1. Mikko, a 5-year old boy and his mother are your regular clients in your Nursing Clinic. You accompanied them to a nearby hospital for referral of what you suspected as an acute case of appendicitis. Mikko’s parents have been legally separated for 5 years now but both enjoy “joint legal custody”. The nurse on duty sought your assistance in asking the mother for her informed consent for immediate surgery. Together with the nurse-on-duty which f the following would be the BEST action?A. Have mother sign the consent and continue the child’s preoperative preparationB. Contact the father to obtain consentC. Have mother sign the consent and inform surgeryD. Have mother sign the consent and inform the surgeon right awayCorrect Answer: D. Joint legal custody means that both parents can make decisions for the child, including medical treatment, but where possible they should consult the other. Upon the death or disability of either parent, legal custody will go to the remaining parent and will give the active parent the sole ability to act as parent for the child without further order of the court. The primary affect of this is a psychological benefit for the parent and the child, so that a child can be told that both parents cared for the child, even though the child had to live most of the time with one of them.Reference; www.lawdictionary.com

2. Another of your pediatric patients named Arjay got rushed to the hospital with sustained bruises and lacerations, and a fractured arm. As Arjay was being treated in the ER, his mother requested for you to come and assist them and the nurse-on-duty (NOD) was informed of your coming as their “family nurse”. Upon arrival you coordinated with the NOD and later you were able to obtain Arjay’s confession that he got involved in a “frat” fight outside school. You and the NOD agreed on which priority actions?A. Ensure documentation on the Arjay’s chartB. Share the information with the hospital social workerC. Share only this information with fellow health professionalsD. Call for the Police and report the findingsCorrect Answer: Report all cases of suspected child abuse; Health care professionals have a legal obligation to report such suspected abuse. Reference: Maternal and Newborn Nursing by M. Hogan p. 387

3. You got invited as a speaker in a class of nursing students to share your experiences and understanding on the handling of potential legal cases while in practice. Which acts would constitute battery?A. When you administer an injection to a schizophrenic patient who refuses to take the medication because he believes it is poisonB. When on doctor’s order you restrain an agitated patient inside the E.R.C. When you chase a patient who tries to run away while taking a walk with you around the hospitalD. When you hold the arms of a manic patient who strikes youCorrect Answer: A Battery is an intentional, unconsented touching of the other person. When a person comes to the hospital, it is implied that the consents to be treated. However, he may refuse certain contracts. If he refuses an injection and the nurse gives it anyway, the latter can be charged with battery.Reference: Professional Nursing in the Philippines, by L. Venzon. p157

4. Jayvee, a 10 year old boy and his family are your clients. He was admitted to the hospital for a skin graft surgery. You went to visit him and when you came he is being rolled back from surgery. He is on D5W infusing into his left arm and you introduced yourself then check with the nurse-on-duty (NOD) and got the following information, he weighs 50 lbs (23.6kg) and the physician’s order was “D5W 2,000cc/24 hours.” At this instance you opted to engage the NOD toA. Set the IV infusion pump controller to run at 84 gtts/minB. Monitor the patient for fluid and electrolyte imbalanceC. Call the physician to clarify the IV fluid orderD. Ensure accurate records of the patient’s intake and outputCorrect Answer: C

5. You visited one of your family clients, a 26-year old mother whose son died of Sudden Infant Death Syndrome (SIDS). As you were conversing it is sound for you to

A. Ask how her son was positioned in bed while in the hospital at the time of his death.B. Allow the mother to cry and talk about her son and related concernsC. Ask about her other children at homeD. Explain the case of SIDSCorrect Answer: A. Numerous theories have been proposed, but the etiology os SIDS remain unknown. Recent findings suggest an increased Incidence of SIDS who sleep in the prone position. There has been a dramatic decrease in the incidence of SIDS since parents and caregivers putting infants to sleep in their backs. Reference: Pediatric Nursing by M. Muscari p. 161

Situation 12- Mary Ann, 32 years old, G2P1, 28 weeks pregnant, visits your clinic and told you that she has been having various discomforts during this pregnancy and wanted some advises.

