1.

Mikko, a 5-year old boy and his mother are your regular clients in your Nursing Clinic. You
accompanied them to a nearby hospital for referral of what you suspected as an acute case of
appendicitis. Mikkos parents have been legally separated for 5 years now but both enjoy joint
legal custody. The nurse on duty sought your assistance in asking the mother for her informed
consent for immediate surgery. Together with the nurse-on-duty which f the following would be
the BEST action?
A. Have mother sign the consent and continue the childs preoperative preparation
B. Contact the father to obtain consent
C. Have mother sign the consent and inform surgery
D. Have mother sign the consent and inform the surgeon right away
Correct Answer: D. Joint legal custody means that both parents can make decisions for the child,
including medical treatment, but where possible they should consult the other. Upon the death or
disability of either parent, legal custody will go to the remaining parent and will give the active
parent the sole ability to act as parent for the child without further order of the court. The primary
affect of this is a psychological benefit for the parent and the child, so that a child can be told that
both parents cared for the child, even though the child had to live most of the time with one of
them.
Reference; www.lawdictionary.com

2.

Another of your pediatric patients named Arjay got rushed to the hospital with sustained bruises
and lacerations, and a fractured arm. As Arjay was being treated in the ER, his mother requested
for you to come and assist them and the nurse-on-duty (NOD) was informed of your coming as
their family nurse. Upon arrival you coordinated with the NOD and later you were able to obtain
Arjays confession that he got involved in a frat fight outside school. You and the NOD agreed on
which priority actions?
A. Ensure documentation on the Arjays chart
B. Share the information with the hospital social worker
C. Share only this information with fellow health professionals
D. Call for the Police and report the findings
Correct Answer: Report all cases of suspected child abuse; Health care professionals have a legal
obligation to report such suspected abuse.
Reference: Maternal and Newborn Nursing by M. Hogan p. 387

3.

You got invited as a speaker in a class of nursing students to share your experiences and
understanding on the handling of potential legal cases while in practice. Which acts would
constitute battery?
A. When you administer an injection to a schizophrenic patient who refuses to take the
medication because he believes it is poison
B. When on doctors order you restrain an agitated patient inside the E.R.
C. When you chase a patient who tries to run away while taking a walk with you around the
hospital
D. When you hold the arms of a manic patient who strikes you
Correct Answer: A Battery is an intentional, unconsented touching of the other person. When a
person comes to the hospital, it is implied that the consents to be treated. However, he may
refuse certain contracts. If he refuses an injection and the nurse gives it anyway, the latter can be
charged with battery.
Reference: Professional Nursing in the Philippines, by L. Venzon. p157

4.

Jayvee, a 10 year old boy and his family are your clients. He was admitted to the hospital for a
skin graft surgery. You went to visit him and when you came he is being rolled back from surgery.
He is on D5W infusing into his left arm and you introduced yourself then check with the nurse-onduty (NOD) and got the following information, he weighs 50 lbs (23.6kg) and the physicians order
was D5W 2,000cc/24 hours. At this instance you opted to engage the NOD to
A. Set the IV infusion pump controller to run at 84 gtts/min
B. Monitor the patient for fluid and electrolyte imbalance
C. Call the physician to clarify the IV fluid order
D. Ensure accurate records of the patients intake and output
Correct Answer: C

5.

You visited one of your family clients, a 26-year old mother whose son died of Sudden Infant
Death Syndrome (SIDS). As you were conversing it is sound for you to
A. Ask how her son was positioned in bed while in the hospital at the time of his death.
B. Allow the mother to cry and talk about her son and related concerns
C. Ask about her other children at home
D. Explain the case of SIDS
Correct Answer: A. Numerous theories have been proposed, but the etiology os SIDS remain
unknown. Recent findings suggest an increased Incidence of SIDS who sleep in the prone position.
There has been a dramatic decrease in the incidence of SIDS since parents and caregivers putting
infants to sleep in their backs.
Reference: Pediatric Nursing by M. Muscari p. 161
Situation 12- Mary Ann, 32 years old, G2P1, 28 weeks pregnant, visits your clinic and told you
that she has been having various discomforts during this pregnancy and wanted some advises.

