Republic of the Philippines

PROFESSIONAL REGULATION COMMISSION

Manila
BOARD OF NURSING
Nurse Licensure Examination
NURSING PRACTICE II – CARE OF HEALTHY/AT RISK MOTHER AND CHILD
INSTRUCTION: Select the correct answer for each of the following
questions. Mark only one answer for each item by shading the box
corresponding to the letter of your choice on the answer sheet
provided.
STRICTLY NO ERASURES ALLOWED.

Situation: The birth process affects the holistic aspects of the mother,
to include physiologic changes to both the mother and the fetus. Nursing
students are now assigned at the OB Admitting Section of the National
Hospital.
1. A nurse is performing an assessment of a pregnant woman who is at 28
weeks of gestation. The nurse measures the fundal height in centimeters
and expects the finding to be which of the following? The student nurse
correctly identifies:
a. 22 cm
b. 30 cm
c. 36 cm
d. 40 cm

2. A nursing student is preparing a class on the process of fetal

circulation. The instructor asks the student specifically to describe
the process through the umbilical cord. Which of the following statements
from the student is correct?
a. “The one artery caries freshly oxygenated blood and nutrient-rich
blood back from the placental to the fetus”
b. “The two arteries carry freshly oxygenated blood and nutrient-rich
blood back from the placental to the fetus.”
c. “The two arteries in the umbilical cord carry blood that is high in
carbon dioxide and other waste products away from the fetus to the
placenta.”
3. Which of the following are not presumptive sign/ symptom of pregnancy?
a. Amenorrhea
b. Urinary changes
c. Softening of the uterus
d. Nausea/ vomiting

4. Of the following probable signs of pregnancy, which describes the

bluish discoloration of the vagina?
a. Chadwick’s sign
b. Hegar’s sign
c. Goodel’s sign
d. Ballotement

5. A nurse is reviewing the record of a client who has just been told
that a pregnancy test is positive. The physician has documented the
presence of Goodel’s sigm. The staff nurse asks the student nurse and
she states that this is:
a. A softening of the cervix
b. The presence of fetal movement
c. The presence of HCG in the urine
d. A soft blowing sound that corresponds to the maternal pulse during
auscultation of the uterus.

Situation: A G1P0 mother went to the health center for a check-up. You
are the nurse assigned.
6. The mother asks the nurse when she will be able to begin feeling the
fetal movements. You respond by telling the mother that fetal movements
will be noted between which of the following weeks of gestation?
a. 6 and 8
b. 8 and 10
c. 10 and 12
d. 16 and 20
7. The mother asks about gestational diabetes, as she has familial
history and was worried about her pregnancy. Which statement by the
client indicates a further need for education?
a. “I need to be in a diabetic diet”
b. “I will perform glucose monitoring at home”
c. “I need to avoid exercise because of the negative effects of insulin
production”
d. “I need to be aware of any infections and report signs of infection
immediately”

8. History revealed that there is a history of twins in the family and

the client was asking about the possibility of having twins as well. The
nurse replies:
a. Monozygotic twins result from fertilization of two ova by different
sperm.
b. Monozygotic twins occur by chance regardless of race or heredity.
c. Dizygotic twins are usually of the same sex.
d. Dizygotic twins occur more often in primigravidthan in multigravid
clients.

9. Sheila, the client’s mother, was worried that her daughter will have
an enormous amount of blood loss during delivery. As a nurse, the best
response would be:
a. The maximum blood loss considered within normal limits is 500 mL.”
b. “The minimum blood loss considered within normal limits is 1,000 mL.”
c. “Blood loss during a delivery is rarely estimated unless there is a
hemorrhage.”
d. “It would be very unusual if you lost more than 100 mL of blood during
the delivery.”

10. During the next visit, the client attended a childbirth preparation
class and tells the nurse that her lower back has been aching. Which of
the following exercises are appropriate for the client?
a. Pelvic rocking
b. Deep breathing
c. Tailor sitting
d. Squatting

11. Syphilis is a chronic disease cause by Treponema palladium. Which

of the following is not true about syphilis?
a. Transmission is by physical contact with syphilitic lesions, which
are usually found on the skin, mucous membranes of the mouth, or
genitals.
b. The infection may not cause abortion or premature labor.
c. It may be passed to the fetus on the fourth month of pregnancy as
congenital syphilis.
d. A serum test (Veneral Disease Research Laboratory or rapid plasma
reagin) for syphilis on the first prenatal visit, and repeated on the
36th week of gestation.

12. Gonorrhea is an infection cause by Neisseria gonorrhoeae that causes

inflammation of mucous membrances of the genital and urinary tracts.
Which of the following is true?
a. Transmission of the organism is by airborne.
b. Infection is not transmissible to a newborn.
c. It may cause Opthalmianeonatorum.
d. It is usually symptomatic, and vaginal discharge is common.

