventions for
pediatric patients with cardiovascular diseases are crucial
to ensure optimal health and recovery.
26. Dan, a 2 month old infant, was born with tetralogy
of fallot. Which statement below is incorrect concerning
how the blood normally flows through the heart?
a. Unoxygenated blood enters through the superior
and inferior vena cava and travels to the left atrium.k
b. The pulmonic valve receives blood from the right
ventricle and allows blood to flow to the lungs via the
pulmonary artery.
c. The left atrium allows blood to flow down through the
bicuspid valve (mitral) into the left ventricle.
d. Oxygenated blood leaves the left ventricle and flows
up through the aortic valve and aorta to be pumped to the
rest of the body.
27. While feeding Dan, you notice the infant’s skin
begins to have a bluish tint and the breathing rate has
increased. Your immediate nursing action is to?
a. Continue feeding the infant and place the infant on
oxygen.
b. Stop feeding the infant and provide suction.
c. Stop feeding the infant and place the infant in the
knee-to-chest position and administer oxygen.
SQUATTING HELPS IN INC SYTEMIC
VASCULAR RESISTANCE DECREASE
SHUNTING OF THE BLOOD FROM THE RIGHT
TO LEFT  MORE BLOOD TO LUNGS MORE
O2
d. Assess the infant’s heart rate and rhythm
TET SPELL
CHILD’S HEART CANNOT MAINTAIN PROPER
O2 LEVELS CYANOSIS+ COMPENSATORY
(INC RR)
28. Now that Dan has severe cyanosis, you anticipate
which drug to give?
a. Indomethacin
b. Diclofenac
c. Celecoxib
d. Alprostadil PROSTAGLANDIN E  KEEPS
THE DUCTUS ARTERIOSUS OPEN  MORE
BLOOD TO PULMONARY ARTERY MORE
BLOOD TO LUNGS MORE O2
29. You are now caring for Cess, a 3 year-old patient
who has a large atrial septal defect who is waiting for
surgery. She is currently experiencing complications
arising from an abnormal shunting of blood throughout
the heart. As the nurse, you know that a _____________
shunt is occurring in the heart due to the defect:
a. Right-to-left
b. Right
c. Left
d. Left-to-right BECAUSE PRESSURE IN THE
LEFT SIDE
30. Cess’s mother comes to you and says, “I am
feeling scared for my daughter. Why does it need to
happen to her? I don’t want to lose her.” What is your
most therapeutic response?
a. Stay silent.
b. “Stop worrying. It will not do you or your daughter
any good.”
c. “Why are you feeling that way?”
d. “I can see that you are losing hope and you think your
daughter will die.”
Situation
5-month-old James was brought by his father to the
hospital for insertion of an external ventricular drain to
manage his hydrocephalus. The following situations
apply.
31. Which of the following signs and symptoms can
you not expect in James?
a. Delayed closure of fontanelles
b. Projectile vomiting
c. High pitched cry
d. None of the above
32. James’s father asks you where external ventricular
drains are inserted. What is the correct answer?
a. Subarachnoid space
b. Lateral Ventricle
c. Epidural space
d. Right Ventricle
33. What is the best position for James
a. Supine
b. Prone
c. Semi Fowler
d. Left sims lying
34. Patients with increased ICP have a high risk of
seizures. If the pediatric patient starts to actively seize.
What is the very first thing the nurse should do?
a. Maintain a patent airway
b. Ensure the surroundings are safe
c. Administer lorazepam
d. Call for help
35. A patient with a history of epilepsy is taking
Phenytoin. The patient’s morning labs are back, and the
patient’s Phenytoin level is 7 mcg/mL. Based on this
finding, the nurse will?
a. Assess the patient for a rash
b. Initiate seizure precautions BECAUSE
PHENYTOIN LEVEL 7 is NOT WITHIN
THERAPEUTIC DOSE
c. Hold the next dose of Phenytoin
d. Continue to monitor the patient
NORMAL PHENYTION LEVEL 10-20 MCG/ML
Situation
Education on sexuality and reproductive health is
important for individuals to have adequate understanding
about their bodies and relationships, decrease their risk-
taking, and decrease the frequency of unprotected sex.