6.

Mary Ann had leg cramps that come and go and are extremely painful. the most effective measure
that you can suggest to relieve cramps is to:
A. Lie down and elevate affected leg with a pillow until the cramps stop
B. Extend affected leg with knee straight then bend foot towards the body
C. Increase intake of high phosphorus foods
D. Stand with feet flat on floor and tiptoe alternately, until cramping stops
Correct Answer: B. Cramps are caused by decreased calcium levels, increased serum
phosphorus levels and possibly, interference with circulation can cause muscle cramps of the lower
extremities during the pregnancy This problem is best relieved if a woman lies on her back
momentarily and extends her involved leg while keeping her knee straight and dorsiflexing the
foot until the pain disappears.
Reference: Maternal and Child Health Nursing by A. Pilleteri p. 284

7.

Mary Ann complains that she doesnt get enough rest and sleep because of her frequent trips to
the bathroom to urinate, the best advise you can give is for her to:
A. Bring urine specimen for urinalysis to check for possible infection
B. Bring a commode to the bedroom to reduce trips to the bathroom
C. Hold urge to urinate to improve muscle tone and bladder capacity
D. Drink more fluids at daytime and decrease intake at night
Correct Answer: D. Encourage the client to void when urge is felt and decrease fluid intake in
evening
Reference: Lippincott Review Series by. Straight et al. p. 110

8.

Mary Ann noted that she has beginning varicosities. You informed Susan that varicosities are
caused by pooling of blood in the large veins of the legs. Prevention of this condition involves the
following, EXCEPT:
A. Walk around to stimulate blood flow if working in prolonged sitting position
B. When sitting for a long time elevate legs six inches from the floor
C. Do not wear tight clothing or crossings legs at the knees
D. When getting out of bed, use support stockings above varicosities
Correct Answer: B All of these are included in the health teaching to patient with varicosities.
Reference: Maternal and Child Health Nursing page 285

9.

Mary Ann complained about difficulty in elimination and worried that she might develop
hemorrhoids. You may advise Mary Ann to:
1. take fiber-rich foods e.g. fresh fruits and vegetables, fruit juices, salads, oatmeal
2. Drink up to 8 glasses of water daily including coffee, tea and softdrinks.
3. Exercise regularly and establish a regular time for elimination
4. During elimination use footrest to avoid straining
A. 1, 2, 3 and 4
B. 1, 3 and 4
C. 1, 2 and 3
D. 2, 3 and 4
Correct Answer: All of these are included In the health teaching except drinking coffee, tea or soft
drinks.

10. Mary Ann yells you that she sometimes does not feel her babys movements. You can instruct
Susan to do fetal movement count (FMC) or kick counts. These statements are true regarding the
fetal movement count
1. Client assumes side-lying or reclining position and palpates fetal movements for an hour
counting for 10
movements
2. Less than 10 movements within two hours may need further evaluation and should be
reported to the
nurse.
3. Counting fetal movement is best done at the same time daily, when the mother is ready to
go to sleep
4. A well oxygenated fetus moves frequently while a fetus with compromised oxygen supple
conserves
energy with less activity.
A. 1, 2 and 3
B. 2, 3 and 4
C. 1, 2 and 4
D. 1, 3 and 4
Correct Answer- C. 1, 2 and 4 are included in checking the fetal movement. Usually this occurs
within 60 minutes. Make sure that fetal movements do vary, especially in relation to sleep cycles
of the fetus, her activity and the time since she last ate.
Reference: Maternal and Child Health Nursing by A. Pilleteri p. 208
Situation 13- Mrs. Rachel Daquis was admitted due to lumbo-sacral pain. She is a G5P3 with 9
weeks AOG. On admission the following findings were revealed: BOW-intact, cervical dilatation of
4cm, Descent-5, FHT 150/minute, BP-120/80 mmHg, Pulse rate-60 beats/minute and temperature
is 36.8 C. Using the PARTOGRAPH you can respons to the following questions and situations
affecting Mrs. Rachel Daquis.
11. You immediately can interpret from the partograph that Mrs. Rachel Daquis condition as
A. There is normal progress of labor
B. Unsatisfactory progress due to cephalo-pelvic disproportion
C. There is fetal-distress
D. Unsatisfactory progress due to inadequate uterine activity
Correct Answer: A The client is in active labor (Descent 5, CV is 4cm) Vitals signs are within
normal limits.
12. You recorded a 3+ in the molding, this means that:
A. The bones are touching each other
B. The bones are severely overlapping each other
C. The bones are overlapping each other
D. The bones are separated and sutures can be felt easily
Correct Answer: B. Moulding is an important indication of how adequately the pelvis can
accommodate the fetal head.
1- separated bones, sutures felt easily
1+- bones just touch each other
2+- overlapping of each other
Reference: Partograph Dr. Shashwat Jani p.. 18
13. Which of the following nursing action should you not include in the care or Mrs. Daquis?
A. Labor Augmentation/doctors order
B. Amniotomy
C. Observe for 30 minutes more for possible caesarian section if no improvement
D. Continue monitoring fetal heart beat and cervical dilatation
Correct Answer; B Amniotomy is the artificial rupturing of membranes. Rupturing of membranes if
they do not rupture spontaneously allows a fetal head to contract the cervix more directly and
although not well proved to do so, may increase the efficiency of contractions and speed pace of
labor.
Reference: Maternal and Child Health Nursing by A. Pilleteri p. 385
14. At 1 AM, what is the frequency and duration of Mrs. Daquis uterine contraction?
A. Two contractions in 15 minutes lasting more than 40 seconds
B. Three contractions in 10 minutes lasting more than 40 seconds

