*

-
RECALLS 5 - NP2
Situation
A nurse should be knowledgeable and skilled in caring for families with a newborn.

1. A newborn’s mouth should be wiped Drst then the nose. What is the most accurate rationale behind
this?
*
0/1

a. Newborns breathe through their mouths

b. Newborns breathe through their nose

c. Newborns may inhale outside air
d. Newborns may drink their amniotic Kuid

Correct answer
b. Newborns breathe through their nose

2. When the Moro ReKex is stimulated in an infant, the infant will _____________the arms with the palms
of the hands turned ___________ and then move the arms ___________ the body.
*
1/1

a. Kex, upward, away from

b. extend, upward, back to

c. Kex, downward, back to

d. extend, downward, away from

3. Most newborns experience physiologic jaundice 24 hours after delivery, as a result of breakdown of fetal
red blood cells. However, when indirect bilirubin levels become above normal, this may be potentially
dangerous because it can:
*
0/1

a. Interfere with the chemical synthesis of brain cells, resulting in permanent cell damage called kernicterus
b. Lead to inadequate levels of red blood cells, resulting in anemia

c. Impair peripheral circulation, leading to decreased tissue perfusion and cyanosis d. Cause build-up of urea under
the skin, resulting in uraemic pruritus

Correct answer
a. Interfere with the chemical synthesis of brain cells, resulting in permanent cell damage called kernicterus
4. Hazel, who just delivered her baby 17 hours ago, asked you: “Why does my baby’s head look weird?”
What is your most appropriate response?
*
1/1

a. “Your baby’s head does look weird. Let us ask your doctor why.”
b. “It looks asymmetrical. Was there anything that happened to your baby’s head?” c. “Your baby’s head was molded
during labor and delivery. This will go back to normal after a few days.”

d. “I don’t know what you are saying. It does not look weird.”
5. Baby Nicole was delivered 1 hour ago. You are tasked to give BCG vaccine, Hepatitis B vaccine, and
Vitamin K injection. What is the best rationale in giving Vitamin K in newborns?
*
1/1

a. Vitamin K aids in the absorption of calcium and phosphorus for newborns to develop healthy bones and
teeth.
b. Vitamin K is a water-soluble nutrient that helps in repairing red blood cells and boosting the immune
system.
c. Vitamin K is used to prevent brain damage in newborns because it is essential for brain
development, neural myelination, and cognitive function.
d. Vitamin K is needed in the production of certain coagulation factors in the intestinal tract to prevent and
treat bleeding diseases in newborns.

Situation
As a nurse, you should have adequate grasp on developmental milestones in order to ebectively assess and
care for pediatric patients.

6. Baby Julie weighed 8 lbs. at birth. How many lbs. should she weigh at 6 months? *
1/1

a. 24 lbs
b. 10 lbs
c. 16 lbs

d. 32 lbs

7. You noted that Baby Casey is using the pincer grasp at 10-month-old. Which option below best
describes this milestone?
*
1/1

a. She is able to grasp large objects with the palm and foreDngers.
b. She is able to grasp small objects with the index Dnger and thumb.

c. She is able to grasp small and large objects with the middle Dnger and thumb. d. She is
able to grasp large objects with the palm and thumb.

8. Baby Casey’s mother asks you about car safety: “What is the best position of a car seat for my
baby?” Your response is:
*
0/1

a. Forward-facing and back seat

b. Forward-facing and front seat

c. Rear-facing and front seat
d. Rear-facing and back seat

Correct answer
d. Rear-facing and back seat

9. You then note that Baby Casey’s anterior fontanelle is open. How would you document this Dnding?
*
1/1

a. Abnormal; should be closed at 2 months

b. Abnormal; should be closed at 6 months
c. Normal, should be closed at 12 months
d. Normal; should be closed at 18 months
10. You are caring for 5 month old Baby John. Which developmental milestone, if not performed
by the infant, should be further investigated?
*
1/1

a. Rolling over

b. Crawling
c. Pincer grasp
d. Sitting without support

Situation
Psychosocial development is crucial throughout the entire lifespan. It emphasizes the social nature of human
beings, develops one’s personality, and inKuences social relationships.

11. The school-age child experiences many physical changes throughout this developmental time
period. Which of the following is not a change experienced by this age group?
*
0/1

a. The child typically grows about 2.5 inches per year.

b. Most of the child’s 28 permanent teeth will be erupted by the end of this developmental period.

c. The child’s weight triples from the age of 6 to 12 years.

d. The child’s gross motor skills allow them to ride a bike without training wheels, swim, and skate.

Correct answer
c. The child’s weight triples from the age of 6 to 12 years.

