1. May arrives at the health care clinic and tells the
nurse that her last menstrual period was 9 weeks ago. She also tells the nurse
that a home pregnancy test was positive but she began to have mild cramps and
is now having moderate vaginal bleeding. During the physical examination of the
client, the nurse notes that May has a dilated cervix. The nurse determines
that May is experiencing which type of abortion?
|
A
|
Inevitable
|
|
B
|
Incomplete
|
|
C
|
Threatened
|
|
D
|
Septic
|
2.Nurse Reese is reviewing the record of a pregnant
client for her first prenatal visit. Which of the following data, if noted on
the client’s record, would alert the nurse that the client is at risk for a
spontaneous abortion?
|
A
|
Age 36 years
|
|
B
|
History of syphilis
|
|
C
|
History of genital herpes
|
|
D
|
History of diabetes mellitus
|
3.Nurse Hazel is preparing to care for a client who is
newly admitted to the hospital with a possible diagnosis of ectopic pregnancy.
Nurse Hazel develops a plan of care for the client and determines that which of
the following nursing actions is the priority?
|
A
|
Monitoring weight
|
|
B
|
Assessing for edema
|
|
C
|
Monitoring apical pulse
|
|
D
|
Monitoring temperature
|
4.Nurse Oliver is teaching a diabetic pregnant client
about nutrition and insulin needs during pregnancy. The nurse determines that
the client understands dietary and insulin needs if the client states that the
second half of pregnancy require:
|
A
|
Decreased caloric intake
|
|
B
|
Increased caloric intake
|
|
C
|
Decreased Insulin
|
|
D
|
Increase Insulin
|
5.Nurse Michelle is assessing a 24 year old client
with a diagnosis of hydatidiform mole. She is aware that one of the following
is unassociated with this condition?
|
A
|
Excessive fetal activity.
|
|
B
|
Larger than normal uterus for gestational age.
|
|
C
|
Vaginal bleeding
|
|
D
|
Elevated levels of human chorionic gonadotropin.
|
6.A pregnant client is receiving magnesium sulfate for
severe pregnancy induced hypertension (PIH). The clinical findings that would
warrant use of the antidote , calcium gluconate is:
|
A
|
Urinary output 90 cc in 2 hours.
|
|
B
|
Absent patellar reflexes.
|
|
C
|
Rapid respiratory rate above 40/min.
|
|
D
|
Rapid rise in blood pressure.
|
7.During vaginal examination of Janna who is in labor,
the presenting part is at station plus two. Nurse, correctly interprets it as:
|
A
|
Presenting part is 2 cm above the plane of the ischial spines.
|
|
B
|
Biparietal diameter is at the level of the ischial spines.
|
|
C
|
Presenting part in 2 cm below the plane of the ischial spines.
|
|
D
|
Biparietal diameter is 2 cm above the ischial spines.
|
8.A pregnant client is receiving oxytocin (Pitocin)
for induction of labor. A condition that warrant the nurse in-charge to
discontinue I.V. infusion of Pitocin is:
|
A
|
Contractions every 1 ½ minutes lasting 70-80 seconds.
|
|
B
|
Maternal temperature 101.2
|
|
C
|
Early decelerations in the fetal heart rate.
|
|
D
|
Fetal heart rate baseline 140-160 bpm.
|
9.Calcium gluconate is being administered to a client
with pregnancy induced hypertension (PIH). A nursing action that must be
initiated as the plan of care throughout injection of the drug is:
|
A
|
Ventilator assistance
|
|
B
|
CVP readings
|
|
C
|
EKG tracings
|
|
D
|
Continuous CPR
|
10.A trial for vaginal delivery after an earlier
caesareans, would likely to be given to a gravida, who had:
|
A
|
First low transverse cesarean was for active herpes type 2 infections;
vaginal culture at 39 weeks pregnancy was positive.
|
|
B
|
First and second caesareans were for cephalopelvic disproportion.
|
|
C
|
First caesarean through a classic incision as a result of severe fetal
distress.
|
|
D
|
First low transverse caesarean was for breech position. Fetus in this
pregnancy is in a vertex presentation.
|
11.Nurse Ryan is aware that the best initial approach
when trying to take a crying toddler’s temperature is:
|
A
|
Talk to the mother first and then to the toddler.
|
|
B
|
Bring extra help so it can be done quickly.
|
|
C
|
Encourage the mother to hold the child.
|
|
D
|
Ignore the crying and screaming.
|
12.Baby Tina a 3 month old infant just had a cleft lip
and palate repair. What should the nurse do to prevent trauma to operative
site?
|
A
|
Avoid touching the suture line, even when cleaning.
|
|
B
|
Place the baby in prone position.
|
|
C
|
Give the baby a pacifier.
|
|
D
|
Place the infant’s arms in soft elbow restraints.
|
13.Which action should nurse Marian include in the
care plan for a 2 month old with heart failure?
|
A
|
Feed the infant when he cries.
|
|
B
|
Allow the infant to rest before feeding.
|
|
C
|
Bathe the infant and administer medications before feeding.
|
|
D
|
Weigh and bathe the infant before feeding.
|
14.Nurse Hazel is teaching a mother who plans to
discontinue breast feeding after 5 months. The nurse should advise her to
include which foods in her infant’s diet?
|
A
|
Skim milk and baby food.
|
|
B
|
Whole milk and baby food.
|
|
C
|
Iron-rich formula only.
|
|
D
|
Iron-rich formula and baby food.