C. Three contractions in 15 minutes lasting more than 40 seconds

D. Three contractions in 10 minutes lasting less than 40 seconds
Reference:
15. The descent of the head at 1PM is at:
A. Two fingers above the symphysis pubis
C. Three fingers above the symphysis pubis
B. Five fingers above the symphysis pubis
D. The fetal head is engaged
Correct Answer: The rule of fifth means the palpable fifth of the fetal head is felt by the
abdominal examination above the level of symphisis pubis. Since the descent is 5-, this means
that it is five fingers ios above the symphisis pubis.
Reference: Partograph Dr. Shashwat Jani p. 36
Situation 14- Good and comprehensive nursing assessment among infants and children is an
important aspect of determining appropriate, safe and quality nursing care interventions. The
following apply:
16. A 4-week old infant with symptoms of pyloric stenosis was brought by her mother to your clinic.
Which of the following statements would you expect the mother to make about her sons
symptoms?
A. My sons bowel movements have turned black and sticky
B. My son spits green liquid after feeding.
C. My son seems hungry all the time.
D. I really have to encourage my son to suck the bottle
Correct Answer: B. Pyloric Stenosis happens if the muscles surrounding the sphincter
hypertrophied or undergo hyperplasia that will result for it to empty in a difficult way. Infants are
usually hungry immediately after vomiting because they are nauseated.
Reference: Maternal and Child Health Nursing by A. Pilleteri p. 1331
17. A teenager comes to your clinic with problems of fatigue, sore throat, and flu-like symptoms in the
last 2 weeks. Physical examination reveals enlarged lymph nodes and temperature of 37.9 C.
Which of these statements do you BEST make?
A. Stay in your room until all of your symptoms are gone.
B. Do not share your drinking glass or silverware with anybody.
C. Eat in a separate room away from your family.
D. Cover your mouth and nose when you sneeze or cough.
Correct Answer; D Airborne/Droplet Precaution
18. You are caring for a 2-month old infant to which a pH probe test indicated reflux. Which nursing
action is MOST appropriate?
A. Raise the head of infants bed
C. Instruct properly the mother how to
do CPR
B. Do not give the next feeding
D. Keep a normal feeding schedule
Correct Answer: A Raise the head of the bed is done. pH probe test is inserted through the nose
into the esophagus where it remains for 24 hours to detect how many times the esophagus
exposed to acid.
19. You are visiting a 3-month old child whom you previously saw in your clinic. He is now on
Christophers Traction for developmental dysplasia of the hips. Which of the following toys would
be appropriate for you to offer the infant to keep him occupied while hospitalized?
A. Colorful plastic, non-toxic blocks
C. A stuffed toy animal
B. A toy rattle
D. Nursery rhymes played on tape
Correct Answer: B. Appropriate for 1st to 3 mos. Old infants include mobiles, mirrors, music
boxes, stuffed animals without detachable parts and RATTLES
Reference: Pediatric Nursing by M. Muscari page 28
20. One early morning as you were opening your nursing clinic, a 5-year old boy was rushed to you in
an emergency after ingesting a bottle of baby aspirin. You are to observe the boy for which signs
and symptoms?

