A quick test performed on a baby at 1 and 5 minutes a.

Do medical and surgical handwashing

after birth? b. Perform gowning and gloving
a. Unang Yakap c. Support the perineum using the dominant
b. Ballard Scoring hand
c. Newborn Screening d. Drape the patient accordingly
d. APGAR Screening
Nurse Ryan performs cord care to the newborn, He
Initially, the newborns temperature should be taken recalls that a newborn should be thoroughly dry for
at? atleast _____?
a. None of the choices a. 30 seconds
b. Rectum b. 2 minutes
c. Axilla c. 60 seconds
d. Orally d. 5 minutes

A patient was in labor. Upon the initial assessment of This stage of labor is the period from the birth of the
the OB physician, it has an I.E of 5-6cm. Contractions baby through the delivery of the placenta?
becomes longer, more severe and frequent. In what a. Stage of Expulsion
phase of the 1st stage of labor does the patient is b. Stage of Physical Recovery
experiencing? c. Placental Stage
a. Transition phase d. Stage of Dilatation
b. Active stage
c. Latent phase A medication instilled to the both eyes of the newborn
d. Descent phase to prevent ophthalmia neonatorum?
a. Crede’s Prophylaxis
True or False. Do not suction unless the mouth/nose b. Crede’s Maneuver
are blocked with secretions or other materials? c. MMR Immunization
a. True d. Hep B immunoglobulin (HBIG)
b. False
True or False. In Handling a Delivery procedure, Do we
Vitamin K injection should be administered at what encourage the patient to push/bear down once uterus
particular site? is at the height of its contraction?
a. Vastus lateralis a. True
b. Deltoid muscle b. False
c. Ventrogluteal
d. Dorsogluteal In an Apgar test, the healthcare provider examines
following category, EXCEPT for?
A term wherein the fetal presenting part is not a. Breathing effort
engaged in pelvic inlet? b. Heart rate
a. Engagement c. Neuromuscular maturity
b. Descent d. Skin color
c. Floating
d. Fixed Upon the delivery of the placenta, Student Nurse
Carla noticed that the placenta is presenting the shiny
During the birthing process, massaging the uterus over and glistening side of the fetal membrane, She is
the fundus promotes uterine _____? correct if she states that the placenta being delivered
a. Vasodilation was a ____?
b. Protection a. Calkin
c. Relaxation b. Duncan
d. Contractions c. Schultze
d. Teary placenta
Based on the procedure, what should you do FIRST
before handling a delivery?
It denotes the extraction of the fetal head using one b. Army navy retractor
hand to pull the fetal chin from between the maternal c. Placental bowl
anus and the coccyx, and the other on the fetal d. Needle holder
occiput to control speed of delivery?
a. Crede’s Maneuver It is a surgical incision of the perineum made to
b. Brand-Andrews Maneuver prevent tearing of the perineum with the birth and to
c. Ritgen’s Maneuver release pressure of the fetal head during delivery?
d. Internal Rotation Maneuver a. Episiorraphy
b. Laceration
A method of expressing the placenta by grasping the c. Epistaxis
umbilical cord with one hand and placing the other d. Episiotomy
hand on the abdomen, application of the traction on
the cord by moving the forcep up, down, left, right? Which is the correct sequence of Cardinal Movements
a. Internal Rotation Maneuver of the newborn upon delivery?
b. Brandt-Andrews Maneuver Engagement, Descent, Flexion, Internal
c. Crede’s Maneuver Rotation, Extension, External Rotation,
d. Ritgen’s Maneuver Expulsion

After the umbilical pulsations have stopped, student In assisting a Normal Spontaneous Vaginal Delivery,
nurse Carla clamps the cord using a sterile plastic Student Nurse Mia must anticipate the use of what
clamp at ______ from the base of the newborn? anesthetic agent?
a. 4-6 cm a. Novovacaine
b. 8 cm b. Mepivacaine
c. 2 cm c. Lidocaine
d. 5 cm d. Bupivacaine

