Maternal and Child Heath Nursing Exam 1
The uterus has already risen out of the
(25 items)
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1. A client asks the nurse what a third degree
laceration is. She was informed that she had
one. The nurse explains that this is:
A. that extended their anal
sphincter
B. through the skin and into the
muscles
C. that involves anterior rectal wall
D. that extends through the perineal
muscle.
Third degree laceration involves all in the
second degree laceration and the external
sphincter of the rectum. Options B, C and D
are under the second degree laceration.
2. Betina 30 weeks AOG discharged with a
diagnosis of placenta previa. The nurse
knows that the client understands her care at
home when she says:
A. I am happy to note that we can
have sex occasionally when I
have no bleeding.
B. I am afraid I might have an
operation when my due comes
C. I will have to remain in bed until
my due date comes
D. I may go back to work since I stay
only at the office.
Placenta previa means that the placenta is
the presenting part. On the first and
second trimester there is spotting. On the
third trimester there is bleeding that is
sudden, profuse and painless.
3.
pelvis and is experiencing farther into the
abdominal area at about the:
A. 8th week of pregnancy
B. 10th week of pregnancy
C. 12th week of pregnancy
D. 18th week of pregnancy
On the 8th week of pregnancy, the uterus is
still within the pelvic area. On the 10th
week, the uterus is still within the pelvic
area. On the 12th week, the uterus and
placenta have grown, expanding into the
abdominal cavity. On the 18th week, the
uterus has already risen out of the pelvis
and is expanding into the abdominal area.
4. Which of the following urinary symptoms
does the pregnant woman most frequently
experience during the first trimester:
A. frequency
B. dysuria
C. incontinence
D. burning
5. Mrs. Jimenez went to the health center for
pre-natal check-up. the student nurse took
her weight and revealed 142 lbs. She asked
the student nurse how much should she gain
weight in her pregnancy.
A. 20-30 lbs
B. 25-35 lbs
C. 30- 40 lbs
D. 10-15 lbs
6. The nurse is preparing Mrs. Jordan for
cesarean delivery. Which of the following key
concept should the nurse consider when
implementing nursing care?
A. Explain the surgery, expected
outcome and kind of
anesthetics.
B. Modify preoperative teaching to
meet the needs of either a
 planned or emergency cesarean
birth.
C. Arrange for a staff member of the
anesthesia department to
explain what to expect post-
operatively.
D. Instruct the mother’s support
person to remain in the family
lounge until after the delivery.
7. Bettine Gonzales is hospitalized for the
treatment of severe preecplampsia. Which of
the following represents an unusual finding
for this condition?
A. generalized edema
B. proteinuria 4+
C. blood pressure of 160/110
D. convulsions
8. Nurse Geli explains to the client who is 33
weeks pregnant and is experiencing vaginal
bleeding that coitus:
A. Need to be modified in any way
by either partner
B. Is permitted if penile penetration
is not deep.
C. Should be restricted because it
may stimulate uterine activity.
D. Is safe as long as she is in side-
lying position.
9. Mrs. Precilla Abuel, a 32 year old mulripara
is admitted to labor and delivery. Her last 3
pregnancies in short stage one of labor. The
nurses decide to observe her closely. The
physician determines that Mrs. Abuel’s cervix
is dilated to 6 cm. Mrs. Abuel states that she
is extremely uncomfortable. To lessen Mrs.
Abuel’s discomfort, the nurse can advise her
to:
A. lie face down
B. not drink fluids
C. practice holding breaths
between contractions
D. assume Sim’s position
10. Which is true regarding the fontanels of
the newborn?
A. The anterior is large in shape
when compared to the posterior
fontanel.
B. The anterior is triangular shaped;
the posterior is diamond shaped.
C. The anterior is bulging; the
posterior appears sunken.
D. The posterior closes at 18
months; the anterior closes at 8
to 12 months.
11. Mrs. Quijones gave birth by spontaneous
delivery to a full term baby boy. After a minute
after birth, he is crying and moving actively.
His birth weight is 6.8 lbs. What do you expect
baby Quijones to weigh at 6 months?
A. 13 -14 lbs
B. 16 -17 lbs
C. 22 -23 lbs
D. 27 -28 lbs
12. During the first hours following delivery,
the post partum client is given IVF with
oxytocin added to them. The nurse
understands the primary reason for this is:
A. To facilitate elimination
B. To promote uterine contraction
C. To promote analgesia
D. To prevent infection
13. Nurse Luis is assessing the newborn’s
heart rate. Which of the following would be
considered normal if the newborn is
sleeping?
A. 80 beats per minute
B. 100 beats per minute
C. 120 beats per minute
D. 140 beats per minute
14. The infant with Down Syndrome should go
through which of the Erikson’s developmental
stages first?
A. Initiative vs. Self doubt
B. Industry vs. Inferiority
C. Autonomy vs. Shame and doubt
D. Trust vs. Mistrust
15. The child with phenylketonuria (PKU)
must maintain a low phenylalanine diet to
prevent which of the following
complications?
A. Irreversible brain damage
B. Kidney failure
C. Blindness
D. Neutropenia
16. Which age group is with imaginative
minds and creates imaginary friends?
A. Toddler
B. Preschool
C. School
D. Adolescence
17. Which of the following situations would
alert you to a potentially developmental
problem with a child?
A. Pointing to body parts at 15
months of age.
B. Using gesture to communicate at
18 months.
C. Cooing at 3 months.
D. Saying “mama” or “dada” for the
first time at 18 months of age.
18. Isabelle, a 2 year old girl loves to move
around and oftentimes manifests negativism
and temper tantrums. What is the best way to
deal with her behavior?
A. Tell her that she would not be
loved by others is she behaves
that way..
B. Withholding giving her toys until
she behaves properly.
C. Ignore her behavior as long as
she does not hurt herself and
others.
D. Ask her what she wants and give
it to pacify her.
19. Baby boy Villanueva, 4 months old, was
seen at the pediatric clinic for his scheduled
check-up. By this period, baby Villanueva has
already increased his height by how many
inches?
A. 3 inches
B. 4 inches
C. 5 inches
D. 6 inches
20. Alice, 10 years old was brought to the ER
because of Asthma. She was immediately put
under aerosol administration of Terbutaline.
After sometime, you observe that the child
does not show any relief from the treatment
given. Upon assessment, you noticed that
both the heart and respiratory rate are still
elevated and the child shows difficulty of
exhaling. You suspect:
A. Bronchiectasis
B. Atelectasis
C. Epiglotitis
D. Status Asthmaticus
21. Nurse Jonas assesses a 2 year old boy
with a tentative diagnosis of nephroblastoma.
Symptoms the nurse observes that suggest
this problem include:
A. Lymphedema and nerve palsy
B. Hearing loss and ataxia
C. Headaches and vomiting
D. Abdominal mass and weakness
22. Which of the following danger sings
should be reported immediately during the
antepartum period?
A. blurred vision
B. nasal stuffiness
C. breast tenderness
D. constipation
23. Nurse Jacob is assessing a 15 month old
child with acute otitis media. Which of the
following symptoms would the nurse
anticipate finding?
A. periorbital edema, absent light
reflex and translucent tympanic
membrane
B. irritability, purulent drainage in
middle ear, nasal congestion and
cough
 C. diarrhea, retracted tympanic
membrane and enlarged parotid
gland
D. Vomiting, pulling at ears and
pearly white tympanic
membrane
24. Which of the following is the most
appropriate intervention to reduce stress in a
preterm infant at 33 weeks gestation?