13. A clinic nurse is performing a psychosocial assessment of Alice.

Which assessment finding indicates to the nurse that the client is at
high risk for contracting human immunodeficiency virus?
a. A client who has a history of intravenous drug use.
b. A client who has a significant other who is heterosexual
c. A client who has a history of sexually transmitted diseases.
d. A client who has had 1 sexual partner for the past10 years.

14. When Alice was in her third trimester, she was admitted to the
hospital with a diagnosis of sever preeclampsia. A nurse monitors for
complications associated with the diagnosis and assesses the client for:
a. Enlargement of the breasts
b. Complaints of feeling hot when the room is cool.
c. Periods of fetal movement followed by quiet periods.
d. Evidence of bleeding, such as in the gums, bruises, petechiae, and
purpura.

15. Alice gave birth to a stillborn infant. After the delivery, the
family remained together, holding and touching the infant. Which
statement by the nurse would further assist the family in their assist
the family in their initial period of grief?
a. “Anong pwede kong gawin para saiyo?”
b. “Ngayon may anghel ka na sa langit”
c. “Huwag kang mag-alala, wala tayong hindi nagawa”
d. “Gagawa tayo ng paraan na mapauwi ka ng maaga para di mo na maalala
ang mga pinagdaanan mo dito”

16. Which of the following is a proper description for Placenta Accreta?

a. Premature separation of the placenta of the uterine wall after the
twentieth week of gestation and before the fetus is delivered
b. The placenta penetrates the uterine muscle itself
c. An abnormally adherent placenta
d. Placenta goes all the way through the uterus.

17. A nurse in the labor room is preparing to care for a client with
hypertonic uterine contractions. The nurse is told that the client is
experiencing uncoordinated contractions that are erratic in their
frequency, duration, and intensity. The priority nursing intervention
in caring for the client is to:
a. Provide pain relief measures
b. Prepare the client for an amniotomy
c. Promote ambulation every 30 minutes
d. Monitor the oxytocin infusion closely.

18. Jenny, a nurse, is performing an initial assessment on a client who

has just been told that a pregnancy test is positive. Which assessment
finding would indicate that the client is at risk for preterm labor?
a. The client is a 36- year old primigravida
b. The client has a history of cardiac disease
c. The client’s haemoglobin level is 13.5 g/dL
d. The client is a 20-year-old primigravida of average weight and height.

19. A nurse in a labor room is monitoring a client with dysfunctional

labor for signs of fetal or maternal compromise. Which of the following
assessment findings would alert the nurse to a compromise?
a. Maternal fatigue
b. Coordinated uterine contractions
c. Progressive changes in the cervix
d. Persistent non reassuring fetal heart rate

20. A client in labor is transported to the delivery room and prepared

for ta caesarean delivery. After the client is transferred to the
delivery room table, a nurse places her in:
a. Supine position with a wedge under the right hip
b. Trendelenburg’s position with the legs in stirrups.
c. Prone position with the legs separated and elevated
d. Semi-Fowler’s position with a pillow under the knees.

SITUATION: Grounded theory is a general inductive method that is not

inextricably linked to a particular theoretical perspective or type of
data. Grounded theory researchers seek to understand the actions in a
substantive area from the perspectives of those involved.
21. The nurse researcher comprehends that people who pioneered studies
in grounded theory includes the following apart from?
a. Glaser & Strauss
b. Strauss & Corbin
c. Corbin& Tanner
d. None of the above
22. Coding in Glaserian grounded theory approach is used to conceptualize
data into patterns. The nurse-researcher incorrectly identifies
conceptualization of the substance of the topic under study as:
a. Substantive codes
b. Open codes
c. Selective codes
d. Theoretical codes

23. In-vivo codes are directly derived from the language of the
substantive area. The nurse-researcher correctly identifies these codes
as:
a. Level I
b. Level II
c. Level III
d. Level IV

24. In grounded theory approach, data analysis employs:

a. Domain analysis
b. Constant comparative analysis
c. Componential analysis
d. Taxonomic analysis

25. The six (6) C’s in families of theoretical codes for grounded theory
analysis developed by Glaser (1978) excludes:
a. Contingencies
b. Covariances
c. Continuum
d. Consequences

26. The nurse is teaching a postpartum client about breast-feeding. Which

of the following instructions should the nurse include?
a. Prenatal vitamins should be discontinued.
b. The diet should include additional fruits.
c. Organic, hypoallergenic soap should be used to cleanse the breasts.
d. Galactagogues should be avoided.

