COR JESU COLLEGE, INC.

COLLEGE OF HEALTH SCIENCES

Tres de Mayo, Digos City, Davao del Sur

Bachelor of Science in Nursing

Second Semester; AY: 2021 – 2022

PRELIM EXAMINATION
EPI, IMCI, Maternal & Child

NAME: (LASTNAME, FIRST NAME, MI.)

Prepared by: JANILYN MAE C. SABAN, RN (Clinical Instructor)

General Instructions:
1. Read all the instructions carefully.
2. Any forms of alterations or erasures are considered wrong.
3. ALL final answers must be written on the answer sheet provided.

TEST I – Multiple Choice: Choose the best lettered response in each case. Shade the letter of your choice on
the answer sheet provided.

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 be experiencing which type of abortion?
a. Inevitable
b. Incomplete – passes of product of conception – pero naa pa nahabilin
c. Threatened - less than 20 weeks gestation, presents with vaginal bleeding, abdominal cramping,
cervical os is closed
d. Septic – complications of your incomplete abortion
Is a termination of pregnancy that cannot be prevented. Moderate to severe bleeding with mild cramping and
cervical dilatation would be noted in this type of abortion
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? pregnancy loss at less than 20 weeks' gestation in the absence of elective
medical or surgical measures to terminate the pregnancy - - - nakuhaan siya before 5months
a. Age 36 years – high risk due to both the decrease in quality of eggs in older age and the higher risk
of chronic conditions.
b. History of syphilis – cross placental
c. History of genital herpes - Genital herpes won't put you at higher risk of a miscarriage but it
can be passed onto babies during pregnancy. It can cause a serious illness called neonatal herpes.
d. History of diabetes mellitus - Women with diabetes are at a much greater risk of miscarriage,
stillbirth, and neonatal fatalities than women without diabetes
Answer: (B) History of syphilis
Rationale: Maternal infections such as syphilis, toxoplasmosis - People often get the infection from eating
undercooked meat. You can also get it from contact with cat feces. The parasite can pass to a baby during
pregnancy., and rubella are causes of spontaneous –remember RUBELLA and also chicken pox is
teratogenic… teratogenic – can cause developmental malformations
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

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 c. Monitoring apical pulse
d. Monitoring temperature
If the patient has an ectopic pregnancy, clinical manifestation na atong ma observe? Patient is in PAIN? Vaginal
bleeding…. The patient is at risk to develop Hypovolemic shock? Yessss lalo na kung ruptured ectopic
pregnancy
Answer: (C) Monitoring apical pulse
Rationale: 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. HYPOVOLEMIC
SHOCK – hypo tachy tachy--- lalo na ruptured na…soooo bleeding

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: positive question therefore you look for a positive answer
Second half of pregnancy - the middle part of your pregnancy, from weeks 13 to 26
a. Decreased caloric intake
b. Increased caloric intake
c. Decreased Insulin
d. Increase Insulin
Answer: Increased caloric intake
Rationale: 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 Third Trimester (27 to 40
Weeks) 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. Refers to the number of calories (energy content)
consumed.. protein / carbohydrates
Caloric intake during pregnancy
1st semester –1,800
2nd semester – 2,200
3rd semester – 2,400

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? Walay apil / except…. A slow-growing tumor
that develops from trophoblastic cells (cells that help an embryo attach to the uterus and help
form the placenta) after fertilization of an egg by a sperm. A hydatidiform mole contains many cysts
(sacs of fluid).
a. Excessive fetal activity – failure to detect fetal heart activity
b. Larger than normal uterus for gestational age
c. Vaginal bleeding
d. Elevated levels of human chorionic gonadotropin.
Answer: (A) Excessive fetal activity.
Rationale: 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.
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: asa daw diri na finding na
nagpapakita na kailangan nimo mg hatag og calcium gluconate because the patient develop
hypermagnesemia
a. Urinary output 90 cc in 2 hours. – decrease urine output – magnesium sulfate side effect
b. Absent patellar reflexes. - hypermagnesemia
c. Rapid respiratory rate above 40/min
d. Rapid rise in blood pressure.
Answer: (B) Absent patellar reflexes
Rationale: Absence of patellar reflexes is an indicator of hypermagnesemia, which requires administration of
calcium gluconate

