B.

Give ORS if there is skin petechiae

C. Apply alternative plan if there
bleeding from the nose or gums
D. Prevent low blood sugar

Review Practice
Questions
GENERAL INSTRUCTIONS:
1. This test questionnaire contains 100
test questions.
2. Shade only one (1) box for each
question on your answer sheets. Two
or more boxes shaded will invalidate
your answer.
3. AVOID ERASURES.
4. Detach one (1) answer sheet from the
bottom of your Examinee ID/Answer
Sheet Set.
5. Write the subject title NURSING
PRACTICE II on the box provided.
Situation 1- The Philippines witnessed the
rise in the incidences of DENGUE in various
parts of the country starting 2009. The
following situations affecting children
apply.
1.

In a Barangay in Iloilo where there were

high incidences malaria, a child was
brought by her mother with on and off
feeling of dryness and warm skin,
temperature reached 37.5 C and above ,
the child has no genera; danger signs, with
stiff neck, no runny nose, no measles and
no other obvious cause of fever. The Child
may be classified as having:
A. Malaria
C. Fever: Malaria unlikely
B. Fever: No Malaria
D.
Severe
febrile
disease/Malaria

2.

It is understood that if a child were living

in a no malaria risk area but who has
presenting signs of stiff neck. The child
may be classified as having:
A. Severe febrile disease
B. Fever no
malaria
C. Malaria
D.
Severe Malaria

3.

You attended to a 3 year old child with

measles and with eye complications. This
should be treated with the following
EXCEPT:
A. Apply gentian violet
C. Give Vitamin A
B. Apply tetracycline ointment
D. Follow-up 2 days

4.

In classifying dengue cases, which of the

following is NOT possible classification of
dengue hemorrhagic fever?
A. None of these
C. Dengue Hemorrhagic Fever:
unlikely
B. Sever Dengue Hemorrhagic Fever
D.
Dengue
Hemorrhagic Fever

5.

You are attending to 5 cases of dengue in 2

clusters of Barangays assigned to you.
Which of the following treatment modalities
SHOULD NOT be considered if the children
you are attending to has severe dengue
hemorrhagic fever?
A. Give aspirin

is

Situation 2- Documentation is an important

aspect of every nurses activity. This is a
major area of responsibility which helps
facilitate continuity of work within a 24
hour cycle.
6.

A 26 year old mother was admitted for

hyperemesis gravidarum. While taking the
history of this client it would be MOST
important to report which of the following?
A. The client has cool lower extremity
bilaterally.
B. The client has diminished palpable
peripheral pulses.
C. The client is anxious about the effect of
her condition to the baby.
D. The client has allergy of shellfish

7.

You are on duty and you received report

from the previous shift. Which of the
following clients should you attend to
FIRST?
A. A client who is receiving ciprofloxacin
and complains of a fine macular rash
B. A client who is receiving a blood
transfusion and complains of a dry mouth
C. A client who is scheduled to receive
heparin and the PTT is 70 seconds
D. A client who is receiving IV potassium
and complains of burning at the IV site

8.

You are reviewing the nurses notes in your

clients chart. You would be MOST
concerned by which of the following
entries?
A. Foley catheter draining clear urine and
the pH is 6.5
B. The client drinks 3 glasses of orange
juice every day
C. The clients skin is blanched over the
scapular areas
D. Vital signs are within normal limits

9.

You are attending to clients in your clinic.

As you return to your desk you find 4
phone messages. Which of the following
messages should you return FIRST?
A. A client is nauseated and has vomited 6
times in the previous 24 hours.
B. A client with stage II decubitus ulcer at
home reports that the dressing has come
off.
C. A client is complaining of leg pain after
walking half a mile.
D. A client with cold symptoms has an oral
temperature of 39.4C
10. At approximately 6PM, a nurse deployed
for duty in one of the affiliate hospitals,
begin to open the nurse notes for the
evening shift. The last entry is noted for
1pm, and there is no signature. The MOST
appropriate nursing response is to:
A. Begin charting on the next line below
the last entry, inform the day nurse, to
make a last entry to complete the chart

2
B. Do not enter anything until the day nurse
has been notified of the problem and returns
to the unit to complete her charting.
C. Review with the client the activities after
1PM, and enter what are determined to be
the activities after 1PM.
D. Leave approximately 3 or 4 lines for the
day nurse to enter some of her missed
entries and sign the chart.
Situation 3- The nurse is involved in
community organizing activities of Barangay
Tapat. The following questions pertain to this
situation.
11. The nurse makes an ocular survey of
Barangay Tapat. Upon reaching the barangay
it is appropriate for her to:
A. Pay a visit to the barangay captain
C.
Introduce
self
to
the
community
B. Encourage community involvement
D.
Assemble
community
members for a meeting
12. Carrying out the planned activities involving
maximum
community
participation
is
referred to as:
A. Mobilization
B. Integration
C.
Community
Organization
D.
Community assembly

13. To ensure collective participation of the

people, community organization should be
formed through a community assembly. The
purpose of having community assemblies
are the following, EXCEPT:
A. Gain cooperation, pledge support and
work together on their own
B. Help people i9dentify their own problem
C. Plan for the solution of identified
problem/s
D. Undertake measures to solve existing
problems of the community
14. Which of the following approaches is the
BEST in applying community organization in
Community Health?
A. Primary Health Care
C. Community-Oriented Organization
B. Universal Health Care
D. Community Development
15. Community organizing ends when the
community is already self-reliant. This
signals that the community organizers are
now ready to pull out of the community
because:

A. Organizers can expand to other poor

communities
C. It indicates that
community organization is finished
B. It can evaluate the outcomes of the
programs
D.
It
will
prevent
dependency of the community

Situation 4- A nurse is assigned to a

community health center where the variety
of experiences and the culture of the
community influences the care she gives to
the clients.
16. While in the community health center, you
note various practices among the families
you serve. Which of the following situations
will be OF CONCERN to you as the nurse?
A. Aling Pat applies Vicks VapoRub to the
chest and back of her grandson with colds
B. Mang Berting wears a copper bracelet for
his rheumatoid arthritis
C. Aling Lita uses Atis seeds on the hair of
her granddaughter to treat lice.
D. Mang Pedro gives his son various herbs
everyday
17. Mr. Estrella diagnosed with Alzheimers
disease, is brought to the center by his
daughter to seek help regarding home care.
In planning the care of Mr. Estrella priority
should focus on
A. Providing food rich in fiber to prevent
constipation.
B. Protecting the client from possible injury
in his environment
C. Assisting the client to perform activities of
daily living.
D. Assisting all family members deal the
challenges of long term care of this client.
18. You are following up a client who has
cataract. The most important nursing
action/instruction to implement would be to
A. Advise the client to wear, dark glasses
indoors and outdoors to guard v.s. sun glare
B. Provide adequate lighting at home at all
times.
C. Instruct family not to change furniture
arrangement at home
D. Advise the client to have the cataracts
removed.
19. While on duty at the community health
center, some clients are brought for
consultation. Based on your assessment, the
FIRST client to attend would be:
A. Aling Tekya, with Dementia, who wanders
in the streets every morning.
B. Mang Miyo, 65 year old with congestive
heart failure and 3+ pitting edema.
C. Aling Lena, 56 year old, terminal client
with weight loss (15 lbs) last month.

3
D. Mang Ramon, 70 year old, with
Parkinsons
Disease
and
started
hallucinating.
20. You are visiting a newly discharged
cerebrovascular
accident
(CVA)
client
currently confined to a wheelchair for long
periods of time. Your most appropriate
PRIORITY intervention would be to:
A. Ask the client to move his buttocks every
two hours to increase blood circulation to
the area.
B. Prevent skin breakdown by putting a
pressure relieving cushion in the seat of the
wheelchair.
C. Refer to physical therapist to teach client
to transfer from bed to wheelchair.
D. Instruct family to feed client high protein
diet for better skin integrity.
Situation 5- Nurse Jen Delos Santos,
initiated the organizing of the Caring
Frontiers Nursing Service Company in
Leyte. This was envisioned to deliver health
care and various nursing services through
home health care services well within the
scope of nursing practice.
21. Nurse Dana is one of their Registry Officials
and acts as a liaison between families and
communities served by the company to
actively engage on policy and social change
that will support and promote family health
in their province. Nurse Dana is performing
what role?
A. Care Provider
B. Counselor
C. Client Advocate
D.
Facilitator
22. Formulating and implementing a supervisory
plan, monitoring and evaluating beginning
nurse practitioners performance in the
implementation of public health programs
are what functions of a public health nurse?
A. Trainer
B. Coordinator
C. Supervisor
D.
Manager
23. As an advocate, Registry Nurse Dana places
her clients rights as priority. She is aware
that advocacy work involves which of the
following?
A. Influencing public opinion
C. Coordination with the health
team
B. Obtaining a general information about the
community D. Prioritizing health conditions
and problems
24. According to the World Health Organization
(WHO), one of the leading causes of
mortality in the Philippines is which of the
following?
A. Leukemia
C. Malignant Neoplasm

B. Heart Disease
D. Lower respiratory tract infections
25. Registry Nurse Dana is conducting a
community
diagnosis
composed
of
Demographic
variables,
socio-economic
variables, health and illness patterns, health
resources and political/leadership patterns.
What type of community diagnosis is Nurse
Dana conducting?
A. Individualized Nursing Diagnosis
C. Comprehensive Community Diagnosis
B. Population Focused Diagnosis
D.
Problem
Oriented
Community
Diagnosis
Situation 6- Myths and fallacies as pertain
care of the birthing mothers and their
newborn have been debunked resulting in
the development of what is now known as
Essential Intrapartum Newborn Care or
EINC. The following applies.
26. On December 7, 2009, the Department of
Health issued an Administrative Order
implementing the ENC protocol with the goal
of rapidly reducing the number of newborn
deaths in the Philippines. With international
standards integrated in Intrapartal care the
program has now evolved into the EINC
program under the guidance of the W.H.O.
Now considered as myths and fallacies
include:
1. Use of enema to reduce the risk of
infections and shorten the duration of labor.
2. Shaving the pubic hair of women in
labor as hygienic practice to minimize
infection.
3. Restricted intake of food and fluid
during active labor for possible risk of
aspirating gastric contents due to
anesthesia
4. Application of IV therapy to hydrate
women dut to food and drink restrictions.
5. Use of fundal pressure to help the
mother in the expulsion of her fetus.
6. Early amniotomy and oxytocin
augmentation in order to prevent operative
delivery
A. 4, 5, and 6
B. none
of these
C. 1, 2 and 3
D. all of these
27. In the immediate care of the newborn there
are also practices which were debunked as
practices based on false beliefs. Which are
they?
1. Routine suctioning believed to be
necessary to clear the babys airway and
stimulate him to breathe.
2. Foot printing as a means of
Identification for the newborn.
3. Early bathing and washing as a form
of hygienic practice.

