Siemon Paolo M.

Atienza
1. A couple who wants to conceive but has been unsuccessful during the last
2 years has undergone many diagnostic procedures. When discussing the
situation with the nurse, one partner states, “We know several friends in
our age group and all of them have their own child already, Why can’t we
have one?”. Which of the following would be the most pertinent nursing
diagnosis for this couple?
a. Fear related to the unknown
b. Pain related to numerous procedures.
c. Ineffective family coping related to infertility.
d. Self-esteem disturbance related to infertility.
Answer - D
Rationale:
Based on the partner’s statement, the couple is verbalizing feelings of inadequacy and
negative feelings about themselves and their capabilities. Thus, the nursing diagnosis of
self-esteem disturbance is most appropriate. Fear, pain, and ineffective family coping
also may be present but as secondary nursing diagnoses
Safe and Quality Nursing care/Core Competency 7

2. Which of the following urinary symptoms does the pregnant woman most
frequently experience during the first trimester?
a. Dysuria
b. Frequency
c. Incontinence
d. Burning
Answer - B
Rationale:
Pressure and irritation of the bladder by the growing uterus during the first trimester is
responsible for causing urinary frequency. Dysuria, incontinence, and burning are
symptoms associated with urinary tract infections.
Safe and Quality Nursing care/Core Competency 1

3. Heartburn and flatulence, common in the second trimester, are most likely
the result of which of the following?
a. Increased plasma HCG levels
b. Decreased intestinal motility
c. Decreased gastric acidity
d. Elevated estrogen levels
Answer - C
Rationale :
During the second trimester, the reduction in gastric acidity in conjunction with pressure
from the growing uterus and smooth muscle relaxation, can cause heartburn and
flatulence. HCG levels increase in the first, not the second, trimester. Decrease
intestinal motility would most likely be the cause of constipation and bloating. Estrogen
levels decrease in the second trimester

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 Safe and Quality Nursing care/Core Competency 1

4. Which of the following represents the average amount of weight gained

during pregnancy?
a. 12 to 22 lb
b. 15 to 25 lb
c. 24 to 30 lb
d. 25 to 40 lb
Answer - C
Rationale :
The average amount of weight gained during pregnancy is 24 to 30 lb. This weight gain
consists of the following: fetus – 7.5 lb; placenta and membrane – 1.5 lb; amniotic fluid –
2 lb; uterus – 2.5 lb; breasts – 3 lb; and increased blood volume – 2 to 4 lb;
extravascular fluid and fat – 4 to 9 lb. A gain of 12 to 22 lb is insufficient, whereas a
weight gain of 15 to 25 lb is marginal. A weight gain of 25 to 40 lb is considered
excessive.
Safe and Quality Nursing care/Core Competency 1
5. When talking with a pregnant client who is experiencing aching swollen,
leg veins, the nurse would explain that this is most probably the result of
which of the following?
a. Thrombophlebitis
b. Pregnancy-induced hypertension
c. Pressure on blood vessels from the enlarging uterus
d. The force of gravity pulling down on the uterus
Answer – C

Rationale :
Pressure of the growing uterus on blood vessels results in an increased risk for venous
stasis in the lower extremities. Subsequently, edema and varicose vein formation may
occur. Thrombophlebitis is an inflammation of the veins due to thrombus formation.
Pregnancy-induced hypertension is not associated with these symptoms. Gravity plays
only a minor role with these symptoms.
Safe and Quality Nursing care/Core Competency 1

6. Cervical softening and uterine souffle are classified as which of the

following?
a. Diagnostic signs
b. Presumptive signs
c. Probable signs
d. Positive signs
Answer - C
Rationale :
Cervical softening (Goodell sign) and uterine soufflé are two probable signs of
pregnancy. Probable signs are objective findings that strongly suggest pregnancy. Other
probable signs include Hegar sign, which is softening of the lower uterine segment;
Piskacek sign, which is enlargement and softening of the uterus; serum laboratory tests;
changes in skin pigmentation; and ultrasonic evidence of a gestational sac. Presumptive
signs are subjective signs and include amenorrhea; nausea and vomiting; urinary

