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Review Practice Questions

GENERAL INSTRUCTIONS:1. This test questionnaire contains 100 test questions.2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer.3. AVOID ERASURES.4. Detach one (1) answer sheet from the bottom of your Examinee ID/Answer Sheet Set.5. Write the subject title NURSING PRACTICE II on the box provided.

Situation 1- The Philippines witnessed the rise in the incidences of DENGUE in various parts of the country starting 2009. The following situations affecting children apply.

1. In a Barangay in Iloilo where there were high incidences malaria, a child was brought by her mother with on and off feeling of dryness and warm skin, temperature reached 37.5 C and above , the child has no genera; danger signs, with stiff neck, no runny nose, no measles and no other obvious cause of fever. The Child may be classified as having: A. MalariaC. Fever: Malaria unlikelyB. Fever: No MalariaD. Severe febrile disease/Malaria

2. It is understood that if a child were living in a no malaria risk area but who has presenting signs of stiff neck. The child may be classified as having:A. Severe febrile diseaseB. Fever no malariaC. MalariaD. Severe Malaria

3. You attended to a 3 year old child with measles and with eye complications. This should be treated with the following EXCEPT:A. Apply gentian violetC. Give Vitamin AB. Apply tetracycline ointmentD. Follow-up 2 days

4. In classifying dengue cases, which of the following is NOT possible classification of dengue hemorrhagic fever?A. None of theseC. Dengue Hemorrhagic Fever: unlikelyB. Sever Dengue Hemorrhagic FeverD. Dengue Hemorrhagic Fever

5. You are attending to 5 cases of dengue in 2 clusters of Barangays assigned to you. Which of the following treatment modalities SHOULD NOT be considered if the children you are attending to has severe dengue hemorrhagic fever?A. Give aspirinB. Give ORS if there is skin petechiaeC. Apply alternative plan if there is bleeding from the nose or gumsD. Prevent low blood sugar

Situation 2- Documentation is an important aspect of every nurses activity. This is a major area of responsibility which helps facilitate continuity of work within a 24 hour cycle.

6. A 26 year old mother was admitted for hyperemesis gravidarum. While taking the history of this client it would be MOST important to report which of the following?A. The client has cool lower extremity bilaterally.B. The client has diminished palpable peripheral pulses.C. The client is anxious about the effect of her condition to the baby.D. The client has allergy of shellfish

7. You are on duty and you received report from the previous shift. Which of the following clients should you attend to FIRST?A. A client who is receiving ciprofloxacin and complains of a fine macular rashB. A client who is receiving a blood transfusion and complains of a dry mouthC. A client who is scheduled to receive heparin and the PTT is 70 secondsD. A client who is receiving IV potassium and complains of burning at the IV site

8. You are reviewing the nurses notes in your clients chart. You would be MOST concerned by which of the following entries?A. Foley catheter draining clear urine and the pH is 6.5B. The client drinks 3 glasses of orange juice every dayC. The clients skin is blanched over the scapular areasD. Vital signs are within normal limits

9. You are attending to clients in your clinic. As you return to your desk you find 4 phone messages. Which of the following messages should you return FIRST?A. A client is nauseated and has vomited 6 times in the previous 24 hours.B. A client with stage II decubitus ulcer at home reports that the dressing has come off.C. A client is complaining of leg pain after walking half a mile.D. A client with cold symptoms has an oral temperature of 39.4C10. At approximately 6PM, a nurse deployed for duty in one of the affiliate hospitals, begin to open the nurse notes for the evening shift. The last entry is noted for 1pm, and there is no signature. The MOST appropriate nursing response is to:

A. Begin charting on the next line below the last entry, inform the day nurse, to make a last entry to complete the chartB. Do not enter anything until the day nurse has been notified of the problem and returns to the unit to complete her charting.C. Review with the client the activities after 1PM, and enter what are determined to be the activities after 1PM.D. Leave approximately 3 or 4 lines for the day nurse to enter some of her missed entries and sign the chart.

Situation 3- The nurse is involved in community organizing activities of Barangay Tapat. The following questions pertain to this situation.

