SITUATION 1 c. Frequent monitoring of patient.

Nurse Eudora is the Charge of the Obstetrics & d. Ensure 24-hour responsible watcher.
Gynecology Ward of a government hospital. Nurse Luna
is one of the staff nurses in that ward. The Ward is beset SITUATION 2
by problems such as having inadequate supplies. Nurse Donna, a nurse in Barangay Tibay Health Center,
will conduct Health education to the residents of the
1. What is the BEST initiative that Nurse Luna can do, Barangay on Reproductive Health.
should there be non-availability of supply of alcohol used
for hand hygiene that is vital in preventing cross- 6. As a Community Nurse, Nurse Donna should be able
infection? to demonstrate knowledge of current laws on
reproductive health in which she practices. One of the
topic topics that Nurse Myrna will discuss is RA 10354
a. Requisition of the items from Central Supply before
which is entitled ________.
the supply runs out.
b. Inform the Head nurse of its non-availability.
c. Have your own alcohol until hospital supply is a. Reproductive Health Act of 2012
available. b. The Responsible Parenthood and Reproductive Health
d. Request the patients to provide their own alcohol. Act of 2012
c. The Responsible Parenthood and Reproductive
2. One major way of preventing cross-infection is Parenthood of 2012
frequent handwashing. However, today, Nurse Luna just d. RH Bill
found out there is water interruption. The INITIAL step
that Nurse Luna ought to do is report the problem to 7. This Law provides reproductive health care program
____. to all citizens prioritizing, which of the following?

1. Women
a. Head nurse
2. The Poor
b. Manila Water
3. Marginalized
c. Chief Nurse
4. Those invulnerable or crisis situations
d. Nurse Supervisor

3. Nurse Luna as a beginning assigned on the Obstetric a. A. 1, 2, 3 and 4

Ward was asked by Head nurse Liji an example of how b. B. 1, 2 & 3
she will be able to manage her environment. Which of C. 1 only
her responses are CORRECT? Select all that apply. D. 1 & 2

8. When conducting health education on Reproduction

1. Check availability and expiry date of fire
Health, it is important that Nurse Donna examines her
extinguishers in the Obstetric Ward.
values because of which of the following reasons?
2. Compliance of Republic Act 9003
3. Provision of a separate container for each type of
1. We all hold personal values that can influence
waste for on-site collection properly marked as
how we respond to our clients.
“compostable”, “non-recyclable”, “recyclable” or special
2. One’s values may change in response to life
waste”.
experiences.
4. Proper isolation of patients known or suspected of
3. Encounters with clients and colleagues may
harboring infectious diseases.
influence your beliefs without your having
much of a chance to reflect on these changes.
a. A. 1, 2 & 4
4. Others exist at a deeper level, so that we don’t
b. B. 1, 3 & 4
necessarily recognize the influence they have
c. 1, 2, 3 & 4
on our behavior and judgments as health care
d. 2, 3 & 4
providers.
4. Should Nurse Luna request for Alcohol-based hand
rub to be effective for application to the hands for a. A. 1, 2 and 3
reducing the number of viable microorganism on the b. B. 1, 2, 3 and 4
hands, the ethyl content should be _____. c. 1, 3 and 4
d. 2, 3 & 4
a. 60 9. Reproductive Health service include the following,
b. 90
c. 70 a. Gender-based Violence
d. 95 b. Finding the correct partner
c. Management and prevention of maternal and perinatal
5. Nurse Luna discovered that bed mattresses in the Pay
d. Malnutrition and anemia
Ward slide easily, either to the left or right side of the
bed causing patient fall. What would be Nurse 10. Factors that affect reproductive health care, which of
Angelina’s MOST appropriate way to provide patient’s the following?
safety?
1. Economic circumstances,
a. Use restraint on Patient. 2. Education,
b. Raise upper and preferably lower fall rails at all times. 3. Living conditions and family environment,
 4. Social and gender relationships a. 3 2 1 4
b. 3 4 1 2
a. A. 1 & 2 c. 4 2 3 1
b. B. 1, 2 and 3 d. 2 3 4 1
c. 1, 2, 3, & 4
d. 2, 3, & 4 SITUATION 4
A nurse is performing an admission assessment on
SITUATION 3 Sheldon a 4-year-old, who has been diagnosed with
Patient Natalia a gravida 1, para 0. Patient is admitted at nephrotic syndrome.
the labor room. Her cervix is 100% effaced, and upon IE,
her cervix is 3 cm dilated, the fetus is at + 1 station. 16. What sign will BEST support the medical diagnosis
Staff Nurse Karina attends to her. of nephrosis?