A. Sensory stimulation including

several senses at a time
B. tactile stimulation until signs of
over stimulation develop
C. An attitude of extension when
prone or side lying
D. Kangaroo care
25. The parent of a client with albinism would
need to be taught which preventive
healthcare measure by the nurse:

A. Ulcerative colitis diet

B. Use of a high-SPF sunblock
C. Hair loss monitoring
D. Monitor for growth retardation
Maternal and Child Heath Nursing Exam 2 5. Mrs. Bendivin states that she is
(25 items) experiencing aching swollen, leg veins. The
nurse would explain that this is most
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exams/philippine-nursing-licensure-exam-
pnle/pnle-maternal-and-child-health- A. Thrombophlebitis
nursing-exam-2/ B. PIH
C. Pressure on blood vessels from
1. Nurse Bella explains to a 28 year old the enlarging uterus
pregnant woman undergoing a non-stress D. The force of gravity pulling down
test that the test is a way of evaluating the on the uterus
condition of the fetus by comparing the fetal 6. Mrs. Ella Santoros is a 25 year old
heart rate with: primigravida who has Rheumatic heart
disease lesion. Her pregnancy has just been
A. Fetal lie diagnosed. Her heart disease has not caused
B. Fetal movement her to limit physical activity in the past. Her
C. Maternal blood pressure cardiac disease and functional capacity
D. Maternal uterine contractions classification is:
2. During a 2 hour childbirth focusing on labor
and delivery process for primigravida. The A. Class I
nurse describes the second maneuver that B. Class II
the fetus goes through during labor progress C. Class III
when the head is the presenting part as which D. class IV
of the following: 7. The client asks the nurse, “When will this
soft spot at the top of the head of my baby
A. Flexion will close?” The nurse should instruct the
B. Internal rotation mother that the neonate’s anterior fontanel
C. Descent will normally close by age:
D. External rotation
3. Mrs. Jovel Diaz went to the hospital to have A. 2-3 months
her serum blood test for alpha-fetoprotein. B. 6-8 months
The nurse informed her about the result of the C. 10-12 months
elevation of serum AFP. The patient asked her D. 12-18 months
what was the test for: 8. When a mother bleeds and the uterus is
relaxed, soft and non-tender, you can
A. Congenital Adrenal Hyperplasia account the cause to:
B. PKU
C. Down Syndrome A. Atony of the uterus
D. Neural tube defects B. Presence of uterine scar
4. Fetal heart rate can be auscultated with a C. Laceration of the birth canal
fetoscope as early as: D. Presence of retained placenta
fragments
A. 5 weeks of gestation 9. Mrs. Pichie Gonzales’s LMP began April 4,
B. 10 weeks of gestation 2010. Her EDD should be which of the
C. 15 weeks of gestation following:
D. 20 weeks of gestation
A. February 11, 2011
 B. January 11, 20111
C. December 12, 2010
D. Nowember 14, 2010
10. Which of the following prenatal laboratory
test values would the nurse consider as
significant?
A. Hematocrit 33.5%
B. WBC 8,000/mm3
C. Rubella titer less than 1:8
D. One hour glucose challenge test
110 g/dL
11. Aling Patricia is a patient with
preeclampsia. You advise her about her
condition, which would tell you that she has
not really understood your instructions?
A. “I will restrict my fat in my diet.”
B. “I will limit my activities and rest
more frequently throughout the
day.”
C. “I will avoid salty foods in my
diet.”
D. “I will come more regularly for
check-up.”
12. Mrs. Grace Evangelista is admitted with
severe preeclampsia. What type of room
should the nurse select this patient?
A. A room next to the elevator.
B. The room farthest from the
nursing station.
C. The quietest room on the floor.
D. The labor suite.
13. During a prenatal check-up, the nurse
explains to a client who is Rh negative that
RhoGAM will be given:
A. Weekly during the 8th month
because this is her third
pregnancy.
B. During the second trimester, if
amniocentesis indicates a
problem.
C. To her infant immediately after
delivery if the Coomb’s test is
positive.
D. Within 72 hours after delivery if
infant is found to be Rh positive.
14. A baby boy was born at 8:50pm. At
8:55pm, the heart rate was 99 bpm. She has a
weak cry, irregular respiration. She was
moving all extremities and only her hands and
feet were still slightly blue. The nurse should
enter the APGAR score as:
A. 5
B. 6
C. 7
D. 8
15. Billy is a 4 year old boy who has an IQ of
140 which means:
A. average normal
B. very superior
C. above average
D. genius
16. A newborn is brought to the nursery. Upon
assessment, the nurse finds that the child
has short palpebral fissures, thinned upper
lip. Based on this data, the nurse suspects
that the newborn is MOST likely showing the
effects of:
A. Chronic toxoplasmosis
B. Lead poisoning
C. Congenital anomalies
D. Fetal alcohol syndrome
17. A priority nursing intervention for the
infant with cleft lip is which of the following:
A. Monitoring for adequate
nutritional intake
B. Teaching high-risk newborn care
C. Assessing for respiratory distress
D. Preventing injury
18. Nurse Jacob is assessing a 12 year old
who has hemophilia A. Which of the following
assessment findings would the nurse
anticipate?
A. an excess of RBC
B. an excess of WBC
C. a deficiency of clotting factor VIII
 D. a deficiency of clotting factor IX
19. Celine, a mother of a 2 year old tells the
nurse that her child “cries and has a fit when I
have to leave him with a sitter or someone
else.” Which of the following statements
would be the nurse’s most accurate analysis
of the mother’s comment?
A. The child has not experienced
limit-setting or structure.
B. The child is expressing a physical
need, such as hunger.
C. The mother has nurtured
overdependence in the child.
D. The mother is describing her
child’s separation anxiety.
20. Mylene Lopez, a 16 year old girl with
scoliosis has recently received an invitation
to a pool party. She asks the nurse how she
can disguise her impairment when dressed in
a bathing suit. Which nursing diagnosis can
be justified by Mylene’s statement?
A. Anxiety
B. Body image disturbance
C. Ineffective individual coping
D. Social isolation
21. The foul-smelling, frothy characteristic of
the stool in cystic fibrosis results from the
presence of large amounts of which of the
following:
A. sodium and chloride
B. undigested fat
C. semi-digested carbohydrates
D. lipase, trypsin and amylase
22. Which of the following would be a
disadvantage of breast feeding?
A. involution occurs rapidly
B. the incidence of allergies
increases due to maternal
antibodies
C. the father may resent the infant’s
demands on the mother’s body
D. there is a greater chance of error
during preparation
23. A client is noted to have lymphedema,
webbed neck and low posterior hairline.
Which of the following diagnoses is most
appropriate?
A. Turner’s syndrome
B. Down’s syndrome
C. Marfan’s syndrome
D. Klinefelter’s syndrome
24. A 4 year old boy most likely perceives
death in which way:
A. An insignificant event unless
taught otherwise
B. Punishment for something the
individual did
C. Something that just happens to
older people
D. Temporary separation from the
loved one.
25. Catherine Diaz is a 14 year old patient on
a hematology unit who is being treated for
sickle cell crisis. During a crisis such as that
seen in sickle cell anemia, aldosterone
release is stimulated. In what way might this
influence Catherine’s fluid and electrolyte
balance?
A. sodium loss, water loss and
potassium retention
B. sodium loss, water los and
potassium loss
C. sodium retention, water loss and
potassium retention
D. sodium retention, water
retention and potassium loss
Maternal and Child Health Nursing Exam 3
(100 items)
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1. A pregnant woman who is at term is
admitted to the birthing unit in active labor.
The client has only progressed from 2cm to 3
cm in 8 hours. She is diagnosed with
hypotonic dystocia and the physician ordered
Oxytocin (Pitocin) to augment her
contractions. Which of the following is the
most important aspect of nursing
intervention at this time?
A. Timing and recording length of
contractions.
B. Monitoring.
C. Preparing for an emergency
cesarean birth.
D. Checking the perineum for
bulging.
2. A client who hallucinates is not in touch
with reality. It is important for the nurse to:
A. Isolate the client from other
patients.
B. Maintain a safe environment.
C. Orient the client to time, place,
and person.
D. Establish a trusting relationship.
3. The nurse is caring to a child client who has
had a tonsillectomy. The child complains of
having dryness of the throat. Which of the
following would the nurse give to the child?
A. Cola with ice
B. Yellow noncitrus Jello
C. Cool cherry Kool-Aid
D. A glass of milk
4. The physician ordered Phenylephrine (Neo-
Synephrine) nasal spray to a 13-year-old
client. The nurse caring to the client provides
instructions that the nasal spray must be
used exactly as directed to prevent the
development of:
A. Increased nasal congestion.
B. Nasal polyps.
C. Bleeding tendencies.
D. Tinnitus and diplopia.
5. A client with tuberculosis is to be admitted
in the hospital. The nurse who will be
assigned to care for the client must institute
appropriate precautions. The nurse should:
A. Place the client in a private
room.
