NURSING PRACTICE II

Community Health Nursing and Care of the Mother and Child

GENERAL INSTRUCTIONS:
1. This test questionnaire contains 100 test items
2. Shade only one (1) box for each question on your answer sheets. Two or more boxes shaded will invalidate your answer.
3. AVOID ERASURES
4. Write the Subject title “NURSING PRACTICE II” on the box provided.
Situation 1 – Nurse Dang Casillo, initiated the organizing of the “Caring Frontiers Nursing Service Company” in Leyte. This was
envisioned to deliver health care and various nursing services through home health care services well within the scope of nursing
practice.

1. Nurse Lanie is one of their Registry Officials and acts as a liason between families and communities served by the company to
actively engage on policy and social change that will support and promote family health in their Province. Nurse lanie is
performing what role?
a. Care Provide r b. Counselor c. Client Advocate d. Facilitator
2. Formulating and implementing a supervisory plan, 2 and 5monitoring and evaluating beginning nurse practitioners performance
in the implementation of public health programs are what functions of a public health nurse?
a. Trainer b. Coordinator c. Supervisor d. Manager
3. As an advocate, Registered Nurse Lanie places her client’s right as priority. She is aware that advocacy work involves which of
the following?
a. Influencing public opinion c. Coordination with the team
b. Obtaining a general information about the d. Prioritizing health conditions and problems
community
4. According to the World Health Organization (W.H.O), one of the leading cause of mortality in the Philippines is which of the
following?
a. Leukemia c. Malignant Neoplasm
b. Heart Disease d. Lower respiratory tract infections
5. Registered Nurse Lanie is conducting a community diagnosis composed of Demographic variables, socio-economic variables,
health and illness patterns, health resources and political/leadership patterns. What type of community diagnosis is nurse Lanie
conducting?
a. Individualized Nursing Diagnosis c. Comprehensive Community Diagnosis
b. Population Focused Diagnosis d. Problem Oriented Community Diagnosis

Situation 2 – A nurse is assigned to a community health center where the variety of experiences and the “culture” of the community
influences the care she gives to the clients.

6. While in the community health center, you note various practices among the families you serve. Which of the following
situations will be OF CONCERN to you as the nurse?
a. Mang Tomas wears a copper bracelet for his rheumatoid arthritis
b. Mang Andoy gives his son various herbs everyday
c. Aling Pat applies Vicks VapoRub to the chest and back of her grandson with colds.
d. Aling Mika uses Atis seeds on the hair of her granddaughter to treat lice.
7. Mr. Cruz, diagnosed with Alzheimer ’s disease, is brought to the center by his daughter to seek help regarding home care. In
planning the care of Mr. Cruz priority should focus on
a. Providing food rich in fiber to prevent constipation
b. Protecting the client from possible injury in his environment
c. Assisting client to perform activities of daily living
d. Assisting all family members deal with the challenges of long term care of this client,
8. You are following a client who has cataract. The most important nursing action/instruction to implement would be
a. Advice the client to wear dark glasses indoors and outdoors to guard v.s. sun glare
b. Provide adequate lightning at home at all times
c. Instruct family not to change furniture arrangement at home
d. Advise the client to have the cataracts removed
9. While on duty the community health center, some clients are brought for consultation. Based on your assessment, the FIRST
client to attend to would be
a. Aling Juana, with Dementia, who wanders in the streets every morning
b. Mang Sixto 65 years old with congestive heart failure and 3+ pitting edema
c. Aling Maria, 56 years old, terminal client with weight loss (15 lbs) last month
d. Manf Ramon, 70 years old, with Parkinson’s disease and started hallucinating
10. You are visiting a newly discharged cerebrovascular accident ( CVA) client currently confined to a wheelchair for long periods of
time. Your most appropriate PRIORITY intervention would be
a. Ask the client to move his buttocks every two hours to increase blood circulation to the area
b. Prevent skin breakdown by putting a pressure relieving cushion in the seat of the wheelchair.
c. Refer to physical therapist to teach client to transfer from bed to wheelchair
d. Instruct the family to feed client high protein diet for better skin integrity.