12. Which of the following is the most important achievement in a school age child? *
0/1

a. Being able to control their urges to urinate or defecate

b. Being able to learn their sexual identity through awareness of genital area c. Being
able to establish good relationships with people of the opposite sex

d. Being able to learn a skill or hobby

Correct answer
d. Being able to learn a skill or hobby

13. What would be your best advice for parents of a school age child? *
1/1

a. Allow the child to complete a project and make them feel rewarded for the accomplishment
b. Praise the child’s ability to make decisions rather than judging the correctness of their decisions c. Allow the
child to create bonds and friendship with peers of the opposite sex d. Provide visual stimulation for active child
involvement

14. A 10-year-old is being prepped for heart surgery to replace a heart valve. What fears or stressors
does the nurse anticipate this child could experience during this hospitalization?
*
1/1

a. Fear of strangers
b. Fear of punishment
c. Fear of having no privacy
d. Fear of pain

15. According to Kohlberg’s Stages of Moral Development, what would be the reason for conformity
to the rules for a 9-year-old child?
*
0/1

a. The child conforms to the rules because of the rewards given for good behavior. b. The
child conforms to the rules because it maintains social order.

c. The child conforms to the rules because it causes others to view them as being good. d. The
child conforms to the rules because it provides a mutual beneDt.

Correct answer
c. The child conforms to the rules because it causes others to view them as being good.

16. Jean Piaget (1896–1980), a Swiss psychologist, introduced concepts of cognitive development
or the way children learn and think. According to his theory, all but one are expected in an infant:
*
0/1

a. Infants play peek-a-boo because they realize the person playing with them exists behind his or her hands.
b. Infants can recognize that their toy has broken parts.
c. Infants learn they are a separate entity from objects.
d. Infants can recognize that a parent remains the same person whether dressed in a robe and slippers or
pants and a T-shirt.

Correct answer
b. Infants can recognize that their toy has broken parts.

17. According to Piaget's Theory of Cognitive Development a 11-year-old child would be in the
_________________ stage:
*
0/1

a. Preoperational
b. Concrete Operational

c. Sensorimotor
d. Formal Operational

Correct answer
d. Formal Operational
18. Which of the following cognitive abilities is expected in an 11-year old child? *
0/1

a. Centering
b. Decentering
c. Abstract thinking
d. Reversibility

Correct answer
c. Abstract thinking
19. Suppose Carl, 5 years old, tells you that his arm is asking for a warm blanket to get better. What
type of cognition is he using?
*
0/1

a. Deductive reasoning
b. Magical thinking
c. Inductive reasoning

d. Sensorial thought

Correct answer
b. Magical thinking

20. Carl’s mother told you that she is concerned because she saw her son masturbating while taking a
bath. As a nurse, what would be your most appropriate response? *
1/1

a. This is normal behavior for Carl.

b. This behavior should begin by 10 years old.

c. It is recommended that you have him checked with a psychiatrist.
d. Carl may have a disease in his genitalia.

Situation
Chrisa is an 8-year-old child born with asthma and celiac disease. She was brought to the hospital with vital
signs of BP 100/70, PR 99, RR 30, and T 36.8 deg C. She has wheezes, pallor, and rashes on her chest .

21. You asked Chrisa’s mother about her allergies. She responded that Chrisa is allergic to seafood,
which the child accidentally ate prior to her asthma attack. What drug should be immediately given to
the patient for her allergic reaction?
*
0/1

a. Epinephrine
b. Albuterol
c. Montelukast
d. Theophylline

Correct answer
a. Epinephrine

22. What are the three processes behind asthma?

*
1/1
a. Increased bronchial secretions, alveolar collapse, airway constriction
b. Bronchospasm, increased mucus production, upper airway obstruction
c. Bronchospasm, inKammation of bronchial mucosa, and increased bronchial secretions d.

Abnormal production of mucus, blockage of exocrine glands, airway constriction

23. Which of the following breakfast meals should you give to Chrisa? *
0/1

a. Oatmeal with banana and peanut butter

b. Whole wheat toast with fried egg and cheese

c. Rice with beef tapa and fried egg
d. Vegetable salad with shrimp and apples
Correct answer
c. Rice with beef tapa and fried egg

24. Chrisa was prescribed take home medications – inhaled Salmeterol and Fluticasone – for long-term
management of asthma. Which of the following responses show that her mother understands the
correct order of taking these medications?
*
0/1

a. Chrisa inhales the Salmeterol Drst and then waits 5 minutes before inhaling the Fluticasone. b. Chrisa
inhales the Fluticasone Drst and then waits 5 minutes before inhaling the Salmeterol. c. Chrisa inhales the
Salmeterol Drst and then waits 1 minute before inhaling the Fluticasone.

d. Chrisa inhales the Fluticasone and immediately inhales the Salmeterol.