|
15.Mommy Linda is playing with her infant, who is
sitting securely alone on the floor of the clinic. The mother hides a toy
behind her back and the infant looks for it. The nurse is aware that estimated
age of the infant would be:
|
A
|
6 months
|
|
B
|
4 months
|
|
C
|
8 months
|
|
D
|
10 months
|
16.Which of the following is the most prominent
feature of public health nursing?
|
A
|
It involves providing home care to sick people who are not confined in
the hospital.
|
|
B
|
Services are provided free of charge to people within the catchments
area.
|
|
C
|
The public health nurse functions as part of a team providing a public
health nursing services.
|
|
D
|
Public health nursing focuses on preventive, and not curative,
services.
|
17.When the nurse determines whether resources were
maximized in implementing Ligtas Tigdas (Measles Prevention), she is
evaluating:
|
A
|
Effectiveness
|
|
B
|
Efficiency
|
|
C
|
Adequacy
|
|
D
|
Appropriateness
|
18.Vangie is a new B.S.N. graduate. She wants to
become a Public Health Nurse. Where should she apply?
|
A
|
Department of Health
|
|
B
|
Provincial Health Office
|
|
C
|
Regional Health Office
|
|
D
|
Rural Health Unit
|
19.Tony is aware the Chairman of the Municipal Health
Board is:
|
A
|
Mayor
|
|
B
|
Municipal Health Officer
|
|
C
|
Public Health Nurse
|
|
D
|
Any qualified physician
|
20.Myra is the public health nurse in a municipality
with a total population of about 20,000. There are 3 rural health midwives
among the RHU personnel. How many more midwife items will the RHU need?
|
A
|
1
|
|
B
|
2
|
|
C
|
3
|
|
D
|
The RHU does not need any more midwife item.
|
21.According to Freeman and Heinrich, community health
nursing is a developmental service. Which of the following best illustrates
this statement?
|
A
|
The community health nurse continuously develops himself personally
and professionally.
|
|
B
|
Health education and community organizing are necessary in providing
community health services.
|
|
C
|
Community health nursing is intended primarily for health promotion
and prevention and treatment of disease.
|
|
D
|
The goal of community health nursing is to provide nursing services to
people in their own places of residence.
|
22.Nurse Tina is aware that the disease declared
through Presidential Proclamation No. 4 as a target for eradication in the
Philippines is?
|
A
|
Poliomyelitis
|
|
B
|
Measles
|
|
C
|
Rabies
|
|
D
|
Neonatal tetanus
|
23.May knows that the step in community organizing
that involves training of potential leaders in the community is:
|
A
|
Integration
|
|
B
|
Community organization
|
|
C
|
Community study
|
|
D
|
Core group formation
|
24.Beth a public health nurse takes an active role in
community participation. What is the primary goal of community organizing?
|
A
|
To educate the people regarding community health problems
|
|
B
|
To mobilize the people to resolve community health problems
|
|
C
|
To create a sense of cooperation integration and unity among the
people
|
|
D
|
To maximize the community’s resources in dealing with health problems.
|
25.Tertiary prevention is needed in which stage of the
natural history of disease?
|
A
|
Pre-pathogenesis
|
|
B
|
Pathogenesis
|
|
C
|
Prodromal
|
|
D
|
Terminal
|
26.The nurse is caring for a primigravid client in the
labor and delivery area. Which condition would place the client at risk for
disseminated intravascular coagulation (DIC)?
|
A
|
Intrauterine fetal death.
|
|
B
|
Placenta accreta.
|
|
C
|
Dysfunctional labor.
|
|
D
|
Premature rupture of the membranes.
|
27.A full term client is in labor. Nurse Betty is
aware that the fetal heart rate would be:
|
A
|
80 to 100 beats/minute
|
|
B
|
100 to 120 beats/minute
|
|
C
|
120 to 160 beats/minute
|
|
D
|
160 to 180 beats/minute
|
28.The skin in the diaper area of a 7 month old infant
is excoriated and red. Nurse Hazel should instruct the mother to:
|
A
|
Change the diaper more often.
|
|
B
|
Apply talc powder with diaper changes.
|
|
C
|
Wash the area vigorously with each diaper change.
|
|
D
|
Decrease the infant’s fluid intake to decrease saturating diapers.
|
29.Nurse Carla knows that the common cardiac anomalies
in children with Down Syndrome (trisomy 21) is:
|
A
|
Atrial septal defect
|
|
B
|
Pulmonic stenosis
|
|
C
|
Ventricular septal defect
|
|
D
|
Endocardial cushion defect
|
30.Malou was diagnosed with severe preeclampsia is now
receiving I.V. magnesium sulfate. The adverse effects associated with magnesium
sulfate is:
|
A
|
Anemia
|
|
B
|
Decreased urine output
|
|
C
|
Hyperreflexia
|
|
D
|
Increased respiratory rate
|
31.A 23 year old client is having her menstrual period
every 2 weeks that last for 1 week. This type of menstrual pattern is bets
defined by:
|
A
|
Menorrhagia
|
|
B
|
Metrorrhagia
|
|
C
|
Dyspareunia
|
|
D
|
Amenorrhea
|
32.Jannah is admitted to the labor and delivery unit.