6. Mary Ann had leg cramps that come and go and are extremely painful. the most effective measure that you can suggest to relieve cramps is to:A. Lie down and elevate affected leg with a pillow until the cramps stopB. Extend affected leg with knee straight then bend foot towards the bodyC. Increase intake of high phosphorus foodsD. Stand with feet flat on floor and tiptoe alternately, until cramping stopsCorrect Answer: B. Cramps are caused by decreased calcium levels, increased serum phosphorus levels and possibly, interference with circulation can cause muscle cramps of the lower extremities during the pregnancy This problem is best relieved if a woman lies on her back momentarily and extends her involved leg while keeping her knee straight and dorsiflexing the foot until the pain disappears. Reference: Maternal and Child Health Nursing by A. Pilleteri p. 284

7. Mary Ann complains that she doesn’t get enough rest and sleep because of her frequent trips to the bathroom to urinate, the best advise you can give is for her to:A. Bring urine specimen for urinalysis to check for possible infectionB. Bring a commode to the bedroom to reduce trips to the bathroomC. Hold urge to urinate to improve muscle tone and bladder capacityD. Drink more fluids at daytime and decrease intake at nightCorrect Answer: D. Encourage the client to void when urge is felt and decrease fluid intake in eveningReference: Lippincott Review Series by. Straight et al. p. 110

8. Mary Ann noted that she has beginning varicosities. You informed Susan that varicosities are caused by pooling of blood in the large veins of the legs. Prevention of this condition involves the following, EXCEPT:A. Walk around to stimulate blood flow if working in prolonged sitting positionB. When sitting for a long time elevate legs six inches from the floorC. Do not wear tight clothing or crossings legs at the kneesD. When getting out of bed, use support stockings above varicositiesCorrect Answer: B All of these are included in the health teaching to patient with varicosities. Reference: Maternal and Child Health Nursing page 285

9. Mary Ann complained about difficulty in elimination and worried that she might develop hemorrhoids. You may advise Mary Ann to:

1. take fiber-rich foods e.g. fresh fruits and vegetables, fruit juices, salads, oatmeal2. Drink up to 8 glasses of water daily including coffee, tea and softdrinks.3. Exercise regularly and establish a regular time for elimination4. During elimination use footrest to avoid straining

A. 1, 2, 3 and 4 B. 1, 3 and 4 C. 1, 2 and 3 D. 2, 3 and 4Correct Answer: All of these are included In the health teaching except drinking coffee, tea or soft drinks.

10. Mary Ann yells you that she sometimes does not feel her baby’s movements. You can instruct Susan to do fetal movement count (FMC) or kick counts. These statements are true regarding the fetal movement count

1. Client assumes side-lying or reclining position and palpates fetal movements for an hour counting for 10 movements

2. Less than 10 movements within two hours may need further evaluation and should be reported to the nurse.

3. Counting fetal movement is best done at the same time daily, when the mother is ready to go to sleep

4. A well oxygenated fetus moves frequently while a fetus with compromised oxygen supple conserves energy with less activity. A. 1, 2 and 3 B. 2, 3 and 4 C. 1, 2 and 4 D. 1, 3 and 4

Correct Answer- C. 1, 2 and 4 are included in checking the fetal movement. Usually this occurs within 60 minutes. Make sure that fetal movements do vary, especially in relation to sleep cycles of the fetus, her activity and the time since she last ate. Reference: Maternal and Child Health Nursing by A. Pilleteri p. 208

Situation 13- Mrs. Rachel Daquis was admitted due to lumbo-sacral pain. She is a G5P3 with 9 weeks AOG. On admission the following findings were revealed: BOW-intact, cervical dilatation of 4cm, Descent-5, FHT 150/minute, BP-120/80 mmHg, Pulse rate-60 beats/minute and temperature is 36.8 C. Using the PARTOGRAPH you can respons to the following questions and situations affecting Mrs. Rachel Daquis.

