Diag 2 PDF

1-7 Formative Assessment
Question 1
The World Health Organization defines public health as:
- Science and art of preventing disease, prolonging life, promoting health and
efficiency through organized community effort for the sanitation of the environment.
Question 2
Which is the primary goal of community health nursing?
- To enhance the capacity of individuals, families and communities to cope with their
health needs and maximize their potential for high level wellness
Question 3
The utilization of the nursing process in the different levels of clientele- individuals, families,
population group and communities, concerned with the promotion of the health, prevention
of disease and disability and rehabilitation is defined by;
- Maglaya
Question 4
The public health nurse is the supervisor of rural health midwives. Which of the following is
a supervisory function of the public health nurse?
- Providing technical guidance to the midwife
Question 5
The health of individuals and communities are affected by a combination of factors. Based
on the World Health organization’s list of heath determinants, which of the following
incorrectly affects the health of an individual?
- Intelligence
Question 6
As a Public Health Nurse, what is your primary function or responsibility?
- Health Teaching
Question 7
Community health is a part of paramedical and medical intervention/ approach which is
concerned on the health of the whole population. Its aim is to;
- Health promotion, disease prevention and management of factors affecting health
Question 8
A public health nurse has different roles in the community, one of her roles is to identifies
needs, priorities, and problems of individuals, families, and communities, this term refer to?
- Planner/ Programmer
Question 91 pts
Nursing, together with public health, is one of the helping professions in the health care
system which operates at three level of clientele, these are;
- Individuals, families and communities
Question 101 pts

Which of the following is the most prominent feature of Public Health Nursing?
- Public health nursing focuses on preventive, not curative services.
Question 111 pts

Maria’s daughter who is working as a nurse in the community hospital was diagnosed with
Covid. The neighbours are asking and are anxious about the situation. Maria has to
determine what information will be released from the family. Maria is fulfilling the role of:
- C. Gatekeeper
Question 121 pts

In what stage of family development the family is to allocate its resources well.
- B. Childbearing family
Question 131 pts

Duvall’s model of Family development is applicable to all family structures.
- B. No
Question 141 pts

The family is the most frequent focus of health decisions and action because the needs of
each member has to be considered.
- A. TRUE
Question 151 pts

Nurse Stef plans to disseminate information on safety precautions for Covid19 in their
barangay where there is no internet signal. She needs to make sure that everybody will be
informed so she made pamphlets on Covid19 to be distribute to each family. This is
because.
- C. The family is an effective and available channel for health workers
Question 161 pts
Nurse Stef reviews the records of patients who are enrolled in the DOTS program for
patients who has TB. She needs to ensure that each patient follows strictly the therapeutic
regimen. Which of the following role Nurse Stef is fulfilling.
- D. Health Monitor
Question 171 pts

Nurse Stef in the rural health unit received a report that a patient suffered from Stroke/CVA
at home and is unconscious. She is being asked for help by the family. Their barangay is 2-
hour-drive from the nearest hospital. She immediately informed the Municipal Doctor who is
in a seminar and headed to the patient’s home. Upon arriving she immediately rendered
first aid. Nurse Stef is performing which role?
- B. Provider of Care
Question 181 pts

Nurse Stef called the ambulance driver to pick up the patient for possible transport to the
city. She also called the hospital admission staff that they will be bringing a patient for
possible admission and reported the details over the phone. Nurse Stef is performing which
role.
- C. Coordinator
Question 191 pts

Nena sees to it that their house is clean and orderly where she can see her children playing
without fear of getting sick or getting injured. This is because it is the task of the family is to:
- Maintaining a home environment conducive to health maintenance
Question 201 pts

"Hindi na, wag na lang kung jan din lang, Baka lumala pa sakit ko. Doon nalang ako sa
bayan, Mr. Ricardo Cruz said when asked if he would like to go to the health center despite
being told that there are free medicines and services available in the health center which is
just 3 blocks away from their home. The family is unable to to the following health task.
- Utilize community resources for health care
2-4 Assignment 2-4 Formative Assessment #2 -

MCQ 15 items
The nurse addresses the health needs and problems of a family in a logical and systematic
way using a series of steps. We call this:
- Family Nursing Process
In which phase of the FNP does the nurse measure the status of the family as a client?
- Assessment
The assessment phase of FNP ends with:

- Problem identification
The data that describe the family's realities, perceptions, and performance is
- Second-level assessment
You are a nurse in Barangay Walangkobid. One family that you are caring for is the
Cervantes family. The Cervantes family is connsidered high risk. Which of the following
are indicators for this?
1. Aling Tetchie, 40 years old is pregnant with their 6th child

2. Mang Rey, 43 years old is presently jobless and was diagnosed to have
pulmonary tuberculosis.
3. Paul, 18 years old, associates with drug dependents in their barangay.
4. Popo, 5 years old, walks barefoot in the street.
5. Two of Mr. Cervantes' sisters are working abraod and regularly send them money.
- 1,2, 3 and 4
As a nurse in Barangay Walangkobid, you assessed the family of Mr. Rey Cervantes. The
following are the data that you were able to gather.
Aling Tetchie, 40 years old, the wife of Mr. Cervantes is pregnant with their 6th child while
Mang Rey, 43 years old is presently jobless and was diagnosed to have
pulmonary tuberculosis. They have five (5) children. The eldest is Paul, 18 years old. He
associates with drug dependents in their barangay. The second child is Riza, who is 16
years old is studying in a public high school near their place. Chelsea, the third, nine years
old is also studying in public elementary school and is assessed to be malnourished. Popo,
5 years old, not yet enrolled in school, walks barefoot in the street. Chin chin, three years
old is left to play with her brother Popo. She also plays in the streets of the barangay
without her slippers. Currently, they are being assisted by the sisters of Mang Rey. His
sisters are working abroad.
When you did the assessment, Aling Tetchie's pregnancy is a?
- Foreseeable crisis
Based on the following data gathered from the Cervantes family:

old is currently studying in a public elementary school and is assessed to be
malnourished. Popo, the fourth child, 5 years old, is not yet enrolled in school, walks
barefoot in the street. Chin chin, the youngest who is three years old is left to play with her
brother Popo. She also plays in the streets of the barangay without her
slippers. Currently, the family is assisted by the sisters of Mang Rey. His sisters are
working abroad.
Mang Rey's pulmonary tuberculosis is considered as_____
- Health Deficit
Using the data gathered from the Cervantes family:

old is currently studying in a public elementary school and is assessed to be
malnourished. Popo, the fourth child, 5 years old, is not yet enrolled in school, walks
barefoot in the street. Chin chin, the youngest who is three years old is left to play with her
brother Popo. She also plays in the streets of the barangay without her
slippers. Currently, the family is assisted by the sisters of Mang Rey. His sisters are
working abroad.
Mang Rey being jobless is considered as____________
- Foreseeable Crisis
You have assessed another family in Barangay Walangkovid. You gathered data
through interviews and observation. You learned that the Batumbangkal family has 12
members in the family and they all stay in a house with two rooms. Each room has a
dimension of 3 meters by 3 meters. The family income (accounting all the working
members of the family) is 800 per day. You observed that garbage disposal is done by
dumping in an open pit at the back of the house. You can see swarms of flies hovering in
the garbage. The toilet facility is closed pit, privy, foul smelling and with plenty of files
which is situated at the back of the house. This is shared with two (2) other familes living in
houses near their house.
Based on these cues, what possible health problems will you be able to identify?
- All of the options listed
As you are assessing the Batumbangkal family, you are able to gather data about how the
Aling Ising, the mother, takes care of her children especially when they were still
young. She mentioned that she practiced exclusive breastfeeding in all her children. Now
that she is pregnant with her fifth child, she expressed her plan to breastfeed her
baby. She said that even if she brestfed her other children before, she is still interested to
know more about breastfeeding. She is worried that now she is about to give birth and will
do breastfeeding, her milk production may not be enough.
As a nurse, you took note of the desire to know more and improve breastfeeding
practices. You identified this as a presence of a wellness condition,. A wellness condition
as you understood is_____________
Another family that you are caring for in the community is the Delos Reyes Family. Based
on the the first level assessment (utilizing the tool, the Assessment Data Base), one of the
health problems that you are able to identify in the family is the presence of a health
deficit. The head of the family, Mr. Lito Delos Reyes, was diagnosed to have Daibetes
Mellitus.
What would be the next step after stating the health condition?
- Determine the family's ability to perform the health tasks related to the identified
health problem
1-3 QUIZ 1
A Home Visit is defined as?

- A professional contact made by the nurse to or on behalf of a case to further the
special activity of the agency.
Which of the following is an advantage of a home visit?

- It provides an opportunity to do first hand appraisal of the home situation.
Which is CONTRARY to the principles in planning a home visit?

- A home visit should be conducted in the manner prescribed by the Rural Health Unit.
The purposes of Home visit are the following except?

- To work efficiently and rapidly during the care so that work with the family may be
effective, thus saving time and effort.
Arrangement of Home Visit should be as follows:

- Prenatal, Postnatal Cases and Communicable diseases
The following are things to consider in determining the Frequency of Home Visit except?
- Hand washing as frequently as the situation Calls for helps in minimizing or avoiding
contamination of the bag and its content.
During your home visit, one of the family members is 7 months pregnant and ask you on
when she can have her prenatal check-up. You best response is;
- 7th month below is once a month, 8th month twice a month, 9th month weekly
One of the primary functions of the Public Health Nurse is to do a Home visit. General
principles on the frequency of home visits is?
Priority selection according to needs should be a factor in determining the frequency of
home visit to the client and family
There is no definite rule as to frequency of home visits
- Both choices
Which of the following statement is our top most priority in conducting a home visit?
- Those expectant mothers who do not have a pre-natal checkup within reasonable
distance from their home.
A Public Health Nurse must schedule her post-natal visit on?

- Daily home visit until the cord is off, then twice a week, until the baby is one month
old. After one month, require the mother to bring the baby to the health centers.
Gina, a single mother lives with her daughter in an apartment in Barangay

Walangkovid. Her mother and sister stays with her. They help her take care of her
daughter who is a pre-schooler. She is the breadwinner of the family and works in a factory
as a contractual worker. Based on your assessment, she is showing signs and symptoms
of a respiratory problem. She is aware that she is sick. However, she expressed that with
her current situation, she cannot afford to be absent from work. She has not gone to the
health center. She has received any care from any health care providers in their
barangay. Thus the nursing problem may be stated as________________.
- Inability or failure to utilize community resources for health care.
While doing an interview with the Delos Reyes family, the following are the data that you
are able to gather:
1. Mr. Lito Delos Reyes is the prime decision maker of the family.
2. The family is an extended family with the parents of Mr. Delos Reyes living in the same
house. They are nine (9) in the family. The members of the family are as follows; Mr.
Lito Delos Reyes, the father; Mrs. Linda Delos Reyes, the mother; Lita, Cindy, Julie,
Leslie and Richard-the children; and Lolo Justininano and Lola Nilda.
3. They are not very demonstrative in terms of their affection with one another.
4. Lola Nilda sometimes have conflicts with Mrs. Linda Delos Reyes especially when it
comes to matters related to child rearing.
5. The children have high respect for the parents and grandparents.
What is/are true about the data that you have gathered?
- All of the options listed.
Situation: The nurse is assessing Filipino families in Barangay Wawa. She gathered different situations on
each family.
One day, the nurse visited the Villanueva Family. Mr. Villanueva is now in Dubai working as a Food and
Beverage Manager to support his family while his wife is taking care of them four children and in charge in
all the decision-making aspects. This is a characteristic of what
- Matricentric
Another family that you are caring for in the community is the Delos Reyes Family. Based on the the first
level assessment (utilizing the tool, the Assessment Data Base), one of the health problems that you are able
to identify in the family is the presence of a health deficit. The head of the family, Mr. Lito Delos Reyes, was
diagnosed to have Daibetes Mellitus.
What would be the next step after stating the health condition?
- Determine the family's ability to perform the health tasks related to the identified health problem
As the nurse assessing the Delos Reyes family in the community where you are assigned, you fully remember
that in order to ensure that data collection is effective and efficient, what important point/s should you
always consider?
- All the options listed
In the family nursing process, during the assessment phase, after generating the data based on the
Assessment Data Base, you as the nurse will go through data analysis. With this sub step, you are reminded
that the imporatnt activities of this substep includes?
Upon assessment of the Teocson family in Barangay Mapagmahal, you found out that Kathryn Teocson, the
25 year old the daughter of Mr. Ryan Teocson and Mrs. Juday Teocson, was found positive for COVID 19
based on COVID 19 swab results. As a nurse applying the family nursing process, you have identified the
presence of an illness state, that is Kathryn Teocson being COVID positive. You identified that this a health
deficit. You continue with the second level assessment. You asked the family, "Ano po sa palagay ninyo ang
sakit na ito?" You further asked, "Ano po sa palagay ninyo ang dahilan nito?"
The questions that were asked can generate data on what particular family health task?
- Ability to resolve the problem , if the family already recognized the presence of the problem.
Nurse Micah works as a Public Health Nurse in Barangay Pineapple, together with Nurse
Ron, Nurse Romel and Nurse Mark. One of the families in the Barangay provided with
care is the Cantos Family. The Cantos family is composed of eight members. Mr. Rody
Cantos, the father is the head of the family. His wife, Mrs. Lucy Cantos, the wife works as
an administrative staff in GR Corporation. Nursing assessment in family health nursing
includes the following EXCEPT:
- None of the options listed.
In the first level assessment, existing and potential health conditions or problems of the
family are identified. If during assessment of a family, the nurse assessed that the children
have faulty eating habits, this problem can be categorized as:
- Health threat
Family disunity is a problem in the Cantos family. In the family nursing process this is
categorized as_______
- Foseeable crisis
Which among the statements is true about second level assessment in Family Health
Nursing?
- All the options listed
Another family in the community that Nurse Augelene is monitoring is the Sinta family. Mrs.
Sini Sinta and Mr. Nagsi Sinta are newlyweds. Mrs. Sini Sinta is currently pregnant. As a
nurse, you are aware that Mrs. Sinta's pregnancy is categorized as_____
- Wellness condition
SL 2-6 Quiz: Bag Technique
Which should not be placed inside the bag of the Public Health Nurse (PHN)?
- Sphygmomanometer
Nurse Joy went visited patient Mika, after giving birth to a healthy baby boy. Where should nurse Joy place
her bag if Mika has no table nor chair?
- On the floor
Which of the following is the best method to prevent contamination?
- Hand washing
Why should the nurse use an apron during treatment of patients at home?
- To protect her uniform from getting contaminated
Why should the nurse fold the apron away form her, with the soiled part folded inward?
- To prevent cross contamination
All of the following are contents of the bag, except:
- Stethoscope
7. An equipment that would enable the nurse to be efficient during home visits:
- Public health bag
This protects the bag from getting soiled
- Plastic lining
Give two (2) purposes of bag technique.
- The 2 purposes of bag technique are to minimize and prevent the spread of infection and to work
efficiently and rapidly during the care so that work with the family may be effective, thus saving
time and effort.
SL 3-2 QUIZ 3: Urine Testing
Which is true about the specific gravity of the urine
Indicator of urine concentration/ amount of solutes
The normal specific gravity is between 1.010 – 1.025
A low specific gravity means there is an excess fluid intake or diseases resulting to failure to concentrate
urine
Fluid deficit, dehydration, excess solutes like glucose causes high urine’s specific gravity
- all are correct
The Urinary pH determines relative alkalinity or acidity/ acid – base status of the urine.
- True
Which of the following results signify abnormal urine test result:
Presence of protein molecules in the urine
The normal specific gravity is between 1.025 – 1.085
A product of breakdown of fatty acids are normally present in urine
pH: 6
- 4 is correct
Which is true about Benedict’s test?
It is use to test for sugar in the urine
A 5ml of Benedict’s solution is placed in a clear test tube and then heated at the closed end of test tube.
A bluish green color after cooling down indicates positive (+)
It is used to test for ketones in the urine and to screen for diabetes
- all are correct except 4

Presence of occult blood in the urine indicates damage in the bladder or anywhere in the urinary tract.
- True
What color would you be looking for to indicate a negative test for the Benedict's test?
- Blue
Which is true about Heat and Acetic Acid test?
Protein is normally found in the blood and if there is a problem with the kidneys, protein can leak into the
urine.
It is used to test for albumin in the urine.
Protein coagulates when heated.
No turbidity of the solution means a negative result of heat and acetic test
- all are correct
After the breakdown of fatty acids it is expected to be seen in the urine.
- False
What are the indications of uncontrolled diabetes?
- Presence of ketones in the urine
What is the principle of Benedict’s test?
When Benedict’s solution and simple carbohydrates are heated, the solution changes to orange red/ brick
red.
Changes in the solution are caused by the reducing property of simple carbohydrates.
Formation of a reddish precipitate within three minutes means presence of reducing sugars like glucose.
Benedict’s solution can be used to test for the presence of glucose in urine.
- all are correct
SL 4-3 Quiz: Halamang Gamot

Mang Jose, 53 years old, visited the Barangay Health Center due to swelling and pain on his knees. When
asked what might have triggered the inflammation, he told you that he ate a bowl of nuts yesterday
afternoon. He said that he has gouty arthritis even before. Which of the following herbal medicines will you
advise Mang Jose to take?
- Ulasimang Bato
Aside from the swelling Mang Jose experiences, you have noticed a round scaly rash on his arm. He
verbalized that it is itchy. Which of the following herbal medicines should be instructed to him?
- Pound mature leaves of akapulko and apply to affected area as a soap
Aling Nena, 63 years old, is diagnosed of Diabetes Mellitus. Because she cannot afford to buy her
medications, which of the following herbal medicines will you advise her to take?
- Boil leaves of ampalaya for 15 minutes and take 1/3 cup 3x a day
Which of the following herbal medicines will not be effective in treating toothache?
- Bawang
Lorebel, 15 years old experiences menstrual cramps. Which of the following herbal medicines will you advise
her to take?
- Yerba Buena
Republic Act 8423 is otherwise known as
- Traditional and Alternative Medicine Act of 1997
Which of the following statements is INCORRECT?
- You may use any part of the plant being advocated
What is the scientific name of Niyug niyogan?

- Quisqualis indica L.
It is indicated for common respiratory symptoms:
- Lagundi
It is commonly known as Peppermint
- Yerba Buena
3-4 Formative Assessment: Planning Phase of
FNCP
It is the blueprint of the care that the nurse designs to systematically minimize or eliminate identified health
problems through explicitly formulated outcomes of care and deliberately chosen set of interventions,
resources and evaluation criteria, standards and methods:
Family Nursing Care Plan
A criterion in problem prioritization that gives consideration to resources of the family is:
Modifiability of the condition/problem
Which prioritization criterion should be given the most emphasis if you want to analyze the probability of
minimizing or eradicating the family’s health problem?
Modifiability
Situation.
Case: You were assigned to render service to a community in Zambales. One of the families you are visiting
is Untal family, an Aeta family from Botolan. Your first home visit yielded the following data:
*Mrs. Untal 18 years old and a plain housewife, is 7 months old pregnant for her 2nd child.
*Mr. Untal, 19 years old, works as a helper to a fruit and vegetable dealer and earns Php 1000/week.
*Husband and wife were observed to be distant as Mrs. Untal recently discovered that Mr. Untal had been
involved in gambling with fellow workers. Their 1st child named Undoy who is 2 years old, weighs about 1.5
kg. below the average weight for a child of his age.
*The following were observed in the family’s home and environment: a small plastic bag hanging on the
wall serves as the family’s garbage container. This plastic bag was observed to be emitting foul odor and
with flies all over it.
Question:
Utilizing the data explicitly stated in this case (limit your analysis to the given data only, please do not
presume), which of the following objectives can be used most appropriately as statement of intended
outcomes for Untal family?
Group of answer choices
After the nursing intervention, the couple will calmly verbalize to each other negative feelings and thoughts
regarding their personal problems
After one week, Undoy’s weight will increase by 2 kg from his current weight
After the health teaching regarding proper garbage disposal, the family will purchase a new garbage bin with
automatic cover
After the nursing interventions, the couple will decide on a specific family planning method they will utilize
Case: You were assigned to render service to a community in Zambales. One of the families you are visiting is
Untal family, an Aeta family from Botolan. Your first home visit yielded the following data:
*The following were observed in the family’s home and environment: a small plastic bag hanging on the wall
serves as the family’s garbage container. This plastic bag was observed to be emitting foul odor and with
flies all over it.
Question:
Given the data pertaining to Untal family, understanding one’s behavior could be addressed by an objective
domain, referred as:
Affective
Which of the following should be the basis of the nurse in considering that a problem is easily modifiable?
Health paraphernalia of the nurse
Nurse Sweng, develops objectives for the healthcare plan designed for Mr. Ubas Family. She considers
objectives as:
Milestone to reach the health target or destination

Case : You were assigned to render service to a community in Zambales. One of the families you are visiting
is Untal family, an Aeta family from Botolan. Your first home visit yielded the following data:
*The following were observed in the family’s home and environment: a small plastic bag hanging on the
wall serves as the family’s garbage container. This plastic bag was observed to be emitting foul odor and
with flies all over it.
Question:
Based on the case about Mrs. Untal, which of the following health problem would be most appropriate for
the nurse to utilize a criterion reference objective?
Unhealthful lifestyle: alcohol drinking
Poor home Environment: unsanitary waste disposal
Health threat: Care- giving burden
Readiness for enhanced capability of parenting
You are discussing the health problem to Mrs. Untal, specifically setting a nursing care goal. Which of the
following would lead to failure of setting the goal with Mrs. Untal?
Mrs. Untal warmly replied: “we’re used to this situation”
It is your second time to visit Mrs. Untal at home, all of the following should be done to develop a health
care plan for the family, except:
Agree with Mrs. Untal on all her perception about her husband
The following are examples of short-term objectives, except:
After nursing intervention, the family will be able to competently take care of its mentally-ill member.
In scoring the list of health problems to prioritize, the nurse should do all of the following, except:
Decide on a score
Which of the following is a nursing goal statement?
After nursing intervention on December 28, 2020, the family will be able to manage COVID 19 disease and
totally be free of infection.
All of the following pertains to the characteristics of objectives, except:
Frequent use of affective domain as basis for health intervention
Which of the following characteristics of domains of objectives could address the family’s inability of the to
recognize the health condition?
Awareness on matters related to the condition with tasks to accomplish
SUMMATIVE ASSESSMENT 2
Parental separation changes children's lives in many ways. Children of divorce have lower psychological well-
being and more behavioral problems than children who grew up in intact families (Amato and James, 2010).
Contrary to the study of Demo and Fine (2010) that growing up in a conflict -ridden but stable family can
have negative effects on children's psychological well-being than parental separation. Given these studies
the first level assessment data collected by the nurse about:
- Family structure, characteristics and dynamics
Nurse KJ on her initial visit to Kellog Family gathers data to know the profile of the family, particularly socio-
economic and cultural characteristics. The data includes:
Occupation, place of work, income of each family member
Ethnic background, religious affiliation, family traditions
Perceptions during conflict, educational attainment
Total family income, type of work, and relaxation activities
- 1&2
Nurse KJ reviews the immunization record of the children, and previous annual physical exam result of Mr.
and Mrs. Kellog. What is being assessed by Nurse KJ?
Understand each member of the family
Definition of health needs
Experience relaxation and healthy lifestyle
Prioritization of family expenditures
- Definition of health needs?
A mother brought her one month old to the RHU for immunization. It's almost three months since the
mother's last consultation. To determine the condition of the baby, the nurse visited the family. What initial
data collection method will the nurse utilize?
Definition of health needs
Understand each family member
Experience relaxation and healthy lifestyle
Prioritization family expenditures

- Definition of health needs?
Which of the following refer to activities that should be conducted as a result of family nursing problem?
Development of Program
Planning
Health action
Health teaching plan implementation
- Planning?
As the nurse assigned to the Banzon family, you were able to identify the following healthe
problems/conditions. Based on the criteria of determining priorities, rank the following according to which
must be attended first in terms of the nature of the problem:
Mrs. Ailyn Banzon is pregnant with their 2nd child.
Mr. William Banzon, upon checking his blood pressure is high, 160/100 mmHg
Mr. William Banzon, the head of the family is taking in medications for his hyperstension based on the
advise of a neighbor.
3, 1 and 2
2, 3 and 1
Cannot be ranked.
1, 2 and 3
- 2, 3, and 1
In Family Health Nursing, a cardinal principle in setting goal is that a goal must be:

stated in terms of nurse's objectives
Goals are more specific statements of desired results or outcome of care.
None of the options listed
set mutually between the nurse and the family
- set mutually between the nurse and the family?
Mr. Glen Litao is a banker. They were subjected for a mandatory swab test for COVID 19 in their office
since he is a frontliner. The result of the swab test is positive. However, Mr. Litao has no symptoms of
COVID 19. He was required to be in quarantine and do observation. In ranking the problem, the nurse
needs to evaluate the modifiability of the problem. What are the factors that should be considered in
considering this criterion?
Current knowledge, technology and interventions.
All of the options listed.
Resources of the nurse.
Resources of the community.
Resources of the family
One of the problems that you are able to identify in the Marquez family is the health condition of Mr. Boy
Marquez. He suffered from stroke five (5) months ago and is now bedridden. As you are ranking this health
deficit, you evaluated it according to preventive potential, particularly severity and duration of the problem.
Which among the following statements is true about these two factors under preventive potential?
The duration of the problem has a direct realtionship with the severity of the problem.
None of the options listed
The nature of the problem will not in any way affect the direct relationship between severity and duration of
the problem.
If the health problem is not severe, the preventive potential is low.

- The duration of the problem has a direct relationship with the severity of the problem?
The children of Mr. and Mrs. Dalumbinti have flu. They recognize that this a problem but do not consider it
as one that will be needing immediate attention. What will be the possssible outcomes for this kind of
situation?
- This will be a barrier to joint goal setting
One of the health problems that you identified in the Cantoria family is the immunization status of the
youngest member of the family, Baby Jellaine. They have not been going to the health center since the
Dengvaxia issue. Baby Jellaine has not received measles vaccine yet. Based on your in depth interview
during the second level assessment, the family nursing problem that you identified is the "inability of the
family to decide on appropriate actions to take." What would be the focus of the interventions?
Identifying the course of action that the family needs to take.
Explore with the family the benefits of complete immunization status of Baby Jellaine.
Discuss with the family the consequences of inaction.
Increase the family's abilty to take care of the sick member of the family.
- Identifying the course of action that the family needs to take.

- Explore with the family the benefits of complete immunization status of Baby Jellaine.
- Discuss with the family the consequences of inaction.
Nurse Charlize jointly set the goal with the Macaspac family in terms of removing the accident hazard in the
home specifically the broken stairs observed in the house of the family. After implementing the
interventions appropriate to the goal and objectives, you are set to do an evaluation. What will be the main
method of evaluation that you will use to determine if the goal was achieved?
Observation
None of the above

Records review
Interview
- Observation and interview?
One of the goals set by Nurse Trinity in the Conocido family was to improve the nutrional status of Elijah,
who during the assessment was found to be malnourished. Realistically, you hope to see the outcomes after
3 of 4 months of nurse-family relationship. Within those months of implementation of the various
intervention geared toward the achievement of the objectives and the goal (in the long run), the nurse
draws ongoing feedbacks from the family and others involved in the resolution of the problem. Periodic
visits were done to determine if plans and interventions are appropriately focused. Changes in the weight
was also monitored. What type of evaluation is Nurse Trinity conducting?
- Formative evaluation
During the implementation phase, Nurse Althea, recognizes the importance of reflective practice in
widening her expertise in family health care. In reflecting on her action, what would be the possible
questions that nurse should ask herself?
How do I feel about what happened
How did my actions match my beliefs and actions?
What other possible actions can I pursue to improve on my understanding of the client's situation?
How is the family responding to the experience?
- What other possible actions can I pursue to improve on my understanding of the client's situation?
and How is the family responding to the experience?
As Nurse Rica and Nurse Jaia tried to select the appropriate nurse family contact in helping the Hyerinko
family solve the health problem of the eldest son showing signs of depression, what will be the
considerations of the nurses in choosing the type of nurse family contact?
Which of the following nursing diagnosis should be the most prioritized health problem?
- Dyspnea of Mr. Ryes as a health deficit
A systematic phase of family nursing process, also referred to as the development of the blueprint of nursing
care:
- Planning
Writing the objectives for a family nursing care plan, includes all the following characteristics except:
The resources available
Covert and overt performance
Conditions that may include the client’s expected experience
Internalization of commitment to feelings expressed as emotions or attitudes.
- Internalization of commitment to feelings expressed as emotions or attitudes.
Which of the following objectives is considered to be under the cognitive domain which demonstrates
client’s comprehension on what is being communicated by recognizing its translated form?
- After watching a 5 – minute video on nutrition the family will be able to give at least three examples
of food choices that will be included in his diet.
Which of the following Objective statements used a criterion-reference in evaluating the performance?
- The family will list five symptoms of high blood pressure
Which of the following Goals is appropriate on your nursing diagnoses: “ Risk for injury of Mr. Ten due to
broken stairs as health threat”
- After nursing intervention, the family of Mr. Ten will be able to fix the broken stairs and be free of
possible injury
Which prioritization criterion should be given the most emphasis if you want to analyze the probability of
minimizing or eradicating the family’s health problem?
- Modifiability
Which prioritization criterion should be considered in order to ensure the family’s participation and
compliance in addressing the identified problem?
- Salience
What effect does duration of a health problem have on its modifiability?
- Both
Which intervention will you undertake in order to help your client family who is unable to make decision on
which course of action to undertake to address a problem?
- Identifying with the family, options that are open to them including the required resources
Which of the following objectives can be possibly attained within the shortest possible time and the least
number of home visits?
- After nursing intervention, the family will be able to discuss in their own words, the importance of
proper nutrition
- After nursing intervention, the family will be able to competently take care of its mentally-ill
member.
Which of the following are you going to consider when prioritizing health problems according to
salience? The family’s:
- Felt needs?
Which of the following is an example of a developmental stress point/crisis situation?
- Loss of job
The preventive potential of a health problem is influenced by which of the following?

- Magnitude of future problems that may be prevented from occurring
What method/s of data gathering is/are not appropriate to use when getting information about the health
status of each family member:
- Perception of the family’s friend
A criterion in problem prioritization that gives consideration to resources of the family is:
- Modifiability of the condition/ problem
Case: The Perez family of Barangay Isidro in Mendez, Cavite has a 2 year-old son who appears to have
enlarged abdomen with low energy level. According to the mother, the child does not wear slippers at home
and does not wash his hand before eating. The family lacks enthusiasm in recognizing the importance of
hygiene and sanitation.
Data collection for first level assessment involves gathering data which will generate the categories of
health conditions or problems of the family. What is the most applicable and urgently needed for the above
situation?
- Value and practices on health promotion/maintenance and disease prevention
Case: The Perez family of Barangay Isidro in Mendez, Cavite has a 2 year-old son who appears to have
enlarged abdomen with low energy level. According to the mother, the child does not wear slippers at home
and does not wash his hand before eating. The family lacks enthusiasm in recognizing the importance of
hygiene and sanitation.
Under second-level assessment, this family is unable to recognize the presence of the condition or problem
due to:
- Health is the least prioritized
In priority setting, a score of zero (0) for salience implies that:
- The identified condition is not a perceived problem for the family

It is the blueprint of the care that the nurse designs to systematically minimize or eliminate identified health
problems through explicitly formulated outcomes of care and deliberately chosen set of interventions,
resources and evaluation criteria, standards and methods:
- Family nursing care plan
It specifies how the nurse will determine changes in health status, condition or situation and achievement of
the outcomes of care specified in the objectives of the family nursing care plan.
- Evaluation
The type of evaluation that guides both the nurse and the family on decisions about modifications of goals,
objectives and intervention, strategies/ measures, depending upon the current situation, emerging or
additional health needs/ problems and priorities of the family.
- Formative
It determines if the goals as specified in the family nursing care plan are achieved as measured by the
outcome criteria and evaluation standards.
- Summative
Nurse KJ is revising a client’s care plan. During which step of the nursing process does such revision take
place?
- Evaluation
One of the problems that Nurse Rain was able to identify is pre eclampsia of Mrs. Cantos, 36 years old
mother of 5 children. She is at 22 weeks AOG, with BP of 140/90. There is pedal edema and weighs 120 lbs.
One of the family nursing problems that was identified was the inability to recognize the presence of
possible complication in pregancy due to lack of knowledge. One of the interventions was geared towards
broadening the knowledge of the family on possible complications of pregnancy. What will be the more
specific actions of the nurse for this? Choose all that apply.
- All
In the course of the implementation, the family and the nurse realized that the objectives were not
achieved. You try to explore possible reasons. Which among the following is a reason for non achievement
of the objectives? Choose all that apply.
- all
Nurse Cha is very keen on evaluation. Early in the planning phase, she already laid out her plan for
evaluation. What are important considerations in making an evaluation plan?
- All
In a health teaching plan, it is important that the nurse specify the learning strategies. In doing so, what
should guide the nurse in designing the learning strategies?
- All
The model’s basic premise is that behavior change is a process, not an event. As a person attempts to
change a behavior, he or she moves through five stages: pre-contemplation, contemplation, preparation,
action, and maintenance. What is model?
- Stages of change model
Which type of family-nurse contact will provide you with the best opportunity to observe family dynamics?
- Home visit
- It provides an opportunity to do first hand appraisal of the home situation
A couple with a 6-year old child would start schooling for the first time, somewhat bothersome to the
couple. This is health problem categorized as:
- Enhance capacity for health

Situation: It is the 5th day of the nurse deployed by the DOH under the Registered Nurses for Health
Enhancement and Local Service (RN HEALS) Program. The nurse supervisor assist the registered nurse
trainees in selecting the appropriate second level assessment among the families in Bgy. Purita, Baba, Sta.
Rosa.
Mrs. Ligaya verbalized “I know that getting vaccinated protects my son’s health. At 6-months-old, for me my
son has completed his immunization, we will just spend our money for food than transportation to this
health center.” Second level assessment shows:
- Inability to provide adequate nursing care to the sick , disabled, dependent or vulnerable/at risk
member of the family
Nurse Gel encourages the mother of 16-year-old teenager to listen to her daughter’s concern of hearing
voices that tells her to hurt herself. The mother smiled at her and asked to leave at once because their
friends are waiting. The second level assessment is:
- Inability to recognize the problem
4-5 Formative Assessment #4 - 10 items
The Reid family was found to have 2 adult members who have uncontrolled Hypertension, James (45 y/o)
and Nadine (42 y/o). James Reid, the head of the family, mentioned “Yes, me and my wife were diagnosed
of Hypertension last month in the health center because we both complained of headache. We were
prescribed medication but we don’t take it because I think we feel okay. I know of a neighbour who has
Hypertension and I think he is also doing okay without the medication.” The nurse and the family in the plan
of care agreed that the objective would be that the family will be able to provide care to the hypertensive
members of the family. Which of the following will be the appropriate intervention?
Offer health center services
Teach about the nature of Hypertensionach about the nature of Hypertension
Assist the family in understanding the complications of uncontrolled Hypertension.
Assist the family in understanding proper management and its impact on control of hypertension?
Give a BP apparatus.
The Zora family has one pregnant member, Sarah the wife of the head of the family. Here are some of the
notable cues from history taking and PA: G5P4T3P1A0L4M0, she is currently 37 years old, AOG 30wks and 2
days, fundic height is 25cm, cephalic, with fetal heart tone of 109bpm at LLQ. You also noted that she
stopped visiting the health center. According to her, she had an argument with one midwife a few months
ago. Which of the following is true about the focus of your interventions in your care plan for Sarah?
Emphasize to Nadine that health center services are free
Refer Nadine to the health center and settle conflict with the health center personnel whom she had
altercation with
Discuss to Nadine’s family the importance of regular prenatal check upshe importance of regular prenatal
check ups
Assist the family in providing adequate care to Nadine by doing daily home visit and Leopolds Maneuver.
Refer Nadine immediately to an OB Gyn doctor and have her checked in a hospital since she has high risk
pregnancy??
The Pitak family is a nuclear family. They are six (6) in the family. They are as follows, Mrs. Pauline Pitak, 38
years old and Mr. Victor Pitak, 45 years old. Mrs. Pitak is currently pregnant with their fifth child. Their
eldest is Tali, 14 years old. The second child is Vico, 12 years old. The third child is Danica, 10 years old and
Oyo is the fourth who is 4 years old. initially, they thought that Oyo will be the last child. Mrs. Pitak stays at
home while Mr. Pitak is a construction worker in a nearby site. He earns around 600 per day. Mrs. Pitak
tries to help augment the family income by making and selling "kakanin". They are worried about their
current situation. When asked about their knowledge on family planning as well as the FP method that
they were using, they said that they did not use any family planning method before. They said that they just
heard from neighbors and friends about FP, but would not exactly know in detail about what it is all about
and the appropriate FP method for them. The nurse identified " family size beyond what family resources
can adequately provide" as the health problem. Based on the in-depth assessment , the family nursing
problem is inability to make decisons with respect to taking appropriate health action due to lack of
knowledge about the alternative courses of action open to them. The goal of care includes helping the
family decide on an action to maintain family size. One of the objectives is for the family to be able to select
a Family Planning method appropriate for them. What will be the best intervention for this objective?
All the options listed.?
Discuss with the couple family planning.
Analyze the advantages and disadvantages of the different FP methods to help them decide on the method
best suited for them.
Discuss with the family the different FP methods.
The Lara family is one one the families assigned to you. One of their favorite past time activities, especially
during this time of the pandemic, is watching their favorite Korean drama every night. They do this while
eating junk food which are high in sodium and fat content. They have been doing this practice on a regular
basis since March of this year. Upon assessment, they do not consider this as a problem. You developed a
plan of care for the family. Hence, you want to assist the family in recognizing the problem. Which among
the following should be the focus of your intervention?
All of the choices listed.?
Assist the family in understanding the implication of eating non-nutritious food.
Discuss with the family the implication of unhealthy eating practices.
Explain to the family the nature of the problem.
As a nurse caring for a family, at certain points during the implementation phase, you ask yourself the
following questions; " How is the client responding to this situation?"; Do I fully understand the
patient's/client's reality?" When you ask these questions and try to answer them, how do you call this
practice?
- Reflective Practice
In this phase of the FNP, the nurse and the client family perform what is required, monitor action taken, and
modify patterns.
- Implementation
Nurse Cecile, during the course of her working relationship with the Dalisay family, continous to give
feedback to the family. She also constantly reviews if interventon strategies are focused. They also consider
the current situation or any other emerging concerns. What is the type of evaluation being done by Nurse
Cecile?
Nurse Erica and the Cutiangco family focused on the malnutrition problem of the children of Mr. and Mrs.
Cutiangco. After developing and implementing the plan of care, Nurse Erica understands that an important
phase of the family nursing process is evaluaton. Which among the following statement is true with
evaluation?
This is a type of evaluation where you chart the assessment data observed and or gathered, the intervention
done, the client’s response or responses to the interventions and any action or actions s taken based on the
responses.
- AIR, A (Assessment, Intervention, Response, Action)
One of the health problems that you identified in the Cantoria family is the immunization status of the
youngest member of the family Baby Jellaine. They have not been going to the health center since the
Dengvaxia issue. Baby jellaine has not received yet measles vaccine. Based on your in depth interview
during the second level assessment, the family nursing problem that you identified is the "inability of the
family to decide on appropriate actions to take." What would be the focus of the interventions?

5-5 Formative Assessment #5
The Code devolved basic services for agriculture extension, forest management, health services, barangay
roads and social welfare to Local Government Units.
- Local Government Code of 1991
A core element of the implementation of the Primary Health Care, which is a strategy adopted by
Department of Health in the late 1970’sin compliance with the Declaration of Alma Ata on Primary Health
Care to ensure that essential health care.
- Decentralization
This is to ensure that essential health care is “made universally accessible to individuals and families in the
community through their full participation and at a cost that the community and country can afford.
- Alma-Ata Declaration of 1978
Introduced a major devolution of national government services, which included the first wave of health
sector reform. The Code devolved basic services for agriculture extension, forest management, health
services, barangay roads and social welfare to Local Government Units.
- Republic Act 7160, Local Government Code of 1991
The aim of decentralization.
- To widen decision-making space of middle level managers, enhance resource allocations from
central to peripheral areas and to improve the efficiency and effectiveness of health services
management.
A body that is good venue for making the local health system more responsive to the needs of the people.
It’s mandate to propose annual budgetary allocations for the operation and maintenance of health facilities
and services within the municipality, city or province.
- Local Health Board
The following are the functions of local health board except;
- To widen decision-making space of middle level managers, enhance resource allocations from
central to peripheral areas and to improve the efficiency and effectiveness of health services
management.
Republic Act 7160 the Local Government Code of 1991, was signed into law on?
- October 10, 1991 and took effect on January 1, 1992
What are the pillars of the Philippine health care delivery system? Select all that apply.
- Health Financing
- Regulation
- Health sevice delivery
- Governance
It is said that despite living longer than in previous years, Filipinos now bear a triple burden of disease. What
is meant by triple burden of disease?
- High prevalence of communicable diseases and NCDs and Diseases of rapid urbanization and
industrialization.
The current health status of the country is said to be characterized with mixed health outcomes. Which
among the statements is true about this description?
- The country only had modest gains in selected health outcome indicators and weak performance in
others.
This is a capable private health facility or an appropriately upgraded public health facility that is either a
Rural Health Unit (RHU) and/or its satellite Barangay Health Station (BHS) or Hospital capable of performing
the following emergency obstetric functions: (1) parenteral administration of oxytocin in the third stage of
labor; (2) parenteral administration of loading dose of anti-convulsants; (3) parenteral administration of
initial dose of antibiotics; (4) performance of assisted deliveries in imminent breech; (5) removal of retained
placental products ; and (6) manual removal of retained placenta.
- Basic Emergency Obstetrics and Newborn Care (BEmONC) Provider
This is the blueprint to achieve a better and more sustainable future for all. They address the global
challenges we face, including those related to poverty, inequality, climate change, environmental
degradation, peace and justice.
- Sustainable Development Goals
In 1978 world leaders, international organizations and health authorities gathered in Alma-Ata (now
Almaty), Kazakhstan, and released the Declaration of Alma-Ata on Primary Health Care, which remains a
landmark document in the history of global health. The principles of PHC includes? Select all that apply?
- Accessibility
- Appropriate Technology
- Community participation
- Health promotion
The Department of Health commenced the implementation of Primary Health Care in 1979. It started on a
pilot basis in twelve provinces representing each region. In 1981, the DOH launched PHC nationwide. Its
implementation may not have been done as smoothly as expected. Currently, PHC is needed more than
ever. What reason supports this?
RLE FHN Quiz
“Malakas kumain ng kanin at malikot ang mga anak ko”, said Rosa. This is a cue that she
has:
1. Inability to recognize problem of malnutrition

2. Inability to utilize community resources
3. Lack of knowledge
4. Inability to make decision
1, 3?
2, 3
4, 3
None of the above
Data: Aling Francia, 45 years old mother, pregnant for the 7th
Aling Francia’s pregnancy is a:
Health Deficit
Health Threat
Health Problem
Foreseeable Crisis?
Health threats include the following:
1. Trining habitually walking barefooted

2. Paul in the company of addicts
3. Two sisters sending money
4. Mang Julio as jobless
5. Aling Francia as multipara
1, 2, 3
1, 2, 5
1, 2?
3, 4, 5
Situation: MAITA, 32 years old is a mother of Nene (5 y/o), Nelson (3 y/o), and Pipoy (2
mos). They live in a slum area 1 km away from the health center. The only source of
livelihood for the couple is scavenging in the nearby city dump. On her first visit, nurse
Gloria noted the following:
• No immunization for all the children

• Rodents and insects are all over the house
• No toilet
• Water source is 3 houses away
The goal of care is:

By January 2021, Rosa will understand malnutrition
By January 2021 , the nutritional state of of Nene and Nelson will improve from second
degree malnutrition to at least first degree malnutrition?
Nene and Nelson will eat vegetables
Given a sample meal plan, Rosa will prepare a well balanced meal

• No toilet
The above condition of Rosa’s family is describe as:

Health threat
Health deficit
Foreseeable crisis
All of the above?

• No toilet
Both Nene and Nelson are 2nd degree malnourished. This is

- Health deficit
All but one of the following data is gathered during the first level assessment.
- Family’s perception of the problem
The process of making continuous appraisal of the family’s response to health care is:
- Evaluation
This is defined as the health judgment related with the client’s capability for optimum health.
- Wellness Potential
The nurse measures the status of the family and its ability to resolve its problems.
Assessment?
Planning
Implementation
Evaluation
The modifiability of the health problem is determined by the following factors: Select all that
apply.
Resources of the Family

Resources of the Nurse
Resources of the community
Current knowledge, technology and interventions to enhance the wellness state
In the family health nursing, a cardinal principle in goal settings is that goals must be:
Stated in terms of nurse's objectives
Specific, measurable, quantifiable
Set mutually between the family and nurse?
Consistent with the goals of health
The Romero family of Barangay Ligaya is considered high risk. Which of the following are
quantifying indicators?
1. Aling Francia, 45 years old mother, pregnant for the 7th

2. Mang Julio, 50 years old father is jobless with undiagnosed PTB.
3. Paul, 18 years old, the eldest son who associates with drug addicts.
4. Trining, 5 years old, the youngest has developmental delays.
5. Two of Julio’s sisters are nurses working abroad regularly sending him money.
1, 2
1, 2, 3
1, 2, 3, 4?
1, 2, 3, 4, 5
Evaluation on the implementation phase is essential because it will:

Analyze how the plan was implemented
Determine the factors what made it successful
Specify the factors associated with the problem
All of the above?
In developing a family nursing care plan, a correctly stated objective is:

Given pertinent information, the client in 10-15 min will describe nutritionally adequate
meals
Given materials on the Filipino food pyramid, the client will enumerate food items rich in
essential nutrients
Given a one week menu model, the client will make a one week meal plan for the family?
The client will gain weight
6-5 Formative Assessment No. 6 - The Ottawa

Charter and PRECEDE PROCEED Model
1) The Public Health Nurse (PHN) set a meeting with the the Kagawad for Health in Bgy. Masigla to discuss
precautionary measures on COVID19 pandemic. Some of the activities identified for a one-week
implementation includes morning zumba for elderly, and twice a day demonstration of handwashing to
children and and adults. This healthcare practices is referred as:
- Health promotion
2) The Non- Government Organization for environment “Berde Tayo”, in collaboration with the Department
of Environment and Natural Resources (DENR), conducted a project on urban planting in the City of Manila.
The NGO group utilized this strategy of health promotion:
- Mediate
3) The company nurse develops a health promotion program to combat obesity at workplace. The nurse
collaborated with the staff of human resources for health, and came up with a memorandum for compliance
of the program by all employees, and eventually developed policies about promotion of healthy lifestyle
practices at workplace. The Ottawa Charter principle applied is:
- Build healthy policy
4) Mayor Isko of Manila City keeps on reminding his constituents to keep not only their houses clean but
their surroundings as well. The Ottawa Charter focused on:
- Protection and built of the environment
5) All of the following statements are correct about Ottawa Charter, except:
- An international conference organized by the World Health Organization Western Pacific Region
6) Kiko, a member of LGBT group went to Bgy Bukas Health Center for consultation of the colds and
abdominal pain he’s been experiencing for four days. He went to the pharmacy area to request for free
medicine from the nurse, although available, the nurse advised him to buy outside the health center instead.
This is contrary to Ottawa Charter’s Principle of:
- c. Enable
7) Mayor Isko has deliberately changed the structures of several departments under his leadership, and
strictly implemented rules and regulations especially on extortion issues of employees towards the people.
The Ottawa Charter Principle is:
Strengthen community action
Advocate
Build healthy policy
8. Which of the following applies the Ottawa Charter principle?

Hand washing among school aged children
Covid 19 Vaccine for kuya Pimentel
Consultation of Mang Kiko Duque on hypertension
Tooth extraction of lola Ines
9) The employees were encouraged to work in a well ventilated area, this is an example of Ottawa strategy?
- Creating supportive environment
10)Which of the following describes the occurrence of illness that could be a basis for the Department of
Health (DOH) to develop a program of development in a certain community?
- Epidemiological diagnosis
11) Jakdu, a farmer in far flung barangay in Leyte, is worried of schistosomiasis. He heard that some of the
farmers got it as they walked through the dumpsite bare footed. Since then he always wear a pair of boots.
This behavior is referred to as:
Enabling factor
Predisposing factor
Reinforcing factor
Reward
12) This model is used to determine the effect of health promotional program that was implemented based
on the health need assessed by the PHN:
- PRECEDE – PROCEED Model
13) Health Secretary Juday designed a structure to plan to care for undernourished children in Bgy. Magaan.
This is referred to as:
- PRECEDE
14) As the Kagawad for Health, nurse Joy acted on hygiene illiteracy in Bgy. Maputi by installing wash areas
in public places. This phase of PRECEDE-PROCEED Model is referred as:
- Administrative and Policy Diagnosis
15) All of the following are components of PRECEDE, except:
- Participating
8-8 Formative Assessment No. 8 - Ethics, Law,

and Entrepreneurial Nursing
Mayor Alma ordered the closure of the Restaurant after seeing clients smoking in the said
facility. Which law was violated by the restaurant owner?
- EO No. 26
Manang Gee went to the Bgy Hall after being battered by her husband. Her husband even
spent the money for their daughter’s newborn screening test for to buy alcoholic drinks and
maybe drugs. She is determined to file a case against her husband for violating:
- RA 9262
Nurse Jina received a call from a certain “relative” of the patient, who insisted to get a copy
of the patient’s ultrasound result. The caller threatened to sue nurse Jina to lose her job
because the caller holds a high rank position in the medical field. She then gave what the
caller asked for. What ethical principle was violated?
Article 1 Ethical Principles for Filipino Nurses
Article 3 Ethical Principles for Filipino Nurses?

Mang Kiko lives in the farthest Poblacion of his town, only when he got hospitalized that he
has known of Philhealth Insurance, he could have spent his spare money to buy some
medicines. What law permits an individual to use Philhealth in emergency or elective case
of hospitalization?
- RA 7875
Semya, a healthy, middle age woman was diagnosed as positive with COVID19 in Makati
Medical Center. Semya also complained of not being able to use her benefit from
Philhealth. Dr. Sharon didn’t tell anyone of the findings as requested by the patient. She
violated:
- RA 11332
All of the following are components of the ehealth vision, except:
Good quality health care for Mang Juan dela Cruz?
Same health benefits for all
Health for all
The Congress just approved the law requiring all employees to wear face shield, and face
mask, and do an hourly hand washing in the work place. All of these would be monitored
electronically by the employer and would submit a report to DOH and DTI. This would
prevent economic loss, and promote one’s health amidst the COVID 19 pandemic. This is
an example of ehealth:
- Legislation, Policy, and compliance
President Duterte called for experts in the field of Science and Medicine to invent drugs and
vaccine that could eradicate COVID19. This is an innovation of:
- Health technology
Public Health Nurse Vilma spends most of her working hours in the Rural Unit organizing
the patients’ files, and keeping track of the children for immunization. What could be the
best ehealth solution for PHN Vilma to maximize her time in providing care to patients?
- Electronic Medical Record
Which of the following activities was initiated by the World Health Organization to look for
opportunities on integrating innovations on health?
- Health Technology Assessment
Which of the following consultancy businesses is appropriate for a nurse who conducts staff
training on communicable diseases and lifestyle – related diseases?
- Teaching
- Program management?
Bgy. Biglang-Awa is an area populated with children mostly less than fiver years old,
pregnant women, unemployed males hanging around with groups for alcohol drink
especially at night. The Bgy Chairman thinks of ways to help the Bgy. Which of the
following services should he seek for consultation?
- Process consultant
This refers to the Program initiated by the Department of Labor and Employment to provide
opportunities to unemployed nurses:
- Entreprenurse
All of the following are reasons to practice entrepreneurship in health care, except:
Medical products provide a good profit regardless of health benefits.?
Collaboration with other sectors could promote health services accessible to all Filipinos.??
Enhancement of skills both on business and healthcare advocacy.

Develop innovations that could help improve the economy.
PHN Vi is contemplating on starting up a business after her retirements. She would then be
called:
- A nurse entrepreneur
- An entrepreneur?
Mayor Alma ordered the closure of the Restaurant after seeing clients smoking in the said
facility. Which law was violated by the restaurant owner?
- EO No. 26
Manang Gee went to the Bgy Hall after being battered by her husband. Her husband even
spent the money for their daughter’s newborn screening test for to buy alcoholic drinks and
maybe drugs. She is determined to file a case against her husband for violating:
- RA 9262
Nurse Jina received a call from a certain “relative” of the patient, who insisted to get a copy
of the patient’s ultrasound result. The caller threatened to sue nurse Jina to lose her job
because the caller holds a high rank position in the medical field. She then gave what the
caller asked for. What ethical principle was violated?
- Article 3 Ethical Principles for Filipino Nurses
Mang Kiko lives in the farthest Poblacion of his town, only when he got hospitalized that he
has known of Philhealth Insurance, he could have spent his spare money to buy some
medicines. What law permits an individual to use Philhealth in emergency or elective case
of hospitalization?
- RA 7875
Semya, a healthy, middle age woman was diagnosed as positive with COVID19 in Makati
Medical Center. Semya also complained of not being able to use her benefit from
Philhealth. Dr. Sharon didn’t tell anyone of the findings as requested by the patient. She
violated:
- RA 11332
All of the following are components of the ehealth vision, except:
- Good quality health care for Mang Juan dela Cruz
The Congress just approved the law requiring all employees to wear face shield, and face
mask, and do an hourly hand washing in the work place. All of these would be monitored
electronically by the employer and would submit a report to DOH and DTI. This would
prevent economic loss, and promote one’s health amidst the COVID 19 pandemic. This is
an example of ehealth:
- Legislation, Policy, and compliance
President Duterte called for experts in the field of Science and Medicine to invent drugs and
vaccine that could eradicate COVID19. This is an innovation of:
- Health technology
Public Health Nurse Vilma spends most of her working hours in the Rural Unit organizing
the patients’ files, and keeping track of the children for immunization. What could be the
best ehealth solution for PHN Vilma to maximize her time in providing care to patients?
- Electronic Medical Record
Which of the following activities was initiated by the World Health Organization to look for
opportunities on integrating innovations on health?
- Health Technology Assessment
Which of the following consultancy businesses is appropriate for a nurse who conducts staff
training on communicable diseases and lifestyle – related diseases?
- Teaching
Bgy. Biglang-Awa is an area populated with children mostly less than fiver years old,
pregnant women, unemployed males hanging around with groups for alcohol drink
especially at night. The Bgy Chairman thinks of ways to help the Bgy. Which of the
following services should he seek for consultation?
- Process consultant
This refers to the Program initiated by the Department of Labor and Employment to provide
opportunities to unemployed nurses:
- Entreprenurse
All of the following are reasons to practice entrepreneurship in health care, except:
- Medical products provide a good profit regardless of health benefits.
PHN Vi is contemplating on starting up a business after her retirements. She would then be
called:
- A nurse entrepreneur
Summative Assessment 3 : FINAL EXAM
The number of cases of Dengue fever usually increases towards the end of the rainy season.
This pattern of occurrence of Dengue fever is best described as:
- Cyclical variation
Nurse Cha is very keen on evaluation. Early in the planning phase, she already laid out her plan
for evaluation. What are important considerations in making an evaluation plan?
Which prioritization criterion should be considered in order to ensure the family’s participation
and compliance in addressing the identified problem?
- Salience
"Hindi na, wag na lang kung jan din lang, Baka lumala pa sakit ko. Doon nalang ako sa bayan,
Mr. Ricardo Cruz said when asked if he would like to go to the health center despite being told
that there are free medicines and services available in the health center which is just 3 blocks
away from their home. The family is unable to to the following health task.
- Utilize community resources for health care
Which of the strategies in FOURmula One Plus aims to promote transparency on the execution
of health programs:
- Group of answer choices

- Better health outcomes
- Good governance
- Equitable health care financing
- Performance accountability
As a nurse caring for a family, at certain points during the implementation phase, you ask
yourself the following questions; " How is the client responding to this situation?"; Do I fully
understand the patient's/client's reality?" When you ask these questions and try to answer
them, how do you call this practice?
- Reflective Practice
It refers to the progression of a disease process in an individual over time, in the absence of
treatment. The progression of the disease provides basis for planning the primary, secondary
and tertiary preventions as interventions.
- The natural history of Disease
Another family in the community that Nurse Augelene is monitoring is the Sinta family. Mrs. Sini
Sinta and Mr. Nagsi Sinta are newlyweds. Mrs. Sini Sinta is currently pregnant. As a nurse, you
are aware that Mrs. Sinta's pregnancy is categorized as_____
- Wellness condition
Analytic epidemiology seeks to answer the questions:
- Why
- How
One of the health problems that you identified in the Cantoria family is the immunization status
of the youngest member of the family Baby Jellaine. They have not been going to the health
center since the Dengvaxia issue. Baby jellaine has not received yet measles vaccine. Based on
your in depth interview during the second level assessment, the family nursing problem that
you identified is the "inability of the family to decide on appropriate actions to take." What
would be the focus of the interventions?
The following are the functions of local health board except;
- To widen decision-making space of middle level managers, enhance resource allocations

from central to peripheral areas and to improve the efficiency and effectiveness of health
services management.
The Reid family was found to have 2 adult members who have uncontrolled Hypertension,
James (45 y/o) and Nadine (42 y/o). James Reid, the head of the family, mentioned “Yes, me and
my wife were diagnosed of Hypertension last month in the health center because we both
complained of headache. We were prescribed medication but we don’t take it because I think
we feel okay. I know of a neighbour who has Hypertension and I think he is also doing okay
without the medication.” Which of the following will be the appropriate intervention?
- Assist the family in understanding the complications of uncontrolled
Foreseeable crisis is present in: (Select all that apply) Group of answer choices
- Mang Julio as jobless and laid-off one month ago
Duvall’s model of Family development is applicable to all family structures.
- No
One of the goals set by Nurse Trinity in the Conocido family was to improve the nutrional status
of Elijah, who during the assessment was found to be malnourished. Realistically, you hope to
see the outcomes after 3 of 4 months of nurse-family relationship. Within those months of
implementation of the various intervention geared toward the achievement of the objectives
and the goal (in the long run), the nurse draws ongoing feedbacks from the family and others
involved in the resolution of the problem. Periodic visits were doen to determine if plans and
interventions are appropriately focused. Changes in the weight was also monitored. what type
of evaluation is Nurse Charlize conducting?
The epidemiologic triad of disease causation refers to
- Agent, host, environment

The children of Mr. and Mrs. Dalumbinti have flu. They recognize that this a problem but do not consider it
as one that will be needing immediate attention. What will be the possssible outcomes for this kind of
situation?
- This will be a barrier to joint goal setting.
Tertiary prevention is needed in which stage of the natural history of disease?
- Terminal illness
In the family nursing process, during the assessment phase, after generating the data based on
the Assessment Data Base, you as the nurse will go through data analysis. With this sub step,
you are reminded that the imporatnt activities of this substep includes?
All of the following are major components of the Philippine Heath Care Delivery System, except:
- The SDGs
The World Health Organization defines public health as:
- Science and art of preventing disease, prolonging life, promoting health and efficiency
through organized community effort for the sanitation of the environment.
In which phase of the FNP does the nurse measure the status of the family as a client?
- Assessment
When you ask yourself whether nursing intervention will make a difference, you are determining
the:
- Nature of the problem

- Preventive potential
- Salience
- Modifiability
Nurse Stef in the rural health unit received a report that a patient suffered from Stroke/CVA at
home and is unconscious. She is being asked for help by the family. Their barangay is 2-hour-
drive from the nearest hospital. She immediately informed the Municipal Doctor who is in a
seminar and headed to the patient’s home. Upon arriving she immediately rendered first aid.
Nurse Stef is performing which role?
- B. Provider of Care
Which of the following are you going to consider when prioritizing health problems according
to salience? The family’s:
- Felt needs
Which of the following nursing diagnosis should be the most prioritized health problem?
- Dyspnea of Mr. Ryes a health deficit
In this phase of the FNP, the nurse and the client family perform what is required, monitor
action taken, and modify patterns
- Implementation
population group and communities, concerned with the promotion of the health, prevention of
disease and disability and rehabilitation is defined by;
- Maglaya
During the implementation phase, Nurse Althea, recognizes the importance of reflective
practice in widening her expertise in family health care. In reflecting on her action, what would
be the possible questions that nurse should ask herself?
- What other possible actions can I pursue to improve on my understanding of the client's
situation?
Nurse Charlize jointly set the goal with the Macaspac family in terms of removing the accident
hazard in the home specifically the broken stairs observed in the house of the family. After
implementing the interventions appropriate to the goal and objectives, you are set to do an
evaluation. What will be the main method of evaluation that you will use to determine if the
goal was achieved?

- Records review
- Observation
- Interview
- None of the above
The Ecologic Model helps the student nurse understand the following
- Pattern of disease occurrence
Nursing, together with public health, is one of the helping professions in the health care system
which operates at three level of clientele, these are;
- Individuals, families and communities
The proper sequence of conducting a family nursing assessment includes
- Conduct of physical assessment, compare patterns with norms and standards, identify
the health condition
- Interview, cluster related data, identify patterns, identify the health condition
- Observe, conduct physical examination, identify the health problem
- Conduct an interview, observe, physical assessment, and identify the health problem
Introduced a major devolution of national government services, which included the first wave of
health sector reform. The Code devolved basic services for agriculture extension, forest
management, health services, barangay roads and social welfare to Local Government Units.
- Republic Act 7160, Local Government Code of 1991
Evaluation on the implementation phase is essential because it will:
- All of the above
The assessment phase of FNP ends with:
- Problem identification
Which one of the following statements explains what is meant by the term 'Clean as you go'?
- Clean down before you leave for home.
Nurse Kimmy is revising a client’s care plan. During which step of the nursing process does such
revision take place?
- Evaluation
Maria’s daughter who is working as a nurse in the community hospital was diagnosed with
Covid. The neighbours are asking and are anxious about the situation. Maria has to determine
what information will be released from the family. Maria is fulfilling the role of:
- Gatekeeper
What effect does duration of a health problem have on its modifiability?
- Both
The data that describe the family's realities, perceptions, and performance is
- Second-level assessment
The nurse addresses the health needs and problems of a family in a logical and systematic way
using a series of steps. We call this:
- Family Nursing Process
Nurses have significant roles in the primary level of preventions. The following are examples of
nurse activities showing primary prevention, except:
- Referrals of cancer clients to tertiary hospitals
This is a type of evaluation where you chart the assessment data observed and or gathered, the
intervention done, the client’s response or responses to the interventions and any action or
actions s taken based on the responses.
- AIR, A (Assessment, Intervention, Response, Action)
As a nurse in Barangay Walangkobid, you assessed the family of Mr. Rey Cervantes. The
following are the data that you were able to gather.
Mang Rey, 43 years old is presently jobless and was diagnosed to have pulmonary
tuberculosis. They have five (5) children. The eldest is Paul, 18 years old. He associates with
drug dependents in their barangay. The second child is Riza, who is 16 years old is studying in
a public high school near their place. Chelsea, the third, nine years old is also studying in public
elementary school and is assessed to be malnourished. Popo, 5 years old, not yet enrolled in
school, walks barefoot in the street. Chin chin, three years old is left to play with her brother
Popo. She also plays in the streets of the barangay without her slippers. Currently, they are
being assisted by the sisters of Mang Rey. His sisters are working abroad.
The process of making continuous appraisal of the family’s response to health care is:
- Evaluation
Which of the following is most likely to be a source of food poisoning bacteria?
- raw meat
As you are assessing the Batumbangkal family, you are able to gather data about how the
Aling Ising, the mother, takes care of her children especially when they were still young. She
mentioned that she practiced exclusive breastfeeding in all her children. Now that she is
pregnant with her fifth child, she expressed her plan to breastfeed her baby. She said that even
if she brestfed her other children before, she is still interested to know more about
breastfeeding. She is worried that now she is about to give birth and will do breastfeeding, her
milk production may not be enough.
As a nurse, you took note of the desire to know more and improve breastfeeding practices.
You identified this as a presence of a wellness condition,. A wellness condition as you
understood is_____________
The ecologic model which emphasizes the role of the agent in causing the disease:
- Wheel
- Pie
- Web
- Lever
After seeking consultation with the Primary Care Physician, Petra Pobre asked you if she can
buy inexpensive medicine having the same effectiveness with branded medicines. You replied:
- No, as explained under RA No. 7160

- No, just buy what’s indicated in the prescription paper.
- Yes, its supported by RA No. 6675
- Yes, its supported by RA No. 996
The Lara family is one one the families assigned to you. One of their favorite past time
activities, especially during this time of the pandemic, is watching their favorite Korean drama
every night. They do this while eating junk food which are high in sodium and fat content.
They have been doing this practice on a regular basis since March of this year. Upon
assessment, they do not consider this as a problem. You developed a plan of care for the
family. Hence, you want to assist the family in recognizing the problem. Which among the
following should be the focus of your intervention?

- Explain to the family the nature of the problem.
- All of the choices listed.
- Discuss with the family the implication of unhealthy eating practices.
- Assist the family in understanding the implication of eating non-nutritious food.
The current health status of the country is said to be characterized with mixed health outcomes.
Which among the statements is true about this description?
- The country only had modest gains in selected health outcome indicators and weak
performance in others.
Nurse Stef called the ambulance driver to pick up the patient for possible transport to the city.
She also called the hospital admission staff that they will be bringing a patient for possible
admission and reported the details over the phone. Nurse Stef is performing which role.
- Coordinator
- After nursing intervention, the family will be able to competently take care of its
mentally-ill member.
The typology of family nursing problems is used in the statement of nursing diagnosis in the
care of families. The youngest child of the de los Reyes family has been diagnosed as mentally
retarded. This is classified as a:
- Health deficit
While doing an interview with the Delos Reyes family, the following are the data that you are
able to gather: Mr. Lito Delos Reyes is the prime decision maker of the family. The family is an
extended family with the parents of Mr. Delos Reyes living in the same house. They are nine (9)
in the family. The members of the family are as follows; Mr. Lito Delos Reyes, the father; Mrs.
Linda Delos Reyes, the mother; Lita, Cindy, Julie, Leslie and Richard-the children; and Lolo
Justininano and Lola Nilda. They are not very demonstrative in terms of their affection with one
another. Lola Nilda sometimes have conflicts with Mrs. Linda Delos Reyes especially when it
comes to matters related to child rearing. The children have high respect for the parents and
grandparents. What is/are true about the data that you have gathered?
Nena sees to it that their house is clean and orderly where she can see her children playing
without fear of getting sick or getting injured. This is because it is the task of the family to:
- Maintaining a home environment conducive to health maintenance
- It provides an opportunity to do first hand appraisal of the home situation.
This is the blueprint of the care that the health worker designs to systematically minimize or
eliminate the identified health problems through explicitly formulated outcomes of care and
deliberately chosen set of interventions, resources and evaluation criteria, standards and
methods.
- Family Nursing Care Plan
In Family Health Nursing, a cardinal principle in setting goal is that a goal must be: Group of
answer choices
• set mutually between the nurse and the family
As Nurse Rica and Nurse Jaia tried to select the appropriate nurse family contact in helping the
Hyerinko family solve the health problem of the eldest son showing signs of depression, what
will be the considerations of the nurses assigned to the Hyerinko family?
• All of the options listed

Most of the mothers in Barangay Masasa practices breast feeding to their newborns and
adheres to the completion of vaccine. This practices indicates:
• A wellness state to prepare for any forthcoming challenges on the care for children
The nurse utilizes which of the following to address the health problem of the client. Select the
best answer.
• Family nursing process
The type of evaluation that guides both the nurse and the family on decisions about
modifications of goals, objectives and intervention, strategies/ measures, depending upon
the current situation, emerging or additional health needs/ problems and priorities of the
family.
• Formative
Evaluations measure:
• The outcomes and impact of a program's activities
When nurse and the client perform what is required, monitor actions taken and modify
patterns, this is referred to as:
• Implementation
Primary health care is a total approach to community development. Which of the following
is an indicator of success in the use of the primary health care approach?
• Health programs are sustained according to the level of development of the

community.
Which Sustainable Development Goal number ensures healthy lives and promote wellbeing
for all at all ages?
• Goal 3
Situation: It is the 5th day of the nurse deployed by the DOH under the Registered Nurses
for Health Enhancement and Local Service (RN HEALS) Program, as the nurse supervisor,
assist her in selecting the appropriate second level assessment among the families in Bgy.
Purita, Baba, Sta. Rosa. Question:
Mrs. Ligaya verbalized: " I know that getting vaccinated protects my son’s health. At 6-
months-old, for me has has completed his immunization, we’ll just spend our money for
food than transportation to this health center.” The second level assessment is:
• Inability to provide adequate nursing care to the sick , disabled, dependent or

vulnerable/at risk member of the family
Describing distribution in epidemiology answers the following:
• Where
• When
• Why
• Who
This is defined as the health judgment related with the client’s capability for optimum health.
• Wellness Potential
In priority setting, a score of zero (0) for salience implies that:
• The identified condition is not a perceived problem for the family
What method/s of data gathering is/are not appropriate to use when getting information
about the health status of each family member:
• Perception of the family’s friend
One of the problems that Nurse Rain was able to identify is the possible complicated
pregnancy of Mrs. Cantos, 36 years old mother of 5 children. She is at 21 weeks AOG,
with BP of 140/90. There is pedal edema and weighs 120 lbs. One of the family nursing
problems that was identified was the inability to recognize the presence of possible
complication in pregancy due to lack of knowledge. The goal of care is that after the
nursing intervention, the family will take the necessary measures to prevent possible
complicated pregnancy such as pre-eclampsia. One of the interventions was geared
towards broadening the knowledge of the family on possible complications of
pregnancy. What will be the more specific actions of the nurse for this? Choose all that
apply.
Discuss with the family the causes of pre eclampsia and risk factors of pre-eclampsia.
Discuss the consequences of a possible consequences of pre-eclampsia.
Explore with the family the available courses of action open to them.
Discuss the implications of the signs and symptoms presented by Mrs. Cantos.
• all?
In the family health nursing, a cardinal principle in goal settings is that goals must be:
• Set mutually between the family and nurse
Nurse Erica and the Cutiangco family focused on the malnutrition problem of the children
of Mr. and Mrs. Cutiangco. After developing and implementing the plan of care, Nurse Erica
understands that an important phase of the family nursing process is evaluaton. Which
among the following statement is true with evaluation?
• All of the options listed.
Health Promotion as a positive concept is organized by the World Health Organization on

the first International Conference in 1986. This is known as:
• The OTTAWA Charter
The main reason for keeping kitchens clean is:
• to prevent contamination of food
A component of the family nursing care plan which specifies the criteria by which the
degree of effectiveness of care are to be measured
• Objectives of care
The preventive potential of a health problem is likely to be affected by the following factors:
(Select all that apply)
• Duration of the problem

• Current technology, knowledge and intervention to solve the problem
• Severity of the problem
• Exposures of any high-risk group
True or False
1. The Department of Health is the national agency mandated to lead the health sector towards
assuring quality health care for all Filipinos.
2. The Department of Health provides guidance and technical assistance to the Local
Government Units (LGUs) in various regions of the country.
• If first statement is true and second statement is false
Which among the statements is true about second level assessment in Family Health
Nursing? Group of answer choices
• All the options listed
Which of the following objectives can be possibly attained within the shortest possible time
and the least number of home visits? Group of answer choices
Objective C: After the first home visit, the malnourished member will be able to attain
normal weight.
B&C
A&B
Objective B: After nursing intervention, the family will be able to discuss in their own words,
the importance of proper nutrition.
Objective A: After nursing intervention, the family will be able to feed the undernourished
child according to the prescribed quality and quantity of food.
Help the novice nurses in RHU – Yagit, Banana, Rizal to categorize this health
situation/problem: Mrs. Nadyn, cried for help about her baby Jernadyn, who’s been
vomiting and has inability to move her legs.
• Health deficit
In a health teaching plan, it is important that the nurse specify the learning strategies. In
doing so, what should guide the nurse in designing the learning strategies?
• All of the options listed
In what year did the Philippines Government devolved the management and delivery of
health services from the National Department of Health to locally elected provincial, city and
municipal governments.
• 1992
The type of evaluation that guides both the nurse and the family on decisions about
modifications of goals, objectives and intervention, strategies/ measures, depending upon
the current situation, emerging or additional health needs/ problems and priorities of the
family.
• Formative
Which is contrary to the principles in planning a home visit?

• Home visit should be conducted in the manner prescribed by the RHU
The modifiability of the health problem is determined by the following factors: Select all that
apply.
• Resources of the Nurse

• Current knowledge, technology and interventions to enhance the wellness state
• Resources of the community
• Resources of the family
Data: Mang Julio, 50 years old father is jobless with undiagnosed PTB.
Mang Julio’s PTB is a:
• Health deficit
Which of the following best describes the family as the basic unit in society?
The health problems that should only be attended are only those for treatment
Values, beliefs and cultural practices should also be considered in nursing care?
The health services available are limited to out of pocket payment in hospitals
Care of the family focuses on restoring one’s health
In terms of understanding the natural history of disease, Epidemiology seeks to study the
following: Select all that apply.
Communicable or Infectious Diseases
Emerging diseases
Injuries
Violence
Non communicable or non-infectious diseases
- All?
Aling Francia is proud of her big family and accepts her present pregnancy. Mang Julio is
unconcern about being jobless since his sisters send him money. Second level assessment
reveals the following problems:
1. Inability to recognize the problem
2. Inability to provide home environment conducive to health
3. Due to philosophy/attitude
4. Ignorance of preventive measure
2 and 4
1 and 4
1 and 3?
2 and 3
Situation: Help the novice nurses in RHU – Yagit, Banana, Rizal to categorize the health
problem/situation.
Allan, first year college student in Pasay City is bothered on how can he go to school
because of various road closure due to conduct of SEA Games.
Health deficit
Wellness state?
Foreseeable crisis
Health threat
Adopting a national code of marketing of breast milk substitutes, breast milk supplement
and related products, penalizing violations thereof, and for other purpose is :
- EO No. 51
True or False
1. The Philippines is a member of global system of nations interacting with each other.
2. The health status of the Filipinos will never be affected by any events that happen
outside the country.
If both statements are false
If first statement is false and second statement is true.
If both statements are true
If first statement is true and second statement is false?
3.3 - Formative assessment
As a student nurse, you are aware that medication safety protocol help prevent medication error.
To ensure that you are giving the right drug, you should read the label:
- Three times
While preparing the medication, you are asked by your clinical instructor on how do you administer
sublingual medication. Your best answer would be:
- Place it under the tongue
Parenteral forms are administered thru: (Select all that apply)
Intraosseous
Intramuscular
Intradermal
Buccal
- All except D
One important goals of medication safety is to practice the “Five plus five Rights” of medication
administration. This includes: (Select all that apply)
Right drug
Right decision
Right education
Right time
- All except B
The nurse is aware that all are considered an acceptable abbreviations of dug administration
except:
- q.d
What information is essential for the nurse to know related to right documentation? (Select all that
apply.)
The correct site of injectable medication
The necessity to document all medications given at the end of a shift
Patient response to an antiemetic
Patient’s blood pressure prior to giving an antihypertensive
Date and time of dose and necessity for the nurse’s initials/signature
- all except b
A patient refuses to take the prescribed medication. Which is the nurse’s best response to this
patient?
- Explain the risks of not taking the medication

Nurses should strongly adhere to drug administration medication safety to prevent incidence of
blood-borne related infections such as HIV/AIDS and Hepatitis B. Which of the following address
this safety?
- Sharps safety
4.6- Formative assessment
Convert the 35 lbs to kg = ________kg (no rounding of , 2 decimal places, numbers only)
Example: 12.25
Answer: 15.91 / 15.90
Example: 5.25
Answer: 6.82 / 6.81
Example: 12.00
Answer: 50.00
Convert the 12 kg to lbs = ________lbs (no rounding of , 2 decimal places, numbers only)
Example: 12.30
Answer: 26.40
Calculation by weight: (no rounding of , 2 decimal places, numbers only) Example: 12.00
Give Acetaminophen 10.5 mg/kg every 4 hours for pediatric weighting 12 kg.
Answer: 126
The doctor’s order is to give Tramadol 1.5 mg/kg of body weight. The weight is 110 lbs.
Answer: 75
Convert the 75 kg to lbs = ________lbs (no rounding of , 2 decimal places, numbers only)
Example: 12.00
Answer: 165.00
Dimensional Analysis The doctor’s order is to give 5 grains of Aspirin. Available is 5 grains
per tablet. How many tablet will you give?
Answer: 1
The doctor’s order is to give 200 mg Sulfisosxazole. The bottle contains 125 mg / 5 ml. How
much liquid should you give?
Answer: 8
Use the Clark’s Rule: Compute for the child dose. Adult dose = 500mg every 6 hours
Child’s weight = 28 kgs
Answer: 205.33
Compute for Child dose: Analyze first the formula that you will use, Adult dose = 500mg
every 6 hours Infant’s age = 4 months
Answer: 13.33
Give Tamiflu 2.5 mg/kg/day divided into doses for infant weighing 7.5 kg.
Answer: 9.37
Calculation by Weight and Age: Use the Clark’s rule: Compute for the child dose. Adult
dose = 500 mg every 8 hours Child’s weight = 42 lbs
Answer: 140 mg
Compute for Child dose: Analyze first the formula that you will use, Adult dose = 500 mg
every 6 hours Child’s age = 7 y/o
Answer: 184.21 mg
The doctor’s order is to give Tramadol 1.5 mg/kg of body weight. The weight is 110
lbs.
Answer: 75
Calculation by weight: (no rounding of , 2 decimal places, numbers

only) Example: 12.00
Give Acetaminophen 10.5 mg/kg every 4 hours for pediatric weighting 12 kg.
Answer: 1.2
5.5- Formative assessment
1. The type of intravenous set that that delivers small drop (60 gtt/mL) and is used when small
amounts of drug or more precise administration is needed is: Microdrip
2. You are assigned to administer an IV fluid to a client with diarrhea. While preparing materials
needed, you have noticed that an electronic infusion device is not available. How will you manually
administer the IV fluid? Calculate IV flow rate in gtt/min
3-5. Patient-Controlled Analgesia (PCA) is another method of electronic device used to administer
drugs intravenously. List the 3 reasons of using PCA Calculate for the following:
1. Effective pain control without the patient feeling oversedated
2. Considerable reduction in the amount of narcotic used (approximately one half that
3. Patients’ feelings of having greater control over their pain
6. Order: 1000ml of D5NSS to infuse over 12 hours using microdrip set. Calculate IV flow rate in
gtt/min 83.33 gtts/min
Situation for 7-9: Order: 3 L IV solution to infuse over 24 hours.
7. Each liter should infuse for how many hours? 8hrs
8. How many mL/h need to be administered? 125ml/h

9. Using a drop factor of 15 gtt/ mL, how many gtt/min should a patient receive per liter of fluid?
10.42 gtts/min
10. Order: 1000 mL of D5 ½NS, 1 vial of multiple vitamin (MVI), and 10 mEq of potassium chloride
(KCl) to be infused over 10 hours Available: 1000 mL of D5 1⁄2 NS; MVI: 1 vial = 10 mL; KCl 20
mEq/20 mL vial Macrodrip set, 15 gtt/mL; microdrip set, 60 gtt/mL. What is the total volume of the
solution to be infused in 10 hours? 102 ml/h
At 8am you received a doctors order that you have to Infuse 1,500ml of D5W in 12 hours to
Mr Dela Cruz. What is the correct rate of this isotonic solution when the drop factor is 15 gtt
= 1ml?
- 31.249 qtts/min
A patient is to receive a microdrip infusion of 1,000ml of normal (0.9%) saline solution over
24 hours. The drop factor is 60mcgtt = 1ml. What is the correct flow rate?
- 41.67 mcqtts/min
At 3 p.m., a patient must receive 1 g of Cefazolin (Ancef) intravenous piggyback (I.V.P.B.)

in 150ml of Dextrose 5% in water (D5W), to be infused over 30 minutes. The drop factor is
10 gtt=1 ml. What is the correct flow rate of this antibiotic solution?
- 50 qtts/min
At 9 a.m., a patient has 500 ml of a D5W solution remaining in an infusion bag. The infusion
must end at 1 pm, and the drop factor is 20 gtt= 1 ml. What is the correct flow rate?
- 41.67 qtts/ml
At 10 am you received a doctors order that you have to Infuse 1,000ml of PNSS in 10
hours to Mr Dela Cruz. What is the correct rate of this isotonic solution when the drop factor
is 10 gtt = 1ml?
- 16.67 qtts/min
A patient is to receive a microdrip infusion of 500ml of normal (0.9%) saline solution over 12
hours. The drop factor is 60mcgtt = 1ml. What is the correct flow rate?
- 41.67 qtts/min
At 5 p.m., a patient must receive 500mg of Cefazolin (Ancef) intravenous piggyback

(I.V.P.B.) in 100ml of Dextrose 5% in water (D5W), to be infused over 45 minutes. The drop
factor is 10 gtt=1 ml. What is the correct flow rate of this antibiotic solution?
- 22.22 qtts/min
At 8 a.m., a patient has 500 ml of a D5W solution remaining in an infusion bag. The infusion
must end at 3 pm, and the drop factor is 20 gtt= 1 ml. What is the correct flow rate?
- 23.81 qtts/min
The drop factor is 15 and the amount of solution to be infused each hour is 100ml. Using
the formula, determine the number of drops to infuse each minute.
- 24.99 qtts/min
The drop factor is 20and the amount of solution to be infused each hour is 70ml. Using the
formula, determine the number of drops to infuse each minute.
- 23.33 qtts/min
6. 3 - Formative assessment
A patient has liver and kidney disease. He is given a medication with a half-life of 30 hours.
The nurse expects the duration of this medication to?
- Increase
When assessing older adults and those with renal dysfunction, the nurse knows that
creatinine clearance is usually –
- Decreased
A patient sustains significant burns to the skin and is experiencing fluid shift associated with
edema in the fluid overload phase. The nurse would anticipate that this will interfere most
with which phase of pharmacokinetics?
- Distribution
Most drugs are metabolized in which body organ?

- Liver
Why are some drugs administered with food?

- Some drugs irritate the gastric mucosa
Why are some drugs taken on an empty stomach?

- Food in the GI tract may interfere with the dissolution and absorption of certain drugs
Why are some drugs not administered by mouth?

- they are destroyed in the small intestine by digestive enzymes
Lidocaine and some nitroglycerines have extensive first-pass metabolism. What happens
when drugs undergo first pass metabolism?
- most of the dose would be destroyed in the liver
Why is the dose of an oral medication more than the dose of the same medication
administered via the intravenous route?
- The percentage of bioavailability for the oral route is always less than 100%
Given that lidocaine and some nitroglycerines have extensive first-pass metabolism, which
is the best way to administer these drugs?
- Intravenous
7.3. Formative Assessment
A patient felt drowsy after taking diphenhydramine (Benadryl). How would you classify drowsiness
as an effect?
- Secondary
A patient receives an opioid drug that depresses the patient’s respiratory rate. The nurse
administers an antidote. This is an example of what type of drug effect?
- Antagonistic
What type of serum blood screen would allow for the health care provider to know if the patient is
getting the right amount of the medication?
- peak & trough drug level
Which nursing actions would be most appropriate for ensuring patient safety with a medication that
has a low therapeutic index?
- Monitoring serum peak and trough levels
What signifies the pharmacodynamic phase when taking acetaminophen (Tylenol) for a headache?
- relief of headache
Which statement describes a drug agonist?

- Drugs that occupy receptors and activates them.
Mrs. Hemson is taking mepiprazole (Psigodal), an antidepressant. It acts by blocking 5-HT2A and
α1-adrenergic receptors and has also been shown to inhibit the reuptake. What kind of drug is
mepiprazole?
- antagonist
Mr. Jackson is ordered bethanecol (Urecholine) to relieve post-operative urinary retention. Knowing
that bethanecol has non-specific drug effect, which would be your best action?
- Monitor vital signs.
Which statement is true about non-selective drugs?
- Drugs that affect alpha1, beta1, and beta2 receptors
This is used when immediate drug response is desired. Large initial dose of drug is given to achieve
a rapid minimum effective concentration in the plasma.
- Loading Dose
8.2 Pre-lecture activity
TRUE OR FALSE: Write T if you think that the statement is TRUE and F if the statement is
FALSE.
T 1. Asking about the client’s ethnicity/religious/cultural beliefs prior to medication
administration is important.
T 2. Nurses are not allowed to prescribe medications as part of dependent nursing
intervention.
F 3. The nurse may opt not to give the drug depending on the changes in the client’s status
without referring to the doctor.
F 4. It is okay for Patient B to call the nurse to change their IV fluid or ask about discharge
plans (plan when the patient can go home) while the nurse is giving medication to Patient A.
F 5. Health teaching about medication should be done by the attending doctor and followed up
by the nurse.
T 6. Drug study is made by lifting information from the drug handbook and any form of
modification is not allowed.
F 7. Errors in medication occur solely because of nurse’s mistakes.
T 8. Assessment and diagnosis may change before, during and after medication administration.
F 9. There are 5 rights of medication administration to consider in planning medication
administration.
F 10. Drug study is ready made in the internet which students can use for their client.
The doctor prescribed the following medication as follows: Give Diclofenac Na 250mg PO PRN for
pain. What should prompt you to give this medication?
- Pain scale of 8
A hypertensive patient who was prescribed with Losartan (Anti-hypertensive) talks to you and asks
if she is taking her medications correctly because she thinks it is not working well on lowering her
BP. What is the most relevant and priority nursing diagnosis given this situation?
- Readiness for enhanced knowledge
Which of the following objectives is considered psychomotor domain relevant to medication

administration?
- Checks the medication checklist to be presented to the doctor during follow-up check-up
Which component of the Nursing Process is it when the nurse compares the current BP and the BP
15 minutes after taking a SL HPN drug.
- Evaluation
The client expressed her satisfaction with the prescribed medication and the affordability of the
medication. This is a process evaluation that reflects:
- Adequacy
Who will the nurse collaborate with within the hospital personnel if the nurse needs orange juice to
go with the iron medication to increase absorption?
- Dietitian
Which component of the Nursing Process is it when the nurse approaches the doctor to clarify
written prescription.
- Implementation
Which component of the Nursing Process is it when the nurse identifies which size of syringe is to
be used for IV drug administration.
- Planning
Which component of the Nursing Process is it when the nurse asks about the frequency of vomiting
in the last 24 hours during the endorsement of a patient who has been admitted in the last 3 days.
- Evaluation
Which component of the Nursing Process is it when the nurse identifies risks for fall as relevant to
clients receiving anti-histamine medication due to its dizziness as side effect.
- Diagnosis
Therapeutic class
Side effects
Pharmacologic class
Route
Adverse effect
Summative Assessment for Modules 1-8-
Midterm Exam
A nurse is to administer a dose of furosemide (Lasix). The nurse is aware that Lasix is the
________ for the drug.
- brand name
Approaching the doctor to clarify written prescription.
- Implementation
Among the parenteral routes of medication, which route has the fastest systemic action or effect?
- Intravenous
Which is an example of a drug classified according to body system?
- cardiovascular drug
Milliequivalent (mEq) is refers to the ionic activity of the drug.
- True
Asking about the client’s ethnicity/religious/cultural beliefs prior to medication administration is

important.
- True
An 18-year-old has an external ear infection to be treated with eardrops. The nurse correctly
instructs the patient to angle the ear in what direction?
- up and back
Medications during the ancient times are limited to medicinal plants.
- False
The first drug-related book discovered in ancient Greece and Rome containing list of plants used
and its preparation to treat illnesses.
- De Materia Medica
There are 5 rights of medication administration to consider in planning medication administration.
- False
The Philippine National Drug Formulary is BEST described as:
- A book with a list of approved medications in the Philippines
Drug study is made by lifting information from the drug handbook and any form of modification is not
allowed.
- True
This is an act to promote, require, and ensure the production of an adequate supply, distribution,
use, and acceptance of drugs and medicines identified by their generic names.
- Republic Act No. 6675
The Z-track method is the preferred method of administration for which drug?
- Iron dextran
Nurses are not allowed to prescribe medications as part of dependent nursing intervention.
- True
A pregnancy category which identifies drug that is evident of fetal harm
- Pregnancy Category X
Which among the following is a drug classified according to physiologic or chemical actions?
- calcium channel blocker
PDEA may issue special license to the doctor to prescribe addictive and dangerous drugs.
- True
Health teaching about medication should be done by the attending doctor and followed up by the
nurse.
- False
Drugs that are currently categorized Over-the-Counter or OTC drugs is classified as:
- S-5 (Schedule 5) drug
The drop factor is 15 and the amount of solution to be infused each hour is 100. Using the formula,
determine the number of drops to infuse each minute.
- 25 qtts/min
The Philippine Food and Drug Administration (FDA) regulates food, cosmetics, health devices and
drugs in the Philippines.
- True
Amoxicillin is a commonly used drug to fight bacteria. The pharmacologic class of this drug is:
- Amino-penicillin-beta-lactamase inhibitors
Known as clinical pharmacology that deals with the use of drugs in treatment, prevention and
diagnosis of diseases
- Pharmacotherapeutics
During the ancient times (3000 BC) , who is the individual to whom villagers go to to ask about
herbal treatments for certain illness?
- Elderly
Drug classification which includes combination of the following categories: Mechanism of action,
physiologic effect and chemical structure of drug.
- Pharmacologic class
A nurse is planning to administer an intradermal injection to a patient. Which represents the

appropriate technique for this route?
- 26-gauge needle at 15 degrees
An old system used for measuring and weighing drugs and solutions by use of fractions
- Apothecary system
Pregnant women can take antibiotics without risk to the fetus.
- False
The nurse may opt not to give the drug depending on the changes in the client’s status without
referring to the doctor.
- False
Which is an example of a drug classified according to therapeutic use or clinical indication?
- antacid
Example of household system EXCEPT:
- Grains
Which statement about transdermal drugs is true?
- Transdermal drugs provide more consistent blood levels than oral and injection forms.
The phase in clinical trial when the drug can be commercialized in the market but continuous
evaluation and study of drug effects continue for further improvement of drug.
- Phase IV- Post-marketing Surveillance and Follow-up
Refers to the intended use of drugs to treat, prevent and diagnose disease/s/
- Therapeutic indication
Drugs that are currently categorized as having acceptable medical use in treatment but with severe
restriction. Additional license of physician is needed to prescribe this drug.
- S-2 (Schedule 1) drug
Which statement describes a drug antagonist
- Drugs that block receptor activation.
Risks for fall is relevant to clients receiving anti-histamine medication due to its dizziness as side
effect.
- Diagnosis
Drugs can have either desirable or undesirable secondary effects.
- True
It is okay for Patient B to call the nurse to change their IV fluid or ask about discharge plans (plan
when the patient can go home) while the nurse is giving medication.
- False
The drug "Zytiga" used for cancer patient has this therapeutic class:
- Anti-cancer drug / Anti-neoplastic
Medicinal plants nowadays can be manufactured, commercialized and sold easily.
- False
Drug effect which is unintentional and/or unexpected after administration of drug in normal dosage.
- Adverse effect
The total dosage amount that is given to a patient in a day to achieve therapeutic effect.
- Daily dose
Physician PRC license is NOT the only license needed to prescribe all kinds of drugs.
- True
The amount of drug which when given will cause imminent death to the patient
- Lethal dose
The sub-phase in Phase 2 of a clinical trial that involves analysis whether the new drug meets the
global standard of effect.
- Comparative efficacy
Identify which size of syringe is to be used for IV drug administration.

- Planning
Client has been receiving round-the-clock (RTC) medication to relieve vomiting. During the initial
nurses’ round and endorsement, the nurse asks about the frequency of vomiting in the last 24
hours.
- Evaluation
Phase 1 of a clinical trial to test whether the new drug is effective and safe is known as:
- Animal testing
The nursing care plan (NCP) is the only tool needed by the nurse to prepare for drug administration.
- False
Drugs can help prevent, treat and diagnose illness.
- True
All medicines we buy in the pharmacy needs prescription.
- False
GCQ, a 53-year-old woman, has a diabetic wound infection. The culture report states that the
infection is due to Pseudomonas aeruginosa, and GCQ’s temperature has risen to 104°F (40°C).
Amikacin sulfate was order to treat the existing infection. What is the
- Aminoglycosides
When would a wound culture and sensitivity test be obtained to determine the appropriate
antibacterial agent?
- Before initiating antibiotics
Amantadine hydrochloride is not recommended anymore as prophylaxis to influenza A virus. As a

student nurse you know that it is because of:
- Resistance to the circulating influenza
A patient is taking a cephalosporin. The nurse anticipates which appropriate nursing intervention(s)
for this medication? (Select all that apply.)
- Monitoring renal function studies

- Monitoring liver function studies
- Infusing intravenous medication over 30 minutes
- Monitoring the patient for mouth ulcers
After receiving the wound culture and sensitivity test of patient GCQ, you have noticed that the
pathogen is sensitive to Amikacin but is resistant to Oxacillin. As a student nurse the antibacterial
you will give is/are:
- Amikacin
Metronidazole, an example of antiprotozoal/antibiotic is indicated to patient with? (Select all that

apply).
- Amebiasis
- Trichomoniasis
A school nurse asks you the drug classification of Praziquantel. Your response is:
- Anthelmintic
A patient is diagnosed with malaria and is prescribed Atovaquone. The nurse
anticipates that which lab test will be ordered?
- Liver enzymes
Acyclovir had been ordered for patient with viral infection. While preparing the medication, you
double check the action of this drug. This drug is intended for what type of viral infection? (select all
that apply)
- Herpes simplex
- Chicken pox
- Shingles
The type of parasitic worms that enter to the intestine via contaminated food (pork, beef, fish, and
dwarf) Taenia solium (pork tapeworm), T. saginata (beef tapeworm), Diphyllobothrium latum (fish
tapeworm), and Hymenolepis nana (dwarf tapeworm) is:
- Cestodes
PRE-TEST
1. This microorganisms is also called mycosis, tinea, or candidiasis
- Fungi
2. A patient is admitted to the health care facility with methicillin-resistant Staphylococcus aureus
(MRSA). The nurse anticipates administration of which drug?
- Vancomycin (Vancocin)
3. Patient is expected to receive antiviral drugs for Influenza A and B? Which of the following drug is
sensitive to influenza A?
- Oseltamivir
4. Metronidazole, an example of antiprotozoal/antibiotic is indicated to patient with? (Select all that

apply)
- Trichomoniasis, Amebiasis, Pneumocystis carinii

This is a substance released from cells in response to cytotoxic T-cell activity
- Interferons
How do interleukins exert its therapeutic benefits inside the body
- By increasing the number of natural killer cells and lymphocytes
Which immune stimulant is usually used for treatment of blood-related cancers?
- colony-stimulating factors
All of the following are not true about immune modulators, except:
- Infection control is an integral part of drug therapy.
Which of the following responses identifies a role of T-lymphocytes?
- Transplant rejection
All of the following complaints will alert the nurse of colony stimulating factor adverse effect, except:
- Coughing
When the nurse administers interferons to a patient, which of the following is the major side-effect of
this drug?
- flulike syndrome
Proteins formed when cells are exposed to the viral or foreign agents that are capable of activating
other components of the immune system are referred as:
- interferons
Cytotoxic T cells is best described as:
- lyse cells infected with virus
Immune modulators have the following therapeutic actions, except:
- Increasing the release of various cytokines involved in the inflammatory response
11.8 - Formative assessment 1

The doctor admitted a 34 year old, female client with depression and is writing a prescription for this
client. Which of the following medication will probably be prescribed to this patient? Select three
medication classification that applies:
- Tricyclic Anti-depressant
- Monoamine Oxidase Inhibitors (MAOI)
- Selective Serotonin Reuptake Inhibiotr (SSRI)
A patient with end-stage prostate cancer is in severe pain. Which of the following medications would
be prescribed to this patient? Select two drug classifications indicated for the client:
- Narcotic agonist
- Narcotic agonist-antagonist
Prior to your duty at the Neuro ward, you are studying drugs that are given to patients with seizure.
Select three drugs which are classified as anti-epileptics:
- Barbiturates
- Benzodiazepine
- Hydantoins
The anesthesiologists would like to control the amount of secretions (from mouth, nose, etc) to
prevent aspiration while patient is sedated (unawake) during operation. Which of the following drug
should be given to the client for this purpose? Choose one for two points.
- Anti-cholinergic drug
Which of the following drug classifications can be given to hypertensive patients? Choose five.
- Beta1 selective adrenergic blocking agents

- Alpha-specific adrenergic agonists
- Alpha and beta adrenergic blocking agents
- Alpha1 selective adrenergic blocking agents
- Beta adrenergic blocking agents

The nurse is aware that folic acid deficiency in pregnancy may result in any of the following except –
- placenta previa
An RN on orientation is working with a patient with gestational hypertension. Which action by the
orienting nurse necessitates intervention by the supervising RN? When the orienting nurse–
- places the patient in the right lateral recumbent position
A pregnant patient who is prescribed a liquid iron supplement complains that her teeth have
become discolored. What is the proper response by the nurse?
- “This is a normal reaction to liquid iron supplementation. You can minimize it by drinking the
supplement through a straw.”
The nurse identifies which as a clinical manifestation of maternal magnesium sulfate toxicity?
- Nasal congestion
A patient has a serum magnesium level of 10 mg/dL. The nurse anticipates administration of
- calcium gluconate.
A woman in her 24th month of pregnancy who has elevated BP tells you, “I am very scared of what
may happen to me and my baby with this elevated BP.” What is the best response to this
statement?
- Most women still can deliver a healthy baby if hypertension is detected and treated early.
When asked by a new nurse how is Preeclampsia managed, your response should be:
- Delivery of infant and placenta is the only cure.
In a pregnant woman prescribed acetaminophen, which information should cause concern?