The critical laboratory result for this client would be:
|
A
|
Oxygen saturation
|
|
B
|
Iron binding capacity
|
|
C
|
Blood typing
|
|
D
|
Serum Calcium
|
33.Nurse Gina is aware that the most common condition
found during the second-trimester of pregnancy is:
|
A
|
Metabolic alkalosis
|
|
B
|
Respiratory acidosis
|
|
C
|
Mastitis
|
|
D
|
Physiologic anemia
|
34.Nurse Lynette is working in the triage area of an
emergency department. She sees that several pediatric clients arrive
simultaneously. The client who needs to be treated first is:
|
A
|
A crying 5 year old child with a laceration on his scalp.
|
|
B
|
A 4 year old child with a barking coughs and flushed appearance.
|
|
C
|
A 3 year old child with Down syndrome who is pale and asleep in his
mother’s arms.
|
|
D
|
A 2 year old infant with stridorous breath sounds, sitting up in his
mother’s arms and drooling.
|
35.Maureen in her third trimester arrives at the
emergency room with painless vaginal bleeding. Which of the following
conditions is suspected?
|
A
|
Placenta previa
|
|
B
|
Abruptio placentae
|
|
C
|
Premature labor
|
|
D
|
Sexually transmitted disease
|
36.A young child named Richard is suspected of having
pinworms. The community nurse collects a stool specimen to confirm the
diagnosis. The nurse should schedule the collection of this specimen for:
|
A
|
Just before bedtime
|
|
B
|
After the child has been bathe
|
|
C
|
Any time during the day
|
|
D
|
Early in the morning
|
37.In doing a child’s admission assessment, Nurse
Betty should be alert to note which signs or symptoms of chronic lead
poisoning?
|
A
|
Irritability and seizures
|
|
B
|
Dehydration and diarrhea
|
|
C
|
Bradycardia and hypotension
|
|
D
|
Petechiae and hematuria
|
38.To evaluate a woman’s understanding about the use
of diaphragm for family planning, Nurse Trish asks her to explain how she will
use the appliance. Which response indicates a need for further health teaching?
|
A
|
“I should check the diaphragm carefully for holes every time I use it”
|
|
B
|
“I may need a different size of diaphragm if I gain or lose weight
more than 20 pounds”
|
|
C
|
“The diaphragm must be left in place for at least 6 hours after
intercourse”
|
|
D
|
“I really need to use the diaphragm and jelly most during the middle
of my menstrual cycle”.
|
39.Hypoxia is a common complication of
laryngotracheobronchitis. Nurse Oliver should frequently assess a child with
laryngotracheobronchitis for:
|
A
|
Drooling
|
|
B
|
Muffled voice
|
|
C
|
Restlessness
|
|
D
|
Low-grade fever
|
40.How should Nurse Michelle guide a child who is
blind to walk to the playroom?
|
A
|
Without touching the child, talk continuously as the child walks down
the hall.
|
|
B
|
Walk one step ahead, with the child’s hand on the nurse’s elbow.
|
|
C
|
Walk slightly behind, gently guiding the child forward.
|
|
D
|
Walk next to the child, holding the child’s hand.
|
41.When assessing a newborn diagnosed with ductus
arteriosus, Nurse Olivia should expect that the child most likely would have
an:
|
A
|
Loud, machinery-like murmur.
|
|
B
|
Bluish color to the lips.
|
|
C
|
Decreased BP reading in the upper extremities
|
|
D
|
Increased BP reading in the upper extremities.
|
42.The reason nurse May keeps the neonate in a neutral
thermal environment is that when a newborn becomes too cool, the neonate
requires:
|
A
|
Less oxygen, and the newborn’s metabolic rate increases.
|
|
B
|
More oxygen, and the newborn’s metabolic rate decreases.
|
|
C
|
More oxygen, and the newborn’s metabolic rate increases.
|
|
D
|
Less oxygen, and the newborn’s metabolic rate decreases.
|
43.Before adding potassium to an infant’s I.V. line,
Nurse Ron must be sure to assess whether this infant has:
|
A
|
Stable blood pressure
|
|
B
|
Patent fontanelles
|
|
C
|
Moro’s reflex
|
|
D
|
Voided
|
44.Nurse Carla should know that the most common
causative factor of dermatitis in infants and younger children is:
|
A
|
Baby oil
|
|
B
|
Baby lotion
|
|
C
|
Laundry detergent
|
|
D
|
Powder with cornstarch
|
45.During tube feeding, how far above an infant’s
stomach should the nurse hold the syringe with formula?
|
A
|
6 inches
|
|
B
|
12 inches
|
|
C
|
18 inches
|
|
D
|
24 inches
|
46.In a mothers’ class, Nurse Lynnette discussed
childhood diseases such as chicken pox. Which of the following statements about
chicken pox is correct?
|
A
|
The older one gets, the more susceptible he becomes to the
complications of chickenpox.
|
|
B
|
A single attack of chickenpox will prevent future episodes, including
conditions such as shingles.
|
|
C
|
To prevent an outbreak in the community, quarantine may be imposed by
health authorities.
|
|
D
|
Chicken pox vaccine is best given when there is an impending outbreak
in the community.
|
47.Barangay Pinoy had an outbreak of German measles.