11. You immediately can interpret from the partograph that Mrs. Rachel Daquis’ condition asA. There is normal progress of laborB. Unsatisfactory progress due to cephalo-pelvic disproportionC. There is fetal-distressD. Unsatisfactory progress due to inadequate uterine activityCorrect Answer: A The client is in active labor (Descent 5, CV is 4cm) Vitals signs are within normal limits.

12. You recorded a 3+ in the molding, this means that:A. The bones are touching each otherB. The bones are severely overlapping each otherC. The bones are overlapping each otherD. The bones are separated and sutures can be felt easilyCorrect Answer: B. Moulding is an important indication of how adequately the pelvis can accommodate the fetal head. 0- separated bones, sutures felt easily 1+- bones just touch each other 2+- overlapping of each other Reference: Partograph Dr. Shashwat Jani p.. 18

13. Which of the following nursing action should you not include in the care or Mrs. Daquis?A. Labor Augmentation/doctor’s orderB. AmniotomyC. Observe for 30 minutes more for possible caesarian section if no improvementD. Continue monitoring fetal heart beat and cervical dilatationCorrect Answer; B Amniotomy is the artificial rupturing of membranes. Rupturing of membranes if they do not rupture spontaneously allows a fetal head to contract the cervix more directly and although not well proved to do so, may increase the efficiency of contractions and speed pace of labor. Reference: Maternal and Child Health Nursing by A. Pilleteri p. 385

14. At 1 AM, what is the frequency and duration of Mrs. Daquis’ uterine contraction? A. Two contractions in 15 minutes lasting more than 40 secondsB. Three contractions in 10 minutes lasting more than 40 secondsC. Three contractions in 15 minutes lasting more than 40 secondsD. Three contractions in 10 minutes lasting less than 40 secondsReference:

15. The descent of the head at 1PM is at:A. Two fingers above the symphysis pubis C. Three fingers above the symphysis pubis

B. Five fingers above the symphysis pubis D. The fetal head is engagedCorrect Answer: The rule of fifth means the palpable fifth of the fetal head is felt by the abdominal examination above the level of symphisis pubis. Since the descent is 5-, this means that it is five fingers ios above the symphisis pubis. Reference: Partograph Dr. Shashwat Jani p. 36

Situation 14- Good and comprehensive nursing assessment among infants and children is an important aspect of determining appropriate, safe and quality nursing care interventions. The following apply:

16. A 4-week old infant with symptoms of pyloric stenosis was brought by her mother to your clinic. Which of the following statements would you expect the mother to make about her son’s symptoms?A. “My son’s bowel movements have turned black and sticky”B. “My son spits green liquid after feeding.”C. “My son seems hungry all the time.”D. “I really have to encourage my son to suck the bottle”

Correct Answer: B. Pyloric Stenosis happens if the muscles surrounding the sphincter hypertrophied or undergo hyperplasia that will result for it to empty in a difficult way. Infants are usually hungry immediately after vomiting because they are nauseated. Reference: Maternal and Child Health Nursing by A. Pilleteri p. 1331

17. A teenager comes to your clinic with problems of fatigue, sore throat, and flu-like symptoms in the last 2 weeks. Physical examination reveals enlarged lymph nodes and temperature of 37.9 C. Which of these statements do you BEST make?A. “Stay in your room until all of your symptoms are gone.”B. “Do not share your drinking glass or silverware with anybody.”C. “Eat in a separate room away from your family.”D. “Cover your mouth and nose when you sneeze or cough.”Correct Answer; D Airborne/Droplet Precaution

18. You are caring for a 2-month old infant to which a pH probe test indicated “reflux”. Which nursing action is MOST appropriate?A. Raise the head of infant’s bed C. Instruct properly the mother how to do CPRB. Do not give the next feeding D. Keep a normal feeding scheduleCorrect Answer: A Raise the head of the bed is done. pH probe test is inserted through the nose into the esophagus where it remains for 24 hours to detect how many times the esophagus exposed to acid.

