lOMoARcPSD|38271980

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Fundamentals in nursing (Manila Central University)

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the student nurse how much should she gain

PNLE : Maternal and Child Health Nursing weight in her pregnancy.
Exam 1
1. A client asks the nurse what a third degree
laceration is. She was informed that she had A. 20-30 lbs
one. The nurse explains that this is: B. 25-35 lbs
C. 30- 40 lbs
D. 10-15 lbs
A. that extended their anal
sphincter
B. through the skin and into the 6. The nurse is preparing Mrs. Jordan for
muscles cesarean delivery. Which of the following key
C. that involves anterior rectal wall concept should the nurse consider when
D. that extends through the implementing nursing care?
perineal muscle.
A. Explain the surgery, expected
2. Betina 30 weeks AOG discharged with a outcome and kind of anesthetics.
diagnosis of placenta previa. The nurse knows B. Modify preoperative teaching to
that the client understands her care at home meet the needs of either a
when she says: planned or emergency cesarean
birth.
C. Arrange for a staff member of
A. I am happy to note that we can the anesthesia department to
have sex occasionally when I have explain what to expect
no bleeding. post-operatively.
B. I am afraid I might have an D. Instruct the mother’s support
operation when my due comes person to remain in the family
C. I will have to remain in bed until lounge until after the delivery.
my due date comes
D. I may go back to work since I
stay only at the office. 7. Bettine Gonzales is hospitalized for the
treatment of severe preecplampsia. Which of
the following represents an unusual finding
3. The uterus has already risen out of the for this condition?
pelvis and is experiencing farther into the
abdominal area at about the:
A. generalized edema
B. proteinuria 4+
A. 8th week of pregnancy C. blood pressure of 160/110
B. 10th week of pregnancy D. convulsions
C. 12th week of pregnancy
D. 18th week of pregnancy
8. Nurse Geli explains to the client who is 33
weeks pregnant and is experiencing vaginal
4. Which of the following urinary symptoms bleeding that coitus:
does the pregnant woman most frequently
experience during the first trimester:
A. Need to be modified in any way
by either partner
A. frequency B. Is permitted if penile penetration
B. dysuria is not deep.
C. incontinence C. Should be restricted because it
D. burning may stimulate uterine activity.
D. Is safe as long as she is in
side-lying position.
5. Mrs. Jimenez went to the health center for
pre-natal check-up. the student nurse took
her weight and revealed 142 lbs. She asked

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9. Mrs. Precilla Abuel, a 32 year old mulripara A. To facilitate elimination

is admitted to labor and delivery. Her last 3
B. To promote uterine contraction
pregnancies in short stage one of labor. The
C. To promote analgesia
nurses decide to observe her closely. The
D. To prevent infection
physician determines that Mrs. Abuel’s cervix
is dilated to 6 cm. Mrs. Abuel states that she
is extremely uncomfortable. To lessen Mrs. 13. Nurse Luis is assessing the newborn’s
Abuel’s discomfort, the nurse can advise her heart rate. Which of the following would be
to: considered normal if the newborn is sleeping?

A. lie face down A. 80 beats per minute

B. not drink fluids B. 100 beats per minute
C. practice holding breaths between C. 120 beats per minute
contractions D. 140 beats per minute
D. assume Sim’s position

14. The infant with Down Syndrome should go

10. Which is true regarding the fontanels of through which of the Erikson’s developmental
the newborn? stages first?

A. The anterior is large in shape A. Initiative vs. Self doubt

when compared to the posterior B. Industry vs. Inferiority
fontanel. C. Autonomy vs. Shame and doubt
B. The anterior is triangular shaped; D. Trust vs. Mistrust
the posterior is diamond shaped.
C. The anterior is bulging; the
posterior appears sunken. 15. The child with phenylketonuria (PKU) must
D. The posterior closes at 18 maintain a low phenylalanine diet to prevent
months; the anterior closes at 8 which of the following complications?
to 12 months.
A. Irreversible brain damage
11. Mrs. Quijones gave birth by spontaneous B. Kidney failure
delivery to a full term baby boy. After a C. Blindness
minute after birth, he is crying and moving D. Neutropenia
actively. His birth weight is 6.8 lbs. What do
you expect baby Quijones to weigh at 6
months? 16. Which age group is with imaginative minds
and creates imaginary friends?

A. 13 -14 lbs
B. 16 -17 lbs A. Toddler
C. 22 -23 lbs B. Preschool
D. 27 -28 lbs C. School
D. Adolescence

12. During the first hours following delivery,

the post partum client is given IVF with 17. Which of the following situations would
oxytocin added to them. The nurse alert you to a potentially developmental
understands the primary reason for this is: problem with a child?

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C. Epiglotitis
A. Pointing to body parts at 15
D. Status Asthmaticus
months of age.
B. Using gesture to communicate at
18 months. 21. Nurse Jonas assesses a 2 year old boy
C. Cooing at 3 months. with a tentative diagnosis of nephroblastoma.
D. Saying “mama” or “dada” for the Symptoms the nurse observes that suggest
first time at 18 months of age. this problem include:

18. Isabelle, a 2 year old girl loves to move A. Lymphedema and nerve palsy
around and oftentimes manifests negativism B. Hearing loss and ataxia
and temper tantrums. What is the best way C. Headaches and vomiting
to deal with her behavior? D. Abdominal mass and weakness

A. Tell her that she would not be 22. Which of the following danger sings
loved by others is she behaves should be reported immediately during the
that way.. antepartum period?
B. Withholding giving her toys until
she behaves properly.
C. Ignore her behavior as long as A. blurred vision
she does not hurt herself and B. nasal stuffiness
others. C. breast tenderness
D. Ask her what she wants and give D. constipation
it to pacify her.

23. Nurse Jacob is assessing a 15 month old

19. Baby boy Villanueva, 4 months old, was child with acute otitis media. Which of the
seen at the pediatric clinic for his scheduled following symptoms would the nurse anticipate
check-up. By this period, baby Villanueva has finding?
already increased his height by how many
inches?
A. periorbital edema, absent light
reflex and translucent tympanic
A. 3 inches membrane
B. 4 inches B. irritability, purulent drainage in
C. 5 inches middle ear, nasal congestion and
D. 6 inches cough
C. diarrhea, retracted tympanic
membrane and enlarged parotid
20. Alice, 10 years old was brought to the ER gland
because of Asthma. She was immediately put D. Vomiting, pulling at ears and
under aerosol administration of Terbutaline. pearly white tympanic membrane
After sometime, you observe that the child
does not show any relief from the treatment
given. Upon assessment, you noticed that both 24. Which of the following is the most
the heart and respiratory rate are still appropriate intervention to reduce stress in a
elevated and the child shows difficulty of preterm infant at 33 weeks gestation?
exhaling. You suspect:

A. Sensory stimulation including

A. Bronchiectasis several senses at a time
B. Atelectasis

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B. tactile stimulation until signs of AFP. The patient asked her what was the test
over stimulation develop for:
C. An attitude of extension when
prone or side lying
D. Kangaroo care A. Congenital Adrenal Hyperplasia
B. PKU
C. Down Syndrome
25. The parent of a client with albinism would D. Neural tube defects
need to be taught which preventive
healthcare measure by the nurse:
4. Fetal heart rate can be auscultated with a
fetoscope as early as:
A. Ulcerative colitis diet
B. Use of a high-SPF sunblock
C. Hair loss monitoring A. 5 weeks of gestation
D. Monitor for growth retardation B. 10 weeks of gestation
C. 15 weeks of gestation
D. 20 weeks of gestation
PNLE : Maternal and Child Health Nursing
Exam 2
1. Nurse Bella explains to a 28 year old 5. Mrs. Bendivin states that she is
pregnant woman undergoing a non-stress test experiencing aching swollen, leg veins. The
that the test is a way of evaluating the nurse would explain that this is most probably
condition of the fetus by comparing the fetal the result of which of the following:
heart rate with:
A. Thrombophlebitis
A. Fetal lie B. PIH
B. Fetal movement C. Pressure on blood vessels from
C. Maternal blood pressure the enlarging uterus
D. Maternal uterine contractions D. The force of gravity pulling down
on the uterus

