NURSING SEMINAR SAS ANS COMPILATION a.

The theory of self-care

b. The self-care deficit
theory c. The 21 nursing
problems
SAS 1 d. The theory of nursing systems
1. Florence Nightingale’s theory focused on the environment. Which of RATIO: A, B, and D is included in Dorothea Orem’s nursing theory. Letter C is
the following did she define and describe in her theory? identified by another nursing theorist, Faye Abdellah.
a. Food, air, water, elimination, and shelter 9. This theory from Dorothea Orem focuses on the performance or
b. Ventilation, warmth, light, diet, cleanliness, and noise practice of activities that individuals initiate and perform on their own
c. Physical, emotional, mental and spiritual behalf to maintain life, health and well-being.
d. Physiologic, safety, love & belongingness, self-esteem, and
self- actualization a. Theory of self-care
b. The self-care deficit theory
RATIO: In Florence Nightingale’s theory she has focused on ventilation, c. The theory of nursing systems
warmth, light, diet or nutrition, cleanliness and elimination of noise. Letter A d. All of the above
leans more into the physiologic needs of a patient. Letter C is not related to
any nursing theories. Letter D is talking about Maslow’s hierarchy of needs. RATIO: Letter B (Self-care deficit theory) delineates when nursing is needed.
Nursing is required when an adult (or in the case of a dependent, the parent
2. In Jean Watson’s Theory of Human Caring, she has stated that nursing or guardian) is incapable of or limited in the provision of continuous effective
is concerned with the following EXCEPT self-care. Letter C (The theory of nursing systems) This theory is the product
of a series of relations between the persons: legitimate nurse and legitimate
a. Promoting health
client. This system is activated when the client’s therapeutic self-care
b. Preventing illness
demand exceeds available self-care agency, leading to the need for nursing.
c. Caring for the sick
d. Identifying the basic needs 10. How many methods of helping did Dorothea Orem identify?
RATIO: Choices A, B, and C are in Jean Watson’s statement that says, “Nursing a. 3
is concerned with promoting health, preventing illness, caring for the sick, b. 5
and restoring health.” Letter D is not included in this statement. c. 7
d. 9
3. According to Jean Watson, which one is central to nursing practice
and promotes health better than a simple medical cure? RATIO: Orem has identified 5 methods of helping namely: (1) acting for and
doing for others, (2) guiding others, (3) supporting another, (4) Providing an
a. Caring
environment promoting personal development in relation to meet future
b. Compassion
demands, and (5) teaching another
c. Dedication
d. Empathy 11. In Martha E. Roger’s Theory of Human Beings she defined nursing as
RATIO: According to Jean Watson’s theory, caring should be central or a. “The act of assisting others in the provision and management of
essential to nursing practice. She did not indicate compassion, dedication, self-care to maintain or improve human functioning at home
and empathy in her theory. level of effectiveness.”
b. “Unique profession that is concerned with all of the
4. In Jean Watson’s theory she has stated to focus on which of the following?
variables affecting an individual’s response to stress.”
a. Treatment of diseases c. “An art and science that is humanistic and humanitarian.”
b. Rehabilitation d. “Health care profession that focuses on human life processes
c. Health promotion and patterns and emphasizes promotion of health for
d. Control of environment individuals, families, groups, and society as a whole.”

RATIO: In Jean Watson’s theory, she has focused on health promotion in RATIO: Letter A is from Dorothea Orem’s theory, Letter B is from Betty
order for the people to achieve a great well-being and avoid the occurrence Neuman’s theory, while Letter D is from Sister Callista Roy’s theory.
of illnesses.
12. Which of the following sentences is NOT a concept related to
5. In Patricia Benner’s nursing theory she has described the Florence Nightingale’s theory?
advanced- beginner nurse as
a. "Poor or difficult environments led to poor health and disease"
a. They are taught general rules to help perform tasks, and b. "Environment could be altered to improve conditions so that
their rule-governed behavior is limited and inflexible. the natural laws would allow healing to occur"
b. Shows acceptable performance, and has gained prior c. The goal of nursing is “to put the patient in the best condition
experience in actual nursing situations. for nature to act upon him”
c. Generally, has two or three years’ experience on the job in d. "Human beings are open systems in constant interaction with
the same field. the environment"
d. Perceives and understands situations as whole parts.
RATIO: Letter D is from Imogene King’s Goal Attainment theory. The rest of
RATIO: Choice A is pertaining to a nurse novice. While Letter C is the choices are related concepts related to Florence Nightingale’s Theory.
talking about a competent nurse. Letter D meanwhile is describing a
13. In Martha E. Roger’s the Science of Unitary Human Beings contains
proficient nurse. Expert nurses no longer rely on principles, rules, or
two dimensions: the science of nursing, which is the knowledge specific to
guidelines to connect situations and determine actions.
the field of nursing that comes from scientific research; and
6. How many levels of nursing experience did Patricia Benner identify?
a. Art of nursing
a. 3 b. Adaptation Model
b. 4 c. Behavioral Systems Model
c. 5 d. Carative caring
d. 7
RATIO: The art of nursing, which involves using the science of nursing
RATIO: Patricia Benner has identified 5 levels of nursing experience namely creatively to help better the life of the patient. Letter B is from Sister Callista
the novice nurse, the competent nurse, the proficient nurse, and the Roy, Letter C is from Dorothy Johnson, and Letter D is from Katie Eriksson.
expert nurse.
14. What are the five variables identified in Betty Neuman’s System model?
7. According to Katie Eriksson’s nursing theory, she said to take which of
a. Oral, Anal, Phallic, Latent, and Genital
the following into use when caring for the human being in health and
b. Physiologic, safety and security, love and belongingness,
suffering?
self- esteem, and self-actualization
a. Charity c. Ventilation, warmth, light, diet, cleanliness, and noise
b. Chastity d. Physiological, psychological, sociocultural, developmental,
c. Comfort and spiritual
d. Caritas
RATIO: Letter A is from Sigmund Freud’s Psychosexual Theory, Letter B is from
RATIO: In Katie Eriksson’s theory she has used caritas which is Latin for Maslow’s Hierarchy of Needs, Letter C is from Florence Nightingale’s nursing
“Love for all” when caring for the human being in health and suffering. theory.

8. Which of the following is NOT a part of Dorothea Orem’s nursing theory?

15. In Betty Neuman’s model, the focus is on the client as a system 21. Which phase of interpersonal relations in Peplau’s Theory of
(which may be an individual, family, group, or community) and on the Interpersonal Relations should the nurse establish rapport with the
client’s responses to client?

a. Illness a. Orientation
b. Stressors b. Identification
c. Needs c. Exploitation
d. Health promotion d. Resolution

RATIO: In Neuman’s System Model, she defined nursing as a “unique RATIO: Establishment of rapport is done during the orientation phase, in the
profession in that is concerned with all of the variables affecting an identification phase the nurse identifies the major problems of the client,
individual’s response to stress.” while in the exploitation phase the nurse works with the client with problem
solving, and the last stage which is the resolution phase is where the nurse
16. In Imogene King’s nursing theory, her model focuses on the attainment
evaluates and ends her professional relationship with the client.
of which of the following?
22. The nursing theorist who identified the 5 stages of the nursing process is
a. Goal
b. Well-being a. Lydia Hall
c. Balanced nutrition b. Madeleine Leininger
d. Basic needs c. Ida Jean Orlando
d. Imogene King
RATIO: Imogene M. King’s Theory of Goal Attainment focuses on this process
to guide and direct nurses’ in the nurse-patient relationship, going hand-in- RATIO: Lydia Hall’s theory is the Core, Care, Cure model, Madeleine
hand with their patients to meet the goals towards good health. Leininger’s theory is about transcultural nursing, and Imogene King’s theory is
all about Goal Attainment. Ida Jean Orlando identified the 5 stages of the
17. Which of the following is the theory associated with Sister Callista Roy?
nursing process namely: (1) Assessment, (2) Diagnosis, (3) Planning, (4)
a. Behavioral System Model Implementation, and (5) Evaluation.
b. Theory of Carative Caring
23. According to Joyce Travelbee’s theory, nursing is accomplished through
c. Adaptation Model of Nursing
d. Theory of Bureaucratic Nursing a. Human-to-human relationships
b. Nurse-patient relationship
RATIO: Letter A is from Dorothy Johnson’s theory, Letter B is from Katie
c. Manipulation of the environment
Eriksson, while Letter D is from Marilyn Ann Ray. In Adaptation Model, Roy
d. Promoting health
defined nursing as a “health care profession that focuses on human life
processes and patterns and emphasizes promotion of health for individuals, RATIO: States in her Human-to-Human Relationship Model that the purpose
families, groups, and society as a whole.” of nursing was to help and support an individual, family, or community to
prevent or cope with the struggles of illness and suffering and, if necessary,
18. In Dorothy Johnson’s Behavioral System Model, she defined which of
to find significance in these occurrences, with the ultimate goal being the
the following statements?
presence of hope. Nursing was accomplished through human-to-human
a. “Nursing is a science and the performing art of nursing is relationships.
practiced in relationships with persons (individuals, groups, and
24. In Lydia Hall’s Core, Care, Cure model, she has identified the core as which
communities) in their processes of becoming.”
of the following?
b. “participation in care, core and cure aspects of patient care,
where CARE is the sole function of nurses, whereas the CORE and a. Primary role of a professional nurse such as providing bodily
CURE are shared with other members of the health team.” care for the patient
c. “People may differ in their concept of nursing, but few b. The patient receiving nursing care
would disagree that nursing is nurturing or caring for c. The aspect of nursing which involves the administration
someone in a motherly fashion.” of medications and treatments
d. “an external regulatory force which acts to preserve the d. the purpose of nursing was to help and support an
organization and integration of the patients’ behaviors at an individual, family, or community
optimum level under those conditions in which the behavior
constitutes a threat to the physical or social health, or in RATIO: The “care” circle defines the primary role of a professional nurse such
which illness is found.” as providing bodily care for the patient. The “core” is the patient receiving
nursing care. The “cure” is the aspect of nursing which involves the
RATIO: Letter A is from Rosemarie Rizzo Parse’s Theory of Human Becoming, administration of medications and treatments.
Letter B is from Lydia Hall’s Core, Care and Cure Theory, while Letter C is from
Ernestine Wiedenbach’s The Helping Art of Clinical Nursing. 25. Faye Glenn Abdellah’s 21 nursing problems were categorized into
which of the following?
19. According to Myra Levine’s theory, she states that nursing is
a. Physical, sociological, and emotional needs
a. An art b. Prevention, treatment, and rehabilitation
b. Human interaction c. Physiological, psychological, and spiritual
c. Concerned with promoting health, preventing illness, caring d. Food, air, and water
for the sick, and restoring health.
d. Science and the performing art of nursing is practiced in RATIO: The 21 nursing problems fall into three categories: physical,
relationships with persons (individuals, groups, and sociological, and emotional needs of patients; types of interpersonal
communities) in their processes of becoming.” relationships between the patient and nurse; and common elements of
patient care. She used Henderson’s 14 basic human needs and nursing
RATIO: According to the Conservation Model, “Nursing is human interaction.” research to establish the classification of nursing problems.
Logically congruent, is externally and internally consistent, has breadth as
well as depth, and is understood, with few exceptions, by professionals and
consumers of health care.
SAS 2
20. In Hildegard Peplau’s Theory of Interpersonal Relations, she has
identified four components which are 1. Nurse Edberg is about to perform a physical assessment of the
abdomen. Which order of assessment must Nurse Edberg do?
a. Digestion, respiration, elimination, and
sleep b. Person, environment, health, and a. Inspection, palpation, percussion, and auscultation
nursing b. Auscultation, percussion, palpation, and
c. Orientation, identification, exploitation, and resolution inspection c. Inspection, auscultation, percussion, and
d. Air, food, water, and shelter palpation
d. Any order that the nurse desires
RATIO: The four components of the theory are: person, which is a developing
organism that tries to reduce anxiety caused by needs; environment, which RATIO: Letter C is the correct order that must be done in order to avoid any
consists of existing forces outside of the person, and put in the context of alterations in the bowel sounds. Letter A is done for the rest of the body.
culture; health, which is a word symbol that implies forward movement of
2. Nurse Ann is going to assess a newly admitted client who is suspected to
personality and nursing, which is a significant therapeutic interpersonal
have Dengue Hemorrhagic Fever. Which of the following should she record
process that functions cooperatively with other human process that make
as subjective data?
health possible for individuals in communities. The nursing model identifies
four sequential phases in the interpersonal relationship: orientation, a. Body temperature of 38.8 degrees Celsius
identification, exploitation, and resolution. b. Complete blood count result
c. Patient’s complaint about abdominal pain
d. Client’s blood pressure of 110/78
RATIO: Subjective data also known as symptoms are things that the patient c. The diaphragm detects high-pitched sounds best
alone can feel and observe. The other choices will fall under objective data or d. The diaphragm detects low-pitched sounds best
also known as signs, these are things that the medical worker can assess from
the patient. RATIO: The diaphragm is used when detecting high-pitched sounds while the
bell is used for detecting low-pitched sounds.
3. Which of the following is the purpose of the physical examination?
10. Nurse Vincent is teaching the community about the importance
a. To obtain subjective data from the patient of exercise to prevent the occurrence of type II diabetes mellitus.
b. To know about the patient’s chief complaint
c. To determine changes in a patient’s health status and how to a. Primary prevention
respond to a problem as well as promote healthy lifestyles b. Secondary prevention
and wellbeing c. Tertiary prevention
d. To evaluate the outcome of the nursing interventions d. Passive prevention

RATIO: Letter A, B, and D will fall into Letter C’s statement. It is the duty of RATIO: Promoting the community’s well-being in order to prevent the
the nurse to do physical examination in order to assess the patient’s health occurrence of diseases would be primary prevention, secondary prevention is
status and formulate a plan on how to address any changes in the normal done when a medical worker gives the patient a treatment for a certain
bodily functioning of the patient. disease, while tertiary prevention involves rehabilitation of patients with
chronic illnesses or who has debilitating conditions. There is no passive
4. A student nurse is instructed to perform an intramuscular injection by prevention.
using the Z-track method. The student nurse must know that the purpose
of doing the Z-track method is 11. When observing universal precaution, the nurse must always
practice which of the following to prevent the transmission of infection?
a. To enhance blood flow to the injection site
b. To allow faster absorption of the drug into the muscle a. Having a proper diet
c. To prevent drug leakage into the subcutaneous tissue, helps b. Maintain adequate exercise
seal the drug in the muscle, and minimizes skin irritation. c. Taking supplemental vitamins and
d. To allow faster drug clearance. minerals d. Practice hand hygiene at all
times
RATIO: The Z-track method is a type of IM injection technique used to
prevent tracking (leakage) of the medication into the subcutaneous tissue RATIO: The primary mandate of universal precaution to prevent the
(underneath the skin). During the procedure, skin and tissue are pulled and transmission of infection would always be handwashing. By practicing
held firmly while a long needle is inserted into the muscle. handwashing, people can eliminate the transmission of contagious or
communicable diseases.
5. Nurse Aladdin Abdulrahman is reviewing the patient’s blood pressure
after administering an oral antihypertensive 30 minutes before. The nurse is 12. Nurse Jason is going to feed the patient via the nasogastric tube.
employing which stage of the nursing process? Which nursing action is essential in performing enteral feeding?