Correct answer
a. Chrisa inhales the Salmeterol Drst and then waits 5 minutes before inhaling the Fluticasone.

25. All but one are expected signs and symptoms in patients with gluten sensitivity: *
0/1

a. Cachexia
b. Steatorrhea

c. Abdominal distention
d. None of the above

Correct answer
d. None of the above

Situation
One of the most common congenital diseases are cardiovascular diseases. Nursing interventions for pediatric
patients with cardiovascular diseases are crucial to ensure optimal health and recovery.

26. Dan, a 2 month old infant, was born with tetralogy of fallot. Which statement below is incorrect
concerning how the blood normally Kows through the heart? *
0/1
a. Unoxygenated blood enters through the superior and inferior vena cava and travels to the left atrium.
b. The pulmonic valve receives blood from the right ventricle and allows blood to Kow to the lungs via the
pulmonary artery.

c. The left atrium allows blood to Kow down through the bicuspid valve (mitral) into the left ventricle.
d. Oxygenated blood leaves the left ventricle and Kows up through the aortic valve and aorta to be pumped to
the rest of the body.
Correct answer
a. Unoxygenated blood enters through the superior and inferior vena cava and travels to the left atrium.

27. While feeding Dan, you notice the infant’s skin begins to have a bluish tint and the breathing rate
has increased. Your immediate nursing action is to?
*
1/1

a. Continue feeding the infant and place the infant on oxygen.

b. Stop feeding the infant and provide suction.
c. Stop feeding the infant and place the infant in the knee-to-chest position and administer oxygen.
d. Assess the infant’s heart rate and rhythm.

28. Now that Dan has severe cyanosis, you anticipate which drug to give? *
0/1

a. Indomethacin
b. Diclofenac
c. Celecoxib

d. Alprostadil

Correct answer
d. Alprostadil

29. You are now caring for Cess, a 3 year-old patient who has a large atrial septal defect who is
waiting for surgery. She is currently experiencing complications arising from an abnormal shunting of
blood throughout the heart. As the nurse, you know that a _____________ shunt is occurring in the
heart due to the defect:
*
1/1

a. Right-to-left
b. Right
c. Left
d. Left-to-right

30. Cess’s mother comes to you and says, “I am feeling scared for my daughter. Why does it need
to happen to her? I don’t want to lose her.” What is your most therapeutic response?
*
0/1

a. Stay silent.
b. “Stop worrying. It will not do you or your daughter any good.”
c. “Why are you feeling that way?”

d. “I can see that you are losing hope and you think your daughter will die.”

Correct answer
a. Stay silent.

Situation
5-month-old James was brought by his father to the hospital for insertion of an external ventricular drain to
manage his hydrocephalus. The following situations apply.

31. Which of the following signs and symptoms can you not expect in James? *
0/1

a. Delayed closure of fontanelles

b. Projectile vomiting
c. High pitched cry
d. None of the above

Correct answer
a. Delayed closure of fontanelles

32. James’s father asks you where external ventricular drains are inserted. What is the correct
answer?
*
1/1

a. Subarachnoid space
b. Lateral Ventricle

c. Epidural space
d. Right Ventricle

33. What is the best position for James

*
0/1

a. Supine
b. Prone
c. Semi Fowler
d. Left sims lying

Correct answer
c. Semi Fowler

34. Patients with increased ICP have a high risk of seizures. If the pediatric patient starts to actively
seize. What is the very Drst thing the nurse should do?
*
0/1

a. Maintain a patent airway

b. Ensure the surroundings are safe
c. Administer lorazepam

d. Call for help

Correct answer
a. Maintain a patent airway

35. A patient with a history of epilepsy is taking Phenytoin. The patient’s morning labs are back, and
the patient’s Phenytoin level is 7 mcg/mL. Based on this Dnding, the nurse will?
*
0/1

a. Assess the patient for a rash

b. Initiate seizure precautions
c. Hold the next dose of Phenytoin

d. Continue to monitor the patient

Correct answer
b. Initiate seizure precautions
Situation
Education on sexuality and reproductive health is important for individuals to have adequate understanding
about their bodies and relationships, decrease their risk-taking, and decrease the frequency of unprotected
sex.

