NP2 (RN PEDIA) 9.

Calcium gluconate is being administered to a client with

pregnancy induced hypertension (PIH). A nursing action that
1. May arrives at the health care clinic and tells the nurse must be initiated as the plan of care throughout injection of
that her last menstrual period was 9 weeks ago. She also the drug is:
tells the nurse that a home pregnancy test was positive but A. Ventilator assistance
she began to have mild cramps and is now having moderate B. CVP readings
vaginal bleeding. During the physical examination of the C. EKG tracings
client, the nurse notes that May has a dilated cervix. The D. Continuous CPR
nurse determines that May is experiencing which type of 10. A trial for vaginal delivery after an earlier caesareans,
abortion? would likely to be given to a gravida, who had:
A. Inevitable A. First low transverse cesarean was for active herpes
B. Incomplete type 2 infections; vaginal culture at 39 weeks
C. Threatened pregnancy was positive.
D. Septic B. First and second caesareans were for cephalopelvic
2. Nurse Reese is reviewing the record of a pregnant client disproportion.
for her first prenatal visit. Which of the following data, if noted C. First caesarean through a classic incision as a
on the client’s record, would alert the nurse that the client is result of severe fetal distress.
at risk for a spontaneous abortion? D. First low transverse caesarean was for breech
A. Age 36 years position. Fetus in this pregnancy is in a vertex
B. History of syphilis presentation.
C. History of genital herpes 11.Nurse Ryan is aware that the best initial approach when
D. History of diabetes mellitus trying to take a crying toddler’s temperature is:
3. Nurse Hazel is preparing to care for a client who is newly A. Talk to the mother first and then to the toddler.
admitted to the hospital with a possible diagnosis of ectopic B. Bring extra help so it can be done quickly.
pregnancy. Nurse Hazel develops a plan of care for the client C. Encourage the mother to hold the child.
and determines that which of the following nursing actions is D. Ignore the crying and screaming.
the priority? 12.Baby Tina a 3 month old infant just had a cleft lip and
A. Monitoring weight palate repair. What should the nurse do to prevent trauma to
B. Assessing for edema operative site?
C. Monitoring apical pulse A. Avoid touching the suture line, even when cleaning.
D. Monitoring temperature B. Place the baby in prone position.
4. Nurse Oliver is teaching a diabetic pregnant client about C. Give the baby a pacifier.
nutrition and insulin needs during pregnancy. The nurse D. Place the infant’s arms in soft elbow restraints.
determines that the client understands dietary and insulin 13. Which action should nurse Marian include in the care
needs if the client states that the second half of pregnancy plan for a 2 month old with heart failure?
require: A. Feed the infant when he cries.
A. Decreased caloric intake B. Allow the infant to rest before feeding.
B. Increased caloric intake C. Bathe the infant and administer medications before
C. Decreased Insulin feeding.
D. Increase Insulin D. Weigh and bathe the infant before feeding.
5. Nurse Michelle is assessing a 24 year old client with a 14.Nurse Hazel is teaching a mother who plans to
diagnosis of hydatidiform mole. She is aware that one of the discontinue breast feeding after 5 months. The nurse should
following is unassociated with this condition? advise her to include which foods in her infant’s diet?
A. Excessive fetal activity. A. Skim milk and baby food.
B. Larger than normal uterus for gestational age. B. Whole milk and baby food.
C. Vaginal bleeding C. Iron-rich formula only.
D. Elevated levels of human chorionic gonadotropin. D. Iron-rich formula and baby food.
6. A pregnant client is receiving magnesium sulfate for 15.Mommy Linda is playing with her infant, who is sitting
severe pregnancy induced hypertension (PIH). The clinical securely alone on the floor of the clinic. The mother hides a
findings that would warrant use of the antidote , calcium toy behind her back and the infant looks for it. The nurse is
gluconate is: aware that estimated age of the infant would be:
A. Urinary output 90 cc in 2 hours. A. 6 months
B. Absent patellar reflexes. B. 4 months
C. Rapid respiratory rate above 40/min. C. 8 months
D. Rapid rise in blood pressure. D. 10 months
7. During vaginal examination of Janah who is in labor, the 16.Which of the following is the most prominent feature of
presenting part is at station plus two. Nurse, correctly public health nursing?
interprets it as: A. It involves providing home care to sick people who
A. Presenting part is 2 cm above the plane of the are not confined in the hospital.
ischial spines. B. Services are provided free of charge to people
B. Biparietal diameter is at the level of the ischial within the catchments area.
spines. C. The public health nurse functions as part of a team
C. Presenting part in 2 cm below the plane of the providing a public health nursing services.
ischial spines. D. Public health nursing focuses on preventive, not
D. Biparietal diameter is 2 cm above the ischial spines. curative, services.
8. A pregnant client is receiving oxytocin (Pitocin) for 17.When the nurse determines whether resources were
induction of labor. A condition that warrant the nurse in- maximized in implementing Ligtas Tigdas, she is evaluating
charge to discontinue I.V. infusion of Pitocin is: A. Effectiveness
A. Contractions every 1 ½ minutes lasting 70-80 B. Efficiency
seconds. C. Adequacy
B. Maternal temperature 101.2 D. Appropriateness
C. Early decelerations in the fetal heart rate. 18.Vangie is a new B.S.N. graduate. She wants to become a
D. Fetal heart rate baseline 140-160 bpm. Public Health Nurse. Where should she apply?
A. Department of Health
 B. Provincial Health Office 28.The skin in the diaper area of a 7 month old infant is
C. Regional Health Office excoriated and red. Nurse Hazel should instruct the mother
D. Rural Health Unit to:
19.Tony is aware the Chairman of the Municipal Health A. Change the diaper more often.
Board is: B. Apply talc powder with diaper changes.