36. The Reproductive Health Law of the Philippines
provides universal and free access to modern
contraceptive methods, mandates age- and development-
appropriate reproductive health education in government
schools, and recognizes a woman’s right to postabortion
care in the Philippines as part of the right to reproductive
healthcare. Which of the following pertains to the RH
Law?
a. RA 8423 TRADITIONAL AND ALTERNATIVE
MEDICINE ACT
b. RA 10354
c. RA 7305 MAGNA CARTA
d. RA 9262 ANTIVIOLENCE AGAINST WOMEN
AND THEIR CHILDREN ACT
37. 17 year-old Jen came to you to ask about
contraceptives. She has a history of vascular disease.
Which of the following options should you not
recommend to her?
a. Condoms
b. IUD
c. Diaphragm
d. Oral contraceptive pills INCREASE TENDENCY
TOWARD CLOTTING as an effect to INC
ESTROGEN
38.Fertility awareness involves detecting when a woman
is fertile so she can use periods of abstinence during that
time. If a couple is having coitus, when is it safe to avoid
pregnancy?
a. When the woman’s basal body temperature rises a full
degree FERTILE
b. When the woman’s cervical mucus becomes copious,
thin, watery, and transparent FERTILE
c. When the woman is breastfeeding for 7 months
LACTATION AMENORRHEA METHOD UP TO ^
MONTHS ONLY
d. When the woman is two days away from her
menstrual period
39. Hannah, 24 years old and G2P2, has a copper-based
IUD. What do you expect to include in the teaching
plan?
a. Amenorrhea is a common side effect of IUDs. NO,
HEAVY MENSTUAL BLEEDING AND
SUBSEQUANT AANEMIA
b. Severe cramping may occur when the IUD is
inserted.
c. She needs to have it changed yearly. No,
DEPENDING ON THE BRAND IT CAN LAST 3-12
YEARS
d. IUDs are more costly than other forms of
contraception. NO, LESS COSTLY
IDEAL TIME TO PUT IUD: DURING MENSES
40. The Anti-Violence Against Women and their
Children Act of 2004 seeks to address the prevalence of
violence against women and their children (VAWC) by
their intimate partners like their husband or ex-husband,
live-in partner or former live-in partner,
boyfriend/girlfriend or ex-boyfriend/ex-girlfriend, dating
partner or former dating partner. Which of the following
situations is not included in psychological abuse?
a. When angry, Kim destroys their household
property in front of Casie. ECONOMIC ABUSE
b. Martin threatens Kyla that he will inflict physical harm
on himself if she leaves her.
c. After filing for annulment, Oli deprives Keith of
custody and access to their twins.
d. After their break up, Ben continuously stalks Hailey
everytime she goes out.
Situation
Cognitive delay may be present in some pediatric
patients. Nurses have an important role in ensuring that
they maintain safety and are assisted towards
development.
41. The nurse is evaluating Dennis, a 3-year-old child
with a developmental delay. Which assessment finding
would indicate that this child might have a type of
autistic spectrum disorder?
a. The child does not enjoy playing frequently with the
same toy. NO, THEY PLAY REPEATEDLY THE
SAME TOY
b. The child goes to bed without a nighttime routine. NO,
STRICT ROUTINE
c. The child is using echolalia. ABNORMAL
COMMUNICATION PATTERN, YES IT IS SEEN IN
ASD
d. The child enjoys imaginative play. NO, THEY
DON’T
42. Which of the following statements by Dennis’s
parents determines that a goal of treatment has been
met?
a. Dennis now eats with a fork. GOAL MET
b. Dennis repeats questions asked to him. NO, ITS
ABNORMAL
c. Dennis sits still for 1 minute this morning. ADHD
d. All of the above
43. The parents then ask the nurse what medications
will be used to help cure the child. What is the nurse's
best response?
a. "The doctor will order methylphenidate (Ritalin)."
b. "Treatment for autism focuses on behavior change,
not medications."
c. "Dennis will be admitted to a psychiatric facility for
medications."
d. “Dennis will be given medication at an outpatient
clinic."