36. The Reproductive Health Law of the Philippines provides universal and free access to modern
contraceptive methods, mandates age- and development-appropriate reproductive health education in
government schools, and recognizes a woman’s right to postabortion care in the Philippines as part of
the right to reproductive healthcare. Which of the following pertains to the RH Law?
*
1/1

a. RA 8423
b. RA 10354

c. RA 7305
d. RA 9262

37. 17 year-old Jen came to you to ask about contraceptives. She has a history of vascular disease.
Which of the following options should you not recommend to her? *
1/1

a. Condoms
b. IUD
c. Diaphragm
d. Oral contraceptive pills

38. Fertility awareness involves detecting when a woman is fertile so she can use periods of
abstinence during that time. If a couple is having coitus, when is it safe to avoid pregnancy?
*
0/1

a. When the woman’s basal body temperature rises a full degree

b. When the woman’s cervical mucus becomes copious, thin, watery, and transparent

c. When the woman is breastfeeding for 7 months

d. When the woman is two days away from her menstrual period

Correct answer
d. When the woman is two days away from her menstrual period

39. Hannah, 24 years old and G2P2, has a copper-based IUD. What do you expect to include in
the teaching plan?
*
1/1

a. Amenorrhea is a common side ebect of IUDs.

b. Severe cramping may occur when the IUD is inserted.

c. She needs to have it changed yearly.

d. IUDs are more costly than other forms of contraception.

40. The Anti-Violence Against Women and their Children Act of 2004 seeks to address the
prevalence of violence against women and their children (VAWC) by their intimate partners like their
husband or ex-husband, live-in partner or former live-in partner, boyfriend/girlfriend or
ex-boyfriend/ex-girlfriend, dating partner or former dating partner. Which of the following situations is
not included in psychological abuse? *
0/1
a. When angry, Kim destroys their household property in front of Casie.
b. Martin threatens Kyla that he will inKict physical harm on himself if she leaves her. c. After
Dling for annulment, Oli deprives Keith of custody and access to their twins.

d. After their break up, Ben continuously stalks Hailey everytime she goes out.

Correct answer
a. When angry, Kim destroys their household property in front of Casie.

Situation
Cognitive delay may be present in some pediatric patients. Nurses have an important role in ensuring
that they maintain safety and are assisted towards development.
41. The nurse is evaluating Dennis, a 3-year-old child with a developmental delay. Which assessment
Dnding would indicate that this child might have a type of autistic spectrum disorder?
*
0/1

a. The child does not enjoy playing frequently with the same toy.

b. The child goes to bed without a nighttime routine.

c. The child is using echolalia.
d. The child enjoys imaginative play.

Correct answer
c. The child is using echolalia.

42. Which of the following statements by Dennis’s parents determines that a goal of treatment has
been met?
*
0/1

a. Dennis now eats with a fork.

b. Dennis repeats questions asked to him.
c. Dennis sits still for 1 minute this morning.
d. All of the above

Correct answer
a. Dennis now eats with a fork.

43. The parents then ask the nurse what medications will be used to help cure the child. What is the
nurse's best response?
*
1/1

a. "The doctor will order methylphenidate (Ritalin)."

b. "Treatment for autism focuses on behavior change, not medications."

c. "Dennis will be admitted to a psychiatric facility for medications."

d. “Dennis will be given medication at an outpatient clinic."

44. You are also caring for Karen, 6 years old, who is being evaluated for attention deDcit/hyperactivity
disorder. Which assessment Dnding (persisting more than 6 months) is consistent with the DSM-5
diagnostic criteria for hyperactivity and impulsivity? *
0/1

a. Often has diqculty waiting for turn in line or activity

b. Often has diqculty organizing tasks and activities

c. Often loses things necessary for tasks or activities

d. Often fails to Dnish schoolwork, chores, or duties

Correct answer
a. Often has diqculty waiting for turn in line or activity

45. If diagnosed with ADHD, which of the following drugs do you expect to be prescribed to improve
focus, and decrease impulsivity and hyperactive behavior, which are the three hallmark ADHD
symptoms?
*
0/1

a. Aripiprazole (Abilify)
b. Risperidone (Risperdal)
c. Citalopram (Celexa)
d. Methylphenidate (Ritalin)

Correct answer
d. Methylphenidate (Ritalin)

Situation
Teenagers are one of the most vulnerable groups in developing eating disorders. The following questions
apply.

46. Who among the following patients has the highest risk of developing an eating disorder?
*
1/1

a. Diana, 3 years old, who is a picky eater.

b. Celine, 15 years old, who has been bullied for being larger than her peers.

c. Kiana, 18 years old, who is a working student.

d. Carlo, 14 years old, has been training in basketball since he was 8 years old.