To prevent congenital rubella, what is the BEST advice that you can give to
women in the first trimester of pregnancy in the Barangay Pinoy?
|
A
|
Advise them on the signs of German measles.
|
|
B
|
Avoid crowded places, such as markets and movie houses.
|
|
C
|
Consult at the health center where rubella vaccine may be given.
|
|
D
|
Consult a physician who may give them rubella immunoglobulin.
|
48.Myrna a public health nurse knows that to determine
possible sources of sexually transmitted infections, the BEST method that may
be undertaken is:
|
A
|
Contact tracing
|
|
B
|
Community survey
|
|
C
|
Mass screening tests
|
|
D
|
Interview of suspects
|
49.A 33-year old female client came for consultation
at the health center with the chief complaint of fever for a week. Accompanying
symptoms were muscle pains and body malaise. A week after the start of fever,
the client noted yellowish discoloration of his sclera. History showed that he
waded in flood waters about 2 weeks before the onset of symptoms. Based on her
history, which disease condition will you suspect?
|
A
|
Hepatitis A
|
|
B
|
Hepatitis B
|
|
C
|
Tetanus
|
|
D
|
Leptospirosis
|
50.Mickey a 3-year old client was brought to the
health center with the chief complaint of severe diarrhea and the passage of
“rice-watery” stools. The client is most probably suffering from which
condition?
|
A
|
Giardiasis
|
|
B
|
Cholera
|
|
C
|
Amebiasis
|
|
D
|
Dysentery
|
51.The most prevalent form of meningitis among
children aged 2 months to 3 years is caused by which microorganism?
|
A
|
Haemophilus influenzae
|
|
B
|
Morbillivirus
|
|
C
|
Streptococcus pneumoniae
|
|
D
|
Neisseria meningitidis
|
52.The student nurse is aware that the pathognomonic
sign of measles is Koplik’s spot and you may see Koplik’s spot by inspecting
the:
|
A
|
Nasal mucosa
|
|
B
|
Buccal mucosa
|
|
C
|
Skin on the abdomen
|
|
D
|
Skin on neck
|
53.Angel was diagnosed as having Dengue fever. You
will say that there is slow capillary refill when the color of the nail bed
that you pressed does not return within how many seconds?
|
A
|
3 seconds
|
|
B
|
6 seconds
|
|
C
|
9 seconds
|
|
D
|
10 seconds
|
54.In Integrated Management of Childhood Illness, the
nurse is aware that the severe conditions generally require urgent referral to
a hospital. Which of the following severe conditions DOES NOT always require
urgent referral to a hospital?
|
A
|
Mastoiditis
|
|
B
|
Severe dehydration
|
|
C
|
Severe pneumonia
|
|
D
|
Severe febrile disease
|
55.Myrna a public health nurse will conduct outreach
immunization in a barangay Masay with a population of about 1500. The estimated
number of infants in the barangay would be:
|
A
|
45 infants
|
|
B
|
50 infants
|
|
C
|
55 infants
|
|
D
|
65 infants
|
56.The community nurse is aware that the biological
used in Expanded Program on Immunization (EPI) should NOT be stored in the
freezer?
|
A
|
DPT
|
|
B
|
Oral polio vaccine
|
|
C
|
Measles vaccine
|
|
D
|
MMR
|
57.It is the most effective way of controlling
schistosomiasis in an endemic area?
|
A
|
Use of molluscicides
|
|
B
|
Building of foot bridges
|
|
C
|
Proper use of sanitary toilets
|
|
D
|
Use of protective footwear, such as rubber boots
|
58.Several clients is newly admitted and diagnosed
with leprosy. Which of the following clients should be classified as a case of
multibacillary leprosy?
|
A
|
3 skin lesions, negative slit skin smear
|
|
B
|
3 skin lesions, positive slit skin smear
|
|
C
|
5 skin lesions, negative slit skin smear
|
|
D
|
5 skin lesions, positive slit skin smear
|
59.Nurses are aware that diagnosis of leprosy is
highly dependent on recognition of symptoms. Which of the following is an early
sign of leprosy?
|
A
|
Macular lesions
|
|
B
|
Inability to close eyelids
|
|
C
|
Thickened painful nerves
|
|
D
|
Sinking of the nose bridge
|
60.Marie brought her 10 month old infant for
consultation because of fever, started 4 days prior to consultation. In
determining malaria risk, what will you do?
|
A
|
Perform a tourniquet test.
|
|
B
|
Ask where the family resides.
|
|
C
|
Get a specimen for blood smear.
|
|
D
|
Ask if the fever is present everyday.
|
61.Susie brought her 4 years old daughter to the RHU
because of cough and colds. Following the IMCI assessment guide, which of the
following is a danger sign that indicates the need for urgent referral to a
hospital?
|
A
|
Inability to drink
|
|
B
|
High grade fever
|
|
C
|
Signs of severe dehydration
|
|
D
|
Cough for more than 30 days
|
62.Jimmy a 2-year old child revealed “baggy pants”. As
a nurse, using the IMCI guidelines, how will you manage Jimmy?
|
A
|
Refer the child urgently to a hospital for confinement.
|
|
B
|
Coordinate with the social worker to enroll the child in a feeding
program.
|
|
C
|
Make a teaching plan for the mother, focusing on menu planning for her
child.
|
|
D
|
Assess and treat the child for health problems like infections and
intestinal parasitism.
|
63.Gina is using Oresol in the management of diarrhea
of her 3-year old child. She asked you what to do if her child vomits. As a
nurse you will tell her to:
|
A
|
Bring the child to the nearest hospital for further assessment.
|
|
B
|
Bring the child to the health center for intravenous fluid therapy.
|
|
C
|
Bring the child to the health center for assessment by the physician.
|
|
D
|
Let the child rest for 10 minutes then continue giving Oresol more
slowly.
|
64.Nikki a 5-month old infant was brought by his
mother to the health center because of diarrhea for 4 to 5 times a day. Her
skin goes back slowly after a skin pinch and her eyes are sunken. Using the
IMCI guidelines, you will classify this infant in which category?
