SUMMER GRP 3B R/E JULY 14 6. Naya is concerned that she has been taking 11.

oncerned that she has been taking 11.Immediately after birth the nurse Aguinaya notes
medication in the first trimester before she was aware the following on a male newborn: respirations 66;
1. To determine the nutritional status of the pregnant of her pregnancy. The nurse looks up the medication apical hearth rate 160 BPM, nostril flaring; mild
woman, the following should be considered: intercostal retractions; and grunting at the end of
and finds that it is categorized for level of fetal risk as
expiration. Which of the following should the nurse do?
A. Height, Weight and MUAC (MID-UPPER ARM FDA Category A for drug use during pregnancy. The A. Call the assessment data to the physician’s attention
CIRCUMFERENCE) nurse would inform the pt that: B. Start oxygen per nasal cannula at 2 L/min.
B. Height, Skin Color and MUAC C. Suction the infant’s mouth and nares
C. Height, Weight, Hair Color A. The medication may cause serious harm to her D. Recognize this as normal first period of reactivity
D. None of the Above newborn
B. The medication is not known to cause fetal harm
12.The order reads: administer 1 gm Ampicillin IV q 4
based on current research
2. The recommended timing of visit throughout the hours. The pharmacy sends the medication diluted in
C. The medication has abortive properties
pregnancy are the following: 50 ml with the instructions to administer over 30
D. There is insufficient human studies conducted to
A. 1st visit (not applicable), 2nd visit (24-26 weeks), minutes. The infusion pump runs in Ml/hour. The
establish fetal risks
3rd visit (32 weeks), 4th visit (during labor) nurse will set the pump to how many mL/hr?
B. 1st visit (12-24 weeks), 2nd visit (32 weeks), 3rd
7. Of the following infections, the one known to be a
visit (33 weeks), 4th visit (36-38 weeks) A. 25ml/hr
powerful, multi-system teratogen is:
C. 1st visit (8-12 weeks), 2nd visit (16- 20 weeks), B. 100 ml/hr
A. Rubella
3rd visit (24-32 weeks), 4th visit (36-38 weeks) B. Rubeola C. 50 ml/hr
D. 1st visit (8-12 weeks), 2nd visit (24-26 weeks), 3rd C. Covid-19 D. 60 ml/hr
visit (32 weeks), 4th visit (36-38 weeks) D. Community Acquired Pneumonia
13. A 20-year-old pt at 10 weeks gestation is preparing
8. Before assessing the postpartum client’s uterus for for her first prenatal visit. She confides, “This
3. A woman is being treated for pre-eclampsia with pregnancy was unplanned, I’m not sure if I want to be
firmness and position in relation to the umbilicus and
magnesium sulfate. The nurse is concerned that the pt pregnant or not. I haven’t even decided whether I’m
midline, which of the following should the nurse do
is in early drug toxicity. What assessment finding by going to continue the pregnancy.” Which of the
first?
the nurse indicates early magnesium sulfate toxicity? following is the best response?
A. Assess the vital signs
A. Blood pressure of 140/90 B. Administer analgesia A. “ At your age, it’s normal to have doubts. Pls call your
B. Areflexia C. Ambulate her in the hall partner so we can discuss about your situation”
C. Polyuria D. Assist her to urinate B. “It’s common to feel ambivalent about pregnancy in
D. Hyperthermia the first trimester. Let’s talk about your
situation.”
9. The nurse prepares a plan of care for the client with C.“I understand how you fill, I will refer you to a family
4. Kulasa a 35 y.o G2P1 just delivered a newborn who pre-eclampsia and documents that if the client planning counsellor”
was later diagnosed with Spina Bifida. The nurse is progresses from pre-eclampsia to eclampsia, the nurse D. “ You have to think about your baby’s future, He/she
aware that this condition can be prevented through should take which first action? might one day become our President”
taking supplements of: A. Administer oxygen by face mask
A. Folic Acid B. Clear and maintain an open airway 14.Which of the following actions would be least effective
B. Vit. A C. Administer Magnesium Sulfate Iv in maintaining a neutral thermal environment for the
C. Ferrous Sulfate (Iron) D. Assess BP and FHR newborn?
D. Vit C A. Placing infant under radiant warmer after bathing
10. The nurse assists in the vaginal delivery of a newborn B. Covering the scale with a warmed blanket prior to
weighing
5. Dr. Stranger ordered to incorporate 3 iu of Oxytocin infant. After the delivery, the nurse observes the umbilical
C. Placing crib close to nursery window for family
to the Plain NSS @ 300 cc level, of a client in labor. cord lengthen and a spurt of blood from the vagina. The viewing
The nurse knows that the stock dose is 10 units/ml. nurse documents these observations as a sign of which D. Covering the infant’s head with a knit stockinette
Calculate the appropriate dose to be given. condition?