27. A nurse is planning to care for a post-partum client who had a

vaginal delivery 2 hours ago. The client had a 4cm midline episiotomy
and has several haemorrhoids. What is the priority nursing diagnosis for
this client?
a. Acute pain
b. Disturbed body image
c. Impaired urinary elimination
d. Risk for imbalanced fluid volume.

28. A nurse is caring for four 1-day postpartum clients. Which client
has an abnormal finding that would require further intervention?
a. The client with mild afterpains rated 4/10
b. The client with a pulse rate of 70 beats per minute
c. The client with colostrum discharge from both breasts
d. The client with lochia that is red and has a foul smelling color.

29. Robi, a nurse, is providing postpartum instructions to a client who

will be breast-feeding her newborn. Which of the following determines
that the client understood the instructions? Select all that apply.
1. “magsusuot ako ng bra na may suporta”
2. “Nakakasama ang pag-inom ng alak para sa aking gatas-ina”
3. “Ang kape ay maaaring makakapagpababa ng aking gatas-ina”
4. “Sisimulan ko ang pag-inom ng estrogen pills pag karating sa
amingbahay”
5. “Alam ko na kung ang aking suso ay panandaliang lumaki, ihihinto ko
ang pagpapasuso”
6. “Iinom ako ng maraming tubig upang maparami ang aking gatas-ina” A.
1, 6, 5, 3
B. 1, 2, 3, 6
C. 2, 3, 4, 5
D. 3, 4, 5, 6

30. A prolapsed umbilical cord is when the umbilical cord is displaced

between the presenting part and the amnion or protruding through the
cervix, causing compression of the cord and compromising fetal
circulation. Which of the following assessment findings are not
indicative of a prolapsed cord?
a. The client has a feeling that something is coming through the vagina.
b. Umbilical cord is visible or palpable
c. Sweating, cool and damp skin
d. Fetal heart monitor shows variable decelerations or bradycardia after
rupture of the membranes.

Situation: Joshua is a public health nurse assigned in the family

planning clinic. Rose, a 19 year old client reported that she has been
sexually active for one year and is asking about family planning methods.
31. Nurse Joshua talks to the client regarding Natural Family Planning
Methods which are based on scientific facts on fertility. Which of the
following are not natural methods of FP?
a. Sympto-Hormonal Method (SMH)
b. Sympto-Thermal Method (STM)
c. Cervical Mucus Method (CMM)
d. Modified Pomeroy Method (MPM)

32. BBT is another natural FP method. Which of the following is not true
about this method?
a. The basal body temperature of a woman is higher before ovulation,
until it decreases to a lower level beginning around the time of
ovulation.
b. After her ovulation, her BBT typically rises slightly and stays in a
slightly higher range until her next period begins. This slight increase
in BBT from ovulation until menstruation is a sign that she ovulated
during this cycle.
c. The BBT of a woman is lower before her ovulation, until it rises to
a higher level beginning around the time of ovulation.
d. Women who are able to have at least 3 hours of continuous sleep every
day at almost the same time can use BBT.

33. The Ovulation Method or “OM” entails having to observe the changes
in color, consistency and amount of discharge. Which of the following
is not true?
a. During infertile days, the uterine cervix secretes a discharge which
is thick and scanty in which sperm survival is poor.
b. On fertile days, discharge is thin and copious. This type of discharge
is conducive for sperm penetration and survival and subsequent
fertilization.
c. During the woman’s fertile period, she feels dry and sees stretchy
and clear discharge.
d. During the woman’s fertile period, the discharge nourishes and
provides a channel for sperm to reach the egg. R: OM is also called CMM.
During the fertile period, she feels wet and sees slippery, stretchy,
watery and clear mucus.

34. CycleBeads™ represents the woman’s menstrual cycle. Each bead

represents a day of her cycle. Which of the following is true?
a. The RED bead marks the first day of menstrual period.
b. The WHTE beads represent the days when the woman can have intercourse
and not become pregnant.
c. The BROWN beads are the days when a woman can become pregnant.
d. The CHOCOLATE BROWN bead helps you know if your cycle is less than
24 days long.

35. Nurse Josh stated that the Lactational Amenorrhea Method (LAM) was
not applicable for Rose. The LAM method:
a. Is for non- breastfeeding mothers
b. Is for mothers whose menstruation has returned (this does not include
the spotting that occurs 56 days post partum)
c. Is for mothers whose infant is more than 24 weeks old
d. Is considered as a temporary, short-term method.
36. Which of the following is a proper description for Placenta Accreta?
a. Premature separation of the placenta of the uterine wall after the
twentieth week of gestation and before the fetus is delivered
b. The placenta penetrates the uterine muscle itself
c. An abnormally adherent placenta
d. Placenta goes all the way through the uterus.