11. Taken from the assessment data above that the fetus a. Gross hematuria, tea-colored, scanty urine
is at + station, how will Nurse Karina interpret this? That b. History of a streptococcal infection
the head of the fetus is _________. c. Periorbitaledema
d. Anasarca
a. Below the ischial spines
b. Visible at the vaginal opening 17. Sheldon receives prednisone as the major treatment
c. Not yet engaged for his nephrosis. Which of the following actions should
d. Entering the pelvic inlet be observed by the nurse in the administration of
prednisone?
12. Nurse Karina monitors the contractions of the patient.
She recorded the contractions as follows: started at 10:00 a. All of the options.
A.M; another began at 10:15 A.M. In MINUTES, what is b. Administer the drug on a full stomach.
the frequency of the contractions? c. Monitor Carlo’s temperature.
a. 10 d. Protect Carlo from infection.
b. 9
c. 15 18. Which side effect of prednisone will be MOST
d. 14 prominent on Tonton and for which he should be
prepared before its administration?
13. Nurse Karina assesses the duration of the patient’s
contractions by timing them from ________ to
________. a. Hypotension
b. Decreased weight
c. mooning of face
a. Beginning of one contraction to the beginning of the d. vomiting
next contraction
b. End of the contraction to the beginning of the next 19. What is the nursing diagnosis for a child with severe
contraction edema caused from nephrotic syndrome? It is risk
c. End of the contraction to the end of the next for_________.
contraction
d. Beginning of one contraction to the end of the same a. Impaired skin integrity
contraction b. Constipation
14. After doing Leopold’s maneuvers on the patient I c. Ineffective thermoregulation
labor, the nurse determines that the fetus is in the ROA d. Imbalanced nutrition more than body requirements
position. Where should the nurse place the Doppler to 20. What will be the APPROPRIATE recommend diet
BEST auscultate the fetal heart tones? for Sheldon?

a. Below the umbilicus near the left groin a. High iron, no protein
b. Below the umbilicus on the right side b. High calorie, high protein
c. Above the umbilicus in the midline c. High sodium, high protein
d. Above the umbilicus on the left on the left side d. Low sodium, moderate protein
15. Patient Natalia was given epidural anesthesia. This SITUATION 5
indicates late deceleration of the fetus and so the nurse Nurse Odette has been assigned in the Pediatric Ward for
has to do important nursing interventions. ARRANGE almost a year. Her Headnurse is on Maternity Leave for
the following nursing interventions in ORDER or the next 6 months. She was appointed by the Area Nurse
PRIORITY. Supervisor to be the Charge Nurse.
1. Increase intravenous fluids 21. Nurse Odette recalls that one of the major
2. Change position of the patient to the left side responsibilities of a Headnurse is record keeping. These
lying are many reasons for keeping records in health care, but
3. Reassess fetal heart rate pattern two stand out above all others. These are to ______.
4. Document intervention and maternal/fetal 1. Compile a complete record of the patient’s journey
response through services
2. Enable continuity of care for the patient both within b. Pregnancy outside the uterus
and between services. c. Termination of pregnancy before the age of viability
d. Abnormal lower implantation of the placenta
3. Make available for legal purposes 27. The abdominal pain associated with abruption
placentae may be INITIALLY caused by which of the
4. Protect nurses from ligitation following?
*
1 point a. Disseminated intravascular coagulation
b. Blood in the myometrium
a. A. 1 & 4
c. Hemorrhagic shock
b. B. 2 &
d. Concealed haemorrhage
c. 3 & 4
d. 1 & 2 28. The bleeding following severe abruption placentae is
usually caused by which of the following condition?
22. The following statements demonstrate to Nurse
Odette that record keeping is good, EXCEPT:
a. Thrombocytopenia
b. Hyperglobulinemia
a. Entries are dated and timed as close to the actual time
c polycythemia
of the events as possible.
d hypofibrinogenemia
b. Relevant information about the condition of the
patient/ client at any given time and the measures you 29. What should the nurse prepare for the POSSIBLE
have taken to respond to their needs. order of the physician?
c. Abbreviation is used.
d. A full account of your assessment and the care you
a. The administration of the oxytocin
have planned and provided.
b. A high- forceps birth
23. On record keeping, the Area Supervisor reminds c. An immediate caesarean birth
Nurse Melissa that for most Nurses who find themselves d. The insertion of a fetal monitor
involved in legal proceedings, the best defense to win the
30. Abruption Placenta can cause hemorrhagic disorder
case is _____.
which can lead to hypovolemic shock. What is the LATE
sign of hypovolemic shock that the nurse should watch
a. Honesty for?
b. Good memory
c. Quality of nursing documentation
a. Hypertension
d. Knowledge
b. Tachycardia
24. Which statement is incorrect regarding record c. hypotension
keeping? d. tachypnea