Situation 3 – Documentation is an important aspect of every nurse’s activity. This is a major area of responsibility which helps
facilitate continuity of work within a 24 hour cycle.
11. A 26 years old mother was admitted for hyperemesis gravidarum. While taking the history of this client it would be MOST
important to report which of the following?
a. The client has cool lower extremity bilaterally
b. A client has diminished palpable peripheral pulses
c. The client is anxious about the effect of her condition to the baby
d. The client has allergy to shellfish
12. You are on duty and you received report from the previous shift. Which of the following clients should you attend to FIRST?
 a. A client who is receiving ciprofloxacin and complains of a fine macular rash.
b. A client who is receiving a blood transfusion and complains of a dry mouth.
c. A client who is scheduled to receive heparin and the PTT is 70 seconds
d. A client who is receiving I.V. potassium and complains of burning at the IV site
13. You are reviewing the nurse’s notes in your client’s chart. You would be MOST concerned by which of the following entries?
a. “ Foley catheter draining clear urine and the pH is 6.5” c. “ Client’s skin is blanched over the scapular areas”
b. “ The client drinks 3 glasses of orange juice every day” d. “Vital signs are within normal limits”
14. You are attending to clients in your clinic. As you return to your desk you find 4 phone messages. Which of the following
messages should you return FIRST?
a. A client is nauseated and has vomited 6 times in the previous 24 hours
b. A client with stage II decubitus ulcer at home reports that the dressing has come off.
c. A client is complaining of leg pain after walking half a mile
d. A client with cold symptoms has an oral temperature of 39.4 C.
15. At approximately 6pm a nurse deployed for duty in one of the affiliate hospitals, begin to open the nurse’s notes for the evening
shift. The last entry is noted for 1 pm and there is no signature. The MOST appropriate nursing response is to
a. Begin charting on the next line below the last entry, inform the day nurse to make a late entry to complete her charting
b. Do not enter anything until the day nurse has been notified of the problem and returns to the unit to complete her
charting.
c. Review with the client the activities after 1 pm, and enter what are determined to be the activities after 1 pm.
d. Leave approximately 3 or 4 lines for the day nurse to enter some of her missed entries and sign the chart

Situation 4- Myths and fallacies as pertain care of the birthing mothers and their newborn have been debunked resulting in the
development of what is now known as Essential Intrapartum Newborn Care or EINC. The following applies

16. On December 7,2009, the Department of Health issued an Administrative Order implementing the ENC protocol with the goal of
rapidly reducing the number of newborn deaths in the Philippines. With international standards integrated in intrapartal care the
program has now evolved into the EINC program under the guidance of the W.H.O. Now considered as myths and fallacies
include
1. Use of enema to reduce the risk of infections and shorten the duration of labor.
2. Shaving the public hair of women in labor as a hygienic practice to minimize infection.
3. Restricted intake of food and fluid during active labor for possible risk of aspirating gastric contents due to anesthesia
4. Application of I.V. therapy to hydrate women due to food and drink restrictions
5. Use of fundal pressure to help the mother in the expulsion of her fetus
6. Early amniotomy and oxytocin augmentation in order to prevent operative delivery
a. 4,5, and 6 b. None of these c. 1,2 and 3 d. All of these 6
17. In the immediate care of the newborn there are also practices which were debunked as practices based on false beliefs. Which
are they?
1. Routine suctioning believed to be necessary to clear the baby airway and stimulate him to breathe
2. Foot printing as a means of Identification for the newborn
3. Early bathing and washing as a form of hygienic practice
4. Routine Separation (baby in the nursery while mother is in her room).
5. Continuance to providing artificial feeding (starts with pre- lacteals then artificial milk substitutes).
a. 2 and 5 c. Only 2
b. 1, 3 and 5 d. All 5 are taken now as wrong beliefs
18. On INTRAPARTAL CARE, one among 5 recommended practices include MATERNAL POSITIONING especially during 1 st stage of
labor. The recommended practice now is
a. Allow women to assume an upright position v.s. the former recumbent (supine/semi-recumbent and lateral)
b. Strictly follow the traditional medical model of labor and delivery
c. Encourage women to take up the position they find most comfortable to them
d. Allow women to assume any other upright position (walking, standing, sitting, kneeling) v.s. recumbent
19. On ESSENTIAL CARE OF THE NEWBORN, the three (3) new major RECOMMENDED PRACTICES are
1. Practice Rooming-in 4. Use of partograph
2. Skin to skin contact 5. Properly timed cord clamping
3. Strict Hand washing of Cares handling the 6. Initiation of Breastfeeding
newborn child
a. 1, 3, and 4 b. 4, 6, and 2 c. 2, 5, and 6 d. 4, 5, and 1
20. Essential intrapartum and Newborn Care (EINC) is our country’s instrument in health addressing the challenge of the United
Nations 2 out of 8 Millennium Development Goals (MDGs) targeted to be achieved by 2015. Which are these 2 MDGs?
a. MDGs 3 and 6 b. MDGs 4 and 5 c. MDGs 1 and 2 d. MDGs 7 and 8