- Chronic alcohol use
Which among the following drugs is classified as a pregnancy category C drug (which changes to
category D if used in the third trimester) and if taken late in pregnancy, may cause premature
closure of the ductus arteriosus?
- Ibuprofen
Which among the following is a bulk-forming fiber laxative?
- Metamucil

Nursing consideration in giving ______________: “Give sublingual preparations under the
tongue and instruct not to swallow to ensure that therapeutic level is achieved.”
(Use three words, ALL first letters are capital)
Answer: Anti-Anginal Agents
One of heart characteristics that each cell has ability to conduct impulses to the next
cell. (Use Proper Noun).
Answer: Conductivity
It is a hollow muscular organ that has a cone-shape, pumps blood for body’s circulation.
(Use Proper Noun)
Answer: Heart
Irregular rhythm and rate of heart beat. Includes bradycardia, tachycardia, premature
ventricular contraction (PACs), premature ventricular contraction (PVCs), atrial flutter, atrial
fibrillation. (Two Words, Capital ALL first letter, Plural)
Answer: Cardiac Arrhythmias
Drug classification that causes decrease in blood pressure and decrease aldosterone
secretion. (3 Letter acronym and 1 word capital first letter)
Answer: ACE Inhibitors
Amount of blood that is pumped out of the ventricle with each heartbeat.
- Stroke Volume
Generates electrical impulse that sets rhythm to the heart; the primary pacemaker of the
heart.
- SA node
Cardiotonic Drugs (Inotropic) . Increase intracellular calcium and allow more calcium to
enter myocardial cells during depolarization.Increase force of myocardial contraction.
Increase cardiac output and renal perfusion. Slows heart rate, Decrease conduction speed
through the AV node
- Digoxin(Lanoxin)
Angiotensin-Converting Enzyme (ACE) inhibitors.
- Captopril
Action potential of the heart it occurs when the cell reaches a point of stimulation, the sodium
channel opens and rushes into the cell, this positive flow of electrons into the cell results to an
electrical potential
- Phase 0

System of organs functioning in respiration (Links to an external site.), do the process of exchange
of gases: oxygen and carbon dioxide and in humans consisting especially of the nose, nasal
passages, pharynx, larynx, trachea, bronchi, and lungs. (Two Words, All first letter capital)
- Respiratory System
Structural and Basic functional unit of the lung. (Proper Noun)
- Alveoli
Drug classification that acts directly on the medullary cough center of the brain to depress the
cough reflex. (Use Proper Noun)
- Antitussive
Drug Classification which decrease inflammatory response in the airway & increase airflow and
facilitates respiration. (Two words, All Start at capital letter, end in "s")
- Inhaled Steroids
Drug classification which Increase productive cough to clear the airways.
- Expectorant
Enhances the output of respiratory tract fluids by reducing the adhesiveness and surface tension of
these fluids, allowing easier movement of the less viscous secretions.
- Expectorant
Breaks down mucus in order to aid the risk of coughing up thick, tenacious secretions
- Mucolytics
Mast cell Stabilizer.
- Nedocromil
Anti-cholinergic / Bronchodilator. Relaxes smooth muscle in the bronchi dilates bronchi. (Drug
acting in Lower Respiratory Tract)
- Ipratropium
Anti-asthmatic / Bronchodilator (Xantines)
- Theophylline
The nurse shouldn’t instruct a client who is taking an expectorant to:
A. Increase fluids
B. Restrict fluids
C. Avoid vaporizers
D. Take antihistamines
A nurse is giving instructions a patient who is taking levothyroxine (Synthroid). The nurse tells the
client that the best time to take this medicine is?
A. During bedtime
B. After lunch
C. Taken with food
D. Taken in an empty stomach
Montelukast (Kastair) is prescribed to a client with asthma. During the medication therapy which of
the following laboratories should be monitored?
A. Complete blood count (CBC)
B. Sodium potassium
C. Calcium and Platelet count
D. ALT and AST
Linda, an 80 year old female is experiencing blurred visions and halos. She is currently on Losartan
and Digoxin. Blurred vision or halos are signs of:
A. Lanoxin toxicity
B. Nothing related to digoxin
C. Digoxin and Lanoxin interaction
D. Digoxin toxicity
Conduction defects will most likely be adverse associated with the use of:
A. Verapamil
B. Adalat
C. Nimodipine
D. Amplodipine
Which of the following effects of calcium channel blockers causes a reduction in blood pressure?
A. increased cardiac output
B. decreased renal blood flow
C. Calcium influx into cardiac muscles
D. decreased peripheral vascular resistance ----
Johanna has ventricular ectopy and manifests premature ventricular contractions on 12-L EKG,
which of the following drugs is the first line used to treat her condition?
A. quinidine (cardioquin)
B. Lidocaine (Xylocaine) -----
C. Procainamide (pronestyl)
D. Digozin (lanoxin)
All of the following antridepressant medications are classified as monoamine oxidase inhibitors
(MAOI) EXCEPT:
A. duloxetine (Cymbalta) ----
B. Tranylcypromine (parnate)
C. Phenelzine (Nardil)
D. Isocarboxazid (marplan)
a client with myasthenia gravis has become frequently complaining of weakness and fatigue. The
physician plans to identify whether the client is responding to an overdose of the medication or a
worsening of the disease. A tension test is performed. Which of the following would indicate that the
client is experiencing an overdose of the medication?
A. complaints of muscle spasms
B. improvement of the weakness and fatigue
C. no change in the condition

D. temporarily worsening of the condition
Mydriasis occurs after instillation of the following drugs into eye except:
A. pilocarpine
B. tropicamide
C. epinephrine
D. atropine
B blockers should be avoided in which of the following conditions?
A. hypertension
B. myocardial infarction
C. bronchoconstriction
D. angina pectoris
A client is receiving intravenous heparin therapy. The nurse ensures the availability in which of the
following medication?
A. Protamine SO4
B. Calcium gluconate
C. Acetylcysteine (Mucomyst)
D. Vitamin K (Mephyton)
Drug classification which includes combinations of the following categories: Mechanism of action,
physiologic effect and chemical structure of drug.
A. Pharmacologic class
B. Therapeutic class
C. Substance abuse class
D. Pregnancy category
Which of the following clients is at greatest risk for digital toxicity?
A. A 90-year-old client with CHF
B. A 25-year-old client with congenital heart disease
C. A 56-year-old client with CHF
D. A 30-year-old client with after myocardial infarction
A nurse is providing instruction to a client who is on nicotinic acid for the treatment of
hyperlipidemia. Which statement made by the nurse indicates a comprehension of the instruction?
A. I should take aspirin 30 minutes before nicotinic acid
B. I will drink alcohol in moderation
C. Yellowing of the skin is a common side effect
D. This medication is taken on an empty stomach
A private nurse visits a client who is taking Humulin NPH insulin daily. The client asks the nurse on
how is the storage of the unopened vials of insulin. The nurse tells the client to:
A. Store it in the refrigerator
B. Store it in the freezer
C. Store it at room temperature
D. Keep the insulin in a sunlight, dry place
Nurse Emy is giving instructions to her client who is taking antihistamine. Which of the following
nurse teachings is appropriate for the client?
A. Avoid ingesting alcohol
B. Be aware that you may need to take a decongestant
C. Be aware that you may have increased saliva
D. Expect a relief in 24 hours

Muscarinic receptor stimulation resulting in bronchoconstriction can be blocked by:
A. Prazocin
B. Ipratropium
C. Isoproterenol
D. propanolol
Fluoxetine, paroxetine, citalopram and escitalopram, compared to tricyclic antidepressant:
A. Exhibit increased anticholinergic and sedating effects
B. Exhibit reduced likelihood of gastrointestinal difficulties and sleep impairment
C. Neither
D. Both
A nurse is giving discharge instructions a patient who is taking levothyroxine (Synthroid). The nurse
instructs the client to notify the physician if which of the following occurs?
A. Cold intolerance
B. Tremors
C. Coarse, dry hair
D. Muscle cramps
A patient with myasthenia gravis is started on Pyridostigmine. What assessment finding

demonstrates the drug is working correctly?
A. The patient experiences dilation of the pupils
B. The patient experiences a relaxed bladder
C. The patient experiences normal muscle function in the face and eyes
D. The patient experiences bronchodilation
A client with renal failure is currently taking captropil. Which of the following laboratory values
should the nurse monitor?
A. Electrolyte levels
B. Liver function test
C. Glomerular filtration rate
D. Hematocrit
Breaks down mucus in order to aid risk of coughing up thick, tenacious secretions
A. Expectorant
B. Decongestant
C. ACE inhibitor
D. Mucolytics
A patient is started on a norepinephrine drip. What side effects can this medication cause?
A. Tachycardia, Hypotension
B. Tachycardia, Hypertension
C. Bradycardia, Hypotension
D. Bradycardia, Hypertension
A nurse is about to administer albuterol (Ventolin HFA) 2 puff and Budesonide (Pulmicort
Turbohaler) 2 puff by metered dose inhaler. The nurse plans to administer by. A. Alternating with a
single puff each, starting with albuterol.
B. Alternating with a single puff each, starting with budesonide
C. Budesonide inhaler first then the albuterol
D. Albuterol inhaler first then the budesonide
A nurse is caring for a client receiving a warfarin. The nurse expects that which of the following
laboratory will be prescribed to monitor the therapeutic effect of warfarin?
A. Prothrombin time (PT)
B. Activated partial thromboplastin time (aPPT)

C. Hematocrit (Hgb)
D. Hemoglobin (Hct)
83. When the nurse administers interferons to a patient, which of the following is the major
sideeffect of this drug?
A. gastrointestinal syndrome
B. neurologic disturbances
C. dermatologic disturbances
D. flulike syndrome
A nurse is giving instructions to a client who is receiving Cholestyramine (Questran) for the
treatment of hyperlipidemia. Which of the following statements made by the client indicates the
need for further instructions?
A. “I will continue taking nicotinic acid as part of the treatment”
B. “This medication comes in a powder that must me mixed with juice or water before
administration”
C. “I will avoid eating foods rich in saturated fats”
D. “Constipation, belching and heartburn are some of the side effects”
A nurse is monitoring a client who is taking Carvedilol. Which of the following assessment made by
the nurse would warrant a possible complication with the use of this medication?
A. Complaints of dyspnea
B. Baseline blood pressure of 160/100 mm hg followed by a blood pressure of 120/70 mm hg

after 3 doses
C. Baseline heart rate of 97 bpm followed by a heart rate of 62 bpm after 3 days
D. Complaints of nightmares and insomnia
The therapeutic drug level for digoxin is:
A. 0.2-2.0 ng/mg
B. 0.5-2.0 ng/mg
C. 1.0-2.0 ng/mg
D. 0.1-0.5 ng/mg
Which of the following is a contraindication for digoxin administration?
A. Heart rate below 60
B. Blood pressure of 140/90
C. Respiratory rate above 20
D. Heart rate above 80
Maria will be having her exam in pharmacology tomorrow. She should be aware that antitussive is
indicated to:
A. encourage removal of secretions through coughing
B. relieve rhinitis
C. control a productive cough
D. Supresses coughing response
Lowering the blood pressure of a hypertensive client with an agent that has a reduced likelihood of
increasing bronchomotor tone is best accomplished with:
- Atenolol
A patient is taking insulin glargine injection daily. The nurse instruct the client that the onset action
will likely happen?
- 2-4 hours after administration
A client arrives in the emergency with complaints of chest pain and is diagnosed with acute MI. A
morphine 4mg IV was given 5 minutes ago and was further given isosorbide dinitrate (Isordil)
sublingually. Which of the following assessment made by the nurse indicates a further immediate
action?
- The client still complains of chest pain with a pain scale of 2/10.
Daniel has vertigo when he is riding a bus going to the province, which antihistamine is best for his
condition?
- Meclizine
Airway resistance is decreased after administration of:
- Terbutaline
Give 150 mg Paracetamol syrup PO PRN for fever. Available stock is Paracetamol 125mg/ 5ml.
How many teaspoon should the nurse give when patient has fever?
- 1.2 teaspoon
FAR EASTERN UNIVERSITY

INSTITUTE OF NURSING 1ST SEMESTER – AY 2020 – 2021
NCM 107 CARE OF MOTHER & CHILD,
ADOLESCENT (WELL CLIENT)
MODULE 1: FRAMEWORK OF
MATERNAL AND CHILD HEALTH
NURSING
Del Rosario, Ayeza E.
BSN 202
PRETEST
1. Scope of the nursing practice in maternal and child health includes except;
A. Care of infants during the perinatal period (6 weeks before conception to 6 weeks after birth)
B. Care of children from birth through adolescence
C. Care in settings as varied as the birthing room, the pediatric intensive care unit, and the home
D. None of the above
2. Maternal and child health nursing includes a high degree of independent nursing functions, because
teaching and counseling are minor interventions.
A. True
B. False
C. Either
D. Neither
3. Educating clients to be aware of good health through teaching and role modelling
A. Health promotion
B. Health maintenance
C. Health restoration
D. Health rehabilitation
4. Diagnosing and treating illness using interventions that will return client to wellness fast
A. Health promotion
5. Also known as nurse consultants, where they focus on ensuring delivery of quality patient care
services in maternal and child’s health.
A. Health educator
B. Health counselor
C. Nurse specialist D. health researcher
6. The first 28 days of life is known as;

A. Neonatal period
B. Infancy period
C. Both
D. None of the above
7. Intervening to maintain health when risk of illness is present.

A. Health promotion
8. Care of child during illness, care of woman during pregnancy complications are examples of; A.
Health promotion
9. The nurse interacts with and contributes to the professional development of peers, colleagues, and
other health care providers.
A. Standard of ethics
B. Standard of collegiality
C. Standard of collaboration
D. Standard of research
10. Maternal and child health nursing is a challenging role for nurses and a major factor in keeping
families well and optimally functioning.
A. True
B. False
C. Both
D. Neither A nor B
MODULE 1: PRINCPLES OF GROWTH AND DEVELOPMENT
True/False
1. The primary focus of a well-child visit is to determine the child’s developmental stage.
- True
2. Cognitive development refers to the ability to learn and solve problems.

- True
3. Reaction pattern refers to a child’s response on initial contact with a new stimulus.
- False
4. According to Erikson, the developmental task for infants is learning trust versus mistrust.
- True
5. Piaget referred to the infant stage as the sensorimotor stage.

- True
Fill in the Blank
1. Maturation is a synonym for development.

2. Temperament refers to an individual’s characteristic manner of thinking.
3. Egocentrism is perceiving one’s thoughts and needs are better or more important than those of
others.
4. Developmental milestones are considered major markers of normal development.

5. Development indicates an increase in skill or the ability to function.
MODULE 2: MODULE 2: REPRODUCTIVE AND SEXUAL HEALTH
PRETEST
1. Following fertilization the blastocyst secrets a hormone called?

A. Human Chorionic Gonadotropin
B. Oxytocin
C. FSH
D. LH
2. A body organ that produces the cells necessary for reproduction both in male and female.
A. Estrogen
B. Corpus luteum
C. Gonads
D. Prostate gland
3. Two convoluted pouches that lie along the lower portion of the posterior surface of the bladder
secrete a viscous alkaline liquid that has a high sugar, protein, and prostaglandin content.
A. Vas deferens
B. Seminal vesicle
C. Cowper’s gland
D. Testes
4. A small (approximately 1 to 2 cm), rounded organ of erectile tissue at the forward junction of the labia
minora covered by a fold of skin which is sensitive to touch and temperature. A. Glans penis
B. Urethral meatus
C. Clitoris
D. Vestibule
5. An increase of levels of this hormone in the female at puberty influences the development of the
uterus, fallopian tubes, and vagina; typical female fat distribution and hair patterns; breast
development; and an end to growth.
A. Androgen
B. Progesterone
C. Estrogen
D. Growth hormone
6. It is a rugated, skin-covered, muscular pouch suspended from the perineum. Its functions are to
support the testes and to help regulate the temperature of sperm,
A. Prepuce
B. Scrotum
C. Mons veneris
D. Bartholins gland
7. This is the portion of the tube that is cut or sealed in a tubal ligation, or tubal sterilization procedure.
A. Interstitial
B. Isthmus
C. Ampulla
D. Infundibulum
8. It is the transition period during which the woman’s reproductive function gradually diminishes and
disappears.
A. Menarche
B. Menopause
C. Andropause
D. Gonadostat
9. The end of an arbitrarily defined menstrual cycle because it is the only external marker of the cycle,
A. Menstruation (should be “Menses”)
B. Menarche
C. Proliferative
D. Follicular
10. Arise from each upper corner of the uterine body and extend outward and backward until each opens
at its distal end, next to an ovary. Their function is to convey the ovum from the ovaries to the uterus
and to provide a place for fertilization of the ovum by sperm.
A. Fallopian tube
B. Isthmus
C. Ampulla
D. Ovary
MODULE #3 – RESPONSIBLE PARENTHOOD SAQ
Sariya, 32 year-old gravida 4 para 4 visits the clinic and tells the nurse that she desires to
use contraception. She asks the nurse regarding the different contraceptive devices available.
1. She inquires about subdermal hormonal implant such as Norplant for contraception. The
nurse should explain to the client that a common side effect of Norplant is:
A. Potential manic behavior
B. Weight gain
C. Scant menstrual bleeding
D. Increased hair growth
2. She inquires about the use of diaphragm. After fitting the client for diaphragm, a nurse
should instruct Sariya to:
A. Be refitted for the diaphragm every year
B. Avoid the use of diaphragm during menses
C. Wash the diaphragm after use in soap & water
D. Remove the diaphragm 1 hour after use
3. If she uses the oral contraceptive “pills”, the nurse should explain to the client that a
common side effect of this type of contraception is:
A. Heavy menstrual flow
B. Monilial infection
C. Weight gain
D. Shortness of breath
4. Sariya decides to have Bilateral tubal ligation, during the immediate postoperative period, a
priority assessment for the nurse to make is:
A. Presence of constipation
B. Nausea and vomiting
C. Abdominal distention
D. Bleeding
5. The most common site of BTL is what segment of the fallopian tube?
A. Ampulla
B. Fimbria
C. Infundibulum
D. Isthmus
6. Another client, Julia, 26-years old G3P2 [1-1-1-2] where her 2nd pregnancy was an ectopic
pregnancy. Tells the nurse that she desires to use an IUD. The nurse should explain to the
client that the most common side effect of an IUD is increased.
A. Cost
B. Menstrual flow
C. Uterine cramping
D. Incidence of PIH
7. Which part of the obstetric history of Julia makes her not a good candidate for the use of
IUD?
A. History of preterm infant
B. Ectopic pregnancy
C. Abortion
D. Age
8. Celia, 29-year old, visits the clinic for routine Pap smear. She tells the nurse that she and her
partner use condom and spermicides for contraception. Which of the following statements
if made by the client indicates that she has an understanding of the use of this type of
barrier method?
A. “My partner can withdraw his penis after it becomes flaccid after intercourse”
B. “My partner can place the condom even if the penis is not well erected”
C. “I do not need to use the spermicidal product if my partner uses condom”
D. “I should insert the spermicidal product no more than 1 hour prior to coitus”
9. A client is prescribed an OCP. The nurse has explained to the client about the non-
contraceptive benefits of OCP. The nurse determines that the client needs further
instructions when the client says that the OCP decreases the incidence of:
A. Premenstrual syndrome
B. Blood clots
C. Fibrocystic breast disease
D. Endometrial cancer
10. Which of the following findings in the history of the client would alert the nurse as a
contraindication for OCP use?
A. Multiple gestation
B. Thromboembolic disease
C. Gestational diabetes
D. Dysmenorrheal
11. A client has been receiving Depo Provera every 12 weeks for her contraception. The nurse
should encourage the client to increase her daily intake of which of the following nutrients?
A. Iron
B. Calcium
C. Vit. C
D. Vit. A
12. A male client is scheduled for semen analysis. The nurse should instruct the client that to
ensure an adequate specimen and ensure the motility he should:
A. Keep the specimen in cool place during transport
B. Obtain the specimen after 8 hours abstinence
C. Place the specimen in a dark-colored container
D. Keep the specimen next to his body during transport
13. If a client with menstrual cycle of 30 days asked the nurse of the best day that she and her
husband avoid coitus so that pregnancy will most likely not occur, she would respond best:
A. Ovulation would occur on the first or second day
B. Ovum is released on day 16
C. Ovum release is unpredictable
D. Ovulation would occur on the fourteenth day
14. A client has been instructed that her cervical mucus will be tested using a spinnbarkeit test.
The nurse should explain to the client that this will test her cervical mucus for:
A. Amount of ferning pattern
B. Stretchability
C. Level of progesterone
D. Level of cervical mucus
15. Which conditions made by a couple would indicate that they need additional teaching as to
the factors decreasing the likelihood of conception?
A. Pelvic inflammatory disease
B. Highly alkaline vaginal pH
C. Endometriosis
D. Excessively thick cervical mucus
MODULE #5 – INTRAPARTAL CARE
SELF-ASSESSMENT QUESTIONS
Situation: A primigravida, Nathalie Covida is expecting to give birth. She has concerns regarding her
upcoming labor. She feels nervous about the onset of her labor but she looks forward to it. Mrs. Covida is
your neighbor and she know that you are a nursing student and planning to ask you the following
questions:
1. What would be the first sign of impending or approaching labor? Your correct response should be:
she will have to experience:
A. Rupture of BOW
B. Lightening
C. Loss of weight
D. Nesting Behavior
2. What are the signs indicating that she is now in true labor? The following are your answer to her
EXCEPT one:
A. Uterine contractions are regular and rhythmical
B. Presence of pink show
C. Presence of Lightening
D. Cervical effacement and dilatation is present
3. She also asks you what causes labor to begin. Which of the following statements is a possible
explanation?
A. Progesterone levels rise at term to initiate contractions.
B. Ovary releases additional estrogen at term
C. Prostaglandins may be the causative factors of labor
D. Calcium is drawn from bones to block relaxation fibers
4. You also informed her that the smallest head diameter of the fetus must be presented to the birth
canal in order to best traverse/travel to the birth canal. Which of the following is the smallest
anteroposterior cranial diameter of a fetus?
A. Suboccipito bregmatic
B. Occipitomental
C. Biparietal
D. Occipitofrontal
Situation: Mrs. Covida was admitted to the hospital due to labor pains. Internal Examination was done
and the result is 2 cm. cervical dilation, 50% effaced, Station 0, the distance between ischial spines are
wide and amniotic sac is intact.
5. This finding tells you that Mrs. Covida is of what phase in Labor?
A. Dilatational phase
C. Active phase
B. Latent phase
D. Acceleration phase
Note: The latent stage is the beginning of labor from approximately 0 cm dilated to 3 to 4
cm dilated. The active stage is from when the cervix is 4 cm dilated to 8 cm dilated. Active
labor begins to become more uncomfortable for the patient and the contractions are
usually stronger, longer, and closer together. Transition is approximately 8 to 10 cm. The
second stage of labor is from when the patient is 10 cm dilated to delivery of the baby. The
third stage of labor is from the delivery of the baby to the delivery of the placenta.
6. An effaced cervix of 50% will mean which of the following statements:

A. Thinning of the cervical canal of 2 cm in thickness
B. Thinning of the cervical canal of 1 cm in thickness
C. Cervical canal admits 2 fingers
D. Cervical canal admits 1 finger
7. Station 0 will mean which of the following statements?

A. The presenting part is seen on the vaginal canal
B. The presenting part is below the ischial spines
C. The presenting part is on the level of the ischial spines
D. The presenting part is above the ischial spines
Note: When the presenting part is above the ischial spines, it is noted as a negative station. Since the
measurement is 2 cm, the station would be -2. A 0 station indicates that the fetal presenting part is at the
level of the ischial spines. Positive stations indicate that the presenting part is below the level of the ischial
spines.
8. Pelvic measurements were done to determine if there is anything in the mother’s pelvis that may
complicate delivery process. Measuring the distance between the two bones at the level of the
anus by the use of meter caliper/ pelvimeter is the measurement of:
A. Diagonal conjugate
B. Ischial Tuberosity diameter
C. True conjugate
D. Interischial diameter
9. While performing Leopold’s Maneuver, which of the following finding will tell you that the fetus
occupies cephalic presentation?
A. During first maneuver when you feel a rounded mass, hard in consistency
B. During first maneuver when you feel a slightly broad mass, somewhat soft and somewhat hard
and moves with the fetal body
C. During the second maneuver when you feel the back of the fetus on the right side of the
mother’s abdomen and the extremities on the left side
D. During the third maneuver when you cannot move the mass occupying the pelvic inlet
10. The following are signs indicating that labor is progressing, EXCEPT one:
A. The intensity of uterine contraction becomes strong and board like in consistency
B. The duration becomes longer lasting for 10 to 20 minutes
C. The interval becomes shorter
D. The frequency is every 2 to 3 minutes
11. The following are signs indicating a danger sign of labor EXCEPT:
A. fetal heart rate of 170 bpm
B. fetal heart rate of 100 bpm
C. excessive fetal movements
D. meconium staining in breech presentation
12. Upon internal examination which of the findings is the best indicator that Mrs. Covido is now in the
second stage of labor?
A. Increased amount of pink show
B. Bag of waters has ruptured
C. Cervical dilatation of 10 cm
D. Cervical effacement of 100%??
13. Mrs. Covido is transported to the delivery room for the second stage of labor. During this stage the
fetus is moved along the birth canal by mechanisms of labor. Which of the following sequences of
position changes illustrates chronological order of the mechanism of labor?
A. descent, flexion, internal rotation, extension, external rotation, expulsion
B. flexion, internal rotation, extension, external rotation, descent, expulsion
C. descent, flexion, external rotation, extension, internal rotation, expulsion
D. flexion, descent, internal rotation, extension, external rotation, expulsion
14. You are now preparing Mrs. Covido at the delivery room; how will you positioned the client?
A. Sim’s
B. Lithotomy
C. Side-lying
D. Fowler’s
15. When the largest diameter of the fetal head is visible at the vagina, this means that:
A. Extension has occurred
B. Crowning has occurred?
C. Expulsion of the head will occur
D. All of the above
MODULE #6 – POSTPARTAL CARE
SELF-ASSESSMENT QUESTIONS
1. Which of the following actions would alert you that Joan Cooper, 2 days postpartum, is
entering a postpartal taking- hold phase?
A. She tells you she has painful contractions for 8 hours.
B. She sleeps as if exhausted from the effort of her labor.
C. She urges her baby to stay awake so that she can breastfeed.
D. She says that she has not selected a name for her baby as yet.
2. You care for Joan Cooper at a 6-week postpartum visit. What should her fundal height be at
this time?
A. Six fingerbreadths below the umbilicus.
B. No longer palpable on her abdomen.
C. One centimeter above the symphysis pubis.
D. Inverted and palpable at the cervix.
3. A 36 year old woman Gravida 4 Para 4 who delivered a baby girl at 38 weeks gestation after
8 hours of labor. The client’s vital signs are stable, uterus is firm and her lochia is scanty
bright red and is ready to be discharged. The nurse palpates the uterus of a client 24 hours
after delivery. Where does the nurse expect to feel the fundus?
A. Midline of the abdomen halfway between the symphysis pubis and umbilicus
B. At the level of the umbilicus
C. One fingerbreadth below the umbilicus
D. Two centimeters above the umbilicus
4. The nurse is performing a postpartum assessment on a client, and notes the presence of
clots in the lochia. The nurse examines the clots and notes that they are multiple, larger
than 1 cm. Which of the following nursing actions is the most appropriate?
A. Reassess the client in two hours
B. Encourage increased oral fluid intake
C. Document the findings
D. Notify the physician
5. Jane, G4P4 is 48 hours postpartum. Her vital signs are stable, her fundus is two fingers
below the umbilicus, and her lochia rubra is moderate. Her breasts are hard and warm to
touch. Which of the following is the nurse’s primary concern for the mother??
A. Her baby and his needs?
B. Her husband’s needs and response to the baby
C. Her own needs and comfort
D. All of the above
6. A client delivered 4 hours ago. The nurse assesses the client and finds the following: fundus
firm at the level of the umbilicus, moderate amount of lochia rubra and midline episiotomy
well approximated. The nurse understands that fourth stage nursing care for the client
includes which of the following?
A. Application of ice beginning 4 hour after delivery
B. Ice pack to the perineum for up to 60 minutes per application
C. Inspection every 15 minutes during the first hours after childbirth
D. Instructions to avoid intercourse for at least 12 weeks?
7. A client is 4 hours postpartum. Her vital signs are stable, but her fundus is firm, two fingers
above the umbilicus, and displaced to the right, lochia rubra is moderate. Her breasts are
hard and warm to touch. What is the most appropriate intervention?
A. Massage the fundus until it is firm
B. Have the client void and reassess the fundus?
C. Notify the physician
D. Start a pad count
8. A primiparous client who delivered vaginally was monitored by the nurse midwife at home.
Findings revealed: (Day 1) BP 116/72, T 98.6, P 68; (Day 2) BP 114/80, T 100.6, P 76; (Day 3)
BP 114/80, T 101.6, P 80. The nurse should suspect that the client:
A. May have an infection
B. Has normal vital signs
C. Is going into shock
D. Is dehydrated
9. The nurse finds a client crying on her third postpartum day. The client states that she
doesn’t know why she is crying and she can’t stop. Which of the following is the nurse’s
most appropriate statement?
A. “You have a healthy baby; there is no need to cry.”
B. “You seem to be dissatisfied with our care.”
C. “Many new mothers have shared to me their same confusion of feelings; would you like
to talk about it?”
D. “You’ll get over it, this happens to lots of mothers.”
10. Maryann is on her 3rd day post normal spontaneous delivery. She remarks “Do you think I
have enough milk for my baby?” This signal what phase of the puerperium?
A. post-partum blues
B. post-partum psychosis
C. taking-hold
D. taking-in
FILL IN THE BLANKS: Insert the term that corresponds to each of the following descriptions
related to newborn characteristics and care.
1. Neutral thermal environment Environment that allows the newborn to maintain a stable
normal body temperature.
2. Thermogenesis Heat production or generation; for the newborn, it occurs as a

result of increased muscle activity.
3. Non-shivering thermogenesis Heat production process unique to the

newborn accomplished primarily by brown fat and secondarily by increased metabolic
activity in the brain, heart, and liver.
4. Convection Flow of heat from the body surface to cooler ambient air. Two
measures to reduce heat loss by this method would be to keep the ambient air at 24° C and
wrap the infant.
5. Radiation Loss of heat from the body surface to a cooler, solid surface not in
direct contact but in relative proximity. To prevent this type of heat loss, cribs and
examining tables are placed away from outside windows and care is taken to avoid direct air
drafts.
6. Evaporation Loss of heat that occurs when a liquid is converted to vapor; in the
newborn heat loss occurs when moisture from the skin is vaporized. This heat loss can be
intensified by failure to dry the newborn directly after birth or by drying the newborn too
slowly after a bath.
7. Conduction Loss of heat from the body surface to cooler surfaces in direct
contact. When admitted to the nursery, the newborn is placed in a warmed crib to minimize
heat loss. Placing a protective cover on the scale when weighing the newborn will also
minimize heat lost by this method.
8. Hyperthermia High body temperature that develops more rapidly in the newborn
than in the adult. The newborn has a decreased ability to increase evaporative skin water
losses because sweat glands do not function sufficiently to allow the newborn to sweat;
serious overheating can cause cerebral damage from dehydration or heat stroke and death.
9. Telangiectatic nevi (nevus simplex) Pinkish, easily blanched areas on the upper
eyelids, nose, upper lip, back of head, and nape of neck. They are also known as stork bites
or salmon patches.
10. Molding Overlapping of cranial bones to facilitate movement of the fetal head
through the maternal pelvis during the process of labor and birth
MODULE #1 FORMATIVE ASSESSMENT (POST TEST)

Question 1
0 / 1 pts
The leading cause of neonatal infant mortality is:
- Prematurity
Question 2
1 / 1 pts
It is the number of deaths that occur as a direct result of the reproductive process per 100,000 live
births.
- Maternal mortality rate
Question 3
1 / 1 pts
Maternal and child health nursing is family centered; hence, assessment must be done in individual
assessment data.
- False
Question 4
1 / 1 pts
It is the controlled investigation of problems that have implications for nursing practice, provides
evidence for practice and justification for implementing activities for outcome achievement,
ultimately resulting in improved and cost-effective patient care.
- Nursing research
IncorrectQuestion 5
0 / 1 pts
It is important in evaluating the health of a nation because it reflects the overall quality of maternal
health and prenatal care.
- Fetal Death Rate
Question 6
1 / 1 pts
An advanced-practice role for nurses who are skilled in the care of newborns, both well and ill.
- Neonatal nurse practitioner
Question 7
1 / 1 pts
Nursing care, is designed and implemented in a thorough manner, using an organized series of
steps, to ensure quality and consistency of care.
- Nursing process
Question 8
1 / 1 pts
The nurse systematically evaluates the quality and effectiveness of nursing practice, the nurse
ensures the;
- Quality of care
IncorrectQuestion 9
0 / 1 pts
Preventing further complications from an illness, bringing client back to an optimal state of wellness,
helping client accept inevitable death
- Health rehabilitation
IncorrectQuestion 10
0 / 1 pts
Nurse provides continuous and comprehensive care to the family, group of people and community
and emphasizes more on promotive and preventive health care.
- Health care provider
0 / 1 pts
Which sustainable development goal focus on maternal and child care?
- SDG 3
0 / 1 pts
The following are the strategic thrust for the attainment of the goal of UHC:
- All of the above
Question 13
1 / 1 pts
The crude birth rate of a community is 70/1,000 live birth. This rate implies:
- The community has high fertility.
0 / 1 pts
The infant mortality rate of a community is 80/1,000 live births. This rate implies:
- The community has poor environmental condition
Question 15
1 / 1 pts
Deaths of infants which is influenced by environmental and nutritional factors and not merely
genetic and prenatal factors can be measured using:
- Postneonatal Mortality Rate
MODULE #2 FORMATIVE ASSESSMENT (POST TEST)

Catriona, 27-year old female is desirous of getting pregnant. She asks the nurse regarding her
concerns about ovulation. Her LMP: August 12, 2020; PMP: July 10, 2020.
What is the length of Catriona’s menstrual cycle?
- 33 days
Catriona, 27-year old female is desirous of getting pregnant. She asks the nurse regarding her concerns
about ovulation. Her LMP: August 12, 2020; PMP: July 10, 2020.
What day in July did Catriona ovulate?
- July 28
When will you advise Catriona and her husband to engage in coitus next month?
- August 30
When will be Catriona’s next menstruation if she will not get pregnant?
- September 14
During the secretory phase of the menstrual cycle, the hormone responsible for the development of rich
spongy lining of the uterus is: Group of answer choices
- Progesterone
The prerequisite for ovulation is:
- LH surge
The ovulation day of a 28-day cycle is:
- Day 14
menstrual cycle is a woman most fertile?
- Days 10 – 17
Which of the following are signs of ovulation?
Mittelschmerz;
Spinnbarkeit;
Thin watery cervical mucus;
Elevated body temperature of 4.0 degrees centigrade
- 1, 2, & 3
Vasectomy is a procedure done on a male for sterilization. The organ involved in this procedure is
- Vas deferens
Breast self-examination is best done by the woman on herself every month during
- Right after the menstrual period so that the breast is not being affected by the increase in hormones
particularly estrogen
Spinnbarkeit is an indicator of ovulation which is characterized as:
- Thin watery mucus which can be stretched into a long strand about 10 cm
A woman is considered to be menopause (Links to an external site.) if she has experienced cessation of her
menses for a period of
- 12 months
If pregnancy does not occur, the corpus luteum will disintegrate and turn into what is called the?
- Corpus Albicans
Note: Primordial follicle (premature egg cell) – graafian follicle (watery substance) – corpus luteum
(yellowish) – corpus albicans (grayish)
The ridge of tissue formed by the posterior joining of the two labia minora and the labia majora. This is the
structure that is sometimes cut (episiotomy) during childbirth to enlarge the vaginal opening.
- Fourchette
NUR 1208 MATERNAL - MODULE #3
FORMATIVE ASSESSMENT (POST TEST)
A Roman Catholic couple with three children has come to the family planning clinic for consultation
asking about the best birth control method that is sanctioned by the Roman Catholic Church. The
nurse recommended the calendar method. If the client’s menstrual period in March started on the
15th day, lasting for 3-5 days, the menstrual period in April started on the 16th day, again lasting for
4 days, and the menstrual period in May started on the 18th, again lasting for 3-5 days. The nurse
would instruct the client that her ‘fertile period’ would be days:
- 14 – 21
Karylle Ganda is a 35 year old G4P4 who comes to the clinic for subdermal contraceptive implant
(Levonorgestrel). Which of the following statements to the nurse reflects understanding of this
method?
- “I can become fertile immediately upon removal of my implants.”
In a family planning clinic, patients ask the nurse about postcoital contraception. Accurate
information from the nurse would include which of the following statements?
- “A birth control pill containing Norgestrel and Ethinyl estradiol is the most common
current treatment.”
Daniel Milby visits a birth control clinic. He decides that he’s going to use condoms for
contraception. When counseling him about the use of the condom, it is important for the nurse to
teach Daniel that:
- The condom should be placed when the penis is erect.
A couple comes to the health clinic interested in using a diaphragm or a cervical cap. The couple
asks the nurse, “What is the difference between the two methods?” The nurse’s correct response is:
- “The cap may be inserted hours before intercourse and left in place longer than the
diaphragm; use of additional spermicide with repeated intercourse is optional.”
Meganda is a 37 year old gravida 3 para 2 with a history of smoking and hypertension. She asks
the community health nurse about contraception after the birth of her third baby’ “which method of
contraception is best for me, the pill or an Intrauterine device (IUD)? The nurse’s best response is:
- “The IUD is a better choice for you than the pill; hormonal contraception places
women older than age 35 with your history at greater risk for complications.”
After having a vasectomy, Cedric Navarro asks the nurse if he’ll become sterile immediately. The
nurse’s best response is:
- “It may take three months and as many as 30 to 40 ejaculations to remove all the
live sperm.”
A 25 year old G3 P3 (3003) patient tells you that she and her husband of 8 years is considering a
tubal ligation before discharge from the hospital. Which of the following statement by her indicates
understanding of the procedure?
- “Hopefully, I’ll never have to worry about getting pregnant again.”
SITUATION: Luis and Mariel are married couples with three children. The couple consulted a
family planning clinic. As the nurse manning the clinic you counselled the couple regarding
family planning.
Luis had sperm analysis. You told him that his sperm count is normal. A normal sperm count ranges
from:
- 20 to 100 million/ml
During which of the following phases of the menstrual cycle is it ideal for implantation of a fertilized
egg to occur?
- Secretory
family planning.
Luis asks the nurse about vasectomy. He understands that this is a minor operation and asks if he’ll
become sterile immediately. The nurse’s best response is:
- “It may takes several weeks and as many as 30 to 40 ejaculations to remove all the
live sperm.”
family planning.
Mariel on the other hand plans to use the rhythm method for contraception. She has a regular
menstrual cycle of 28 days each month. What days during her menstrual cycle would be her fertile
period?
- Days 10 to 17
family planning.
As the nurse manning the clinic, you advised Mariel about tubal ligation after the birth of her third
child. Which of the following statements by Mariel indicates understanding of the procedure?

In counseling about contraceptive methods, the nurse informs the couple that the least effective
method is the:
- Spermicidal cream or jelly
family planning.
Luis and Mariel asks what is the most common problem that may occur with an intrauterine device
(IUD)? The nurse’s best response is?
- Expulsion of the device
MODULE #4 FORMATIVE ASSESSMENT (POST

TEST)
Mariel sometimes feels ambivalent about being pregnant. What is the psychological task you’d like to see
her complete during the first trimester of pregnancy?
- Accept the fact that she’s pregnant.
Mariel’s physician told her she had a positive Chadwick’s sign. She asks you what this means, and you tell
her that:
- Her vagina has darkened in color
Mariel is aware that she’s been showing some narcissistic tendencies since becoming pregnant. Which of her
actions best describes narcissism?
- Her thoughts tend to be mainly about herself
Mariel used a urine pregnancy test but was surprised to learn that a positive result is not a sure sign of
pregnancy. She asks you what would be a positive sign. Your best answer would be:
- The fetal heart can be seen on ultrasound
Mariel overheard her doctor say that insulin is not as effective during pregnancy as usual. How would you
explain how decreased insulin effectiveness safeguards the fetus?
- the lessened action prevent the fetus from gaining too much weight
- decreased??
Why is it important to ask Mariel about past surgery in a pregnancy health history?
- Adhesions from surgery could limit uterine growth.
Mariel has not had a pelvic examination since she was in high school. What advice would you give her to
help her relax during her first prenatal pelvic examination?
- She should breathe slowly and evenly during the examination?

You tell Mariel about the danger signs of pregnancy. Which of the following would you tell her to report if it
should occur?
- She gains more weight than 2 lb a week beginning at 20 weeks.
Suppose Mariel has a normal BMI. What would be the recommended weight gain for her during pregnancy?
- 30 lb
Mariel is scheduled to have an ultrasound examination. What instruction would you give her before her
examination?
- “You will need to drink at least 3 glasses of fluid before the procedure.”
The nurse is preparing to teach a prenatal class about fetal circulation. Which statements should be
included in the teaching plan? Select all that apply:
“Two arteries carry deoxygenated blood and waste products away from the fetus.”
"The ductus arteriosus allows blood to bypass the fetal lungs."
“one vein carries”??
The nursing instructor asks a nursing student to explain the characteristics of amniotic fluid. The student
responds correctly by explaining which as characteristics of amniotic fluid. Select all that apply:
Surrounds, cushions, and protects the fetus
Maintains the body temperature of the fetus
Can be used to measure fetal kidney function
Allows fetal movement
A pregnant client tells the clinic nurse that she wants to know the sex of her baby as soon as it can bet
determined. The nurse informs the client that she should be able to find out the sex at 16 weeks’ gestation
because of which factor?
- The appearance of the fetal external genitalia

The nurse instructor asks the student to describe fetal circulation, specifically the ductus venosus. Which
statement by the student indicates an understanding of the ductus venosus?
- “It connects the umbilical vein to the inferior vena cava.”
The nurse is performing an assessment on a client who is at 38 weeks’ gestation and notes that the fetal
heart rate (FHR) is 174 beats per minute. On the basis of the findings, what is the priority nursing action?
- Notify the doctor
The nurse is conducting a prenatal class on the female reproductive system. When a client in the class asks
why the fertilized ovum stays in the fallopian tube for 3 days, what is the nurse’s best response?
- “It promotes the fertilized ovum’s normal implantation in the top portion of the uterus.”
Note: Zygote (fertilized egg) = (16-50 cells = morula) = blastocyst
Fertilization = ampulla
Isthmus = cut during TL
CST = Positive = fetal distress
Negative = normal
A nonstress test is performed on a client who is pregnant, and the results of the test indicate nonreactive
findings. How should the nurse document these findings?
- An abnormal result
The nurse in a health care clinic is instructing a pregnant client how to perform “kick counts”. Which
statement by the client indicates a need for further instruction?
- “I need to lie flat on my back to perform the procedure.”

The nurse is performing an assessment of a pregnant client who is at 28 weeks of gestation. The nurse
measures the fundal height in centimeters and notes the fundal height is 29 cm. How should the nurse
interpret this finding?
- The client is normal for gestational age
The mother undergoes a biophysical profile. The result is 3. How should the nurse interpret this?
- Fetus is potentially in jeopardy

SITUATION: Margarette Uy is a primigravida admitted to the labor unit at 40 weeks gestation.
Vaginal exams revealed that her cervix is 8 cm dilated, 80% effaced, and the presenting part is at
zero station, membranes intact. During a vaginal examination of Margarette, the nurse palpates the
fetal head and a large diamond-shaped fontanel. The nurse correctly interprets this which type of
fetal presentation?
- Brow Presentation
A nurse in the labor room is monitoring the client in labor. 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:
- Monitor the fetal heart tones
The nurse is preparing to instruct Margarette regarding her findings of left sacrum anterior. The
nurse should include which of the following in the teaching plan?
- “Your baby’s hips are flexed and the knees are extended.”
The nurse informed a pregnant client in labor that the smallest head diameter of the fetus must be
presented to the birth canal in order to best traverse/travel to the birth canal. Which of the following
is the smallest anterioposterior cranial diameter of a fetus?
- Suboccipito bregmatic
SITUATION: A 25 year old primigravida client in her last trimester of pregnancy calls the physician’s
office and tells the nurse that she thinks she is in labor. She has several concerns regarding her
upcoming labor. What would be the first sign of impending or approaching labor? Your correct
response should be: she will have to experience EXCEPT:
- Weight gain and edema
The client arrives at the hospital and is admitted to the feto-maternal unit for labor monitoring. The
client informs the nurse that she was admitted to the unit 3 days ago but that turned out to be a
false labor. The nurse examines the client obtaining the vital signs. When is the most appropriate
time to take the client’s vital signs?
- With the client positioned on her left side, between contractions
Situation: After the vaginal examination, the physician indicates that the client is in the latent phase
of the first stage of labor. A progress note is written in the client’s admission records. When the
nurse reviews the client’s admission records, which assessment finding is most reliable indicator the
client is in true labor?
- The cervix is dilated
A pregnant client was admitted to the labor room. An assessment is performed. Internal
Examination was done and the result is 2 cm. cervical dilation, 50% effaced, Station -1, the distance
between ischial spines are wide and amniotic sac is intact. Which of the following is an appropriate
interpretation of the nurse?
- Latent phase, thinning of the cervical canal 1 cm in thickness, unengaged, adequate

pelvis?
Nurse Sweetie is assisting a client in the labor room. While performing Leopold’s Maneuver, which
of the following finding will tell you that the fetus occupies cephalic presentation?
- During first maneuver when you feel a slightly broad mass, somewhat soft and somewhat
hard and moves with the fetal body
The nurse is monitoring the client in labor. The nurse performed abdominal palpation to assess the
frequency, duration, and strength of the contractions of the client in labor. Client’s data include “8
am.: contraction, moderate, lasts 45 sec; 8:05 am.; contraction moderate, lasts for 45 sec.; 8:10 am;
contraction moderate, lasts for 45 seconds. Based on these data, the nurse would correctly interpret
the client’s INTERVAL of uterine contractions as:
- 4 minutes and 15 seconds
The nurse is reviewing the progress of labor of a pregnant woman. The nurse notes that the
physician documented that the woman has circular shaped, moderate depth, wide pubic arch,
moderately curved sacrum on internal examination. An internal examination was done and the
nurse was instructed to chart his findings of the patient’s diagonal conjugate 12.5 cms and the
height of the symphysis pubis is normal. The nurse estimates the obstetric conjugate as
approximately:
- 10.5
Note: diagonal conjugate = pelvic inlet = sacrum to posterior symphysis pubis

Anus – prominent bone = pelvic outlet = biischial tuberosity
The laboring client is 8 cms dilated, 100 percent effaced, with vertex presenting at +2 station. The
fetal heart rate gradually slows during each contraction, returning to baseline by the end of the
contraction. The nurse concludes that which of the following is the explanation of the client’s
condition?
- The fetal head is becoming compressed.
Note: early deceleration = head compression = normal
Situation: A 29 year old multiparous client who has had an uneventful healthy pregnancy is admitted
to the hospital. The physician informs the client is in the active phase of labor. The record also
shows that the full term baby is in the left occiput posterior position. The nurse correctly says that
the following are signs indicating that the labor is progressing, EXCEPT one:
- The duration becomes longer lasting for 10 to 20 minutes
A nurse performed a vaginal examination of a laboring client. The nurse determines that labor is
progressing and the cervix is 8 cms dilated, 75% effaced. The client enters the transition phase of
the first stage of labor. Which nursing action best meets the client’s needs during the transition
phase?
- Frequently praising the client
An internal examination of a 20 year old client revealed the following: cephalic presentation, cervix 3
cms dilated, 75% effaced, station is -1, frequency is 2-3 minutes, duration 45 seconds, moderate
intensity. When asked to perform the partograph, which of the following indicates that the nurse
needs further teaching?
- Latent phase of labor
Note: normal urine output = 30cc/hr

4 hrs = 120 cc
12 hrs = 240 cc (notify the doctor)
Mechanism of labor
PROM = premature rupture of membranes
Prevent laceration – support perineum
Heartburn = intervention is small frequent meals
Side effect of epidural anesthesia = hypotension
Reproductive health law – program for couples
Two days after delivery, the nurses assess a heavy amount of lochia rubra containing four blood
clots about the size of quarters. This assessment is:
- A sign of complication or hemorrhage
The postpartum patient states, “I feel so let down and sad, I don’t know what to do.” The
appropriate nursing response is:
- Offer empathy and support
On the second day postpartum, the nurse palpates the fundus one fingerbreadth below the
umbilicus. Which nursing action is appropriate if the fundus is firm?
- Document the findings
The nurse observes a creamy white vaginal discharge at the client's 2-week postpartum clinic visit.
Which term would the nurse use to document this finding?
- Lochia alba
A client is scheduled for discharge 3 days post-cesarean delivery. The nurse enters to find her
crying and with no obvious evidence of a physical problem. The nurse should:
- Say, "You seem upset. Would you like to talk about it?"
On the second day postpartum, the nurse assesses the client's temperature to be 100.6 degrees
Fahrenheit. What nursing action is most appropriate?
- Assess further for signs or symptoms of infection
The nurse understands that which breast assessment finding is considered normal for the client
who gave birth less than 24 hours ago?
- Thin yellow drainage is noted from the nipple.
A client delivered 4 hours ago. The nurse assesses the client and finds the following: fundus slightly
boggy and 2 fingers above the umbilicus, moderate amount of lochia rubra and midline episiotomy
well approximated. What should the nurse’s priority nursing intervention be?
- Gently massage the fundus until firm
A 36 year old woman Gravida 4 Para 4 who delivered a baby girl at 38 weeks gestation after 8
hours of labor. The client’s vital signs are stable, uterus is firm and her lochia is scanty bright red
and is ready to be discharged. The nurse palpates the uterus of a client 24 hours after delivery.
Where does the nurse expect to feel the fundus?
- One fingerbreadth below the umbilicus
The nurse is performing a postpartum assessment on a client, and notes the presence of clots in
the lochia. The nurse examines the clots and notes that they are multiple, larger than 1 cm. Which
of the following nursing actions is the most appropriate?
- Notify the physician
Situation: Julie Anne Go is a 22 year old gravida 1 who vaginally delivered her first infant.
The vaginal delivery was uncomplicated.
One hour after delivery, which of the following findings would the nurse expect in a patient who
didn’t have complications?
- Firm uterus; heavy amount of lochia rubra with small clots
Before assessing the position of Julie Anne’s fundus, the nurse should:
- Ask Julie Anne to empty her bladder
It’s now 24 hours since Julie Anne’s delivery. In accordance with the normal involution process, the
nurse should locate Julie Anne’s fundus in which of the following positions?
- Midline, 1 cm below the umbilicus
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?
- Assist her to urinate
On the fifth day postpartum, the fundus is palpated at level of the umbilicus. This indicates which of
the following:
- The uterus has not undergone the normal involution process
Caput Succedaneum is a generalized, easily identifiable edematous area of the scalp usually over
the occiput.
Cephalhematoma is a collection of blood between a skull bone and its periosteum as a result of
pressure during birth.
Mongolian Spots is a bluish-black pigmented areas usually found on back and buttocks but can
occur anywhere on the exterior surface of the body including the
Acrocyanosis is a bluish discoloration of the hands and feet, especially when chilled as a result of
vasomotor instability and capillary stasis; it occurs for the first 7 to 10 days of life.
Vernix caseosa is a white, cheesy substance that coats and protects the fetus’s skin while in utero.
Milia are white facial pimples caused by distended sebaceous glands.
Jaundice is referred to as the yellowish skin discoloration caused by increased levels of serum
bilirubin.
Meconium is the thick, tarry, dark green-black stool usually passed within 24 hours of birth.
Erythema toxicum is a transient newborn rash characterized by erythematous macules, papules,

and small vesicles; it may appear suddenly anywhere on the body.
Uric acid crystals is the substance present in the urine of newborns that cause a pink-tinged stain
or “brick dust” on the diaper; it is a normal finding and not representative of bleeding.
SKILLS #1 - ASEPTIC TECHNIQUE FORMATIVE

ASSESSMENT (POST TEST)
Question 1
Select the proper procedure for removing gown and gloves at the end of a case:
- Pull off gown from shoulders first and then remove gloves by glove-to-glove, skin-to-skin technique*
Question 2
Scrub person's hands remain inside gown sleeves and should not touch cuff edges
- closed gloving
Question 3
Used for subsequent gloving, and when performing procedures when a gown is not worn ex.
Catheterization
- open gloving
Question 4
In removing soiled gown and gloves, the _ removed first. To remove gloves, grasp the _ of the first glove and
then _ of the second.
- Gown is, outside, inside.
Question 5
All of the following statements apply when drying the hands and arms EXCEPT:
- Roll the towel before discarding into the appropriate container
Question 6
The closed-glove technique is used:
- Only when the hands have never passed through the gown cuffs
Question 7
Which statement regarding the use of masks is false?
- Cross strings behind the head for better aeration.

Question 8
When is the open glove technique preferred over the closed glove technique?
- To change a glove during a procedure
Question 9
The foundation for the practice of strict aseptic and sterile technique is:
- A surgical conscience
Question 10
When taking off the gown at the end of the case, the gloves' cuffs usually turn down as the sleeves pass off
the arms. The wearer removes the gloves using which one of the techniques listed below?
- Glove-to-glove and then skin-to-skin
NUR 1208 SKILLS #2 - PREP OF MEDS

A nurse makes a medication error. The best action is to
- Document in the patient’s record the error by either noting the omission of a drug or adding
the drug as given if it does not appear on the MAR; also document on the incident or quality
assurance report
Among the following patient’s right, which is not included?
- Right site of administration
It is important not to leave medication at the beside because
- You will not be able to document that the patient actually took the medication
For safety and accuracy of medication being administered to the patient, one of the considerations
is the three checks. Which of the following is not applicable?
- Reading the label after the medications has been administered.
Which is the following route has the faster effect?
- Intravenous
Requires that the effectiveness of the medication be administered by client’s response to the
medication; it is appropriate to determine the extent of side effects and adverse reaction supports
which of the following medication golden rule?
- Right evaluation
Which of the following is not a principle for giving medications?
- When a medication error is made, report it immediately to the nurse in charge and/or
physician.
When the client resists taking a liquid medication that is essential to treatment, the nurse
demonstrates critical thinking by doing which of the following first?
- Notifying the physician that the nurse was unable to give the client this medication
It is the administration of medication into the dermal layer of the skin just beneath the epidermis
- Intradermal
Subcutaneous injection is used for the following, except:
- Sensitivity Test
The following are advantages of oral route of medication, except:
- Fastest route
The nurse is administering an intradermal tuberculin skin test to a client. The client comments that
this "shot" was different than the usual shots. The nurse explains that the difference in the shots is
that intradermals are administered at a different angle than intramuscular injections. The angle for
intradermal injections is
- 15 degrees
The nurse is administering medication in an extended care facility. The client answers to Mr. Smith
and Mr. Brown. What is the best way for the nurse to correctly identify the client before
administering the medications?
- Check the arm band.
Check the name on the room door. In a very slim person, which of the following angles would be
most appropriate for subcutaneous injection?
- 45o angle
To administer 1 mL of a flu vaccine intramuscularly (IM) to an obese adult in the deltoid area you
would use what size needle?
- 1 1/2 inch
In intramuscular injection, what is done immediately after the insertion of the needle?
- The plunger is pulled back
While preparing to give a morning medication, the first nursing action is to:
- Wash hands
The following are advantages of subcutaneous medication over oral medication administration,
except:
- Patient does not have to be conscious or rational
The following are landmarks used to identify the dorsogluteal site, except:
- Cleaner
An equipment used to distend blood vessels.
- Tourniquet
NUR 1208 MATERNAL CONCEPT EXAM
Which of the following exercises should be taught to a pregnant woman who complains of
backaches?
- Pelvic rocking
A client G1P0 attending the prenatal clinic for the first time tells the nurse that her last menstrual
cycle began on January 11. The client also states that she had 1 day of light spotting on February 7.
The client’s expected day of delivery is calculated to be:
- October 18
A 30-year-old primigravida tells the nurse that her hemorrhoids have become itchy and painful. After
instructing the patient about relief measures, the nurse determines that the patient needs further
instructions when she says:
- “I should decrease my fluid intake.”
On performing Leopold’s maneuver on a multiparous client in early labor, the nurse finds no fetal
parts in the fundus or above the symphysis. The fetal head is palpated in the right mid quadrant.
The nurse notifies the obstetrician. Which of the following is safe to assume?
- Transverse lie
You have been asked to assign an Apgar score to the following infant at five minutes of life. The
male infant was born vaginally; his respiratory effort is irregular, pulse is 90, he is floppy and blue
and only minimally grimaces. What is his apgar score?
- 1
The nurse teaches a couple that the diaphragm is an excellent method of contraception. In creating
a teaching plan, the nurse considers the following.
1. Does not use any cream or jelly with it

2. Douches promptly after its removal
3. Leaves it in place for 6 hours following intercourse
4. Inserts it at least 5 hours prior to having intercourse
5. Spermicide added protection
- 3&5
The nurse is caring for a G 3 P3 woman who is 1 day postpartum following a vaginal birth. Which of
the following indicates a need for further assessment?
- Temperature of 100.8 ˚F (38.2˚C)
Meribeth is a 26-year-old who consulted for prenatal check-up. LMP was January 28, 2020.
Meribeth provides a maternal history, including the following data; one healthy female delivered at
term; one miscarriage at 8 weeks; one stillborn male delivered at term; one therapeutic abortion at 6
weeks; one premature male delivered at 32 weeks. During this pregnancy, Meribeth would be
considered as:
- Gravida 6 Para 2
A client G2P1 (1001) at 38 weeks AOG is having a contraction stress test or CST. When assessing
the fetal monitor strip, the nurse notices that with most of the contractions, the fetal heart rate
uniformly slows at mid contraction and then returns to baseline about 20 seconds after the
contraction is over.The nurse would interpret the test result to be:
- Reactive: negative
Labor may begin with rupture of the membranes, experienced either as a sudden gush or as scanty,
slow seeping of clear fluid from the vagina. Mrs. Lopez, your 30 week pregnant client, was rushed
to the emergency room, complaining that she expelled blood tinged mucus 24 hours ago. She also
reports that some twenty minutes ago, a heavy gush of warm liquid suddenly flowed. This was
followed by regular, more intense and more painful uterine contractions. Mrs. Lopez informs you
that her BOW has ruptured. Your priority question would be:
- “What did the fluid look like?”
When analyzing the need for health teaching of a prenatal mutligravida, the nurse should ask which
of the following questions?
- “Do you ever drink alcohol?”
Which statement by a woman indicates an understanding of the basal body temperature (BBT)
method?
- "I can expect a change in my temperature if ovulation occurs."
Sarah Jane Hodgkins, a G1P1 (1001) postpartum patient states that she would like to take a nap
but allows the nurse to take vital signs and perform an assessment. According to Reva Rubin, the
nurse recognizes that Sarah Jane is experiencing what phase?
- Taking-in phase
A client enters the prenatal clinic. She states that she believes she is pregnant. Which of the
following hormone elevations will indicate a high probability that the client is pregnant?
- Chorionic gonadotropin
During a childbirth preparation class, the nurse explains that in the post-partum period, the process
whereby the uterus shrinks to its pre pregnancy state is called:
- Involution
A woman has gotten pregnant with a Copper T intrauterine device (IUD) in place. The physician
has ordered an ultrasound to be done to evaluate the pregnancy. The client asks the nurse why
this is so important. The nurse should tell the woman that the ultrasound is done primarily for which
of the following reasons?
- Assesses for presence of an ectopic pregnancy
Follicles attempt maturation. One follicle succeeds to do so, while others degenerate along the
course of their growth and become replaced by fibrous tissue and atretic follicles. The one that
succeeds to mature enlarges further in size and pushes over the tunica albuginea and accumulates
more fluid. This is now called the _____.
- Mature graafian follicles

During a home visit, a single parent who is multigravida at 32 weeks’ gestation, tells the nurse that
she craves and often eats laundry starch for lunch and usually has a bowl of soup for supper. Total
weight gain to date has been 12 lb (5kg). A priority nursing diagnosis for the patent is:
- Altered nutrition, less than body requirements, related to pica
A nurse student during shower noted two large folds of skin lying outside the labia minora and
covering them. The inner skin is devoid of hair, but outer skin has hair follicles, sebaceous and
sweat glands. The core of CT is rich in fat cells as well as blood vessels and nerves. What is this?
- Labia majora
The nurse is assessing client 24 hours after delivery and finds the fundus to be slightly boggy and 1
centimeter above the umbilicus. What should the priority nursing intervention be?
- Gently massage the fundus until firm
Ana tells the nurse that she usually takes herbal medicine her mother gives her every time she feels
dizzy. The nurse recognizes which statement as the most culturally respectful response?
- “Let’s check first to be certain the herbs won’t cause an interaction.”
Betty, a 30 year old G1P0, was admitted due to labor pains. IE: Cervix 2cm dilated, 50% effaced,
cephalic, station -1, intact bag of waters. Clinical Pelvimetry: Diagonal conjugate= 13.5cm,
Bispinous diameter = approximately 10cm, Bituberous diameter <10cm. Betty asks the nurse what
station – 1 means. Which of the following statement of the nurse is correct?
- “The presentation part of the fetus is 1 cm above the ischial spines.”
A male client receives instructions from the nurse about the proper use of condoms for pregnancy
prevention. Which of the following statements would indicate that the client understands the
instructions for use of condoms?
- “I should unroll the condom and check it for holes before applying it.”
Which statement by a class member indicates a need for further teaching about breathing
techniques during labor and delivery?
- “I’ll request an epidural anesthetic when my contractions begin and won’t need to use
breathing techniques.”
Before assessing the position of the postpartum woman’s uterine Fundus, the nurse should:
- Ask her to empty her bladder

Babi is 2 months pregnant and is worried because she has some nasal congestion with
accompanying elevation in temperature. She asks whether she could take OTC medications to
prevent her sickness from worsening. Your most appropriate response would be:
- “Let us talk to your doctor to see which medication would be alright for you to take”
A 38 year old, G1P0, was admitted due to complain of decrease fetal movement associated with
mild uterine contractions. Cervix is 6 – 7 cm dilated, 80% effaced, station -1, intact Bag of water.
Uterine contractions every 2 to 3 minutes, strong, 60 seconds duration.Which of the following may
happen if the uterus becomes overstimulated by oxytocin during the augmentation of labor?
- Tetanic contractions prolonged to more than 90 seconds
Mrs. Betina Mendez, a 30-year old primapara at 5 months gestation consults at the barangay clinic
for prenatal check-up. The nurse palpates the abdomen of Mrs. Mendez. At 5 lunar months
gestation, what level of the abdomen can the fundus be palpated?
- Midpoint between umbilicus and xiphoid
Which explanation by a nurse counseling a group of women reflects accurate information about
conception?
- Fertilization takes place in the isthmus of the fallopian tube

- Conception is a single event that occurs in isolation
The characteristics of uterine contraction can help determine if the client is experiencing preliminary
signs of labor or if she is already experiencing true labor. Mrs. Lopez inquiries about the difference
of true from false labor, and your response is:
- “False contractions are regular and do not achieve cervical dilatation while true contractions
begin irregularly but become regular and they achieve cervical dilatation.”
A 39-year-old woman in her first pregnancy delivered twin sons 2 hours ago. There were no
significant antenatal complications. She had been prescribed ferrous sulphate and folic acid during
the pregnancy as anemia prophylaxis, and her last hemoglobin was 10.9 g/dL at 38 weeks.Which of
the following nursing interventions would the nurse perform during this stage of labor?
- Obtain a urine specimen and other laboratory tests.
Mrs. Jones is confirmed to be 12 weeks pregnant. You then decide to conduct a health teaching
regarding pregnancy. You know that the right order of the occurrence of pregnancy events is:
- Positive urine pregnancy test, audible fetal heart tones heard via Doppler, presence of fetal
movement felt by the client
The client has come to La Loma Health Center to discuss the use of contraceptives. To facilitate a
productive discussion, the nurse should:
- Inform the client about use, side effects, and effectiveness of different contraceptive options
so that the client can select one that meets her needs.
In response to the nurse’s question about how she is feeling, a postpartum client states that she is
fine. She then begins talking to the baby, checking the diaper, and asking infant care
questions. The nurse determines the client is in which postpartal phase of psychological adaptation
- Taking hold
Nurse Marie attends to a pregnant client who has two children. Her history reveals that her first
pregnancy ended in a stillbirth at 32 weeks of gestation, her second pregnancy with the birth of her
daughter, at 35 weeks, and her third pregnancy with the birth of her son at 41 weeks. Using the GP
TPALM format, Nurse Marie would record the woman’s current obstetrical history as:
- G4P4 (T2 P1 A0 L1 M0)
SITUATION: Kim is a 32 year old executive in a call center. She has been married for one year and
is very serious to get pregnant. Her previous menstrual period was October 15 to 18 and her
menstrual period started last November 13. How many days is her menstrual cycle?
- 28
A nursing student has her last menstrual period (LMP) on November 23, 2019. Past menstrual
period (PMP) is October 24, 2019. Her menstrual cycle is 30 days interval. If you are asked to
explain her menstrual cycle, in which of the following phases of the menstrual cycle does ovulation
occur?
- Secretory phase
While doing Leopold’s maneuver on a client, Nurse Julie notes the presence of a firm round
prominence over the pubic symphysis, a smooth convex structure down her right side, an irregular
lump down her left side, and soft roundness in the fundus. Nurse Julie should conclude that the fetal
position is:
- ROA (Right Occiput Anterior)
Maternal mortality rate (MMR) has been increasing in third world country such as Africa, by far the
highest at 456 maternal deaths per 100,000. In the Philippines MMR was reported at 114 maternal
deaths per 100,000 live births (2015). Which DOH program will be considered best to address the
problem with the Philippine Maternal Mortality rate (MMR)?
- Responsible Parenthood and Reproductive Health law

Four different intrapartum patients are present in the labor unit. Which of these patients would
require a cesarean delivery?
- Multipara with a transverse lie confirmed by the ultrasound
Susan, a gravida 1 para 1001, has vaginally delivered a full-term infant without complications. After
the first postpartum day, she tells the postpartum nurse that she’s afraid that something is wrong
because she’s perspiring and urinating more than normal. Her temperature is 100.0OF (37.8OC).
The nurse should appropriately reply:
- “It’s common to perspire and urinate a lot after childbirth; your body is getting rid of the
excess fluid that was used in pregnancy.”
There are four phases of maternal and child health care, which phase includes helping a patient
with residual effects to achieve an optimal state of wellness and independence?
- Health rehabilitation
A client is in the first hour of her recovery after a vaginal birth.During an assessment, the lochia is
moderate to heavy, bright red, and is trickling from the vagina. The nurse located the fundus at the
umbilicus: it is firm and midline, with no palpable bladder. The client’s vital signs remain at their
baseline. Based on the information, the nurse would implement which of the following actions?
- Report the findings to the health care provider.
The client tells the nurse that she thinks her membranes have ruptured. The nurse performs a
nitrazine test and confirms that the membranes have ruptured with the color blue. The physician
orders internal electronic fetal monitoring. The client asks the nurse about any danger the
procedure causing harm to her baby. The nurse’s best response would be:
- “The procedure requires attachment of a small spiral electrode to the fetal scalp and poses
a slight risk of soft-tissue injury and infection.”
The nurse is teaching a couple about fetal development. Which statement by the nurse is correct
about the morula stage of development?
- “The fertilized egg has yet to implant into the uterus.”
A woman, who wishes to use the calendar method for contraception, reports that her last 6
menstrual cycles were 28, 32, 29, 36, 30, and 27 days long, respectively. In the future, if used
correctly, she should abstain from intercourse on which of the following days of her cycle?
- Days 9-25
Nurse Liza counsels a pregnant woman about reproductive system. She describes the portion of
the uterus whose significant characteristic is to expand during pregnancy is the:
- Cervix
In a vasectomy, a small incision or puncture wound is made on each side of the scrotum. The vas
deferens at that point is then located, cut and tied, cauterized, or plugged, blocking the passage of
spermatozoa. Mr. Ocha is thinking about undergoing a vasectomy. The nurse plans to give further
teaching if he says:
- “My wife and I might need to use an additional family planning method after vasectomy.”
SITUATION: Maricel is on her 3rdday post normal spontaneous delivery. She complains of
inability to defecate in spite of taking regular meals and frequent ambulation. The following are
recommended to reestablish here regular defecation. Which one is LEAST priority?
- Do manual extraction
To decrease the possibility of perineal laceration during delivery, the nurse performs which of the
following interventions prior to delivery?
- Supporting the perineum when the woman bears down
A multigravida at 37 weeks’ gestation tells the nurse that she has frequent heartburn. After
providing the patient with suggestions for obtaining relief from the heartburn, the nurse determines
that the patient has understood the instructions when the patient says:
- “I should eat smaller, more frequent meals with fluids.”
The nurse is providing care for a G2P1 pregnant woman on her 24th The woman asks the nurse
how she can best deal with her fatigue. The nurse should instruct her to:
- Try to get more rest by going to bed earlier
Which of the following is UNTRUE about maternal and child health nurse?
- The nurse demonstrates high dependency to the medical doctor for delivery of adequate
and reliable care
A woman, who is in active labor, is told by her obstetrician, “Your baby is in the flexed attitude.”
When she asks the nurse what that means, the nurse should say?
- “The baby’s chin is resting on its chest”
You help a postpartum woman out of bed for the first time postpartally and notice that she has a
heavy lochia flow. Which of the following assessment findings would best help you decide that the
flow is within normal limits?
- The color of the flow is bright red
As the nurse manning the clinic, you advised Sabina about tubal ligation after the birth of her third
child. Which of the following statements by Sabina indicates understanding of the procedure?
The client is in the third stage of labor. Which of the following assessments should the nurse
make/observe for?
- Uterus rising in the abdomen and feeling globular
The nurse is discussing reproductive health with female adolescents. She would explain which of
the following as the chief function of the progesterone? Select all that applies.
1. Prevents lactation during pregnancy

2. Decreases uterine contractility
3. Act as a thermoregulatory
4. Influences the increased supply of glycogen, arterial blood and amino acids in the endometrium
5. Proliferation of vaginal epithelium
6. Prepares the breasts for lactation
- 123456
A primigravida in labor is monitored by the labor room nurse whose fetus has a frank breech
presentation. Vaginal examination revealed fetus is in left sacrum anterior position and station -1.
The nurse would be safe to interpret this as:
- The fetal sacrum is toward the maternal symphysis pubis
A client, who has been taking birth control pill for 2 months, calls the clinic with the following
complaint: “I have had a bad headache for the past couple of days and I now have pain in my right
leg.” Which of the following responses should the nurse make?
- “Come to the clinic this afternoon so that we can see what is going on.”
Immediately following administration of an epidural anesthesia, the nurse must monitor the mother
for which of the following?
- Drop in blood pressure
A pregnant woman informs the nurse that her last normal menstrual period was on September 20,
2017. Using Naegele’s rule, the nurse calculates the client’s estimated date of delivery as:
- June 27, 2018
On her second visit, the woman eight weeks pregnant is surprise that her blood pressure is lower
than it was before she became pregnant. The nurse explains blood pressure drops slightly during
the first trimester because:
- Peripheral vessels dilate
At a postpartum checkup 11 days after childbirth, the nurse asks the client about the color of her
lochia. Which of the following colors is expected?
- White
Celina is pregnant for the second time. Since she is breastfeeding her first baby, she has not
menstruated. She reports having noticed tingling breast tenderness. If Celina has not menstruated
after her first child, what sign will estimate her gestational age in the absence of ultrasound?
- Quickening
A woman whose prenatal weight was 105 lb weighs 108 lb at her 12-week visit.Which of the
following comments by the nurse is appropriate at this time?
- “Your weight gain is exactly what we would expect it to be at this time.”
A woman is in the transition phase of labor. Which of the following comments should the nurse
expect to hear?
- “I can’t stand this pain any longer.”
Beauty had her blood chemistry done, and the results revealed that her hemoglobin level has
dropped to 10mg/dL from her pre-pregnancy hemoglobin level of 12.6mg/dL. You correctly teach
Mrs. Beauty to increase intake of which of the following?
- Liver, cereals fortified with iron, clams, and green leafy vegetables
The nurse working in an outpatient obstetric office assesses four primigravid clients. Which of the
client findings would the nurse highlight for the physician?
- 27 weeks’ gestation; complains of constipation
Aling Glory, a 36-year-old G5P5 laundry woman seeks consultation at the Family Planning Clinic.
She has 5 children and her youngest is 6 months old. She wants to undergo bilateral tubal ligation
(BTL). She asks about the possibility for getting pregnant after BTL. Which of the following is the
appropriate response of the nurse?
- The probability is rare.”
Reproductive life planning includes all the decisions an individual or couple make about whether
and when to have children, how many children to have, and how they are spaced. Mrs. Bellita, 25
years old, is newly married and needs counselling regarding natural family planning methods. You
proceed with reproductive health assessment prior to conducting health teaching about
contraception methods. Ovulation is the process wherein the ovum is set free from the surface of
the ovary. Mrs. Bellita reports that her menstrual cycle usually lasts for 44 days and she starts
ovulating on the 22nd day. You should tell her that:
- “The day of your ovulation is on the 30th day.”
A newborn male has 4 mm breast nodules, fuzzy scalp hair, some cartilage in his ear lobes, and
some sole creases in addition to partially descended testis with a small scrotal sac. You correctly
assigned his gestational age as:
- 41 weeks
A client appears in the health center for her first prenatal visit at 26 weeks’ gestation. She states, “I
didn’t see any point in coming sooner since I felt fine.” The nurse uses which of the following
statements to explain why prenatal care in the first trimester is important?
- “Important cellular growth happens in the first trimester. Early assessment and education
promote a healthy pregnancy during this time.”
To change her center of gravity and make ambulation easier, a pregnant woman tends to stand
straighter and taller than usual. This stance is sometimes referred to as the “pride of pregnancy.”
Standing this way, with the shoulders back and the abdomen forward, creates a lordosis, which may
lead to backache. In her 8th month of pregnancy, Mrs. Esteban returns to the clinic and you notice
that she rubs her back frequently. She asks you how she can keep her backache from getting
worse. You will instruct the patient to:
- Stand with the neck and shoulders straight and the back flattened
Si client receives instructions from the nurse about the proper use of condoms for pregnancy
prevention. Which of the following statements xpelled from her vagina about an hour from
admission, quickly followed by contractions as frequent as every 5 minutes of 40-60 second
duration. She states that the contractions are getting more intense You would like to assess the
frequency, duration, and intensity of the contractions. In order to do these, which of the following will
you do?
- Noting the duration of the contractions by timing from the end of one contraction to the end
of the next contraction
Nurse Alma incorporates nursing, computer, and information sciences to store data and improve
patient care. Nurse Alma is utilizing____
- Nursing informatics
A primigravida at 10 weeks’ gestation tells the nurse that she continues to have a urinary frequency.
The nurse should instruct the patient to:
- Empty her bladder frequently throughout the day
Probable indications of pregnancy are objective findings that can be documented by an examiner.
Although these signs are strong indicators of pregnancy, a positive diagnosis of pregnancy cannot
be based on these findings because they may be caused by other conditions. All but one of the
following is a probable sign of pregnancy:
- Upon Nurse Ita’s palpation, she felt an outline of the fetus in Jessica’s abdomen.
A client is now in her second trimester. While listening to the fetal heart, the nurse hears a heartbeat
at the rate of 136 in the right upper quadrant and also at the midline below the umbilicus. The
sources of these sounds are:
- Fetal heart rate and funic soufflé
The nurse is providing follow-up with clients 1 week after the birth of their neonate. The nurse would
anticipate what outcomes from this new mother?
1. The client feels tired but is able to care for herself and her new infant.
2. The family has adequate support from one another and others.
3. Lochia is changing from red to pink and smaller in amount.
4. The client feeds the baby every 6 to 8 hours without difficulty
5. The client has positive comments about her new infant
- All but 4
SITUATION: A pregnant client in her 36 weeks AOG was seen for prenatal follow-up. While
performing Leopold’s Maneuver, which of the following finding will tell you that the fetus occupies
cephalic presentation?
A 36-week gestation gravid lies flat on her back. Which of the following maternal signs/symptoms
would the nurse expect to observe?
- Dizziness
The nurse is discussing reproductive health with female adolescents. She would explain which of
the following as the chief function of the progesterone? Select all that applies.
1. Prevents lactation during pregnancy
2. Decreases uterine contractility
3. Act as a thermoregulatory
4. Influences the increased supply of glycogen, arterial blood and amino acids in the endometrium
5. Proliferation of vaginal epithelium
6. Prepares the breasts for lactation
- 123456
Alyssa is a 33-year-old primigravida who has come to the hospital because she experienced bright
red vaginal bleeding. She’s at 35 weeks gestation. Her clinic chart indicates that she was diagnosed
with placenta previa 3 weeks earlier. Immediately after delivery the nurse would expect to assess
Ms. Alyssa’s fundus to be:
- Firm and contracted at the umbilicus
SITUATION: Kathryn Padillais a primigravida admitted to the labor unit at 40 weeks’ gestation.
Vaginal exams revealed that her cervix is 8 cm dilated, 80% effaced, and the presenting part is at
zero station, membranes intact. During a vaginal examination of Kathryn, the nurse palpates the
fetal head and a large diamond-shaped fontanel. The nurse correctly interprets this which type of
fetal presentation?
- Brow presentation
The nurse discusses BTL (Bilateral Tubal Ligation), which of the following pre-operative instructions
is paramount to the couple. Select all that apply
1. Bring a companion.
2. She and her husband must be certain that this procedure is permanent.
3. NPO after midnight until after the procedure.
4. Take a bath before the procedure.
- 1&2
In conducting a health education class among Grade 5 students, Nurse Liza created a diagram of
the reproductive system. This includes the following EXCEPT:
- The Bartholin’s gland and Skene’s gland lubricates the vulva during sexual intercourse
An internal examination of a 20 year old client revealed the following: cephalic presentation, cervix 3
cms dilated, 75% effaced, station is -1, frequency is 2-3 minutes, duration 45 seconds, moderate
intensity. When asked to perform the partograph, which of the following indicates that the nurse
- Latent phase of labor

It is 4 pm, a client, G1 P0 (0000), 3 cm dilated, asks the nurse when the dinner tray will be served.
The nurse replies:
- “A heavy meal is discouraged. I can get clear fluids for you whenever you would like them.”
A client gave birth vaginally 2 hours ago and has a third-degree laceration. There is ice in place on
her perineum. However, her perineum is slightly edematous, and the client is having pain rated 6
on a scale of 1 to 10. Which nursing intervention would be the most appropriate at this time?
- Begin sitz bath
Combined oral contraceptives are composed of synthetic estrogen combined with small amounts of
synthetic progesterone. Your client, Mrs. Undertaker, has been using COCs as her primary
contraception method. She comes to the clinic complaining “Bakit hindi pa din ako mabuntis?
Tumigil na naman ako ng paginom ng pills.”. Your most appropriate response will be:
- “Your body just needs time to recover from the effects of the pill. It may be difficult to get
pregnant during the first 3 to 12 months after discontinuation.”
The laboring client asks the nurse if she will delivery vaginally. Measuring adequacy of the bony
pelvis from the posterior aspect of the symphysis pubis to the sacral prominence by internal
examination is what pelvic measurement?
- Diagonal conjugate
SITUATION: Covida, a 13-year-old Filipino Japanese girl is seen at the school clinic for her annual
physical checkup. She expresses her desire to learn more about the physiologic changes
associated with puberty. Which is the normal time sequence of bodily changes that is manifested by
Covida?
1.
1. Breast development
2. Appearance of axillary and pubic hair
3. Menarche
- 1,2,3
Situation: Martinez was admitted to the hospital due to labor pains. Internal Examination
was done and the result is 2 cm. cervical dilation, 50% effaced, Station 0, the distance
between ischial spines are wide and amniotic sac is intact. Mrs. Martinez is transported to the
delivery room for the second stage of labor. During this stage the fetus is moved along the birth
canal by mechanisms of labor. Which of the following sequences of position changes illustrates
chronological order of the mechanism of labor?
- descent, flexion, internal rotation, extension, external rotation, expulsion

A woman had a baby by normal spontaneous delivery 10 minutes ago. The nurse notes that a gush
of blood was just expelled from the vagina and the umbilical cord lengthened. What should the
nurse conclude?
- The woman is about to deliver the placenta
A woman is menstruating, if hormonal studies were done at this time, which of the following
hormonal levels would the nurse expect to see?
- Both estrogen and progesterone are low
During a home visit on the fourth postpartum day, a primapirous client tells the nurse that she is
aware of a “let-down sensation” in her breasts and asks what causes it.The nurse explains that this
is stimulated by which of the following?
- Oxytocin
SITUATION: Mendoza 24 year old gravida 4 para 2 visits the prenatal clinic for her check-
up. Her last LMP was August 21, 2010. Determine the age of gestation [AOG] of the client on
December 25, 2010.
- 18 weeks
The nurse is providing care for a patient with a twin pregnancy. Which of the following fetal factors
would enhance the possibility of a vaginal birth?
Twin A is in a breech presentation
Evidence exists of fetal distress in one fetus
Twin A is in a vertex presentation
Gestation is less than 32 weeks, and the fetal size is less than 2, 000 g ??
The nurse is teaching husband how to time the frequency of his wife’s contractions who is in labor.
Which of the following statements would the nurse use in her teaching?
- Duration is timed from the beginning of a contraction to the end of the same contraction
A pregnant woman eats 2 eggs with toast to facilitate her iron intake. The nurse teaches that iron is
absorbed poorly, and absorption will be enhanced by:
- Drinking orange juice with her meal

Mirriam, a 35 weeks pregnant client approaches the hospital and verbalizing "Nurse, pumutok na
ata yung panubigan ko." Which of the following findings would the nurse expect?
- Fernlike pattern when vaginal fluid dries on a glass slide
A patient at a prenatal class asks the nurse, “How do my baby’s lungs get air now that I’m
pregnant?” The nurse’s correct response is:
- "Your baby’s lungs don’t need air at this time; the fetal lungs don’t function as lungs until
birth."
A client had an episiotomy and complains of perineal discomfort. She is also afraid to have a bowel
movement. Which of the following nursing diagnoses is the highest priority for this client at this
time?
- Pain
The nurse is assessing a client at her postpartum check-up 6 weeks after a vaginal birth.The
mother is bottle feeding her baby. Which client finding indicates a problem at this time?
- Firm, fundus at the symphysis
A client is to be discharged 12 hours after delivery. The nurse should delay the discharge and notify
the physician if which of the following is observed?
- Three voiding totaling 240 cc in 12 hours.
Which of the following, if stated by the client, would indicate that teaching about cervical mucus
changes as an indicator for ovulation has been understood?
- “If my cervical mucus is thin and watery, I am probably fertile.”
A patient, G2P1102, who delivered her baby 8 hours ago, now has temperature of 100.2˚F. Which
of the following is the appropriate nursing intervention at this time?
- Encourage intake of water and other fluids
A primigravid client gave birth vaginally 2 hours ago with no complications. As the nurse plans care
for this postpartum client, which postpartum goal would have the highest priority?
- The client will demonstrate self-care and infant care by the end of the shift.
Situation: Catherine delos Reyes is a 22 year old Gravida 1 who vaginally delivered her first infant.
The vaginal delivery was uncomplicated. One hour after delivery, which of the following findings
would the nurse expect in as patient who didn’t have complications?
- firm uterus; heavy amount of lochia rubra with small clots
A client G3P2(1102), about 8 weeks pregnant, ask the nurse when she will be able to hear the fetal
heartbeat. The nurse would respond by feeling the client that the fetal heartbeat can be heard with a
Doppler ultrasound device when the gestation is as early as:
- 8 weeks
Patty delivered spontaneously to a live baby girl weighing 3,600 grams. Immediate postpartal care
is done by the nurse assigned to her. After the delivery has been completed, the following
interventions are done, EXCEPT:
Soiled linen under her buttocks are replaced with a sterile perineal pad.
Lower her legs from the stirrups one after the other.
Cover her with blanket to avoid chilling.
Monitor her VS (every 10-15 minutes).
Situation: A nurse is monitoring Angel Manzano in active labor and notes that the client is having
contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between
contractions is 100 beats per minute. Labor monitoring was done. The nurse caring for the client in
labor monitors the fetal heart rate patterns. The nurse notes the presence of episodic accelerations
on the electronic fetal monitor tracing. Which of the following actions is most appropriate to be done
by the nurse?
Take the mother’s vital signs and instruct the mother that bed rest is required to conserve oxygen
Reposition the mother and check the monitor for changes in the fetal tracing
Notify the physician of the findings
Document the findings and tell the mother that the monitor indicates fetal well being
NUR 1208 SKILLS #3 - CARE OF PREGNANT
WOMEN FORMATIVE ASSESSMENT (POST
TEST)
The nurse is assessing a client in the fourth stage of labor/birth and finds that the client has
saturated two perineal pads within an hour's time. Which action should the nurse do first?
Put the client on a bedpan to void.
Notify the supervising RN quickly.?
Assure the client that this is normal.
Start a pad count and chart it.
The nurse understands that a 3-cm dilatation with contractions 3 to 5 minutes apart would indicate
which phase of labor?
Transition phase, second stage
Active phase, first stage
Latent phase, first stage?
Active phase, second stage
With the cervix dilated to 8 cm, the client's contractions are stronger, and she becomes irritable
towards her support person. She yells, "Don't touch me!" The best response by the nurse would be
to EXCEPT:
Position the client on her left side.
Apply warm soaks or back rubs to the lower back.
Remind the support person that this is normal at this point in labor.
Ask the client to push actively since she is ready to deliver.?
Before performing Leopold’s maneuvers, the nurse explains to the pregnant patient, what she will
be doing. The nurse states the primary purpose of this assessment is to:
Determined the length of the fetus
Locate the head of the fetus?

Determine the station of the fetus
Chroma, 22 years old, has missed her two regular menstrual periods. Her doctor confirms an early
intrauterine pregnancy. To determine Chroma’s expected due date, which of the following is the
most important?
Date of last intercourse
Dates of first menstrual period
Age of menarche
Dates of last normal menstrual period?
The uterus rises out of the pelvis and becomes an abdominal organ about the:
Eight week of pregnancy
Eighteenth weeks of pregnancy
Twelfth week of pregnancy?
Tenth week of pregnancy
When the nurse is talking with a client who is experiencing "lightening," the client would most likely
state which of the following?
My lower back pain is gone now."
"I can breathe easier now."?
"I don't have to urinate as often now."
"My feet are more swollen than before."
Following the confirmation of pregnancy, the client has come into the clinic for her first prenatal visit.
She reports having a 5-year-old child who was born at 40 weeks’ gestation, a set of 3-year-old
triplets who were born at 34 weeks’ gestation, and a first trimester abortion when she was in
college. The nurse would make which of the following entries on her medical record?
Gravida 3, para 3112
Gravida 4, para 1114?
SITUATION: Bella Bernardo 24 year old gravida 4 para 2 visits the prenatal clinic for her check-
up. Her last LMP was August 21, 2020. Determine the age of gestation [AOG] of the client on
December 25, 2020.
9 weeks
18 months
18 weeks?
8 weeks
Why is it important to ask a pregnant client about past surgery in a pregnancy health history?
To assess whether she could be allergic to any medication.?
To test both her recent and long-term memory.
To determine if she has effective health insurance.
Adhesions from surgery could limit uterine growth.
Using Naegele's rule, the nurse would understand that the client's due date was ____________ if
the last menstrual period was between May 6 and May 11.
February 18th?
February 13th
February 11th
February 6th
When a patient is admitted to the unit in active labor, what is the action the nurse should take?
Catheterize for urine specimen
Assess for ruptured membranes
Perform Leopold’s maneuver
Take vital signs only and check FHT?

The nurse expects which step next when the doctor says the vertex of the infant is presenting?
Have the client hold her breath to stop pushing so the doctor can turn the baby around.
Continue to support the couple in the labor process.?
Have the client do a knee-chest position to move the cord from around the neck.
Prepare for an emergency cesarean section.
When questioned about the average length of time a primigravida is usually in active labor, the
nurse explains that it is usually about how long?
8 to 12 hours?
4 to 6 hours
16 to 18 hours
12 to 14 hours
When clarifying a teaching plan during a routine prenatal visit, the nurse knows the client
understands when the client explains which hormone is the source of fetal maturity and initiation of
labor?
- Progesterone
A client attending the prenatal clinic for the first time tells the nurse that her last menstrual cycle
began on January 11. The client also states that she had 1 day of light spotting on February 7. The
client’s expected day of delivery is calculated to be:
- October 18
A client is admitted to the birthing unit. She is bearing down uncontrollably with contractions and
says, “The baby is coming!” Which of the following is the priority action of the nurse?
- Put on gloves and prepare for immediate birth
SITUATION: Bella Bernardo 24 year old gravida 4 para 2 visits the prenatal clinic for her check-up.
Her last LMP was August 21, 2020. Determine the age of gestation [AOG] of the client on
December 25, 2020. The nurse anticipates the following laboratory exams to be requested, except:
Urinalysis
Complete blood count
Serum HBsAg
Blood glucose level?
Sandra Marquez feels well so she asks you why she needs to come for prenatal care. The best
reason for her to receive regular care is:
- It provides time for education about pregnancy and birth
The nurse hears the obstetrician say that engagement has occurred; the nurse would understand
that this means:
- The presenting part has entered the true pelvis.
SITUATION: Bella Bernardo 24 year old gravida 4 para 2 visits the prenatal clinic for her check-up.
Her last LMP was August 21, 2020. Determine the age of gestation [AOG] of the client on
December 25, 2020. When will you advise the client to come back for her next visit?
- Next month
Mrs. Sarah Geronicelli 24 year old gravida 1 para 0 visits the prenatal clinic for her check-up. Her
last LMP was April 21, 2020. Determine the age of gestation [AOG] of the client on December 18,
2020.
- 34 weeks 4 days
A client in labor complains of feeling faint, so the nurse turns her to her left side. The nurse
understands that this position will affect the laboring contractions in which manner?
It will increase the intensity of the contractions.
Little or no effect on the contractions?
It will stop the contractions.
It will increase the frequency of the contractions.
The doctor has documented a fetus in an RMP position. What would the nurse expect to see
delivered first?
- Chin
During an initial prenatal visit a pregnant client states she has had 1 miscarriage at 12 weeks, one
child delivered at 38 weeks, and another child delivered at 40 weeks. The LPN/LVN documents this
as:
- G3P2/T2A1.
Mrs. Nena wants to know when her baby will be born. Her last menstrual period began October 22,
2019. The nurse calculates her delivery date to be:
- July 29, 2020
Nurse Annabeth is assisting a client in the labor room. While performing Leopold’s Maneuver, which
of the following finding will tell you that the fetus occupies cephalic presentation
The nurse performs Leopold’s maneuver before placing the fetal monitoring device on a primigravid
client’s fundus. In performing the third maneuver, the nurse explains that this maneuver is done for
which of the following?
- To determine whether the fetal presenting part is engaged
Using Mc Donald’s rule, how do the nurses calculate the length of pregnancy in weeks?
- multiply fundic height in cms by 8/7
The nurse is to perform Leopold’s Maneuver on a pregnant patient. What instructions does the
nurse give the patient just before the assessment?
- Urinate just prior to procedure
Take note:
Mod 2
1. July 10 Aug 12
31-10 = 21 + 12 = 33 days cycle
2. Ovulation =
3.
4.
5.
6. Bright red at birth --> Rubra—dark red (first 2-3 days) --> Serosa—pink (3-10 days) -->
Alba—creamy white or light yellowish --> Clear
NUR 1208 PEDIA- SAQ #1 GROWTH AND

DEVELOPMENT
True/False
True 1. The primary focus of a well-child visit is to determine the child’s developmental stage.
True 2. Cognitive development refers to the ability to learn and solve problems.
False 3. Reaction pattern refers to a child’s response on initial contact with a new stimulus.
True 4. According to Erikson, the developmental task for infants is learning trust versus mistrust.
True 5. Piaget referred to the infant stage as the sensorimotor stage.