2. During a 2 hour childbirth focusing on labor

and delivery process for primigravida. The 6. Mrs. Ella Santoros is a 25 year old
nurse describes the second maneuver that primigravida who has Rheumatic heart disease
the fetus goes through during labor progress lesion. Her pregnancy has just been
when the head is the presenting part as which diagnosed. Her heart disease has not caused
of the following: her to limit physical activity in the past. Her
cardiac disease and functional capacity
classification is:
A. Flexion
B. Internal rotation
C. Descent A. Class I
D. External rotation B. Class II
C. Class III
D. class IV
3. Mrs. Jovel Diaz went to the hospital to
have her serum blood test for
alpha-fetoprotein. The nurse informed her 7. The client asks the nurse, “When will this
about the result of the elevation of serum soft spot at the top of the head of my baby
will close?” The nurse should instruct the

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mother that the neonate’s anterior fontanel B. “I will limit my activities and rest
will normally close by age: more frequently throughout the
day.”
C. “I will avoid salty foods in my
A. 2-3 months diet.”
B. 6-8 months D. “I will come more regularly for
C. 10-12 months check-up.”
D. 12-18 months

12. Mrs. Grace Evangelista is admitted with

8. When a mother bleeds and the uterus is severe preeclampsia. What type of room
relaxed, soft and non-tender, you can account should the nurse select this patient?
the cause to:

A. A room next to the elevator.

A. Atony of the uterus B. The room farthest from the
B. Presence of uterine scar nursing station.
C. Laceration of the birth canal C. The quietest room on the floor.
D. Presence of retained placenta D. The labor suite.
fragments

13. During a prenatal check-up, the nurse

9. Mrs. Pichie Gonzales’s LMP began April 4, explains to a client who is Rh negative that
2010. Her EDD should be which of the RhoGAM will be given:
following:

A. Weekly during the 8th month

A. February 11, 2011 because this is her third
B. January 11, 20111 pregnancy.
C. December 12, 2010 B. During the second trimester, if
D. Nowember 14, 2010 amniocentesis indicates a
problem.
C. To her infant immediately after
10. Which of the following prenatal laboratory
delivery if the Coomb’s test is
test values would the nurse consider as
positive.
significant?
D. Within 72 hours after delivery if
infant is found to be Rh positive.
A. Hematocrit 33.5%
B. WBC 8,000/mm3
C. Rubella titer less than 1:8 14. A baby boy was born at 8:50pm. At
D. One hour glucose challenge test 8:55pm, the heart rate was 99 bpm. She has a
110 g/dL weak cry, irregular respiration. She was
moving all extremities and only her hands and
feet were still slightly blue. The nurse should
11. Aling Patricia is a patient with enter the APGAR score as:
preeclampsia. You advise her about her
condition, which would tell you that she has
A. 5
not really understood your instructions?
B. 6
C. 7
A. “I will restrict my fat in my diet.” D. 8

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15. Billy is a 4 year old boy who has an IQ of would be the nurse’s most accurate analysis of
140 which means: the mother’s comment?

A. average normal A. The child has not experienced

B. very superior limit-setting or structure.
C. above average B. The child is expressing a physical
D. genius need, such as hunger.
C. The mother has nurtured
overdependence in the child.
16. A newborn is brought to the nursery. Upon D. The mother is describing her
assessment, the nurse finds that the child child’s separation anxiety.
has short palpebral fissures, thinned upper
lip. Based on this data, the nurse suspects
that the newborn is MOST likely showing the 20. Mylene Lopez, a 16 year old girl with
effects of: scoliosis has recently received an invitation to
a pool party. She asks the nurse how she can
disguise her impairment when dressed in a
A. Chronic toxoplasmosis bathing suit. Which nursing diagnosis can be
B. Lead poisoning justified by Mylene’s statement?
C. Congenital anomalies
D. Fetal alcohol syndrome
A. Anxiety
B. Body image disturbance
17. A priority nursing intervention for the C. Ineffective individual coping
infant with cleft lip is which of the following: D. Social isolation

A. Monitoring for adequate 21. The foul-smelling, frothy characteristic of

nutritional intake the stool in cystic fibrosis results from the
B. Teaching high-risk newborn care presence of large amounts of which of the
C. Assessing for respiratory following:
distress
D. Preventing injury
A. sodium and chloride
B. undigested fat
18. Nurse Jacob is assessing a 12 year old who C. semi-digested carbohydrates
has hemophilia A. Which of the following D. lipase, trypsin and amylase
assessment findings would the nurse
anticipate?
22. Which of the following would be a
disadvantage of breast feeding?
A. an excess of RBC
B. an excess of WBC
C. a deficiency of clotting factor A. involution occurs rapidly
VIII B. the incidence of allergies
D. a deficiency of clotting factor IX increases due to maternal
antibodies
C. the father may resent the
19. Celine, a mother of a 2 year old tells the infant’s demands on the mother’s
nurse that her child “cries and has a fit when body
I have to leave him with a sitter or someone
else.” Which of the following statements

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D. there is a greater chance of The client has only progressed from 2cm to 3
error during preparation cm in 8 hours. She is diagnosed with hypotonic
dystocia and the physician ordered Oxytocin
(Pitocin) to augment her contractions. Which
23. A client is noted to have lymphedema, of the following is the most important aspect
webbed neck and low posterior hairline. of nursing intervention at this time?
Which of the following diagnoses is most
appropriate?
A. Timing and recording length of
contractions.
A. Turner’s syndrome B. Monitoring.
B. Down’s syndrome C. Preparing for an emergency
C. Marfan’s syndrome cesarean birth.
D. Klinefelter’s syndrome D. Checking the perineum for
bulging.
24. A 4 year old boy most likely perceives
death in which way: 2. A client who hallucinates is not in touch
with reality. It is important for the nurse to:
A. An insignificant event unless
taught otherwise A. Isolate the client from other
B. Punishment for something the patients.
individual did B. Maintain a safe environment.
C. Something that just happens to C. Orient the client to time, place,
older people and person.
D. Temporary separation from the D. Establish a trusting relationship.
loved one.

3. The nurse is caring to a child client who has

25. Catherine Diaz is a 14 year old patient on had a tonsillectomy. The child complains of
a hematology unit who is being treated for having dryness of the throat. Which of the
sickle cell crisis. During a crisis such as that following would the nurse give to the child?
seen in sickle cell anemia, aldosterone release
is stimulated. In what way might this
influence Catherine’s fluid and electrolyte A. Cola with ice
balance? B. Yellow noncitrus Jello
C. Cool cherry Kool-Aid
D. A glass of milk
A. sodium loss, water loss and
potassium retention
B. sodium loss, water los and 4. The physician ordered Phenylephrine
potassium loss (Neo-Synephrine) nasal spray to a 13-year-old
C. sodium retention, water loss and client. The nurse caring to the client provides
potassium retention instructions that the nasal spray must be
D. sodium retention, water retention used exactly as directed to prevent the
and potassium loss development of:

PNLE : Maternal and Child Health Nursing A. Increased nasal congestion.

Exam 3 B. Nasal polyps.
1. A pregnant woman who is at term is C. Bleeding tendencies.
admitted to the birthing unit in active labor.

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D. Tinnitus and diplopia. 8. Which of the following complications during

a breech birth the nurse needs to be
alarmed?
5. A client with tuberculosis is to be admitted
in the hospital. The nurse who will be assigned
to care for the client must institute A. Abruption placenta.
appropriate precautions. The nurse should: B. Caput succedaneum.
C. Pathological hyperbilirubinemia.
D. Umbilical cord prolapse.
A. Place the client in a private room.
B. Wear an N 95 respirator when
caring for the client. 9. The nurse is caring to a client diagnosed
C. Put on a gown every time when with severe depression. Which of the
entering the room. following nursing approach is important in
D. Don a surgical mask with a face depression?
shield when entering the room.