B. Wear an N 95 respirator when
caring for the client.
C. Put on a gown every time when
entering the room.
D. Don a surgical mask with a face
shield when entering the room.
6. Which of the following is the most frequent
cause of noncompliance to the medical
treatment of open-angle glaucoma?
A. The frequent nausea and
vomiting accompanying use of
miotic drug.
B. Loss of mobility due to severe
driving restrictions.
C. Decreased light and near-vision
accommodation due to miotic
effects of pilocarpine.
D. The painful and insidious
progression of this type of
glaucoma.
7. In the morning shift, the nurse is making
rounds in the nursing care units. The nurse
enters in a client’s room and notes that the
client’s tube has become disconnected from
the Pleurovac. What would be the initial
nursing action?
A. Apply pressure directly over the
incision site.
 B. Clamp the chest tube near the
incision site.
C. Clamp the chest tube closer to
the drainage system.
D. Reconnect the chest tube to the
Pleurovac.
8. Which of the following complications
during a breech birth the nurse needs to be
alarmed?
A. Abruption placenta.
B. Caput succedaneum.
C. Pathological hyperbilirubinemia.
D. Umbilical cord prolapse.
9. The nurse is caring to a client diagnosed
with severe depression. Which of the
following nursing approach is important in
depression?
A. Protect the client against harm to
others.
B. Provide the client with motor
outlets for aggressive, hostile
feelings.
C. Reduce interpersonal contacts.
D. Deemphasizing preoccupation
with elimination, nourishment,
and sleep.
10. A 3-month-old client is in the pediatric
unit. During assessment, the nurse is
suspecting that the baby may have
hypothyroidism when mother states that her
baby does not:
A. Sit up.
B. Pick up and hold a rattle.
C. Roll over.
D. Hold the head up.
11. The physician calls the nursing unit to
leave an order. The senior nurse had
conversation with the other staff. The newly
hired nurse answers the phone so that the
senior nurses may continue their
conversation. The new nurse does not
knowthe physician or the client to whom the
order pertains. The nurse should:
A. Ask the physician to call back
after the nurse has read the
hospital policy manual.
B. Take the telephone order.
C. Refuse to take the telephone
order.
D. Ask the charge nurse or one of
the other senior staff nurses to
take the telephone order.
12. The staff nurse on the labor and delivery
unit is assigned to care to a primigravida in
transition complicated by hypertension. A
new pregnant woman in active labor is
admitted in the same unit. The nurse
manager assigned the same nurse to the
second client. The nurse feels that the client
with hypertension requires one-to-one care.
What would be the initial actionof the nurse?
A. Accept the new assignment and
complete an incident report
describing a shortage of nursing
staff.
B. Report the incident to the nursing
supervisor and request to be
floated.
C. Report the nursing assessment
of the client in transitional labor
to the nurse manager and
discuss misgivings about the
new assignment.
D. Accept the new assignment and
provide the best care.
13. A newborn infant with Down syndrome is
to be discharged today. The nurse is
preparing to give the discharge teaching
regarding the proper care at home. The nurse
would anticipate that the mother is probably
at the:
A. 40 years of age.
B. 20 years of age.
C. 35 years of age.
D. 20 years of age.
14. The emergency department has shortage
of staff. The nurse manager informs the staff
nurse in the critical care unit that she has to
float to the emergency department. What
should the staff nurse expect under these
conditions?
A. The float staff nurse will be
informed of the situation before
the shift begins.
B. The staff nurse will be able to
negotiate the assignments in the
emergency department.
C. Cross training will be available
for the staff nurse.
D. Client assignments will be
equally divided among the
nurses.
15. The nurse is assigned to care for a child
client admitted in the pediatrics unit. The
client is receiving digoxin. Which of the
following questions will be asked by the nurse
to the parents of the child in order to assess
the client’s risk for digoxin toxicity?
A. “Has he been exposed to any
childhood communicable
diseases in the past 2-3 weeks?”
B. “Has he been taking diuretics at
home?”
C. “Do any of his brothers and
sisters have history of cardiac
problems?”
D. “Has he been going to school
regularly?”
16. The nurse noticed that the signed consent
form has an error. The form states,
“Amputation of the right leg” instead of the
left leg that is to be amputated. The nurse has
administered already the preoperative
medications. What should the nurse do?
A. Call the physician to reschedule
the surgery.
B. Call the nearest relative to come
in to sign a new form.
C. Cross out the error and initial the
form.
D. Have the client sign another
form.
17. The nurse in the nursing care unit checks
the fluctuation in the water-seal
compartment of a closed chest drainage
system. The fluctuation has stopped, the
nurse would:
A. Vigorously strip the tube to
dislodge a clot.
B. Raise the apparatus above the
chest to move fluid.
C. Increase wall suction above 20
cm H2O pressure.
D. Ask the client to cough and take
a deep breath.
18. The pediatric nurse in the neonatal unit
was informed that the baby that is brought to
the mother in the hospital room is wrong. The
nurse determines that two babies were
placed in the wrong cribs. The most
appropriate nursing action would be to:
A. Determine who is responsible for
the mistake and terminate his or
her employment.
B. Record the event in an
incident/variance report and
notify the nursing supervisor.
C. Reassure both mothers, report to
the charge nurse, and do not
record.
D. Record detailed notes of the
event on the mother’s medical
record.
19. Before the administration of digoxin, the
nurse completes an assessment to a toddler
client for signs and symptoms of digoxin
toxicity. Which of the following is the earliest
and most significant sign of digoxin toxicity?
A. Tinnitus
B. Nausea and vomiting
C. Vision problem
D. Slowing in the heart rate
20. Which of the following treatment modality
is appropriate for a client with paranoid
tendency?
 A. Activity therapy.
B. Individual therapy.
C. Group therapy.
D. Family therapy.
21. The client with rheumatoid arthritis is for
discharge. In preparing the client for
discharge on prednisone therapy, the nurse
should advise the client to:
A. Wear sunglasses if exposed to
bright light for an extended
period of time.
B. Take oral preparations of
prednisone before meals.
C. Have periodic complete blood
counts while on the medication.
D. Never stop or change the amount
of the medication without
medical advice.
22. A pregnant client tells the nurse that she
is worried about having urinary frequency.
What will be the most appropriate nursing
response?
A. “Try using Kegel (perineal)
exercises and limiting fluids
before bedtime. If you have
frequency associated with fever,
pain on voiding, or blood in the
urine, call your doctor/nurse-
midwife.
B. “Placental progesterone causes
irritability of the bladder
sphincter. Your symptoms will go
away after the baby comes.”
C. “Pregnant women urinate
frequently to get rid of fetal
wastes. Limit fluids to 1L/daily.”
D. “Frequency is due to bladder
irritation from concentrate urine
and is normal in pregnancy.
Increase your daily fluid intake to
3L.”
23. Which of the following will help the nurse
determine that the expression of hostility is
useful?
A. Expression of anger dissipates
the energy.
B. Energy from anger is used to
accomplish what needs to be
done.
C. Expression intimidates others.
D. Degree of hostility is less than
the provocation.
24. The nurse is providing an orientation
regarding case management to the nursing
students. Which characteristics should the
nurse include in the discussion in
understanding case management?
A. Main objective is a written plan
that combines discipline-
specific processes used to
measure outcomes of care.
B. Main purpose is to identify
expected client, family and staff
performance against the timeline
for clients with the same
diagnosis.
C. Main focus is comprehensive
coordination of client care, avoid
unnecessary duplication of
services, improve resource
utilization and decrease cost.
D. Primary goal is to understand
why predicted outcomes have
not been met and the correction
of identified problems.
25. The physician orders a dose of IV
phenytoin to a child client. In preparing in the
administration of the drug, which nursing
action is not correct?
A. Infuse the phenytoin into a
smaller vein to prevent purple
glove syndrome.
B. Check the phenytoin solution to
be sure it is clear or light yellow
in color, never cloudy.