a. Nursing diagnosis a. Elevating the head of the bed

b. Planning b. Positioning the patient to the left side
c. Implementation c. Warming the formula before administering it
d. Evaluation d. Hanging a full day’s worth of formula at one time

RATIO: By reviewing the effects of a drug that was administered prior, the RATIO: The nurse must make sure that before feeding the patient via the
nurse here is employing the final step of the nursing process which is nasogastric tube, the nurse must properly position the head of the bed in an
evaluation. elevated position. With this position, the feeding will easily go down the tube
due to gravity.
6. A patient named Jasmine Allamudin is in the bathroom when Nurse Belle
enters to give a prescribed medication. What should the nurse in charge 13. Nurse Joy is going to administer a tablet via the sublingual route.
do? She should instruct her patient to place the tablet on the:

a. Wait for the patient to return to her bed then leave a. Inside of the cheek
the medication at her bedside. b. Floor of the mouth
b. Return shortly to the patient’s room and remain there until c. Roof of the mouth
the patient takes her medication. d. Top of the tongue
c. Tell the patient to be sure to take the medication and then leave
it at her bedside. RATIO: The sublingual route is under the tongue or also known as the floor of
d. Leave the medication at her patient’s bedside. the mouth. Drug administration inside of the cheek would be the buccal
route.
RATIO: This ensures that the patient is compliant by taking the medication at
the right time. The nurse must see to it that medications are really taken by 14. Which of the following best describes Kussmaul respirations?
the patients.
a. Increased rate and depth of breathing over a prolonged period of time. In
7. Dr. Rodrigo Robredo orders heparin, 7500 units, to be administered response to metabolic acidosis, the body's attempt to blow of f CO2 to
subcutaneously every 6 hours. The vial reads 10000 units per milliliter. buffer a fixed acid such as ketones.
Nurse Leni should anticipate giving how much heparin for each dose?
b. Gradual increase in volume and frequency, followed by a gradual
a. 0.25 ml decrease in volume and frequency, with apnea periods of 10 - 30 seconds
b. 0.5 ml between cycle.
c. 0.75 ml
c. Short episodes of rapid, deep inspirations followed by 10 - 30
d. 1.25 ml
second apneic period.
RATIO: Doctor’s order/Stock Dose x Quantity (in ml) 7500 units/10000 units x
d. Only able to breathe comfortable in an upright position (such as sitting in
1 ml = 0.75 ml (cancel out the units).
a chair), unable to breath laying down.
8. A patient named Panfilo dela Rosa is suffering from hypoxia. The
RATIO: Letter A best describes Kussmaul respirations. Letter B is
physician is most likely to order which of the following tests?
describing Cheyne-Stokes Respirations. Letter C is describing Biot’s
a. Arterial blood gas analysis respirations, while Letter D describes orthopnea.
b. Total hemoglobin and hematocrit
15. Doctor Rodrigo Robredo has ordered dextrose 5% in water, 1000 ml to
c. Chest X-ray
be infused over 8 hours. The I.V. tubing is delivering 15 drops per milliliter.
d. Complete blood count
Nurse Bong should run the infusion rate at:
RATIO: In order to totally know the patients O2 and CO2 levels in his blood
a. 15 drops per minute
the most accurate test to do this would be through ABG analysis. Choices B,
b. 21 drops per
C, and D will not measure the oxygen and carbon dioxide saturation in the
minute c. 31 drops
blood.
per minute
9. Nurse Ishbelle uses a stethoscope to auscultate a female patient’s chest. d. 125 drops per minute
Which statement about the stethoscope with the bell and the diaphragm
RATIO: volume in ml x drop factor = gtt/min
is true?
Time in hrs x 60 min
a. The bell detects thrills best
b. The bell detects high-pitched sounds best 1000 ml x 15 gtt/ml = 15000 gtts = 31.25 gtts/min

8 x 60 480 min
16. Which of the following is true about the working phase of the 22. Doctor Eren has ordered Nurse Misaka to administer cefuroxime
nurse- patient relationship? (Ceftin) 500 mg via IV bolus t.i.d to a patient with acute glomerulonephritis.
The nurse would expect to give the drug to be given
a. Obtain subjective data
b. Make the patient comfortable a. Twice a day
c. Greet the patient b. Thrice a day
d. Establish rapport c. Once a day
d. Four times a day
RATIO: Obtaining data is one of the things done in the working phase of the
nurse-patient relationship. The remaining choices are done during the RATIO: t.i.d. latin abbreviation for “ter in die” meaning three times a day.
orientation phase of the relationship. b.i.d. – “bis in die” – twice a day, o.d. – “omne in die” – once a day, q.i.d. –
“quater in die” – four times a day
17. Which of the following interventions is considered as a primary level
of prevention? 23. A physician orders 250 mg of an antibiotic suspension, the label on
the suspension reads “500 mg/5 ml” how much would the nurse
a. Using physical therapy to help the patient cope with above-
administer?
the- knee amputation.
b. Obtaining a breast biopsy to detect breast cancer a. 2.5 ml
c. Administering an anti-Hepatitis B immunization to an infant b. 5 ml
d. Administering Ceftriaxone (Rocephin) to a patient who c. 7.5 ml
has gonorrhea d. 10 ml

RATIO: Letter A is under tertiary level of prevention. Letter B and D is under RATIO: doctor’s order x quantity in ml = amount in ml
secondary level of prevention.
Stock dose
18. Nurse JM is tasked to do a nursing care plan in the ward. The
identification of actual or potential health problems is done during 250 mg x 5 ml = 2.5 ml
which step of the nursing process?
500mg
a. Assessment
b. Nursing diagnosis 24. A nurse is to administer 500 mg of a drug intramuscularly. The label on
c. Planning the multidose vial reads 250 mg/ml. How much of the medication would the
d. Implementation nurse prepare on the syringe?

RATIO: In the nursing diagnosis stage of the nursing process this is where a. 0.5 ml
the nurse identifies the problems of the patient and prioritizes them in what b. 1 ml
the nurse sees fit. c. 1.5 ml
d. 2 ml
19. A female patient named Mikasa Ackerman has been found to be
suffering from deep-vein thrombosis. Which nursing diagnosis should Nurse RATIO: doctor’s order x quantity in ml = amount in ml
Eren prioritize at this time?
Stock dose
a. Altered peripheral tissue perfusion related to venous congestion
500 mg x 1 ml = 2 ml
b. Risk for injury related to edema
c. Fluid volume excess related to peripheral vascular disease 250 mg
d. Impaired gas exchange related to decreased blood flow
25. When assessing for the liver functioning of a patient who is
RATIO: Due to the deep-vein thrombosis, there is an alteration in the receiving hepatotoxic drugs the nurse must check which of the
patient’s tissue perfusion resulting into the congestion of blood in the leg following?
veins of the patient. Since blood flow is obstructed, pooling of blood in the
lower extremities will occur. a. Blood urea nitrogen (BUN)
b. Creatinine clearance (CLcr)
20. Nurse Erina has found out that after giving proper interventions to c. Complete blood count
Soma who has fever brought about by meningitis, the patient’s fever has d. Alanine aminotransferase and aspartate aminotransferase
not subsided yet. She is revising patient Soma’s nursing care plan. During
which step of the nursing process does revision take place? RATIO: The presence of alanine aminotransferase and aspartate
aminotransferase would indicate liver damage. Choices A and B would
a. Nursing diagnosis indicate kidney problems. Letter C is not related to assessment of the liver in
b. Planning the lab.
c. Evaluation
d. Assessment

RATIO: During the evaluation step of the nursing process, the nurse SAS 3
determines whether the goals established in the care plan have been
achieved and evaluates the success of the plan. If a goal is unmet or partially 1. Which of the following statements by Nurse Stella is a great example of
met, the nurse reexamines the data and revises the plan. Assessment the therapeutic communication technique known as giving recognition?
involves data collection. Planning involves setting priorities, establishing
a. “I’m glad that you are already taking your medication. They
goals, and selecting appropriate interventions. Implementation involves
will help you a lot.”
providing actual nursing care.
b. “I can see that you have a new dress today and it seems that
21. A client named Kakashi has been prescribed diphenhydramine you have washed your hair.”
(Benadryl) for his allergies. He then contacts the nurse and complains of c. “I will sit beside you until it is time for your group session.”
drowsiness after taking the medication making it almost impossible for him d. “I’ve noticed that you did not attend the group session today.
to do his work. This is an example of Are you willing to talk about that?”

a. Drug synergism RATIO: This is a good example of the therapeutic communication technique
b. Side effect of giving recognition. Giving recognition acknowledges the patient and shows
c. First-pass effect awareness from the nurse. This type of therapeutic communication
d. Drug resistance technique avoids giving any judgment from the nurse.

RATIO: Side effect is a secondary, typically undesirable effect of a drug or 2. A client named Rodrigo De Lima tells the nurse, “Whenever I am furious,
medical treatment. Synergism, Synergy. An interaction between two or more I always get into a fistfight with my spouse, sometimes I punch my children
drugs that causes the total effect of the drugs to be greater than the sum of as well.” The nurse states, “I have observed you smiling while you talk about
the individual effects of each drug. A synergistic effect can be beneficial or domestic violence.” The therapeutic communication technique employed
harmful. The first pass effect (also known as first-pass metabolism or by the nurse is
presystemic metabolism) is a phenomenon of drug metabolism whereby the
a. Making observations
concentration of a drug, specifically when administered orally, is greatly
b. Formulating a plan of action
reduced before it reaches the systemic circulation. Antibiotic resistance
c. Providing general leads
happens when germs like bacteria and fungi develop the ability to defeat the
d. Exploring
drugs designed to kill them.
RATIO: The nurse in the situation has made an observation when she has
stated that the patient has smiled while talking about domestic violence. This
technique of making observations allows the patient to compare personal
perceptions with those of the nurse.
3. A client named Agot tells Nurse Jinky, “I feel awful because my mom d. “Tell me one of the wonderful things that has occurred to you
does not allow me to go back home after I am discharged from the this week.”
hospital.” Which response from Nurse Jinky is therapeutic?
RATIO: Focusing is a therapeutic communication that takes notice of a single
a. “Your mom sounds like she is an empathic person. I’ll help you thought or word and works with the client who is experiencing flight of
talk to her.” ideas or looseness of association.
b. “You feel that your mom will not allow you to return to
your home?” 10. A patient named Mocha tells the nurse, “You will not believe what my
c. “Why will you not speak this out with your mom? You father said to me during visiting hours. How dare he talk to me that way. I
may probably learn that she really does not feel that don’t deserve any of that.” Which would be the best response by the
way?” nurse?
d. “It’s somehow common for patients to have feelings like this
after long periods of being in the hospital.” a. “Describe to me what has occurred during your time with your
father.”
RATIO: The nurse is employing a therapeutic communication technique here b. “Why do you think your father has behaved that way?”
known as restatement. Restating is done to clarify the client's message by c. “What do you think is your role in this relationship with
repeating the same statement back to the client your father?”
d. “Does your father often treat you in that manner?”
4. Nurse Ronald is conducting an interview with a depressed patient.
Which statement from Nurse Ronald is a great example of giving general RATIO: This is a therapeutic communication known as exploring. The nurse
leads? employs this in order to explore more about what has occurred and for
the patient to talk more about her feelings about the incident with her
a. “I can see that and then?” father.
b. “Why are you feeling so depressed right now?”
c. “Can you give me the date and time we are currently in today?” 11. A patient named Bong is experiencing hallucinations and tells the
d. “You seem so tense right now.” nurse, “I can hear voices telling me to eat a lot of soap.” Which of the
following therapeutic communication skills must the nurse employ?
RATIO: Letter A is giving a general lead. Giving general leads allows the
patient to talk more about his current condition and feelings. a. Focusing
b. Seeking clarification
5. Nurse Roque has told his patient who will undergo a major surgery, c. Present reality
“Don’t worry, we’ve got some great doctors here at the hospital. You’ll be in d. Provide general leads
good shape once the operation is done.” The type of non-therapeutic
technique applied in the statement is RATIO: The nurse must employ the therapeutic communication technique
known as present reality whenever a patient is experiencing either a
a. Interrogation hallucination, illusion, or delusion.
b. Giving advice
c. False reassurance 12. When Nurse Martha visits a patient at home the patient tells her,
d. Defending “I haven’t slept during the last couple of nights.” Which of the
following statements from the nurse is therapeutic for the patient?
RATIO: The nurse’s statements in the situation portrays false
reassurance. Giving false reassurance indicates to the patient that there a. “I too have trouble sleeping
is no cause for anxiety therefore devaluing the patient’s feelings. sometimes.” b. “I see that you have
difficulty sleeping.”
6. A patient named Panfilo has had a left above-the-knee amputation after c. “Is that so?”
a motor vehicular accident. Upon regaining consciousness, the patient d. “I see.”
states, “What happened? I can’t recall anything.” What is the nurse’s initial
response? RATIO: The nurse is employing restatement as a therapeutic communication
skill in this situation. This type of skill assists the nurse in obtaining a more
a. “I think you will recall more about the incident as you get better.” specific perception of the problem of the patient.
b. “It was necessary to amputate your leg after the
accident.” c. “You were in a motor-vehicular accident last 13. Nurse Mona is assigned 4 patients in the infectious disease ward.
night.” Which of the following patients must Nurse Mona attend to first?
d. “Tell me what you think happened?”
a. A 54-year old male patient who is recently diagnosed to
RATIO: This is truthful and gives the patient information that may initiate have pulmonary tuberculosis
recollection about the accident. Letter A ignores the client’s question and is b. A 66-year old female patient who has community
non-therapeutic. Letter B is too blunt for an initial response to the patient; he acquired pneumonia
may not be ready to hear this at this time. Letter D is not necessary since the c. A 37-year old male patient who is diagnosed to have
client may feel frustration of trying to remember what has happened. Acquired Immunodeficiency Syndrome (AIDS)
d. A 24-year old female patient who is suspected to have
7. After giving anxiolytics, the patient says to Nurse Tina, “It seems that a streptococcus infection
you are too busy to stay with me.” How should nurse Tina respond?
RATIO: The nurse must prioritize seeing patients who are
a. “You’ll feel better after I’ve given you the medication.” immunocompromised first. This avoids the transmission of infection from one
b. “You will be able to sleep after the drug starts to take effect.” patient to another.
c. “I have to attend to other patients, however, I will be back after
10 minutes.” 14. A 7-year old child recently had German measles or rubella. Being
d. “I apologize but I need to attend to other patients in the ward.” immune to rubella after having the disease would be