Situation 5 – You are newly passed and registered nurse applying for beginning nursing job. While waiting you heard your Parish
Priest calling for volunteers for a parish Baes Health Program. You signed up to help and practice your profession. Among health
conditions you would normally encounter are obstetrical cases.

21. A 22 year old mother misses 2 of her regular menstrual period. The Parish medical volunteer confirms an early, intrauterine
pregnancy. This is her 1st pregnancy. To determine her expected due date, which of the following assessments is most
important?
a. Dates of last normal menstrual period c. Age of menarche
b. Date of last intercourse d. Dates of her 1st menstrual period
22. The actions of hormones during pregnancy affects the body by:
a. Blocking the release of insulin from the pancreas c. Enhancing the conversion of food to glucose
b. Raising resistance to insulin utilization d. Preventing the liver from metabolizing glycogen
23. A 38 year old mother has had diabetes mellitus since she was an adolescent. Now she is 8 weeks pregnant. Hyperglycemia
during the first trimester will have what effect on the fetus?
a. Abnormal positioning of the fetus c. Excessive fetal size
b. Hyporinsulinemia d. Potential malformation of the fetal organs
 24. You also attend to another young diabetic parishioner-mother who is in her 1st trimester of pregnancy. As her pregnancy
continues what changes in her medication needs should you also anticipate?
a. A steady increased in insulin requirements
b. The variable pattern of insulin absorption throughout the pregnancy requires constant close adjustments
c. Oral hypoglycemic drugs will be given several times daily
d. Indicates means glucose level over a 1-to 3- month period
25. A glycosylated hemoglobin level is ordered for a pregnant diabetic because it
a. Will predict how well the pancreas can respond to the stress of pregnancy
b. Given diagnostic information related to the peripheral effects of diabetes
c. Is the most accurate method of determining present insulin levels.
d. Indicated means glucose level over a 1 to 3 month period

Situation 6 – Susan 30 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 advices.

26. Susan had leg cramps that come and go are extremely painful. The most effective measure that you can suggests 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
27. Susan complains that she doesn’t get enough rest and sleep because of her frequent trips to the bathroom to urinate. The
beast 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 bathroom 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
28. Susan 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 crossing legs at the knees
d. When getting out of bed, use support stocking above varicosities
29. Susan complained about difficulty in elimination and worried that she might develop hemorroids. You may advised Susan to
1. Take fine 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 soft drinks
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
30. Susan tells you that she sometimes do not feel her baby’s movements. You can instruct Susan to do fetal movement count
(FMC). These statements are true regarding the fetal movement count
1. Clients assume 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 supply conserves energy with less
activity.
a. 1 2, 3 b. 2,3, 4 c. 1, 2, 4 d. 1, 3, 4

Situation 7 – 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.