C. Plan to give phenytoin over 30-60
minutes, using an in-line filter.
D. Flush the IV tubing with normal
saline before starting phenytoin.
26. The pregnant woman visits the clinic for
check –up. Which assessment findings will
help the nurse determine that the client is in
8-week gestation?
A. Leopold maneuvers.
B. Fundal height.
C. Positive radioimmunoassay test
(RIA test).
D. Auscultation of fetal heart tones.
27. Which of the following nursing
intervention is essential for the client who
had pneumonectomy?
A. Medicate for pain only when
needed.
B. Connect the chest tube to water-
seal drainage.
C. Notify the physician if the chest
drainage exceeds 100mL/hr.
D. Encourage deep breathing and
coughing.
28. The nurse is providing a health teaching to
a group of parents regarding Chlamydia
trachomatis. The nurse is correct in the
statement, “Chlamydia trachomatis is not
only an intracellular bacterium that causes
neonatal conjunctivitis, but it also can cause:
A. Discoloration of baby and adult
teeth.
B. Pneumonia in the newborn.
C. Snuffles and rhagades in the
newborn.
D. Central hearing defects in
infancy.
29. The nurse is assigned to care to a 17-year-
old male client with a history of substance
abuse. The client asks the nurse, “Have you
ever tried or used drugs?” The most correct
response of the nurse would be:
A. “Yes, once I tried grass.”
B. “No, I don’t think so.”
C. “Why do you want to know that?”
D. “How will my answer help you?”
30. Which of the following describes a health
care team with the principles of participative
leadership?
A. Each member of the team can
independently make decisions
regarding the client’s care
without necessarily consulting
the other members.
B. The physician makes most of the
decisions regarding the client’s
care.
C. The team uses the expertise of
its members to influence the
decisions regarding the client’s
care.
D. Nurses decide nursing care;
physicians decide medical and
other treatment for the client.
31. A nurse is giving a health teaching to a
woman who wants to breastfeed her newborn
baby. Which hormone, normally secreted
during the postpartum period, influences
both the milk ejection reflex and uterine
involution?
A. Oxytocin.
B. Estrogen.
C. Progesterone.
D. Relaxin.
32. One staff nurse is assigned to a group of 5
patients for the 12-hour shift. The nurse is
responsible for the overall planning, giving
and evaluating care during the entire shift.
After the shift, same responsibility will be
endorsed to the next nurse in charge. This
describes nursing care delivered via the:
A. Primary nursing method.
B. Case method.
C. Functional method.
D. Team method.
33. The ambulance team calls the emergency
department that they are going to bring a
client who sustained burns in a house fire.
While waiting for the ambulance, the nurse
will anticipate emergency care to include
assessment for:
A. Gas exchange impairment.
B. Hypoglycemia.
C. Hyperthermia.
D. Fluid volume excess.
34. Most couples are using “natural” family
planning methods. Most accidental
pregnancies in couples preferred to use this
method have been related to unprotected
intercourse before ovulation. Which of the
following factor explains why pregnancy may
be achieved by unprotected intercourse
during the preovulatory period?
A. Ovum viability.
B. Tubal motility.
C. Spermatozoal viability.
D. Secretory endometrium.
35. An older adult client wakes up at 2 o’clock
in the morning and comes to the nurse’s
station saying, “I am having difficulty in
sleeping.” What is the best nursing response
to the client?
A. “I’ll give you a sleeping pill to
help you get more sleep now.”
B. “Perhaps you’d like to sit here at
the nurse’s station for a while.”
C. “Would you like me to show you
where the bathroom is?”
D. “What woke you up?”
36. The nurse is taking care of a multipara
who is at 42 weeks of gestation and in active
labor, her membranes ruptured
spontaneously 2 hours ago. While
auscultating for the point of maximum
intensity of fetal heart tones before applying
an external fetal monitor, the nurse counts
100 beats per minute. The immediate nursing
action is to:
A. Start oxygen by mask to reduce
fetal distress.
B. Examine the woman for signs of
a prolapsed cord.
C. Turn the woman on her left side
to increase placental perfusion.
D. Take the woman’s radial pulse
while still auscultating the FHR.
37. The nurse must instruct a client with
glaucoma to avoid taking over-the-counter
medications like:
A. Antihistamines.
B. NSAIDs.
C. Antacids.
D. Salicylates.
38. A male client is brought to the emergency
department due to motor vehicle accident.
While monitoring the client, the nurse
suspects increasing intracranial pressure
when:
A. Client is oriented when aroused
from sleep, and goes back to
sleep immediately.
B. Blood pressure is decreased
from 160/90 to 110/70.
C. Client refuses dinner because of
anorexia.
D. Pulse is increased from 88-96
with occasional skipped beat.
39. The nurse is conducting a lecture to a
class of nursing students about advance
directives to preoperative clients. Which of
the following statement by the nurse js
correct?
A. “The spouse, but not the rest of
the family, may override the
advance directive.”
B. “An advance directive is required
for a “do not resuscitate” order.”
C. “A durable power of attorney, a
form of advance directive, may
only be held by a blood relative.”
D. “The advance directive may be
enforced even in the face of
opposition by the spouse.”
40. A client diagnosed with schizophrenia is
shouting and banging on the door leading to
the outside, saying, “I need to go to an
appointment.” What is the appropriate
nursing intervention?
A. Tell the client that he cannot
bang on the door.
B. Ignore this behavior.
C. Escort the client going back into
the room.
D. Ask the client to move away from
the door.
41. Which of the following action is an
accurate tracheal suctioning technique?
A. 25 seconds of continuous
suction during catheter insertion.
B. 20 seconds of continuous
suction during catheter insertion.
C. 10 seconds of intermittent
suction during catheter
withdrawal.
D. 15 seconds of intermittent
suction during catheter
withdrawal.
42. The client’s jaw and cheekbone is sutured
and wired. The nurse anticipates that the
most important thing that must be ready at
the bedside is:
A. Suture set.
B. Tracheostomy set.
C. Suction equipment.
D. Wire cutters.
43. A mother is in the third stage of labor.
Which of the following signs will help the
nurse determine the signs of placental
separation?
A. The uterus becomes globular.
B. The umbilical cord is shortened.
C. The fundus appears at the
introitus.
D. Mucoid discharge is increased.
44. After therapy with the thrombolytic
alteplase (t-PA), what observation will the
nurse report to the physician?
A. 3+ peripheral pulses.
B. Change in level of
consciousness and headache.
C. Occasional dysrhythmias.
D. Heart rate of 100/bpm.
45. A client who undergone left nephrectomy
has a large flank incision. Which of the
following nursing action will facilitate deep
breathing and coughing?
A. Push fluid administration to
loosen respiratory secretions.
B. Have the client lie on the
unaffected side.
C. Maintain the client in high
Fowler’s position.
D. Coordinate breathing and
coughing exercise with
administration of analgesics.
46. The community nurse is teaching the
group of mothers about the cervical mucus
method of natural family planning. Which
characteristics are typical of the cervical
mucus during the “fertile” period of the
menstrual cycle?
A. Absence of ferning.
B. Thin, clear, good spinnbarkeit.
C. Thick, cloudy.
D. Yellow and sticky.
47. A client with ruptured appendix had
surgery an hour ago and is transferred to the
nursing care unit. The nurse placed the client
in a semi-Fowler’s position primarily to:
A. Facilitate movement and reduce
complications from immobility.
B. Fully aerate the lungs.
C. Splint the wound.
D. Promote drainage and prevent
subdiaphragmatic abscesses.
48. Which of the following will best describe a
management function?
A. Writing a letter to the editor of a
nursing journal.
B. Negotiating labor contracts.
 C. Directing and evaluating nursing
staff members.
D. Explaining medication side
effects to a client.
49. The parents of an infant client ask the
nurse to teach them how to administer
Cortisporin eye drops. The nurse is correct in
advising the parents to place the drops:
A. In the middle of the lower
conjunctival sac of the infant’s
eye.
B. Directly onto the infant’s sclera.
C. In the outer canthus of the
infant’s eye.
D. In the inner canthus of the
infant’s eye.