|
A
|
No signs of dehydration
|
|
B
|
Some dehydration
|
|
C
|
Severe dehydration
|
|
D
|
The data is insufficient.
|
65.Chris a 4-month old infant was brought by her
mother to the health center because of cough. His respiratory rate is
42/minute. Using the Integrated Management of Child Illness (IMCI) guidelines
of assessment, his breathing is considered as:
|
A
|
Fast
|
|
B
|
Slow
|
|
C
|
Normal
|
|
D
|
Insignificant
|
66.Maylene had just received her 4th dose of tetanus
toxoid. She is aware that her baby will have protection against tetanus for
|
A
|
10 years
|
|
B
|
5 years
|
|
C
|
3 years
|
|
D
|
Lifetime
|
67.Nurse Ron is aware that unused BCG should be discarded
after how many hours of reconstitution?
|
A
|
2 hours
|
|
B
|
4 hours
|
|
C
|
8 hours
|
|
D
|
At the end of the day
|
68.The nurse explains to a breastfeeding mother that
breast milk is sufficient for all of the baby’s nutrient needs only up to:
|
A
|
5 months
|
|
B
|
6 months
|
|
C
|
1 year
|
|
D
|
2 years
|
69.Nurse Ron is aware that the gestational age of a
conceptus that is considered viable (able to live outside the womb) is:
|
A
|
8 weeks
|
|
B
|
12 weeks
|
|
C
|
24 weeks
|
|
D
|
32 weeks
|
70.When teaching parents of a neonate the proper
position for the neonate’s sleep, the nurse Patricia stresses the importance of
placing the neonate on his back to reduce the risk of which of the following?
|
A
|
Aspiration
|
|
B
|
Sudden infant death syndrome (SIDS)
|
|
C
|
Suffocation
|
|
D
|
Gastroesophageal reflux (GER)
|
71.Which finding might be seen in baby James a neonate
suspected of having an infection?
|
A
|
Flushed cheeks
|
|
B
|
Increased temperature
|
|
C
|
Decreased temperature
|
|
D
|
Increased activity level
|
72.Baby Jenny who is small-for-gestation is at
increased risk during the transitional period for which complication?
|
A
|
Anemia probably due to chronic fetal hypoxia
|
|
B
|
Hyperthermia due to decreased glycogen stores
|
|
C
|
Hyperglycemia due to decreased glycogen stores
|
|
D
|
Polycythemia probably due to chronic fetal hypoxia
|
73.Marjorie has just given birth at 42 weeks’
gestation. When the nurse assessing the neonate, which physical finding is
expected?
|
A
|
A sleepy, lethargic baby
|
|
B
|
Lanugo covering the body
|
|
C
|
Desquamation of the epidermis
|
|
D
|
Vernix caseosa covering the body
|
74.After reviewing the Myrna’s maternal history of
magnesium sulfate during labor, which condition would nurse Richard anticipate
as a potential problem in the neonate?
|
A
|
Hypoglycemia
|
|
B
|
Jitteriness
|
|
C
|
Respiratory depression
|
|
D
|
Tachycardia
|
75.Which symptom would indicate the Baby Alexandra was
adapting appropriately to extra-uterine life without difficulty?
|
A
|
Nasal flaring
|
|
B
|
Light audible grunting
|
|
C
|
Respiratory rate 40 to 60 breaths/minute
|
|
D
|
Respiratory rate 60 to 80 breaths/minute
|
76.When teaching umbilical cord care for Jennifer a
new mother, the nurse Jenny would include which information?
|
A
|
Apply peroxide to the cord with each diaper change
|
|
B
|
Cover the cord with petroleum jelly after bathing
|
|
C
|
Keep the cord dry and open to air
|
|
D
|
Wash the cord with soap and water each day during a tub bath.
|
77.Nurse John is performing an assessment on a
neonate. Which of the following findings is considered common in the healthy
neonate?
|
A
|
Simian crease
|
|
B
|
Conjunctival hemorrhage
|
|
C
|
Cystic hygroma
|
|
D
|
Bulging fontanelle
|
78.Dr. Esteves decides to artificially rupture the
membranes of a mother who is on labor. Following this procedure, the nurse
Hazel checks the fetal heart tones for which the following reasons?
|
A
|
To determine fetal well-being.
|
|
B
|
To assess for prolapsed cord
|
|
C
|
To assess fetal position
|
|
D
|
To prepare for an imminent delivery.
|
79.Which of the following would be least likely to
indicate anticipated bonding behaviors by new parents?
|
A
|
The parents’ willingness to touch and hold the newborn.
|
|
B
|
The parent’s expression of interest about the size of the newborn.
|
|
C
|
The parents’ indication that they want to see the newborn.
|
|
D
|
The parents’ interactions with each other.
|
80.Following a precipitous delivery, examination of
the client’s vagina reveals a fourth-degree laceration. Which of the following
would be contraindicated when caring for this client?
|
A
|
Applying cold to limit edema during the first 12 to 24 hours.
|
|
B
|
Instructing the client to use two or more peri pads to cushion the
area.
|
|
C
|
Instructing the client on the use of sitz baths if ordered.
|
|
D
|
Instructing the client about the importance of perineal (kegel)
exercises.
|
81.A pregnant woman accompanied by her husband, seeks
admission to the labor and delivery area. She states that she’s in labor and
says she attended the facility clinic for prenatal care. Which question should
the nurse Oliver ask her first?
|
A
|
“Do you have any chronic illnesses?”
|
|
B
|
“Do you have any allergies?”
|
|
C
|
“What is your expected due date?”
|
|
D
|
“Who will be with you during labor?”
|
82.A neonate begins to gag and turns a dusky color.