31. Nurse Jhoana is a member of the birthing team the day Mrs. Maria Luwalhati 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 c. Covering the baby with a clean, dry cloth immediately
b. Covering the baby with a clean, dry cloth after the after birth
cord has been cut d. Drying the baby thoroughly after the cord has been
cut
32. Nurse Jhoana 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 placing the baby in a c. Stimulating the bay by slapping the soles of the
warming incubator baby’s feet
b. Removing used wet cloth, and covering the baby with d. Deep suctioning of the airway to remove mucus
clean, dry cloth
33. In further applying essential new born care (ENC), nurse Jhoana 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
34. Administration of Vitamin K to the newborn is necessary since
a. Newborns have no intestinal bacteria c. the newborn’s liver is incapable of producing sufficient
vitamin K yet
b. Hemolysis of the fetal red blood cells destroys vitamin K d. newborns are susceptible to a vitaminosis
35. 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 preterm 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 8 – In the community, nurses serves a pivotal role in the process of communication exchanges between clients and the
providers of care. The following events are evidences of these.

36. In a prenatal visit by Angela to your Family Care clinic you noted her saying, “during the first 3 months of my pregnancy I have
been very nauseated; and I do not seem to understand why?” Which may be your BEST response?
a. “The nausea you experience is due to an increase in the basal metabolic rate brought about by your pregnancy.”
b. “The nausea you experience is caused by the secondary influx of hormones produced by the endocrine system.”
c. “If you take different kinds of food you will not be nauseated.”
d. “Fatigue as a result of your pregnancy brings about nausea.”
37. On a Monday morning at your Family Care Nursing Clinic, a mother of a 2 year old postoperative child and who has just been
discharged from the hospital came appearing to be overly anxious and tells you, “ My child seems so restless”. Your FIRST
course of action should be:
a. Try taking a child for a walk c. Check and see when the child had his last pain
b. Check the child’s vital sign medication
d. Check if the child’s sutures are still intact
38. You know that all Fridays are Family Care Nursing clinic HOLIDAYS. On Fridays you prefer to do personal “visits”. You follow up
patients in their homes, do volunteer health work in schools or visit industries within the vicinity. In a student health clinic
confides to you that her boyfriend informed her that he tested positive for hepatitis B. which of the following is your BEST
response?
a. “You will receive the Hepatitis B immune c. “That must be real shocking to you”
globulin(HBIG)” d. “You should also be tested for hepatitis B”
b. “Have you had sex with your boyfriend?”
39. An eye surgeon aware of your “Friday-Visit Program” called on you one day and referred a 4 year old client whom he scheduled
for an eye surgery. When you met her mother, she ask how best to prepare her daughter for the eye surgery. Which of the
following actions would be BEST?
a. Draw a picture of the eye and explain what will happen during surgery
b. Help the mother explain to the child how to get ready for surgery using dolls
c. Instruct the mother to tell her daughter that the surgery will only take an hour
d. Guide the mother to read to her daughter an age appropriate illustrated book about eye surgery
40. You are back on your usual Nursing Clinic duties, it is a Tuesday and a woman at 38 weeks gestation comes to you with
problems of vaginal bleeding. Which of the following remarks, if made by the client would suggest PLACENTA PREVIA as
potential cause of bleeding?
a. “ I feel fine, but the bleeding scares me” d. “The bleeding started after I carried 4 bags of
b. “I’ve been experiencing severe abdominal cramps” groceries.”
c. “I feel nauseated more during the past few weeks.”

Situation 9 – The Philippines witnessed the rise in the incidences of DENGUE in various parts of the country starting 2009. The
following situations affecting children apply.