4
4. Routine Separation (baby in the
nursery while mother is in her room)
5. Continuance to providing artificial
feeding (starts with pre-lacteals then
artificial milks substitutes)
A. 2 and 5
B. 1, 3 and 4
C. only 2
D. All of
the above
28. On INTRAPARTAL CARE, one among 5
recommended practices include MATERNAL
POSITIONING especially during the 1 st stage
of labor. The recommended practice now is
A. Allow women to assume an upright
position
v.s.
the
former
recumbent
(supine/semi-recumbent and lateral)
B. Strictly follow the traditional medical
model of labor and delivery
C. Encourage women to take up the position
they find most comfortable to them
D. Allow women to assume any other upright
position (walking, standing, sitting, kneeling)
v.s. recumbent
29. On ESSENTIAL CARE OF THE NEWBORN, the
three (3) new major RECOMMENDED
PRACTICES are
1. Practice Rooming-in
2. Skin to skin contact
3. Strict Handwashing of Carers handling
the newborn child
4. Use of partograph
5. Properly timed cord clamping
6. Initiation of Breastfeeding
A. 1, 3 and 4
B. 4, 6
and 2
C. 2, 5, and 6
D. 4, 5 and 1:
30. Essential Intrapartum and Newborn Care
(EINC) is our countrys instrument in health
addressing the challenge of the United
Nations 2 out of 8 Millennium Development
Goals (MDGs) targeted to be achieved by
2015. Which are these 2 MGDs?
A. MDGs 3 and 6
B. MDGs 4 and 5
C. MDGs 1 and 2
D. MDGs 7 and 8
Situation 7- You are newly passed and
registered nurse applying for beginning
nursing job. While waiting you heard your
Parish Priest calling for volunteers for a
Parish-Based Health Program. you signed up
to help and practice your profession. Among
health conditions you would normally
encounter are obstetrical cases.
31. A 22 year old mother missed 2 of her
regular menstrual periods. The Parish
Medical Volunteer confirms an early,
intrauterine pregnancy. This is her 1 st
pregnancy. To determine her expected due
date, which of the following assessments is
most important?

A. Dates of last normal menstrual period

C. Age of menarche
B. Date of last intercourse
D. Dates of her 1st menstrual period
32. The action of hormones during pregnancy
affects the body by:
A. Blocking the release of insulin from the
pancreas C. Enhancing the conversion of
food to glucose
B. Raising the resistance to insulin utilization
D. Preventing the liver from
metabolizing glycogen
33. A 28 year old mother has had diabetes
mellitus since she was adolescent. Now she
is 8 weeks pregnant. Hyperglycemia during
the first trimester will have what effect on
the fetus?
A. Abnormal positioning of the fetus
C. Excessive fetal size
B. Hyperinsulinemia
D. Potential malformation of the
fetal organs
34. You also attend to another young diabetic
parishioner-mother who is in her 1 st
trimester of pregnancy. As her pregnancy
continues what changes in her medication
needs should you also anticipate?
A. A steady increase in insulin requirements
B. The variable pattern of insulin absorption
throughout the pregnancy requires constant
close adjustments
C. Oral hypoglycemic drugs will be given
several times daily.
D. A decrease in the need for short-acting
insulin
35. A glycosylated hemoglobin level is ordered
for a pregnant diabetic because it:
A. Will predict how well the pancreas can
respond to the stress of pregnancy
B. Gives diagnostic information related to
the peripheral effects of diabetes
C. Is the most accurate method of
determining present insulin levels
D. Indicates mean glucose level over a 1 to
3 month period
Situation 8- In the community, nurses
serves a pivotal role in the process of
communication exchanges between clients
and the providers of care. The following
events are evidences of these.
36. In a prenatal visit by Liz to your Family Care
clinic you noted her saying, during the first
3 months of my pregnancy I have been very
nauseated, and I do not seem to understand
why? Which may be your BEST response?
A. The nausea you experience is due to an
increase in the basal metabolic rate brought
about by your pregnancy

5
B. The nausea you experience is caused by
the secondary influx of hormones produced
by the endocrine system.
C. If you take different kinds of food you
will not be nauseated.
D. Fatigue as a result of your pregnancy
brings about your nausea.
37. On a Monday morning at your Family Care
Nursing Clinic, a mother of a 2-year old
postoperative child and who has just been
discharged
from
the
hospital
came
appearing to be overly anxious and tells you,
my child seem so restless. Your FIRST
course of action should be:
A. Try taking the child for a walk
C. Check and see when the child had his
last pain medication
B. Check the childs vital signs
D. Check if the childs sutures are still
intact
38. You opt that all Fridays are Family Care
Nursing clinic HOLIDAYS. On Fridays you
prefer to do personal visits. You follow-up
patients in their homes, do volunteer health
work in schools, or visit industries within the
vicinity. In a student health clinic a client
confides to you that her boyfriend informed
her that he tested positive for Hepatitis B.
which of the following is you BEST answer?
A.You will receive the Hepatitis B immune
globulin (HGBI)
B. Have you had sex with your boyfriend?
C. That must be real shocking to you.
D. You should also be tested for Hepatitis
B.
39. An eye surgeon aware of you Friday-Visit
Program called on you one day and referred
a 4-year old client whom he scheduled for
an eye surgery. When you met her mother
she asks how best to prepare her daughter
for the eye surgery. Which of the following
actions would be BEST?
A. Draw a picture of the eye and explain
what will happen during the surgery
B. Help the mother explain to the child how
to get ready for surgery using dolls
C. Instruct the mother to tell her daughter
that the surgery will only take an hour
D. Guide the mother to read her daughter an
age-appropriate illustrated book about eye
surgery
40. You are back on your usual Nursing Clinic
duties, it is a Tuesday and a woman at 38weeks gestation comes to you with problems
of vaginal bleeding. Which of the following
remarks, if made by the client would suggest
PLACENTA PREVIA as potenti9al cause of
bleeding?
A. I feel fine, but the bleeding scares me.
B. Ive been experiencing severe abdominal
cramps.

