Maternal and Child Heath Nursing Exam 1 B.

10th week of pregnancy

(25 items) C. 12th week of pregnancy
D. 18th week of pregnancy
Link:
https://www.rnpedia.com/practice-exams/philipp On the 8th week of pregnancy, the uterus is still
ine-nursing-licensure-exam-pnle/pnle-maternal- within the pelvic area. On the 10th week, the
and-child-health-nursing-exam-1/ uterus is still within the pelvic area. On the
12th week, the uterus and placenta have grown,
1. A client asks the nurse what a third degree expanding into the abdominal cavity. On the
laceration is. She was informed that she had one. 18th week, the uterus has already risen out of
the pelvis and is expanding into the abdominal
The nurse explains that this is: area.
A. that extended their anal sphincter
B. through the skin and into the 4. Which of the following urinary symptoms
muscles does the pregnant woman most frequently
C. that involves anterior rectal wall experience during the first trimester:
D. that extends through the perineal
muscle.
A. frequency
Third degree laceration involves all in the B. dysuria
second degree laceration and the external C. incontinence
sphincter of the rectum. Options B, C and D are D. burning
under the second degree laceration. 5. Mrs. Jimenez went to the health center for
pre-natal check-up. the student nurse took her
weight and revealed 142 lbs. She asked the
student nurse how much should she gain weight
2. Betina 30 weeks AOG discharged with a in her pregnancy.
diagnosis of placenta previa. The nurse knows
that the client understands her care at home
A. 20-30 lbs
when she says:
B. 25-35 lbs
C. 30- 40 lbs
A. I am happy to note that we can D. 10-15 lbs
have sex occasionally when I have 6. The nurse is preparing Mrs. Jordan for
no bleeding. cesarean delivery. Which of the following key
B. I am afraid I might have an concept should the nurse consider when
operation when my due comes implementing nursing care?
C. I will have to remain in bed until
my due date comes
A. Explain the surgery, expected
D. I may go back to work since I stay
outcome and kind of anesthetics.
only at the office.
B. Modify preoperative teaching to
3. The uterus has already risen out of the pelvis
meet the needs of either a planned
and
Placenta previa means that the placenta is the or emergency cesarean birth.
is
presenting part. On the first and second C. Arrange for a staff member of the
trimester there is spotting. On the third anesthesia department to explain
trimester there is bleeding that is sudden, what to expect post-operatively.
profuse and painless. D. Instruct the mother’s support
person to remain in the family
experiencing farther into the abdominal area at lounge until after the delivery.
about the: 7. Bettine Gonzales is hospitalized for the
treatment of severe preecplampsia. Which of the
A. 8th week of pregnancy
following represents an unusual finding for this A. 13 -14 lbs
condition? B. 16 -17 lbs
C. 22 -23 lbs
A. generalized edema D. 27 -28 lbs
B. proteinuria 4+ 12. During the first hours following delivery, the
C. blood pressure of 160/110 post partum client is given IVF with oxytocin
D. convulsions added to them. The nurse understands the
8. Nurse Geli explains to the client who is 33 primary reason for this is:
weeks pregnant and is experiencing vaginal
bleeding that coitus: A. To facilitate elimination
B. To promote uterine contraction
A. Need to be modified in any way by C. To promote analgesia
either partner D. To prevent infection
B. Is permitted if penile penetration is 13. Nurse Luis is assessing the newborn’s heart
not deep. rate. Which of the following would be
C. Should be restricted because it may considered normal if the newborn is sleeping?
stimulate uterine activity.
D. Is safe as long as she is in side- A. 80 beats per minute
lying position. B. 100 beats per minute
9. Mrs. Precilla Abuel, a 32 year old mulripara is C. 120 beats per minute
admitted to labor and delivery. Her last 3 D. 140 beats per minute
pregnancies in short stage one of labor. The 14. The infant with Down Syndrome should go
nurses decide to observe her closely. The through which of the Erikson’s developmental
physician determines that Mrs. Abuel’s cervix is stages first?
dilated to 6 cm. Mrs. Abuel states that she is
extremely uncomfortable. To lessen Mrs. A. Initiative vs. Self doubt
Abuel’s discomfort, the nurse can advise her to: B. Industry vs. Inferiority
C. Autonomy vs. Shame and doubt
A. lie face down D. Trust vs. Mistrust
B. not drink fluids 15. The child with phenylketonuria (PKU) must
C. practice holding breaths between maintain a low phenylalanine diet to prevent
contractions which of the following complications?
D. assume Sim’s position
10. Which is true regarding the fontanels of the A. Irreversible brain damage
newborn? B. Kidney failure
C. Blindness
A. The anterior is large in shape when D. Neutropenia
compared to the posterior fontanel. 16. Which age group is with imaginative minds
B. The anterior is triangular shaped; and creates imaginary friends?
the posterior is diamond shaped.
C. The anterior is bulging; the A. Toddler
posterior appears sunken. B. Preschool
D. The posterior closes at 18 months; C. School
the anterior closes at 8 to 12 D. Adolescence
months. 17. Which of the following situations would
11. Mrs. Quijones gave birth by spontaneous alert you to a potentially developmental problem
delivery to a full term baby boy. After a minute with a child?
after birth, he is crying and moving actively. His
birth weight is 6.8 lbs. What do you expect baby A. Pointing to body parts at 15 months
Quijones to weigh at 6 months? of age.
 B. Using gesture to communicate at D. Abdominal mass and weakness
18 months. 22. Which of the following danger sings should
C. Cooing at 3 months. be reported immediately during the antepartum
D. Saying “mama” or “dada” for the period?
first time at 18 months of age.
18. Isabelle, a 2 year old girl loves to move A. blurred vision
around and oftentimes manifests negativism and B. nasal stuffiness
temper tantrums. What is the best way to deal C. breast tenderness
with her behavior? D. constipation
23. Nurse Jacob is assessing a 15 month old
A. Tell her that she would not be child with acute otitis media. Which of the
loved by others is she behaves that following symptoms would the nurse anticipate
way.. finding?
B. Withholding giving her toys until
she behaves properly. A. periorbital edema, absent light
C. Ignore her behavior as long as she reflex and translucent tympanic
does not hurt herself and others. membrane
D. Ask her what she wants and give it B. irritability, purulent drainage in
to pacify her. middle ear, nasal congestion and
19. Baby boy Villanueva, 4 months old, was cough
seen at the pediatric clinic for his scheduled C. diarrhea, retracted tympanic
check-up. By this period, baby Villanueva has membrane and enlarged parotid
already increased his height by how many gland
inches? D. Vomiting, pulling at ears and
pearly white tympanic membrane
A. 3 inches 24. Which of the following is the most
B. 4 inches appropriate intervention to reduce stress in a
C. 5 inches preterm infant at 33 weeks gestation?
D. 6 inches
20. Alice, 10 years old was brought to the ER A. Sensory stimulation including
because of Asthma. She was immediately put several senses at a time
under aerosol administration of Terbutaline. B. tactile stimulation until signs of
After sometime, you observe that the child does over stimulation develop
not show any relief from the treatment given. C. An attitude of extension when
Upon assessment, you noticed that both the heart prone or side lying
and respiratory rate are still elevated and the D. Kangaroo care
child shows difficulty of exhaling. You suspect: 25. The parent of a client with albinism would
need to be taught which preventive healthcare
A. Bronchiectasis measure by the nurse:
B. Atelectasis
C. Epiglotitis A. Ulcerative colitis diet
D. Status Asthmaticus B. Use of a high-SPF sunblock
21. Nurse Jonas assesses a 2 year old boy with a C. Hair loss monitoring
tentative diagnosis of nephroblastoma. D. Monitor for growth retardation
Symptoms the nurse observes that suggest this
problem include:

A. Lymphedema and nerve palsy

B. Hearing loss and ataxia
C. Headaches and vomiting
Maternal and Child Heath Nursing Exam 2
(25 items)

Link:
https://www.rnpedia.com/practice-exams/philipp
ine-nursing-licensure-exam-pnle/pnle-maternal-
and-child-health-nursing-exam-2/

