OCHONDRA CA - FinalExam - 2020

Republic of the Philippines
Set 1
Biliran Province State University Serial No.: ______
(formerly NAVAL STATE UNIVERSITY) Seat No. : ______
ISO 9001:2015 CERTIFIED
SCHOOL OF NURSING AND HEALTH SCIENCES
NCM 411: COMPETENCY APPRAISAL I

Final Term Examination
INSTRUCTION: Select the correct answer for each of the following questions. Mark only one answer
for each item by shading the corresponding letter of your choice on the answer
sheet provided. STRICTLY NO ERASURES ALLOWED. Use pencil #2 only.
Situation 1: A nurse is giving a lecture to the nursing affiliates on the legalities affecting the
practice of Maternal Child Health Nursing.
1. RA 9173 stipulated that maternity RN’s can perform IE when:

a. The nurse is trained and can do so in pre-intra and post-natal conditions.
b. The nurse is trained and there is no antenatal bleeding and only during labor.
c. The nurse is trained and assigned in the delivery room.
d. Whenever the woman is in labor.
2. The newborn screening test is a simple procedure done to all NBs. All these are true, except:
a. It is done immediately after birth to determine congenital metabolic disorders that may lead to
mental retardation or even death if left untreated.
b. Dome immediately after 24 hours from birth, by a trained nurse, physician, or midwife.
c. The basic NB screen covered by PhilHealth is that will cost 550. Expanded NBS will test 28
disorders.
d. Can be available in hospitals and medical centers only. Babies can be brought to these
health care facility when need be.
a. 1 & 2 b. 2 & 3 c. 3 & 4 d. 1 & 4
3. To address the high mortality rate in the Philippines, a strategy was created through
AO 2008-0029 with the following intermediate goals, EXCEPT:
a. Every pregnancy is supervised through the Prenatal Clinic.
b. Every pregnancy is wanted and planned.
c. Every delivery must be in the hospital setting.
d. Every mother and baby secure postpartum and postnatal visits.
4. The nurse differentiates MDGs and SDGs – both global goals of the UN, WHO, and other
agencies. Which is NOT TRUE among these statements?
a. MDG have 8 goals while SDG have 17.
b. MDG sought to reduce MMR by 52% in 2015.
c. SDG ensures the health and well-being.
d. By 2030, the SDG goal is to reduce neonatal mortality rate at 12 per 1000 births and under 5
mortality rate to at least 25:1,000 live births.
5. Based on statistics and reports, maternal death generally occurs:

a. During the last trimester of pregnancy.
b. During labor and delivery.
c. During labor, delivery, and intermediate postpartum.
d. After 24 hours during puerperium.
Ground Floor Administration Building, Main Campus, P. Inocentes St., P.I. Garcia, Naval, Biliran Province, Phillipines 6560
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SUC Level III-A (Per DBM-CHED Joint Circular #B dated June 21, 2007
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Biliran Province State University

(formerly NAVAL STATE UNIVERSITY)
6. Three delays of safe motherhood have been identified by global health agencies. When there is
unavailable IV sets and fluids in the health care facility, which type of delay is identified?
a. Delay in seeking care.
b. Delay in reaching the facility.
c. Delay in receiving appropriate care.
d. Delay in recognizing the severity of the complication.
7. Identified as the major cause of NB death globally are:

a. Babies with congenital anomalies. c. Babies with infections.
b. Babies born asphyxiated. d. babies born too soon or before 37 weeks.
8. The BEST CHOICE so far of Corticosteroid given ante-natal to mothers who are at risk for
preterm birth is:
a. Dexamethasone – 24 mg IM STAT.
b. Dexamethasone – 12 mg IM x 4doses.
c. Dexamethasone – 12 mg x 4 doses.
d. Dexamethasone – 6 mg every 12 hours x 4 doses.
9. The first step towards ensuring the survival of both the mother and her newborn is:
a. That the pregnancy was spaced and planned.
b. Provision of a good antenatal care.
c. That the mother delivered in a high level of health care facility.
d. That the woman was attended by a doctor, nurse, or a midwife.
10. Baseline laboratory information on the first visit or following the first visit include:
1. CBC, Hemoglobin and Hematocrit Count. 3. Diabetic Screening Test.
2. Rapid Plasma Reagent. 4. Urinalysis
a. 1, 2 & 3 b. 1, 3 & 4 c. 1, 2 & 4 d. 1, 2 & 3
11. A pregnant woman seeks your advice regarding her frequent nasal congestion and stuffiness
as well nose bleeding at intervals. What would be the BEST ANSWER?
a. Allow her to continue the Decolgen that she takes occasionally due to nasal stuffiness.
b. Inform her that these discomforts are due to edema and vascular congestion caused by
increased estrogen levels.
c. Explain that this a normal and expected in pregnancy, due to high levels of progesterone.
d. Immediately refer her to the doctor.
12. These are the changes observed in the vagina and eternal genitalia in pregnancy, EXCEPT:
a. Increased vascularization causes the tissues to thicken and soften.
b. Increased vascularization causes the vagina to be bluish and purplish.
c. Vaginal discharge tends to be thick, white, and alkaline (pH-above 7).
d. The woman is prone to Moniliasis.
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13. The goal of prenatal care is to regularly monitor all pregnant woman and prevent
complications. ALL BUT ONE is a preventive measure for prenatal complications.
a. Administering Tetanus Toxoid or Tetanus Diphtheria Immunization.
b. Give of Iron and Folic Acid supplementation.
c. Dexamethasone is given in the second trimester to prevent respiratory distress syndrome in
newborn.
d. In endemic areas, antimalarial preventive treatment is given.
Situation 2: Prompt nurses’ knowledge on the complications in pregnancy, labor, and

delivery are important to practice of nursing.
14. These are the correct definitions of preterm labor.

1. Before 8 completed months of pregnancy.
2. More than one month before EDC.
3. From 20 to 36 weeks of gestation.
4. When the baby’s estimated weight is less than 2000 grams at labor.
a. 1, 2 & 3 b. 2, 3 & 4 c. 3 and 4 only d. All of the above
15. A teenage mother is at-risk for all these conditions, EXCEPT:

a. Possible CPD b. Preeclampsia c. Placenta previa d. Preterm labor
16. Obstructed labor or dystocia is one of the causes of maternal death in the Philippines.
a. Fetal infection b. Fetal injury c. Fetal anomalies d. Fetal cretinism
17. Upon the delivery of the baby, the attendant begins to tug or pull the cord without waiting for
the cord pulsation to stop or signs of placental separation, what abnormality is anticipated?
a. Uterine rupture b. Uterine inversion c. Uterine atony d. Uterine prolapse
18. A pregnant woman seeks consultation for abdominal pain and spotting. She is 10 weeks
pregnant. The nurse begins to suspect which condition as she initiates the assessment?
a. Abortion b. Ectopic pregnancy c. Placenta previa d. Abruptio placenta
19. If the woman’s hemoglobin level is 9 mg/dl, the standard management of the nurse is to:
a. Give regular iron intake since the mother is mild anemic.
b. Mother is severely anemic, injectable iron preparation or a blood transfusion is given.
c. Increase the dose of iron supplement, since the mother is moderately anemic.
d. Admit the mother and monitor hemoglobin level regularly.
20. The nurse who delivers the baby assesses whether the baby is alive or dead. These are signs
of live birth that may occur independently or as a whole:
1. Baby breathes spontaneously at birth. c. With heart rate.
2. There are spontaneous movement of the baby. d. Baby weighs 2800 grams at birth.
a. 1 and 2 b. 2 and 3 c. 1, 2 and 3 d. 1, 2, 3 and 4
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21. The nurse in the prenatal care is monitoring the patient’s status. The BOW ruptured
instantaneously. Which of the following will be the least of her worries?
a. Labor might suddenly begin.
b. There is a risk for chorioamnionitis.
c. There is a danger of the cord protruding in the vulva.
d. Maternal hypovolemia may occur.
22. The mother in the labor room is attending to a mother who is anxious over the birth
complications. She asks what can be a major cause of bleeding. The nurse identifies which of the
following?
a. Perineal laceration that may reach the cervix if nor properly prevented.
b. The possibility of blood disorders that might occur in DIC.
c. Over distended uterus.
d. The placenta might get retained.
23. The DR nurse attends to a woman who just passed out an abortus. The woman cannot
remember her LMP. The nurse measures the length of the fetus to be 17 cm. The nurse eliminates
the AOG of the pregnancy to approximately:
a. First month b. Second month c. Fourth month d. Fifth month
24. A pregnant woman at 12 weeks verbalizes her anxiety, of possible fetal anomalies. This is
because of poor genetic history of herself and her husband. She requests for test to detect these.
Which among these can be done?
1. Direct, indirect Coombs Test 3. Chorionic Villi Sampling
2. Blood test to detect blood incompatibility 4. Amniocentesis
a. 1 and 3 b. 2 and 3 c. 3 and 4 d. 1 and 4
25. Jane, an 18 years old primigravid, was informed that she would undergo operative delivery.
She anxiously asks the nurse why so. The nurse explains that the primary indication of CS is:
a. Abnormality of the power c. Abnormality of the fetus
b. Abnormality of the passage d. Prolonged labor, especially among primagravid
26. Which assessment sign signals the nurse to suspect preeclampsia at the earliest time
possible?
a. 130/80 mmHg BP at 20 weeks AOG.
b. Rapid increase of weight in the 1st trimester.
c. Rapid increase of weight in the 2nd semester.
d. Proteinuria (+) at 20 weeks AOG
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Situation 3: Nilda, 33 years old is 24 weeks pregnant & seeks consultation at the prenatal
care where you are the assigned nurse, She tells you she had “one kunan”, premature na
kambal and a baby who was born dead.
27. Per WHO, Nilda’s visit falls on the second mandated antenatal visit. When will you ask her to
return?
a. 3rd visit at 7 months c. 3rd visit at 9 months
rd
b. 3 visit at 8 months d. 3rd visit at term & 4th before her EDC
28. What is the OB score of Nilda?