SITUATION 7
a. Patients now have a legal right to see their own Preterm newborns are considered high risk because of
records. their immaturity to adapt to the extrauterine life. They
b. Keeping records of patient care and treatment is NOT need special treatment and specialized process of nursing
an integral part of nursing practice. care.
c. Any later alteration or addition must be carefully
indicated, insuring that the original entry can still be 31. The goal of a neutral thermal environment is to assist
clearly read. the newborns to stabilize its temperature that does not
d. All records must be signed by the person making the drop below which of the following?
entry together with the date and time of the entry.
a. 98.6 degree F
25. When the patients asks where to get his/her medical
b. 99.5 degree F
record after discharge, the correct answer is _______.
c. 97.7 degree F
d. 96.7 degree F
a. Office of the Attending Physician
b. Medical Record Section 32. Nurses should be alert when caring for a preterm
c. Admission Section newborn, particularly for which of the following signs?
d. Office of the Administrative Officer
a. Hypercalcemia
SITUATION 6
b. Premature closure of ductus arterious
Patient Ussopp, who is in the third trimester, arrives at
c. Meconium aspiration syndrome
the hospital with vaginal bleeding. She states that she
d. Hypoglycemia
snorted cocaine approximately 2 hours ago.
33. The nurse starts giving information about preterm
26. Which defined complication is MOST likely causing
newborns to the parent. She tells them that preterm
the client’s vaginal bleeding?
newborns exhibits which of the following
characteristics/signs?
a. Premature separation of normally implanted placenta
a. Allow elbows to be brought past the midline of the 39. Which of the following is the independent variable of
chest. the study?
b. Exhibit an abundance of brown fat.
c. Resists when the right heel is brought to the right ear. a. Highest risk
d. Assume significant flexed posture. b. Three generation of OC
c. OC
34. Hypothermia is common in preterm newborns
d. MI
because of their inability to control heat. Which of the
following is an EXCEPTION to the APPROPRIATE 40. Identify the groups in the study that will validate the
nursing intervention to prevent heat loss? occurrence of the MI among OC users.

a. Using mechanical pressure a. Old cases of MI

b. Drying and wrapping the baby b. Prevalence of MI
c. Placing the crib beside the wall c. old and new cases of MI
d. Doing kangaroo care d. incidence of MI
35. Which of the following conditions is NOT SITUATION 9
INCLUDED among the effects of cold stress? Nurse Alice is assigned at the postpartum ward. The
a. Hypoglycemia following questions refer to postpartum patients.
b. Metabolic acidosis
c. Increase intracranial pressure 41. Beatrix, a multiparous patient, 28 hours after
d. Cerebral palsy Ceasarian delivery (CS), who is breastfeeding, complains
of severe abdominal cramps. Nurse Alice explains that
SITUATION 8 these are caused by which of the following?
Nurse Even works in the research unit of the Prinsesa
Urduja Women’s Clinic. In the close monitoring of their
patients using oral contraceptives (OC), she noted several a. Flatulence accumulation after CS.
cases of myocardial infarction (MI). b. Release of Oxytocin during the breastfeeding session.
c. Healing of the abdominal incision after CS.
36. To establish the relationship between MI and OC, d. Side effects of the medications Administered after
Nurse Even should make a research proposal for which delivery.
of the following STUDY design?
42. Three hours postpartum, a primiparous patient’s
fundus is firm and midline. On perineal inspection by
a. Retrospective Nurse Alice, she observes a small constant trickle of
b. Prospective cohort blood. What will the nurse suspect for the patient to
c. incidence have?
d. cross- sectional