A. Mayor C. Wash the area vigorously with each diaper change.
B. Municipal Health Officer D. Decrease the infant’s fluid intake to decrease
C. Public Health Nurse saturating diapers.
D. Any qualified physician 29.Nurse Carla knows that the common cardiac anomalies in
20.Myra is the public health nurse in a municipality with a children with Down Syndrome (tri-somy 21) is:
total population of about 20,000. There are 3 rural health A. Atrial septal defect
midwives among the RHU personnel. How many more B. Pulmonic stenosis
midwife items will the RHU need? C. Ventricular septal defect
A. 1 D. Endocardial cushion defect
B. 2 30.Malou was diagnosed with severe preeclampsia is now
C. 3 receiving I.V. magnesium sulfate. The adverse effects
D. The RHU does not need any more midwife item. associated with magnesium sulfate is:
21.According to Freeman and Heinrich, community health A. Anemia
nursing is a developmental service. Which of the following B. Decreased urine output
best illustrates this statement? C. Hyperreflexia
A. The community health nurse continuously develops D. Increased respiratory rate
himself personally and professionally. 31.A 23 year old client is having her menstrual period every
B. Health education and community organizing are 2 weeks that last for 1 week. This type of menstrual pattern
necessary in providing community health services. is bets defined by:
C. Community health nursing is intended primarily for A. Menorrhagia
health promotion and prevention and treatment of B. Metrorrhagia
disease. C. Dyspareunia
D. The goal of community health nursing is to provide D. Amenorrhea
nursing services to people in their own places of 32. Jannah is admitted to the labor and delivery unit. The
residence. critical laboratory result for this client would be:
22.Nurse Tina is aware that the disease declared through A. Oxygen saturation
Presidential Proclamation No. 4 as a target for eradication in B. Iron binding capacity
the Philippines is? C. Blood typing
A. Poliomyelitis D. Serum Calcium
B. Measles 33.Nurse Gina is aware that the most common condition
C. Rabies found during the second-trimester of pregnancy is:
D. Neonatal tetanus A. Metabolic alkalosis
23.May knows that the step in community organizing that B. Respiratory acidosis
involves training of potential leaders in the community is: C. Mastitis
A. Integration D. Physiologic anemia
B. Community organization 34.Nurse Lynette is working in the triage area of an
C. Community study emergency department. She sees that several pediatric
D. Core group formation clients arrive simultaneously. The client who needs to be
24.Beth a public health nurse takes an active role in treated first is:
community participation. What is the primary goal of A. A crying 5 year old child with a laceration on his
community organizing? scalp.
A. To educate the people regarding community health B. A 4 year old child with a barking coughs and flushed
problems appearance.
B. To mobilize the people to resolve community health C. A 3 year old child with Down syndrome who is pale
problems and asleep in his mother’s arms.
C. To maximize the community’s resources in dealing D. A 2 year old infant with stridorous breath sounds,
with health problems. sitting up in his mother’s arms and drooling.
D. To maximize the community’s resources in dealing 35.Maureen in her third trimester arrives at the emergency
with health problems. room with painless vaginal bleeding. Which of the following
25.Tertiary prevention is needed in which stage of the natural conditions is suspected?
history of disease? A. Placenta previa
A. Pre-pathogenesis B. Abruptio placentae
B. Pathogenesis C. Premature labor
C. Prodromal D. Sexually transmitted disease
D. Terminal 36.A young child named Richard is suspected of having
26.The nurse is caring for a primigravid client in the labor pinworms. The community nurse collects a stool specimen to
and delivery area. Which condition would place the client at confirm the diagnosis. The nurse should schedule the
risk for disseminated intravascular coagulation (DIC)? collection of this specimen for:
A. Intrauterine fetal death. A. Just before bedtime
B. Placenta accreta. B. After the child has been bathe
C. Dysfunctional labor. C. Any time during the day
D. Premature rupture of the membranes. D. Early in the morning
27.A fullterm client is in labor. Nurse Betty is aware that the 37.In doing a child’s admission assessment, Nurse Betty
fetal heart rate would be: should be alert to note which signs or symptoms of chronic
A. 80 to 100 beats/minute lead poisoning?
B. 100 to 120 beats/minute A. Irritability and seizures
C. 120 to 160 beats/minute B. Dehydration and diarrhea
D. 160 to 180 beats/minute C. Bradycardia and hypotension
D. Petechiae and hematuria
38.To evaluate a woman’s understanding about the use of D. Chicken pox vaccine is best given when there is an
diaphragm for family planning, Nurse Trish asks her to impending outbreak in the community.
explain how she will use the appliance. Which response 47.Barangay Pinoy had an outbreak of German measles. To
indicates a need for further health teaching? prevent congenital rubella, what is the BEST advice that you
A. “I should check the diaphragm carefully for holes can give to women in the first trimester of pregnancy in the
every time I use it” barangay Pinoy?
B. “I may need a different size of diaphragm if I gain or A. Advice them on the signs of German measles.
lose weight more than 20 pounds” B. Avoid crowded places, such as markets and movie
C. “The diaphragm must be left in place for atleast 6 houses.
hours after intercourse” C. Consult at the health center where rubella vaccine
D. “I really need to use the diaphragm and jelly most may be given.
during the middle of my menstrual cycle”. D. Consult a physician who may give them rubella
39.Hypoxia is a common complication of immunoglobulin.