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 7. During vaginal examination of Janah 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.
Answer: (C) Presenting part in 2 cm below the plane of the ischial spines.
Rationale: Fetus at station plus two indicates that the presenting part is 2 cm below the plane of the ischial
spines
8. A pregnant client is receiving oxytocin (Pitocin) for induction of labor. A condition that the nurse in-
charge to discontinue 1.V. infusion of Pitocin is: OXYTOCIN classification is oxytocic hormones
therefore it is a natural hormone with mechanism of action is to stimulates uterine contractions
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.
Answer: (A) Contractions every 1 ½ minutes lasting 70-80 seconds.
Rationale: Contractions every 1 1/2 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…
which can lead to changes in the baby's heart rate and the need for emergency caesarean
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 - Central venous pressure, which is a measure of pressure in the vena cava, can
be used as an estimation of preload and right atrial pressure. Central venous pressure is often used
as an assessment of hemodynamic status, particularly in the intensive care unit.
c. EKG tracings
d. Continuous CPR – wala pa gani ng arrest ang patient – ng cpr nah..
Answer: (C) EKG tracings
Rationale: 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.
10. A trial for vaginal delivery after an earlier caesarean, would likely to be given to a gravida, who had:
kinsa ang candidate for trial of normal delivery
a. First low transverse cesarean was for active herpes type 2 infections, vaginal culture at 39 weeks
pregnancy was positive – kailangan ba siya I CS?
b. First and second caesareans were for cephalopelvic disproportion – kailangan ba I CS
c. First caesarean through a classic incision as a result of severe fetal distress – kailangan ba I CS
d. First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex
presentation. Vertex presentation – the crown or top of the head (called the vertex), enters the
birth canal first
Answer: (D) First low transverse caesarean was for breech position. Fetus in this pregnancy is in a vertex
presentation
Rationale. This type of client has no obstetrical indication for a caesarean section as she did with her first
caesarean delivery.
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
Answer. (A) Talk to the mother first and then to the toddler.
Rationale: 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.
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?
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 a. Avoid touching the suture line, even when cleaning – that makes the statement mali - The suture line
should be cleaned gently to prevent infection, which could interfere with healing and damage the
cosmetic appearance of the repair.
b. Place the baby in prone position. - A baby in a prone position may rub her face on the sheets and
traumatize the operative site.
c. Give the baby a pacifier. This can damage the operative sites therefore do not give
d. Place the infant's arms in soft elbow restraints – therefore the answer is letter D because 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
Answer: (D) Place the infant's arms in soft elbow restraints.
Rationale: 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.
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 – samot mf exert effort ang bata – therefore need increase demand of
oxygen – makapoi si heart
b. Allow the infant to rest before feeding.
c. Bathe the infant and administer medications before feeding – paligoan jd?
d. Weigh and bathe the infant before feeding – paligoan jd?
Answer. (B) Allow the infant to rest before feeding.
Rationale: Because feeding requires so much energy, an infant with heart failure should rest 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.
Answer: (C) Iron-rich formula only.
Rationale: 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.

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 - At age 4 to 6 months, infants can't sit securely alone
b. 4 months - At age 4 to 6 months, infants can't sit securely alone
c. 8 months - infants can sit securely alone but cannot understand the permanence of objects
d. 10 months - A 10 month old infant can sit alone and understands object permanence, so he would
look for the hidden toy.
Answer: (D) 10 months
Rationale: 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
16. 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)? DIC is characterised by widespread
blood clotting (coagulation) in the blood vessels. There is a depletion of platelets and coagulation
factors kanus a ni mahiabo? during ongoing activation of blood clotting (deposition of fibrin) therefore
the patient may develop to organ dysfunction and bleeding
a. Intrauterine fetal death.
b. Placenta accreta. - Placenta accreta is a serious pregnancy condition that occurs when the
placenta grows too deeply into the uterine wall. Typically, the placenta detaches from the

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 uterine wall after childbirth. With placenta accreta, part or all of the placenta remains attached. This
can cause severe blood loss after delivery. Because poor uterine contractions
c. Dysfunctional labor.
d. Premature rupture of the membranes.
Answer: (A) Intrauterine fetal death.
Rationale: 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
17. A fullterm 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
Answer: (C) 120 to 160 beats/minute
Rationale: A rate of 120 to 160 beats/minute in the fetal heart appropriate for filling the heart and pumping it
out to the system.
18. 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 - The American Academy of Pediatrics (AAP) advises
parents not to use cornstarch or talc-based baby powders when changing a diaper. Keeping
the area clean and moisturized with simple, natural products is best.
c. Wash the area vigorously with each diaper change. – dapat ba? dili
d. Decrease the infant's fluid intake to decrease saturating diapers. Dapat ba? dili
Answer: (A) Change the diaper more often.
Rationale: Decreasing the amount of time the skin comes contact with wet soiled diapers will help heal the
irritation.
19. 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
Answer: (D) Endocardial cushion defect
Rationale: Endocardial cushion defects are seen in children syndrome, asplenia, orpolysplenia.
20. Malou was diagnosed with severe preeclampsia is now receiving IV. magnesium sulfate. The adverse
effects associated with magnesium sulfate is
a. Anemia
b. Decreased urine output
c. Hyperreflexia
d. Increased respiratory rate
Answer: (B) Decreased urine output
Rationale: 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.

21. A 23 year-old client is having her menstrual period every 2 weeks that last for week. This of menstrual
pattern is best defined by:
a. Menorrhagia
b. Metrorrhagia- abnormal bleeding between regular menstrual periods
c. Dyspareunia - medical term for painful intercourse---- persistent or recurrent genital pain that occurs
just before, during or after sex
d. Amenorrhea - the absence of menstruation
Answer: (A) Menorrhagia
Rationale: Menorrhagia is an excessive menstrual period.
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 22. 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
Answer: (C) Blood typing
Rationale: 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.
23. 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
Answer: (D) Physiologic anemia
Rationale: Hemoglobin values and hematocrit decrease during pregnancy as the increase in plasma volume
exceeds the increase in red blood cell production
24. 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: who is your highest
priority..imohang unahon
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.- Croup is a childhood condition
that affects the windpipe (trachea), the airways to the lungs (the bronchi) and the voice box
(larynx). Children with croup have a distinctive barking cough and will make a harsh sound, known
as stridor, when they breathe in.
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.
Answer: (D) A 2 year old infant with stridorous breath sounds, sitting up in his mother's arms and drooling
Rationale: The infant with the airway emergency should be treated first, because of the risk of epiglottitis.
ABC – airway, breathing and circulation
25. 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
Answer: (A) Placenta previa
Rationale: Placenta previa with painless vaginal bleeding.
26. 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
Answer: (D) Early in the morning
Rationale 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.