C. I feel nauseated more during the past

few weeks.
D. The bleeding started after I carried 4
bags of groceries.
Situation 9- Paula, a 12-month old infant,
was brought to the health center for her
regular well baby check up. Her mother is
concerned with her childs growth and
development. She expressed her desire to
learn more about this concern.
41. The childs birth weight was 8 lbs. upon
assessment the child now weighs 18 lbs. in
documenting this result, you know that this
weight is
A. Appropriate for the childs age
C. Above the expected weight
B. Below the expected weight
D. Individualized and thus unpredictable
42. In formulating the nursing diagnosis
regarding the mothers concern, which of the
following should you consider?
A. Health seeking behavior
B. Anxiety
C. Knowledge deficit
D. Altered health maintenance

43. In planning care for the infant, you should

advise the mother that the best way to help
her child complete the development task for
the first year is to
A. Respond to her consistently
B. Expose her to many caregivers to help
her learn variability
C. Keep her stimulated with many toys
D. Talk to her at a special time each day

44. To relieve teething

discomfort which
measure would you suggest an infants
mother to use?
A. Provide her with a fluid diet for 2 days C.
Ask her pediatrician for a sedative for her
B. Offer her Aspergum to chew
D. Give her a cold teething ring to chew

45. In evaluating the health teaching on

breastfeeding, which of the following
observations made by the mother would
reveal correct understanding of breastfed
infants?
A. Breastfed infants usually have fewer
stools than bottle-fed infants
B. Stools of breastfed infants tend o have a
strong odor.
C. Breastfed infants usually have soft stools
than bottle-fed infants
D. Stools of breastfed infants are usually
harder than those of bottle-fed infants

6
46. Nurse Nina is a Community Health nurse
conducting prenatal care at a Rural Health
Unit in one of the communities in Cotabato.
Nurse
Nina
is
aware
that
recent
developments in Maternal Care strongly
places emphasis on quality antenatal care.
the strength of this advocacy is on:
A. Consistent vaginal examination on every
prenatal visit
B. Proper care to every pregnant woman
providing support to normal pregnancy AND
early
detection
and
management
of
complications
C. Doing monthly antenatal care during the
first seven (7) months, every two weeks on
the 8th month, and weekly on the 9th month.
D. Spending more time with every pregnant
women especially the high risk ones
47. On May 12, 2012 a primigravida mother
named Mrs. Carla Del Pilar came to Nurse
Nina for check-up. Her EDC happens to be
May 21. What can you expect to find during
assessment?
A. Cervix open, FH-2 fingers below xyphoid
process, floating.
B. FH at least at the level of the xyphoid
process, engaged.
C. FH-2 fingers below xyphoid process,
engaged.
D. Cervix closed, unaffected, fundic height
(FH)-midway between the umbilicus and
symphysis pubis.
48. One Monday morning a community nursing
assignment, Nurse Nina was transferred to
their RHU-attached district hospital. She
attends to Mrs. Lalaine Mariano who is on
her second vaginal examination and labor.
Nurse Nina finds the fetus in the right
occiput anterior position and at (-) 1 station.
Nurse Nina based her findings from
A. 1 cm below the ischial spines presentation
B. 1 cm above the ischial spines
presentation
C. Presentation in no relationship with the
ischial spine condition
D. Presentation directly in line with that of
the ischial spines
49. By 12:00nn same Monday, another patient
attended to by nurse Lucy in the RHU named
Mrs. Nicole Angeles got admitted in active
labor, Nurse Nina locates the fetal heart
sounds in the upper right quadrant of the
mothers abdomen. Nurse Nina would
recognize which of the following?
A. This position is referred to as left anteropelvic
B. Nicole will probably deliver very quickly
and without problems
C. The fetus is in the most common anterior
fetal position

D. Nicole
delivery

will

probably

have

breech

50. By 3pm, Nurse Nina was done with her

endorsement when another mother, Mrs.
Kristine De Castro came in active labor. She
trembles was very tense with contractions
and quite irritable. She frequently says,
Hindi ko na kaya ito! (I can no longer bear
this!). this behavior may be indicative of
the client
A. Developing some abnormality in terms of
uterine contractions
B. Already entering the transition phase of
labor
C. As having been poorly prepared for labor
in the parents classes
D. Needs immediate administration of an
analgesic or anesthetic
Situation 11- having a privately owned,
community-situated nursing care facility
makes the nurse develop rapport with
greater number of community residents. She
can become a vital community resource with
her nursing skills and knowledge BUT with
the nature of the nurses work, it is
necessary to be conscious about legal
considerations.
51. Mikko, a 5-year old boy and his mother are
your regular clients in your Nursing Clinic.
You accompanied them to a nearby hospital
for referral of what you suspected as an
acute case of appendicitis. Mikkos parents
have been legally separated for 5 years now
but both enjoy joint legal custody. The
nurse on duty sought your assistance in
asking the mother for her informed consent
for immediate surgery. Together with the
nurse-on-duty which f the following would
be the BEST action?
A. Have mother sign the consent and
continue the childs preoperative preparation
B. Contact the father to obtain consent
C. Have mother sign the consent and inform
surgery
D. Have mother sign the consent and inform
the surgeon right away