laryngotracheobronchitis. Nurse Oliver should frequently 48.Myrna a public health nurse knows that to determine
assess a child with laryngotracheobronchitis for: possible sources of sexually transmitted infections, the BEST
A. Drooling method that may be undertaken is:
B. Muffled voice A. Contact tracing
C. Restlessness B. Community survey
D. Low-grade fever C. Mass screening tests
40.How should Nurse Michelle guide a child who is blind to D. Interview of suspects
walk to the playroom? 49.A 33-year old female client came for consultation at the
A. Without touching the child, talk continuously as the health center with the chief complaint of fever for a week.
child walks down the hall. Accompanying symptoms were muscle pains and body
B. Walk one step ahead, with the child’s hand on the malaise. A week after the start of fever, the client noted
nurse’s elbow. yellowish discoloration of his sclera. History showed that he
C. Walk slightly behind, gently guiding the child waded in flood waters about 2 weeks before the onset of
forward. symptoms. Based on her history, which disease condition will
D. Walk next to the child, holding the child’s hand. you suspect?
41.When assessing a newborn diagnosed with ductus A. Hepatitis A
arteriosus, Nurse Olivia should expect that the child most B. Hepatitis B
likely would have an: C. Tetanus
A. Loud, machinery-like murmur. D. Leptospirosis
B. Bluish color to the lips. 50.Mickey a 3-year old client was brought to the health
C. Decreased BP reading in the upper extremities center with the chief complaint of severe diarrhea and the
D. Increased BP reading in the upper extremities. passage of “rice water” stools. The client is most probably
42.The reason nurse May keeps the neonate in a neutral suffering from which condition?
thermal environment is that when a newborn becomes too A. Giardiasis
cool, the neonate requires: B. Cholera
A. Less oxygen, and the newborn’s metabolic rate C. Amebiasis
increases. D. Dysentery
B. More oxygen, and the newborn’s metabolic rate 51.The most prevalent form of meningitis among children
decreases. aged 2 months to 3 years is caused by which
C. More oxygen, and the newborn’s metabolic rate microorganism?
increases. A. Hemophilus influenzae
D. Less oxygen, and the newborn’s metabolic rate B. Morbillivirus
decreases. C. Steptococcus pneumoniae
43.Before adding potassium to an infant’s I.V. line, Nurse D. Neisseria meningitidis
Ron must be sure to assess whether this infant has: 52.The student nurse is aware that the pathognomonic sign
A. Stable blood pressure of measles is Koplik’s spot and you may see Koplik’s spot by
B. Patant fontanelles inspecting the:
C. Moro’s reflex A. Nasal mucosa
D. Voided B. Buccal mucosa
44.Nurse Carla should know that the most common C. Skin on the abdomen
causative factor of dermatitis in infants and younger children D. Skin on neck
is: 53.Angel was diagnosed as having Dengue fever. You will
A. Baby oil say that there is slow capillary refill when the color of the
B. Baby lotion nailbed that you pressed does not return within how many
C. Laundry detergent seconds?
D. Powder with cornstarch A. 3 seconds
45.During tube feeding, how far above an infant’s stomach B. 6 seconds
should the nurse hold the syringe with formula? C. 9 seconds
A. 6 inches D. 10 seconds
B. 12 inches 54.In Integrated Management of Childhood Illness, the nurse
C. 18 inches is aware that the severe conditions generally require urgent
D. 24 inches referral to a hospital. Which of the following severe
46. In a mothers’ class, Nurse Lhynnete discussed childhood conditions DOES NOT always require urgent referral to a
diseases such as chicken pox. Which of the following hospital?
statements about chicken pox is correct? A. Mastoiditis
A. The older one gets, the more susceptible he B. Severe dehydration
becomes to the complications of chicken pox. C. Severe pneumonia
B. A single attack of chicken pox will prevent future D. Severe febrile disease
episodes, including conditions such as shingles. 55.Myrna a public health nurse will conduct outreach
C. To prevent an outbreak in the community, immunization in a barangay Masay with a population of
quarantine may be imposed by health authorities.
about 1500. The estimated number of infants in the barangay are sunken. Using the IMCI guidelines, you will classify this
would be: infant in which category?
A. 45 infants A. No signs of dehydration
B. 50 infants B. Some dehydration
C. 55 infants C. Severe dehydration
D. 65 infants D. The data is insufficient.
56.The community nurse is aware that the biological used in 65.Chris a 4-month old infant was brought by her mother to
Expanded Program on Immunization (EPI) should NOT be the health center because of cough. His respiratory rate is
stored in the freezer? 42/minute. Using the Integrated Management of Child Illness
A. DPT (IMCI) guidelines of assessment, his breathing is considered
B. Oral polio vaccine as:
C. Measles vaccine A. Fast
D. MMR B. Slow
57.It is the most effective way of controlling schistosomiasis C. Normal
in an endemic area? D. Insignificant
A. Use of molluscicides 66.Maylene had just received her 4th dose of tetanus toxoid.
B. Building of foot bridges She is aware that her baby will have protection against
C. Proper use of sanitary toilets tetanus for
D. Use of protective footwear, such as rubber boots A. 1 year
58.Several clients is newly admitted and diagnosed with B. 3 years
leprosy. Which of the following clients should be classified as C. 5 years
a case of multibacillary leprosy? D. Lifetime
A. 3 skin lesions, negative slit skin smear 67.Nurse Ron is aware that unused BCG should be
B. 3 skin lesions, positive slit skin smear discarded after how many hours of reconstitution?
C. 5 skin lesions, negative slit skin smear A. 2 hours
D. 5 skin lesions, positive slit skin smear B. 4 hours
59.Nurses are aware that diagnosis of leprosy is highly C. 8 hours
dependent on recognition of symptoms. Which of the D. At the end of the day
following is an early sign of leprosy? 68.The nurse explains to a breastfeeding mother that breast
A. Macular lesions milk is sufficient for all of the baby’s nutrient needs only up
B. Inability to close eyelids to:
C. Thickened painful nerves A. 5 months
D. Sinking of the nosebridge B. 6 months
60.Marie brought her 10 month old infant for consultation C. 1 year
because of fever, started 4 days prior to consultation. In D. 2 years
determining malaria risk, what will you do? 69.Nurse Ron is aware that the gestational age of a
A. Perform a tourniquet test. conceptus that is considered viable (able to live outside the
B. Ask where the family resides. womb) is:
C. Get a specimen for blood smear. A. 8 weeks
D. Ask if the fever is present everyday. B. 12 weeks
61.Susie brought her 4 years old daughter to the RHU C. 24 weeks
because of cough and colds. Following the IMCI assessment D. 32 weeks
guide, which of the following is a danger sign that indicates 70.When teaching parents of a neonate the proper position
the need for urgent referral to a hospital? for the neonate’s sleep, the nurse Patricia stresses the