A. Tinnitus and gastric distress

C. Nausea and vertigo
B. Dysrrhythmia and hypoventilation
D. Epistaxis and paralysis
Correct Answer: A. Side effects changes: Visual changes, TINNITUS, heaptotoxocity, allergic
reaction and GI bleeding
Reference: Comprehensive Review for NCLEX-RN by M. Hogan page 636
Situation 15- After 10 meaningful years of professional practice and using her savings, Nurse Trish
decides to set up her proprietary home healthcare agency. This may be regarded as another
journey towards personal and professional development.
21. As owner of the agency, Nurse Trish must be concerned about:
A. Making her agency yield reasonable return of investments (ROI) for viability and
sustained business growth
B. Finding out her agency can be exempt from paying taxes
C. Looking for funding support from other business organizations
D. Knowing which government regulatory agencies she should report to
Correct Answer: A
22. Nurse Trish hires registered nurses to work with her as home healthcare nurses whom she assigns
to individuals and families requiring nursing care in their homes. One such case is a 60 year old
client who needs irrigation of his colostomy following surgery for cancer. This case may not be
qualify of Phil Health reimbursement because the client:
A. Qualifies as low-income client
C. Is under the age of 65
B. Is under home-based care
D. Is not considered handicapped
Correct Answer B
Case Rates
Since September 1, 2011, the following medical cases and surgical procedures are being paid through
case rate:

Medical Cases
1. Dengue I (Dengue fever, DHF grades I&II)

8,000

2. Dengue II (DHF grades III & IV)

16,000

3. Pneumonia I ( moderate risk)

15,000

4. Pneumonia II (high risk)

32,000

5. Essential Hypertension

9,000

6. Cerebral Infarction (CVA-I)

28,000

7. Cerebral Hemorrhage (CVA-II)

38,000

8. Acute Gastroenteritis (AGE)

6,000

9. Asthma

9,000

10. Typhoid Fever

14,000

11. Newborn Care Package in Hospitals and Lying in Clinics

1,750

Surgical Cases
1. Radiotherapy

3,000

2. Hemodialysis

4,000

3. Maternity Care Package (MCP)

8,000

4. NSD Package in Level I Hospitals

8,000

5. NSD Package in Levels 2 to 4 Hospitals

6,500

6. Caesarean Section

19,000

7. Appendectomy

24,000

8. Cholecystectomy

31,000

9. Dilatation and Curettage

11,000

10. Thyroidectomy

31,000

11. Herniorrhaphy

21, 000

12. Mastectomy

22,000

13. Hysterectomy

30,000

14. Cataract Surgery

Reference: www.philhealth.gov.ph
23. Nurse Trish has a caseload of clients whom she needs to see on a regular basis. Which of the
following clients may immediately be admitted as a matter of PRIORITY to a private home
healthcare program?
A. A woman who has delivered a normal healthy infant in a government-managed birthing center
B. A client in the terminal stages of cancer at the hospital and will be discharged for home care
C. A family with three (3) family members who tested positive for tuberculosis and just
moved into a barangay
D. A teenage drug abuser who has refused medical treatment but is being seen by a a counselor
at school
Correct Answer: C. Tuberculosis Provide public health nursing and outreach services for home
supervision of patients to supervise therapy directly and to arrange for examination and
preventive treatment of contacts.
Reference: Public Health Nursing in the Philippines by NLGPN page 241