41. In a Barangay in Iloilo where there were high incidences of malaria, a child was brought by her mother with on and off feeling
of dryness and warm skin, temperature reached 37.5 c and above, the child has no general danger signs, with stiff neck, no
runny nose, no measles, and no other obvious causes of fever. The child may be classified as having
a. Malaria c. Fever malaria unlikely
b. Fever no malaria d. Severe febrile disease/malaria
42. It is understood that if a child were living in a “no malaria risk area “ but who has presenting signs of stiff neck. The child may
be classified as having
a. Severe febrile disease c. Malaria
b. Fever no malaria d. Severe malaria
43. You attended to a 3 year old child with measles and with eye complications. This child should be treated with the following
EXCEPT:
a. Apply gentian violet c. Give vitamin A
b. Apply tetracycline ointment d. Follow-up in 2 days
44. In classifying dengue cases, which of the following is NOT possible classification of dengue hemorrhagic fever?
a. None of these c. Dengue hemorrhagic fever: unlikely
b. Severe dengue hemorrhagic fever d. Dengue hemorrhagic fever
45. You are attending to 5 cases of dengue in 2 clusters of Barangays assigned to you. Which of the following treatment modalities
SHOULD NOT be considered if the children you are attending to has severe dengue hemorrhagic fever?
a. Give aspirin c. Apply alternative plan if there is bleeding from the nose
b. Give ORS if there is skin petechial or gums
d. Prevent low blood sugar
Situation 10 – Having a privately owned, community-situated nursing care facility makes the nurse develop rapport with greater
number of community residents. She can become a vital community resource with her nursing skills and knowledge. But with nature
of nurse’s work, it is necessary to be conscious about legal considerations.

46. Alvin, a 5 year old boy and his mother are your regular clients in your Nursing Clinic. You accompanied them to nearby hospital
for referral of what you suspected as an acute case of appendicitis. Alvin’s parents have been legally separated for 5 years now
but both enjoys “joint legally 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 of the following would the best action?
a. Have mother sign the consent and continue the child’s preoperative preparation
b. Contact the father to obtain consent
c. Have mother sign the consent and inform the surgery
d. Have mother sign the consent and inform the surgeon right away
47. Another of your pediatric patients named duked got rushed to the hospital with sustained bruises and lacerations, and a
fractured arm. As duke was being treated in the E.R. 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 coordinate with the NOD and later you were
able to obtain Duke’s 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 Duke’s chart
b. Share the information with the hospital social worker
c. Share on this information with fellow health professionals
d. Call for the Police and report the findings
48. You got invited as 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 doctor’s order you restrain an agitated 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
49. Nathan a 10 year old boy and his family are you 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 checked with the nurse-on-duty (NOD) and got the following information, he weighs 50 lbs. (23.6 kg) and the
physician’s order was “D5W 2,000cc/24 hours.” At this instance you opted to engage the NOD to
a. Set the I.V. infusion pump controller to run at 84 c. Call the physician to clarify the I.V. fluid order
gtts/min d. Ensure accurate records of the patient’s intake and
b. Monitor the patients for fluid and electrolyte balance output
50. You visited one of your family client, 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 c. Ask about her other children at
home
b. Allow the mother to cry and talk about her son and related concerns d. Explain the cause of SIDS.

Situation 11- Mary, a 12-month old infant, was brought to the health center for her regular well baby check-up. Her mother is
concerned with her child’s growth and development. She expressed her desire to learn more about this concern.

51. The child’s weight birth was 8 lbs. upon assessment the child now weighs 18 lbs. In documenting this result, you know that this
weight is
a. Appropriate for the child’s age c. Above the expected weight
b. Below the expected weight d. Individualized and thus unpredictable
52. In formulating the nursing diagnosis regarding the mother’s concern, which of the following should you consider?
a. Health seeking behavior c. Knowledge deficit
b. Anxiety d. Altered health maintenance
53. In planning care for the infant, then you should advise the mother that the best way to help her child complete the
development task for the first year is to
a. Respond to her consistently c. Keep her stimulated with many toys
b. Expose her to many caregivers to help her learn variability d. Talk to her at a special time each day
54. To relieve teething discomfort which measure would you suggest an infant’s mother to use?
a. Provide her with a fluid diet for 2 days c. Keep her simulated at a special day
b. Offer her asper gum to chew d. Provide her with a fluid diet for 2 days
55. In evaluating the health teaching on breastfeeding, which of the following observations made by the mother would reveal
correct understanding of breastfed infants?
a. Breastfed infants usually have fewer stools than bottle fed infants
b. Stools of breastfed infants tend to have a strong odor
c. Breastfed infants usually have soft stools than bottle-fed infants
d. Stools of breastfed infants are usually harder than those of bottle fed infants

Situation 12 - a nurse even as generalist needs the necessary competencies to attend to birthing mothers, normal, at risk, and most
especially the high risk in varied settings. The following conditions apply.