A process of rating the infant’s physical and Contractions during this phase are usually very strong
neuromuscular maturity? that would last 60-90 seconds and occurring every few
a. Unang Yakap minutes?
b. APGAR Scoring a. Active stage
c. Ballard Scoring b. Latent phase
d. Newborn Screening c. Transition phase
d. Descent phase
Infants with mothers tested positive for HepB surface
antigen (HBsAg) should also receive an immunization A baby should undergone a Newborn Screening (NBS)
called ______? within how many hours from birth?
a. Hep B vaccine a. 48 hours
b. Hep B immunoglobulin (HBIG) b. 24 hours
c. Vitamin K c. 6 hours
d. MMR Immunization d. 72 hours

Student Nurse Tom understands that in Assisting a When the face and the head of the baby is delivered,
Delivery his MAJOR nursing responsibility is to? what would Nurse Mia initially DO?
a. Deliver the placenta a. Gently wipe the baby’s mouth and nose with
b. None of the choices clean gauze
c. Support the perineum of the patient b. Apply downward pulling motion to deliver the
d. Prepares the materials (OB pack and top shoulder then lift the baby up to deliver
instruments set to be used in the delivery) the lower shoulder. Gently deliver the rest of
the baby.
All of the instruments below are commonly used c. Place the baby to the mother’s abdomen in
during the Delivery, EXCEPT? prone position
a. Tissue forcep
 d. Wait for external rotation (within 1-2 min) the
head of the baby will turn sideways bringing
one shoulder just below the symphysis pubis
and the other facing the perineum

Student Nurse Sophia was assigned in handling a

delivery, she recalls that the following were the signs
of placental separation, EXCEPT?
a. The uterus rises in the abdomen
b. Sudden gush of blood
c. None of the choices
d. Lengthening of the cord

Student Nurse Chloe noticed that secretions is evident

upon the delivery of the newborn, what is the BEST
nursing intervention she should do?
a. Do APGAR scoring immediately then after 5
minutes
b. Check breathing, do not ventilate unless not
breathing and do not suction unless with
secretions but first suction the nose first
c. Remove the wet cloth
d. Check breathing, do not ventilate unless not
breathing and do not suction unless with
secretions but first suction the mouth first