27. 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
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 c. Bradycardia and hypotension
d. Petechiae and hematuria
Answer: (A) Irritability and seizures
Rationale. 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.
28. 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?meaning wala kasabot ang pasyente – therefore kailangan nimo siya explainan fyrther
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 atleast 6 hours after intercourse"
d. "I really need to use the diaphragm and jelly most during the middle of my menstrual cycle"
Answer: (D)"I really need to use the diaphragm and jelly most during the middle of my menstrual cycle"
Rationale: 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-lahi lahi ang cycle sa babae. To be effective, the
diaphragm should be inserted before every intercourse.
29. Hypoxia is a common complication of laryngotracheobronchitis (CROUP), Nurse Oliver should
frequently assess a child with laryngotracheobronchitis for: refers to inflammation of the larynx,
trachea, and bronchi.
a. Drooling - drop saliva uncontrollably from the mouth.
b. Muffled voice - Muffled voice is a sign of a narrowed upper airway
c. Restlessness
d. Low-grade fever
Answer: (C) Restlessness
Rationale: 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.
30. 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. Guide ka sa patient
c. Walk slightly behind, gently guiding the child forward.
d. Walk next to the child, holding the child's hand.
Answer, (B) Walk one step ahead, with the child's hand on the marse's elbow.
Rationale. This procedure is generally recommended to follow in guiding a person who is blind
31. When assessing a newborn diagnosed with patent ductus arteriosus, Nurse Olivia should expect that the
child most likely would have an: - The ductus arteriosus is a normal blood vessel that connects two
major arteries — the aorta and the pulmonary artery — that carry blood away from the heart. The
lungs are not used while a fetus is in the womb because the baby gets oxygen directly from the
mother's placenta.
Patent ductus arteriosus (PDA) is an extra blood vessel found in babies before birth and just after
birth. In most babies who have an otherwise normal heart, the PDA will shrink and close on its own in
the first few days of life. If it stays open longer, it may cause extra blood to flow to the lungs.
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.
Answer: (A) Loud, machinery-like murmur
Rationale: A loud, machinery-like murmur is a characteristic finding associated with patent ductus arteriosus
32. The reason nurse May keep 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
Answer: (C) More oxygen, and the newborn's metabolic rate increases.

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Rationale: 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.

33. 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. Patant fontanelles
c. Moro’s reflex
d. Voided
Answer: (D) Voided
Rationale: Before administering potassium 1.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.
34. 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 every day.
Answer: (B) Ask where the family resides.
Rationale: Because malaria is endemic, the first question to determine malaria risk is where the client's family
resides. If the area of residence is not a known endemic area, ask if the child had traveled within the past 6
months, where she was brought and whether she stayed overnight in that area.
35. 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 – diarrhea -
d. Cough for more than 30 days
Answer: (A) Inability to drink
Rationale: A sick child aged 2 months to 5 years must be referred urgently to a hospital if he/she has one or
more of the following signs: not able to feed or drink, vomits everything, convulsions, abnormally sleepy or
difficult to awaken.
36. 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.
Answer: (A) Refer the child urgently to a hospital for confinement.
Rationale: "Baggy pants" is a sign of severe marasmus. The best management is urgent referral to a hospital.
37. Gina is using Oresol in the management of diarrhea of her 3-year old child. She to do if her child vomits.
As a nurse you will tell her to: on going treatment of ORESOL ang bata, unsa buhaton sa mama kung
iyng anak mg vomits during pagpainom sa ORESOL – unsa ang iingon sa NURSE?
a. Bring the child to the nearest hospital for further assessment. - If the child vomits persistently, that
is, he vomits everything that he takes in, he has to be referred urgently to a hospital kasi considered
siya DANGER SIGN
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.
Answer: (D) Let the child rest for 10 minutes then continue giving Oresol more slowly.
Rationale: If the child vomits persistently, that is, he vomits everything that he takes in, he has to be referred
urgently to a hospital kasi considered siya DANGER SIGN. Otherwise based on the scenario ng vomit lng siya
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during pag painom tambal, vomiting is managed by letting the child rest for 10 minutes and then continuing
with Oresol administration. Teach the mother to give Oresol more slowly…… IF VOMIT: STOP oreesol
temporary, REST, GIVE oresol slowly
38. 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 (green) – no enough sign
b. Some dehydration (yellow) - Skin turgor goes back slowly, RIDS – restlessness, irritable, drink
eagerly / thirsty, sunken eye = 2 or more ani – iclassify imong bata as yellow
c. Severe dehydration (pink) – skin turgor goes back very slowly, ASIS – abnormally sleepy / lethargy,
stuporous, inability to drink, sunken eyes
d. The data is insufficient.
Pero what if naay sign from pink isa then iyng sign 1 sa yellow – how will you classify? YELLOW
Answer: (B) Some dehydration
Rationale: Using the assessment guidelines of IMCI, a child (2 months to 5 years old) with diarrhea is classified
as having SOME DEHYDRATION if he shows 2 or more of the following signs: restless or imitable, sunken
eyes, the skin goes back slow after a skin pinch.
39. 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
Answer: (C) Normal
Rationale in IMCI, a respiratory rate of 50/minute or more is fast breathing for an infant aged 2 to 12
Infant (0-12 months old): 30 to 60 breaths per minute. Toddler (1-3 years old): 24-40 breaths per minute.
Preschooler (4-5 years old): 22-34 breaths per minute. School-aged child (6-12 years old): 18-30 breaths per
minute.
40. Maylene had just received her 4th dose of tetanus toxoid. She is aware that her baby will have protection
against tetanus for
a. I year
b. 3 years
c. 5 years
d. Lifetime
Answer (A) 1 year
Rationale: The baby will have passive natural immunity by placental transfer of antibodies. The mother will
have active artificial immunity lasting for about 10 years 5 doses will give the mother lifetime protection.
PROTECTION
1st dose – NONE
2nd dose – 1 to 3years
3rd dose – atleast 5 years
4th dose – atleast 10 years
5th dose – lifetime – for all childbearing years and possibly longer
Interval
1st dose – during pregnancy
2nd dose – atleast 4weeks after 1st dose
3rd dose – 6months 2nd dose
4th dose – 1 year after dose 3rd
5th dose – 1 year after dose 4th