11. The nurse makes an ocular survey of Barangay Tapat. Upon reaching the barangay it is appropriate for her to:A. Pay a visit to the barangay captain C. Introduce self to the communityB. Encourage community involvementD. Assemble community members for a meeting

12. Carrying out the planned activities involving maximum community participation is referred to as:A. MobilizationB. IntegrationC. Community Organization D. Community assembly

13. To ensure collective participation of the people, community organization should be formed through a community assembly. The purpose of having community assemblies are the following, EXCEPT:A. Gain cooperation, pledge support and work together on their ownB. Help people i9dentify their own problemC. Plan for the solution of identified problem/sD. Undertake measures to solve existing problems of the community

14. Which of the following approaches is the BEST in applying community organization in Community Health?A. Primary Health CareC. Community-Oriented OrganizationB. Universal Health CareD. Community Development

15. Community organizing ends when the community is already self-reliant. This signals that the community organizers are now ready to pull out of the community because:A. Organizers can expand to other poor communities C. It indicates that community organization is finishedB. It can evaluate the outcomes of the programsD. It will prevent dependency of the community

Situation 4- A nurse is assigned to a community health center where the variety of experiences and the culture of the community influences the care she gives to the clients.

16. While in the community health center, you note various practices among the families you serve. Which of the following situations will be OF CONCERN to you as the nurse?A. Aling Pat applies Vicks VapoRub to the chest and back of her grandson with colds B. Mang Berting wears a copper bracelet for his rheumatoid arthritisC. Aling Lita uses Atis seeds on the hair of her granddaughter to treat lice.D. Mang Pedro gives his son various herbs everyday17. Mr. Estrella diagnosed with Alzheimers disease, is brought to the center by his daughter to seek help regarding home care. In planning the care of Mr. Estrella priority should focus onA. Providing food rich in fiber to prevent constipation.B. Protecting the client from possible injury in his environmentC. Assisting the client to perform activities of daily living.D. Assisting all family members deal the challenges of long term care of this client.

18. You are following up a client who has cataract. The most important nursing action/instruction to implement would be toA. Advise the client to wear, dark glasses indoors and outdoors to guard v.s. sun glareB. Provide adequate lighting at home at all times. C. Instruct family not to change furniture arrangement at homeD. Advise the client to have the cataracts removed.

19. While on duty at the community health center, some clients are brought for consultation. Based on your assessment, the FIRST client to attend would be:A. Aling Tekya, with Dementia, who wanders in the streets every morning.B. Mang Miyo, 65 year old with congestive heart failure and 3+ pitting edema.C. Aling Lena, 56 year old, terminal client with weight loss (15 lbs) last month.D. Mang Ramon, 70 year old, with Parkinsons Disease and started hallucinating.20. You are visiting a newly discharged cerebrovascular accident (CVA) client currently confined to a wheelchair for long periods of time. Your most appropriate PRIORITY intervention would be to:A. Ask the client to move his buttocks every two hours to increase blood circulation to the area.B. Prevent skin breakdown by putting a pressure relieving cushion in the seat of the wheelchair.C. Refer to physical therapist to teach client to transfer from bed to wheelchair.D. Instruct family to feed client high protein diet for better skin integrity.

Situation 5- Nurse Jen Delos Santos, initiated the organizing of the Caring Frontiers Nursing Service Company in Leyte. This was envisioned to deliver health care and various nursing services through home health care services well within the scope of nursing practice.

21. Nurse Dana is one of their Registry Officials and acts as a liaison between families and communities served by the company to actively engage on policy and social change that will support and promote family health in their province. Nurse Dana is performing what role?A. Care ProviderB. CounselorC. Client AdvocateD. Facilitator

22. Formulating and implementing a supervisory plan, monitoring and evaluating beginning nurse practitioners performance in the implementation of public health programs are what functions of a public health nurse?A. TrainerB. CoordinatorC. SupervisorD. Manager

23. As an advocate, Registry Nurse Dana places her clients rights as priority. She is aware that advocacy work involves which of the following?A. Influencing public opinionC. Coordination with the health teamB. Obtaining a general information about the communityD. Prioritizing health conditions and problems