Fill in the Blank
Maturation is a synonym for development.
Temperament refers to an individual’s characteristic manner of thinking.
Egocentrism is perceiving one’s thoughts and needs are better or more important than those of others.
Milestones are considered major markers of normal development.
Development indicates an increase in skill or the ability to function.
MODULE 2: CARE OF A FAMILY WITH AN INFANT
True/False
True 1. As a rule, most infants double their birth weight by 4 to 6 months.
False 2. A major milestone at 6 months is the pincer grasp.
True 3. Fear of strangers reaches its height during the eighth month.
True 4. Solid food can be introduced when the infant is 4 to 6 months old.
False 5. The infant should be placed on his or her stomach to sleep.
Fill in the Blank

1. Until age 3 to 4 months, a(n) extrusion reflex prevents some infants from eating.
2. A(n) 8 -month-old child should be able to sit securely without any additional support.
3. It’s important that parents child proof their home to help ensure safety of the child.
4. Colic is paroxysmal abdominal pain that generally occurs in infants under 3 months of age and is marked
by loud, intense crying.
5. Miliaria or prickly heat rash can occur in warm weather or when the babies are overdressed.
NUR 1208 PEDIA: SAQ FOR TODDLER
True/False
True 1. Toddlerhood is a critical time for language development.
True 2. Active toddlers may need up to 1,400 kcal daily to supply all their needs.
False 3. All toddlers should be potty trained by their second birthday.
True 4. Making a statement instead of asking a question can help avoid many negative responses
with toddlers.
False 5. Sneaking out of the house helps lessen the toddler’s separation anxiety.
Fill in the Blank
1. During the toddler years, children are involved in parallel play.

2. Toddlers are able to remember an action and imitate it later is called deferred imitation.
3. Discipline is/are setting rules so children know what is expected of them.
4. The tendency to focus on only one aspect of a situation at one time is known as centration.
5. The first dental visit should happen at about 12 months.
SELF ASSESSMENT FOR PRE SCHOOL

AGE
True/False
True 1. Children generally have all 20 of their deciduous teeth by age 3 years.
False 2. An Oedipus complex refers to the strong emotional attachment a preschool girl
demonstrates toward her father.
True 3. Preschoolers should sit in the back seat buckled in a car seat or booster seat.
True 4. It is important for parents of preschoolers to respect creativity.
True 5. Many preschoolers have an imaginary friend.

Fill in the Blank
1. A(n) Oedipus complex is the attachment a preschool boy demonstrates toward his mother.
2. Contour body changes are definitive that a future body type, such as ectomorphic or slim body build,
becomes apparent.
3. A 3-year-old child typically has a vocabulary of about 900 words.
4. Children of preschool age determine right from wrong based on their parents’ rules.
5. Time out is a useful technique for correcting behavior throughout the preschool years.
NUR 1208 PEDIA - MODULE #1 (POST TEST FOR

PRINCIPLES OF GROWTH AND
DEVELOPMENT) BSN 202
A 2-year-old always puts his teddy bear at the head of his bed before he goes to sleep. The parents
ask the nurse if this behavior is normal. The nurse should explain to the parents that toddlers use
ritualistic patterns to:
- Establish sense of security

This refers to a child’s response on initial contact with a new stimulus
Reaction pattern
Rhythmicity
Threshold of response?
Temperament
One of the essential physical data when making an assessment and should be accurately plotted
on a growth chart
- Weight
A mother of a toilet-trained 3-year-old expresses concern over her child’s bed –wetting while
hospitalized. The nurse should tell the mother
- “It’s very common for children to regress when they’re in the hospital.”
The school nurse is invited to attend a meeting with several parents who express frustrations with
the amount of time their adolescent spend in front of the mirror and the length of time it takes them
to get dressed. The nurse explains that this behavior indicates:
- A result of developing self-concept
A 2-year-old always puts his teddy bear at the head of his bed before he goes to sleep. The parents
ask the nurse if this behavior is normal. The nurse should explain to the parents that toddlers use
ritualistic patterns to:
Loss of this crucial environmental influence can interfere with a child’s desire to eat, improve, and
advance
- Parent-child relationship
The school nurse is invited to attend a meeting with several parents who express frustrations with
the amount of time their adolescent spend in front of the mirror and the length of time it takes them
to get dressed. The nurse explains that this behavior indicates:
- A result of developing self-concept

To encourage autonomy in a 4-year-old, the nurse should instruct the mother to:
- praise the child’s attempts to dress herself
Considered as major markers of normal development
- Developmental milestone
The primary focus of a well-child visit is
- to determine the child’s developmental stage
A nurse is assessing the growth and development of a 14-year-old boy. He reports that his 13-year-
old sister is 2 inches taller than he is. The nurse should advise the boy that the growth spurt in
adolescent boys, compared with the growth spurt of adolescent girls occurs:
- 2 years later
A mother is visiting her baby in the pediatric intensive care unit. Her baby is fussy and the mother
wants to know what to do. In order to quiet a sick baby, which of the following can the nurse teach
the mother to do?
- Use constant gentle touch
The terms “growth” and “development” are often used interchangeably. To which of the following
does “development” refer?
- He learns to throw a ball overhand.
NUR 1208 SKILLS #4 - ESSENTIAL NEWBORN
CARE FORMATIVE ASSESSMENT (POST TEST)
An infant’s intestines are sterile at birth therefore lacking the bacteria necessary for the synthesis of:
- Prothrombin
The finding which would probably necessitate intense follow-up care of a newborn would be:
- An umbilical cord that contains only 2 vessels
When administering an IM injection to an infant, the nurse should use which site
- Vastus lateralis
Of the following diagnoses for a high risk newborn, which requires the most immediate intervention
by the nurse?
- Ineffective airway clearance related to pulmonary secretions
A mother was diagnosed with gonorrhea immediately after delivery. When providing nursing care
for her baby, an important goal is to:
- Prevent development of ophthalmia neonatorum
What nursing diagnosis would be the highest priority when caring for a preterm infant?
- Ineffective thermoregulation related to lack of subcutaneous fats
During a typical initial newborn assessment, a nurse would not expect to identify the presence of:
Hands and feet that have bluish color
An apical heart rate of 94 bpm
An umbilical stump that has 2 veins and 1 artery
An eye discharge that is yellow and watery?
Which condition can result from an untreated maternal chlamydial infection?
Vesicular lesions around the vagina?
Hemolytic anemia
Deafness
Chronic conjunctivitis
Sean is delivered at 44 weeks’ gestation by cesarean section because of fetal distress. At delivery,
he has a thick, green-tinged coating, cyanosis, and signs of respiratory distress. The physician
diagnosed meconium aspiration syndrome. Which factor would predispose Sean to meconium
aspiration syndrome?
Prematurity
Postmaturity?
Maternal diabetes
Maternal sepsis
When reviewing the data recorded on a newborn’s chart, the information that would indicate to the
nurse that this baby requires special attention would be:
- The APGAR score at birth was a 3
Baby del Rio, delivered at 46 weeks gestation, weighs 3400 grams. Her birth length is 59
centimeters. The baby’s birth length is:
- Long
An indication that the newborn is at gestational age of 38-40 weeks is:
Flat ears
Blanched skin
Mongolian spot
Creases in soles and palms?

The cord of the baby must be cut between 2 clamps and tied using sterile scissors or blade.
Immediately after this procedure, where should you place the baby?
- Breast of the mother
The first two hours after delivery, the mother should be watched for bleeding. What should be the
most important parameter to check?
Uterus
Laceration
Placenta
Vital signs?
Applying the essential newborn care, the nurse will do which of the following interventions first upon
the delivery of the baby?
- Suctioning the airway to prevent respiratory distress
If the Apgar score is 8 within one minute after birth, what will be your immediate response?
- No response as this is a normal occurrence

When measuring the length of the baby, where do you place the tape measure first?
- Head of the newborn
When both vitamin K and Hepatitis B is administered in a newborn immediately after delivery. What
is the site for vitamin K injection?
- Left thigh
A new mother is breastfeeding her 2-day-old infant and tells the nurse that she cannot believe her
newborn wants to be breastfeed again, since she just fed him 2 ½ hours ago. The nurse should
plan to teach the client that a newborn usually should be nursed as the Mandated law of the
Department Of Health
- Every four hours
Exclusive Breastfeeding entails that an infant will receives only breast milk without any additional
food or drink, not even water. Rooming – In and Breast-feeding Act of 1992 known as:
- Republic Act (RA) 7600

NUR 1208 PEDIA - MODULE #2 (POST TEST
FOR INFANCY)
A mother is visiting her baby in the pediatric intensive care unit. Her baby is fussy and the
mother wants to know what to do. In order to quiet a sick baby, which of the following can the
nurse teach the mother to do?
- Use constant gentle touch
To assess the development of a 1-month-old, the nurse asks the parent if the infant is able to
- Turn head side to side
After explaining the immunization schedule, the parent of a 2-month-old infant is hesitant to consent
to the recommended vaccinations. The nurse should first ask the parent:
- “What personal beliefs or safety concerns do you have about vaccinations?”
Has overcome fear of strangers and is alert and responsive again when approached
- 8 months
A reflex that prevents some infants from eating
- Extrusion reflex
Which information would the nurse use to support her idea of referring an eight-month-old child to
a health care provider?
Inability to stoop to recover an object
Inability to stand momentarily without holding onto furniture?
Inability to stand alone well for long periods of time eto ba
Inability to sit without support for long periods of time mali

A 10-month-old looks for objects that have been removed from his view. The nurse should instruct
the parents that:
- the child understands the permanence of objects even though the child cannot see them.
A six-week old infant smiles in return to an interested person’s nodding and smiling. This is called:
- Social smile
The first tooth eruption is at:
- 6 months
Lila, a 6-month-old, is undergoing a hearing assessment. The nurse would expect Tracy to be able
to locate sounds made _______ the head
- Above
A parent brings a 4-month-old to the clinic for a regular well visit and expresses concern that the
infant is not developing appropriately. Which is the most significant finding in the infant that merits
further developmental screening?
- Does not babble
Which of the following would you use to assess if a 12- month-old child has appropriate language
development?
- Saying 2-3 words besides mama and dada
Pincer grasp begins at about

- 10 months
Which of the following data is typical in a breast-fed infant?
Stools of breastfed infants are usually harder than those of bottle-fed infants.?
Stools of breastfed infants tend to have a strong odor.
Breastfed infants usually have fewer stools than bottle-fed infants.
Breastfed infants are less likely to be constipated than bottle-fed infants.
An infant’s immune system becomes functional at what age

- two months
Which among the infants will require immediate developmental referral for a gross motor delay?
The 6-month-old who does not creep
The 10-month-old who does not stand holding on?
The 2-month-old who does not roll over
The 4-month-old who does not sit without support
NUR 1208 PEDIA: POST TEST FOR TODDLER

AND PRE SCHOOLER
A 2-year-old child brought by his mother to the clinic for a routine check-up. Which of the following
should the nurse expect the child to be able to do?
- Kick a ball forward
Which of the following is unnecessary for toilet training readiness for a 2-year-old?
- Ability to play with other 2-year-olds

A mother of a toilet-trained 3-year-old expresses concern over her child’s bed –wetting while
hospitalized. The nurse should tell the mother:
- “It’s very common for children to regress when they’re in the hospital.”
The mother asks the nurse for advice about discipline for her 18-month-old. Which of the following
should the nurse suggest the mother to use?
- Time-out
A 2-year-old child brought to the clinic by her parents is uncooperative when the nurse tries to look
in her ears. Which of the following should the nurse try first?
- Allow a parent to assist
A 2-year-old always puts his teddy bear at the head of his bed before he goes to sleep. The
parents ask the nurse if this behavior is normal. The nurse should explain to the parents that
toddlers use ritualistic patterns to:
To encourage autonomy in a 3-year-old, the nurse should instruct the mother to:
- praise the child’s attempts to dress herself
When you examine a toddler, you suggest to his mother that the activity that could most
appropriately foster his developmental task according to Erikson would be to
- allow him to pull a talking-duck toy
The moral developmental theory is about the basis of decision making for people of different stages
of development. Children of toddler determine right from wrong based on:
- Parents’ rules
The developmental task of a toddler according to Erickson
- Autonomy versus shame or doubt
A 5-year-old child insists that the site for blood extraction be covered with a bandage. When the
parent tries to remove the bandage before leaving the office, the child screams that all the blood will
come out. The nurse encourages the parent to leave the bandage in place and tells the parent that
the child:
- does not understand body integrity
The mother of a preschooler reports that her child creates a scene every night at bedtime. The
nurse and the mother decide that the best course of action would be to do which of the following?
- Establish a set bedtime and follow a routine
The mother of a 4-year-old expresses concern that her child may be hyperactive. She describes
the child as always in motion, constantly dropping and spilling things. Which of the following actions
would be appropriate at this time?
- Explain that this is not unusual behavior
A preschooler falls off the swing and cries, “Bad swing! You made me fall!” This child’s response is
an example of:
- Animism
What is the most appropriate advice for the nurse to offer parents who are concerned about their
preschooler’s masturbation?
- Try to interest the child in another activity
Choose the most appropriate teaching for parents of a child with enuresis or bedwetting
- The child should empty his bladder before going to bed
Bedtime for the preschooler child should include:
- A quiet activity such as a story
The child stopped making tantrums so that the mother will give her a beautiful teddy bear.
- Individualism and Exchange
A pre-schooler came home from playing outside with neighbors. He was so hungry. A healthy snack
foods for pre-school children are:
- Fruits, vegetable, and grains

The mother noticed that her child is using his left hand when writing as compared to some other
children who were writing with their right hand. The teacher explained to the mother that this is
called:
- Handedness
SELF ASSESSMENT FOR SCHOOL AGE

True/False
FALSE 1. Brain growth is complete by age 9 years.

FALSE 2. The average child gains 32 teeth between 6 and 12 years of age.
TRUE 3. An important part of developing a sense of independence is learning how to solve
problems.
FALSE 4. The most common speech problem of the school-age child is broken fluency.
FALSE 5. Children with a mesomorphic build are more likely to become obese.
Fill in the Blank
1. Decentering is the ability to project one’s self into other people’s situation.
2. Conservation - is the ability to appreciate that a change in shape does not necessarily mean a
change in size.
3. Caries (cavities) are progressive, destructive lesions of the tooth enamel.
4. The onset of puberty is started by secretions from the hypothalamus transmits an enzyme to the
anterior pituitary gland to begin production of gonadotropic hormones.
5. During the early school years, gaining a sense of industry is learning how to do things well.
SELF ASSESSMENT FOR ADOLESCENT
True/False
TRUE 1. Adolescents gain their wisdom teeth between 18 and 21 years of age.
TRUE 2. The final stage of cognitive development begins at age 12 or 13 years.
FALSE 3. Parent–child friction tends to peak at around age 16 years.
TRUE 4. Fatigue is a common complaint of adolescents, and there is no need for
parents to get concerned.
TRUE 5. Adolescents are in a high-risk group for date rape.
Fill in the Blank
1. Adolescents generally do better on a(n) 1,800 calories per day diet.

2. Adolescents who are having difficulty demonstrating maturity may look to adult roles? to show
they are maturing.
3. Alcohol and drugs are the most frequently abused illicit substances used by
adolescents.
4. The development of secondary sex characteristics is completed during adolescence and
classified according to Tanner stages.
5. Adolescents are very oriented toward the present, so programs and goals should be planned
accordingly.
NUR 1208 PEDIA: POST TEST FOR SCHOOL
AGE AND ADOLESCENT (BSN 202)
To assess a 9-year-old’s social development, the nurse asks the parent if the child:
- Has a best friend
The mother asks the nurse about her 9-year-old child’s apparent need for between-meal snacks,
especially after school. When developing a sound nutritional plan for the child with the mother, the
nurse should advise the mother that:
- “The child should help with preparing his or her own snacks.”
A nurse is assessing the growth and development of a 14-year-old boy. He reports that his 13-
year-old sister is 2 inches taller than he is. The nurse should advise the boy that the growth spurt in
adolescent boys, compared with the growth spurt of adolescent girls occurs:
- 2 years later
A 10-year-old child proudly tells the nurse that brushing and flossing her teeth is her own
responsibility. The nurse interprets this statement as which of the following about the child?
- She is most likely capable of this responsibility
Permanent teeth don’t replace the deciduous teeth until
- School age
A nurse is assessing the growth and development of a 10-year-old. What behavior would you
expect when assessing the growth and development of a 10-year-old child?
- Has a strong sense of justice and fair play
A mother asks the nurse how she will know when her son is entering puberty. The nurse tells the
mother to watch for which sign?
- Testicular enlargement
A nurse is teaching the parents of a school-age child. Which teaching topic should take priority?
- Accident prevention
An 8-year-old is NPO while he awaits surgery for central line placement later in the afternoon. The
nurse is trying to engage the child in some form of activity to distract him from thinking about his
upcoming surgery. Which is the best method of distraction for a child of this age in this situation?
- Encourage the child to play a board game.
The nurse caring for an 8-year-old boy is trying to encourage developmental growth. What activity
can the nurse provide for the child to encourage his sense of industry?
- Provide the child with the homework his teacher has sent in.
Parents of a 15-year-old state that he is moody and rude. Which of the following actions would the
parents take to appropriately address the concern?
- Discuss their feelings with their child
The school nurse develops a plan with an adolescent to provide relief from dysmenorrhea to aid in
her development of which of the following?
- Positive self-identity
An adolescent tells the nurse that she would like to use tampons during her period. What should
the nurse suggest first?
- Provide information about preventing toxic shock syndrome
Several high-school seniors are referred to the school nurse because of suspected alcohol
misuse. When the nurse assesses the situation, the most important to determine is:
- The reason they choose to use alcohol
Which stage of development is most unstable and challenging regarding the development of
personal identity?
- Adolescence
Which age group would have a tendency towards eating disorders
- Adolescence
A 16-year-old is admitted to the hospital for acute appendicitis and an appendectomy is

performed. Which of the following nursing interventions is most appropriate to facilitate
normal growth and development?
- Allow the child to participate in activities with other individuals in the same age group when
the condition permits
A 16 year old child is hospitalized, according to Erik Erikson, what is an appropriate intervention?
- Tell the friends to visit the child
The nurse is teaching a group of adolescent girls about personal hygiene. Which statement by an
adolescent indicates the need for further teaching?
- "It's unsafe to bathe during your period."
The nurse observes a gun under the jacket of a visitor who's visiting a 17-year-old client. Which
action should the nurse take first?
- Notify security immediately
The mother of 11-year-old fraternal twins tells the nurse at their well-child checkup that she
is concerned because her daughter has gained more weight and height than her twin
brother. The mother is concerned that there is something wrong with her son. The nurse's
best response is:
- "It is normal for girls to grow a little taller and gain more weight than boys at this age."
Module 5: EXPANDED PROGRAM ON

IMMUNIZATION
PRE-TEST
1. The greatest protection of individuals from acquiring Hepatitis B infection that may develop into a
chronic liver disease is:
- c. Hepatitis B immunization
2. Mrs. Manzon is due to bring her baby back to the health center for the third dose of
immunization three weeks from now but she came today with her baby and requested that her baby
be immunized because they are going abroad tomorrow and will return only to the country after 4
weeks. The nurse tells Mrs. Manzon that:
- a. It is alright for the third immunization to be delayed for a week anyway lengthening the
interval between doses of vaccines leads to higher antibody levels.
3. Which of the following vaccines is not administered by intramuscular injection?

- a. Measles vaccine
4. Which of the following conditions is not true about contraindication to immunization?

- b. Do not give BCG if the child has known hepatitis
5. This is the vaccine needed before a child reaches one (1) year in order for him/her to qualify as a
“fully immunized child”
- a. Measles
6. Mrs. Allata brought her 6 month old baby Anna to the clinic for immunization. She told the nurse
that Jena has already received BCG and a first dose of DT when she was 8 weeks old. Mrs. Allta
was not able to bring Anna to the clinic for her next DPT immunization because they went to the
province. She is asking the nurse if Anna can still receive her DPT immunization. The nurse’s reply
is that:
- b. Anna will be given her 2nd dose of DPT and Mrs. Allata should bring her back to the clinic
7. Which is not true of measles vaccine?

- b. It should be given at nine months because it provides higher protection than if it is given at 12
months
8. Which of the following dose of tetanus toxoid is given to the mother to protect the infant from
neonatal tetanus and likewise provide 10 years protection for the mother?
- d. Tetanus toxoid 4
9. The goal of the government’s EPI program is to eliminate which diseases by year 2008?
- d. Hepatitis and poliomyelitis
10. Hepatitis vaccine is given intramuscularly at a dose of 0.5 mL. It can be given as early as
- c. At birth
NUR 1208 SKILLS #5 - EPI FORMATIVE
1. Measles is given subcutaneously on a dose of 0.5 mL. A nurse is administering the correct
procedure if she gives it at age
- a. Nine months
2. BCG provides protection from the following infections EXCEPT:
- a. Leprosy
3. The vaccines are easily damaged by heat. The vaccines that are most sensitive to heat are:
- c. OPV and AMV
4. The temperature of the refrigerator where vaccines are stored should be checked how many
times a day?
- a. Two times a day, in the morning and afternoon before going home.
5. A new mother asked the nurse why she must immunize her baby at so young an age against
hepatitis B when they do not have family history of the disease. The nurse explains to the mother
that:
a. Hepatitis B infection is easily spread nowadays by droplet and kissing of the baby by adults.
b. Even if the mother is immune against hepatitis B, the immunity is never transferred to the baby so
all newborns are susceptible.
c. Even if no family members have the disease, it is possible that they are carriers and can still
transmit the microorganism causing hepatitis to the newborn
d. Hepatitis B vaccine contains modified virus that will stimulate antibody production in her baby to
provide lifelong immunity
6. If the child spits the OPV vaccine administered, the nurse:
- c. Should not give another dose because OPV vaccine is absorbed by the glands in the tongue
immediately after giving it
7. In order for a child to be classified as Fully Immunized Child (FIC), he should have received the
following immunizations before he reaches the age of one:
a. 3 doses DPT, single dose AMV, 5 doses TT, single dose BCG, 3 doses OPV, 3 doses Hepa B
b. Single dose BCG, 3 doses each of DPT, OPV, AMV, and Hepa B
c. Single dose BCG, 3 doses OPV, one dose measles vaccine, 3 doses Hepa B, 3 doses DPT
d. 3 doses OPV, one dose BCG, 3 doses measles vaccine, 3 doses DPT, single dose Hepa B
8. All of the following immunizing agents come in liquid form EXCEPT:
a. BCG, AMV, OPV, TT
b. DPT, OPV, AMV, TT
c. Hepa B, TT, OPV, DPT
d. BCG, Hepa B, TT, OPV
9. A nurse should see to it that anti measles vaccine is administered as follows:
- c. 0.5 mL subcutaneously
10. What age group is targeted by the DOH health teams during immunization days?
a. 0 – 24 months
b. 0 – 59 months
c. 0 – 12 months
d. 1 – 5 years old
The following two vaccines are easily damaged by heat but not destroyed by freezing:
- Polio and measles vaccine
The correct temperature to store vaccines in a refrigerator is:

- Between +2C and +8C
The correct technique of preparing the measles vaccine is:

- Always use 5 ml syringe to withdraw diluents to be mixed with measles vaccine
Protection against polio is increased if given earlier. When is the right age to start giving OPV?
- 6 weeks
Which vaccine is a requirement for school entrants regardless of the presence of BCG scar?
Hepa B
BCG
DPT
Anti tetanus
The baby of Mrs. Corpuz will receive oral DPT vaccine today. The nurse needs additional
knowledge when she instructed the mother to:
- Apply warm compress on the injection site
MODULE 6: FILIPINO CULTURES, VALUES, AND PRACTICES IN RELATION TO MATERNAL AND CHILD CARE
Fill in the blanks with the correct answer.
1. Culture is a set of traditions that a specific social group uses and transmits to the next generation.
2. Ethnicity refers to the cultural group into which a person was born.
3. Hiya is a cultural value of Filipinos described as kind of anxiety, fear of being left exposed,
unprotected and unaccepted.
4. A Filipino cultural belief of avoiding eating black foods to avoid the birth of an infant with a dark skin
tone.
5. Unpleasant emotions experienced by pregnant women is a Filipino belief blamed for causing
birthmarks in an infant.
6. Traditional custom in the Philippines dictates that women should not bathe for about ten days after
giving birth and during menstruation to prevent any illness.
7. Postpartum women in the Philippines may be massaged with coconut oil, with the aim of restoring
their lost health, expelling blood clots from the uterus, returning the uterus into a normal position,
and promoting lactation.
8. Filipino mothers considers Colostrum as ‘dirty milk’ and not fed to a newborn and are discarded.
9. Filipino belief that paglilihi or “pregnancy cravings” during pregnancy has a direct influence on the
physical attributes of the baby.
10. Usog is an age-old Filipino superstition that cause discomfort to the baby by a stranger or visitor
who is said to have an evil eye.
NUR 1208 PEDIA: POST TEST FOR SCOPE &

STANDARDS AND FILIPINO CULTURE
This is what you called Reproductive Health Law which guarantees universal access to methods on
contraception, fertility control, sexual education, and maternal care
RA 7600
RA 10354
RA 10028
AO-2008-0029
This implemented health reform is for the rapid reduction of maternal and newborn mortality
RA 10354
AO-2008-0029
RA 10028
RA 7600
Services implemented to give to pregnant mothers:
All (Tetanus Toxoid, Pre natal check up, Vitamins)
Calcium, Iron
Tetanus vaccine, Essential Vitamins
Folic Acid, Iron, Essential vitamins
The Local Government Units will provide all health centers/birthing centers, healthcare providers
such as:
Physicians, Nurses
Student nurses, midwives, Physician
Nurses and licensed midwives
Midwives, barangay health workers
A test used for newborn to identify genetic disorder:
Essential Newborn Care
NB Screening
In vitro fertilization
Genetic testing
A surgical procedure if vaginal delivery is not possible:
Water birth
Home birth
Lamaze method
CS
An ethical consideration which is about the right to refuse medical therapies
Right to inform
Informed consent
Voluntary participation
Do no harm
An obligation of not to inflict harm intentionally
Informed consent
Non maleficence
Only assess relevant components
A condition in which the identity of individual subjects is not known to researchers
Informed consent
Confidentiality
Anonymity
A sheath-shaped barrier device used during sexual intercourse to reduce the probability of
pregnancy or a sexually transmitted Infection
Implant
Condom
IUD
Diaphragm
A set of traditions that a specific social group uses and transmits to the next generation.
race
cultural values
ethnicity
culture
Refers to the cultural group into which a person was born
culture
cultural bias
ethnicity
race
A Filipino cultural belief of avoiding eating _____ foods to avoid the birth of an infant with a dark
skin tone.
violet
herbal
black
dark brown
Unpleasant emotions experienced by pregnant women is a Filipino belief blamed for causing
_______ in an infant.
Mongolian spots
sumpong
water marks
birthmarks
Traditional custom in the Philippines dictates that women should not bathe for about ______ after
giving birth and during menstruation to prevent any illness.
10 days
5 days
14 days
7 days
Postpartum women in the Philippines may be massaged with_________, with the aim of restoring
their lost health, expelling blood clots from the uterus, returning the uterus into a normal position,
and promoting lactation.
efficascent oil
baby oil
coconut oil
oil with luya
Filipino mothers considers ________ as ‘dirty milk’ and not fed to a newborn and are discarded.
colostrum
hindmilk
foremilk
mature milk
Filipino belief that ________ or “pregnancy cravings” during pregnancy has a direct influence on the
physical attributes of the baby.
bati
pangangasim
paghihilom
paglilihi
An age-old Filipino superstition that cause discomfort to the baby by a stranger or visitor who is said
to have an evil eye.
usal
tawas
kulam
usog
An important cultural value of Filipinos translated roughly as ‘embarrassment’, ‘shame’ or ‘face’. It

has been described as a kind of anxiety, a fear of being left exposed, unprotected and unaccepted.

nerbiyos
Hiya
agam
kaba
NUR 1208 SKILLS #6 - IMCI FORMATIVE

ASSESSMENT
Two children were brought to you. One with chest indrawing and the other had diarrhea.
Using the IMCI approach, how would you classify the 1st child?

Pneumonia
Severe pneumonia
No pneumonia: cough or colds
Bronchopneumonia
Two children were brought to you. One with chest indrawing and the other had diarrhea.
The 1st child who is 13 months has fast breathing. Using IMCI parameters he has:
- 40 breaths per minute or more
Nene, the second child has diarrhea for 5 days. There is no blood in the stool. She is irritable and her
eyes are sunken. The nurse offered fluids and the child drinks eagerly. How would you classify
Nene’s illness?
- Some dehydration
Nene, the second child has diarrhea for 5 days. There is no blood in the stool. She is irritable and
her eyes are sunken. Nene’s treatment should include the following EXCEPT:
- Do not give any other foods to the child for home treatment
While on treatment, Nene 18 months old weighed 18 kg and her temperature registered at 37 o Her
mother says she developed cough 3 days ago. Nene has no general danger signs. She has 45
breaths per minute, no chest indrawing, no stridor. How would you classify Nene’s manifestations?
- Pneumonia
Baby Ruth, 3 months old, is brought to the health center for consultation because of fever and
cough. You suspected that Baby Ruth has a respiratory infection. Based on the IMCI protocol, Baby
Ruth belongs to what row?
- Pink
Baby Ruth, 3 months old, is brought to the health center for consultation because of fever and
cough. You suspected that Baby Ruth has a respiratory infection. If Baby Ruth has stridor, what is
the classification?

Pneumonia
No pneumonia: cough/cold
Very severe disease
Severe pneumonia
IMCI as a strategy deqls with managing different common childhood illnesses. It is a/an _______
Effort conducted by DOH, APSOM, ADCPN, CHED

Coordinated
Integrated
All of the above
Collaborative
To assess whether the child has stridor, it is best to:

Place your ear near the child’s mouth and listen for a harsh sound
All of the above
Listen when the child is calm
Listen to the child’s breath during breathing – in
Sandra is 3 years old. She is lethargic. Her mother brought her to the health center because of
diarrhea for 5 days. She does not have cough and fever. She does not have an ear problem. The
nurse assesses Sandra’s diarrhea. Sandra is lethargic. She has sunken eyes. When the abdomen
was pinched, it went back its original state very slowly. Then nurse will classify Sandra as having:

dysentery
Diarrhea with some dehydration
Diarrhea with severe dehydration
Severe persistent diarrhea
NUR 1210 MATERNAL MODULE #1 FORMATIVE

The reasons for high maternal and newborn mortality rate in the Philippines are:
- Delay in deciding to seek medical care, delay in identifying and reaching appropriate facility, and
delay in receiving adequate care
The following vital statistical report of Malibu Province was submitted for the year 2020.
Estimated population as of July 1, 2020
4,800,000
Total livebirths
115,000
Still birth
60
Deaths under 5 years
8,352
Deaths under 1 year
5,645
Neonatal deaths
2,000
Maternal deaths
190
Total death
45,120
What is the Under 5 mortality rate of Malibu Province?
- 72.3?
A high risk pregnancy is one in which the mother or fetus has a significant increase chance of harm, damage,
injury or disability. Mrs. Hilario, a 45-year-old mother is to undergo amniocentesis. Which of the following
about the procedure indicates a need for further teaching?
- Amniotic fluid is obtained by inserting a small catheter intravaginally
At her first prenatal visit, a woman relates that her maternal aunt has cystic fibrosis, an autosomal recessive
illness. Which of the following statements is appropriate for the nurse to make?
- “We can check to see whether or not you are a carrier for cystic fibrosis.”
A male client consulted the Pediatric Unit with underdeveloped testes, breast development, subnormal
intelligence, and an abnormal karyotype. The client is most likely considered to have:
- Klinefelter Syndrome
A client just had an amniocentesis to determine whether or not her baby has an inheritable disease. What
priority intervention would the nurse do?
- Assess fetal heart rate
Which of the client responses indicates the nurse’s teaching about care following chorionic villus sampling
has been successful?
- If the woman starts to bleed or to contract, she should call her physician.
CASE: Maria is a 30 years old mother from Sorsogon Province gave birth to her seventh baby at home with
the assistance of a traditional birth attendant (TBA). The TBA instructed her to use sanitary napkins as she
may bleed. However, a day has passed and she was still bleeding profusely and later she experienced
dizziness. Her husband went to see the only midwife in their barangay but she was attending to another
delivery, then he wanted to bring her to the provincial hospital but they had no means of transportation at
that time. Finally, he was able to bring her to the hospital but it was already too late. She died of heavy
bleeding. Maria has six previous pregnancies and five living children delivery yearly. She has history of
hypertension but never took any medications. She had never used contraceptives and this last pregnancy
was unwanted. In addition, she was poor, illiterate and lived in a rural area.
The following were the predisposing factors that caused the death of Maria, EXCEPT?
- Appropriate medical and midwife support
The under 5 mortality rate which is the death of children between birth and exactly 5 years of age is an
important indicator for child health. The denominator for such rate is which of the following?
- Number of live births in the same year
Down syndrome is a result of chromosomal abnormalities, EXCEPT:
- Isochromosomes
Webbed neck, small stature, and gonodal dysgenesis are characteristics of:
- XO
Chromosomes are threadlike structures of nucleic acids and protein found in the nucleus of most living cells,
carrying genetic information in the form of genes which are the basic units of heredity that determine both
the physical and cognitive characteristics of people. Once oogenesis is complete, the result gamete cell
contains how many chromosomes?
- 23
Amy Perez is pregnant with her first child. Her genotype refers to:
- Her actual genetic composition
Amy Perez is pregnant with her first child. Her phenotype refers to:
- Her outward appearance

The following are true about Down Syndrome, EXCEPT
- It is due to deletion of the chromosomes during cell division
Lyndon was born with an extra X chromosome. He has undeveloped testes and enlarged breasts, and is tall.
Lyndon would be diagnosed with ___ syndrome.
- Klinefelter
Considering that males are produced by Klinefelter (XXY) syndrome, XYY and normal XY chromosome
combinations, and females are produced by Turner (XO) syndrome, triple-X (XXX) and normal XX
combinations, it is obvious that
- maleness is caused by the minimal presence of one Y chromosome.
The nurse evaluates understanding of fetal development in a prenatal class. Which of the following would be
the result of nondisjunction of the sex chromosomes?
- Turner syndrome XO
A mother tells the nurse that the pediatrician has expressed concern that her 4 year old child exhibits
developmental delays. Chromosomal abnormality tests was requested. Based on the gene sequence below,
this patient may have:
- Turner syndrome
The clients have one child with Tay-Sachs disease, but neither of the clients have the disease. They are in the
clinic for genetic counseling prior to conceiving another child. Which of the following is a characteristic of a
recessive human disease?
- Two unaffected parents can have affected offspring.
If you crossed an individual homozygous for freckles with a person heterozygous for freckles, what would
the genotypic ratios be?
N – Freckles
n – no freckles
- None of the Above
A genetic counselor’s report state, “The genetic nomenclature for this fetus is 46XX. How the nurse should
interpret this result?
- The baby is female with normal number of chromosomes
If the parents are AB and BO genotypes for the ABO blood group, their children could include which
genotype, EXCEPT?
- OO
A 35 year old primigravida consulted the obstetrical unit. Amniocentesis was requested for karyotyping with
the following results. based on the karyotype, the pregnant client may have a fetus diagnosed as which of
the following?
- Down syndrome
The nurse is doing a research on the infant and maternal mortality of Covido City with the following data:
Which district/s have the highest maternal mortality rate?
- Marina
Materna is an island group in the South Pacific, with a population of some 700,000 as of July 2020. It is a
matriarchal society, offering equal opportunities to both men and women in all aspects of life, particularly in
education, employment, police and the right to have more than one legal spouse. The isles are made up of
two big islands and three small ones. Island Pediatrica has a population of 250,000 and maternal mortality
rate of 2.4 per 1,000. Crude birth rate is 30 per 1,0000. Live birth in the province accounts for 7,500. What is
the number of maternal deaths of Island Pediatrica?
- 1.8
The nurse is doing a research on the infant and maternal mortality of Covido City with the following data:
Which two (2) districts have the most number of infant deaths?
Esperanza and Marina
Which of the following human genetic disorders is NOT caused by nondisjunction?
- Fragile X Syndrome
During a genetic evaluation, it is discovered that the woman is carrying one autosomal dominant gene for a
serious late adult-onset disease while her partner’s history is unremarkable. Based on this information,
which of the following members should be considered high risk and in need of genetic counseling?
The woman’s fetus
The woman’s sisters
The woman’s in-laws
The woman’s brothers
The woman’s parents
The woman’s partner
- 1, 2, 4 & 5
The genetic counselor informs a couple that they have a 25% probability of getting pregnant with a child
with severe genetic disease. The couple asks the nurse exactly what that means. Which of the following
responses by the nurse is appropriate?
- If they have four children, one of the children will have the disease
The infant mortality rate for Philippines in 2013 was 12.5 deaths per 1000 live births comprising of 4.1% of
the total deaths reported during the year. The top three leading cause of infant mortality during that year
according to their rank which of the following?
- Pneumonia, bacterial sepsis, respiratory distress

Belinda, a 14-year old high school graduate, her first pregnancy on her 20 weeks gestation sought
consultation at your clinic for her initial prenatal visit. History revealed that this is an unpleasant pregnancy
with her 3rd boyfriend who broke up with her upon hearing about the pregnancy. During the 1st 3-months
of her pregnancy, she had several episodes of nausea and vomiting for which she noticed apparent weight
loss. Which of the following reasons could lead to a mortality of Belinda?
- Young age and first pregnancy
While discussing antenatal care to a group of pregnant women, one of the women asks the nurse about
diagnostic tests in high risk pregnancy. Which of the following is true about the advantages of Chorionic villi
sampling (CVS) over amniocentesis?
- It can be done earlier or before the end of first trimester
A woman asks a nurse about presymptomatic genetic testing for Huntington’s disease. The nurse should
base her response on which of the following?
- If the woman is positive for the gene Huntington’s, she will develop the disease later in life
A mother tells the nurse that the pediatrician has expressed concern that her 4 year old child exhibit
developmental delays. Chromosomal abnormality tests was requested. Based on the gene sequence below
the patient may have:
- Turner Syndrome
A woman is seeking genetic counseling during her pregnancy. She has a strong family history of diabetes
mellitus. She wishes to have amniocentesis to determine whether or not she is carrying a baby who will
“develop diabetes.” Which of the following replies the nurse will make based on the Multifactorial
(Polygenic) Inheritance?
- “Although diabetes does have a genetic component, diet and exercise also determine whether or
not someone is diabetic.”
If the parents are AO and BO genotypes for the ABO blood group, their children could include which of the
following genotypes?
- AO, BO, AB, and OO only
If individuals exhibiting a dominant phenotype are crossed and produce only offspring with the dominant
phenotype, what would be the logical genotype of the parents?
- Homozygous dominant
Mrs. Wong, a 35 year old primigravida, and her husband are seen in the antepartal clinic. Mr. Wong asks the
nurse about several tests to analyze the amniotic fluid. The nurse would answer that the following disorders
can be identified in an elevated alpha feto protein levels EXCEPT:
- Down syndrome
The nurse is creating the symbolic representation of family relationships and transmission of inherited traits
from a client’s family history. Which of the following symbols should the nurse use to represent a still born?
- Triangle
The nurse is assigned to do a home visit for a mother with a baby diagnosed of 47XX18+. Which of the
following conclusions can the nurse make about the female baby.
- She has Edward's Syndrome.
Persons with Klinefelter’s syndrome have _____ chromosomes.
- 47
Which of the statement by a gravid client who is a carrier of muscular dystrophy, an X-linked recessive
disease, indicates that she understands the implications of her status?
- “If I have a girl, she will be healthy.”
A client who is at 40 weeks’ gestation, seems upset and tells the nurse that the physician told her about a
possibility of Down syndrome of her baby. Which statement is NOT true about Down syndrome?
- Greatly increased incidence occurs with fathers over age 35.

Ang G2P1 presents to the Obstetrical Unit with complaints of moderate vaginal bleeding and severe
abdominal pain. Examination reveals: FH – 34 centimeters. Frequency of contractions is every 1.5 minutes,
duration of 60 seconds, strong with increasing resting tone. Fetal monitoring shows late decelerations.
Which of the following nursing assessment is consistent with the development of abruptio placenta?
- The client admits to using cocaine.
Which of the following long-term goals is appropriate for a client, 10 weeks’ gestation, who is diagnosed
with gestational trophoblastic disease (hydatidiform mole)?
- Client will be cancer-free 1 year from diagnosis.
Which finding should the nurse expect when assessing a client with placenta previa?
- Painless vaginal bleeding.
A client being seen in the ED has an admitting medical diagnosis of: third trimester bleeding/rule out
placenta previa. Each time a nurse passes by the client’s room, the woman asks, “Please tell me, do you
think the baby will be all right?” Which of the following is an appropriate nursing diagnosis for this client?
- Anxiety related to inconclusive diagnosis.
A 20-year-old primigravida at 8 weeks gestation visits the clinic with symptoms of slight reddish vaginal
bleeding and an occasional uterine cramp. The pregnancy test is positive. The patient states that no tissue
has been passed. The nurse should explain to the patient that these symptoms are indicative of a type of
abortion termed:

Missed
Incomplete
Threatened?
Martin at 33 weeks gestation complains of vaginal bleeding. The nurse assessing the client is aware that an
abruptio placenta is not accompanied by which of the following assessment findings, EXCEPT:
- Uterine tenderness upon palpation
Which of the following findings would the nurse expect to see when assessing a first-trimester gravida
suspected of having gestational trophoblastic disease (hydatidiform mole) that the nurse would not expect
to see when assessing a first-trimester gravida with a normal pregnancy? Select all that apply.
- Grape-like clusters passed from the vagina.

- Markedly elevated blood pressure.
Nurse Ana admitted a 21 year old woman in the ER. She missed 2 menstrual period and a tentative diagnosis
of ruptured ectopic pregnancy was made. What is the characteristic pain related to ectopic pregnancy?
- Unilateral
The nurse is caring for a 34-year-old multipara during the immediate post operative period after evacuation
of a molar pregnancy. The nurse should instruct the patient to avoid pregnancy for at least 12 to 18 months
to confirm the absence of:
- Choriocarcinoma
All of the following are the characteristic symptoms of ectopic pregnancy. Select all that apply:
Negative pregnancy test
Cullen’s sign
Abdominal pain
Back pain
Positive pregnancy test
- 2, 3 & 5
A 25-year-old client is admitted with the following history: 12 weeks pregnant, vaginal bleeding, no fetal
heartbeat seen on ultrasound. The nurse would expect the doctor to write an order to prepare the client for
- Dilation and curettage.
A thirty year old G2P1, Mrs. Rico receives a diagnosis of complete H. Mole which was treated by thorough
evacuation with suction curettage. Which of the following discharge health instruction needs further
teaching?
- Avoid pregnancy for 6 months
A client is being discharged from the hospital after evacuation of a molar pregnancy. The nurse recognizes
that which of the following client statements needs further teaching?
- “I will need to see the doctor yearly for follow-up.”
In the 12 week of gestation, a client completely expels the products of conception. Because the client is Rh
negative, the nurse must:
- Administer Rhogam within 72 hours

Nurse A admitted another patient with the diagnosis of hydatidiform mole. All but one is a characteristic of
woman with molar pregnancy:
- Brown vaginal discharge
Which of the following condition increases the risks of the mother to another abortion?
- A mother whose child diagnosed with German measles
On arrival at the emergency Department, a client tells the nurse that she suspects that she may be pregnant
by has been having a small amount of bleeding and has severe pain in the lower abdomen. The client's blood
pressure is 70/50 mm Hg and her pulse rate is 120 BPM. The nurse notifies the Primary Health care provider
immediately because of the possibility of:
- ectopic pregnancy
If the client develops a complete abruption, the nursing care plan should include careful assessment for
signs and symptoms of which of the following?
Jaundice
hypovolemic shock?
Impending convulsion
marianette, an unmarried but sexually active nursing student tells the nurse that she missed one menstrual
cycle and her next cycle resulted in a slight amount of blood flow. Considering the history of her menstrual
cycle, the nurse suspects she may have a tubal pregnancy. What is the most appropriate initial intervention
of the nurse?
- position her on the examination table and palpate her abdomen for the presence of a unilateral
pelvic pain over a mass
Situation 1: Alex on her 12 weeks gestation with her third baby sought consultation to a nurses clinic for
observation. She has a history of spontaneous abortion and is spotting. She told the nurse she had minimal
vagina bleeding, without passage of placenta with embryonic sac and slight uterine cramping. On
examination, the physician on duty determines that her cervix is closed. The nurse would think that the
client is exhibiting signs of:
- Missed Abortion
The physician ordered to prepare a client suspected of ectopic pregnancy with a negative culdocentesis
result. Which statement by the client indicates understanding of the management for her condition?
“I will be maintained in a left lateral position. “
“sterile gloves, vagina speculum, lubricant and lamp”
“my hemoglobin and hematocrit will be periodically monitored.”?
Gestational trophoblastic disease occurred during fertilization, when the egg cell was fertilized with more
than one sperm cell producing fertilized egg cell containing ___ chromosomes
- 69
Which of the following nursing actions would take priority when caring for the woman with a suspected
ectopic pregnancy?
- Monitoring vital signs
A hospitalized gravida’s blood work is: hematocrit 30% and hemoglobin 10 gm/dL. In light of the laboratory
data, which of the following meal choices should the nurse recommend to this patient?
- Chicken livers, sliced tomatoes, and dried apricots.
Mendoza, amenorrheic for two months is diagnosed to have ectopic pregnancy based on the sign and
symptoms of sudden, severe low quadrant pain radiating to the shoulder, Cullen sign and minimal external
vagina bleeding. Which of the following actions would be implemented?
- Monitoring of vital signs
Which of the following findings should the nurse expect when assessing a client, 8 weeks’ gestatio , with
gestational trophoblastic disease (hydatidiform mole)?
- Dark brown vaginal bleeding

The pregnant client with molar pregnancy was treated with suction curettage. The nurse recognizes that
additional discharge teaching is required when the client states which of the following discharge health
instructions?
- “I will need to see the doctor yearly for follow up.”
The client has history of 3 spontaneous abortion, a diagnosis of incompetent cervix is made. It is defined as:
- premature dilation of the cervix before 20 weeks
The usual management for incompetent cervix or the following except:
- deliver the baby CS after the removal of the sutures
The doctor ordered a transvaginal ultrasound to confirm diagnosis of molar pregnancy. The findings will
reveal which of the following:
- snow storm pattern
A 34 year old client comes to the emergency room with abdominal cramping and vaginal bleeding. History
revealed two missed menstrual periods. Incomplete abortion is considered by the nurse. Which of the
following statements by the nurse is most appropriate? (SELECT ALL THAT APPLY)
- “this must be difficult for you. I'm so sorry.”

- “Would you like to speak with a hospital counselor?”
A woman is admitted with a diagnosis of ectopic pregnancy. For which of the following would you anticipate
beginning preparation?
- immediate surgery
A pregnant woman at 36 weeks gestation is diagnosed with abruption placenta. Assessment findings would
include:
- abdominal pain of increasing severity

A nurse is caring for four prenatal clients in the clinic. Which of the clients is at high risk for placenta previa?
- Infertility client who is carrying in-vitro triplets.
A client amenorrheic for 3 months, comes to the hospital with complaints of vaginal discharge and is
diagnosed to have Gestational Throphoblastic Disease. Which of the following signs is not consistent with
the diagnosis?
- Bluish discoloration at the navel
G3P2 Maxine at 16 weeks gestation was admitted to the maternity unit for a McDonald cerclage procedure.
When asked about the purpose of this procedure, the client needs no further teaching if Maxine explained
that this procedure is to:
Evaluate cephalopelvic disproportion?
Reinforce an incompetent cervix temporarily
In the 5thmonth of pregnancy, ultrasonography is performed on a client. The results indicate that the fetus
is small for gestational age and there is evidence of placenta previa partialis. The client asks the nurse if this
condition will warrant an abdominal delivery/ceasarean section. Your response would be:
- It would be early to tell since placental migration bleed profusely if vaginal delivery would still be
possible as pregnancy progresses be permitted
A threatened abortion is suspected at the 10 weeks pregnant client, Becky. Nurse Sarah instructs the client
regarding management of care. Which statement made by the Becky indicates a need for further
instructions?
- “I will maintain strict bedrest throughout the remainder of the pregnancy.”?
When assessing a 34-year-old multigravida at 34 weeks’ gestation experiencing moderate vaginal bleeding,
which of the following would most likely alert the nurse that placenta previa is present?
- Painless vaginal bleeding

A 35 year old multigravid client who is at 32 weeks gestation is admitted to the obstetric unit for
observation. The admission diagnosis is total placenta previa. Based on the client’s clinical presentation,
which admission information should the nurse obtain first?
- Blood pressure and pulse rate
A BSN nursing student as a competent maternity care provider should be able to identify early signs of
abortion in order to be able to save a product of conception. Which of the following represents an
incomplete abortion?
Profuse vaginal bleeding
Passage of fetus, placenta, embryonic sac
Mild abdominal pain
Severe uterine cramps
- 1&4
Legazpi, G4 P3 is admitted to the prenatal clinic at eight and one half months gestation with a diganosis of
placenta previa partialis. Chief complaint is vaginal bleeding without contractions. Which action should the
nurse perform initially?
- Assess the amount and character of bleeding
A client being seen in the ED has an admitting medical diagnosis of: third trimester bleeding/rule out
placenta previa. Each time a nurse passes by the client’s room, the woman asks, “Please tell me, do you
think the baby will be alright?” Which of the following is an appropriate nursing diagnosis for this client?
- Anxiety related to inconclusive diagnosis.
A G1P0 confirmed to be pregnant at 14 weeks gestation has sudden bright red vaginal bleeding and uterine
cramps. Internal examination revealed 3 – 4 centimeters cervical dilatation. The nurse would suspect the
client to be experiencing which of the following bleeding conditions?
- Inevitable abortion
Another patient consulted the prenatal clinic. She is 3 months pregnant and an ultrasound was done. The
results revealed absent FHT. The nurse knows the diagnosis of this condition is:
- Missed abortion
A 20-year-old primigravida at 8 weeks gestation visits the clinic with symptoms of slight reddish vaginal
bleeding and an occasional uterine cramp. The pregnancy test is positive. The patient states that no tissue
has been passed. The nurse should explain to the patient that this client needs:
- Bed rest
A suction curettage is performed to treat H mole. Nurse Ana understands that after the procedure the
patient should:
- Have HCG level monitored accordingly
A gravid woman has just been admitted to the emergency department subsequent to a head-on automobile
accident. Her body appears to be uninjured. The nurse carefully monitors the woman for which of the
following complications of pregnancy?
Placenta previa.
Transverse fetal lie.
Placental abruption.
Severe pre-eclampsia.
Preterm labor.
1 and 5
3 and 5
4 and 5
1 and 3?
Nurse Ana admitted a 21 year old woman in the ER. She missed 2 menstrual period and a tentative
diagnosis of ruptured ectopic pregnancy was made. Upon examination, nurse Ana noticed scanty
vaginal bleeding. This means:
- Bleeding inside the peritoneal cavity is present
A multigravid client is admitted to the hospital with a diagnosis of unruptured ectopic pregnancy. Which of
the following may be prescribed for the patient as the nurse creates a plan of care?
- Methotrexate

ASSESSMENT (Post Test)
A 22 year old primigravid client is in her 22nd week of pregnancy. The physician informed the
client that she has pregnancy induced hypertension. She is admitted to the hospital. The nurse
concludes that the client was diagnosed with pregnancy induced hypertension when the vital
signs taken today show that the blood pressure has increased during pregnancy from 100/60 to
130/80. When assessing the client, the nurse should thoroughly explore which finding at each
visit?
Any sudden weight gain
An increase in urine output
A decrease in pulse rate
A decrease in urine protein level
A 26-year-old female is 28 weeks pregnant with her second child. The woman is blood type A
negative. Which of the following statements does not need further instructions if this is
mentioned by a student nurse during health promotion?
Since the mother is A- the baby can be Rh positive, which could lead to an immune attack on
the mother's body.
If the patient was A+ she would need to receive RhIG
The baby will need to receive RhIG after it’s born.
The patient will need to receive RhIG during this visit to prevent hemolytic disease of the
newborn
A 17 y/o. primigravid registers at 16 weeks’ gestation with a BP of 100/60. At 38 weeks’

gestation, she is seen in the clinic with a BP of 146/94 and negative proteinuria. She is
admitted in the hospital for further evaluation, where, on overnight observation, she has
persistent BP above 140/90. A 24-hour urine protein determination is 20mg. The nurse
correctly identifies that this is what type of hypertensive disorder in pregnancy?
Eclampsia
Severe preeclampsia
Mild preeclampsia
Chronic HPN
Gestational HPN
The nurse is providing instructions to a pregnant client with human immunodeficiency virus
(HIV) infection regarding care to the newborn after delivery. The client asks the nurse about the
feeding options that are available. Which response should the nurse make to the client?
“You will need to feed your newborn by nasogastric tube feeding.”
“You will be able to breast-feed for 9 months and then will need to switch to bottle-feeding.”
“You will need to bottle-feed your newborn.”
“You will be able to breast-feed for 6 months and then will need to switch to bottle-feeding.”
Marie a 16-year-old primigravid comes to the prenatal clinic for her monthly check-up. She has
gained 20 lb from her 30-36 weeks, with edema of the face and hands. Urinalysis revealed
proteinuria +4. She is diagnosed as having severe preeclampsia and was referred to the high-
risk Obstetrical Unit. The client’s weight increase is most likely due to:
Fluid retention
Hypertension
Obesity
Over eating
A 32-year-old G1P0 diabetic patient unsure of the date of her last menstrual period (LMP)
sought here first prenatal checkup. She says that she missed three menses, but her fundus is
palpated slightly below the level of umbilicus. The physician requested for ultrasonography to
estimate the gestational age. Family history is positive for DM (father). When should the nurse
advise the client to have her GCT checked?
32 - 36 weeks
At term
24 - 28 weeks
28 - 32 weeks
A 28-year old primigravida comes to your clinic on her 30th week of gestation complaining of
chest pain. On examination she was seen to have cardiomegaly which strengthened the
diagnosis of heart disease in pregnancy. The nurse would advise the client that if the patient is
without any obstetrical indication, she will best deliver by:
Cesarean section under epidural anesthesia
Outlet forceps extraction under epidural anesthesia
Normal spontaneous delivery under pudendal block
Cesarean section under general anesthesia
A diabetic patient is unsure of the date of her last menstrual period (LMP); she says that she
missed three menses, but her fundus palpated slightly below the level of umbilicus. The nurse
prepares a teaching plan. For a newly diagnosed diabetic pregnant patient. Which of the
following should not be included in the teaching plan?
Nutritional requirements for pregnancy and diabetic control
To be aware of any infections and report signs of infection immediately to the health care
provider
Effects of diabetes on the pregnancy and fetus
To avoid exercise due to its negative effects on insulin production
A pregnant 85 lbs woman sought her very first prenatal consult. Being underweight, the
physician formulated a good nutritional surveillance for her. The nurse should counsel the
patient which of the following constitute a sound part of the plan?
Serially weigh her to achieve appropriate weight gain
Monthly hgb and hct determination
Ensure she force feeds herself everyday
Give 60 mg iron tablets 3x a day
The nurse implements a teaching plan for a pregnant client who is newly diagnosed with
gestational diabetes mellitus. Which statement made by the client indicates a need for further
teaching?
“I should stay on the diabetic diet.”

“I should be aware of any infections and report signs of infection immediately to my
obstetrician.”
“I should perform glucose monitoring at home.”
“I should avoid exercise because of the negative effects on insulin production.
A nurse is monitoring a 28 year old client G1P0, 26 weeks AOG who is receiving magnesium
sulfate for preeclampsia and is assessing the client every 30 minutes. Which of the following
findings would indicate a need to immediately report the findings?
Urinary output of 20 ml
Fetal heart rate of 120 beats/min
Respirations of 10 breaths/minute
Deep tendon reflexes of +2
A client who has just learned she is pregnant tells the nurse that she smokes two packs of
cigarettes a day. In counseling, the nurse encourages her to stop smoking because studies
show that newborns of mothers who smoke are often:
Excessively large for gestational age
Post mature with meconium aspiration syndrome
Born with congenital facial malformations
Small for gestational age
Nurse Anne is providing instructions to a G1P0, 25 years old on her 30 weeks AOG pregnant
client in the maternity center with a history of cardiac disease regarding appropriate dietary
measures. Which statement, if made by the client, indicates an understanding of the
information provided by the nurse?
“I should lower my blood volume by limiting my fluids.”
“I should increase my sodium intake during pregnancy.”
“I should maintain a low-calorie diet to prevent any weight gain.”

“I should drink adequate fluids and increase my intake of high-fiber foods.”
Mrs. Martinez, 32 years old primigravida at 34 weeks AOG is admitted in the Obstetrical Unit
because of preterm labor. The physician ordered magnesium sulfate deep IM. While the client
is receiving magnesium sulfate, the nurse routinely assesses the client’s vital signs and notes
the following: BP 160/90, and blurring of vision. In caring for the client the nurse should:
Encourage her to drink clear fluids
Isolate her in a dark room
Maintain her in a supine position
Protect her against strenuous stimuli
A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The
nurse determines that the client is experiencing toxicity from the medication if which findings
are noted on assessment? Select all that apply.
Respirations of 10 breaths per minute
Serum magnesium level of 4 mEq/L (2 mmol/L)
Proteinuria of +3
Urine output of 20 mL in an hour
Presence of deep tendon reflexes
The nurse is providing instructions to a pregnant client with a history of cardiac disease
regarding appropriate dietary measures. Which statement, if made by the client, indicates an
understanding of the information provided by the nurse?
“I should drink adequate fluids and increase my intake of high fiber foods.”
“I should increase my sodium intake during pregnancy.”
“I should maintain a low-calorie diet to prevent any weight gain.”
“I should lower my blood volume by limiting my fluids.”

The client is in her last trimester of pregnancy and her diabetes has been well controlled. She
tells the nurse that she is excited but also scared that something could be wrong with her baby
because of her diabetes. Which response of the nurse is most appropriate?
“Your baby will be diabetic.”
“Your baby may be small but otherwise healthy.”
“Your baby will have a minor birth defect.”
“Your baby may be large and initially will need blood glucose monitoring.”
A 30-year-old G3P2 at 24 weeks AOG complained of urinary frequency, dysuria, urgency,

fever, chills and costovertebral angle tenderness. Urinalysis showed pyuria and bacteriuria. The
nurse would formulate a nursing plan based on which of the following most probable diagnosis?
Cystitis
Urethritis
Acute pyelonephritis
Asymptomatic bacteriuria
A 29 years old female, married, G1P0 AOG 16 weeks, complained of vague abdominal wall
pain for 3 days, with slight fever and urgency. She took Paracetamol 500 mg and there was
temporary relieved of symptoms. A few minutes prior to consultation, she noticed blood tinged
urine. Husband is an overseas worker (Seaman). What is the probable clinical impression on
consultation?
Acute urethritis syndrome
Acute pyelonephritis complicated
Acute cystitis, hemorrhagic
Acute pyelonephritis uncomplicated
The Rh negative mother and Rh positive baby may have blood mix leading to Rh incompatibility
could be possibly contributed by the following, EXCEPT:
Exposure to chemicals
Previous pregnancy
Miscarriage
Bleeding during pregnancy
The nurse is assessing a client with pregnancy induced hypertension. Which of the following
are the expected classic triad symptom? Select all that apply.
Vascular spasm
Proteinuria
Polyphagia
Edema/weight gain
Hypertension
Seizure may occur in a pregnant client with eclampsia. Which of the following action should be
done to minimize the stimuli and prevent seizure?
Darken room
Administer medications as ordered
Monitor laboratory values frequently
Check vital signs frequently
The nurse is aware that a mother with gestational diabetes may at risk to develop which fetal
effect?
Hypoglycemia
Anemia
Infection
SGA
Asymptomatic infections are potentially dangerous in pregnant woman because they can
progress to pyelonephritis which are associated with preterm labor and premature rupture of
membranes. You know that pyelonephritis is an infection of:
Urethra
Ureter
Renal pelvis
Urinary Bladder
A 23-year-old G1 at 35 weeks age of gestation comes in for severe headache and visual
blurring. On prenatal check-up 1 week prior, her BP was noted to be 130/85 mmHg from her
usual 110/70. On examination, BP was now at 160/110 mmHg, FHT 140/min, no contractions
after ten minutes of observation. Cervix was 1cm, 30% effaced, intact membranes, station-2.
Most likely hypertensive disorder in pregnancy diagnosis is:
Severe preeclampsia
Chronic hypertension with superimposed preeclampsia
Chronic hypertension
Mild preeclampsia
A true anemia may occur in the second trimester when a woman’s hemoglobin concentration is:
Less 12 mg/dL (hematocrit <33%)
Less than 9.6 g/dL (hematocrit less than 31%)
Less than 10.5 g/dL (hematocrit <32%)
Less than 11 g/dL (hematocrit <33%)
To assist a pregnant client with the prevention of infections, the nurse should instruct the client
to:
Take showers instead of tub baths

Avoid using tissues and other hygienic materials
Cleaning the perineum from front to back
Drink citrus fruit juices
Magnesium sulfate was ordered to a client. The nurse should ensure to have on hand as an
antidote for magnesium toxicity?
Calcium carbonate
Potassium chloride
Sodium chloride
Calcium gluconate
A woman diagnosed with hyperemesis gravidarum may show an elevated hematocrit

concentration at her monthly prenatal visit. This condition may occur because:
The condition lead to persistent vomiting
The inability to retain fluid has resulted in hemoconcentration
The condition lead to persistent nausea
The condition lead to excessive fluid electrolytes loss

1. Bettina, 24 year old G1P0 at 40 weeks’ gestation is admitted to the lying-in-clinic IE

findings; 2-3 cm cervical dilatation; 80% effaced; station -1; breech presentation; + BOW.
62. Bettina expresses concern about the method of delivery she will undergo considering
the status of the fetus. Which of the following methods will the nurse anticipate most
likely?
Low outlet forceps
Normal spontaneous delivery
Cesarean section
Breech extraction
2. A G3P2 patient had a cesarean delivery because of a previous myomectomy. In the ER
she was 3-4 cms, breech presentation, with contractions every 4-7 minutes. The nurse
would instruct that the best management for this patient is which of the following?
Await vaginal delivery
Send her home but advise to return with regular contractions.
Start oxytocin to improve contractions.
Have her prepared for an emergency cesarean delivery.
3. The nurse is monitoring a client who is in the active stage of labor. The client has been
experiencing contractions that are short, irregular, and weak. The nurse documents that
the client is experiencing which type of labor dystocia?
Hypotonic
Hypertonic
Precipitous
Preterm labor
4. A patient at 38 weeks complaining of labor pains came in the emergency room. Vital
signs were normal. Fundic height is 30 cms. If the lower extremities of the fetus are
flexed at the hips and extended at the knees so that the feet lie in close proximity to the
head, the presentation is which of the following
Incomplete breech
Complete breech
Footling breech
Frank breech
5. The 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. What is the priority nursing
action?
Prepare the client for an amniotomy
Promote ambulation every 30 minutes
Provide pain relief measures
Monitor the oxytocin infusion closely.
6. A 25-year-old primigravida, is admitted at 7 in the morning to the labor unit and is in

active labor. Monitoring of the client was done by the nurse with the following findings:
7 AM – 6 cms dilated, 80% effaced station 0; 8 AM – 6 cms dilated, 80% effaced, station
0; 9 AM – 6 cms dilated, 80% effaced, station 0; 10 AM – 6 cms dilated, 80% effaced,
station 0. Which of the following is an appropriate dystocia classification of the nurse?
Prolonged 2nd stage of labor
Protracted active phase
Arrest of cervical dilatation
Prolonged latent phase
7. A 30 y/o G1P0 on her 28th weeks of gestation based on her LMP, & early ultrasound.
She presents with a history of a “gush of fluids” from her vagina, an hour ago. Speculum
exam shows fluid from the os, which is nitrazine and fern positive. The patient’s cervix is
1-2 cm dilated, 80% effaced EFM revealed FHR of 170/min and there are occasional
uterine contractions. The patient is afebrile, and her uterus is not tender. Her WBC is
13,000/cc. Which of the ff. is the most likely problem in this case?
Neonatal intraventricular hemorrhage
Pulmonary hypoplasia
Intrauterine infection
Premature labor
8. A 22 year old G1P0 patient at 39 weeks AOG was admitted for elective Cesarean Section
for breech presentation. She requested to her obstetrician that a transverse suprapubic
abdominal incision be done to her. The student nurse tasked to assist the operation
would correctly identify that the type of incision is which of the following?
Low segment transverse
C. Pfannensteil
Kerr
Classical
Kronig
9. A 19 year old G1P0 PU 40 weeks, not in labor, was seen at the OPD for decreased fetal
movement. She was hooked to an electronic fetal monitor and tracing showed: Baseline
FHT- 140’s, good variability, with more than 2 accelerations of 20 bpm lasting for 20
secs. The tracing will be interpreted by the nurse as which of the following?
Negative
Non-reactive
Positive
Reactive
10. In the labor unit, Mrs. Amelia Tan, 39 weeks AOG, primigravida was subjected to labor
monitoring. During clinical pelvimetry, the ischial spines were noted to be prominent, the
sidewalls convergent and the sacrosciatic notch is narrow. The nurse would understand
that of the following, what is the most common consequence of these findings?
Production of abnormal presentation is facilitated
Extreme posterior asynclitism is favored
There is increase likelihood for transverse arrest of fetal head
This promotes cord prolapse

11. A 25 year old G1P0, 38-39 weeks AOG was admitted at the labor unit due to regular
uterine contractions. Leopold’s findings revealed:
L1 – Large nodular mass
L2 – Hard, resistant structure at the right side of the mother; Small, irregular, mobile parts on
the left side of the mother
L3 – Movable hard round mass
L4 – Tips of the fingers able to meet
The nurse would adequately and correctly identify that the fetal heart tones can be best heard
in which of the following area?
Right lower quadrant
Right upper quadrant
Right upper quadrant
Left lower quadrant
12. A 20 year old, primigravid, PU 39 weeks, presented at the ER in labor for 3 hours. PE
revealed multiple vesicular lesions in the vulva and perineal area. IE showed 3 cm cervical
dilatation, 50% effaced, (+) BOW, cephalic , station -1. Clinical pelvimetry was adequate.
The nurse would advise the patient that the best route of delivery is which of the
following?
Spontaneous vaginal delivery
Cesarean section
Vacuum extraction
Outlet forceps extraction

13. A 25 y.o. primigravid consulted at the Emergency Room on her 36th weeks age of
gestation with abdominal pain and decreased fetal movement. On palpation, there was
note of titanic uterine contractions. Internal examination revealed the cervix to be 3 cm
dilated, fully effaced. The next best thing to do is:
Augment labor
Emergency cesarean section
Amniotomy
Tocolysis
14. A primigravid was brought to the ER by the attending nurse-midwife after 10 hours of
labor. Apparently she has been bearing down for 2 hours already. Exam showed that the
fetal scalp is visible at the introitus without separating the labia. The sagittal suture was
at AP diameter. The mother appeared weakened by her efforts to bear down. The nurse
would understand that the best management for this patient is which of the following?
Cesarean section
Strong fundal pressure
15. A 32 year old G1 at 39 weeks gestation is admitted in labor at 4 cm dilated and

completely effaced; the fetal head is at station 0. You perform clinical pelvimetry and
find the following: the diagonal conjugate is 10 cm, the interischial spine distance is 11
cm with non convergent sidewalls, and the intertuberous distance is 9 cm. These
measurements describe which of the following types of pelvis?
Contracted midpelvis
Normal pelvis
Contracted pelvic outlet
Generally contracted pelvis
Contracted pelvic inlet
16. A 30 year old G1P0, term was admitted for labor pains. FH- 34 cm, FHT- 140 bpm. IE-
cervix is 4 cm dilated, 60% effaced, cephalic, station -2, rupture BOW. Uterine
contractions every 2-3 mins, moderate. After 2 hours, IE- cervix 4-5 cm dilated, 70 %
effaced, station -2. After 2 hours, IE- cervix is 5-6 cm dilated, 80% effaced, station -1. The
nurse would correctly describe the progress of labor as which of the following?
Arrest in descent
Protracted descent
Protracted cervical dilatation
Normally progressing
17. A 31 year old, primigravid was admitted 5 cms. 50% effaced, cephalic, station -1 at 12
noon. In an hour she was 7cm, 60% effaced, station 0. At 2 pm she was 9 cm, fully
effaced, Station +1 and was fully dilated at 3 pm. The correct assessment of the nurse is
Protracted active phase dilatation
Protracted descent
Normal labor
18. 21 year old primigravida in labor for 10 hours presented with a 6 cm cervical dilatation.
The nurse midwife is monitoring the patient. The bag of waters ruptured and the
presenting fetal head was palpated at station 0. What conclusion regarding the pelvis
can be made by the nurse?
Pelvic midplane is inadequate

Pelvic inlet is inadequate
Pelvic midplane is adequate
Pelvic inlet is inadequate
19. The nurse is reviewing the health care provider’s prescriptions for a client admitted for
premature rupture of the membranes. Gestational age of the fetus is determined to be
37 weeks. Which prescription should the nurse question?
Perform a vaginal examination every shift
20. A 35 year old G1P0 had an infertility work-up from which she was prescribed clomiphene
citrate. She got pregnant and was diagnosed to have twin pregnancy. What is the most
probable type of twinning?
Dizygotic
21. A nullipara was admitted on active labor at 5 cms., ruptured bag of waters, station -2.
The nurse in a labor room is monitoring the client with dysfunctional labor for signs of
fetal or maternal compromise. Which assessment finding would alert the nurse to a
compromise?
Persistent non reassuring fetal heart rate
22. A 20 year old, primigravid, PU 39 weeks, presented at the ER in labor for 3 hours. PE
revealed multiple vesicular lesions in the vulva and perineal area. IE showed 3 cm cervical
dilatation, 50% effaced, (+) BOW, cephalic , station -1. Clinical pelvimetry was adequate.
The nurse would advise the patient that the best route of delivery is which of the
following?
Cesarean section
23. A 25 year old G1P0, 38-39 wks. AOG consulted at the emergency room due to labor
pains. She has no prenatal check-ups and family history revealed diabetes mellitus in
sister and mother. Abdominal exam revealed fundic height = 40 cm, uterine contractions
every 2-3 mins, 45- 50 secs. duration. Internal exam has remained unchanged at 6 cms
dilated, fully effaced, station -2, cephalic, (-) BOW for the past 2 1⁄2 hrs. The serious
complication during vaginal delivery of this baby where there is arrest in delivery of the
shoulder is:
Shoulder dystocia
24. A primigravid was brought to the ER by the attending nurse-midwife after 10 hours of
labor. Apparently she has been bearing down for 2 hours already. Exam showed that the
fetal scalp is visible at the introitus without separating the labia. The sagittal suture was
at AP diameter. The mother appeared weakened by her efforts to bear down. The nurse
would understand that the best management for this patient is which of the following?

Cesarean section
Strong fundal pressure
25. During routine ultrasound surveillance of a twin pregnancy, twin A weighs 1200 g and
twin B weighs 750 g. Hydramnios is noted around twin A while twin B has
oligohydramnios. Which statement concerning the ultrasound findings in this twin
pregnancy is true?
The donor twin develops hydramnios more often than does the recipient twin
Gross differences may be observed between donor and recipient placentas
The donor twin usually suffers from a hemolytic anemia
The donor twin often develops polycythemia
The donor twin is more likely to develop widespread thromboses

26. After a precipitous delivery, the nurse notes that the new mother is passive and only
touches her newborn infant briefly with her fingertips. What should the nurse do to help
the woman process the delivery?
Support the mother in her reaction to the newborn infant.
27. A G5P4 pregnant uterine 39 weeks was in active labor for 3 hours. IE showed cervix 7
cms dilated, fetal head at station -1 to 0. Suddenly, fetal heart rate decelerated and
maternal blood pressure dropped from 120/80 to 90/60 mm Hg. On doing IE, the
presenting part appeared to retract. The nurse would identify which of the following is
the most probable diagnosis?
Spontaneous uterine rupture
A 32 year old G6P5 patient in labor comes in 7 cm. dilated, 80% effaced at 10 am. Labor
monitoring was instituted. Uterus was contracted at 2-3 minutes frequency, 60 seconds
duration and strong intensity. Fetal heart tones ranges from 130 – 140 bpm. Amniotomy
revealed clear amniotic fluid. What time would the nurse expect the patient to be fully dilated if
labor progress is normal?
1 pm
12 am
11 am
2 pm
A 22 year old G2P1 (1001) at 35 weeks AOG has a chief complaint of regular uterine
contractions for 12 hours. She has stable vital signs. Fundic height is 27 cm, estimated fetal
weight is 2,400 grams. Fetal heart tones are 148 bpm and presentation is cephalic. On internal
examination, the cervix is 7 cm dilated, fetal head at station 0, intact bag of waters. What would
be your management?

Start IV tocolytics to control labor.
Admit her and allow labor to progress
Send her home with prescription for oral tocolytics.
Administer betamethasone.
A 33 y.o. primigravid on her 38th week of gestation was brought to the Emergency Room by
her husband for a sudden gush of fluid from the vagina. On pelvic examination, the umbilical
cord was noted to be coming out of the vagina. Important management of the nurse at this
point is which of the following?
Ask the patient to start bearing down
Place the patient in trendelenburg position
Await spontaneous vaginal delivery
Apply downward pressure on the presenting part
A 20 y.o. primigravida came in labor with age of gestation 38 weeks. Internal exam showed the
cervix to be 7 cm dilated, BOW ruptured, station -1. After an hour, the cervix became fully
dilated with the fetal head still at station -1. At this point, the nurse impression is which of the
following?
Dysfunctional labor, failure of descent
Prolonged deceleration phase
Protracted active phase
Dysfunctional labor, arrest of descent

The nurse clinical instructor is supervising nursing students monitoring a laboring client in the
Obstetrical Unit. During the discussion of abnormalities of labor, which of the following
division/phase of labor is most sensitive to analgesia and maternal sedation?
Preparatory division
Pelvic division
Deceleration phase
Dilatational division
A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy
experiencing uterine contractions. She was presented of an ultrasound findings of multiple
gestation. The phenomenon of locked twins is more common in this type of presentation:
Twin I – breech, twin II – cephalic
Twin I – cephalic, twin II – cephalic
Twin I – cephalic, twin II – breech
Twin I – breech, twin II – transverse lie
Immediately after an apparently normal labor and delivery, the mother suddenly manifested
with dyspnea and went into convulsions. Blood pressure likewise dropped sharply from 120/80
mm Hg. Cardiopulmonary arrest rapidly ensued. The nurse would identify which of the
following is the probable cause?
Postpartum cardiomyopathy
Cerebrovascular accident
Eclampsia
Amniotic fluid embolism
A nullipara was admitted on active labor at 5 cms., ruptured bag of waters, station -2. After 3
hours of good contractions, 2 – 3 minutes frequency, 60 seconds duration, strong intensity,
cervix was 5 cms dilated, station -2. The nurse would identify that the patient is in which of the
following condition?
Arrest of descent
Protracted active phase of labor
Prolonged latent phase of labor
A client in her 30-week gestation complains of hardening of her uterus every 10 minutes. She is
admitted with a diagnosis of preterm labor. IV fluid was started and was advised complete bed
rest without bathroom privileges. The physician orders Terbutaline infusion as treatment for the
client. The nurse is caring for a patient receiving Terbutaline. The nurse observes that the
medication is having a therapeutic effect when the patient:
Has a pulse rate that increases from 90 to 120 beats/minute
Dilates 1.5 cm every hour during labor
No longer perceives pain in her perineal area
Has contractions that decrease in frequency and duration

A 28 y.o. G3P2 (2002) was brought to the Delivery Room. Internal examination showed a fully
dilated cervix with the head at station +2. On auscultation, the fetal heart tone was noted to be
100 beats per minute associated with uterine contractions but with recovery. The most probable
cause of deceleration is:
Maternal exhaustion
Uteroplacental insufficiency
Fetal head compression
Umbilical cord compression
A nullipara was admitted on active labor at 5 cms., ruptured bag of waters, station -2. The nurse
has developed a plan of care for the client experiencing dystocia and includes several nursing
actions in the plan of care. What is the priority nursing action?
Keeping the significant other informed of the progress of the labor
Providing comfort measures
Changing the client’s position frequently
Monitoring the fetal heart rate

A patient at 37 weeks, complaining of hypogastric pain of 2 hours, came in the emergency
room. Her vital signs were normal. Fundic height was 35 cms. Fundus is occupied by a hard,
round, ballotable mass, fetal back palpated at the left, as well on the right, another hard, round
mass on the hypogastric area, fetal heart tones of 143/min heard at the left periumbilical area
and 152/min heard at the right lower quadrant. On internal examination, the cervix was 5 cms.
dilated, 1 cm long, ruptured bag of waters, cephalic, station -2. All her previous pregnancies
were delivered at home. What is the recommended mode of delivery?
An outright cesarean section
A vaginal delivery for both
A vaginal delivery for the first of twin then an internal podalic version for the second of twin
A vaginal delivery for the first of twin then a cesarean section for the second
After a successful cesarean section delivery for breech, the G1P1 mother asked the nurse if she
has a chance to have vaginal delivery next time she gets pregnant. The nurse would instruct the
client which of the following conditions may make vaginal delivery possible?
Abnormal placentation-previa
Mother has contracted pelvis
Malpresented fetus
Previous scar is a low segment cesarean
During a case conference, you are asked to present a 35 y/o patient, G2P1 who complained of
vaginal bleeding during the third trimester of pregnancy. Your impression is placenta previa.
One of your differential diagnosis is a rare anomaly associated with velamentous insertion of
the cord in which the vessels insert between the amnion and the chorion, cross the internal
cervical us and presents ahead of the fetal presenting part. What is your differential diagnosis?
Vasa previa
Abruptio placenta
Ruptured marginal sinus
Tumor previa
A 25 y/o G3P2 was admitted at 7 cm cervical dilatation, cephalic with frequency of uterine
contractions at 2 – 3 minutes, 45 seconds duration, moderate intensity, Station 0. The nurse
would expect the cleint to deliver in how many hours?
Myrna, a primigravida, on her 32nd week AOG, came in for prenatal check-up. Auscultation of
the FHT yields negative result and the ultrasound revealed fetal death in utero. The nurse will
inform Myrna which of the following will be done to manage her?
Wait for spontaneous labor

Prostaglandins
Curettage
Hysterotomy
A nurse is preparing to care for a client in labor. The physician has prescribed an intravenous
infusion of oxytocin (Pitocin). The nurse ensures that continuous fetal monitoring was
implemented before initiating the infusion. The nurse is caring for patients on induction of
labor. Which of the following patients would the nurse consider a priority to have a successful
induction of labor?
Multiparous; cervix 1 cm dilated/20% effaced/station 0
Primiparous; cervix 2 cm dilated/20% effaced/station -1
Multiparous; cervix 2 cm dilated/80% effaced/station -1
Primiparous; cervix 2 cm dilated/20% effaced/station 0
A 25 year old G1P0 PU 38 weeks AOG is in labor. An obstetrician was assigned to deliver the
baby. The nurse was assisting the obstetrician. Forceps was applied on the fetal head with the
following findings: head was at station +2 with the sagittal suture at left occiput anterior
position. The nurse would classify this forceps extraction as which of the following?
Mid forceps delivery

High forceps delivery
Low forceps delivery
Outlet forceps delivery
Maria, 19 years of age, 38 weeks age of gestation is admitted at the Obstetrical Unit for labor
monitoring. The latent phase of labor of the 19 y.o. primigravid already exceeded 20 hours. The
preferred treatment for this case is which of the following?
Cesarean section
Oxytocin drip
Therapeutic rest
Expectant management
A patient at 38 weeks AOG came in labor. I.E. cervix is 5 cm dilated, 50% effaced, intact BOW,
cephalic, station -3. Clinical pelvimetry shows the ischial spine is bilaterally prominent, pelvic
sidewalls are convergent and concavity of the sacrum is shallow. With these findings, the nurse
would suspect the presence of:
Midpelvic contraction
Pelvis is adequate
Pelvic inlet contraction

Pelvic outlet contraction
A pregnant client was admitted to the labor room. An assessment is performed, and the
nurse notes that the fetus is at -1 station. Monitoring of the client was done by the nurse.
The nurse informed a pregnant client in labor that the smallest head diameter of the fetus
must be presented to the birth canal in order to best traverse/travel to the birth
canal. Which of the following is the smallest anterioposterior cranial diameter of a fetus?
Biparietal
Occipitofrontal
Suboccipito bregmatic
Occipitomental
Maria pregnant G1P0 was admitted in labor. Labor monitoring was done. The physician asks the
nurse the frequency of a laboring client’s contractions. The nurse assesses the client’s
contractions by timing from the beginning of one contraction to the beginning of the next
contraction. During the active phase of labor, the membranes ruptured. Immediately after the
membranes ruptured. Internal examination by the nurse was done. Inlet contraction is likely if
the nurse’s assessment is which of the following?
Sidewalls are convergent
Obstetric conjugate is less than 11.5 cm
Diagonal conjugate is less than 11.5 cm
Interspinous diameter is less than 10.5 cm

The nurse is assessing a client who is 6 hours postpartum after delivering a full-term healthy infant.
The client complains to the nurse of feelings of faintness and dizziness. Which of the following
nursing actions would be most appropriate?
Inform the nursery room nurse to avoid bringing the newborn infant to the mother until the feelings
of lightheadedness and dizziness have subsided
Elevate the mother’s legs
Instruct the mother to request help when getting out of bed
Obtain hemoglobin and hematocrit level
A postpartum client complains of stress in incontinence. What information should the nurse suggest
to the client to overcome stress incontinence?
Reduce fluid intake
Perform aerobic exercises
Perform Kegel’s exercises
Frequently empty the bladder
While the postpartum client is receiving heparin for thrombophlebitis, which of the following drugs
would the nurse expect to administer if the client develops complications related to heparin therapy?
Methylergonovine (Methergine)
Nitrofurantoin (Macrodantin)
Protamine Sulfate
Calcium Gluconate
Mrs. Malou Wang, G1P1, 5 days postpartum client develops endometritis. When planning nursing
care, which activity would be best advice for Mrs. Malou Wang?
Alternating between prone and supine positions
Reading while resting in a slight Trendelenburg position
Lying supine with a cold cloth on her forehead

Walking around her room listening to music
(DITO KASI DAPAT FOWLERS POSITION PAG ENDOMETRITIS)
At delivery, a perineal laceration tore through the skin of the fourchette, vaginal mucous membrane,
and the fascia and perineal muscles of the perineal body but not the anal sphincter of mucosa. This
should be recorded by the nurse in the medical record as what type of laceration?
Second-degree
A primigravid at 39 weeks delivered by low forceps extraction. On the first post-partum day, the
patient complained of excruciating vulvar pain. On examination, there was a fluctuant, violaceous
gray, 8x6 cm mass on the postero-lateral aspect of the vulva, tense and tender on palpation. What
is your diagnosis?
Vulvar hematoma
Bartholin’s cyst
Gartner’s duct cyst
Bartholin’s glands abscess
Six hours after being on the postpartum unit, Mrs. Rivera complains of excruciating perineal and
rectal pain and a feeling of fullness in the vaginal area, the nurse may suspect the cause of the pain
to be related to which of the following?
Vaginal hematoma
Full bladder
Episiotomy
Hemorrhoid
Marjorie, a 28 year old primigravida who vaginally delivered a full term infant with a forceps assisted
delivery and midline episiotomy. Four hours after a difficult labor and birth, the primiparous woman
refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should:
Recognize as a behavior of the taking-hold stage
Record the behavior as ineffective maternal-newborn attachment
Tell the mother she can rest after she feeds her baby
Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time
A puerpera came for her postnatal follow up 2 weeks after an uncomplicated vaginal delivery. The
nurse recognizes that which of the following events are the expected findings on her physical
examination:
Lochia alba
Uterus at the level of the symphysis pubis
cervix open and thick
bipedal edema
Darleen is a gravida 2 para 1001 who experienced a prolonged second stage of labor but finally
delivered a girl weighing 4.139 grams. She was then transferred to the postpartum unit. In the
immediate puerperium, in a setting of excessive of vaginal bleeding, the guide to instituting blood
transfusion therapy is:
The systolic blood pressure

The diastolic blood pressure
The amount of blood lost (pinakamalapit ulit)
The pulse rate
Linda, 18 year old, delivered an 8 lbs baby. There was note of laceration on the lateral wall off the
vaginal vault with profuse vaginal bleeding. There was a sudden drop of BP. Post partum there was
note amenorrhea. Lab examination shows destruction of the pituitary gland. Linda has what
syndrome?
- Sheehan's syndrome
A gravida 1 para 1001 has vaginally delivered a full term infant without complications. After the first
postpartum day, she tells the nurse that she’s afraid that something is wrong because she’s
perspiring and urinating more than normal. Her temperature is 37.8 C. The nurse should
appropriately reply:
"It's common to perspire and urinate a lot after childbirth; your body is getting rid
of the excess fluid that was used in pregnancy."
A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse
notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects
a pulmonary embolism. Which should be the initial nursing action?
Prepare to administer morphine sulfate
Assess the client’s blood pressure
Administer oxygen, 8 to 10 L/ minute, by face mask
Initiate an intravenous line
The nurse is developing a plan of care for postpartum clients admitted in the obstetric unit. The
nurse is preparing to care for four assigned clients. Which of the following clients is at highest risk
for hemorrhage?
A multiparous client who delivered a large baby after oxytocin (Pitocin) induction
A multiparous client who delivered 6 hours ago
A primiparous client who delivered 6 hours ago and had epidural anesthesia
A primiparous client who delivered 4 hours ago
Colette is 35 year old multipara who delivered a full term infant via cesarean section because of
breech presentation. THe nurse is monitoring a client in the immediate postpartum period for signs
of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?
A blood pressure change form 130/88 to 124/80 mm Hg
An increase in the respiratory rate from 18 to 22 breaths/minute
An increase in the pulse rate from 88 to 102 beats/minute
A temperature of 100.4 F
The nurse is developing a plan of care for a postpartum client with a small vulvar hematoma. The
nurse should include which specific action during the first 12 horse after delivery?
Assess vital signs every 4 hours.
Prepare an ice pack for application to the area
Measure fundal height every 4 hours.

Inform the health care provider of assessment findings.
C., 28 y/o, G2P2, delivered spontaneously to a live fetus 8 days ago at home assisted by a
nurse. She developed high-grade fever on the 5th post-partum day associated with body
malaise, lower abdominal pain & moderate vaginal bleeding. On admission, the patient was
febrile and on IE, the cervix was open, the uterus was enlarged to 18 week-size & both
adnexae were tender and foul-smelling lochia was noted. Your impression is .
Puerperal infection
Pelvic inflammatory disease
Uterine subinvolution
Retained placenta fragments
Collete is 25 year old primipara who delivered a full term infant via cesarean section because of
breech presentation. The nurse is providing instructions about measures to prevent postpartum
mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a
need for further instruction?
“I should wash my nipples daily with soap and water.”
“I should change the breast pads frequently.”
“I should wash my hands well before breastfeeding.”
“I should breast-feed every 2 to 3 hours.”
The nurse is assisting a multiparous woman to the bathroom for the first time since her delivery 3
hours ago. When the patient stands up, blood runs down her legs and pools on the floor. The
patient turns pale and feels weak. The first action of the nurse is to:
Begin an Intravenous fluid infusion
Assist the patient to empty her bladder

Assess her blood pressure and pulse
Help the patient back to bed to check her fundus
Postpartum hemorrhage can cause hypovolemic shock. If a postpartum patient is experiencing

hypovolemic shock resulting from uterine atony, important nursing diagnosis is fluid volume deficit
related to excessive blood loss. Which of the following complications is most likely responsible for a
delayed postpartum hemorrhage?
Perineal laceration
Uterine subinvolution
Clotting deficiency
Malou Wang has a risk for deep vein thrombosis (DVT) during the postpartal period. What would be
the best suggestion the nurse could make to help prevent this?
Increase fluid intake to reduce blood viscosity.
Assume a knee- chest position for 15 minutes every day.
Rest in bed as much as possible for the first several days.
Ambulate early and consistently to improve circulation.
Brenda Mage is a 32 year old primigravida who vaginally delivered a full term infant without
complications. She states that she would like to take a nap but allows the nurse to take vital signs
and perform an assessment. The nurse is aware that a higher incidence of postpartum blues can
result from which of the following?
Fatigue
Neonatal jaundice
Subinvolution
Pregnancy-ind
nurse should include which specific action during the first 12 hours after delivery?
Prepare an ice pack for application to the area.
Linda, 18 year old, delivered an 8 lbs baby. There was note of laceration on the lateral wall off the
vaginal vault with profuse vaginal bleeding. There was a sudden drop of BP. Post partum there was
note of amenorrhea. Lab examination shows destruction of the pituitary gland. Linda has what
syndrome?
Sheehan’s syndrome
Simmonds syndrome
Edward’s syndrome
rectal pain and a feeling of fullness in the vaginal area. The nurse may suspect the cause of the
pain to be related to which of the following?
Full bladder
Episiotomy
Vaginal hematoma
Kim Chi is a 30-year-old woman who had a “textbook perfect” pregnancy. You enter her room 4
hours after she gave birth to an 8-lb girl, but, because she is sleeping and appears comfortable, you
hesitate to awaken her. When you observe her more closely, however, you realize she appears
abnormally pale. You obtain her vital signs and document her pulse as 90 beats per minute and her
blood pressure as 96/50 mm Hg. When you fold back her bedclothes, you discover her bed is
soaked with blood. You suspect she is experiencing one of the most serious complications of
pregnancy: postpartum hemorrhage. Yet because she was sleeping, she was totally unaware of it.
Which of the following complications may be indicated by continuous seepage of blood from the
vagina of a postpartum client when palpation of the uterus reveals a firm uterus 1 cm below the
umbilicus?
Retained placental fragment
Uterine atony
Urinary tract infection
Cervical laceration
Collete is 25 year old primipara who delivered a full term infant via cesarean section because of
breech presentation. The nurse is providing instructions about measures to prevent postpartum
mastitis to a client who is breast-feeding her newborn. Which client statement would indicate a need
for further instruction?
“I should wash my nipples daily with soap and water.”
“I should change the breast pads frequently.”
“I should wash my hands well before breastfeeding.”
“I should breast-feed every 2 to 3 hours.”
Marjorie, a 28 year old primigravida who vaginally delivered a full term infant with a forceps assisted
delivery and midline episiotomy. Four hours after a difficult labor and birth, the primiparous woman
refuses to feed her baby, stating that she is too tired and just wants to sleep. The nurse should:

Recognize this as a behavior of the taking-hold stage
Tell the mother she can rest after she feeds her baby
Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time
Record the behavior as ineffective maternal-newborn attachment
Carole Holmes, a 28 year old multipara delivered vaginally a term infant. The postpartum patient
was in labor for 30 hours and had ruptured membranes for 24 hours. Which of the following would
the nurse be alert?
Endometriosis
Salpingitis
Endometritis
Pelvic thrombophlebitis
A postpartum client complains of stress incontinence. What information should the nurse suggest to
the client to overcome stress incontinence?
Reduce fluid intake
Frequently empty the bladder
Perform Kegel's exercises
Perform aerobic exercises
At delivery, a perineal laceration tore through the skin of the fourchette, vaginal mucous membrane,
and the fascia and perineal muscles of the perineal body but not the anal sphincter or mucosa. This
should be recorded by the nurse in the medical record as what type of laceration?
Second-degree
First-degree
Third-degree
Fourth-degree
Malou Wang has a risk for deep vein thrombosis (DVT) during the postpartal period. What would be
the best suggestion the nurse could make to help prevent this?
Ambulate early and consistently to improve circulation.
Assume a knee- chest position for 15 minutes every day.
Increase fluid intake to reduce blood viscosity.
Rest in bed as much as possible for the first several days.
rectal pain and a feeling of fullness in the vaginal area. The nurse may suspect the cause of the
pain to be related to which of the following?
Full bladder
Vaginal hematoma
Episiotomy
Hemorrhoid
A gravida 1 para 1001 has vaginally delivered a full term infant without complications. After the first
postpartum day, she tells the postpartum nurse that she’s afraid that something is wrong because
she’s perspiring and urinating more than normal. Her temperature is 37.8 C. The nurse should
appropriately reply:
“It’s common to perspire and urinate a lot after childbirth; your body is getting rid of the excess fluid
that was used in pregnancy.
“You’re temperature is slightly elevated. You could have an infection. I’ll call the doctor to report
your temperature.”
“You’re probably responding to an infection in your body; I’ll call the doctor and report your
symptoms.”
“I’m surprised you’re urinating a lot because you don’t have other signs of diabetes.”
Darleen is a gravida 2 para 1001 who experienced a prolonged second stage of labor but finally
delivered a girl weighing 4,139 grams. She was then transferred to the postpartum unit. In the
immediate puerperium, in a setting of excessive of vaginal bleeding, the guide to instituting blood
transfusion therapy is:
the amount of blood lost
the systolic blood pressure
the pulse rate
the diastolic blood pressure
nurse should include which specific action during the first 12 hours after delivery?
Prepare an ice pack for application to the area.