RATIO: This response demonstrates that the nurse shows care to her patient a. Natural active acquired immunity
and will make sure to have time for the patient’s emotional needs. This b. Artificial active acquired immunity
approach allays the patient’s anxiety and reduces stress. c. Natural passive acquired immunity
d. Artificial passive acquired immunity
8. A patient named Historia seems tense and anxious during a nurse-
client interaction, which nursing statement belittles the patient’s feelings RATIO: If a patient gains immunity after being exposed to a certain disease
and concerns? such as measles, mumps, chicken pox, and rubella. This process is known as
natural active acquired immunity. Letter B example would be having
a. “You seem to be assuming a lot of things.” immunizations. Letter C example would be the infant obtaining antibodies
b. “I have observed that you are biting your nails again.” from the mother through breastfeeding. Letter D would be acquiring
c. “You seem anxious today.” antibodies from animal sources.
d. “Come on, I know you can do better than that.”
15. Nurse Susan is currently assigned to the medical ward. She is tasked
RATIO: This nursing statement is an example of a non-therapeutic to properly practice the proper isolation techniques. Which of the
communication known as belittling feelings. This occurs if the nurse following patients should Nurse Susan place in reverse isolation?
misjudges the degree of the client’s discomfort showing a lack of empathy.
a. A 45-year old patient who is suffering from pneumonia
9. Which of the following statements from Nurse Katrina shows a b. A 28-year old patient who is diagnosed with acute
good example of focusing? myelogenous leukemia
c. A 33-year old patient who has a diabetic foot
a. “You mentioned growing up with your mother. Let’s discuss d. A 55-year old patient who is suffering from
that further.” pulmonary tuberculosis
b. “Your time with me today is for an hour. I’ll stay with you
until then.” RATIO: Patients who have leukemia are immunocompromised. The
c. “I’m finding it hard to understand what you mean.” nurse must practice reverse isolation techniques in order to prevent the
patient from having an infection.
16. A patient named Bato who has an infected wound of the head is RATIO: Human chorionic gonadotropin is a hormone produced primarily by
positive for methicillin-resistant staphylococcus aureus. Nurse Chel must syncytiotrophoblastic cells of the placenta during pregnancy. The hormone
practice which of the following? stimulates the corpus luteum to produce progesterone to maintain the
pregnancy
a. Standard precautions
b. Respiratory isolation 2. With this pregnancy, Aling Nena is a
c. Reverse isolation
d. Contact Isolation a. P3 G3
b. Primigravida
RATIO: Contact or Body Substance Isolation (BSI) involves the use of barrier c. P3 G4
protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) d. P0 G3
whenever direct contact with any bodily fluid is expected. When determining
the type of isolation to use, one must consider the mode of transmission. The RATIO: Para/parity (P) means number of births after 20 AOG. She has had 3
hands of personnel continue to be the principal mode of transmission for children and 1 current pregnancy. Gravida (G) indicates the number of
methicillin resistant staphylococcus aureus (MRSA). pregnancies that the mother has had no matter what the outcome of the
pregnancy is. She is currently pregnant so her Gravida is at G4. P3G4
17. Nurse Joyce is teaching the community the best way to prevent the
transmission of infection. This is best done by teaching which of the 3. In explaining the development of her baby, you identified in
following to the community? chronological order of growth of the fetus as it occurs in pregnancy as

a. Proper wearing and using face a. Ovum, embryo, zygote, fetus, infant
masks b. Hand hygiene b. Zygote, ovum, embryo, fetus,
c. Cleaning the surroundings infant c. Ovum, zygote, embryo,
d. Eating nutritious food fetus, infant
d. Zygote, ovum, fetus, embryo, infant
RATIO: Handwashing is the best practice to eliminate the transmission of
infection. Various microorganisms are eliminated with proper hand hygiene. RATIO: The ovum is the female sex cell produced by the ovaries. A zygote is
the union of the sperm cell and the egg cell. Also known as a fertilized ovum,
18. Nurse Jessie is currently adhering to the principles of medical asepsis the zygote begins as a single cell but divides rapidly in the days following
when performing patient care in the hospital setting. Which nursing fertilization. After this two-week period of cell division, the zygote eventually
action performed by the nurse follows these recommended guidelines? becomes an embryo. If this goes well, the embryo becomes a fetus. Once the
fetus is born, it will now be known as the infant.
a. The nurse carries the patient’s soiled bed linens close to the
body to prevent spreading microorganisms into the air. 4. When teaching Aling Nena about her pregnancy, you should include
b. The nurse places soiled bed linens and hospital gowns on the personal common discomforts. Which of the following is an indication
floor when making the bed. for prompt professional supervision?
c. The nurse moves the patient table away from the nurse’s
body when wiping it off after a meal. a. Constipation and hemorrhoids
d. The nurse cleans the most soiled items in the patient’s b. Backache
bathroom first and follows with the cleaner items. c. Facial edema
d. Frequency of urination
RATIO: This prevents the transmission of infection if objects are held away
from the nurse’s body. Choices A, B, and D do not follow the recommended RATIO: Choices A, B, and D are common discomforts during pregnancy that
guidelines of medical asepsis. can be easily avoided or attended to by the mother. Choice C however is an
indication that the mother may have pregnancy induced hypertension and
19. A 44-year old female is recently diagnosed to have pulmonary needs immediate professional help.
tuberculosis. She is currently undergoing treatment at the DOTS center.
The nurse assigned to her must know that the tubercle bacilli is 5. Which of the following statements would be appropriate for you to
transmitted in which of the following? include in Aling Nena’s prenatal teaching plan?

a. Airborne a. Exercise is very stressful, it is not recommended

b. Contact b. Limit your food intake to vegetables only
c. Droplet c. Alcohol has no harmful effects on the fetus
d. All of the above d. Avoid unnecessary fatigue, rest periods should be included in
your schedule
RATIO: The most frequent means of transmission of the tubercle bacillus is by
droplet nuclei. The bacillus is present in the air as a result of coughing, RATIO: Exercises are still needed during pregnancy, especially pelvic muscle
sneezing, and expectoration of sputum by an infected person. exercises in order to facilitate easy delivery. The mother should never limit
her food intake to vegetables only since she needs other sources of food that
20. Nurse Naya is teaching the community about the importance of hand is rich in protein and other nutrients. Alcohol can have a harmful effect on
hygiene. Which component of hand washing should the nurse include that the fetus which can cause fetal alcohol syndrome. Letter D is the correct
is most important for removing microorganisms? answer, unnecessary fatigue can stress the mother especially if the mother is
working, this can sometimes have an effect on pregnancy. Rest periods
a. Friction
should always be included.
b. Water
c. Time SITUATION: Nurse Dina is assigned at the City Health Office to teach
d. Soap contraception to Mang Jess and Aling Sion who are respectively 35 and 34
years old. The couple has had 4 children and has decided to use
RATIO: Friction is necessary for the removal of microorganisms. Although
contraceptives. The couple seems interested in both the artificial methods
water flushes some microorganisms from the skin, without friction it has
and surgical methods of contraception.
minimal value. Although the length of time the hands are washed is
important, without friction it has minimal value. Although soap reduces 6. Aling Sion asks Nurse Dina about the details of bilateral tubal ligation.
surface tension, which helps remove debris, without friction it has minimal Which of the following information is NOT true with regard to bilateral
value. tubal ligation?

a. It is a surgical procedure that can be done through laparoscopy.

b. It is a surgical procedure that creates a temporary
SAS 4
contraception
SITUATION: Aling Nena, a 32-year-old fish vendor from Barangay Carael or sterilization that can be easily reversed in the future.
came to see you at the prenatal clinic. She brought with her all her three c. There is a risk of ectopic pregnancy albeit a rare occurrence
children. Feliza, 1 year 6 months; Loreta, 3 and Voltaire, 7 years old. She d. No other contraceptive methods will be used once the
mentioned that she stopped taking oral contraceptives several months ago female undergoes the minor surgery.
and now suspects she is pregnant. She cannot remember her LMP.
RATIO: Choices A, C, and D are correct information regarding BTL. Letter B is
1. Which hormone is necessary for a positive pregnancy test? incorrect since it is not really a temporary form of contraception. Reversal
of BTL is difficult and very inconvenient on the part of the mother.
a. Progesterone
b. Human chorionic gonadotropin 7. Mang Jess on the other hand wants information about vasectomy. Which
c. Estrogen of the following is NOT true regarding vasectomy?
d. Lactogen
a. A vasectomy can be done in an ambulatory setting, such as in
a primary health care clinic.
b. The man may experience a small amount of local pain afterward,
which can be managed by taking a mild analgesic and applying
ice to the site.
 c. The male can have unprotected sex with his spouse RATIO: For women who are under 35 years of age, only one or two fertilized
immediately after the surgery has been done. ova are chosen and transferred back to her uterine cavity through the
d. The surgical procedure is about 99.5% effective. cervix by means of a thin catheter. If the woman is more than 40 years of
age up to five embryos may be transferred.
RATIO: Choice A, B, and D are correct. Letter C is wrong since the husband
needs to have 20 ejaculations before engaging in unprotected sex with his 14. Why is progesterone or luteinizing hormone prescribed to a woman
spouse. The male should wear a condom first if he wants to engage in sexual after undergoing IVF?
intercourse with his spouse during the next 20 ejaculations post-vasectomy.
a. Due to the blockage of the fallopian tubes
8. During the discussion about oral contraceptive pills Aling Sion asked b. Hormonal imbalances brought about by the procedure
Nurse Dina, “What do I do if I forget to take an oral contraceptive pill?” c. The corpus luteum can be injured by the aspiration of the follicle
Nurse Dina must reply which of the following? d. Due to cysts growing on the mother’s ovaries

a. “If the pill omitted was one of the placebo ones, ignore it and RATIO: One of the common occurrences in aspirating ova from the female’s
just take the next pill on time the next day.” ovaries is that the needle tends to rupture the corpus luteum which is
b. “If you forgot to take one of the active pills, take it as soon as responsible for producing progesterone.
you remember. Continue the following day with your usual pill
schedule. Missing one pill this way should not initiate ovulation.” 15. Prior to aspiration of ova from the female, which of the following
c. “If you miss two consecutive active pills, take two pills as soon hormones will be given to the woman 1 month prior to the
as you remember. Then, continue the following day with your procedure?
usual schedule. You may experience some vaginal spotting with
two forgotten pills.” a. Follicle-stimulating hormone
d. All of the above b. Luteinizing hormone
c. Estrogen
RATIO: All of the choices are true based on Adele Pilliteri’s Maternal and d. Human chorionic gonadotropin hormone
Child Health Nursing.
RATIO: 1 month prior to the procedure, the woman is given FSH to stimulate
9. The couple has finally chosen the intrauterine device as a method of oocyte growth. Beginning, about the 10th day of the menstrual cycle, the
contraception. Nurse Dina must inform Aling Sion of which of the ovaries are examined daily by sonography to assess the number and size of
following? developing oocytes.

a. Breast tenderness after insertion of the IUD SITUATION: Aling Leni, a 33-year old mother came to the health center for
b. Vaginal discoloration 1 week after insertion of the IUD her prenatal check-up. She is currently in her second trimester of her
c. Amenorrhea for 6 months after the insertion of the IUD pregnancy, at about 22 weeks’ age of gestation with a score of P2G4.
d. Vaginal spotting and uterine cramping during the first 2 or 3
weeks after IUD insertion. 16. Upon interview, Aling Leni told Nurse Kristine that she can feel
fetal movements. Nurse Kristine that the fetal movements can be felt
RATIO: The most common discomfort the female can have related to IUD is by the mother as early as
Letter D. Choices B, C, and D are not related with IUD usage.
a. 12-15 weeks AOG
10. Aling Sion asks Nurse Dina, “How long should I be having the b. 16-20 weeks AOG
intrauterine device?” Nurse Dina must tell Aling Sion that the effectiveness c. 21-25 weeks AOG
of the Copper T380 IUD is at around d. 8-11 weeks AOG

a. 10 years RATIO: Fetal movements may be felt by a pregnant woman as early as 16-20
b. 5 years weeks of pregnancy. An objective examiner can discern fetal movements at
c. 3 years about the 20th to 24th week of pregnant unless the woman is extremely
d. 6 months obese.

RATIO: Copper T380 is effective for 10 years. The Levonorgestrel-releasing 17. Nurse Kristine began assessing Aling Leni’s pregnancy. Which of
intrauterine device system 52 mg (Mirena) IUD is effective for 5-7 years. The the following findings would indicate a positive pregnancy?
Levonorgestrel-releasing intrauterine system 13.5 mg (Skyla) is effective for 3
years. The Levonorgestrel-releasing intrauterine system 19.5 mg (Kyleena) is a. Linea nigra that has formed on the mother’s abdomen
effective for 5 years. b. Goodell’s sign
c. Fetal movements felt by the mother
SITUATION: Rodrigo a 35-year-old male and Leni a 33-year-old female are d. Fetal heart tone heard by the nurse through the stethoscope
visiting a fertility clinic. The couple has mentioned that they have been
married for 7 years and have been trying since then to conceive a child. RATIO: There are only 3 positive signs of pregnancy. Fetal movements
They have always been unsuccessful. It was found out that the female detected by the health care worker; fetal heart tone is audible, sonographic
has obstructed fallopian tubes. The physician has recommended the evidence of fetal outline.
couple to undergo in vitro fertilization (IVF).
18. Nurse Kristine has told Aling Leni about the importance of taking folic
11. The nurse must know that the process of in vitro fertilization acid supplements. Aling Leni asks the significance of taking these
involves which of the following procedures? supplements.
Nurse Kristine must state that
a. Oophorectomy
b. Laparoscopy a. Folic acid prevents the occurrence of mental retardation in
c. Salpingectomy the fetus
d. Drug therapy b. Folic acid prevents iron deficiency anemia in the pregnant
mother c. Folic acid prevents neural tube defects from developing
RATIO: Laparoscopy is utilized to obtain one or more oocytes from the in the
woman’s ovary and fertilized by exposure to sperm in a laboratory. fetus
d. Folic acid prevents gestational diabetes in the mother
12. How many hours after fertilization will the laboratory-grown zygotes
be inserted into the woman’s uterus? RATIO: Folic acid prevents the development of neural tube defects in the
fetus such as spina bifida occulta, meningocele, and myelomeningocele. To
a. 12 hours prevent iron-deficiency anemia which is a common problem during
b. 24 hours pregnancy, she must be prescribed iron supplements.
c. 48 hours
d. 40 hours 19. Aling Leni has observed that there was a change in the color of her
vagina which went from pink to violet. Which of the following statements by
RATIO: By 40 hours after fertilization, the fertilized ovum will have undergone Nurse Kristine is correct with this finding?
their first cell division. This is the perfect time to insert the zygotes into the
mother’s uterus. a. “It is a normal occurrence during pregnancy known as
Chadwick’s sign.”
13. Based on the information above, how many fertilized eggs will be b. “It is a normal occurrence during pregnancy known as
inserted in the woman’s uterus? Goodell’s sign.”
c. “It is a normal occurrence during pregnancy known as
a. 1 only
Hegar’s sign.”
b. 1-2 fertilized ova
d. “It is a normal occurrence during pregnancy known as
c. 3-4 fertilized ova
Braxton- Hicks’ sign.”
d. Up to 5 fertilized ova may be transferred
RATIO: Chadwick’s sign is the color change of the vagina from pink to violet.
Goodell’s sign is softening of the cervix. Hegar’s sign is the softening of the
lower uterine segment. Braxton-Hicks contractions are periodic uterine
tightening.
20. Which of the following is TRUE with regard to Aling Leni’s collection of blood) found between the skull and periosteum of a
psychological change during her second trimester of her pregnancy? newborn baby as a result of birth trauma. Craniosynostosis is a birth
defect in which the bones in a baby's skull join together too early.
a. The woman and her partner both spend time recovering from
the surprise of learning that they are pregnant and concentrate 5. For this newborn who is experiencing birth asphyxia, which of
on what it feels like to be pregnant. the following would be the most appropriate nursing diagnosis?
b. The woman and her partner move through emotions such as
narcissism and introversion as they concentrate on what it a. Imbalanced nutrition: less than body requirements
feels like to be a parent. b. Risk for hypothermia
c. The woman and her partner prepare clothing and sleeping c. Ineffective breathing
arrangements for the baby but also grow impatient as they pattern d. Impaired gas
ready themselves for birth. exchange
d. The woman has a common reaction of ambivalence, or
feeling both pleased and not pleased about the pregnancy. RATIO: Letters A and B are not a priority in birth asphyxia. Although letter C is
somehow correct this is not the root of the problem in birth asphyxia. Letter
RATIO: Letter B is known as “accepting the fetus.” Letter A and D is true D is the correct answer since this condition of impaired gas exchange or
during the first trimester of the pregnancy; this is known as “accepting the inadequate blood flow will eventually lead to persistent hypoxemia and
pregnancy”. Letter C is true during the third trimester of pregnancy, this is hypercarbia that occurs in temporal proximity to labor (peripartum) and
known as “Preparing for the baby and end of pregnancy.” delivery (intrapartum).