A. Protect the client against harm to

6. Which of the following is the most others.
frequent cause of noncompliance to the B. Provide the client with motor
medical treatment of open-angle glaucoma? outlets for aggressive, hostile
feelings.
C. Reduce interpersonal contacts.
A. The frequent nausea and vomiting D. Deemphasizing preoccupation
accompanying use of miotic drug. with elimination, nourishment, and
B. Loss of mobility due to severe sleep.
driving restrictions.
C. Decreased light and near-vision
accommodation due to miotic 10. A 3-month-old client is in the pediatric
effects of pilocarpine. unit. During assessment, the nurse is
D. The painful and insidious suspecting that the baby may have
progression of this type of hypothyroidism when mother states that her
glaucoma. baby does not:

7. In the morning shift, the nurse is making A. Sit up.

rounds in the nursing care units. The nurse B. Pick up and hold a rattle.
enters in a client’s room and notes that the C. Roll over.
client’s tube has become disconnected from D. Hold the head up.
the Pleurovac. What would be the initial
nursing action?
11. The physician calls the nursing unit to
leave an order. The senior nurse had
A. Apply pressure directly over the conversation with the other staff. The newly
incision site. hired nurse answers the phone so that the
B. Clamp the chest tube near the senior nurses may continue their conversation.
incision site. The new nurse does not knowthe physician or
C. Clamp the chest tube closer to the client to whom the order pertains. The
the drainage system. nurse should:
D. Reconnect the chest tube to the
Pleurovac.
A. Ask the physician to call back
after the nurse has read the
hospital policy manual.

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B. Take the telephone order. What should the staff nurse expect under
C. Refuse to take the telephone these conditions?
order.
D. Ask the charge nurse or one of
the other senior staff nurses to A. The float staff nurse will be
take the telephone order. informed of the situation before
the shift begins.
B. The staff nurse will be able to
12. The staff nurse on the labor and delivery negotiate the assignments in the
unit is assigned to care to a primigravida in emergency department.
transition complicated by hypertension. A new C. Cross training will be available for
pregnant woman in active labor is admitted in the staff nurse.
the same unit. The nurse manager assigned D. Client assignments will be equally
the same nurse to the second client. The divided among the nurses.
nurse feels that the client with hypertension
requires one-to-one care. What would be the
initial actionof the nurse? 15. The nurse is assigned to care for a child
client admitted in the pediatrics unit. The
client is receiving digoxin. Which of the
A. Accept the new assignment and following questions will be asked by the nurse
complete an incident report to the parents of the child in order to assess
describing a shortage of nursing the client’s risk for digoxin toxicity?
staff.
B. Report the incident to the
nursing supervisor and request to A. “Has he been exposed to any
be floated. childhood communicable diseases
C. Report the nursing assessment of in the past 2-3 weeks?”
the client in transitional labor to B. “Has he been taking diuretics at
the nurse manager and discuss home?”
misgivings about the new C. “Do any of his brothers and
assignment. sisters have history of cardiac
D. Accept the new assignment and problems?”
provide the best care. D. “Has he been going to school
regularly?”

13. A newborn infant with Down syndrome is

to be discharged today. The nurse is
preparing to give the discharge teaching
regarding the proper care at home. The nurse
would anticipate that the mother is probably
at the:
16. The nurse noticed that the signed consent
form has an error. The form states,
“Amputation of the right leg” instead of the
left leg that is to be amputated. The nurse
has administered already the preoperative
medications. What should the nurse do?

A. 40 years of age.
B. 20 years of age. A. Call the physician to reschedule
C. 35 years of age. the surgery.
D. 20 years of age. B. Call the nearest relative to come
in to sign a new form.
C. Cross out the error and initial the
14. The emergency department has shortage form.
of staff. The nurse manager informs the
staff nurse in the critical care unit that she
has to float to the emergency department.

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D. Have the client sign another C. Vision problem

form. D. Slowing in the heart rate

17. The nurse in the nursing care unit checks 20. Which of the following treatment
the fluctuation in the water-seal modality is appropriate for a client with
compartment of a closed chest drainage paranoid tendency?
system. The fluctuation has stopped, the
nurse would:
A. Activity therapy.
B. Individual therapy.
A. Vigorously strip the tube to C. Group therapy.
dislodge a clot. D. Family therapy.
B. Raise the apparatus above the
chest to move fluid.
C. Increase wall suction above 20 cm 21. The client with rheumatoid arthritis is for
H2O pressure. discharge. In preparing the client for
D. Ask the client to cough and take discharge on prednisone therapy, the nurse
a deep breath. should advise the client to:

18. The pediatric nurse in the neonatal unit A. Wear sunglasses if exposed to
was informed that the baby that is brought bright light for an extended
to the mother in the hospital room is wrong. period of time.
The nurse determines that two babies were B. Take oral preparations of
placed in the wrong cribs. The most prednisone before meals.
appropriate nursing action would be to: C. Have periodic complete blood
counts while on the medication.
D. Never stop or change the amount
A. Determine who is responsible for of the medication without medical
the mistake and terminate his or advice.
her employment.
B. Record the event in an
incident/variance report and 22. A pregnant client tells the nurse that she
notify the nursing supervisor. is worried about having urinary frequency.
C. Reassure both mothers, report to What will be the most appropriate nursing
the charge nurse, and do not response?
record.
D. Record detailed notes of the A. “Try using Kegel (perineal)
event on the mother’s medical
exercises and limiting fluids
record.
before bedtime. If you have
frequency associated with fever,
19. Before the administration of digoxin, the pain on voiding, or blood in the
nurse completes an assessment to a toddler urine, call your
client for signs and symptoms of digoxin doctor/nurse-midwife.
toxicity. Which of the following is the B. “Placental progesterone causes
earliest and most significant sign of digoxin irritability of the bladder
toxicity? sphincter. Your symptoms will go
away after the baby comes.”
C. “Pregnant women urinate
A. Tinnitus frequently to get rid of fetal
B. Nausea and vomiting wastes. Limit fluids to 1L/daily.”

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D. “Frequency is due to bladder administration of the drug, which nursing

irritation from concentrate urine action is not correct?
and is normal in pregnancy.
Increase your daily fluid intake
to 3L.” A. Infuse the phenytoin into a
smaller vein to prevent purple
glove syndrome.
23. Which of the following will help the nurse B. Check the phenytoin solution to
determine that the expression of hostility is be sure it is clear or light yellow
useful? in color, never cloudy.
C. Plan to give phenytoin over 30-60
minutes, using an in-line filter.
A. Expression of anger dissipates D. Flush the IV tubing with normal
the energy. saline before starting phenytoin.
B. Energy from anger is used to
accomplish what needs to be
done. 26. The pregnant woman visits the clinic for
C. Expression intimidates others. check –up. Which assessment findings will
D. Degree of hostility is less than help the nurse determine that the client is in
the provocation. 8-week gestation?

24. The nurse is providing an orientation A. Leopold maneuvers.

regarding case management to the nursing B. Fundal height.
students. Which characteristics should the C. Positive radioimmunoassay test
nurse include in the discussion in (RIA test).
understanding case management? D. Auscultation of fetal heart tones.