37. A nurse in the labor room is preparing to care for a client with
hypertonic uterine contractions. The nurse is told that the client is
experiencing uncoordinated contractions that are erratic in their
frequency, duration, and intensity. The priority nursing intervention
in caring for the client is to:
a. Provide pain relief measures
b. Prepare the client for an amniotomy
c. Promote ambulation every 30 minutes
d. Monitor the oxytocin infusion closely.

38. Jenny, a nurse, is performing an initial assessment on a client who

has just been told that a pregnancy test is positive. Which assessment
finding would indicate that the client is at risk for preterm labor?
a. The client is a 36- year old primigravida
b. The client has a history of cardiac disease
c. The client’s haemoglobin level is 13.5 g/dL
d. The client is a 20year old primigravida of average weight and height.

39. A nurse in a labor room is monitoring a client with dysfunctional

labor for signs of fetal or maternal compromise. Which of the following
assessment findings would alert the nurse to a compromise?
a. Maternal fatigue
b. Coordinated uterine contractions
c. Progressive changes in the cervix
d. Persistent non reassuring fetal heart rate
40. A client in labor is transported to the delivery room and prepared
for ta caesarean delivery. After the client is transferred to the
delivery room table, a nurse places her in:
a. Supine position with a wedge under the right hip
b. Trendelenburg’s position with the legs in stirrups.
c. Prone position with the legs separated and elevated
d. Semi-Fowler’s position with a pillow under the knees.

SITUATION: Schumacher, L. (2010) conducted a phenomenological study

entitled “The caregiver’s journey: a phenomenological study of the lived
experience of leisure for caregivers in the sandwich generation who care
for a parent with dementia.” She focused her study on the subjective
burden of care giving and lived bereavement of mid-life people who were
simultaneously caring for a parent with Alzheimer’s Disease and Related
Disorders (ADRD) and a dependent child to fully capture the essence of
the experience.
41. Phenomenologists believe that lived experience gives meaning to each
person’s perception of a particular phenomenon. A nurse-researcher has
an accurate understanding of phenomenological inquiry if she states that
the aspects of lived experience that are of interest to phenomenologists
are the following but:
a. Spatiality
b. Corporeality
c. Temporality
d. Rationality

42. The nurse researcher misunderstood the phenomenological process if

she stated that the main method of data collection in phenomenological
studies are the following but?
a. Participant observation
b. Use of close-ended interview questions
c. In-depth interview sessions
d. Let the patient describe the lived experience through essay
43. Bracketing is a process of identifying and holding in abeyance
preconceived beliefs and opinions about the phenomenon under study. It’s
a technique to minimize bias in Husserlian phenomenology. Ahern (1999)
provided tips to help qualitative researchers with bracketing through
notes in a reflexive journal. The nurse researcher may do the following
excluding:
a. Identify interests that the research participants may take for granted
b. Recognize gatekeepers’ interests and make note of the degree to which
they are favorably or unfavorably disposed toward the study
c. Reflect on and profit from methodologic problems that occur during
the study
d. Consider addressing biases in data collection or analysis by
interviewing the participant the second time or reanalyzing the
transcript in question

44. According to Gadamer (1976), the interpretive phenomenology process

must start from the whole of a text in terms of its parts and the parts
in terms of the whole. The nurse-researcher correctly identifies this
process as:
a. Circular bracketing
b. Intuiting
c. Cyclical deduction
d. Hermeneutic circle

45. The nurse-researcher now performs analysis of phenomenological data.

She chooses a method which requires inter-subjective agreement to be
reached with other expert judges. She correctly identifies the method
as:
a. Colaizzi’s
b. Van Kaam’s c. Giorgi’s
d. Van Manen’s
Situation: The goal of the Integrated Management of Childhood Illnesses
is to significantly reduce global mortality and morbidity associated
with major causes of diseases in children, and to contribute to healthy
growth and development of children.
46. This program is the campaign for all practitioners and health
facilities to adopt and embrace the safe and quality care of Essential
Intrapartum and Neonatal Care (EINC) for our birthing mothers and their
newborns.
a. Family Planning
b. MNCHN
c. UnangYakap
d. MDG 4 & 5

47. The Department of Health issues this Administrative Order to guide

health workers in revitalizing and sustaining mother-baby friendly
hospitals, so as to promote and support breast-feeding.
a. AO 2007-0025
b. AO 2007-0026
c. AO 2007- 0027
d. AO 2007- 0028

48. The Essential Intrapartum Neonatal Care Evidence-based standard

practices for safe and quality care of birthing mothers and their
newborns, within __ hours of intrapartum period (labor and delivery) and
a week of life for the newborn.
a. 12
b. 24
c. 36
d. 48