A. Inability to drink importance of placing the neonate on his back to reduce the
B. High grade fever risk of which of the following?
C. Signs of severe dehydration A. Aspiration
D. Cough for more than 30 days B. Sudden infant death syndrome (SIDS)
62.Jimmy a 2-year old child revealed “baggy pants”. As a C. Suffocation
nurse, using the IMCI guidelines, how will you manage D. Gastroesophageal reflux (GER)
Jimmy? 71.Which finding might be seen in baby James a neonate
A. Refer the child urgently to a hospital for suspected of having an infection?
confinement. A. Flushed cheeks
B. Coordinate with the social worker to enroll the child B. Increased temperature
in a feeding program. C. Decreased temperature
C. Make a teaching plan for the mother, focusing on D. Increased activity level
menu planning for her child. 72.Baby Jenny who is small-for-gestation is at increased risk
D. Assess and treat the child for health problems like during the transitional period for which complication?
infections and intestinal parasitism. A. Anemia probably due to chronic fetal hyposia
63.Gina is using Oresol in the management of diarrhea of B. Hyperthermia due to decreased glycogen stores
her 3-year old child. She asked you what to do if her child C. Hyperglycemia due to decreased glycogen stores
vomits. As a nurse you will tell her to: D. Polycythemia probably due to chronic fetal hypoxia
A. Bring the child to the nearest hospital for further 73.Marjorie has just given birth at 42 weeks’ gestation. When
assessment. the nurse assessing the neonate, which physical finding is
B. Bring the child to the health center for intravenous expected?
fluid therapy. A. A sleepy, lethargic baby
C. Bring the child to the health center for assessment B. Lanugo covering the body
by the physician. C. Desquamation of the epidermis
D. Let the child rest for 10 minutes then continue D. Vernix caseosa covering the body
giving Oresol more slowly. 74.After reviewing the Myrna’s maternal history of
64.Nikki a 5-month old infant was brought by his mother to magnesium sulfate during labor, which condition would nurse
the health center because of diarrhea for 4 to 5 times a day. Richard anticipate as a potential problem in the neonate?
Her skin goes back slowly after a skin pinch and her eyes A. Hypoglycemia
B. Jitteriness
 C. Respiratory depression D. Observing for flakes of vernix in the vaginal
D. Tachycardia discharge.
75.Which symptom would indicate the Baby Alexandra was 84. A baby girl is born 8 weeks premature. At birth, she has
adapting appropriately to extra-uterine life without difficulty? no spontaneous respirations but is successfully resuscitated.
A. Nasal flaring Within several hours she develops respiratory grunting,
B. Light audible grunting cyanosis, tachypnea, nasal flaring, and retractions. She’s
C. Respiratory rate 40 to 60 breaths/minute diagnosed with respiratory distress syndrome, intubated, and
D. Respiratory rate 60 to 80 breaths/minute placed on a ventilator. Which nursing action should be
76. When teaching umbilical cord care for Jennifer a new included in the baby’s plan of care to prevent retinopathy of
mother, the nurse Jenny would include which information? prematurity?
A. Apply peroxide to the cord with each diaper change A. Cover his eyes while receiving oxygen.
B. Cover the cord with petroleum jelly after bathing B. Keep her body temperature low.
C. Keep the cord dry and open to air C. Monitor partial pressure of oxygen (Pao2) levels.
D. Wash the cord with soap and water each day during D. Humidify the oxygen.
a tub bath. 85. Which of the following is normal newborn calorie intake?
77.Nurse John is performing an assessment on a neonate. A. 110 to 130 calories per kg.
Which of the following findings is considered common in the B. 30 to 40 calories per lb of body weight.
healthy neonate? C. At least 2 ml per feeding
A. Simian crease D. 90 to 100 calories per kg
B. Conjunctival hemorrhage 86. Nurse John is knowledgeable that usually individual twins
C. Cystic hygroma will grow appropriately and at the same rate as singletons
D. Bulging fontanelle until how many weeks?
78.Dr. Esteves decides to artificially rupture the membranes A. 16 to 18 weeks
of a mother who is on labor. Following this procedure, the B. 18 to 22 weeks
nurse Hazel checks the fetal heart tones for which the C. 30 to 32 weeks
following reasons? D. 38 to 40 weeks
A. To determine fetal well-being. 87. Which of the following classifications applies to
B. To assess for prolapsed cord monozygotic twins for whom the cleavage of the fertilized
C. To assess fetal position ovum occurs more than 13 days after fertilization?
D. To prepare for an imminent delivery. A. conjoined twins
79.Which of the following would be least likely to indicate B. diamniotic dichorionic twins
anticipated bonding behaviors by new parents? C. diamniotic monochorionic twin
A. The parents’ willingness to touch and hold the new D. monoamniotic monochorionic twins
born. 88. Tyra experienced painless vaginal bleeding has just been
B. The parent’s expression of interest about the size of diagnosed as having a placenta previa. Which of the
the new born. following procedures is usually performed to diagnose
C. The parents’ indication that they want to see the placenta previa?
newborn. A. Amniocentesis
D. The parents’ interactions with each other. B. Digital or speculum examination
80.Following a precipitous delivery, examination of the C. External fetal monitoring
client’s vagina reveals D. Ultrasound
a fourth-degree laceration. Which of the following would be 89. Nurse Arnold knows that the following changes in
contraindicated when caring for this client? respiratory functioning during pregnancy is considered
A. Applying cold to limit edema during the first 12 to 24 normal:
hours. A. Increased tidal volume
B. Instructing the client to use two or more peripads to B. Increased expiratory volume
cushion the area. C. Decreased inspiratory capacity
C. Instructing the client on the use of sitz baths if D. Decreased oxygen consumption
ordered. 90. Emily has gestational diabetes and it is usually managed
D. Instructing the client about the importance of by which of the following therapy?
perineal (kegel) exercises. A. Diet
81. A pregnant woman accompanied by her husband, seeks B. Long-acting insulin
admission to the labor and delivery area. She states that C. Oral hypoglycemic
she’s in labor and says she attended the facility clinic for D. Oral hypoglycemic drug and insulin
prenatal care. Which question should the nurse Oliver ask 91. Magnesium sulfate is given to Jemma with preeclampsia
her first? to prevent which of the following condition?