24. According to the World Health Organization (WHO), one of the leading causes of mortality in the Philippines is which of the following?A. LeukemiaC. Malignant NeoplasmB. Heart DiseaseD. Lower respiratory tract infections

25. Registry Nurse Dana is conducting a community diagnosis composed of Demographic variables, socio-economic variables, health and illness patterns, health resources and political/leadership patterns. What type of community diagnosis is Nurse Dana conducting?A. Individualized Nursing DiagnosisC. Comprehensive Community DiagnosisB. Population Focused DiagnosisD. Problem Oriented Community Diagnosis

Situation 6- Myths and fallacies as pertain care of the birthing mothers and their newborn have been debunked resulting in the development of what is now known as Essential Intrapartum Newborn Care or EINC. The following applies.

26. On December 7, 2009, the Department of Health issued an Administrative Order implementing the ENC protocol with the goal of rapidly reducing the number of newborn deaths in the Philippines. With international standards integrated in Intrapartal care the program has now evolved into the EINC program under the guidance of the W.H.O. Now considered as myths and fallacies include:1. Use of enema to reduce the risk of infections and shorten the duration of labor.2. Shaving the pubic hair of women in labor as hygienic practice to minimize infection.3. Restricted intake of food and fluid during active labor for possible risk of aspirating gastric contents due to anesthesia4. Application of IV therapy to hydrate women dut to food and drink restrictions.5. Use of fundal pressure to help the mother in the expulsion of her fetus.6. Early amniotomy and oxytocin augmentation in order to prevent operative deliveryA. 4, 5, and 6B. none of theseC. 1, 2 and 3D. all of these

27. In the immediate care of the newborn there are also practices which were debunked as practices based on false beliefs. Which are they?1. Routine suctioning believed to be necessary to clear the babys airway and stimulate him to breathe.2. Foot printing as a means of Identification for the newborn.3. Early bathing and washing as a form of hygienic practice.4. Routine Separation (baby in the nursery while mother is in her room)5. Continuance to providing artificial feeding (starts with pre-lacteals then artificial milks substitutes)A. 2 and 5B. 1, 3 and 4C. only 2D. All of the above28. On INTRAPARTAL CARE, one among 5 recommended practices include MATERNAL POSITIONING especially during the 1st stage of labor. The recommended practice now isA. Allow women to assume an upright position v.s. the former recumbent (supine/semi-recumbent and lateral)B. Strictly follow the traditional medical model of labor and deliveryC. Encourage women to take up the position they find most comfortable to themD. Allow women to assume any other upright position (walking, standing, sitting, kneeling) v.s. recumbent

29. On ESSENTIAL CARE OF THE NEWBORN, the three (3) new major RECOMMENDED PRACTICES are1. Practice Rooming-in2. Skin to skin contact3. Strict Handwashing of Carers handling the newborn child4. Use of partograph5. Properly timed cord clamping6. Initiation of BreastfeedingA. 1, 3 and 4B. 4, 6 and 2C. 2, 5, and 6D. 4, 5 and 1:

30. Essential Intrapartum and Newborn Care (EINC) is our countrys instrument in health addressing the challenge of the United Nations 2 out of 8 Millennium Development Goals (MDGs) targeted to be achieved by 2015. Which are these 2 MGDs?A. MDGs 3 and 6B. MDGs 4 and 5C. MDGs 1 and 2D. MDGs 7 and 8

Situation 7- You are newly passed and registered nurse applying for beginning nursing job. While waiting you heard your Parish Priest calling for volunteers for a Parish-Based Health Program. you signed up to help and practice your profession. Among health conditions you would normally encounter are obstetrical cases.