49. Which of the following are not included in the EINC practices during
the intrapartum period?
a. Spontaneous pushing in a semi-upright position
b. Physical contact between mother and the newborn
c. Continuous maternal support by a companion of choice
d. Non-drug pain relief

50. A nurse was performing the EINC practices for newborn care, which
are time-bound interventions at the time of birth. Which of the following
practices is done third?
a. Unang Yakap
b. Properly-timed cord clamping and cutting
c. Early skin-to-skin contact between mother and the newborn
d. Immediate and thorough drying of the newborn Situation: You are the
nurse assigned in the nursery unit and your patients are of various ages.

51. Assessment an infant, the nurse knows that a pincer grasp normally
appear
a. At the same time as the palmar grasp
b. Between 9 & 12 month of age
c. Between 5 & 7 month of age
d. Along with the ability to "rake" objects toward themselves

52. In a child development, the period of negativism begins when the

child
A. Can manipulate his or her parents
B. Copies negative behavior of sibling.
C. Is struggling between dependence and independence
D. Is learning manual skills

53. The nurse is caring for a hospitalized toddler who was toilet trained
home. He wets his pants. The best response to this situation is to say
A. "It’s okay, try not to wet your pants next time”
B. "That's okay. Now let’s get you cleaned up”
C. "I know you understand how to use the toilet; what happened?"
D. "Your mom told me you don't wet anymore; what's wrong?"
54. Which of the following behavior would a normal 18 months old be
likely to exhibit during the first few hours of hospitalization?
A. Crying loudly when parents leave
B. Readily accepting the nurse caring for him
C. Showing considerable interest in new toy
D. Sitting quietly in the comer of the cab, showing little or no interest
in his surrounding

55. Jason answers every question of his mother by saying “No!” How can
she minimize this?
A. Tell Jayson she doesn’t want him to say no anymore
B. Answer all Jayson’s question by saying “No”
C. Reduce number of questions she asks Jason.
D. Explain hen is not using good communication skills.

Situation: Nurse Rose is the school nurse in Jose Reyes Elementary

school. Her responsibility is to attend to the health needs of the
students particularly nutrition.
56. Kwashiorkor is a condition usually seen among pre- school children.
This is characterized by which of the following signs?
A. retarded growth and hairs
B. loss of appetite
C. edema
D. all these signs

57. Vitamin A deficiency will lead to which of the following conditions?

A. high blood pressure
B. swollen face, body and limb
C. inability to see in the dark
D. enlargement of the neck
58. In the nutritional assessment of grade 6 pupils, which of the
following nutritional assessment method is most appropriate?
A. Height for age
B. Weight for age
C. Body mass index
D. Mid upper arm circumference

59. Pupils with below normal nutritional status are candidates for a
school feeding program. Which of the following is a prerequisite for a
child to be included in a feeding program?
A. Deworming
B. Parental consent
C. Head to toe physical examination
D. Attendance in a nutritional class by a parent

Situation: One of the trending news today is about the Reproductive

health bill. The following questions are about the Philippine
Reproductive Health.
60. The main objectives of Philippine Reproductive Health includes the
following:
1. Reduce the maternal mortality rate
2. Reducing the child mortality
3. Halting and reversing the spread of HIV/AIDS
4. Increasing access to Reproductive health information services
5. Reduce paternal mortality to prostate cancer
A. All of the above
B. All except 5
C. All except 4
D. All except 3
61. According to this framework, the foremost intervention in attaining
reproductive health is:
A. Family planning
B. Counselling
C. Safe Sex Campaign Drive
D. Maternal and Child Health and Nutrition

62. Because of insufficient technical readiness and availability of

resources, the DOH has focused in addressing the health concerns on the
first four priority elements of the reproductive health namely:
1. Adolescent Reproductive health
2. Family Planning
3. Prevention and Management of Reproductive Tract Infection Including
STIs and HIV/AIDS
4. Maternal and Child Health and Nutrition
5. Prevention of Infertility and sexual Dysfunction
A. All except 5
B. 1,3,4,5
C. 2,3,4,5
D. 1,2,4,5

Situation: A pregnancy can be considered a high-risk pregnancy for a

variety of reasons. It is one in which some condition puts the mother,
the developing fetus, or both at higher-than-normal risk for
complications during or after the pregnancy and birth.
63. Which of the following is the most likely effect on the fetus if the
woman is severely anemic during pregnancy?
A. Large for gestational age (LGA) fetus
B. Hemorrhage
C. Small for gestational age (SGA) baby
D. Erythroblastosis
64. Upon assessment the nurse found the following: fundus at 2
fingerbreadths above the umbilicus, last menstrual period (LMP) 5 months
ago, fetal heart beat (FHB) not appreciated. Which of the following is
the most possible diagnosis of this condition?
A. Hydatidiform mole
B. Missed abortion
C. Pelvic inflammatory disease
D. Ectopic pregnancy