56. Nurse Lucy is a community Health nurse conducting prenatal care at the Rural Health Unit in one of the communities in
Cotabato. Nurse Lucy is aware that recent development in Maternal Care strongly places emphasis on quality antenatal care.
The strength of this advocacy is on :
a. Consistent vaginal examination on every prenatal visit
b. Proper care to every pregnant woman providing support to normal pregnancy AND early detection and management of
complications
c. Doing monthly antenatal care during the first 7 months, every two weeks on the 8 th month, and weekly on the 9th month.
d. Spending more time with every pregnant women especially the high risk ones
57. On May 12, 2012 a primigravida mother named Mrs. Jenna Dela Cruz came to Nurse Lucy for check-up. Her EDC happens to be
May 21. What can you expect to find during assessment?
a. Cervix open, FH-2 fingers below xypoid process, floating
b. FH at least at the level of the xyphoid process, engaged
c. FH-2 fingers below xypoid process, engaged
d. Cervix closed, uneffaced, fundic height (FH)- midway between the umbilicus and symphysis pubis
58. One Monday morning from a community nursing assignment, Nurse Lucy was transferred to their RHU-attached district hospital.
She attends to Mrs. Evelyn Datunggalen who is on her second vaginal: examination and at (.) 1 station. Nurse Lucy based her
findings from
a. 1 cm below the ischial presentation d. Presentation directly in line with that of the ischial
b. 1 cm above the ischial spina condition spines
c. Presentation is no relationship with the ischial spina
condition
 59. By 12:00nn same Monday, another patient attended to by nurse Lucy in the RHU named Mrs. Almira Dela Rea got admitted in
active labor. Nurse Lucy locates the fetal heart sounds in the upper right quadrant of the mother’s abdomen. Nurse Lucy would
recognize which of the following?
a. This position is referred to as left antero-pelvic c. The fetus is in the most common anterior fetal position
b. Almira will probably deliver very quickly and without d. Almira will probably have a breech delivery
problems
60. By 3pm, nurse Lucy was done with her endorsement when another mother, Mrs. Mercy Shalimar came in active labor. She
trembles was very tense with contractions and quite irritable. She frequently says, “ Hindi ko na kaya ito!” (“I can no longer bear
this!”). this behavior may be indicative of the client
a. Making her agency yield reasonable return of investments (RO!) for viability and sustained business growth
b. Already entering the transition phase of labor
c. As having been poorly prepared for labor in the parent classes
d. Needs immediate administration of an analgesic or anesthetic

Situation - 13 After 10 meaningful years of professional practice and using her savings nurse Ruthchelle decides to set p her
proprietary home health care agency. This may be regarded as another journey toward people and professionals development.

61. As owner of the agency, nurse Ruthchelle must be concerned about:

a. Making her agency yield reasonable return of investment (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
62. Nurse Rutchelle hires registered nurses to work with her as home health care 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 qualify for Phil Health reimbursement because the client
a. Qualifies as a low income client c. Is under the age of 65
b. In under home-based care d. Is not considered handicapped
63. Nurse Marissa 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 counselor at school
64. A client who had open heart surgery 2 weeks ago and about to be discharged was referred to nurse Ruthchelles Home
HealthCare Agency for daily dressing changes, cardiac rehabilitation and physical therapy. The assigned home healthcare nurse
should be:
a. Complete the necessary assessment on a weekly basis c. Directly supervise the physical therapy the client receives
b. Develop an individualized plan of care d. Provide daily physical care for the client
65. Nurse Ruthchelle plans to present to the local city health board a “Stop Smoking” campaign to the community local public as her
social responsibility program. Ruthchelle understands that if the proposal is accepted, the funding would come from
a. Philanthropic donations c. Local community funds generated from taxes
b. Phil health contributions d. The home Healthcare agency owned by nurse Ruthchelle

Situation 14 - Mrs. Noime Reyes 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 4 cm, Descent-5 FHT-150/minute, BP-120/80, Pulse rate - 60
beats/minute and temperature is 36.8C. Using the PARTOGRAPH (please see at the last page) you can respond to the following
questions and situations affecting Mrs. Noime Reyes.