50. The nurse is assessing on the client who
is admitted due to vehicle accident. Which of
the following findings will help the nurse that
there is internal bleeding?
A. Frank blood on the clothing.
B. Thirst and restlessness.
C. Abdominal pain.
D. Confusion and altered of
consciousness.
51. The nurse is completing an assessment to
a newborn baby boy. The nurse observes that
the skin of the newborn is dry and flaking and
there are several areas of an apparent
macular rash. The nurse charts this as:
A. Icterus neonatorum
B. Multiple hemangiomas
C. Erythema toxicum
D. Milia
52. The client is brought to the emergency
department because of serious vehicle
accident. After an hour, the client has been
declared brain dead. The nurse who has been
with the client must now talk to the family
about organ donation. Which of the following
consideration is necessary?
A. Include as many family members
as possible.
B. Take the family to the chapel.
C. Discuss life support systems.
D. Clarify the family’s
understanding of brain death.
53. The nurse is teaching exercises that are
good for pregnant women increasing tone
and fitness and decreasing lower backache.
Which of the following should the nurse
exclude in the exercise program?
A. Stand with legs apart and touch
hands to floor three times per
day.
B. Ten minutes of walking per day
with an emphasis on good
posture.
C. Ten minutes of swimming or leg
kicking in pool per day.
D. Pelvic rock exercise and squats
three times a day.
54. A client with obsessive-compulsive
behavior is admitted in the psychiatric unit.
The nurse taking care of the client knows that
the primary treatment goal is to:
A. Provide distraction.
B. Support but limit the behavior.
C. Prohibit the behavior.
D. Point out the behavior.
55. After ileostomy, the nurse expects that
the drainage appliance will be applied to the
stoma:
A. When the client is able to begin
self-care procedures.
B. 24 hours later, when the swelling
subsided.
C. In the operating room after the
ileostomy procedure.
D. After the ileostomy begins to
function.
56. A female client who has a 28-day
menstrual cycle asks the community health
nurse when she get pregnant during her
cycle. What will be the best nursing
response?
 A. It is impossible to determine the
fertile period reliably. So it is best
to assume that a woman is
always fertile.
B. In a 28-day cycle, ovulation
occurs at or about day 14. The
egg lives for about 24 hours and
the sperm live for about 72
hours. The fertile period would
be approximately between day
11 and day 15.
C. In a 28- day cycle, ovulation
occurs at or about day 14. The
egg lives for about 72 hours and
the sperm live for about 24
hours. The fertile period would
be approximately between day
13 and 17.
D. In a 28-day cycle, ovulation
occurs 8 days before the next
period or at about day 20. The
fertile period is between day 20
and the beginning of the next
period.
57. Which of the following statement
describes the role of a nurse as a client
advocate?
A. A nurse may override clients’
wishes for their own good.
B. A nurse has the moral obligation
to prevent harm and do well for
clients.
C. A nurse helps clients gain greater
independence and self-
determination.
D. A nurse measures the risk and
benefits of various health
situations while factoring in cost.
58. A community health nurse is providing a
health teaching to a woman infected with
herpes simplex 2. Which of the following
health teaching must the nurse include to
reduce the chances of transmission of
herpes simplex 2?
A. “Abstain from intercourse until
lesions heal.”
B. “Therapy is curative.”
C. “Penicillin is the drug of choice
for treatment.”
D. “The organism is associated with
later development of
hydatidiform mole.
59. The nurse in the psychiatric ward
informed the male client that he will be
attending the 9:00 AM group therapy
sessions. The client tells the nurse that he
must wash his hands from 9:00 to 9:30 AM
each day and therefore he cannot attend.
Which concept does the nursing staff need to
keep in mind in planning nursing intervention
for this client?
A. Depression underlines ritualistic
behavior.
B. Fear and tensions are often
expressed in disguised form
through symbolic processes.
C. Ritualistic behavior makes
others uncomfortable.
D. Unmet needs are discharged
through ritualistic behavior.
60. The nurse assesses the health condition
of the female client. The client tells the nurse
that she discovered a lump in the breast last
year and hesitated to seek medical advice.
The nurse understands that, women who
tend to delay seeking medical advice after
discovering the disease are displaying what
common defense mechanism?
A. Intellectualization.
B. Suppression.
C. Repression.
D. Denial.
61. Which of the following situations cannot
be delegated by the registered nurse to the
nursing assistant?
A. A postoperative client who is
stable needs to ambulate.
B. Client in soft restraint who is very
agitated and crying.
 C. A confused elderly woman who
needs assistance with eating.
D. Routine temperature check that
must be done for a client at end
of shift.
62. In the admission care unit, which of the
following client would the nurse give
immediate attention?
A. A client who is 3 days
postoperative with left calf pain.
B. A client who is postoperative hip
pinning who is complaining of
pain.
C. New admitted client with chest
pain.
D. A client with diabetes who has a
glucoscan reading of 180.
63. A couple seeks medical advice in the
community health care unit. A couple has
been unable to conceive; the man is being
evaluated for possible problems. The
physician ordered semen analysis. Which of
the following instructions is correct regarding
collection of a sperm specimen?
A. Collect a specimen at the clinic,
place in iced container, and give
to laboratory personnel
immediately.
B. Collect specimen after 48-72
hours of abstinence and bring to
clinic within 2 hours.
C. Collect specimen in the morning
after 24 hours of abstinence and
bring to clinic immediately.
D. Collect specimen at night,
refrigerate, and bring to clinic the
next morning.
64. The physician ordered Betamethasone to
a pregnant woman at 34 weeks of gestation
with sign of preterm labor. The nurse expects
that the drug will:
A. Treat infection.
B. Suppress labor contraction.
C. Stimulate the production of
surfactant.
D. Reduce the risk of hypertension.
65. A tracheostomy cuff is to be deflated,
which of the following nursing intervention
should be implemented before starting the
procedures?
A. Suction the trachea and mouth.
B. Have the obdurator available.
C. Encourage deep breathing and
coughing.
D. Do a pulse oximetry reading.
66. A client is diagnosed with Tuberculosis
and respiratory isolation is initiated. This
means that:
A. Gloves are worn when handling
the client’s tissue, excretions,
and linen.
B. Both client and attending nurse
must wear masks at all times.
C. Nurse and visitors must wear
masks until chemotherapy is
begun. Client is instructed in
cough and tissue techniques.
D. Full isolation; that is, caps and
gowns are required during the
period of contagion.
67. A client with lung cancer is admitted in
the nursing care unit. The husband wants to
know the condition of his wife. How should
the nurse respond to the husband?
A. Find out what information he
already has.
B. Suggest that he discuss it with
his wife.
C. Refer him to the doctor.
D. Refer him to the nurse in charge.
68. A hospitalized client cannot find his
handkerchief and accuses other cient in the
room and the nurse of stealing them. Which
is the most therapeutic approach to this
client?
A. Divert the client’s attention.
 B. Listen without reinforcing the
client’s belief.
C. Inject humor to defuse the
intensity.
D. Logically point out that the client
is jumping to conclusions.
69. After a cystectomy and formation of an
ileal conduit, the nurse provides instruction
regarding prevention of leakage of the pouch
and backflow of the urine. The nurse is
correct to include in the instruction to empty
the urine pouch:
A. Every 3-4 hours.
B. Every hour.
C. Twice a day.
D. Once before bedtime.
70. Which telephone call from a student’s
mother should the school nurse take care of
at once?
A. A telephone call notifying the
school nurse that the child’
pediatrician has informed the
mother that the child will need
cardiac repair surgery within the
next few weeks.
B. A telephone call notifying the
school nurse that the child’s
pediatrician has informed the
mother that the child has head
lice.
C. A telephone call notifying the
school nurse that a child has a
temperature of 102ºF and a rash
covering the trunk and upper
extremities of the body.
D. A telephone call notifying the
school nurse that a child
underwent an emergency
appendectomy during the
previous night.
71. Which of the following signs and
symptoms that require immediate attention
and may indicate most serious complications
during pregnancy?
A. Severe abdominal pain or fluid
discharge from the vagina.
B. Excessive saliva, “bumps around
the areolae, and increased
vaginal mucus.