1. Nurse Bella explains to a 28 year old pregnant

woman undergoing a non-stress test that the test
is a way of evaluating the condition of the fetus
by comparing the fetal heart rate with:

A. Fetal lie
B. Fetal movement
C. Maternal blood pressure
D. Maternal uterine contractions
2. During a 2 hour childbirth focusing on labor
and delivery process for primigravida. The nurse
describes the second maneuver that the fetus
goes through during labor progress when the
head is the presenting part as which of the
following:

A. Flexion
B. Internal rotation
C. Descent
D. External rotation
3. Mrs. Jovel Diaz went to the hospital to have
her serum blood test for alpha-fetoprotein. The
nurse informed her about the result of the
elevation of serum AFP. The patient asked her
what was the test for:

A. Congenital Adrenal Hyperplasia

B. PKU
C. Down Syndrome
 D. Neural tube defects 9. Mrs. Pichie Gonzales’s LMP began April 4,
4. Fetal heart rate can be auscultated with a 2010. Her EDD should be which of the
fetoscope as early as: following:

A. 5 weeks of gestation A. February 11, 2011

B. 10 weeks of gestation B. January 11, 20111
C. 15 weeks of gestation C. December 12, 2010
D. 20 weeks of gestation D. Nowember 14, 2010
5. Mrs. Bendivin states that she is experiencing 10. Which of the following prenatal laboratory
aching swollen, leg veins. The nurse would test values would the nurse consider as
explain that this is most probably the result of significant?
which of the following:
A. Hematocrit 33.5%
A. Thrombophlebitis B. WBC 8,000/mm3
B. PIH C. Rubella titer less than 1:8
C. Pressure on blood vessels from the D. One hour glucose challenge test
enlarging uterus 110 g/dL
D. The force of gravity pulling down 11. Aling Patricia is a patient with preeclampsia.
on the uterus You advise her about her condition, which
6. Mrs. Ella Santoros is a 25 year old would tell you that she has not really understood
primigravida who has Rheumatic heart disease your instructions?
lesion. Her pregnancy has just been diagnosed.
Her heart disease has not caused her to limit A. “I will restrict my fat in my diet.”
physical activity in the past. Her cardiac disease B. “I will limit my activities and rest
and functional capacity classification is: more frequently throughout the
day.”
A. Class I C. “I will avoid salty foods in my
B. Class II diet.”
C. Class III D. “I will come more regularly for
D. class IV check-up.”
7. The client asks the nurse, “When will this soft 12. Mrs. Grace Evangelista is admitted with
spot at the top of the head of my baby will severe preeclampsia. What type of room should
close?” The nurse should instruct the mother that the nurse select this patient?
the neonate’s anterior fontanel will normally
close by age: A. A room next to the elevator.
B. The room farthest from the nursing
A. 2-3 months station.
B. 6-8 months C. The quietest room on the floor.
C. 10-12 months D. The labor suite.
D. 12-18 months 13. During a prenatal check-up, the nurse
8. When a mother bleeds and the uterus is explains to a client who is Rh negative that
relaxed, soft and non-tender, you can account RhoGAM will be given:
the cause to:
A. Weekly during the 8th month
A. Atony of the uterus because this is her third pregnancy.
B. Presence of uterine scar B. During the second trimester, if
C. Laceration of the birth canal amniocentesis indicates a problem.
D. Presence of retained placenta C. To her infant immediately after
fragments delivery if the Coomb’s test is
positive.
 D. Within 72 hours after delivery if nurse’s most accurate analysis of the mother’s
infant is found to be Rh positive. comment?
14. A baby boy was born at 8:50pm. At 8:55pm,
the heart rate was 99 bpm. She has a weak cry, A. The child has not experienced
irregular respiration. She was moving all limit-setting or structure.
extremities and only her hands and feet were B. The child is expressing a physical
still slightly blue. The nurse should enter the need, such as hunger.
APGAR score as: C. The mother has nurtured
overdependence in the child.
A. 5 D. The mother is describing her
B. 6 child’s separation anxiety.
C. 7 20. Mylene Lopez, a 16 year old girl with
D. 8 scoliosis has recently received an invitation to a
15. Billy is a 4 year old boy who has an IQ of pool party. She asks the nurse how she can
140 which means: disguise her impairment when dressed in a
bathing suit. Which nursing diagnosis can be
A. average normal justified by Mylene’s statement?
B. very superior
C. above average A. Anxiety
D. genius B. Body image disturbance
16. A newborn is brought to the nursery. Upon C. Ineffective individual coping
assessment, the nurse finds that the child has D. Social isolation
short palpebral fissures, thinned upper lip. Based 21. The foul-smelling, frothy characteristic of
on this data, the nurse suspects that the newborn the stool in cystic fibrosis results from the
is MOST likely showing the effects of: presence of large amounts of which of the
following:
A. Chronic toxoplasmosis
B. Lead poisoning A. sodium and chloride
C. Congenital anomalies B. undigested fat
D. Fetal alcohol syndrome C. semi-digested carbohydrates
17. A priority nursing intervention for the infant D. lipase, trypsin and amylase
with cleft lip is which of the following: 22. Which of the following would be a
disadvantage of breast feeding?
A. Monitoring for adequate nutritional
intake A. involution occurs rapidly
B. Teaching high-risk newborn care B. the incidence of allergies increases
C. Assessing for respiratory distress due to maternal antibodies
D. Preventing injury C. the father may resent the infant’s
18. Nurse Jacob is assessing a 12 year old who demands on the mother’s body
has hemophilia A. Which of the following D. there is a greater chance of error
assessment findings would the nurse anticipate? during preparation
23. A client is noted to have lymphedema,
A. an excess of RBC webbed neck and low posterior hairline. Which
B. an excess of WBC of the following diagnoses is most appropriate?
C. a deficiency of clotting factor VIII
D. a deficiency of clotting factor IX A. Turner’s syndrome
19. Celine, a mother of a 2 year old tells the B. Down’s syndrome
nurse that her child “cries and has a fit when I C. Marfan’s syndrome
have to leave him with a sitter or someone else.” D. Klinefelter’s syndrome
Which of the following statements would be the
24. A 4 year old boy most likely perceives death the physician ordered Oxytocin (Pitocin) to
in which way: augment her contractions. Which of the
following is the most important aspect of
A. An insignificant event unless nursing intervention at this time?
taught otherwise
B. Punishment for something the A. Timing and recording length of
individual did contractions.
C. Something that just happens to B. Monitoring.
older people C. Preparing for an emergency
D. Temporary separation from the cesarean birth.
loved one. D. Checking the perineum for bulging.
25. Catherine Diaz is a 14 year old patient on a 2. A client who hallucinates is not in touch with
hematology unit who is being treated for sickle reality. It is important for the nurse to:
cell crisis. During a crisis such as that seen in
sickle cell anemia, aldosterone release is A. Isolate the client from other
stimulated. In what way might this influence patients.
Catherine’s fluid and electrolyte balance? B. Maintain a safe environment.
C. Orient the client to time, place, and
A. sodium loss, water loss and person.
potassium retention D. Establish a trusting relationship.
B. sodium loss, water los and 3. The nurse is caring to a child client who has
potassium loss had a tonsillectomy. The child complains of
C. sodium retention, water loss and having dryness of the throat. Which of the
potassium retention following would the nurse give to the child?
D. sodium retention, water retention
and potassium loss A. Cola with ice
B. Yellow noncitrus Jello
C. Cool cherry Kool-Aid
D. A glass of milk
4. The physician ordered Phenylephrine (Neo-
Synephrine) nasal spray to a 13-year-old client.
The nurse caring to the client provides
instructions that the nasal spray must be used
exactly as directed to prevent the development
of:

Maternal and Child Health Nursing Exam 3 A. Increased nasal congestion.