47. The nurse is assessing a client who is obese and reports eating to the point of discomfort at
least twice a week for the past year. The client denies the use of laxatives, self-induced vomiting,
ipecac syrup, or enemas and reports feeling unable to control the behavior. The client feels
embarrassed and has stopped going out with friends. Which eating disorder should the nurse
suspect?
*
0/1

a. Purging
b. Anorexia nervosa
c. Binge-eating disorder
d. Bulimia nervosa

Correct answer
c. Binge-eating disorder

48. A 17 year old gymnast is admitted to the hospital due to weight loss and dehydration
secondary to starvation. Which of the following nursing diagnoses will be given priority for the
client?
*
0/1

a. Altered self-image
b. Fluid volume deDcit
c. Altered nutrition: less than body requirements

d. Inebective coping

Correct answer
b. Fluid volume deDcit

49. In the management of patients with bulimia, the following nursing interventions will promote a
therapeutic relationship, except:
*
0/1

a. Establish an atmosphere of trust

b. Discuss their eating behavior.
c. Help patients identify feelings associated with binge-purge behavior

d. Teach patient about bulimia nervosa

Correct answer
b. Discuss their eating behavior.

50. The client with anorexia nervosa is improving if:

*
0/1

a. She eats meals in the dining room.

b. She attends ward activities.
c. She has a more realistic self concept.

d. She gains weight.

Correct answer
d. She gains weight.
Situation
Caring for Childbearing and Childrearing Families

51. A couple went to you to ask regarding conception. When assessing the adequacy of sperm for
conception to occur, which of the following is the most useful criterion? *
0/1

a. Sperm count
b. Sperm motility
c. Sperm maturity

d. Semen volume

Correct answer
b. Sperm motility

52. A woman states that she Dnds it hard to conceive because she has a condition in which the
entire uterus is tipped far forward. What term is applicable to this positional deviation of the uterus?
*
0/1
a. Anteversion
b. Retroversion

c. AnteKexion
d. RetroKexion

Correct answer
a. Anteversion

53. What hormone is active early in the cycle and is responsible for maturation of the ovum?
*
0/1

a. Estrogen
b. Progesterone
c. FSH
d. LH

Correct answer
c. FSH
54. Sheila typically has a menstrual cycle of 34 days. She tells you she had sexual intercourse on days
8, 10, 15, and 20 of her last cycle. Which is the day on which she most likely conceived?
*
0/1

a. Day 8
b. Day 10
c. Day 15

d. Day 20

Correct answer
d. Day 20

55. Cleo is already in her menopausal age. Because of the hormonal changes present in women at
menopause, what condition should you educate her about prevention because it is most common?
*
0/1

a. Breast cancer

b. Fractures
c. Diabetes
d. Anemia

Correct answer
b. Fractures

56. Kara, 35 years old, is currently pregnant with 23 weeks AOG. She has 2 children, the Drst one is
10 years old and the other one is 8 years old. The Drst one was delivered at 38 weeks AOG and the
second one was delivered at 35 weeks AOG. She got pregnant when she was 19 years old, but
miscarried at 2 months AOG. She also had a false pregnancy when she was 23 years old. What is her
obstetric score?
*
1/1

a. G5T1P1A2L2
b. G4T2P0A1L2
c. G5T1P1A1L2
d. G4T1P1A1L2

57. What is the psychological task of Kara?

*
0/1

a. Accept the pregnancy

b. Accept the baby
c. Prepare for parenthood

d. Anticipate baby’s needs

Correct answer
b. Accept the baby

58. Which of the following physiological changes is not expected in Kara? *

0/1

a. Quickening
b. Anemia
c. Urinary frequency
d. Leukorrhea

Correct answer
c. Urinary frequency

59. Kara then tells you that she is experiencing leg cramps and is awakened by the cramps at
night. To provide relief from the leg cramps, you advise the client to: *
0/1

a. DorsiKex the foot while extending the knee when the cramps occur
b. DorsiKex the foot while Kexing the knee when the cramps occur
c. Plantar Kex the foot while Kexing the knee when the cramps occur

d. Plantar Kex the foot while extending the knee when the cramps occur.

Correct answer
a. DorsiKex the foot while extending the knee when the cramps occur

60. Upon checking Kara’s fundal height, she complains of feeling dizzy and lightheaded. Her skin is
also pale and moist. What is your initial response?
*
0/1

a. Assess Kara’s blood pressure and pulse

b. Have Kara breathe into a paper bag
c. Raise Kara’s legs

d. Turn Kara on her side.

Correct answer
d. Turn Kara on her side.