41. 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
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 d. At the end of the day
Answer: (B) 4 hours
Rationale: While the unused portion of other biologicals in EPI may be given until the end of the day, only
BCG is discarded 4 hours after reconstitution. This is why BCG immunization is scheduled only in the morning.
42. 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
Answer: (B) 6 months
Rationale: After 6 months, the baby's nutrient needs, especially the baby's iron requirement, can no longer be
provided by mother's milk alone.
43. 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? After
amniotomy ngano kailangan nato I check ang fetal heart tone? This is assuring that the cord isn't
prolapsed and that the baby tolerated the procedure well
a. To determine fetal well-being. - assessed via a non-stress test
b. To assess for prolapsed cord -  when the cord falls (prolapses) into the vagina ahead of the baby.
Compression of the cord results in vasoconstriction and resultant fetal hypoxia, which can lead to
fetal death or disability if not rapidly diagnosed and managed.
c. To assess fetal position - determined by vaginal examination
d. To prepare for an imminent delivery. - Artificial rupture of membranes doesn't indicate an imminent
delivery.
Answer: (B) To assess for prolapsed cord
Rationale: Rationale: After a client has an amniotomy, the nurse should assure that the cord isn't prolapsed and
that the baby tolerated the procedure well. The most effective way to do this is to check the fetal heart rate.

44. Which of the following would be least likely to indicate anticipated bonding behaviors by new parents?
means hinahanap natin dito yong least likely (dili) nag iindicate ng parental bonding
a. The parents' willingness to touch and hold the new born. – ng iindicate ba ng behavior indicating
parental bonding? yes
b. The parent's expression of interest about the size of the new born. - ng iindicate ba ng behavior
indicating parental bonding? yes
c. The parents' indication that they want to see the newborn. ng iindicate ba ng behavior indicating
parental bonding? yes
d.The parents' interactions with each other. - : Parental interaction will provide the nurse with a good
assessment of the stability of the family's home life but it has no indication for parental bonding.
Answer (D) The parents' interactions with each other.
Rationale: Parental interaction will provide the nurse with a good assessment of the stability of the family's
home life but it has no indication for parental bonding. Willingness to touch and hold the newborn, expressing
interest about the newborn's size, and indicating a desire to see the newborn are behaviors indicating parental
bonding.
45. 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? Precipitous
delivery -expulsion of the fetus within less than 3 h of commencement of regular contractions 
a. Applying cold to limit edema during the first 12 to 24 hours. – this is important measures when the
client has a fourth-degree laceration
b. Instructing the client to use two or more peripads to cushion the area.
c. Instructing the client on the use of sitz baths if ordered. - this is important measures when the client
has a fourth-degree laceration
d. Instructing the client about the importance of perineal (kegel) exercises. - this is important measures
when the client has a fourth-degree laceration
Answer: (B) Instructing the client to use two or more peripads to cushion the area

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Rationale: Using two or more peripads would do little to reduce the pain or promote perineal healing. Cold
applications, sitz baths, and Kegel exercises are important measures when the client has a fourth-degree
laceration
46. 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?"
Answer: (C) "What is your expected due date?"
Rationale: When obtaining the history of a client who may be in labor, the nurse's highest priority is to
determine her current status, particularly her due date, gravidity, and parity. Gravidity and parity affect the
duration of labor and the potential for labor complications. Later, the nurse should ask about chronic illnesses,
allergies, and support persons.
47. A neonate begins to gag and turns a dusky color. What should the nurse do first?
a. Calm the neonate. – how? Baby be calm
b. Notify the physician. – before referral – do initial action – therefore ang gipangutana unsa imong
unang buhaton?
c. Provide oxygen via face mask as ordered. Kuhaa sa ang secretions before giving oxygen – to have
optimal level of oxygen deliver to the newborn
d. Aspirate the neonate's nose and mouth with a bulb syringe.
Answer: (D) Aspirate the neonate's nose and mouth with a bulb syringe.
Rationale: The nurse's first action should be to clear the neonate's airway with a bulb syringe. After the airway
is clear and the neonate's color improves, the nurse should comfort and calm the neonate. If the problem recurs
or the neonate's color doesn't improve readily, the nurse should notify the physician. Administering oxygen
when the airway isn't clear would be ineffective.
48. 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. - appropriate assessments for determining whether
a client has ruptured membranes.
b. Checking vaginal discharge with nitrazine paper. - appropriate assessments for determining
whether a client has ruptured membranes.
c. Conducting a bedside ultrasound for an amniotic fluid index. – dili na trabaho sa nurse
d. Observing for flakes of vernix in the vaginal discharge. - appropriate assessments for
determining whether a client has ruptured membranes.
Answer: (C) Conducting a bedside ultrasound for an amniotic fluid index.
Rationale: It isn't within a nurse's scope of practice to perform and interpret a bedside ultrasound under these
conditions and without specialized training. Observing for pooling of straw-colored fluid, checking vaginal
discharge with nitrazine paper, and observing for flakes of vernix are appropriate assessments for determining
whether a client has ruptured membranes.
49. A baby girl is born 8 weeks premature (7months). 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? We are not asking initial intervention / highest priority / first action..ang ginapangita asa
diri ang nursing action that be included 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.
Answer: (C) Monitor partial pressure of oxygen (Pao2) levels.
Rationale: Monitoring PaO, levels and reducing the oxygen concentration to keep Pao, within normal limits
reduces the risk of retinopathy of prematurity in a premature infant receiving oxygen, Covering the infant's eyes