(100 items) B. Nasal polyps.
C. Bleeding tendencies.
Link:
D. Tinnitus and diplopia.
https://www.rnpedia.com/practice-exams/philipp 5. A client with tuberculosis is to be admitted in
ine-nursing-licensure-exam-pnle/pnle-maternal- the hospital. The nurse who will be assigned to
and-child-health-nursing-exam-3/ care for the client must institute appropriate
precautions. The nurse should:

1. A pregnant woman who is at term is admitted A. Place the client in a private room.
to the birthing unit in active labor. The client has B. Wear an N 95 respirator when
only progressed from 2cm to 3 cm in 8 hours. caring for the client.
She is diagnosed with hypotonic dystocia and C. Put on a gown every time when
entering the room.
 D. Don a surgical mask with a face D. Deemphasizing preoccupation with
shield when entering the room. elimination, nourishment, and
6. Which of the following is the most frequent sleep.
cause of noncompliance to the medical treatment 10. A 3-month-old client is in the pediatric unit.
of open-angle glaucoma? During assessment, the nurse is suspecting that
the baby may have hypothyroidism when mother
A. The frequent nausea and vomiting states that her baby does not:
accompanying use of miotic drug.
B. Loss of mobility due to severe A. Sit up.
driving restrictions. B. Pick up and hold a rattle.
C. Decreased light and near-vision C. Roll over.
accommodation due to miotic D. Hold the head up.
effects of pilocarpine. 11. The physician calls the nursing unit to leave
D. The painful and insidious an order. The senior nurse had conversation with
progression of this type of the other staff. The newly hired nurse answers
glaucoma. the phone so that the senior nurses may continue
7. In the morning shift, the nurse is making their conversation. The new nurse does not
rounds in the nursing care units. The nurse knowthe physician or the client to whom the
enters in a client’s room and notes that the order pertains. The nurse should:
client’s tube has become disconnected from the
Pleurovac. What would be the initial nursing A. Ask the physician to call back after
action? the nurse has read the hospital
policy manual.
A. Apply pressure directly over the B. Take the telephone order.
incision site. C. Refuse to take the telephone order.
B. Clamp the chest tube near the D. Ask the charge nurse or one of the
incision site. other senior staff nurses to take the
C. Clamp the chest tube closer to the telephone order.
drainage system. 12. The staff nurse on the labor and delivery unit
D. Reconnect the chest tube to the is assigned to care to a primigravida in transition
Pleurovac. complicated by hypertension. A new pregnant
8. Which of the following complications during woman in active labor is admitted in the same
a breech birth the nurse needs to be alarmed? unit. The nurse manager assigned the same nurse
to the second client. The nurse feels that the
A. Abruption placenta. client with hypertension requires one-to-one
B. Caput succedaneum. care. What would be the initial actionof the
C. Pathological hyperbilirubinemia. nurse?
D. Umbilical cord prolapse.
9. The nurse is caring to a client diagnosed with A. Accept the new assignment and
severe depression. Which of the following complete an incident report
nursing approach is important in depression? describing a shortage of nursing
staff.
A. Protect the client against harm to B. Report the incident to the nursing
others. supervisor and request to be
B. Provide the client with motor floated.
outlets for aggressive, hostile C. Report the nursing assessment of
feelings. the client in transitional labor to the
C. Reduce interpersonal contacts. nurse manager and discuss
misgivings about the new
assignment.
 D. Accept the new assignment and A. Call the physician to reschedule the
provide the best care. surgery.
13. A newborn infant with Down syndrome is to B. Call the nearest relative to come in
be discharged today. The nurse is preparing to to sign a new form.
give the discharge teaching regarding the proper C. Cross out the error and initial the
care at home. The nurse would anticipate that form.
the mother is probably at the: D. Have the client sign another form.
17. The nurse in the nursing care unit checks the
A. 40 years of age. fluctuation in the water-seal compartment of a
B. 20 years of age. closed chest drainage system. The fluctuation
C. 35 years of age. has stopped, the nurse would:
D. 20 years of age.
14. The emergency department has shortage of A. Vigorously strip the tube to
staff. The nurse manager informs the staff nurse dislodge a clot.
in the critical care unit that she has to float to the B. Raise the apparatus above the chest
emergency department. What should the staff to move fluid.
nurse expect under these conditions? C. Increase wall suction above 20 cm
H2O pressure.
A. The float staff nurse will be D. Ask the client to cough and take a
informed of the situation before the deep breath.
shift begins. 18. The pediatric nurse in the neonatal unit was
B. The staff nurse will be able to informed that the baby that is brought to the
negotiate the assignments in the mother in the hospital room is wrong. The nurse
emergency department. determines that two babies were placed in the
C. Cross training will be available for wrong cribs. The most appropriate nursing
the staff nurse. action would be to:
D. Client assignments will be equally
divided among the nurses. A. Determine who is responsible for
15. The nurse is assigned to care for a child the mistake and terminate his or
client admitted in the pediatrics unit. The client her employment.
is receiving digoxin. Which of the following B. Record the event in an
questions will be asked by the nurse to the incident/variance report and notify
parents of the child in order to assess the client’s the nursing supervisor.
risk for digoxin toxicity? C. Reassure both mothers, report to
the charge nurse, and do not
A. “Has he been exposed to any record.
childhood communicable diseases D. Record detailed notes of the event
in the past 2-3 weeks?” on the mother’s medical record.
B. “Has he been taking diuretics at 19. Before the administration of digoxin, the
home?” nurse completes an assessment to a toddler client
C. “Do any of his brothers and sisters for signs and symptoms of digoxin toxicity.
have history of cardiac problems?” Which of the following is the earliest and most
D. “Has he been going to school significant sign of digoxin toxicity?
regularly?”
16. The nurse noticed that the signed consent A. Tinnitus
form has an error. The form states, “Amputation B. Nausea and vomiting
of the right leg” instead of the left leg that is to C. Vision problem
be amputated. The nurse has administered D. Slowing in the heart rate
already the preoperative medications. What 20. Which of the following treatment modality is
should the nurse do? appropriate for a client with paranoid tendency?
 A. Activity therapy. D. Degree of hostility is less than the
B. Individual therapy. provocation.
C. Group therapy. 24. The nurse is providing an orientation
D. Family therapy. regarding case management to the nursing
21. The client with rheumatoid arthritis is for students. Which characteristics should the nurse
discharge. In preparing the client for discharge include in the discussion in understanding case
on prednisone therapy, the nurse should advise management?
the client to:
A. Main objective is a written plan
A. Wear sunglasses if exposed to that combines discipline-specific
bright light for an extended period processes used to measure
of time. outcomes of care.
B. Take oral preparations of B. Main purpose is to identify
prednisone before meals. expected client, family and staff
C. Have periodic complete blood performance against the timeline
counts while on the medication. for clients with the same diagnosis.
D. Never stop or change the amount C. Main focus is comprehensive
of the medication without medical coordination of client care, avoid
advice. unnecessary duplication of
22. A pregnant client tells the nurse that she is services, improve resource
worried about having urinary frequency. What utilization and decrease cost.
will be the most appropriate nursing response? D. Primary goal is to understand why
predicted outcomes have not been
A. “Try using Kegel (perineal) met and the correction of identified
exercises and limiting fluids before problems.
bedtime. If you have frequency 25. The physician orders a dose of IV phenytoin
associated with fever, pain on to a child client. In preparing in the
voiding, or blood in the urine, call administration of the drug, which nursing action
your doctor/nurse-midwife. is not correct?
B. “Placental progesterone causes
irritability of the bladder sphincter. A. Infuse the phenytoin into a smaller
Your symptoms will go away after vein to prevent purple glove
the baby comes.” syndrome.
C. “Pregnant women urinate B. Check the phenytoin solution to be
frequently to get rid of fetal wastes. sure it is clear or light yellow in
Limit fluids to 1L/daily.” color, never cloudy.
D. “Frequency is due to bladder C. Plan to give phenytoin over 30-60
irritation from concentrate urine minutes, using an in-line filter.
and is normal in pregnancy. D. Flush the IV tubing with normal
Increase your daily fluid intake to saline before starting phenytoin.
3L.” 26. The pregnant woman visits the clinic for
23. Which of the following will help the nurse check –up. Which assessment findings will help
determine that the expression of hostility is the nurse determine that the client is in 8-week
useful? gestation?