19. You are visiting a 3-month old child whom you previously saw in your clinic. He is now on Christopher’s Traction for developmental dysplasia of the hips. Which of the following toys would be appropriate for you to offer the infant to keep him occupied while hospitalized?A. Colorful plastic, non-toxic blocks C. A stuffed toy animalB. A toy rattle D. Nursery rhymes played on tapeCorrect Answer: B. Appropriate for 1st to 3 mos. Old infants include mobiles, mirrors, music boxes, stuffed animals without detachable parts and RATTLES Reference: Pediatric Nursing by M. Muscari page 28

20. One early morning as you were opening your nursing clinic, a 5-year old boy was rushed to you in an emergency after ingesting a bottle of baby aspirin. You are to observe the boy for which signs and symptoms?A. Tinnitus and gastric distress C. Nausea and vertigoB. Dysrrhythmia and hypoventilation D. Epistaxis and paralysisCorrect Answer: A. Side effects changes: Visual changes, TINNITUS, heaptotoxocity, allergic reaction and GI bleeding Reference: Comprehensive Review for NCLEX-RN by M. Hogan page 636

Situation 15- After 10 meaningful years of professional practice and using her savings, Nurse Trish decides to set up her proprietary home healthcare agency. This may be regarded as another journey towards personal and professional development.

21. As owner of the agency, Nurse Trish must be concerned about:A. Making her agency yield reasonable return of investments (ROI) for viability and sustained business growthB. Finding out her agency can be exempt from paying taxesC. Looking for funding support from other business organizationsD. Knowing which government regulatory agencies she should report toCorrect Answer: A

22. Nurse Trish hires registered nurses to work with her as home healthcare nurses whom she assigns to individuals and families requiring nursing care in their homes. One such case is a 60 year old client who needs irrigation of his colostomy following surgery for cancer. This case may not be qualify of Phil Health reimbursement because the client:A. Qualifies as low-income client C. Is under the age of 65B. Is under home-based care D. Is not considered handicapped

Correct Answer B

Case Rates

Since September 1, 2011, the following medical cases and surgical procedures are being paid through case rate:

Medical Cases

1. Dengue I (Dengue fever, DHF grades I&II) 8,000

2. Dengue II (DHF grades III & IV) 16,000

3. Pneumonia I ( moderate risk) 15,000

4. Pneumonia II (high risk) 32,000

5. Essential Hypertension 9,000

6. Cerebral Infarction (CVA-I) 28,000

7. Cerebral Hemorrhage (CVA-II) 38,000

8. Acute Gastroenteritis (AGE) 6,000

9. Asthma 9,000

10. Typhoid Fever 14,000

11. Newborn Care Package in Hospitals and Lying in Clinics 1,750

Surgical Cases

1. Radiotherapy 3,000

2. Hemodialysis 4,000

3. Maternity Care Package (MCP) 8,000

4. NSD Package in Level I Hospitals 8,000

5. NSD Package in Levels 2 to 4 Hospitals 6,500

6. Caesarean Section 19,000

7. Appendectomy 24,000

8. Cholecystectomy 31,000

9. Dilatation and Curettage 11,000

10. Thyroidectomy 31,000

11. Herniorrhaphy 21, 000

12. Mastectomy 22,000

13. Hysterectomy 30,000

14. Cataract Surgery

Reference: www.philhealth.gov.ph

23. Nurse Trish has a caseload of clients whom she needs to see on a regular basis. Which of the following clients may immediately be admitted as a matter of PRIORITY to a private home healthcare program?A. A woman who has delivered a normal healthy infant in a government-managed birthing centerB. A client in the terminal stages of cancer at the hospital and will be discharged for home careC. A family with three (3) family members who tested positive for tuberculosis and just moved into a barangayD. A teenage drug abuser who has refused medical treatment but is being seen by a a counselor at schoolCorrect Answer: C. Tuberculosis Provide public health nursing and outreach services for home supervision of patients to supervise therapy directly and to arrange for examination and preventive treatment of contacts. Reference: Public Health Nursing in the Philippines by NLGPN page 241

24. A client who had open heart surgery 2 weeks ago and about to be discharged was referred to nurse Trish’s Home HealthCare Agency for daily dressing changes, cardiac rehabilitation and physical therapy. The assigned home healthcare nurse shouldA. Complete the necessary assessment on a weekly basisB. Develop an individualized plan of careC. Directly supervise the physical therapy the client receivesD. Provide daily physical care for the client Correct Answer: B. Individualized patient care is given according to the case of the patient.