37. Since OCs are categorized into 1st, 2nd and 3rd a. Uterine inversion
generations, Nurse Even decided to study not only the b. Perineal lacerations
relationship of MI and OC but also which of the three c. Retained placenta
generations of OCs will have the highest risk for MI. d. Bladder distention
Hence, which of the following groups will she include in
her study? 43. On the first postpartum day, a primiparous patient
complains of perineal pain that was unrelieved by
Ibuprofen 400 mg given two hours ago. Nurse Alice
a. Those who do not take OC, and those who take OC should assess for which of the following?
from 1st, 2nd, ad 3rd OCs.
b. All those who take OC and those who do not.
c. Those who take 1st OC 2nd OC and 3rd OC. a. Vaginal lacerations.
d. Those with MI and those with no MI. b. Perineal Hematoma.
c. History of drug abuse.
38. Statistical analyses revealed odds ratio for MI among d. Puerperal infection.
women who used any type of OC, as compared with non-
users, was .99. What does this mean?* 44. Twelve hours after vaginal delivery, Nurse Alice
palpated the fundus of a primiparous patient and finds it
to be firm, above the umbilicus and deviated to the right.
a. Accept the null hypothesis; there is no significant
What is the Best thing for Nurse Alice to do for the
relationship between MI and OC.
patient?
b. The study focused on the three groups: 1st OC users
with MI, 2nd OC users with MI and 3rd OC users with
MI. a. Contact the physician for an order of
c. There is a relationship between MI and OC and the methylergonovine.
risk of MI among users of any type of oral contraceptive b. Gently massage the fundus to expel the clots.
is twice that of non users. c. Encourage patient to ambulate and to void.
d. The odds of getting MI among OC users and those d. Document this as a normal finding in the patient’s
who are not users is 1:2 records.

45. After instructing a primiparous patient about

episiotomy care, which of the following indicates
successful teaching? using refocusing technique?

a. “I will wipe the area from front to back using a A. “What were you saying about your mother-in-law?”
blotting motion.” B. “All mother s-in-law are just as helpful, so it will be
b. “I will put ice packs on the site 15 minutes once a day better to just accept her”.
for 3 to 4 days.” C. “I think we were talking about breast engorgement
c. “Before bedtime, I will do a cold water sitz bath.” which brought about.”
d. “I’ll use sudsy water to clean the episiotomy.” D. “What did you do about the pain you felt on your
breast?”

50. In the course of Geraldine’s duty in the OB Ward,

SITUATION 10 she also learned that she has to adjust her style of
Geraldine is a new nurse in the Obstetrics Ward. She communication for different types of patients. Thus, Liza
remember her Clinical instruction saying that a nurse should adjust to which of the following characteristics of
must learn how to communicate well with her patients. Nami? Select all that apply.
46. Geraldine learned active listening. How will 1. Level of usual communication
Geraldine demonstrate this on her patient named Nami?
She Should ________.
2. Pace of interaction
1. Listen to what Nami verbalizes and observe how she
expresses her feelings 3. Display of emotions

2. Demonstrate interest on what Grace is talking about 4. Full development of topic

by avoiding her eyes.
a. A. 1, 2, 3, 4
3. Maintain a close body posture such as keeping arms b. B. 1 and 2
crossed and clenching fist. c. 3 and 4
d. 1, 2, 3
4. Tune out other thoughts and refrain from SITUATION 11
interrupting Grace while she is talking Goldilocks, G2 P3, is a Type I diabetes mellitus (DM)
since she was 10 years old. She is in her first trimester of
a. 1 and 2 pregnancy. Linlin is her nurse.
b. 1 and 4
c. 3 and 4 51. What could be the MOST possible effect of DM to
d. 2 and 3 Goldilocks? She can have ______.