Situation
Celine arrives at the emergency department (ED) with abruptio placentae at 34 weeks’ gestation. The following
questions apply.
61. Upon reviewing her history, which of the following data puts her at most risk for abruptio
placentae?
*
1/1

a. Diagnosis of hypertension 3 years ago

b. 34 weeks AOG
c. Exercising during pregnancy
d. Eating more than recommended caloric intake

62. What should you assess in Celine?

*
0/1

a. Bright red, painless vaginal bleeding

b. Concealed or external dark red bleeding

c. Palpable fetal outline
d. Soft and nontender abdomen

Correct answer
b. Concealed or external dark red bleeding
63. Assessment showed that Celine is experiencing moderate vaginal bleeding. Based on these
Dndings, you would prepare the client for:
*
0/1

a. Complete bed rest for the remainder of the pregnancy

b. Delivery of the fetus
c. Strict monitoring of intake and output

d. The need for weekly monitoring of coagulation studies until the time of delivery

Correct answer
b. Delivery of the fetus

64. Based on your knowledge regarding abruptio placentae, Celine is at risk for which of the following
blood dyscrasias?
*
0/1

a. Thrombocytopenia
b. Idiopathic thrombocytopenic purpura (ITP)

c. Disseminated intravascular coagulation (DIC)

d. Heparin-associated thrombosis and thrombocytopenia (HATT)

Correct answer
c. Disseminated intravascular coagulation (DIC)

65. Because of the blood dyscrasias that may occur in Celine, which assessment Dnding is least likely
to be associated with this hematological condition?
*
0/1

a. Swelling of the calf in one leg

b. Prolonged clotting times
c. Decreased platelet count

d. Petechiae, oozing from injection sites, and hematuria

Correct answer
a. Swelling of the calf in one leg

Situation
Intrapartum and Postpartum care

66. You are caring for a client in the active phases of labor. The nurse is assessing the fetal patterns
and notes a late deceleration on the monitor strip. The most appropriate nursing action is to:
*
0/1

a. Place the mother in the supine position

b. Document the Dndings and continue to monitor the fetal patterns

c. Administer oxygen via face mask

d. Increase the rate of pitocin IV infusion

Correct answer
c. Administer oxygen via face mask

67. You are reviewing the record of a client in the labor room and note that the fetus is at (-1) station.
You document that the fetal presenting part is:
*
1/1

a. 1 cm above ischial spine

b. 1 in below coccyx
c. 1 Dngerbreadth below symphysis pubis
d. 1 in below iliac crest

68. During stage 3 of labor, you note a gush of blood and that the uterus changes shape from an oval
shape to globular shape. This indicates what?
*
0/1

a. Postpartum hemorrhage
b. Imminent delivery of the baby

c. Signs of placental separation

d. Answers B and C

Correct answer
c. Signs of placental separation

69. Upon assessment, you got the following Dndings: 2 perineal pads highly saturated with blood
within 1.5 hours postpartum, PR = 90 bpm, fundus soft and boundaries not well deDned. The
appropriate nursing diagnosis is:
*
1/1

a. Normal blood loss

b. Blood volume deDciency
c. Inadequate tissue perfusion related to hemorrhage
d. Hemorrhage secondary to uterine atony
70. During an internal examination, the nurse palpated the posterior fontanel to be at the left side of
the mother at the upper quadrant. The interpretation is that the position of the fetus is:
*
0/1

a. LOA
b. ROP
c. LOP
d. ROA

Correct answer
a. LOA

71. When doing perineal care in preparation for delivery, you should observe the following,
except:
*
0/1

a. Use up-down technique with one stroke

b. Clean from the mons veneris to the anus

c. Use mild soap and warm water
d. Paint the inner thighs going towards the perineal area

Correct answer
d. Paint the inner thighs going towards the perineal area
72. You transported a client in labor to the delivery room and prepared her for a cesarean delivery.
Upon transferring her to the delivery room table, you place the client in what position?
*
1/1

a. Trendelenburg’s position with the legs in stirrups

b. Semi-Fowler position with a pillow under the knees
c. Prone position with the legs separated and elevated
d. Supine position with a wedge under the right hip

73. You are instructing a postpartum mother regarding lochia and the amount of expected lochia
drainage. You instruct the mother that the normal amount of lochia may vary but should never
exceed the need for:
*
0/1

a. One peripad per day

b. Three peripads per day

c. Eight peripads per day

d. Twelve peripads per day

Correct answer
c. Eight peripads per day

74. Five hours after a diqcult labor and birth, a primiparous woman refuses to hold and feed her baby,
stating that she is too tired and just wants to sleep. You should: *
0/1
a. Tell the woman she can rest after she feeds her baby

b. Recognize this as a behavior of the taking-hold stage

c. Record the behavior as inebective maternal-newborn attachment
d. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time

Correct answer
d. Take the baby back to the nursery, reassuring the woman that her rest is a priority at this time

75. Methergine or pitocin was prescribed for your client with postpartum hemorrhage. However,
upon reading the patient’s history, you decided to contact her healthcare provider before medication
administration because you noted that she has which of the following conditions?
*
0/1

a. Peripheral vascular disease

b. Hypothyroidism
c. Hypotension

d. Type 1 diabetes

Correct answer
a. Peripheral vascular disease

Situation
Shane, a 35-year-old female, is currently 16 weeks AOG. She reported the following health history:
G5P4T3P1A0L4, BMI 29, diagnosis of hypertension and depression, and family history of Type 2 diabetes.