25. Nurse Trish plans to present t the local city health board a “Stop Smoking” campaign to the community’s local public as her social responsibility program. Trish understands that if the proposal is accepted, the funding would come fromA. Philanthropic donationsB. Philhealth contributionsC. Local community funds generated from taxesD. The home Healthcare agency owned by Nurse TrishCorrect Answer; C. WHO established four pillars for successful anti-tobacco programs. These four pillars may be categorized as: 1. Aggressive health information and dissemination2. Government supported and multisectoral programs 3. Building anti tobacco coalitions 4. The taxation of tobacco products

Reference: Public Health Nursing in the Philippines by NLGPN page 220-221

Situation 16- In some hospitals, nurses assigned to care for mothers with reproductive health concerns are given a TRIAGE assignment. They rotate in the obstetrics unit/ward, the labor room, and delivery room. Your nursing to clients in these units are vital in maintaining wellness of these women. The following questions apply.

26. You are taking care of a woman in the labor room whose abdomen remains rigid and hard between contractions. Upon further assessment the fetal heart rate registered at 100/minute. The PRIORITY PROBLEMS in the care of this client would beA. Risk for fetal death C. Ineffective breathingB. Alteration in comfort D. Fluid and electrolyte imbalanceCorrect Answer: C 100/minute is considered moderate bradycardia but not considered serious, probably due to vagal response elicited by compression of fetal head during laborReference: Maternal and Child Health Nursing by A. Pilleteri page 378

27. During a vaginal examination, a prolapsed cord is assessed, your PRIORITY intervention would be toA. Instruct the client not to push during contractions C. Prepare client for emergency caesarean sectionB. ask relatives to leave the room for privacy D. Place the client in Trendelenberg positionCorrect Answer: D. Place mother’s hips higher than head to relieve pressure on the cord and restore fetal oxygenation. Reference; Maternal and Newborn Nursing by M. Hogan page 197

28. Of the following clients endorsed to you by the outgoing nurse on duty, who would you assess immediately? the client who:A. Exhibits early decelerations on the fetal monitorB. Is upset because her obstetrician in on vocationC. is 10 cm dilated and 100% effacedD. cannot decide if she wants anesthesia during deliveryCorrect Answer: C. Effacement is shortening and thinning of the cervical canal. Dilatation refers to an enlargement or widening of the cervical canal from an opening a few millimeters wide to one large enough to permit passage of the fetus. Reference: Maternal and Child Health Nursing by A. Pilleteri page 358

29. You are assigned to the postpartum unit/ward and you are to take care of several clients. When prioritizing care for these clients you will first assess the client who:A. Is upset because the baby does not nurse when breast fedB. Has saturated several sanity napkin during the nightC. Refuses to have the newborn “room-in” with herD. Complains of pain and burning sensation upon urinationCorrect Answer: B. If you have observe a woman is soaking through a pad every 60 minutes, she is losing more than the average amount of blood. The doctor must check if there no cervical or vaginal tear causing bleeding.Reference: Maternal and Child Health nursing by A. Pilleteri page 249

30. Your client in labor is diagnosed with pre-eclampsia. Which interventions would be most appropriate for this client?

1. Check current intravenous administration of Magnesium Sulfate2. Frequently check client’s telemetry monitor3. Assess the client’s deep tendon reflexes4. Inform the nursery for incoming infant5. Administer Furosemide (Lasix) intravenously as ordered

A. 2, 3, 5 B. 1, 2, 5 C. 2, 4, 5 D. 1, 3, 4Correct Answer; D

Situation 17- You are the nurse assigned in the OB-GYNE Unit of the hospital in your Provincial Hospital. The following conditions and situations apply.