65. When a pregnant woman goes into a convulsive seizure, the MOST
immediate action of the nurse to ensure safety of the patient is:
A. Apply restraint so that the patient will not fall out of bed
B. Put a mouth gag so that the patient will not bite her tongue and the
tongue will not fall back
C. Position the mother on her side to allow the secretions to drain from
her mouth and prevent aspiration
D. Check if the woman is also having a precipitate labor

66. A gravido-cardiac mother is advised to observe bed rest primarily

to:
A. Allow the fetus to achieve normal intrauterine growth
B. Minimize oxygen consumption which can aggravate the condition of the
compromised heart of the mother
C. Prevent perinatal infection
D. Reduce incidence of premature labor

67. A pregnant mother is admitted to the hospital with the chief

complaint of profuse vaginal bleeding, AOG 36 wks, not in labor. The
nurse must always consider which of the following precautions:
A. The internal exam is done only at the delivery under strict asepsis
with a double set-up
B. The preferred manner of delivering the baby is vaginal
C. An emergency delivery set for vaginal delivery must be made ready
before examining the patient
D. Internal exam must be done following routine procedure
68. Before giving a repeat dose of magnesium sulfate to a pre-eclamptic
patient, the nurse should assess the patient’s condition. Which of the
following conditions will require the nurse to temporarily suspend a
repeat dose of magnesium sulfate?
A. 100 cc urine output in 4 hours
B. Knee jerk reflex is (+) 2
C. Serum magnesium level is 10mEg/L.
D. Respiratory rate of 16/min

69. Which of the following is TRUE in Rh incompatibility?

A. The condition can occur if the mother is Rh(+) and the fetus is Rh(-
)
B. Every pregnancy of an Rh(-) mother will result to erythroblastosis
fetalis
C. On the first pregnancy of the Rh(-) mother, the fetus will not be
affected
D. RhoGam is given only during the first pregnancy to prevent
incompatibility

Situation: Promotion of a healthy growth and development as well as the

prevention of diseases in pediatric clients is one of the vital roles
of a nurse.
70. Nurse Rolen is teaching parents about the nutritional needs of their
2 month old infant who is breastfeeding. Which response shows that the
parent understands their infant’s dietary needs?
A. “We wont start any new foods now”
B. “ We’ll start the bay on skim milk”
C. “We’ll introduce cereal into her diet now”
D. “We should add new fruits to the diet at a time”

71. A mother is concerned that she might be spoiling her 2 month old
daughter by picking her up each time she cries. Which suggestion should
the nurse offer?
A. “If the baby’s diaper is dry when she is crying, leave her alone and
she’ll fall asleep”
B. “Continue to pick her up when she cries because young infants needs
cuddling and holding to meet their needs”
C. “Leave your baby alone for 10 minutes. If she hasn’t stopped crying
by then; pick her up”
D. “Crying at their age indicates hunger. Try feeding her when she cries”

72. The nurse observes an infant in a playpen sitting up without support.

He is playing with a plastic blocks and large plastic beads, bending
over to pick them up, and changing them from one hand to the other. When
another child hides a toy behind the infants back, he does not attempt
to look for it. The nurse would be most correct in estimating the infant’s
age to be:
A. 4 months
B. 6 months
C. 8 months
D. 10 months

73. In assessing an infant, the nurse should be aware that the birth
weight of infant triples by:
A. 5-6 months
B. 12 months
C. 30 months
D. 3 years

74. At 6 months, the following are expected to be observed from the baby
except:
A. She can sit without support
B. Teething
C. She starts eating solid foods
D. None of the above
SITUATION: Charge nurse Sugar has recently been assigned to manage a
pulmonary progressive unit in St. Bernard’s Hospital, the best hospital
in their region. For the hospital and her career to be successful, she
must utilize her leadership skills appropriately.
75. The management was right, Sugar can comfortably shift her leadership
styles considering her area of assignment and depending on the call of
the situation. She has grown into a flexible and well-rounded leader.
She must have mastered which leadership style now?
a. Participative
b. Ultraliberal
c. Bureaucratic
d. Contingency

Situation: Janice went to a health center for her prenatal check-up. She
is a G3P2 mother.
76. A nurse is providing instructions to a client in the first trimester
of pregnancy regarding measures to assist in reducing breast tenderness.
The nurse tells the client to:
a. Avoid wearing a bra.
b. Wash the breast with warm water and keep them dry.
c. Wear tight-fitting blouses or dresses to provide support.
d. Wash the nipples and areolar area daily with soap, and massage the
breasts with lotion.