76. Which among the following risk factors increases Shane’s risk of developing gestational
diabetes mellitus? Select all that apply
*
1/1

a. 35-years-old
b. 16 weeks pregnant
c. G5P4T3P1A0L4
d. BMI 29
e. Hypertension
f. Depression
g. Family history of Type 2 diabetes

77. Which test below is used to diagnose a patient with this condition? *
0/1

a. 1 hour glucose tolerance test

b. 24 hour urine collection

c. Hemoglobin A1C
d. 3 hour glucose tolerance test

Correct answer
d. 3 hour glucose tolerance test

78. fter being diagnosed with GDM, Shane asks you how it can abect her baby. As the nurse, you
know that her baby is at risk for? Select all that apply.
*
1/1
a. Hyperglycemia
b. Hypoglycemia
c. Respiratory distress
d. Hyperbilirubinemia

e. Hyperthermia

79. Fortunately, Shane’s pregnancy was healthy and she delivered a healthy baby boy. However,
upon check up, you observe several interactions between Shane and her new son. What statement
would you investigate further to identify a possible maladaptive behavior regarding parent-infant
attachment?
*
0/1

a. “My baby is hungry all the time. He wants to breastfeed every hour.”

b. “This is my Dfth baby. I’m not sure how we can handle our Dnances for all of our children, but my husband will
take care of it.”
c. “This will be my last pregnancy. I don’t think it’s healthy for me to breastfeed and lose more sleep in the
future.”
d. “I don’t like looking at my baby’s eyes. I only remember the pain of delivering him and now thinking how
he will abect our Dnances.”

Correct answer
d. “I don’t like looking at my baby’s eyes. I only remember the pain of delivering him and now thinking how
he will abect our Dnances.”

80. depressed at home with my new baby?” What are the helpful guidelines you may give? Select
all that apply.

i. Plan a balanced program of nutrition, exercise, and sleep.

ii. Stay with your baby all the time.

iii. Share your feelings with a support person.

iv. Avoid doing other stub aside from baby care.

v. Do not try to be perfect.

*
0/1

a. i, ii, iv
b. i, iii, v
c. i, iii, iv, v

d. i, ii, iii, iv, v

Correct answer
b. i, iii, v
Situation
Fetal development and pregnancy

81. A prenatal client at 35 weeks gestation is scheduled for an amniocentesis to determine fetal lung
maturity. The nurse expects the lecithin/sphingomyelin (L/S) ratio to be:
*
1/1

a. 0.5:1
b. 1:1
c. 2:1

d. 3:1

82. A client states that she had a spontaneous abortion 12 months ago. The client asks if her hormones
may have contributed to the loss of the pregnancy. The nurse’s response is based upon her knowledge
of which of the following facts?
*
1/1

a. Implantation occurs when progesterone levels are low.

b. hCG reaches a maximum level at 4 weeks gestation.
c. Progesterone decreases the contractility of the uterus.

d. Progesterone is only produced by the corpus luteum during pregnancy.

83. Amniocentesis was done on a pregnant client 16 weeks AOG. You documented that the fetal
urine is a strong yellow. How would you interpret this?
*
0/1

a. Normal, fetal urine is dark yellow in color.

b. Abnormal, this indicates blood incompatibility

c. Abnormal, this indicates presence of meconium
d. Abnormal, this indicates decreased alpha fetoprotein

Correct answer
b. Abnormal, this indicates blood incompatibility

84. Upon checking for the amniotic Kuid, you noted that the alpha fetoprotein (AFP) is too high.
What can be investigated further as a possible condition of the fetus? *
0/1

a. Down syndrome
b. Trisomy 21
c. Open body defect
d. Decreased lung surfactant

Correct answer
c. Open body defect

85. During a prenatal visit a patient tells you her last menstrual period was August 28, 2016. Based
on the Naegele's Rule, when is the estimated due date of her baby? *
0/1

a. July 4, 2017
b. June 3, 2017

c. June 4, 2017
d. July 1, 2016

Correct answer
c. June 4, 2017

86. During a prenatal visit a patient tells you her last menstrual period was January 30, 2016. Based
on the Naegele's Rule, when is the estimated due date of her baby? *
1/1

a. November 6, 2016

b. October 25. 2017

c. November 4, 2017
d. October 22, 2016

87. Your patient is 24 weeks pregnant, and you’re measuring the fundal height. Which Dnding below
is a normal measurement for this patient?
*
1/1

a. 16 cm
b. 28 cm
c. 26 cm

d. 12 cm

88. A patient is 40 weeks pregnant, and you Dnd the fundal height to be 4 cm below the xiphoid
process. Your next nursing action is to:
*
0/1

a. Notify the MD immediately

b. Chart this as a normal Dnding

c. Place the patient on continuous fetal monitoring
d. Assess the baby’s heart rate with a Doppler