A 34 year old G4P4 delivered vaginally an 8 lb baby at home assisted by a hilot. The placenta
was delivered without difficulty. However, a few minutes later, there was profuse vaginal
bleeding and the patient was rushed to the hospital. In the ER, the patient was hypotensive,
tachycardic and pale. On abdominal examination, the uterine fundus was soft and above the
umbilicus. There were no vaginal or cervical lacerations. What is the most probable diagnosis?
retained placental fragments
uterine rupture
uterine inversion
uterine atony
Barbara is a 22 year old Gravida 1 who delivered vaginally her first infant. Th vaginal delivery
was uncomplicated. The nurse is providing instructions about measures to prevent postpartum
hemorrhage. Lacerations that include the skin and mucous membrane, the fascia and the
muscles of the perineal body are classified as:
First-degree laceration
Third-degree laceration
Second-degree laceration
Fourth-degree laceration
A nurse is performing an assessment on a 2-day postpartum mother. The mother complains of

severe pain and an intense feeling of swelling and pressure in the vulvar area. After hearing
these complaints, the nurse specifically checks the clients.
Episiotomy for drainage
Rectum for hemorrhoids
Vagina for lacerations
Vulva for a hematoma

On the client’s third postpartum day, the nurse enters the room and finds the client crying. The
client states that she doesn’t know why she is crying and she can’t stop. Which of the following
is the most appropriate statement of the nurse to make?
“This happens to lots of mothers, you’ll get over it.”
“Are you dissatisfied with your care.”
“There is no need to cry, you have a healthy baby.”
“Many new mothers have shared with us their same confusion of feelings, would you like to talk
about them.”
Collete is 35 year old multipara who delivered a full term infant via cesarean section because of
breech presentation. The nurse is monitoring a client in the immediate postpartum period for
signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss?
An increase in the pulse rate from 88 to 102 beats/minute
An increase in the respiratory rate from 18 to 22 breaths/minute
A temperature of 100.4 ° F
A blood pressure change from 130/88 to 124/80 mm Hg
The nurse is making an effort to address Mrs. Malou Wang’s psychosocial health in addition to
her physiologic well- being. Which of Mrs. Wang’s statement would be most suggestive of
possible postpartal psychosis?
“I’m happy not to have any children”.
“I’ve felt exhausted ever since birth”.
“Breastfeeding is way harder than I thought”.
“I wish my baby had longer hair”.
During a childbirth preparation, the nurse explains that in the postpartum period, In placenta
accreta/increta/percreta, the placenta is abnormally adherent to the myometrium due to partial
or total absence of:
Decidua vera
Decidua basalis
Decidua capsularis
Decidua parietalis

A couple has been unable to conceive. The client and her husband are in today for an appointment
at the infertility clinic where the nurse works. The client has had pelvic inflammatory disease caused
by Chlamydia trachomatis. She is at risk for which of the following?
Ectopic pregnancy
Cervical dysplasia
Multifetal pregnancy
Anovulatory menstrual cycles
at the infertility clinic where the nurse works. Which of the following statements by the client about
Clomiphene Citrate does not need further instructions?
“Dosage should not exceed 50 mg/day.”
“It acts by stimulating estrogen production and binding.”
“It should be administered in conjunction with progesterone.”
“It results in an increase in the release of follicle stimulating hormone from the pitutitary.”
at the infertility clinic where the nurse works. Which of the following does not result in decreased
sperm production resulting from thermal shock?
Sitting on the testicles for long periods of time with poor heat dispersion
Spending excessive time in hot tubs or hot baths
Wearing tight clothing
Living in climate where the temperature exceeds 90 F for long periods
at the infertility clinic where the nurse works. The male client was subjected for sperm analysis.
After the semen specimen is collected, semen analysis should be performed within:
8 hours
6 hours
2 hours
4 hours
at the infertility clinic where the nurse works. Which of the following is NOT a method for optimizing
the chances of conception?
Engaging in intercourse within a few hours of ovulation
Checking blood samples for testosterone levels
Analyzing the woman’s urine or saliva for LH
Tracking vaginal mucus
Charting basal body temperature
at the infertility clinic where the nurse works. Sperm analysis revealed abnormal sperm morphology.
Which of the following is not associated with abnormal sperm morphology?
Immunologic factors, including anti sperm antibodies
Infection
Varicocele
Stress
at the infertility clinic where the nurse works. The client has been instructed that her cervical mucus
will be tested using a spinnbarkeit test. The nurse should explain to the client that this will test her
cervical mucus for:
Stretchability
Level of progesterone
Level of cervical mucus
Amount of ferning pattern
at the infertility clinic where the nurse works. 15. Which conditions made by a couple would indicate
that they need additional teaching as to the factors decreasing the likelihood of conception?
Pelvic inflammatory disease
Endometriosis
Highly alkaline vaginal pH
Excessively thick cervical mucus
at the infertility clinic where the nurse works. Which of the following is the most appropriate initial
test for infertility in case the client is 32 year old G2P2 (2002) and the husband is 35 year old man
with no children?
Endometrial biopsy
Basal body temperature record
Hysterosalpingogram
Semen analysis
Post coital test
A couple has been unable to conceive. The client and her husband are in today for an
appointment at the infertility clinic where the nurse works. Which of the following is the most
appropriate initial test for infertility in case the client is 21 year old G1P0 (0010) who has
had amenorrhea since an elective abortion that was followed by infection?

Endometrial biopsy
Hysterosalpingogram
Post coital test
Anti sperm antibodies
Semen analysis
test for infertility in case the client is 32 year old G0 with a history of chronic pelvic pain and
dysmenorrhea whose partner has a normal sperm count?
- Hysterosalpingogram
test for infertility in case the client is 28 year old G1P1 (1001) who wishes to increase her chance of
pregnancy by the timing of intercourse?
Hysterosalpingogram
Post coital test
Basal body temperature record
A couple has been unable to conceive. The client and her husband are in today for an appointment at
the infertility clinic where the nurse works. The nurse interprets that partner sperm intrauterine
insemination is likely to be indicated for a couple when which of the following has occurred?
The male partner has a varicocele.
The female partner has irregular menses.
The male partner has human immunodificiency virus.

The female partner produces anti-sperm antibodies.
test for infertility in case the client is 26 year old G0 with a history of irregular periods, who works
several jobs, and has unpredictable sleeping patterns?
Post coital test
Hysterosalpingogram
Luteal phase progesterone
Endometrial biopsy
appointment at the infertility clinic where the nurse works. Which of the following is the most
appropriate initial test for infertility in case the client undergoing infertility evaluation who
demonstrate clumping of sperm on Huhner Sims test?
Hysterosalpingogram
Post coital test
Post coital test
Semen analysis
appointment at the infertility clinic where the nurse works. If present in the client, the major
causes of infertility in the client includes all of the following EXCEPT:

An irregularly shaped uterus
Obstructions of the reproductive tract
Failure to ovulate
Declining hormone levels
Endometriosis
appointment at the infertility clinic where the nurse works. Which of the following statements
made by the client scheduled for in vitro fertilization would indicate the need for additional
teaching?
“The fertilized eggs will be implanted into my uterus 2 to 3 days after the egg retrieval.”
“I will have eight embryos implanted to maximize my chance of carrying a baby to term.”
“The egg retrieval procedure may be uncomfortable, but medication will be available for me.”
“I will need to limit my activities the day of the egg retrieval and the day of implantation.”
appointment at the infertility clinic where the nurse works. The client’s ova are viable, but she is
not ovulating on a regular basis. What fertility methods are the couple candidates for?
Artificial insemination
Donor IVF
Embryonic transfer
In vitro fertilization
Adoption
appointment at the infertility clinic where the nurse works. Which of the following statements
made by the client indicates that she and her husband are having difficulty coping with their
infertility regimen.
“My husband just hates having to plan when we make love.”

“I am never going to consider prenancy a spontaneous event again.”
“We had to take out a home equity loan to pay for these treatments.”
“I don’t like giving myself shots, but I’ll do it to get pregnant.”
appointment at the infertility clinic where the nurse works. The nurse determines that which of
the following clients in the infertility clinic needs to be seen first?
A 34 year old man in for semen analysis results.

A 32 year old woman on Pergonal and HCG complaining of severe abdominal pain.
A 27 year old woman being seen for an initial infertility exam.
A 30 year old woman in for a pregnancy test following implantation of in vitro fertilization and
GIFT.
appointment at the infertility clinic where the nurse works. The client is scheduled for a
hysterosalpingogram. Which of the following should the nurse include in the preoperative
assessment?
Presence of metal implants

Allergy to iodine or shellfish
History of sexually transmitted infections.
Difficulty swallowing
appointment at the infertility clinic where the nurse works. A female client is considering in vitro
fetilization and gamete intrafallopian transfer (GIFT). Which of the following statements
indicates that she needs additional information?
“I will give myself injections of medications to cause my ovaries to ripen more than one egg.”
“I will be in the hospital overnight for this procedure.”
“My husband will need to produce a sample of his sperm the day my eggs are retrieved.”
“I can expect to have some discomfort after the procedure.”
appointment at the infertility clinic where the nurse works. The nurse interprets that a client who
has a complete bicornuate uterus with two vaginas will: (Select all that apply)
Be unable to ever achieve pregnancy

Need to be delivered via cesarean section.
Be at risk for multiple pregnancy loss.
Need to be artificially inseminated to concieve
Be at increased risk for preterm labor.
appointment at the infertility clinic where the nurse works. The client is a 43 year old nullipara
who is in for her first intrauterine insemination of her partner’s washed semen. The nurse
determines that client teaching has been effective when the client states:
“If I do not get pregnant, I’ll see a dip an an increase in my BBT.”
“If I get pregnant, I’ll see a decrease in my BBT.”
“If I do not become pregnant, I’ll see an increase in my BBT.”
“If i get pregnant, I’ll see an increase in my BBT.”
appointment at the infertility clinic where the nurse works. The client tells the nurse that she
plans to use the basal body temperature method for sexual intercourse timing. Which of the
following statements indicates that she has understood this type of method?
“My temperature will fall and then rise at ovulation”
“I should take my temperature before bedtime"
“I must use this method with additional contractive method”
“My temperature will rise and then fall at ovulation”
appointment at the infertility clinic where the nurse works. The client reports that her menstrual
cycle usually lasts for 44 days and she starts ovulating on the 22nd day. The nurse should tell
her that:
“No, where did you get that information? You ovulate on the 14th day of your cycle.
“Yes, that is correct. Well done, Mam.”
“The day of your ovulation is on the 30th day.”
“No, the day of your ovulation is on the 28th day.”
appointment at the infertility clinic where the nurse works. The nurse has explained to the client
that the results of her hysterosalpingogram revealed bilateral tubal bloackage. The nurse
realizes that further education is needed when the client asks which of the following questions?
“Will the surgery to unblock my tubes br done in the hospital or the surgery center?”
“Will long distance running and a low percentage of body fat affect the success of the surgery?”
“Will the acupucture treatments I am getting interfere with the surgical procedure?”
“Will this plug in my fallopian tubes go away forever after i become pregnant.”
appointment at the infertility clinic where the nurse works. The nurse explains to the male client
with a vas deferens blockage to expect which of the following problems?
Decreased sperm in his seminal fluid
Frequent urination
Inability to achieve or maintain an erection
Decreased sexual drive

appointment at the infertility clinic where the nurse works. The client has been scheduled to
have a hysterosalpingogram. Which of the following questions does the nurse need to ask?
“What was your age at menarche?”

“Do you have any metal implants?”
“When was the first day of your last menstrual period?”
“When was the last time you had intercourse?”
NUR 1210 SKILLS LAB MODULE #1

Newborn screening is a form of preventive health care in which babies are tested within the first
days of their life to discover evidence of diseases for which the principal symptoms may not yet be
apparent. Newborn screening identifies conditions that can affect a child’s long- term health or
survival. Four newborns have had blood drawn for the Guthrie test for phenylketonuria. The nurse
would question the results of the baby in which of the following situations?
Who has breast-fed for the 24 hours before the test.
Tested immediately after birth.
Whose test is performed at 48 hours of age
Fed glucose water followed by formula for 30 hours

An infant was born 24 hours ago. The nurse has been instructed to collect blood by heel stick for
neonatal screening for congenital hypothyroidism before the baby is discharged. The nurse discusses
options with the pediatrician knowing that 24 to 48 hours after birth is not the optimal time to collect
this specimen because: GGroup of answer choices
The baby needs to digest formula before a blood sample can be taken
A thyroid scan should be done first.
At 24 hours, the T4 level will be extremely low.
There is an immediate rise in the TSH after birth.
In many parts of the world mass screening for congenital hypothyroidism is done routinely. Here in
the Philippines it is included in the Newborn Screening Act of 2004. The nurse would include in the
health teaching to a client the following important statements for this disorder, EXCEPT: G
Serum thyroxine (T4) level is low
Clinical features of cretinism are usually apparent during the first weeks of life
T3 resin uptake is low
Tyroxine binding globulin (TBG) level is usually normal
Thyoid stimulating hormone levels (TSH) may be high, normal, or low
The nurse was working with a group of parents of children with phenylketonuria. The nurse has
completed family teaching on the dietary restrictions. The parents are given sample menus to choose
a meal for their child. Which menu choice indicates understanding of the dietary instructions?
Steak and mashed potatoes with orange juice.
A large bowl of cereal with strawberries and apple juice.
Milkshakes and grilled cheese sandwich.
A hamburger and diet soda sweetened with aspartame.

Mothers in the waiting room of the endocrine clinic are discussing their children illnesses the mother
of children with phenylketonuria and congenital hypothyroidism recognize there is a common goal
in the early treatment of their children. That goal is the avoidance of:
Fever
Protein foods
Obesity
Mental retardation
In the management of clients with various health problems, the nurse should be equipped with the
knowledge of basic nursing procedures. The following are TRUE of the Newborn Hearing Screening
EXCEPT:
Performed after 24 hours of life but not late than 6 months
All infants whether high risk or non-high risk
By age 2 months hearing loss is diagnosed
By age 6 months hearing intervention must start
By age 1 month the baby must have been screened
Nursing is a dynamic profession. As a responsible member of the health team, the nurse should be
abreast with the current trends in the advancement of the profession. When is newborn screening
performed in a breastfed neonate?
12 hours after birth

1 hour after birth
6 hours after birth
The local church in Barangay Chubibo is in the midst of extreme poverty. Most of the people are
very poor. Less than 10% of the population have regular jobs, mostly as janitors, laborers, domestic
helpers, sales clerk and the like. There is a nurse in the barangay health station. Most of the cases
seen by the nurse are referred to the main health center, one jeepney ride away. Which of the
following statements is FALSE about CH? Group of answer choice
The baby may appear normal at birth.
There is presence of ambiguous genitalia.
Hypotonia or poor muscle tone is present.
There is developmental delay, including mental retardation.
A 1-hour-old newborn is transferred to the nursery because he is cyanotic. His vital signs are as
follows: heart rate 170, respiratory rate 66, blood pressure 59/40. He isn’t exhibiting nasal flaring,
grunting, or retractions. Breath sounds are equal and bilateral. His oxygen saturation is 85%. The
first action of the nurse is to:
Put the baby under an oxygen hood of 30% oxygen
Prepare the baby for chest tube insertion
Give the baby flow by oxygen
Call the doctor
You have been asked to assign an APGAR score to the following infant at five minutes of life. The
and only minimally grimaces. What is his APGAR score?
5
7
You are observing a doctor performing the ballard scoring. As a student nurse you know that if the
doctor bilaterally flex the elbows up hold about 5 seconds, then extend arms down next to side and
release then observe elbow angle and movement /pull back of the arm is of which neuromuscular
maturity?
Scarf sign
Square window
Arm recoil
Popliteal angLE
Soon after delivery, BALLARD scoring should be performed to the newborn within 24 hours.
Assessing the neuromuscular maturity includes: (select all that apply)
Scarf sign
Posture
Heel to ear
Eye and ear
Which of the following assessment shows a normal creases of the plantar surface of the foot? Group
of answer choices
Faint red marks on the
Anterior transverse
Undetermined crease of the sole

Creases on the anterior 2/3 of the sole
Cyanosis of the feet and hand is considered normal in the 1st 24 hours because: G
Because newborn has difficulty adjusting the outside environment
The quantity of oxygen bound to hemoglobin are greater in the fetal circulation
The peripheral circulation of a newborn remains sluggish
The lungs after birth is oxygenated by the newborn own blood that was formerly oxygenated by the
placenta
A student nurse is observing a specialist performing the hearing test to a newborn. Which of the
following is not considered a risk factor to develop hearing loss?
Infections that can damage the brain after birth, such as meningitis or measles
Trauma
Exposure to certain toxic chemicals or medicines while in the womb or after birth
Family History
The best test available for newborns and infants up to 6 months of age that can provide information
about the softest level of sound the ear can hear is:
Otoacoustic Emissions Test (OAEs)
Auditory Brainstem Response Test (ABR)
Auditory test
Hearing test
Nursing practice is governed by laws and ethics principles. As a beginner nurse, knowledge of these
laws and principles helps in the prevention of law suits arising from malpractice. Section 10 of the
Newborn Screening Act of 2004 states that:
Health practitioners have the obligation to inform mothers about newborn screening.
A Newborn Screening Reference Center shall be established.
Every newborn should be offered the opportunity to undergo newborn screening.
The Department of Health shall act as the lead agency
The nurse in a neonatal intensive care unit (NICU) receives a telephone call to prepare for the
admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning for admission
of this newborn, what is the nurse’s highest priority?
Turn on the apnea and cardiorespiratory monitors.
Set the radiant warmer control temperature at 36.5° C (97.6° F).
Connect the resuscitation bag to the oxygen outlet.
Set up the intravenous line with 5% dextrose in water.
You are assessing physical maturation of a newborn male. The following result (testes in upper canal
with rare rugae, slightly curved pinna; smooth, and slow recoil, stippled areola 1-2 mm bud, anterior
transverse crease only, abundant lanugo and gelatinous and translucent skin) will give you a score
of?
7
8
A newborn male has 4 mm. breast nodules, fuzzy scalp hair, and some cartilage in his ear lobes, and
assigned his gestational age as:
41 weeks
27 weeks
33 weeks
37 weeks
To validate the applicability of nursing intervention with the rapidly changing technology based care
of clients. The nurse should engage in the continuous search for scientific knowledge to improve the
knowledge base of the nursing profession. When doing a culture related research, the nurse should
be aware of the cultural beliefs and practices. According to the Department of Health, this is the
most common among the 6 disorders detected by the basic Newborn screening kit.
PKU
CA
GAL
G6PD Deficiency
Congenital hypothyroidism is one of the diseases screened in newborn screening program. When
asked by the mother why her newborn baby does not manifest signs of hypothyroidism when it is a
congenital condition, the nurse’s response will reflect an understanding of which fact:

Thyroid hormones can pass through placental barrier and the fetus had received enough to delay the
onset of the signs of hypothyroidism.
The influence of the anterior pituitary gland is not so much in the neonatal period, causing the delay
in the onset of signs.
The mother’s own antibodies act to protect the newborn from early signs of hypothyroidism.
The immaturity of the thyroid gland at the time of birth favors the delayed onset of hypothyroidism.
The doctor is assessing the 6 hours male newborn baby on how he listen to the voice produced by the
external environment or observed on how he concentrate on his mother’s face and respond by either
widening the eyes, head held as if listening to a voice or smile when cuddled by the parent. As a
student nurse, you know that this procedure pertains to:
Neonatal behavioral assessment scale
Neurologic and physical assessment scale
Ballard Assessment scale
Brazelton Neonatal Behavioral Assessment Scale
The best test available for newborns and infants up to 6 months of age that can provide information
about the softest level of sound the ear can hear is:
Auditory Brainstem Response Test (ABR)
Hearing test
Otoacoustic Emissions Test (OAEs)
Auditory test
Which of the following assessment indicates moderate respiratory distress?

No expiratory grunt, minimal nares dilatation, and visible intercostal retraction
No nares dilatation, No xiphoid retraction, with visible xiphoid retraction
Seesaw respirations, visible intercostal retraction, and visible xiphoid retraction
Visible intercostal retraction, Expiratory grunt audible by stethoscope, and no nares dilatation
following is not considered a risk factor to develop hearing loss?
Family History
Trauma
Exposure to certain toxic chemicals or medicines while in the womb or after birth
Infections that can damage the brain after birth, such as meningitis or measles
Newborn screening is a form of preventive health care in which babies are tested within the first
days of their life to discover evidence of diseases for which the principal symptoms may not yet be
apparent. Newborn screening identifies conditions that can affect a child’s long- term health or
survival. Four newborns have had blood drawn for the Guthrie test for phenylketonuria. The nurse
would question the results of the baby in which of the following situations?
Who has breast-fed for the 24 hours before the test.
Tested immediately after birth.
Whose test is performed at 48 hours of age

Fed glucose water followed by formula for 30 hours
In many parts of the world mass screening for congenital hypothyroidism is done routinely. Here in
the Philippines it is included in the Newborn Screening Act of 2004. The nurse would include in the
health teaching to a client the following important statements for this disorder, EXCEPT:
Serum thyroxine (T4) level is low
Clinical features of cretinism are usually apparent during the first weeks of life
T3 resin uptake is low
Tyroxine binding globulin (TBG) level is usually normal
Thyoid stimulating hormone levels (TSH) may be high, normal, or low
The nurse was working with a group of parents of children with phenylketonuria. The nurse has
completed family teaching on the dietary restrictions. The parents are given sample menus to choose
a meal for their child. Which menu choice indicates understanding of the dietary instructions?
Steak and mashed potatoes with orange juice.
A large bowl of cereal with strawberries and apple juice.
Milkshakes and grilled cheese sandwich.

A hamburger and diet soda sweetened with aspartame.
In the management of clients with various health problems, the nurse should be equipped with the
knowledge of basic nursing procedures. The following are TRUE of the Newborn Hearing Screening
EXCEPT:
Performed after 24 hours of life but not late than 6 months
All infants whether high risk or non-high risk
By age 2 months hearing loss is diagnosed
By age 6 months hearing intervention must start
By age 1 month the baby must have been screened
Nursing is a dynamic profession. As a responsible member of the health team, the nurse should be
abreast with the current trends in the advancement of the profession. When is newborn screening
performed in a breastfed neonate?
1 hour after birth

6 hours after birth
The local church in Barangay Chubibo is in the midst of extreme poverty. Most of the people are
very poor. Less than 10% of the population have regular jobs, mostly as janitors, laborers, domestic
helpers, sales clerk and the like. There is a nurse in the barangay health station. Most of the cases
seen by the nurse are referred to the main health center, one jeepney ride away. Which of the
following statements is FALSE about CH?
The baby may appear normal at birth.
There is presence of ambiguous genitalia.
Hypotonia or poor muscle tone is present.
There is developmental delay, including mental retardation.
A 1-hour-old newborn is transferred to the nursery because he is cyanotic. His vital signs are as
Put the baby under an oxygen hood of 30% oxygen
Prepare the baby for chest tube insertion

Give the baby flow by oxygen
Call the doctor
You have been asked to assign an APGAR score to the following infant at five minutes of life. The
and only minimally grimaces. What is his APGAR score?
Soon after delivery, BALLARD scoring should be performed to the newborn within 24 hours.
Assessing the neuromuscular maturity includes: (select all that apply)
Scarf sign
Posture
Heel to ear
Eye and ear
The nurse performs a gestational age assessment on a newborn admitted to the nursery and notes
the following findings: lanugo hair covers the entire body, soles are smooth and without creases, the
pinna is soft and stays folded, and testes are palpable in the inguinal canal. The nurse should
assess that this newborn is approximately:
33 to 35 weeks
39 to 41 weeks
30 to 32 weeks
36 to 38 weeks
The newly elected mayor of a fifth class municipality is an engineer who never had any exposure to
the local health delivery system. PHN Lucia, as the head of the rural health unit will prepare a health
report. Which of the following sections of the Newborn Screening act of 2004 provides for the
establishment and accreditation of Newborn Screening Center?
Section 15
Section 14
Section 12
Section 13
Social history-parent interaction is necessary to include in history taking. A mother who smoke
heavily or use narcotics could tend to have a baby that is:
Very large for gestational age

Small for gestational age
Large for gestational age
Accurate for gestational age
following is not considered symptom of a profound hearing loss?
Does not respond to your voice
Does not not response to loud noise
Does not make simple sounds
Does possibly have beginning speech challenge
The nurse in a newborn nursery is monitoring a preterm newborn for respiratory distress
syndrome. Which assessment findings should alert the nurse to the possibility of this
syndrome? Select all that apply.
Xiphoid retractions
Hypotension
Audible grunts
Nasal flaring
Presence of a barrel chest
The nurse is conducting health teaching to a group of postpartum mothers. Regarding

congenital adrenal hyperplasia caused by a deficiency of 21-hydroxylase, which of the following
statements needs further teaching?
Male infants may have ambiguous genitalia
Infants may present with hyponatremia and hyperkalemia
Female infants may have virilization
It is an autosomal recessive disorder.

Skin hyperpigmentation may be present
A 4-month old infant has been diagnosed with PKU. The child k=has eczema and sensitivity to
the sunlight. The mother asks the nurse why her child’s skin is so sensitive. An appropriate
explanation by the nurse would be:
“The phenylketones in your baby’s blood concentrate the sun’s rays, making burning more
likely. Children with PKU can never be in the sun.”
“Your child has a deficiency in melanin because of decreased tyrosine. You will always have to
take special care of his skin.”
“Some children just have sensitive skin.”
“Your child will outgrow his sensitivity when he is 5 years old. Just use sunscreen for now.”
A teenage mother arrives at the clinic with her new baby who has recently been diagnosed with
congenital hypothyroidism. When instructing the mother about administering levothyroxine
medication, the nurse would include the information that she should:
Understand that the medication will not be needed after age 5.
Crush the medication and place in a full bottle of formula or juice to disguise the taste.
Administer the medication every third day.
Give the crushed medication in a syringe or in the nipple mixed with a small amount of formula.
A new mother of an infant diagnosed with phenylketonuria (PKU) meets with the nurse who
informs her that PKU follows autosomal recessive inheritance. The mother states that is a relief
since she now knows her next baby will not have the disease. What additional information does
the mother need?
With autosomal recessive inheritance, each baby has a 25% chance of having the disease.
The mother passes the gene only to male offspring.
Since she already has one baby with the disease, the next one will probably be a carrier for the
disease.
Only female babies will have PKU

What equipment and supplies are needed for initiation of IV therapy
Tourniquet, IV tubing, forcep
None on the above options
Alcohol swabs, tourniquet, syringe
IV solution, IV tubing, clean gloves
When administering IV therapy, nursing interventions that help avoid or minimize lawsuits include:
Documenting care in a legible, objective and complete manner
Observing for signs and symptoms of complications and taking prompt action
All of the above mention
Maintaining a caring and therapeutic relationship
Nurse Nick will infuse 250 ml of D5W for over 2 hours and 45 mins. The drop factor is 60 drops per mL.
Nurse Nick should regulate the IV for how many drops per minute?
80 gtts/min
91 gtss/min
75 gtts/min
95 gtts/min
The next IV order for the patient reads "1000 mL DsW with 20 mEq of KCl to run over 8 hours." The drop
factor is 15 gtt/ mL. The correct flow rate per minute is ___ gtt/min.
27
31
25
32.
The nurse must assess for complications of IV therapy. Signs of common complications include: (Select all
that apply)
Swelling and coolness at the site.
Redness along the vein.
Pale skin at the insertion site.
Immobility of the extremity.
Erythema and tenderness
3,4,5
2,3,4
1,2,3,4
1,2,3,5
What information is needed to be documented on the actual IV site. Select all that apply;
a. Time
b. Date
c. Patient initial
d. Gauge of IV needle
b, c, a
c, d
a,b, d
d, a, c
If a patient has an IV inserted, do fluids always run through it?
No answer text provided.
Yes
No
Where would one find the antecubital fossa?
Forearm
Hand
Wrist
Anterior elbow
What are the general reasons for having an IV?
Both
To maintain optimal health when a patient is unable to tolerate oral intake
a. To deliver fluids and medicines directly into the vein
When administering IV therapy, nursing interventions that help avoid or minimize lawsuits include:
Documenting care in a legible, objective and complete manner
All of the above mention
Observing for signs and symptoms of complications and taking prompt action
Maintaining a caring and therapeutic relationship.
A client has an order to receive 1000 mL of dextrose in 0.45% NaCl. After gathering the appropriate
equipment, the nurse takes which action first before spiking the IV bag with the tubing?
Uncaps the distal end of the tubing
Uncaps the spike portion of the tubing
Opens the roller clamp on the IV tubing
Closes the roller clamp on the IV tubing
A nurse is doing a routine assessment of a client's peripheral IV site. The nurse notes that the site is cool,
pale, and swollen and that the IV has stopped running. The nurse determines that which of the following has
probably occurred?
Phlebitis
Infiltration
Infection
Thrombosis
Doctor’s order says: Infuse 650 mL of D5W over 6 hours. Drop factor: 10 gtts/mL. Calculate the flow rate in
drops per minutes. Show the computation. Final answer to the nearest whole number.
650 mL x 10 gtts/mL ÷ 6 hrs x 60 min = 18.08 = 18 gtts/min
Doctor’s order says: Infuse 50 mL of Zofran over 15 minutes. Drop factor: 15 gtts/mL. Calculate the flow rate
in drops per minutes. Show the computation. Final answer to the nearest whole number.
50 mL x 15 gtts/mL ÷ 15 min = 50gtts/min
performing a venipuncture to initiate continuous IV therapy, a nurse should
Inspect the IV solution and exp date
A patient’s IV is about to change. The nurse is preparing for changing the IV fluid. Choose the
correct order in which of the following should be done
12354
The nurse assesses a peripheral IV dressing and notes that it is damp and the tape is loose. The
best nursing action is to:
Ensure tight IV tubing connections

A new IV site is required every few days to prevent infection and other major complications
True
False
Intravenous related lawsuits against a nurse are most likely to occur because of failure in:
Addition of certain medications to solutions
Selecting and preparing the correct equipment
Properly maintaining the IV solution
The prevention and early detection in IV associated problems
When a health care professional is inserting a peripheral IV, where is the best
Forearm
Hand
Antecubital fossa
Upper arm
A nurse caring for a client receiving IV therapy monitors for which signs of infiltration at the catheter site of
an IV infusion? select all that apply:
slowing of the IV rate

tenderness at the insertion site
edema around the insertion site
skin tightness at the insertion site
warmth of skin at the insertion site
fluid leaking from the insertion site
1,2,3,4
2,3,4,5,6
1,3,4,5,6
1,2,3,4,6
A nurse is checking the insertion site of a peripheral IV catheter. The nurse notes the site to be reddened,
warm, painful, and slightly edematous in the area of the vein proximal to the IV catheter. The nurse
interprets that this is likely the result of:
An allergic reaction to the IV catheter material
Phlebitis of the vein
Hypersensitivity to the IV solution
Infiltration of the IV line
Doctor’s order says: Infuse 300 mL of Penicillin 5M units to infuse over 40 minutes. Drop factor: 20 gtts/mL.
Calculate the flow rate in drops per minutes. Show the computation. Final answer to the nearest whole
number.
300 mL x 20 gtts/mL ÷ 40 min = 150 gtts/min

Doctor’s order says: Infuse 2500 mL of D5 ½ Normal Saline over 48 hours. Calculate the hourly rate. Show
the computation. Final answer to the nearest whole number.
2500 mL ÷ 48 hrs = 52.08 = 52 gtts/hr
LV, a 5-month-old baby is admitted to Room ##204 with chief complaint of severe nausea and
vomiting occurring 7 - 8 times a day with associated symptoms: sunken eyes, very poor skin turgor,
unable to breastfeed, weight is 15 lbs. Doctor’s order says: Infuse D5LR to run at 175 cc/hr for 6
hours. At about 6 hours, the nurse noticed that the arm was swollen, with cool skin and blanching.
The nurse saw the IV stopped infusing. What could be the possible condition? What is the nurse’s
immediate interventions?
extravasion

A practitioner orders chest physiotherapy with percussion and vibration for a newly admitted patient. Which
information obtained by the nurse during the health history should alert the nurse to question the
practitioners order?
Cystic fibrosis.
Chronic bronchitis
Osteoporosis.
Emphysema.
Nurse Christian is caring for a client who is having difficulty breathing. The client is lying in bed and is already
receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurses priority?
Increase the oxygen flow.
Promote removal of pulmonary secretions.
Attain a specimen for arterial blood gases.
Assist the client to Fowlers position.
The nurse is preparing care for a client receiving oxygen therapy. Which of the following normal conditions
would a nurse expect to find when performing a physical assessment of a patient’s respiratory system,
EXCEPT?
When assessing tactile fremitus by placing a palm to the patient’s chest wall, the vibrations from the
patient’s repeated word should be equal bilaterally in different areas on the chest wall.
The chest contour is slightly convex with no sternal depression.
The contour of the intercostal spaces should be rounded, and the movement of the chest should be
symmetric.
The anteroposterior diameter of the chest should be less than the transverse diameter.
The nurse is preparing to care for a client receiving oxygen therapy. Which of the following is inappropriate
nursing action when performing oropharyngeal suctioning?
Apply suction during withdrawal of the suction catheter tip:
Measure length of catheter from the tip of the nose to tip earlobe to the xiphoid process
Lubricate suction catheter tip with alcohol
Place the client in semi – Fowler’s or lateral position.
The nurse is preparing care for a client receiving oxygen therapy. While suctioning a client in ICU, the nurse
notices that the activity brings about deep breathing and coughing maneuvers by the client. This is
considered a good action because:
Deep breathing is impossible to perform when one has a respiratory disease, and coughing is a reflex action.
Deep breathing has no effect on the lungs or the ability of the client to cough.
Deep breathing is impossible to perform when one has a respiratory disease, and coughing is a reflex action.
Deep breathing oxygenates the lungs, and coughing loosens and moves secretions in the lungs.
Nurse Jolibette is teaching a client with oxygenation problem how to perform pursed-lip breathing. The
client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse
provide?
It prolongs the inspiratory phase of respiration
It decreases use of accessory breathing muscles
It increases inspiratory muscle strength
It helps prevent early airway collapse

Nurse Maribeth is preparing to perform suctioning for a client. The following are appropriate guidelines for
the nurse to follow EXCEPT?
Use a new catheter for each suctioning attempt.
Limit suctioning to 2 to 3 attempts.
Apply suction while withdrawing the catheter.
Perform suctioning on a routine basis every 2 to 3 hours.
The nurse is to teach a client with Chronic Obstructed Pulmonary Disease safety precautions for using
oxygen at home. The nurse knows that the client understands the safety principles discussed when he says
the following:
"Smoking is permitted when oxygen is in use."
"Fire extinguishers do not need to be stored."
"Avoid materials that generate static electricity."
"Acetone, oil, and alcohol are appropriate substances to use with clients who are using oxygen."
The nurse is preparing to care for a client receiving oxygen therapy. Which of the following is not to be
included in the nursing interventions for a client receiving oxygen therapy?
Place sterile water into the oxygen humidifier
Place the client in semi – Fowler’s position
Place a “No smoking” sign at the bedside
Lubricate nares with oil to prevent dryness of the mucous membrane.
Nurse Stephanie is assessing a client who has an acute respiratory infection that puts her at risk for
hypoxemia. The following findings are early indications that should alert the nurse that the client is
developing hypoxemia, EXCEPT:
Restlessness.
Bradycardia.
Pallor.
Tachypnea.
The nurse is preparing to care for a client receiving oxygen therapy. A mouthpiece should be used instead of
a face mask when giving a nebulizer. During health teaching, the nurse would correctly explain that:
It provides a higher level of drug deposition.
This is the only method that all drugs can be given by.
Patients breathe through their mouths.
It often feels more comfortable for the patient.
A long term COPD client is receiving oxygen at 1 L/min. Her visiting cousin decides she ‘doesn’t look too
good” and increases her oxygen to 7 L/minute, what should the nurse’s initial action be?
Elevate the client’s head and take vital signs
Notify the physician
Immediately decrease the oxygen
Thank the client’s cousin and continue to observe the client
Nurse Clarence is taking care a client with oxygenation disorder. A client has been placed on 6 L of
humidified oxygen via nasal cannula. Which action by the nurse is most appropriate?
Keep the water sterile by draining it from the water trap back into the humidifier.
Remove condensation in the tubing by disconnecting and emptying it appropriately.
Turn down the humidity when condensation begins to collect in the tubing.
Drain condensation back into the humidifier, maintaining a closed system.
The nurse is preparing to care for a client receiving oxygen therapy. An adult is receiving oxygen by nasal
prongs. Which statement by the client indicates that client teaching regarding oxygen therapy has been
effective?
“I was feeling fine so I removed my nasal prongs.”
“My family was angry when I told them they could not smoke in my room.”
“I’ve increased my fluids to six glasses of water daily.”
“Don’t forget to come back quickly when you get me out of bed; I don’t like to be without my oxygen for too
long.”
The nurse is preparing care for a client receiving oxygen therapy. The nurse is choosing a catheter to use to
suction the patient's endotracheal tube via an open system. On which variable would the nurse base the size
of the catheter to use?
The type of secretions to be suctioned
The height and weight of the patient
The age of the patient
The size of the endotracheal tube
Type of normal breath sounds produced by gas movement through the distal most portions of lung units.
Vesicular sounds
Bronchial sounds
Tracheal sounds
Bronchovesicular sounds
Purposes of suctioning is to maintain patent airway on clients whose swallowing reflex is limited in case/s of
the following:
All of the choices
Unconscious client
Critically ill patients
Client recovering from anesthesia
A type of oxygen face mask wherein the client breathes only the source gas from the bag.
Venturi mask
Simple face mask
Partial rebreather mask
Non- rebreather mask
A deep gasping respirations, representing hyperventilation, “blowing off” of excess carbon dioxide and
compensation for an abnormal accumulation of metabolic acids in the blood.
Kussmauls
Cheyne-stokes
Biot's
Agonal
Abnormal respiratory patterns characterized by increasing rate and tidal volume, which increases to a
maximum, then gradually decreases.
Agonal
Kussmaul's
Biot's
Cheyne-stokes
The aspiration of secretions often through a rubber or polyethylene catheter connected to a suction
machine or wall outlet.
Venturi mask
Oxygen hood
Suctioning
Oxygen administration
A nurse is caring for a 16-year-old male patient who has been hospitalized for an acute asthma exacerbation.
Which of the following testing methods will the nurse not use to measure the patient's oxygen saturation?
Maximal respiratory pressure
Pulse oximetry
Spirometry
Peak expiratory flow rate
A nurse assesses the breath sounds of a client diagnosed with pneumonia. The nurse documents the
assessment data as rhonchi located in the left lung. The nurse bases the assessment on which of the
following the characteristics of rhonchi?
Musical or hissing noise heard on inspiration
A rattling or gurgling noise heard on expiration
A grating noise heard on expiration

Creaking noise heard on inspiration
The nurse is preparing care for a client receiving oxygen therapy. Mr. Marcelo has oxygenation disorder. His
nurse has taught him pursed-lip breathing, which helps him in which of the following ways?
Decreases the amount of air trapping and resistance
Helps liquefy his secretions
Teaches him to prolong inspiration and shorten expiration
Increases carbon dioxide, which stimulates breathing
The nurse is preparing to care for a client receiving oxygen therapy. Which is the nurse's priority
intervention for a confused client who is to start oxygen therapy?
Instruct the client about the importance of leaving the oxygen delivery device on.
Determine which method of oxygen delivery the client will best tolerate.
Explain to the client that he will not be allowed to smoke while receiving oxygen.
Monitor the client's ability to tolerate removal of oxygen while eating.
The most common device used to administer oxygen therapy.
Oxygen hood
Face mask
Oxygen tent
Nasal cannula
Irregular pattern and volume, with intermittent periods of apnea.
Cheyne-stokes
Kussmauls
Biot's
Agonal
NUR 1210 SKILLS LAB (WED) MODULE #4

FORMATIVE ASSESSMENT (Post Test)
The nurse is inserting an indwelling catheter into a female client. Which interventions
should be implemented? Rank in the order of performance.
1. Explain the procedure to the client.
2. Set up the sterile field.
3. Inflate the catheter bulb.

4. Place absorbent pads under the client.
5. Clean the perineum from clean to dirty with
Betadine.
1, 3, 4, 2, 5
1, 2, 3, 4, 5
1, 2, 4, 3, 5
1 , 4, 2, 3, 5 1, 5, 2,
3, 4
1/4/2/5/3 = correct
A client who has an indwelling catheter reports the need to urinate. Which of the following
interventions should the nurse perform?
Reassure the client that it is not possible for her to urinate

Check to see whether the catheter is patent
Collect a urine specimen for analysis

Re-catheterize the bladder with a larger gauge catheter
The catheter slips into the vagina during a straight catheterization of a female client. The
nurse does which action?
Leaves the catheter in place and gets a new sterile catheter.

Leaves the catheter in place and gets a new sterile catheter.
Removes the catheter, wipes it with a sterile gauze, and redirects it to the urinary
meatus.
Leaves the catheter in place and asks another nurse to attempt the procedure.
Removes the catheter and redirects it to the urinary meatus.
When inserting an indwelling urinary catheter in a male patient, the nurse cleanses the
penis with an antiseptic wash. Which step should she take next?
Gently insert the tip of the prefilled syringe into the urethra to instill the lubricant.
Insert the catheter about 7 to 9 inches (17 to 22.5 cm) or until urine flows.
Slowly insert the end of the catheter into the urinary meatus. Ask the
patient to bear down as though trying to void.
Which statement indicates a need for further teaching of the home care client with a long-
term indwelling catheter?
"Soaking in a warm tub bath may ease the irritation associated with the catheter."
"I should use clean technique when emptying the collecting bag."
"Intake of cranberry juice may help decrease the risk of infection."
"I will keep the collecting bag below the level of the bladder at all times."
What is an urgent reason for catheterizing a patient?
Acute urinary retention.

Because they asked.
Incontinence. Urinary tract
infection.
Requires a closed drainage system and inflation of a balloon to keep the catheter in place.

Indwelling catheterization
Catheters
Intermittent catheterization
Condom catheterization
Which catheter is used for one time use and removed immediately after the insertion and
drainage of urine?
Indwelling catheter
Condom catheter
Straight catheter
Triple lumen catheter
Maintaining a Foley catheter drainage bag in the dependent position prevents:
Urinary incontinence
Urinary retention
Reflex incontinence Urinary
reflux
A type of catheterization that is made of rubber or polyvinyl chloride (PVC), making them
softer and more flexible than indwelling catheters; single-lumen catheter.
Intermittent
Condom
Indwelling All of the
choices
Lubricate 2 to 3 inches (5 to 7 cm) of the catheter tip using sterile lubricant included in
tray, or add lubricant using sterile technique. The purpose of this is?

To reduce the transmission of microorganisms.
To facilitate cleaning of perineal area and ease in doing the procedure.
To prevents the catheter from sliding out
To minimizes urethral trauma, discomfort, pain and urethral spasm during proced
ure
A nurse is preparing to insert an indwelling urinary catheter for a female patient.

When beginning the insertion procedure, the nurse should instruct the patient to:
Take a deep breath

Bear down
Hold her breath
Sip water
Which of the following facts about the lower urinary tract system should be kept in mind
when considering catheterization?

Pathogens introduced into the bladder remain in the bladder.
A normal bladder is as susceptible to infection as an injured one.
The bladder normally is a sterile cavity.
The external opening to the urethra should always be sterilized.
A type of catheters that are used for continuous bladder irrigation and for instilling
medications into the bladder; the additional lumen delivers the irrigation fluid into the
bladder.
Straight lumen catheter

Double lumen catheter
Triple lumen catheter Single
lumen catheter
The nurse is preparing a female patient for catheterization. Which of the following are
appropriate steps in this procedure? (Select all that apply.)
Explain to the patient that the procedure is painless and should cause no discomfort.
Place the patient on a soft surface, preferably a soft mattress or pillow.
Clean the genital and perineal area with antiseptic solution.
Place a fenestrated sterile drape over the perineal area, exposing the labia.
Place the patient in the dorsal recumbent position.
The nurse is preparing a female patient for catheterization. When collecting a urine
specimen for urinalysis, the nurse should be aware of which of the following facts? (Select
all that apply.)

A sterile urine specimen is required for a routine urinalysis.
Strict aseptic technique must be used when collecting and handling urine specimens.
A clean-catch specimen of urine may be collected in midstream.
If a woman is menstruating, a urine specimen cannot be obtained for urinalysis.
Sterile urine specimens may be obtained by catheterizing the patient’s bladder.
The nurse is preparing a female patient for catheterization. Which of the following actions
are appropriate when conducting a physical assessment of a patient’s urinary function?
(Select all that apply.)

To examine the meatus, the female patient should be placed in a dorsal recumbent
position.
The nurse checks for costovertebral tenderness by placing one palm flat over the
costovertebral angle and striking the back of the hand with the other fist.
When percussing the bladder, a dull sound indicates an empty bladder.
The nurse may use a bedside scanner to assess the bladder.
The nurse is preparing a female patient for catheterization. Which of the following
statements accurately describe the function and composition of the urinary bladder? (Select
all that apply.)
The urinary bladder serves as a reservoir for urine.
The urinary bladder is composed of two layers of muscle tissue, the inner and outer
longitudinal layer.
The urinary bladder muscle is innervated by the autonomic nervous system.
The autonomic nervous system carries inhibitory impulses to the bladder and motor
impulses to the internal sphincter.
Motor impulses to the bladder and inhibitory impulses to the internal sphincter cause the
detrusor muscle to contract and the sphincter to relax.
The nurse is preparing a female patient for catheterization. Which of the following actions
would a nurse perform when measuring a patient’s urinary output? (Select all that apply.)
The nurse pours the urine from the collection device into the appropriate measuring
device.
The nurse places the calibrated container on a flat surface for an accurate reading and
reads the amount by looking down into the specimen.
The nurse asks the patient to void into a bedpan, urinal, or specimen hat, either in bed or
in the bathroom.
The nurse records the total amount voided during each shift and the 24-hour period on the
patient’s permanent record.
A practitioner uses a urine specimen for culture and sensitivity via a straight catheter for a
patient. What should the nurse do when collecting this urine specimen?

Inflate the balloon with 10 mL of sterile water.
Have the patient void before collecting the specimen.
Use a sterile specimen container.
Collect urine from the catheter port.
Which action represents the appropriate nursing management of a client wearing a

condom catheter?

Ensure that the tip of the penis fits snugly against the end of the condom.
Tape the collecting tubing to the lower abdomen.
Change the condom every 8 hours.
Check the penis for adequate circulation 30 minutes after applying
The health care provider has ordered an indwelling catheter inserted in a hospitalized
male patient. What consideration would the nurse keep in mind when performing this
procedure?

In the hospital, a clean technique is used for catheter insertion.
Since it uses a closed system, the risk for UTI is absent.
The male urethra is more vulnerable to injury during insertion.
The catheter is inserted 2 to 3 in into the meatus.
The usual length of time between catheter changes varies and can be anywhere from?
1-7 days
5 days to 2 weeks
7 days to 3 weeks 2
weeks to 1 month
The nurse knows that indwelling catheters are placed before a cesarean section because:

The patient will not interrupt the procedure by asking to go to the bathroom.
The patient may void uncontrollably during the procedure.
Spinal anesthetics can temporarily disable urethral sphincters.
A full bladder can cause the mother's heart rate to drop.
How much sterile water should you inflate the foley balloon?

4-5 ml
2-8 ml
4-7 ml
6-10 ml
In the procedure for inserting an indwelling catheter, after urine appears in the tubing,
the catheter is advanced an additional two inches in order to:

Promote bladder tone
Increase the amount of urine drained
Stimulate normal bladder contraction
Minimize the risk of balloon inflation in urethra
On inserting urinary catheter, you gently introduce well lubricated catheter into urethral
meatus using strict aseptic technique until urine flows. How long is the length of your
insertion?

5 –7 cm
1-5 cm
6-10 cm
3-8 cm
Which of the following actions should a nurse take when removing a patient indwelling
urinary catheter?
Deflate the balloon completely
Make sure the patient has voided within 12-hour post removal
Tell the patient to expect to feel a tugging sensation on removal
Pull the catheter out as quickly as possible
Perineal care must be performed prior to urinary catheterization. Initial step is to place the
client in the appropriate position and drape all areas except the perineum. What should be
the ideal position of the client?
Side lying position, with 1 knee flexed

Supine position, with knees flexed, feet about 2 feet apart and hips slightly externally
rotated
Lithotomy position, with 2 legs on the padded stirrups
Supine position, with knees flexed, legs apart
The goal of nursing care of the client with an indwelling catheter and continuous drainage
is largely directed at preventing infection of the urinary tract and encouraging urinary flow
through the drainage system. Which of the following interventions encouraged by nurses
working with these clients would not be appropriate in meeting this goal?
Having the client drink up to 2000 mL per day
Routine hygienic care
Changing indwelling catheters every 72 hours.
Encouraging the client to eat foods that increase the acid in the urine
Care for an indwelling urinary catheter should include which of the following interventions?
Insert the catheter using clean technique.
Keep the drainage bag on the bed with the client.
Remove obvious encrustations from the external catheter surface by washing it gently with
soap and water.
Lay the drainage bag on the floor to allow for maximum drainage through gravity.
Which of the following would not be done before catheterizing?

Ring patient's next of kin.
Expiry dates to be checked.
Gain patient consent.
Patient to be washed.
What is the difference between a male and a female catheter?

Male and female catheters are different colours.
Female catheters are longer than
Male catheters are bigger than female catheters.
Male catheters are longer than female catheters.
A female client has a urinary tract infection. Which teaching points by the nurse should be
helpful to the client? Select all that apply.
Wipe the perineal area from back to front.
Wear cotton underclothes
Limit the fluid to avoid the burning sensation on urination
Take baths rather than shower
When a condom catheter is applied, the catheter should be secured on the penile shaft in
such manner that the catheter is:
Secured with adhesive tape applied in a circular pattern

Dependent and draining well
Snug and secure but without causing constriction that impedes blood flow.
Tight and draining well
Which action represents the appropriate nursing management of a client wearing a

condom catheter?
Tape the collecting tubing to the lower abdomen.
Ensure that the tip of the penis fits snugly against the end of the condom.
Check the penis for adequate circulation 30 minutes after applying.
Change the condom every 8 hours.
Check the penis for adequate circulation 30 minutes after applying
How are you going to secure the catheter tubing?

None of the choices are correct
Secure the tubing to the bed linens and the bag below the level of the bladder. No tubing
should fall below the top of the bag
Secure the catheter tubing to the inner right for the client on the up thigh, with enough
slack to allow usual movement.
Both choices are correct
Catheterization is performed for all the following reasons except:

To relieve urinary retention

To relieve urinary incontinence when no other means is practical
Patients requiring accurate output monitoring
For relief of urinary suppression with overflow
The nurse prepares for insertion of an indwelling urinary catheter for a male client. The
nurse is right-handed. Where should the nurse stand to perform the procedure?
At the clients left lower leg
At the end of the client’s bed
On the client’s left side
On the client’s right side
Refers to the insertion of a catheter tube through the urethra and into the bladder to drain
urine.
Condom catheterization
Indwelling catheterization
Intermittent catheterization
Urinary catheterization
1. A 50 year old G4P4 presents for her well-woman examination. She had one cesarean delivery followed by
three vaginal deliveries. Her menses stopped 1 year ago and she occasionally still has a hot flash. She tells
the nurse that about 10 years ago she was treated with a laser conization for carcinoma in situ of her cervix.
Since that time, all of her Pap Test have been normal. What recommendation should the nurse made
regarding how frequently she should undergo Pap Smear testing?
Every year
Every 3 months
Every 6 months
Every 2 years
Every 3 years
2. Melanie verblized “I am afraid to undergo pelvic exam. What if the doctor find out something?” Which of
the following is the best response of the nurse?
“I understand your concerm. What makes you feel anxious about the pelvic exam?”
“Dont worry the doctor will be gentle.”
“You will not feel any pain during the exam. Just relax.”
“Pray while the doctor is performing the pelvic exam to free your mind of the procedure.”
3. While the doctor is performing a speculum exam. Suddenly the patient shouted “Don’t. Stop.” The vital
signs suddenly went up. The doctor is unable to remove the speculum. Which of the following interventions
would be appropriate at this time?
Talk to the patient. Ask the patient to breath through the mouth.
Administer general anesthesia.
Administer Valium at once.
Immediately remove the speculum.

4. A nurse is performing a vaginal examination to a client for Pap smear examination. The best way to
reposition a speculum for a client with a cervix with posterior orientation is:
To insert the speculum more deeply and posteriorly through compression of the perineal tissue. The blade
tips will slip under the cervix into the posterior fornix.
To reinsert less deeply and anteriorly, with the base of the lower blade actually compressing the anterior
wall of the vagina.
By choosing a plastic speculum of a larger size and reinserting as you did prior.
All of the choices
5. During a Pap test visit, when does the health care provider seek to obtain informed verbal consent from
the client?
After you have explained the external exam, speculum exam and the Pap test procedure and before you
begin.
At the start of the consultation
After completing the external exam, speculum exam and the Pap test.
At the end of the consultation

6. You are a preparing to perform the genital exam on a patient. Assume you have already gathered your
supplies, explained the process and donned gloves. The nurse understands that the primary step in the
order of performance of the procedure is which of the following?
Position the patient on the gynecological table and drape the patient.
Remove the speculum.
Photograph the external genitalia and collect specimens from external genitalia
Insert speculum using proper technique and continually assess patient’s tolerance.
Position yourself in front of the patient’s perineum and inspect the external genitalia
7. A Bethesda system Pap smear that reads “Within normal limits” is most compatible with which of the
following?
Inflammation
Mild dysplasia
Moderate dysplasia
Severe dysplasia
8. A Bethesda system Pap smear report that reads “Low-grade squamous intraepithelial lesison” is most
consistent with
Mild dysplasia
Inflammation
Moderate dysplasia
Severe dysplasia
9. A Class III Pap smear would be considered
Mild dysplasia
Normal
Inflammation
Moderate dysplasia
10. A Class IV Pap smear suggests

Carcinoma in situ
Squamous cell cancer
Moderate dysplasia
Inflammation
11. It is acceptable to lubricate the speculum with:
Warm water
Lubricating jelly
Vaseline
Betadine solution
12. An acceptable way to insert the speculum is which of the following EXCEPT:
With the blade tips against the upper (anterior) wall of the vagina
At an oblique angle
With the speculum closed
The speculum is angled 45° downward toward the small of the client’s back
13. The rectovaginal examination should be performed
At the initial patient visit and all annual visits
Only when there are symptoms of pelvic relaxation or fecal incontinence
Only at the initial patient visit, except when symptoms are present
At intervals of 5 years
14. Which of the following is not an ideal client conditions for cervical screening?
During menses
Avoidance of vaginal douching for 24 hours before the test
Avoidance of use of contraceptive creams or jellies for 24 hours before the test
Avoidance of intercourse for 24 hours before the test

Mid-menstrual cycle
15. A Class II Pap smear would be considered
Inflammation
Normal
Mild dysplasia
Moderate dysplasia
16. A smaller and narrower speculum should be used with:
All of the choices
Clients with vaginismus
Nulliparous clients
Circumcised clients
Clients whose vaginal orifices have contracted post-menopausally

17. Pap smears using slide technology should be fixed no more than how many seconds after preparation?
10
30
60
18. A 39 years old women Para 6 has presented with complaint of post coital bleeding for the past three
months. The nurse first investigation should be:
Paps smear
Dilatation and curettage
Cone biopsy
Colposcopy
Laparoscopy
19. Vaginal lubricant is most useful for:

Inserting the speculum
Obtaining cervical cytology
Obtaining cervical cultures
Completing wet preparation
20. A quality assurance (QA) project is done by a group of physicians staffing an outpatient clinic to study
rates of false negative Pap smears. The QA project reveals that one physician has accounted for half of all
the false negative Pap smears collected by the group over the prior year, when compared to follow-up
testing. The physician's collection techniques are analyzed, and of the following procedures practiced, which
is the only one that is appropriate?
Wrote the patient's name on the slides
Air-dried the slides prior to shipping
Advised the patient to have intercourse the day prior to the appointment
Scheduled the patient visit during the menstrual phase of her cycle
Advised the patient to douche the day prior to the appointment

The nurse is performing a vaginal examination to a gynecologic client G4P4. The following abnormal findings
on the cervix should be investigated appropriately or referred to a specialist EXCEPT:
Pink colour area
Friable tissue (soft, eroded)
Red patchy areas
Abnormal bleeding, and inflammation
Granular areas, white patches
High-grade SIL on a Bethesda system Pap smear report is least likely to suggest
Inflammation
Mild dysplasia
Moderate dysplasia
Severe dysplasia
A Class I Pap smear would be considered
Normal
Inflammation
Mild dysplasia
Moderate dysplasia
If a client appears apprehensive before the exam, it is best to:
Ask open-ended questions about their apprehension about the procedure
Force the client for examination
Reassure them and press forward
Tell them that there is nothing to worry about
NUR 1210 PEDIA (2ND) MODULE #1

The nurse in a neonatal intensive care nursery (NICU) receives a telephone call to prepare
for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning
for admission of this newborn, what is the nurse’s highest priority?
Connect the resuscitation bag to the oxygen outlet.
Turn on the apnea and cardiorespiratory monitors.
Set the radiant warmer control temperature at 36.5° C (97.6° F).
Set up the intravenous line with 5% dextrose in water.
The postpartum nurse is providing instructions to the mother of a newborn with

hyperbilirubinemia who is being breast-fed. The nurse should provide which most
appropriate instruction to the mother?
Switch to bottle-feeding the infant for 2 weeks.
Stop breast-feeding and switch to bottle-feeding permanently.
Feed the newborn less frequently.
Continue to breast-feed every 2 to 4 hours.
The nurse is preparing to care for a newborn receiving phototherapy. Which interventions
should be included in the plan of care?
Select all that apply.
Reposition the newborn every 2 hours.
Avoid stimulation.
Expose all of the newborn’s skin.
Cover the newborn’s eyes with eye shields or patches.
Decrease fluid intake.
A newborn delivered at home was admitted to the hospital 24 hours ago after sustaining
blunt chest trauma. The nurse monitors for which earliest clinical manifestation of acute
respiratory distress syndrome (ARDS)?
Cyanosis and pallor
Diffuse crackles and rhonchi on chest auscultation
Haziness or “white-out” appearance of lungs on chest radiograph
Increase in respiratory rate from 18 to 30 breaths per minute
A nurse is assessing a 3-day-old preterm neonate with a diagnosis of respiratory distress

syndrome (RDS). Which assessment finding indicates that the neonate’s respiratory status
is improving?
Presence of a systolic murmur
Urine output of 3 mL/kg/hour
Respiratory rate between 60 and 70 breaths per minute
Edema of the hands and feet
The nurse is preparing to care for a newborn. The post term neonate with meconium-
stained amniotic fluid needs care designed to especially monitor for which of the following?
Integumentary problems
Elimination problems
Gastrointestinal problems
Respiratory problems
The nurse is preparing to care for a newborn. Which nursing action should be included in
the baby's plan of care to prevent retinopathy of prematurity?
Monitor partial pressure of oxygen (Pao2) levels.
Cover his eyes while receiving oxygen.
Keep her body temperature low

Humidify the oxygen.
A one month old infant in respiratory distress is brought to the emergency department. The
nurse should observe the infant for which of the following signs?
Jugular venous distension
Cool clammy moist skin
Clubbing of fingers and toes
Nasal flaring and see-saw chest
Miranda’s baby has ABO incompatibility and has hyperbilirubinemia. She asked what
should she avoid when she feeds her baby:
Immunization.
Artificial milk formula.
Breast feeding.
Exposure of the baby to sunlight
A nurse assesses the vital signs of a 12-month-old infant with respiratory infection. The
respiratory rate is 35 breaths per minute. Based on this finding, which action is most
appropriate?
Notify the physician
Document the findings
Reassess the respiratory rate in 15 minutes
Administer oxygen
Josephine, delivered 3 days ago at 28 weeks gestation, develops a heart murmur. The
physician diagnoses patent ductus arteriosus (PDA) and orders IV fluid administration and
intubation on a mechanical ventilator. Which nursing intervention is not appropriate for
Josephine?
Auscultating breath sounds
Increasing external stimuli
Monitoring arterial blood gas values
Monitoring fluid intake and output
Marissa, delivered 3 days ago at 28 weeks gestation, develops a heart murmur. The
intubation on a mechanical ventilator. In a healthy full term neonate, the ductus arteriosus
closes how soon after delivery?
7 days
4 days
3 days
1 day
The nurse is preparing to care for a newborn. A nurse is performing an assessment on a

post-term infant. Which physical characteristic should the nurse expect to observe?
Peeling of the skin
Vernix that covers the body in a thick layer
Smooth soles without creases
Lanugo covering the entire body
Jonalyn is delivered at 44 weeks’ gestation by cesarean section because of fetal distress.

At delivery, she has a thick, green tinged coating, cyanosis and signs of respiratory
distress. The pediatrician diagnoses meconium aspiration syndrome. If the pediatrician
suspects that Jonalyn has pneumothorax, the nurse should prepare to do all of the
following, EXCEPT:
Assist with chest tube insertion
Encourage Jonalyn to cry
Assist with intubation
Administer oxygen
A newly delivered newborn is assessed thoroughly for danger signs and symptoms. Which
of the following assessment findings would alert the nurse to anticipate the development of
jaundice in a full term newborn?
Presence of cephalhematoma
A negative direct Coomb’s test result
Presence of a caput succedaneum
Newborn blood type O-negative
A 24-hour-old baby is receiving phototherapy because of a high bilirubin level of 14 mg/dL.

The nurse should include which of the following in the care plan?
1. Cover the newborn’s eyes

2. Limit the newborn’s oral intake
3. Apply skin lotion to the exposed skin
4. Assess skin integrity, fluid and electrolyte status of the neonate
1&2
1&4
1, 2, 3 & 4
1, 2, & 4
The nurse observes slight facial jaundice in a 2-day-old full term neonate during a
postpartum home visit. The nurse interprets this finding using which one of the following
assessment guidelines?
The neonate possesses an adequate supply of liver enzymes to conjugate excess bilirubin.
Jaundice is visible on the skin of a neonate at levels from 4 to 6 mg/dL, which is normal in
2-day old neonate.
Facial jaundice is common in the first 24 hours
Bilirubin is produced at a minimal rate in the neonate immediately following delivery.
The nurse is preparing to care for a newborn. A one-day-old newborn infant is in respiratory
distress. The nurse should observe the infant for which of the following signs?
Bradycardia
Sweating, cool, clammy skin
Nasal flaring and chest retractions
Clubbing of fingers and toes
While performing an initial newborn assessment, the nurse notes yellowish vernix. The
nurse promptly calls this to the physician’s attention because this may be a sign of:
Rh or ABO incompatibility
An intrauterine gonorrheal infection
Fetal postmaturity
Maternal diabetes mellitus
The nurse caring for a premature baby use careful hand-washing techniques because they
know premature infants are more susceptible to infection than full-term infants. Which of the
following explains why premature infants are more likely to develop infection?
Premature infants receive few antibodies from the mother because antibodies pass across
the placenta during the last month of pregnancy.
Their liver enzymes are immature
Premature babies may receive steroid drugs, which affects the immune system.
Surfactant is decreased in premature infants.
Nurse hope is in the NICU receives a telephone call and is informed that a newborn infant with
apgar scores of 1 and 4 will be brought to their department. The nurse quickly prepares for the
arrival of the newborn and determines that the priority intervention is to:
• · Prepare for the insertion of an intravenous line with D5W

• · Set up the radiant warmer control temperature at 36.5 C
• · Connect the resuscitation bag to the oxygen
• · Turn on the apnea and cardiorespiratory monitor
Abby a student nurse auscultate the newborns chest to get the PR. She notices that there is a
slight murmur. She knows that this is because the shunts are not fully closed. Which of the
following situations initiate the closure of the ductus arteriosus.
· Decreased pulmonary vascular resistance and increased systemic vascular
resistance
Baby carlos, a 72 hour old newborn infant appears slightly jaundiced and has a biliburin level of
10 mg/dl. A nurse would give the parent which of the following instructions?
• · Expose the babys skin to direct sunlight daily for one hour
• · Feed the baby at least every 3 hours
• · Check the babys temperature every 4 hours
• · Give the baby formula instead of breastfeeding 48 hours
Pedia Q1
1. The nurse observes slight facial jaundice in a 2-day-old full term neonate during a
• Jaundice is visible on the skin of a neonate at levels from 4 to 6 mg/dL, which is normal in
2-day old neonate.
2. Wilfred, delivered 3 days ago at 28 weeks gestation, develops a heart murmur. The physician
diagnoses patent ductus arteriosus (PDA) and orders IV fluid administration and intubation on a
mechanical ventilator. Which nursing intervention is not appropriate for Wilfred?
• Monitoring fluid intake and output

• Increasing external stimuli
• Auscultating breath sounds
• Monitoring arterial blood gas values
3. A 1-hour-old newborn is transferred to the nursery because he is cyanotic. His vital signs ar as
• Call the doctor
• Put the baby under an oxygen hood of 30% oxygen
• Give the baby flow by oxygen
• Prepare the baby for chest tube insertion
4. Hyaline membrane disease or respiratory distress syndrome is most likely to occur in the infant
who is:
• 38 weeks’ gestation and over and who weighs under 2500 g (5 lb 8 oz).
• 37 weeks’ gestation and under and who weighs under 1500 g (3 lbs oz)
• 38 weeks’ gestation and over and who weighs over 2500 g.
• 44 weeks’ gestation or more and who weighs 2500 g.
5. At age 36 hours, the neonate is to receive phototherapy. After explaining phototherapy to the
parents, the nurse determines that the mother needs further instruction from which statement?
• “The baby’s intake and output will be monitored closely during phototherapy”
• “The baby’s vital signs will be monitored every 2 hours during phototherapy”
• “The eye patches need to stay on when I feed the baby out of the lights”
• “The eye patches need to stay on during phototherapy”
6. Wendy Villarosa is a 19-year-old primigravida with few support systems who gives birth at 38
weeks’ gestation. Her newborn girl is only 2.3 kilos and is evaluated as small for gestational age.
Because her newborn is SGA, which of the following interventions would have the highest
priority?
• Birth weight of 3500g

• The infant has a positive Babinski reflex
• 20ml of milky-colored fluid aspirated from stomach
• The APGAR score at birth was 3
7. A client delivered a 32 week, 1250 grams male infant. The infant demonstrates nasal flaring,
intercostal retractions, expiratory grunt, and slight cyanosis. The nurse will place the infant in a
heated isolette because:
Her temperature control mechanism is immature

The infant has a small body surface for her weight
Heat within the isolette facilitates drainage of mucus
Heat increases flow of oxygen to the extremities
8. The nurse is assessing a newborn and observes that the baby has minimal lanugo and vernix, a
wide eyed appearance, and cracked skin. Which of the following questions should arise because
of these assessment findings?
• Has the other received narcotics during her labor?

• Is this the mother’s first baby?
• What was the mother’s estimated date of confinement?
• Has the newborn been breastfed yet?
9. When evaluating an infant’s laboratory results for effectiveness of phototherapy, the NICU nurse
should expect which of the following?
• decreased RH positive antibodies

• red blood cell count: 5 million/cu mm
• serum bilirubin 5 mg/dL
• increased urine specific gravity
10. A 24-hour-old baby is receiving phototherapy because of a high bilirubin level of 14 mg/dL. The
nurse should include which of the following in the care plan?
• 1,2,3,&4
• 1&4
• 1&2
• 1,2,&4
11. Nurse Elisa is observing the parents at the bedside of their small for gestational age (SGA) female
infant, who was born at 27 weeks’ gestation. The infant’s mother states, “She is so tiny and fragile.
I’ll never be able to hold her with all those tubes.” Nurse Elisa interprets the mother’s statement
to indicate which of the following nursing diagnoses?
• Risk for caregiver role strain

• Compromised family coping
• Risk for impaired parenting
• Impaired adjustment
12. Mateo, age 3 months was treated for respiratory distress syndrome at birth. Initially, he required
continuous positive airway pressure (CPAP) followed by 2 weeks of 100% oxygen and mechanical
ventilation. All of the following observations indicate respiratory distress in an infant
EXCEPT:
• Grunting
• Noisy breathing
• Substernal retractions
• Rapid deep breathing
13. The amniotic fluid of a client has a greenish tint. The nurse interprets this to be the result of:
• Vernix
• Meconium
• Lanugo
• Hydramnios
14. The nurse, caring for a child with left-to-right shunt of the heart, should be aware that the major
common symptom of this type congenital disorder is:
• Severe retarded growth

• The presence of an audible heart murmur
• Polycythemia
• Clubbing of finger and toes
15. Mrs. Lim G1P1 expresses anxiety because her 1 day old son, who was very alert at birth, is now
sleeping most of the time and seen to have yellowing of the sclera. All of the following conditions
predispose a neonate to hyperbilirubinemia EXCEPT:
• Bottle feeding
• Enclosed hemorrhage
• Sepsis
• ABO blood incompatibility
16. Student Nurse John is providing bottle-feeding instructions to the mother of a newborn infant.
Student Nurse John provides instructions regarding the amount of formula to be given, knowing
that the stomach capacity for a newborn infant is approximately:
• 30 to 90 mL
• 10 to 20 mL
• 5 to 10mL
• 75 to 100 mL
17. When caring for preterm infants, the precautions that should be taken against retinopathy of
prematurity or retrolental fibroplasia include:
• Using phototherapy to prevent retinopathy

• Keeping oxygen at a reduced concentration and discontinuing it as soon as feasible
• Carefully controlling isolette temperature and humidity
• Maintaining concentration of oxygen at 50-75%
18. The nurse performs a gestational age assessment on a newborn admitted to the nursery and notes
the following findings: lanugo hair covers the entire body, soles are smooth and without creases,
the pinna is soft and stays folded, and testes are palpable in the inguinal canal.
The nurse should assess that this newborn is approximately:
• 39 to 41 weeks
• 33 to 35 weeks
• 36 to 38 weeks
• 30 to 32 weeks
19. Marlon is delivered at 44 weeks gestation by cesarean section because of fetal distress. At delivery,
he has a thick, green tinged coating, cyanosis and signs of respiratory distress. The pediatrician
diagnoses meconium aspiration syndrome. If the pediatrician suspects that Marlon has
pneumothorax, the nurse should prepare to do all of the following, EXCEPT:
• Encourage Marlon to cry

• Administer oxygen
• Assist with chest tube insertion
• Assist with intubation
20. A nurse is preparing to assess the apical heart rate of a newborn infant. The nurse performs the
procedure and notes that the heart rate is normal if which of the following is noted?
• A heart rate of 140 beats per minute
A 1 hour old newborn is transferred to the nursery because he is cyanotic. His vital signs ar as
follows: heart rate 170, RR 66, BP 59/40. HE isn’t exhibiting nasal flaring, grunting, or
retractions. Breath sounds are equal and bilateral. His Oxygen saturation is 85%. The first action
of the nurse is to:
· Call the doctor
Wendy Villarosa is a 10 yr old primagravida with few support systems who gives birth at 38
weeks gestation
· The apgar score at birth is 3
A newborn male has 4 mm. breast nodules, fuzzy scalp hair, and some cartilage in his earlobes,
and some sole creases in addition…
· 37 weeks
A 5 day old infant is diagnosed with neonatal sepsis is receiving a parenteral antibiotics. Which
of the following findings would best indicate an improvement in the babys condition
· Increase in the strength of the sucking reflex
· Six wet diapers in 24 hours
· 18 hours of sleep daily
· Moist mucus membranes
A newly delivered newborn is assessed thoroughly for danger signs and symptoms…
· Presence of cephalhematoma
Wilfred, delivered 3 day ago at 28 weeks gestation
· Increasing external stimuli
After birth the newbonrns circulation converts from fetal to neonatal circulation. The nurse is
assessing the breath sounds of a preterm newborn.
· Expiratory grunting
The nurse observes slight facial jaundice in a 2 day old full term neonate during postpartum
home visit…
· Jaundice is visible on the skin of a neonate at levels from 4-6 mg/dl. Which is normal in 2 day
old neonate
The nurse caring for a child with left to right shunt of the heart, should be aware that the major
· The presence of an audible heart murmur

The nurse performs a gestational age assessment on a newborn admitted to the nursery and
notes the following findings: lanugo hairs…
· 30-32 weeks
Sarah G, has delivered a baby girl at 36 weeks gestation. At 4 hours of age
· Continue routine monitoring
Mateo, age 3 months was treated for respiratory distress syndrome at birth. Initially, he required
continous positive airway pressure (CPAP)
· Rapid deep breathing
A nurse provides a class to new mothers on newborn care. When teaching cord care the nurse tells
the new mothers:
· Apply alcohol to the cord ensuring that all areas around the cord are cleaned two to three times
a day.
Hyaline membrane disease or respiratory distress syndrome is most likely to occur in the infant
who is:
· 37 weeks gestation and under and who weighs 1500g (3 lbs oz)
While performing an initial newborn assessment the nurse notes yellowish vernix, the
nurse promptly calls this to the physicians attention because thois may be a sign of: · Rh or
ABO incompatibility
A 24 hour old baby is receiving phototherapy because of a high biliburin level of 14 mg/sl.
1 cover the newborns eyes
2 limit the newborns oral intake
3 apply skin lotion to the exposed skin
4 assess skin integrity, fluid and electrolyte status of the neonate
· 1 &4
A client delivered a 32 week, 1250 grams male infant, the infant demonstrates nasal flaring,
intercostals retractions, expiratory gruntm and slight cyanosis. The nurse will palce the infant in
a heated isolette because:
· Her temperature control mechanism is immature
· Heat increases flow of oxygen to the extremeties
· Heat within the isolette facilitates drainage of mucus
· The infant has a small body surface for her weight
Beatriz, a 5-day old small for gestational age neonate weighing only 1,500 grams at birth…
· Hematocrit of 72%
You have been asked to assign an apgar score to the following infant at five minutes of life…
· 3
The nurse caring for a premature baby use careful hand washing techniques because they
know premature infants are more susceptible to infection than full term infants. Which of the
following explains why premature infants are more likely to develop infection.
• · Their liver enzymes are immature

• · Premature babies may receive steroid drugs which affects the immune system
• · Surfactant is decreased in premature infants
• · Premature infants receives few antibodies from the mother because pass across..
Which of the following would the nurse identify as characteristic of SGA newborn
· Maternal history of malnutrition or premature placental aging
When teaching parents of a neonate the proper position for the neonates sleep
· Sudden infant death syndrome
A one month old infant in respiratory distress is brought to the emergency department…
· Nasal flaring and see-saw chest
Nurse George is performing an assessment on a post tern infant in neonatal intensive care unit
of JRRMMC hospital. Which physical characteristic should the nurse expect to observe?
• · Vernix that covers the body in a thick layer

• · Peeling of skin
• · Lanugo covering the entire body
• · Smooth soles without creases
The nurse recognizes respiratory distress when the newborn exhibits all of the following except.
· Absence of flaring nasal alae

A one-day-old newborn infant is in respiratory distress. The nurse should observe the infant for
which of the following signs?
· Nasal flaring and chest retractions
A 5-day old infant diagnosed with neonatal sepsis is receiving…
· Increase in the length of the sucking reflex
When caring for a term neonate who has been receiving phototherapy for 8 hours, the nurse
notifies the pediatrician if which of the following is noted?
· Dark urine
· Bronze colored skin
· Low urine gravity
· Absent moro reflex
Which nursing action should be included in the babys plan of care to prevent retinopathy of
prematurity?
· Keep her body temperature low
· Humidity the oxygen
· Monitor parital pressure of oxygen levels
· Cover his eyes while receiving oxygen
the earliest sign in idiopathic respiratory distress syndrome in a young infant
· Sterna and subcostal retractions
David was delivered vaginally at 32 weeks gestation…
• · Identifying his risk for hypoglycemia

• · Minimizing environmental stimulation
• · Observing him closely for signs of increasing respiratory effort
• · Assessing for hypoxia and implementing measures to relieve it
An infant begins to show
· 5,2
Baby simon is a 9 lb 8 oz
· Cracked
After a long and difficult labor
· There are microorganism
1. A nurse provides a class to new mothers on newborn care. When teaching cord care, the nurse
tells the new mothers:
Apply alcohol to the cord, ensuring that all areas around the cord are cleaned two to three times
a day.
A.
B. All that is necessary is to wash the cord with antibacterial soap and allow it to air dry once a
day.
C. Apply alcohol thoroughly to the cord, being careful not to move the cord because it will cause
the newborn infant pain.
D. If antibiotic ointment has been applied to the cord, it is not necessary to do anything else to it.
2. Marissa has just delivered a large for gestational age (LGA) infant by the vaginal route. Marissa
verbalizes concern regarding the infant’s facial bruising. To enhance attachment, the nurse
makes which therapeutic statement?
A. “It is a normal finding in large babies and nothing to be concerned about.”

B. “Because the bruising is painful, it is advisable that you not touch the baby’s face.”
C. “The bruising is temporary, and it is important to interact with your infant.”
D. “The bruising is caused by polycythemia, which usually leads to jaundice.”
3. After birth the newborn’s circulation converts from a fetal to neonatal circulation. The nurse is
assessing the breath sounds of a preterm newborn. Which of the following symptoms would the
nurse expect to observe in a newborn diagnosed with expiratory distress syndrome?
A. Inspiratory grunting
B. Expiratory grunting
C. Expiratory wheezing
D. Inspiratory stridor
4. Marlon is delivered at 44 weeks gestation by cesarean section because of fetal distress. At

delivery, he has a thick, green tinged coating, cyanosis and signs of respiratory distress. The
pediatrician diagnoses meconium aspiration syndrome. If the pediatrician suspects that Marlon
has pneumothorax, the nurse should prepare to do all of the following, EXCEPT:
A. Assist with intubation

B. Assist with chest tube insertion
C. Encourage Marlon to cry
D. Administer oxygen
5. A newborn male has 4 mm. breast nodules, fuzzy scalp hair, and some cartilage in his ear lobes,
and some sole creases in addition to partially descended testis with a small scrotal sac. You
correctly assigned his gestational age as:
A. 27 weeks
B. 37 weeks
C. 41 weeks
D. 33 weeks
6. The nurse caring for a premature baby use careful hand-washing techniques because they
know premature infants are more susceptible to infection than full-term infants. Which of the
following explains why premature infants are more likely to develop infection.
PREMATURE INFANTS RECEIVE FEW ANTIBODIES FROM THE MOTHER BECAUSE ANTIBODIES PASS ACROSS
THE PLACENTA DURING THE LAST MONTH OF PREGNANCY.
7. Baby Simon is a 9 lb 8 oz baby born at 43 weeks’ gestation. He was delivered vaginally 10

hours ago. His APGAR scores were 7 and 8. Simon’s physical characteristics will include which
of the following:
A. cracked, peeling skin and scant vernix caseosa

B. ruddy complexion and flaccid extremities
C. abundant lanugo and thin, transparent skin
D. yellow stained skin and abundant subcutaneous fat
8. Which of the following would the nurse identify as characteristic of a SGA newborn?
A. Stable temperature control.

B. Weight above 10th percentile on standard growth chart.
C. Maternal history of malnutrition or premature placental aging
D. Small anterior fontanel.
9. A client delivered a 32 week, 1250 grams male infant. The infant demonstrates nasal flaring,
intercostal retractions, expiratory grunt, and slight cyanosis. The nurse will place the infant in a
heated isolette because:
A. Her temperature control mechanism is immature

B. Heat within the isolette facilitates drainage of mucus
C. The infant has a small body surface for her weight
D. Heat increases flow of oxygen to the extremities
10. When evaluating an infant’s laboratory results for effectiveness of phototherapy, the NICU
nurse should expect which of the following?
A. increased urine specific gravity
B. serum bilirubin 5 mg/dL
C. red blood cell count: 5 million/cu mm
D. decreased RH positive antibodies
11. A 24-hour-old baby is receiving phototherapy because of a high bilirubin level of 14 mg/dL. The

A. 1&4
B. 1, 2, 3, & 4
C. 1, 2, & 4
D. 1&2
12. Hyaline membrane disease or respiratory distress syndrome is most likely to occur in the infant
who is:
A. 44 weeks’ gestation or more and who weighs 2500 g. B. 38

weeks’ gestation and over and who weighs over 2500 g.
C. 38 weeks’ gestation and over and who weighs under 2500 g (5 lb 8 oz).
D. 37 weeks’ gestation and under and who weighs under 1500 g (3 lbs oz)
14. Beatriz, a 5-day old small for gestational age neonate weighing only 1,500 grams at birth was
born to a 35 year old preeclamptic patient. Beatriz APGAR scores were 1 and 5 immediately
after delivery and her initial vital signs were: heart rate, 156 beats/min, respiratory rate, 62
breaths/min; temperature 36.2C, hematocrit 72% and blood glucose level 130 mg/dl. She was
started on nasogastric tube feedings and exhibits feeding intolerance and has abdominal
distention. Which assessment findings indicates that Beatriz is at risk for necrotizing enterocolitis
(NEC)?
A. Hematocrit of 72%
B. Blood glucose level of 130 mg/dl
C. Heart rate of 156 beats/min, respiratory rate of 62 breaths/min and temperature of 36.2C D.
Nasogastric feeding started on the fourth day after birth
15. You have been asked to assign an APGAR score to the following infant at five minutes of life.
The male infant was born vaginally; his respiratory effort is irregular, pulse is 90, he is floppy and
blue and only minimally grimaces. What is his APGAR score?
A. 5
B. 3
C. 7
D. 1
16. A 5-day old infant diagnosed with neonatal sepsis is receiving parenteral antibiotics. Which of
the following findings would best indicate an improvement in the baby’s condition?
A. 18 hours of sleep daily

B. Moist mucus membranes
C. Increase in the length of the sucking reflex
D. Six wet diapers in 24 hours
17. The nurse recognizes respiratory distress when the newborn exhibits all of the following, except:
A. Respiratory rate over 60 per minute B.

Much activity of the intercostals muscles.
C. Expiratory grunting.
D. Absence of flaring of nasal alae.
18. A newly delivered newborn is assessed thoroughly for danger signs and symptoms. Which of
the following assessment findings would alert the nurse to anticipate the development of
jaundice in a full term newborn?
A. Newborn blood type O-negative

B. Presence of a caput succedaneum
C. A negative direct Coomb’s test result
D. Presence of cephalhematoma
19. After a long and difficult labor, baby boy James was born with a caput succedaneum and
significant molding over the occipital area. Low forceps were used for the birth, resulting in
ecchymotic areas on both cheeks. James’ parents tell the nurse that they are very concerned
that James may have experienced brain damage. During the first 24 hours of life, it is essential
that the nurse monitor a newborn’s breathing pattern for signs of distress and newborn is
consider sepsis.
Which of the following statement referred to as sepsis in newborn?
A. “There are microorganism in my child’s blood.”

B. “ I know that my husband had given my son his disease.”
C. “My baby contracted this disease due to presence of excessive chromosomes in her blood”
D. “Sepsis in my child is related to my diabetes”
20. A nurse assesses the vital signs of a 12-month-old infant with respiratory infection. The
respiratory rate is 35 breaths per minute. Based on this finding, which action is most
appropriate?
A. Document the findings

B. Administer oxygen
C. Reassess the respiratory rate in 15 minutes
D. Notify the physician
When teaching parents of a neonate that proper position for the neonate’s sleep. Nurse Patricia
stresses the importance of placing the neonate on his back to reduce the risk of which of the
following: SUDDENT INFANT DEATH SYNDROME (SIDS)
After birth, the newborn’s circulation converts from fetal to neonatal circulation. The nurse is
assessing the breath sounds of a preterm newborn. Which of the following symptoms would the
nurse expect to observe in a newborn diagnosed with expiratory distress syndrome? EXPIRATORY
GRUNTING
Baby Carlos, a 72-hour old newborn infant, appears slightly jaundice and ha a bilirubin level of 10
mg/dl. A nurse would give the parent which of the following instructions?
“GIVE THE BABY FORMULA INSTEAD OF BREASTFEEDING 48 HOURS.”
“FEED THE BABY AT LEAST EVERY THREE HOURS”
“EXPOSE THE BABY’S SKIN TO DIRECT SUNLIGHT DAILY FOR ONE HOUR”
While performing an initial newborn assessment, the nurse notes yellowish vernix. The nurse
promptly calls this to the physician’s attention because this may be a sign of: RH OR ABO
INCOMPATIBILITY
The post term neonate with meconium-stained amniotic fluid needs care designed to especially
monitor for which of the following? RESPIRATORY PROBLEMS
A newborn male has 4mm breast nodules, fuzzy scalp hair, and some cartilage in his eat lobes, and
assigned his gestational age as: 37 WEEKS
Baby Simon is a 9 lb. 8 oz baby born at 43 weeks’ gestation. He was delivered vaginally 10 hours
ago. His APGAR scores were 7 and 8. Simon’s physical characteristics will include which of the
following: CRACKED, PEELING SKIN, AND SCANT VERNIX CASEOSA
A 5-day old infant diagnosed with neonatal sepsis is receiving parental antibiotics. Which of the
following findings would best indicate an improvement in the baby’s condition? INCREASE IN THE
LENGTH OF THE SUCKING REFLEX
David was just delivered vaginally at 32 weeks gestation. His APGAR score are 7 and 9. On
admission to the neonatal nursery, he has respiratory rate of 72 breaths/minute, moderate
substernal retractions, nasal flaring, and expiratory grunting. Which interventions is the nurse’s
priority when David exhibits signs and symptoms of RDS?
MINIMIZE ENVIRONMENTAL STIMULATION
ASSESSING FOR HYPOXIA AND IMPLEMENTING MEASURES TO RELIEVE IT
IDENTIFYING THE RISK FOR HYPOGLYCEMIA
When caring for a term neonate who has been receiving phototheraphy for 8 hours, the nurse
notifies the pediatrician if which of the following is noted?
ABSENT MORO REFLEX
A one-month old infant in respiratory distress is brought to the emergency department. The nurse
should observe the infant for which of the following signs? NASAL FLARING AND SEE-SAW
CHEST
Hyaline membrane disease or respiratory distress syndrome is mot likely to occur in the infant who
is:
37 WEEKS’ GESTATION AND UNDER AND WHO WEIGHS UNDER 1500 G (3 LBS OZ)
44 WEEKS’ GESTATION OR MORE AND WHO WEIGHS 2500 G
38 WEEK’S GESTATION AND OVER WHO WEIGHS OVER 2500 G
A 24-hour-old baby is receiving phototheraphy because of high bilirubin level of 14 mg/dL. The

4. Assess the skin integrity, fluid and electrolytes status of neonate
1&2
1,2,3, & 4
1&4
1, 2, & 4
Anne, a preterm newborn who weighs 3 lbs and 12 oz (1,800g) at 34 weeks gestation, is admitted
to the neonatal intensive care unit (NICU) after her birth for observation and supportive care. Anne’s
nutritional needs are a critical concern in her care. Oral formula feedings are being considered
through her parent Maria do not loose hope to feed her newborn through breastfeeding. An infant
begins to show signs of respiratory distress. The nursing action listed below are all appropriate
response in this situation.
1. Notify the physician
2. Give oxygen if cyanosis occurs
3. Record – time, symptoms, degree of symptoms, and whether oxygen relived symptoms
4. Apply electrodes from apnea monitor
5. Maintain an open airway
Which answer best ranks the first and second nursing actions
MAINTAIN AN OPEN AIRWAY (5), THE GIVE OXYGEN IS CYANOSIS OCCURS (2)
The nurse performs gestational age assessment on a newborn admitted to the nursery and notes
the following findings: lanugo hair covers the entire body, soles are smooth and without creases, the
pinna is soft and stay folded, and the testes are palpable in the inguinal canal. The nurse should
assess that this newborn is approximately. 30 TO 32 WEEKS
A Nurse assesses the vital signs of 12-month-old infant with respiratory infection. The respiratory
rate is 35 breaths per minute. Based on this finding, which action is most appropriate.
REASSESS THE RESPIRATORY RATE IN 15 MINUTES (wrong answer)
DOCUMENT THE FINDINGS
NOTIFY THE PHYSICIAN

ADMINISTER OXYGEN
At age 36 hours, the neonate is to receive phototheraphy. After explaining phototheraphy to the
parents, the nurse determines that the mother need further instruction from which statement? THE
EYE PATCHES NEEDS TO STAY ON WHEN I FEED THE BABY OUT OF THE LIGHTS
Which of the following is the most important concept associated with high-risk newborns?
IDENTIFY COMPLICATIONS WITH EARLY INTERVENTION IN THE HIGH-RISK NEWBORNS TO
REDUCE MORTALITY AND MORBIDITY
Mrs. Lim G1P1 express anxiety because her 1-day old son, who was very alert at birth, is now
sleeping most of the time and seen to have yellowing of the sclera. All of the following conditions
predispose a neonate to hyperbilirubinemia EXCEPT: BOTTLE FEEDING
Marlon is delivered at 44 weeks gestation by caesarian section because of fetal distress. At

delivery, he has thick, green tinged coating, cyanosis, and signs of respiratory distress. The
pediatrician diagnoses meconium aspiration syndrome. If the pediatrician suspects that Marlon has
pneumothorax, the nurse should prepare to do all the following EXCEPT: ENCOURAGE MARLON
TO CRY
Sarah G. has delivered a baby girl at 36 weeks gestation. At 4 hours of age, the newborn has
shallow respirations at 54 breaths/minute with periods of apnea lasting 5-7 seconds. The nurse’s
priority action would be to: CONTINUE ROUTINE MONITORING
Which nursing action should be included in the baby’s plan of care to prevent retinopathy of
prematurity? MONITOR PARTIAL PRESSURE OF OXYGEN (PAO2) LEVELS
Mateo, age 3 months, was treated for RDS at birth. Initially, he required continuous positive airway
pressure (CPAP) followed by 2 weeks of 100% oxygen and mechanical ventilation. All of the FF
observations indicate RDS in an infant except: RAPID DEEP BREATHING
You have been ask to assign an APGAR. The male infant was born vaginally
Wendy Villarosa is a 19-year old The apgar score at birth was
3
1. A client was admitted due to difficulty of breathing. When planning discharge teaching for the
parents a child with asthma, the nurse should include telling the parents to increase the child’s fluid
intake and to have the child: - Avoid exertion and exposure of cold
4. An 18-month-old child is seen in the Emergency Department with respiratory distress and is
admitted with a diagnosis of pneumonia. Following the initial workup, the baby is still short of breath
but is rubbing his eyes as if he is sleepy. The infant refuses to lie down. The nurse would suggest:
- the mother allow the baby to sleep in an upright position
6. Appropriate intervention is vital many children with heart disease in order to go on to live active,
full lives. Which of the following outlines an effective nursing intervention to decrease cardiac
demands and minimize cardiac workload? - Scheduling care to provide for uninterrupted rest period
11. A 3-year-old child was admitted 48 hours ago and recently developed a productive cough and
fever. Coarse crackles were heard in the right lower lobe on assessment. A chest x-ray showing
infiltrates with consolidation in the right lower lobe lead to the diagnosis of community acquired
pneumonia. Which of the following microbes caused the condition of the child? - Respiratory
syncytial virus
12. A client was admitted because of shortness of breath. On examination, expiratory wheezes was
assessed. The nurse identifies the nurse diagnosis of activity intolerance for a patient with asthma.
A common etiologic factor for this nursing diagnosis in patients with asthma is which of the
following? - Work of breathing
13. A 6-year-old preschooler was admitted 48 hours ago and recently developed a productive
cough and fever. The nurse on assessment, noted coarse crackles in the right and lover lobe. A
chest x-ray shows infiltrates with consolidation in the right lower lobe. The most frequent pathogens
of pneumonia in this child is: - mycoplasma pneumoniae
15. Beta-androgenic agonist such as albuterol are given to Reggie, a child with asthma. Such drugs
are administered primarily to do which of the following? - Dilate the bronchioles
18. Which of the following definitions best describes the etiology of sudden infant death syndrome
(SIDS)? - Unexplained death of an infant
19. A condition in which an acute, severe prolonged asthma attack and unresponsive to usual
treatment is referred to as which of the following? - Status asthmaticus
20. An infant with a patent ductus arteriosus is admitted to the pediatric unit ward. The nurse
anticipates which of the following medications will be given to the infant? – Ibuprofen
25. a patient who is experiencing an acute asthma attack is admitted to the emergency department.
The nurse’s first action should be to: - obtain the forced expiratory flow rate / Determine when the
dyspnea started
26. which findings would alert a nurse that a hospitalized 6-year old child is at risk for severe
asthma exacerbation? - History of steroid-dependent asthma
27. when preparing a child with asthma for discharge, the nurse must emphasize to the family that:
- medications must be continued even if the child is asymptomatic

28. which of the following infants is least probable to develop sudden infant syndrome (SIDS)?
- Baby jimmy who sleeps on his back
30. a 2-year-old child has been admitted to the hospital for management of pneumonia. The child is
placed in an oxygen tent. Taking into consideration the child’s age and developmental level and the
treatment being administered, which of statement is appropriate for the nurse to make to the
parents? - You can sit next to him and hold his hand through the tent, but he needs to remain inside
if it.
32. A 8-year old boy with severe asthma attack is brought to the emergency by his parents. what
statements by the 8-year old child indicates that the he understands the use of a peak expiratory
flow meter? - “My peak flow meter can tell me if an asthma episodes might be coming through I
might still be feeling okay.”
33. Following an assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis
of ineffective airway clearance. Which information best support this diagnosis? - Weak,
nonproductive cough effort
34. When communicating with the grieving family after a death from sudden infant death syndrome
(SIDS), the nurse should: - stress that the death isn’t parent’s fault
36. After discussion with the pediatric, the parents of an infant ask the nurse to explain once again
what patent ductus arteriosus is. The nurse’s best response would be: - an abnormal opening
between the right and left ventricle
37. What effect does hemoglobin amount have an oxygenation status? - Low hemoglobin levels
cause reduced oxygen-carrying capacity
38. A patient with asthma received a nebulizer of Albuterol. What is the side effects of this
medication? - Tachycardia
39. Which of the following risk factors is related to sudden infant death syndrome (SIDS)? - Low
birth weight
41. A patient was admitted 48 hours ago and recently developed a productive cough and fever. On
assessment, you note coarse crackles in the right lower lobe. A chest x-ray shows infiltrates with
consolidation in the right lower lobe. This is known as what type of pneumonia?
- Aspiration pneumonia
- HOSPITAL-ACQUIRED PNEUMONIA
42. Which finding would alert nurse that a hospitalized 6-year old child is at risk for severe asthma
exacerbation? - History of steroid-dependent asthma
1. Dingdong, delivered 3 days ago at 28 weeks gestation, develops a heart murmur. The
Dingdong?
· Increasing external stimuli

· Monitoring fluid intake and output
· Auscultating breath sounds
· Monitoring arterial blood gas values
2. A 8-year old boy with severe asthma attack is brought to the emergency department by his
parents. What statements by the 8-year old child indicates that he understands the use of a
peak expiratory flow meter?
· “When I do my peak flow, it works best if I do three breaths without pausing in between
breaths.”
· “If I use my peak flow meter every day, I will not have an asthma attack.”
· “I always start with the meter reading about halfway up. That way I don’t waste any breath.”
· “My peak flow meter can tell me if an asthma episode might be coming, even though I might still
be feeling okay.”
3. Arlene, age 2, is admitted to the pediatric unit after being treated in the Emergency Department
for status asthmaticus. Upon arrival on the unit, Arlene received an IV theophylline drip and a
maintenance solution of dextrose 5% in a 0.2% saline solution. In preparing Arlene for
discharge, the nurse should be primarily concerned with:
· Teaching Arlene’s parents about postural drainage

· Discussing strategies to rid the home of known allergens
· Arranging a follow-up appointment at the asthma clinic
· Instructing Arlene’s parents to restrict her activity
4. Abby a student nurse auscultate the newborn’s chest to get the PR. She notices that there is a
slight murmur. She knows that this is because the shunts are not yet fully closed. Which of the
following situations initiate the closure of the ductus arteriosus?
· Decreased pulmonary vascular resistance and decreased systemic vascular resistance
· Increased pulmonary vascular resistance and decreased systemic vascular resistance
· Increased pulmonary vascular resistance and increased systemic vascular resistance
· Decreased pulmonary vascular resistance and increased systemic vascular resistance
5. When offering support to the family of a 3-month old infant who dies from sudden infant death
syndrome (SIDS), it is important to recognize that the infant’s older sibling may experience.
· An understanding that the infant is dead.