A. Main objective is a written plan 27. Which of the following nursing

that combines discipline-specific intervention is essential for the client who
processes used to measure had pneumonectomy?
outcomes of care.
B. Main purpose is to identify
expected client, family and staff A. Medicate for pain only when
performance against the timeline needed.
for clients with the same B. Connect the chest tube to
diagnosis. water-seal drainage.
C. Main focus is comprehensive C. Notify the physician if the chest
coordination of client care, avoid drainage exceeds 100mL/hr.
unnecessary duplication of D. Encourage deep breathing and
services, improve resource coughing.
utilization and decrease cost.
D. Primary goal is to understand why
28. The nurse is providing a health teaching
predicted outcomes have not
to a group of parents regarding Chlamydia
been met and the correction of
trachomatis. The nurse is correct in the
identified problems.
statement, “Chlamydia trachomatis is not only
an intracellular bacterium that causes
25. The physician orders a dose of IV neonatal conjunctivitis, but it also can cause:
phenytoin to a child client. In preparing in the
A. Discoloration of baby and adult
teeth.

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B. Pneumonia in the newborn. D. Relaxin.

C. Snuffles and rhagades in the
newborn.
D. Central hearing defects in 32. One staff nurse is assigned to a group of
infancy. 5 patients for the 12-hour shift. The nurse is
responsible for the overall planning, giving and
evaluating care during the entire shift. After
29. The nurse is assigned to care to a the shift, same responsibility will be endorsed
17-year-old male client with a history of to the next nurse in charge. This describes
substance abuse. The client asks the nurse, nursing care delivered via the:
“Have you ever tried or used drugs?” The
most correct response of the nurse would be:
A. Primary nursing method.
B. Case method.
A. “Yes, once I tried grass.” C. Functional method.
B. “No, I don’t think so.” D. Team method.
C. “Why do you want to know that?”
D. “How will my answer help you?”
33. The ambulance team calls the emergency
department that they are going to bring a
30. Which of the following describes a health client who sustained burns in a house fire.
care team with the principles of participative While waiting for the ambulance, the nurse
leadership? will anticipate emergency care to include
assessment for:

A. Each member of the team can

independently make decisions A. Gas exchange impairment.
regarding the client’s care B. Hypoglycemia.
without necessarily consulting the C. Hyperthermia.
other members. D. Fluid volume excess.
B. The physician makes most of the
decisions regarding the client’s
care. 34. Most couples are using “natural” family
C. The team uses the expertise of planning methods. Most accidental
its members to influence the pregnancies in couples preferred to use this
decisions regarding the client’s method have been related to unprotected
care. intercourse before ovulation. Which of the
D. Nurses decide nursing care; following factor explains why pregnancy may
physicians decide medical and be achieved by unprotected intercourse
other treatment for the client. during the preovulatory period?

31. A nurse is giving a health teaching to a A. Ovum viability.

woman who wants to breastfeed her newborn B. Tubal motility.
baby. Which hormone, normally secreted C. Spermatozoal viability.
during the postpartum period, influences both D. Secretory endometrium.
the milk ejection reflex and uterine
involution?
35. An older adult client wakes up at 2 o’clock
in the morning and comes to the nurse’s
A. Oxytocin. station saying, “I am having difficulty in
B. Estrogen.
C. Progesterone.

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sleeping.” What is the best nursing response B. Blood pressure is decreased from
to the client? 160/90 to 110/70.
C. Client refuses dinner because of
anorexia.
A. “I’ll give you a sleeping pill to help D. Pulse is increased from 88-96
you get more sleep now.” with occasional skipped beat.
B. “Perhaps you’d like to sit here at
the nurse’s station for a while.”
C. “Would you like me to show you 39. The nurse is conducting a lecture to a
where the bathroom is?” class of nursing students about advance
D. “What woke you up?” directives to preoperative clients. Which of
the following statement by the nurse js
correct?
36. The nurse is taking care of a multipara
who is at 42 weeks of gestation and in active
labor, her membranes ruptured spontaneously A. “The spouse, but not the rest of
2 hours ago. While auscultating for the point the family, may override the
of maximum intensity of fetal heart tones advance directive.”
before applying an external fetal monitor, the B. “An advance directive is required
nurse counts 100 beats per minute. The for a “do not resuscitate” order.”
immediate nursing action is to: C. “A durable power of attorney, a
form of advance directive, may
only be held by a blood relative.”
A. Start oxygen by mask to reduce D. “The advance directive may be
fetal distress. enforced even in the face of
B. Examine the woman for signs of a opposition by the spouse.”
prolapsed cord.
C. Turn the woman on her left side
to increase placental perfusion. 40. A client diagnosed with schizophrenia is
D. Take the woman’s radial pulse shouting and banging on the door leading to
while still auscultating the FHR. the outside, saying, “I need to go to an
appointment.” What is the appropriate nursing
intervention?
37. The nurse must instruct a client with
glaucoma to avoid taking over-the-counter
medications like: A. Tell the client that he cannot
bang on the door.
B. Ignore this behavior.
A. Antihistamines. C. Escort the client going back into
B. NSAIDs. the room.
C. Antacids. D. Ask the client to move away from
D. Salicylates. the door.

38. A male client is brought to the emergency 41. Which of the following action is an
department due to motor vehicle accident. accurate tracheal suctioning technique?
While monitoring the client, the nurse
suspects increasing intracranial pressure
when: A. 25 seconds of continuous suction
during catheter insertion.
B. 20 seconds of continuous suction
A. Client is oriented when aroused during catheter insertion.
from sleep, and goes back to
sleep immediately.

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C. 10 seconds of intermittent B. Have the client lie on the

suction during catheter unaffected side.
withdrawal. C. Maintain the client in high
D. 15 seconds of intermittent Fowler’s position.
suction during catheter D. Coordinate breathing and
withdrawal. coughing exercise with
administration of analgesics.

42. The client’s jaw and cheekbone is sutured

and wired. The nurse anticipates that the 46. The community nurse is teaching the
most important thing that must be ready at group of mothers about the cervical mucus
the bedside is: method of natural family planning. Which
characteristics are typical of the cervical
mucus during the “fertile” period of the
A. Suture set. menstrual cycle?
B. Tracheostomy set.
C. Suction equipment.
D. Wire cutters. A. Absence of ferning.
B. Thin, clear, good spinnbarkeit.
C. Thick, cloudy.
43. A mother is in the third stage of labor. D. Yellow and sticky.
Which of the following signs will help the
nurse determine the signs of placental
separation? 47. A client with ruptured appendix had
surgery an hour ago and is transferred to the
nursing care unit. The nurse placed the client
A. The uterus becomes globular. in a semi-Fowler’s position primarily to:
B. The umbilical cord is shortened.
C. The fundus appears at the
introitus. A. Facilitate movement and reduce
D. Mucoid discharge is increased. complications from immobility.
B. Fully aerate the lungs.
C. Splint the wound.
44. After therapy with the thrombolytic D. Promote drainage and prevent
alteplase (t-PA), what observation will the subdiaphragmatic abscesses.
nurse report to the physician?

48. Which of the following will best describe

A. 3+ peripheral pulses. a management function?
B. Change in level of consciousness
and headache.
C. Occasional dysrhythmias. A. Writing a letter to the editor of
D. Heart rate of 100/bpm. a nursing journal.
B. Negotiating labor contracts.
C. Directing and evaluating nursing
45. A client who undergone left nephrectomy staff members.
has a large flank incision. Which of the D. Explaining medication side
following nursing action will facilitate deep effects to a client.
breathing and coughing?

49. The parents of an infant client ask the

A. Push fluid administration to nurse to teach them how to administer
loosen respiratory secretions.

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Cortisporin eye drops. The nurse is correct in D. Clarify the family’s understanding
advising the parents to place the drops: of brain death.