SITUATION: Rhea, a 32-year-old primigravida at 39-40 weeks AOG was

admitted to the labor room due to hypogastric and lumbo-sacral pains.
SAS 5 Internal examination revealed a fully dilated, fully effaced cervix. Station 0.

SITUATION: Baby James, an 8-hour old newborn is admitted to the NICU 6. She is immediately transferred to the DR table. Which of the
because of a low APGAR Score. His mother had a prolonged second stage of following conditions signify that delivery is near?
labor.
a. A desire to defecate
1. Which of the following is the most important concept associated with b. Begins to bear down with uterine contraction
all high-risk newborn? c. Perineum
bulges d. All of
A. Support the high-risk newborn's cardiopulmonary adaptation
the above
by maintaining adequate airway
B. Identify complications with early intervention in the high- RATIO: A woman near labor experiences desire to defecate because of the
risk newborn to reduce morbidity and mortality pressure of the fetal head that forces the stool out from the anus. She cannot
C. Assess the high-risk newborn for any physical complications help but bear down with each of the contractions and as crowning occurs,
that will assist the parent with bonding The perineum bulges. A woman with a 50 second contraction is still at the
D. Support mother and significant others in their request ACTIVE PHASE labor [40 to 60 seconds duration, 3 to 5 minutes interval]
toward adaptation to the high-risk newborn Women who are about to give birth experience 60-90 seconds contraction
occurring at 2-3 minutes interval.
RATIO: The 3 major and initial and immediate needs of newborns both
normal and high risks are AIR/BREATHING, CIRCULATION and TEMPERATURE. 7. Artificial rupture of the membrane is done. Which of the following
C and D are both eliminated because they do not address the immediate nursing diagnoses is the priority?
newborn needs. Identifying complications with early intervention is
important, however, this does not address the IMMEDIATE and MOST a. High risk for infection related to membrane
IMPORTANT newborn needs. rupture b. Risk for injury related to prolapsed cord
c. Alteration in comfort related to increasing strength of
2. Which of the following would the nurse expect to find in a newborn uterine contraction
with birth asphyxia? d. Anxiety related to unfamiliar procedure
A. Hyperoxemia RATIO: In any case that INFECTION was one of the choices, remove it as soon
B. Acidosis as you see it in ALL CASES during the intra and preoperative nursing care.
C. Hypocapnia Infection will only occur after 48 hours of operation or event. B is much more
D. Ketosis immediate and more likely to occur than A, and is much more FATAL.

RATIO: Birth Asphyxia is a term used to describe the inability of an infant to 8. Rhea complains of severe abdominal pain and back pain during
maintain an adequate respiration within 1 minute after birth that leads to contraction. Which two of the following measures will be MOST effective
acidosis, hypoxia, hypoxemia and tissue anoxia. This results in Hypercapnia in reducing pain?
not Hypocapnia due to the increase in carbonic acid concentration in the
fetal circulation because the carbon dioxide fails to get eliminated from the a. Rubbing the back with a tennis ball and effleurage
infant's lungs because of inadequate respiration. Ketosis is the presence of b. Guided imagery
ketones in the body because of excessive fat metabolism. This is seen in c. Proper breathing techniques
diabetic ketoacidosis. d. Offer warm compresses

3. When planning and implementing care for the newborn that has RATIO: B Imagery is not used in severe pain. This is labor pain and the mother
been successfully resuscitated, which of the following would be will never try to imagine nice and beautiful scenery with you at this point
important to assess? because the pain is all encompassing and severe during the transition phase
of labor. Remove C because breathing techniques is not a method to
A. Muscle flaccidity ELIMINATE PAIN but a method to reduce anxiety, improve pushing and
B. Hypoglycemia prevent rapid expulsion of the fetus during crowning. warm compresses also
C. Decreased intracranial pressure are not effective in severe pain felt during labor.
D. Spontaneous respiration
9. Lumbar epidural anesthesia is administered. Which of the following
RATIO: There is no need to assess for spontaneous respiration because OF nursing responsibilities should be done immediately following
the word SUCCESSFULLY RESUSCITATED. What is it to assess is the quality and procedure?
quantity of respiration. Infants who undergo tremendous physical challenges
during birth like asphyxia, prolonged labor, RDS are all at high risk for a. Reposition from side to side
developing hypoglycemia because of the severe depletion of glucose stores b. Administer oxygen
to sustain the demands of the body during those demanding times. c. Increase IV fluids as indicated
d. Assess for maternal hypotension
4. When assessing the head of the newborn’s head, the nurse has
observed swelling and the appearance of the head is as though it appears RATIO: Hypotension is one of the side effects of an epidural anesthesia. An
like a cone. Which of the following terms must the nurse note on her epidural anesthesia is injected on the L3 - L4 or L4 - L5 area. The injection lies
chart? just above the dura and must not cross the dura [spinal anesthesia crosses
the dura]. Nursing intervention revolves in assessing RR, BP and other vital
a. Caput succedaneum signs for possible complications and side effects. There is no need to position
b. Molding the client from side to side, the preferred position during the transition phase
c. Cephalhematoma of labor is LITHOTOMY. Oxygen is not specific after administration of an
d. Craniosynostosis epidural anesthesia. IV fluid is not increased without doctor's order.
RATIO: Caput succedaneum is a type of swelling around the skull, which can 10. Which is NOT the drug of choice for epidural
give an infant a “conehead” appearance. When a baby is born in a head-
first position, pressure on the head in the birth canal may mold the head anesthesia? a. Sensorcaine
into an oblong shape. A cephalhematoma or cephalohematoma is a b. Xylocaine
hemorrhage (a c. Ephedrine
d. Marcaine
RATIO: A, B and D are all drugs of choice for epidural anesthesia. Ephedrine is lasts at around 3 hours in primis and 2 hours in multis. Effacement of 100% is
the drug used to reverse the symptom of hypotension caused by epidural a characteristic of the TRANSITION PHASE as well as being self-focused.
anesthesia. It is a sympathomimetic agent that causes vasoconstriction,
bronchodilation [in asthma] and can increase the amount of energy and SITUATION: Baby boy Berlin was delivered spontaneously following a term
alertness. pregnancy. Apgar scores are 8 and 9 respectively. Routine procedures are
carried out.
SITUATION: Mocha, a 27-year-old mother is at G4P3 at full term gestation is
brought to the ER after a gush of fluid passes through her vagina while 16. When is the APGAR Score taken?
shopping at the supermarket.
a. Immediately after birth and at 30 minutes after birth
11. Mocha is brought to the emergency room. The fetal heart tone (FHT) is b. At 5 minutes after birth and at 30 minutes after
noted to be 116 beats per minute. Which of the following actions should birth c. At 1 minute after birth and at 5 minutes
the nurse do first? after birth
d. Immediately after birth and at 5 minutes after birth
a. Monitor FHT every 15 minutes
b. Administer oxygen inhalation RATIO: APGAR score taken 1 minute after birth determines the initial
c. Ask the charge nurse to notify the status of the newborn while the 5-minute assessment after birth
obstetrician d. Place her on the left lateral position determines how well the newborn is adjusting to the extra uterine life.

RATIO: Remove A. An FHR of 114 bpm is 6 beats below normal. Though 17. The best way to position a newborn during the first week of life is to
monitoring is continuous and appropriate, this is not your immediate action. lay him
B, Oxygen inhalation needs doctor's order and therefore, is a DEPENDENT
nursing action and won't be your first option. Although administration of a. Prone with head slightly elevated
oxygen by the nurse is allowed when given at the lowest setting during an b. On his back, flat
emergency situation. C is appropriate, but should not be your IMMEDIATE c. On his side with his head flat on bed
action. The best action is to place the client on the LEFT LATERAL POSITION to d. On his back with head slightly elevated
decrease the pressure in the inferior vena cava [ by the gravid uterus] thereby
RATIO: Sudden infant death syndrome occurs when the fetus is in a prone
increasing venous return and giving an adequate perfusion to the fetus. Your
position. Knowing this will allow you to eliminate A first. During the first week
next action is to call and notify the obstetrician. Remember to look for an
of life, the fetus has an immature cardiac sphincter and musculature for
independent nursing action first before trying to call the physician.
swallowing, knowing this will let you eliminate B. Side lying position is the
12. Nurse Jhunela checks the perineum of Mocha. Which of the best position for a neonate during the first few weeks of life. This will
following characteristics of the amniotic fluid would cause an alarm to decrease the risk of aspiration of secretion.
the nurse?
18. Baby boy Berlin has large sebaceous glands on his nose, chin,
a. Greenish and forehead. These are known as
b. Scanty
a. Milia
c. Colorless
b. Lanugo
d. Blood tinged
c. Hemangiomas
RATIO: A greenish amniotic fluid heralds’ fetal distress not unless the fetus is d. Mongolian spots
in breech presentation and pressure is present on the bowel. Other colors
RATIO: Newborn sebaceous glands are sometimes unopened or plugged.
that a nurse should thoroughly evaluate are: Tea colored or strong yellow
They are called MILIA. They will disappear once the gland opens at around 2
color that indicates hemolytic anemia as in RH incompatibility.
weeks after delivery. They are characterized by a pinpoint white papule.
13. Mocha asks nurse Jhunela, "Why do I have to be on complete bed rest? I Lanugo is the fine hair that covers the newborn. It disappears starting 2
am not comfortable in this position." Which of the following responses of weeks after birth. A premature infant has more lanugo than a post mature
the nurse is most appropriate? infant. Hemangiomas are vascular tumors of the skin. Mongolian spots are
patches that are gray in color and are often found in sacrum or buttocks.
a. Keeping you on bed rest will prevent the possibility of They disappear as the child grows older.
cord prolapse
b. Completed bed rest will prevent more amniotic fluid to escape 19. Baby boy Berlin must be carefully observed for the first 24 hours for?
c. You need to conserve your energy so you will be strong enough
a. Respiratory distress
to push later during the delivery
b. Duration of cry
d. Let us ask your obstetrician when she returns to check on you
c. Frequency of voiding
RATIO: Once the membrane ruptures, as in the situation of alpha, the d. Range in body temperature
immediate and most appropriate nursing diagnosis is risk for injury related
RATIO: Range in body temperature needs to be observed and carefully
to cord prolapse. Keeping the client on bed rest is one of the best
monitored for the first 24 hours after delivery. A newborn has an inadequate
interventions in preventing cord prolapse. Other interventions are putting
and immature temperature regulating mechanism. RDS is observed
the client in a modified T position or Knee chest position. Once the amniotic
immediately after delivery, not in a continuous 24-hour observation. Once
fluid escapes, it is allowed to escape. Although bed rest does save energy, it
the fetus establishes a normal breathing pattern it is not anymore of a
is not the most appropriate response why bed rest is prescribed after
concern. RDS occurs when the Surfactants are absent or insufficient. The
membranes have ruptured. Not answering the client's question now will
adequacy of these surfactants is measured by the L:S ratio [Lecithin:
promote distrust and increase client's anxiety. It will also make the client
Sphingomyelin] An L:S ratio of 2:1 is considered mature and adequate to
think that the nurse is incompetent for not knowing the answer.
sustain fetal lung expansion and ventilation. Therefore, a child born without
14. Mocha wants to know how many fetal movements per hour is RDS is unlikely to have RDS in 24 hours.
normal, the correct response of nurse Jhunela would be
20. According to the WHO, when should the mother start breastfeeding
a. Twice the infant?
b. Thrice
a. Within 30 minutes after birth
c. Four times
b. Within 12 hours after birth
d. 10-12 times
c. Within a day after birth
RATIO: According to Sandovsky, to count for the fetal movement, Mother is d. After infant’s condition establishes
put on her LEFT SIDE to decrease placental insufficiency. This is usually done
RATIO: According to the WHO, the mother should start breastfeeding her
after meals. The mother is asked to record the number of fetal movements
infant within 30 minutes after birth.
per hour. A fetus moves Twice every 10 minutes and 10 to 12 times an hour.