66. You immediately can interpret from the partograph that Mrs. Noime Reyes conditions as
a. There is normal progress of labor c. There is fetal distress
b. Unsatisfactory progress due to cephalo-pelvic disproportion d. Unsatisfactory progress due to inadequate uterine activity
67. You recorded a 3+ in the moldings, this means that
A. The bones are touching each other C. The bones are overlapping each other
B. The bones are severely overlapping each other D. The bones are separated and sutures can be felt easily
68. Which of the following nursing action, should you not include in the care of Mrs. Reyes?
A. Labor augmentation/doctors order
B. Amniotomy
C. Observe for 40 minutes more for possible caesarian section if no improvement
D. Continue monitoring fetal heart beat and cervical dilation
69. At 1 am what is the frequency and duration of Mrs. Reyes uterine contraction?
A. Two contraction in 15 minutes lasting more than 40 C. Three contractions in 15 minutes lasting more than40
seconds seconds
B. Three contraction in 10 minutes lasting more than 40 D. Three contractions in 10 minutes lasting less than 40
seconds seconds
70. the descent of the head at 1 pm 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

Situation 15 – 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.

71. 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 too make about her son’s symptoms?
a. “My son’s bowel vowel movements has turned black and c. “My son seems hungry all the time”
sticky.” d. “I really have to go encourage my son to suck the bottle”
b. “My son spits green liquid after feeding”
72. 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.” c. “Eat in a separate room away from your family”
b. “Do not share your drinking water or silverware with d. “Cover your mouth and nose when you sneeze or cough.”
anybody”
73. You are caring for a 2 month old infant to which a pH probe test indicated “reflex”. Which of 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.
74. You are visiting a 3 month old child whom you previously saw in your clinic. He is now on Bryant’s 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 nontoxic blocks c. a stuffed toy animal
b. toy rattle d.nursery rhymes played on tape
75. 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. Dysrhythmia and hypoventilation d. Epistaxis and paralysis
Situation 16 – In some hospitals, nurses assigned to care for mothers with reproductive health concerns a given a TRIAGE
assignment. They rotate in the obstetrics unit/ward, the labor room and the delivery room. Your nursing to clients in these units are
vital in maintaining wellness of these women. The following questions apply.
76. You are taking care of a woman in the labor room whose abandon 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 of fetal death c. Ineffective breathing
b. Alteration in comfort d. Fluid and electrolyte imbalance
77. 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 caesarian section
b. Ask relatives to leave the room for privacy d. Place the client in Trendelenburg position
78. Of the following clients endorsed to you by the outgoing nurse on duty, who would you assess immediately? The client who
a. Exhibits early deceleration on the fetal monitor c. Is 10 cm dilated and 100% effaced
b. Is upset because her obstetrician in on vacation d. Cannot decide if she wants anesthesia during
delivery
79. 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 breastfed c. refuses to have the newborn “room in” with her
b. has saturated several sanitary napkins during the night d. complains of burn and burning sensation upon urination
80. Your client in labor is diagnosed with pre-eclampsia. Which interventions would be most appropriate with this client?
1. Check current intravenous administration of 4. Inform the nursery for incoming infant
Magnesium Sulfate 5. Administer Furosemide (Lasix) intravenously as
2. Frequently check client’s telemetry monitor ordered
3. Assess the client’s deep tendon reflexes
a. 2, 3, 5 b. 1, 2, 5 c. 2, 4, 5 d. 1, 3, 4

Situation 17 – Care of children, well, at risk, or even at high risk conditions places overwhelming responsibilities to nurses. The
following conditions apply