After the OB physician sutured the perineum area, the

operative site must be flush with what kind of
solution?
a. Lactated Ringer’s Solution
b. Dextrose 5% in Lactated Ringer Solution
c. Normal Saline
d. Betadine Solution
1. A 35-year-old female patient is admitted in a. Bring the blood bag and tubing set to the patient's
Emergency Room at St. Vincent General Hospital due to room.
fever, loss of appetite, vomiting, and abdominal pain. b. Record blood product, volume, and time of blood
As the nurse goes to attach the distal end of the IV administration in the patient's chart.
tubing to a needleless connector, the exposed tubing c. Tell patient to immediately report any itching, chills,
drops and hits the top of the hand basin. Which of the or nausea.
following is the appropriate action by the nurse? d. Ensure an informed consent has been obtained.
a. Attach a new needleless connector
b. Wipe the distal end of the tubing with Betadine 5. Nurse Marly is assigned in trauma unit, three patients
c. Scrub the needleless connector with an alcohol swab will be receiving blood transfusions during his time of
d. Obtain new IV tubing duty. A female patient is prescribed to receive 1 unit of
packed red blood cells (PRBCs), a male teenager will be
2. Nurse Marly is assigned in trauma unit, three patients receiving a platelet transfusion, and a 3 unit Fresh-
will be receiving blood transfusions during his time of frozen plasma to a newly admitted male adult patient.
duty. A female patient is prescribed to receive 1 unit of A male teenager patient is receiving a platelet
packed red blood cells (PRBCs), a male teenager will be transfusion. Nurse Marly determines that the patient is
receiving a platelet transfusion, and a 3 unit Fresh- gaining from this therapy if he exhibits which of the
frozen plasma to a newly admitted male adult patient. following?
The patient is receiving the PRBCs blood transfusion, a. Less frequent febrile episodes
which of the following intravenous solutions should b. Increased level of hemoglobin
nurse Marly hang with the blood product patient's c. Increased level of hematocrit
bedside? d. Less episodes of bleeding
a. 5% dextrose in 0.45% sodium chloride
b. 5% dextrose in 0.9% sodium chloride 6. A female patient with severe trauma caused by
c. 0.9% sodium chloride vehicular accident is brought to Emergency Room. A
d. Balanced Multiple Solution with 5% Dextrose blood transfusion is ordered stat to her whose blood
type is A. Prior to administering a blood transfusion,
3. Nurse Marly is assigned in trauma unit, three patients which nursing intervention takes highest priority for
will be receiving blood transfusions during his time of this patient?
duty. A female patient is prescribed to receive 1 unit of a. Documenting blood administration in the chart.
packed red blood cells (PRBCs), a male teenager will be b. Informing the patient that the transfusion usually
receiving a platelet transfusion, and a 3 unit Fresh- takes 4 to 6 hours.
frozen plasma to a newly admitted male adult patient. c. Warming the blood prior transfusion.
The patient is receiving a first-time blood transfusion of d. Instructing the patient to report any subjective
1 unit packed red blood cells (PRBCs). How long should symptoms such as itching, chills, nausea, chest pain, or
Nurse Marly stay and monitor the patient to ensure a dyspnea.
transfusion reaction will not happen?
a. 30 minutes 7. A 35-year-old female patient is admitted in
b. 60 minutes Emergency Room at St. Vincent General Hospital due to
c. 15 minutes fever, loss of appetite, vomiting, and abdominal pain.
d. 45 minutes The IV therapy nurse is inserting an IV line into a client's
vein. After the initial stick, the nurse continues to
4. A 35-year-old woman is admitted in the hospital due advance the catheter if:
to extreme blood loss when she experienced a. Blood return shows in the backflash chamber of the
incomplete spontaneous abortion. When performing catheter.
assessment, the abortion is now complete, the b. The client does not complain of discomfort
bleeding has stopped and her vital signs are stable. The c. The vein is distended under the needle
physician prescribed two successive whole blood d. The catheter advances easily.
transfusions for this patient to replace her lost volume.
Which is a primary nursing action prior to starting a 8. Nurse Marly is assigned in trauma unit, three patients
blood transfusion? will be receiving blood transfusions during his time of
duty. A female is prescribed to receive 1 unit of packed