52. Another of your pediatric patients named

Arjay got rushed to the hospital with
sustained bruises and lacerations, and a
fractured arm. As Arjay was being treated in
the ER, his mother requested for you to
come and assist them and the nurse-on-duty
(NOD) was informed of your coming as their
family nurse. Upon arrival you coordinated
with the NOD and later you were able to
obtain Arjays confession that he got
involved in a frat fight outside school. You

7
and the NOD agreed on which priority
actions?
A. Ensure documentation on the Arjays
chart
B. Share the information with the hospital
social worker
C. Share only this information with fellow
health professionals
D. Call for the Police and report the findings
53. You got invited as a speaker in a class of
nursing students to share your experiences
and understanding on the handling of
potential legal cases while in practice. Which
acts would constitute battery?
A. When you administer an injection to a
schizophrenic patient who refuses to take
the medication because he believes it is
poison
B. When on doctors order you restrain an
agitated patient inside the E.R.
C. When you chase a patient who tries to
run away while taking a walk with you
around the hospital
D. When you hold the arms of a manic
patient who strikes you
54. Jayvee, a 10 year old boy and his family are
your clients. He was admitted to the hospital
for a skin graft surgery. You went to visit
him and when you came he is being rolled
back from surgery. He is on D5W infusing
into his left arm and you introduced yourself
then check with the nurse-on-duty (NOD)
and got the following information, he weighs
50 lbs (23.6kg) and the physicians order
was D5W 2,000cc/24 hours. At this
instance you opted to engage the NOD to
A. Set the IV infusion pump controller to run
at 84 gtts/min
B. Monitor the patient for fluid and
electrolyte imbalance
C. Call the physician to clarify the IV fluid
order
D. Ensure accurate records of the patients
intake and output
55. You visited one of your family clients, a 26year old mother whose son died of Sudden
Infant Death Syndrome (SIDS). As you were
conversing it is sound for you to
A. Ask how her son was positioned in bed
while in the hospital at the time of his death.
B. Allow the mother to cry and talk about
her son and related concerns
C. Ask about her other children at home
D. Explain the case of SIDS
Situation 12- Mary Ann, 32 years old, G2P1,
28 weeks pregnant, visits your clinic and
told you that she has been having various
discomforts during this pregnancy and
wanted some advises.

56. Mary Ann had leg cramps that come and go

and are extremely painful. the most effective
measure that you can suggest to relieve
cramps is to:
A. Lie down and elevate affected leg with a
pillow until the cramps stop
B. Extend affected leg with knee straight
then bend foot towards the body
C. Increase intake of high phosphorus foods
D. Stand with feet flat on floor and tiptoe
alternately, until cramping stops
57. Mary Ann complains that she doesnt get
enough rest and sleep because of her
frequent trips to the bathroom to urinate,
the best advise you can give is for her to:
A. Bring urine specimen for urinalysis to
check for possible infection
B. Bring a commode to the bedroom to
reduce trips to the bathroom
C. Hold urge to urinate to improve muscle
tone and bladder capacity
D. Drink more fluids at daytime and
decrease intake at night
58. Mary Ann noted that she has beginning
varicosities. You informed Susan that
varicosities are caused by pooling of blood in
the large veins of the legs. Prevention of this
condition involves the following, EXCEPT:
A. Walk around to stimulate blood flow if
working in prolonged sitting position
B. When sitting for a long time elevate legs
six inches from the floor
C. Do not wear tight clothing or crossings
legs at the knees
D. When getting out of bed, use support
stockings above varicosities
59. Mary Ann complained about difficulty in
elimination and worried that she might
develop hemorrhoids. You may advise Mary
Ann to:
1. take fiber-rich foods e.g. fresh fruits
and vegetables, fruit juices, salads, oatmeal
2. Drink up to 8 glasses of water daily
including coffee, tea and softdrinks.
3. Exercise regularly and establish a
regular time for elimination
4. During elimination use footrest to
avoid straining
A. 1, 2, 3 and 4
B. 1, 3 and 4
C. 1, 2 and 3
D. 2, 3 and 4
60. Mary Ann yells you that she sometimes does
not feel her babys movements. You can
instruct Susan to do fetal movement count
(FMC) or kick counts. These statements are
true regarding the fetal movement count
1. Client assumes side-lying or reclining
position and palpates fetal movements for
an hour counting for 10
movements