A. In the middle of the lower 53. The nurse is teaching exercises that are
conjunctival sac of the infant’s good for pregnant women increasing tone and
eye. fitness and decreasing lower backache. Which
B. Directly onto the infant’s sclera. of the following should the nurse exclude in
C. In the outer canthus of the the exercise program?
infant’s eye.
D. In the inner canthus of the
infant’s eye. A. Stand with legs apart and touch
hands to floor three times per
day.
50. The nurse is assessing on the client who is B. Ten minutes of walking per day
admitted due to vehicle accident. Which of with an emphasis on good posture.
the following findings will help the nurse that C. Ten minutes of swimming or leg
there is internal bleeding? kicking in pool per day.
D. Pelvic rock exercise and squats
three times a day.
A. Frank blood on the clothing.
B. Thirst and restlessness.
C. Abdominal pain. 54. A client with obsessive-compulsive
D. Confusion and altered of behavior is admitted in the psychiatric unit.
consciousness. The nurse taking care of the client knows
that the primary treatment goal is to:

51. The nurse is completing an assessment to

a newborn baby boy. The nurse observes that A. Provide distraction.
the skin of the newborn is dry and flaking and B. Support but limit the behavior.
there are several areas of an apparent C. Prohibit the behavior.
macular rash. The nurse charts this as: D. Point out the behavior.

A. Icterus neonatorum 55. After ileostomy, the nurse expects that

B. Multiple hemangiomas the drainage appliance will be applied to the
C. Erythema toxicum stoma:
D. Milia

A. When the client is able to begin

52. The client is brought to the emergency self-care procedures.
department because of serious vehicle B. 24 hours later, when the swelling
accident. After an hour, the client has been subsided.
declared brain dead. The nurse who has been C. In the operating room after the
with the client must now talk to the family ileostomy procedure.
about organ donation. Which of the following D. After the ileostomy begins to
consideration is necessary? function.

A. Include as many family members 56. A female client who has a 28-day
as possible. menstrual cycle asks the community health
B. Take the family to the chapel.
C. Discuss life support systems.

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nurse when she get pregnant during her cycle. reduce the chances of transmission of herpes
What will be the best nursing response? simplex 2?

A. It is impossible to determine the A. “Abstain from intercourse until

fertile period reliably. So it is lesions heal.”
best to assume that a woman is B. “Therapy is curative.”
always fertile. C. “Penicillin is the drug of choice
B. In a 28-day cycle, ovulation for treatment.”
occurs at or about day 14. The D. “The organism is associated with
egg lives for about 24 hours and later development of
the sperm live for about 72 hydatidiform mole.
hours. The fertile period would
be approximately between day 11
and day 15. 59. The nurse in the psychiatric ward
C. In a 28- day cycle, ovulation informed the male client that he will be
occurs at or about day 14. The attending the 9:00 AM group therapy
egg lives for about 72 hours and sessions. The client tells the nurse that he
the sperm live for about 24 must wash his hands from 9:00 to 9:30 AM
hours. The fertile period would each day and therefore he cannot attend.
be approximately between day 13 Which concept does the nursing staff need to
and 17. keep in mind in planning nursing intervention
D. In a 28-day cycle, ovulation for this client?
occurs 8 days before the next
period or at about day 20. The A. Depression underlines ritualistic
fertile period is between day 20
behavior.
and the beginning of the next
B. Fear and tensions are often
period.
expressed in disguised form
through symbolic processes.
57. Which of the following statement C. Ritualistic behavior makes others
describes the role of a nurse as a client uncomfortable.
advocate? D. Unmet needs are discharged
through ritualistic behavior.

A. A nurse may override clients’

wishes for their own good. 60. The nurse assesses the health condition
B. A nurse has the moral obligation of the female client. The client tells the
to prevent harm and do well for nurse that she discovered a lump in the
clients. breast last year and hesitated to seek
C. A nurse helps clients gain greater medical advice. The nurse understands that,
independence and women who tend to delay seeking medical
self-determination. advice after discovering the disease are
D. A nurse measures the risk and displaying what common defense mechanism?
benefits of various health
situations while factoring in cost. A. Intellectualization.
B. Suppression.
58. A community health nurse is providing a C. Repression.
health teaching to a woman infected with D. Denial.
herpes simplex 2. Which of the following
health teaching must the nurse include to

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61. Which of the following situations cannot D. Collect specimen at night,

be delegated by the registered nurse to the refrigerate, and bring to clinic
nursing assistant? the next morning.

A. A postoperative client who is 64. The physician ordered Betamethasone to

stable needs to ambulate. a pregnant woman at 34 weeks of gestation
B. Client in soft restraint who is with sign of preterm labor. The nurse expects
very agitated and crying. that the drug will:
C. A confused elderly woman who
needs assistance with eating.
D. Routine temperature check that A. Treat infection.
must be done for a client at end B. Suppress labor contraction.
of shift. C. Stimulate the production of
surfactant.
D. Reduce the risk of hypertension.
62. In the admission care unit, which of the
following client would the nurse give
immediate attention? 65. A tracheostomy cuff is to be deflated,
which of the following nursing intervention
should be implemented before starting the
A. A client who is 3 days procedures?
postoperative with left calf pain.
B. A client who is postoperative hip
pinning who is complaining of pain. A. Suction the trachea and mouth.
C. New admitted client with chest B. Have the obdurator available.
pain. C. Encourage deep breathing and
D. A client with diabetes who has a coughing.
glucoscan reading of 180. D. Do a pulse oximetry reading.

63. A couple seeks medical advice in the 66. A client is diagnosed with Tuberculosis
community health care unit. A couple has been and respiratory isolation is initiated. This
unable to conceive; the man is being evaluated means that:
for possible problems. The physician ordered
semen analysis. Which of the following A. Gloves are worn when handling
instructions is correct regarding collection of
the client’s tissue, excretions,
a sperm specimen?
and linen.
B. Both client and attending nurse
A. Collect a specimen at the clinic, must wear masks at all times.
place in iced container, and give C. Nurse and visitors must wear
to laboratory personnel masks until chemotherapy is
immediately. begun. Client is instructed in
B. Collect specimen after 48-72 cough and tissue techniques.
hours of abstinence and bring to D. Full isolation; that is, caps and
clinic within 2 hours. gowns are required during the
C. Collect specimen in the morning period of contagion.
after 24 hours of abstinence and
bring to clinic immediately.
67. A client with lung cancer is admitted in
the nursing care unit. The husband wants to

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know the condition of his wife. How should pediatrician has informed the
the nurse respond to the husband? mother that the child has head
lice.
C. A telephone call notifying the
A. Find out what information he school nurse that a child has a
already has. temperature of 102ºF and a rash
B. Suggest that he discuss it with covering the trunk and upper
his wife. extremities of the body.
C. Refer him to the doctor. D. A telephone call notifying the
D. Refer him to the nurse in charge. school nurse that a child
underwent an emergency
appendectomy during the previous
68. A hospitalized client cannot find his
night.
handkerchief and accuses other cient in the
room and the nurse of stealing them. Which is
the most therapeutic approach to this client? 71. Which of the following signs and
symptoms that require immediate attention
A. Divert the client’s attention. and may indicate most serious complications
B. Listen without reinforcing the during pregnancy?
client’s belief.
C. Inject humor to defuse the A. Severe abdominal pain or fluid
intensity. discharge from the vagina.
D. Logically point out that the client B. Excessive saliva, “bumps around
is jumping to conclusions. the areolae, and increased vaginal
mucus.
C. Fatigue, nausea, and urinary
69. After a cystectomy and formation of an
frequency at any time during
ileal conduit, the nurse provides instruction
pregnancy.
regarding prevention of leakage of the pouch
D. Ankle edema, enlarging
and backflow of the urine. The nurse is
varicosities, and heartburn.
correct to include in the instruction to empty
the urine pouch:
72. The nurse is assessing the newborn boy.
A. Every 3-4 hours. Apgar scores are 7 and 9. The newborn
B. Every hour. becomes slightly cyanotic. What is the initial
C. Twice a day. nursing action?
D. Once before bedtime.
A. Elevate his head to promote
gravity drainage of secretions.
70. Which telephone call from a student’s
B. Wrap him in another blanket, to
mother should the school nurse take care of
reduce heat loss.
at once?
C. Stimulate him to cry,, to increase
oxygenation.
A. A telephone call notifying the D. Aspirate his mouth and nose with
school nurse that the child’ bulb syringe.
pediatrician has informed the
mother that the child will need
cardiac repair surgery within the 73. The nurse is formulating a plan of care to
next few weeks. a client with a somatoform disorder. The
B. A telephone call notifying the
school nurse that the child’s

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nurse needs to have knowledge of which 76. The nurse wants to know if the mother of
psychodynamic principle? a toddler understands the instructions
regarding the administration of syrup of
ipecac. Which of the following statement will
A. The symptoms of a somatoform help the nurse to know that the mother needs
disorder are an attempt to adjust additional teaching?
to painful life situations or to
cope with conflicting sexual,
aggressive, or dependent feelings. A. “I’ll give the medicine if my child
B. The major fundamental gets into some toilet bowl
mechanism is regression. cleaner.”
C. The client’s symptoms are B. “I’ll give the medicine if my child
imaginary and the suffering is gets into some aspirin.”
faked. C. “I’ll give the medicine if my child
D. An extensive, prolonged study of gets into some plant bulbs.”
the symptoms will be reassuring D. “I’ll give the medicine if my child
to the client, who seeks gets into some vitamin pills.”
sympathy, attention and love.