a. G4P2 (1112) b. G3P2 (1123) c. G5P2 (1122) d. G4P1 (1123)
29. You would expect the fetal length to be?

a. 25 cm b. 30 cm c. 36 cm d. 40 cm
Situation 4: A woman on her 37th week of pregnancy came for consultation. Leopold’s
maneuver was done to assess the fetus. A hard, ballotable mass was found at the fundus,
irregular nodules on the left side of the mother.
30. What can be assess on the first maneuver?

a. Lie, presentation and attitude
b. Lie, presentation and presenting part
c. Position
d. Attitude and cephalic prominence location
31. In this situation, what is the position of the fetus?

a. LOA b. ROA c. RMA d. LOP
32. What is the presentation of the fetus?

a. Cephalic b. Breech c. Face presentation d. Shoulder presentation
33. The RN assesses the pregnant woman for pre-eclampsia. These are the characteristics of the
disorder, EXCEPT:
a. The diastolic pressure is 90-100 mmHg on 2 occasions, 4 hours apart.
b. There is protein in the urine.
c. It can occur anytime during pregnancy.
d. The diastolic pressure can raise to over 110 mm Hg that can lead to seizure.
34. The pregnant mother was injected tetanus toxoid for the 3 rd time. This means:
a. The NB will be protected from tetanus for life & the mother for 5 years.
b. The toxoid was given at least 4 weeks after TT.
c. The mother is protected for 5 years, the toxoid was given 6 months after the second dose
and the NB is protected from tetanus.
d. The toxoid was given at least 1 year after TT.
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35. Which among these preventive measures during pregnancy should not be given in the first
trimester?
a. Iron – 60 mg b. Folic Acid – 400 mcg c. Iodine – 200 mg d. Mebendazole – 500 mg
36. The RN is monitoring the fetus in her birthing she noted the heart rate to fluctuate from 100-
100 beats per minute. What is her immediate action?
a. Ask or look for other person to listen, using a Doppler to validate her findings.
b. Turn the woman on her left side and give oxygen 4-6 L per minute, and refer.
c. Allow the presence of a significant other.
d. Keep her informed of her progress of labor, allow food & drink only during latent phase.
37. The nurse provides supportive care in labor. This means all of the following, EXCEPT:
a. Ensure confidentiality & privacy during examinations and discussions.
b. Allow her to assume any position she wants, as long as her condition is normal.
c. Allow the presence of a significant other.
d. Keep her informed of her progress of labor, allow food & drink only during latent phase.
38. Identity the order on which the nurse handles a spontaneous delivery:
1. Support the perineum as the head extends
2. Assist in a comfortable, upright position as possible
3. Deliver the head of the baby in between contractions, asks the mother to “pant”
4. Check room temperature at 25-28 C, prepare instrument, supplies
a. 1, 2, 3 and 4 b. 2, 1, 3 and 4 c. 4, 2, 1 and 3 d. 4, 1, 2 and 3
39. When is the best time to inject oxytocin to the mother, following the concept of AMTSL (Active
Management of the Third Stage of Labor?
a. Immediately after the delivery of the baby.
b. After the delivery of the baby as long as the cord has stopped pulsating.
c. When the placental signs of the separation are present.
d. After the placenta is expelled.
40. Immediate postpartum period is the most critical time for mothers. The nurse then monitors the
uterus to be:
a. At the level of the navel, midline.
b. Slightly below the navel, contracted and at the midline of the abdomen.
c. Slightly over the navel, contracted & midline.
d. Below the navel, left or right side of the abdomen, contracted.
41. For normal delivery to occur, the pelvis & the fetal skull must complement each other. This
means:
a. The occipitobegmatic diameter is 10 cm & the fetal head flexes to present the
suboccipitobegmatic.
b. The occipitobegmatic diameter is 10 cm & the fetal head extends to present the
c. The occipitobegmatic diameter is 11.5 cm & the fetal head molds to present the
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d. The occipitobegmatic diameter is 10 cm & the fetal head flexes to present the biparietal
diameter of 9.5 cm.
42. The nurse assigned in the labor room admitted a woman G3P2, apparently assessed as in
normal labor. She was hooked to a cardiotocograph (CTG) machine to assess fetal wellbeing. The
nurse knows that CTG monitoring would:
a. Need a written consent from the mother.
b. Interfere with the mobility of the mother as well as comfort.
c. Allow the nurse to do her other tasks as the mother would be left alone since the machine
monitors the FHR independently.
d. Reduces risk for vaginal instrumental birth or C/S.
43. The mother in labor had rupture of the membranes 24 hours prior to onset of labor. The nurse
would: (Select all that apply.)
1. Monitor vital signs especially pulse rate & BP.