C. Fatigue, nausea, and urinary
frequency at any time during
pregnancy.
D. Ankle edema, enlarging
varicosities, and heartburn.
72. The nurse is assessing the newborn boy.
Apgar scores are 7 and 9. The newborn
becomes slightly cyanotic. What is the initial
nursing action?
A. Elevate his head to promote
gravity drainage of secretions.
B. Wrap him in another blanket, to
reduce heat loss.
C. Stimulate him to cry,, to increase
oxygenation.
D. Aspirate his mouth and nose with
bulb syringe.
73. The nurse is formulating a plan of care to
a client with a somatoform disorder. The
nurse needs to have knowledge of which
psychodynamic principle?
A. The symptoms of a somatoform
disorder are an attempt to adjust
to painful life situations or to
cope with conflicting sexual,
aggressive, or dependent
feelings.
B. The major fundamental
mechanism is regression.
C. The client’s symptoms are
imaginary and the suffering is
faked.
D. An extensive, prolonged study of
the symptoms will be reassuring
to the client, who seeks
sympathy, attention and love.
74. An infant is brought to the health care
clinic for three immunizations at the same
time. The nurse knows that hepatitis B, DPT,
and Haemophilus influenzae type B
immunizations should:
 A. Be drawn in the same syringe
and given in one injection.
B. Be mixed and inject in the same
sites.
C. Not be mixed and the nurse must
give three injections in three
sites.
D. Be mixed and the nurse must
give the injection in three sites.
75. A female client with cancer has radium
implants. The nurse wants to maintain the
implants in the correct position. The nurse
should position the client:
A. Flat in bed.
B. On the side only.
C. With the foot of the bed elevated.
D. With the head elevated 45-
degrees (semi-Fowler’s).
76. The nurse wants to know if the mother of a
toddler understands the instructions
regarding the administration of syrup of
ipecac. Which of the following statement will
help the nurse to know that the mother needs
additional teaching?
A. “I’ll give the medicine if my child
gets into some toilet bowl
cleaner.”
B. “I’ll give the medicine if my child
gets into some aspirin.”
C. “I’ll give the medicine if my child
gets into some plant bulbs.”
D. “I’ll give the medicine if my child
gets into some vitamin pills.”
77. To assess if the cranial nerve VII of the
client was damaged, which changes would
not be expected?
A. Drooling and drooping of the
mouth.
B. Inability to open eyelids on
operative side.
C. Sagging of the face on the
operative side.
D. Inability to close eyelid on
operative side.
78. The community health nurse makes a
home visit to a family. During the visit, the
nurse observes that the mother is beating her
child. What is the priority nursing intervention
in this situation?
A. Assess the child’s injuries.
B. Report the incident to protective
agencies.
C. Refer the family to appropriate
support group.
D. Assist the family to identify
stressors and use of other coping
mechanisms to prevent further
incidents.
79. The nurse in the neonatal care unit is
supervising the actions of a certified nursing
assistant in giving care to the newborns. The
nursing assistant mistakenly gives a formula
feeding to a newborn that is on water feeding
only. The nurse is responsible for the mistake
of the nursing assistant:
A. Always, as a representative of
the institution.
B. Always, because nurses who
supervise less-trained
individuals are responsible for
their mistakes.
C. If the nurse failed to determine
whether the nursing assistant
was competent to take care of
the client.
D. Only if the nurse agreed that the
newborn could be fed formula.
80. The nurse is assigned to care for a client
with urinary calculi. Fluid intake of 2L/day is
encouraged to the client. the primary reason
for this is to:
A. Reduce the size of existing
stones.
B. Prevent crystalline irritation to
the ureter.
C. Reduce the size of existing
stones
 D. Increase the hydrostatic
pressure in the urinary tract.
81. The nurse is counseling a couple in their
mid 30’s who have been unable to conceive
for about 6 months. They are concerned that
one or both of them may be infertile. What is
the best advice the nurse could give to the
couple?
A. “it is no unusual to take 6-12
months to get pregnant,
especially when the partners are
in their mid-30s. Eat well,
exercise, and avoid stress.”
B. “Start planning adoption. Many
couples get pregnant when they
are trying to adopt.”
C. “Consult a fertility specialist and
start testing before you get any
older.”
D. “Have sex as often as you can,
especially around the time of
ovulation, to increase your
chances of pregnancy.”
82. The nurse is caring for a cient who Is a
retired nurse. A 24-hour urine collection for
Creatinine clearance is to be done. The client
tells the nurse, “I can’t remember what this
test is for.” The best response by the nurse is:
A. “It provides a way to see if you
are passing any protein in your
urine.”
B. “It tells how well the kidneys
filter wastes from the blood.”
C. “It tells if your renal insufficiency
has affected your heart.”
D. “The test measures the number
of particles the kidney filters.”
83. The nurse observes the female client in
the psychiatric ward that she is having a hard
time sleeping at night. The nurse asks the
client about it and the client says, “I can’t
sleep at night because of fear of dying.” What
is the best initial nursing response?
A. “It must be frightening for you to
feel that way. Tell me more about
it.”
B. “Don’t worry, you won’t die. You
are just here for some test.”
C. “Why are you afraid of dying?”
D. “Try to sleep. You need the rest
before tomorrow’s test.”
84. In the hospital lobby, the registered nurse
overhears a two staff members discussing
about the health condition of her client. What
would be the appropriate action for the
registered nurse to take?
A. Join in the conversation, giving
her input about the case.
B. Ignore them, because they have
the right to discuss anything they
want to.
C. Tell them it is not appropriate to
discuss such things.
D. Report this incident to the
nursing supervisor.
85. The client has had a right-sided
cerebrovascular accident. In transferring the
client from the wheelchair to bed, in what
position should a client be placed to facilitate
safe transfer?
A. Weakened (L) side of the cient
next to bed.
B. Weakened (R) side of the client
next to bed.
C. Weakened (L) side of the client
away from bed.
D. Weakened (R) side of the cient
away from bed.
86. The child client has undergone hip surgery
and is in a spica cast. Which of the following
toy should be avoided to be in the child’s
bed?
A. A toy gun.
B. A stuffed animal.
C. A ball.
D. Legos.
87. The LPN/LVN asks the registered nurse
why oxytocin (Pitocin), 10 units (IV or IM)
must be given to a client after birth fo the
fetus. The nurse is correct to explain that
oxytocin:
A. Minimizes discomfort from
“afterpains.”
B. Suppresses lactation.
C. Promotes lactation.
D. Maintains uterine tone.
88. The nurse in the nursing care unit is aware
that one of the medical staff displays unlikely
behaviors like confusion, agitation, lethargy
and unkempt appearance. This behavior has
been reported to the nurse manager several
times, but no changes observed. The nurse
should:
A. Continue to report observations
of unusual behavior until the
problem is resolved.
B. Consider that the obligation to
protect the patient from harm
has been met by the prior reports
and do nothing further.
C. Discuss the situation with friends
who are also nurses to get ideas .
D. Approach the partner of this
medical staff member with these
concerns.
89. The physician ordered tetracycline PO qid
to a child client who weights 20kg. The
recommended PO tetracycline dose is 25-50
mg/kg/day. What is the maximum single dose
that can be safely administered to this child?
A. 1 g
B. 500 mg
C. 250 mg
D. 125 mg
90. The nurse is completing an obstetric
history of a woman in labor. Which event in
the obstetric history will help the nurse
suspects dysfunctional labor in the current
pregnancy?
A. Total time of ruptured
membranes was 24 hours with
the second birth.
B. First labor lasting 24 hours.
C. Uterine fibroid noted at time of
cesarean delivery.
D. Second birth by cesarean for
face presentation.
91. The nurse is planning to talk to the client
with an antisocial personality disorder. What
would be the most therapeutic approach?
A. Provide external controls.
B. Reinforce the client’s self-
concept.
C. Give the client opportunities to
test reality.
D. Gratify the client’s inner needs.
92. The nurse is teaching a group of women
about fertility awareness, the nurse should
emphasize that basal body temperature:
A. Can be done with a mercury
thermometer but no a digital
one.
B. The average temperature taken
each morning.
C. Should be recorded each
morning before any activity.