MEDICATION FOR SYMPTOMS: RISPERIDONE &
ARIPIPRAZOLE FOR TREATING IRRITABILITY
(NIH 2021)
44. You are also caring for Karen, 6 years old, who is
being evaluated for attention-deficit/hyperactivity
disorder. Which assessment finding (persisting more than
6 months) is consistent with the DSM-5 diagnostic
criteria for hyperactivity and impulsivity?
a. Often has difficulty waiting for turn in line or
activity --HYPERACTIVITY & IMPULSIVITY
b. Often has difficulty organizing tasks and activities --
INATTENTION
c. Often loses things necessary for tasks or activities
INATTENTION
d. Often fails to finish schoolwork, chores, or duties
INATTENTION
45. If diagnosed with ADHD, which of the following
drugs do you expect to be prescribed to improve focus,
and decrease impulsivity and hyperactive behavior,
which are the three hallmark ADHD symptoms?
a. Aripiprazole (Abilify)
b. Risperidone (Risperdal)
c. Citalopram (Celexa)
d. Methylphenidate (Ritalin) STIMULANT but in
ADHD HELPS IN CONCENTRATION,
ATTENTION AND LISTENING SKILLS
Situation
Teenagers are one of the most vulnerable groups in
developing eating disorders. The following questions
apply.
46. Who among the following patients has the highest
risk of developing an eating disorder?
a. Diana, 3 years old, who is a picky eater.
b. Celine, 15 years old, who has been bullied for being
larger than her peers. BULLYING OR TEASING IS
BIG FACTOR IN ED
c. Kiana, 18 years old, who is a working student.
d. Carlo, 14 years old, has been training in basketball
since he was 8 years old.
47. The nurse is assessing a client who is obese and
reports eating to the point of discomfort at least twice a
week for the past year. The client denies the use of
laxatives, self-induced vomiting, ipecac syrup, or
enemas and reports feeling unable to control the
behavior. The client feels embarrassed and has stopped
going out with friends. Which eating disorder should the
nurse suspect?
a. Purging
b. Anorexia nervosa
c. Binge-eating disorder SELF PURGING, BINGING
d. Bulimia nervosa
48. A 17 year old gymnast is admitted to the hospital
due to weight loss and dehydration secondary to
starvation. Which of the following nursing diagnoses will
be given priority for the client?
a. Altered self-image
b. Fluid volume deficit
c. Altered nutrition: less than body requirements
d. Ineffective coping
49. In the management of patients with bulimia, the
following nursing interventions will promote a
therapeutic relationship, EXCEPT:
a. Establish an atmosphere of trust
b. Discuss their eating behavior. MAY LEAD TO
FEELINGS OF SHAME FOCUS ON THE
FEELINGS OF THE PATIENT
c. Help patients identify feelings associated with binge-
purge behavior
d. Teach patient about bulimia nervosa
50. The client with anorexia nervosa is improving if:
a. She eats meals in the dining room. THEY CAN
PURGE AFTER
b. She attends ward activities. NOT AN INDICATOR,
IT IS AN INTERVENTION
c. She has a more realistic self concept. BODY IMAGE
IS A FACTOR BUT IT IS NOT AN INDIVATOR FOR
IMPROVEMENT
d. She gains weight.
Situation
Caring for Childbearing and Childrearing Families
51. A couple went to you to ask regarding conception.
When assessing the adequacy of sperm for conception to
occur, which of the following is the most useful
criterion?
a. Sperm count
b. Sperm motility
c. Sperm maturity
d. Semen volume
52. A woman states that she finds it hard to conceive
because she has a condition in which the entire uterus is
tipped far forward. What term is applicable to this
positional deviation of the uterus?
a. Anteversion UTERUS IS TIPPED FORWARD
b. Retroversion ENTIRE UTERUS IS TIPPED
BACKWARD
c. Anteflexion BODY OF THE UTERUS IS BENT
SHARPLY FORWARD AT THE JUNCTION WITH
THE CERVIX
d. Retroflexion BODY BENT SHARPLY BACK JUST
ABOVE THE CERVIX
53. What hormone is active early in the cycle and is
responsible for maturation of the ovum?