77. Janice asks the nurse about the types of exercises that are allowable
during pregnancy. The nurse should instruct the client that the safest
exercise to engage in is which of the following?
a. Swimming
b. Scuba diving
c. Low-impact gymnastics
d. Bicycling with the legs in the air.
78. During her check-up, the physician prescribed transvaginal
sonography for Janice. She then asks the nurse about the procedure. The
nurse tells her that:
a. The procedure takes about 2 hours
b. It will be necessary to drink 1 to 2 quarts of water before the
examination.
c. Gel is spread over the abdomen, and a round disk transducer will be
moved over the abdomen to obtain the picture.
d. The probe that will be inserted into the vagina will be covered with
a disposable cover and coated with a gel.

79. The nurse also performed a nonstress test on Janice. The fetal
monitor strip was viewed and was interpreted as reactive and understands
this as:
a. Normal findings
b. Abnormal findings
c. The need for further evaluation
d. That the findings on the monitor were difficult to interpret:

80. After a few days, she calls the nurse and reports that she has
noticed a thin, colorless vaginal discharge. The nurse should make which
statement to the client?
a. “Go to an Ob-Gyn immediately.”
b. “Report to the emergency department of the nearest BeMONC center
immediately.”
c. “The vaginal discharge may be bothersome, but it is a normal
occurrence.”
d. “Use multiple maternity pads if the discharge is bothersome, and
change every 2 hours.”

81. The Ballard Tool is used to assess for the gestational age of a
client. Which of the following statements on ratings is not true?
a. An overall rating below the 10th percentile = Small for gestational
age (SGA)
b. A rating between the 10th and 90th percentile = Appropriate for
gestational age (AGA)
c. A rating above the 90th percentile = Large for gestation age (LGA)
d. The rating is marked on a graph along with the newborn’s weight and
body circumference only.

82. Identify the parameter defined. It is elicited by flexing the

newborn’s hand toward the ventral forearm until resistance is felt and
measuring the angle.
a. Arm recoil
b. Square window sign
c. Popliteal Angle
d. Scarf sign

83. One of your primary clients in the community is the Cruz family.
They were selected because one of their children, Jon, a 4 year old boy
diagnosed with Down’s syndrome. They were referred to you for supportive
care. How will your approach be when assessing Cruz?
a. Treat him like a toddler and expect that he would exhibit
developmental attributes younger than his chronological age.
b. Treat him like a 4 year old and expect that he would exhibit
developmental attributes according to his age.
c. Treat him on the basis of your assessment findings.
d. Avoid handling the family as your primary patient.

84. You are assessing Alec, a 17-year-old college student for his annual
physical examination. When asked about his sexual activities, he admitted
that he prefers to be in a relationship with persons of the same sex.
However, he could not express himself fully in fear of his parent’s
rejection, given that he is the eldest child who is to inherit his
family’s business. What psychosocial stage is being compromised in this
situation?
a. Identity vs. role confusion
b. Intimacy vs. isolation
c. Integrity vs. despair
d. Autonomy vs. shame and doubt
85. Which of the following car safety devices should be used for a child
who is 8 years old and is 4 feet tall?
a. Seat belt
b. Booster seat
c. Rear-facing convertible seat
d. Front-facing convertible seat

Situation: Nurse Caring is caring for patients in the community. She is

focusing on the young population of the barangay. The following questions
apply.
86. A nurse assesses the vital signs of a 12-month-old infant with a
respiratory infection and notes that the respiratory rate is 35
breaths/min. Based on this finding, which action is appropriate?
a. Administer oxygen.
b. Notify the physician.
c. Document the findings.
d. Reassess the respiratory rate in 15 minutes.

87. A nurse is monitoring a 3-month-old infant for signs of increased

intracranial pressure. On palpation of the fontanels, the nurse notes
that the anterior fontanel is soft and flat. Based on this finding, which
nursing action is appropriate?
a. Increase oral fluids.
b. Notify the physician.
c. Document the finding.
d. Elevate the head of the bed to 90 degrees.

88. A 16-year-old is admitted to the hospital for acute appendicitis and

an appendectomy is performed. Which nursing intervention is appropriate
to facilitate normal growth and development postoperatively?
a. Encourage the child to rest and read.
b. Encourage the parents to room inwith the child.
c. Allow the child to interact with others in his or her same age group.
d. Allow the family to bring in the child’s favourite computer games.
89. A mother arrives at a clinic with her toddler and tells a nurse that
she has a difficult time getting the child to go to bed at night. Which
of the following is appropriate for the nurse to suggest to the mother?
a. Avoid a nap during the day.
b. Allow the child to set bedtime limits.
c. Allow the child to have temper tantrums.
d. Inform the child of bedtime a few minutes before it is time for bed.