A. “Do you have any chronic illnesses?” A. Hemorrhage
B. “Do you have any allergies?” B. Hypertension
C. “What is your expected due date?” C. Hypomagnesemia
D. “Who will be with you during labor?” D. Seizure
82.A neonate begins to gag and turns a dusky color. What 92. Cammile with sickle cell anemia has an increased risk for
should the nurse do first? having a sickle cell crisis during pregnancy. Aggressive
A. Calm the neonate. management of a sickle cell crisis includes which of the
B. Notify the physician. following measures?
C. Provide oxygen via face mask as ordered A. Antihypertensive agents
D. Aspirate the neonate’s nose and mouth with a bulb B. Diuretic agents
syringe. C. I.V. fluids
83. When a client states that her “water broke,” which of the D. Acetaminophen (Tylenol) for pain
following actions would be inappropriate for the nurse to do? 93. Which of the following drugs is the antidote for
A. Observing the pooling of straw-colored fluid. magnesium toxicity?
B. Checking vaginal discharge with nitrazine paper. A. Calcium gluconate (Kalcinate)
C. Conducting a bedside ultrasound for an amniotic B. Hydralazine (Apresoline)
fluid index. C. Naloxone (Narcan)
D. Rho (D) immune globulin (RhoGAM)
94. Marlyn is screened for tuberculosis during her first 2. The nurse is providing a health teaching to the mother of
prenatal visit. An intradermal injection of purified protein an 8-year-old child with cystic fibrosis. Which of the following
derivative (PPD) of the tuberculin bacilli is given. She is statement if made by the mother would indicate to the nurse
considered to have a positive test for which of the following the need for further teaching about the medication regimen
results? of the child?
A. An indurated wheal under 10 mm in diameter A. “My child might need an extra capsule if the meal is
appears in 6 to 12 hours. high in fat”
B. An indurated wheal over 10 mm in diameter B. “I’ll give the enzyme capsule before every snack”
appears in 48 to 72 hours. C. “I’ll give the enzyme capsule before every meal”
C. A flat circumcised area under 10 mm in diameter D. “My child hates to take pills, so I’ll mix the capsule
appears in 6 to 12 hours. into a cup of hot chocolate
D. A flat circumcised area over 10 mm in diameter 3. The mother brought her child to the clinic for follow-up
appears in 48 to 72 hours. check up. The mother tells the nurse that 14 days after
95. Dianne, 24 year-old is 27 weeks’ pregnant arrives at her starting an oral iron supplement, her child’s stools are black.
physician’s office with complaints of fever, nausea, vomiting, Which of the following is the best nursing response to the
malaise, unilateral flank pain, and costovertebral angle mother?
tenderness. Which of the following diagnoses is most likely? A. “I will notify the physician, who will probably
A. Asymptomatic bacteriuria decrease the dosage slightly”
B. Bacterial vaginosis B. “This is a normal side effect and means the
C. Pyelonephritis medication is working”
D. Urinary tract infection (UTI) C. “You sound quite concerned. Would you like to talk
96. Rh isoimmunization in a pregnant client develops during about this further?”
which of the following conditions? D. “I will need a specimen to check the stool for
A. Rh-positive maternal blood crosses into fetal blood, possible bleeding”
stimulating fetal antibodies. 4. An 8-year-old boy with asthma is brought to the clinic for
B. Rh-positive fetal blood crosses into maternal blood, check up. The mother asks the nurse if the treatment given
stimulating maternal antibodies. to her son is effective. What would be the appropriate
C. Rh-negative fetal blood crosses into maternal blood, response of the nurse?
stimulating maternal antibodies. A. I will review first the child’s height on a growth chart
D. Rh-negative maternal blood crosses into fetal blood, to know if the treatment is working
stimulating fetal antibodies. B. I will review first the child’s weight on a growth chart
97. To promote comfort during labor, the nurse John advises to know if the treatment is working
a client to assume certain positions and avoid others. Which C. I will review first the number of prescriptions refills
position may cause maternal hypotension and fetal hypoxia? the child has required over the last 6 months to give
A. Lateral position you an accurate answer
B. Squatting position D. I will review first the number of times the child has
C. Supine position seen the pediatrician during the last 6 months to
D. Standing position give you an accurate answer
98. Celeste who used heroin during her pregnancy delivers a 5. The nurse is caring to a child client who is receiving
neonate. When assessing the neonate, the nurse Lhynnette tetracycline. The nurse is aware that in taking this
expects to find: medication, it is very important to:
A. Lethargy 2 days after birth. A. Administer the drug between meals
B. Irritability and poor sucking. B. Monitor the child’s hearing
C. A flattened nose, small eyes, and thin lips. C. Give the drug through a straw
D. Congenital defects such as limb anomalies. D. Keep the child out of the sunlight
99. The uterus returns to the pelvic cavity in which of the 6. A 14 day-old infant with a cyanotic heart defects and mild
following time frames? congestive heart failure is brought to the emergency
A. 7th to 9th day postpartum. department. During assessment, the nurse checks the apical
B. 2 weeks postpartum. pulse rate of the infant. The apical pulse rate is 130 beats
C. End of 6th week postpartum. per minute. Which of the following is the appropriate nursing
D. When the lochia changes to alba. action?
100. Maureen, a primigravida client, age 20, has just A. Retake the apical pulse in 15 minutes
completed a difficult, forceps-assisted delivery of twins. Her B. Retake the apical pulse in 30 minutes
labor was unusually long and required oxytocin (Pitocin) C. Notify the pediatrician immediately
augmentation. The nurse who’s caring for her should stay D. Administer the medication as scheduled
alert for: 7. The physician prescribed gentamicin (Garamycin) to a
A. Uterine inversion child who is also receiving chemotherapy. Before
B. Uterine atony administering the drug, the nurse should check the results of
C. Uterine involution the child’s:
D. Uterine discomfort A. CBC and platelet count
B. Auditory tests
1. The student nurse is assigned to take the vital signs of the C. Renal Function tests
clients in the pediatric ward. The student nurse reports to the D. Abdominal and chest x-rays
staff nurse that the parent of a toddler who is 2 days 8. Which of the following is the suited size of the needle
postoperative after a cleft palate repair has given the toddler would the nurse select to administer the IM injection to a
a pacifier. What would be the best immediate action of the preschool child?