D. Has a lower degree of accuracy
in predicting ovulation than the
cervical mucus test.
93. The nursing applicant has given the
chance to ask questions during a job
interview at a local hospital. What should be
the most important question to ask that can
increase chances of securing a job offer?
A. Begin with questions about client
care assignments, advancement
opportunities, and continuing
education.
B. Decline to ask questions,
because that is the responsibility
of the interviewer.
C. Ask as many questions about the
facility as possible.
 D. Clarify information regarding
salary, benefits, and working
hours first, because this will help
in deciding whether or not to take
the job.
94. The nurse advised the pregnant woman
that smoking and alcohol should be avoided
during pregnancy. The nurse takes into
account that the developing fetus is most
vulnerable to environment teratogens that
cause malformation during:
A. The entire pregnancy.
B. The third trimester.
C. The first trimester.
D. The second trimester.
95. A male client tells the nurse that there is a
big bug in his bed. The most therapeutic
nursing response would be:
A. Silence.
B. “Where’s the bug? I’ll kill it for
you.”
C. “I don’t see a bug in your bed,
but you seem afraid.”
D. “You must be seeing things.”
96. A pregnant client in late pregnancy is
complaining of groin pain that seems worse
on the right side. Which of the following is the
most likely cause of it?
A. Beginning of labor.
B. Bladder infection.
C. Constipation.
D. Tension on the round ligament.
97. The nurse is conducting a lecture to a
group of volunteer nurses. The nurse is
correct in imparting the idea that the Good
Samaritan law protects the nurse from a suit
for malpractice when:
A. The nurse stops to render
emergency aid and leaves before
the ambulance arrives.
B. The nurse acts in an emergency
at his or her place of
employment.
C. The nurse refuses to stop for an
emergency outside of the scope
of employment.
D. The nurse is grossly negligent at
the scene of an emergency.
98. A woman is hospitalized with mild
preeclampsia. The nurse is formulating a plan
of care for this client, which nursing care is
least likely to be done?
A. Deep-tendon reflexes once per
shift.
B. Vital signs and FHR and rhythm
q4h while awake.
C. Absolute bed rest.
D. Daily weight.
99. While feeding a newborn with an
unrepaired cardiac defect, the nurse keeps
on assessing the condition of the client. The
nurse notes that the newborn’s respiration is
72 breaths per minute. What would be the
initial nursing action?
A. Burp the newborn.
B. Stop the feeding.
C. Continue the feeding.
D. Notify the physician.
100. A client who undergone appendectomy 3
days ago is scheduled for discharge today.
The nurse notes that the client is restless,
picking at bedclothes and saying, “I am late
on my appointment,” and calling the nurse by
the wrong name. The nurse suspects:
A. Panic reaction.
B. Medication overdose.
C. Toxic reaction to an antibiotic.
D. Delirium tremens.
Pediatric Nursing Exam (60 items) 5. Based on Kohlberg’s theory, what is the
stage of moral development of Raphael?
Link: https://www.rnpedia.com/practice-
exams/philippine-nursing-licensure-exam- A. Punishment-obedience
pnle/pediatric-nursing-exam-2/ B. “good boy-Nice girl”
C. naïve instrumental orientation
D. social contact
Situation 2 Baby boy Lacson delivered at 36
Situation 1: Raphael, a 6 year’s old prep pupil
weeks gestation weighs 3,400 gm and height
is seen at the school clinic for growth and
of 59 cm (6-10)
development monitoring (Questions 1-5)
6. Baby boy Lacson’s height is
1. Which of the following is characterized the
rate of growth during this period?
A. Long
B. Short
A. most rapid period of growth
C. Average
B. a decline in growth rate
D. Too short
C. growth spurt
7. Growth and development in a child
D. slow uniform growth rate
progresses in the following ways EXCEPT
2. In assessing Raphael’s growth and
development, the nurse is guided by
principles of growth and development. Which A. From cognitive to psychosexual
is not included? B. From trunk to the tip of the
extremities
C. From head to toe
A. All individuals follow cephalo-
D. From general to specific
caudal and proximo-distal
8. As described by Erikson, the major
B. Different parts of the body grows
psychosexual conflict of the above situation
at different rate
is
C. All individual follow standard
growth rate
D. Rate and pattern of growth can A. Autonomy vs. Shame and doubt
be modified B. Industry vs. Inferiority
3. What type of play will be ideal for Raphael C. Trust vs. mistrust
at this period? D. Initiation vs. guilt
9. Which of the following is true about
Mongolian Spots?
A. Make believe
B. Hide and seek
C. Peek-a-boo A. Disappears in about a year
D. Building blocks B. Are linked to pathologic
4. Which of the following information indicate conditions
that Raphael is normal for his age? C. Are managed by tropical steroids
D. Are indicative of parental abuse
10. Signs of cold stress that the nurse must
A. Determine own sense self
be alert when caring for a Newborn is:
B. Develop sense of whether he can
trust the world
C. Has the ability to try new things A. Hypothermia
D. Learn basic skills within his B. Decreased activity level
culture C. Shaking
 D. Increased RR
Situation 3 Nursing care after delivery has an
important aspect in every stages of delivery
11. After the baby is delivered, the cord was
cut between two clamps using a sterile
scissors and blade, then the baby is placed at
the:
A. Mother’s breast
B. Mother’s side
C. Give it to the grandmother
D. Baby’s own mat or bed
12. The baby’s mother is RH(-). Which of the
following laboratory tests will probably be
ordered for the newborn?
A. Direct Coomb’s
B. Indirect Coomb’s
C. Blood culture
D. Platelet count
13. Hypothermia is common in newborn
because of their inability to control heat. The
following would be an appropriate nursing
intervention to prevent heat loss except:
A. Place the crib beside the wall
B. Doing Kangaroo care
C. By using mechanical pressure
D. Drying and wrapping the baby
14. The following conditions are caused by
cold stress except
A. Hypoglycemia
B. Increase ICP
C. Metabolic acidosis
D. Cerebral palsy
15. During the feto-placental circulation, the
shunt between two atria is called
A. Ductus venosous
B. Foramen Magnum
C. Ductus arteriosus
D. Foramen Ovale
16. What would cause the closure of the
Foramen ovale after the baby had been
delivered?
A. Decreased blood flow
B. Shifting of pressures from right
side to the left side of the heart
C. Increased PO2
D. Increased in oxygen saturation
17. Failure of the Foramen Ovale to close will
cause what Congenital Heart Disease?
A. Total anomalous Pulmunary
Artery
B. Atrial Septal defect
C. Transposition of great arteries
D. Pulmunary Stenosis
Situation 4 Children are vulnerable to some
minor health problems or injuries hence the
nurse should be able to teach mothers to give
appropriate home care.
18. A mother brought her child to the clinic
with nose bleeding. The nurse showed the
mother the most appropriate position for the
child which is:
A. Sitting up
B. With low back rest
C. With moderate back rest
D. Lying semi flat
19. A common problem in children is the
inflammation of the middle ear. This is
related to the malfunctioning of the:
A. Tympanic membrane
B. Eustachian tube
C. Adenoid
D. Nasopharynx
20. For acute otitis media, the treatment is
prompt antibiotic therapy. Delayed treatment
may result in complications of:
A. Tonsillitis
B. Eardrum Problems
C. Brain damage
D. Diabetes mellitus
21. When assessing gross motor
development in a 3 year old, which of the
following activities would the nurse expect to
finds?
 A. Riding a tricycle
B. Hopping on one foot
C. Catching a ball
D. Skipping on alternate foot.
22. When assessing the weight of a 5-month
old, which of the following indicates healthy
growth?
A. Doubling of birth weight
B. Tripling of birth weight
C. Quadrupling of birth weight
D. Stabilizing of birth weight
23. An appropriate toy for a 4 year old child is:
A. Push-pull toys
B. Card games
C. Doctor and nurse kits
D. Books and Crafts
24. Which of the following statements would
the nurse expects a 5-year old boy to say
whose pet gerbil just died
A. “The boogieman got him”
B. “He’s just a bit dead”
C. “Ill be good from now own so I
wont die like my gerbil”
D. “Did you hear the joke about…”
25. When assessing the fluid and electrolyte
balance in an infant, which of the following
would be important to remember?