· Lack of concern about where the infant is.
· Guilt that he or she may have caused the infant’s death.
· Acceptance of the infant’s death.
6. A 2 year old is admitted to the pediatric unit with a diagnosis of acute asthma. A blood sample
is obtained to measure the child’s arterial blood gases. The nurse should expect which of the
following findings?
· A decreased bicarbonate level

· An elevated pH
· An increased carbon dioxide level
· A raised oxygen level
7. An asthmatic patient was discharged from the hospital and placed on a home medication
regimen. She takes her medications regularly as directed. In case of an asthma attack, the
patient should be instructed to:
· Remain calm, drink plenty of tepid fluids, use her metered dose inhaler as instructed, and seek
medical attention if the attack does not subside within a reasonable time.
· Do breathing exercises, use her metered dose inhaler, and go to the nearest emergency
department immediately.
· Rest and do breathing exercises
· Take another dose of medication and rest
8. During assessment of a patient with a history of asthma, the nurse notes wheezing and
dyspnea. The nurse will anticipate giving medications to reduce:
· Laryngospasm
· Pulmonary edema
· Alveolar distention
· Airway narrowing
9. The parents who have just experienced the death of an infant from sudden infant death
syndrome (SIDS) request time alone with the infant. You should take which of the following
actions?
· Allow the parents as much time alone with the infant as they need.
· Deny the parents’ request because they are emotionally distraught.
· Discourage the parents from seeing the infant because it will be too painful.
· Allow the parents to view the infant, but remain in the room with them.
10. A 17-year-old high school student with a history of asthma is brought to emergency department.
The nurse recognizes that the adolescent is experiencing an acute asthma exacerbation when
assessment reveals:
· Confusion, tachypnea, and crackles

· Lethargy, hypotension, and fever
· Hypertension, bradycardia, and tremor
· Tachycardia, anxiety, and wheezing
·
11. A 10-year old boy with severe asthma attack is brought to the emergency department by his
parents. Considering the child’s diagnosis, the child is most likely to have which of these
findings?
· Itching at base of neck or upper back

Hacking, non-productive cough
Shortness of breath, prolonged expiratory phase
· Mild, inspiratory wheezing
12. Which finding would be the best indication that the patient having an acute asthma attack was
responding to the prescribed bronchodilator therapy?
· The respiratory effort decreases

· Vesicular breath sounds resolve
· Wheezes are more easily heard
· The O2 saturation is 89%
13. In asthma attack, an audible, wheezy breathing more common during expiration. An emergency
department nurse is assessing a 5-year-old experiencing an acute asthma attack. Which one of
these findings should be reported immediately?
· Prolonged expiratory phase

· Cyanosis
· Non-productive cough
· Absence of wheezing
14. Beta-adrenergic agonists such as albuterol are given to Reggie, a child with asthma. Such
drugs are administered primarily to do which of the following?
· Decrease post natal drip

· Reduce secondary infections
· Dilate the bronchioles
· Reduce airway inflammation
15. The nurse is teaching a family with a newborn about safety during sleep. What information is
the most important for the family to understand?
· A stuffed animal may be placed in the crib for comfort.

· The infant should be covered loosely with a blanket
· The infant should be placed on his back to sleep.
· Small pillows should be used to support the infant.
16. Fred is a 12-year old boy diagnosed with pneumococcal pneumonia. Which of the following
would nurse Mica expect to assess?
·
· Slight fever
· Bulging fontanel
· Chest pain
· Mild cough
17. What effect does hemoglobin amount have on oxygenation status?
· More hemoglobin reduces the client’s respiratory rate

· Low hemoglobin levels cause increased oxygen-carrying capacity.
· Low hemoglobin levels cause reduced oxygen-carrying capacity
· No effect
18. Which of the following client histories is most consistent with the diagnosis of sudden infant
death syndrome (SIDS)?
· The child was physically abused in the past

· The infant was healthy and was found shortly after being put down to sleep
· The infant was described as lethargic, irritable, and feeding poorly before being put down to
sleep
· The infant had a history of many medical problems
19. A child with bacterial pneumonia is crying and says it hurts when he coughs. The nurse would
teach the child to:
· Ask for pain medicine before he coughs.

· Try very hard not to cough.
· Take a sip of water before coughing.
· Hug his teddy bear when he coughs.
20. A diagnosis of pneumonia is typically achieved by which of the following diagnostic tests?
· ABG analysis
· Chest xray
· Blood cultures
· Sputum culture and sensitivity
When preparing to teach the parents of an infant about preventing sudden infant death
syndrome the nurse should include:
· Positioning the infant on his back to sleep
· Positioning the infant in an infant seat to sleep
· Positioning the infant on his stomach when sleeping
· Positioning the infant in a side-lying position to sleep
·
Which of the following infants is least probable to develop sudden infant death syndrome
(SIDS)?
· Baby Gabriel with prenantal drug exposure
· Baby angela who was premature
· Baby jimmy who sleeps on his back
· Sibling of baby angie who died of SIDS
A diagnosis of pneumonia is tyipically achieved by which of the following diagnostic tests?

· Sputum culture and sensitivity
· Blood cultures
· Chest xray
· ABG analysis
A patient was admitted 48 hours ago and recently developed a productive cough and fever. On
assessment, you note coarse crackles in the right lower lobe. A chest xray shows infiltrates with
consolidation in the right lower lobe. This is known as what type of pneumonia?
· Ventilator acquire pneumonia
· Community acquired pneumonia
· Aspiration pneumonia
· Hospital acquired pneumonia
A 10-year old boy with severe asthma is brought to the emergency department by his parents.
Considering the childs diagnosis, the child is most likle to have which of these findings?
· Shortness of breath
· Mild, inspiratory breathing
· Hacking non productive cough
· Itching at base of neck
Which finding would be the best indication that the patient having an acute asthma attack...
· Vesicular breath sounds resolve
· The O2 saturation is 89%
· Wheezes are more easily herd
· The respiratory effort decreases
A 2 year old boy admitted to the pediatric unit with diagnosis of acute asthma...
· A decreased bicarbonate level
· An elevated pH
· An increased carbon dioxide level
· A raised oxygen level
In asthma attack an audible wheezy breathing more common during expiration...
· Non productive cough
· Prolonged expiratory phase
· Cyanosis
·
· Absence of wheezing
When preparing for a child with asthma for discharge, the nurse must emphasize to the family
that:
· When the child is asymptomatic the disease is gone
· Limits shout not be placed on childs behaviour
· A cold dry environment is best for the child
· Medications must be continued even if the child is asymptomatic
The nurse caring for a child with left to right shunt if the heart, should be aware that the major
· Clubbing of fingers and toes
· Severe retarded growth
· Polycythemia
· He presence of an audible heart murmur
with the pediatric cardiologist, the parents of an infant ask the nurse to explain once again what
patent ductus arerosus is...
· An enlarged aorta and pulmonary artery
· An abnormal opening between the right and left ventricles
· A connection between the pulmonary artery and aorta
· A narrowing of pulmonary artery
A 17 year old boy in high school with a history of asthma is brought to the emergency
department. The nurse recognizes that the adolescent is ...
· Hypertension, bradycardia and tremor
· Lethargy hypotension and fever
· Confusion tachypnea and crackles
· Tachycardia anxiety and wheezing
A 2 year old child has been admitted to the hospital for management of pneumonia...
· You can sit next to him and hold his hand through the tent but he needs to remain inside of it
· He can play in the tent with his blocks and plush stuffed animals
·
·
Before you leave for the night it is good idea to rock him...
· At his age separation anxiety is high so bringing him...
A client was admitted due to difficulty of breathing. When planning discharge...

· Avoid exertion and exposure of cold
· Avoid foods high in fat
· Increase the usual calorie intake
· Stay in the house for at least 2 weeks
A 8 year old boy with severe asthma attack is brought... what statements by the 8 year old boy
indicates...
· I always start the meter reading...
· My peak flow meter can tell me...
· If i use my peak flow meter...
· When i do my peak flow...
The parents who have just experienced the death of an infant... ·
Allow the parents to view the infant
· Allow the parents as much time alone...
· Deny the parents request...
· Discourage the parents...
An asthmatic patent was discharged from the hospital and placed..
· Remain calm, drink plenty of tepid...
· Take another dose of medication....
· Do breathing exercises
· Rest and do breathing exercises...
Following an assessment of a patient with pneumonia the nurse identifies a nursing diagnosis...
· Large amounts of greenish sputum
· Respiratory rate of 28...
· Weak non-productive
· Resting pulse oximetry...
Dingdong, delivered 3 days ago at 28 weeks gestation...
·
· Monitoring fluid intake..
· Increasing external stimuli...
· Monitoring arterial blood...
· Auscultating breath sounds...
A client was admitted because of shortness of breath...

· Work of breathing
An 18 month old child is seen in the emergency department...

· The mother allow the baby to sleep in an upright...
A 3 year old child was admitted 48 hours ago and recently developed
· Streptococcus pneu
· H influenza
· Respiratory sync
· Mycoplasma
· Group A
During assessment of a patient with history of asthma...

· Airway narrowing
When offering support to the family of a 3 month old who dies from sudden...
· Guilt that he or she may have caused...
· An understanding
Lack of concerns
Acceptance
Which of the following risk factors is related to SIDS...

· Low birth weight
What effect does haemoglobin amount have on oxygen...

· Low hemoglobin levels cause reduced oxygen carrying
A patient with asthma received a nebulizer of albuterol...

· Tachycardia
Appropriate intervention is vital for many children with heart disease in order....
· Developing and implementing...
· Feeding the infant...
· Scheduling care to provide....
· Allowing the infant... a 6 year old pre schooler was

admitted 48 hours ago...
· Adenovirus
· H influenza
· Mycoplasma
· Group A
· Streptoccocus
Arlene is admitted to the pediatric unit after being treated in the...
· Discussing
· Instructing
· Arranging
· teaching
Abby a student nurse auscultated...
· Decrease.... increase...
Which finding would alert a nurse that a hospitalized 6 year old...
· History of steroid dependent asthma
Which of the following client histories is most consistent with the diagnosis of SIDS...
· The infant was healthy and was found shortly after being put down to sleep
An infant with a patient ductus arteriosus is admitted to the pediatric unit...
· Ibuprofen
A patient who is experiencing an acute asthma attack is admitted.
· Ask about
· Determine when the dyspnea...
· Listen to the...
· Obtain the…
During the assessment of a patient with a history of asthma, the nurse notes wheezing and
dyspnea. The nurse will anticipate giving medications to reduce: AIRWAY NARROWING
When preparing to teach the parents of an infant about preventing sudden death syndrome
(SIDS), the nurse should include:
POSITIONING THE INFANT IN SIDE-LYING POSITION TO SLEP
POSITIONING THE INFANT ON HIS BACK TO SLEEP
POSITIONING THE INFANT ON HIS STOMACH WHEN SLEEPING (wrong answer)
POSITION THE INFANT IN AN INFANT SEAT TO SLEEP
Which of the following risk factors is related to sudden infant death syndrome (SIDS)? Gestational
age of 42 weeks.
- LOW BIRTH WEIGHT
After discussion with the pediatric cardiologist, the parents of an infant ask the nurse to explain
once again what patent ductus arteriosus is. The nurse’s best response would be:
AN ABNORMAL OPENING BETWEEN THE RIGHT AND LEFT VENTRICLES
A connection between the pulmonary artery and the aorta
A condition in which acute, severe prolonged asthma attack and unresponsive to usual treatment
is referred to as which of the following? STATUS ASTHAMATICUS
Which of the following definitions best describe the etiology of sudden infant death syndrome
(SIDS)?
- UNEXPLAINED DEATH OF AN INFANT
A 6-year-old preschooler was admitted 48 hours ago and recently develop a productive cough and
fever. The nurse on assessment, noted coarse crackles in the right lower lobe. A chest x-ray shows
infiltrates with consolidation in the right lower lobe. The MOST frequent pathogens of pneumonia
in this child is: MYCOPLASMA PNEUMONIAE
Which finding would alert a nurse that a hospitalized 6-year old is at risk for a severe asthma
attack exacerbation?
HISTORY OF STEROID-DEPENDENT ASTHMA
A newborn baby boy was seen to have cleft palate. What does cleft palate repair typically
occur? - 8-12 months
A child diagnosed acute glomerulonephritis will mostly likely have a history of which of the
following? – Recent illness such as strep throat
7. A patient has a burn on the back of the torso that is extremely red and painful but no blisters are
present. When you pressed on the skin it blanches. You document this as a:
– 1st degree (superficial) burn
8. A toddler is hospitalized with severe dehydrations. The nurse should assess the child for which
possible complications?
– Hypokalemia
9. A patient has full-thickness burns on the front and back of both arm and hands. It is nursing
priority to:
– Elevate and extend the extremities
When admitting a patient with acute glomerulonephritis, the nurse will ask the patient about
– Recent sore throat and fever
A preschooler with severe vomiting and diarrhea was admitted to the hospital. The vomiting has stopped
and rehydration has begun intravenously. When should the nurse begin feeding the
child solid food? - After the child has been rehydrated
What’s the best way to keep children from getting poisoned form over-the-counter and prescriptions
medications? – All of the above options
A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse
caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? - -
- Decreased wheezing
A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the
nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place
the infant? 2
- Back rather than on the stomach
Before preparing a teaching plan for the parents of an infant with ductus arteriosus, it is important that
Nurse Korina understands this condition. Which statement best describes patent ductus arteriosus?
- Patent ductus arteriosus involves a defect in which the fetal shunt between the aorta and the
pulmonary artery fails to close
The nurse is caring for Gabby experiencing an acute asthma attack. The client stops wheezing and breath
sounds aren’t audible. The reason for this change is that:
The swelling has decreased
The airways are so swollen that no air can get through
Crackles have replaced wheezes
The attack is over
As a client advocate, the nurse should ensure protection of the client’s rights during heath teaching. When
preparing to teach the parents of an infant about preventing sudden infant death syndrome (SIDS), the
nurse should include:
- Positioning the infant on his back to sleep
Which finding would alert a nurse that a hospitalized 6-year old child is at risk for a severe asthma
exacerbation?
- History of steroid-dependent asthma
As a client advocate, the nurse should ensure protection of the client’s rights during heath teaching. All the
following are considered as risk factors for asthma morbidity and mortality EXCEPT:
Air pollution exposure
Female gender
Poor response to systemic steroid therapy
Poverty
Roldan, 6 years old child was admitted due to difficulty of breathing. When planning discharge teaching for
the parents of the child with asthma, the nurse should include telling the parents to increase the child’s fluid
intake and to have the child:
Avoid exertion and exposure of cold
Avoid foods high in fat
Stay in the house for at least 2 weeks
Increase the usual calorie intake
Marissa, a 3-year-old child was admitted 48 hours ago and recently developed a productive cough and fever.
Coarse crackles were heard in the right lower lobe on assessment. A chest x-ray showing infiltrates with
consolidation in the right lower lobe lead to the diagnosis of community acquired pneumonia. Which of the
following microbes caused the condition of the child?
Respiratory syncytial virus
H. influenzae (type b, nontypable)
Group A streptococci
Streptococcus pneumoniae
Mycoplasma pneumoniae
Karla, age 2, is admitted to the pediatric unit after being treated in the Emergency Department for status
asthmaticus. Upon arrival on the unit, Karla received an IV theophylline drip and a maintenance solution of
dextrose 5% in a 0.2% saline solution. In preparing Karla for discharge, the nurse should be primarily
concerned with:
Arranging a follow-up appointment at the asthma clinic
Teaching Karla’s parents about postural drainage
Instructing Karla’s parents to restrict her activity
Discussing strategies to rid the home of known allergens
Which statements by an 8-year old child indicates that she understands the use of a peak expiratory flow
meter?
“My peak flow meter can tell me if an asthma episode might be coming, even though I might still be feeling
okay.”
“If I use my peak flow meter every day, I will not have an asthma attack.”
“When I do my peak flow, it works best if I do three breaths without pausing in between breaths.”
“I always start with the meter reading about halfway up. That way I don’t waste any breath.”
A patient admitted 72 hours ago recently developed a productive cough and fever. On
assessment, you note coarse crackles in the right lower lobe. A chest x-ray shows
infiltrates with consolidation in the right lower lobe. This is known as what type of
pneumonia?
Ventilator-acquired pneumonia
Hospital- acquired pneumonia
Community-acquired pneumonia
Aspiration pneumonia
Abby, a student nurse auscultate the newborn’s chest to get the PR. She notices that there is a slight
murmur. She knows that this is because the shunts are not yet fully closed. Which of the following situations
initiate the closure of the ductus arteriosus?
Increased pulmonary vascular resistance and increased systemic vascular resistance.
Decreased pulmonary vascular resistance and increased systemic vascular resistance

Increased pulmonary vascular resistance and decreased systemic vascular resistance
Decreased pulmonary vascular resistance and decreased systemic vascular resistance

1. A patient is in the acute phase of burn management. The patient experienced full-thickness
burns to the perineum and sacral area of the body. In the patient’s plan of care, which nursing
diagnosis is priority at this time?
Impaired Skin integrity
Risk for fluid volume overload
Risk for infection
Ineffective coping
2. A nurse is evaluating an infant brought to the clinic with severe diarrhea. What signs and
symptoms indicate that the infant has severe dehydration?
Normal pulse and blood pressure, intense thirst
Irritability, moderate thirst, normal eyes and fontanel
Tachycardia, decreased tears, 5% weight loss
Tachycardia, capillary refill greater than 3 seconds, sunken eyes and fontanel
3. A 7 year old has been having vomiting with diarrhea for 3 days. How do you expect the child to
present clinically?
None of the options are correct
Bradycardia, dry mucous membranes, absence of tears
Tachycardia, dry mucous membranes, weight loss
Sunken eyeballs and bradycardia
4. When admitting patient with acute glomerulonephritis, the nurse will ask the patient about
Recent sore throat and fever
Frequency of UTIs
Family history of kidney disease
History of high pressure
5. A patient has full thickness burns on the front and back of both arm and hands. It is nursing
priority to:
Elevate and extend extremities

Elevate and flex the extremities
Keep extremities below heart level and extended
Keep extremities level with the heart level and flexed.
6. A 2-month-old breastfed infant successfully rehydrated with oral rehydration solutions (ORS)
for acute diarrhea. What instructions to the mother about breastfeeding should be included by
the nurse?
Stop breastfeeding until diarrhea is absent for 24 hours.
Express breast milk and dilute with sterile water before feeding
Stop breastfeeding until breast milk is cultured
Continue breastfeeding
7. A mother brings her child in the office for a follow-up appointment and voices concern that her
child has started urinating more normal and is constantly thirsty and hungry. As the RN, you
suspect?
Tret’s syndrome
Diabetes mellitus
Phenylkentonuria
Hypoglycemia
8. To prevent further urinary tract infections in a preschooler, what measures would you teach her
mother?
Suggest she drink less fluid daily to concentrate urine.
Encourage her to be more ambulatory to increase urine output
Teach to wipe her perineum front to back after voiding
Teach her to take frequent tub baths to clean her perineal area
9. A 15 year old, who is type 1 diabetic, reports that she almost “passes out” during gym class.
What information would you assess from the teenage?
How she takes her blood glucose after exercise
None of the options are correct
Her eating prior to gym class
What type of form she needs to have filled out so she can be excused from gym class
10. A symptom often seen in acute glomerulonephritis is edema. The most common site the
edema is first noted is in which area of the body?
Sacrum
Hands
Eyes
11. Four sick children with type 1 diabetes have been admitted to the hospital. Which child is
most at risk of developing hypoglycemia? The child with
Bacterial sepsis
Chickenpox
Intussusception
Jaundice
12. The nurse establishes a nursing diagnosis of excess fluid volume related to inflammation at
the glomerular basement membrane in a patient with acute glomerulonephritis. To best
evaluate whether the problem identified in the nursing diagnosis has resolved, the nurse
will monitor for Proteinuria
Elevated creatinine
Hematuria
Periorbital edema
13. A 4-year-old has had diarrhea for several days, and her perineum is inflamed and almost
excoriated. What nursing actions are indicated? (Select all that apply)
A. Gently wash the perineum with cold water and mild soap after each stool.
B. Apply an ointment to the inflamed area to provide a moisture barrier.
C. Place the child without underwear for brief periods to allow the air to the area.
D. Turn the child at least every two hours
- B, C, D
14. Why are infants at greater risk for fluid and electrolyte imbalances than older children?
Their metabolic rate is lower
Their kidney functioning is immature
Their daily exchange of extracellular fluid is decreased.
15. A patient has experienced full-thickness burns to the face and neck. As the nurse it is
priority to
Assess the airway
Assess the blood pressure
Prevent hypothermia
Prevent infection
16. A patient has a burn on the back of the torso that is extremely red and painful but not
blisters are present. When you pressed the skin it blanches. You document this as a:
3rd degree (full thickness) burn
4 degree (deep full-thickness) burn
th
2 degree (partial-thickness)
nd
burn
1 degree (superficial) burn
st
17. A preschooler with severe vomiting and diarrhea was admitted to the hospital. The vomiting
has stopped and rehydration has begun intravenously. When should the nurse begin
feeding the child solid food?
after the diarrhea has stopped for 24
hours when the IV rehydration can be
stopped after the child has been
rehydrated
when the parents fiver their permission to feed their child
18. The nurse is collecting data on 6-year-old child admitted with a possible urinary tract
infection. Which of the following vital signs might indicate the possibility of an infection?
Pulse oximeter 93% on room air
Blood pressure 100/70
Respirations 22 per minutes
Pulse rate 135 bmp
19. The nurse is caring for a child admitted with acute glomerulonephritis. Which of the
following is crucial manifestations would likely have been noted in the child with this
diagnosis?
Loose, dark stools
Strawberry red tounge
Jaundiced skin
Smoky colored urine
20. What is the best way to keep children from getting poisoned from over-the-counter and
prescription medications?
Keep all medicines out of reach
All of the above
Make sure house guests don’t leave medicines lying around
Never call medicine candy
21. A newborn baby boy was seen to have cleft palate, what does cleft palate repair typically
occur?
8-12 mos
12-16 mos
4-8 mos
20-41
mos
22. A child diagnosed acute glomerulonephritis will most likely have a history of which of the
following?
Sibling diagnosed with the same disease
Hearing loss with impaired speech
Recent illness such as strep throat
Hemorrhage or history of bruising easily
23. You are going over insulin administration education with a patient’s mother. Why statement
by her raises concern?
“I ordered her a medic-alert bracelet yesterday”
“I will bring her in every 3 months for a glycosylate hemoglobin blood drawn”
“I always carry sugary items in case she has a hypoglemic attack”
“When she is sick I will hold her insulin”
24. A toddler is hospitalized with severe dehydration. The nurse should assess the child fro
which possible complications?
A rapid, bounding pulse
Decreased specific gravity
Hypertension
hypokalemia
25. A nurse is performing an assessment on a child. Which of the following would be indicative
of a potential for a urinary tract infection? Not using cleansing towelettes routinely
Washing the genital area with water daily
Holding urine while at school
Not using soap when cleaning the urethral area
26. Which of the following household items is the most harmful if swallowed?
Fluoride toothpaste
Liquid dish soap
Liquid or powdered automatic dishwashing detergent
Mouthwash
27. Parents have a 23-month-old daughter who started having vomiting and diarrhea
yesterday. When should the pediatrician’s office be called to find out what to do?
A. If their daughter doesn’t urinate for longer than 4 hours
B. If their daughter’s fontanel appears sunken
C. If crying produces no tears
D. When the diarrhea has been present for 24 hours
E. The toddler has a fever (>39 degree Celsius)
F. If severe abdominal cramps occurs
- C, D, E ,F
28. When assessing the patient who has a lower urinary tract infection (UTI), the nurse will
initially ask about
Flank pain
Nausea
Pain with urination
Poor urine output
29. What does rule of tens not include for cleft and palate repair
10 weeks
10 hemoglobin
10 pounds
10 hematocrit
A student was burned in a jeepney accident. The entire front side of both
arms was burned, both legs was completely burned, lower front torso and
genitalia was burned. The nurse would compute that the total burned surface
area is:
45%
55%
72%
63%
The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The
nurse monitors the infant, knowing that which is a clinical manifestation associated
with this disorder?
Sausage-shaped mass palpated in the upper right abdominal quadrant
The passage of currant jelly-like stools
Failure to pass meconium stool in the first 24 hours after birth
Bile stained fecal emesis
You are the telephone triage nurse and have received a call from a mother
who states that her 4-year-old son has ingested an unknown amount of
aspirin. She administered 15 ml of syrup of ipecac 20 minutes ago, but the
child has not vomited yet. You instruct the mother to take which of the
following actions? Group of answer choices
Take child to the Emergency Department immediately.

Wait 15 more minutes, then if the child still has not vomited, take him to the
Emergency Department.
Repeat the 15 ml syrup of ipecac now, and immediately take the child to the
Emergency Department.
Repeat the syrup of ipecac, but increase the dose to 30 ml, and immediately
take the child to the Emergency Department
The nurse is teaching the parents of a preschooler information about urinary tract
infection and means of reducing their recurrence. Which statements by the parents
indicates the need for additional teaching? Group of answer choices
“I will buy her underwear a little large.”
“Soaking in a bubble bath will reduce meatal irritation.”
“If I notice her starting to wet the bed again. I need to have her checked for anther
urinary tract infection.”
“I should try to get her to drink a lot of water and juices.”
The nurse tells a male adolescent with type 1 diabetes that if he begins to
experience an insulin reaction while at a basketball game, should: Group of
answer choices
Rest in a quiet place until his symptoms subside
Call his parents immediately
Administer regular insulin as soon as possible
Buy a Coke and hamburger to eat
The clinic nurse reviews the record of an infant and notes that the health care
provider has documented a diagnosis of suspected Hirschsprung’s disease.
The nurse reviews the assessment findings documented in the record,
knowing that which symptom most likely led the mother to seek health care
for the infant?
Diarrhea
Regurgitation of feedings
Projectile vomiting
Foul smelling ribbon like stool
The parents of a child with acute glomerulonephritis are very concerned about
activity restrictions after discharge. The nurse is teaching the mother of a
diabetic child how to recognize the signs and symptoms of hypoglycemia.
Which signs and symptoms should the nurse discuss?
Nausea, fruity breath odor, headache and fatigue
Enlarged tongue, hypotonia, easy weight gain and cool skin temperature
Behavioral changes, increased heart rate, sweating and tremors
Polydipsia, polyuria, polyphagia and weight loss
You are to administer activated charcoal to a child who has consumed

numerous unidentified pills. Because the child has a decreased level of
consciousness, your most appropriate action to administer the charcoal would
be which of the following? Group of answer choices
Administer the charcoal orally as long as the child has a gag reflex
Do not administer the charcoal because the child has a decreased
level of consciousness
Insert a nasogastric tube and administer the activated charcoal as ordered.
Question the order for activated charcoal until the pills have been identified.
The nurse is teaching the parents of a child with diabetes. Which of the
following agents should the nurse teach the parents to administer if their child
suffers a severe hypoglycemic reaction? Group of answer choices
IV dextrose
Subcutaneous insulin administration
Oral fast acting carbohydrate administration
Subcutaneous glucagon administration
Which of the following should the nurse do first in a child diagnosed with Hirschsprung’s
Disease with a complaint of fever and watery explosive diarrhea?
- Notify the physician immediately
The nurse review the record of a child with complaint of brown colored urine
and who is suspected to have glomerulonephritis. The child was admitted
with the diagnosis of glomerulonephritis. When performing a physical
assessment, the
nurse should expect to find:
Anorexia, hematuria, proteinuria (1+), and decreased blood pressure
Normal blood pressure, periorbital edema, proteinuria (1+), and glycosuria
(3+) Lowered blood pressure, periorbital edema, proteinuria (1+), and
decreased specific gravity (1.001)
Moderately elevated blood pressure, periorbital edema, proteinuria (4+), and
increased specific gravity (1.0 )
The parent of a 2 year old child asks you what precautionary measures can be taken at home
to help prevent accidental poisonings. You know that the parent requires further instructions
when he makes which of the following comments?
- “I will have syrup of ipecac available at home and administer it to my child if he swallows
any type of poison.”
The nurse is teaching an adolescent with diabetes. Which statement by the adolescent indicates
that teaching was effective?
- “I will monitor my blood glucose level to determine how much insulin I need.”
The nurse is teaching the mother of a child diagnosed with type 1 diabetes.
The mother asks why her child must inject insulin and can’t take pills as her
uncle does. Which reply is most appropriate? Group of answer choices
“Pills only affect fat and protein metabolism, not sugar.”
“Your child may be able to take pills when he’s older”
"The only way to replace insulin is by injection”
“Because a child’s pancreas is less developed than an adults, antidiabetic
pills aren’t recommended for children”
15/20
1. a patient has experienced full-thickness burns to the face and neck. as the nurse it is
priority to – assess the airway
2. what does rule of tens not include for cleft lip and palate repair – 10 hematocrit
3. The nurse is collecting data on a 6-year-old child admitted with a possible urinary tract
infection. Which of the following vital signs might indicate the possibility of an infection? –
PULSE RATE 135 BPM
4. Four sick children with Type 1 diabetes are admitted to the hospital. Which child is most
at risk for developing hypoglycemia? The child with: - BACTERIAL SEPSIS
5. To prevent further urinary tract infections in a preschooler, what measures would you
teach her mother? – TEACH HER TO WIPE HER PERINEUM FRONT TO BACK AFTER
VOIDING
6. A newborn baby boy was seen to have cleft palate, what does cleft palate repair typically
occur – 8-12 months
7. a 2-month-old breastfed infant is successfully rehydrated with oral rehydration solutions
for acute diarrhea. what instructions to the mother about breastfeeding should be
included by the nurse – CONTINUE BREASTFEEDING
8. When assessing the patient who has a lower urinary tract infection, the nurse will ask
about – PAIN WITH URINATION
9. A 4-year-old has diarrhea for several days and her perineum is inflamed and almost
excoriated. What nursing actions are indicated (Select all that apply) – APPLY AN
OINTMENT, PLACE THE CHILD AND TURN THE CHILD (B, C, D)
10. A mother brings her child in the office for a follow-up appointment and voices concern
that her child has started urinating more than normal and is constantly thirsty and hungry.
As the RN, you suspect? – DIABETES MELLITUS
11. A nurse is performing an assessment on a child. Which of the following would be
indicative of a potential for a urinary tract infection? - Holding urine while at school.
12. a toddler is hospitalized with severe dehydration. the nurse should assess the child for
which possible complication – HYPOKALEMIA
13. Parents have a 23-month-old daughter who started having vomiting and diarrhea
yesterday. When should the pediatrician's office be called to find out what to do?
(SELECT ALL THAT
APPLY.)
A. If their daughter doesn't urinate for longer than 4 hours
B. If their daughter's fontanel appears sunken
C. If crying produces no tears
D. When the diarrhea has been present for 24 hours
E. The toddler has a fever (> 39 degrees Celsius [102 degrees F])
F. If severe abdominal cramps occur
14. The nurse is caring for a child admitted with acute glomerulonephritis. Which clinical
manifestation would likely have been noted in the child with this diagnosis? – SMOKY
COLORED URINE
15. A patient is in the acute phase of burn management. The patient experienced full-thickness
burns to the perineum and sacral area of the body. In the patient's plan of care, which nursing
diagnosis is priority at this time? – RISK FOR INFECTION
16. A child diagnosed with acute glomerulonephritis will most likely have a history of: - RECENT
ILLNESS SUCH AS STREP THROAT
edema is first noted is in which area of the body? – EYES
18. A patient with a history is diabetes is exhibiting sweating and slurred speech. What do
you suspect is the cause? – HYPOGLYCEMIA
19. WHICH OF THE FOLLOWING HOUSEHOLD ITEMS IS THE MOST HARMFUL IF
SWALLOWED? – LIQUID OR POWEDERED AUTOMATIC DISHWASHING
DETERGENT
16/20
20. The nurse is collecting data on a 6 year old child admitted with a possible urinary tract
infection. Which of the following vital signs might indicate the possibility of an infection?
- PULSE RATE 135 BPM
21. A mother bring her child in the office for a follow-up appointment and voices concern
that her child started urinating more than normal and constantly thirsty and hungry. As
RN, you suspect? -DIABETES MELLITUS
22. A newborn baby body was seen to have cleft palate. What does cleft palate repair
typically occur? -8-12 MONTHS
23. Why are infants at greater risk for fluid and electrolyte imbalances than older children? -
Their kidney functioning is immature
24. A patient has experienced full-thickness burns to the face and neck. As the nurse it is
priority to -ASSESS THE AIRWAY
25. A Child diagnosed acute glomerulonephritis will most likely have a history of which of
the following? -RECENT ILLNESS SUCH AS STREP THROAT
26. A patient has burn on the back torso that is extremely red and painful but no blisters are
present. When you pressed on the skin it blanches. You document this as a -1 ST
DEGREE (SUPERFICIAL) BURN

27. A toddler is hospitalized with sever dehydration. The nurse should assess the child for
which possible complication? -HYPOKALEMIA
28. Patient has full-thickness burns on the front and back of the both arms and hands. It is
nursing priority to -Elevate and extend the extremities
29. A nurse is performing an assessment on a child. Which of the following would be
indicative of a potential for UTI? -HOLDING URINE WHILE AT SCHOOL
30. To prevent futher urinary tract infections in a preschooler, what measures would you
teach her mother? -TEACH HER TO WIPE HER PERINEUM FRONT TO BACK AFTER
VOIDING
31. Parents have a 23 month old daughter who started having vomiting and diarrhea
yesterday. When should the pediatrician’s office be called to find out what to do? (Select
all that apply) -C, D, E, F
32. The nurse establishes a nursing diagnosis of excess fluid volume related to
inflammation at the glomerular basement membrane in a patient with acute
glomerulonephritis. To best evaluate whether the problem identified in the nursing
diagnosis has resolved, the nurse will monitor for - PERIORBITAL EDEMA
33. A nurse is evaluating an infant brought to the clinic with sever diarrhea. What signs and
symptoms indicate that the infant has sever dehydration?
- tachycardia, capillary refill greater than 3 seconds, sunken eyes and fontanel
edema is first noted is in which area of the body? -EYES
35. When assessing the patient who has lower urinary tract infection (UTI), the nurse will
initially ask about -PAIN WITH URINATION
36. A 2 month old breastfed infant is successfully rehydrated with oral rehydration solution
(ORS) for acute diarrhea. What instructions to the mother about breastfeeding should
be included by the nurse? -CONTINUE BREASTFEEDING
37. A patient with history is diabetes is exhibiting sweating and slurred speech. What do you
suspect is the case? -HYPOGLYCEMIA
The nurse is teaching an adolescent with diabetes about occurrences that can alter insulin
requirement. Which of the following occurrences should be emphasized?
Water intake, illness, stress, and exercise

Exposure to ultra violet light, illness, stress, and exercise
Sodium intake, exercise, stress, and illness
Illness, stress, growth, food intake, and exercise
One nutritional principle to be followed in clients with type 1 diabetes is to provide for
compensatory changes. The nurses reviews with a client how compensation for increased
physical activity can be achieved and instructs the client to:
Increase dietary intake when there is a plan to exercise more than

Lower the insulin dose in the morning when extra exercise is anticipated
Take the oral hypoglycemic medication on days of heavy exercise
Eat more rapidly absorbed simple sugars to compensate for extra exercise
A 9 year old boy with type 1 diabetes takes a mixture of regular and NPH insulin. He’s
scheduled to go on a camping trip and his mother asks the nurse whether it’s safe for him to
participate in this activity. What’s the most appropriate response?
“He should have a light snack before doing any hiking.”

“Have him increase his morning NPH insulin to compensate for higher metabolism while
hiking.”
“He needs to understand the physical limitations placed on a client with diabetes.”
“He shouldn’t go on this trip because it’s potentially dangerous.”
An 18 month old child with a history of cleft lip and palate had been admitted for palate surgery.
The best rationale to give parents who are questioning the use of elbow restraints with their
child who has had cleft palate repair is:
The restraints help us remember that the child is NPO after surgery.
This device is frequently used postoperatively to protect the IV site in small children.
Elbow restraints are used post operatively to keep their hands away from the surgical site.
The restraints will help us maintain proper body alignment.
A student was burned in a jeepney accident. The entire front side of both arms was burned,
both legs was completely burned, lower front torso and genitalia was burned. The nurse would
compute that the total burned surface area is: 55%
The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The
nurse monitors the infant, knowing that which is a clinical manifestation associated with this
disorder?
Failure to pass meconium stool in the first 24 hours after birth
Bile stained fecal emesis
The passage of currant jelly-like stools

Sausage-shaped mass palpated in the upper right abdominal quadrant
The nurse is caring for a child with type 1 diabetes. The nurse enters the child’s room and
finds him diaphoretic and unable to be awakened. The nurse should anticipate which of the
following emergency interventions?
Administering IV dextrose
Administering orange juice followed by a protein source
Administering insulin
Administering honey followed by a protein source
A home care nurse provides instructions to the mother of an infant with cleft palate
regarding feeding. Which statement if made by the mother indicates a need for further
instruction?
“I will use a nipple with a small hole to prevent choking.”

“I will stimulate sucking by rubbing the nipple on the lower lip.”
“I will allow the infant time to swallow”
“I will allow the infant to rest frequently to provide time for swallowing what has been placed
in the mouth”
The parents of a child with acute glomerulonephritis are very concerned about activity
restrictions after discharge. The nurse bases the answer to them on the fact that after the
urinary findings are nearly normal:
The child must not play active games

Activity does not affect the course of the disease
Activity must be limited for 1 month
The child must not remain in bed for 2 weeks
A 10-year-old boy with type 1 diabetes comes to the pediatrician’s office. Which of the
following techniques best ensures responsible insulin administration?
The child learns to draw up his own insulin and his parents inject it
The child learns to administer his insulin supervision
The child observes his parents as they administer his injections
The child manages his insulin administration independently
The client has burns on both legs. These areas appear white and leather-like. No blisters or
bleeding are present, and there is just a “small amount of pain.” How will the nurse categorize
this injury?
Partial-thickness deep
Superficial
Partial-thickness superficial
Full-thickness
A student was burned in a jeepney accident. The entire front side of both arms was burned,
both legs was completely burned, lower front torso and genitalia was burned. The nurse would
compute that the total fluid requirement in the first 24 hours in the client with a body weight of
60 kilograms is which of the following?
13,200 ml
10, 800 ml
6,600 ml
15,120 ml
When planning nursing care for a 5 year old with acute glomerulonephritis, the nurse
realizes that the child needs help in understanding the necessary restrictions, one of which
is:
Daily doses of IM penicillin

Bed rest for at least 4 weeks
A bland diet high in protein
Isolation from other children with infections
The nurse tells a male adolescent with type 1 diabetes that if he begins to experience an
insulin reaction while at a basketball game, should:
Administer regular insulin as soon as possible

Rest in a quiet place until his symptoms subside
Call his parents immediately
Buy a Coke and hamburger to eat
The nurse is teaching the parents of a child with diabetes. Which of the following agents
should the nurse teach the parents to administer if their child suffers a severe hypoglycemic
reaction?
Oral fast acting carbohydrate administration

Subcutaneous insulin administration
IV dextrose
Subcutaneous glucagon administration
You are to administer activated charcoal to a child who has consumed numerous unidentified
pills. Because the child has a decreased level of consciousness, your most appropriate action
to administer the charcoal would be which of the following?
Insert a nasogastric tube and administer the activated charcoal as ordered.

Do not administer the charcoal because the child has a decreased level of consciousness
Administer the charcoal orally as long as the child has a gag reflex
Question the order for activated charcoal until the pills have been identified.
The parents of a child with acute glomerulonephritis are very concerned about activity
restrictions after discharge. The nurse is teaching the mother of a diabetic child how to
recognize the signs and symptoms of hypoglycemia. Which signs and symptoms should the
nurse discuss?
- Behavioral changes, increased heart rate, sweating and tremors
You are providing care to a toddler who has ingested an unknown amount of his grandfather’s
medication, which is described as a “White Pill”. The physician has ordered the administration
of syrup of ipecac and activated charcoal. What action would you take?
Administer the activated charcoal, then administer the syrup of ipecac.

Insert a nasogastric tube for the administration of the syrup of ipecac and activated
charcoal.
Question the order because syrup of ipecac and activated charcoal are not to be used
together. Administer the ipecac, and after the child vomits, administer the activated
charcoal.
An infant is admitted to the hospital with a sudden episode of acute abdominal pain. To
establish a diagnosis of intussusception, the nurse should ask which question?
- “Does the infant’s stool look like currant jelly?”
The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse
review’s the child’s record and expects to note which symptom of this disorder is
documented?
Profuse projectile vomiting

Bright red blood and mucus in the stools
Watery diarrhea
Ribbon like stools
1. When admitting a patient with acute glomerulonephritis, the nurse ask the patient about
· Frequency
· Family history
· Recent sore
· History of highlood
15. A 7 year old has been vomiting with diarrhea for 3 days...
· d. none of the options
· bradychardia
· tachycardia
· sunken eyeballs
16. a 2 month old breastfed infant...
· stop breastfeeding... 24 hours
· express breast milk
· stop bfeeding until breastmilk is cultured
· continue breastfeeding.
17. A 15 year old, who is type 1 diabetic...
· How she takes her blood...
· d. none of the options are correct...
· her eating habits prior...
· what type of form...
18. four sick children with type 1 diabetes...
· bacterial sepsis...
· chicken pox
· intussusceptions
· jaundice
19. why are infants at greater risk for fluid...
· their metabolic...
· their metabolic...
· their kidney functioning...
· their daily exchange...

20. a patient has a burn on the back of the torso that is extremely red... 3 degree.
rd
· 4 degree
th
· 2 degree
nd
· 1 degree
st
21. The nurse is caring for a child admitted with acute glomerulo...
· Loose, dark stools
· Strawberry red tongue
· Jaundiced skin
· Smoky colored urine
22. A newborn baby was seen to have a cleft palate...
·
8-12
· 12-16
· 4-8
· 20-24
23. A child diagnosed with acute glomerulo...
· Sibling diagnose...
· Hearing loss...
· Recent illness...
· Hemorrhage...
24. Which of the following household items is the most harmful if swallowed?
· Liquid or powdered
· Fluoride toothpaste
· Mouthwash
· Liquid dish soap
25. A patient with a history of diabetes is exhibiting...
· Hypoglycemia
· Hyper
· Hyponateria
· Hyernaterima
The nurse is caring for a child admitted with acute glomerulonephritis. Which of the
following clinical
manifestations would likely have been noted in the child with this diagnosis?
Jaundiced skin
Loose, dark stools
Strawberry red tongue
Smoky colored urine
A patient has full-thickness burns on the front and back of both arm and hands. It is nursing
priority to:
Keep extremities level with the heart level and flexed
Elevate and flex the extremities
Elevate and extend the extremities
Keep extremities below heart level and extended
You are going over insulin administration education with a patient's mother. Which
statement by her raises concern?
"I ordered her a Medic-Alert bracelet yesterday."
"I always carry sugary items in case she has a hypoglemic attack."
"I will bring her in every 3 months for a glycosylate hemoglobin blood drawn."
"When she is sick I will hold her insulin."
When planning nursing care for a 5 year old with acute glomerulonephritis, the nurse realizes
that the child needs help in understanding the necessary restrictions, one of which is:
A bland diet high in protein
Isolation from other children with infections
Daily doses of IM penicillin
Bed rest for at least 4 weeks
A preschooler with a history of cleft palate repair comes to the clinic for a routine well-child
checkup. To determine whether this child is experiencing a long-term effect of cleft palate,
the nurse asks the parent which question?
“Has the child had any difficulty swallowing food?”
“Does the child play with an imaginary friend?”
“Was the child recently treated for pneumonia?”
“Is the child unresponsive when given directions?”
The parent of a 2 year old child asks you what precautionary measures can be taken at home
to
help prevent accidental poisonings. You know that the parent requires further instructions
when
he makes which of the following comments?
“I will have syrup of ipecac available at home and administer it to my child if he swallows
any type of poison.”
“I will have the poison control center phone number available at every phone.”
“I will check for poisonous houseplants and remove them from the home or place them out
of my child’s reach.
“I will lock up all medications, household cleaners, and other potentially poisonous
substances.
A 4 year- old has diarrhea for several days, and her perineum is inflamed and almost
excoriated. what nursing action are indicated? - B, C D. ( APPLY an ointtment ot the
inflamed area to provide a moisture barrier, placed the child without underwear for brief
periods to allow air to the area and turn the child at least every two hours.
a patient has experienced full- thickness burns to the face and neck, as the nurse it is priority
to: - assess the airways.
a 2 month old breastfed infant is sucessfully rehydrated with oral rehydration solution ors for
acute diarreha. what instructions to the mother about breastfeeding should be include by the
nurse? - continue breastfeeding
why are infants at greater risk for fluid and electrolyte imbalance than older children? - their
kidney functioning is immature
parents have 23- month old daughter who started having vomiting and diarrhea yesterday.
when should the pediatrician's office be called to find out what to do? - C,D,E, F ( IF
CRYING
PRODUCE NO TEAR, WHEN THE DIARRHEA HAS BEEN PRESENT FOR 24 HOURS,
THE TODDLER HAS A FEVER, IF SEVER ABDOMINAL CRAMPS OCCUR)
When developing the plan of care for a newborn who has an imperforate anus and an oral
intake restriction, which of the following activities should the nurse consider as most
appropriate for the newborn’s emotional needs?
Encourage the mother to sing to the newborn during feeding.
Explain the condition and the planned procedure for the baby.
Encourage the mother to cuddle the newborn when giving small feedings.
Inform the mother that the use of a pacifier is most helpful
A healthy, thriving, 4-month old boy suddenly experiences episodes of acute abdominal
pain. The infant is admitted to the hospital with the diagnosis of intussusception. In an
interview with the nurse, the infant’s mother describes his behavior. The mother would most
likely describe him as crying.
Intermittently and drawing his knees to his chest
Constantly and extending his legs
Shrilly when ingesting food
Intermittently when positioned on his left side
The parents of a child diagnosed with upper urinary tract infection (UTI) asks the nurse why
the
child needs a daily weight. In formulating a response, the nurse includes that it is important
because daily weight will:
Determine if the child’s caloric intake is adequate
Keep tract of possible loss or gain of fluid retained in body tissues.
Indicate the need for dietary restrictions of sodium and potassium.
Track the amount if fluid ingested orally each day
When reviewing pathophysiology of diabetes mellitus with an 8-year-old, newly diagnosis

child,
the nurse’s plan should take into consideration that:
Peer influence will decrease in importance to the child
The child will respond favorable to opportunities to participate in self- care
The child’s current developmental task involves achieving a sense of identity
The child is the abstract level of cognition
a 2 month old breastfed infant is sucessfully rehydrated with oral rehydration solution ors for
acute diarreha. what instructions to the mother about breastfeeding should be include by the
nurse?
- continue breastfeeding
An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right
side. The nurse should place the infant in which best position at this time?
Prone position
On the stomach
Right lateral position
Left lateral position
The nurse is creating a teaching plan for a school age child with a urinary tract infection
(UTI). Which should the nurse assess first?
Toileting habits
Calcium intake
Dietary intake
Activity level.
The nurse is assessing a child who might have diabetes. Which of the following laboratory
values would help confirm a diagnosis of type 1 diabetes?
A fasting plasma glucose level of 110 mg/dl

A 2 hour glucose tolerance test of 140 mg/dl
A random plasma glucose level of 180 mg/dl
A fasting plasma glucose level of 126 mg/dl
Which of the following signs would the nurse recognize as an indication of moderate
dehydration in a preschooler?
Sunken fontanel
Dry mucous membranes
Decreased urine specific gravity
Diaphoresis
The nurse understands that which information collected during the assessment of a
child recently diagnosed with glomerulonephritis is most often associated with the
diagnosis?
Child fell off a bike onto the handlebars
Streptococcal throat infection 2 weeks before diagnosis
Urticaria and itching for 1 week before diagnosis
Nausea and vomiting for the last 24 hours

Student Nurse Marissa is performing an assessment of a child who is to receive a
measles, mumps, and rubella (MMR) vaccine. The nurse notes that the child is allergic to
eggs. Which of the following would the student nurse Marissa anticipate being prescribed
for this child? Group of answer choices
Taking a careful history about the allergy and reporting this to the physician before
administering the MMR vaccine
Administering diphenhydramine (Benadryl) and acetaminophen (Tylenol) before
administering the MMR vaccine
Administering epinephrine (Adrenalin) before the administration of the MM
Eliminating this vaccine from the immunization schedule
AJ, age 7, was admitted to the hospital with symptoms of fatigue and fever and a
“cold that keeps hanging on.” His mother states that AJ has not been eating or
drinking much and is unable to tolerate school activities. He has had to stay
home for the past 3 days. In the admission history the nurse learns that AJ lives
alone with his mom. A diagnosis of Bronchitis was made after lab results were
reviewed. A nurse receives a telephone call from the emergency department and
is told that a 7-month-old infant with febrile seizures will be admitted to the
pediatric unit. When planning care for the admission of the infant, the nurse
would anticipate the need for which of the following?
A code cart at the bedside
Suction equipment and an airway at the bedside
A padded tongue blade taped to the head of the bed
Restraints at the bedside
John Robert a child is admitted to the pediatric unit of DLSMC with a diagnosis of
meningitis. Which of the following actions should the nurse perform? Select all
that apply.
Raise the head of the bed.
Dim the lights in the room.
Place the child on droplet isolation.
Administer intravenous antibiotics, as prescribed.
Perform passive range-of-motion exercises of the neck.

Place the child on droplet isolation.
Perform passive range-of-motion exercises of the neck. (EXCEPT)
Dim the lights in the room.
Administer intravenous antibiotics, as prescribed.
Raise the head of the bed.
Amira 10 year old child is experiencing high fever and neck pain is diagnosed
with viral meningitis. She was brought by her mother and accompanied by her
husband, looks anxious and worried about Amira's condition. Which of the
following should the nurse include in the discharge teaching? Group of answer
choices
Pad the child’s bed headboard.
Rent a commode for the child to use at home.
Administer over-the-counter analgesics as needed
Keep the child isolated until the temperature returns to normal.
JM, age 6, arrived at the Emergency Department with her mother at 5 PM. Her
mother reported that she had become lethargic in recent days. Her mother
became concerned when she felt warm to the touch and hadn’t urinated as much
as she normally would. The mother reports that JM had a strep throat 4 weeks
ago, but she recovered and she was fine up to a few days ago. Assessment
data: Temperature 101.3°F +1 pitting edema bilaterally arms and legs. Slight
edema around the eyes. Urine analysis showed hematuria, proteinuria, and
specific gravity is 1.034 g/mL. Blood serum shows elevated creatinine and BUN.
Urine culture and sensitivity is positive for streptococcal bacteria. A client who is
admitted to the hospital for an unrelated medical problem is diagnosed with
urethritis caused by chlamydial infection. The nursing assistant assigned to the
client asks the nurse what measures are necessary to prevent contraction of the
infection during care. The nurse tells the nursing assistant that: Group of answer
choices
Gloves and mask should be used when in the client’s room.
Contact isolation should be initiated, because the disease is highly contagious.
Enteric precautions should be instituted for the client.
Standard precautions are sufficient, because the disease is transmitted sexually
A young woman name Hope Angela single, unemployed is being seen in the
women’s health clinic in your area . She states that she had unprotected
intercourse about one month earlier, and she is worried that she may have
contracted HIV. Which of the following signs/symptoms would indicate that her
worries may be correct? Group of answer choices
Abnormally heavy menstrual period
Severe abdominal cramps accompanied by diarrhea
Macular papular rash covering her thorax
Exhaustion accompanied by muscle aches and pains
As part of the activity in given by the clinical instructor, the student nurse is
providing HIV education to a group of individuals. During the session, the nurse
discusses actions that have been shown to reduce the transmission of HIV.
Which of the following information did the nurse include in her discussion?
HIV is eradicated from the body when 2 to 3 different antiretroviral medications

are taken for at least one year.
Babies born to HIV positive mothers are less likely to contract HIV if they are
exclusively breastfed.
The HIV vaccination has been approved for men and women between the ages
of 16 and 26 years of age.
Circumcised men are less likely to contract and transmit HIV than are
uncircumcised men.
JM, age 6, arrived at the Emergency Department with her mother at 5 PM. Her
mother reported that she had become lethargic in recent days. Her mother
became concerned when she felt warm to the touch and hadn’t urinated as much
as she normally would. The mother reports that JM had a strep throat 4 weeks
ago, but she recovered and she was fine up to a few days ago. Assessment
data: Temperature 101.3°F +1 pitting edema bilaterally arms and legs. Slight
edema around the eyes. Urine analysis showed hematuria, proteinuria, and
specific gravity is 1.034 g/mL. Blood serum shows elevated creatinine and BUN.
Urine culture and sensitivity is positive for streptococcal bacteria. Initial testing for
human immunodeficiency virus (HIV) is performed because of the child’s
exposure to HIV infection. Which home care instruction should the nurse provide
to the parents of the child? Group of answer choices
Wash your hands with half-strength bleach if they come in contact with the child’s
blood.
Avoid sharing toothbrushes.
Wipe up any blood spills with a rag, and allow them to air dry.
Avoid all immunizations until the diagnosis is established.
Information and education campaign is a well known strategy use by the nurse in giving
information in our patient. During a duty in the Outpatient department , the nurse is
providing education to pregnant women who have a family history of severe allergies.
Which of the following information should the nurse convey regarding actions the
women should take to minimize their children’s potential for developing allergies? Group
of answer choices
When they begin to feed their infant solid foods, to begin serving high-allergy foods
shortly aft er low-allergy foods have been introduced
Delay feeding their infant any solid foods until the infant is seven to eight months of age.
Remove high-allergy foods from their diet during their pregnancy and while
breastfeeding.
If they decide not to breastfeed their baby, to feed the baby a soy-based rather than a
cow’s milk–based formula.
The nurse is providing education to pregnant women who have a family history of severe
allergies. Which of the following information should the nurse convey regarding actions
the women should take to minimize their children’s potential for developing allergies?
Remove high-allergy foods from their diet during their pregnancy and while
breastfeeding.
When they begin to feed their infant solid foods, to begin serving high-allergy foods
shortly aft er low-allergy foods have been introduced
If they decide not to breastfeed their baby, to feed the baby a soy-based rather than a
cow’s milk–based formula.
Delay feeding their infant any solid foods until the infant is seven to eight months of age.
A client with a wound infection and osteomyelitis is to receive hyperbaric oxygen

therapy. During the therapy, the nurse implements which priority intervention?
Administers sedation to prevent claustrophobia
Maintains an intravenous access

Provides emotional support to the client’s family
Ensures that oxygen is being delivered
Katrina Concepcion RN is assigned to take care of clients in the infectious unit.

Several clients are admitted for treatments of various conditions. The nurse is
discussing about infection control and prevention of transmission. The nurse
understand which of the following infections typically has an incubation period of
less than 2 weeks? Group of answer choices
Varicella
Rubella
Measles
Mumps
A nurse is assigned to take care of clients in the infectious unit. Several clients are admitted for
treatments of various conditions. The nurse is discussing about infection control and prevention of
transmission. The nurse understand which of the following infections typically has an incubation period
of less than 2 weeks?
Rubella
Measles
Varicella
Mumps
You are the nurse assigned to Baby Dasik and you are preparing a discharge
teaching to his parent about proper care. In addition to the familiar
maculopapular rash, measles is typically characterized by all of the following
EXCEPT:
Coryza
Cough
Conjunctivitis
Arthritis
Moderate or high fever
The nurse is assigned to a pediatric client is preparing a discharge teaching to his parent about proper
care. In addition to the familiar maculopapular rash, measles is typically characterized by all of the
following EXCEPT:
Arthritis
Cough
Conjunctivitis
Coryza
Moderate or high fever
A 3 year old boy has had a temperature of 39C and a stiff back for the last 3 days.
Examination shows a red throat, large non tender anterior and posterior cervical nodes,
and slight resistance of the neck to flexion. The nurse understands that Immediate
management should include which of the following? Group of answer choices
Lumbar puncture
Throat culture and oral penicillin for 7 days
Heterophil test
Throat culture, white blood cell count, and reexamiation in 24 hours
A 18 y/o commercial sex worker consulted a health clinic for yellowish vaginal
discharge, abnormal odor and vulvar pruritus. She’s single, but she uses oral
contraceptives. Speculum exam revealed vulvo-vaginal erythema and “colpitis
macularis” or “strawberry cervix”. This case is most likely Group of answer
choices
Bacterial vaginosis
Candidiasis
Trichomoniasis
Herpes simplex
Gonorrhea
The nurse-client relationship is significant in ensuring client cooperation in the

care. A child has been diagnosed with bacterial meningitis. The parent asks the
nurse how long the child will be in isolation. The nurse’s reply will be based on a
protocol that isolation continues: Group of answer choices
The antibiotics have been administered for 24 hours.
The antibiotics are initiated.
Ten days of antibiotic therapy have been completed.
The organism is located
Ten years after the local government of San Jaunico significantly increased the
budget for STI Prevention Program, the Sangguniang Bayan hired a nurse
researcher to evaluate the program. In relation to the public health implications of
gonorrhea diagnosed in a 16 year old nursing student, the nurse should be most
interested in: Group of answer choices
Finding the client’s contacts
The reasons for the client’s promiscuity
Instructing the client about birth control.
Interviewing the client’s parents
A nurse researcher was hired to evaluate the LGUs STI Prevention Program program. In relation to the
public health implications of gonorrhea diagnosed in a 16 year old nursing student, the nurse should be
most interested in:
Interviewing the client’s parents
Instructing the client about birth control.
Finding the client’s contacts

The reasons for the client’s promiscuity
A 4 year old child has been exposed to chickenpox. After the nurse has provided
information about chicken pox, the nurse asks the mother to repeat the
information. The statement by the mother that indicates a need for additional
information is: Group of answer choices
“I should monitor my child for Reye syndrome, which is a complication of

chickenpox.”
“My child should not visit my pregnant sister at this time.”
“During the prodromal period, my child will have pox all over his body.”
“Chickenpox is a viral infection that can be spread to other children.”
A child has been admitted with a history of a seizure 2 hours ago. The history
reports fever, chills, and vomiting for the past 24 hours. In report, the nurse is
told that the child has a positive Brudzinski’s sign. The nurse knows that this is
most likely caused by which of the following? Group of answer choices
Encephalitis
Intraventricular hemorrhage
Meningeal irritation
Increased intracranial pressure
o validate the applicability of the nursing intervention with the rapidly changing
technology based care of clients, the nurse should institute health care teaching.
A 12 year old child with HIV+ antibodies is going home from the hospital. Which
of the following are the most important home-going instructions? Group of
answer choices
Prevention of the spread of HIV
Growth and development milestones
Lab studies and results
Immunization schedules
Nurse Elaine is coordinating an educational session for middle school students in Paranaque
University regarding human immunodeficiency virus (HIV). The Nurse Elaine should advise
students that which of the following behaviors place them at high risk of contracting HIV?
Eating food prepared by an individual with HIV.
Engaging in oral intercourse with an individual with HIV.
Sharing marijuana cigarettes with an individual with HIV.
Using natural skin condoms while having sex with an individual with HIV.
Drinking alcoholic beverages out of the same container as an individual with HIV.

Sharing marijuana cigarettes with an individual with HIV.
Engaging in oral intercourse with an individual with HIV.
Using natural skin condoms while having sex with an individual with HIV.
Eating food prepared by an individual with HIV. Drinking alcoholic beverages out of the same
container as an individual with HIV.
Nurse Donna Imperial caring for a client in the emergency department of MDH, during a
procedure she is stuck by a contaminated needle. Which of the following actions should Nurse
Donna Imperial will perform? She should:
-begin post exposure prophylactic treatment within 72 hours of the HIV exposure
-be prepared to receive an intravenous infusion of HIV immune globulin in the emergency
departmen
Marcos a 7-year-old child has just had a lumbar puncture in the emergency department of
DLSMC for complaints of elevated temperature and a stiff neck. Which of the following cerebral
spinal fluid findings would indicate that this child has bacterial meningitis? -Glucose 20 mg/dL
Carlo a 1-year-old child is being seen in the pediatrician’s office accompanied by his parents.
The child is up to date on all immunizations. The mother asks, “Will my child need to receive
any shots today?” Which of the following responses by the nurse is appropriate?
–“The measles, mumps, and rubella (MMR); varicella (VAR); and hepatitis A (HepA) vaccines
are all given once the children reach one year of age)
A nurse is caring for a child who has been diagnosed with rubeola (measles). The nurse notes
that physicians has documented the presence of Koplik’s spots. On the basis of this
documentation, which of the following would the nurse expect to note during the assessment of
the child?
-Small, blue-while spots with a red base fund on the buccal mucosa.
An 18-year-old man Alfie Alonte reports to a nurse that he had unprotected anal intercourse
with a man 3 years earlier. When Nurse Hadji suggests that the patient have an HIV test, he
states, “Why, I’m fine. I don’t have any symptoms at all.” Which of the following responses by
Nurse Hadji would be appropriate to make?
“You should be tested anyway because it can take up to 10 years before any symptoms of the
disease are detected.”
“You are probably correct because having intercourse with an infected woman is much more
dangerous than with a man.”
“You are probably correct because unless you had gastrointestinal symptoms after you had
intercourse, you are probably not infected.”
“I understand that there is virtually no chance that you are infected, but it is recommended that
all who are 13 and older be tested.”
The clinic nurse reviews the record of an infant and notes that the health care provider has
documented a diagnosis of infectious disease. The nurse reviews the assessment findings
documented in the record. The nurse assesses a patient for signs of meningeal irritation and
observes her for nuchal rigidity. Which of the following indicates the presences of the signs of
meningeal irritation? -Resistance to flexion of the neck
A nurse is providing a teaching session for adolescents and their parents regarding HIV. Which
of the following information should the nurse include in the teaching session? Select all that
apply.
-It is recommended that all individuals aged 18 and older be tested for HIV
-A person can contract more than one strain of HIV, increasing the likelihood of the disease
progressing to AIDS
-The potential for contracting HIV increases when a person has intercourse with multiple
persons
-Although HAART help to delay the onset of AIDS, all patients with HIV will die within
approximately 20 years of the time of initial infection
Education is vital to give information to our patient specially the current situation happening to
us right now. Joy Sia a nurse is providing education to parents of young children regarding the
children’s potential for developing allergies. Joy informs the parents that which are the most
common allergies of childhood? -Foods
A newborn infant has been found to be human immunodeficiency virus (HIV) positive. When
teaching the infant’s mother, the Nurse Jericho should instruct the mother to:
Check the anterior fontanel for bulging and the sutures for widening each day.
Feed the infant with a special nipple and burp the infant frequently to decrease the tendency to
swallow air.
Provide meticulous skin care to the infant and change the infant’s diaper after each voiding or
stool.
Feed the infant in an upright position with the head and chest tilted slightly back to avoid
aspiration.
Baby Boy Joshua a 10-month-old infant has been exposed to chickenpox. Since you are the
nurse on duty in the area and as a nurse you would expect the baby’s primary health-care
provider to order which of the following interventions to prevent the baby from contracting the
illness?
Nothing because the baby is protected by the mother’s antibodies
Varicella immunization
Intravenous antibiotics
Varicella zoster immune globulin.
Marcos a 7-year-old child has just had a lumbar puncture in the emergency department of
DLSMC for complaints of elevated temperature and a stiff neck. Which of the following cerebral
spinal fluid findings would indicate that this child has bacterial meningitis?
Glucose 20 mg/dL
Markedly lower than normal pressure
White blood cell count 3 cells/mm3
Clear fluid
The research Committee of the San Timoteo Medical Center is reviewing the research proposals
from the different nursing departments of the hospital. The nursing staff has a team conference
on AIDS and discussed the routes of transmission of human immunodeficiency virus (HIV). The
nurse understands that the major risk factor for transmission of HIV virus infection from mother
to newborn is a mother who:
Has received blood products
Is promiscuous
Is a nurse in a dialysis unit
Has migrated from an endemic area
Is an IV drug abuser
The nursing staff has a team conference on AIDS and discussed the routes of transmission of
human immunodeficiency virus (HIV). The nurse understands that the major risk factor for
transmission of HIV virus infection from mother to newborn is a mother who:
Has received blood products
Has migrated from an endemic area
Is promiscuous
Is an IV drug abuser
Is a nurse in a dialysis unit
During an infection control seminar, the speaker specified the prevention measures in the
spread of HIV. The nurse is aware that the teaching should be understood by the clients who
attended the seminar. Which of the following statements mentioned by the clients needs
further teaching?
Needles should be disposed into a puncture resistant container
Blood spills should be cleaned with chlorox
Blood and other specimens should be labelled AIDS
Precaution Patients with AIDS should be isolated
The establishment of a therapeutic nurse-client relationship is the cornerstone for providing care
to clients. When explaining the occurrence of febrile convulsions to a parent’s class, the nurse
should include that they are common in children and:
Usually occur after the first year of life
May occur in minor illnesses
Occur more frequently in females than males

The cause is usually readily identified
During an infection control seminar, the speaker specified the prevention measures in the spread
of HIV. The nurse is aware that the teaching should be understood by the clients who attended
the seminar. Which of the following statements mentioned by the clients needs further teaching?
Needles should be disposed into a puncture resistant container
Blood and other specimens should be labelled AIDS Precaution
Patients with AIDS should be isolated
Blood spills should be cleaned with chlorox
In the management of clients with various health problems, the nurse should be equipped with
knowledge of various health problems. The nurse is caring for a child who is experiencing a
febrile seizure. Which nursing intervention takes a highest priority when caring for this child?
Use a padded tongue blade to protect the airway
Protect the child from injury
Allow seizure activity to end without interference
Shout at the child to end the seizure
An 18 month old child is observed having a febrile seizure. The nurse notes that the child’s jaws
are clamped. The priority nursing responsibility at this time would be:
Start oxygen via mask
Insert padded tongue blade
Protect the child from harm from the environment.
Restrain child to prevent injury to soft tissue

documented a diagnosis of infectious disease. The nurse reviews the assessment findings
documented in the record. The nurse assesses a patient for signs of meningeal irritation and
observes her for nuchal rigidity. Which of the following indicates the presence of this sign of
meningeal irritation?
Curling in a fetal position
Resistance to flexion of the neck
Tonic spasms of the legs
Arching of the neck and back
A 7-year-old child has just had a lumbar puncture in the emergency department for complaints of
elevated temperature and a stiff neck. Which of the following cerebral spinal fluid findings
would indicate that this child has bacterial meningitis?
- Glucose 20 mg/dL
Nurse Kathleen is assigned in the pediatric ward of Delos Santos Medical Center , she is
providing health promotion/disease prevention education to a group of parents confined in the
area. Which of the following information should the Nurse Kathleen will include in the
teaching?
A well-padded helmet should be worn by any child who plays a contact sport or rides a bicycle.
Aspirin should be administered to children who are sick with viral illnesses.
The parent should carefully check the tongue for injury whenever a child experiences severe
head trauma
The rotavirus vaccine will protect their children from the infection that causes meningitis.
The nurse assigned in the pediatric ward is providing health promotion/disease prevention
education to a group of parents confined in the area. Which of the following information should
the nurse include in the teaching?
A well-padded helmet should be worn by any child who plays a contact sport or rides a bicycle.
Aspirin should be administered to children who are sick with viral illnesses.
The parent should carefully check the tongue for injury whenever a child experiences severe
head trauma
The rotavirus vaccine will protect their children from the infection that causes meningitis.
A nurse is providing a teaching session for adolescents and their parents regarding HIV. Which
of the following information should the nurse include in the teaching session?
It is recommended that all individuals aged 18 and older be tested for HIV.
Th e potential for contracting HIV increases when a person has intercourse with multiple
partners.
A person can contract more than one strain of HIV, increasing the likelihood of the disease
progressing to AIDS.
Although HAART helps to delay the onset of AIDS, all patients with HIV will die within
approximately 20 years of the time of the initial infection.
Anyone who is diagnosed with hepatitis B or hepatitis C is at high risk for also being infected
with HIV.
A hospitalized child Martin Rivera develops exanthema (rash) that covers the trunk and
extremities. The nurse reviews the child’s health history and notes that the child was exposed to
varicella 2 weeks ago. The appropriate nursing intervention is to:
Assess the progression of the exanthema and report it to the physician.
Allow the child to play in the playroom until the physician can be contacted. Immediately admit
the client to any available bed.
Place the child in a private room on strict isolation.
Carlo a 1-year-old child is being seen in the pediatrician’s office accompanied by his parents.
The child is up to date on all immunizations. The mother asks, “Will my child need to receive
any shots today?” Which of the following responses by the nurse is appropriate?
“Children’s first influenza vaccination (IIV) is administered at one year of age, and it will be
given again every year at this same time.”
“Th e rotavirus (RV) vaccine will be given today to prevent severe diarrhea.”
“Th e last hepatitis B (HepB) vaccine is due to be administered.”
“Th e measles, mumps, and rubella (MMR); varicella (VAR); and hepatitis A (HepA) vaccines
are all given once children reach one year of age.”
The nurse places the young child scheduled for a lumbar puncture in a side lying position with
head flexed and knees drawn up to the chest. The mother asks why the child has to be
positioned this way. The nurse explains the rationale for the positioning is that:
Restraint is needed to prevent unnecessary movement
Injury to the spinal cord is prevented
Access to the spinal fluid is facilitated
Pain is decreased through this comfort measure
In the management of clients with various health problems, the nurse should be equipped with
knowledge of various health problems. A female toddler has a tonic-clonic seizure because of a
high fever. During the tonic-clonic stage of the seizure the nurse’s priority should be to:
Protect her from injury
Turn her on her side
Establish a patent airway
Call for additional help
A 14 year old girl awakens with a mild sore throat, low grade fever, and a diffuse maculopapular
rash, During the next 24 hours she develops tender swelling of her wrists and redness of her
eyes. In addition, there is mild tenderness and marked swelling of her posterior cervical and
occipital lymph nodes. Four days after the onset of her illness the rash has vanished. The most
likely condition of this 14 year old girl is:
Rubeola
Varicella
Roseola infantum
Rubella
The clinic nurse reviews the record of an adolescent and notes that the health care provider has
documented a diagnosis of sexually transmitted infection. The nurse reviews the assessment
findings documented in the record. The nurse understands that which of the following is
characteristic of secondary syphilis?
Serologic testing for syphilis generally active
Low grade fever, headache, malaise, sore throat, anorexia, and generalized lymphadenopathy
Non-infectious mucous patches
Asymptomatic chancre that is often missed
A mother overhears two nurses discussing a measles outbreak. The nurses are talking about the
incubation period. The mother asks the nurses why it is important to know the incubation
period for a childhood disease. The nurses reply would be based on the knowledge that the
incubation period:
Is a period of time when medications can prevent the development of symptoms.
Describes a period when the child might be contagious.
Determines the severity of the infection.
Varies depending on the age of the child.
documented a diagnosis of viral disease. The nurse reviews the assessment findings
documented in the record. The nurse understands that a viral disease that begins with
respiratory inflammation and skin rash and may result in grave complications is:
Rubella
Yellow fever
Varicella
Rubeola
Moira pediatric nurse is providing counselling to parents regarding an important action they can
take to prevent their children from developing bacterial meningitis. Which of the following
actions did the Nurse Moira will suggest?
-Teach children to wash their hands after toileting and before eating
Winnie, a 18 year old female, nursing student, present with endocervical purulent discharge and
urethritis. Gram stain of the exudates showed polymorphonuclear leucocytes and an absence of
gram negative intracellular diplococcic. The most likely sexually transmitted infection is:
- Chlamydia Trachomatis
To validate the applicability of the nursing intervention with the rapidly changing technology
based care of clients, the nurse should institute health care teaching. A 12 year old child with
HIV+ antibodies is going home from the hospital. Which of the following are the most important
home-going instructions? - Prevention of the spread of HIV
A female nursing student is very upset with her diagnosis of gonorrhea and asks the nurse,
“What can I do to prevent getting another infection in the future? The nurse is aware that the
teaching has been understood when the client states “My best protection is to:
- insist that my partner use a condom.
A mother overhears two nurses discussing a measles outbreak. The nurses are talking about the
incubation period. The mother asks the nurses why it is important to know the incubation period
for a childhood disease. The nurses reply would be based on the knowledge that the incubation
period: - Describes a period when the child might be contagious.
Appropriate management of client’s condition requires critical thinking. Infection in a bone can
reach the bone through bloodstream or from a nearby tissue frequently caused by
Staphylococcus aureus. Which of the following statements made by the parent of a child being
discharged with osteomyelitis requires further teaching by the nurse?
-I can stop the antibiotic when I see that my child is feeling better
Winnie, a 18 year old female, nursing student, presents with endo…. The most likely sexually
transmitted infection is: -Gonorrhea
A 14 year old girl awakens with a mild sore throat, low grade fever, and diffuse maculopapular
rash, during the next 24 hours -Rubella
Providing holistic nursing care requires an understanding of the disease process. A mother asks
the nurse how to tell the difference between measles -A high fever and koplik’s spots
A nurse receives a telephone call from the emergency department and is told that a 7 month old
infant with febrile seizures will be admitted to the pediatric unit. When planning care for the
admission of the infant, the nurse would anticipate the need for which of the following? -Suction
equipment and an airway at the bedside
An 18 year old man Alfie Alonte reports to a nurse that he had unprotected anal intercourse with
a man 3 years earlier. When Nurse Hadji suggests that the patient have an HIV test, he states
“Why, I’m fine. I don’t have any symptoms at all.” Which of the following responses by Nurse
Hadji would be appropriate to make?
-“You should be tested anyway because it can take up to 10 years before any symptoms of the
disease are detected”
A young man name Hope Angela single, unemployed is being seen in the women’s health clinic
in your area. She states that she had unprotected intercourse about one month earlier, and she is
worried that she may have contracted HIV. Which of the following signs/symptoms would
indicate that her worries are correct? -Exhaustion accompanied by muscle aches and pains
In the management of the clients with various health problems, the nurse should be equipped
with knowledge of various health problems. The nurse is caring for a child who is experiencing a
febrile seizure. Which nursing intervention takes highest priority when caring for this child?
-Protect the child from injury
A 18 y/o commercial sex worker consulted a health clinic for yellowish vaginal discharge.
Abnormal odor and vulvar pruritus. She’s single, but she uses oral contraceptives. Speculum
exam revealed vulvovaginal erythema and colpitis macularis or strawberry cervix. The case is
most likely: -Trichomoniasis
Febrile seizure – allow the client to verbalize
Meningitis – receive all the immunizations recommended for meningitis
Arthur Martinez, 1 year old infant together with his parents came into the emergency
room at 8 AM. His mother reported that he has been lethargic and coughing. His mother
said he had a temperature of 102.4°F during the overnight hours and he hasn’t been
feeling well for a week or so. She and her husband became concerned when his face
began turning red. Assessment data: Temperature 102.5°F. Periorbital edema.
Conjunctivitis. Red flat rash on the child’s face and faint the rash on his trunk. Severe
coughing. Watery nose. Swollen lymph nodes. The parents are unsure about the child’s
vaccinations.
A nurse is caring for the child who has been diagnosed with rubeola (measles). The
nurse notes that the physician has documented the presence of Koplik’s spots. On the
basis of this documentation, which of the following would the nurse expect to note
during the assessment of the child?
- Small, blue-white spots with a red base found on the buccal mucosa
Gavreel, age 6, arrived at the Emergency Department with her mother at 5 PM. Her mother reported
that she had become lethargic in recent days. Her mother became concerned when she felt warm to the
touch and hadn’t urinated as much as she normally would. The mother reports that Gavreel had a strep
throat 4 weeks ago, but she recovered and she was fine up to a few days ago.
Assessment data: Temperature 101.3°F +1 pitting edema bilaterally arms and legs. Slight edema around
the eyes. Urine analysis showed hematuria, proteinuria, and specific gravity is 1.034 g/mL. Blood serum
shows elevated creatinine and BUN. Urine culture and sensitivity is positive for streptococcal bacteria.
The nursing assistant assigned to the client asks the nurse what measures are necessary to prevent
contraction of the infection during care. The nurse tells the nursing assistant that:
Contact isolation should be initiated, because the disease is highly contagious.
Gloves and mask should be used when in the client’s room.
Enteric precautions should be instituted for the client.
Standard precautions are sufficient, because the disease is transmitted sexually
An infant with AIDS will be attending daycare. The daycare workers are concerned about spreading the
virus. The public health nurse is explaining to the workers the precautions they should take. These
precautions includes which of the following?
Minimizing contact with the infant when he is febrile.
Storing all of the infants supplies separately from the other children.
Always wearing gloves and isolation gowns when handling the infant.
Wearing gloves when changing the child’s diapers.
A nurse who works in the parent-child center of a large city hospital is responsible for health teaching of
both child and parent, discharge teaching, and the orientation of new nurses to the various units. When
the mother contracts German measles early in pregnancy, effects on the fetus may include all of the
following EXCEPT:
Cataract
Thrombocytosis
Patent ductus arteriosus
Glaucoma
Hepatosplenomegaly
The nurse while on duty at the primary health center is performing an assessment of a child who is to
receive a measles, mumps, and rubella (MMR) vaccine. The nurse notes that the child is allergic to eggs.
Which of the following would the nurse anticipate being prescribed for this child?
Administering diphenhydramine (Benadryl) and acetaminophen (Tylenol) before administering the

MMR vaccine
Taking a careful history about the allergy and reporting this to the physician before administering the
MMR vaccine
Eliminating this vaccine from the immunization schedule
Administering epinephrine (Adrenalin) before the administration of the MMR
A client and her infant have undergone testing for human immunodeficiency virus (HIV), and both
clients were found to be positive. The news is devastating, and the mother is crying. The nurse
determines that which intervention will meet the client’s needs at this time?
Calling an HIV counselor and making an appointment for the mother and infant
Listening quietly while the mother talks and cries
Describing the progressive stages and treatments of HIV
Examining with the mother how she got HIV

A mother with a child who is admitted in your institution says to the nurse , “I am afraid that my
child might have another febrile seizure.” The nurse makes which therapeutic statement to the
mother?
“Tylenol can prevent another seizure from occurring.”
“Tell me what frightens you the most about seizures.”
“Most children will never experience a second seizure.”
“Why worry about something that you cannot control?”

A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort
and begins to have episodes of vomiting. On further assessment, the nurse notes
abdominal distention. On the basis of these findings, the nurse should take which action?
Increase the intravenous fluids.

Administer an antiemetic.
Place the child in a Sims’s position.
Notify the health care provider (HCP).
A 14-year-old adolescent has just been fitted for a Milwaukee brace. Which nursing
diagnosis should take highest priority when working with an adolescent with scoliosis?
Anxiety related to outcome of treatment for scoliosis
Body image disturbance related to treatment of scoliosis
Fear related to treatment and unknown outcomes
Diversional activity deficit related to treatment of scoliosis
An adolescent on consolidation chemotherapy for acute lymphocytic leukemia (ALL) asks

the nurse to come quickly to evaluate “blood in my urine.” The nurse would do which of the
following as the most important action?
Recognize that this is untoward and report the event.
Measure intake and output.
Explain this is normal for these drugs.

Force fluids to improve the hematuria.
A child is receiving chemotherapy to induce remission in acute leukemia. When considering

common side effects of chemotherapy, an appropriate nursing diagnosis early in the
course of therapy would include: Group of answer choices
Risk for impaired tissue perfusion: peripheral
Sleep pattern disturbance
Risk for infection
Altered mucous membranes
A nurse in the newborn nursery prepares to admit a newborn infant with spina bifida,
myelomeningocele type. Which nursing action is most important for the care for this infant?
Monitoring the specific gravity of the urine
Monitoring the blood pressure
Monitoring the temperature
Inspecting the anterior fontanel for bulging
A 5 month old infant is being assessed for developmental dysplasia of the hip. The nurse
completes an orthopedic assessment on this child. The nurse will look for a positive: Group
of answer choices
Barlow's sign
Allis sign
Ortolani sign
Trendelenburg sign
Parent of an unborn infant have just learned that based on ultrasound, their infant has
clubfoot. They ask the nurse how clubfoot is treated. Which of the following treatments
should the nurse discuss with the parents?
Weekly cast changes with manipulation

Probable surgery on the affected limb
Use of a Dennis Brown splint to achieve correction
Abduction device to keep the hip in full abduction
You are assigned to the postoperative care of a client with a below-the-knee amputation for
osteogenic sarcoma. Nursing care of the child would include:
Maintaining bedrest until able to use permanent prosthesis
Applying a dressing to the stump that allows continuous visualization of the distal stump.
Keeping stump elevated continuously until prosthesis applied.
Encouraging early visits from friends.
A child is placed in skeletal traction for treatment of a fractured femur. The nurse develops
a plan of care and includes which intervention?
Ensure that the weights are resting lightly on the floor.

Restrict diversional and play activities until the child is out of traction.
Check the health care provider’s (HCP’s) prescriptions for the amount of weight to be
applied
Ensure that all ropes are outside the pulleys.
The parents of a child with neutropenia secondary to chemotherapy have been taught
protective isolation behaviors. Nursing observations that indicate a need for further
education is when the parents:
Wash their hands before entering the child’s room but not upon exiting the room.
Bring the child toys from home.
Pull the child in a wagon around the nursing unit for entertainment.
Encourage friends to visit by phone rather than visit.
A 14-year-old adolescent has just been fitted for a Milwaukee brace. Which of the following
should the nurse include in teaching about this brace?
The brace should be worn next to the skin.
Exercises to increase pelvic tilt should be done several times per day while in the brace.
The brace should be worn only when the adolescent is sleeping or in the recumbent
position.
The adolescent should experience no pain as a result of wearing this brace.
A young child has just been diagnosed with cerebral palsy. The nurse is teaching the
parents how to meet the dietary needs of their child. The nurse would explain that children
with cerebral palsy frequently have special dietary needs or feeding challenges because:
The child’s inactivity increases the risk of obesity.
The paralysis of their muscles decreases their caloric need.
All children with cerebral palsy require assistance with feedings.
The spasticity of muscles increases their caloric need.
A client is to begin radiation therapy after the removal of Wilm’s tumor. The parent statement that
indicates a lack of understanding of related skin care would be:

“We will protect our child from sun exposure.”
“We will keep the area moist with Vaseline.”
“We will use loose-fitting clothes on our child.”
“We will prevent our child from scratching the site.”
Knowing the stages of bone healing, the second and third stage would need which type of cells:
Osteoclasts
Osteoblasts
osteocytes
osteon
The laboratory results of the client with leukemia indicate bone marrow depression. The nurse should
encourage the client to:
Sleep with the head of his bed slightly elevated
Drink citrus juices frequently for nourishment
Use a soft toothbrush and electric razor
Increase his activity level and ambulate frequently’
Post amputation of the left lower extremity, the client is withdrawn and refuses to look at his
stump when the dressings are being changed. The nurse may do all of these interventions
EXCEPT one:
Demonstrate acceptance
Encourage verbalization of fears
Encourage to participate in his own care
Offer emotional support
Following the application of the cast, the patient complained of abdominal pressure, feeling of tightness
or bloating and inability to take deep breath. These indicate signs of:
Nerve impairment
Circulatory impairment
Plaster sore
Cast syndrome
Whenever there is fracture, we try to give first aid management. We splint the fractured extremity
though our goal is to obtain union of the fractured bones. We call this:
Recognition
Retention
Reduction
Rehabilitation
Nurse Lara performs assessments in the well-baby clinic. She identifies which of the following as a
warning sign of Cerebral Palsy:
The infant smiles at the mother by 3 months
The infant uses arms and legs to crawl across the room
The infant has poor head control after 3 months
The infant sits with support by 8 months
Which of the choices below is the nurses’ initial priority for a child with acute lymphocytic leukemia?
Encouraging adequate intake of iron-rich foods
Instituting infection control precautions
Administering medications via IM injections
Assisting with coping with chronic illness

A child is admitted with osteogenesis imperfecta. Which of the following statements made
by a parent of a child with OI needs clarification by the nurse?
“My child will need to be home schooled to protect him from injury.”
“My child may be able to participate in sports.”
“There are no medications available to help this disease process.”
“Surgery may be needed to place rods in the bone for stability.”
Upon performing a physical assessment of a 7-year-old child, the nurse notes an abnormal
finding that could suggest cerebral palsy. The finding suggestive of cerebral palsy is that
the child has:
Absence of tongue extrusion.
No Moro or startle reflex
Positive tonic neck reflex
No head lag when pulled to a sitting position.
The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull
fracture. The nurse reviews the health care provider’s (HCPs) prescriptions and should
contact the health care provider to question which prescription?
Suction as needed
Obtain daily weight
Provide clear liquid intake
Maintain a patent intravenous line.

A 6 year old child has a cast applied for a fractured radius. The nurse completes an
orthopedic assessment on this child. Which of the following symptoms requires immediate
attention and should be reported to the physician.
Skin surrounding the cast is warm
Edema in the affected fingers that improves with elevation
Child describing feeling of the affected hand being asleep.
Capillary refill of 4 seconds in the affected hand
Chemotherapy is a usual therapeutic management in clients with leukemia. Which of the

following statements about chemotherapy is true?
it affects both normal and tumor cells
it has been proven as a complete cure for cancer
it is often used as a palliative measure
it is a local treatment affecting only tumor cells
Management for both sprain and strain is RICES. What nursing intervention can we
implement for the R in RICES?
Application of cold compress
Application of elastic bandage
Brace or cast
Crutches
For a client with hip dislocation, proper positioning can prevent further hip problem by:
Position leg in adduction
Externally rotate the feet
Position leg in abduction
Keep both knees together
A child is being treated for ALL. He is in this stage wherein the goal is to prevent leukemia
cells from invading the CNS. This is called:
CNS prevention therapy
Consolidation Therapy
Induction therapy
Maintenance therapy
A parent asks Nurse Lara to tell her what cerebral palsy is. Nurse Lara’s best response
would be that it is a:
Complication of the birth process that causes brain damage
Disorder of the brain that results in mental retardation
Brain disorder that involves seizures
Motor disability caused by a non-progressive disturbance in brain development
Parents bring their 2-week-old infant to a clinic for treatment after a diagnosis of clubfoot
made at birth. Which statement by the parents indicates a need for further teaching
regarding this disorder? Group of answer choices
“Treatment needs to be started as soon as possible.”
“I realize my infant will require follow-up care until fully grown.”
“I need to bring my infant back to the clinic in 1 month for a new cast.”
“I need to come to the clinic every week with my infant for the casting.”
The nurse is assisting a health care provider (HCP) examining an infant with developmental
dysplasia of the hip perform an Ortolani maneuver. The nurse understands that this
maneuver is performed for which purpose?
To push the femoral head out of the acetabulum
To assess for hip instability
To ensure that hyperextension and full range of motion exist
To assess for movement of the hips
A common problem in children is the inflammation of the middle ear. This is related to the
malfunctioning of the: Group of answer choices
Tympanic membrane
Eustachian tube
Nasopharynx
Adenoid
An adolescent with osteosarcoma is a candidate for amputation of the lower extremity.