nurse? A. 18 G, 1-1/2 inch
A. Notify the pediatrician of this finding B. 25 G, 5/8 inch
B. Reassure the student that this is an acceptable C. 21 G, 1 inch
action on the parent’s part D. 18 G, 1inch
C. Discuss this action with the parents 9. A 9-year-old boy is admitted to the hospital. The boy is
D. Ask the student nurse to remove the pacifier from being treated with salicylates for the migratory polyarthritis
the toddler’s mouth accompanying the diagnosis of rheumatic fever. Which of the
following activities performed by the child would give a best accept her newly born sister”. It is appropriate to the nurse to
sign that the medication is effective? response that:
A. Listening to story of his mother A. The older daughter be given more responsibility and
B. Listening to the music in the radio assure her “that she is a big girl now, and doesn’t
C. Playing mini piano need Mommy as much”
D. Watching movie in the dvd mini player B. The older daughter not have interaction with the
10. The physician decided to schedule the 4-year-old client baby at the hospital, because she may harm her
for repair of left undescended testicle. The Injection of a new sibling
hormone, HCG finds it less successful for treatment. To C. The older daughter stay with her grandmother for a
administer a pentobarbital sodium (Nembutal) suppository few days until the parents and new baby are settled
preoperatively to this client, in which position should the at home
nurse place him? D. The mother spend time alone with her older
A. Supine with foot of bed elevated daughter when the baby is sleeping
B. Prone with legs abducted 17. A 2-year-old client with cystic fibrosis is confined to bed
C. Sitting with foot of bed elevated and is not allowed to go to the playroom. Which of the
D. Side-lying with upper leg flexed following is an appropriate toy would the nurse select for the
11. The nurse is caring to a 24-month-old child diagnosed child:
with congenital heart defect. The physician prescribed A. Puzzle
digoxin (Lanoxin) to the client. Before the administration of B. Musical automobile
the drug, the nurse checks the apical pulse rate to be 110 C. Arranging stickers in the album
beats per minute and regular. What would be the next D. Pounding board and hammer
nursing action? 18. Which of the following clients is at high risk for
A. Check the other vital signs and level of developmental problem?
consciousness A. A toddler with acute Glomerulonephritis on
B. Withhold the digoxin and notify the physician antihypertensive and antibiotics
C. Give the digoxin as prescribed B. A 5-year-old with asthma on cromolyn sodium
D. Check the apical and radial simultaneously, and if C. A preschooler with tonsillitis
they are the same, give the digoxin. D. A 2 1/2 –year old boy with cystic fibrosis
12. An 8-year-old client with cystic fibrosis is admitted to the 19. Which of the following would be the best divesionary
hospital and will undergo a chest physiotherapy treatment. activity for the nurse to select for a 2 weeks hospitalized 3-
The therapy should be properly coordinated by the nurse year-old girl?
with the respiratory therapy department so that treatments A. Crayons and coloring books
occur during: B. doll
A. After meals C. xylophone toy
B. Between meals D. puzzles
C. After medication 20. A nurse is providing safety instructions to the parents of
D. Around the child’s play schedule the 11-month-old child. Which of the following will the nurse
13. The nurse is providing health teaching about the includes in the instructions?
breastfeeding and family planning to the client who gave A. Plugging all electrical outlets in the house
birth to a healthy baby girl. Which of the following statement B. Installing a gate at the top and bottom of any stairs
would alert the nurse that the client needs further teaching? in the home
A. “I understand that the hormones for breastfeeding C. Purchasing an infant car seat as soon as possible
may affect when my periods come” D. Begin to teach the child not to place small objects in
B. “Breastfeeding causes my womb to tighten and the mouth
bleed less after birth” 21. An 8-year-old girl is in second grade and the parents
C. “I may not have periods while I am breastfeeding, decided to enroll her to a new school. While the child is
so I don’t need family planning” focusing on adjusting to new environment and peers, her
D. “I can get pregnant as early as one month after my grades suffer. The child’s father severely punishes the child
baby was born” and forces her daughter to study after school. The father
14. A toddler is brought to the hospital because of severe does not allow also her daughter to play with other children.
diarrhea and vomiting. The nurse assigned to the client These data indicate to the nurse that this child is deprived of
enters the client’s room and finds out that the client is using a forming which normal phase of development?
soiled blanket brought in from home. The nurse attempts to A. Heterosexual relationships
remove the blanket and replace it with a new and clean B. A love relationship with the father
blanket. The toddler refuses to give the soiled blanket. The C. A dependency relationship with the father
nurse realizes that the best explanation for the toddler’s D. Close relationship with peers
behavior is: 22. A 5-year-old boy client is scheduled for hernia surgery.