8
2. Less than 10 movements within two
hours may need further evaluation and
should be reported to the
nurse.
3. Counting fetal movement is best done
at the same time daily, when the mother is
ready to go to sleep
4. A well oxygenated fetus moves
frequently while a fetus with compromised
oxygen supple conserves
energy with less activity.
A. 1, 2 and 3
B. 2, 3
and 4
C. 1, 2 and 4
D. 1, 3 and 4
Situation 13- Mrs. Rachel Daquis was
admitted due to lumbo-sacral pain. She is a
G5P3 with 9 weeks AOG. On admission the
following findings were revealed: BOWintact, cervical dilatation of 4cm, Descent-5,
FHT 150/minute, BP-120/80 mmHg, Pulse
rate-60 beats/minute and temperature is
36.8 C. Using the PARTOGRAPH you can
respons to the following questions and
situations affecting Mrs. Rachel Daquis.
61. You immediately can interpret from the
partograph
that
Mrs.
Rachel
Daquis
condition as
A. There is normal progress of labor
B. Unsatisfactory progress due to cephalopelvic disproportion
C. There is fetal-distress
D.
Unsatisfactory
progress
due
to
inadequate uterine activity
62. You recorded a 3+ in the molding, this
means that:
A. The bones are touching each other
B. The bones are severely overlapping each
other
C. The bones are overlapping each other
D. The bones are separated and sutures can
be felt easily
63. Which of the following nursing action should
you not include in the care or Mrs. Daquis?
A. Labor Augmentation/doctors order
B. Amniotomy
C. Observe for 30 minutes more for possible
caesarian section if no improvement
D. Continue monitoring fetal heart beat and
cervical dilatation
64. At 1 AM, what is the frequency and duration
of Mrs. Daquis uterine contraction?
A. Two contractions in 15 minutes lasting
more than 40 seconds
B. Three contractions in 10 minutes lasting
more than 40 seconds
C. Three contractions in 15 minutes lasting
more than 40 seconds
D. Three contractions in 10 minutes lasting
less than 40 seconds

65. The descent of the head at 1PM is at:

A. Two fingers above the symphysis pubis
C. Three fingers above the symphysis
pubis
B. Five fingers above the symphysis pubis
D. The fetal head is engaged
Situation 14- Good and comprehensive
nursing assessment among infants and
children
is
an
important
aspect
of
determining appropriate, safe and quality
nursing care interventions. The following
apply:
66. A 4-week old infant with symptoms of
pyloric stenosis was brought by her mother
to your clinic. Which of the following
statements would you expect the mother to
make about her sons symptoms?
A. My sons bowel movements have turned
black and sticky
B. My son spits green liquid after feeding.
C. My son seems hungry all the time.
D. I really have to encourage my son to
suck the bottle
67. A teenager comes to your clinic with
problems of fatigue, sore throat, and flu-like
symptoms in the last 2 weeks. Physical
examination reveals enlarged lymph nodes
and temperature of 37.9 C. Which of these
statements do you BEST make?
A. Stay in your room until all of your
symptoms are gone.
B. Do not share your drinking glass or
silverware with anybody.
C. Eat in a separate room away from your
family.
D. Cover your mouth and nose when you
sneeze or cough.
68. You are caring for a 2-month old infant to
which a pH probe test indicated reflux.
Which nursing action is MOST appropriate?
A. Raise the head of infants bed
C. Instruct properly the mother how to
do CPR
B. Do not give the next feeding
D. Keep a normal feeding
schedule
69. You are visiting a 3-month old child whom
you previously saw in your clinic. He is now
on Christophers Traction for developmental
dysplasia of the hips. Which of the following
toys would be appropriate for you to offer
the infant to keep him occupied while
hospitalized?
A. Colorful plastic, non-toxic blocks
C. A stuffed toy animal
B. A toy rattle
D. Nursery rhymes played on tape

9
70. One early morning as you were opening your
nursing clinic, a 5-year old boy was rushed
to you in an emergency after ingesting a
bottle of baby aspirin. You are to observe
the boy for which signs and symptoms?
A. Tinnitus and gastric distress
C. Nausea and vertigo
B. Dysrrhythmia and hypoventilation
D. Epistaxis and paralysis
Situation 15- After 10 meaningful years of
professional practice and using her savings,
Nurse Trish decides to set up her proprietary
home healthcare agency. This may be
regarded as another journey towards
personal and professional development.
71. As owner of the agency, Nurse Trish must be
concerned about:
A. Making her agency yield reasonable
return of investments (ROI) for viability and
sustained business growth
B. Finding out her agency can be exempt
from paying taxes
C. Looking for funding support from other
business organizations
D. Knowing which government regulatory
agencies she should report to
72. Nurse Trish hires registered nurses to work
with her as home healthcare nurses whom
she assigns to individuals and families
requiring nursing care in their homes. One
such case is a 60 year old client who needs
irrigation of his colostomy following surgery
for cancer. This case may not be qualify of
Phil Health reimbursement because the
client:
A. Qualifies as low-income client
C. Is under the age of 65
B. Is under home-based care
D. Is not considered handicapped

73. Nurse Trish has a caseload of clients whom

she needs to see on a regular basis. Which
of the following clients may immediately be
admitted as a matter of PRIORITY to a
private home healthcare program?
A. A woman who has delivered a normal
healthy infant in a government-managed
birthing center
B. A client in the terminal stages of cancer
at the hospital and will be discharged for
home care
C. A family with three (3) family members
who tested positive for tuberculosis and just
moved into a barangay
D. A teenage drug abuser who has refused
medical treatment but is being seen by a a
counselor at school