2. Monitor the temperature more frequently.
3. Check the color of the amniotic fluid.
4. Ask the woman to lie in bed on left side position
a. 1, 2 and 3 b. 2, 3 and 4 c. 1, 3 and 4 d. 1, 2, 3 and 4
44. A class of 100 nurses recently took their oath after passing the board exam. The invited guest
speaker, who is a nurse icon emphasized that as professional, they are mandated by law to
continuously update their knowledge, skills in the best interest of patient safety. This is provided
for in which of the following laws?
a. RA 9173 b. RA 10968 c. RA 10354 d. RA 10912
45. As BSN graduates, based on the Philippine Qualification Framework (PQF), they belong to
which level in the educational ladder?
a. Level 5 b. Level 6 c. Level 7 d. Level 8
46. It is the duty of the professional nurse to go into specialized competencies to give better, safer
& quality care. One of the global demands is certification. At which level in the PQF will this fall?
a. Level 5 b. Level 6 c. Level 7 d. Level 8
47. February 20, 2019 President Duterte signed the Universal Health Care Law – a breakthrough
in the Health of All Filipinos. What is TRUE in this law?
1. This is now known as RA 11223.
2. Guarantees equitable access to quality healthcare services for all Filipinos.
3. All hospitals shall be required to allot a certain percentage of their bed capacity for ward
accommodation on the implementation of this law.
4. There will be a return service agreement for all graduates of allied & health related courses
who are recipients of government scholarships to serve the public sector for at least three
(3) years.
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a. 1 and 2 b. 1, 2 and 3 c. 1, 3, and 4 d. 1, 2, 3 and 4
Situation 5: Breastfeeding is an advocacy of the maternal and child health nursing. Below
are questions pertaining to BF.
48. Which among the following actions of the mother is significant in transmitting signals to the
mother’s brain for the initiation of BF?
a. Mother holding her baby to her breast.
b. Skin-to-skin contact of the mother and baby.
c. Sucking of the baby on the mother’s breast.
d. Proper positioning of the mother for breastfeeding.
49. Which part of the breasts is composed of milk-secreting cells & muscle cells. Which contract to
eject the milk?
a. Alveoli b. Milk ducts c. Lactiferous sinuses d. Montgomery gland
50. Nurse Lilly just admitted a primipara to the OB ward. She has so many question and is not
confident to breastfeed. She asked Nurse Lilly. “What is the best position to breastfeed so I can be
comfortable?” Lilly’s BEST RESPONSE would be:
a. “You can lie on your back or on your side.”
b. “You can sit in a chair.”
c. “You can sit cross-legged, or even stand up.”
d. “There is readily no one “correct” position for breastfeeding.”
Situation 6: Nurse Melai is taking care of a 12-year old female hospitalized with a suspected
diagnosis of acute bacterial meningitis.
51. In performing the lumbar puncture, which safety measure would Nurse Melai implement while
CSF specimen is obtained?
a. Place the child in a sitting position with the head extended.
b. Place the child in a side-lying position with the back closest to the edge of the bed.
c. Do not wear gloves because the physician is collecting the specimen.
d. Place one arm behind the child’s neck and the other behind the knees.
52. Nurse Melai reviews the results of the CSF analysis and determines that which of the following
results would confirm bacterial meningitis?
a. Cloudy CSF, ↓protein, and ↓ glucose. c. Clear CSF, ↑ protein, and ↓ glucose.
b. Cloudy CSF, ↑ protein, and ↓ glucose. d. Clear CSF, ↓ protein, and ↑ glucose.
53. Based on the mode of transmission of this infection, which of the following would be included
in the plan of care?
a. No precautions are required as long as antibiotics have been started.
b. Maintain enteric precautions.
c. Maintain respiratory isolation precautions for at least 24 hours after the initiation of
antibiotics.
d. Maintain neutropenic precautions.
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54. In planning for a roommate for the child, Nurse Melai should realize that a child of this
developmental level will:
a. Prefer another girl of her own age.
b. Most likely seek out opportunities to socialize with teenagers.
c. Enjoy being with either a girl or boy, as long as they are the same age.
d. Feel helpful if given the opportunity to look after a slightly younger age.
55. As the child recovers meningitis, for which long-term complication should Nurse Melai watch
carefully?
a. Encephalitis b. Hydrocephalus c. Learning disability d. Mental retardation
Situation 7: A child is admitted to the hospital with a history of vomiting and diarrhea for
two days. The admitting diagnosis is gastroenteritis and isotonic dehydration.
56. The nurse understands that isotonic dehydration:

a. Occurs when water and electrolytes are lost in about the same proportions as they exist in
the body.
b. Occurs when the loss of electrolytes is greater than the loss of water.
c. Occurs when the loss of water is greater than the loss of electrolytes.
d. Causes the serum sodium level to rise above 150 meq/L.
57. What type of room assignment should the nurse make?

a. A room near the nurse’s station so that he can be checked frequently and heard if he
vomits.
b. A single room with a sink near the doorway for isolation use.
c. A double room with another toddler who also has vomiting and diarrhea.
d. A bed in the pediatric intensive care unit, in case dehydration develops.
58. Which priority nursing intervention should be included when caring for a client diagnosed with
gastroenteritis?
a. Encouraging optimal nutritional intake.
b. Alleviating abdominal pain and cramping.
c. Administering oral anti-emetic every 2 hours.
d. Monitoring intake and output, and electrolytes levels.
59. The nurse is assessing the child for dehydration. The nurse determines that the child is
moderately dehydrated if which of the following symptoms is noted on assessment?
a. Flat fontanels b. Moist mucus membrane c. Pale skin color d. Oliguria
60. The nurse prepares to take the nurse temperature and avoids which method of measurement?
a. Tympanic b. Axillary c. Rectal d. b and c
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Situation 8: The nurse is working in the Holy Child Ward. One of her patient is an infant
diagnosed with Cystic Fibrosis.
61. The foul-smelling, frothy characteristics stool in Cystic Fibrosis results from the presence of
large amount of?
a. Undigested fat. c. Semi-digested carbohydrates.
b. Sodium and Chloride. D. Lipase, trypsin, and amylase.
62. The nurse when planning care, recalls that chest percussion and postural drainage for a
toddler with Cystic Fibrosis are BEST DONE:
a. After suctioning. c. One hour after meal .
b. Before aerosol therapy. d. Immediately after meal.
63. Medications that will probably be used in the therapeutic regimen for a child with Cystic
Fibrosis include:
a. A steroid and an antimetabolite.
b. Pancreatic enzymes and antibiotics.
c. Aerosol mists, decongestants, and fat-soluble vitamins.
d. Antibiotics, multivitamins, and cough drops.
64. At a previous visit, the parents of an infant with Cystic Fibrosis received instruction in
administration of Pancrelipase (Pancrease). During the follow-up visit, which finding in the infant
suggests that the parent is not administering the drugs as instructed?
a. Fatty stools. b. Bloody urine. c. Bloody urine. d. Glucose in urine
65. In young children with Cystic Fibrosis, frequent stool and tenacious mucus often produce:
a. Anal fissures b. Intussusception c. Rectal prolapse d. Meconium ileus
Situation 9: The following cases pertain to the different Gastrointestinal Disorders in