red blood cells (PRBCs), a male teenager will be 12. Nurse Marly is assigned in trauma unit, three
receiving a platelet transfusion, and a 3 unit Fresh- patients will be receiving blood transfusions during his
frozen plasma to a newly admitted male adult patient. time of duty. A female is prescribed to receive 1 unit of
When evaluating the normal appearance of packed red packed red blood cells (PRBCs), a male teenager will be
blood cells in a blood bag, which of the following would receiving a platelet transfusion, and a 3 unit Fresh-
Nurse Marly expect to find? frozen plasma to a newly admitted male adult patient.
a. Clots form inside the bag When administering a transfusion of packed red blood
b. Yellow color separates from middle to top portion of cells. Nurse Marly is aware that the entire unit of blood
the blood in the bag is transfused within:
c. Red color with no leaks and coagulates in the bag a. 12 hours
d. Gas bubbles seen above and below inside the blood b. 4 hours
bag c. 8 hours
d. 24 hours
9. A 35- year old female patient is admitted in
Emergency Room at St. Vincent General Hospital due to 13. Nurse Marly is assigned in trauma unit, three
fever, loss of appetite, vomiting, and abdominal pain. patients will be receiving blood transfusions during his
The distal end of the tubing connects to an extension time of duty. A female is prescribed to receive 1 unit of
set or catheter which allows fluid to transfer from the packed red blood cells (PRBCs), a male teenager will be
bag to the patient, this part of the infusion set receiving a platelet transfusion, and a 3 unit Fresh-
specifically refers to: frozen plasma to a newly admitted male adult patient.
a. Bag spike A patient with a low hemoglobin and low hematocrit
b. Luer lock and adapter has an order to receive one unit of PRBCs. Nurse Marly
c. Vent recalls her knowledge that a PRBCs is best describes as:
d. Injection port a. Red blood celss from whole blood by removing
plasma as by centrifiguration
10. A 5- year old girl is admitted to the hospital with b. A blood product made from the liquid portion of
cystic fibrosis and pneumonia. The nurse has a whole blood to treat low blood clotting or low levels of
prescription by the physician to begin peripheral IV line blood proteins condition
so that antibiotics and other medications like c. Tiny cells in the blood that help stop the bleeding
theophylline can be given intravenously . ALL BUT ONE d. A human blood that has all of them in the treatment
are advantages of micro drip infusion set: of massive bleeding, in exchange transfusion, and
a. Allows fluid resuscitation autologous blood donation
b. Easy to titrate
c. Delivers accurate small amount of infusion to the 14. A 35- year old female patient is admitted in
children Emergency Room at St. Vincent General Hospital due to
d. Avoids fluid overload fever, loss of appetite, vomiting, and abdominal pain.
The following materials are prepared by the nurse for
11. A 35- year old female patient is admitted in starting IVF therapy EXCEPT:
Emergency at St. Vincent General Hospital due to fever, a. 1 liter 0.9% sodium Chloride IV solution bottle and
loss of appetite, vomiting, and abdominal pain. In the Single-use sterile IV Start kit
physician’s order sheet, an IVF treatment of 0.9% b. 24 G IV catheter and Micro-drip IV tubing set
Sodium Chloride (PNSS)1 liter at 30 gtts/min should be c. 22 G IV cannula & Macrodrip IV tubing set
immediately started. Which of the following reasons d. IV pole and clean gloves
best apply to this patient pertaining to administering an
isotonic IV solution? 15. Nurse Seth is assigned in trauma unit, three patients
a. To administer blood or blood products will be receiving blood transfusions during his time of
b. To deliver nutrients and nutritional supplements duty. A female patient is prescribed to receive 1 unit of
c. To provide glucose that serves the main fuel for packed red blood cells (PRBCs), a male teenager will be
metabolism in the body receiving a platelet transfusion, and a 3 unit Fresh-
d. To treat fluid loss and restore sodium chloride frozen plasma to a newly admitted male adult patient.
balance Nurse Seth confirms the validity of the doctor’s order
and patient’s consent before the transfusion of blood
to take place, which of the following IV tubing set would a. 5 gtts/ml
Nurse Seth prepare in order to transfuse packed red b. 60 drops/ml
blood cells (PRBCs)? c. 10, 15, or 20 gtts/ml
a. Tubing with an in-line filter d. 30 – 45 drops/ml
b. Photofusion set