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humidifying the oxygen don't reduce the risk of retinopathy of prematurity. Because cooling increases the risk
of acidosis, the infant should be kept warm so that his respiratory distress isn't aggravated
50. 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
Answer: (A) 110 to 130 calories per kg.
Rationale: Calories per kg is the accepted way of determined appropriate nutritional intake for a newborn. The
recommended calorie requirement is 110 to 130 calories per kg of newborn body weight. This level will
maintain a consistent blood glucose level and provide enough calories for continued growth and development.
51. 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 - no
b. 18 to 22 weeks - no
c. 30 to 32 weeks –yes because individual twins usually grow at the same rate as singletons until 30 to
32 weeks' gestation, then don't can no longer keep pace with the nutritional requirements of both
fetuses after 32 weeks
d. 38 to 40 weeks - there's some growth retardation in twins if they remain in utero at 38 to 40 weeks.
Answer: (C) 30 to 32 weeks
Rationale: individual twins usually grow at the same rate as singletons until 30 to 32 weeks' gestation, then don't
can no longer keep pace with the nutritional requirements of both fetuses after 32 weeks, so there's some growth
retardation in twins if they remain in utero at 38 to 40 weeks.
52. 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
Answer: (A) conjoined twins
Rationale: The type of placenta that develops in monozygotic twins depends on the time at which cleavage of
the ovum occurs. Cleavage in conjoined twins occurs more than 13 days after fertilization. Cleavage that occurs
less than 3 day after fertilization results in diamniotic dicchorionic twins Cleavage that occurs between days 3
and 8 results in diamniotic monochorionic twins. Cleavage that occurs between days 8 to 13 result in
monoamniotic monochorionic twins
53. 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? Diagnostic test/ procedure
a. Amniocentesis - Amniocentesis is contraindicated in placenta previa
b. Digital or speculum examination - A digital or speculum examination shouldn't be done as this may
lead to severe bleeding or hemorrhage
c. External fetal monitoring - External fetal monitoring won't detect a placenta previa, although it will
detect fetal distress, which may result from blood loss or placenta separation.
d. Ultrasound
Answer: (D) Ultrasound
Rationale: Once the mother and the fetus are stabilized, ultrasound evaluation of the placenta should be done to
determine the cause of the bleeding. Amniocentesis is contraindicated in placenta previa. A digital or speculum
examination shouldn't be done as this may lead to severe bleeding or hemorrhage External fetal monitoring
won't detect a placenta previa, although it will detect fetal distress, which may result from blood loss or placenta
separation.
54. Nurse Amold knows that the following changes in respiratory functioning during pregnancy considered
normal:
a. Increased tidal volume - A pregnant client breathes deeper, which increases the tidal volume of gas
moved in and out of the respiratory tract with each breath.
b. Increased expiratory volume - The expiratory volume and residual volume decrease as the pregnancy
progresses
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 c. Decreased inspiratory capacity - The inspiratory capacity increases during pregnancy.
d. Decreased oxygen consumption - The increased oxygen consumption in the pregnant client is 15%
to 20% greater than in the non-pregnant state