24. A client who had open heart surgery 2 weeks ago and about to be discharged was referred to
nurse Trishs Home HealthCare Agency for daily dressing changes, cardiac rehabilitation and
physical therapy. The assigned home healthcare nurse should
A. Complete the necessary assessment on a weekly basis
B. Develop an individualized plan of care
C. Directly supervise the physical therapy the client receives
D. Provide daily physical care for the client
Correct Answer: B. Individualized patient care is given according to the case of the patient.
25. Nurse Trish plans to present t the local city health board a Stop Smoking campaign to the
communitys local public as her social responsibility program. Trish understands that if the
proposal is accepted, the funding would come from
A. Philanthropic donations
B. Philhealth contributions
C. Local community funds generated from taxes
D. The home Healthcare agency owned by Nurse Trish
Correct Answer; C. WHO established four pillars for successful anti-tobacco programs. These
four pillars may be categorized as:
1. Aggressive health information and dissemination
2. Government supported and multisectoral programs
3. Building anti tobacco coalitions
4. The taxation of tobacco products
Reference: Public Health Nursing in the Philippines by NLGPN page 220-221
Situation 16- In some hospitals, nurses assigned to care for mothers with reproductive health
concerns are given a TRIAGE assignment. They rotate in the obstetrics unit/ward, the labor room,
and delivery room. Your nursing to clients in these units are vital in maintaining wellness of these
women. The following questions apply.
26. You are taking care of a woman in the labor room whose abdomen remains rigid and hard between
contractions. Upon further assessment the fetal heart rate registered at 100/minute. The
PRIORITY PROBLEMS in the care of this client would be
A. Risk for fetal death
C. Ineffective breathing
B. Alteration in comfort
D. Fluid and electrolyte imbalance
Correct Answer: C 100/minute is considered moderate bradycardia but not considered serious,
probably due to vagal response elicited by compression of fetal head during labor
Reference: Maternal and Child Health Nursing by A. Pilleteri page 378
27. During a vaginal examination, a prolapsed cord is assessed, your PRIORITY intervention would be
to
A. Instruct the client not to push during contractions
C. Prepare client for emergency
caesarean section
B. ask relatives to leave the room for privacy
D.
Place
the
client
in
Trendelenberg position
Correct Answer: D. Place mothers hips higher than head to relieve pressure on the cord and
restore fetal oxygenation.
Reference; Maternal and Newborn Nursing by M. Hogan page 197
28. Of the following clients endorsed to you by the outgoing nurse on duty, who would you assess
immediately? the client who:
A. Exhibits early decelerations on the fetal monitor
B. Is upset because her obstetrician in on vocation
C. is 10 cm dilated and 100% effaced
D. cannot decide if she wants anesthesia during delivery
Correct Answer: C. Effacement is shortening and thinning of the cervical canal. Dilatation refers
to an enlargement or widening of the cervical canal from an opening a few millimeters wide to one
large enough to permit passage of the fetus.
Reference: Maternal and Child Health Nursing by A. Pilleteri page 358