a. Estrogen MATURATION OF FOLLICLES + PROLIFIRATION OF
ENDOMETRIAL LINING
b. Progesterone THICKENS ENDOMETRIAL LINING
c. FSH MATURATION OF OVUM
d. LH RESPONSIBLE FOR OVULATION OR RELEASING OF
MATURE EGG
54. Sheila typically has a menstrual cycle of 34 days.
She tells you she had sexual intercourse on days 8, 10,
15, and 20 of her last cycle. Which is the day on which
she most likely conceived?
a. Day 8
b. Day 10
c. Day 15
d. Day 20 OVULATION OCCURS 14 DAYS BEFORE MENSES
55. Cleo is already in her menopausal age. Because of
the hormonal changes present in women at menopause,
what condition should you educate her about prevention
because it is most common?
a. Breast cancer
b. Fractures
c. Diabetes
d. Anemia
MENOPAUSE CESSATION OF OVARIAN FUNCTION  DEC.
ESTROGEN PRONE TO WEAKENING OF BONES/
OSTEOPOROSIS/FRACTURES
56. Kara, 35 years old, is currently pregnant with 23
weeks AOG. She has 2 children, the first one is 10 years
old and the other one is 8 years old. The first one was
delivered at 38 weeks AOG and the second one was
delivered at 35 weeks AOG. She got pregnant when she
was 19 years old, but miscarried at 2 months AOG. She
also had a false pregnancy when she was 23 years old.
What is her obstetric score?
a. G5T1P1A2L2
b. G4T2P0A1L2
c. G5T1P1A1L2
d. G4T1P1A1L2
57. What is the psychological task of Kara?
a. Accept the pregnancy
b. Accept the baby
c. Prepare for parenthood
d. Anticipate baby’s needs
58. Which of the following physiological changes is
not expected in Kara?
a. Quickening
b. Anemia
c. Urinary frequencyNOT EXPECTED IN 2nd
TRIMESTER SUSPECT GDM
d. Leukorrhea
59. Kara then tells you that she is experiencing leg
cramps and is awakened by the cramps at night. To
provide relief from the leg cramps, you advise the client
to:
a. Dorsiflex the foot while extending the knee when
the cramps occur
b. Dorsiflex the foot while flexing the knee when the
cramps occur
c. Plantar flex the foot while flexing the knee when the
cramps occur
d. Plantar flex the foot while extending the knee when
the cramps occur.
60. Upon checking Kara’s fundal height, she
complains of feeling dizzy and lightheaded. Her skin is
also pale and moist. What is your initial response?
a. Assess Kara’s blood pressure and pulse
b. Have Kara breathe into a paper bag
c. Raise Kara’s legs
d. Turn Kara on her side. DO THIS FIRST TO REMOVE
PRESSURE IN THE AORTA AND VENA CAVA
Situation
Celine arrives at the emergency department (ED) with
abruptio placentae at 34 weeks’ gestation. The following
questions apply.
61. Upon reviewing her history, which of the
following data puts her at most risk for abruptio
placentae?
a. Diagnosis of hypertension 3 years ago
b. 34 weeks AOG
c. Exercising during pregnancy
d. Eating more than recommended caloric intake
62. What should you assess in Celine?
a. Bright red, painless vaginal bleeding PLACENTA PREVIA
b. Concealed or external dark red bleeding
c. Palpable fetal outline
d. Soft and nontender abdomen
63. Assessment showed that Celine is experiencing
moderate vaginal bleeding. Based on these findings, you
would prepare the client for:
a. Complete bed rest for the remainder of the pregnancy
b. Delivery of the fetus MOD SEVER BLEEDING 
DANGEROUS FOR THE MOTHER AND THE BABY
c. Strict monitoring of intake and output
d. The need for weekly monitoring of coagulation studies
until the time of delivery
64. Based on your knowledge regarding abruptio
placentae, Celine is at risk for which of the following
blood dyscrasias?