Answer: (A) Increased tidal volume

Rationale: A pregnant client breathes deeper, which increases the tidal volume of gas moved in and out of the
respiratory tract with each breath. The expiratory volume and residual volume decrease as the pregnancy
progresses. The inspiratory capacity increases during pregnancy. The increased oxygen consumption in the
pregnant client is 15% to 20% greater than in the non-pregnant state
55. 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
Answer: (A) Diet
Rationale: Clients with gestational diabetes are usually managed by diet alone to control their glucose tolerance
Oral hypoglycemic drugs are contraindicated in pregnancy. Long-acting insulin usually isn't seeded for blood
glucose control in the client with gestational diabetes.
56. Magnesium sulfate is given to Jemma with preeclampsia to prevent which of the following condition?
a. Hemorrhage - Magnesium doesn't help prevent hemorrhage in preeclamptic clients.
b. Hypertension - Antitrypertensive drug other than magnesium is preferred for sustained hypertension
c. Hypomagnesemia - Hypomagnesemia isn't a complication of preeclampsia
d. Seizure - The anticonvulsant mechanism of magnesium is believe to depress seizure foci in the brain
and peripheral neuromuscular blockade
Answer: (D) Seizure
Rationale: The anticonvulsant mechanism of magnesium is believe to depress seizure foci in the brain and
peripheral neuromuscular blockade. Hypomagnesemia isn't a complication of preeclampsia. Antitrypertensive
drug other than magnesium is preferred for sustained hypertension. Magnesium doesn't help prevent
hemorrhage in preeclamptic clients.
57. 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. 1.V. fluids
d. Acetaminophen (Tylenol) for pain
Answer: (C) IV, fluids
Rationale: A sickle cell crisis during pregnancy is usually managed by exchange transfusion oxygen, and IV
Fluids. The client usually needs a stronger analgesic than acetaminophen to control the pain of a crisis.
Antihypertensive drugs usually aren't necessary. Diuretic wouldn't be used unless fluid overload resulted
58. 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)
Answer: (A) Calcium gluconate (Kalcinate)
Rationale: Calcium gluconate is the antidote for magnesium toxicity. Ten milliliters of 10% calcium ghaconate
is given L.V. push over 3 to 5 minutes Hydralazine is given for sustained elevated blood pressure in
preeclamptic clients. Rho (D) immune globulin is given to women with Rh-negative blood to prevent antibody
formation from RH-positive conceptions. Naloxone is used to correct narcotic toxicity.
59. 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.
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 d. A flat circumcised area over 10 mm in diameter appears in 48 to 72 hours.
Answer: (B) An indurated wheal over 10 mm in diameter appears in 48 to 72 hours.
Rationale: A positive PPD result would be an indurated wheal over 10 mm in diameter that appears in 48 to 72
hours. The area must be a raised wheal, not a flat circumcised area to be considered positive.
60. 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)
Answer: (C) Pyelonephritis
Rationale: The symptoms indicate acute pyelonephritis, a serious condition in a pregnant client. UTI symptoms
include dysuria, urgency, frequency, and suprapubic tenderness. Asymptomatic bacteriuria doesn't cause
symptoms. Bacterial vaginosis causes milky white vaginal discharge but no systemic symptoms
61. 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.
Answer: (B) Rh positive fetal blood crosses into maternal blood, stimulating maternal antibodies.
Rationale: Rh isoimmunization occurs when Rh-positive fetal blood cells cross into the maternal circulation and
stimulate maternal antibody production. In subsequent pregnancies with Rh-positive fetuses, maternal
antibodies may cross back into the fetal circulation and destroy the fetal blood cells.
62. 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
Answer: (C) Supine position
Rationale: The supine position causes compression of the client's aorta and inferior vena cava by the fetus. This,
in turn, inhibits maternal circulation, leading to maternal hypotension and, ultimately, fetal hypoxia. The other
positions promote comfort and aid labor progress. For instance, the lateral, or side-lying, position improves
maternal and fetal circulation, enhances comfort, increases maternal relaxation, reduces muscle tension, and
eliminates pressure points. The squatting position promotes comfort by taking advantage of gravity. The
standing position also takes advantage of gravity and aligns the fetus with the pelvic angle.
63. Celeste who used heroin during her pregnancy delivers a neonate. When assessing the neonate, the nurse
Lhynnette 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.
Answer: (B) Irritability and poor sucking
Rationale: Neonates of heroin-addicted mothers are physically dependent on the drug and experience
withdrawal when the drug is no longer supplied. Signs of heroin withdrawal include irritability, poor sucking,
and restlessness. Lethargy isn't associated with neonatal heroin addiction. A flattened nose, small eyes, and thin
lips are seen in infants with fetal alcobol syndrome. Heroin use during pregnancy hasn't been linked to specific
congenital anomalies.
64. The uterus returns to the pelvic cavity in which of the following time frames?
a. 7 to 9 day postpartum
b. 2 weeks postpartum
c. End of 6 week postpartum.
d. When the lochia changes to alba.

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Answer: (A) 7 to 9 day postpartum
Rationale: The normal involutional process returns the uterus to the pelvic cavity in 7 to 9 days. A significant
involutional complication is the failure of the uterus to return to the pelvic cavity within the prescribed time
period. This is known as subinvolution.
65. 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
Answer: (B) Uterine atony
Rationale: Multiple fetuses, extended labor stimulation with oxytocin, and traumatic delivery commonly are
associated with uterine atony, which lead to postpartum hemorrhage. Uterine inversion may precede or follow
delivery and commonly results from apparent excessive traction on the umbilical cord and attempts to deliver
the placental manually. Uterine involution and some uterine discomfort are normal after delivery
66. In Integrated Management if 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? #54
a. Mastoiditis
b. Severe dehydration
c. Severe pneumonia
d. Severe febrile disease
Answer: (B) Severe dehydration
Rationale: The order of priority in the management of severe dehydration is as follows: intravenous fluid
therapy, referral to a facility where IV fluids can be initiated within 30 minutes, Oresol or nasogastric tube.
When the foregoing measures are not possible or effective, then urgent referral to the hospital is done.
67. Myrna a public health nurse will conduct outreach immunization in a barangay Zone III with a
population of about 1500. The estimated number of infants in the barangay would be: #55
a. 45 infants
b. 50 infants
c. 55 infants
d. 65 infants
Answer: (A) 45 infants
Rationale: To estimate the number of infants, multiply total population by 3%
68. The community nurse is aware that the biological used in Expanded Program Immunization (EPI)
should NOT be stored in the freezer? #56
a. DPT
b. Oral polio vaccine
c. Measles vaccine
d. MMR - measles, mumps, and rubella combination vaccine
Answer: (A) DPT
Rationale: DPT is sensitive to freezing. The appropriate storage temperature of DPT is 2 to 8°C only. OPV and
measles vaccine are highly sensitive to heat and require freezing MMR is not an immunization in the Expanded
Program on Immunization.