74. A client who had open heart surgery 2

weeks ago and about to be discharged was
referred to nurse Trishs Home HealthCare
Agency for daily dressing changes, cardiac
rehabilitation and physical therapy. The
assigned home healthcare nurse should
A. Complete the necessary assessment on a
weekly basis
B. Develop an individualized plan of care
C. Directly supervise the physical therapy
the client receives
D. Provide daily physical care for the client
75. Nurse Trish plans to present t the local city
health board a Stop Smoking campaign to
the communitys local public as her social
responsibility program. Trish understands
that if the proposal is accepted, the funding
would come from
A. Philanthropic donations
B. Philhealth contributions
C. Local community funds generated from
taxes
D. The home Healthcare agency owned by
Nurse Trish
Situation 16- In some hospitals, nurses
assigned
to
care
for
mothers
with
reproductive health concerns are given a
TRIAGE assignment. They rotate in the
obstetrics unit/ward, the labor room, and
delivery room. Your nursing to clients in
these units are vital in maintaining wellness
of these women. The following questions
apply.
76. You are taking care of a woman in the labor
room whose abdomen remains rigid and
hard between contractions. Upon further
assessment the fetal heart rate registered at
100/minute. The PRIORITY PROBLEMS in the
care of this client would be
A. Risk for fetal death
C. Ineffective breathing
B. Alteration in comfort
D. Fluid and electrolyte imbalance
77. During a vaginal examination, a prolapsed
cord is assessed, your PRIORITY intervention
would be to
A. Instruct the client not to push during
contractions
C. Prepare client for
emergency caesarean section
B. ask relatives to leave the room for privacy
D.
Place
the
client
in
Trendelenberg position
78. Of the following clients endorsed to you by
the outgoing nurse on duty, who would you
assess immediately? the client who:
A. Exhibits early decelerations on the fetal
monitor

10
B. Is upset because her obstetrician in on
vocation
C. is 10 cm dilated and 100% effaced
D. cannot decide if she wants anesthesia
during delivery
79. You are assigned to the postpartum
unit/ward and you are to take care of
several clients. When prioritizing care for
these clients you will first assess the client
who:
A. Is upset because the baby does not nurse
when breast fed
B. Has saturated several sanity napkin
during the night
C. Refuses to have the newborn room-in
with her
D. Complains of pain and burning sensation
upon urination
80. Your client in labor is diagnosed with preeclampsia. Which interventions would be
most appropriate for this client?
1.
Check
current
intravenous
administration of Magnesium Sulfate
2. Frequently check clients telemetry
monitor
3. Assess the clients deep tendon
reflexes
4. Inform the nursery for incoming
infant
5.
Administer
Furosemide
(Lasix)
intravenously as ordered
A. 2, 3, 5
B. 1, 2, 5
C. 2, 4, 5
D. 1, 3, 4
Situation 17- You are the nurse assigned in
the OB-GYNE Unit of the hospital in your
Provincial Hospital. The following conditions
and situations apply.
81. A client named Heidi; gravid 2 para 1 was
admitted with complaints of hypertension.
She even remarked that her wedding band
was tight. In doing your assessment which
of the following directs you to entertain early
pre-eclampsia?
A. Pain in her epigastrium together with
headache C.
Blurring
of
vision and
proteinuria
B. Swelling of her face with proteinuria
D. Hypertonic reflexes together with
polyuria
82.

You also have Lailani who is on her 4 th

Stage of Labor. Where do you palpate the
fundus?
A. 2 cm above the umbilicus
C. to the right of the umbilicus
B. 3 cm below the umbilicus
D. at the umbilicus

83. Another patient a 21 year old woman who is

at her 16-weeks gestation and underwent
amniocentesis. Her name is Beverly. She
asked you what her OB doctor intends to
find
out
from
the
procedure.
Your
appropriate response is based on the
understanding that which of the following
conditions may be detected through this
test?
A. cleft lip palate
C. Tetralogy of Fallot
B. Talipes equinovarus
D. Hemolytic disease of the newborn
84. Doctor Vincent Magalong is attending to a
43-year old woman whom he had confined
for observation and whom he just placed on
estrogen (premarin) 0.625mg OD. Learning
about this treatment regimen you are aware
of the initial side effects of this medication
which is?
A. Nausea
B. Tinnitus
C. Visual disturbances D. Ataxia
85. You are caring for Reyna, a multipara client
who just delivered a female infant one hour
ago. You observed that Reynas breasts are
soft; the uterus boggy, to the right of the
midline, and 2 cm below the umbilicus;
moderate lochia rubra. What action is called
for you to undertake with these findings?
A. Perform a straight catheterization
B. Massage the uterine fundus
C. Put her baby to her breast
D. Offer bedpan immediately
Situation 18- As it is true that health
education is very m$uch a great part of our
nursing responsibilities, the same should be
evidently practiced with birthing mothers.
The following conditions speak of these
responsibilities.
86. A diabetic mother named Ruffa plans to
breastfeed her baby. You explained that, if
Ruffa is hyperglycemic,
A. The production of milk may be impaired
C. Her baby will not grow well
B. Her baby will receive insulin in the milk
D. The glucose content of her breast milk
may be high
87. Shine has successfully adapted in her letdown reflex and ably breastfeeding, but
preventing the occurrence of cracked nipples
now becomes one of your nursing concerns.
Shine should therefore be taught to:
A. Wash her nipples with water only
C. Use plastic bra liners
B. Nurse at least 20 minutes on each breast
the first day
D. Apply lanolin prior to
feelings