77. To assess if the cranial nerve VII of the

74. An infant is brought to the health care client was damaged, which changes would not
clinic for three immunizations at the same be expected?
time. The nurse knows that hepatitis B, DPT,
and Haemophilus influenzae type B
immunizations should: A. Drooling and drooping of the
mouth.
B. Inability to open eyelids on
A. Be drawn in the same syringe and operative side.
given in one injection. C. Sagging of the face on the
B. Be mixed and inject in the same operative side.
sites. D. Inability to close eyelid on
C. Not be mixed and the nurse must operative side.
give three injections in three
sites.
D. Be mixed and the nurse must give 78. The community health nurse makes a home
the injection in three sites. visit to a family. During the visit, the nurse
observes that the mother is beating her child.
What is the priority nursing intervention in
75. A female client with cancer has radium this situation?
implants. The nurse wants to maintain the
implants in the correct position. The nurse
should position the client: A. Assess the child’s injuries.
B. Report the incident to protective
agencies.
A. Flat in bed. C. Refer the family to appropriate
B. On the side only. support group.
C. With the foot of the bed D. Assist the family to identify
elevated. stressors and use of other coping
D. With the head elevated mechanisms to prevent further
45-degrees (semi-Fowler’s). incidents.

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79. The nurse in the neonatal care unit is B. “Start planning adoption. Many
supervising the actions of a certified nursing couples get pregnant when they
assistant in giving care to the newborns. The are trying to adopt.”
nursing assistant mistakenly gives a formula C. “Consult a fertility specialist and
feeding to a newborn that is on water feeding start testing before you get any
only. The nurse is responsible for the mistake older.”
of the nursing assistant: D. “Have sex as often as you can,
especially around the time of
ovulation, to increase your
A. Always, as a representative of chances of pregnancy.”
the institution.
B. Always, because nurses who
supervise less-trained individuals 82. The nurse is caring for a cient who Is a
are responsible for their retired nurse. A 24-hour urine collection for
mistakes. Creatinine clearance is to be done. The client
C. If the nurse failed to determine tells the nurse, “I can’t remember what this
whether the nursing assistant test is for.” The best response by the nurse
was competent to take care of is:
the client.
D. Only if the nurse agreed that the
newborn could be fed formula. A. “It provides a way to see if you
are passing any protein in your
urine.”
80. The nurse is assigned to care for a client B. “It tells how well the kidneys
with urinary calculi. Fluid intake of 2L/day is filter wastes from the blood.”
encouraged to the client. the primary reason C. “It tells if your renal
for this is to: insufficiency has affected your
heart.”
D. “The test measures the number
A. Reduce the size of existing of particles the kidney filters.”
stones.
B. Prevent crystalline irritation to
the ureter. 83. The nurse observes the female client in
C. Reduce the size of existing the psychiatric ward that she is having a hard
stones time sleeping at night. The nurse asks the
D. Increase the hydrostatic client about it and the client says, “I can’t
pressure in the urinary tract. sleep at night because of fear of dying.”
What is the best initial nursing response?

81. The nurse is counseling a couple in their

mid 30’s who have been unable to conceive for A. “It must be frightening for you
about 6 months. They are concerned that one to feel that way. Tell me more
or both of them may be infertile. What is the about it.”
best advice the nurse could give to the B. “Don’t worry, you won’t die. You
couple? are just here for some test.”
C. “Why are you afraid of dying?”
D. “Try to sleep. You need the rest
A. “it is no unusual to take 6-12 before tomorrow’s test.”
months to get pregnant,
especially when the partners are
in their mid-30s. Eat well, 84. In the hospital lobby, the registered
exercise, and avoid stress.” nurse overhears a two staff members
discussing about the health condition of her

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client. What would be the appropriate action D. Maintains uterine tone.

for the registered nurse to take?

88. The nurse in the nursing care unit is

A. Join in the conversation, giving
her input about the case.
B. Ignore them, because they have
the right to discuss anything they
want to.
C. Tell them it is not appropriate to
discuss such things.
D. Report this incident to the
nursing supervisor.
85. The client has had a right-sided
cerebrovascular accident. In transferring the
client from the wheelchair to bed, in what
position should a client be placed to facilitate
safe transfer?
A. Weakened (L) side of the cient
next to bed.
B. Weakened (R) side of the client
next to bed.
C. Weakened (L) side of the client
away from bed.
D. Weakened (R) side of the cient
away from bed.
aware that one of the medical staff displays
unlikely behaviors like confusion, agitation,
lethargy and unkempt appearance. This
behavior has been reported to the nurse
manager several times, but no changes
observed. The nurse should:
A. Continue to report observations
of unusual behavior until the
problem is resolved.
B. Consider that the obligation to
protect the patient from harm
has been met by the prior
reports and do nothing further.
C. Discuss the situation with friends
who are also nurses to get ideas .
D. Approach the partner of this
medical staff member with these
concerns.
89. The physician ordered tetracycline PO qid
to a child client who weights 20kg. The
recommended PO tetracycline dose is 25-50
mg/kg/day. What is the maximum single dose
that can be safely administered to this child?

86. The child client has undergone hip surgery

and is in a spica cast. Which of the following A. 1g
toy should be avoided to be in the child’s bed? B. 500 mg
C. 250 mg
D. 125 mg
A. A toy gun.
B. A stuffed animal.
C. A ball. 90. The nurse is completing an obstetric
D. Legos. history of a woman in labor. Which event in
the obstetric history will help the nurse
suspects dysfunctional labor in the current
87. The LPN/LVN asks the registered nurse pregnancy?
why oxytocin (Pitocin), 10 units (IV or IM)
must be given to a client after birth fo the
fetus. The nurse is correct to explain that A. Total time of ruptured
oxytocin: membranes was 24 hours with the
second birth.
B. First labor lasting 24 hours.
A. Minimizes discomfort from C. Uterine fibroid noted at time of
“afterpains.” cesarean delivery.
B. Suppresses lactation.
C. Promotes lactation.

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D. Second birth by cesarean for in deciding whether or not to

face presentation. take the job.

91. The nurse is planning to talk to the client 94. The nurse advised the pregnant woman
with an antisocial personality disorder. What that smoking and alcohol should be avoided
would be the most therapeutic approach? during pregnancy. The nurse takes into
account that the developing fetus is most
vulnerable to environment teratogens that
A. Provide external controls. cause malformation during:
B. Reinforce the client’s
self-concept.
C. Give the client opportunities to A. The entire pregnancy.
test reality. B. The third trimester.
D. Gratify the client’s inner needs. C. The first trimester.
D. The second trimester.