During the conference, doctors agreed that they will remove the tumor and the adjacent
tissue excluding the limb from amputation.
Total joint prosthesis

Rotation plasty
Limb salvage
Surgical excision
Nurse Shelly is observing a child diagnosed with autism. Nurse Shelly expects to observe which
characteristic of this disorder:

Normal verbal but abnormal nonverbal communication
Associative play
Lack of social interaction
Normal responses to sensory stimuli only
Following the diagnosis of Wilm’s tumor, the child undergoes removal of the affected kidney. In
the post-operative period, priority nursing assessments should focus on:
Temperature
Lung sounds
The incision
Kidney function
From your knowledge of clubfoot what is the least invasive therapeutic procedure done?
Tendon Transfer
Varus Derotation Osteotomy
Percutaneous Tenotomy
Ponsetti method
In children, there are many diagnostic procedures which can be done to determine if
leukemia cells had reached the brain. This is called:
Bone scan
Lumbar Tap
Cytogenetics
Bone marrow aspiration
The nurse is caring for a child with cancer of the kidney. Child has a very
distended abdomen accompanied by abdominal pain. What is her priority
nursing responsibility pre operatively? Group of answer choices
Closely monitor arterial blood gases
Prepare child and family for long-term dialysis
Avoid abdominal palpation
Prepare child and family for renal transplantation
Chemotherapy has several side effects. As a nurse taking care of a child

undergoing chemotherapy, we understand that the child may have
stomatitis. We have several nursing interventions to prevent discomfort on
patients with stomatitis: Group of answer choices
Balanced diet
Bland food
Low residue
diet
small frequent, high calorie, high potassium, high protein diet
A 3 day old infant is born with a myelomeningocele. The nurse caring for
the neonate should place the infant in which of the following positions?
Fowler's
Trendelenburg's
Prone
Side lying
An infant is placed in a Pavlik harness for developmental dysplasia of the hip. Which of the
following statements made by a parent indicates correct knowledge of the care of this infant?
“It will take a long time for my child to wake and crawl.”
“The straps of the harness should be placed next to the skin.”
“I can move my child around on a large skateboard.”
“The harness should be worn for 6 hours a day.”
An infant is placed in a pavlik harness for developmental dysplasia of the hip. Which of the
following statements made by the parent indicates correct knowledge of the care of this
infant?
I can move my child around on a large skateboard
The harness should be worn for 6 hours a day
The straps of the harness should be placed next to the skin
It will take a long time for my child to wake and crawl
The nurse is providing client education for a family whose child has cerebral palsy and is
receiving baclofen epidural therapy to control spasticity. Which of the following is most
important for the nurse to include in the discussion?
The drug acts to inhibit the neurotransmitter
The child should be able to run with normal gait after insertion of the pump
Parents must bring the child back to the clinic on a regularbasis to have more medicine added
to the pump
Parents can be taught to regulate the dosage on the sliding scale
A child is admitted with osteogenesis imperfecta. Which of the following nursing

diagnoses takes highest priority for the child hospitalized with osteogenesis imperfecta?
Body image disturbance related to short stature
Risk for injury related to disease state

Pain related to fractures
Impaired skin integrity related to cast
A newborn is being admitted to the newborn nursery. The nurse would assess the
infant for congenital defects. In addition to the abnormal position of the foot, the nurse
would note which of the following if clubfoot is present.
Affected foot is cooler
Affected limb is larger
There is calf muscle atrophy of the affected limb
Affected foot is larger and

longer
A 14-year-old adolescent has just been fitted for a Milwaukee brace. Which of the following
symptoms is not typical in an adolescent with idiopathic structural scoliosis?
Skirts that hang unevenly
Back pains
Uneven waist angles
Unequal shoulder heights
The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the
child is experiencing a painful exacerbation of the disease. The parents ask the nurse if
the child can perform the range-of-motion exercise at this time. The nurse should make
what response?
Have the child perform simple isometric exercises during this time
Administer additional pain medication before performing ROM exercises
Avoid all exercise during painful periods
ROM exercises must be performed everyday

A child with a myelomeningocele is started on a bowel management plan. The child’s mother
questions why this is being done. The nurse’s response will be based on the understanding that:
Lack of innervation to the colon predisposes the child to diarrhea.
Lack of mobility decreases the need for regular bowel movements.
Lack of innervation to the anal sphincter predisposes the child to being incontinent
Lack of mobility increases the gastric-colic reflex.
A child with a myelomeningocele is started on a bowel management plan. The child’s mother
questions why this is being done. The nurse’s response will be based on the understanding that:
Lack of innervation to the colon predisposes the child to diarrhea.
Lack of mobility decreases the need for regular bowel movements.
Lack of innervation to the anal sphincter predisposes the child to being incontinent
Lack of mobility increases the gastric-colic reflex.
The nurse is providing instructions to the parents of a child with scoliosis regarding the
use of a brace. Which statement by the parents indicates a need for further
instruction?
I will encourage my child to perform prescribed exercises
I should apply lotion under the brace to prevent skin breakdown

I will gave my child wear soft fabric clothing under the brace
I should avoid the use of the powder because it will cake under the brace
A child is admitted with osteogenesis imperfecta. In reviewing laboratory findings the

nurse would expect to find abnormal growth levels of:
Vitamin D
Phosphorous
Precollagen type 1
Calcium
The parent of a child with neuroblastoma verbalizes regret at not coming in earlier for the
client’s complaints. An appropriate response is:
This is the most common childhood cancer.
This is a silent tumor, which is difficult to diagnose early
This is very common brain tumor in children.
This tumor maybe diagnosed early because of obvious symptoms.
The parents of a child recently diagnosed with cerebral palsy ask the nurse about the
disorder. The nurse bases the response on the understanding that cerebral palsy is which
type of condition?
A chronic disability characterized by impaired muscle movement and posture
an infectious disease of the central nervous system
An inflammation of the brain as a result of viral illness
A congenital condition that results in moderate to severe retardation
A child will be undergoing chemotherapy. The nurse discusses the issue of hair loss
with the child and family before chemotherapy begins. Later the family questions the
nurse on why this information was given to the child at this time. The nurses response
will induce the information that:
Hair loss can be prevented with appropriate nursing interventions
It is the nurses legal responsibility to discuss the issue with the child
The presence or absence of hair is related to body image. Strategies for handling hair
loss should precede the event
A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia

of the hip. On assessment, the nurse understands that which finding should be noted in
this condition?
Limited range of motion in the affected hip
An apparent lengthened femur in the on the affected side
Asymmetrical adduction of the affected hip when the infant is placed supine with the
knees and hips flexed
Symmetry of the gluteal skin folds when the infant is placed prone on the legs are
extended against the examining table
Which of the choices below is the nurse's initial priority of a child with acute lymphocytic
leukemia?
Encouraging adequate intake of iron-rich food

Instituting infection control precautions
Administering medications via IM injections
Assisting with coping with chronic illness
The nurse is caring for a child with cancer of the kidney. Child has a very dentended
abdomen accompanied by abdominal pain. What is her priority nursing responsibility
pre operatively?
Prepare the child and family for long term dialysis
Avoid abdominal palpation
Closely monitor arterial blood gases
Prepare child and family for renal transplantation
A 4-year-old is diagnosed with acute lymphocytic leukemia. Following teaching about the
testing and therapy, the nurse evaluates the family’s understanding of the problem. The
statement by the family that indicates appropriate knowledge would be:
Tests will determine the extent of the tumor process and support the need for palliation
Tests will determine if surgery is needed
Tests will determine the extents of the malignant process and stage the leukemia
Tests will help to determine if the radiation or chemotherapy should be used in the
treatment
The nursing diagnosis for a child undergoing chemotherapy for leukemia is altered
nutrition: less than body requirements related to nausea and anorexia. An appropriate
goal for this client would be:
The child does not complain of nausea
Intake and output are approximately equal
The child’s caloric intake will be within normal range

Administer antiemetics PRN
A 4-year-old child sustains a fall at home and after an x-ray examination the child is
determined to have a fractured arm and a plaster cast is applied, the nurse provides
instructions to the parents regarding care for the child's cast. Which statement by the
parents indicates a need for further instruction?
A small amount of white shoe polish can touch up a soiled white cast
I can use lotion or powder around the cast edges to relieve itching
if the cast becomes wetm a blow dryer set on the cool setting may be used to dry the
cast
The cast may feel warm as the cast dries
An adolescent is being admitted for an amputation to a bone tumor. Which age-related

nursing diagnosis is most appropriate?
Risk for disuse syndrome
Body image disturbance
Activity intolerance
Self-care deficit
The laboratory results of the client with leukemia indicate bone marrow depression. The
nurse should encourage the client to:
Increase his activity level and ambulate frequently
Drink citrus juices frequently for nourishment
Sleep with the head of his bed slightly elevated
Use a soft toothbrush and electric razor

A child has been treated with chemotherapy for cancer. Neutropenia is an expected
consequence. The nurse would teach the parents to do which of the following,
anticipating that neutropenia may occur?
Avoid spicy foods
Avoid crowded spaces
Avoid contact sports
Avoid all immunizations

1. A mother attends the pediatric clinic with her child for consultation. The child is being
evaluated by the nurse. The child was just diagnosed with impetigo. What is the most
important action the nurse should take to make sure it does not spread? Group of
answer choices
Apply Bacitracin
Isolate the child at home
Keep it covered.
Teach and use good handwashing.
evaluated by the nurse. The child, 18 months old has been diagnosed with scabies.
Lindane has been prescribed for the child. The nurse questions the prescription if which
is noted in the child’s record?
The child is 18 months old.
The child has a history of frequent respiratory infections.
A sibling is using Lindane for the treatment of scabies.
The child is being bottle-fed.
evaluated by the nurse. In teaching the childm the nurse would explain that lice on the
child can be most easily spread by:
Riding on the same bus
Sharing hats at recess

Riding in the same car
Sitting close to someone who had lice
evaluated by the nurse. When assessing the client who has been beaten and abused,
the nurse is aware that potential nursing diagnosis for this client at tis time would be:
Disturbed thought processes related to fear of the attacker
Ineffective coping related to difficulty assimilating the situation
Social isolation related to embarrassment over the sexual attack (SABI NI THEA)
Interrupted family processes related to the husband’s feelings about the attack
evaluated by the nurse. The nurse is providing a teaching session for the mother about
the over-the-counter treatment for head lice. Which of the following will be mentioned as
appropriate for treating this problem?
Silver sulfadiazine
Neosporin
Mafenide
Permethrin
evaluated by the nurse. The mother told that there’s an outbreak of scabies at her
child's day care center. The nurse should instruct the mother to check her child for
which findings associated with scabies infestation?
Oval white dots adhered to the hair shafts
Pain, erythema and edema at the site of the bite
Pruritic papules, pustules, and linear burrows of the fingers and toe webs
Diffuse pruritic wheals
evaluated by the nurse. The child is diagnosed with head lice and the mother asks how
she should get the nits out of her child’s hair. The nurse should tell the mother that:
Combing the hair after shampooing is necessary
Treatment should be repeated every day for

7 days
All children that had contact with the child should be prophylactically treated.
The treatment should be repeated in 7 to 12 days
evaluated by the nurse. A physical assessment is performed on the suicidal client upon
admission to the inpatient unit. The nurse understands its importance because it
provides information regarding: Group of answer choices
Both subjective and objective baseline data
Existing medical problems and complaints
Evidence of physical self-harm
The presence of abnormalities
evaluated by the nurse. The nurse explains to the mother that the child who has begun
treatment for impetigo with a topical antibiotic can return to daycare:
As soon as crusts are evident
When crusts fall off
Immediately
After 48 hours
evaluated by the nurse. When teaching the mother how to use and anti lice shampoo,
the nurse should include the information that she should:
Use hot water for both shampoo and rinse.
Apply about 2 ounces of shampoo to wet hair.
Use ample shampoo to cover the hair
Leave the shampoo on hair for 20 to 30 minutes before rinsing

evaluated by the nurse. The adolescent was assessed to be dependent on drugs.
During the assessment, which action should the nurse take to plan appropriate nursing
care? Group of answer choices
Ask the client why he started taking illegal drugs.
Ask the client about the amount of drug use and its effect
Ask the client how long he thought that he could take drugs without someone finding
out.
Not ask any questions for fear that the client is in denial and will throw the nurse out of
the clinic.
evaluated by the nurse. Permethrin is prescribed for a child with a diagnosis of scabies.
The nurse should give which instruction to the mother regarding the use of this
treatment. Group of answer choices
Apply the lotion to areas of the rash only.
Avoid putting clothes on the child over the lotion.
Apply the lotion to cool, dry skin at least 30 minutes after bathing.
Apply the lotion and leave it on for hours
evaluated by the nurse. The mother tells the nurse that the child has been scratching
the skin continuously and has developed a rash. The nurse assesses the child and
suspects the presence of scabies. The nurse bases this suspicion on which finding
noted on assessment of the child’s skin.
Fine grayish red lines
Thick honey colored crusts
Purple colored lesions

Clusters of fluid filled vesicles
evaluated by the nurse. The child is 2 year old with multiple fractures and bruises ad
abuse is suspected. The nursing assessment that most supports this diagnosis in this
child is: Group of answer choices
Thumb sucking
Bed wetting
Demand for physical closeness
Underdevelopment for age
evaluated by the nurse. The nurse has provided an instructional session about impetigo
to the mother. Which statement, if made by the mother, needs further instruction?
“It might show up in an area of broken skin, such as an insect bite.”
“Lesions most often are located on the arms and chest.”
“It is extremely contagious.”
“It is most common in humid weather.”
evaluated by the nurse. Hospitalization of a critically ill child results in the disturbance of
the dynamics in family life. The most appropriate nursing diagnosis is:
Diversional activity deficit related to separations from siblings and peers.
Sleep pattern disturbance related to unfamiliar surroundings

Ineffective individual coping related to procedures
Altered family processes related to hospitalization
evaluated by the nurse. The child has informed his friends and family that he plans to
commit suicide. As the school nurse, you further investigate this child’s comments. Your
actions are based on which of the following?
Most adolescents threaten to commit suicide.
If he does not have a specific plan, then he is not serious.
Threats of suicide should not be ignored.
No intervention is required because he has made these threats in the past.
evaluated by the nurse. When performing a health screening on the adolescent, you
would determine he is at a higher risk of suicide than other adolescents of his age
based on which of the following facts that he discloses?
He states that he is homosexual

He states that he only has a small group of close friends
He states that he often skips meals and does not worry about nutrition
He states that he sleeps late on the weekends.
evaluated by the nurse. When assessing the child’s hair and scalp, the nurse notices
what looks like dandruff but it does not flake off easily. The nurse suspects the child
has: Group of answer choices
Pediculosis capitis
Scabies
Impetigo
Eczema
A mother attends the pediatric clinic with her child for consultation. The child is being
evaluated by the nurse. When the client atempt suicide, an immediate short-term
goal during this crisis situation would be to:
Strengthen coping skills

Recognize why suicide was attempted
Restore psychologic balance
Learn problem solving techniques
evaluated by the nurse. Pediculosis capitis (head lice) was considered. Which
findings indicates the child had a “positive” head check?
Maculopapular lesions behind the ears

Lesions in the scalp that extend to the hairline or neck
White sacs attached to the hair shaft in the occipital area.
White flaky particles throughout the entire scalp region.
evaluated by the nurse. A plan of care to best meet the needs of a neglected child:

A vigorous schedule of stimulation geared to the infants present level of
development.
A plan to have staff members pick up and play with the child whenever they
can.
A schedule of care that allows the infant stimulation and physical contact by several
staff members.
As consistent a caregiver as possible, with stimulation that is moderate and
purposeful.
evaluated by the nurse. The child is 2 year old with multiple fractures and bruises ad
abuse is suspected. If there is suspicion of chid abuse, the nurse must:

Report suspicions to the police
Report suspicions to the physician
Refer parents to a therapy group
Elicit more information from parents
evaluated by the nurse. A nurse is teaching parents how to reduce the spread of
impetigo. The nurse should encourage parents to:
Isolate the child with impetigo from other members of the family
Teach children the importance of proper hand washing
Teach children to cover their mouths and noses when they sneeze
Have their children immunized against impetigo
A mother attends the pediatric clinic with her child for consultation. The child is
being evaluated by the nurse. Which of the following would be appropriate home
care instructions for the mother with the child that has a lice infestation? Group of
answer choices
Vacuum floor and furniture to remove hair that might have live nits.
Take the child’s clothing and bed linens to a dry cleaner for sanitation.
Use commercial anti-lice sprays on furniture and mattresses.
Immerse combs and brushes in boiling water for 30 minutes to kill lice.
evaluated by the nurse. Parents can be expected to experience a grief process when
they are told their child will be physically or cognitively challenged or is terminally ill.
During conversation, the mother state that “ How could this have happened?’. This
reaction pertains to what stage of grief?
Bargaining
Anger
Depression
Denial
evaluated by the nurse. When the client atempt suicide, an immediate short-term goal
during this crisis situation would be to:
Learn problem solving techniques
Restore psychologic balance
Recognize why suicide was attempted
Strengthen coping skills
evaluated by the nurse. Which finding should lead the nurse to suspect impetigo?
Small, red lesions on the trunk and in the skin folds
Vesicular lesions with drainage, forming crusts on the face and extremities
A discrete pink-red maculopapular rash that starts on the head and progresses down
the body
Red spots with a blue base found on the buccal membranes
evaluated by the nurse. The child is being treated with Elmite for scabies. The child’s
mother is concerned that the drug hasn’t been effective because her child continues to
scratch. Which response by the nurse is most appropriate?
Apply the drug every day until the rash disappears.
Stop treatment because the drug isn’t safe for children under age 2.
Tell the mother that pruritus is common under age 5 treated with Elmite
Tell the mother that pruritus can be present for weeks after treatment.
evaluated by the nurse. Permethrin 5% was prescribed to the child diagnosed with
scabies. What instructions should the nurse provide for the mother?
Apply lotion only after the child has had a bath and dried throughly
Leave the lotion on for 4 to 6 hours
Apply the lotion liberally from head to toe
Wrap the child in a clean sheet after treatment
2-3 FA #1 on Health Statistics- MCQ 15 items
Which of the following is not a function of the public health nurse in Vital Statistics?
- Consolidate Data
The public health nurse is responsible for presenting the municipal health statistics using graphs and
tables. To compare the frequency of the leading causes of mortality in the municipality, which graph
will you prepare?
- Bar
To describe the sex composition of the population, which demographic tool may be used?
- Any of these may be used
You are computing the crude rate of your municipality, with a total population of about 18,000 for
last year. There were 94 deaths. Among those who died, 20 died because of diseases of the heart and
32 were aged 50 years or older. What is the crude death rate?
- 5.2/1000
Which statistic can give the most accurate reflection of the health status of a community?

1-4 year old age-specific mortality rate
- Swaroop’s index
In 2019, Barangay 395 had an average population of 1,655. 46 babies were born in that year, 2 of
whom died less than 4 weeks after they were born. There were 4 recorded stillbirths. What is the
neonatal mortality rate?
- 43.5/1000
Which statistics best reflects the nutritional status of a population?
- 1-4 year old age-specific mortality rate
What numerator is used in computing general fertility rate?
- Number of registered live birth
Civil registries are important sources of data. Which law requires registration of births within 30 days
from the occurrence of the birth?
- RA 3753
As an epidemiologist, the nurse is responsible for reporting cases or notifiable diseases. What law
mandates reporting cases of notifiable diseases?
- Act 3573
Which of the following is a natality rate?
- Crude birth rate
You are computing the crude death rate of your municipality, with a total population of about 18,000,
for last year. There were 94 deaths. Among those who died, 20 died because of diseases of the heart
and 32 were aged 50 years or older. What is the crude death rate?
- 5.2/1,000
An example of Exhaustive Data
- Why did you choose Pills as a Family Planning Method?
A graphical presentation of the age and sex composition
- Problem Tree or Population pyramid

4-3 FORMATIVE QUIZ #2B
-Who
-When
-Where
The ecologic model that usually illustrates the causation of Coronary Heart Disease in most
clients is:
- Web Model
A disease that was reported fewer than 10 cases per year, last week, 1 case was reported, 3
months ago, 2 cases were reported. It can be described as:
- Sporadic
- The natural history of Disease

Which term best describes the pattern of occurrence of a disease where there were 50-60 cases
per week and last week was 58 cases.
- Endemic
5-1 Summative Assessment #1
Question 31
Differentiate the different ecologic models and explain its importance in doing the Nursing
Process especially in the Community setting
There 3 different ecologic models which are the lever, the wheel, and the web. In the lever
model, the disease develops as a result of an imbalance in the interactions among three key
players: the host, agent, and environment. When a disease-causing agent is introduced into a
suitable environment on a vulnerable host, the disease is activated. In the wheel model, since
the agent is no longer the only factor contributing to illness, this theory focuses on the myriad
ways in which these factors interact. In addition, genetics is now a factor. There are three
sections to the outside circumference: environmental, biological, and physical. Also, genetic
predisposition are shown in the center. Lastly, in the web model, multiple causes producing a
disease cannot be described by a linear causal relationship because there are complex
antecedents to each causative factor in the chain that have their separate complicated
interactions that overlap. The result is the impression of a complex network of interconnections
rather than a simple linear causal relation. Moreover, it is important to establish ecologic models
for comprehending the many and interconnected factors of health behavior as nursing process
aids in identifying the client's health care requirements, establishing priorities, setting objectives,
and determining the expected results of treatment. It also provides nursing interventions tailored
to the client's or community's needs.
Question 32
Explain the Natural History of Disease and how it will help you in doing Nursing Process
From what I’ve learned, It is vital to know the natural history of disease because it helps us
comprehend how an illness progresses from onset through cure or death. Natural history is
equally as important as knowing the causes of disease for disease prevention and treatment. It
will help me in the nursing process because the sooner I discover the etiology of a patient’s
illness, the better my chances of planning and saving lives.
Question 1
● Violence
● Injuries
● Communicable or Infectious Diseases
● Emerging diseases
● Non communicable or non-infectious diseases
Question 2
Pattern of disease occurrence of a disease that is usually no more than 3-5 cases per week.
Last week, there were 20 cases reported.
● Endemic
● Pandemic
● Sporadic
● Epidemic
Question 3
Nursing, together with public health, is one of the helping professions in the health care system
which operates at three level of clientele. these are;
● Biological and social science, ecology. clinical nursing
● Individuals. families and communities
● Medical Officer. Public Health Nurse, Rural Health Midwife
● Community diagnosis, vital statistics, priority setting
Question 4
The public health nurse is responsible for presenting the municipal health statistics using graphs
and tables. To compare the frequency of the leading causes of mortality in the municipality,
which graph will you prepare?
● Pie
● Line
● Scatter Diagram
● Bar
Question 5
A public health nurse has different roles in the community, one of her roles is to identifies needs,
priorities, and problems of individuals, families, and communities, this term refer to?
● Trainer/ Health Educator
● Planner/ Programmer
● Provider of Nursing care
● Community organizer
Question 6
The rate or number of deaths from COVID 19 is referred to as:
● Health status
● Health conditions
● Morbidity
● Mortality
Question 7
In 2019, Barangay 395 had an average population of 1,655. 46 babies were born in that year, 2
of whom died less than 4 weeks after they were born. There were 4 recorded stillbirths. What is
the neonatal mortality rate?
● 27.8/1000
● 86.9/1000
● 130.4/1000
● 43.5/1000
Rationale: nasa last formative
Question 8
Which term best describes the pattern of occurrence of a disease where there were 50-60
cases per week and last week was 58 cabes.
● Endemic
● Epidemic
● Outbreak
● Sporadic
Question 9
clients is:
● Wheel Model
● Pic
● Web Model
Rationale: Accq sa Module, “An example of a disease the causation of
which can be depicted using the WEB model is the occurrence of Coronary Heart
Disease.”
● Lever
Question 10
You are computing the crude rate of your municipality, with a total population of about 18,000
for last year. There were 94 deaths. Among those who died, 20 died because of diseases of the
heart and 32 were aged 50 years or older. What is the crude death rate?
● 6.3/1000
● 5.2/1000
● 4.1/1000
● 7.3/1000
Question 11
The ecologic model which emphasizes the role of the agent in causing the disease:
● Web
● Pie
● Wheel
● Lever
Question 12
Nurse Sheena plans to disseminate information on safety precautions for Covid19 in their
barangay where there is no internet signal. She needs to make sure that everybody will be
informed so she made pamphlets on Covid19 to be distribute to each family. This is because.
● C. The family is an effective and available channel for health workers
● B. The family can do something to perform their developmental tasks
● D. The family can correct its own health problems
● A. The family is developing
Question 13
● Neonatal mortality rate
● General fertility rate
● Infant Mortality rate

● Crude birth rate
Question 14
Analytic epidemiology seeks to answer the questions:
● How
● Who
● What
● Why
Question 15
Civil registries are important sources of data. Which law requires registration of births within 30
days from the occurrence of the birth?
● PD 651
● Act 3573
● RA 3753
● GRA 3375
Question 16
● Source, mode of transmission, susceptible host
● Time, person, place
● Who, when, where
● Agent. host. environment
Question 17

● Reporting of cases
● Community Diagnosis
● Health Teaching
● Health Promotion
Question 18
A disease that was reported fewer than 10 cases per year, last week, 1 case was reported, 3
months ago, 2 cases were reported. It can be described as:
● outbreak
● Epidemic
● Sporadic
● Endemic
Question 19
● Swaroop's index
● 1-4 year old age-specific mortality rate
● Infant mortality rate
● Proportionate mortality rate
Question 20
● What family planning methods do you and husband use?
● Why did you choose Pills as a Family Planning Method?
● How old are you?

● What is your name?
Question 21
● Problem Tree
● Bar Graph
● Chart
● Demography
Question 22
Nurse Sheena reviews the records of patients who are enrolled in the DOTS program for
regimen. Which of the following role Nurse Stef is fulfilling
● D. Health Monitor
Rationale: quizlet heheh :D SO HELP ME GOD
● B. Facilitator
● C. Coordinator
● A. Counselor
Question 23
Public Health according to the World Health Organization is:
● Science and art of preventing disease, prolonging life, promoting health and
efficiency through organized community effort for the sanitation of the environment.
● A service rendered by a professional nurse with communities. groups, families,

individuals at home, in health centers, clinics, schools, places of work for promotion of
health, prevention of illness, and care of the sick at home and rehabilitation.
● The art of applying science in the context of politics so as to reduce inequalities in

health while ensuring the best health for the greater number
● Astate of complete physical, mental and social well- being and not merely the
absence of disease or infirmity
Question 24
● The history of disease causation
● The natural history of Discase
● The ecologic Model
● The pre-pathogenesis phase
Question 25

● Individual, family and community
● School health nursing, occupational health nursing- workplace and public health
nursing home
● Health promotion, disease prevention and management of factors affecting health
Rationale link: https://www.rnpedia.com/nursing-notes/community-health-nursing-

notes/community-health-nursing-overview/
● Science of public health, public health nursing skills and social assistance function
Question 26
● Makes use of existing research data to analyze possible disease causation
● identify the factors causing a disease

● The interaction between the epidemiological triad
● Pattern of disease occurrence.
Question 27
In the conduct of a census, the method of population assignment based on the actual physical
location of the people is termed as
● De facto
● De novo
● De jure
● De locus
Question 28
● Collects Data
● Analyze Data
● Tabulate Data
● Consolidate Data
Question 29
population group and communities, concerned with the promotion of the health, prevention of
disease and disability and rehabilitation is defined by;
● Nisces
● Shetland
● Maglaya
● Freeman
Question 30
● Number of registered live births
● Number of females of reproductive age
● Estimated midyear population
● Number of pregnancies in the year
Referring cases or patients to the midwife
Proving nursing care to cases referred by the midwife
Providing technical guidance to the midwife
Formulating and implementing training programs for midwives
Nurse Sheena called the ambulance driver to pick up the patient for possible transport to
the city. She also called the hospital admission staff that they will be bringing a patient for
role.
B. Provider of Care
A. Counselor
C. Coordinator
D. Health Monitor
Who
Why
Where
When
Question 31
Differentiate the different ecologic models and explain its importance in doing the Nursing
Process especially in the Community setting
Question 32
Explain the Natural History of Disease and how it will help you in doing Nursing Process
Who, when, where
Time, person, place
Source, mode of transmission, susceptible host
Agent, host, environment

Referring cases or patients to the midwife
Proving nursing care to cases referred by the midwife
Providing technical guidance to the midwife
Formulating and implementing training programs for midwives
Communicable or Infectious Diseases
Non communicable or non-infectious diseases
Emerging diseases
Violence
Injuries
Nurse Sheena called the ambulance driver to pick up the patient for possible transport to
the city. She also called the hospital admission staff that they will be bringing a patient for
role.
B. Provider of Care
A. Counselor
C. Coordinator
D. Health Monitor
Who
Why
Where
When
As an epidemiologist, the nurse is responsible for reporting cases or notifiable diseases.

What law mandates reporting cases of notifiable diseases?

RA 1082
RA.3753
Act 3573
RA 1054
1-4 year old age-specific mortality rate
Swaroop’s index
Infant mortality rate
Proportionate mortality rate
clients is:
Pie
Lever
Web Model
Wheel Model
population group and communities, concerned with the promotion of the health, prevention
of disease and disability and rehabilitation is defined by;
Freeman
Maglaya
Shetland
Nisces
Pattern of disease occurrence of a disease that is usually no more than 3-5 cases per week.
Last week, there were 20 cases reported.
Endemic
Sporadic
Epidemic
Pandemic
Number of pregnancies in the year
Number of registered live births
Estimated midyear population
Number of females of reproductive age
Population pyramid
Chart
Demography
Bar Graph
Science of public health, public health nursing skills and social assistance function
Health promotion, disease prevention and management of factors affecting health
Individual, family and community
School health nursing, occupational health nursing- workplace and public health nursing-
home
Who among the following investigated the cholera outbreak using non experimental
methods earned him the title the father of field epidemiology:
John Travolta
Robert Koch
John Snow
John Gaunt
Public Health according to the World Health Organization is:
A service rendered by a professional nurse with communities, groups, families, individuals

at home, in health centers, clinics, schools, places of work for promotion of health,
prevention of illness, and care of the sick at home and rehabilitation.
A state of complete physical, mental and social well-being and not merely the absence of
disease or infirmity.
The art of applying science in the context of politics so as to reduce inequalities in health
while ensuring the best health for the greater number.
Science and art of preventing disease, prolonging life, promoting health and efficiency
through organized community effort for the sanitation of the environment.
Which of the following must the nurse take note of when reviewing the health and illness
patterns?
Child's weight based on his/her age
Physical characteristics of the community
Political orientation
Social class
You are computing the crude rate of your municipality, with a total population of about
18,000 for last year. There were 94 deaths. Among those who died, 20 died because of
diseases of the heart and 32 were aged 50 years or older. What is the crude death rate?
7.3/1000
5.2/1000
4.1/1000
6.3/1000
A public health nurse has different roles in the community, one of her roles is to identifies
needs, priorities, and problems of individuals, families, and communities, this term refer to?
Provider of Nursing care
Community organizer
Planner/ Programmer
Trainer/ Health Educator

What is your name?
How old are you?
Why did you choose Pills as a Family Planning Method?
What family planning methods do you and husband use?
The public health nurse is responsible for presenting the municipal health statistics using
graphs and tables. To compare the frequency of the leading causes of mortality in the
municipality, which graph will you prepare?
Line
Scatter Diagram
Bar
Pie
The health of individuals and communities are affected by a combination of factors. Based
on the World Health organization’s list of heath determinants, which of the following
incorrectly affects the health of an individual?

Intelligence
Traditions
Low educational level
Higher salary
Community Diagnosis
Health Teaching
Reporting of cases
Health promotion
Neonatal mortality rate
Crude birth rate
Infant mortality rate
General fertility rate
Nurse Sheena plans to visit a rural area in Baguio City. How would she find out the health
needs and of the community:
Must interview the Barangay Chairman for Health
Conduct a survey
Must only apply de facto during conduct of census
Determine the population size and composition of the population
In 2019, Barangay 395 had an average population of 1,655. 46 babies were born in that
year, 2 of whom died less than 4 weeks after they were born. There were 4 recorded
stillbirths. What is the neonatal mortality rate?
130.4/1000
86.9/1000
27.8/1000
43.5/1000
Which of the following is the most prominent feature of Public Health Nursing?
The public health nurse functions as part of a team providing public health nursing service
Public health nursing focuses on preventive, not curative services.
Services are provided free of charge to people within the catchment area
It involves in providing home care to sick people who are not confined in the hospital
The interaction between the epidemiological triad

identify the factors causing a disease
Makes use of existing research data to analyze possible disease causation
Pattern of disease occurrence
Nurse Sheena reviews the records of patients who are enrolled in the DOTS program for
regimen. Which of the following role Nurse Stef is fulfilling.
D. Health Monitor
C. Coordinator
B. Facilitator
A. Counselor
Consolidate Data
Analyze Data
Collects Data
Tabulate Data
7-4 FORMATIVE ASSESSMENT #3
A useful method of collecting data when informants are unable to directly supply information or may
likely give inaccurate information is OBSERVATION. In collecting data using the “Observation”
process, the following are examples, EXCEPT:
Ocular Survey
Participant Observation
Key Informant Interview
They may be described in terms of social, economic, environmental and political factors that aggravate
the illness inducing situations in the community.
Health Status problems
Health related problems
Health Resources Problems
In the conduct of a census, the method of population assignment based on the actual physical location of
the people is termed;

De facto
De locus
De jure
De novo
This may be described in terms of mortality, morbidity, fertility or reduced capability for wellness
Health resources problems
Health-related problems
In the conduct of risk factor assessment or RFA where only those who are present are taken data,
the method of assignment is termed as:
De facto
De novo
De jure
De locus
Identify the categories of community health problems for Increased incidence of Dengue Fever in
Sitio Malala.

C. Health Resources Problem
A. Health Status Problem
B. Health Related Problem
These are data that are directly obtained by the nurse specifically to answer the community diagnosis
objectives:
Records Review
Focus Group Discussion
Primary Data
Secondary Data
Select all that applies to Community Diagnosis:
If the community will not cooperate the nurse can go to the next community
Involves analyzing and synthesizing health data
There is a need to determine the objectives before data collection to ascertain the depth and
scope of the study,
Consists of collecting data, organizing and interpreting data

This helps to facilitate the direction and flow of exchange of ideas on specific topics or concepts among
the participants. The facilitator does not need to strictly adhere to the sequence of the questions but
makes certain that all concepts are exhaustively discussed
Key Informant Interview Guide
Focus Group Discussion Guide
Observation Checklist
The nurse describes the community in terms of the following: Select all that apply:
Formal and informal power structures and the attitudes of people towards authority
Interesting people in the community
Practices or approached that are effective in resolving issues and concerns within the community
Conditions, events or issues that cause social conflict or the opposite (social bonding)
Identify the categories of community health problems for Presence of Armed conflict in Brgy
Marawi.
Health Resources Problem
Health Status Problem
Health Related Problem
Identify the categories of community health problems for Poor health status among children 0-4
years old as evidenced by 30% of children having Malnutrition.

Identify the categories of community health problems for Low educational level among residents
of Sitio Ubihan.
They may be described in terms of lack of or absence of manpower, money, materials, or institutions
necessary to solve health problems.
Health Resources problems
Health-related problems
Select all the applies to Data Analysis.
It aims to establish trends and patterns in terms of health needs and problems of the community
It also allows for comparison of obtained data with standard values

Generates broad range of data
It depends largely on the type of data obtained
8-3 FORMATIVE ASSESSMENT #4 - 15 items

MCQ
This refers to the process that entails formulation of steps to be undertaken in the future to achieve a
desired end.
- Planning
Planning for groups, populations and communities involved application of the nursing process. This
statement is:
- True
Are conditions or situations that may interfere with the community's capability to achieve Wellness.
Generally categorized as second that this problem, health resources and health related problems
- Community health problems
The following is true about planning cycle according to Mercado, 1993:
- All of these choices
Which of the following statement is not true about planning?
- Planning is constant
“To promote and maintain a healthy lifestyle practices among adult person” is considered to be a:
- Goal
The statement: at the end of the year 2020, the community health nurse will be able to conduct at
least 3 health teaching activities and basic food groups and proper nutrition in the barangay is an
example of a:
- Objective
The following are reason why do we have to use S.M.A.R.T. objectives except:
- None of these choices
The statement: by December 31, 2019, our target is to increase the percent of normal weight children
ages 5 y/o and below by 100% is an example of a:
- Objective
To maintain a normal weight of children ages 5 years old and below is an example of a:
- Goal
To reduce the incidence of measles in barangay masaya by end of the year 2021 is an example of:
- Goal
According to mercado, gathering health data, tabulating, analyzing and interpreting data belong to
which part of the plan cycle?
- Situational analysis
Determining outcomes as well as specifying criteria and standards belong to which part of the
planning cycle?
- Evaluation
Designing community health programs and analyzing constraints and limitations belong to which
part of the plan?
- Strategy/activity setting
To become a registered community health nurse by the year 2023 is an example of a:
- Goal
9-1 SUMMATIVE ASSESSMENT #2 :

MIDTERMS
Semya, a healthy, middle age woman was diagnosed as positive with COVID19 in Makati Medical
Center. Semya also complained of not being able to use her benefit from Philhealth. Dr Sharon didn't
tell anyone of the findings as requested by the patient. She violated:
- Ra 11332
Examples of data that are Mutually Exclusive:
- Gender
His investigation of the cholera outbreak using non experimental methods earned him the title the
father of field epidemiology:
- John Snow
The following are methods of collecting interview, except:
- RR
Nurse Sted called the ambulance driver to pick up the patient for possible transport to the city. She
also called the hospital admission staff that they will be bringing a patient for possible admission and
reported the details over the phone. Nurse Stef is performing which role.
- Health Monitor
11-3 FORMATIVE ASSESSMENT #5 - 15 items
MCQ
Student nurse enchong, believe that the foremost goal of community organizing involves
achieving effective power for the people to maximize their own potential, this refers to…
• Integration
• People empowerment
• Participative Action
• Core group formation
Student nurse bernadette experienced refusal in the conduct of her community health survey.
She verbalized to her clinical instructor that she somehow lacks opportunity to develop a better
communication with the people that includes building rapport. The process of establishing
rapport with the people in a continuing effort to imbibe community life refers to…
• Integration
Barangay Lorenzo was considered one of the most established communities in Laguna in terms
of community organizing process is concern. Leaders were already identified and were currently
working hand in hand with FEU student nurse. “Identification of potential leader” is otherwise
known as…
• Integration
As a community organizer, student nurse Cesar focus on the attainment of his goals. To identify
the demographic profile, socio-economic system, and health status of Barangay Masaya. This
systematic process of collecting. Collating, synthesizing, and analyzing data to draw a clear
picture of the community, particularly its problem refers to…
• Community diagnosis
• Integration
One of the most important activity in doing the community study and deepening social
investigation is data gathering. Data gathering include the following data except…
• Geographical, education, cultural patterns and education

• Physical, beliefs, health practices and inactive core groups
Nina, a student nurse was assigned as a community organizer at Brgy. Iba, Silang Cavite.
During the pre-entry phase, the following are the criteria she should follow in identifying her host
family except…
• The host family should belong to the well to do segment of the community
In the entry and integration phase of community organizing, the following are the ideal activities
a student nurse should have accomplished except…
• None of these choices
During the time Rein, a community health nurse was setting up the community wide
organization, he encountered resistance from the people especially in encouraging attendance.
Setting up the community wide organization is also known as…
• Community assembly
In order for a community health nurse to gain respect and recognition from the people of
barangay Lorenzo during the integration period, she should possess the following traits…
except…
• Aggressiveness in implementing fund generating projects

As a community organizer, Jam’s main goals are the following except…
• Enhanced economic status
The phase of C.O. according to Maglaya where the nurse facilitates and coordinates the
assistance and support from external sources from the community refers to:
• Inter-sectoral collaboration phase
The phase of C.O. according to Maglaya where activities are directed towards creating a
people’s organization:
• Organizational Phase
The phase of C.O. according to Maglaya where activities would include Training of Community
Health Workers, Health Services and Mobilization, and Leadership Formation Activities.
• Education and Training Phase
The phase of C.O. according to Maglaya where the community assumes greater responsibility
in managing their own health and the nurse prepares for the turnover of the work to the
community:
• Phase out Phase
The phase of C.O. according to Maglaya where activities includes area selection, community
profiling, entry in the community, and integration with the people.
• Preparatory Phase
Which one of the following statements explain what is meant by the term clean as you go?
- Clean up before..
The main reason for keeping kitchens clean is
- to prevent contamination of food
which of the following is most likely to be a source of food poisoning bacteria
- raw meat
all but one are the things to consider in constructing a toilet facility
- at least 5 meter away
wastes are disposed of through section of pipe bent into a U shape…
- water seal
using CDC's framework for program evaluation in public health, you wish to ensure that lessons
learned are used and shared. according to the checklist for ensuring effective evaluation reports,
which of the following is not recommended?
explain the evaluation and its limitation
describe stakeholder and their roles
use illustrations, examples and stories
According to CDC's framework for program evaluation and public health, when are evaluation
conclusions justified?
- only if they highlighted the strength within the program
why is monitoring and evaluation important to the connect programme?
- all of the above
this type of evaluation wherein it aimed program decision makers
- summative evaluation
this identifies strong and weak points of programmed operations
- monitoring
evaluations measure:
- the outcomes and impact of a program's activities
a good monitoring system helps answer which of the following questions?
- all of the above
all but one are under monitoring process
- .
at what stage of a program should monitoring take place?
- throughout the life of the program
it is known as comprehensive sanitation code in the Philippines
- PD 856, 1978
In the country's eHealth system, EMR stands for:
Electronic Medical Record
One key solution to the healthcare problems that has recently been gaining traction, is the
development of a framework for eHealth in the Philippines. This initiative led to the development of:
Philippine eHealth Strategic Framework and Plan 2014-2020
The government agency that spearhead the initiatives such as the Philippine eHealth Strategic
Framework and Plan In the country's eHealth system:
Department of Health
Even where health care is available, health access is not so easily obtained. On the average, it takes a
Filipino 39 minutes to travel to the nearest health care facility- minutes that can mean life or death in
the worst instances. This refers to what particular aspect of our health care system?
Poor accessibility
By 2020, the vision of the government initiatives on the Philippine eHealth Strategic Framework and
Plan In the country's eHealth system focuses on:
All of these choices
Problem still stems from the fact that patient data or information, which are necessary in order to
provide adequate healthcare, is often incomplete, inaccurate, misplaced, or at times, simply
unknown. This refers to:
Lack of patient data or information
In a country where more than half of health spending comes from out of pocket payments, this
uncertainty greatly deters citizens from getting necessary healthcare. This refers to:
High cost of health care
Directing and coordinating eHealth goals, strategies and activities at all levels (ex. Health facilities,
health care providers, policy/decision making) are part of which eHealth components?
Infrastructure
Human Resources
Strategy and Investment
Leadership, Governance and Multi-sector Engagement
The stage of Forming is aligned with the stage of
Conflict
Working group
Cohesiveness
Orientation and Dependency
Conflicts is a key ingredient to form a more cohesive group.
True
False
Sometimes true and sometimes false
Maybe
In the storming stage, the following are inevitable occurences
Members are judgmental of others
Hostility towards the leader
Struggle for control
Tear experience differences of opinion
Intervention for the anxiety during the Stage 1 of Group Development is
O Awareness of the behaviour to the group
O Process, negotiate and resolve conflicts
O Acting as completer or resource person

O To provide orientation, structure and direction
To lessen anxiety or uncertainty during the Stage 1, the following can be done
Icebreaker to get to know co-members
Clarifying goals, objectives, expectations should be done
Allow opportunities to air grievances and complains
Time to interview co-members be given
In 3-5 sentences, share a challenge/problem you experienced in working with Groups, then identify
which stage of group development it happened, then mention an appropriate intervention based on
the discussion.
I joined a summer camp when I was just in junior high, and I feel so overwhelmed and
anxious because all my teammates were strangers. I can identify this as the first stage of group
development which is forming. Fortunately, as we made use of our time in the first day, our leader
made the first intervention to facilitate group growth by orienting us, directing, and explaining the
structure ahead. This made me feel calm and hopeful that everything will be alright, and I will enjoy
the activities prepared for us.
Health Education program on topics such as Smoking Cessation, Obesity and Behavioral Health is
geared towards what particular aspect of health care?
Curative health
Rehabilitative care
Disease prevention
Community Based project encourages and enhance health and wellness. Which of the following
projects mainly focus on enhancing quality of life?
Physical injury prevention
Chronic diseases
Physical activity and healthy lifestyle
None of these choices
As a nurse entrepreneur, you are planning to put up a Wellness Center in your Barangay. What
particular Wellness dimensions is involve if you intend to put up a Personality Development Center?
Spiritual
Environmental
Intellectual & Social
Physical
Examples of Health Project which focus on the Preventive aspect of health care are the following
except:
Occupational and Physical Therapy
Injury and Violence Prevention
Tobacco Cessation
Diabetes Control Program
Community Based project covers a wide variety of different within a community or groups. Which of
the following projects mainly focus on health improvement?
Oral health
Mental illness and behavioral health
Physical activity and healthy lifestyle

Which of the following is not a factor for the increased risk of global health concerns spreading?
poor economies
inadequate health care
ethnic conflicts
decreasing population
Health issues that transcend national boundaries and governments and therefore require
collaborative research among nations for their cure are called?
illness concerns
sickness prevention issues
global health issues
wellness issues
What does the term burden of disease refer to and what can it be measure with?
the inverse impact of all health conditions on a population; health metrics only
the adverse impact of a particular health condition or conditions on a population, health metrics and
economic indicators
the adverse impact of a particular health condition (or group of conditions on a population inches and
meters
the inverse impact of all health conditions on a population inches and meters
Low-cost primary prevention activities are usually the most
cost-effective interventions
best buys
efficient cures
all of the above
Groups focused on equity prioritize projects that will address perceived injustices and reduce health
disparities, while groups focused on global health security prioritize direct threats to peace and
stability as well as other national interest of sponsoring governments.
True
False
Maybe
It depends
What is the meaning of Globally?
Gradually
Internationally
Strongly
Growly
The meaning of Contribute
To give something
To steal something
To watch something
To grow something
What are some of the factors that affect health?
O Socioeconomic development
O Income & Employment
O Education, Income, and Employment
O Education & income
What do the priorities identified by groups viewing global health with different lenses do?
Point toward solutions for shared concerns
None of the above

Identify Global Health issues
Provide insight into global common health challenges
Select some of the top public health problems of the early 21st century
Institute a rational healthcare system
Eliminate health disparities
Achieve a longer health span (healthy aging)
Prepare to respond to emerging non-communicable diseases
3-1.3A RLE CHN 2 Summative Assessment
1. In determining drinking water supply of a family, the following are the 4 most important factors a
community nurse should consider
Storage Source Potability, and Distance from the house
Storage, Licensed merchant, potability
Storage, Source. Water taste, and Distance from the house
Source, Storage, Container, and Distance from the house
2. According to Dr. C.E. Winslow, public health is a science and art of, select all that applies Promotion of
health, capacity building, disease prevention
Preventing disease. Prolonging efficiency and health,
Preventing diseases, prolonging life, promotion of health
Promotion of health, disease prevention
3. The following items are included as part of the Social Indicators except:
Transportation system
Communication networks
Educational level
Population
4. This serves as basis for developing and implementing community health nursing interventions and
strategies. The statement refers to
Community diagnosis
Community problems
None of these items
Community health
5. Which of the following is a function of epidemiology?
Evaluating the effectiveness of the implementation of the Integrated Management of Childhood Illness
Determining the efficacy of the antibiotic used in the treatment of the 3 year old client with pneumonia
Identifying the disease condition based on manifestations presented by a client
Determining factors that contributed to the occurrence of pneumonia in a 3 year old
6. One of the most the most important activity in doing the community study is data gathering Data
gathering include the following data except:
Geographical, economic, education and health facilities

Physical, demographic, economic and nutritional status
Physical beliefs, health practices and inactive core groups
Geographical education, cultural patterns and education
7. What role of the Public Health Nurse (PHN) is described as establishing multi-sectoral linkages by
referral system?
Clinician
Health educator
Facilitator
supervisor
8. Which of the following health indicators is described as the sum total of new and old cases of a
particular disease?
Incidence rate
Prevalence rate
Swaroop's index
Crude death rate
9. According to nurse Hetty, they need more barangay health nutritionist to complete the assessment
on under five year-old children in the community. It's categorized as..
health resources
10. Which of the following health indicators is described as the number of deaths of individuals who are
more than 50 years old?
Crude death rate
Maternal mortality rate
Swaroop's index
Crowding index
11. Philippine General Hospital is classified as a tertiary/apex hospital. On the other hand Binangonan
Rural Health Unit (RHU) is classified as what level of facility?
Tertiary
Primary
Secondary
Intermediate
12. The Universal Health Care Act (RA 11223) of the Philippines has the following provisions. except:
Financial risk protection through the National Health Insurance Program (PhilHealth)
Improved health care facilities at all levels
Free branded medicines for Filipino senior citizens
Access to quality health care services
13. Nursing, together with public health, is one of the helping professions in the health care system
which operates at three level of clientele, these are:
Biological and social science, ecology, clinical nursing
Individuals, families and communities
Community diagnosis, vital statistics, priority setting
Medical Officer, Public Health Nurse, Rural Health Midwife
This refers to the system of referral from primary to secondary to tertiary level health facilities, based on
the need of the patient and available resources of the health facility. This is considered as one of the
major pillars of the implementation of UHC law.
Service Delivery Network
MVP Group of hospitals

Health Care Provider Network
Inter Local health Zones
15. The public health nurse takes an active role in community participation. What is the primary goal of
community organizing?
To maximize the community’s resources in dealing with health problems
All of the options given
To mobilize the people to resolve community health problems
To educate the people regarding community health problems
2-4 Formative Assessment for Module 1 & 2
Nursing Informatics improves data security, integrity, and data access
- True
Which event was a critical milestone for nursing and computers in the 1980s?
- ANA approved the formation of the Council on Computer Applications in Nursing (CCAN)
Computers were introduces into the nursing profession over 40 years ago.
- True
Which event in the 2000s became significant milestone for the promotion of HIT systems in the United
States?
- ONC was established in 2004 and first ONC Coordinator named
Which event was a critical historical nursing and computer milestone in 1990s?
- ANA recognized nursing informatics as a new nursing specialty

Mrs. P is a married, mother of two 8-month old twins. Mrs. P has been discharged from the hospital
after she underwent reconstructive abdominal surgery last week, due to an umbilical hernia. She is not
allowed to lift any weight above 11 lbs (5 kg) for 8 weeks after the surgery. Mrs. P. is has insulin
dependent diabetes and she injects insulin to her abdomen several times a day.
Data
- Q
Information
- Q
Knowledge
- Q
Wisdom
- Q
Wisdom is knowledge used to make appropriate decisions and acting on those decisions.
- True
It is the information that has been processed and organized so that relations and interactions are
identified.
- Information
In 1960s, computers in healthcare were used for administrative and accounting functions.
- False
In 1970s, one of the significant milestone in the history of NI is the use of computer technology began to
be explored.
- False
Nursing Informatics causes documentation to worsen making health care facilities to increases operating
and patient care costs.
- False
Information are raw, uninterrupted facts without meaning.
- False
The elements of the DIKW theory have a certain hierarchical structure: data constructs information,
information grows into knowledge and knowledge progresses to wisdom to be applied in practice.
- True
It is the appropriate use of knowledge to manage and solve human problems. It also includes knowing
why certain procedures should or should not be implemented in specific cases.
- Wisdom
In the DIKW theory, it is a continuum of progressively developing and clustered data; It answers
questions such as who, what, where, and when.
- Information
Where is Nursing Informatics Used? (select all that apply)
- Research, Nursing Administration, Clinical Practice
Which event was considered to be the first major computerized system(s) used for nursing practice in
the 1970s?
- Physiological Monitoring Systems in Hospital ICUs
This area of Nursing Informatics uses automated staff scheduling, reminders, and calendar tools. It also
uses cost analysis and budget preparation.
- Nursing Administration
In the DIKW (Data, Information, Knowledge, Wisdom) theory:
1. Wisdom answers questions on who, what, where, and when
2. Knowledge answers questions on why and how
3. Data is composed of the most discrete components of the theory

4. Information guides the clinician in recognizing the situation at hand, based on the
clinician's expertise and experience.
- 3 and 4 are true
Which is considered the most discrete components of the DIKW theory?
- Data
2-6 Formative Assessment: Pirates of Silicon Valley
Steve Jobs recruited John Sculley to be Apple's new CEO. Where did John work prior to Apple?
- Pepsi-Cola
What was the name of the computer that Apple developed after the Apple IIE computer?
- Lisa
At the important meeting, Gates and co tell some well-dressed executives that Microsoft has what
they need. What Microsoft product are they referring to?
- MS-DOS
Another company actually developed the innovative feature of the Apple IIE's successor. One which
its Board of Directors decided not to produce, but to turn over to Apple instead (for free). What
company?
- Xerox
Which college did the founders of Apple attend?
- Berkeley- California
What college did those founders-to-be of Microsoft, Bill and Steve, attend?
- Harvard, in Boston
Which of the following Steves is NOT in the film, Pirates of Silicon Valley?
- Steve McScanders
Why was Steve Wozniak hospitalized?
- His private plane had crashed
What was so special about the computer made after the Apple IIE?
- It had a mouse and a graphical user interface (GUI)
As the three Microsoft eccentrics run through Miami airport carrying their luggage in one hand (and
suits in the other), they are late for an important meeting. In the toilets where they are about to put
on their suits, Bill suddenly realizes he's forgotten his tie. What happens next?
- Ballmer leans over a cubicle door and asks the man in there for his tie
Formative Assessment on Module 3
Physiologic monitoring systems consist of the following basic parts, EXCEPT.
- Documentation component
What are examples of telehealth technologies? (please select all that apply)
-Video chat between doctor and patient from different countries
-A nurse sends and email with pictures of patient’s wounds to a wound specialist for evaluation
-Phone call between a nurse and a patient from two different cities
Is telehalth possible with pre-recorded interaction (for example sending an email with patient
symptoms to another health provider for evaluation)?
- Yes. Telehealth can be done with pre-recorded interaction, like emails
Benefits of Telehealth include reduction and preventable healthcare service costs, improved
quality of life for patients and help them gain ownership of a health facility.
- False
Telehealth is defined as using electronic communications and information technology to provide

and support healthcare on a face-to-face manner of consultation.
- False
Telehealth can enable the exchange of all types of healthcare data, including voice, video
images, which could be wound images, radiologic images such as X-rays, device readings, vital
signs parameters, between patients and clinicians, and also between clinicians on behalf of the
patients.
- True
Telehealth has been used just recently and become as successful as expected.
- False
Telehealth is defined as using electronic communications and information technology to
provide and support healthcare on a face-to-face manner of consultation.
- False
Electronic health record is defined as _________________.
"a digital version of a patient's paper chart"
" an information available instantly and securely to authorized users"
"a are real-time, patient-centered records"
- all choices are correct
EHR have huge changes and identifies core functions that most of the systems have. These are: (select
all that apply)
-there are provider computerized order entry modules
-EHRs tend to promote data exchanges

4-3 Formative Assessment: Applications in
Evidence-Based Nursing Practice
These are systematically developed statements to assist practitioners and patient make decisions about
appropriate health care.
- Clinical Practice Guidelines
This evidence-based practice application focuses on quality and coordination of care.
- Clinical pathway
This makes specific recommendations on health care and links these to research evidence
Which of the following is considered a barrier in the implementation of clinical pathway?
- reluctance to change
This was initiated to plan care for the patient and at the same time cut the time consuming preparations
of nurses:
- Computerized Nursing Care Plan
Which of the following provides detailed guidance for each stage in the management of a patient?
- Clinical pathway
Which of the following evidence-based practice applications has a focus on the timeline of the patient?
- Clinical pathway
These are algorithms based on scientifically sound practices that physician's use in order for them to
treat the patient:
Which of the following is considered a deviation form the clinical pathway?
- Variance
Which of the following is not included in the quality improvement review?
- Clinical Studies
5-5 Formative Assessment for Module 5

Which one of the following would be classified as sensitive personal data?
Religion
How many key principles are there under the Data Protection Act 2012?
5
After you have finished using someone's personal data, what should you do with it?
Securely delete or destroy it
If you lose some personal data, such as on a laptop, who should you report it to?
The Information Commissioner’s Office
If a company's information were subjected to a data breach, how long do you have to notify the National
Privacy Commission of this situation?
within 72 hours
What is Netiquette?
The proper use of Çs and etiquette on the internet
What is considered shouting over the Internet?
Writing in all CAPS.
Following a good netiquette practice and respect to others' privacy, it is okay to share personal
information, photos, or videos of another person. This would make him/her popular influencer.
False
I can legally share my movie collection with my friends by either uploading them to the internet or
burning copies, as long as I don't sell them for profit.
False
I can legally upload scenes from my favorite movies to youtube or facebook.
False
Which one of the following would be classified as sensitive personal data?

CCTV video
Name
Address
Religion
How many key principles are there under the Data Protection Act 2012?
5
After you have finished using someone's personal data, what should you do with it?
Securely delete or destroy it
Pass it on to someone else
Give it back to the owner Throw it out
If you lose some personal data, such as on a laptop, who should you report it to?
The Health and Safety Executive
The Information Commissioner’s Office
The local authority The government
If a company's information were subjected to a data breach, how long do you have to notify the National
Privacy Commission of this situation?
within 72 hours
What is Netiquette?
The proper use of manners and etiquette on the internet
What is considered shouting over the Internet?
Writing in all CAPS.
Screaming at your computer.

Putting a lot of exclamation marks at the end of a sentence.
Not answering a friend request on Facebook.
Following a good netiquette practice and respect to others' privacy, it is okay to share personal
information, photos, or videos of another person. This would make him/her popular influencer.
False
I can legally share my movie collection with my friends by either uploading them to the internet or
burning copies, as long as I don't sell them for profit.
False
I can legally upload scenes from my favorite movies to youtube or facebook.

False
8-3 Formative Assessment: Computer Use in
Nursing Research
What are the six common components—tools and resources—employed throughout the
research process:
- Refinement of the idea, selection of approaches, development of methods, capturing

the data, analyzing the results, and disseminating the findings
What must one understand on how computer and nursing research coexist?
- One must understand underlying terminologies, sources of data, communication of the

information, and elements in the nursing environments
What are some of the new technologies which have enhanced the research process?
- Personal computers, wireless technologies, cloud computing, text processing software,
and new data processing applications
Identify whether the statement below refers to: quantitative or qualitative research
methodology.
Research proposal must be fully developed before collecting any data
- Quantitative
methodology.
Theories used are tested from the subject’s point of view
- Qualitative
methodology.
Knowledge developed is generated from participant’s experiences
- Qualitative
methodology.
Functions of philosophical data evolve into meaningful interpretations
- Quantitative
methodology.
Statistical packages are the mainstay for methodologists

- Quantitative
Which method best serves as an online research quantitative data collection tool?
Input online paper-and-pencil narrative text directly into the computer to be analyzed
Data entry by patients and sent via snail mail
What type of computer software is best used for qualitative research?
- Software that can be used for analyzing qualitative data, for example, Ethnograph
8-5 Formative Assessment: Information
Literacy and Computerized Information
Resources
Essential computerized resources (ECR) are defined as those vital and necessary to for
professional practice
- True
The ECR use bibliographical retrieval systems such as MEDLINE or CINAHL databases
- True
Supportive computerized resources (SCR) are those helpful and/or interesting but not necessary
for professional practice
- True
The ECR use electronic publishers and/or metasites on the World Wide Web (WWW)
- True
The WWW requires knowledge of both ECR and SCR resources
- False
TJC insists that nursing care should be based on information derived from best practice
evidence. To do so the nurse must apply the information literacy process which is to:
- Recognize the need for evidence, know how to search and find relevant information, and
assess, utilize, and evaluate the information
The landmark study conducted by the ANA demonstrated that many nurses were not aware that
they needed information or how to use online databases to obtain information. They found that
the respondents either needed or strongly needed:
- Tools to implement evidence-based practice, online education and skill-building

modules in evidence-based practice, and an online resource center with best EBPs for
patients
What is the most essential computer resource for a practitioner to use to become current on a
specific nursing topic?
- BRS, current awareness services, and review services

Which best describes a bibliographic retrieval system (BRS) such as CINAHL?
- Able to filter and sort vast amount of indexed published material
Which are considered computerized social media resources for collaboration and networking
with other professionals?
- www.blogs, chat rooms, and electronic mail

Formative Assessment on Module 9
What are the types of computerized clinical decision support systems?

- All options are correct
How are computerized clinical decision support systems used to improve clinicians performance?
- Adoption of computerized clinical decision support systems support care decisions through the
provision of additional and current Information at the time and place of care delivery while final
decision authority will remain with the clinician
Are computerized clinical decision support systems used to improve patient outcomes in healthcare?
- Current evidence indicates that CDSS can improve patient care quality. reduce medication
errors, minimize variances in care, improve guideline compliance and promote cost savings
What is the single most important characteristics of the CDSS to predict success?
- Ease of use within existing workflow practice will determine the success of a CDSS
Why is clinical decision support easily used in computerized systems?
- The Computer Has Virtually Unlimited Capacity For Proc and storage of data
True or False? Is the computerized clinical decision support system in the EHR a component of the
Meaningful Use certified EHR?
- True
How can patient decision support (PDS) support patient care?

- PDS interventions increase patients' knowledge, produce more accurate expectations, and lead
to more conservative approaches to treatment that are more congruent with patients informed
preferences
Where do the legal responsibility lie when computerized clinical decision support systems are used?
- The legal responsibility for treatment and advice given to a patient rests with the clinician
regardless of whether a CDSS is used
The research question is "Does massage therapy increase satisfaction during cesarean delivery?" Which
of the following is/are the dependent variable(s)?
- Satisfaction
Identifying and understanding the nature of nursing phenomena and the relationships among the
phenomena includes the following except:
a. Describe what exists in nursing practice
b. Discover new information
d. Declassify information for use in the discipline?
c. Promote understanding of situations
A researcher is studying the effect of massage on the alleviation of pain in cancer patients. This is an
example of what type of study?
- C. Applied
Which of the following limits the power of the scientific method to answer questions about human life?
- B. The difficulty of accurately measuring complex human traits.
The following are types of variables except:
d. Confounding
b. Dependent
c. Experience?
a. Independent
Which group would best served by the clinical nursing research?
- C. Nurses’ clients
One of the primary foundations for evidence-based nursing practice is:
- b. Research results.
A researcher wants to investigate the effect of patients' body position on blood pressure. This is an
example of what type of study?
- C. Quantitative
Determining if studying the problem will lead to results that are applicable to nursing practice is
essential when analyzing the _________ of the problem.
- d. Significance
Nursing Research provides the following except:
b. Explanation of concepts
d. Prediction and control of interventions
a. Identification and description of concepts
b. Enumeration of concepts?
Obstacles to using nursing research in practice include lack of:
- a. Education, beliefs/attitudes, and support/resources.
Research utilization begins with empirical findings for consideration in practice settings. Where does
evidence-based practice begin?
- C. A search for the best possible information for addressing a clinical problem
Applied research builds a body of knowledge for nursing practice because it is the basis of:
- a. Evidence-based practice.
When developing a nursing research project, why is it important to remember the ethical constraints?
- b. The protection of human subjects underlies all human research projects

What is the role of a consumer in nursing research?
B. Participate in generating evidence by doing research.
C. Participate in journal club in a practice setting.
D. Solve clinical problems and make clinical decisions.
A. Read research reports for relevant findings.?
A researcher wants to study the process by which people make decisions about seeking treatment for
infertility. What is the researcher's paradigmatic orientation?
- D. Naturalism
What is the continuum of participation on research?
- B. Consumers to producers
What is the issue of greatest concern when developing a research project?
- c. The protection of the vulnerable subject
What 4 pieces make up evidence-based practice?
Evidence from research, evidence-based theories, clinical experts, and opinion leaders
Evidence from assessment of patient's history and physical and available health care resources
Clinical expertise
Information about patient preferences and values
b. 2&3
a. 1&2
c. 3&4
d. all of the above?
From the Research question below, Please label the underline phrase.
Is the music therapy related to the level of stress among preoperative surgical patients?
Independent variable
Moderating variable
Dependent variable?
Extraneous variable?
The following are steps of EBP?
1. Selecting a topic and formulating a clinical question

2. Forming a team
3. Tracking down the best possible evidence
4. Appraising the evidence critically
c. 3&4
b. 2&3
a. 1&2
d. all of the above?
Which term is not used by qualitative researchers to refer to people who participate in a study?
C. Study participants
B. Key informants
D. Subjects?
A. Informants
Which is not a characteristic of traditional scientific method?
- D. Emphasis on a holistic view of a phenomenon, studied in a rich context.
A RN is putting research into practice. What step of the process is involved with the validity of study
findings?
- C. Appraising the evidence
What is the goal of explanatory research?

- A. Understand the underpinnings of natural phenomena and to explain systematic relationships
among them.
Many nurses do not appreciate research because:
a. Research isn't necessary for their practice.
d. Patients don't expect them to use research.
b. Most nurses are too old
c. Research is like a foreign language?
Which is not a major barrier to evidence-based practice in nursing?
- D. The absence of quality, clinically relevant nursing studies
The following are purposes of Nursing Research except:
- d. To question practice and take for granted rationale for activities
Evidence-based practice typically involves weighing various types of evidence in an effort to determine
best evidence. Most evidence hierarchies put which systematic review at the pinnacle?
D. Meta-analyses of multiple clinical trials
A. Randomized controlled trials
Quiz #2 Conceptual phase

1. This is a written document that will give the respondents with information about their
decision in participating a research study
Research protocol
Research instrument
Biodata of the researcher
Informed consent
2. From the Research question below, Please label the underline phrase.
Is the music therapy related to the level of stress among preoperative surgical patients?
Moderating variable
Extraneous variable
Dependent variable
3. The research questions are basis for the statement of hypotheses.

True
False
4. From the research question below, label the underline word.
What is the relationship of teaching strategies to the performance of students in the Nursing
research subject?
Dependent variable
Extraneous variable
Moderating variable
5. Which of the following is an example of a primary source in a research study?

A doctoral dissertation that critiques all another study.
A textbook in Research.
A journal article about a study that used large, previously unpublished databases.
6. A published commentary on the findings of another study.
He hypothesized that elderly patients who have pet therapy are less likely to experience
depression than those who do not have. You understand that this is an example of:

Complex and non-directional hypothesis
Simple and directional hypothesis
Simple and non directional hypothesis
Complex and directional hypothesis
7. You hypothesized that individuals who do not exercise and eat many times a day are
related to development of obesity and cardiac diseases. This is an example of:
Complex and non directional hypothesis
Simple and directional hypothesis
Simple and non directional hypothesis
Complex and directional hypothesis
8. Null hypothesis is similar to a research hypothesis.

True
False
9. You are doing a literature review in your own study. You are using EBSCO host, a
commercial vendor to access CINAHL. Which is not true about CINAHL?
It covers references to nursing, allied health journals and business topics.

It can be used for ascendancy approach.
It can be used for descendancy searches
It provides abstract s of most citations
10. All research studies have framework.

True
False
11. All are steps in doing a qualitative research except:

Selecting the sample
Review of related literature
Data collection
Formulation of hypothesis
12. The word " student " is defined like this : refers to third year FEU nursing students
enrolled in research with GPA equivalent to A+, A, B+, B, C+, C, D+ , D, F.
The above is an example of an OPERATIONAL Definition.

True
False
13. All except one is considered vulnerable research participants.

Elderly groups
Incarcerated women
Pregnant women
Adult patients with Hypertension
14. If the subjects of your study are animals, there is no need for strict ethical review.
True
False
15. You are a researcher and happen to note that one of your respondents is an HIV
positive. When you return home, you call one of your friends about the condition of
this respondent. This is an example of
Breach of Privacy of information
Breach of Confidentiality of information
Breach of Confidentiality
Breach of Information
16. Nurse Esther distributes her research questionnaires among her respondents and
you notice that in the Profile section, there is an item there that reads.... NAME
(OPTIONAL). This is an example of:
Maintaining privacy and confidentiality of information
Maintaining safe information
Maintaining privacy information
Maintaining confidentiality of information
17. Nurse Nel conducted a literature review. Upon reading his work, you observed that
some of his ideas are taken from published journals and without citations. He can be
charged of;
Plagiarism
Falsification of data
Fabrication of data
Research conduct
18. You are conducting a qualitative study, what is an example of a purpose statement
under this type of research.
The purpose is to explore the lived experience of patients with Hansinites disease.
The purpose is to describe the effect of teaching strategy to students enrolled in First
Semester 2020
The purpose is to explore the Phenomenon Covid 19 experience.
The purpose is to compare the differences between betadine and alcohol solution in
cleaning the umbilical stump among newborn babies.
19. Bella told you that she will study the correlates of migration intention of nurses in government
owned tertiary hospitals. What will you advise her?
She will use questionnaire to get data from chief nurses of selected hospitals
She will do quasi-experimental study
This is not researchable: she should think of another one
She will first do a review of related literature
20. In conducting a literature review, the leader is least interested in which of the following
information about a research study?
how the research variables were operationally defined
opinions about the research study
research study results
research study methodology
21. You intend to conduct a study on the lived experience of mother's whose baby dies during
delivery. As a supervisor in the ward, you wanted to conduct this study to develop a nursing protocol on
how to deal with this experience appropriately. This kind of study should be
allowed because of the contribution it can give to nursing practice
Allowed because the risk is small and the benefit is big
Not allowed since this can pose emotional harm to the mother who needs to recall the pain
Not allowed since this violates the principle of non-maleficence or do no harm
Allowed as long as we are not more than intrusive on what the study ought to be and needs to be aware
of our intrusion in a person's psyche.
22. What is the most important aspect in ethics

informed consent
beneficence
justice
the right to self determination
23. As of September 20, 2020, the total Covid case in the Philippines was reported at
286,743 by the Department of Health. This statement could fall under
scope
knowledge gap
consequences
problem identification
24. here is a significant relationship between Teaching Style and Academic Performance
among Nursing Students. The hypothesis statement is
Somewhat stated (few of the elements are present)
Well stated (Most of the elements are present)
Incorrectly stated (no elements are present)
Very Well Stated (all the elements are present)
What is one of the advantages in conducting a computerized literature search rather than
using printed indexes?
no libraries have printed indexes available
the entire articles may always be printed at the end of the search
search terms can be combined
primary sources are easy to locate
The study proves the effectiveness of Breast Massage on Breast Pain among Multipara
Breastfeeding Mothers. What is incorrect in stating the statement of purpose
the declarative form
the direction
the population
the independent variable
the dependent variable
You intend to conduct a qualitative research study. While planning for your ethics protocol,
you will
ask permission to record the conversation but change the voice tone for anonymity
take down notes then ask the participants to sign later as proof of the interview
just take notes so that anonymity is ensured
ask permission and de-identify the recorded proceedings and store the data in a safe and
secured file.
Example of Minimal Risk includes EXCEPT

lumbar tap
appendectomy
ultrasound
interviewing a rape victim
You would like to study on the "Effectiveness of Syzygium samarangense (Macopa Fruit) on
Blood Glucose Levels". This type of study needs to be subjected to a/an
no need for review

exempted from review
complete review
expedited review
You would like to conduct a study on the "Online Competency of Grade 2 to Grade 6
Elementary Students: A Comparative Study" . When conducting this kind of study, you
should ask for
assent and consent
assent
teacher consent, assent and guardian consent
this study should not be conducted because they are regarded as vulnerable groups
Which one is NOT a characteristic of transparency

truthfulness
risk benefit ratio
honesty
Disclosure
Being an observant nurse in your area, you notice an increase in the prevalence rate of
infant diagnose with Jaundice. A friend from Malaysia informed you that they are using
Massage to decrease the bilirubin level and seemed to be promising. You wanted to do the
study also in the Philippines and you remember the ethical issue that may confront
you. This kind of study isnot allopw
Neonate is considered vulnerable groups
you just need to ask permission from the mothers
not allowable since neonates are so fragile
studyis necessary since they can never be done to non-vulnerable groups
Self determination means EXCEPT

the right to refuse to provide information
the right to withdraw from the study
the right to decide to participate voluntarily
the right to benefit from the study
the right to ask question
The process of conducting review of related literature are as follows

• search , secure, screen, review, read, organize, analyze, and write
• Search, screen, secure, review. Read, organize, analyze and write
• Screen, secure, review, read, organize, analyze and write
• Search, screen, search, secure, review, read, organize, analyze and write
To improve the delivery of nursing care in the ICU, which of the following study should be
undertaken?
• Survey on the perception of patients on the presence of affiliating nursing students in
the wards
• Hand washing practices of residents and interns
• Correlation of medication errors
• Learning needs of patients and their families
Which one is considered RISK in ethics research
• Possible side effect of newly develop drug
• Exposure of the identity of your participants
• All of the above
• Dishonesty in terms of survey answers
Identify a vulnerable group

• 60 year old working as supervisor in a hospital
• 45 year old with impaired hearing loss
• 20 year old with impaired ill patient
• 18 year old whose leg was amputated
MIDTERM EXAM ALL SECTIONS
The question “Is there a relationship between caffeine intake and intraocular pressure in
patients with glaucoma?” is an example of which type of research?
What criteria do qualitative researchers use to assess the quality of a study?
C. Accuracy
D. Dependability
B. Reliability
A. Validity
The registered nurse knows that which is correct about hypotheses in research reports?
A. Hypotheses derived from theory are generally nondirectional in wording.
D. Hypotheses must express the expected relationship among at least three variables.
C. Qualitative research proceeds with hypotheses.
B. Hypotheses are more abstract than purpose statements.
researchers communicate their aims as problem statements, statements of purpose,

research questions, or hypotheses. What does subjects receiving antiemetic therapy by a
patient controlled pump will be less nauseous? represent?
D. Research question
C. Statement of purpose
A. Hypothesis
B. Problem statement
Written literature reviews are undertaken for many different purposes. In a qualitative
research report, what section of the report would the thematic analysis of the data be
presented?
D. Discussion
A. Introduction
B. Methods
C. Results
Which can cause bias in a study?
D. Adequate study design
C. Consistent methods of data collection
A. Participants' truthful responses
B. Researcher subjectivity
A researcher uses multiple sources or referents to draw conclusions about what constitutes
the truth. What is this called?
A. Triangulation
D. Credibility
C. Confirmability
B. Dependability
What is a major potential risk of research to participants?
D. Physical boredom
A. Monetary gains
C. Opportunity to discuss personal feelings and experiences with an objective listener.
B. Access to a new and potentially beneficial treatment
b. Correlational
d. Phenomenological
c. Historical
a. Basic
What provides prospective participants with information needed to make a reasoned

decision about participation?
D. Right to privacy
A. Confidentiality
B. Anonymity
C. Informed consent
What type of hypothesis is represented by the statement women who smoke are as likely to
have low-birth-weight babies as women who do not?
A. Directional
B. Nondirectional
C. Research
D. Null
A pediatric RN undertakes a study of the effect of low birth weight on infants' cognitive
development. A developmental psychologist collaborates on the study. A second RN helps
by recruiting families into the study. A graduate student is asked to give statistical advice in
analyzing the data. This is an example of what type of study?
C. Funded research
B. Qualitative research
A. Multisite research
D. Collaborative research
What is a simple hypothesis?
A. Predicted relationship between one independent variable and one dependent variable
D. Anticipated relationship between two independent variables and two dependent variables
C. Anticipated existence of relationships, not their direction

B. Predicted direction of the relationship
What is a research problem?
B. Articulation of the problem and description of the need for a study through the
development of an argument
D. Specific accomplishments that will be achieved by conducting the study
C. Specific queries researchers want to answer in addressing the problem
A. Situation involving an enigmatic or disturbing situation amenable to disciplined inquiry
Researchers communicate their aims as problem statements, statements of purpose,

research questions, or hypotheses. What does the following statement represent, Nausea
and vomiting are common side effects among patients on chemotherapy, and interventions
to date have been only moderately successful in reducing these effects? New interventions
that can reduce or prevent these side effects need to be identified?
A. Hypothesis
D. Research question
B. Problem statement
C. Statement of purpose
Written literature reviews are undertaken for many different purposes. In a quantitative
research report, what section of the report would a review of prior research on the problem
under study be located?
C. Results
B. Methods
D. Discussion
A. Introduction
What is a primary source for a research literature review?
D. Any journal article on a topic of interest
A. A description of a study written by researchers who did the study
C. A thesaurus that directs readers to subject headings germane to the topic
B. A summary of relevant research on the topic of interest
The RN is doing a basic search of articles on nurses' stress in the ICU. In conducting a
subject search in an electronic database, what should the nurse type to initiate the search?
C. A topic or keyword
A. An author's name
B. Restrictions to the search
D. A mapping procedure
What serves as the basis for regulations affecting research by the U.S. government?
Group of answer choicesWhat is included in the methods section of a study?
C. Strategies used to address the problem.
A. Review of the literature.
B. Names of the statistical tests that are going to be used.
D. Discussion including recommendations for the research.
B. The Declaration of Helsinki
D. The Code of Ethics of the American Psychological Association

A. The Nuremberg Code
C. The Belmont Report
Which term is used by both qualitative and quantitative researchers to refer to the
abstractions under study?
D. Variable
C. Phenomenon
A. Concept
B. Construct

research questions, or hypotheses. What is the statement of purpose?
B. Specific query researchers want to answer in addressing the research problem.
A. Summarizes the overall study goal.
C. Articulate the nature, context, and significance of the problem.

D. Statement of predicted relationships between two or more variables.
What is the research design in qualitative studies called?
A. Experimental
C. Interpretive
D. Emergent
B. Narrative
The RN is reading a research article. The article talks about constructs. Which would most
likely be called a construct?
A. Gender
D. Blood type
C. Uncertainty in illness
B. Body temperature
There are several major steps in preparing a written research review. What is the first step?
B. Devising a search strategy
D. Retrieving relevant sources
C. Conducting a search
A. Formulating a question
In a qualitative study that involves multiple contacts between the researcher and study
participants, what can the researcher negotiate?
A. Implied consent
D. Risk/benefit ratio
C. Process consent
B. Stipend
What is the process of reflecting critically on the self and of scrutinizing personal values that
could affect interpretation?

C. Transferability
B. Generalizability
A. Reflexivity
D. Thick description
Women who jog regularly are more likely to have amenorrhea than those who do not jog
regularly? Is an example of what type of hypothesis?
D. Nondirectional
C. Directional
A. Null
B. Not corrected stated
Which pair of variables is there most likely to be a relationship that could be described as
causal?
C. Age and health beliefs

B. Stress and coping style
A. Degree of physical activity and heart rate
D. Parity and postpartum depression
A spring scale consistently measures people's weights 4 pounds lighter than their true
weight. What type of bias would this data be on the weight?
D. Absolute bias
A. Sample bias
C. Random bias
B. Systematic bias
Where are registered nurses most likely to find research results?
A. Conference presentations
C. Books
B. Journal articles
D. Dissertations
What technique is the researcher using to control extraneous variables to the study purpose
that can obscure understanding?
A. Confounding
C. Generalizability
B. Reflexivity
D. Transferability
Outcomes research in health care is oriented toward establishing:
c. Predictive relationships
a. characteristics and description of nursing phenomena.
b. Critical indicators
d. Quality and effectiveness

What is the safeguard mechanisms by which even the researcher cannot link the participant
with the information provided?
B. Anonymity
D. Right to privacy
C. Informed consent
A. Confidentiality
When doing a literature review, what type of information will a researcher undertaking a new
study find as an undesirable attribute?
C. How the variables of interest have been operationally defined in prior studies
B. Descriptions of an expert's opinions about the phenomenon
D. What research approaches have been used to study similar problems
Available research findings
Matrices are a convenient means of abstracting and organizing information for a literature
review. When would a reviewer use a results matrix?

B. Record research findings.
D. Facilitate thematic analysis of the retrieved information.
A. Record methodological features of a set of studies.
C. Record quality assessment information.
The researcher wants to explore the extent to which qualitative findings can be transferred
to other settings. What is this called?
D. Thick description
C. Transferability
A. Reflexivity
B. Generalizability
What knowledge is required to fully define nursing research?
b. Ways to perform the major descriptive and inferential statistics needed for analysis
a. An exhaustive list of the research that has already been conducted in nursing
c. Research studies well received by other disciplines for collaborative projects.
d. A determination of what nurses need to know to provide the best patient care.
Florence Nightingale is most noted for which of the following contributions to nursing
research?
a. Case study approach to research
c. Framework and model development
b. Data collection and analysis
d. Quasi-experimental study design
What is beneficence?
C. Participants right to self-determination
D. Freedom to control their own actions
A. Performance of some good

B. Protection from physical and psychological harm and exploitation
In an electronic literature search, what is the researcher doing when she does not know the
precise keywords for retrieving information on a topic?
B. Searching
D. Copying
C. Restricting focus
A. Mapping
Where is the nurse likely to have difficulty getting an idea for research problems?
D. Nursing literature
C. Nursing code of ethics
B. Clinical experience
A. Theories of conceptual frameworks

Under HIPAA regulations, a covered entity such as a hospital can disclose individually
identifiable health information from its records if the patient signs an authorization granting
access. What does this include?
C. The Social Security number of the patient
B. Why they need the information
A. Who will receive the information
D. If the data is not specifically obtained for the research
review. When would a reviewer use an evaluation matrix?
C. Record quality assessment information.
D. Facilitate thematic analysis of the retrieved information.
A. Record methodological features of a set of studies.
B. Record research findings.
Not all problems are amendable to research inquiry. Which question cannot be researched?

D. Do terminally ill patients living with high levels of pain hold more favorable attitudes
toward assisted suicide than those with less pain?
C. What moral dilemmas are perceived by nurses who might be involved in assisted
suicide?
A. Should voluntary tubal ligations be performed on women without children?
B. What are nurses' attitudes toward voluntary tubal ligations?
A research study validates the positive effect that a nursing intervention, patient journaling,
has on decreasing spiritual distress during cancer recovery. This would be an example of
which type of research evidence?
b. Description
c. Explanation
a. Control
d. Prediction
A researcher designs a study to determine if a new teaching modality will benefit a

particular group of special education students that the researcher has been working. Which
design would the researcher be most likely to use?

C. Comparison of one group's status under different circumstances.
A. Comparison between two or more groups.
D. Comparison based on relative rankings.
B. Comparison of one group's status at two or more points in time.
Qualitative researchers discuss methods of enhancing the study's data by what method?
C. Confirmability
D. Credibility
B. Dependability
A. Trustworthiness

research questions, or hypotheses. What are hypotheses?
A. Essential to the conduct of respectable scientific enquiry

B. Needed only when there is an explicit theoretical framework
D. Not appropriate for many nursing research studies
C. Useful in giving direction to quantitative studies
What is a secondary source for a research literature review?
B. A summary of relevant research on the topic of interest
C. A thesaurus that directs readers to subject headings germane to the topic
A. A description of a study written by researchers who did the study
D. A description of the study by an individual unconnected with it
Quantitative and qualitative research approaches are particularly useful in nursing because
they:
d. require few resources
c. provide different views
b. are process oriented

a. are easy to implement
What is the aggregate of those to whom a researcher wishes to generalize study results
called?
D. Consumers
B. Population
C. Sample
A. Gate keepers
What is justice?
A. Right to fair treatment
C. Participants right to self-determination
D. Freedom to control their own actions
B. Protection from physical and psychological harm and exploitation

A study was conducted to determine which palliative care measures patients prefer.
Statistical analysis revealed that most of them ranked evening back rubs and calming music
the highest in helpfulness. This research would most likely fall under which of the following
categories?
a. qualitative research
c. outcomes research
d. there is not enough information to answer this question.
b. quantitative research
Qualitative researchers have varying opinions about reviewing the literature before doing a
new study. What group of researchers is represented when collection of data occurs before
reviewing the literature?
B. Phenomenologists
C. Ethnographogists
A. Grounded theory researchers
D. Grounded theory researchers and phenomenologist
An example of inductive reasoning is:

d. Using a computerized nursing care plan to care for inculin-dependent diabetic patients
a. going from a single diabetic patient to all diabetic patients.
c. Using a standard nursing care plan to care for a specific patient.
b. Moving from all chronically ill patients to a single chronically ill patient.
The nature of the research question is closely allied to paradigms. What is the focus of
research questions for a quantitative study?
C. Initiated to heighten awareness and create a dialogue about a phenomenon
B. Developed within a rich and context bound understanding of the problem
D. Identified major variables in the study and populations under investigation are present.
A. Undertaken because some aspect of a phenomenon is poorly understood
What is the independent variable in the hypothesis Baccalaureate degree prepared nurses
will practice more rehabilitative nursing measures on a client in an ICU than will associate
degree prepared nurses?

D. Type of educational background of nurses
C. Rehabilitative nursing measures
B. Baccalaureate degree prepared nurses
A. Associate degree prepared nurses
What is a nondirectional hypothesis?
Which is a datum from a qualitative research study on the labor and delivery experiences of
women over age 40?
B. 60-minute interviews 1 day after delivery
D. 15 women with a vaginal delivery

A. 14.6 hours in labor
C. It was a lot more painful than I ever imagined?
What is an example of a vulnerable group?
C. People who do not speak English
A. Women hospitalized for a mastectomy
B. Members of a senior citizen group
D. Pediatric clients
Which term is not used by qualitative researchers to refer to people who participate in a
study?
C. Study participants
D. Subjects
A. Informants
B. Key informants
A researcher is studying the relationship between age and involvement in social activities.
This is what type of research?
c. Quasi-experimental
a. Correlational
d. Experimental
b. Descriptive
A researcher finds that a small number of subjects did not provide accurate information
because they had just completed a rigorous session with the physical therapist. What is this
an example of?
C. Random bias
A. Sample bias
B. Systematic bias
D. Absolute bias
Which ethical principle may be violated if a researcher unobtrusively studies interactions
among patients in a psychiatric hospital?
C. Right to self-determination
D. Right to privacy
B. Freedom from harm
A. Confidentiality
What is the statement of the researcher's expectations or predictions about relationships

among study variables?
B. Framework
A. Hypothesis
C. Research question
D. Conceptual definition
a. Basic
b. Correlational
c. Historical
d. Phenomenological
When can the researcher omit informed consent, when existing data from records and/or
specimens are used?
D. The study is gathering data from records over 10 years old.
B. The researcher is gathering data anonymously
A. The study does not involve an intervention.
C. Health professional students are used as subjects.
What document covers primarily ethical issues for practicing nurses and includes principles
that apply to nurse researchers?

B. Ethical Research Guidelines for Registered Nurses
C. Ethical Guidelines in the Conduct, Dissemination, and Implementation of Nursing

Research
D. ICN Code of Ethics for Nurses
A. Code of Ethics for Nurses with Interpretative Statements
review. How many dimension arrays are present?
D. Five
C. Four
A. Two
B. Three
What is the overall plan for answering the research question?
C. Problem statement
A. Sampling plan
D. Research design
B. Proposal
A nurse who reads research articles and incorporates research findings into nursing
practice would demonstrate which of the following research
c. Primary Investigator
d. Producer
b. Consumer
a. Collaborator
What is the purpose of an operational definition in a quantitative study?
B. Specify how a variable will be defined and measured.
A. State the theoretical meaning of the concept.
C. State the expected relationship between the variables under investigation.

D. Designate the conceptual underpinnings of the variable.
What refers to evidence of the researcher's objectivity?
B. Trustworthiness
D. Confirmability
C. Dependability
A. Reliability
When doing a literature review, what type of information will a researcher undertaking a new
study find as an undesirable attribute?
B. Descriptions of an expert's opinions about the phenomenon
D. What research approaches have been used to study similar problems
Available research findings
C. How the variables of interest have been operationally defined in prior studies
Which of the following would be considered level 1 research evidence when evaluating
evidence for the establishment of IV site care and maintenance for a medical-surgical unit?
a. Case study review of dressings used at a similar-sized hospital
c. Quasi- experimental study evaluating types of dressings used at selected hospitals
d. Randomized clinical trial study conducted on types of dressings used in hospital settings
b. Expert opinion of best dressings used in hospital settings
Which is widely used by quantitative nurse researchers?
D. Grounded theory
A. Ask research questions
C. Ethnographic
B. Phenomenological
Which is correct about the research question what is the decision making process among
intensive care unit nurses who decide to assist terminally ill patients to die?

C. Not researchable
A. Most likely to be addressed using a quantitative approach
B. Most likely to be addressed using a qualitative approach
D. Not appropriately worded
What is a complex hypothesis?
How can confidentiality of study participants be increased?
D. Placing all identifying information on manual files rather than in computer files
C. Placing all identifying information on computer files rather than in manual files
B. Avoiding introducing the participants to any of the research personnel
A. Avoiding the collection of any identifying information
What is a moderator variable?
A. Affect the strength or direction of a relationship between independent variables
C. Intervene between the independent and dependent variable
B. Affect the strength or direction of a relationship between the independent and dependent
variables
Quiz #3 Research Design
The research design is a framework for planning your research and answering your research questions.
Creating a research design means making decisions about the following:
1. The type of data you need
2. The location and timescale of the research
3. The participants and sources

4. The variables and hypotheses (if relevant)
5. The methods for collecting and analyzing data
6. The instrument to be used
7. The statistical treatment
1, 2, 3, 4 and 5
A qualitative case study is good for gaining in-depth understanding of a specific context, but it does not
allow you to generalize to a wider population.
True
A laboratory experiment allows you to investigate causes and effects with high internal validity, but it
might not accurately represent how things work in the real world (external validity)
True
You want to know how phone use before bedtime affects sleep patterns. Specifically, you ask how the
number of minutes a person uses their phone before sleep affects the number of hours they sleep.
What is the most appropriate research design that you can think of?
Experimental Design
Both qualitative and quantitative focus on testing theories and hypotheses
False
Key terms: understanding, context, complexity, subjectivity
Qualitative Research
Key terms: testing, measurement, objectivity, replicability
Quantitative Research
The researcher randomly assigns subjects to control and treatment groups.
True Experimental Research Design
In research, a population doesn't always refer to people. It can mean a group containing elements of
anything you want to study, such as objects, events, organizations, countries, species, organisms, etc.
True
When you conduct research about a group of people, it's rarely possible to collect data from every
person in that group. Instead, you select a sample. The sample is the group of individuals who will
actually participate in the research. To draw valid conclusions from your results, you have to carefully
decide how you will select a sample that is representative of the group as a whole. There are two types
of sampling methods:
Non-probability sampling
involves random selection, allowing you to make statistical inferences about the whole group.
Probability sampling
involves non-random selection based on convenience or other criteria, allowing you to easily collect
initial data.
While methods and aims may differ between fields, the overall process of data collection remains
largely the same. Before you begin collecting data, you need to consider:
1. The aim of the research
2. The type of data that you will collect
3. The methods and procedures you will use to collect, store, and process the data
4. The data analysis and reliability
1.2, and 3
Consider the study title. The Lived Experience of Long-Term Complications from a Football- Related
Concussion Which design is most likely for this title?
Phenomenologic Study
You can control and standardize the process for high reliability and validity (e.g choosing appropriate
measurements and sampling methods)
True
You can tailor data collection to your specific research aims (e.g. understanding the needs of your
consumers or user testing your website)
True
However, there are also some drawbacks: data collection can be time-consuming, labor-intensive and
expensive. In some cases, it's more efficient to use secondary data that has already been collected by
someone else, but the data might be less reliable.
True
What is the difference between methodology (2.5 points) and method (2.5 points)?
- Methodology refers to the overarching strategy and rationale of your research project. It is the
theoretical framework to support the methods chosen and a perspective taken on the research,
which dictates how it is approached. On the other hand, methods, are the instruments and
techniques that you use to gather and evaluate data, such as experiments, surveys, and
statistical tests.
Quiz #4 Sampling and Instrument
Bias in a sample for a quantitative study refers to:
- Systematic over or under representation of an attribute vis-à-vis the population

Strata are incorporated into the design of which of the following types of samples?
- quota
Which of the following is NOT a nonprobability sampling method?
- cluster
Which of the following is NOT a nonprobability sampling method?
Identification of the set of elements used for selecting study participants
Process of selecting a subset of the population to represent the entire population
A researcher used a systematic sampling design. The known population size is 3200, and the desired
sample size is 160. What is the sampling interval?
- 20
A sampling strategy that is diametrically opposed to maximum variation sampling is:
- homogenous
Samples of 10 or fewer subjects would be most likely to be found in a
Ethnography
Mixed method
Grounded theory
A researcher used a probability type systematic sampling plan. The sample size w 200 The sampling
interval was 250. The first element drawn was 196. The second element would be
- 446
The sampling plan for a quantitative study need NOT include:
- a plan for participants anonymity
Which of the following instrument can be directly measured
- vital sign
Which of the following will provide the most sensitive measurement of a concept such as pain intensity?
- a visual analog scale
Which of the following
DOES NOT affect
the reliability of
measurement in a
study?
Systematic error
Consistency of instrument
accuracy
In developing an instrument, the researcher should?
- identify the essential content to be covered
Evidence of validity
of measurement
can be obtained
by examining?
- different groups
Finding an appropriate
measurement tool is
based on which of the

following assumptions?
- the concept to be measured has been clearly defined
Which of the following is
not a scale?
semantic
likert
In selecting an instrument for a research project, the primary consideration is:
- Whether the instrument captures the conceptual meaning of the phenomenon of interest
If a researcher is administering a questionnaire to a highly disadvantages population, it is sometimes

advisable to:
- Determine the readability level of the questionnaire
A pretest is NOT usually used for which of the following purposes?
To obtain information on the proper sequencing of instruments within the data collection package
The identify the parts of the data collection package that might be difficult or objectionable
To prioritize data collection needs
Theoretical sampling is used primarily by grounded theorists
- True
II-4B F&E Quiz - (Set B Thurs-Fri Group)

Formative Assessment #1
Lee Angela’s lab test just revealed that her chloride level is 96 mEq/L. As a nurse, you would interpret
this serum chloride level as:
high normal
Low
High
within normal range
Which clinical manifestation would lead the nurse to suspect that a client is experiencing
hypermagnesemia?
Soft-tissue calcification and hyperreflexia
Muscle pain and acute rhabdomyolysis
Increased respiratory rate and depth
Hot, flushed skin and diaphoresis
The body’s compensation of metabolic alkalosis involves:
increasing the respiratory rate
decreasing the respiratory rate
decreasing urine output
increasing urine output
A patient with tented skin turgor, dry mucous membranes, and decreased urinary output is under nurse
Mark’s care. Which nursing intervention should be included in the care plan of Mark for his patient?

Monitoring serum albumin and total protein levels
Clustering necessary activities throughout the day
Administering I.V. and oral fluids
Assessing color, odor, and amount of sputum
Mr. Salcedo has the following arterial blood gas (ABG) values: pH of 7.34, partial pressure of arterial
oxygen of 80 mm Hg, partial pressure of arterial carbon dioxide of 49 mm Hg, and a bicarbonate level of
24 mEq/L. Based on these results, which intervention should the nurse implement?
Encouraging the client to cough and deep breathe
Nothing, because these ABG values are within normal limits.
Administering low-flow oxygen
Instructing the client to breathe slowly into a paper bag
Genevieve is diagnosed with hypomagnesemia, which nursing intervention would be appropriate?

Instituting seizure precaution to prevent injury
Avoiding the use of tight tourniquet when drawing blood
Teaching the client the importance of early ambulation
Instructing the client on the importance of preventing infection
Mrs. Waltraud is receiving digoxin and Lasix daily. Today, she complains of nausea, and her apical pulse
is 130 and irregular. Which of the following nursing interventions is the most appropriate?
Remove the orange juice from the patient’s tray.
Hold the digoxin and check the patient’s potassium level.
Identify the patient as high risk for hyperkalemia.
Assess the patient for other signs of hypernatremia.
Mary Jean, a first year nursing student, was rushed to the clinic department due to hyperventilation.
Which nursing intervention is the most appropriate for the client who is subsequently developing
respiratory alkalosis?

Administering sodium chloride I.V.
Encouraging slow, deep breaths
Administer low-flow oxygen therapy
Preparing to administer sodium bicarbonate
A client with very dry mouth, skin and mucous membranes is diagnosed of having dehydration. Which
intervention should the nurse perform when caring for a client diagnosed with fluid volume deficit?
Obtaining the client’s weight weekly at different times of the day
Assessing urinary intake and output
Monitoring arterial blood gas (ABG) results
Maintaining I.V. therapy at the keep-vein-open rate
Which of the following statements provides the rationale for using a hypotonic solution for a patient
with FVD?

Excessive volumes are recommended in the early postoperative period
A hypotonic solution supplies an excess of sodium and chloride ions
A hypotonic solution is used to treat hyponatremia.
A hypotonic solution provides free water to help the kidneys eliminate the solute.
Orly Khan is suffering from fluid volume deficit (FVD), which of the following symptoms would the nurse
expect to assess in the patient? Select all that applies.
bulging neck veins
rales
tachycardia
bounding pulse
Which of the following arterial blood gas (ABG) values indicates uncompensated metabolic alkalosis?

pH 7.48, PaCO2 42, HCO3 30
pH 7.48, PaCO2 34, HCO3 20
pH 7.48, PaCO2 46, HCO3 30
pH 7.48, PaCO2 34, HCO3 26
Jonas is admitted with 1,000 ml of diarrhea per day for the last 3 days. An IV of 0.45% NaCl mixed with
5% dextrose is infusing. Which of the following nursing interventions is the most appropriate?
Get an infusion controller from central supply
Check the patient’s potassium level and contact the doctor for IV additive orders.
Mix all antibiotics in 0.45% NaCl with 5% dextrose
Assess the patient for signs of hyperkalemia.
Which client situation requires the nurse to discuss the importance of avoiding foods high in potassium?
16-year-old John Joseph with ileostomy

14-year-old Elena who is taking diuretics
16-year-old Gabriel with metabolic acidosis
18-year-old Albert who has renal disease
Joshua is receiving furosemide and Digoxin, which laboratory data would be the most important to
assess in planning the care for the client?
Sodium level
Magnesium level
Potassium level
Calcium level
Nurse John Joseph is totaling the intake and output for Elena Reyes, a client diagnosed with septicemia
who is on a clear liquid diet. The client intakes 8 oz of apple juice, 850 ml of water, 2 cups of beef broth,
and 900 ml of half-normal saline solution and outputs 1,500 ml of urine during the shift. How many
milliliters should the nurse document as the client’s intake.
2,740
2,230
2,320
2,470
Nursing interventions for a patient with hyponatremia include _____. (Select all that applies)
restricting fluid intake
administering hypotonic IV fluids
Administer loop diuretics
encouraging water intake
restricting sodium intake

Mang Teban has a history of chronic obstructive pulmonary disease and has the following arterial blood
gas results: partial pressure of oxygen (PO2), 55 mm Hg, and partial pressure of carbon dioxide (PCO2),
60 mm Hg. When attempting to improve the client’s blood gas values through improved ventilation and
oxygen therapy, which is the client’s primary stimulus for breathing?
Normal pH
Low PO2
High PCO2
Normal bicarbonate (HCO3)
Lab tests revealed that patient Z’s [Na+] is 170 mEq/L. Which clinical manifestation would nurse Natty
expect to assess?
Muscle weakness and paresthesia
Muscle twitching and tetany
Tented skin turgor and thirst

Fruity breath and Kussmaul’s respirations
Jon has a potassium level of 6.5 mEq/L, which medication would nurse Wilma anticipate?
Calcium gluconate
Kayexalate
Sodium tablets
Potassium supplements
When assessing a patient for metabolic alkalosis, the nurse would expect to find:
low serum potassium
increased CVP
changes in urine output
hypotension
Marie Joy’s lab test revealed that her serum calcium is 2.5 mEq/L. Which assessment data does the
nurse document when a client diagnosed with hypocalcemia develops a carpopedal spasm after the
blood-pressure cuff is inflated?
Paresthesia
Tetany
Positive Chvostek’s sign
Positive Trousseau’s sign
John Reid is admitted in the hospital and is currently receiving hypertonic fluids. Nursing management
for the client includes monitoring for all of the following potential complications except:
water intoxication
cellular dehydration
cell shrinkage
fluid volume excess (FVE)

When assessing a patient’s total body water percentage, the nurse is aware that which of the following
factors influence this? Select all that applies.
fat tissue
muscle mass
height & weight
gender
age
When chloride concentration drops below 95 mEq/L, reabsorption of which of the following electrolytes
increases proportionally?
sodium
bicarbonate
potassium
hydrogen
Which of the following diagnoses is most appropriate for a patient with hypocalcemia?
high risk for injury: bleeding
constipation, bowel
high risk for injury: confusion
airway clearance, ineffective
Mr. Wenceslao is scheduled to receive an isotonic solution; which one of the following is an example of
such solution?
0.9% saline
D10% W
3% normal saline W
0.45% saline
Which electrolyte would the nurse identify as the major electrolyte responsible for determining the
concentration of the extracellular fluid?
Sodium
Phosphate
Potassium
Chloride
A client is diagnosed with metabolic acidosis, which would the nurse expect the health care
provider to order?
Bronchodilator
Sodium bicarbonate
Potassium
Serum sodium level

P&S_Formative Assessment No. 1 Set A
It is the invasive incision into the body tissues or a minimally invasive entrance into a body
cavity for either therapeutic or diagnostic purpose during which protective reflexes or self-care
abilities are potentially compromised.
Asepsis
Disinfection
Aseptic Technique
Surgical Procedure
Which of the following microbes described as a microscopic single celled or multi celled plants
that live either or plants or animals, it can infect the mouth, vagina, skin, feet & body parts?
Fungi
Rickettsiae
Protozoa
Bacteria
These are natural disease processes that develop or incubate before the patient is admitted to
the hospital.
Community acquired infection
Nosocomial infection
Cross infection
Reinfection
Which of the following are the responsibilities of perioperative nurse?
Helps plan, implement and evaluate treatment of the patient

Well organized
Flexible and Adaptable
Sensitive and Perceptive
It is the chain of infection in which the pathogens leave the reservoir like human secretions.
Mode of transmission
Reservoir
Portal of entry
Portal of exit
It is the practice and procedure that maintains a clean environment by removing or destroying
the pathogens
Asepsis
Medical asepsis
Aseptic technique
Surgical asepsis
Following are the standard precautions of infection control practices EXCEPT:
Wearing of appropriate PPE

Proper handling of waste and waste disposal
Be free from toxic ingredients and non-fast dyes and be relatively nonabrasive //
Environment cleaning and spills management
The nurse is preparing to leave the room after performing oral suctioning on a client who is in
contact with tions. Which of the following actions will you perform?
Remove gloves, take off goggles, take off the gown, remove N95 respirator, perform hand
hygiene
Take off the gown, remove N95 respirator, take off goggles, remove gloves, perform hand
hygiene
Remove N95 respirator, take off goggles, remove gloves, take off the gown, perform hand
hygiene
Take off goggles, remove gloves, remove N95 respirator, take off the gown, perform hand
hygiene
The circulating nurse prepares the sterile field in the operating room (OR). Fifteen minutes later,
the nurse is informed the surgery is delayed for 20 minutes because the surgeon is working at
another hospital. Which is the best action for the nurse to take?
Monitor the sterile field while awaiting the surgeon. //

Close and tape the OR doors so no one may enter.
Cover the sterile field with a sterile drape until the surgery is about to begin.
Tear down the sterile field until the surgeon arrives in the OR.
While team effort is needed in the OR for efficient and quality patient care delivery, we should
limit the number of people in the room for infection control. Who comprise this team?
Surgeon, assistants, scrub nurse, circulating nurse, anesthesiologist

Surgeon, assistants, anesthesiologist, scrub nurse, pathologist
Surgeon, anesthesiologist, scrub nurse, radiologist, orderly
Surgeon, assistant surgeon, anesthesiologist, intern, scrub nurse
The physical environment and traffic control measures of the operating room are designed
primarily to:
Protect the privacy of the patient

Ensure sufficient completion of surgical procedures
Prevent transmission of infection
Allow smooth functioning of the operating room team
What is the most common source of transmission of microorganisms in the OR?
Faulty ventilation system

Infection
Instruments
Surgical team
Which is an example of a hospital-acquired infection?