29. You are assigned to the postpartum unit/ward and you are to take care of several clients. When
prioritizing care for these clients you will first assess the client who:
A. Is upset because the baby does not nurse when breast fed
B. Has saturated several sanity napkin during the night
C. Refuses to have the newborn room-in with her
D. Complains of pain and burning sensation upon urination
Correct Answer: B. If you have observe a woman is soaking through a pad every 60 minutes, she
is losing more than the average amount of blood. The doctor must check if there no cervical or
vaginal tear causing bleeding.
Reference: Maternal and Child Health nursing by A. Pilleteri page 249
30. Your client in labor is diagnosed with pre-eclampsia. Which interventions would be most
appropriate for this client?
1. Check current intravenous administration of Magnesium Sulfate
2. Frequently check clients telemetry monitor
3. Assess the clients deep tendon reflexes
4. Inform the nursery for incoming infant
5. Administer Furosemide (Lasix) intravenously as ordered
A. 2, 3, 5
B. 1, 2, 5
C. 2, 4, 5
D. 1, 3, 4
Correct Answer; D
Situation 17- You are the nurse assigned in the OB-GYNE Unit of the hospital in your Provincial
Hospital. The following conditions and situations apply.
31. A client named Heidi; gravid 2 para 1 was admitted with complaints of hypertension. She even
remarked that her wedding band was tight. In doing your assessment which of the following
directs you to entertain early pre-eclampsia?
A. Pain in her epigastrium together with headache C. Blurring of vision and proteinuria
B. Swelling of her face with proteinuria
D. Hypertonic reflexes together with
poluria
Correct Answer: B A woman is said to be mildly pre-eclamptic when she has proteinuria and
blood pressure rises to 140/90 mmHg with mild edema in upper extremities or face.
Reference Maternal and child Health nursing by A. Pilleti
32. You also have Lailani who is on her 4th Stage of Labor. Where do you palpate the fundus?
A. 2 cm above the umbilicus
C. to the right of the umbilicus
B. 3 cm below the umbilicus
D. at the umbilicus
Correct Answer: D The fourth stage of labor includes the first few hours after birth. For the first
hour after childbirth, the height of the fundus is at the umbilicus or even slightly above it.
Reference: Maternal and child Health nursing by A. Pilleti p. 428
33. Another patient a 21 year old woman who is at her 16-weeks gestation and underwent
amniocentesis. Her name is Beverly. She asked you what her OB doctor intends to find out from
the procedure. Your appropriate response is based on the understanding that which of the
following conditions may be detected through this test?
A. cleft lip palate
C. Tetralogy of Fallot
B. Talipes equinovarus
D. Hemolytic disease of the newborn
Correct answer: D Amnioncentesis can determine the fetal maturity and detect certain birth
defects such as Down Syndrome, Spina Bifida, HEMOLYTIC DISEAES OF THE NEWBORN and Sex
and Chromosomal abnormalities.
Reference: Maternal and Newborn nursing by B. Straight p. 116
34. Doctor Vincent Magalong is attending to a 43-year old woman whom he had confined for
observation and whom he just placed on estrogen (premarin) 0.625mg OD. Learning about this
treatment regimen you are aware of the initial side effects of this medication which is?
A. Nausea
B. Tinnitus
C. Visual disturbances
D. Ataxia
Correct Answer; A Estrogen causes nausea initially causes nausea and vomiting.

35. You are caring for Reyna, a multipara client who just delivered a female infant one hour ago. You
observed that Reynas breasts are soft; the uterus boggy, to the right of the midline, and 2 cm
below the umbilicus; moderate lochia rubra. What action is called for you to undertake with these
findings?
A. Perform a straight catheterization
C. Put her baby to her breast
B. Massage the uterine fundus
D. Offer bedpan immediately
Correct Answer: D The presenting problem is bladders distention because the uterus is shifted to
the right therefor offer bedpan allow to empty the bladder.
Situation 18- As it is true that health education is very m$uch a great part of our nursing
responsibilities, the same should be evidently practiced with birthing mothers. The following
conditions speak of these responsibilities.
36. A diabetic mother named Ruffa plans to breastfeed her baby. You explained that, if Ruffa is
hyperglycemic,
A. The production of milk may be impaired
C. Her baby will not grow well
B. Her baby will receive insulin in the milk
D. The glucose content of her breast milk may
be high
Correct Answer: D The glucose is high since the mother has Diabetes.
Incorrect: B. Women with diabetes may breastfeed because insulin is one of the few substances
that does not pass into the breastmilk from the blood stream
Reference: Maternal and Child Health Nursing by A. Pilleteri page 545
37. Shine has successfully adapted in her let-down reflex and ably breastfeeding, but preventing the
occurrence of cracked nipples now becomes one of your nursing concerns. Shine should therefore
be taught to:
A. Wash her nipples with water only
C. Use plastic bra liners
B. Nurse at least 20 minutes on each breast the first day D. Apply lanolin prior to feelings
Correct Answer: A Wash nipple with warm water only no soap
Reference: CHN: An Approach to Families and Population groups by David et.al page 283
38. Kimberly just delivered her first baby and whom she is expected to breastfeed. In the
development of your teaching plan which of the following instruction must you include?
A. Try to schedule feedings at least every 3 to 4 hours
C. Avoid nursing bras with plastic
lining
B. Wash nipples with soap and water before each feeding D. Supplement with water feedings
when necessary
Correct Answer: C. Discourage the use of plastic lining that come with nursing bras; it is
preferable to use have air always circulating around the breast.
Reference: Maternal and Child Health Nursing p. 499
39. Jacks prenatal antibody titer shows that she is not immune to rubella and will receive the
immunization after delivery. You would include which of the following instructions in your teaching
plan?
A. Breastfeeding should be postponed for 5 days after the injection
B. Another immunization should be administered in the next pregnancy
C. Pregnancy must be avoided for the next 3 months
D. An injection will be needed after each succeeding pregnancy
Correct Answer B The client should not be vaccinated during the pregnancy as the fetus can
contact from the live virus vaccine. Also avoid pregnancy for three months
Reference: Maternal and Newborn Nursing by M. Hogan page 140
40. Jasmine had a normal vaginal delivery 12 hours ago and is to be discharged from the birthing
center. You evaluated that Jasmin understands the teaching related to the episiotomy and perineal
area when she states,
A. The ice pack should be removed for 10 minutes before replacing it.