A. Expression of anger dissipates the A. Leopold maneuvers.

energy. B. Fundal height.
B. Energy from anger is used to C. Positive radioimmunoassay test
accomplish what needs to be done. (RIA test).
C. Expression intimidates others. D. Auscultation of fetal heart tones.
27. Which of the following nursing intervention D. Nurses decide nursing care;
is essential for the client who had physicians decide medical and
pneumonectomy? other treatment for the client.
31. A nurse is giving a health teaching to a
A. Medicate for pain only when woman who wants to breastfeed her newborn
needed. baby. Which hormone, normally secreted during
B. Connect the chest tube to water- the postpartum period, influences both the milk
seal drainage. ejection reflex and uterine involution?
C. Notify the physician if the chest
drainage exceeds 100mL/hr. A. Oxytocin.
D. Encourage deep breathing and B. Estrogen.
coughing. C. Progesterone.
28. The nurse is providing a health teaching to a D. Relaxin.
group of parents regarding Chlamydia 32. One staff nurse is assigned to a group of 5
trachomatis. The nurse is correct in the patients for the 12-hour shift. The nurse is
statement, “Chlamydia trachomatis is not only responsible for the overall planning, giving and
an intracellular bacterium that causes neonatal evaluating care during the entire shift. After the
conjunctivitis, but it also can cause: shift, same responsibility will be endorsed to the
next nurse in charge. This describes nursing care
A. Discoloration of baby and adult delivered via the:
teeth.
B. Pneumonia in the newborn. A. Primary nursing method.
C. Snuffles and rhagades in the B. Case method.
newborn. C. Functional method.
D. Central hearing defects in infancy. D. Team method.
29. The nurse is assigned to care to a 17-year- 33. The ambulance team calls the emergency
old male client with a history of substance department that they are going to bring a client
abuse. The client asks the nurse, “Have you ever who sustained burns in a house fire. While
tried or used drugs?” The most correct response waiting for the ambulance, the nurse will
of the nurse would be: anticipate emergency care to include assessment
for:
A. “Yes, once I tried grass.”
B. “No, I don’t think so.” A. Gas exchange impairment.
C. “Why do you want to know that?” B. Hypoglycemia.
D. “How will my answer help you?” C. Hyperthermia.
30. Which of the following describes a health D. Fluid volume excess.
care team with the principles of participative 34. Most couples are using “natural” family
leadership? planning methods. Most accidental pregnancies
in couples preferred to use this method have
A. Each member of the team can been related to unprotected intercourse before
independently make decisions ovulation. Which of the following factor
regarding the client’s care without explains why pregnancy may be achieved by
necessarily consulting the other unprotected intercourse during the preovulatory
members. period?
B. The physician makes most of the
decisions regarding the client’s A. Ovum viability.
care. B. Tubal motility.
C. The team uses the expertise of its C. Spermatozoal viability.
members to influence the decisions D. Secretory endometrium.
regarding the client’s care.
35. An older adult client wakes up at 2 o’clock D. Pulse is increased from 88-96 with
in the morning and comes to the nurse’s station occasional skipped beat.
saying, “I am having difficulty in sleeping.” 39. The nurse is conducting a lecture to a class
What is the best nursing response to the client? of nursing students about advance directives to
preoperative clients. Which of the following
A. “I’ll give you a sleeping pill to help statement by the nurse js correct?
you get more sleep now.”
B. “Perhaps you’d like to sit here at A. “The spouse, but not the rest of the
the nurse’s station for a while.” family, may override the advance
C. “Would you like me to show you directive.”
where the bathroom is?” B. “An advance directive is required
D. “What woke you up?” for a “do not resuscitate” order.”
36. The nurse is taking care of a multipara who C. “A durable power of attorney, a
is at 42 weeks of gestation and in active labor, form of advance directive, may
her membranes ruptured spontaneously 2 hours only be held by a blood relative.”
ago. While auscultating for the point of D. “The advance directive may be
maximum intensity of fetal heart tones before enforced even in the face of
applying an external fetal monitor, the nurse opposition by the spouse.”
counts 100 beats per minute. The immediate 40. A client diagnosed with schizophrenia is
nursing action is to: shouting and banging on the door leading to the
outside, saying, “I need to go to an
A. Start oxygen by mask to reduce appointment.” What is the appropriate nursing
fetal distress. intervention?
B. Examine the woman for signs of a
prolapsed cord. A. Tell the client that he cannot bang
C. Turn the woman on her left side to on the door.
increase placental perfusion. B. Ignore this behavior.
D. Take the woman’s radial pulse C. Escort the client going back into
while still auscultating the FHR. the room.
37. The nurse must instruct a client with D. Ask the client to move away from
glaucoma to avoid taking over-the-counter the door.
medications like: 41. Which of the following action is an accurate
tracheal suctioning technique?
A. Antihistamines.
B. NSAIDs. A. 25 seconds of continuous suction
C. Antacids. during catheter insertion.
D. Salicylates. B. 20 seconds of continuous suction
38. A male client is brought to the emergency during catheter insertion.
department due to motor vehicle accident. While C. 10 seconds of intermittent suction
monitoring the client, the nurse suspects during catheter withdrawal.
increasing intracranial pressure when: D. 15 seconds of intermittent suction
during catheter withdrawal.
A. Client is oriented when aroused 42. The client’s jaw and cheekbone is sutured
from sleep, and goes back to sleep and wired. The nurse anticipates that the most
immediately. important thing that must be ready at the bedside
B. Blood pressure is decreased from is:
160/90 to 110/70.
C. Client refuses dinner because of A. Suture set.
anorexia. B. Tracheostomy set.
C. Suction equipment.
 D. Wire cutters. C. Splint the wound.
43. A mother is in the third stage of labor. D. Promote drainage and prevent
Which of the following signs will help the nurse subdiaphragmatic abscesses.
determine the signs of placental separation? 48. Which of the following will best describe a
management function?
A. The uterus becomes globular.
B. The umbilical cord is shortened. A. Writing a letter to the editor of a
C. The fundus appears at the introitus. nursing journal.
D. Mucoid discharge is increased. B. Negotiating labor contracts.
44. After therapy with the thrombolytic alteplase C. Directing and evaluating nursing
(t-PA), what observation will the nurse report to staff members.
the physician? D. Explaining medication side effects
to a client.
A. 3+ peripheral pulses. 49. The parents of an infant client ask the nurse
B. Change in level of consciousness to teach them how to administer Cortisporin eye
and headache. drops. The nurse is correct in advising the
C. Occasional dysrhythmias. parents to place the drops:
D. Heart rate of 100/bpm.
45. A client who undergone left nephrectomy A. In the middle of the lower
has a large flank incision. Which of the conjunctival sac of the infant’s eye.
following nursing action will facilitate deep B. Directly onto the infant’s sclera.
breathing and coughing? C. In the outer canthus of the infant’s
eye.
A. Push fluid administration to loosen D. In the inner canthus of the infant’s
respiratory secretions. eye.
B. Have the client lie on the 50. The nurse is assessing on the client who is
unaffected side. admitted due to vehicle accident. Which of the
C. Maintain the client in high following findings will help the nurse that there
Fowler’s position. is internal bleeding?
D. Coordinate breathing and coughing
exercise with administration of A. Frank blood on the clothing.
analgesics. B. Thirst and restlessness.
46. The community nurse is teaching the group C. Abdominal pain.
of mothers about the cervical mucus method of D. Confusion and altered of
natural family planning. Which characteristics consciousness.
are typical of the cervical mucus during the 51. The nurse is completing an assessment to a
“fertile” period of the menstrual cycle? newborn baby boy. The nurse observes that the
skin of the newborn is dry and flaking and there
A. Absence of ferning. are several areas of an apparent macular rash.
B. Thin, clear, good spinnbarkeit. The nurse charts this as:
C. Thick, cloudy.
D. Yellow and sticky. A. Icterus neonatorum
47. A client with ruptured appendix had surgery B. Multiple hemangiomas
an hour ago and is transferred to the nursing care C. Erythema toxicum
unit. The nurse placed the client in a semi- D. Milia
Fowler’s position primarily to: 52. The client is brought to the emergency
department because of serious vehicle accident.
A. Facilitate movement and reduce After an hour, the client has been declared brain
complications from immobility. dead. The nurse who has been with the client
B. Fully aerate the lungs. must now talk to the family about organ
donation. Which of the following consideration to assume that a woman is always
is necessary? fertile.
B. In a 28-day cycle, ovulation occurs
A. Include as many family members at or about day 14. The egg lives
as possible. for about 24 hours and the sperm
B. Take the family to the chapel. live for about 72 hours. The fertile
C. Discuss life support systems. period would be approximately