Children.
66. A toddler is brought to the emergency department with sudden onset of the abdominal pain,
vomiting, and stools that look like red currant jelly. To confirm intussusception, the suspected
cause of these findings, the nurse would expect the physician to order?
a. Barium enema. c. NGT insertion.
b. Suprapubic aspiration. d. Indwelling urinary catheter insertion.
67. The nurse documents that the infant with GERD should be maintained in which position
following feeding and at night in order to manage reflux?
a. 30-degree angle when supine. c. Head elevated prone position.
b. 60-degree angle when supine. d. 20-degree angle when supine.
68. A 5 year old child has lactose intolerance. The nurse tells the mother that is necessary to
provide which dietary supplement in the child’s diet?
a. Zinc b. Protein c. Calcium d. Fats
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69. The nurse reviews the record of a 3-week-old infant and notes the physician has documented
a diagnosis of suspected Hirschsprung’s disease. The nurse reviews the assessment findings
documented in the record, knowing that which symptoms most likely led the mother to seek
healthcare for the infant?
a. Diarrhea c. Regurgitation of feedings
b. Bile-stained vomiting d. Foul-smelling ribbon-like stools
70. The nurse monitors the infant with suspected diagnosis of imperforated anus, knowing that
which of the following is a clinical manifestation associated with this disorder?
a. Sausage-shaped mass palpated in the upper right abdominal quadrant.
b. Bile-stained fecal emesis.
c. Failure to pass meconium stool in the first 24 hours after birth.
d. The passage of currant jelly-like-stools.
Situation 10: The nurse received a telephone call from the admitting section and was told
that a 9-year-old girl with rheumatic fever will be arriving in the nursing unit for admission.
71. On admission, the nurse prepares to ask the mother which question to elicit assessment
information specific to the development of the disease?
a. Did the child have a sore throat or an unexpected fever within the last 12 months?
b. Has the child had any nausea vomiting?
c. Has the child complained of headache?
d. Has the child complained of back pain?
72. Which laboratory study would assist in conforming the diagnosis of the disease?
a. WBC count b. RBC count c. Immunoglobulin d. ASO titer
73. Which assessment findings would the nurse observe from the child?
a. Macular rash that is pruritic c. Elevated C-reactive protein levels
b. Decreased ASO titer d. Decreased ESR count
74. The child experiences the following signs and symptoms of the disease. The nurse should plan
any interventions based on the knowledge that the only complication of the disease may result in
permanent damage is:
a. Syndenham’s Chorea c. Carditis
b. Migratory Polyarthritits d. Erythema Marginatum
75. The best room-mate for the child would be:

a. An 8-year-old girl with impetigo;
b. A 9-year-old girl with a tonsillectomy;
c. A 10-year-old girl with concussion;
d. An 11-year-old girl with a fractured elbow in skeletal traction.
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Situation 11: The first hours after birth represent a critical adjustment period for the
newborn. The nurse must provide direct care to the newborn immediately after birth.
76. Which of the following would the nurse identify as goal of newborn care in the initial
postpartum period?
a. To facilitate development of a close parent-newborn relationship.
b. To assist parents in developing healthy attitudes about childbearing practices.
c. To identify actual or potential problems requiring immediate or emergency attention.
d. To provide the parents of the newborn with information about well-baby programs.
77. Which of the following actions would be least effective in maintaining a neutral environment for
the newborn?
a. Placing an infant under a radiant warmer after bathing.
b. Covering the scale with a warmed blanket prior to weighing.
c. Placing crib close to the nursery window for family viewing.
d. Covering the infant’s head with a stockinet.
78. When preparing to administer the vitamin K to neonate, the nurse would select which of the
following sites as appropriate for the injection?
a. Deltoid muscle. c. Vastus lateralis muscle.
b. Anterior femoris muscle. d. Gluteus maximus muscle.
79. The first period of reactivity in the newborn begins at birth. The following are characteristics of
this period, EXCEPT:
a. This lasts for 30 minutes. c. Flaring of nares and grunting are common.
b. Respirations are increased to 80/minute. d. Bowel sounds are present.
80. A nurse providing care to a newborn would use knowledge of which of the following concepts
underlying adaptation of the newborn’s immune system?
a. Iron stores from the mother are sufficient to carry the newborn through the 5 th month of
extra-uterine life.
b. Unconjugated bilirubin can leave the vascular system and permeate the other extravascular
tissues.
c. The newborn is unable to limit invading organisms at their point of entry.
d. Most newborns void in the first 24 hours after birth and 5 to 20 times thereafter.
Situation 12: Santino, a 3-year-old child is scheduled for a tonsillectomy.
81. The nurse is reviewing the laboratory results of Santino. The nurse determines that which of
the following laboratory values is MOST SIGNIFICANT to review?
a. Prothrombin time. c. Blood urea nitrogen
b. Sedimentation rate. d. Creatinine
82. On the day of surgery, Santino will most likely be fearful of:
a. Intrusive procedure; c. Premature death;
b. Perceived abandonment; d. Unfamiliar caregivers
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83. A nurse planning care for Santino knows that which of the following would present the highest
risk of aspiration during surgery?
a. Difficulty in swallowing. c. Bleeding during surgery
b. The presence of loose teeth. d. Exudate in the throat area
84. After tonsillectomy, the nurse documents on the plan of care to place Santino in which MOST
appropriate position?
a. Supine. c. Side-lying.
b. Trendelenburg. d. High Fowler.
85. After a tonsillectomy, the nurse suspects hemorrhage postoperatively when the child:
a. Snores noisily. c. Complains of thirst.
b. Becomes pale. d. Swallows frequently.
Situation 13: A 2-week-old is diagnosed as having hypertrophic pyloric stenosis, and is