31. A client named Heidi; gravid 2 para 1 was admitted with complaints of hypertension. She even remarked that her wedding band was tight. In doing your assessment which of the following directs you to entertain early pre-eclampsia?A. Pain in her epigastrium together with headache C. Blurring of vision and proteinuriaB. Swelling of her face with proteinuria D. Hypertonic reflexes together with poluriaCorrect Answer: B A woman is said to be mildly pre-eclamptic when she has proteinuria and blood pressure rises to 140/90 mmHg with mild edema in upper extremities or face. Reference Maternal and child Health nursing by A. Pilleti

32. You also have Lailani who is on her 4th Stage of Labor. Where do you palpate the fundus?A. 2 cm above the umbilicus C. to the right of the umbilicusB. 3 cm below the umbilicus D. at the umbilicus Correct Answer: D The fourth stage of labor includes the first few hours after birth. For the first hour after childbirth, the height of the fundus is at the umbilicus or even slightly above it. Reference: Maternal and child Health nursing by A. Pilleti p. 428

33. Another patient a 21 year old woman who is at her 16-weeks gestation and underwent amniocentesis. Her name is Beverly. She asked you what her OB doctor intends to find out from the procedure. Your appropriate response is based on the understanding that which of the following conditions may be detected through this test?A. cleft lip palate C. Tetralogy of FallotB. Talipes equinovarus D. Hemolytic disease of the newbornCorrect answer: D Amnioncentesis can determine the fetal maturity and detect certain birth defects such as Down Syndrome, Spina Bifida, HEMOLYTIC DISEAES OF THE NEWBORN and Sex and Chromosomal abnormalities. Reference: Maternal and Newborn nursing by B. Straight p. 116

34. Doctor Vincent Magalong is attending to a 43-year old woman whom he had confined for observation and whom he just placed on estrogen (premarin) 0.625mg OD. Learning about this treatment regimen you are aware of the initial side effects of this medication which is?A. Nausea B. Tinnitus C. Visual disturbances D. AtaxiaCorrect Answer; A Estrogen causes nausea initially causes nausea and vomiting.

35. You are caring for Reyna, a multipara client who just delivered a female infant one hour ago. You observed that Reyna’s breasts are soft; the uterus boggy, to the right of the midline, and 2 cm below the umbilicus; moderate lochia rubra. What action is called for you to undertake with these findings?A. Perform a straight catheterization C. Put her baby to her breastB. Massage the uterine fundus D. Offer bedpan immediatelyCorrect Answer: D The presenting problem is bladders distention because the uterus is shifted to the right therefor offer bedpan allow to empty the bladder.

Situation 18- As it is true that health education is very m$uch a great part of our nursing responsibilities, the same should be evidently practiced with birthing mothers. The following conditions speak of these responsibilities.

36. A diabetic mother named Ruffa plans to breastfeed her baby. You explained that, if Ruffa is hyperglycemic,A. The production of milk may be impaired C. Her baby will not grow wellB. Her baby will receive insulin in the milk D. The glucose content of her breast milk may be highCorrect Answer: D The glucose is high since the mother has Diabetes. Incorrect: B. Women with diabetes may breastfeed because insulin is one of the few substances that does not pass into the breastmilk from the blood streamReference: Maternal and Child Health Nursing by A. Pilleteri page 545

37. Shine has successfully adapted in her let-down reflex and ably breastfeeding, but preventing the occurrence of cracked nipples now becomes one of your nursing concerns. Shine should therefore be taught to:A. Wash her nipples with water only C. Use plastic bra linersB. Nurse at least 20 minutes on each breast the first day D. Apply lanolin prior to feelingsCorrect Answer: A Wash nipple with warm water only no soap Reference: CHN: An Approach to Families and Population groups by David et.al page 283

38. Kimberly just delivered her first baby and whom she is expected to breastfeed. In the development of your teaching plan which of the following instruction must you include?A. Try to schedule feedings at least every 3 to 4 hours C. Avoid nursing bras with plastic liningB. Wash nipples with soap and water before each feeding D. Supplement with water feedings when necessary

Correct Answer: C. Discourage the use of plastic lining that come with nursing bras; it is preferable to use have air always circulating around the breast. Reference: Maternal and Child Health Nursing p. 499