15. Upon examination by the obstetrician, he charted that Mocha is in

the early stage of labor. Which of the following is true in this state? SAS 6
a. Self-focused 1. A client, 12 weeks’ gestation, comes to the prenatal clinic complaining of
b. Effacement is 100% severe nausea and frequent vomiting. The nurse suspects that this client
c. Lasts for 2 hours has hyperemesis gravidarum and knows that this is frequently associated
d. Cervical dilatation of 1-3 cm with
RATIO: The earliest phase of labor is the first stage of labor: latent phase a. Excessive amniotic fluid
characterized by a cervical dilation of 0-3 cm, Mild contraction lasting for 20 b. A GI history of cholecystitis
to 40 seconds. This lasts approximately 6 hours in primis and 4.5 hours in c. High levels of chorionic gonadotropin hormone
multis. C is the characteristic of ACTIVE PHASE of labor, Characterized by a d. Slowed secretion of free hydrochloric acid
cervical dilation of 4-7 cm and contractions of 40 to 60 seconds. This phase
RATIO: The usual findings for a woman suffering from hyperemesis placenta is situated at the lower aspect of the uterus. A hydatidiform mole is
gravidarum is having high levels of serum HCG. Normal level at around 12 growth of an abnormal fertilized egg or an overgrowth of tissue from the
weeks’ gestation should be at 25,700–288,000 mIU/mL. placenta. Women appear to be pregnant, but the uterus enlarges much more
rapidly than in a normal pregnancy. Most women have severe nausea and
2. A client in the thirty-third week of pregnancy begins to experience
vomiting, vaginal bleeding, and very high blood pressure. Endometriosis is an
contractions. She is to be treated at home with bed rest. The teaching
often-painful disorder in which tissue similar to the tissue that normally lines
plan for this client should include the information that the client
the inside of your uterus — the endometrium — grows outside your uterus.
a. Needs to have the foot of the bed raised on blocks
8. Which of the following would be the initial action of a nurse to a
b. Needs to sit in bed with several large pillows supporting her
mother who is suffering from abruptio placenta?
back c. Should be placed on her side with her head raised on a
small a. Monitor for contractions
pillow b. Obtain baseline vital signs and measure the abdominal girth
d. Should assume the knee-chest position every 2 hours for c. Monitor fetal heart tone
10 minutes while awake d. Measure the urine output of the mother

RATIO: Placing the mother on the side will help prevent hypotension. Also RATIO: The initial nursing action should always be assessment which should
advise the mother not to lie flat on her back since this can increase the be Letter B. Obtaining baseline information and measuring the abdominal
contractions. girth is important in order to compare later results and changes. The nurse
should always follow the steps in the nursing process.
3. In the fifth month of pregnancy, ultrasonography is performed on a client.
The results indicate that the fetus is small for gestational age and there is 9. Abruptio placenta is most likely to occur in a woman with
evidence of a low-lying placenta. The nurse would use this information in
the last trimester of pregnancy by assessing the client for signs of possible a. Cardiac disease
b. Hyperthyroidism
a. Placenta previa c. Cephalopelvic disproportion
b. Premature labor d. Pregnancy-induced hypertension
c. Abruptio placenta
d. Precipitate delivery RATIO: High blood pressure during pregnancy can affect the development of
the placenta, causing the nutrient and oxygen supply to the baby to be
RATIO: Placenta Previa is a condition where the placenta lies low in the limited. This can lead to an early delivery, low birth weight, placental
uterus and partially or completely covers the cervix. Preterm labor occurs separation (abruption) and other complications for the baby.
when regular contractions result in the opening of your cervix after week 20
and before week 37 of pregnancy. Abruptio placentae is defined as the 10. The nurse must anticipate for which of the following complications of
premature separation of the placenta from the uterus. Precipitate delivery the blood that may occur after abruption placenta?
refers to childbirth after an unusually rapid labor (combined 1st stage and
second stage duration is under two hours) and culminates in the rapid, a. Thrombosis
spontaneous expulsion of the infant. b. Disseminated intravascular coagulation
c. Cerebrovascular accident
4. A client experiences an episode of painless vaginal bleeding during the d. Deep vein thrombosis
last trimester. The nurse realizes that this may be caused by
RATIO: The DIC syndrome is the most common cause of an abnormal
a. Placenta previa hemorrhage tendency during pregnancy and the puerperium and reflects
b. Abruptio placenta systemic activation of the coagulation cascade by circulating thromboplastic
c. Frequent intercourse material, with secondary activation of the fibrinolytic system
d. Excessive alcohol ingestion
11. The first assessable objective sign of a seizure in a client with eclampsia
RATIO: One of the signs of placenta previa is painless vaginal bleeding during is frequently
the last trimester. Abruptio placenta on the other hand has a sign of painful
and often concealed bleeding. Choices C and D do not cause vaginal bleeding. a. Epigastric pain, nausea, and vomiting
b. Persistent headache and blurred vision
5. The care of a client with placenta previa includes c. Spots or flashes of light before the
eyes
a. Vital signs at least once per shift d. Rolling of the eyes to one side with a fixed stare
b. A tap-water enema before delivery
c. Observation and recording of the RATIO: One of the common auras of seizure in women who have PIH would
bleeding d. Limited ambulation until be visual disturbances such as spots or flashes of light before the eyes of the
bleeding stops mother. A and B are not signs of an impending seizure. While letter D is
already a sign of seizure (petit mal).
RATIO: Most women diagnosed with placenta previa require bed rest
and limited activity to prevent bleeding. That may include avoiding 12. Which of the following would be the definitive treatment for
exercise or sexual activity for the duration of the pregnancy. pregnancy- induced hypertension?

6. A client is admitted with the diagnosis of possible placenta previa. a. Oral antihypertensives
Following the physician’s orders, the nurse starts IV fluids, administers b. Magnesium sulfate
oxygen, and draws blood for laboratory tests. The client’s apprehension is c. Diuretics
increasing and she asks the nurse what is happening. The nurse tells her d. Delivery
not to worry, that she is going to be alright, and everything is under control.
The nurse’s statements are RATIO: PIH only occurs once the woman becomes pregnant. After the
delivery of the woman’s child all signs and symptoms of PIH are going to
a. Adequate, since all preparations are routine and need disappear.
no explanation
b. Proper, since the client’s anxieties would be increased if 13. When giving magnesium sulfate to a severely preeclamptic mother who
she knows the dangers is at 25 weeks AOG, the nurse must prepare which of the following
c. Correct, since only the physician should explain why medications at the bedside in case magnesium toxicity occurs?
treatments are being done
a. Potassium chloride
d. Questionable, since the client has the right to know
b. Aluminum
what treatment is being given and why
hydroxide c. Calcium
RATIO: The communication technique used by the nurse is non-therapeutic gluconate
because she is doing self-reassurance. The patient also has the right to know d. Spironolactone
why the treatment is being done.
RATIO: Calcium gluconate is the antidote for magnesium toxicity. The nurse
7. A client comes to the clinic for a sonography at 36 weeks’ gestation. must watch out for signs of symptoms of magnesium toxicity such as
Before the test begins, the client complains of severe abdominal pain. Heavy diarrhea, nausea and vomiting, lethargy, and muscle weakness.
vaginal bleeding is noted and the client’s BP drops while her pulse rate
14. Which of the following assessment findings from the patient would
increases. The nurse should suspect that the client has
the nurse suspect for her to have pregnancy-induced hypertension?
a. Hydatidiform mole
a. Nausea and vomiting usually felt by the mother in the
b. Endometriosis
morning b. The mother tells you that she no longer can wear her
c. Marginal placenta previa
wedding
d. Complete abruptio placenta
ring
RATIO: The signs and symptoms are associated with abruptio placenta. Signs c. Complains that she has difficulty defecating
and symptoms of placenta previa include, bright red painless bleeding, and d. Reports of frequency of urination especially in the afternoon
RATIO: One of the signs of having preeclampsia is edema of the hands and 1. A 22-year old woman has been brought into the delivery room and
face. If the mother can no longer wear her wedding ring this may indicate was diagnosed to have tachysystole labor. What would be the
that her fingers are edematous due to PIH. characteristic of tachysystole labor?

15. The nurse understands that the diabetic mother’s metabolism a. Infrequent and brief contractions
is significantly altered during pregnancy as a result of b. More than 5 contractions per 10 minute intervals in 2
consecutive intervals
a. The lower renal threshold for glucose
c. Prolonged active phase
b. The increased effect of insulin during pregnancy
d. Uterus can be easily indented by the fingertip
c. An increase in the glucose tolerance level of the blood
d. The effect of hormones produced in pregnancy on RATIO: Uterine tachysystole is a condition of excessively frequent uterine
carbohydrate and lipid metabolism contractions during pregnancy. Uterine tachysystole is defined as more than 5
contractions in 10 minutes, averaged over a 30-minute window.
RATIO: In pregnancy, the hormones that are secreted by the placenta make
the mother’s body less responsive to insulin. This is known as insulin 2. Which of the following would contribute to the pain felt by the
resistance. It should be noted that all pregnancies have a degree of insulin mother during tachysystole labor?
resistance in order to make nutrients in the maternal bloodstream available
for the growing fetus. a. Cephalopelvic disproportion
b. Malpresentation
16. Which of the following conditions may happen to the fetus in a c. Anoxia
mother who is diagnosed to have gestational diabetes? d. Malposition

a. Small-for-gestational age RATIO: Malpositions are abnormal positions of the vertex of the fetal head
b. Hydrocephaly (with the occiput as the reference point) relative to the maternal pelvis.
c. Large-for-gestational age Malpresentations are all presentations of the fetus other than vertex. Women
d. Low birth weight with occiput posterior presentations may experience more back pain, slower
labor, or spend more time pushing than when the baby is facing your back.
RATIO: The increased risk of macrosomia in GDM is mainly due to the
increased insulin resistance of the mother. In GDM, a higher amount of blood 3. A 25-year old woman in the delivery room has been diagnosed to have
glucose passes through the placenta into the fetal circulation. As a result, hypotonic labor. The nurse would confirm the diagnosis with the presence
extra glucose in the fetus is stored as body fat causing macrosomia, which is of which of the following characteristics?
also called ‘large for gestational age'.
a. Contractions has more than 90 seconds duration
17. A mother was assessed for the type of abortion that she may have, the b. Frequency of contractions are less than 2 minutes
cervix is still closed, there is slight bleeding and mild uterine contractions, c. The number of contractions is usually infrequent which is
the fetus is still in the womb of the mother. Which among the following is not more than 2 or 3 occurring in a 10-mute period
happening? d. Strong and frequent contractions

a. Threatened abortion RATIO: A mother who has hypotonic labor has the following signs and
b. Missed abortion symptoms: the number of uterine contractions in hypotonic contractions is
c. Complete abortion unusually slow or infrequent; there are only two or three contractions
d. Incomplete abortion occurring within a 10-minute period; the strength of contractions does not
rise above 10 mmHg, and they occur mostly during the active phase of labor.
RATIO: When your body is showing signs that you might miscarry, that is
called a ‘threatened abortion. You may have a little vaginal bleeding or lower 4. Which of the following cases would strongly contribute to the
abdominal pain. It can last days or weeks and the cervix is still closed. hypotonic labor of the mother?
Sometimes, the baby has died but stayed in the uterus. This is known as a
‘missed abortion.’ A complete abortion has taken place when all the a. Nulliparity
pregnancy tissue has left your uterus. Sometimes, some pregnancy tissue will b. Polyhydramnios
remain in the uterus. Vaginal bleeding and lower abdominal cramping may c. Small for gestational age
continue as the uterus continues trying to empty itself. This is known as an fetus d. Grand multiparity
‘incomplete abortion.
RATIO: The uterus of a mother who has given birth four or more times (grand
18. Which of the following is NOT a characteristic of ectopic pregnancy multiparity) becomes lax leading to the occurrence of hypotonic labor. Other
predisposing factors of hypotonic labor would be multiple gestations,
a. Any gestation outside the uterine cavity macrosomia, and hydramnios.
b. Most frequent in the fallopian tubes, where the tissue is
incapable of the growth needed to accommodate pregnancy, so 5. In order for the nurse to prevent the occurrence of hypotonic labor,
rupture of the site usually occurs before 12 weeks. the nurse should avoid excessive use of which of the following
c. Any condition that diminishes the tubal lumen may predispose medications?
a woman to ectopic pregnancy.
d. There is also a low lying placenta present during a. Oxytocin
the ultrasonography b. Methergine
c. Sedatives
RATIO: Choices A, B, and C are true for ectopic pregnancy while letter D is not d. Analgesic
true and is indicative of a condition known as placenta previa.
RATIO: Sedatives can cause uterine muscle relaxation which can worsen the
19. Which of the following laboratory findings would be significant in labor of a mother who is suffering from hypotonic labor. In order to increase
the mother who has ectopic pregnancy the force of contractions of mothers with this condition, oxytocin is further
increased.
a. Increased hematocrit and hemoglobin levels
b. Decreased hematocrit and hemoglobin levels 6. During hypotonic labor the fetus may be in distress. When the
c. Elevated red blood cell count obstetrician has performed amniotomy, which of the following is the nurse
d. Decreased white blood cell count going to do?

RATIO: Low hemoglobin and hematocrit values, together with higher a. Observe for the odor of the amniotic fluid
gravidity at the time of admission, may indicate an increased risk of tubal b. Determine the amount of amniotic fluid
rupture. present c. Observe for the color of the amniotic
fluid
20. The characteristic pain of a mother who has ectopic pregnancy is d. Check for the presence of blood in the amniotic fluid

