Maternal and Child Heath Nursing Exam 1
10th week of pregnancy
(25 items)
Link:
https://www.rnpedia.com/practice-exams/philipp
ine-nursing-licensure-exam-pnle/pnle-maternal-
and-child-health-nursing-exam-1/
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.
3. The uterus has already risen out of the pelvis
and
Placenta previa means that the placenta is the
is
presenting part. On the first and second
trimester there is spotting. On the third
trimester there is bleeding that is sudden,
profuse and painless.
experiencing farther into the abdominal area at
about the:
A. 8th week of pregnancy
B.
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
(25 items)

Link:
https://www.rnpedia.com/practice-exams/philipp
ine-nursing-licensure-exam-pnle/pnle-maternal-
and-child-health-nursing-exam-2/

1. Nurse Bella explains to a 28 year old pregnant

woman undergoing a non-stress test that the test
is a way of evaluating the condition of the fetus
by comparing the fetal heart rate with:

A. Fetal lie
B. Fetal movement
C. Maternal blood pressure
D. Maternal uterine contractions
2. During a 2 hour childbirth focusing on labor
and delivery process for primigravida. The nurse
describes the second maneuver that the fetus
goes through during labor progress when the
head is the presenting part as which of the
following:

A. Flexion
B. Internal rotation
C. Descent
D. External rotation
3. Mrs. Jovel Diaz went to the hospital to have
her serum blood test for alpha-fetoprotein. The
nurse informed her about the result of the
elevation of serum AFP. The patient asked her
what was the test for:

A. Congenital Adrenal Hyperplasia

B. PKU
C. Down Syndrome
 D. Neural tube defects
4. Fetal heart rate can be auscultated with a
fetoscope as early as:
A. 5 weeks of gestation
B. 10 weeks of gestation
C. 15 weeks of gestation
D. 20 weeks of gestation
5. Mrs. Bendivin states that she is experiencing
aching swollen, leg veins. The nurse would
explain that this is most probably the result of
which of the following:
A. Thrombophlebitis
B. PIH
C. Pressure on blood vessels from the
enlarging uterus
D. The force of gravity pulling down
on the uterus
6. Mrs. Ella Santoros is a 25 year old
primigravida who has Rheumatic heart disease
lesion. Her pregnancy has just been diagnosed.
Her heart disease has not caused her to limit
physical activity in the past. Her cardiac disease
and functional capacity classification is:
A. Class I
B. Class II
C. Class III
D. class IV
7. The client asks the nurse, “When will this soft
spot at the top of the head of my baby will
close?” The nurse should instruct the mother that
the neonate’s anterior fontanel will normally
close by age:
A. 2-3 months
B. 6-8 months
C. 10-12 months
D. 12-18 months
8. When a mother bleeds and the uterus is
relaxed, soft and non-tender, you can account
the cause to:
A. Atony of the uterus
B. Presence of uterine scar
C. Laceration of the birth canal
D. Presence of retained placenta
fragments
9. Mrs. Pichie Gonzales’s LMP began April 4,
2010. Her EDD should be which of the
following:
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)
Link:
https://www.rnpedia.com/practice-exams/philipp
ine-nursing-licensure-exam-pnle/pnle-maternal-
and-child-health-nursing-exam-3/
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)
Link:
https://www.rnpedia.com/practice-exams/philipp
ine-nursing-licensure-exam-pnle/pediatric-
nursing-exam-2/
Situation 1: Raphael, a 6 year’s old prep pupil is
seen at the school clinic for growth and
development monitoring (Questions 1-5)
1. Which of the following is characterized the
rate of growth during this period?
A. most rapid period of growth
B. a decline in growth rate
C. growth spurt
D. slow uniform growth rate
2. In assessing Raphael’s growth and
development, the nurse is guided by principles
of growth and development. Which is not
included?
 A. All individuals follow cephalo-
caudal and proximo-distal
B. Different parts of the body grows
at different rate
C. All individual follow standard
growth rate
D. Rate and pattern of growth can be
modified
3. What type of play will be ideal for Raphael at
this period?
A. Make believe
B. Hide and seek
C. Peek-a-boo
D. Building blocks
4. Which of the following information indicate
that Raphael is normal for his age?
A. Determine own sense self
B. Develop sense of whether he can
trust the world
C. Has the ability to try new things
D. Learn basic skills within his culture
5. Based on Kohlberg’s theory, what is the stage
of moral development of Raphael?
A. Punishment-obedience
B. “good boy-Nice girl”
C. naïve instrumental orientation
D. social contact
Situation 2 Baby boy Lacson delivered at 36
weeks gestation weighs 3,400 gm and height of
59 cm (6-10)
6. Baby boy Lacson’s height is
A. Long
B. Short
C. Average
D. Too short
7. Growth and development in a child progresses
in the following ways EXCEPT
A. From cognitive to psychosexual
B. From trunk to the tip of the
extremities
C. From head to toe
D. From general to specific
8. As described by Erikson, the major
psychosexual conflict of the above situation is
A. Autonomy vs. Shame and doubt
B. Industry vs. Inferiority
C. Trust vs. mistrust
D. Initiation vs. guilt
9. Which of the following is true about
Mongolian Spots?
A. Disappears in about a year
B. Are linked to pathologic conditions
C. Are managed by tropical steroids
D. Are indicative of parental abuse
10. Signs of cold stress that the nurse must be
alert when caring for a Newborn is:
A. Hypothermia
B. Decreased activity level
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
communication
B. Assessment and evaluation of the
program
C. Research studies
D. Target setting
42. What does herd immunity means?
A. Interruption of transmission
B. All to be vaccinated
C. Selected group for vaccination
D. Shorter incubation
43. Measles vaccine can be given
simultaneously. What is the combined vaccine to
be given to children starting at 15 months?
A. MCG
B. MMR
C. BCG
D. BBR
Situation 7: Braguda brought her 5-month old
daughter in the nearest RHU because her baby
sleeps most of the time, with decreased appetite,
has colds and fever for more than a week. The
physician diagnosed pneumonia.
44. Based on this data given by Braguda, you
can classify Braguda’s daughter to have:
A. Pneumonia: cough and colds
B. Severe pneumonia
C. Very severe pneumonia
D. Pneumonia moderate
45. For a 3-month old child to be classified to
have Pneumonia (not severe), you would expect
to find RR of:
A. 60 bpm
B. 40 bpm
C. 70 bpm
D. 50 pbm
46. You asked Braguda if her baby received all
vaccines under EPI. What legal basis is used in
implementing the UN’s goal on Universal Child
Immunization?
A. PD no. 996
B. PD no. 6
C. PD no. 46
D. RA 9173
47. Braguda asks you about Vitamin A
supplementation. You responded that giving
Vitamin A starts when the infant reaches 6
months and the first dose is”
A. 200,000 “IU”
B. 100,000 “IU”
C. 500,000 “IU”
 D. 10,000 “IU” the penis. The physician is notified because the
48. As part of CARI program, assessment of the nurse would suspect which of the following?
child is your main responsibility. You could ask
the following question to the mother except: A. Phimosis
B. Hydrocele
A. “How old is the child?” C. Epispadias
B. “IS the child coughing? For how D. Hypospadias
long?” 54. When teaching a group of parents about seat
C. “Did the child have chest belt use, when would the nurse state that the
indrawing?” child be safely restrained in a regular automobile
D. “Did the child have fever? For how seatbelt?
long?”
49. A newborn’s failure to pass meconium A. 30 lb and 30 in
within 24 hours after birth may indicate which B. 35 lb and 3 y/o
of the following? C. 40 lb and 40 in
D. 60 lb and 6 y/o
A. Aganglionic Mega colon 55. When assessing a newborn with cleft lip, the
B. Celiac disease nurse would be alert which of the following will
C. Intussusception most likely be compromised?
D. Abdominal wall defect
50. The nurse understands that a good snack for A. Sucking ability
a 2 year old with a diagnosis of acute asthma B. Respiratory status
would be: C. Locomotion
D. GI function
A. Grapes 56. For a child with recurring nephritic
B. Apple slices syndrome, which of the following areas of
C. A glass of milk potential disturbances should be a prime
D. A glass of cola consideration when planning ongoing nursing
51. Which of the following immunizations care?
would the nurse expect to administer to a child
who is HIV (+) and severely A. Muscle coordination
immunocomromised? B. Sexual maturation
C. Intellectual development
A. Varicella D. Body image
B. Rotavirus 57. An inborn error of metabolism that causes
C. MMR premature destruction of RBC?
D. IPV
52. When assessing a newborn for A. G6PD
developmental dysplasia of the hip, the nurse B. Hemocystinuria
would expect to assess which of the following? C. Phenylketonuria
D. Celiac Disease
A. Symmetrical gluteal folds 58. Which of the following would be a
B. Trendelemburg sign diagnostic test for Phenylketonuria which uses
C. Ortolani’s sign fresh urine mixed with ferric chloride?
D. Characteristic limp
53. While assessing a male neonate whose A. Guthrie Test
mother desires him to be circumcised, the nurse B. Phenestix test
observes that the neonate’s urinary meatus C. Beutler’s test
appears to be located on the ventral surface of D. Coomb’s test
59. Dietary restriction in a child who has
Hemocystenuria will include which of the
following amino acid?

A. Lysine
B. Methionine
C. Isolensine tryptophase
D. Valine
60. A milk formula that you can suggest for a
child with Galactosemia:

A. Lofenalac
B. Lactum
C. Neutramigen
D. Sustagen