47. Which of the following should Not be considered by a. Ketoacidosis

the nurse in interpreting nonverbal messages of a patient? b. Hyperinsulinism
c. Hyperglycemia
a. Culture, educational attainment and position in society. d. Hypoglycemia
b. Congruency of nonverbal expressions with spoken
words. 52. Which of the following would require an increased
c. Facial expression, posture, tone of voice and age. dose of medication once Goldilocks is in the second half
d. Eye contact with all patients at all times regardless of of pregnancy?
race.
a. Insulin
48. Demonstrating what she learned from school in terms b. Pancreatic enzymes
of obtaining feedback, Geraldine’s APPROPRIATE c. estrogenic hormone
response to Robin’s complaint, “My breasts are engorged d. antihypertensives
and it is so painful, “should be _______.
a. “Tell me about the pain. Is it tolerable, moderate or 53. What is the route of administration for insulin during
severe?” pregnancy?
b. “It is alright all breastfeeding mother feel the same as
you”. a. Intravenous
c. “That’s a sacrifice that mothers should do for her b. Subcutaneous
babies”.
d. “Just continue breastfeeding, it will relieve you from c. oral
your pain”.
d. shot with flex pen
49. Geraldine also recalled her learning on how to
REFOCUS conversations. Thus, when Nami’s 54. Considering Goldilocks’s condition, Nurse Linlin
subsequent messages were, “I have this painful engorged will anticipate what effect to the fetus? The condition
breasts and my mother-in-law wants me to bottle feed will be_______.
instead of breastfeed”. What will be Liza’s BEST answer
a. Large for gestational age
b. Macrosomia 2. Releases those involved in his/her care from any
c. Intrauterine growth retardation (IUGR) obligation relative to the consequences of his decision.
d. Meningomyelocele

55. On the first postpartum day, which of the following 3. His/her decision will not prejudice public health and
requirements for insulin will be anticipated by the nurse safety
to be ordered by the physician?
4. Appropriate arrangement has been made to settle the
a. Remain unchanged unpaid bill.
b. Decrease sharply and suddenly
c. Increase rapidly a. A. 1, & 2
d. Decrease slowly and steady b. B. 1, 2, & 4
c. 3 & 4
SITUATION 12 d. 1, 2, 3, & 4
Nurse Luffy is newly assigned in the Pediatric Ward in
Grandline Medical Center. Since he will be taking care SITUATION 13
of pediatric patients, there is a need for Nurse Luffy to be Mrs. Yetty, gravida 3 para 3003, is admitted to the
abreast with the legal aspects of pediatric nursing care. postpartal unit after an uncomplicated labor and vaginal
delivery. She opted to breastfeed her baby. Nurse Jolly is
56. Which of the following regulates the practice of the around to take care of her.
nursing profession?
a. Department of Health 61. The first day after delivery, Mrs. Yetty tells the nurse
b. Professional Regulation Commission that his wife has been talking constantly about her recent
c. Civil Service Commission delivery experience. He asks if this is a sign of postpartal
d. Professional Regulation Board of Nursing blues. What should be the BEST response of the nurse?

57. One of the Luffy’s patients to undergo invasive a. “Do you feel uncomfortable about her talking on her
procedure. Based on the Patient’s Bill of Rights, delivery experience?”
sequence the persons from whom Nurse Luffy could b. “Yes, it’s clear sign of post-partum blues. She may
obtain consent? need a psychiatric evalution.”
1. Parents 3. Next of kin c. “This is a normal reaction. It allows her to accept the
reality of the birth of your baby.”
2. Legal guardian 4. Physician d. “No, you should divert her attention away from her
delivery.”
a. A. 1, 2, 4, & 3
b. B. 1, 4, 2, & 3 62. Later that day, Mrs. Yetty tells Nurse Jolly that she
c. 1, 2, 3, & 4 has urinated four times within the last hour but only in
d. 1, 3, 2, & 4 small amounts. What should be the INITIAL ACTION
of the nurse?
58. Based on the Right to Privacy and Confidentiality
under the Patient’s Bill of Rights, the patient has the a. Explain that this is normal during the first 24 hours
right to demand the following, but NOT ______ after delivery.
pertaining to his care as confidential. b. Palpate Mrs.Yetty’s fundus to assess uterine
consistency and location.
a. Information c. Catheterize Mrs.Yetty immediately to expel any
b. Communication retained urine.
c. Records d. Begin measuring and recording and recording
d. financial Status Mrs.Yetty’s intake and output.