31. A 22 year old mother missed 2 of her regular menstrual periods. The Parish Medical Volunteer confirms an early, intrauterine pregnancy. This is her 1st pregnancy. To determine her expected due date, which of the following assessments is most important?A. Dates of last normal menstrual period C. Age of menarcheB. Date of last intercourseD. Dates of her 1st menstrual period

32. The action of hormones during pregnancy affects the body by:A. Blocking the release of insulin from the pancreas C. Enhancing the conversion of food to glucoseB. Raising the resistance to insulin utilizationD. Preventing the liver from metabolizing glycogen

33. A 28 year old mother has had diabetes mellitus since she was adolescent. Now she is 8 weeks pregnant. Hyperglycemia during the first trimester will have what effect on the fetus?A. Abnormal positioning of the fetusC. Excessive fetal sizeB. HyperinsulinemiaD. Potential malformation of the fetal organs

34. You also attend to another young diabetic parishioner-mother who is in her 1st trimester of pregnancy. As her pregnancy continues what changes in her medication needs should you also anticipate? A. A steady increase in insulin requirementsB. The variable pattern of insulin absorption throughout the pregnancy requires constant close adjustmentsC. Oral hypoglycemic drugs will be given several times daily.D. A decrease in the need for short-acting insulin

35. A glycosylated hemoglobin level is ordered for a pregnant diabetic because it:A. Will predict how well the pancreas can respond to the stress of pregnancyB. Gives diagnostic information related to the peripheral effects of diabetesC. Is the most accurate method of determining present insulin levelsD. Indicates mean glucose level over a 1 to 3 month period

Situation 8- In the community, nurses serves a pivotal role in the process of communication exchanges between clients and the providers of care. The following events are evidences of these.

36. In a prenatal visit by Liz to your Family Care clinic you noted her saying, during the first 3 months of my pregnancy I have been very nauseated, and I do not seem to understand why? Which may be your BEST response?A. The nausea you experience is due to an increase in the basal metabolic rate brought about by your pregnancyB. The nausea you experience is caused by the secondary influx of hormones produced by the endocrine system.C. If you take different kinds of food you will not be nauseated.D. Fatigue as a result of your pregnancy brings about your nausea.

37. On a Monday morning at your Family Care Nursing Clinic, a mother of a 2-year old postoperative child and who has just been discharged from the hospital came appearing to be overly anxious and tells you, my child seem so restless. Your FIRST course of action should be:A. Try taking the child for a walk C. Check and see when the child had his last pain medicationB. Check the childs vital signsD. Check if the childs sutures are still intact

38. You opt that all Fridays are Family Care Nursing clinic HOLIDAYS. On Fridays you prefer to do personal visits. You follow-up patients in their homes, do volunteer health work in schools, or visit industries within the vicinity. In a student health clinic a client confides to you that her boyfriend informed her that he tested positive for Hepatitis B. which of the following is you BEST answer?A.You will receive the Hepatitis B immune globulin (HGBI)B. Have you had sex with your boyfriend?C. That must be real shocking to you.D. You should also be tested for Hepatitis B.39. An eye surgeon aware of you Friday-Visit Program called on you one day and referred a 4-year old client whom he scheduled for an eye surgery. When you met her mother she asks how best to prepare her daughter for the eye surgery. Which of the following actions would be BEST?A. Draw a picture of the eye and explain what will happen during the surgeryB. Help the mother explain to the child how to get ready for surgery using dollsC. Instruct the mother to tell her daughter that the surgery will only take an hourD. Guide the mother to read her daughter an age-appropriate illustrated book about eye surgery

40. You are back on your usual Nursing Clinic duties, it is a Tuesday and a woman at 38-weeks gestation comes to you with problems of vaginal bleeding. Which of the following remarks, if made by the client would suggest PLACENTA PREVIA as potenti9al cause of bleeding?A. I feel fine, but the bleeding scares me.B. Ive been experiencing severe abdominal cramps.C. I feel nauseated more during the past few weeks.D. The bleeding started after I carried 4 bags of groceries.

Situation 9- Paula, a 12-month old infant, was brought to the health center for her regular well baby check up. Her mother is concerned with her childs growth and development. She expressed her desire to learn more about this concern.