92. The nurse is teaching a group of women

about fertility awareness, the nurse should 95. A male client tells the nurse that there is
emphasize that basal body temperature: a big bug in his bed. The most therapeutic
nursing response would be:

A. Can be done with a mercury

thermometer but no a digital one. A. Silence.
B. The average temperature taken B. “Where’s the bug? I’ll kill it for
each morning. you.”
C. Should be recorded each morning C. “I don’t see a bug in your bed, but
before any activity. you seem afraid.”
D. Has a lower degree of accuracy in D. “You must be seeing things.”
predicting ovulation than the
cervical mucus test.
96. A pregnant client in late pregnancy is
complaining of groin pain that seems worse on
93. The nursing applicant has given the chance the right side. Which of the following is the
to ask questions during a job interview at a most likely cause of it?
local hospital. What should be the most
important question to ask that can increase
chances of securing a job offer? A. Beginning of labor.
B. Bladder infection.
C. Constipation.
A. Begin with questions about client D. Tension on the round ligament.
care assignments, advancement
opportunities, and continuing
education. 97. The nurse is conducting a lecture to a
B. Decline to ask questions, because group of volunteer nurses. The nurse is
that is the responsibility of the correct in imparting the idea that the Good
interviewer. Samaritan law protects the nurse from a suit
C. Ask as many questions about the for malpractice when:
facility as possible.
D. Clarify information regarding A. The nurse stops to render
salary, benefits, and working
emergency aid and leaves before
hours first, because this will help
the ambulance arrives.

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B. The nurse acts in an emergency Situation 1: Raphael, a 6 year’s old prep pupil
at his or her place of employment. is seen at the school clinic for growth and
C. The nurse refuses to stop for an development monitoring (Questions 1-5)
emergency outside of the scope
of employment. 1. Which of the following is characterized the
D. The nurse is grossly negligent at rate of growth during this period?
the scene of an emergency.
A. most rapid period of growth
98. A woman is hospitalized with mild B. a decline in growth rate
preeclampsia. The nurse is formulating a plan C. growth spurt
of care for this client, which nursing care is D. slow uniform growth rate
least likely to be done?
2. In assessing Raphael’s growth and
A. Deep-tendon reflexes once per development, the nurse is guided by principles
shift. of growth and development. Which is not
B. Vital signs and FHR and rhythm included?
q4h while awake.
C. Absolute bed rest. A. All individuals follow
D. Daily weight.
cephalo-caudal and proximo-distal
B. Different parts of the body
99. While feeding a newborn with an grows at different rate
unrepaired cardiac defect, the nurse keeps on C. All individual follow standard
assessing the condition of the client. The growth rate
nurse notes that the newborn’s respiration is D. Rate and pattern of growth can
72 breaths per minute. What would be the be modified
initial nursing action?
3. What type of play will be ideal for Raphael
A. Burp the newborn. at this period?
B. Stop the feeding.
C. Continue the feeding. A. Make believe
D. Notify the physician.
B. Hide and seek
C. Peek-a-boo
100. A client who undergone appendectomy 3 D. Building blocks
days ago is scheduled for discharge today.
The nurse notes that the client is restless,
4. Which of the following information indicate
picking at bedclothes and saying, “I am late on
that Raphael is normal for his age?
my appointment,” and calling the nurse by the
wrong name. The nurse suspects:
A. Determine own sense self
B. Develop sense of whether he can
A. Panic reaction.
trust the world
B. Medication overdose.
C. Has the ability to try new things
C. Toxic reaction to an antibiotic.
D. Learn basic skills within his
D. Delirium tremens.
culture

PNLE: Pediatric Nursing Exam

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5. Based on Kohlberg’s theory, what is the D. Are indicative of parental abuse

stage of moral development of Raphael?

10. Signs of cold stress that the nurse must

A. Punishment-obedience be alert when caring for a Newborn is:
B. “good boy-Nice girl”
C. naïve instrumental orientation
D. social contact A. Hypothermia
B. Decreased activity level
C. Shaking
Situation 2 Baby boy Lacson delivered at 36 D. Increased RR
weeks gestation weighs 3,400 gm and height
of 59 cm (6-10)
Situation 3 Nursing care after delivery has an
6. Baby boy Lacson’s height is important aspect in every stages of delivery

11. After the baby is delivered, the cord was

A. Long cut between two clamps using a sterile
B. Short scissors and blade, then the baby is placed at
C. Average the:
D. Too short

A. Mother’s breast
7. Growth and development in a child B. Mother’s side
progresses in the following ways EXCEPT C. Give it to the grandmother
D. Baby’s own mat or bed

A. From cognitive to psychosexual

B. From trunk to the tip of the 12. The baby’s mother is RH(-). Which of the
extremities following laboratory tests will probably be
C. From head to toe ordered for the newborn?
D. From general to specific

A. Direct Coomb’s
8. As described by Erikson, the major B. Indirect Coomb’s
psychosexual conflict of the above situation C. Blood culture
is D. Platelet count

A. Autonomy vs. Shame and doubt 13. Hypothermia is common in newborn

B. Industry vs. Inferiority because of their inability to control heat. The
C. Trust vs. mistrust following would be an appropriate nursing
D. Initiation vs. guilt intervention to prevent heat loss except:

9. Which of the following is true about A. Place the crib beside the wall
Mongolian Spots? B. Doing Kangaroo care
C. By using mechanical pressure
D. Drying and wrapping the baby
A. Disappears in about a year
B. Are linked to pathologic
conditions 14. The following conditions are caused by
C. Are managed by tropical steroids cold stress except

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D. Lying semi flat

A. Hypoglycemia
B. Increase ICP
C. Metabolic acidosis 19. A common problem in children is the
D. Cerebral palsy inflammation of the middle ear. This is
related to the malfunctioning of the:
15. During the feto-placental circulation, the
shunt between two atria is called A. Tympanic membrane
B. Eustachian tube
C. Adenoid
A. Ductus venosous
D. Nasopharynx
B. Foramen Magnum
C. Ductus arteriosus
D. Foramen Ovale 20. For acute otitis media, the treatment is
prompt antibiotic therapy. Delayed treatment
may result in complications of:
16. What would cause the closure of the
Foramen ovale after the baby had been
delivered? A. Tonsillitis
B. Eardrum Problems
C. Brain damage
A. Decreased blood flow
D. Diabetes mellitus
B. Shifting of pressures from right
side to the left side of the heart
C. Increased PO2 21. When assessing gross motor development
D. Increased in oxygen saturation in a 3 year old, which of the following
activities would the nurse expect to finds?
17. Failure of the Foramen Ovale to close will
cause what Congenital Heart Disease? A. Riding a tricycle
B. Hopping on one foot
C. Catching a ball
A. Total anomalous Pulmunary Artery
D. Skipping on alternate foot.
B. Atrial Septal defect
C. Transposition of great arteries
D. Pulmunary Stenosis 22. When assessing the weight of a 5-month
old, which of the following indicates healthy
growth?
Situation 4 Children are vulnerable to some
minor health problems or injuries hence the
nurse should be able to teach mothers to give A. Doubling of birth weight
appropriate home care. B. Tripling of birth weight
C. Quadrupling of birth weight
18. A mother brought her child to the clinic
D. Stabilizing of birth weight
with nose bleeding. The nurse showed the
mother the most appropriate position for the
child which is: 23. An appropriate toy for a 4 year old child
is:
A. Sitting up
B. With low back rest A. Push-pull toys
C. With moderate back rest B. Card games
C. Doctor and nurse kits

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D. Books and Crafts 28. When assessing a family for potential

child abuse risks, the nurse would observe for
which of the following?
24. Which of the following statements would
the nurse expects a 5-year old boy to say
whose pet gerbil just died A. Periodic exposure to stress
B. Low socio-economic status
C. High level of self esteem
A. “The boogieman got him” D. Problematic pregnancies
B. “He’s just a bit dead”
C. “Ill be good from now own so I
wont die like my gerbil” 29. Which of the following is a possible
D. “Did you hear the joke about…” indicator of Munchausen syndrome by proxy
type of child abuse?