A. 30 ml A. Hemorrhage 15. A primigravida presents to labor and delivery stating
B. 3 ml B. Uterine Atony she is 39 weeks pregnant and her water broke 12hours
C. .3 ml C. Placenta Previa ago. Her contractions are irregular and she is dilated 4
D. 1.5 ml D. Placental Separation cm. BP100/60. Which medication order does the nurse
anticipate?
 A. Oxytocin C. Their skin is more susceptible to conduction of cold
B. HNBB (Buscopan) D. They are preterm so are born relatively small in size 26. The nurse is providing nutrition counseling to a
C. Magnesium Sulfate primigravida who is 10 weeks pregnant. Which meal
D. Valium
21. Baby John develops hyperbilirubinemia. What is a choice stated by the client indicates she needs
method used to treat hyperbilirubinemia in a additional information?
16. Naya is scheduled to have an ultrasound examination.
newborn? A. Black beans, wild rice, collard greens
What instructions would you give her before her
A. Keeping infants in a warm and dark environment B. Dry cereal, milk, dried cranberries
examination?
B. Administration of cardiovascular stimulant C. Tuna, broccoli, baked potato
A. The intravenous fluid infused to dilate your uterus
C. Gentle exercise to stop muscle breakdown D. Beef strips, lentils, red peppers
does not hurt the fetus
D. Early feeding to speed passage of meconium
B. you will need to drink at least 3 glasses of fluid
27. The pregnant client (GlPO) in the first trimester tells
before the procedure
the nurse that she is anxious about losing her baby,
C. void immediately before the procedure to reduce
22. Ms. Aguinaya is scheduled for CS delivery under prenatal care, and her labor and birth. Which teaching
your bladder size
General Anesthesia due to prolonged labor and leaking need should the nurse identify as priority?
D. you can have medicine for pain for any contractions
BOW. What type of drug is usually prescribed to A. Sexual relations with her spouse
cause by the test
minimize the risk of aspiration of vomitus? B. Fetal growth and development
17. Naya is scheduled to have an ultrasound C. Options for labor and delivery
examination. What instructions would you give her A. anticonvulsant such as diazepam (Valium). D. Preparing needed items for the baby
before her examination? B. A nerve relaxant such as Phenobarbital.
A. The intravenous fluid infused to dilate your uterus C. Metoclopramide (Reglan) to speed gastric emptying. 28. The nurse is teaching the client who is wishing to
does not hurt the fetus D. Oxytocin to increase the effectiveness of labor travel by airplane during the first 36 weeks of her
B. you will need to drink at least 3 glasses of fluid pregnancy. Which is the primary risk of air travel for
before the procedure 23.Ms. Aguinaya reports in early labor she isn’t having this client that the nurse should address?
C. void immediately before the procedure to reduce much pain. You assess that her contractions are also A. Risk of preterm labor
your bladder size not strong. What position usually promotes efficient B. Deep vein thrombosis
D. you can have medicine for pain for any contractions uterine contractions in any labor? C. Spontaneous abortion
cause by the test A. Sitting or standing C. Lying prone D. Nausea and vomiting
B. Lying supine D. Side-lying position
18. At 17 weeks’ gestation, a type 1 diabetic undergoes 29.. The client who is actively bleeding due to a
an ultrasound examination. What information 24. The client tells the nurse, “Most days, I am so spontaneous abortion asks the nurse why this is
about the fetus at this time in pregnancy would be the happy I am pregnant, but other days, I am not sure happening. The nurse advises the client that the
results of this examination provide? that I am ready to have a baby.” Which is the most majority of first-trimester losses are related to which
A. Placental maturity C. Gestational age accurate response from the nurse? problem?
B. Estimated fetal weight D. Fetal lung maturity A. “This is such a happy time in your life. You need to be A. Cervical incompetence
optimistic to feel happy.” B. Chronic maternal disease
19. The Code of Nurses B. “How does your spouse feel about the pregnancy? I C. Poor implantation
A. Delineates all obligations and responsibilities of the hope he is happy about the baby.” D. Chromosomal abnormalities
nurse C. “Feeling differently from day to day is normal. How do
B. Is a binding oath, which tells nurses how to make you feel today?” 30. The pregnant client presents with vaginal bleeding
ethical decisions D. “Why do you feel this way? Is there something I can and increasing cramping. Her exam reveals that the
C. Assists the nurse in formulating a personal belief do to make it better for you?” cervical os is open. Which term should the nurse
system expect to see in the client’s chart notation to most
D. Supports the concept of respect for all persons 25. The nurse is counseling the client who is pregnant. accurately describe the client’ condition?