41. The childs birth weight was 8 lbs. upon assessment the child now weighs 18 lbs. in documenting this result, you know that this weight isA. Appropriate for the childs ageC. Above the expected weightB. Below the expected weightD. Individualized and thus unpredictable

42. In formulating the nursing diagnosis regarding the mothers concern, which of the following should you consider?A. Health seeking behaviorB. Anxiety C. Knowledge deficit D. Altered health maintenance

43. In planning care for the infant, you should advise the mother that the best way to help her child complete the development task for the first year is toA. Respond to her consistentlyB. Expose her to many caregivers to help her learn variabilityC. Keep her stimulated with many toysD. Talk to her at a special time each day

44. To relieve teething discomfort which measure would you suggest an infants mother to use?A. Provide her with a fluid diet for 2 days C. Ask her pediatrician for a sedative for herB. Offer her Aspergum to chewD. Give her a cold teething ring to chew

45. In evaluating the health teaching on breastfeeding, which of the following observations made by the mother would reveal correct understanding of breastfed infants?A. Breastfed infants usually have fewer stools than bottle-fed infantsB. Stools of breastfed infants tend o have a strong odor.C. Breastfed infants usually have soft stools than bottle-fed infantsD. Stools of breastfed infants are usually harder than those of bottle-fed infants

46. Nurse Nina is a Community Health nurse conducting prenatal care at a Rural Health Unit in one of the communities in Cotabato. Nurse Nina is aware that recent developments in Maternal Care strongly places emphasis on quality antenatal care. the strength of this advocacy is on:A. Consistent vaginal examination on every prenatal visitB. Proper care to every pregnant woman providing support to normal pregnancy AND early detection and management of complicationsC. Doing monthly antenatal care during the first seven (7) months, every two weeks on the 8th month, and weekly on the 9th month.D. Spending more time with every pregnant women especially the high risk ones47. On May 12, 2012 a primigravida mother named Mrs. Carla Del Pilar came to Nurse Nina for check-up. Her EDC happens to be May 21. What can you expect to find during assessment?A. Cervix open, FH-2 fingers below xyphoid process, floating.B. FH at least at the level of the xyphoid process, engaged.C. FH-2 fingers below xyphoid process, engaged.D. Cervix closed, unaffected, fundic height (FH)-midway between the umbilicus and symphysis pubis.

48. One Monday morning a community nursing assignment, Nurse Nina was transferred to their RHU-attached district hospital. She attends to Mrs. Lalaine Mariano who is on her second vaginal examination and labor. Nurse Nina finds the fetus in the right occiput anterior position and at (-) 1 station. Nurse Nina based her findings fromA. 1 cm below the ischial spines presentationB. 1 cm above the ischial spines presentationC. Presentation in no relationship with the ischial spine conditionD. Presentation directly in line with that of the ischial spines

49. By 12:00nn same Monday, another patient attended to by nurse Lucy in the RHU named Mrs. Nicole Angeles got admitted in active labor, Nurse Nina locates the fetal heart sounds in the upper right quadrant of the mothers abdomen. Nurse Nina would recognize which of the following?A. This position is referred to as left antero-pelvicB. Nicole will probably deliver very quickly and without problemsC. The fetus is in the most common anterior fetal positionD. Nicole will probably have a breech delivery

50. By 3pm, Nurse Nina was done with her endorsement when another mother, Mrs. Kristine De Castro came in active labor. She trembles was very tense with contractions and quite irritable. She frequently says, Hindi ko na kaya ito! (I can no longer bear this!). this behavior may be indicative of the clientA. Developing some abnormality in terms of uterine contractionsB. Already entering the transition phase of laborC. As having been poorly prepared for labor in the parents classesD. Needs immediate administration of an analgesic or anesthetic

Situation 11- having a privately owned, community-situated nursing care facility makes the nurse develop rapport with greater number of community residents. She can become a vital community resource with her nursing skills and knowledge BUT with the nature of the nurses work, it is necessary to be conscious about legal considerations.

51. 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. Mikkos 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 childs 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 away

52. 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 Arjays 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 Arjays chartB. Share the information with the hospital social workerC. Share only this information with fellow health professionalsD. Call for the Police and report the findings

53. 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 doctors 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 you

54. 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 physicians 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 patients intake and output55. 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 toA. 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 SIDS

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.