69. James is a 13week old child, was brought by his mother to the health center for a check-up. Which of the
following vaccinations would you expect to be administered to him prior to his visit today?
a. BCG, OPV2, DPT2, HEPA B2
b. BCG, OPV1, DPT1, HEPA B1
c. BCG, OPV1, DPT2, HEPA B2
d. BCG, OPV2, DPT1, HEPA B2
70. A clinical instructor is supervising her student giving immunization. During OPV administration the
student nurse opens the child’s mouth by squeezing the cheeks gently between her finger and put drops

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 of vaccine from the dropper to the child’s tongue(mali); however, the child spits it out. The instructor
reminds her student to;
a. Advise the mother to maintain child’s upright position while breast feeding
b. Wipe child’s mouth and position baby to supine
c. Repeat OPV dose and breastfeed immediately
d. Put two drops of vaccine straight from the dropper on child’s mouth but precaution not to
allow the dropper touch child’s tongue – spit = give another dose---- vomited – give another
dose within 30 mins
71. The Integrated Management of Childhood Illness (IMCI) chart provides the necessary procedure when
identifying the appropriate interventions to be done. However, the community health nurse should be
aware that the following factor should be considered in utilizing the case management chart: elements
assess and classify..
assess – checking for danger signs, asking condition about common conditions, examining the child, and
checking nutrition and immunization status..assessment includes checking the child for other health
problems
classify- a child’s illnesses using a clour-coded triage system.
Treat the child
Counsel mothe
RED/PINK – urgent pre-referral and referral
YELLOW – specific medical treatment and advice
GREEN – simple advice on home management
a. Chief complaint
b. Age of the child – sick child – 2mos up to 5years old…sick young infant age 1week to 2 mos
c. Dangers signs – assess and classify
d. Problem of the child
72. In the IMCI classification tables, color yellow indicates that a:
a. Child needs an appropriate antibiotic or other treatment
b. Child does not need specific medical treatment - green
c. Referral or admission is needed – red/pink
d. Chief complaint that needs an urgent attention
73. James is an 18month old child who has cough for 7 days with no general danger signs with temperature
37.5C and respiratory rate of 41 breaths/minute. How will you classify James breathing?
a. Slow breathing
b. Fast breathing ----12months to 5 years old --- 40breaths per minute or more
2months up to 12 months – 50breaths per minute or more
c. Normal breathing
d. Very fast breathing
What are the danger signs?
Unable to drink or breast feed
Vomiting everything
Seizure / convulsion
Lethargic
Stuporous REMEMBER : patient with danger signs kailangan I refer but before I refer initial
treatment should be given
74. James illness can be classified as:
a. Pneumonia – fast breathing
b. Very service disease
c. Severe pneumonia – any general danger signs or chest indrawing or stridor in calm child
d. No pneumonia: cough or cold
75. After 3 days, the nurse notes that James has chest in drawing and stridor. His mother returned him to the
health center immediately. The nurse should:
a. Change the medicine to the second line antibiotics
b. Advice mother to observe the child and continue giving the antibiotics
c. Give first dose of antibiotics and refer urgently
d. Observe the child in the center.
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76. The nurse should consider the following assessing the child for chest in drawing EXCEPT:
a. Chest in drawing should be present at all times
b. The lower chest wall does not go in when the breaths in
c. The lower chest goes in when the child breaths in
d. The child should be calm
77. Joel a 3 years old, has diarrhea for 5days and is irritable. He has sunken eyeballs(pink) but has no blood
in his stools (dysentery). He drinks eagerly (yellow) when offered liquid. Skin pinch at the abdomen
shows slow return (yellow). Using Integrated Management of Chidlhood Illness (IMCI), Joel’s illness
maybe classified as:
a. No dehydration
b. Some dehydration
c. Severe dehydration
d. Persistent Diarrhea- more than 14 days without sign of dehydration
78. Which of the following treatments should be immediately considered in Joel’s case?
a. Reassess the child after 4 hours and classify his dehydration
b. Give 900-1,400 ORS during the first four hours
c. Explain to the mother how to prepared ORS
d. Continue feeding
79. Fely is a 1 year-old has had diarrhea for 2 days. She has sunken eyes, skin pinch goes back very slowly
and she is drinking poorly and is irritable. There is no blood in the stool. How will you classify Fely’s
illness?
a. Severe dehydration
b. No dehydration
c. Persistent diarrhea – 14 days
d. Some dehydration
80. A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a
papular lesion on the perineum. Which initial action is most appropriate? Herpes zoster type II – macule
and papule the vesicles and form pustules and crusts (scab)
a. Document the finding
b. Report the finding to the doctor
c. Prepare the client for a Cesarean Section
d. Continue primary care as prescribed
81. A client with a diagnosis of Human Papilllomavirus is at risk for which of the following?
a. Hodgkin’s lymphoma
b. Cervical cancer
c. Multiple myeloma
d. Ovarian Cancer
82. The doctor suspects that the client has an ectopic pregnancy. Which symptom is consistent with a
diagnosis of ectopic pregnancy
a. Painless vaginal Bleeding
b. Abdominal cramping
c. Throbbing pain in the upper quadrant
d. Sudden, stabbing pain in the lower quadrant
83. Which of the following would be the priority nursing diagnosis for a client with an ectopic pregnancy?
a. Risk for infection
b. Pain
c. Knowledge Deficit
d. Anticipatory Grieving
84. The nurse is discussing breastfeeding with a postpartum client. Breastfeeding is contraindicated in the
postpartum client with:
a. Positive HIV
b. Diabetes
c. Hypertension
d. Thyroid Disease