The nurse should teach that which assessment finding A. Ectopic pregnancy
20. Why are small-for-gestational-age newborns at risks requires follow-up with the HCP? B. Complete abortion
for difficulty maintaining body temperature? A. Dependent edema C. Imminent abortion
A. They do not have as many fat stores as other B. Edema in the hands D. Incomplete abortion
infants C. Generalized edema
B. They are more active than usual so throw off covers D. Edema occurring every evening
31. The nurse finds documentation in the 4-hour-old 4. A 17 year old gymnast is admitted to the hospital due D. Impaired social interaction related to repressed
newborn’s medical record that states, “Clamping of the to weight loss and dehydration secondary to anger.
umbilical cord was delayed until cord pulsations starvation. Which of the following nursing diagnoses
ceased.” When assessing and collecting additional will be given priority for the client? 10. The nurse ensures a therapeutic environment for
information about the newborn, what effect should the A. altered self-image the client. Which of the following best describes a
nurse find as a result of the delayed cord clamping? B. fluid volume deficit therapeutic milieu?
C. altered nutrition less than body requirements A. A therapy that rewards adaptive behavior
A. More rapid expulsion of meconium by the newborn D. altered family process B. A cognitive approach to change behavior
B. Increased level of newborn alertness after birth 5.  What is the best intervention to teach the client when C. A living, learning or working environment.
C. An increase in the newbom’s initial temperature she feels the need to starve? D. A permissive and congenial environment
D. An increase in the newbom’s hemoglobin and A. Allow her to starve to relieve her anxiety
hematocrit B. Do a short term exercise until the urge passes 11. The nurse asks a client to roll up his sleeves so she
C. Approach the client and talk out her feelings can take his blood pressure. The client replies “If you
32. The nurse is caring for the newborn infant. The D. Call her mother on the phone and tell her how she want I can go naked for you.” The most therapeutic
nurse should prepare to assess the newborn’s anterior feels response by the nurse is:
fontanel by which method? 6. Initial intervention for a client with Phobia should be A. “You’re attractive but I’m not interested.”
to: B. “You wouldn’t be the first that I will see naked.”
A. Lay the infant on his or her back. A. Encourage to verbalize his fears as much as he C. “I will report you to the guard if you don’t control
B. Stimulate the infant to cry strongly. wants yourself.”
C. Feel near the parietal and occipital bones. B. Assist him to find meaning to his feelings in relation D. “I only need access to your arm. Putting up your
D. Place the infant in a sitting position. to his past. sleeve is fine.”
C. Establish trust through a consistent approach.
PSYCHIATRIC NURSING D. Accept his fears without criticizing. 12. Knowledge and skills in the care of violent clients is
1  When working with a male client suffering phobia vital in the psychiatric unit. A nurse observes that a
about black cats, Nurse Trish should anticipate that a 7. Which of the following should be included in the client with a potential for violence is agitated, pacing
problem for this client would be? health teachings among clients receiving Valium: up and down the hallway and making aggressive
1. Anxiety when discussing phobia A. Avoid taking CNS depressant like alcohol. remarks. Which of the following statements is most
2. Anger toward the feared object B. There are no restrictions in activities. appropriate to make to this patient?
3. Denying that the phobia exist C. Limit fluid intake. A. What is causing you to become agitated?
4. Distortion of reality when completing daily D. Any beverage like coffee may be taken B. You need to stop that behavior now.
routines 8. . A young woman is brought to the emergency room C. You will need to be restrained if you do not change
appearing depressed. The nurse learned that her child your behavior.
2. The parents express apprehensions on their ability to
died a year ago due to an accident. The initial nursing D. You will need to be placed in seclusion.
care for their maladaptive child. The nurse identifies
diagnosis is dysfunctional grieving. The statement of
what nursing diagnosis:
the woman that supports this diagnosis is: 13.
A. hopelessness
A. “I feel envious of mothers who have toddlers”
B. altered parenting role
B. “I haven’t been able to open the door and go into 14. During the initial care of rape victims the following
C. altered family process
my baby’s room “ are to be considered EXCEPT:
D. ineffective coping A. Assure privacy.
C. “I watch other toddlers and think about their play
B. Touch the client to show acceptance and empathy
activities and I cry.”