A. The toddler did not bond well with the maternal The nurse is preparing to do preoperative teaching with the
figure child. The nurse should knows that the 5-year-old would:
B. The blanket is an important transitional object A. Expect a simple yet logical explanation regarding
C. The toddler is anxious about the hospital the surgery
experience B. Asks many questions regarding the condition and
D. The toddler is resistive to nursing interventions the procedure
15. The nurse has knowledge about the developmental task C. Worry over the impending surgery
of the child. In caring a 3-year-old-client, the nurse knows D. Be uninterested in the upcoming surgery
that the suited developmental task of this child is to: 23. The nine-year-old client is admitted in the hospital for
A. Learn to play with other children almost 1 week and is on bed rest. The child complains of
B. Able to trust others being bored and it seems tiresome to stay on bed and doing
C. Express all needs through speaking nothing. What activity selected by the nurse would the child
D. Explore and manipulate the environment most likely find stimulating?
16. A mother who gave birth to her second daughter is so A. Watching a video
concerned about her 2-year old daughter. She tells the B. Putting together a puzzle
nurse, “I am afraid that my 2-year-old daughter may not C. Assembling handouts with the nurse for an
upcoming staff development meeting
 D. Listening to a compact disc D. “Breastfeeding protects me from pregnancy
24. The parent of a 16-year-old boy tells the nurse that his because it keeps my hormones down, so I don’t
son is driving a motorbike very fast and with one hand. “It is need any contraception until I stop breastfeeding”
making me crazy!” What would be the best explanation of the 30. A community nurse enters the home of the client for
nurse to the behavior of the boy? follow-up visit. Which of the following is the most appropriate
A. The adolescent might have an unconscious death area to place the nursing bag of the nurse when conducting
wish a home visit?
B. The adolescent feels indestructible A. cushioned footstool
C. The adolescent lacks life experience to realize how B. bedside wood table
dangerous the behavior is C. kitchen countertop
D. The adolescent has found a way to act out hostility D. living room sofa
toward the parent 31. The nurse in the health center is making an assessment
25. An 8-month-old infant is admitted to the hospital due to to the infant client. The nurse notes some rashes and small
diarrhea. The nurse caring for the client tells the mother to fluid-filled bumps in the skin. The nurse suspects that the
stay beside the infant while making assessment. Which of infant has eczema. Which of the following is the most
the following developmental milestones the infant has important nursing goal:
reached? A. Preventing infection
A. Has a three-word vocabulary B. Providing for adequate nutrition
B. Interacts with other infants C. Decreasing the itching
C. Stands alone D. Maintaining the comfort level
D. Recognizes but is fearful of strangers 32. The nurse in the health center is providing immunization
26. The community nurse is conducting a health teaching in to the children. The nurse is carefully assessing the condition
the group of married women. When teaching a woman about of the children before giving the vaccines. Which of the
fertility awareness, the nurse should emphasize that the following would the nurse note to withhold the infant’s
basal body temperature: scheduled immunizations?
A. Should be recorded each morning before any A. a dry cough
activity B. a skin rash
B. Is the average temperature taken each morning C. a low-grade fever
C. Can be done with a mercury thermometer but not a D. a runny nose
digital one 33. A mother brought her child in the health center for
D. Has a lower degree of accuracy in predicting hepatitis B vaccination in a series. The mother informs the
ovulation than the cervical mucus test nurse that the child missed an appointment last month to
27. The community nurse is providing an instruction to the have the third hepatitis B vaccination. Which of the following
clients in the health center about the use of diaphragm for statements is the appropriate nursing response to the
family planning. To evaluate the understanding of the mother?
woman, the nurse asks her to demonstrate the use of the A. “I will examine the child for symptoms of hepatitis B”
diaphragm. Which of following statement indicates a need for B. “Your child will start the series again”
further health teaching? C. “Your child will get the next dose as soon as
A. “I should check the diaphragm carefully for holes possible”
every time I use it.” D. “Your child will have a hepatitis titer done to
B. “The diaphragm must be left in place for at least 6 determine if immunization has taken place.”
hours after intercourse.” 34. The community health nurse implemented a new
C. “I really need to use the diaphragm and jelly most program about effective breast cancer screening technique
during the middle of my menstrual cycle for the female personnel of the health department of
D. “I may need a different size diaphragm if I gain or Valenzuela. Which of the following technique should the
lose more than 20 pounds” nurse consider to be of the lowest priority?
28. The client visits the clinic for prenatal check-up. While A. Yearly breast exam by a trained professional
waiting for the physician, the nurse decided to conduct health B. Detailed health history to identify women at risk
teaching to the client. The nurse informed the client that C. Screening mammogram every year for women over
primigravida mother should go to the hospital when which age 50
patter is evident? D. Screening mammogram every 1-2 years for women
A. Contractions are 2-3 minutes apart, lasting 90 over age of 40.
seconds, and membranes have ruptured 35. Which of the following technique is considered an aseptic
B. Contractions are 5-10 minutes apart, lasting 30 practice during the home visit of the community health
seconds, and are felt as strong menstrual cramps nurse?
C. Contractions are 3-5 minutes apart, accompanied A. Wrapping used dressing in a plastic bag before
by rectal pressure and bloody show placing them in the nursing bag
D. Contractions are 5 minutes apart, lasting 60 B. Washing hands before removing equipment from
seconds, and increasing in intensity the nursing bag
29. A nurse is planning a home visit program to a new C. Using the client’s soap and cloth towel for hand
mother who is 2 weeks postpartum and breastfeeding, the washing
nurse includes in her health teaching about the resumption of D. Placing the contaminated needles and syringes in a
fertility, contraception and sexual activity. Which of the labeled container inside the nursing bag
following statement indicates that the mother has understood 36. The nurse is planning to conduct a home visit in a small