A. Infant can concentrate urine at
an adult level
B. The metabolic rate of an infant is
slower than in adults
C. Infants have more intracellular
water that adult do
D. Infant have greater body surface
area than adults
26. When assessing a child with aspirin
overdose, which of the following will be
expected?
A. Metabolic alkalosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Respiratory acidosis
27. Which of the following is not a possible
systemic clinical manifestation of severe
burns?
A. Growth retardation
B. Hypermetabolism
C. Sepsis
D. Blisters and edema
28. When assessing a family for potential
child abuse risks, the nurse would observe
for which of the following?
A. Periodic exposure to stress
B. Low socio-economic status
C. High level of self esteem
D. Problematic pregnancies
29. Which of the following is a possible
indicator of Munchausen syndrome by proxy
type of child abuse?
A. Bruises found at odd locations,
with different stages of healing
B. STD’s and genital discharges
C. Unexplained symptoms of
diarrhea, vomiting and apnea
with no organic basis
D. Constant hunger and poor
hygiene
30. Which of the following is an inappropriate
interventions when caring for a child with
HIV?
A. Teaching family about disease
transmission
B. Offering large amount of fresh
fruits and vegetables
C. Encouraging child to perform at
optimal level
D. Teach proper hand washing
technique
Situation 5 Agata, 2 years old is rushed to the
ER due to cyanosis precipitated by crying. Her
mother observed that after playing she gets
tired. She was diagnosed with Tetralogy of
Fallot.
31. The goal of nursing care fro Agata is to:
 A. Prevent infection
B. Promote normal growth and
development
C. Decrease hypoxic spells
D. Hydrate adequately
32. The immediate nursing intervention for
cyanosis of Agata is:
A. Call up the pediatrician
B. Place her in knee chest position
C. Administer oxygen inhalation
D. Transfer her to the PICU
33. Agata was scheduled for a palliative
surgery, which creates anastomosis of the
subclavian artery to the pulmonary artery.
This procedure is:
A. Waterston-Cooley
B. Raskkind Procedure
C. Coronary artery bypass
D. Blalock-Taussig
34. Which of the following is not an indicator
that Agata experiences separation anxiety
brought about her hospitalization?
A. Friendly with the nurse
B. Prolonged loud crying, consoled
only by mother
C. Occasional temper tantrums and
always says NO
D. Repeatedly verbalizes desire to
go home
35. When Agata was brought to the OR, her
parents where crying. What would be the
most appropriate nursing diagnosis?
A. Infective family coping r/t
situational crisis
B. Anxiety r/t powerlessness
C. Fear r/t uncertain prognosis
D. Anticipatory grieving r/t gravity of
child’s physical status
36. Which of the following respiratory
condition is always considered a medical
emergency?
A. Laryngeotracheobronchitis (LTB)
B. Epiglottitis
C. Asthma
D. Cystic Fibrosis
37. Which of the following statements by the
family of a child with asthma indicates a need
for additional teaching?
A. “We need to identify what things
triggers his attacks”
B. “He is to use bronchodilator
inhaler before steroid inhaler”
C. “We’ll make sure he avoids
exercise to prevent asthma
attacks”
D. “he should increase his fluid
intake regularly to thin
secretions”
38. Which of the following would require
careful monitoring in the child with ADHD
who is receiving Methylphenidate (Ritalin)?
A. Dental health
B. Mouth dryness
C. Height and weight
D. Excessive appetite
Situation 6 Laura is assigned as the Team
Leader during the immunization day at the
RHU
39. What program for the DOH is launched at
1976 in cooperation with WHO and UNICEF
to reduce morbidity and mortality among
infants caused by immunizable disease?
A. Patak day
B. Immunization day on Wednesday
C. Expanded program on
immunization
D. Bakuna ng kabtaan
40. One important principle of the
immunization program is based on?
A. Statistical occurrence
B. Epidemiologic situation
C. Cold chain management
D. Surveillance study
41. The main element of immunization
program is one of the following?
 A. Information, education and B. PD no. 6
communication C. PD no. 46
B. Assessment and evaluation of D. RA 9173
the program 47. Braguda asks you about Vitamin A
C. Research studies supplementation. You responded that giving
D. Target setting Vitamin A starts when the infant reaches 6
42. What does herd immunity means? months and the first dose is”

A. Interruption of transmission A. 200,000 “IU”

B. All to be vaccinated B. 100,000 “IU”
C. Selected group for vaccination C. 500,000 “IU”
D. Shorter incubation D. 10,000 “IU”
43. Measles vaccine can be given 48. As part of CARI program, assessment of
simultaneously. What is the combined the child is your main responsibility. You
vaccine to be given to children starting at 15 could ask the following question to the
months? mother except:

A. MCG A. “How old is the child?”

B. MMR B. “IS the child coughing? For how
C. BCG long?”
D. BBR C. “Did the child have chest
Situation 7: Braguda brought her 5-month old indrawing?”
daughter in the nearest RHU because her D. “Did the child have fever? For
baby sleeps most of the time, with decreased how long?”
appetite, has colds and fever for more than a 49. A newborn’s failure to pass meconium
week. The physician diagnosed pneumonia. within 24 hours after birth may indicate which
of the following?
44. Based on this data given by Braguda, you
can classify Braguda’s daughter to have:
A. Aganglionic Mega colon
B. Celiac disease
A. Pneumonia: cough and colds C. Intussusception
B. Severe pneumonia D. Abdominal wall defect
C. Very severe pneumonia 50. The nurse understands that a good snack
D. Pneumonia moderate for a 2 year old with a diagnosis of acute
45. For a 3-month old child to be classified to asthma would be:
have Pneumonia (not severe), you would
expect to find RR of:
A. Grapes
B. Apple slices
A. 60 bpm C. A glass of milk
B. 40 bpm D. A glass of cola
C. 70 bpm 51. Which of the following immunizations
D. 50 pbm would the nurse expect to administer to a
46. You asked Braguda if her baby received all child who is HIV (+) and severely
vaccines under EPI. What legal basis is used immunocomromised?
in implementing the UN’s goal on Universal
Child Immunization?
A. Varicella
B. Rotavirus
A. PD no. 996
 C. MMR B. Sexual maturation
D. IPV C. Intellectual development
52. When assessing a newborn for D. Body image
developmental dysplasia of the hip, the nurse 57. An inborn error of metabolism that
would expect to assess which of the causes premature destruction of RBC?
following?
A. G6PD
A. Symmetrical gluteal folds B. Hemocystinuria
B. Trendelemburg sign C. Phenylketonuria
C. Ortolani’s sign D. Celiac Disease
D. Characteristic limp 58. Which of the following would be a
53. While assessing a male neonate whose diagnostic test for Phenylketonuria which
mother desires him to be circumcised, the uses fresh urine mixed with ferric chloride?
nurse observes that the neonate’s urinary
meatus appears to be located on the ventral A. Guthrie Test
surface of the penis. The physician is notified B. Phenestix test
because the nurse would suspect which of C. Beutler’s test
the following? D. Coomb’s test
59. Dietary restriction in a child who has
A. Phimosis Hemocystenuria will include which of the
B. Hydrocele following amino acid?
C. Epispadias
D. Hypospadias A. Lysine
54. When teaching a group of parents about B. Methionine
seat belt use, when would the nurse state C. Isolensine tryptophase
that the child be safely restrained in a regular D. Valine
automobile seatbelt? 60. A milk formula that you can suggest for a
child with Galactosemia:
A. 30 lb and 30 in
B. 35 lb and 3 y/o A. Lofenalac
C. 40 lb and 40 in B. Lactum
D. 60 lb and 6 y/o C. Neutramigen
55. When assessing a newborn with cleft lip, D. Sustagen
the nurse would be alert which of the
following will most likely be compromised?

A. Sucking ability
B. Respiratory status
C. Locomotion
D. GI function
56. For a child with recurring nephritic
syndrome, which of the following areas of
potential disturbances should be a prime
consideration when planning ongoing nursing
care?

A. Muscle coordination