• Gunshot wound septicemia
• Catheter-associated urinary tract infection
• Diabetic gangrene
• Tuberculosis
When gathering data to evaluate patient outcomes, the nurse should include the:
• Clarity of any narrative charting in the patient record
• Patient’s complaints of pain during the perioperative period
• Educational level of staff working in the operating room
• Number of personnel required for the operative procedure
Appendectomy is classified as:
Ablative
Constructive
Reconstructive
Palliative
This is worn in the restricted areas to contain and filter droplets containing microorganisms
expelled from the mouth and nasopharynx during breathing, talking, sneezing and coughing.
• Goggles
• Shoe cover
• Mask
• Gloves
The OR team performs distinct roles for one surgical procedure to be accomplished within a
prescribed time frame and deliver a standard patient outcome. While the surgeon performs the
surgical procedure, who monitors the status of the client like urine output, blood loss?
• Circulating nurse
• Surgeon
• Anaesthesiologist
• Scrub nurse
The nurse is preparing to change the linens on the bed of a client who has an infected wound in
sacral area. Which PPE items will you use? Select the answer.
• N95 respirator and goggles
• Surgical mask and gown
• Goggles and gown
• Gloves and gown
While surgery was ongoing, a power failure occured. It took 5 minutes before the hospital
generator could be started. Emergency lights were malfunctioning. Whose responsibility was it
to prepare hand flashlights in the OR?
• Circulating nurse
• Assistant surgeon
• Scrub nurse
• Surgeon
He is a Greek physician who performed an extensive dissection in animals, also he studied the
muscles, spinal cord, heart, urinary system, and proved that the arteries are full of blood.
• Florence Nightingale
• Abraham Lincoln
• Lord Berkely george Moynihan
• Claudius Galen
P&S_ Formative Assessment No. 2 Set B
Which of the following characterizes excitement stage of anesthesia?
From the loss of lid reflex to the loss of most reflexes
Occurs from the administration of anesthesia to the loss of consciousness
From the loss of most reflexes to respiratory and circulatory failure
Extends from the loss of consciousness to the loss of lid reflex, characterized by struggling and talking
To prevent headache after spinal anesthesia the patient should be positioned:
Semi-fowler’s
Prone position
Flat on bed for 6 to 8 hours
Modified Trendelenburg
Which of the following nursing actions should be given highest priority when admitting the patient into
the operating room?
Patient identification and correct operative consent
Vital signs
Positioning and skin preparation

Level of consciousness
What is the primary reason for the gradual change of position of the patient after surgery?
To prevent muscle injury
To promote comfort
To prevent respiratory distress
To prevent sudden drop of BP
Which of the following assessment data is most important to determine when caring for a patient who
has received spinal anesthesia?
Amount of wound drainage
The time of return of motion and sensation in the legs and toes
The character of respiration
Level of consciousness
32. Which of the following postop findings should the nurse report to the M.D.?
VS are as follows: BP=110/70;PR=95;RR=19,Temp=36.8C
Urine output is 20ml/hr for the past two hours
The patient pushes out the oral airway wit h his tounge
Wound drainage is serosanguinous
Which of the following is the earliest sign of poor respiratory function?
Restlessness
Fast thready pulse
Cyanosis
Faintness
If wound eviscerations occurs, the immediate nursing action is:
Cover the wound with sterile gauze moistened with sterile NSS
Cover the wound with sterile dry gauze
Cover the wound with water-soaked gauze
Leave the wound uncovered and pull the skin edges together
The best time to provide preoperative teaching on deep breathing, coughing and turning exercises is:
Upon admission of the client in the recovery room
Before administration of preoperative medications
The afternoon or evening prior to surgery
Several days prior to surgery
The following are the appropriate nursing actions before administration of preoperative medications
EXCEPT:
Ensure that NPO has been maintained
Shave the skin at the site of surgery
Instruct patient to empty his bladder
Ascertain the consent has been signed

The patient has been observed pacing along the hallway, goes to the bathroom frequently and asks
questions repeatedly during preoperative assessment. The most likely cause of the behavior is:
She has an underlying emotional problem
She is anxious about the surgical procedure
She has urinary tract infection
She is worried about separation from the family
Which of the following nursing actions would help the patient decrease anxiety during the preoperative
period?
Encouraging sleep and limiting interruptions

Explaining all procedures thoroughly in chronological order
Reassuring the patient that the surgical staff are competent professional
Spending time listening to the patient and answering questions
Which of the following is the primary purpose of maintaining NPO for 6 to 8 hours before surgery?
To prevent intestinal obstruction
To prevent aspiration pneumonia
To prevent malnutrition
To prevent electrolyte imbalance
The following ensure validity of informed written consent EXCEPT:

The consent is secured before administration of any medication that alter the level of consciousness
The patient is of legal age with proper mental disposition
If the patient is unable to write, secure the consent from a relative
The consent has been secured within 24 hours before the surgery
Which of the following drugs is administered to minimize respiratory secretions preop?
Phenergan (Promethazine)
Atropine Sulfate
Nubain ( Nalbuphine HCL)
Valium (Diazepam)
Which of the following is experienced by the patient who is under spinal anesthesia?
The patient experiences amnesia
The patient experiences total loss of sensation
The patient is awake
The patient is unconscious
The patient who has undergone TAHBSO complains of pain. Which of the following is an initial nursing
action?
Instruct to do deep breathing exercises
Assess the VS
Change the patient’s position

Administer the PRN analgesics
How frequent should the nurse monitor the VS of the patient in the recovery room?
Every 15 minutes
Every 30 mins
Every 45 mins
Every 60 mins
Which of the following drugs is given to relieve nausea and vomiting?
Plasil
Mepivacaine
Nubain
Aquamephyton
Which of the following materials for skin preparation is incorrect?
Soup suds
Betadine
Shaving equipment
Surgical skin marker pens

Summative Assessment (Pain &Surgery
Concept Exam)
Summative Assessment 1
The nurse is evaluating the effectiveness of imipramine (Tofranil), a tricyclic antidepressant, for
a patient who is receiving the medication to help relieve chronic cancer pain. Which information
is the best indicator that the imipramine is effective?
The patient sleeps 8 hours every night.
The patient says that the pain is manageable and that he or she can accomplish desired activities.
The patient has no symptoms of anxiety.
A home health patient has a prescription for pentazocine (Talwin,) a mixed opioid agonist-
antagonist. When teaching the patient and family about adverse effects, the nurse will plan to
focus on how to monitor for
agitation
physical dependence.
respiratory depression.
hypotension.
Which of the following factors ensure validity of informed written consent, except:

If the patient is unable to write, the nurse signs the consent for the patient
If the patient is a child, secure consent from the parents or legal guardian
The consent is secured before administration of preoperative medications
The patient is of legal age with proper mental disposition
The most appropriate assessment of the efficacy of administered pain medication would be:
The patient’s perception measured on a pain scale.
Changes in blood pressure, pulse, and respiratory rate.
The nurses visual assessment.
The nurse’s verbal assessment.
A client is scheduled for surgery in the morning. Preoperative orders have been written. What is
most important to do before surgery?
Verify that all laboratory work is complete
Inform family or next of kin
Have all consent forms signed
Remove all jewelries or tape wedding ring
A patient receiving prn intermittent IV administration of opiates following gastric surgery

watches a favorite television program every morning. The patient does not request pain
medication during this time and when questioned denies the need for medication. The nurse’s
evaluation of this situation is that
lying quietly in bed is the best method of controlling the patient’s incisional pain.
the distraction of the television enables the patient to decrease the perception of pain.
encouraging the patient to watch other television programs will decrease the pain.
the patient’s dose of opiates needs to be decreased because her pain is well controlled.
The nurse is assessing a 36-year-old woman who has been admitted for knee surgery. Which
information obtained during the preoperative assessment should be reported to the surgeon
before surgery?
The patient’s concern that she will be unable to care for her children postoperatively
The patient’s lack of knowledge about postoperative pain control measures
The patient’s statement that her last menstrual period was 8 weeks previously
The patient’s history of a postoperative infection following a prior cholecystectomy
You are caring for a patient who borrowed pain medication from a friend at a beauty salon. She
seems to be experiencing side effects of the medication. Your most appropriate response would
be:
Instruct the patient as to the proper use of the medication.
Stop the medication and call the friend’s practitioner.
Take the medication with milk.
Continue the medication if pain relief is adequate.

To prevent complications of immobility, which activity would a nurse plan for the first
postoperative day after colon resection?
t is not necessary to worry about complications of immobility on the first postoperative day
Get the client out of bed and ambulate to a bedside chair
Turn, cough, and deep breathe every 30 minutes around the clock
Provide passive range of motion three times a day
An 82-year-old man is admitted to the hospital the evening before a prostatectomy. He is alert
and oriented but has difficulty seeing and hearing. His wife answers most questions directed to
the patient. To accomplish preoperative teaching with the patient, the nurse plans to
ask the patient’s wife to wait in the hall in order to focus preoperative teaching with the patient
himself.
provide additional time for the patient to understand preoperative instructions and carry out
procedures.
use printed materials for instruction so that the patient will have more time to review the
material.
direct the teaching toward the wife because she is the obvious support and caregiver for the
patient.
A patient’s family history reveals that the patient may be at risk for malignant hyperthermia
(MH) during anesthesia. The nurse explains to the patient that
surgery must be performed under local anesthetic to prevent development of a sudden, extreme
increase in body temperature.
as long as succinylcholine (Anectine) is not administered as a muscle relaxant, the reaction

should not occur.
surgery will be delayed until the patient is genetically tested to determine whether he or she is
susceptible to malignant hyperthermia.
anesthesia can be administered with minimal risks with the use of appropriate precautions and
medications.
The nurse is obtaining the health history for a patient who is scheduled for outpatient knee
surgery. Which statement by the patient is most important to report to the health care provider?
“I had bacterial pneumonia 2 years ago.”
“I had rheumatic fever when I was 6 years old.”
“I have knee pain whenever I walk or jog.”
“I have a strong family history of breast cancer.”
The nurse from the general surgical unit is asked to bring the patient’s hearing aid to the surgical
suite. The nurse will take the hearing aid to the
scrub sink areas.
clean core.
corridors of the operating room area.
nursing station or information desk.
A patient with a dislocated shoulder is prepared for a closed, manual reduction of the dislocation
with conscious sedation. The nurse anticipates the administration of
intramuscular fentanyl/droperidol (Innovar).
intramuscular ketamine (Ketalar).

inhaled nitrous oxide.
IV midazolam (Versed)
Ten minutes after receiving the ordered preoperative opioid by intravenous (IV) injection, the
patient asks to get up to go to the bathroom to urinate. The most appropriate action by the nurse
is to
allow the patient up to the bathroom because the onset of the medication takes more than 10
minutes.
assist the patient to the bathroom and stay with the patient to prevent falls.
ask the patient to wait because catheterization is performed at the beginning of the surgical
procedure.
offer a urinal or bedpan and position the patient in bed to promote voiding.
After orienting a new staff member to the scrub nurse role, the charge nurse will know that the
education was effective if the new staff member
takes the patient to the postanesthesia recovery area.
labels all specimens to send to the lab.
keeps both hands above the operating table level.
documents all patient care accurately.
A patient with chronic cancer pain experiences breakthrough pain (level 9 of 10) and anxiety
while receiving sustained-release morphine sulfate (MS Contin) 160 mg every 12 hours. All
these medications are ordered for the patient. Which one will be most appropriate for the nurse to
administer first?

Lorazepam (Ativan) 1 mg orally
Ibuprofen (Advil) 400-800 mg orally
Immediate-release morphine 30 mg orally
Amitriptyline (Elavil) 10 mg orally.
You are the nurse caring for a patient who will receive a transsacral block. In what surgeries
would a transsacral block be useful for pain control?
Thoracotomy
Breast reduction
Inguinal hernia repair
Closed reduction of a right humerus
The nurse notes that the oxygen saturation is 88% in an unconscious patient who was transferred
to the PACU 10 minutes previously. Which action should the nurse take first?
Perform the jaw-thrust maneuver.
Suction the patient’s mouth.
Increase the oxygen flow rate.
Elevate the patient’s head.
A patient with chronic abdominal pain has learned to control the pain with the use of imagery
and hypnosis. A family member asks the nurse how these techniques work. The nurse’s reply
will be based on the information that these strategies
slow the release of transmitter chemicals in the dorsal horn.
prevent transmission of nociceptive stimuli to the cortex.
increase the modulating effect of the efferent pathways.
impact the cognitive and affective components of pain
A patient is seen at the health care provider’s office several weeks before hip surgery for
preoperative assessment. The patient reports use of echinacea, saw palmetto, and
glucosamine/chondroitin. The nurse should
teach the patient that these products may be continued preoperatively.
discuss the supplement use with the patient’s health care provider.
advise the patient to stop the use of all herbs and supplements at this time.
ascertain that there will be no interactions with anesthetic agents.
On admission of a patient to the postanesthesia care unit (PACU) from surgery, the nurse should
first assess the
patient’s oxygen saturation.
dressing at the surgical site.
patient’s level of consciousness.
intravenous (IV) site and fluid rate.

The nasogastric (NG) tube is removed on the second postoperative day for a patient who had
abdominal surgery. A clear liquid diet is ordered. Four hours later, the patient complains of
abdominal distention and sharp, cramping gas pains. The most appropriate nursing action is to
place the patient on NPO status.
reinsert the NG tube.
assist the patient to ambulate in the hall.
administer the ordered as-needed morphine sulfate.
Following gallbladder surgery, a patient has a T-tube with thick, dark green drainage. When the
patient asks about the tube and the drainage, the best response by the nurse is
“The drainage is old blood and fluid that accumulates at the surgical site. Its removal will
promote healing.”
“The tube you see has been placed in the bile duct, and the drainage is normal bile.”
“The drainage is from your gallbladder, but it should be bright yellow rather than green.”
“The tube is draining secretions from the duodenum and small bowel, and this is normal drainage
from this area.”
During the preoperative interview with the nurse, a patient scheduled for an elective
hysterectomy to treat benign tumors of the uterus tells the nurse that she just does not know
whether she can go through with the surgery because she knows she will die in surgery as her
mother did. The most appropriate response by the nurse is:
“Surgical techniques have improved a lot in recent years.”
“Tell me more about what happened to your mother.”
“Many people have fears and anxieties about surgery.”

“You will receive medications to reduce your anxiety.”
A patient is to receive atropine before surgery. The nurse teaches the patient to expect
dry mouth.
forgetfulness.
weakness.
dizziness.
The perioperative nurse encourages a family member or a friend to remain with a patient in the
preoperative holding area until the patient is taken into the operating room primarily to
ensure the proper identification of the patient prior to surgery.
protect the patient from cross-contamination with other patients.
assist the perioperative nurse to obtain a complete patient history.
help relieve the stress of separation for the patient and significant others.
When the nurse interviews a 53-year-old patient who is to have abdominal surgery using a
general anesthetic, which information is most important to communicate to the surgeon and
anesthesiologist before surgery?
The patient’s father died after receiving general anesthesia for abdominal surgery.
The patient drank a glass of apple juice 3 hours before coming to the hospital.
The patient drinks 1 to 2 cups of coffee every morning before going to work.
The patient usually takes a baby aspirin daily and stopped taking aspirin 10 days ago.
Your patient is a 35-year-old female who has been administered general anesthesia. The patient
is in stage II (the excitement stage) of anesthesia. Which intervention might you need to
implement during this stage?
Rub the patient's back
Stroke the patient's hand
Restrain the patient
Encourage the patient to express feelings
Appropriate preoperative teaching for a patient scheduled for abdominal surgery includes
the need to complete all ordered antibiotics after surgery.
care for the surgical incision.
methods for effective deep breathing and coughing.
medications used during surgery.
During the preoperative assessment of a patient scheduled for a colon resection, the patient tells
the nurse about using St. John’s wort to prevent depression. The nurse should alert the staff in
the postanesthesia recovery area that the patient may
experience increased pain.

have hypertensive episodes.
take longer to recover from the anesthesia.
have more postoperative bleeding than expected.
Which of the following is the primary purpose of maintaining NPO for 6 to 8 hours before
surgery?
To prevent malnutrition
To prevent electrolyte imbalance
To prevent aspiration pneumonia
To prevent intestinal obstruction
A patient in surgery receives a neuromuscular blocking agent as an adjunct to general anesthesia.

At completion of the surgery, it is most important that the nurse monitor the patient for
confusion.
laryngospasm or bronchospasm.
nausea.
weak chest-wall movement.
37/50
1.) When a patient is transferred from the PACU to the clinical surgical unit, the first
action by the nurse on the surgical unit should be to
a.) Take the patient’s vital signs.
2.) A patient with a history of chronic cancer pain is admitted to the hospital. When
reviewing the patient's home medications, which of these will be of most concern to the
admitting nurse?
a.) Meperidine (Demerol) 25 mg every 4 hours
3.) Which of the following is the primary purpose of maintaining NPO for 6 to 8
hours before surgery?
a.) To prevent aspiration pneumonia
4.) The nasogastric (NG) tube is removed on the second postoperative day for a
patient who had abdominal surgery. A clear liquid diet is ordered. Four hours later, the
patient complains of abdominal distention and sharp, cramping gas pains. The most
appropriate nursing action is to
a.) assist the patient to ambulate in the hall.
5.) A postoperative patient has not voided for 7 hours after return to the postsurgical
unit. Initially the nurse should
a.) Palpate the bladder - Palpate and percuss the bladder nasa net
6.) You are the circulating nurse in an outpatient surgery center. Your patient is
scheduled to receive moderate sedation. You know that a patient receiving this form of
anesthesia should what?
a.) Never be left attended by the nurse.
7.) The nurse evaluates that the interventions for the nursing diagnosis of ineffective
airway clearance in a postoperative patient have been successful when the
a.) patient's breath sounds are clear to auscultation.
8.) When caring for a patient during the second postoperative day after abdominal
surgery, the nurse obtains an oral temperature of 100.8° F. Which action is appropriate
for the nurse to take first?
a.) Have the patient use the incentive spirometer
9.) The nurse is obtaining the health history for a patient who is scheduled for
outpatient knee surgery. Which statement by the patient is most important to report to the
health care provider?
a.) "I had rheumatic fever when I was 6 years old."

10.) The nurse notes that the oxygen saturation is 88% in an unconscious patient
who was transferred to the PACU 10 minutes previously. Which action should the nurse
take first?
a.) Perform the jaw-thrust maneuver.
11. A nurse is caring for a patient following surgery under a spinal anesthetic. What
interventions
can the nurse implement to prevent a spinal headache?
-Keep the patient lying flat
12. Which of the following factors ensure validity of inform written consent, except:
-If the patient is unable to write, the nurse signs the consent for the patient
13. A preoperative patient in the holding area asks the nurse, “Will the doctor put me to sleep
with a mask over my face?” The most appropriate response by the nurse is,
-A drug will be injected through your IV line, which will cause you to go to sleep almost
immediately
14. Postoperatively a patient is receiving low-molecular-weight heparin (LMWH). When

administering this drug, the nurse
• Abdomen, anterior-lateral aspect
15. The circulating nurse and the scrub technician find a discrepancy in the sponge count. Which
action should be the circulating nurse take first?
-Recount all sponges
16. A client is experiencing confusion in the immediate postoperative period. Which of the
following assessments is essential to determine the reason for the confusion?
-Airway Status
2. cardiac rhythm
3. level of consciousness
4. level of anxiety
17. The nurse recognize that the use of local anesthesia would be particularly beneficial to a
patient when
19. A surgical patient received a volatile liquid as an inhalation anesthetic during surgery.
Postoperatively the nurse should monitor the patient for.
-Incisional pain
20. A postoperative patient who has undergone extensive bowel surgery moves as little as
possible and does not use the incentive spirometer unless specifically reminded. The patient
rates the pain severity as 8 on a 10-point scale but tells the nurse, “I can tough it out.” In
encouraging the patient to use pain medication, the best explanation by the nurse is that,
-Unrelieved pain can be harmful due to the effect on respiratory function and activity level
While assessing patients for complications during recovery from anesthesia, the nurse recognizes
that the patient who is at the greatest risk for developing postoperative hypothermia
· 62-year old undergoing a laparoscopic cholecystectomy under general anesthesia
· 34-year-old who is having a repair of a knee cartilage under local anesthesia
· 48-year-old trauma victim having repair of multiple injuries under general

anesthesia
· 68-year-old diabetic undergoing a great-toe amputation under local anesthesia
An elderly patient has a two-year history of back pain from arthritis. You would encourage:
· Use of narcotics for pain management
· Lifestyle modification and NSAIDs
· Diagnostic tests
· Vigorous physical therapy
Data obtained during the perioperative nurse’s assessment of a patient in the preoperative
holding area that would indicate a need for special protection techniques during surgery include:
· A history of spinal and hip arthritis
· Verbalization of anxiety by the patient
· Having a sip of water 2 hours previously
· A stated allergy to cats and dogs
Which information about medication use in a preoperative patient is most important to

communicate to the health care provider
· The patient takes garlic capsules daily but did not take any on the surgical day
· The patient uses acetaminophen (Tylenol) as needed for occasional aches and
pains
· The patient took a sedative medication to the previous night to assist in falling
asleep
· The patient has a history of cocaine use but quit using the drug over 10 years ago.
Appropriate preoperative teaching for a patient scheduled for abdominal surgery includes:
· The need to complete all ordered antibiotics after surgery
· Care for the surgical incision

· Methods for effective deep breathing and coughing
· Medications used during surgery
The nurse is admitting a patient to the operating room. Which of the following nursing actions
should be given highest priority by the nurse?
· Checking the patient’s vital signs
· Checking the patient’s identification and correct operative permit
· Positioning and performing skin preparation to the patient
· Assessing the patient’s level of consciousness
The health care provider plans to titrate a patient-controlled opioid infusion(PCA) to provide
pain relief for a patient with acute surgical pain who has never received opioids in the past.
Which of the following nursing actions regarding opioid administration are appropriate at this
time? Select all that apply
· Teaching about the need to decrease opioid doses by the second postoperative day
· Educating the patient about how analgesics improve postoperative activity level
· Emphasizing that the risk of opioid side effects increases over time
· Monitoring for therapeutic and adverse effects of opioid administration
· Assessing for signs that the patient is becoming addicted to the opioid
A patient being treated for chronic musculoskeletal pain tells the nurse. “ I feel depressed
because I can’t even go out and play a round of golf”. The patient describes the pain as “aching”
and says it is usually at a level 7 of a scale of 1 to 10. Based on these assessment data, which
patient goal is most appropriate? After treatment, the patient will
· Be able to play 1 to 2 round of golf

· Say that the aching has decreased
· Exhibit fewer signs of depression
· State that pain is at level 2 of 10
You are caring for a patient who borrowed pain medication from a friend at a beauty salon. She
seems to be experiencing side effects of the medication. Your most appropriate response would
be:
· Stop the medication and call the friend’s practitioner
· Continue the medication if pain relief is adequate
· Instruct the patient as to the proper use of the medication
· Take the medication with milk
31-40
31. In intervening to promote ambulation, coughing, deep breathing, and turning by a

postoperative patient on the first postoperative day, which action by the nurse is most helpful?
1. Administer ordered analgesic medications before these activities.
32. On the first postoperative day after a fractured femur, the patient is resting quietly, watching
TV. Your nursing interventions would include:
1. asking the patient what their pain level is on a scale of 1 to 10.

33. You are the circulating nurse caring for a 78-year-old patient who is scheduled for a total hip
replacement. Which of the factors should you consider during the preparation of the patient in
the operating room?
1. Pressure points should be assessed and well padded.
34. A client is scheduled for surgery in the morning. Preoperative orders have been written. What
is most important to do before surgery?
1. Have all consent forms signed
35. You are caring for a male patient who has had spinal anesthesia. The patient is under a
physician's order to lie flat postoperatively. When the patient asks to go to the bathroom, you
encourage him to comply with the physician's order. What is the rationale for complying with
this order?
1. A headache
36. Your post discharge instructions for a 65-year-old male with peripheral neuropathy from
diabetes would include:
1. Wear socks and shoes.

37. Prior to giving a requested pain medication, you would:
1. assess the vital signs.
38. A patient with chronic abdominal pain has learned to control the pain with the use of imagery
and hypnosis. A family member asks the nurse how these techniques work. The nurse's reply will
be based on the information that these strategies.
1. impact the cognitive and affective components of pain.
39. An 82-year-old man is admitted to the hospital the evening before a prostatectomy. He is
alert and oriented but has difficulty seeing and hearing His wife answers most questions directed
to the patient. To accomplish preoperative teaching with the patient, the nurse plans to
1. provide additional time for the patient to understand preoperative instructions and carry
out procedures.
40. A patient with a dislocated shoulder is prepared for a closed, manual
reduction of the dislocation with conscious sedation. The nurse anticipates
the administration of
1. IV midazolam (Versed).
41. The most appropriate assessment of the efficacy of administered pain medication would be:
1. The patient’s perception measured on a pain scale
42. A postoperative client receives a dinner tray with gelatin, pudding, and vanilla ice cream.
Based on the foods on the clients tray, what would the nurse anticipate the client's current diet
order to be:
1. Full liquid diet
43. To obtain the most complete assessment data about a patient’s chronic pain pattern the
nurse asks the patient
1. Can you describe your daily activities in relation to your pain?
44. A hospice patient is in continous pain, and the health care provider has left orders to
administer morphine at a rate that controls the pain. When the nurse visits the patient, the
patient is awake but moaning with severe pain and asks for an increase in morphine dosage.
The respiratory rate is 10 breaths per minute. The most appropriate action by the nurse is to
1. Titrate the morphine dose upward until the patient states there is adequate pain relief.
45. Which of the following primarily prevents postop complications?
1. Early ambulation
46. Following gallbladder surgery, a patient has a T-tube with thickm dark green drainage.
When the patient asks about the tube and the drainage, the best response by the nurse is
1. The tube you see has been placed in the bile duct, and the drainage is normal bile.
47. A patient is being treated for chronic musculoskeletal pain tell the nurse, “I feel depressed
because I can’t even go out and play a round of golf.” the patient describe the pain as aching
and says it is usually at a level of 7 on a scale of 1 to 10. Based on these assessment data, which
patient goal is most appropriate? After treatment, the patient will
1. Be able to play 1 to 1 rounds of golf.
48. The perioperative nurse encourages a family member or a friend to remain with a patient in
the perioperative holding area until the patient is taken into the operating room primarily to
1. Help relieve the stress of separation for the patient and significant others
49. A 42-year-old patient is recovering from anesthesia in the PACU. On admission to the PACU
the blood pressure (bp) was 124/70. Thirsty minutes after admission, the blood pressure falls
to 112/60, with a pulse of 72 and warm, dry skin. The most appropriate action by the nurse at
this time is to
1. Continue to take vital signs every after 15 minutes
What is the best rationale for intubation during a procedure?
• The tube provides an airway for ventilation.
After a new nurse has been oriented to the PACU, the charge nurse will evaluate that the
orientation has been successful when the new nurse
• turns a patient to the side when the patient arrives in the PACU.
A 75-year-old patient is to be discharged from the ambulatory surgical unit following left eye
surgery. The patient tells the nurse, “I do not know if I can take care of myself with this
patch over my eye.” The most appropriate nursing action is to
• discuss the specific concerns regarding self-care.
The nurse recognizes that the use of local anesthesia would be particularly beneficial to a
patient when
• the patient has recently taken food and fluids.
An elderly patient with chronic arthritis asks you for suggestions for pain relief. You advise
• guided imagery.
All the following medications are included in the admission orders for an 86-year-old patient
with moderate degenerative arthritis in both hips. Which medication will the nurse use as an
initial therapy?
A patient’s blood pressure in the PACU has dropped from an admission blood pressure of
138/84 to 110/78 with a pulse change of 68 to 84. The first action indicated by the nurse is
to
It would not be unusual for a patient with chronic pain to be taking:
• tricyclic antidepressants.
A patient who has just started taking sustained-release morphine sulfate (MS Contin) for
chronic pain complains of nausea and abdominal fullness. The most appropriate initial
action by the nurse is to
• administer the ordered metoclopramide (Plasil) 10 mg IV.
When a postoperative patient in the PACU complains of pain at the abdominal incision site,
the nurse should
• consult with the ACP to determine an effective dose of an analgesic for the patient.
While caring for a postoperative patient on the second postoperative day, which information
about the patient is most important to communicate to the health care provider?
• The right calf is swollen, warm, and painful.
A 45-year-old patient has breast cancer that has spread to the liver and spine. The patient
has been taking oxycodone (OxyContin) and amitriptyline (Elavil) for pain control at home
but now has constant severe pain and is hospitalized for pain control and development of a
pain-management program. When doing the initial assessment, which question will be most
appropriate to ask first?
• How would you describe your pain?
A two-day postoperative right-below-the-knee amputation patient complains of severe right

foot pain. Your appropriate nursing response would be to:
• medicate the patient for pain.
While caring for a patient with abdominal surgery the first postoperative day, the nurse
notices new bright-red drainage about 6 cm in diameter on the dressing. In response to this
finding, the nurse should initially
• take the patient’s vital signs.
You are the circulating nurse in an operating room that has several surgeries
scheduled. You would know to monitor which patient during the intraoperative period
because he or she is at increased risk for hypothermia?
• A 72-year-old woman
II. Day 4 Quiz on IVT, BT & IVF Calculation
A client with low blood volume is receiving blood transfusion. 45 minutes after the initiation of
blood transfusion, the client said “I think something is wrong.” The nurse immediately assessed
the client and the following findings were found: cough, DOB, distended neck veins, tachycardia
and hypertension. Based on the assessment of the nurse, all of the following interventions must
be done, EXCEPT?
Stop or slow the transfusion
Notify the primary care provider
Obtain a blood specimen from the client for culture
Administer diuretics and oxygen as ordered
A health care provider has written a prescription to discontinue an intravenous (IV) line. The
nurse should obtain which item from the unit supply area for applying pressure to the site after
removing the IV catheter?
Elastic wrap
Adhesive bandage
Betadine swab
Sterile 2x2 gauze
The most common complications associated with I.V. therapy in children include:
infection, emboli, fluid overload, and allergic reactions.

infection, infiltration or extravasation, fluid overload, and deep vein thrombosis.
infection, infiltration or extravasation, fluid overload, and allergic reactions.
infection, infiltration or extravasation, phlebitis, and allergic reactions.
During rounds at 0630H, the IVF of the patient is D5NM1L at 1000cc level going on at
62ugtts./min. At around 1430H how many ml is the remaining IVF?
110 mL
504 ml
656 ML
404 ml
Patient LDS was admitted to our unit. The doctor ordered for patient LDS to start:
Omeprazole drip: 80mg Omeprazole in 80cc D5Water to make 100cc solution. The drip will
run at 8mg/hour. How many cc/hour will you run the solution?
12.5 hours
12 hours
11 hours
11.5 hours
The Dr. ordered for 1 liter of PNSS to be administered over 9 hours. The drip factor is 15.
Calculate the number of drops per minute
26 gtts/min
28 gtts/min
30 gtts/min
24 gtts/min
The nurse is making initial rounds on the nursing unit to assess the condition of assigned
clients. The nurse notes that a client’s intravenous (IV) site is cool, pale, and swollen, and
the solution is not infusing. The nurse concludes that which complication has occurred?
Infection
Phlebitis
Thrombosis
Infiltration
During the preparation of blood transfusion, the blood bag shows an estimate volume of 250
cc of packed red blood cells blood component. The doctor’s order shows: Run each bag of
blood for 4 hours. Using a drop factor of 20 drops per ml, how many drops per minute will
you regulate the blood?
62gtts./min
11gtts./min
21gtts./min (X)
16gtts./min
The physician has ordered parenteral fluids, 1,000 ml of D5LR in eight hours. The IV tubing
delivers a drip factor of 20gtts/ml. How many drops/min. should be infused?
60
42
30
50
Blood Transfusion was ordered to patient LDS. Transfuse 3 units Packed Red Blood Cells
properly typed and cross -matched. Based on the case you presented, what will be the
reason for the doctor to start blood transfusion? Select all that apply.
Patient LDS experienced 3 episodes of hematochezia accompanied with abdominal pain.
Patient hemoglobin: 5.2 Hematocrit: 16.2 and RBC: 1.71
Patient LDS has history of chronic non-steroidal anti-inflammatory drug use for 5 months for
pain.
Patient LDS has 1 episode of dark, tarry stool 1 day prior to consult.
Fresh frozen plasma must be transfused within:

5 hours
6 hours
8 hours
4 hours
During blood administration, the nurse should carefully monitor for adverse reaction. To
monitor this, it is essential for the nurse to:
Run the infusion at a faster rate during the first 15 minutes
Stay with the client for the first 15 minutes of blood transfusion
Stay with client for the first 30 minutes after the initiation of blood transfusion
Tell the client to notify the staff immediately for any adverse reaction
Stay with the client for the entire period of blood transfusion
Your patient has swelling at the I.V. site, discomfort, burning, decreased skin temperature,
and blanching around the site. These are signs of which of the following I.V. complications?
Phlebitis
Occlusion
Infiltration
Air embolism
A 42-year-old with a history of alcohol abuse is admitted with upper GI bleeding. You begin
a transfusion of packed red blood cells and the patient suddenly develops abdominal pain,
flushing, fever, and chills. What type of transfusion reaction might this patient be
experiencing?
Bacterial contamination
Plasma protein incompatibility

Febrile reaction
Allergic reaction
A client has a prescription to receive a unit of packed red blood cells. The nurse should
obtain which intravenous (IV) solution from the IV storage area to hang with the blood
product at the client’s bedside?
5% dextrose in 0.9% sodium chloride
5% dextrose in 0.45% sodium chloride
Lactated Ringer’s
0.9% sodium chloride
A man is rushed to a hospital nearly dying after a massive blood loss in an accident. There
is not much time to do x-matching, so the physician decides to order for one of the following
blood groups. Which of the following blood groups should the physician decide?
AB
Dr’s order is 1 Liter of NSS to be administered at 125 mL/hour. How many hours will pass
before you change the IV bag?
12 hours
9 hours
8 hours
10 hours
To minimize the risk of a hemolytic reaction during a blood transfusion, recipient and donor
blood should be tested for incompatibilities. Which tests are most important to include?
Blood typing
Direct antiglobulin
Hemoglobin level and hematocrit
Platelet count
Rh typing
Cross matching
After removing a intravenous catheter the nurse notices that the tip has broken off, and
it can be palpated at the site. What should the nurse do first?
Assess the client for respiratory complications.

Remove the tip with a scalpel.
Notify the physician immediately
Apply a tourniquet above the insertion site.
How quickly can a transfusion reaction occur after the start of the infusion?
30 minutes
15 minutes
60 minutes
20 minutes
Nauna na me kia hahaha
A 29-year-old patient is admitted to your unit after sustaining injuries in a motor vehicle
accident. He has I.V. fluids infusing in his left antecubital area. How often should you
change the I.V. administration set?
Every 24 hours
Every 48 hours
With every bag change
Every 72 hours
The nurse determines that a client is having a transfusion reaction. After the nurse stops
the transfusion, which action should be taken next?
Run normal saline at a keep-vein-open rate.
Obtain a culture of the tip of the catheter device removed from the client.
Run a solution of 5% dextrose in water.
Remove the intravenous (IV) line.
The MD ordered an IV needle gauge of 20. What color of IV needle gauge must the
nurse obtain?
Violet
Blue
Green
Pink
Yellow
Intravascular infections can be prevented by which of the following precautions?

Changing insertion sites according to facility policy
Washing your hands after inserting the device
Securing the venous access device with gauze
Applying the tourniquet 6” to 8” (15 to 20 cm) above the insertion site
42
client rings the call light and complains of pain at the site of an intravenous (IV) infusion.
The nurse assesses the site and determines that phlebitis has developed. The nurse
should take which actions in the care of this client? Select all that apply.
Remove the IV catheter at that site.

Notify the health care provider (HCP).
Apply warm moist packs to the site
Document the occurrence, actions taken, and the client’s response
Start a new IV line in a proximal portion of the same vein.
The nurse received an order of 1500 mL of IV fluids to run for 12 hours. The IV set
available delivers 10 drops/ml how many drops per minute will need to be given?
24 gtts/min
21 gtts/min
20 gtts/min
15 gtts/min
An 80 year old woman, diagnosed with DM, is admitted direct to room accompanied by
her son after losing consciousness. She is started on D5NR 1L infusing at 28
gtts./min. How many cc/hour is infused, using a drop factor of 20gtts./ml?
63 cc/hr
42 cc/hr
74 cc/hr
84 cc/hr
If you detect signs or symptoms of a transfusion reaction, the first thing you should do
is:
notify the practitioner.

stop the infusion.
slow down the infusion rate.
notify the blood bank.
A client with low blood volume is receiving blood transfusion. 45 minutes after the
initiation of blood transfusion, the client said “I think something is wrong.” The nurse
immediately assessed the client and the following findings were found: cough, DOB,
distended neck veins, tachycardia and hypertension. Based on the assessment of the
nurse, all of the following interventions must be done, EXCEPT?
• Obtain a blood specimen from the client for culture
An 89-year-old patient with a history of heart failure has an I.V. solution that’s being
infused through microdrip tubing. Microdrip tubing delivers how many drops per
milliliter?
• 60 gtt
Intravascular infections can be prevented by which of the following precautions?

• Changing insertion sites according to facility policy
A health care provider has written a prescription to discontinue an intravenous (IV) line.
The nurse should obtain which item from the unit supply area for applying pressure to
the site after removing the IV catheter?
• Sterile 2x2 gauze
The most common complications associated with I.V. therapy in children include:
• infection, infiltration or extravasation, fluid overload, and allergic reactions.
Formative Assessment No. 1 Set B
A child is for blood transfusion, if allergic reaction arise, the nurse first intervention would
be
Slow the flow rate
Stop the blood at once
Administer antihistamine
Call the physician
With a diagnosis Of ALL the nurse should consider it unusual to observe:
Marked fatigue and pallor
Marked jaundiced and generalized edema
Enlarged lymph nodes , spleen and liver

Multiple bruises and petechiae
When examining the laboratory reports of a child with ALL, the nurse notes that the child is
neutropenic . The alteration is a result of:
Decrease intake of iron rich nutrients
Increase internal bleeding
Increased immune cell growth
Overwhelming infection
A child receiving chemotherapy for treatment of cancer is at rik for mouth lesion from
chemotherapy. The nurse must stress to the mother the importance of:
Brushing with foam tip applicator
Frequent washing of undiluted mouthwash
Brushing 3x a with a toothbrush
Frequent mouth rinsing with hydrogen peroxide
When providing g hygiene and comfort for the child with leukemia who is
receiving chemotherapy, the nurse should avoid the use of:
Any powder
A toothbrush
Mouthwash
Straw
The nurse is instructing the client to perform a testicular self-examination. The nurse tells
the client:
The best time for the examination is after a shower
That testicular examination should be done at least every 6 months
To examine the testicles while lying down
To gently feel the testicle with one finger to feel for a growth
A 35 years old client with ovarian cancer is prescribed hydroxyurea (Hydrea), an

antimetabolite drug. Antimetabolites are a diverse group of antineoplastic agents that
interfere with various metabolic actions of the cell. The mechanism of action of
antimetabolites interferes with:
Cell division or mitosis during the M phase of the cell cycle
Normal cellular processes during the S phase of the cell cycle
The chemical structure of deoxyribonucleic acid (DNA) and chemical binding between DNA
molecules (cell cycle–nonspecific)
One or more stages of ribonucleic acid (RNA) synthesis, DNA synthesis, or both (cell cycle–
nonspecific)
What should a male client over age 52 do to help ensure early identification of prostate
cancer?
Have a digital rectal examination and prostate-specific antigen (PSA) test done yearly
Perform monthly testicular self-examinations, especially after age 50
Have a transrectal ultrasound every 5 years
Have a complete blood count (CBC) and blood urea nitrogen (BUN) and creatinine levels
checked yearly
Nina, an oncology nurse educator, is speaking to a women’s group about breast cancer.
Questions and comments from the audience reveal a misunderstanding of some aspects of
the disease. Various members of the audience have made all of the following statements.
Which one is accurate?
Breast cancer requires a mastectomy
Men can develop breast cancer
Mammography is the most reliable method for detecting breast cancer
Breast cancer is the leading killer of women of childbearing age
Nurse Mary is instructing a premenopausal woman about breast self-examination. The

nurse should tell the client to do her self-examination:
Immediately after her menstrual period
At the end of her menstrual cycle
On the same day each month
On the 1st day of the menstrual cycle
A terminally ill adult refuses for further therapy, In such situation, it is generally agreed that:
The person has the right to such decision
Only responsible family members should make the decision
Health worker should use every effortto dissuade the patient from refusing the therapy.
Only the client’s physician should make the decision
Group of answer choicesWhich of the following diagnostic procedure would indicate a

diagnosis of esophagitis and aspiration?
Barium swallow
EGD
Barium Enema
ERCP
Which of the following is a risk factors for bladder cancer ?
Frequent urination
High fat diet
Incontinence
Smoking
Which of the following lab test are used to monitor the effectiveness of coumadin therapy?
C reactive CHON
PT
PTT
CBC
Which of the following types of cell “turn off ” the immune response when not needed?
stu
IgE
IgD
IgM
Which of the following are needed for the formation of anti bodies?
Cytokines
B Lympocytes
Lympokines
Immunoglubulin
Which of the following is the reason to perform a spinal tap on a client newly diagnosed with
leukemia?
To aid in classification of the leukemia
To decrease intracranial pressure
To assess for central nervous system infiltration
To rule out meningitis

During a routine physical examination, a firm mass is palpated in the right breast of a 35-
year-old woman. Which of the following findings or client history would suggest cancer of
the breast as opposed to fibrocystic disease?
Cyclic changes in mass size
Increased vascularity of the breast
History of anovulatory cycles
History of early menarche
During a routine health examination, a 30-year-old patient tells the nurse about a family
history of colon cancer. The nurse will plan to
Schedule a sigmoidoscopy to provide baseline data about the patient
Teach the patient about the need for a colonoscopy at age 50
Ask the patient to bring in a stool specimen to test for occult blood
Have the patient ask the doctor about specific tests for colon cancer
On a clinic visit a client who has a relative with cancer, is asking about the warning signs
that may relate to cancer. The nurse correctly identifies the warning signs of cancer by
responding:
“If a sore healing took a month or more to heal, cancer should be suspected.”
“A lump located only in the breast area may suggest the presence of cancer.”
“Presence of dry cough is one of the warning signs of cancer.”
“Sudden weight loss of unexplained etiology can be a warning sign of cancer.”

Formative Assessment No. 2 Set B (Thur/Fri)
A combination of drugs which includes Vincristine and prednisone is prescribed for a child
with leukemia. Because of their toxicity the nurse should expect:
Neurologic symptoms
Anemia and fever
Irreversible alopecia
Gastro intestinal symptoms
An adolescent client started on chemo drugs – vincristine, prednisone, L asparaginase . the

side effect of the drugs that requires early preparation of this client is:
Alopecia
Constipation
Retarded growth and height
Generalized short term paralysis
A client with tumor of the brain experience seizure, Client was given phytoin .
Important nursing responsibility for the client who only 3 years old would be:
Administer scrupulous oral hygiene
Observe for flushing of the face
Check pupillary reaction
Offer urinal frequently
A client with esophageal cancer is to receive TPN, a right Subclavian catheter was
inserted primarily to:
The large amount of blood helps to dilute the concentrated solution
More convenient for the client
less chance of infusion filtration
Prevent development of phlebitis
A client undergo BMA, Immediately post procedure, the nurse should:
Briefly apply pressure over aspiration site
Cleanse the site with antiseptic solution
Begin frequent monitoring of VS
Position client on affected site
What are the three most important prognostic factors in determining long-term survival for
children with acute leukemia?
Histologic type of disease, initial WBC count, and client’s age at diagnosis
Progression of illness, WBC at the time of diagnosis, and client’s age at the time of
diagnosis
Histologic type of disease, initial platelet count, and type of treatment
Type of treatment and client’s sex
Nausea and vomiting are common adverse effects of radiation and chemotherapy. When
should a nurse administer antiemetics?
30 minutes before the initiation of therapy
With the administration of therapy
Immediately after nausea begins
When therapy is completed
The nurse is developing a plan of care for the client with multiple myeloma. The nurse
includes which priority intervention in the plan of care?
Encouraging fluids
Providing frequent oral care
Coughing and deep breathing
Monitoring red blood cell count
A nurse is providing education in a community setting about general measures to avoid

excessive sun exposure. Which of the following recommendations is appropriate?
Apply sunscreen with a sun protection factor (SPF) of 30 or more before sun exposure
Avoid peak exposure hours from 9am to 1pm
Apply sunscreen only after going in the water

Wear loosely woven clothing for added ventilation
A client with stomach cancer is admitted to the oncology unit after vomiting for 3 days.
Physical assessment findings include irregular pulse, muscle twitching, and complaints of
prickling sensations in the fingers and hands. Laboratory results include a potassium level
of 2.9 mEq/L, a pH of 7.46, and a bicarbonate level of 29 mEq/L. The client is experiencing:
Metabolic alkalosis
Respiratory acidosis
Metabolic acidosis
Respiratory alkalosis
The primary reason for using prednisone for children in treatment of acute leukemia is:
To decrease inflammation
To reduce irradiation edema
Suppress mitosis in lymphocytes
Increase appetite and sense of well being
After supra pubic prostatectomy, the client should encourage to walk cautioned not to
sit for long period of time primarily:
Increased risk of bleeding
Potentiates risk of infection
Decrease amount of urine

Produce valsalva maneuver
What is the rationale why a client with surgery of upper Gi should not be given straw?
They can swallow much air using them
It is difficult to monitor I and O
It is difficult for client o create suction to seal around the straw
It might injure the suture site
A client has had a mastectomy is concerned that her affected arm will become enlarged and
sore, which of the following nursing intervention will decrease lymphedema of the affected
arm?
Take BP and draw blood from unaffected arm
Continue to bind affected arm to chest wall while hospitalized
Perform passive range of motion exercise to affected arm
Instruct client to wear loose, comfortable bra
In addition to rectal bleeding, what information in the client’s medical history strongly
suggest that he may have colorectal cancer?
Bowel habit have change
He has difficulty in swallowing

He experienced chronic indigestion
Some food give him intestinal gas
Before liver biopsy, a client may receive an IV infusion of vit _ to decrease the chance of
bleeding.
Which of the following lifestyle habits has been lined to development of oral cancer?
Chewing tobacco
Cosmetic overuse
Non steroidal anti inflammatory drug use
Spicy foods
Understanding the side effects of vincristine , the nurse plans a diet for the client as:
High both in roughage and fluids
High Iron with decrease fluid
Low in residue with increased fluid

Low in fat with regular fluids
When observing a client for cortisone overdose the nurse should be alert for:
Behavioral changes
Anaphylactic shock
Severe anorexia
Hypoglycemia
To prevent bleeding post prostatectomy the client should be instructed to avoid straining ,
therefore increase of food intake of _ is encourage.
Green vegetables
Creamed potatoes
Ripe bananas
Milk products
Summative Assessment (Concept Exam)
ALL LETTER A
Question 1
1 / 1 pts
Which of the following clients is most at risk for developing multiple myeloma?
Correct!
A 60-year-old African-American man
A 52-year-old Hispanic woman

A 35-year-old White man
A 25-year-old Asian woman
Question 2
1 / 1 pts
Nurse Brian is developing a plan of care for marrow suppression, the major dose-limiting
adverse reaction to floxuridine (FUDR). How long after drug administration does bone marrow
suppression become noticeable?
Correct!
7 to 14 days
21 to 28 days
2 to 4 days
24 hours
Question 3
1 / 1 pts
Nurse April is teaching a client who suspects that she has a lump in her breast. The nurse
instructs the client that a diagnosis of breast cancer is confirmed by:
Correct!
Fine needle aspiration
Chest X-ray
Mammography
Breast self-examination
Question 4
1 / 1 pts
Skin reactions are common in radiation therapy. Nursing responsibilities on promoting skin
integrity should be promoted apart from:
Correct!
Washing the area with a bar of scented soap and water and patting it dry not rubbing it
Avoiding direct sunshine or cold.
Using soft cotton fabrics for clothing
Avoiding the use of ointments, powders and lotion to the area
Question 5
1 / 1 pts
For a female client newly diagnosed with radiation-induced thrombocytopenia, the nurse should
include which intervention in the plan of care?
Correct!
Inspecting the skin for petechiae once every shift
Placing the client in strict isolation

Providing for frequent rest periods
Administering aspirin if the temperature exceeds 102° F (38.8°C)
Question 6
1 / 1 pts
A client complained of nodule in the breast that is fixed , other deviation that should be
reported would be all, EXCEPT:
Correct!
Inverted nipple
Orange de Peau
Dimpling
Evident Asymmetry
Question 7
1 / 1 pts
The nurse is caring for a female client experiencing neutropenia as a result of chemotherapy and
develops a plan of care for the client. The nurse plans to:
Correct!
Teach the client and family about the need for hand hygiene
Insert an indwelling urinary catheter to prevent skin breakdown
Restrict fluid intake
Restrict all visitors
Question 8
1 / 1 pts
The male client is receiving external radiation to the neck for cancer of the larynx. The most
likely side effect to be expected is:
Correct!
Sore throat
Constipation
Dyspnea
Diarrhea
Question 9
1 / 1 pts
Joseph who had a history of long-term smoking and alcoholism is diagnosed with
oropharyngeal cancer. He is admitted into the chemo unit for the initiation of chemotherapy.
Which of the following tests is performed before the infusion of chemotherapeutic agents?
Correct!
Liver function test
Complete blood count (CBC)

Peripheral blood smear
Lumbar puncture
Question 10
1 / 1 pts
Which of the following interventions is the key to increasing the survival rates of clients with
lung cancer?
Correct!
Early detection
Smoking cessation
Early bronchoscopy
High-dose chemotherapy
Question 11
1 / 1 pts
According to American Cancer Society Surveillance Research (ref: MS of Brunner & Suddarth)
the leading cancer deaths for both male and female from Northern America and Asia are:
Correct!
Lung & Bronchus
Colon & Rectum
Pancreas & Ovary
Prostate & Breast
Question 12
1 / 1 pts
A 56-year-old woman is currently receiving radiation therapy to the chest wall for recurrent
breast cancer. She calls her health care provider to report that she has pain while swallowing
and burning and tightness in her chest. Which of the following complications of radiation
therapy is A. Radiation enteritis likely responsible for her symptoms?
Correct!
Esophagitis
Radiation enteritis
Stomatitis
Hiatal hernia
Question 13
1 / 1 pts
Which plan of care would be your highest priority for client with Hgb of 10%, RBC of 4.5, WBC of
5,000 and PC of 75,000?
Correct!
Implement bleeding precaution
Implement rest period activity

Implement neutropenic precaution
Implement universal precaution
Question 14
1 / 1 pts
Gio, a community health nurse, is instructing a group of female clients about breast self-
examination. The nurse instructs the client to perform the examination:
Correct!
1 week after menstruation begins
Weekly at the same time of day
Every month during ovulation
At the onset of menstruation

Question 15
1 / 1 pts
A female client with cancer is being evaluated for possible metastasis. Which of the following is
one of the most common metastasis sites for cancer cells?
Correct!
Liver
Colon
Reproductive tract
White blood cells (WBCs)
Question 16
1 / 1 pts
Nurse John is assigned to Medical Surgical ward and it is part of his daily routine to explain to
his patients the disease process. Nurse John shared to his patients that the process of
transforming normal cells into malignant cells is called:
Correct!
carcinogenesis
cancer
chemotherapy
cytokenesis
Question 17
1 / 1 pts
Which intervention is appropriate for the nurse caring for a male client in severe pain receiving a
continuous I.V. infusion of morphine?
Correct!
Obtaining baseline vital signs before administering the first dose
Discontinuing the drug immediately if signs of dependence appear

Assisting with a naloxone challenge test before therapy begins
Changing the administration route to P.O. if the client can tolerate fluids
Question 18
1 / 1 pts
The nurse is preparing a client for a mammography. The nurse tells the client
Correct!
To avoid the use of deodorants, powders, or creams on the day of the test.
That there is no discomfort associated with the procedure
To maintain a nothing-by-mouth status on the day of the test
That mammography takes about 1 hour.

Question 19
1 / 1 pts
Parents of pediatric clients who undergo irradiation involving the central nervous system should
be warned about postirradiation somnolence. When does this neurologic syndrome usually
occur?
Correct!
Within 5 to 8 weeks
Within 3 to 6 months
Within 1 to 2 weeks
Immediately
Question 20
1 / 1 pts
The nurse is assessing the stoma of a client following a ureterostomy. Which of the following
would the nurse expect to note?
Correct!
A red and moist stoma
A dark- colored stoma
A dry stoma
A pale stoma
Question 21
1 / 1 pts
The ABCD method offers one way to assess skin lesions for possible skin cancer. What does the
A stand for?
Correct!
Asymmetry
Actinic
Arcus
Assessment
Question 22
1 / 1 pts
During a routine physical examination, a firm mass is palpated in the right breast of a 35-year-
old woman. Which of the following findings or client history would suggest cancer of the breast
as opposed to fibrocystic disease?
Correct!
Increased vascularity of the breast
History of anovulatory cycles
Cyclic changes in mass size
History of early menarche

Question 23
1 / 1 pts
The hospice nurse visits a client dying of ovarian cancer. During the visit, the client shouted “why
Lord, why me ?” Which phase of coping is this client experiencing
Correct!
Anger
Depression
Bargaining
Denial
Question 24
1 / 1 pts
Nurse Amy is speaking to a group of women about early detection of breast cancer. The average
age of the women in the group is 47. Following the American Cancer Society guidelines, the
nurse should recommend that the women:
Correct!
Have a mammogram annually
Perform breast self-examination annually
Have a hormonal receptor assay annually
Have a physician conduct a clinical examination every 2 years
Question 25
1 / 1 pts
Clinical manifestation that are often found in client diagnose with CA of the esophagus are the
following,EXCEPT:
Correct!
Positive for HBSag test
Substernal burning pain

Eructation
Pain upon ingestion of tea
Question 26
1 / 1 pts
Nurse Kent is teaching a male client to perform monthly testicular self-examinations. Which of
the following points would be appropriate to make?
Correct!
Testicular cancer is a highly curable type of cancer
Testicular cancer is very difficult to diagnose
Testicular cancer is the number one cause of cancer deaths in males
Testicular cancer is more common in older men

Question 27
1 / 1 pts
Which of the following immunizations should not be given to a 4-month-old sibling of a client
with leukemia?
Correct!
Oral poliovirus vaccine (OPV)
Hepatitis B vaccine
Diphtheria and tetanus and pertussis (DPT) vaccine
Haemophilus influenzae type b vaccines (Hib)
Question 28
1 / 1 pts
A female client is receiving chemotherapy to treat breast cancer. Which assessment finding
indicates a fluid and electrolyte imbalance induced by chemotherapy?
Correct!
Dry oral mucous membranes and cracked lips
Serum potassium level of 3.6 mEq/L
Blood pressure of 120/64 to 130/72 mm Hg
Urine output of 400 ml in 8 hours
Question 29
1 / 1 pts
The nurse is instructing the client to perform a testicular self-examination. The nurse tells the
client:
Correct!
The best time for the examination is after a shower
To examine the testicles while lying down

To gently feel the testicle with one finger to feel for a growth
That testicular examination should be done at least every 6 months
Question 30
1 / 1 pts
A pneumonectomy is a surgical procedure sometimes indicated for treatment of non-small-cell

lung cancer. A pneumonectomy involves removal of:
Correct!
An entire lung field
One lobe of a lung
One or more segments of a lung lobe
A small, wedge-shaped lung surface

Question 31
1 / 1 pts
A female client with cancer is scheduled for radiation therapy. The nurse knows that radiation at
any treatment site may cause a certain adverse effect. Therefore, the nurse should prepare the
client to expect:
Correct!
Fatigue
Vomiting
Hair loss
Stomatitis
Question 32
1 / 1 pts
A 40 year old male diagnosed with acute lymphocytic leukemia finished his first cycle of
chemotherapy. Which of the following statements by the patient warrants further teaching by
the nurse?
Correct!
“Try eating sashimi in one of the famous Japanese restaurants around the city”
“You can eat soft cheeses from pasteurized milk”
“You can enjoy the turkey on the day of thanksgiving party”
“ A medium well steak is a good idea of a sumptuous meal”
Question 33
1 / 1 pts
The nurse is developing a plan of care for the client with multiple myeloma. The nurse includes
which priority intervention in the plan of care?
Correct!
Encouraging fluids
Providing frequent oral care

Coughing and deep breathing
Monitoring red blood cell count
Question 34
1 / 1 pts
Which of the following complications are three main consequences of leukemia?
Correct!
Anemia, infection, and bleeding tendencies
Bone deformities, spherocytosis, and infection
Polycythemia, decreased clotting time, and infection
Lymphocytopoiesis, growth delays, and hirsutism

Question 35
1 / 1 pts
Sam is 6 yrs old diagnosed with ALL. His asked if they could tell their child that he is dying, the
best response of the nurse Aimelle would be:
Correct!
Being honest promote an atmosphere in which thoughts and feelings can be shared
Most research suggest that dying should not be known to the child
Only child over 10 years old could understandconcept of death
In my experience, telling the child he is dying would cause anxiety
Question 36
1 / 1 pts
A client had undergone radiation therapy (external). The expected side effects include the
following apart from:
Correct!
Constipation
Headache
Ulceration of oral mucous membranes
Hair loss
Question 37
1 / 1 pts
Which of the following is the reason to perform a spinal tap on a client newly diagnosed with
leukemia?
Correct!
To assess for central nervous system infiltration
To aid in classification of the leukemia

To rule out meningitis
To decrease intracranial pressure
Question 38
1 / 1 pts
The client with which of the following types of lung cancer has the best prognosis?
Correct!
Squamous cell
Oat cell
Small cell
Adenocarcinoma
Question 39
1 / 1 pts
Nurse Mary is instructing a premenopausal woman about breast self-examination. The nurse
should tell the client to do her self-examination:
Correct!
Immediately after her menstrual period
At the end of her menstrual cycle
On the same day each month
On the 1st day of the menstrual cycle
Question 40
1 / 1 pts
Mina, who is suspected of an ovarian tumor is scheduled for a pelvic ultrasound. The nurse
provides which pre-procedure instruction to the client?
Correct!
Drink six to eight glasses of water without voiding before the test
Eat a light breakfast only
Maintain an NPO status before the procedure
Wear comfortable clothing and shoes for the procedure
Question 41
1 / 1 pts
What would the nurse anticipate findings into the health history of client diagnose with cervical
cancer?
Correct!
post coital bleeding
weight gain
dysmenorrhea
irregular menses
Question 42
1 / 1 pts
A client with leukemia has neutropenia. Which of the following functions must be frequently
assessed?
Correct!
Breath sounds
Blood pressure
Bowel sounds
Heart sounds
Question 43
1 / 1 pts
Nurse Jane is a pediatric nurse, the admitting department is about to admit a 6yrs
child diagnosed with ALL. The best room mate of the child would be:
Correct!
a 7 years old who receive new kidney
a 4yrs old with fever and unknown origin
a 6 years old with pneumonia
a 9 years old with rupture AP
Question 44
1 / 1 pts
Nurse Cindy is caring for a client who has undergone a vaginal hysterectomy. The nurse avoids
which of the following in the care of this client?
Correct!
Elevating the knee gatch on the bed
Assisting with range-of-motion leg exercises
Checking placement of pneumatic compression boots
Removal of antiembolism stockings twice daily
Question 45
1 / 1 pts
A female client is undergoing tests for multiple myeloma. Diagnostic study findings in multiple
myeloma include:
Correct!
Bence Jones protein in the urine
Hypocalcemia
A low serum protein level
A decreased serum creatinine level
Question 46
1 / 1 pts
Nausea and vomiting are common adverse effects of radiation and chemotherapy. When should
a nurse administer antiemetics?
Correct!
30 minutes before the initiation of therapy
With the administration of therapy
Immediately after nausea begins
When therapy is completed

Question 47
1 / 1 pts
A male client with a cerebellar brain tumor is admitted to an acute care facility. The nurse
formulates a nursing diagnosis of Risk for injury. Which “related-to” phrase should the nurse add
to complete the nursing diagnosis statement?
Correct!
Related to impaired balance
Related to psychomotor seizures
Related to visual field deficits
Related to difficulty swallowing
Question 48
1 / 1 pts
Warning signs and symptoms of lung cancer include persistent cough, bloody sputum, dyspnea,
and which of the other following symptoms?
Correct!
Recurrent pleural effusion
Generalized weakness
Dizziness
Hypotension
Question 49
1 / 1 pts
The physician started Methotrexate on client , which laboratory result should your priority to
monitor?
Correct!
LFT
ESR
UA
FA
Question 50
1 / 1 pts
The nurse is preparing for a female client for magnetic resonance imaging (MRI) to confirm or
rule out a spinal cord lesion. During the MRI scan, which of the following would pose a threat to
the client?
Correct!
The client wears a watch and wedding band
The client hears thumping sounds
The client asks questions

III. Day 3 Formative Assessment Oxy-Respi
Skills
In using incentive spirometer, greater lung expansion is achieved with a;
• Brisk breath
• Very slow inspiration
• Very slow expiration
• Shallow breath
Deep ventilation may loosen secretions, and coughing can facilitate their removal
• Partly False
• Partly True
• False
• True
The nurse is planning to perform percussion and postural drainage. Which of the following is an
important aspect of planning the client’s care
• A good time to perform percussion and postural drainage is in the morning after
breakfast when the client is well rested
• The order should be coughing, percussion, positioning and then suctioning
• Percussion and postural drainage should be done before the lunch
• Percussion and postural drainage always be preceded by 3 minutes of 100% oxygen
The purpose of chest percussion and vibration is to loosen secretions in the lungs. The
difference between the procedure is:
• Percussion uses only one hand while vibration uses both hands
• Percussion delivers cushioned blows to the chest with cupped palms while vibration
gently shakes secretion loose on the exhalation cycle
• In both percussion and vibration, the hands are on top of each other and hand action is
in tune with the client's breath rhythm
• Percussion slaps the chest to loosen secretions while vibration shakes the secretions
along with the inhalation of air
Which of the following is not advisable during the incentive spirometry test?
• Hold or place the spirometer in an upright position
• Make sure the patients lean forward during the test
• Ensure that a good seal is kept on the mouthpiece
• Continue until no more air can be exhaled
All of the following are steps to consider in preparing the site for pulse oximetry reading except:
• Nail polish or acrylic nails may not be removed when taking the pulse oximetry reading
• Cleanse the site with alcohol wipe before applying the sensor
• Nail polish must be removed because it may interfere with accurate measurements
• Position the sensor on the side of the finger rather than perpendicular to the nail bed
Which action indicates that the client understands teaching on the correct way to perform
diaphragmatic breathing?
• Lying prone
• Lying on side with knees bent
• Having hands on abdomen
• Having hands over head
Arrange the steps in correct order on how to apply the sensor and connect it to the pulse
oximeter
I.Attach the sensor cable to the connection outlet of the oximeter
II.Observe for audible beep indicating each arterial pulsation
III.Make sure LED and the photodetector…..
IV.Turn on the machine
V.Ensure that the bar of light or waveform….
• IV, V, III,I,II
• III,I,IV,II,V
• II,I,V,IV,III
• I,II,III,IV,V
The nurse observes the nursing student suctioning the client. Which intervention on the nurse’s
part has the greatest potential to cause tissue damage?
• Hyper-oxygenating the client after removing the suction catheter
• Applying suction when the catheter is inserted
• Applying intermittent suctioning
• Oxygen saturation post suctioning is 93%
Which of the following statements is accurate regarding pulse oximetry?

• A light is used to estimate the oxyhemoglobin saturation of hemoglobin
• Pulse oximetry is particularly sensitive to detecting high venous oxygen saturation
• Percent saturation of hemoglobin with oxygen abbreviated as Pa02
• Percent saturation refers to the amount of oxygen that is dissolved in the plasma of
blood
The considered protocol are the following except

• When medication should not be given
• When emergency services should be contacted.
• None of the above
• Maximum dose over a 12 hour period
The purpose of nebulization is the following except

• When the child or young has an acute asthma attack
• When a child or young person is not respiratory distress
• When a child or young person has stridor
I will do the following instruction to my patient.

• Explain the procedure to the patient, including the drugs, equipment, why it is necessary
and possible side effects. Written patient information will be provided on the first
treatment.
• All patients must be treated in a room equipped with negative pressure filtration, and
ensure the windows are closed.
• Obtain verbal positive patient identification and secure hospital identity bracelet.
Equipment’s required except

• Inhaler
• Tissue paper
• Dr.’s order card is not important.
The purpose of this therapy selects that do not apply

• To correct the underlying respiratory disorders responsible for bronchospasm
• To relieve respiratory insufficiency only
• To liquefy and remove retained thick secretions form from the lower respiratory tract
• To reduce inflammatory and allergic responses in the upper respiratory tract
Most aerosol medication has _______ effects and is administered by respiratory therapist.
• Liquefying effects
• Remove thick secretions
• Reduced difficulty of breathing
• Broncho dilating effects
A therapy that liquefies and remove retained secretions from the respiratory tract. A nebulizer is
device that stable aerosol of fluid and/or drug particles.
• Suctioning
• Steam inhalation therapy
• Nebulization therapy
Protocol for use of Inhaled Medications select that applies

• Date the protocol the time comes into effect and a review date and/or expiration date.
• Possible triggering factors
• Possible warning signs
Another protocols to be considered are the following select all that applies
• All of the following except B
• All of the following except A
• Whether a repeated dose can be given.
• When inhaled medication should not administered
• Time interval for a repeated dose.
• How much is given.
Prepare the medication following the rights of medication administration except:

• Right reason
• Explain to the client what you're going to do
• Right response
• Assist client to make comfortable position in lying position
These are the purposes of steam inhalation EXCEPT:

• To lessen irritation of the respiratory membranes by warming and….
• To loosen secretions
• To relieve muscle pain
• To treat chronic or acute infections…
These are the supplies and equipment needed in steam inhalation, EXCEPT:
• Steam inhalator with water
• Extension spout or conveyor
• Face towel
• Baking powder
In steam inhalation it needs that when the steam comes out, direct spout towards the patient’s
face
• True
• False
After we check the doctor’s order of nebulization, we must assemble all equipment at the
bedside
• True
• False
These are the supplies and equipment needed for nebulization, EXCEPT:
• Nebulizer
• Prescribed drug
• D5 water
• Spout with medicine container
In steam inhalation we should not give the treatment for the prescribed length of time
• True
• False
After we check the doctor’s order of nebulization, we must assemble all equipment at the
bedside
• True
• False
Drawing into the respiratory tract, a non-volatile drug, transformed into a fine mist with the use
of nebulizer, or aerosol apparatus
• Steam inhalation
• Aspiration
• Nebulization
• Suctioning
In nebulization we must measure the prescribed amount of drug with a syringe needle and place
into the nebulizer’s drug compartment
• True
• False
Drawing in of a plain steam, impregnated with drug into the respiratory tract. Brings moist heat
to the respiratory tract which produce vasodilation thus reducing edema of the respiratory
membranes
• Water inhalation
• Humidification
• Moisture inhalation
• Steam inhalation
The home care nurse is performing chest physiotherapy on an elderly client with chronic
airflow limitations (CAL). Which of the following actions should the nurse take FIRST?
A. Perform chest physiotherapy prior to meals.
B. Auscultate the chest prior to beginning the procedure.
C. Administer bronchodilators after the procedure.
D. Percuss each lobe prior to asking the client to cough.
In doing incentive spirometry, intermittent elevation of the balls..

FALSE
Module 5_CDN Formative Assessment 1
if a torniquet test is done to count the petechiae in an imaginary 2.5...
20 or more
it is considered as the most dangerous plasmodium species.

Falciparum
viruses in ebola genus are recognizable because of their?
long filaments
what is the mode of transmission of H1N1 disease?
coughing and sneezing
the following are manifestations of dehydration except:
flushed skin
The most dangerous situation on the case of dengue hemorrhagic fever is:
high grade fever delirium
the standard treatment for malaria is?
Chloroquine
plasmodium species are:
protozoal parasites
which of the following is the source of infection of dengue hemorrhagic fever?
tap water of the school
drug of choice for dengue fever is:
praziquantel
what is the average incubation period of hepatitis A?
30 days
college student is required to be inoculated for hepatitis before beginning college…
hepatitis B
what is the causative agent for pulmoary tuberculosis?
Mycobacterium tuberculosis
what is the pathognomonic symptom of cholera?
rice watery stool
after performing your physical assessment to Mr. Santos, which of the following signifies that he is
having pneumonia?
Chest indrawing in visible impatient
percussion is cleared over areas of pneumonia
equal chest wall expansion occurs during inspiration
what is the causative agent of typhoid fever?
Salmonella typhosa
Amoebiasis is also rampant now days, the nurse should give the following instruction:
boil water for drinking
what vector mosquito is specific to transmit plasmodium species?

Anopheles
Upon assessment, Leo was diagnosed to have hepatitis A. Which mode of transmission has the infection
agent taken?
Fecal-oral one to two weeks before onset
the drug of choice for filariasis infection is:
hetrazan
albendazole
nurse alfred is aware that best time to collect blood sample in determining filariasis infestation is:
In the evening
preventive measure to prevent getting infected with H1N1 disease is by:
receive vaccine every year
All, but one, are drugs intended for pulmonary tuberculosis.
Rifampicin
Which of the following is the nursing consideration for typhoid fever?
all of the above
What is the causative agent of COVID 19 infection?
SARS-COV 2
Which of the following is plasmodium specie?

Aedes Aegypti
Malariae
Anopheles
Wuchereria Bancrofti
Day 6: Summative Assessment_Inflammatory

and Immunologic Diseases
Question 1
1 / 1 pts
What is the screening diagnostic test for AIDS?
Western Blot
Eliza Test
Kahn Wasserman Test
FTA-ABS Test
Question 2
1 / 1 pts
A college student is required to be inoculated for hepatitis before beginning college. The nurse realizes
this client will be inoculated to prevent the development of:
Hepatitis C
Hepatitis E
Hepatitis B
Hepatitis D
Question 3
1 / 1 pts
What is the causative agent of COVID 19 infection?
SARS-COV 2
Corona Virus 1
Corona Virus 2
COV2a
Question 4
1 / 1 pts
Drug or medication of choice for patient diagnosed with Syphilis
Benzathine Penicillin
Obimin
Foladin
Natalac
IncorrectQuestion 5
0 / 1 pts
Which of the following is the source of infection of Dengue Hemorrhagic fever?
Airborne droplet
Aedes Aegypti bite
Tap water of the school

Party foods
Question 6
1 / 1 pts
Preventive measure to prevent getting infected with H1N1 disease is by:
Avoid eating fish
Receive vaccine every year
Cleanse environment as always
Avoid eating pork and beef
Question 7
1 / 1 pts
Etiologic agent of Syphilis.
Trachomatis
Retro virus
Pallidum
Neisseria
Question 8
1 / 1 pts
During case finding of the TB infected persons, which procedure is immediately done by the Nurse?
X-ray exam
Isoniazid treatment
Collection of sputum
BCG injection
Question 9
1 / 1 pts
What is the cause of Ulcerative Colitis?
Environment
Genetics
Unknown but it can be an autoimmune condition.
All of the above
Question 10
1 / 1 pts
What is the mode of transmission of H1N1 disease?
Eating pork and beef
Sexual contact
Coughing and sneezing
Hugging and embracing
0 / 1 pts
What vector mosquito is specific to transmit plasmodium species?
Mansori Mosquito
Aedes Aygypti
Anopheles
Cules Mosquito
Question 12
1 / 1 pts
The standard treatment for malaria is?
Ceftriaxone
Primaquine
Tetracycline
Chloroquine
Question 13
1 / 1 pts
AIDS opportunistic infection are the following, except:
Striae Gravidarum
Cytomegalovirus (CMV)
Candida Albicans
Toxoplasmosis
Question 14
1 / 1 pts
The following are treatments for Nephrotic Syndrome, except:
Diuretics
Anticoagulants
Fluid therapy
Blood pressure medications
Question 15
1 / 1 pts
Management for patient diagnosed with Measles, except one:
Antipyretics
Trendelenburg Position
MMR vaccine
Vitamin A supplementation
Question 16
1 / 1 pts
What barn animal is predominantly carrier of MERSCOV infection?
Camel
Pingolin
Goat
Chicken
Question 17
1 / 1 pts
The most frequent disseminated opportunistic infection seen with AIDS. It causes the most serious
disease as pneumonia in the lung.
Retro virus
Toxoplamosis
Cytomegalovirus (CMV)
Herpes Simplex
Question 18
1 / 1 pts
What is the causative agent for Pulmoary Tuberculosis?
Mycobaterium tuberculosis
Mycobacterium leprae
Mycobacterium Bovis
Mycobacterium Aves
Question 19
1 / 1 pts
Amoebiasis is also rampant now days, the nurse should give the following instruction:
Wash hands with water
Destroy breeding places of mosquito
Eat fresh vegetables
Boil water for drinking
Question 20
1 / 1 pts
Acronym MMR stands for?
Measles Mumps Rubella vaccine
Mumps Measles Rubella vaccine
Mumps Measels Rubeolla vaccine
Measles Mumps Rubeolla vaccine
Question 21
1 / 1 pts
Clinical manifestations of Measles:

Fever, runny nose , dehydration
Petechaie, Koplik’s spots , coryza
Conjunctivitis, coryza , Koplik’s spots
Koplik’s spots, hepatomegaly, rashes
Question 22
1 / 1 pts
A treponemal antibody diagnostic test for Syphilis.
Eliza Test
Swab Test
FTA-ABS Test
Thayer Martin Culture
Question 23
1 / 1 pts
After performing your physical assessment to Mr. Santos, which of the following signifies that he is
having pneumonia?
Equal chest wall expansion occurs during inspiration
Percussion is cleared over areas of pneumonia
Chest indrawing in visible in patient
Chest auscultation reveals bronchial breath sounds
Question 24
1 / 1 pts
What is the etiologic agent of genital warts?
MMR
CMV
GWV
HPV
Question 25
1 / 1 pts
Medication of choice for Varicella:
Pen G
Oresol
Acyclovir
Acinlovir
Question 26
1 / 1 pts
Rheumatoid arthritis can affect many nonjoint structures, except:
Genitalia
Kidneys
Lungs
Heart
Question 27
1 / 1 pts
Viruses in Ebola genus are recognizable because of their?
Long Filaments
Due to their oblong heads

Unique Color
Hooked shape
Question 28
1 / 1 pts
Ebola virus outbreak occurred due to human-to-human transmission. Which of the following can cause
you to have an Ebola?
Direct contact through broken skin or mucous membrane, Blood, Stool, Urine, Saliva, Semen
Stool, urine, semen
Droplets and airborne
Semen, droplets, urine
Question 29
1 / 1 pts
What is the average incubation period of Hepatitis A?
14 days
60 days
40 days
30 days
Question 30
1 / 1 pts
If a tourniquet test is done to count the petechiae in an imaginary 2.5 cm square just below the cuff,
how many petechiae count is positive?
20 or more
Regardless of how many

Exactly 20
Less than 20
Question 31
1 / 1 pts
Medication prescribed for patient with Gonorrhea:
Metformin
Ceftriaxone Sodium
Simvastatin
Thiazide
Question 32
1 / 1 pts
Chicken pox is also called as.
Rubeola
Rubella
Varicella
German Measles
Question 33
1 / 1 pts
What is the causative agent of typhoid fever?
Salmonella typhosa
Vibrio El tor
Entamoeba Histolytica
Clostridium Tetani
Question 34
1 / 1 pts
The drug of choice for Filariasis infection is:
Albendazole
Doxycycline
Ivermectin
Hetrazan
Question 35
1 / 1 pts
What is the pathognomonic symptom of cholera?
Bloody mucoid stool
Severe dehydration
Diarrhea
Rice watery stool
Question 36
1 / 1 pts
Diagnostic Test, NAATs means?
None of the above
Nucleic Acid Amplified Tests
Nucleic Acid Amplification Tests
Nucleic Acid Amplifier Tests

Question 37
1 / 1 pts
Nurse Alfred is aware that best time to collect blood sample in determining Filariasis infestation is:
In the morning
In the afternoon
Dusk and dawn
In the evening
Question 38
1 / 1 pts
The following are manifestations of dehydration except:
Sunken eyeballs
Excessive thirst
Poor skin turgor
Flushed skin
Question 39
1 / 1 pts
Most common causative agent of UTI.
Aedes Aegypti
Gonococcus
Staphylococcus
E. coli
Question 40
1 / 1 pts
A person who harbors the microorganism but does not manifest the signs and symptoms of the disease
is called:
Carrier
Infected
Contact
Suspect
Question 41
1 / 1 pts
Which of the following term refers to the degree of pathogenicity of a microbe, or in other words the
relative ability of a microbe to cause disease?
Virulence
Infection
Susceptibility
None of the given options
Question 42
1 / 1 pts
A client with TB who is taking anti-TB drugs who calls the nurse because of urine discoloration.
According to the client his urine turned reddish-orange. The nurse told the client that the reddish-
orange discoloration of urine is the side effect of which anti-TB drug?
Ethambutol
Isoniazid
Rifampicin
Pyrazinamide
Question 43
1 / 1 pts
Rumpel Leads Test for DHF is positive when:
20 or more petechiae per 2.5 cm square or 1 inch square are observed
No petechiae are present
10-15 petechiae per 2.5 cm square or 1 inch square are observed
15-20 petechiae per 2.5 cm square or 1 inch square are observed
Question 44
1 / 1 pts
Preventive measures for malaria least likely include:
None of the given options
Planting of Neem trees and other herbal plants.
Wearing of clothing that covers the arms and legs at daytime. c. Using mosquito repellents, mosquito
coils.
Using mosquito repellents, mosquito coils.
Question 45
1 / 1 pts
A child with measles (rubeola) is being admitted to the hospital. In preparing for the admission of the
child, which of the following will the nurse include in the plan of care?
respiratory isolation
blood precaustion
enteric precautions
contact precautions
Question 46
1 / 1 pts
Koplik spots are the pathognomic signs of Measles. Student nurse understands that Pathognomonic
means:
characteristic of a disease
untoward symptoms
pathology of disease
prodromal signs
Question 47
1 / 1 pts
Emy is a 4- year old child who developed chicken pox. At the late stage of life she is expected to develop:
Small pox
shigella
Varicella
Shingles
Chicken pox
Question 48
1 / 1 pts
During interview Rina stated that vesicles of chicken pox grows from ____ to -_____-.
head
Chest
Toes
Distal Parts
Arms
Abdomen
6,5
2,4
1,2
1,3
2,3
0 / 1 pts
During inspection you noted for the progression of lesion of chicken pox as:
Pustules, Vesicles, Macules, Papules, Scabs, Crusts, Pock Marks
Macules, Pustules, Papules, Scabs, Vesicles, crusts, pock marks
Papules, Macules, Vesicles, Crusts, Scabs, Pustules, Pock Marks
Macules, papules, vesicles, pustules, crusts, scabs, pock marks
Question 50
1 / 1 pts
Trina has jaundice and diagnosed with Hepatitis E. She asks the nurse how to prevent the transmission
of disease to her family members?
Do not donate blood.
Do not engage in unprotected sex with your husband.
Do not share needles with family
Do not share eating utensils.

Question 51
1 / 1 pts
Trina would like to know what diet is best for patients like her with Hepatitis E. The nurse’s best
response is:
high fiber diet
high calorie, high carbohydrate, high protein
low salt, low fat
high carbohydrates, low protein, high caloric
PartialQuestion 52
0.67 / 1 pts
The cause of multiple sclerosis is unknown but there are risk factors that may contribute to the
deveopment of the disease. Select all that applies.
History of Epstein-Barr infection
20 and 40 years of age.
Men
Asian
Catholic
If one of your parents or siblings has had the disease
Women
Question 53
1 / 1 pts
Patient MS will undergo diagnostic test that will record the electrical signals produced by your nervous
system in response to stimuli. This means she will be undergoing__.
Evoked potential tests
MRI
Blood tests
Spinal tap (lumbar puncture)
Question 54
1 / 1 pts
Patient with multiple sclerosis is experiencing electric-shock sensations that occur with certain neck
movements, especially bending the neck forward. This is characterized as:
Lhermitte sign
Kernig's sign
Brudzinski Sign
Risus Sardonicus sign
Question 55
1 / 1 pts
Guillain-Barré syndrome is usually treated with immune system treatments, which help your child's
immune system go back to working normally. These includes the following. Select all the applies.
Plasma exchange (plasmapheresis)
Immunoglobulin therapy (IVIG)
Atropine
edrophonium test.
Mestinon
0 / 1 pts
Which of the following diagnostic test for Myasthenia gravis is both intented to diagnose and manage
signs and symptoms
MRI
Electrodiagnostics
edrophonium test.
Blood test
Question 57
1 / 1 pts
Ulcerative colitis (UC) is an inflammatory bowel disease. It causes irritation, inflammation, and ulcers in
the lining of your large intestine. There are many types of UC. Please select all that applies.
Cholecystitis
Proctosigmoiditis
Gastritis
Pancolitis
Left-sided colitis
Ulcerative proctitis
Pancreatitis
Question 58
1 / 1 pts
This test indicates your child's average blood sugar level for the past three months.
Hemoglucotest
Glycated hemoglobin (A1C) test.
Random blood sugar test.
Fasting blood sugar test.
Question 59
1 / 1 pts
Client DM is manifesting the following signs and symptoms:
Increased thirst
Frequent urination
Bed-wetting in children who previously didn't wet the bed during the night
Extreme hunger
Unintended weight loss
Irritability and other mood changes
Fatigue and weakness
Blurred vision
Which of the following is the priority nursing diagnosis?
Imbalanced nutrition: less than body requirements related to insufficient caloric intake to meet growth
and development needs and the inability of the body to use nutrients
Risk for injury related to blurred vision
Risk for impaired skin integrity related to slow healing process and decreased circulation.
Risk for infection related to elevated glucose levels.
Question 60
1 / 1 pts
Which of the following is the pathognomonic sign of Systemic Lupus Erythematous?
photosensitivity
Butterfly-shaped rash
Raynaud's phenomenon
Joint pain
Primary signs of Syphilis.
Hair loss
Sore throat
Rashes
Chancre
• Mode of transmission of Measles.

Droplet
Sexual Contact
Airborne
Direct Contact
• Multiple Sclerosis is best described as:

Disabling disease of brain and spinal cord
People have long-term nerve damage.
Begins with tingling and weakness starting in your feet and legs and spreading to your
upper body and arms.
A person's own immune system damages their nerve cells, causing muscle weakness
• A fungus causing infection of mouth and vagina appearing as white thick, cottage
cheese-like exudates and oral thrush.
CMV
pneumocystis Carini
Herpes Simplex
Candida Albicans
What is the mode of transmission of the MERSCOV disease?

Auto-immune
Vector borne
Fecal-oral
Airborne
Patients diagnosed with DM type 1 are mostly, except one:
Oc. Young onset
O d. Obese
a. Juvenile
b. Within ideal body weight but mostly thin
Most of common neoplasm and an HIV associated malignancies:
Kaposis Sarcoma
Cryptococcus Neoformans
Candida Albicans
Non-Hodgkin's Lymphoma
Which of the following is the nursing consideration for typhoid fever?
O Avoid antispasmodic and laxative

All of the above
O Educate public about control of flies
Drug of choice is chloramphenicol
Incubation period of AIDS.
10 days and above.
Median 10-12 days
Median 10-12 years.
Median 10-12 months

3.11 Formative Assessment Oxy-Cardio Skills
V1 - Precordial lead place on the 4th intercostal space, right of the sternum
V2 - Precordial lead place on the 4th intercostal space, left of the sternum
V5 - Precordial lead place on the anterior axiliary las the same level of V4.
V4 - Precordial lead place on the (above) 5th intercostal space, midclavicular line
Electrocardiogram - A test that records the electrical activity of the heart.
Red - Limb lead place on right hand.
V6 - Precordial lead place on the midaxillary line in line with V4.
Green - Limb lead place on Left foot.

Green - Precordial lead place midway between leads V2 and V4, and the color of this is?
Yellow - Limb lead place on left hand

Module 5.3 (Oxy- Cardio)_ Formative
Assessment #3
The following are the signs and symptoms if MI except;

• increased /decreased heart rate
• Decreased left ventricular function and cardiac output
• Difficulty of breathing/shortness of breath
• Increased left ventricular function and cardiac output
Health teaching in CAD is focused on the following, except;

• Increasing exercise
• Controlling BP and blood sugar level
• Decreasing dietary intake of fats and cholesterol
• Increasing dietary intake of sodium, fats and cholesterol
The chest pain in angina pectoris radiates to;

• The jaw, the left arm, neck, inner aspect of upper arms on the left
• The jaw, both arms, neck, inner aspect of left and right upper arms
• The jaw, the left arm, neck, outer aspect of the upper arms on the left
• The jaw, both arms, neck, outer aspect of left and right arms
Patient reports no pain but there is an ECG changes with a stress test which is an
evidence of ischemia is what type of angina?
• Silent angina
• Silent ischemia
• Variant ischemia
• Variant angina
All of the following are associated factors in anginal attack, except;
• Stress
• Physical exertion
• Exposure to warm temperature
• Eating heavy meal
These are common signs and symptoms of CAD except;

• Dyspnea and chest pain
• Dyspnea and syncope
• Chest pain and palpitations
• Palpitation and dyspnea
• Fear and anxiety
It is characterized by episodes of chest pain or pressure in the anterior chest.

• Atherosclerosis
• Congestive heart disease
• Coronary artery disease
• Angina pectoris
The objective of medical and nursing management of Angina Pectoris is to increase the
oxygen demand of the myocardium and to increase the oxygen supply.
• TRUE
• FALSE
It improves the circulation of blood to muscles of the heart at risk for infarct due to
obstructed artery.
• Vascular stent
• PTCA
• Coronary Artery Bypass Grafting
• Laser angioplasty
A surgical management that compresses the lipid plaques against the wall of the artery
• Laser angioplasty
• Atherectomy
• CABG
• PTCA
Examples of drugs that reduces vasospasm and also dilates coronary arteries.
• Metoprolol
• Nitroglycerine
• Aténalol
• Norvast
An example of a non-modifiable risk factor in CAD is;
• Obesity
• increased level of lipids/fats
• increasing age
• physical inactivity
These are drugs to decrease the filling pressure and resistance to eject as well as it dilates
the coronary artery.
• beta blockers
• cholesterol-lowering medications
• calcium channel blockers
• nitrates
The most common cause of coronary artery disease is;

• increased BP
• increased level of lipids
• increased blood glucose
• abnormal accumulation of fats
A complication of Myocardial Infarction that must be watched out closely by the nurse
caring for the client is;
• stress/anxiety
• hypertension
• chest pain
• dysrhythmias
Morphine S04 is a drug of choice as analgesic in Myocardial Infarction. The action of this drug are the
following except:
decreases cardiac output
Nitroglycerine medications act to:
decrease filling pressure and resistance to eject as well as dilates the coronary arteries
reduce vasospasm
reduce development of atherosclerotic plaques
reduce the BP
Chest pain in angina pectoris is described as:
mild to severe retrosternal pain, squeezing, tightness and burning sensation
Which of the following is not a modifiable risk factor of Myocardial Infarction?
ethnic background
These are all signs and symptoms of Angina Pectoris except:
light sensation and tightness in upper chest
During anginal attack in MI, it is best to advise the patient to stop all activities. Then administer
Nitroglycerine sublingually then wait for 5 minutes. If unrelieved, take again one tablet sublingually then
wait for 5 minutes. If unrelieved, then take again one tablet sublingually then wait for 5 minutes. If
unrelieved take again one tablet sublingually then wait another 5 minutes. If still unrelieved, advise to
seek immediate medical consult or attention.
False
Which of the following promotes myocardial perfusion?
encourage to increase physical activities
instruct patient on Valsalva Manuever
provide laxatives or high fiber diet to lessen constipation
minimize anxiety
The following are nursing care to consider in caring for clients with Myocardial Infarction, except;
provide active ROM exercises

provide adequate rest periods
provide passive ROM exercises
provide O2 at 2LPM and position in semi-Fowler's
Module 6.4 Formative Assessment #4
It measures how quickly the erythrocytes settle in the bottom of the test tube that contains
a blood sample
• blood chemistry
• blood CS
• erythrocyte sedimentation rate
• CBC
Most characteristic symptoms of pericarditis.
• high WBC count

• chest pain
• Fever
• ST changes in ECG
After an anterior wall myocardial infarction, which of the following problems is indicated
by
Auscultation of crackles in the lungs?
• Right-sided heart failure

• Tricuspid valve malfunction
• Left-sided heart failure
• Pulmonic valve malfunction
All of the following are TRUE about Pump Failure, except:
• unable to maintain adequate circulation to meet the metabolic needs of the body
• a process by which areas of myocardial cells are permanently destroyed
• inability of the heart to pump sufficiently
• classified according to the major ventricular dysfunction
All of the following are manifestations of chronic myocarditis, except:

• shortness of breath
• Fatigue
• sensation of skipped heart beats
• chest pain
When examining a patient with pericarditis, a pericardial friction rub is detected. What a
distinguishes a pericardial friction rub from a pleural friction rub? D
• A pleural friction rub can only be detected laterally

• Pericardial friction rub is a palpable vibration on the anterior chest wall that is in
tandem with the apical pulse
• A pleural friction rub only appears upon inspiration when the thoracic cavity
expands
• A pericardial friction rub can still be detected with the cessation of breathing
Which of the following are manifestations of left sided CHF?
• hepatomegaly, weight gain, anorexia

• wright gain, pulsus alterans, ascites
• decreased peripheral pulses, tachycardia, fatigue
• anorexia, nausea, distended neck veins
The clinical manifestation of fatigue in left sided CHF is due to;
• decreased brain perfusion

• increased cardiac output
• kidney is affected already
• decreased cardiac output
The manifestation of body weakness in right sided CHF is due to;
• decreased cardiac output and impaired circulation

• venous engorgement
• increased venous pressure
• retention of fluid
A patient presents to the ER with complaints of chest pain and body malaise. Which of
the following heart muscle diseases is unrelated to other cardiovascular diseases?
• Myocardial infarction
• Pericardial effusion
• Coronary artery disease
• Cardiomyopathy
A patient is having difficulty understanding the complication of additional fluid surround the heart. They
report that "having extra fluid means extra protection around their heart". What information would be
best used to educate the patient on their condition.
More fluid is surrounding the heart allows for less blood to fill the heart to be pumped out leading to
poor circulation.
The primary presenting symptoms of infective endocarditis are;
fatigue and weakness
weight loss and joint pain
fever and chills
fever and heart murmurs
Which of the following system is the most likely origin of pain the client describes as knifelike chest pain
that increases in intensity with inspiration?
Musculoskeletal
Module 7 (Oxy- Cardio)_ Formative

Assessment #5
It is the inflammation of the deep vein of lower extremities and pelvis veins.
Deep vein thrombosis
Pain in the calf upon dorsiflexion of the foot.
Homan's sign
It is the narrowing and hardening of arteries that supplies the peripheral extremities.
Arteriosclerosis
Aneurysm
Atherosclerosis
Peripheral Arterial Occlusive Disorder
All of the following are manifestations of Peripheral Arterial Occlusive Disease except
pale skin when extremity is elevated
warm sensation and numbness of the legs
muscle atrophy
progressive pain on the leg
It is the hallmark of peripheral arterial occlusive disorder.
intermittent claudication
palpitations
difficulty of breathing
tingling sensation
The following manifestations in client with peripheral arterial occlusive disease must be watched
closely, except;
increased urine output
bleeding
decrease urine output
bematuria
As a preventive measure of arteriosclerosis and atherosclerosis includes the following, except
low fiber diet
A fusiform aneurysm is described as:
entire arterial segment becomes dilated
Clinical manifestations of the disorders of the peripheral arteries include the following, except;
body malaise
Nicotine use as a modifiable risk factor of disorders of the peripheral arteries may result to the
following, except;
decrease risk of clot formation by increasing platelet aggregation
Module 8.4 (Oxy- Cardio)_ Formative

Assessment #6
Which of these blood types carries no antigens:
blood type O
Hemostasis involves 3 major processes, except;
dilation of blood vessels

Which one of the following groups consist of granulocytes:
neutrophils, eosinophils, and basophils
Blood Type A has an antigen A and antibody A.
FALSE
It is called as the cellular immunity mediators.
T-lymphocytes
The average functional lifespan of an RBC is:
100-120 days
The following are formed elements in the blood system, except:
Plasmsa
It acts to dissolve clots and lyse fibrin.
Plasmin
Blood Type B has an antigen B and antibody A.
TRUE
An individual who lives at a high altitude may normally have an increased RBC count because
hypoxia caused by decreased atmospheric oxygen stimulates erythropoiesis.