a. Thrombocytopenia
b. Idiopathic thrombocytopenic purpura (ITP)
c. Disseminated intravascular coagulation (DIC)
d. Heparin-associated thrombosis and thrombocytopenia
(HATT)
65. Because of the blood dyscrasias that may occur in
Celine, which assessment finding is least likely to be
associated with this hematological condition?
a. Swelling of the calf in one leg (-) THROMBOPHLEBITIS
b. Prolonged clotting times(+) BLEEDING IN DIC
c. Decreased platelet count (+) PLATELET CONSUMED
d. Petechiae, oozing from injection sites, and hematuria
(+) BLEEDING
Situation
Intrapartum and Postpartum care
66. You are caring for a client in the active phases of
labor. The nurse is assessing the fetal patterns and notes a
late deceleration on the monitor strip. The most
appropriate nursing action is to:
a. Place the mother in the supine position LEFT SIDLYINGG
b. Document the findings and continue to monitor the
fetal patterns AFTER INTERVENTION
c. Administer oxygen via face mask INC O2
d. Increase the rate of pitocin IV infusion
67. You are reviewing the record of a client in the
labor room and note that the fetus is at (-1) station. You
document that the fetal presenting part is:
a. 1 cm above ischial spine
b. 1 in below coccyx
c. 1 fingerbreadth below symphysis pubis
d. 1 in below iliac crest
68. During stage 3 of labor, you note a gush of blood
and that the uterus changes shape from an oval shape to
globular shape. This indicates what?
a. Postpartum hemorrhage
b. Imminent delivery of the baby
c. Signs of placental separation
d. Answers B and C
69. Upon assessment, you got the following findings:
2 perineal pads highly saturated with blood within 1.5
hours postpartum, PR = 90 bpm, fundus soft and
boundaries not well defined. The appropriate nursing
diagnosis is:
a. Normal blood loss
b. Blood volume deficiency
c. Inadequate tissue perfusion related to hemorrhage
d. Hemorrhage secondary to uterine atony
70. During an internal examination, the nurse palpated
the posterior fontanel to be at the left side of the mother
at the upper quadrant. The interpretation is that the
position of the fetus is:
a. LOA
b. ROP
c. LOP
d. ROA
71. When doing perineal care in preparation for
delivery, you should observe the following, except:
a. Use up-down technique with one stroke
b. Clean from the mons veneris to the anus
c. Use mild soap and warm water
d. Paint the inner thighs going towards the perineal
area PERINEAL AREA TO THIGHS
72. You transported a client in labor to the delivery
room and prepared her for a cesarean delivery. Upon
transferring her to the delivery room table, you place the
client in what position?
a. Trendelenburg’s position with the legs in stirrups
b. Semi-Fowler position with a pillow under the knees
c. Prone position with the legs separated and elevated
d. Supine position with a wedge under the right hip
73. You are instructing a postpartum mother regarding
lochia and the amount of expected lochia drainage. You
instruct the mother that the normal amount of lochia may
vary but should never exceed the need for:
a. One peripad per day
b. Three peripads per day
c. Eight peripads per day
d. Twelve peripads per day
74. Five hours after a difficult labor and birth, a
primiparous woman refuses to hold and feed her baby,
stating that she is too tired and just wants to sleep. You
should:
a. Tell the woman she can rest after she feeds her baby
b. Recognize this as a behavior of the taking-hold stage
c. Record the behavior as ineffective maternal-newborn
attachment
d. Take the baby back to the nursery, reassuring the
woman that her rest is a priority at this time
75. Methergine or pitocin was prescribed for your
client with postpartum hemorrhage. However, upon
reading the patient’s history, you decided to contact her
healthcare provider before medication administration
because you noted that she has which of the following
conditions?
a. Peripheral vascular disease METHERGINE WORSENS
VASOCONSTRICTION
b. Hypothyroidism
c. Hypotension
d. Type 1 diabetes
Situation
Shane, a 35-year-old female, is currently 16 weeks AOG.
She reported the following health history:
G5P4T3P1A0L4, BMI 29, diagnosis of hypertension and
depression, and family history of Type 2 diabetes.