the teaching? community. Which of the following is the most important
A. “Because breastfeeding speeds the healing process factor when planning the best time for a home care visit?
after birth, I can have sex right away and not worry A. Purpose of the home visit
about infection” B. Preference of the patient’s family
B. “Because I am breastfeeding and my hormones are C. Location of the patient’s home
decreased, I may need to use a vaginal lubricant D. Length of time of the visit will take
when I have sex” 37. The nurse assigned in the health center is counseling a
C. “After birth, you have to have a period before you 30-year-old client requesting oral contraceptives. The client
can get pregnant again’ tells the nurse that she has an active yeast infection that has
recurred several times in the past year. Which statement by
the nurse is inaccurate concerning health promotion actions A. “Condoms should be used because they can
to prevent recurring yeast infection? prevent infection and because they may prevent
A. “During treatment for yeast, avoid vaginal pregnancy”
intercourse for one week” B. “Condoms should be used even if you have recently
B. “Wear loose-fitting cotton underwear” tested negative for HIV”
C. “Avoid eating large amounts of sugar or sugar- C. “Condoms should be used every time you have sex
bingeing” because condoms prevent all forms of sexually
D. “Douche once a day with a mild vinegar and water transmitted diseases”
solution” D. “Condoms should be used every time you have sex
38. During immunization week in the health center, the even if you are taking the pill because condoms can
parent of a 6-month-old infant asks the health nurse, “Why is prevent the spread of HIV and gonorrhea”
our baby going to receive so many immunizations over a 44. The department of health is promoting the breastfeeding
long time period?” The best nursing response would be: program to all newly mothers. The nurse is formulating a
A. “The number of immunizations your baby will plan of care to a woman who gave birth to a baby girl. The
receive shows how many pediatric communicable nursing care plan for a breast-feeding mother takes into
and infectious diseases can now be prevented.” account that breast-feeding is contraindicated when the
B. “You need to ask the physician” woman:
C. “The number of immunizations your baby will A. Is pregnant
receive is determined by your baby’s health history B. Has genital herpes infection
and age” C. Develops mastitis
D. “It is easier on your baby to receive several D. Has inverted nipples
immunizations rather than one at a time” 45. The City health department conducted a medical mission
39. The community health nurse is conducting a health in Barangay Marulas. Majority of the children in the Barangay
teaching about nutrition to a group of pregnant women who Marulas were diagnosed with pinworms. The community
are anemic and are lactose intolerant. Which of the following health nurse should anticipate that the children’s chief
foods should the nurse especially encourage during the third complaint would be:
trimester? A. Lack of appetite
A. Cheese, yogurt, and fish for protein and calcium B. Severe itching of the scalp
needs plus prenatal vitamins and iron supplements C. Perianal itching
B. Prenatal iron and calcium supplements plus a D. Severe abdominal pain
regular adult diet 46. The mother brought her daughter to the health center.
C. Red beans, green leafy vegetables, and fish for iron The child has head lice. The nurse anticipates that the
and calcium needs plus prenatal vitamins and iron nursing diagnosis most closely correlated with this is:
supplements A. Fluid volume deficit related to vomiting
D. Red meat, milk and eggs for iron and calcium needs B. Altered body image related to alopecia
plus prenatal vitamins and iron supplements C. Altered comfort related to itching
40. A woman with active tuberculosis (TB) and has visited D. Diversional activity deficit related to hospitalization
the health center for regular therapy for five months wants to 47. The mother brings a child to the health care clinic
become pregnant. The nurse knows that further information because of severe headache and vomiting. During the
is necessary when the woman states: assessment of the health care nurse, the temperature of the
A. “Spontaneous abortion may occur in one out of five child is 40 degree Celsius, and the nurse notes the presence
women who are infected” of nuchal rigidity. The nurse is suspecting that the child might
B. “Pulmonary TB may jeopardize my pregnancy” be suffering from bacterial meningitis. The nurse continues to
C. “I know that I may not be able to have close contact assess the child for the presence of Kernig’s sign. Which
with my baby until contagious is no longer a finding would indicate the presence of this sign?
problem A. Flexion of the hips when the neck is flexed from a
D. “I can get pregnant after I have been free of TB for lying position
6 months” B. Calf pain when the foot is dorsiflexed
41. The Department of Health is alarmed that almost 33 C. Inability of the child to extend the legs fully when
million people suffer from food poisoning every year. lying supine
Salmonella enteritis is responsible for almost 4 million cases D. Pain when the chin is pulled down to the chest
of food poisoning. One of the major goals is to promote 48. A community health nurse makes a home visit to a child
proper food preparation. The community health nurse is with an infectious and communicable disease. In planning
tasks to conduct health teaching about the prevention of food care for the child, the nurse must determine that the primary
poisoning to a group of mother everyday. The nurse can help goal is that the:
identify signs and symptoms of specific organisms to help A. Child will experience mild discomfort
patients get appropriate treatment. Typical symptoms of B. Child will experience only minor complications
salmonella include: C. Child will not spread the infection to others
A. Nausea, vomiting and paralysis D. Public health department will be notified
B. Bloody diarrhea 49. The mother brings her daughter to the health care clinic.
C. Diarrhea and abdominal cramps The child was diagnosed with conjunctivitis. The nurse
D. Nausea, vomiting and headache provides health teaching to the mother about the proper care
42. A community health nurse makes a home visit to an of her daughter while at home. Which statement by the
elderly person living alone in a small house. Which of the mother indicates a need for additional information?
following observation would be a great concern? A. “I do not need to be concerned about the spreading
A. Big mirror in a wall of this infection to others in my family”
B. Scattered and unwashed dishes in the sink B. “I should apply warm compresses before instilling
C. Shiny floors with scattered rugs antibiotic drops if purulent discharge is present in
D. Brightly lit rooms my daughter’s eye”
43. The health nurse is conducting health teaching about C. “I can use an ophthalmic analgesic ointment at
“safe” sex to a group of high school students. Which of the nighttime if I have eye discomfort”
following statement about the use of condoms should the D. “I should perform a saline eye irrigation before
nurse avoid making? instilling, the antibiotic drops into my daughter’s eye
if purulent discharge is present”
50. A community health nurse is caring for a group of flood
victims in Marikina area. In planning for the potential needs
of this group, which is the most immediate concern?
A. Finding affordable housing for the group
B. Peer support through structured groups
C. Setting up a 24-hour crisis center and hotline
D. Meeting the basic needs to ensure that adequate
food, shelter and clothing are available