c. Microfusion set 19. A 35-year-old woman is admitted in the hospital
d. Polyvol Pro Burette Set due to extreme blood loss when she experienced
incomplete spontaneous abortion. When performing
16. Rebecca has just passed the Philippine Nurses’ assessment, the abortion is now complete, the
Licensure Exam and got her luck to work at Vicente bleeding has stopped and her vital signs are stable. The
Sotto Memorial Medical Hospital. On her first day of physician prescribed two successive whole blood
duty, she is making initial rounds on the nursing unit to transfusions for this patient to replace her lost volume.
assess the condition of assigned patients with acute What significant assessment need to be made by the
and life-threatening traumatic injuries. Nurse Rebecca nurse to the patient before initiating the blood
observes that the surrounding insertion site of a transfusion?
patient’s peripheral IV catheter is reddened, warm, a. Record elimination patterns
painful, and slightly swollen. Nurse Rebecca should take b. Check skin color and condition
which actions in the care of this patient? (Select All That c. Chart oral and parenteral intake
Apply): 1. Starts a new IV line in a proximal portion of d. Obtain temperature, pulse, respirations, and blood
the same vein 2. Informs the physician 3. Removes the pressure
IV catheter at that site 4. Applies warm moist packs to
the site 5. Administer nonsteroidal anti-inflammatory 20. Nurse Seth is assigned in trauma unit, three patients
drug 6. Documents the occurrence, actions taken, and will be receiving blood transfusions during his time of
the client's response. duty. A female patient is prescribed to receive 1 unit of
a. 3, 4, 5, 6 packed red blood cells (PRBCs), a male teenager will be
b. 2, 3, 4, 6 receiving a platelet transfusion, and a 3 unit Fresh-
c. 2, 3, 1, 6 frozen plasma to a newly admitted male adult patient.
d. 3, 4, 5, 1 A 3 unit Fresh-frozen plasma (FFP) is ordered to a
patient who experienced blood loss due to a deep
17. A 5-year-old girl is admitted to the hospital with puncture wound. Nurse Seth determines that the
cystic fibrosis and pneumonia. The nurse has a reason behind this order is to:
prescription by the physician to begin peripheral IV line a. Treat thrombocytopenia
so that antibiotics and other medications like b. Increase hemoglobin, hematocrit, and neutrophil
theophylline can be given intravenously. Micro-drip IV levels.
tubing is used mostly in pediatric which is described as: c. Treat platelet dysfunction
a. An IV administration set with a small needle in the d. Provide clotting factors and volume expansion
chamber
b. An administration set which the rate of infusion is 21. A 5-year-old girl is admitted to the hospital with
regulated by an electronic pump cystic fibrosis and pneumonia. The nurse has a
c. An IV administration set with a volume control prescription by the physician to begin peripheral IV line
chamber so that antibiotics and other medications like
d. An IV administration set without needle in the theophylline can be given intravenously. A micro drip IV
chamber tubing set delivers a drop factor of:
a. 5 gtts/ml
18. A 35-year-old female patient is admitted in b. 60 drops/ml
Emergency Room at St. Vincent General Hospital due to c. 30 – 45 drops/ml
fever, loss of appetite, vomiting, and abdominal pain. d. 10, 15, or 20 gtts/ml
While connecting the infusion tubing set to the bag of
IV solution, the nurse recalls that a macro drip chamber 22. Nurse Seth is assigned in trauma unit, three patients
set is used to infuse large volumes or to infuse fluids will be receiving blood transfusions during his time of
quickly that delivers a drop factor of which of the duty. A female patient is prescribed to receive 1 unit of
following? packed red blood cells (PRBCs), a male teenager will be
receiving a platelet transfusion, and a 3 unit Fresh- blood transfusion is needed during or after the
frozen plasma to a newly admitted male adult patient. procedure. The patient has stated on admission that
To confirm the age of blood cells in a blood, Nurse Seth she is a Jehovah’s Witness. What would the nurse do
will check which of the following? about this?
a. Blood group a. Ask for any donated blood be screened twice by the
b. Blood expiration date blood bank
c. Blood identification number b. Explain the risk and benefits and procedure of blood
d. Blood Type transfusion. Inform the physician and let the patient
sign the waiver if will exist not to perform blood
23. A 35-year-old female patient is admitted in transfusion