59. The Right to Information does not include ____. 63. Which assessment finding is MOST indicative that
Mrs. Yetty is developing puerperal infection?
a. Any change in the plan of care before the change is
made a. Increased pulse rate
b. Extent to which payment maybe expect from b. Foul- smelling lochia
Philhealth c. Elevated body temperature
c. Discount for the professional fee of the attending d. A white blood cell count of 25,000/mcg
doctor(s)
d. Result of the evaluation of the nature and extent of 64. Mrs. Yetty asks Nurse Jolly when her menstrual
his/her disease period will return. The nurse answers that a breastfeeding
patient typically resumes menstruating in
60. A patient has the right to leave the hospital regardless about____________.
of his physical condition provided s/he is informed of
which of the following? Select all that apply. a. 8 to 12 weeks
b. 3 to 6 months
1. Is informed of the medical consequences of his/ her c. 4 to 6 months
decision. d. 4 to 6 weeks
65. Mrs. Yetty complains of pain due to breast of abortion nor fetal demise. Her last menstrual period
engorgement. What will the nurse do to encourage her to began February 7, 2017 and ended February 12, 2017.
continue breastfeeding?
71. What is the GTPAL for Mrs. Chichi?
a. Let her continue breastfeeding on schedule.
b. Put hot compress over the breast for 15 minutes before a. G = 1, T = 1 , P = 1, A = 0, L = 1
breastfeeding. b. G = 2, T = 0 , P = 0, A = 0, L = 1
c. Put cold compress over the breast for 15 minutes c. G = 3, T = 2 , P = 0, A = 0, L = 1
before breastfeeding. d. G = 2, T = 1 , P = 0, A = 0, L = 1
d. Let her continue breastfeeding on demand.
72. What is the expected change in the hemotologic
SITUATION 14 system that occurs during the END of the first trimester
Nurses Hulyo and Hulya are assigned in high risk of pregnancy that Nurse Dende should recognize?
maternity ward. Here are some cases which they handle
for the morning shift. a. An increase in hematocrit
b. A decrease in WBC’s
66. Mrs. Minchin, 38 weeks generation is admitted at the c. An increase in blood volume
High Risk Ward. She was admitted due to labor pains d. A decrease in sedimentation rate
with cervix of 6 cm. BP was 160/110mmHg. She is given
MgSo4 per IV. How will Nurse Jessy determine that the 73. Mrs. Chichi asks about the functions of placenta.
MgSo4 therapy has been effective? Which of the following items should Nurse Dende
include in the teaching plan?
a. Labor pains decreased. 1. The placenta filters the fetal urine.
b. There is clonus of the ankle.
c. BP is maintained. 2. Fetal and maternal blood mix in the placenta to
d. Seizures are prevented exchange nutrients.
67. What would Nurse Hulyo monitor to suspect MgSo4
toxicity on Mrs. Minchin? 3. The placenta filters the alcohol from the mother’s
blood.
a. Tingling in the toes.
b. Rapid pulse rate and hyperventilation. 4. Substances are exchanged by the placenta without
c. Decreased deep tendon reflexes. mixing the maternal and fetal blood.
d. Hypertension
5. Fetal respiration, nutrition and excretion are carried
68. If Mrs. Minchin begins to exhibit signs of labor after out by the placenta.
eclamptic seizure, what will Nurse Hulyo anticipate to a. 1, 2, 3
occur? b. 4, 5
a. Severe infection. c. 3, 4, 5
b. Abruptio placenta. d. 1, 2
c. Uterine atony.
d. Placenta accrete. 74. Mrs. Chichi asks “When will be my expected date of
delivery (EDD)?” Based on her knowledge of Naegeles’
69. Nurse Hulya is assisting an obstetrician in the care of Rule, which should be the CORRECT answer of Nurse
a pregnant woman in labor with herpes simplex viral Margie?
infection. The nurse would anticipate which management
of the condition?
a. November 14, 2017
b. October 14, 2017
a. Administration of anti-viral drug. c. October 19, 2017
b. Vaginal douche. d. November 19, 2017
c. Hot sitz bath TID.
d. Preparation for Ceasarian section. 75. Nurse Jubel Explained the chronological order of the
growth and development of the fetus as it occurs in
70. One of the patients of Hulya has been exhibiting pregnancy which is the following __________.
signs and symptoms of Rheumatic Heart Disease (RHD).
These are the following, EXCEPT:
a. Fever a. Ovum, zygote, morula, embryo, fetus, infant
b. Abnormal pulse rhythm b. Morula, zygote, ovum, fetus, embryo, infant
c. Petechia c. Morula, ovum, embryo, zygote, fetus, infant
d. Heart murmurs d. Zygote, ovum, morula, embryo, fetus, infant