25. When assessing the fluid and electrolyte

balance in an infant, which of the following A. Bruises found at odd locations,
would be important to remember? with different stages of healing
B. STD’s and genital discharges
C. Unexplained symptoms of
A. Infant can concentrate urine at diarrhea, vomiting and apnea with
an adult level no organic basis
B. The metabolic rate of an infant is D. Constant hunger and poor hygiene
slower than in adults
C. Infants have more intracellular
water that adult do 30. Which of the following is an inappropriate
D. Infant have greater body surface interventions when caring for a child with
area than adults HIV?

26. When assessing a child with aspirin A. Teaching family about disease
overdose, which of the following will be transmission
expected? B. Offering large amount of fresh
fruits and vegetables
C. Encouraging child to perform at
A. Metabolic alkalosis optimal level
B. Respiratory alkalosis D. Teach proper hand washing
C. Metabolic acidosis technique
D. Respiratory acidosis

Situation 5 Agata, 2 years old is rushed to

27. Which of the following is not a possible the ER due to cyanosis precipitated by crying.
systemic clinical manifestation of severe Her mother observed that after playing she
burns? gets tired. She was diagnosed with Tetralogy
of Fallot.
A. Growth retardation 31. The goal of nursing care fro Agata is to:
B. Hypermetabolism
C. Sepsis
D. Blisters and edema A. Prevent infection
B. Promote normal growth and
development
C. Decrease hypoxic spells

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D. Hydrate adequately D. Cystic Fibrosis

32. The immediate nursing intervention for 37. Which of the following statements by the
cyanosis of Agata is: family of a child with asthma indicates a need for
additional teaching?

A. Call up the pediatrician

B. Place her in knee chest position A. “We need to identify what things
C. Administer oxygen inhalation triggers his attacks”
D. Transfer her to the PICU B. “He is to use bronchodilator inhaler
before steroid inhaler”
C. “We’ll make sure he avoids exercise
33. Agata was scheduled for a palliative surgery, to prevent asthma attacks”
which creates anastomosis of the subclavian artery D. “he should increase his fluid intake
to the pulmonary artery. This procedure is: regularly to thin secretions”

A. Waterston-Cooley 38. Which of the following would require careful

B. Raskkind Procedure monitoring in the child with ADHD who is receiving
C. Coronary artery bypass Methylphenidate (Ritalin)?
D. Blalock-Taussig

A. Dental health
34. Which of the following is not an indicator that B. Mouth dryness
Agata experiences separation anxiety brought C. Height and weight
about her hospitalization? D. Excessive appetite

A. Friendly with the nurse Situation 6 Laura is assigned as the Team Leader
B. Prolonged loud crying, consoled only during the immunization day at the RHU
by mother
C. Occasional temper tantrums and 39. What program for the DOH is launched at
always says NO 1976 in cooperation with WHO and UNICEF to
D. Repeatedly verbalizes desire to go reduce morbidity and mortality among infants
home caused by immunizable disease?

35. When Agata was brought to the OR, her A. Patak day
parents where crying. What would be the most B. Immunization day on Wednesday
appropriate nursing diagnosis? C. Expanded program on immunization
D. Bakuna ng kabtaan

A. Infective family coping r/t

situational crisis 40. One important principle of the immunization
B. Anxiety r/t powerlessness program is based on?
C. Fear r/t uncertain prognosis
D. Anticipatory grieving r/t gravity of
child’s physical status A. Statistical occurrence
B. Epidemiologic situation
C. Cold chain management
36. Which of the following respiratory condition is D. Surveillance study
always considered a medical emergency?

41. The main element of immunization program is

A. Laryngeotracheobronchitis (LTB) one of the following?
B. Epiglottitis
C. Asthma

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implementing the UN’s goal on Universal Child

A. Information, education and
Immunization?
communication
B. Assessment and evaluation of the
program A. PD no. 996
C. Research studies B. PD no. 6
D. Target setting C. PD no. 46
D. RA 9173
42. What does herd immunity means?
47. Braguda asks you about Vitamin A
supplementation. You responded that giving Vitamin
A. Interruption of transmission
A starts when the infant reaches 6 months and the
B. All to be vaccinated
first dose is”
C. Selected group for vaccination
D. Shorter incubation
A. 200,000 “IU”
B. 100,000 “IU”
43. Measles vaccine can be given simultaneously. C. 500,000 “IU”
What is the combined vaccine to be given to D. 10,000 “IU”
children starting at 15 months?

48. As part of CARI program, assessment of the

A. MCG
child is your main responsibility. You could ask the
B. MMR
following question to the mother except:
C. BCG
D. BBR
A. “How old is the child?”
B. “IS the child coughing? For how
Situation 7: Braguda brought her 5-month old long?”
daughter in the nearest RHU because her baby C. “Did the child have chest indrawing?”
sleeps most of the time, with decreased appetite, D. “Did the child have fever? For how
has colds and fever for more than a week. The long?”
physician diagnosed pneumonia.

44. Based on this data given by Braguda, you can

49. A newborn’s failure to pass meconium within 24
classify Braguda’s daughter to have:
hours after birth may indicate which of the
following?
A. Pneumonia: cough and colds
B. Severe pneumonia
A. Aganglionic Mega colon
C. Very severe pneumonia
B. Celiac disease
D. Pneumonia moderate
C. Intussusception
D. Abdominal wall defect
45. For a 3-month old child to be classified to have
Pneumonia (not severe), you would expect to find
50. The nurse understands that a good snack for a
RR of:
2 year old with a diagnosis of acute asthma would
be:
A. 60 bpm
B. 40 bpm
A. Grapes
C. 70 bpm
B. Apple slices
D. 50 pbm
C. A glass of milk
D. A glass of cola
46. You asked Braguda if her baby received all
vaccines under EPI. What legal basis is used in

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51. Which of the following immunizations would the 56. For a child with recurring nephritic syndrome,
nurse expect to administer to a child who is HIV which of the following areas of potential
(+) and severely immunocomromised? disturbances should be a prime consideration when
planning ongoing nursing care?

A. Varicella
B. Rotavirus A. Muscle coordination
C. MMR B. Sexual maturation
D. IPV C. Intellectual development
D. Body image

52. When assessing a newborn for developmental

dysplasia of the hip, the nurse would expect to 57. An inborn error of metabolism that causes
assess which of the following? premature destruction of RBC?

A. Symmetrical gluteal folds A. G6PD

B. Trendelemburg sign B. Hemocystinuria
C. Ortolani’s sign C. Phenylketonuria
D. Characteristic limp D. Celiac Disease

53. While assessing a male neonate whose mother 58. Which of the following would be a diagnostic
desires him to be circumcised, the nurse observes test for Phenylketonuria which uses fresh urine
that the neonate’s urinary meatus appears to be mixed with ferric chloride?
located on the ventral surface of the penis. The
physician is notified because the nurse would
suspect which of the following? A. Guthrie Test
B. Phenestix test
C. Beutler’s test
A. Phimosis D. Coomb’s test
B. Hydrocele
C. Epispadias
D. Hypospadias 59. Dietary restriction in a child who has
Hemocystenuria will include which of the following
amino acid?
54. When teaching a group of parents about seat
belt use, when would the nurse state that the child
be safely restrained in a regular automobile A. Lysine
seatbelt? B. Methionine
C. Isolensine tryptophase
D. Valine
A. 30 lb and 30 in
B. 35 lb and 3 y/o
C. 40 lb and 40 in 60. A milk formula that you can suggest for a child
D. 60 lb and 6 y/o with Galactosemia:

55. When assessing a newborn with cleft lip, the A. Lofenalac

nurse would be alert which of the following will B. Lactum
most likely be compromised? C. Neutramigen
D. Sustagen

A. Sucking ability
B. Respiratory status
C. Locomotion
D. GI function

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