D. Clarify the family’s understanding between day 11 and day 15.
of brain death. C. In a 28- day cycle, ovulation occurs
53. The nurse is teaching exercises that are good at or about day 14. The egg lives
for pregnant women increasing tone and fitness for about 72 hours and the sperm
and decreasing lower backache. Which of the live for about 24 hours. The fertile
following should the nurse exclude in the period would be approximately
exercise program? between day 13 and 17.
D. In a 28-day cycle, ovulation occurs
A. Stand with legs apart and touch 8 days before the next period or at
hands to floor three times per day. about day 20. The fertile period is
B. Ten minutes of walking per day between day 20 and the beginning
with an emphasis on good posture. of the next period.
C. Ten minutes of swimming or leg 57. Which of the following statement describes
kicking in pool per day. the role of a nurse as a client advocate?
D. Pelvic rock exercise and squats
three times a day. A. A nurse may override clients’
54. A client with obsessive-compulsive behavior wishes for their own good.
is admitted in the psychiatric unit. The nurse B. A nurse has the moral obligation to
taking care of the client knows that the primary prevent harm and do well for
treatment goal is to: clients.
C. A nurse helps clients gain greater
A. Provide distraction. independence and self-
B. Support but limit the behavior. determination.
C. Prohibit the behavior. D. A nurse measures the risk and
D. Point out the behavior. benefits of various health situations
55. After ileostomy, the nurse expects that the while factoring in cost.
drainage appliance will be applied to the stoma: 58. A community health nurse is providing a
health teaching to a woman infected with herpes
simplex 2. Which of the following health
A. When the client is able to begin
teaching must the nurse include to reduce the
self-care procedures.
chances of transmission of herpes simplex 2?
B. 24 hours later, when the swelling
subsided.
C. In the operating room after the A. “Abstain from intercourse until
ileostomy procedure. lesions heal.”
D. After the ileostomy begins to B. “Therapy is curative.”
function. C. “Penicillin is the drug of choice for
56. A female client who has a 28-day menstrual treatment.”
cycle asks the community health nurse when she D. “The organism is associated with
get pregnant during her cycle. What will be the later development of hydatidiform
best nursing response? mole.
59. The nurse in the psychiatric ward informed
the male client that he will be attending the 9:00
A. It is impossible to determine the
AM group therapy sessions. The client tells the
fertile period reliably. So it is best
nurse that he must wash his hands from 9:00 to C. New admitted client with chest
9:30 AM each day and therefore he cannot pain.
attend. Which concept does the nursing staff D. A client with diabetes who has a
need to keep in mind in planning nursing glucoscan reading of 180.
intervention for this client? 63. A couple seeks medical advice in the
community health care unit. A couple has been
A. Depression underlines ritualistic unable to conceive; the man is being evaluated
behavior. for possible problems. The physician ordered
B. Fear and tensions are often semen analysis. Which of the following
expressed in disguised form instructions is correct regarding collection of a
through symbolic processes. sperm specimen?
C. Ritualistic behavior makes others
uncomfortable. A. Collect a specimen at the clinic,
D. Unmet needs are discharged place in iced container, and give to
through ritualistic behavior. laboratory personnel immediately.
60. The nurse assesses the health condition of B. Collect specimen after 48-72 hours
the female client. The client tells the nurse that of abstinence and bring to clinic
she discovered a lump in the breast last year and within 2 hours.
hesitated to seek medical advice. The nurse C. Collect specimen in the morning
understands that, women who tend to delay after 24 hours of abstinence and
seeking medical advice after discovering the bring to clinic immediately.
disease are displaying what common defense D. Collect specimen at night,
mechanism? refrigerate, and bring to clinic the
next morning.
A. Intellectualization. 64. The physician ordered Betamethasone to a
B. Suppression. pregnant woman at 34 weeks of gestation with
C. Repression. sign of preterm labor. The nurse expects that the
D. Denial. drug will:
61. Which of the following situations cannot be
delegated by the registered nurse to the nursing A. Treat infection.
assistant? B. Suppress labor contraction.
C. Stimulate the production of
A. A postoperative client who is stable surfactant.
needs to ambulate. D. Reduce the risk of hypertension.
B. Client in soft restraint who is very 65. A tracheostomy cuff is to be deflated, which
agitated and crying. of the following nursing intervention should be
C. A confused elderly woman who implemented before starting the procedures?
needs assistance with eating.
D. Routine temperature check that A. Suction the trachea and mouth.
must be done for a client at end of B. Have the obdurator available.
shift. C. Encourage deep breathing and
62. In the admission care unit, which of the coughing.
following client would the nurse give immediate D. Do a pulse oximetry reading.
attention? 66. A client is diagnosed with Tuberculosis and
respiratory isolation is initiated. This means that:
A. A client who is 3 days
postoperative with left calf pain. A. Gloves are worn when handling the
B. A client who is postoperative hip client’s tissue, excretions, and
pinning who is complaining of linen.
pain.
 B. Both client and attending nurse cardiac repair surgery within the
must wear masks at all times. next few weeks.
C. Nurse and visitors must wear B. A telephone call notifying the
masks until chemotherapy is school nurse that the child’s
begun. Client is instructed in cough pediatrician has informed the
and tissue techniques. mother that the child has head lice.
D. Full isolation; that is, caps and C. A telephone call notifying the
gowns are required during the school nurse that a child has a
period of contagion. temperature of 102ºF and a rash
67. A client with lung cancer is admitted in the covering the trunk and upper
nursing care unit. The husband wants to know extremities of the body.
the condition of his wife. How should the nurse D. A telephone call notifying the
respond to the husband? school nurse that a child underwent
an emergency appendectomy
A. Find out what information he during the previous night.
already has. 71. Which of the following signs and symptoms
B. Suggest that he discuss it with his that require immediate attention and may
wife. indicate most serious complications during
C. Refer him to the doctor. pregnancy?
D. Refer him to the nurse in charge.
68. A hospitalized client cannot find his A. Severe abdominal pain or fluid
handkerchief and accuses other cient in the room discharge from the vagina.
and the nurse of stealing them. Which is the B. Excessive saliva, “bumps around
most therapeutic approach to this client? the areolae, and increased vaginal
mucus.
A. Divert the client’s attention. C. Fatigue, nausea, and urinary
B. Listen without reinforcing the frequency at any time during
client’s belief. pregnancy.
C. Inject humor to defuse the D. Ankle edema, enlarging
intensity. varicosities, and heartburn.
D. Logically point out that the client is 72. The nurse is assessing the newborn boy.
jumping to conclusions. Apgar scores are 7 and 9. The newborn becomes
69. After a cystectomy and formation of an ileal slightly cyanotic. What is the initial nursing
conduit, the nurse provides instruction regarding action?
prevention of leakage of the pouch and backflow
of the urine. The nurse is correct to include in A. Elevate his head to promote gravity
the instruction to empty the urine pouch: drainage of secretions.
B. Wrap him in another blanket, to
A. Every 3-4 hours. reduce heat loss.
B. Every hour. C. Stimulate him to cry,, to increase
C. Twice a day. oxygenation.
D. Once before bedtime. D. Aspirate his mouth and nose with
70. Which telephone call from a student’s bulb syringe.
mother should the school nurse take care of at 73. The nurse is formulating a plan of care to a
once? client with a somatoform disorder. The nurse
needs to have knowledge of which
A. A telephone call notifying the psychodynamic principle?
school nurse that the child’
pediatrician has informed the A. The symptoms of a somatoform
mother that the child will need disorder are an attempt to adjust to
 painful life situations or to cope 77. To assess if the cranial nerve VII of the
with conflicting sexual, aggressive, client was damaged, which changes would not
or dependent feelings. be expected?
B. The major fundamental mechanism
is regression. A. Drooling and drooping of the
C. The client’s symptoms are mouth.
imaginary and the suffering is B. Inability to open eyelids on
faked. operative side.
D. An extensive, prolonged study of C. Sagging of the face on the
the symptoms will be reassuring to operative side.
the client, who seeks sympathy, D. Inability to close eyelid on
attention and love. operative side.
74. An infant is brought to the health care clinic 78. The community health nurse makes a home
for three immunizations at the same time. The visit to a family. During the visit, the nurse
nurse knows that hepatitis B, DPT, and observes that the mother is beating her child.
Haemophilus influenzae type B immunizations What is the priority nursing intervention in this
should: situation?