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 frequency; breast tenderness and changes; excessive fatigue; uterine enlargement; and
quickening.
Safe and Quality Nursing care/Core Competency 1
7. Which of the following common emotional reactions to pregnancy would
the nurse expect to occur during the first trimester?
a. Introversion, egocentrism, narcissism
b. Awkwardness, clumsiness, and unattractiveness
c. Anxiety, passivity, extroversion
d. Ambivalence, fear, fantasies
Answer - B
Rationale :
During the first trimester, common emotional reactions include ambivalence, fear,
fantasies, or anxiety. The second trimester is a period of well-being accompanied by the
increased need to learn about fetal growth and development. Common emotional
reactions during this trimester include narcissism, passivity, or introversion. At times the
woman may seem egocentric and self-centered. During the third trimester, the woman
typically feels awkward, clumsy, and unattractive, often becoming more introverted or
reflective of her own childhood.
Safe and Quality Nursing care/Core Competency 1
8. FHR can be auscultated with a fetoscope as early as which of the
following?
a. 5 weeks gestation
b. 10 weeks gestation
c. 15 weeks gestation
d. 20 weeks gestation
Answer - D
Rationale:
The FHR can be auscultated with a fetoscope at about 20 week’s gestation. FHR
usually is ausculatated at the midline suprapubic region with Doppler ultrasound
transducer at 10 to 12 week’s gestation. FHR, cannot be heard any earlier than 10
weeks’ gestation.
Safe and Quality Nursing care/Core Competency 1
9. Which of the following characteristics of contractions would the nurse
expect to find in a client experiencing true labor?
a. Occurring at irregular intervals
b. Starting mainly in the abdomen
c. Gradually increasing intervals
d. Increasing intensity with walking
Answer – D
Rationale:
With true labor, contractions increase in intensity with walking. In addition, true labor
contractions occur at regular intervals, usually starting in the back and sweeping around
to the abdomen. The interval of true labor contractions gradually shortens.
Safe and Quality Nursing care/Core Competency 1

10. During which of the following stages of labor would the nurse assess
“crowning”?
a. First stage
b. Second stage

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 c. Third stage
d. Fourth stage
Answer – B
Rationale:
Crowing, which occurs when the newborn’s head or presenting part appears at the
vaginal opening, occurs during the second stage of labor. During the first stage of labor,
cervical dilation and effacement occur. During the third stage of labor, the newborn and
placenta are delivered. The fourth stage of labor lasts from 1 to 4 hours after birth,
during which time the mother and newborn recover from the physical process of birth
and the mother’s organs undergo the initial readjustment to the nonpregnant state.
Safe and Quality Nursing care/Core Competency 1

1. With regards to Women’s Health and Safe Motherhood Project, the

following strategies are included to prevent maternal mortality, except one:

a. Establishment of BEmoNC and CEmoNC networks

b. TBA facilitated home deliveries
c. Improved Family Planning counselling
d. Emphasis on Facility based deliveries
Answer – B
Rationale:
Home deliveries are not recommended by the government even it is assisted by a
health professional or a trained hilot nowadays. Maternal complications leading to
maternal mortality has been found to be due to this.
Safe and Quality Nursing care/Core Competency 1

2. The following qualifications reflect possible delivery in the Rural Health

Unit, except for one:
a. Cephalic presentation
b. Adequate pelvis
c. History of caesarian section delivery
d. Less than five pregnancies
Answer - C
Rationale:
Rural health units do not have the capacity and the facilities to facilitate CS delivery.
Aside from that women with history of CS deliveries usually have previous history of
serious or potentially serious complications, thus they are usually advised to seek
consult to the nearest hospital during their prenatal period to prepare them for their
delivery.
Safe and Quality Nursing care/Core Competency 1

3. You are assigned to provide baby care to the newly delivered healthy baby.
What procedure are you going to do first?
a. Examine the newborn and check for defects, deformities and birth injuries.
b. Provide warmth to the newborn and have a quick check for breathing
c. Clamp and cut the cord after cord pulsations have stopped.
d. Facilitate the bonding between the mother and the newborn through early skin
– to - skin contact.
Answer - B