SITUATION 15 SITUATION 16
Nurse Dende is collecting data from a newly admitted Nurse Sakura admitted a laboring primigravida, Tsunade,
patient, Mrs. Chichi, who is pregnant with twins. She has brought by an anxious taxi driver.
a healthy 3-year-old child who was delivered at 38 76. Nurse Sakura calms down the similarly anxious
weeks. She also revealed that she does not have a history patient by telling her that the DEFINITIVE sign that
labor about BEGIN is _____.
 b. Only Dr. A but not the nurse because the latter was
a. Rupture of bag of water just following orders from the physician.
b. Lengthening of cord c. Dr. A and the nurse because of their failure to perform
c. Initiation of contraction their perspective duties with diligence and care.
d. Bulging of perineum d. Dr. A and the hospital administrator because of
command responsibilities on the treatment and care to
77. The discomfort expected with TRUE LABOR the patient.
contractions is MOST accurately described by which of
the following? Discomfort ________. 82. Under the situation, if the physician and the nurse are
liable over the consequence of the treatment and care of
a. Begins in the lower back, abdomen and then radiates the patient, what applicable legal doctrine will this be?
over the entire abdomen
b. Begins in the fundus and then radiated downward to a. Respondeat Superior
the cervix b. Captain of Ship Doctrine
c. Radiates from the umbilicus to the iliac region then to c. Patient’s Proximate Negligence
the lower extremities d. Res Ipsa Loquitor
d. Centers in the fundus of the uterus during the entire
contraction. 83. If the nurse is called to testify on the alleged surgical
procedure performed to the patient to determine whether
78. Nurse Sakura completed the vaginal examination on there was lack of necessary care and diligence, the nurse
the patient. She recorded 75%, 7cm, 0. Which of the should testify only on matters which are ________.
following is a CORRECT interpretation of the date?
a. Within her personal knowledge
a. Effacement is 5 cm complete. b. Documented in the chart
b. Fetal presenting part is engaged. c. Advised by her lawyer
c. Dilatation 75% is completed. d. Being asked by the court
d. Acceleration phase of the first stage of labor is about
to begin. 84. Medical records have legal implications. In as much
as the nurse failed to chart the discharge instructions,
79. Nurse Sakura would further estimate that the above what principle in records management was violated?
data means the cervix is _______ of its length.
a. “If it was not documented, it was not done.”
a. ¾ b. “Completion of chart should be within 48 hours.”
b. 1/3 c. “No document, no discharge.”
c. ¼ d. “Not all documented data are true.”
d. ½
85. Hospital A practices clinical pharmacy. Physician
80. When does the membranes of a patient in labor writes the order of medications, pharmacist prepares it
MOST likely to rupture? and the nurse administers it. Who then will be liable for
any drug overdose administered intravenously by the
a. During the perineal phase of the second stage of labor nurse?
as the head of the body crowns.
b. During the active phase of the first stage of labor, a. Pharmacist
usually at the peak of a contraction. b. Nurse and Physician
c. During the latent phase of the 1st stage of labor c. Nurse
between contractions. d. nurse and pharmacist
d. Just immediately before the labor begins.
SITUATION 18
SITUATION 17 Nursing assessment of individuals across the life span
Nurse Vivi attends to Patient Shaki who is three months requires a nurse to be familiar with the physiological,
pregnant when a pelvic sonogram was conducted on her cognitive, and psychosocial changes that occur during
revealing the fetus’ weak cardiac pulsation. Nurse Vivi each stage of development.
advised the patient to have a follow up visit to their clinic
after a week but it was only after two weeks that the 86. The factors that affect the ability of individuals to
patient returned when she started to suffer from severe cope are______. Select all that apply.
abdominal pains. Upon examination, the doctor found 1. Level of development
out that there was a dead fetus in her womb. The patient
underwent hysterectomy and as a result, she had no more 2. Coping skills
chance to bear a child.

81. Shaki filed legal charges against all people concerned 3. Previous experiences with illness and hospitalization
regarding the outcome of the procedure done to redress
the damages caused by the procedure. Who among the 4. Seriousness of diagnosis
following will be accountable to the patient?
a. 2, 3, and 4
a. None, all members of the health care team performed b. 1, 2 and 4
their professional duties on the patient. c. 1, 2, 3, and 4
d. 1, 2, and 3 made by the parent, indicated the need for further
instructions?
87. Appropriate nursing diagnoses for patients with
developmental problems are, EXCEPT:
a. “If the child vomits after medication administration, I
will repeat the dose.”
a. Delayed growth and development b. “If more than one dose is missed, I will call the
b. Compromised family Coping physician.”
c. Impaired social interaction c. “I will take the child’s pulse before administering the
d. Altered Sleeping Pattern medication.”
d. “I will not mix the medication with any food and
88. Patient’s participation in the planning phase of the
drinks.”
nursing diagnosis depends on ______. Select all that
apply. 93. Which of the following instructions about ORAL
1. Development Status pediatric medications is TRUE as these interfere with
milk and milk products or food eaten by young children?
2. Psychological condition Oral medication should be given_____________.