What should the nurse do first?
|
A
|
Calm the neonate.
|
|
B
|
Notify the physician.
|
|
C
|
Provide oxygen via face mask as ordered
|
|
D
|
Aspirate the neonate’s nose and mouth with a bulb syringe.
|
83.When a client states that her “water broke,” which
of the following actions would be inappropriate for the nurse to do?
|
A
|
Observing the pooling of straw-colored fluid.
|
|
B
|
Checking vaginal discharge with nitrazine paper.
|
|
C
|
Conducting a bedside ultrasound for an amniotic fluid index.
|
|
D
|
Observing for flakes of vernix in the vaginal discharge.
|
84.A baby girl is born 8 weeks premature. At birth,
she has no spontaneous respirations but is successfully resuscitated. Within
several hours she develops respiratory grunting, cyanosis, tachypnea, nasal
flaring, and retractions. She’s diagnosed with respiratory distress syndrome,
intubated, and placed on a ventilator. Which nursing action should be included
in the baby’s plan of care to prevent retinopathy of prematurity?
|
A
|
Cover his eyes while receiving oxygen.
|
|
B
|
Keep her body temperature low.
|
|
C
|
Monitor partial pressure of oxygen (Pao2) levels.
|
|
D
|
Humidify the oxygen.
|
85.Which of the following is normal newborn calorie
intake?
|
A
|
110 to 130 calories per kg.
|
|
B
|
30 to 40 calories per lb of body weight.
|
|
C
|
At least 2 ml per feeding
|
|
D
|
90 to 100 calories per kg
|
86.Nurse John is knowledgeable that usually individual
twins will grow appropriately and at the same rate as singletons until how many
weeks?
|
A
|
16 to 18 weeks
|
|
B
|
18 to 22 weeks
|
|
C
|
30 to 32 weeks
|
|
D
|
38 to 40 weeks
|
87.Which of the following classifications applies to
monozygotic twins for whom the cleavage of the fertilized ovum occurs more than
13 days after fertilization?
|
A
|
conjoined twins
|
|
B
|
diamniotic dichorionic twins
|
|
C
|
diamniotic monochorionic twin
|
|
D
|
monoamniotic monochorionic twins
|
88.Tyra experienced painless vaginal bleeding has just
been diagnosed as having a placenta previa. Which of the following procedures
is usually performed to diagnose placenta previa?
|
A
|
Amniocentesis
|
|
B
|
Digital or speculum examination
|
|
C
|
External fetal monitoring
|
|
D
|
Ultrasound
|
89.Nurse Arnold knows that the following changes in
respiratory functioning during pregnancy is considered normal:
|
A
|
Increased tidal volume
|
|
B
|
Increased expiratory volume
|
|
C
|
Decreased inspiratory capacity
|
|
D
|
Decreased oxygen consumption
|
|
90.
|
Emily has gestational diabetes and it is usually
managed by which of the following therapy?
|
A
|
Diet
|
|
B
|
Long-acting insulin
|
|
C
|
Oral hypoglycemic
|
|
D
|
Oral hypoglycemic drug and insulin
|
91.Magnesium sulfate is given to Jemma with
preeclampsia to prevent which of the following condition?
|
A
|
Hemorrhage
|
|
B
|
Hypertension
|
|
C
|
Hypomagnesemia
|
|
D
|
Seizure
|
92.Cammile with sickle cell anemia has an increased
risk for having a sickle cell crisis during pregnancy. Aggressive management of
a sickle cell crisis includes which of the following measures?
|
A
|
Antihypertensive agents
|
|
B
|
Diuretic agents
|
|
C
|
I.V. fluids
|
|
D
|
Acetaminophen (Tylenol) for pain
|
93.Which of the following drugs is the antidote for
magnesium toxicity?
|
A
|
Calcium gluconate (Kalcinate)
|
|
B
|
Hydralazine (Apresoline)
|
|
C
|
Naloxone (Narcan)
|
|
D
|
Rho (D) immune globulin (RhoGAM)
|
94.Marlyn is screened for tuberculosis during her
first prenatal visit. An intradermal injection of purified protein derivative
(PPD) of the tuberculin bacilli is given. She is considered to have a positive
test for which of the following results?
|
A
|
An indurated wheal under 10 mm in diameter appears in 6 to 12 hours.
|
|
B
|
An indurated wheal over 10 mm in diameter appears in 48 to 72 hours.
|
|
C
|
A flat circumcised area under 10 mm in diameter appears in 6 to 12
hours.
|
|
D
|
A flat circumcised area over 10 mm in diameter appears in 48 to 72
hours.
|
95.Dianne, 24 year-old is 27 weeks’ pregnant arrives
at her physician’s office with complaints of fever, nausea, vomiting, malaise,
unilateral flank pain, and costovertebral angle tenderness. Which of the
following diagnoses is most likely?
|
A
|
Asymptomatic bacteriuria
|
|
B
|
Bacterial vaginosis
|
|
C
|
Pyelonephritis
|
|
D
|
Urinary tract infection (UTI)
|
96.Rh isoimmunization in a pregnant client develops
during which of the following conditions?
|
A
|
Rh-positive maternal blood crosses into fetal blood, stimulating fetal
antibodies.
|
|
B
|
Rh-positive fetal blood crosses into maternal blood, stimulating
maternal antibodies.
|
|
C
|
Rh-negative fetal blood crosses into maternal blood, stimulating
maternal antibodies.