a. Pain felt just above the symphysis pubis of the mother RATIO: The first thing that the nurse should do once amniotomy is done
b. Pain felt during contractions of the during a hypotonic labor is to assess for the color of the amniotic fluid and
uterus c. Pain felt at one side of the check for the presence of meconium. If the amniotic fluid is green, this must
abdomen be reported immediately since the fetus is already in distress.
d. Pain felt at the right lower quadrant of the abdomen
7. When assessing the mother who is undergoing hypotonic labor the nurse
RATIO: The pain felt by the mother with ectopic pregnancy is usually one- must assess signs of infection if the labor is already prolonged. Which of
sided in the lower abdomen. Since only one fallopian tube is affected in this the following would indicate that the mother has an infection?
type of pregnancy.
a. Fetal bradycardia
b. Presence of meconium in the amniotic
fluid c. Fever and chills
SAS 7
d. Distended bladder
RATIO: The presence of fever alone would indicate that the mother is RATIO: A caesarean section is the only safe option in the case of double
currently experiencing an infection. Fever is a defense mechanism of the footling breech, small or narrow pelvis and a very large fetus.
body in order to decrease the proliferation of microorganisms in the body.
15. In a transverse type of position the presenting part is
8. If induction of labor is unsuccessful and full dilatation has not occurred
when the mother has hypotonic labor the next step that the nurse is going usually a. One of the shoulders
to expect for the obstetrician to do is b. An iliac crest
c. A hand
a. Prep the mother for caesarean section d. Any of the above
b. Use assistive tools such as forceps
c. Help the mother in the labor through vacuum extraction RATIO: In transverse position, the presenting part of the fetus is typically the
d. Perform an episiotomy shoulder. During abdominal examination, the head or the buttocks cannot be
felt at the bottom of the uterus and the head is usually felt in the side.
RATIO: If all measures by the obstetrician have been made and are Vaginal examination— A shoulder may be felt during a vaginal examination.
unsuccessful the next thing that the nurse is going to anticipate is for the
physician to perform CS. Letters B, C, and D are no longer helpful since these 16. This type of presentation is caused by hyper-extension of the fetal
choices need the full dilatation of the cervix. head so that neither the occiput nor the sinciput is palpable on vaginal
examination
9. During an ultrasonography the physician has noticed that the baby’s hips
and knees are flexed so that the baby is sitting cross-legged, with feet a. Sinciput
beside the bottom. What is being presented in this situation? b. Occiput
c. Transverse
a. Frank breech d. Face
b. Incomplete breech
c. Complete breech RATIO: Face presentation occurs when baby's spine extended until the head
d. Footling breech is shifted back so baby's face comes through the pelvis first. Baby may settle
in a face presentation before labor. A baby who is in a face-first position
RATIO: Complete breech is when both of the baby's knees are bent and his often started as an extended (chin up) occiput posterior or occiput
feet and bottom are closest to the birth canal. Incomplete breech is when transverse position.
one of the baby's knees is bent and his foot and bottom are closest to the
birth canal. Frank breech is when the baby's legs are folded flat up against his 17. Which of the following is true with regards to face chin-anterior
head and his bottom is closest to the birth canal. There is also a footling position type of malpresentation?
breech where one or both feet are present.
a. Descent and delivery of the head may occur
10. Which of the following conditions must the nurse alert to the b. The fully extended head is blocked by the sacrum which
obstetrician when performing a delivery? prevents descent and labor is arrested
c. Labor progress is slowed with slowed descent of the fetal head
a. Cord prolapse d. Fetus lies horizontally in the pelvis so that the longest fetal axis
b. Rupture of membranes is perpendicular to that of the mother
c. Crowning of head
d. External rotation of the head RATIO: This is the correct answer since it is impossible for vaginal delivery to
occur with this type of malpresentation. Caesarean section will be the only
RATIO: Cord prolapse must be placed in priority since this will cause fetal option.
distress due to the cord compression due to the prolapse. This can lead to
oxygen flow obstruction to the fetus. 18. Which of the following medical procedures is avoided during a
face presentation?
11. When the fetus is in a breech presentation, the nurse must
perform which of the following procedures early in labor? a. Augmentation of labor with oxytocin
b. Caesarean section
a. Ritgen’s maneuver c. Delivery by
b. Episiotomy forceps d. Vacuum
c. External cephalic version extraction
d. Fundal push
RATIO: Vacuum extraction is avoided during a face presentation to avoid
RATIO: In order to facilitate easy delivery in a breech presentation, the nurse injury to the face of the infant.
must perform Ritgen’s Maneuver in order to protect the perineum during
delivery. Since it is difficult for the mother to deliver the malpresented fetus 19. When assessing for the well-being of the fetus the nurse must
during delivery, the perineum is prone to develop tears or worse the tears monitor which of the following if the fetus is malpresented?
can extend to the anus causing large lacerations.
a. Vital signs of the mother
12. Vaginal breech delivery is done by a skilled health care provider and b. Fetal heartbeat
is safe and feasible under the following conditions EXCEPT c. Maternal contractions
d. Maternal respirations
a. Adequate clinical pelvimetry
b. Complete or frank breech RATIO: It is always best to assess the fetal heart tone to assess the well-
c. Had a previous caesarean section for cephalopelvic being of the fetus especially if the fetus is having a distress.
disproportion 2 years ago
d. Fetus has a flexed head 20. Kiara, the mother who is already in labor, says to the nurse, “This
is hopeless; I really can’t do it anymore. I’m so frustrated.” Which of
RATIO: If the reason for having CS 2 years ago was cephalopelvic the following nursing responses is most therapeutic?
disproportion then it is therefore not possible for the mother to deliver
vaginally since the mother’s birth canal is too narrow for birth to occur. a. “The doctor is doing everything she can in order to help you
get past this labor.”
13. During ultrasonography the obstetrician has found out that the fetus is b. “Would you opt to be placed in a caesarean section instead?”
in a complete breech presentation on the 28th week of gestation. The c. “It must be hard for you to be experiencing this. But let’s
doctor will attempt to perform an external version at what week? think
positive and be patient, you can still do this.”
a. 37 weeks d. “We’ll see other options that we can do in order to augment
b. 32 weeks this labor that you are experiencing.”
c. 38 weeks
d. 30 weeks RATIO: The nurse acknowledges the difficulties of the mother during labor
and encourages the mother to push through with it. The rest of the other
RATIO: External cephalic version is the turning of the fetus from a breech to a options are non-therapeutic.
cephalic position before birth. It may be done as early as 34-35 weeks,
although the usual time is by 37-38 weeks of pregnancy to prepare for the
delivery in the last weeks of pregnancy.
SAS 8
14. Caesarean section will be performed if the type of breech presented is
1. Nurse Nami is currently visiting the Dimatulac family 2 weeks after being
a. Complete breech discharged from the hospital. Upon observation, the nurse notes that the
b. Frank breech umbilical cord has dried and fallen off. The area appears to have healed
c. Double footling breech with no discharges or erythema present. The mother can be taught to
d. None of the above
a. Cover the umbilicus with a band-aid
b. Continue to clean the stump with 70% alcohol for a week
c. Apply an antibiotic ointment on the stump
 d. Give the infant a tub bath now 8. Nurse Mikasa is caring for a newborn who has just been diagnosed
with hypospadias. After discussing the defect with the parents, the nurse
RATIO: When your baby is born the umbilical cord is cut and there is a stump
must teach that
left. The stump should dry and fall off by the time your baby is 5 to 15 days
old. Sponge bath the rest of your baby, as well. DO NOT put your baby in a a. Surgery will be performed in stages
tub of water until the stump has fallen off. b. Initial repair is delayed until the age of 6 to 8
c. Post-operative appearance will be normal
2. Aling Jona a mother of a term newborn has curiously asked about
d. Circumcision can be performed at any time
the thick, white, cheesy coating on her son’s skin. The nurse must
correctly describe this as RATIO: Hypospadias repair is done most often when boys are between 6
months and 2 years old. The surgery is done as an outpatient. The child rarely
a. lanugo
has to spend a night in the hospital.
b. milia
c. café-au-lait 9. A full-term newborn was just born. Nurse Sasha must know that the
spots d. vernix most important nursing intervention to perform first would be
caseosa
a. Assessing the APGAR score
RATIO: Vernix caseosa or vernix is the waxy or cheese-like white substance b. Remove the wet blankets
found coating the skin of newborn human babies. It is produced by dedicated c. Apply eye prophylaxis
cells and is thought to have some protective roles during fetal development d. Elicit the Moro reflex
and for a few hours after birth.
RATIO: When newborns are wet they can become hypothermic from heat
3. When Nurse Kiara is assessing the newborn, she has noted that the loss resulting from evaporation. They may then develop cold stress
newborn has caput succedaneum. Which of the following statements syndrome.
about this condition is correct?
10. Which of the following newborns is at highest risk for cold
a. It usually resolves within 3 to 6 weeks stress syndrome?
b. It involves swelling of tissue over the presenting part of
the presenting head a. Neonate who has Trisomy 21
c. It doesn’t cross the cranial suture lines b. Infant who has a diabetic mother
d. It’s a collection of blood between the skull and the periosteum c. Infant with erythroblastosis
fetalis d. Post-term infants
RATIO: Caput succedaneum is the swelling of tissue over the presenting part
of the fetal scalp due to sustained pressure; it resolves in 3-4 days. RATIO: Cold stress syndrome (CSS) in the Florida manatee Trichechus
manatus latirostris has been defined as morbidity and mortality resulting
4. Nurse Diwata is attending a newborn. To help her limit the development from prolonged exposure to water temperatures <20°C.
of hyperbilirubinemia in the newborn, her plan of care for her patient should
include 11. A newborn is born with erythroblastosis fetalis. Which of the
following signs and symptoms would the nurse expect to observe?
a. Monitoring for the passage of meconium each shift
b. Instituting phototherapy for 30 minutes every 6 hours a. Ruddy complexion
c. Substituting breastfeeding for formula during the 2nd day b. Erythema toxicum
after birth c. Anasarca
d. Supplementing breastfeeding with glucose water during the d. Alopecia
first 24 hours
RATIO: Babies born with erythroblastosis fetalis often are in severe
RATIO: Bilirubin is excreted via the GI tract; if meconium is retained, the congestive heart failure and, therefore, exhibit anasarca.
bilirubin is reabsorbed.
12. Four newborns with the following conditions are in the well-baby
5. Nurse Gian is preparing to administer a vitamin K shot to a newborn. Aling nursery. The baby with which of the following conditions is at high risk for
Julia is asking the nurse why her newborn infant needs the injection. The physiological jaundice?
best nursing response would be
a. Mongolian spots
a. “Your infant needs vitamin K to develop immunity passive b. Harlequin coloring
artificial immunity.” c. Cephalhematoma
b. “Vitamin K will protect your infant from having jaundice.” d. Caput succedaneum
c. “Newborn infants are deficient in vitamin K, and this shot
will prevent your infant from any abnormal bleeding.” RATIO: Newborns with a cephalhematoma have a collection of blood that
d. “Newborns have sterile bowels, and vitamin K will help will need to be reabsorbed and will be at greater risk for developing
promote the growth of good bacteria in the digestive tract.” physiological jaundice.

RATIO: Vitamin K helps the blood to clot and prevents serious bleeding. In 13. Nurse Angel notes that a 6-hour-old newborn has cyanotic hands
newborns, vitamin K injections can prevent a now rare, but potentially fatal, and feet. Which of the following nursing interventions would be
bleeding disorder called 'vitamin K deficiency bleeding' (VKDB), also known as appropriate?
'haemorrhagic disease of the newborn' (HDN).
a. Assess oxygen saturation with the pulse oximeter
6. A preterm neonate is to be fed with breast milk through the b. Swaddle the newborn in a blanket
nasogastric tube. The nurse recognizes that breast milk is preferred over c. Place the child under the UV light
formula milk because it d. Administer oxygen

a. Has fewer fatty acids RATIO: The baby's extremities are cyanotic as a result of the baby’s immature
b. Provide antibodies circulatory system. Swaddling helps to warm the baby's hands and feet.
c. Is higher in carbohydrates Acrocyanosis, or bluish discoloration of the hands and feet in the neonate
d. Contains more lactose (also called peripheral cyanosis), is a normal finding and shouldn’t last more
than 24 hours after birth.
RATIO: Breast milk also contains antibodies, which means that babies who
are breastfed have passive immunity for longer. The thick yellowish milk 14. The nursing history for a newborn suspected of having pyloric
(colostrum) produced for the first few days following birth is particularly rich stenosis would most likely reveal which of the following?
in antibodies.
a. Frequent vomiting of bile-stained fluid
7. Nurse Santibanez is admitting a preterm newborn to the nursery. b. Cyanosis and vomiting immediately after
The nurse should assess which of the following from this newborn? feedings c. Mild emesis progressing to projectile
vomiting
a. Clavicle fracture d. Absence of gastrointestinal peristalsis
b. Palsies
c. Respiratory distress RATIO: Mild regurgitation or emesis that progresses to projectile vomiting is
d. Shoulder dystocia a pattern of vomiting associated with pyloric stenosis.

RATIO: Newborn respiratory distress syndrome (NRDS) happens when a 15. Nurse Alyana is assessing the reflexes of a newborn. The nurse
baby's lungs are not fully developed and cannot provide enough oxygen, assesses which of the following reflexes by placing a finger in the
causing breathing difficulties. It usually affects premature babies. It's also newborn’s mouth?
known as infant respiratory distress syndrome, hyaline membrane disease or
a. Sucking reflex
surfactant deficiency lung disease.
b. Landau reflex
c. Babinski reflex
d. Moro reflex
RATIO: The sucking reflex is tested by placing something, such as a finger, in 2. An infant child named Giselle would learn to explore the
the infant’s mouth and seeing if the infant begins to suck on the object. The environment through which of the following?
Moro reflex is tested by suddenly lowering the newborn’s body. The infant
should demonstrate a bilateral arm extension and leg flexion. The rooting a. mouth
reflex is tested by stroking the cheek. The infant may open the mouth. The b. hands
Babinski reflex is tested by firmly stroking the plantar surface. The anticipated c. feet
response is the incurving of the toes as in plantar the grasp, with uncurling d. eyes
and fanning out.
Infants explore the world by mouthing objects or fingering them. This also
16. Nurse Kim is assessing a newborn on admission to the NICU. Which of helps them separate self from environment.
the following findings should the nurse report to the attending physician?
3. A mother of a child tells the nurse, “I constantly see my five-year-old son
a. Intercostal retractions fondling with his genitals.” She appears tensed because according to him
b. Caput succedaneum this may seem deviant for a preschooler. The nurse should tell the father
c. Epstein’s pearls that
d. Harlequin sign
a. “This behavior is abnormal. You should scold your child when you
RATIO: Intercostal retractions are a sign of respiratory distress. see him next time.”
b. “Just ignore the behavior of the child.”
17. An indirect bilirubin level at birth is 1 to 4 mg/100 ml. any increase over c. “This act is to deviant. He probably will develop sexual
this amount reflects the release of bilirubin as excessive red blood cells begin disorders later on.”
their breakdown. To treat the occurrence of jaundice brought by these d. “Tell the child to do it privately in his room. And make no issue
events it is important for the newborn to undergo? out of it.”

a. Vaccination Proper sex education must be done by parents that they should explain
b. Phototherapy that certain things are done in some places but not in others. Children can
c. Cord dressing relate to this kind of direction without feeling inhibited, just as they can
d. APGAR scoring accept the fact that they use bathroom in private or eat only at the table.

RATIO: Phototherapy is treatment with a special type of light (not sunlight). 4. A mother tells the nurse, “My 4-year-old daughter tells me that she
It's sometimes used to treat newborn jaundice by making it easier for your hates me. What should I do?” As a nurse you are going to tell her
baby's liver to break down and remove the bilirubin from your baby's blood.
Phototherapy aims to expose your baby's skin to as much light as possible. a. “You may be mistreating your daughter. That’s why she hates you.”
b. “You should take your daughter out for a play sometimes for
18. If the newborn’s APGAR score is zero. Which of the following would her to like you.”
be the best nursing intervention? c. “You should tell your daughter that you love her very much.”
d. “You should be patient about your daughter. She is undergoing a
a. Resuscitate the patient
stage which is normal for her. Just be supportive.”
b. Place the patient in close monitoring
c. Do nothing since the patient is a well-baby Electra complex is the strong emotional attachment of a preschool girl toward
d. Inject IV epinephrine her father is normal phenomenon

RATIO: Reflex Response: 0 means no response to their airways being 5. A 2-year-old child named James is very curious about his
stimulated which means that the patient should be resuscitated. environment. Which of the following statements would be true about a
toddler?
19. Assess the Apgar score of the female infant with the following
assessments: the infant appears blue overall, she grimaces when slapped on a. Allowing the toddler to explore his environment for him to
the foot and when a catheter is placed in her nostril, the heart has 72 beats learn while providing him with safety.
per minute, there is some flexion of the extremities and there is a slow b. Inhibit all of the child’s desires.
weak cry. What is the APGAR score? c. Give in always to the child’s temper tantrums to stop the
child from crying.
a. 2
d. Be strict in the child’s toilet training.
b. 3
c. 4 During the second year, toddlers are moving around more, and are aware of
d. 5 themselves and their surroundings. Their desire to explore new objects and
people also is increasing. During this stage, toddlers will show greater
RATIO: Appears blue overall – 0; grimaces when slapped on the foot – 1;
independence; begin to show defiant behavior; recognize themselves in
heart rate of 72 bpm – 1; some flexion of extremities – 1; slow weak cry – 1;
pictures or a mirror; and imitate the behavior of others, especially adults and
(0+1+1+1+1=4).
older children.
20. Upon assessing the newborn child on his fifth minute you have
6. Which of the following would indicate that the adolescent has
observed for the following: the child’s heart rate is 123 beats per minute,
already developed a sense of identity?
there is a slow, irregular weak cry, he sneezes when a catheter is placed in
his nostril, he grimaces when the foot is slapped and there is acrocyanosis. a. A teenager is performing poorly in his course because his
What is the APGAR score? parents chose the course for him.
b. A teenager who is not satisfied with his course because her
a. 6
friends goaded her to join them.
b. 7
c. A teenager who secretly hides his sexuality to everyone, but in
c. 8
his thoughts, he is a homosexual.
d. 9
d. A teenager who excels very well in a course, and loves what he
RATIO: The Apgar score describes the condition of the newborn infant is studying.
immediately after birth and, when properly applied, is a tool for standardized
Those who are able to develop a strong sense of identity are better able to
assessment 18. It also provides a mechanism to record fetal-to-neonatal
have self-confidence, or a sense of trust in their abilities, qualities, and
transition. Apgar scores do not predict individual mortality or adverse
judgements.
neurologic outcome.
7. The infant named Juliana at this stage can say mam-ma and dad-da, plus
2 words such as milk and water. She can also take her first few steps at this
SAS 9 stage. Her birth weight has already tripled. What month is she in?