3. Level of intelligence a. With meals always

b. On an empty stomach
c. ½ hour after meals
4. Comprehension of his disease
d. With the night time formula
a. 2 & 3
b. 1 & 2 94. Joe has a blood pressure of 92/78; resting pulse of 60;
c. 1, 2, 3, & 4 respirations 28 and a potassium level of 4.8 mEg/L. He is
d. 3 & 4 irritable and has vomited twice since the morning dose of
digoxin. Which finding is most indicative of digoxin
89. When a 15-year-old female patient is so engrossed
toxicity?
and worries as to what her friends think about her, she is
categorized to be in the psychosocial development stage.
Nurse Eudora needs to inform the mother that this is a a. Vomiting
normal behavior. In what stage of the psychosocial b. Lethargy
development is the patient in? c. Bradycardia
d. Irritability
a. Identity versus Role Confusion 95. Considering Joe’s age, which of the following is the
b. Autonomy versus Doubt and Shame BEST approach by the nurse when administering
c. Industry versus Inferiority medication?
d. Initiative versus Guilt

90. The Head nurse of Pediatric Ward asked a staff nurse a. “You will feel better if you take your medication.”
who is assigned to a 3 month old infant. At what age will b. “Would you like to take your medicine from a spoon
her patient start to drink from a cup? The staff nurse’s or a cup?”
answer should be _____. c. “Do you want to take this pretty red medicine?”
d. This is your medicine and you must take it all right
now.”
A. 12
B. 24 SITUATION 20
C. 9 Erwin, a 5- year- old child, is admitted to the hospital for
D. 5 abdominal pain. The mother reports that the child has
been pale, tires easily and has hematomas in the arms and
SITUATION 19
legs. On physical examination, lymphadenopathy and
Joe, 3 years old, who underwent ventricular septal defect
hepatosplenomegaly are noted. Diagnostic studies are
repair, is placed on a maintenance dosage of digoxin
being performed on the child because acute lymphocytic
(Lanoxin) elixir. Nurse Hannah, complete with the
leukemia is suspected.
knowledge of the disease, is assigned to him
96. Which of the following procedures will confirm this
91. The dosage is 0.07 mg/kg/day, and the client’s
diagnosis?
weight is 7.2 kg. The physician orders the Digoxin to be
given twice daily. How much Digoxin should Nurse
Love prepare to administer at each dose? a. A lumbar puncture
b. A platelet count
c. Bone marrow biopsy
a) 2.5 mg
d. White blood cell count
b) 0.5 mg
c) 0.37 mg 97. Based on the instructions of the nurse, which of the
d) 0.25 mg following activities should NOT be done by the parents
in monitoring possible infection on Hani?
92. Nurse Love provides home care instructions to the
parents of Joe regarding the procedure for the
administration of digoxin (Lanoxin). Which statement, if a. Taking the rectal temperature daily
b. Inspecting the skin daily for redness
c. Inspecting the mouth daily for lesions
d. Performing proper hand washing techniques

98. What is the PRIMARY effect of leukemia on the

bone marrow?

a. a selective reduction in the number of neutrophils

b. Leucopenia, thrombocytopenia, and anemia
c. The crowding out of normal cells on the site
d. Proliferation of cells producing blood components

99. The patient’s parents asked why her child has

hematomas and anemia. Which of the following should
be the explanation of Nurse Jean?

a. “Hematomas and anemia are related to the child’s

inactivity.”
b. “All blood cells are made in the bone marrow.
Hematomas and anemia are due to decreased RBC and
platelet count.”
c. “Hematomas and anemia are indicative that the end is
near.”
d. “the anemia is because the child hasn’t been eating
well; the hematomas are from the multiple needle sticks.”

100. Patients Hani is not expected to survive. Hani says

to her mother, “Will you take care of me when I am dead
the way you do now?” the child’s mother asks Nurse
Jean how to answer her child. The nurse’s response
should be based on which of the following understanding
of the child’s behaviour.

a. “Children of this age do not understand the finality of

death.”
b. “The child is denying that he has a terminal illness.”
c. “Most 5-year-old children have a great fear of
mutilation.”
d. “the child may be having visual and auditory
hallucinations.”