11
88. Kimberly just delivered her first baby and
whom she is expected to breastfeed. In the
development of your teaching plan which of
the following instruction must you include?
A. Try to schedule feedings at least every 3
to 4 hours C. Avoid nursing bras with
plastic lining
B. Wash nipples with soap and water before
each feeding
D.
Supplement
with
water feedings when necessary
89. Jacks prenatal antibody titer shows that she
is not immune to rubella and will receive the
immunization after delivery. You would
include which of the following instructions in
your teaching plan?
A. Breastfeeding should be postponed for 5
days after the injection
B.
Another
immunization
should
be
administered in the next pregnancy
C. Pregnancy must be avoided for the next 3
months
D. An injection will be needed after each
succeeding pregnancy
90. Jasmine had a normal vaginal delivery 12
hours ago and is to be discharged from the
birthing center. You evaluated that Jasmin
understands the teaching related to the
episiotomy and perineal area when she
states,
A. The ice pack should be removed for 10
minutes before replacing it.
B. The anesthetic spray, then the heat
lamp, will help a lot.
C. The water for the Sitz bath should be
warm, about 102-105 F.
D. I know the stitches will be removed at
my postpartum clinic visit.
Situation 19- A current initiative of the
Department of Health (DOH) is the program
called Essential Newborn Care or ENC. This
outlines simple yet meaningful measures to
be undertaken by healthcare workers in
doing
immediate
newborn
care
management. The following situations apply.
91. Nurse Dianne is a member of the birthing
team the day Mrs. Gador gave birth to her
1st born. Inside the delivery room nurse
Jhoana assisted the attending obstetrician.
To address the concerns of keeping the baby
warm, her first step in obtaining thermal
protection for the newborn was
A. Drying the baby thoroughly immediately
after birth
B. Covering the baby with a clean, dry cloth
after the cord has been cut
C. Covering the baby with a clean, dry cloth
immediately after birth
D. Drying the baby thoroughly after the cord
has been cut

92. Nurse Dianne did not stop by simply drying

the baby thoroughly upon birth, she
observed other details as essential part of
the immediate care of a normal newborn
which included:
A. Skin-to-skin contact followed by placin30g
the baby in a warming incubator
B. Removing used wet cloth, and covering
the baby with clean, dry cloth
C. Stimulating the baby by slapping the
soles of the babys feet
D. Deep suctioning of the airway to remove
mucus
93. In further applying essential newborn care
(ENC), Nurse Dianne keeps in mind that care
of the umbilicus should include:
A. Cleansing with cooled, boiled water and
leaving umbilicus uncovered
B. Applying antibiotic cream
C. Covering with a sterile compress
D. Cleansing with alcohol
94. Administration of Vitamin K to the newborn
is necessary since
A. Newborns have no intestinal bacteria
B. Hemolysis of the fetal red blood cells
destroys vitamin K
C. The newborns liver is incapable of
producing sufficient vitamin K yet
D. Newborns are susceptible to avitaminosis
95. Cord clamping and the traditional milking
of the cord immediately post delivery have
now proven to be non-beneficial and may
result
in
causing
more
harm
and
complications especially in preterms and
fragile blood vessels in the brain of the
newborn. NOW new practices have been
introduced as part of essential newborn
care termed as
A. Properly Timed Cord Clamping
C. Unang Yakap
B. Routine separation
D. Partographing
Situation 20- Care of children, well, at risk,
or even at high risk conditions places
overwhelming responsibilities to nurses. The
following conditions apply.
96. A couple brought with them their 7-year old
girl diagnosed as having pituitary dwarfism.
The couple seems anxious and was looking
for some kind of emotion and psychological
support. In your assessment, you expected
which clinical manifestations to be MOST
likely to be evident?
A. Abdominal body proportions
C. Delicate features
B. Course, dry skin
D. Early sexual maturation

12
97. A 14 year old girl whose parents have been
consulting with you in your Family Care
Nursing Clinic (FCNC) was admitted to the
hospital for treatment of 2nd and 3rd degree
burns sustained from a house fire. You
visited them in the hospital and noted an IV
infusion started over the girls left forearm.
Instantly what comes to mind is that the
primary purpose of this IV is to:
A. Maintain fluid balance
C. Provide a route for pain medications
B. Prevent GI upset
D. Obtain blood specimens for analysis
98. A toddler name Louie, whose parents were
also consulting in your FCNC had lead
poisoning and was rushed to the hospital.
There was an order to encourage fluids and
the same were relayed to the parents. When
you visited the parents asked what kind of
fluids are best given, and as a family nurse
coordinating closely with the nurse-on-duty
(NOD) you reiterated that it is best to give:
A. Fruit juices
B. Orange juice
C. Water
D. Milk
99. A 24-year old single mother dropped by your
FCNC and tells you that she always have
difficulty forming relationships. The mother

conveyed to you the message that she is

worried that her 7-year old daughter might
have the same problems later. Of the
following statements which do you think is
the BEST to make?
A. Children develop trust from 6-12 years
of age.
B. Children develop trust from birth to 18
months of age.
C. Children develop trust from 18 months
to 3 years of age
D. Children develop from 3 to 6 years of
age.
100.
Again at you FCNC, a couple came to
you with relating problems relative to the
care of their newborn with fetal alcohol
syndrome. Which of the following should be
reiterated as important considerations by the
parents?
A. Provide feedings via gavage to decrease
energy expenditure
B.
Decrease
touch
to
prevent
overstimulation
C. Replace vitamins depleted as a result of
poor maternal diet
D. Prevent iron deficiency anemia