Emergency Room at St. Vincent General Hospital due to c. Take iron supplement before the surgery and eat
fever, loss of appetite, vomiting, and abdominal pain. green leafy vegetables
Based on the information provided in the situation, the d. Do the blood transfusion as ordered as this is needed
nurse anticipates that an IVF theraphy will be ordered for the patient.
by the physician in addition to laboratory tests.
Intravenous Fluid Theraphy is best defined as: 27. A 5-year-old girl is admitted to the hospital with
a. The administration of a fluid substance (solution) cystic fibrosis and pneumonia. The nurse has a
directly into a vien as a therapeutic treatment. prescription by the physician to begin peripheral IV line
b. A treatment that uses a dialysate that is placed into so that antibiotics and other medications like
the patient’s abdominal cavity theophylline can be given intravenously. The mother
c. A treatment that uses machine and filter to remove reports the nurse that his son’s IV drip chamber stops
fluid and waste products from the blood. flowing. The nurse notes that the child’s IV site is cool,
d. A treatment that uses certain parts of a person’s pale, and swollen, and the solution is not infusing. The
immune system to fight infection and disease. nurse concludes that which of the following
complications has occurred.
24. A female patient with severe trauma caused by a. Thrombosis
vehicular accident is brought to Emergency Room. A b. Infection
blood transfusion is ordered stat to her whose blood c. Phlebitis
type is A. A fresh whole blood type O is only available in d. Infiltration
the blood bank. The nurse understand that patient can
safely receive blood group O because: 28. A 5-year-old girl is admitted to the hospital with
a. Type O blood contains A antigens cystic fibrosis and pneumonia. The nurse has a
b. Type O blood contains no A antigens prescription by the physician to begin peripheral IV line
c. Type O blood contains no anti-A antibodies so that antibiotics and other medications like
d. Type O blood contains no anti-B antibodies theophylline can be given intravenously. In which of the
following circumstances that may affect the
25. A 35-year-old female patient is admitted in effectiveness of IV flow rate?
Emergency Room at St. Vincent General Hospital due to a. IV tubing drip chamber is at 3 feet above IV insertion
fever, loss of appetite, vomiting, and abdominal pain. site
Once drip chamber is already a half-filled with IV b. Cannula is located in an are away of flexion
solution, the nurse opens the clamp to fill IV fluid in IV c. Cannula is dislodged into the surrounding tissue
tubing to remove air. This method is called: d. Cannula is placed in a bigger vein
a. Turbulent flushing or stop-start
b. Priming IV Tubing 29. Nurse Marly is assigned in trauma unit, three
c. Purging IV Tubing patients will be receiving blood transfusions during his
d. Terminating IV line time of duty. A female patient is prescribed to receive
1 unit of packed red blood cells (PRBCs), a male
26. A female patient with severe trauma caused by teenager will be receiving a platelet transfusion, and a
vehicular accident is brought to Emergency Room. A 3 unit Fresh-frozen plasma to a newly admitted male
blood transfusion is ordered stat to her whose blood adult patient. Nurse Marly receives a blood unit of
type is A. A female patient requiring abdominal surgery PRBC’s from the blood bank and rechecks the blood bag
is ordered to have a standby blood secured if in case a openly with the Head Nurse in the unit. Which of the
following data that is most important to pay attention
before transfusing the blood? (Select All that Apply): 1.
Blood tag label 2. Blood requisition form 3. Date of
expiration 4. Donor’s Name
a.1, 2, and 3
b. 1 only
c. 4 only
d. 2 only

30. A 5-year-old girl is admitted to the hospital with

cystic fibrosis and pneumonia. The nurse has a
prescription by the physician to begin peripheral IV line
so that antibiotics and other medications like
theophylline can be given intravenously. The mother
reports the nurse that his son’s IV drip chamber stops
flowing. The nurse notes that the child’s IV site is cool,
pale, and swollen, and the solution is not infusing.
Based on the assessment observed by the nurse, which
of the following is the best initial response by the nurse
a.Stop the infusion and remove the IV
b. Perform venipuncture in a different location and
restart the infusion, as ordered
c. Apply moist heat to the site
d. Remove the IV catheter and apply a cool compress to
the site