3. A client with moderate stage dementia says to the C. Accompany the client in the examination room.
D. “I often find myself thinking of how I could have
nurse who offers her breakfast, “Oh no, I will wait for D. Maintain a non-judgmental approach.
prevented the death.
my husband. We will eat together” The therapeutic
9. The client said “I can’t even take care of my baby. I’m 15. When planning the discharge of a client with
response by the nurse is:
good for nothing.” Which is the appropriate nursing chronic anxiety, Nurse Even evaluates achievement of
A. “Your husband is dead. Let me serve you your the discharge maintenance goals. Which goal would be
diagnosis?
breakfast.” most appropriately having been included in the plan of
A. Ineffective individual coping related to loss.
B. “I’ve told you several times that he is dead. It’s time care requiring evaluation?
B. Impaired verbal communication related to
to eat.” A. The client eliminates all anxiety from daily
inadequate social skills. situations
C. “You’re going to have to wait a long time.”
C. Low esteem related to failure in role performance B. The client ignores feelings of anxiety
D. “What made you say that your husband is alive?
C. The client identifies anxiety producing situations C. Antiseptic wash
D. The client maintains contact with a crisis counselor 22. A nurse observes a client sitting alone in her room D. Moisturizer
crying. As the nurse approaches her, the client states,
16. Five months after a rape incident the client “I’m feeling sad. I don’t want to talk now.” The nurse’s 27.  Mr Kulang who has a chronic user of cocaine reports
complains of difficulty to concentrate, poor appetite, best response would be: that he feels like he has cockroaches crawling under
inability to sleep and guilt. She is likely suffering from: his skin. His arms are red because of scratching. The
A. “It will help you feel better if you talk about it.”
A. Adjustment disorder nurse in charge interprets these findings as possibly
B. “I’ll come back when you feel like talking.” indicating which of the following?
B. Somatoform Disorder C. “I’ll stay with you a few minutes.” A. Delusion
C. Generalized Anxiety Disorder D. “Sometimes it helps to talk.” B. Formication
D. Post traumatic disorder C. Flash back
23. .A male client in the Psychiatric unit becomes upset D. Confusion
17. Mr. Tapioca was diagnosed with Severe Anxiety and breaks a chair when a visitor does not show up.
Disorder. The nurse is aware that the most appropriate The first nursing intervention should be to: 28.  In recognizing common behaviors exhibited by male
nursing intervention is to: A. Stay with the client during the stressful time client who has a diagnosis of schizophrenia, nurse Josie
A. Give specific instructions using speak in concise can anticipate:
B. Ask direct questions about the client’s behavior
statements. A. Slumped posture, pessimistic out look and flight
C. Set limits and restrict the client’s behavior of ideas
B. Ask the client to identify the cause of her anxiety. D. Plan with the client for how can he better handle the B. Grandiosity, arrogance and distractibility
C. Explain in detail the plan of care developed situation C. Withdrawal, regressed behavior and lack of social
D. Urge the client to focus on what the nurse is saying skills
24. The nurse has been interviewing a client who has not D. Disorientation, forgetfulness and anxiety
18. Which of the following statements best describes a been able to discuss any feelings. 5 minutes before the
mentally healthy individual? time is over, the client begins to talk about important
A. Has ability to make decisions and live life feelings. The intervention is to:
B. Does not exhibit physical and emotional problems A. Go over the agreed upon time, as the client is finally
C. Has self-acceptance and can meet his own basic able to discuss his feelings with him Good Luck!
needs B. Tell the client that it is time to end the session now,
D. Has absence of anxiety and happy but another nurse will discuss his feelings with him
C. Set an extra meeting time a little later to discuss
19. A defense mechanism wherein the individual dispels these feelings
an action is: D. End just as agreed, but tell the client that these are
A. Fantasy very important feelings and he can continue tomorrow
B. Undoing
C. Symbolism
D. Substitution 25.Following an amputation of a lower limb of Mr. Dy,
20. In a therapeutic nurse-patient relationship, the nurse provides an instruction on how to prevent a
information about the termination phase is introduced: hip flexion contracture.  The nurse should instruct the
A. During the orientation phase client to:
B. During the working phase
C. When the patient can tolerate it A. Perform quadriceps muscle setting exercises twice a
D. As the goals of the relationship are reached day.
B. Sit in a chair for 30 minutes three times a day.
21. Mrs. Reyes expressed that her socializing with C. Lie on the abdomen 30 minutes every four hours.
neighbors is limited because her husband thinks she is D. Turn from side to side every 2 hours
getting overly friendly with a guy next door. Which of
the following would the nurse emphasize as basic? 26. Naya has entered the chemical dependency unit for
A. Keeping trust in the relationship treatment of alcohol dependency. Which of the
B. Avoid relating with neighbors to minimize conflict following client’s possession will the nurse most likely
C. Be assertive to express her individuality place in a locked area?
D. Ignore the husband and just be supportive A. Toothpaste
B. Shampoo