B. The anesthetic spray, then the heat lamp, will help a lot.
C. The water for the Sitz bath should be warm, about 102-105 F.
D. I know the stitches will be removed at my postpartum clinic visit.
Situation 19- A current initiative of the Department of Health (DOH) is the program called
Essential Newborn Care or ENC. This outlines simple yet meaningful measures to be undertaken
by healthcare workers in doing immediate newborn care management. The following situations
apply.
41. Nurse Dianne is a member of the birthing team the day Mrs. Gador gave birth to her 1 st born.
Inside the delivery room nurse Jhoana assisted the attending obstetrician. To address the concerns
of keeping the baby warm, her first step in obtaining thermal protection for the newborn was
A. Drying the baby thoroughly immediately after birth
B. Covering the baby with a clean, dry cloth after the cord has been cut
C. Covering the baby with a clean, dry cloth immediately after birth
D. Drying the baby thoroughly after the cord has been cut
Correct Answer: A. Within the first 30 seconds, the nurse should dry and provide warmth with
baby. Use a clean, dry cloth to thoroughly dry the baby by wiping the eyes, face, head, front and
back, arms
and legs.
Reference: Newborn Care until the First week of life (WHO,UNICEF and DOH) p. 1
42. Nurse Dianne did not stop by simply drying the baby thoroughly upon birth, she observed other
details as essential part of the immediate care of a normal newborn which included:
A. Skin-to-skin contact followed by placin30g the baby in a warming incubator
B. Removing used wet cloth, and covering the baby with clean, dry cloth
C. Stimulating the baby by slapping the soles of the babys feet
D. Deep suctioning of the airway to remove mucus
Correct Answer: B. The next step is Removed the used wet cloth and cover the baby with clean,
dry cloth
Reference: Newborn Care until the First week of life (WHO,UNICEF and DOH) p. 1
43. In further applying essential newborn care (ENC), Nurse Dianne keeps in mind that care of the
umbilicus should include:
A. Cleansing with cooled, boiled water and leaving umbilicus uncovered
B. Applying antibiotic cream
C. Covering with a sterile compress
D. Cleansing with alcohol
Correct Answer: A Put nothing on the stump.
CORD CARE
Fold diaper below stump. Keep cord stump loosely covered with clean clothes.
If stump is soiled, wash it with clean water and soap. Dry it thoroughly with clean cloth.
Explain to the mother that she should seek care if the umbilicus is red or draining pus.
Teach the mother to treat local umbilical infection three times a day.
Wash hands with clean water and soap.
Gently wash off pus and crusts with boiled and cooled water and soap.
Dry the area with clean cloth.
Paint with gentian violet.
Reference; Newborn Care until the First week of life (WHO,UNICEF and DOH) p. 8
44. Administration of Vitamin K to the newborn is necessary since
A. Newborns have no intestinal bacteria
B. Hemolysis of the fetal red blood cells destroys vitamin K
C. The newborns liver is incapable of producing sufficient vitamin K yet
D. Newborns are susceptible to avitaminosis
Correct Answer: A