39. Jack’s prenatal antibody titer shows that she is not immune to rubella and will receive the immunization after delivery. You would include which of the following instructions in your teaching plan?A. Breastfeeding should be postponed for 5 days after the injectionB. Another immunization should be administered in the next pregnancyC. Pregnancy must be avoided for the next 3 monthsD. An injection will be needed after each succeeding pregnancyCorrect Answer B The client should not be vaccinated during the pregnancy as the fetus can contact from the live virus vaccine. Also avoid pregnancy for three months Reference: Maternal and Newborn Nursing by M. Hogan page 140

40. Jasmine had a normal vaginal delivery 12 hours ago and is to be discharged from the birthing center. You evaluated that Jasmin understands the teaching related to the episiotomy and perineal area when she states,A. “The ice pack should be removed for 10 minutes before replacing it.”B. “The anesthetic spray, then the heat lamp, will help a lot.”C. “The water for the Sitz bath should be warm, about 102-105 F.”D. “I know the stitches will be removed at my postpartum clinic visit.”

Situation 19- A current initiative of the Department of Health (DOH) is the program called Essential Newborn Care or ENC. This outlines simple yet meaningful measures to be undertaken by healthcare workers in doing immediate newborn care management. The following situations apply.

41. Nurse Dianne is a member of the birthing team the day Mrs. Gador gave birth to her 1st born. Inside the delivery room nurse Jhoana assisted the attending obstetrician. To address the concerns of keeping the baby warm, her first step in obtaining thermal protection for the newborn wasA. Drying the baby thoroughly immediately after birthB. Covering the baby with a clean, dry cloth after the cord has been cutC. Covering the baby with a clean, dry cloth immediately after birthD. Drying the baby thoroughly after the cord has been cut

Correct Answer: A. Within the first 30 seconds, the nurse should dry and provide warmth with baby. Use a clean, dry cloth to thoroughly dry the baby by wiping the eyes, face, head, front and back, armsand legs.Reference: Newborn Care until the First week of life (WHO,UNICEF and DOH) p. 1

42. Nurse Dianne did not stop by simply drying the baby thoroughly upon birth, she observed other details as essential part of the immediate care of a normal newborn which included:A. Skin-to-skin contact followed by placin30g the baby in a warming incubatorB. Removing used wet cloth, and covering the baby with clean, dry clothC. Stimulating the baby by slapping the soles of the baby’s feetD. Deep suctioning of the airway to remove mucusCorrect Answer: B. The next step is Removed the used wet cloth and cover the baby with clean, dry cloth Reference: Newborn Care until the First week of life (WHO,UNICEF and DOH) p. 1

43. In further applying essential newborn care (ENC), Nurse Dianne keeps in mind that care of the umbilicus should include:A. Cleansing with cooled, boiled water and leaving umbilicus uncoveredB. Applying antibiotic creamC. Covering with a sterile compressD. Cleansing with alcoholCorrect Answer: A Put nothing on the stump.CORD CARE – Fold diaper below stump. Keep cord stump loosely covered with clean clothes.– If stump is soiled, wash it with clean water and soap. Dry it thoroughly with clean cloth.– Explain to the mother that she should seek care if the umbilicus is red or draining pus.– Teach the mother to treat local umbilical infection three times a day.– Wash hands with clean water and soap.– Gently wash off pus and crusts with boiled and cooled water and soap.– Dry the area with clean cloth.– Paint with gentian violet.Reference; Newborn Care until the First week of life (WHO,UNICEF and DOH) p. 8

44. Administration of Vitamin K to the newborn is necessary sinceA. Newborns have no intestinal bacteriaB. Hemolysis of the fetal red blood cells destroys vitamin KC. The newborn’s liver is incapable of producing sufficient vitamin K yetD. Newborns are susceptible to avitaminosisCorrect Answer: A Reference: Newborns are at risk for bleeding disorders during the first week of life because their gastrointestinal tract is sterile at birth and unable to produce vitamin K which is necessary for blood coagulation.