scheduled for corrective surgery.
86. When palpating the infant’s abdomen, the nurse would expect to find:
a. An impacted and distended colon.
b. Marked tenderness around the umbilicus.
c. An olive-sized mass in the right upper quadrant.
d. Rhythmic peristaltic waves in the lower abdomen.
87. The nurse should carefully observe the infant for:

a. Quality of cry. c. Signs of dehydration.
b. Character of stool. d. Coughing after feeding.
88. After the corrective surgery, the nurse caring for an infant, who had been formula-fed, notices
that the post-operative orders are similar to those for the other infants having undergone such
surgery and include:
a. Thickened formula 24 hours after surgery.
b. Withholding all feedings for the first 24 hours.
c. Regular formula feeding 24 hours after the surgery.
d. Additional glucose feeding as desired after the first 24 hours.
89. When the corrective surgery for hypertrophic pyloric stenosis is completed, the infant was
returned in stable condition to the pediatric unit with an intravenous infusion and a nasogastric
tube in place. The PRIORITY NURSING ACTION should be to:
a. Apply adequate restrains. c. Assess the IV site for infiltration.
b. Administer a mild sedative. d. Attach the nasogastric tube to wall suction.
90. To reduce vomiting, the nurse should teach the mother that immediately after the feeding the
infant, she should:
a. Rock the baby for 20 minutes. c. Place the baby flat on the right side.
b. Place the baby in an infant seat. d. Keep the baby awake with sensory stimulation.
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Situation 14: Nurses must know the developmental milestones of children in order to
perform age-appropriate assessments.
91. Which behavior should the nurse expect a 3-year-old child to be capable of doing:
a. Going up the stairs on alternate feet. c. Dressing without supervision.
b. Pedaling a bicycle. d. Tying shoelaces.
92. The BEST WAY to perform a DDST on a 9-month-old is to:

a. Take the infant form the mother and ask her to wait in the child’s room.
b. Take the infant from the mother and ask her to come with them to the testing area.
c. Briefly talk first with the mother, then take the infant to the testing area alone.
d. Ask the infant’s mother to carry the child to testing area.
93. At 7 months of age, an infant exhibits the following skills. The nurse should know that the most
recently acquired skill is the ability to:
a. Roll over c. Bear some weight on legs.
b. Sit up d. Pick up objects with palmar grasp.
94. In assessing the development of a 5-year-old, the nurse would not expect the child to be able
to:
a. Name primary colors. c. Know the days of the week.
b. Count to 100. d. Give telephone number and address.
95. Which of the following activities should a 2-year-old child be able to do?
a. Build a tower of 8 cubes. c. Wash and dry his hands.
b. Point out a picture. d. Remove a garment.
Situation 15: Nurse Jean is working in the orthopedic ward, wherein she encounters
various cases of fractures in children.
96. A 9-year-old child has a fractured tibia, and a full leg cast has been applied. Nurse Jean
should immediately notify the physician if assessment demonstrates:
a. A pedal pulse of 90. c. An inability to move the toes.
b. An increased urinary output. d. A plaster cast that is still damp after 4 hours.
97. To hasten drying of the cast, Nurse Jean should include the following in the care plan.
a. Using a blow dryer
b. Exposing the casted extremity
c. Covering the cast with a light sheet
d. Opening the window slightly to circulate air
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98. An 11-year-old child has just had the application of a cast for a fractured wrist. The wrist and
elbow are immobilized. When providing home care instructions before discharge, Nurse Jean
should include the fact that the:
a. Child can resume usual activities.
b. Casted arm should be elevated while upright and resting.
c. Physician should be notified if swelling of the fingers occurs.
d. Shoulder on the affected side should remain immobilized in a splint.
99. After orthopedic surgery, a 15-year-old complains of pain and is given 15 mg of codeine
sulfate as ordered every 3 hours PRN. Two hours after having been given this medication, the
adolescent complains of severe pain. Nurse Jean should:
a. Report that the adolescent has an apparent idiosyncrasy to codeine.
b. Tell the adolescent that the additional medication cannot be given for more than 1 hour.
c. Request that the physician evaluate the adolescent’s need for additional medication.
d. Administer another dose of codeine within 30 minutes, because it is a relatively safe drug.
100. Nurse Jean takes care of an 8-year-old child with a diagnosis of a basilar skull fracture. Nurse
Jean reviews the physician’s orders and contacts the physician to question which of the following
in the order?
a. Clear liquid intake. c. Daily weight.
b. Maintain a patent intravenous line. d. Suction as needed.
Prepared:
ARLENE SANOSA-SUPREMO, Ph.D., M.P.M., R.N.

Course Instructor, Level Coordinator & DQMR - SNHS
Date: __________
Reviewed and Approved:
JOVY DIA R. SANIEL, Ph.D.N.Sc.

Dean - SNHS
Date: __________
Tel. (053) 507-9023 ‫ ן‬Telefax. (053) 507-9023
#WoWBiPSU!

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Republic of the Philippines

NCM 411: COMPETENCY APPRAISAL I

1. RA 9173 stipulated that maternity RN’s can perform IE when:

5. Based on statistics and reports, maternal death generally occurs:

Biliran Province State University

7. Identified as the major cause of NB death globally are:

a. 1, 2 & 3 b. 1, 3 & 4 c. 1, 2 & 4 d. 1, 2 & 3

Biliran Province State University

Situation 2: Prompt nurses’ knowledge on the complications in pregnancy, labor, and

14. These are the correct definitions of preterm labor.

a. 1, 2 & 3 b. 2, 3 & 4 c. 3 and 4 only d. All of the above

15. A teenage mother is at-risk for all these conditions, EXCEPT:

a. 1 and 2 b. 2 and 3 c. 1, 2 and 3 d. 1, 2, 3 and 4

Biliran Province State University

a. 1 and 3 b. 2 and 3 c. 3 and 4 d. 1 and 4

Biliran Province State University

28. What is the OB score of Nilda?

29. You would expect the fetal length to be?

30. What can be assess on the first maneuver?

31. In this situation, what is the position of the fetus?

32. What is the presentation of the fetus?

Biliran Province State University

a. 1, 2, 3 and 4 b. 2, 1, 3 and 4 c. 4, 2, 1 and 3 d. 4, 1, 2 and 3

Biliran Province State University

a. 1, 2 and 3 b. 2, 3 and 4 c. 1, 3 and 4 d. 1, 2, 3 and 4

Biliran Province State University

Biliran Province State University

56. The nurse understands that isotonic dehydration:

57. What type of room assignment should the nurse make?

Biliran Province State University

Situation 9: The following cases pertain to the different Gastrointestinal Disorders in

Biliran Province State University

75. The best room-mate for the child would be:

Biliran Province State University

Situation 12: Santino, a 3-year-old child is scheduled for a tonsillectomy.

Biliran Province State University

Situation 13: A 2-week-old is diagnosed as having hypertrophic pyloric stenosis, and is

87. The nurse should carefully observe the infant for:

Biliran Province State University

92. The BEST WAY to perform a DDST on a 9-month-old is to:

Biliran Province State University

ARLENE SANOSA-SUPREMO, Ph.D., M.P.M., R.N.

Reviewed and Approved:

JOVY DIA R. SANIEL, Ph.D.N.Sc.

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