76. Which among the following risk factors increases
Shane’s risk of developing gestational diabetes mellitus?
Select all that apply
a. 35-years-old
b. 16 weeks pregnant
c. G5P4T3P1A0L4
d. BMI 29
e. Hypertension
f. Depression
g. Family history of Type 2 diabetes
77. Which test below is used to diagnose a patient with
this condition?
a. 1 hour glucose tolerance test
b. 24 hour urine collection
c. Hemoglobin A1C
d. 3 hour glucose tolerance test
78. fter being diagnosed with GDM, Shane asks you
how it can affect her baby. As the nurse, you know that
her baby is at risk for? Select all that apply.
a. Hyperglycemia
b. Hypoglycemia
c. Respiratory distress
d. Hyperbilirubinemia
e. Hyperthermia
79. Fortunately, Shane’s pregnancy was healthy and
she delivered a healthy baby boy. However, upon check
up, you observe several interactions between Shane and
her new son. What statement would you investigate
further to identify a possible maladaptive behavior
regarding parent-infant attachment?
a. “My baby is hungry all the time. He wants to
breastfeed every hour.”
b. “This is my fifth baby. I’m not sure how we can
handle our finances for all of our children, but my
husband will take care of it.”
c. “This will be my last pregnancy. I don’t think it’s
healthy for me to breastfeed and lose more sleep in the
future.”
d. “I don’t like looking at my baby’s eyes. I only
remember the pain of delivering him and now
thinking how he will affect our finances.”
80. depressed at home with my new baby?” What are
the helpful guidelines you may give? Select all that
apply.
i. Plan a balanced program of nutrition, exercise, and
sleep.
ii. Stay with your baby all the time.
iii. Share your feelings with a support person.
iv. Avoid doing other stuff aside from baby care.
v. Do not try to be perfect.
a. i, ii, iv
b. i, iii, v
c. i, iii, iv, v
d. i, ii, iii, iv, v
Situation
Fetal development and pregnancy
81. A prenatal client at 35 weeks gestation is
scheduled for an amniocentesis to determine fetal lung
maturity. The nurse expects the lecithin/sphingomyelin
(L/S) ratio to be:
a. 0.5:1
b. 1:1
c. 2:1
d. 3:1
82. A client states that she had a spontaneous abortion
12 months ago. The client asks if her hormones may
have contributed to the loss of the pregnancy. The
nurse’s response is based upon her knowledge of which
of the following facts?
a. Implantation occurs when progesterone levels are low.
b. hCG reaches a maximum level at 4 weeks gestation.
c. Progesterone decreases the contractility of the
uterus.
d. Progesterone is only produced by the corpus luteum
during pregnancy.
83. Amniocentesis was done on a pregnant client 16
weeks AOG. You documented that the fetal urine is a
strong yellow. How would you interpret this?
a. Normal, fetal urine is dark yellow in color.
b. Abnormal, this indicates blood incompatibility
c. Abnormal, this indicates presence of meconium
d. Abnormal, this indicates decreased alpha fetoprotein
84. Upon checking for the amniotic fluid, you noted
that the alpha fetoprotein (AFP) is too high. What can be
investigated further as a possible condition of the fetus?
a. Down syndrome
b. Trisomy 21
c. Open body defect
d. Decreased lung surfactant
85. During a prenatal visit a patient tells you her last
menstrual period was August 28, 2016. Based on the
Naegele's Rule, when is the estimated due date of her
baby?
a. July 4, 2017
b. June 3, 2017
c. June 4, 2017
d. July 1, 2016
86. During a prenatal visit a patient tells you her last
menstrual period was January 30, 2016. Based on the
Naegele's Rule, when is the estimated due date of her
baby?
a. November 6, 2016
b. October 25. 2017
c. November 4, 2017
d. October 22, 2016
87. Your patient is 24 weeks pregnant, and you’re
measuring the fundal height. Which finding below is a
normal measurement for this patient?