45. Cord clamping and the traditional “milking” of the cord immediately post delivery have now proven to be non-beneficial and may result in causing more harm and complications especially in preterms and fragile blood vessels in the brain of the newborn. NOW new practices have been introduced as part of “essential newborn care” termed asA. Properly Timed Cord Clamping C. Unang YakapB. Routine separation D. Partographing

Situation 20- Care of children, well, at risk, or even at high risk conditions places overwhelming responsibilities to nurses. The following conditions apply.

46. A couple brought with them their 7-year old girl diagnosed as having pituitary dwarfism. The couple seems anxious and was looking for some kind of emotion and psychological support. In your assessment, you expected which clinical manifestations to be MOST likely to be evident?A. Abdominal body proportions C. Delicate features

B. Course, dry skin D. Early sexual maturationCorrect Answer: children with hyppituitarism generally grow normally during the first year and then follow a slowed growth curve that is below the 3rd percentile. Height may be retarded more than weight because with good nutrition, these children can become overweight or obese. Reference: Maternal and Child health nursing by A. pilleteri p. 1682

47. A 14 year old girl whose parents have been consulting with you in your Family Care Nursing Clinic (FCNC) was admitted to the hospital for treatment of 2nd and 3rd degree burns sustained from a house fire. You visited them in the hospital and noted an IV infusion started over the girl’s left forearm. Instantly what comes to mind is that the primary purpose of this IV is to:A. Maintain fluid balance C. Provide a route for pain medicationsB. Prevent GI upset D. Obtain blood specimens for analysisCorrect Answer: immediately after a severe burn, the child’s circulatory system becomes hypovolemic, due to loss of plasma that oozes hypovolemic from the burn site and fluid that sequesters in edematous tissue surrounding the site. Therefore purpose of Intravenous line is to maintain fluid balance. Reference: Maternal and Child Health Nursing by A. Pilliteri (Fourth edition) p. 1621

48. A toddler name Louie, whose parents were also consulting in your FCNC had lead poisoning and was rushed to the hospital. There was an order to encourage fluids and the same were relayed to the parents. When you visited the parents asked what kind of fluids are best given, and as a family nurse coordinating closely with the nurse-on-duty (NOD) you reiterated that it is best to give:A. Fruit juices B. Orange juice C. Water D. MilkCorrect Answer: D Much of the biochemical effect of lead involves an interaction with calcium. Lead may block the ability of calcium to reach a regulatory site. It may enter a cell and mobilize calcium or mimic the regulating action of calcium. ‘Reference; Nursing care of Infants and children by Hockenberry and Wilson page 692

49. A 24-year old single mother dropped by your FCNC and tells you that she always have difficulty forming relationships. The mother conveyed to you the message that she is worried that her 7-year old daughter might have the same problems later. Of the following statements which do you think is the BEST to make?A. “Children develop trust from 6-12 years of age.”B. “Children develop trust from birth to 18 months of age.”C. “Children develop trust from 18 months to 3 years of age”D. “Children develop from 3 to 6 years of age.Correct Answer: B Erickson’s phase (birth to one year) is concerned with a acquiring a sense of trust while overcoming a sense of mistrust. The trust of self, of others and of the world Reference: Nursing care of Infants and children by Hockenberry and Wilson page 506

50. €Again at you FCNC, a couple came to you with relating problems relative to the care of their newborn with fetal alcohol syndrome. Which of the following should be reiterated as important considerations by the parents?A. Provide feedings via gavage to decrease energy expenditureB. Decrease touch to prevent overstimulationC. Replace vitamins depleted as a result of poor maternal dietD. Prevent iron deficiency anemiaCorrect Answer: B Fetal Alcoholic Syndrome typically manifest hyperactivity, irritability and priority nursing intervention Is to reduce environemental stimuli. Strategies to provide individualized developmental care areaimed to provide individualized developmental care and reduced environmental stimuli and

helping the infantachieve self-regulation. Reference: Nursing care of Infants and children by Hockenberry and Wilson page 411

Comprehensive Review for NCLEX-RN by M. Hogan p. 951