Which antigen(s) does type AB blood contain:
A and B antigens
It releases chemicals that can cause activation of fibrinogen.
platelet
Which of these blood types carries no antigens:
blood type O
It is increased in allergic and parasitic reactions.
Eosinophils
SUMMATIVE ASSESSMENT: OXY-CARDIO

HEMA CONCEPT
Which of the following conditions most commonly results in coronary artery disease?
O atherosclerosis
O Renal Failure
O Myocardial Infarction
O Diabetes Mellitus
Nursing care for a patient immediately after a bone marrow biopsy and aspiration includes;
O preparing to administer a blood transfusion
O instructing on need to lie still with a sterile pressure dressing intact.
O instructing on the need for preprocedure and postprocedure antibiotic medications
Omonitoring vital signs and assessing the site for excess drainage or bleeding
Situation:
Jon, is 11 years old and has a Type A Hemophilia. He is brought to the emergency room after
being knocked down in a football game. This condition is accompanied by frequent bruising and
persistent bleeding even from minor injuries.
Question:
Jon is found to be bleeding into his knee joint. You anticipate that the most likely treatment will
be
O Fresh Frozen plasma or cryoprecipitate
Fresh Whole blood

O Vitamin K
O Exchange transfusion
The cause of angina pectoris is insufficient coronary blood flow resulting in a decreased oxygen
supply when there is decreased myocardial demand for oxygen.
OTRUE
O No answer text provided.
OFALSE
Which of the following data is most important to elicit during the interview once with this kind of
diagnosis of to "rule out aplastic anemia"?
O exposure to chemicals and drugs.
O recent travel outside the country
O medication allergies
O history of blood transfusion

A variant angina is also called Prinzmetal Angina characterized by pain at rest with reversible
ST-segment elevation thought to be caused by coronary artery vasodilation.
O FALSE
O TRUE
All of the following are etiologic factors associated with Idiopathic Thrombocytopenic Purpura
(ITP), except:
O immunization of live virus
O viral infection
O reaction to nicotine use
O drug reaction
Disseminated Intravascular Coagulation or DIC is thought to be caused by widespread injury to

endothelial cells.
O renal disease
O malignancy/cancer
O major trauma
O abruptio placenta
O sepsis
Which of the following characterizes sickle cell anemia?
O microcytic RBC
O large RBC being produced
O disc-shaped or crescent moon-shaped RBC
O too small RBC being produced
A type of von Willebrand's Disease which is characterized by decrease in structurally normal

von Willebrand's factor.
O Type 3 von Willebrand's Disease

A client is to be discharged home with a transdermal nitroglycerin patch. Which instruction will
the nurse include in the client's teaching plan?
O "Apply the patch to the same site each day!"
O "Apply the patch to a non hairy area of the upper torso or arm."
O "If you have chest pain, apply a second patch next to the first patch."
O "If you have a headache, remove the patch for 4 hours and then reapply."
Hemophilia B is caused by;
O deficient and defective clotting factor XI
O deficient and defective clotting factor IX
O deficient and defective clotting factor VII
deficient and defective clotting factor X
Reducing myocardial oxygen demand and increasing O2 supply can be achieved by the
following, except:
O medication
O increased O2 supply/administration
O bedrest
O active exercise/physical exertion
The nurse acknowledges that beta blockers are as effective as antianginals because they do
what?
O Decrease heart rate and decrease myocardial contractility.
O Increase oxygen to the systemic circulation.
O Maintain heart rate and blood pressure.
O Decrease heart rate and increase myocardial contractility.
Which one of the following represents the proper sequence of hemostasis:
O vascular spasm, coagulation, platelet plug formation
O coagulation, platelet plug formation, vascular spasm

O coagulation, vascular spasm, platelet plug formation.
O vascular spasm, platelet plug formation, coagulation.
Fragments of cells in the bloodstream that breakdown on exposure to injured tissue and begin
the chain reaction leading to a blood clot are known as;
O leukocytes
O erythrocytes.
O monocytes
O platelets
Disseminated Intravascular Coagulation DIC is a disorder in which;
O a disease process stimulates coagulation processes with resultant thrombosis, as well as

depletion of clotting factors, leading to diffuse clotting and hemorrhage
O an underlying disease depletes hemolytic factors in the blood, leading to diffuse thrombotic
episodes and infarcts.
O the coagulation pathway is genetically altered, leading to thrombus formation in all major
blood vessels.
O an inherited predisposition causes a deficiency of clotting factors that leads to overstimulation

of coagulation processes in the vasculature.
Mr. Herrera was admitted to the Coronary Care Unit (CCU) with a diagnosis of myocardial
infarction Shortly after admission, he states that he might as well have died because now he
won't be able to do anything Your best response would be;
O "Don't worry about it. Mr. Herrera. Everything will be alright."
O Take life one day at a time, Mr. Herrera"
O "You shouldn't be thinking about that because you are doing so well now."
O "What do you mean about not being able to do anything, Mr. Herrera?"
Diagnostic tests on hemostasis and thrombosis are the following, except:
Oblood count
O bleeding time
O prothrombin time
O platelet count
In type A Hemophilia, a child is deficient in the clotting factor of;
O IX
O XII
O XI
O VIII
When a client is receiving an anti-coagulant should include observation for;
Onausea
O epistaxis
O headache
Ochest pain
Unstable angina is to increase in frequency and severity; while stable angina is to:
O relieved by rest and Nitrates, predictable and inconsistent pain that occurs on exertion
O relieved by rest and Nitrates, predictable and consistent pain that occurs on exertion
O severe capacitating chest pain
O severe incapacitating chest pain

Situation:
Jon, is 11 years old and has a Type A Hemophilia. He is brought to the emergency room after
being knocked down in a football game. This condition is accompanied by frequent bruising and
persistent bleeding even from minor injuries.
Question:
Jon has been transferred to the pediatric unit. In your nursing care plan for Jon, you would
include:
O active exercise of the affected limb
O passive exercises to the affected limb
O traction of the affected limb
Immobilization of the joint
It is best to consider the following laboratory findings in client with coronary artery disease,
except
O triglycerides level of 150mg/dl or lower
O bad cholesterol level of 120mg/dl

O good cholesterol level of 100mg/dl
O cholesterol level of 129mg/dl
In reviewing cardiac waveform strips or ECG for a hospitalized client, the nurse instructed a
student nurse that the P wave represents:
O atrial repolarization
O ventricular repolarization
O atrial depolarization
O ventricular depolarization
Situation:
One evening Mr. Herrera awakes with severe substernal chest pressure and dyspnea. He takes
two Nitroglycerin tablets without relief. In five minutes, he takes two more without relief. He calls
his physician who instructs him to go directly to the hospital
Question:
One afternoon. Mr. Herrera requests a snack. Food on the menu that would be the most
appropriate for him is;
O fresh fruits
O ice cream
O chicken sandwich
O seafood salad
A client has heart failure and is prescribed Lasix. The nurse is aware that furosemide (Lasix) is
what kind of drug?
O Thiazide diuretic
O High-ceiling (loop) diuretic
O Osmotic diuretic
O Potassium-sparing diuretic
What B vitamin is lacking that contributes to the development of Pernicious anemia
O B10
B6
B1
O B12
Heparin therapy is to Disseminated Intravascular Coagulation: while plasmapheresis is to;
O Thrombosis
O Hemorrhage
O Idiopathic Thrombocytopenic Purpura
O Hemostasis
The goal of the therapy is to maintain the normal hemoglobin levels by the administration of
blood transfusion
O Thalassemia
O Von Willebrand's Disease
O Factor Vil Disorder
O Hemophilia
An adult woman is admitted to the cardiac care unit with a myocardial infarction. The morning
after admission he and her husband tell the nurse that she must be home tonight to care for the
children when her husband goes to work. The problem identified at this point would be:
Oinability of the client/family to understand the disease process

O anxiety related to physical limitations
Osafety needs related to inability to cope
O alteration in cardiac output
It is generally caused by a genetic defect that results in deficient or defective clotting factor Vill
O Hemophilia B
O Hemophilia A
O Vitamin K Deficiency
O Parenchymal Disease of the Liver
The nurse is aware that the term bradycardia means;
O Heart rate of over 90 beats per minute
O heart rate that has regular skipped beats
O Heart rate of under 60 beats per minute.
O grossly irregular heart beats.

The nurse understands that the client with pernicious anemia will have which distinguishing
laboratory rings!
ORBC's 5.0 million
Schilling's test, elevated
Intrinsic factor, absent
C Sedimentation rate, 16 mm/hour
A client was admitted with iron deficiency anemia and blood-streaked emesis. Which question is
most appropriate for the nurse to ask in determining the extent of the client's activity
intolerance?
O 'Are you more tired now than you used to be?
O "What activities were you able to do 6 months ago
O How long have you had this problem?"
compared with the present
Have you been able to keep up with all your usual activities?"
Insufficient folate in the body will lead to what hematologic disorder

O microblastic anemia
O megaloblastic anemia
O leukemia
O aplastic anemia
Which of the following diagnostic findings are most likely for a client with aplastic anemia?
O Reed-Stemberg cells and lymph node enlargement
O Decreased production of T-helper cells.
O Decreased levels of white blood cells, red blood cells, and platelets
O Increased levels of WBCs, RBCs, and platelets
Which of the following blood components is decreased in anemia?
O leukocytes
O erythrocytes
O platelets
O granulocytes
Laboratory findings which may help diagnose Peripheral Arterial Occlusive Disease are the
following except
Ⓒincreased doppler flow studies
Osensation of cold
O numbness of extremities
unequal pulses between extremities
Situation:
Mr. Herrera, a 57 years old vice president of a bank, began having intermittent chest discomfort
over the past weeks but did not seek medical consultation; however, the pain finally interrupted
his activities during the day he went to the physician. After evaluation, a diagnosis of angina
pectoris due to atherosclerotic heart disease was made. Nitroglycerin was prescribed to control
Mr. Herrera's attack.
Question:
When instructing Mr. Herrera on how to adjust to his condition, it should be emphasized that
angina may be brought on by many things, but the most common is:
Osudden change in position

O stress
Ophysical exertion
O constant activity
All of the following is true about hemophilia, except
O Management is symptomatic treatment approach
It is most frequently transmitted by union of unaffected male with a trait carrier female
It can result from the union between the affected male and normal female or a carrier female
It is most frequently transmitted by union of affected male with a trait carrier female
These are considered as the reliable and critical marker of damage to myocardium in
Myocardial Infarction
O Troponin 1 and CK-MB
O Troponin I and Troponin T
O Elevated CK MB and CK-MM

OST elevation and T wave inversion in ECG
In the nurse's understanding of the cardiac cycle, when do coronary arteries primarily receive
blood
O during inspiration
O during expiration
Oduring diastole
O during systole
Reduced production of globin chains
O Thalassemia
O Factor VII Disease
O Hemophilia
Mr. de Guzman was diagnosed with leukemia. His laboratory results indicate bone marrow
depression. The mune should encourage him to:
O increase activity level and ambulates frequently
O sleep with head of the bed slightly elevated
O use a soft toothbrush and electric razor
O drink citrus fruits frequently for nourishment
The nurse is caring for an adult who is being treated for a myocardial infarction. Oxygen is
administerd Administering oxygen to this client is related to which of the client problems?
Ochest pain
O ineffective myocardial perfusion
O alteration in heart rate, rhythm and conduction
O anxiety
The nurse in the coronary care unit should observe for one of the following complications of
myocardial, which is:
O anaphylactic shock
O cardiac enlargement
Hypokalemia
O cardiac dysrhythmias
Joint bleeding causing pain
O Thalassemia
O Hemophilia
O Factor VII Disorder
Laboratory findings in von Willebrand's Disease are the following, except:
O prolonged aPTT
O increased bleeding time.
O decreased clotting factor Vill

O abnormal platelet count
You are taking care of a male patient who has the following laboratory values from his CBC
WBC 6.5-103/UL Hgb 13.4 g/dL, Hct 40%, platelets 50x 103/uL. What are you most concerned
about?
O Your patient is neutropenic
O Your patient is at fall risk due to his anemia.
O Your patient has an infection.
O Your patient is at risk for bleeding,
Which client would be most at risk for developing disseminated intravascular coagulation
(DICI)?
OA 35 year old pregnant client with placenta previa
O A 42 year old client with a pulmonary embolus
O A60 year old client receiving hemodialysis 3 days a week
O A 78 year old client with septicemia

These are manifestations of Idiopathic Thrombocytopenic Purpura (ITP) in the laboratory
examination results, except:
prolonged bleeding time
Decreased WBC
Odecreased hemoglobin level
Oplatelet count Iss than 20,000
The nurse would instruct the client to eat which of the following foods to obtain the best supply
of vitamin B12?
O whole grains
O broccoli and brussels sprouts
O Green leafy vegetables
O Meats and dairy products
Situation:
over the past three weeks but did not seek medical consultation, however, the pain finally
interrupted his activities during the day.so he went to the physician. After evaluation, a diagnosis
of angina pectoris due to atherosclerotic heart disease was made. Nitroglycerin was prescribed
to control Mr. Herrera's attack
Question:
As a nurse administering nitroglycerin sublingually, you have to take note of the following except
O do not swallow the medication
Oplace under the tongue until fully absorbed
monitor vital signs
Do not give fluid prior to sublingual
The nurse implements which of the following for the client who is starting a Schilling test?
O Starting a 24 to 48 hour urine specimen collection
O Administering methylcellulose (Citrucel)
O Maintaining NPO status
O Starting a 72 hour stool specimen collection
von Willebrand's Disease is a common bleeding disorder affecting males and females equally
usually inherited as recessive trait
O TRUE
O FALSE
The following are manifestations of Disseminated Intravascular Coagulation Disease, except;
O increased hematocrit and platelet count
O increased PT and aPTT
O bruising and purpura
O decreased hematocrit and platelet count
These are group of hereditary anemias characterized by hypochromia, hemolysis, extreme

microcytosis and varying
degrees of anemia.
O Thalassemia
O Hemophilia
O Idiopathic Thrombocytopenic Purpura
O Hemostasis and Thrombosis
Frank Starling Law states that;
O The more that the cardiac muscle is stretched the weaker the contraction
The force of conducting system of the heart is a group of specialized cells
The force of contraction is proportional to the degree of stretching of the cardiac muscle fibers
O The force of resistance the heart must pump is to eject the blood
Situation
over the past three weeks but did not seek medical consultation, however, the pain finally
interrupted his activities during the day, so he went to the physician. After evaluation, a
diagnosis of angina pectoris due to atherosclerotic heart disease was made. Nitroglycerin was
prescribed to control Mr Herrera's attack
Question:
As part of your nursing knowledge, you know that the pain is due to
O Rubbing of the epicardium against the pericardial sac
O Inability of the coronary arteries to meet crypen requirements of the pericardium
Olitation of the cardiac nerve ending
O inability of the coronary arteries to meet oxygen requirements of the myocardium
O Spasm of the coronary arteries
The nurse devises a teaching plan for the patient with aplastic anemia. Which of the following is
the most
important concept to teach for health maintenance?
Ⓒ Eat animal protein and dark leafy vegetables each day
Practice yoga and meditation to decrease stress and anxiety.
O Avoid exposure to others with acute infection
O Get 8 hours of sleep at night and take naps during the day
Which laboratory result would the nurse expect in the client diagnosed with Disseminated
Intravascular Coagulation?
O an increase platelet count
A low fibrinogen level
O a decreased prothrombin time
an increased white blood cell count
Hemarthroses is to Hemophilia; while Wide-set eyes with flat nose is to;
O Thalassemia Major
O von Willebrand's Disease
O Thrombosis
O Hemostasis
Situation:
One evening Mr. Herrera awakes with severe substernal chest pressure and dyspnea. He takes
two Nitroglycerin tablets without relief. In five minutes, he takes two more without relief. He calls
his physician who instructs him to go directly to the hospital.
Question:
In evaluating the rationale for the physician's instructions, the nurse knows that sudden death
(outside of the hospital) in association with coronary artery disease is most often due to;
O Pump failure accompanied by pulmonary congestion
O acute myocardial infarction
O arrhythmias
O papillary muscle dysfunction
A client with anemia may be tired due to a tissue deficiency of which of the following
substances?
O Oxygen
O T-cell antibodies
O carbon dioxide
O Factor VIII
Joint bleeding is:
O Hemarthrosis
O Hematopoeia
O Hemarthritis
O Hematochezia
Atherosclerosis impedes coronary blood flow by which of the following mechanism?
O hardened vessels dilate to allow blood to flow
through
O plaques obstruct the veins
O blood clots formed outside the vessel wall
O plaques obstruct the artery
Nursing interventions of Disseminated Intravascular Coagulation Disease are the following,

except;
O monitor urine output
O monitor vital signs
O monitor fluid intake

O monitor hemorrhage and signs of shock
Management of Hemophilia are the following. except;
O administration of replacement factor as prescribed
O assess and monitor the neurologic status
O monitor for hypotension
O monitor urine for presence of blood
A drug of choice for Peripheral Arterial Occlusive Disease is Trental. This drug acts to;
O reduce blood viscosity
O increases vasodilation
O inhibit platelet aggregation
O increase blood viscosity
Situation:
over the past three weeks but did not seek medical consultation; however, the pain finally
interrupted his activities during the day, so he went to the physician. After evaluation, a
diagnosis of angina pectoris due to atherosclerotic heart disease was made. Nitroglycerin was
prescribed to control Mr. Herrera's attack.
Question:
Your knowledge about angina pectoris was challenged upon handling Mr. Herrera. As a nurse
you know that there are types of angina. An angina described as severe incapacitating chest
pain is;
stable angina
unstable angina
O Intractable or refractory angina
O variant angina
Angina Pectoris is characterized by;
O abnormal accumulation of fatty substances and
fibrous tissues in the vessel wall
O fatty substances accumulating the vessel that widens the lumen of the vessel
O fatty substances accumulating the vessel thereby increasing the blood flow to the muscles of
the heart
O abnormal accumulation of fluid and air in the vessel wall
Which of the following classes of medications maximizes cardiac performance by increasing

myocardial contractility?
O diuretics
O calcium channel blockers
O beta-adrenergic blockers
O inotropics
Which of the following risk factors for coronary artery disease can be prevented?
gender
O cigarette smoking
O age
O heredity
Angina is usually caused by atherosclerotic disease and associated with significant obstruction
of at least one minor coronary artery.
O True
O False
5.2. SL_CD Formative Assessment
An adult client has a virulent respiratory infection, which of these actions best prevents the
transfer of airborne organism?
• Instructing the family effective hand washing only
• Having the clients dishes sterilized after use.
• Having the clients laundry disinfected after use.
• Use N5 respirator mask as much as possible and institute hand washing always
Hand washing prevent the spread of infection in hospitalized patient. The position of the hands
during medical hand washing is:
• Pointed straight
• Pointed downward
• Pointed upward
• All of the given options
A nurse is bathing a client who has infection spread by droplets. Prior to reporting to work, the
nurse's hand was scratch by her pet cat. Which of the following will not be included?
• Mask
• Goggles
• Gloves
• Gown
In caring for a client on contact precautions for a draining infected foot ulcer, correct technique
includes?
• following standard precautions in all interactions with the client
• wearing a mask during dressing changes
• providing disposable meal trays & silverware
• using surgical aseptic technique for all direct contact with the client.
Which of the following PPE may be reused by the same RN during a single shift caring for a
single client?
• gown
• goggles
• clean gloves
• surgical mask
After caring for a client with COVID 19, the nurse performs which of the following actions when
removing protective wear?
• Remove gown, N95 mask, gloves, face shield
• Remove gloves. N95 mask, gown, face shield
• Remove gloves, face shield, gown, N-95 mask
• Remove N95 mask, gown, gloves, face shield t
Sequence in putting on personal protective equipment are as follows:

• gown, mask, face shield
• gown, mask, face shield, gloves
• Gown, mask, gloves, face shield
• gown, gloves, mask, face shield
Which of the following is an appropriate principle to prevent spread of infection?

• Touching surfaces as long as it is clean
• Frequent touching of face to adjust Personal Protective Equipment
• Perform hand hygiene before and after each procedure
• Using gloves for 24-hour duty
When leaving an isolation room, the nurse correctly removes her equipment:
• Mask, gown and gloves
• Gown, gloves and mask
• Gloves, goggles, gown, mask
• Gown and mask inside the room and gloves outside the room
The nurse is planning a staff development program for health care staff on how to care for
clients with hepatitis A. Which of the following precautions would the nurse indicate as essential
when caring for clients with hepatitis A?
• Assigning the client in a private room
• wearing gloves when giving direct care
• Gowning when entering a client's room
• wearing a mask when providing care
The nurse is preparing to take care a COVID-19 positive patient. Which of the following should
the nurse wear at least?
• Gloves and surgical mask
• Gloves, eye protection, and particulate respirator
• Gloves, gown, eye protection, and surgical mask
• Gloves gown, particulate respirator mask, face shield, cap, disposable boots
The nurse receives a client that is under contact precautions. What personal protective
equipment will be needed for the client's morning care?
• gloves
• gloves and mask
• gloves, gown, mask
• gloves, goven, goggles
When caring for a single client during one shift, it is appropriate for the nurse to re-use which of
the following personal protective equipment?
• Gown
• Surgical mask
• Goggles
• Clean gloves
One important type of personal protective equipment is a respirator. Which statement is FALSE
about a respirator?
• It is important to be fitted for a respirator annually by employer.
• A respirator is to be worn at all times when a patient is in droplet precautions
• After providing patient care, the nurse will remove the respirator outside the patient's
room
• After donning a respirator, the nurse must perform a seal check
Module 1- 4 (Oxy/ Respi) _ Formative

Assessment
Which of this statement is TRUE for pulmonary respiration?
- Exchange of gases between alveoli of lungs and the blood
Systems are going to deliver oxygen at a rate higher than the patient's minute per ventilation.
Remember, this is not a hard AND fast 6liters per minute rule... it is Relative to the patient's own minute
ventilation, which will change based on heir physiologic status, activity and one person to person.
- HIGH-FLOW systems
Which of the following is NOT the function of the respiratory system?
- Protection against blood loss
Gas exchange takes place in the?
- Alveoli
It involves substances moving across concentration gradients from areas of higher concentration to
areas of lower concentration. This is the process involved with gas exchange. (answer: ALL small letters)
- diffusion
Deliver the oxygen at rate that is less than the amount of air that the patient can inhale or exhale in
oneminute (CALLED "MINUTE VENTILLATION.)
- LOW-FLOW systems
Nose, larynx, pharynx, lungs trachea, and bronchi are the parts of the respiratory system
- True
The process of exchanging oxygen and carbon dioxide, which is essentially breathing Oxygen comes
intothe body via the airway. Its offloaded onto the red cells while carbon dioxide diffuses across the
membrane into the alveoli and is then exhaled. You breath in oxygen and exhale CO2. (answer: ALL small
letters)
- ventilation
Types of Alveolar Epithelial Cells most abundant, thin & flat where gas exchange occurs
- Type I Pneumocytes
It is the body process of supplying oxygenated blood to the cells and is reliant on adequate cardiac
output to be optimal...
- Perfusion
A slightly obese female client with a history of allergy-induced asthma, hypertension and mitral valve
prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history
and performs a thorough physical examination, paying special attention to the cardiovascular and
respiratory system. When percussing the client's chest wall, the nurse expects to elicit:
- Resonant sounds
The nurse is teaching a male client with chronic bronchitis about breathing exercises Which of the
following should the nurse include in the teaching?
- Use diaphragmatic breathing
A female client is undergoing a complete physical examination as requirement for the college. When
checking the client's respiratory status. The nurse observes respiratory excursion to help assess:
- Chest movements
A male client abruptly sits up in bed, reports having difficulty of breathing and has arterial oxygen
saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations?
- Non-rebreather mask
Nurse Fatima is caring for a client after a bronchoscopy and biopsy. Which of the following signs, if
noticed in the client, should be reported immediately to the physician?
- Blood-streaked sputum
It is ordered for patients in acute care situation respiratory distress, and is often used in an intensive
care situation
- mechanical ventilation
It competitively blocks the effects of histamine at H1-receptor sites, has atropine-like, antipruritic and
sedative effects.
- Antihistamine
Xanthines are classified as:
- Bronchodilators
When prone positioning is used in the care of a patient with acute respiratory distress syndrome (ARDS),
which information obtained by the nurse indicates that the positioning is effective?
- The patient's PaO2 is 90 mm Hg, and the SaO2 is 92%
After receiving change-of-shift report, which patient will the nurse assess first?
- A patient with septicemia who has intercostal and suprasternal retractions
The area between the lungs is known as the?
- Mediastinum
Oxygen and hemoglobin bind in a reversible manner to form
- Oxyhemoglobin
What is the name of the gland which secrete melatonin?
- Pineal gland
Which of the following controls the normal breathing process?
- Dorsal respiratory group
It binds to intracellular corticosteroid receptors, thereby initiating many natural complex reactions that
are responsible for its anti-inflammatory and immunosuppressive effects.
- steroids
Module 5 - 6 (Oxy/ Respi) _Formative
Assessment
Which method of oxygenation least likely produces anxiety and apprehension?
- Nasal Cannula
You are about to set the suction pressure be used to Mr. Evangelista. Using portable suction equipment,
how much pressure of suction equipment is needed to prevent trauma to mucus membrane and air
ways in case of portable suction units?
- 10-15 mmHg
Which of the following is not true about OXYGEN?
- Excessive oxygen administration results in respiratory acidosis
Andrew, A new nurse in the hospital is about to administer oxygen on patient with Respiratory distress.
As his senior nurse, you should intervene if Andrew will:
- Put a non-rebreather mask in the patient before opening the oxygen source
Which of the following is the initial sign of hypoxemia in an adult client?
1. Tachypnea.
2. Tachycardia
3. Cyanosis
4. Pallor
5. Irritability
6. Flaring of Nares
- 2,5
Which of the following, if done by the nurse, indicates incompetence during suctioning an unconscious
client?
- Measure the length of the suction catheter to be inserted by measuring from the tip of
the nose, to the earlobe, to the xiphoid process
Which of the following will alert the nurse as an early sign of hypoxia?
- Client is frequently turning from side to side
Cedric Evangelista, a 60-year-old Filipino client was mobbed by teen gangsters near New York, Cubao.
He was rushed to Cardinal Medical Center and was unconscious. You are his nurse and you are to
suction his secretions. In which position should you place Mr. Evangelista?
- Side lying
There are four catheter sizes available for use, which one of these should you use for Mr. Evangelista?
- Fr. 18
Which of the following oxygen delivery method can deliver 100% oxygen at 15 LPM?
- Non re-breather mask
A male patient has a sucking stab wound to the chest. Which action should the nurse take first?
- Applying a dressing over the wound and taping it on three sides

Nurse Cathy instructs a female client to use the pursed-lip method of breathing, and the client asks the
nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary
purpose of pursed lip breathing is to:
- Using a high-flow venturi mask to deliver oxygen as prescribe
An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall.
Which of these signs would indicate the presence of a pneumothorax in this client?
- Diminished breath sound
While changing the tape and dressing on a tracheostomy tube, the male patient coughs and the tube is
dislodged. The initial nursing action is to:
- Go the retention sutures to spread the opening
For a patient with advance chronic obstructive pulmonary disease (COPD), which nursing action best
promotes adequate gas exchange?
- Using a high flow venturi mask to deliver oxygen as prescribe

1.It is the permanent distention of air spaces.
a.Pulmonary Emphysema
b.COPD
c.Pulmonary Edema
d.Acute Respiratory Syndrome
2.In acute respiratory distress syndrome, histamine and other inflammatory substances increase
capillary permeability, allowing fluid to shift into the interstitial space. As a result, the patient may
experience:
a.Tachypnea, dyspnea, tachycardia
b.Bradycardia, dyspnea, tachycardia
c.Apnea, dyspnea, bradycardia
d.Bradycardia and dyspnea
3.The following are signs and symptoms of pulmonary emphysema except:
a.Bradycardia
b.Hypercapnia
c.Hypoxemia
d.Barrel chest
4.In acute respiratory distress syndrome, as capillary permeability increases, proteins and more fluid
leak out, increasing interstitial osmotic pressure and causing pulmonary edema. At this stage, the
patient may experience;
a.Dyspnea, apnea, tachycardia
b.Bradypnea, apnea, cyanosis

c.Tachypnea, dyspnea, cyanosis
d.Apnea, dyspnea, cyanosis
5.It is a type of pulmonary emphysema which affects the lower lung and forms a bleb.
a.Panlobular emphysema
b.Centrilobular emphysema
c.Paraseptal emphysema
d.Pulmonary emphysema
6.It is termed as the high blood pressure in the pulmonary arteries.
a.Hypertension
b.Pulmonary emphysema
c.Pulmonary hypertension
d.Pulmonary artery hypertension
7.It is a severe decrease concentration of oxygen in the blood.
a.Hypoxemia
b.Hypocapnia
c.Hypoxia
d.Hypercapnia
8.The type of pulmonary emphysema that is most common and affects the upper lung region
a.Centrilobular emphysema
b.Paraseptal emphysema
c.Centriseptal emphysema
d.Panlobular emphysema
9.All of the following are predisposing factors of pulmonary edema, except:

a.Aging process
b.Smoking
c.Heredity
d.Environment
10.Mean airway pressure is a parameter in ARDS, in which it:
a.Maintain maximal recruitment of alveolar units
b.Promote recruitment and predictor of hemodynamic effects
c.Promote vasoconstriction
d.Predict the presence of alveolar overdistention
11. It is considered as the major cause of emphysema.
a.Cigarette smoking
b.Drug addiction
c.Occupational aspect
d.Alcohol beverages drinking
12.A patient has a nursing diagnosis of ineffective airway clearance related to thick, secretions.
Which action will be best for the nurse to include in the plan of care?
a.Teach the patient the importance of coughing
b.Offer the patient fluids at frequent intervals
c.Increase oxygen level to keep O2 saturation > 95%
d.Encourage use of the incentive spirometer
13.Which is a proper nursing action for a patient in acute respiratory failure?
a.Provide chest physical therapy for patients who produce more than 30 mL of sputum per day
b.Use continuous positive airway pressure (CPAP) if the patient has weak or absent respirations
c.Administer packed red blood cells to maintain the hemoglobin level at 7 g/dL or higher
d.Administer 100% oxygen to an intubated patient until the pathology has resolved.
14.When admitting a patient in possible respiratory failure with a high PaCO2, which assessment
information will be of most concern to the nurse?
a.The patient complains of weakness.
b.The patient’s blood pressure is 162/94
c.The patient’s SpO2 is 90%
d.The patient is somnolent
15.What distinguishes hypercapnic respiratory failure from hypoxemic respiratory failure?
a.Low oxygen saturation despite administration of supplemental oxygen
b.Heart rate increases above 100 beats/minute
c.Acidemia for which the body cannot compensate
d.Respiration rate greater than 30 breaths/minute

A 7-year-old client is brought to the E.. He's tachypneic and afebrile and has a respiratory rate of 36
breaths / minute and a non-productive cough. He recently had a cold. From his history, the client may
have which of the following?
a. Chronic obstructive pulmonary disease
b. Emphysema
c. Bronchial pneumonia
d. Acute asthma
An 18-year-old comes into the emergency department with acute asthma. His respiratory rate is 44
breaths / minute, and he appears to be in acute respiratory distress. Which of the following actions
should be taken first?
a. Apply a cardiac monitor to the client
b. Provide emotional support to the client.
c. Take a full medication history
d. Give a bronchodilator by nebulizer
Which of the following assessment findings would help confirm a diagnosis of asthma in a client
suspected of having the disorder?
a. Inspiratory and expiratory wheezing
b. Normal breath sounds
c. Circumoral cyanosis
d. Increased forced expiratory volume
Where will the CTT be inserted if we are to drain fluids accumulated in Mang Nestor's pleura?
a. 4th ICS
b. 8th ICS (source)
c. 5th ICS
d. 2nd ICS
Acute tracheobronchitis is an acute inflammation of the mucous membranes of the trachea and the
bronchial tree. It occurs after an infection in the upper respiratory tract. Patients with viral infections
have decreased resistance and can readily develop a secondary bacterial infection. All of the following
are included in the correct management of acute tracheobronchitis, EXCEPT:
a. Encourage and assist the patient to sit up and cough effectively
b. Encourage client to engage in strenuous activities
c. Increased fluid intake
d. Advise patient to rest
The physician prescribes an order for the nurse to discontinue a patient's nasogastric tube. Before
removing the tube, the nurse should
a. Assess for client's bowel sounds
b. Determine the integrity of the taste buds
c. Aspirate gastric content to make sure that the residual volume is less than 50 ml
d. Make sure that the client is able to swallow and chew food
Which of the following types of asthma involves an acute asthma attack brought on by an upper
respiratory infection?
a. Emotional
b. Intrinsic
c. Extrinsic
d. Mediated
A client with acute respiratory infection is admitted to the hospital with a diagnosis of sinus tachycardia.
The nurse develops a plan of care for the client and includes which intervention.
a. Eliminate sources of caffeine
b. Measuring the client’s pulse once each shift
c. Provide client with short, frequent walks

d. Limit oral and intravenous fluids
Inhibit protein synthesis in susceptible bacteria leading to the inability of the bacteria to multiply.
a. Aminoglycosides
b. Adrenergic drugs
c. Tetracyclines
d. Macrolides
The nurse is aware that the organs most important in maintaining the fluid and electrolyte balance are
the:
a. Lungs and kidneys
b. Brain stem and heart
c. Pituitary gland and liver
d. Liver and kidneys
A client with COPD is in constant need of oxygen. The nurse uses which of the following to administer
oxygen to the patient.
a. Simple oxygen mask
b. Nonrebreather
nasal cannulas
A client with acute asthma showing inspiratory and expiratory wheezes and a decreased expiratory
volume should be treated with which of the following classes of medication right away?
O Inhaled steroids
O Oral steroids
O Bronchodilators
O Beta-adrenergic blockers
The term "pink puffer" refers to the client with which of the following conditions?
- Emphysema
The best method of oxygen administration for client with COPD uses:
O Cannula
O Simple Face maski
O Venturi mask
O Non-rebreather maski
Which of the following pathophysiological mechanisms that occurs in the lung parenchyma allows
pneumonia to develop?
A. Atelectasis
B. Bronchiectasis
C. Effusion
D. Inflammation
There is a continuous bubbling in the water sealed drainage system with suction. And oscillation is
observed. As a nurse, what should you do?
O Prepare a petrolatum gauze dressing
O Notify the physician
O Check for tube leak
O Consider this as normal findings.
An elderly client with pneumonia may appear with which of the following symptoms first?
1. Altered mental status and dehydration
2. Fever and chillds
3. Hemoptysis and dyspnea
4. Pleuritic CP and cough
A 66-year-old client has marked dyspnea at rest, is thin, and uses accessory muscles to breathe. He's
tachypneic, with a prolonged expiratory phase. He has no cough. He leans forward with his arms braced
on his knees to support his chest and shoulders for breathing. This client has symptoms of which of the
following respiratory disorders?
O Chronic obstructive bronchitis
OARDS
O Asthma
O Emphysema
Preoperative teaching for the client who is to have a pneumonectomy should include all of the
following. Which is of highest priority?
O Leg exercises.
O Management of postoperative pain.
O Turning, coughing and deep breathing exercises.
O How to move with the least pain..
An adult is admitted to the hospital with progressive dyspnea on exertion, which has become
increasingly severe during the last six months. Physical examination reveals crackles at the base of the
lung and clubbing of fingers. The client has asbestosis that has caused fibrosis in the alveoli. Soon after
admission, the nurse helps the client to the bathroom. Before he returns to bed, he is very short of
breath. Considering the severity of his symptoms, it is essential for the nurse to include which of the
following in the plan of care.
- Allow the client to move at his own pace.
MCN 2 Answers
1. Materna is an island group in the South Pacific, with a population of some 700,000 as of
July 2020. It is a matriarchal society, offering equal opportunities to both men and women
in all aspects of life, particularly in education, employment, police and the right to have
more than one legal spouse. The isles are made up of two big islands and three small ones.
Island Pediatrica has a population of 250,000 and maternal mortality rate of 2.4 per 1,000.
Crude birth rate is 30 per 1,0000. Live birth in the province accounts for 7,500. What is the
number of maternal deaths of Island Pediatrica?
Answer: 1.8
2. A high-risk pregnancy is one in which the mother or fetus has a significant increase chance
of harm, damage, injury or disability. Mrs. Hilario, a 45-year-old mother is to undergo
amniocentesis. Which of the following about the procedure indicates a need for further
teaching?
Answer: Amniotic fluid is obtained by inserting a small catheter intravaginally
3. The reasons for high maternal and newborn mortality rate in the Philippines are:
Answer: Delay in deciding to seek medical care, delay in identifying and reaching
appropriate facility, and delay in receiving adequate care
4. A client just had an amniocentesis to determine whether or not her baby has an inheritable
disease. What priority intervention would the nurse do?
Answer: Assess fetal heart rate
5. The under 5 mortality rate which is the death of children between birth and exactly 5 years
of age is an important indicator for child health. The denominator for such rate is which of
the following?
Answer: Number of live births in the same year
6. While discussing antenatal care to a group of pregnant women, one of the women asks the
nurse about diagnostic tests in high-risk pregnancy. Which of the following is true about
the advantages of Chorionic villi sampling (CVS) over amniocentesis?
Answer: It can be done earlier or before the end of first trimester
7. Amy Perez is pregnant with her first child. Her genotype refers to:
Answer: Her actual genetic composition

8. The nurse is creating the symbolic representation of family relationships and transmission
of inherited traits from a client’s family history. Which of the following symbols should
the nurse use to represent a still born?
Answer: Triangle
9. A woman asks a nurse about presymptomatic genetic testing for Huntington’s disease. The
nurse should base her response on which of the following?
Answer: If the woman is positive for the gene Huntington’s, she will develop the disease
later in life
10. The following are true about Down Syndrome, EXCEPT

Answer: It is due to deletion of the chromosomes during cell division
11. The nurse is assigned to do a home visit for a mother with a baby diagnosed of 47XX18+.
Which of the following conclusions can the nurse make about the female baby.
Answer: She has Edward's Syndrome.
12. The nurse evaluates understanding of fetal development in a prenatal class. Which of the
following would be the result of nondisjunction of the sex chromosomes?
Answer: Turner syndrome XO
13. Two nursing students are arguing about the possibilities of chromosomal abnormalities in
an online class. If an egg with 22 autosomes is fertilized by a sperm with 22 autosomes and
an X chromosome, the offspring will be _____.
Answer: Female, XO
14. Which of the statement by a gravid client who is a carrier of muscular dystrophy, an X-
linked recessive disease, indicates that she understands the implications of her status?
Answer: “If I have a girl, she will be healthy.”
15. A woman is seeking genetic counseling during her pregnancy. She has a strong family
history of diabetes mellitus. She wishes to have amniocentesis to determine whether or not
she is carrying a baby who will “develop diabetes.” Which of the following replies the
nurse will make based on the Multifactorial (Polygenic) Inheritance?
Answer: “Although diabetes does have a genetic component, diet and exercise also
determine whether or not someone is diabetic.”
16. Parent A has curly hairs, Parent B has straight hairs. What is the probability that the child
will have straight hairs if the Genotype: Curly – Cc and Straight – cc?
Answer: 50%
17. A client who is at 40 weeks’ gestation, seems upset and tells the nurse that the physician
told her about a possibility of Down syndrome of her baby. Which statement is NOT true
about Down syndrome?
Answer: Greatly increased incidence occurs with fathers over age 35.
18. A client who is at 40 weeks’ gestation, seems upset and tells the nurse that the physician
told her about a possibility of Down syndrome of her baby. Which statement is NOT true
about Down syndrome?
Answer: Trisomy 13
19. If you crossed an individual homozygous for freckles with a person heterozygous for
freckles, what would the genotypic ratios be? N – Freckles n – no freckles
Answer: None of the Above
20. A nurse is caring for four prenatal clients in the clinic. Which of the clients is at high risk
for placenta previa?
Answer: Infertility client who is carrying in-vitro triplets.
21. A hospitalized gravida’s blood work is: hematocrit 30% and hemoglobin 10 gm/dL. In light
of the laboratory data, which of the following meal choices should the nurse recommend
to this patient?
Answer: Chicken livers, sliced tomatoes, and dried apricots.
22. A 34 year old client comes to the emergency room with abdominal cramping and vaginal
bleeding. History revealed two missed menstrual periods. Incomplete abortion is
considered by the nurse. Which of the following statements by the nurse is most
appropriate? (SELECT ALL THAT APPLY)
Answer: - “Would you like to speak with a hospital counselor?” - “This must be difficult
for you. I’m so sorry.”
23. Martin at 33 weeks gestation complains of vaginal bleeding. The nurse assessing the client
is aware that an abruptio placenta is not accompanied by which of the following assessment
findings, EXCEPT:
Answer: Uterine tenderness upon palpation
24. In the 12 week of gestation, a client completely expels the products of conception. Because
the client is Rh negative, the nurse must:
(Soft abdomen upon palpation, No complaint of abdominal pain, Lack of uterine
irritability)
Answer: Administer Rhogam within 72 hours
25. The pregnant client with molar pregnancy was treated with suction curettage. The nurse
recognizes that additional discharge teaching is required when the client states which of
the following discharge health instructions?
Answer: “I will need to see the doctor yearly for follow-up.”
26. Which of the following condition increases the risks of the mother to another abortion?
Answer: A mother whose child diagnosed with german measles
27. Nurse Ana admitted a 21 year old woman in the ER. She missed 2 menstrual period and a
tentative diagnosis of ruptured ectopic pregnancy was made. Upon examination, nurse Ana
noticed scanty vaginal bleeding. This means:
Answer: Bleeding inside the peritoneal cavity is present
28. The client has history of 3 spontaneous abortion, a diagnosis of incompetent cervix is made.
It is defined as:
Answer: Premature dilatation of the cervix before 20 weeks
29. When assessing a 34-year-old multigravid at 34 weeks’ gestation experiencing moderate

vaginal bleeding, which of the following would most likely alert the nurse the nurse that
placenta previa is present?
Answer: Painless vaginal bleeding
30. The nurse is caring for a 34-year-old multipara during the immediate post operative period
after evacuation of a molar pregnancy. The nurse should instruct the patient to avoid
pregnancy for at least 12 to 18 months to confirm the absence of:
Answer: Choriocarcinoma
31. A threatened abortion is suspected at the 10 weeks pregnant client, Becky. Nurse Sarah
instructs the client regarding management of care. Which statement made by the Becky
indicates a need for further instructions?
Answer: “I will maintain strict bedrest throughout the remainder of the pregnancy.”
32. The usual management for incompetent cervix are the following except:
(Cerclage, Deliver the baby after the removal of the sutures, Bedrest)
Answer: Deliver the baby CS after the removal of the sutures
33. Mendoza, amenorrheic for two months is diagnosed to have ectopic pregnancy based on
the sign and symptoms of sudden, severe low quadrant pain radiating to the shoulder,
Cullen sign and minimal external vaginal bleeding. Which of the following actions would
be implemented?
Answer: Monitoring of vital signs
34. A client being seen in the ED has an admitting medical diagnosis of: third trimester
bleeding/rule out placenta previa. Each time a nurse passes by the client’s room, the woman
asks, “Please tell me, do you think the baby will be all right?” Which of the following is
an appropriate nursing diagnosis for this client?
Answer: Anxiety related to inconclusive diagnosis.
35. Nurse A admitted another patient with the diagnosis of hydatidiform mole. All but one is
a characteristic of woman with molar pregnancy:
Answer: Brown vaginal discharge
36. Which of the following nursing actions would take priority when caring for the woman
with a suspected ectopic pregnancy?
Answer: Monitoring vital signs
37. A gravid woman has just been admitted to the emergency department subsequent to a head-
on automobile accident. Her body appears to be uninjured. The nurse carefully monitors
the woman for which of the following complications of pregnancy?
Answer: Placental abruption and Preterm labor
38. A G1P0 confirmed to be pregnant at 14 weeks gestation has sudden bright red vaginal
bleeding and uterine cramps. Internal examination revealed 3 – 4 centimeters cervical
dilatation. The nurse would suspect the client to be experiencing which of the following
bleeding conditions?
Answer: Inevitable abortion

39. The doctor ordered a transvaginal ultrasound to confirm diagnosis of molar pregnancy. The
findings will reveal which of the following:
Answer: Snowstorm pattern
40. Marie a 16-year-old primigravid comes to the prenatal clinic for her monthly check-up.
She has gained 20 lb from her 30-36 weeks, with edema of the face and hands. Urinalysis
revealed proteinuria +4. She is diagnosed as having severe preeclampsia and was referred
to the high-risk Obstetrical Unit. The client’s weight increase is most likely due to:
Answer: Fluid retention
41. A 32-year-old G1P0 diabetic patient unsure of the date of her last menstrual period (LMP)
sought here first prenatal checkup. She says that she missed three menses, but her fundus
is palpated slightly below the level of umbilicus. The physician requested for
ultrasonography to estimate the gestational age. Family history is positive for DM (father).
When should the nurse advise the client to have her GCT checked?
Answer: 24 - 28 weeks
42. A nurse is monitoring a 28 year old client G1P0, 26 weeks AOG who is receiving
magnesium sulfate for preeclampsia and is assessing the client every 30 minutes. Which of
the following findings would indicate a need to immediately report the findings?
Answer: Respirations of 10 breaths/minute
43. A 28-year old primigravida comes to your clinic on her 30th week of gestation complaining
of chest pain. On examination she was seen to have cardiomegaly which strengthened the
diagnosis of heart disease in pregnancy. The nurse would advise the client that if the patient
is without any obstetrical indication, she will best deliver by:
Answer: Outlet forceps extraction under epidural anesthesia
44. The nurse is providing instructions to a pregnant client with human immunodeficiency
virus (HIV) infection regarding care to the newborn after delivery. The client asks the nurse
about the feeding options that are available. Which response should the nurse make to the
client?
Answer: “You will need to bottle-feed your newborn.”

45. Mrs. Martinez, 32 years old primigravida at 34 weeks AOG is admitted in the Obstetrical
Unit because of preterm labor. The physician ordered magnesium sulfate deep IM. While
the client is receiving magnesium sulfate, the nurse routinely assesses the client’s vital
signs and notes the following: BP 160/90, and blurring of vision. In caring for the client
the nurse should:
Answer: Protect her against strenuous stimuli
46. A 22 year old primigravid client is in her 22nd week of pregnancy. The physician informed
the client that she has pregnancy induced hypertension. She is admitted to the hospital. The
nurse concludes that the client was diagnosed with pregnancy induced hypertension when
the vital signs taken today show that the blood pressure has increased during pregnancy
from 100/60 to 130/80. When assessing the client, the nurse should thoroughly explore
which finding at each visit?
Answer: Any sudden weight gain
47. The nurse is providing instructions to a pregnant client with a history of cardiac disease
regarding appropriate dietary measures. Which statement, if made by the client, indicates
an understanding of the information provided by the nurse?
Answer: “I should drink adequate fluids and increase my intake of high fiber foods.”
48. A pregnant client is receiving magnesium sulfate for the management of preeclampsia. The
nurse determines that the client is experiencing toxicity from the medication if which
findings are noted on assessment? Select all that apply.
Answer: Urine output of 20 mL in an hour, Respirations of 10 breaths per minute
49. A 29 years old female, married, G1P0 AOG 16 weeks, complained of vague abdominal
wall pain for 3 days, with slight fever and urgency. She took Paracetamol 500 mg and there
was temporary relieved of symptoms. A few minutes prior to consultation, she noticed
blood tinged urine. Husband is an overseas worker (Seaman). What is the probable clinical
impression on consultation?
Answer: Acute cystitis, hemorrhagic
50. Nurse Anne is providing instructions to a G1P0, 25 years old on her 30 weeks AOG
pregnant client in the maternity center with a history of cardiac disease regarding
appropriate dietary measures. Which statement, if made by the client, indicates an
understanding of the information provided by the nurse?
Answer: “I should drink adequate fluids and increase my intake of high-fiber foods.”
51. The nurse implements a teaching plan for a pregnant client who is newly diagnosed with
gestational diabetes mellitus. Which statement made by the client indicates a need for
further teaching?
Answer: “I should avoid exercise because of the negative effects on insulin production.
52. A 26-year-old female is 28 weeks pregnant with her second child. The woman is blood
type A negative. Which of the following statements does not need further instructions if
this is mentioned by a student nurse during health promotion?
Answer: Since the mother is A- the baby can be Rh positive, which could lead to an immune
attack on the mother's body.
53. The client is in her last trimester of pregnancy and her diabetes has been well controlled.
She tells the nurse that she is excited but also scared that something could be wrong with
her baby because of her diabetes. Which response of the nurse is most appropriate?
Answer: “Your baby may be large and initially will need blood glucose monitoring.”
54. A 23-year-old G1 at 35 weeks age of gestation comes in for severe headache and visual
blurring. On prenatal check-up 1 week prior, her BP was noted to be 130/85 mmHg from
her usual 110/70. On examination, BP was now at 160/110 mmHg, FHT 140/min, no
contractions after ten minutes of observation. Cervix was 1cm, 30% effaced, intact
membranes, station-2. Most likely hypertensive disorder in pregnancy diagnosis is:
Answer: Severe preeclampsia
55. A Pregnant client with hyperemesis gravidarum may start a small amount of clear fluid if
no vomiting occurs after restricting oral intake within:
Answer: 24 hours
56. A woman diagnosed with hyperemesis gravidarum may show an elevated hematocrit
concentration at her monthly prenatal visit. This condition may occur because:
Answer: The inability to retain fluid has resulted in hemoconcentration
57. Asymptomatic urinary tract infections are potentially dangerous in pregnant woman
because they can progress to pyelonephritis which are associated with preterm labor and
premature rupture of membranes. You know that pyelonephritis is an infection of:
Answer: Renal pelvis
58. The Rh negative mother and Rh positive baby may have blood mix leading to Rh
incompatibility could be possibly contributed by the following, EXCEPT:
(Previous pregnancy, Miscarriage, Bleeding during pregnancy)
Answer: Exposure to chemicals
59. Magnesium sulfate was ordered to a client. The nurse should ensure to have on hand as an
antidote for magnesium toxicity?
Answer: Calcium gluconate
60. A 25 y/o G3P2 was admitted at 7 cm cervical dilatation, cephalic with frequency of uterine
contractions at 2 – 3 minutes, 45 seconds duration, moderate intensity, Station 0. The nurse
would expect the cleint to deliver in how many hours?
Answer: 2
61. A 35 year old G1P0 had an infertility work-up from which she was prescribed clomiphene
citrate. She got pregnant and was diagnosed to have twin pregnancy. What is the most
probable type of twinning?
Answer: Dizygotic
62. The 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. What is the priority nursing
action?
Answer: Provide pain relief measures
63. A G3P2 patient had a cesarean delivery because of a previous myomectomy. In the ER she
was 3-4 cms, breech presentation, with contractions every 4-7 minutes. The nurse would
instruct that the best management for this patient is which of the following?
Answer: Have her prepared for an emergency cesarean delivery
64. The nurse is monitoring a client who is in the active stage of labor. The client has been
experiencing contractions that are short, irregular, and weak. The nurse documents that the
client is experiencing which type of labor dystocia?
Answer: Hypotonic
65. A pregnant client was admitted to the labor room. An assessment is performed, and the
nurse notes that the fetus is at -1 station. Monitoring of the client was done by the nurse.
The nurse informed a pregnant client in labor that the smallest head diameter of the fetus
must be presented to the birth canal in order to best traverse/travel to the birth canal. Which
of the following is the smallest anterioposterior cranial diameter of a fetus?
Answer: Suboccipito bregmatic
66. Immediately after an apparently normal labor and delivery, the mother suddenly
manifested with dyspnea and went into convulsions. Blood pressure likewise dropped
sharply from 120/80 mm Hg. Cardiopulmonary arrest rapidly ensued. The nurse would
identify which of the following is the probable cause?
Answer: Amniotic fluid embolism
67. A 25 year old G1P0 PU 38 weeks AOG is in labor. An obstetrician was assigned to deliver
the baby. The nurse was assisting the obstetrician. Forceps was applied on the fetal head
with the following findings: head was at station +2 with the sagittal suture at left occiput
anterior position. The nurse would classify this forceps extraction as which of the
following?
Answer: Low forceps delivery
68. A nullipara was admitted on active labor at 5 cms., ruptured bag of waters, station -2. After
3 hours of good contractions, 2 – 3 minutes frequency, 60 seconds duration, strong
intensity, cervix was 5 cms dilated, station -2. The nurse would identify that the patient is
in which of the following condition?
Answer: Arrest of cervical dilatation
69. Maria, 19 years of age, 38 weeks age of gestation is admitted at the Obstetrical Unit for
labor monitoring. The latent phase of labor of the 19 y.o. primigravid already exceeded 20
hours. The preferred treatment for this case is which of the following?
Answer: Therapeutic rest
70. A client in her 30-week gestation complains of hardening of her uterus every 10 minutes.
She is admitted with a diagnosis of preterm labor. IV fluid was started and was advised
complete bed rest without bathroom privileges. The physician orders Terbutaline infusion
as treatment for the client. The nurse is caring for a patient receiving Terbutaline. The nurse
observes that the medication is having a therapeutic effect when the patient:
Answer: Has contractions that decrease in frequency and duration
71. A 22 year old G1P0 at 38 weeks AOG has a chief complaint of regular uterine contractions
for 12 hours. She has stable vital signs. Labor monitoring was instituted. Fetal distress is
occurring with the laboring client. As the nurse prepares the client for a cesarean birth,
what is the most important nursing action?
Answer: Administer oxygen, 8 to 10 L/minute, via face mask
72. A patient at 38 weeks AOG came in labor. I.E. cervix is 5 cm dilated, 50% effaced, intact
BOW, cephalic, station -3. Clinical pelvimetry shows the ischial spine is bilaterally
prominent, pelvic sidewalls are convergent and concavity of the sacrum is shallow. With
these findings, the nurse would suspect the presence of:
Answer: Midpelvic contraction
73. A 33 y.o. primigravid on her 38th week of gestation was brought to the Emergency Room
by her husband for a sudden gush of fluid from the vagina. On pelvic examination, the
umbilical cord was noted to be coming out of the vagina. Important management of the
nurse at this point is which of the following?
Answer: Place the patient in trendelenburg position
74. A 32 year old G6P5 patient in labor comes in 7 cm. dilated, 80% effaced at 10 am. Labor
monitoring was instituted. Uterus was contracted at 2-3 minutes frequency, 60 seconds
duration and strong intensity. Fetal heart tones ranges from 130 – 140 bpm. Amniotomy
revealed clear amniotic fluid. What time would the nurse expect the patient to be fully
dilated if labor progress is normal?
Answer: 11 am
75. A patient at 37 weeks, complaining of hypogastric pain of 2 hours, came in the emergency
room. Her vital signs were normal. Fundic height was 35 cms. Fundus is occupied by a
hard, round, ballotable mass, fetal back palpated at the left, as well on the right, another
hard, round mass on the hypogastric area, fetal heart tones of 143/min heard at the left
periumbilical area and 152/min heard at the right lower quadrant. On internal examination,
the cervix was 5 cms. dilated, 1 cm long, ruptured bag of waters, cephalic, station -2. All
her previous pregnancies were delivered at home. What is the recommended mode of
delivery?
Answer: An outright cesarean section
76. Maria pregnant G1P0 was admitted in labor. Labor monitoring was done. The physician
asks the nurse the frequency of a laboring client’s contractions. The nurse assesses the
client’s contractions by timing from the beginning of one contraction to the beginning of
the next contraction. During the active phase of labor, the membranes ruptured.
Immediately after the membranes ruptured. Internal examination by the nurse was done.
Inlet contraction is likely if the nurse’s assessment is which of the following?
Answer: Diagonal conjugate is less than 11.5 cm
77. A 22 year old G2P1 (1001) at 35 weeks AOG has a chief complaint of regular uterine
contractions for 12 hours. She has stable vital signs. Fundic height is 27 cm, estimated fetal
weight is 2,400 grams. Fetal heart tones are 148 bpm and presentation is cephalic. On
internal examination, the cervix is 7 cm dilated, fetal head at station 0, intact bag of waters.
What would be your management?
Answer: Admit her and allow labor to progress
78. A 20 y.o. primigravida came in labor with age of gestation 38 weeks. Internal exam showed
the cervix to be 7 cm dilated, BOW ruptured, station -1. After an hour, the cervix became
fully dilated with the fetal head still at station -1. At this point, the nurse impression is
Answer: Dysfunctional labor, failure of descent
79. After a successful cesarean section delivery for breech, the G1P1 mother asked the nurse
if she has a chance to have vaginal delivery next time she gets pregnant. The nurse would
instruct the client which of the following conditions may make vaginal delivery possible?
Answer: Previous scar is a low segment cesarean
80. A nurse is performing an assessment on a 2-day postpartum mother. The mother complains
of severe pain and an intense feeling of swelling and pressure in the vulvar area. After
hearing these complaints, the nurse specifically checks the clients.
Answer: Vulva for a hematoma
81. Postpartum hemorrhage can cause hypovolemic shock. If a postpartum patient is

experiencing hypovolemic shock resulting from uterine atony, important nursing diagnosis
is fluid volume deficit related to excessive blood loss. Which of the following
complications is most likely responsible for a delayed postpartum hemorrhage?
Answer: Uterine subinvolution
82. At delivery, a perineal laceration tore through the skin of the fourchette, vaginal mucous
membrane, and the fascia and perineal muscles of the perineal body but not the anal
sphincter or mucosa. This should be recorded by the nurse in the medical record as what
type of laceration?
Answer: Second-degree
83. A postpartum client complains of stress incontinence. What information should the nurse
suggest to the client to overcome stress incontinence?
Answer: Perform Kegel's exercises
84. The nurse is assessing a client who is 6 hours postpartum after delivering a full-term
healthy infant. The client complains to the nurse of feelings of faintness and dizziness.
Which of the following nursing actions would be most appropriate?
Answer: Instruct the mother to request help when getting out of bed
85. Linda, 18 year old, delivered an 8 lbs baby. There was note of laceration on the lateral wall
off the vaginal vault with profuse vaginal bleeding. There was a sudden drop of BP. Post
partum there was note of amenorrhea. Lab examination shows destruction of the pituitary
gland. Linda has what syndrome?
Answer: Sheehan’s syndrome
86. A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse
notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects
a pulmonary embolism. Which should be the initial nursing action?
Answer: Administer oxygen, 8 to 10 L/minute, by face mask.
87. Kim Chi is a 30-year-old woman who had a “textbook perfect” pregnancy. You enter her
room 4 hours after she gave birth to an 8-lb girl, but, because she is sleeping and appears
comfortable, you hesitate to awaken her. When you observe her more closely, however,
you realize she appears abnormally pale. You obtain her vital signs and document her pulse
as 90 beats per minute and her blood pressure as 96/50 mm Hg. When you fold back her
bedclothes, you discover her bed is soaked with blood. You suspect she is experiencing
one of the most serious complications of pregnancy: postpartum hemorrhage. Yet because
she was sleeping, she was totally unaware of it. Which of the following complications may
be indicated by continuous seepage of blood from the vagina of a postpartum client when
palpation of the uterus reveals a firm uterus 1 cm below the umbilicus?
Answer: Cervical laceration
88. Brenda Mage is a 32 year old primigravida who vaginally delivered a full term infant
without complications. She states that she would like to take a nap but allows the nurse to
take vital signs and perform an assessment. The nurse is aware that a higher incidence of
postpartum blues can result from which of the following?
Answer: Fatigue
89. Carole Holmes, a 28 year old multipara delivered vaginally a term infant. The postpartum
patient was in labor for 30 hours and had ruptured membranes for 24 hours. Which of the
following would the nurse be alert?
Answer: Endometritis
90. Marjorie, a 28 year old primigravida who vaginally delivered a full term infant with a
forceps assisted delivery and midline episiotomy. Four hours after a difficult labor and
birth, the primiparous woman refuses to feed her baby, stating that she is too tired and just
wants to sleep. The nurse should:
Answer: Take the baby back to the nursery, reassuring the woman that her rest is a
priority at this time
91. On the client’s third postpartum day, the nurse enters the room and finds the client crying.
The client states that she doesn’t know why she is crying and she can’t stop. Which of the
following is the most appropriate statement of the nurse to make?
Answer: “Many new mothers have shared with us their same confusion of feelings,
would you like to talk about them.”
92. A 34 year old G4P4 delivered vaginally an 8 lb baby at home assisted by a hilot. The
placenta was delivered without difficulty. However, a few minutes later, there was profuse
vaginal bleeding and the patient was rushed to the hospital. In the ER, the patient was
hypotensive, tachycardic and pale. On abdominal examination, the uterine fundus was soft
and above the umbilicus. There were no vaginal or cervical lacerations. What is the most
probable diagnosis?
Answer: uterine atony
93. Barbara is a 22 year old Gravida 1 who delivered vaginally her first infant. Th vaginal
delivery was uncomplicated. The nurse is providing instructions about measures to prevent
postpartum hemorrhage. Lacerations that include the skin and mucous membrane, the
fascia and the muscles of the perineal body are classified as:
Answer: Second-degree laceration
94. A gravida 1 para 1001 has vaginally delivered a full term infant without complications.
After the first postpartum day, she tells the postpartum nurse that she’s afraid that
something is wrong because she’s perspiring and urinating more than normal. Her
temperature is 37.8 C. The nurse should appropriately reply:
Answer: “It’s common to perspire and urinate a lot after childbirth; your body is getting
rid of the excess fluid that was used in pregnancy.”
95. C., 28 y/o, G2P2, delivered spontaneously to a live fetus 8 days ago at home assisted by a
nurse. She developed high-grade fever on the 5th post-partum day associated with body
malaise, lower abdominal pain & moderate vaginal bleeding. On admission, the patient
was febrile and on IE, the cervix was open, the uterus was enlarged to 18 week-size & both
adnexae were tender and foul-smelling lochia was noted. Your impression is .
Answer: Puerperal infection
96. The nurse is developing a plan of care for a postpartum client with a small vulvar
hematoma. The nurse should include which specific action during the first 12 hours after
delivery?
Answer: Prepare an ice pack for application to the area.
97. Darleen is a gravida 2 para 1001 who experienced a prolonged second stage of labor but
finally delivered a girl weighing 4,139 grams. She was then transferred to the postpartum
unit. In the immediate puerperium, in a setting of excessive of vaginal bleeding, the guide
to instituting blood transfusion therapy is:
Answer: the amount of blood lost
98. Six hours after being on the postpartum unit, Mrs. Rivera complains of excruciating
perineal and rectal pain and a feeling of fullness in the vaginal area. The nurse may suspect
the cause of the pain to be related to which of the following?
Answer: Vaginal hematoma
99. Collete is 25 year old primipara who delivered a full term infant via cesarean section
because of breech presentation. The nurse is providing instructions about measures to
prevent postpartum mastitis to a client who is breast-feeding her newborn. Which client
statement would indicate a need for further instruction?
Answer: “I should wash my nipples daily with soap and water.”
100. A couple has been unable to conceive. The client and her husband are in today for
an appointment at the infertility clinic where the nurse works. The client has had pelvic
inflammatory disease caused by Chlamydia trachomatis. She is at risk for which of the
following?
Answer: Ectopic pregnancy
an appointment at the infertility clinic where the nurse works. The client tells the nurse that
she plans to use the basal body temperature method for sexual intercourse timing. Which
of the following statements indicates that she has understood this type of method?
Answer: “My temperature will rise and then fall at ovulation”
an appointment at the infertility clinic where the nurse works. Which of the following
statements by the client about Clomiphene Citrate does not need further instructions?
Answer: “It results in an increase in the release of follicle stimulating hormone from the
pitutitary.”
an appointment at the infertility clinic where the nurse works. Which of the following is
NOT a method for optimizing the chances of conception?
Answer: Checking blood samples for testosterone levels
an appointment at the infertility clinic where the nurse works. The male client was
subjected for sperm analysis. After the semen specimen is collected, semen analysis should
be performed within:
Answer: 2 hours
an appointment at the infertility clinic where the nurse works. The client reports that her
menstrual cycle usually lasts for 44 days and she starts ovulating on the 22nd day. The
nurse should tell her that:
Answer: “The day of your ovulation is on the 30th day.”
an appointment at the infertility clinic where the nurse works. Which of the following does
not result in decreased sperm production resulting from thermal shock?
Answer: Living in climate where the temperature exceeds 90 F for long periods
an appointment at the infertility clinic where the nurse works. Sperm analysis revealed
abnormal sperm morphology. Which of the following is not associated with abnormal
sperm morphology?
Answer: Immunologic factors, including anti sperm antibodies
the most appropriate initial test for infertility in case the client is 32 year old G2P2 (2002)
and the husband is 35 year old man with no children?
Answer: Semen analysis
who has had amenorrhea since an elective abortion that was followed by infection?
Answer: Hysterosalpingogram
who wishes to increase her chance of pregnancy by the timing of intercourse?
Answer: Basal body temperature record

the most appropriate initial test for infertility in case the client is 32 year old G0 with a
history of chronic pelvic pain and dysmenorrhea whose partner has a normal sperm count?
Answer: Hysterosalpingogram
the most appropriate initial test for infertility in case the client is 26 year old G0 with a
history of irregular periods, who works several jobs, and has unpredictable sleeping
patterns?
Answer: Luteal phase progesterone
the most appropriate initial test for infertility in case the client undergoing infertility
evaluation who demonstrate clumping of sperm on Huhner Sims test?
Answer: Anti sperm antibodies
PEDIA ANSWER
1. The nurse in a neonatal intensive care nursery (NICU) receives a telephone call to prepare
for the admission of a 43-week gestation newborn with Apgar scores of 1 and 4. In planning
for admission of this newborn, what is the nurse’s highest priority?
Answer: Connect the resuscitation bag to the oxygen outlet.
2. The postpartum nurse is providing instructions to the mother of a newborn with

hyperbilirubinemia who is being breast-fed. The nurse should provide which most
appropriate instruction to the mother?
Answer: Continue to breast-feed every 2 to 4 hours.
3. The nurse is preparing to care for a newborn receiving phototherapy. Which interventions
should be included in the plan of care? Select all that apply
Answer: Reposition the newborn every 2 hours., Cover the newborn’s eyes with eye
shields or patches.
4. A newborn delivered at home was admitted to the hospital 24 hours ago after sustaining
blunt chest trauma. The nurse monitors for which earliest clinical manifestation of acute
respiratory distress syndrome (ARDS)?
Answer: Increase in respiratory rate from 18 to 30 breaths per minute
5. A nurse is assessing a 3-day-old preterm neonate with a diagnosis of respiratory distress

syndrome (RDS). Which assessment finding indicates that the neonate’s respiratory status
is improving?
Answer: Urine output of 3 mL/kg/hour
6. The nurse is conducting health teaching to postpartum women. Hyaline membrane disease
or respiratory distress syndrome is most likely to occur in the infant who is:
Answer: 37 weeks’ gestation and under and who weighs under 1500 g (3 lbs oz)
7. An infant is diagnosed with patent ductus arteriosus. Which of the following drugs may be
administered in hopes of achieving pharmacologic closure of the defect?
Answer: ndomethacin
8. A one month old infant in respiratory distress is brought to the emergency department. The
nurse should observe the infant for which of the following signs?
Answer: Nasal flaring and see-saw chest
9. The nurse is preparing to care for a newborn. Baby Carlos, a 72 hour old newborn infant,
appears slightly jaundiced and has a bilirubin level of 10 mg/dl. A nurse would give the
parent which of the following instructions?
Answer: “Feed the baby at least every three hours.”
10. The nurse is preparing to care for a newborn. Which nursing action should be included in
the baby's plan of care to prevent retinopathy of prematurity?
Answer: Monitor partial pressure of oxygen (Pao2) levels.

11. The nurse is preparing to care for a newborn. A nurse is performing an assessment on a
post-term infant. Which physical characteristic should the nurse expect to observe?
Answer: Peeling of the skin
12. While performing an initial newborn assessment, the nurse notes yellowish vernix. The
nurse promptly calls this to the physician’s attention because this may be a sign of:
Answer: Rh or ABO incompatibility

13. A 24-hour-old baby is receiving phototherapy because of a high bilirubin level of 14
mg/dL. The nurse should include which of the following in the care plan?
Answer: Cover the newborn’s eyes and Assess skin integrity, fluid and electrolyte status
of the neonate
14. The nurse caring for a premature baby use careful hand-washing techniques because they
know premature infants are more susceptible to infection than full-term infants. Which of
the following explains why premature infants are more likely to develop infection?
Answer: Premature infants receive few antibodies from the mother because antibodies
pass across the placenta during the last month of pregnancy.
15. Josephine, delivered 3 days ago at 28 weeks gestation, develops a heart murmur. The
Josephine?
Answer: Increasing external stimuli
16. The nurse is preparing to care for a newborn. A one-day-old newborn infant is in respiratory
distress. The nurse should observe the infant for which of the following signs?
Answer: Nasal flaring and chest retractions
17. The nurse is assessing a newborn at the Neonatal Intensive Care Unit. When evaluating an
infant’s laboratory results for effectiveness of phototherapy, the NICU nurse should expect
Answer: Serum bilirubin 5 mg/dL

18. Jonalyn is delivered at 44 weeks’ gestation by cesarean section because of fetal distress.
At delivery, she has a thick, green tinged coating, cyanosis and signs of respiratory distress.
The pediatrician diagnoses meconium aspiration syndrome. If the pediatrician suspects that
Jonalyn has pneumothorax, the nurse should prepare to do all of the following, EXCEPT:
(Administer oxygen, Assist with intubation, Assist with chest tube insertion)
Answer: Encourage Jonalyn to cry
19. The nurse is preparing to care for a newborn. The nurse, caring for a child with left-to-right
shunt of the heart, should be aware that the major common symptom of this type congenital
disorder is:
Answer: The presence of an audible heart murmur
20. The nurse observes slight facial jaundice in a 2-day-old full term neonate during a
Answer: Jaundice is visible on the skin of a neonate at levels from 4 to 6 mg/dL, which is
normal in 2-day old neonate.
21. A 10-year-old child with asthma is treated for acute exacerbation in the
emergency department. The nurse caring for the child should monitor for which sign,
knowing that it indicates a worsening of the condition?
Answer: Decreased wheezing
22. A new parent expresses concern to the nurse regarding sudden infant death syndrome
(SIDS). She asks the nurse how to position her new infant for sleep. In which position
should the nurse tell the parent to place the infant? 2
Answer: Back rather than on the stomach
23. Before preparing a teaching plan for the parents of an infant with ductus arteriosus, it is
important that Nurse Korina understands this condition. Which statement best describes
patent ductus arteriosus?
Answer: Patent ductus arteriosus involves a defect in which the fetal shunt between the
aorta and the pulmonary artery fails to close
24. The nurse is caring for Gabby experiencing an acute asthma attack. The client stops
wheezing and breath sounds aren’t audible. The reason for this change is that:
Answer: The airways are so swollen that no air can get through
25. A 2-year-old child has been admitted to the hospital for management of pneumonia. The
child is placed in an oxygen tent. Taking into consideration the child's age and
developmental level and the treatment being administered, which statement is appropriate
for the nurse to make to the parents?
Answer: "You can sit next to him and hold his hand through the tent, but he needs to
remain inside of it."
26. As a client advocate, the nurse should ensure protection of the client’s rights during heath
teaching. The nurse is teaching a family with a newborn about safety during sleep. What
information is the most important for the family to understand?
Answer: The infant should be placed on his back to sleep.
teaching. A child with bacterial pneumonia is crying and says it hurts when he coughs. The
nurse would teach the child to:
Answer: Hug his teddy bear when he coughs.
28. A condition in which an acute, severe prolonged asthma attack and unresponsive to usual
treatment is referred to as which of the following?
Answer: Status asthmaticus
29. Which of the following infants is least probable to develop sudden infant death syndrome
(SIDS)?
Answer: Baby Jimmy who sleeps on his back
teaching. Of the following, the strongest identifiable factor for the persistence of childhood
asthma is
Answer: Allergy
31. A patient who is experiencing an acute asthma attack is admitted to the emergency
department. The nurse’s first action should be which of the following?
Answer: Listen to the patient’s breath sounds
32. Which finding would alert a nurse that a hospitalized 6-year old child is at risk for a severe
asthma exacerbation?
Answer: History of steroid-dependent asthma
33. Abby, a student nurse auscultate the newborn’s chest to get the PR. She notices that there
is a slight murmur. She knows that this is because the shunts are not yet fully closed. Which
of the following situations initiate the closure of the ductus arteriosus?
Answer: Decreased pulmonary vascular resistance and increased systemic vascular

resistance
34. Roldan, 6 years old child was admitted due to difficulty of breathing. When planning
discharge teaching for the parents of the child with asthma, the nurse should include telling
the parents to increase the child’s fluid intake and to have the child:
Answer: Avoid exertion and exposure of cold
35. Karla, age 2, is admitted to the pediatric unit after being treated in the Emergency
Department for status asthmaticus. Upon arrival on the unit, Karla received an IV
theophylline drip and a maintenance solution of dextrose 5% in a 0.2% saline solution. In
preparing Karla for discharge, the nurse should be primarily concerned with:
Answer: Discussing strategies to rid the home of known allergens
36. In asthma attack, an audible, wheezy breathing more common during expiration. An
emergency department nurse is assessing a 5-year-old experiencing an acute asthma attack.
Which one of these findings should be reported immediately?
Answer: Absence of wheezing
37. Marissa, a 3-year-old child was admitted 48 hours ago and recently developed a productive
cough and fever. Coarse crackles were heard in the right lower lobe on assessment. A chest
x-ray showing infiltrates with consolidation in the right lower lobe lead to the diagnosis of
community acquired pneumonia. Which of the following microbes caused the condition of
the child?
Answer: Respiratory syncytial virus

38. Elizabeth, a 17-year-old high school student with a history of asthma is brought to
emergency department. The nurse recognizes that the adolescent is experiencing an acute
asthma exacerbation when assessment reveals:
Answer: Tachycardia, anxiety, and wheezing
39. Which statements by an 8-year old child indicates that she understands the use of a peak
expiratory flow meter?
Answer: “My peak flow meter can tell me if an asthma episode might be coming, even
though I might still be feeling okay.”
40. During assessment of a patient with a history of asthma, the nurse notes wheezing and
dyspnea. The nurse will anticipate giving medications to reduce:
Answer: Airway narrowing
41. A student was burned in a jeepney accident. The entire front side of both arms was burned,
both legs was completely burned, lower front torso and genitalia was burned. The nurse
would compute that the total fluid requirement in the first 24 hours in the client with a body
weight of 60 kilograms is which of the following?
Answer: 13,200 ml
42. A student was burned in a jeepney accident. The entire front side of both arms was burned,
both legs was completely burned, lower front torso and genitalia was burned. The nurse
would compute that the total burned surface area is:
Answer: 55%
43. The clinic nurse reviews the record of an infant and notes that the health care provider has
documented a diagnosis of suspected Hirschsprung’s disease. The nurse reviews the
assessment findings documented in the record, knowing that which symptom most likely
led the mother to seek health care for the infant?
Answer: Foul smelling ribbon like stools
44. A healthy, thriving, 4-month old boy suddenly experiences episodes of acute abdominal
pain. The infant is admitted to the hospital with the diagnosis of intussusception. In an
interview with the nurse, the infant’s mother describes his behavior. The mother would
most likely describe him as crying.
Answer: Intermittently and drawing his knees to his chest
45. A preschooler with a history of cleft palate repair comes to the clinic for a routine well-
child checkup. To determine whether this child is experiencing a long-term effect of cleft
palate, the nurse asks the parent which question?
Answer: “Is the child unresponsive when given directions?”
46. The nurse review the record of a child who is suspected to have glomerulonephritis and
expects to note which finding that is associated with this diagnosis?
Answer: Brown colored urine
47. The nurse is assessing a young female child who may have a UTI. A female child is more
susceptible to UTIs than a male because she has:
Answer: A shorter urethra
48. The doctor orders a clean catch urine specimen on an infant who is not toilet trained. The
best means of collecting this urine by the nurse on duty would be to.
Answer: Apply a urine collection bag.
49. The nurse is creating a teaching plan for a school age child with a urinary tract infection
(UTI). Which should the nurse assess first?
Answer: Toileting habits
50. A school age child is diagnosed with AGN. Which nursing action takes priority when
caring for this child?
Answer: Monitoring blood pressure every 4 hours
51. The parents of a child diagnosed with upper urinary tract infection (UTI) asks the nurse
why the child needs a daily weight. In formulating a response, the nurse includes that it is
important because daily weight will:
Answer: Keep tract of possible loss or gain of fluid retained in body tissues.
52. An 18 month old child with a history of cleft lip and palate had been admitted for palate
surgery. The best rationale to give parents who are questioning the use of elbow restraints
with their child who has had cleft palate repair is:
Answer: Elbow restraints are used post operatively to keep their hands away from the
surgical site.
53. An infant is admitted to the hospital with a sudden episode of acute abdominal pain. To
establish a diagnosis of intussusception, the nurse should ask which question?
Answer: “Does the infant’s stool look like currant jelly?”
54. A 10-year-old boy with type 1 diabetes comes to the pediatrician’s office. Which of the
following techniques best ensures responsible insulin administration?
Answer: The child learns to administer his insulin supervision
55. Which of the following should the nurse do first in a child diagnosed with Hirschsprung’s
Disease with a complaint of fever and watery explosive diarrhea?
Answer: Notify the physician immediately
56. The nurse is teaching the mother of a child diagnosed with type 1 diabetes. The mother
asks why her child must inject insulin and can’t take pills as her uncle does. Which reply
is most appropriate?
Answer: “The only way to replace insulin is by injection”
57. The nurse is teaching the parents of a child with diabetes. Which of the following agents
should the nurse teach the parents to administer if their child suffers a severe hypoglycemic
reaction?
Answer: Subcutaneous glucagon administration
58. The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse
review’s the child’s record and expects to note which symptom of this disorder is
documented?
Answer: Bright red blood and mucus in the stools
59. A 9 year old boy with type 1 diabetes takes a mixture of regular and NPH insulin. He’s
scheduled to go on a camping trip and his mother asks the nurse whether it’s safe for him
to participate in this activity. What’s the most appropriate response?
Answer: “He should have a light snack before doing any hiking.”
60. The parents of a child with acute glomerulonephritis are very concerned about activity
restrictions after discharge. The nurse bases the answer to them on the fact that after the
urinary findings are nearly normal:
Answer: Activity does not affect the course of the disease
61. Arthur Martinez, 1 year old infant together with his parents came into the emergency room
at 8 AM. His mother reported that he has been lethargic and coughing. His mother said he
had a temperature of 102.4°F during the overnight hours and he hasn’t been feeling well
for a week or so. She and her husband became concerned when his face began turning red.
Assessment data: Temperature 102.5°F. Periorbital edema. Conjunctivitis. Red flat rash on
the child’s face and faint the rash on his trunk. Severe coughing. Watery nose. Swollen
lymph nodes. The parents are unsure about the child’s vaccinations. A nurse is caring for
the child who has been diagnosed with rubeola (measles). The nurse notes that the
physician has documented the presence of Koplik’s spots. On the basis of this
documentation, which of the following would the nurse expect to note during the
assessment of the child?
Answer: Small, blue-white spots with a red base found on the buccal mucosa
62. Gavreel, age 6, arrived at the Emergency Department with her mother at 5 PM. Her mother
reported that she had become lethargic in recent days. Her mother became concerned when
she felt warm to the touch and hadn’t urinated as much as she normally would. The mother
reports that Gavreel had a strep throat 4 weeks ago, but she recovered and she was fine up
to a few days ago. Assessment data: Temperature 101.3°F +1 pitting edema bilaterally
arms and legs. Slight edema around the eyes. Urine analysis showed hematuria, proteinuria,
and specific gravity is 1.034 g/mL. Blood serum shows elevated creatinine and BUN. Urine
culture and sensitivity is positive for streptococcal bacteria. The nursing assistant assigned
to the client asks the nurse what measures are necessary to prevent contraction of the
infection during care. The nurse tells the nursing assistant that:
Answer: Standard precautions are sufficient, because the disease is transmitted sexually
63. A 10-month-old infant has been exposed to chickenpox. The nurse on duty in the area
would expect the baby’s primary health-care provider to order which of the following
interventions to prevent the baby from contracting the illness?
Answer: Varicella zoster immune globulin
64. A nursing student is being seen in the women’s health clinic. She states that she had
unprotected intercourse about one month earlier, and she is worried that she may have
contracted HIV. Which of the following signs/symptoms would indicate that her worries
may be correct?
Answer: Exhaustion accompanied by muscle aches and pains
65. The nurse is providing counseling to parents regarding an important action they can take
to prevent their children from developing meningitis. Which of the following actions will
the nurse suggest?
Answer: Have children receive all recommended immunizations.
66. The nurse is providing education to pregnant women who have a family history of severe
allergies. Which of the following information should the nurse convey regarding actions
the women should take to minimize their children’s potential for developing allergies?
Answer: When they begin to feed their infant solid foods, to begin serving high-allergy
foods shortly aft er low-allergy foods have been introduced
67. The nurse is providing education to parents of young children regarding the children’s
potential for developing allergies. The nurse informs the parents that which of the
following are the most common allergies of childhood?
Answer: Foods
68. A mother with a child who is admitted in your institution says to the nurse , “I am afraid
that my child might have another febrile seizure.” The nurse makes which therapeutic
statement to the mother?
Answer: “Tell me what frightens you the most about seizures.”
69. A client with a wound infection and osteomyelitis is to receive hyperbaric oxygen therapy.
During the therapy, the nurse implements which priority intervention?
Answer: Ensures that oxygen is being delivered
70. A nurse is coordinating an educational session for middle school students in regarding
human immunodeficiency virus (HIV). The nurse should advise students that which of the
following behaviors place the middle school students at high risk of contracting HIV,
EXCEPT:
Answer: Using natural skin condoms while having sex with an individual with HIV.
71. The nurse is caring for a client in the emergency department. During a procedure she is
stuck by a contaminated needle. Which of the following actions should the nurse perform?
Answer: Begin post exposure prophylactic treatment within 72 hours of the HIV
exposure
72. During an infection control seminar, the speaker specified the prevention measures in the
spread of HIV. The nurse is aware that the teaching should be understood by the clients
who attended the seminar. Which of the following statements mentioned by the clients
Answer: Patients with AIDS should be isolated
73. To validate the applicability of the nursing intervention wfith the rapidly changing
technology-based care of clients, the nurse should institute health care teaching. A 12 year
old child with HIV+ antibodies is going home from the hospital. Which of the following
are the most important home-going instructions?
Answer: Prevention of the spread of HIV
74. An 18 month old child is observed having a febrile seizure. The nurse notes that the child’s
jaws are clamped. The priority nursing responsibility at this time would be:
Answer: Protect the child from harm from the environment.
75. A mother overhears two nurses discussing a measles outbreak. The nurses are talking about
the incubation period. The mother asks the nurses why it is important to know the
incubation period for a childhood disease. The nurses reply would be based on the
knowledge that the incubation period:
Answer: Describes a period when the child might be contagious.
76. The nurse-client relationship is significant in ensuring client cooperation in the care. A
child has been diagnosed with bacterial meningitis. The parent asks the nurse how long the
child will be in isolation. The nurse’s reply will be based on a protocol that isolation
continues:
Answer: The antibiotics have been administered for 24 hours.
77. A 4 year old child has been exposed to chickenpox. After the nurse has provided
information about chicken pox, the nurse asks the mother to repeat the information. The
statement by the mother that indicates a need for additional information is:
Answer: “During the prodromal period, my child will have pox all over his body.”
78. A nursing student, presents with endocervical purulent discharge and urethritis. Gram stain
of the exudates showed polymorphonuclear leucocytes and an absence of gram negative
intracellular diplococci. The most likely sexually transmitted infection is:
Answer: Chlamydia trachomatis
79. A nurse who works in the parent-child center of a large city hospital is responsible for
health teaching of both child and parent, discharge teaching, and the orientation of new
nurses to the various units. When the mother contracts German measles early in pregnancy,
effects on the fetus may include all of the following EXCEPT: (Hepatosplenomegaly,
Glaucoma, Cataract, Patent ductus arteriosus)
Answer: Thrombocytosis
80. The nurse places the young child scheduled for a lumbar puncture in a side lying position
with head flexed and knees drawn up to the chest. The mother asks why the child has to be
positioned this way. The nurse explains the rationale for the positioning is that:
Answer: Access to the spinal fluid is facilitated
81. A newborn is being admitted to the newborn nursery. The nurse would assess the infant for
congenital defects. In addition to the abnormal position of the foot, the nurse would note
which of the following if clubfoot is present.
Answer: There is calf muscle atrophy of the affected limb
82. A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of
the hip. On assessment, the nurse understands that which finding should be noted in this
condition?
Answer: Limited range of motion in the affected hip
83. A child is admitted with osteogenesis imperfecta. Which of the following nursing
diagnoses takes highest priority for the child hospitalized with osteogenesis imperfecta?
Answer: Risk for injury related to disease state
84. A 14-year-old adolescent has just been fitted for a Milwaukee brace. Which of the
following symptoms is not typical in an adolescent with idiopathic structural scoliosis?
Answer: Back pains
85. The parents of a child with juvenile idiopathic arthritis call the clinic nurse because the
child is experiencing a painful exacerbation of the disease. The parents ask the nurse if the
child can perform range-of-motion exercises at this time. The nurse should make which
response?
Answer: “Have the child perform simple isometric exercises during this time.”
86. A child has a right femur fracture caused by a motor vehicle crash and is placed in skin
traction temporarily until surgery can be performed. During assessment, the nurse notes
that the dorsalis pedis pulse is absent on the right foot. Which action should the nurse take?
Answer: Notify the health care provider (HCP)
87. The parent of a child with neuroblastoma verbalizes regret at not coming in earlier for the
client’s complaints. An appropriate response is:
Answer: This is a silent tumor, which is difficult to diagnose early
88. A child will be undergoing chemotherapy. The nurse discusses the issue of hair loss with
the child and family before chemotherapy begins. Later the family questions the nurse on
why this information was given to the child at this time. The nurse’s response will include
the information that:
Answer: The presence or absence of hair is related to body image. Strategies for handling
hair loss should precede the event.
89. The nursing diagnosis for a child undergoing chemotherapy for leukemia is Altered
nutrition: less than body requirements related to nausea and anorexia. An appropriate goal
for this client would be:
Answer: The child’s caloric intake will be within normal range.
90. A child with a myelomeningocele is started on a bowel management plan. The child’s
mother questions why this is being done. The nurse’s response will be based on the
understanding that:
Answer: Lack of innervation to the anal sphincter predisposes the child to being
incontinent
91. A child has been treated with chemotherapy for cancer. Neutropenia is an expected
consequence. The nurse would teach the parents to do which of the following, anticipating
that neutropenia may occur?
Answer: Avoid crowded spaces
92. The nurse is providing instructions to the parents of a child with scoliosis regarding the use
of a brace. Postoperative care of an adolescent following a spinal fusion for scoliosis
includes
Answer: Nasogastric intubation
93. A child is being treated for ALL. He is in this stage wherein the goal is to prevent
leukemia cells from invading the CNS. This is called:
Answer: Consolidation Therapy
94. The laboratory results of the client with leukemia indicate bone marrow depression. The
nurse should encourage the client to:
Answer: Use a soft toothbrush and electric razor
95. The nurse is caring for a child with cancer of the kidney. Child has a very distended
abdomen accompanied by abdominal pain. What is her priority nursing responsibility pre
operatively?
Answer: Avoid abdominal palpation
96. An adolescent with osteosarcoma is a candidate for amputation of the lower extremity.
During the conference, doctors agreed that they will remove the tumor and the adjacent
tissue excluding the limb from amputation.
Answer: Limb salvage
97. A parent asks Nurse Lara to tell her what cerebral palsy is. Nurse Lara’s best response
would be that it is a:
Answer: Motor disability caused by a non-progressive disturbance in brain development
98. A common problem in children is the inflammation of the middle ear. This is related to
the malfunctioning of the:
Answer: Eustachian tube
99. Whenever there is fracture, we try to give first aid management. We splint the fractured
extremity though our goal is to obtain union of the fractured bones. We call this:
Answer: Retention
100. From your knowledge of clubfoot what is the least invasive therapeutic procedure
done?
Answer: Ponsetti method
101. A mother attends the pediatric clinic with her child for consultation. The child is
being evaluated by the nurse. The nurse explains to the mother that the child who has begun
treatment for impetigo with a topical antibiotic can return to daycare:
Answer: After 48 hours
being evaluated by the nurse. When teaching the mother how to use and anti lice shampoo,
the nurse should include the information that she should:
Answer: Apply about 2 ounces of shampoo to wet hair.
being evaluated by the nurse. The child has informed his friends and family that he plans
to commit suicide. As the school nurse, you further investigate this child’s comments. Your
actions are based on which of the following?
Answer: Threats of suicide should not be ignored.
being evaluated by the nurse. When performing a health screening on the adolescent, you
would determine he is at a higher risk of suicide than other adolescents of his age based on
which of the following facts that he discloses?
Answer: He states that he is homosexual
being evaluated by the nurse. Permethrin 5% was prescribed to the child diagnosed with
scabies. What instructions should the nurse provide for the mother?
Answer: Apply lotion only after the child has had a bath and dried thoroughly
being evaluated by the nurse. Which of the following would be appropriate home care
instructions for the mother with the child that has a lice infestation?
Answer: Vacuum floor and furniture to remove hair that might have live nits.
being evaluated by the nurse. Pediculosis capitis (head lice) was considered. Which
findings indicates the child had a “positive” head check?
Answer: White sacs attached White sacs attached to the hair shaft in the occipital area.
being evaluated by the nurse. Permethrin is prescribed for a child with a diagnosis of
scabies. The nurse should give which instruction to the mother regarding the use of this
treatment.
Answer: Apply the lotion to cool, dry skin at least 30 minutes after bathing.
being evaluated by the nurse. The child is being treated with Elmite for scabies. The child’s
mother is concerned that the drug hasn’t been effective because her child continues to
scratch. Which response by the nurse is most appropriate?
Answer: Tell the mother that pruritus can be present for weeks after treatment.
being evaluated by the nurse. The child, 18 months old has been diagnosed with scabies.
Lindane has been prescribed for the child. The nurse questions the prescription if which is
noted in the child’s record?
Answer: The child is 18 months old.
being evaluated by the nurse. The mother tells the nurse that the child has been scratching
the skin continuously and has developed a rash. The nurse assesses the child and suspects
the presence of scabies. The nurse bases this suspicion on which finding noted on
assessment of the child’s skin.
Answer: Fine grayish red lines

being evaluated by the nurse. A physical assessment is performed on the suicidal client
upon admission to the inpatient unit. The nurse understands its importance because it
provides information regarding:
Answer: Evidence of physical self-harm
being evaluated by the nurse. The mother told that there’s an outbreak of scabies at her
child's day care center. The nurse should instruct the mother to check her child for which
findings associated with scabies infestation?
Answer: Pruritic papules, pustules, and linear burrows of the fingers and toe webs
being evaluated by the nurse. The child is 2 year old with multiple fractures and bruises ad
abuse is suspected. The nursing assessment that most supports this diagnosis in this child
is:
Answer: Underdevelopment for age
being evaluated by the nurse. Parents can be expected to experience a grief process when
they are told their child will be physically or cognitively challenged or is terminally ill.
During conversation, the mother state that “ How could this have happened?’. This
reaction pertains to what stage of grief?
Answer: Denial
being evaluated by the nurse. A nurse is teaching parents how to reduce the spread of
impetigo. The nurse should encourage parents to:
Answer: Teach children the importance of proper hand washing
being evaluated by the nurse. A plan of care to best meet the needs of a neglected child:
Answer: As consistent a caregiver as possible, with stimulation that is moderate and

purposeful.
being evaluated by the nurse. When assessing the client who has been beaten and abused,
the nurse is aware that potential nursing diagnosis for this client at tis time would be:
Answer: Ineffective coping related to difficulty assimilating the situation
being evaluated by the nurse. The child is 2 year old with multiple fractures and bruises ad
abuse is suspected. If there is suspicion of chid abuse, the nurse must:
Answer: Report suspicions to the police
being evaluated by the nurse. The adolescent was assessed to be dependent on drugs.
During the assessment, which action should the nurse take to plan appropriate nursing care?
Answer: Ask the client about the amount of drug use and its effect
- While perform AOG assessment new deliver male neonate vaginally 27 expect to find
(intensive grogea in scrotum)
- When assessing 42 weeks neonate (epidermis)
- A woman delivers 3250g which finding is expected (wrinkled skin)
- G1P1 7 pounds delivered without a problem (APGAR)
- Newborn admitted in NICU testes are palpable in inguinal canal and extensive lanugo a
newborn is (30-32 weeks)
- When reviewing the data recorded in newborn start the information that will indicate that
the baby required a special attention (APGAR Score 3)
- Baby simon is 9 pounds 8 onces APGAR score is 7 and 8 43 weeks (crack peeling skin)
- Respiratory distress syndrome nurse in NICU which sign that wil alert the nurse (
takipnia and external extraction)
- RDS the nurse will prepare ( indotrchaeal tube)
- Main role of surfactant
- RDS priority of nurse will be (constantly
- Ductus arteriosus (connection of artery and aorta)
- Post-partum nurse is providing information about the mother about hyperbilirubinemia
(Continue brestfeeding 2-4)
- Greenish tint (meconium stain)
- 4 month old boy mother describe him crying (in drawing of knees in his chest)
- Hisprown disease (colon)
- 2-week-old infant hillsprawn (ribbon like stool)
- Infant Immediate care (trauma from the suture line)
- Preventing aspiration the infant upright position how to feed infant with cleft lip (upright
position)
- Spina bifida (position on prone)
- A woman is 6 weeks pregnant with spina bifida response (concentration of alpha pito
protein)
- Spina bifida which is the following sign the shot is functioning properly (Decrease head
circumference)
- which is the following sign Otitis media (tagging on the ears)
- A nurse discharging 10 month old with Otitis media (pull ear lobe downward and
backward)
- Meningitis need to watch (iratibility, fever and vomiting)
- Meningi irritation (arching of the neck)
- (protect the child from injury)
- Imperforate anus (failure to pass meconium)
- Which action will the nurse check first (give IV)
- Burn torso arm (55 percent)
- Cerebral palsy response on understanding (chronic disability charac with muscle
impaired and bone structure)
- Unusual (Jaundice and anasarca)
- Leukemia bone marrow involvement (patique and fatige)
- Asthma nurse expect ( increase carbon dioxide)
- UTI (toilet inhabits)
- Blastoma (
- Rheumatic fever nurse demonstrate (positive
- Rheumatic fever beta hemolytic antibiotic therapy (reverse
- Common system of rheumatic fever help to alleviate (bed cradle to avoid bed linen)
- Presence of arthritis
- Type 1 diabetes Mother inject of insulin (the only way is injection for insulin)
- 7am receive information 180 sugar level (give insulin)
- Characteristic of secondary syphilis (low grade fever
- Scoliosis adolescne to correct the defoemities indicates teaching I successful ( the brace
is wear 23 hours per day)

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1-7 Formative Assessment

Question 101 pts

Question 111 pts

Question 121 pts

Question 131 pts

Question 141 pts

Question 151 pts

Question 171 pts

Question 181 pts

Question 191 pts

Question 201 pts

2-4 Assignment 2-4 Formative Assessment #2 -

The assessment phase of FNP ends with:

1. Aling Tetchie, 40 years old is pregnant with their 6th child

Based on the following data gathered from the Cervantes family:

Using the data gathered from the Cervantes family:

A Home Visit is defined as?

Which of the following is an advantage of a home visit?

Which is CONTRARY to the principles in planning a home visit?

The purposes of Home visit are the following except?

Arrangement of Home Visit should be as follows:

There is no definite rule as to frequency of home visits

A Public Health Nurse must schedule her post-natal visit on?

Gina, a single mother lives with her daughter in an apartment in Barangay

- All the options listed

- All of the options listed.

Which of the following is the best method to prevent contamination?

- To protect her uniform from getting contaminated

- To prevent cross contamination

All of the following are contents of the bag, except:

- Public health bag

This protects the bag from getting soiled

Which is true about the specific gravity of the urine

Indicator of urine concentration/ amount of solutes

The normal specific gravity is between 1.010 – 1.025

- all are correct

Which of the following results signify abnormal urine test result:

Presence of protein molecules in the urine

The normal specific gravity is between 1.025 – 1.085

A product of breakdown of fatty acids are normally present in urine

Which is true about Benedict’s test?

It is use to test for sugar in the urine

A bluish green color after cooling down indicates positive (+)

- all are correct except 4

Which is true about Heat and Acetic Acid test?

It is used to test for albumin in the urine.

Protein coagulates when heated.

- all are correct

After the breakdown of fatty acids it is expected to be seen in the urine.

What are the indications of uncontrolled diabetes?

- Presence of ketones in the urine

What is the principle of Benedict’s test?

SL 4-3 Quiz: Halamang Gamot

- Pound mature leaves of akapulko and apply to affected area as a soap

Republic Act 8423 is otherwise known as

- Traditional and Alternative Medicine Act of 1997

Which of the following statements is INCORRECT?

- You may use any part of the plant being advocated

What is the scientific name of Niyug niyogan?

It is indicated for common respiratory symptoms:

It is commonly known as Peppermint

Family Nursing Care Plan

Modifiability of the condition/problem