|
|
D
|
Rh-negative maternal blood crosses into fetal blood, stimulating fetal
antibodies.
|
97.To promote comfort during labor, the nurse John
advises a client to assume certain positions and avoid others. Which position
may cause maternal hypotension and fetal hypoxia?
|
A
|
Lateral position
|
|
B
|
Squatting position
|
|
C
|
Supine position
|
|
D
|
Standing position
|
98.Celeste who used heroin during her pregnancy
delivers a neonate. When assessing the neonate, the nurse Lynnette expects to
find:
|
A
|
Lethargy 2 days after birth.
|
|
B
|
Irritability and poor sucking.
|
|
C
|
A flattened nose, small eyes, and thin lips.
|
|
D
|
Congenital defects such as limb anomalies.
|
|
.
|
99.The
uterus returns to the pelvic cavity in which of the following time frames?
|
A
|
7th to 9th day postpartum.
|
|
B
|
2 weeks postpartum.
|
|
C
|
End of 6th week postpartum.
|
|
D
|
When the lochia changes to alba.
|
100.Maureen, a primigravida client, age 20, has just
completed a difficult, forceps-assisted delivery of twins. Her labor was
unusually long and required oxytocin (Pitocin) augmentation. The nurse who’s
caring for her should stay alert for:
|
A
|
Uterine inversion
|
|
B
|
Uterine atony
|
|
C
|
Uterine involution
|
|
D
|
Uterine discomfort
|
ANSWERS & EXPLAINATIONS
Question 1 Explanation: ANS-A
An inevitable abortion is termination of
pregnancy that cannot be prevented. Moderate to severe bleeding with mild
cramping and cervical dilation would be noted in this type of abortion
Question 2 Explanation: ANS-B
Maternal infections such as syphilis,
toxoplasmosis, and rubella are causes of spontaneous abortion
Question 3 Explanation: ANS-C
Nursing care for the client with a
possible ectopic pregnancy is focused on preventing or identifying hypovolemic
shock and controlling pain. An elevated pulse rate is an indicator of shock
Question 4 Explanation: ANS-B
Glucose crosses the placenta, but insulin does not.
High fetal demands for glucose, combined with the insulin resistance caused by
hormonal changes in the last half of pregnancy can result in elevation of
maternal blood glucose levels. This increases the mother’s demand for insulin
and is referred to as the diabetogenic effect of pregnancy..
Question 5 Explanation: ANS-A
The most common signs and symptoms of
hydatidiform mole includes elevated levels of human chorionic gonadotropin,
vaginal bleeding, larger than normal uterus for gestational age, failure to
detect fetal heart activity even with sensitive instruments, excessive nausea
and vomiting, and early development of pregnancy-induced hypertension. Fetal
activity would not be noted
Question 6 Explanation: ANS-B
Absence of patellar reflexes is an indicator of
hypermagnesemia, which requires administration of calcium gluconate.
Question 7 Explanation: ANS-C
Fetus at station plus two indicates that the
presenting part is 2 cm below the plane of the ischial spines.
Question 8 Explanation: ANS-A
Contractions every 1 ½ minutes lasting 70-80
seconds, is indicative of hyperstimulation of the uterus, which could result in
injury to the mother and the fetus if Pitocin is not discontinued
Question 9 Explanation: ANS-C
A potential side effect of calcium
gluconate administration is cardiac arrest. Continuous monitoring of cardiac
activity (EKG) through administration of calcium gluconate is an essential part
of care
Question 10 Explanation: ANS-D
This type of client has no obstetrical indication for
a caesarean section as she did with her first caesarean delivery.
Question 11 Explanation: ANS-A
When dealing with a crying toddler, the
best approach is to talk to the mother and ignore the toddler first. This
approach helps the toddler get used to the nurse before she attempts any
procedures. It also gives the toddler an opportunity to see that the mother
trusts the nurse
Question 12 Explanation: ANS-D
Soft restraints from the upper arm to the wrist
prevent the infant from touching her lip but allow him to hold a favorite item
such as a blanket. Because they could damage the operative site, such as
objects as pacifiers, suction catheters, and small spoons shouldn’t be placed
in a baby’s mouth after cleft repair. A baby in a prone position may rub her
face on the sheets and traumatize the operative site. The suture line should be
cleaned gently to prevent infection, which could interfere with healing and
damage the cosmetic appearance of the repair.
Question 13 Explanation: ANS-B
Because feeding requires so much energy,
an infant with heart failure should rest before feeding
Question 14 Explanation: ANS-C
The infants at age 5 months should
receive iron-rich formula and that they shouldn’t receive solid food, even baby
food until age 6 months
Question 15 Explanation: ANS-D
A 10 month old infant can sit alone and understands
object permanence, so he would look for the hidden toy. At age 4 to 6 months,
infants can’t sit securely alone. At age 8 months, infants can sit securely
alone but cannot understand the permanence of objects.
Question 16 Explanation: ANS-D
The catchments area in PHN consists of a residential
community, many of whom are well individuals who have greater need for
preventive rather than curative services.
Question 17 Explanation: ANS-B
Efficiency is determining whether the
goals were attained at the least possible cost
Question 18 Explanation: ANS-D
R.A. 7160 devolved basic health services to local
government units (LGU’s ). The public health nurse is an employee of the LGU.
Question 19 Explanation: ANS-A
The local executive serves as the
chairman of the Municipal Health Board
Question 20 Explanation: ANS-A
Each rural health midwife is given a
population assignment of about 5,000
Question 21 Explanation: ANS-B
The community health nurse develops the
health capability of people through health education and community organizing
activities.