a. 16 cm
b. 28 cm
c. 26 cm +/- 2 cm
d. 12 cm
88. A patient is 40 weeks pregnant, and you find the
fundal height to be 4 cm below the xiphoid process. Your
next nursing action is to:
a. Notify the MD immediately
b. Chart this as a normal finding
c. Place the patient on continuous fetal monitoring
d. Assess the baby’s heart rate with a Doppler
89. Starting 16 weeks AOG, a pregnant mother may
secrete colostrum. The hormone _____ is responsible for
its production, while the hormone _____ is responsible
for its secretion.
a. Prolactin, oxytocin
b. Oxytocin, prolactin
c. Estrogen, prolactin
d. Progesterone, estrogen
90. You are conducting Leopold’s Maneuver to a
pregnant client. While doing the umbilical grip to
determine position, you palpated that the baby lies
transversely. What landmark is this?
a. Occiput
b. Mentum
c. Sacrum
d. Acromion
Situation
Breastfeeding is an important activity among mothers.
The following questions apply.
91. According to the Philippine Milk Code of 1986 or
EO 51, which among the following is recommended to
protect and promote breastfeeding?
a. Advertisement of breastmilk substitutes
b. Infant formula manufacturers giving mothers free
breastmilk substitutes
c. Including infant formula milk in relief goods
d. Teaching mothers in the community how to collect
breast milk
92. The nurse assesses the mother of a newborn who is
breastfeeding. Which assessment finding indicates
ineffective breastfeeding of the newborn?
a. The newborn’s mouth grasps the mother’s nipple with
the tongue down.
b. The newborn swallows audibly, spontaneously, and
frequently.
c. The newborn smacks their lips loudly during
breastfeeding.
d. The newborn turns to the breast when its cheek is
stroked with a nipple.
93. Which of the following is the primary predisposing
factor related to mastitis?
a. Epidemic infection from nosocomial sources localizing
in the lactiferous glands and ducts
b. Endemic infection occurring randomly and localizing
in the peri glandular connective tissue
c. Temporary urinary retention due to decreased
perception of the urge to avoid
d. Breast injury caused by overdistention, stasis, and
cracking of the nipples
94. You are providing instructions to a mother who
has been diagnosed with mastitis. Which of the following
statements, if made by the mother, indicates a need for
further teaching?
a. “I need to take antibiotics, and I should begin to feel
better in 24-48 hours.”
b. “I can use analgesics to assist in alleviating some of
the discomfort.”
c. “I need to wear a supportive bra to relieve the
discomfort.”
d. “I need to stop breastfeeding until this condition
resolves.”
95. What psychosocial component is developed when
a mother responds to a baby’s need to feed?
a. Trust
b. Love
c. Respect
d. Warmth
Situation
Ethical principles apply in all nursing care. You are
caring for a Sarah, a pregnant mother who belongs to an
Indigenous People group.
96. Cultural awareness is an in-depth self-examination
of one’s:
a. Background, recognizing biases and prejudices
b. Social, cultural, and biophysical factors
c. Engagement in cross-cultural interactions
d. Motivation and commitment to caring
97. Which factor is least significant during assessment
when gathering information about Sarah’s cultural
practices?
a. Language, timing
b. Touch, eye contact
c. Biocultural needs
d. Pain perception, management expectations
98. If an ethical dilemma regarding care for Sarah
arises, the solution to the dilemma requires negotiation
among members of the healthcare team. Your point of
view is valuable because:
a. Nurses have a legal license that encourages their
presence during ethical discussions.
b. The principle of autonomy guides all participants to
respect their own self-worth.
c. Nurses develop a relationship to the client that is
unique among all professional health care providers.
d. The nurse’s code of ethics recommends that a nurse be
present at any ethical discussion about client care.
99. While Sarah is in severe pain, you left her alone
with the side rails down, and the bed in a high position.
She then falls and developed bleeding. What law has
been broken?
a. Assault
b. Battery
c. Negligence
d. Civil tort

100. Despite Sarah being economically disadvantaged,

you provided her quality care and gave her resources she
needed just like other patients. What ethical principle is
applicable in this situation?

a. Beneficence
b. Justice
c. Non-maleficence
d. Autonomy