Correct answer
b. Chart this as a normal Dnding

89. Starting 16 weeks AOG, a pregnant mother may secrete colostrum. The hormone _____ is
responsible for its production, while the hormone _____ is responsible for its secretion.
*
0/1

a. Prolactin, oxytocin
b. Oxytocin, prolactin
c. Estrogen, prolactin
d. Progesterone, estrogen

Correct answer
a. Prolactin, oxytocin

90. You are conducting Leopold’s Maneuver to a pregnant client. While doing the umbilical grip to
determine position, you palpated that the baby lies transversely. What landmark is this?
*
0/1

a. Occiput
b. Mentum

c. Sacrum
d. Acromion

Correct answer
d. Acromion
Situation
Breastfeeding is an important activity among mothers. The following questions apply.

91. According to the Philippine Milk Code of 1986 or EO 51, which among the following is
recommended to protect and promote breastfeeding?
*
0/1

a. Advertisement of breastmilk substitutes

b. Infant formula manufacturers giving mothers free breastmilk substitutes c.

Including infant formula milk in relief goods
d. Teaching mothers in the community how to collect breast milk

Correct answer
d. Teaching mothers in the community how to collect breast milk

92. The nurse assesses the mother of a newborn who is breastfeeding. Which assessment
Dnding indicates inebective breastfeeding of the newborn? *
0/1

a. The newborn’s mouth grasps the mother’s nipple with the tongue down.

b. The newborn swallows audibly, spontaneously, and frequently.

c. The newborn smacks their lips loudly during breastfeeding.
d. The newborn turns to the breast when its cheek is stroked with a nipple.

Correct answer
c. The newborn smacks their lips loudly during breastfeeding.

93. Which of the following is the primary predisposing factor related to mastitis? *
0/1

a. Epidemic infection from nosocomial sources localizing in the lactiferous glands and ducts b. Endemic
infection occurring randomly and localizing in the peri glandular connective tissue
c. Temporary urinary retention due to decreased perception of the urge to avoid d. Breast
injury caused by overdistention, stasis, and cracking of the nipples

Correct answer
d. Breast injury caused by overdistention, stasis, and cracking of the nipples

94. You are providing instructions to a mother who has been diagnosed with mastitis. Which of the
following statements, if made by the mother, indicates a need for further teaching?
*
0/1

a. “I need to take antibiotics, and I should begin to feel better in 24-48 hours.” b. “I can
use analgesics to assist in alleviating some of the discomfort.”

c. “I need to wear a supportive bra to relieve the discomfort.”

d. “I need to stop breastfeeding until this condition resolves.”

Correct answer
d. “I need to stop breastfeeding until this condition resolves.”

95. What psychosocial component is developed when a mother responds to a baby’s need to
feed?
*
0/1

a. Trust
b. Love
c. Respect
d. Warmth

Correct answer
a. Trust
Situation
Ethical principles apply in all nursing care. You are caring for a Sarah, a pregnant mother who belongs to
an Indigenous People group.

96. Cultural awareness is an in-depth self-examination of one’s:

*
0/1

a. Background, recognizing biases and prejudices

b. Social, cultural, and biophysical factors

c. Engagement in cross-cultural interactions

d. Motivation and commitment to caring

Correct answer
a. Background, recognizing biases and prejudices

97. Which factor is least signiDcant during assessment when gathering information about
Sarah’s cultural practices?
*
1/1

a. Language, timing
b. Touch, eye contact
c. Biocultural needs

d. Pain perception, management expectations

98. If an ethical dilemma regarding care for Sarah arises, the solution to the dilemma requires
negotiation among members of the healthcare team. Your point of view is valuable because:
*
1/1

a. Nurses have a legal license that encourages their presence during ethical discussions. b. The principle
of autonomy guides all participants to respect their own self-worth. c. Nurses develop a relationship to the
client that is unique among all professional health care providers.

d. The nurse’s code of ethics recommends that a nurse be present at any ethical discussion about client care.

99. While Sarah is in severe pain, you left her alone with the side rails down, and the bed in a high
position. She then falls and developed bleeding. What law has been broken? *
1/1
a. Assault
b. Battery
c. Negligence

d. Civil tort
100. Despite Sarah being economically disadvantaged, you provided her quality care and gave her
resources she needed just like other patients. What ethical principle is applicable in this situation?
*
1/1

a. BeneDcence
b. Justice

c. Non-maleDcence
d. Autonomy
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