1. The relationship that is of extreme importance in the formation of a. 12 months

the personality is the b. 11 months
c. 9 months
a. Peer d. 10 months
b. Sibling
c. Parent-child Expect your baby to double his or her birth weight by about age 5 months.
d. Heterosexual From ages 6 to 12 months, a baby might grow 3/8 inch (about 1 centimeter) a
month and gain 3 to 5 ounces (about 85 to 140 grams) a week. Expect your
Children view their own worth by the response received from their parents. baby to triple his or her birth weight by about age 1 year.
This sense of worth sets the basic ego strengths and is vital to the
formation of the personality. 8. Which of the following behaviors would a newly born infant who is
named Kyla going to demonstrate?

a. Playing with mobile toys

b. Patty Cake
 c. Peek-a-Boo c. It is designed for same-sex to spite or exclude another child
d. Enjoys face of caregiver

Newborn enjoys watching a simple

mobile.

9. A mother named Susan asks Nurse Joyce about the type of toys that are
appropriate for her child who is 10 months old. Which of the following
must Nurse Joyce advise to the mother?

a. Mobile toys
b. Push or pull toys
c. Jack-in-the-box
d. Walker

10 months old may enjoy playing with egg cartons, blocks, balls, stacking
toys, and push-pull toys.

10. Lavender Brown is crawling or creeping on the floor with her abdomen of
it. She already can exhibit the pincer grasp by using her thumb and
forefinger. What month can she be in?

a. 6 months
b. 10 months
c. 11 months
d. 9 months

The pincer grasp is the ability to hold something between the thumb and first
finger. This skill usually develops in babies around 9 to 10 months old.

11. During the assessment of the newborn Nurse Stella is stroking the side
of the sole of the foot in an inverted “J” curve from the heel upward, the
newborn fans the toes. This is known as

a. Moro reflex
b. Extrusion reflex
c. Babinski reflex
d. Rooting reflex

The Babinski reflex occurs after the sole of the foot has been firmly stroked.
The big toe then moves upward or toward the top surface of the foot. The
other toes fan out. This reflex is normal in children up to 2 years old.

12. A mother named Janella is asking Nurse Jade when her son will be able
to do toilet training. Nurse Jade must know that physical readiness for toilet
training occurs at age

a. 18-24 months
b. 36-42 months
c. 12-17 months
d. 43-50 months

Toilet training may come up during children's 18-month, 2-year, 2½-year, and
3-year well-child visits. The average age toilet training begins in the United
States is between 2 and 3 years of age.

13. A mother named Rowena is at the mall with her toddler son Charlie.
When leaving the department store Charlie is crying and throwing a fit due
to the toys he has seen. When dealing with temper tantrums the parents
must take into consideration the following interventions EXCEPT

a. Give the toddler frequent opportunities to make

developmentally appropriate choices.
b. Give in always to the child’s wants in order to prevent the
child from having temper tantrums.
c. Give the child advance warning of a request to help
prevent temper tantrums.
d. Ignore tantrums when the toddler is seeking attention or trying
to get what he wants.

The best approach for parents is to tell their child simply that they disapprove
of the tantrum and then ignore it. They might say, “I’ll be in the bedroom.
When you’re done kicking, you come into the bedroom, too.” Children who
are left alone in a room this way will usually not continue a tantrum but will
stop after 1 or 2 minutes and rejoin their parents. Parents should then accept
the child warmly and proceed as if tantrum had not occurred.

14. A mother named Janine is observing her 6-year old daughter play with
her friends at the playground. She has seen them playing tag. This would
be an example of which of the following types of play?

a. Parallel play
b. Solitary play
c. Cooperative
play d.
Competitive play

Competitive play is when children learn to play organized games with clear
rules and clear guidelines on winning and losing.

15. Maria has belonged to a series of clubs for 9-year-old girls. A

usual characteristic of clubs for this age is

a. The club has formal rules and regulations

b. It is designed to help shy children socialize
 d. Clubs include both boys and girls

Nine-year-olds take the values of their peer group very seriously. They are
much more interested in how other children dress than in what their parents
want them to wear. This is typically the gang age because children form clubs,
usually “spite clubs.”

16. A mother named Alison has consulted her nurse friend with regard to
the types of play that her school-aged child can do. Suggested play for the
9-12 years old include the following EXCEPT

a. Sculpturing materials such as pottery clay

b. Model kits, collections and hobbies
c. Video game of a more mature content
d. Handicrafts of all kind

During a 2021 survey, 38 percent of video game players still come from the
18 to 34 age demographic, and seven percent are 65 years and older.

17. This is one of the strongest motivating forces of behavior of

the adolescents

a. Peers
b. Celebrities
c. Parents
d. Siblings

Adolescence develop values through talking to peers and they have a need to
interact with peers to learn more about themselves and others.

18. Sharon a 15-year-old female has recently consulted the school

nurse about certain fears. What would be the major fear of the
adolescent?

a. Fear of the dark

b. Fear of separation
c. Fear of body image disturbance
d. Fear of intrusive procedures

As such, adolescents with body image dissatisfaction may experience

heightened anxiety responses upon exposure to appearance-related social
evaluative threats, but have a limited capacity to regulate emotions, cognitive
vulnerabilities, and safety behaviors.

19. A 4-yeard old child named Levi is talking to his toy cars and action
figures. The mother of this child seems bothered because she thinks that
her child may be developing developmental disorders. What would be the
best response by the nurse?

a. “Your son may really have a developmental disorder like

autism. You need to see a psychiatrist at once.”
b. “Your son’s behavior is normal for a preschooler. Just don’t
make any issue out of it.”
c. “Your son’s behavior is deviant. You should further observe
your son for other signs.”
d. “You should apprehend your child immediately if you see this
type of behavior again.”

At this age, their imaginations are keener than they will be at any other time
in their lives, so they enjoy games that use imitation such as pretending to
be teachers, cowboys, firefighters, and store clerks.

20. Which is NOT true regarding the toddler’s toilet training?

a. Physical maturation must be reached before training is possible.

b. Helping the toddler understand the physiologic signals by
pointing out behaviors they display when they need to void or
defecate.
c. Helping the toddler make the connection between dry pants
and the toilet or potty chair.
d. Bladder training comes first before bowel training.

Toilet training need not start this early, however, because cognitively and
socially, many children do not understand what is being asked of them
until they are 2 or even 3 years old. The markers of readiness are subtle,
but as a rule children are ready for toilet training when they begin to be
uncomfortable in wet diapers.

SAS
10

Situation 1: An infant named Russell was diagnosed to have Down

syndrome. This syndrome has a trisomy in the 21st chromosome causing
certain abnormalities in the child.

1. The doctor explained to Russell’s parents that the type of Down

syndrome that he has is Mosaicism. Which of the following statements
would best explain this type?

a. This kind of Down syndrome is frequently associated to

women with advanced age.
b. There is mixture of normal cells and cells that are trisomic for 21.
c. Chromosome is transmitted by the mother who is a carrier
but age is not a factor.
 d. This type is inherited when the father is carrier of the genes Endotracheal intubation prevents the cough reflex and interferes with
that are trisomic for 21 and a mother who is normal. normal muco-ciliary function, therefore increasing airway secretion
production and decreasing the ability to clear secretions. Endotracheal tube
People with mosaic Down's syndrome have an extra chromosome 21 in only
(ETT) suction is necessary to clear secretions and to maintain airway patency,
some of their cells. They therefore have a mixture of trisomic cells and
and to therefore optimize oxygenation and ventilation in a ventilated
ordinary cells.
patient.
2. Nurse Gina, who is taking care of baby Russell noticed that there is
8. It is imperative to teach the parents to turn their child from side to side to
speckling of the iris of the child. This speckling is commonly known as
prevent which of the following complications of prolonged immobility on
a. Mongolian spots the bed?
b. Kayser-Fleischer
a. Orthostatic
Ring c.
hypotension b.Hypostatic
Brushfield’s Spots
pneumonia
d. Roth’s Spot
c. Aspiration pneumonia
Brushfield spots are small, white or greyish/brown spots on the periphery of d. Anemia
the iris in the human eye due to aggregation of connective tissue, a normal
Hypostatic pneumonia results from the collection of fluid in the dorsal region
constituent of the iris stroma. The spots are named after the physician
of the lungs and occurs especially in those (as the bedridden or elderly)
Thomas Brushfield, who first described them in his 1924 M.D. thesis.
confined to a supine position for extended periods. Lying flat on your back for
3. Russell is further assessed for other signs of Down syndrome. The a long time can increase your risk of developing pneumonia.
nurse would indicate that positive signs of Down syndrome are the
9. The child is sent home after everything has already been stabilized but
following EXCEPT
the doctor again advised the parents to return with their child for the next
a. Delayed or incomplete sexual development (men with operation which is palatoplasty? When would be the best time to do this?
Down syndrome usually are infertile)
a. 1 ½ years old
b. Inner epicanthic folds and oblique palpebral fissures
b. 5 years old
c. Hypotonic musculature (protruding abdomen, umbilical hernia)
c. 7 years old
d. Small head with a sloping forehead
d. 3 years old
Only letter C. Hypotonic musculature (protruding abdomen, umbilical hernia)
A cleft palate usually is repaired with surgery called palatoplasty when the
is not included in the positive signs of down syndrome.
baby is 10–12 months old. The goals of palatoplasty are to: Close the opening
4. The nurse is about to take the history of the parents of Russell. Which of between the nose and mouth. Help create a palate that works well for
the following findings would show that the mother of Russell would speech.
indicate a high-risk factor to have a child with Down syndrome?
10. After the child has had palatoplasty, which of the following
a. The mother is suffering from adult-onset diabetes mellitus. position should the child be placed unto to prevent aspiration
b. The mother during pregnancy took in liberal amounts of pneumonia and drainage of secretions?
ferrous sulfate.
a. High-Fowlers
c. The mother is age 45 during her pregnancy.
b. Supine
d. The mother did not properly medicate herself with insulin
c. Reverse-Tredenlenburg
during pregnancy
d. Prone
One factor that increases the risk for having a baby with Down syndrome is
Posturing methods to treat aspiration include: Place infants in an
the mother's age. Women who are 35 years or older when they become
upright/prone position.
pregnant are more likely to have a pregnancy affected by Down syndrome
than women who become pregnant at a younger age. Situation 3: Mark was observed to have spina bifida upon birth. This
condition is a malformation of the spine that is caused by certain factors.
5. After teaching the parents about their child’s condition, which of
Immediate interventions should be done in order for the child to develop
the following statements would need further teaching?
properly. The mother of mark is also suffering from seizure disorders and is
a. “Our son will need supervision when he will grow up because known to take anticonvulsant medications during her pregnancy.
he may be cognitively challenged.”
11. The doctor upon observing Mark’s spina bifida has seen protrusion
b. “Russell must avoid crowded places as to prevent him from
of both meninges and spinal cord. This kind of spina bifida is known as
having an infection.”
c. “We will try to take him to a regular school and help him a. Spina bifida occulta
mingle with children the same age as his.” b. Meningocele
d. “We may need to bring Russell to a speech therapist to help c. Myelomeningocele
him talk.” d. Anencephaly

Some of the specific learning difficulties that characterize many children with A myelomeningocele is a defect of the backbone (spine) and spinal cord.
Down syndrome include: Hearing and vision weakness. Fine motor skill Before birth, the baby's spine, the spinal cord and the spinal canal do not
impairment due to low muscle tone. Weak auditory memory. form or close normally. A myelomeningocele is the most serious form of
spina bifida.
Situation 2: A child named Christian is seen to have both unilateral cleft lip
and palate. He was born to have deformity. He is now 9 months of age 12. The father of Mark asks the nurse what is the common cause of this
and the parents brought their child to the hospital to have a repair. kind of condition. The nurse is utterly correct when she says

6. The child will have to undergo Cheiloplasty as the surgeon has advised a. “Spina bifida is primarily caused by intake of a teratogen known
the parents. The following is NOT true regarding this kind of operation. as thalomid.”
b. “This condition is caused by a deficiency in folate during
a. Age for repair is usually after the child has grown but
the pregnancy of your wife.”
before speech is well developed.
c. “Spina bifida is passed on genetically and your wife is a
b. Helps parents with the visible aspects of the defect
probable carrier of this ailment.”
c. Aids infant’s ability to suck
d. “The condition of your child can be caused in the deficiency of
d. Performed soon after birth – further modification may
thiamine and riboflavin during pregnancy.”
be necessary
If you do not get enough folic acid before and during pregnancy, your baby is
Cleft lip repair, or cheiloplasty, is typically performed between 4 and 6
at higher risk for neural tube defects. Neural tube defects are serious birth
months of age. The goal of this surgery is to complete the cosmetic repair of
defects that affect the spine, spinal cord, or brain and may cause death.
the lip and to aid in nursing or feeding and later speech development. Your
surgeon will attempt to adjust the scar that was formed from previous 13. This is the defect of the occipitocervical region with swelling
surgeries. and displacement of the medulla and spinal cord

7. After the operation the nurse should expect which of the a. Hydrocephalus
following equipment at the bedside of the child? b. Chiari malformation
c. Galeazzi’s sign
a. Tracheostomy set
d. Kernig’s sign
b. Defibrillator
c. Ambu bag Chiari malformation type 1 occurs when the section of the skull containing a
d. Endotracheal tube and suction part of the brain (cerebellum) is too small or is deformed, thus putting
pressure on and crowding the brain. The lower part of the cerebellum
(tonsils) is displaced into the upper spinal canal.
14. When taking care of the sac of the child with spina bifida it is essential 1. Which of the following statement best describe pyloric stenosis?
for the nurse to do which of the following EXCEPT?
a. Failure of the membrane separating the rectum from the anus
a. Avoid pressure on the sac to absorb during eighth week of fetal life
b. The area must be kept clean, especially from urine and feces b. Absence of parasympathetic ganglion cells in a portion of the
c. Sterile gauze with antibiotic solution may be placed over the bowel, which causes enlargement of the bowel proximal to
sac d. Administer oral paracetamol to reduce fever the defect
c. Telescoping of one portion of the intestine into another;
Administering oral paracetamol is not needed when taking care of the sac of
occurs more frequently at the ileocecal valve
the child with spina bifida.
d. Congenital hypertrophy of muscular tissue of the pyloric sphincter,
15. Which of the following drugs for seizure would most likely cause the usually asymptomatic until 2 to 4 weeks after birth
child to have neural tube defects?
The lower portion of the stomach that connects to the small intestine is
a. Valproic acid known as the pylorus. In pyloric stenosis, the muscles in this part of the
(Depakene)
b. Carbamazepine (Tegretol) stomach enlarge, narrowing the opening of the pylorus and eventually
c. Lamotrigine (Oxtellar) preventing food from moving from the stomach to the intestine.
d. Topiramate (Topimax)
2. What site is commonly affected to a child who is suffering from
Some medications that are used to treat seizures, specifically valproic acid aganglionic megacolon?
and carbamazepine, have been associated with an increased chance of
a. Ascending colon
having a pregnancy affected by a neural tube defect.
b. Descending colon
Situation 4: A newborn named Julie is seen to have hydrocephalus. Her c. Transverse colon
head circumference was larger than what is normal. She also has d. Rectosigmoid colon
protruding eyeballs. There are prominent scalp veins.
Hirschsprung's disease, also known as congenital aganglionic megacolon, is
16. Julie’s intracranial pressure is expected to above the normal range. a congenital absence of parasympathetic nerve ganglia in the distal colon.
What would be the normal intracranial pressure in infants? The descending and sigmoid colon are called the distal colon.