Rationale:

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 Within the first 30 seconds, the objective of the nurse is to dry and provide warmth to
the newborn to prevent from hypothermia.
Safe and Quality Nursing care/Core Competency 1

4. The basis for the improvement in strategies in maternal and neonatal care
is on Millennium Development Goals, which are:
a. MDGs 1 & 2
b. MDGs 2 & 4
c. MDGs 3 & 5
d. MDGs 4 & 5
Answer - D
Rationale:
MDG 4 focuses on reducing child mortality and MDG 5 corresponds to the improvement
of maternal health.
Safe and Quality Nursing care/Core Competency 1

5. The following are the intermediate results that can lower the risk for dying
from pregnancy and childbirth with the integration of the MNCHN services
in the community:
a. Every delivery is facility- based and managed by skilled birth attendants
b. Every pregnancy is adequately managed during pre and post partum courses
c. Every pregnancy is wanted, planned and supported
d. Only answers A & C
Answer - D
Rationale:
Only A & C are correct; every pregnancy is adequately managed throughout its course,
not only during prenatal and post-partum periods.
6. Which is the best preventive measure for dengue hemorrhagic fever?
a. Frequent fogging in the vicinity to kill mosquitoes
b. Use of mosquito nets and mosquito coils
c. Use of mosquito repellent lotions
d. Cleaning of surroundings and proper disposal of coconut shells, tires, and containers
Answer – D
Rationale:
Fogging is not recommended for it only scares away mosquito and it even causes some
respiratory consequences; use of mosquito nets, coils and repellants are options but the
best preventive measure is through searching and destroying of breeding sites by
cleaning the surroundings.
Safe and Quality Nursing care/Core Competency 1

7. What are the signs and symptoms of DHF assessed as Grade II?
a. Herman’s signs, bone and joint pains, fever with headache, and abdominal pain
b. Hypotension, anorexia, nausea and vomiting, fever, and rapid weak pulse
c. Herman’s signs, fever with headache, epistaxis, and melena
d. Narrowing pulse pressure, restlessness, and cold clammy perspiration
Answer - C
Rationale:
DHF Grade II includes the signs of Grade I plus spontaneous bleeding. Choice A refers
only to signs and symptoms found in Grade I, while options B and D correspond to
signs and symptoms of Grade III.
Safe and Quality Nursing care/Core Competency 1

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 8. What diagnostic procedure will confirm that the client is having DHF?
a. Blood smear
b. Urine and Stool examinations
c. Cerebrospinal fluid examination
d. Sputum examination
Answer - A
Rationale:
By testing through blood smear DHF will be confirmed. The rest diagnostic procedures
are not relevant to the confirmation process of this said disease.
Safe and Quality Nursing care/Core Competency 1

9. Dengue hemorrhagic fever can be fatal. The following manifestations are

present in DHF, except for one.
a. Thrombocytosis
b. Prolonged bleeding time
c. Thrombocytopenia
d. Positive Rumpel Leade test
Answer - A
Rationale:
Thrombocytosis is not a manifestation of DHF instead there is depletion of
thrombocytes in the system referring to as thrombocytopenia; which can be evidenced
by prolonged bleeding time and petechial rashes.
Safe and Quality Nursing care/Core Competency 1

Situation III: IMCI or the Integrated Management for Childhood Illnesses is an

important tool for public health nurses for managing cases of children seeking
health care.
10. What should you look for in assessing the child’s condition?
a. Does the child vomit everything?
b. Is the child able to breastfeed or drink?
c. Is the child lethargic or unconscious?
d. Is the child having some breathing difficulties?
Answer - C
Rationale: ​
Options A and B refers to what you should ask for during assessment, but what you
really need to look for is if the child is lethargic – which is a danger sign. It also refers to
as objective data instead of subjective one as verbalized by mother. Option D is asked if
you are querying the child to have pneumonia or not.
Safe and Quality Nursing care/Core Competency 1

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