90. A nurse is preparing to care for a 5-year-old who has been placed
in traction following a fracture of the femur. The nurse plans care,
knowing that which of the following is the most appropriate activity for
this child?
a. A radio
b. A sports video
c. Large picture books
d. Crayons and a coloring book

Situation: The goal of the Integrated Management of Childhood Illnesses

is to significantly reduce global mortality and morbidity associated
with major causes of diseases in children, and to contribute to healthy
growth and development of children.
91. Which of the following are not components of the IMCI program?
a. Improving case management skills of healthcare workers
b. Pre-service and In-service training
c. Improving family and community practices.
d. All of the above
e. None of the above

92. Which of the following is not a general danger sign?

a. Is the child able to drink or breast feed?
b. Does the child vomit everything?
c. Has the child had a history of flu-like symptoms?
d. Is the child abnormally sleepy or difficult to awaken?
93. Mutya is 15 months old. She weighs 8.5kg. Her temperature is 35.5
degrees centigrade. She has been coughing for 4 days, and is not eating
well. This is her initial visit. Mutya’s mother said that she does not
want to breastfeed. The nurse offered Mutya some water. She was too weak
to lift her head. She was not able to drink from the cup. She has not
been vomiting and had no episodes of convulsions. She was not abnormally
sleepy or difficult to awaken. Which of the following main symptoms is
applicable?
a. Cough
b. Diarrhea
c. Fever
d. Ear problems

94. Which of the following interventions is included for the treatment

of mastoiditis?
a. Perform dry wicking
b. Give Amoxicillin for 5 days
c. Give Quinolone otic drops for 14 days
d. Perform urgent referral.

95. For a child with severe dehydration, the following assessment

findings are noted, except:
a. Absent tears
b. Skin pinch goes back slowly
c. Lips and tongue are very dry
d. Child is lethargic and unconscious

SITUATION : A newly passed nurse is attending an agency orientation

regarding the nursing model of practice implemented in the health care
facility.
96. The nurse is told that the nursing model is a team nursing approach.
The nurse understands that planning care delivery will be based on which
characteristic of this type of nursing model of practice?
a. A task approach method is used to provide care to clients
b. Managed care concepts and tools are used in providing client care
c. An RN leads nursing personnel in providing care to a group of clients
d. A single RN is responsible for providing nursing care to a group of
clients

97. The nurse orientee acknowledges that in team nursing, the most
important principle of management exhibited is?
a. Order
b. Esprit de corps
c. Subordination of personal interests
d. Equity

98. The nurse manager has implemented a change in the method of the
nursing delivery system from team to functional nursing. The nurse
orientee knows that functional nursing employs which principle of
management according to Henri Fayol?
a. Unity of command
b. Remuneration
c. Stability of tenure
d. Division of labor

99. The nurse orientee is now on the ICU/CCU for her special area
orientation. She recognized that a single nurse is providing direct total
care to a single patient. The care delivery system applied in the ICU/CCU
is?
a. Functional nursing
b. Primary nursing
c. Case method
d. Modular method

100. One week after her orientation in ICU/CCU, she is permanently

assigned by the chief nurse on the medical ward. She observed that the
care delivery system practiced is somewhat a combination of primary and
team nursing. She correctly identifies this system as?
a. Modified team nursing
b. Modified primary nursing
c. Case method
d. Modular method
 KEY TO CORRECTION
1. A 21. C 41. D 61. A 81. D
2. B 22. D 42. C 62. A 82. B
3. C 23. A 43. A 63. C 83. C
4. A 24. B 44. D 64. A 84. A
5. A 25. C 45. B 65. C 85. B
6. D 26. B 46. C 66. B 86. C
7. A 27. A 47. B 67. A 87. C
8. B 28. D 48. D 68. A 88. C
9. A 29. B 49. B 69. C 89. D
10. A 30. C 50. B 70. A 90. D
11. B 31. D 51. B 71. B 91. E
12. C 32. A 52. C 72. C 92. C
13. A 33. C 53. B 73. B 93. A
14. D 34. A 54. A 74. A 94. D
15. A 35. D 55. C 75. D 95. B
16. C 36. C 56. D 76. B 96. C
17. A 37. A 57. C 77. A 97. B
18. B 38. B 58. C 78. D 98. D
19. D 39. D 59. A 79. A 99. A
20. A 40. A 60. B 80. C 100. D