81. A couple brought with them their 7- year old girl diagnosed as having pituitary dwarfism. The couple seem 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. Abnormal body proportions c. Delicate features
b. Course, dry skin d. Early sexual maturation
82. A 14 year old girl whose parents have been consulting with your, Family Care Nursing Clinic (FCNC) was admitted to the hospital
for treatment of 2nd 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 G.I upset d. Obtain blood specimens for analysis
83.A toddler name Peter, which parents were also consulting in your FCNC had lead poisoning and 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 juices c. Water d. Milk
84. A 34 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 7 year old daughter might have the same problems later. Of the following
statements which do you think is BEST to make?
a. “Children develop trust from 6-12 years old” c. “Children develop trust from 18 months to 3 years of
age”
b. “Children develop trust from birth to 18 months of age” d. “Children develop trust from 3-6 years of age”
85. Again at your FCNC a couple came to you with relating problems relative to the care of the 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 c. Replace vitamins depleted as a result of poor maternal
diet
b. Decrease touch to prevent over stimulation d. Prevent iron deficiency anemia

Situation 18 – You are the nurse assigned in the OB-GYNE Unit of the hospital in your Provincial Hospital. The following conditions
and situations apply.

86. A client named Heidi, gravida 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 polyuria
87. You also have Jinky 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 above the umbilicus d. At the umbilicus
88. Another patient a 21 year old woman who is at her 16 weeks gestation and underwent amniocentesis. Her name is Gemma. She
asked you for her OB doctor intend 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
89. Doctor Edwin Rodriguez is attending to a 43 years old women whom he had confined for observation and whom he just placed
on estrogen (premarin) 0.625 mg 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
90. You are caring for Nympha, a multipara client who just delivered a female infant one hour ago. You observed that Nympha's
breast are soft; the uterus bogy 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 her uterine fundus D. offer bedpan immediately

Situation 19 - The nurse is involved in community organizing activities of Barangay Malusog. The following questions pertain to this
situation
91. The nurse makes an ocular surveys of Barangay Malusog. Upon reaching the barangay it is appropriate for her to:
A. pay a visit to the barangay captain C. introduce self to the community
B. encourage community involvement D. assemble community members for a meeting
92. Carrying out the planned activities involving maximum community participation is referred to as
A. mobilization B. integration C. community organization D. community assembly
93. To ensure collective participation of the people, community organization should be formed through a community assembly. the
purpose of having a community assemblies are the following EXCEPT:
a. Gain cooperation, pledge support and work together on their own c. plan for the solution of identified problems
b. Help people identify their own problem d. undertake measure to solve existing problems of the
community
94. Which of the following approaches is the BEST in applying community organization in community Health?
a. Primary Health care c. Community oriented Organization
b. Universal Health care d. Community Development
95. Community organizing ends when the community is already self-reliant. This signals that the community organizers is now ready
to pull out of the community because;
A. organizers can expand to other poor communities C. it indicates that community organization is finished
B. it can evaluate the outcomes of the programs D. it will prevent dependency of the community

Situation 20 - As it is true that the health education is very much a great part of our nursing responsibilities, the same should be
evidently practiced with birthing mothers. The following conditions speak of these responsibilities.

96. A diabetic mother named Maffie plans to breastfeed her baby. You explained that, if Maffie is hyperglymic,
A. the production of milk may be impaired C. her baby will not grow well
B. her baby will received insulin in the milk D. the glucose content of their breast milk may be high
97. Shine is successfully adapted in her let-down reflex and ably breastfeeding, but preventing the occurrence of cracked nipples now
become 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 feedings
98. 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 d. Supplement with water feedings when necessary
b. Wash nipples with soap and water before each feeding
c. Avoid nursing bras with plastic lining
99. Jackie Lyn’s pre-natal 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 C.pregnancy must be avoided for the next 3 month
B.another immunization should be administer in the next pregnancy d. An injection will be needed after each succeeding pregnancy
100. Jasmin 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
c. " The water for the Sitz bath should be warm, about 102-105F."
b. “the anesthetic spray then the heat lamp, will help a lot.'
d. “I know the stiches will be removed at my postpartum clinic visit”