A. Be drawn in the same syringe and A. Assess the child’s injuries.

given in one injection. B. Report the incident to protective
B. Be mixed and inject in the same agencies.
sites. C. Refer the family to appropriate
C. Not be mixed and the nurse must support group.
give three injections in three sites. D. Assist the family to identify
D. Be mixed and the nurse must give stressors and use of other coping
the injection in three sites. mechanisms to prevent further
75. A female client with cancer has radium incidents.
implants. The nurse wants to maintain the 79. The nurse in the neonatal care unit is
implants in the correct position. The nurse supervising the actions of a certified nursing
should position the client: assistant in giving care to the newborns. The
nursing assistant mistakenly gives a formula
A. Flat in bed. feeding to a newborn that is on water feeding
B. On the side only. only. The nurse is responsible for the mistake of
C. With the foot of the bed elevated. the nursing assistant:
D. With the head elevated 45-degrees
(semi-Fowler’s). A. Always, as a representative of the
76. The nurse wants to know if the mother of a institution.
toddler understands the instructions regarding B. Always, because nurses who
the administration of syrup of ipecac. Which of supervise less-trained individuals
the following statement will help the nurse to are responsible for their mistakes.
know that the mother needs additional teaching? C. If the nurse failed to determine
whether the nursing assistant was
A. “I’ll give the medicine if my child competent to take care of the client.
gets into some toilet bowl cleaner.” D. Only if the nurse agreed that the
B. “I’ll give the medicine if my child newborn could be fed formula.
gets into some aspirin.” 80. The nurse is assigned to care for a client with
C. “I’ll give the medicine if my child urinary calculi. Fluid intake of 2L/day is
gets into some plant bulbs.” encouraged to the client. the primary reason for
D. “I’ll give the medicine if my child this is to:
gets into some vitamin pills.”
 A. Reduce the size of existing stones. A. “It must be frightening for you to
B. Prevent crystalline irritation to the feel that way. Tell me more about
ureter. it.”
C. Reduce the size of existing stones B. “Don’t worry, you won’t die. You
D. Increase the hydrostatic pressure in are just here for some test.”
the urinary tract. C. “Why are you afraid of dying?”
81. The nurse is counseling a couple in their mid D. “Try to sleep. You need the rest
30’s who have been unable to conceive for about before tomorrow’s test.”
6 months. They are concerned that one or both 84. In the hospital lobby, the registered nurse
of them may be infertile. What is the best advice overhears a two staff members discussing about
the nurse could give to the couple? the health condition of her client. What would be
the appropriate action for the registered nurse to
A. “it is no unusual to take 6-12 take?
months to get pregnant, especially
when the partners are in their mid- A. Join in the conversation, giving her
30s. Eat well, exercise, and avoid input about the case.
stress.” B. Ignore them, because they have the
B. “Start planning adoption. Many right to discuss anything they want
couples get pregnant when they are to.
trying to adopt.” C. Tell them it is not appropriate to
C. “Consult a fertility specialist and discuss such things.
start testing before you get any D. Report this incident to the nursing
older.” supervisor.
D. “Have sex as often as you can, 85. The client has had a right-sided
especially around the time of cerebrovascular accident. In transferring the
ovulation, to increase your chances client from the wheelchair to bed, in what
of pregnancy.” position should a client be placed to facilitate
82. The nurse is caring for a cient who Is a safe transfer?
retired nurse. A 24-hour urine collection for
Creatinine clearance is to be done. The client A. Weakened (L) side of the cient
tells the nurse, “I can’t remember what this test next to bed.
is for.” The best response by the nurse is: B. Weakened (R) side of the client
next to bed.
A. “It provides a way to see if you are C. Weakened (L) side of the client
passing any protein in your urine.” away from bed.
B. “It tells how well the kidneys filter D. Weakened (R) side of the cient
wastes from the blood.” away from bed.
C. “It tells if your renal insufficiency 86. The child client has undergone hip surgery
has affected your heart.” and is in a spica cast. Which of the following toy
D. “The test measures the number of should be avoided to be in the child’s bed?
particles the kidney filters.”
83. The nurse observes the female client in the A. A toy gun.
psychiatric ward that she is having a hard time B. A stuffed animal.
sleeping at night. The nurse asks the client about C. A ball.
it and the client says, “I can’t sleep at night D. Legos.
because of fear of dying.” What is the best initial 87. The LPN/LVN asks the registered nurse why
nursing response? oxytocin (Pitocin), 10 units (IV or IM) must be
given to a client after birth fo the fetus. The
nurse is correct to explain that oxytocin:
 A. Minimizes discomfort from A. Provide external controls.
“afterpains.” B. Reinforce the client’s self-concept.
B. Suppresses lactation. C. Give the client opportunities to test
C. Promotes lactation. reality.
D. Maintains uterine tone. D. Gratify the client’s inner needs.
88. The nurse in the nursing care unit is aware 92. The nurse is teaching a group of women
that one of the medical staff displays unlikely about fertility awareness, the nurse should
behaviors like confusion, agitation, lethargy and emphasize that basal body temperature:
unkempt appearance. This behavior has been
reported to the nurse manager several times, but A. Can be done with a mercury
no changes observed. The nurse should: thermometer but no a digital one.
B. The average temperature taken
A. Continue to report observations of each morning.
unusual behavior until the problem C. Should be recorded each morning
is resolved. before any activity.
B. Consider that the obligation to D. Has a lower degree of accuracy in
protect the patient from harm has predicting ovulation than the
been met by the prior reports and cervical mucus test.
do nothing further. 93. The nursing applicant has given the chance
C. Discuss the situation with friends to ask questions during a job interview at a local
who are also nurses to get ideas . hospital. What should be the most important
D. Approach the partner of this question to ask that can increase chances of
medical staff member with these securing a job offer?
concerns.
89. The physician ordered tetracycline PO qid to A. Begin with questions about client
a child client who weights 20kg. The care assignments, advancement
recommended PO tetracycline dose is 25-50 opportunities, and continuing
mg/kg/day. What is the maximum single dose education.
that can be safely administered to this child? B. Decline to ask questions, because
that is the responsibility of the
A. 1 g interviewer.
B. 500 mg C. Ask as many questions about the
C. 250 mg facility as possible.
D. 125 mg D. Clarify information regarding
90. The nurse is completing an obstetric history salary, benefits, and working hours
of a woman in labor. Which event in the first, because this will help in
obstetric history will help the nurse suspects deciding whether or not to take the
dysfunctional labor in the current pregnancy? job.
94. The nurse advised the pregnant woman that
A. Total time of ruptured membranes smoking and alcohol should be avoided during
was 24 hours with the second birth. pregnancy. The nurse takes into account that the
B. First labor lasting 24 hours. developing fetus is most vulnerable to
C. Uterine fibroid noted at time of environment teratogens that cause malformation
cesarean delivery. during:
D. Second birth by cesarean for face
presentation. A. The entire pregnancy.
91. The nurse is planning to talk to the client B. The third trimester.
with an antisocial personality disorder. What C. The first trimester.
would be the most therapeutic approach? D. The second trimester.
95. A male client tells the nurse that there is a newborn’s respiration is 72 breaths per minute.
big bug in his bed. The most therapeutic nursing What would be the initial nursing action?
response would be:
A. Burp the newborn.
A. Silence. B. Stop the feeding.
B. “Where’s the bug? I’ll kill it for C. Continue the feeding.
you.” D. Notify the physician.
C. “I don’t see a bug in your bed, but 100. A client who undergone appendectomy 3
you seem afraid.” days ago is scheduled for discharge today. The
D. “You must be seeing things.” nurse notes that the client is restless, picking at
96. A pregnant client in late pregnancy is bedclothes and saying, “I am late on my
complaining of groin pain that seems worse on appointment,” and calling the nurse by the
the right side. Which of the following is the wrong name. The nurse suspects:
most likely cause of it?
A. Panic reaction.
A. Beginning of labor. B. Medication overdose.
B. Bladder infection. C. Toxic reaction to an antibiotic.
C. Constipation. D. Delirium tremens.
D. Tension on the round ligament.
97. The nurse is conducting a lecture to a group
of volunteer nurses. The nurse is correct in
imparting the idea that the Good Samaritan law
protects the nurse from a suit for malpractice
when:

A. The nurse stops to render

emergency aid and leaves before
the ambulance arrives. Pediatric Nursing Exam (60 items)
B. The nurse acts in an emergency at
his or her place of employment. Link:
C. The nurse refuses to stop for an https://www.rnpedia.com/practice-exams/philipp
emergency outside of the scope of ine-nursing-licensure-exam-pnle/pediatric-
employment. nursing-exam-2/
D. The nurse is grossly negligent at
the scene of an emergency.
98. A woman is hospitalized with mild
preeclampsia. The nurse is formulating a plan of Situation 1: Raphael, a 6 year’s old prep pupil is
care for this client, which nursing care is least seen at the school clinic for growth and
likely to be done? development monitoring (Questions 1-5)
1. Which of the following is characterized the
A. Deep-tendon reflexes once per rate of growth during this period?
shift.
B. Vital signs and FHR and rhythm A. most rapid period of growth
q4h while awake. B. a decline in growth rate
C. Absolute bed rest. C. growth spurt
D. Daily weight. D. slow uniform growth rate
99. While feeding a newborn with an unrepaired 2. In assessing Raphael’s growth and
cardiac defect, the nurse keeps on assessing the development, the nurse is guided by principles
condition of the client. The nurse notes that the of growth and development. Which is not
included?
 A. All individuals follow cephalo- A. Autonomy vs. Shame and doubt
caudal and proximo-distal B. Industry vs. Inferiority
B. Different parts of the body grows C. Trust vs. mistrust
at different rate D. Initiation vs. guilt
C. All individual follow standard 9. Which of the following is true about
growth rate Mongolian Spots?
D. Rate and pattern of growth can be
modified A. Disappears in about a year
3. What type of play will be ideal for Raphael at B. Are linked to pathologic conditions
this period? C. Are managed by tropical steroids
D. Are indicative of parental abuse
A. Make believe 10. Signs of cold stress that the nurse must be
B. Hide and seek alert when caring for a Newborn is:
C. Peek-a-boo
D. Building blocks A. Hypothermia
4. Which of the following information indicate B. Decreased activity level
that Raphael is normal for his age? C. Shaking
D. Increased RR
A. Determine own sense self Situation 3 Nursing care after delivery has an
B. Develop sense of whether he can important aspect in every stages of delivery
trust the world
C. Has the ability to try new things 11. After the baby is delivered, the cord was cut
D. Learn basic skills within his culture between two clamps using a sterile scissors and
5. Based on Kohlberg’s theory, what is the stage blade, then the baby is placed at the:
of moral development of Raphael?
A. Mother’s breast
A. Punishment-obedience B. Mother’s side
B. “good boy-Nice girl” C. Give it to the grandmother
C. naïve instrumental orientation D. Baby’s own mat or bed
D. social contact 12. The baby’s mother is RH(-). Which of the
Situation 2 Baby boy Lacson delivered at 36 following laboratory tests will probably be
weeks gestation weighs 3,400 gm and height of ordered for the newborn?
59 cm (6-10)
A. Direct Coomb’s
6. Baby boy Lacson’s height is B. Indirect Coomb’s
C. Blood culture
A. Long D. Platelet count
B. Short 13. Hypothermia is common in newborn because
C. Average of their inability to control heat. The following
D. Too short would be an appropriate nursing intervention to
7. Growth and development in a child progresses prevent heat loss except:
in the following ways EXCEPT
A. Place the crib beside the wall
A. From cognitive to psychosexual B. Doing Kangaroo care
B. From trunk to the tip of the C. By using mechanical pressure
extremities D. Drying and wrapping the baby
C. From head to toe 14. The following conditions are caused by cold
D. From general to specific stress except
8. As described by Erikson, the major
psychosexual conflict of the above situation is A. Hypoglycemia
 B. Increase ICP A. Tonsillitis
C. Metabolic acidosis B. Eardrum Problems
D. Cerebral palsy C. Brain damage
15. During the feto-placental circulation, the D. Diabetes mellitus
shunt between two atria is called 21. When assessing gross motor development in
a 3 year old, which of the following activities
A. Ductus venosous would the nurse expect to finds?
B. Foramen Magnum
C. Ductus arteriosus A. Riding a tricycle
D. Foramen Ovale B. Hopping on one foot
16. What would cause the closure of the C. Catching a ball
Foramen ovale after the baby had been D. Skipping on alternate foot.
delivered? 22. When assessing the weight of a 5-month old,
which of the following indicates healthy
A. Decreased blood flow growth?
B. Shifting of pressures from right
side to the left side of the heart A. Doubling of birth weight
C. Increased PO2 B. Tripling of birth weight
D. Increased in oxygen saturation C. Quadrupling of birth weight
17. Failure of the Foramen Ovale to close will D. Stabilizing of birth weight
cause what Congenital Heart Disease? 23. An appropriate toy for a 4 year old child is:

A. Total anomalous Pulmunary Artery A. Push-pull toys

B. Atrial Septal defect B. Card games
C. Transposition of great arteries C. Doctor and nurse kits
D. Pulmunary Stenosis D. Books and Crafts
Situation 4 Children are vulnerable to some 24. Which of the following statements would the
minor health problems or injuries hence the nurse expects a 5-year old boy to say whose pet
nurse should be able to teach mothers to give gerbil just died
appropriate home care.
A. “The boogieman got him”
18. A mother brought her child to the clinic with
B. “He’s just a bit dead”
nose bleeding. The nurse showed the mother the
C. “Ill be good from now own so I
most appropriate position for the child which is:
wont die like my gerbil”
D. “Did you hear the joke about…”
A. Sitting up 25. When assessing the fluid and electrolyte
B. With low back rest balance in an infant, which of the following
C. With moderate back rest would be important to remember?
D. Lying semi flat
19. A common problem in children is the
A. Infant can concentrate urine at an
inflammation of the middle ear. This is related to
adult level
the malfunctioning of the:
B. The metabolic rate of an infant is
slower than in adults
A. Tympanic membrane C. Infants have more intracellular
B. Eustachian tube water that adult do
C. Adenoid D. Infant have greater body surface
D. Nasopharynx area than adults
20. For acute otitis media, the treatment is 26. When assessing a child with aspirin
prompt antibiotic therapy. Delayed treatment overdose, which of the following will be
may result in complications of: expected?
 A. Metabolic alkalosis B. Promote normal growth and
B. Respiratory alkalosis development
C. Metabolic acidosis C. Decrease hypoxic spells
D. Respiratory acidosis D. Hydrate adequately
27. Which of the following is not a possible 32. The immediate nursing intervention for
systemic clinical manifestation of severe burns? cyanosis of Agata is:

A. Growth retardation A. Call up the pediatrician

B. Hypermetabolism B. Place her in knee chest position
C. Sepsis C. Administer oxygen inhalation
D. Blisters and edema D. Transfer her to the PICU
28. When assessing a family for potential child 33. Agata was scheduled for a palliative surgery,
abuse risks, the nurse would observe for which which creates anastomosis of the subclavian
of the following? artery to the pulmonary artery. This procedure
is:
A. Periodic exposure to stress
B. Low socio-economic status A. Waterston-Cooley
C. High level of self esteem B. Raskkind Procedure
D. Problematic pregnancies C. Coronary artery bypass
29. Which of the following is a possible D. Blalock-Taussig
indicator of Munchausen syndrome by proxy 34. Which of the following is not an indicator
type of child abuse? that Agata experiences separation anxiety
brought about her hospitalization?
A. Bruises found at odd locations,
with different stages of healing A. Friendly with the nurse
B. STD’s and genital discharges B. Prolonged loud crying, consoled
C. Unexplained symptoms of only by mother
diarrhea, vomiting and apnea with C. Occasional temper tantrums and
no organic basis always says NO
D. Constant hunger and poor hygiene D. Repeatedly verbalizes desire to go
30. Which of the following is an inappropriate home
interventions when caring for a child with HIV? 35. When Agata was brought to the OR, her
parents where crying. What would be the most
A. Teaching family about disease appropriate nursing diagnosis?
transmission
B. Offering large amount of fresh A. Infective family coping r/t
fruits and vegetables situational crisis
C. Encouraging child to perform at B. Anxiety r/t powerlessness
optimal level C. Fear r/t uncertain prognosis
D. Teach proper hand washing D. Anticipatory grieving r/t gravity of
technique child’s physical status
Situation 5 Agata, 2 years old is rushed to the 36. Which of the following respiratory condition
ER due to cyanosis precipitated by crying. Her is always considered a medical emergency?
mother observed that after playing she gets tired.
She was diagnosed with Tetralogy of Fallot. A. Laryngeotracheobronchitis (LTB)
B. Epiglottitis
31. The goal of nursing care fro Agata is to:
C. Asthma
D. Cystic Fibrosis
A. Prevent infection
37. Which of the following statements by the A. Interruption of transmission
family of a child with asthma indicates a need B. All to be vaccinated
for additional teaching? C. Selected group for vaccination
D. Shorter incubation
A. “We need to identify what things 43. Measles vaccine can be given
triggers his attacks” simultaneously. What is the combined vaccine to
B. “He is to use bronchodilator inhaler be given to children starting at 15 months?
before steroid inhaler”
C. “We’ll make sure he avoids A. MCG
exercise to prevent asthma attacks” B. MMR
D. “he should increase his fluid intake C. BCG
regularly to thin secretions” D. BBR
38. Which of the following would require Situation 7: Braguda brought her 5-month old
careful monitoring in the child with ADHD who daughter in the nearest RHU because her baby
is receiving Methylphenidate (Ritalin)? sleeps most of the time, with decreased appetite,
has colds and fever for more than a week. The
A. Dental health physician diagnosed pneumonia.
B. Mouth dryness
44. Based on this data given by Braguda, you
C. Height and weight
can classify Braguda’s daughter to have:
D. Excessive appetite
Situation 6 Laura is assigned as the Team Leader
during the immunization day at the RHU A. Pneumonia: cough and colds
B. Severe pneumonia
39. What program for the DOH is launched at C. Very severe pneumonia
1976 in cooperation with WHO and UNICEF to D. Pneumonia moderate
reduce morbidity and mortality among infants 45. For a 3-month old child to be classified to
caused by immunizable disease? have Pneumonia (not severe), you would expect
to find RR of:
A. Patak day
B. Immunization day on Wednesday A. 60 bpm
C. Expanded program on B. 40 bpm
immunization C. 70 bpm
D. Bakuna ng kabtaan D. 50 pbm
40. One important principle of the immunization 46. You asked Braguda if her baby received all
program is based on? vaccines under EPI. What legal basis is used in
implementing the UN’s goal on Universal Child
A. Statistical occurrence Immunization?
B. Epidemiologic situation
C. Cold chain management A. PD no. 996
D. Surveillance study B. PD no. 6
41. The main element of immunization program C. PD no. 46
is one of the following? D. RA 9173
47. Braguda asks you about Vitamin A
A. Information, education and supplementation. You responded that giving
communication Vitamin A starts when the infant reaches 6
B. Assessment and evaluation of the months and the first dose is”
program
C. Research studies A. 200,000 “IU”
D. Target setting B. 100,000 “IU”
42. What does herd immunity means? C. 500,000 “IU”
 D. 10,000 “IU” the penis. The physician is notified because the
48. As part of CARI program, assessment of the nurse would suspect which of the following?
child is your main responsibility. You could ask
the following question to the mother except: A. Phimosis
B. Hydrocele
A. “How old is the child?” C. Epispadias
B. “IS the child coughing? For how D. Hypospadias
long?” 54. When teaching a group of parents about seat
C. “Did the child have chest belt use, when would the nurse state that the
indrawing?” child be safely restrained in a regular automobile
D. “Did the child have fever? For how seatbelt?
long?”
49. A newborn’s failure to pass meconium A. 30 lb and 30 in
within 24 hours after birth may indicate which B. 35 lb and 3 y/o
of the following? C. 40 lb and 40 in
D. 60 lb and 6 y/o
A. Aganglionic Mega colon 55. When assessing a newborn with cleft lip, the
B. Celiac disease nurse would be alert which of the following will
C. Intussusception most likely be compromised?
D. Abdominal wall defect
50. The nurse understands that a good snack for A. Sucking ability
a 2 year old with a diagnosis of acute asthma B. Respiratory status
would be: C. Locomotion
D. GI function
A. Grapes 56. For a child with recurring nephritic
B. Apple slices syndrome, which of the following areas of
C. A glass of milk potential disturbances should be a prime
D. A glass of cola consideration when planning ongoing nursing
51. Which of the following immunizations care?
would the nurse expect to administer to a child
who is HIV (+) and severely A. Muscle coordination
immunocomromised? B. Sexual maturation
C. Intellectual development
A. Varicella D. Body image
B. Rotavirus 57. An inborn error of metabolism that causes
C. MMR premature destruction of RBC?
D. IPV
52. When assessing a newborn for A. G6PD
developmental dysplasia of the hip, the nurse B. Hemocystinuria
would expect to assess which of the following? C. Phenylketonuria
D. Celiac Disease
A. Symmetrical gluteal folds 58. Which of the following would be a
B. Trendelemburg sign diagnostic test for Phenylketonuria which uses
C. Ortolani’s sign fresh urine mixed with ferric chloride?
D. Characteristic limp
53. While assessing a male neonate whose A. Guthrie Test
mother desires him to be circumcised, the nurse B. Phenestix test
observes that the neonate’s urinary meatus C. Beutler’s test
appears to be located on the ventral surface of D. Coomb’s test
59. Dietary restriction in a child who has
Hemocystenuria will include which of the
following amino acid?

A. Lysine
B. Methionine
C. Isolensine tryptophase
D. Valine
60. A milk formula that you can suggest for a
child with Galactosemia:

A. Lofenalac
B. Lactum
C. Neutramigen
D. Sustagen