Question 22 Explanation: ANS-B
Presidential Proclamation No. 4 is on
the Ligtas Tigdas Program
Question 23 Explanation: ANS-D
In core group formation, the nurse is
able to transfer the technology of community organizing to the potential or
informal community leaders through a training program
Question 24 Explanation: ANS-D
Community organizing is a developmental
service, with the goal of developing the people’s self-reliance in dealing with
community health problems. A, B and C are objectives of contributory objectives
to this goal
Question 25 Explanation: ANS-D
Tertiary prevention involves rehabilitation,
prevention of permanent disability and disability limitation appropriate for
convalescents, the disabled, complicated cases and the terminally ill (those in
the terminal stage of a disease).
Question 26 Explanation: ANS-A
Intrauterine fetal death, abruptio placentae, septic
shock, and amniotic fluid embolism may trigger normal clotting mechanisms; if
clotting factors are depleted, DIC may occur. Placenta accreta, dysfunctional
labor, and premature rupture of the membranes aren’t associated with DIC.
Question 27 Explanation: ANS-C
A rate of 120 to 160 beats/minute in the
fetal heart appropriate for filling the heart with blood and pumping it out to
the system
Question 28 Explanation: ANS-A
Decreasing the amount of time the skin comes contact
with wet soiled diapers will help heal the irritation.
Question 29 Explanation: ANS-D
Endocardial cushion defects are seen
most in children with Down syndrome, asplenia, or polysplenia
Question 30 Explanation: ANS-B
Decreased urine output may occur in clients receiving
I.V. magnesium and should be monitored closely to keep urine output at greater
than 30 ml/hour, because magnesium is excreted through the kidneys and can
easily accumulate to toxic levels.
Question 31 Explanation: ANS-A
Menorrhagia is an excessive menstrual
period
Question 32 Explanation: ANS-C
Blood type would be a critical value to
have because the risk of blood loss is always a potential complication during
the labor and delivery process. Approximately 40% of a woman’s cardiac output
is delivered to the uterus therefore, blood loss can occur quite rapidly in the
event of uncontrolled bleeding
Question 33 Explanation: ANS-D
Hemoglobin values and hematocrit
decrease during pregnancy as the increase in plasma volume exceeds the increase
in red blood cell production
Question 34 Explanation: ANS-D
The infant with the airway emergency
should be treated first, because of the risk of epiglottitis
Question 35 Explanation: ANS-A
Placenta previa with painless vaginal
bleeding
Question 36 Explanation: ANS-D
Based on the nurse’s knowledge of
microbiology, the specimen should be collected early in the morning. The
rationale for this timing is that, because the female worm lays eggs at night
around the perineal area, the first bowel movement of the day will yield the
best results. The specific type of stool specimen used in the diagnosis of
pinworms is called the tape test
Question 37 Explanation: ANS-A
Lead poisoning primarily affects the
CNS, causing increased intracranial pressure. This condition results in
irritability and changes in level of consciousness, as well as seizure
disorders, hyperactivity, and learning disabilities
Question 38 Explanation: ANS-D
The woman must understand that, although
the “fertile” period is approximately mid-cycle, hormonal variations do occur
and can result in early or late ovulation. To be effective, the diaphragm
should be inserted before every intercourse.
Question 39 Explanation: ANS-C
In a child, restlessness is the earliest
sign of hypoxia. Late signs of hypoxia in a child are associated with a change
in color, such as pallor or cyanosis
Question 40 Explanation: ANS-B
This procedure is generally recommended
to follow in guiding a person who is blind
Question 41 Explanation: ANS-A
A loud, machinery-like murmur is a
characteristic finding associated with patent ductus arteriosus.
Question 42 Explanation: ANS-C
When cold, the infant requires more
oxygen and there is an increase in metabolic rate. Non-shivering thermogenesis
is a complex process that increases the metabolic rate and rate of oxygen
consumption, therefore, the newborn increase heat production.
Question 43 Explanation: ANS-D
Before administering potassium I.V. to
any client, the nurse must first check that the client’s kidneys are
functioning and that the client is voiding. If the client is not voiding, the
nurse should withhold the potassium and notify the physician
Question 44 Explanation: ANS-C
Eczema or dermatitis is an allergic skin
reaction caused by an offending allergen. The topical allergen that is the most
common causative factor is laundry detergent
Question 45 Explanation: ANS-A
This distance allows for easy flow of
the formula by gravity, but the flow will be slow enough not to overload the
stomach too rapidly.
Question 46 Explanation: ANS-A
Chickenpox is usually more severe in
adults than in children. Complications, such as pneumonia, are higher in
incidence in adults
Question 47 Explanation: ANS-D
Rubella vaccine is made up of attenuated
German measles viruses. This is contraindicated in pregnancy. Immune globulin,
a specific prophylactic against German measles, may be given to pregnant women
Question 48 Explanation: ANS-A
Contact tracing is the most practical
and reliable method of finding possible sources of person-to-person transmitted
infections, such as sexually transmitted diseases.
Question 49 Explanation: ANS-D
Leptospirosis is transmitted through
contact with the skin or mucous membrane with water or moist soil contaminated
with urine of infected animals, like rats
Question 50 Explanation: ANS-B
Passage of profuse watery stools is the
major symptom of cholera. Both amoebic and bacillary dysentery are
characterized by the presence of blood and/or mucus in the stools. Giardiasis
is characterized by fat malabsorption and, therefore, steatorrhea
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