56. 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 stops57. Mary Ann complains that she doesnt 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 night

58. 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 varicosities

59. 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 strainingA. 1, 2, 3 and 4B. 1, 3 and 4C. 1, 2 and 3D. 2, 3 and 4

60. Mary Ann yells you that she sometimes does not feel her babys movements. You can instruct Susan to do fetal movement count (FMC) or kick counts. These statements are true regarding the fetal movement count1. Client assumes side-lying or reclining position and palpates fetal movements for an hour counting for 10 movements2. 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 sleep4. A well oxygenated fetus moves frequently while a fetus with compromised oxygen supple conserves energy with less activity. A. 1, 2 and 3B. 2, 3 and 4C. 1, 2 and 4D. 1, 3 and 4

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.

61. 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 activity

62. 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 easily

63. Which of the following nursing action should you not include in the care or Mrs. Daquis?A. Labor Augmentation/doctors orderB. AmniotomyC. Observe for 30 minutes more for possible caesarian section if no improvementD. Continue monitoring fetal heart beat and cervical dilatation

64. 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 seconds

65. The descent of the head at 1PM is at:A. Two fingers above the symphysis pubisC. Three fingers above the symphysis pubisB. Five fingers above the symphysis pubisD. The fetal head is engaged

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:

66. 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 sons symptoms?A. My sons bowel movements have turned black and stickyB. 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

67. 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.

68. 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 infants bed C. Instruct properly the mother how to do CPRB. Do not give the next feedingD. Keep a normal feeding schedule

69. You are visiting a 3-month old child whom you previously saw in your clinic. He is now on Christophers 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 blocksC. A stuffed toy animalB. A toy rattleD. Nursery rhymes played on tape

70. 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 distressC. Nausea and vertigoB. Dysrrhythmia and hypoventilationD. Epistaxis and paralysis

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.

71. 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 to

72. 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 clientC. Is under the age of 65B. Is under home-based careD. Is not considered handicapped

73. 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 school

74. A client who had open heart surgery 2 weeks ago and about to be discharged was referred to nurse Trishs 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

75. Nurse Trish plans to present t the local city health board a Stop Smoking campaign to the communitys 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 Trish

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.

76. 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 deathC. Ineffective breathingB. Alteration in comfortD. Fluid and electrolyte imbalance

77. 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 privacyD. Place the client in Trendelenberg position

78. 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 delivery

79. 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 urination

80. 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 clients telemetry monitor3. Assess the clients deep tendon reflexes4. Inform the nursery for incoming infant5. Administer Furosemide (Lasix) intravenously as orderedA. 2, 3, 5B. 1, 2, 5C. 2, 4, 5D. 1, 3, 4

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.

81. 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 proteinuriaD. Hypertonic reflexes together with polyuria

82. You also have Lailani who is on her 4th Stage of Labor. Where do you palpate the fundus?A. 2 cm above the umbilicusC. to the right of the umbilicusB. 3 cm below the umbilicusD. at the umbilicus

83. 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 palateC. Tetralogy of FallotB. Talipes equinovarusD. Hemolytic disease of the newborn

84. 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. Ataxia

85. You are caring for Reyna, a multipara client who just delivered a female infant one hour ago. You observed that Reynas 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 catheterizationB. Massage the uterine fundusC. Put her baby to her breastD. Offer bedpan immediately

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.

86. 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 high

87. 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 dayD. Apply lanolin prior to feelings

88. 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 feedingD. Supplement with water feedings when necessary

89. Jacks 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 pregnancy

90. 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.

91. 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

92. 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 babys feetD. Deep suctioning of the airway to remove mucus

93. 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 alcohol94. 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 newborns liver is incapable of producing sufficient vitamin K yetD. Newborns are susceptible to avitaminosis

95. 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 ClampingC. Unang YakapB. Routine separationD. Partographing

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

96. 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 proportionsC. Delicate featuresB. Course, dry skinD. Early sexual maturation

97. 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 girls left forearm. Instantly what comes to mind is that the primary purpose of this IV is to:A. Maintain fluid balanceC. Provide a route for pain medicationsB. Prevent GI upsetD. Obtain blood specimens for analysis

98. 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 juicesB. Orange juiceC. WaterD. Milk

99. 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 ageD. Children develop from 3 to 6 years of age.

100. 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 anemia