a. 10 to 15 mm Hg 3. Which of the following is the characteristic of stools in an infant who

b. Less than 3 to 7 mm Hg has aganglionic megacolon?
c. Less than 1.5 to 6 mm
a. Passage of ribbonlike or pellet-like stools
Hg
b. Currant-jelly stools
d. 20 to 25 mm Hg
c. Rice-watery stools
The normal range for ICP varies with age. Values for pediatric subjects are not d. Black-tarry stools
as well established. Normal values are less than 10 to 15 mm Hg for adults
Constipation results from absence of ganglion cells in the rectum and colon,
and older children, 3 to 7 mm Hg for young children, and 1.5 to 6 mm Hg for
and is present since the neonatal period with passage of frequent foul-
term infants. ICP can be subatmospheric in newborns.
smelling, ribbon-like, or pellet-like stools.
17. Which of the following signs and symptoms would indicate that Julie
4. If an olive-mass is palpated on the abdomen of the child, the child
is suffering from increased intracranial pressure?
is positive for pyloric stenosis. Where is this usually palpated?
a. Projectile vomiting not associated with feeding, irritability,
a. Right lower quadrant
anorexia, high shrill cry, seizures
b. Left upper quadrant
b. Dizziness, there is low-pitched cry, increased feeding, fever
c. Right upper
and weight loss
quadrant
c. Child appears calm, lethargy, leakage of cerebrospinal fluid
d. Left lower quadrant
from the ears and nose
d. There are rashes on the scalp, bloodshot eyes, epistaxis, and Palpation of the abdomen may reveal an olive shaped mass in the right
gum bleeding upper quadrant. Palpation of an olive is pathognomonic for pyloric stenosis.
The symptoms and signs of raised intracranial pressure are often non-specific 5. What is the description of the vomitus of the patient who is suffering
and insidious in onset: headache, drowsiness, anorexia, visual disturbances, from pyloric stenosis?
commonly occur with changes in posture, papilledema, neck/back pain,
nausea and/or vomiting, seizures. a. Projectile, non-bile stained
b. Non projectile, red stained
18. The doctor of Julie advised the parents to undergo treatment to relieve c. Projectile, brown stained
the hydrocephalus of the child. What would be the best intervention for d. Non projectile, yellow stained
the child’s condition?
Infants with pyloric stenosis classically present with projectile, non-bilious
a. Ventriculo-peritoneal shunting vomiting. Vomiting may be intermittent or occur after each feeding. Emesis
b. Ventriculostomy should not be bilious.
c. Burr-hole drainage
d. Craniotomy 6. After feeding the infant who has undergone an abdominal surgery
because of pyloric stenosis. The child must be placed on which of the
The most common treatment for hydrocephalus is a medical device called following position afterwards?
a shunt, a flexible tube, which is placed in the ventricular system of the
brain and connected to a valve. a. Supine
b. Left side lying
19. If hydrocephalus is left untreated the child may grow up to c. Prone
d. Right side lying
be a. Cognitively challenged
b. Autistic Prone with the head of the bed elevated.
c. Attention-deficit hyperactive disorder
d. Conduct disorder 7. When positioning the infant who has diaphragmatic hernia it is best
to place the infant on
Without treatment, hydrocephalus results in compromised mental
functioning, visual disturbances, walking difficulty, incontinence, and reduced a. The affected side
conscious state. b. The stomach
c. The unaffected side
20. When monitoring for the child’s intracranial pressure it is important d. The back
that the nurse must avoid giving the child which of the following
medications? To allow greater respiration in the unaffected side.

a. Diuretics 8. Which of the following types of enema would help relieve

b. Sedative the intussusception of the child?
c. Analgesics
d. Antipyretics a. Barium enema
b. Fleet enema
Antipyretic is not indicated as a medication for increase ICP. c. Carminative enema
d. Cleansing enema

SAS 11
They may also use the enema to treat the intussusception, in which case it is Situation: A 5-year old female named Erina Nakiri was brought to the
referred to as a therapeutic enema. During this procedure, the doctor instills hospital. According to her mother she has been experiencing fever for more
air or a solution containing contrast material (iodine or barium) into the than 5 days. Upon assessment Nurse Alice has observed polymorphous rash
large intestine through a small, soft tube placed in the rectum. on the trunk. Aside from those she has observed peeling of the palms and
soles. The child also has a strawberry-tongue.
9. A child named Paul Macchiato is diagnosed to have β-Thalassemia, his
parents are of Italian descent. He tells you that he is constantly tired even 16. The possible diagnosis of the child would be
by doing a small amount of activity. Which of the following is the best
nursing diagnosis for him? a. Measles
b. Scarlet fever
a. Body image c. Kawasaki disease
disturbance b. Activity d. Rubella
intolerance
c. Altered family processes Kawasaki disease (KD), or mucocutaneous lymph node syndrome, is an illness
d. Impaired gas exchange that causes inflammation in arteries, veins, and capillaries. It also affects your
lymph nodes and causes symptoms in your nose, mouth, and throat. It's the
Activity intolerance related to imbalance of oxygen supply and most common cause of heart disease in children.
consumption needs.
17. The cause of Erina’s disease would be
10. β – Thalassemia is an autosomal disorder with varied expressivity.
The basic defect of this disease is found to be associated with which of a. Viral
the following deficiencies? b. Allergic reaction
c. Unknown
a. α-chain polypeptide deficiency d. Bacterial
b. Iron deficiency
c. β – chain polypeptide deficiency The exact cause of Kawasaki disease is unknown. Because it causes a high
d. Vitamin B12 deficiency fever and swelling of the lymph nodes, Kawasaki disease is thought to be
related to an infection. It may occur in children who have a genetic
The β-thalassemias are characterized by a quantitative deficiency of β- predisposition to the disease. The disease is not contagious.
globin chains underlaid by a striking heterogeneity of molecular defects.
18. One of the possible complications from this disease would
11. This is known as the excessive storage of iron in various tissues of
the body, especially the spleen, heart, and pancreas. be a. Aneurysms
b. Hypertension
a. Hemosiderosis c. Seizures
b. Hemochromatosis d. Asthma
c. Ferrosis
d. Hematoma Kawasaki disease can affect the heart by causing the following complications:
Coronary artery aneurysms (or ballooning of the arteries) Leakage of valves
Hemochromatosis, or iron overload, is a condition in which your body stores (often mitral valve regurgitation).
too much iron. It’s often genetic. It can cause serious damage to your body,
including to your heart, liver and pancreas. 19. With Erina’s disease, Nurse Alice must know that it is common
from which geographic location?
12. A child who has Wilm’s tumor (nephroblastoma) also has
cryptorchidism which is a. Mediterranean
b. Pacific
a. Undescended testes c. Middle East
b. Abnormal enlargement of the testes d. Caribbean
c. Absence of the testes
d. Swelling of the testes Kawasaki disease is most common in children, particularly those of Asian
descent. About 75 percent of KD cases are children under the age of 5,
Children with Wilms tumor may have associated hemihyperplasia and urinary according to the KDF.
tract anomalies, including cryptorchidism and hypospadias. Cryptorchidism is
a condition in which one or both of the testes fail to descend from the 20. The doctor has started acetylsalicylic acid (Aspirin) therapy for Erina.
abdomen into the scrotum. The nurse must know that the purpose of the drug therapy is

13. A child named Robert is being diagnosed for the presence of tumor in a. Prevent thrombus formation
the kidneys. It was found that he has nephroblastoma. The tumor is only b. Control the child’s hypertension
encapsulated within the kidney. What stage of cancer is the child on? c. Increase the blood volume
d. Improve cardiac contractility
a. Stage I
b. Stage II The purpose of the drug therapy in Kawasaki disease is to lower fever and
c. Stage III inflammation and prevent heart damage.
d. Stage IV

Stage I: Cancer is found in one kidney only and can be completely removed by
surgery. About 41% of all Wilms tumors are stage I. SAS 12

14. If the child has the presence of an encapsulated tumor in the kidney, 1. Which is the primary goal of community health nursing?
the most appropriate nursing diagnosis for him is
A. To support and supplement the efforts of the medical
a. Fear profession in the promotion of health and prevention of illness
b. Altered family processes B. To enhance the capacity of individuals, families and
c. Risk for injury communities to cope with their health needs
d. Altered nutrition C. To increase the productivity of the people by providing them
with services that will increase their level of health
Some affected children have abdominal pain, fever, a low number of red D. To contribute to national development through promotion of
blood cells (anemia), blood in the urine (hematuria), or high blood pressure family welfare, focusing particularly on mothers and
(hypertension). Additional signs of Wilms tumor can include loss of appetite, children.
weight loss, nausea, vomiting, and tiredness (lethargy).
To contribute to national development through promotion of family welfare,
15. When caring for the child with nephroblastoma the priority focusing particularly on mothers and children.
nursing intervention for the child is to
2. CHN is a community-based practice. Which best explains this statement?
a. Palpate the abdomen for tender swelling and a nontender
mass which is usually confined to one side of the abdomen A. The service is provided in the natural environment of people.
b. Observe for the presence of blood in the urine which is B. The nurse has to conduct community diagnosis to
indicative of stage III cancer determine nursing needs and problems.
c. Look for signs of metastasis such as cough, dyspnea, shortness C. The services are based on the available resources within
of breath. the community.
d. Place a sign over the bed saying, “Do not palpate the abdomen.” D. Priority setting is based on the magnitude of the health problems
identified.
Other findings associated with compression of neighboring organs or
metastasis (e.g., lungs: cough, dyspnea, shortness of breath). Community-based practice means providing care to people in their own
natural environments: the home, school and workplace, for example.
3. Population-focused nursing practice requires which of the younger than 50 years).
following processes?

A. Community organizing
B. Nursing process
C. Community diagnosis
D. Epidemiologic process

Population-focused nursing care means providing care based on the greater

need of the majority of the population. The greater need is identified through
community diagnosis.

4. R.A. 1054 is also known as the Occupational Health Act. Aside from
number of employees, what other factor must be considered in
determining the occupational health privileges to which the workers will be
entitled?

A. Type of occupation: agricultural, commercial,

industrial B. Location of the workplace in relation to
health facilities
C. Classification of the business enterprise based on net profit
D. Sex and age composition of employees

Based on R.A. 1054, an occupational nurse must be employed when there are
30 to 100 employees and the workplace is more than 1 km.

5. A business firm must employ an occupational health nurse when it has

at least how many employees?

A. 21
B. 101
C. 201
D. 301

Based on R.A. 1054, an occupational nurse must be employed when there are
30 to 100 employees and the workplace is more than 1 km.

6. When the occupational health nurse employs ergonomic principles, she

is performing which of her roles?

A. Health care provider

B. Health educator
C. Health care coordinator
D. Environmental
manager

Ergonomics is improving efficiency of workers by improving the worker's

environment through appropriately designed furniture, for example.

7. A garment factory does not have an occupational nurse. Who shall

provide the occupational health needs of the factory workers?

A. Occupational health nurse at the Provincial Health Office

B. Physician employed by the factory
C. Public health nurse of the RHU of their municipality
D. Rural sanitary inspector of the RHU of their

municipality This question is based on R.A.1054.

8. “Public health services are given free of charge.” Is this statement true
or false?

A. The statement is true; it is the responsibility of government

to provide basic services.
B. The statement is false; people pay indirectly for public
health services.
C. The statement may be true or false, depending on the
specific service required.
D. The statement may be true or false, depending on policies of
the government concerned.

Community health services, including public health services, are prepaid paid
services, through taxation, for example.

9. According to C.E.Winslow, which of the following is the goal of Public

Health?

A. For people to attain their birthrights of health and longevity

B. For promotion of health and prevention of disease
C. For people to have access to basic health services
D. For people to be organized in their health efforts

According to Winslow, all public health efforts are for people to realize their
birthrights of health and longevity.

10. We say that a Filipino has attained longevity when he is able to reach
the average lifespan of Filipinos. What other statistic may be used to
determine attainment of longevity?

A. Age-specific mortality rate

B. Proportionate mortality
rate C. Swaroop’s index
D. Case fatality rate

Swaroop’s index is the percentage of the deaths aged 50 years or older. Its
inverse represents the percentage of untimely deaths (those who died
11. Which of the following is the most prominent feature of public
health nursing?

A. It involves providing home care to sick people who are

not confined in the hospital.
B. Services are provided free of charge to people within
the catchment area.
C. The public health nurse functions as part of a team providing
a public health nursing services.
D. Public health nursing focuses on preventive, not curative, services.

The catchment area in PHN consists of a residential community, many of

whom are well individuals who have greater need for preventive rather
than curative services.

12. According to Margaret Shetland, the philosophy of public health

nursing is based on which of the following?

A. Health and longevity as birthrights

B. The mandate of the state to protect the birthrights of its citizens
C. Public health nursing as a specialized field of
nursing D. The worth and dignity of man

This is a direct quote from Dr. Margaret Shetland’s statements on

Public Health Nursing.

13. Region IV Hospital is classified as what level of facility?

A. Primary
B. Secondary
C. Intermediat
e D. Tertiary

Regional hospitals are tertiary facilities because they serve as training

hospitals for the region.

14. Which is true of primary facilities?

A. They are usually government-run.

B. Their services are provided on an out-patient basis.
C. They are training facilities for health professionals.
D. A community hospital is an example of this level of
health facilities.

Primary facilities government and non-government facilities that provide

basic out-patient services.

15. Which is an example of the school nurse’s health care provider functions?

A. Requesting for BCG from the RHU for school entrant

immunization B. Conducting random classroom inspection
during a measles
epidemic
C. Taking remedial action on an accident hazard in the
school playground
D. Observing places in the school where pupils spend their free time

Random classroom inspection is assessment of pupils/students and

teachers for signs of a health problem prevalent in the community.

16. When the nurse determines whether resources were maximized

in implementing Ligtas Tigdas, she is evaluating

A. Effectivenes
s B. Efficiency
C. Adequacy
D. Appropriateness

Efficiency is determining whether the goals were attained at the least

possible cost

17. You are a new B.S.N. graduate. You want to become a Public
Health Nurse. Where will you apply?

A. Department of Health
B. Provincial Health Office
C. Regional Health
Office D. Rural
Health Unit

R.A. 7160 devolved basic health services to local government units (LGU’s).
The public health nurse is an employee of the LGU.

18. R.A. 7160 mandates devolution of basic services from the national
government to local government units. Which of the following is the
major goal of devolution?

A. To strengthen local government units

B. To allow greater autonomy to local government units
C. To empower the people and promote their self-reliance
D. To make basic services more accessible to the people

People empowerment is the basic motivation behind devolution of basic

services to LGU’s.

19. Who is the Chairman of the Municipal Health Board?

 A. Mayor
B. Municipal Health Officer
C. Public Health Nurse
D. Any qualified physician

The local executive serves as the chairman of the Municipal Health Board.

20. Which level of health facility is the usual point of entry of a client into
the health care delivery system?

A. Primary
B. Secondary
C. Intermediate
D. Tertiary

The entry of a person into the health care delivery system is usually through a
consultation in out-patient services.

SAS 13

SAS 14

SAS 15

SAS 16

SAS 17

SAS 18

SAS 19

SAS 20