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85. For the client who is using oral contraceptives, the nurse informs the client about the need to take the pill
at the same time each day to accomplish which of the following?
a. Decrease the incidence of nausea
b. Reduce side effects
c. Prevent drug interactions
d. Maintain hormonal levels
86. When taking an Obstetrical history on a pregnant client who states, “I had a son born at 38 weeks
gestation, a daughter born at 30 weeks gestation and I lost a baby at about 8 weeks, “the nurse should
record her obstetrical history as which of the following?
a. G2 T2 P0 A0 L2
b. G4 T1 P1 A0 L2
c. G3 T2 P0 A0 L2
d. G4 T1 P1 A1 L2 – gravida – term (37-42) – premature before 37 or 28weeks to 37– abortion -
live
87. A client in her third trimester tells the nurse, “I’m constipated all the time!” Which of the following
should the nurse recommend?
a. Daily enemas
b. Laxatives
c. Increased fiber intakes
d. Decreased fluid intake
88. When developing a plan of care for a client newly diagnosed with gestational diabetes, which of the
following instructions would be the priority?
a. Dietary intake
b. Medication
c. Exercise
d. Glucose monitoring
89. The client tells the nurse that her last menstrual period started on January 14 and ended on January 20.
Using Nagele’s rule, the nurse determines her EDD to be which of the following?
a. September 27
b. October 21
c. November 27
d. December 27
90. A client 12 weeks pregnant come to the emergency department with abdominal cramping and moderate
vaginal bleeding. Speculum examination reveals 2 to 3cm cervical dilatation. The nurse would
document these findings as which of the following?
a. Threatened abortion
b. Imminent abortion
c. Complete abortion
d. Missed abortion
91. Before assessing the postpartum client’s uterus for firmness and position in relation to the umbilicus and
midline, which of the following should the nurse do first?
a. Assess the vital signs
b. Administer analgesic
c. Ambulate her in the hall
d. Assist her to urinate
92. Which of the following should the nurse do when primipara who is lactating tells the nurse that she has
sore nipples? Gutok/breast engorgement
a. Tell her to breast feed more frequently
b. Administer a narcotic before breast feeding
c. Encourage her to wear a nursing brassiere
d. Use soap and water to clean the nipples
93. The nurse assesses the postpartum vaginal discharge (lochia) on four clients. Which of the following
assessments would warrant notification of the physician?
a. A dark red discharge on a 2 day postpartum client - normal
b. A pink to brownish discharge on a client who is 5days postpartum - normal
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 c. Almost colorless to whitish yellow discharge on a client 2 weeks after delivery - normal
d. A bright red discharge 5days after delivery
RUBRA ---- DARk red – 3 to 4days
SEROSA ----- pinkish brown – 4 to 10days
ALBA --- whitish yellow --- 10-28days
94. Which of the following actions would be least effective in maintaining a neutral thermal environment
for the newborn?
a. Placing infant under radiant warmer after bathing.
b. Covering the scale with a warmed blanket prior to weighing.
c. Placing crib close to nursery window for family viewing.
d. Covering the infant’s head with a knit stockinette.
95. A client is having hyperemesis gravidarum. All of the following are recommended nursing management
to a pregnant woman, except:
a. Small frequent feedings
b. Carbonated beverages after eating – acid formation = mao na magsakit kuto2 makasuka siya
c. Low sodium crackers before arising in the morning
d. Increase protein intake at night
96. After 4 hours of active labor, the nurse notes that the contractions of a primigravid client are not strong
enough to dilate the cervix. Which of the following would the nurse anticipate?
a. Obtaining an order to begin IV oxytocin
b. Administering a light sedative to allow the patient to rest for several hours
c. Preparing for cesarean section for failure to progress
d. Increasing the encouragement to the patient when pushing begins.
97. Mils is admitted in active labor has only progressed from 2 to 3 cm in 8 hours. She is diagnosed as
having hypotonic dystocia and is given oxytocin (Pitocin) to augment her contractions. The most
important aspects of nursing at this time is:
a. Monitoring the FHR
b. Timing and recording the length of contractions
c. Checking the perineum for bulging
d. Preparing for an emergency cesarean delivery
98. In evaluating the effectiveness of IV Pitocin for a client with secondary dystocia-dili siya mobaba or
descent= arrest in descent = CS, the nurse should expect: "Dystocia" (difficult or obstructed
labor)2 encompasses a variety of concepts, ranging from "abnormally" slow dilation of the cervix or
descent of the fetus during active labor3 to entrapment of the fetal shoulders after delivery of the head
("shoulder dystocia," an obstetric emergency).
a. A painless delivery
b. Cervical Effacement
c. Infrequent contractions
d. Progressive cervical dilation
99. Aling Anabelle is experiencing stomach and right shoulder pain. She is diagnosed with severe
preeclampsia. She was ordered with Magnesium Sulfate. Which of the following would you note as the
first sign of an excessive blood magnesium level:
a. Disturbance in sensorium
b. Development of cardiac dysrhythmia
c. Increase in respiratory rate
d. Disappearance of the knee-jerk reflex – hypermagnesemia
100. The client is having fetal heart rates of 90-110bpm during the contractions. The first action the
nurse should take is:
a. Reposition the monitor
b. Turn the client to her left side
c. Ask the client to ambulate
d. Prepare the client for delivery

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Since the 1950's it has been standard of care to place laboring pregnant women in the left lateral tilt
position to displace the uterus from the inferior vena cava and thus improve maternal
hemodynamics and gas exchange.

~~END OF EXAMINATION~~

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