Reference: Newborns are at risk for bleeding disorders during the first week of life because their
gastrointestinal tract is sterile at birth and unable to produce vitamin K which is necessary for
blood coagulation.
45. Cord clamping and the traditional milking of the cord immediately post delivery have now proven
to be non-beneficial and may result in causing more harm and complications especially in
preterms and fragile blood vessels in the brain of the newborn. NOW new practices have been
introduced as part of essential newborn care termed as
A. Properly Timed Cord Clamping
C. Unang Yakap
B. Routine separation
D. Partographing
Situation 20- Care of children, well, at risk, or even at high risk conditions places overwhelming
responsibilities to nurses. The following conditions apply.
46. A couple brought with them their 7-year old girl diagnosed as having pituitary dwarfism. The
couple seems anxious and was looking for some kind of emotion and psychological support. In
your assessment, you expected which clinical manifestations to be MOST likely to be evident?
A. Abdominal body proportions
C. Delicate features
B. Course, dry skin
D. Early sexual maturation
Correct Answer: children with hyppituitarism generally grow normally during the first year and
then follow a slowed growth curve that is below the 3 rd percentile. Height may be retarded more
than weight because with good nutrition, these children can become overweight or obese.
Reference: Maternal and Child health nursing by A. pilleteri p. 1682
47. A 14 year old girl whose parents have been consulting with you in your Family Care Nursing Clinic
(FCNC) was admitted to the hospital for treatment of 2 nd and 3rd degree burns sustained from a
house fire. You visited them in the hospital and noted an IV infusion started over the girls left
forearm. Instantly what comes to mind is that the primary purpose of this IV is to:
A. Maintain fluid balance
C. Provide a route for pain medications
B. Prevent GI upset
D. Obtain blood specimens for analysis
Correct Answer: immediately after a severe burn, the childs circulatory system becomes
hypovolemic, due to loss of plasma that oozes hypovolemic from the burn site and fluid that
sequesters in edematous tissue surrounding the site. Therefore purpose of Intravenous line is to
maintain fluid balance.
Reference: Maternal and Child Health Nursing by A. Pilliteri (Fourth edition) p. 1621
48. A toddler name Louie, whose parents were also consulting in your FCNC had lead poisoning and
was rushed to the hospital. There was an order to encourage fluids and the same were relayed to
the parents. When you visited the parents asked what kind of fluids are best given, and as a
family nurse coordinating closely with the nurse-on-duty (NOD) you reiterated that it is best to
give:
A. Fruit juices
B. Orange juice
C. Water
D. Milk
Correct Answer: D Much of the biochemical effect of lead involves an interaction with calcium.
Lead may block the ability of calcium to reach a regulatory site. It may enter a cell and mobilize
calcium or mimic the regulating action of calcium.
Reference; Nursing care of Infants and children by Hockenberry and Wilson page 692
49. A 24-year old single mother dropped by your FCNC and tells you that she always have difficulty
forming relationships. The mother conveyed to you the message that she is worried that her 7year old daughter might have the same problems later. Of the following statements which do you
think is the BEST to make?
A. Children develop trust from 6-12 years of age.
B. Children develop trust from birth to 18 months of age.
C. Children develop trust from 18 months to 3 years of age
D. Children develop from 3 to 6 years of age.
Correct Answer: B Ericksons phase (birth to one year) is concerned with a acquiring a sense of
trust while overcoming a sense of mistrust. The trust of self, of others and of the world
Reference: Nursing care of Infants and children by Hockenberry and Wilson page 506

50. Again at you FCNC, a couple came to you with relating problems relative to the care of their
newborn with fetal alcohol syndrome. Which of the following should be reiterated as important
considerations by the parents?
A. Provide feedings via gavage to decrease energy expenditure
B. Decrease touch to prevent overstimulation
C. Replace vitamins depleted as a result of poor maternal diet
D. Prevent iron deficiency anemia
Correct Answer: B Fetal Alcoholic Syndrome typically manifest hyperactivity, irritability and priority
nursing intervention Is to reduce environemental stimuli. Strategies to provide individualized
developmental care are
aimed to provide individualized developmental care and reduced environmental stimuli and helping
the infant
achieve self-regulation.
Reference: Nursing care of Infants and children by Hockenberry and Wilson page 411
Comprehensive Review for NCLEX-RN by M. Hogan p. 951